Problem Management Plus

1. Introduction

Version followed: WHO Problem Management Plus (PM+): Individual psychological help for adults impaired by distress in communities exposed to adversity, generic field-trial version 1.1 (WHO/MSD/MER/16.2, 2016; v1.1 2018), Chapters 1–7. For the group format: WHO Group Problem Management Plus (Group PM+), generic field-trial version 1.0 (2020, Series on Low-Intensity Psychological Interventions No. 4, written by Katie Dawson), front matter to Chapter 5. For the later strategies (Get Going Keep Doing, Strengthening Social Support, Staying Well) the purpose and core content follow the developers' published description (Dawson et al. 2015, World Psychiatry); the manuals' step-by-step text for these chapters is not cited, so finer steps there are marked [synthesis].

PM+ is a WHO low-intensity, transdiagnostic psychological programme for adults whose daily functioning is impaired by distress (depression, anxiety, stress-related symptoms) in communities exposed to adversity such as conflict, violence, poverty or disaster. It was designed for task-sharing: trained and supervised non-specialist "helpers" (or facilitators in the group version) deliver it, though mental health professionals new to CBT also train in it. It is a manualised programme, not an open therapy model. [source: WHO 2018 PM+ manual Ch1–2; DIGNITY overview]

How change is meant to happen: the client learns four practical, evidence-informed strategies (slow breathing to manage stress; structured problem solving for practical problems; behavioural activation to break the inactivity–low mood cycle; strengthening social support), practises them between sessions, and is helped to keep using them after the programme. The helper is framed as a teacher or coach of strategies, building the client's own coping rather than solving problems for them. Psychoeducation that normalises stress reactions to adversity supports engagement. [source: WHO 2018 PM+ manual Ch2, Ch5; WHO 2020 Group PM+ manual Ch2–3]

2. Framework

Delivery format (individual PM+, v1.1). Pre-PM+ assessment (about 60 min) → five weekly individual sessions of about 90 min → post-PM+ assessment within a few weeks of ending, with a follow-up around three months later recommended. Home practice between all sessions. Family members or friends may join parts of Session 1 and Session 3, but not the Managing Problems work. [source: WHO 2018 PM+ manual Ch2, Ch4]

Session-by-session plan (individual, approximate minutes from the manual's time guide) [source: WHO 2018 PM+ manual Ch2]:

Every session opens with a general review and the brief during-session PSYCHLOPS, reviews home practice (what was done, what was learned, what got in the way), resolves practice problems, then teaches the new strategy; every session closes with slow breathing practice, a summary of agreed home practice, handouts, a check of understanding and confirmation of the next appointment. [source: WHO 2018 PM+ manual Ch2]

Group PM+ (v1.0). Pre-intervention assessment (~60 min); five weekly sessions of about two hours (run as two halves of ~45–50 min with an optional break, plus 10–15 min arrival); optional family engagement session (~45 min); optional brief during-intervention check each session; post-assessment (~40 min). One facilitator per six participants, maximum 12 participants; two facilitators ideal (one leads, one keeps time and supports individuals). Same-gender groups recommended where possible; tested with adults over 18. [source: WHO 2020 Group PM+ manual Ch1–2, Ch5]

[source: WHO 2020 Group PM+ manual, session overview] Note: the Nepal Group PM+ trial protocol lists a locally adapted order (stress management; behavioural activation; managing problems; social support; review) with grounding techniques added to Session 1 [source: Nepal Group PM+ protocol table]. Follow the generic WHO order unless working under a local adaptation. [uncertain about which other local versions exist]

Criteria for entry and moving on. PM+ is fixed-length: progression is session-by-session rather than criterion-based. Entry: adult with distress and impaired functioning. Screening in trials has combined a distress measure and a disability measure (e.g. GHQ-12 plus WHODAS in the Pakistan trial; no cut-offs given in the abstract opened) [source: Pakistan PM+ trial abstract]. Exclusion: a plan to end one's life in the near future; severe impairment from a mental, neurological or substance use disorder (e.g. psychosis, substance dependence, severe intellectual disability, dementia). People with acute needs or protection risks first receive Psychological First Aid; PM+ can follow. Refer onward when the client is in severe distress, has suicidal thoughts or plans at the end of PM+ or at follow-up, or engaged well but changed little. [source: WHO 2018 PM+ manual Ch2, Ch4] Moving to a harder problem in Managing Problems is a judgement made after early success; check with the supervisor first for very hopeless clients. [source: WHO 2018 PM+ manual Ch7]

