Step-by-Step · Atlas

1. Introduction

Version followed: WHO Step-by-Step (SbS) as described for the Lebanon programme (Carswell et al., 2018, mHealth; Lebanon pilot, Harper Shehadeh et al., 2020; Lebanon RCT protocol, van 't Hof et al., 2021; Lebanon trial report, Cuijpers et al., 2022; WHO EMRO trial news page), with the self-guided "contact-on-demand" variant tested with Syrian refugees in Egypt (Burchert et al., 2024) noted where it differs. The component list (psychoeducation, behavioural activation, stress management, a gratitude and a positive self-talk exercise, social support, relapse prevention), session pacing, helper contact format, helper training and supervision are based on the pilot paper, the trial protocol, WHO EMRO and WHO 2026 news pages. Not checked against the official WHO 2026 manual Psychological self-help interventions or the 136-page Step-by-Step web annex (WHO ref. B09738, CC BY-NC-SA 3.0 IGO), which hold the in-app content; so in-app exercise wording, the name of the second stress-management technique, the exact form of the gratitude and self-talk exercises, and the helper contact scripts remain unchecked [uncertain].

Step-by-Step is not a therapy a clinician delivers face to face. It is a WHO self-help programme for depression: five short sessions, delivered mainly by smartphone app or web, told as an illustrated story and supported by brief weekly contact from a trained non-specialist "e-helper" [source: Carswell 2018]. It was adapted from WHO's Problem Management Plus (PM+); problem management was dropped because it was judged hard to deliver by technology in low- and middle-income settings [source: Carswell 2018]. Behavioural activation (BA) is the main active ingredient. Around it sit psychoeducation, stress management (slow breathing plus a second technique), identifying strengths, a gratitude and positive self-talk exercise, increasing social support, and relapse prevention [source: Carswell 2018; van 't Hof 2021; Cuijpers 2022].

How change is meant to happen: the user identifies with a story character who is struggling with low mood. A health-worker character teaches that character (and so the user) to re-engage step by step in small pleasant and meaningful activities, manage the stress that gets in the way, and reconnect with other people. The user practises between sessions, and brief human encouragement keeps them going [source: Carswell 2018; Cuijpers 2022]. A practising clinician's likely roles are (a) e-helper or helper supervisor in a service that runs SbS, (b) programme lead adapting it to a population, or (c) a therapist offering it as a low-intensity step and supporting a client through it [synthesis].

2. Framework

Overall shape [source: Carswell 2018; Cuijpers 2022; SbS-F protocol table]

Phase	Content	Goal
Onboarding / registration	Information, eligibility screening, account set-up; a slow-breathing exercise appeared in onboarding in the refugee app prototype [source: Burchert 2019]	Check fit, consent, safety screen, get the user into the app
Introduction: "Your Strengths"	Questionnaires on mood, functioning and the user's own problems, plus a short strengths exercise; the user chooses a story character	Baseline, engagement, a positive starting point
Session 1 "Get started"	Psychoeducation about depression; trying small pleasant activities	Normalise, give a model, start doing
Session 2 "Get active"	Behavioural activation	Plan and do more rewarding activities
Session 3 "Beat obstacles"	More complex activation; stress management to deal with anxiety about doing activities	Tackle harder tasks and avoidance
Session 4 "Get together"	Increasing social support	Reconnect with people and practical help
Session 5 "Keep it up"	Relapse prevention; largely revisits earlier techniques [source: Burchert 2024]	Consolidate and plan for setbacks

Session format. Versions differ. The 2018 description gives about 30 minutes per session in two roughly 15-minute halves: the illustrated story (about 50 slides in the original), then interactive coaching and exercises [source: Carswell 2018]. WHO's account of the Lebanon trial version gives three parts per session, about 20 minutes in total, fully illustrated and audio-narrated [source: WHO EMRO news page]; the trial report describes two or three smaller parts that could be done in one sitting or over several days [source: Cuijpers 2022]. The Lebanese public app describes each session as a story part (an illustrated character who recovered from depression) followed by an interactive part in which an illustrated doctor character gives tips and techniques [source: Step by Step app listing, independent editorial page]. Text is written in easy language with optional audio or narrated video for low literacy, and the app was designed to work offline after download [source: Carswell 2018; Burchert 2019].

Pacing and criteria for moving on.

