Transcript here - (RSAT) Training and Technical Assistance

WRAP: A Problem Solving
Therapy for RSAT Clients with CoOccurring Disorders
Housekeeping: Functions
Housekeeping: Communication
WRAP: A Problem Solving
Therapy for RSAT Clients with CoOccurring Disorders
Wellness Recovery Action
Plan (WRAP)
Mary Ellen Copeland, PhD
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!
(CLEAR) Program for Young People Living With HIV
Substance use frequency
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 SelfAdvocacy 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 (LaGrange)
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 CoOccurring Recovery
http://store.samhsa.gov/product/Taking-Action-A-Mental-Health-Recovery-Self-Help-Educational-Program/SMA14-4857
For more information:
http://mentalhealthrecovery.com/wrap-is/