1. The programme at a glance
Indication. Adjustment disorder in adults: after an identifiable stressor — a separation, a job loss, an illness, a conflict — an invasive preoccupation and a life that no longer keeps up, without another disorder better accounting for the picture. The programme also applies to a person seen after a suicidal act in whom this diagnosis is made, once the crisis has been dealt with and the safety plan written (section 10).
Reference model. A brief cognitive behavioural therapy (CBT), focused on the stressor and its consequences. It brings together three components: problem solving, as formalised by Nezu, Nezu and D'Zurilla (2013); behavioural activation, which consists in taking up scheduled activities again without waiting for the desire to come back; and cognitive work on the preoccupation and on the way the person interprets the blow. The conceptual framework is the one ICD-11 adopted: adjustment disorder described as a stress-response syndrome, made up of preoccupation and failure to adapt (Maercker et al., 2007).
Format. At most eight individual sessions: the first lasts 75 minutes, the following ones 50 minutes. Sessions 1 to 6 are weekly; sessions 7 and 8 take place a fortnight apart, so that the person can try out on their own what they have learnt. Six sessions are enough when sessions 6 and 7 have no purpose, which is decided at session 5 (section 15). Three booster sessions follow, at one, three and six months. This brevity is consistent with the published trials, which have mostly evaluated brief interventions: a self-help booklet used for a month (Bachem and Maercker, 2016), a four-week internet programme (Holas et al., 2026), eight weekly group sessions (Sanz Cruces et al., 2018). The programme itself has not been evaluated as such, and the detail of its format is a choice made by this manual, which section 15 sets out.
Mechanism targeted. Not making the stressor disappear, since it is real and sometimes lasting, but obtaining three changes: that thinking about the blow stops occupying the day; that the person acts on what can change and makes room for what cannot; and that they take up their activities, relationships and roles again, at work as elsewhere.
| Session |
Focus |
Session output |
| 1 |
Assess, sort, make safe |
Diagnosis made or ruled out, risk assessed, baseline measures |
| 2 |
Understand and take stock |
Circle drawn, consequences sorted, goals written |
| 3 |
Preoccupation time |
Fixed time set up, one question made concrete |
| 4 |
One problem at a time |
A first action taken or dated |
| 5 |
Taking the days back |
Three activities scheduled, mid-point measures |
| 6 |
What I tell myself, and what does not change |
One interpretation revised, one loss named |
| 7 |
Work and other people |
Written return-to-work plan, one request made |
| 8 |
Review and plan for what comes next |
Measures repeated, written plan |
What the person takes away. Nine printable worksheets, listed in section 34: my week, what has changed and what depends on me, the time to think about it, one problem at a time, my days, what I tell myself, my safety plan, the corner for those close to you, my plan for what comes next.
What distinguishes this programme from the other manuals on this site. Three things. It begins by deciding whether to treat, and what: a normal reaction does not need a protocol, and a full-threshold disorder needs another manual (section 8). It is brief, and focused on the concrete consequences of the stressor, separating what can be solved from what has to be borne. And it treats suicide risk as seriously as in disorders reputed to be severe, because this diagnosis's reputation for being benign is one of the reasons why the risk is missed.
2. Before you begin
The four preliminary decisions
Is it a disorder, or a normal reaction? After a job loss or a break-up, sadness, worry, disturbed sleep and recurring thoughts are the rule. They become a disorder when the preoccupation invades the days and the person no longer manages to function in an important area of their life (section 3). This decision is made at session 1, and it is shared with the person.
Does another disorder explain it better? Both classifications reserve this diagnosis for presentations that no other disorder explains better. A major depressive episode, post-traumatic stress disorder or prolonged grief disorder therefore come first, each with its own manual, respectively Treating depression in adults: a therapist's manual, Post-traumatic stress disorder in adults: a therapist's manual and Treating prolonged grief in adults: a therapist's manual (section 8).
What is the suicide risk? It is looked for explicitly from the first session, then at every session (section 10). It is the question most readily forgotten when faced with a diagnosis that passes for mild.
