“This is my story, I am!”

Narrative Exposure Therapy (NET):

coming home to the own life

Maggie Schauer

Interview with Dori Laub, Professor of Psychiatry at Yale University Fortunoff Video Archive for Holocaust Testimonies at Yale University: Oral Film Testimonies

The case of Helen Kay D. Laub: “Helen lost her baby during the Holocaust. She didn’t know it. She didn’t even speak to her husband about it. And the camera moves to him and tears are rolling down his eyes… She asked me for treatment. After I spent two years with her, she finally said, yes, my baby died in my arms! Until then, she didn’t own the experience that she had lost a child.” Interviewer to Dori Laub: “Do you think that giving testimony traumatizes the survivors again? D. Laub: “it depends what kind of interviewer it is, and it depends what your experiences were that you are telling about. The loss of a child is one of the worst. The interviewer has to exercise a certain amount of caution.”

Schauer, Neuner, Elbert 2005/2011; Schauer, Ruf, 2012; Elbert et al., 2012

mother screaming

water

It hurt‘s!

I can‘t do anything!

fear

fast breathing

sweating sound of

wave

horror

guilt

shivering Why isn’t any- body helping?

sister‘s doll

fear

heartbeat

sweating

stick

shame

smell of alcohol

Will it end?

Why is he doing this?

body position

aeroplane

temple I am going to die!

Where should I hide?

anger

despair

heartbeat

blood headache

legs shivering

Schauer, Neuner, Elbert 2005/2011; Schauer, Ruf, 2012; Elbert et al., 2012

Schauer & Ruf-Leuschner Psychotherapeut, 2014

1.  Session (ca. 120min): Diagnostic Interview Explore types of traumatic events using an event list (allocentric) 2. Session (90-120min): Laying out the Lifeline, Biographical overview along a timeline (allocentric) 3. Session –> end of treatment (each 90-120min): Narrating and reprocessing the events in chronological order (egocentric)

Approaching a traumatic event in NET

Arou

sal

Zeit

Pflegefamilie Ehe

sex. Gewalt

Mobbing Schule betrunken

Autounfall

Suizidversuch

Gewalt Partner

Kind Krankenhaus

present

1st traumatic event

2nd traumatic event

3rd traumatic event

birth

session 3 session 4

session 5…. session 8…

session 12 Schauer, Neuner, Elbert 2005/2011; Schauer, Ruf, 2012; Elbert et al., 2012

Lifetime periods, general & specific events displayed as arousal curve A

rous

al

Time Kinder- garden

Primary school Foster family

Occupational training Marriage

sex. abuse

bullying

robbing a petrol station

being gang raped suicide attempt

domestic violence - my little son dies

new life with my daughter

in a social

community

my aunts takes care for me until she dies

‘Peter’ falling In love Tim dies

on the street time In prison

Schauer & Ruf-Leuschner Psychotherapeut, 2014

Flowers: positive events, resources Stones: negative events (traumatic, life events) Sticks: actively involved in violence, delinquency etc. Candles: loss/death of a loved one, grief, social rejection etc.

Schauer, Neuner, Elbert, Narrative Exposure Therapy, 2005/2011 Schauer, M. & Ruf-Leuschner, M. (2014) Psychotherapeut, in press.

Schauer, M., Ruf-Leuschner, M., Landolt, M. (2014). In: K. Priebe, A. Dyer, Metaphern und Symbole in der Traumatherapie, in press.

FORNET: Behandlung von traumatisierten und nicht-traumatisierten Gewalttätern mittels Narrativer Expositionstherapie. Elbert, T., Hermenau, K., Hecker, T., Weierstall, R., Schauer, M. (2012); in In: J. Endrass, A. Rossegger, F. Urbaniok, B. Borchard (Hrsg.) Interventionen bei Gewalt- und Sexualstraftätern: Hermenau K, Hecker T, Schaal S, Mädl A, Elbert T (2013) Journal of Aggression, Maltreatment & Trauma, 22:8, 916-934.

Symbols for the LIFELINE in NET, KIDNET and FORNET

history and place (Vergeschichtlichung und Verortung)

!

time and space !

!!

!

!