One session per week is expected, so the core programme runs about five to seven weeks including the introduction [source: Cuijpers 2022; SbS-F protocol table].
A session unlocks only once the previous one is finished, so users practise in between [source: Cuijpers 2022]. In the Lebanon versions there was also a time lock: in the pilot, Session 1 opened 3 days after the introduction and later sessions were released every 4 days, with 8 weeks to finish all five [source: Harper Shehadeh 2020]; in the trial version a session unlocked four days after the previous one was completed, with one session a week recommended [source: WHO EMRO news page]. In the Egypt version the wait was three days, with six weeks to complete [source: Burchert 2024].
There are no clinical criteria for progression beyond completing the previous session. Completion of the programme was defined in trials as at least four of five sessions [source: Cuijpers 2022; Burchert 2024].
Between sessions users log practice and feedback in an interactive "toolbox" and rate mood daily on a 5-point scale [source: van 't Hof 2021; Cuijpers 2022].

Guidance format. Weekly helper contact of up to 15 minutes (15 to 20 minutes in the 2018 description and the pilot), by phone, synchronous messaging or secure email [source: Carswell 2018; Cuijpers 2022]. In the Lebanon pilot, contact was optional (encouraged, not required) and users chose their channel at sign-up: email or WhatsApp (57%), phone (25%) or website chat (18%) [source: Harper Shehadeh 2020]. Because the content stands alone, SbS can also run with contact on request only or unguided [source: Carswell 2018]. WHO's 2026 launch news states it can be used alone (unguided) or with brief regular support (guided), the support coming either within existing appointments or from a trained, supervised non-specialist helper, and that the trials delivered it with about 15 minutes of support a week over five weeks [source: WHO news, 1 June 2026].

Who it was for in trials. Adults (18+) with depressive symptoms and impaired functioning: PHQ-9 of 10 or more and WHODAS 2.0 above 16 (Lebanon); K10 above 15 and WHODAS above 16 (Egypt). People reporting serious suicidal thoughts or a plan in the past month were excluded and directed to emergency services or a suicide line [source: van 't Hof 2021; Burchert 2024]. These are trial criteria, not WHO-mandated eligibility rules [uncertain].

Formats other than the app. The authors state the content can be delivered as a book, video or face-to-face guide if the core story and activities stay the same [source: Carswell 2018].

Training, supervision and permission to deliver. No formal certification, licence or accreditation scheme is described on the WHO publication, news or programme pages cited, nor in the trial papers [source: WHO news 1 June 2026; WHO self-help interventions page; Harper Shehadeh 2020; van 't Hof 2021]. Trial helpers were non-specialists: psychology and public health graduates in the pilot (6 days of training on the intervention, mental health conditions, communication skills and working with distressed people), and in the RCTs graduates with a psychology or social-work degree given 4.5 days of training in the research protocols and the intervention, who had to pass a competency test [source: Harper Shehadeh 2020; van 't Hof 2021]. They worked from a manual with session-by-session outlines for support contacts; supervision was group clinical and management supervision every 2 weeks plus on-demand telephone supervision by a clinical psychologist in the pilot, and weekly clinical supervision in the RCTs, with fidelity checklists applied to about 5% of contacts [source: Harper Shehadeh 2020; van 't Hof 2021; Cuijpers 2022]. The trial protocol states WHO's aim of releasing SbS with adaptation and implementation guidance for other settings [source: van 't Hof 2021]; the 2026 manual and annex are that release, published under CC BY-NC-SA 3.0 IGO (non-commercial, share-alike) [source: WHO B09738 page]. National digital versions run in Lebanon (National Mental Health Programme) and Thailand [source: WHO news 1 June 2026]. Whether WHO requires registration or approval for adapted versions, and what helper competency standard the 2026 manual sets, is not confirmed from the manual itself [uncertain].

3. Guiding principles

[source: Carswell 2018; van 't Hof 2021; Cuijpers 2022; Burchert 2019, 2024, unless tagged]

