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 C H A P T E R 14

Narrative Exposure Therapy

MAGGIE SCHAUER
KATY ROBJANT
THOMAS ELBERT
FRANK NEUNER

Narrative exposure therapy (NET) is a treatment for adult and child survivors
who continue to suffer from past experiences of traumatic stressors. It is spe-
cifically designed for individuals who have been exposed to complex and mul-
tiple traumata, after having survived severe and repeated physical and social
threats to life and integrity. NET enables individuals to establish a coherent
autobiographical narrative of their most significant experiences. The narration
contextualizes life events that were highly arousing, so that internal remind-
ers, threat-related cues, lose their dominance over the person’s experience of
emotions, physiological responses, cognitive patterns, and relationships to self
and others in the present. Consequently, NET has been frequently used to treat
individuals who suffer from deliberate, repeated, and prolonged interpersonal
trauma (Schauer, Neuner, & Elbert, 2011).
In order to be universally applicable for the treatment of traumatic stress
disorders in diverse populations affected by continuous domestic, community,
or organized violence, NET was designed to meet the following requirements
(Schauer, Neuner, & Elbert, 2005; Elbert, Schauer, & Neuner, 2015):

1. The therapy is applicable to various traumatized groups. Exclusions

are not made on the basis of demographics such as age (when capable of epi-
sodic memory), gender, or education. Traumatized people are not excluded due
to ethnicity or social group. It is possible to sensitively adapt the procedure to
different environments and cultural settings.

309
310 INDIVIDUAL TREATMENT MODALITIES AND MODELS

2.  NET has been evaluated in ecologically valid, real-world settings. The
intervention shows cumulative beneficial effects, evident after only a few ses-
sions. This is especially important in attending to resource-poor communities
in low-income countries or crisis regions, and relevant in providing trauma
treatment for children and adults living in informal urban poverty areas, asy-
lum centers, refugee settlements, or difficult-to-access areas around the globe.

3.  The simplicity and robustness of NET and its potential for dissemina-
tion is such that integration into large-scale service provision within a cascade
model of public mental health care is possible (Schauer & Schauer, 2010).

4.  Complex trauma inevitably involves the abuse of human rights. In

NET, acknowledgment of this fact is fundamental, since it allows both survi-
vor and therapist to compare the atrocities that have occurred against objec-
tive, agreed-upon principles of how human beings should behave toward each
other. Sharing information about the cruelties of war, torture, and abuse may
be used to counter stigma associated with survivors (Schneider et al., 2018) and
raise awareness of human rights violations in the younger generation (Winkler,
2017). For victims, regaining access to their biographies and communicating
their history to others can empower them to stand up for their rights as victims
of violence and overcome feelings of anger, hopelessness, and powerlessness.

Rationale for NET

Individuals with complex trauma histories typically had to cope with several
forms of interpersonal traumatic stressors—stones, as we refer to them—
including sexual abuse, neglect, exploitation, relational betrayal, rejection,
physical violence, and so forth, often from the earliest days of childhood onward,
but sometimes under adult conditions of detention and torture. The expecta-
tion that other humans (especially caregivers) are trustworthy, nurturing, and
protective may have been severely violated. Such environments often frustrate
basic needs for human belonging, control and autonomy, personal appreciation,
and physical care. This leads to negative beliefs about the self and others, and
to corresponding behavioral patterns and survival-based schemas of “struggle
without protection,” as well as unhealthy coping strategies, such as addictions
and self-injurious or suicidal behavior. “Many survivors of relational and other
forms of early life trauma are deeply troubled, and often struggle with feelings
of anger, grief, alienation, distrust, confusion, low self-esteem, loneliness, shame
and self-loathing. . . . They often have diffuse identity issues and feel like out-
siders, different from other people . . . They often feel a sense of personal con-
tamination and that no one understands or can help them” (Courtois & Ford,
2009, p. 4). As a result of this distress and acquired survival-oriented patterns
of interacting with others, professionals may feel challenged by complex trauma
survivors’ dependence, aggression, self-destructiveness, and distrust. Therapists
 Narrative Exposure Therapy 311

may feel frustrated, confused, angry, and exhausted by patterns of behaviors and
relations that are perceived to be akin to personality disorders. However, the
corollary of having developed strategies for survival is that complex trauma sur-
vivors often also show a remarkable capacity for resilience and empathy toward
others. These individuals’ sensitivity and compassionate advocacy for weaker,
less powerful individuals and animals often go unacknowledged as achieve-
ments—flowers, so to speak, in their autobiographies. Prior to, during, or after
times of trauma, each life story contains sources of strength, joy, mastery, hap-
piness, and love. Consequences of the negative, stressful and traumatic times are
buffered by individual resilience factors and beneficial experiences such as cor-
rective relationships, events with positive valence, achievements, experiences of
social recognition and pride, and so forth, that form resources (Schauer, Neuner,
& Elbert, 2005, 2011).
The rationale for NET begins with this fundamental understanding of
harm due to cumulative “building blocks” (Schauer & Robjant, 2018) caused
by increasing experiences of “threats to human life.” These include events and
adverse experiences that risk physical health, survival of self and kin, and social
status. Events that damage each of these domains have predictable impacts on
regulatory systems (neural, immune, epigenetic) and in turn on mental health
(see, e.g., Elbert & Schauer, 2014). Memories of trauma share common emo-
tions and cognitions such as fear, horror, or helplessness and thoughts about
the imminence of death, powerlessness, and extreme loneliness. Therefore, an
associative network of these “hot” memories with mutually excitatory connec-
tions is formed (i.e., memories of the fear experienced during one event may
also call into play memories of other arousing events). Connections become
particularly strong the higher the arousal, and with it, the autonomic respond-
ing (e.g., Schauer et al., 2011, Elbert & Schauer, 2014). Remembering threats
can activate this memory network and may trigger a flight–fight response,
with its high sympathetic arousal, a fright response with tonic immobility, and
excessive dual autonomic tone, and a flag–faint dissociative shutdown with
parasympathetic dominance (Schauer & Elbert, 2010).
The representation of the first single event of its type is stored in con-
nection to the particular context, the when and where it happened (“cold”
memory). If the event is recalled, place and time are also remembered well.
Additional stressful experiences then interconnect with the existing memory
of previous traumatic experiences inasmuch as they share a similar context—
sometimes to the degree that they share the emotions (fear, shame, etc.) and
cognitions (“I will die, I cannot do anything . . . ”). At the same time, the
connection to the context, to the “cold” memory is lost, as it is not possible
to relate the rising fear to different times and places. In contrast, the sensory,
cognitive, emotional, and physiological representations (“hot” memory) con-
nect with increasingly mutual excitatory power. With more experiences, more
and more hot elements become associated with each other. The fear/trauma
network loses its connections to time and place. Therefore, fear, horror, and
helplessness generalize, giving rise to feelings of impending threat even months
312 INDIVIDUAL TREATMENT MODALITIES AND MODELS

