WHO’s “Doing What Matters in Times of Stress”: A Methodological Review of the Toolkit

By Matthias Behrends

Review & Opinion

TL;DR

• The toolkit: The World Health Organization's Doing What Matters in Times of Stress teaches five acceptance- and values-based skills: grounding, unhooking, acting on values, being kind and making room. The set is coherent, accessible and designed for wide use.
• The techniques: Each skill has a plausible purpose, but they do different jobs. Present-moment orientation, distance from thoughts, direction through values, kindness and acceptance should not be treated as interchangeable or as a complete account of emotional stabilization.
• The delivery: Parts of the public audio are usable, but the package is too explanation-heavy and unevenly sequenced. Clear transitions, quick routes into practice, meaningful choice, stopping instructions and support options are conditions for responsible broad use, not optional refinements.
• The evidence: The often-cited 2023 analysis studied Self-Help Plus, a five-session facilitated group programme that uses the guide. It did not test reading the guide alone or isolate individual techniques. Later supported-use trials report positive short-term findings. A separate matched active-comparison trial found no difference on its preregistered combined anxiety and post-traumatic-stress outcome.
• My conclusion: The guide is accessible and contains some usable elements, especially grounding and parts of the audio. But I do not consider the toolkit state of the art. It is too explanation-heavy, unevenly sequenced and includes a “making room” exercise that I do not consider acceptable as a broadly distributed first-line intervention.

If an institution asked me whether Doing What Matters in Times of Stress is a good toolkit, I would not begin with the study. I would begin with the techniques.

A study can tell us whether a defined intervention package changed selected outcomes in a defined population. It cannot, by itself, tell us whether every technique inside the package is well chosen, well sequenced or sufficient for the situations in which the toolkit may later be used.

The reverse is also true. A toolkit can contain sensible ideas without having demonstrated that its complete package produces meaningful benefit beyond credible alternatives.

My evaluation therefore starts with a practical methodological question:

What is each technique intended to change, for whom, under which conditions, with what support, and compared with what other option?

1. What exactly is being evaluated?

The World Health Organization (WHO) publishes Doing What Matters in Times of Stress as a 132-page illustrated guide for people facing stress and adversity. It is based on principles from Acceptance and Commitment Therapy (ACT), uses simple illustrations and offers accompanying audio exercises.

The same material can appear in different intervention formats:

1. Independent use: a person reads the guide, with or without the public audio.
2. Individually supported use: a trained helper provides brief contact, practice support and action planning.
3. Self-Help Plus (SH+): the guide is used inside five facilitated group sessions, which lasted approximately 90 to 120 minutes in the trials reviewed here, with prerecorded exercises and trained, supervised non-specialist facilitators.
4. Stepped care: the material serves as an initial low-intensity layer, followed by more intensive support when distress remains high or needs exceed its scope.

These are related, but they are not the same intervention. They differ in contact time, privacy, rehearsal, facilitator competence, supervision, adherence support, monitoring and referral.

2. How I evaluate a technique

A useful technique review needs more than a list of benefits. I use six questions.

1. Function: What capacity is the technique trying to develop?
2. Mechanism: What does the person actually do, and why might that help?
3. Fit: For whom and in which state or situation is the technique likely to be usable?
4. Delivery: How much explanation, practice, repetition and support does it require?
5. Choice and recovery: Can the person pause, stop, reorient or choose another route if distress increases?
6. Evidence: Was this technique tested directly, or only as one part of a larger programme?

This lens does not require every public toolkit to contain every possible method. It does require the toolkit's job to be clear.

3. Grounding: a practical point of entry

The guide describes grounding as noticing thoughts and feelings, slowing down, connecting with the body and then refocusing on the world around you. The audio moves attention through the body, the breath and the immediate environment.

Grounding is the toolkit's clearest usable component. It gives the person something concrete to do. It can interrupt narrowing attention and restore contact with the present situation. It also translates well into audio because pacing and pauses are part of the practice.

