NET is NICE

Some of the work of our research team has been used as evidence for the latest update of the NICE guidelines for the treatment of PTSD. Narrative Exposure Therapy (NET) has now been included as an acceptable treatment for PTSD (NICE, Dec 2018), after several years of researchers and clinicians arguing for its inclusion. This is good news for those who will benefit from NET.

Three of our articles were used for the evidence:

• Alghamdi, M., Hunt, N. & Thomas, S. (2015). The Effectiveness of Narrative Exposure Therapy with Traumatised Fire-fighters in Saudi Arabia: A Randomised Controlled Study. Behaviour Research and Therapy, 66, 64-71.
• Zang, Y., Hunt, N. & Cox, T. (2014). Adapting Narrative Exposure Therapy for Chinese earthquake survivors:  A pilot randomised controlled feasibility study. BMC Psychiatry, 14, 262.
• Zang, Y., Hunt, N. & Cox, T. (2013). A randomised controlled pilot study: The effectiveness of narrative exposure therapy with adult survivors of the Sichuan Earthquake. BMC Psychiatry, 13(1), 41.

These articles are based on the studies of two of my PhD students, Yinyin Zang and Mohammed Alghamdi.

Yinyin was the first of our team to use NET. We were studying the survivors of the Sichuan earthquake in China which took place in 2008. Over 42,000 people were killed, many more were injured and made homeless. Our study was initially intended to obtain quantitative data regarding the psychological impact of the earthquake, but we quickly found that people wanted to tell their stories, so Yinyin altered her PhD to incorporate NET, which was at the time a relatively new treatment. She initially used a four session treatment plan with people who were showing relatively high levels of psychological symptomatology. This worked very well. Using a waiting list design all 22 participants showed significant reduction of symptoms of PTSD, depression and anxiety. Indeed, the procedure worked so well we tried a two session NET, comparing it to the four session procedure and found it worked just as well. We were only able to do a three month follow up, but symptoms remained low in all groups.

Mohammed studied firefighters in Saudi Arabia. They were all treated using NET and their symptom scores reduced, in a similar but not as dramatic way as for the earthquake survivors. The follow up, though, showed some differences. Many of the firefighters showed increased scores after several months. On closer inspection – using an interview procedure – it turned out that many of them had experienced very stressful events in the interim, and it may have been this that caused the increase in scores. They did suggest that a regular ‘top-up’ NET might be helpful, but we did not have the resources for that.

Along similar lines, Ashraf Al-Hadethe, another one of my PhD students, conducted a NET study with Iraqi civilians in Baghdad at a time when there was still a lot of violence in the city. While the participants – again all with high symptom levels – showed some benefit from NET, they very quickly lost the benefits because of the continued violence.

These two studies, on Saudi firefighters and Iraqi civilians, may show that while NET has significant benefits for people who are in the post-trauma phase, ie they are not experiencing continuing problems, the procedure may not be protective for future stressful or traumatic events. Does it focus too much on past events and not consider the necessary tools to provide protection against future events? This clearly needs further research.

The China study, along with the many hundreds of other NET studies, clearly shows that there are benefits to NET, and people with PTSD and related problems are likely to experience significant benefits. Given the storied nature of NET it is likely that some people who are unable or unwilling to undergo a full course of CBT may find NET more acceptable, as it has the storied component – and we naturally get satisfaction from telling stories, even traumatic ones if their is suitable support.