PROBLEM MANAGEMENT PLUS

PROBLEM MANAGEMENT PLUS (PM+)
Individual psychological help for adults impaired by distress in communities
exposed to adversity

Preface
There are tens of millions of people in the world who live in extremely difficult circumstances and suffer emotionally.
Numerous people live in chronic poverty and live through hardships in urban slums, long-term humanitarian
emergencies or in camps for displaced people. They may experience loss of family, friends and livelihoods and
may confront extreme stressors such as violent deaths, sexual violence or missing relatives. They often live in
communities that lack security, basic services and livelihood opportunities. The term “adversity” is often used to
describe such difficult circumstances. People who experience adversity are at greater risk of developing mental
health and social problems. They are at greater risk if being impaired by distress. As a result, a range of mental
health and psychosocial supports need to be available, including psychological interventions. However, these
interventions are rarely accessible to those who need them.
With this manual, the World Health Organization (WHO) is responding to requests from colleagues around the
world who seek guidance on psychological interventions for people exposed to adversity. Our mental health
Gap Action Programme (mhGAP) recommends a range of psychological and pharmacological interventions by
non-specialized care providers. It recommends, for example, cognitive behavioural therapy (CBT) and interpersonal
psychotherapy (IPT) for adult depression. In most countries there are mental health professionals who are
expected to offer these psychological interventions. However, these professionals are scarce and too often are
not trained in CBT or IPT. There is a need to develop psychological interventions in simplified form so that they
can be quickly learned not only by professionals but also by people who are not mental health professionals.
We often refer to these simplified, scalable interventions as “low-intensity psychological interventions”, in that
their delivery requires a less intense level of specialist human resource use. It means that the intervention has
been modified to use fewer resources compared with conventional psychological interventions. People with and
without previous training in mental health care can effectively deliver low-intensity versions of CBT and IPT as
long as they are trained and supervised. Also, people experiencing severe levels of depression can benefit from
low-intensity interventions.
This manual describes a low-intensity psychological intervention called Problem Management Plus (PM+) for
adults impaired by distress in communities who are exposed to adversity. Aspects of CBT have been changed to
make them feasible in communities that do not have many specialists. To ensure maximum use, the intervention
is developed in such a way that it can help people with depression, anxiety and stress, whether or not exposure
to adversity has caused these problems. It can be applied to improve aspects of mental health and psychosocial
well-being no matter how severe people’s problems are.
The value of PM+ has been confirmed through independent randomized controlled trials in Pakistan and Kenya.
I hope that you will use this manual, after necessary adaptions for your context, and share your feedback with us
so that we can further strengthen future revisions.
Dr Shekhar Saxena
Director
Department of Mental Health and Substance Abuse
WHO, Geneva

Acknowledgements

Project coordination
The PM+ project is coordinated by Mark van Ommeren under the direction of Shekhar Saxena (Director,
Department of Mental Health and Substance Abuse).

Writing and conceptualization
This manual has been written by Katie Dawson (University of New South Wales (UNSW)). PM+ has been
conceptualized by Mark van Ommeren (WHO), Richard Bryant (UNSW), Katie Dawson (UNSW), Melissa Harper
(WHO), Alison Schafer (World Vision International) and Alvin Tay (UNSW).

Review
The following people have reviewed the manual and/or the concept paper that formed the basis for it: Nancy
Baron (Psycho-Social Services and Training Institute), Pierre Bastin (International Committee of the Red Cross),
Jonathan Bisson (Cardiff University), Dan Chisholm (WHO), Neerja Chowdhary (Sangath), Rachel Cohen
(Common Threads), Pim Cuijpers (VU University Amsterdam), JoAnne Epping-Jordan (Seattle, USA), Steve Fisher
(Basic Needs), Michelle Funk (WHO), Claudia Garcia-Moreno (WHO), Steven Hollon (Vanderbilt University), Sarb
Johal (Massey University), Dayle Jones (WHO), Lynne Jones (Harvard School of Public Health), Mark Jordans
(Healthnet TPO), Berit Kieselbach (WHO), Annet Kleiboer (VU University Amsterdam), Roos Korste (Amsterdam,
the Netherlands), Aisyha Malik (University of Oxford), Anita Marini (Rimini, Italy), Laura Murray (Johns Hopkins
University), Sebastiana Nkomo Da Gama (WHO), Bhava Poudyal (Baku, Azerbaijan), Atif Rahman (University of
Liverpool), Alison Schafer (World Vision International), Marian Schilperoord (United Nations High Commissioner for
Refugees (UNHCR)), Yutaro Setoya (WHO), Marit Sijbrandij (VU University Amsterdam), Renato Souza (University
of São Paolo), Wietse Tol (Johns Hopkins University), Peter Ventevogel (UNHCR), Helena Verdeli (Colombia
University), Inka Weissbecker (International Medical Corps), Valérie Wisard (Geneva, Switzerland), Taghi Yasamy
(WHO), Bill Yule (King’s College London) and Doug Zatzick (University of Washington).
The following people have reviewed the accompanying training material (available upon request): Nancy Baron
(Psycho-Social Services and Training Institute), Neerja Chowdhary (Sangath) and Nina Josefowitz (University of
Toronto).

Testing
The following agencies were partners in testing PM+ though a feasibility and a definitive randomized controlled
trial in Nairobi, Kenya: Ministry of Health Kenya; Nairobi City County; University of New South Wales; VU University
Amsterdam; WHO, and World Vision.
The following agencies were partners in testing PM+ though a feasibility and a definitive randomized controlled trial
in Peshawar, Pakistan: Government Health Services KPK Peshawar; Human Development Research Foundation;
Lady Reading Hospital; University of Liverpool; University of New South Wales; VU University Amsterdam; WHO;
and the WHO Collaborating Centre at the Institute of Psychiatry, Rawalpindi.

Funding
The United Nations High Commissioner for Refugees (UNHCR) funded the conceptualization phase of this manual.
Grand Challenges Canada with matching funds from World Vision Canada and World Vision Australia supported
the pilot and definitive randomized controlled trials in Nairobi, Kenya.
The Office of Foreign Disaster Assistance (OFDA) funded the pilot randomized controlled trial in Peshawar,
Pakistan.
Enhancing Learning and Research for Humanitarian Assistance (ELRHA)’s Research for Health in Humanitarian
Crises (R2HC) – through funds from the Department of International Development (DFID) and the Wellcome Trust
– supported the definitive randomized controlled trial in Peshawar, Pakistan.

Document production
We thank David Wilson for text editing, Julie Smith for artwork and Alessandro Mannocchi for graphic design and
layout

Contents
CHAPTER 1: BACKGROUND 
CHAPTER 2: THE PROBLEM MANAGEMENT PLUS (PM+) INTERVENTION 
CHAPTER 3: BASIC HELPING SKILLS 
CHAPTER 4: PM+ ASSESSMENTS 
CHAPTER 5: UNDERSTANDING ADVERSITY AND THE PM+ INTERVENTION 
CHAPTER 6: MANAGING STRESS 
CHAPTER 7: MANAGING PROBLEMS 
CHAPTER 8: GET GOING, KEEP DOING 
CHAPTER 9: STRENGTHENING SOCIAL SUPPORT 
CHAPTER 10: STAYING WELL AND LOOKING FORWARD 

APPENDIX A: PRE-PM+ ASSESSMENT 
APPENDIX B: DURING-PM+ ASSESSMENT 
APPENDIX C: POST-PM+ ASSESSMENT 
APPENDIX D: ASSESSING AND RESPONDING TO THOUGHTS OF SUICIDE RISK 
APPENDIX E: CLIENT HANDOUTS 
APPENDIX F: IMAGINING HOW TO HELP OTHERS – CASE EXAMPLES 
APPENDIX G: PM+ INTERVENTION PROTOCOL 

Chapter 1
BACKGROUND
The Problem Management Plus (PM+) Intervention
This brief psychological intervention for adults applies an approach that we call Problem Management Plus (PM+).
In addition to 2 assessment sessions, intervention sessions take place once a week for five weeks. All sessions are
individual.1
 The intervention also allows for involving family or friends if this is what the client wants. The approach
involves problem management (PM) (also known as problem-solving counselling or problem-solving therapy) plus
(+) selected behavioural strategies. Hence the term PM+. In combining these strategies, this programme aims to
address both psychological problems (e.g. stress, fear, feelings of helplessness) and, where possible, practical
problems (e.g. livelihood problems, conflict in the family and so on).
PM+ aims to reduce problems that clients identify as being of concern to them. Given the briefness of this
intervention, it will not deal with the full range of difficulties that someone may experience following adversity.2
As a result, it may be best used in addition to other appropriate supports. The IASC (2007) Guidelines on Mental
Health and Psychosocial Support in Emergency Settings describe other relevant supports and services applicable
to emergencies.3
PM+ is useful for a range of emotional problems. It does not involve diagnosing mental disorders, even though it
is likely to help people with mood and anxiety disorders.
Throughout the manual, we use the term “problem management” rather than “problem-solving counselling”.
This is because clients are likely to face many problems that may be difficult to solve. For example, they may
have little or no control over problems, such as war, communal violence or chronic poverty. By using the term
“management”, we hope that helpers and clients understand that when problems are challenging to solve there
may still be ways to provide relief from their impact.
This is a reference manual to be used with training and under supervision. It includes an Intervention Protocol
(Appendix G) that guides helpers on how to carry out each session. The manual includes detailed descriptions
of each strategy and how you can best introduce them to your client. However, reading the manual is not enough
to learn the strategies. The only way of learning how to be a helper using this manual is through practical training
and supervision.

This needs to include:
(a) learning both basic helping skills and PM+ strategies;
(b) practising these skills and strategies through role-plays and with practice clients; and
(c) regular supervision when putting PM+ into practice with clients.
Who can use this manual
This manual is aimed at (a) professionals who have never been trained in these techniques before; (b) a wide range
of people without professional training in mental health care (ranging from people with a degree in psychology
but without formal training and supervision in counselling to community workers and other lay helpers); and (c)
trainers and supervisors of people who offer PM+.
This PM+ manual may be for you if you:
1. work in an organization that offers help to people affected by adversity;
2. have a genuine motivation to help others and are based in a work setting that allows you to spend enough
time with your clients;
3. have preferably at least completed high school education;
4. have completed training in how to use PM+;
5. work in a team with others; and
6. receive continuing support and supervision from a trained supervisor. Ideally this should be a mental health
professional thoroughly trained in cognitive behaviour therapy (CBT). If this is not possible, it should be
someone who has extra training and practice both in the methods used in the manual and in carrying out
supervision.

Training
Training of helpers who are not mental health professionals should involve classroom training and infield training. The classroom training should be at least 80 hours (10 full days). This should be conducted by
a mental health professional who is competent and experienced in all of the strategies included in PM+ (i.e.
problem-solving therapy, stress management, behavioural activation and strengthening social supports).
Classroom training includes:
•	 information about common mental health problems (i.e. depression, anxiety, stress);
•	 the rationale for each of the strategies;
•	 basic helping skills;
•	 role-play (trainer demonstrations and trainee participation) on delivering strategies and basic helping
skills. Towards the end of the training, one full day includes role-playing;
•	 helper self-care.
In-field training is required. Knowing the theory of PM+ does not make someone skilled in delivering
it. Supervised practice strengthens helpers’ knowledge of and skills in PM+ and is essential to build the
necessary confidence. Following classroom training, at least two clients should be seen for five sessions (i.e.
15 hours) of supervised practice of PM+. The five sessions may occur over a two-week period (minimum).
The in-field practice sessions should happen with clients with less severe presentations (e.g. not with
severe depression) and under close supervision (1–2 supervision sessions per week). After training in the
intervention, PM+ should be implemented under routine supervision. The frequency of supervision (e.g.
weekly or fortnightly) depends on the skill levels of the helpers, which may change over the course of time.
Mental health professionals without formal clinical training in CBT may also seek to learn PM+. Their
training should be completed in 40 hours (five full days), followed by two cases of closely supervised
practice. Routine supervision (weekly or fortnightly, depending on skill levels of the helpers) should occur
after training.

Supervision
Supervision is essential. Group supervision for 2–3 hours per week is a good model. It is helpful to limit
supervision groups to six helpers per group. Supervisors should have experience in mental health care.
They should have completed the PM+ training and an additional two days of training in supervision. All
supervisors should have or should gain experience in delivering PM+ themselves.
Peer supervision and one-on-one supervision (e.g. in response to an urgent client issue or crisis) can be
helpful additions to a group supervision model.
Supervision involves:
•	 discussion about clients’ progress;
•	 discussion about difficulties experienced with clients or when delivering strategies;
•	 role-playing how to manage difficulties or to practise skills (to improve helpers’ skills in PM+);
•	 helper self-care

For more information about training and supervision, please refer to the PM+ Helpers’ Training Guide (available
upon request).
Structure of this manual
The manual has three main parts.
1. The first part describes:
•	 Background to the manual (Chapter 1)
•	 The PM+ Intervention (Chapter 2)
•	 Basic Helping Skills (Chapter 3).
2. The second part describes each of the main parts of the intervention, which are:
•	 PM+ Assessments (Chapter 4)
•	 Understanding Adversity and the PM+ Intervention (Chapter 5)
•	 Managing Stress (Chapter 6)
•	 Managing Problems (Chapter 7)
•	 Get Going, Keep Doing (Chapter 8)
•	 Strengthening Social Support (Chapter 9)
•	 Staying Well (Chapter 10). 

