Clinical Psychology Review 30 (2010) 1030–1039

Contents lists available at ScienceDirect

Clinical Psychology Review

The emerging evidence for Narrative Exposure Therapy: A review

Katy Robjant a,⁎, Mina Fazel b,1
a
Traumatic Stress Service, Clinical Treatment Centre, Maudsley Hospital, Denmark Hill, London SE5 8AZ, United Kingdom
b
Department of Psychiatry, Oxford University, Warneford Hospital, Oxford OX3 7JX, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Individuals who have experienced multiple traumatic events over long periods as a result of war, conflict and
Received 25 March 2010 organised violence, may represent a unique group amongst PTSD patients in terms of psychological and
Received in revised form 25 June 2010 neurobiological sequelae. Narrative Exposure Therapy (NET) is a short-term therapy for individuals who
Accepted 22 July 2010
have PTSD symptoms as a result of these types of traumatic experiences. Originally developed for use in low-
income countries, it has since been used to treat asylum seekers and refugees in high-income settings. The
Keywords:
Narrative Exposure Therapy
treatment involves emotional exposure to the memories of traumatic events and the reorganisation of these
Review memories into a coherent chronological narrative. This review of all the currently available literature
Post-traumatic stress disorder investigates the effectiveness of NET in treatment trials of adults and also of KIDNET, an adapted version for
Refugees children. Results from treatment trials in adults have demonstrated the superiority of NET in reducing PTSD
symptoms compared with other therapeutic approaches. Most trials demonstrated that further improve-
ments had been made at follow-up suggesting sustained change. Treatment trials of KIDNET have shown its
effectiveness in reducing PTSD amongst children. Emerging evidence suggests that NET is an effective
treatment for PTSD in individuals who have been traumatised by conflict and organised violence, even in
settings that remain volatile and insecure.
© 2010 Elsevier Ltd. All rights reserved.

Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1030
1.1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1030
1.2. PTSD and its treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1031
2. Narrative Exposure Therapy as a new model for treating PTSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1032
2.1. Theoretical background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1032
2.2. Conducting NET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1032
3. Evidence available on NET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1033
3.1. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1033
3.2. Evidence from low- and middle-income countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1033
3.3. Evidence from high-income countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1036
3.4. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1036
3.5. Studies in children: the development of KIDNET and emerging evidence for its efficacy . . . . . . . . . . . . . . . . . . . . . . 1037
3.5.1. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1037
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1037
Disclosure statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1038
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1038
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1038

1. Introduction

1.1. Background
⁎ Corresponding author. Tel.: + 44 20 3228 2969; fax: + 44 20 3228 3573.
E-mail addresses: katy.robjant@slam.nhs.uk (K. Robjant),
mina.fazel@psych.ox.ac.uk (M. Fazel). The global burden of disease as a result of armed conflict continues
1
Tel.: + 44 1865 223733; fax: + 44 1865 793101. to rise each year and the affected individuals, predominantly in low-

