Atlas›Domain V · Systemic, relational, group & community›Guide 165
Guide V-165

Thinking Healthy Programme

Atif Rahman2007Pakistan
A 27 · L 63 · M 1023 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: WHO Thinking Healthy: A manual for psychosocial management of perinatal depression, WHO generic field-trial version 1.0 (2015, WHO/MSD/MER/15.1), adapted from Atif Rahman's Pakistan manual. Where the original Pakistan trial version (Rahman 2007; Rahman et al. 2008) or the peer-delivered version (THPP, Atif et al. 2017; Sikander et al. trial) differ, this is stated.

What it is. The Thinking Healthy Programme (THP) is a manualised, simplified cognitive-behavioural intervention for perinatal depression. It was designed to be delivered at home by non-specialist community health workers (CHWs), originally Pakistan's Lady Health Workers, with no prior mental health training. It runs from pregnancy through the infant's first year. It is the first manual in WHO's series on low-intensity psychological interventions. It shows how to deliver the mhGAP recommendation that psychosocial care comes first in pregnancy and breastfeeding. [source: WHO 2015 manual; Rahman 2007]

How change is thought to happen. Unhelpful thoughts drive strong unhelpful emotions, and those emotions drive unhelpful behaviour, which keeps the cycle going. The mother breaks the cycle in three steps, repeated every session: she identifies unhealthy thinking, replaces it with healthier thinking, and practises healthy thinking and action between sessions. The work is anchored in a goal the whole family shares, the baby's health and development. This removes the stigma of "depression" and brings in family support. Behavioural activation (doing small health-promoting activities, tracked on pictorial charts) carries much of the effect, especially when cognitive work is hard for the deliverer. [source: WHO 2015 manual; Rahman 2007; Atif et al. 2017]

Scope note on "other lay-counsellor models". Other lay-counsellor models also exist. This guide covers THP and its published variants: the original LHW version, the WHO generic version, peer-delivered THPP and THPP+, the group version in Turkish pregnancy schools, and the nurse-delivered version in China. Other task-shared programmes (for example Problem Management Plus or the Friendship Bench) have their own manuals and were not researched here. [uncertain]

Who it is for (as published). Mothers with mild to moderate perinatal depression. Women with postpartum or other psychosis were excluded from the original trial. [source: Rahman 2007; Rahman et al. 2008] The WHO version says the target group (screened mothers, high-risk mothers or all mothers) can be chosen locally, provided the changes are documented. [source: WHO 2015 manual]

2. Framework

2.1 Schedule (WHO 2015 generic version)

  • Opening Session (1 or 2 visits), anywhere from 14 to 40 weeks of pregnancy.
  • Module 1 "Preparing for the baby" (prenatal): three weekly sessions.
  • Module 2 "The baby's arrival" (early postnatal): three sessions. The manual places these in postnatal weeks 3 to 5; the text extract labels them fortnightly. The original version had three sessions in the first postnatal month. [uncertain on exact spacing]
  • Module 3 "Early infancy" (months 2–4), Module 4 "Middle infancy" (months 5–7), Module 5 "Late infancy" (months 8–10): three monthly sessions each.
  • Dose: 15 module sessions plus the Opening Session. The manual calls these 16 home visits the optimal dose. Sessions last 45–60 minutes.

[source: WHO 2015 manual]

Same three areas in every module, one session each. Each module has a session on (1) the mother's personal health, (2) her relationship with the baby (unborn or born), and (3) her relationship with the people around her. The third area covers intimate support from household members and community support from neighbours, groups and health workers. [source: WHO 2015 manual; Rahman 2007]

Original Pakistan trial schedule. 16 sessions of about 45 minutes: four weekly sessions in the last month of pregnancy, three in the first postnatal month, then nine monthly sessions. [source: Rahman et al. 2008; Rahman 2007]

Peer-delivered THPP (Pakistan). Up to 14 sessions from the third trimester to six months postnatal:

  • ten individual home sessions (four prenatal, six postnatal);
  • four group sessions folded into the LHWs' existing monthly women's groups, covering psychoeducation and child development.

India used 6–14 individual sessions timed to pregnancy stage and infant age (0–2, 3–4 and 5–6 months). [source: Atif et al. 2017; THPP+ SAP]

THPP+ booster phase. From six months postnatal: 18 peer-led group sessions, monthly for six months and then every two months until the child is three. These use vignettes, picture card games and play activities from WHO Care for Development. [source: THPP+ SAP]

Other published variants:

  • Turkey: five antenatal group sessions of about one hour in pregnancy schools, run by nurses. The first session lasts 90 minutes. [source: Boran et al. 2023]
  • China: seven sessions delivered by hospital nurses alongside routine perinatal visits. [source: Nisar et al. 2020]

2.2 Standard session format (every session)

  1. Review the key messages of the previous session.
  2. Review the mood chart.
  3. Work through the three steps on the session's focus area, using that session's pictures in the Health Calendar.
  4. Explain and agree the practice work (homework) for the coming period, and set the date of the next session.