Is the stressor over, ongoing, or dangerous? A job loss is a dated event; a serious illness or divorce proceedings go on producing their effects; separating from a violent partner exposes the person to real danger. The programme adapts to the first two cases; the third begins with safety (section 10).
What this programme does not treat
A normal reaction to a blow. It calls for information, support and a reassessment a few weeks later, not for treatment (section 33).
A full-threshold disorder. A major depressive episode falls under Treating depression in adults: a therapist's manual; generalised anxiety, under Treating generalised anxiety disorder in adults: a therapist's manual; post-traumatic stress disorder, under Post-traumatic stress disorder in adults: a therapist's manual; prolonged grief disorder, under Treating prolonged grief in adults: a therapist's manual.
An acute suicidal crisis. It is dealt with first, with the emergency services and following Suicidal behaviour in adults: a therapist's manual; this programme can then be linked to that work (section 10).
Children and adolescents. The disorder exists at these ages, but the work there goes through the parents and the school; section 29 only says what needs to be known about suicide risk in adolescence.
How to use it
Read the whole thing before the first session, in particular sections 3, 8 and 10: the sorting, the limits of the diagnosis and safety. Each session is described following the same framework: the aim, the steps, what you say, common errors, and the criterion for moving on.
Three warnings specific to this reason for referral.
The "mild" label is misleading. Adjustment disorder is often benign and transient. But it is frequently diagnosed in people seen in hospital after a suicidal act (Fegan and Doherty, 2019), and the suicide rate in this diagnosis is clearly higher than in the general population (Gradus et al., 2010). Section 10.
The drift to watch for is endless support. Each week's session can be spent listening to the account of what happened: the person leaves relieved, and nothing moves. The interventions that have data behind them are structured (section 12).
And the opposite error exists: turning an ordeal into an illness. A diagnosis made too quickly on a proportionate reaction teaches the person that they cannot get through on their own what most people get through. The sorting at session 1 protects against both errors.
3. Five presentations not to be confused
Five situations present after a blow, and they do not call for the same approach; section 8 gives the rules for moving from one to another.
1. The normal reaction
What you observe. In the weeks that follow, sadness, worry, anger, disturbed sleep, thoughts that keep coming back. The person sleeps less well, works less quickly, and yet goes on doing the essentials.
What points the way. Proportion and trajectory: distress in keeping with the event, given the person's context and culture, functioning preserved in the essentials, and improvement from week to week. For the most serious events, ICD-11 even conceives of the acute stress reaction as a normal phenomenon, which may call for help without constituting a disorder (Maercker et al., 2013).
What it implies. Information, support, taking activities up again, and a reassessment a few weeks later. No programme.
2. Adjustment disorder
What you observe. An invasive preoccupation, centred on the stressor and its consequences, and a failure to adapt: sleep, concentration, work, relationships or ordinary tasks no longer keep up.
What points the way. An identifiable stressor, an onset generally within the month that follows according to ICD-11 and within three months according to DSM-5-TR, clear impairment, and the absence of another disorder that would better account for the picture.
What it implies. This is the programme described here.
3. The major depressive episode
What you observe. Low mood or loss of interest has been present nearly every day for at least two weeks, and the picture has become generalised: self-deprecation and slowing set in, and pleasure has disappeared even for things that have nothing to do with the event.
What it implies. Treating depression in adults: a therapist's manual, even if a trigger is obvious.
4. Post-traumatic stress disorder
What you observe. After an event in which life or physical integrity was threatened, re-experiencing lived in the present, organised avoidance of what recalls the event, and hypervigilance.
What points the way. Re-experiencing imposes itself as if the event were happening again; the preoccupation of adjustment disorder is a thought about the event and its aftermath, which the person knows to be a thought (Eberle and Maercker, 2022).
What it implies. Post-traumatic stress disorder in adults: a therapist's manual.
