Doing What Matters in Times of Stress

1. Introduction

Version followed: WHO (2020) Doing What Matters in Times of Stress: An Illustrated Guide, English field-test version (ISBN 978-92-4-000391-0 electronic), with its companion audio exercises. For group delivery, this guide follows the WHO Self-Help Plus (SH+) group course (2021, generic field-trial version 1.0) as described on WHO, partner and trial-protocol pages. Session-level SH+ detail is marked [uncertain].

What it is. Doing What Matters (DWM) is a WHO self-help book for stress management. It has short text, many illustrations and optional audio. It is written for anyone under stress, from everyday problems to war and displacement, including carers and health workers. It is not a therapy a clinician delivers session by session. It can be used in three ways: (a) alone, as unguided self-help; (b) as the participant book of SH+, a 5-session group course led by trained non-specialist facilitators using pre-recorded audio; or (c) as a low-intensity adjunct that a clinician hands out and reviews [synthesis]. [source: WHO 2020 DWM front matter; WHO SH+ publication page; DIGNITY SH+ summary]

Origin. Russ Harris wrote the text and first sketches for SH+, drawing on his earlier The Illustrated Happiness Trap. Mark van Ommeren (WHO Mental Health Unit) initiated it within WHO's series of low-intensity psychological interventions. Kenneth Carswell and JoAnne Epping-Jordan managed the project, and Julie Smith drew the illustrations. It was field-tested with people affected by emergencies in Syria, Turkey, Uganda and Ukraine. The book itself does not name its model. Trial reports and WHO partners describe it as based on Acceptance and Commitment Therapy (ACT). [source: WHO 2020 DWM acknowledgements; Tol et al. 2018 World Psychiatry; ClinicalTrials.gov NCT03587896 protocol; ACBS page]

How change happens. Stress pulls people into being "hooked" by difficult thoughts and feelings. Once hooked, they make "away moves": arguing, withdrawing, avoiding, self-criticism or substance use. These bring short-term relief, but life gets worse and the person drifts from their values. The book does not try to remove anger, fear or sadness. It teaches five brief skills: grounding, unhooking, acting on values, being kind, and making room. These help the person stay present, stop struggling with inner experience and take small actions that fit who they want to be. Regular short practice builds the skills "like muscles". [source: WHO 2020 DWM Sections 1–5]

2. Framework

Structure: five sections, one idea and one technique each [source: WHO 2020 DWM "How to use this book" and tool summaries]

Phase / section	Goal	Core skill (tool card)
1. Grounding	Notice stress and hooks; come back to the present and engage with what you are doing	Tool 1: notice, slow down and connect with the body, refocus on surroundings and engage
2. Unhooking	Stop the struggle with difficult thoughts and feelings; see the cost of away moves	Tool 2: notice, name, refocus
3. Acting on your values	Clarify values (vs goals); turn them into small actions; choose a response to hard situations	Tool 3: daily values, weekly small action, three approaches to difficult situations
4. Being kind	Apply kindness to others and to oneself; unhook from harsh self-talk	Tool 4: notice pain, respond kindly, unhook from unkind thoughts
5. Making room	Allow painful feelings to be present without being harmed by them, and then engage	Tool 5: notice, name, make room, let it pass like weather

Pacing as published. Read one section every few days and practise in between. Alternatively, read the whole book once and then again more slowly. Practise a few minutes a day: at home, on breaks or before sleep. Use both brief practices (1–2 minutes) and longer ones (5–10 minutes), planned in advance. Spend at least a day or two on a section's skill before moving on. The audio versions and the written and illustrated instructions are interchangeable. [source: WHO 2020 DWM]

Criterion for moving on. The book's only criterion is time-based practice: a day or two of using the section's skill. When a clinician guides the work, a practical criterion is that the client can (i) say the skill in their own words, (ii) report trying it at least a few times, including once in a real stressful moment, and (iii) has a plan for when to practise next. If none of these hold, stay on the section rather than adding the next [synthesis].

