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Bringing Mental Health to the Frontlines: What Community Organizations Can Learn from PM+ and Step-by-Step

Intervention Brief Half Circle Logo Intervention Brief​

Introduction

In Canada’s social sector, front-line staff are stretched thin. Coaches and advocates often find themselves supporting clients facing housing instability, food insecurity, trauma, and extreme stress—without adequate tools, training, or time. As demand for mental health-informed approaches rises, so does the need for interventions that are evidence-based, scalable, and designed for delivery by non-specialists.

That’s why two innovations from the World Health Organization (WHO)—Problem Management Plus (PM+) and Step-by-Step (SbS)—deserve attention. Developed for conflict and disaster-affected populations, both have been shown to significantly reduce psychological distress, even when delivered by trained laypeople. They are low-cost, scalable, and relevant far beyond their original global contexts.

This brief explores how these interventions work, why they’re effective, and how they might inform stabilization support in community based non-profits.

What Is PM+?

Problem Management Plus (PM+) is a brief, structured, intervention developed by the WHO and designed to address many mental health challenges for people facing extreme adversity. It targets depression, anxiety, grief, and stress through five core strategies, delivered in five sessions:

    • Managing stress
    • Problem solving
    • Behavioral activation
    • Strengthening social support
    • Staying well and relapse prevention
 

Importantly, PM+ is designed for delivery by non-specialist helpers—people who receive brief, structured training and ongoing supervision. This makes it suitable for integration into community support contexts.

“PM+ is not therapy in the traditional sense. It’s a focused problem-solving approach delivered by trained laypeople.” – Dawson et al., 2015Sustainable-Livelihoods

What Is Step-by-Step?

Step-by-Step (SbS) is a digital, guided self-help version of PM+, optimized for mobile delivery. Individuals progress through five modules at their own pace, supported by brief weekly check-ins with a helper (either by phone or chat). It uses stories, animations, and exercises to teach the same core PM+ skills.

Studies in Lebanon and other contexts show that SbS significantly reduces depression and improves functioning—even among people with severe trauma histories or displacement.

“Guided digital self-help interventions like SbS offer a feasible, scalable way to address large unmet mental health needs.” – Wang et al., 2020

Why It Works: Core Design Principles

1. Simplicity Without Oversimplifying

Both PM+ and SbS use short, structured modules built on behavioral principles. This keeps delivery manageable for helpers and accessible for participants.

2. Transdiagnostic Approach

Rather than diagnose or pathologize, PM+ helps participants tackle practical problems. This aligns well with the stabilization-first philosophy of organizations like Rise Calgary.

3. Behavioral Activation at the Core

Both programs rely on helping participants “do more of what matters”—a proven technique for breaking cycles of rumination and withdrawal, especially in depression and chronic stress.

4. Scalable Delivery by Non-Specialists

Perhaps most critically, both models have been shown to work when delivered by trained laypersons—freeing up specialist time while expanding access.

Evidence and Outcomes

A recent meta-analysis by Dorsey et al. (2020) showed that PM+ consistently reduced depression and anxiety symptoms across multiple conflict and crisis settings. Notably, it also improved functioning—a critical, often overlooked outcome.

Key findings include:

  • A moderate to large effect on psychological distress across populations
  • Delivery by non-specialists still yielded significant benefits
  • Positive outcomes sustained for at least 3–6 months post-intervention

For Step-by-Step, studies have shown:

  • Up to 40% reduction in depressive symptoms
  • High retention even among refugees with no prior digital literacy
  • Acceptability among both clients and helpers
 
“The most powerful thing about these models is their transferability. They show that even under extreme adversity, structured support delivered by peers can work.” – Rahman et al., 2016

The global rollout of Problem Management Plus (PM+) and Step-by-Step (SbS) has produced consistently strong results across settings marked by displacement, trauma, poverty, and limited mental health infrastructure. Crucially, these outcomes have been achieved even when interventions were delivered by trained laypeople or through digital tools.