Assessment instruments. The PSYCHLOPS (a brief client-generated outcome measure of the person's own problems and wellbeing) is used at pre-assessment and briefly (5–10 min) at each session; suicidal thoughts are monitored closely for anyone who reported them at pre-assessment or scored 4–5 on PSYCHLOPS item 1.4. Assessment forms sit in the manual's appendices (not reproduced here). [source: WHO 2018 PM+ manual Ch4] WHODAS 2.0 was not seen in the manual chapters opened. [uncertain]

Training, supervision and certification. Non-specialist helpers: at least 80 hours (10 days) of classroom training, then at least two supervised practice clients each taken through all five sessions (~15 hours); mental health professionals without CBT training: 40 hours (5 days) then two closely supervised cases. Group PM+: at least 96 hours of training for non-specialists, then at least two supervised groups (~20 hours). Supervision: group supervision 2–3 hours weekly (no more than six helpers per supervisor group), then weekly or fortnightly by skill level; supervisors need mental health experience, PM+ training, two extra days of supervision training and their own PM+ delivery experience. [source: WHO 2018 PM+ manual Ch2; WHO 2020 Group PM+ manual Ch1] WHO publishes PM+ under a CC BY-NC-SA 3.0 IGO licence; no WHO licence fee or formal certification scheme was found. Practice is quality-assured through the training-plus-supervised-cases route, and WHO lists separate PM+ and Group PM+ training manuals for trainers (contents not drawn on). [uncertain] [source: WHO publication pages] [uncertain whether any national body certifies helpers]

3. Guiding principles

[source: WHO 2018 PM+ manual Ch2–3, Ch7; WHO 2020 Group PM+ manual Ch1, Ch3]

• Helper as teacher/coach, not expert advisor. You teach strategies and support the client to apply them; you do not fix their problems.
• Avoid giving advice. Two exceptions only: encouraging use of PM+ strategies, and flagging clearly harmful solutions during Managing Problems.
• Put aside personal values. Do not judge the client's choices, beliefs or solutions; respect the client's values when brainstorming.
• Confidentiality with stated limits. Explain at Session 1 that risk to the client's life, risk to others and child abuse must be passed on even without consent, and that the supervisor sees case information.
• Communicate concern. Show warmth and interest in words and behaviour throughout.
• Non-verbal skills. Culturally appropriate eye contact, nodding, open posture and brief listening sounds.
• Praise openness. Thank the client for sharing difficult material, every time.
• Validate and normalise. Treat reactions as understandable responses to adversity; never claim to know exactly how the client feels.
• Respect culture, gender and language. Adjust examples, matching of helper and client gender, and language to the client.
• Private, comfortable setting. Arrange privacy before starting; this matters for disclosure.
• Strategies, not trauma processing. PM+ targets practical problems and current functioning; in the manual chapters cited and in the developers' description (Dawson et al. 2015), no step asks clients to recount traumatic events in detail, so do not add one. [synthesis]
• Practice is the active ingredient. Every session sets and reviews home practice; review shows you care about progress.
• Small, achievable steps. Start with an easier problem or activity for early success, then build.
• Safety first. Assess suicide risk at entry and keep monitoring; in ongoing adversity, consider whether solutions are safe.
• Work within supervision. Consult the supervisor on risk, very hopeless clients, harder problems and anything outside competence.
• Helper self-care. Look after your own wellbeing; the manual treats this as a helping skill.
• Fidelity with local adaptation. Keep the four strategies and structure; adapt examples, case stories and wording to the local context (e.g. a local relaxation practice may replace slow breathing in Group PM+).

4. Intervention inventory

Order follows the individual manual. All example language is illustrative wording, not manual text. Worksheets and handouts (Managing Stress handout, Managing Problems worksheet, activities calendar) are in the manual appendices and are not reproduced.

