Narrative Exposure Therapy (NET) Overview and Protocol

Narrative Exposure Therapy: Basis and Core Aims

• Designed specifically for survivors who have suffered repeated traumatic events.

• Foundations and clinical roots:

  • Drawn directly from testimony approaches.
  • Maintains a foundational human rights focus.

• Overarching therapeutic aim:

  • To embed traumatic experiences firmly into an individual's autobiographical life context.

• Functions and rationale of the human rights focus:

  • Directly assists with resolving re-experiencing symptoms.
  • Helps individuals understand complex patterns of behaviours, thinking, and feeling.

Questions & Discussion

• Question regarding clinical application in training:
  • Why am I doing it in placement if it is deemed a time-limited approach?
  • Contextual consideration: Narrative Exposure Therapy is structured as a short-term, time-limited manualised intervention, making its implementation within clinical placements a specific model for treating cumulative trauma efficiently by contextualising fragmented memories into an autobiographical narrative.

Memory Systems in Trauma: Traumatic Versus Normal Memory

• Traumatic Memory characteristics:

  • Fragmented: Stored in disconnected pieces rather than an integrated whole.
  • Experienced as now: Carries no temporal distance; relived in the present moment.
  • Sensory and emotional experience: Highly affective and sensory, making it inherently hard to verbalise.
  • Vivid with a sense of current threat: Accompanied by intense perceptual clarity and immediate danger.
  • Easily triggered: Readily activated by trauma-related cues and reminders.
  • Non-contextual: Not anchored in context or historical time.

• Normal Memory characteristics:

  • Chronological: Organised sequentially along a timeline.
  • Experienced as a past memory: Consciously recognised as an event that occurred in the past.
  • Narrative form: Encoded as a coherent story; does not invoke high sensory arousal during recall.
  • Faded: Perceived with natural temporal fading; distinctly recognised as belonging to the past.
  • Ethical recollection: Permits reflective, coherent, and ethical recall of events.
  • Autobiographical context: Firmly situated within the broader context of personal life history.

Neurobiology of Traumatic Memory: Amygdala and Hippocampal Disconnect

• Core neurobiological structures:

  • Amygdala: Operates as the brain's threat system, governing the fight-or-flight survival response.
  • Hippocampus: Dedicated brain region responsible for storing, integrating, and contextualising information.

• Disconnect mechanism during traumatic exposure:

  • A distinct functional disconnect occurs between the amygdala and the hippocampus during trauma.
  • Under acute threat, the amygdala becomes increasingly active, shifting all resources to focus entirely on survival.
  • Simultaneously, the hippocampus becomes overloaded, impairing its optimal functioning and preventing normal contextual storage.

• Flashbacks and processing failure:

  • The occurrence of a flashback following trauma is a normal psychological and biological attempt to process memory.
  • Processing failure occurs when flashbacks happen outside the window of tolerance:
  • The hippocampus goes offline.
  • The amygdala fires repeatedly.
  • The memory fails to process and remains trapped in an unintegrated state.

Dual-Memory Representation: Cold Declarative Versus Hot Non-Declarative Memory

• Cold Memory (Declarative):

  • Provides contextual anchoring.
  • Encodes declarative facts: who, what, where, and when.

• Hot Memory (Non-Declarative):

  • Imbued with an active sense of current threat.
  • Stores comprehensive and detailed sensory, cognitive, emotional, and motor information.
  • Characteristically non-contextual.
  • Identifies the specific memory network that needs active therapeutic processing.

Fear Networks and Stimulus Generalisation

• Structural organisation of fear networks:

  • Fear networks are interconnected through matching sensory, cognitive, and affective stimuli.

• Activation dynamics:

  • A sensory reminder belonging to a single traumatic incident can trigger the simultaneous activation of multiple connected fear networks.

• Interpretative impact:

  • Cognitive interpretations become tied to a multitude of cumulative past trauma exposures.

Narrative Exposure Therapy Protocol Structure

• Diagnostic Interview - Assessment:

  • Comprehensive assessment and baseline diagnostic profiling before commencing exposure sessions.

• Session 1 - Psychoeducation:

  • Educating the client on trauma mechanisms, the functioning of memory systems, and the rationale behind exposure.

• Session 2 - NET Lifeline:

  • Construction of the physical lifeline representing the person's entire autobiographical history.

• Session 3 - Narration of Early Life:

  • Beginning the chronological testimony process, initiating narration from early childhood.

• Session 4 Onwards - Progressive Review and Narration:

  • Each session begins by re-viewing the written narration recorded during the prior session.
  • Narration proceeds forward through recent life events.
  • The pace is slowed down deliberately when reaching stories/traumatic events to enable deep exposure and emotional processing.

The NET Lifeline Methodology and Symbolic Components

• Lifeline purpose and overview:

  • Acts as a structured map providing a bird's-eye overview of the life experienced thus far.
  • Focuses explicitly on engaging cold memory (declarative contextual information).
  • A photograph is taken at the end of the session to preserve the completed layout.

• Symbolic components used on the lifeline:

  • Stories / Stones: Represent negative events.
  • A big stone represents long periods of trauma.
  • Smaller stomes/stones represent specific negative events placed alongside.
  • Flowers: Represent positive life events and resources.
  • Coiled up part: Denotes future aspirations and hopes.
  • Stick: Signifies aggressive acts the individual has committed.
  • Candles: Represent experiences of loss, whether symbolic loss or bereavement.