Narrative exposure therapy and KIDNET

1. Introduction

Version followed: Schauer, Neuner & Elbert, Narrative Exposure Therapy, 2nd revised and expanded edition (Hogrefe, 2011), as laid out in the manual's table of contents and introduction (publisher sample) and in vivo international's own procedural summary of the manual; KIDNET as described by Onyut et al. (2005) and Schauer, Neuner & Elbert (2017); FORNET as described by Elbert et al. (2015). A 3rd edition (Narrative Exposure Therapy (NET) for Survivors of Traumatic Stress, Hogrefe, 2025) exists but is not drawn on; any changes it makes are not reflected here [uncertain].

Narrative Exposure Therapy (NET) is a short-term, individual, exposure-based treatment for trauma-spectrum disorders in people who have lived through multiple or prolonged traumatic events, such as organised violence, torture, war, sexual violence and childhood abuse. It was developed by Maggie Schauer, Frank Neuner and Thomas Elbert at the University of Konstanz and the NGO vivo international, first in refugee and post-war settings (early case reports from a Kosovar refugee camp in Macedonia), and draws on the testimony therapy developed in Chile [source: Hogrefe sample; Neuner, Schauer & Elbert case reports; ISTSS interview with Neuner]. KIDNET is the child and adolescent version, which adds creative tools (drawings, a rope lifeline built and drawn by the child, role play, body positioning) [source: Onyut et al. 2005; CEBC]. FORNET (Forensic Offender Rehabilitation NET) is a variant for people who have both suffered and committed violence, such as former combatants and gang members [source: Elbert et al. 2015].

How change happens, as the authors describe it: traumatic experience is stored abnormally. Sensory, emotional and bodily ('hot') memory elements become detached from the autobiographical ('cold') facts of when and where they happened, so fragments intrude and trigger a 'fear network' as if the danger were present. Rather than suppress the network, NET has the person narrate their whole life in chronological order, slowing down at each traumatic event to re-activate the hot memory in detail while anchoring every sensation and emotion to its time and place. Fragments are woven into a coherent autobiography; the fear network is restructured and the person can register that the danger belongs to the past. The written narrative is read back, corrected and finally signed, which also serves as acknowledgement, a restoration of dignity and, with consent, a human-rights testimony [source: Hogrefe sample; vivo summary; ISTSS interview]. The authors relate the approach to emotional processing theory and to dual-representation models of traumatic memory [source: vivo summary (Elbert & Schauer 2002); Psychology Tools summary].

2. Framework

NET is delivered in a fixed sequence. The manual's own chapter structure is: first session (diagnosis and psychoeducation), second session (lifeline), third session (start of narration), following sessions (continued narration), last session, post-treatment diagnostic sessions, with KIDNET as an adapted variant [source: e-bookshelf front matter of the 2011 manual].

Dose and format. Individual sessions, usually 90–120 minutes. Reported totals vary by version and population: 3–6 sessions in the manual's own summary of field and controlled trials [source: KOPS record of the 2011 manual]; 4–6 sessions of 90–120 minutes in the FORNET paper [source: Elbert et al. 2015]; 4–14 sessions of about 90 minutes, adjusted to setting, in Neuner's account [source: ISTSS interview]. Exposure to a single traumatic event ('stone') typically needs 90–120 minutes, so plan session length around completing a stone, not around the clock [source: vivo summary]. KIDNET: 4–6 sessions of 1–2 hours in the first pilot [source: Onyut et al. 2005]; 8 weekly sessions of 90–120 minutes in the programme profile [source: CEBC]. FORNET: six sessions after diagnostics and psychoeducation, plus one or more rehabilitation sessions [source: Elbert et al. 2015]. With long, complex histories expect the upper end of these ranges [synthesis].

Phase 1 – Diagnostic assessment (session 1, first part). Goal: establish trauma-spectrum diagnosis and map exposure history. The manual's appendices include an event checklist (war and torture events) and the MACE adverse childhood experience scale; trials used structured interviews and self-report PTSD measures [source: e-bookshelf front matter; Onyut et al. 2005]. Move on when a trauma-related disorder is confirmed and the person consents.

Phase 2 – Psychoeducation and consent (session 1). Goal: normalise symptoms, give the memory/fear-network rationale, explain the plan (lifeline, narration, testimony), warn about avoidance, obtain informed consent (the manual includes a consent form). Move on when the person understands the rationale and agrees, including to the therapist encouraging them to continue when avoidance appears [source: vivo summary; ISTSS interview].

Phase 3 – Lifeline (session 2; optional in adult NET). Goal: a cold, factual, chronological bird's-eye map of positive events (flowers) and traumatic events (stones), used to plan which events will be narrated. Completed in one session. Move on once all key events are placed and the stones that drive symptoms are prioritised. The authors note the lifeline has not been shown to work on its own without the narration that follows [source: vivo summary; Elbert et al. 2015].

