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. 2025 Oct 27;16(1):2567094. doi: 10.1080/20008066.2025.2567094

Empowering narratives: aid to self-help for Ukrainian refugees: a randomized controlled trial of Narrative Exposure Therapy (NET) delivered by supervised Ukrainian health workers in Norway

Narrativas empoderadoras: auxiliar a la autoayuda para refugiados ucranianos: un ensayo controlado aleatorizado de Terapia de Exposición Narrativa (NET) impartida por personal de la salud ucraniano supervisado en Noruega

Vanessa Nolasco Ferreira a,f,CONTACT, Helene Hjelmervik a, Ashley Rebecca Bell-Mizori b, Miroslava Tokovska c, Signe Alexandra Domogalla d, Fernanda Serpeloni e,f, Susanne Axelson f, Ivan Arango f,g, Sarah Weber a
PMCID: PMC12570239  PMID: 41143444

ABSTRACT

Background: The Russian invasion of Ukraine has resulted in forced displacement, with over six million Ukrainian refugees across Europe, of whom 81,770 are residing in Norway. This displacement and, in many cases, preceding war experiences, has led to increased vulnerability to trauma and mental health challenges. There is to date little knowledge about the extent to which structured mental health interventions can mitigate symptoms in Ukrainian refugees. Narrative Exposure Therapy (NET), a short-term trauma-focused intervention, has demonstrated efficacy in reducing post-traumatic stress disorder (PTSD), depression and dissociation symptoms among individuals exposed to organized violence and war.

Aim: The protocol aims to assess the clinical effects of NET on PTSD, dissociation, and depression symptoms among Ukrainian refugees in Norway and to facilitate training and supervised praxis for Ukrainian health professionals in using NET.

Methods: This study employs a pretest-posttest randomized controlled experimental design (RCT). Ukrainian health workers in Norway will receive a total of 450 hours of NET training through an online course. As a part of the training, they will, under supervision, administrate NET to Ukrainian refugees. Participants will be screened and assessed at three time points: baseline, immediately after treatment, and at a 6-month follow-up. Validated instruments in Ukrainian and Russian will be used to assess trauma experiences, symptoms, and comorbidities. Exclusion criteria: active psychotic spectrum disorders, neurodevelopmental disorders and concurrent trauma therapy. The study also contains an embedded qualitative sub study that will involve phronetic iterative thematic analysis of anonymized therapy narratives collected during NET sessions, aiming to understand how participants construct meaning from traumatic events, how narrative coherence evolves throughout therapy, and how identity reconstruction occurs post-trauma.

Trial registration: ClinicalTrials.gov identifier: NCT07062042..

KEYWORDS: PTSD, depression, dissociation, trauma, Ukrainian refugees, NET, RCT

HIGHLIGHTS

  • The research uses a randomized controlled trial to measure outcomes at three intervals, with a qualitative sub-study examining therapy narratives to understand trauma processing and identity reconstruction.

  • The study investigates how Narrative Exposure Therapy (NET) can alleviate post-traumatic stress disorder, depression, and dissociation symptoms in Ukrainian refugees in Norway, who have experienced war-related trauma.

  • The research includes Ukrainian health workers in Norway who will receive 450 hours of NET training online, enabling them to provide structured mental health support to Ukrainian refugees.

1. Introduction

The Russian Federation's annexation of Crimea in 2014 marked the beginning of the Russo-Ukrainian conflict. The full-scale invasion, launched on February 24, 2022, precipitated a humanitarian crisis, resulting in the largest refugee movement in Europe since World War II (Podgórska et al., 2024). By April 2025, over 6.9 million Ukrainian refugees were recorded globally, with approximately 6.3 million residing in Europe. Norway, with a population of 5.5 million, has been impacted by this influx. As of early 2025, approximately 81,790 Ukrainian refugees had sought protection in Norway, making Ukrainians the second-largest immigrant group in the country (UNHCR, 2025).

