“I Get My Therapy From Work”

Abstract

Although the Wellness Recovery Action Plan (WRAP) has been studied in the context of recovery from mental illness, peer-led services, effectiveness, and improving self-advocacy skills of clients, the relationship between employment success and WRAP has not yet been examined. The objective of the study was to explore the impact of WRAP on employment and how individuals with psychiatric disabilities utilized WRAP strategies for employment success. Ten working-age individuals who completed WRAP training and subsequently worked for at least 90 days engaged in semi-structured interviews about their experiences with WRAP and employment. Transcripts of the interviews were analyzed and three themes emerged from the study: (a) Then and Now, (b) Strategies for Wellness, and (c) Toward Employment Success. Findings showed that WRAP strategies facilitated success in employment and that employment was an important component of recovery from mental illness.

Keywords

psychiatric disability(ies)work adjustment career/vocational self-determination

The Wellness Recovery Action Plan (WRAP) and other illness self-management programs have been studied in the context of recovery from mental illness (Cook, n.d.; Cook, Copeland, Jonikas, et al., 2012; Fukui et al., 2011; Hill, Roberts, & Igbrude, 2010; Starnino et al., 2010), peer-led services (Cook et al., 2010), effectiveness (Cook et al., 2009; Cook, Copeland, Floyd, et al., 2012; Doughty, Tse, Duncan, & McIntyre, 2008; Finn, Bishop, & Sparrow, 2009; Higgins et al., 2012; Pratt, MacGregor, Reid, & Given, 2012), and improving self-advocacy skills of clients (Jonikas et al., 2013). Researchers have not yet examined the relationship between employment success and WRAP. The research questions for this study were the following:

Research Question 1: How does WRAP impact employment?

Research Question 2: How are employees using tools or strategies learned through WRAP on the job?

Because this is a new area of inquiry, a qualitative, phenomenological approach was used to allow for thorough exploration of possible topics that were both introduced by the researchers and raised by study participants.

Recovery and WRAP

The purpose of WRAP is to afford the individual with a psychiatric disability the possibility of recovery. Recovery from serious mental illness has been described and defined in several ways. Fukui and colleagues (2011) synthesized characterizations from various sources to derive the following definition: “Recovery has been conceptualized as both a process and an outcome with common themes that include the development of self-confidence, a self-concept beyond the illness, symptom management, and a sense of well-being, hope and optimism about the future” as well as the ability of the individual to “live a meaningful life in a community of his or her choice while striving to achieve his or her full potential” (p. 214). According to Mary Ellen Copeland, the originator of WRAP, WRAP is designed

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 as cited in Fukui et al., 2011, p. 215)

The definitions of recovery and WRAP parallel one another, providing an indication that WRAP addresses recovery.

Hill and colleagues (2010) found that self-management activities were effective when peer-run. WRAP follows this model as it is generally taught in an 8-week class run by a trained peer. Several individuals with psychiatric disabilities take the class together, discussing their responses to a series of prompts. Upon completion of the class, each participant has identified her or his triggers, developed a daily maintenance plan, identified people who might be a support, and established an advance directive in case of psychiatric emergency. Participants are encouraged to keep their plan with them, revising it as live circumstances change (Copeland, n.d.). Clearly, WRAP is an applied skills program with the aim of individual, daily use.

Recovery through employment is explicitly investigated in this study. However, it is not mentioned directly in any of the definitions of recovery we encountered, though success in the workforce is implied in the definition by Mueser and colleagues (2004) who stated that “recovery occurs when people with mental illness discover, or rediscover, their strengths and abilities for pursuing personal goals and develop a sense of identity that allows them to grow beyond their mental illness” (p. 34). Although the traditional view is that mental illnesses are intractable and beyond the control of the individual, recovery contrasts with this belief (Borkin, 2000) by placing control of symptoms, goals, and life circumstances firmly in the hands of the person with a psychiatric disability. WRAP embodies the recovery view by giving individuals the tools and strategies they need to self-manage. The program includes several key components such as (a) the daily maintenance plan: things an individual does daily to maintain wellness; (b) the toolbox: the array of possible strategies a person has available to use; (c) understanding one’s triggers: being aware of what people or situations cause symptoms; (d) support: reaching out for help from family and friends; and (d) planning for a crisis (Copeland, n.d.).

Identification of Illness Management Programs

Studies show that self-management—the determination to get better, manage the illness, take action, solve problems, and make choices—facilitates recovery from mental illness (Allott, Loganathan, & Fulford as cited in Cook, 2005, p. 1). Moreover, Cook (n.d.) asserted that self-management is at the heart of consumer-directed mental health treatment. Mueser et al. (2004) pointed out, “It is now widely recognized that people with mental illness can participate actively in their own treatment and can become the most important agents of change for themselves” (p. 45). Doughty and colleagues (2008) noted there is a movement toward greater consumer involvement in mental health and that several have developed similar notions of recovery: to solve problems, set goals, control symptoms, prevent relapse, and participate in decision-making. Cook (2005) identified some illness management programs including Taking Charge, Advance Crisis Management, Florida Self-Directed Care, Empowerment Initiatives, and Recovery, Inc. WRAP has much in common with the principles and methods of other self-management programs. It is, internationally, the most popular self-management tool for maintaining mental health (Slade, as cited in Hill et al., 2010). Perhaps what has made WRAP so successful is that its implementation is widespread, it is peer-run, simple to teach and learn, and taught in groups, thus improving the potential for mutual peer support in the practice of self-management. These factors may be especially salient and may have added to both the popularity of the method and success of WRAP. The fact that WRAP classes run parallel to professional, clinical services may be one of its many strengths as a method.

