Self-Help Plus

1. Introduction

Version followed: WHO Self-Help Plus (SH+): a group-based stress management course for adults (2021, ISBN 9789240035119; English audio Sessions 1–5 plus an "Alternative Session 1"), used with the WHO illustrated guide Doing What Matters in Times of Stress (2020) and the SH+ training manual (WHO, 2024, ISBN 9789240095052). The participant exercises below are checked against the illustrated guide itself (WHO 2020, page references given). The facilitator manual and training manual are cited through WHO's publication pages and the trial literature: the Uganda trial protocol and pilot (Brown et al. 2018; Tol et al. 2018), the Uganda trial abstract (Tol et al. 2020), the RE-DEFINE protocol, the DIGNITY implementation package and WHO's online orientation course page. These give the group format, the facilitator role, facilitator selection, training length and content, competency checks, supervision and fidelity arrangements, and pilot problems with their fixes. Not confirmed from WHO's own facilitator text [uncertain]: the audio's session-by-session mapping, the steps of Alternative Session 1 and when to use it, and the supervision frequency WHO itself requires (trial arrangements are given instead). [source: WHO SH+ page; WHO training-manual page; MHPSS.net; Brown et al. 2018; Tol et al. 2018]

SH+ is not a psychotherapy delivered by a clinician. It is WHO's five-session, guided self-help stress management course for groups of up to 30 adults, delivered by trained and supervised non-specialist facilitators using pre-recorded audio and the illustrated book. It is transdiagnostic, based on Acceptance and Commitment Therapy (ACT), and intended for people with and without mental disorders, including refugees, asylum seekers and people in humanitarian emergencies, but also "wherever they live and whatever their circumstances". It can be used alone, as a first step in stepped care, as a community intervention, or alongside other mental health care. The developers were a WHO team with ACT author Russ Harris (Epping-Jordan, Harris, Brown, Carswell, Foley, García-Moreno, Kogan & van Ommeren, 2016); Harris also recorded an English version of the audio. [source: WHO SH+ page; MHPSS.net; gov.uk R4D record of Epping-Jordan et al. 2016; RE-DEFINE protocol]

Core idea of change: stress drives people to get "hooked" by difficult thoughts and feelings and to drift from what matters to them. Fighting or pushing these experiences away is not the aim; instead people learn to ground themselves in the present, unhook by noticing and naming, make room for painful feelings, act in small ways on their values and treat themselves and others kindly. Reduced struggle plus more values-guided action and social support are expected to lower distress and prevent onset of disorders. [source: WHO 2020 illustrated guide pp. 15–19, 109, 117; RE-DEFINE protocol; WHO SH+ page]

For a practising psychotherapist the realistic roles are: (a) trainer or supervisor of SH+ facilitators (WHO's stated ideal is a mental health professional experienced in psychological interventions or guided self-help); (b) running or co-running an SH+ group in a service; (c) using SH+ as a step in a stepped-care pathway and referring onward; (d) borrowing the five skills and the illustrated book in individual work, which is an adaptation, not SH+ as tested [synthesis]. [source: MHPSS.net]

2. Framework

Format. Five sessions, each about 2 hours, once a week (about 5 weeks). WHO describes groups of up to 30; trials used 20–25 (Uganda protocol), 20–30 (Uganda trial) and 10–40 (RE-DEFINE, single-gender to fit cultural norms and preferences). Two facilitators run each group; in the Uganda pilot one operated the audio and the other responded to participants. The pre-recorded audio teaches the skills, guides individual exercises and cues small-group discussions; the facilitators open the group, introduce the audio, read out discussion exercises, give brief clarifications and answer basic questions. Participants receive the illustrated book (400+ illustrations, minimal text), which summarises key points for review between sessions and can also be used alone. [source: WHO SH+ page; MHPSS.net; RE-DEFINE protocol; Brown et al. 2018; Tol et al. 2018; Tol et al. 2020]

Sessions and skills. WHO lists five core skills in this order, and the course has one audio file per session:

Session	Core skill (WHO wording)	Goal
1	Grounding in stressful situations	Learn to steady yourself when stress hits; refocus on here-and-now
2	Unhooking from difficult thoughts and feelings	Notice and name what hooks you; return attention to what you are doing
3	Acting on your values	Identify values; choose small values-based actions
4	Being kind (linked to social support)	Self-kindness and kindness to others
5	Making room	Allow difficult feelings to come and go while doing what matters