3. The third part consists of the appendices, which include:
•	 Assessment tools (consent procedures, pre-PM+, during-PM+ and post-PM+ assessments) (Appendices
A, B and C)
•	 Assessing and responding to thoughts of suicide (Appendix D)
•	 Client handouts (Appendix E)
•	 Case examples for imagining how to help others (Appendix F)
•	 The Intervention Protocol (which is a job aid that describes the whole session-by-session intervention)
(Appendix G). 

Example dialogues
We have included example dialogues – which need to be adapted for the local context –
throughout the manual and Intervention Protocol. It is important to follow them as closely as
possible. This is because the scripts include all the information that you may need for the
client to understand a particular strategy. However, reading directly from the dialogues is not
ideal for building a good relationship with a client. You might find a more sensitive way of describing a strategy,
and as a result moving away from the scripts can be acceptable. Also, you may want to include general examples
when you are describing a common problem (e.g. as in Understanding Adversity) and how a particular strategy
might be useful (e.g. Managing Stress to reduce anxiety). We suggest you use examples that are relevant and
meaningful for the client and their problems.

Grey boxes describe how to work with challenging client presentations (e.g. people affected by sexual
violence) and clients living in difficult situations (e.g. conflict settings). It is especially important that you
familiarize yourself with the material in these boxes before working with more difficult presentations or in
more challenging contexts.

Handouts
You can use the client handouts (Appendix E) as aids for when you are describing a particular strategy to your
client. They can also be given to clients to remind them of what was discussed in the session. There is also a
calendar you can use with clients to record when they will complete an action plan or activity. 

Who is PM+ for?
As mentioned above, PM+ is for adults with depression, anxiety or stress who live in communities affected by
adversity.
PM+ was not developed for use with the following problems:
1. a plan to end one’s life in the near future;
2. severe impairment related to a mental, neurological or substance use disorder (e.g. psychosis, alcohol or drug
use dependence, severe intellectual disability, dementia).
For clients presenting with acute needs and/or protection risks (e.g. a young woman who is at acute risk of being
assaulted), it is advised that you respond initially with psychological first aid (PFA).4
 If appropriate, such clients
may also receive PM+.
Chapter 4 on assessments explains how to assess for exclusion criteria and provides referral options.

What if the client has not improved by the end of the intervention?
You should discuss the client’s progress with your supervisors. If you and your supervisor decide that a client has
not improved enough by Session 5 (e.g. there is little or no change in emotional problems, such as mood, anxiety
or stress), there are several options you may consider (see below). You and your supervisor may decide this either
(a) between Sessions 4 and 5 or (b) after you have seen the client in Session 5.
1. Based on discussions with your supervisor, you may encourage the client to continue practising PM+
strategies independently and arrange to follow them up at an arranged time in the future (e.g. three months
after Session 5). This would only be recommended if the client’s level of distress is not severe and they do
not have thoughts of suicide.
2. Based on discussions with your supervisor, you may refer the client to a (mental) health professional for
assessment and further care. This would be recommended for clients in severe distress or with thoughts
or plans of suicide at the end of PM+ or at the three-month follow-up assessment. This would also be
recommended if the client has engaged well in PM+ but there has been little change to their distress.
3. Based on discussions with your supervisor, you may offer additional sessions of PM+, using the same
strategies. For instance, a client who has taken longer to feel comfortable trusting you as a helper and begins
to show improvement in later sessions may benefit from this option.
For most clients, it is important that they practise PM+ strategies on their own in their daily lives for a few months 
after completing PM+. Often, changes in distress and coping occur in this time after the intervention. So it is
important to encourage clients to try to do this without further psychological assistance, if this is safe for them.
It is also recommended that you arrange to follow up the client after a period of time, such as three months after
completing the intervention. Therefore, if they are continuing to experience problems, they can receive further
assistance then.

Cultural and local adaptations to this manual
This manual in its current form is the generic version of PM+.
You may need to adapt the manual for the local context to address a number of issues, including the following:
•	 correct and understandable translation into the local language;
•	 inclusion of local expressions and metaphors;
•	 socio-cultural differences in how help should be offered (e.g. in someone’s home versus a centre, helpers
being or not being of the same sex as their clients, how to obtain consent, how to involve family members
and how to discuss taboo topics with clients, such as sexual violence);
•	 appropriateness of the strategies. The setting of a humanitarian crisis may prevent you from delivering
certain parts of PM+ exactly as they are described in this manual (for example, you should not select
activities from Get Going, Keep Doing that put a client at risk of harm);
•	 legal differences in reporting suicide and child abuse;
•	 differences in terms of locally available resources (formal and informal) to protect people who are at acute
risk of sexual violence;
•	 differences in social services, including protection services;
•	 differences in health systems, including access to care for mental, neurological and substance use problems
in the general and specialist health-care system;
•	 adaptation of the pictures and images that accompany this manual.

Putting PM+ into practice
You need to take account of a number of important decisions:
•	 how to organize training and supervision;
•	 where to offer the sessions;
•	 how to identify potential clients;
•	 how to make initial and follow-up appointments with people;
•	 how to follow up with people who do not show up for planned appointments;
•	 how to monitor PM+;
•	 how and where to refer people who need more or different help.


Chapter 2
THE PROBLEM MANAGEMENT PLUS (PM+)
INTERVENTION
LEARN
What will you learn
in this chapter?

SESSION
What session does this
chapter link to?

WORKSHEETS
What worksheets link to
this chapter?
•	 Get an overview of PM+
(e.g. structure of the
intervention, order of
strategies)
•	 Learn a little about each

PM+ strategy
•	 The whole intervention •	 PM+ client handouts –
Appendix E
Problem Management Plus (PM+) is the term used to describe the overall approach of this brief intervention. It
combines the well-known strategies of problem-solving with certain behavioural strategies. The overall aim of
PM+ is to build a client’s ability to manage their own emotional distress and, when possible, to reduce their own
practical problems. For this reason, the language used is similar to training or coaching approaches and PM+
avoids giving advice.
Every client will receive all of the PM+ strategies, in the order they are described in this manual.
PM+ strategies
The following is a brief description of all the psychological strategies that make up PM+.


Managing Stress (Chapter 6)
Teaching the client a brief stress management strategy will help them to better manage anxiety and stress. It can
prevent states of extreme stress or anxiety by practising daily. It can help the person calm down at moments of
stress. The strategy used is slow breathing. Although we expect slow breathing to be appropriate in most settings,
effective local relaxation methods (e.g. techniques drawn from yoga) may also be used.

Managing Stress is introduced very early on in PM+ (Session 1). In addition, it should be practised at the end of
every session.
Managing Problems (Chapter 7)
This is a strategy to apply in situations where a client is experiencing practical problems (e.g. unemployment,
conflict in the family and so on). We refer to this strategy as Managing Problems. This is introduced in Session 2.
You and the client will work together to consider possible solutions to the problem that is causing the client most
concern. Jointly you can choose those solutions that are most helpful to influencing the problem and then plan a
strategy to carry out these solutions.

Get Going, Keep Doing (Chapter 8)
This strategy is aimed at improving clients’ levels of activity (e.g. social activities or carrying out necessary tasks
or jobs). Many clients who have reduced their activity are feeling depressed. Depression can look different in
different people but often involves feeling easily tired, lacking energy and motivation, experiencing low mood,
not enjoying activities previously enjoyed, and feeling hopeless or worthless. Often people can also experience
different bodily complaints (e.g. they can get headaches or backaches). People with depression often stop doing
things they used to do. Get Going, Keep Doing aims to increase the client’s activity levels, which has a direct
impact on their mood. This strategy is introduced in Session 3.
Strengthening Social Support (Chapter 9)
Individuals with emotional problems can be isolated from supportive people and organizations. Strengthening a
client’s social support (e.g. with trusted friends, family, co-workers or community organizations) promotes wellbeing. This strategy is introduced in Session 4. If the client appears to have good social support and is using it
regularly, you may only need to encourage them to continue to do so. However, for other clients, you may need
to spend some time discussing how they can strengthen their social support and help them develop a practical
plan to receive more social support.

PM+ structure
PM+ is made up of five 90-minute individual sessions. It is recommended that you have the sessions once a week.
However, you may need to see clients more or less frequently depending on their needs and the local context.
Below you will find a chart of the entire intervention, including the main parts of each session. Next to each of these
are suggested times for the average client. Unless there are specific reasons, we would encourage that, as best
you can, you stick roughly to these indicated times so that you can cover all the strategies in enough detail in each
session. What you should avoid is putting your favourite strategies into practice while ignoring others. However, there
is some flexibility. For instance, a client with few practical problems but who experiences severe depression might
need more time to understand and plan the Get Going, Keep Doing session compared with Managing Problems.
So, it would be fine to spend more time on Get Going, Keep Doing. Thus, while PM+ is structured, with the support
of your supervisor, we encourage some degree of flexibility to make sure that it fits your clients’ main problems.

Chart: PM+ structure
1
 Introduction to PM+
•	 Introductions and confidentiality (5 mins)
•	 Review from assessment and PSYCHLOPS (10 mins)
•	 What is PM+? (20 mins)
•	 Understanding Adversity (30 mins)
•	 Managing Stress (20 mins)
•	 Ending the session (5 mins)
2
 PM+
•	 General review and PSYCHLOPS (5 mins)
•	 Managing Problems (70 mins)
•	 Managing Stress (10 mins)
•	 Ending the session (5 mins)
3
 PM+
•	 General review and PSYCHLOPS (5 mins)
•	 Managing Problems (35 mins)
•	 Get Going, Keep Doing (35 mins)
•	 Managing Stress (10 mins)
•	 Ending the session (5 mins)
4
 PM+
•	 General review and PSYCHLOPS (5 mins)
•	 Managing Problems (20 mins)
•	 Get Going, Keep Doing (20 mins)
•	 Strengthening Social Support (30 mins)
•	 Managing Stress (10 mins)
•	 Ending the session (5 mins)
5
 Ending treatment
•	 General review (20 mins)
•	 Staying Well (30 mins)
•	 Imagining How to Help Others (20 mins)
•	 Looking to the future (15 mins)
•	 Ending the programme (5 mins)

Structure of the sessions
At the beginning of each session, you will ask the client to complete the during-intervention assessment (Appendix
B). You may use the client’s responses from this assessment to discuss how they have been feeling and coping in
general since the last appointment (e.g. in the last week). In this review, you might consider discussing generally
how things have been. This will give the client the opportunity to talk about any positive experiences or difficulties
that have arisen in the last week or so. You may also want to ask the client specifically about their symptoms
of emotional distress to see if there has been any change in these (e.g. if the client’s mood has improved or
worsened in the last week). You may also consider discussing the practice tasks the client and you had planned
for them to do between sessions (e.g. talking about their achievements and what they learned doing this practice,
as well as any problems).
Before you begin introducing the core strategies for each session, you may choose to spend some time trying
to solve or help the client manage any problems that have arisen during their home practice. Following this brief
review, you may want to outline for the client what you will be focusing on in today’s session (e.g. reviewing
Managing Problems, introducing a new strategy to improve their mood, practising Managing Stress together).
At the end of each session, briefly summarize the agreed practice tasks the client is going to complete and give
them any worksheets that might help them with these tasks. Always check that the client understands what is
expected of them before the next session, and finally say goodbye and confirm when and where you will meet
with them for the next appointment.
The Intervention Protocol (Appendix G) shows in detail what each session looks like.

Presence of family or friends during PM+ sessions
There may be times during PM+ when the client would like a trusted friend or family member to be with them.
This can be very helpful for many clients, especially in helping them engage and practise strategies outside of
the session. However, having extra people in a session can also be challenging. Some people might take over the
session or be unhelpful (e.g. talking negatively to your client, criticizing PM+ strategies and so on). When other
people the client trusts are involved in sessions, remember that you are not focusing on their problems. The role of
the other person is to support your client with the strategies, such as Managing Stress and Get Going, Keep Doing.
In general, it may be very appropriate for a trusted family member or friend to attend all of Session 1 (after the
PSYCHLOPS assessment  has been completed) to learn about the intervention and about the strategy Managing
Stress. In addition, a trusted family member or friend may be invited to attend part of Session 3 to learn about Get
Going, Keep Doing. In these sessions the person your client trusts can learn the particular strategies and might 
feel better equipped to support the client when they experience a future problem or become distressed. However,
we would not expect this other person to act as the client’s helper as they may not feel confident doing so.
We encourage you not to include family and friends in Managing Problems (Session 2 and parts of Sessions 3, 4
and 5). This is because the client might feel that they cannot talk about particular problems they are having with
that person in the room. Similarly, you should consider the advantages and disadvantages of having family or
friends present during any assessment when you hope the client can share personal information.

In this chapter you learned
•	 About the PM+ Intervention, including some information on each strategy
•	 About the structure of PM+ sessions
•	 When to include trusted family members or friends


Chapter 3
BASIC HELPING SKILLS

LEARN
What will you learn
in this chapter?

SESSION
What session does this
chapter link to?