Epidemiological studies have begun to assess the health status of Ukrainian refugees in Norway, analyzing trends in self-reported health among Ukrainian refugees. In what concerns mental health, an assessment of Ukrainian refugees who arrived in Norway in 2022 showed that the mean score on the Hopkins Symptom Checklist (HSCL-5) was 2.24 among Ukrainian refugees, indicating higher psychological distress compared to the Norwegian average of 1.60 (Labberton et al., 2023 May 2023).

A Norwegian cross-sectional study surveyed 727 adult Ukrainian refugees in Norway (October 2022– January 2023), revealing variations based on the month of arrival in 2022. Individuals who arrived later in 2022 (September–December) reported significantly poorer long-term health – including higher prevalence of chronic illnesses and disabilities – compared to early arrivals (February–April) (adjusted odds ratios 2.71 and 1.74, respectively), while experiencing lower psychological distress and better oral health scores. Despite having similar access to healthcare, later arrivals – who tended to be younger, more often male, and with lower education – were more likely to report unmet health needs. The findings highlight evolving health profiles over time and emphasize the importance of tailored health service planning for Ukrainian refugees based on arrival patterns and individual health care needs (Labberton et al., 2024).

To our knowledge, no studies published up until the time of the submission of this article, have examined effects of structured mental health interventions for Ukrainian refugees in Norway. The overall aim of the present study is to evaluate the use of Narrative Exposure Therapy (NET) to address trauma-related symptoms and comorbidities among Ukrainian adults that have sought collective protection in Norway after February 2022. Specifically, the aims are: (I) To assess the effect of NET on PTSD, depression and dissociation symptoms among Ukrainian refugees in Norway; (II) To collect longitudinal data on trauma symptomatology and treatment outcomes; (III) To gain insight in how refugees create meaning from traumatic events and use narrative coherence to cope and reconstruct their identity post-trauma (embedded qualitative sub-study). In addition, this study will facilitate a training for Ukrainian health workers in Norway (including those that are authorized health professionals in Ukraine but do not necessarily have authorization as health personnel in Norway), possibly contributing to their professional integration in Norway.

NET is a comprehensive trauma-focused treatment that integrates elements from cognitive behavioural therapy (CBT) and neuropsychological models, emphasizing exposure and the associative fear network theory. It incorporates testimony therapy, highlighting the importance of witnessing and documenting trauma, and draws from the humanistic approach of Person-Centered Therapy by Carl R. Rogers (Rogers, 1951), focusing on empathy, congruence, and unconditional positive regard. Unlike classic Rogerian therapy, NET employs a directive exposure conversation, allowing therapists to guide clients through their trauma narratives while maintaining a forward-focused approach. Utilizing a biographical method known as Life Review, NET encourages individuals to explore all facets of their lives, both positive and negative, to effectively process trauma and PTSD, ultimately helping them organize and make sense of their life stories. The method emphasizes stabilization through therapeutic structure and is supported by evidence from randomized controlled trials (RCT) showing reductions in PTSD symptoms. The approach is protocol-driven and applicable in low-resource settings under supervision (Schauer et al., 2025; Smaik et al., 2023).

While NET has been successfully adapted to diverse cultural contexts (Schauer et al., 2025), a distinctive feature of this study is the involvement of Ukrainian health professionals living in Norway as therapists for Ukrainian refugees. Speaking the same language and understanding the cultural context, these professionals are well positioned to create a therapeutic space of trust and safety. In line with international guidelines for culturally sensitive trauma care (Committee I-AS, 2007; WHO, 2021), this approach reduces barriers such as language and stigma, while strengthening local service capacity to address the mental health consequences of war and forced migration.

1.1. Hypotheses

1.1.1. Primary hypotheses

H1: Participants receiving NET will show a significantly greater reduction in PTSD symptoms (International Trauma Questionaaire – ITQ) from baseline to post-treatment than participants in the control group.

H2: Participants receiving NET will show a significantly greater reduction in dissociation symptoms (Shutdown Dissociation Scale – Shut-D) from baseline to post-treatment than participants in the control group.

H3: Participants receiving NET will show a significantly greater reduction in depression symptoms (Patient Health Questionaaire – PHQ-9) from baseline to post-treatment than participants in the control group.

