Reviewing Illness Self-Management Programs: A Selection Guide for Consumers, Practitioners, and Administrators
Abstract
Illness self-management (ISM) programs for adults with serious mental illness offer strategies to increase self-directed recovery activities to maximize wellness and increase independence from the service delivery system. This article describes five of the most popular ISM programs: Pathways to Recovery, The Recovery Workbook, Building Recovery of Individual Dreams and Goals through Education and Support, Wellness and Recovery Action Planning, and Illness Management and Recovery. It provides guidance for administrators, practitioners, and consumers for the purposes of selecting the program or programs providing the best fit. The framework for describing the five programs encompasses four contextual domains that supplement empirical evidence for a more comprehensive evaluation: structure, value orientation toward recovery, methods of teaching, and educational content. Contextual domains distinguish programs from one another, including length and time commitment, requisite resources, inclusion of group support, utilization of medical language and pathology, degree of traditional didactic education, and prioritization of consumer-driven self-exploration. The authors also searched PsycINFO, Google Scholar, and Cochrane Reviews for empirical evidence and evaluated the five programs on the strength of the evidence and the effectiveness of the intervention. Evidence of program effectiveness was found to range from low to moderate. However, empirical evidence alone is insufficient for selecting among the five programs, and contextual domains may offer the most relevant guidance by matching program features with goals of consumers, practitioners, and administrators.
Recovery is the paramount goal of mental health services (1), focusing on building hope and engaging personal agency to promote healing, change, and growth (2,3). Illness self-management (ISM) programs endeavor to help consumers pursue recovery by nurturing nascent hope and fostering self-regulated learning to develop effective recovery strategies. Given the unique and personal nature of recovery, providers and consumers have an enormous task of assessing which interventions will best meet overall needs and preferences. Selection of ISM programs should broadly maximize the fit between consumer interests, provider endorsement and skills, agency culture, and resources available for adoption, implementation, and maintenance. This article guides the selection of ISM programs for consumers, providers, and administrators by reviewing their structure, value orientation toward recovery, methods of teaching, educational content, and empirical evidence.
ISM Programs
ISM programs provide a framework for consumers to enhance capabilities for self-management, focusing on controlling the disorder, maximizing overall health and wellness, and ameliorating the psychosocial sequelae of illness (4). Traditionally, health professionals have conceived of ISM training as unidirectional, didactic education (5); however, skepticism has grown about clinician-centered approaches that tacitly demand adherence to plans created by health care professionals (6). Although providers have specialized education and knowledge, consumers are experts on the lived experience of pursuing health with a given disorder. Consumers, therefore, often prefer a “decentralized” approach to self-management, wherein the power and authority traditionally and wholly ascribed to providers diffuses and is shared by consumers. Thus, rather than learning to adopt prescriptive strategies from providers, consumers may learn effective self-management strategies best from personal trial and error in the context of daily life (5). Such an approach promotes self-regulated learning (7) and fosters self-agency in the process of discovering personally effective recovery strategies (4–6).
The purpose of ISM programs extends beyond learning a constellation of strategies; these programs offer a framework for personal exploration to (re)discover or (re)construct a stable sense of self as an “active and responsible agent” (8). Davidson and Strauss (8) suggest four such topics that underlie consumer priorities when they pursue recovery: discovering the possibility of an active sense of self; identifying strengths, weaknesses, and possibilities for change; initiating action and integrating the results of those behaviors into one’s construction of actual capabilities; and using the resources of one’s sense of self to provide refuge from illness and pernicious elements of one’s social environment. ISM programs that provide structure for such personal exploration most closely align with consumer preferences and may maximize engagement and resulting benefits of the intervention.
Five of the most popular ISM programs have been selected for this review: Pathways to Recovery (PTR), The Recovery Workbook (TRW), Building Recovery of Individual Dreams and Goals through Education and Support (BRIDGES), Wellness and Recovery Action Planning (WRAP), and Illness Management and Recovery (IMR). Derivations of these programs, such as the IMR adaptation known as Wellness Self-Management (9), were not included to enable a more focused, concise guide to ISM programs. Readers who identify other programs can use our framework to evaluate them against the five presented here.
PTR
PTR is a self-help workbook focusing on strengths (10). Although the workbook is primarily intended for individual use, support groups have used the content of the program to supplement individual work. PTR promotes in-depth assessment of multiple dimensions of a holistic framework for recovery, from housing, career development, and financial asset management to sexuality, intimacy, and spirituality. Each topic includes a framework for assessment of strengths, resources, goal identification, and obstacle analysis. PTR focuses on reducing stress and encouraging enactment of strategies to pursue goals in a variety of life domains. PTR suggests that by pursuing goals, reducing stress, and experiencing success, the impact of illness diminishes while recovery naturally emerges and grows. Accordingly, the program purposefully omits content on symptom management, referring participants to WRAP to learn strategies to manage symptoms serious enough to overtake one’s recovery journey.
TRW
TRW is a self-help workbook, ideally initiated with a chosen support person and sometimes offered in a group format for which a facilitator manual is available (11). TRW claims recovery is a process of critical self-reflection that begets a new self-identity as a person capable of actualizing goals. Identity naturally transforms while the person learns to cope and attends to recovery-supporting activities, and the person becomes aware of strengths, limitations, and new priorities from which meaningful goals can be identified. The program provides structured activities for self-reflection directed at feelings, reactions, and goals in the process of emerging identity development while encouraging unstructured reflection in the form of journaling. TRW focuses on strengths and simultaneously explores the impact of and strategies for improving four areas affecting identity and recovery: impairment, dysfunction, disability, and disadvantage. TRW relies minimally on providing guidance and concrete strategies for self-management and instead emphasizes self-directed exploration and reflection—reinforcing consumer competence and expertise. TRW does not purposefully exclude or consistently embrace medical and diagnostic language, choosing instead to acknowledge a spectrum of preferences.
BRIDGES
BRIDGES is typically offered in a peer-led weekly meeting format over eight to ten weeks (12,13). The goals for each meeting are to increase knowledge about mental illness and recovery strategies while fostering an environment where participants can educate and learn from one another. Worksheets are provided for participants to apply learning by reflecting on personal needs and goals while making recovery plans. BRIDGES emphasizes the emotional and psychosocial impacts of experiencing mental illness and encourages participants to identify as active agents, responsible for actualizing personal recovery goals. The program is largely didactic and psychoeducational, with activities to build skills in problem solving and interpersonal effectiveness. Participants share personal recovery stories, identify barriers to recovery, and engage in collaborative problem solving as a group to simultaneously enhance skills and develop strategies to resolve participants’ real-time barriers to recovery. Companion support groups are intended to concurrently augment the structured programming (tmhca-tn.org). Of the five programs reviewed here, BRIDGES has the most extensive curriculum focused on the physiology of mental illness and the mechanisms of medications.
WRAP
WRAP is commonly delivered in eight weekly group meetings and sometimes through one-on-one interactions, with self-help guides available for individual use. When offered in group settings, WRAP is cofacilitated by trained peers, who identify either as mental health consumers or as WRAP practitioners without regard to mental health status. WRAP encourages participant introspection to identify simple, accessible activities that have been personally effective in the past at supporting wellness (14). Participants are guided through a holistic recovery framework to develop a comprehensive, goal-oriented action plan to promote, maintain, and reestablish wellness with several components: a proactive daily maintenance plan describing wellness tools and activities for everyday use, contingency plans identifying actions to ameliorate triggers and stressful antecedents to decreasing wellness, a crisis plan, a postcrisis plan, and an advance directive to guide care in the event of crisis. Participants can choose to focus with depth on any or all of the components and are referred to additional resources throughout the curriculum. WRAP focuses almost exclusively on strengths and wellness while purposefully excluding diagnostic language and pathology. Facilitators and self-help guides reinforce self-determination and personal agency as the foundation of recovery.