Phase 4 – Narrative exposure (session 3 to penultimate). Goal: chronological narration from birth (or earliest memories) to the present, with full exposure at each stone. Each session opens with reading back the previous narrative. Criterion to close an event and a session: arousal has peaked and fallen noticeably; never stop midway through a stone. Move to the final session when the narrative reaches the present [source: vivo summary; Elbert et al. 2015].

Phase 5 – Final session. Goal: read the whole narrative, correct it, sign it (client, therapist, interpreter/witness), hand a copy to the client; final lifeline ritual including flowers for future hopes; with consent, prepare the narrative as testimony [source: vivo summary; Elbert et al. 2015; Neuner et al. case reports].

Phase 6 – Post-treatment diagnostics. Reassessment after the end of treatment; trials re-tested at about one month and again months later [source: e-bookshelf front matter; Onyut et al. 2005]. FORNET adds rehabilitation sessions (group or individual) on the current situation and future before this point [source: Elbert et al. 2015].

Readiness. The sources give no formal readiness checklist; the manual has sections on challenging moments and ethics that are not drawn on [uncertain]. In the earliest case reports NET was used cautiously, after attempts to stabilise the person's social situation, and the authors warned that confrontational methods may harm people in the immediate aftermath of trauma [source: Neuner et al. case reports]. The authors also designed NET for insecure, low-resource settings, with an oral narration where a written record would be unsafe [source: Elbert et al. 2015]. Practical readiness check before starting narration [synthesis]: confirmed trauma-related disorder; no acute psychosis, acute intoxication or acute suicidal crisis needing other care first; client not currently living with the perpetrator or facing imminent danger that makes processing unsafe (if threat is ongoing, prioritise protection and discuss with the client whether to proceed); the client can attend sessions long enough to finish a stone; an interpreter is available if needed; for children, caregiver consent and a safe base.

3. Guiding principles

Whole life, not one index trauma. Narrate the full lifespan in order, because accumulated adversity drives symptoms. Practical meaning: do not pick a 'worst event' and skip the rest; go birth-to-present. [source: ISTSS interview; vivo summary]
Link hot to cold. Every emotion, sensation and thought must be tied to a when, where and what. Practical meaning: keep asking for time, place and sequence while the client is feeling the memory. [source: vivo summary; Hogrefe sample]
Context before the stone. Set the scene (date, season, life situation, political situation) and slow down roughly two hours before the event. Practical meaning: never jump straight to the worst moment. [source: vivo summary; Elbert et al. 2015]
Stay until it settles; never half-expose. Remain at the hot spot until visible relief; do not end a session in the middle of a stone, and do not return to an event once it has been closed. [source: vivo summary; Elbert et al. 2015]
Then versus now. Keep the client oriented to the present while reliving the past by contrasting feelings then with feelings now. Practical meaning: alternate 'what did you feel then?' with 'what do you feel now as you tell me?'. [source: vivo summary; Elbert et al. 2015]
Lifeline stays cold. On the lifeline record only labels, dates and places, not detailed emotions. Practical meaning: if strong emotion appears, acknowledge it, summarise the facts and defer to the narration session. [source: vivo summary; Elbert et al. 2015]
Resources count too. Flowers (good events, supportive people) are part of the life story and are validated. Practical meaning: actively ask for good people and what each gave the client. [source: vivo summary; Hogrefe sample]
Rogerian warmth with an active, structuring therapist. Empathic understanding, active listening, congruence and unconditional positive regard, combined with active guidance of recall. Practical meaning: you lead the chronology and the questions, warmly. [source: vivo summary; KOPS KIDNET 2017 abstract; Elbert et al. 2015]
Advocacy rather than neutrality. The therapist acknowledges human-rights violations and gives the survivor a voice; with consent the narrative can become testimony. Practical meaning: name injustice as injustice; offer, never press, documentary use. [source: ISTSS interview; Hogrefe sample; Neuner et al. case reports]
The client's account is not cross-examined. Credibility is not questioned; inconsistencies are treated as a normal feature of traumatic memory and gently clarified. Practical meaning: clarify for coherence, not to test truth. [source: Neuner et al. case reports] The account is recorded as the client's experience; it is not a forensic verification [synthesis].
Avoidance is expected and named in advance. Practical meaning: agree in psychoeducation that you will encourage the client to continue when they want to stop. [source: vivo summary]
Non-judgement, including about violence committed. In FORNET, positive emotions linked to violence (power, excitement) are elicited and accepted without moral judgement. Practical meaning: model acceptance; the moral discussion comes from the client's current perspective after exposure. [source: Elbert et al. 2015]
Write it down afterwards, in the client's words. No note-taking during emotional elaboration; write the narrative after the session, in past tense, recording only what was felt then. [source: vivo summary; Elbert et al. 2015]
Simple, transferable, culturally portable. The procedure needs only minor cultural change and can be delivered by trained lay counsellors with supervision. Practical meaning: adapt explanations and metaphors to the client's background, keep the procedure intact. [source: ISTSS interview; vivo summary]
Therapist fit and supervision. Especially for FORNET, start only if the approach fits your values and competence, with training and peer and external supervision. [source: Elbert et al. 2015] The manual also treats therapist avoidance as a named obstacle [source: e-bookshelf front matter].