Methodologically, however, “grounding” is a broad label. Different exercises may aim at sensory orientation, attentional control, physiological settling or simple interruption of rumination. Those are related capacities, but they are not identical.

The practical question is therefore not only whether grounding is useful. It is which grounding exercise is being used, for what immediate purpose, and how the person knows whether it is helping.

Grounding in the room is also not the same as emotional stability. A person may know where they are and still feel profoundly unsafe, unsupported or overwhelmed. Present-moment orientation can be an important first step without being the whole process.

My professional sequencing preference, especially when someone is overwhelmed, is to establish contact with the external environment before inviting more inward attention. Participation, posture and whether the eyes are open or closed should remain choices. This is a fit and sequencing hypothesis, not a universal finding established by the cited trials.

4. Unhooking: creating distance from thoughts and feelings

Unhooking asks the person to notice that a difficult thought or feeling has captured attention, name it and then refocus on what they are doing. In ACT language, this resembles cognitive defusion: learning to relate to a thought as a mental event rather than automatically treating it as a command or complete description of reality.

That can be valuable. Naming an experience may create a small amount of distance. Refocusing can support agency. The technique also avoids requiring the person to prove a thought wrong before acting.

The boundary is equally important. “Being hooked” is not a diagnosis and it should not be reduced to one trauma-specific pattern. Recurrent thoughts, intrusive memories, worry, anger and self-criticism may all involve different processes and may require different levels of support.

For someone with enough stability to observe and redirect attention, unhooking may be a useful skill. For someone who is highly activated, dissociated or flooded, the instruction to notice and name may not create sufficient distance on its own. The technique needs a clear route back to orientation, choice and support.

The available outcome studies do not isolate unhooking from the rest of the programme. We can discuss its logic and practical fit. We cannot attribute the programme's outcomes specifically to this component.

5. Acting on values: direction is not the same as stabilization

Acting on values asks what matters and what small action could move life in that direction. This can help a person reconnect behaviour with meaning rather than allowing distress to dictate every choice.

That is a worthwhile capacity. Values can provide direction when circumstances are difficult and cannot be changed immediately. Small actions can also restore a sense of participation in one's own life.

But values work answers a different question from stabilization. Knowing what matters does not necessarily make a person ready or able to act. Severe overwhelm, exhaustion, danger, poverty, displacement, discrimination, insecure legal status or unsafe work cannot be resolved by clarifying values.

This does not make values work irrelevant. It means that timing and context matter. Values may guide action once enough stability, support and practical possibility exist. They should not become a moral demand placed on someone whose immediate need is safety, recovery or structural help.

The values also belong to the participant, not the programme. Rest, leaving danger, seeking help, refusing an unreasonable demand or addressing a structural barrier may all be values-consistent actions. A method should not turn conditions such as displacement, discrimination or material insecurity into an individual failure to act.

The concern is not only that values work may be insufficient. When distress is generated or maintained by danger, displacement, discrimination, insecure status, poverty or unsafe work, a self-management toolkit can redirect attention toward the individual's coping while those conditions remain untouched. Used that way, it risks helping people adapt to what should be changed.

Seth Godin has described the wider gap between the change people say they want and the choices they continue to reinforce. My image for the same institutional problem here is putting fertilizer on weeds: investing attention, credibility and limited contact time in adaptation while the conditions producing the distress continue to grow. Individual support still matters, but it should not make harmful circumstances easier for a system to leave unchanged.

6. Being kind: more than a general appeal

The guide's kindness chapter is more substantial than a general message to “be nice.” It asks the participant to notice pain in themselves or another person, unhook from harsh thoughts and respond with kinder self-talk and action. It also offers an optional embodied exercise in which a hand is placed on the body while warmth or kindness is imagined flowing through it.