4.1 Pre-PM+ assessment and suitability check

• Purpose / when: Before Session 1 (about 60 min). Decide suitability, establish baseline (PSYCHLOPS), screen for imminent risk and exclusions, and identify acute needs. [source: WHO 2018 PM+ manual Ch4]
• Steps: (1) Explain purpose and confidentiality limits. (2) Administer the pre-PM+ assessment including the PSYCHLOPS (record the client's own main problems in their words; these feed Managing Problems later). (3) Ask directly about thoughts of ending life; if present, ask about plans. (4) Screen for exclusion conditions (psychosis, substance dependence, severe intellectual disability, dementia). (5) Check for acute needs or protection concerns; if present, give Psychological First Aid and link to services first. (6) Decide: start PM+, defer, or refer. Consult the supervisor on any doubt.
• Example language (illustrative): "Some people who go through hard times have thoughts of ending their life. Have you had thoughts like that in the last month?"
• Watch for: A plan to end life in the near future = do not start PM+; follow the imminent-risk procedure (4.2). Thoughts without a plan can be held within PM+ with close monitoring. [source: WHO 2018 PM+ manual Ch4]

4.2 Suicide risk monitoring and imminent-risk response

• Purpose / when: At assessment and throughout; whenever the client reported suicidal thoughts at baseline or scores 4–5 on PSYCHLOPS item 1.4. [source: WHO 2018 PM+ manual Ch4]
• Steps: (1) Ask direct, clear questions about thoughts, plans and means. (2) If thoughts without a plan: continue PM+, check at every session, record, inform the supervisor. (3) If a plan to die soon: contact the supervisor immediately; create a safe, quiet environment; remove access to means where possible; do not leave the person alone. (4) A suicide attempt during PM+ requires referral to more specialised care. (5) Re-check at the end of PM+ and at follow-up; refer if thoughts or plans persist. [source: WHO 2018 PM+ manual Ch4]
• Example language (illustrative): "Thank you for telling me. Because I'm worried about your safety, I'm going to call my supervisor now, and I'll stay here with you."
• Watch for: Helpers' reluctance to ask; rehearse this in training. Risk to others and child abuse also break confidentiality. [synthesis]

4.3 Basic helping skills (used throughout)

• Purpose / when: The relational base of every contact. [source: WHO 2018 PM+ manual Ch3]
• Steps: Arrange a private setting; explain confidentiality and its limits; use culturally fitting non-verbal attention; praise the client's openness after disclosures; validate ("that makes sense given…") without claiming to know their experience; set aside your own values; avoid advice except about PM+ strategies and clearly harmful solutions; attend to gender, culture and language preferences; look after your own wellbeing.
• Example language (illustrative): "It took courage to talk about that. Many people facing what you are facing feel exactly this tired."
• Watch for: Slipping into advice-giving or reassurance ("you should…"). If the client asks you what to do, return the question through the strategy (e.g. brainstorming). [synthesis]

4.4 Session structure: review, PSYCHLOPS check and home-practice review

• Purpose / when: Opening of Sessions 2–5 (and briefly Session 1). [source: WHO 2018 PM+ manual Ch2]
• Steps: (1) General review: how was the week? (2) During-PM+ PSYCHLOPS (5–10 min); note change and any risk item. (3) Review each practice task: what was done, what effect it had, what got in the way. (4) Praise any attempt, even partial. (5) Solve practice problems before teaching the new strategy. (6) At the end: summarise agreed practice, give handouts, check understanding (ask the client to explain the task back), confirm the next appointment.
• Example language (illustrative): "Last week you planned to talk with your neighbour on Tuesday. How did that go? What made it easier or harder?"
• Watch for: Skipping review when time is short. The manual treats review as showing the helper cares and as the place where learning consolidates.

4.5 What is PM+? (Session 1, ~20 min)

• Purpose / when: Session 1. Explain structure and aims, and build commitment to attend and practise. [source: WHO 2018 PM+ manual Ch2, Ch5]
• Steps: (1) Explain that PM+ teaches strategies for practical and emotional problems over five sessions, one new strategy per session. (2) Emphasise that the aim is building the client's own coping, not the helper solving problems. (3) Stress the importance of attending all sessions and practising at home. (4) Invite questions and expectations.
• Example language (illustrative): "Over five meetings I'll teach you four skills that many people find helpful. My job is to coach you; you'll be the one trying them out during the week."
• Watch for: Expectations of material aid or advice; clarify what PM+ can and cannot offer, and link to other services for practical aid. [synthesis]