Key Results Across Populations

  • PM+ (Syrian refugees in Jordan)
    • ↓ PHQ-9 depression scores* by ~4.2 points
    • ↑ Daily functioning
    • Format: 5 in-person sessions over 5 weeks with non-specialist helpers
  • Step-by-Step (Refugees in Europe)
    • 3× greater recovery rates than control
    • ↑ Well-being and daily functioning
    • Format: 5–8 weeks, mobile app with weekly chat support
  • PM+ (Women in Kenya)
    • ↓ Psychological distress
    • ↑ Ability to manage daily life
    • Format: Delivered in both individual and group formats
  • Step-by-Step (Adolescents in Lebanon)
    • ↓ Depression symptoms
    • ↑ Behavioral activation and hope
    • Format: 6 weeks, self-led mobile app with optional helper check-ins

Rahman eta l. (2016
Dawson et al. (2015)
Dorsey at al. (2020)
Wang et al. (2020)

* for illustration – based on narrative results.

Dawson et al. (2015)
Rahman eta l. (2016)
Dorsey at al. (2020)
Wang et al. (2020)

* for illustration – based on narrative results.

What Stands Out?

  • 60–70% completion rates, even among participants with low literacy, high trauma exposure, and limited digital access
  • Functional gains were as significant as mental health improvements, reinforcing the role of these interventions in rebuilding daily agency—not just reducing symptoms
  • Both PM+ and SbS demonstrated flexibility across formats (individual, group, mobile) and applicability across age groups, from adolescents to adults
 

These outcomes are especially notable in humanitarian and low-resource contexts—yet the underlying principles of action planning, problem-solving, and emotional regulation are equally relevant in urban Canadian settings where clients face chronic stress, poverty, and precarious housing. 

What is PHQ-9?

The PHQ-9 is a brief questionnaire used to assess depression. It measures how often a person has been bothered by nine symptoms over the past two weeks. Scores range from 0 to 27, with higher scores indicating more severe symptoms. A reduction of 4+ points is considered a clinically meaningful improvement.

Implications for Canadian Social Sector Organizations

Many of the challenges PM+ and SbS were designed to address—trauma, instability, lack of access to care—are deeply familiar to Canadian advocates and coaches working in stabilization. The difference is that these interventions provide a scalable model, backed by strong evidence, for offering emotional and behavioral support at the front lines.

Imagine equipping housing support workers, food bank volunteers, or employment coaches with the tools to help clients de-escalate stress, problem-solve, and re-engage with their goals—not in a clinical role, but as trained supporters within their existing remit.

At Rise Calgary, for example, Stabilization Advocates are already operating in this relational space. What’s often missing is the structure, language, and evidence-backed techniques that allow for consistent support—something PM+ and SbS may offer a blueprint for.

Recommendations for Practice

For Canadian organizations working with individuals facing instability, Problem Management Plus (PM+) and Step-by-Step (SbS) offer a blueprint for embedding structured, evidence-informed support within frontline roles—without requiring clinical credentials.

Here’s how you can build on their core principles:

  • Pilot brief, structured interventions like behavioral activation or simple problem-solving exercises during housing, income, or crisis support meetings.
  • Embed ‘problem mapping’ or ‘stress management check-ins’ into your intake or coaching sessions. These can be as simple as asking: “What’s one stressor you’re facing this week? What’s one small step we could try together?”
  • Train peer helpers, coaches, or volunteers in delivering low-intensity interventions, with clear scripts and supervision—mirroring PM+’s non-specialist delivery model.
  • Adapt digital self-help or guided reflection tools from SbS for mobile-first delivery. These could be accessed between visits, during waitlists, or as part of community resource navigation.
  • Introduce simple goal-setting language tied to emotional regulation. PM+ uses phrases like “doing more of what matters” or “building support” to shift from “stuckness” to action.
  • Evaluate what matters most. Instead of measuring only service counts, track stress levels, emotional regulation, goal clarity, or re-engagement over time. Even short-term gains can matter.

What Can You Try Today?

Even without a full PM+ or SbS program, here are three things you or your team could start doing immediately:

1. Ask a “manageable next step” question

Try: “What’s one small thing you could try this week that might help with that stress?”

This simple reframing draws directly from behavioral activation and helps shift focus from overwhelm to action.

2. Normalize common reactions

During early conversations, consider sharing:

“It makes sense to feel stuck when life’s been this hard. A lot of people we work with say the same. We can figure things out together.”

This echoes PM+’s trauma-informed stance and helps reduce shame or self-blame.

