Profile: Dr Katy Robjant Talks Narrative Exposure Therapy

Dr Katy Robjant is a Consultant clinical psychologist and researcher, specializing in the treatment of PTSD and other trauma related disorders in asylum seekers, refugees and victims of trafficking. She is Director of National Clinical Services at Freedom From Torture and Vice President of vivo international. We talked to Katy about what makes NET so powerful, her recent fieldwork in the DRC with child soldiers, and implications for the future of treating trauma.

The path to working within trauma

What attracted you to clinical psychology initially?

I didn’t initially intend to go into clinical psychology, I was very interested in social psychology and understanding memory processes, cognition and the broader picture. I liked the way psychology mixes a lot of different ways of thinking together and has a broad applicability to many different areas of life, but there’s also the more solid, hard science element which I appreciate as well. Having done the degree, it seemed to me that the most interesting way of applying psychology was to go into clinical psychology. I was fascinated with mental health at the time and wanted to work with people.

How did you become interested in working with refugees and survivors of conflict-related trauma?

After deciding to do applied psychology, I knew straightaway that I wanted to work with trauma and refugees’ mental health. I’d been very interested in human rights and social justice issues for a long time, and was very passionate about refugee work. Trauma in psychology is very interesting. It was  clear to me that there was an obvious role for psychologists within healing trauma, in a way that was less clear cut for other mental health problems, where there might be good evidence base for pharmacology as well. I really liked how psychology seemed to have an important role in terms of understanding memory processes, and what this meant for treatments of PTSD.

Where are you working now?

I’m the Director of National Clinical Services at Freedom From Torture, an organization which primarily provides rehabilitation services to survivors of torture. I came in 2 years ago to redesign the clinical model and introduce an evidence-based approach for treating trauma focused therapies and mental health problems. I’m really proud of what we’re doing, because we have a very strong emphasis on being survivor-led, and our new clinical model was co-designed with survivors. We did a very thorough survey to identify what kind of clinical service they wanted, and we’re about to roll out co-led therapies: where survivors are going to co-lead stabilization groups and other kinds of reintegration group. We’re also testing for cultural replicability with our survivors.

Is co-designing the clinical model common practice within trauma services?

There is an understanding generally that it’s best practice to involve service users in what services look like. But interestingly, in all the trauma services that I’ve worked in, within both the NHS and voluntary sector organizations, there tends to be less service user involvement in the most meaningful ways. All services tend to have service user groups, with informal and formal feedback mechanisms, but those are quite low down in terms of the ladder of empowerment. We’ve tried to take it further than that. We involved survivors in our project board when we were looking at the new model, and we surveyed survivors in different languages. We’ve just introduced a new directorate for survivor empowerment, and recruited a survivor of torture into this role. We are advertizing for salaried posts, so survivors will be paid to help us deliver these stabilization groups. We’re looking at doing some research to see what benefits there are for the survivors who are delivering these services as well. Within the worlds of psychosis and addiction, it’s very well recognized that for new service users who are coming in, it’s really empowering to see people who’ve come out the other side. These are some of the most complex areas of mental health, and we want service users to feel empowered here too.

Narrative Exposure Therapy

Can you give me the 2-minute version of NET? Why should clinicians know about it, what makes it so powerful, and why?

Narrative exposure therapy was developed for treating Post-Traumatic Stress Disorder and trauma spectrum disorders, in people who have experienced multiple traumas in the context of human rights abuses. Since then, it’s been expanded for people who’ve experienced basically all types of trauma. I think it’s powerful for a few reasons. Firstly, it’s a very straightforward model, so clients can understand it easily. It essentially maps out someone’s traumatic experiences along a lifeline, within the context of their whole life. Secondly, it identifies where the sources of strength are, what resources can be drawn on, and the good experiences they’ve had within their life. We understand the importance of the building block effect, whereby trauma has a cumulative impact, with later traumas build on those that have happened earlier.

Because NET takes this lifeline approach, everything is within context. Trauma doesn’t just happen to people in isolation: it’s not just a single event, it’s within the context of their life. So, we also look at what the immediate context is for individuals in terms of their family life and their socio-political situation at the time. There is considerable emphasis on meaning making. When you’re talking about trauma occurring within human rights violations, it’s also very important for the human rights perspective to be considered and acknowledged.