H4: Participants receiving NET will have significantly lower PTSD symptoms (ITQ) at 6-month follow-up compared to baseline, with no significant differences between follow-up and post-treatment.

H5: Participants receiving NET will have significantly lower dissociation symptoms (Shut-D) at 6-month follow-up compared to baseline, with no significant differences between follow-up and post-treatment.

H6: Participants receiving NET will have significantly lower depression symptoms (PHQ-9) at 6-month follow-up compared to baseline, with no significant differences between follow-up and post-treatment.

1.1.2. Secondary hypotheses

H7: Direct Experience with the Event (Happened to me – Life Event Checklist – LEC-5) will be associated with greater baseline symptom severity (ITQ, Shut-D, PHQ-9).

H8: Participants with greater baseline symptom severity will experience a greater reduction in symptoms from baseline to post-treatment, compared to participants with milder initial symptom severity.

H9: Change in narrative coherence mediates the reduction in PTSD symptoms from baseline to post-treatment.

2. Methods

2.1. Design

This is a pretest-posttest randomized controlled experimental study with two arms: immediate treatment group and wait-list control group. The intervention consists of 8–12 NET sessions delivered individually, including baseline  – and lifeline constructions (clinical interview). The exact number of sessions will depend on the number of traumatic experiences reported in the LEC-5 (Weathers et al., 2013) and on the number of sessions each participant needs to create a coherent story of their life. The embedded qualitative sub study has the purpose to provide insights into participants’ lived experiences. This component of the study explores the nuanced processes of meaning-making, narrative coherence, and identity reconstruction that quantitative measures alone might not fully capture. This offers the possibility to complement and enhance the primary quantitative data (Creswell & Clark, 2017; Plano Clark, 2017). The integration of both methods allows researchers to triangulate findings, offering a more holistic view of the intervention's impact and facilitating a deeper understanding of how and why NET affects participants, thus bridging the gap between numerical outcomes and personal experiences (Figure 1).

Figure 1.

Figure 1.

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Study flow chart.

2.2. Participants and recruitment

Participants to the RCT include Ukrainian refugees aged 18+, residing in Norway under collective protection having arrived after 24th February 2022, with trauma exposure related to war or forced displacement. Ukrainian health workers recruit participants via community outreach and referrals. The recruitment is also advertised via the Kristiania University of Applied Sciences website, making it public and accessible. Every health worker will be assigned two participants based on their place of residence in Norway to minimize travel time to therapy sessions. Within each pair of participants, the allocation to treatment group and wait-list control group will be randomly sorted in Excel. Participants with active psychotic symptoms, neurodevelopmental disorders, or concurrent trauma therapy will be excluded from the study.

2.3. Instruments

2.3.1. International Trauma Questionnaire (ITQ)

Based on the ICD-11 criteria for diagnosing PTSD and complex PTSD (CPTSD), the ITQ (Cloitre et al., 2018) assess both symptoms and functional impairment in the past month. Six items measure core elements of PTSD (re-experiencing, avoidance and sense of threat), and an additional six items measure three aspects of disturbances in self-organization, a core element of CPTSD (affective dysregulation, negative self-concept and disturbances in relationships). Both symptom assessments are followed by three questions about whether the symptoms have affected different areas of life. All 18 items are answered on a 5-point Likert scale specified as: ‘Not at all’, ‘a little bit’, ‘moderately’, ‘quite a bit’ and ‘extremely’. In addition, subjects give a brief description of the traumatic event they experienced and indicate how long ago it occurred.

2.3.2. Shutdown Dissociation Scale (Shut-D)

The Shut-D (Schalinski et al., 2015) measures three types of dissociation that can occur in PTSD: intrusion, hyperarousal and dissociation. The 13 items are evaluated on a 4-point Likert scale specified as: ‘Not at all’, ‘once a month or less/little’, ‘several times a month/sometimes’ and ‘several times a week/often’.