4. Intervention inventory

Core adult NET (4.1–4.13), then KIDNET (4.14–4.19), then FORNET and setting adaptations (4.20–4.25). All example language is my own illustrative wording; none is quoted from the manual.

4.1 Diagnostic interview and trauma-exposure mapping

Purpose / when: Session 1, before anything else; confirms a trauma-spectrum disorder and gives a first view of the event load. [source: vivo summary; e-bookshelf front matter]
Steps: (1) Take demographic, medical and psychiatric history and current complaints. (2) Administer an event checklist covering war, torture, violence and other adversities (the manual appends its own vivo checklist and the MACE childhood-adversity scale; use the licensed forms, do not improvise items). (3) Assess PTSD (trials used structured clinical interviews and self-report PTSD scales such as the PDS) and depression. (4) Note dissociative responding, current threats, and suicidality. [source: Neuner et al. case reports; Onyut et al. 2005; e-bookshelf front matter] Step 4's risk items are [synthesis].
Example language (illustrative): "I'm going to ask about many kinds of hard experiences people go through. You only need to say yes or no for now; we'll come back to the details later, in a careful way."
Watch for: Shutdown or fainting already during checklist questions (flags a 'shutdown' pattern to plan for, see 4.11); events that are still ongoing.

4.2 Psychoeducation: the memory and fear-network model

Purpose / when: Session 1, after diagnosis; gives the rationale so the client can tolerate exposure and expect avoidance. [source: vivo summary; ISTSS interview]
Steps: (1) Normalise symptoms as typical consequences of many traumatic experiences. (2) Explain the brain model: hot sensory-emotional fragments are cut off from the facts of when and where, so reminders fire the alarm as if the danger were now; avoidance keeps the network unchanged. (3) Explain that telling the whole life story in order, slowly and in detail, lets the memories be put back into their place in the past. (4) Lay out the plan: lifeline, narration sessions, final reading and signed document. (5) Explain avoidance and get agreement that you will encourage continuation. (6) Where relevant, refer to universal human rights and the injustice of what was done (the early protocol explained the UN Universal Declaration of Human Rights). (7) Tailor depth from simple metaphor to detailed neuroscience to the client's background. [source: vivo summary; Neuner et al. case reports; ISTSS interview; Psychology Tools summary]
Example language (illustrative): "Your memories of the worst moments are stored like loose pages: the fear, smells and pictures are there, but the date and place are missing, so your body reacts as if it is happening today. We will write your life as one book, in order, so these pages get their date and place again."
Watch for: Nods without understanding; check by asking the client to explain the idea back. Fear that talking will make things worse is a cue to revisit avoidance.

4.3 Informed consent and the testimony option

Purpose / when: Session 1, before the lifeline. [source: vivo summary; e-bookshelf front matter (consent form appendix)]
Steps: (1) Describe the procedure, session length, temporary rise in distress, and the client's control over taking part. (2) Explain that a written narrative will be produced, read back and signed, that the client keeps a copy, and that any other use (human-rights organisations, lawyers, publication) happens only with separate explicit consent. (3) Use the manual's consent form or your service's equivalent. (4) For children, obtain caregiver consent plus the child's assent. [source: Neuner et al. case reports; Onyut et al. 2005] Being transparent about limits of the evidence was part of the early protocol [source: Neuner et al. case reports].
Example language (illustrative): "The document belongs to you. Whether anyone else ever sees it is your decision, and you can decide that at the end."
Watch for: Pressure from third parties (asylum lawyers, family) to produce a document; keep the therapeutic and legal purposes separate [synthesis].