The Uganda protocol names the skills taught as present-moment awareness and grounding; defusion from and acceptance of difficult thoughts and feelings; identifying valued directions and acting on them; and compassion for self and others, with skills reinforced in later weeks. The one-skill-per-session mapping in the table follows WHO's listed order and the illustrated guide's five sections (Grounding, Unhooking, Acting on your values, Being kind, Making room); the audio's exact session mapping and how much recap and practice review each session holds are [uncertain]. Versions differ: after the Uganda pilot, where facilitators found a repeated grounding exercise too long, the audio was simplified and sessions and some exercises were shortened. An "Alternative Session 1" audio exists that includes an "Awareness of an Object" exercise; its steps and when to choose it are not published outside the course materials [uncertain]. [source: WHO SH+ page; WHO 2020 illustrated guide; MHPSS.net; Brown et al. 2018; Tol et al. 2018]

Before the course. Trials screened for eligibility (adults; distress, e.g. GHQ-12 of 3 or more) and excluded imminent or moderate-to-high suicide risk, impaired decision-making capacity and acute medical conditions; WHO states SH+ is not suitable for people with severe impairment from a mental, neurological or substance use disorder or at imminent suicide risk, though it may be used as an add-on once other needs are met. Services should have a structured referral pathway in place before the first session. [source: MHPSS.net; RE-DEFINE protocol]

Moving between sessions. The course is fixed-sequence and time-based: one session per week regardless of individual progress; no mastery criteria are published. The illustrated guide suggests spending at least a day or two practising each section before moving to the next (WHO 2020 pp. 51, 78). Practical readiness markers a supervisor can use [synthesis]: the participant attended or caught up on the previous audio; has tried the skill a few times between sessions; and shows no new safety concern requiring referral.

Stepped-care position. In Ukraine's national model, Doing What Matters is step 1 (self-help), SH+ step 2 (group guided self-help), Problem Management Plus step 3, then specialist care. After SH+, people with persisting impairment or a disorder are referred upward. [source: howareu.com interventions overview; WHO SH+ page]

Facilitators, training, supervision and licensing. Facilitators are non-specialists, ideally from the participants' community or a similar culture, with some experience in health, social, psychosocial, community or volunteer work; the Uganda trial also required completed secondary education and fluency in the delivery language. Two facilitators run each group. Reported facilitator training is about 5 days in person: the Uganda pilot facilitators were trained for 5 days by SH+ developers (then 4 more days after the package changed), covering psychological distress, identifying and managing participant distress, managing group processes, the aims and background of SH+, and going through the course as participants; each trainee then passed two role-plays (running a session; supporting a distressed participant). DIGNITY's package uses an optional 2-hour webinar, a 5-day workshop with pre/post evaluation, a 5-day training of trainers and a 2-day supportive-supervision training. RE-DEFINE training added basic helping skills and recognition of serious adverse events such as imminent suicide risk. Trainers and supervisors are ideally mental health professionals experienced in psychological interventions or guided self-help; WHO trained the local trainers in RE-DEFINE, and a WHO master trainer led the Uganda training. WHO's 2-hour online orientation course (modules include group facilitation basics, common challenges, foundational helping skills and talking to participants individually) is for mental health professionals and programme coordinators, as a first step towards self-training as a facilitator; it is not suitable for people without prior experience delivering psychological interventions, who need SH+ training. The 2024 training manual has Part A (setting up and implementing SH+, training and supervision requirements) and Part B (step-by-step workshop instructions), plus a slide set; the workshop length WHO itself prescribes is not confirmed here [uncertain]. Materials are free under CC BY-NC-SA 3.0 IGO; no WHO certification or licence to deliver SH+ was found. [source: WHO training-manual page; WHO orientation-course page; WHO SH+ page; MHPSS.net; RE-DEFINE protocol; Brown et al. 2018; Tol et al. 2018; DIGNITY package]

Adaptation. Translations exist in 12+ languages. The trial procedure was: translate into colloquial language with a warm, caring tone; have native speakers review the book and a draft recording; revise repeatedly until language, voice and accent fit; record professionally; then pilot with 3–4 people per site. [source: WHO SH+ page; RE-DEFINE protocol]