0272-7358/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2010.07.004
 K. Robjant, M. Fazel / Clinical Psychology Review 30 (2010) 1030–1039
and middle-income countries, are a particularly challenging group to
treat. This is because they often live in insecure settings that have
limited access to resources and few trained professionals to manage
their care. Narrative Exposure Therapy (NET) was developed with
these populations in mind, it is a brief, manualised treatment for the
psychological sequelae of torture and other forms of organised
violence, and can be delivered by non-mental health professionals.
Since its development less than a decade ago, it has been shown to
have therapeutic benefits for a wide range of individuals and settings.
These include successful use in both adults and children, with asylum
seeker, refugee and native populations and in a number of different
countries, both high and lower income. This review aims to collate all
the information so far available on the therapeutic effects of NET.
The numbers of individuals fleeing war and political violence
varies each year but recent estimates suggest that over 1% of the
world's population, 67 million people, are currently forcibly uprooted
(UNHCR, 2008). The worldwide refugee population has continued to
rise over the last few decades with a tenfold increase in the numbers
affected in the last decade of the twentieth century (UNHCR, 2000,
2008). Of note, the nature of conflict has changed, with a greater
proportion of current war victims being civilians rather than
combatants (Stockholm International Peace Research Institute, 2000).
A dose–response relationship between traumatic events and
symptoms of post-traumatic stress disorder (PTSD) amongst civilians
affected by war and organised violence has been demonstrated in
many populations including amongst survivors of the Pol Pot regime
(Mollica et al., 1998); in Bhutanese (Shrestha et al., 1998) and
Burmese (Allden et al., 1996) refugees; in Ugandan and Sudanese
nationals and Sudanese refugees (Neuner, Schauer, Karunakara, et al.,
2004) and in adults living in Afghanistan (Scholte et al., 2004). Similar
findings have also been found amongst asylum seekers and refugees
in high-income settings, reporting stressful events in both their
country of origin and whilst settling in their host country (Silove et al.,
1997).
A meta-analysis investigating the mental health of refugees and
other populations exposed to mass conflict and displacement across
the globe found high rates of psychopathology (Steel et al., 2009). In
145 surveys (n = 64,332) the overall weighted prevalence of PTSD
was 30.6%. In another meta-analysis investigating pre- and post-
displacement factors associated with mental health difficulties (Porter
& Haslam, 2005), refugees (including internally and externally
displaced individuals) had poorer mental health than non-refugee
controls, even though some comparison groups had experienced war
and its associated violence.
1.2. PTSD and its treatment
The three core symptoms of PTSD are firstly the re-experiencing of
intrusive vivid memories of traumatic events both during sleep and in
the day, when the individual often has a sense they are re-living the
event. Secondly, the active avoidance of anything that may trigger
these memories, with associated emotional numbing, derealisation
and depersonalisation. The final symptom is persistent hyperarousal
and an exaggerated startle response, reflecting the readiness of the
body's fight or flight response.
In a review by Brewin and Holmes (2003) three main theories of
PTSD were identified as having the most explanatory power for the
current empirical findings and observed clinical symptoms in
patients. These are 1) emotional processing theory (Foa & Rathbaum,
1998) 2) dual representation theory (Brewin, Dalgleish, & Joseph,
1996) and 3) Ehlers and Clark's cognitive model (Ehlers, Clark,
Hackmann, McManus, & Fennell, 2005). There are a number of
similarities between the models which all emphasise maladaptive
processing of traumatic events. They also explain how a fragmented
autobiographical memory, lacking in contextual information, results
in a subjective sense of current threat, as the traumatic event is
1031
indistinguishable from the present context. The three models also
construe that the intrusive re-living phenomena associated with PTSD
occurs through activation of the entire memory of the traumatic event
following exposure to one or more internal or external cues (although
they differ in their conceptualisation of how this occurs).
Whilst these models account for PTSD resulting from single event
trauma, the relevance for complex PTSD that can follow multiple
traumatic events is less clear (Green et al., 2000). Some authors have
suggested that PTSD symptoms following multiple or chronic
traumatic events, particularly those originating from organised
violence or torture, is sufficiently different to warrant further
diagnostic refinement (Herman, 1992; Silove, 1996, 1999). There is
evidence of lasting neurobiological differences amongst survivors of
severe organised violence including torture (Elbert, Rockstroh,
Schauer, & Neuner, 2006). Conversely, some have argued that PTSD
itself is an unhelpful diagnosis which may not be culturally relevant to
those who have experienced trauma associated with war and
organised violence, where an understanding of the social and political
context is important (Bracken, Giller, & Summerfield, 1995; Summer-
field, 2001). Other authors have pointed to the accruing evidence of
biochemical, neuroanatomical and phenomenological characteristics
differentiating PTSD from other psychiatric conditions. This is
particularly true of memory distortions and other cognitive abnor-
malities associated with PTSD (Mezey & Robbins, 2001).
One of the clearest benefits of the conceptualisation of psycho-
logical models of PTSD has been the development of successful
psychological treatments. This is most evident in the clinically
effective cognitive–behavioural treatment protocol devised by Ehlers
et al. (2005). There is good evidence for the efficacy of Trauma
Focused CBT (TFCBT) and Eye Movement Desensitisation and
Reprocessing (EMDR) for the treatment of PTSD, and these are both
recommended in the National Institute for Health and Clinical
Excellence (NICE) guidance for treating PTSD (NICE, 2005).
In a review and meta-analysis of 38 randomised controlled trials
undertaken as part of the preparation for these guidelines, Bisson et al.
(2007) demonstrated the superiority of TFCBT and EMDR over other
psychological approaches. Two other approaches: stress management
and group CBT, were also found to be effective in reducing PTSD.
Exposure to the memories of the traumatic event is a core feature of
both EMDR and TFCBT, and therapies that did not focus on the trauma
itself but instead focused on current or historical problems were not
as effective in reducing PTSD. Ehlers et al. (2010) show that, in seven
out of eight meta-analyses or systemic reviews, trauma-focused
psychological treatments are most effective in treating PTSD although
one meta-analysis showed that all treatments are equally effective
(Benish, Imel, & Wampold, 2008). Few of the studies were conducted
on individuals who had experienced multiple, severe events in the
context of war and organised violence and the two studies involving
Vietnam War veterans, had less favourable outcomes. The authors
suggest that this population are more difficult to treat. The reason for
this is unclear, but it is feasible that the severity and multiplicity of
traumatic incidents occurring in war contexts sets this group apart
(Silove, 1999). Other authors have highlighted the necessity of
continuing to develop and improve existing treatments as well as to
be innovative in creating new treatments to reduce drop out rates and
treatment failures (Cukor, Spitalnick, Difede, Rizzo, & Rothbaum,
2009).
A further therapy: testimony therapy, has been developed as a
type of therapy that places the trauma within the cultural socio-
political context in which it occurred (Cienfuegos & Monelli, 1983). To
our knowledge there are no published trials comparing this therapy
with other trauma-focused treatments.
In general there is a paucity of data available regarding effective
treatments for trauma-related sequelae from lower-income settings,
