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WRAP: A Problem Solving Therapy for RSAT Clients with Co-Occurring Disorders
WRAP: A Problem Solving Therapy for RSAT Clients with Co-Occurring Disorders
Wellness Recovery Action Plan (WRAP) Mary Ellen Copeland, Ph. D Manualized group intervention for adults with mental illness. Guides participants thru the process of identifying and understanding their personal wellness resources (“wellness tools”) and then helps them develop an individualized plan to use them on a daily basis. SAMHSA NREPP
National Registry of Evidence-Based Programs and Practices: Problem Solving Therapy ATHENA (Athletes Targeting Healthy Exercise & Nutrition Alternatives) Intention to use steroids/creatine Intention to engage in unhealthy weight loss Choosing Life: Empowerment! Action! Results! Substance use frequency (CLEAR) Program for Young People Living With HIV sexual risk behavior (condom use) Project TALC (Teens and Adults Learning to Communicate) Problem Behaviors Emotional Distress Conduct Behavior Drug Dependency Teen Intervene Frequency of substance use Symptoms of substance abuse and dependence Negative consequences related to alcohol and other drug involvement Wellness Recovery Action Plan (WRAP) Symptoms of mental illness Hopefulness Recovery from mental illness Self-advocacy Physical and mental health
Disclaimer: Advocates for Human Potential as so impressed with WRAP as an evidence-based Problem Solving Therapy (PST) that it bought it. Neither Andy Klein nor Jon Grand are certified WRAP facilitators. This webinar is designed to introduce broad operational concepts of PST, using WRAP as an example.
WRAP: A Problem Solving Therapy for RSAT Clients with Co-Occurring Disorders WRAP GOALS -Teach how to implement key concepts of recovery- hope, personal responsibility, education, self-advocacy, & support- in daily lives -Help participants organize list of wellness tools-activities to help feel better in response to mental health difficulties or prevent their onset -Help participants to create advance directives that guide family/supporters to intervene when participants can’t act appropriately on their own behalf -Help participants develop individualized post-crisis plan for use as mental health difficulty subsides to promote return to wellness
WRAP USE -Only criterion: Voluntary -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. , decision-making, interpersonal relationships). -Usually groups 8 -12 w/ two trained cofacilitators, using lectures, discussions, and individual and group exercises. Key WRAP concepts illustrated through examples from the lives of the co-facilitators and group. 8 weekly 2 hour sessions, but adaptable.
WRAP Research Cook, J. et al. (2012). Results of a randomized controlled trial of mental illness self-management using Wellness Recovery Action Planning, Schizophrenia Bulletin, 38 (4), 881 -891 Cook, J. et al. (2009). Initial outcomes of a mental illness selfmanagement program based on Wellness Recovery Action Planning, Psychiatric Services, 60(2), 246 -249
WRAP RESEARCH FINDINGS -Significant greater reduction in the severity and number of symptoms from baseline to post-test to 6 month follow up (Brief Symptom Inventory, BSI) -Significant greater improvement in hopefulness across time from baseline to post-test to 6 -month follow-up (Hope Scale, HS) -Significant improvement one month after post-test in RAS scores for overall recovery (personal confidence, willingness to ask for help, goal orientation, reliance on others, and freedom from symptom domination (Recovery Assessment Scale, RAS) -Significant improvement one month post-test in self advocacy (Patient Self. Advocacy Scale, PSAS) -Significant improvement one month post-test in physical and mental health (Short Form-12 Health Survey, SF-12)
WRAP includes: Wellness Toolbox Daily Maintenance Plan Triggers and Action Plan Early Warning Signs and Action Plan When Things Are Breaking Down & Action Plan Crisis Planning Post Crisis Planning
Implementing WRAP Developing a wellness toolbox -Listing of things you have done in the past or could do to help yourself stay well, & -Things you could do to help you feel better when you are not doing well
Common Wellness Tools Talk to a friend Talk to a health care provider Peer counseling Focusing exercise Relaxation and Stress Reduction Exercises Guided imagery Creative and affirming activities Journaling Listen to music Exercise Extra rest Attend a support group Do something normal like wash hair Get a medication check Surround yourself with people who are positive Make a list of your accomplishments Get some little thing done Take a warm shower Do something that makes you laugh
AVOID Alcohol, sugar, caffeine Going to bars Getting over tired Certain people Certain places Thinking about certain topics
Daily Maintenance Plan First List (Baseline): Describe yourself when you are feeling well, descriptive words to help you remember what being well feels like. e. g. Bright Cheerful Talkative Outgoing Boisterous Active Quiet Peaceful Humorous Happy Enjoy crowds Dramatic Athletic Optimistic Calm Argumentative Reasonable Responsible Industrious Curious a Jokester A chatterbox Supportive Competent Reserved