IMR
IMR is a highly intensive program generally offered in weekly individual or group meetings lasting between three and ten months (15). The curriculum focuses on didactic instruction about mental illness as well as management and recovery strategies, and it incorporates structured activities for skills building. Individual recovery goals are identified early in the program and broken down into manageable steps, and progress toward goal attainment is monitored throughout the program. Facilitators are encouraged to use motivational interviewing strategies to elicit consumers’ ideas and motivation for change, often regarding reasons to learn particular information and skills conducive to meeting personal recovery goals. IMR balances collaboration and empowerment with didactic education and skills building, underscoring feedback from the program facilitator, who is typically a professional practitioner. IMR is highly structured, with educational handouts and worksheets to guide homework assignments as participants learn and implement self-management strategies. Skills enhancement activities include problem solving, decision making, social skills, and effective communication.
Comparative Assessment of Programs
Selecting the best-fit program depends on several factors that may be overlooked by traditional reviews but that have important implications for the lived experience of consumers, practitioners, and administrators who utilize the programs in real-world contexts. We systematically reviewed the curriculum and the published literature for each program and identified four major contextual domains that supplement empirical evidence for a more comprehensive evaluation: structure, value orientation toward recovery, methods of teaching, and educational content. Together, these domains provide a framework by which consumers and providers can make informed decisions about program selection. Because ISM programs may be complementary, some consumers choose to access more than one over time; therefore, the best-fit program may actually refer to a combination of programs.
Structure
The structure of programs can be compared in two ways: the selected health domains around which content is built and the manner in which curriculum is disseminated, with accompanying costs of resources for implementation. All five programs provide structured, reflexive content in major health domains to guide construction of holistic recovery plans; the only notable difference is that PTR offers dedicated content on sexuality and culture (Table 1). The primary difference in the structure of the programs revolves around their format and delivery of content.
| Topic | PTR | TRW | BRIDGES | WRAP | IMR |
|---|---|---|---|---|---|
| Addresses biopsychosocial health domain | |||||
| Somatic | ✓ | ✓ | ✓ | ✓ | ✓ |
| Psychological or emotional | ✓ | ✓ | ✓ | ✓ | ✓ |
| Employment | ✓ | ✓ | ✓ | ✓ | |
| Sexuality | ✓ | ||||
| Social | ✓ | ✓ | ✓ | ✓ | ✓ |
| Spiritual | ✓ | ✓ | ✓ | ✓ | ✓ |
| Cultural or heritage | ✓ | ||||
| Assessments to check understanding of program material | ✓ | ||||
| Practitioner guides for facilitating group programming | ✓ | ✓ | ✓ | ✓ | |
| Peer delivered | Can be | Can be | ✓ | ✓b | ✓c |
| Group intervention | Can be | Can be | ✓ | ✓ | ✓ |
| Individual intervention | ✓ | ✓ | ✓ | ✓ | |
| Typical length | Individual pace | Individual pace | 8-week | 8-week | 3 to 10 months |
| Open (O) or static (S) participation when offered in group format | O | O | S | S | S |
| Open-access manuald | No | No | No | No | Yes |
| Standardized training, certification required for program facilitator | No | No | Yes | Yes | Noe |
| Intensity, time commitment for training | Minimal | Minimal | Initial standardized training, ongoing as needed | Initial WRAP course, personal plan development, standardized training every two years | Knowledge base required for program content, motivational interviewing, problem-solving, goal setting and monitoring, and decision making |
a
PTR, Pathways to Recovery; TRW, The Recovery Workbook; BRIDGES, Building Recovery of Individual Dreams and Goals through Education and Support; WRAP, Wellness and Recovery Action Planning; IMR, Illness Management and Recovery
b
WRAP’s definition of “peer” has changed to include anyone who practices WRAP, without regard to mental illness.
c
IMR is typically not peer delivered; however, some trials include peer facilitation.
d
Free access online; no purchase necessary for manuals
e
No standardized training required by the program; local governments or mental health authorities may have requirements
PTR and TRW are primarily workbooks with optional group components. PTR support groups have grown up organically in various locations; TRW offers a facilitator guide with a recommended 30-session format to structure peer support and cooperative learning.
BRIDGES is offered in a group format and typically cofacilitated by peers who identify as having mental health challenges. Programming varies from a condensed two-day format to a weekly meeting format over eight weeks. To become a facilitator, a person must attend formal training, at which time a practitioner guide is provided, and subsequently take part in periodic refresher trainings.
WRAP is commonly accessed through group programming, although sometimes through one-on-one facilitation. Individuals can access WRAP without formal facilitation through WRAP workbooks, and apps are available for supplemental online support. WRAP group programming is always cofacilitated and typically offered in a weekly meeting format over eight to 12 weeks. To become a facilitator, a person must first develop a personal WRAP plan and subsequently be trained and certified and engage in refresher courses every two years to ensure fidelity to the program model and core values (16).
IMR was initially designed to be facilitated by a practitioner and has since incorporated peer facilitation. IMR can be offered in individual or group formats, usually over three to ten months of twice-weekly to biweekly meetings. All IMR material is free and available on the Web site of the Substance Abuse and Mental Health Services Administration (SAMHSA), with guides for participants and facilitators that are further categorized by group and individual format (15). Although no standardized training or certification is required by the program, facilitation requires proficiency in program content and skills related to motivational interviewing, problem solving, decision making, and setting and monitoring of goals.
Value Orientation Toward Recovery
Values reflect beliefs about the nature of mental illness and health, conceptualizations of recovery, relative emphasis on holistic wellness versus targeted attention to symptom remediation, and the overall approach guiding the most effective route toward recovery. The manuals of programs describe some values overtly, while other values can be inferred as a result of content that is included or omitted, language used, and strategies embedded within program manuals and workbooks (Table 2).
| Topic | PTR | TRW | BRIDGES | WRAP | IMR |
|---|---|---|---|---|---|
| Overarching focus | |||||
| Management of illness | ✓ | ✓ | ✓ | ||
| Wellness | ✓ | ✓ | ✓ | ✓ | ✓ |
| Recovery | ✓ | ✓ | ✓ | ✓ | ✓ |
| Adjust expectations, learn to live with abilities and limitations | ✓ | ✓ | ✓ | ✓ | |
| Personal responsibility | ✓ | ✓ | ✓ | ✓ | ✓ |
| Focus on reducing symptoms and hospitalizations | ✓ | ✓ | |||
| Emphasis on psychoeducation and guided skills building | ✓ | ✓ | |||
| Use of medical and diagnostic language | ✓ | ✓ | ✓ | ||
| Focus primarily on strengths to support recovery | ✓ | ✓ | |||
| Dual focus on strengths and problems to support recovery | ✓ | ✓ | ✓ |
a
PTR, Pathways to Recovery; TRW, The Recovery Workbook; BRIDGES, Building Recovery of Individual Dreams and Goals through Education and Support; WRAP, Wellness and Recovery Action Planning; IMR, Illness Management and Recovery
All five programs promote wellness and recovery, but only IMR, BRIDGES, and TRW offer significant content on managing symptoms and controlling one’s disorder—suggesting underlying values of openly addressing illness and prioritizing symptom management. WRAP and PTR eschew language of pathology and illness and focus almost exclusively on strengths as a means to promote wellness and recovery. The other programs include strengths, problems and deficits, and medical and diagnostic language, and they offer explicit content on symptom management. BRIDGES and IMR place overt value on reducing hospitalization and a higher priority on traditional, didactic psychoeducation overall—especially regarding mental illness, medications, and symptom reduction strategies. IMR particularly values regular and systematic assessments of growth in knowledge, skills, and goal attainment, both from provider and consumer perspectives.