3. Guiding principles

The audio teaches; the facilitator facilitates. Play the recordings as made; your job is the room, timing, discussion and brief clarification, not re-teaching or adding therapy. Uganda trial facilitators were trained not to give detailed explanations; after the pilot their role was widened only to opening the group, introducing the audio and short clarifications. [source: MHPSS.net; RE-DEFINE protocol; Brown et al. 2018; Tol et al. 2018]
Fidelity through standardisation. The pre-recorded format exists so that the key components are delivered as intended without extensive training; do not swap in other exercises. [source: RE-DEFINE protocol]
Transdiagnostic and non-medicalising. Address stress and adversity, not diagnoses; welcome people with and without disorders, within the safety exclusions. [source: RE-DEFINE protocol; WHO SH+ page]
Don't fight thoughts and feelings. The guide asks people to let difficult feelings be there, like weather passing through the sky, rather than fight them; the aim is less struggle, not fewer feelings. In practice, don't reassure people out of feelings or argue with thoughts. [source: WHO 2020 illustrated guide pp. 109, 117]
Notice and name. Awareness and labelling of what hooks you is the main way to unhook; you can model it in your own language. [source: WHO 2020 illustrated guide pp. 61–64, 70]
Values guide action; start small. Change is measured in small, concrete, realistic actions this week, not insight; if a plan feels too hard, make it smaller. [source: WHO 2020 illustrated guide p. 92]
Kindness and social support. Kindness goes both ways: being kind to yourself is presented as giving more energy and motivation to help others; encourage peer warmth in the group. [source: WHO 2020 illustrated guide p. 105; MHPSS.net]
Practise little and often, including in calm moments. The guide says the skills can be practised anytime and anywhere, briefly, with a plan for when and where; regular practice during ordinary activities builds the skill for hard moments. [source: WHO 2020 illustrated guide pp. 49, 51, 70, 75]
Accept what can't be changed, change what can. In hard situations, choose between leaving, changing what you can while living your values, or giving up; SH+ does not ask people to accept injustice they can act on. [source: WHO 2020 illustrated guide pp. 96–98]
Cultural fit and peer delivery. Use community facilitators, local language and tone, and same-gender groups where expected. [source: RE-DEFINE protocol]
Safety first, scale second. Screen, know the referral pathway, and recognise serious adverse events; the course is not for acute crisis. [source: MHPSS.net; RE-DEFINE protocol]
Supervised non-specialists. Facilitators work under regular professional supervision; escalate rather than improvise clinically. [source: MHPSS.net; RE-DEFINE protocol]

4. Intervention inventory

The participant exercises (A) are delivered by the audio and the illustrated book; their steps below paraphrase the WHO illustrated guide (2020), with page references. The facilitator procedures (B) combine what the WHO pages and trial protocols state with my own operational detail, marked [synthesis] where these sources are silent. The exact audio scripts and in-session discussion questions are in the facilitator manual and audio [uncertain]: when running SH+, follow the manual and audio, not this paraphrase.

A1. Grounding (Session 1)

Purpose / when: steady yourself when a stressful thought, feeling or situation hits, so you can act rather than be swept along; also the base skill for all later sessions. [source: WHO 2020 illustrated guide pp. 10–51; MHPSS.net]
Steps: (1) Notice the thoughts and feelings present right now. (2) Slow down and connect with your body: slowly press your feet into the floor, stretch or press your hands together, and slow your breathing. (3) Refocus on the world around you: what you can see, hear, smell, touch and taste. (4) Engage: notice where you are, who is with you and what you are doing, and turn back to the task in hand. Repeat the cycle if needed, and finish by grounding and engaging again. [source: WHO 2020 illustrated guide pp. 38–40, 44, 50]
Example language (illustrative): "Notice what's going on inside you now… now press your feet into the floor and feel the ground… look around: what can you see, what can you hear? Notice where you are and what you are doing."
Watch for: people treating grounding as a way to make feelings vanish; the aim is to be more present and in control of actions while the feeling is still there [synthesis from the guide's anti-avoidance stance]. Signs it is working: participants describe using it in a real stressful moment and being able to carry on with what they were doing. Trauma-exposed participants may become more aware of distressing sensations when turning attention to the body; let them keep eyes open and favour the external-senses step [synthesis].

