The New Zealand Mental Health Commission has defined recovery as. The Wellness Recovery Action Plan (WRAP): workshop evaluation CONSUMER ISSUES

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1 CONSUMER ISSUES The Wellness Recovery Action Plan (WRAP): workshop evaluation Carolyn Doughty, Samson Tse, Natasha Duncan and Leo McIntyre Objective: This study evaluated the delivery of a series of workshops on mental health recovery. The aims were to determine if the workshops changed participants attitudes and knowledge about recovery, if there were any differences in views between consumers and health professionals of mental health services, and how the delivery and content of the program could be improved. Methods: A total of 17 consumers and health professionals from mental health services attended a workshop based on the Wellness Recovery Action Plan (WRAP). Questionnaires were administered before and after the workshop. Results: There was a significant change in total attitudes and knowledge about recovery (pb.1) in the expected direction, with no differences between consumers and health professionals. The majority of participants found the workshop useful, and the majority of comments were positive. Conclusions: This study provides preliminary support for the use of WRAP to change consumers and mental health professionals knowledge and attitudes about recovery. Key words: Action Plan. consumer-led, recovery, self-management, Wellness Recovery Australasian Psychiatry. Vol 1, No. December Carolyn Doughty Research Fellow, Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, University of Otago, Otago, New Zealand. Samson Tse Associate Professor, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand. Natasha Duncan Research Assistant, School of Medicine, University of Auckland, Auckland, New Zealand. Leo McIntyre Chairperson, Balance NZ Bipolar & Depression Network, Wellington, New Zealand. Correspondence: Dr Samson Tse, Social and Community Health, School of Population Health, Tamaki Campus, University of Auckland, Private Bag 919, Auckland 11, New Zealand. s.tse@auckland.ac.nz The New Zealand Mental Health Commission has defined recovery as the ability to live well in the presence or absence of one s mental illness (or whatever people choose to name their experience). 1 This view of recovery was developed primarily by consumer groups, as part of a movement toward greater consumer involvement in mental health services, including a marked increase in the number of entirely consumer-run organizations. It promotes a shift from mental health management to more active collaboration between health professionals and consumers, a mutual decision-making process about what the goals are and how they can be achieved. Many self-help or self-management programs developed from this or similar notions of recovery, and were designed to allow people to problem solve, set goals, control symptoms, prevent relapse and partake in the decisions that are made about them. 3, Furthermore, they are either guided, as with a workshop or individual sessions, or non-guided, as with a self-help book or internet resource. THE WELLNESS RECOVERY ACTION PLAN The Wellness Recovery Action Plan (WRAP) is a self-management system designed by consumers, 5 assisting people to identify the factors that contribute to or prolong unwellness and to create an action plan to manage these, including what will happen to them if they are no longer able to 5 doi: 1.1/ # The Royal Australian and New Zealand College of Psychiatrists

2 make a decision. WRAP can be used by people who identify themselves as having experienced a mental health problem, and by health practitioners who may utilize it in their work. WRAP has the potential to be applied to any condition, including substance abuse, depression and other mental health conditions., OBJECTIVE This study sought to determine whether workshops could change participants attitudes and knowledge about recovery, if there were any differences in views between consumers of mental health services and health professionals, and how the delivery and content of the program could be improved or adapted for a specific setting. METHODS Procedures This study used a pre-test/post-test questionnaire design to evaluate four workshops that were conducted in New Zealand from November to December. Ethical approval was granted by the Canterbury, Wellington and Manawatu-Wanganui Medical Ethics Committees. Participation in the workshops and associated study was voluntary. Workshops were advertised in newspapers, newsletters and community notice boards, and on the website for Balance NZ, the Bipolar and Depression Network. Four hundred s were sent to governmental and non-governmental mental health organizations, and their clients and family members. Workshop attendees were approached by the researchers at the beginning of the meetings and invited to participate in the study. For those who consented to participate, questionnaires were administered by the researchers immediately prior to and after the workshops. informed consent, had difficulties in the data collection process or if there was a risk of immediate harm to themselves or others. Intervention The four workshops on WRAP were developed and delivered by people with experience of mental illness, and held in different areas of New Zealand (Table 1). The format of delivery was a mix of didactic presentation, small group discussion, and sharing of recovery experiences. Key topics presented and discussed in the workshops were:. recovery concepts of hope, personal responsibility, self-advocacy, education, and receiving and giving support;. getting medical care and how to manage medications;. developing a set of tools to use as part of daily living to enhance wellness ;. identifying triggers, and early and late symptoms of a worsening situation;. developing a personal crisis plan, including a list of supporters and their roles and phone numbers, a list of medications the person is using and information on why they are being used, symptoms that indicate the person needs their supporters to take over responsibility for their care, and instructions that tell supporters what the person wants them to do. The workshop was delivered over one or two full days. The second or extra day was used to expand and reinforce participants learning about wellness planning and to consider the implementation of WRAP within healthcare settings. Participant requirements To participate in the study, individuals were required to be over 1 years of age, able to read and write in the English language, and attend a full day at a workshop. Participants were excluded if they were not able to give Table 1: Number of study participants attending workshops by area Workshop area Days a Participants Nonresponders Measures Both pre- and post-test questionnaires required participants to answer questions about their attitudes and knowledge about recovery on a 5-point Likert-type rating scale (1strongly disagree, 5strongly agree), Included in analyses Consumers Health professionals Wellington (3%) 7 (37%) Christchurch (3%) 5 (57%) Palmerston North (%) 9 (9%) Wanganui (9%) 1 (%) Total a Post-test questionnaires were administered at the end of both days. All of the analyses in this study used the questionnaire at the end of the first day. Australasian Psychiatry. Vol 1, No. December 51