Methods of Teaching
One major difference among programs is the strategies they employ to teach curricular information and overall self-management frameworks (Table 3). WRAP and BRIDGES are traditionally peer led and embrace modeling by facilitators and mutual sharing by participants to foster learning from peers. BRIDGES and IMR use role-play and skills-building exercises during group meetings to enhance proficiency in solving problems, engaging others in reciprocal problem-solving processes, implementing plans, communicating effectively, and (for IMR) developing and refining social skills. Given that PTR and TRW are traditionally self-help guides, participants are encouraged to read material, create structured time for self-reflection, and engage in activities independently and with social support. PTR attempts to create peer support in the text by including quotes and anecdotes, some by others pursuing recovery.
| Topic | PTR | TRW | BRIDGES | WRAP | IMR |
|---|---|---|---|---|---|
| Structured, didactic instruction | ✓ | ✓ | |||
| Modelingb | |||||
| Self-management behaviors | ✓ | ✓ | |||
| Goal identification, prioritizing | ✓ | ✓ | |||
| Problem-solving strategies | ✓ | ✓ | |||
| Present personal and consumer anecdotes | ✓ | ✓ | ✓ | ✓ | ✓ |
| Learn collaboratively from peersb | ✓ | ✓ | |||
| Role play | ✓ | ✓ | |||
| Collaborative problem solving; guided practice applying strategies with others | ✓ | ✓ | |||
| Worksheets or written guides | ✓ | ✓ | ✓ | ✓ | ✓ |
| Structured enactment of skills to obtain facilitator or group feedback | ✓ | ✓ | |||
| Guided writing activities | ✓ | ✓ | ✓ | ✓ | ✓ |
| Unstructured writing activities or journaling | ✓ | ||||
| Identify implementation barriers (cognitive, attitude, behavior); develop strategies to overcome barriers | ✓ | ✓ | |||
| Written assessment or progress tracking | ✓ | ✓ | ✓ | ||
| Structured self-assessment of knowledge and skills | ✓ | ||||
| Practitioner assessment of participant progress and needs | ✓ | ||||
| Written companion guides | ✓ | ✓ | ✓ | ✓ | ✓ |
a
PTR, Pathways to Recovery; TRW, The Recovery Workbook; BRIDGES, Building Recovery of Individual Dreams and Goals through Education and Support; WRAP, Wellness and Recovery Action Planning; IMR, Illness Management and Recovery
b
In group settings, the topic may apply to all 5 programs.
Educational Content
Educational content refers to types of knowledge people need about health and decrements in wellness to effectively use strategies to pursue recovery. Two types of knowledge relevant to self-regulated learning in ISM programs are addressed in Table 4 and discussed separately below: propositional knowledge (knowing that) and procedural knowledge (knowing how). Propositional knowledge refers to facts and information that one can know either a priori (without having to first observe something) or a posteriori (through empirical observation and testing after an observation has been made) (7). ISM programs present content in propositional knowledge and encourage self-reflection by participants to discover what is personally relevant. Procedural knowledge refers to knowing how to engage in a behavior or applying information to complete a task (7). It is fostered by providing process-oriented techniques to support implementation of recovery strategies and by encouraging participants to practice and apply strategies both during group programming and individually through trial and error in the context of daily life. Emphasizing application of knowledge and implementation of strategies promotes self-regulated learning as participants discover available strategies and evaluate which are personally effective in promoting recovery.
| Topic | PTR | TRW | BRIDGES | WRAP | IMR |
|---|---|---|---|---|---|
| Definition of serious mental illness and diagnoses | ✓ | ✓ | |||
| Etiology or physiology of serious mental illness | ✓ | ✓ | |||
| Stress-diathesis model | ✓ | ✓ | |||
| Medication choices, mechanisms, and side effects | ✓ | ✓ | |||
| Co-occurring substance use disorders | ✓ | ✓ | ✓ | ||
| Street drugs: physiological effects, costs and benefits of use | ✓ | ||||
| Definition of recovery | ✓ | ✓ | ✓ | ✓ | ✓ |
| Healthy lifestyle tips, goal prompts | ✓ | ✓ | ✓ | ✓ | ✓ |
| Smoking cessation benefits and resources | ✓ | ✓ | |||
| Stigma | ✓ | ✓ | ✓ | ✓ | ✓ |
| Psychotherapeutic modalities | ✓ | ||||
| Health services and basic needs benefits | ✓ | ✓ | ✓ | ||
| Conceptualization of “meaningful work” | ✓ | ✓ | |||
| Employment and Social Security | ✓ | ||||
| Expand feelings vocabulary | ✓ | ||||
| Importance of prioritizing trauma treatment | ✓ | ||||
| Self-regulated learning: self-observation, self-assessment, self-reactions | ✓ | ✓ | ✓ | ✓ | ✓ |
| Coping strategies | |||||
| Minimize psychosocial effects of illness | ✓ | ✓ | ✓ | ✓ | ✓ |
| Techniques to reduce symptoms, control disorder | ✓ | ✓ | ✓ | ||
| Stress-reduction techniques | ✓ | ✓ | ✓ | ✓ | ✓ |
| Cognitive restructuring | ✓ | ✓ | ✓ | ✓ | ✓ |
| Set goals and priorities | ✓ | ✓ | ✓ | ✓ | ✓ |
| Build proactive plans | |||||
| Develop wellness tools or coping strategies | ✓ | ✓ | ✓ | ✓ | ✓ |
| Identify daily wellness activities | ✓ | ✓ | |||
| Discontinue substance use and relapse prevention | ✓ | ✓ | |||
| Build reactive plans | |||||
| Manage early signs of illness exacerbation | ✓ | ✓ | ✓ | ✓ | |
| Crisis plan | ✓ | ✓ | |||
| Postcrisis plan | ✓ | ✓ | |||
| Advance directive | ✓ | ✓ | |||
| Manage suicidal ideations | ✓ | ✓ | |||
| Implement structured problem-solving framework | ✓ | ✓ | |||
| Rebuild positive identity | ✓ | ✓ | ✓ | ✓ | ✓ |
| Social support: build and use | ✓ | ✓ | ✓ | ✓ | ✓ |
| Collaborate with providers | |||||
| Build treatment team or select best-fit services | ✓ | ✓ | ✓ | ✓ | ✓ |
| Shared decision making | ✓ | ✓ | ✓ | ||
| Advocacy and negotiation | ✓ | ✓ | ✓ | ✓ | |
| Decision making about use of medication | ✓ | ✓b | ✓ | ||
| Use of medications effectively and management of side effects | ✓ | ✓b | ✓ | ||
| Communication skills and interpersonal effectiveness | ✓ | ✓ | ✓ | ✓ | |
| Social skills | ✓ | ||||
| Assertiveness skills | ✓ | ||||
| Advocacy skills and framework | ✓ | ✓ | ✓ | ||
| Structured decision making | ✓ |
a
PTR, Pathways to Recovery; TRW, The Recovery Workbook; BRIDGES, Building Recovery of Individual Dreams and Goals through Education and Support; WRAP, Wellness and Recovery Action Planning; IMR, Illness Management and Recovery
b
Not a priority, minimal focus
Content in propositional knowledge.
