Psychiatric Rehabilitation Journal 2011, Volume 34, No.

3, 214-222

Copyright 2011 Trustees of Boston University DOI: 10.2975/34.3.2011.214.222

Article Effect of Wellness Recovery Action Plan (WRAP) Participation on Psychiatric Symptoms, Sense of Hope, and Recovery
t

Sadaaki Fukui, Vincent R. Starnino, Mariscal Susana, Lori J. Davidson, Karen Cook, Charles A. Rapp and Elizabeth A. Gowdy University of Kansas

Acknowledgements: Developed by the University of Kansas School of Social Welfare Office of Mental Health Research and Training through a contract with the Kansas Department of Social and Rehabilitation Services. In memory of Elizabeth A. Gowdy (July 28, 2009).

Objective: Self-management of psychiatric illness is a central tenet of consumerdirected mental health treatment. While several manualized self-management programs have been developed in recent years, the most widely disseminated is the Wellness Recovery Action Plan (WRAP). This study examined the effects of WRAP participation on psychiatric symptoms, hope, and recovery outcomes for people with severe and persistent mental illness. Methods: A quasi-experimental study, with an experimental (n=58) and a comparison (n=56) group was conducted. WRAP sessions (8-12 week) were facilitated by one staff person and one peer worker at five community mental health centers in a Midwestern state. The Modified Colorado Symptom Index, the State Hope Scale, and the Recovery Markers Questionnaire (RMQ) were employed at the first and last WRAP sessions, as well as six months following the intervention. Repeated measures analysis of covariance and planned comparisons before and after the intervention were conducted. Results: Findings revealed statistically significant group intervention effects for symptoms and hope, but not for RMQ. Planned comparisons showed statistically significant improvements for the experimental group in psychiatric symptoms and hope after the intervention, while non-significant changes occurred in the comparison group. Conclusions and Implications for Practice: The study results offer promising evidence that WRAP participation has a positive effect on psychiatric symptoms and feelings of hopefulness. If recovery is the guiding vision for mental health system reform, the study results provide evidence that WRAP programming may warrant a place in the current array of services offered through the publicly funded mental health system. Keywords: consumer-centered services, recovery, group intervention, illness management

Introduction

Recovery has been conceptualized as

both a process and an outcome with common themes that include the development of self-confidence, a selfconcept beyond the illness, symptom management, and a sense of wellbeing, hope and optimism about the

future (Deegan, 1988; Anthony, 1993; Ralph, 2000; Frese, Stanley, Kress, & Vogel-Scibilia, 2001; Deegan, 2003; Davidson, 2005). Consistent with this view, the Substance Abuse and Mental Health Services Administration (U.S. Department of Health and Human Services, 2005) issued a consensus statement on mental health recovery in 2005, which defines recovery as a journey of healing and transformation

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enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential. Ten fundamental components of recovery are identified in the statement: self-direction, individualized and person-centered approaches, empowerment, holistic views, nonlinearity, strengths-based, peer support, respect, responsibility, and hope. As noted by Cook (2005), self-management of psychiatric illnesses is a central tenet of consumer-directed mental health treatment. The most widely disseminated manualized self-help program is the Wellness Recovery Action Plan, known as WRAP (Copeland, 1997). WRAP is a peer-based program in which participants identify internal and external resources for facilitating recovery (Cook et al., 2010). These resources are then used as tools to develop an individualized self-management plan. The goal of participation is health-related behavioral and attitudinal change, emphasizing the acquisition of new information and skills to better manage symptoms and maintain increased levels of health and functioning (Cook, 2005). The premise of WRAP is to allow individuals with severe and persistent mental illness to: (1) improve their ability to effectively take responsibility for their own wellness and stability, (2) manage and reduce mental health symptoms using a variety of self-help techniques, and (3) effectively learn skills to reach out and use support (Copeland, 1997; 2004). To achieve these objectives, WRAP users create individualized plans to assist them in recognizing the progression of symptoms and plan, in advance, how to selfmanage these symptoms. In addition to learning the aspects of a WRAP plan, groups also provide an introduction to key recovery concepts, exposure to a

