Evaluation of the METRA + intervention on mental health and social functioning in Afghan refugee adolescents in Pakistan: a pilot study.

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Learn more: PMC Disclaimer | PMC Copyright Notice Eur J Psychotraumatol . 2026 Apr 13;17(1):2650894. doi: 10.1080/20008066.2026.2650894 Search in PMC Search in PubMed View in NLM Catalog Add to search Show available content in en es Evaluation of the METRA + intervention on mental health and social functioning in Afghan refugee adolescents in Pakistan: a pilot study Evaluación de la intervención METRA + sobre salud mental y funcionamiento social en adolescentes refugiados afganos en Pakistán: estudio piloto Sayed Jafar Ahmadi Sayed Jafar Ahmadi a Psychology Program, Bard College, Annandale-on-Hudson, NY, USA b School of Psychological Sciences, Monash University, Melbourne, Australia c Department of Psychology, The New School, New York, NY, USA Conceptualization, Formal analysis, Methodology, Resources, Software, Supervision, Validation, Writing – original draft, Writing – review & editing Find articles by Sayed Jafar Ahmadi a, b, c, CONTACT , Zeinab Musavi Zeinab Musavi d Department of Student Affairs, American University of Afghanistan, Doha, Qatar Formal analysis, Writing – review & editing Find articles by Zeinab Musavi d , Mohammad Wali Farhat Mohammad Wali Farhat e Behrawan Research and Psychology Services Organization, Kabul, Afghanistan Data curation, Project administration, Writing – review & editing Find articles by Mohammad Wali Farhat e , Shafiqa Mehry Shafiqa Mehry e Behrawan Research and Psychology Services Organization, Kabul, Afghanistan Investigation, Writing – review & editing Find articles by Shafiqa Mehry e , Daniel Mcavoy Daniel Mcavoy f Centre for Humanitarian Leadership, Deakin University, Melbourne, Australia Validation, Writing – review & editing Find articles by Daniel Mcavoy f , Azi Berzengi Azi Berzengi g Department of Clinical Psychology and Psychological Therapies, University of East Anglia, Norwich, UK Methodology, Writing – review & editing Find articles by Azi Berzengi g , Adam Brown Adam Brown h Department of Psychology, The New School for Social Research, New York, NY, USA i Department of Psychiatry, New York University School of Medicine, New York, NY, USA Validation, Writing – review & editing Find articles by Adam Brown h, i , Justin Dainer-Best Justin Dainer-Best a Psychology Program, Bard College, Annandale-on-Hudson, NY, USA Formal analysis, Visualization, Writing – review & editing Find articles by Justin Dainer-Best a , Laura Jobson Laura Jobson j Turner Institute for Brain and Mental Health & School of Psychological Sciences, Monash University, Melbourne, Australia Conceptualization, Formal analysis, Methodology, Supervision, Writing – review & editing Find articles by Laura Jobson j Author information Article notes Copyright and License information a Psychology Program, Bard College, Annandale-on-Hudson, NY, USA b School of Psychological Sciences, Monash University, Melbourne, Australia c Department of Psychology, The New School, New York, NY, USA d Department of Student Affairs, American University of Afghanistan, Doha, Qatar e Behrawan Research and Psychology Services Organization, Kabul, Afghanistan f Centre for Humanitarian Leadership, Deakin University, Melbourne, Australia g Department of Clinical Psychology and Psychological Therapies, University of East Anglia, Norwich, UK h Department of Psychology, The New School for Social Research, New York, NY, USA i Department of Psychiatry, New York University School of Medicine, New York, NY, USA j Turner Institute for Brain and Mental Health & School of Psychological Sciences, Monash University, Melbourne, Australia CONTACT Sayed Jafar Ahmadi [email protected] Psychology Program, Bard College, Annandale-on-Hudson, NY 12504, USA Roles Sayed Jafar Ahmadi : Conceptualization, Formal analysis, Methodology, Resources, Software, Supervision, Validation, Writing – original draft, Writing – review & editing Zeinab Musavi : Formal analysis, Writing – review & editing Mohammad Wali Farhat : Data curation, Project administration, Writing – review & editing Shafiqa Mehry : Investigation, Writing – review & editing Daniel Mcavoy : Validation, Writing – review & editing Azi Berzengi : Methodology, Writing – review & editing Adam Brown : Validation, Writing – review & editing Justin Dainer-Best : Formal analysis, Visualization, Writing – review & editing Laura Jobson : Conceptualization, Formal analysis, Methodology, Supervision, Writing – review & editing Received 2025 Nov 3; Accepted 2026 Mar 20; Collection date 2026. © 2026 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( http://creativecommons.org/licenses/by-nc/4.0/ ), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. PMC Copyright notice PMCID: PMC13078654  PMID: 41973476 ABSTRACT Background: Afghan adolescents have been exposed to decades of war, displacement, and limited access to mental health care. Memory Training for Recovery–Adolescent Plus (METRA+) was developed to address posttraumatic stress (PTSD), depression, and social functioning through a brief, culturally adapted, and scalable approach. This pilot study evaluated the feasibility and preliminary efficacy of METRA + among Afghan refugee adolescents in Pakistan. Methods: A single-arm mixed-methods design was used, with 41 Afghan adolescents (27 girls, 14 boys; mean age = 15 .4 years) completing a 13-session METRA + programme integrating compassionate communication, memory specificity, and written exposure. Quantitative measures assessed PTSD symptoms, depression symptoms, anxiety, and social functioning, administered at baseline, after each module, and at two-month follow-up. Data were analyzed using repeated-measures analysis of variance (ANOVA). Post-intervention focus groups explored participants’ experiences and emotional changes, with thematic analysis conducted using MAXQDA 2024, following Braun and Clarke’s ( 2006 ) framework. Results: Significant reductions were observed in symptoms of PTSD, p < .001, partial η ² = .34, depression, p = .001, partial η ² = .16, and anxiety, p = .004, partial η ² = .13, with significant reductions in anxiety observed at follow-up but not immediately post-intervention, and all reductions maintained at follow-up. Improvements in social and communication skills were non-significant, but qualitative analyses indicated that METRA + enhanced emotion regulation, self-efficacy, empathy, academic motivation, and the normalization of traumatic memories. Participants and facilitators reported high satisfaction and strong cultural relevance of the programme. Conclusions: METRA + appears feasible, acceptable, and has potential efficacy for improving mental health and psychosocial outcomes among Afghan refugee adolescents. Findings highlight the promise of memory-focused and compassion-based interventions for youth in humanitarian and low-resource settings. Larger randomized controlled trials are warranted. Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12624001453572.. KEYWORDS: METRA+, Afghan refugee adolescents, PTSD, depression, anxiety, compassionate communication, social functioning, memory specificity training and thematic analysis HIGHLIGHTS METRA +  significantly reduced symptoms of posttraumatic stress, depression, and anxiety among Afghan refugee adolescents in Pakistan. The findings demonstrate the feasibility and promise of culturally adapted, memory-focused, and compassion-based interventions in humanitarian settings. Abstract Antecedentes: Los adolescentes afganos han estado expuestos a décadas de guerra, desplazamiento y acceso limitado a la atención de salud mental. El programa de Entrenamiento de Memoria para la Recuperación – Adolescente Plus (METRA+) se desarrolló para abordar el estrés postraumático (TEPT), la depresión y el funcionamiento social mediante un enfoque breve, adaptado culturalmente y escalable. Este estudio piloto evaluó la viabilidad y la eficacia preliminar de METRA + en adolescentes refugiados afganos en Pakistán. Métodos: Se utilizó un diseño de métodos mixtos de un solo grupo, con 41 adolescentes afganos (27 niñas, 14 niños; edad media = 15 ,4 años) que completaron un programa METRA + de 13 sesiones que integraba comunicación compasiva, especificidad de la memoria y exposición escrita. Se administraron medidas cuantitativas para evaluar los síntomas de TEPT, los síntomas de depresión, la ansiedad y el funcionamiento social, al inicio del estudio, después de cada módulo y en el seguimiento a los dos meses. Los datos se analizaron mediante análisis de varianza (ANOVA) de medidas repetidas. Los grupos focales posteriores a la intervención exploraron las experiencias y los cambios emocionales de los participantes, y se realizó un análisis temático utilizando MAXQDA 2024, siguiendo el marco de Braun y Clarke ( 2006 ). Resultados: Se observaron reducciones significativas en los síntomas de TEPT ( p < 0,001, η ² parcial = 0 ,34), depresión ( p = 0,001, η ² parcial = 0 ,16) y ansiedad ( p = 0,004, η ² parcial = 0 ,13). Se observaron reducciones significativas en la ansiedad en el seguimiento, pero no inmediatamente después de la intervención, y todas las reducciones se mantuvieron en el seguimiento. Las mejoras en las habilidades sociales y de comunicación no fueron significativas, pero los análisis cualitativos indicaron que METRA + mejoró la regulación emocional, la autoeficacia, la empatía, la motivación académica y la normalización de los recuerdos traumáticos. Los participantes y facilitadores reportaron una alta satisfacción y una fuerte relevancia cultural del programa. Conclusiones: METRA + parece factible, aceptable y con potencial eficacia para mejorar la salud mental y los resultados psicosociales en adolescentes refugiados afganos. Los hallazgos resaltan el potencial de las intervenciones centradas en la memoria y basadas en la compasión para jóvenes en contextos humanitarios y de bajos recursos. Se justifican ensayos controlados aleatorizados de mayor envergadura. PALABRAS CLAVE: METRA+, adolescentes refugiados afganos, TEPT, depresión, ansiedad, comunicación compasiva, funcionamiento social, entrenamiento en especificidad de la memoria y análisis temático 1. In 2024 over 122.6 million people worldwide were forcibly displaced (UNICEF, 2024 ). Of these, 71% resided in low- and middle-income countries (LMICs), and 40% were under the age of 18 (UNICEF, 2024 ). Adolescents with refugee backgrounds are often exposed to adverse experiences, trauma, and significant losses both before and during displacement. In host countries, they face additional challenges, such as protracted legal processes, language barriers, adaptation to new living conditions, anti-refugee sentiment and discrimination (Fazel et al., 2012 ; Frounfelker et al., 2020 ). These stressors are associated with elevated levels of psychosocial distress, including symptoms of posttraumatic stress disorder (PTSD) and depression (Mohd Saleem et al., 2021 ; Tyrer & Fazel, 2014 ). UNICEF ( 2024 ) has warned that the number of adolescents in need of humanitarian support has reached its highest level since World War II. A systematic review by Kien et al. ( 2019 ) reported that the prevalence of PTSD among refugee youth residing in European countries ranged between 19% and 52%. However, there is significantly less research on the prevalence of mental health issues among refugee youth residing in LMICs, which is problematic given most refugee youth live in LMICs (Frounfelker et al., 2020 ). Nevertheless, the existing research indicates that the prevalence of mental health problems among refugee youth in LMICs is higher than that of local populations (Reed et al., 2012 ). The ongoing crisis in Afghanistan is among the most complex humanitarian emergencies (ACAPS, 2021 ; United Nations OCHA, 2025 ). Afghanistan has endured over four decades of war, civil unrest, and recurrent humanitarian crises. Since the Taliban’s return to power in August 2021, restrictions on education for girls, widespread displacement, and economic collapse have exacerbated vulnerabilities for children and adolescents (Ahmadzai & Morrissey, 2025 ; UNICEF, 2021 ). Recent analyses emphasize that Afghan youth represent one of the most at-risk groups in the region (Jobson et al., 2024 ). Prolonged conflict, poverty, and structural inequalities have profoundly affected the mental health of Afghan youth, particularly girls (Ahmadi et al., 2022 ). Afghan adolescents, including those who are refugees, exhibit clinically significant rates of PTSD and depression (Ahmadi et al., 2022 ; Neshat Doost et al., 2013 ). These symptoms have potential lasting consequences on adolescent’s academic, emotional, and social functioning (Ahmadi et al., 2022 ; Neuner, 2019 ). In this context, UNICEF ( 2021 ) reported that ‘the needs of Afghan children have never been more acute,’ highlighting the urgency of psychosocial support for adolescents experiencing anxiety and fear (UN News, 2021 ). Addressing adolescent mental health during this critical developmental period is, therefore, a humanitarian imperative (Ahmadi et al., 2022 ). As recent global health research emphasizes, psychosocial care in humanitarian crises is now regarded as equally essential as food and shelter (Charlson et al., 2023 ; Velu et al., 2025 ). Various efforts have been made to reduce the psychological burden experienced by adolescents with refugee backgrounds, including evidence-based interventions, such as cognitive–behavioural therapy (CBT; Bosqui et al., 2023 ; King & Said, 2019 ; Rondung et al., 2022 ), eye movement desensitization and reprocessing (EMDR; Banoğlu & Korkmazlar, 2022 ; Kuiper & Uriakhel, 2020 ), writing for recovery (Kalantari et al., 2012 ), and narrative exposure therapy (KIDNET; Said et al., 2021 ; Peltonen & Kangaslampi, 2019 ). Although a recent meta-analysis confirmed the effectiveness of such treatments (Huang et al., 2022 ), access to these psychological interventions in LMICs remains severely limited due to resource constraints, high costs, a shortage of trained professionals, and the relatively low prioritization of mental health in global health discourse (Juengsiragulwit, 2015 ). Consequently, the mental health treatment gap is estimated to be as high as 85% in LMICs (Ndetei et al., 2023 ). In response to this, our team developed a low-cost, structured, and evidence-based intervention, Memory Training for Recovery Adolescents (METRA). This intervention targets two cognitive features underpinning PTSD and depression: (1) overgeneral autobiographical memory and (2) intrusive trauma-related memories (Brewin, 2011 ; Dalgleish & Werner-Seidler, 2014 ; Moradi et al., 2014 ; Neshat Doost et al., 2013 ; Williams et al., 2007 ). First, adolescents experiencing trauma-related disorders often recall vague, generalized personal life memories, rather than memories of specific life events (Neshat Doost et al., 2014 ; Williams et al., 2007 ). This in turn potentially disrupts key psychological processes (e.g. problem-solving, rumination, avoidance) and the processing of negative and trauma memories (i.e. processes integral to posttraumatic recovery), consequently maintaining symptoms of PTSD and depression (Moradi et al., 2014 ; Williams et al., 2007 ). Importantly, targeted interventions can improve memory specificity, which in turn can reduce symptomatology (Barry et al., 2019 ; Moradi et al., 2014 ; Neshat Doost et al., 2013 ). Second, those with PTSD often experience disruptions in how they remember traumatic events, including