Formats and dose

Unguided self-help: the person reads the book and uses the audio alone. There is no fixed number of sessions. Done at the book's pace, the sequence takes about 1–3 weeks [synthesis, from the book's pacing].
SH+ group course: 5 sessions of about 2 hours, usually weekly over about 5 weeks. Groups are large: "up to 20" (DIGNITY), "up to 30" (WHO page), 20–30 (Uganda) or 10–40 (Turkey trial, single-gender). Pre-recorded audio carries the core teaching and guides individual exercises and small-group discussions. Two non-specialist facilitators work as a team and follow a written facilitator guide. Participants receive DWM as the illustrated companion. WHO also offers an alternative Session 1 audio built around an "Awareness of an Object" exercise. [source: WHO SH+ page; DIGNITY; NCT03587896; Tol et al. 2018] The exact match of SH+ Sessions 1–5 to DWM Sections 1–5 is [uncertain].
Clinician-guided self-help / adjunct [synthesis]: hold a 20–30-minute orientation, assign one section per week, and do brief weekly check-ins of 10–20 minutes, in person or by phone, for about 5 weeks. In an ACT-informed therapy, assign the matching section as homework.

Who it is for, and screening. DWM is written for anyone under stress. SH+ is described as unsuitable for people in acute crisis or overwhelmed by their situation. Trials excluded people with imminent suicide risk, observable signs of severe mental disorder, severe cognitive impairment or impaired decision-making capacity. The Turkey prevention trial also excluded anyone meeting criteria for a mental disorder on the M.I.N.I. (a research-specific choice). Screening tools used in trials included the K6 (Uganda) and the GHQ-12 (Turkey). Before starting, set up a referral network to more specialised care. [source: DIGNITY; Tol et al. 2018; NCT03587896]

Delivering under the SH+ name: training and fidelity. The book is free under a CC BY-NC-SA 3.0 IGO licence, which allows non-commercial copying and adaptation with attribution. No certification is needed to hand it out. For SH+, published partner and trial models include:

a 4–5-day facilitator training;
group rehearsal and ongoing supportive supervision by mental health professionals (weekly in Uganda);
5-day training-of-trainers and 2-day supervision trainings for scale-up;
facilitators trained to recognise serious adverse events such as imminent suicide risk;
fidelity checks by a supervisor sitting in on a share of sessions (10% in Uganda).

WHO also publishes an SH+ online orientation course and an SH+ training manual (2024), neither of which is drawn on here. No formal licensing or certification body was found [uncertain]. [source: DIGNITY; Tol et al. 2018; NCT03587896; WHO search listings]

3. Guiding principles

[source: WHO 2020 DWM unless tagged otherwise]

Stress is common and understandable; you are not alone. Normalise first; do not frame stress as illness.
The aim is engagement and values-based action, not feeling better. Tell clients the exercises are not meant to remove anger, fear or sadness. Measure success by what the person does.
Hooks and away moves are the target. Help clients spot the moment a thought or feeling takes over and the behaviour that follows.
Struggling with inner experience backfires. Review with the client what their control strategies cost over time (avoiding, isolating, arguing, alcohol, tobacco or drugs). Do not shame them.
Notice and name before acting. Labelling an experience ("I notice…") creates distance. Use the client's own words for the hook.
Engage with the here and now. End every exercise by returning attention to the room, the people present and the task.
Values are not goals. Goals may be blocked by circumstances; values can still be lived through small actions today.
Small, specific, realistic steps. If a plan feels too hard, shrink it until it is doable this week.
There is always something that helps a little. When a situation cannot be left, change what can be changed, accept the pain that cannot, and live by your values.
Kindness applies to others and to oneself. Treat harsh self-talk as a hook, not as truth, and answer it with kind words.
Feelings are like weather; you are the sky. Painful states are allowed to move through and do not harm the person who holds them.
Skills grow with brief daily practice, like muscles. Prescribe 1–2-minute practices many times a day rather than rare long ones.
Accessible by design. Minimal text, many illustrations and optional audio. Do not let literacy limit who can use it.
Self-help has limits. If the exercises are not enough, seek help from health or social services or trusted people. Keep a referral route ready.
Delivered by non-specialists with supervision (SH+). Facilitators guide the process and the audio carries the content; they do not do therapy. [source: WHO SH+ page; NCT03587896]
Clinician stance when guiding it [synthesis]: stay low-intensity and in the book's language. Model the skills rather than explain theory. Ask about practice before anything else. Do not turn check-ins into open-ended processing.

4. Intervention inventory

All steps below paraphrase WHO (2020) DWM; page references are approximate (field-test PDF). Therapist wording is illustrative unless quoted. The book is written to the reader, so "clinician use" notes describe how to teach or review each skill [synthesis].

