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. Author manuscript; available in PMC: 2022 Nov 14.
Published in final edited form as: Qual Health Res. 2020 Dec 8;31(4):631–642. doi: 10.1177/1049732320975729

How Adults with Serious Mental Illness Learn and Use Wellness Recovery Action Plan’s Recovery Framework

Ryan Petros 1, Phyllis Solomon 2
PMCID: PMC9648532  NIHMSID: NIHMS1841429  PMID: 33292068

Abstract

This study was conducted to investigate how adults with serious mental illness learn and utilize an illness self-management framework for pursuing recovery through a program called Wellness Recovery Action Plan (WRAP). The researchers employed an interpretive descriptive methodology with thematic analysis. Data were collected from three focus groups (n=26) and in-depth interviews with follow-up member-checks with 10 participants (n=20 interviews). Findings aligned with main constructs of Self Determination Theory (SDT) to explain how an autonomy-supportive environment created opportunities for participants to build competency implementing personalized recovery strategies that are socially endorsed by peers, resulting in internalized motivation for continued application of WRAP’s framework. SDT appears to explain mechanisms of change for WRAP. Recommendations for mental health organizations include broadly ensuring autonomy-supportive environments and services that maximize opportunities to build competence in recovery strategies in collaboration with peers. Future research may utilize SDT as the theoretical basis for investigating self-management programs.

Keywords: mental health, serious mental illness, recovery, self-management, self-determination theory, qualitative

Introduction

Mental health professionals have historically dominated the care and treatment of adults with serious mental illness. Their expertise was considered sacrosanct, and services often focused on increasing compliance to treatment orders. However, privileging providers’ authority over service user autonomy is antithetical to a recovery orientation that is now the law of the land (New Freedom Commission, 2003). Providers are charged with helping service users take control of developing their own recovery strategies, but there is minimal research to guide practitioners or service users on how to engage in self-directed learning of recovery strategies.

One promising body of research is illness self-management (ISM). ISM interventions provide a framework for service users to develop personalized recovery strategies. ISM is compatible with a recovery-orientation, and there is growing research on the efficacy of self-management programs (Petros & Solomon, 2015). The most widely used ISM intervention is Wellness Recovery Action Plan (WRAP) (Roberts & Wolfson, 2004; Cook et al., 2012b). WRAP enhances recovery, self-advocacy, and hope in personal agency (Cook et al., 2009; 2010; 2012a; 2012b; Fukui et al., 2011; Higgins et al., 2012; Jonikas et al., 2013; Starnino et al., 2010); however, the magnitude of change is “relatively modest” (Cook et al., 2012b, p. 888; Jonikas et al., 2013, p. 266). Thus, while WRAP is philosophically compatible with recovery and appears at least minimally effective at enhancing recovery, there may be opportunities to enhance the magnitude of change and strengthen WRAP’s outcomes.

One strategy to enhance the effectiveness of an intervention is to identify the mechanisms of change and specify “targets” for augmentation (NIMH, 2015). Thus, this research sought to answer the following question: How do adults with serious mental illness learn and utilize WRAP’s ISM framework for pursuing recovery?

Illness Self-Management

ISM programs are designed to help adults with serious mental illness advance recovery by encouraging self-regulated learning of recovery strategies (Petros & Solomon, 2015). Rather than offering a list of ready-made techniques, ISM programs offer a framework for personal exploration, encouraging trial and error in daily life to develop plans to manage illness, maximize wellness, and attain goals. People with psychiatric disabilities are recognized as experts of their lived experience and are encouraged to reflect on what works, while partnering with others as necessary to develop new strategies for resolving barriers to recovery. Consequently, ISM programs offer a framework to advance requisite skills for the development and implementation of effective recovery strategies; however, it is not clear how people learn and use those skills.

To support skill development, ISM programs systematically underscore the three processes of self-regulated learning – self-observation, self-judgment, and self-reaction (Zimmerman, 1989) – that are necessary for the development and implementation of recovery strategies. Self-observation refers to monitoring one’s overall performance and progress toward achieving one’s goals (Zimmerman, 1989). It requires practice and skill in self-reflection about one’s experience and goals. Self-judgment involves reflecting on one’s own performance, comparing it to some other goal or standard, and judging the efficacy of the strategies used (Zimmerman, 1989). Self-reaction describes the process of using the valuation of one’s self-observation and self-judgment to make decisions about whether to retain or adopt new strategies (Zimmerman, 1989). WRAP encourages such self-regulated learning and is a prime example of an ISM intervention.

Wellness Recovery Action Plan (WRAP)

WRAP programming is usually delivered in a small-group format over the course of 8–12 weekly sessions (Cook et al., 2012b; Roberts & Wolfson, 2004). WRAP is co-facilitated by certified “peers,” who are typically people with serious mental illness in advanced states of recovery and are always personal practitioners of WRAP. The creator, Mary Ellen Copeland, proposes that recovery is built upon five “key concepts”: hope, personal responsibility, education, self-advocacy, and support (Copeland, 2010). Hope is prominently featured in the program. WRAP users are encouraged to believe in the possibility of living a full and self-directed life, while developing strategies conducive to actualizing recovery goals (Copeland, 2010).

Throughout WRAP programming, participants are guided through activities that culminate in the development of a series of plans to reestablish, maintain, and enhance wellness. Participants engage in self-reflection to build insight into signs of personal wellness and decrements of wellness and to identify strategies appropriately matched to variations in wellness needs and goals. Plans include proactive strategies for use on a daily basis, reactive strategies to respond to triggers and threats to wellness, and contingency plans to manage crises and post-crisis periods, including advanced directives (Cook et al., 2012a; 2012b; Copeland, 2010).

SAMHSA encourages the use of WRAP (Kobrin, n.d., SAMHSA, n.d.) and cites research on its efficacy, much of which was completed several years ago. Empirical evidence demonstrates WRAP’s “relatively modest” efficacy at promoting recovery, enhancing hopefulness, reducing symptoms, improving quality of life, and increasing self-advocacy (Cook et al., 2012a; 2012b; Jonikas et al., 2013). While WRAP may be transformative for some, others experience minimal benefit. Research is needed to investigate possible mechanisms of change so that strategies can be identified to augment programming and enhance its effectiveness.

