Narrative Exposure Therapy (NET):

A Short Term Treatment for

Traumatic Stress Disorders

NET Training | 2022

What is Narrative Exposure Therapy (NET)?
2

NET – an intervention for the treatment of complex

traumatic stress in children and adults.

✔ short-term
✔ field-oriented
✔ culturally
sensitive
✔ science-based
✔ therapeutic &
✔ human rights
 Narrative Exposure Therapy (NET)
3

Combination of behavioral exposure and testimony therapy

(Lira and Weinstein)

Diagnostic Assessment and Psychoeducation

Exposure to traumatic events
Documentation of biography

Use of the narration for human rights work

or personal use of the client
 Narrative Exposure Therapy (NET)
4

TWO GOALS:
1. Reduction of PTSD 2. Construction of a
symptoms by consistent document.
confronting/exposing the
client with the memories
of the traumatic event.

EXPOSURE: NARRATION of the

Imaginative reliving, client’s biography,
emotional processing, especially the
reweaving hot and cold consequences: survivor
memory. testimony.
 Relevant Mechanisms
5

- Chronological reconstruction of the

autobiographic/episodic memory

- Activation of the fear network through

exposure to modify the emotional network

- Meaningful integration of hot and cold

memories
- Reinterpretation of the memories; regaining a
sense of dignity and the need for
acknowledgement
 Cumulative Effect of Traumatic Events
and Adverse Life Experiences
6

◻ More different types of stressful

events, the more likely
someone is to develop PTSD

(Catani et al., 2008, BMC Psychiatry)

 8

NET, KIDNET, & FORNET: The Evidence

9 Effective Treatments for PTSD
◻ Cognitive behavioral treatment
◻ Trauma-focused CBT (TFCBT)
◻ Eye Movement Desensitization and Reprocessing (EMDR)
◻ Stress management
◻ Prolonged Exposure
Trauma-focused psychological treatments are most effective.
10 Randomized Controlled Trials of NET
◻ Refugees, internally displaced persons (IDPs), asylum seekers
🞑 Romania, Uganda, Rwanda, Germany, Norway

◻ Living in their original homes, camps in their own countries,

neighboring countries, or far from original home
◻ Individuals across the lifespan
🞑 Children ≥ 7 years
🞑 Adolescents
🞑 Adults
◻ Simple and complex trauma
 Effectiveness of NET
Lely et al. (2019)
11
Effectiveness of NET cont.
Nose et al. (2017)
 Effectiveness of NET cont.
Siehl et al. (2020)
13
 KIDNET: Randomized Controlled Trials with
14 Children and Adolescents

▪ Children with PTSD of asylum seekers in Germany

Ruf et al., Journal of Traumatic Stress (2010)

PTSD severity pre 6 months post 1 year follow-up

(UPID score)
KIDNET 42.33 18.08 18.92
Effect sizes d= 1.85 d=1.74
Waiting-list 38.31 33.77

▪ Tamil children traumatized by war and Tsunami treated by trained local

counsellors (former school teachers) Catani et al. (2009), BMC
Psychiatry
▪ Former child soldiers treated by local counsellors Ertl et al. (2011), JAMA
 NET with Sudanese Refugees
Imvepi Camp, Uganda
15

“leaving the camp”

PTSD diagnosis:
1 year follow up

Neuner et al., JCCP 2004

 Affective Picture Processing in PTSD

Pleasant picture (4 s)

ISI & fixation (6-8 s random)

Neutral picture (4 s)

t
Unpleasant picture (4 s)

Pictures of the
‘International Affective Pictures are presented in a flickering
Picture System (IAPS)’ mode of 10 Hz
(40 on-off cycles) each
17 Effects of NET on the Brain

Changes within the group

(pre-post):
Significant increase of left
occipital activity selectively
towards threatening cues

NET vs Waiting-list:
Significant increase of
superior-parietal activity
in the NET group
selectively towards
threatening pictures.