4.4 The lifeline (flowers, stones, candles, sticks)

Purpose / when: Session 2 (one session); gives a cold, chronological map and a plan for which events to narrate; also surfaces resources. Optional in adult NET. [source: vivo summary; Elbert et al. 2015]
Steps: (1) Lay a rope or ribbon on the floor or table: one end is birth, the other end is coiled to stand for the future. (2) Invite a bird's-eye view of the life. (3) The client places flowers for good events and good times and stones for frightening and traumatic events, in chronological order. (4) Other symbols: sticks mark acts of violence the client committed or fights they took part in (sticks avoid assigning a moral value) [source: Elbert et al. 2015]; the final ritual includes candles alongside flowers, stones and sticks, used for losses [source: vivo summary; the exact candle convention is not described in the sources, uncertain]. Clients may combine symbols to show mixed feelings, and may create their own; symbols should reflect how the event felt at the time. (5) For each symbol, the client gives a short label, the approximate age or date and the place. Do not place symbols before birth. For events with gradual impact, date them from when the client first became aware of the effect. (6) Keep to cold facts: what, when, where. If emotion rises, acknowledge it, summarise the facts and say the detail will come in a later session. (7) If few flowers appear, ask about good people in the client's life and what each gave them. (8) Praise and encourage generously when the client places a high-shame event. (9) Photograph or sketch the lifeline with brief notes, prioritise stones that drive PTSD symptoms for narration, and let the client choose how to pack it up. [source: vivo summary; Elbert et al. 2015]
Example language (illustrative): "Let's look at your life from above, like a bird. Put a stone where something terrible happened and a flower where something good happened. Just give it a name and roughly when; we'll talk about it properly later."
Watch for: Lifeline turning into early exposure (client describing sensory detail): gently return to labels. Clusters of many stones in one period (plan more session time there). A very bare first half of life may reflect avoidance or early-memory gaps; do not fill gaps by suggestion [synthesis]. Working sign: the client can see the shape of their life and agrees a narration order.

4.5 Opening each narration session: read-back and corrections

Purpose / when: Start of every narration session from session 4 onward; consolidates the narrative and serves as an additional brief exposure. [source: vivo summary; Onyut et al. 2005; Neuner et al. case reports]
Steps: (1) Read aloud the narrative written after the previous session. (2) Invite the client to correct, change or add details. (3) Note emotional reactions; if a closed event still produces strong arousal on read-back, slow the reading and let the client stay with it until it settles [synthesis]. (4) Pick up the chronology where you stopped.
Example language (illustrative): "I'll read what we wrote last time. Stop me whenever something is not right or something is missing."
Watch for: Lower arousal on re-reading than during the original telling is a sign of processing [synthesis]. Request for many factual changes is normal.

4.6 Narrating the life between stones

Purpose / when: Throughout narration; builds the cold autobiographical context, including flowers and everyday life, in chronological order from birth to the present. [source: vivo summary; Elbert et al. 2015; ISTSS interview]
Steps: (1) Begin with family background and earliest memories. (2) Move through life periods at a moderate pace, asking about where the client lived, who was around, what daily life was like, and the political or social situation. (3) Spend time on flowers: what happened, who was there, how it felt. (4) Slow down as you approach the next stone (see 4.7).
Example language (illustrative): "Tell me about the house you grew up in. Who lived there with you? What did a normal day look like?"
Watch for: Rushing through childhood to 'get to the important part'; whole-life coverage is a core principle.

4.7 Slow-motion exposure at a stone (the hot spot)

Purpose / when: At every stone chosen for narration; the core exposure procedure. Plan 90–120 minutes per stone. [source: vivo summary]
Steps: (1) Context first: establish the date, season, place, what was going on in the client's life and around them; explore roughly the two hours before the event. (2) Begin at the start of the event and have the client narrate in slow motion, moment by moment. (3) Elicit all levels at each moment: what they saw, heard, smelled, felt in the body (sensory); what they thought (cognitive); what they felt (emotional); heart, breathing, sweating, trembling, freezing (physiological). Ask clarifying questions and offer tentative guesses about feelings that the client may correct. (4) Then and now: for the event, use past tense; at points, switch to present tense to ask what the client feels now while telling it, and contrast it with then. Present tense tends to increase arousal ('heat'); past tense tends to lower it, so use tense to regulate. (5) Link repeatedly: tie each emotion and body reaction to specific facts of time and place. (6) Stay at the worst moment until arousal has peaked and clearly decreased; do not stop halfway. (7) Carry on to the end of the event and the time immediately afterwards (when the danger was over), so the memory has an ending. (8) Close the stone only when arousal has fallen; do not mix opening and closing phases, and do not reopen a closed event in the same session. [source: vivo summary; Elbert et al. 2015; Onyut et al. 2005] Step 7's emphasis on reaching safety is my framing of 'completing the event' [synthesis].
Example language (illustrative): "It is evening, the rain has stopped, you are at the door. What do you see now? … What does your body do? … And as you tell me this today, sitting here with me, what do you feel? … That was then, in that village, in that year. Now you are here, and you survived."
Watch for: Rising then falling arousal within the session is the expected course; full reduction is not expected in one session and continues between sessions [source: Elbert et al. 2015]. Flat, detached telling or slowing speech, glazed eyes and loss of contact signal dissociation (see 4.11). Skipping or summarising the worst moment is avoidance (see 4.10).

