Article of the Week:
Does Narrative Exposure Therapy Reduce PTSD in Survivors of Mass Violence?
by McPherson, J. (2012).
(Research on Social Work Practice, 22(1), 29-42. DOI: 10.1177/1049731511414147)
As a comeback to my series of summaries of interesting scientific research articles in psychology, I’ll start with something directly relevant to my current work as a PhD Candidate researcher.
After a particularly frightening, dangerous or otherwise intensely stressful experience, stress reactions can be considered normal. However, if such symptoms persist for several months, we may speak of persistent post-traumatic stress symptoms and, in cases where they reach a certain clinically significant level, of Post-Traumatic Stress Disorder (PTSD). Typically, PTSD symptoms consist of involuntarily re-experiencing the traumatic event in some way (flashback phenomena, intrusive thoughts and memories), avoiding places, people and things that are reminders of the trauma or act as triggers for re-experiencing, and hyper-arousal (problems concentrating, sleeping, over-vigilance, feelings of danger).
The standard treatments for PTSD and related symptoms include trauma-focused and other forms of cognitive behavioral therapy. However, clinicians and researchers have found that these standard treatments often do not work so well with individuals who have repeatedly experienced many traumatic incidents, especially in contexts such as war and armed conflict. With this in mind, new forms of therapy appropriate for such sequentially traumatized individuals are needed.
One such relatively new form of therapy is Narrative Exposure Therapy (NET), developed by M. Schauer, F. Neuner and T. Elbert, drawing on emotional processing theory, trauma-focused CBT and testimonial therapy. It is a program of on average eight sessions, where emotional processing and thus healing is thought to occur through repeated narration of the traumatic events leading to habituation to their distressing effects, as well as through the reconstruction of a coherent narrative of the events and their place in the individual’s autobiographical memories. The entire life story of the patient, including her/his most negative and traumatic as well as positive experiences, is narrated and written down in detail during the therapy.
The article summarized here is a review by J. McPherson of the evidence “so far” (until 2011 or so, that is) on the effectiveness of Narrative Exposure Therapy to reduce PTSD symptoms, mainly in survivors of different forms of mass violence.
Results & Discussion
The author conducted several database searches and contacted the developers of NET to find all RCTs conducted on NET that used PTSD symptomatology as the primary outcome variable. She ended up with eight peer-reviewed studies published between 2004-2010 that she then analyzed and compared, though no meta-analytic methods were employed here.
Six of the studies looked at the effectiveness of NET in adults, and two at the effectiveness of KIDNET (a version of NET customized for children) in children and adolescents, in “diverse groups of
trauma survivors in terms of age, gender, nationality, location, and legal status.” The results of the studies on adults can be summarized as follows:
1) In 43 Sudanese refugees in Uganda who met diagnostic criteria for PTSD, at 1-year follow-up, 29 % of those treated with NET met diagnostic criteria, as compared to 79 % of those who received trauma counseling and 80 % of those who received psychoeducation only.
2) In 18 elderly Romanians who had been held as political detainees decades ago and who, again, met diagnostic criteria for PTSD, 56 % saw remittance of PTSD at six months’ follow-up when treated with NET, as compared to 11 % remittance in those who received psychoeducation only.
3) 24 local recruits were trained to provide NET to 277 Rwandan and Somali refugees with PTSD. At 9 months’ follow-up, PTSD was no longer present in 70 % of NET participants, as compared to 65 % of those who received trauma counseling and 37 % of those on a waiting list. Limitations of this study, the largest and most ambitious presented here, include possible imprecision in PTSD diagnosis and a large dropout rate in the trauma counseling group.
4) NET was compared to interpersonal psychotherapy (IPT) by providing four treatment sessions of each to half of 26 genocide orphans between 14 and 28 years of age in Kigali, Rwanda, with chronic PTSD. At six months’ follow-up, 25% in the NET group but 71% in the IPT group still had PTSD. NET participants improved significantly more in terms of PTSD and depression symptom severity.
5) In Germany, in 32 asylum seekers of various backgrounds with PTSD due to a history of state-sponsored violence, NET was compared to Treatment-As-Usual (TAU). At six months’ follow-up, NET, but not TAU, produced significant reduction in PTSD symptoms, though all but one in the NET group and all participants in the TAU group still met the diagnostic criteria of PTSD. Limitations of the study include variation in what was considered TAU and the heterogeneity of the sample.