Behavioural activation first. Practical meaning: whatever the conversation, steer back to what the user did this week and what they will do next.
The programme carries the content; the helper carries motivation. Practical meaning: as helper, do not re-teach or add therapy; review the story and the practice, encourage, solve technical problems.
Minimal, scalable guidance. Practical meaning: keep contacts to about 15 minutes a week; longer contacts are a signal to review fit or refer, not to extend the session [synthesis on the second half].
Non-specialist helpers, specialist backup. Practical meaning: helpers use basic helping skills and preset protocols; anything clinical (risk, deterioration, complex presentations) goes to the supervisor.
Safety is built in. Practical meaning: screen for suicide risk at entry, watch weekly scores, follow preset protocols for suicide risk, child abuse, gender-based violence and acute distress, and report adverse events.
Identification through story. Practical meaning: refer to the character's experience ("the character tried…") to make techniques feel normal and less personal.
Broad, non-specific, non-pathologising cultural tailoring. Practical meaning: adapt by gender, life stage, dress and language; avoid naming specific traumatic events (such as conflict) so many people can relate; let users choose a character.
Low burden and accessibility. Practical meaning: short sessions, easy reading, audio, offline use, low data cost; help users fit sessions into real life.
User control over what is shared. Practical meaning: in the refugee app, focus groups wanted helpers not to see user entries by default; ask before discussing what a user wrote [source: Burchert 2019].
Practice between sessions. Practical meaning: sessions unlock in sequence so time is left for practice; ask about practice at every contact.
Fidelity. Practical meaning: follow the contact outline; the most common deviation found was helpers skipping review of the story or practice exercises [source: Cuijpers 2022].

4. Intervention inventory

How to read this section: the cited sources name each component and its session but do not reproduce the in-app exercise text, which is in the WHO 2026 web annex (B09738) with the full session content, exercises and materials [uncertain: annex text not used here]. For each component, "what the programme does" is sourced; the step-by-step instructions are written for the helper or clinician supporting a user through that component and are marked [synthesis] where they go beyond the sources. All example language is illustrative. Part A covers what the user does in the programme; Part B covers what the helper and service do.

Part A. Programme components (user-facing)

A1. Onboarding and entry screening

Purpose: confirm the person is an adult with depressive symptoms and impaired functioning, screen out imminent suicide risk, get consent and set up the account [source: van 't Hof 2021; Burchert 2019].
Steps: (1) Person registers in the app or web, reads programme information and consents. (2) Completes screening (trials used PHQ-9 and WHODAS 2.0, or K10 and WHODAS). (3) Answers a single question on serious suicidal thoughts or a plan in the past month; a "yes" triggers an on-screen message advising emergency care or the national suicide line, a list of local services and self-care tips, and in trials, exclusion [source: van 't Hof 2021]. (4) If you are offering SbS clinically rather than in a trial, do your own fuller risk assessment before starting and do not rely on the single item [synthesis].
Example language (illustrative): "Before you begin, I'd like to check how things have been, including whether you've had thoughts of ending your life, so we can make sure this programme is the right level of help."
Watch for: high distress that needs more than self-help; no private device or data; low literacy (offer audio); someone signing up on behalf of another person [synthesis].

A2. Introduction: "Your Strengths" and character choice

Purpose: baseline questionnaires on mood, functioning and the user's own problems, plus a brief exercise identifying personal strengths, so the programme starts from what the person can already do [source: Carswell 2018; Harper Shehadeh 2020]. In the pilot the introduction also contained a relaxation exercise, included in case completing the questionnaires made the user anxious [source: Harper Shehadeh 2020]. The user also picks a story character (in Lebanon: Zeina with or without headscarf, Karim with or without beard; later a married-with-children or younger-single storyline) [source: Carswell 2018; van 't Hof 2021].
Steps for the helper: (1) At first contact, confirm the introduction is done; 40% of Lebanon users who registered did not finish it [source: Cuijpers 2022]. (2) Ask which strengths the user noted and reflect one back. (3) Check the character feels relatable; if not, say the details of the story are less important than the skills [synthesis].
Example language (illustrative): "You wrote that you're patient with your children. That's a strength we can use in the coming weeks."
Watch for: users who can name no strengths; offer a prompt such as something a friend would say they do well [synthesis].

A3. The illustrated story and helper character

Purpose: the delivery vehicle. A character with low mood visits a health worker (a doctor in Lebanon; the authors suggest this could be a community elder or other figure elsewhere) and tells their story while the health worker teaches each technique. In the refugee app the story became a messenger-style chat between a former user and "the doctor" [source: Carswell 2018; Burchert 2024]. Images hint at common adversities (illness, bereavement) without naming causes such as conflict [source: Carswell 2018].
Steps for the helper: (1) At each contact ask what happened in the story this week. (2) Link the character's experience to the user's: "Did any of that sound familiar?" (3) Use the character to depersonalise setbacks [synthesis].
Example language (illustrative): "In this week's part, the character didn't feel like going out but tried a short walk anyway. How did that compare with your week?"
Watch for: the word "doctor" was flagged by refugee users as a possible negative trigger [source: Burchert 2019]; story felt too long or repetitive for some [source: Burchert 2019].

