Subject:
RECOVERY

Short Description:
Helping the Severely Mentally Ill to Help Themselves

Background:

“Self-management” is a newly popular buzzword among clinicians treating the seriously mentally ill. Self-management programs include psychoeducation for patients about their illness, training to help patients communicate more effectively with their doctors, and instruction on how to advocate for themselves in treatment settings.

One of the more popular self-management programs is Wellness Recovery Action Planning (WRAP). In WRAP, trained peer instructors lead weekly sessions consisting of group exercises, lectures, and voluntary homework. Group topics include such items as maintaining wellness, recognizing symptoms, managing crises, and learning where to obtain credible information about one’s condition. In a controlled trial early last year, patients of public mental health clinics who participated in WRAP had fewer psychiatric symptoms and an enhanced quality of life than those not receiving WRAP training (Cook JA et al, Schiz Bull 2011;online ahead of print).

One possible explanation for the efficacy of WRAP is that it facilitates a patient’s self-determination and builds self-advocacy skills. To test this hypothesis, the researchers randomized 555 community mental health patients, most of whom had been diagnosed with psychotic or mood disorders (but no substance use disorders), to either a two-month WRAP intervention (276 patients) or to treatment as usual (279 patients). All patients continued to receive medications, case management, and therapy if and when indicated. “Self-advocacy” was measured by the Brashers’ Patient Self-Advocacy Score (PSAS). This scale consists of three subscales: education, the patient’s willingness to learn about his/her illness; assertiveness, the patient’s ability to be assertive during a health-care encounter; and mindful non-adherence, the patient’s inclination to disregard a provider’s recommendations (while we often consider “non-adherence” an undesirable outcome, in this case, it represents the patient’s ability to act autonomously in an informed way) (Brashers et al, Health Communication 1999;11(2):97–121).

Patients who received WRAP training had greater self-advocacy scores over time than those assigned to treatment as usual. This was particularly true on the measure of mindful non-adherence; scores on the other subscales did not change significantly. Higher overall self-advocacy scores were significantly correlated with higher levels of hopefulness (correlation coefficient r = 0.45), better quality of life (r = 0.28), and lower symptom severity, as measured by the Brief Symptom Inventory (BSI) Global Severity Index (r = -0.23). (Jonikas JA et al, Comm Ment Health J Dec 2011;online ahead of print).

TCPR's Take:
WRAP training appears to be a simple and inexpensive way of increasing the assertiveness of the seriously mentally ill. We’d like to see longer term follow-up, but meanwhile we recommend referring patients to such a program if you can find one in your community.