Part 1. The Development of WRAP
I get lots of e-mails from people all over the country and all over the world. E-mail is a great tool for keeping us all connected in ways that weren’t possible just a few years ago. I often hear distressing stories of how people live for years with terrible mental health challenges. Although I do hear stories of helpful treatment, I hear far too many stories of people who have been badly treated when they reached out for help, or when they were coerced into getting help. This troubling scenario often keeps people from getting the help they need. Their quality of life is compromised. Too often the despair overwhelms them and they end their own lives. Or they die young, victims of the medications and treatments that were supposed to be so helpful.
I wish that everyone knew about WRAP (Wellness Recovery Action Plan). It has been helpful to so many people. The research has proved that it helps people to feel better and move on with their lives. The problem is, far too few people know about. I do the best I can to network it, and I now have lots and lots of people helping me. But it is not enough. Kids should know about WRAP, or how to take care of themselves from childhood. Adults need to learn how to do the same thing. It is my wish that when someone starts to feel badly, they look at the resources they have and figure out how to help themselves feel better. If they reach out to an agency, or even a doctor for help, the help begins by working the person, step-by-step through the non-invasive, self-determined and empowering WRAP process. The first questions should be about what the person knows help them to feel better.
I am often given credit for developing WRAP. That is not true. I did not develop WRAP. In this article I will share with you how, according to my recollection, WRAP was developed, as I described it recently at a conference. In the second part I will describe the values and ethics that have evolved around WRAP. I think these same values and ethics should guide mental health service provision at every level.
On a cold winter day in northern Vermont in 1997 I was finishing up an 8 day training teaching almost 40 people, mostly people who had serious mental health issues, who had braved the wind-chill and the blowing snow, the skills and strategies I had learned through my studies. I thought I had done a great job. Then a woman stood up in the back of the room and said, “This is all well and good. But I have been in state hospitals all over the country and I wouldn’t have any idea how to organize these things to make them work in my life.” I will never forget that moment. I heard her, and so did all the other people who were there. And we made a commitment that day to keep meeting until we had come up with some kind of a system so that people could organize the skills and strategies they had been learning into their lives.
We spent three full days deliberating. Trying this idea and that idea. We worked with sheets of newsprint paper across the wall. Sharing ideas. Discussing things. Crossing things out. Adding new things. Until, after 3 days, it felt like we had something. And someone said, “Let’s call it the Wellness Recovery Action Plan–it has such a good acronym”–and so WRAP was born.
I am going to describe for you how that process went. I think it is important. The structure that they came up with is the same structure that is WRAP today. And the one that has been thoroughly studied, the one that is now evidence based and listed in the National Registry of Evidence-based Programs and Practices.
First they decided you have to have a list of all of the possibilities, all of the things you can use to help yourself feel better and help yourself stay well. That became the Wellness Toolbox. It included things like all the skills and strategies I had been teaching them all week–relaxation and stress reduction techniques, diet changes, exercise, focusing, arts, music–the list can go on and on and on and often does. I have over 80 Wellness Tools on my list. And it can keep growing and growing and growing as the person keeps growing and changing and as their needs change.
Then they agreed you need a list of those tools you need to use every day. Call it the Daily Maintenance Plan. It shouldn’t be too long so you can be sure to get it all done. And then they said, before that you need at least a list of words that describe you when you are well. You need a point of reference. You could write a paragraph, or a book, or put in a picture, but a simple list of descriptive words would be fine. And then they said, after your list of things you need to do every day, you need a list of things you might need to do on any given day to avoid stress–things like buy groceries, make an appointment, keep an appointment, call a friend, clean your living space.
Then they said, what about those unexpected things that happen that get us off course–triggers they called them. Things like someone being rude, or a big disappointment like losing a job, or seeing an accident, or an upsetting news story, or the anniversary date of a great loss. We need to list them. We can add to this list as we discover new ones. Then they said we need an action plan so we don’t get overwhelmed when these things come up. So, back they went to their Wellness Toolbox and came up with lists of possible things they could do to keep from getting overwhelmed or stressed or to get back to feeling OK after an unexpected event or trigger. They felt that, because these things happen at lots of unanticipated times and in unanticipated places, they would need different options of actions they could take. As you can see, a new way of proactive thinking is evolving here. They were coming up with a structure that anyone could use to develop their own personal WRAP, their Wellness Recovery Action Plan.
Then they said there are times when we just start feeling worse and we don’t know why. I could really relate to that. Sometimes I just feel off. I don’t feel like buckling my seat belt. I don’t feel like answering the phone. I have a slight headache. I have a negative attitude. I am self-critical. They wanted to call this time Early Warning Signs. This was all sounding so sensible to me. They said we should make a list of these early warning signs, and then develop another action plan of things they must do when they notice these signs. For me personally these were the kinds of things I always used to ignore. So taking action at this time was a new concept for me, a new way of thinking. I put things on my list like getting at least on hour of exercise, working on either a drawing or quilting project, playing the piano for half an hour, and making my favorite Creamed Dried Beef on Toast for lunch.