yet the majority of refugees reside in such areas (approximately
9 million of the world's 13 million refugees) (UNHCR, 2008). Research
1032 K. Robjant, M. Fazel / Clinical Psychology Review 30 (2010) 1030–1039
has shown that psychological treatments are effective in reducing
PTSD in high-income countries, although the evidence for the
effectiveness of these treatments in reducing PTSD in those who
have experienced multiple traumatic events of a severe and chronic
nature is less clear. Western psychological models which have been
shown to be effective have included an element of exposure, whilst
other therapies designed for victims of organised violence have
stressed the importance of giving testimony (Cienfuegos & Monelli,
1983). The NICE guidelines refer to the limited data for this specific
group and mention the efficacy data that had recently emerged for
Narrative Exposure Therapy (Neuner, Schauer, Klaschik, Karunakara,
& Elbert, 2004) as ‘encouraging’.
2. Narrative Exposure Therapy as a new model for treating PTSD
2.1. Theoretical background
NET is a new treatment that has been devised specifically for the
victims of organised violence, incorporating many of the exposure
elements of existing models with an additional focus of clearly
documenting the atrocities endured (Schauer, Neuner, & Elbert,
2005). Originally devised to be administered in refugee camps with
the aim that it could meet the pragmatic demands of providing care in
emergency settings by being delivered by non-mental health
professionals in a short period of time, it has now being tested with
asylum seekers and refugees in high-income countries. NET includes
some of the components of other evidence based therapeutic
approaches such as prolonged exposure and TFCBT with the giving
of testimony to the abuses endured. However, as a result of the unique
method of exposure and narration of the traumatic memories in NET,
the traumatic experiences become embedded within the autobio-
graphical context.
The development of NET was informed by the theoretical
understanding of both autobiographical memory (Conway, 2001)
and the framework it provides in understanding intrusive symptoms
(Brewin et al., 1996; Ehlers & Clark, 2000), as well as fear networks
and how these can be activated in the brain (Foa & Kozak, 1986; Foa &
Rathbaum, 1998; Lang, 1979). The authors make the distinction
between declarative ‘cold’ memory (similar to C-reps in ‘contextual
memory’ in Brewin's revised, dual representation theory (Brewin,
Gregory, Lipton, & Burgess, 2010)) and non-declarative ‘hot’ memory
(S-reps in Brewin's revised model).
Cold memory contains contextualised information about one's life
at different levels of organisation, with increasingly specific informa-
tion at each stage (Conway & Pleydell-Pearce, 2000). The first and
most accessible stage contains information relating to ‘lifetime
periods’, describing phases or stages in life such as where a person
lived, or their occupation over a certain period (Neuner, Catani, et al.,
2008). The next stage contains information about ‘general events’.
These can either be single or repeated events and describe what life
was like at this time, such as a memory of the journey to work. Event
specific knowledge is the next stage, and contains detailed contextual
information about specific occasions such as a wedding. In addition to
the contextual information stored, sensory and perceptual informa-
tion (referred to as ‘hot memory’) is also linked to this event specific
knowledge (Schauer et al., 2005).
‘Hot’ memory includes detailed sensory information as well as
cognitive and emotional perceptions and physiological and motor
responses, all of which are intertwined. Unlike with cold memories,
there is evidence that the limbic structures associated with emotion
are heavily involved in sensory perceptual representations of events.
For traumatic events, these sensory perceptual representations are
known as ‘fear networks’ or ‘fear structures’ (Lang, 1979, 1984, 1993).
The associations between the individual items within these fear
networks are particularly strong, so that when an individual later
encounters one external or internal stimulus within the fear network,
this results in activation of the entire network. Flashbacks in PTSD are
therefore thought to occur when the whole network is activated.
Within this model, PTSD is conceptualised as a consequence of
physiological changes in the brain affecting memories that occur as a
result of the noradrenergic response to stress. When stress occurs
during life threatening events and subsequently in the re-experienc-
ing of these in PTSD, the functioning of the hippocampus is
significantly impaired. Whereas the hippocampus is impaired by
stress hormones, the amygdala is more intensely activated resulting in
an accentuated sensory representation of the event. This dispropor-
tionate engagement of the neural structures (amygdala and hippo-
campus) means that memories for traumatic events differ from
normal memories in that they include an increased number of cues,
and the associations between cues are stronger. As a consequence of
these differences, traumatic memories can be more easily activated. At
the same time, reduced functioning of the hippocampus means that
spatio-temporal information is not incorporated into the memory,
making it very difficult for the individual to narrate the event.
Furthermore, the lack of contextual information means that the
individual maintains a sense of current threat when the memory is
activated (Neuner, Catani, et al., 2008) and the autobiographical
memory is disrupted. The individual is therefore unlikely to be able to
provide a consistent chronological account of events. This theory
demonstrates how repeated or multiple events are more likely to
result in severe psychological disturbance. Fear networks increase and
become more readily activated through repeated experiences and can
also become linked to elements within the present context, such as
continued threat to life or insecurity (Elbert et al., 2006).
2.2. Conducting NET
Following the recommendations of Brewin et al. (1996), one of the
aims of NET is to enhance the encoding of declarative autobiograph-
ical memory (cold memory) when hot memories are activated. This
anchors the event in time and reduces the sense of current threat. NET
therefore aims to construct a consistent autobiographical represen-
tation of traumatic events within the context of a narrative of the
individual's whole life. As NET has been developed for individuals who
are likely to have experienced multiple traumatic events, and as fear
structures are likely to overlap, patients are not asked for the ‘worst
event’. Rather they narrate all stressful life events in chronological
order from birth to the present day. Individuals who are able to form a
consistent narrative of individual traumatic events have been shown
to benefit most from exposure therapy for PTSD (Foa, Molnar, &
Cashman, 1995) suggesting that whilst habituation to the memory of
the traumatic event is crucial, constructing a meaningful narrative of
the event is also important in aiding recovery (Neuner, Catani, et al.,
2008). As more contextual autobiographical information is included
into the hot memory, the fear structure is gradually inhibited, thereby
reducing PTSD symptoms (Neuner, Catani, et al., 2008). Whilst the
meaning of the atrocities the individual has endured remains, this
process can at least provide relief in alleviating symptoms of PTSD and
in accompanying the individual, step by step, through the narration
and documentation of their ordeals (Neuner, Schauer, Roth, & Elbert,
2002; Onyut et al., 2005; Schauer et al., 2004, 2005).
NET is a manualised treatment (Schauer et al., 2005). The patient
first undergoes psychoeducation in which the theoretical under-
pinnings of PTSD and the process of NET and rationale for treatment
are explained. Psychoeducation about how avoidance of reminders of
traumatic events is a key feature of PTSD, and the impact of this on
inhibiting treatment, is provided. Once informed consent has been
obtained, the therapy can begin. Sessions are usually 60–120 min in
length and ideally occur in close succession preferably with one or
more sessions per week and a maximum of a fortnight between
sessions.
 K. Robjant, M. Fazel / Clinical Psychology Review 30 (2010) 1030–1039
