Styrkende Narrativ: Hjelp Til Selvhjelp for Ukrainske Flyktninger / Empowering Narratives: Help to Self-help to Ukrainian Refugees
Phase: NA
Conditions: PTSD - Post Traumatic Stress Disorder, Depression Disorders, Dissociation, Refugee
Sponsor: Kristiania University College

Project Plan Cover Page 
Official Study Title: 
Empowering Narratives: Aid to Self-help for Ukrainian Refugees 
A Randomized Controlled Trial of Narrative Exposure Therapy (NET) Delivered by 
Supervised Ukrainian Health Professionals in Norway 
 
ClinicalTrials.gov Identifier (NCT Number): 
NCT07062042NCT00000000 (Replace with actual number once registered) 
 
Document Type: 
Project Plan – focused on methodological procedures 
 
Responsible Institution: 
Kristiania University College 
School of Health Sciences and School of Art, Design, and Media 
 
Principal Investigator: 
Vanessa Nolasco Ferreira, PhD 
Associate Professor, Clinical Psychologist 
Kristiania University College 
vanessanolasco.ferreira@kristiania.no  
 
Date of Document: 
14th October 2024 12th August 2025 
 
Formatted: Superscript

Project Plan - methodological procedures 
 
Oversight:  
Human Subjects Review: REK ref nr. 790305  
Board Name: REK sør-øst 
Board Affiliation: REK sør-øst A 
Phone:+47 22857547 
Email: rek-sorost@medisin.uio.no 
Address: Gullhaugveien 1-3, 0484 Oslo 
 
Study Description:  
Brief Summary:  
Background: The Russian invasion of Ukraine has resulted in forced displacement, with 
over 80,000 Ukrainian refugees now residing in Norway(1). This displacement, and, in 
many cases, preceding war experiences, has led to increased vulnerability to trauma 
and mental health challenges. Narrative Exposure Therapy (NET), a short-term trauma-
focused intervention, has demonstrated efficacy in reducing PTSD symptoms among 
individuals exposed to organized violence and war. (2) 
Aim: The protocol aims to assess the clinical effects of Narrative Exposure Therapy 
(NET) on PTSD and depression symptoms among Ukrainian refugees in Norway and to 
facilitate training and supervised praxis for Ukrainian health professionals in using NET.  
Methods: This study employs a pretest-posttest randomized controlled experimental 
design. Ukrainian health professionals in Norway will receive standardized NET training 
through a digital course. Subsequently, they will treat Ukrainian refugees using NET 
under supervision. Participants will be screened and assessed at three time points: 
baseline, immediately after treatment, and at 6-month follow-up. Validated instruments 
in Ukrainian and Russian will be used to assess trauma experiences, symptoms, 
comorbidities : PHQ-9(3), ITQ(4), LEC-5(5, 6), SHUT-D(7), and demographic 
questionnaire. Exclusion criteria include active psychotic spectrum disorders, 
neurodevelopmental disorders and concurrent trauma therapy.  
Ethics and Dissemination: Ethical approval was sought from REK under the reference 
number 790305 and SIKT, under the reference number 116071. All data will be 
anonymized and stored using Services for sensitive data (TSD). Results will be 

disseminated through peer-reviewed publications, public presentations, and digital 
media. Emergency procedures for participants presenting severe mental health 
symptoms are in place, including psychoeducational consultations and referral to 
public health services.  
 
