EASE (Early Adolescent Skills for Emotions)

Version followed: WHO/UNICEF Early Adolescent Skills for Emotions (EASE): group psychological help for young adolescents affected by distress in communities exposed to adversity, generic field-trial version 1.0 (2023; Series on Low-Intensity Psychological Interventions No. 6), plus the WHO/UNICEF EASE Training manual (2025). Session lists, scheduling, screening, helper rules and difficult-situation guidance below come from manual chapters 1–4 and the training manual. Each session's one-line aim (training manual §1.3.2–1.3.3), group size, caregiver session length and extra exclusion criteria are based on the training manual, the 2019 Trials protocol abstract and a Pakistan trial registration (ISRCTN17755448). The session-by-session chapters, annexes, workbook, storybook and caregiver handouts are not cited, and no published source gives the session scripts. So the numbered steps in 4.4–4.13 are [synthesis]: generic low-intensity CBT practice, not EASE wording. The slow-breathing count, the problem-solving step names, the Annex 1 risk steps and the Annex 2 games remain [uncertain].

1. Introduction

EASE is a brief, transdiagnostic, group-based low-intensity psychological intervention from WHO and UNICEF. It is for young adolescents (about 10–15 years) with internalising problems (stress, anxiety, low mood) that interfere with functioning, living in communities exposed to adversity. It has 7 adolescent group sessions and 3 separate caregiver group sessions. It is designed for trained, supervised non-specialist helpers, not specialists. It is a manualised programme within a task-sharing model, not a single-therapist psychotherapy. [source: WHO publication page; EASE manual v1.0 ch.1–3] Dawson, Watts et al. (2019) give the target age as 10–14; the 2023 manual gives 10–15. [uncertain]

How change is meant to happen. The adolescent strand teaches four evidence-supported strategies, chosen by review and by common-elements analysis (PracticeWise): identifying feelings, calming physical arousal through slow breathing, behavioural activation, and simplified problem solving with help-seeking. A final session prepares participants to keep using the skills alone. [source: Dawson, Watts et al. 2019] The caregiver strand aims to help caregivers comfort a distressed child, use praise rather than physical discipline, and look after their own stress, so that the home supports the adolescent's new skills. [source: Dawson, Watts et al. 2019; EASE manual v1.0] The developers do not publish an explicit causal model beyond this. [uncertain]

2. Framework

Overall shape. The full cycle is pre-assessment, then 7 weekly adolescent sessions with 3 caregiver sessions running alongside, then post-assessment. The manual's example timeline is about 9 weeks. [source: EASE manual v1.0 ch.2–4]

Phase 0: preparation (before any group). [source: EASE manual v1.0; DIGNITY package]

Required beforehand: functioning referral pathways, resources to follow up high-risk cases, and available health and mental-health services. [source: EASE manual v1.0]
Local adaptation: keep the core skills and content. Delivery, examples, language, images and storybook settings may be adapted with supervisor agreement. [source: EASE manual v1.0]
A partner implementation package estimates 1–3 months of preparation and a 5- or 10-day helper workshop, depending on experience. [source: DIGNITY package; secondary]

Phase 1: pre-intervention assessment and selection. Done about 1–2 weeks before EASE, in one visit, by an assessor or trained helper. [source: EASE manual v1.0 ch.4]

Adolescent and caregiver are assessed separately unless the adolescent agrees otherwise. Another adult must be present with the adolescent.
Steps:
1. Introductions, purpose, confidentiality, an overview of EASE, and consent.
2. Adolescent questions: demographics, an internalising measure (e.g. the PSC-17/PSC-35 internalising subscale or the WHO mhGAP tool), then a two-question screen for imminent self-harm or suicide risk.
3. Caregiver questions.
4. Summary and feedback.
5. Consent to join EASE.
Exclusions (refer on instead):
- imminent risk of self-harm or suicide;
- behaviour that would disrupt the group (violent or aggressive, or unable to follow instructions);
- severe mental, neurological or substance-use impairment (e.g. psychosis, severe intellectual disability, dependence). The training manual adds that EASE does not address externalising (behaviour) problems or neurodevelopmental difficulties; these need referral elsewhere. [source: EASE training manual 2025 §1.3.1]
Acute protection risks (e.g. family violence) go to child protection first. The young person may join later if a protection professional and an EASE supervisor recommend it, after reassessment and with their agreement.
Make reasonable accommodations for disability where participation is safe and communication is possible.

