Narrative Therapy for Anxiety and Depression in Palestinian Refugee Adolescents (NT-AD)

Nablus University for Vocational and Technical Education

Status: Completed

Conditions: Anxiety; Depression - Major Depressive Disorder

Treatments: Behavioral: Culturally Adapted Narrative Therapy

Study type: Interventional

Funder types: Other

Identifiers

NCT07691021

Nrs. May 2024/1 (Other Identifier)

Ref: Nrs. May, 2024/1

Details and patient eligibility

About

This study evaluated whether a culturally adapted 10-week narrative therapy program could reduce anxiety and depression symptoms among middle school students living in refugee camps in Northern Palestine. Adolescents aged 12-15 years from UNRWA-operated schools with moderate-to-severe anxiety and depression symptoms participated. The study used a quasi-experimental design with 120 students assigned to either the narrative therapy program (n=60) or standard school services (n=60). The 10-week program included weekly 60-minute group sessions that incorporated Palestinian cultural metaphors such as sumud (steadfastness) and olive tree symbolism. Participants completed the Revised Children's Anxiety and Depression Scale (RCADS) at three time points: before the program, immediately after the 10-week intervention, and three months later. The study measured changes in anxiety and depression symptoms, clinical improvement, and feasibility outcomes including retention, fidelity, and acceptability. Results showed that participants in the narrative therapy program experienced greater reductions in anxiety and depression symptoms compared to those receiving standard school services. The effects were maintained at the three-month follow-up. Seventy-two percent of intervention participants achieved clinically significant improvement compared to 21% of controls. The program demonstrated high retention (95%), good implementation fidelity (87.3%), and strong acceptability (85% of participants found the cultural metaphors helpful). The findings suggest that culturally adapted school-based narrative therapy may be a feasible and promising approach for addressing mental health needs among refugee adolescents in humanitarian settings. However, because this was not a randomized controlled trial, the results should be interpreted as associations rather than definitive causal effects.

Full description

This quasi-experimental study evaluated the effectiveness of a culturally adapted, school-based narrative therapy program for reducing anxiety and depression among Palestinian refugee adolescents. The study was conducted in UNRWA-operated middle schools across three refugee camps in Northern Palestine (Jenin, Balata, and Askar) from June to December 2024.

The 10-week manualized intervention integrated Palestinian cultural metaphors including sumud (steadfastness), olive tree symbolism, and traditional storytelling practices. The program consisted of weekly 60-minute group sessions delivered by trained school counselors and psychologists, with sessions progressively guiding participants from psychological safety building toward problem externalization, agency restoration, collective resilience, mindfulness practice, and future-oriented narrative reconstruction. Facilitator training included 20 hours of instruction in session protocols, cultural competence, and trauma-informed care.

Outcome measures were administered at baseline, immediately post-intervention, and at 3-month follow-up. Statistical analyses employed mixed-effects repeated-measures ANCOVA to test the Group × Time interaction. The study received ethical approval from the Research Ethics Committee of Nablus University for Vocational and Technical Education, Ibn Sina College for Health Professions (Approval Ref: Nrs. May, 2024/1).

Enrollment: 120 patients

Sex: All

Ages: 12 to 15 years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• Middle school students in grades 6-9
• Aged 12-15 years
• Moderate-to-severe symptoms of anxiety and depression as measured by the Revised Children's Anxiety and Depression Scale (RCADS T-scores ≥ 65)
• Written informed consent from parent or legal guardian
• Written assent from the student
• Enrolled in a UNRWA-operated middle school in one of the participating refugee camps (Jenin, Balata, or Askar)

Exclusion criteria

• Current involvement in other mental health interventions or psychotherapy
• Severe psychiatric disorders requiring specialist care (e.g., psychosis, bipolar disorder, severe eating disorders)
• Inability to complete study assessments due to language or cognitive barriers
• Severe emotional or behavioral difficulties that would prevent participation in group sessions

Trial design

Primary purpose: Treatment

Allocation: Non-Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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120 participants in 2 patient groups

Arm 1 (Intervention) Narrative Therapy Program

Experimental group

Description:

Participants received a 10-week culturally adapted narrative therapy program delivered in weekly 60-minute group sessions. The program incorporated Palestinian cultural metaphors including sumud (steadfastness) and olive tree symbolism, and focused on problem externalization, agency restoration, and collective resilience.

Treatment:

Behavioral: Culturally Adapted Narrative Therapy

Arm 2 (Control) Standard School Services

No Intervention group

Description:

Participants received standard school-based services including regular educational activities, social skills activities, music/art therapy, and sports activities as typically provided in UNRWA-operated schools. Individual counseling was available but limited.