All five programs offer information about conceptualizing recovery and identifying elements of a holistic approach to pursuing recovery. IMR and BRIDGES also prioritize biological contributions to mental illness and associated etiology, physiology, and psychopharmacology. Varying emphasis is placed on formal, external services and benefits—IMR, BRIDGES, and TRW particularly attend to basic-needs benefits as well as to mental health and general social services.
Content in procedural knowledge.
All programs encourage the three subprocesses of self-regulated learning: self-observations, self-assessment, and self-reactions (7). Guided activities help participants observe and identify their strengths and needs (self-observation), assess the success of coping and wellness strategies employed in the past (self-assessment), and decide whether to retain or develop new strategies (self-reaction). Such self-regulated learning is encouraged in the context of creating plans to proactively maintain and enhance wellness; however, each program uniquely fosters skills to implement recovery strategies.
PTR regularly prompts readers to (re)explore personal needs, abilities, and available resources (internal and external) to guide the selection of priorities, set an appropriate pace, mobilize one’s resources, and select strategies to pursue recovery. Consumers are subsequently encouraged to reflect on how successfully they implemented goal-directed strategies, making adjustments as needed. Thus consumers are guided through the cyclical process of self-regulated learning, focusing on how to implement recovery strategies.
TRW includes unstructured exploration with workbook pages designated for nondirective, open journaling to balance and personalize the otherwise structured program. Such reflection reinforces self-regulated learning, relying heavily on self-reaction about how strategies are working.
Comparatively, WRAP has the predominant focus on developing proactive and contingency plans to promote, maintain, and reestablish wellness. WRAP uses the process of creating plans to engage all aspects of self-regulated learning. Consumers are encouraged to continue self-reaction and amend or create new plans as needed.
IMR and BRIDGES guide consumers through the process of self-regulated learning by developing recovery goals and strategies grounded in past successes; however, they also incorporate structured curriculum to learn and practice a formal problem-solving model to resolve barriers to recovery and facilitate implementation of recovery strategies prospectively. Thus IMR and BRIDGES emphasize formal process-oriented learning of implementation strategies and include structured practice during meetings to reinforce learning.
Empirical Evidence
Empirical support for each program is summarized in Table 5. Studies were identified using PsycINFO, Google Scholar, and Wiley Online Library for Cochrane Reviews, with search terms “pathways to recovery,” “recovery workbook,” “BRIDGES,” “building recovery of individual dreams and goals through education and support,” “WRAP,” “wellness recovery action plan*,” “IMR,” and “illness management and recovery.” Systematic reviews were not included because only one has been completed (17), and each qualifying study was included in this review. Articles were excluded if the focus was exclusively on implementation, fidelity, or consumer satisfaction or if the study employed a qualitative approach only. Although qualitative investigations are vital to understanding consumers’ lived experiences with these programs, the intent was to determine effectiveness. Readers should note that studies often employed a battery of tests, and although outcomes of some measures showed null results, only positive findings are reported here.
| Referencea | Program format | Sample size and setting | Design and methods | Outcomes |
|---|---|---|---|---|
| Pathways to Recovery | ||||
| Fukui et al., 2010 (19) | Peer-led group format, 12 weekly 90-minute meetings | 47 adults with serious and persistent mental illness from 6 consumer-run organizations; Midwestern state | Pre-post; measured pre- and postintervention | Improved self-esteem, self-efficacy, perceived social support, spirituality, and symptoms |
| The Recovery Workbook | ||||
| Barbic et al., 2009 (20) | Modified to 12 weekly group meetings; recommended 30 weekly meetings shortened to 12 | 33 adults receiving assertive community treatment (ACT) in 2 outpatient mental health sites; control group, 17; intervention group, 16; Ontario | Randomized controlled trial (RCT); multicenter, single-blind | For TRW, increased hope, empowerment, and perceived recovery; improved scores on subscales for personal confidence and hope and for goal and success orientation |
| BRIDGES | ||||
| Cook et al., 2012 (21); Pickett et al., 2012 (22); Steigman et al., 2014 (23) | 8 weekly 2.5-hour group meetings cofacilitated by peers | 428 adults with serious mental illness; intervention, 212; waitlist control group, 216; Tennessee | RCT, single blind; measured via telephone interviews at enrollment, postintervention, and 6 months later | For BRIDGES, improved empowerment and improved scores on subscale of self-esteem; improved perceived recovery and improved scores on subscales of personal confidence, goal orientation, and no symptom domination; no significant improvement on advocacy scale but improvement on assertiveness subscale; no significant improvement on hope scale but improvement on agency subscale |
| Pickett et al., 2010 (24) | 8-weekly 2.5-hour group meetings cofacilitated by peers | 160 adults with serious mental illness; Tennessee | Pre- and postintervention; structured interviews | Improved perceived recovery, symptoms, hope, self-advocacy, empowerment, and maladaptive coping |
| WRAP | ||||
| Cook et al., 2009 (25) | 8 weekly 2.5-hour sessions cofacilitated by peers | 80 adults with serious mental illness; Ohio | Pre-post; telephone interviews pre-WRAP and 1 month post-WRAP | Improved symptom severity, perceived recovery, hope, and self-advocacy; decrease in empowerment |
| Cook et al., 2010 (26) | 4 models of program, with modifications to length and duration; Vermont, 40 hours of WRAP delivered to groups cofacilitated by 1 peer and 1 staff in 3 formats ranging from 7 to 40 weeks; Minnesota, 16 hours of WRAP delivered to groups cofacilitated by peers for 8 weeks | 381 adult consumers of mental health services; Vermont, 147; Minnesota, 234 | Pre-post; measured with instruments designed ad hoc for each state | Improvement in attitudes, knowledge, and skills related to self-management |
| Cook et al., 2012 (27); Cook et al., 2012 (28); Jonikas et al., 2013 (29) | 8 weekly 2.5-hour group meetings cofacilitated by peers | 519 adults with serious mental illness; waitlist control, 268; WRAP, 251; Ohio | RCT, single blind; measured 6 weeks before and 6 weeks after WRAP and at 6-month follow-up | For WRAP, reduced symptom severity, positive symptoms, depression, and anxiety; increased perceived recovery and improved scores on subscales of personal confidence and goal orientation, perceived self-advocacy, mindful nonadherence to prescribed treatment, and hope and initiation; improved scores on the following quality-of-life subscales: opportunities for new skills and information, enhanced leisure and recreation, and feelings of security and freedom |
| Cook et al., 2013 (30) | 9 weekly 2.5-hour sessions cofacilitated by peers; control program followed same schedule, facilitated by nonpeers | 143 adults with serious mental illness; WRAP, 72; control condition (nutrition education group), 71; Chicago | RCT, single blind; measured via telephone interviews at baseline and 2 and 8 months postintervention | For WRAP, decreased use of individual or group services and perceived need for overall and group services; for both conditions, improved symptom severity and perceived recovery |
| Doughty et al., 2008 (31) | 1- or 2-day workshops facilitated by peers | 187 consumers and health professionals; New Zealand | Pre-post; questionnaire designed to measure recovery knowledge and attitudes; administered before and after a peer-facilitated workshop | Enhanced recovery knowledge and attitudes |
| Fukui et al., 2011 (32) | 8–12 weekly meetings cofacilitated by 1 peer and 1 staff | 114 adults with serious and persistent mental illness; experimental, 58; comparison, 56; Kansas | Quasi-experimental; measured at first and last WRAP meeting and 6 months later; matched pairs identified via administrative data for age, gender, and diagnosis; analysis conducted within each group rather than between groups | For WRAP, improved symptoms and hope |
| Higgins et al., 2012 (33) | Consecutive 2- and 5-day modified formats | 253 practitioners, family members, caregivers, and consumers; 2-day group, 194; 5-day group, 59; Ireland | Pre-post; mixed methods; 2- and 5-day formats evaluated separately | Improved recovery knowledge and attitudes in 2-day but not in 5-day group; beliefs about recovery and WRAP were measured by 2 subscales; both were significant for the 2-day group, and only one subscale was significant for the 5-day group |