(Adenauer et al., BMC Neuroscience, 2011)

 Processing of Aversive Stimuli in PTSD

 rapid and strong reaction of the autonomic nervous system

 very early frontal activation (“alarm”)
 Reduced processing in posterior brain areas (“avoidance”)

Narrative Exposure Therapy

 enhanced activation in occipital cortical areas

 increased visual processing

 enhanced activity in parietal areas

 selective attention and episodic memory retrieval – evaluation of the
situation by taking into account the actual context
 reduction of the fear response
19
Refugees Becoming Therapists

▪ Therapies with Sudanese and

Rwandese refugees in Nakivale
Refugee Camp, Uganda

▪ Training of refugees without any

medical/ psychological
background as NET therapists

▪ Randomized controlled trials

comparing NET, “Trauma
Counseling” and a “Monitoring
Group”

(Neuner et al. 2008)

 Traumatic Stress and
Posttraumatic Stress
Disorder
Etiological Model and Diagnostic Aspects
+ Traumatic Event (DSM-5)
22
Criterion A. Stressor

🞑 Exposure to actual or threatened death, serious injury,

or sexual violence in one (or more) of the following:
■ Direct experience
■ Witnessing, in person
■ Indirectly (to close family member or friend)
■ Repeated/extreme indirect exposure to aversive
details:
▪ Through professional duties (e.g. first
responders, treatment providers)
▪ Not via media, TV, movies etc.
Source: APA, 2013
 + The Function of Fear
23

▪ Brain takes cues from environment and

activates body for an appropriate
response to potential danger/threat
▪ Quick response to threat is
evolutionarily adaptive
▪ Brain triggers the secretion of stress
hormones and prepares body system
for rapid (alarm) response to threat:
▪ FLIGHT or FIGHT
[Link]

[Link]
+ Key Brain Structures
24

◻ Thalamus: relay station between midbrain to cortex, sleep/wake,

arousal
◻ Hypothalamus: Central to neuroendocrine functioning, hormones,
HPA Axis activation
◻ Association cortex: higher order cognition, complex
◻ Prefrontal cortex: executive functions, personality, emotion
regulation
◻ Hippocampus: episodic memory (autobiographical), consolidation
of short-term to long-term memory
◻ Amygdala: emotion facilitated memory, memory consolidation
◻ Anterior cingulate gyrus: modulates emotional expression
Slide credit: Mandi Burnette, PhD, University of Rochester
 The Alarm Response to Stress

25

Flight
or
Fight
 (Suggested) Effects of Stress/Trauma
on Brain Structures
26
Remembering the Trauma
 Formulate a short narrative about
one of the following topics
28

“First time I rode a bicycle …”

“First time I drove a car/ driving license exam…”
“My first public presentation…”
“My first romantic kiss …”
 Taxonomy of Memory
29

Long term memory

declarative (explicit) Non-declarative (implicit)

semantic
episodic (knowledge about the world) classical
procedural Priming conditioning
(abilities)
emotional muscles
associations

medial temporal Basal ganglia Cerebral Amygdala Cerebellum

lobes (Hippocampus) (striatum) cortex
 Memory Theory
30

Non-declarative Declarative memory

memory (Cold memory)
(Hot Memory)
⮚ Deliberately retrievable
⮚ Automatically activated by
cues ⮚ Knowledge about the event
⮚ Sensory, emotional & in the context of life, time
physiological perceptions & space
⮚ Fragmentary reports ⮚ Chronological report
⮚ Sensation of “Here and
Now“
 Autobiographic Memory
31
Knowledge
Knowledge about
about life time general events
periods
Knowledge
about
specific
events
Narration
 Knowledge about…
32

I can remember that it was a warm day in Lifetime periods

spring. It was near my parent‘s house,
someday in the 80s, I was not yet going General Events
to school. I had a blue bike, it was a
Specific event
friend‘s bike who lived next to us at this
time. My father was pushing me and I
can remember well the feeling I had when Emotional/Sensory
Network
I started rolling on my own.
 Sensory-Perceptual Network ([Link],1994)
HOT sensory cognitive emotional physiological