intrusive recollection of trauma memories (Brewin, 2011 ). PTSD models theorize symptoms persist because trauma memories are poorly integrated and inadequately processed (Ehlers & Clark, 2000 ). Gold-standard PTSD treatments use exposure techniques to process the trauma memories by reducing avoidance and promoting emotional processing (Schrader & Ross, 2021 ). While traditional PTSD treatments rely on face-to-face therapy to process trauma memories, growing evidence supports written exposure approaches as an effective alternative, which are brief, scalable, and lower in burden for both clients and providers (DeJesus et al., 2024 ). As shown in Figure 1 , METRA’s first module targets memory specificity  – an approach proposed to increase engagement with specific memories and reduce rumination and avoidance. Targeting memory specificity has been found to reduce symptoms of depression and PTSD (Barry et al., 2019 ; Moradi et al., 2014 ; Neshat Doost et al., 2013 ). The second module of METRA involves guided written exposure exercises aimed at processing traumatic memories (DeJesus et al., 2024 ). As highlighted in Figure 1 , enhancing the specificity of memories in Module 1 has the potential to strengthen an individual's capacity for memory processing, potentially supporting more effective trauma exposure work in Module 2, thereby further reducing trauma-related distress (Moradi et al., 2014 ). Figure 1. Open in a new tab Proposed mechanisms underpinning METRA. To date, three clinical trials have evaluated METRA. The first, conducted among Afghan adolescent girls in Kabul, demonstrated significant reductions in symptoms of PTSD, depression, anxiety, and cultural distress – improvements that remained stable at a three-month follow-up (Ahmadi, Jobson et al., 2023 ). The second study, conducted with Afghan adolescent boys following a terrorist attack in Kabul, reported high levels of acceptability and improvements in PTSD and depression symptomatology (Ahmadi, Musavi et al., 2023 ). A third trial further confirmed METRA’s efficacy, and feasibility among war-affected youth in Iraq (Jobson et al., 2025 ). Despite these promising findings, all three studies reported limited improvements in adolescent social functioning. Specifically, although psychological symptoms (depression, PTSD and anxiety) decreased, participants continued to report challenges in social interactions and peer relationships. Given the importance of social relationships for healthy development, quality of life, posttrauma recovery and long-term adjustment (Calhoun et al., 2022 ; Holt-Lunstad, 2024 ; Li et al., 2025 ; Maercker & Horn, 2013 ), the findings of our previous studies underscored the need for potential modifications to METRA to include a focus on social and interpersonal skills. Therefore, the present study, which focused on the development and preliminary evaluation of METRA+, was designed. We developed a new additional module to add to METRA, focused on social and interpersonal skills resulting in METRA+. This new module, which was presented prior to the memory-focused modules, consisted of three training sessions based on the nonviolent communication (NVC) model (Rosenberg, 2015 ) and focused on improving communication, peer relationships, and family interactions. NVC is a communication framework that emphasizes empathy, active listening, and the expression of needs in a non-judgmental manner. It encourages individuals to articulate observations, emotions, needs, and requests in ways that foster mutual understanding and constructive relationships (Alshughry, 2018 ; Rosenberg, 2015 ). Research indicates NVC increases self-compassion, reduces anger, and improves communication, relationships with others and the ability to express oneself (Branscomb, 2011 ; Burleson et al., 2011 ; Suarez et al., 2014 ). NVC has been used previously with refugee samples displaced in LMIC contexts, with participants reporting improved self-compassion, communication and empathy (Alshughry, 2018 ). Thus, we proposed that including a NVC-focused module prior to the memory work would (a) lead to the development of social skills improving adolescent social functioning, and (b) increase self-compassion, empathy and the expression of emotions and cognitions, which could enhance memory engagement in the subsequent modules (see Figure 2 ) and consequently, enhance symptom improvement. Figure 2. Open in a new tab Proposed mechanisms underpinning METRA+. NVC has previously been implemented with students and faculty at Kabul University (NCPR, 2016 ) and was culturally adapted for Afghan refugee adolescents in Pakistan through a structured translation and contextual refinement process. The principal investigator worked with trained facilitators and local practitioners to modify language, scenarios, metaphors, and examples to ensure age-appropriateness, cultural relevance, and alignment with Afghan collectivist values. The module was reviewed by ten Afghan refugee teachers and school administrators prior to implementation, and revisions were made to enhance linguistic clarity and cultural sensitivity, including attention to gender norms within mixed-gender refugee school settings. Although formal participatory focus groups were not feasible, facilitators were trained to monitor comprehension and document feedback during delivery. No significant difficulties were reported, and qualitative findings indicated meaningful engagement with the four core NVC elements – observation, feeling, need, and request – within an empathic communication framework (Rosenberg, 2015 ). 1.2. Current study The objective of this study was to evaluate the feasibility, acceptability, and preliminary efficacy of METRA+, as a culturally adapted, potentially scalable intervention designed to improve the psychological and social outcomes, among Afghan refugee adolescents resettled in Pakistan – a country currently hosting approximately 3.7 million Afghan refugees (UNESCO, 2023 ). Specifically, we examined whether METRA + would lead to changes in symptomatology and social functioning at post-intervention and two-month-follow-up. We hypothesized that at post-intervention and follow-up, participants would have lower levels of PTSD, depression and anxiety symptomatology, and improved social functioning (i.e. social skills and non-violent communication), when compared to baseline. We also conducted exploratory analyses examining whether there were symptom and social functioning changes between the specific modules to assist with future generation of hypotheses, particularly as we added Module 1 in developing METRA+. 2. Method 2.1. Trial design This study was approved by the Monash University Human Research Ethics Committee (MUHREC, Approval No. 45802) and registered with the Australian New Zealand Clinical Trials Registry (ANZTCR; ID ACTRN12624001453572). The trial was conducted in early 2025 and followed a clinical design with a two-month follow-up phase to evaluate the preliminary efficacy of METRA+. Participants were assessed in Dari across five time points: baseline, post-Module 1, post-Module 2, post-Module 3 (post-intervention), and at a two-month follow-up. The METRA + intervention consisted of three modules: (1) Compassionate Communication , informed by the NVC approach, delivered in three one-hour sessions to improve communication skills, empathy, and needs expression; (2) Memory Specificity Training (MEST) , delivered in five one-hour sessions, aimed at enhancing the recall of specific and detailed autobiographical memories to reduce overgeneralized memory patterns, and (3) Written Exposure Therapy (WET) , comprising five one-hour sessions focused on reducing trauma symptoms through gradual written exposure of the traumatic memories. A CONSORT flow diagram is presented in Figure 3 , and adherence to CONSORT reporting guidelines is detailed in Supplemental Table 1. Figure 3. Open in a new tab Flowchart of participant recruitment and assessment. 