In the first session the patient constructs the ‘lifeline’. This is a
physical representation of their life using a rope, beginning at birth
and ending at the present day, with a section of the rope left uncoiled
representing the future. The patient then briefly goes through their
life, in chronological order, placing a symbol (e.g. flowers of different
shapes and sizes) on the line to represent happy events and a different
symbol (e.g. stones) for sad or frightening events. The therapist's role
is to ensure the correct chronology of these events. The lifeline is
useful in establishing the therapeutic relationship and in providing an
indication of the number of sessions that may be necessary to address
all traumatic events (although some events may only be disclosed
later in therapy). Following this session, subsequent sessions are
dedicated to the narration of the person's life, in chronological order,
with particular focus on and attention to the traumatic events. Periods
between events are described in brief to contextualise the traumatic
events within the individual's life and produce a coherent narrative.
On approaching a traumatic incident, the focus is on contextual
information, firstly establishing what life was generally like at that
time (where was the person living, what were they doing, what was a
typical day) and then narrowing this down as precisely as possible to
what happened when the event occurred. The traumatic events are
then narrated in great detail, gently resisting the patient's attempt to
hurry through or avoid emotional engagement with the memory.
The patient then slowly narrates their traumatic experience in
chronological order, as they experienced it at the time. They are
encouraged to describe all sensory modalities along with their
thoughts and feelings. The aim of NET is to connect the hot memories
into the corresponding information held within the cold memory for
the event and so the patient must be emotionally involved in the
narration but must also put these experiences into words, constantly
integrating the contextual information. At the same time as the
narration of the traumatic event progresses, the patient's current
physical, emotional and cognitive reactions are observed and
verbalised. The therapist continually guides the patient back and
forth between what is happening for the patient at the time of the
narration (present time) and what occurred at the time of the event.
One of the aims of the therapy is for the person to be emotionally
exposed to the memory of the event for sufficient time that
habituation occurs and their emotional response to the memory is
diminished over the course of therapy. However, this is unlikely to
occur within a single session. The session ends at a safe point in the
narrative, at the end of a traumatic event, once the therapist has
ensured that the patient's arousal has diminished and that their
emotional state is improved. The events in the period after the
traumatic incident are narrated to help the patient place the episode
in context.
The narrative as described in the session is written up by the
therapist between sessions (see example in Box 1), this provides an
opportunity for the therapist to ensure they have fully understood the
details and chronology of the events described and therefore high-
lights areas in the story which do not seem as coherent and possibly
need further exploration at the next session. At the beginning of the
next session the narrative from the previous session is read to the
patient to ensure accuracy, once again expose the patient to memories
of the event, elicit further information and promote integration of the
hot and cold memories. Usually the patient notices a reduced
physiological and affective reaction from the first session, although
several sessions may be necessary for habituation to occur for severely
traumatic events. At the end of the re-reading of the narrative, the
period between this event and the next traumatic event is briefly
narrated, before moving forward to the next traumatic episode, which
is again narrated in intricate detail. This process continues until all
stressful events have been narrated and the affective responses to the
memories have reduced. At this point, the patient and therapist will
have created a testimony of the person's life from birth to the present
day, with a detailed narration of the traumatic events. At the end of
1033
the therapy some time is spent discussing hopes and aspirations for
the future, following which all parties who have been involved in the
therapy (including the patient, therapist and interpreter) sign the
completed testimony. The patient receives a copy of this for their own
private records and the authors report that it is common to find
patients sharing their testimonies with others including lawyers and
human rights organisations (Schauer et al., 2005).
3. Evidence available on NET
3.1. Methods
There have been a number of trials in adult populations, both
published (Bichescu, Neuner, Schauer, & Elbert, 2007; Halvorsen &
Stenmark, 2010; Neuner, Catani, et al., 2008; Neuner, Schauer,
Klaschik, et al., 2004; Neuner et al., 2010; Schaal, Elbert, & Neuner,
2009) and unpublished (Adenauer et al., in preparation; Ertl, Pfeiffer,
Schauer, Neuner, & Elbert, 2008; Hensel-Dittman et al., in preparation;
Jacob, Neuner, Schaal, Maedi, & Elbert, 2010; Stenmark, Catani,
Neuner, Elbert, & Holen, in preparation). The studies have taken
place in both low- and middle-income as well as high-income
settings, and on populations who are refugees, internally displaced
persons (IDPs) and asylum seekers either living in their original
homes, or in camps in their own countries; in neighbouring countries
or far from their original homes. NET has been used to treat PTSD in
individuals across the life span and in those who have recently
experienced traumatic events as well as in those with chronic PTSD.
The studies are summarised below and those published are in Table 1.
The studies were identified using a search of NET on Medline and
Scopus and with full cooperation of the NET development team at the
Universities of Konstanz and Bielefeld, Germany. In addition, authors
were individually approached at an internal NET working group to
ensure all studies with complete data had been identified.
3.2. Evidence from low- and middle-income countries
There are six trials that have been conducted in low- and middle-
income countries to date, four have been published (Bichescu et al.,
2007; Neuner, Onyut, et al., 2008; Neuner, Schauer, Klaschik, et al.,
2004; Schaal et al., 2009), and the further two have been presented as
a PhD thesis (Jacob et al., 2010) and as a conference presentation (Ertl
et al., 2008). Three studies have been conducted in Uganda with
Sudanese, Rwandan and Somali refugees (Neuner, Onyut, et al., 2008;
Neuner, Schauer, Klaschik, et al., 2004), and with former child
soldiers (Ertl et al., 2008); two have been conducted in Rwanda
(Jacob et al., 2010; Schaal et al., 2009) and another in Romania
(Bichescu et al., 2007). All studies show promising results in that NET
was found to be an effective treatment for reducing symptoms and
rates of PTSD as well as reducing comorbid disorders in some cases.
The sample sizes in the studies range from 18 to 277 and so the power
of much of the work to demonstrate efficacy is limited. However, the
studies show the feasibility of providing effective psychological
treatments to individuals who have experienced organised violence
living in poorly equipped conditions. In addition, they also demon-
strate how both mental health professionals and lay counsellors can
deliver NET.
The first trial conducted into NET demonstrated its effectiveness in
treating PTSD. This randomised controlled trial (Neuner, Schauer,
Klaschik, et al., 2004) compared psychoeducation alone with
psychoeducation plus NET or supportive counselling (SC) for the
treatment of Sudanese refugees in a Ugandan refugee camp. All
participants received psychoeducation on the nature of PTSD
symptoms. 12 participants did not receive any further intervention
after this session, effectively providing a control condition. In the two
treatment conditions, therapists provided both types of treatment in
order to minimise therapist effects, and adherence to the treatment
1034 K. Robjant, M. Fazel / Clinical Psychology Review 30 (2010) 1030–1039

