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Developing the evidence base for peer-led services: Changes among participants following Wellness Recovery Action Planning (WRAP) Education in two statewide initiatives

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Abstract

The purpose of this analysis was to evaluate the outcomes of two statewide initiatives in Vermont and Minnesota, in which self-management of mental illness was taught by peers to people in mental health recovery using Wellness Recovery Action Planning (WRAP). Pre-post comparisons were made of reports from 381 participants (147 in Vermont and 234 in Minnesota) on a survey instrument that assessed three dimensions of self-management: 1) attitudes, such as hope for recovery and responsibility for one's own wellness; 2) knowledge, regarding topics such as early warning signs of decompensation and symptom triggers; and 3) skills, such as identification of a social support network and use of wellness tools. Significant positive changes in self-management attitudes, skills and behaviors were observed on 76% of items completed by Vermont participants (13 of 17 survey items), and 85% of items completed by Minnesota participants (11 of 13 items). In both states, participants reported significant increases in: 1) their hopefulness for their own recovery; 2) awareness of their own early warning signs of decompensation; 3) use of wellness tools in their daily routine; 4) awareness of their own symptom triggers; 5) having a crisis plan in place; 6) having a plan for dealing with symptoms; 7) having a social support system; and 8) ability to take responsibility for their own wellness. Given the rapid growth of this intervention in the U.S. and internationally, these results contribute to the evidence base for peer-led services, and suggest that more rigorous investigations are warranted in the future.
Developing the Evidence Base
for Peer-Led Services: Changes
among Participants following
Wellness Recovery Action
Planning (WRAP) Education in
Two Statewide Initiatives
t
Judith A. Cook
University of Illinois at Chicago
Mary Ellen Copeland
Mental Health Recovery and WRAP, Inc.,
Dummerston, VT
Linda Corey
Vermont Psychiatric Survivors, Inc.,
Rutland, VT
Erica Buffington
St. Louis Park, MN
Jessica A. Jonikas
University of Illinois at Chicago
Laurie C. Curtis
Advocates for Human Potential, Inc.,
Montpelier, VT
Dennis D. Grey
University of Illinois at Chicago
William H. Nichols
Vermont Department of Mental Health,
Waterbury, VT
Acknowledgements:
This research is funded by the U.S. Department
of Education, National Institute on Disability
and Rehabilitation Research; and the Substance
Abuse and Mental Health Services
Administration, Center for Mental Health
Services and Consumer Affairs Program, under
Cooperative Agreement No. H133B050003. The
views expressed do not reflect the policy or
position of any Federal agency. The authors of
this study would like to acknowledge the fol-
lowing for their support of the Vermont
Recovery Education project: Beth Tanzman,
Susan Foster, Jane Winterling, Martha Roberts,
Joan Knight, the Van Ameringen Foundation, the
Vermont Department of Mental Health, and the
Vermont Mental Health Performance Indicator
Project (John A. Pandiani, PhD, Director). The
Vermont Wellness Recovery Action Plan Project
was funded by the Substance Abuse and Mental
Health Services Administration, Center for
Mental Health Services and Consumer Affairs
Program, under Grant No. SM03-007. The
Minnesota Wellness Recovery Action Plan
Project was funded by the Community Action
Grant Program of the Substance Abuse and
Mental Health Services Administration, Center
for Mental Health Services under Grant No. 1
Objective: The purpose of this analysis was to evaluate the outcomes of two
statewide initiatives in Vermont and Minnesota, in which self-management of
mental illness was taught by peers to people in mental health recovery using
Wellness Recovery Action Planning (WRAP). Methods: Pre-post comparisons were
made of reports from 381 participants (147 in Vermont and 234 in Minnesota) on a
survey instrument that assessed three dimensions of self-management: 1) atti-
tudes, such as hope for recovery and responsibility for one’s own wellness; 2)
knowledge, regarding topics such as early warning signs of decompensation and
symptom triggers; and 3) skills, such as identification of a social support network
and use of wellness tools. Results: Significant positive changes in self-manage-
ment attitudes, skills and behaviors were observed on 76% of items completed by
Vermont participants (13 of 17 survey items), and 85% of items completed by
Minnesota participants (11 of 13 items). In both states, participants reported sig-
nificant increases in: 1) their hopefulness for their own recovery; 2) awareness of
their own early warning signs of decompensation; 3) use of wellness tools in their
daily routine; 4) awareness of their own symptom triggers; 5) having a crisis plan
in place; 6) having a plan for dealing with symptoms; 7) having a social support
system; and 8) ability to take responsibility for their own wellness. Conclusions:
Given the rapid growth of this intervention in the U.S. and internationally, these
results contribute to the evidence base for peer-led services, and suggest that
more rigorous investigations are warranted in the future.
Keywords: illness management, recovery, peer support, program evaluation
Introduction
The notion that peers can teach other
peers skills, attitudes, and behaviors
that enable them to self-manage their
mental illness is not widely accepted.