Self-Determination Theory: Informing Qualitative Inquiry

Self-Determination Theory (SDT) is a macro-theory about motivation, social development, and well-being (Ryan & Deci, 2000). The theory describes the process of self-regulation, wherein people internalize values and external contingencies for behaviors; behaviors move from controlled to autonomous, when they align with personal values and goals (Ryan & Deci, 2000). The theory posits that all people are inherently equipped with a drive toward growth and wellness, and people will naturally strive toward realizing their full potential if their basic psychological needs are met (Deci & Ryan, 2008; 2015; Ryan, 2009; Ryan & Deci, 2000; Ryan, Huta, & Deci, 2008).

Ryan and Deci (2000) claim that humans are gifted with deep wells of intrinsic motivation, but many activities are extrinsically motivated by things such as tangible rewards or social pressures. Whereas intrinsically motivated activities involve engagement in those activities for their inherent pleasure, externally motivated activities are performed for the purpose of obtaining some outcome or reward, separate from the experience of the activities themselves. Although many activities in which people engage are extrinsically motivated, there is a correlation between the degree to which people internalize motivations for engaging in such activities and their level of persistence toward goals, behavioral quality and mastery, and enhanced wellbeing (Ryan & Deci, 2000). Moreover, people are more likely to experience a sense of volition for engaging in activities that are externally motivated, if they accept and take ownership of the value of those activities, a process called “internalization” (Ryan & Deci, 2008).

According to SDT, a person’s environment can support internalization for goal-oriented activities by meeting three basic psychological needs: autonomy, competence, and relatedness. Volition for engagement in an externally motivated activity may increase, for instance, when social pressure exists; by adopting the social value for that activity, internalization increases. Thus relatedness is an important factor for internalization. Similarly, people are more likely to internalize motivation for activities, if they feel competent and in control (autonomous) over their execution. Ultimately, people’s wellness is related to the degree of internalized motivation for the activities in which they engage, which is in turn impacted by the relative support in their environment for autonomy, competence, and relatedness.

The mental health system historically has failed to meet these three psychological needs for people with serious mental illnesses. Serious mental illness, such as schizophrenia, was defined by an inevitable course of deterioration in functioning (Harding, Brooks, Ashikaga, Strauss, & Breier, 1987; Zipursky, Reilly, & Murray, 2013). The primary treatment included long-term institutionalization, precluding autonomy in housing choice (Mechanic, 2007; Williams, Bellis, & Wellington, 1980). Institutionalization ipso facto removed people from their social networks and prevented entrance to the labor market, thus thwarting relatedness and the development of competence. Community-dwelling adults with psychiatric disabilities often endured paternalistic providers who disregarded self-determination, and instead, focused on increasing compliance to treatment orders (Breeze, 1998; Monahan et al., 2005; Szmukler & Appelbaum, 2008). Thus, in many ways, historic approaches to treatment were antithetical to SDT.

Self-management interventions, on the other hand, are designed to promote a self-directed approach to the identification and implementation of personalized recovery strategies (Petros & Solomon, 2015). While WRAP literature makes no overt mention of its theoretical underpinnings, SDT seems extremely compatible with its overall approach to helping participants realize their full potential (Petros & Solomon, 2019), and the researchers used it as a sensitizing theory to inform the conceptual framework for the study (Corbin, & Strauss, 2014; Glaser & Strauss, 1967; Heath & Cowley, 2004). Although the original plan for qualitative inquiry did not include questions designed to test the “fit” between participants’ experiences and SDT, nor did the plan include a deductive analysis driven by the main constructs of SDT, the theory was a component of the conceptual framework from the beginning, which influenced plans for data collection and analysis.

Overall Study Design and Research Questions

The parent study (Petros, 2017) used a sequential exploratory design (Creswell, 2014; Kettles, Creswell, & Zhang, 2011), and all phases of the research protocol were approved by Institutional Review Boards at the [Omitted] and [Omitted]. In a sequential exploratory design, qualitative inquiry is emphasized and conducted first. This article reports on the qualitative portion of the parent study. The goal of the study was to investigate the question: How do adults with serious mental illness learn and utilize WRAP’s framework for pursuing recovery?

Methods

The qualitative inquiry employed an interpretive descriptive methodology using thematic analysis (Braun & Clarke, 2006). All interviews were conducted by the first author; planning and analysis occurred in collaboration with the second author during weekly meetings and with support from a biweekly critical inquiry group of qualitative researchers (Abboud et al., 2017).

Positionality

Particularly because WRAP was developed by and for people with serious mental illness, it is important to acknowledge the authors’ relevant personal and scholarly backgrounds related to the research (Creswell, 2013; Marshall & Rossman, 2016). Neither author identifies as having serious mental illness, but both have worked and researched extensively with adults with psychiatric disabilities and are committed to recovery as both a self-driven and professionally-supported endeavor. The researchers had no formal relationship with any of the organizations or service-users involved in this research, aside from living and working in the same general community and having collegial relationships with some of the providers in the community-based organizations. To further sensitize themselves to the research process, both authors reviewed WRAP’s guidebook (Copeland, 2010) and completed a systematic review of the most popular self-management programs, which included WRAP (Petros & Solomon, 2015). The first author had several meetings with WRAP facilitators from the national training organization and personal communication with a principal investigator of research on WRAP’s efficacy. In addition, the first author completed WRAP programming and developed a personalized WRAP plan.

Data collection

Primary data were collected through group and individual interviews. Focus groups help to generate breadth of information quickly; they are “socially-oriented” and particularly useful when interaction between group members is desired (Braun & Clarke, 2013; Creswell, 2013; Marshall & Rossman, 2016). Focus groups had intuitive appeal for this research because WRAP programming most often occurs in group settings, and group dynamics that influenced participants’ experience with WRAP may surface and/or be recreated in a group interview setting.