In spite of its apparent success, there is little research to confirm that WRAP is effective. However, extant research is promising. Fukui et al. (2011) found that WRAP participants experienced reductions in psychiatric symptoms as well as a significantly improved sense of hope. Higgins and colleagues (2012) found that participation in WRAP increased positive attitudes toward recovery; participants attributed their learning to the storytelling, disclosure, and dialogue that was fostered in WRAP sessions. At 6-month follow-up, those who completed WRAP were also more likely than controls to engage in self-advocacy (Jonikas et al., 2013). WRAP has been shown to have a positive impact on hopefulness, quality of life, and psychiatric symptoms (Jonikas et al., 2013). A study by Cook et al. (2010) revealed significant positive changes in recovery attitudes, hopefulness, awareness of early warning signs, use of wellness tools, awareness of triggers, possession of a crisis plan and a plan for dealing with symptoms, a social network, and increased ability to take responsibility. It also showed an increased ability to manage medications, improvement in lifestyles, and decreased difficulty engaging in recovery-oriented activities. Compared with controls, WRAP participants’ measured levels of depression and anxiety decreased (Cook, Copeland, Jonikas, et al., 2012).

WRAP and Employment

Borkin (2000) suggested that discussion of recovery should include various consequences of mental illness such as unemployment. Although we found no research that shows how WRAP and recovery tools may influence employment success, many people have the recovery goal of employment that is “congruent with personal preferences and is personally satisfying” (Bond, Salyers, Rollins, Rapp, & Zipple, 2004, p. 571). We are able to extrapolate that those improvements in hopefulness, self-advocacy skills, symptom management, and the myriad of other factors influenced by WRAP would also have a positive impact on the individual’s ability to obtain and maintain employment. Cunningham, Wolbert, and Brockmeier (2000) confirmed this view: “Those individuals who are most successful at gaining and maintaining employment tend to have a clear perspective on their illness and the place of the illness in their lives more generally” (pp. 490–491). In other words, those who are most successful are also engaging in some sort of self-management. Indeed, Krupa (2007) reported that self-management techniques such as communication, assertiveness, problem solving, and frustration management are essential for employment success. In the words of Cunningham and colleagues (2000),

Overall, the majority of the people interviewed were aware of the pressures of work and the need for management of their illness. However, those who were more successful at continuous employment have specific strategies in managing their illness that they have found successful. (p. 491)

Methodology

In qualitative research, a set of research questions or objectives are set and data collection proceeds flexibly, making it a powerful tool for exploring new ideas. In this study, the researchers began collecting data with a great deal of knowledge about employment and disability but without an understanding of (a) how individuals with psychiatric disabilities manage the daily demands of work or (b) how tools such as those found in WRAP might be beneficial on the job for an individual with a psychiatric disability. Our approach was to use our interviewing skills to probe those very issues.

Design: Phenomenology

Phenomenology is a tradition within qualitative research that provides avenues for exploring the lived experience of individuals (Creswell, 2013). Rather than comparing the responses of participants to norms, standards, or objective facts, the phenomenologist seeks to understand how situations appear to participants and how these situations, people, and events impact the person’s behaviors and choices (Taylor & Bogdan, 1998). Phenomenology was selected to focus on understanding the meaning that WRAP had for participants, whereas grounded theory would be most useful in finding out how WRAP works (Charmaz, 2014; Creswell, 2013). Our research probes the experience of working individuals who completed an 8-week training in WRAP, to discover if and how WRAP impacted their employment. WRAP graduates were sought because WRAP is a self-management program that is readily available to individuals in the community in which the research took place.

Recruitment

Participants were recruited through a Southern California provider agency that works individually with men and women with psychiatric disabilities to help them find remunerative employment that matches their skills and interests. Participants were recruited by the employment agency’s program manager who reviewed the files of former and current program participants to find those who had both completed WRAP classes (offered in the employment agency’s offices by a peer-run organization) and subsequently had worked for at least 90 days. The program manager contacted each eligible participant by phone to request his or her participation. To protect the anonymity of potential recruits, the authors received an exclusive list of names, telephone numbers, and email addresses of 16 interested participants who met the criteria of the study. Ultimately, 10 of the 16 completed interviews. The second author contacted participants and shared pertinent information and the purpose and process of the study. Individuals were included who fit the following criteria: (a) had a psychiatric diagnosis and received employment services through the employment agency, (b) completed the full 8 weeks of WRAP training, (c) were currently employed or were employed for at least 90 days subsequent to the completion of WRAP training, (d) spoke conversational English, and (e) were of working age. During a subsequent telephone conversation, the second author described the study to potential participants and the selection process was completed.

