Narrative Exposure Therapy: A Case for Use With Refugees via Telehealth With the use of an Interpreter

Theoretical and Research Basis for Treatment

Refugee/asylum-seekers have a high prevalence rate of trauma-related mental disorders. Despite this psychological impairment, refugee/asylum-seekers are expected to integrate into the host society and to meet high functional requirements (i.e., social integration and financial independence) (Schick et al., 2016). The United Nations’ Refugee Agency’s (UNHCR) figures suggest that there are 79.5 million displaced people around the world with approximately 26 million being refugees (UNHCR, 2020). Additionally, refugee and asylum-seekers have a greater likelihood of having experienced traumatic events than the general population within high-income countries (Kalt et al., 2013). The nature, severity and duration of trauma experienced by refugees is different to that of other populations (Schick et al., 2016). Not surprisingly, rates of PTSD and depression are at least as high as or higher among samples of refugees than in the general population (Lambert & Alhassoon, 2015).

As defined by the Diagnostic Statistical Manual of Mental Disorders-5 (DSM-5), post-traumatic stress disorder results from exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: directly experiencing the traumatic event; witnessing, in person, the events as it occurred to others; learning that the traumatic event occurred to a close family member or friend; and experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (American Psychiatric Association, 2013). PTSD requires the presence of one or more intrusion symptoms associated with the traumatic event. Some examples of intrusive symptoms are recurrent, involuntary, and intrusive distressing memories of the traumatic event, recurrent distressing dreams related to the traumatic event, and dissociative reactions (e.g., flashbacks) where the individual feels as if the traumatic events were recurring. A diagnosis of PTSD additionally requires the presence of persistent avoidance of stimuli associated with the traumatic event(s) as evidenced by one or both of the following: avoidance of or efforts to avoid distressing memories, thoughts, or feelings about the traumatic event(s) and/or avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings, associated with the traumatic event(s). A diagnosis of PTSD requires two or more symptoms associated with marked alterations in arousal and reactivity associated with the traumatic event(s), such as irritable behavior and angry outbursts, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbance. Lastly, the duration of these symptoms lasts for more than 1 month and causes clinically significant distress or impairment in social, occupational, or other important areas of functioning and is not attributable to the physiological effects of a substance (e.g., medication and alcohol) or other medical condition (American Psychiatric Association, 2013).

As mentioned, rates of depression are at least as high as or higher among samples of refugees than in the general population (Lambert & Alhassoon, 2015). As defined by the Diagnostic Statistical Manual of Mental Disorders-5 (DSM-5), Major Depressive Disorder (MDD) requires the presence of five (or more) of the following symptoms, including at least one of the symptoms of (1) depressed mood or (2) loss of interest or pleasure, that have been present during the same 2-week period and represent a change from previous functioning. Symptoms associated with MDD include, depressed mood most of the day, nearly every day, as indicated by either subjective reports or observation made by others; markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day; significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day; insomnia or hypersomnia nearly every day; psychomotor agitation or retardation nearly every day; fatigue or loss of energy nearly every day; feelings of worthlessness or excessive or inappropriate guilt nearly every day; diminished ability to think or concentrate, or indecisiveness, nearly every day; and recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. Additionally, these symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning and is not attributable to the physiological effects of a substance (e.g., medication and alcohol) or other medical condition (American Psychiatric Association, 2013).

Typically, exposure to a traumatic event may occur pre-migration, during transit, and/or post-migration (Zimmerman et al., 2011). Post-displacement risk factors include life-threatening migration often through smuggling (Schwarzer & Schulz, 2003). Being displaced in a new country creates additional stressors which can exacerbate existing mental health issues (Wright et al., 2020). Compared with other populations, relatively few randomized controlled trials of trauma-focused therapies have been conducted with refugees. Lambert and Alhasoon (2015) conducted a meta-analysis of randomized controlled trials of trauma-focused therapy for refugees and identified seven studies that used Narrative Exposure Therapy (NET), four studies that used Cognitive-Behavioral Therapy (CBT), and one study that used Eye Movement Desensitization and Reprocessing (EMDR). They evaluated the overall effect sizes for reduction of PTSD and depression and examined moderators of PTSD outcome based on study methods. They found that the overall effect sizes were large when comparing treated participants to those in control conditions, suggesting that the trauma-related distress of refugees can be effectively treated with these approaches.

A 30-year review evaluated evidence-based psychological interventions for adult survivors of torture and trauma, which included interventions either delivered individually or as groups. McFarlane and Kaplan (2012) identified 40 studies that empirically investigated interventions for survivors of torture and trauma. Included interventions were multicomponent rehabilitation and outpatient psychiatric services, Cognitive-Behavioral Therapy (CBT), cognitive-processing therapy (CPT), exposure therapy (ET), healing and reconciliation workshops, NET, psychodynamic therapy, psychotherapy, stress and coping skills training, testimony therapy (TT), and trauma counseling (McFarlane & Kaplan, 2012). For the purposes of this case study, this author will focus on the interventions and studies that were conducted with asylum-seekers and resettled refugees.

Hinton, Hoffman, Pollack, and Otto (2009) conducted a randomized controlled treatment study with 24 Cambodian resettled refugees diagnosed with PTSD who received a culturally adapted form of CBT for 12 weeks and were compared to a delayed treatment group. They found significant improvements in PTSD symptoms, affect regulation, panic, and systolic blood pressure compared to delayed treatment (Hinton et al., 2009). Neuner, Kurreck, Ruf, Odenwald, and Schauer (2010) carried out a randomized controlled treatment study with 32 asylum-seekers in Germany. Participants with PTSD received either treatment as usual, which was public mental health care, or five to 17 sessions of NET. After treatment, NET participants had significantly improved PTSD and pain symptoms compared to treatment as usual (Neuner et al., 2010).

Kruse et al. (2009) compared trauma-focused psychotherapy with treatment as usual (social counseling and medical treatment) with 64 Bosnians in Germany who had PTSD and somatoform disorder. Trauma therapy is a form of therapy that can help an individual deal with the emotional response caused by a traumatic event. Trauma therapy consisted of 25 hours of treatment that focused on the therapeutic alliance, psychoeducation, affect regulation, safety, and coping. 12 months after therapy began there were significant improvements in PTSD symptoms, global severity of psychiatric symptoms and mental and physical symptoms (Kruse, et al., 2009).