[source: WHO 2015 manual]

The original version described each session as active listening, then the three-step approach, then homework. [source: Rahman 2007]

2.3 Phase goals

  • Opening Session. Engage the mother and family around the child's future. Explain what the programme can and cannot offer. Teach the thought–feeling–behaviour cycle and the three steps. Agree ground rules. Recruit a family helper. Start the Health Calendar and mood chart. [source: WHO 2015 manual]
  • Module 1 (prenatal). Build self-care habits (diet, rest, antenatal care), begin bonding with the unborn baby, and map and re-open social support. [source: WHO 2015 manual]
  • Module 2 (first postnatal weeks). Restore self-care despite exhaustion: small steps, exercise, rest and breastfeeding. Apply the three steps to the new baby and to family relationships. [source: WHO 2015 manual]
  • Modules 3–5 (infancy). Apply the same three areas to the infant's developmental stage. The session-level content of Sessions 2.2–5.3 is not drawn on (see Section 4). [uncertain]

2.4 Criteria for moving on and ending

  • Pacing is fixed to time, not symptoms. Pacing follows gestational age and infant age, not symptom thresholds. No symptom-based criteria for moving between modules are given in the sources. [source: WHO 2015 manual; uncertain]
  • Non-response. Mothers who do not respond in primary care may need secondary or tertiary care. Psychosis was an exclusion criterion. [source: Rahman et al. 2008]
  • Practical decision rules. The following are [synthesis], not from the sources:
    • Rate the mood chart and a validated screen at the start, at the end of each module and at the end of the programme.
    • If mood has not improved after Module 2, or has worsened at any point, discuss the case in supervision and arrange mhGAP-level assessment.
    • Assess and refer at once, without waiting for the module schedule, in any of these cases: suicidal ideation, psychotic features, severe functional collapse, or concern about infant care.
    • Do not drop the remaining modules just because mood has improved. Later modules carry the infant-relationship and relapse-prevention work.

2.5 Training, supervision, fidelity and permission to deliver

  • Training (WHO 2015).
    • At least 5 days; 10 days is the target.
    • Groups of no more than 15 trainees, ideally with two trainers.
    • Brief lectures, discussion and above all role play.
    • Trainers should ideally have completed THP training and practised it in the community under supervision for 12 months. CBT expertise is not required.
    • CHWs who lack training in maternal nutrition, breastfeeding, weaning or immunisation need that content added.
    [source: WHO 2015 manual]
  • Supervision (WHO 2015). At least monthly half-day groups, using brief role plays, brainstorming locally acceptable solutions, checklists for constructive feedback, space to share difficulties and recognition of successes. Fidelity to the design is stressed. [source: WHO 2015 manual]
  • Original version.
    • A 2-day workshop with a training video and role plays, including a session on difficult situations, plus a 1-day refresher.
    • Monthly half-day group supervision of about 10 LHWs, led by a mental health professional and a public health expert.
    • Supervision was judged the most valuable part of training.
    [source: Rahman 2007; Rahman et al. 2008]
  • Peer version.
    • Peers selected on schooling, life experience as a mother and interpersonal qualities.
    • Selection role plays with an 80% competency threshold.
    • Five days of classroom training plus field training.
    • Competency rated per skill (0 = not done, 2 = done well).
    • Trainers supervised fortnightly by a mental health specialist.
    [source: Atif et al. 2017]
  • Licensing. The WHO manual is freely available. Adaptations (group, mobile, electronic, self-help, changed timing or target group) are allowed if fidelity to the core principles and dose is reasonably kept, and changes are documented and reported. No formal certification or licensing requirement is given in the sources. [source: WHO 2015 manual; uncertain on any current accreditation scheme]

3. Guiding principles

[source for 1–13: WHO 2015 manual; 14–16: Rahman 2007; 17: Atif et al. 2017]