2.2. Participants Participants were 41 Afghan adolescent refugees (27 girls and 14 boys). All participants were students in Grades 5 through 12 at a private school in Pakistan, with a large Afghan refugee student cohort. Participants ranged in age from 10 to 18 years, with a mean age of 15.44 years ( SD = 2.12). Inclusion criteria were scoring above 30 on the CRIES-13, indicating significant symptoms of PTSD, and no history of drug use or psychotropic medication. To identify eligible participants, approximately 250 adolescents were initially screened using the CRIES-13. Of those, 77 scored above the cutoff and were invited to participate in the study. Due to a winter school closure, only 41 students were able to enrol in the study. 2.3. Procedure Following baseline assessment, participants commenced METRA+, which is composed of three Modules and is delivered over 13 group sessions, with 8–10 adolescents in each group. Follow-up evaluations were conducted two-months post-intervention to examine the stability of the intervention's effects. All of the below measures were administered in Dari. The CRIES-13, MFQ-SF and RCMAS were already available in Dari from use in our previous studies with Afghan youth (Ahmadi, Jobson et al., 2023 ; Ahmadi, Musavi et al., 2023 ; Ahmadi et al., 2024 ). The MESSY-2 has been previously adapted and used with Persian-speaking youth (e.g. Karami et al., 2013 ). No formal adaptation framework (e.g. ADAPT-ITT or Bernal’s ecological validity model) was systematically applied. Instead, a pragmatic, community-informed approach was used. The NVCBS were translated into Dari using gold-standard forward–backward translation procedures; the questionnaire was independently translated from English into Dari by two bilingual translators. The translations were then reviewed to produce a single version, which was then back-translated into English by independent bilingual translators who were blinded to the original questionnaire. The original and back-translated versions were compared to identify and resolve discrepancies and develop a finalised version (Brislin, 1970 ). Feasibility and acceptability were primarily examined through consideration of retention rates and qualitative feedback. 2.4. Measures 2.4.1. Children’s Revised Impact of Event Scale (CRIES-13) The Children’s Revised Impact of Event Scale (CRIES-13) is a 13-item PTSD self-report questionnaire assessing intrusion, avoidance, and arousal symptoms over the last seven days (Children and War Foundation, 2005 ). This measure was designed for children and adolescents over 8 years of age and has high validity. Previous work has used a cut-off point of 26 for the diagnosis of PTSD (Ahmadi et al., 2018 ; Neshat-Doost et al., 2013 ). Past work has shown a reliability coefficient among Afghan adolescents of 0.82–0.91 based on Cronbach’s alpha (Ahmadi et al., 2018 ; 2024 ). Internal consistency was good in the current study (Cronbach’s alpha = .75). 2.4.2. Mood and feelings questionnaire-short form (MFQ-SF) The MFQ-SF is a 13-item questionnaire assessing symptoms of depression (Angold et al., 1995 ). Items were rated on 3-point scales with respect to the past two weeks. Items were summed to provide a total depression symptom score, with higher scores indicating greater depression severity. It has good psychometric properties (Angold et al., 1995 ) and has been used with Afghan youth (Ahmadi et al., 2018 ; Ahmadi, Jobson et al., 2023 ; Ahmadi, Musavi et al., 2023 ). Internal consistency was good in the current study (Cronbach’s alpha = .91). 2.4.3. Revised children’s manifest anxiety scale (RCMAS) The RCMAS is a widely used instrument for assessing manifest anxiety in children and adolescents aged 6–19 (Reynolds & Richmond, 1978 ). The RCMAS includes 37 dichotomous (yes/no) items that cover three subscales: physiological anxiety, worry/oversensitivity, and social concerns/defensiveness. Each ‘Yes’ answer scores 1, while ‘No’ scores 0. The scale has demonstrated strong psychometric properties, including high internal consistency (KR-20 ≈ 0.85) and robust construct and concurrent validity (Reynolds & Richmond, 2008 ) and has been previously used with Afghan youth (Ahmadi et al., 2018 ; Ahmadi, Jobson et al., 2023 ; Ahmadi, Musavi et al., 2023 ). In this study internal consistency was good (Cronbach’s alpha = .78). 2.4.4. Matson evaluation of social skills with youngsters second edition (MESSY-2) The MESSY was developed by Matson et al. ( 1983 ) to measure social skills in individuals aged 4–18 years. The second edition (MESSY-2), released in 2012, comprises 56 items rated on a 5-point Likert scale (1 = Never to 5 = Always ), organized into five subscales: Appropriate Social Skills, Inappropriate Assertiveness/Antisocial Behavior, Impulsiveness and Aggression, Superiority/Conceit, and Peer Relations. The scale has shown good internal consistency (Cronbach’s α = .89), test-retest reliability ( r = .91), and discriminant validity ( r = .54). Previous studies with the Persian adaptation have similar psychometric properties; Cronbach’s alpha = .86, split-half reliability = .70, and construct validity = .85 (Yousefi & Kheir, 2002 ). In this study internal consistency was good (Cronbach’s alpha = .83). 2.4.5. Nonviolent Communication Behaviors Scale (NVCBS) We used the Nonviolent Communication Behaviors Scale (NVCBS) to assess behaviours related to nonviolent communication (Cheung et al., 2022 ). This is a 7-item self-report questionnaire designed to evaluate key behavioural aspects of nonviolent communication, such as awareness of emotions and honest self-expression. The NVCBS uses 4-point Likert scales (1 = Never and 4 = Frequently ). Scores on items are summed to give a total score, with scores ranging from 7–28 and higher scores indicating a higher frequency of NVC use. The scale was psychometrically evaluated in a sample of young adults and demonstrated a unidimensional structure. The internal consistency of the scale was reported to be satisfactory and test-retest reliability was also found to be acceptable. Construct validity has been supported by positive correlations with empathy and negative correlations with negative beliefs about emotion (Cheung et al., 2022 ). In the current sample, internal consistency was modest (Cronbach’s alpha = .52), which may reflect the small sample size and the brief nature of the 7-item scale. This lower reliability should be considered when interpreting the findings. 2.5. Focus groups We used focus groups to obtain in-depth qualitative insights into participants’ experiences with METRA+. At post-intervention, all participants who completed METRA + were invited to participate in focus groups and all 35 adolescents participated. Focus groups included 6–10 adolescents in each group. The focus group facilitator had not been involved in the delivery of METRA + and aimed to provide a safe and supportive environment for the adolescents to share their reflections on the sessions, emotional changes, and social interactions that occurred throughout the programme. The discussions were recorded, transcribed, and analyzed thematically using MAXQDA 2024, following Braun and Clarke’s ( 2006 ; 2021 ) framework to identify key patterns and themes emerging from participants’ narratives (see Data Analysis Section below). 