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. Author manuscript; available in PMC: 2026 May 16.
Published in final edited form as: Behav Ther. 2025 Aug 26;57(2):269–283. doi: 10.1016/j.beth.2025.08.005

A Feasibility and Acceptability Trial of Narrative Exposure Therapy during Pregnancy

Avelina C Padin 1, Michelle L Miller 2, Marisa J Perera 3, Samantha Addante 1, Adela Scharff 1, Danie J Meyer 4, Madeleine U Shalowitz 1,5, Natalie R Stevens 6
PMCID: PMC13178739  NIHMSID: NIHMS2168442  PMID: 41741099

Abstract

Perinatal posttraumatic stress disorder (PTSD) poses a significant risk to maternal and infant mental and physical health. Addressing PTSD during pregnancy is crucial to improving perinatal health; however, evidence-based trauma-focused psychotherapy tailored to this population remains understudied. The current study examined the feasibility, acceptability, and potential treatment effects of Narrative Exposure Therapy (NET) in a diverse sample that includes Black/African American and Hispanic/Latina pregnant women. Pregnant participants (N = 29) in this nonrandomized, open-label trial received a course of NET and completed assessment measures before treatment, 1-week and 1-month post-treatment, and at 1-month postpartum. Measures of feasibility (treatment engagement and retention) and acceptability (participant pre-treatment expectations and post-treatment feedback) were examined. Exploratory analyses examined within-subjects changes in PTSD and depression symptoms to investigate potential treatment effects. The majority of participants reported positive pre-treatment expectations of NET (91.3%), and a high degree of satisfaction (69.6%) and perceived benefit (100%) from NET post-treatment. Linear mixed models showed significant decreases in PTSD and depressive symptoms over time, with sustained symptom improvement extending into the postpartum period. Within-subjects effect size calculations revealed large treatment effects from pre-treatment to 1-week post-treatment and from pre-treatment to postpartum for both PTSD and depression symptoms. Findings suggest that NET is feasible, acceptable, and beneficial during pregnancy, including among minoritized populations, and suggest it is an appropriate approach to treating perinatal PTSD.

Keywords: Perinatal, Pregnancy, Posttraumatic stress disorder, Narrative Exposure Therapy

Introduction

Prenatal posttraumatic stress disorder (PTSD) affects up to 1 in 5 trauma-exposed pregnant individuals and is associated with increased risk for pregnancy (e.g., pre-eclampsia, gestational diabetes) and birth complications (e.g., preterm birth, low birth weight) (Lev-Wiesel et al., 2009; Shaw et al., 2014, 2017; Yildiz et al., 2017; Yonkers et al., 2014). Effects of prenatal PTSD have the potential to reverberate across generations, as untreated symptoms are likely to persist into the postpartum period, where they can have deleterious effects on the maternal-child relationship and child development (Cook et al., 2018; Muzik et al., 2016). Accessible, effective PTSD treatment during pregnancy may play a critical role in mitigating adverse biopsychosocial outcomes associated with perinatal PTSD; however, clinical research has historically excluded pregnant participants, much less specifically focused on treatment considerations during the perinatal period, leaving limited evidence available to inform best practices for PTSD treatment during pregnancy (Baas et al., 2020; Stevens et al., 2021).

Several PTSD treatment guidelines recommend evidence-based trauma therapies as the first-line treatment for PTSD over pharmacotherapy (Martin et al., 2021), and meta-analytic evidence suggests that trauma-focused psychotherapy provides greater sustained improvement in PTSD symptoms compared to pharmacotherapy (Lee et al., 2016). The American Psychological Association (APA) and International Society for Traumatic Stress Studies (ISTSS) recommend Prolonged Exposure (PE; Foa et al., 2007) and Cognitive Processing Therapy (CPT; Resick et al., 2017) as frontline therapies with the highest level of evidence, with Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 2018) and trauma-focused cognitive behavioral therapies (TF-CBT) such as Narrative Exposure Therapy (NET; Schauer et al., 2011) at varying levels of empirical support. Overall treatment effect sizes for frontline PTSD treatments range from moderate to high (Watkins et al., 2018), but treatment gaps persist.

To date, there has been just one completed RCT examining an evidence-based PTSD treatment during pregnancy using EMDR (Baas et al., 2021), with promising results. Additionally, a nonrandomized open-label trial of Written Exposure Therapy (WET; Nillni et al., 2023) among pregnant individuals found evidence of improved PTSD symptoms that were sustained 6-months post-treatment. These trials provide preliminary evidence supporting the use of exposure techniques to address PTSD during pregnancy. However, much remains unknown about the acceptability and feasibility of PTSD treatment during pregnancy, particularly among minoritized populations. This is a critical knowledge gap, because Black, Indigenous, and people of color (BIPOC) pregnant people have rates of PTSD more than four times higher than those in white pregnant women (Grekin & O’Hara, 2014; Powers et al., 2020; Resnick et al., 1993; Seng et al., 2009). Higher rates of trauma exposure, barriers to accessing mental healthcare, and chronic exposure to institutional racism among BIPOC individuals contribute to this disparity (Harnett & Ressler, 2021; Sibrava et al., 2019).