2.3.3. Patient Health Questionnaire (PHQ-9)

The PHQ-9 (Kroenke et al., 2001) is a brief questionnaire measuring nine symptoms of depression on a 4-point Likert scale specified as: ‘Not at all’, ‘several days’, ‘more than half the days’ and ‘nearly every day’. An additional question about the symptoms’ effects on different areas of life is also rated on a 4-point Likert scale.

2.3.4. Life Events Checklist (LEC-5)

The LEC-5 (Weathers et al., 2013) measures life-time exposure to 17 categories of potentially traumatic events, including experiences with war, death, injury and assault. For each event category, different types of exposure are assessed: ‘Happened to me’, ‘witnessed it’, ‘learned about it’, ‘part of my job’, ‘not sure’ and ‘doesn’t apply’.

2.4. Procedure

2.4.1. Training of NET therapists

Ukrainian health workers are receiving training in NET. The recruitment for health workers was advertised through a public call on the Kristiania University of Applied Sciences website. The key requirements to apply were: a healthcare professional background from Ukraine; bachelor's degree in a relevant field (psychology, medicine, social work, pedagogy, nursing etc.); the ability to speak English to follow the course and supervisions; and residing in Norway. The application required submission of the following documents: one-page motivation letter; CV highlighting relevant experience in healthcare; digital copies of diplomas and transcripts; Norwegian Ministry of Education letter containing an assessment of the formal and documented high level of education (if applicable); English language certificates (if available); and registration of interest agreeing with the conditions of the participation in the training and practice. Thirty-eight health workers applied and had their documents analysed and were called to an interview. Within the framework of the current study, 24 health workers could be offered training. Out of all the health workers that applied, the most qualified were selected to receive training. The selection prioritized education directly connected to mental health and previous experience with mental health treatments and therapy. Two health workers withdrew from the course before the recruitment of patients started, therefore 22 health workers are receiving training, hence contributing to the data collection connected to this study protocol.

The programme has started as of January 6th, 2025. On 17 January health workers had finished the theoretical part of the programme, having received a total of 1755 minutes or 29 hours and 15 minutes of structured education and practice in seminars with mandatory attendance online. That part of the training combined 11 theory-based lectures held live through Zoom and five real-time practical small group exercises to support participants in applying NET principles in real-world settings. The curriculum covered a comprehensive range of topics relevant to trauma-informed care and NET. Key areas addressed included foundational knowledge on violence, PTSD, depression and dissociation (with references to WHO and ICD-11), as well as the role of shame and guilt in trauma. Ethical and relational aspects were highlighted through sessions on therapeutic alliance and Norwegian ethical guidelines. Technical and clinical skills were developed through lectures and hands-on practice related to mental health screening, the lifeline construction, and NET’s core techniques including processing of traumatic memories, grief and positive memories. Further content addressed forensic narrative exposure therapy (FORNET), rapid NET (short version of the technique), Netfacts (community-level extension of NET), and psychohygiene.

In addition to the theory-based lectures with practical small group sessions and self-study, the on-going training offers a total of 51 group supervision sessions of 90 minutes each. Each supervision session involves six health workers. Before starting to administer NET to the participants of the current study, each health worker had to attend at least two supervisions in which practice on screening and conducting diagnostic interviews were repeated and psychoeducation of the symptoms were addressed. The plan for the supervised practice involves that each of the health workers must prepare and present the cases of the participants that they are assigned to, for a minimum of 10 supervision sessions. The structure of the supervisions is as follows: two health workers present their cases, and the other four health workers discuss the case with guidance of a trained supervisor in NET that has a psychologist or a psychiatrist background. Simultaneous translation via interpreter has been offered in both the theoretical part and the supervisions to ensure quality and proper understanding of the sessions’ content.

To ensure adherence to the NET Manual, fidelity measures are implemented for health workers. They receive hands-on materials in Ukrainian detailing each treatment step, including screening, lifeline, exposure, and final sessions. A checklist outlines the session sequence to maintain study design integrity. After each session, health workers must report within 24 hours using Nettskjema, documenting session content, difficulties, participant requests, and any deviations from guidelines. This form links to a secure system (TSD) compliant with GDPR and ethical standards, creating a participant journal. The primary investigator and supervisors review these journals to advise health workers and ensure adherence to NET and study design. Assessor report measures include rating each health worker's adherence to the NET manual and instructions.