Participants

The study was comprised of six women and four men; eight of the 10 participants were White. Participants ranged in age from 48 to 69 years and all were single. Five of the 10 individuals sampled had college degrees: two Bachelor’s, two Master’s, and one Juris Doctor degree. Of the five other individuals, two had vocational certificates, one was a high school graduate, and the remaining two are unknown. It is important to note that the individuals in the study had psychiatric disabilities including clinical depression, bipolar disorder, schizophrenia, schizoaffective disorder, and co-occurring mental health and substance abuse issues. In the recent past, people with these diagnoses were often not considered for vocational rehabilitation. Nonetheless, seven participants were successfully working at the time of data collection in a wide range of careers including advocacy, nursing, program management, and retail; two were actively seeking employment and had a work history, and one had retired.

When asked about their backgrounds, we found that nearly everyone had experienced either (a) early traumas such as abuse or neglect, violence, alcoholism, and drug addiction in the family; (b) caregivers with mental illness; (c) growing up in foster care; or (d) suicide in the family. Nor did the trauma end with childhood: Several participants had been homeless for periods of time, had been suicidal, or had experienced voices. A few reported abusive, suicidal, or substance-abusing mates.

Rather than identify individuals using pseudonyms, their quotes are introduced using vague identifiers such as “this individual,” “a man,” “according to one woman,” or similar generic phrases. The community of people with psychiatric disabilities is a small one, and we are, therefore, compelled to hide the identities of participants to the best of our ability.

Data Collection

Instrumentation

The interview guide used was comprised of 11 main questions and prompts for follow-up questions to each of the 11 questions. Questions were derived from published literature on WRAP and the first author’s previous research experience. Question content included participant background, experience with mental illness, experience with the WRAP class, important learning derived from the WRAP class, the impact of learned WRAP principles on the participant’s employment, and how the participant applied WRAP principles in employment. The first and second authors were both present for all but one interview. The first author took the lead using the interview guide to ask questions of the participants. Though participants were allowed to take the lead in many cases, the interviewers ensured all questions were answered by the end of the interview.

Interviewing

We conducted individual interviews with 10 working-age adults who completed an 8-week course in WRAP and were subsequently employed in competitive jobs for at least 90 days. Eight interviews were completed in a conference room of the employment agency. The room was comfortable, free of distractions, and private. Water was provided for the comfort of participants. One interview was conducted in a private meeting room of a public library and another took place at a participant’s place of work to accommodate the needs of these individuals. Each interview ranged from 50 to 75 min; the average length of each interview was 60 min. All interviews were audio recorded and transcribed verbatim, omitting any identifying information.

The authors began establishing rapport from the first contact with participants and developed it further during the initial meeting prior to beginning the interview. Also, due to the semi-structured nature of the interview, trust was further developed by allowing participants to take the lead and raise issues of interest to them, inviting a dialogue. Semi-structured interviewing permitted the researchers to thoroughly explore pre-determined interview questions while giving participants flexibility and allowing the emergence of new ideas, directions, and concepts they may not have considered previously. Care was taken not to lead participants but to create a climate for full exploration of the interview questions.

Data analysis

Transcripts from the 10 individual interviews comprised 239 single-spaced pages. Saturate, a web-based data analysis application, was used to facilitate qualitative analysis. Though it cannot analyze data for you, the use of computer software can simplify the process of sorting by code and theme and hence is useful for analyzing large amounts of qualitative data. Data analysis begins with coding. Each passage was coded by the individual authors, who reviewed interview transcripts and generated codes based on initial impressions. Using the constant comparative method, researchers examined early transcripts for categories and utilized emerging ideas in subsequent analytical activities (Bogdan & Biklen, 1998). Although the constant comparative method is often used in grounded theory (Charmaz, 2014), we found that examining earlier transcripts in preparation for later interviews was a very useful process. Data were sorted by categories, and again by broader categories, a deductive process. Themes were then created through a dialogue between the two authors, which included active negotiation, refinement, and placement of the codes into the final three themes, an inductive process. This process was used until every code was assigned and the authors agreed with their placement. The authors assured the trustworthiness of the findings through intensive discussion and negotiation, beginning with developing codes and ending with assigning codes to themes.

Findings

Using transcripts from interviews and our research questions, we construct a story about how WRAP impacted participants’ employment and the strategies they used to be successful as employees. The study yields three distinct themes. The first theme, labeled “Then and Now,” though not directly addressing either research question, is included to provide a better understanding of the impact of WRAP on employment. It includes discussion of the history and background of participants, and the turning point of realizing one’s power to manage symptoms and reclaim one’s life. It describes how WRAP changed the participants’ thinking and lives, in general, and provides a broader context for understanding participants’ comments. The second theme, “Strategies for Wellness,” addresses the first research question, “How does WRAP impact employment?” It provides an exploration of the knowledge, tools, and support employed by the study participants as learned through WRAP and how these impacted their work life. The third theme, “Toward Employment Success,” addresses the second research question, “How are employees using tools or strategies learned through WRAP on the job?” The job experiences of participants are explored in this section as well as specific strategies learned through WRAP that were used to maintain and enhance employment.