4.0 Orientation and setting up practice (clinician or facilitator)

Purpose: Frame the book, set expectations and plan practice before Section 1. [source: DWM "How to use this book"; SH+ sources for group context]
Steps: (1) Screen for exclusions and acute risk (see Section 2). (2) Explain that the book has five sections, each with one idea and one skill, and that practice matters more than reading. (3) Agree a pace: one section every few days to a week. (4) Choose fixed practice times, such as before or after meals, on a break or in bed. Plan both 1–2-minute and 5–10-minute practices. (5) Show the client how to get the audio or how to use the pictures without reading. (6) Say what to do if it is not enough: who to contact, and where [synthesis for the explicit plan].
Example language (illustrative): "This book won't make stress disappear. It teaches five small skills to help you handle it and keep doing what matters to you. A few minutes a day is enough to start."
Watch for: Expectations that the feelings will go away. Low literacy, so offer the audio. Acute crisis, which calls for higher-intensity help. Working: the client leaves with a concrete when and where for practice.

4.1 Psychoeducation on stress, hooks, values and away moves (Section 1)

Purpose: Give a shared language. Stress shows up in the body (headaches, stomach upset, muscle tension) and in thinking, mood, appetite and sleep. Strong thoughts and feelings "hook" us, and hooked behaviour moves us away from our values. Being hooked also disengages us from what we are doing. [source: DWM Section 1]
Steps: (1) Ask how stress shows up for the client, in body and mind. (2) Introduce values as the kind of person they want to be. (3) Introduce "hooked" and "away moves" using the client's own examples, such as snapping at family or withdrawing. (4) Contrast hooked with engaged: full attention on the present activity.
Example language (illustrative): "When that worry grabs you and you end up shouting at the kids, that's what the book calls being hooked. The shouting is an away move, away from the parent you want to be."
Watch for: Clients hearing "away moves" as blame. Frame them as normal and understandable. Working: the client starts spontaneously naming hooks and away moves from their week.

4.2 Awareness of drinking (everyday mindful engagement)

Purpose: Train attention and engagement using an ordinary activity. It is the bridge to grounding. [source: DWM Section 1, approx. pp. 30–31]
Steps: (1) Take a warm or cold drink (tea, coffee, water). (2) Drink slowly, noticing temperature, taste and the act of swallowing. (3) Each time the mind wanders, notice it and bring attention back to the drink. (4) Generalise: do the same while eating, listening to someone, doing chores or talking with others.
Example language (illustrative): "Let's try it now with this water. Notice how cool it is in your mouth … the taste … swallowing. If your mind drifts, just notice that and come back to the water."
Watch for: Clients judging themselves for mind-wandering. Noticing and returning is the skill. Working: the client reports moments of fuller attention in daily tasks, such as with their children.

4.3 Grounding Exercise 1 (quick, about 30 seconds)

Purpose: The emergency skill for "emotional storms" and the default short practice. It is the basis of Tool 1. [source: DWM Section 1, approx. p. 44; Tool 1, p. 122]
Steps: (1) Notice what you are feeling and thinking. (2) Slow down and connect with your body: breathe out slowly, stretch, press your feet into the floor. (3) Refocus outward through the senses: what you can see, hear, touch, smell and taste. (4) Engage with where you are and what you are doing.
Example language (illustrative): "Pause. Notice what's here inside you right now … Breathe out slowly … Push your feet into the floor and feel it under you … Now look around: name three things you can see and two things you can hear … Notice where you are and what you're doing."
Watch for: Using it to make feelings vanish. Its purpose is to steady and re-engage the person. Rehearse it in session at low arousal first. Working: the client uses it unprompted at the moment of a trigger and can go back to the task.

4.4 Grounding Exercise 2 (short, with stretch)

Purpose: A brief variant to use many times a day. [source: DWM approx. p. 45]
Steps: Repeat the Exercise 1 sequence in about a minute. Include a stretch and deliberately notice where you are and what you are doing.
Example language (illustrative): "Stretch your arms … notice the stretch … now notice this room and the conversation we're having."
Watch for: Practice only at bad moments. Encourage practice at neutral times too, so the skill is ready.