2.4.2. Data collection

The study will collect quantitative data in the form of questionnaires, using the instruments described above (Section 2.3). For the treatment group, quantitative data will be collected at three timepoints: (1) a baseline assessment, before NET starts, (2) a post-treatment assessment after the last NET session, and (3) a follow-up assessment, six months after NET completion. For the control group, data will be collected at (1) baseline and at (2) post-treatment assessment (i.e. after the waiting period that corresponds to the treatment period of the case intervention group).

For ethical purposes, the control group will be offered NET intervention and symptom assessment after the conclusion of NET, respecting the requirements of the Helsinki declaration (World Medical Association, 2013). Symptom assessment feedback after the conclusion of NET will also be offered to give the control group participants the same opportunities as the treatment group. The aim of this feedback is to communicate the results of the treatment connected to the mental health status after the intervention. In addition, demographic data, including time in Norway, gender, age, marital status, highest level of education, long term illness, general view about the health, will be collected for both groups. Qualitative data in the form of participants’ transcribed narratives collected during the therapy sessions will be analysed according to the premises described in the qualitative embedded sub study (Section 3.2).

All dropout instances will be recorded with reason (if provided), and then categorized as: voluntary withdrawal, symptom worsening, relocation, or non-contactable. The dropout will be recorded by each health worker in the participant’s journal through the specific report form (Nettskjema). To minimize the chance of dropout in the control group participants placed in the waiting list will be contacted every 15 days by the health worker responsible for conducting their treatment.

3. Data analysis

3.1. Quantitative data analysis

To investigate the effects of NET, linear mixed-effects models (will be calculated for each of the three symptom measures; ITQ, Shut-D and PHQ-9. Post-treatment effects will be investigated with a model with fixed factors for the effects of Group (treatment; control) and Time (baseline; post-treatment) as well as their interaction (Group x Time). In order to assess whether randomization resulted in equal groups, we will test if there are any significant differences between treatment and control group at baseline, and include variables that show significant differences as covariates in the model. Longer-term development of symptoms will be investigated in the treatment group with a fixed factor for the effect of Time (baseline; post-treatment; follow-up). For all analyses, we will compare intent-to-treat and completer sample results in order to investigate potential bias due to drop-out. While we expect a low dropout rate at post-treatment, due to the short duration of NET and in line with previous studies (Lely et al., 2019), the dropout rate at 6-months follow-up might be higher, which could increase the risk of bias.

Additional analyses will be calculated to investigate the effect of trauma exposure on baseline symptom severity, and the effect of baseline symptom severity on treatment effect/symptom reduction. The study outcome measures in connection with each hypothesis are presented in Table 1 for better visualization:

Table 1.

Outcome measures.

Outcome measure Instrument Description Time points Outcome focus
Primary outcome measures
PTSD Symptom Severity (ITQ) ITQ Assesses symptoms of PTSD and Complex PTSD, including re-experiencing, avoidance, threat perception, and functional impairment. Baseline, post-treatment, 6-month Follow-up Reduction in PTSD symptoms scores over time (H1, H4)
Dissociation Symptoms (Shut-D) Shut-D Measures dissociative responses specific to trauma, including cognitive-emotional shutdown, sensory-motor dissociation, and behavioural shutdown. Baseline, post-treatment, 6-month Follow-up Reduction in dissociation symptom scores over time (H2, H5)
Depression Symptoms (PHQ-9) PHQ-9 Measures the frequency of depressive symptoms over the past two weeks, including somatic and cognitive-affective dimensions, plus functional impairment. Baseline, post-treatment, 6-month Follow-up Reduction in depressive symptoms (H3, H6)
Secondary outcome measures
Exposure to Traumatic Events (LEC-5) LEC-5 Captures direct and indirect exposure to 17 categories of potentially traumatic events, including whether the event ‘happened to me.’ Baseline Association between level of trauma exposure and symptom severity (H7)
Narrative Coherence (Qualitative Coding) Qualitative content analysis or validated narrative coherence scale Evaluates improvement in the structure, clarity, and emotional processing of the autobiographical trauma narrative as constructed during NET. Session 2 (Lifeline) vs Final exposure (between session 7 and 11, depending on the participant’s trauma necessity for more exposure) Mediation analysis of change in PTSD symptoms through increased narrative coherence (H9)
Other pre-specified measures
Demographic Variables Custom questionnaire Age, gender, marital status, education, time in Norway, long-term illness, and general health perception Baseline Covariates or moderators in outcome models
Functional Impairment Embedded in ITQ and PHQ-9 Assesses impact of PTSD and depression on daily functioning Baseline, post-treatment, 6-month Follow-up Supplementary analysis of clinical relevance
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3.2. Qualitative data analysis