Phase 2: group delivery. [source: EASE manual v1.0 ch.2–3]

Adolescent sessions run weekly, about 90 minutes each, 4–6 days apart to allow home practice:

#	Adolescent session	Core strategy
1	Understanding My Feelings	rapport, psychoeducation on adversity and distress, identifying emotions
2	Calming My Body	bodily effects of stress, anxiety and anger; slow breathing
3–4	Changing My Actions, parts 1–2	behavioural activation: planning meaningful and pleasant activities
5–6	Managing My Problems, parts 1–2	simplified problem solving plus seeking social support
7	Brighter futures	relapse prevention and using skills independently

[source: session titles from EASE manual v1.0; content from Dawson, Watts et al. 2019]

Caregiver sessions run about 90 minutes each (up to 2 hours for session 1). [source: EASE manual v1.0; EASE training manual 2025 §1.3.3; ISRCTN17755448 Pakistan trial registration] Dawson et al. (2019), an earlier description, give about 2 hours each. This guide follows the 2023/2025 versions.

#	Caregiver session	Content
C1	Understanding big feelings	psychoeducation; comforting an overwhelmed child; emotion identification; active listening; slow breathing
C2	The power of praise	praise; building confidence; stopping physical discipline; quality time
C3	Caregiver self-care and brighter futures	sleep, nutrition, stress reduction; coping with the environment and with parenting a distressed adolescent

[source: EASE manual v1.0; Dawson, Watts et al. 2019]

Caregiver scheduling:

C1 before adolescent session 3, ideally before session 1.
C2 before adolescent session 5.
C3 before adolescent session 7.
Alternatives: one caregiver session a week for three weeks, or a single one-day workshop held before adolescent session 3.

Caregivers also learn the adolescent strategies across their sessions. [source: EASE manual v1.0; Dawson, Watts et al. 2019]

Group format. [source: EASE manual v1.0]

Group size: 8 is ideal and 12 at most (manual v1.0); the training manual gives 6–12 adolescents, or 6–12 caregivers, per group. [source: EASE training manual 2025 §1.3.2–1.3.3] Groups may be split by gender depending on context.
Staffing: two helpers, a lead and a co-helper. The adolescent and caregiver group leads should preferably be different people.
Each session has a welcome activity, review, skill teaching through the storybook (main character Kian), activities and practice, home practice recorded in the workbook, and a closing activity.
Materials: helper copy of the storybook, adolescent workbook, posters, caregiver handouts, paper and pens.

Moving between phases. Progression is fixed and calendar-based. There are no symptom-based criteria for advancing. Strategies are introduced in order of complexity, and each session reviews the earlier ones. [source: Dawson, Watts et al. 2019] Missed sessions are handled by finding out why, considering catch-up options, and discussing with the supervisor after two or more misses. [source: EASE manual v1.0]

Phase 3: post-intervention assessment. Ideally the same measures as pre-assessment, about 1–2 weeks after the last session. [source: EASE manual v1.0 ch.4] What to do with non-responders is not stated in the cited sections [uncertain]. My suggestion: re-screen risk and refer anyone still above threshold to specialist care. [synthesis]

Training and authorisation to deliver. [source: EASE training manual 2025; EASE manual v1.0]

Classroom training: at least 80 hours over up to 10 days, led by a trained mental-health professional.
In-field training: at least two supervised practice groups with less severe presentations, over about 2 months, with 2–3 hours of supervision a week.
Ongoing supervision: group supervision of 2–6 helpers for 2–3 hours weekly (minimum 1.5 hours), with individual supervision preferred in the first month. It may drop to fortnightly after more than five groups but is never removed.
Supervisors: should be trained in CBT and able to manage safety; those without a mental-health background need mental-health supervision themselves.
Competency is assessed with the WHO EQUIP tools (ENACT, WeACT, GroupACT) on four levels. This is not pass/fail.
There is no formal certification. Organisations decide readiness.
The materials are open-licensed (CC BY-NC-SA 3.0 IGO). Training enquiries go to WHO (EASEtraining@who.int).

3. Guiding principles

Principles are from the EASE manual v1.0 (ch.1–3) and the training manual unless tagged otherwise.