WORKSHEETS
What worksheets link to
this chapter?
•	 How to use basic helping
skills to build good, trusting
relationships with your
clients
•	 What to consider about the
client-helper relationship
•	 How to manage difficult
problems that clients may
present with
•	 You use these skills every
time you speak with your
clients
•	 None


Before covering specific PM+ strategies, we will discuss basic helping skills, which focus on communication in
the sessions and building a relationship with your client. Building a relationship based on trust and respect is
essential for all forms of psychological support. In fact, these basic helping skills are the groundwork for PM+. The
formal PM+ strategies are unlikely to be successful without you always using these skills.

Respecting clients
You should have a genuine wish to help the client, be open to new ideas and have an interest in listening to other
people. Overall, care should always be provided in a way that respects the dignity of the person, that is culturally
sensitive and appropriate, and that is free from discrimination on the basis of race, colour, gender, age, language,
religion, political or other opinion, national, ethnic, indigenous or social origin, property, sexual orientation, birth,
or other status. These attitudes are important to form a relationship with your client. Without a good relationship,
the intervention is unlikely to benefit your client.

Cultural, gender and linguistic understanding
Before seeing clients, you should have a good understanding of the local cultures within which you will be
working. This is usually not a great problem if you are from the local community yourself or you have a similar
cultural background. Nonetheless, there can be enormous differences within countries, regions and communities.
Societies are complex and have many cultural groups and influences, and you may not always be familiar with 
each culture. This includes gender roles and expectations and various religious beliefs and practices of your
clients. At times, you may need to learn more about a person’s cultural belief system. You can do this by asking
clients about their beliefs and the customs of their group, religion or culture. By asking these questions, you
express respect for the possible differences and help reduce the chances that you are offending the client or
missing important information.
There may also be times when you decide (with supervision) that it is important to challenge particular cultural
beliefs or practices (e.g. “rape is the fault of the victim”, “beating the spirit out heals mental illness”) that are clearly
harmful. You need to do this with extreme sensitivity so that the client is still willing to continue with the intervention.
Some clients may feel more comfortable working with a helper of the same gender. Where possible, you should
arrange this. You may also consider the preferred language or dialect of the client. Again, where possible, clients
should be matched with helpers who are confident speaking the relevant language or dialect. 

Basic Helping Skills
To promote a healthy relationship with your client, there are a number of qualities and psychological skills that
you should adopt and practise regularly. When reading through the description of these skills, try to think back to
a time when a close friend or family member was thankful to talk to you about a problem they were having. It is
likely that you used a lot of these skills while you were listening to them. These skills can be very natural and show
clients that you are listening and willing to support them.

A. Confidentiality
Trust and confidentiality are important in your relationship with a client. A client needs to know that when they
speak openly about personal things, that information is going to remain confidential or private. This is especially
true for survivors of intimate forms of traumatic experiences and even more so when there is stigma about the
events (e.g. in the case of sexual assault). However, it is also very important for the client to be aware of any
legal boundaries to this confidentiality. For example, depending on the laws of the country and the protection
and social services systems in place, you may have to break confidentiality and tell the appropriate agency or
authority when a client appears to be at risk of of ending their life or of harming someone else.7
Ongoing supervision is another limit to confidentiality. Through supervision, you will be discussing your client’s
problems and progress throughout the intervention with your supervisor and possibly a team of helpers.
Supervision makes the most of the positive effect of the intervention and you should let the client know of this
limit to confidentiality.
As part of confidentiality, it is important that all information about clients (e.g. their assessment results, personal
details and so on) is kept in a safe and locked place (e.g. a filing cabinet).8
 This is also important for the assessment
data that are collected at the beginning of each session each week.

B. Communicating concern
Communicating concern to your client is an important skill. Try to understand, as best you can, your client’s
situation, including the emotions they are experiencing. At the other extreme, it is also important that you do not
get too involved in the client’s feelings and take them on as your own. This can cause you to feel stressed and
overburdened by your work.
Statements that show concern include the following:
•	 That sounds like it was very challenging/upsetting/frightening (and so on) for you.
•	 I can see in your face how painful this was for you.
•	 You have experienced many difficulties.
•	 You went through a lot.
•	 I can hear how sad/frightening this was for you.

C. Non-verbal skills
Non-verbal skills also communicate to the client that you are listening to them and can also be a way of
communicating concern. These include maintaining culturally appropriate eye contact, culturally appropriate
nodding of your head and, in most cultures, keeping your posture open (e.g. avoiding crossing your arms and
sitting with a stiff position or turning away from the client). Sometimes showing emotions similar to those of your
client shows that you are hearing what they are saying. This might mean expressing sadness on your face when
they express sadness (because they have teary eyes). You can also use brief verbal indications that you are
listening, such as “uh-huh”, “okay”, “I see” and “mmm”. It is important to remember that there can be wide cultural
variations to all of the above.

D. Praising openness
To help a client feel comfortable talking about personal, difficult or embarrassing topics, try to thank or even
genuinely praise them for being so open. Throughout the intervention, you may also praise the client’s efforts to
engage in the PM+ strategies and to get better.
Some examples are shown below.
•	 Thank you for telling that to me.
•	 You were very courageous in sharing those intimate feelings with me.
•	 Although it may have been hard to talk about that with me, I think it will be very helpful for your recovery.
•	 I can see that you are really trying to practise Managing Stress regularly.
•	 Use local proverbs: e.g. You double happiness and halve sorrow by sharing what’s on your mind.

E. Validating
Many clients will feel embarrassed talking about their problems with a stranger. They might think that no one
else feels the same way as them. They may also think that talking about emotions or personal problems is a
sign that they are becoming ill, going crazy or that they are weak. Some clients might even blame themselves for
how they feel. It is important that throughout the intervention you help the client to dispel these myths. You can
do this by normalizing the client’s problems by helping them understand that many other people experience the
same reactions, and difficulties. This is “validating” their problems, which means that you are letting them know
that their reactions are understandable. This is a very good way of communicating concern too. However, we
recommend that you do not tell the client you know what they are going through. Although you might be trying to
validate their experience, it can have the opposite effect for clients, as they may not believe you.
Some examples of validating are shown below.
•	 You have been through a very difficult experience and it’s not surprising that you would be feeling stressed.
•	 What you have just described is a common reaction for people to have in these situations.
•	 Many people I have worked with have also described feeling this way.
•	 The reactions you have described are very common.
•	 I am not surprised that you are so scared.

F. Putting aside your personal values
Demonstrating these basic helping skills will mean that at all times you will need to respect your client’s personal
values and beliefs. This can be challenging, especially when you do not agree with their values or beliefs. You
should not judge your clients, no matter what they might say to you. This means not allowing your own personal
beliefs or values to influence how you respond to the client. The experience of having someone just listen without
judgement might be something the client has not experienced before and this can greatly help them to trust you.

G. Giving advice
You should generally not give advice to clients. Giving advice is different from giving your client important or
helpful information (e.g. about legal services or other community organizations that might be helpful). Giving
advice means telling a client what to do or what not to do (e.g. do not talk to your husband about this).
All helpers will feel tempted to give advice at some time. This is a very normal temptation. For example, a client who
is feeling very hopeless and showing signs of depression might find the Managing Problems strategy challenging,
especially thinking of potential solutions to help with their problems. It would be very tempting to advise the client
what solutions would be good to try. But you should avoid giving direct advice. If the client has been relying on
your advice, they are unlikely to be able to manage their own problems in the future, when they have completed
the PM+ intervention.
One strategy that can be helpful to use in situations where you are very tempted to give advice is asking the client
what they would suggest or say to a close friend or family member who was in a similar situation. For instance,
a client who is very withdrawn and depressed might not seek out social support because they do not want to
burden others. Rather than giving advice that they should ask for support and that their thoughts are too negative,
you might ask them, “What would you say to a close friend or family member who was thinking the same? Would
you want them to be alone with their problems or ask you for help? And would you feel burdened by that?” This
type of questioning may help the client to think about their concerns and behaviours from a different viewpoint,
without you directly telling them to do something different.

There are two exceptions to this rule about giving advice.
1. When delivering PM+, you will be advising clients to become more active, seek social support and practise
stress management, as these strategies are part of PM+.
2. When you are teaching the strategy Managing Problems, your aim is to help the client decide how helpful
the potential solutions are in managing the problem. At this stage, the client may have a number of obviously
unhelpful solutions (e.g. solutions that cause problems for their emotional or physical health, harmful or
illegal acts and so on). You will need to help the client consider whether solutions are helpful or unhelpful.
To discourage the client from focusing on an unhelpful solution, you can ask what they would have advised
a close friend or family member experiencing a similar problem to do (e.g. “Would you have advised them to
use this solution?”). If the client continues to focus on a solution that is obviously unhelpful (e.g. getting drunk,
doing something illegal), you may be direct and identify these solutions as unhelpful. It will be important for
you to give good reasons why the solution is not considered helpful (in other words, by commenting on the
problematic or harmful consequences), but these should not be related to your values. 

The client-helper relationship
A. The role of the helper
For some people, seeing a helper may be likened to admitting weakness. Because of this, they may have a difficult
time getting involved in the intervention as a whole or parts of it. Others may see you as someone similar to a
doctor or a traditional healer, and expect to be “fixed” or “healed” by you. It is important that throughout PM+ you
normalize the client’s feelings as well as educate them about your role.
In PM+, we encourage you to liken your role to that of a teacher (see the end of this section for some alternative
metaphors).
Teachers provide information to students and help them learn. However, the teacher cannot
sit an exam for the student or tell them what to write. They can only help prepare them for the
exam as much as possible. It is up to the student to listen in class and study to do well in the
exam. The student is ultimately responsible. Although you are an adult, it is the same with our
relationship. I am going to teach you about some important and helpful strategies, but
ultimately you are responsible for practising those strategies. I cannot do them for you. You
might compare your everyday life to the exam a child will sit. You will be responsible for how
well you apply the strategies in your everyday life. Nevertheless, I will support you and help
prepare you to do the best you can.
Similarly, you should also emphasize to the client that you are both “experts” in the room. You may want to use
a locally adapted example. You are the expert on emotions and how you can detect and reduce poor emotional
well-being. The client is the expert on their own life, about which you will only know a little. The client is also the
expert on their particular type of problem and how it affects their life. The aim is to bring together the two types
of expertise. This is important for building the confidence of the client and dispelling any myth that your task is to
“fix” the client’s problems.

Alternative metaphors to explain the helper-client relationship
•	 Adult education metaphor: PM+ is like teaching an adult a new skill, such as using new agricultural
equipment or a technique. The teacher will give all the information so the trainee can use the new equipment
or strategy. But it is the trainee who will have to apply the new equipment or strategy on their own land,
without the teacher being there.
•	 Medical metaphor: Although the doctor does a lot to help heal a physical disease by giving you
recommendations for treatment, it is the patient who is ultimately responsible for their own recovery. They
need to follow the treatment recommendations, which might involve avoiding particular types of food, taking
medication or using various ointments. The doctor does not do these things for the patient, but teaches 
them how best to follow these recommendations and supports the patient. This is the same with a helper.
You might explain, “I will give you some recommendations to improve your emotional well-being and life
situation, and will train and support you in applying these strategies, but you are responsible for practising
them and applying them in your everyday life.”
•	 Sports coach metaphor: A coach’s role is to teach and support an athlete’s exercise programme. However,
the coach does not run the race for the athlete. The athlete is responsible for following their coach’s
instruction and advice about training. The same relationship applies with you and the client. Your role is to
teach the client the strategies and coach them as they practise the strategies in real life. But the client must
ultimately use them in their everyday life. You cannot do this.

B. The reluctant client
Some clients will initially feel hesitant about talking to you. This may be for a range of different reasons, such as:
•	 lack of trust;
•	 mental health problems being taboo;
•	 psychological counselling being unknown in the culture;
•	 a lack of understanding or misperceptions about what PM+ actually is;
•	 a lack of understanding of your role as a helper;
•	 being forced to attend PM+ by a family member;
•	 feeling embarrassed about the experiences they have been exposed to;
•	 feeling embarrassed about how they are coping now;
•	 gender issues, such as speaking with someone of the opposite sex about personal things;
•	 topics that are a sexual taboo.

You may find that with time and consistent use of the helping skills described here, many clients will begin to relax
and open up. However, some clients may remain quite reluctant or shy. As a helper it is important that you discuss
this with your supervisor. You should respect the fact that the client may not be ready to be completely open at
the time of receiving PM+. There may be unknown reasons that contribute to this, and you may never know these
reasons. These clients can be somewhat challenging to talk with, as they may not give you a lot of information.
While you may want to gently and respectfully encourage clients to talk, you should never pressure them. This is
especially true of clients with a suspected history of having experienced sexual assault or torture. It is important
for you to show a readiness and openness to listen if they want to share private information about their distressing
experiences, but the decision is entirely up to them. If a client refuses to talk further about a topic, it is important
to your relationship with them that you respect this.

For instance, you may say:
I can see that this is upsetting for you to talk about and I want to respect that. However, if you
do want to return to talking about this topic, I want you to know that I am ready to listen to you
at any time.
Or, you may find that a client appears very distressed while discussing a particular topic, but has not said that
they do not want to talk about it. In this situation, you may want to say that it is okay to stop talking about this
topic if they prefer that. Some clients may believe that there is an expectation that they have to do everything you
suggest, including talking about sensitive and personal topics. 