Detailed Description:  
Background:  
The Russian Federation's annexation of Crimea in 2014 marked the beginning of the 
Russo-Ukrainian conflict. The full-scale invasion launched on February 24, 2022, 
precipitated a humanitarian crisis, resulting in the largest refugee movement in Europe 
since World War II. By April 2025, over 6.9 million Ukrainian refugees were recorded 
globally, with approximately 6.3 million residing in Europe. Norway, with a population of 
5.5 million, has been impacted by this influx. As of early 2025, approximately 80 
thousand Ukrainian refugees had sought protection in Norway, making Ukrainians the 
second-largest immigrant group in the country (1) 
Epidemiological studies have begun to assess the health status of Ukrainian refugees in 
Norway analyzing trends in self-reported health among Ukrainian refugees, revealing 
variations based on the month of arrival in 2022. One study indicated that refugees who 
arrived later in 2022 generally reported poorer long-term health but less psychological 
distress than those who arrived earlier in the year(8). In what concerns mental health, an 
assessment of the self-reported health status and healthcare needs of Ukrainian 
refugees who arrived in Norway in 2022 showed that the mean score on the Hopkins 
Symptom Checklist (HSCL-5) was 2.24 among Ukrainian refugees, indicating higher 
psychological distress compared to the Norwegian average of 1.60(9).  
Although some research has been conducted no studies, to our knowledge, have 
examined effects of structured mental health interventions for Ukrainian refugees in 
Norway. This study will evaluate the use of Narrative Exposure Therapy (NET) to address 
trauma-related symptoms among Ukrainian Adults that have sought collective 
protection in Norway after February 2022.  
Narrative Exposure Therapy (NET) is a short-term, trauma-focused intervention 
developed for individuals exposed to multiple traumatic events, including refugees and 
survivors of war and organized violence. It is grounded in principles of cognitive-
behavioral therapy and testimonial therapy. NET helps adults reconstruct a coherent 
narrative of their life by integrating fragmented traumatic memories through structured 
exposure within a chronological autobiographical framework. Core components include 
lifeline construction, imaginal exposure to traumatic events, and reprocessing of 
emotional responses. The method emphasizes stabilization through therapeutic 
structure and is supported by evidence from randomized controlled trials showing 

reductions in PTSD symptoms. The approach is protocol-driven and applicable in low-
resource settings under supervision, as outlined in the practice document.  
The study also involves training Ukrainian health workers and professionals in Norway to 
deliver NET, with the goal of assessing outcomes and examining how such an approach 
can be implemented within refugee communities. 
Objectives: 
• 
To evaluate the effect of NET on PTSD, depression and dissociation symptoms 
among Ukrainian refugees in Norway.  
• 
To train Ukrainian health professionals in Norway to deliver NET and facilitate 
their professional integration.  
• 
To collect longitudinal data on trauma symptomatology and treatment 
outcomes.  
 
Structure – Training Health Workers  
The training program conducted from January 6th to 17th consisted of a total of 1,755 
minutes, which equals 29 hours and 15 minutes of structured education and practice. 
The curriculum covered a comprehensive range of topics relevant to trauma-informed 
care and Narrative Exposure Therapy (NET). Key areas addressed included foundational 
knowledge on violence, PTSD, and dissociation (with references to WHO and ICD-11), 
as well as the role of shame and guilt in trauma. Ethical and relational aspects were 
highlighted through sessions on therapeutic alliance and Norwegian ethical 
guidelines. Technical and clinical skills were developed through lectures and hands-on 
practice related to mental health screening, the lifeline method, and NET’s core 
techniques, including processing of traumatic and positive memories (“stones,” 
“sticks,” and “flowers”). Further content addressed FORNET and rapid NET, NETfacts, 
and psychohygiene. The training combined theory-based lectures with practical small 
group exercises to support participants in applying NET principles in real-world settings. 
In addition to the training, a total of 51 group supervision sessions of 90 minutes each, 
involving 6 health professionals and workers per supervision were offered to the 21 
health workers in the project. Each of them must prepare and present the case 
progression in at least 10 supervision sessions. Two health workers / professionals 
present per supervision session and the other 4 discuss the case with guidance of a 
supervisor that has a psychologist or a psychiatrist background.  
To ensure adherence to the NET Manual some fidelity measures were included. All the 
health workers receive a hands-on material in Ukrainian with the content and 
instructions for each step of the treatment (screening, lifeline session, exposure 
sessions, and final session with the re-reading of the participant’s whole narrative). A 
Formatted: Font: Not Bold