Only with the adoption of a recovery
paradigm in the field of public mental
health has a national context existed
for the formal development and testing
of these kinds of programs. This article
describes the collaboration between an
academic research center, a nationally-
recognized recovery educator, and two
statewide consumer organizations to
develop the evidence base for self-
management of mental health well-
ness. The model under study is
Wellness Recovery Action Planning™
or WRAP. In this article, we describe
WRAP’s content and active ingredients,
113
Psychiatric Rehabilitation Journal
2010, Volume 34, No. 2, 113–120
Copyright 2010 Trustees of Boston University
DOI: 10.2975/34.2.2010.113.120
special section
Ps y c h i a t r i c R eh a b i l itat i o n Jo u r n a l Developing the Evidence Base for Peer-Led Services
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article
how individuals are trained and certi-
fied to teach it, and how we used eval-
uations of two statewide WRAP
initiatives to advance the state of the
science in peer-led interventions, with
the hope of empirically supporting and
thereby encouraging WRAP’s dissemi-
nation and widespread adoption.
Review of the Literature
Chronic Illness Self-Management.
Illness self-management programs for
individuals with chronic medical condi-
tions such as arthritis, diabetes, can-
cer, and asthma are an important
component of patient-centered medical
care as defined by the Institute of
Medicine’s “Crossing the Quality
Chasm” report (Institute of Medicine,
2001). Use of structured techniques for
managing illness symptoms and ongo-
ing self-assessment and self-monitor-
ing are considered active ingredients
of behavior change in this type of inter-
vention. Lorig and colleagues (1999,
2001) used random assignment to eval-
uate a self-management program for
patients with chronic medical condi-
tions taught by trained volunteer lay
leaders (71% of whom had chronic ill-
nesses themselves) that included the
following topics: use of medications;
dealing with fear, anger and depres-
sion; communicating with health pro-
fessionals; problem solving;
decision-making; exercise; nutrition;
fatigue and sleep management; cogni-
tive symptom management; and use of
community resources. Groups of 10-15
participants of diverse ages and med-
ical conditions (i.e., heart disease,
stroke, lung disease, and arthritis) par-
ticipated in the training over seven
weekly 2 and ½ hour sessions.
Compared to controls, treatment sub-
jects demonstrated improvements in
weekly minutes of exercise, frequency
of cognitive symptom management
strategies, communication with physi-
cians, and self-reported health. Also
observed were reductions in health
exercising, praying/meditating, engag-
ing in creative endeavors, practicing
good nutrition, and self-advocacy
(Copeland, 2001).
Building on these early findings, men-
tal illness self-management programs
have been developed to impart infor-
mation, teach recovery skills, provide
emotional support, and enhance em-
powerment and self-advocacy (Anzai et
al., 2002; Lawn et al., 2007). For exam-
ple, the Taking Charge program, based
on the self-help tenets of Recovery,
Inc., is a series of weekly classes in
which participants learn cognitive-be-
havioral techniques for dealing with
conflict and tension, symptom man-
agement skills to build self-esteem and
reduce inner turmoil, and emotional
wellness tools to regain a sense of con-
trol over one’s life (VanSickle, 1996).
Another example is the Illness
Management and Recovery program
that consists of weekly sessions where
people with a mental illness learn
structured problem solving, develop
personalized strategies for managing
their symptoms, build social support
systems, set personal goals, and de-
velop plans for moving forward in their
lives (Gingerich & Mueser, 2005).
In addition to the foregoing self-man-
agement programs, Wellness Recovery
Action Planning™ (WRAP) is probably
the most widely disseminated in the
U.S. (Roberts & Wolfson, 2004). WRAP
is a program in which participants
identify internal and external resources
for facilitating recovery, and then use
these tools to create their own, individ-
ualized plan for successful living
(Copeland, 1997). The principles and
practice of WRAP were laid out in its
first formal publication in 1997 and,
since then, WRAP has been taught to
tens of thousands of consumers and
providers, nationally and international-
ly (Copeland, 2001). The typical WRAP
series lasts for 8-10 weeks with weekly
distress, fatigue, disability, and social
limitations, as well as fewer inpatient
admissions and days hospitalized.
Compared to baseline, at both one and
two years post-training, treated sub-
jects reported fewer Emergency Room
and outpatient visits, reduced health
distress, and greater self-efficacy, indi-
cating that the effects of illness self-
management training persisted over
time. In a review article of illness self-
management clinical trials for arthritis,
diabetes, asthma, and mixed chronic
conditions, Bodenheimer and col-
leagues (2002) conclude that patient
education programs teaching self-man-
agement skills produce superior out-
comes to programs teaching medical
information alone. Therefore, enough
randomized controlled trial research
evidence exists to warrant classifying
these programs as an evidence-based
practice intervention.
Self-Management of Mental Health
Recovery. A small number of programs
dealing with mental illness self-man-
agement (Mueser et al., 2002) are
highly similar in their philosophy and
intended outcomes to those used in
the foregoing studies, with an addi-
tional focus on recovery. Although the
concept of mental health recovery is
relatively new (Deegan, 1988), people
with mental health difficulties have
been self-managing and functioning in
the community long before the idea of
recovery became popularized (Eldred,
Brooks, Deane & Taylor, 1962; Harding,
Brooks, Ashikaga, Strauss & Breier,
1987). Studies show that self-manage-
ment—or a person’s determination to
get better, manage the illness, take ac-
tion, face problems, and make choic-
es—facilitates recovery from mental
illnesses (Allott, Loganathan & Fulford,
2002). Self-managed care strategies
are as varied as people themselves,
but some common techniques include
writing down or talking about prob-
lems, speaking with or visiting friends,
fa l l 2 0 1 0— V o l u m e 34 N u m b er 2
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symptoms, and advance crisis
planning.