C. Physical contact
In some cultures using physical touch, such as laying a hand on a friend’s knee to offer support, is very acceptable.
In other cultures, physical touch is not appropriate. You should be aware of these cultural differences and try to
respect them. In general, we would encourage you not to use physical contact or touch to express support and
concern to clients. This avoids any problems associated with clients misinterpreting the meaning of this contact
or feeling uncomfortable as a result.

D. The setting
You should try to find a private, comfortable setting in which to carry out sessions with clients. Give clients the
opportunity to ask for particular settings to meet. If this sort of setting is not available, discuss this with the client
and agree on another solution. This may mean that at times when you cannot make sure there is privacy, you
should avoid discussing intimate issues.

E. Managing your own distress
Listening to and working with people who have experienced a lot of adversity can be tiring and even distressing
for some people. It is not uncommon for helpers to feel affected by or even overwhelmed by repeatedly hearing
about adversity. To prevent feeling overwhelmed or even experiencing excessive feelings of distress yourself (e.g.
stress, low mood, anxiety, anger, hopelessness and so on) you should consider the following:
•	 Speak with colleagues and your supervisor regularly.
•	 Schedule adequate breaks between clients (breaks might include talking with your colleagues, doing some
slow breathing or a similar strategy to manage stress, or doing an enjoyable activity).
•	 Ask for help (e.g. talk to your supervisor) if you are experiencing distress or you find that your work is
bothering you when you are doing other tasks (e.g. thinking repetitively about a particular client when you
are trying to sleep).

Challenging presentations or contexts

1. Sexual assault and other forms of intimate traumatic experience
Helping people who are survivors of sexual violence or other forms of what we label here “intimate forms of
traumatic experience” (e.g. sexual violence, torture and severe domestic violence) needs extra sensitivity,
for four reasons:
1. The survivor may not be safe, and the experiences may reoccur.
2. The psychological experience of these events is usually extremely threatening or horrific. The survivor
may experience traumatic stress and may seek to avoid reminders of the event.
3. These events are often private and culturally taboo, making it difficult for survivors to share them and
get support.
4. Survivors can face stigma and rejection from their family or community if it becomes known what has
happened to them.
When survivors of other forms of adversity share their experiences with you, they often feel “validated”
(in other words, you will show you understand that a traumatic experience has taken place). But survivors
of intimate forms of traumatic experience are too often denied this validation, because they do not speak
about it, are pressured to stay quiet or are simply not believed. Worse, their sense of dignity is further
undermined when people joke about what has happened to them or blame them for it. Any rejection by
family or community members is likely to cause further suffering (e.g. poverty). In many societies, the
situation can be made worse when clients openly discuss sexual violence. So, when a client shares their
story of an intimate traumatic experience with you, they are showing great courage in doing so. You need
to be extra sensitive in your response to this. Your confidentiality is essential.
The needs of survivors of sexual violence are many. They will probably also suffer social, legal and physical
health problems. You should let them know about other services and support for these other needs.9
This manual does not provide specific trauma-focused psychotherapeutic strategies. Instead, it gives
you helpful general strategies that can be safely provided by helpers who have received brief training. In
many cases, these general psychological strategies should help your client a lot. In other cases, clients
presenting with these issues will need advanced treatments that are beyond the scope of this manual. For
many clients, these events may not be revealed to you because of the personal nature and stigma possibly
attached to them.
Whenever clients choose to tell you information about intimate forms of traumatic experience, it is very
important to show a willingness and openness to hear their story. As mentioned earlier, this is because
clients are often denied the opportunity to have their story heard and validated. In many communities, people
will falsely blame them for the events they have experienced or think negatively about them as a result.
When a client talks about intimate forms of traumatic experience, it is essential that you show genuine
concern and remember to apply all the basic helping strategies. However, do not try to jump in immediately
to offer the intervention strategies. The client may not experience this as validating. The strategies in this
manual still apply, but it is important that you show respect, listen and praise the client for their courage
in telling their story. One way of doing this is to go at a slower pace when listening to the story being told,
using all the basic helping skills referred to previously in this chapter. Once you believe the client has
been heard with respect and dignity, you may slowly move into the more active helping role and apply the
appropriate strategies suggested in this manual (e.g. Managing Stress and so on).
What should you do when you think your client may have a history of sexual assault?
Sometimes you become aware of information (e.g. rumours in the community) that suggests that your client
has been sexually assaulted. However, your client does not share this information with you in the session.
This is a very challenging dilemma. It is very important that you do not immediately assume that sexual
assault has taken place. Get supervision when you are in this situation.
When you think that a sexual assault may have happened recently and you are concerned about the client’s
ongoing safety, you may believe that it is best to ask the client about it. If you choose to do this, it is very
important that you do so in a gentle and respectful way. For instance, you may say: “There is something
that I would like to talk with you about. I don’t want to make you uncomfortable or embarrassed at all. But I
am concerned about your safety and I want to make sure you are okay. It is entirely your decision whether
you want to talk to me about it or not, okay? Please don’t feel pressured to talk about something you feel
uncomfortable about. I am concerned that people have recently done things to you against your will and
that you are still at risk of this happening again. This is something that does happen to a lot of women and
men and it is not their fault that it happens. I am definitely not going to judge you if this has happened to
you. Remember that aside from my supervisor, I will not tell anyone about this if it has happened to you. But
if this has happened and you feel okay talking with me about it, I encourage you to do so. This way I might
be able to do something to help you stay safe or cope with having been through something so horrific.”
If you think that the sexual assault is not in the recent past (in other words, it happened years ago), it is
probably unnecessary for you to bring this up with the client. However, it may be helpful for the client
to know that you are comfortable talking about these topics confidentially and without judgment. If you
believe it is appropriate, you may want to use examples when you are describing a common problem (e.g.
as in Understanding Adversity) and how a particular strategy might be useful (e.g. Managing Stress for
anxiety). In providing examples, you may make an effort to use examples about sexual assault. This may
send a message to your client that you are comfortable talking about such a difficult and taboo topic. This
might help the client open up later to you about the sexual assault.
However, in all cases you should respect the client’s decision not to share information about sexual assault
if they do not wish to.

2. Conflict settings
In communities facing conflict, many people may be fearful of security forces, of armed opposition groups,
of authority figures and sometimes of other people in the community. In some cases, you might realize
that clients find it difficult to trust you as a helper. They might find answering questions in the assessment
very stressful. At all times, you should respect your clients’ decision not to be open or to tell you personal
details. You should also expect their story to change over time. This is not because they are lying to you.
Building trust and using basic helping skills will be very important in conflict settings. Supervision will be
especially helpful for you when working in these situations. In particular, discussions may be needed about
how to introduce PM+ into the community as well as to your clients. 

Chapter 4
PM+ ASSESSMENTS

LEARN
What will you learn
in this chapter?

SESSION
What session does this
chapter link to?
WORKSHEETS

What worksheets link to
this chapter?
•	 About the different
assessments
•	 How to carry out the
necessary assessments
•	 How to assess and respond
to clients with plans to end
their life in the near future
•	 Before (pre-intervention)
and after (post-intervention)
PM+ and at the beginning
of every session (duringintervention)
•	 Allow 60 minutes for the
pre-PM+ assessment and 5
minutes for the during-PM+
assessment.
•	 All assessment protocols –
Appendices A, B and C
•	 Thoughts of suicide –
Appendix D


When will you complete assessments?
There are three types of assessment:
1. pre-PM+ assessment: this happens before you start PM+ with a client (Appendix A)
2. at the beginning of every PM+ session: this is a brief assessment to monitor a client’s progress (Appendix B)
3. post-PM+ assessment: this happens within a few weeks of the client completing PM+ (Appendix C).
You may also arrange to follow up your client several months after they have completed PM+. This would be
a good opportunity to check on their progress. You may decide to use the same assessment questions as in
Appendix C to guide this follow-up or you may prefer a less formal check-in. 

Why do an assessment?
Doing an assessment before PM+ is very important. It gives you an opportunity to:
•	 meet your client;
•	 hear your client’s story;
•	 decide if a client is suitable and ready for PM+;
•	 gather specific information about their practical and emotional problems to help you prepare for PM+.
Completing assessments during and after PM+ is helpful to monitor your client’s progress and better support
their emotional recovery. Clients may not improve immediately. Knowing this from the assessments done at the 
beginning of every session will help you and your supervisor decide how to improve the care offered.


How to do an assessment
Good assessors will always use their basic helping skills. Make sure you use the skills described in Chapter 3
(Basic Helping Skills) when doing an assessment. Some important things for you to consider include the following:
•	 Use simple and clear language.
•	 Make sure you speak appropriately for the client’s age, sex, culture and language.
•	 Be friendly, respectful and non-judgmental at all times.
•	 Respond sensitively to private and distressing information (e.g. about sexual assault or self-harm).
Steps to follow to complete an assessment
1. Introduce yourself.

2. Tell the person the reason for the assessment and what will happen.
•	 Tell them:
– the assessment is to find out if PM+ might be helpful for the type of problems they are having;
– you will be asking them to talk about some of their difficulties;
– you will be asking them specific questions about their problems and feelings;
– it should only take one hour.
•	 Tell clients they should not feel forced to share personal information if this makes them feel uncomfortable:
– I will ask you a lot of questions. I hope that you will feel free to answer. If you are uncomfortable
with some of what I ask, please tell me. Please answer only what you feel most comfortable with.
I recognize that it can be difficult to speak to a new person about your problems and experiences.

3.	 Tell them about confidentiality.
•	 Make sure that clients understand what information will be kept private and who this information will be
shared with:
– All information is kept private unless the client gives you permission to share it with someone else.
– All information will be shared with your supervisor so they can make sure the client is being looked
after and receiving the best care.
– During assessment or PM+, if the client is believed to be at risk of ending their life or harming someone
else, or they tell you about child abuse (e.g. physical or sexual abuse or neglect), you will have to let
someone know,10 even if the person does not consent to this

Before we begin today, I want you to understand that everything that is discussed in our
sessions will be kept private. I will not be able to talk with any of your family or other people
about you or what goes on in these sessions without your permission.
However, there are some limits to this privacy that I want you to understand. If I am very
concerned that you are at risk of ending your life or harming someone else, I will talk with you
about how we can come up with a plan to keep you and others safe. This will usually mean
that I need to talk with my supervisor and try to get you the best kind of help. (You will need
to adapt this according to the laws of the country.) This is because my role is to care about
your welfare and safety.
I will also be speaking regularly with my supervisor about your progress. This supervisor has
received special training in helping clients with emotional problems and they will be making
sure that I am giving you the best care.
Does this make sense to you, or do you have any questions about your privacy?
4. Give brief information about PM+.
•	 Tell clients that PM+:
– can help adults with practical and emotional problems;
– is an individual intervention (they will meet with you on their own);
– happens once a week for five weeks.
•	 Make sure the client knows what PM+ is not:
– Clients will not receive any materials, money or medication.
•	 Be very honest about what the client will and will not receive from PM+.
5. Begin the assessment.
•	 Ask all the questions as they are written in the pre-PM+ assessment protocol, including the beforeintervention version of the PSYCHLOPS (Appendix A).

Assessments at the beginning of sessions
At the beginning of every PM+ session you should complete the during-intervention version of the PSYCHLOPS
assessment (Appendix B). This is a brief interview (requiring 5–10 minutes to complete) and gives you an idea of
how your client is progressing. You can use the client’s responses to the PSYCHLOPS assessment to talk further
about the past week and their home practice.

Monitoring plans to end one’s life
In the weekly PSYCHLOPS assessment, you will also be monitoring thoughts of suicide of some clients:
1. clients who express having suicidal thoughts at the pre-PM+ assessment;
2. clients whose mood is very low (who score a 4 or 5 on Question 1.4 of the PSYCHLOPS during-intervention
version).
By monitoring clients’ thoughts of suicide, you can help them receive the type of care they need.
For instance, a person who has a plan to end their life in the near future needs urgent care to keep
them safe, and PM+ would not be suitable for them at this time. PM+ will also not be enough for a
person who has made a suicide attempt during the intervention because the person will need more
specialized help. Clients who have thoughts of suicide but do not plan to carry out this act can be
helped through PM+.

Assessment of thoughts of suicide
You will have to ask the client direct questions about suicide throughout the assessment and intervention. You
will need to follow the assessment questions as they are written. You will need to decide whether the client has a
plan to end their life in the near future and respond appropriately.
Throughout the intervention, you will need to monitor the client’s thoughts of suicide in the during-intervention
assessment and respond appropriately to help keep them safe.
Many people avoid asking direct questions about suicide even if they suspect a person has these troubling
thoughts. This is often because they are afraid that talking about suicide will put ideas in the other person’s head
and that if they had not considered suicide previously, they might now. This is a very common but incorrect
belief. And unfortunately one of the upsetting consequences of keeping silent about suicide is that the person
suffering from these thoughts will remain alone and without support. So, as a helper, it is important for you to feel
comfortable talking openly about suicide and to show your client that you are not shocked by anything they might
say. Lastly, because suicide can be such a sensitive topic, it is important that you put aside any personal beliefs
you might have about suicide and communicate very clearly that you do not judge the client for their thoughts,
plans or any previous attempts. This can be challenging.