Task sharing. Trained lay helpers deliver the programme, and specialists train and supervise. If you are a specialist, your usual role is trainer, supervisor or referral point rather than group helper. [source; the role framing is synthesis]
Helper selection. Helpers should be motivated, experienced with young people and caregivers, preferably educated to high-school level, have time for participants, and have access to supervision. Teachers should not be helpers, because of the power dynamics of the school role. [source for the rule; rationale is synthesis]
Fidelity to core skills, flexibility in delivery. Keep the four strategies, their order and the reviews. Localise examples, language, images and story settings, with supervisor agreement.
Transdiagnostic and low-intensity. One programme covers anxiety, depression and stress together. Do not add trauma processing or diagnostic work inside the group. [source: Dawson, Watts et al. 2019; the 'do not add' point is synthesis]
Safety first. Screen for imminent risk, protection concerns and severe disorders before entry. Refer anyone who is not suitable. Never start without working referral pathways.
Confidentiality with three exceptions. The exceptions are imminent self-harm or suicide, likely serious harm to others, and abuse or harm by anyone. These go to the supervisor even if the participant objects. Explain this at the start, in plain words.
Basic helping skills.
- Communicate concern and show attentiveness without words.
- Praise openness.
- Validate and normalise experiences.
- Set aside your own values.
Do not give direct advice. Ask what they would suggest to a friend. This builds the young person's own problem-solving.
Cultural and gender sensitivity. Respect differences. Challenge clearly harmful beliefs (e.g. about physical punishment) only carefully and with supervisor support.
Engage through stories, pictures and activity. Teach each skill through the storybook and practise it, rather than lecturing. [source: Dawson, Watts et al. 2019; EASE manual v1.0]
Practice between sessions. Set home practice every session, record it in the workbook, and review it next time.
Voluntary participation. Do not force anyone to stay, and do not ask them to leave. Explore barriers instead.
Be honest about scope. Tell families that EASE does not provide material goods, money or medication.
Supervision is non-negotiable. Every helper is supervised throughout delivery, not only during training.
Involve caregivers. Caregivers learn the adolescent skills and supportive responses so that skills are reinforced at home. [source: Dawson, Watts et al. 2019]

4. Intervention inventory

How to read this section:

The purposes, session placement and components are sourced: EASE manual v1.0 ch.1–4, the training manual (2025), and Dawson, Watts et al. (2019).
The numbered in-session steps for the skills sessions (4.4–4.13) are [synthesis]. No published step-by-step text for these sessions was found outside the manual's session chapters. They are standard low-intensity CBT procedures consistent with the published one-line descriptions, not EASE manual text. If you deliver EASE under its name, use the manual's own session scripts, storybook pages and workbook instead.
Example wording is my own (illustrative).

4.1 Pre-intervention assessment and risk screen

Purpose / when: To decide eligibility, get a baseline and pick up risk. Done 1–2 weeks before the first session. [source: EASE manual v1.0 ch.4]
Steps:
1. Meet the adolescent and caregiver separately, unless the adolescent agrees to be seen together. Another adult must be present with the adolescent.
2. Explain the purpose, what EASE is (weekly groups for 7 weeks, plus caregiver sessions) and what it does not provide (materials, money, medication), and the three limits to confidentiality.
3. Get the adolescent's permission and the caregiver's consent for the assessment only. Written consent is preferred if safe; verbal is acceptable. Consenting to assessment does not commit anyone to EASE, and either person can withdraw at any time.
4. Ask the demographic questions, then give an internalising measure (e.g. the PSC-17/35 internalising subscale or the mhGAP tool, translated and locally validated). Do not reproduce items; use the licensed or adapted version your organisation chose.
5. Introduce the risk questions by normalising that some young people under stress think about ending their life. Then ask the two screening questions: (a) any thoughts, plans or actions about ending their life (thoughts or plans in the past month, actions in the past year); (b) current thoughts, plans or steps. Record the details.
6. If (b) is yes or unsure, or (a) is yes and the young person is extremely agitated, follow the imminent-risk steps in the manual's Annex 1 or your organisation's own procedure. Do not enrol them; refer them and involve the supervisor. In the Lebanon and Jordan trials, a structured imminent-risk check based on mhGAP was used, and adolescents at imminent risk were excluded and referred for specialist support under inter-agency procedures [source: Brown et al. 2019, Trials].
7. Ask the caregiver questions about the caregiver's own feelings and the adolescent's feelings. Explain why the self-harm questions were asked.
8. Give feedback, then get consent to join EASE. Families may take time to decide.
Example language (illustrative): "Some young people who feel really stressed have thoughts about not wanting to be alive. Lots of people have felt that way. I ask everyone, so I can make sure you get the right help."
Watch for:
- Exclusion criteria: imminent risk, disruptive or aggressive behaviour, severe neurological, psychiatric or substance-use impairment.
- Child-protection concerns, which need protection referral first.
- Whether the young person can communicate in the group language.
- It is working if you can make a clear decision (enrol, defer or refer) and each family understands why.

4.2 Group set-up: rules, confidentiality, welcome and closing activities

Purpose / when: To build safety and cohesion. Rules are set in session 1; welcome and closing activities happen every session. [source: EASE manual v1.0; Dawson, Watts et al. 2019]
Steps:
1. Seat the group so everyone can see the storybook and posters.
2. Introduce both helpers and their roles.
3. Agree group rules together. Include confidentiality, taking turns, and a no-teasing rule (the manual names no-teasing as a remedy for cliques).
4. Explain the three exceptions to confidentiality.
5. Open every session with a short welcome activity or game, and close with a closing activity. The training manual tells helpers to use the energisers in the manual's Annex 2 when group energy is low. [source: EASE training manual 2025, Activity 1.7.3] Annex 2 itself is not cited, so no game names are given here. [uncertain]
Example language (illustrative): "What we share here stays here. The only time I'd talk to my supervisor is if I'm worried someone might get badly hurt. I'd tell you first."
Watch for: Cliques and power imbalances. Rotate seating and pairs.