| Starnino et al., 2010 (34) | 12 weeks, 1.5- to 2-hour meetings | 30 adults with serious mental illness from 3 Midwestern mental health centers | Pre-post | Improved hope and perceived recovery; marginally nonsignificant for symptoms |
| Illness Management and Recovery (IMR) | ||||
| Bartels et al., 2014 (35) | Modified version of IMR, known as “Integrated-IMR”: 8 months of weekly meetings with clinician, biweekly meetings with nurse | 71 middle-aged and older adults with serious mental illness and comorbid general medical condition randomly assigned to I-IMR or treatment as usual; delivered at 2 community mental health centers; New Hampshire | RCT; measured at baseline and 10 and 14 months | For I-IMR group, improved psychiatric and diabetes self-management; greater preference for obtaining detailed diagnosis and treatment information in primary care |
| Fardig et al., 2011 (36) | Group format, once per week for 9 months cofacilitated by clinicians | 41 Swedish-speaking adults with schizophrenia or schizoaffective disorder at 6 outpatient rehabilitation centers: IMR, 21; treatment as usual, 20; Sweden | RCT; measured at baseline and 9 and 21 months | For IMR, greater improvement in illness management and suicidal ideation assessed by nonblinded clinicians and self-report; greater improvement in psychiatric symptoms assessed by blinded clinicians and self-report; greater improvement on the following coping factors subscales: seeking social support, escape-avoidance, and planful problem solving |
| Fujita et al., 2010 (37) | Group and individual format, 60- and 90-minute meetings 1 or 2 times per week | 35 adults with schizophrenia in 2 outpatient facilities; 35 recruited; 10 agreed to begin as waitlist controls of whom 4 later joined IMR; 25 IMR completers analyzed; Japan | Pre-post, quasi-controlled with nonequivalent comparison group; measured at baseline and posttreatment | Analysis for IMR only: improved functioning, symptoms, activation, social functioning, satisfaction in community living, self-efficacy in daily living, and social relationships; between-conditions analysis: improved social functioning; social relationships, satisfaction with life, social skills, social relationships, and psychological functioning |
| Garber-Epstein et al., 2013 (38) | 9 months, varied facilitation | 252 Hebrew-speaking adults with serious mental illness; 29 IMR groups defined by facilitator type: mental health professional, peer provider, and paraprofessional; sample drawn from agencies offering IMR and agencies not offering IMR; Israel | Quasi-experimental; no randomization; treatment-as-usual comparison group; measured pre- and postintervention | No difference between 3 IMR treatment groups; compared with treatment as usual, improved pre-post IMR scale composite for each treatment group; compared with treatment as usual, improved knowledge and goals for professional- and paraprofessional-led groups |
| Hasson-Ohayon et al., 2007 (39) | Weekly 1-hour meetings for 8 months cofacilitated by clinicians | 210 Hebrew-speaking adults with serious mental illness at 13 community rehabilitation centers; Israel | RCT; IMR versus treatment as usual; measured pre- and postintervention | For IMR, improved clinician-rated IMR scales and client-rated subscales of knowledge and goals |
| Johnson, 2007 (40) | Weekly groups administered by 2 therapists | 34 adults with serious and persistent mental illness at a state hospital; IMR, 19; treatment as usual, 15; Madison, Wisconsin | Pre-post with nonequivalent comparison group; convenience sampling; measured at baseline and 3 months post-IMR initiation | For IMR, improvement in perceived recovery over comparison group |
| Levitt et al., 2009 (41) | 2 1-hour group meetings per week for 20 weeks | 104 adults with serious mental illness from supportive housing sites assigned to IMR and waitlist control group; IMR, 54; control group, 50; New York | RCT; measured at baseline, 5 months later, and 6 months posttreatment | For IMR, improved IMR scales, psychosocial functioning, and symptoms on BPRSb scale but not on MCSIc scale |
| Lin et al., 2013 (42) | 6 90-minute group meetings over 3 weeks; adapted IMR with only 3 modules | 97 adults with schizophrenia at 2 hospitals; Taiwan | RCT; compared adapted IMR and treatment as usual; groups started during 3rd week of hospitalization | For adapted IMR, improved knowledge of illness, attitude toward medication, and insight into illness; possible improvement for anergia |
| Mueser et al., 2006 (43) | Group and individual formats, weekly for 9 months; varied facilitation by clinicians and nurses | 24 adults with serious mental illness; 2 centers in North Carolina and 1 center in Australia | Pre-post; measured pre- and posttreatment and at 3-month follow-up | Improved symptoms, Global Assessment of Functioning score, perceived effectiveness in coping, knowledge of illness, and perceived recovery; improved scores on subscales of hope, goal orientation, and no domination by symptoms |
| Mueser et al., 2012 (44) | Modified version of IMR, known as “Integrated-IMR”; I-IMR curriculum included material on general medical illness; weekly individual meetings for 8 months; facilitation included community health center nurse | 8 older adults with serious mental illness and comorbid general medical conditions who met a threshold of attendance | Pre-post case study; measured at baseline and 8 to 10 months later; because of missing data, only 5 included in analysis | Improvements in self-management of psychiatric and general medical conditions, receipt of preventive health care, and self-perceived ability to manage disorders |
| Pratt et al., 2011 (45) | Modified version of IMR with only 4 modules, 16 weekly group meetings; 2 groups cofacilitated by nonpeers, 2 by 1 peer and 1 nonpeer | 66 adults with serious mental illness; IMR, 46, with 29 included in analysis; waitlist control, 20; 10 control group participants later attended IMR, with 7 included in analysis; New Jersey | RCT and pre-post; measured at baseline and 4 and 8 months later | IMR improved over control group in IMR scales; control group improved over IMR on social support; pre-post test within IMR condition indicated improvement in IMR scales, perceived social support, and symptoms |
| Salyers et al., 2009 (46) | Individual weekly meetings for 4 to 8 months; peer facilitated | 11 adult ACT participants, Indianapolis, Indiana | Pre-post; mixed methods; 11 IMR completers measured pre- and postintervention; qualitative assessment at 9 months postbaseline | Improvement in perceived recovery; nonsignificant trend toward improvement in knowledge about mental illness |
| Salyers et al., 2009 (47) | Initial implementation of traditional IMR structure; peer facilitated | 324 adults with serious mental illness at 7 sites; Indiana | Pre-post; no random assignment; no comparison group; secondary analysis of data from primary study; evaluation of IMR implementation; measured at baseline and 6 and 12 months; analyzed data for those who completed 80% or more of measures | Increase in illness management skills and hope; dropout rates of 10%–50% |
| Salyers et al., 2010 (48) | Weekly meetings for 10 months cofacilitated by 1 peer and 1 or 2 clinicians | 122 ACT participants; experimental, 49; control group, 73; Indiana | 4 ACT teams; two randomly assigned to add delivery of IMR; measured at baseline and 12 and 24 months | For IMR, reduced substance use, hospital admissions, number admitted, and log- transformed hospital days |
| Salyers et al., 2011 (49) | Unspecified | 498 adult ACT participants; ACT plus IMR, 144; Indiana | Retrospective cohort study of 5 years of Medicaid claims data; 5 ACT teams offering IMR; compared those who received IMR with those who did not | For those who received some IMR, fewer hospital days compared with ACT only; for IMR graduates, fewer emergency department visits compared with ACT only |
| Salyers et al., 2014 (50) | Weekly meetings for 9 months cofacilitated by clinician and clinical student | 118 adults with schizophrenia or schizoaffective disorder; IMR, 60; problem-solving group, 58; Indiana | RCT; measured at baseline and 9 and 18 months; control group provided group support to solve problems with no structured problem-solving tasks, goals setting, or homework | IMR no better than control |
a
BRIDGES, Building Recovery of Individual Dreams and Goals through Education and Support; WRAP, Wellness and Recovery Action Planning
b
Brief Psychiatric Rating Scale
c
Modified Colorado Symptom Index
In the Assessing the Evidence Base series published in Psychiatric Services in 2014, Dougherty and colleagues (18) summarized criteria for judging the strength of evidence and the effectiveness of interventions. The strength of evidence is measured in three categories—high, moderate, and low—and refers to the overall quality and rigor of research designs of published studies, whereas effectiveness refers to the degree to which a treatment achieves its intended outcomes (18).