The current study evaluated the acceptability and feasibility of NET during pregnancy in a diverse sample including Black/African American and Hispanic/Latina pregnant participants. NET is a brief therapy for individuals with PTSD which draws on elements of testimony therapy (Cienfuegos & Monelli, 1983) and exposure therapy (Foa & Kozak, 1986) with the aim of reducing trauma avoidance and contextualizing traumatic memories within one’s autobiographical memory. NET has been tested and demonstrated efficacious in various settings (e.g., rural and urban settings; lower-, middle-, and higher-income countries) and across diverse samples (e.g., migrated refugees of all ages, adult human trafficking survivors, transgender and gender diverse adolescents and young adults, etc.; Julian et al., 2023; Lely et al., 2019; Robjant & Fazel, 2010). Similar to other frontline PTSD treatments, research suggests that NET is also effective for improving clinical correlates of PTSD, including depression and suicidal ideation (Ertl et al., 2011; Raghuraman et al., 2021), which have been identified by the Centers for Disease Control as two leading causes of maternal mortality in the United States (Centers for Disease Control, 2020).

NET was chosen as the study intervention for several reasons. NET has high retention rates (Raghuraman et al., 2021; Steuwe et al., 2016) and requires less time and resources than other frontline therapies, as it has been shown to be effective in as few as three to six 90-minute sessions and can be safely and effectively delivered via telehealth (Kaltenbach et al., 2021; Robjant et al., 2020). Additionally, NET involves no handbooks, worksheets or homework. These factors make NET particularly well-suited for pregnant patients balancing multiple medical appointments and preparing for a new infant. We also believe NET is a particularly promising intervention for pregnant BIPOC patients due to its basis in narrative therapy. Rather than framing trauma survivors’ distress from a deficit model perspective, narrative therapy acknowledges survivors’ strengths and the role of systemic oppression in creating and perpetuating psychological distress by empowering the survivor to narrate their experiences of trauma and resilience, dismantle externally derived narratives of self-blame and shame, and take ownership of their life story (Julien et al., 2023; Neuner et al., 2020). Researchers have suggested that narrative therapy’s emphasis on positioning the therapist as partner rather than expert, supporting patients in reauthoring their own story, and highlighting resilience in the face of oppression may be particularly salient and validating for BIPOC patients (e.g., Hankerson et al., 2015; Semmler & Williams, 2000). Indeed, prior research indicates narrative therapy approaches are effective in reducing psychological distress among BIPOC participants (Goddu et al., 2015; Gómez et al., 2020) and suggests that NET is effective across diverse cultures and geographies (Robjant & Fazel, 2010).

Little is known about the viability, patient perceptions, and outcomes of PTSD treatments for pregnant populations, including those from minoritized groups and disinvested communities. Therefore, our primary aim was to examine the feasibility (i.e., recruitment, engagement, and retention), acceptability (i.e., pre-treatment expectations and post-treatment satisfaction), and benefit (i.e., changes in PTSD and depression symptoms) of Narrative Exposure Therapy (NET) in a diverse sample of pregnant patients. Exploratory analyses assessed within-subjects changes in PTSD and depression symptoms as a preliminary investigation of the potential treatment effects of NET during pregnancy. Based on prior research indicating that NET is a low-burden, well-received, and effective PTSD intervention across diverse samples, we hypothesized that NET intervention during pregnancy would be feasible, acceptable, and beneficial to pregnant patients.

Methods

Design and Setting

To conduct this pilot feasibility trial of perinatal NET, we recruited pregnant patients during 2019-2022 from two outpatient obstetrics and gynecology clinics at a large academic medical center in the Midwest US. This study was designed as an open-label, nonrandomized acceptability and feasibility trial to inform the development of a scalable behavioral intervention for perinatal PTSD, in line with ORBIT Phase II recommendations for developing and testing behavioral treatments (Czajkowski et al., 2015). Annually, over 1,200 pregnant patients are served in these clinics. Approximately 75% of clinic patients receive some form of public assistance, including Medicaid. Many patients reside in the local urban community, which is majority African American and 35% Hispanic/Latinx. Sessions were originally planned as a mix of in-person and telehealth sessions, with the first four sessions conducted in person and the last two sessions conducted virtually. However, after the COVID-19 global pandemic started, all NET sessions were transitioned to virtual telehealth sessions. In-person NET sessions were conducted within a hospital-based outpatient psychotherapy clinic located near the obstetric clinics. Study therapists confirmed that participants completed telehealth sessions from a safe, private location. All procedures were approved by the University Institutional Review Board.

Eligibility Criteria

Participants were in their first or second trimester of pregnancy. Inclusion criteria were: (1) age 18 years or older, (2) able to read and speak in English, (3) ≤ 28 weeks gestation, and (4) probable PTSD diagnosis based on endorsement of a DSM-5 Criterion-A trauma at least 3 months prior to the current pregnancy and score ≥ 33 on the PTSD Checklist for DSM-5 (PCL-5). A 3-month time frame for having a traumatic event before pregnancy was used to minimize the likelihood that participants' symptoms would resolve prior to initiating NET treatment, based on prior research suggesting that a significant proportion of trauma-exposed individuals will experience resolution of PTSD symptoms by 3-months post-trauma, after which time symptoms appear to stabilize (Diamond et al., 2022). Exclusion criteria included: (1) > 28 weeks gestation, (2) current legal involvement due to traumatic events (due to concern for re-traumatization and potential logistical barriers to study completion), (3) lifetime history of psychotic or manic symptoms, (4) self-reported cognitive impairment that impaired one’s ability to provide informed consent, (5) current involvement in trauma-focused treatment, (6) change in psychotropic medication that occurred < 6 weeks prior to eligibility screening, and current, severe (7) suicidal ideation or (8) dissociative symptoms.