Another common treatment option for working with refugees/asylum-seekers is cognitive-processing therapy (CPT). Schulz et al. (2006) examined outcomes after CPT and whether having an interpreter or not influenced outcomes. Six Afghan and 47 Bosnian refugees with PTSD at a community mental health service were assigned to routine care with an interpreter or without an interpreter. The researchers found that there were significant improvements in PTSD symptoms for both groups after an average of 17 sessions of CPT (Schulz et al., 2006). Treatment effects were greater for those without an interpreter than those with an interpreter but not significally different.

Narrative Exposure Therapy (NET), which was the treatment of choice and was utilized in this case study, is a trauma-focused short-term psychotherapy that was developed for the treatment of PTSD (Neuner et al., 2010) and is particularly effective when treating refugee populations, because it enables individuals to discuss their traumatic experiences in a testimonial approach (as opposed to a potentially more stigmatizing clinical approach) and explicitly acknowledges the role of human rights violations in producing psychological distress (Wright et al., 2020). Research has shown that there are positive findings for NET in long-term follow-ups that are consistent within reviews regarding psychological therapies utilized with refugee populations (Crumlish & O'Rourke, 2010; Nosè et al., 2017). In comparison to other psychological interventions, NET has a low dropout rate. For example, Palic and Elklit (2011) found that the dropout rate for NET was approximately 4% whereas for CBT the dropout rate is often higher, around 20%.

According to a systematic review and meta-analysis on the efficacy of NET for trauma-related outcomes in refugees/asylum-seekers, all studies reported a significant reduction in trauma scores in the NET group in comparison to the control groups, indicating that NET can be effective in reducing symptoms of trauma (Wright et al., 2020). Wright et al. (2020) additionally looked at whether the NET interventions had been successfully culturally adapted. They found that most of the included studies in their systematic review did not explicitly state if cultural adaptation had taken place, despite all studies utilizing a language interpreter if required, making it challenging to determine if the sessions were culturally relevant to the participants (Wright et al., 2020).

While the aforementioned meta-analysis focused broadly on different types of trauma, intimate partner violence (IPV) is a form of trauma that merits consideration among refugee populations. The overall prevalence of IPV during marriage in Iran (from which a large subset of refugees originates from and where the client of this case study is from) is estimated to be up to 66% (Vameghi et al., 2013). Specific to IPV, NET has been found to be effective in a sample of Iranian women exposed to ongoing IPV. In a randomized controlled trial Orang et al., (2018) randomized 45 IPV-affected women with a diagnosis of PTSD to 10 to 12 sessions of either NET (n = 24) or treatment as usual (TAU) (n = 21). Primary outcome measures that included the assessment of PTSD, depression, and perceived stress symptoms were examined at pre-treatment and three- and 6 month follow-ups. Orang and colleagues found that NET participants showed significantly greater symptoms reduction in comparison with the TAU group in PTSD, depression, and perceived stress at both follow-ups.

When working with refugee and/or asylum-seeker populations it is important to keep in mind the Westernization of the conceptualization of these disorders, their subsequent treatments, and outcome measures that are often utilized to measure effectiveness. In McFarlane and Kaplan’s (2012) 30-year review of the literature on evidence-based psychological interventions for adult survivors of torture and trauma, they discussed the limitations of overreliance on the PTSD diagnosis and PTSD symptom severity scores as outcome measures for treatment effectiveness. Therefore, this case study should be reviewed with this in mind.

The use of interpreters may influence the quality of the therapeutic alliance (d’Ardenne et al., 2007; Miller et al., 2005), which is particularly salient given the importance of establishing safety with traumatized clients (Briere and Scott, 2013). Further, interpreters, who are typically not trained in psychotherapy, could have difficulty effectively communicating mental health concepts (Miller et al., 2005; Westermeyer, 1990). Given the above, in their meta-analysis Lambert and Alhasoon (2015) also examined if treatment outcome depended on whether an interpreter was used to facilitate therapy sessions. While they noted that, to date, there has been little research on the use of interpreters in psychotherapy with refugees, across the studies included in their meta-analysis they found a nonsignificant difference between studies that used an interpreter and those that did not.

Due to COVID-19, mental health providers have had to adapt to the crisis by utilizing telemental health. Research on telemental health with refugee clients is limited, despite a recognition in the literature that telemental health has the potential to address some mental healthcare disparities (Almoshmosh et al., 2020; Ashfaq et al., 2020; Soron et al., 2019). The literature is scant about how to utilize telemental health practices most effectively with refugee clients. This is problematic as refugee clients may not speak English and require an interpreter, may have limited technological proficiency or access, and/or have additional case management needs and coordination as part of their treatment plan (Disney, Mowbry, & Evans, 2021). Disney et al. (2021) conducted a study to understand how mental health clinicians and case workers at a refugee-serving mental health clinic are successfully shifting their face-to-face practice to telemental health. In their analysis, two main themes emerged from the data: (1) refugee mental health providers display initiative and flexibility in their adaptation to telemental health and (2) providers reported numerous obstacles to effective telemental health, including client barriers, technology barriers, communication issues, and the challenge of reading nonverbal cues virtually. Disney and colleagues discussed that, by understanding telemental health when working with refugees, clinicians will be more effective in meeting the needs of a population with significant mental health needs and limited mental healthcare access.

In summary, NET has been found to be effective for the treatment of PTSD in refugee/asylum-seekers as well as in Iranian women exposed to IPV. The use of interpreters in trauma-focused care does not seem to significantly impact the course of treatment, although the research on this topic is limited. A review of the literature suggests that more research should be conducted to examine cultural adaptations to trauma-focused treatments, such as NET, including the integration of interpreters in session.

Case Introduction

“Amaya” is a 26-year-old Afghani/Iranian bilingual (Dari and Farsi) woman who was referred by an international center to a specialized clinic for victims of crime in an urban city in the mountain west. Amaya sought services to process and manage symptoms related to extensive trauma that she endured in her marriage and during her escape and passage from one country in the middle east to another. She was referred to the specialized clinic for trauma treatment. Amaya’s treatment took place via telehealth audio during the pandemic of COVID-19. Due to the necessity of an interpreter/translator that was only available via telephone, therapy was conducted as a three-way call between clinician, interpreter, and Amaya via the telephone on a secure landline phone in the clinic where services were provided.

Presenting Complaints

When Amaya met with the clinician via telehealth services (telephone), she reported that she had obtained political asylum status and immigrated to the United States 8 months prior to the initial intake session to escape the middle east where she had been a victim of interpersonal violence in her marriage and, after her husband’s disappearance, was threatened and pressured to marry her brother-in-law. She shared that in the process of being smuggled from Iran to the Turkey border, she was violently raped numerous times by an individual who had agreed to smuggle her and her two young children.