4.5 Grounding Exercise 3 (longer, with breathing, about 5–10 minutes)

Purpose: Daily longer practice that builds attention control. [source: DWM approx. pp. 46–50; audio Grounding 3]
Steps: (1) Notice your current state. (2) Slow the breath: gently empty the lungs, then breathe in slowly and gently. (3) Watch the breath with curiosity. After breathing out, pause and count to three. (4) If you feel dizzy, light-headed or tight in the chest, slow down further and breathe shallowly; do not breathe deeply. (5) Whenever you are hooked, notice it and bring attention back to the breath, as often as needed. (6) Finish by grounding again and engaging with your surroundings.
Example language (illustrative): "Gently breathe all the way out … and let the breath come back in slowly. After the out-breath, pause and count one, two, three. If you feel light-headed, make the breaths smaller and slower."
Watch for: Breathing too deeply or too fast. Breath focus feeling panicky for people with panic or trauma histories: let them keep their eyes open and widen attention to the room [synthesis]. Working: the client can sit through a few minutes while repeatedly noticing hooks and coming back to the breath.

4.6 Reviewing control strategies: "does struggling work?" (Section 2)

Purpose: Build motivation to unhook instead of struggling. [source: DWM Section 2]
Steps: (1) List with the client what they do to get rid of painful thoughts and feelings. The book's examples include yelling, avoiding situations, isolating, starting arguments, self-criticism, and alcohol, tobacco or drugs. (2) For each, ask what it gives in the short term. (3) Ask what it costs over time and whether it moves them toward or away from their values. (4) Name common hooks: memories of bad events, fears about the future, feeling not good enough. (5) Offer the alternative: stop the struggle and unhook.
Example language (illustrative): "When you stay in your room all day, does the worry go away? … For how long? … And what does it cost you with your family?"
Watch for: Lecturing, or implying the client is to blame. Substance use disclosed here may need separate assessment [synthesis]. Working: the client says in their own words that the struggle has costs.

4.7 Unhooking: notice, name, refocus (Tool 2)

Purpose: The core defusion skill: loosen the grip of a thought or feeling and return to the task or person. [source: DWM Section 2, approx. pp. 61–70; Tool 2, p. 123]
Steps: (1) Notice that you have been hooked. (2) Name the thought or feeling silently. Examples from the book include naming "tightness in my chest" or "anger" with the phrase "here is…". Adding "I notice" unhooks further, as in "I notice here is anger" [source: DWM]. (3) Refocus on what you are doing and engage fully with the people and activity in front of you. (4) Keep acting on your values while the feeling is still present.
Example language (illustrative): "Let's catch one now. What's hooking you as we talk? … Say it silently: 'I notice here is the thought that I'm failing.' … Now bring your attention back here, to me and to what we're planning."
Watch for: Naming used as a way to argue with or suppress the thought. Keep the tone neutral and curious. Working: the gap between being hooked and noticing it shrinks, and the client re-engages faster.

4.8 Grounding during emotional storms (Tool 1 used as a coping card)

Purpose: Apply grounding to acute distress, not only to practice times. [source: DWM approx. p. 74, p. 122]
Steps: When a storm of emotion hits: notice, slow down, connect with the body, refocus on surroundings and engage. Repeat until you can act. Then choose a toward move.
Example language (illustrative): "When the storm comes, you don't have to stop it. Just drop your anchor: feet on the floor, slow breath out, look around, and do the next small thing."
Watch for: Storms that do not settle and come with risk. Move to risk assessment (Section 5).

4.9 Values versus goals (Section 3 psychoeducation)

Purpose: Show that values (how I want to be with myself, others and the world) can be lived now, even when goals (things to achieve) are blocked. [source: DWM Section 3]
Steps: (1) Ask about a goal that circumstances have blocked, such as a job, going home or a reunion. (2) Ask what that goal says about how they want to be: caring, responsible, brave and so on. (3) Point out that the value can be acted on today through small words and actions. (4) Show the book's list of common values: kind, caring, generous, supportive, patient, responsible, brave, persistent, forgiving, grateful, loyal, respectful, trustworthy, fair. Ask which fit.
Example language (illustrative): "You can't get the job back this month. But being a provider who is responsible and caring — is there a small way to live that this week?"
Watch for: Values written as feelings ("to be happy") or as other people's behaviour. Steer them back to the client's own actions [synthesis]. Working: the client names 2–3 values in their own words.