A2. Grounding during everyday activities (home practice)

Purpose / when: build the skill in calm moments so it is available in hard ones. [source: WHO 2020 illustrated guide pp. 49, 51]
Steps: make a plan for when and where you will practise; pick routine activities (waiting, washing, eating, getting ready to sleep); during them, briefly do the notice / slow down and feel the body / refocus on senses / engage sequence; practise anytime, anywhere, even briefly. [source: WHO 2020 illustrated guide pp. 49, 51]
Example language (illustrative): "This week, choose one ordinary thing you do every day, like washing your hands or drinking tea, and do the grounding steps while you do it."
Watch for: practice only in crises (harder to learn); ask at the next session which everyday moments people used [synthesis].

A3. Alternative Session 1: "Awareness of an Object"

Purpose / when: WHO publishes an alternative Session 1 audio that includes an exercise named "Awareness of an Object" [source: WHO SH+ page]. Its steps and the criteria for choosing this version over the standard Session 1 are not published outside the course materials [uncertain].
Steps: play the alternative audio as recorded; do not reconstruct the exercise from other ACT sources.
Watch for: the choice between the two Session 1 versions should follow the facilitator manual and supervisor's advice [uncertain].

A4. Noticing and naming (unhooking, Session 2)

Purpose / when: when a difficult thought or feeling has pulled attention away from the people or activity in front of you ("hooked"), create distance from it and come back. [source: WHO 2020 illustrated guide pp. 52–78; MHPSS.net]
Steps: (1) Notice that a thought or feeling has hooked you and pulled your attention away. (2) Name it silently, e.g. "Here is a difficult thought" or "Here is tightness in my chest"; adding "I notice" unhooks a little more. (3) Refocus on what you are doing and the people with you, engaging fully through the senses. Practise every time you notice you have been hooked, and at set times such as before or after meals. [source: WHO 2020 illustrated guide pp. 61, 63, 67, 70, 73, 75]
Example language (illustrative): "When you notice your mind has taken you away, just say quietly to yourself, 'Here is a difficult thought', then bring your attention back to the person you're talking to."
Watch for: naming used as an argument with the thought ("This is just a thought, so it's false"); the point is noticing, not disputing [synthesis]. Working signs: participants can describe being hooked vs unhooked in their own words and report catching it sooner.

A5. Hooked vs unhooked (recognition, Session 2)

Purpose / when: help participants recognise the state of being hooked so they know when to apply A4. The illustrated guide describes being hooked as being pulled away from your values and only half-engaged (for example only half-listening to a friend), and being unhooked as noticing, naming and refocusing; the book illustrates both. [source: WHO 2020 illustrated guide pp. 15–19, 54, 67]
Steps: use the book's illustrations and the audio's explanation; invite people (in pairs or small groups, as the audio cues) to share an everyday example of being hooked and what it led them to do [the pairing format is synthesis; the audio-cued small-group discussions are sourced to the RE-DEFINE protocol].
Example language (illustrative): "Think of a time this week when a worry pulled you away from what you were doing. What did you do while you were hooked?"
Watch for: confessional sharing of traumatic detail in a large group; redirect to the everyday example (see 5.4).

A6. Identifying values (Session 3)

Purpose / when: give participants a direction for action in circumstances they cannot control. Values describe the person you want to be; goals are things you are trying to get. [source: WHO 2020 illustrated guide pp. 79–80; MHPSS.net]
Steps: (1) Look through the guide's list of common values and choose those that matter most. (2) If it is hard, think of someone you admire and pick three or four of their qualities you value. (3) Choose an important relationship and the values you want to live by in it; values apply towards others and towards yourself. (4) Each morning, pick two or three values to live by that day, look for ways to act on them, and acknowledge each time you do. [source: WHO 2020 illustrated guide pp. 85–88, 95]
Example language (illustrative): "Even when life is very hard, what kind of person do you want to be, with your family, your neighbours, yourself?"
Watch for: values confused with goals or with what others expect; despair that values are impossible "here". Respond with the smallest possible expression of the value today [synthesis].