Methods
The Statewide Initiatives
In 1997, a peer-led organization named
Vermont Psychiatric Survivors (VPS) re-
ceived a grant from the Henry van
Ameringen Foundation to establish the
Vermont Recovery Education Project in
partnership with the Vermont DMH
(VPS, 2000). As part of this initiative,
WRAP education was delivered across
the state of Vermont and northern
Massachusetts over the next three
years.
In 2002, the Minnesota
Consumer/Survivor Network received a
Community Action Grant from the
Center for Mental Health Services of
the Substance Abuse and Mental
Health Services Administration
(Buffington, 2003). The purpose of this
grant was to deliver WRAP education
and educator training to people in re-
covery around the state. Another objec-
tive was to engage in a two-year
consensus building process to encour-
age the adoption of WRAP as an exem-
plary practice by stakeholder groups in
diverse communities.
Sample
Data were gathered from 147 partici-
pants in the Vermont initiative who
identified themselves as “consumers
or survivors of psychiatric services”
and completed both a WRAP pretest
and the posttest, for a response rate of
44 percent. Almost three-quarters of
the Vermont participants (73%) were
female and they ranged in age from 19
to 81 years of age, with 15% reporting
ages of 18-30 years, 29% age 31-40,
34% age 41-50, and 22% age 51 or
older. The second group of participants
was comprised of 305 individuals in
Minnesota who self-identified as men-
tal health service consumers and par-
sessions of 1-2 hour group education.
Topics include: Introduction to WRAP
Principles, Developing a Wellness
Toolbox, Creating a Daily Maintenance
Plan, Identifying Triggers, Identifying
Early Warning Signs, Managing When
Things Break Down, and Crisis
Planning. Coursework is interactive,
using lecture, group discussion, elicita-
tion of personal examples from the
lives of educators and participants,
and individual or group exercises. At
the first session, participants receive
an empty WRAP binder to hold hand-
outs and daily exercises completed at
each meeting. Over time this binder
comes to constitute the individual’s
personalized WRAP plan. Between ses-
sions, participants are encouraged to
work on their WRAP plan by adding
new material and observations that
grow out of voluntary “homework” ex-
ercises and daily plan use.
WRAP graduates who are actively using
their own WRAP plan and who elect to
participate in an intensive 5-day train-
ing from the Copeland Center for
Wellness and Recovery can earn a
Mental Health Recovery Educator cer-
tificate. This qualifies them to lead
WRAP groups on their own. Once certi-
fied, WRAP educators are encouraged
to attend an annual conference spon-
sored by the Copeland Center to up-
date their WRAP knowledge base and
facilitator skills.
While the growth of WRAP has been im-
pressive, only one published study has
examined outcomes reported by partic-
ipants. In research involving 80 indi-
viduals in Ohio who completed eight
two-and-one-half-hour sessions of
WRAP (Cook et al., 2009), paired t-tests
of pre- and post-intervention scores re-
vealed significant improvement in self-
reported symptoms, recovery,
hopefulness, self-advocacy, and physi-
cal health. The next step in building an
evidence base for WRAP’s effectiveness
is to explore what happens when it is
introduced on a large scale, such as
across an entire state in multiple re-
gions and local communities. The
question at this stage of knowledge de-
velopment is whether participants in
such broad initiatives experience the
same positive changes in recovery atti-
tudes, skills, and behaviors as those
reported by participants in individual
WRAP groups.
To explore these questions and add to
the body of knowledge in this area, re-
searchers from the National Research
and Training Center on Psychiatric
Disability, located at the University of
Illinois at Chicago (UIC), teamed with
Dr. Mary Ellen Copeland, co-creator of
WRAP, and the leadership of two
statewide consumer organizations:
Vermont Psychiatric Survivors, and the
Minnesota Consumer/Survivor
Network. Working together, this group
identified data sets that had been col-
lected to evaluate each of the state’s
WRAP initiatives and explored similari-
ties and differences in data elements
and evaluation design. Additional part-
ners in the evaluation of Vermont’s ini-
tiative—the Vermont Department of
Mental Health (DMH) and the graduate
program in Social Work at the
University of Vermont—were also invit-
ed to join in the collaborative effort.
Working together, the group decided to
focus on changes in specific attitudes
and behaviors that were measured in
common by both states, as well as
changes in areas that were studied in
one state but not the other. The study’s
overarching hypothesis was that, com-
pared to their self-reported attitudes
and behaviors prior to participation,
those who completed WRAP education
would show significant increases in
knowledge, behavior, and attitudes re-
lated to recovery, self-management of
Ps y c h i a t r i c R eh a b i l itat i o n Jo u r n a l Developing the Evidence Base for Peer-Led Services
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ticipated in a WRAP education series.