A qualitative sub study will be conducted alongside the RCT to explore participants’ lived experiences of NET. This sub study will involve phronetic iterative thematic analysis (Tracy, 2018) of anonymized therapy narratives collected during NET sessions. The analysis will alternate between inductive (emic) insights and theoretical (etic) interpretations to uncover how participants construct meaning from traumatic events, how narrative coherence evolves throughout therapy, and how identity reconstruction occurs post-trauma.

Initially, all autobiographical lifelines and session narratives will be organized chronologically and examined for thematic continuity. Researchers will immerse themselves in these texts to identify patterns of meaning and context-specific markers of trauma, coping, and identity reconstruction. Through primary-cycle coding, in-vivo and descriptive codes will be generated directly from participants’ testimonies to preserve authenticity and ground the analysis in their lived experience. These codes will be documented in an evolving codebook that defines each code’s meaning and inclusion criteria, enabling analytic consistency across cases (Tracy et al., 2024).

In the secondary-cycle coding phase, the research team will group and refine initial codes into higher-order analytical categories, examining how trauma is situated within personal and sociopolitical contexts. The analysis will proceed through iterative abductive reasoning, oscillating between emergent themes in the narratives and sensitizing theoretical concepts such as posttraumatic growth, memory integration, and meaning making. Negative case analysis will be applied to challenge emerging interpretations and enhance trustworthiness. Analytic memos and reflective notes will be maintained throughout to capture evolving insights and ensure transparency. The final phase will involve constructing a narrative synthesis that links individual trauma accounts to broader psychosocial patterns, thus generating actionable knowledge grounded in both empirical data and practical understanding (Tracy, 2018; Tracy et al., 2024).

Research Questions (in connection with the embedded qualitative study)

  • How do Ukrainian refugees make sense of war-related trauma through their narratives?

  • What are the common thematic shifts in personal narratives before and after NET (what is added or removed in the re-reading of the narratives of the previous exposure session)?

  • How is narrative coherence presented in connection with psychological recovery?

3.3. Ethics and dissemination

Ethical approval was sought and granted from Regional Committees for Medical and Health Research Ethics (REK) under the reference number 790305 and from the Norwegian Agency for Shared Services in Education and Research (SIKT), under the reference number 116071. All data will be anonymized and stored using Services for sensitive data (TSD). Results will be disseminated through peer-reviewed publications, public presentations, popular science publications and digital media. Emergency procedures for participants presenting severe mental health symptoms are in place, including psychoeducational consultations and referral to public health services through the general practician in case of moderately severe or severe depression and or suicidal ideation. The emergency procedures will also be activated in case of presence of mental health issues described in the exclusion criteria.

4. Discussion

This protocol aims to assess the impact of NET on symptoms of PTSD, CPTSD, dissociation, and depression among Ukrainian refugees who arrived in Norway following the Russian invasion on February 24, 2022. The large-scale displacement resulting from the invasion has necessitated that several European countries, including Norway, develop solutions for accommodating significant numbers of refugees, many of whom have experienced trauma due to war and forced displacement. Studies of Ukrainian refugees in a variety of countries have shown increased levels of psychological distress, PTSD and depression (Ellis et al., 2024; Figueiredo et al., 2024). Reducing possible symptoms of posttraumatic stress and resulting health challenges will be a key task during the integration process. However, to our knowledge, there are to date no published evaluations of therapies for symptom reduction among Ukrainian refugees in Europe, even though a recent pilot feasibility study of a group intervention in Sweden showed promising effects on perceived anxiety/stress and perceived general health (Ekblad et al., 2025). NET was specifically developed for treating PTSD and has been shown to be effective in reducing symptoms of both PTSD, dissociation and depression in other refugee groups (Grech & Grech, 2020; Gwozdziewycz & Mehl-Madrona, 2013; Lely et al., 2019; Raghuraman et al., 2021).

