Positive Approaches Journal, Volume 8, Issue 3

Volume 8 ► Issue 3 ► 2019

Wellness Recovery Action Planning and Mental Health Advanced Directives

Gina Calhoun, Matthew Federici, and Sue Walther

Abstract

When we think about recovery, we think about freedom from...freedom from addiction, freedom from anxiety controlling one’s life, freedom from stigma and discrimination, freedom from institutionalization.

Recovery is also freedom to – freedom to take risks to be the well person we want to be; freedom to explore a self-determined life based on hopes, dreams and goals; freedom to be included in one’s community.

The Wellness Recovery Action Plan (WRAP®) through a Peer Group Model offers the opportunity for participants to discover a self-determined well life and take action toward the freedom we want to achieve.

For the context of this article, we will focus on fidelity to the peer group model.  For ease in reading the article and for readers new to WRAP®, please note the language of Wellness Tools. Wellness Tools are defined as “a list of things you have done in the past, or could do to help yourself stay as well as possible, and the things you could do to help yourself feel better when you are not doing well.” ^{1, 2, 3} The Wellness Toolbox is the cornerstone of developing a WRAP®.  WRAP® is a designed plan to put your wellness tools into action.  Developing a Wellness Recovery Action Plan® promotes self-determination; you can take action and make intentional decisions about your wellness.

In Pennsylvania, we recognize the right of people to have voice and choice in their lives, even in the midst of crisis.  Pennsylvania Mental Health Advanced Directives are highlighted in this article.

The article is written in first-person language in an effort to recognize the value of “I” statements when sharing perspectives and to bring the evidence-based practice of a peer group model to life.

Introduction

I'm Gina Calhoun, a program director and trainer at the Copeland Center for Wellness and Recovery. At the Copeland Center, the practice of the Wellness Recovery Action Plan (WRAP®) is a shared peer group experience that leads to each person developing their own wellness plan to live a self-determined life. 

I learned about WRAP®, after escaping from Harrisburg State Hospital to live on the streets.  At that time, I didn’t have much hope for a meaningful life in the future.  The WRAP® material helped me to shift my thoughts away from what’s wrong and towards what’s strong in my life.  The WRAP® peer group experience offered the validation and support I needed to put these new thoughts into action. I love being part of the WRAP® community, especially when we work together to translate our values and ethics into practical applications.  When we create strength-based approach with mutual learning and rich connections, endless possibilities emerge.

In 2010, WRAP® groups were recognized by the United States Substance Abuse and Mental Health Services Administration (SAMHSA) as an evidence-based practice and listed in the National Registry of Evidence-Based Programs and Practices. ⁴ Researcher Dr Judith Cook from the Department of Psychiatry at the University of Illinois at Chicago (UIC) released the results of a randomized control trial study that demonstrated significant positive behavioral health outcomes for individuals with severe and persistent mental health challenges who participated in peer-led WRAP® groups. ⁵

Research studies on WRAP® from UIC revealed positive outcomes were tied to the fidelity of the WRAP® co-facilitation model. This model was based on specific values-based practices highlighted further in this article. As WRAP® expands to schools, the healthcare system and developmental programs, we are called to ensure fidelity of a proven model that works.  We want the very best possible outcomes for people we have the honor to support toward an everyday life.

At The Copeland Center, we like to distinguish WRAP®’s meaning by emphasizing that we are “Recovering our Wellness” not recovering from an illness.   As the acronym denotes, it is also a plan.  It is a structured system that I develop for myself to take back control of my life and move toward a wellness goal.  Perhaps I want to take back control of my life from unhealthy eating habits and move towards a healthier diet or a healthier weight – I can develop a WRAP® for that.  Perhaps I want to take back control of my life from unemployment and move towards getting a job – I can write a WRAP® for that.  Perhaps I want to discover a way to be happier and healthier in my everyday life – YES, I can write a WRAP® for that too.  WRAP® is not a plan that I put on the shelf; WRAP® is a plan I put into action.  WRAP® works if I work it; it doesn’t if I don’t.

One example of how I’ve used WRAP® in my own life, includes developing a plan to become a nonsmoker.  When I was court-committed to a State Hospital, I didn’t get outside for almost 2 years because I wasn’t on a so-called privilege level.  Then I found out that smokers, no matter what privilege level they were on got outside every 2 hours for two cigarettes.  I could put two and two together and I started smoking. After 15 years of a pack of cigarettes a day, it became one of the hardest habits to break.

There are benefits to smoking, at least there were for me…I can name a few: 1) It lessened the noisiness in my head so I could focus outwardly on relationships. 2) It offered a purposeful pause to my life, making it easier to transition from one task or activity to the next. 3) It momentarily lessened boredom and eased anxiety.