4.10 Role-model exercise

Purpose: Find values through someone the client admires. This works well where talk about the self is unfamiliar. [source: DWM approx. p. 86]
Steps: (1) Think of a respected person in your community. (2) Identify three or four values they show. (3) Choose which of those you want to model in your own life.
Example language (illustrative): "Who in your village do people look up to? … What is it about how they treat people? … Which of those would you like people to see in you?"
Watch for: Idealising the model into impossible standards. Keep it to qualities, not achievements.

4.11 Relationship values

Purpose: Apply values to the people around the client, where most stress-driven away moves happen. [source: DWM approx. p. 86]
Steps: Ask which values the client wants to live by with the people around them: partner, children, relatives, neighbours, colleagues.
Example language (illustrative): "With your sister, when things are tense, how do you want to be?"

4.12 Values action plan (weekly)

Purpose: Turn values into specific, realistic behaviour. [source: DWM approx. pp. 88–92; Tool 3]
Steps: (1) Choose an important relationship with someone you see regularly. (2) Choose 2–3 values to live by in that relationship. (3) Plan one or more specific, realistic actions for the next week. The book's examples include about 10 minutes reading with a child, or greeting a relative warmly and thanking them. (4) If it feels too hard, choose something smaller. (5) Expect hooks that block the plan. Notice them, unhook and carry on.
Example language (illustrative): "So the value is 'patient' with your son. What exactly will you do, on which days? … On a scale of how likely, is that realistic? If not, let's make it smaller."
Watch for: Vague or oversized plans, and plans that depend on others' responses. Working: at review, the action happened at least once. If it did not, explore which hook got in the way rather than the outcome [synthesis].

4.13 Daily values practice (Tool 3)

Purpose: Keep values present throughout ordinary days. [source: DWM approx. pp. 95, 124]
Steps: (1) Each morning, pick 2–3 values for the day. (2) Look for chances to act on them throughout the day. (3) Each time you do, acknowledge it to yourself.
Example language (illustrative): "Tomorrow morning, before you get up, pick two words for the day, maybe 'kind' and 'brave'. Tonight, notice the moments you lived them."

4.14 Three approaches to difficult situations

Purpose: A decision aid for problems that cannot simply be fixed. [source: DWM approx. pp. 96–98, 124]
Steps: Lay out the three options. (1) Leave the situation if that is possible and wise. (2) If you cannot leave, change what can be changed, accept the pain that cannot be changed, and live by your values; take small actions to improve things, because there is always something that can help a little. (3) Give up and act in ways that move you away from your values. The book presents this as the least helpful option. Help the client choose, then plan the first small action.
Example language (illustrative): "Can you leave this situation? … If not, what part of it can you change, even slightly? What part can't be changed, and how could you make room for that pain while still living as the person you want to be?"
Watch for: This tool must never be read as "accept abuse or danger". Leaving is option 1. Screen for violence or exploitation and do safety planning before any acceptance work [synthesis]. Problem-solving and practical help may need to be added.

4.15 Acts of kindness (Section 4)

Purpose: Kindness is a value that applies to others and oneself. Small kind words and acts make a difference, and kindness to oneself gives energy to help others. [source: DWM Section 4]
Steps: (1) Notice pain in others and in yourself. (2) Respond with a small kind act or kind words. (3) Include yourself as a recipient.
Example language (illustrative): "What's one small kind thing you could do this week, for someone else and for yourself?"

4.16 Unhooking from unkind thoughts

Purpose: Reduce the pull of harsh self-judgement (book examples: being weak, being at fault). [source: DWM approx. pp. 102–104; audio track]
Steps: (1) Choose an unkind thought you have about yourself. (2) Notice and name it, for example as "an unkind thought" or "a harsh self-judgement", using the "I notice here is…" frame. (3) Ground yourself and engage with your surroundings. (4) Speak to yourself kindly.
Example language (illustrative): "Try: 'I notice here is the harsh judgement that it's all my fault.' … Feet on the floor, look around … Now, what would you say to a friend who had been through this?"
Watch for: Guilt about real harm the client caused. Do not dismiss it; acknowledge responsibility and work on repair [synthesis]. Self-criticism that is pervasive may signal depression that needs higher-intensity care.

4.17 Sky and weather metaphor (Section 5)

Purpose: Reframe the relationship to painful states before making room. [source: DWM Section 5]
Steps: Explain that thoughts and feelings are like weather: they change, sometimes violently. The person is like the sky, which holds all weather without being harmed by it, and the weather always changes.
Example language (illustrative): "However bad the storm, the sky isn't damaged by it. Your sadness is weather; you are the sky that has room for it."