Box 1

It was just before lunchtime that it happened. I was sitting in class and my stomach was rumbling because I was hungry. I felt restless and
wanted to go home for lunch but I knew I had to finish the writing before I could go. I was rushing as much as I could to copy the letters
when I heard a huge bang and I knew that something was wrong. My stomach dropped and I felt afraid. Everyone was looking at each
other and we were all frightened. The teacher went to the window and looked out and we were looking at him to see what would happen.
I thought it sounded like shelling but it was louder than normal and this meant it was closer. Then my friend said ‘no dogs!’ and I thought
that was weird because normally the dogs bark loudly when there is shelling. I felt more afraid then because I didn't know what was going
on. My legs were shaking and I was gripping the edge of the desk. We were all looking at the teacher and he turned around and had fear on
his face. His eyes were wider and his jaw was tight. He shouted at us to wait there and he ran out of the room. I was worried and wondered
what was happening. I thought it was serious because my teacher was running out. I wanted to be at home and I felt everything shaking
inside me. I heard someone cry out and as I turned around my friend bumped into me from behind and ran over to the window. I went to
see too and then I felt bumped and pushed from behind on my head and back, as all the boys were rushing up to see what was happening.
Out of the window I could see the bit of ground by the school where we play and I could see lots of students outside rushing about and
shouting. There were lots of voices so I couldn't work out what was going on, but I heard someone shout ‘the army!’ Then out of the corner
of my eye I saw my friends arm pointing out and he shouted out ‘look!’ and his voice was high because he was afraid. Then I saw over the
playground in the field there was a line of men from my village and they were surrounded by soldiers. They were walking up and down
with their guns pointed at them. Suddenly I felt angry and very scared. The other boys were still pushing me about and there was
someone's head in the way so I couldn't see well and I felt agitated in my arms and legs as I tried to see. I pushed one boy's head out of the
way to see. One man suddenly stepped out of the line and I said ‘He has been identified’ and one of my classmates said ‘By who? No one is
there?’ and I felt sick with worry for the man because he was a nearby neighbour to me, and a friend of my father's. Then suddenly I
thought ‘What if my father is there in the line?’ I suddenly felt complete panic and my arms were frantic, pushing all the boys out of the
way so I could see who was in the line but I couldn't get close because everyone else was pushing too. Suddenly there was a loud bang and
I saw the man who had stepped forward fall to his knees and turn around a bit. Someone shouted out in the room and someone else
shouted ‘Quiet!’ because they were afraid. Everyone was looking at the man and he was convulsing on the floor. There was more and more
blood coming out of his mouth and chest. I felt sick and frightened and I thought ‘we are never safe’.