Once Amaya was reunited with her family in Turkey, she reported the onset of severe symptoms of PTSD and was unable to sleep due to nightmares and reported “constantly living in fear.” Amaya indicated having difficulty with sleep and stated that “the past is always in front of me, and I see pictures from my past.” She reported having difficulty remembering things and that she was often forgetful. Before arriving to the United States, Amaya had successfully escaped Iran and was living in Turkey with her family for 2 years. She reported that she moved to the U.S. to “get away” from the trauma that she experienced in Iran and to provide a “safer and better life” for her children. Amaya reported that even in the U.S, she continued to struggle with symptoms because of her traumatic experiences. During Amaya’s intake, she reported that she had recently experienced an episode while she was at work where she became “extremely stressed” and then had a “black out and fainted.” Amaya reported that her co-workers called an ambulance which took her to the hospital. Amaya reported that at the hospital, she was told she had a panic attack.

History

Amaya was born in Afghanistan and is one of eight children with five brothers and two sisters. Her and her family moved to Iran when she was 1 year old. She described having an “average” childhood and that the only issue was with the restrictions that were placed on her about where she could go to school because she was an Afghan immigrant in Iran. Amaya’s highest level of education is completing the third grade in Iran.

Amaya met and married her husband when she was 14 years old after having met many suitors that had been arranged by her parents. Her parents did not approve of her choice for A husband and Amaya and her husband eloped as a result. The ceremony was unable to be performed without Amaya’s parents and she had no choice but to contact them. Amaya’s parents still did not approve of the marriage but gave permission for the ceremony to go forward. She had her first child when she was 17 years old and her second child when she was 21 years old.

Amaya reported extensive trauma throughout her marriage. Her husband was very abusive, both physically and emotionally. She reported that her husband was an addict and was on multiple drugs, such as heroin and narcotics, as well as alcohol. She reported that, prior to her marriage, she had no idea that her husband was an addict, and it took almost a year into the marriage for Amaya to realize his addiction. She reported that he would beat her repeatedly and would force her to buy him drugs. Amaya reported that when they had their second child, a daughter, her husband was unhappy about the baby being a girl. He would threaten to kill their daughter and when he would become very drunk and/or high he would try to harm and frighten their daughter by “lunging at her and being very rough with her.” Due to fear of admitting failure in her marriage, which had already been disapproved of by her family, and having extreme feelings of shame, self-blame, and embarrassment, Amaya did not disclose to anyone the abuse that she was suffering in her marriage. This caused further isolation and feelings of loneliness and helplessness.

Additionally, the lack of adequate domestic violence legislation and limited access to resources or emergency accommodations in Iran perpetuated her isolation and inability to receive assistance. (SOURCE?) Amaya’s fear and isolation because of her trauma with her husband, resulted in her feeling as if she did not have control over her and her children’s lives and safety.

Amaya described that she would get reprieve from her husband’s threats and abuse because he would leave for a week, or weeks, at a time, and she would have no idea where he was or when he would come back. She reported that the last time her husband left, he was gone for 4 months without any contact from him, and Amaya was required to work multiple jobs to support her family. During this time, Amaya worked as a maid in wealthy Iranian homes, including her brother-in-law’s home. Because her husband was gone for so long, it was presumed that he had died. Amaya reported that, soon after her husband’s suspected death, her brother-in-law began to pressure her into marrying him. She repeatedly told him she did not want to marry him. Amaya’s brother-in-law became aggressive and threatened to take away her children if she did not marry him because her children were “his blood.” Amaya recalled one occasion where she came home from her work and her children were gone. Amaya went to her brother-in-law’s home, and he refused to let her see her children or let her into the house. She reported that her brother-in-law kept her young children from her for 1 week without any contact with them. Amaya recalled that, while her brother-in-law was not home, she was able to convince his wife to let her see her children. At this time, Amaya managed to take her children and leave the house with them.

Amaya planned to leave Iran to escape her brother-in-law and was in contact with her mother who was in Turkey and who helped Amaya and her children find a means to cross the border into Turkey illegally with some smugglers. While in a border city, Amaya and her children were taken to a dilapidated apartment building where another “smuggler” was staying. After her children had fallen asleep, the man entered their room and began to inappropriately touch her. After Amaya attempted to shun his advances, he began to threaten her by stating that if she did not have sex with him, he would call someone to take her children away.

Amaya reported that she was raped on multiple occasions, some more violently than others, over 3 days. The man threatened Amaya by saying that he was going to “keep” her for another week and not let her and her children cross the border into Turkey. Amaya recalled a time when he FaceTimed another individual and began to talk about her as if she was going to be sex trafficked. On the third day, after Amaya’s mother continued to call for an update on her status, the smuggler released Amaya and drove her and her children to the border where they would be smuggled into Turkey on a commercial truck. Amaya reported that she was bleeding for a whole month after having been raped repeatedly for 3 days. The doctors in Turkey had to give her an injection to stop the bleeding. Amaya reported that she never told the doctors she had been raped, but she knew that they knew what had happened to her based on their examinations. Amaya did not tell her family either. After a couple of months in Turkey, Amaya had found out that her brother-in-law and father-in-law were looking for her and wanted to kill her and take her children. This exacerbated Amaya’s trauma symptoms and she continued to live in constant fear. She reported that she refused to leave her parent’s apartment in Turkey and pulled her children from school out of fear that they would find her. This went on for a couple of months.

Everything Amaya endured led to the development of PTSD and, even after she was reunited with her family in Turkey, she avoided ever having to speak about what occurred in Iran more than she had to and kept her sexual assault entirely to herself. She received psychiatric services where she was prescribed medication for 2 years in Turkey but was not able to fully process her trauma therapeutically. As a result, she barely left the house for 2 years and lived with her symptoms without knowing that they were symptoms of PTSD. Amaya experienced a deep amount of shame and guilt associated with her sexual assault and putting her children in harm’s way by attempting to flee Iran. Not being able to process her trauma or label her experiences as traumatic caused her to feel “crazy” and exacerbated her schema of little control. These symptoms continued when she acquired asylum status and moved to the United States.

Assessment

Amaya completed a semi-structured diagnostic interview designed to gather information about her psychosocial history, presenting concerns, and psychological symptoms. Specifically, the intake consisted of a thorough assessment of symptoms; questions on Amaya’s developmental history, including a review of childhood, adolescence, and young adulthood; educational history; vocational information; legal history; medical history; substance use history; family history of behavioral health and mental health; history of behavioral health treatment; medications; individual strengths; and treatment goals. During intake, Amaya additionally completed the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (fifth ed.; DSM-5; American Psychiatric Association, 2013) (PCL-5; Weathers et al., 2013) to assess for PTSD symptoms, the Patient Health Questionnaire-9 (PHQ-9) to assess for symptoms of depression, and the Generalized Anxiety Disorder-7 (GAD-7) to assess for symptoms of anxiety.