To achieve a high level of evidence, interventions must meet a threshold of rigorous research such that further investigations are unlikely to diminish confidence in key findings. Typically, this requires three well-designed randomized controlled trials (RCTs) or two RCTs supported by two quasi-experimental trials—all with satisfactory designs. A moderate level of evidence describes interventions with adequate research to judge efficacy, acknowledging that future investigation could alter conclusions about effectiveness. To obtain this ranking, an intervention may have two RCTs with some methodological weaknesses, two or three quasi-experimental trials, or a combination of one RCT and one or more quasi-experimental trials, depending on the quality of design and general rigor. Finally, a low level of evidence refers to interventions for which some, but insufficient, evidence exists to draw conclusions about efficacy. This level refers to interventions for which the evidence base is primarily from studies with nonexperimental designs, for which there are too few quasi-experimental trials or RCTs, or from studies with significant methodological weaknesses. Using these criteria, we rated the effectiveness of each of the five ISM programs in accordance with the strength of evidence available.
With only one study each (19,20), PTR and TRW have low empirical evidence. Effectiveness is difficult to determine because of a lack of corroborating evidence; however, both studies measured and demonstrated improvement in widely used domains of recovery-oriented research.
There have been two research studies of BRIDGES, and the evidence comes close to, but does not quite achieve, a moderate level. The findings from one large-scale RCT with a robust research design (21–23) and one pre-post study (24) support claims of moderate treatment effectiveness. Researchers measured a broad range of recovery goals that improved after individuals participated in the BRIDGES intervention, including perceived recovery and empowerment.
WRAP’s efficacy (25–34) is supported by numerous nonexperimental studies (25,26,31,33), one quasi-experimental study (32), and two RCTs (27–30). Both RCTs recruited relatively large samples (519 and 143 participants) with good retention rates, utilized blind assessors to administer standardized instruments of recovery outcomes, and delivered the intervention comparably to similar populations. Although the use of blind assessors reduces the potential for bias, the creator of WRAP was a coauthor in articles reporting results of both RCTs, an indicator of decreased evidential strength (18). Furthermore, the RCT that included an active control group of nutrition education revealed improvements in both conditions but no statistically significant differences between groups in symptom severity and perceived recovery (30). The remaining RCT demonstrated relatively modest changes in outcomes (28,29). The overall strength of evidence for WRAP, therefore, is moderate, with equally moderate claims about its effectiveness regarding perceived recovery and symptom severity.
The most widely researched of the five programs is IMR (35–50). Like WRAP, several studies included researchers who were also involved in the development of the program. Randomization was utilized in seven studies with varying degrees of rigor (36,39,41,42,45,48,50). One trial randomly selected two of four ACT teams to add IMR (minimal randomization), with less than 26% of participants receiving any IMR and less than 4% completing the program (48). Two RCTs investigated only abbreviated versions of IMR, each offering fewer than half of the total modules (42,45).
The remaining four RCTs utilized IMR in its entirety, and all used IMR scales developed to assess the construct of psychiatric self-management with 15 Likert items measuring progress in IMR modules and rated by both consumers and providers who facilitated programming. Authors from one study in Israel reported a dropout rate of 28%, with no details on attendance rates of remaining participants (39). Measurement was limited to IMR scales only. Although providers’ total ratings on IMR scales showed significant improvement over the control condition, only two consumer-rated items improved significantly: knowledge about mental illness and progress toward personal goals. Providers’ ratings, however, may be biased toward improvement given their dual role as program facilitators and evaluators of progress. The trial in Sweden showed significant improvement in IMR scales for provider and consumer total scores (36). Improvements were found in suicidal ideation and psychiatric symptoms assessed by clinicians blinded to condition, and findings related to coping strategies were mixed: three of eight subscales improved for the IMR group and one for the control condition. Perceived recovery and quality of life did not change significantly.
Of the two remaining RCTs, one showed improvement in the IMR condition, compared with a waitlist control group, in psychiatric self-management (measured by IMR scales), psychosocial functioning, and one of two instruments measuring symptoms (41). The other remaining RCT found improvement in both conditions but no significant difference between IMR and an active control group that used nonstructured problem-solving group support; however, participation in both conditions was limited, with more than half of the sample attending less than 50% of meetings (50).
The major quasi-experimental study occurred in Israel (38). Only IMR scales were used, and two of the 15 items were excluded, along with the associated module covering drug and alcohol use. Only participants who attended at least the first three IMR sessions were included in the final analysis. The two other studies that utilized quasi-experimental designs lacked rigor in identifying comparison groups, contributing to methodological weaknesses that diminished confidence in internal validity (37,40). The retrospective study limited outcomes to hospitalization rates and emergency department visits, with no reports on recovery-related outcomes (49).
One final RCT of a program variant, “Integrated IMR,” assessed the efficacy of integrating IMR content with generalized medical illness self-management strategies for adults with serious mental illness and co-occurring general medical conditions (35). Total scores for provider- and consumer-rated IMR scales improved for the experimental condition over the usual-care control group, and diabetes self-management improved. No significant results were found related to self-management of the other general medical disorders studied or standardized measures of symptoms and community functioning. Perceived recovery was not assessed.
IMR studies typically contend with issues related to participation, sometimes discussed as penetration, attrition, attendance, and completion rates. A low penetration rate refers to minimal exposure to the intervention (48), and attrition and noncompletion rates, sometimes exceeding 50% (47), refer to persons who discontinue participation in the study and in the intervention, respectively. Studies with relatively high penetration and retention rates may not have consistently high attendance. Bartels and colleagues (35) reported that 75% attended at least one-third of the sessions with the IMR clinician, with a mean attendance of just over half. Efficacy may be unrelated to attendance rates beyond a certain threshold; however, in a qualitative investigation, participants who discontinued the program noted that program content and the other participants were below their level of education and knowledge about mental illness (41), underscoring the range of abilities and needs for potential consumers.