variety of self-help techniques, and specific concerns that may need to be addressed in order to complete and use a plan effectively (e.g., trauma recovery, general health care, medications, and suicide prevention). Thus, by participating in a WRAP group and developing a WRAP plan, individuals can gain a sense of hope and empowerment while learning effective self-management skills to better control their symptoms, and become an active participant in their own recovery. WRAP is being used in a variety of settings both nationally and internationally, and there are considerable anecdotal reports suggesting that it is a useful tool for managing a variety of emotional, psychiatric, and physical disabilities (Copeland, 1997). There have been, however, only two published studies conducted to examine the benefits of completing a WRAP plan for mental health consumers. Using a pre-post design, Cook et al (2009) found significant improvements in selfreported psychiatric symptoms, recovery, hopefulness, self-advocacy, and physical health. Our pilot study found significant improvements in hope and recovery, but not psychiatric symptoms using a single group pre-post design (Starnino et al., 2010). The current study reports the results of a quasi-experimental design to assess the impact of WRAP participation. We hypothesized that WRAP program participants would experience a decrease in self-reported psychiatric symptoms and increases in hope and recovery after completion of the program as compared to the comparison group who did not participate in the program.

WRAP groups during the research period. The WRAP group program followed the specific guidelines of the Copeland Center, the national center for training and technical assistance (Copeland, 2004). Each group initially contained between 4 and 12 members and consisted of 8 to 12 weekly sessions, lasting from 1 to 2 hours each. One of the basic tenets of WRAP is that people begin where they are and proceed at their own pace. Each of the groups was asked to complete a basic 8-week course of WRAP but was also given permission, based on the individuals in the group and their needs, to continue for up to 12 weeks. The groups were facilitated by one staff person and one peer worker who had attended a 2-day WRAP facilitators training offered by the University of Kansas School of Social Welfare (trainings were presented by a Copeland Center certified recovery educator). Each of the facilitators was required to have led at least one complete WRAP training prior to participating in the research. A total of seven individuals served as co-facilitators with each group incorporating both a peer WRAP educator and a community mental health center (CMHC) psychosocial rehabilitation group leader. Peer educators who were not employed at the CMHC were compensated $250 for the planning, preparation and teaching of the group sessions. The CMHC co-facilitators were not compensated outside of their agency salary. Research participants We used a quasi-experimental design (nonequivalent groups design, which assignment to group is not random), with an experimental and a comparison group. Between August, 2005 and December, 2007, data was collected at pretest, posttest, and a six-month follow-up.

Methods
WRAP group Each of five participating research sites offered between 1 and 6 individual

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The sample consisted of adult participants who had a documented severe mental illness and were receiving community support services (CSS) through a community mental health center in Kansas at the time of the research. Each participant was asked to self-report their diagnosis during the initial contact. In addition, a statewide information database system used to monitor community mental health centers activities (Kansas Department of Social and Rehabilitation Services, 2005) was accessed by the researchers to confirm diagnosis. A standard definition of Severe and Persistent Mental Illness (SPMI) was used, based on specific criteria set by the State of Kansas. Criteria included being diagnosed with a major mental disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2000) (e.g., schizophrenia, bipolar disorder, major depressive disorder, borderline personality disorder), and experiencing significant functional impairment directly related to ones mental illness (e.g., hospitalization, inability to work, required help attending to daily living activities) (Kansas Department of Social Services and Rehabilitation Services, 2005). The experimental group participants were recruited from individuals who voluntarily joined WRAP groups offered at the five community mental health centers (CMHCs) where they were receiving services. Of 90 individuals who joined a WRAP group, 58 consented to participate in our researchresearch participation rate was 64%. They were not exposed to WRAP before. To ensure that the experimental group had sufficient exposure to the WRAP intervention we set a standard of 75% attendance during the group sessions. All research participants attended at least 75% of the WRAP group and completed the program based on our crite-

ria for the research participation. Group facilitators were responsible for tracking the program attendance. None of the participants subsequently dropped out of the research. A list of potential comparison group participants was created by matching characteristics (diagnosis, gender, and age) with WRAP group participants at the same five CMHCs. The list was generated using the Kansas statewide information database used to monitor CMHC activities (Kansas Department of Social and Rehabilitation Services, 2005). Approximately three potential comparison group participants were identified for each experimental group participant. Due to confidentiality requirements, only client numbers (ID numbers in the database) associated with the matched information (i.e., diagnosis, gender, and age) were available to the researchers. The list included 170 potential comparison group participants ID numbers. The five CMHCs staff members were responsible for matching the ID numbers with names and requests for the participation in our research were given to the potential participants case manager. The case manager invited them to participate. Only individuals who had never completed a WRAP program or a WRAP plan, and had no current involvement in a WRAP group, were eligible. Some of the individuals identified in the initial list were not approached by their case managers because case managers were not able to meet with them during the required two week recruitment period. Of the 99 consent forms returned to the researchers, 56 individuals agreed to participate in the researchresearch participation rate was 57%. Comparison group participants were informed that involvement in the research did not prevent them from joining a WRAP group in the future.