Procedure

Recruitment.

To identify potential participants, obstetrics clinic staff asked all patients to complete the two-item PTSD Symptom Checklist (PCL-2; Lang & Stein, 2005) at their initial prenatal appointment. Those with positive screens (i.e., PCL-2 score ≥ 4) were provided information about the study and invited to complete the eligibility interview. Additional recruitment methods included brochures placed in waiting rooms and prenatal welcome packets and referrals from affiliated prenatal care and psychotherapy clinics. Referred participants were contacted by trained study staff to schedule a 30-minute eligibility interview by telephone, which included administration of the Life Events Checklist (LEC; Weathers, Blake, et al., 2013) to assess history of at least one Criterion A traumatic event and the PCL-5 to assess for score of 33 or higher. Ineligible participants were provided outside mental health referral resources. See Figure 1 for participant flow.

Figure 1. CONSORT diagram depicting participant flow.

Figure 1.

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Intervention Procedures.

After providing informed consent, participants were assigned to a designated NET therapist who worked with them exclusively to ensure continuity of care. NET treatment consists of four stages: 1) assessment of PTSD symptoms and lifetime trauma history, 2) psychoeducation about trauma, PTSD, and NET treatment, 3) laying the lifeline, and 4) exposure sessions. Each NET session lasted 90-120 minutes; participants were encouraged to meet with their NET therapist weekly but could schedule sessions flexibly with their NET therapist. Given prior research indicating clinical benefit from NET in as few as four sessions (Neuner et al., 2004; Zang et al., 2013), we set the recommended number of sessions at six in order to balance providing adequate treatment dose with reducing burden for pregnant individuals managing numerous prenatal care appointments.

The NET therapist and participant completed the first two stages of treatment during the initial intake session. The subsequent session focused on laying the lifeline, where participants created a representation of their life course using symbols to represent traumatic events (stones) and significant positive events (flowers). At the close of the lifeline session, the therapist and participant collaborated to identify critical events to explore further in future exposure sessions. During each exposure session, participants were asked to narrate one critical event from their lifeline in chronological order. At the direction of the NET therapist, participants provided details on the sensory, emotional, and cognitive elements of the memory while remaining connected to the “here and now” through therapist instruction to notice present moment body sensations. This process allows the patient to anchor the traumatic event in the past while integrating the fragmented traumatic memory into a coherent, declarative narration (Schauer et al., 2011). Following each exposure session, the NET therapist composed a narrative of the exposure and read it aloud at the beginning of the next session to check for errors and missing information.

The study therapist team consisted of psychology postdoctoral fellows, one licensed clinical professional counselor, and a licensed clinical psychologist who served as lead clinical supervisor. All NET therapists completed a 12-hour NET training conducted by expert NET trainers. Study therapists participated in regular individual supervision with the lead clinical supervisor and group supervision with the full study team. The lead clinical supervisor also reviewed the written exposure narratives and reviewed video recorded sessions to ensure all components of the treatment model were present. Group supervision was used to troubleshoot common clinical challenges (e.g., navigating dissociation during exposure sessions), role-play NET techniques, and review participant lifelines and exposure narratives.

Data Collection.

Data were captured electronically and managed using Research Electronic Data Capture (REDCap) hosted by the University (Harris et al., 2009, 2019). Data were collected at the initial intake session (T1), before each NET treatment session (T2), 1-week post-completion of the participant’s final NET treatment session (T3), 1-month post-completion of the participant’s final NET treatment session (T4), and 1-month after the participant gave birth (T5). Participants were offered the opportunity to complete a qualitative feedback interview upon completion of treatment or upon early withdrawal from treatment. Participants were compensated for completion of the pre-treatment questionnaire, each of the three post-treatment questionnaires, and the post-treatment qualitative interview, for a total of up to $170.00 in electronic gift cards for completion of all assessments.

Feasibility and Acceptability Criteria

Feasibility.

Feasibility was defined as (a) engagement in treatment and (b) retention in the study. Engagement in treatment was defined as the percentage of eligible individuals who attended at least the initial intake session. The retention rate was the percentage of participants who completed the minimum number of treatment sessions (≥4 sessions). Additionally, the mean number of weeks needed to complete the recommended 6-session protocol was assessed.

Acceptability.

Acceptability was determined by measuring self-reported participant expectations before treatment and participant feedback at post-intervention assessments. When examining pre-treatment expectations, we calculated the number of participants that held the belief that it is possible to recover from PTSD (≥5 on a 10-point Likert scale). To determine acceptability post-treatment, participants rated the usefulness, safety, and structure of the NET intervention (see Measures).