Amaya’s scores on the GAD-7 and the PHQ-9 did not indicate the presence of symptoms consistent with symptoms of anxiety nor depression.

The PCL is a 20-item self-report measure that assesses the presence and severity of PTSD symptoms. Items on the PCL-5 correspond with DSM-5 criteria for PTSD. The PCL-5 serves to quantify and monitor symptoms over time, screening individuals for PTSD, and assisting in making a provisional diagnosis of PTSD. Respondents are asked to rate how bothered they have been by each of 20 items in the past month on a 5-point Likert scale ranging from 0–4 (0 = Not at all; 1 = A little bit; 2 = Moderately; 3 = Quite a bit; and 4 = Extremely). Items are summed to provide a total severity score (range = 0–80). One of the ways the PCL-5 determines a provisional diagnosis of PTSD is by summing all 20 items (range 0–80) and using a cut-point score of 31–33 for a diagnosis of PTSD. Amaya’s score on the PCL-5 was a 15, which suggested that her pattern of responses did not indicate the presence of symptoms consistent with a diagnosis of PTSD. It was hypothesized, however, that her low score on the PCL was due to the PCL having been administered verbally and via an interpreter and was unable to be culturally representative of how she perceived her symptoms. Because the interpretation services were only able to be done via telephone, the clinician was unable to provide a visual of the checklist for the interpreter and for Amaya to follow along with (which could have been done through screen share if HIPAA compliant zoom was being utilized).

This hypothesis of invalidity of the screener was supported during the intake/clinical interview, where Amaya continued to live with symptoms consistent with PTSD. While reviewing the trauma history portion of the intake, Amaya was tearful throughout her recount. During the intake, Amaya verbally endorsed the following symptoms of PTSD: trouble remembering important parts of the stressful experience; repeated, disturbing, and unwanted memories of the stressful experience and avoiding memories, thoughts, or feelings related to the stressful experience; repeated, disturbing dreams of the stressful experience; suddenly feeling or acting as if the stressful experience were actually happening again; having strong physical reactions when something reminded her of the experience; having strong negative feelings, such as fear, horror, anger, guilt, or shame; being “super alert” or watchful or on guard; feeling jumpy or easily startled; having difficulty concentrating; and having trouble falling or staying asleep. Additionally, Amaya reported having suffered from a few panic attacks. It became clear during the intake that these symptoms were causing functional impairment at home and at work.

Therefore, Amaya’s initial scores on the PCL-5 were deemed invalid. This led to the decision of not using the PCL-5 to monitor progress at the end of treatment. Instead, her PTSD symptoms were measured by using a similar interview style that was used at intake to assess for symptoms common with PTSD. This included reading a description and example of each symptom of PTSD from an informational worksheet and having Amaya rate the current severity of each symptom (post-treatment) on a scale of 0–5 (0 being not at all and 5 being extremely). The clinician reviewed the PTSD symptom worksheet with Amaya via the telephone and using an interpreter. In other words, an interview style was used that coincided with the PCL-5 to assess for the presence and severity of PTSD symptoms at the end of treatment.

Case Conceptualization

The clinician conceptualized this case from a trauma-informed lens with the integration of Narrative Exposure Therapy. As discussed above, Amaya experienced multiple traumatic events, such as domestic violence and sexual violence, leading this clinician to diagnose her with PTSD. The utilization of NET as the intervention of choice for Amaya was due to NET being a culturally universal intervention that uses narratives, which are integral parts of every culture, to reduce traumatic stress symptoms in survivors of serious and repeated life-threatening events (Schauer et al., 2011). NET contextualizes the elements of the fear network and the sensory, affective, and cognitive memories of trauma to understand and process the memory of a traumatic event in the course of the client’s life (Schauer et al., 2011).

Emotional memories are tied together in a network of Sensory/Cognitive/Emotional/Physiological elements. Multiple traumas are conceptualized as the broadening of fear networks through experience of multiple traumatic events so that the fear network can be triggered by exposure to any of the cues contained within the network, from any of the traumatic events that a person has experienced (Elbert & Schauer, 2002).

NET leads to a reorganization of the fear network by inducing a long-term structural change in a person’s memory. Trauma subsists through the abnormal coding of memories, and, at times, conscious recollection of the past becomes impossible, but barely noticeable traces sneak into consciousness which evoke memories of the traumatic events that are so vivid and real that fear and horror have become routine (Schauer et al., 2011). Because Amaya experienced multiple traumatic events throughout her life, Net allowed her to revisit certain aspects of her life in chronological order to make sense and process her traumatic experiences. The horror of her traumatic experiences can never be erased or undone, but her suffering could be reduced a great deal by NET by reorganizing her fear network associated with her vivid and intrusive memories of the traumatic events.

As discussed previously, Amaya never disclosed to her family the domestic violence that was occurring in her family, nor did she disclose the violent sexual assaults that occurred to her when crossing the border. After enduring her traumas, Amaya described feelings of shame, guilt, and embarrassment, leading Amaya to believe that she had brought her traumas upon herself. Self-blame is unfortunately a symptom often seen in PTSD, which can perpetuate feelings of loneliness and social isolation, both of which are recurring themes among survivors. These feelings persisted for Amaya even after she had moved to the United States with asylum status.

This inability to disclose or talk about her traumatic experiences led Amaya to continue to live in a constant state of survival, fear, loneliness, and isolation. One of the key components that NET addresses in its theoretical framework is one’s speechlessness versus the wish and fear to disclose the events and which forms the dialectic of psychological trauma (Schauer et al., 2011). Common among survivors is the belief that others cannot possibly understand or be able to share their experience so why bother opening old wounds? For Amaya, she never spoke about her traumatic experiences to anyone until she received psychiatric services in Turkey and then subsequently mental health services in the United States. Additionally, Amaya lacked an awareness that what she was suffering from was a mental illness or what she endured was, in fact, a trauma until after receiving mental health treatment. When Amaya experienced her symptoms, she had no idea that she was suffering from a disorder, specifically PTSD, let alone that this disorder could be treated.