4.3 Basic helping skills (used throughout)

Purpose / when: These are the relational base for all content, used in every interaction. They are assessed with ENACT, WeACT and GroupACT. [source: EASE manual v1.0; EASE training manual 2025]
Steps:
1. Show concern and attention without words: eye contact as culturally appropriate, open posture, and turning towards the speaker.
2. Thank and praise the participant for sharing.
3. Validate and normalise: name the feeling and say it makes sense given what they face.
4. Hold back your own values and advice. Turn questions back with a "what would you tell a friend?" prompt.
5. Use simple language, and check understanding by asking the participant to say the idea back.
Example language (illustrative): "Thank you for telling us that. It makes sense you felt scared. If your friend had that problem, what would you suggest to them?"
Watch for: Helpers lecturing, advising or moralising. In ENACT terms, Level 1 means any unhelpful or harmful behaviour, for example shaming. [source: EASE training manual 2025]

4.4 Storybook and workbook as teaching vehicles

Purpose / when: To teach each skill through a story about a character (Kian) facing problems similar to the participants', then apply it to their own lives in the workbook. Used every session. [source: EASE manual v1.0] The storybook uses an image of three birds to illustrate emotions; how the birds are used in session is not described here. [uncertain]
Steps [synthesis]:
1. Read or show the storybook pages for the session.
2. Ask what the character feels, thinks and does.
3. Connect the story to the skill.
4. Have participants try the skill in pairs or as a group.
5. Fill in the workbook page, adapting for literacy (drawing, helper scribing).
Example language (illustrative): "What do you think Kian is feeling here? Where might he feel it in his body?"
Watch for:
- Participants who are not literate; use pictures and verbal practice.
- Locally adapted characters and settings, which must be agreed with the supervisor.

4.5 Understanding My Feelings (adolescent session 1)

Purpose / when: Rapport, group cohesion, psychoeducation about adversity and emotional distress, and learning to identify emotions. This is the foundation for emotion regulation and comes first. [source: Dawson, Watts et al. 2019; EASE manual v1.0]
Steps [synthesis]:
1. Welcome everyone, do introductions, and set group rules (4.2).
2. Give brief psychoeducation: hard events and stress commonly lead to feelings such as sadness, worry, fear and anger, and these feelings are normal and can be managed.
3. Use the storybook to name the character's feelings.
4. In the group, name a range of feelings and where they show in the body and in behaviour, for example with a feelings chart or by acting out faces.
5. Each participant identifies a recent situation and the feeling that went with it.
6. Home practice: notice and record one or two feelings a day, with the situation.
Example language (illustrative): "Feelings are like messages. Today we'll get better at noticing them and giving them names."
Watch for:
- Distress when feelings are named (see 4.14).
- Participants who only name 'good' or 'bad'; widen their vocabulary.
- It is working when participants can link a situation to a named feeling by session 2.

4.6 Calming My Body: stress psychoeducation and slow breathing (adolescent session 2)

Purpose / when: To teach the bodily effects of stress, anxiety and anger, and slow breathing to reduce physical arousal. The training manual describes the session as using slow breathing to ease difficult feelings. Used in session 2, then whenever participants are distressed, including inside sessions. [source: Dawson, Watts et al. 2019; EASE training manual 2025 §1.3.2; EASE manual v1.0 §3.6.4 recommends Calming My Body for in-session distress]
Steps [synthesis]:
1. Explain how the body reacts to stress: fast heart, tight muscles, quick breathing.
2. Ask participants where they feel stress in their bodies.
3. Model slow breathing: sit comfortably, breathe out slowly and fully, breathe in gently through the nose, and pause briefly. Keep the pace unhurried and do not force deep breaths.
4. Practise as a group for a few minutes. Ask each participant to rate how tense they feel before and after.
5. Plan when to use it: at bedtime, before tests, after arguments.
6. Home practice: daily slow breathing.
- The manual has its own annexes for this session: Annex 5 on calming the body and Annex 6 on alternatives to slow breathing, for participants for whom breathing practice does not suit [source: EASE manual v1.0, Spanish UNICEF edition, table of contents]. Their wording is not reproduced here, and the steps above are generic slow-breathing practice, not the manual's script. [uncertain]
Example language (illustrative): "Let's let our breath slow down, like a balloon slowly letting out air. In through your nose, and out slowly."
Watch for:
- Dizziness from over-breathing; slow the pace.
- Breath focus that triggers trauma memories; let them keep eyes open or count objects instead [synthesis], or use one of the manual's alternatives to slow breathing (Annex 6) [source: EASE manual v1.0, contents].
- It is working when tension ratings fall and participants report using it unprompted.

