Narrative exposure therapy for war-affected Middle Eastern refugees: a scoping review of outcomes, delivery contexts and implementation gaps

Abstract

Background

Refugees from the Middle East are exposed to multiple war-related and displacement-related stressors. Narrative Exposure Therapy (NET) and its child-adapted version (KIDNET) have been applied in various settings, but evidence remains scattered.

Objective

To map the available evidence on NET/KIDNET among war-affected Middle Eastern refugees, focusing on outcomes, delivery contexts, study designs, and implementation gaps.

Methods

Peer-reviewed articles were systematically reviewed by screening three electronic databases: PubMed, ScienceDirect and Scopus. Inclusion criteria included: studies published from 2015 to 2025, in English or French, involving Middle Eastern refugees or war-affected displaced populations, and reporting psychosocial outcomes after NET/KIDNET intervention.

Results

A total of 24 studies met the inclusion criteria: 7 primary studies and 17 secondary studies. Most of the included studies highlighted the potential benefits of NET and its applicability among child and adult refugees. Findings showed significant reduction of Post-traumatic Stress Disorder (PTSD), with limited evidence regarding NET’s impact on depression and anxiety. The review identified limitations in follow-up processes to assess sustainability of results as well as cultural adaptability of NET.

Conclusion

NET may be beneficial, but evidence is heterogeneous and limited by study design, follow-up duration and contextual adaptation.

Clinical trial number

Not applicable.

Background

More than 117 million individuals have been forcibly displaced worldwide as of June 2025 including refugees, asylum seekers and internally displaced persons due to wars, violence, armed conflicts, persecution and human rights violations [1]. The load of traumatic events prior, during and after the forced displacement leads to high prevalence of mental health conditions, particularly PTSD, depression, and anxiety, especially among Middle Eastern refugees [2, 3]. Symptoms are often passed intergenerationally and can persist for up to six years post-resettlement [4]. Yet, access to mental health services remains limited due to cultural, financial, contextual, and legal barriers [5]. Therefore, there’s a pressing need to incorporate more culturally adapted interventions to better meet the needs of refugees and improve acceptability and efficacy [6, 7].

Among such interventions, Narrative Exposure Therapy (NET), is a short-term trauma focused therapy developed by Neuner et al., (2004a, b, 2010) originally designed to treat survivors of armed conflicts, wars, and torture in an autobiographical context [8–10]. The intervention involves guided exposure to the memories of traumatic events which are then reorganized into a coherent chronological narrative by the participant [11]. In NET, the therapist and participant collaboratively construct a timeline of the participant’s life, which is then explored chronologically in subsequent sessions. Materials used are a rope symbolizing life, flowers representing pleasant events and stones reflecting unpleasant or traumatic events [11]. NET has been shown to reduce PTSD symptoms among refugees though evidence for depression, anxiety, and somatic outcomes remains more heterogeneous [12, 13]. This intervention is nowadays recommended by the American Psychological Association as a second line treatment for PTSD [14]. Following the pioneering studies of NET, early research demonstrated strong interest in its impact on psychosocial outcomes, especially PTSD, among Syrian and Iraqi Middle Eastern refugees and asylum seekers in Western countries including USA [15], Norway [16] and Finland [17].

Despite growing interest in empirically assessing the benefits of NET, evidence gaps persist regarding its psychosocial outcomes, delivery contexts, and implementation among Middle Eastern refugees, the world’s second-largest refugee population [18].

Despite this fact, limited NET empirical studies were found, to the best of our knowledge, to be recently conducted with refugees in low and middle-income hosting countries like Lebanon, Jordan, Iraq and Türkiye [19–24]. This gap is particularly striking given that Lebanon ranks first worldwide to host the largest number of refugees (1 in 8) and Jordan ranks seventh (1 in 21) [1]. Most recent empirical studies on NET with child and adult Middle Eastern refugees affected by war continue to be conducted in Western countries like Norway [25], Germany [26], Netherlands [27] and Finland [28, 29].The above-mentioned studies, as well as recent scoping, systematic reviews and meta-analyses [30–32] summarize the direction and nature of reported psychosocial outcomes, effects, delivery quality and implementation gaps across contexts [12, 33–36].

However, evidence on NET remains fragmented across multiple dimensions, including contexts (e.g., host countries and displacement settings), moderators (e.g., age, gender, trauma exposure), methodologies (e.g., experimental, quasi-experimental, observational, and review designs), and outcomes (e.g., psychological, somatic, and social). This signals a lack of consolidated findings with this specific diverse population.

Accordingly, considering the cultural, contextual, and rigorous experimental gaps identified above, this scoping review aims to map and synthesize the existing literature on NET outcomes among war-affected Middle Eastern refugees, with particular attention to delivery contexts, to identify key gaps and inform implementation considerations.

Methods

This scoping review was conducted in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews) guidelines.

Eligibility and study selection

The search included peer-reviewed studies written in English or French published between 2015 and 2025. Nevertheless, the search was last updated in March 2026 to identify all eligible studies published up to December 2025, allowing for indexing delays. Additionally, due to limits in primary data, both primary (qualitative, quantitative, or mixed-methods studies, including randomized controlled trials (RCT), observational studies, and case studies) and secondary studies (systematic, scoping and literature reviews) were included in alignment with the context of a scoping review to map the existing evidence. Primary studies provided evidence on the psychosocial outcomes of the intervention, while review articles were used to contextualize findings and identify gaps. This approach ensured a comprehensive and transparent synthesis of the literature.

Studies of all designs were included if they:

• i)involved war-affected Middle Eastern refugees, asylum seekers, or displaced persons, including mixed refugee samples with Middle Eastern participants;
• ii)evaluated NET or KIDNET as a psychological intervention or reported relevant evidence on the use of NET/KIDNET, even when other trauma-focused interventions were also examined;
• iii)reported at least one psychosocial or mental health outcome, such as PTSD, depression, anxiety, functioning, wellbeing, resilience, somatic symptoms, or treatment acceptability;
• iv)were published in English or French between January 2015 and December 2025.