By putting words to the trauma, or in Amaya’s case, finally disclosing what happened to her, victims become empowered to overcome their sense of speechlessness and lack of explicit memory (Schauer et al., 2011). The theoretical framework of NET believes that true healing occurs once there is an externalization of the feelings, abuse, and distrust by encouraging the telling of the trauma story and by reliving the past traumatic sceneries within an imaginative exposure design (Schauer et al., 2011). The goal of this imaginative exposure design is to allow for the modification of the fear network co-constructed by traumatic and stressful events (Schauer et al., 2011).

The NET model draws a distinction between COLD memories, which consists of context and facts, and HOT memories, which consists of cognitions, emotions, physiological feelings, and sensory information (smell, touch, sight, hearing, speaking) (Elbert & Schauer, 2002). The NET model suggests that in PTSD, HOT memory is involuntarily retrieved without links to the cold memory, because of neurobiological processes occurring at the time of a traumatic event (Elbert & Schauer, 2002). In other words, in NET, the hot memories need to be anchored to the cold memories in order to diminish the PTSD symptoms, such as flashbacks, intrusive thoughts, nightmares, etc.

In this way, NET suggests weaving hot implicit memories—that is, sensations, feelings, and thoughts associated with a specific trauma memory to the corresponding sequences in the autobiography by putting all memory fragments into words and thus into declarative memory (Schauer et al., 2011). These “hot” memories, where the clinician often moves into present tense to modulate arousal (“increase the heat”) are weaved into the narrative and unfolded by cool declarative memories, or past tense to “cool things down.” In other words, when speaking about the past, the past tense is used, but contrasts between the present (using the present tense: “are you feeling that way now?”) and the past is also used (Schauer et al., 2011). As part of this process, the clinician uses a lot of clarifying questions to fully elaborate all cues/nodes of the memory network. The therapist should not be afraid of suggesting what they think the patient might be feeling—as long as it is offered as a suggestion the patient should feel comfortable to correct the therapist if the guess is incorrect (i.e., “You look disgusted. Do you feel that now? And back then?”; “You look like you feel quite defeated?”). In this way, intrusive recollections and fragments are integrated into their original context, and a consistent autobiographical narrative develops (Schauer et al., 2011).

During narrative exposure the previously unconnected fear networks for the traumatic events are activated and linked with the cold memory, which helps in contextualizing the events (Elbert & Schauer, 2002). To complete the autobiographical memory, the hot and cold memory needs to be linked to contextualize each event. In addition, the fear response is inhibited by exposure to the traumatic memory. Creating new meaning occurs as a result of re-visiting the traumatic memory and allowing the patient to see the event in the context of their ongoing life, instead of an event being re-experienced in the present (Elbert & Schauer, 2002). Amaya often experienced intrusive thoughts at unwanted times, such as having panic attacks at work, which impaired her daily functioning which was re-experiencing the traumatic event in the present. NET helped Amaya contextualize her traumatic event as having taken place in the past so that her PTSD symptoms did not become so overwhelming in her present life.

Amaya’s treatment plan consisted of decreasing her symptoms of PTSD by increasing her ability to make sense of her traumatic experiences through imaginative exposure and to come to terms emotionally with her experiences. Additionally, a treatment goal for Amaya was to experience less intense emotional and/or physical reactions when having memories or reminders of the trauma. Expected outcomes of treatment were for Amaya to effectively improve how to handle distress, especially around trauma reminders and to decrease or diminish PTSD symptoms.

Course of Treatment and Assessment of Progress

Amaya was seen for an intake and 18 therapeutic sessions. As mentioned previously, the intake and all her sessions were conducted over the telephone with an interpreter. During the first and second treatment session, she was provided psychoeducation on trauma and PTSD as well as the treatment rationale for Narrative Exposure Therapy (NET) and establishing goals for her treatment plan.

During the third treatment session, Amaya’s lifeline as part of NET was completed verbally as we could not complete the timeline in-person using NET’s recommended twine, flowers, and rocks to compile a lifeline. Should the session have been done in person, a rope is laid down where one end signifies when they were born, and the other end would be rolled up to indicate life yet to come and “stones” and “flowers” are explained as signifying bad memories/traumatic events and positive experiences, respectively. However, because therapy was conducted via the telephone this physical exercise was unable to be done in this way. Instead, this clinician described the symbolism of the rope, the “Flower” and the “Rock” and asked client to imagine her lifeline. The clinician thus encouraged Amaya to chronologically describe “life moments” as either a flower or a rock to organize her memories. While completing the lifeline, too much detail about the events should be avoided because there is not enough time to deal with these properly. It is important to stay on the “cool,” contextual side of things (Schauer et al., 2011). Instead, the lifeline exercise should be viewed as more of an overview of a person’s life and, at this stage, the clinician avoids questions about the hot memory and instead focuses on the cold memory.

During Session 4, Amaya’s narrative began with her birth and continued to age 17 (the first traumatic event. Amaya was encouraged to narrate the “hot” memory of her first “rock,” or traumatic event, which was an incident of domestic violence and abuse by her husband. A “hot” memory entails providing in-depth details of the sensations, feelings, and thoughts of the event as if it was happening in the present. NET describes placing trauma incidents within the context of the rest of that day. For example, if the traumatic event being described happened in the afternoon, one would start by asking questions about the morning on that particular day, such as “Do you remember what you were doing that morning?” “Who was there?” “How did you feel?” As one gets closer to the traumatic moment, the clinician is recommended to go more slowly and encourage more details to be reported. For example, Amaya was encouraged to focus on the details that she remembered, specifically the sensory information. Descriptions of sensory information that Amaya included in her first “rock” memory was, “It was a rainy day, and the rain was cold. My hands were freezing, and my heart was beating very fast because he came home very drunk and on drugs.” As the narrative continued into the traumatic event itself, Amaya began to cry. Sensory memories, whether visual or physical, can be images that are in the fear/trauma structure, and that individuals see these images or “pictures” in the form of intrusions anyway. Therefore, it is crucial to try and help the individual put these images into words before they are given an opportunity to avoid them (Schauer et al., 2011). The NET manual describes two types of interventions that help in activating elements of the fear/trauma structure that was utilized with Amaya. One type of intervention is the use of direct questions where the clinician addresses the elements of the fear/trauma structure across different levels (sensory, cognitive, emotional, and physiological) (i.e., “What and how exactly did you feel in this moment?”). The second type of intervention that helps in activating elements of the fear/trauma structure that was utilized with Amaya was feedback of observation. Feedback of observation entails the clinician giving direct feedback on observations that the clinician makes as it has to do with physiological responses that the individual has while recounting their narrative (i.e., “I can hear that you are crying”). This type of feedback allows for the individual to become more aware of these sensations and will lead to further activation of the elements of the fear/trauma structure (Schauer et al., 2011). However, because NET was used via telehealth, specifically over the phone, physical observations were unable to be made. This clinician did offer feedback on how Amaya’s voice sounded while retelling certain details and if she was crying while narrating. This kind activation of hot memories for traumatic events were utilized for each of Amaya’s “rock” memories, or traumatic events, on her lifeline. The clinician and Amaya ended the fourth session with Amaya describing the events after the traumatic experience to provide closure and for Amaya to regulate safely before ending session.