Measures

Prior to initiating NET treatment, participants self-reported their demographic characteristics, obstetric history, and mental health treatment history. Childhood trauma history was assessed using the abuse subscales (i.e., physical, sexual, and emotional abuse) from the Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998). Scores for each subscale range from 5-25, and clinically significant childhood abuse was defined using cutoff scores from Walker and colleagues (physical abuse score≥8, sexual abuse score≥8, emotional abuse score ≥10; 1999). Birth outcome data for the current pregnancy were extracted from electronic medical records. Internal consistency for the current sample was Cronbach’s α = .924.

Pre-Treatment Expectations.

To assess pre-treatment expectations, a 6-item treatment expectations measure was developed for this study using items from established treatment expectations measures (Credibility and Expectancies Questionnaire, Devilly & Borkovec, 2000; Foa et al., 1991). The scale includes three components: The first 3-item section asked participants how much they believed it was possible to heal from trauma and PTSD and their confidence in PTSD treatment using an 11-point Likert scale (0 = completely disagree; 10 = completely agree). The second section included a single item assessing how much improvement in trauma symptoms participants believed would occur, scored from 0-100%, with higher scores indicating greater symptom improvement. In the final two-item section (from Devilly & Borkovec, 2000) participants rated how much they “really feel” therapy would reduce their trauma symptoms (10-point Likert scale, 1 = not at all; 10 = very much) and how much improvement they “really feel” would occur (scored on a slider scale of 0-100% with higher scores indicating greater improvement in their trauma symptoms). Internal consistency for the current sample was Cronbach’s α = .913.

Post-Treatment Satisfaction and Acceptability.

The Client Satisfaction Questionnaire short form (CSQ-4) is a four-item questionnaire used to assess overall satisfaction with a program (Attkisson & Zwick, 1982). Respondents indicated the extent to which they were satisfied with NET on a 4-point Likert scale. Internal consistency for the current sample was Cronbach’s α = .953.

The NET Acceptability and Feasibility Questionnaire (NET-AQ; Quinn, 2015), a 10-item measure of participant feedback about NET, was used to evaluate treatment acceptability. NET-AQ was developed for use in a prior study to assess participants’ beliefs about NET. Items are completed using a 5-point Likert scale (1=I don’t agree at all to 5=I totally agree); item agreement was defined as a score of 4 or 5. Psychometric data have not been published; this scale was used with permission from the author. Internal consistency reliability for the current sample was Cronbach’s α = .713.

Primary Measure of Potential Treatment Effect.

The PTSD Symptom Checklist for DSM-5 (PCL-5; Weathers et al., 2013) was used as the primary measure of NET treatment effect. The PCL-5 is a 20-item measure of PTSD symptoms across four clusters (Re-experiencing, Avoidance, Hypervigilance, and Negative Mood/Cognitions) on a 0-4 scale ranging from “Not at all” to “Extremely.” Total scores range from 0 to 80, with a score of 28-33 suggesting a “probable diagnosis” of PTSD. A 10-point reduction on the PCL-5 indicates clinically meaningful change (Weathers et al., 2013). Internal consistency for the current sample was Cronbach’s α = .932.

Secondary Outcome Measure.

As PTSD is frequently comorbid with depression, the Edinburgh Postnatal Depression Scale (EPDS; Cox et al., 1987) was used to assess depression symptom severity. Total scores range from 0 to 30, with a score of 10 or higher indicating a probable diagnosis of depression (Cox & Holden, 2003). A reduction of 4 points on the EPDS is indicative of clinically meaningful change (Matthey, 2004). Internal consistency for the current sample was Cronbach’s α = .863.

Statistical Analysis

Analyses were conducted in SPSS version 27. Descriptive statistics were calculated to evaluate treatment feasibility, acceptability, and satisfaction, as outlined above. Symptom changes were considered clinically significant if there was a minimum 10-point improvement on the PCL-5 for PTSD (Weathers et al., 2013) and a minimum 4-point improvement on the EPDS for depression (Matthey, 2004). To estimate treatment effect sizes with 95% confidence intervals, we calculated Gibbons’ within-subjects variant of Cohen’s d (Gibbons et al., 1993), which provides a standardized mean difference between assessments accounting for correlated within-subject data. We estimated effect sizes from pre-treatment to 1-week post-treatment and from pre-treatment to 1-month postpartum. Effect sizes were categorized as small (d > 0.20), medium (d > 0.50), or large (d > 0.80), consistent with benchmark recommendations from Cohen (1988). An a priori power analysis suggested that a sample size of at least 28 participants was necessary to detect a within-group treatment effect size of d = 0.50, with 0.80 power and 0.05 alpha level.

To further explore the trajectory of symptom change across the treatment period, linear mixed models were performed to assess within-subject trends in PTSD and depression symptoms across measurement timepoints (i.e., baseline, each NET session, and 1-week, 1-month, and postpartum follow-up assessments). Normality of the variables of interest was inspected and deemed acceptable. With respect to missing data, only 2.5% of observations were missing for the PCL and EPDS across time points; therefore, no further steps were taken to address missingness. Participant ID was the grouping variable; time was measured in weeks from baseline and included as a continuous variable. We computed models with linear and quadratic effects of time to model the decreasing rate of change that is typically found in assessments of symptom change across psychotherapy. Although theoretically predicted, the addition of a quadratic time effect does not necessarily improve model fit. Therefore, we compared the relative fit of linear only or linear and quadratic models for time by comparing model −2 log likelihood values; for both outcomes, the quadratic model was superior to the linear only model based on chi-square difference tests. Maximum likelihood was used as the estimation method for all models. Random intercepts and slopes for the effect of time and unstructured covariance matrices were included for depression and PTSD models. We also computed exploratory models including potential moderators of treatment outcome. In the model for PTSD symptoms, we included main effects and interactions with time for pre-treatment depression severity (baseline EPDS), severity of childhood trauma (CTQ), and number of NET sessions attended as fixed effects. In the model for depression symptoms, we included main effects and interactions with linear time for severity of childhood trauma (CTQ) and number of NET sessions attended as fixed effects. Moderators were chosen based on previous research examining their influence on PTSD treatment effects (e.g., Kline et al., 2021; Lely et al., 2019; Schneider et al., 2020).