Studies were excluded from the review if they:

• i)did not involve war-, conflict-, or displacement-related trauma;
• ii)did not include Middle Eastern refugees, asylum seekers, or displaced persons as a distinct population;
• iii)did not evaluate NET/KIDNET;
• iv)did not report psychosocial or mental health outcomes;
• v)were study protocols, clinical guidelines, editorials, commentaries, conference abstracts or opinion pieces without empirical results;
• vi)were not available in English or French;
• vii)were published outside the predefined date range.

Search strategy

A systematic literature search was performed across three major databases—PubMed, ScienceDirect and Scopus—to comprehensively map and identify the available evidence on NET among Middle Eastern refugees. These databases were selected to ensure comprehensive coverage of biomedical, psychosocial and interdisciplinary literature. PubMed was included for its extensive medical and mental health coverage, Scopus for its multidisciplinary indexing, and ScienceDirect for access to full-text articles from Elsevier journals. Grey literature was not included due to feasibility constraints and to maintain focus on peer-reviewed indexed studies.

The search strategy used free-text keywords combined with Boolean operators (AND/OR) and was structured into four main concepts: intervention, population, geographic context, and mental health outcomes. The search was limited to studies published between 2015 and 2025. Searches were conducted between December 2025 and March 2026 and databases were accessed through the university library institutional subscription. No formal methodological quality or risk-of-bias assessment was conducted, as this scoping review aimed to map the available literature rather than evaluate study quality. The full reproducible search strategies are provided in the table below(Table 1).

Table 1.

Full database search strings

Databases	Search Strategy
PubMed	(“Narrative Exposure Therapy” OR NET OR KIDNET) AND (refugees OR “asylum seekers” OR “displaced persons” OR “forcibly displaced” OR children OR adolescents OR minors) AND (Lebanon OR “Middle East” OR Syria OR Palestine OR Iraq OR Jordan) AND (war OR “armed conflict” OR violence OR trauma)
ScienceDirect	(“narrative exposure therapy” OR NET OR KIDNET) AND (refugees OR “asylum seekers” OR “displaced persons” OR migrants OR children OR adolescents OR “forcibly displaced”) AND (Lebanon OR “Middle East” OR Syria OR Palestine OR Iraq OR Jordan) AND (war OR trauma OR “armed conflict” OR violence OR PTSD OR depression)
Scopus	(“narrative exposure therapy” OR NET OR KIDNET) AND (refugees OR “asylum seekers” OR “forcibly displaced” OR “displaced persons” OR migrants) AND (Lebanon OR “Middle East” OR MENA OR Syria OR Palestine OR Iraq OR Jordan) AND (war OR trauma OR violence OR “armed conflict” OR PTSD OR depression)

In addition, we applied the following filters: articles published between 2015 and 2025, English or French language, and document type restricted to original articles and reviews. Study selection was conducted in two stages (title/abstract screening followed by full-text screening). The second author (TA) performed the initial screening of records retrieved from the selected databases. The lead author (NT) independently reviewed them and assessed the eligibility and selection. An additional manual search of reference lists of included studies was conducted to identify additional relevant articles. This data selection process is illustrated in a PRISMA-ScR flow diagram in the results section.

Data Extraction and Synthesis

Data extraction was performed independently using a standardized Excel form developed for this review and any discrepancies were resolved through discussion and consensus. The form was piloted on a subset of included studies and refined before full extraction. Duplicates were removed manually after being checked by two reviewers, and references were added on Zotero. We extracted the following data on articles: all contributing authors, year of publication, study design, participant characteristics and sample size, psychosocial variables, their measurements and key findings based on the inclusion criteria.

All the included studies (primary and secondary) were grouped based on their characteristics and results, analyzed and summarized in alignment with the review’s inclusion criteria and objective. Potential overlap between primary and secondary studies was anticipated. To reduce the risk of double-counting, we cross-checked primary studies reported within included reviews against the RCTs identified in our search during data extraction. While this process minimized duplication in the synthesis, some degree of overlap may still be present given the nature of secondary evidence.

Results

The initial literature search resulted in a total of 2439 citations. After removing duplicates and assessing for eligibility based on titles and abstracts, a total of 91 articles were screened. Afterwards, 67 articles were excluded following further full text assessment and reading based on the inclusion and exclusion criteria. Therefore, a total of 24 articles were included in this scoping review (Fig. 1).

Fig. 1.

PRISMA flow diagram of the study selection process

Study characteristics

A total of 24 articles were included, comprising 7 primary studies [23, 24, 26–29, 37] and 17 secondary studies [12, 13, 31–36, 38–46]. Primary studies included 2 RCTs, 1 secondary analysis of RCT, 3 quantitative observational studies and 1 qualitative case report, while secondary studies included 12 systematic reviews, 1 umbrella review, 1 scoping review and 3 narrative/literature reviews. Participants were primarily adult refugees or asylum-seekers from the Middle East residing in Western countries. Most studies investigated NET, while others examined Cognitive Behavioral Therapy (CBT) and multi-component psychotherapies. Outcomes measured included PTSD, depression, and functional recovery, with interventions delivered in community-based or clinical settings. Detailed study characteristics of primary and secondary studies are presented respectively in Tables 2 and 3, organized by study design.

Table 2.