Blue bike joy

I am doing it!
Fast breathing
fear
Landscape
moving Is this fast!
Heart beating

Wind in
the hair
excitement

I was going to I was living in Before that we were

COLD Kindergarten at New York. having lunch.
that time.
 Stress and Memory
34
memory performance

100
75 Amygdala

Hippocampus
50
25
0
stress level
 Fear Network of a Traumatic Event
Sensory Cognitive Emotional Physiological
sister screaming anger
It hurts!
fast breathing
HOT
I can‘t do shivering
anything fear
carpet horror

heart beating
Why isn‘t
anybody helping?
gun despair
soldiers sweating
guilt

I was living It happened Before that I’ve been to

COLD in Mogadishu. during the school.
afternoon.
Source: Vivo (2013)
 Dose-Effect of Traumatic Stress
36

Tamil school children,

North-East Sri Lanka
(Catani et al., 2005, ESTSS)
 Cumulative Effect of Traumatic Events
and Adverse Life Experiences
37

(Catani et al., 2008, BMC Psychiatry)

38
 Posttraumatic Stress Disorder (PTSD)
39

◻ DSM-5: “Trauma-and
Stressor Related
Disorders”
◻ 8 diagnostic criteria
◻ Enduring reaction to
trauma
◻ “Stuck” in this past
traumatic memory

◻ Unable to integrate sensory, cognitive, emotional,

and physiological aspects of the experience into the
particular declarative memory of the event
 Criterion A.
40

Exposure to actual or threatened death, serious injury or

sexual assault through ONE of the following:

◻ Directly experiencing the event

◻ Witnessing the event in person
as it occurred to others
◻ Learning that the traumatic
event(s) occurred to a close
family member or friend
◻ Experiencing repeated or
extreme exposure to aversive
details of the traumatic event(s)
Source: APA, 2013; Photo credit: Center for Mental Health
+ Criterion B. Intrusion
Symptoms
41

◻ Event is re-experienced (at least ONE)

🞑 Recurrent, involuntary, intrusive memories
🞑 Traumatic nightmares
🞑 Dissociative reactions/flashbacks
■ Vary from brief to full loss of consciousness

🞑 Intense distress after exposure to reminders

🞑 Physiological reactivity after exposure to reminders

Source: APA, 2013; Photo credit: [Link]; Slide credit: Mandi Burnette, PhD,
University of Rochester
+ Criterion C.
Avoidance Symptoms
42

◻ Persistent effortful avoidance of distressing

trauma-related stimuli (at least ONE)

🞑 Trauma-related thoughts or feelings

🞑 Trauma-related external reminders
(e.g., people, places, things)

Source: APA, 2013; Photo credit: [Link]

Slide credit: Mandi Burnette, PhD, University of Rochester
+ Criterion D. Negative Alterations
43
in Cognition & Mood

◻ Negative alterations in cognitions and mood that began

or worsened after the trauma (at least TWO)
▪ Inability to recall key features of event (not due to head
injury, alcohol or drugs)
▪ Persistent (often distorted) negative beliefs and
expectations about oneself and the world
▪ Feeling alienated from others
▪ Persistent negative trauma-related emotions (e.g., fear,
horror, anger, guilt, shame)
▪ Markedly diminished interest
▪ Constricted affect: inability to experience positive emotions
Source: APA, 2013; Photo credit: [Link]; Slide credit: Mandi Burnette, PhD,
University of Rochester
+
Criterion E. Alterations in Arousal
44 and Reactivity Symptoms

◻ Trauma-related alterations in arousal and reactivity that

began or worsened after the traumatic event (at least
TWO)
■ Irritable or aggressive behavior
■ Self-destructive or reckless behavior
■ Hypervigilance
■ Exaggerated startle response
■ Problems in concentration
■ Sleep disturbance

Source: APA, 2013; Photo credits:[Link]

Slide credit: Mandi Burnette, PhD, University of Rochester
+
Other Criteria
45

◻ Criterion F. Duration of symptoms is

more than 1 month.