4.7 Changing My Actions: behavioural activation (adolescent sessions 3–4)

Purpose / when: To counter inactivity and withdrawal by planning meaningful and pleasant activities that lift mood. The training manual frames the session as learning how activities affect feelings. Sessions 3–4. [source: Dawson, Watts et al. 2019; EASE training manual 2025 §1.3.2; EASE manual v1.0 storybook example of a planned pleasant activity]
Steps [synthesis]:
1. Use the storybook to show how stopping activities keeps low mood going, and how doing small things can help.
2. Each participant lists activities they used to enjoy or that matter to them, feasible within local constraints such as safety, cost and gender norms.
3. Choose one small, specific activity and plan when, where and with whom.
4. Anticipate barriers and decide on a backup.
5. Record mood before and after the activity.
6. Home practice: do the planned activity.
7. Session 4: review how it went, praise effort rather than outcome, troubleshoot, then increase the number or variety of activities, including social ones and helping others.
Example language (illustrative): "When we feel down, we stop doing things, and then we feel even more down. Let's pick one small thing you could do this week, even if you don't feel like it."
Watch for:
- Plans that are too big, unsafe or need money; scale them down.
- Activities blocked by caregivers; brief the caregiver group (C2, quality time).
- It is working when activities are completed and mood ratings rise afterwards.

4.8 Managing My Problems: simplified problem solving and seeking support (adolescent sessions 5–6)

Purpose / when: To build independent problem solving with a simplified method, with prompts to seek social support. Sessions 5–6, after behavioural activation. The training manual's examples of target problems are practical ones, such as friendship disagreements and schoolwork. [source: Dawson, Watts et al. 2019; EASE training manual 2025 §1.3.2; EASE manual v1.0] The manual's own step names and any mnemonic are not given in the cited sources. Do not assume they match the steps below. [uncertain]
Steps [synthesis]:
1. Use the storybook to show the character stuck with a problem.
2. Help participants sort problems into ones they can change or influence and ones they cannot. For the second kind, use calming, pleasant activities and talking to trusted people.
3. Pick one manageable problem and state it in one concrete sentence.
4. Brainstorm as many solutions as possible without judging them. Use the prompt "What would you tell a friend?" and peers' ideas.
5. Weigh each option: is it helpful or harmful, and can I do it?
6. Choose one or a combination, and plan the steps, timing and who could help.
7. Home practice: try the plan.
8. Session 6: review, praise the attempt, revise the plan, and practise on a second problem. Stress who the participant can ask for help.
Example language (illustrative): "Let's not solve it for you; let's get the whole group's ideas. Any idea counts for now. We'll pick the best ones after."
Watch for:
- Problems that are protection issues (abuse, exploitation); these are not group homework. See 4.14.
- Problems outside the young person's control; redirect to coping and support.
- It is working when participants generate options without help and name a support person.

4.9 Brighter futures: relapse prevention (adolescent session 7)

Purpose / when: To review all the skills, prepare participants to use them alone and to manage big feelings in future, and close the group. Session 7. [source: Dawson, Watts et al. 2019; EASE training manual 2025 §1.3.2; EASE manual v1.0]
Steps [synthesis]:
1. Recap each skill with the storybook or posters.
2. Each participant identifies the skill that helped most and their own early warning signs.
3. Make a personal plan: what I'll do when I notice I'm struggling, and who I'll tell.
4. Name future stresses (exams, moves) and plan which skill to use for each.
5. Say where to get further help.
6. Hold a closing celebration or acknowledgement of progress.
7. Remind participants about the post-assessment.
Example language (illustrative): "You now have four tools. Which one will you reach for first next time things feel hard?"
Watch for:
- Distress about the group ending.
- Anyone still struggling a lot, who should be flagged to the supervisor for post-assessment and possible referral. [synthesis]

4.10 Home practice and review

Purpose / when: To transfer skills into daily life. Set at the end of every session and reviewed at the start of the next, with sessions 4–6 days apart. [source: EASE manual v1.0; Dawson, Watts et al. 2019]
Steps [synthesis]:
1. Agree one specific practice task and write it in the workbook.
2. Problem-solve when and where it will happen.
3. Next session, ask each participant briefly how it went.
4. Praise attempts.
5. Explore barriers without blame.
Example language (illustrative): "Who managed to try it, even once? What got in the way for anyone who didn't?"
Watch for: Shame about not doing it; low literacy; workbooks that are unsafe to keep at home. Allow verbal reporting.