4.8 Writing the narrative between sessions

Purpose / when: After each narration session; produces the autobiography and testimony. [source: vivo summary; Elbert et al. 2015]
Steps: (1) Do not take notes during emotional elaboration; write immediately after the session. (2) Write in first person, past tense, in the client's own words as far as possible. (3) Record what the client experienced and felt at the time; present-moment reactions discussed in session are not written into the narrative. (4) Where writing is unsafe (insecure settings, risk of seizure of documents), use oral narration and repeat the lifeline as closing ritual instead. [source: vivo summary; Elbert et al. 2015] Store the document as confidential clinical material [synthesis].
Watch for: Your own wording creeping in; read-back will expose it.

4.9 Meaning-making from the present perspective

Purpose / when: After a stone has settled; helps the client place the event in their life and update beliefs. [source: Elbert et al. 2015 (FORNET, after violent acts); Psychology Tools summary (cognitive reappraisal, e.g. registering survival)]
Steps: (1) Once arousal has fallen, ask what the client understands now about what happened, about their reactions then, and about what it meant for their life. (2) Highlight survival and the fact that reactions then were responses to real danger. (3) Do not argue; reflect and link to later life events. [synthesis for steps 2–3]
Example language (illustrative): "Looking back from today, what do you know about that night that you could not know then?"
Watch for: Self-blame that persists after exposure; note it for the shame/guilt guidance in section 5.

4.10 Counter-avoidance techniques within narration

Purpose / when: When the client skips, summarises, changes topic or wants to stop during a stone. [source: vivo summary; e-bookshelf front matter (sections on avoidance, withholding)]
Steps: (1) Recall the agreement made in psychoeducation. (2) Keep the client engaged with more specific questions about thoughts and feelings at the time. (3) Make the scene concrete with drawings, small figures, or by asking the client to show their body position at the time. (4) Return to the last detail before the jump and continue in slow motion. [source: vivo summary]
Example language (illustrative): "We agreed that this is the moment when I would ask you to stay with me. You were standing by the wall. Show me how you were standing. What did you hear next?"
Watch for: Distinguish avoidance from shame-based withholding or dissociation; each needs a different response (section 5).

4.11 Managing dissociation during exposure

Purpose / when: When a client starts to lose contact with the present (dissociative flashback, 'spacing out', fainting tendency), especially in clients with the 'shutdown' pattern. [source: vivo summary; Hogrefe sample (defense cascade, uproar vs shutdown); KOPS record of Schauer & Elbert 2010]
Steps (sources): (1) Distinguish intrusive memories, which are expected and wanted in exposure, from dissociative flashbacks in which the client loses touch with the present, which are to be prevented. (2) Ask the client to speak slowly. (3) Contrast past with present explicitly. (4) Use past tense to lower arousal. (5) Teach grounding techniques outside exposure sessions. (6) For dissociative clients, the authors refer to specific interventions in Schauer & Elbert (2010) and the manual's section on 'spacing out' [source: vivo summary]; these specific techniques are not drawn on [uncertain].
Steps (my additions, [synthesis]): keep the client's eyes open and on you; ask for short answers about the room; have them sit upright, press feet into the floor or squeeze an object; for fainting tendency, have them tense large muscles or stand briefly, then resume the narrative from the last oriented point at a slower pace. Check medical causes of fainting before continuing a course.
Example language (illustrative): "Stay with me. Look at me. You are here, in this room, today. Tell me slowly, in the past: and then what happened?"
Watch for: Working: the client can feel the memory while answering present-orientation questions. Not working: repeated loss of contact; slow the pace and shorten the segment before stopping exposure altogether. Never close a session while the client is dissociated (section 5).

4.12 Final session: reading the full narrative, signing, and closing ritual

Purpose / when: Last session, once the narrative reaches the present. [source: vivo summary; Elbert et al. 2015; Neuner et al. case reports]
Steps: (1) Read the whole narrative; the client stays engaged with it rather than distancing. (2) Make final corrections. (3) Client, therapist and any interpreter or witness sign it; the client receives a copy. (4) Lay out the lifeline once more with all symbols (flowers, stones, candles, sticks), then the client places flowers on the coiled end for hopes and wishes for the future. (5) Discuss hopes and plans. (6) Ask about consent for documentary use (human-rights organisation, lawyer, research, publication) and respect a no. [source: vivo summary; Elbert et al. 2015; Neuner et al. case reports]
Example language (illustrative): "This is your life in your words. By signing it we both say: this happened to you, and it was wrong. What would you like to put at the end of the rope, for the time that is still coming?"
Watch for: Mourning when the full story is heard; leave time. Pride in the document is a common and welcome reaction [synthesis].