◻ Criterion G. Causes clinically significant

distress or impairment in the individual’s:
■ social interactions
■ capacity to work
■ or other important areas of
functioning.
◻ Criterion H. Not the physiological result
of another medical condition, medication,
drugs or alcohol.

Source: APA, 2013; Slide credit: Mandi Burnette, PhD, University of Rochester
+
Specify whether…
46

◻ With dissociative symptoms:

🞑 Depersonalization: experience of being outside
observer of or detached from oneself (feeling as if
this were a dream)
🞑 Derealization: experience of unreality, distance, or
distortion

◻ If happens more than 6 months after trauma –

called delayed expression

Source: APA, 2013; Photo credit: [Link]; Slide credit: Mandi Burnette, PhD,
University of Rochester
+ The Defense Cascade
Schauer & Elbert (2010). Dissociation Following Traumatic Stress, Journal of Psychology

47
 Characteristics of Events That May Elicit
Dissociative Fright, Flag, or Faint
48

◻ Imminence of threat/aggressor and total helplessness (e.g.,

direct body contact with perpetrator, being constrained, and
danger of skin penetration by sharp objects

◻ Rapid arousal peak and startle response due to unexpected

and sudden proximity of threat or aggressor

◻ Presence of fresh blood or mutilated bodies

◻ Being contaminated and contact to infectious material (e.g.,

body fluids, sperm, feces)

◻ Anal, vaginal, or oral penetration of the victim

◻ Severe pain being inflicted on the victim

(Schauer & Elbert, 2010)
 PTSD Prevalence Rates in the U.S:
The National Comorbidity Survey (NCS)
(Kessler et al., 1995; NCS, Kessler et al., 2008)
49

Women Men
“lifetime prevalence” 10.4 % 5.0 %
(7.8% on average)
development of PTSD after 20.4% 8.2 %
confrontation with a
traumatic event
(depending on trauma type) up to 48.8% (rape) up to 38.8% (war combat)
- sexual violence - participation in a combat
most frequent trauma types - physical assault situation
- being threatened with a - childhood physical abuse
weapon
- childhood physical abuse
Comorbid disorders 79% 83%
present?
Types of comorbid anxiety disorders, substance abuse, mood disorders
disorders
PTSD in Survivors of Organized Violence
Population n PTSD
Sudan 664 49%
Uganda 1419 19%
Sudanese refugees in Uganda 1240 48%

Rwandese refugees in Uganda 959 31%

Somali refugees in Uganda 527 51%

Tamil children in Sri Lanka 425 24%

Sri Lankan children after Tsunami 265 18 - 41%

Afghan children in Kabul 287 19%

Asylum seekers in Germany 40 40%

Children of Asylum seekers in Germany 120 20%

Disorders Frequently Comorbid with
PTSD in Adults (National Comorbidity survey)

diagnosis lifetime prevalence

(women vs men)
major depressive disorder 48%
dysthymia 22%
GAD 16%
simple phobia 30%
social phobia 28%
panic disorder 13 vs 7 %
alcohol abuse 28 vs 52 %
drug abuse 27 vs 35%
conduct disorder 15 vs 43 % 51
Kessler et al. (1995)
TREATMENT OF PTSD with
NET
Overview
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Diagnostic Assessment
Assessing PTSD in Adults
Self-report measures
Impact of Event Scale (IES)
Impact of Event Scale – revised (IES-R)
Posttraumatic Stress Diagnostic Scale (PDS)
Penn Inventory for Posttraumatic Stress

Clinical Interview (specific for PTSD)

Clinician Administered PTSD Scale (CAPS) Tools for specific populations:
Structured Interview for PTSD (SI-PTSD) Mississippi Scale for Combat-Related PTSD

PTSD Symptom Scale-Interview PTSD-Scale – Military

Standardized Clinical Interview (general)

Composite International Diagnostic Interview (CIDI)
Structured Clinical Interview for DSM-IV Axis I Disorders (SCID)
Mini International Neuropsychiatric Interview (M.I.N.I.)
 Assessing PTSD in Children
56