and years after the events. NET is thought to reverse this process by recon-
necting hot and cold memories, while segregating the memory traces of the
different events. Since trauma memory is decontextualized, there is need for
a biographical timeline approach that focuses on the arousing and important
situations and their evolving schemas within life periods during development:
the lifeline (Schauer et al., 2011).
Trauma survivors experience both threats and strengthening and soothing
human (and animal) contacts in a uniquely personal sequence of specific events
at different stages of their development. Trauma-focused therapies often try
to identify an “index trauma” to target with exposure techniques (Schnyder
et al., 2015), together with the instruction to hide or dissociate other trauma
material. However, after multiple severe trauma experiences, it is not advisable
to aim to identify or single out a worst event to be reprocessed (Priebe et al.,
2018). Earlier experiences determine the perception, response to, and process-
ing of the subsequent events. Consequently, NET suggests going through all
of the significant life events in chronological order: Long-term healing in psy-
chotherapy is achieved through attention to the entire life biography. Working
through the life history with empathic therapeutic support is a robust variant
of effective trauma therapy and allows the emergence of personal identity. Spe-
cific, highly arousing events are uncovered within the lifetime periods and are
revisited, recounted, processed, and contextualized.

Evidence for NET

It has been demonstrated that adult and child survivors with multiple trau-
matizing life events benefit from NET (Schauer et al., 2011; Jacob, Wilker,
& Isele, 2017, Nosè et al., 2017). Individuals from diverse backgrounds,
with lives torn apart by stressful events such as childhood abuse and neglect,
loss of caregivers, adoption, forced recruitment into armed groups or gangs,
migration, political violence and torture, life-threatening illnesses, severe disas-
ters, and so forth, show significantly reduced clinical symptomatology, and
enhanced quality of life and level of occupational and social functioning. NET
has been used to successfully treat survivors of organized violence and severe
torture experiences, producing large effect sizes (Hensel-Dittmann et al., 2011;
Neuner et al., 2010) as well as other complex trauma survivors (e.g., Pabst
et al., 2014; Domen, Ejiri, & Mori, 2012; Mauritz et al., 2016; Steuwe et
al., 2016). Stenmark, Catani, Neuner, Elbert, and Holen (2013) demonstrated
that with NET, asylum seekers can be successfully treated for posttraumatic
stress disorder (PTSD) and depression in a general psychiatric health care sys-
tem. The most pronounced improvements are observed at (long-term) follow-
up. This suggests that NET delivered in a relatively short time period elicits
a significant enough change in self-perception and self-regulation to trigger
a longer term healing process that leads to a sustained improvement in psy-
chopathological symptoms, physical health, functioning, and quality of life.
NET has been effectively and safely applied in situations that remain volatile
 Narrative Exposure Therapy 313

and insecure, such as conditions of continuous trauma (i.e., ongoing domestic

violence; Orang et al., 2018) or objective life threat in war and conflict, reduc-
ing symptoms while enabling the individual to bear witness to the atrocities
endured. Reviews identified NET as an evidence-based treatment for different
groups of survivors of violence (e.g., Nosè et al., 2017; Thompson, Vidgen, &
Roberts, 2018).
Manuals have appeared in print in Dutch, English, Farsi, French, Ital-
ian, Japanese, Korean, and Slovakian; Arab, Spanish, and German translations
are in preparation. NET is available in special adaptations for child soldiers
and ex-combatants (forensic offender rehabilitation [FORNET]; Elbert, Her-
menau, Hecker, Weierstall, & Schauer, 2012; Robjant et al., 2019) or street
children (Crombach & Elbert, 2015) with previous family violence, and a
child-friendly version for other children and adolescents (KIDNET; Schauer
et al., 2011; Schauer, Neuner, & Elbert, 2017). NET also has been suggested
as a promising approach in inhibiting the transgenerational transmission of
trauma (Ullmann et a., 2017). The effect of NET has been demonstrated in
improvements in clinical and social symptoms and in validating these results
in neurophysiological and molecular biomarkers. Using neuroimaging, Ade-
nauer et al. (2011) observed that NET enhances cortical top-down regulation,
which is associated with the ability to inhibit the fear response. NET also was
shown to improve health parameters (e.g., frequencies of cough, diarrhea, and
fever), even under harsh living conditions (Neuner et al., 2008). In the immune
system, T cells are critical for maintaining balance, regulating the immune
response, and preventing autoimmune diseases. Morath et al. (2014a) dem-
onstrated a treatment-related increase in the previously reduced proportion of
regulatory T cells in the NET group at 1-year follow-up. NET is able to reverse
the pathological levels of damaged DNA in individuals with PTSD back to a
normal level (Morath et al., 2014b). These findings have obvious implications
for physical health, including autoimmune diseases. Key strengths of NET are
its low dropout rate, even for complex cases (e.g., 91% individuals suffer-
ing from borderline personality disorder completed NET in a German study;
Steuwe et al., 2016) and due to its robust nature, the potential for dissemina-
tion, including to counselors in low-income countries, war zones, and crisis
regions (Schauer & Schauer, 2010; Neuner et al., 2008, Jacob, Neuner, Mädl,
Schaal, & Elbert, 2014; Koebach, Schaal, Hecker, & Elbert, 2017).