Three focus groups were completed with 11, 7, and 8 participants each, using a combination of purposive and nomination sampling. Each focus group took place at a different agency in Philadelphia, PA: one mental health association and two Community Integrated Recovery Centers (CIRCs), which offer community-based recovery-oriented services to adults with serious mental illness. After detailing inclusion and exclusion criteria at all three locations, administrators and providers requested the researchers utilize nomination sampling wherein providers invite potential participants to speak with researchers directly about the study (Padgett, 2017). The first author traveled to each organization to meet with eligible participants, obtain written informed consent, and conduct the focus groups with a note taker present. Participants were given $20 and two transportation tokens to compensate them for their time. Focus groups were semi-structured and began with an invitation to share “How you are currently using WRAP.” To enhance confidentiality, participants were asked to select and use a pseudonym. Participants were adults who completed WRAP programming and self-identified as having serious mental illness. The first focus group included only WRAP facilitators; the second and third included WRAP users who had not progressed to become facilitators.

Individual interviews followed, using a combination of purposeful and nomination sampling at two CIRCs in Philadelphia; one of the agencies had also participated in recruitment for a focus group, but no participant engaged in both a focus group and an individual interview. To avoid recruiting a sample of WRAP enthusiasts only, providers were asked to invite two people who reported difficulty learning or using WRAP. All 10 participants provided written informed consent and agreed to a second interview for member checks and follow-up questions; they were compensated $20 and two transportation tokens for their time after each interview. Like the focus groups, individual interviews were semi-structured and began with the same opening question. Participants were adults who self-identified as having serious mental illness, completed WRAP programming, and had not progressed to become facilitators.

Overall, participants were almost equally split between men (19) and women (17), and 28 of the 36 were Black (see Table 1). Age ranged from 36 to 60 with an overall mean of 50.6, and the most common diagnosis was schizophrenia.

Table 1:

Demographics for Interview/Focus Group Participants

Focus Group 1: Number/ Mean (SD) Focus Group 2: Number/ Mean (SD) Focus Group 3: Number/ Mean (SD) Interviews: Number/ Mean (SD) Total: Number/ Mean (SD)
Gender
 Men 6 4 3 6 19
 Women 5 3 5 4 17
Race/Ethnicity
 White 2 1 1 4
 Black/AA 7 5 8 8 28
 Latino/a / Hispanic 2 2
 Asian/ PI 1 1
 Other 1 1
Age 47.1 (6.2) 49.1 (8.6) 49.9 (10.0) 56.1 (4.7) 50.6 (7.9)
Diagnosis
 Schizophrenia 1 6 5 12
 Schizoaffective 3 1 2 6
 Bipolar 4 3 1 1 9
 Major Depression 3 2 5
 Other 2 1 3
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Analysis

All interviews were audio recorded, transcribed verbatim, and entered into NVivo 10, a qualitative data management software program, for thematic analysis. Thematic analysis is atheoretical and can be adapted for use with a variety of frameworks (Braun & Clarke, 2006). For this inquiry, data were initially analyzed inductively, meaning no pre-existing theory or model was used to drive analysis. Instead, themes were identified from a “bottom-up” approach, so that they remained very close “to the data themselves” (Braun & Clarke, 2006; Miles, Huberman & Saldana, 2014). Inductive analysis was completed using the first five of Braun and Clarke’s (2006) analytic phases: Researchers familiarized themselves with the data as a whole, generated initial codes, searched for themes, reviewed themes in consultation with a critical inquiry group, and named each defined theme. After completing the inductive thematic analysis, findings appeared to be resonant with SDT. A decision was made to engage in a subsequent deductive analysis to investigate if and how the inductive findings mapped onto the main constructs of SDT.

Researcher biases in analysis were managed using two primary strategies to enhance rigor: First, member checks were conducted with each participant of in-depth interviews to ensure resonance of preliminary findings (Padgett, 2017). Second, the first author participated in biweekly meetings of a critical inquiry group made up of health and mental health researchers (Abboud et al., 2017); during these meetings, the researcher shared transcripts, iterations of the codebook, analytical approach, and findings at various stages of completion to critically examine possible bias and enhance the trustworthiness of findings (Padgett, 2017).

Findings

“You have to find a way” (Competence)

Participants shared how they developed effective strategies to pursue recovery by first learning to engage in self-reflection during WRAP programming. Through the process of looking inward, they developed insight into signs of wellness and decrements to wellness – how they felt, looked, and behaved. With guidance from the facilitators, participants carefully reflected on the kinds of strategies that had been helpful in the past and began to consider how those same strategies could be used intentionally to impact their journey toward recovery. “You know, I was just sleeping. Eatin’ anything that I wanna eat. Doin’ what I wanna do. And now the WRAP group taught me to—you know, wellness, I got to be well in this”. Participants identified activities that were compatible with healthy living and easily accessible, which could be incorporated into action plans to pursue recovery and mitigate risks to wellness. Participants underscored the importance of finding effective strategies that were personalized to their own situation, generally in two categories of strategies: proactive and reactive (see Table 2 for a summary of findings).

Table 2.

Summary of Findings

SDT Construct Inductive Findings
Competence “You have to find a way”
   Proactive
   Reactive
Relatedness “If they can believe it, I can believe it”
   Normalizing the struggle and learning to cope
   Reaching out, connecting with others
   Building momentum through group processes
Autonomy “The plan is for you to get yourself back together”
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Proactive.

Participants described the utility of developing a routine of activities they did every day to maintain their wellness, some of which were short and perfunctory: “Say how to stay well – you get up, eat, you take your medicine. All of the things that you need to do – everything’s to take care of ourselves”. In addition to daily wellness activities, participants shared that they developed strategies to advance their wellness and reach recovery goals:

I knew I needed more. I just couldn’t be stuck like them…I’ve got things in life that I want to do. I’m not tryin’ to be 20 years here [at the mental health agency]…. And if I can overcome my depression, I’m gonna go over there and try to do something…I wanted to change, I wanted something to do.

As participants intentionally initiated activities conducive to wellness goals, they developed a sense of competence in their ability to impact their recovery. Participants talked about using WRAP to accomplish goals like returning to work, going to school, and smoking cessation.

It also gave me an opportunity to look at my whole life. And different areas of my life that I really would benefit from some adjustments, realignments…I thought, “I wanna go back to school. I’m at a stage in my recovery where I think I can handle this.” WRAP was the very first thing I went to. Because I know myself well enough to know that when I take on a lot of things, sometimes that’s a set-up for a fall… So this was an opportunity to say “Imani, you really want to do this,” and “How can you do this and still walk through it and keep standing and keep growing and keep moving forward and stay well?” Um, “Develop a WRAP.”