During Sessions 5 and 6, Amaya’s narrative continued in the same vein as session 4 with the ongoing domestic violence in her marriage, the pressure from her brother-in-law to marry him once it was presumed that her husband was dead, and him threatening to take her children away. During session 6, Amaya had reported that, after recalling details of her traumatic experiences, she had noticed that she would get “very bad headaches.” The clinician provided some psycho education around physiological effects that exposure therapy can have and offered some coping skills for the client to use after session, such as taking a hot or cold shower and taking a couple of minutes to take deep breaths and drink some water.

Sessions 7 and 8 focused on Amaya narrating her biggest traumatic event memory of getting raped repeatedly while she and her children were being held in a house awaiting to be smuggled across the Iran and Turkey border. Recalling this memory was difficult for Amaya and she cried while recalling details. For the memories of the rapes, she had a difficult time recalling exact details because she had “blacked out” and disassociated from her body while it was occurring. During Session 8, Amaya’s narration of her sexual assault was read back to her to begin to desensitize her to traumatic memories in the hope that it could decrease the severity of her PTSD symptoms. Before the narration was read back to her, Amaya reported feeling anxious in her body as a result. In re-reading Amaya’s narration back to her, this clinician reiterated the reasoning behind re-reading the narrative back to her. Habituation was described to Amaya as the decrease in symptoms that occur after being exposed to the stressor for a significant amount of time. The continuous process for activating and narrating hot memory will lead to habituation, which means that the emotional impact and physiological arousal decreases over time (Schauer et al., 2011). After habituation takes place, hot memory is transmuted into cool memory. During the re-reading of her narration for that “rock” memory, Amaya remembered some more details which were then added to her narrative. After that portion of the narrative was told back to her, Amaya reported feeling like a “big weight was lifted” when she re-heard her trauma and could regulate herself while hearing it. As per NET’s guidelines, after the arousal has been reduced noticeably, it is important to bring the narrative to a close and to ensure that the session does not end with the individual still recovering from a traumatic scene. After the event narration, the clinician asked Amaya to verbalize what happened in the time period following the incident to enable her to integrate the incident into the greater life story (Schauer et al., 2011).

Sessions 9 through 11 completed Amaya’s narrative and focused on her experiences arriving at the Turkey border and being “rescued” by the Turkish police, being reunited with her family, and living in Turkey for 2 years. Although there were traumatic aspects to the journey across the border after leaving her rapist’s home and being in Turley for those 2 years, Amaya did not become dysregulated and was able to provide many details for this section of her trauma narrative. The day the narrative was completed, Amaya informed the clinician that it was the day that marked the 1-year anniversary of having arrived to the United States. She reported that she felt good about having completed the narrative on this anniversary.

Sessions 12 through 14 focused on reading Amaya’s narrative back to her while encouraging her to practice grounding techniques in vivo. Reading back the part of her narrative of the domestic violence was difficult for her to hear, but Amaya was able to describe that she had a new perspective on her experience upon hearing it read back to her. Amaya reported that it became more clear to her how abusive her husband was and how sad it made her. During part of her narrative, she reported that she could feel her body become hot and flushed while hearing back her memories. While reading back the portion of the narrative where Amaya was repeatedly raped by the man who claimed to be able to smuggle her into Turkey, she was able to recall new details to be added to the narrative, such as how the man’s voice sounded and reported that, while the narrative was being read back, she “all of a sudden heard his voice very clearly” in her head. Amaya was successfully regulated and utilized her grounding techniques of drinking cold water and taking a couple of deep breaths. Amaya reported that it was still “scary” to hear her memory read back, but that it was not as bad as the first time it was read back to her.

Following exposure sessions, such as re-reading the narrative back, a series of processing steps often occur in individuals in NET therapy that occurred to Amaya. For example, thoughts or feelings that a person had previously been avoiding may surface and, subsequently, they may experience more unrest than usual or may suffer from increased sensitivity to cues triggering the fear/trauma network (Schauer et al., 2011). This clinician informed Amaya that such responses are normal responses to exposure therapy and that it plays an integral part in the healing process.

During Session 15, this clinician assessed for PTSD symptoms and their severity by reviewing the symptoms of PTSD and asking Amaya to rate each currently experienced symptom on a scale of 0–10, with 0 being not at all present and 10 being experiencing the symptom so intensely that it caused functional impairment. This method of assessing for PTSD symptoms and severity was used because the PCL-5 used at intake was invalid due to language barriers and the use of an interpreter. However, the symptoms that were assessed after treatment were similar to symptoms that are assessed on the PCL-5. Each symptoms was described in detail and was accompanied by an example. For “feeling scared,” Amaya rated this symptom as a 0 because she was able to talk to people more about her feelings. For “Looking out for danger,” or hypervigilance and alertness, she rated this symptom as 3 or 4 because she was still aware of her surroundings and was still suspicious of people initially. For “Avoidance,” she rated this at a 0. Amaya reported that she allowed thoughts and memories of the trauma to occur and that she “reviews” them and tries to let “them pass.” She reported that she was not isolating herself and that she engaged in being more social. Client did not report any feelings of dissociation. For “Nightmares and poor sleep,” client rated this symptom at a 3. Amaya reported occasional issues with sleep but denied having nightmares. For “Problems with Concentration and Attention,” Amaya rated this as a 0 with regards to her trauma. She acknowledged she gets easily distracted and had difficulty concentrating, but she attributed this to normal life stressors, such as being a single parent and working. Amaya reported that she no longer experiences “Flashbacks” and rated this as a 0. For “Difficulty Trusting People,” she rated this symptom as a 5. Amaya reported she still finds herself being extremely suspicious of people and their intentions when she first meets them, but after she meets them, she is “okay.” For “Blaming Self,” Amaya rated this as a 5. She reported that she intellectually realizes it was not her fault that she was raped but that she cannot help from thinking things such as “If I had never left the house in Iran then this would not have happened.” Amaya reported a 0 for “Feeling angry and/or irritable.” For “Feelings in body/Somatic Complaints,” she rated this as a 5. Amaya reported that she thought this was a combination of recalling traumatic experiences and life stressors. She reported that when she would think of the traumatic experience, she would occasionally get headaches, but they are not as bad as they used to be. Amaya rated “feelings of sadness and hopelessness” at a 0 and that she has a great outlook on the future.