A4. Psychoeducation about depression (Session 1 "Get started")

Purpose: explain what depression is, normalise it and introduce the idea that doing small things can lift mood. The same page of psychoeducation was used as the control condition in the Lebanon trials [source: Carswell 2018; Cuijpers 2022]. In the Filipino adaptation's session table, Session 1 explains that adversity can lower mood and cause physical symptoms, links actions, mood and the body, and ends by asking the user to try one activity that might help [source: SbS-F protocol, Table 5].
Steps for the helper [synthesis]: (1) Ask what the user took from the explanation. (2) Check they understand the link between withdrawing from activity and feeling worse. (3) Correct misunderstandings simply (weakness, blame). (4) Move to the activity task.
Example language (illustrative): "Many people find that when they feel low they stop doing things, and then feel even lower. This week is about gently reversing that."
Watch for: shame or stigma about the label "depression"; the Lebanon adaptation made content deliberately non-pathologising [source: Burchert 2024].

A5. Trying small pleasant activities (Session 1)

Purpose: get the user doing a few small, easy, enjoyable activities in the first week [source: Carswell 2018].
Steps [synthesis on detail]: (1) User picks one or a few small activities they used to enjoy or could enjoy now. (2) Makes each small enough to do even on a bad day. (3) Plans when. (4) Does it and notes mood before and after in the toolbox or mood tracker. (5) Helper reviews at next contact.
Example language (illustrative): "What's one small thing you could do this week that might give you even a little enjoyment? Something that takes ten minutes is fine."
Watch for: choosing tasks that are too big; "I did it but felt nothing" (praise doing it; pleasure often lags) [synthesis].

A6. Behavioural activation and activity planning (Session 2 "Get active")

Purpose: the central technique: schedule and carry out more rewarding and meaningful activities to break the cycle of inactivity and low mood [source: Carswell 2018; Cuijpers 2022]. The refugee app included a planner with notifications [source: Burchert 2024].
Steps [synthesis on detail]: (1) Review last week's activities and mood ratings. (2) Choose activities: some enjoyable, some that give a sense of achievement or that matter to the user. (3) Schedule specific days and times in the planner and turn on reminders. (4) Do them regardless of mood. (5) Record mood before and after. (6) Next week, keep what helped and add a little more.
Example language (illustrative): "Let's put it in the planner for a specific day and time. When the reminder pops up, the idea is to do it even if you don't feel like it."
Watch for: working: more activity entries and gradually improving daily mood ratings. Not working: planned but not done (go smaller, check obstacles; Session 3 skills).

A7. Breaking down harder activities and beating obstacles (Session 3 "Beat obstacles")

Purpose: "more complex" activation: tackle activities that feel difficult or that the user has been avoiding, and handle the anxiety that stops them [source: Carswell 2018; SbS-F protocol table].
Steps [synthesis]: (1) Name the activity being avoided. (2) Break it into smaller steps. (3) Start with the easiest step. (4) Use a stress-management technique (A8) just before or during the step. (5) Record and review.
Example language (illustrative): "Calling about that form feels like too much. What would the very first small part be? Maybe just finding the phone number?"
Watch for: avoidance driven by real external barriers (money, safety, legal status) rather than mood; problem management was removed from SbS, so refer such problems to practical services [source: Carswell 2018 for the removal; synthesis for the response].

A8. Stress management: slow breathing and a second technique

Purpose: reduce stress and the anxiety that blocks activities; taught alongside harder activation in Session 3 and available as a stand-alone exercise; a relaxation exercise also appears in the introduction (pilot) and slow breathing appeared at onboarding in the refugee prototype [source: Carswell 2018; Burchert 2019; Harper Shehadeh 2020]. The Filipino adaptation's Session 3 addresses anxiety, teaches slow breathing and has users practise relaxation before planning a complex activity in steps [source: SbS-F protocol, Table 5]. The Lebanon protocol names "2 stress management techniques" without naming them, and elsewhere refers to "a stress reduction exercise and cognitive coping strategies" [source: van 't Hof 2021]. Only slow breathing is named in the cited sources; the second technique is not identified (it is presumably described in the WHO web annex) [uncertain]. Do not assume it is grounding or muscle relaxation.
Steps for slow breathing [synthesis, generic practice, not the WHO script]: (1) Sit comfortably, feet on the floor. (2) Breathe out fully. (3) Breathe in gently through the nose for a slow count. (4) Breathe out more slowly than the in-breath. (5) Repeat for a few minutes, keeping the breath relaxed rather than deep or forced. (6) Use it before a planned hard activity and whenever stress rises; log use in the toolbox.
Example language (illustrative): "The aim isn't big breaths, it's slow ones, especially a long, easy breath out. Try it for two minutes before you make that phone call."
Watch for: dizziness or tingling from over-breathing (slow down, breathe less deeply); breathing focus increasing panic in some people (open eyes, shorten practice) [synthesis]. Working: user reports using it before activities and feeling a bit calmer.