This is a small self-compassion practice with an experiential element. It can counter harsh self-judgment, isolation and the tendency to treat distress as personal failure. The embodied option should remain voluntary, with non-touch and non-imagery alternatives for people who do not find it helpful or appropriate.

The methodological question is not whether kindness is desirable. It is which part of this practice is intended to produce change: noticing pain, unhooking from harsh thoughts, self-talk, imagery, bodily contact or subsequent action. The chapter combines these elements, and the available studies do not separate them.

The programme-level studies cannot tell us how much of any observed change came from this component, from the wider group setting or from supportive facilitator contact.

7. Making room: not appropriate as a general first-line instruction

Making room asks the person to allow difficult thoughts and feelings to be present without fighting them, while continuing to act in line with values. The intention is not to approve of pain or remain passive. It is to reduce the additional struggle created by trying to suppress an experience that is already present.

In some circumstances, this can be useful. Persistent efforts to eliminate every unwanted thought or feeling can consume attention and narrow life. Acceptance can reduce that struggle.

The technique becomes more demanding when the person is already overwhelmed. Directing further attention toward painful inner material may be poorly timed if the person has little capacity to regulate attention, lacks support or does not know how to stop and reorient.

The cited trials did not isolate this exercise, demonstrate that it caused harm or compare it with a resource-oriented alternative. My objection is therefore a professional judgment about fit and sequencing, not a claim that the trials established harm.

I do not consider “making room” acceptable as a general first-line instruction for an unknown person who may already be overwhelmed. Directing more attention toward painful inner material is the wrong starting direction when pain already dominates attention and the resource cannot assess the person's state. In broadly distributed material, the exercise should be removed from the general route or visibly restricted to suitable situations, with support, informed choice, stopping, reorientation and an alternative that does not require further contact with pain.

The guide does advise seeking help when the exercises are not enough for intolerable stress. That general boundary is important. It is not the same as an immediate, technique-specific instruction for stopping and reorienting during an exercise.

8. The audio may be the toolkit's strongest practical element

The most useful part of my review was listening to the English audio exercises rather than reading only the programme description.

Several recordings are longer and more usable than the brief text visible in the guide. They slow the material down, create pacing and turn an illustrated explanation into something a person can follow. This is a genuine strength.

At the same time, explanation, metaphor, recap and practice are not always cleanly separated. A person returning to an exercise should be able to reach the practice quickly without repeatedly listening to an extended introduction.

Transitions also carry responsibility. Grounding may move between the body, breath and environment. Unhooking moves from noticing and naming toward refocusing. Making room turns attention toward painful inner experience. These transitions should make five things explicit:

• what the next exercise is intended to do;
• whether participation is optional;
• how to pause or stop;
• how to reorient to the room or another activity; and
• where to seek support if distress increases.

These are not decorative instructions. They are part of the intervention's design, especially when the material is distributed beyond a controlled group setting.

9. The capability I still find missing

The five skills cover present-moment attention, distance from thoughts, values, kindness and acceptance. The kindness practice does offer a generic way to evoke warmth and support. What the toolkit does not teach is the broader, personalized process of identifying which supportive inner experience is accessible to this person now, selecting it deliberately, monitoring its effect and reinforcing it over time.

Emotional Resource Work asks what memory, person, place, activity, image, spiritual reference or other personally meaningful material can provide support now, and how contact with that experience can be approached, monitored and closed responsibly. Guided Affective Imagery is one possible method family for developing this capacity.

This is not forced positivity. It is not an instruction to suppress pain. It is a deliberate attempt to make support emotionally accessible.

Grounding in the room is not the same as strengthening a supportive inner state. Acting on values is not the same as experiencing support. Making room for pain is not the same as having a resource available while approaching it.

Our Academy position is that a programme offered to people facing significant adversity should preserve a route that does not require more contact with pain in order to participate. A resource option can be brief, voluntary and bounded, with non-imagery alternatives.