Participants were asked to report to their case managers if they started WRAP and the case manager would report it to the researchers. We did not receive any reports that comparison group participants started WRAP during the research time. From the initial contact, participants were asked to complete a basic information sheet that included at least two self-identified contact persons who would know how to reach the participant (i.e., a case manager, psychosocial group leader, or a family member). When initial attempts to reach the participant were not successful, researchers contacted these individuals for help in locating the participant. The dropout rate for the comparison group was 7%: three individuals voluntarily left the research and one died. The experimental group was compensated $25 for the combination of pretest and posttest questionnaires, and $15 for the 6-month follow-up questionnaire. Comparison group participants received compensation of $15 for each of the three time periods in which they completed questionnaires. Written informed consent was obtained from all participants using procedures approved by the University of Kansas Institutional Review Board. Measurements In addition to demographics, standardized questionnaires were administered to experimental group participants, face-to-face, by bachelors- or masterslevel trained researchers at the first and last session of the WRAP program, with a six-month mailed follow-up. Comparison group participants completed the same series of questionnaires by mail. Participants completed the Modified Colorado Symptom Index (Conrad et al., 2001), the State Hope Scale (Snyder et al., 1996) , and the Recovery Markers Questionnaire [RMQ] (Ridgway et al., 2003).

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The Modified Colorado Symptom Index (Conrad et al., 2001) is a fourteen-item brief self-report measure of psychological symptoms (Range: 1-5), with higher scores indicating more self-reported psychological symptoms. The Index was tested with a national sample consisting of 1,381 persons in treatment for mental illness or substance abuse that were either homeless or considered at risk for homelessness (Conrad et al., 2001). The Index showed excellence for several types of validity, testretest reliability, internal consistency, and dimensionality. The test-retest (intra-class correlation) was .79 (15 days interval). Cronbachs alpha ranged from .87 to .92. Based on a principle components analysis, the Index is used as a single construct of psychological symptomotology. Cronbachs alpha for the sample in this research was .93. The State Hope Scale (Snyder et al., 1996) is a six item scale designed to measure hope as it shifts over time and according to life situations. The State Hope Scale is an offshoot of the prior developed dispositional Hope Scale (Snyder et al., 1991)which was designed to measure a more longstanding and generalized hope characteristic within an individual. In a review of four studies which outline the development and validation of the State Hope Scale, it was concluded that the scale is reliable and valid (Snyder et al., 1996). It can be scored either according to its subscales (agency and pathways) or as a total 6item scale which reflects an overlaying indicator of state hope. Cronbachs alpha for the total 6-item scale ranged from .79 and .93. In this research, a total 6 items were used (Range: 1-8), with higher scores indicating greater levels of hope. Cronbachs alpha for the sample in this research was .82.

The Recovery Markers Questionnaire [RMQ]originally a subscale of the Recovery Enhancing Environment Scale (Ridgway et al., 2003)is a 28-item self-report checklist designed to outline markers of recovery. Respondents are asked to place a checkmark beside each statement that is true for them right now. Recovery Markers represent various recovery domains including process factors (i.e., I am growing as a person), goal-oriented thinking (i.e., I have reasons to get out of bed in the morning), selfagency (i.e., I control the important decisions in my life), self-efficacy (i.e., I believe I can make positive changes in my life), symptoms (i.e., My psychiatric symptoms are under control), social support (i.e., I have trusted people I can turn to for help), and basic resources (i.e., I have enough income to meet my needs). The items were rated either 0 (No) or 1 (Yes). The scale has not been tested for validity psychometrically (i.e., construct validity), but has content validity (Ridgway et al., 2003). Cronbachs alpha ranged from .86 to .93 (Ratzlaff, McDiarmid, Marty, & Rapp, 2006). Cronbachs alpha for the sample in this research was .69. The measures used in this research are identical to the ones for our pilot study (Starnino et al., 2010) and were chosen based on their ability to capture changes through time in their recoveryrelated domains. Data Analyses Repeated measures analysis of covariance was applied to examine the intervention effect for symptoms, hope, and RMQ. The model included time (pretest, posttest, & a 6-month followup) as the within-subjects factors and group (comparison vs. experimental group) as the between-subjects factors. Based on the nature of correlation among outcomes (self-reported psychi-

