Narrative Therapy for Anxiety and Depression in Palestinian Refugee Adolescents

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.

Completed

Looking for future studies?

Notify Me

Key information

Conditions

Anxiety Anxiety Disorders Behavior Depression - Major Depressive Disorder Mental Disorders Personal Satisfaction Psychological Well-Being

Age range

12 year–15 year

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

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

Nablus, West Bank, P401, Palestinian Territories

About this study

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).

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

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

Treatment and study plan

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.

Primary outcomes

Change in Anxiety and Depression Symptoms

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

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.

Sponsors and collaborators

Lead sponsor

Nablus University for Vocational and Technical Education

Other

Registry information

Official study title

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

Acronym: NT-AD

Important dates

Study start: 2024
Primary completion: 2024
Study completion: 2024
First posted: Jul 8, 2026
Registry last updated: Jul 8, 2026

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

Published trials that share one or more normalized conditions with this study.

Completed