My recommendation is not simply to add one resource exercise to the existing package. I would redesign the first phase around external orientation, supportive emotional resources, paced practice and distancing options, while sharply reducing explanation. I believe this would use limited contact time more effectively because it targets stabilization and agency directly. That is my professional position, not a superiority finding from the studies reviewed here. It should be tested in a matched direct comparison.

10. What the studies contribute

The most frequently discussed paper is a 2023 individual-participant-data meta-analysis by Karyotaki and colleagues. It combined three randomized trials of Self-Help Plus involving 1,795 adult refugees and asylum seekers across Western Europe, Türkiye and Uganda.

The comparison condition was enhanced care as usual. Immediately after the programme, the difference in depressive symptoms favoured Self-Help Plus but did not reach statistical significance. Self-identified problems and well-being improved, and the paper reported benefits on several outcomes at five to six months. It did not establish differences in post-traumatic-stress symptoms or functioning. Results varied substantially across the three trials.

This is a mixed pattern, not evidence that the programme does nothing and not evidence of uniform benefit.

The study is relevant because it evaluates a defined delivery package. It is not the centre of the technique review because it did not isolate grounding, unhooking, values, kindness or making room. It also did not test independent use of the guide or compare SH+ with an equal-time credible psychological programme.

One separate trial does address part of the active-comparison question. Riello and colleagues tested a supervised online version using Doing What Matters materials with 238 care-home workers in Northern Italy. The comparison group received an equally supervised, similarly structured illustrated-reading and reflection activity. The preregistered combined anxiety and post-traumatic-stress outcome did not differ between groups after the intervention.

That result matters because it controls more of the attention, structure and expectation surrounding participation. It does not establish that every component is ineffective, and it does not transfer automatically from Italian care-home workers during the COVID-19 pandemic to populations facing displacement or conflict. It does show why package-specific claims should not rely only on waiting-list or usual-care comparisons.

Later research has evaluated supported versions of Doing What Matters more directly. Two small 2022 pilot trials supported feasibility but did not find statistically significant between-group differences. A 2025 Kenyan study tested guide and audio access supported through three meetings with trained barbers and reported large short-term improvements compared with a waiting list. A 2026 trial with 303 Farsi-speaking refugees in Indonesia, 278 of whom were from Afghanistan, tested the guide plus five brief video calls, action planning and supervised community facilitators and found a moderate short-term reduction in psychological distress compared with repeated assessment.

The later supported-use studies reported positive short-term results. Across the studies reviewed here, support was part of the intervention that was tested. None establishes the effect of the book alone, the contribution of one individual technique or whether the same time and attention could produce better outcomes with a differently sequenced intervention. The Riello trial provides a useful active comparison at package level; the later refugee and supported-use studies reviewed here do not answer that same comparison question.

11. What a more informative study would test

The next generation of research should separate format, support and method.

1. Compare unsupported access with an otherwise identical supported version.
2. Extend matched active-comparison research across relevant populations, with equal time, attention, credibility and practice.
3. Define the capacity each technique is intended to change and measure that capacity directly.
4. When examining individual components, vary one component while keeping contact time and delivery conditions stable.
5. Measure adherence, choice, unwanted emotional activation, stopping, referral, functioning and durability.
6. Record the structural conditions that may produce or maintain distress and cannot be addressed through an individual technique.
7. If testing the Academy's resource-access hypothesis, compare a bounded resource-oriented addition with an equal-time non-imagery addition rather than simply adding more contact.

This design would help answer not only whether a package may help, but which part helps, for whom, under which conditions and at what burden.

12. My overall assessment

Doing What Matters in Times of Stress is accessible, widely translatable and contains several usable ideas. That is not enough for a positive overall verdict. I do not consider the toolkit state of the art. It is too explanation-heavy, provides too little carefully sequenced practice and combines techniques serving different purposes without a sufficiently clear progression.

