Self‐Help Plus (<scp>SH</scp>+): a new <scp>WHO</scp> stress management package

Consistent with its recommendations for stress management interventions1, the World Health Organization (WHO) has developed a new psychological intervention for managing stress and coping with adversity. This new intervention is intended to be relevant for coping with any type of adversity, including chronic poverty, endemic community and gender-based violence, long-term armed conflict, and displacement. It is especially targeted towards places with enormous needs but limited humanitarian access, such as Syria and South Sudan. Following exposure to adversity, rates of diverse mental health problems and non-pathological distress increase. At the same time, most people affected by adversity do not have access to effective mental health and psychosocial support2. Without mental health specialists on the ground, either for direct service delivery or for training and supervising non-specialists3, 4, new approaches need to be established that can be delivered without an extensive workforce for mental health. SH+ was developed to address these needs. It does not require much time from experts for implementation: instead, it uses a guided self-help format and is delivered through a pre-recorded audio course, complemented with bibliotherapy. The potential of using a course to access hard-to-reach populations has been demonstrated previously5. Evidence for bibliotherapy is also promising6. Furthermore, research has found that guided self-help programs produce better results than “pure” (unguided) self-help, and the effects produced by guided self-help are surprisingly similar to face-to-face psychological treatment7. SH+ was designed to be relevant for large segments of adversity-affected populations: it is intended to be transdiagnostic, easily adaptable to different cultures and languages, and both meaningful and safe for people with and without mental disorders. The program was developed with experts in psychological care and global mental health, and colleagues in the humanitarian field. It underwent extensive peer-review, with 43 external experts reviewing the intervention. The SH+ package has two components: a pre-recorded course and a self-help book. Pre-recorded audio material (locally adapted) is delivered across five 2-hour sessions and in groups of 20 to 30 people. The audio material imparts key information about stress management and guides participants through individual exercises and small group discussions. A written facilitator guide helps briefly trained non-specialist facilitators to conduct the course using these audio materials. To augment the course materials, an illustrated self-help book reviews all essential content and concepts. The book – inspired by an existing illustrated self-help guide8 – contains more than 400 illustrations and conveys key points with minimal text. It was written to be useful both as a standalone product and as a key resource for those participating in the course. The format of SH+ is innovative in that it seeks to ensure that key intervention components are delivered as intended through the use of pre-recorded audio, without the burden of extensive training and supervision. This mode of delivery holds promise for helping hard-to-reach populations: the package may be introduced in areas where a conventionally delivered mental health intervention would not be feasible (e.g., remote areas, or areas where humanitarian access is limited). SH+ is based on acceptance and commitment therapy (ACT), a form of cognitive-behavioral therapy, with distinct features9. ACT is based on the concept that ongoing attempts to suppress unwanted thoughts and feelings can paradoxically make these problems worse. Instead, it emphasizes learning new ways to accommodate difficult thoughts and feelings – primarily through mindfulness approaches – without letting them dominate, while guiding people to take proactive steps towards living in a way that is consistent with their values. ACT has been shown to be useful for a range of mental health issues10 and has been used successfully in a guided self-help format11. Components of the SH+ package are currently being piloted in Syria, with Syrian refugees in Turkey, and with South Sudanese refugees in northern Uganda. Initial feedback has been positive. Funding has been secured for a full-scale randomized controlled trial to evaluate the SH+ course in Uganda later this year. Following evaluation and any necessary revisions, the SH+ package may become part of WHO's growing collection of low-intensity psychological interventions. Thinking Healthy (for perinatal depression)12 and Problem Management Plus (PM+; delivered in face-to-face sessions)4 are the first two of this collection. Over the next five years, the WHO will design and rigorously test additional psychological interventions for different age groups and using varying delivery models. Mental health specialists will always be essential for supervision and for management of those for whom these interventions are insufficient. Yet these potentially scalable intervention programs may reduce reliance on scarce specialists, thereby hopefully making mental health care more widely available to those in need. JoAnne E. Epping-Jordan1, Russ Harris2, Felicity L. Brown3, Kenneth Carswell4, Claudette Foley2, Claudia García-Moreno 4 , Cary Kogan5, Mark van Ommeren4 1WHO Consultant, Seattle, WA, USA; 2WHO Consultant, Melbourne, Australia; 3Harvard T.H. Chan School of Public Health, Boston, MA, USA; 4World Health Organization, Geneva, Switzerland; 5University of Ottawa, Ottawa, Canada The authors alone are responsible for the views expressed in this letter, that do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. SH+ was developed through funds from United Nations (UN) Multi-Partner Trust Fund for UN Action Against Sexual Violence in Conflict, and the WHO Country Office in Syria. Testing with South Sudanese refugees in Uganda is supported by Enhanced Learning and Research for Humanitarian Assistance (ELHRA)'s Research for Health in Humanitarian Crises (R2HC) initiative funded by the UK Department for International Development and the Wellcome Trust.

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