Theme 1: Then and Now—First Steps Toward Employment as Part of Recovery

At some point in their lives, participants realized that as much as they wanted help, it was not going to come to them in the form of a pill from the psychiatrist, nor could therapists recover for them. One individual expressed that realization: “I think that . . . we all know that we’re sort of accountable for our life, but it was never really broken down [for us by professionals].” Moreover, their therapists and psychiatrists had seldom discussed ways to manage the disability and other recovery-oriented topics, or told them recovery was possible. So to them, WRAP was a revelation:

It was like my eyes were just popped open . . . the first class I went to with WRAP, when they said there’s recovery, because I was told I have chronic depression. I would have it the rest of my life—and “live with it; here are your drugs—live with it.”

The realization that the individual is the only person who can control his or her symptoms was at once frightening and liberating to participants. As one participant put it, “WRAP put accountability right into . . . my pocket, and . . . said, ‘Okay . . . you gotta do it. You gotta do the hard work.’” One woman credited her experience with WRAP for initiating her recovery, as did nearly every other participant:

I’ve learned how to look at things in a positive way. And you’re gonna be surprised later on because I’m gonna reveal a lot of things to you that this WRAP has done. . . . Facing challenges is every day, but if you know how to use your tools, you’ll be okay. Because my diagnosis has no ending, I will be recovering every day of my life. This is all right with me. But I am functional. I am functioning the way I know that I can do.

Clearly, experience with WRAP increased insights for these participants. It allowed them to assess their situation honestly and with hope.

Rebuilding one’s life is a primary task in recovery. For many participants, there was a dramatic change between then and now. As individuals met various life goals, their expectations changed accordingly. A formerly homeless man stated,

I have a car. I have a house. I mean, that’s not a problem. . . . Now it’s a matter of happiness and wanting to fulfill. I don’t know how to explain better than that. So much of my life was empty because of the mental illness, that I wasn’t able to be happy. I didn’t know what happiness was. Today, I know what happiness is to a degree: I’ve gotten a taste of it and I like it.

Participants had undergone dramatic changes in their lives. To a large degree, they credited WRAP and the knowledge and hope they gained from it with the positive changes.

Theme 2: Strategies for Wellness

Developing strategies for wellness and recovery is a major task in preparing for, and succeeding in, the world of work. WRAP has several critical components that directly impact an individual’s employability, including (a) the daily maintenance plan (i.e., things one must do daily to stay well), (b) the toolbox (i.e., strategies to use as needed), (c) understanding one’s triggers (i.e., knowing what to do to stay well in stressful situations), (d) planning for a crisis, and (e) garnering support from family and friends (Copeland, n.d.). Participant experiences with these strategies directly addressed our first research question, “How does WRAP impact employment?” Participants recognized how empowering the simple techniques of WRAP can be and credited them in their success with finding and retaining a job. These strategies, taken as a whole, permitted those who otherwise could not work, to be successful on the job. These strategies are discussed in the context of three categories: self-knowledge, tools for daily maintenance, and support and significant relationships.

Self-knowledge

As a person with a psychiatric disability, having an awareness and understanding of one’s emotional triggers can have a powerful effect on wellness. Knowing what to do to avoid triggers, or deal effectively with them when they cannot be avoided, empowers a person to maintain more stability in his or her everyday life. In discussing how WRAP has impacted her self-awareness and self-knowledge, particularly in employment situations, one woman stated, “I think that I have an advantage over . . . other people. I think that WRAP and learning how to empower yourself and that accountability for yourself puts us far beyond people that don’t.”

In addition, crisis planning was considered a crucial part of the WRAP experience and a key factor in retaining employment. If a triggering event progresses, understanding how to stop it can prevent negative consequences at work. One of the men expressed this belief well:

The advance directive, crisis planning . . . and also knowing about your triggers and different stages . . . when things are falling apart . . . there’s a certain progression that we go through and if we can stop it at the beginning, we can save ourselves a lot of hurt, a lot of pain, and a lot of heartache for ourselves and those that care about us.

Tools for daily maintenance

Participants mentioned daily maintenance as an important factor that impacted their ability to obtain and retain employment. Activities such as meditation and breathing exercises, doing something for others, physical activity, watching or listening to something funny, and making contact with a friend or family member were valuable to maintenance of their well-being and to their ability to successfully deal with stresses on the job. Such activities help an individual become more self-aware, balanced, centered, and open to other people, all factors that contribute to a healthier, more positive attitude, and a greater probability of experiencing success on the job. Others mentioned additional tools in their “tool box” that they could employ to maintain their wellness. These included remembering to take medication, talking to a therapist or counselor, making contact with a peer, being with positive people, listening to music, playing with a pet, or listing one’s accomplishments. One of the men said he liked to “focus on the moment, go for a walk, read, and stay home and be cozy.” A woman described a high level of insight about how to manage stress at home and work by using her wellness tools:

And if I step back, if something kind of bothers me or I get extra stressed or something like that, I’ve got a whole host of . . . tools: deep breathing, medication, self-talk . . . affirming talk, reaching out to friends.

