One of the most widely circulat-ed programs that expands mental health recovery and consumer movements to include self-management is the Wellness Recovery Action Plan (WRAP).8 WRAP is patient-directed and centers on identifying internal and external resources for facilitating recovery. Using presentations, demonstrations, interactive discussions, and related activities, WRAP facilitators teach participants that to successfully recover from mental illness, they must be determined to get better, manage illness, take action, face problems, and make choices. WRAP facilitators assist participants in creating a personal “Wellness Toolbox” that consists of simple and easily accessible strategies, such as healthy diet, exercise, sleep, and meeting life and vocational goals, in addition to the identification of “early warning signs” and how to effectively manage a crisis situation.
Over the past several years, a number of other well-established, peer-led mental health recovery programs have incorporated self-management concepts. In the mid-1990s, Building Recovery of Individual Dreams and Goals through Education and Support (BRIDGES)9 began to involve peers in teaching courses on recovery and in facilitating ongoing support groups promoting overall wellness.
Similarly, the National Alliance on Mental Illness (NAMI) Peer-to-Peer program10 uses peers to assist persons with mental illness to establish and maintain their recovery through a unique, experimental consumer education and learning program (NAMI 2005). The Vet-to-Vet Peer Support program11 and the Massachusetts Peer Educators Project stress that meetings should encourage, validate, and support recovery in an ongoing fashion.
To help individuals gain the skills needed to lead more peaceful and productive lives, Abraham Low Self-Help Systems (the result of a merger of Recovery International and the Abraham Low Institute) also provide a safe place to talk about life’s struggles with others who have had similar experiences.
As with medical self-management interventions, peer-led mental health programs use the power and influence of peer networks to model physical and social functioning and further build self-efficacy. Peer-led self-management programs are increasingly becoming part of mainstream care delivery in the public mental health system. More than half of state Medicaid programs reimburse peers who provide these evidence-based services. In the context of peer support, self-management allows mental health consumers to become active participants in their health care, leading them to an overall sense of well-being despite their illnesses.
Medical disease self-management among persons with serious mental illness
Research shows that persons with serious mental illness are at elevated risk for a wide range of chronic medical conditions that contribute to increased morbidity and premature death.12,13 Compared with the general population, persons with serious mental illness die about 25% earlier. More specifically, 60% of premature deaths in persons with schizophrenia are due to medical conditions, such as cardiovascular, pulmonary, and infectious diseases.13
Modifiable risk factors, such as physical inactivity, poor diet, smoking and other drug use, problems with medication adherence, and limited health literacy, increase the incidence of illness. At the same time, individuals with serious mental illness face a series of barriers to effectively manage their illness and access appropriate health care. Persons with serious mental illness experience greater social challenges that include unemployment, homelessness, incarcerations, victimization/trauma, poverty, and social exclusion. Consequently, it is particularly important for these persons to acquire the skills to self-manage both their chronic medical conditions and their mental illness.
The Health and Recovery Peer (HARP) program is an adaptation of the CDSMP. It is the first fully peer-led program specifically designed to be delivered by, and to, mental health consumers.
To adapt the CDSMP for mental health consumers, modifications that address potential gaps in health literacy and cognitive limitations were made, and peer coaching sessions were added to personalize the program and reinforce each group session. Materials emphasizing the connection between the mind and body, the importance of coordinating information and medications between primary care providers and mental health clinicians, and the need to consider a mental health advanced directive were also added. The diet and exercise sections were adapted to address high rates of poverty and social disadvantage in this population, and interactive cooking and exercise classes were added.
In a pilot trial, participants in the HARP program showed significant improvement in patient activation (a measure of an individual’s self-management capacity) and in using primary care medical services.12 These benefits appeared greatest in populations with financial and social disadvantage. A multisite, randomized trial of the intervention is now under way in Georgia.