ACT Self Help and the World Health Organization: "Doing What Matters in Times of Stress" and Self-Help Plus (SH+)

The World Health Organization (WHO) decided around 2015 to test ACT as a fully scalable psychological intervention. Dr. Mark van Ommeren, head of Mental Health, was looking for a radically transdiagnostic approach that could help with the wide variety of mental and behavioral consequences of war. The breadth of outcomes across different problems areas world wide for ACT attracted his attention. The war in the South Sudan was a particular issue at the time and Van Ommeren was aware that ACT had been deployed in Sierra Leone by the "Commit and ACT" clinic in Bo. ACT was proving helpful in the ebola outbreak there. Dr. Ommeren consulted with leaders of the ACT community (including Steve Hayes), asking for ideas of how best to simplify ACT and was referred to the work of Russ Harris. Van Ommeren was especially impressed with the simplicity of Russ Harris Illustrated Happiness Trap and Russ agreed to work with the WHO team to produce what became Doing What Matters in Times of Stress ("DWM"; 2020) -- an illustrated guide to ACT ideas stated in very non-technical language with graphical images.

WHO does not distribute health care advice until it is rigorously tested in a series of high quality randomized trials, beginning with very careful pilot work. These evaluation studies are deliberately conducted with developers held at arms length. If the methods are helpful they are then distributed for free. At the time, WHO had no fully scalable psychological interventions in its portfolio that could be distributed without the involvment of highly trained professionals. Over a period of 4-5 years ACT self-help was tested both in the simplest way (distributing the book, wih some minimal addition supports) and with the lessons in the book being described in audiotapes and discussed in a small group format by non-specialists in a program called "Self-Help +" ("SH+"; Brown et al., 2018; Tol et al., 2018).

ACT self-help successfully passed through these tests of efficacy across a range of settings, cultures, language communities, and problem areas. SH+ reduced anxiety and depression with war refugees at a level that was similar to self-help in economically privileged societies (Tol et al., 2020; Turrini et al., 2022), and reduced future development of mental health disorders by nearly by half over a year's time (Purgato et al., 2022). Importantly, increases in psychological flexibility were shown to mediate these changes (Lakin et al., 2023). Said simply, the evaluation studies suggested that ACT works and works via its putative processes of change.

Doing What Matters in Times of Stress is now distributed by WHO on a website that describes it in unusually broad terms: "Informed by evidence and extensive field testing, the guide is for anyone who experiences stress, wherever they live and whatever their circumstances." As an example of that view, when the COVID pandemic hit and WHO did not have an evidence-based approach for that problem, people were referred to that page  https://www.who.int/publications/i/item/9789240003927 and studies were quickly conducted on DWM and SH+. The data showed that stressed health care workers were indeed helped (Riello et al., 2021; Mediavilla et al., 2023). Similarly WHO is now actively disseminating ACT self-help in the Ukraine to help with war survivors. Data are being collected there but it is not yet published.

ACT self-help is increasingly being built into the fabric of global health at WHO. In 2023 in an invited plenary talk at the World Congress of Cognitive and Behavioral Therapies in Seoul, Korea, WHO Mental Health head van Ommeren said that Doing What Matters in Times of Stress was now the most downloaded physical or mental health document of any kind at the World Health Organization.

SELF-HELP PLUS (SH+) (2021)
A group-based stress management course for adults (World Health Organization)
https://www.who.int/publications/i/item/9789240035119

Overview
Self-Help Plus (SH+) is WHO’s 5-session stress management course for large groups of up to 30 people. It is delivered by supervised, non-specialist facilitators who complete a short training course and use pre-recorded audio and an illustrated guide (Doing What Matters in Times of Stress) to teach stress management skills. The course is suitable for adults who experiences stress, wherever they live and whatever their circumstances. It has been shown to reduce psychological distress and prevent the onset of mental disorders. The format of SH+ makes it well-suited for use alongside other mental health interventions, as a first step in a step.

Available in English, Arabic, Juba Arabic, French, Portuguese, Spanish, Turkish, Ukrainian.

Doing What Matters in Times of Stress (2020)
An Illustrated Guide
https://www.who.int/publications/i/item/9789240003927
https://iris.who.int/handle/10665/331901

Overview
Doing What Matters in Times of Stress: An Illustrated Guide is a stress management guide for coping with adversity. The guide aims to equip people with practical skills to help cope with stress. A few minutes each day are enough to practice the self-help techniques. The guide can be used alone or with the accompanying audio exercises.
Informed by evidence and extensive field testing, the guide is for anyone who experiences stress, wherever they live and whatever their circumstances.

Available in Arabic, Armenian, Bengali, Burmese, Chinese, Czech, Dari, English, Estonian, Farsi/Persian, Finnish, French, German, Georgian, Greek, Hungarian, Indonesian, Italian, Japanese, Juba Arabic, Korean, Lithuanian, Malay, Polish, Portuguese, Romanian, Russian, Slovak, Spanish, Swedish, Tigrinya, Tongan, Turkish, Ukrainian, Urdu, Vietnamese.

How to Use WHO Self-help Plus Protocol
Webinar presented by Russ Harris and Claudette Foley
April 13, 2022
https://contextualscience.org/video/how_to_use_who_selfhelp_plus_protocol_webinar

Overview
This is a webinar on WHO's ACT protocol for refugees. We will answer Frequently Asked Questions about the protocol–also known as “Self-help Plus”-and explore how to implement it.