Something many participants noted was that WRAP strategies have to be employed continually for maximal effectiveness. One of the male participants put it this way: “You have to practice this. You can’t read it once and . . . think you know it. . . . It’s something [you] have to practice on a daily basis.”

Support and significant relationships

Having a network of supportive friends and/or family members was critical to each individual’s success as employees. Besides emotional support, it enabled participants to gain a different perspective on problems experienced at work and find creative ways to deal with them. Several participants talked about how they established lasting and deep friendships with people they met at WRAP or peer support specialist training and how having this support impacted their employment success by teaching them specific skills, including self-advocacy. These sustaining connections and interpersonal skills were seen as critical to both recovery and job retention:

I’ve got a support system now, which I didn’t have before. I’m able to ask for help, which was something that just has been a progression for me. It’s not just that. The WRAP has also taught me about how to stand up for my rights in certain respects; advocating, I guess would be a good term for it.

Several participants talked about how they were learning to provide support, develop a support network, and be supported by others, all strategies learned through WRAP that were highly impactful to their success on the job. Many participants had not previously experienced having a support network. One shared, “I think the reaching out to friends thing, making a habit of that on a regular basis, is just something kinda new for me.” All reported that it helped them realize that they are not alone, and how important it is to listen to, connect with, and empathize with others. Using this support network enabled them to talk about issues they experienced on the job, gain a better perspective, and find ways to deal with problems or challenges. They talked about getting together for coffee, talking on the phone, and having WRAP friends over to their homes. One of the participants described the WRAP community as a culture:

Well, a lot of it was just being a lot more self-aware. I mean, having gone through the process. . . . It’s kind of a culture that you learn . . . in the WRAP classes, I think. And so, you kind of come out of that acculturated and . . . sensified toward those kinds of things a lot more.

The bonds between people appeared to be strong and mutually supportive:

Yeah, I’m not going to let myself get sick without letting my girlfriends know. I have such a wonderful group of people. We text and talk every day, several times a day, every day. You know, if one of us isn’t doing that, we’re at their door. We’re at their door.

Theme 3: Toward Employment Success

Our second research question, “How are employees using the tools or strategies learned through WRAP on the job?” is explored in this third and final theme. Three categories emerged: (a) commitment to a daily routine, (b) use of WRAP tools for job retention, and (c) use of support networks at work. Participants explored the direct relationship between their success on the job and their use of WRAP strategies.

Commitment to a daily routine

The commitment to a daily maintenance routine, part of the daily maintenance plan structured through WRAP, made finding and retaining employment an attainable goal for participants. WRAP’s daily maintenance plan is a routine set up by an individual for the purpose of providing structure to their daily lives, giving them a foundation from which they can work toward other achievements. For several participants, getting up, taking a shower, and going to work became a non-negotiable part of their daily routine. One man described this imperative as follows: “What I have done is have something I have got to do each day, whether it’s work or a volunteer job or something, or the class. And I have to get out of bed for that.” Another man noted the importance of “[g]etting up and getting out of bed and going to work. Right there you’ve got it, I mean [a daily routine] helps me keep my job. It helps me stay focused.” Regardless of how they felt, these individuals reported they would make sure they were up, showered, and ready for work. It was evident to the researchers that being engaged in employment or an activity involving a daily routine helped people maintain wellness and was instrumental in their success of finding and retaining employment.

Use of WRAP tools for job retention

For some individuals, learning WRAP tools gave them what they needed to manage daily stressors on the job. One participant expressed it this way: “The concepts of WRAP are extremely simple. They’re extremely powerful, and I think that they can be used . . . whether you’re dealing with a staff member or management or any of the people.” She further explained,

In the work life, if I start getting stressed, its like, “Okay, what’s stressing me? Is it something I can change? Is it something in my control?” And that’s another thing that is talked about in WRAP is that we can’t control the world, but we can control ourselves. And . . . that’s a big thing.

Another woman explained how she deals with difficult situations involving her manager, who lacks sensitivity toward staff members, and how she, as a supervisor, incorporates WRAP strategies to help staff members cope with the manager’s behaviors: “She doesn’t realize she’s stigmatizing, and then her stuff comes down and rolls down to my staff and I have to turn around to my staff and say, ‘Come on, let’s use our WRAP.’”

One individual who had been a victim of domestic violence worked at a job assisting domestic violence victims. She underscored that in difficult situations, knowing the principles of WRAP helped her be able to step back and not go into crisis by asking for help rather than taking the burden all on herself:

I would have felt like I needed to do all of this myself—that there was no other help; that I had to get this woman help; I had to get her to call the police; I had to do this; I had to do that . . . without asking for any help. And I can see where that could have been a catastrophe . . .

One man pointed out that learning the principles of WRAP helped him retain his job:

For one thing I’m able to hold on to a job. I’m in a position where people respect me, instead of where I’m wondering whether they do or not. I’m responsible today, which is something that I can attribute a lot to the WRAP. . . . I show up on time.

He explained that participating in WRAP groups, learning principles like responsibility and accountability, having the WRAP book with him for easy reference to his personal tools, and having peer support were all related to his work success. He pointed out further that WRAP helped him change his response to difficult situations with people he supervised at work:

The past would have been something very abrupt—probably fire the person on the spot and not hear what they had to say. . . . I had a facilitator that was insistent upon leaving religious fliers on the table while she was conducting her groups. And I, in the past, would have handled it myself in a very abrupt manner, and instead went to my superiors and got their support before I handled this.