2.6. Interventions METRA + is a manualized group training (8–10 adolescents/group) comprising three modules (13 × 1-hour sessions) which was delivered every other day over a 5-week period. Module 1 was designed to strengthen self-compassion, empathy, and positive interaction skills among refugee adolescents with a history of trauma. The specific objectives of Module 1 included increasing awareness of the impact of trauma on the mind and body, teaching stress and emotional regulation skills, enhancing self-compassion and personal acceptance, improving empathy skills, and building resilience to cope with life challenges. The first session focused on introducing basic concepts, explaining PTSD symptoms, normalizing trauma-related experiences, outlining group rules, and teaching deep breathing exercises. In the second session, participants were introduced to the concept of self-compassion and engaged in writing compassionate letters to themselves as a way to better understand and accept their emotions and experiences. The third session focused on teaching empathy toward others through hypothetical scenarios and role-playing activities, enabling adolescents to recognize others’ needs and feelings and respond appropriately. Homework assignments included daily deep breathing practice, writing empathetic letters, and applying the learned skills in interactions with family members to reinforce learning in real-life contexts (Rosenberg, 2015 ). Module 2 was based on MEmory Specificity Training (MEST; Erten & Brown, 2018 ; Neshat-Doost et al., 2013 ). Session 1 provided psycho-education and participants practiced recalling specific memories in response to positive and neutral cues. Session 1 homework included generating a specific memory for 10 cues (positive and neutral). Session 2 included a summary of Session 1, homework review and further practice recalling memories in response to positive and neutral cues. Session 2 homework was the same as Session 1. Session 3 was similar to Session 2; however, participants now worked with negative cues. Session 4 involved exercises using negative and ‘counterpart’ positive cues and discussions and exercises to promote metacognitive awareness. Session 5 included further practice and a summary of Module 3. Module 3 was a modified form writing for recovery (Child Outcomes Research Consortium, 2021 ; Kalantari et al., 2012 ). Session 1 included a brief outline of the purpose of Module 3. In the five sessions, participants wrote about their trauma for a full 30 min. They were encouraged to write about the details of the trauma(s) as they remember it now (including specifics of what happened, thoughts and feelings, worst aspects of the event, how the event had touched their life). Between sessions, facilitators read the narratives to ensure the participants had understood the task and were engaging appropriately. 2.7. Facilitators and treatment fidelity METRA + was delivered by facilitators (community members with a health or education background) with minimal training; each facilitator received 10 h of training (five 2-hour sessions). Facilitators received supervision from a clinical psychologist. Facilitators were supervised by a clinical psychologist. After each session, facilitators’ adherence to the treatment protocol was assessed using a checklist. To reduce group contamination, participants were requested to not discuss the treatment with others. 2.8. Data analysis plan To evaluate the impact of METRA+, participants were assessed across five time points: baseline, post-Module 1, post-Module 2, post-Module 3 (post-intervention), and two-month follow-up. However, in line with our hypotheses, the focus of our analyses was on baseline, post-intervention and follow-up scores. Our outcome measures were PTSD symptoms, depressive symptoms, anxiety, social skills and non-violent communication. All data were analyzed using SPSS (v.27). Following the approach of recent large-scale studies (Fan et al., 2023 ; Kuang et al., 2023 ), to assess the METRA+’s efficacy across baseline, post-intervention, and follow-up, a series of repeated-measures analyses of variance (ANOVAs) were conducted for each outcome measure. Significant findings were followed up using pairwise comparisons comparing (a) post-intervention to baseline and (b) follow-up to baseline. Effect sizes for all ANOVA effects were reported using partial η², with values of .01, .06, and .14 being interpreted as small, medium, and large effects, respectively (Cohen, 1988 ). Mauchly's Test of Sphericity was used to determine whether the assumptions were met. For PTSD symptoms, χ²(9) = 39.70, p < .001, depression symptoms, χ²(9) = 23.71, p = .005, anxiety, χ²(9) = 29.19, p = .001, social support, χ²(9) = 45.02, p < .001, and non-violent communication, χ²(9) = 21.19, p = .012, there was a violation of sphericity. Accordingly, degrees of freedom were corrected using the Greenhouse-Geisser estimate of sphericity, PTSD ϵ = .65; depression ϵ = .70; anxiety ϵ = .70; social support ϵ = .62; and non-violent communication ϵ = .79. Exploratory pairwise comparisons were also conducted to examine change between the specific modules. All analyses were conducted on the 35 participants who completed all modules and follow-up (per-protocol). Missing data at specific time points were handled using listwise deletion in the repeated-measures ANOVAs. Only participants with complete data across all relevant time points for a given analysis were included. As a result, the sample size varied slightly across analyses depending on data completeness. We also compared whether participants who dropped out of the study differed significantly from completers in baseline symptom severity or sociodemographic characteristics and found there were no significant differences. 2.9. Analysis of qualitative data To analyze the qualitative data, we employed thematic analysis (Braun & Clarke, 2006 ; 2021 ), and used MAXQDA 2024 software. Two researchers familiarized themselves with the data and generated initial codes and searched for themes. The research team then reviewed, defined and named the themes. Throughout this process an audit trail was maintained to document decisions, code development, and theme refinement. As outlined in Table 2, the analysis process followed three hierarchical levels of coding: (1) initial codes (147 codes), (2) axial codes (11 categories), and (3) overarching themes (six themes). The analytical process included the following steps. First, regarding familiarization with the data, focus group transcripts were read by the research team multiple times to allow for immersion in the content and to develop a holistic understanding of participants’ narratives. Second, two researchers commenced initial coding, whereby meaningful phrases and expressions were labelled as initial codes (e.g. ‘sense of self-worth,’ ‘anger control’). Third, the two researchers focused on axial coding, whereby related codes were grouped into broader conceptual categories (e.g. ‘hope and self-efficacy,’ ‘emotion regulation’). Finally, regarding theme development, the axial codes were synthesized into overarching themes representing core participant experiences and reported changes following the intervention (e.g. ‘enhancement of psychological capital,’ ‘emotion regulation’). The iterative coding process was conducted rigorously and reviewed by the research team to ensure trustworthiness of findings. 3. Results 3.1. Participant characteristics The total sample included 41 (27 girls and 14 boys) adolescents. The adolescents ranged in age from 10–18 years, with the mean age being 15.44 years ( SD = 2.12). Participants had lived in Pakistan for an average of 9.00 years ( SD = 5.97; range 1–18 years) and reported living with an average of 5.76 family members ( SD = 1.71, range 2–11 family members). Six participants discontinued the intervention after the third session due to changes in migration status or graduation. Therefore, 35 participants (23 girls and 12 boys) completed the full intervention. There were no important harms or unintended effects reported by participants. 