4.18 Making room (Tool 5)

Purpose: Acceptance skill: let a painful feeling or thought be present without struggling, then re-engage with life. [source: DWM approx. pp. 110–114, 126; audio track]
Steps: (1) Notice the difficult thought or feeling with curiosity and name it ("I notice here is sadness"). (2) Imagine it as an object: its size, shape, colour and temperature. (3) Breathe out slowly and pause. Breathe in, imagining the breath flowing into and around the object. (4) Allow it to be there. Optionally, imagine placing it gently in your lap, or on the pages of a book that you tuck under your arm. (5) When hooked, notice and name what hooked you, then return to breathing and making room. (6) Engage: notice where you are, who is with you and what you are doing.
Example language (illustrative): "Where do you feel the grief? … If it had a shape, what shape? … Heavy or light? … Breathe out … and as you breathe in, imagine the breath flowing around it, making a little space … You don't have to like it, just let it be there … Now notice the room and the sounds around you."
Watch for: Intense trauma memories flooding in. Shorten the exercise, move back to grounding with eyes open, and consider trauma-focused care [synthesis]. The book says it may take a few minutes at first and gets quicker with practice. Working: the client reports "it was still there, but I could still do things".

4.19 Being kind to yourself: the kind hand

Purpose: Self-compassion through imagery and touch to one's own body. [source: DWM approx. pp. 118–119; Tool 4]
Steps: (1) Imagine filling one hand with kindness. (2) Place it gently on the part of the body where you feel pain. (3) Imagine breathing kindness in and out through the hand. (4) Optionally use both hands. (5) Combine with breathing and making room, for example when lying awake at night.
Example language (illustrative): "Let one hand fill with kindness, the way you'd comfort a child, and rest it where it hurts. Breathe as if the kindness flows through your hand."
Watch for: Touch to the body can trigger people with a history of abuse. Offer resting the hand on a lap or table instead [synthesis]. This is self-touch only; the practitioner does not touch the client.

4.20 Tool summary cards and audio set (maintenance)

Purpose: Carry the skills after the course ends. [source: DWM pp. 122–126; audio list]
Steps: Show the five one-page tool summaries (Grounding; Unhooking; Acting on values; Being kind; Making room) and the audio set: Grounding 1–3, Notice and Name, Unhooking from Unkind Thoughts, Being Kind to Yourself, Making Room. Have the client choose 1–2 tools for daily use and say which card they will use in which situation. A photo of the card on the phone works as a cue [synthesis].
Example language (illustrative): "Which of the five tools has helped most? Let's put it somewhere you'll see it every day."

4.21 SH+ group procedures (for facilitators)

Purpose: Group delivery of the same skills through pre-recorded audio. [source: WHO SH+ page; NCT03587896; DIGNITY; Tol et al. 2018]
Steps (published outline): Two facilitators run 5 sessions of about 2 hours with a large group. They play the session audio, which teaches the content and guides individual exercises and small-group discussions. They follow the written facilitator guide, and participants keep DWM for between-session practice. Facilitators report adverse events and requests for extra help in supervision. The facilitator scripts, the points where the audio is paused and the session-by-session activities are in the SH+ manual [uncertain]. Do not improvise content beyond the guide.

5. Handling problems

The book itself addresses only a few problems: obstacles to practice, plans that are too hard, situations that cannot be left, dizziness during breathing, and needing more help. Those are tagged [source: DWM]. Everything else is [synthesis].

Not practising / "this is useless". The book predicts obstacles such as tiredness, sadness, anger and thoughts like "this is useless", and advises simply returning to practice [source: DWM]. Treat "this is useless" as a hook to notice and name. Shrink the dose to one 30-second grounding tied to an existing routine, such as tea, prayer or a meal. Ask what got in the way before re-teaching [synthesis].

Plans too big / values action not done. Make the action smaller [source: DWM]. Check whether the plan depends on someone else's response. Rewrite it as something entirely within the client's control [synthesis].

Dizziness or panic during breath work. Slow down further and use shallow breaths, not deep ones [source: DWM]. If panic persists, switch to the outward-focused Grounding 1 with eyes open, feet pressed down and naming objects in the room [synthesis].