Of these 305 individuals, 234 complet-
ed both the pretest and posttest, for a
response rate of 77%. Among the 234
Minnesota respondents, 60% were fe-
male; 70% were Caucasian, 14% Native
American, 6% African American, 6%
Hispanic, and 4% Asian. They ranged
in age from 18-61+ years with 17% aged
18-30 years, 24% aged 31-40 years,
31% 41-50 years, and 27% 51 years or
older.
Intervention
Vermont. In Vermont, forty hours of
WRAP education was delivered to
groups of 15-20 individuals in twenty-
one separate cycles from July 1997
through January 2000. Two educators
taught each cycle; one was an individ-
ual with a psychiatric disability and the
other a community mental health staff
member (in some instances the com-
munity mental health staff had also ex-
perienced a mental illness). The forty
hours were structured as either: 1) two
hours per week for twenty weeks; 2)
one hour a week for forty weeks; or 3)
one six-hour day per week for seven
weeks. Each cycle covered the follow-
ing topics: recovery concepts such as
hope, responsibility, self-advocacy, ed-
ucation and support; medical care and
health management; how to develop
and use various support systems; de-
veloping a healthy lifestyle; suicide
prevention; beginning steps to dealing
with trauma; and the development of a
personal WRAP plan. The Vermont
WRAP cycles were taught in urban,
rural, and suburban areas of the state.
Minnesota. WRAP education in
Minnesota involved a total of sixteen
hours delivered in eight, two-hour
classes to groups of 4-15 individuals.
Thus the 16-hour exposure to WRAP in
Minnesota was briefer than the 40-
hour exposure received by Vermont
participants. Altogether, 42 eight-week
classes were held from May 2002
thority administrators, county board
commissioners and board staff, policy
makers, and advocates. Special efforts
were made to reach members of club-
houses and community residences.
Workshops were also presented at
statewide and local consumer confer-
ences. At these meetings, brief presen-
tations were given regarding WRAP
content, a video was shown if time al-
lowed, brochures were distributed, and
question and answer sessions were
held. Participants were recruited from
35 different urban, suburban, and rural
communities around the state of
Minnesota, including one Indian
reservation.
Instruments
In Vermont, a pretest/posttest survey
instrument was designed by the pro-
ject’s workgroup, with assistance from
the graduate program in Social Work at
the University of Vermont. The survey
was piloted during two cycles of WRAP
classes and, based on the results, it
was revised and used to evaluate the
21 remaining cycles. Questions were
focused on respondents’ recovery man-
agement attitudes and abilities, includ-
ing: 1) maintaining hopefulness about
one’s own recovery, 2) identifying early
warning signs and symptom triggers,
3) using coping skills, 4) developing a
crisis plan, 5) taking medications, 6)
identifying support services, 7) self-ad-
vocacy, and 8) using wellness tools.
Respondents used a 4-point Likert-
scale response format with the anchors
of strongly agree, agree, disagree, and
strongly disagree.
The survey instrument used in
Minnesota was designed by the state’s
Mental Health Consumer/Survivor
Network and modeled on the Vermont
survey. It also consisted of a pretest
and posttest questionnaire with 13 re-
peated items asking about the follow-
ing recovery skills and attitudes: 1)
participants’ sense of hopefulness, 2)
through June 2003. Each class was co-
facilitated by two certified WRAP edu-
cators who were both individuals in
mental health recovery. Topics includ-
ed: recovery and the importance of
hopefulness, sources of support, edu-
cation and self-advocacy; medical care
and health management; developing a
Wellness Toolbox and Daily
Maintenance Plan; identifying and re-
sponding to symptom triggers and
early warning signs; handling decom-
pensation; developing a Crisis Plan
and a Post-Crisis Plan; and leading a
wellness-centered lifestyle. Minnesota
WRAP classes were held in diverse re-
gions of the state including urban, sub-
urban, and rural locales, as well as at
an Indian reservation.
Recruitment
In Vermont, participants were recruited
in a variety of ways including clinician
and peer referral, word of mouth, and
advertisements. Clients of community
mental health treatment and rehabilita-
tion programs were encouraged to at-
tend by clinical staff and
administrators. Participants in VPS
self-help groups were also encouraged
to attend WRAP education by support
group leaders and other peers. In many
parts of the state, WRAP cycles were
advertised locally in newspapers,
newsletters, and bulletin board post-
ings. Participants were recruited from
10 urban, suburban, and rural counties
around the state of Vermont and north-
ern Massachusetts and there was no
screening process that eliminated any
individual who wished to attend.
In Minnesota, recruitment involved 45
separate WRAP information meetings
held with stakeholders around the
state including consumers, family
members, community-based clinicians
(psychiatrists, psychologists, social
workers, vocational rehabilitation
counselors), state hospital staff and
administrators, state mental health au-
fa l l 2 0 1 0— V o l u m e 34 N u m b er 2
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Minnesota, pretests and posttests
could not be linked due to the absence
of a unique ID number, making paired
t-tests impossible. Tabulated data,
compiled by Minnesota project staff,
were analyzed by researchers at the
UIC Center using two-tailed t-tests of
differences in proportions between
pretest and posttest. In the final step,
UIC researchers compiled results from
the two evaluations into a single sum-
mary table, matching results from simi-
lar questionnaire items, and separately
reporting results from items that were
unique to each state’s evaluation
instrument.