Reactive.

In addition to proactive strategies, participants described how they developed strategies to manage threats to wellness and reestablish their degree of recovery: “You have to write down something that when you get to that point in your life where you’re that angry or that upset or that sad, you have to find a way to get yourself around that.” For many, warning signs that wellness might deteriorate were coupled with repeating, predictable problems; they developed strategies to ameliorate those problems that were almost always effective.

When I get angry, I take a walk, put my music in…then I’ll be all right. And then [a peer] wants me to count to 10. It works sometimes. It really does. When I count to 10, I mean it works. I’ll take a walk, come back maybe 10, 20 minutes later. I’m good.

Participants underscored the importance of developing personalized strategies and practicing until their implementation became rote. Effective strategies were identified through trial and error and metaphorically stored in a “toolbox,” which was either a written or mental list of accessible strategies to feel healthy and well. Several participants said the tools in the box should “always” be effective and should generalize to every situation: “You should have every tool that you need in that toolbox when the time comes…. it’s like when you buildin’ a house. You start at the foundation, and you make it grow.”

Most people agreed that of all the plans created during WRAP programming, the wellness toolbox was the most important. The wellness toolbox contains the strategies that people use to deal with challenging situations and feelings, and it represents the skills people feel competent utilizing to impact their recovery and wellness.

“If they can believe it, I can believe it” (Relatedness)

Beyond the mechanics of how people use WRAP and for what purposes, WRAP programming had a profound impact on how people understood their relationship to mental health challenges and recovery, normalizing their struggles and fostering hope. They discovered a greater priority for social support and developed increased investment for utilizing WRAP’s framework to pursue wellness because of the broad social endorsement of other WRAP participants and the facilitators.

Normalizing the struggle and learning to cope.

Participants shared a pre-WRAP unwillingness to admit to themselves or others that they struggled with mental health challenges. Because they ignored their problems, they never developed solutions to resolve them.

I still was in denial of my mental health challenges because I thought I was different… But when I went to the WRAP and see other people…that put me at the level, you know, to handle myself…And be more honest about what my mental health challenge is. And do something about it.

For many, stigma about mental illness prevented them from feeling comfortable enough to learn and enact strategies to change. Rather than seeking support or services, people chose to ignore challenges and stoically bore the burdens they experienced. Engaging with other WRAP participants throughout the program served as a catalyst to reconsider their relationship with mental health struggles and the strategies they used to actively manage those challenges.

I was amazed at how many other people also had depression and other challenges. And how were they coping with it because, um, I guess growing up it was like an embarrassment to have these challenges, difficulties. And just to – knowing how other people were coping and living their life and recognizing that kinda like inspired me to make some changes in life. And not to feel embarrassed anymore being who I am.

Reaching out, connecting with others.

Participants reported various reasons for keeping personal struggles with mental illness to themselves, but a common experience was struggling alone. In order to feel comfortable opening up to others, people first wanted to know that others shared similar experiences, that reaching out was normal, and that getting support was helpful. Many learned those lessons in WRAP programming where there was a facilitator to model the behavior and other group members with whom to practice.

It made me feel like, you know, I can open up, and I’m not the only one that’s going through mental health issues. It’s a whole great big world of people out there going through symptoms and being well about it and getting on with their lives.

For some, the importance of social support was about hope surrogacy: having someone else believe that recovery was possible – even when they did not yet believe it themselves. Having others express hopefulness helped people to develop their own hope that they could indeed feel better.

Right, and that makes me feel like I can do it. When someone believes that you can do it. And if you doubt yourself, then say, “If they can believe it, I can believe it. I can do it.”

Building momentum through group processes.

Although the specifics of what people learned based on the curriculum of WRAP seemed important, many participants reported that the group processes of WRAP programming was instrumental to its success. As the program progressed, broad enthusiasm for self-management built within WRAP groups, engendering the belief that recovery is possible, reinforcing buy-in to the key concepts of the program, and underscoring social endorsement for the ideas that people can take control of their personal journeys toward recovery.

A one-on-one doing a WRAP is a good thing. But it’s more difficult, it seems, to really complete that – have the person really drawn in and invested. It’s different when it’s a group because the energy is contagious, right? So the one person becomes interested, and you start finding similarities around the room, and then everyone becomes invested because everyone can see a part of themselves in what’s being shown and talked about. And then you – once you become invested – then you wanna know more.

A similar process occurred during the focus groups. Participants built energy as the focus group progressed, sharing with more enthusiasm and articulating a re-commitment to the intentional pursuit of recovery. As participants observed one another grow in excitement, their internal sense of enthusiasm grew accordingly, illustrating the importance of relatedness – particularly the importance of peers’ social endorsement for internalizing commitment to self-management.

Participant 1: And then every once in a while it just so happens a person like [the focus group moderator] comes by and just refreshes everything and shakes it all up for me. [General agreement: “Yeah.” “Appreciate that!”]

Participant 2: As we are all sitting here and having these conversations, that is exactly – what is happening is kinda reinvigorating on some level on realigning my focus.

In one focus group, participants provided peer support to a participant who they worried had incomplete strategies to pursue recovery: they encouraged him to find new strategies to deal with his challenging emotions and spent time brainstorming with him. On three separate occasions during the two-hour meeting, group members took a break from responding to the moderator’s questions to provide peer support to participants in the group who had emotional reactions to the stories they shared about their personal journeys toward recovery. At the end of the focus group participants exchanged phone numbers with the intention of continuing their incipient relationships to provide peer support to each other in the future. Thus, the experience of discussing the merits of self-management in a group, as well as giving and receiving support around self-management strategies, built a surplus of energy resulting in recommitment, reinvigoration, and reinforced internalization of self-management.