4.13 Post-treatment diagnostic sessions

Purpose / when: After the end of treatment, to measure change. [source: e-bookshelf front matter; Onyut et al. 2005]
Steps: Repeat the diagnostic measures used at baseline, ideally with a clinician other than the therapist (trials used blind assessors at about one month and at months-long follow-up). [source: Onyut et al. 2005] Plan further help for residual difficulties [synthesis].
Watch for: Symptom reduction often continues after treatment ends [synthesis, consistent with between-session reduction noted in Elbert et al. 2015].

KIDNET (children and adolescents)

KIDNET follows the same sequence with child-friendly tools. It was originally adapted for children older than about 8; studies enrolled children and adolescents up to their late teens. [source: Onyut et al. 2005; CEBC] Obtain caregiver consent and the child's assent before starting [source: Onyut et al. 2005].

4.14 KIDNET psychoeducation

Purpose / when: Before treatment; brief, child-level explanation that the symptoms are common after many frightening experiences and that telling the life story helps. [source: Onyut et al. 2005]
Steps: Use simple language and a short standard rationale; adapt to age; include the caregiver as appropriate [synthesis for caregiver role].
Example language (illustrative): "When very scary things happen, the brain keeps the scary pictures but forgets where they belong. We'll make a story of your whole life so the pictures can go back to their place."

4.15 Free drawing at the start (and final drawing at the end)

Purpose / when: First session, before the lifeline; repeated at the end of therapy for comparison. [source: Onyut et al. 2005]
Steps: (1) Ask the child to draw anything that comes to mind. (2) Do not interpret it to the child; note any links to the trauma storyline, especially the worst event, as narration proceeds. (3) In the final session, ask for another free drawing and compare the two with the child. [source: Onyut et al. 2005]
Example language (illustrative): "Draw whatever you like, anything at all."

4.16 KIDNET lifeline (rope, stones, flowers, then drawn)

Purpose / when: First KIDNET session; the lifeline was first introduced in trauma therapy through KIDNET. [source: vivo summary; Onyut et al. 2005]
Steps: (1) The child lays a rope and places stones for bad events and flowers for good events in time order. (2) The child then draws the lifeline on paper with brief titles for each event. (3) Rebuild the lifeline at the start of each session before narration resumes. (4) Use a small object to stand for the child and move it along the rope to show where in the story you are. [source: Onyut et al. 2005]
Example language (illustrative): "This little figure is you. Let's put it here, at the start, when you were born, and walk along your life together."
Watch for: Younger children may need you to help with order and dates; use events they remember (school year, seasons, moves) as anchors [synthesis].

4.17 Drawings of scenes and objects

Purpose / when: During narration, when words are hard to find or the scene is confused. [source: CEBC; Onyut et al. 2005]
Steps: Invite the child to draw the place, the people, or an object from the event; use the drawing to ask slow-motion questions about what was seen, heard, felt and thought. [source: CEBC; Onyut et al. 2005]
Example language (illustrative): "Can you draw the room? Where were you? Where was the door?"

4.18 Body positioning and role play

Purpose / when: During exposure to a stone, to reconstruct the moment and help the child find words. [source: CEBC (body-positioning re-enactment); Onyut et al. 2005 (role play)]
Steps: Ask the child to show how they held their body during the event (e.g. crouching, hiding); use small role plays to clarify sequence; then ask about the feelings and body sensations in that position, then and now. [source: CEBC; Onyut et al. 2005] Keep role plays brief and stop them if they escalate beyond the child's control [synthesis].
Example language (illustrative): "Show me how you were sitting when you heard the noise. What does your body remember?"
Watch for: Habituation of arousal before closing the event, as in adult NET; the event is not closed until the emotional response has settled [source: Onyut et al. 2005].

4.19 Future part of the lifeline and the child's document

Purpose / when: End of therapy. [source: Onyut et al. 2005]
Steps: (1) Encourage the child to extend the story into the future, describing hopes, mainly with flowers. (2) Point to the leftover rope to suggest opportunities still to come. (3) Give the child a written document of their life story, including the drawings, the lifeline and their hopes. (4) Adolescents may request a written report for rights advocacy. [source: Onyut et al. 2005; KOPS KIDNET 2017 abstract]
Example language (illustrative): "Look how much rope is still left. What would you like to happen here?"

KIDNET format note

Individual sessions of 1–2 hours (pilot: 4–6 sessions with interpreters; programme profile: 8 weekly sessions of 90–120 minutes). [source: Onyut et al. 2005; CEBC] Session pacing for younger children may need shorter exposure segments within the session [synthesis].