Results

Sample Characteristics

Descriptive statistics on all study variables are presented in Table 1. On average, participants (N = 29) were 27.6 years old and at 18.7 weeks gestation at the time of consent. Almost two-thirds of the sample reported having less than a complete college education (65.5%). Approximately half of the sample reported being single (48.3%) and employed full-time (51.7%). The racial/ethnic breakdown of the sample was 37.9% Black, 24.1% White, 6.9% Asian/Pacific Islander, 3.4% American Indian/Alaskan Native, and 24.1% Other; 44.8% of participants identified as Hispanic/Latina. The majority (89.7%) of participants identified as BIPOC (i.e., Black, Indigenous, People of Color, including those who identified as Asian or Latina in our sample).

Table 1.

Sample characteristics at baseline (N=29)

Variable M (SD) or n(%)
Demographic information
Age (years) 27.6 (3.7)
Gestational age at time of consent (weeks) 18.7 (4.5)
Race
 Black 11 (37.9%)
 White 7 (24.1%)
 Asian/Pacific Islander 2 (6.9%)
 American Indian/Alaskan Native 1 (3.4%)
 Other 7 (24.1%)
Ethnicity (% Latina) 13 (44.8%)
Partner status
 Single 14 (48.3%)
 Cohabitating 5 (17.2%)
 Married 7 (24.1%)
 Separated/Divorced 3 (10.3%)
Education level
 Some high school 1 (3.4%)
 Graduated high school 5 (17.2%)
 Some college 13 (44.8%)
 Graduated college 7 (24.1%)
 Completed graduate school 3 (10.3%)
Employment status
 Unemployed 9 (31.0%)
 Employed full-time 15 (51.7%)
 Employed part-time 5 (17.2%)
Trauma and Mental Health Treatment History
Childhood Maltreatment (CTQ)
 CTQ Total score 18.3 (13.8)
 Sexual abuse (% above clinical cutoff) 13 (44.8%)
 Physical abuse (% above clinical cutoff) 7 (24.1%)
 Emotional abuse (% above clinical cutoff) 9 (31.0%)
Current therapy (% yes) 4 (13.8%)
Current psychiatrist (% yes) 3 (10.3%)
Current psychotropic medication (% yes) 1 (3.4%)
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Prior to starting NET treatment, 13.8% of the sample reported that they had a current therapist; 10.3% had a psychiatrist, and one participant endorsed current psychotropic medication use. Among the four participants receiving concurrent outside therapy, three were receiving “supportive counseling” for <2 months and one had been receiving “cognitive behavioral therapy” for major depressive disorder for over a year prior to study enrollment. Forty-five percent of participants reported clinically significant childhood sexual abuse, 24.1% reported significant physical abuse, and 31% reported significant emotional abuse. See Table 1 for complete trauma and mental health treatment history.

Among 27 participants with available birth outcome data following treatment completion, the average gestational age at delivery was 38 weeks (SD = 3.5); there were four premature births (i.e., birth prior to 37 weeks). On average, infant birth weight was 3241.3 grams (SD = 497.0), with 56.8% of infants at normal birth weight, 17.2% small for gestational age, and 13.8% large for gestational age. Birth outcome data were unavailable for two participants who gave birth at outside hospitals.

Feasibility & Acceptability

Among 345 individuals who were contacted to complete an eligibility interview, 103 (29.9%) declined and 79 (22.9%) could not be reached. Of those who were eligible to participate (N = 38), 29 individuals (76.3%) completed an initial intake session. On average, enrolled participants attended approximately 5 sessions (M = 4.97, SD = 2.29); 72.4% of participants (n = 21) completed the minimum number of treatment sessions (≥4 sessions; see Figure 2). Of all NET session visits, 38% were conducted in-person and 62% were virtual. Participants generally reported positive pre-treatment expectations and high post-treatment satisfaction (see Table 2). Prior to treatment, most participants (91.3%) endorsed the belief that it is possible to recover from PTSD.

Figure 2. Session attendance by participant.

Figure 2.

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Note: Participant #20 enrolled in the study and provided baseline data but did not attend any treatment sessions.

Table 2.

Results of pre-treatment expectations and post-treatment satisfaction and acceptability.