A7. Small values-based action for the week (Session 3)

Purpose / when: turn a chosen value into behaviour; the main home task from Session 3 onward. [source: WHO 2020 illustrated guide p. 92]
Steps: (1) Pick one value. (2) Make a small, realistic action plan for the next week: one or more specific actions that express it; if it feels too hard, make it smaller. (3) Decide specifically what you will do or say, and when [synthesis on detail]. (4) Check for hooks: notice whether difficult thoughts stop you and whether what you do moves you towards or away from your values; use grounding or unhooking when they get in the way. [source: WHO 2020 illustrated guide pp. 92–93]
Example language (illustrative): "Make it small enough that you can do it even on a bad day: for example, greeting a neighbour or helping a child with one task."
Watch for: over-large plans that fail and feed hopelessness; report-back the following week should praise any attempt [synthesis].

A8. Three options in a difficult situation (Session 3)

Purpose / when: when someone is stuck in a hard situation, clarify the choices: (1) leave it if you can; (2) stay, change what can be changed, accept the pain that can't be changed, and live by your values; or (3) give up and move away from your values. If leaving is not possible, the choice is between (2) and (3), and the guide recommends (2). [source: WHO 2020 illustrated guide pp. 96–98]
Steps: describe the situation; ask whether leaving is possible; if not, list what can be changed and what can't; choose one values-based action for the changeable part; use grounding, unhooking and making room for the part that can't be changed [sequence is synthesis based on the guide's options].
Example language (illustrative): "Can you leave this situation? If not, what part of it can you change, even a little, and what part do you need to make room for?"
Watch for: the option framework being heard as "accept abuse or injustice"; make explicit that leaving or changing comes first where safe, and link to protection or legal services where needed [synthesis].

A9. Noticing pain and responding with kindness (Session 4)

Purpose / when: when you or others are suffering; kindness to self is presented as giving energy and motivation to be kind to others, and the session is linked to social support. [source: WHO 2020 illustrated guide pp. 99–106; MHPSS.net]
Steps: (1) Notice pain in yourself or someone else. (2) Respond with small kind acts and kind words (the guide's example is acknowledging how painful something is and saying you are there for the person). [source: WHO 2020 illustrated guide pp. 104–105]
Example language (illustrative): "If a good friend were going through what you are going through, what would you say to them? Can you say something like that to yourself?"
Watch for: guilt or shame about self-kindness ("selfish", "weak"); cultural framings of kindness differ, so invite local words [synthesis].

A10. Unhooking from unkind thoughts + kind self-talk (Session 4)

Purpose / when: when harsh self-criticism ("I am weak", "it is my fault") hooks you. [source: WHO 2020 illustrated guide pp. 101–102]
Steps: (1) Notice the unkind thought. (2) Name it, e.g. "I notice here is a harsh self-judgement" (as in A4). (3) Ground yourself and engage with the world. (4) Speak to yourself kindly, as to someone you care about. [source: WHO 2020 illustrated guide pp. 101–103, 105]
Example language (illustrative): "Notice: 'Here is an unkind thought.' Now, what is a kinder thing you could say to yourself right now?"
Watch for: participants trying to replace criticism with forced positive statements they don't believe; the guide's aim is kindness, not positive thinking [synthesis].

A11. Kind hand (Session 4, optional)

Purpose / when: a physical self-kindness exercise for painful feelings or places of pain in the body. In the illustrated guide it sits in the Making Room section; its placement in the audio sessions is [uncertain]. [source: WHO 2020 illustrated guide pp. 118–119]
Steps: (1) Imagine one hand filling with kindness. (2) Place it gently where you feel pain or discomfort, for example over the heart, belly or forehead; both hands can be used. (3) Imagine the warmth of kindness flowing from the hand into that area, holding yourself kindly. [source: WHO 2020 illustrated guide pp. 118–119]
Example language (illustrative): "If it feels okay, place that kind hand where it hurts and imagine the warmth spreading there."
Watch for: self-touch can feel uncomfortable or culturally odd, or can trigger memories for survivors of violence; make it optional and offer to keep the hand in the lap instead [synthesis].

A12. Being kind to others / social support (Session 4)

Purpose / when: strengthen connection and mutual support; WHO links this skill to social support. [source: MHPSS.net; RE-DEFINE protocol (aim of increasing social support)]
Steps: plan one small act of kindness or kind words towards someone else this week [source for small kind acts and words: WHO 2020 illustrated guide p. 104; planning it as an extension of A7 is synthesis]; discuss in the group, as the audio cues.
Example language (illustrative): "Who around you is also struggling? What is one small kind thing you could do for them this week?"
Watch for: people already overextended in caring roles; balance with self-kindness [synthesis].