Daily Maintenance Plan Second List: Doable things you know you need to do to stay happy and healthy. -Eat 3 healthy meals/ snacks -Exercise for at least ½ hour -Get outside light at least ½ hour -Take 20 minutes for rest/relaxation -Check in with partner for at least 10 minutes -Go to work if it is a work day -Write in my journal for at least 15 minutes -Get support from someone I can be real with -Check in with myself, assess physical, emotional, spiritual status
Daily Maintenance Plan Third List What I need to do or would be good to do each day. -Spend time with counselor, case manager, etc. -Set up appt. with health care provider -Do peer counseling (AA/NA etc. ) -Be in touch with family -Get sleep -Do some house work -Write some letters -Buy groceries -Plan something fun for the weekend -Have some personal time -Take a bubble bath -Call my sponsor -Plan a trip -Go to a meeting -Do the laundry
Triggers First list What might happen that will make me feel worse. -Anniversary of bad events -Traumatic news -Being over tired -Work stress -Being around people drinking/drugging -Relationship ending -Too much alone time -Guilt from saying NO -Being criticized, put down, teased -Money problems -Physical illness -Loud noises -Being scapegoated -Reminders of abandonment or deprivation -Certain foods
Responses to External Triggers (Trigger Action Plan) -Make sure I do everything on my Daily Maintenance Plan -Call a support person and ask them to listen while I walk thru the situation -Do some deep breathing exercises -Remember it is OK to take care of myself -Work on changing negative thoughts to positive ones -Get validation from someone I am close to Also: journaling, going for walk, focusing exercises, peer counseling, seeing case manager/sponsor, time out in comfortable place, enjoy structured play time, playing a musical instrument, singing/dancing, going to community activity, vigorous exercise (See Daily Maintenance Plan…)
Early Internal Warning Signs Staying well: Subtle internal changes may indicate we may need to take some further action. -anxiety -nervousness -forgetfulness -inability to experience pleasure -lack of motivation -substance abuse -weepiness -not answering phone -easily frustrated -feeling slowed down or speeded up -being uncaring -avoiding others, isolating self -being obsessed with trivial thing -feeling worthless -being too quiet -compulsive behaviors -increased negativity -increased irritability -increase in smoking -spending money on unneeded things -impulsivity -over/ under eating -craving drugs/alcohol -feeling abandoned/rejected
Early Internal Warning Signs Responses (Early Warning Signs Action Plan) Things to do: -Do things on Daily Maintenance Plan even if don’t feel like it -Tell support/counselor how I am feeling -Peer counseling daily -Do at least one focus exercise -Do 3 to 10 minutes relaxation exercises -Write in my journal for at least 15 minutes daily -Spend at least 1 hour involved in activity I enjoy -Ask others to take over my housekeeping responsibilities for the day -Go to 12 step meeting
Early Internal Warning Signs Responses Things to do that feel right for me: -Check in with my physician/ health care provider -Surround myself with loving/affirming people -Spend time with my pet -Read a good book -Dance, sing, listen to music, play instrument -Exercise -Go fly a kite -Go fishing
When things are breaking down or getting worse Preventing a crisis… List things that indicate well-being has worsened and you are close to crisis stage: -feeling very over-sensitive and fragile -irrational responses to events and others -unable to sleep for… -sleeping all of the time -increased pain, headaches -avoiding eating -racing thoughts -risk taking, like driving too fast -thoughts of self harm -substance abuse -obsessed with negative thoughts -inability to slow down -bizarre behavior, e. g…… -dissociations (spacing out/losing time) -seeing things -taking anger out on others -chain smoking -spending excessive amount of money, e. g. … -Not feeling -drinking -paranoia
Response When Things Are Breaking Down List what to do when things are breaking down: -Call doctor or health care provider, follow their instructions -call and talk to supporter -arrange for someone to stay around the clock until feel better -take action to prevent self harm, e. g. give medications, check book, credit cards, car keys to pre-arranged friend for safe keeping -make sure I am doing everything on Daily Maintenance Plan -arrange and take at least 3 days off from my responsibilities -have at least two peer counseling sessions daily -do 3 deep breathing relaxation exercises -do two focusing exercises -write in journal for at least 30 minutes Do I need a physical examination? Have medication checked?
Crisis Planning Before Crisis Occurs Develop when you are well to instruct others about how to care for you when you are not. Help them help you. Unlike prior exercises, this will be used by others. Once completed, after careful consideration, give copies to supporters.