Primary studies characteristics

Author(s), Year	Study Design	Sample Size (N)	Population	Geographical Setting	Outcome & Measurements	Key Findings
Peltonen & Kangaslampi  (2019)	Randomized control Trial	50	N=50, boys and girls between ages of 9 and 17; 37 middle eastern children refugees	Finland	Traumatic experiences: customized checklist based on the Event Checklist for War, Detention, and Torture Experiences, the Child and Adolescent Intake Form of the Center for Victims of Torture, and adverse childhood experiences studies PTSD: Revised Impact of Event Scale (CRIES) Depression: Depression Self-Rating Scale for Children (DSRS), Resilience: Child and Youth Resilience Measure (CYRM) Psychological distress (child and guardian-rated) : the Strengths and Difficulties Questionnaire (SDQ).	Clinical PTSD symptoms decreased overtime in both groups, and NET showed stronger within-group improvements. However, there was no statistically significant advantage of NET over TAU in the main outcome, difficulties in recruitment of participants and limited follow-up data restricts stronger conclusions. This study highlights a gap between experts guidelines and clinical practice, especially in treating multiple-traumatized children, and calls for more real-world research.
Kangaslampi & Peltonen (2020)	Secondary analysis of RCT	50	N=50, boys and girls between ages of 9 and 17; 37 middle eastern children refugees	Finland	Traumatic experiences: customized checklist based on the Event Checklist for War, Detention, and Torture Experiences, the Child and Adolescent Intake Form of the Center for Victims of Torture, and adverse childhood experiences studies PTSD: Revised Impact of Event Scale (CRIES) Depression: Depression Self-Rating Scale for Children (DSRS), Resilience: Child and Youth Resilience Measure (CYRM) Psychological distress (child and guardian-rated) : the Strengths and Difficulties Questionnaire (SDQ).	NET did not outperform TAU in changing posttraumatic cognitions or memory quality, possibly due to spillover effects from therapists or the resilience of maladaptive cognitions formed through prolonged trauma exposure. The modest changes observed suggest that negative cognitions from chronic trauma, especially in war-affected children, may be harder to alter than those from single-incident trauma.
Smaik et al., (2023)	Randomized control Trial (+pre/post design)	40	40 Syrian adult refugees aged between 18 and 64	Jordan	PTSD Symptoms: Harvard Trauma Questionnaire (HTQ-16)Depression and anxiety symptoms: Hopkins Symptoms Checklist-25 (HSCL-25)	This study found that NET was feasible and acceptable. Further, for all three efficacy outcomes – symptoms of PTSD, depression, and anxiety – there was a statistically and clinically significant reduction in symptoms after NET compared to a waitlist control.
Hansen et al., (2018)	Observational	110	N = 110 adults and adolescents from the MENA region (Syria, Iraq, Sudan, Tunisia) exposed to torture or war-related trauma	Middle East	Individual NET delivered by trained therapists (with interpreters). Measures: PTSD :HTQ-16, anxiety & depression HSCL-25, and functioning/disability: WHO Disability Assessment Schedule: WHODAS 2.0–12 item.	NET significantly reduces PTSD, anxiety, and depression symptoms among torture survivors in the MENA region, with the greatest effect on PTSD and some somatic improvements. Cultural familiarity, therapist competence, and short-term in-person delivery contribute to treatment effectiveness, despite limitations such as no control group, high dropout, and missing data.
Kaltenbach et al., (2020)	Observational	28	N=28 refugees from different countries, aged between 14 and 61.	Germany	Traumatic events (At T0): PTSD Symptom Scale – Interview Version (PSS-I) and Life Events Checklist (LEC-5)/ PTSD Symptoms: PCL-5 before each session/ Depression: Patient Health Questionnaire – 9 (PHQ-9) before each session/Daily functioning: costumized items before each session/ Life events during and after treatment: before each session (categories were generated by clustering the clients’ answers)	Patients resented with substantial decreases in PTSD symptoms already during and after NET. However, symptom trajectories differed and ranged from fast responders to slow responders to no immediate response during treatment. Importantly, a persistent worsening of symptoms was not observed, also not after exposure to the most distressing events. In contrast, stressful life experiences seemed to aggravate PTSD symptoms.
De la Rie et al., (2020)	Observational	97	N=97 participants. All participants were refugees	Netherlands	PTSD symptoms were measured using the CAPS interview. Functioning was measured using the General Assessment of Functioning (GAF) scale. Clinician Administered PTSD Scale for DSM-5 (CAPS) measures PTSD severity. GAF measures psychological, social, and work functioning.	Most patients (78.4%) completed NET. PTSD symptoms significantly decreased and daily functioning significantly improved. Around 28–30% showed strong improvement, and four patients no longer met PTSD diagnostic criteria. No patients showed deterioration. Patients with a history of childhood trauma showed less improvement, while those with greater social support experienced better outcomes.
De la Rie et al., (2018)	Qualitative Case Study	2	2 refugees and torture survivors in Netherlands who underwent NET.	Netherlands	Qualitative analysis of the narrative reports of the torture survivors. Assessment: CAPS and GAF administrated before and after the completion of NET. Analysis: The therapist asks about cognitions “back then” and “here and now". A report is written of each session which results in a reconstruction of the life history of the patient at the end of treatment.	After NET was completed, other complaints were aggravated due to current life stressors related to the asylum procedure. Additional treatment was offered to support the middle eastern refugee in dealing with these stressors. The CAPS score decreased marginally  from 46 to 45 and the GAF score from 51 to 45.

Table 3.