4.11 Caregiver session 1: Understanding big feelings

Purpose / when: Psychoeducation on adolescent distress; how to comfort a child who is overwhelmed; practising emotion identification and active listening; and slow breathing, which the training manual frames as caregivers calming their own bodies. Held before adolescent session 3, ideally before session 1. [source: EASE manual v1.0; EASE training manual 2025 §1.3.3; Dawson, Watts et al. 2019] Across the three caregiver sessions (90 minutes each in the trials), the content is psychoeducation, active listening, quality time, praise, caregiver self-care and relapse prevention; staff offered childcare so caregivers could attend [source: Brown et al. 2019, Trials].
Steps [synthesis]:
1. Welcome caregivers, set rules and confidentiality, and give an overview of what their child will learn.
2. Normalise distress after adversity, in both children and caregivers.
3. Teach active listening: stop and give attention; let the child finish; reflect the feeling; avoid immediate fixing or blaming. Practise in pairs as a role-play.
4. Practise naming one's own and the child's feelings.
5. Teach slow breathing for the caregiver and to do with the child.
6. Home practice: one listening conversation, and breathing.
Example language (illustrative): "When your child is upset, the first job is to listen and name the feeling: 'You seem really worried.' Solutions can come later."
Watch for:
- Caregivers' own distress or trauma; offer referral.
- Disclosures of family violence; follow the protection procedure.
- It is working when caregivers report listening rather than correcting.

4.12 Caregiver session 2: The power of praise

Purpose / when: Praise, building the child's confidence, quality time, and stopping physical discipline. Held before adolescent session 5. [source: Dawson, Watts et al. 2019; EASE manual v1.0 lists quality time and praise among caregiver aims]
Steps [synthesis]:
1. Review home practice.
2. Discuss what the caregiver wants their child to do more of.
3. Teach specific, immediate, sincere praise for effort, and practise phrasing it.
4. Plan short regular quality time led by the child.
5. Discuss the effects of harsh and physical discipline on distressed children, and generate the group's own non-physical alternatives (calm, clear instructions; praise for the opposite behaviour). Challenge harmful beliefs respectfully and with supervisor support.
6. Home practice: praise daily and schedule quality time.
Example language (illustrative): "Instead of 'good boy', try naming exactly what he did: 'You helped your sister with her homework. That was kind.'"
Watch for:
- Defensiveness about discipline; validate the stress of parenting first.
- Disclosed abuse; follow the mandatory steps.
- It is working when caregivers report specific praise and fewer harsh responses.

4.13 Caregiver session 3: Caregiver self-care and brighter futures

Purpose / when: Caregiver self-care (sleep, nutrition, stress reduction), coping with the environment and with parenting a distressed adolescent, and a review of skills to keep supporting the child. Held before adolescent session 7. [source: Dawson, Watts et al. 2019; EASE manual v1.0]
Steps [synthesis]:
1. Review praise and quality time.
2. Each caregiver identifies their own stress signs and one or two realistic self-care actions.
3. Revisit slow breathing.
4. Identify sources of support.
5. Plan how to keep supporting the child's skills after the group ends, and how to recognise when more help is needed.
Example language (illustrative): "You can't pour from an empty cup. What's one small thing that helps you recharge, even for ten minutes?"
Watch for: Caregiver depression or crisis; refer to adult services (e.g. PM+ or mhGAP-based care). The referral targets are synthesis.

4.14 Responding to distress and disclosures inside sessions

Purpose / when: Safety and containment whenever a participant becomes upset or discloses harm. Helpers are trained to watch for signs of threats to the adolescent's wellbeing at home and to refer when needed. [source: EASE manual v1.0 §3.1.1–3.1.2, §3.4.2, §3.4.4, §3.6.4, §3.6.8–3.6.9; Dawson, Watts et al. 2019] Annex 1 of the manual covers managing disclosures of abuse and suicide risk; its steps are not reproduced here. [uncertain]
Steps:
- Distress:
  1. Validate first and give the person time.
  2. Offer slow breathing.
  3. The co-helper can sit with the participant one-to-one, or the group can take a ten-minute break.
- Abuse disclosure:
  1. Respond with concern in the moment, without probing in front of the group.
  2. Speak with the young person privately afterwards, away from the group and in a way that does not embarrass them. The manual keeps one-to-one talks during sessions for when someone is very distressed, needs extra help with a skill, or wants to disclose a sensitive or safety issue, and otherwise asks helpers to keep them to a minimum because the rest of the group loses focus [source: EASE manual v1.0 §3.4.2, §3.4.4].
  3. Inform the supervisor. Confidentiality does not apply here, and the young person should be told this.
- Over-disclosure: Agree a signal, or ask the participant privately to share less detail in the group.
- Self-harm or suicide disclosed mid-programme: Tell the supervisor straight away if a participant is at imminent risk of self-harm or suicide, is likely to seriously harm someone else, or is being harmed or abused [source: EASE manual v1.0 §3.1.1]. Tell the young person what will happen next, and pass on only the information that is needed, anonymously where possible [source: §3.1.2]. Use the same two-question screen and the Annex 1 or organisational imminent-risk procedure. [uncertain: Annex 1's own steps are not reproduced here.] Follow your organisation's suicide-risk protocol and involve the supervisor the same day. [synthesis]
Example language (illustrative): "Thank you for trusting us with that. It's important, and I want to talk with you about it properly in a moment, just the two of us."
Watch for: Contagion of distressing detail in the group, and the helper's own distress, which should be brought to supervision.