PTSD Instruments
Self report: UCLA Child PTSD Index (UPID)
PTSD interview: CAPS-CA
Clinical Interview: M.I.N.I. KID

Instruments to assess childhood trauma (family violence)

▪ Early Trauma Inventory – ETI (Bremner, 2000)
▪ Childhood Trauma Questionnaire – CTQ (Bernstein, 1994)
▪ Conflict Tactics Scales Revised – CTS (Murray Strauss)
▪ Event Checklist for Family Violence (Catani, 2008)
Posttraumatic Stress Diagnostic Scale (PDS-
5)
57

• 49 item self-report instrument based on the DSM-IV diagnostic criteria for PTSD
• allows diagnosis of PTSD and provides a severity rating of PTSD symptoms

DSM IV – Diagnosis Severity rating

1) Event list Frequency of symptoms:
2) Worst Event & A-Criterium 0 = not at all / only one time
3) Criteria B, C & D: 1 = once a week / once a while
2 = 2-4 times a week / half the time
Intrusions (5 Items)
3 = 5 or more times a week/ almost always
Avoidance (7 Items)
Hyperarousal (5 Items)
Cut-offs for symptoms severity rating categories:
4) duration & onset of symptoms
<10 = mild
5) level of impairment in functioning
> 11 and <20 = moderate
> 21 and < 35 = moderate to severe
> 36 = severe

Foa et al. (1997). Psychological Assessment

 Diagnostic Assessment: Tips
58

▪ Acknowledge the client’s worst fear

▪ Sensitivity and trust
▪ Remember: The clinician is asking the client to take a
tremendous risk and abandon avoidance and
protection
▪ Ask clients to let you know when interview becomes
upsetting
▪ Keep clients informed – psychoeducation, why you
are doing this
▪ Confidentiality
 59

TREATMENT OF PTSD
Pyschoeducation
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Psychoeducation

Part 1
1. What is PTSD?
a. Connect to client’s
symptoms
b. Normalize
c. Legitimize
 Stress and Memory
62
memory performance

Amygdala

Hippocampus

stress level
 Fear Network of a Traumatic Event
Sensory Cognitive Emotional Physiological
sister screaming anger
It hurts!
fast breathing
HOT
I can‘t do shivering
anything fear
carpet horror

heart beating
Why isn‘t
anybody helping?
gun despair
soldiers sweating
guilt

I was living It happened Before that I’ve been to

COLD in Mogadishu. during the school.
afternoon.
Source: Vivo (2013)
 Psychoeducation

Part 2
Introduce NET
a. Explain the process, imaginative exposure,
written narrative
b. 70‐80% effective at decreasing symptoms
c. Symptoms may get worse before they get better
d. Some relief right away, some after 3‐6 months
e. Stress importance of coming regularly and
following through on process
 Why does NET work? - Therapeutic
Agents
65

◼ Active chronological reconstruction of the

autobiographic/episodic memory
◼ Prolonged exposure to the ‘hot spots’ and full activation of the
fear memory in order to modify the emotional network
◼ Meaningful linkage and integration of psycho-physiological and
somato-sensory responses to the time-, space-, and life-context
◼ The cognitive re-evaluation of behavior and patterns, as well
as reinterpretation of the meaning-content through reprocessing
of negative, fearful and traumatic events
◼ Regaining of survivors dignity and satisfaction of the need for
acknowledgement. Explicit human rights orientation of
‘testifying.’
 Psychoeducation on Lifeline and
66
Exposure
◼ Safety within the client/therapist contact
◼ Treatment and therapist behavior is transparent
and predictable
◼ Physical integrity is respected
◼ Therapist shows compassion
◼ Understanding and non-judgmental acceptance
◼ Confidentiality
The Lifeline
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 Flow of sessions
69

Session #1:
- Assessment and psychoeducation
Session #2:
- Psychoeducation and Lifeline
Session #3 - ? (end of lifeline):
- re-read preliminary narration
- fill in more details
- continue with narration
- slow down whenever you approach a traumatic “stone”
Last session:
- re-read the entire narration for the last time (maybe add hope
for the future)
- signing ritual and handing over of narration (if appropriate)
 Lifeline
70

