Explaining How Adults with Serious Mental Illness Learn and Use Self-Management

Background and Purpose: Wellness Recovery Action Plan (WRAP) is an illness self-management (ISM) intervention used internationally, with demonstrated effectiveness in enhancing recovery, hope, and self-advocacy for adults with psychiatric disabilities; however, effect sizes are small, and it may not improve participants’ ability to develop and adapt recovery strategies once programming has ended. Currently, there is no theoretical understanding of how the intervention causes change. This study was conducted to investigate how adults with serious mental illness learn and utilize an illness self-management framework through WRAP programming, to identify key predictors of recovery outcomes, and to identify an underlying conceptual framework compatible with NIH’s experimental therapeutic approach to guide future research.

Methods: The study employed an exploratory sequential mixed methods design. The qualitative phase used an interpretive descriptive approach with thematic analysis. Data were collected from three focus groups (26 participants), 10 in-depth interviews, and follow-up member checks to investigate how participants learn and utilize WRAP’s framework to pursue recovery and to identify facilitators and barriers. Qualitative participants were adults who self-identified as experiencing serious mental illness and had completed WRAP programming (78% Black, 53% male, 50% schizophrenia-spectrum disorder).  The quantitative phase used an anonymous online survey (N=82; gender: 68% female; race: 44% Black, 40% White; diagnosis: 33% depression, 28% bipolar, 20% schizophrenia-spectrum disorder) to test qualitative findings about the degree to which problem-solving confidence and self-reflection and insight predict the degree of perceived recovery for WRAP users with serious mental illness, employing multiple regression analyses. Eligibility criteria for online survey respondents included adults (at least 18-years-old), diagnosis of serious mental illness, and completed WRAP programming within 6-18 months.

Findings: Participants used WRAP to increase self-reflection and insight about their recovery needs and goals; to develop effective strategies to restore, maintain, and advance wellness; and to rebuild a positive outlook of themselves and their interactions with others, augmented by increased hope and empowerment about their abilities to successfully pursue recovery. Problem-solving and social support were identified as major facilitators and barriers to learning and using WRAP. Problem-solving confidence (p<.001) and social support (p<.001) were the main predictors, accounting for 41% of the variance in the degree of perceived recovery.

Conclusions and Implications: Participants’ descriptions of learning and utilizing WRAP’s illness self-management framework to pursue recovery is consistent with self-determination theory, which posits the importance and centrality of meeting one’s psychological needs for autonomy, competence, and relatedness. Social support (relatedness) and problem-solving confidence (competence) may work in tandem to help people learn and use WRAP’s ISM framework. WRAP users may benefit from additional support to augment competence and relatedness – particularly in the form of group support that incorporates formal problem-solving strategies and ongoing reciprocal peer support to assist in the adaptation and implementation of recovery strategies prospectively as problems, life circumstances, and recovery-oriented goals change. Future research, taking a social work approach, may use self-determination theory to examine the causal mechanisms of change and to develop interventions to augment WRAP’s efficacy.