Sessions 16–18 focused on reviewing and practicing grounding techniques, such as the 5-4-3-2-1 Technique (i.e., 5 things you can see, 4 things you can hear, 3 things you can physically feel, 2 things you can smell, and 1 thing you can taste), mindfulness skills, breathing techniques, meditation exercises, and the use of essential oils. On session 18, Amaya successfully graduated therapy.

In assessing for outcomes of the treatment and Amaya’s graduation from therapy, this clinician analyzed Amaya’s responses to reviewing PTSD symptoms post-treatment and compared it to the reported symptoms that Amaya endorsed at the outset of treatment. By the time treatment had come to an end, Amaya no longer endorsed symptoms at a severity level that were consistent with a diagnosis of PTSD. Specifically, she no longer was experiencing feeling scared, avoidance, disassociation, difficulty with concentration and attention, flashbacks, panic attacks, feelings of irritability, and hopelessness (these symptoms were rated as a 0 post-treatment). Symptoms that Amaya still reported were occasional nightmares (however not as disturbing or severe as pre-treatment), hypervigilance (although not as severe as pre-treatment), difficulty trusting people, blaming self and some somatic complaints. Therefore, with her symptom severity having decreased significantly, her traumatic experiences having been successfully processed, and her desensitization to being able to recall her traumatic experiences, this clinician deemed Amaya to be ready to graduate therapy. This case study suggests the importance of using culturally appropriate material when measuring PTSD.

Complicating Factors

A complicating factor in this case was the language barrier between Amaya and this clinician. Amaya only spoke Dari/Farsi and the use of an interpreter was required for treatment. Due to difficulty directly translating material from the symptom-based assessments into her native language, it was difficult to assess and monitor symptoms quantitatively throughout the course of treatment using such assessments. On psychosocial measures administered during intake, Amaya did not endorse depression, anxiety, or PTSD. However, symptoms were endorsed when Amaya was asked to describe her presenting complaints and symptoms associated with her traumatic experiences. Therefore, assessment of symptoms in treatment heavily relied on reported experiences.

This clinician was given access to the use of interpretation services via telephone. The referral site provided a code to the clinician to access interpretation services over the telephone through The Language Bank. Translation was a variation of sentence by sentence or by paragraph. A problem with this interpretation service was the possibility of getting a different interpreter for each session (based on who was available and who picked up). For doing trauma work, this was not conducive to the healing process since the unfamiliarity of using different interpreters could impact Amaya’s ability to disclose and feel safe and comfortable in therapy. Fortunately, The clinician was able to build a relationship with a specific interpreter who was able to make herself available for the scheduled time and date that Amaya had sessions with the clinician. All three members, the clinician, the interpreter, and Amaya had great rapport and worked well together. An additional complication of using a translation service was that there was not a way for the clinician to know whether all idioms, technical terms, etc. were translated in a way that they were initially meant. To combat this complication, this clinician spoke with the interpreter for a couple of minutes before calling Amaya and went over certain topics to ensure that the interpreter could translate terms and topics correctly and effectively.

A complicating factor was that all interactions with Amaya, the interpreter, and this clinician was over the telephone. Therefore, there was not any face-to-face interaction even via telehealth (i.e., zoom). The interpretation services provided to this clinician was only able to be accessible through a phone line and using other telehealth modalities, such as HIPAA compliant zoom, was not allowed. Due to services being delivered via telephone, this clinician did not have access to physical observations, such as body language and facial expression throughout treatment. Due to the nature of the therapeutic setting and the involvement of Amaya, the clinician, and the interpreter, there was not a way to assess for forward/backward translation without including another interpreter to the session. Due to the sensitive nature of NET, another individual in the therapy session may have been contraindicated.

An additional complicating factor was Amaya’s feelings of shame regarding the sexual assault she experienced crossing the Iranian/Turkey border. This limited her potential access to support and care and Amaya lived with severe trauma symptoms without being able to identify them as such. However, it is important to note, that this did not interfere with her current treatment with NET. She was very willing and ready to participate in therapy and, although she had some difficulty in recalling some details of her traumatic experiences, as expected, she was able to successfully engage in narrative exposure therapy.

Finally, Amaya and this clinician came from different cultural, ethnic, and linguistic backgrounds. Both clinician and Amaya identified as female and were in the same generation/age range. At the onset of treatment, this clinician mentioned the cultural differences between them and gave Amaya the opportunity to express concerns that she may have about not being culturally matched with a clinician. Amaya had mentioned that she did “not mind” the cultural discrepancy and that she preferred it because she expressed concern that if she had a culturally matched clinician, she might be judged for some of her decisions, such as fleeing from her husband’s family, taking her children, and crossing the border. Of course, the language barrier was complicated as was getting used to having to communicate through an interpreter, but everyone involved adapted and made it work. Tone of voice, laughter, distress could all be understood even over the phone and across the two languages that were spoken in treatment.

Access and Barriers of Care

As mentioned previously, Amaya’s primary barrier to care was related to her monolingual status and the lack of clinicians who spoke Dari/Farsi in the Northwest region. She had previously received psychiatric services for 2 years when she was living in Turkey with her family and had reported that it helped. When Amaya arrived in the United States, she was referred to therapy from the regional international center and provided with a clinician who was given access to the use of telephone interpretation services.

Amaya was referred for mental health services during COVID-19, which provided its own unique barriers to care. Due to COVID-19 health mandates, Amaya was only able to receive services via telephone making face-to-face and in-person opportunities not possible. The interpretation services used in this case was only via telephone and Amaya was unable to download or use zoom. As mentioned previously, this limited the ability to observe body language and facial expressions. Due to the language barrier present between this clinician and Amaya, being able to observe body language and facial expressions would have been beneficial. However, COVID-19 made this impossible making this a therapeutic limitation.

An additional barrier is that NET typically suggests the use of physical objects, such as a rope, flowers, and rocks to be included in constructing a client’s lifeline. The use of telephone for treatment made this utilization of physical flowers and rocks to provide visuals for a life line impossible and modifications needed to be made. Alternatively, the clinician asked for client to visualize and identify each memory included in her lifeline and subsequent review of each memory was first introduced as being either a flower or a rock memory.