1. Create a “map” of significant life events on the

rope, using flowers and stones to identify
traumatic events in chronological order
a. Rope as symbol of life
b. Flowers as symbols for joyful/happy/good events
c. Stones as symbols for horrific/painful/bad events
 Lifeline
71

• Only asking for a “headline” for each significant event

• No elaboration
• Ask for main thoughts and feelings of each event
• If it is a clear traumatic event, do not ask for main
thoughts and feelings b/c it risks client becoming
overwhelmed/dissociating
Re-reading and Exposure
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 Re-reading and Exposure
74

1. Start at the beginning of lifeline and develop the

narrative
a. can pause briefly at non-traumatic events to ask if they
would like to change or add to what was written down in
the lifeline

1. Exposure: Slow down at each/most traumatic events to

complete an exposure session
a. Typically, one traumatic event exposure occurs in each
NET session

1. At the following session - re-read narrative from previous

exposure session and continue forward on the lifeline
until the next traumatic event/exposure
 Flow of sessions
75

Session #1:
- Assessment and psychoeducation
Session #2:
- Psychoeducation and Lifeline
Session #3 - ? (end of lifeline):
- Exposure sessions: One for each traumatic event
- 2nd exposure session and on: Re-read preliminary narration
and make corrections if applicable
- Continue with narration
- Slow down whenever you approach a traumatic “stone”
Last session:
- Signing ritual and handing over of narration (if appropriate)
- Optional: Re-read the entire narration for the last time (maybe
add hope for the future)
 Beginning an Exposure Session
76

❑Start to slow down and try to get a clear

picture about the situation before the hot spot
happened (e.g., two hours before)
❑Know or observe that you are approaching a
hot spot
o Client becomes impatient, aroused and
tries to speed up
o Story gets fragmented
 Exposure - Overview
77

❑Create a very detailed “movie” of the event by:

Weaving the hot and cold memories together in
the hot spot

❑While weaving, reinforcing reality by:

comparing “then” and “now”
 Exposure - Overview
❑ Hot Memory ❑ Cold Memory (Context
(Associative memory) memory)
o Automatically o Deliberately
activated by cues retrievable
o Sensory, o knowledge about the
emotional, and event in the context
physiological of life, time, and
perceptions space
o Sensation of the o Chronological report
“here and now” ■ located in the
■ located in the Hippocampus
Amygdala
 Exposure: Integrating Cold and
Hot Memory
79

COLD memory HOT memory

Space: Where did it Cognitive: What did

happen? you think? THEN

Time: When did it Emotional: What did And

happen? you feel?

Chronology: What Physiological: How did

Now
happened? your body react?
What happened next?
Sensory: What did you
see smell, taste, hear?
 Exposure
80

❑Stay in the HOT SPOT until client has experienced

at least some relief
❑Reinforce reality
o Constantly compare “then” and “now”
o Be attentive to prevent
✔Dissociation
✔Avoidance
✔Flashbacks
❑If it’s supportive: May use creative tools for
exploration (e.g. body position, drawings)
 Flow of sessions
81

Session #1:
- Assessment and psychoeducation
Session #2:
- Psychoeducation and Lifeline
Session #3 - ? (end of lifeline):
- Exposure sessions: One for each traumatic event
- 2nd exposure session and on: Re-read preliminary narration
and make corrections if applicable
- Continue with narration
- Slow down whenever you approach a traumatic “stone”
Last session:
- Signing ritual and handing over of narration (if appropriate)
- Optional: Re-read the entire narration for the last time (maybe
add hope for the future)
 Closing
82