The Sequence of the

Therapeutic Intervention in NET
NET proceeds in three essential steps (see Figure 14.1). Since survivors of com-
plex trauma fear a loss of control or abandonment, and expect an unpredict-
able response, the therapeutic alliance in NET commences at the diagnostic
interview with the therapist who will conduct the treatment. To allow a sense
of mastery, the initial interview (Step 1) is highly structured and predictable,
including event checklists matching the experiences of the client (e.g., torture
314 INDIVIDUAL TREATMENT MODALITIES AND MODELS

or sexual abuse events). Childhood experiences are specifically targeted (e.g.,

the Maltreatment and Abuse Chronology of Exposure [MACE]), as well as
dissociative phenomena following traumatic stress (using the Shutdown Dis-
sociation Scale [Shut-D], which is able to discriminate the dissociative subtype;
Schalinski, Schauer, & Elbert, 2015). A brief psychoeducation and a step-by-
step explanation of the therapeutic procedure is then used to normalize, legiti-
mize, and explain complex trauma reactions, as well as fears, resistances, and
worries about the treatment protocol and exposure work ahead.
In the following 90-minute session, a lifeline is laid out (Step 2), symbol-
izing the person’s life from birth to the present. The therapist helps classify
specific life events within lifetime periods along this time axis (spatiotemporal
integration into the individual development context). The creation of a bio-
graphical overview of highly arousing and significant moments (Schauer et al.,
2011; Schauer & Ruf-Leuschner, 2014) is a reparative experience for trauma-
tized children and adults with fragmented episodic memory. This spatiotem-
poral allocation and header-like naming of the most important personal events
(general and specific events) in the successive lifetime periods is a meaningful
component of NET, carried out from an allocentric (an observer’s) position
(Schauer et al., 2011).
In step 3 of NET, the autobiographically explicit, episodic memory is
formed and completed by narration. The therapist invites the survivor to tell
his or her life story now from an egocentric position within several double ses-
sions, from the time of birth and early childhood until the present (see Schauer
et al., 2011). Where there are long periods that do not contain highly arousing
events, the narration is summarized, providing an overview of situations that
the person has experienced, so that the course of life becomes evident. The
therapist takes the role of a witness to the testimony of the narrator. This genu-
ine interest and active listening promotes and encourages narration.
The therapist has an empathic and accepting attitude, while also clearly
condemning violations of the client’s human rights (cf. Neuner, Elbert, &
Schauer, 2018). The life narrative contextualizes the network of cognitive,
affective, and sensory memories of a person’s traumatic and other highly arous-
ing memories by filling in the details of fragmentary memories and developing
a coherent autobiographical story. Each slowed-down narrative, with a focus
on specific life events from the biography, attentive to all levels of experienc-
ing and remembering, makes it possible to connect essential elements of the
trauma and the meaning of this for the person’s whole life. At subsequent ses-
sions, the narration is read back to the client, who completes missing details or
makes corrections, demonstrating to the narrator that the therapist has truly
heard every detail and recorded it, and emphasizing the collaborative nature
of the approach.
Key elements of the therapist’s behavior include compassionate under-
standing, active listening, therapeutic alliance, and unequivocal positive regard
and encouragement. The therapist asks the survivor to describe emotions,
thoughts, sensory information, and physiological and bodily responses in detail
 Narrative Exposure Therapy 315

Face-to-face diagnostic interview

1 1-2 sessions (each 90-120 min)
allocentric position

Building the lifeline as an autobiographical review

2
1 session (90-120 min)
allocentric position

1st traumatic event 2nd traumatic event 3rd traumatic event

birth present

session 3 session 4 session 5 session 6 session 7...

3 Narrative Exposure
6-14 sessions (90-120 min)
Sw i tch be tw e e n e goce ntri c a nd a l l oce ntri c
position in a pendulum motion and
contrast ”then“ and ”now“

” What did you

experience then?“
Narration
Trauma
”her e and now“ ”back then“

cognition
cognition
CONTRAST

sensation
emotion
sensation
emotion
meaning physiology

meaning physiology
”What do you experience
while narrating now?“

FIGURE 14.1. NET step by step: Structured, gradual approach to the trauma material.
316 INDIVIDUAL TREATMENT MODALITIES AND MODELS

(see Figure 14.1) and invites a “slow-motion” reliving without losing connec-
tion to the present. Staying present is achieved by utilizing permanent reminders
that the emotions and physical responses sparked by memories are linked to
episodic facts (e.g., time and place) and filled with meaning. When treatment
ends, a documented autobiography created by the therapist (or in well-educated
clients, with the help of the therapist) is presented to the survivor.

How Does NET Facilitate and Sustain

Client Engagement in Treatment?
Engagement of complex traumatized individuals in NET requires recognition
and comprehensive acknowledgment of key barriers inherent in trauma-related
disorders.

Autobiographical Memory Disturbance

NET enables the client to approach and recover memories of the past in a struc-
tured, stepwise manner following this sequence: First, the individual’s experi-
ences of life events are explored (a simple acknowledgment of these events on a
checklist that does not require details: yes/no it did/did not (“What?”) happen
to me, date (“When?”), place (“Where?”). Afterward, symptoms of suffer-
ing are identified using a structured interview, followed by an informed con-
sent (according the cognitive development, age, and education of the client),
a brief psychoeducation, and an explanation about the therapeutic procedure
(90–120 minutes).
Second, in the next session, a biographic overview along a timeline is
constructed with the lifeline exercise (90 minutes). At this stage, the specific
(highly arousing) events are differentiated from general events and contextu-
alized within a lifetime period. This helps the client identify which specific
events are most distressing. Marking the lifetime period enables the client to
order events more easily. During the lifeline stage, the therapist guides the cli-
ent away from submerging into “hot” memory material and helps him or her
stay on the “cold” memory side. The final (longest) part is narrative expo-
sure, which is the narration of the whole life in chronological order, from
birth to the present, highlighting with imaginal exposure the “hot” memory
content. Important and arousing moments of positive and negative valence
(e.g., traumata, loss/grief, meaningful moments, specific events with important
attachment figures, personal achievements, and one’s own aggressive acts) are
now processed fully and in depth. Chronological processing of each event in
context and within life periods enables further memory recall and “lightbulb
moments” of linkage: Emotional episodes are coded in memory as networks of
mutually activating information units. When processing the network, activity
in one unit is transmitted to adjacent units, and depending on the strength of
activation, the entire structure may be engaged. An extremely decelerated and
 Narrative Exposure Therapy 317