A9. Gratitude exercise

Purpose: a gratitude exercise is confirmed as a programme component by the trial protocol ("a gratitude and positive self-talk exercise") and by WHO's description of the trial version [source: van 't Hof 2021; Cuijpers 2022; WHO EMRO news page]. Its exact form and the session in which it appears are not described in the cited sources [uncertain]; the helper steps below are [synthesis].
Steps for the helper [synthesis]: (1) Ask whether the user did the exercise. (2) Ask for one example they recorded. (3) Encourage brief regular repetition if it helped.
Example language (illustrative): "What was one thing you noticed this week that you felt thankful for, however small?"
Watch for: users who find gratitude invalidating amid real hardship; acknowledge the hardship first, then keep the exercise optional [synthesis].

A10. Positive self-talk

Purpose: counter discouraging self-statements that sap motivation, using kinder, encouraging statements. Positive self-talk is confirmed as a programme component by the trial protocol, WHO's trial news page and the Lebanese public app description [source: Carswell 2018; van 't Hof 2021; WHO EMRO news page; Step by Step app listing]; the protocol also refers to "cognitive coping strategies" [source: van 't Hof 2021]. In the Filipino adaptation it sits in Session 3: the session discusses self-criticism and self-affirming statements, and users write positive self-talk as if speaking to a friend; Session 4 then applies it, with stepwise activities and relaxation, to social activities [source: SbS-F protocol, Table 5]. The Lebanon version's exact in-app wording is not reproduced here [uncertain].
Steps for the helper [synthesis]: (1) Ask what the user tends to say to themselves when they don't manage an activity. (2) Ask what they would say to a friend in the same position. (3) Help them write one short, believable encouraging phrase to use before or after activities.
Example language (illustrative): "If a friend said they'd only managed half of their plan, what would you tell them? Could you say that to yourself?"
Watch for: statements that are unbelievable or forced (make them more modest and realistic) [synthesis]. Do not extend this into formal cognitive restructuring; it is not part of SbS as described [synthesis].

A11. Increasing social support (Session 4 "Get together")

Purpose: help the user reconnect with people and get emotional or practical support [source: Carswell 2018; SbS-F protocol table].
Steps [synthesis on detail]: (1) Identify people the user trusts or used to see. (2) Identify the kind of support needed (company, someone to talk to, practical help, information). (3) Plan one small contact (a message, a call, a visit, joining a group or community activity). (4) Do it and record how it went. (5) Review and plan the next one.
Example language (illustrative): "Who is one person you've been out of touch with but might be glad to hear from? What's the smallest way to reach out this week?"
Watch for: people who are isolated, displaced or have no safe contacts (suggest community or organisational supports); unsafe relationships, including possible gender-based violence, which triggers the risk protocol (B3) [source: Cuijpers 2022 for GBV protocol; synthesis for the rest].

A12. Relapse prevention (Session 5 "Keep it up")

Purpose: consolidate the skills and plan for future low periods; this session largely revisits earlier techniques [source: Carswell 2018; Burchert 2024]. In the Filipino adaptation, users reflect on their progress, are encouraged to accept that mood goes up and down, identify their personal warning signs of worsening mood, and save their activity entries [source: SbS-F protocol, Table 5].
Steps [synthesis on detail]: (1) Review which techniques helped most. (2) Identify personal early warning signs of low mood. (3) Make a plan: which activities, breathing and contacts to use when signs appear. (4) Identify where to seek further help if mood drops badly. (5) Keep the toolbox accessible after the programme.
Example language (illustrative): "Looking back over the five weeks, what made the most difference? If you notice yourself slipping back, what's your first step?"
Watch for: only about one in five Lebanon intervention users completed Session 5 [source: Cuijpers 2022], so cover relapse ideas briefly in earlier helper contacts too [synthesis].