atric symptoms, hope, and recovery), our assumption was that the intervention effect for an outcome would be affected by the initial stage (pretest score) of other outcomes. Therefore, pretest scores of the other two outcomes were included as covariates adjusting for baseline status when testing the intervention effect of a third outcome. Planned comparisons (pretest vs. posttest & a 6-month follow-up) were conducted to compare the mean differences before and after the intervention. To solve the unbalanced design (unequal sample sizes in each treatment condition), main effects and interaction were tested using Type III sum of squares which produces the same results as an unweighted-means solution (Howell, 2007). Group differences at pretest for demographics and outcomes as well as selection bias were also assessed for the group comparability prior to the repeated measures analysis of covariance. Statistical significance was assessed at .05. Average missing data on outcomes for experimental group were 4% for pretest (Symptoms: 8.6%; Hope: 1.7%; RMQ: 1.7%), 1% for posttest (Symptoms: 1.7%; Hope: 0%; RMQ: 1.7%), and 10% for 6-month follow-up (Symptoms: 10.3%; Hope: 10.3%; RMQ: 8.6%), while comparison group were 2% for pretest (Symptoms: 1.7%; Hope: 3.5%; RMQ: 0%), 4% for posttest (Symptoms: 3.7%; Hope: 3.7%; RMQ: 3.7%), and 12% for 6-month follow-up (Symptoms: 11.5%; Hope: 11.5%; RMQ: 11.5%). Since the missing data were assumed to be missing at random (missing mechanism did not depend on the unobserved data) (Alison, 2002), these data ware recovered by multiple imputation (Graham et al., 2003). Multiple imputation (MI) using the missing at random assumption is a reasonably well-executed method even when some of the missing data mechanisms are missing not at random (Enders, 2010).

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All statistical analyses applied intention-to-treat analysis, which is suggested when using multiple imputation to missing data including dropout participants (Little & Yau, 1996). SPSS version 17 was used for the analyses.

Results
The average age was 44.2, with a range of 21 to 80 for the experimental group and 42.8, with a range of 22 to 73 for the comparison group. Over 60% were female (62% experimental vs. 63% comparison). The majority of the participants (65% experimental vs. 66% comparison) were white, followed by African American (32% experimental vs. 29% comparison), and other racial groups (4% experimental vs. 5% comparison). Just over 40% of the participants had schizophrenia or a related

psychotic disorder as a primary diagnosis (44% experimental vs. 45% comparison), nearly 30% were diagnosed with major depressive disorder (26% experimental vs. 29% comparison), approximately 20% had bipolar disorder (21% experimental vs. 23% comparison), followed by other diagnoses, including post-traumatic stress disorder, personality disorder, and anxiety disorder (9% experimental vs. 4% comparison). While some participants had some college or higher (35% experimental vs. 24% comparison), a majority had an education level of high school or less (66% experimental vs. 76% comparison). There were no statistically significant differences between experimental and comparison group participants for any of the demographic variables (Table 1).

The two groups were equivalent regarding outcomes (Symptoms, Hope, and RMQ) at pretest. There were no statistically significant group differences between the comparison and experimental groups at pretest for Symptoms (t (112) = .581, p = 0.56), Hope (t (112) = .846, p = 0.40), and RMQ (t (112) = 1.341, p = 0.18). Further, two-stage least squares selection bias tests (Barnow, Glen, & Arthur, 1980; Heinrich, 1998) were conducted to examine the selection bias which leads to biased-estimations of the intervention effects on the outcomes: Symptoms, Hope, and RMQ. The predicted probability of selection variable using gender, age, diagnosis of mental illness, and education considered to be relevant to selection into the experimental group did not show statistically significant relationships with the outcome