emotion- and body-focused narration of a remembered biographical scene (the

hot spot of a specific event) leads to priming and finally the appearance of the
older, underlying trauma material.

Belief That the Trauma Is the Actual Reality in the Present

This belief is a result of the distorted memory representations (threat struc-
ture without context memory) that are being repaired through NET, so that a
memory feels like a memory, as a past event in the context of life. The thera-
pist enables the client to establish a sense of “past” by working through the
lifeline in which a “bird’s-eye view” of the client’s life is obtained, and frag-
mented and chaotic memories are organized and situated in context. While
processing in the narrative exposure stage, the therapist regularly invites the
narrator to change focus between the past time and the here and now, as well
as facilitating a pendulum motion between the egocentric and the allocentric
view (see Figure 14.1). The narrator is constantly helped and grounded, and
safety is reinforced. The therapist is asking primarily closed questions, while
being clearly directive, making suggestions about emotions, cognitions, physi-
cal experiences, and meaning content that the client may have experienced at
the time, so that the “stones” are relived in the present, as differentiated from
the client’s experience of them in the past.

Fear of Being Reminded of and Reliving Painful States,

and Fear of Loss of Control over One’s Mental State
Initially, the therapist assists the client in reducing this fear through psychoedu-
cation about the rationale for therapy and reinforcement of the therapist’s con-
fidence in the ability of the client to complete the therapy and to withstand the
emotions. During exposure to the “stones,” active involvement of the therapist
in an “exposure conversation” style (Robjant, Roberts, & Katona, 2017)—
unique among trauma exposure therapies—allows the client to experience the
therapist as constantly present in the narration. Listening to the life account
and understanding its meaning reaches far beyond mere confrontation of worst
events and instead honors the individual’s way of living, surviving, and react-
ing. With the help of a supportive, nonjudgmental, accepting, and empathic
therapist, the trauma material is approached step by step and in a foreseeable,
directive, and structured manner. At each stage of the process, the client is
aware of how far they have come, and what must still be done before reaching
the present day on the lifeline.

The Inner Conflict between the desire to Communicate

and the Perceived Incommunicability of Trauma
Responding to the strong, innate human motivation to communicate and to
feel, the therapist understands the inability to voluntarily access trauma mate-
318 INDIVIDUAL TREATMENT MODALITIES AND MODELS

rial and takes care of this by offering explanation for the suffering and inviting
the client to listen to an empathic version of his or her life story. Overcoming
gaps in cold memory is supported by working through the biographic con-
texts, exploring carefully the perceptions/sensations, cognitions, emotions,
bodily reactions, and meaning contents (see Figure 14.1). The therapist sig-
nals patience in supporting efforts of the survivor to talk about what has hap-
pened. A firm belief in the survivor’s ability to remember his or her own bio-
graphic events, and a persistent willingness to listen and stay in close contact
throughout the process is vital. Where clients become “stuck” for words, the
therapist redirects the survivor’s attention to the here and now, and gently
helps him or her focus on sources for cues: bodily reactions, emotions, and so
forth. The therapist can help the narration by asking questions or suggesting
a word or a description for the client’s experience at that time (past) or in the
moment (present), for the narrator to acknowledge or refute. The pendulum
motion inherent in NET of exploring the highly arousing past moments and
contrasting them in the same moment in time with the current experience in
the present, thereby constructing an allocentric perspective, helps the client to
restructure and understand the traumatic memory and its sequelae. The testi-
mony focus in NET recognizes suffering not only as a medical/psychological
condition and the consequence of abuse but also as a human rights violation
and injustice. Traumas are occurring within a specific context of meaning, and
this is specifically recognized and acknowledged.

Unsettled Identity: “Who Am I?”

People with broken lifelines need a comprehensive approach of narrative
restructuring of not only their trauma memories but also their entire biogra-
phy, especially their highly arousing negative and positive events: “I am what
I remember about myself, my life and the meaning of it.” A stable sense of
identity requires an autobiography, sometimes including even the history of the
family or tribe. NET offers corrective relationship experiences while reliving
and linking past interpersonal situations and their ensuing schemas. From the
lifeline onward, the client is aware that the therapist is interested in the whole
life, and understands the context of traumas. Offering therapeutic suggestions
when survivors cannot find words helps the client to feel connected to the
therapist and to understand that the therapist is willing and able to understand
the whole story. The testimony focus acknowledges that trauma has involved
human rights abuse and injustice.