Guidance when assessing thoughts of suicide in clients

Ask direct, clear questions:
•	 Ask the questions as they are written in the assessment.
•	 When asking questions about suicide, avoid using less direct words that could be misunderstood.
•	 Direct questions help clients feel that they are not being judged for having suicidal thoughts or plans
or having made attempts in the past.
•	 Some people may feel uncomfortable talking with you about suicide, but you can tell them that it is
very important for you to clearly understand their level of safety.
•	 Asking questions about suicide will not put ideas in a person’s head to end their life if they had not
thought about this before.

Responding to a client with a plan to end their life in the near future:
•	 Always contact your supervisor.
•	 Create a secure and supportive environment.
•	 Remove means of self-harm if possible.
•	 Do not leave the person alone. Have carers or staff stay with them at all times.
•	 If possible, offer a separate, quiet room while waiting.
•	 Attend to the person’s mental state and emotional distress with your basic helping skills.


Challenges during assessment
The following scripts can help you to manage people in need of additional attention during the assessment.

1. When a client is shy or reluctant to share information
It is important to respect the client at all times. If they appear to be nervous or uncomfortable about sharing
information, do not pressure them to tell you personal information.
It can also be helpful to let the client know at the beginning that they do not have to answer your questions. It
is important for the client to feel in charge of the session and not feel forced to provide information if they feel
uncomfortable about doing so.
If you don’t feel comfortable answering any question I ask you, you don’t have to answer. Just
share with me what you are comfortable with.

2. When you need to stop a client from talking
There will be times when you need to redirect a client who might be talking a lot about a topic that is not relevant
to the assessment or if you need to get some specific information you do not have. It is important that you display
warmth when prompting a client to move on.
The following dialogue is a suggestion for how you might sensitively change topics.
It sounds like you are faced with a lot of difficulties at the moment. One thing I am most
interested in hearing about at the moment though, is (ask next question) …
Sometimes you may need to be a little more direct with a client, especially if you are running out of time. It is
important that you still communicate concern and warmth when doing this. For example:
I am very interested in hearing about this, but I do not want to run out of time. I still have a
number of questions I need to ask you. Would it be okay if we went through those now and
with the time we have left we can talk about these other concerns you have?

Chapter 5
UNDERSTANDING ADVERSITY AND THE PM+ INTERVENTION
Helping the client to understand and participate in PM+
You need to give the client a brief overview of what the intervention will be like and what you expect from them.
It is important that you are warm in your delivery so you do not come across as strict or controlling, particularly
when talking with the client about the importance of their attendance. However, you also want to emphasize to
the client the importance of taking part in the intervention and that it is only effective if they attend and make the
most of their time.
In PM+ we will work together to learn some strategies that can help you to overcome the
difficulties you have told me about today. Including today’s session, there are five sessions.
Sessions will happen once a week and will last up to 90 minutes. In these sessions I will teach
you the different strategies and we will have time to practise them as well. Between our
meetings I will encourage you to practise these strategies so you can start making changes
to the problems in your life and learn how to become your own helper.
The strategies I will teach you will help you reduce and manage the problems you have told
me are causing you the most distress (say what these problems are for the client). I will teach
you strategies to help manage practical problems, improve your activity, reduce your feelings
of stress and anxiety and improve your support. Each of these strategies has been found to
be very helpful for people in situations similar to your own.
It will work best if you come to every session for the next five weeks. I understand that it can be difficult to come to sessions if you are feeling very anxious or depressed, or maybe
you are physically unwell or you have family or community obligations. I would like to make
an agreement with you that you will talk with me about this12 instead of not showing up or
avoiding sessions. This is because I want you to get the most out of our time together. And
I don’t want you to feel uncomfortable talking to me about problems with coming to the
sessions. I will not be angry or upset. Does this sound okay to you? Do you see any difficulties
with coming to all the sessions?

(If the client has said that they may have problems coming to all the sessions, spend some time managing these
problems – e.g. choose a better location, time, day and so on.)

Good and less good reasons for joining PM+
Ask the client one or two questions from the table below. This will help them think about the good reasons for
joining PM+ and the less good reasons for joining. This discussion should last only 10–15 minutes.
If clients are literate, you can write their responses down on the table (which you draw on a separate piece of
paper) and give them the completed handout to keep. For illiterate clients, you can still write down their responses
so you can keep the handout and discuss it with your supervisor. After asking these questions, summarize the
client’s responses and emphasize the reasons they have stated why PM+ will be helpful for them.
If the client is still not certain about taking part in PM+, talk further about their concerns. Some of these concerns
might actually be incorrect beliefs that you can easily deal with. For other clients, it may be obvious that taking
part in PM+ now will be too demanding and may cause them extra problems (e.g. significant time away from
children or work, or their other community obligations are too great, and taking part in PM+ may actually increase
their stress).
During the intervention, the client’s motivation to continue with PM+ might change. At any time, you can return to
this table and talk about the good and less good reasons for staying in PM+.
The client should not feel judged or guilty if they decide they cannot commit to PM+. You should also encourage
them to contact you again if they decide at a later stage that they would like to take part in the intervention. Just
because they have refused the first time does not mean that they cannot come back later.

Alternative uses for “Good and Less Good Reasons” table:
responding to suicidal ideation
During PM+, some clients might have thoughts about ending their life, but they do not have plans to do this in the
near future. The “Good and Less Good Reasons” table is a good way of helping clients who have thoughts about
suicide to think about the reasons for staying alive. You would use the table in much the same way as above,
but the focus is on reasons to live and reasons not to live. Your task will be to gently help the client come up
with important reasons to stay alive and realize that their reasons to die are most likely only temporary (e.g. their
depression, which is causing them to want to die, can improve).
Begin by asking the client the reasons they think it would be better if they were dead. Then discuss their reasons
for living – see some example questions below:
•	 What is keeping you alive at the moment?
•	 Are there any family members or friends you are staying alive for?
•	 Are there some things that you have enjoyed in life? Recently? Long ago?
•	 Have you always felt this way? If not, what did you used to enjoy in life?
•	 What are some hopes that you have for your future? (Help them to think about solving their practical
problems, reducing their emotional problems, etc.)
•	 What if you did not have the problems you are experiencing at the moment, would that change your thoughts
about not being alive?
 PM+ is designed to help you better manage and reduce these problems. If you stayed in PM+, and if these
problems decreased, would this be a good reason to stay alive now?

After hearing the client’s responses, summarize their main reasons to live and not to live, emphasizing their
reasons to live. Again you can repeat the client’s reasons why PM+ will be helpful for them. This advice is for
clients who do not have plans to end their life in the near future. For clients who do have such plans, you need to
contact your supervisor and take a number of immediate actions (create a secure and supportive environment;
remove means of self-harm if possible; do not leave the person alone; have carers or staff stay with the person at
all times; if possible, offer a separate, quiet room while waiting; attend to the person’s mental state and emotional
distress with your basic helping skills).

Understanding Adversity
This part of the session is a chance for the client to hear about common reactions among people living in
communities exposed to adversity. The emphasis is on normalizing the client’s reactions in the context of hardship
and stress – i.e. communicating that their reactions are understandable given what they are being exposed to and
are not a sign that they are going crazy or that they are weak.
In giving the client information about adversity, you may want to include examples of emotional and practical
problems that relate more closely to the client than those included in the dialogue. Your examples may be of
previous clients who experienced similar problems (but leaving out their names) or examples you have from your
knowledge of common problems and how particular strategies can help reduce those problems.
I would like to spend some time now talking to you about why you might be experiencing the
problems we have just talked about and how this intervention can help you manage and
overcome these kinds of problems.
When people live in difficult circumstances and experience stressful events, most will
usually experience a range of different emotions, like intense fear, grief, extreme sadness
and excessive hopelessness. Some people even describe not feeling any emotions at all or
feeling numb. Or the feelings you have described, such as (list some of the main emotions
previously named), are also common.
There is a reason why people react that way. Our bodies are designed to keep us alive in lifethreatening situations. So when we think we are in danger, our bodies can respond by being
extremely alert – this is so we can look out for danger and avoid it. Or our heart can beat very
fast, our breathing might quicken, we might feel tense, etc. These reactions help us to run or
fight if needed.
For many people, these problems and reactions go away over time. But for some these
feelings continue. They can then get in the way of us being able to do the things we need
to do in our daily lives, like work at home or on a job. For example, long-lasting feelings of
severe grief can cause people to isolate themselves from family and community members.
Feelings of hopelessness can stop someone doing important tasks for survival. (If possible,
give an example of how the client’s problems have caused difficulties in their life.) Or as you
described, …. In any of these examples, it is clear to see how over time these feelings might
cause many disruptions in someone’s life. In PM+, we have strategies to help you feel better.
I expect that the strategies I will teach you in the next few weeks will be enough to help you
feel better.
So, the first piece of information I would like you to learn today is that many people in your
situation experience emotional and practical difficulties. So the problems you are experiencing
are not a sign that you are weak, and you are not to blame for what you are experiencing.
Actually, having survived very challenging experiences says something about how remarkable
you are. You are also brave to discuss your experiences with me. I believe this is important for
helping improve your own life. It is also important for the lives and futures of your family and
your community. In fully taking part in this intervention, you can expect that you will be likely
to feel better and be able to be a part of your family’s and community’s lives better than you
are at the moment.


Chapter 6
Background
Slow breathing is a basic strategy for relaxation or managing physical symptoms of stress and anxiety. When we
feel stressed or anxious, our natural physical response is for our breathing to quicken, and to take place in the
chest and become shallower. This change might be very subtle and we do not even notice it. But we might notice
the after-effects of this change in breathing – e.g. a headache, chest pain, tiredness, dizziness and so on. By
slowing the rate of breathing and taking breaths from the stomach instead of the chest, we are sending a message
to the brain that we are relaxed and calm. The brain then tells the rest of the body, like the muscles and the heart,
this message and the whole body begins to relax. Being relatively calm and relaxed is an important state to be in,
especially if the client needs to make important decisions or when facing difficult situations.

Including family or friends
Remember that if a client would like a trusted family member or friend to be present when you introduce Managing
Stress, you should invite them in. 

Instructions for slow breathing
The following dialogue helps you explain the purpose of slow breathing to your clients. Where you can, add
information that is relevant to your client’s presenting problems (e.g. specific physical complaints they have,
mentioning examples of times when they have become extremely stressed or anxious and so on): this will make
the instructions more meaningful to the client. Before the client starts to focus on their breathing, get them to try
to relax their body a little bit. This is especially helpful for clients who look tense. To do this you can ask them to
relax their body or muscles by shaking out their arms and legs, making them floppy and loose. They can also roll
their shoulders back or tilt their head to both sides.
Ideally, you would like to help clients breathe at a rate of 10–12 breaths a minute. We use a basic counting strategy
to help clients slow their breathing – three seconds to breathe in and three seconds to breathe out. If clients
become stressed by trying to breathe exactly to the counts, this will not be helpful. Just encourage clients to try
to breathe slowly.
Many people exposed to hardship, danger and stressful life events complain of feeling
overwhelmed by stress and anxiety. For some, this can take the form of constantly having
stressful thoughts fill their heads. Others may experience stress or anxiety in a very physical
way – they might feel tense or uptight all the time, find themselves breathing too quickly or
that their heart is beating much faster than normal. If you experience any of these sensations,
it is first very important for you to know that it is safe for your body to do this. In fact, your
body was designed to do this. If there was a real threat to your life, these physical reactions
are meant to help you respond, in other words you could either run away very fast or fight
back. But unfortunately, for you these physical sensations are very uncomfortable and not
necessary when you are not in a life-threatening situation. They can be a bit like a spring or a
coil. Over time the spring gets tighter and tighter and this becomes uncomfortable. The
strategy I’m going to teach you today will help you uncoil that tight spring. This may not
happen straight away, but with lots of practice the spring will gradually uncoil until you feel
more relaxed and calm.
I am going to teach you how to breathe in a way that will relax your body and your mind. It
will take some practice before you really feel the benefits of it, so we will be practising it at
the end of every session.
The reason this strategy focuses on breathing is because when we feel stressed our breathing
often shortens and quickens. This causes many of the other uncomfortable feelings I
mentioned previously, like feeling tense. So to change feelings like tension, it is helpful to
change your breathing.
Before we start, I want to relax your body a little bit. Shake out your arms and legs and let them
go floppy and loose. Roll your shoulders back and gently move your head from side to side.
Now, placing your hands on your stomach (belly), I want you to imagine you have a balloon
in your stomach, and when you breathe in you are going to blow that balloon up, so your
stomach will expand. And when you breathe out, the air in the balloon will also go out, so
your stomach will flatten. Watch me first. I am going to exhale first to get all the air out of my
stomach. (Demonstrate breathing from the stomach – try and exaggerate the pushing out
and in of your stomach. Do this for at least five breaths.)
Okay, so now you try to breathe from your stomach with me. Remember, we start by breathing
out until all the air is out, then breathe in. If you can, try and breathe in through your nose and
out through your mouth. (Practise with the client for at least two minutes.)
Great! Now the second step is to slow the rate of your breathing down. So we are going to
take three seconds to breathe in and three seconds to breathe out. I will count for you.
Okay, so breathe in, one, two, three. And breathe out, one, two, three. Do you notice how
slowly I count? (Repeat this for approximately two minutes.)
That’s great. Now when you practise on your own, don’t be too concerned about trying to
keep exactly to three seconds. Just try your best to slow your breathing down, remembering
that when you are stressed you will breathe fast.
Okay, so you try on your own for the next few minutes.