“The plan is for you to get yourself back together” (Autonomy)

Once participants invested in the program and developed hope in the possibilities for recovery, they turned their attention inward to carefully examine how to realize their own vision for recovery: “You gotta take actions for your own self. You know, and the plan is for you to get yourself back together.” WRAP provided structure for participants to systematically reflect on strengths, areas for growth, and the effectiveness of recovery strategies. Beyond requisite skills, participants had to make a choice to engage in self-reflection in daily life. For many, the process of looking inward became routine and was directly related to taking personal responsibility for recovery, “The WRAP did help me because I have to look into myself, and I have to help myself. I wasn’t doing’ that before.”

In addition to self-reflection, participants had to make a choice to utilize their personalized strategies to address challenges.

So every little tangled thing would just trigger me all the way off. You know what I’m saying? And so to learn about my triggers and what I could do and the tools that I could use to just help me with the triggers that really had overtaken my life…at that point is when I really embraced WRAP.

During programming, people were encouraged to consider past strategies that have been successful in promoting and regaining wellness and to be mindful about using those strategies more purposefully when emotional challenges arise, “…being aware of your symptoms, and when your symptoms do occur, you could actually do something about it, and you have ways of coping with it.”

Participants also shared the importance of evaluating the effectiveness of chosen solutions and continuing to engage in self-directed trial and error in their daily lives.

You have to really see if anything that you learned from your WRAP is really working for you, ‘cause in here, we got plenty of support. It’s when you’re out there in them lonely streets is when you might get in a situation and you want to know how to deal with this and you can’t get nobody on the phone to de-escalate you or calm you down. You have to find a way to calm yourself down.

Discussion

Self-determination theory appears consistent with participants’ description of how they learned and used WRAP’s framework to pursue recovery. Whereas some theories position people as passive responders to external stimuli, SDT suggests that people are inherently oriented toward psychological growth and wellness, driven by endogenous stimuli (Petros & Solomon, 2019; Ryan & Deci, 2002, 2017). While participants did discuss the importance of specific skills they learned, they were also clear that something more than skills-building was necessary for recovery to flourish: an internal shift in volition and enthusiasm for the pursuit of recovery and wellness.

Relatedness

Participants affirmed that the spirit of recovery is like a snowball rolling down a hill, getting bigger as it gains momentum; they described how that spirit grew in themselves during WRAP programming, spurred on by the infectious energy of others, and how they changed internally as WRAP programming progressed. For these participants, recovery began to take shape before new skills were ever implemented. Deegan (1992) described how recovery is not just about what one does, but it is about how one sees oneself:

Thus, part of the work that faces us in our journey toward independent living is to learn to identify, challenge, and change mentalism and the false charity that robs us of our right to failure and the dignity of risk. We are learning that we are not fragile cripples that need to be protected. We are discovering our pride and our dignity. We are discovering that we are a strong people with fiercely tenacious spirits. (p. 15)

Participants developed a deeper understanding of recovery through the social components of programming. They found a sense of normalization about the experience of mental health challenges and, through testimonies from facilitators and other group members, developed an integrated understanding of how problems can coexist with recovery (Leamy et al., 2011; Mizock, Russinova, & Shani, 2014). Participants gained a readiness to acknowledge such difficulties and learned the benefits of reaching out to others to develop solutions.

Relatedness – particularly a shared social endorsement of the self-management framework – was paramount to the internalization of using WRAP. Throughout programming, participants learned to view the pursuit of recovery as their own personal responsibility and to believe they are capable of reaching recovery goals. Facilitators disclosed personal success using WRAP, inspiring others to try for themselves. Progressively, group members shared initial attempts and successes implementing WRAP’s framework in their daily lives, reinforcing shared belief in its value and efficacy. Thus, as collective social endorsement grew, participants internalized motivation for using WRAP.

Competence

Consistent with WRAP’s recommendations, participants created individualized action plans to pursue recovery. The plans included routine daily activities that were easily accessible, free or low-cost, and promoted a sturdy baseline of wellness. WRAP plans also included reactive or contingency plans, referred to as strategies stored in a “wellness toolbox,” for use when participants encountered challenging emotions or difficult situations. Only a small minority reported having crisis or post-crisis plans.

For the majority of participants, the most important aspect of their plans seemed to have been the process of writing it. As participants engaged in WRAP programming, they were guided through a process of self-reflection. During these guided reflections, they gained insight into personal signs of wellness and decrements of wellness as well as insight into effective strategies for maintaining, restoring, and promoting wellness. Thus, the process of writing plans facilitated skills-building in systematic self-reflection, the identification of recovery strategies, and assessment of the degree to which those strategies were effective at preserving and advancing recovery. Throughout programming, participants implemented strategies in their daily lives through a process of trial and error, sharing results with the group and building skills as they practiced their strategies. The majority of participants perceived increased competence in self-reflection, their ability to match strategies to wellness needs, and implementation of wellness strategies – all key goals of self-management programs (Petros & Solomon, 2015; Clark et al., 1991). Successes reinforced their motivation for continued application of WRAP’s framework, consistent with SDT’s proposition that people are more inclined to internalize motivation for activities for which they feel competent (Deci & Ryan, 2008; 2015; Ryan, 2009; Ryan & Deci, 2000; Ryan, Huta, & Deci, 2006).

Autonomy

A common refrain amongst participants was that “WRAP works if you work it,” underscoring the necessity of self-determination and personal responsibility in the pursuit of recovery. Successful use of WRAP requires that people choose to engage in self-reflection and use trial and error to determine what works and what does not. Participants were clear that no one can force someone to engage in WRAP; each person must autonomously elect it. The process of framing interventions as a choice subverts the dominant idea that providers have expertise, without which a person cannot recover. The process of choosing to learn and use WRAP’s framework is consistent with the central purpose of recovery, to live a self-directed life worth living (Deegan 1988; Leamy et al., 2011).

The Relevance of SDT to Self-Management

SDT is concerned with behavior that leads to psychological growth and the social environmental conditions that supports such behavior (Ryan & Deci, 2017). Conceptually, SDT has clear overlap with self-management, given that both are concerned with self-regulated learning and enactment of health-promoting behavior (Petros & Solomon, 2019). The motivational concepts associated with SDT may provide special considerations for how self-management programs may be studied and augmented. The more a person acts with autonomous motivation, the more likely that person will be able to experience well-being and psychological growth (Deci & Ryan 2015; Ryan & Deci 2017), which comports with participants’ descriptions of their experience with WRAP. They progressively built autonomous motivation for implementing WRAP’s framework to continuously identify and enact behaviors conducive to recovery. Rather than adopting a prescribed list of strategies, what appeared most salient to participants was the experience of freedom, personal responsibility, and internalization of motivation to figure out for themselves what was helpful. The shift in outlook and approach to learning and enacting strategies was essential to their gains in recovery and wellness. Although this research focused specifically on WRAP, findings are likely transferrable to other ISM programs, such as Illness Management and Recovery and BRIDGES (Petros & Solomon, 2019).