3 Australasian Psychiatry. Vol 1, No. December with additional room for comments on the postquestionnaire (Table ). All of the analyses in this study used the data collected from the pre- and posttest questionnaires at the end of the first day. Analysis A reliability test on all 1 items within both pre- and post-tests was conducted using Cronbach s alpha, to examine how well a set of items (or variables) measures a single unidimensional construct. Paired sample t- tests were carried out on the overall set of items and each item separately using Cohen s d 7 as a measure of effect size. Items were reversed if they were expected to move in the negative direction. One way analysis of variance was used to determine whether there were differences between consumers of mental health services and health professionals with or without experience of mental illness, for the pre-test and post-test scores, and the overall change in attitudes and knowledge about recovery, using the partial Eta squared as a measure of effect size. Another analysis of variance was performed to determine whether there were differences in the overall change in attitudes and knowledge about recovery between the workshops, including the -day workshop. RESULTS Participants Of the 195 people who attended the workshops, 17 participated in the study, with % of participants aged between 31 and years. Thirty people attending the four workshops participating in the evaluation did not complete either a pre- or post-test questionnaire, so a total of 157 people (%) were included in the final analyses. Reliability analysis The Cronbach s alpha score for all items in both the pre- and post-test questionnaire was a.1, indicating fairly high reliability between the items to measure recovery concepts. Differences between pre- and post-tests There was a significant change in total attitudes and knowledge about recovery (n133, t1.13, df 13, pb.1), with a large effect size (d.). The difference between the means of the total scores for all 1 items on a 5-point Likert scale was 5.11 (95% CI.75.9) in the expected direction (Figure 1). Table shows the results of paired sample t-tests for each item separately. The biggest increase in mean values from pre- to post-test questionnaire was for Item 1, which asked participants if they had a clear understanding of what a Wellness Recovery Action Plan is. However, even without this item, the total scores of the remaining 15 items were still significant (n133, t9., df13, pb.1). The two items that changed in the opposite direction were I believe that for some recovery is not possible and The opinions of health professionals should be given more weight than a person receiving treatment, both of which were reversed items. Differences between consumers and health professionals There were no significant differences between consumers and health professionals with or without experience of mental illness in the change in attitudes and knowledge about recovery, although the health professionals with experience of mental illness had significantly less variation in their scores than health professionals without experience of mental illness. Differences between workshops The workshop held in Wanganui had significantly higher total scores on the Likert scale than those held in Christchurch and Palmerston North for both pre- (df3, F5.173, pb.5) and post-test questionnaires (df 3, F.75, pb.1) (see Figure ). However, there were no differences between workshops in the overall change in attitudes and knowledge about recovery. Also, there was no difference in total scores between the end of day one and day two of the Christchurch and Wanganui workshops. This showed that the more intense training (longer duration) did not increase the overall magnitude of change. Usefulness In the post-test questionnaires 9% of people agreed they had the knowledge and skills to develop a WRAP, 7% agreed they had the knowledge and skills to develop a WRAP for someone else, and % agreed the workshop would be useful in their work, with no apparent differences between consumers and health professionals. Usefulness ratings were high across all aspects of both morning and afternoon sessions. DISCUSSION Between groups differences Overall, there was a significant change in attitudes and knowledge about recovery in the expected direction before and after attending the workshops, indicating that the program may have been effective for targeting this domain. There were no significant differences between consumers and health professionals, as we had expected health professionals to have higher scores on the pre-test questionnaires due to the greater likelihood of previous exposure to WRAP or similar models. This finding suggests that programs such as WRAP need to be included in the training of mental health professionals in New Zealand. 5