Grounding and parts of the audio are worth retaining. Unhooking, values and kindness can each have a place under suitable conditions. But I oppose presenting “making room” for painful inner material as a broadly applicable first-line exercise. Where pain already dominates attention, the first tasks should be orientation, distance, supportive emotional resources and meaningful choice.

The WHO's authority makes the design choices more consequential. A widely translated toolkit can become the assumed baseline even when important questions about format, sequencing and comparison remain unanswered. That is where the fertilizer-on-weeds problem becomes institutional: credibility, training time and funding can reinforce a limited model and crowd out direct comparison with alternatives that may fit the actual need better.

Before using the guide, I would ask:

1. What is the immediate purpose?
2. Which delivery format is actually being offered?
3. Is the person able to use this technique in their current state?
4. What choice, stopping and support routes are available?
5. What credible alternative might fit the purpose better?
6. What relevant capacity is missing from this set?
7. How will nonresponse, worsening or the need for another level of support be noticed?

On balance, I would not recommend this toolkit as the default model for first-line stress management. I would preserve its usable parts, remove or tightly restrict the making-room component, reduce conceptual explanation, strengthen consent and stopping routes, and redesign the first phase around external orientation and resource-building. Practical help, relational support and action on the conditions producing the distress must remain part of the response.

The decisive question is not whether someone can gain something from the package. People often make something useful from weak material. The question is whether this is the best use of scarce time and institutional attention. My answer is no.

The methodological conclusion is simple: do not ask only whether a toolkit contains useful ideas. Ask what each technique is meant to do, what was actually tested, what stronger alternative should be compared, and what the person still needs.

Evidence and scope

This Review & Opinion article is a focused educational analysis of selected primary studies and official World Health Organization materials searched through 27 August 2026. It combines cited evidence with clearly signalled interpretation by Matthias Behrends and the Deep Emotional Work Academy. It is not a systematic review or clinical guideline. The studies differ in intervention format, population, comparator, follow-up, outcome and support, so their findings should not be transferred beyond those conditions without further assessment.

Selected sources

1. World Health Organization. (2020). Doing What Matters in Times of Stress: An Illustrated Guide.
2. Epping-Jordan, J. E., Harris, R., Brown, F. L., et al. (2016). Self-Help Plus: a new WHO stress management package. World Psychiatry, 15(3), 295-296.
3. World Health Organization. (2021). Self-Help Plus: A Group-Based Stress Management Course for Adults.
4. 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.
5. World Health Organization. (2024). The Self-Help Plus Training Manual: For Training Facilitators to Deliver the SH+ Course.
6. Riello, M., Purgato, M., Bove, C., et al. (2021). Effectiveness of Self-Help Plus in reducing anxiety and post-traumatic symptomatology among care-home workers during the COVID-19 pandemic: a randomized controlled trial. Royal Society Open Science, 8(11), 210219.
7. Acarturk, C., Uygun, E., Ilkkursun, Z., et al. (2022). Doing What Matters in Times of Stress to decrease psychological distress during the COVID-19 pandemic: a randomized controlled pilot trial. Intervention, 20(1), 16-25.
8. Yabunga, P. M., Koyiet, P. N., Musimbi, H., et al. (2025). Effectiveness of barber-facilitated Doing What Matters in Times of Stress intervention among urban literate youths in Western Kenya: A cluster randomised trial. PLOS Global Public Health, 5(6), e0004712.
9. Nickerson, A., et al. (2026). Efficacy of a World Health Organization-guided self-help intervention for reducing psychological distress in Afghan refugees: Randomized controlled trial. JMIR Mental Health, 13, e89928.
10. Thakur, H. K., Schäfer, C. G., Kunzler, A. M., et al. (2026). Effectiveness and implementation of Self-Help Plus and Doing What Matters in Times of Stress: protocol of a systematic review and meta-analysis. BMJ Open, 16, e117737.
11. World Health Organization. (2026). Psychological self-help interventions: delivering self-help for individuals, featuring Step-by-Step and Doing What Matters in Times of Stress.