A13. Making room (Session 5)

Purpose / when: when a difficult feeling won't go away and struggling with it is making things worse; WHO describes it as a mindfulness exercise. [source: MHPSS.net; WHO 2020 illustrated guide pp. 107–121]
Steps: (1) Notice and name the difficult thought or feeling, e.g. "I notice here is sadness", and observe it with curiosity. (2) Breathe slowly and imagine the breath flowing into and around the pain. (3) Imagine the feeling as an object with a size, shape, colour and temperature; make room for it, for example resting it gently on your lap. (4) Allow it to be there, like weather passing through the sky, without fighting it. (5) Engage with the world around you and give full attention to what you are doing. (6) If you get hooked, notice and name the hook, then return to making room. [source: WHO 2020 illustrated guide pp. 109–114, 117]
Example language (illustrative): "You don't have to like this feeling. Just see if you can give it a little space as you breathe, and keep doing what matters."
Watch for: rising distress when attention is turned to the feeling; let people stop and ground instead (A1). Working signs: participants report less struggle and more ability to carry on while the feeling is present, not that the feeling has gone [synthesis].

A14. Using the illustrated book

Purpose / when: reinforce each session's skill at home, including for low-literacy participants (400+ illustrations, minimal text); also usable alone as step 1 of stepped care. [source: RE-DEFINE protocol; howareu.com overview; WHO SH+ page]
Steps: after each session, point participants to the matching section, which summarises key points for review between sessions; where reading is hard, a literate family member can read it with them, as in the Uganda trial; in the group, show the book's illustrations to support key concepts (a post-pilot change). [source: Brown et al. 2018; Tol et al. 2018]
Watch for: people who never open it; use pictures from it as a recap at the start of the next session [synthesis].

B1. Running a session (facilitator)

Purpose: deliver the audio-led session safely and on time. [source: MHPSS.net; RE-DEFINE protocol]
Steps: (1) Before: remind participants (Uganda facilitators visited homes the day before each session); prepare a sheltered space for the group, a reliable audio player and speakers, and copies of the book. (2) Open: welcome people, optionally use a short energiser, agree group ground rules (Session 1) and introduce the session's audio. (3) Play the audio: one facilitator operates it, the other attends to participants; pause where the audio cues individual exercises and small-group discussions, read out discussion exercises, and pause to clarify briefly if the recording confuses people. (4) Close: answer basic questions, point to the book and home practice, and stay after for individual concerns and anyone who may need referral. (5) Afterwards: both facilitators complete the session form or adherence checklist and join the peer review (B3). [source: Brown et al. 2018; Tol et al. 2018; RE-DEFINE protocol; MHPSS.net] The step order and the end-of-session individual check are [synthesis].
Example language (illustrative): "Today's recording will guide us through the next skill. I'll pause it when it asks us to talk in small groups."
Watch for: facilitators lecturing over the audio, or skipping or replacing exercises (fidelity drift, which the adherence checklist is meant to catch [source: Brown et al. 2018]); the co-facilitator watches for visibly distressed participants [synthesis].

B2. Screening, referral and follow-up (facilitator/service)

Purpose: keep SH+ to people it suits and route others to care. [source: MHPSS.net; RE-DEFINE protocol]
Steps: screen before enrolment (trials used a distress screener and a structured suicide-risk assessment); exclude imminent suicide or other life-threatening risk, observable signs of severe mental disorder such as psychosis, severe impairment and impaired decision-making capacity; refer those with a probable disorder through a structured, manualised pathway; follow up the referral (RE-DEFINE checked with the receiving contact 3–5 weeks later). In trials, adverse events (e.g. increased distress, injuries on the way to sessions) were recorded, and serious ones (e.g. suicide attempts, serious violence) reported to the safety board within 24 hours. [source: RE-DEFINE protocol; MHPSS.net; Brown et al. 2018; Tol et al. 2018]
Watch for: distress that rises during the course; re-assess and refer at any session [synthesis].