Ultimately, conclusions about IMR’s effectiveness are difficult to make given the variability of research designs, modifications to the program, variation in outcome measures used, and varying degree of attrition and participation. Despite the methodological concerns limiting comparability of research studies, the overall strength of evidence appears to be moderate, as does IMR’s effectiveness at increasing knowledge about illness and improving self-management strategies as indicated by IMR scales.
Discussion
Philosophically and theoretically, ISM programs embody the spirit of the recovery movement and have potential to reduce reliance on the service delivery system. Taken collectively, the body of empirical literature illustrates the efficacy of ISM programs. Although SAMHSA recognizes IMR and WRAP as evidence-based practices, empirical evidence alone does not provide overwhelming support for any one program over the others. All five programs have some evidence supporting their effectiveness at enhancing recovery, and all would benefit from additional research.
The current state of research provides strong evidence that recovery is a unique and personal process, and ISM programs provide a framework by which participants can engage in self-regulated learning to develop effective, personalized recovery strategies. Selecting the intervention or interventions with the best fit can be guided by consumer and practitioner needs and priorities, agency culture, and personal preference.
For providers and consumers seeking inexpensive programs with relatively less structure and more self-guided reflection, PTR and TRW might best support personal introspection about identity transformation and the development of recovery strategies. Whereas groups for PTR develop organically and maintain flexible structures, TRW offers a manual to guide implementation in a group setting, adding structure to the otherwise flexible program.
WRAP maintains the decentralized values of PTR and TRW while increasing program structure. WRAP may be the best-fit program for providers and consumers interested in developing comprehensive action plans to address various decrements of wellness. WRAP helps consumers build a toolbox for maintaining, enhancing, and managing threats to wellness and recovery. Because it is the most widely used ISM program, WRAP may support continuity of care for consumers seeking services at multiple agencies. Agency administrators should note the required capital investment for providers to engage in regular training and certification. Providers make significant personal investment: they must use WRAP to qualify for facilitator training and to maintain a vibrant sense of practicing WRAP.
IMR requires less initial capital outlay, because all materials are free; however, it requires significant organizational investment of staff time devoted to training and implementation of the intensive three- to ten-month program. IMR offers a relatively more structured intervention, prioritizing skills-building activities and didactic education in addition to personal exploration of recovery strategies. IMR might be the best-fit program for consumers interested in a comprehensive, structured program offering regular interaction with and feedback from facilitators; however, consumers need to commit to a relatively longer time frame to fully complete the program.
BRIDGES similarly prioritizes didactic psychoeducation and structure but is shorter than IMR and requires less time commitment from participants and providers. Like WRAP, it requires some capital commitment from agencies to ensure proper training and certification for implementation. BRIDGES may be the best program for consumers interested in structured education that concurrently reinforces decentralized power, with opportunities for personal and interpersonal skills building and with process-oriented problem-solving skills for managing recovery strategies within dynamic personal contexts.
Conclusions
Exercising personal agency and (re)building a healthy, stable identity are vital components of recovery; programs that support personal exploration and self-regulated learning reinforce positive identity development. The natural range and variation of consumer needs and goals underscore the necessity for multiple self-management frameworks and programs. Endorsing the universal adoption of any single protocol of self-management strategies is contraindicated for the provision of recovery-oriented services, which seek to meet individualized needs within complex social environments. The five programs described in this article reflect current popular trends in ISM interventions, and nuances of each should be matched to consumer needs and preferences when selecting the best-fit program or programs. Similarly, consideration must be given to agency culture, priorities, and resources to ensure compatibility with extant services and staffing as well as long-term sustainability of programming.
Empirical evidence is only one of many criteria on which to base decisions about program selection, and it may not address the most salient concerns of consumers, practitioners, or administrators. This article provides a systematic framework to evaluate other domains, important in real-world contexts laden with competing priorities and preferences. Given the equivocal nature of empirical evidence, program selection may ultimately be determined by relatively few components of other domains, including requisite personnel and expertise, program length, breadth and depth of content, language, or alignment with a medical or recovery orientation. Future research and systematic reviews should consider the relevance and necessity of including contextual domains to offer a more comprehensive evaluation of meaningful evidence.
References
1.
Hogan MF: The President’s New Freedom Commission: recommendations to transform mental health care in America. Psychiatric Services 54:1467–1474, 2003
2.
Deegan PE: Recovery: the lived experience of rehabilitation. Psychosocial Rehabilitation Journal 11:11–19, 1998
3.
Anthony WA: Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal 16:11–23, 1993
4.
Gallant MP: The influence of social support on chronic illness self-management: a review and directions for research. Health Education and Behavior 30:170–195, 2003
5.
Kralik D, Koch T, Price K, et al: Chronic illness self-management: taking action to create order. Journal of Clinical Nursing 13:259–267, 2004
6.
Koch T, Jenkin P, Kralik D: Chronic illness self-management: locating the “self.” Journal of Advanced Nursing 48:484–492, 2004
7.
Zimmerman BJ: A social cognitive view of self-regulated academic learning. Journal of Educational Psychology 81:329–339, 1989
8.
Davidson L, Strauss JS: Sense of self in recovery from severe mental illness. British Journal of Medical Psychology 65:131–145, 1992
9.
Salerno A, Margolies P, Cleek A, et al: Wellness Self-Management: an adaptation of the Illness Management and Recovery program in New York State. Psychiatric Services 62:456–458, 2011
10.
Ridgeway P, McDiarmid D, Davidson L, et al: Pathways to Recovery: A Strengths Recovery Self-Help Workbook. Lawrence, University of Kansas School of Social Welfare, 2002
11.
Spaniol L, Koehler M, Hutchinson D: The Recovery Workbook: Practical Coping and Empowerment Strategies for People With Psychiatric Disabilities. Boston, Center for Psychiatric Rehabilitation, Boston University, 2009
12.
Diehl SM, Baxter EA, Talley CL, et al: Building Recovery of Individual Dreams and Goals through Education and Support: A Peer-Taught Curriculum on Recovery From Mental Illness. Chicago, University of Illinois, 2006
13.
Hix L: BRIDGES in Tennessee: Building Recovery of Individual Dreams and Goals through Education and Support; in On Our Own Together: Peer Programs for People With Mental Illness. Edited by Clay S. Nashville, Tenn, Vanderbilt University Press, 2005
14.
Copeland ME: WRAP Plus. Dummerston, Vt, Peach Press, 2010
15.
Illness Management and Recovery: practitioner guides and handouts. HHS pub no SMA-09-4462, Rockville, Md, Substance Abuse and Mental Health Services Administration, 2009. Available at store.samhsa.gov/shin/content/SMA09-4463/PractitionerGuidesandHandouts.pdf
16.
The Way WRAP Works! Strengthening Core Values and Practices. Brattleboro, Vt, Copeland Center for Wellness and Recovery, 2014. copelandcenter.com/sites/copelandcenter.com/files/attachments/The%20Way%20WRAP%20Works%20Final.pdf
17.
McGuire AB, Kukla M, Green A, et al: Illness Management and Recovery: a review of the literature. Psychiatric Services 65:171–179, 2014
18.
Dougherty RH, Lyman DR, George P, et al: Assessing the evidence base for behavioral health services: introduction to the series. Psychiatric Services 65:11–15, 2014
19.