  1. Conversation, not a medical model. You help through talk and shared activity, not procedures or medicines. Don't present yourself as prescribing a cure.
  2. Home and community delivery. See the mother where she lives, ideally as part of routine maternal and child health contact.
  3. Frame it around mother and infant wellbeing, not "depression". Use local, non-stigmatising words such as "stress", "burden" or "tension". The original version called the programme "training" and the worker a "trainer".
  4. The baby's development is the shared agenda. Open every topic with what it means for the child. This is how families come to accept the work.
  5. Empowerment through active participation. The mother does the work between sessions. Practice work is part of the programme, not an optional extra.
  6. Pictorial, literacy-free materials. Every key message has a picture, so non-literate mothers can follow and review it.
  7. Whole-family involvement. Recruit a family member or friend as helper, and invite family to suggest healthy alternatives.
  8. Integrate with existing CHW work. Fold THP into routine maternal and child health messages so it is not an extra burden.
  9. Empathy, listening and respect first. Trust comes before disclosure. Listen before you advise, summarise so she can correct you, and praise effort.
  10. Share ideas rather than dictate. Make plans together. Ask, suggest and check what fits her household.
  11. Be honest about the limits. Say early that the programme cannot remove life's problems or provide money or medicine. It helps the family help itself.
  12. Flexibility in the three steps. If identifying and replacing thoughts is too hard, briefly point out the contrast in the pictures ("plant the seed") and move to Step 3 activities (behavioural activation).
  13. Never force disclosure. Don't press for feelings, especially in front of family. Stress confidentiality and stay out of family politics; bring the focus back to mother and baby.
  14. Pictures can challenge indirectly. Illustrated characters can show the unhelpful thought, so you never contradict the mother face to face.
  15. Cultural and religious fit. Use local idioms, beliefs, traditional wisdom and customs, and plan around them (for example postnatal confinement periods).
  16. Supervision sustains the worker. Working with depressed mothers in poverty is stressful. Bring hard cases to group supervision, where solutions are brainstormed rather than prescribed.
  17. Peer authenticity within boundaries. In the peer version, sharing some personal experience and scheduling flexibly were accepted, but family conflict was still avoided.

4. Intervention inventory

All example language below is illustrative wording, not manual text. The WHO manual's job aids are pictures with short key messages. Use your local or translated Health Calendar rather than inventing pictures. [source: WHO 2015 manual]

4.1 Engagement and empathic communication skills

  • Purpose / when: Builds the trust needed before a mother will discuss problems. A prerequisite for every visit, practised in training role plays. [source: WHO 2015 manual]
  • Steps:
    1. Book the visit with the mother and greet the family.
    2. Explain confidentiality.
    3. Sit at her eye level and speak softly.
    4. Open by reviewing the last visit.
    5. Ask open questions.
    6. Summarise what you heard and invite correction.
    7. Use eye contact and nods where culturally acceptable.
    8. Praise her efforts, and stay positive when progress is slow.
    9. Always listen before advising.
    [source: WHO 2015 manual]
  • Example language (illustrative): "Before we look at the pictures, tell me how this week has been for you and the baby." / "So you're saying the nights are hardest and you feel nobody notices — have I got that right?"
  • Watch for: Lecturing too early, or talking over her to family members. Working: she starts bringing her own concerns and corrects your summaries.

4.2 Opening Session: framing, contract and family helper

  • Purpose / when: The first 1–2 visits in pregnancy. Engages mother and family and sets expectations. [source: WHO 2015 manual]
  • Steps:
    1. Frame the programme around the child's future and share ideas rather than dictate.
    2. Introduce the three areas: her health, her relationship with the baby, and her relationships with people around her.
    3. State the limits: no money, no medicine, no removal of life's problems. The aim is to help the family help itself.
    4. Explain the thought–feeling–behaviour cycle and the three steps with the introductory illustrations (see 4.3).
    5. Agree ground rules: active participation, being on time, doing practice work, and reporting illness or problems.
    6. Identify a family member or friend who will help her.
    7. Give her the Health Calendar and start the daily mood chart (4.8).
    [source: WHO 2015 manual]
  • Example language (illustrative): "These meetings are about helping you and your family give this baby the best start, and that starts with how you are feeling." / "I can't bring money or medicine, but together we can find things that make the days easier." / "Who in the house could help you remember the activities we plan?"
  • Watch for: Family expecting material help or medicine (restate the limits kindly). The helper being someone she feels controlled by: ask her privately whom she would choose. [synthesis] Working: a named helper agrees, and the calendar is kept somewhere visible.

4.3 Psychoeducation: the thinking–feeling–doing cycle

  • Purpose / when: Gives the rationale for the three steps. Introduced in the Opening Session and revisited with each session's pictures. [source: WHO 2015 manual]
  • Steps:
    1. Show the picture pair of a mother thinking unhelpfully, then feeling low and acting in ways that worsen things (for example withdrawing or neglecting her health).
    2. Show the contrasting picture with helpful thinking and action.
    3. Ask her what each mother is thinking and feeling, and what happens next for the baby.
    4. Link it to her own life only as far as she is willing.
    [source: WHO 2015 manual; Rahman 2007]
  • Example language (illustrative): "What do you think this mother is telling herself? … And how does that make her feel? … What does she end up doing?"
  • Watch for: Shame ("that's me, I'm a bad mother"). Answer with normalising and with the healthier picture. [synthesis] Working: she can name the link between a thought and what she did.