Self-Injurious/Deliberate Self-Harm and Dissociation

Implicit reliving of trauma cues causes anxiety and inner tension. In contrast,
self-harm (especially pain caused by tissue damage) initiates a parasympa-
thetic relief response with dissociation. In NET, imaginal exposure is com-
bined with active anti-dissociative maneuvers. This is why the therapist must
be active while the survivor recounts the trauma story, stimulating sensory
 Narrative Exposure Therapy 319

perception and applied muscle tensing in the here and now to prevent dis-
sociative shutdown. Active management of dissociative states is achieved by
continuously contrasting the past trauma and the current reality and coun-
teracting shutdown dissociation (Schauer & Elbert, 2010) during NET expo-
sure sessions. When there is a risk of an intrusion (top-down processing only)
and fusion of the trauma with the present reality or of dissociation (Schal-
inski et al., 2015; Schauer et al., 2011), the therapist increases the contrast
between the here and now and the past. Sensory contrasting the past event
to the present is crucial for overcoming dissociation (e.g., context: war scene
vs. treatment room). They direct the attention of the survivor into the pres-
ent (orienting/grounding) and afterward return to the trauma scene, with
the help of spatiotemporal differentiation, sensory distinctions, and active
motoric countermaneuvers as antidissociative strategies (Schauer & Elbert,
2010). In this way, the narrator is continually reoriented in the present when
reliving the past: In NET attention should oscillate like a pendulum between
then and now. This allows ex-posure (Latin for “exit a position”) in a dual
awareness.
Other measures are used during narrative exposure to counteract fainting,
loss of muscle tension, and bodily weakness. The survivor is engaged in active
body movement, managing vasovagal (pre-)syncope by leg crossing, muscle
arm tensing, physical counterpressure maneuvers (e.g., squeezing a ball) and
stabilizing blood pressure (e.g., cycling, staircase or a lying position). These
techniques must be used during the imaginal exposure sessions, while the sur-
vivor is narrating the hot memory traumatic events, together with the help of
the therapist (not as a homework exercise between sessions).

Comorbid Feelings of Shame and Guilt

Guilt-prone individuals, with their strong desire to understand what has hap-
pened in order to control the future, try to prepare for upcoming (social)
threats and make sure of group inclusion by showing remorse and the will
to take reparative action. A coherent and detailed narrative can significantly
help to reduce cognitive distortions that lead to guilt. A complementary exer-
cise often performed in trauma therapies is the allocation of a more objective
percentage of one’s own wrongdoing or failure set against the proportion of
that of others and the circumstances involved in the incident. Reasons for one’s
own behavior at the time become apparent when experiences are thoroughly
worked through in slow motion, by sorting out the sequence of events, knowl-
edge, and decisions, and by fostering self-acceptance and enabling understand-
ing of one’s own decisions and actions in the context, including the emotional
and physiological states. For example, one can understand that decisions that
turned out to be wrong were made in exceptional moments under the highest
stress, with no time and limited knowledge. Survivor guilt can be understood
as a fear of being rejected by the social group when having survived while oth-
ers have not. The therapist’s welcoming reception is therefore key, and sharing
the narrative can help.
320 INDIVIDUAL TREATMENT MODALITIES AND MODELS

Shame is a painful emotional reaction signaling social devaluation, status

loss, and degradation. The validating eye of the other is needed to balance the
humiliation caused by complex trauma experiences. The close “exposure con-
versation” style of the NET therapist is supportive, empathic, and involved,
and therefore the client feels accepted. Social appreciation in therapeutic con-
tact, as well as narration and sensitive processing of hurtful moments of rejec-
tion, also are key. Redirecting shame to the perpetrator to balance the social
dominance situation and learning to publicly show self-confidence alongside
social support can counter the suffering of social pain and allow the individual
to regain dignity. The survivor is likely to be discussing the most shameful
moments for the first time, and to be met with empathy and care rather than
rejection is a hugely reparative experience that can also inspire confidence in
engaging in social relationships again.

Difficulties with Relationships

When a client has been in abusive relationships, attention is paid to the posi-
tive and negative feelings associated with relationships, as well as moments
of disappointment, when the client failed to get the much longed for love and
care for which he or she hoped. When clients have been multiply exploited but
do not recognize this (e.g., when the trauma occurred at a very young age),
gradual narration through the “stones” can lead to realizing for the first time
that the relationship was abusive. Great care is then needed in responding to
the loss and grief of this idealized relationship if the client comes to a more
realistic understanding. The process of NET can produce meaningful attach-
ment repair, as the client can experience true empathy, compassion, and care
from a person who listens and responds with emotion. This may lead the client
subsequently to seek more healthy relationships in the future.

Fear of Overwhelming the Therapist

with Dissociation/Flashbacks
During recall of past trauma, the therapist is reliably there (“shoulder to shoul-
der”) every second with the client, an empathic monitor of the experience, who
contrasts past and present feelings and thoughts and slows down the reexperi-
encing to ensure mastery. There is never a moment when the client is left alone.
The therapist assists the client in achieving a sense of control, supports stay-
ing in a window of emotional tolerance throughout the work (no overengage-
ment or underengagement). NET prepares therapists to handle freeze, flight,
and fight stages, as well as to countermaneuver fright, flag, or faint stages
(Schauer & Elbert, 2010). This creates predictability and gives the client a
feeling of strength, calmness and competence in dealing with the various previ-
ously uncontrollable stages of the defense cascade. By referring to the proper
context, focusing on the work to be done (i.e., enabling emotional processing),
and sticking to the role of a witness of the testimony, the therapist is able to
 Narrative Exposure Therapy 321

avoid excessive or inappropriate psychological identification (overidentifying)

or getting caught in a conspiracy of silence. Therapists with their own trauma
histories are advised to ensure that their own trauma work is complete before
providing care for others. In contexts in which traumata are highly likely to
have been experienced by therapists, NET trainings are set up in such a way
that trainees process their own traumatic events.

Concerns of Both Therapists and Survivors about Causing

Harm, Prompting Rejection, or Worsening Symptoms
Therapists are advised to manage their own overwhelming emotional feel-
ings with appropriate self-care, professional boundaries, and use of clinical
supervision. In addition, the very act of writing out the narration after the
client has left the session helps the therapist to maintain a boundary with the
client, to realize that these experiences were part of the client’s life and not
the therapist’s, so that both are able to contextualize the events appropriately.
Finally, the human rights focus in NET, acknowledging shattered beliefs, bit-
terness, and anger that both client and therapist may feel about the viola-
tions that have occurred (directed clearly toward the perpetrators), as well as
“encouragement” for the therapist to act as advocate when appropriate and
not remain “neutral” enables the therapist to resolve difficult feelings associ-
ated with having witnessed the client’s extreme distress in response to horrific
experiences.

