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Wellness Recovery Action Plan (WRAP)

Wellness Recovery Action Plan (WRAP) is a manualized group intervention for adults with mental illness. WRAP guides participants through the process of identifying and understanding their personal wellness resources ("wellness tools") and then helps them develop an individualized plan to use these resources on a daily basis to manage their mental illness. WRAP has the following goals:

Teach participants how to implement the key concepts of recovery (hope, personal responsibility, education, self-advocacy, and support) in their day-to-day lives
Help participants organize a list of their wellness tools--activities they can use to help themselves feel better when they are experiencing mental health difficulties and to prevent these difficulties from arising
Assist each participant in creating an advance directive that guides the involvement of family members or supporters when he or she can no longer take appropriate actions on his or her own behalf
Help each participant develop an individualized postcrisis plan for use as the mental health difficulty subsides, to promote a return to wellness

WRAP groups typically range in size from 8 to 12 participants and are led by two trained cofacilitators. Information is imparted through lectures, discussions, and individual and group exercises, and key WRAP concepts are illustrated through examples from the lives of the cofacilitators and participants. The intervention is typically delivered over eight weekly 2-hour sessions, but it can be adapted for shorter or longer times to more effectively meet the needs of participants. Participants often choose to continue meeting after the formal 8-week period to support each other in using and continually revising their WRAP plans.

Although a sponsoring agency or organization may have its own criteria for an individual's entry into WRAP, the intervention's only formal criterion is that the person must want to participate. WRAP is generally offered in mental health outpatient programs, residential facilities, and peer-run programs. Referrals to WRAP are usually made by mental health care providers, self-help organizations, and other WRAP participants. Although the intervention is used primarily by and for people with mental illnesses of varying severity, WRAP also has been used with people coping with other health issues (e.g., arthritis, diabetes) and life issues (e.g., decisionmaking, interpersonal relationships) as well as with military personnel and veterans.

Descriptive Information

Areas of Interest	Mental health treatment
Outcomes	Review Date: September 2010 1: Symptoms of mental illness 2: Hopefulness 3: Recovery from mental illness 4: Self-advocacy 5: Physical and mental health
Outcome Categories	Mental health Quality of life Social functioning Treatment/recovery
Ages	26-55 (Adult)
Genders	Male Female
Races/Ethnicities	American Indian or Alaska Native Asian Black or African American Hispanic or Latino White Race/ethnicity unspecified
Settings	Residential Outpatient Other community settings
Geographic Locations	Urban Suburban Rural and/or frontier
Implementation History	In 1997, WRAP was first implemented, and the first edition of the book "Wellness Recovery Action Plan" was published. Since then, more than a million WRAP books and related resources have been distributed worldwide, and millions of people have benefited from the WRAP intervention. Formal training for WRAP facilitators was first offered in 1997, and the first edition of the structured WRAP facilitator training manual, "Mental Health Recovery Including Wellness Recovery Action Plan Curriculum," was published in 1998. The not-for-profit Copeland Center for Wellness and Recovery was established in 2005 with a mission to implement and network the WRAP training model, nationally and internationally. As of February 2010, more than 2,000 people had been trained as a WRAP facilitator, and 120 of these individuals had been trained as an advanced-level facilitator. Trainings have been conducted in Australia, Canada, England, Hong Kong, Ireland, Japan, New Zealand, Scotland, and the United States, and WRAP groups, which are conducted by trained facilitators, exist in these countries. In the United States, local and regional WRAP programs sponsored by mental health agencies and peer-run centers exist in every State, and over 25 States have integrated statewide WRAP initiatives. There have been at least six evaluations of this intervention in the United States, as well as one in New Zealand and one in Scotland.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: No
Adaptations	The book "Wellness Recovery Action Plan" and other WRAP implementation materials have been translated into many languages, including Chinese, French, Japanese, Polish, and Spanish. In addition, many international trainings and presentations have been adapted to accommodate unique cultural perspectives on mental health, language differences, and cultural norms.
Adverse Effects	Preliminary data analysis conducted for a study published in 2009 by Cook et al. (see Study 2) indicated that participation in WRAP may have had negative effects on empowerment. However, this finding has not been replicated in subsequent evaluations and analyses with larger samples. To date, no additional accounts of adverse effects of WRAP have been published.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Review Date: September 2010

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Cook, J. A., Copeland, M. E., Jonikas, J. A., Hamilton, M. M., Razzano, L. A., Grey, D. D., et al. (2010). Results of a randomized controlled trial of mental illness self-management using Wellness Recovery Action Planning. Manuscript submitted for publication.