check list with the course and order of the sessions are also provided to ensure that the 
study design will be followed. As self-report measures the health workers, after every 
session, must, in maximum 24 hours, report through a specific form (Nettskjema) the 
content of the sessions and any difficulties, disturbances, request of the participant that 
are under treatment, and the use of any different approach that were not predict in the 
guidelines. The form is connected directly to a security system (TSD), complying with all 
the GDPR regulations and ethical requirements, forming a participant journal. The 
primary investigator and the supervisors access the journals and advise the health 
workers ensuring that the premises of NET and the design of the study are being 
followed, this is part of the assessor report measures, that also include rating the 
percentage that each health work adhered to the NET manual and followed the 
instructions provided. 
Study Design and Methodology  
Design:  
This is a pretest-posttest randomized controlled experimental study with two arms: 
immediate treatment group and wait-list control group. The intervention consists of 8–12 
NET sessions delivered individually, depending on the number of sessions each 
participant needs in order to create a coherent story of their life and depending on the 
number of traumatic experiences reported in the LEC5.  
Participants and Recruitment  
Participants include Ukrainian refugees aged 18+, residing in Norway, with trauma 
exposure related to war or forced displacement. Ukrainian health professionals will 
recruit patients via community outreach and referrals. Every health professional will be 
assigned to participants based on their place of residence in order to minimize travel 
time to therapy sessions. Within each pair of participants, the allocation to treatment 
group and wait-list control group will be random sorted in Excel.   
Inclusion and Exclusion Criteria  
Inclusion: Ukrainian adult refugees, exposure to war or flight trauma, and informed 
consent.  
Exclusion: Active psychotic symptoms, neurodevelopmental disorders, concurrent 
trauma therapy, or severe cognitive impairment. 
Instruments:  
Internation Trauma Questionnaire (ITQ). Based on the ICD-11 criteria for diagnosing 
PTSD and complex PTSD, the ITQ(4) assesses both, symptoms and functional 
impairment in the past month. Six items measure core elements of PTSD (re-
experiencing, avoidance and sense of threat), and an additional six items measure three 

aspects of disturbances in self-organization, a core element of CPTSD (affective 
dysregulation, negative self-concept and disturbances in relationships). Both symptom 
assessments are followed by three questions about whether the symptoms have 
affected different areas of life. All 18 items are answered on a 5-point Likert scale from 
“not at all” to “extremely”. In addition, subjects give a brief description of the traumatic 
event they experienced and indicate how long ago it occurred.  
Shutdown Dissociation Scale (Shut-D). The Shut-D(7) measures three types of 
dissociation that can occur in PTSD: intrusion, hyperarousal and dissociation. The 13 
items are evaluated based on experiences, on a 4-point Likert scale ranging from “not at 
all” to “5 or more times a week”.  
Patient Health Questionnaire (PHQ-9). The PHQ-9(3) is a brief questionnaire 
measuring nine symptoms of depression on a 4-point Likert scale from “not at all” to 
“almost every day”. An additional question about the symptoms’ effects on different 
areas of life is also rated on a 4-point Likert scale.  
Life Events Checklist (LEC-5). The LEC-5 (6)measures life-time exposure to 17 
categories of potentially traumatic events, including experiences with war, death, injury 
and assault. For each event category, different types of exposure are assessed: 
Happened to me, Witnessed it, Learned about it, Part of my job, Not sure, Doesn’t apply.  
Method:  
The study will collect qualitative data in the form of participants’ narratives that are 
created during the therapy sessions, and quantitative data in the form of questionnaires. 
For the treatment group, quantitative data will be collected at three timepoints: 1) a 
baseline screening measurement before treatment starts, 2) a post-treatment screening 
measurement after the last treatment session, and 3) a follow-up screening 
measurement six months after treatment completion. For the control group, data will be 
collected at baseline and post-treatment (i.e. after the waiting period that corresponds 
to the treatment group’s treatment period). At each timepoint, the following instruments 
will be used: Internation Trauma Questionnaire (ITQ) (4)an 18-item questionnaire 
measuring elements of PTSD and complex PTSD as well as functional impairment; the 
Shutdown Dissociation Scale (Shut-D) (7), measuring three types of dissociation in 
PTSD; and the Patient Health Questionnaire (PHQ-9) (10) measuring nine symptoms of 
depression as well as functional impairment. At baseline, participants will also fill in the 
Life Events Checklist (LEC-5) (6), measuring different types of exposure to 17 categories 
of potentially traumatic events. In addition, demographic data, including time in Norway, 
gender, age, marital status, highest level of education, long term illness, general view 
about the health, will be collected.  
To investigate the effects of NET, linear mixed-effects models with fixed effects for Group 
(treatment, control) and Time (baseline, post-treatment, follow-up) and their interaction 