Results
Pre-Post Changes in Recovery Attitudes.
Significant positive changes in recov-
knowledge about symptom triggers, 3)
awareness of early warning signs, 4)
use of personal support systems, 5) de-
veloping a crisis plan, 6) ability to take
responsibility for one’s own wellness,
and 7) living a recovery oriented
lifestyle. Respondents used a dichoto-
mous “yes/no” response format for
each item.
Procedures
In both states, the pretest/posttest
survey was administered by WRAP edu-
cators at the first session and then
again at the last session using the
same or similarly worded items to
measure changes in attitudes, knowl-
edge, and skills. In both studies, edu-
cators who administered the survey
explained its purpose, answered gen-
eral questions about the evaluation,
and assured participants that it was
completely voluntary and confidential.
Work conducted as part of the present
study was approved by the Institutional
Review Board of the University of
Illinois at Chicago. There are no known
conflicts of interest for any of the au-
thors, and all authors have certified
their responsibility for the manuscript.
Analysis
In Vermont, data were entered and ana-
lyzed using SPSS software by staff of
the Research and Statistics Unit of the
state’s Department of Developmental
and Mental Health Services. Since par-
ticipants’ surveys were linked via an
identification code, it was possible to
examine changes in individual’s pre-
and posttest responses using two-
tailed, paired t-tests of difference. In
Table 1–T-tests of Pre-Post Changes in Wellness Recovery Action Planning (WRAP) Participants’
Self-Reported Attitudes, Behaviors, and Skills Regarding Mental Illness Self-Management
in Vermont and Minnesota Statewide WRAP Initiatives
Vermont Minnesota
Self-Reported Attitudes, Skills, and Behaviors Pretest Posttest t value & nPretest Posttest t value & n
Mean (SD) Mean (SD) significance Mean (SD) Mean (SD) significance
Hopefulness for own recovery 5.10 (1.62) 5.71 (1.37) 4.37*** 126 0.69 (0.46) 0.98 (.14) 3.40*** 234
Awareness of own early warning signs 2.19 (0.76) 2.42 (0.56) 3.07*** 119 0.56 (0.50) 0.94 (0.24) 5.25*** 234
Use of wellness tools in daily routine 4.29 (1.48) 4.88 (1.26) 4.92*** 125 0.58 (0.49) 0.98 (0.14) 4.97*** 234
Awareness of own symptom triggers 1.99 (0.73) 2.33 (0.67) 4.19** 120 0.60 (0.49) 0.85 (0.36) 3.14** 234
Having a crisis plan in place 0.36 (0.48) 0.65 (0.48) 5.81*** 147 0.61 (0.49) 0.99 (0.10) 4.55*** 234
Having crisis plan for symptoms when triggered
0.35 (0.48) 0.67 (0.47) 6.26*** 147 0.68 (0.47) 0.94 (0.24) 3.18*** 234
Having a social support system 0.44 (.050) 0.73 (0.44) 5.72*** 147 0.74 (0.44) 0.95 (0.22) 2.45** 234
Take responsibility for own wellness/advocacy
1.90 (0.88) 2.17 (0.72) 3.87*** 147 0.74 (0.44) 0.98 (0.14) 2.79** 234
Decreased difficulty with crisis plan creation
0.39 (0.49) 0.12 (0.32) 5.69*** 121 Not Asked 234
Preference for support from friends/neighbors
2.23 (0.64) 2.40 (0.57) 2.48* 119 Not Asked 234
Preference for using support from consumers
2.10 (0.66) 2.31 (0.61) 2.90** 111 Not Asked 234
Use of support groups 2.04 (0.90) 2.31 (0.67) 3.90*** 114 Not Asked 234
Comfort obtaining information about services
2.02 (0.90) 2.40 (0.72) 4.61*** 124 Not Asked 234
Managing medications well Not Asked 0.72 (0.45) 0.88 (0.32) 1.96* 234
Having a lifestyle that promotes recovery Not Asked 0.55 (0.50) 0.96 (0.20) 5.11*** 234
Difficulty engaging in recovery activities Not Asked 0.68 (0.47) 0.09 (0.08) 10.27*** 234
*p<.05, **p<.01, ***p<.001
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ery attitudes were observed on 76% of
items completed by Vermont con-
sumers (thirteen of the seventeen sur-
vey items), and 85% of items
completed by Minnesota consumers
(eleven of the thirteen survey ques-
tions). As shown in Table 1, both
groups of WRAP participants reported
significant increases in: 1) their hope-
fulness for their own recovery; 2)
awareness of their own early warning
signs of decompensation; 3) use of
wellness tools in their daily routine; 4)
awareness of their own symptom trig-
gers; 5) having a crisis plan in place; 6)
having a plan for dealing with symp-
toms; 7) having a social support sys-
tem; and 8) ability to take
responsibility for their own wellness.