Allow the client to practise trying to slow down their breathing on their own for at least two minutes. Try to count
their breaths in and out so you can judge whether they are doing it too quickly. Afterwards, spend some time
talking about any difficulties they had.
Okay, so how was it doing it on your own? Was it more difficult trying to keep your breathing
to a slower rate?
Encourage the client to practise this strategy regularly but also to practise it when they feel anxious or stressed.
You will end every session with Managing Stress, but you may also choose to use it if you notice that your client
is becoming stressed or anxious in the session. In these situations, ask the client if they are feeling anxious or
stressed and whether they would feel comfortable if you stopped the conversation to practice Managing Stress
together. Ask the client whether they would like to do it themselves or whether they would like you to lead them in
it (i.e. count the breathing in and out).
Give your client the Managing Stress handout (Appendix E) to remind them of how to practise the strategy between
sessions.


Problems with slow breathing exercises
Clients might present with a range of different problems when they try to practise slow breathing on their own.
Below is a list of common problems they might encounter. Always speak with your supervisor about how to
manage any problems or complaints a client has when practising any strategy.
Problem 
The client is too concerned about breathing
correctly (e.g. keeping to the three seconds in and
out, breathing from their stomach)
Solution
Encourage the client not to be worried about
following the instructions exactly.
•	 Help them to understand that the main aim is
simply to slow their breathing down in the way
that best suits them, even if it means that they are
not keeping to the counts of three or even if they
are not breathing from their stomach.
•	 Once they have mastered how to slow their
breathing down, they can try to use the counting
or breathe from their stomach.


The client cannot slow their breathing down when
they are at the peak of their anxiety or stress.

•	 Say to the client that this would be very hard for
anyone to do straight away, even a helper.
•	 Spend some time helping the client to identify
early signs that they are beginning to feel anxious
or stressed so they can start slow breathing
earlier.
•	 If this is too difficult, help them to schedule
specific times throughout the day to practise slow
breathing so they learn how to use it before they
get too anxious.

Focusing on breathing makes the client speed up
their breathing and feel more anxious.

•	 Help them to focus on a ticking clock and breathe
to the count of the clock rather than focus only on
the breathing (or a musical beat in a song).


They might also experience feelings of lightheadedness or dizziness, or feel they are losing
control.

•	 Remind them that these sensations are safe and
they are not losing control.
•	 Encourage them to focus just on blowing all the
air out (just the breathing out) and letting the inbreath come naturally (or by itself).
•	 Then they can return to focusing on the whole
process of breathing (in and out).

Chapter 7
Background
Adversity can reduce a person’s ability to respond well to practical problems. They may feel helpless or lack
confidence in managing their problems, or possibly their feelings of anxiety or grief will get in the way of managing
practical problems effectively. Managing Problems is a structured strategy that aims to improve clients’ ability to
solve and manage practical problems. You will spend about 70 minutes of Session 2 teaching this strategy to your
client while applying it to their chosen problem (i.e. usually the one causing them the most distress).

Steps to Managing Problems
Managing Problems follows several steps, explained in detail below. Explain each step in detail to clients while
working through an identified problem in the session. Showing clients the Managing Problems handout can aid
this discussion.

1. Listing problems
In the PSYCHLOPS assessment, you asked the client to name two concerns. The first step of Managing Problems
involves reviewing these concerns, asking if the client has other concerns and deciding whether these are solvable
problems, unsolvable problems or unimportant problems.13 Discuss with your client first which problems are
important but also solvable; in other words, can the client have any control or influence over the problem, or even
just part of it? If your client is feeling very hopeless, they may think that none of their problems can be solved, so
you may have to tell them why you think a problem is actually solvable.
Unsolvable problems are those that you cannot change or have any influence or control over, such as living in a
slum. But sometimes there are parts of an unsolvable problem that can be changed. This usually relates to the
client’s view of the problem. For example, someone with cancer may not be able to change their illness but there
might be things they can do to help with their pain or with problems relating to accessing medical treatments. As
a helper, you will have to explore with the client whether there are any parts to the problem that can be changed
or influenced.
Finally, you should list any problems that the client may see as not important. Tell your client that Managing
Problems is a strategy that can be used to fix or change the solvable problems. 

2. Choose a problem
The second step of Managing Problems is to choose which problem the client would like to focus on. It does not
have to be the same problem as mentioned in the assessment. We would recommend that the client chooses an
easier problem first. This will give them the opportunity to experience early success in the intervention. However,
you should try, at some time during the intervention, to tackle a bigger or more difficult problem with your client.
This is because it may be more challenging for them to properly use Managing Problems without your support.
However, as with other decisions, you should discuss this with your supervisor – as this may not be an appropriate
decision to make with some clients who feel very hopeless.

3. Define the problem
Next, you will help the client to define the problem as specifically as you can. Your task as the helper is to
decide at this point which parts of the problem are practical in nature and suitable for Managing Problems. The
defined problem should also contain elements that can be influenced or controlled. A client might say that “feeling
worthless” is a problem they want to change. But this problem is too big and vague. You need to help the client 
make it more specific and practical. To do this, you might ask some of the following questions (which can also be
used with other examples).
•	 When is this a problem for you? In what situations does this problem happen?
•	 What does this problem look like? If I were to watch you when this problem happened, what would I see,
what would you look like, what would you be doing or not doing?
•	 How would your life (e.g. daily living) be different if you did not experience this problem?
Defining the problem can be the most challenging step for a helper. It is an important step to do well, as it sets
up how you will teach the rest of the strategy. Therefore, we encourage you to prepare, between Sessions 1 and
2, how you might help the client to define some of the problems identified at assessment. This can be a useful
discussion during supervision. 

4. Brainstorm
Once the problem is defined, you should encourage the client to brainstorm or think of as many solutions or
ideas as possible that may solve or change this problem, or part of it. If possible, write down the solutions on a
piece of paper so you can remember them all. This will be important for when you come to Step 5. Consider that
possible solutions may also include existing strengths, resources or support the client already has.

This is not giving advice
Many clients will need some help with brainstorming solutions, particularly if they are feeling excessively hopeless.
The temptation for you will be to tell the client different solutions, especially if you are feeling impatient because
the client is slow with this. However, since PM+ acts like a training programme, it is important that you guide the
client by suggesting general ideas that can help them think of more specific solutions. For example, for a client
who is feeling overwhelmingly stressed about a taboo issue in their life (e.g. a history of sexual assault), you might
encourage them to think about talking about this problem with someone they trust. This would be a preferred
method of encouraging brainstorming as opposed to telling the client to talk with a specific person, such as their
mother, about the problem. The aim is to help the client come up with their own ideas.

Be aware of personal values
This is also a time when you need to be careful that you are not allowing your own personal values to interfere.
For example, you may disagree with the values associated with the possible solutions your client is considering
(e.g. talking with a specific religious leader, cheating to complete a work-related task, refusing to help someone
else), or you might want to suggest a solution that is based on your own value system and not the client’s. It is
very important that during PM+ you put aside your personal values and help the client to make decisions based
on their own personal values and beliefs. Be reassured that this is difficult to do for all kinds of helpers. However,
it is very important for you to respect your clients and not take issue with their values.

Solutions that fix the entire problem
At this stage, it is also important that the client does not become too concerned about only coming up with
solutions that will completely fix the problem. This is often where many clients become stuck when they try to deal
with an issue by themselves. The aim at this stage is to think of any solutions, no matter how effective (or not) they
are in solving the problem, or even just part of it. You might even use humour and offer silly suggestions to illustrate
this point. Also, be sure to remind the client, if they are judging the effectiveness of the solutions or rejecting any of
them, that at this stage they are just trying to come up with as many solutions as possible and not evaluate them.

Feelings of hopelessness
Clients who feel depressed or very hopeless may have a lot of difficulty in thinking of solutions or ideas to change their
problem. This is because they often think that nothing will get better and they have a lot of doubt about their abilities
to change their situation. You can use a number of questions to encourage responses from the client, including:
•	 Asking them to think of ideas that might work for a friend in a similar situation, but who does not feel
depressed.
•	 Asking them what they have been able to try in the past (regardless of whether or not it has worked).
•	 Give broad or vague ideas – e.g. “Some people have found that talking to others can be helpful. Does this
sound like a solution you could use? Who could you talk to? What could you say or ask that might help solve
part of the problem?”

5. Decide and choose
Once you have exhausted all the possible solutions with the client, this is when you help them to evaluate or judge
each solution. You will help the client choose only those strategies that are helpful in influencing or managing the
problem. 

Short- and long-term consequences
In evaluating solutions, it might be helpful to consider both the short- and long-term consequences of different
decisions. For example, choosing to deal with difficult memories of a loved one who has died by getting drunk
might help a client with their emotions in the short term. However, this is an unhelpful long-term solution as it can
cause other problems. So it would not be a good solution for the client to choose.
Unhelpful solutions
When the client chooses a solution that is clearly unhelpful, you can be more direct. An unhelpful solution would
be one that causes significant problems for their physical or emotional well-being, for their friends and family
members or for their work or social life.
For example, let’s use the previous example of regularly getting drunk to manage grief. In the short term this
might be effective, but long-term heavy alcohol use is likely to cause more difficulties with the client’s emotional
well-being (e.g. it keeps people feeling depressed) and also physical well-being (e.g. it can lead to liver and kidney
problems). It might also upset family and friends, and affect the person’s ability to work (e.g. having to take days
off work because of drinking, poor concentration at work because of a hangover). Other examples of unhelpful
solutions include becoming physically aggressive, using drugs or engaging in illegal or dangerous activities

Achievable solutions
You should help the client consider how achievable it is to carry out each solution. While one idea might be very
effective, if the client cannot carry it out due to a lack of resources, it is not going to be a good solution to pick.
For example, one client identified not having a job as his major problem. The helper worked with him on thinking of
particular solutions to the problem. In this discussion, the client mentioned that he had been offered a job recently
with a good wage. Although this would have been a very good solution to his problem, after further discussion
the client realized that the job was actually very risky – he would have to work at night in a very dangerous area
of the city. The client decided that, because he had a young family, he did not want to risk his life to get the job.
Because of this, he decided that this particular job was an unhelpful solution to his problem. However, the helper
and client decided that he could speak with the manager and ask whether there were other jobs in less dangerous
areas of the city.
The client will then choose the best solution (one solution or a combination of them) for their problem. 

6. Action plan
Lastly, it is very important to spend a good amount of time helping the client to design an action plan to carry out
the chosen solution. This includes:
•	 breaking down the solution into small steps (e.g. finding work might involve getting information about what
work is available, learning about what is needed for different jobs, reviewing and, for some jobs, updating
letters of recommendation and so on);
•	 helping the client to choose a specific day and time when they will carry out each of the tasks will also help
them to succeed in completing those steps. You may use the calendar (Appendix E) to record when the
client will complete the action plan steps;
•	 suggesting reminders that might help make sure that the client completes the desired tasks (e.g. using
alerts on a mobile phone, arranging tasks so that they coincide with community activities or meal times, or
having a friend or family member remind them are all good ways of helping the client complete the tasks).
If a solution involves talking to someone else and the client does not feel confident about this, role-play (or
practise) this interaction with the client. This can be a good way of helping them practise what they would say if
their plan involves asking for something or talking to someone. It can improve their confidence and the chances
of them carrying out the plan.

7. Review
In the next session, you will spend a large part of the time reviewing how things went in completing the planned
tasks. Discuss and manage any difficulties that came up in completing the tasks, so the client can spend the
following week trying to carry out the desired tasks again. If the client managed to complete the plan, you may
talk about what next steps they need to carry out to continue managing the problem.
Reviewing is also important in increasing the client’s self-confidence, as well as conveying to them that you
believe that completing these tasks is important and you care about whether the client can get them done.
This helps to build the relationship, as well as keeping the client responsible for making efforts to practise the
strategies in their own time.

Introducing Managing Problems
Today we are going to start with the problem you said is causing you the most concern. (Name
it and check that the client still wants to work on this problem first.) Our starting point with any
problem is to decide which parts of it are practical. (You may need to tell the client what parts
are practical the first time.)
The strategy I am going to teach you today will help you with the practical parts of your
problem. It is called Managing Problems. Our aim is to see what elements of the problem
you can solve or influence. You might not always be able to solve the whole problem, but
rather you might be able to influence it somewhat or change the way you are responding
to the problem, which can help reduce negative feelings. (Specify with the client’s negative
feelings.)
Go through each of the Managing Problems steps with the client. Be sure to explain clearly the aim of each step
(use the Managing Problems handout to help you).
For example, you might say the following for Step 3, Brainstorming solutions:
At this point, all you want to do is come up with as many possible solutions to this problem as
you can, no matter whether they are good or bad ideas. In the next step you will decide which
solutions are most helpful to solving the problem.
Ongoing adversity or threat
Many of your clients are likely to be experiencing continuing adversity or even threatening situations, and
these may work against their ability to solve or manage their problem. This may be because it is unsafe
for them to carry out particular solutions (or even engage in other strategies). At all times you will need to
consider this and discuss ways to make sure that the client is as safe as they can be, while also helping
them to consider ideas to manage their problems. Both you and the client may need to acknowledge that
particular problems cannot be “solved” by them in the midst of their current situation (e.g. if they are in
poverty, an area of conflict, etc.).
It will also be important for you to keep finding information as to what the realistic risks are for the client. In
all situations there is likely to be some risk involved. However, clients may overestimate likely threats. If you
are not sure about whether the probability of risk is high for a particular activity, you should always consult
your supervisor first.