References:

Fietta, V., Rizzi, S., De Luca, C., Gios, L., Pavesi, M. C., Gabrielli, S., Monaro, M., & Forti, S. (2024). A Chatbot-Based Version of the World Health Organization–Validated Self-Help Plus Intervention for Stress Management: Co-Design and Usability Testing. JMIR Human Factors, 11, e64614. DOI: 10.2196/64614

Karyotaki, E., Sijbrandij, M., Purgato, M., et al (2023). Self-Help Plus for refugees and asylum seekers: an individual participant data meta-analysis. BMJ Mental Health, 26, e300672. DOI: 10.1136/bmjment-2023-300672

Lakin, D. P., Cooper, S. E., Andersen, L., Brown, F. L., Augustinavicius, J. L. S., Carswell, K., Leku, M., Adaku, A., Au, T., Bryant, R., Garcia-Moreno, C., White, R. G., & Tol, W. A. (2023). Psychological flexibility in South Sudanese female refugees in Uganda as a mechanism for change within a guided self-help intervention. Journal of Consulting and Clinical Psychology, 91(1), 6–13. DOI: 10.1037/ccp0000774

Mediavilla, R., Felez-Nobrega, M., McGreevy, K. R., Monistrol-Mula, A., Bravo-Ortiz, M. F., Bayón, C., ... & Ayuso-Mateos, J. L. (2023). Effectiveness of a mental health stepped-care programme for healthcare workers with psychological distress in crisis settings: A multicentre randomised controlled trial. BMJ Mental Health, 26(1), 1-8. DOI: 10.1136/bmjment-2023-300697

Acarturk, C., Uygun, E., Ilkkursun, Z., et al. (2022). Effectiveness of a WHO self-help psychological intervention for preventing mental disorders among Syrian refugees in Turkey: A randomized controlled trial. World Psychiatry, 21, 88–95. DOI: 10.1002/wps.20939

Acarturk, C., Kurt, G., Ilkkursun, Z., Uygun, E., & Karaoglan-Kahilogullari, A. (2022). “Doing What Matters in Times of Stress” to decrease psychological distress during COVID-19: A randomised controlled pilot trial. Intervention, 20(2), 170-178. DOI: 10.4103/intv.intv_29_21

Turrini, G., Purgato, M., Tedeschi, F., Acartürk, C., Anttila, M., Au, T., et al. (2022). Long-term effectiveness of Self-Help Plus in refugees and asylum seekers resettled in Western Europe: 12-month outcomes of a randomised controlled trial. Epidemiology and Psychiatric Sciences, 31, E39. DOI: 10.1017/S2045796022000269

Park, A., Waldmann, T., Kösters, M., et al. (2022). Cost-effectiveness of the Self-Help Plus Intervention for Adult Syrian Refugees Hosted in Turkey. JAMA Network Open, 5(5), e2211489. DOI: 10.1001/jamanetworkopen.2022.11489

Purgato, M., Carswell, K., Tedeschi, F., Acarturk, C., Anttila, M., Au, T., Bajbouj, M., Baumgartner, J., Biondi, M., Churchill, R., Cuijpers, P., Koesters, M., Gastaldon, C., Ilkkursun, Z., Lantta, T., Nosè, M., Ostuzzi, G., Papola, D., Popa, M., Roselli, V., Sijbrandij, M., Tarsitani, L., Turrini, G., Välimäki, M., Walker, L., Wancata, J., Zanini, E., White, R., van Ommeren, M., & Barbui, C. (2021). Effectiveness of Self-Help Plus in preventing mental disorders in refugees and asylum seekers in Western Europe: A multinational randomized controlled trial. Psychotherapy and Psychosomatics, 90, 403–414. DOI: 10.1159/000517504

Riello, M., Purgato, M., Bove, C., Tedeschi, F., MacTaggart, D., Barbui. C., & Rusconi, E. (2021). Effectiveness of self-help plus (SH+) in reducing anxiety and post-traumatic symptomatology among care home workers during the COVID-19 pandemic: A randomized controlled trial. Royal Society of Open Science, 8, 210219. DOI: 10.1098/rsos.210219

Tol, W.A., Leku, M.R., Lakin, D.P., Carswell, K., Augustinavicius, J., Adaku, A., Au, T.M., Brown, F.L., Bryant, R.A., Garcia-Moreno, C., Musci, R.J., Ventevogel, P., White, R.G., van Ommeren, M. (2020) Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trial. Lancet Global Health, 8(2), e254–63.  DOI: 10.1016/S2214-109X(19)30504-2

Tol, W. A., Augustinavicius, J., Carswell, K. Adaku, A. M., Leku, R., Brown, F. L., Garcia-Moreno, C., Ventevogel, P., White, R. G., Kogan, C.S., Bryant, R. and van Ommeren, M. (2018). Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in Uganda. World Psychiatry, 17(2), 234-235. DOI: 10.1002/wps.20537

Tol, W. A., Augustinavicius, J., Carswell, K., Brown, F. L., Adaku, A. M., Leku, R., Garcia-Moreno, C., Ventevogel, P., White, R. G. and van Ommeren, M. (2018). Translation, adaptation, and pilot of a guided self-help intervention to reduce psychological distress in South Sudanese refugees in Uganda. Global Mental Health. DOI: 10.1017/gmh.2018.14

Brown, F. L., Carswell, K., Augustinavicius, J., Adaku, A., Leku, M. R., White, R. G., Ventevogel, P., Kogan, C. S., García-Moreno, C., Bryant, R. A., Musci, R. J., van Ommeren, M., & Tol, W. A. (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. DOI: 10.1017/gmh.2018.17

Epping-Jordan, J., Harris, R., Brown,F.L., 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, 295-296. DOI: 10.1002/wps.20355