Among items asked only in Vermont,
WRAP participants reported decreased
difficulty in creating their own crisis
plans, and increases in their: 1) prefer-
ence for using friends and neighbors
as natural/community supports; 2)
preference for support from individuals
who have experienced mental illness;
3) use of support groups; and 4) com-
fort obtaining information about com-
munity services. For items completed
only by Minnesota participants, re-
spondents reported: 1) increased abili-
ty to manage their medications well; 2)
increased recovery-promoting
lifestyles; and 3) decreased difficulty
engaging in recovery-promoting activi-
ties.
In both states, there were some as-
pects of recovery for which WRAP par-
ticipants reported no significant
changes. In Vermont, there were no
significant changes in items asking
about: 1) feeling comfortable question-
ing a doctor or psychiatrist about med-
ications, 2) personal preference for
using mental health service providers,
3) preference for using other types of
service providers, and 4) preference for
using family/partners for support. In
Minnesota, there were no significant
I feel I am beginning to understand
how to manage the symptoms of de-
pression and mania through this sys-
tem—recognizing the early warning
signs and strategies for dealing with
them. (Vermont)
Participants also noted the growth in
their support networks and comment-
ed that they felt less social isolation.
This was reflected in comments about
how WRAP education led them to “be
around positive people more”
(Minnesota), introduced them to “peo-
ple I would like to stay in contact with”
(Vermont), and helped them realize
“that I am not the only one out there
having to cope with problems similar to
mine” (Vermont).
Another common theme was the appli-
cation of specific WRAP strategies and
skills in everyday life. Participants ex-
pressed pride in the new knowledge
and skills that they had acquired and
were continuing to practice.
[I] added to my daily maintenance and
triggers list. Also changed my support
system. (Minnesota)
I have an action plan. I now know about
the resources that are available.
(Vermont)
Doing my Daily Maintenance and items
in my Toolbox has been the most helpful.
(Minnesota)
Finally, participants noted that having
WRAP educators who were also con-
sumers was especially powerful for in-
stilling hope. As a Vermont participant
stated, “No one can tell it like someone
who’s been through it.”
Conclusions
Evaluation findings from two separate
statewide WRAP initiatives provide
support for the notion that participants
experience significant changes after re-
ceiving WRAP education. At the end of
their WRAP experience, self-reported
improvement was found on 76% to
changes in: 1) attitudes about the im-
portance of educating oneself about
symptoms; and 2) ability to make
lifestyle changes that led to feeling
better.
Qualitative Findings. In both evalua-
tions, participants were given opportu-
nities to describe in their own words
any ways that WRAP education had af-
fected their lives. This written feedback
was provided anonymously on the
posttest questionnaires in a separate
section where respondents were asked
to provide their comments. The method
of Constant Comparative Analysis
(Glaser & Strauss, 1967) was used to
code these comments and then group
them into similar concepts from which
themes were derived in order to illus-
trate the different ways in which WRAP
was perceived as promoting recovery.
One common theme was participants’
new view of wellness as an attainable,
ongoing process, influenced by the
support of others. A participant from
Vermont noted:
This course has helped me see that
there are options for me in how I live my
life with my problems, and that recovery
and health happen by degrees, with
steady effort; that supporting and being
supported by friends, etc. is really just
one of the most integral parts of any-
one’s life.
A Minnesota participant echoed:
I feel different about life and I know
what I need to work on to stay healthy,
so I can live on my own. And now my
team listens to me.
Another common theme was an in-
creased ability to recognize and suc-
cessfully manage stressors and
symptoms.
I now use my response to triggers and
early warning signs when before, I
thought they were [signs I was already
in] crisis. (Minnesota)
fa l l 2 0 1 0— V o l u m e 34 N u m b er 2
119
article
Copeland and WRAP educators in the
state of Ohio on a large-scale random-
ized study that explores whether
changes in WRAP participant outcomes
can be directly attributed to the inter-
vention itself. With this promising
start, future studies of the efficacy and
effectiveness of this model in promot-
ing recovery can advance our under-
standing of peer-led self-management
interventions.
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and skills about which participants
were queried. Moreover, satisfaction
with the intervention was extremely
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the case despite differences in the
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tribute the changes observed among
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tion. Another weakness is the self-re-
port nature of the data collected from
participants. Respondents’ reports
could have been influenced by positive
response bias or mistaken self-percep-
tions of improvement. A third limitation
is the short-term nature of the follow-
up. Collection of outcome data immedi-
ately following the intervention does
not allow us to determine whether any
observed gains were maintained over
time. Fourth, the surveys used were
not psychometrically validated. Thus
we have no information on their validi-
ty and reliability. Fifth, while the nature
of the two groups was statewide in
both evaluations, the study population
does not represent a random sample of
individuals with severe mental illness
in those states. As a result, these find-
ings may not be generalizable to the
state as a whole or the larger U.S. pop-
ulation. Sixth, the fact that participant
self-reports were obtained from lead-
ers of WRAP groups rather than having
an independent evaluator obtain rat-
ings outside the context of the group is
another weakness of the study.