3.2. PTSD symptoms As shown in Table 1 (Supplementary Figure 1), there was a statistically significant main effect of time for PTSD symptoms, F (2.61, 88.68) = 17.65, p < .001, partial η ² = .34, with a large effect size observed. Follow-up pairwise comparisons showed that, when compared to baseline, there was a significant reduction in PTSD symptoms at post-intervention, M diff = 13.06, SE = 2.22, p < .001, 95% CI [8.55, 17.57], and follow-up, M diff = 13.51, SE = 2.53, p < .001, 95% CI [8.37, 18.66]. Our exploratory analyses examining change between modules showed significant reductions in PTSD symptoms between the modules; post-Module 1 vs post-Module 2, M diff = 5.23, SE = 1.22, p < .001, 95% CI [2.75, 7.70]; post-Module 2 vs post-Module 3, M diff = 4.26, SE = 1.65, p = .015, 95% CI [0.90, 7.62], with no significant difference in PTSD scores between post-Module 3 and follow-up, M diff = 0.46, SE = 1.41, p = .748, 95% CI [−2.41, 3.33]. Table 1. Means (and standard deviations) for the outcome measures at baseline, post-Module 1, post-Module 2, post-Module 3 (post-intervention) and follow-up. Baseline Post-Module 1 Post-Module 2 Post-Module 3 Follow-up PTSD Symptoms 38.29 (5.96) 34.71 (9.62) 29.49 (11.28) 25.23 (10.87) 24.77 (12.39) Depression Symptoms 13.17 (7.19) 13.66 (6.60) 11.69 (6.01) 10.29 (5.85) 10.29 (7.54) Anxiety Symptoms 21.51 (5.73) 22.23 (6.34) 20.54 (6.88) 18.83 (7.97) 18.46 (7.46) Social Support 205.74 (25.39) 210.80 (27.69) 211.57 (24.88) 211.63 (29.71) 212.97 (29.24) Non-Violent Communication 18.23 (3.62) 18.66 (3.30) 18.40 (3.62) 19.09 (3.17) 18.11 (4.21) Open in a new tab Note : PTSD = posttraumatic stress disorder. 3.3. Depressive symptoms As shown in Table 1 (Supplementary Figure 2), there was a significant effect of time on depressive symptoms, F (2.80, 95.20) = 6.37, p = .001, partial η ² = .16, with a large effect size observed. Follow-up pairwise comparisons showed that, when compared to baseline, there was a significant reduction in depression symptoms at post-intervention, M diff = 2.89, SE = 1.04, p = .009, 95% CI [0.78, 4.99], and follow-up, M diff = 2.89, SE = 1.23, p = .025, 95% CI [0.39, 5.38]. Our exploratory analyses examining change between modules showed significant reductions in depression symptoms between modules; post-Module 1 vs post-Module 2, M diff = 1.97, SE = 0.70, p = .008, 95% CI [0.56, 3.38]; post-Module 2 vs post-Module 3, M diff = 3.37, SE = 0.75, p < .001, 95% CI [1.66, 5.08], with no significant difference in depression scores between post-Module 3 and follow-up, M diff < 0.01, SE = 1.70, p = 1.00, 95% CI [−1.42, 1.42]. 3.4. Anxiety symptoms There was a significant effect of time on anxiety symptoms, F (2.81, 95.69) = 4.91, p = .004, partial η ² = .13, with a moderate effect size observed ( Table 1 , Supplementary Figure 3). Follow-up pairwise comparisons showed that, compared to baseline, the reduction in anxiety symptoms at post-intervention approached significance ( M diff = 2 .69, SE = 1.37, p = .058, 95% CI [−0.09, 5.46]), whereas a significant reduction was observed at follow-up ( M diff = 3 .06, SE = 1.38, p = .033, 95% CI [0.26, 5.85]). Our exploratory analyses showed significant reductions in anxiety symptoms between modules; post-Module 1 vs post-Module 2, M diff = 1 .69, SE = 0.69, p = .016, 95% CI [0.32, 3.06,]; post-Module 2 vs post-Module 3, M diff = 1 .71, SE = 0.84, p = .045, 95% CI [0.03, 3.39], with no significant difference in anxiety scores between post-Module 3 and follow-up, M diff = 0 .37, SE = 0.91, p = .684, 95% CI [–1.43, 2.17]. 3.5. Social skills The main effect of time on social skills was not significant, F (2.46, 83.68) = 2.50, p = .076, partial η ² = .07, with a moderate effect size observed ( Table 1 , Supplementary Figure 4). Given that the finding was just above the significance threshold, alongside the exploratory nature of the study, we conducted follow-up analyses. We found there was a significant improvement in social skills at post-intervention, M diff = −5.89, SE = 2.83, p = .040, 95% CI [−11.56, −0.23], and follow-up, M diff = −7.23, SE = 3.06, p = .023, 95% CI [−13.41, −1.06]. However, there were no significant improvements in social skills between modules; post-Module 1 vs post-Module 2, M diff = −0.77, SE = 2.41, p = .754, 95% CI [−5.70, 4.17]; post-Module 2 vs post-Module 3, M diff = −0.06, SE = 2.69, p = .981, 95% CI [−5.51, 5.39], post-Module 3 vs follow-up, M diff = −1.34, SE = 2.65, p = .621, 95% CI [−6.74, 4.07]. 3.6. Non-violent communication The repeated measures ANOVA revealed no statistically significant effect of time on non-violent communication skills, F (3.14, 106.71) = 0.56, p = .652, partial η ² = .02, with a small effect size observed. 3.7. Qualitative findings As outlined in Table 2 , there were six overarching themes; (1) enhancement of psychological capital, 2) academic motivation and learning, (3) emotion regulation, (4) compassionate connection, (5) normalization of traumatic memories, and (5) programme challenges. Table 2. Coding structure of thematic analysis. Overarching Theme Axial Code Sample Initial Codes Frequency Enhancement of psychological capital Assertiveness, hope, and self-efficacy Improved attention in class, reduced anxiety when speaking, increased social interactions, increased self-worth, acceptance of the past, enhanced self-belief 12 Academic motivation and learning Memory and concentration Memory, concentration, improved recall, attention to detail 9 Emotion regulation Anger and emotional control Anger management, emotional expression, stress regulation, coping with fears 30 Compassionate connection Empathy with self and others Empathy, deeper understanding, refraining from self/other-blame, improved communication 20 Normalization of traumatic memories Writing without harm Writing as therapy, normalization of trauma recall, learning from past experiences 18 Programme challenges Difficulty with trauma disclosure Feelings of guilt, emotional distress, difficulty recalling negative experiences 10 Open in a new tab Note. Frequencies indicate the number of references coded under each theme and are not intended to reflect statistical significance. 3.7.1. Theme 1. Enhancement of psychological capital: assertiveness, hope and self-efficacy Youth noted that METRA + had improved assertiveness, hope and self-efficacy. Specifically, youth noted that METRA + had assisted them in reducing social anxiety and increasing the number of positive social interactions. They noted that METRA + had increased self-worth and self-belief; ‘Before joining this programme, I had very little self-confidence.’ (female participant, 15 years old) and ‘I used to think I couldn't do anything. But after these sessions, I realized I can believe in myself and that I have value’ (female participant, 15 years old). Participants also noted that following METRA + they had greater acceptance of the past and future; ‘I used to worry a lot about the future … ’ (female participant, 15 years old). 3.7.2. Theme 2. Academic motivation and learning: memory and concentration Participants commented that following METRA + they had noticed improvements in memory, concentration, and attention to detail. As one youth noted: Before joining this program, I had an exam, but I couldn’t remember anything. Then the METRA + teacher told us to take deep breaths and focus – Now I can learn my lessons much more effectively. (female participant, 16 years old) Another youth noted: Before I joined this program, I had trouble focusing on school lessons (I wasn’t really interested). But afterward, I paid more attention in class and forgot things less often (female participant, 15 years old). 