Study 2

Cook, J. A., Copeland, M. E., Hamilton, M. M., Jonikas, J. A., Razzano, L. A., Floyd, C. B., et al. (2009). Initial outcomes of a mental illness self-management program based on Wellness Recovery Action Planning. Psychiatric Services, 60(2), 246-249.

Supplementary Materials

University of Illinois at Chicago (UIC) National Research and Training Center (NRTC) Ohio (OH) WRAP Study: Fidelity Scale

Outcomes

Outcome 1: Symptoms of mental illness
Description of Measures	Symptoms of mental illness were assessed using the Brief Symptom Inventory (BSI), a 53-item self-report instrument. The BSI yields scores on the Global Severity Index (an overall measure of psychological distress), the Positive Symptom Total (a measure of the number of symptoms), and nine symptom subscales: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Using a 5-point scale ranging from "not at all" to "extremely," participants rate each item for how much the symptom bothered them in the past week.
Key Findings	Participants were randomly assigned to an intervention group that received WRAP or to a wait-list control group that received services as usual. The BSI was administered to participants 6 weeks before (baseline) and 6 weeks after (posttest) they received the intervention and at a 6-month follow-up. WRAP participants had a significantly greater reduction in the severity and number of symptoms across time (from baseline to posttest to 6-month follow-up) relative to control group participants, as indicated by scores on the BSI Global Severity Index (p = .023); Positive Symptom Total (p = .027); and subscales measuring interpersonal sensitivity (p = .023), depression (p = .022), anxiety (p = .022), phobic anxiety (p = .034), and paranoid ideation (p = .009). No statistically significant differences were found between the two groups across time on somatization, obsessive-compulsive, hostility, and psychoticism subscales.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.9 (0.0-4.0 scale)

Outcome 2: Hopefulness
Description of Measures	Hopefulness was assessed using the Hope Scale (HS), a 12-item self-report instrument with two subscales: one that measures belief in one's capacity to initiate and sustain actions and another that measures ability to generate routes by which goals may be reached. Participants rate each item on a 4-point scale ranging from "definitely false" to "definitely true," and scores for each item are summed to produce a total score.
Key Findings	In one study, participants were randomly assigned to an intervention group that received WRAP or to a wait-list control group that received services as usual. The HS was administered to participants 6 weeks before (baseline) and 6 weeks after (posttest) they received the intervention and at a 6-month follow-up. WRAP participants had a significantly greater improvement in hopefulness across time (from baseline to posttest to 6-month follow-up) relative to control group participants, as indicated by total HS scores (p = .018) and the subscale for belief in one's capacity to initiate and sustain actions (p = .020). No statistically significant difference was found between the two groups across time on the subscale for ability to generate routes by which goals may be reached. In another study, the HS was administered to participants before (pretest) and 1 month after (posttest) they received the intervention. From pre- to posttest, participants who received WRAP had a significant increase in feelings of hopefulness, as indicated by scores on the two HS subscales (p < .01 for each subscale).
Studies Measuring Outcome	Study 1, Study 2
Study Designs	Experimental, Preexperimental
Quality of Research Rating	3.7 (0.0-4.0 scale)

Outcome 3: Recovery from mental illness
Description of Measures	Recovery from mental illness was assessed using the Recovery Assessment Scale (RAS), a 41-item self-report instrument with five subscales: personal confidence, willingness to ask for help, goal orientation, reliance on others, and freedom from symptom domination. Participants rate each item on a 5-point scale ranging from "strongly agree" to "strongly disagree," and scores for each item are summed to produce a score for overall recovery.
Key Findings	The RAS was administered to participants before (pretest) and 1 month after (posttest) they received the intervention. From pre- to posttest, WRAP participants had a significant improvement in RAS scores for overall recovery (p < .001) and in the five subscales: personal confidence (p < .001), willingness to ask for help (p < .05), goal orientation (p < .05), reliance on others (p < .05), and freedom from symptom domination (p < .05).
Studies Measuring Outcome	Study 2
Study Designs	Preexperimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

Outcome 4: Self-advocacy
Description of Measures	Self-advocacy was assessed using the Patient Self-Advocacy Scale (PSAS), a 12-item self-report instrument that measures three dimensions: patient knowledge, assertiveness, and potential for nonadherence to treatment. Participants rate each item on a 5-point scale ranging from "strongly agree" to "strongly disagree."
Key Findings	The PSAS was administered to participants before (pretest) and 1 month after (posttest) they received the intervention. From pre- to posttest, WRAP participants had a significant improvement in self-advocacy, as indicated by scores in all three dimensions (p < .01 for each dimension).
Studies Measuring Outcome	Study 2
Study Designs	Preexperimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