4.4 Step 1: Identifying unhealthy thinking

  • Purpose / when: Every session, applied to that session's focus area. [source: WHO 2015 manual]
  • Steps:
    1. Use the session's picture to show typical unhealthy thoughts about the topic.
    2. Ask whether she has thoughts like these.
    3. Help her spot the style using the manual's list: blaming oneself; not giving oneself credit; gloomy predictions; mind reading (assuming others think badly of her); all-or-nothing thinking; doubting her own ability; giving up before trying.
    4. Explore the consequences of the thought for her health and the baby's.
    [source: WHO 2015 manual]
  • Example language (illustrative): "When the baby cries and you think 'I'm useless at this', what kind of thought is that?" / "What happens to your energy for the day after that thought?"
  • Watch for: Over-intellectualising with a mother who is exhausted or has little schooling. Shorten it (see 4.6). Working: she spontaneously labels a thought ("that's a gloomy prediction again").

4.5 Step 2: Replacing with healthy thinking

  • Purpose / when: Straight after Step 1. [source: WHO 2015 manual]
  • Steps:
    1. Help her question the accuracy of the thought: what supports it, what doesn't.
    2. Show the healthier picture and its key message.
    3. Invite her to generate alternatives in her own words.
    4. Invite the helper or family members to suggest healthier ways of seeing it. The original version adapted CBT this way, drawing on family.
    5. Draw on religious beliefs and traditional wisdom where these support the healthier view.
    6. Agree one alternative thought to carry into practice.
    [source: WHO 2015 manual; Rahman 2007]
  • Example language (illustrative): "Is it true that you do nothing right? What did you manage this week, even small things?" / "What would you say to your sister if she said this about herself?" / "(to mother-in-law) What do you notice she does well for the baby?"
  • Watch for: You supplying the answer rather than her arriving at it. Family using the moment to criticise: redirect to strengths and the baby's needs. [synthesis] Working: she offers her own alternative, and it shows up in her mood-chart notes.

4.6 Step 3: Practising healthy thinking and action (practice work / behavioural activation)

  • Purpose / when: The end of every session. The manual's "behavioural activation" route. When Steps 1–2 are too hard, you can briefly "plant the seed" with the picture contrast and move quickly to this step. [source: WHO 2015 manual; Atif et al. 2017]
  • Steps:
    1. Choose small, concrete health-promoting activities linked to the session topic (diet, rest, relaxation, bonding, social contact, exercise, using services).
    2. Agree how often she will do them, and who in the house will help.
    3. Record them on the relevant chart in the Health Calendar.
    4. At the next session, review what was done, praise effort and adjust.
    5. Let her choose activities from the calendar rather than prescribing them (the China adaptation made this explicit).
    [source: WHO 2015 manual; Nisar et al. 2020; Rahman 2007]
  • Example language (illustrative): "Which of these could you manage on most days this week — even ten minutes?" / "Let's mark it here so your husband can see it too."
  • Watch for: Plans that are too big for a depressed, overloaded mother. Charts that are useless to literate, urban groups (removed in the Turkish group version). [source: Boran et al. 2023] Working: ticks on the chart and mood ratings drifting upward.

4.7 Imagery rehearsal

  • Purpose / when: A key technique for practising the new thinking in a real situation. Use it when she can recall a specific recent episode. [source: WHO 2015 manual]
  • Steps:
    1. Ask her to recall a recent real situation in which she felt bad, and to picture it.
    2. Identify the thought she had.
    3. Have her replay the scene in her mind, this time with the healthier thought, and notice how the feeling and action change.
    4. Plan to use the new thought next time.
    [source: WHO 2015 manual; step detail synthesis]
  • Example language (illustrative): "Close your eyes if that's comfortable and go back to yesterday evening when the baby wouldn't settle… Now play it again, but this time you tell yourself 'he's tired, not angry with me'. What changes?"
  • Watch for: Distressing memories, for example of abuse. Stop, ground her and do not push. [synthesis] Working: she reports trying the new thought in the moment.