FORNET (people who have suffered and committed violence)

FORNET keeps the NET sequence and adds procedures for appetitive aggression (violence experienced as exciting or rewarding). The authors stress that therapists need solid training, peer and external supervision, and personal comfort with the work before starting. [source: Elbert et al. 2015]

4.20 FORNET lifeline with sticks

Purpose / when: Lifeline session for ex-combatants, gang members, violent offenders. [source: Elbert et al. 2015]
Steps: (1) As in 4.4, with sticks for active involvement in violent acts (no moral valence), combinable with stones or flowers for mixed feelings, reflecting feelings at the time. (2) Mark or at least mention entry into and exit from armed groups or gangs. (3) For first violent acts (first fight, first killing, first rape committed), place the first occurrence. (4) Keep to facts and dates; defer emotional detail. [source: Elbert et al. 2015]
Example language (illustrative): "Some things you did yourself, like fights. Put a stick there. If it felt good and bad at once, you can put a stick and a stone together."

4.21 Narrating perpetrated violence and appetitive memories

Purpose / when: Narration of violent acts committed, especially the first ones, alongside the client's own trauma. [source: Elbert et al. 2015]
Steps: (1) Set context as for any stone. (2) Explore the first attack or killing in fine detail, including the thoughts that allowed the client to overcome inhibition (such as seeing others as enemies). (3) Elicit and name positive emotions linked to the violence (power, excitement, pleasure) together with negative ones; explore primary emotions (fear, disgust, joy) and self-conscious emotions (guilt, pride). (4) Ask about the victim's appearance and reactions, and let the client put into words any sense of their own vulnerability. (5) Stay non-judgemental and accepting throughout. (6) After exposure, invite the client to give the event meaning from their current perspective; if it still evokes positive emotion, remain non-judgemental. [source: Elbert et al. 2015]
Example language (illustrative): "Many people feel a rush of power in moments like that. What did you feel in your body? … And now, telling me about it, what do you feel?"
Watch for: Your own disgust or moralising (therapist avoidance). Legal and safeguarding duties if disclosures concern ongoing risk to others (section 5).

4.22 FORNET rehabilitation session: group format

Purpose / when: After the narrative is complete; addresses the current situation and prevention of re-offending. [source: Elbert et al. 2015]
Steps: Groups of 3–4 former members of armed groups, gangs or armies with one therapist. Discuss positive and negative aspects of the former role, emotions around leaving (e.g. handing over a weapon), and the advantages and difficulties of the current situation; develop coping strategies together; each states future plans. [source: Elbert et al. 2015]
Example language (illustrative): "What did you lose when you left the group, and what did you gain?"

4.23 FORNET rehabilitation session: individual format

Purpose / when: Alone or added to the group session. [source: Elbert et al. 2015]
Steps: (1) Ask about aims, obstacles and personal strengths. (2) Ask the client to recall a recent socially acceptable exciting moment linked to power, pride or control. (3) Stop the narration at peak positive arousal, summarise strengths and give positive feedback to build self-esteem and self-efficacy. [source: Elbert et al. 2015]
Example language (illustrative): "Tell me about a recent time you felt strong and in control, in a way that hurt nobody."

4.24 Working with interpreters

Purpose / when: Whenever the client's language differs from yours; standard in NET's refugee settings. [source: Neuner et al. case reports; Onyut et al. 2005]
Steps: Brief the interpreter beforehand on the psychological goals; the therapist writes the translated account; the interpreter signs the final narrative as a witness. [source: Neuner et al. case reports; vivo summary] Additional: brief the interpreter on first-person interpreting, slow pace during hot spots, confidentiality, and offer debriefing after sessions [synthesis].

4.25 Lay-counsellor and low-resource delivery

Purpose / when: Settings without specialists (camps, post-conflict regions). [source: ISTSS interview; vivo summary]
Steps: Train local lay therapists (teachers, fellow refugees) in the procedure, with supervision; local trainers can train the next cohort (train-the-trainer). Training details and certification are held by vivo international and the authors' groups [source: ISTSS interview]; specific certification requirements were not found [uncertain]. Use oral narration if a written record would be unsafe [source: Elbert et al. 2015].

5. Handling problems

The manual has a section on 'challenging moments' (avoidance; dissociation or spacing out; social emotions; withholding information; lack of habituation; therapist avoidance; memory and reality; the therapist-patient relationship and ethics) [source: e-bookshelf front matter], but its text is not drawn on. Guidance below is from the sources where tagged; everything else is [synthesis].