Pre-treatment expectations
Item Min Max M SD
I believe it is possible to heal from trauma 0.0 10.0 7.5 2.8
I believe it is possible to recover from PTSD 3.0 10.0 7.3 1.9
I feel confident that I will be successful in my PTSD treatment 3.3 10.0 7.6 2.2
By the end of the therapy period, how much improvement in your trauma symptoms do you think will occur? 34% 100% 72.3% 18.4
At this point, how much do you really feel that therapy will help you to reduce your trauma symptoms? 2.0 10.0 7.2 1.9
By the end of the therapy period, how much improvement in your trauma symptoms do you really feel will occur? 48% 100% 74.9% 16.4
Post-treatment satisfaction (CSQ-4)
Item Min Max M SD
To what extent has NET met your needs? 2 4 3.17 0.8
Did what you received help you to deal more effectively with your problems? 2 4 3.17 0.8
In an overall, general sense, how satisfied are you with what you have received? 2 4 3.35 0.7
If you were to seek help again, would you come back to NET? 2 4 3.43 0.7
Post-treatment acceptability (NET-AQ)
Item Min Max M SD
I understand what NET is 3 5 4.6 0.7
I think NET is useful 4 5 4.9 0.4
Six weeks of NET is enough 1 5 3.4 1.3
I feel safe discussing traumatic events in my life 3 5 4.7 0.6
I believe NET can provide relief when you feel sad or down in the dumps 2 5 4.4 1.0
I believe telling my story to a counselor can help me work through my negative feelings and emotions 1 5 4.7 0.9
I think the time needed for NET sessions is ok 3 5 4.6 0.6
I think the NET counselor helped me 4 5 4.9 0.3
Having my life story written by the NET counselor is ok 4 5 4.8 0.4
I would recommend NET to others if I think they needed it 4 5 4.8 0.4
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At the post-treatment assessment, 69.6% percent of respondents reported a “significant degree” or “the highest degree” of satisfaction with NET; 87% indicated that they would return to NET if seeking help in the future. Overall, participants indicated a high degree of agreement with items on the NET Acceptability Questionnaire (M = 45.78, SD = 3.79, minimum = 38, maximum = 50; see Table 2). The majority of participants (91.3%) felt they understood what NET was at the conclusion of treatment, while 100% of participants indicated that NET was useful and that they would recommend it to others who needed it. Most participants (95.6%) indicated that the time needed for NET sessions was acceptable; however, participants were not in agreement as to whether six weeks of NET was enough, with 43.5% agreeing that 6 weeks was sufficient, 30.4% neither agreeing nor disagreeing, and 26.0% disagreeing that 6 weeks was sufficient. Most participants (91.3%) felt a sense of comfort and safety discussing trauma material with a therapist.

Changes in PTSD and Depression Symptoms over Time

Calculations of Gibbons’ within-subjects variant of Cohen’s d revealed large treatment effect sizes from pre-treatment to 1-week post-treatment and from pre-treatment to postpartum for both PTSD and depression (see Table 3). To avoid artificially inflating estimates, clinically significant change is reported relative to the total sample (N = 29); however, this includes 5 participants who did not provide post-treatment follow-up data and 7 participants without postpartum data. We observed clinically significant improvement in PTSD symptoms among 22 (75.9%) participants from pre-treatment to 1-week post-treatment, which were maintained for 19 (65.5%) at 1-month follow-up and for 20 (69.0%) at 1-month postpartum. There was clinically significant improvement in depression symptoms among 16 (55.2%) of participants from pre-treatment to 1-week post-treatment, which were maintained for 15 (51.7%) at 1-month follow-up and for 15 (51.7%) at 1-month postpartum. We saw no evidence of clinical decompensation in PTSD symptoms, even after birth. A small number of participants demonstrated a clinically significant increase in depression symptoms between baseline and 1-month follow-up (7.0%); however, none of the participants showed clinically significant increases in depression symptoms between baseline and the 1-week follow-up or postpartum visits.

Table 3.

Results of within-subjects models examining changes in depression and PTSD scores over time

Time Measure M SE Cohen’s d 95% CI
Pre-treatment PCL-5
EPDS		 40.70
14.42		 13.82
4.68		 -
-		 -
-
1-week post-treatment PCL-5
EPDS		 15.54
7.27		 9.39
3.61		 2.13
1.84		 1.33, 2.92
1.02, 2.66
1-month postpartum PCL-5
EPDS		 15.48
7.74		 12.10
5.13		 1.98
1.46		 1.22, 2.74
0.57, 2.36
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Note: EPDS=Edinburgh Postnatal Depression Scale; PCL-5=PTSD Checklist for DSM-5. Gibbons’ within-subjects variant of Cohen’s d reflects the effect size for change from pre-treatment to each follow-up time point (1-week post-treatment and 1-month postpartum).

In analyses including all study timepoints, both the linear and quadratic effects of time on PTSD symptoms were significant (see Table 4 for all results of linear mixed models). As shown in Figure 3, mean PTSD scores decreased from pre-treatment through visit six (the final NET visit for most participants) before leveling off. When baseline depression, childhood trauma, and number of NET sessions were included as potential moderators of treatment trajectory, the linear and quadratic effects of time remained significant. The interaction of baseline depression severity with time was also significant, suggesting that PTSD severity improved to a greater extent among participants with higher baseline depression. The number of sessions attended by time interaction was non-significant, and there were no significant main effects or interactions with time for the CTQ.

Table 4.

Results of linear mixed models examining trajectories of symptom change across all timepoints.