4.15 Post-intervention assessment

Purpose / when: To measure change and pick up remaining risk, 1–2 weeks after the end. [source: EASE manual v1.0 ch.4]
Steps: Repeat the pre-assessment measures and the risk screen, separately for adolescent and caregiver. Give feedback. Refer anyone with continuing significant symptoms or risk. The referral step is synthesis.
Watch for: A rise in symptoms or new risk. EASE is not intended for severe presentations, so step up care.

4.16 Supervision and competency checks (helper-level procedure)

Purpose / when: To maintain fidelity and safety throughout. [source: EASE training manual 2025; EASE manual v1.0] In the Lebanon and Jordan trials, groups were led by two trained non-specialist facilitators (one male, one female) after 8 days of training, a supervised practice cycle and a competency assessment; local trainers gave weekly supervision; each facilitator pair completed a checklist after every session; and 10% of sessions were observed with a structured form [source: Brown et al. 2019, Trials].
Steps:
1. Hold weekly group supervision (2–6 helpers, 2–3 hours), with individual supervision in the first month.
2. Review attendance, risk cases, difficult group moments and adherence to the session plans.
3. Rate competencies with ENACT, WeACT and GroupACT. Give feedback in this order: strengths first, then specific improvements, then end positively.
4. Move to fortnightly supervision only after more than five groups.
Watch for: Helpers drifting into advice-giving or lecturing, missed risk escalations, and helper burnout.

5. Handling problems

The first group of items is from the manual's section on difficult situations. [source: EASE manual v1.0 §3.6] The rest is marked [synthesis].

Dominant participant.

Thank them for the contribution.
Redirect to others ("Let's hear from someone who hasn't spoken yet").
Give them a role, such as timekeeper or reader.
If it continues, speak to them privately.

Quiet or withdrawn participant. Invite them gently or in pairs. Respect a wish to stay quiet; do not force them to share.

Conflict between participants.

Respond early.
Remind the group of the rules they agreed.
Seat the people concerned apart.
Use an energiser game to reset.

Cliques and teasing. Rotate seating and pairs. Set and enforce a no-teasing rule.

Running over time because a discussion is valuable. You may let a useful discussion run and shorten a later part of the session, but plan when the skipped material will be covered: ask the group to stay a little longer, to arrive early next time, or shorten breaks (participants can carry on talking in the break if they wish). Always discuss these choices with your supervisor so no core content is lost. [source: EASE manual v1.0 §3.6.1]

Discussion going off topic. The manual has a section on this (§3.6.5, p. 34), but its wording is not reproduced here. [uncertain] Suggested response [synthesis]: acknowledge the topic in one sentence, park it for the break or a private talk, and link back to the session's skill. If the topic is a pressing worry, offer to talk afterwards.

Doubt or criticism about the EASE skills. The manual covers this in §3.6.11 (p. 37), but its wording is not reproduced here. [uncertain] Suggested response [synthesis]: validate the doubt without arguing, and invite a one-week try of the skill. Ask peers who found it useful to say how, and adjust the examples so the skill fits the participant's real situation.

Over-disclosure in the group. Use an agreed signal, or ask privately for less detail. Follow up one-to-one.

Acute distress in a session.

Validate.
Allow time.
Offer slow breathing.
The co-helper sits with the participant, or the group takes a 10-minute break.
Assess risk if needed.

Disclosure of abuse or harm. Respond with concern, talk privately afterwards, and inform the supervisor. Confidentiality does not apply.

Non-attendance.

Find out why.
Offer catch-up options.
After two or more missed sessions, discuss with the supervisor.
Never force anyone to stay, and do not exclude them.

Stuck client: no progress by mid-programme. [synthesis]

Check whether the person understood the skill, did the home practice, and whether something is blocking them (protection issue, worsening mood, caregiver obstruction).
Re-screen risk.
Discuss with the supervisor.
Keep them in the group if it is safe, and plan a referral at post-assessment.
Do not add individual therapy content inside EASE sessions.