4.6 Good and Less Good Reasons (motivation exercise, Session 1, 10–15 min)

• Purpose / when: Session 1, to strengthen motivation to engage. [source: WHO 2018 PM+ manual Ch5]
• Steps: (1) With the client, list the good reasons for taking part (benefits they hope for). (2) List the less good reasons (costs, obstacles such as time, travel, family attitudes). (3) Problem-solve obstacles where possible. (4) Summarise, ending on the benefits. In Group PM+ this is done as a group discussion of reasons and challenges. [source: WHO 2020 Group PM+ manual Ch5]
• Example language (illustrative): "What might be good about coming each week? … And what might make it hard? Let's see if we can find a way around that."
• Watch for: Unspoken barriers (childcare, cost, a family member who objects). Name them early to prevent dropout. [synthesis]

4.7 Understanding Adversity (psychoeducation, Session 1, ~30 min)

• Purpose / when: Session 1. Normalise reactions and link them to the programme. [source: WHO 2018 PM+ manual Ch5]
• Steps: (1) Ask what the client has been through and how it has affected them, without pressing for detail. (2) Explain that strong stress reactions are common, understandable responses to hardship and do not mean the person is weak or "going crazy". (3) Describe the body's stress response in simple terms. (4) Explain how persistent reactions can disrupt sleep, work, relationships and daily tasks. (5) Use relatable local examples. (6) Frame having coped so far as a sign of resilience. (7) Link each type of difficulty to the PM+ strategy that addresses it.
• Example language (illustrative): "Your body is reacting as if danger is still close. That is a normal reaction to what you've lived through, and there are things we can practise that calm it."
• Watch for: Relief and recognition in the client ("so I'm not the only one") suggests it has landed.

4.8 Managing Stress (slow breathing; taught Session 1, practised every session)

• Purpose / when: Taught in Session 1 (~20 min); practised at the end of every later session (~10 min) and daily at home, plus whenever the client feels stressed. Reduces physical arousal. [source: WHO 2018 PM+ manual Ch6]
• Steps: (1) Explain the rationale: stress tightens the body and speeds the breath; slowing the breath helps the body calm. (2) Relax the body first: shake out arms and legs, roll the shoulders, gently move the head. (3) Teach belly breathing: hands on the stomach; the stomach rises on the in-breath and flattens on the out-breath. Demonstrate first. (4) Slow the breath: count about three seconds in and three seconds out, aiming for roughly 10–12 breaths a minute. (5) Practise together with the helper counting aloud for about two minutes. (6) The client practises alone for a few minutes while the helper counts silently to check the pace. (7) Discuss what was hard. (8) Give the Managing Stress handout and agree daily practice times. (9) If the client becomes distressed in a later session, offer to pause and breathe together, asking whether they want to lead or be guided. In Group PM+, a local relaxation method (e.g. a yoga or meditation practice) may be substituted. [source: WHO 2018 PM+ manual Ch6; WHO 2020 Group PM+ manual Ch2]
• Example language (illustrative): "Breathe in, two, three… and out, two, three. Let your stomach do the work, not your shoulders."
• Watch for and fixes (manual troubleshooting, paraphrased): Worrying about doing it "correctly" → the only goal is to slow down; add counting and belly breathing once slowing is natural. Cannot slow down at peak anxiety → start at early warning signs, and schedule practice through the day. Attending to breath increases anxiety → breathe in time with a ticking clock. Dizziness or feeling out of control → explain it is harmless, focus on breathing out fully and let the in-breath happen by itself, then return to the full cycle. Working: client reports using it unprompted and feeling calmer or sleeping better. [source: WHO 2018 PM+ manual Ch6]