Model B (95% CI) SE t (df) p
PTSD symptoms by time
  Intercept 43.173 (37.087, 49.259) 3.003 14.376 (36.857) <.001
  Time −5.603 (−6.811, −4.395) 0.611 −9.166 (152.873) <.001
  Time2 .258 (0.175, 0.340) 0.042 6.200 (135.080) <.001
PTSD symptoms by time with baseline depression, childhood trauma, and no. of sessions
  Intercept 6.377 (−13.625, 26.380) 9.740 0.655 (26.514) .518
  Time −2.316 (−4.531, −0.100) 1.102 −2.102 (48.286) .041
  Time2 0.252 (0.166, 0.338) 0.043 5.791 (127.191) <.001
  Baseline EPDS 2.076 (1.064, 3.087) 0.489 4.244 (23.229) <.001
  Baseline EPDS*Time −0.162 (−0.253, −0.070) 0.044 −3.652 (21.553) .001
  CTQ 0.283 (−0.038, 0.605) 0.155 1.823 (22.899) .081
  CTQ*Time −0.017 (−0.046, 0.013) 0.014 −1.175 (21.868) .253
  Number of sessions 0.210 (−2.062, 2.483) 1.115 0.189 (31.622) .852
  No. of sessions*Time −0.101 (−0.339, 0.138) 0.117 −0.862 (10.450) .395
Depression symptoms by time
  Intercept 15.745 (13.521, 17.968) 1.102 14.286 (42.214) <.001
  Time −1.477 (−1.990, −0.964) 0.260 −5.687 (150.917) <.001
  Time2 0.064 (0.029, 0.098) 0.018 3.630 (129.260) <.001
Depression symptoms by time with childhood trauma score and no. of sessions
  Intercept 13.439 (7.402, 19.477) 2.972 4.523 (34.220) <.001
  Time −0.946 (−1.754, −0.138) 0.405 −2.337 (67.542) .022
  Time2 0.061 (0.027, 0.096) 0.018 3.505 (127.138) .001
  CTQ 0.124 (−0.018, 0.265) 0.069 1.794 (26.900) .084
  CTQ*Time −0.009 (−0.024, 0.005) 0.007 −1.312 (24.957) .202
  Number of sessions 0.028 (−1.017, 1.075) 0.515 0.056 (33.715) .956
  No. of sessions*Time −0.064 (−0.179, 0.051) 0.056 −1.141 (30.817) .263
Open in a new tab

Note. Significant effects appear in bold. Time measured in weeks from baseline; EPDS = Edinburgh Postnatal Depression Scale, CTQ = Childhood Trauma Questionnaire. Number of sessions refers to number of NET sessions attended.

Figure 3.

Figure 3

Open in a new tab

Results of linear mixed models examining changes in PTSD and depressive symptoms over the course of the study. Note: Data points depict raw mean scores with error bars representing 95% confidence intervals.

Similarly, time had significant linear and quadratic effects on depression severity (see Table 4), such that depression scores tended to decrease during active treatment and level off after six sessions (see Figure 3). The linear and quadratic effects of time remained significant when accounting for childhood trauma severity and number of sessions attended, but the main effects and interactions with time for CTQ and number of sessions were non-significant.

Discussion

Results of this open trial suggest that NET is feasible, acceptable, and beneficial during pregnancy. Participants largely endorsed the belief that it is possible to heal from PTSD and that PTSD treatment could benefit them during pregnancy, suggesting that a subset of pregnant individuals are motivated to address trauma-related symptoms during this period. Results also suggest high post-treatment satisfaction, including unanimous agreement that NET is useful, that it helped participants, and that they would recommend it to others. Furthermore, participants showed improvement in PTSD and depression symptoms from pre- to post-treatment and improvements were largely maintained in the postpartum period. Within-subjects effect size estimates revealed large treatment effects from pre-treatment to 1-week post-treatment and 1-month postpartum for both PTSD and depression symptoms. Although exploratory, results did not suggest that the effect of treatment depended on childhood trauma severity or number of sessions attended. However, participants with higher baseline depression levels did appear to experience greater improvement in PTSD symptoms across treatment. Notably, this is the first trial of an evidence-based PTSD treatment during pregnancy in a racially/ethnically diverse sample of primarily BIPOC individuals.

Although exploratory, results did not suggest that the effect of treatment depended on childhood trauma severity or number of sessions attended. However, participants with higher baseline depression levels did appear to experience greater improvement in PTSD symptoms across treatment. This finding is contrary to recent meta-analytic evidence suggesting that higher baseline depression symptoms are associated with attenuated improvements in PTSD symptoms in prior PTSD treatment trials (Kline et al., 2021). At the same time, another study examining trauma-focused narrative therapy also showed greater reduction in PTSD symptoms among individuals with greater baseline depression symptoms (Cloitre et al., 2017), suggesting that more research is needed to determine when and to what extent baseline depression predicts PTSD treatment outcomes.