6) Again in Germany, NET was compared with Stress Inoculation Training (SIT) in 28 PTSD patients with experiences of war and torture. At 4 weeks, 6 months and 1 year after treatment, NET but not SIT produced significant reduction in PTSD symptom severity. Rates of major depression and other comorbid disorders, however, did not decrease significantly. Limitations of this study include a complex, heterogeneous sample and large loss to follow-up at 1 year (13 out of 23 lost).
The two studies on children:
7) KIDNET and a form of meditation relaxation were compared as provided by local teacher counselors to 31 internally displaced children in Sri Lanka who met the diagnostic criteria for “preliminary” PTSD in the aftermath of a tsunami. At six months’ follow-up, both treatments seemed effective, with 81 % recovery rates with NET and 71 % with meditation relaxation. Limitations included having no control group (due to ethical concerns) that would have demonstrated rates of spontaneous remission.
8) In 26 refugee children of various backgrounds in Germany with PTSD, those treated with KIDNET showed a clinically relevant, statistically significant reduction in post-traumatic stress symptoms, as compared to a waitlist condition, with average symptom severity in the KIDNET group dropping to 60%.
Based on these eight studies, the author concludes there is already “good evidence to support the use of NET for treatment of PTSD among survivors of mass violence and torture.” In these studies, its effectiveness was similar to trauma counseling and meditation relaxation and better than supportive counseling, psychoeducation, group interpersonal therapy, treatment-as-usual and waitlist/no treatment conditions. The studies had rigorous, randomized designs and used standardized measures, but most were limited by small sample sizes, making subsample comparisons of the diverse samples impossible. As NET aims to be a “culturally universal” intervention, it is also promising that the evidence these studies provide comes from many different countries and nationalities.
The author calls for more research into the universal applicability and effectiveness of NET, especially with larger trials and better blinding procedures. The possible effects of the use of translators should also be studied. She also notes that the developers of the intervention in question were heavily involved in the studies examined here, appearing as authors or co-authors in all of them. This is not surprising in a treatment as new as NET, but clearly points to a need for more research in new populations by independent researchers.
As this review shows, evidence from small but rigorous, well-planned, randomized and (at least mostly) blinded trials for the effectiveness of Narrative Exposure Therapy is increasing. Further, in addition to the randomized controlled trials examined here, a number of case studies and other less rigorous studies on NET have been completed. In a variety of conditions, NET seems to work at least as well, and possibly better, than other alternatives in reducing PTSD symptoms and improving people’s lives. Most of the evidence so far is with adults, but applications with children look promising, too.
Clearly, as these studies too show, a single program of NET will not heal every patient. Looking at the rates reported here, around 20-40 % of participants could still be diagnosed with PTSD at follow-up, even after having received NET. This is not surprising, as long-term post-traumatic stress symptoms are difficult to treat, even more so in the uncertain conditions where many of the participants of these studies live.
The fact that these studies were carried out in wildly different conditions, including such demanding settings as refugee camps, and with such dissimilar populations and time frames (from right after a traumatic event to decades later) naturally creates immense sources of variation in the results. But at the same time, such apparent universal usefulness of the method is also very encouraging for its practical applicability on a wider scale.
Though McPherson does not discuss this in detail, reading this review also elicits questions in my mind about efficacy versus effectiveness. In two of the studies, NET was carried out by trained locals who were not mental health professionals. In those cases at least, we can probably say we are studying the practical effectiveness of NET. In cases where the treatment was provided by experts in, and indeed in some cases the developers of, NET, it may be more correct to speak of the optimum-case efficacy of NET.
McPherson calls for more research into NET with bigger samples and by independent researchers. At the same time, scientific discussion on PTSD and its treatment has begun to move from studying the effectiveness of trauma interventions to also examining their underlying working mechanisms, or agents of change, if you will.
The upcoming clinical study of our research group in Tampere, headed by Dr. Kirsi Peltonen, is an attempt to combine these two goals. We will study Narrative Exposure Therapy as compared to Treatment-As-Usual in immigrant children and adolescents traumatized by war at several outpatient clinics and look at not only the effectiveness of NET but also potential mediating factors of said effectiveness, such as the recovery of memory functions and the quality of trauma memories as well as changes in post-traumatic cognitive appraisals. Stay tuned for more!