Schauer & Elbert, J of Psychology, 2010

mother dies (11 yrs) – torture jail in Moghadishu (13 yrs) – fleeing in a truck to Kenia – imprisoned in Sudan in Sudan (14 yrs) – Driving and walking through the desert, starvation - Boat refugee to Malta end of 2008 – detention camp in Malta, living in one overcrowded cell for 8 month with 46 men, violence – seeking asylum in Germany

Multiple events with sympathetic activation

Boat Refugee Malta

08.09.19xx born in Berlin

5 years old: my mother dies, orphanage

6 yrs: I like my grandmother, she gives me a cat as a present

9yrs: bullying at school, being often beaten on the way home Foster family; start of my training as veterinary assistant

18yrs: My grandmother dies; I couldn’t see her to take leave

New live: with the help of social workers I start living in a sheltered housing and continue my education A lot of pain in my body, suffering and problems ever after…

BorderlinePD / Complex trauma

Repeated events with para-sympathetic activation

Pabst A, Schauer M, Bernhardt K, Ruf M, Goder R, Rosentraeger R,

Elbert T, Aldenhoff J, Seeck-Hirschner M (2012) Psychotherapy

and Psychosomatics 81, 61-63

!

!

!

!

!!

!!

!

!

!

!

!

!

!

24% of PTSD patients suffer from Borderline Personality Disorder (Harned et al., 2010; Pagura et al. 2010)

suicidality, self-Injurious behavior, emotional dysregulation, low remission rate of BPD symptoms

NET – an intervention for the treatment of trauma spectrum disorders in children & adults

■  short-term ■  field-oriented ■  culturally sensitive ■  evidence-based ■  therapeutic & human rights focus

Schauer, Neuner, Elbert, Narrative Exposure Therapy, 2005/2011

work in chronological order on 4 levels:‘what happened ?’

1. emotions (feelings)

2. cognitions (thoughts)

3. body sensations (sensory perceptions, behavioral responses, physiology)

Narrative Exposure:

Schauer, Neuner, Elbert, Narrarive Exposure Therapy, 2005/2011

4. meaning

“What did you experience then?”

“What do you experience while recollecting now?”

“How do you feel/think about remembering all of this?”

Dual Awareness: contrasting ‘time-space’

Chronologic narration of the traumatic event

….

Narration process

presence

traumatic event ?

How to activate network-associations?

Narration

Raum und Zeit von Jani B

1.  explore different spacial environments of the

lifetime period (places, room, typical scenes) 2.  objects/persons in the space –> image 3.  emotion/physiology -> action

Context Image (static) sequence (action)

present

1st traumatic event

2nd traumatic event

3rd traumatic event

birth

session 3 session 4

session 5…. session 8…

session 12

Complete Narration- Eyewitness Testimony

Schauer, Neuner, Elbert 2005/2011; Schauer, Ruf, 2012; Elbert et al., 2012

Studied outcome indicators for NET !

• Reduction of PTSD symtoms • Reduction of symptoms of Depression, Suicidality and Complex trauma symptoms (dissociation, borderline symptoms) • Increased socio-economic activity & income • Ability to re-settle in place of preference • Improved scholastic achievements • Increase in health (improved immune system functioning) e.g. reduced pain, headache, fever, digestive problems • Normalization of brain functioning (reversal of memory pathology) •  and others

For Review: -  Robjant, K. & Fazel, M., The Emerging Evidence for Narrative Exposure Therapy: A Review

Clinical Psychology Review, 2010 - McPherson J., Does Narrative Exposure Therapy Reduce PTSD in Survivors of Mass Violence?

Social Work Practise 2011

Treatment Manual: M. Schauer, F. Neuner, T. Elbert (2005/2011) Narrative Exposure Therapy (NET). A Short-Term Intervention for Traumatic Stress Disorders. Cambridge/Göttingen: Hogrefe & Huber Publishers. ___________________________________________________________________________________ Literature selected: Ruf, M. & Schauer, M. (2012). Facing childhood trauma: Narrative Exposure Therapy within a Cascade Model of Care. In: Jennifer Murray (Ed.) Exposure Therapy: New Developments. New York: Nova Science Publishers, pp. 229-261. Schauer M, Schauer E (2010) Trauma-Focused Public Mental-Health Interventions: A Paradigm Shift in Humanitarian Assistance and Aid Work. In E. Martz (ed): Trauma Rehabilitation After War and Conflict, Springer: New York, pp. 361-430. Pabst, A., Schauer, M., Bernhardt, K., Ruf-Leuschner, M., Goeder, R., Elbert, T., Rosentraeger, R., Robjant, K., Aldenhoff, J., Seeck-Hirschner, M. Evaluation of Narrative Exposure Therapy (NET) for Borderline Personality Disorder with comorbid Posttraumatic Stress Disorder. Submitted Pabst, A., Schauer, M., Bernhardt, K., Ruf, M., Goder, R., Rosentraeger, R., Elbert, T., Aldenhoff, J., Seeck-Hirschner, M. (2012) Treatment of patients with borderline personality disorder (BPD) and comorbid posttraumatic stress disorder (PTSD) using narrative exposure therapy (NET): a feasibility study. Psychotherapy and Psychosomatics, 81, 61-63.