A13. Mood tracking and the toolbox

Purpose: self-monitoring and practice log. Users rate mood daily on a 5-point scale and record exercise practice and feedback in an interactive toolbox; past exercises remain available. Exercises can accept text, audio or photo input [source: van 't Hof 2021; Cuijpers 2022; Burchert 2019]. Weekly brief distress scores (PHQ-4 in Lebanon) are taken through the story character and shown to helpers [source: Carswell 2018; van 't Hof 2021].
Steps for the helper [synthesis]: (1) Check the dashboard before each contact. (2) Ask permission before discussing entries (B1). (3) Link mood changes to activities done.
Example language (illustrative): "I see your mood ratings were a bit better on the days you went to your sister's. Did you notice that too?"
Watch for: no entries (practice not happening, or technical problems); a worsening weekly category (B4).

Part B. Helper and service components

B1. Weekly guidance contact (standard guided model)

Purpose: brief technical and emotional support to keep motivation up; the content stays in the app. Sourced elements: review the previous session, discuss practice of skills, encourage, use basic helping skills, help with using the system, direct to other local support [source: Carswell 2018; van 't Hof 2021; Cuijpers 2022]. In the pilot, support was described as technical help, motivational support and clinical support such as simple problem solving and troubleshooting of the exercises [source: Harper Shehadeh 2020]. The Lebanese public app describes the e-helper's role as encouragement to engage with the self-help material only, about 15 minutes a week, and not a replacement for treatment [source: Step by Step app listing]. Up to 15 minutes a week (15 to 20 in the 2018 description and pilot), by phone, synchronous messaging or secure email. Trial helpers worked from a manual with session-by-session contact outlines [source: van 't Hof 2021; uncertain on content].
Steps (a contact structure built from the sourced elements; the order is [synthesis]): (1) Check the dashboard: sessions done, mood entries, weekly score and any flag. (2) Greet, confirm it is a good and private time to talk, state the time available. (3) Brief check on wellbeing and safety if the score has risen. (4) Review the story: what happened and what the character learned. (5) Review practice: what was tried, what helped, what got in the way. (6) Problem-solve barriers to using the programme (time, phone, login, motivation); keep advice within SbS techniques. (7) Encourage and agree what to do before next contact (next session, specific activities). (8) Close, confirm next contact time and how to get help in between. (9) Record the contact, note any adverse event, raise concerns with the supervisor.
Example language (illustrative): "Hi, it's [name] from Step-by-Step. Is now still a good time for our ten-minute check-in? … What stood out from this week's part of the story? … Which activity did you manage? … What would help you start Session 3 this week?"
Watch for: contacts drifting into counselling or repeated long calls (bring back to the programme, discuss with supervisor); skipping review of story or practice, the commonest fidelity deviation [source: Cuijpers 2022]. Working: user completes about one session a week and reports activities between contacts.

B2. Contact-on-demand (self-guided variant)

Purpose: lighter guidance in which the user initiates contact. In the Egypt trial, in-app asynchronous messages were answered within 48 hours, mainly about technical and practical matters; the user chose a topic (question about SbS, motivation, technical, research, other); helpers used a decision-tree of standard replies, signed with a gender-neutral pseudonym, could refer, and agreed any new topic with the study team first [source: Burchert 2024]. Focus groups had found 48 hours too long [source: Burchert 2019].
Steps [source: Burchert 2024; synthesis for order]: (1) Triage the message by topic and for any risk content. (2) Reply using the agreed response bank. (3) Escalate anything clinical or new to the supervisor. (4) Reply within the promised time.
Example language (illustrative): "Thanks for your message. If the session won't load, try opening it while on Wi-Fi; it will then work offline. If it still doesn't work, tell me what phone you use."
Watch for: very low use (only 9.4% of Egypt users used it, median one contact) [source: Burchert 2024]; if you need engagement, use scheduled weekly contact instead [synthesis].

B3. Risk identification and management protocol

Purpose: helpers identify, assess, manage and report risk and adverse events to the clinical supervisor; preset protocols covered high suicide risk, child abuse, gender-based violence and acute distress [source: Carswell 2018; Cuijpers 2022]. In Lebanon, helpers followed local pathways and laws for disclosed plans or serious protection concerns; serious adverse events were reported within 24 hours on working days and other adverse events within 2 business days [source: van 't Hof 2021].
Steps [source as above; detail is synthesis]: (1) Listen for and ask directly about suicidal thoughts, plans or harm to or from others when distress rises or is disclosed. (2) If present, stay with the person, follow the service protocol, give emergency and crisis line contacts, and contact the supervisor the same day (immediately if imminent). (3) For child protection or gender-based violence disclosures, follow the local mandatory reporting and referral pathway, putting the person's safety first. (4) Document and report as an adverse event within the required time. (5) Supervisor decides whether SbS continues or the person moves to more intensive care.
Example language (illustrative): "You said you've been feeling there's no point going on. Sometimes when people feel like that they think about ending their life. Has that been happening for you?"
Watch for: disclosures in written messages that arrive out of hours; agree in advance how these are monitored and what auto-reply gives crisis numbers [synthesis]. Lethal-means counselling, if needed, is for a qualified clinician (secure or remove means; no method detail) [synthesis].

