In this study we examined the efficacy and safety of NET, a short-term treatment approach for therapy of traumatised adults. The results supported the efficacy of NET in treating adult survivors of the Sichuan earthquake. Significant effects were found across a number of psychological variables post treatment. Levels of reported symptoms of PTSD, depression and anxiety, and general mental health were significantly reduced, and these reductions were stable for the 2 month follow up. Negative posttraumatic changes were reduced and positive changes increased. NET had little effect on either coping styles or social support.
Significant improvements in posttraumatic symptom categories after NET may reflect the mechanism of emotional habituation elicited by the exposure  and the efficiency of the narrative approach in the remediation of distortion of the explicit autobiographic memory about traumatic events, such as intrusive memory fragment, avoidance of thoughts, and trauma reminders . Depression, anxiety and general mental distress scores were also significantly reduced with NET. The impact of NET on reducing depression has been observed by Bichescu et al. . This may because persistent posttraumatic symptoms contribute to additional psychological and physical disturbances [42, 43]. It indicates that NET could reduce comorbid symptoms beyond the core set of PTSD.
The size of the treatment effect on posttraumatic symptoms at posttest (1.09-1.35) was higher than the effect sizes (0.6) reported in previous NET with traumatized refugees populations (e.g. ). The score on positive changes was relatively high in this sample (25-26/30), compared with other samples assessed using the CiOQ (20.50/30) . Anecdotally, the participants generally reported a high positive appraisal of the government’s rapid response to the earthquake. The social and political context, in this case the positive view of the government, could have an influence on the outcome of psychotherapies, though this is speculative, and needs further systematic research.
The difference to previous NET studies may be ascribed to the Chinese state-led support and assistance after the earthquake, as opposed to the insecurity and severe economical problems with refugees.
In addition, an improvement in positive change (posttraumatic growth) and reduction in negative change after treatment was found, with the outcome being stable at the 2 month follow-up. This suggests that treatment not only decreases symptoms but may also improve growth. It is consistent with one study with 65 PTSD patients treated with exposure therapy which showed that people experienced posttraumatic growth through finding new possibilities and personal strengths . The current findings may be linked to NET treatment focusing on helping people develop narratives about what has happened to them. Previous research has indicated the importance of narrative development for meaning-making after traumatic events .
Contrary to our hypothesis is there is only weak indication of improvement in perceived social support and coping. Other studies have found that chronic disorders such as PTSD can corrode social support [46, 47]. However, NET did not specifically address how people can change their social behaviour; it may be too short to have a significant effect on social support. Regarding coping, findings in this area are mixed. Individual differences in coping style have been found to influence the transition from distress to disorder . Other studies indicate that coping have limited predictive power for PTSD . The relationship between events, coping and disorder is likely to be complicated . Previous NET studies have not assessed coping style and little is known about the effect on coping of the intervention. However, this result may manifest that a short term intervention can unlikely change the coping. Alternatively, it may be that the measure chosen was not sensitive enough to pick up subtle changes. In addition, it may relate to coping style being a personality characteristic, and it is unlikely that a procedure such as NET will change its levels, or two month is too short to find the improvement.
The study was the first time NET has been applied to a Chinese setting and in earthquake-related PTSD. Although the efficacy of NET has already been shown across cultures in Europe, Africa and Asia [6, 15, 20], the psychosocial environment in this study was different from previous work which has largely focused on people affected by war and torture. While the choice of IES-R in this study was based on evidence of its effectiveness in other studies, a direct comparison of PTSD severity with previous NET studies using other measures (e.g. CAPS) is not possible. However, compared with populations of previous NET studies who experienced multiple or chronic traumatic events, particularly those originating from organised violence or torture of a severe and chronic nature, it is possible that earthquake survivors have a less severe or complex level of trauma. NET was originally designed to examine traumatic situations where there was a perpetrator, as it is derived in part from testimony therapy, which enables a witness document to be created. Nevertheless, the current study showed that for possibly simpler traumatic events without a perpetrator, NET can be effective. Further research is required to determine the effectiveness of NET with different types and severity of trauma. What this study indicates is the possibility of extending the approach outside of situations where testimony may be required and that people want to create narratives under different types of situations.
The lack of dropouts in the NET is in line with other NET studies [6, 42]. Most participants informally reported that they felt relieved and more comfortable after NET. This may be because of the nature of the intervention. NET uses narrative, which is the approach we all use in interactions so, unlike approaches such as CBT, it has good face validity and is not intimidating to the participant.
The main limitation of the study is the sample size and the lack of a longer term follow up. The sample size is small as the study aimed to test the effectiveness of NET in a new population (Chinese, and no perpetrator of the traumatic event), and practical considerations meant that a longer term follow up was impractical, as many of the participants were being moved into new accommodation in the period after the study, and would not always be traceable. Clearly, the sample may not be representative of Chinese earthquake survivors in general – at least in part because most participants were women. This reflected the sampling typically found in research of this area  and in survivor population as and most men were out for work in day time. However, the overall effectiveness of the intervention demonstrated its utility in such circumstances.
We found that some participants were not interested in signing off their final written biography. It may because of their poor education level or – perhaps more likely – that there are no perpetrators so there is no need for a signed witness report. Furthermore, according to feedback, four sessions was too long for many participants. This was because it usually took one session on the narration of their previous trauma experiences of traumatic life events, but 10 of the 22 participants had no other trauma experiences except the earthquake. Therefore, most changes to the narrative and to symptoms appeared to occur in the first two sessions (though there is no empirical evidence for this, so it will be necessary to conduct further research to test this). Some participants reported automatically reduced PTSD symptoms (e.g. better sleep, less intrusion etc.) and improved well-being (e.g. starting to hum while walking) after two sessions. This may suggest the standard four-session NET could perhaps be adapted and shortened for disaster-related traumatic events. Studies with larger sample sizes are needed to investigate such matters and to extend the present findings. Our study provided evidence for the applicability of a western developed approach in the Chinese population.