Crisis Plan First Step: What you are like when you are feeling well. Same as first section of the Daily Maintenance Plan. This will alert ER doctors, for example, what you are like when you are well and not confuse them which are symptoms of poor feelings and which are not e. g. Being Talkative or Reserved Being Practical or Adventurous Being Quiet or Outspoken
Crisis Plan Second Step: Signs that indicate that others need to take responsibility for your care. -Unable to recognize family/friends -Inability to control body functions -High fever -Severe pain -Unable to stay still, pacing -Very rapid breathing/ seeming to gasp for air -Severe agitation, unable to stop -Catatonic, unmoving for long periods -Inability to stop compulsive behaviors, like constantly counting everything -Neglecting personal hygiene -Not cooking or doing any housework -Extreme mood swings -Destruction to property, throwing things -Thinking I am someone I am not -Substance abuse -Refusing food/drink
Crisis Plan Third Step: --List at least five supporters who are liable to be available. Some may be designated for specific tasks, e. g. bill paying, taking care of children/pets, staying with you, taking you to health care appointments, etc. --List people you do NOT want involved in your care. --Hierarchy of decision-makers on your behalf, who decides…
Crisis Plan Fourth Step: --List Medications, physicians and pharmacy, allergies you have --List Medications currently you are on and for what --Preferences for other medicines if necessary and why you prefer them --Medications you don’t want and why.
Crisis Plan Fifth Step: Treatments: what you prefer, what should be avoided e. g. , electroshock therapy, massage therapy, acupuncture… Sixth Step: Plan to be able to stay at home or in care facility in the community and still get the care you need. Seventh Step: Treatment facilities preferred or opposed if need hospitalization
Crisis Plan Inform helpers how they can best help you. What supporters can do to help you. -Listen to me without judging -Hold me -Let me pace -Peer counsel with me -Take me on a walk -Make sure I get outdoor light -Don’t or do talk to me -Play me comic videos -Just let me rest -Play me good music -Keep me from hurting myself even if you must restrain me -Do what is necessary to keep me from hurting others -Encourage me -Reassure me -Feed me good food -Give me space to express my feelings -Lead me thru a relaxation or stress reduction technique
Crisis Plan Things others should avoid doing to help: -Forcing me to do something -Trying to entertain me -Chattering -Playing certain kinds of music -Playing certain videos -Getting angry with me -Being impatient with me -Not believing me -Not listening to me
Crisis Plan Ninth Step: Signs that your supporters are no longer needed: -When I have slept thru three nights -When I eat at least two good meals a day -When I am reasonable and rational -When I can be in a crowd without being anxious -When I am taking care of my personal hygiene needs -When I can carry on a good conversation -When I keep my living space organized
Crisis Planning Take Your Time: -Review, update and provide supporters with up-to-date copies -Reach out to others for help and advise in completing plan -Don’t rush it, work on the plan over days/weeks
Post-Crisis Plan You may need time to fully recover even when crisis is passed, just like from a successful operation Post crisis plan can be based on Wellness Tool Box and Daily Maintenance Plan
PST for RSAT Participants w/Co-Occurring Disorders Plenty of time to think, reflect, and develop Tools for Problem Solving Therapies RSAT programs can facilitate process by assembling groups to work on developing these tools Groups can be facilitated by RSAT Program staff or outside volunteer peers who have training in PST
WRAP Example for RSAT In Georgia prisons: The Georgia Department of Corrections opened two integrated treatment facilities in 2012, featuring 9 month highly structured programs actively combining interventions intended to address both mental health and substance use disorder. Elements include screening, assessment to include risk-need responsivity, individualized treatment, on-going monitoring of mental health symptoms, cognitive behavioral treatment, illness management, trauma-focused treatment, psychoeducational, therapy, cognitive restricting groups, motivational enhancement therapy, relapse prevention, medication assisted therapies, psycho-pharmacologic interventions and illness management, problem-solving skills, dual recovery mutual self-help recovery, and a reentry plan to include a Wellness Recovery Action Plan (WRAP).
WRAP Example for RSAT In Mississippi jail: Jail Takes Steps to Improve Mental Health Care By James Cone …The local nonprofit (which is not affiliated with the County Mental Health Department) now facilitates two new weekly group sessions at the Tompkins County Jail called WRAP and Talk. About three to four men and the same number of women meet separately in back-to-back sessions, which is the ideal number of participants, said Parker Carver, though he would like to see the frequency of the classes increase. The sessions are not technically “group therapy, ” as they are not led by licensed therapists but by Mental Health Association employees who have undergone an intensive one-week training.
Other Prisons and Jails Currently Using WRAP Federal Bureau of Prisons: Dublin, CA, Waseca, MN, Fort Worth, TX & Danbury, CT State DOCs: NH, PA (Laurel Hill), OR, CO, ND, RI, IA, KY (La. Grange) Counties: Volusia County Corrections – Deland, FL Stafford Creek Corrections Center – Aberdeen, WA Thurston County Corrections Facility – Olympia, WA Kit Carson Correction Center – Burlington, CO Taycheedah Correctional Inst. – Fond du Lac, WI
WRAP-based Curriculum for Mental Health and Co -Occurring Recovery http: //store. samhsa. gov/product/Taking-Action-A-Mental-Health-Recovery-Self-Help-Educational-Program/SMA 14 -4857
For more information: http: //mentalhealthrecovery. com/wrap-is/