Seventh, while anecdotal and qualita-
tive feedback suggests that many indi-
viduals’ lives improved following WRAP
education, no independent statistical
data on outcomes were collected.
Finally, the evaluations did not collect
information from those participants
who dropped out of a cycle or did not
complete both a pre and post survey.
Because of this, we know little about
the positive or negative experiences
and outcomes of those who exited the
program prematurely.
Future Directions. The results of this
study advance the knowledge base for
peer-led services by providing the first
statistical evidence from a large num-
ber of individuals in two regionally di-
verse states suggesting that WRAP may
be an effective self-management inter-
vention for people with a mental ill-
ness. These positive initial results,
along with the fact that WRAP initia-
tives are currently ongoing in all 50
states in the U.S., offer a wealth of op-
portunities to engage in further, more
rigorous evaluations. To that end, the
UIC Center is working with Dr.
Ps y c h i a t r i c R eh a b i l itat i o n Jo u r n a l Developing the Evidence Base for Peer-Led Services
120
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Linda Corey, MS, Director, Vermont
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Laurie C. Curtis, MA, CPRP, Senior Program
Associate, Advocates for Human Potential,
Inc., Montpelier, VT.
Dennis D. Grey, BA, Project Coordinator,
University of Illinois at Chicago.
William (Nick) H. Nichols, MSW, Mental
Health Policy Director, Vermont Department
of Mental Health, Waterbury, VT.
Corresponding author:
Dr. Judith A. Cook
University of Illinois at Chicago,
Department of Psychiatry
1601 West Taylor St., 4th Floor, M/C 912
Chicago, IL 60612
Ph: 312-355-1696
Fax 312-355-4189
cook@ripco.com
... As commentators have noted, challenges with evaluating effectiveness include the diverse array of roles and responsibilities adopted by peer providers, particularly in naturalistic community based settings (Jones, Teague, Wolf, & Rosen, 2020;Salzer, Schwenk, & Brusilovskiy, 2010) and lack of consensus and consistency in the operationalizations of peer roles and selection and measurement of outcomes in research trials (Chinman et al., 2016;King & Simmons, 2018). Overall, evidence tends to be stronger for manualized peer-led interventions such as Wellness Recovery Action Planning (WRAP), a group based structured intervention revolving around the development of a symptom self-management and advance crisis plan (Cook et al., 2010;Cook, Copeland, et al., 2012a). Research on the implementation of peer services consistently identify numerous barriers and areas in which support for peer roles is lacking, including role ambiguity, low pay and lack of benefits, poor or inadequate supervision and lack of opportunities for growth or advancement (Cabral et al., 2014; Kosyluk, Gius, Wolf, & Rosen, 2019). ...
... An important next step is the investigation of (potential) causal relationships between altered service utilization patterns and client-level outcomes. To date, virtually all evidence concerning the effectiveness of peer support has stemmed from specific clinical trials, often focused on narrow interventions, such as WRAP (Cook et al., 2010;Cook, Copeland, et al., 2012a) (Cook et al., 2010;Cook, Copeland, et al., 2012a) or BRIDGES (Cook, Steigman, et al., 2012b), that fail to encapsulate the breadth and diversity of real-world peer provider roles. Documenting improved outcomes in large, real-world implementation settings and unpacking mechanisms of action in these settings, is critical. ...
... An important next step is the investigation of (potential) causal relationships between altered service utilization patterns and client-level outcomes. To date, virtually all evidence concerning the effectiveness of peer support has stemmed from specific clinical trials, often focused on narrow interventions, such as WRAP (Cook et al., 2010;Cook, Copeland, et al., 2012a) (Cook et al., 2010;Cook, Copeland, et al., 2012a) or BRIDGES (Cook, Steigman, et al., 2012b), that fail to encapsulate the breadth and diversity of real-world peer provider roles. Documenting improved outcomes in large, real-world implementation settings and unpacking mechanisms of action in these settings, is critical. ...
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Aim: To examine whether roles of peer specialists affect service use among Black, Latinx and White youth ages 16-24 with serious mental illness (SMI) in Los Angeles and San Diego Counties. Methods: Administrative data from 2015 to 2018 was used to summarize service use among 6329 transition age youth age 16-24 with SMI who received services from 76 outpatient public mental health programs with peer specialists on staff. Roles of peer specialists were assessed via a program survey. Generalized linear models were used to assess the relationship between peer specialist characteristics and service use outcomes (ie, outpatient and inpatient). Results: Having a transition age youth peer specialist on staff (vs older peer specialists) and having peer specialists that provide four or more services (vs fewer services) was associated with an increase in annual outpatient visits in both counties (P = <.001 each). In Los Angeles County, having three or more peer specialist trainings (vs fewer trainings) was associated with lower use of inpatient services (P < .001). In San Diego County, having a transition age youth peer specialist and peer specialists that provide four or more services was associated with lower use of inpatient services (P < .001 each). Conclusions: Types of peer support and number of types of peer services were associated with mental health service utilization. Detailed examination of the roles of peer specialists is merited to identify the specific pathways that improve outcomes.