NET was designed with an understanding that it would be most needed in the areas with the least likelihood of having specialist trauma services or mental health professionals in place. It’s designed so that it’s possible to train people who are not necessarily mental health experts to deliver the treatment quite easily. It was also developed with an acknowledgement that the areas with the greatest need were going to be areas that are likely to be really insecure. The people in most need don’t have six or twelve months living in a safe, secure setting where they’re stable enough to take part in long, in-depth therapy. There’s likely to be ongoing conflict, and huge incidence of further trauma during and after the therapy. So, when you’re developing appropriate treatment for areas like this, you need something that can be delivered quickly, which is going to efficiently get people to the point where they’re able to survive, do well and recover.

One other difference between NET and other trauma focused therapies is that it has a dual emphasis. We focus on reducing distress and treating symptoms, but equally, it’s also very important to produce a narrative or testimony of a person’s experiences, which acknowledges and bears witness to the human rights abuses that people have endured.

How is it possible for NET to be delivered successfully by people who aren’t necessarily mental health experts?

The approach is actually incredibly systematic and formulaic, so it can be taught. We teach how to do the diagnostics, psychoeducation, the lifeline approach, and the theory about why it’s important to do exposure work, and what’s happening with the memory when we do the reprocessing. The majority of the time is spent learning the skill in very small groups. The facilitator is literally live training the process of delivering an exposure of a stone (a trauma). It’s an intense process but because our method is actually straightforward, manualized and consistent, it’s very easy to go through this process of intense training to pass this knowledge on. We provide intensive follow up supervision as well.

Firstly, we’re usually training people who have been affected by trauma, who are living in the same communities as the survivors they’re working with. So, there is already an understanding of the context and some trauma experience. There will be people who grasp it better, who are more empathetic and naturally able to do it, but the key thing that we look for when we’re trying to find people to train, is not a high education level or a high experience of working in mental health. It’s emotional attunement and empathy. People who have that make the best therapists, and we can train people to use the approach. That said, it is now very well used in most specialist trauma services by experts too, and obviously they deliver a more sophisticated version, to great effect.

Secondly, and maybe a bit more controversially, I would say that when you look at the trials for the evidence-based approaches for PTSD, they show that NET is doing really well. It’s making such an impact, and has the most convincing evidence base for people who have PTSD from multiple traumas. The approach is firmly rooted in science (within psychology and also beyond into other fields). Many of the trials show the effectiveness of the therapy when delivered by people who do not have experience as a mental health professional, and with an intervention where actually you don’t need huge numbers of sessions. Arguably, if we can train people to do that, then I wonder if the other approaches actually are over relying on the professionalism of the therapy to some extent. I sometimes think things are being over complicated and over professionalized.

Can you explain a bit about how the exposure element in NET is different to other trauma treatments?

Often people think that it’s just like reliving an experience, and then simply writing a narrative of what is said, but it’s actually really different. During exposure work in NET, the therapist is incredibly directive. You hear the therapist’s voice much more than you would in either EMDR or trauma focused CBT. I always refer to the processing of trauma in NET as an ‘exposure conversation’. The therapist is right there with the client, directing, and is incredibly attentive to every expression that passes on the client’s face. Every movement that they make, the therapist will mirror back to them. So they might say “Now I can see you look really, really scared. Is that how you felt back then?” Or “You look angry? Did you feel angry back then?”, “I can see that you’re moving over to your right, is it that direction that you fell?” It’s this piecing together of the picture and understanding the person’s experience of the trauma based on what they can see right then in the room that helps the client to feel very contained and very well understood. There’s also a lot more around emotional attunement and empathy than maybe is emphasized in other exposure approaches. This is why it is so useful for complex trauma, because this emotional attunement during exposure is where the attachment repair occurs.

What is the significance of the testimony?

The narrative testimony is constructed by the therapist during the process of the therapy and read back each session and also at the end of the process. At the end, the client and the therapist both sign that this is an accurate testimony of the person’s experience. It can be used in many ways but until recently they’re often kept individually, and might be sent to human rights charities/ networks, to enable human rights defenders, or used by solicitors to assist with immigration claims.

We have looked at whether NET works as well without the narrative, how vital it is to the process, and actually, it doesn’t work as well without it. There is something in addition to the memory re-processing that happens through developing the narrative. It keeps clients engaged in the therapy because they know the testimony process is going on. They know that at each session they’re going to be processing a really difficult trauma, and like any exposure treatment it’s going to be painful and incredibly hard, but they know there’s also a secondary objective: that they’re working together with a therapist to produce an account of their experiences. I think this really motivates some people to keep going and can feel rewarding.

Fieldwork in Democratic Republic of Congo

You recently returned from carrying out fieldwork research in DRC with vivo international and the University of Konstanz. Can you tell us a bit about what you were doing there?