One of the main strengths of NET, compared to many other forms of exposure therapies, is that it is low threshold and cost-effective, thereby offering the possibility of mental health help to a comparatively large amount of people (Schauer et al., 2025). In the current study, health workers can complete the NET training (including theory and supervised practice) over the course of an average of 12 weeks full time work. The fact that the training can be taken in the form of an online course further increases its feasibility and allows for a network of NET therapists across the country to be built. This is crucial because it means that refugees in different locations will be able to receive therapy sessions, which are conducted in the form of one-on-one physical meetings. A particular strength of this study is the fact that NET therapists are Ukrainian health workers. The existing literature on NET RCTs includes both: interventions where refugees were displaced within the country and received NET from therapists with the same nationality, and interventions where refugees settled in a new country and received NET from therapists that were nationals of their new home country (Grech & Grech, 2020; Gwozdziewycz & Mehl-Madrona, 2013 Lely et al., 2019;). While NET has been shown to be effective under both of these circumstances, there could be an added advantage of using therapists with the same nationality as the refugees, such as in the current study. The first expected advantage will be that there is no language barrier, which allows for more direct communication between the therapist and the participant without the need for an interpreter. The second expected advantage will be that the similarity in cultural background might increase trust, openness and understanding between the therapist and the participant, with potentially beneficial effects on the therapeutic alliance and therapy outcomes. Indeed, a comparison between NET with fellow refugees as counsellors versus NET with professional other-country counsellors has shown considerably greater therapy effects in studies with fellow refugees as NET counsellors (Gwozdziewycz & Mehl-Madrona, 2013). More generally, studies on the effectiveness of other forms of psychotherapy also support the beneficial role of therapist cultural competence (Soto et al., 2018; Tao et al., 2015) and culturally adapted psychotherapy (Anik et al., 2021; Benish et al., 2011) for treatment success. Culturally sensitive and linguistically appropriate trauma treatment is also part of international guidelines for refugee health care (Committee I-AS, 2007; WHO, 2021), and the current study will follow these recommendations in order to maximize the expected effectiveness of NET.

The study includes a randomized control group that does not receive NET during the study period in order to exclude alternative explanations for potential symptom reduction, such as regression to the mean or other temporal confounders. However, participants in the intervention group may experience symptom reduction due to expectation effects that arise from knowing that they are following an intervention which is intended to help them. That way, any intervention effect could in part be due to a placebo effect, a possible limitation of this study. Placebo effects are difficult to control in psychotherapy intervention studies, which are difficult to blind since participants are aware of the experimental condition that they have been assigned to (Boot et al., 2013; Huneke et al., 2025). Still, waitlist is one of the most commonly used control conditions for NET studies (Lely et al., 2019; Raghuraman et al., 2021). Further, NET has been shown to be effective in reducing PTSD and depression symptoms when compared to active control conditions (Grech & Grech, 2020 Lely et al., 2019;). Given the extensive literature on NET effects with different types of control conditions, it will be possible to compare effect sizes in the current study with effect sizes from other studies with active and inactive control conditions.

Another limitation of the study is that the health workers have different professional health care backgrounds and varied experiences with psychosocial interventions, which might influence the course of treatments. In addition, since the therapy is conducted by health workers who are also refugees with possible similar experiences, strong emotional reactions and connection to personal trauma experiences can bring challenges to the implementation of the therapeutic method. To reduce the impact of these limitations, the psychohygiene part of the theoretical training addresses techniques to deal with overactivation and prevent secondary traumatization. In addition, the supervised practice, following the premises of CBT supervisions training, is key to mitigate both limitations (Rakovshik et al., 2016).