Another man spoke about how his responses to stressful work situations have changed due to his use of WRAP strategies like self-awareness and positive self-assertiveness. Instead of contributing to the escalation of a situation, he has learned through WRAP to “work it down,” or take positive steps to help de-escalate it:

I notice when I’m getting excited . . . I work it down instead of up. I’ve been able to, like usually something that would tick me off, I notice that I’m gettin’ . . . instead of the hair trigger, it’s much slower. . . . I’m able to assert myself positively better in a non-threatening way . . . a lot of times I’d use fairly harsh language just straight up off the cuff—working man language with people in the past, where now I try . . . not be judgmental and . . . harsh.

Learning to take supervision is difficult for many people, and especially difficult for those who have not had an extensive work history. Apparently, WRAP taught them how to accept feedback and take direction. One participant summed it up: “Having had the WRAP certainly made me feel like I had a better grip on my workplace situation.” By participating in WRAP groups, and learning and practicing WRAP techniques and strategies, participants were able to manage work stresses.

Use of support networks at work

Many participants had made important connections at work, and their work friends had become a critical part of their support network, a key component of WRAP. Learning to talk with a support person about stressful work situations helped them successfully cope with and navigate through them. One woman noted, “And then also here with work—this is the most incredible group of people I have ever worked with. . . . We’re really close, because we are peers, so you know, there’s that equality.”

She continued,

If something kind of bothers me or I get extra stressed . . . I know that there are people that are really good that have been in stressful situations . . . so I can . . . talk to them. . . . That was one of the best coping tools of WRAP.

These successful employees used WRAP strategies liberally. From developing a daily routine to managing conflicts, supervising staff, relating to supervisors, and cultivating friendships, the individuals in the study applied the principles of WRAP creatively to their work situations.

Discussion

We originally posed two research objectives: to explore how WRAP impacts employment and examine how employees are using the tools and strategies learned through WRAP on the job. Initially, we understood employment and disability but not how individuals with psychiatric disabilities manage the daily demands of work, or how tools such as those found in WRAP might be beneficial on the job for an individual with a psychiatric disability. Through this study, we learned how WRAP helped participants in these areas.

Our findings lend support to earlier research showing that self-management skills facilitate recovery from mental illness (Allott, Loganathan, & Fulford as cited in Cook, 2005; Cook, n.d.; Cook, Copeland, Jonikas, et al., 2012; Fukui et al., 2011; Hill et al., 2010; Starnino et al., 2010) and go further to show that WRAP has a definite, positive impact on participant employment outcomes. We found a strong relationship between participants’ employment success and their use of the tools and strategies learned through WRAP, and learned how employees are using WRAP tools to be successful on the job. Participants reported that WRAP helped them meet the daily demands of work by adhering to a daily routine, including getting showered, dressed, and to work on time each day, a central part of their maintenance plan. Participants used WRAP strategies in a number of ways, especially in interpersonal situations, and learned to manage conflict on the job. Individuals in supervisory roles called on their staff to use the principles of WRAP in difficult situations. Being aware of their triggers and knowing how to respond when things were not going well were strategies that fit well in the workplace and contributed to participants’ ability to successfully deal with work stresses. Many participants mentioned keeping their WRAP book with them and referring to it often.

The study further implicates an unexpected, yet significant finding that goes beyond our original research questions: that employment is a key component to recovery. It appears that work adds to quality of life in a myriad of ways: self-esteem, income, meaningful activity, and relationships, to name just a few. From the perspective of study participants, work was one of the daily activities that kept them well. One proclaimed, “I get my therapy from work” and went on to explain that having a job is “very cathartic” for him. Another indicated how working equates to a positive feeling at the end of the day: “I’ve done a long day and it’s been a good day.” Other participants reported similar reactions. One woman made a powerful claim about the role of work, “It’s the key to life.” Another individual agreed: “I knew work was important—I just didn’t realize to the extent that it was”; he attributed much of his ability to hold on to his job to strategies learned through WRAP. These findings indicate the importance participants placed on their work—how central it was to their happiness and to their identities. According to the participants, work was not something individuals “coped with”; rather, it helped them cope. Work was indeed therapy. The implication that work is an integral part of recovery, coupled with the findings of this study that WRAP can have a positive impact on employment success, holds great promise for people with psychiatric disabilities. Nonetheless, participants reported that employment and recovery were not the center of their mental health services.

Three specific themes emerged from the interviews: (a) Then and Now: analysis of how people changed through their experience with WRAP, (b) Strategies for Wellness: description of WRAP components and their impact on employment, and (c) Toward Employment Success: application of WRAP knowledge to the job. It was striking that participants saw their WRAP training experience as life-changing and that many of them talked about then, before WRAP, and now, after WRAP. Although their symptoms and difficult situations had not changed due to the training, their outlook had. Participants used WRAP strategies in both home and work settings, personalizing the principles to fit their lives. They focused on support, daily maintenance, social support, or interpersonal skills, depending on their area of greatest need. By using the self-management strategies learned through WRAP to enhance the employment experience, participants discovered new levels of mastery as well as enjoyed tangible rewards such as being able to afford a home or a car. WRAP, like other excellent programs that promote self-determination, could be useful for many populations and in multiple situations, including individuals with physical and intellectual disabilities, as well as in various vocational rehabilitation programs.