B3. Supervision (clinician role)

Purpose: support non-specialist facilitators and manage risk. [source: MHPSS.net; RE-DEFINE protocol; WHO training-manual page]
Steps (Uganda trial model; the frequency WHO itself requires is not confirmed here [uncertain]): after every SH+ session, hold a group peer review with the facilitators covering delivery difficulties, participant and facilitator concerns, and adverse events; a local clinical or social-work supervisor oversees delivery, supervises the facilitator team leader weekly or less often, and sometimes joins the peer reviews; the supervisor directly observes at least 10% of sessions using the same adherence checklist the facilitators complete; deviations go to the master trainer, who gives remote support as needed (no more than 1 hour a week). In the pilot, supervision calls with the developer were roughly weekly and under an hour, with a social worker on call for emergencies. DIGNITY's package specifies group-based supportive supervision of facilitator teams. Supervision also protects facilitators against burnout and secondary stress. [source: Brown et al. 2018; Tol et al. 2018; DIGNITY package; RE-DEFINE protocol]
Watch for: facilitators carrying risk alone or offering counselling beyond their role [synthesis].

B4. Language and cultural adaptation (service lead)

Purpose: make the audio and book acceptable in a new language or group. [source: RE-DEFINE protocol; WHO SH+ page]
Steps: check whether a WHO translation exists (12+ languages listed); if not, translate in colloquial, warm, caring language; have native speakers review the book and a draft recording; iterate until language, tone, voice and accent are judged right; record professionally; pilot with a handful of participants before rollout. Respect the CC BY-NC-SA licence terms (non-commercial, share-alike). [source: RE-DEFINE protocol; WHO SH+ page]
Watch for: adaptations that change the skills themselves rather than their language and examples [synthesis].

5. Handling problems

The cited sources specify safety exclusions, referral pathways and supervision, and the Uganda pilot reports practical problems and fixes; detailed group-management advice belongs to the facilitator manual and WHO's orientation course (modules on common challenges and on talking to participants individually) and is not reproduced here [uncertain]. Responses below are my own synthesis unless tagged with a source.

5.1 Imminent suicide risk or acute crisis. SH+ is not suitable for people at imminent suicide risk; facilitators are trained to recognise serious adverse events such as imminent suicide risk. [source: MHPSS.net; RE-DEFINE protocol] Response: the facilitator stops individual engagement in the group, speaks with the person privately with the co-facilitator holding the group, and contacts the supervising clinician the same day; the clinician completes a standard risk assessment and safety plan, including lethal-means counselling (safe storage or removal), and links the person to crisis or specialist care. The person may return to the group later as an add-on once safe [synthesis; add-on use per MHPSS.net].

5.2 Probable mental disorder or severe impairment emerges. Refer via the structured pathway and follow up (RE-DEFINE: contact the receiving service 3–5 weeks later). Continuing SH+ alongside care is possible where the person is not severely impaired. [source: RE-DEFINE protocol; MHPSS.net]

5.3 Overwhelm during an exercise (e.g. making room, body-focused grounding, kind hand). [synthesis] Let people keep eyes open, stop the exercise and return to grounding through the external senses (A1 step 3); the co-facilitator checks in quietly; afterwards, normalise and discuss choice ("you can do as much or as little as feels okay"). For survivors of violence, make body-touch and body-focus steps optional.

5.4 Trauma disclosure in the large group. [synthesis] Acknowledge briefly and kindly, then redirect to the skill ("thank you for trusting us with that; let's see how the skill might help with a moment like that"); offer a private conversation after the session; screen for referral. SH+ is not a trauma-processing intervention.

5.5 "This won't fix my real problems" (housing, money, safety, legal status). Use the three options frame (A8): what can be left, what can be changed, and what must be made room for. Pair SH+ with practical and protection referrals; the trial comparator itself gave information on free mental health, social, community and NGO services, which an SH+ service should also provide. [source: WHO 2020 illustrated guide pp. 96–98; RE-DEFINE protocol; application is synthesis]

5.6 Non-attendance and drop-out. In the Uganda pilot, competing priorities (childcare, household work, a clash with a food distribution) caused missed sessions; facilitators visited homes the day before each session as a reminder. [source: Tol et al. 2018] [synthesis] Schedule around work, childcare, transport and aid distributions; let people who miss a session listen to that session's audio before the next one; check barriers at the next contact. The course is fixed-sequence, so a missed session leaves a skill gap; at least cover the matching section of the book.