(Group X Time) will be calculated for each of the three symptom measures; ITQ, Shut-D 
and PHQ-9. To investigate the effect of NET, a 2x2 ANOVA (between-subject factor 
group: treatment, control; within-subject factor timepoint: baseline, post-treatment) will 
be calculated for each of the three symptom measures, ITQ, Shut-D and PHQ-9. In order 
to investigate the long-term effects of NET and the development of symptoms over a 
longer time period, a Repeated Measures ANOVA will be calculated for the treatment 
group for baseline, post-treatment and follow-up assessments. Additional analyses will 
be calculated to investigate the effect of trauma exposure on baseline symptom severity, 
and the effect of baseline symptom severity on treatment effect/symptom reduction.  
Primary hypotheses: 
H1: Participants receiving NET will show a significantly greater reduction in PTSD 
symptoms (ITQ) from baseline to post-treatment than participants in the control group 
H2: Participants receiving NET will show a significantly greater reduction in dissociation 
symptoms (Shut-D) from baseline to post-treatment than participants in the control 
group.  
H3: Participants receiving NET will show a significantly greater reduction in depression 
symptoms (PHQ-9) from baseline to post-treatment than participants in the control 
group. 
H4: Participants receiving NET will have significantly lower PTSD symptoms (ITQ) at six-
months follow-up compared to baseline, with no significant differences between follow-
up and post-treatment.  
H5: Participants receiving NET will have significantly lower dissociation symptoms 
(Shut-D) at six-months follow-up compared to baseline, with no significant differences 
between follow-up and post-treatment.  
H6: Participants receiving NET will have significantly lower depression symptoms (PHQ-
9) at six-months follow-up compared to baseline, with no significant differences 
between follow-up and post-treatment.  
 
Secondary hypotheses:  
H7: Direct Experience with the Event (Happened to me - LEC-5) will be associated with 
greater baseline symptom severity (ITQ, Shut-D, PHQ-9).  
H8: Participants with greater baseline symptom severity will experience a greater 
reduction in symptoms from baseline to post-treatment, compared to participants with 
milder initial symptom severity.  

H9: Change in narrative coherence mediates the reduction in PTSD symptoms from 
baseline to post-treatment.  
Embedded Qualitative Study:  
A qualitative substudy will be conducted alongside the RCT to explore participants’ lived 
experiences of NET. This substudy will involve phronetic iterative thematic analysis(11) 
of anonymized therapy narratives collected during NET sessions. The analysis will 
alternate between inductive (emic) insights and theoretical (etic) interpretations to 
uncover how participants construct meaning from traumatic events, how narrative 
coherence evolves throughout therapy, and how identity reconstruction occurs post-
trauma.  
Research Questions  
• 
How do Ukrainian refugees make sense of war-related trauma through narrative?  
• 
What are the common thematic shifts in personal narratives before and after 
NET?  
• 
How is narrative coherence associated with psychological recovery?  
Analytical Procedure (Step-by-Step)  
1. Data Organization: Anonymized narratives are digitized and categorized by case 
and treatment stage (pre/post).  
2. Immersion: Researchers read and reread the data, noting key emotional, 
temporal, and identity-related elements.  
3. Primary-Cycle Coding: Open descriptive coding is conducted using NVivo, with 
in vivo labels capturing participant language and early conceptual codes.  
4. Codebook Development: A preliminary codebook is created, refined after inter-
coder dialogue, including definitions, inclusion/exclusion criteria, and examples.  
5. Secondary-Cycle Coding: First-level codes are clustered into second-level 
interpretive themes. Existing theoretical frameworks (e.g., NET theory, trauma 
recovery models) are used to deepen understanding.  
6. Thematic Mapping: Themes are hierarchically organized to show narrative 
transformation (e.g., victimhood → resilience).  
7. Memo Writing: Reflective analytic memos are produced iteratively to document 
insights and guide interpretation.  
8. Saturation and Triangulation: Data is revisited until thematic saturation is 
achieved. Therapist notes and supervision feedback are triangulated to validate 
interpretations.  