4.8 Mood chart (daily pictorial rating)

  • Purpose / when: Self-monitoring from the Opening Session onward. Reviewed as task 2 of every session. [source: WHO 2015 manual]
  • Steps:
    1. Show the five-face scale, from "very well" to "very poorly".
    2. Ask her to mark her mood once a day and, if she can, note any unhelpful thoughts. A family helper can record for a non-literate mother.
    3. At each session, look at the pattern together and link good and bad days to activities and thoughts.
    [source: WHO 2015 manual; Atif et al. 2017]
  • Example language (illustrative): "Your faces were brighter on the days you walked to your mother's — what do you make of that?"
  • Watch for: Blank charts. Explore why (see Section 5). Persistent bottom ratings mean you should assess risk. [synthesis] Working: she uses the chart herself to explain her week.

4.9 Health Calendar (main job aid)

  • Purpose / when: The single tool needed to deliver each session. It holds each session's pictures and key messages, the monitoring charts and space for notes. A copy is left with the mother from the Opening Session. It also supports consistent delivery and fidelity monitoring. [source: WHO 2015 manual; Rahman 2007]
  • Steps:
    1. Open the calendar at the session's page.
    2. Use its pictures to run the three steps.
    3. Fill in the charts with her.
    4. Leave it in the home as a visual reminder between visits.
    [source: WHO 2015 manual]
  • Watch for: Pictures that are culturally off. Adaptations redraw them with local women and settings (China, Turkey). [source: Nisar et al. 2020; Boran et al. 2023]

4.10 Health corner

  • Purpose / when: Original Pakistan version. A designated space in the home for health activities and materials, so practice is visible and routine. [source: Rahman 2007]
  • Steps: Agree with the mother and family on a spot (for example where the calendar hangs) and use it for practice activities. [source: Rahman 2007; detail synthesis]
  • Watch for: Lack of private space at home, a barrier noted in Turkey. [source: Boran et al. 2023]

4.11 Household diet chart (Session 1.1 onward)

  • Purpose / when: Personal-health sessions. Counters fatalism ("illness is my fate") and self-neglect. [source: WHO 2015 manual]
  • Steps:
    1. With the whole family, build a balanced diet plan from foods the household already eats and can afford. It does not need to be expensive.
    2. Record it on the diet chart.
    3. Review it at later sessions, including use of iron tablets (checked in Session 1.3).
    Give no calorie or weight targets. [source: WHO 2015 manual]
  • Example language (illustrative): "Which of the foods you cook anyway could go on her plate each day? Who serves her?"
  • Watch for: Mothers eating last or least in the household. Involving the family is the lever. [synthesis] Note that the Turkish group version dropped the diet and rest charts, because pregnancy schools already covered them. [source: Boran et al. 2023]

4.12 Rest and relaxation chart with slow breathing

  • Purpose / when: From Session 1.1. Rest, relaxation, walking, sleep and an afternoon nap, plus less heavy lifting and demanding farm work in pregnancy. [source: WHO 2015 manual]
  • Steps:
    1. Plan daily rest periods and a nap with the family, and who will cover her chores.
    2. Teach slow breathing: an even, slow in-breath and out-breath of a few seconds each (the manual gives about three seconds each way). Practise together.
    3. Add short walks.
    4. Record on the rest chart and review.
    Session 1.2 continues slow breathing once a day. [source: WHO 2015 manual]
  • Example language (illustrative): "Let's breathe together — in slowly, two, three… and out, two, three."
  • Watch for: Dizziness from over-breathing (slow it down). Family resistance to her resting. [synthesis] Working: rest periods marked, and she reports feeling calmer.

4.13 Health-service navigation and danger-sign education

  • Purpose / when: Personal-health sessions. Replaces passivity and fatalism with early help-seeking and use of available resources. [source: WHO 2015 manual]
  • Steps:
    1. Give directions to the nearest antenatal centre and midwifery service.
    2. Review warning signs in pregnancy and childbirth, and third-trimester problems, and how to get help. The WHO Safe Childbirth Checklist may be used.
    3. Encourage vaccination.
    4. Check iron tablets.
    5. Give breastfeeding advice after birth.
    The peer version added standard messages on iron supplementation and exclusive breastfeeding to six months, and referred general health needs to LHWs or Anganwadi workers. [source: WHO 2015 manual; Atif et al. 2017]
  • Watch for: Content outside your competence. Refer to maternal health staff. [synthesis]