5. Prolonged grief disorder
What you observe. After the death of someone close, an intense longing for the deceased or a preoccupation centred on them, with intense emotional pain, persisting beyond what the person's cultural environment expects.
What it implies. Treating prolonged grief in adults: a therapist's manual. Grief that is running its course is not treated, and it is not in itself an adjustment disorder; section 8 says what to do when it is the practical consequences of the death that become overwhelming.
The three sorting questions
"Since what happened to you, how much time a day do you spend thinking about it, and what does it stop you doing?" It isolates the two cores of the disorder: preoccupation and failure to adapt.
"Do the sadness or the lack of drive spill over beyond what concerns the event?" It points towards major depression.
"Do images come back as if you were there, or do you think about what happened and what will come next?" It separates re-experiencing from preoccupation.
4. The two cores, and what comes with them
Preoccupation
What you observe. Thoughts that keep coming back to the stressor and its aftermath: "why me?", "how am I going to pay?", "what should I have done?". They take hours, they come back at bedtime, and the person says they think of nothing else.
What needs to be specified. ICD-11 makes it the first core of the disorder, in three forms: excessive worry, repeated distressing thoughts about the event, and rumination about what it implies. The scoping review by Eberle and Maercker (2022) — a review that maps what has been published on a question, without assessing effectiveness — describes it as factual thinking, centred on the stressor, time-consuming and laden with negative emotions. According to these authors, rumination and worry may be ways of reacting to this preoccupation, which maintain it instead of resolving it.
What distinguishes it. It is not re-experiencing: the person thinks about the event, they do not relive it. Nor is it an isolated automatic thought: it is a way of thinking that lasts, that returns to the same questions, and that is worked on as an activity (section 26).
Failure to adapt
What you observe. The person no longer manages to do what they used to do. They sleep badly, have difficulty concentrating, let the post pile up, do not go back to work, no longer see their friends.
What needs to be specified. It is the second core, and it is what makes the disorder: without significant impairment in personal, family, social or occupational life, ICD-11 does not make the diagnosis. Sleep disturbance and difficulty concentrating are typical examples of it (Lorenz et al., 2016). In practice, this failure is described in terms of precise activities: what is no longer done, since when, and what it costs.
The associated features
Sadness, anxiety, avoidance and irritability. The reference questionnaire of this manual measures them alongside the two cores (section 11): low mood and loss of interest, anxiety when the person thinks about the event, avoidance of what recalls it, and new irritability or impulsivity (Lorenz et al., 2016). DSM-5-TR derives subtypes from them (section 7).
What you need to know about the subtypes. They are not borne out by the data: in a cohort of injured people followed for a year, symptom profiles were distinguished by their severity, not by subtype (O'Donnell et al., 2016). Note the features that are present, because they guide the work, without expecting the subtype to change the treatment.
The body. New and prominent fatigue, tension or headaches are checked with the doctor.
The question of time
The features generally appear within the month following the stressor according to ICD-11, which allows a later onset, and within three months according to DSM-5-TR (O'Donnell et al., 2019; World Health Organization, 2024). They most often resolve within six months, unless the stressor persists. A chronic illness, lasting unemployment or a conflict with no way out can maintain the disorder beyond that, and a recent systematic review shows that some people keep this diagnosis, or receive another one, months or years later (Morgan et al., 2022).
5. What maintains the disorder
The stressor sets things off; it does not on its own explain why the reaction does not settle. Five mechanisms maintain the disorder, and each has its place in the programme.
Preoccupation that spins its wheels
Thinking repeatedly about a problem is not always harmful. Watkins's review (2008) shows that repetitive thinking can help a person recover from a distressing event and prepare for the future, or on the contrary maintain depression and anxiety. The difference lies partly in the level of the thinking: when it is concrete, it bears on what happened and on what can be done; when it is abstract, it bears on the "why" and on what the event says about oneself or the world. In adjustment disorder, preoccupation readily takes the abstract form: questions without answers, gone over a hundred times, which give the impression of working on the problem and consume the time and energy that would serve to act. Session 3.