Recommendations

As Fukui and colleagues (2011) noted, recovery includes (a) a self-concept that extends beyond illness, (b) symptom management, (c) a sense of well-being, (d) optimism, (e) living meaningful lives, and (f) the opportunity to strive to meet one’s potential. Examining this definition, it appears that having meaningful employment supports each aspect of recovery. Because employment appears to be an aspect of recovery, employment services for individuals with psychiatric disabilities should be paired with WRAP training.

Incorporate WRAP into employment services

Supported employment programs and vocational placement agencies as well as the state-federal vocational rehabilitation program could easily work recovery principles and attending WRAP classes into each individual’s plan, thus supporting his or her need for skills, supports, and self-management. For example, the counselor should be familiar with the individual’s WRAP plan and utilize the tools (daily maintenance plan, identification of triggers, crisis planning, etc.) during discussions of employment preparation or retention. There are several good reasons for selecting WRAP. Although a number of self-management programs exist, WRAP is broadly used and often readily available in large communities. Sessions are also peer-directed, a fact that is not lost on consumers of mental health services. The course is manualized, thus assuring a modicum of fidelity to the curriculum as developed by Copeland.

Because WRAP is accessible in many communities, it may make sense to pair it with other vocational services. Modalities such as supported employment provide rapid placement and support, usually off the job. Supported employment is an evidence-based practice that is used broadly, but retention can be an issue (Drake, Becker, Clark, & Mueser, 1999). Pairing supported employment with WRAP may provide individuals with the strategies they need to persist on the job. Individuals with psychiatric disabilities frequently access services through the state-federal vocational rehabilitation program. Such services might be improved when job seekers master skills related to self-management. The rehabilitation counselor who is familiar with the client’s WRAP is in a unique position to facilitate the client’s self-awareness and self-determination.

Educate clinicians and doctors about recovery

Because our findings implicated a close relationship between recovery and work, and WRAP was found to have a positive impact on employment, we were struck by the fact that participants repeatedly noted that their therapists and psychiatrists had not discussed recovery with them, nor had they recommended a program such as WRAP. Considering the age of participants in this study, one can only assume that the many years that could have been devoted to recovery activities, including participation in employment, were spent experiencing symptoms and receiving medications while not employed. Clinicians and medical personnel need to be exposed to recovery principles and programs, thus assuring that people with psychiatric disabilities might experience real improvements in their lives, including the possibility of remunerative employment. Rehabilitation counselors should be familiar with WRAP, know how to use WRAP, be familiar with and know how to locate WRAP training in their community, and be able to use WRAP strategies with their clients to more successfully help them find and retain employment.

Limitations

A convenience sample was used for this study, resulting in some limitations. Because we did not intentionally seek out individuals of color, the vast majority of participants were White. Also, the sample was skewed toward older participants. It would be interesting to learn whether age is a factor in employment success. All participants were former or current clients of the California state-federal vocational rehabilitation agency, thus omitting potential participants who sought and obtained employment on their own (O’Leary, Livermore, & Stapleton, 2011). In addition, five of the 10 individuals sampled had college degrees, which may not have fairly represented those who had less education (MacDonald-Wilson, Rogers, Ellison, & Lyass, 2003). There may be a difference between the work histories and education levels of these participants and those generally served through state-federal vocational rehabilitation programs; these factors should be taken into account in any future research. Despite these limitations, this study provides important insights into the recovery-oriented factors that likely cause people with serious mental illness to work successfully.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Bogdan

R. C.

Biklen

S. K.

(1998). Qualitative research for education: An introduction to theory and methods (3rd ed.). Boston, MA: Allyn & Bacon.

Bond

G. R.

Salyers

M. P.

Rollins

A. L.

Rapp

C. A.

Zipple

A. M.

(2004). How evidence based practices contribute to community integration. Community Mental Health Journal, 40, 569–588.

Borkin

J. R.

(2000). Recovery attitudes questionnaire: Development and evaluation. Psychiatric Rehabilitation Journal, 24, 95–102.

Charmaz

(2014). Constructing grounded theory (2nd ed.). Thousand Oaks, CA: SAGE.