Table 1Characteristics of 114 participants by group

Experimental group (N=58) Demographics Age Gender Female Male Race White African American Other Diagnosis Schizophrenia Major depressive disorder Bipolar disorder Other Education level High school or less Some college or Bachelors degree Graduate studies 36 16 3 65.5 29.1 5.5 41 12 1 75.9 22.2 1.9 25 15 12 5 43.9 26.3 21.1 8.8 25 16 13 2 44.6 28.6 23.2 3.6 37 18 2 64.9 31.6 3.6 37 16 3 66.1 28.6 5.4 36 22 62.1 37.9 35 21 62.5 37.5 Frequency M =44.2 Percentage SD =11.2 Comparison group (N=56) Frequency M = 42.8 Percentage SD = 10.9 t (111) = .694, p =.49 Group equivalency

c2 (1, N=113) = .014, p =.90

c2 (2, N=113) = .309, p =.86

c2 (3, N=113) = 1.35, p =.72

c2 (2, N=109) = 1.89, p =.39

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Table 2Mean changes before (Pretest) and after the WRAP intervention (Posttest & a 6-month follow-up)
Pretest M (SD) Symptoms Experiment 2.79 (.99) Comparison Hope Experiment 5.42 (1.58) Comparison RMQ Experiment 0.59 (.18) Comparison 0.54 (.23) Note 1 * p < .05, ** p < .01 2 For each scale, item scores were summed and divided by the number of items 3 The experimental group (n=58) and the comparison group (n=56) 4 Planned comparison was not processed for RMQ due to non-significant interaction effect 0.68 (.19) 0.56 (.25) 0.64 (.20) 0.52 (.26) 5.17 (1.62) 6.12 (1.43) 5.46 (1.76) 5.88 (1.28) 5.01 (1.88) 0.06 0.730 0.0 0.58 0.013* 0.4 2.68 (.97) 2.49 (.92) 2.51 (.99) 2.42 (.95) 2.80 (1.02) 0.03 0.765 0.0 0.33 0.001** 0.4 Posttest M (SD) A 6-month follow-up M (SD)

DM Baseline vs. After intervention

Cohens d

variables, which led to the conclusion that selection bias is not a problem. The analyses showed statistically significant interaction effects for symptoms (F (2,110) = 5.02, p = .007, hp2 =.04) and hope (F (2,110) = 3.68, p = .027, hp2 = .03), but not for RMQ (F (2,110) = 2.61, p = .076, hp2 = .02). The interaction effects indicate that the mean scores improvements after the intervention for symptoms and hope depended on which group the research participants belonged to. Planned comparisons showed that the mean levels improved after intervention for the experimental group in symptoms (DM = .33, p< .001, d = 0.4) (Figure 1) and hope (DM = .58, p = .013, Cohens d = 0.4) (Figure 2). Effect sizes were 0.4, which are considered medium in size

(Cohen, 1988). The mean levels did not change at .05 significance level for the comparison group in symptoms or hope before and after the intervention.

Discussion
Mental illness self-management is at the heart of consumer-directed care (Cook, 2005) and involves consumers taking personal control of their recovery and drawing from their own expertise and experience. This is the first evaluation of WRAP that employed a comparison group and follow-up measurement. The research results indicate that the experimental group participants experienced reductions in psychiatric symptoms as well as significantly improved their sense of

hope after the WRAP intervention. The findings are similar to the results found in two other evaluations of WRAP (Cook et al., 2009; Starnino et al., 2010). The main focus of WRAP is to help participants learn strategies to manage psychiatric symptoms using a variety of self-techniques (Copeland, 1997; 2004). This long-term research with 6month follow-up after the intervention captured symptom reduction that is typically hard to observe in a shorter term study (Starnino et al., 2010). Study limitations include (1) generalizability, (2) comparability of the two groups, (3) fidelity, (4) statistical power, and (5) potential factors affecting the outcomes. First, the study lacked a randomized control group and participants were recruited from only

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Figure 1Mean change in Symptoms scale and the 95% confidence intervals

one Midwestern state. Second, the variables used to match subjects were limited and it is possible that motiva-

tion levels would vary between the groups. The different data collection methods (face-to-face vs. mail using