Member Checks and Trustworthiness

When considering the trustworthiness and credibility of findings presented in this article, there is reason to believe the member checks were not pro forma, but supported resonance of the findings. The process of member checks involved not only the preliminary analysis of each participant’s individual interview, but also the preliminary analysis of findings from the entire corpus of qualitative data. All participants provided some degree of clarification or offered alternative interpretations until we developed a shared understanding of the findings. The presence of critical feedback provided an indication that participants did not merely acquiesce to the researchers’ presumed authority and were not unduly affected by social desirability bias or reactivity to the research. On the contrary, most of the participants thanked the interviewer for the opportunity to participate in the research and provide feedback, and one person raised his arms in triumph after his member check, saying, “I did it!” out of pride for his contribution to research. Participants seemed to feel a personal responsibility to ensure the research was resonant and trustworthy.

Limitations of the Research

Participants in this qualitative inquiry were disproportionately Black and people with schizophrenia, located in an east coast urban city, which may impact the transferability of findings; however, the use of member checks strengthens the credibility of the findings, which resonated with participants. In addition, because the final deductive analysis sought to investigate the degree to which main findings mapped onto constructs of SDT, it is possible that had the authors selected another theory for a deductive analysis, the presentation of findings may have changed. For instance, the two sensitizing theories that informed the conceptual framework of the study were SDT and Social Cognitive Theory (SCT). While many of the findings also mapped onto components of SCT, the “fit” was more parsimonious with SDT. Moreover, only some parts of SCT were represented in the findings; therefore, SDT was selected for deductive analysis because of a conceptual resonance with findings from the initial inductive analysis. In addition, no question on the interview guides inquired directly about the main constructs of self-determination theory, which gives us greater confidence that we did not merely “find what we looked for.”

Practice and Research Implications

Because ISM programs for adults with serious mental illness uniquely privilege the self-determination and autonomy of service users, having access to them is an issue of social justice, particularly given the paternalism that long-dominated mental health treatment. However, certain conditions must be met for ISM programs to flourish at an organization.

Administrators must have the will to offer ISM programs, and providers’ collective values must be compatible with the principles of self-management, which are decidedly client-centered and recovery-oriented (Petros & Solomon, 2015). Providers often position people with psychiatric disabilities as risky individuals who need management and containment (Rose, 1998), but efforts to control behavior and impose decisions on service users removes their self-determination and creates new risks to their recovery (Sykes, Brabban, & Reilly, 2015). Administrators who err on the side of risk aversion may employ staff who are unwilling or not empowered to support the right of service users to take the risks inherent in the autonomous process of trial and error constitutive of self-management. Providers and administrators can serve as effective change-agents by creating organizational cultures that honor the dignity and worth of adults with psychiatric disabilities (Moran, Russinova, Gidugu, Yim, & Sprague, 2012) and recognize their right to engage in ISM programs that promote risk-taking.

A mental health system that promotes ISM programs needs providers who are trained in compatible practices that are collaborative and promote self-determination. Shared-decision-making and motivational interviewing are two practices emerging in the field as best practices that support autonomy, while fostering positive change (Lukens, Solomon, & Sorenson, 2013; Tennille, Solomon, & Bohrman, 2014).

Findings suggest that people learn WRAP’s framework best by interacting with peer facilitators and other people who are learning and implementing the self-management framework. The social processes appear instrumental by helping to meet service users’ psychological need for relatedness. Participants developed a sense of competence in utilizing WRAP’s framework by practicing strategies in daily life as they learned with their peers. As programming progressed, participants developed a sense of personal responsibility and embraced their autonomy for implementing WRAP’s framework. Future research may assess the results presented here by measuring constructs of relatedness, competency, and autonomy to evaluate their possible role as mediators of change for recovery outcomes for self-management interventions. Environments that are autonomy-supportive and offer opportunities for skills-building and social engagement may maximize the impact of such interventions. These findings are consistent with other research that suggests people with serious mental illness learn best by putting strategies into action and have a preference for peer-based supports and services (Cabassa et al., 2013) – not only receiving support, but also providing it to others (Moran et al., 2012). Moreover, recovery seems to flourish when people volitionally engage in self-management behaviors (Moran et al., 2012).

Conclusion

Illness self-management programs are philosophically compatible with a recovery orientation, and growing evidence suggests their efficacy in advancing recovery for adults with serious mental illness (Petros & Solomon, 2015). The ways in which people learn and use ISM frameworks have important implications for how such programs are situated within the mental health service delivery system. Providers and administrators may consider how the service environments in which they work support or thwart service users’ psychological needs for autonomy, relatedness, and competence. The array of services offered within an organization may vary in their compatibility with SDT and may provide an indication of the degree to which the service environment is conducive to self-determination. Services within organizations can be carefully selected to reinforce autonomy and augment service users’ internalization for learning and utilizing an ISM framework.

Footnotes

The authors disclose receipt of the following financial support for the research, authorship, and/or publication of this article: Ruth L. Kirschstein National Research Service Award through the National Institute of Mental Health to the first author.

The Authors declare that they have no conflicts of interest.

Contributor Information

Ryan Petros, University of Washington School of Social Work, 4101 15th Ave NE Seattle, WA 98105, USA.

Phyllis Solomon, University of Pennsylvania School of Social Policy and Practice, 3701 Locust Walk Philadelphia, PA 19104, USA.