B4. Progress monitoring and deterioration flags

Purpose: catch worsening early. A clinical dashboard shows helpers and supervisors each user's progress including weekly distress scores; in Lebanon the system flagged users whose PHQ-4 category worsened (mild to moderate, or moderate to severe) [source: Carswell 2018; van 't Hof 2021].
Steps [synthesis]: (1) Check flags before each contact. (2) For a flagged user, raise it gently, ask about life events and safety, and discuss with the supervisor. (3) Agree with the supervisor whether to continue, add support or refer.
Example language (illustrative): "Your answers this week suggest things have been harder. Can you tell me what's been going on?"
Watch for: no improvement after several sessions (review fit; consider PM+, face-to-face BA or specialist care) [synthesis].

B5. Referral and signposting

Purpose: helpers direct users to other local support; trials gave all participants a list of primary health facilities with mhGAP-trained staff and crisis lines [source: Carswell 2018; van 't Hof 2021; Cuijpers 2022]. Users with severe problems asked for a referral route and access to a real person [source: Burchert 2019].
Steps [synthesis]: (1) Keep an up-to-date local list (primary care mental health, crisis line, protection, social and legal services). (2) Refer when needs are outside SbS (severe depression, risk, psychosis, substance problems, practical crises). (3) Follow up that the referral happened.
Example language (illustrative): "What you're dealing with with housing is really important, and it's more than this programme can help with. Can I give you the number of a service that can?"
Watch for: referral used to end contact with someone difficult rather than for their benefit [synthesis].

B6. Helper training, supervision and fidelity monitoring

Purpose: safe delivery by non-specialists. Training of about 4.5 to 6 days covering depression and other mental health problems, the intervention, guiding users, crisis identification, adverse events and consent, followed by a competency test; weekly clinical supervision (group in Lebanon, plus individual on demand) by a qualified clinician; a fidelity checklist applied to about 5% of calls or messages [source: Carswell 2018; van 't Hof 2021; Cuijpers 2022].
Steps for a clinician supervisor [synthesis on structure]: (1) Review flagged and risk cases first. (2) Listen to or read a sample of contacts against the fidelity checklist. (3) Give specific feedback (reviewed story? reviewed practice? kept to time? encouraged?). (4) Discuss helper wellbeing and boundaries. (5) Record decisions.
Example language (illustrative): "In this call you did a great job encouraging her. Next time, ask about the story and the practice before moving to solutions."
Watch for: helper drift into therapy, over-involvement, or secondary distress [synthesis].

B7. Cultural and contextual adaptation

Purpose: make the programme relatable and usable in a new population. Sourced steps: formative research with the target groups (Lebanon involved Lebanese, Syrian and Palestinian input; refugee app used user-centred design with focus groups and usability testing), changing the story's characters, dress, life-stage storylines and helper character, using the local dialect (Levantine Arabic was preferred to formal Arabic), keeping tailoring broad and avoiding specific events, and recruiting an illustrator and programmer; versions exist for Filipino, Chinese and Albanian populations among others [source: Carswell 2018; Burchert 2019, 2024; SbS-F protocol table].
Steps [synthesis on order]: (1) Talk with future users and local stakeholders. (2) Test understanding of text and images (cognitive interviewing). (3) Revise language, characters and examples. (4) Usability-test the app. (5) Keep the core story structure and techniques unchanged.
Example language: not applicable.
Watch for: users found early versions long, repetitive, childish-looking or strictly linear; wanted adjustable font sizes and more languages [source: Burchert 2019].

B8. Non-digital formats

Purpose: reach people without devices. The authors state SbS can be delivered as a book, video or face-to-face guide as long as the core story and activities stay constant [source: Carswell 2018]. WHO's 2026 manual gives guidance and tools for delivering self-help through digital platforms, printed materials and video, guided or unguided, with scripts and materials for the guided versions [source: WHO 9789240120785 publication page]; its specific rules for print and video delivery are not reproduced here [uncertain].
Steps [synthesis]: use the same session order, one session a week, with the same weekly brief helper contact.
Watch for: drifting into a different therapy when delivered face to face; keep to the programme content [synthesis].