Figure 2Mean change in Hope scale and the 95% confidence intervals

self-report measures) used in our study might have caused a response bias (including social desirability bias and interviewer bias) for the significant improvement of outcomes for the experimental group while improvement was not observed for the comparison group. Third, at the time the research was conducted, no WRAP fidelity and research protocol existed. The lack of systematic monitoring of the intervention could mean there was variation in quality between WRAP groups. Because the research relied on group facilitators when tracking the WRAP group participants attendance, we do not have information about each individual participants attendance rate other than receiving certification that research participants completed 75% of the group sessions. There might be a potential relationship between number of sessions attended and the intervention effect, which is of interest for a future study. Given increased attention to the effects of WRAP, the development of a WRAP fidelity measure is indicated. Fourth, there might have been an underpowered issue involved for our repeated measures analysis design to detect the intervention effect for the RMQ outcome. The mental health recovery experience is a long process and does not reflect linear growth. In order to capture the non-linear growth over time, more participants and time points may be necessary. Fifth, we have a lack of formal and informal service usage information on the participants. Active service users, including possible WRAP group participants, might be involved in multiple health care services. This research does not capture how the interaction between service usage and WRAP would impact the improvement of recovery related outcomes. Despite the limitations, the findings are informative, especially at a time when states are increasing their fund-

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ing for peer-delivered services. A growing number of states are also using peer support servicesnow reimbursable through Medicaidin community mental health centers. If recovery is the guiding vision for mental health system reform (Presidents New Freedom Commission on Mental Health, 2003), the study results provide evidence that WRAP programming may warrant a place in the current array of services offered through the publically funded mental health system.

References
Alison, P. (2002). Missing data: Quantitative applications in the social sciences. Sage Publications. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: Fourth edition, text revision. Washington, DC: American Psychiatric Association. Anthony, W. A. (1993). The decade of recovery. Psychosocial Rehabilitation Journal, 16, 1. Barnow, B., Glen, C., & Arthur, G. (1980). Issues in the analysis of selectivity bias. In E. W. Stromsdorfer & G. Farkas (Eds.), Evaluation Studies Review Annual, 5 (pp. 4259). Beverly Hills: Sage Publications. Cohen, J. (1988). Statistical power analysis for the behavioral sciences, 2nd ed. Hillsdale, NJ, Lawrence Earlbaum Associates. Conrad, K. J., Yagelka, J. R., Matters, M. D., Rich, A. R., Williams, V. & Buchanan, M. (2001). Reliability and validity of a modified Colorado Symptom Index in a national homeless sample. Mental Health Services Research, 3, 141153. Cook, J. A. (2005). Patient-centered and consumer-directed mental health services. Retrieved from University of Illinois at Chicago National Research and Training Center on Psychiatric Disability Website: http://www.cmhsrp.uic.edu/download/IO Mreport.pdf Cook, J. A., Copeland, M. E., Hamilton, M. M., Jonikas, J. A., Razzano, L. A., Floyd, C. B., Hudson, W. B., Macfarlane, B. A., & Grey, D. B. (2009). Initial outcomes of a mental illness self-management program based on Wellness Recovery Action Planning. Psychiatric Services, 60, 246249. Cook, J. A., Copeland, M. E., Corey, L., Buffington, E., Jonikas, J. A., Curtis, L. C.,Nichols, W. (2010). Developing the evidence base for peer-led services: Changes among participants following Wellness Recovery Action Plan (WRAP) education in two statewide initiatives. Psychiatric Rehabilitation Journal, 34, 113120. doi:10-2975/34.2.2010.113-120. Copeland, M. E. (1997). Wellness Recovery Action Plan. Brattleboro, VT: Peach Press. Copeland, M. E. (2004). Leading a mental health recovery and WRAP facilitator training. Brattleboro, VT: Peach Press. Davidson, L. (2005). Recovery, self management and the expert patient: Changing the culture of mental health from a UK perspective. Journal of Mental Health, 14, 2535. Deegan, P. E. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11, 1119.