1. May re-read entire narrative

2. Give the client the narrative (if they would like it)
3. Honor the end of the process however the client would like
a. Hopes/dreams for the future
b. Identifying goals for therapy that arose during NET
 Narrative Exposure Therapy Lifeline
83
 Narrative Exposure Therapy Lifeline
84

present
 Narrative Exposure Therapy Lifeline
85

present
present
 Narrative Exposure Therapy Lifeline
86

present
 Narrative Exposure Therapy Lifeline
87

present
present
 Narrative Exposure Therapy Lifeline
88

present

associated features:
shame, guilt, de-realization, de-personalization, and de-attachment
 Narrative Exposure Therapy Lifeline
89

present
 Dealing with Stones:
90
THE WORST MISTAKES
❑Stopping at the height if fear

❑Allowing de-realization/dissociation and avoidance

Always be clear about the direction that you

are going: no mixture of exposure and closure

EXPOSURE: arousal and emotions going up

CLOSURE: decrease in arousal, support and

calming down
 Behavioral Changes Associated With
Dissociation (“Shut-Down” Reaction)
91

◻ Sensory-afferent signs: person may become unresponsive,

with unfocused gaze

◻ Motor-afferent signs: visible decrease of bodily movements

and immobility
🞑 Bodily numbing and slight paralysis (mainly in legs)
🞑 Yawning in the middle of the arousing exposure (in order to get
blood to muscles and increase heart rate)
🞑 Dizziness, blurred vision, weakness of the muscles

◻ Language processing: unclear/confused speech, fragmented

sentences, or inability to speak
🞑 Almost no or delayed response to sounds
(Schauer & Elbert, 2010)
 Therapeutic Intervention for
Shut Down” Reactions
92

Sensory-afferent: Stimulate the senses in the here & now, turn

on bright, present tactile sensations (e.g.,
fabric, ice-pack), focus attention to sounds in
the room

Motor-afferent: Activate skeletal muscles & enhance blood

pressure & muscle tone (e.g., applied tension,
physical exercises, leg crossing; body
balancing tasks)

Language Emphasize the narration of the PAST

processing: traumatic scene, supported by the facilitation
of continuous narrative engagement in the
PRESENT (e.g., active communication;
enhance speech production)
(Schauer & Elbert, 2010)
 Things to Avoid (Both PTSD Subtypes)
93

◻ Ending exposure session prematurely before the event has been

contextualized and integrated into cold memory
◻ Disengagement from here and now
◻ Relaxation instead of activation
◻ Sensory similarities between the trauma context and the
therapeutic setting
◻ Stimuli that are associated with disgust or similar to body fluids and
feces
◻ Threat cues in the here and now (present safety signals instead)
◻ Semi-darkness in the room and objects for hiding behind (e.g.,
furniture, large plants)

(Schauer & Elbert, 2010)

 Therapeutic Agents of NET
94

◼ Active chronological reconstruction of the

autobiographic/episodic memory
◼ Prolonged exposure to the ‘hot spots’ and full activation of the
fear memory in order to modify the emotional network
◼ Meaningful linkage and integration of psycho-physiological and
somato-sensory responses to the time-, space-, and life-context
◼ The cognitive re-evaluation of behavior and patterns, as well
as reinterpretation of the meaning-content through reprocessing
of negative, fearful and traumatic events
◼ Regaining of survivors dignity and satisfaction of the need for
acknowledgement. Explicit human rights orientation of
‘testifying.’
 Levels of Parallel Processing During NET
95

◻ The Incident – what happened then and at the time of the incident?
◻ Here and now – what happens now during the session?
◻ Present – What is going on now in the life of the client and how does
it influence therapy?
◻ The narrative of the narrative – during the session and when updating
the testimony.
◻ The therapeutic contact – how are “we” doing during and between
sessions?
◻ The therapist – how am “I” doing during and between sessions?
◻ Cognitive and emotional reorganization – during and between
sessions.
◻ Admin – timing, appointments, during and between sessions.
 Questions to Therapists
96

◻ Am I convinced that it is good for the client to be

exposed again to the traumatic memories?

◻ Do I want to hear “it”?

◻ What about my fear, that “it” will be horrible to
listen to?

◻ Be aware of two snares:

Conspiracy of silence and over-identification