Cook

J. A.

(n.d.). Mental illness self-management through Wellness Recovery Action Planning. Copeland Center for Wellness & Recovery. Retrieved from http://www.mentalhealthrecovery.com/wrap/wrap_research_findings_judithcook.php

Cook

J. A.

(2005). “Patient-centered” and “consumer-directed” mental health services. Retrieved from http://scholar.google.com/scholar?cluster=586735593265713254&;hl=en&as_sdt=0,5&sciodt=0,5

Cook

J. A.

Copeland

M. E.

Corey

Buffington

Jonikas

J. A.

Curtis

L. C.

… Nichols

W. H.

(2010). 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. doi:10.2975/34.2.2010.113.120

Cook

J. A.

Copeland

M. E.

Floyd

C. B.

Jonikas

J. A.

Hamilton

M. M.

Razzano

… Boyd

(2012). A randomized controlled trial of effects of Wellness Recovery Action Planning on depression, anxiety, and recovery. Psychiatric Services, 63, 541–547. doi:10.1176/appi.ps.201100125

Cook

J. A.

Copeland

M. E.

Hamilton

M. M.

Jonikas

J. A.

Razzano

Floyd

C. B.

… Grey

D. D.

(2009). Initial outcomes of a mental illness self-management program based on Wellness Recovery Action Planning. Psychiatric Services, 60, 246–249. Retrieved from http://ps.psychiatryonline.org.libproxy.sdsu.edu/article.aspx?articleid=100183

10.

Cook

J. A.

Copeland

M. E.

Jonikas

J. A.

Hamilton

M. M.

Razzano

L. A.

Grey

D. D.

… Boyd

(2012). Results of a randomized controlled trial of mental illness self-management using Wellness Recovery Action Planning. Schizophrenia Bulletin, 38, 881–891. doi:10.1093/schbul/sbr012

11.

Copeland

M. E.

(n.d.). What is WRAP? Copeland Center for Wellness & Recovery. Retrieved from http://copelandcenter.com/wellness-recovery-action-plan-wrap

12.

Creswell

J. W.

(2013). Qualitative inquiry & research design: Choosing among five approaches (3rd ed.). Thousand Oaks, CA: SAGE.

13.

Cunningham

Wolbert

Brockmeier

M. B.

(2000). Moving beyond the illness: Factors contributing to gaining and maintaining employment. American Journal of Community Psychology, 28, 481–494.

14.

Doughty

Tse

Duncan

McIntyre

(2008). The Wellness Recovery Action Plan (WRAP): Workshop evaluation. Australasian Psychiatry, 16, 450–456. doi:10.1080/10398560802043705

15.

Drake

R. E.

Becker

D. R.

Clark

R. E.

Mueser

K. T.

(1999). Research on the individual placement and support model of supported employment. Psychiatric Quarterly, 70, 289–301.

16.

Finn

L. D.

Bishop

B. J.

Sparrow

(2009). Capturing dynamic processes of change in GROW mutual help groups for mental health. American Journal of Community Psychology, 44, 302–315. doi:10.1007/s10464-009-9265-5

17.

Fukui

Starnino

Susana

Davidson

Cook

Rapp

C. A.

Gowdy

E. A.

(2011). Effect of Wellness Recovery Action Plan (WRAP) participation on psychiatric symptoms, sense of hope, and recovery. Psychiatric Rehabilitation Journal, 34, 214–222. doi:10.2975/34.3.2011.214.222

18.

Higgins

Callaghan

DeVries

Keogh

Morrissey

Nash

… Carter

(2012). 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. doi:10.1111/j.1365-2648.2011.05937.x

19.

Hill

Roberts

Igbrude

(2010). Experience of support time and recovery workers in promoting WRAP. The Psychiatrist, 34, 279–284. doi:10.1192/pb.bp.108.024539

20.

Jonikas

J. A.

Grey

D. D.

Copeland

M. E.

Razzano

L. A.

Hamilton

M. M.

Floyd

C. B.

… Cook

J. A.

(2013). Improving propensity for patient self-advocacy through Wellness Recovery Action Planning: Results of a randomized controlled trial. Community Mental Health Journal, 49, 260–269. doi:10.1007/s10597-011-9475-9

21.

Krupa

(2007). Interventions to improve employment outcomes for workers who experience mental illness. The Canadian Journal of Psychiatry, 52, 339–345.

22.

MacDonald-Wilson

Rogers

Ellison

Lyass

(2003). A study of the Social Security work incentives and their relation to perceived barriers to work among persons with psychiatric disability. Rehabilitation Psychology, 48, 301–309.

23.

Mueser

K. T.

Corrigan

P. W.

Hilton

D. W.

Tanzman

Schaub

Gingerich

… Herz

M. I.

(2004). Illness management and recovery: A review of the research. Focus: The Journal of Lifelong Learning in Psychiatry, 2(1), 34–47.

24.

O’Leary

Livermore

G. A.

Stapleton

D. C.

(2011). Employment of individuals in the Social Security programs. Social Security Bulletin, 71(3), 1–10.

25.

Pratt

MacGregor

Reid

Given

(2012). Wellness Recovery Action Planning (WRAP) in self-help and mutual support groups. Psychiatric Rehabilitation Journal, 35, 403–405. doi:10.1037/h0094501

26.

Starnino

V. R.

Mariscal

Holter

M. C.

Davidson

L. J.

Cook

K. S.

Fukui

Rapp

C. A.

(2010). Outcomes of an illness self-management group using Wellness Recovery Action Planning. Psychiatric Rehabilitation Journal, 34(1), 57–60. doi:10.2975/34.1.2010.57.60

27.

Taylor

S. J.

Bogdan

(1998). Introduction to qualitative research methods: A guidebook and resource. New York, NY: Wiley.