Impact of NET on torture survivors in the MENA region

Narrative Exposure Therapy (NET) is a brief cognitive-behavioural intervention for individuals with posttraumatic stress disorder (PTSD) which has mostly been used to treat traumatised asylum seekers and refugees in highincome settings. Evidence is scarce on the effectiveness of NET with torture survivors, especially in the Middle East and North African (MENA) region where health systems are unable to meet the increasing needs of mental health disorders caused by war and displacement.

During the period 2013 to 2016 DIGNITY - Danish Institute Against Torture, in collaboration with partners, implemented a capacity-building training programme on NET among 44 Arabic health professionals from highly specialised torture rehabilitation centers in Jordan, Palestine, Egypt, Lebanon, Iraq, Tunisia, Libya, Sudan and Syria. A multi-centre study was carried out across all centres comprising of the collection of client data on socio-demographic variables, torture exposure, and psychosomatic health indicators. Clinical assessment of mental health symptoms among torture survivors was performed by the NET therapists pre- and post NET therapy and at four months' follow-up, and means were compared.

Our findings show a statistically significant reduction in average psychological symptom load for PTSD (from 3.20 to 1.80), anxiety (2.78 - 1.61) and depression (2.75 - 1.96) with the largest effect on PTSD symptoms, and a larger effect for women than men. The results indicate improvements in selfreported health (3.85-2.82) and physical disabilities (2.90-1.76), as well as reduction in pain perceptions after therapy (4.44 -3.44). The duration of treatment was three months on average with a span from one to eight months.

This study provides new evidence suggesting a strong positive effect of NET in an Arab cultural setting which remains under-represented in the NET evidence base. However, some important limitations of the study preclude drawing firm conclusions, namely the lack of a control group, a high number of dropouts in follow up data and a potential risk of information bias. Contexts familiar to the torture survivor and shared cultural norms and language between the client and the therapist might positively affect the effect of NET on PTSD symptoms. This capacity-building training programme established a community of Arab trauma mental health experts in the MENA-region, and their implementation of NET was associated in time with a reduction of the mental health symptom load of survivors of torture and war.