protocol was monitored. The psychoeducation session was then
followed by either four sessions of NET as outlined in the manual
(Schauer et al., 2005) or four sessions of SC with a focus on problem
solving and enhancing personal, social and cultural resources. None of
the 16 patients from the NET group dropped out of treatment (one
person declined treatment at the outset) whilst two of 14 patients in
the SC group dropped out. The authors report participant enthusiasm
for receiving the narrative account of their experiences. Pre- and post-
test data and follow-up data at four months and one year were
collected.
Results for treatment of PTSD showed that NET had a larger effect
size at post-test than SC, and, when compared with the psychoeduca-
tion-only group, there was a negative effect size indicating that
participants who had received no further intervention had deterio-
rated. Between post-test and four month follow-up there was an
increase in PTSD symptoms for all groups, possibly attributable to the
continued difficult conditions, including a reduction in food rations
and pressure to return to the places from which they had fled. At one
year follow-up, those subjects who had received NET showed
significantly lower scores for PTSD than those who received SC or
psychoeducation-only. Furthermore, despite the fact that 93% of
participants had experienced at least one additional traumatic event
since completing treatment, 71% of participants in the NET condition
no longer met diagnostic criteria for PTSD. This was a significantly
higher remission rate than in the other groups, where 21% of those
receiving SC and 20% in the psychoeducation-only group were in
remission of PTSD. In addition, there was some evidence that those
who had received NET had improved functioning and social skills, as
at one year follow up, they were significantly more likely to have
moved away from the refugee camp than those in the other two
treatment conditions (often moving because they had found
employment or to move to safer areas or closer to their original
homes).
Another study demonstrated how lay counsellors recruited from
the local area and trained to deliver NET had results equivalent in
efficacy to trials in which NET was delivered by mental health
professionals (Neuner, Onyut, et al., 2008). In this trial of 227 refugees
in a Ugandan refugee camp, 111 were treated with NET, 55 were
monitored but received no treatment, and 111 received six sessions of
trauma counselling (TC). TC was deliberately designed as a model of
therapy which may emerge if individuals who had been trained in
NET do not have to adhere to the standardised, manualised approach.
Therapists were trained in NET as well as other therapy skills and
these therapists were told to provide therapy following their intuition.
The main aim of TC was to relate current difficulties to previous
experiences of traumatic events. The lay counsellors who provided
both types of therapy were recruited from the local community and
were trained for six weeks. The counsellors were refugees themselves,
had been educated to varying levels and approximately half met
diagnostic criteria for PTSD and were treated with NET as part of their
training. NET was found to be effective in reducing severity of PTSD
symptoms from pre-test to post-test, however, no additional
reduction in symptom severity occurred between post-test and
follow-up (six months after treatment). TC was also effective in
reducing PTSD severity, and both treatments were significantly better
than the no treatment control group. At nine month follow-up, 37% of
participants in the no treatment control group no longer met
diagnostic criteria for PTSD. Rates of remission were significantly
higher in both of the treatment arms, and were reported at 65% in the
TC group and 70% in the NET group. At six month follow-up,
participants in both treatment groups reported fewer physical health
symptoms, whilst the no-treatment control group reported signifi-
cantly higher levels of physical symptoms at follow-up. Consistent
with other trials of NET, drop out rates were low, with only 4% of those
treated in the NET condition refusing or prematurely terminating
treatment compared with 21% in the TC condition.
Another study using NET to treat PTSD symptoms in former child
soldiers in Uganda also demonstrated how local counsellors can
effectively deliver NET (Ertl et al., 2008). In this trial, 86 former child
soldiers with PTSD, were randomly assigned either to a NET treatment
 K. Robjant, M. Fazel / Clinical Psychology Review 30 (2010) 1030–1039 1035

Table 1
Published studies of narrative exposure therapy.

Country Population Trial design Outcome Results Other Effect

of study measures information size for
NET

NET trials in low- and middle-income countries

Bichescu et Romania Romanian 5 sessions NET (n = 9) CIDI, BDI 6 month follow-up: significant NET group: Cohen's
al. (2007) older Control group: 1 session PED reduction in PTSD scores in NET significant d = 3.15 at
adults (n = 9) but not PED condition. Remission: reduction in 6 month
55.5% in NET and 11.1% in PED depression at follow-up
6 month follow-up
Neuner, Uganda Sudanese 4 sessions NET (n = 17) or CIDI, PDS, Significant NET group Cohen's
Schauer, Klaschik, refugees SC group: (n = 14) Control SRQ-20, SF- reduction significantly less d = 1.6 at
et al. (2004) group: 1 session PED (n = 12) 12 in PTSD symptoms on PDS likely to have 1 year
and CIDI in NET group remained in follow-up
compared to both SC and refugee camp,
PED group. Remission: 71.4% indicating better
in NET, 21.4% in SC, 20% in functioning
PED at 1 year follow-up
Neuner, Uganda Rwandan 6 sessions NET (n = 111) or TC PDS, CIDI, Significant reduction in PTSD Significant Cohen's
Onyut, et al. (2008) and Somali (n = 111) (both delivered by lay checklist of scores for both treatment reduction in d = 1.4 at
refugees counsellors) Control group: no physical groups. Remission: 69.8% in NET, physical health 9 month
treatment (n = 55) health 65.2% in TC and 36.8% in controls symptoms for NET follow-up
symptoms and TC groups
Schaal et al. (2009) Rwanda Rwandan 4 sessions NET (n = 12) or group CAPS, MINI, Significantly greater reduction in Significant η2 = 0.71
orphans IPT (n = 14) HRSD PTSD symptoms in NET group reduction in at 6 month
aged 14–28 compared to IPT group. Remission: depression scores follow-up
75% in NET, 29% in IPT for NET group at (Cohen’s
follow-up d = 1.29)

NET trials in high-income

countries
Neuner et al. (2010) Germany Asylum 9 sessions NET (n = 16), or PDS, CIDI, Significant reduction in PTSD at No significant Cohen's
seekers TAU (n = 16) HSCL-25 and follow-up in NET group but not in reduction in d = 1.6 at
sum of pain TAU group depression or pain 6 month
symptoms scores follow-up
Halvorsen & Stenmark Norway Refugee and 10 sessions NET (n = 16) CAPS, HRSD Significant reduction in PTSD scores Significant Cohen's
(2010) asylum at post-test, and further significant reduction in d = 1.16 at
seeker reduction at 6 month follow-up. depression scores 6 month
torture at follow-up. follow-up
survivors

KIDNET trials
Onyut et al. (2005) Uganda Somali 6 sessions KIDNET (n = 6) CIDI All adolescents
Significant reduction in PTSD symptoms Not
adolescents who had
between pre-test, and post-test as well reported
as at 9 month follow-up. Remission: presented with
66.6% of KIDNET group depression at pre-
test were no
longer depressed
at follow-up
Catani, Kohiladevy, Sri Lanka Sri Lankan 6 sessions KIDNET (n = 16), or UPID and 5 Significant reduction in PTSD symptoms Significant Cohen's
et al. (2009) children MED (n = 15) (both delivered by item at post-test and follow-up for both improvement in d = 1.96 at
aged 8–14 lay counsellors) questionnaire treatment groups. Remission: 81% in functioning at 6 month
on KIDNET, 71% in MED 1 month, follow-up
functioning maintained at
follow-up
Ruf, Schauer, Germany Refugee 7–10 sessions of KIDNET (n = 13) UCLA PTSD Significant reduction in PTSD symptoms Significant Hedge's
et al. (2010) children Waiting list control group Index for at post-test, maintained at follow-ups improvement in g = 1.8 at
from 6 (n = 13) DSM-IV, RPM, Remission at 6 months: 83%of KIDNET RPM between 6 12 month
countries MINI KID group. and 12 months in follow-up
aged 7–16 NET group (Cohens
d = 1.81)