9. Negative Case Analysis: Deviant narratives are explored to refine and challenge 
emerging findings.  
10. Reporting: Themes are described with illustrative quotes, connecting them to the 
guiding research questions and literature.  
Outcome Measures:  
Primary Outcome Measures 
1. PTSD Symptom Severity (ITQ) 
o Instrument: International Trauma Questionnaire (ITQ) 
o Description: Assesses symptoms of PTSD and Complex PTSD, including 
re-experiencing, avoidance, threat perception, and functional impairment. 
o Time Points: Baseline, Post-treatment, 6-month Follow-up 
o Outcome Focus: Change in PTSD symptom scores over time (H1, H4) 
2. Dissociation Symptoms (Shut-D) 
o Instrument: Shutdown Dissociation Scale (Shut-D) 
o Description: Measures dissociative responses specific to trauma, 
including cognitive-emotional shutdown, sensory-motor dissociation, and 
behavioral shutdown. 
o Time Points: Baseline, Post-treatment, 6-month Follow-up 
o Outcome Focus: Change in dissociation symptom scores over time (H2, 
H5) 
3. Depression Symptoms (PHQ-9) 
o Instrument: Patient Health Questionnaire-9 (PHQ-9) 
o Description: Measures the frequency of depressive symptoms over the 
past two weeks, including somatic and cognitive-affective dimensions, 
plus functional impairment. 
o Time Points: Baseline, Post-treatment, 6-month Follow-up 
o Outcome Focus: Change in depressive symptoms (H3, H6) 
 
Secondary Outcome Measures 
4. Exposure to Traumatic Events (LEC-5) 
o Instrument: Life Events Checklist for DSM-5 (LEC-5) 

o Description: Captures direct and indirect exposure to 17 categories of 
potentially traumatic events, including whether the event “happened to 
me.” 
o Time Point: Baseline 
o Outcome Focus: Association between level of trauma exposure and 
symptom severity (H7) 
5. Narrative Coherence (Qualitative Coding) 
o Instrument: Qualitative content analysis or validated narrative coherence 
scale (to be specified in analytic plan) 
o Description: Evaluates improvement in the structure, clarity, and 
emotional processing of the autobiographical trauma narrative as 
constructed during NET. 
o Time Points: Session 2 (Lifeline) vs Session 7 (final exposure) 
o Outcome Focus: Mediation analysis of change in PTSD symptoms through 
increased narrative coherence (H9) 
 
Other Pre-Specified Measures 
7. Demographic Variables 
o Instrument: Custom questionnaire 
o Description: Age, gender, marital status, education, time in Norway, long-
term illness, and general health perception 
o Time Point: Baseline 
o Analytical Use: Covariates or moderators in outcome models 
8. Functional Impairment 
o Embedded in: ITQ and PHQ-9 
o Description: Assesses impact of PTSD and depression on daily functioning 
o Time Points: Baseline, Post-treatment, 6-month Follow-up 
o Outcome Focus: Supplementary analysis of clinical relevance 
 
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Traumatic Stress. 3 ed: Hogrefe Publishing; 2025. 
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Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression 
severity measure. J Gen Intern Med. 2001;16(9):606-13. 
4. 
Cloitre M, Shevlin M, Brewin C, Bisson J, Roberts N, Maercker A, et al. 
International trauma questionnaire. European Journal of Trauma & Dissociation. 2018. 
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Gray MJ, Litz BT, Hsu JL, Lombardo TW. Psychometric properties of the life events 
checklist. Assessment. 2004;11(4):330-41. 
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Weathers FW, Blake, D.D., Schnurr, P.P., Kaloupek, D.G., Marx, B.P., & Keane, T.M. 
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