Bichescu, D., Neuner, F., Schauer, M., & Elbert, T. (2007). Narrative exposure therapy for political imprisonment-related chronic posttraumatic stress disorder and depression. Behaviour Research and Therapy, 45, 2212-2220. Elbert, T., Schauer, M., Neuner, F. (2014). Narrative Exposure Therapy (NET) – reorganizing memories of traumatic stress, fear and violence. In: Schnyder U, Cloitre M (eds.) Evidence based psychological treatments for trauma-related disorders. Berlin, Heidelberg, New York, Tokio: Springer, in press. Ertl, V., Pfeiffer, A., Schauer, E., Elbert, T., & Neuner, F. (2011). Community-Implemented Trauma Therapy for Former Child Soldiers in Northern Uganda: A Randomized Controlled Trial. JAMA, 206, 503-512. Halvorsen, J. O. & Stenmark, H. (2010). Narrative exposure therapy for posttraumatic stress disorder in tortured refugees: A preliminary uncontrolled trial. Scandinavian Journal of Psychology, 51, 495-502. Hensel-Dittmann D, Schauer M, Ruf M, Catani C, Odenwald M, Elbert T, Neuner F (2011): The treatment of traumatized victims of war and torture: a randomized controlled comparison of Narrative Exposure Therapy and Stress Inoculation Training. Psychotherapy and Psychosomatics 80:345-352 Hermenau K, Hecker T, Schaal S, Mädl A, Elbert T (2013) Addressing posttraumatic stress and aggression by means of Narrative Exposure: a randomized controlled trial with Ex-Combatants in the Eastern DRC, Journal of Aggression, Maltreatment & Trauma, 22:8, 916-934. Morath J, Moreno-Villanueva M, Hamuni G, Kolassa S, Ruf M, Schauer M, Bürkle A, Elbert T, Kolassa IT (2014). Effects of psychotherapy on DNA strand break accumulation originating from traumatic stress. Psychotherapy & Psychosomatics (in press)

Morath J, Gola H, Sommershof A, Hamuni G, Kolassa S, Catani C, Adenauer H, Ruf-Leuschner M, Schauer M, Elbert T, Groettrup M, Kolassa IT (2014). The effect of trauma-focused therapy on the altered T cell distribution in individuals with PTSD. Evidence from a randomized controlled trial. Journal of Psychiatric Research (in press) Schauer E, Neuner F, Elbert T, Ertl V, Onyut, PL, Odenwald, M., Schauer, M (2004) Narrative Exposure Therapy in Children – a Case Study in a Somali Refugee. Intervention, 2 (1), 18-32. Schaal, S., Elbert, T., & Neuner, F. (2009). Narrative exposure therapy versus interpersonal psychotherapy: A pilot randomized controlled trial with Rwandan genocide orphans. Psychotherapy and Psychosomatics, 78, 298-306. Schauer, M. & Ruf-Leuschner, M. (2014). Die Lifeline in der Narrativen Expositionstherapie (NET), Psychotherapeut, in press. Schauer, M., Ruf-Leuschner, M., Landolt, M. (2014) Dem Leben Gestalt geben: Die Lifeline in der Traumatherapie von Kindern und Jugendlichen. In: K. Priebe, A. Dyer, Metaphern und Symbole in der Traumatherapie, Hogrefe: in press. Stenmark, H., Catani, C., Neuner, F., Elbert, T., & Holen, A. (2013). Treating PTSD in refugees and asylum seekers within the general health care system. A randomized controlled multicenter study. Behaviour research and therapy, Vol 51(10), 641-647. Zang, Y., Hunt, N. & Cox, T. (2013). A randomized controlled pilot study: the effectiveness of narrative exposure therapy with adult survivors of the Sichuan earthquake. BMC Psychiatry, 13, 41.

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