Outcome 5: Physical and mental health
Description of Measures	Physical and mental health was assessed using the Medical Outcomes Study 12-Item Short Form Survey (SF-12), a self-report instrument that evaluates health indicators, allowing for examination of the presence and seriousness of physical and mental conditions, acute symptoms, age and aging, changes in health, and recovery from depression.
Key Findings	The SF-12 was administered to participants before (pretest) and 1 month after (posttest) they received the intervention. From pre- to posttest, WRAP participants had a significant improvement in physical and mental health (p < .01).
Studies Measuring Outcome	Study 2
Study Designs	Preexperimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	26-55 (Adult)	66% Female 34% Male	63% White 28% Black or African American 5% Hispanic or Latino 3% American Indian or Alaska Native 1% Asian
Study 2	26-55 (Adult)	64% Female 36% Male	66% White 25% Black or African American 5% Race/ethnicity unspecified 4% Hispanic or Latino

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

1. Reliability of measures	4. Missing data and attrition
2. Validity of measures	5. Potential confounding variables
3. Intervention fidelity	6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Symptoms of mental illness	4.0	4.0	4.0	4.0	3.5	4.0	3.9
2: Hopefulness	4.0	4.0	3.6	3.4	3.0	4.0	3.7
3: Recovery from mental illness	4.0	4.0	2.8	2.8	2.0	4.0	3.3
4: Self-advocacy	4.0	4.0	2.8	2.8	2.0	4.0	3.3
5: Physical and mental health	4.0	4.0	2.8	2.8	2.0	4.0	3.3

Study Strengths

All outcome measures used in both studies have strong, well-established psychometric properties. Both studies assessed fidelity though multiple methods, including a checklist that documented adherence to prescribed topics, timeframes, and instructional modalities; weekly teleconference calls by the research team and the study's local WRAP coordinators to discuss each site's attendance and fidelity scores; and the use of trained, experienced facilitators. One study used random assignment and found no significant baseline differences between the intervention and control groups in regard to demographics, clinical status, and employment status. Attrition in both groups for this study was relatively low and was addressed appropriately in the analyses. The same study used a strong experimental design to minimize potential bias owing to confounding variables. Both studies' analytic strategy for data was thorough and appropriate.

Study Weaknesses

The instrument used in both studies to assess intervention fidelity has unknown psychometric properties. One study used a preexperimental design and had high attrition. The other study did not provide adequate information on the services received by the control group, such as exposure to peer-led support groups and medications, which raises concerns about potential confounds.

Readiness for Dissemination

Review Date: September 2010

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Copeland, M. E. (1999). Winning against relapse: A workbook of action plans for recurring health and emotional problems. Dummerston, VT: Peach Press.

Copeland, M. E. (2001). The depression workbook: A guide for living with depression and manic depression (2nd ed.). Oakland, CA: New Harbinger Publications.

Copeland, M. E. (2006). Wellness Recovery Action Planning (WRAP) project: WRAP group facilitator's kit.

Copeland, M. E. (2009). Facilitator training manual: Mental health recovery including Wellness Recovery Action Plan curriculum. Dummerston, VT: Peach Press.

Copeland, M. E. (2010). WRAP facilitator manual.

Copeland, M. E., & Mead, S. (2004). Wellness Recovery Action Plan and peer support: Personal, group, and program development. Dummerston, VT: Peach Press.

My WRAP [Participant binder]

Program Web site for facilitators, http://www.copelandcenter.com

Program Web site for participants, http://www.mentalhealthrecovery.com

University of Illinois at Chicago (UIC) Courses in Recovery Study: WRAP Fidelity Assessment

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
3.8	4.0	3.0	3.6

Dissemination Strengths

An extensive array of well-developed implementation materials is available. All materials are consistent in content and approach, and they include guidance for adapting the program for use with specific populations. Extensive opportunities are available for facilitator trainings. The facilitator training manual is well organized and includes a comprehensive curriculum. The trainings cover all aspects of organizing, preparing, and conducting group sessions, with training activities and discussions closely following the content of the manuals. Online training options make this program accessible to those who cannot attend an in-person facilitator training session. Extensive support materials (e.g., handouts, worksheets) are available for participants and facilitators, and many of these materials are accessible at the participant and facilitator resource Web sites. A certification program for facilitators helps to ensure fidelity to the model. The fidelity tool includes both content and process questions, and information derived from use of the fidelity tool can be discussed with a local program coordinator.