Follow-Up

This clinician was unable to conduct follow-up assessments with Amaya using the PCL-5 because her initial PCL-5 score was deemed invalid because an interpreter had to be utilized. As mentioned previously, Amaya met criteria for PTSD through self-report at intake. Assessing for PTSD symptoms post-treatment of NET, this clinician engaged Amaya in more of an interview style of assessment of symptoms of PTSD. Therefore, follow-up sessions using the PCL-5 after Amaya graduated from therapy were not conducted. This is a limitation of this case study.

Treatment Implications of the Case

The major treatment implication of this case is that NET is effective at diminishing trauma symptoms in asylum-seekers with the use of an interpreter via telehealth. While research has demonstrated effectiveness of NET for trauma-related outcomes in refugees/asylum-seekers (Wright et al., 2020), there is limited research on the effectiveness of the use of an interpreter for NET with refugees/asylum-seekers (Lambert & Alhassoon, 2015) and there seems to be limited research on the use of telehealth with refugees. The use of an interpreter in psychotherapy may still present challenges including difficulties in building rapport or conveying empathy to the client, or misunderstanding of roles (Kuay et al., 2015), and this may be further exacerbated by the use of a telehealth platform (as was the case for this client). However, when a good relationship is established between the clinician and interpreter and, subsequently, with a client, the effectiveness of therapy, in this case, NET, is successful. This relationship between three parties was imperative in the sense that, by nature, NET requires participants to be vulnerable in sharing the details of their traumatic experiences with both the clinician and an interpreter. Refugee mental health care services in most high-income countries involve long-term intensive treatments, delivered by scarce and expensive mental health professionals (Wright et al., 2020). Implications from this case are that NET is a short-term, cost-effective means for providing trauma-focused care for refugees/asylum-seekers.

There were several limitations to this case. One important limitation that has been mentioned, is the fact that services were provided through telephone making it impossible to have any behavioral observations accompanying sessions. A component of NET is to utilize these behavioral observations, such as facial expressions and body language, and to point them out to a client to elicit more complete “hot memories” associated with the retelling of traumatic events in the lifeline. However, pointing out Amaya’s tone of voice while recalling traumatic events was an observation that was utilized by his clinician in lieu of other behavioral observations.

As mentioned above, an additional limitation to this case study is the lack of quantitative data that results from administering symptom screeners pre- and post-treatment as well as during follow-up sessions. The clinical interview indicated that Amaya met criteria for PTSD and because of that it was determined the PLC-5 was not an effective way to assess PTSD for Amaya (because of language and cultural barriers).

An ongoing issue is that there are an insufficient number of mental health professionals to meet the needs of refugees experiencing significant psychological distress (Sijbrandij et al., 2017), especially limited professionals who may speak the language of many refugee/asylum-seekers. This case shows that the use of an interpreter does not hinder progress in therapy and can be successfully utilized with NET given the relationship between the clinician, interpreter, and client is strong. This is important because it suggests that future research should focus on cross-sectional measures of the clinician, interpreter, and client relationship and how that plays a role in the reduction of PTSD symptoms in trauma-focused evidence-based treatments.

Additionally, this case shows the importance of clinician flexibility in the delivery of telemental health and interventions being utilized. Research shows that refugee mental health providers that utilize a holistic, flexible framework in their cross-cultural clinical work can help explain how providers can overcome telehealth obstacles, such as communication struggles (due to not speaking English or speaking limited English), incorporation of a third person in the session (interpreter), low technological literacy (due to lack of technological usage in homeland), and/or lack of access to computers phones (Disney et al., 2021).

Recommendations to Clinicians and Students

Narrative Exposure Therapy has been shown to be effective for reducing symptoms of PTSD in refugee populations and researchers have postulated that this is because it enables individuals to discuss their trauma in a testimonial approach, which may be less stigmatizing (Wright et al., 2020). However, there has been little research on specific factors that contribute to the success of NET with the use of consistent interpreters. As mentioned previously, Lambert and Alhassoon (2015), in their meta-analysis, found effect sizes that were not significantly different for studies that utilized an interpreter and those that did not. This suggests that the use of interpreters in trauma-focused therapy can be effective. They mentioned that this is encouraging given that using an interpreter in mental health is often necessary when working with refugees. The current case study corroborates these results in that Amaya’s PTSD symptomatology decreased as a result of receiving NET with the use of an interpreter via telehealth. Additionally, it is important for clinicians to practice flexibility in the delivery of telemental health with refugees, especially when the use of an interpreter is required. Therefore, the current study adds to the body of research that the use of interpreter in telehealth for trauma-focused therapies can be effective, particularly with NET.

Factors that contributed to the efficacy of the use of an interpreter with Amaya was the clinician’s ability to ensure that there was only one interpreter used throughout her treatment. This can be difficult if interpretation services that are offered to clinicians are from a language bank where any available interpreter can accept the phone call at any given time. It is of extreme importance to establish the use of one consistent interpreter for each session of any trauma-focused therapy due to the inherent vulnerabilities, such as mistrust, stigma, and distress, that can often accompany trauma work. It is the belief of the clinician working on this case that this was an important contribution to the success of NET with Amaya.

The utilization of NET with refugees, even with interpreters, is recommended to clinicians and students. If using an interpreter with NET, it is important to establish a good relationship with the interpreter and have clear communication. Research has mentioned that interpreters are not typically trained in psychotherapy and may have difficulty effectively communicating mental health concepts (Miller et al., 2005; Westermeyer, 1990). Therefore, it would be beneficial to conduct a debriefing period before and after each session in which the clinician and the interpreter discuss the content of the session, review psychological terms, symptoms, etc., what linguistically worked and what did not work in the session, and allowing for any clarifying questions to be asked by the interpreter. This ensures that clinician can somewhat monitor how the interpreter is relaying information to the client and, additionally, be able to gather information that the interpreter may have been able to pick up on during the session that the clinician could not (i.e., cultural considerations, idioms, metaphors used, etc.). When utilizing NET is used with an interpreter, it would be prudent to review specific NET terms (i.e., “rock,” “flower,” “hot” memories, and “cold” memories) and components with the interpreter that will be used in the session prior to the session. The clinician should also review PTSD and its symptoms with the interpreter in case the interpreter, assuming they culturally match with the client, can offer insight into cultural perceptions of such symptoms and diagnoses. This would all be important information for a clinician to have to best understand and serve their client.

Implications of this case point to the fact that meaningful therapeutic connections can be made despite there being language barriers and the use of an interpreter. As long as the process is approached with an open-mind devoid of biases, intimidation, and assumptions a therapeutic alliance will be formed that mimics one that would not require the use of an interpreter.