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

Effectiveness of Narrative Therapy in Reducing Anxiety and Depression Among Middle School Students in Refugee Camps in Northern Palestine: A Quasi-Experimental Study

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.

Study Overview

• Status: Completed
• Conditions: Anxiety; Depression - Major Depressive Disorder
• Intervention / Treatment: Behavioral: Culturally Adapted Narrative Therapy

Detailed 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).

• Study Type: Interventional
• Enrollment (Actual): 120
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Palestinian Territories
  • West Bank
    • Nablus, West Bank, Palestinian Territories, P401
      • Nablus University for Vocational and Technical Education, Ibn Sina College for Health Professions

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child
• Accepts Healthy Volunteers: No

Description

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

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Arm 1 (Intervention) Narrative Therapy Program; 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; 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.
No Intervention: Arm 2 (Control) Standard School Services; 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.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
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

Collaborators and Investigators

• Sponsor: Nablus University for Vocational and Technical Education

Study record dates

Study Major Dates

• Study Start (Actual): June 16, 2024
• Primary Completion (Actual): September 14, 2024
• Study Completion (Actual): December 14, 2024

Study Registration Dates

• First Submitted: June 30, 2026
• First Submitted That Met QC Criteria: July 6, 2026
• First Posted (Actual): July 8, 2026

Study Record Updates

• Last Update Posted (Actual): July 8, 2026
• Last Update Submitted That Met QC Criteria: July 6, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Keywords: Mental Health; Cultural Adaptation; School-Based Intervention; Narrative Therapy; Palestine; Quasi-Experimental; Refugee Adolescents; UNRWA
• Additional Relevant MeSH Terms: Mental Disorders; Behavior; Personal Satisfaction; Anxiety Disorders; Psychological Well-Being
• Other Study ID Numbers: Ref: Nrs. May, 2024/1; Nrs. May 2024/1 (Other Identifier: Ibn Sina College Ethics Committee)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No