4.14 Bonding with the unborn baby (Session 1.2)

  • Purpose / when: Mothers who feel nothing for the baby, blame themselves as "bad mothers", or believe the baby grows by itself, or that her tension doesn't affect it. [source: WHO 2015 manual]
  • Steps:
    1. Run the three steps on these thoughts. The healthier messages: feelings can grow over time; the unborn baby needs her care; lowering her stress helps the baby; bonding grows with effort.
    2. Agree practice work: singing or humming a lullaby and picturing the baby 3–4 times a day.
    3. Keep up the diet and rest charts and daily slow breathing.
    4. Do not force her to disclose feelings. Consider how family reactions to the pregnancy shape her feelings.
    [source: WHO 2015 manual]
  • Example language (illustrative): "Lots of mothers don't feel close yet — that feeling often comes with time. What could you do now to start getting to know this baby?"
  • Watch for: Unwanted pregnancy, pregnancy from coercion, or sex-preference pressure from family. Treat these with care and privately. [synthesis]

4.15 Social support diagram (Session 1.3)

  • Purpose / when: Withdrawal, "nobody cares about me", feeling inferior, family tension. [source: WHO 2015 manual]
  • Steps:
    1. Run the three steps on social thoughts. The healthier messages: make an effort to reduce family tension; going out is fine in pregnancy; reach out to those willing to help; people differ.
    2. Draw with her a diagram of her support in two domains, family and community, and name the main supporters in each.
    3. Pick one or two people to reconnect with.
    4. Stay out of family politics. Stress that the whole family should support the baby's development.
    [source: WHO 2015 manual]
  • Example language (illustrative): "Let's put you in the middle. Who at home helps, even a little? Who outside — neighbours, friends, the health worker?"
  • Watch for: An empty diagram means isolation or a controlling household. Consider the group (4.16) and screen for violence privately (Section 5). [synthesis]

4.16 Mother and Baby Health Group

  • Purpose / when: From Session 1.3, a weekly group for social support, "if feasible". Attendance continues postnatally. The peer version used the LHWs' existing monthly women's groups for four group sessions, covering psychoeducation and child development. [source: WHO 2015 manual; Atif et al. 2017]
  • Steps:
    1. Identify a local venue and the participating mothers.
    2. Agree a regular time.
    3. Use the group to share experiences, rehearse key messages and do activities.
    4. Encourage attendance as practice work.
    Detailed group procedures for the WHO version were not found. [uncertain]
  • Watch for: Confidentiality in close-knit villages. [source: Atif et al. 2017]

4.17 Postnatal exercise chart (Session 2.1)

  • Purpose / when: First postnatal weeks, alongside the three steps on thoughts such as "too busy or tired to care for myself", "my health is someone else's job" or "not good enough to be a mother". [source: WHO 2015 manual]
  • Steps:
    1. Teach three gentle exercises: a breathing exercise with abdominal tightening, pelvic floor squeezes, and a lying-down leg-slide exercise.
    2. Record them on the exercise chart.
    3. Continue the diet and rest charts and give breastfeeding advice.
    Mothers who already do heavy physical work should not overexert. Do not set exercise targets beyond the manual's chart. [source: WHO 2015 manual]
  • Watch for: Pain, heavy bleeding or wound problems after delivery. Pause and refer to maternity staff. [synthesis]

4.18 Time-for-health calculation (Session 2.1)

  • Purpose / when: Mothers who feel overwhelmed or undeserving of self-care. [source: WHO 2015 manual]
  • Steps:
    1. Add up with her the minutes per day her health activities actually need.
    2. Ask whether that time is worth it for her and the baby.
    3. Break the activities into small steps that fit her day, and find time to rest.
    [source: WHO 2015 manual]
  • Example language (illustrative): "Exercises, rest and a proper meal come to under an hour. Is an hour a day worth it for a healthier mother for this baby?"
  • Watch for: Guilt about taking time. Reframe self-care as care for the child. [synthesis]

4.19 Postnatal and infancy sessions (2.2 to 5.3)

  • What the sources confirm:
    • Each of Modules 2–5 has three sessions: personal health, relationship with the baby, and relationship with people around her.
    • Each uses the same four-task format and three steps, with pictures matched to the infant's age.
    • Module titles: "The baby's arrival", "Early infancy", "Middle infancy", "Late infancy".
    [source: WHO 2015 manual; Rahman 2007]
  • What could not be verified: The specific unhealthy thoughts, key messages and practice activities for Sessions 2.2–5.3. The manual's text was cut off after Session 2.1 in the copy opened. Use your printed manual and Health Calendar for those sessions. [uncertain]
  • How to run a session from a module page (illustrative template) [synthesis]:
    1. Personal health: review her charts and add one new self-care activity.
    2. Relationship with baby: run the three steps on her thoughts about the baby (for example "the baby cries to punish me" or "talking to a baby is pointless"). Plan age-appropriate interaction (talking, singing, responsive feeding, simple play), using your service's child-development guidance.
    3. Relationship with others: revisit the support diagram and plan one request for help or one social activity.
  • Related published material: THPP+ boosters used WHO Care for Development play activities and picture card games to encourage mother–infant interaction and play. [source: THPP+ SAP] The Turkish version added the first 1000 days, maternal responsiveness, breastfeeding and colic to the baby session. [source: Boran et al. 2023]