4.9 Managing Problems (structured problem solving; Session 2, reviewed Sessions 3–4)

• Purpose / when: Introduced in Session 2 (~70 min), reviewed and repeated with new problems in Sessions 3 (~35 min) and 4 (~20 min). Targets the practical parts of problems; the aim may be to influence a problem or change how the client responds to it, not to solve it completely. [source: WHO 2018 PM+ manual Ch7]
• Steps (seven-step method):
  1. List problems. Start from the problems recorded at assessment (PSYCHLOPS) and ask about others. Sort into solvable (the client has some control or influence, even over part), unsolvable (no control, though parts may be changeable, often how the client views or responds to it) and unimportant. With hopeless clients, the helper may need to show why a problem is partly solvable.
  2. Choose a problem. The client chooses; usually start with an easier solvable problem for early success, tackle harder ones later (check with supervisor first if the client is very hopeless).
  3. Define the problem. Narrow it to a specific, practical version the client can influence. Useful questions: when does it happen? what would an observer see? how would daily life be different without it? Helpers prepare likely definitions before Session 2.
  4. Brainstorm. Generate as many solutions as possible, including partial ones and existing strengths and supports; write them all down; do not judge yet. Guide rather than advise: ask what they would suggest to a friend in the same position, or what they have tried before; offer broad prompts (e.g. "talking to someone") and ask the client to make them specific; respect the client's values. Light humour can show ideas need not be perfect.
  5. Decide and choose helpful solutions. For each idea consider short- and long-term effects on health, relationships, work and social life, and whether the client can realistically do it. Drop ideas that would cause significant harm (one of the two places where the helper may steer). The client chooses one solution or a combination.
  6. Action plan. Break the chosen solution into small steps; give each a day and time; add reminders (phone alerts, linking to a daily routine, asking someone to prompt); record it on the activities calendar. If the plan involves speaking to someone, rehearse the conversation in session.
  7. Review at the next session: what was done, what effect it had, what got in the way; plan the next steps for the coming week. [source: WHO 2018 PM+ manual Ch7]
• Example language (illustrative): "Of these problems, which ones could you have even a little influence over?" / "If your sister had this problem, what ideas would you give her?" / "Let's pick a day and time for the first step."
• Case example: The manual follows a client (Loma) whose chosen problem is frequent arguments with her husband; she finds brainstorming hard at first and the helper uses prompts, including the idea of talking with a trusted friend. [source: WHO 2018 PM+ manual Ch7] Use the manual's case stories or a local adaptation's, not invented ones, in training.
• Watch for: In ongoing adversity some solutions may be unsafe; discuss how to stay as safe as possible, acknowledge when a problem cannot be solved in the current situation, keep checking realistic risks (clients may also overestimate threat) and consult the supervisor when unsure. Family members do not join this part. Working: the client generates ideas more independently over sessions and completes at least some action steps. [source: WHO 2018 PM+ manual Ch2, Ch7]

4.10 Get Going, Keep Doing (behavioural activation; Session 3, reviewed Session 4)

• Purpose / when: Introduced in Session 3 (~35 min), reviewed in Session 4 (~20 min) in the manual's session plan; the developers' 2015 description places its introduction from Session 2 [uncertain: version difference]. It aims to increase positive reinforcement from the person's environment and counter inertia, with the person re-engaging gradually in pleasant and task-oriented activities, practising between sessions and reviewing the practice at the next session [source: Dawson et al. 2015]. Group PM+ teaches it with an "Inactivity Cycle" poster; the Nepal adaptation has participants examine the cycle of inactivity, choose a small enjoyable activity (e.g. making tea, visiting a friend) and write a detailed when-and-how plan. [source: WHO 2018 PM+ manual Ch2; WHO 2020 Group PM+ session overview; Nepal Group PM+ protocol table] The breakdown into numbered steps below is the writer's synthesis from these descriptions and standard behavioural activation. [synthesis]
• Steps: (1) Draw the inactivity cycle with the client: low energy and mood → doing less → fewer pleasant or meaningful experiences and more undone tasks → lower mood [source: Group PM+ "Inactivity Cycle"; wording synthesis]. (2) Ask what the client used to do and has stopped (enjoyable, social, necessary tasks). (3) Choose one or two activities: at least one pleasurable or social, and one task-oriented [source for pleasant plus task-oriented activities: Dawson et al. 2015]. (4) Break each into very small steps, starting easy, so that re-engagement is gradual [source for gradual re-engagement: Dawson et al. 2015]. (5) Schedule the first step with a day and time [source: Nepal protocol's when-and-how plan]. (6) Plan for obstacles (low energy, others' reactions) [synthesis]. (7) At the next session review what was done and the effect on mood, then grade up [source for between-session practice and review: Dawson et al. 2015]. Family members may join part of Session 3 and can support planned activities. [synthesis except where cited]
• Example language (illustrative): "When we feel low we do less, and doing less leaves us feeling lower. Let's break that cycle with something small, like making tea for a neighbour on Thursday afternoon."
• Watch for: Steps that are too big ("clean the whole house"); waiting to feel motivated before acting. Working: activities completed and the client notices even a slight mood lift. [synthesis]