References

  1. Abboud S, Kim SK, Jacoby S, Mooney-Doyle K, Waite T, Froh E, … & Kagan S (2017). Co-creation of a pedagogical space to support qualitative inquiry: An advanced qualitative collective. Nurse Education Today, 50, 8–11. 10.1016/j.nedt.2016.12.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Braun V, & Clarke V (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. 10.1191/1478088706qp063oa [DOI] [Google Scholar]
  3. Braun V, & Clarke V (2013). Successful qualitative research: A practical guide for beginners SAGE Publications. [Google Scholar]
  4. Breeze J (1998). Can paternalism be justified in mental health care?. Journal of Advanced Nursing, 28(2), 260–265. [DOI] [PubMed] [Google Scholar]
  5. Cabassa LJ, Parcesepe A, Nicasio A, Baxter E, Tsemberis S, & Lewis-Fernández R (2013). Health and wellness photovoice project: Engaging consumers with serious mental illness in health care interventions. Qualitative Health Research, 23(5), 618–630. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Clark NM, Becker MH, Janz NK, Lorig K, Rakowski W, & Anderson L (1991). Self-management of chronic disease by older adults: A review and questions for research. Journal of Aging and Health, 3(1), 3–27. 10.1177/089826439100300101 [DOI] [Google Scholar]
  7. Cook JA, Copeland ME, Corey L, Buffington E, Jonikas JA, Curtis LC, … & Nichols WH (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. 10.2975/34.2.2010.113.120 [DOI] [PubMed] [Google Scholar]
  8. Cook JA, Copeland ME, Floyd CB, Jonikas JA, Hamilton MM, Razzano L, … & Boyd S (2012a). A randomized controlled trial of effects of wellness recovery action planning on depression, anxiety, and recovery. Psychiatric Services, 63(6), 541–547. 10.1176/appi.ps.201100125 [DOI] [PubMed] [Google Scholar]
  9. Cook JA, Copeland ME, Hamilton M, Jonikas J, Razzano L, Floyd C, … & Grey D (2009). Initial outcomes of a mental illness self-management program based on wellness recovery action planning. Psychiatric Services, 60(2), 246–249. 10.1176/ps.2009.60.2.246 [DOI] [PubMed] [Google Scholar]
  10. Cook JA, Copeland ME, Jonikas JA, Hamilton MM, Razzano LA, Grey DD, … & Boyd S (2012b). Results of a randomized controlled trial of mental illness self-management using Wellness Recovery Action Planning. Schizophrenia Bulletin, 38(4), 881–891. 10.1093/schbul/sbr012 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Copeland ME (2010). WRAP plus Dummerston, VT: Peach Press. [Google Scholar]
  12. Corbin J, & Strauss A (2014). Basics of qualitative research: Techniques and procedures for developing grounded theory Sage Publications. [Google Scholar]
  13. Creswell JW (2013). Qualitative inquiry and research design: Choosing among five approaches (3rd ed.). Los Angeles, CA: SAGE Publications. [Google Scholar]
  14. Creswell JW (2014). Research design: Quantitative, qualitative, and mixed methods approaches (4th ed.). SAGE Publications. [Google Scholar]
  15. Deci EL, & Ryan RM (2008). Self-determination theory: A macrotheory of human motivation, development, and health. Canadian Psychology/Psychologie Canadienne, 49(3), 182–185. 10.1037/a0012801 [DOI] [Google Scholar]
  16. Deci EL, & Ryan RM (2015). Self-determination theory. In International Encyclopedia of the Social & Behavioral Sciences (2nd ed. pp. 486–491). Elsevier. 10.1016/B978-0-08-097086-8.26036-4 [DOI] [Google Scholar]
  17. Deegan PE (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4), 11–19. 10.1037/h0099565 [DOI] [Google Scholar]
  18. Deegan PE (1992). The independent living movement and people with psychiatric disabilities: Taking back control over our own lives. Psychosocial Rehabilitation Journal, 15(3), 3–19. 10.1037/h0095769 [DOI] [Google Scholar]
  19. Fukui S, Starnino VR, Susana M, Davidson LJ, Cook K, Rapp CA, & Gowdy EA (2011). Effect of Wellness Recovery Action Plan (WRAP) participation on psychiatric symptoms, sense of hope, and recovery. Psychiatric Rehabilitation Journal, 34(3), 214. 10.2975/34.3.2011.214.222 [DOI] [PubMed] [Google Scholar]
  20. Glaser B, & Strauss A (1967). The discovery of grounded theory Hawthorne, NY: Aldine Publishing Company. [Google Scholar]
  21. Harding CM, Brooks GW, Ashikaga T, Strauss JS, & Breier A (1987). The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. American Journal of Psychiatry, 144(6), 727–735. [DOI] [PubMed] [Google Scholar]
  22. Heath H, & Cowley S (2004). Developing a grounded theory approach: A comparison of Glaser and Strauss. International Journal of Nursing Studies, 41(2), 141–150. [DOI] [PubMed] [Google Scholar]
  23. Higgins A, Callaghan P, deVries J, Keogh B, Morrissey J, Nash M, … & Carter T (2012). Evaluation of mental health recovery and Wellness Recovery Action Planning education in Ireland: a mixed methods pre–postevaluation. Journal of Advanced Nursing, 68(11), 2418–2428. 10.1111/j.1365-2648.2011.05937.x [DOI] [PubMed] [Google Scholar]
  24. Jonikas JA, Grey DD, Copeland ME, Razzano LA, Hamilton MM, Floyd CB, … & Cook JA (2013). Improving propensity for patient self-advocacy through Wellness Recovery Action Planning: results of a randomized controlled trial. Community Mental Health Journal, 49(3), 260–269. 10.1007/s10597-011-9475-9 [DOI] [PubMed] [Google Scholar]
  25. Kettles AM, Creswell JW, & Zhang W (2011). Mixed methods research in mental health nursing. Journal of Psychiatric and Mental Health Nursing, 18(6), 535–542. 10.1111/j.1365-2850.2011.01701.x [DOI] [PubMed] [Google Scholar]
  26. Kobrin M (n.d.). SAMHSA Encourages Use of Life-Changing Wellness Strategies SAMHSA https://mfpcc.samhsa.gov/ENewsArticles/Article03b_2018.aspx