Then they said that next they need to know When Things have Gotten Much Worse. H’mmm. Isn’t this the time when we should go to the emergency room or call the crisis team? Or better yet, we could help ourselves around this and get ourselves feeling good again. They wanted to call this section “When Things are Breaking Down”. And again, it would start with developing our own individual list for what, personally, for us, indicates that things are breaking down. Things like crying all the time, not eating at all, being unable to sleep for three nights, yelling at people you love, feeling like drinking alcohol or drinking alcohol, feeling like cutting or even cutting. They acknowledged that these signs are very idiosyncratic. What might be an early warning sign for one person might mean things were breaking down for someone else. And then they said, we need an action plan–something we are committed to do even when we don’t feel like it, something that is very structured with few choices, something like what a good hospital day would look like in a perfect world. It might be 4 relaxation exercises a day, a half hour playing my trumpet, two-fifteen minute sessions of being listened to by a friend, one hour of walking or riding my exercise bicycle, and wearing my power outfit.
It took lots of haggling to get this far. We had been warned that people wouldn’t be able to stay in a session for 15 minutes. They worked on this from 9-4 for 3 days. They felt exuberant about it.
They said there is one more piece we need. Given what we have already come up with, we think we can avoid a crisis where other people have to step in and take care of us. But given the uncertainty of the future, we should include a Crisis Plan or Advance Directive. Something that tells others what to do for us when we cannot take responsibility for ourselves. Something we actually give to others. All had been in agreement that this WRAP needed to be developed by the person who was using it and only they would determine what was in it and they didn’t have to show it to anyone else unless they wanted to. But this part of the plan had to be different so others would understand it.
What they came up with has some of the usual “boiler plate” that is found in all Advance Directive forms. But they also included some innovative sections that they felt were critical to their recovery. One was a list of signs that indicate someone needs to step in and take over–to prevent well-meaning supporters from stepping in when you are already doing what you need to do to help yourself feel better. It includes a list of those supporters–and a list of people who should not be included in any crisis responses. It includes a plan so that they can stay at home or in the community rather than be hospitalized, it has a list of things that they would like others to do for them that would help them feel better, and a list of things that others should not do, things that would make them feel worse.
So that was WRAP. And people were really happy about it. They all left with a strong commitment to try it. I did too. I went home and the next afternoon, when my spouse went off to make maple syrup, I decided to write my WRAP. This is now March 1997. I wrote my WRAP. And I started using it. I was amazed. My own personal level of wellness moved ahead faster than I could have imagined. I was thrilled. I was getting reports from others who helped with the development of WRAP that they were getting the same results.
So I decided to share it at the next conference I was invited to speak to–the International Conference for Depression and Manic Depression. When I got to the conference and realized there were lots of workshops on brain anatomy and the chemical formulation of pharmaceuticals, I cringed. But I decided to go forward with my plan. I presented WRAP to a full house. At first people seemed incredulous. But by the time I finished everyone was with me. I got a standing ovation. People said, “Finally something we can do to help ourselves.
Things happened quickly after that. Everyone wanted WRAP. I wrote the red WRAP book that describes it. And those books went flying across the country and around the world. We experimented with various formats for sharing WRAP and found that, while there are various ways people can learn about WRAP and use it in their lives, the one that works best is the WRAP group, facilitated by a trained facilitator. So, working with a group of people who were committed to recovery, we developed the Mental Health Recovery and WRAP Curriculum and a five-day training protocol for training facilitators. It has been enormously successful.
And Richard Hart from West Virginia convinced many others and me that we needed a post crisis plan. We came up with one, checked it out with lots of people, revised it over and over again, and then, added it to WRAP. It was what people felt like they needed to guide their way back to wellness, to again using their Daily Maintenance Plan, when they had been through the worst of times.
We now have thousands of facilitators around the world leading WRAP groups. There are 250 Advanced Level Facilitators who are teaching people how to be WRAP facilitators. There are mental health agencies and organizations in every state and in many countries around the world using WRAP as the cornerstone of their wellness and recovery efforts. Uncounted numbers of people are developing WRAP on their own using one of the many WRAP resources.
The Copeland Center and the Advanced Level Facilitators continue to train more and more WRAP group facilitators. People purchase training manuals, self help books, videos, audios and e-learning courses based on WRAP. They love the MY WRAP and the MYWRAP Crisis Plan booklets. Over 12,000 people visit our website every month. And that is with no money from government or pharmaceutical companies.
But it is still not enough. It won’t be enough until everyone who needs to know about WRAP or even self help can easily access and find their way to a rich and rewarding life.
Let me finish by telling you about a man, I will call him Wesley. Wesley is a very important person in my life. He was in that group in northern VT that developed WRAP. Wesley attended with a care provider. He couldn’t come alone. He was anxious and agitated and often had to go outside to regain his composure. His speech was garbled. He was very hard to understand. He dressed in dark clothing, always wore a hat and kept his head done. He avoided interactions with others. I let him know that I was glad he was there–and I didn’t ask or expect anything of him. His being there was enough. A huge step for him. After the group was over, I got a call from time to time from a care provider asking where there might be another group Wesley could attend. Then I didn’t see him for a few years and lost track of him. I was invited to a WRAP group graduation. I enjoy those celebrations so, when I can, I go. This time I was met by a man wearing shorts in a Hawaiian shirt, grinning broadly. He said, “Hi Mary Ellen”. I did a double take. Then he said, “You don’t recognize me, do you.” And then suddenly, I did. It was Wesley. Wesley. He had been to many, many WRAP groups and here he was. His speech was fine. He didn’t need a care provider to bring him. He stayed through the gathering. Life is good for Wesley now. Who would have ever anticipated that?
In Part 2 I will describe the Values and Ethics that have evolved around WRAP.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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