4.11 Strengthening Social Support (Session 4, ~30 min)

• Purpose / when: Session 4, once the person has some sense of control over their symptoms. It aims to help the person re-engage with their community: seek support from other people or from agencies, and also offer support to others [source: Dawson et al. 2015]. Strengthen support from trusted friends, family, co-workers or community organisations, with a practical plan to get more support. Group PM+ uses participant support planning; the Nepal adaptation has participants identify current and potential supporters and use social network mapping. [source: WHO 2018 PM+ manual Ch2; WHO 2020 Group PM+ session overview; Nepal Group PM+ protocol table] The numbered steps below are the writer's synthesis. [synthesis]
• Steps: (1) Explain why support helps with stress and low mood. (2) Map the client's network: who is there now, who used to be, which organisations exist (e.g. community, religious, women's or refugee groups) [source for mapping current and potential supporters: Nepal Group PM+ protocol table]. (3) Distinguish practical support (help with tasks, information) from emotional support (someone to talk to). (4) Pick one person, group or agency and one realistic way to connect (a visit, a call, asking for one specific thing) [source for seeking support from people or agencies: Dawson et al. 2015]. (5) Decide how much to share; it is fine to seek support without discussing distress. (6) Rehearse the request in session. (7) Schedule it; review next session. (8) Look for one small way the client can offer support to someone else [source: Dawson et al. 2015]. [synthesis except where cited]
• Example language (illustrative): "Who is one person you trust even a little? What is one small thing you could ask them for this week?"
• Watch for: Clients for whom disclosure is unsafe (stigma, abusive household) → choose safer sources such as community organisations and plan what not to share. Clients with no network after displacement → start with organisations and small contact. Working: at least one new or renewed contact. [synthesis]

4.12 Staying Well (Session 5, ~30 min)

• Purpose / when: Session 5. Consolidate the four strategies and plan for keeping well after the programme [source: WHO 2018 PM+ manual Ch2]. The developers describe this as relapse prevention: identifying the person's own early warning signs, checking how well they recall the strategies and can apply them to specific problems, and setting future goals [source: Dawson et al. 2015].
• Steps: (1) Review each strategy: what it is, when the client used it, what helped. (2) Ask the client which strategy fits which kind of difficulty, using specific problems [source for (1)–(2), checking recall and application: Dawson et al. 2015]. (3) Identify personal early warning signs [source: Dawson et al. 2015]. (4) Write a short plan: which strategy to use when those signs appear, and who can help [synthesis]. (5) Discuss how to keep practising [synthesis].
• Example language (illustrative): "If you notice you're sleeping badly and staying indoors again, which of the skills could you start with?"
• Watch for: The client crediting change solely to the helper; return credit to their own practice. [synthesis]

4.13 Imagining How to Help Others (Session 5, ~20 min)

• Purpose / when: Session 5. Review the strategies by applying them to other people's difficulties; in Group PM+ this uses the "Helping Others" case examples. [source: WHO 2018 PM+ manual Ch2; WHO 2020 Group PM+ session overview]
• Steps: Present a short case of someone in difficulty (from the manual's case examples or a local adaptation); ask the client which strategy could help and how they would explain it; praise accurate use. [synthesis on exact procedure]
• Example language (illustrative): "Imagine a friend who has stopped going out and feels hopeless. Which skill might help her first, and how would you teach it?"
• Watch for: Ability to explain a strategy suggests it has been learned. [synthesis]

4.14 Looking to the Future and ending the programme (Session 5, ~15 + 5 min)

• Purpose / when: Close of Session 5. [source: WHO 2018 PM+ manual Ch2]
• Steps: Discuss future hopes and set future goals, and how the strategies support them [source for goal-setting: Dawson et al. 2015]; acknowledge progress; say goodbye; explain the post-PM+ assessment and follow-up; arrange referral if needed. Group PM+ ends with a closing ceremony and optional shared meal. [source: WHO 2020 Group PM+ session overview; synthesis on steps]
• Example language (illustrative): "What would you like to be doing six months from now, and which skills will help you get there?"
• Watch for: Sadness at ending is normal; anxiety about ending can be met with the Staying Well plan. [synthesis]