Although pregnant people have historically been excluded from PTSD trials, ostensibly due to concerns about negatively affecting the pregnancy and/or contributing to adverse birth outcomes, there was no evidence of higher rates of adverse birth outcomes in our study compared to the general population. These findings are consistent with a randomized trial of EMDR during pregnancy that found no evidence of adverse obstetric or neonatal outcomes among participants randomized to the PTSD treatment group compared to those receiving usual care (Baas et al., 2023). One participant with a history of suicidal ideation reported worsening distress and hopelessness partway through NET, resulting in a temporary pause in treatment to assess for safety and the potential need for inpatient treatment; however, this participant did not attribute symptom exacerbations to NET and ultimately completed treatment (see Stevens et al., 2020 for additional case details). Nearly all participants reported improvements in PTSD and depression symptoms over the course of treatment, and none endorsed suicidal ideation on self-report measures administered at the post-treatment or postpartum timepoints. Together, prior findings and ours highlight that psychotherapy treatment of PTSD poses little to no risk to pregnant individuals and their fetuses.

We believe that NET is particularly well-suited to address the needs of pregnant individuals and reduce barriers to receiving effective care. Among the general population, rates of treatment dropout from trauma-focused CBTs such as PE and CPT are typically high, with estimates ranging from 27% to 68% (Fernandez et al., 2015; Kehle-Forbes et al., 2016; Meis et al., 2019). CPT and PE also involve between-session homework, which can pose additional challenges to successful treatment, even among patients who manage to complete the treatment protocol (Cooper et al., 2017; Stirman et al., 2018). Both treatments also ask clients to identify an “index” trauma which serves as the primary treatment focus, while NET allows participants to explore multiple traumatic events and contextualize events within their life chronology. Our results suggest that pregnant patients with PTSD benefitted from a treatment protocol designed to minimize patient burden by limiting the number of sessions, providing most sessions via telehealth, and utilizing an intervention that does not rely on between-session homework.

Limitations

The limitations of the current study warrant careful consideration when interpreting findings and guiding future research. The generalizability of study findings is limited by self-selection bias, as individuals who elect to participate in psychotherapy research may be more likely to describe the treatment as acceptable and satisfactory compared to the general population. Notably, 52.7% of pregnant patients who screened positive for PTSD and were contacted to participate in the study either declined the eligibility screening interview or could not be reached, suggesting that more research is needed to better understand treatment preferences and barriers in this population. Additionally, due to the study’s small sample size and lack of a control group, results concerning the effects of NET on PTSD and depression symptoms and potential treatment moderators should be considered exploratory, as our study was focused on better understanding the feasibility and acceptability of PTSD treatment during pregnancy.

This study’s reliance on self-report measures introduces potential response biases and regression to the mean effects, which can influence observed symptom changes over time. This highlights the need for future studies to integrate additional varying methods of data collection (i.e., clinical interview) to account for potential biases, especially in the context of no control condition. Additionally, while our study included data collection during the postpartum period, a study strength, we did not collect follow-up data beyond one month postpartum, which poses limitations in assessing the longer-term maintenance of treatment effects and generalization of results to further timepoints. Finally, the current study did not measure NET treatment fidelity due to the lack of validated fidelity measures; instead, the study therapist team maintained active involvement in supervision with an expert trainer to ensure treatment was implemented accurately and consistently.

Implications and Future Directions

Although the current study provides initial support for the feasibility and acceptability of NET in a sample of majority BIPOC, pregnant participants, it also highlights the need for future trials aimed at further optimizing PTSD treatment engagement, acceptability, and efficacy in this population. Critically, the majority of pregnant patients declined to participate in the trial, and several participants highlighted limitations of NET, including a desire for longer treatment. This highlights the need for further examination of barriers to recruitment and retention, especially among BIPOC patients given stark disparities in treatment access and engagement for this population (Davis et al., 2008; McGuire & Miranda, 2008; Salameh et al., 2019; Stevens et al., 2018). Future research should also seek to examine the acceptability and benefit of NET within specific communities, as BIPOC is a broad term that encompasses diverse communities with specific treatment needs, barriers, and preferences. Furthermore, the heterogeneity observed in treatment effects underscores the importance of future research investigating individual differences (i.e., symptom severity, treatment preferences) to better understand which subgroups of pregnant individuals may benefit most from NET and other PTSD treatments. Future research should examine the durability of treatment outcomes and generalization of results across different stages of the perinatal period.

Our findings suggest that NET is feasible, acceptable, and beneficial to use during pregnancy. Although more empirical evidence is warranted, NET appears to be a safe and viable option for PTSD treatment during pregnancy, including among BIPOC populations. NET is a culturally appropriate approach to treating PTSD that may require less patient time and resources compared to other frontline treatments and is especially appropriate for individuals with cumulative and complex trauma, as it allows individuals to process several traumatic experiences rather than focusing on a single index trauma event. Overall, NET may be well-suited to meet the unique needs of pregnant BIPOC individuals with a history of trauma and PTSD.

Highlights.

  • Research identifying evidence-based therapies for PTSD during pregnancy is limited.

  • Narrative Exposure Therapy (NET) may be a promising approach in this population.

  • Findings suggest NET is feasible for and acceptable to pregnant people.

  • NET completers demonstrated PTSD and depression symptom improvement.

Acknowledgements:

We would like to thank the Bross Family Foundation for their generous contributions to this program of research.

Funding:

This work was supported by the Bross Family Foundation

Footnotes

Declaration of interests: None.

Ethics approval: All subjects gave written informed consent in accordance with the Declaration of Helsinki. All procedures were approved by the University Institutional Review Board on February 27, 2019 (Reference no.: 18111901-IRB01).

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