Fear of Being Abandoned by the Attachment

Figure/Inability to Let Go of the Therapist
The pain of having been abandoned and violated in the past by attachment
figures is tied back to the context in which it originally occurred. For the new
relationship with the listener (the therapist), the narrator (client) can experi-
ence the undivided and unconditional attention and warmth of the therapist as
the narration unfolds, step by step. This is highly structured along the chrono-
logical flow of the person’s biography, and is therefore predictable, boundar-
ied, and contained. The testimony approach provides respect and dignity, and
it satisfies the need for acknowledgment. When nearing the end of the narra-
tion in the present, closing rituals finalize the process with a natural ending:
two persons who respect each other and let go. NET is time limited. This is an
advantage in contrast to long-lasting therapies forming intense bonds that may
foster dependencies.

Clinical Case Example

This case was referred to a specialist trauma service after the client described
dissociative experiences, self-harm, and suicidality to her family doctor during
322 INDIVIDUAL TREATMENT MODALITIES AND MODELS

a routine medical appointment. During the assessment session, the therapist

administered the Life Events Checklist and suspected the client had been a
victim of trafficking. The client acknowledged experiencing different types of
multiple traumatic events, including severe abuse and adversities beginning in
early childhood, and exposure later to life-threatening events such as severe
hunger, risk of suffocation while being transported in a container, and the
loss of a child. The therapist used the Posttraumatic Stress Diagnostic Scale to
ascertain a diagnosis of PTSD. The Shut-D (Schalinski et al., 2015) revealed
extensive dissociative experiences. The client was failing to eat regularly and
was self-harming by cutting her abdomen and thighs. The client had no social
contact and spent most of her time alone in her flat, leaving the house as rarely
as possible.
During psychoeducation, the therapist explained the nature of the treat-
ment, and the client was extremely ambivalent, believing herself unable to “put
the pieces together and remember what happened,” as well as fearing that she
would become overwhelmed by emotion if she purposefully thought and talked
about her experiences and “lose the last will to live that I have.” The therapist
explained that together they would take this journey to explore her life history,
and that this time, the client would have with her someone who cared, every
step of the way, through every detail. The client agreed to try the treatment on
the following condition: If she wanted to stop the treatment, she would not be
contacted by the therapist ever again. This request not only displayed her initial
ambivalence toward the treatment but also her distrust of the therapist, with
strong feelings of both needing and rejecting close contact.
During the lifeline session, events frequently had to be reordered to obtain
as accurate a history as possible. Later, the client recalled further events, and
three events were reordered as her autobiographical memory was restored.
By the end of the lifeline session, the skeletal details of the client’s life were as
follows. Born in Cambodia, her early life included multiple events of severe
physical and emotional abuse by her mother, and sexual abuse by her father.
She was severely punished for mild misdemeanors and accidents, and lived
in fear of both parents. She attended school but did not like talking to other
children, afraid that they would not like her because she was poorly cared for
and often bruised.
Following the lifeline session, the therapist immediately started the narra-
tion, beginning with the earliest arousing events. Excerpts from the narrations
are detailed here, with the contrasting “here-and-now” information obtained
by therapist shown in brackets. For the purposes of description, parts of the
narration are shown at different points during the exposition. In an actual
session, the therapist must start at the beginning with the general details of
the life at the time of the trauma, before establishing the exact details before
the trauma occurred, then slowing down and exploring each moment of the
trauma in slow motion, attending to all the elements of the hot memory and
connecting to the cold memory.
 Narrative Exposure Therapy 323

Narration Excerpt 1 from Exposition Session 1:

My Father Abusing Me
[After describing sensory details—pictures, sounds, smells . . . ]

“I could tell from his face that he was angry and I was terrified (I still feel ter-
rified now as we talk about it). I was screaming out for help (I just wanted
someone to help me, I still do), my heart was beating (it’s beating now and
I feel panicky) and I tried to get off the bed but he pushed me back hard
against it (I can feel where his hands were on my chest, even as I talk about it
now, so heavy and strong). He put his hand over my mouth (yes, it was like
this—[the client shows the therapist the position of the man’s hand over her
mouth]—and his face came right up to my face (I can still see the look in his
eyes, but no—I can’t see him now—I see you). He smelled of alcohol (here in
this room I smell the orange oil [orange oil was used to counter dissociation
in this session]). I thought, ‘It will be worse because he has had beer.’ I felt
terrified and disgusted (now I just feel like crying. My heart is so heavy and I
feel such pity for myself. I am angry now too. In my chest and arms I can feel
it. He was my father! I was a child! He should have been protecting me, not
using me for sex. Ugh, he was disgusting.) My heart was racing and I felt sick
(no, I don’t feel sick now, just angry). My arms were gripped against the side
of the bed (like this, how I’m holding the chair now, except then it was the
side of the bed). I was holding tightly. He said I would do as he wanted, as
I was his little girl. I started crying because I was so scared, and I just didn’t
want it to happen again tonight. . . . ”

Later her father died unexpectedly in an accident, and she was sold to a
brothel by her mother when she was 9 years old. She was raped on the first
night of entering the brothel and was introduced to a woman who ran the busi-
ness, who regularly physically abused her as a way of controlling her.

Narration Excerpt 2 from Exposition Session 4:

Meeting the Brothel Owner
In this excerpt, the beginning of the event is explored. The therapist has already
identified the lifetime period in which the event occurred, and initially gathers
as much cold memory (context) information as possible before beginning to
process the “stone.”