Overwhelm, flashbacks or dissociation in an exercise [synthesis]. Stop the inward-focused exercise. Ground with eyes open: orient to the date, the place and who is present, and press the feet down. Shorten future exercises to 1–2 minutes and skip making room for trauma memories until the person can ground reliably. If re-experiencing dominates, assess for PTSD and refer to trauma-focused care. Low-intensity self-help is a first step, not a substitute.

Unrelenting adversity; "accepting my situation" feels like an insult (rupture risk) [synthesis]. Validate first. Make clear that the book does not ask anyone to accept injustice. Its first option is to leave, and its second starts with changing what can be changed (Section 4.14). Pair the skills with practical help: protection, legal aid, livelihoods, links to services. A stress-skills book offered instead of material help feels dismissive.

Safety: violence, abuse or exploitation [synthesis]. Ask directly before any acceptance work. Do safety planning and make protection referrals. Never frame staying in danger as "living by values".

Suicidal thoughts or self-harm. The book contains no crisis guidance [source: DWM]. SH+ trials excluded imminent suicide risk at screening and trained facilitators to recognise serious adverse events [source: Tol et al. 2018; NCT03587896]. What to do [synthesis]:

Screen at intake and ask again at check-ins if mood worsens.
If risk emerges, do a standard risk assessment and a collaborative safety plan: warning signs, coping steps, people and services to contact.
Do lethal-means counselling (safe storage or removal), and make an urgent referral when needed.
In groups, the facilitator speaks to the person privately after the session, or during it if risk is immediate, and escalates to the supervisor the same day.

Symptoms beyond the low-intensity range (severe depression, psychosis, substance dependence, cognitive impairment) [synthesis]. These match the trial exclusions [source: Tol et al. 2018; NCT03587896]. Step up to specialist care. DWM can continue alongside if helpful.

Literacy, language and culture. The book is mostly pictures, has audio, and has been translated into many languages [source: DWM; ACBS page]. Use the client's language version. Check that the examples and values words fit their context, for example collective rather than individual framing. Let clients choose their own words for "hooks" [synthesis]. Trials adapted the material through translation, review by native speakers and pilot testing [source: NCT03587896].

Mistaking skills for control strategies [synthesis]. Signs include using grounding or naming to make feelings go away, and frustration when the feeling stays. Restate the aim from the book: engagement and action, not removal of feelings [source: DWM]. Ask, "Did you manage to keep doing what mattered while it was there?"

Religious or spiritual objections to mindfulness-like practice [synthesis]. Present the skills as attention and kindness practices. Link them to the client's own traditions where the client chooses to.

Group problems in SH+ [synthesis; the SH+ manual's own guidance is not drawn on, uncertain]:

Dominating participants: thank them and redirect to the audio or to small-group turn-taking.
Distress in the room: one facilitator steps aside with the person while the other continues the audio.
Disclosures: do not explore trauma in the group. Offer a private conversation and a referral.
Missed sessions: give the person the matching DWM section and audio to catch up.
Throughout: report adverse events and requests for help in supervision [source: Tol et al. 2018].

No change after the full course [synthesis]. Review practice frequency and which tools were used. If practice happened and distress or impairment is unchanged, step up to a higher-intensity intervention, such as Problem Management Plus or a disorder-specific therapy, rather than repeating the book.

Clinician drift [synthesis]. In guided use, keep check-ins brief and centred on the skills, so the low-intensity character and scalability are kept. In SH+, facilitators deliver the audio content and stay within the guide; supervisors check fidelity [source: Tol et al. 2018].

Sources

Sources

Further reading (not drawn on) [uncertain where relied on]

World Health Organization (2021). Self-Help Plus (SH+): a group-based stress management course for adults (facilitator manual, generic field-trial version 1.0). The download was refused, so the session scripts were not seen.
World Health Organization (2024). The Self-Help Plus (SH+) training manual: for training facilitators to deliver the SH+ course.
Brown, F. L., et al. / Tol, W. A., et al. (2018). Self Help Plus: study protocol for a cluster-randomised controlled trial of guided self-help with South Sudanese refugee women in Uganda. Global Mental Health, 5, e27. (Download refused.)
Harris, R. (2014). The Illustrated Happiness Trap (named by WHO as the inspiration for the SH+ content).

← Previous · V-161Step-by-Step Next · V-163 →Caregiver Skills Training