Fukui S, Davidson LJ, Holter MC, et al: Pathways to Recovery (PTR): impact of peer-led group participation on mental health recovery outcomes. Psychiatric Rehabilitation Journal 34:42–48, 2010
20.
Barbic S, Krupa T, Armstrong I: A randomized controlled trial of the effectiveness of a modified Recovery Workbook program: preliminary findings. Psychiatric Services 60:491–497, 2009
21.
Cook JA, Steigman P, Pickett S, et al: Randomized controlled trial of peer-led recovery education using Building Recovery of Individual Dreams and Goals through Education and Support (BRIDGES). Schizophrenia Research 136:36–42, 2012
22.
Pickett SA, Diehl SM, Steigman PJ, et al: Consumer empowerment and self-advocacy outcomes in a randomized study of peer-led education. Community Mental Health Journal 48:420–430, 2012
23.
Steigman PJ, Pickett SA, Diehl SM, et al: Psychiatric symptoms moderate the effects of mental illness self-management in a randomized controlled trial. Journal of Nervous and Mental Disease 202:193–199, 2014
24.
Pickett SA, Diehl S, Steigman PJ, et al: Early outcomes and lessons learned from a study of the Building Recovery of Individual Dreams and Goals through Education and Support (BRIDGES) program in Tennessee. Psychiatric Rehabilitation Journal 34:96–103, 2010
25.
Cook JA, Copeland ME, Hamilton MM, et al: Initial outcomes of a mental illness self-management program based on Wellness Recovery Action Planning. Psychiatric Services 60:246–249, 2009
26.
Cook JA, Copeland ME, Corey L, et al: Developing the evidence base for peer-led services: changes among participants following Wellness Recovery Action Planning (WRAP) education in two statewide initiatives. Psychiatric Rehabilitation Journal 34:113–120, 2010
27.
Cook JA, Copeland ME, Floyd CB, et al: A randomized controlled trial of effects of Wellness Recovery Action Planning on depression, anxiety, and recovery. Psychiatric Services 63:541–547, 2012
28.
Cook JA, Copeland ME, Jonikas JA, et al: Results of a randomized controlled trial of mental illness self-management using Wellness Recovery Action Planning. Schizophrenia Bulletin 38:881–891, 2012
29.
Jonikas JA, Grey DD, Copeland ME, et al: Improving propensity for patient self-advocacy through Wellness Recovery Action Planning: results of a randomized controlled trial. Community Mental Health Journal 49:260–269, 2013
30.
Cook JA, Jonikas JA, Hamilton MM, et al: Impact of Wellness Recovery Action Planning on service utilization and need in a randomized controlled trial. Psychiatric Rehabilitation Journal 36:250–257, 2013
31.
Doughty C, Tse S, Duncan N, et al: The Wellness Recovery Action Plan (WRAP): workshop evaluation. Australasian Psychiatry 16:450–456, 2008
32.
Fukui S, Starnino VR, Susana M, et al: Effect of Wellness Recovery Action Plan (WRAP) participation on psychiatric symptoms, sense of hope, and recovery. Psychiatric Rehabilitation Journal 34:214–222, 2011
33.
Higgins A, Callaghan P, DeVries J, et al: Evaluation of mental health recovery and Wellness Recovery Action Planning education in Ireland: a mixed methods pre-postevaluation. Journal of Advanced Nursing 68:2418–2428, 2012
34.
Starnino VR, Mariscal S, Holter MC, et al: Outcomes of an illness self-management group using Wellness Recovery Action Planning. Psychiatric Rehabilitation Journal 34:57–60, 2010
35.
Bartels SJ, Pratt SI, Mueser KT, et al: Integrated IMR for psychiatric and general medical illness for adults aged 50 or older with serious mental illness. Psychiatric Services 65:330–337, 2014
36.
Färdig R, Lewander T, Melin L, et al: A randomized controlled trial of the Illness Management and Recovery program for persons with schizophrenia. Psychiatric Services 62:606–612, 2011
37.
Fujita E, Kato D, Kuno E, et al: Implementing the Illness Management and Recovery program in Japan. Psychiatric Services 61:1157–1161, 2010
38.
Garber-Epstein P, Zisman-Ilani Y, Levine S, et al: Comparative impact of professional mental health background on ratings of consumer outcome and fidelity in an Illness Management and Recovery program. Psychiatric Rehabilitation Journal 36:236–242, 2013
39.
Hasson-Ohayon I, Roe D, Kravetz S: A randomized controlled trial of the effectiveness of the Illness Management and Recovery program. Psychiatric Services 58:1461–1466, 2007
40.
Johnson BA: Comparison of Illness Management and Recovery Treatment and Psychological Treatment-as-Usual in a State Psychiatric Hospital. Doctoral dissertation. Minneapolis, Minn, Capella University, Psychology Department, 2007. Available at gradworks.umi.com/32/90/3290978.html
41.
Levitt AJ, Mueser KT, Degenova J, et al: Randomized controlled trial of Illness Management and Recovery in multiple-unit supportive housing. Psychiatric Services 60:1629–1636, 2009
42.
Lin EC-L, Chan CH, Shao W-C, et al: A randomized controlled trial of an adapted Illness Management and Recovery program for people with schizophrenia awaiting discharge from a psychiatric hospital. Psychiatric Rehabilitation Journal 36:243–249, 2013
43.
Mueser KT, Meyer PS, Penn DL, et al: The Illness Management and Recovery program: rationale, development, and preliminary findings. Schizophrenia Bulletin 32(suppl 1):S32–S43, 2006
44.
Mueser KT, Bartels SJ, Santos M, et al: Integrated Illness Management and Recovery: a program for integrating physical and psychiatric illness self-management in older persons with severe mental illness. American Journal of Psychiatric Rehabilitation 15:131–156, 2012
45.
Pratt CW, Lu W, Swarbrick M, et al: Selective provision of Illness Management and Recovery modules. American Journal of Psychiatric Rehabilitation 14:245–258, 2011
46.
Salyers MP, Hicks LJ, McGuire AB: A pilot to enhance the recovery orientation of assertive community treatment through peer-provided Illness Management and Recovery. American Journal of Psychiatric Rehabilitation 12:191–204, 2009
47.
Salyers MP, Godfrey JL, McGuire AB, et al: Implementing the Illness Management and Recovery program for consumers with severe mental illness. Psychiatric Services 60:483–490, 2009
48.
Salyers MP, McGuire AB, Rollins AL, et al: Integrating assertive community treatment and Illness Management and Recovery for consumers with severe mental illness. Community Mental Health Journal 46:319–329, 2010
49.
Salyers MP, Rollins AL, Clendenning D, et al: Impact of Illness Management and Recovery programs on hospital and emergency room use by Medicaid enrollees. Psychiatric Services 62:509–515, 2011
50.
Salyers MP, McGuire AB, Kukla M, et al: A randomized controlled trial of Illness Management and Recovery with an active control group. Psychiatric Services 65:1005–1011, 2014
Information & Authors
Information
Published In
Cover: Horse Drawn Cabs at Evening, New York, by Childe Hassam, circa 1890. Watercolor. Daniel J. Terra Collection, 199.66. Terra Foundation for American Art. Photo credit: Terra Foundation for American Art, Chicago/Art Resource, New York City.
History
Received: 11 August 2014
Revision received: 25 November 2014
Revision received: 3 February 2015
Accepted: 9 March 2015
Published online: 1 July 2015
Published in print: November 01, 2015
Authors
Funding Information
The authors report no financial relationships with commercial interests.
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).