When I decided to become a nonsmoker, I developed a WRAP® to quit smoking.  First, I developed a list of Wellness Tools that would meet the same needs that smoking once met and Wellness Tools that were incompatible with having a cigarette.  For example, you can’t take a shower and smoke at that same time; the first two months of becoming a nonsmoker, I was the cleanest person in the world.  Rock climbing was a particularly helpful Wellness Tool because the left to right physical activity of climbing helped me to balance my left-right brain activity.  I got to envision what I’d be like as a nonsmoker – the things I needed to do every day to control cigarettes so they didn’t control me and the things I might choose to do on occasion especially if

I was saving money becoming cigarette free.  I recognized my Triggers and Early Warning Signs AND how I could take action using my wellness tools.  I learn so much about myself – why I smoke and what I could do if I was choosing not to.  As a reward for developing my WRAP® – I celebrated with two cigarettes.  It is when I took personal responsibility for implementing my WRAP® and gathered supporters to encourage my journey – I was able to quit smoking. 

WRAP® works when you live your self-determined plan.

WRAP® is also an evidence-based practice. WRAP® groups are co-facilitated by people living WRAP® in their own lives and who have taken the opportunity to complete a WRAP® Facilitators Course.  This course is essential to the fidelity of WRAP® groups.  Through training, co-facilitators experience living the values and ethics intra- and interpersonally.

I’m Matthew Federici and in 2010 I came to work for the Copeland Center for Wellness and Recovery as the executive director.  Prior to this position, I had been on a journey that many of you have been on; from providing direct human services, management and then directing mental health programs.  In this journey I was increasingly drawn toward programs and models based on individual strengths, practical approaches, and peer-to-peer models.  When I signed up for a team working to transform Pennsylvania through the training and implementing of Peer Specialist, I met more and more people like Gina Calhoun. 

Gina is a peer supporter, who was demonstrating that with the right opportunities, people considered to be in the “backwards” of institutions with little hope for recovery, can indeed succeed as full contributors in the community.  Yet it was through the workshops on the Wellness Recovery Action Plan with Gina and other peer colleagues, side by side, that I found my voice, my story of wellness recovery. 

Underneath my professional journey was a deep-seated belief in any individual’s potential for personal transformation because I had experienced it and witnessed firsthand.  I had grown through times of near self-destruction. I grew with my family through times of mental health crisis. I visited my older brother in state hospitals and group homes.  As a family, we recovered with a supportive community that never gave up hope, took responsibility, learned everything we could, advocated for our goals and found the peer support we needed.  It wasn’t until attending my WRAP® workshop that I found a clear explanation of why my encounter and my brother’s encounter with the mental health system didn’t result in chronicity. 

The Copeland Center’s work and Dr. Copeland’s initial research leading to the first WRAP® book validated the message of hope, self-efficacy, and personal empowerment.  It validated messages that were just waiting to take root and expand in my professional and personal life.  My application of WRAP® started by illuminating my inner strengths and life lessons learned and today remains active to guide me in new personal bests in my wellness.  Without my active use of WRAP® with peer support I am convinced I would have burned out five times over by now. 

The practice of WRAP® is expanding to support more and more people around more and more life issues.  The most encouraging part for me is that this practice came from the people of our society who were written off as having the least insight into recovery.

Highlighting the fidelity to values-based practices

As executive director, I have had the privilege to collaborate, network, and learn from likely close to a thousand people applying WRAP® in their own lives but also that are facilitating the application of WRAP® for thousands of other people.  One of my consistent observations over the past 10 years is how the WRAP® Co-Facilitator course impacts our lives.  A pre-requisite for this course is having learned and used our WRAP® so that we can build on that individual application and focus on critical values and practices in how we create a shared learning environment as co-facilitators.

Over the years, I have experienced and witnessed a key impact in learning these values and practices: a deepening understanding of how our WRAP® is not isolated to our personal, private life.  Wellness recovery happens in relationships with others and is strengthened by an ongoing process of living with supporters whom we choose.   A few of my favorite values and practices are focusing on strengths, placing no limits on recovery, focus on the mutual learning of peers working together and being the expert in our own life. These may give you a sense of the stark contrast to some traditional beliefs.   However, it is not just a few that makes the environment so empowering to me - it is the synergy and totality of all the values and practices embraced by each diverse group that I see compelling people toward personal transformation.

I once had the pleasure to meet another great professional hero in my career, Dr. William Anthony, considered the founder of the Psychiatric Rehabilitation model out of Boston University.  He pointed out to me that evidence-based practices are great but how we will innovate and create evidence for new effective practices is not just doing the same old things. Instead, it is focusing on values-based practices. 

When the values and practices are alive in the group, people begin to unleash the power within themselves, try new ways of thinking and behaving and move toward a life filled with self-determination, empowerment, self-advocacy and personal responsibility.