4.20 Problem solving

  • Purpose / when: Practical problems (money, workload, family conflict) that keep low mood going. The original programme called its approach simplified "here and now" problem-solving CBT. The Turkish group version taught an explicit five-step problem-solving approach, with everyday examples, in its second session. [source: Rahman 2007; Boran et al. 2023]
  • Steps: The exact five steps used in Turkey were not given in the source opened. [uncertain] A generic sequence [synthesis]:
    1. Name one specific problem.
    2. Brainstorm options, with family if helpful.
    3. Weigh the pros and cons.
    4. Pick one and plan who, what and when.
    5. Review the result at the next session.
  • Example language (illustrative): "Let's take just one of these worries. What are all the things that could be tried, even ones that seem silly?"
  • Watch for: Problems that cannot be solved (bereavement, chronic poverty). Shift to coping and support. [synthesis]

4.21 Linking to community resources

  • Purpose / when: Social problems such as poverty or abuse. The original LHWs connected mothers to resources. Published examples: a micro-credit loan, a neighbour support group, and a respected local spiritual mentor who spoke to an abusive husband. [source: Rahman 2007]
  • Steps (detail is [synthesis]):
    1. Identify the need.
    2. Map local resources: welfare schemes, NGOs, community or religious leaders, women's groups.
    3. Discuss with the mother what she consents to.
    4. Make the link and follow up.
  • Watch for: Bringing in leaders or family without the mother's consent, or in ways that raise her risk of violence. [synthesis]

4.22 Group-format techniques (adaptations)

  • Purpose / when: When THP is delivered in groups:
    • Turkey: pregnancy-school groups using relaxation and breathing, role plays, group sharing, illustrations, the mood chart and problem solving.
    • THPP+: peer groups using culturally grounded vignettes and picture card games carrying wellbeing messages, behavioural activation as needed, and age-appropriate play demonstrations.
    • China: a fictional local mother whose story walks through the steps.
    [source: Boran et al. 2023; THPP+ SAP; Nisar et al. 2020]
  • Steps (detail is [synthesis]):
    1. Open with check-in and mood ratings.
    2. Present a vignette.
    3. Ask the group to identify the character's unhelpful thoughts and suggest healthier ones.
    4. Role-play the new response.
    5. Each member chooses one practice activity.
    6. Close with breathing or relaxation.
  • Watch for: Members who dominate, and disclosure of risk in the group. Follow up individually. [synthesis]

4.23 Supervision procedures (for clinicians supervising THP deliverers)

  • Purpose / when: Monthly, or fortnightly in some peer sites. Maintains fidelity and supports deliverers. [source: WHO 2015 manual; Atif et al. 2017]
  • Steps:
    1. Run brief role plays of difficult moments.
    2. Have the group brainstorm locally acceptable solutions rather than prescribing them.
    3. Give feedback using a fidelity checklist; peer sites also rated audio recordings on a therapy quality scale.
    4. Leave space for deliverers to share stress.
    5. Recognise successes.
    [source: WHO 2015 manual; Rahman 2007; Atif et al. 2017]
  • Watch for: Deliverer burnout, and drift toward giving advice or getting pulled into family conflict. [source: Rahman 2007; Atif et al. 2017]