5. Handling problems

What the sources report: very high attrition is the main problem. In the Lebanon trial 60% of the intervention group finished the introduction, and session completion fell from 40% (Session 1) to 19% (Session 5); people who dropped out cited technical problems (Wi-Fi, phones, login details), changed life circumstances and competing priorities [source: Cuijpers 2022]. Refugee users found content long and repetitive, disliked strict linearity, and wanted human contact and referral for severe cases [source: Burchert 2019]. The sources give little concrete guidance on responses; most responses below are therefore [synthesis].

Never finishes registration or the introduction. Contact early (within the first week) by the user's preferred channel; walk through login by phone; offer audio; set a specific time to do the introduction together or straight after the call [synthesis].
Stops between sessions (most common). Make the next step tiny ("just open the first part of Session 2"); remind that parts can be done over several days [source: Cuijpers 2022 for split sessions]; agree a day and time; send one reminder; after two missed contacts, send a warm message leaving the door open and stating how to restart [synthesis].
Technical barriers. Download on Wi-Fi and use offline; reset login details; switch between app and web; for no device or data, consider the print or face-to-face format [source: Carswell 2018; Burchert 2019; synthesis].
Content feels long, boring or not relevant. Acknowledge it; focus on the exercise rather than every slide; link the story to the user's life; point out that Session 5 mostly repeats skills already learned [source: Burchert 2019, 2024 for the problem; synthesis for response].
Not doing practice (non-adherence). Ask what got in the way without blame; shrink the activity; tie it to a daily routine; use the planner reminder; use positive self-talk about partial success [synthesis].
Activities done but no mood change (stuck). Explain that doing often comes before feeling better; check activity mix (pleasure and achievement, meaningful to the user); check for hidden avoidance; if mood is unchanged or worse after about three sessions, discuss with the supervisor and consider stepping up [synthesis].
Overwhelm or acute distress in a contact. Slow down, listen, use slow breathing together, postpone programme review, check safety; follow the acute-distress protocol and inform the supervisor [source: Cuijpers 2022 for protocol existence; synthesis for steps].
Risk disclosure (suicide, child abuse, gender-based violence). Follow B3 immediately; do not continue routine programme review in that contact [source: Cuijpers 2022; van 't Hof 2021].
Wants more than the helper can give ("I need a real therapist"). Validate; explain the helper's role honestly; refer via B5 while encouraging continued use if helpful [source: Burchert 2019 for the request; synthesis].
Overwhelming practical problems (money, housing, legal status, safety). SbS has no problem-management module; acknowledge, refer to practical services or consider PM+ (which includes problem management), and adjust activities to what is possible now [source: Carswell 2018; synthesis].
Rupture or mistrust (e.g. worry about privacy, who reads entries, a pseudonymous helper). Explain who sees what data and why; ask before discussing entries; apologise for any misunderstanding and agree how to continue [source: Burchert 2019 on privacy preference; synthesis].
Story or character feels alienating ("doctor" trigger, unfamiliar life situation). Switch character or storyline if possible; stress the skills over the story details [source: Burchert 2019; synthesis].
Helper boundary problems (calls running long, personal contact, rescuing). Keep to the 15-minute frame; use supervision; no personal phone numbers or social media [synthesis].
Clinician offering SbS within therapy. Use it as a low-intensity step or between-session support; avoid duplicating content in sessions; review progress at each appointment; step up if no response [synthesis].
Contraindications to consider (not specified as such in the cited sources). Imminent suicide risk (excluded in trials), and by clinical judgement severe depression with marked impairment, psychosis, mania, severe substance use or cognitive impairment that prevents self-help, and unsafe living situations where an app on the phone could be seen by an abuser [source: van 't Hof 2021 for suicide exclusion; synthesis for the rest].

Sources

Main sources:

Further references (not the basis of specific steps): Heim et al. 2021 feasibility RCT (Internet Interventions); WHO Thailand feature story on Step-by-Step; WHO news item of 17 June 2026 on Step-by-Step as a humanitarian innovation.

Works cited:

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. Geneva: WHO. ISBN 978-92-4-012078-5. CC BY-NC-SA 3.0 IGO. With web annex: Step-by-Step: a self-help intervention for depression (WHO reference B09738). Cited via the WHO publication pages; the manual and annex texts are not used for specific steps [uncertain].
Carswell K, Harper-Shehadeh M, Watts S, et al. (2018). Step-by-Step: a new WHO digital mental health intervention for depression. mHealth, 4:34.

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