Avoidance (skipping, summarising, wanting to stop). Recall the agreement from psychoeducation; ask more specific questions about thoughts and feelings then; use drawings, figures or body position to re-enter the scene [source: vivo summary]. If the client insists on stopping mid-stone, negotiate a slower pace or past tense rather than stopping; if they still refuse, respect it, take them to a point of relative safety in the story, reduce arousal and plan to complete the stone next session [synthesis]. Do not pressure beyond consent: the early protocol told clients they controlled the process and would not be pushed [source: Neuner et al. case reports].
Overwhelm and very high arousal. Shift to past tense, slow down, anchor repeatedly in time and place, contrast then and now [source: vivo summary]. Do not end the session at peak arousal; stay until it falls [source: vivo summary; Elbert et al. 2015]. Plan session length so a stone can be completed [synthesis].
Dissociation, shutdown and fainting. See 4.11. In the case reports a client who fainted while narrating continued once she regained consciousness, and fainting stopped by the third session [source: Neuner et al. case reports]. Medical review of recurrent fainting, keeping the client seated, and grounding before any session ends are [synthesis]. Never let a client leave dissociated: reorient (date, place, names), check they can describe how they will get home, and arrange accompaniment if not [synthesis].
Shame and guilt ('social emotions'). Praise and encourage when high-shame events are placed on the lifeline [source: vivo summary]; telling the story to a compassionate listener is held to reduce shame and isolation [source: ISTSS interview]; in FORNET, guilt and shame must be addressed before reintegration [source: Elbert et al. 2015]. The manual's specific procedure for social emotions is [uncertain]. Practical steps: name shame as a common response to being humiliated; slow down at the shame moment and ask what the client thought others saw; after exposure, explore from the present perspective what they could and could not have done [synthesis].
Withholding information. Some clients leave out events (sexual violence, own perpetration, events that endanger others). Revisit consent and confidentiality; offer the option of narrating without the detail being written down; return to the event later in chronology [synthesis].
Lack of habituation. If arousal does not fall across a stone or on read-back, check for avoidance within the narration (missing the worst moment), dissociation, ongoing threat, or an unaddressed later stone linked to the same cues; narrate more slowly and in more detail at the true hot spot [synthesis]. Remember that full reduction is not expected in one session [source: Elbert et al. 2015].
Therapist avoidance. The manual names it as an obstacle [source: e-bookshelf front matter]. Signs: rushing past details, taking notes to escape, changing topic, not asking about sexual or perpetration details. Response: supervision, rehearsing hot-spot questions, monitoring your own arousal [synthesis]; for FORNET, peer and external supervision are required [source: Elbert et al. 2015].
Memory and reality. Treat inconsistencies as normal and clarify gently without questioning credibility [source: Neuner et al. case reports]. The narrative records the client's experience; never use suggestion, leading questions or imagery to fill gaps, and when memories are unclear write what the client remembers and that the rest is uncertain [synthesis]. If the narrative may be used in court or asylum proceedings, make clear to all parties that it is a therapeutic narrative, not a forensic interview [synthesis].
Stuck at the start (bare childhood, few flowers). Ask about good people and what each gave [source: vivo summary]; use concrete anchors (homes, schools, seasons); accept gaps rather than construct memories [synthesis].
Non-attendance and drop-out. The written biography is described as a major motivator for completing treatment [source: vivo summary]. After a missed session, reach out promptly; begin the next session with read-back; if avoidance is driving absence, revisit the rationale [synthesis]. Avoid long breaks between sessions where possible [synthesis].
Ruptures in the relationship. Empathy, congruence and unconditional positive regard are the stance [source: vivo summary; KOPS KIDNET 2017]. If the client feels pushed or judged, name it, acknowledge your part, recall the shared aim, and agree pace together before continuing [synthesis].
Ongoing threat or insecure setting. The authors used NET in camps and post-conflict areas and recommend oral narration where writing is unsafe [source: Elbert et al. 2015]; the early reports first tried to stabilise the social situation [source: Neuner et al. case reports]. If the client still lives with a perpetrator or faces imminent danger, prioritise protection and safety planning; postpone exposure to ongoing danger [synthesis].
Suicidality and self-harm. Assess at intake and when distress rises; if acute risk appears, pause narration at a closed point, follow standard risk assessment and safety planning (including lethal-means counselling: secure storage or removal), and resume when risk is managed [synthesis].
Disclosures of others' risk (FORNET, child protection). Explain limits of confidentiality at consent; follow local mandatory reporting duties for child abuse or imminent danger to others [synthesis].
Children: caregiver issues. Obtain caregiver consent [source: Onyut et al. 2005]; if the caregiver is distressed or is a source of current threat, address safety first and involve child-protection services as required [synthesis].
Interpreter difficulties. Interpreters can be distressed by the content or soften it. Brief, debrief, and use the same interpreter throughout [synthesis]; brief them on the psychological goals [source: Neuner et al. case reports].
Pressure to use the testimony. Use outside therapy only with explicit consent [source: Neuner et al. case reports; vivo summary]; the decision is revisited at the final session and can be declined [synthesis].

Sources

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