5. Handling problems

5.1 Problems the sources address

  • Family sees no problem, or thinks talk therapy is pointless. Make the baby's health and development the agenda the whole family shares. [source: Rahman 2007]
    • Illustrative: "This is about giving your grandchild the best start."
  • Stigma and fear of labels. Avoid the word "depression". Use "stress", "burden" or "tension", and present the work as training. [source: Rahman 2007; WHO 2015 manual; Atif et al. 2017]
  • Family suspicion (for example fears of "brainwashing"). Involve the whole household from the Opening Session and build shared goals. [source: Rahman 2007]
  • Passivity, or expecting medicine or material help. State the programme's limits early. Require active participation and practice work. Deliver at home rather than in a clinic. [source: WHO 2015 manual; Rahman 2007]
  • Practice work not done. The manual has family members gently persuade the mother. The ground rules agreed at the start include doing practice work. [source: WHO 2015 manual]
    • [synthesis] Also: shrink the task to the smallest step, link it to an existing routine, have the helper prompt her, and ask what got in the way without judging.
  • Cognitive steps too hard (for the mother or the deliverer). Briefly point out the contrast in the pictures and move to behavioural activation. [source: WHO 2015 manual; Atif et al. 2017]
  • Low literacy. Use the pictures, the face scale and a family scribe. [source: WHO 2015 manual; Rahman 2007]
  • Cultural confinement periods and travel.
    • In Pakistan the programme did not suggest outdoor activities during the 40-day postnatal confinement (chilla). [source: Rahman 2007]
    • China added the confinement month. [source: Nisar et al. 2020]
    • In Goa, mothers going to their own mother's home for the birth interrupted sessions. Plan for this: telephone contact was tried as an option. [source: Atif et al. 2017]
  • Family conflict and the mother-in-law relationship. Stay out of family politics and bring the focus back to mother and child. China added mother-in-law conflict as a stressor in its materials. [source: WHO 2015 manual; Atif et al. 2017; Nisar et al. 2020]
  • Poverty and abuse. Link her to resources. One published case used a respected spiritual mentor to speak to an abusive husband. [source: Rahman 2007] For safety caveats see 5.2.
  • Confidentiality and gossip in close communities. Stress confidentiality and never press for disclosure in front of family. One peer-version mother dropped out over stigma. [source: WHO 2015 manual; Atif et al. 2017]
  • No private space or internet (group and online versions).
    • Online delivery in Turkey needed devices and data. Providing internet packages was proposed.
    • Lack of privacy at home remained unsolved.
    • Charts that didn't help were dropped.
    [source: Boran et al. 2023]
  • Deliverer stress, burnout and drift. Hold regular group supervision, solve problems together and recognise successes. [source: Rahman 2007; WHO 2015 manual]

5.2 Problems the sources do not cover

Everything in this subsection is [synthesis]. Check it against mhGAP and local protocols.

  • Suicidal ideation or self-harm.
    • Ask directly about thoughts of death or suicide when mood is very low, the mood chart is persistently at the bottom, or she says the family would be better off without her.
    • Assess intent, plan, past attempts and protective factors.
    • If risk is present, do not leave her alone if risk is imminent. Involve the supervisor the same day and arrange urgent mhGAP-level or specialist assessment.
    • Agree a safety plan with a trusted family member, with her consent where possible.
    • Advise safe storage or removal of means in the home (for example pesticides or medicines).
    • Lay deliverers should hand over risk management, not hold it alone. Whether the full WHO manual has its own risk section could not be checked. [uncertain]
  • Thoughts of harming the baby, or neglect.
    • Separate intrusive, unwanted worries (common, and distressing to her) from intent.
    • Escalate any intent or neglect under local safeguarding procedures, and increase support in the home.
  • Psychosis, mania or severe postpartum illness. These are outside THP's scope (excluded in the original trial). [source: Rahman et al. 2008] Refer urgently.
  • No improvement or worsening.
    • Re-check engagement, how much practice is being done, and any ongoing stressors such as violence or illness.
    • Discuss in supervision.
    • Step up to specialist assessment. mhGAP guidance applies to any medication decision in pregnancy and breastfeeding.
  • Overwhelm in session.
    • Slow down, use the slow breathing, and drop to one small activity.
    • Shorten the session and keep the next contact.
  • Rupture: she feels lectured, judged or that confidentiality was broken.
    • Name it and apologise for any part you played.
    • Return to listening and let her set the agenda for that visit.
    • Check the family helper is not being used to monitor her.
  • Intimate partner or family violence.
    • Screen privately, never in front of family.
    • Do not involve the abuser or community figures without her consent and a safety assessment.
    • Refer to local violence services.
  • Pregnancy loss, stillbirth, infant illness or death.
    • Suspend the infant-focused modules.
    • Offer bereavement support and refer.
    • Resume or adapt only with her agreement.
  • Missed visits and dropout.
    • Contact her through the helper.
    • Offer flexible times or a phone check-in.
    • Ask whether family opposition, stigma or travel is the reason.
    • Don't let the dose slip unnoticed: record it, because the manual treats 16 sessions as the optimal dose.

Sources

Sources

Further reading (not drawn on)

  • Turner EL, Sikander S, Bangash O, et al. (2016) The effectiveness of the peer-delivered Thinking Healthy Programme for perinatal depression in Pakistan and India: the SUNDAR study protocol. Trials. [uncertain]
  • WHO (2016) mhGAP Intervention Guide, version 2.0 (referenced by the THP manual for depression management and referral). [uncertain]

Gaps: session-level content for Sessions 2.2–5.3; any risk-management section in the full WHO manual; current certification arrangements; other lay-counsellor models.

← Previous · V-164iSupportNext · V-166 →Common Elements Treatment Approach (CETA)