Case example
Loma is a 34-year-old woman who reports that her main difficulty is her relationship with her husband.
She told her helper that her husband had recently lost his job and that he has been particularly stressed
and angry since that time. This has put a lot of pressure on their relationship and Loma is beginning to feel
extremely hopeless about the situation. They are fighting nearly every day. It is also affecting her mood –
she says she feels very sad most days and has a lot of difficulty doing things she used to do. In particular
she has not been seeing her friends recently, partly because she just does not feel like it, but also because
she is embarrassed about the problems she has been having.
Loma and her helper discussed all the problems she had reported in the assessment and decided that
the problem of fighting with her husband was the most important and most solvable one. They decided to
choose this problem because it was causing her a lot of difficulties. She did not have an easier problem
she wanted to deal with. Problems that were considered important but unsolvable included her husband
getting a new job and stopping her husband from feeling angry or stressed. She did not believe that any of
her problems were unimportant, so this list was left blank.
Loma carried out the Managing Problems strategy with her helper, although initially she had a difficult
time brainstorming possible solutions. She and her helper worked together – see the completed Managing
Problems worksheet on the following page.

Chapter 8

Background
Where there is adversity, many people experience symptoms of depression. These can look different for different
people, but depressive symptoms commonly include feelings of being easily tired, hopelessness, continuing low
mood, lack of motivation or lack of enjoyment in activities that usually gave the person pleasure. Also, people
often have a lot of physical complaints (e.g. aches and pains). Over time, many people will respond by withdrawing
from their usual activities. This is also common among people who have experienced traumatic events or who are
experiencing grief related to the loss of loved ones, job loss or loss of meaningful possessions.
Types of activities that people often stop or reduce include the following:
•	 pleasant events (e.g. activities they used to enjoy);
•	 social events;
•	 essential activities for daily living, which include:
- household duties (e.g. cleaning, tidying the house, food shopping and preparation, child-care tasks);
- employment duties (e.g. reduced activity at work or in extreme cases no longer going to work regularly
or at all);
- looking after themselves (e.g. getting out of bed, washing regularly, changing clothes and eating
regular meals).
Over time they will develop a cycle of inactivity and low mood. This is often because a client who is feeling low will
say, “I will do xx when I feel like it.” Unfortunately, withdrawing from these activities only causes the low mood to
continue. The lower a person feels, the harder it is for them to start doing things again.

Get Going, Keep Doing aims to break this cycle and improve the client’s mood by encouraging them to get
involved again in pleasant and task-oriented activities in spite of their mood.14 You will need to communicate to
clients that they need to “do first and the motivation or positive feelings will follow”, rather than wait until they feel
motivated before starting an activity.
Because clients will probably feel like they cannot take part in an activity or have very little motivation to do it, it
is important that you set very small goals for the client to achieve. This is a strategy in which experiencing some
success in doing even a small part of a task is really helpful for improving the client’s mood, sense of achievement
and confidence. So it is important to try to set up the task as best you can in a way that means there will be
some success. Choosing simple tasks and breaking them into small steps is one way of making sure that this is
a success.

Case example
A client was no longer taking part in a community event that he previously enjoyed. The event took place
three evenings a week. The client’s helper suggested that he begin by going to one event with a friend,
but not actually take part in the event (in other words, just watch). The client could then slowly build up to
attending more times in the week as well as increasing his involvement in the event. 

In more severe cases of inactivity and depression, you may need to break the tasks down into very small steps.
Many clients find that starting the task is the most difficult part but that once they have started, they can continue
with the task and possibly complete more of it than originally planned. For this reason, suggesting to the client a
simple and easy first task might help them to get started.

Case example
A client decided to do clothes washing over the coming week. She was feeling very tired and sad and
thought the task was too big, and as a result she had not been doing any washing. The helper suggested
breaking the task down into smaller steps – collecting all the dirty clothes that need washing one day,
sorting the clothes into different piles another day. This would be followed by choosing one pile of clothing
to start with and aiming to wash one item of clothing each day.

When motivation or mood is particularly low, developing a routine or scheduling activities at a specific time of the
day may help. Help the client choose a time and a day when they will be least distracted and also the time when
they often feel the least tired or hopeless (e.g. mornings after the children have gone to school). Using the calendar
worksheet (see Appendix E) might be helpful in recording this information for the client to take home. Using
other reminders might also be helpful: for example, using alerts on their phone, matching tasks with community
activities or meal times or having a friend or family member remind them are all good ways of helping the client
complete the tasks.

Explaining Get Going, Keep Doing to the client
As with all the strategies you introduce, it is important to explain that Get Going, Keep Doing is effective and vital
for emotional well-being. Giving a good explanation is particularly important if a client has tried to increase their
activity in the past but has failed. It may take some time to convince them to try again. Often there has been failure
because the client has set goals that are too ambitious and difficult to complete. As a result, it is very important
that when providing an explanation to the client you communicate warmth and understanding for their concerns,
even if these include a lack of faith in this strategy. Consider emphasizing to the client that they have nothing to
lose by trying to become more active.

Including family or friends
Remember that if a client would like a trusted family member or friend to be present when you introduce Get
Going, Keep Doing, you should invite them in. This may be helpful, especially if the friend or family member can
help the client take part in their tasks and activities. 

1. Introducing the inactivity cycle
In introducing Get Going, Keep Doing, be sure to relate the general information to the client’s specific problems.
In particular, talk about how you see the client’s problems contributing to their current withdrawal from specific
activities. Also show the client the Get Going, Keep Doing handout (Appendix E) when explaining the cycle.
The following is a standard introduction. You may want to add information that is relevant and specific to the
client, or you may want to include more specific information after giving this introduction (e.g. “Now what I have
become aware of from what you have told me is that you have stopped doing…”). It is a matter of what you feel
most comfortable and confident with.

It is very common for people who are exposed to hardship, loss and stressful life events to
experience changes in their mood and to get tired easily. Over time, if a person’s mood does
not improve, they often begin to feel a lack of energy and motivation to do things they used
to do quite easily. They may also start to find they no longer enjoy activities that used to give
them pleasure. This can start a cycle where the person’s mood gets lower, which leads to
more withdrawal from activities, which results in a further lowering of mood and so on. (Draw
this cycle, as above, for the client.)
We call this cycle the inactivity cycle. Unfortunately, this cycle of inactivity keeps you stuck
in your low mood or grief. Often people will think, “I will start doing things again when I feel
better.” Or they think that feeling energetic leads to getting active, but actually getting active
leads to feeling energetic. So many people do not start feeling better until they get active.
To break this cycle you need to start doing things again, even though you may not feel like it.
Remember that many people do not start feeling better until they get active.
For many people it is starting the activity that is the hardest. But I can assure you that many
people find that once they start doing activities it gets easier to keep going

Case example
A client had excessive feelings of hopelessness about unemployment, poverty and high rates of violence
in his community, which made it unsafe for his family to leave the house. He often said in sessions, “Life
will never improve. I cannot do anything to change this; my children will grow up in poverty because I
cannot change anything.” He had begun to withdraw significantly from his family, due to feelings of extreme
worthlessness and guilt that he could not provide a better life for them.
His helper said to him, “This situation sounds difficult for you and your family. And I think it’s understandable
that to some extent you would feel hopeless about it and also upset about how it might affect your children.
But I can also see how these feelings may actually be keeping you stuck in this situation because they are
very strong. Although you cannot change the whole problem of poverty and violence in your community,
there are often small things you can do to help improve your situation or improve your mood, so that when
situations change you can act on them, because you are feeling more positive. For example, taking small
steps to get going now will make it easier to find a way to make a living if an opportunity becomes available.
Acting on this kind of opportunity can be too difficult to do when you are feeling very hopeless or worthless.
“These feelings of hopelessness and worthlessness are common for people who live in situations like yours.
And it is very common for people to begin to withdraw from their usual activities, such as doing enjoyable
things with their family, because they feel so negative or tired. But over time a cycle of inactivity develops
and actually makes your mood worse, so that you may feel depressed or completely unable to act in a
positive way on practical problems. I want to talk with you now about a strategy that aims to increase your
activity again so that your mood and feelings of tiredness will improve. You may also find that you are better
able to face these difficult practical problems once you start this strategy.”

2. Identify activities in which the client can begin to get involved again
For this step, you can use the examples from the activities boxes below. Spend a very brief time identifying at least
one pleasant activity (any activity from the first three boxes) and at least one task (any activity from the last two
boxes). A pleasant activity could be something enjoyable that the client used to do but has stopped doing (e.g.
playing with their children). Essential tasks for daily living would include paying bills, shopping for food, washing,
eating and so on. Having a balance between activities that give pleasure and those that improve the client’s sense of
achievement can be very helpful for improving mood. Be aware of keeping this balance. In other words, try to avoid
having the client only take part in pleasant events unless they already carry out everyday tasks without difficulty.
Many clients might have their own suggestions about what activities they would like to take part in again. These
might be activities that used to bring them pleasure or peace, help manage pain or help them feel like they have 
achieved something. However, if the client needs some help in identifying activities, give examples from the boxes
below or activities you consider appropriate for the client.
It is up to you and the client to decide together how many activities would be manageable for the client in a week.
But you want, as best you can, to make sure that the client will have some success so they can increase their
confidence. If the client is unlikely to be able to manage two activities, pick one (pleasant or task-oriented) that will
make the greatest difference for them. This may be decided by the client if there is something they really want to
start doing regularly again. Or there may be an activity that you believe will be very helpful for the client’s mood or
other practical problems if they take part in that activity again (e.g. playing with the children may lessen a client’s
identified problem of a child being very demanding of their attention).
You may find that the client chooses some activities that also involve other strategies, such as visiting friends
(Strengthening Social Support) or slow breathing (Managing Stress). This can be very helpful.
Thinking about the things you used to do before you were feeling this way, what is one pleasant
or enjoyable activity that you could start doing again or do more often? And thinking about
when you were feeling better, what is one task, at home or at work, that you were doing
regularly that you are no longer doing or that you do less? Great, so we will spend some time
now scheduling in these tasks for you to start doing them again over the next week.

3. Breaking down the task into smaller steps
Given the client’s low mood, lack of energy or grief, it is important to break the overall task down into smaller
and more manageable steps. Remember, this is so that the client does not feel overwhelmed with the task and
to make sure that they experience some success in completing the task. This will encourage self-confidence and
begin to influence their mood.
For example, “cleaning your apartment or hut” might be a major task. Breaking this task down by choosing small
sections of the apartment or hut to clean (e.g. cooking area, sleeping area and so on) makes it more manageable
and achievable for the client. 

4. Schedule in tasks
Be very specific with the client about choosing a day and a time when they will plan to do the activity, and write this
information on the Get Going, Keep Doing worksheet. You may only start with small goals, such as completing the
activity once in the next week. Using reminders might be a helpful way of making sure that the client completes
the desired tasks. For example, it may be helpful to use alerts on their phone (if they have one), matching tasks
with community activities or meal times, or asking a friend or family member to remind them. You may also find it
helpful to use the calendar worksheet to help the client remember to complete their activity or task. 


Grief and loss
Grief is a very individual experience. People grieve the death of loved ones or other losses (e.g. their
home, job, possessions) in different ways and for different lengths of time. However, there are often some
similarities in the emotional problems that people describe when they have experienced the loss of a
loved one. For example, it is quite common for clients to experience psychological distress that looks very
similar to depression – persistently low mood, not enjoying things as much as they used to, withdrawing or
isolating themselves from others, lacking energy and so on.
For most people, these emotional problems will diminish over time. In some societies, people are expected
to return to normal life in a month and in others in a year or more. Yet in many other societies this is
not specified. In most cases, people will start to return to their normal selves within the first six months
after their loss. This does not mean that they have necessarily stopped grieving, just that these emotional
problems are no longer interfering with their functioning in life (e.g. going to work, socializing and so on).
However, for a separate group of people, these problems can continue.
Get Going, Keep Doing (along with Strengthening Social Support) is an appropriate strategy to use with a
grieving client when their emotional problems and withdrawal from usual activities and routines interfere
with their expected functioning. However, you should not use it if the withdrawal or lack of activity is seen
as part of a culturally appropriate period of mourning.

