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

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 η² = .34, depression, p = .001, partial η² = .16, and anxiety, p = .004, partial η² = .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..