What Drives Change in Children and Adolscents Receiving Telephone-Delivered Mental Health Intervention?

Background

High risk of developing mental health difficulties, yet the availability of mental health services is severely limited.

In Lebanon, over 1.5 million Syrian refugees live in precarious conditions, often having faced a multitude of stressors (e.g., war exposure, human rights violations) linked to displacement. The combined impact of war-related trauma, daily hardship and maltreatment is known to heighten the risk of developing mental health difficulties. With a 90% treatment gap before the refugee crisis, the availability of mental health services remains limited due to cost and being geographically inaccessible to many communities. In response to this growing need, researchers and humanitarian workers explore the low-cost, community-based approach, t-CETA, to bring psychological care to those who need it most.

 

What were the aims of this study?

An exploration of the telephone-delivered Common Elements Treatment Approach (t-CETA).

The study aimed to explore what drives psychological change in Syrian refugee children and adolescents receiving t-CETA, a modular and flexible form of cognitive-behavioural therapy. Specifically, it examined whether overall symptom improvement was linked to specific treatment components, which elements of t-CETA were associated with particular symptom changes, and what factors facilitated or hindered treatment success.

 

How was this study carried out?

Refugee children and adolescents took part in a session-by-session study of t-CETA.

The researchers analysed detailed data from nine Syrian refugee children (aged 8 to 14 year) and their caregivers who completed a full course of t-CETA. They all lived in tented settlements in Lebanon’s Beqaa Valley and were experiencing mental health difficulties such as post-traumatic stress, anxiety and depression.

t-CETA is a transdiagnostic therapy addressing multiple mental health difficulties through a set of core, evidence-based components. It is designed to treat symptoms of a range of common mental health problems, including post-traumatic stress disorder, anxiety, depression, and conduct problems. Delivered by trained lay counsellors, it combines elements such as cognitive restructuring (“Thinking in a Different Way”), behavioural activation (“Getting Active”), and prolonged imaginal exposure (“Talking about Difficult Memories”), and parenting skills training.

Each child’s symptoms were tracked using questionnaires completed at the start of every session. Counsellors also made detailed notes about each session that were reviewed during clinical supervision and included observations about engagement, challenges, life events, and family participation. Using a “multiple n=1” design, treating each child as their own mini case study, the researchers examined how symptoms changed week by week and how those changes linked to specific therapy modules as well as factors related and unrelated to treatment.

 

What were the key findings?

Symptom improvement occurred particularly after trauma- and depression- focused t-CETA modules however external factors matter too.

All nine children displayed measurable improvement in their mental health following t-CETA.

For example, one 11-year-old girl, who had suffered from symptoms of PTSD after witnessing people being killed in Syria, showed marked improvement by the end of treatment. She explained to the counsellor how she got many benefits from the session, including fewer nightmares and more confidence.

More children reported large reductions in symptoms of trauma, anxiety, depression, and behavioural problems by the end of treatment. The strongest improvements appeared after two modules in particular: Talking about Difficult Memories, which helps children revisit and process traumatic experiences, and Getting Active, which encourages engagement in positive, meaningful activities to lift mood.

However, improvement was not linear. Several children experienced temporary increases in distress during the “Thinking in a Different Way” sessions, likely due to confronting difficult thoughts before developing coping strategies. Yet, these spikes were short-lived, followed by sustained decreases in symptoms. Importantly, some children began to improve even before active treatment began, suggesting that the initial sense of connection and safety with a counsellor may itself be therapeutic.

External circumstances also shaped recovery. Children who started school, moved to safer housing, or experienced stronger family relationships tended to improve faster. Conversely, those facing ongoing stress (e.g., economic hardship or family conflict) made slower progress. Caregiver involvement emerged as a particularly strong factor: children whose parents or guardians participated actively in therapy and home practice sessions had the most consistent improvement across all symptom clusters.

 

What are the implications of this research?

Structured, telephone-based therapy can be both effective and feasible in humanitarian settings but must be integrated with systemic support.

While well-adapted psychological intervention, t-CETA, facilitated children to manage trauma and depression, lasting recovery depended on stable housing, education and safe family environments. The role of caregivers was central. Parental engagement appeared to improve therapeutic outcomes, especially when parents learnt to reinforce skills at home.

In humanitarian crises, where formal mental health infrastructure is scarce, the implications of this are far-reaching: community-based, telephone-delivered therapy, supported by trained lay counsellors and engaged families, can make a measurable difference to children’s well-being and resilience.

Effects are strongest when treatment is delivered alongside services supporting families’ broader needs.

 

About the study team

Our multidisciplinary research team comprises experts in psychology, including Tania Bosqui (American University of Beirut); Fiona S. McEwen (Queen Mary University of London, King’s College London); Nicolas Chehade and Patricia Moghames (Medecins du Monde); Stephanie Skavenksi and Laura Murray (John Hopkins Bloomberg School of Public Health); Elie Karam (IDRAAC, Lebanon); Roland Weierstall-Pust (Medical School of Hamburg) and Michael Pluess (Queen Mary University and University of Surrey).