Secondary studies characteristics

Author(s), Year	Study Design	Number of Studies Included	Population	Geographical Setting	Interventions	Key Findings
Gruner et al., (2020)	systematic review	15	Refugees and asylum seekers	Western countries	CBT, Common Elements Treatment Approach (CETA), NET, Community-based / psychosocial psychotherapy programs, Task-shifting models in primary health care and culturally adapted mental health interventions	NET consistently improved PTSD, but effects on depression were mixed, standard-length NET (8-10 sessions) showed stronger effects than brief versions, better outcomes are associated with culturally-adapted interventions and community based settings. Insecure asylum status reduces effectiveness as well a socio-cultural and gender mismatches.
Tribe et al., (2019)	systematic review	40	Refugees with PTSD, depression, anxiety	European countries	NET, CBT and EMDR	This review found medium to high quality evidence supporting the use of NET. A lack of culturally adapted treatments was apparent and there was less evidence to support standard CBT, EMDR and multidisciplinary treatments.
Turrini et al., (2024)	systematic review and meta analysis	103	Refugees and asylum seekers with PTSD, depression, or anxiety	n/a	NET, Counselling, EMDR, Creative expressive interventions, Integrative therapy and TAU	PTSD: NET showed greater effectiveness than TAU in reducing PTSD symptoms, though confidence in the evidence was low due to heterogeneity and study limitations. Depression and Anxiety: NET demonstrated potential benefits for both outcomes, but effect estimates were imprecise and based on fewer trials. Comparative effectiveness: No clear evidence that NET was superior to other trauma-focused interventions as confidence intervals overlapped. NET was generally acceptable, with drop-out rates comparable to other structured psychological interventions.
Molendijk et al., (2024)	systematic review and meta analysis	116	Refugees and asylum seekers, Both adults and children With PTSD, depression or anxiety	n/a	CBT, EMDR, NET, Expressive/art therapy, Mindfulness-based interventions, Mixed-element psychosocial intervention and Psychoeducation	CBT and EMDR outperformed psychoeducation for depression in adults. For most therapies (including NET), effect sizes were within the same general range as overall analyses. Although the meta-analysis pooled all treatment types together, NET was one of several trauma-focused interventions contributing to the large PTSD effect sizes observed in both adults and children.
Lely et al., (2019)	systematic review and meta analysis	16	Traumatized refugees and other trauma survivors	n/a	NET, Compared against: Non-active controls Trauma-focused interventions Non-trauma-focused interventions	Sixteen RCTs showed that NET had large effects on PTSD symptoms and moderate effects on depression at post-treatment and follow-up. NET outperformed non-active comparators for PTSD and depression, and non-TF active comparators for PTSD. Older age predicted better outcomes, while migration history predicted smaller improvements in depression.
Raghuraman et al., (2021)	systematic review and meta analysis	15	Refugees and trauma survivors	n/a	NET	NET consistently reduces PTSD symptoms with small-to-medium effect sizes. Effects on depression are smaller, significant mainly midterm. Strongest evidence vs. inactive controls; active controls reduce apparent effect size. Heterogeneity and risk of bias exist but sensitivity analyses support robustness of PTSD findings.
Velu et al., (2025)	systematic review and meta analysis	47	Refugee children and adolescents aged between 0 and 18 years old	n/a	CBT, EMDR, KIDNET, Art therapy and other psychosocial/creative interventions, General trauma-focused treatments	32 studies included in the meta-analysis showed positive PTSD outcomes for CBT-based interventions, EMDR, KIDNET, and art therapy. Medium effects were found for CBT-based interventions, large effects for EMDR, and promising follow-up effects for KIDNET. Interpretation was limited by high heterogeneity and generally low study quality.
Siehl et al., (2021)	systematic review	56	Adults and children traumatized by war and/or torture with PTSD symptoms	30 countries around the world including Europe, Africa, The Middle East, Asia and North America	NET, KIDNET and FORNET	In a total of 56 studies from 30 countries, comparing 1,370 participants treated with NET to 1,055 controls, results showed large between-group effect sizes for the reduction of PTSD symptoms in favor of NET. Analyses of RCTs with active controls showed small to medium effect sizes in the short term and large effect sizes in the long term.
Thompson et al., (2018)	systematic review	16	Refugees and asylum seekers with PTSD	n/a	EMDR, NET Other trauma-focused psychological interventions	All evidence was rated low to very low quality using Grading of Recommendations Assessment, Development and Evaluation (GRADE) warranting cautious interpretation. Trauma-focused psychological interventions showed efficacy in reducing PTSD severity and diagnostic rates compared with inactive controls. NET demonstrated beneficial effects, including long-term outcomes, consistent with previous refugee-focused reviews. EMDR showed large effects versus waitlist controls but was based on only two small studies and did not outperform active controls. No evidence supported other CBT-based approaches.
Turrini et al., (2017)	Umbrella review	27	Adult and child asylum seekers and refugees	Low, middle, and high-income countries	CBT, NET, Other psychosocial interventions Pharmacological treatments	13 reviews reported prevalence data on common mental disorders and 14 on psychological or pharmacological interventions. Despite variability in prevalence rates, depression and anxiety were at least as common as PTSD, affecting up to 40% of asylum seekers and refugees. Cognitive-behavioural interventions, particularly NET, were the most studied psychosocial treatments, showing positive effects compared with inactive but not active controls.
Nosè et al., (2017)	systematic review	12	Adult refugees and asylum seekers with PTSD	High income countries	Psychosocial interventions (overall group) NET, CBT Compared with waiting list or treatment as usual (TAU)	Psychosocial interventions reduced PTSD symptoms compared with control groups. NET, a trauma-focused CBT variant, was the most supported intervention based on randomized controlled trials. However, the overall methodological quality of the included studies was limited.
Weber et al., (2025)	Scoping Review	60	Children and adolescents with PTSD	n/a	Psychoeducation-based interventions, NET, Supportive therapy, Coping skills training, Trauma narrative-based therapies, Combined therapeutic approaches, Prolonged Exposure Therapy, School-based interventions and Group therapy	Most NET studies reported significant reductions in PTSD symptoms, consistent with trauma-focused therapies using structured narrative exposure. NET was generally comparable to other trauma-focused interventions and more effective than supportive therapies. It showed short- to medium-term benefits, with some variability in long-term outcomes depending on study design and follow-up. Overall, NET demonstrated relatively stable effects compared with non–trauma-focused interventions. Evidence quality ranged from low to high (GRADE), reflecting heterogeneity across studies. NET has a growing evidence base and is a feasible manualized intervention, particularly suited to children with complex trauma and use in low-resource settings.
Fegert et al., (2018)	Literature review	n/a	Children and adolescents refugees	European countries	NET, EMDR, CBT	Evidence from meta-analyses shows moderate to large effects for psychosocial interventions in traumatized children, with no clear differences in effectiveness between EMDR, KIDNET, and CBT. Despite their differences, these therapies share key elements: psychoeducation, trauma confrontation, and normalization of fear responses which appear central to PTSD recovery.
Ford et al., (2015)	Literature review	n/a	Adults with PTSD	n/a	NET, CBT, Pharmacotherapy	NET has demonstrated the ability not only to help traumatized adults recover from PTSD but also to enable them to shift from a survival brain to a learning brain and to regain some of their bodies’ vital healing capacities.
Wright et al., (2020)	systematic review and meta analysis	6	Adult refugees and asylum-seekers With trauma-related disorders	High income countries	NET	6 RCTs reported significant reductions in trauma symptoms with NET, while effects on depression were less consistent, with only two studies showing significant improvement. Meta-analyses indicated medium-to-large effects in favor of NET for both trauma and depression, although results showed substantial heterogeneity. Reporting of cultural adaptation was limited and often non-systematic; when described, it mainly involved language support and consideration of refugees’ sociopolitical context, without use of structured adaptation frameworks.
Genç (2022)	systematic review	20	Refugee children and adolescents exposed to trauma	n/a	Trauma-Focused Cognitive Behavioural Therapy, NET, EMDR, Mein Weg (My Way) programme and Multimodal trauma-focused treatments	NET/KIDNET was the most frequently studied and most effective trauma treatment for refugee children and adolescents, with only NET trials showing large effects, controlled designs, and long-term follow-up. Other interventions, including EMDR, Trauma-focused CBT, art therapy, Mein Weg, and multimodal trauma-focused treatments, showed positive effects on PTSD symptoms but were limited by a lack of control groups and follow-up data. Overall, only 20 experimental studies were identified, indicating a substantial evidence gap. The review also highlighted limited and insufficient cultural adaptation of Western-developed interventions, underscoring the need for more contextually appropriate approaches.
De Fouchier et al., (2015)	Litterature review	11	Adult refugee trauma survivors with PTSD,	Bosnia, United States, Iraq	Trauma Focused–CBT, Somatic Focused-CBT, NET, CBT and exposure therapy	6 studies assessed therapeutic efficacy of NET. NET was compared to supportive counseling, psychoeducation, trauma counseling, no-treatment, treatment as usual, and stress inoculation training and each comparison showed a significant and greater decrease on PTSD measures than the control group.