Deegan, G. (2003). Discovering recovery. Psychiatric Rehabilitation Journal, 26, 368376. Enders, C. (2010). Applied missing data analysis. New York, NY: Guilford Press. Frese, F. J., Stanley, J., Kress, K., & VogelScibilia, S. (2001). Integrating evidencebased practices and the recovery model. Psychiatric Services, 52, 14621468. Graham, J. W., Cumsille, P. E., & Elek-Fisk, E. (2003). Methods for handling missing data. In J. A. Schinka & W. F. Velicer (Eds.), Research methods in psychology, Vol. 2 (pp. 87114). New York: John Wiley & Sons. Heinrich, C. (1998). Returns to education and training for the highly disadvantaged: What does it take to make an impact? Evaluation Review, 22, 637667. Howell, D. (2007). Statistical methods for psychology. (6th Ed.). Wadsworth Publishing Co. Kansas Department of Social and Rehabilitation Services, Disability and Behavioral Health Services. (2005). The Automated Management Information System (AIMS). Profile available at: <http://www.srskansas.org/hcp/MHSIP/ MHSIPAIMS.htm> Little, R., & Yau, L. (1996). Intent-to-treat analysis for longitudinal studies with drop-outs. Biometrics, 52, 13241333. Presidents New Freedom Commission on Mental Health (2003). Achieving the promise: Transforming mental health care in America. Final Report. Washington, DC: Department of Health and Human Services. Ralph, R. (2000). Recovery. Psychiatric Rehabilitation Skills, 4, 480517. Ratzlaff, S., McDiarmid, D., Marty, D. & Rapp, C. (2006). The Kansas consumer as provider program: Measuring the effect of a supported education initiative. Psychiatric Rehabilitation Journal, 29, 174182. Ridgway, P. A., Press, A., Ratzlaff, S., Davidson, L., & Rapp, C. A. (2003). Report on field testing the Recovery Enhancing Environment (REE) measure. Lawrence, KS, University of Kansas School of Social Welfare, Office of Mental Health Research and Training. Snyder, C. R., Harris, C., Anderson, J. R., Holleran, S. A., Irving, L. M., Sigmon, S. T., Yoshinobu, L., Gibb, J., Langelle, C. & Harney, P. (1991). The will and the ways: Development and validation of an individual-differences measure of hope. Journal of Personality and Social Psychology, 60(4), 570585.

Conclusions
WRAP is now offered in all 50 states (Cook et al., 2009). The study results offer promising evidence that WRAP participation has a positive effect on psychiatric symptoms and hope, thereby providing an effective complement to current mental health treatment offered in community mental health settings. Areas for future research include more rigorous methods, such as randomized controlled trials, to confirm these results. Attention to the organizational factors that facilitate or inhibit the incorporation of self-directed illness management principles throughout the service organization could be profitable. It can be assumed that selfdirected illness management would be more prevalent and more effective if organizational efforts were not limited to an isolated WRAP program but rather involved case managers, therapists, and other psychosocial staff. This could also include the format of treatment plans and protocols for treatment plan reviews.

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Snyder, C. R., Sympson, S. C., Ybasco, F. C., Borders, T. F., Babyak, M. A., & Higgins, R. L. (1996). Development and validation of the State Hope Scale. Journal of Personality and Social Psychology, 70, 321335. Starnino, V., Mariscal, S., Holter, M., Cook, K., Davidson, L., Fukui, S., & Rapp, C. A. (2010). Outcomes of an illness self-management group using Wellness Recovery Action Planning. Psychiatric Rehabilitation Journal, 34, 5760. doi: 10.2975/34.1.2010.57.60. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Center for Mental Health Services. (2005). National Consensus Statement on Mental Health Recovery 2005. Profile available at: http://mentalhealth.samhsa.gov/ publications/allpubs/sma05-4129/

Sadaaki Fukui, PhD, is a Research Associate at the University of Kansas Center for Research Methods and Data Analysis and School of Social Welfare. Vincent R. Starnino, MSW, is a PhD candidate at the University of Kansas School of Social Welfare. Mariscal Susana, MSW, is a doctoral student at the University of Kansas School of Social Welfare. Lori J. Davidson, LMSW, is a project coordinator at the University of Kansas School of Social Welfare, Office of Mental Health Research and Training. Karen Cook is a program assistant at the University of Kansas School of Social Welfare, Office of Mental Health Research and Training. Charles A. Rapp, PhD, is a Professor and Director at the University of Kansas School of Social Welfare, Office of Mental Health Research and Training. Elizabeth A. Gowdy, MSW, PhD, was a research consultant at the University of Kansas School of Social Welfare, Office of Mental Health Research and Training.

Contact the main author: Sadaaki Fukui, PhD Ph: 785-864-5874 fsadaaki@ku.edu

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