Participants in this group will receive a culturally adapted version of the World Health Organization's Problem Management Plus (PM+) program, with an added Emotional Processing (EP) module. The intervention will be delivered through six individual sessions over one month by trained Afghan facilitators of the same gender as the participant. Sessions will focus on managing distress, solving problems, building social support, and processing difficult emotions.

Participants in this group will not receive the intervention during the study period but will complete the same assessments as the intervention group. After the study concludes, they will be offered the opportunity to receive the PM+ EP sessions.

PM+ EP comprises of Problem Management Plus, an evidence-based low intensity psychological intervention developed by the World Health Organization (WHO), with an additional Emotional Processing module specifically to address psychological distress related to trauma exposure. The core of the intervention is designed for adults impaired by distress in communities exposed to conflict and adversity; it consists of CBT techniques that have been adapted for communities that do not have good availability of specialist care. The additional module was developed by researchers treating refugee youth (Alozkan Sever et al, 2021). For this study, PM+ EP will be a six-session individual and guided support program. The original sections of PM+ are available in many languages including Farsi, and the additional EP module will be translated by PoMA's Afghan translator. The sessions cover the topics of managing stress, strengthening social support, staying well and persevering.

In this pilot RCT, the primary outcome is to explore the feasibility and acceptability of delivering the PM+ EP intervention in Afghanistan. The study serves to demonstrate whether such interventions could be safety scaled and produce positive outcomes for the target population. All participants will complete four surveys for assessment at study points T0, T1, T2 and T3. The Hopkins Symptom Checklist 25 (HSCL-25) is one outcome measure designed to measure for anxiety and depression. Hopkins Symptom Checklist-25 (HSCL-25) is a 25 item self-report questionnaire assessing symptoms of psychological distress; 10 items for anxiety symptoms and 15 items for depression symptoms (2 of which identify somatic symptoms) (Mollica et al, 1987). The items are rated on a 4-point Likert scale, ranging from 1 (never) to 4 (always) with the anxiety scale ranging from 10-40 and the depression scale from 15-60. The total scale (range 25-100) represents psychological distress.

The primary outcome of this pilot RCT is to assess the feasibility and acceptability of delivering the PM+ EP intervention in Afghanistan and its potential for safe scale-up and positive impact. All participants will complete four assessments at T0, T1, T2, and T3. PTSD symptoms will be measured using the PTSD Checklist for DSM-5 (PCL-5), a 20-item self-report tool that assesses symptoms over the past month. Each item is scored from 0 (Not at all) to 4 (Extremely), covering four symptom clusters: Re-experiencing, Avoidance, Negative Cognition/Mood, and Hyperarousal. A provisional PTSD diagnosis can be made if participants endorse the minimum number of symptoms in each cluster at a rating of 2 or higher. A total score between 31-33 suggests probable PTSD. This outcome will help determine whether PM+ EP is a feasible and acceptable approach to reducing trauma symptoms among conflict-affected youth in Afghanistan.

This outcome explores the relationship between mental health symptoms and violent behavior through qualitative interviews with a purposive sample of participants and facilitators conducted after the intervention (T3). Interviews will investigate perceived changes in psychological distress, aggressive behavior, and attitudes toward violence, as well as the cultural relevance and acceptability of the PM+ EP intervention. Data will be analyzed thematically using ATLAS.ti. Results will be used to illustrate context-specific linkages between mental health and violence and to inform future adaptation and scale-up of culturally tailored psychological interventions in conflict-affected settings.