Problems left as they are
The stressor produces concrete consequences: paperwork, a debt, the children's custody, a job search, medical treatment. Left as they are, they accumulate and in turn become stressors. Rarely through incompetence: most often, the person avoids, because each step recalls the blow and its injustice, or because they judge the problem insurmountable. Problem-solving therapy calls this second attitude a negative problem orientation: seeing the problem as a threat, doubting one's ability to solve it, expecting to fail (Nezu et al., 2013). Session 4.
Withdrawal
Activities are dropped one by one, because the person "isn't up to it", is tired, or is ashamed of what is happening to them. Fewer opportunities for pleasure and achievement mean a mood that drops and more time for preoccupation. It is the mechanism targeted by behavioural activation in depression, where it has proved itself (Ekers et al., 2014). Session 5.
The interpretations of the blow
"I'll never get over it." "It's my fault." "It's unfair, and I can't accept it." Lazarus and Folkman's transactional model of stress (1984) explains why these sentences matter: what weighs is not only the event, but the way the person appraises what is at stake and the resources available to them (section 6). An appraisal of the kind "everything is lost, and there's nothing I can do" discourages action, which leaves the problems as they are, which confirms the appraisal. Session 6.
Sleep, alcohol and sick leave that drags on
Disturbed sleep reduces the capacity to solve problems. Alcohol often serves to silence the evening's thoughts. And sick leave that goes on without a return plan can take away a role, a structure and contacts. No trial in this disorder has compared such leave with a prepared return; but the interventions that shortened sick leave were active and focused on the return (van der Klink et al., 2003; Arends et al., 2012). Sessions 5 and 7.
The complete circle
The stressor produces consequences and thoughts. The thoughts turn into questions without answers, which take up time and energy. The concrete problems remain as they are, and activities are dropped. Functioning declines, which creates new problems and new reasons to think about it. And the interpretation — "I won't manage" — is confirmed. This is the diagram you draw with the person at session 2.
Frequently asked questions
Is adjustment disorder a real diagnosis, or a catch-all category?
For a long time it was an ill-defined category, with no symptoms of its own. ICD-11 has given it two: preoccupation with the stressor and failure to adapt (section 7). These are what the programme measures and treats.
Should it be treated, or should we wait for it to pass?
A proportionate reaction, improving from week to week, is not treated. An established disorder is treated, because it can last, turn into another disorder, and be accompanied by suicide risk (sections 9 and 10).
The stressor is still there. Can we treat it anyway?
Yes. The programme does not target the stressor, but the room it takes up and what it has brought to a halt in the person's life. When it lasts, the share devoted to what does not change increases (section 29).
The person mainly wants to talk about what happened to them.
Give this account its place at session 1, and acknowledge the blow clearly. After that, bring each session back to what it has produced: the account repeated every week risks feeding the preoccupation instead of reducing it (section 15).
Should sick leave be extended?
It is not your decision: it belongs to the doctor. You can say that nothing shows that prolonged rest without a plan helps more, and that active approaches have shortened sick leave in this disorder; your role is to prepare the return (section 28).
And if the person meets the criteria for depression during the programme?
The diagnosis changes, and treatment follows Treating depression in adults: a therapist's manual. That is why the sorting is redone at each measurement point (section 8).
Eight sessions: is that really enough?
The interventions evaluated in this disorder are mostly brief, and we found no trial showing that longer treatment does better. The exact number of sessions remains a choice made by the manual (section 15). If eight sessions are not enough, the first hypothesis is another diagnosis (section 31).
Is suicide risk really high in such a mild disorder?
Yes. The diagnosis is frequent in people seen after a suicidal act, the suicide rate is markedly increased in those who have received it, and suicidal ideation and behaviour can occur with less intense symptoms than in depression (section 10).
The event was serious, but there is no re-experiencing.
An incomplete post-traumatic picture may fall under adjustment disorder. If the preoccupation concerns the consequences of the event, this programme is suitable; if re-experiencing appears, the work on the memory becomes the priority (section 8).