4 Table : Differences between pre- and post-test questionnaires for each item Item N Mean a 95% CI SD df p-value Effect size b 1 I have a clear understanding of what a Wellness , B Recovery Action Plan is I feel confident in my ability to empower and motivate people , B.1.5 to work toward recovery 3 I take personal responsibility for my own wellness , I believe that for some recovery is not possible , B People who experience mental illness should have the opportunity , B.1.1 to choose what treatment they will receive Having suitable employment is an important part of maintaining 15.., wellbeing 7 All people who experience mental illness have similar treatment needs , I know what an advance directive is 1.3., B The opinions of health professionals should be given more weight , than a person receiving treatment 1 The opinions of those receiving treatment should be given more , B.1.37 weight than those of psychiatrists and other health professionals 11 People who experience mental illness should decide whether or not , B.1.9 family members and significant others are to be consulted regarding their treatment and recovery process 1 Being able to contribute to the community in a meaningful way is an , important part of keeping myself well 13 I understand what is meant by peer support , B It is important that all consumers/tangata whai ora know about , B mental health recovery concepts 15 It is important that non-consumers know about mental health , recovery concepts 1 I know how to change negative thoughts into positive ones , B.1.31 a Difference between the means pre- and post-test for the questionnaire (unitchange on a 5-point Likert Scale, positiveexpected direction, negativeopposite direction to expected). b d calculated using the pooled standard deviation. 53 Australasian Psychiatry. Vol 1, No. December

5 Pre-Test Total Scores for Attitudes and Knowledge About Recovery Post-Test Total Scores for Attitudes and Knowledge About Recovery Figure 1: Distribution of the summed scores for 1 items on attitudes and knowledge about recovery. Australasian Psychiatry. Vol 1, No. December Future improvements for the workshop The majority of participants found the workshop useful, and 7% of comments were positive. To maximize its usefulness, the workshop may need to have a minimum duration of days, as participants of the 1-day workshop sometimes felt there was not enough time to cover all the scheduled material. Some participants also indicated that more small group work would have been helpful. Incorporating a module or sessions on how the program can be implemented practically into the workplace may be worthwhile, particularly as many participants were mental health professionals and were considering how to apply WRAP in their work settings. Limitations This study is limited in that there was that there was no comparison group. Second, it is important to note that participants volunteered to take part in the workshops;thusthesampleisnotlikelytoberepresentative of the general population of health professionals or mental health consumers and may have attracted individuals motivated to change. Future directions One possible direction for future research would be to evaluate the evidence of effectiveness for recovery using an experimental approach that measured 5

6 Pre-test total scores for Wellington Pre-test total scores for Christchurch Post-test total scores for Wellington Post-test total scores for Christchurch Pre-test total scores for Wanganui Post-test total scores for Wanganui Pre-test total scores for Palmerston North Post-test total scores for Palmerston North Figure : Differences between workshops in summed scores for attitudes and knowledge about recovery, for preand post-test questionnaires. outcomes for a larger group of individuals using WRAP after participating in training, and by controlling for other confounding factors. Therefore, to provide unequivocal evidence for effectiveness, a fully funded, randomized controlled trial would need to be conducted using standardized outcomes so that the WRAP program can be compared to other self-management programs or evaluated as an adjunct to traditional care. Outcomes would need to be measured immediately after a workshop, but also much later at a designated follow-up point to see if there was any longer term effect from training or to establish whether any effect, positive or negative, was maintained over time. ACKNOWLEDGEMENTS The authors thank Mary Ellen Copeland and Ed Anthes for facilitating the workshops, and Veronica Playle for assisting with database development and data entry. The project was funded by Balance NZ, Bipolar Support Canterbury, Pathways to Wellbeing, Capital and Coast District Health Board, Eli Lilly, and the JR McKenzie Trust. Participants paid a small registration fee to attend to cover costs. However, neither the researchers nor any of the host organizations gained financially from the workshops or research. REFERENCES 1. Mental Health Commission. Recovery Competencies for New Zealand Mental Health Workers. Wellington: Mental Health Commission,.. Goldstrom I, Campbell J, Rogers J et al. National estimates for mental health mutual support groups, self-help organizations, and consumer-operated services. Administration & Policy in Mental Health ; 33: 913. Australasian Psychiatry. Vol 1, No. December 55

7 3. Bachman J, Swenson S, Reardon M, Miller D. Patient self-management in the primary care treatment of depression. Administration & Policy in Mental Health and Mental Health Services Research 5; 33: 75.. Davidson L. Recovery, self management and the expert patient changing the culture of mental health from a UK perspective. Journal of Mental Health 5; 1: Copeland M, Mead S. Wellness Recovery Action Plan and Peer Support. Chandler, AZ: Peach Press,.. Mueser K, Corrigan P, Hilton D, Tanzman B. Illness management and recovery: a review of the research. Focus ; : Cohen J. Statistical Power Analysis for the Behavioral Sciences, nd edn. New Jersey: Lawrence Erlbaum, 19. Australasian Psychiatry. Vol 1, No. December 5

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