Dissemination Weaknesses

Use of some self-help tools may require peer or facilitator support because of the these tools' complex and dense language. The use of the fidelity tool is not emphasized in program materials. The role and expectations of the local program coordinator, who provides fidelity monitoring support, are not fully discussed.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Facilitator Training Manual: Mental Health Recovery Including Wellness Recovery Action Plan Curriculum	$129 each	Yes, one source of implementation guidance is required
Wellness Recovery Action Plan [book]	$10 each	Yes, one source of implementation guidance is required
Assorted books and videos for facilitators and participants	$2-$60 each	Yes, one source of implementation guidance is required
Online participant materials	Free	No
Wellness Recovery Action Plan and Peer Support: Personal, Group, and Program Development	$24.95 each	No
Winning Against Relapse: A Workbook of Action Plans for Recurring Health and Emotional Problems	$16.95 each	No
The Depression Workbook: A Guide for Living With Depression and Manic Depression	$24.95 each	No
5-day, off-site facilitator training at various locations across the United States	$1,200 per participant	No
5-day, off-site advanced facilitator training at various locations across the United States	$1,400 per participant	No
Correspondence course	$299 per participant	No
On-site consultation	Cost varies depending on site needs	No

Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

Cook, J. A., Copeland, M. E., Corey, L., Buffington, E., Jonikas, J. A., Curtis, L. C., et al. (2010). Developing the evidence base for peer-led services: Changes among participants following Wellness Recovery Action Planning (WRAP) education in two statewide initiatives. Psychiatric Rehabilitation Journal, 34(2), 113-120.

Copeland, M. E. (2002). Wellness Recovery Action Plan: A system for monitoring, reducing and eliminating uncomfortable or dangerous physical symptoms and emotional feelings. Occupational Therapy in Mental Health, 17(3), 127-150.

Davidson, L. (2005). Recovery, self management and the expert patient: Changing the culture of mental health from a United Kingdom perspective. Journal of Mental Health, 14(1), 25-35.

Doughty, C., Tse, S., Duncan, N., & McIntyre, L. (2008). The Wellness Recovery Action Plan (WRAP): Workshop evaluation. Australasian Psychiatry, 16(6), 450-456.

Gordon, J., & Cassidy, J. (2009). Wellness Recovery Action Plan (WRAP) training for BME women: An evaluation of process, cultural appropriateness and effectiveness. Retrieved from http://www.scottishrecovery.net/View-document-details/65-Wellness-Recovery-Action-Plan-WRAP-Training-for-BME-women-full-report.html

Higgins, A., Callaghan, P., DeVries, J. M. A., Keogh, B., Morrissey, J., Nash, M., et al. (2010). Evaluation of the Mental Health Recovery and WRAP education programme: Report to the Irish Mental Health & Recovery Education Consortium. Retrieved from http://www.imhrec.ie/wp-content/uploads/2010/08/TCD-Evaluation-Report-13-05-10.pdf

Scottish Centre for Social Research & Pratt, R. (2010). An evaluation of wellness planning in self-help and mutual support groups. Retrieved from http://www.scottishrecovery.net/Latest-News/wrap-research-reports-overwhelmingly-positive-results.html

Starnino, V. R., Mariscal, S., Holter, M. C., Davidson, L. J., Cook, K. S., Fukui, S., et al. (2010). Outcomes of an illness self-management group using Wellness Recovery Action Planning. Psychiatric Rehabilitation Journal, 34(1), 57-60.

Sterling, E. W., von Esenwein, S. A., Tucker, S., Fricks, L., & Druss, B. G. (2010). Integrating wellness, recovery, and self-management for mental health consumers. Community Mental Health Journal, 46(2), 130-138.

Zhang, W., Li, Y., Yeh, H.-S., Wong, S. Y., & Zhao, Y. (2007). The effectiveness of the Mental Health Recovery (including Wellness Recovery Action Planning) Programme with Chinese consumers. Retrieved from http://www.tepou.co.nz/file/Knowledge-Exchange-stories/bo-ai-she-the-effectiveness-of-the-mental-health-recovery-research-paper.pdf

Contact Information

To learn more about implementation, contact:
Mary Ellen Copeland, Ph.D.
(802) 254-5335
info@copelandcenter.com

To learn more about research, contact:
Judith A. Cook, Ph.D.
(312) 355-3921
cook@ripco.com

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):

http://www.mentalhealthrecovery.com

http://www.copelandcenter.com