Primary Studies

Table 2 presents the following data from the seven primary studies: main author and year of publication, study design, population characteristics, geographical setting, psychological outcomes, their measurements and the corresponding results. Two studies were conducted in the Middle East [23, 24], two in Finland [28, 29], two in the Netherlands [27, 37] and one in Germany [22]. Two studies [24, 29] were RCTs and one is a follow up secondary analysis [24], three studies adopted a pre-post observational design [23, 26, 27], and one was a qualitative case report [33]. All studies included Middle Eastern participants exposed to war and armed conflicts, children, adolescents and adults, with a total number of 377.

Synthesis of contextual characteristics

Across the seven included studies, NET was delivered across diverse host countries and care settings, from specialized torture rehabilitation centers in the Middle East and North Africa (MENA) to refugee mental health services in Europe. Overall, treatment closely followed the original NET manual with high fidelity. Reported adaptations mainly focused on improving accessibility and acceptability for refugee participants.

The two studies conducted in the MENA region demonstrated the highest degree of culturally responsive implementation [23, 24]. Hansen et al. (2018) implemented NET across specialized torture rehabilitation centers in nine Arab countries: Jordan, Palestine, Egypt, Lebanon, Iraq, Tunisia, Libya, Sudan and Syria following a regional capacity-building program led by the Danish Institute Against Torture [23]. The intervention consisted of 10 NET sessions delivered by the trained Arab psychologists and psychiatrists. Although the protocol remained unchanged, the authors suggested that shared language, cultural norms and familiar treatment contexts between therapists and participants may have enhanced the therapeutic outcomes. Similarly, Smaik et al. (2023) delivered 10 NET sessions to Syrian refugees in Jordan through the Jordanian Psychological Sciences Association using therapists from the same religious and ethnic community as participants [24]. In addition to the therapist-patient cultural concordance, implementation addressed refugee-specific barriers including concerns regarding confidentiality, distrust of authority figures, travel costs, and respect for cultural norms, contributing to a good treatment acceptability and retention.

The European studies primarily reported contextual rather than cultural adaptations. In Finland, NET was implemented across outpatient mental health services including primary healthcare centers, psychiatric outpatient clinics and third-sector trauma services, by trained providers which comprised psychologists, psychiatrists, psychiatric nurses and social workers who received standardized NET training [28, 29]. Treatment fidelity was maintained while language support through trained interpreted represented the principal adaption for refugee participants. Similarly in Germany, Kaltenbach et al. (2020) implemented NET within a specialized refugee trauma center using trained clinical psychologists supported by ongoing supervision and experienced interpreters, who themselves received training in mental health interpretation and self-care [26]. Although approximately half of therapy sessions required interpreters, no modifications to the therapeutic protocol were reported. In the Netherlands, NET was embedded within a one-year multidisciplinary outpatient day-treatment program for refugees with severe and complex trauma-related disorders at a specialized national trauma center [27]. Weekly NET sessions formed the second phase of treatment and were delivered by trained therapists with good adherence to the protocol. While no cultural adaptations were described, the program incorporated additional consultation sessions to address post-migration stressors, representing contextual adaptations that supported treatment engagement without altering the intervention itself. The accompanying qualitative study conducted within the same program similarly reported implementation of standard NET without cultural modification [37].

