Narrative Therapy for Anxiety and Depression in Palestinian Refugee Adolescents

NCT07691021 | Completed

• 2 other identifiers: Ref: Nrs. May, 2024/1Nrs. May 2024/1
• Study Type: interventional
• Target: 120
• Locations: 1 country
• Sites: 1

Brief Summary

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.

Conditions

Anxiety; Depression - Major Depressive Disorder

Keywords

Narrative Therapy; Refugee Adolescents; Palestine; School-Based Intervention; Cultural Adaptation; Mental Health; Quasi-Experimental; UNRWA

Outcome Measures

Primary Outcomes (1)

• Change in Anxiety and Depression Symptoms

  Change in total score on the Revised Children's Anxiety and Depression Scale (RCADS) from baseline to post-intervention and from baseline to 3-month follow-up. The RCADS is a 47-item self-report questionnaire measuring anxiety and depression symptoms across six subscales: separation anxiety (7 items), social phobia (9 items), generalized anxiety (6 items), panic disorder (9 items), obsessive-compulsive disorder (6 items), and major depression (10 items). Items are rated on a 4-point scale (0 = never, 1 = sometimes, 2 = often, 3 = always), with higher scores indicating greater symptom severity.

  Baseline (pre-intervention), immediately post-intervention (Week 10), and 3-month follow-up

Study Arms (2)

Arm 1 (Intervention) Narrative Therapy Program

EXPERIMENTAL

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.

Behavioral: Culturally Adapted Narrative Therapy

Arm 2 (Control) Standard School Services

NO INTERVENTION

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.

Interventions

Culturally Adapted Narrative Therapy BEHAVIORAL

A 10-week manualized narrative therapy program delivered in weekly 60-minute group sessions. The program integrates Palestinian cultural metaphors including sumud (steadfastness) and olive tree symbolism. Key components include problem externalization (using shadow and cloud metaphors), agency restoration (identifying personal strengths and resilience stories), collective resilience (community narratives), mindfulness practices, and future-oriented narrative reconstruction. Each session follows a structured format including check-in, main activity, discussion, and closing reflection. The program was delivered by trained school counselors and psychologists in UNRWA-operated middle schools.

Arm 1 (Intervention) Narrative Therapy Program

Eligibility Criteria

• Age: 12 Years - 15 Years
• Sex: all
• Healthy Volunteers: No
• Age Groups: Child (0-17)

You may qualify if:

• 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)

You may not qualify if:

• 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

Sponsors & Collaborators

• Nablus University for Vocational and Technical Education: lead

Study Sites (1)

Nablus University for Vocational and Technical Education, Ibn Sina College for Health Professions

Nablus, West Bank, P401, Palestinian Territories

Location

MeSH Terms

Conditions

Anxiety Disorders; Psychological Well-Being

Condition Hierarchy (Ancestors)

Mental Disorders; Personal Satisfaction; Behavior

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: NON RANDOMIZED
• Masking: NONE
• Masking Details: Complete blinding was not feasible due to the nature of the behavioral intervention.
• Purpose: TREATMENT
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Associate Prof in Mental Health Nursing

Model Details: Participants were assigned to either a 10-week narrative therapy intervention or standard school services (control) in a parallel design.

Study Record Dates

• First Submitted: June 30, 2026
• First Posted: July 8, 2026
• Study Start: June 16, 2024
• Primary Completion: September 14, 2024
• Study Completion: December 14, 2024
• Last Updated: July 8, 2026

Record last verified: 2026-07

Locations

PA (1)