BDI = Beck Depression Inventory; CAPS = Clinician-Administered PTSD Scale; CIDI = Composite International Diagnostic Interview; HRSD = Hamilton Rating Scale for Depression;
HSCL-25 = Hopkins Symptom Checklist-25; IPT = Interpersonal Therapy; MINI. = Mini-International Neuropsychiatric Interview; NET = Narrative Exposure Therapy; PDS = Post-
traumatic Stress Diagnostic Scale; PED = Psychoeducation; SC = Supportive Counselling; SF-12 = 12-Item Short Form Health Survey; SRQ-20 = Self-Reporting Questionnaire;
TC = Trauma counselling; TAU = Treatment As Usual; UPID = UCLA PTSD Index for DSM-IV.

condition or to an active, or waiting-list control group. A significant
decrease in symptoms was observed in both of the treatment groups,
and NET was found to be the superior treatment.
Two further trials have demonstrated the efficacy of NET with
Rwandan genocide orphans (Jacob et al., 2010; Schaal et al., 2009) and
with older adults in Romania (Bichescu et al., 2007). Schaal compared
Rwandan orphans (aged 14–28, mean 19.4 years) receiving either
individual NET or a group adaptation of Interpersonal Psychotherapy
(IPT). 12 participants were randomly allocated to NET and 14 to IPT
(Schaal et al., 2009). Both conditions were delivered weekly for four
1036 K. Robjant, M. Fazel / Clinical Psychology Review 30 (2010) 1030–1039
sessions and each session lasted 2 to 2.5 h. In the group IPT sessions,
participants were in small, single sex groups of 3–4 participants. All
participants were assessed twice prior to the commencement of
treatment: six months and immediately before treatment.
All subjects met diagnostic criteria for PTSD prior to the treatment
starting. There were no significant changes in the six month period
between baseline and pre-test assessments in the subjects for PTSD or
depression scores. Following treatment, of those who had received
NET, at three month follow-up only 58% met diagnostic criteria for
PTSD dropping to 25% at six month follow-up. This was significantly
less than the IPT group, where 71% continued to have PTSD at both the
three and six month follow-up assessments.
Further evidence for the efficacy of NET as provided by local
mental health practitioners has been demonstrated in a two part
dissemination trial for Rwandan widows and orphans (Jacob et al.,
2010). In this trial, Rwandan psychologists were first trained in NET
and IPT and treated 37 individuals using a combination of these
therapies. Then, the newly trained therapists trained another group of
therapists in the combined therapy who in turn treated 31 patients. In
this study, individuals treated by the first group showed a reduction in
PTSD symptoms at three months, and had further improved at
12 month follow-up. Of note, the second group of patients, those who
had been treated by the new therapists, also showed similar
improvements.
Bichescu compared NET with psychoeducation-only in 18 older
adults with PTSD in Romania who had experienced political
imprisonment and torture 40 years previously under the Communist
regime (Bichescu et al., 2007). Prior to treatment, PTSD and
depressive symptoms had remained stable for one year. In order to
assess the effectiveness of NET in treating symptoms with consider-
able chronicity, 18 patients were randomly allocated to either five
sessions of NET (9) or psychoeducation (9). Results showed NET to be
effective in treating PTSD, with four out of nine participants no longer
meeting diagnostic criteria at six month follow-up. Eight out of nine
participants who attended a single session of psychoeducation
continued to meet diagnostic criteria for PTSD. All participants
completed the treatment and those treated with NET were keen to
receive their written narratives. The authors suggest that the large
effect size observed for NET in this study may be because these
participants were living in stable conditions, unlike for those living in
refugee camps.
3.3. Evidence from high-income countries
Four studies have been conducted to date in high-income
countries, two are published (Halvorsen & Stenmark, 2010;
Neuner et al., 2010) and two are as yet unpublished (Adenauer
et al., in preparation; Hensel-Dittman et al., in preparation). The
Neuner 2009 study had a sub-sample published in an earlier paper
(Schauer, 2006) and the Halvorsen study is reporting results from
a sub-sample of a larger study (Stenmark, Catani, Elbert, &
Gotestam, 2008; Stenmark et al., in preparation). Asylum seekers
and refugees in high-income settings represent a different
population. Living in these host countries may be less immediately
life threatening, but there are additional stressors potentially
facing this group including uncertainty regarding asylum status,
the possibility of detention and forced removal, acculturation to
the host country and language barriers. Insecurity regarding
asylum status has been reported as distressing by participants in
a number of studies (Silove, Steel, McGorry, & Mohan, 1998;
Sinnerbrink, Silove, Field, Steel, & Manicavasagar, 1997; Steel et
al., 2004). In addition, fear of threat to safety has been shown to
be an important mediating factor in both depression and PTSD
(Basoglu et al., 2005). Comorbidity of psychiatric disorders is
commonplace (Porter & Haslam, 2005).
The first trial to investigate the use of NET for asylum seekers
and refugees in a German outpatient clinic demonstrated the
superiority of NET compared with treatment as usual (TAU)
(Neuner et al., 2010). Thirty-two asylum seekers with PTSD and a
history of exposure to organised violence participated in the trial.
Sixteen received NET, whilst 16 received TAU (which included
medication in 12 cases and psychotherapy in 6 cases). Dropout
rates were low with two patients leaving the NET condition and
all completing the TAU condition. Significant reductions in PTSD
symptoms were observed in those treated with NET but not in
those who had received TAU. 10 out of 16 (63%) NET patients
showed a significant reduction in PDS scores compared with only
three out of 16 (19%) TAU patients. By contrast, two NET patients
and eight TAU patients showed a worsening of symptoms. A
randomised controlled trial currently in progress in Norway has
investigated the efficacy of NET compared with TAU (Stenmark et
al., in preparation). In this study, 51 asylum seekers and refugees
received NET and 30 received TAU, both interventions were
delivered in an outpatient setting.
In the first study to compare NET with another trauma-
symptom focused therapy (but without an exposure component)
compared NET with Stress Inoculation Therapy (SIT) in Germany
(Hensel-Dittman et al., in preparation). The SIT conducted for the
study involved teaching techniques to reduce stress in daily life,
with no focus on the traumatic events themselves. All 28
participants had PTSD and had experienced organised violence,
most were asylum seekers and needed interpreters. Results
showed a significant reduction in PTSD symptom severity between
initial assessment and six month follow-up in the NET group, but
not in the SIT group.
A study investigating the effects of NET on refugees and asylum
seekers in Norway (Halvorsen & Stenmark, 2010), looked at a sub-
sample of participants who had been tortured, all of whom are
part of a larger unpublished trial (Stenmark et al., 2008, in
preparation). 16 torture survivors who were mainly from Iraq
were treated with 10 sessions of NET. PTSD symptoms were
significantly reduced at post-test compared with pre-test scores. A
further clinically significant reduction in symptoms occurred
between post-test and at 6 month follow-up. Overall, this means
that over 60% achieved a clinically significant reduction in PTSD
symptoms at follow-up compared with pre-treatment scores and
between 40 and 65% of participants no longer met diagnostic
criteria for PTSD at follow-up.
Finally, two studies have shown that benefits observed in
improved clinical symptoms were observable in changes in
neuromagnetic activity (Adenauer et al., in preparation; Schauer,
2006). In a preliminary study, Schauer showed that at six month
follow-up, reductions in measures of PTSD symptoms in 16
participants treated with NET were associated with changes in
neuromagnetic activity (Schauer, 2006). The brain activity in those
having completed NET was more similar to that of normal controls
than those who had received treatment as usual. A more recent
trial of 34 refugees treated with NET further investigated the
neurocognitive correlates of NET and has shown that individuals
treated with NET had differences in the processing of aversive
stimuli (Adenauer et al., in preparation).
3.4. Summary
NET has been shown to be effective amongst individuals who have
experienced multiple, repeated traumatic events. The studies of NET
in adults have consistently demonstrated its efficacy in treating
individuals with PTSD living in a variety of low- and middle-income
settings. Trials have demonstrated the effectiveness of NET in
reducing PTSD symptoms to the point of remission in a number of
cases, and have also demonstrated superiority over other therapeutic
 K. Robjant, M. Fazel / Clinical Psychology Review 30 (2010) 1030–1039
approaches. Most trials have demonstrated improvements at post-
test and further improvements at follow-up indicating sustained
change. In addition NET has also been found to be effective in the
treatment of asylum seekers and refugees in high-income settings.
Some NET trials in low- and middle-income countries have also
found improvement in comorbid conditions (Bichescu et al., 2007;
Schaal et al., 2009), in overall psychological well being (Neuner,
Schauer, Klaschik, et al., 2004) and in physical health symptoms
(Neuner, Onyut, et al., 2008). NET has also been shown to reduce the
rates and severity of PTSD in asylum seekers and refugees in high-
income countries (Halvorsen & Stenmark, 2010; Hensel-Dittman et
al., in preparation; Neuner et al., 2009).
3.5. Studies in children: the development of KIDNET and emerging
evidence for its efficacy
With promising findings from NET trials in adults, a version of this
therapy, KIDNET, has been developed for use with children and
adolescents. Research has shown that children living in conflict zones
are at risk of developing moderate to severe PTSD (Catani, Jacob, Schauer,
Kohila, & Neuner, 2008; Catani, Schauer, et al., 2009; Dyregrov, Gupta,
Gjestad, & Mukanoheli, 2000; Schaal et al., 2009; Yule, 2000). In addition
to the distressing and incapacitating effects of PTSD, symptoms may also
interfere with cognitive development and educational functioning
(Elbert et al., 2009). In KIDNET, construction of the lifeline takes greater
prominence and includes the creation of a permanent record, painted or
drawn by the child at the end of the first session, which is then referred to
in subsequent sessions as an aide memoire (Schauer et al., 2004). In
KIDNET, emphasis is placed on thinking about life ahead and aspirations
for the future and in the final session, the lifeline is extended to
incorporate this with flowers placed on the lifeline to represent these
hopes and wishes. Additional procedures adopted in KIDNET are the use
of small toys and role play to aid autobiographical memory.
To date there have been six studies investigating the use of