Chapter 9
Background
People tend to cope better when they have good social support networks (in other words, friends, family members,
community or religious groups, mental health support groups and so on, who offer care and support). A person
does not necessarily need many social supports, but they need someone who can be helpful. Specifically, they
should be useful for the person’s needs.
Sometimes emotional problems can affect a client’s ability to get support when they need it. Grief is a particular
case where isolation can be common. This is because many grieving people believe that they cannot spend time
with others because it is meaningless without their loved one around or that no one would understand what they
are experiencing. They may yearn for, or think constantly about, the person who has died. They can present with
problems similar to depression, such as low mood, lack of energy and lack of enjoyment in activities.
Over time, isolation can be devastating for a client’s emotional well-being. Spending time focusing on helping
clients strengthen their social supports may have a big effect on their overall emotional well-being and
functioning.
Strengthening social support can mean different things to different people. Different forms of support include:
1. having a friend or family member listen and validate the person’s concerns and emotions, rather than be
dismissive and not show any care;
2. connecting with an agency that is providing needed and appropriate information and support to the person;
3. getting help to complete a difficult task or providing a way of completing a task (e.g. driving them somewhere,
borrowing something from them, etc.);
4. Spending time with others but not necessarily talking about problems (e.g. sharing a meal);
5. Helping other people (while not forgetting to take care of oneself).
When clients do not have any support, you should help them to connect with some form of support, such as
a trusted friend, family member or community service (e.g. a community organization). If clients have support
networks but do not appear to be using them, you should discuss how they could better use these support
networks. For example, a client who has been to a women’s support group in her community once but has
not continued because she felt too tired could be encouraged to start going to the group again. Or you could
encourage a client who has a trusted friend to contact this friend.
Lastly, if clients appear to have support networks that are unhelpful, you should discuss this with them and help
them to find more helpful and appropriate support from new or different networks. For example, a family member
might tell a client that their problems are not as bad as their own. You should encourage this client to consider
how helpful it is to share information with this person and whether there is someone else they can talk to who will
respect and validate their concerns.

Trust
Central to this strategy is having a trusted person or organization from whom the client can get support. Trust is
even more important when you are encouraging a client to share their problems with others. Trust is something
that is developed gradually with someone over time. You do not either trust someone with everything personal
about yourself or not trust them at all. For example, you might start by sharing a little bit of information about
yourself. If you find out that the person has told many other people this information, this is a good indication that
they are not trustworthy. However, if they have kept that information a secret, you might share something a little
more personal with them next time. Each time you talk to them, you might share some more personal information.
In the case that a client is planning to talk with others about their problems or emotions, suggest to them that they
share only small and less important pieces of information if they are not sure whether the person can be trusted
or they are feeling nervous about trusting others. This is also helpful advice for clients who often tell others too
much personal information. This can cause problems if they have not carefully chosen someone to trust and the
information is not kept confidential. In the case that a client decides to ask for support by getting practical help
from someone else, it might be best for them to start with a small request. 

Sexual assault
In the case of sexual assault, or other forms of intimate traumatic experiences, trusting others might be
particularly challenging for the client. While you should respect this, you should also encourage the client
to strengthen their social support as much as possible.
They should never be pressured to discuss their traumatic experiences with someone else if they do not
feel comfortable doing so. In fact, it may not be in their best interests to discuss this if there is a reasonable
chance that the other person will not keep the information private or be sympathetic. Rather they might
strengthen the stigma about this experience. If the other person is likely to not believe them, or dismiss
or blame the client for what happened to them, they should not be encouraged to talk about this with the
person. For more information on the difficulties of clients with a history of sexual assault, see Chapter 3).
For these reasons, it is particularly important that the client picks someone who can be trusted. At first,
the client could share information that does not relate to their assault history. For example, they might talk
about a practical problem (e.g. employment difficulties), they could ask for help with completing a practical
task (e.g. borrowing something). Starting with easy and less threatening information to share will help the
client feel more comfortable in strengthening social support networks. It is also an opportunity for the client
to test out how much they can trust this person.
In the end, the client might decide that they do not want to tell others about their survival of sexual violence,
and you should let the client know that this is okay. The aim of Strengthening Social Support is not
necessarily to tell others about problems. You can encourage the client to spend time with others whose
company they may enjoy, but they might not want to let others know about their experience. You may be
the only person they share details with, but they still need social support from others.

Introducing social support to the client
You may show your client the Strengthening Social Support handout (Appendix E) while explaining the strategy.
Strengthening social support can mean different things to different people. For some people,
it means sharing their difficulties and feelings with other people they trust. Or it might just be
helpful spending time with friends or family and not talking about problems. For others, it
might be asking to use resources from trusted people, such as tools or even knowledge that
is needed to get something done. And for others still, it might mean connecting with
community organizations or agencies to get support. These forms of social support can be
very powerful in reducing difficulties and distress. Is there some way you think you might be
able to strengthen your social support?

Help the client to decide in what way they want to strengthen their social support, e.g. by talking to someone, by getting
more practical help, such as borrowing something, or connecting with another agency or community organization.
If the client is not sure about strengthening their social support, even though you have reason to believe they need
to, you may want to discuss this further.
Many people feel unsure about talking with others about their problems or asking others for
help. One reason is because they are worried they will burden the other person with their
problems. This is often not true. People will often share their own problems when they hear
their friend tell them about their problems. Or they might ask for help in return. This might be
because that friend is also experiencing similar problems. Rarely will one person only talk
about their problems or only ask for help. It can also be helpful hearing other people’s
difficulties so you get some perspective on your own issues, especially if you think you are the
only one experiencing a problem.
Another reason people do not get support from others is because they have no one they can
trust. If you think you don’t have anyone you can trust, shall we discuss more together on
finding someone that you can trust?
Spend some time talking with your client about people or services from whom they may feel comfortable getting
some support.
Once the client has identified at least one person, community organization or more formal support agency that
they are willing to get support from, help them with the following.
•	 Plan exactly what they are going to do (e.g. call or visit the person). Be sure to break this plan down into
small, manageable steps.
•	 Decide what day they will do this.
•	 Ask them what they will tell the person or agency or what they will do with them (e.g. talk about a practical
problem and how that makes them feel, about being involved in PM+, about the specific problem you are
working on with the client in the session). You may even make time for the client to rehearse what they will
say to the person or organization.
Using reminders might be a helpful way of making sure that the client completes the desired tasks. For example,
using alerts on their mobile phone, matching tasks with community activities or meal times or having a friend or
family member keep them accountable are all good ways of helping the client complete the tasks.

Excessive social isolation
Some clients may have isolated themselves for a long time. So talking about Strengthening Social Support
may actually make them feel nervous. They may not be ready or willing to connect to people by sharing
personal information, asking for help or even just spending time with others.
In these cases, help the client think about small tasks they could do to start connecting with others. For
example, could they start by smiling at familiar people? Could they make eye contact (or other culturally
appropriate non-verbal signs of communication)? Would they be willing to say hello to their neighbour or
ask a family member over for a meal?
In this way you are helping them build their confidence in connecting with others and gradually strengthening
their social supports.

Chapter 10
STAYING WELL AND LOOKING FORWARD

Recovery and staying well
When we consider how people recover after treatment for a physical illness or injury, it is usually not perfectly
smooth. People will experience varying levels of pain during this recovery. Some days will be better than others.
But generally, if people practise the exercises or keep to the recovery plan their nurse or doctor has given them,
they do get better.
The same process of recovery happens with emotional problems or illnesses. People are likely to experience
“ups and downs” with their emotions in the same way that people recovering from physical illnesses and injuries
do. Continuing to practise the strategies after finishing the intervention is important for staying well. This will help
clients prevent a full return of their problems as well as strengthening their confidence in using the strategies. In
this way, in the future when a problematic situation arises that causes distress, the client is more likely to be able
to respond to it using these strategies.
When clients do face other (new) adversity (e.g. the death of a loved one, loss of a job, illness, increased
community violence and so on), it is normal for them to experience unpleasant feelings, such as sadness, anger,
grief or worry. Remind clients that when these feelings do not interfere with the way they are functioning, the
feelings might be considered normal. However, if a client does start to feel very distressed again and in a way
that interferes with their daily functioning (in other words, going to work, looking after children and so on), it is
important that they respond quickly by practising in one of the PM+ strategies (Managing Problems; Get Going,
Keep Doing; Strengthening Social Support; or Managing Stress). Ask the client to look over their PM+ materials
and start practising the appropriate strategies.
Introducing Staying Well
You will introduce Staying Well in Session 5, the final session with your client. This will happen after you review the
client’s progress on all the strategies you have taught them so far (this should take about 30 minutes). You will have
about 30 minutes to discuss Staying Well with the client before giving them the post-intervention assessment.
This session should be positive. So, start by praising the client for participating in PM+. You may want to ask
them their views on how they have improved or not improved. Where possible, give examples of when the client
has made important gains or shown considerable effort or courage (e.g. when they faced an unrealistic fear
or developed a new trusting relationship with someone). These comments are meant to reinforce the client’s
confidence in practising the strategies by themselves and managing their own emotional problems.
For example:
As you are aware, today is our last session and I want to start by congratulating you on
reaching this stage. You have shown a lot of courage and effort to talk about some difficult
topics and face these head-on. How do you feel about this being the last session? Are there
areas that you think have improved since starting PM+? What about areas that have not
improved? Do you have any ideas about what you can do to try to improve those areas?
Secondly, you should encourage the client to continue practising the strategies to stay well. You might start by
asking them to think about what they can do to stay well. You can also emphasise to the client that they have the
handouts, which they can use to remind themselves of the strategies (see Appendix E).
For example:
So, we are going to talk about how you can stay well after finishing PM+. Do you have any
ideas about what you can do to stay well?
An example where you might be clearer about what the client can do to stay well:
I like to think that PM+ is similar to learning a new language. I have coached you in learning
some strategies to help you deal with different problems in your life. Just like learning a new
language, though, you need to practise it every day if you want to speak it fluently. In the same
way, if you practise these strategies as often as possible you will have a better chance of
staying well. Also, if you face a difficult situation in the future, you will have a better chance of
managing it well if you have been practising the strategies regularly.
There is nothing magical about this intervention. You have learned it all and can apply it to
your life by yourself. You are your own helper now. And if you need any help remembering
how to use the strategies, you have these handouts you can look back over. You might want
to use these pictures or something else to put around your house to help remind you of the
things you have learned here. Some people have stuck notes on their walls or put them in
areas of the house where they spend most of their time so they never forget the strategies.

Spend some time then talking about what specifically the client could do if they experience a severe stressful
event or negative feelings in the future. Give the client the opportunity to tell you what they would do first. Help
them be as detailed as possible in describing how they would respond (e.g. ask them for suggestions about ways
they could improve their social support, rather than just saying, “I will strengthen my social support”).
It is not uncommon for clients to experience difficulties in the future. What do you think you
can do the next time you experience a very difficult situation or notice negative feelings again?
(Give specific examples relevant to the client, e.g. losing a job, conflict with a partner, feeling
depressed and so on.)
Give the client an opportunity to identify some ideas or talk about particular strategies first. You might need to
prompt them to think about what specifically they found helpful in PM+ (in other words, what has already helped
them to manage particular emotions and problems).
In this discussion, you want to encourage the client to make an effort to practise the PM+ strategies they have
found helpful when they face any future difficulties. However, you may also want to tell them that if they are
unsuccessful at managing their problems (i.e. if they are practising the strategies regularly but they are continuing
to experience severe emotional problems), other options might be available for them. These will depend on your
setting and the resources available, but may include contacting you again for extra sessions or a referral to a
specialist. 

Imagining how to help others
For many clients, it may also be helpful to make sure that they understand each of the strategies you have taught
them. Spend about 20 minutes, using the case examples in Appendix F. Ask the client to imagine that each of
these people were a close friend and to think about what strategy they would suggest their friend should practise.
If clients find this task difficult, use it as an opportunity to teach them what strategies suit which problems. If
clients prefer to talk about a real friend who is experiencing problems, use their example instead.
What we are going to do now is work together as helpers, so you can feel confident that you
understand all the strategies in PM+ and when it is best to use them. So, I have some examples
of different people here and I want you to imagine that this is a close friend or family member
of yours. Once I have read the example, we will spend some time talking about how you might
help them deal with their problems using any of the strategies you have learned. (Read the
first example in Appendix F.)
Can you make some suggestions as to which of the strategies you have learned might be
most helpful to them?

Looking to the future
Sometimes it can be helpful to discuss briefly (about 15 minutes) with a client what goals they have for themselves
in the future. This can help clients consider how they might continue practising the strategies, for example by
choosing other problems they want to address with PM+.
Once a client has identified a goal (or some goals), discuss how they might begin to tackle this goal. For example,
what could be the first thing they do or what could they plan to do in the next few days, next week, next month and
so on? The more concrete or specific the client’s goals and plans, the easier it will be for them to carry them out.
Finally, I would like to spend a little bit of time talking about how you might continue to practise
the strategies you have learned in PM+ to achieve some goals you might have. Are there any
current problems that you would like to deal with in the short term with any of the strategies?
(If the client is having difficulties identifying any goals or problems they would like to deal with, you may want to
refer back to their original list of problems from the assessment.)
So, thinking about this problem, what is the first thing you might be able to do to start solving
or reducing the problem? When could you do this?

Post-intervention assessment (if there is time)
At the end of the session, remind clients that you will contact them to complete the post-assessment in the next
1–2 weeks. If it is possible for you to complete the post-assessment at the end of Session 5 this is also okay.
Please see Chapter 4 on how to conduct an assessment.

Ending Session 5 and PM+
To end PM+, thank and congratulate the client again. Wish them luck with their recovery and remind them to keep
working on their strategies. We recommend that you arrange to follow up with the client in several months’ time
to check on their progress. It may be helpful to check at this point whether the client is planning on relocating or
moving out of the area.