We were running three projects. In the first one we used NET with survivors of gender-based violence. It was a randomized control trial, and a dissemination trial. We trained up nurses to deliver the therapy, we then trained those people to become trainers of the second round of people, and then a third round as well. The second project was a randomized control trial working with perpetrators. There’s a newer version of NET developed called FORNET, which is used when treating perpetrators. I and two colleagues further developed this approach to have a much larger group component, which we used with women in Eastern Congo, who had been abducted and made to fight as child soldiers.

Our third project was a community project testing a completely new intervention involving the use of narratives from our various NET and FORNET trials in the area. At the same time, we screened and treated people who needed to have the individual treatments. The community intervention (NETfacts) was found to be feasible and also had immediate post intervention benefits for those involved. This is about to be published and a much larger RCT of the community intervention involving multiple communities is near completion. The NETfacts intervention challenges collective avoidance and allows a collective memory of traumatic events that happened to the whole community (but with different individual experiences), to be understood. We found this had a strong restorative effect and positive impact on the community.

Can you tell us about a time during these projects where you saw particularly powerful outcomes, or when you’ve been most proud of its effect?

I would definitely say this happened during our second project, working with perpetrators. We were in a small area in eastern DRC, where during the war the M23 rebel group took huge numbers of girls and boys from the village and abducted them to be child soldiers. After being with this rebel group for a number of years, they then returned to their home villages. We went there to try to see if we could recruit people for the larger trial, and realized that it was a very special kind of area. There was a group of women walking around in this village who everybody knew had been abducted into the M23. They had then been rejected by their families, and by everybody within the village. There were huge problems of escalating ongoing violence. The women were highly stigmatized, they were being mocked and ridiculed in the street and then reacting incredibly angrily and aggressively because of their exposure to trauma and perpetration of severe violence. As a result, there was this endless cycle of ongoing violence, which stigmatized them further.

We based our approach on the original FORNET protocol but expanded the group component to see if we could help reduce the violent behavior. Some of the original FORNET trials found that they could reduce the post-traumatic stress disorder, but not the aggression. So, we adapted it to work more on the aggression in the group component. Our trial results found not only a reduction in PTSD symptoms, but also aggression. Most importantly, it wasn’t just the sort of aggression as measured by the psychological measures, but also in terms of actual perpetration of ongoing violence. So, the group that received our FORNET compared to the control treatment group, were basically no longer engaging in as many violent acts, which is really important in terms of reducing stigma, and trying to increase integration.

We saw just how important the group component was in this particular setting. It’s interesting because the women all knew each other, but they weren’t friends or really supporting each other. They were trying to stay away from each other. It was really powerful at the end, when we went back to do the final follow up measures. Some of the women were standing up in community meetings, volunteering that they had been raped, but that they now knew that didn’t mean they were worthless. Even though they’d had a child, (meaning a child born of rape) they knew they could still get married to somebody else. So, they were not only acknowledging in public what had happened to them, but were then going on to say, ‘but I now know it doesn’t mean it’s the end of things for me’. That was just really rewarding, and I’m sure they only felt able to say that, because they were surrounded by all these other women who were supporting them.

Were you expecting this result or were you surprised by its efficacy?
By adapting the group component, I suspected that we might be able to persuade people to try to practice more pro-social ways of managing conflict, or just avoiding conflict, but I didn’t expect we would have an impact on their actual feelings of aggression towards others. We also found that their social acknowledgement went up. There was very low social acknowledgement at the beginning, and after treatment the level of social acknowledgement was very much repaired, and I think that played a part as well. If they hadn’t stopped acting so aggressively, they wouldn’t have received the more positive responses from the community. It was those more positive responses from community members which made them feel part of the community, and which started a different cycle of behavior.

Research and influencing the bigger picture

So many clinical psychologists don’t actually end up carrying on with research. Why do you value doing research as well as clinical practice?

I think it’s partly about having a balanced, varied working life. If I was just doing trauma, clinical work all the time, I think there would be a much higher risk of burnout. I like the intellectual challenge and the objectivity of research, and I like to think about how we can adapt treatments and make them better for people. The amount of trauma in the world is only going to get worse so how can we make treatment available to more people?

It’s interesting, because a lot of people who work in trauma will say they feel the need to do something in the bigger picture as well. If you’re doing individual clinical work, you can help on an individual level. Then if you also do research work and think about new treatments, and how they can be disseminated in places where otherwise they wouldn’t happen, you can have an impact at different levels and influence a bigger picture. It helps with my sense of injustice in the world, trying to do something which is going to have a bigger impact.