5.7 No home practice. [synthesis] Shrink the task (one minute of grounding during an everyday activity), tie it to an existing routine, and ask at the start of each session what people tried; praise attempts, not perfection.

5.8 Low literacy, hearing or language barriers. The book is mostly illustrations; use WHO translations and local adaptations. In the Uganda pilot many women could not read the book and had others read it to them, worksheets were dropped for literacy reasons, and some found the audio's language hard to follow, so facilitators paused the recording to explain. [source: RE-DEFINE protocol; WHO SH+ page; Tol et al. 2018; Brown et al. 2018] Seat people with hearing difficulties near the speaker; have someone explain the book pictures in the group [synthesis].

5.9 Dominant, disruptive or argumentative participants. Group ground rules were added after the Uganda pilot, where men's groups had problems with talking during sessions and alcohol use before sessions; the later Uganda trial ran women-only groups. [source: Tol et al. 2018] [synthesis] Agree rules in Session 1 (one person speaks at a time, keep personal stories brief, respect privacy); use small-group discussion times to spread participation; speak privately with persistently disruptive people; if someone is intoxicated or a risk to others, ask them to leave safely and follow up.

5.10 Questions the facilitator can't answer (medication, diagnosis, legal or asylum matters). [synthesis] Say you don't know, note the question, ask the supervisor, and give the referral information next session. Facilitators should not give clinical advice.

5.11 Misunderstanding the skills. [synthesis] Common errors: using grounding or naming to make feelings disappear (re-explain that the aim is less struggle and more freedom to act); making room heard as "accept everything" (return to A8); self-kindness heard as selfishness (link it to having energy to help others, as the guide does). [source for the kindness link: WHO 2020 illustrated guide p. 105]

5.12 Ruptures with the facilitator or group. [synthesis] Name the tension simply, apologise for anything you did that hurt, re-state the group's purpose, and offer a private follow-up; discuss in supervision. Same-gender groups and facilitators from a similar culture reduce some sources of rupture. [source for group composition: RE-DEFINE protocol]

5.13 Fidelity drift and facilitator burden. The pre-recorded audio is meant to carry fidelity; in the Uganda trial both facilitators completed an adherence checklist of all required activities after each session, the supervisor observed at least 10% of sessions with the same checklist, and deviations were reported to the master trainer. DIGNITY's package states that SH+ has no standardised monitoring tool, so services build or adapt their own. Facilitators from the same affected community may carry their own stress; give them supervision and access to the same skills and to support. [source: RE-DEFINE protocol; Brown et al. 2018; DIGNITY package; burden response is synthesis]

5.14 Using SH+ skills in individual therapy. [synthesis] A therapist may teach the five skills one per session using the illustrated book, but this is not SH+ as published (no group, no audio, no lay facilitator) and should be described as "based on" it; where an ACT-trained therapist is available, a full ACT treatment may be more suitable for diagnosed disorders.

5.15 Expectations of material help. Uganda pilot participants were disappointed that no goods or services came with the course, although this had been explained at consent; the authors advise clearer communication of the programme's limits. [source: Tol et al. 2018] [synthesis] State at enrolment and again in Session 1 what SH+ does and does not offer, and give information on practical services (see 5.5).

5.16 Exercises too long or hard to follow. Pilot facilitators found a repeated grounding exercise too long; the audio was then simplified, sessions and exercises shortened, and audio cues added to signal facilitator activities. [source: Tol et al. 2018] [synthesis] Use the current WHO audio, raise recurring problems in supervision, and change materials through the formal adaptation process (B4) rather than editing exercises on the spot.

Sources

Main sources:

Further primary texts (cited via their WHO pages or abstracts): WHO (2021) Self-Help Plus (SH+): a group-based stress management course for adults (facilitator manual and audio); WHO (2024) The SH+ training manual; Tol WA, Leku MR, Lakin DP, Carswell K, Augustinavicius J, Adaku A, et al. (2020) Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trial. Lancet Global Health 8(2):e254–e263 (abstract); Epping-Jordan JE, Harris R, Brown FL, Carswell K, Foley C, García-Moreno C, Kogan C, van Ommeren M (2016) Self-Help Plus (SH+): a new WHO stress management package. World Psychiatry 15(3):295–296.

← Previous · V-158Problem Management Plus Next · V-160 →EASE (Early Adolescent Skills for Emotions)