Primary Studies & Tools Used to Assess

PTSD was the main outcome measured by all the studies using several scales including Revised Impact of Event Scale (CRIES) [28, 29], Harvard Trauma Questionnaire (HTQ-16) [23, 24], PTSD Checklist for DSM-5 (PCL-5) [26] and Clinician Administered PTSD Scale for DSM-5 (CAPS) [27]. Secondary psychosocial outcomes were Depression, measured by Depression Self-Rating Scale for Children (DSRS) [28, 29], Hopkins Symptoms Checklist-25 (HSCL-25) [23, 24] and Patient Health Questionnaire (PHQ-9) [26]; Anxiety measured by Hopkins Symptoms Checklist-25 (HSCL-25) [23, 24]; Resilience measured by Child and Youth Resilience Measure (CYRM) [28, 29]; Psychological Distress measured by Strengths and Difficulties Questionnaire (SDQ) [28, 29]; and Functioning/disability measured by WHO Disability Assessment Schedule 2.0 (WHODAS 2.0–12) [23], a study specific scale [26], and General Assessment of Functioning (GAF) [27].

Relationship between NET and psychosocial outcomes in primary studies

Studies conducted in Middle Eastern countries: Hansen et al. (2018) found statistically significant reduction in PTSD, depression and anxiety in their pre-post observational study, with limitations related to missing data, high dropouts and absence of control group [23]. Smaik et al. (2023) used a two-armed RCTs, and found the same results in comparison to a waitlist group, with limitations related to the randomization procedure, data collection during COVID-19 and no longitudinal follow up to assess the sustainability of results [24]. Studies conducted in European countries: Peltonen & Kangaslampi (2019) found in their RCT study that NET decreased PTSD symptoms over time, but did not outperform treatment as usual (TAU), suggesting that negative cognitions from chronic trauma, especially in war-affected children, may be harder to alter than those from single-incident trauma, as reported in their secondary analysis of the RCT [28]. Additional limitations were also related to an observed gap between experts’ guidelines and clinical practice, especially in treating children with complex trauma. Kaltenbach et al. (2020) found in their pre-post observational study that PTSD symptoms decreased at the end of the treatment continued to decline gradually over time, with stressors related to the asylum procedure mainly contributing to the delayed response [26]. This was also the case with the findings of De la Rie et al. (2018) in their qualitative case report [37]. Nevertheless, in their pre-post observational study, De la Rie et al. (2020) later found a significant decrease in PTSD and improvement in functioning directly after NET, however, participants with childhood trauma showed a reduce response to treatment. Moreover, no longitudinal follow up was employed to assess the sustainability of results [27].

Secondary Studies

Table 3 presents the 17 secondary studies with the following data: main author and year of publication, study design, number of included studies, population, geographical setting, interventions and key findings. These studies can be grouped in several ways, as detailed below.

Outcome Stratification

All secondary studies included in this scoping review focused mainly on the evidence of NET in reducing PTSD as the core psychological outcome, since it is the most common psychological disorder in traumatized refugees, especially those from a middle eastern background [45]. Most reviews found significant and larger size effects on the reduction of PTSD among the Middle Eastern refugees.

Depression was also included in some reviews [12, 13, 33, 36, 41, 42, 45], as well as anxiety [12, 41, 45] but with limited findings and smaller size effects. Other outcomes related to the adaptability of NET were also reviewed by Wright et al. (2020) and Tribe et al. (2019) who found limited adaptability in contrast with Turrini et al. (2024) and Weber et al. (2025) [12, 32, 36, 44].

Grouping per NET exclusivity and review type

Some reviews studied the exclusive impact of NET on psychosocial outcomes among Middle Eastern refugees, while others provided an overview of NET alongside other psychological interventions. For instance, systematic reviews and meta-analyses exclusively studying NET in refugees: Lely et al. (2019) and Raghuraman et al. (2021) studied PTSD and depression [32, 41], Siehl et al. (2020) focused on PTSD [43], and Wright et al. (2020) examined PTSD, depression and cultural adaptability limitations [36]. Furthermore, in the systematic reviews and meta-analyses studying multiple trauma interventions, including NET: Genç (2022), Nosè et al. (2017), Thompson et al. (2018) and Velu et al. (2025) examined PTSD outcome of different psychosocial interventions targeting traumatic symptoms [31, 34, 35, 46]. Other studies extended their outcomes beyond PTSD to include depression and anxiety [12, 13, 41, 45] as well as cultural adaptability and acceptability [44, 45]. While in the scoping review, Weber et al. (2025) studied NET’s impact on PTSD in community settings in refugees and in the literature reviews [32], De Fouchier et al. (2015), Fegert et al. (2018) and Ford et al. (2015) reviewed PTSD outcomes of NET [38–40].

Overview of patterns and trends across reviews

As shown below, data are organized according to the main outcome findings in terms of trends, agreement, inconsistency, gaps and limitations of all reviews.

PTSD

Most reviews reported reductions in PTSD symptoms; however, differences in study design and comparators limit the certainty of evidence. In addition, NET was found to be the most implemented and appropriate trauma-focused therapy for child refugees, especially Middle Eastern [31]. However, no significant difference was observed in comparison with other trauma- focused treatments like CBT and Eye Movement Desensitization and Reprocessing (EMDR) [12, 13, 39, 41, 44], due to lack of NET studies against active comparators [34, 45]. Several therapies demonstrated positive results in decreasing PTSD symptoms in the short and medium term.

Depression and Anxiety

reviews found limited evidence on the impact of NET on depression and anxiety [12, 13, 33, 36, 41, 42, 45] with findings being less consistent and less studied among refugees.

Cultural acceptability and adaptability

some studies endorse NET’s effectiveness in reducing PTSD symptoms, as well as its good acceptability and adaptability in low-resource refugee settings [12, 13] even when implemented by non-specialized mental health [32] in community level. This acceptability and adaptability outcome was inconsistent and debated by Genç (2022), Tribe et al. (2019) and Wright et al. (2020) who, along with Raghuraman et al. (2021), suggested to be examined in further studies [31, 36, 42, 44].