Testimonials ⁶

The value of WRAP® and the community around it is buried right in the title for me. Our world is full of problems and turmoil and it would be very easy to give in to despair faced with any one challenge. I learned in a Copeland Center refresher course last year that the sweet spot in the catastrophe is not in having the ability to solve the problems but in the empowerment of being able to take an action no matter how small that action seems. There is a force and energy that can be unleashed with the endless options of Wellness Tools being shared by the mutual learning in the workshops and the ones I have yet to create. For me, this is the true essence of the first key concept of Hope, the unlimited possibilities of approaching finding wellness in existence in my own unique way.  (Eric, Peer Support Specialist, Pennsylvania)

When I started my recovery journey, I learned that I could have hope, and WRAP® was a major part of that hope. Through WRAP®, I first learned that I was an expert on myself, that I could have hopes and dreams, and that everyone deserved to be treated with dignity, compassion, and respect. I would have been the last person who would have thought that I would be where I am now, living a life, instead of just living. But WRAP® taught me that no matter what happens from day to day, I am able to control my thoughts and feelings about it. WRAP® has been there, through many challenges, and it's given me the ability to come through the other side of those challenges, stronger than I would have been before. I also found a community of the greatest people who are my evidence, every single day, who let me know that I can succeed at the things that I don't realize that I can do, yet. (Joseph, Peer Support Specialist, New York)

Learning about WRAP® was a life changer for me. It taught me to look deep inside myself, to recognize my strengths, put my own label to my name, and to raise my self-awareness by identifying all the difficulties that I face but with a plan to take action in overcoming and dealing with those difficulties when they arise.  WRAP® taught me to see more to me than my story told, and gave me the tools to continue to improve to be the person who I know I really am. I would sit down for hours at a time, developing my WRAP®, learning about myself, and increasing my own awareness to both my good and bad traits. I spent time “experimenting,” you could say, on what worked for me, and what did not. I became aware that I really was the only expert on myself. WRAP® enlightened me to the idea that self-discovery and being my authentic self was possible.  It helped me to find me. (Amey, Program Manager for a Peer-run Organization, Vermont)

WRAP® has been an influence in my life by sharing commonalities with other individuals and been the breaking point for me and my recovery to move forward with work again, leadership, faith, and trust in myself.

There are many reasons why I am where I am today in my life and the factors of WRAP® just in its name stands for, wellness recovery action planning - without wellness there is no recovery, no action, and definitely no planning. (Todd, Executive Director of a Peer-Run Organization, Iowa)

I am Sue Walther, the Executive Director of the Mental Health Association in Pennsylvania (MHAPA). I have held this position for more than 15 years. In my role as executive director, I oversee programs that provide navigation and advocacy for individuals seeking services and supports. In addition, I coordinate trainings and MHAPA’s public policy activities. I have been committed to reducing the stigma surrounding mental illness and to ensuring that everyone has the opportunity to live in the community of their choice.

During my association with MHAPA, I have witnessed a revolution in the mental health system. There is still work to be done, but in my time the system has gone from a medical to a recovery model; it has changed from institutional based to community focused; it is shaped in true partnership with consumers and their families; and finally, it is based on wellness and strengths not illness and weaknesses. We owe a debt of gratitude to individuals and their families with lived experience who were willing to speak out strongly and frequently to ensure a system that works for the individual. Those courageous folks shaped my career at MHAPA and I am forever thankful.

SAMHSA defines recovery as a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.  One of the recovery tools to assist individuals in their journey is a mental health advance directive.

In 2004, Pennsylvania enacted legislation (Act 194) that provides the opportunity for individuals living with mental illness to create a Mental Health Advance Directive (MHAD) and plan ahead for mental health services and supports in the event they become unable to make decisions for themselves. A MHAD offers a clear written statement of an individual’s mental health treatment preferences or other expressed wishes or instructions should they become incapacitated. It can also be used to assign decision-making authority to another person who can act on that person’s behalf during times of incapacitation.

MHADs offer several key benefits. Correctly implemented and executed, they can:

• Promote individual autonomy and empowerment in the recovery from mental illness;

• Enhance communication between individuals and their families, friends, healthcare providers, and other professionals;

• Protect individuals from being subjected to ineffective, unwanted, or possibly harmful treatments or actions; and

• Help in preventing crises and the resulting use of involuntary treatment or safety interventions such as restraint or seclusion.

Components of a mental health advance directive include the specific intent to create a document that allows for advance mental health care decision making; specific instructions about preferences for hospitalization and alternatives to hospitalization, medications, electroconvulsive therapy, and emergency interventions and participation in experimental studies or drug trials; instructions about who should be notified if and when the person is admitted to a psychiatric facility; and also instructions on who should have temporary custody of minor children or pet.

References