4.15 Post-PM+ assessment, follow-up and referral

• Purpose / when: Within a few weeks after Session 5 (or after dropout in Group PM+); follow-up at about three months. [source: WHO 2018 PM+ manual Ch4; WHO 2020 Group PM+ manual Ch2]
• Steps: Repeat outcome measures; re-check suicidal thoughts; refer onward if severe distress persists, if suicidal thoughts or plans remain, or if the client engaged well but showed little change.
• Watch for: Unrecorded dropouts; arrange the post-assessment soon after dropout and record the reason. [source: WHO 2020 Group PM+ manual Ch1]

4.16 Family or friend involvement (individual PM+)

• Purpose / when: Parts of Sessions 1 and 3 may include a family member or friend; not during Managing Problems. [source: WHO 2018 PM+ manual Ch2] Group PM+ offers an optional ~45-min family engagement session. [source: WHO 2020 Group PM+ manual Ch2]
• Steps: With the client's consent, invite the person for the psychoeducation and activity planning parts; explain distress and the strategies; agree on how they can support (e.g. reminders, joining an activity). [synthesis on steps]
• Example language (illustrative): "Your support can help. One useful thing would be reminding her about her planned walk on Saturday."
• Watch for: Family members who blame (e.g. calling the client lazy); use psychoeducation to reframe. Do not include a family member who may be a source of harm. [synthesis]

4.17 Group-specific procedures (Group PM+)

[source: WHO 2020 Group PM+ manual Ch1, Ch5]

• Group guidelines (Session 1, ~10 min). Purpose: safety and cohesion. Steps: invite the group to propose and agree rules; explain the three confidentiality limits (risk to life, the intervention team's access to information, shared responsibility for keeping others' information private); display the rules on a poster; discuss how to behave if members meet outside the group. Example (illustrative): "What would help everyone here feel safe to speak?"
• What is PM+? with case story and connection activity (~15 min). Explain the programme; read the case story (whose details the group may adapt locally); members share reasons for joining using a ball-of-wool activity that links speakers visually. Then discuss expected benefits and barriers, problem-solve barriers and end on benefits.
• Individual goals (~10 min). Each participant sets up to five specific, modest goals for the end of the programme, using guiding questions to make them concrete. Example (illustrative): "If things were a little better by the end, what would you be doing that you aren't now?"
• Individual action plans (end of every session). Each participant records what they will practise before the next session.
• Managing Problems in the group. The manual's case example is worked through as a group first, then participants work on their own problems. [source: WHO 2020 Group PM+ session overview]
• Two-facilitator roles. One leads; the other keeps time and supports individuals, including stepping out with a distressed participant.
• Watch for: See section 5 for dominating, quiet and over-disclosing participants, distress and dropout.

4.18 Grounding (local adaptation only)

• Purpose / when: The Nepal Group PM+ adaptation adds grounding techniques to Session 1 to return attention to the present, and encourages using deep breathing during everyday tasks such as housework or walking. [source: Nepal Group PM+ protocol table] This is not part of the generic WHO manual as opened. [uncertain]
• Steps (illustrative, standard practice): Ask the client to notice their feet on the floor and name a few things they can see and hear right now, then return to slow breathing. [synthesis]

5. Handling problems

From the manuals [source: WHO 2018 PM+ manual Ch4, Ch6, Ch7; WHO 2020 Group PM+ manual Ch1]