KIDNET, three have been published (Catani, Kohiladevy, et al., 2009;
Onyut et al., 2005; Ruf, Schauer, et al., 2010), three are as yet
unpublished (Ruf, Winkler, et al., in preparation; Schauer et al., in
preparation; Winkler et al., in preparation), all but one were
conducted in low- and middle-income settings. In a pilot study of
KIDNET, Onyut treated six Somali refugees aged 12–17 years living in
a Ugandan Refugee camp (Onyut et al., 2005). All children were
assessed for PTSD and depression and attended a psychoeducational
session before receiving four to six sessions of KIDNET, each lasting
60–90 min. All children accepted the offer of KIDNET and completed
the treatment. Pre- and post-tests were conducted measuring
depression and PTSD and all patients were followed up at nine
months. Prior to treatment all children had moderate to severe scores
for PTSD, and four children met diagnostic criteria for depression.
Overall, a reduction in PTSD scores was evident at post-test, and a
further reduction was observed at follow-up.
A Sri Lankan study of KIDNET, post-Tsunami and war, was
conducted and included six sessions of KIDNET compared with six
sessions of meditation and relaxation in 31 children (aged 8–14) with
PTSD (Catani, Kohiladevy, et al., 2009). The meditation protocol
involved breathing and meditation exercises, encouraging the child to
be mindful of their experiences with the aim of helping them control
their fear without re-exposure to the traumatic event. It was
developed by local counsellors and had high cultural validity. Both
treatments were provided by local counsellors and were found to be
effective in reducing PTSD symptoms at post-test with no significant
difference between treatments. Improvements were maintained at six
month follow-up where 71% of children treated with meditation no
longer met diagnostic criteria for PTSD, and 81% of those treated with
KIDNET were in remission. Improvements in daily functioning
(measured across different domains including within the family and
at school) were also observed at follow-up.
1037
In a similar school-based trial of 47 children, both NET and
meditation were effective interventions (Schauer et al., in prepara-
tion). 25 Sri Lankan children aged 8–15, living in an area of ongoing
conflict were treated for PTSD by local teacher counsellors using
KIDNET (six sessions) whilst 22 children were treated with an
equivalent number of meditation sessions. At five month follow-up,
both groups scored significantly lower for PTSD, although there was a
slightly larger effect size for KIDNET than for the meditation group. For
the KIDNET group, recovery was sustained or increased further during
the 14 month follow-up.
One trial of KIDNET has been carried out on asylum seekers living
in Germany (Ruf, Schauer, et al., 2010). In this trial, 13 children aged
between 7–16 years with PTSD were treated with KIDNET for 7 to 10
sessions. Comorbid psychiatric disorders including depression and
separation anxiety were common. Only one child dropped out of
treatment, and this child was re-referred two years later requesting to
continue the therapy. Results from this trial showed that KIDNET
effectively reduced PTSD across all three symptom clusters between
pre- and post-test. These results were maintained at both 6 month
and 1 year follow-up.
In addition to treating PTSD, KIDNET may also be useful in reducing
symptoms of Childhood Traumatic Grief as demonstrated in a study of
HIV/AIDS orphans in Ethiopia (Ruf, Winkler, et al., in preparation)
where KIDNET was combined with four group sessions of adapted
grief counselling (Cohen, Mannarino, & Deblinger, 2006).
A trial of 402 war-affected young people currently underway in
Uganda aims to compare the efficacy of three different interventions
on mental health outcomes, as well as on variables thought to
influence reconciliation (Winkler et al., in preparation). In this trial,
the KIDNET treatment was compared with ‘conflict resolution and
social competence training’; a 10 session group intervention aimed at
teaching and practising anger management, social skills and conflict
resolution skills. A control intervention based on ‘teacher counselling’
was included, in which individuals were given psycho-social support.
All interventions were carried out by local counsellors.
3.5.1. Summary
Although fewer studies exist, results for KIDNET are encouraging,
demonstrating the feasibility of providing effective short-term
psychological treatments to children and adolescents suffering from
PTSD in insecure and unsafe environments. Results indicate that
KIDNET can reduce PTSD symptom severity at post-test and follow-
up. Results for KIDNET also suggest that comorbid disorders and
functional problems may improve with this therapy.
4. Discussion
This review summarises the evidence currently available on NET,
an important new treatment for those with PTSD following multiple
traumatic events such as those occurring in war or as a result of
organised violence. It summarises data from 16 trials, six of which are
on children and adolescents and eleven are conducted in low- and
middle-income settings. Approximately 176 adults and 40 children
and adolescents were treated with NET in the published studies. There
are a number of interesting findings from these trials. All show a
significant reduction in the severity of PTSD in those treated with NET
and most of these findings are sustained or further improved at
follow-up. The dropout rates of treatment are consistently low and lay
counsellors have been trained to effectively administer the sessions. It
has been shown to have an effect in a number of different settings,
both high and lower-income countries and with chronic PTSD as well
as that of more recent onset. The efficacy of NET in reducing PTSD
symptoms in heterogeneous populations attests to the transferability
of the intervention across cultures and adds further evidence to
suggest the therapeutic importance of exposure to traumatic
memories in reducing PTSD symptoms.
1038 K. Robjant, M. Fazel / Clinical Psychology Review 30 (2010) 1030–1039
There are a number of limitations of note to the evidence so far
available on NET. The numbers treated remain small and there is a lack
of comparative data with other recommended, evidence based
treatments such as TFCBT or EMDR. Such data, when available will
provide an important addition to the emerging evidence regarding
NET. All but one of the published trials so far have been conducted by
the research team who developed the therapeutic approach, but
further trials are currently underway in Norway by independent
research teams (for asylum seekers/refugees as well as civil trauma
survivors). In addition, research is required to investigate the effect of
NET on comorbid disorders as there have been some early reports of
positive changes in depressive symptomatology.
Poor mental health, and particularly PTSD associated with war
and political violence is an extensive world public health problem,
affecting individuals in low and middle-income countries as well
as those who seek asylum in high-income countries. NET and
KIDNET are promising treatments for adult and child survivors of
war and organised violence including torture. The therapy is
effective in reducing PTSD symptoms in those who are severely
traumatised and somewhat unique to this therapy, the majority of
trials have been conducted in low and middle-income settings —
places where the majority of refugees and victims of war-related
trauma reside and places where research can often be difficult to
conduct (Sharan, Levav, Olifson, de Francisco, & Saxena, 2007).
Although the treatment involves exposure to previously avoided
traumatic memories, low dropout rates suggest that NET has high
tolerability and is culturally acceptable for those treated. This may
be because oral story telling is common to many cultures (Schauer
et al., 2005). The anticipation of receiving the written narrative,
which can be used to attest to the human rights abuses suffered, is
thought to also contribute to low dropout rates for NET. The
narrative accounts produced during the therapy have been passed
on by patients to human rights organisations and immigration
lawyers and this secondary benefit is unique to NET. The therapy
can also effectively be delivered by lay counsellors recruited from
the local area after just six weeks of training (Neuner, Onyut, et
al., 2008), demonstrating the usefulness of this approach in
delivering pragmatic and sustainable psychotherapeutic solutions
in conflict areas.
Children constitute approximately half of the world's refugees
living in low- and middle-income countries. Levels of PTSD in
refugee children living in high-income countries have been found,
in a systematic review of serious mental illness, to be between 11–
17% (Fazel, Wheeler, & Danesh, 2005). The KIDNET studies to date
demonstrate that it is possible to treat traumatised children
effectively in emergency and non-clinical settings. These studies
have involved children as young as 8 and further research is
required to see whether KIDNET (or adaptations to this protocol)
may be useful in even younger children.
NET and KIDNET have been shown to be effective as a sole
intervention, but they can also be used as part of a psychological
treatment package in which other approaches can be incorporated.
This has been demonstrated with IPT (Jacob et al., 2010) and in a case
study where Mueller describes how NET was used in the treatment of
a refugee with PTSD within the wider context of a cognitive therapy
treatment plan (Mueller, 2009). This case study is useful in
demonstrating how the narrative account produced during NET can
be used to guide further therapeutic work. One study has been
conducted treating non-refugee patients with NET: those with
borderline personality disorder with and without PTSD (Pabst et al.,
2010). Preliminary results on 10 patients suggest that PTSD symptoms
are reduced. Of note, Elwood et al., have suggested certain cognitive
and attributional styles associated with anxiety and depression may
also be linked to PTSD (Elwood, Hahn, Olatunji, & Williams, 2009). A
combined therapeutic approach may therefore be useful for indivi-
duals where there are underlying interpersonal difficulties or
problematic cognitive styles or behaviours that are maintaining the
symptoms.
NET operates on a number of different levels, individual, micro- and
macro-cultural. At an individual level it reduces distressing PTSD
symptoms underpinned by cognitive and neurobiological processes,
through the process of narrating and documenting the trauma endured
which are contextualised within the socio-political context. In addition,
it operates at a micro-cultural level by involving lay counsellors in the
provision of therapy, and at a macro-cultural level by documenting
human rights abuses and reducing the silence which often surrounds
such painful violent events and providing a voice for the victims.
Disclosure statement
MF was a co-applicant and KR was funded by a European Union
Refugee Fund (ERF) – Community Actions Project 2007: Multi-Centre
NETwork Strengthening Grant.
Acknowledgements
We are grateful to the study authors who provided invaluable
further information.
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