Narrative Exposure Therapy (1)

7/28/2019 Narrative Exposure Therapy (1)

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Narrative Exposure Therapy (NET)

NET background

There is a dose-response relationship between trauma and PTSD – once you look at people who havehad 25 or more traumas, all have PTSD.

Although the evidence base is strong for using treatment such as trauma-focused CBT (TF-CBT) withpatients who have had up to a few traumas, the evidence is much less clear for patients with multipletraumas.

NET is based upon Peter Lang’s Emotional (Sensory-Perceptual) Network model of memory. Thismodel links together the Sensory/Cognitive/Emotional/Physiological components of memory in onenetwork, and says that a memory is made up of multiple components.

Multiple trauma is conceptualised as the overlap of fear networks.E.g. the physiological component of “increased heart beat” might be a node in multiple traumas – it

might link to multiple specific trauma memories or trauma cognitions. This explains why people withmultiple trauma often have flashbacks to multiple events at once (“flickbook effect”).

The model draws a distinction between:• COLD memories – e.g. context, facts• HOT memories – implicit (classically conditioned), emotions, feelings, body sensations

NET model argues that HOT memory is involuntarily retrieved – this goes for positive and negativeevents – any part of the memory network can trigger the memory

NET model argues that when HOT and COLD components of memory are connected then thememory for that event is not problematic – the memory has context, and can be retrieved at will.However, when the HOT and COLD components are disconnected then they can become problematicand intrusive.

The aim of NET is to elaborate each event, with context (COLD), in order to contextualise the fearnetwork. Ultimately it should stop smaller fear-memory networks surviving on their own – they getbrought into a bigger contextualised memory - the patient can see the event in the context of theirongoing life, instead of an event being re-experienced in the present.

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Practical elements of NET

• Psychoeducation at the beginning of NETo brain modelo fear network o plan for therapy (lifeline, detailed description)o dangers / problems of avoidanceo *agreement – we will never stop halfway through a narrative, I will ask you to continueo Grounding preparation – what would the patient want the therapist to do if they have a

flashback (go through grounding menu)

• Lifeline

• NET sessions - exposure to flowers & stones

• Re-reading the narrativeo Want patient to engage with the reading and not to dissociate or space out.o Try to promote engagemento e.g. “I will deliberately insert 3 mistakes and I want you to spot them”

• Final session – hopes for the future




Lifeline

This is the NET equivalent of a formulation. It gives a clear indication of what the patient hasexperienced, and shows the tasks of therapy.

Lay out a piece of rope (or ribbon if rope has unhelpful connotations). One end is when they wereborn. The other end should be rolled up to indicate life yet to come.

“We’re taking a birds-eye view of your life”

Stones and flowers are given a label or a name. This can be especially difficult for events involving highlevels of shame – lots of praise & gentle encouragement.

*Don’t let patients avoid during this phase (it would set an unhelpful precedent for the rest of therapy – don’t let a stone or flower be placed on the lifeline unless they are willing to give it a name.

At this point you don’t want too much detail about any events, just an overview of a person’s life.

Stones or flowers can’t be placed for the time before the beginning of the person’s life. You can ask thequestion “when did you become aware of the effects of that event?” and mark the beginning of theirawareness.

Flowers – especially if the client does not volunteer many positive events then it can be helpful toprobe for “positive people you have had in your life” to elaborate you could ask “what did that person give you?”

Arrange and re-arrange the items on the lifeline.

Therapist should take a picture of the lifeline, or make a copy on a piece of paper, with notes about theorder of events, and brief descriptions of each event.

At this first session the plan can be given for future sessions. The rationale given is that each even willbe spoken about. If there are too many individual events then the patient should be involved in making the decision about which events need to be spoken about, and which can be missed.

Finally the lifeline should be packed up – ideally led by the patient.“How should we pack this up for today?”




Narrative exposure

Subsequent NET sessions are spent getting a detailed description of the events on the lifeline. Proceedthrough the lifeline from the beginning to the end.

The start of each session involves the therapist reading out the narrative from the previous session.

Practical note: Take notes about the context of an event, but don’t take notes during the detailedelaboration of the hot memory – therapist needs to be completely focused on client and attuned tohow they look and how they are reacting – instead make notes as soon as possible afterwards.

Context“Let’s start from the beginning of that day…” “What’s the first thing you remember that day…”

The aim of each narrative session is to try to connect the HOT and COLD memories of the trauma.Some descriptions of NET are that it is like ‘weaving’ the two parts of the memory together. Kerry

Young described the therapist’s job as one of ‘wagging’ between cold (context) and hot (emotional)

memories.

When speaking about the past try to use the past tenseButKeep coming back to the present (“are you feeling that now?”) and use the present tense

Lots of clarifying questions to fully elaborate all nodes of the memory network. Therapist shouldn’t be afraid of suggesting what they think the patient might be feeling – as long as itis offered as a suggestion the patient should feel comfortable to correct the therapist if the guess isincorrect.“How do you feel?”

“You look disgusted. Do you feel that now? And back then?” “You look like you feel quite defeated?”

During a narrative exposure session the therapist might move into present-tense to increase the heat, orpast-tense to cool things down. Narrative is always written in past tense.




Stones

Start by eliciting some context. Where did this event take place? What date / month was it? Whatseason? Can they give you some background to what was going on in their life at this point? What wasthe political situation like at the time?

When you get to a stone, slow down and try to get some context for what was happening about 2hours before / the beginning of that day.

Stay in the hot spot until the client experiences some relief.

Prevent – avoidance, dissociation, flashbacks (by which they mean very powerful dissociative flashbacks were the individual loses touch with the present, it would be expected for the patient to have vividintrusive memories during the narrative exposure)

Must challenge avoidance – in your psychoeducation section you will need to have talked aboutavoidance in advance, and the client must know that you will expect and encourage them to carry on

with a narrative right until the end / a safe point.

“I know this is the worst bit, but it won’t help to stop here. I’m right here with you, you’re not on your own. We have tocarry on.”

Head, heart, body, then-and-now You are trying to elicit:• what they were thinking (head) and feeling (heart)• what was going on in their body (body)• getting them to reflect upon how sensations in the here-and-now (now) are similar/different from what happened at the time (then)

Style – clarifying interruptions are quite frequent in NET“and what was going through your mind right then?” “I notice you’re rubbing your neck, do you feel something in it now that is similar to what you felt at the time?” Closely watch the client and tentatively suggest / notice what they might be feeling

If the client is avoidant then the therapist’s job is to try to keep them engaged in the trauma- ask more questions about what they were thinking and feeling at the time- can try getting the patient in to the body position that they were in at the time of the trauma

(careful with this!)

If the client is dissociated then the therapist’s job is to try to bring them back to the here-and-now - ask questions about what they are feeling in the here and now

- grounding techniques (have an assortment of these ready to use)

No mix of exposure (opening up and getting detail) and closure (closing down and moving on)- i.e. don’t go back once you’ve closed down- plan to stay exploring a stone for considerable time

NET proponents recommend that if the client has a completely dissociative flashback then it issensible to call a halt to that day’s session.

When writing the narrative only describe what they felt at the time (when you are discussing the event with them you will be asking questions about what they feel in the here-and-now, but on the written

narrative you only record what they felt at the time)


Documents

Narrative Exposure Therapy (1)