  27. Leamy M, Bird V, Le Boutillier C, Williams J, & Slade M (2011). Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. The British Journal of Psychiatry, 199(6), 445–452. 10.1192/bjp.bp.110.083733 [DOI] [PubMed] [Google Scholar]
  28. Lukens JM, Solomon P, & Sorenson SB (2013). Shared decision making for clients with mental illness: A randomized factorial survey. Research on Social Work Practice, 23(6), 694–705. [Google Scholar]
  29. Marshall C, & Rossman GB (2016). Designing qualitative research (6th ed.). SAGE Publications. [Google Scholar]
  30. Mechanic D (2007). Mental health and social policy: Beyond managed care Pearson Higher Ed. [Google Scholar]
  31. Miles MB, Huberman A, M., & Saldana J (2014). Qualitative data analysis: A methods sourcebook (3rd ed.). Los Angeles, CA: SAGE Publications. [Google Scholar]
  32. Mizock L, Russinova Z, & Shani R (2014). New roads paved on losses: Photovoice perspectives about recovery from mental illness. Qualitative Health Research, 24(11), 1481–1491. [DOI] [PubMed] [Google Scholar]
  33. Monahan J, Redlich AD, Swanson J, Robbins PC, Appelbaum PS, Petrila J, … & McNiel DE (2005). Use of leverage to improve adherence to psychiatric treatment in the community. Psychiatric Services, 56(1), 37–44. [DOI] [PubMed] [Google Scholar]
  34. Moran GS, Russinova Z, Gidugu V, Yim JY, & Sprague C (2012). Benefits and mechanisms of recovery among peer providers with psychiatric illnesses. Qualitative Health Research, 22(3), 304–319. [DOI] [PubMed] [Google Scholar]
  35. National Institute of Mental Health. (2015). Strategic plan for research Bethesda, MD: NIH. Publication Number: 15–6368. Retrieved January 19, 2019 from https://www.nimh.nih.gov/about/strategic-planning-reports/nimh_strategicplanforresearch_508compliant_corrected_final149979.pdf. [Google Scholar]
  36. New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final Report (DHHS Pub. No. SMA-03–3032) Rockville, MD: U.S. Department of Health and Human Services. [Google Scholar]
  37. Padgett DK (2017). Qualitative methods in social work research (3rd ed.). Los Angeles, CA: SAGE Publications. [Google Scholar]
  38. Petros R (2017). Learning and utilizing WRAP’s framework: The process of recovery for serious mental illness Retrieved from ProQuest Dissertations & Theses Global.
  39. Petros R, & Solomon P (2015). Reviewing illness self-management programs: A selection guide for consumers, practitioners, and administrators. Psychiatric Services, 66(11), 1180–1193. [DOI] [PubMed] [Google Scholar]
  40. Petros R, & Solomon P (2019). Application of Self-Determination Theory to Illness Self-Management Interventions: Identifying Mediators. Administration and Policy in Mental Health and Mental Health Services Research, 46(6), 760–767. [DOI] [PubMed] [Google Scholar]
  41. Roberts G, & Wolfson P (2004). The rediscovery of recovery: open to all. Advances in Psychiatric Treatment, 10(1), 37–48. 10.1192/apt.bp.112.010652 [DOI] [Google Scholar]
  42. Rose N (1998). Governing risky individuals: The role of psychiatry in new regimes of control. Psychiatry, Psychology and Law, 5(2), 177–195. 10.1080/13218719809524933 [DOI] [Google Scholar]
  43. Ryan R (2009). Self-determination theory and well being. Social Psychology, 84(822), 848. [Google Scholar]
  44. Ryan RM, & Deci EL (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and wellbeing. American Psychologist, 55(1), 68. 10.1037/0003-066X.55.1.68 [DOI] [PubMed] [Google Scholar]
  45. Ryan RM, & Deci EL (2002). Overview of self-determination theory: An organismic dialectic perspective. In Deci EL & Ryan RM (Eds.), Handbook of self-determination research (pp. 3–33). Rochester: University Rochester Press. [Google Scholar]
  46. Ryan RM, & Deci EL (2017). Self-determination theory: Basic psychological needs in motivation, development, and wellness New York: The Guilford Press. [Google Scholar]
  47. Ryan RM, Huta V, & Deci EL (2008). Living well: A self-determination theory perspective on eudaimonia. Journal of Happiness Studies, 9, 139–170. 10.1007/s10902-006-9023-4 [DOI] [Google Scholar]
  48. SAMHSA. (n.d.). Learn more: Wellness toolbox and WRAP https://brss-tacs-decision-tool.samhsa.gov/DA_files/LearnMore_Wellness_Toolbox.html
  49. Starnino VR, Mariscal S, Holter MC, Davidson LJ, Cook KS, Fukui S, & Rapp CA (2010). Outcomes of an illness self-management group using wellness recovery action planning. Psychiatric Rehabilitation Journal, 34(1), 57–60. 10.2975/34.1.2010.57.60 [DOI] [PubMed] [Google Scholar]
  50. Sykes MJ, Brabban A, & Reilly J (2015). Balancing harms in support of recovery. Journal of Mental Health, 24(3), 140–144. 10.3109/09638237.2014.998812 [DOI] [PubMed] [Google Scholar]
  51. Szmukler G, & Appelbaum PS (2008). Treatment pressures, leverage, coercion, and compulsion in mental health care. Journal of Mental Health, 17(3), 233–244. [Google Scholar]
  52. Tennille J, Solomon P, & Bohrman C (2014). Using the FIELD model to prepare social work students and field instructors on sexuality and intimacy for persons with psychiatric disabilities. Sexuality and Disability, 32(4), 469–483. [Google Scholar]
  53. Williams D, Bellis E, & Wellington S (1980). Deinstitutionalization and social policy: Historical perspectives and present dilemmas. American Journal of Orthopsychiatry, 30(1), 54–64. [DOI] [PubMed] [Google Scholar]
  54. Zimmerman BJ (1989). A social cognitive view of self-regulated academic learning. Journal of Educational Psychology, 81(3), 329–339. 10.1037/0022-0663.81.3.329 [DOI] [Google Scholar]
  55. Zipursky RB, Reilly TJ, & Murray RM (2013). The myth of schizophrenia as a progressive brain disease. Schizophrenia Bulletin, 39(6), 1363–1372. [DOI] [PMC free article] [PubMed] [Google Scholar]

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