Gap and limitations

Most reviews reported methodological limitations in their mentioned studies, reflecting less robust and low-quality experimental NET interventions related to lack of RCTs, professionals’ competence and follow up measures, which leads to treating results with caution [12, 31, 35, 38, 45, 46]. Moreover, most assessment tools used were not culturally adapted or validated for refugee populations, raising concerns about the appropriateness and accuracy of the reported outcomes. In addition, lack of active comparative studies made a necessity to compare future NET experiments with other trauma interventions to assess optimal efficacity with refugee population [34, 43]. Another notable limitation across reviewed studies was the heavy reliance on quantitative outcome measures, which may overlook the nuanced and context-specific aspects of participants’ trauma experiences and recovery processes. The scarcity of qualitative approaches limits deeper understanding of participants lived experiences and the mechanisms through which NET exerts its therapeutic effects.

Discussion

This scoping review aimed to map the existing evidence of NET among Middle Eastern refugees. Both types of studies showed PTSD as the main psychological outcome of NET. Additionally, both primary and secondary studies showed a reduction in PTSD symptoms after completing NET. These results appear to be consistent with other studies that either exclusively implemented NET with traumatized Middle Eastern refugees in Turkey [18] and Jordan [15] or combined NET with another intervention, such as physiotherapy for Middle Eastern torture survivors in Norway [21] or Skills Training in Affective and Interpersonal Regulation for Refugees (STAIR-R) or Supportive Problem-Solving (SPS) for Middle Eastern refugees in Australia [44]. These findings align with those reported in previous NET studies with other refugee and war-exposed populations like Sudanese refugees in Cairo who received NET by lay counselors [47] and North Korean youth refugees in South Korea who received NET by a clinical psychologist [48]. These studies suggest a potential benefit of NET in reducing PTSD symptoms across refugee populations. However, in the broader literature, Al Hadethe et al. (2015) in their study comparing NET with Emotional Freedom Techniques (EFT) with Iraqi male adolescents, found EFT to have larger effect size than NET [20]. Although findings consistently suggested PTSD symptom reduction, interpretation of these outcomes should remain cautious due to several methodological limitations that limit tracking the medium and long-term impact of this therapeutic intervention. This limitation appeared across several of the studies mentioned above, which primarily report immediate post-intervention outcomes following NET, with a maximum follow-up period of 12-month in Al Hadethe et al. (2015) [20].

Primary studies indicate potential reduction of PTSD symptoms on the short and medium term among Middle Eastern refugees [23, 24, 26, 27, 29, 37] negative cognitions being harder to change in adults and children with multiple childhood traumas [28]. Limited evidence regarding long-term PTSD symptom reduction may be attributed to the complicated nature of refugee’s situation in terms of the complexity of their multiple traumatic experiences related not only to war or armed conflict but also to their legal and social status challenges in hosting countries [2]. Another reason for this longitudinal evidence gap may also be attributed to the hardship in reaching refugees caused by their unstable and unsettled lives and frequent displacement within the same hosting countries [49]. This suggests that therapeutic recovery among refugees may be constrained not only by trauma severity but also by persistent post-migration stressors.

Limited evidence was found concerning other psychosocial outcomes like resilience, distress, functioning, depression and anxiety [23, 24, 26, 29]. These findings align with previous NET studies which did not find significant decrease in secondary psychosocial outcomes, especially in depression symptoms [22, 25, 47, 50]. This may reflect the original therapeutic focus of NET on PTSD rather than comorbid conditions which suggests that NET may need to be paired with other interventions to treat wider range of psychological symptoms [49]. However, these results concur with Park et al. (2020) in the broader literature, who found depression to significantly decrease along with insomnia symptoms in their small sample of North Korean refugee youth. Regarding NET’s comparison with other interventions, the only comparison found was with TAU, with no significant differences between interventions [29]. This finding is consistent with Park et al. (2020) where NET was statistically superior to TAU in symptom reduction among North Korean refugee youth, and Al-Hadethe et al. (2015) who found EFT’s larger effect size than NET among Iraqi adolescent high-schoolers, explaining it with cultural considerations of Iraqi males not being comfortable talking about all their traumatic life experiences besides the war-related. Beyond psychosocial outcomes, the empirical studies included in this review highlighted several methodological limitations related to biases in randomization [47, 48, 50], lack of active control group, absence of longitudinal follow up also and concerns about the trained practitioners’ skills and competence [29] which was also a main reported concern in Ellis & Jones (2022) and Nickerson et al. (2026) studies. Additionally, it has been suggested that asylum procedures might aggravate PTSD symptoms [26, 37].

Regarding the contextual characteristics, included studies reported diverse care settings of NET implementation, including specialized torture rehabilitation centers in the MENA region and refugee mental health services in Europe while generally maintaining high fidelity to the original manual. Contextual characteristics varied mainly in terms of service organization and delivery structures, including the use of trained clinicians, multidisciplinary teams, interpreters and in some cases community/lay counsellors, as well as flexible delivery arrangements and attention to post-migration stressors to support engagement. Overall, explicit cultural adaptation was limited, with most studies focusing on strategies to enhance accessibility and feasibility rather than modifying core therapeutic components. Among the included studies, those conducted in the MENA region reported the most comprehensive culturally responsive implementation, whereas European studies largely relied on contextual and organization adaptations while preserving the original NET therapeutic model. This pattern appears broadly consistent with the wider NET literature, where similar implementation approaches are reported with refugees and torture survivors. For instance, studies in South Korea [48] and Australia [50] describe high-fidelity intervention supported by trained psychologists and interpreter use, without substantial adaptation of the content. Likewise, Dibaj et al. (2017) in Norway and Al-Halalameh & Dawoud (2015) in Jordan reflect implementation within specialized or humanitarian service contexts where psychosocial complexity and adherence challenges were noted alongside delivery constraints [19, 25]. Al Hadethe et al. (2015) additionally suggest that cultural factors such as gender norms in Iraq may influence acceptability, although these were not formally operationalized as intervention adaptations [20]. In contrast, Ellis & Jones (2022) describe a more explicitly culturally embedded approach in Egypt, including community consultation, lay counsellor delivery, adjustment of some NET concepts and expressions to ensure cultural relevance, gender-sensitive matching, and NET implementation at the community center, although such approaches appear less common across the identified literature [47]. Overall, the available evidence suggests variability in contextual implementation, while more systematic cultural adaptation of NET is reported less frequently and may warrant further exploration in future research.