3.7.3. Theme 3. Emotion regulation: anger and emotional control Following METRA+, participants noted they could better manage anger and emotions. They also noticed that they could better cope with stress and fear: ‘Before METRA+, when the teacher got angry, my hands would shake. But now I close my eyes and take a deep breath – I feel calm’ (male participant, 18 years old) and ‘In the past, when I got upset, I reacted quickly – either I cried or yelled. Now I’ve learned how to calm myself and manage my emotions better’ (female participant, 17 years old). 3.7.4. Theme 4. Compassionate connection: empathy for self and others Following METRA + participants noticed that they had greater empathy for themselves and others, and had a deeper understanding of what they and others were feeling: ‘These sessions helped me understand what my inner voice was saying. I was able to better connect with myself’ (female participant, 18 years old). Participants noted they could better refrain from self-blame and other-blame and had improved communication with family and friends: ‘After this programme, I understood that I should be kind to my brothers and sisters and try to understand their problems – not just get angry with them’ (female participant, 18 years old). 3.7.5. Theme 5. Normalization of traumatic memories: writing without harm Participants noted that following METRA+, they now perceived the therapeutic value of writing and that this process had assisted them in normalizing the recall of their trauma memories: ‘After writing about that memory every day, it eventually became normal for me’ (female participant, 15 years old). They also noted that METRA + helped them learn from their past experiences: When I first started writing my memories, all the pain and stress came back. But after a few days, it felt normal. Those bad memories don’t upset me anymore (female participant, 17 years old) 3.7.6. Theme 6: program challenges: difficulty with trauma disclosure Participants also highlighted some challenges they had with METRA+. These included difficulties disclosing their traumas, feelings of guilt and emotional distress, and difficulty recalling negative experiences: ‘When I tried to write about my painful memories, I just couldn’t do it. There were some memories I didn’t want to recall at all’ (female participant, 17 years old). However, some participants noted that it did get easier with increased practice of the trauma memory exposure work: ‘At first, I didn’t want to write my memories at all. I thought everything would come back again. But when I kept going, I felt lighter’ (male participant, 18 years old). 4. Discussion The present study evaluated the preliminary efficacy, acceptability and feasibility of METRA + among Afghan refugee adolescents residing in Pakistan. The findings demonstrated that at post-intervention METRA + had led to significant reductions in symptoms of PTSD, depression, and anxiety and these effects were sustained for up to two months following the intervention. The significance of these findings becomes even more apparent when considering the living conditions of these adolescents, which include poverty, insecurity, discrimination, and limited access to psychosocial support. This study represents the first formal evaluation of the updated METRA + and serves as an essential initial step in assessing a novel, culturally sensitive intervention that includes a focus on cognitive and social challenges experienced by refugee youth. Despite improvements in symptoms, statistical analyses did not reveal significant improvements in social skills. The low internal consistency of the NVCBS ( α = .52) suggests that findings related to this measure should be interpreted with caution and may not be reliable, limiting their interpretability. Therefore, conclusions regarding non-violent communication outcomes should be considered tentative. In addition, the NVCBS was not originally developed for Afghan refugee youth and may have limited sensitivity to detect subtle or culturally specific changes. Furthermore, social skill acquisition may precede measurable behavioural change, and thus improvements may not have been captured within the study timeframe. The NVCBS, as a brief self-report measure, may also not adequately capture interpersonal behaviours in real-world contexts. Additionally, regarding social skills (as assessed using the MESSY), the main effect of time was not significant. However, exploratory analyses suggested potential improvements at post-intervention and follow-up, although no significant changes were observed between modules, suggesting a need for further research exploring the effects of METRA + on social skills. Notably, qualitative data indicated perceived improvements in social skills, including empathy, active listening, and emotional regulation, particularly in managing anger and stress. Therefore, further research using more reliable and ecologically sensitive measures (e.g. observer reports or behavioural assessments) is needed to better evaluate social skill outcomes and the potential contribution of Module 1 in METRA+. The qualitative thematic analysis identified six core areas of change that reflect the broader impact of the intervention: (1) enhancement of psychological capital, (2) academic motivation and cognitive performance, (3) emotion regulation, (4) compassionate connection, (5) normalization of traumatic memories, and (6) programme-related challenges. In the domain of psychological capital, participants reported increases in assertiveness, hope, and self-efficacy. They stated that after METRA+, they felt more valued and capable of facing the future and engaging in social interactions. Academic motivation and cognitive functioning also emerged as important positive outcomes. Participants noted improvements in their ability to concentrate, recall information, and maintain interest in schoolwork. Adolescents also reported notable progress in managing anger, stress, and intense emotional reactions. They learned to control their responses using simple techniques, such as, closing their eyes, deep breathing, and positive self-talk. These skills are crucial for emotional resilience and aggression prevention (Gross, 2015 ). In the domain of compassionate communication, many participants described increased empathy toward themselves and others, better understanding of emotional states, and improved family relationships; changes essential for reducing interpersonal conflict and fostering social cohesion (Neff & Germer, 2013 ). Participants also reported the normalization of traumatic memories through daily writing exercises. Participants shared that although the process was initially distressing, it eventually led to a reduction in the emotional intensity of painful memories. This finding aligns with theoretical principles of gradual exposure in trauma-based therapies (Foa et al., 2007 ). Despite these positive outcomes, some challenges in implementing the programme were reported. Several adolescents found it emotionally difficult to write about or share their traumatic experiences. However, most noted that with continued practice, confronting these memories became easier, and they experienced a sense of relief and emotional lightness. These findings highlight the importance of providing a safe psychological environment and employing empathetic, trained facilitators. They also align with broader evidence emphasizing that integrating mental health and psychosocial support (MHPSS) into humanitarian programming across education, protection, and health sectors is critical for sustainable impact (CBM Global, 2023 ; mhpssmsp.net, 2023 ; Velu et al., 2025 ). Overall, METRA + may be considered a low-intensity, practical, and culturally adapted intervention that demonstrated preliminary efficacy among a highly vulnerable population. Its delivery by trained local facilitators, without the need for expensive clinical professionals, makes