3. Introduce a 2-minute breathing tool or grounding practice

Borrowing from PM+’s stress management strategies, start sessions with a simple breathing cue or grounding exercise.

No training needed—just a shared moment of slowing down to build readiness and trust.

Why These Interventions Matter

PM+ and Step-by-Step represent a new generation of scalable, structured, and accessible interventions that meet people where they are. They recognize that emotional distress and social adversity often go hand-in-hand—and that waiting for formal therapy isn’t always possible or necessary.

As community-based organizations across Canada seek to expand reach and deepen impact, these interventions offer a clear message:

You don’t need to be a therapist to help someone regain hope and take their next step.

With the right tools, structure, and support, stabilization staff can be powerful agents of change—starting with just one problem, one helper, and one plan.

About Buoyancy Works:

Buoyancy Works is a Calgary-based social purpose company dedicated to empowering individuals through behavioral science and technology. By providing personalized tools and evidence-backed support, Buoyancy Works helps people manage life transitions, like unemployment, more effectively. Their platform enables real-time collaboration between job seekers and coaches, fostering meaningful human connections and delivering tailored guidance. Aligned with Sustainable Development Goals (SDGs) for economic growth and decent work, Buoyancy Works partners with nonprofits to expand employment opportunities and promote economic empowerment. Learn more at buoyancy.works.

References

Dawson, K. S., Bryant, R. A., Harper, M., Kuowei Tay, A., Rahman, A., Schafer, A., & van Ommeren, M. (2015). Problem Management Plus (PM+): A WHO transdiagnostic psychological intervention for common mental health problems. World Psychiatry, 14(3), 354–357. https://doi.org/10.1002/wps.20255

Dorsey, S., Murray, L. K., Haroz, E. E., Wheaton, W., Kohrt, B. A., Bolton, P., … & Bass, J. (2020). Scaling up science-based mental health interventions in low-resource settings: A call to action. World Psychiatry, 19(1), 116–117. https://doi.org/10.1002/wps.20693

Rahman, A., Hamdani, S. U., Awan, N. R., Bryant, R. A., Dawson, K. S., Khan, M. F., … & van Ommeren, M. (2016). Effect of a multicomponent behavioral intervention in adults impaired by psychological distress in a conflict-affected area of Pakistan: A randomized clinical trial. JAMA, 316(24), 2609–2617. https://doi.org/10.1001/jama.2016.17165

Wang, D., Böttche, M., Hinkel, H., Heinz, A., & Knaevelsrud, C. (2020). A mobile-based mental health program for Syrian refugees: A pilot randomized controlled trial of the Step-by-Step approach. European Journal of Psychotraumatology, 11(1), 1791306. https://doi.org/10.1080/20008198.2020.1791306

Related Measures

1. PHQ-9 (Patient Health Questionnaire – 9 item)

Measures: Depression severity based on DSM-IV criteria

Score range: 0–27 (higher = more severe depression)

Use case: Screening, diagnosis, and monitoring in clinical and research settings

🔗 Official source: https://www.phqscreeners.com

2. WHODAS 2.0 (WHO Disability Assessment Schedule)

Measures: Functional health and disability across six domains (e.g., self-care, life activities, participation)

Score range: 0–100 (higher = more disability)

Use case: Measures general functioning and impact of interventions across health conditions

🔗 Official WHO site: https://www.who.int/tools/whodas

3. GHQ-12 (General Health Questionnaire – 12 item)

Measures: General mental distress including anxiety, depression, social dysfunction

Score range: 0–36 (higher = more distress)

Use case: Screening for psychological distress in general and clinical populations

🔗 Overview and scoring guide (BMJ): https://www.bmj.com/content/324/7342/950

4. WHO-5 (WHO Well-being Index – 5 item)

Measures: Subjective well-being (mood, energy, interest, restfulness)

Score range: 0–100 (higher = better well-being)

Use case: Depression screening and outcome tracking

🔗 Official site: https://www.who-5.org

5. Behavioral Activation for Depression Scale (BADS)

Measures: Levels of avoidance, behavioral activation, and positive reinforcement

Score range: Varies; 25-item version commonly used

Use case: Measures how much individuals engage in meaningful activities (used in BA therapy)

🔗 Validated scale publication (Kanter et al., 2006): https://link.springer.com/article/10.1007/s10862-006-9038-5

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