“I met her on the third day after I had been left in the brothel. It was in the
evening and there were some more people arriving. I couldn’t see them, as
I was in another room. I had been so scared and in so much pain from the
rape the day before and I hadn’t eaten anything. I didn’t understand the
words she used all of the time. I thought she was from a different country.
324 INDIVIDUAL TREATMENT MODALITIES AND MODELS

She looked different. She was glamorous, had beautiful clothes and jewelry,
and wore lots of makeup. She smelled nice, and was so kind to me that first
day. She told me that she was sorry that my mother had left me and I started
to cry (I feel sad now, even though I hate my mother now; back then I was
just longing for her to come back and take me from that place). I felt like
I had knots and rocks in my stomach (I feel it a bit now, too). I felt so sad
and wanted to see my mother again so much, even though I knew she would
beat me if I ran away (now I feel so angry toward her. I hate her now as
we talk about it. I could kill her if I saw her now. I feel it in my fists and in
my chest). I was so scared of everyone that I had seen since I went into this
place (I don’t feel that fear now, well a tiny bit, my heart is a bit fast). There
were no other children there, I just wanted to go home (I feel the sadness
of that now, the longing is still there. I still feel like I never found my way
back home. I wonder if I will ever have a home that is safe). The woman
patted the seat next to her, which had a beautiful golden-colored cushion
on it. Lots of things in this room looked like they cost a lot of money. I sat
down and I felt a bit better as she was smiling at me, and no one had paid
any attention to me for ages. She told me I mustn’t cry, as it wasn’t pretty.
She grabbed my chin and turned it from side to side as she was looking at
me. Then she put one hand under each breast, although I didn’t have any
yet, and then moved her hands down to my waist. I had no idea what she
was doing and was confused (now I know exactly what she was doing. She
was seeing how far into puberty I was. She was disgusting. She was pleased
because there was demand for children who showed no signs of develop-
ment, she knew I would make her a lot of money [the client stands up]. I
feel so angry I could kill that witch. [The therapist at this point reinforces
the anger the client feels now toward the woman who forced her to have
sex with men, and that this was a violation of her rights.] Back then, I felt a
bit uncomfortable but she was smiling at me. I didn’t understand her, but I
didn’t want her to go away, and she was still smiling. I think I giggled, even
though I was scared (now I just feel angry). I didn’t want her to get bored of
me and leave me alone (I feel so sad now as I talk about that [the client starts
crying]—I was so young, so vulnerable, how could they do that to me? I feel
so much pity for myself now as I think about how alone I was). She said she
was going to make me very pretty and she told me I would make her happy
if I made money for her and that one day I would be rich and I could do
whatever I wanted.”

The client placed on the lifeline multiple “stones” of being raped in the
brothel over a 10-year period. At the time of the lifeline session, the client was
unable to identify specific events within this life period of living within the
brothel, so this was done later, once the early childhood memories of abuse
had been processed, since the client frequently confused memories of the two
different rape event contexts.
 Narrative Exposure Therapy 325

Narration Excerpt 3 from Exposition Session 6:

Refusing to Have Sex with a Client

“He laughed at me and asked me who I thought I was wearing this beautiful
underwear if I wasn’t a prostitute? (I feel shame now. I know that I shouldn’t,
but it is there. Those laughing eyes. I can see them now. He looked at me as if
I was completely worthless. Now I can feel it, that heavy shame.) [The client
is looking at the ground, her body hunched over in shame—the therapist asks
if the client was positioned like this back then, and the client recalls that she
was half-sitting, half-lying on the bed at the time, but she was avoiding his
eyes. The therapist encourages the client to look at her. The client replies that
she can see the therapist’s eyes now and not the rapist’s eyes. The client, when
asked, says that the therapist’s eyes look different, there is no hatred, only
kindness. The therapist praises the client’s courage, summarizes the last few
moments, and asks what happens next, and the client continues.] I thought
he was very angry and unpredictable, and I was sure that I was going to be in
a lot of trouble for saying I didn’t want to have sex with him. I was terrified,
my heart racing (yes, I can feel it racing now, it’s the same feeling, I’m scared).
I looked to the door and it was shut. I thought, I know there are guards
nearby, there is nothing I can do. I felt hopeless and desperate but so afraid (I
feel hopeless now, and desperate, too. I feel this knot in my chest, but that’s
not how I felt in my body then; then there was nothing). He came toward me
and hit the side of my face very hard (I can’t feel anything now on my face).
He put his hands around my neck and he squeezed very hard. I could hardly
breathe (I feel a bit breathless now) and I thought I was going to die (now I
feel I could have died, but I didn’t). He didn’t release my neck (my neck hurts
now as we talk about it) but he took off his belt and his trousers fell down.
I shut my eyes. [The client shuts her eyes in the present and the therapist
encourages her to open them.] I felt very warm (I feel warm now, and weak)
and suddenly I noticed I could hardly hear him anymore. [The therapist asks
if client can hear her now, if she can see her clearly. The client says she can,
but cannot hear well. The therapist reinforces that they are together, that the
client should focus on the therapist, and notices the client start to slump in
her chair and asks the client to cross her legs and to begin physical activation,
clenching her hands around a two soft balls and releasing. Then the therapist
asks what happens next.] I couldn’t feel my body anymore properly (I can
feel it a bit now, but it’s a bit numb.) [The therapist and client continue physi-
cal activation.] I felt confused (I feel a bit confused, but now, I know I am
here with you. I know what we are doing). Then he released my neck and I
coughed [the client gasps] (yes, that is what I did then, I could breathe again a
bit more, I can breathe again a bit more now), then I said ‘please’ and started
to cry and beg. He laughed, turned me around and the rape started again. He
pinned me down, leaned his sweating torso heavy on my back so that his hot
breath was in my ear and then forced his big penis into my vagina. What a
326 INDIVIDUAL TREATMENT MODALITIES AND MODELS

terrible pain. I thought, I will crack open. [They continue the narration until
the point where the rapist leaves the room.]”

Ten years later, the client was sold on to another group of traffickers,
working as a prostitute but living with six other women. She was under the
constant surveillance of a guard initially, but over time was “trusted” by her
traffickers and gained some independence, including being allowed to prepare
her own meals and leave the flat. It was during this phase of her life that she
started cutting her abdomen and thighs, usually in response to intrusive memo-
ries of the abuse by her parents and as a child in the brothel. During the lifeline
session in therapy, she had placed a flower for this event and labeled it “my
comforting friend.” She described feeling numb after self-harm. During this
period, a customer paying for sex with the client complained to her traffickers
about her self-harm, and she was severely beaten as a punishment. She began
restricting her eating after she realized that this could also lead to similar feel-
ings of numbness. She gave birth to a child, who was taken from her by the
traffickers. She does not know what happened to the child.