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... El método WRAP se basa en la fortaleza para practicar en el día a día un autotratamiento , que incluye la planificación anticipada de las posibles crisis y que puede desarrollarse y utilizarse de forma individual, pero que a menudo se enseña en grupos. Hay pruebas empíricas que sugieren que el método WRAP mejora el autotratamiento y la capacidad de defenderse, y logra una serie de dominios de resultados orientados a la recuperación (Cook, et al., 2010(Cook, et al., , 2012Fukui, et al., 2011;Stamino, et al., 2010). ...
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... The PRSs received professional certification on motivational interviewing and WRAP, and they received thorough instruction and guided practice on SAMHSA's toolkit and RoadMAP from a content expert. WRAP is a peer-guided evidence-based intervention that helps individuals in recovery identify triggers for substance use and distress, and assists with monitoring early warning signs developing coping strategies to mitigate risk and distress, engaging in daily maintenance of recovery, and developing strategies and plans for crises in recovery (Cook et al., 2010;Copeland, 1997). The RoadMAP curriculum is a CBT group protocol that has shown preliminary evidence for preventing relapse through emphasis on substance use risk functional analysis, scheduling non-substance-related replacement activities, and coping skills via video vignettes, handouts, and group discussion (Brooks et al., 2013). ...
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Most writing on sociological method has been concerned with how accurate facts can be obtained and how theory can thereby be more rigorously tested. In The Discovery of Grounded Theory, Barney Glaser and Anselm Strauss address the equally Important enterprise of how the discovery of theory from data--systematically obtained and analyzed in social research--can be furthered. The discovery of theory from data--grounded theory--is a major task confronting sociology, for such a theory fits empirical situations, and is understandable to sociologists and laymen alike. Most important, it provides relevant predictions, explanations, interpretations, and applications. In Part I of the book, "Generation Theory by Comparative Analysis," the authors present a strategy whereby sociologists can facilitate the discovery of grounded theory, both substantive and formal. This strategy involves the systematic choice and study of several comparison groups. In Part II, The Flexible Use of Data," the generation of theory from qualitative, especially documentary, and quantitative data Is considered. In Part III, "Implications of Grounded Theory," Glaser and Strauss examine the credibility of grounded theory. The Discovery of Grounded Theory is directed toward improving social scientists' capacity for generating theory that will be relevant to their research. While aimed primarily at sociologists, it will be useful to anyone Interested In studying social phenomena--political, educational, economic, industrial-- especially If their studies are based on qualitative data.
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The authors report the latest findings from a 32-year longitudinal study of 269 back-ward patients from Vermont State Hospital. This intact cohort participated in a comprehensive rehabilitation program and was released to the community in a planned deinstitutionalization effort during the mid-1950s. At their 10-year follow-up mark, 70% of these patients remained out of the hospital but many were socially isolated and many were recidivists. Twenty to 25 years after their index release, 262 of these subjects were blindly assessed with structured and reliable protocols. One-half to two-thirds of them had achieved considerable improvement or recovery, which corroborates recent findings from Europe and elsewhere.
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This study evaluated the effectiveness (changes in health behaviors, health status, and health service utilization) of a self-management program for chronic disease designed for use with a heterogeneous group of chronic disease patients. It also explored the differential effectiveness of the intervention for subjects with specific diseases and comorbidities. The study was a six-month randomized, controlled trial at community-based sites comparing treatment subjects with wait-list control subjects. Participants were 952 patients 40 years of age or older with a physician-confirmed diagnosis of heart disease, lung disease, stroke, or arthritis. Health behaviors, health status, and health service utilization, as determined by mailed, self-administered questionnaires, were measured. Treatment subjects, when compared with control subjects, demonstrated improvements at 6 months in weekly minutes of exercise, frequency of cognitive symptom management, communication with physicians, self-reported health, health distress, fatigue, disability, and social/role activities limitations. They also had fewer hospitalizations and days in the hospital. No differences were found in pain/physical discomfort, shortness of breath, or psychological well-being. An intervention designed specifically to meet the needs of a heterogeneous group of chronic disease patients, including those with comorbid conditions, was feasible and beneficial beyond usual care in terms of improved health behaviors and health status. It also resulted in fewer hospitalizations and days of hospitalization.
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To assess the 1- and 2-year health status, health care utilization and self-efficacy outcomes for the Chronic Disease Self-Management Program (CDSMP). The major hypothesis is that during the 2-year period CDSMP participants will experience improvements or less deterioration than expected in health status and reductions in health care utilization. Longitudinal design as follow-up to a randomized trial. Community. Eight hundred thirty-one participants 40 years and older with heart disease, lung disease, stroke, or arthritis participated in the CDSMP. At 1- and 2-year intervals respectively 82% and 76% of eligible participants completed data. Health status (self-rated health, disability, social/role activities limitations, energy/fatigue, and health distress), health care utilization (ER/outpatient visits, times hospitalized, and days in hospital), and perceived self-efficacy were measured. Compared with baseline for each of the 2 years, ER/outpatient visits and health distress were reduced (P <0.05). Self-efficacy improved (P <0.05). The rate of increase is that which is expected in 1 year. There were no other significant changes. A low-cost program for promoting health self-management can improve elements of health status while reducing health care costs in populations with diverse chronic diseases.