it a sustainable and scalable model for low-resource settings – especially in crisis-affected or post-conflict regions. Beyond reducing psychological symptoms, qualitative data suggested that METRA + may contribute to the development of emotional, cognitive, and interpersonal capacities in adolescents. Given that adolescence is a critical developmental period for the formation of identity, emotional patterns, and social relationships, interventions like METRA + may offer long-term and preventive benefits (Pfeifer & Berkman, 2018 ). Thus, the study indicated that METRA may benefit from the inclusion of sessions targeting social and interpersonal skills. However, the findings suggest that METRA + could be improved by iteratively refining the social skills and NVC module (i.e. Module 1). Specifically, this may include more sessions focused on social skill development, including a direct targeting of specific cognitive–behavioural NVC mechanisms. METRA + may also benefit from greater in-vivo practice and group discussions of how youth are applying the social and communication skills learnt in sessions to everyday life. This may also include a greater focus on homework to ensure the skills can be further developed and applied in a structured way. Additionally, Modules 2 and 3 of METRA + could include further review and discussion of the skills developed in Module 1. The inclusion of booster sessions either within Modules 2 and 3 or post-intervention may also lead to greater changes in NVC and social skill development. Finally, further research should examine the benefits of METRA + extending the number of sessions in Module 1 and implementing some of the skills learnt in Module 1 throughout the other two modules. These findings should be interpreted in light of the absence of structured feasibility and acceptability metrics. In the current study, feasibility and acceptability were primarily assessed through retention rates and qualitative feedback rather than standardized quantitative measures. While the retention rate (85%) and positive qualitative reports suggest that the intervention was feasible and well-received, the lack of formal measurement limits the strength of these conclusions. Future research should incorporate structured indicators of feasibility and acceptability, such as session attendance rates, and participant satisfaction scales to provide a more comprehensive evaluation. In addition , this study has several limitations. These include a small sample size, reliance on self-report instruments, absence of a control group, and a short follow-up duration. Second, while the study used a pragmatic, community-informed approach to adapting the intervention, the absence of a formal adaptation framework may limit the reproducibility of the intervention across contexts. Third, as noted above, feasibility and acceptability were primarily assessed through retention rates and qualitative feedback rather than standardized quantitative measures. Fourth, the NVCBS was not originally developed or validated for adolescent refugee populations and demonstrated low internal consistency ( α = .52) in this study, raising concerns about both its reliability and construct validity, which may have influenced the findings. Furthermore, social skill acquisition may precede measurable behavioural change. Therefore, to better assess the generalizability and long-term stability of the findings, future research should employ randomized controlled trial designs, larger samples, extended follow-up periods, culturally and ecologically validated measures, and mixed-method approach.‏ 5. Conclusion The findings of this study provide preliminary evidence that METRA + has efficacy in reducing symptoms of PTSD, depression, and anxiety among Afghan refugee adolescents in Pakistan. While there was limited evidence for METRA + significantly improving social skills, qualitative data indicated METRA + may enhance emotional regulation, self-efficacy, academic motivation, and interpersonal empathy. The programme’s culturally sensitive, low-intensity, and scalable design – delivered by trained local facilitators – makes it a promising model for use in low-resource and conflict-affected settings. Despite some implementation challenges and study limitations, the positive qualitative and quantitative outcomes suggest that METRA + not only supports symptom reduction but may also contribute to the broader psychological resilience and social development of Afghan refugee youth in Pakistan. Further research with larger samples, control groups, and long-term follow-up is needed to confirm and expand upon these findings. Supplementary Material Supplemental Material ZEPT_A_2650894_SM2697.jpg (34.9KB, jpg) Supplemental Material ZEPT_A_2650894_SM2696.jpg (36.4KB, jpg) Supplemental Material ZEPT_A_2650894_SM2695.jpg (146.7KB, jpg) Supplemental Material ZEPT_A_2650894_SM2685.jpg (46KB, jpg) Acknowledgements The authors sincerely thank the participating Afghan adolescents, school staff, and facilitators who contributed to the implementation of the METRA + pilot intervention. All authors conceived and designed the study and were involved in its implementation. S.J.A. led the conceptualization, methodology, data collection, formal analysis, literature review, original draft writing, supervision, and project administration. L.J. contributed to conceptualization, supervision, methodology, funding acquisition, literature review, manuscript review and editing, and project administration. Z.M. contributed to data management, training support, and translation. M.W.F. was responsible for project implementation, field coordination, data collection, and translation, while S.M. assisted with data collection and translation. D. McA., A. B., and A.B. (Adam Brown & Azi Berzengi) contributed to results interpretation and manuscript editing. J.D.-B. provided statistical consultation, results interpretation, and manuscript editing. Funding Statement This work was supported by a grant from the Mental Research Institute (MRI), with no grant number provided. The funding agency had no involvement in the design of the study, data collection, analysis, interpretation of data, or the decision to submit the article for publication. Disclosure statement No potential conflict of interest was reported by the author(s). Ethical standards statement This study received approval from the Monash University Human Research Ethics Committee (MUHREC), Approval No. #45802. Clinical trial registration The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), ID: ACTRN12624001453572.‏ Data availability statement All anonymized data are publicly available in the Harvard Dataverse repository: Ahmadi, Sayed Jafar (2025). ‘Replication Data for: METRA + Intervention on Mental Health and Social Functioning among Afghan Refugee Adolescents in Pakistan.’ Supplemental Material Supplemental data for this article can be accessed online at https://doi.org/10.1080/20008066.2026.2650894 . References ACAPS (2021). 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Supplementary Materials Supplemental Material ZEPT_A_2650894_SM2697.jpg (34.9KB, jpg) Supplemental Material ZEPT_A_2650894_SM2696.jpg (36.4KB, jpg) Supplemental Material ZEPT_A_2650894_SM2695.jpg (146.7KB, jpg) Supplemental Material ZEPT_A_2650894_SM2685.jpg (46KB, jpg) Data Availability Statement All anonymized data are publicly available in the Harvard Dataverse repository: Ahmadi, Sayed Jafar (2025). ‘Replication Data for: METRA + Intervention on Mental Health and Social Functioning among Afghan Refugee Adolescents in Pakistan.’ Articles from European Journal of Psychotraumatology are provided here courtesy of Taylor & Francis ACTIONS View on publisher site PDF (1.3 MB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top