Narration Excerpt 4 from Exposition Session 10:

Losing My Baby
This excerpt is midway through the exposition of the “stone.”

“I sat back down on the bed and I screamed and wept (I am so sad, I am so
lost, where is my baby now? What did they do to her?) [The client is weeping
and sobbing.] I thought, ‘How could they take her from me?’ Nothing can
describe the despair (I cannot describe it even now, ever since that moment
there is a hole in my soul. I feel it now, too. Emptiness, nothingness, I feel
it across my chest and down my arms. [She moves to adopt a position as if
cradling a baby and continues to cry.] My heart was so heavy with agony and
longing. (It is still like this, this never changes, this will never go away.) My
arms felt empty where they had torn her from my arms. I couldn’t think any-
thing except ‘I’ve lost her, I’ve lost her, I cannot live without her. I am nothing
again.’ I realized she had helped me so much, given me a reason to keep going
(I think this still, she was my world. She made me think I wasn’t worthless, I
was at least loving to her dear soul). And now this terrible hell of emptiness. I
just wanted to die (no, I don’t feel this now, now I want to find her). I felt my
insides sort of harden (yes, I feel this now, my stomach tightness, my body is
stiff, I start to freeze over) and I threw the mirror on the floor and it shattered.
I picked up the glass and slashed my thighs and the blood was beautiful and
slowly I could feel myself losing any feelings (yes, I can feel it now, the tension
going). [The therapist restarts physical activation with the client.] I prayed
and prayed that I would die (now I feel it. Death would be so easy, but now
I want her back. I can try to find her. Even if it takes my life. Oh, but there is
no hope [the client begins sobbing again]. . . . ”
 Narrative Exposure Therapy 327

The therapist is in close emotional contact, showing the client empathy,

continuously summarizing and trying to phrase with the client’s own words
what she understands, as well as helping to label feelings. The therapist contin-
ues narrating through the “stone” of the abduction of the child, including when
the client lost consciousness during the event, until the point at which the client
had regained consciousness, tended her wounds somewhat and eaten something
given to her by the traffickers. After a final period of captivity, she managed
to escape while working and traveled to the United Kingdom via an agent. In
the final session, therapist and client reviewed the client’s lifeline, since there
had been many changes over the course of the therapy. The therapist reread
a summary of the entire narration from the therapy. The therapist discussed
the client’s wish to join a survivors’ group and to search for her daughter, and
appropriate referrals were made by the therapist for these purposes.

Key Points of the Intervention

Slowing down the narrative flow in moments of high physiological excitement
ensures improved awareness of internal processing to avoid overwhelming and
confusing feelings. In this way, the therapist ensures that the narration creates
a safe space. The process consists of stages: (1) Exploring perceptions: (“What
did you perceive?”; “What sensory impressions were there: seeing, hearing,
smelling, tasting, touching?”); (2) question about the thoughts (“When you
heard/saw/felt/tasted/smelled this, what did you think at that moment? What
did you think it was? What happened in your mind and body then?”); (3) this
raises the question of emotional and physical experience (“How did you feel
then? Which emotion—fear, disgust, joy, shame, anger, contempt—came up
when you saw this and thought this?”; “How did your body feel? Can you
describe this bodily feeling? What quality is it—hot, cold, heavy . . . ? What is
it? Where exactly do you feel it in your body now?”); (4) finally the meaning of
this moment is explored, which anchors the experience (“When you perceived
this and thought it and had this bodily feeling, what did it mean to you at that
moment? What changed? What did you understand?”) and the behavior at the
time as a consequence of all of this evaluating (“So what did you actually do?
How did you react when you felt/thought/understood? Which behavior did
you show, maybe in contrast to your thoughts and feelings?”)
While the survivor is talking, the therapist actively helps to clearly sepa-
rate the trauma level “then” from the narrative level in the “here and now”
(“Can you feel that it smells, looks, sounds, etc., quite different here? Can you
experience that X is not in this room? Be invited to look to around and really
check out the difference. Maybe you move your body in a way you couldn’t do
then because you were restrained. Feel free to say now, what you were afraid
to express at the time of trauma.”).
All of this reality checking needs to happen literally in the very same sec-
ond of the intense remembering in order to introduce and increase a contrast
328 INDIVIDUAL TREATMENT MODALITIES AND MODELS

between then and now and to let the survivor’s brain and psychological self
experience the proof that “the past” is not here. States of distrust, detach-
ment, anger, grief, shame, and other painful and impulsive moments are under-
stood in the context of their past appearance in the personal biography. Sen-
sory perceptions, cognitions, emotions, bodily reactions, and actual behavioral
responses, as well as meanings of the trauma scenes, are connected back to the
past where they belong, and where they originated. In this way, clients’ dys-
regulations become comprehensible, legitimized, and fade.
Humans use an internalized view of the other as a self-control measure
in the struggle for social recognition and rank, fueled by intense, often pain-
ful, emotions. These unrecognized internal forces of suffering (in particu-
lar “shame” and “guilt”) are explicitly illuminated during the telling of the
life story in the narrative exposure. Moreover, NET processes not only the
traumatic events (“stones”) but also the highly arousing positive experiences
(“flowers”), which are important and meaningful resources to revisit and
regain. The mental representation of “me” as self-reflected awareness is sup-
ported throughout this process. The dependence on the thoughts, feelings, and
actions of the other people in the survivor’s life story as experienced, recalled,
anticipated, or imagined is explored, as well as interpretation of actions and
reaction to this introspection related to the social environment. The individual
is mirrored in the eyes of the empathic and validating listener, the therapist,
allowing corrective relationship experiences that weave together broken life-
lines of complex trauma survivors.

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