• Client cannot think of solutions: ask what they would suggest to a friend in the same situation or what they have tried before; offer broad categories (e.g. talking to others) and ask them to make them specific.
• Hopelessness / "nothing can be done": show which part of the problem is within some influence; start with an easier problem; consult the supervisor before taking on a harder problem with a very hopeless client.
• Unsolvable problems (e.g. loss, displacement, a missing relative): look for changeable parts, such as how the client responds to the problem or manages its effects; pair with Managing Stress and social support.
• Ongoing danger or violence: some solutions may be unsafe; plan how to stay as safe as possible, say honestly when a problem cannot be solved now, keep checking realistic risks (clients can also overestimate threat), consult the supervisor. In groups, if a participant fears for their safety, contact the supervisor at once and make sure every participant knows whom to contact.
• Slow breathing problems: perfectionism, panic at peak stress, anxiety from focusing on breath, dizziness: see 4.8 for the manual's fixes.
• Client becomes distressed in session: validate, give time, offer to pause and do slow breathing together. In a group, with two facilitators one supports the person outside; with one facilitator, call a ~10-minute break and sit with them.
• Suicidal thoughts or plan: see 4.2; a plan to die soon means immediate supervisor contact, a safe environment, means removed, and the person not left alone.
• Dominating group member: thank them, invite others to speak, then talk privately about what lies behind it.
• Quiet group: use the case example, give non-identifying examples, speak to quiet members individually.
• Off-topic talk or requests for non-PM+ strategies: redirect firmly and offer to discuss after the session.
• Over-disclosure in a group: ask the participant to moderate, agree a signal, or gently interrupt; offer individual time.
• Dropout or irregular attendance: try to prevent dropout without forcing; explore reasons, revisit goals, record the reason, arrange the post-assessment soon; never ask someone to leave without consulting the supervisor.
• Engaged well but little change by the end: refer for further care.

Additional guidance (no published PM+ source) [synthesis]

• Non-adherence to home practice: review without criticism; find out the specific obstacle (forgot, no time, did not see the point, family interference); shrink the task; tie it to an existing routine or a reminder; rehearse in session; praise partial attempts. Do not move on to new strategies on top of an unpractised one without revisiting it briefly.
• Rupture (client feels unheard, pushed, or that PM+ does not address their "real" needs, such as money or housing): name it, apologise for any misattunement, validate the need, link to practical services, and show how a strategy can address a part of it. Avoid defending the programme.
• Expectation of advice or material aid: restate the coach role early (4.5); give information about services, which is not the same as personal advice.
• Trauma memories surface: contain rather than explore: validate, ground (slow breathing, present-focused attention), return to the session plan; if intrusive symptoms dominate and do not shift, discuss referral for a trauma-focused treatment with the supervisor.
• Grief and bereavement: treat the loss as an unsolvable problem whose effects (isolation, neglected tasks, sleep) can be worked on through Get Going, Keep Doing and social support; refer if grief is severe and prolonged.
• Low literacy: use pictures, verbal rehearsal and a family member or symbols for the calendar; do not let worksheets block participation.
• Domestic violence disclosed during Managing Problems or social support: prioritise safety planning and referral; avoid solutions (e.g. confronting the partner) that could raise risk; follow local mandatory reporting rules where children are at risk.
• Professional therapists using PM+: resist expanding sessions into open-ended therapy; keep fidelity to the five-session plan and refer for more intensive treatment when needed.
• Helper strain: use supervision for vicarious distress and boundary problems; self-care is part of the manual's helping skills.

Sources

Main sources:

• WHO (2016; v1.1 2018) Problem Management Plus (PM+), generic field-trial version, WHO/MSD/MER/16.2 (WHO IRIS record; Chapters 1–7 used)
• WHO publication page: Problem Management Plus (PM+) individual psychological help for adults impaired by distress in communities exposed to adversity
• WHO (2020) Group Problem Management Plus (Group PM+), generic field-trial version 1.0, Series on Low-Intensity Psychological Interventions No. 4 (front matter to Chapter 5 used).
• Effectiveness of Group PM+ for adults affected by humanitarian crises in Nepal: protocol, Table 1
• Sijbrandij et al.: PM+ in Pakistan, RCT protocol abstract (Keele repository)
• DIGNITY: Problem Management Plus (PM+) overview
• Partners In Health: PM+ sample training materials

Further references:

• PAHO/WHO document page: Problem Management Plus (PM+), generic field-trial version 1.0 (2016)
• WHO (2020). Group Problem Management Plus (Group PM+). Generic field-trial version 1.0. Chapters 6–10 are described here only through the session overview [uncertain].
• Dawson, K. S., Bryant, R. A., Harper, M., Tay, A. K., Rahman, A., Schafer, A., & van Ommeren, M. (2015). Problem Management Plus (PM+): a WHO transdiagnostic psychological intervention for common mental health problems. World Psychiatry, 14(3), 354–357. doi:10.1002/wps.20255 (PMC full text)
• Sijbrandij, M., et al. (2016). PM+ for common mental disorders in a humanitarian setting in Pakistan: study protocol. BMC Psychiatry (doi 10.1186/s12888-015-0602-y) (abstract).