In what concerns the reliance on self-reported fidelity measures by health workers, a limitation resides in the fact that it may introduce subjectivity and potential inaccuracies in reporting (Gearing et al., 2011). Despite the provision of detailed materials and checklists, the effectiveness of these tools depends on the health workers’ understanding and consistent application, which can vary. It is expected that the follow up of the supervisors can mitigate that limitation. While the primary investigator and supervisors review these reports to ensure adherence to the NET manual, this oversight may not capture all deviations from the protocol or address all potential biases in real-time. Furthermore, the process of rating adherence could be influenced by the subjective judgment of the assessors, potentially affecting the reliability of the fidelity assessments (Dusenbury et al., 2003).

In what concern dropouts, although efforts are made to minimize dropout in the control group by contacting participants every 15 days, this additional interaction could influence participant behaviour or perceptions, potentially affecting the study's outcomes.

To summarize, the current study is expected to shed light on the feasibility and effectiveness of NET as a low-threshold trauma-focused therapy for Ukrainian refugees in Europe, taking Norway as an example. We expect reductions in both PTSD and depression symptoms immediately after NET is concluded, with lasting effects that will also be visible six months after therapy conclusion. The qualitative part of the study will additionally give insight into Ukrainian refugees’ experiences from the Russian-Ukrainian war, and more generally into how refugees process and (re)construct meaning from traumatic events during trauma-focused therapy interventions.

Acknowledgements

To Irina Bjørnhaugh, Svitlana Bulkina and Olga Acharadze that, as research assistants with Ukranian background, have been contributing with recruitment and facilitating as interpreters, in the on-going training of Ukrainian Health Workers. To Norsk-Ukrainsk Hjelpeorganisasjon (Norwegian-Ukrainian Help Organization) and Mental Helse (Mental Health Organization) for the partnership and contribution to make the study design relevant to both Ukrainian refugees living in Norway and to the Norwegian Health Authorities. To vivo international for the partnership and knowledge transference that makes the training of Ukrainian health workers possible.

Funding Statement

DAM Stiftelsen, Program Helse (Health Program), under the number DAM_HEL547119.

Authors’ contributions

Vanessa Nolasco Ferreira: responsible for obtaining the grant funding that supported this study. She led the conceptualization and design of the study, including the development of the research questions and methodology. She also leads the qualitative sub-study, including the design and implementation of the thematic analysis of therapy narratives. She also coordinated the overall project management and contributed to the writing (preparation, drafting, review and editing) of the manuscript. Helene Hjelmervik: co-responsible for the quantitative part of the study (statistical design and analysis) and provided expertise in the randomized controlled trial methodology. She also contributed to the writing (preparation, drafting, review and editing). Ashley Rebecca Bell-Mizori: project coordinator. She assisted in the design of the intervention protocol, especially in the qualitative sub-study. She also contributed to the writing (preparation, drafting, review and editing) of the manuscript. Miroslava Tokovska: assisted in the conceptualization of the qualitative sub-study and peer reviewing the design of qualitative sub-study. She also contributed to the writing (review) of the manuscript. Signe Alexandra Domogalla: assisted in the application to the funding that finances the study. She also contributed to the writing (review and editing) of the manuscript. Fernanda Serpeloni: provided expertise in trauma-focused interventions and contributed to the development of the NET training curriculum. She also contributed to the writing (drafting) of the manuscript. Susanne Axelson: provided expertise in trauma-focused interventions and contributed to the development of the NET training curriculum. She also contributed to the writing (drafting) of the manuscript. Ivan Arango: provided expertise in trauma-focused interventions and contributed to the development of the NET training curriculum. He also contributed to the writing (review) of the manuscript. Sarah Weber: responsible for the quantitative part of the study (statistical design and analysis). She provided expertise in the randomized controlled trial methodology and assisted in the literature review and background research for the study. She also contributed to the writing (preparation, drafting, review and editing) of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability

This manuscript does not include any data.

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