All secondary studies analyzing NET exclusively or along with other psychosocial interventions, reported reductions in PTSD symptoms, especially in community settings [32], but it was not superior to other trauma-focused interventions. This finding is in line with other NET secondary reviews [30, 49]. Given the quasi-absence of high-quality experimental studies comparing NET with another evidence-based trauma-focused therapy among refugees, secondary studies mentioned in this review analyze and compare evidence of separate trauma-focused primary studies with the same psychosocial outcomes. Other possible explanations for this finding are the short-term nature of NET which might not produce durable therapeutic effects as well as differences in the practitioners’ background, training and clinical skills and competence [49]. Regarding the overall evidence quality, secondary studies in our scoping review raised methodological issues regarding the lack of recent RCTs, implementation quality biases and cultural adaptability inconsistency [31, 36, 42, 44]. Limited evidence was found on the association between NET and changes in depression and anxiety symptoms [12, 13, 33, 36, 41, 42, 45] suggesting that additional or complementary interventions may be needed to address the broader spectrum of common comorbid symptoms in refugee populations. The available evidence suggests that NET may reduce PTSD symptoms among Middle Eastern refugees, although the evidence remains limited by methodological weaknesses, insufficient long-term follow-up and limited attention to broader psychosocial outcomes and cultural adaptation.

Strengths and limitations

This scoping review was designed to search and broadly map the existing evidence of NET and psychosocial outcomes among Middle Eastern refugees in different geographical contexts. Our review is characterized by the comprehensive search strategy we used in navigating three databases. A key strength of this review lies in the inclusion of both primary and secondary studies, while maintaining a clear and consistent distinction along with a flexible but non-confusing integration between them. This approach facilitated a broader understanding of the quality of evidence retrieved and enabled the identification of additional literature and methodological gaps within NET. This is to our knowledge, the first scoping review within the NET field to be conducted in Lebanon and in the Middle East, making it pertinent, relevant and original.

Despite the above-mentioned strengths, limitations of our review should be acknowledged. First, the potential overlap between primary and secondary studies. Although efforts were made to distinguish evidence sources, some overlap in underlying studies may still be present. Consequently, the review should be interpreted as a mapping of the available literature rather than a quantitative assessment of the cumulative strength of evidence. Second, language restrictions and limited database coverage resulted in the exclusion of potentially relevant studies. Third, this scoping review does not assess the methodological quality of included studies or estimate effect sizes. Additionally, the heterogeneity of included studies in terms of outcomes, population, designs and methodologies posed challenges to synthesizing the results. Finally, study selection was conducted by two independent reviewers however, inter-rater agreement was not formally quantified.

Conclusion

This scoping review synthesized the evidence on NET among Middle Eastern refugees and included 24 articles. The findings indicate that PTSD is the most assessed outcome, with studies generally suggesting short to medium-term reductions in symptoms following NET. However, evidence on other psychosocial outcomes including depression, anxiety and resilience remains limited. Overall, the evidence base is constrained by limited number of NET studies, a scarcity of RCTs, lack of active comparative groups, heterogeneity in study designs, limited longitudinal follow up and inconsistency in implementation and cultural adaptation. These findings should therefore be interpreted with caution. Future research could benefit from longitudinal and comparative study designs in Middle Eastern contexts alongside culturally sensitive mixed-method approaches to better capture both measurable outcomes and locally grounded experiences of healing.

Abbreviations

CAPS

Clinician Administered PTSD Scale for DSM-5

CBT

Cognitive Behavioral Therapy

CRIES

Revised Impact of Event Scale

CYRM

Child and Youth Resilience Measure

DSRS

Depression Self-Rating Scale for Children

EFT

Emotional Freedom Techniques

EMDR

Eye Movement Desensitization and Reprocessing

GAF

General Assessment of Functioning

GRADE

Grading of Recommendations Assessment, Development and Evaluation

HSCL-25

Hopkins Symptoms Checklist-25

HTQ-16

Harvard Trauma Questionnaire

KIDNET

Kid Narrative Exposure Therapy

NET

Narrative Exposure Therapy

PCL-5

PTSD Checklist for DSM-5

PHQ-9

Patient Health Questionnaire

PRISMA

Preferred Reporting Items for Systematic Review And Meta-Analysis

PTSD

Post-Traumatic Stress Disorder

RCT

Randomized Controlled Trial

SDQ

Strengths and Difficulties Questionnaire

SPS

Supportive Problem-Solving

STAIR-R

Skills Training in Affective and Interpersonal Regulation for Refugees

TAU

Treatment As Usual

UNHCR

United Nations Higher Commissioner for Refugees

WHO

World Health Organization

WHODAS 2.0–12

WHO Disability Assessment Schedule 2.0

Author contributions

Author contributions: NT and YR designed the Scoping Review. TA searched and extracted potential articles from the selected databases. NT reviewed them and assessed the eligibility and selection. NT and TA drafted the manuscript, carried out the analysis and interpreted the results. YR, ER and NZ resolved uncertainty during the research process and reviewed the final manuscript. ER and NZ jointly supervised this study. All authors read and gave their consent.

Funding

None to declare.

Data availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. All data included in this scoping review are derived from published literature.

Declarations

Ethical approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.