Non-adherence to home practice. [synthesis]

Shrink the task (one breath practice, one tiny activity).
Link it to an existing routine.
Enlist the caregiver: in C1 and C2, caregivers learn the skills and can prompt and praise.
Accept verbal reports when writing is a barrier or the workbook is unsafe at home.

'Resistance' or low engagement. [synthesis]

With young adolescents this is usually boredom, shame or mistrust. Use more games, movement and storybook discussion, and less talk.
Validate scepticism ("You're not sure this will help; that's fair. Try it for one week and see").
Avoid power struggles. Low engagement is never a reason for exclusion.

Rupture with a helper (e.g. a participant feels judged or shamed). [synthesis]

Name it privately.
Apologise for your part.
Ask what would help.
Bring it to supervision.

With caregivers, ruptures often follow discussion of physical discipline. Validate the pressures of parenting before revisiting alternatives. The manual permits challenging harmful beliefs only with supervisor support.

Overwhelm or trauma reactions to the content. [synthesis]

EASE does not include trauma processing.
If breathing or feelings work triggers flashbacks, use grounding: eyes open, feet on the floor, naming things in the room.
Let the participant step out with the co-helper.
Assess for PTSD at the supervisor's direction and refer to trauma-focused care where available.

Low caregiver attendance. [synthesis, informed by the manual's flexible caregiver scheduling]

Use the manual's alternatives: weekly sessions, or a single one-day workshop held before adolescent session 3.
Hold sessions at times that suit working caregivers.
Send the handouts home.
Give a brief phone summary.

Risk identified during the programme.

Stop group content for that young person.
Run the two-question screen.
Apply the imminent-risk procedure (manual Annex 1 or your organisation's).
Involve the supervisor that day.

Lethal-means counselling with caregivers, meaning safe storage or removal of medicines, weapons and other means, is standard practice. [synthesis; not stated in the cited manual sections]

Specialist clinicians delivering or adapting EASE. [synthesis]

If you are a psychotherapist using EASE in a clinic, keep the group, low-intensity and storybook format, and do not turn it into individual CBT.
Use your expertise mainly in screening, supervision and stepped-care decisions.
Delivering EASE under its name requires the WHO/UNICEF training and ongoing supervision structure.
No formal certification exists, but organisations are expected to check competency with EQUIP tools. [source for training and competency facts: EASE training manual 2025]

Adaptation drift. [synthesis] When adapting for culture, language, disability or online delivery, change examples, images and delivery, not the four core skills or their order, and record every change agreed with the supervisor. The keep–change rule is from the source. Online delivery is not covered in the sources. [uncertain]

Sources

Main sources:

Early Adolescent Skills for Emotions (EASE), WHO publication page
WHO & UNICEF (2023) EASE manual, generic field-trial version 1.0: chapters 1–4 and text to p. 48 used (full reference under Publications cited).
WHO & UNICEF (2025) EASE training manual: Parts A–B, including the §1.3 session overview (pp. 24–54), used (full reference under Publications cited).
Dawson, Watts et al., EASE description, World Psychiatry 2019 (PMC6313693)
Brown et al., EASE study protocol for RCTs in Lebanon and Jordan, Trials 2019 (full tex t)
DIGNITY MHPSS package: What we offer to partners (EASE implementation summary; secondary)
EASE course page, ForChildren/Compassion (lists materials only; secondary)

Further sources:

Publications cited:

World Health Organization & UNICEF (2023). Early Adolescent Skills for Emotions (EASE): group psychological help for young adolescents affected by distress in communities exposed to adversity. Generic field-trial version 1.0. Geneva: WHO. ISBN 978-92-4-008275-5.
World Health Organization & UNICEF (2025). EASE: Training manual for a group psychological intervention for young adolescents affected by distress. Geneva: WHO. ISBN 978-92-4-011371-8.
Dawson, K.S., Watts, S., Carswell, K., et al. (2019). Improving access to evidence-based interventions for young adolescents: Early Adolescent Skills for Emotions (EASE). World Psychiatry, 18(1), 105–107.
Brown, F.L., Steen, F., Taha, K., Aoun, M., Bryant, R.A., Jordans, M.J.D., Malik, A., van Ommeren, M., et al. (2019). Early Adolescent Skills for Emotions (EASE) intervention for the treatment of psychological distress in adolescents: study protocol for randomised controlled trials in Lebanon and Jordan. Trials, 20, 545. doi:10.1186/s13063-019-3654-3; correction in Trials, 20, 617.

Related materials not used for specific steps [uncertain]:

The EASE workbook, storybook, posters and caregiver handouts; the manual's session chapters (5–6) and annexes; the New York City EASE adaptation paper (PMC12509165); and the Bryant et al. (2022) PLOS Medicine Jordan RCT.
The session-level scripts, the Annex 1 risk steps and the Annex 2 games are therefore not reproduced here. [uncertain]

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