Treating posttraumatic stress disorder using Narrative Exposure Therapy: A study of domestic violence survivors in south India

The current understanding of domestic violence is largely nomothetic by design and does not adequately address the treatment and rehabilitation needs of survivors. This thesis aimed to gain a qualitative understanding of the culture-specific experiences of domestic violence in south Indian female survivors, with a focus on the treatment of posttraumatic stress disorder (PTSD), and comorbid psychopathology. An interpretative phenomenological analysis was undertaken with five south Indian women to investigate the in-depth, lived experiences of domestic violence and its mental health sequelae. Responses to, and appraisals of abuse were found to be heavily influenced by pre-abuse identity, interpersonal childhood experiences, societal perceptions of, and stigmatising attitudes towards survivors. These factors impact the experience of disclosure and help-seeking among survivors, with a clear preference for informal sources of support such as family and social care organisations. Further, the findings shed light on the experience of resisting and counteracting the abuse in this context, as well as the complex, non-linear and iterative process of leaving abusive relationships. This was found to be rooted in the sociocultural framework of Indian society, patriarchal ideologies of gender roles, and the systemic and structural disempowerment of women, perpetuating the perpetration and experience of abuse and violence. The treatment protocol examined in this thesis is Narrative Exposure Therapy (NET), which is a short-form psychotherapeutic technique originally developed for survivors of war and organised violence in low-resource contexts. The comprehensive and up-to-date meta-analysis of its current evidence base along with a quality appraisal of the trials included was conducted. The findings revealed low- to medium-quality evidence of NET efficacy for the alleviation of PTSD. High heterogeneity estimates and low powered trials significantly impact the interpretation of the pooled intervention effect estimates. This review also revealed an overreliance on randomised controlled trial findings and a paucity of idiographic research investigating change mechanisms through NET. In the final study, an inductive and deductive thematic analysis was undertaken to investigate the change mechanisms through NET for survivors of domestic violence. NET was administered to seven south Indian women and was well tolerated by the sample. Paired sample t-tests revealed a statistically significant improvement in PTSD and somatic symptoms at post-test. The raw testimony data was qualitative analysed, and a theoretically-informed framework of recovery was developed through thematic analysis to elucidate the specific processes that contribute to change and underlie improvement on symptom scores. There was evidence for several proposed mechanisms based on seminal PTSD theories, as well as some data-driven mechanisms such as positive memories and a focus on future aspirations that contributed to recovery in this sample. There are no published accounts of NET’s use or efficacy in India, and practice implications include culture-specific and stressor-specific applications of NET using the template from the recovery framework. These findings complement the limited RCT evidence of NET from an idiographic perspective. Importantly, the need to consider and explore culture- and context-specific change mechanisms is demonstrated through the framework, which found additional processes contributing to recovery in this sample. Recommendations for the adaptation of individual-focused, empirically supported treatments such as NET that are culturally sensitive and consider the complex socio-ecological milieu of the Indian context are discussed