What prompted the move to start working with combatants and child soldiers?
Within the context of the projects that we ran in the DRC, the question of who is a victim and who is a perpetrator becomes a bit of a false distinction. There were no examples of people who have been extreme perpetrators, where they haven’t also had exposure themselves to trauma early on. Within the typical lifelines that we were doing, regardless of which project, people would have had early experiences of trauma. Potentially abuse within the home or, or multiple war experiences, or they’d been living in the village where a rebel group had attacked and there were traumatic events during that. Then maybe another war, maybe they have a period of time where they can’t afford anything to eat, a rebel group comes through and they’re abducted, and then they’re forced to kill and murder people. You end up seeing that no matter which sort of project we’re working with, there’s no way to separate the two groups – victim and perpetrator.

Over the time you’ve been involved in this area, do you think your approach has changed?

I definitely think it has changed. I can now really see the benefit of making sure that we get the treatment capacity to the places that it’s really needed. I’ve become much more passionate about that than I used to be. I used to just be exposed to NHS trauma services, and while they are amazing services and we need those too, they are largely inaccessible. Even people who speak the language and know the NHS system (so don’t face additional barriers in that way) still have to wait ages to be assessed and treated by a specialist trauma service now. They’ll have to wait for many years and go through multiple assessments to get there. I think it’s really important that we maintain this paradigm shift towards training up people who are not necessarily expert, into delivering the therapies for the people who really need it, where they need it.

I always felt like that’s how it should work in low resource countries. But now even in the UK, the amount of people who need specialist trauma treatment is so big. The most traumatized slip through the gaps in society, they are in hostels or street homeless, fleeing domestic or international violence or are detained in immigration centres or in prisons. I feel like we have a responsibility to make sure we have approaches and train people who are able to learn these skills to deliver them to people who need it wherever they may be. We shouldn’t put this artificial barrier up that you have to be this hugely experienced, educated specialist to be able to learn how to help. I don’t just mean NET, although it is an obvious example, since we can do it with NET, I’m sure we can do it with other approaches.

I’ve often heard clients say that they first tried to open up to someone at their church or to a social support worker, or something like that, and the person said they weren’t specialist enough to deal with their trauma, or they we’re too worried about re-traumatizing them, so they should speak to experts instead. We’ve ended up facilitating this whole idea that it’s better not to talk about the trauma, it’s good to keep it all hidden and to wait until you see the expert, 18 months or more down the line.

Looking ahead

Why is it important for therapists to know about NET even if they don’t work with refugees?

In reality, many NHS trauma services are now using NET for complex trauma clients of all kinds, and it is certainly not just for refugees. We have written a chapter on NET for complex PTSD and the lifeline approach, as understanding the cumulative impact of trauma is very helpful for those who have experienced early trauma in childhood. Dissociation is also understood as a biologically adaptive response to trauma, and NET includes an effective treatment within the exposure sessions themselves using specific simple techniques. This means the approach can be very helpful for complex trauma clients who dissociate (without necessarily the need for preliminary ‘stabilization’ phases of treatment).

Finally, although NET is seen as being very much like CBT – there is a significant focus on emotional attunement during the exposure and attachment repair, and this is particularly important for those who have experienced developmental trauma. All those experiencing interpersonal trauma also benefit from the human rights approach and the testimony, not just those fleeing conflict and political violence. It applies equally to those who have experienced human rights abuse in the home.

How do you think psychologists might be treating people who have been multiply traumatized differently in twenty years’ time?

I hope that we are in a position where treatment is so readily available, that people don’t have to struggle to get it. Because obviously the longer that people go on suffering with trauma, the worse the situation becomes for the individual, their family, and the community. But I also hope that we are looking at where there are cycles of violence happening in society, and using community interventions to try and prevent further trauma happening.

In the DRC, the trauma was just never ending, there were constantly more victims, but through the combination of individual treatments that treat both trauma and aggression, as well as community interventions, we can help integrate people back into communities so that they’re not left struggling on the outskirts. When they’re left on the outside, they’re more likely to rejoin armed groups again, and are therefore going to continue perpetrating violent acts because they’ve got no other way to survive. Obviously, that’s within the context of the Congo, but I think there are implications for other settings as well, for example children who are involved in gangs in this country, and potentially other groups. There is there a lot more work that we could do with violent offenders, who also have a background of trauma, to try and reduce violence, because there’s so much emphasis on reducing trauma. The flip side of that is, what are we doing with the people who are perpetrating violence in order to try and resolve things and bring down the amount of trauma generally? So I hope treatment can be available to everyone, really well understood and not unnecessarily overly protected in this specialist area of expertise anymore, but that more is being done to reduce trauma too. Accessibility is key, and we also just developed some guidelines for delivering NET remotely, which should also increase accessibility.

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