Lord, Jackson, Schroder, Thomas, Sabin-Farrell, Rachel and Naidoo, Rohan
(2023)
Exposing Narrative Exposure Therapy: investigating autobiographical memory integration and the process of exposure and habituation in Narrative Exposure Therapy.
DClinPsy thesis, University of Nottingham.
Abstract
Introduction: Witnessing or being involved in traumas can lead to the development of post-traumatic stress disorder (PTSD). If people are subjected to multiple prolonged traumas this can lead to complex PTSD (CPTSD). Narrative Exposure Therapy (NET) is a treatment used for CPTSD; however, its autobiographical memory integration (ABMI) and exposure and habituation mechanisms of change are not well evidenced. The role of autobiographical memory (ABM) in therapeutic change needs to be explored. It is not appropriate to apply the existing measures of ABM to trauma narratives gained from therapy; therefore, the researcher developed the autobiographical memory integration coding tool (ABMICT). The NET protocol was adapted (termed NET+; Table 2) to allow its mechanisms of change to be examined.
Aims: The primary aim of the study was to investigate NET’s posited ABMI and exposure and habituation mechanisms of change. Secondary aims included: a) investigating the effectiveness of NET+ for trauma symptoms and levels of psychological distress; and b) to explore participants’ experiences and acceptability of NET+.
Methods: A single case design, mixed-method, naturalistic, sequential measurement, A-B, and follow up design was used. Change interviews were conducted after completing therapy. Participants were recruited from a secondary care mental health service within the UK. ABMI was measured by analysing therapy transcripts with the ABMICT. To assess exposure and habituation participants wore a chest strap collecting heart data and subjective units of distress were captured. Participants completed questionnaires to measure psychological distress, symptoms of trauma, and awareness of body experiences. Analyses included visually inspecting the outcome and process data, effect sizes, reliable (RC) and clinically significant change (CSC), and situational modelling analysis were also calculated. Content analysis was used to analyse the qualitative data.
Results: 3 female participants between the ages of 28-35 took part in the study. Two participants experienced symptom reduction in trauma with one experiencing a RC and another a CSC. Treatment effects were noticed in psychological distress for two participants, with small reductions in depression, anxiety, and stress across all participants, and a RC and CSC for one in anxiety. Two participants consistently experienced in session habituation. For all participants throughout therapy there were increases in vividness, sensory details, and decreases in disorganisation. Two participants had decreases in time and place details, emotional distancing, and narrative coherence more often than not. There were mixed results regarding fragmentation as one participant had a decrease across sessions, another an increase, and another had the same number of increases and decreases. For total word count two participants had the same number of increases and decreases, whereas only one experienced consistent decreases.
Conclusions: Claims of NET’s effectiveness in treating trauma and general psychological distress cannot be made, due to the results not being demonstrated across three cases. However, NET did reduce levels of trauma, psychological distress, and anxiety for some participants. The study’s findings do not support NET’s claims of ABMI as a mechanism of change but do support the exposure and habitation element. NET seemed acceptable as the only adaption suggested was to include more sessions. Future research developing the coding tool is needed which would allow the role of ABM phenomenology in mental health conditions to be better understood.
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