Supporting people in becoming skilled at looking after themselves was recently reaffirmed as ‘one of the key pillars of the NHS Improvement Plan vision for a patient-centred care system’. ^{Reference Cayton1} There is growing evidence in physical healthcare that people with long-term conditions find self-care and self-management to be effective in improving quality of life and promoting appropriate use of services. ^{Reference Foster2}

Supporting self-care is a specific work stream arising from the national service framework for long-term conditions linked to the Department of Health's Expert Patient programme. ^3,4 Self-care and self-management have an established role in recovery-based practice, ⁵ and are in line with the expectations laid out in the White Paper Our Health, Our Care, Our Say ⁶ and in the Department of Health's guidance Supporting People with Long-Term Conditions to Self Care. ⁷ Additionally, the Royal College of Psychiatrists, along with other medical Royal Colleges, is now required to include competencies in supporting people in self-care in their core curricula.

There is every indication that self-care is ‘an idea whose time has come’, ^{Reference Cottam and Leadbeater8} and the past 10 years have seen the development of a wide range of supports and programmes for self-management of mental health (Box 1). Self-care and self-management approaches are increasingly popular but of uncertain value. An international review ^{Reference Singh and Ham9} found comparatively little experience of self-management methods in mental health settings, no real evidence of impact, and no real clarity on how self-management could be promoted in mental health services. The need for ‘further research on successful methods of supporting self-management and recovery’ identified in the Royal College of Psychiatrists' Fair Deal campaign ¹⁰ remains a call that has yet to be answered.

The Wellness Recovery Action Plan (WRAP) is, internationally, the most popular self-management tool for maintaining mental health. ^{Reference Slade11} Although there is a large and growing body of anecdotal reports of benefit, ^{Reference Deegan12-Reference Copeland14} it is largely under-researched. One of the few studies of outcome in using WRAP ^{Reference Copeland15} reported beneficial changes (significant improvement in self-reported symptoms, recovery, hopefulness and self-advocacy), but it was uncontrolled and described self-reported outcomes over a very limited time (1 month). Another study found WRAP significantly associated with an increase in participants' hope for recovery, taking responsibility for their own wellness and having a support system in place. ^{Reference Cook, Copeland, Hamilton, Jonikas, Razzano and Floyd16}

The WRAP tool is a structured approach that is written, owned and used by the individual. It is constantly updated in the light of a person's experience of what works for them. It supports a process of structured reflection leading to action plans that an individual uses to modify or overcome adverse experiences and promote well-being. This requires a personal commitment and active engagement to staying well and an ambition to be in control of one's own life. It involves developing a ‘wellness toolbox’ of skills and strategies, planned responses to increasing levels of difficulty and distress, and a crisis plan (advanced directive) as a guide to be followed in the event of recurring severe mental health problems.

The UK mental health organisations' Future Vision Coalition ^{Reference Cook17} highlights WRAP as a key system that supports ‘people with mental distress to work with professionals to identify and prioritise their own personal goals for recovery’ and states that ‘tools of this kind should be much more widely used in everyday practice in mental health services’. Following various training initiatives, WRAP has been used extensively in the south-west of England (www.recoverydevon.co.uk), is promoted by the Black Wellness Initiative (www.blackwellness.co.uk) and forms the core of personal recovery planning at South West London and St George's Mental Health NHS Trust. ¹⁸ It has also influenced other illness-specific approaches such as Recovery In-Sight for bipolar disorder (www.recoveryin-sight.com) and there is currently a major national training programme aimed at developing a cohort of WRAP trainers in Ireland, funded by the Department of Justice, Equality and Law Reform (www.imhrec.ie).

Wellness Recovery Action Plan originated from a service user perspective and is largely delivered by peers (people who have experience of mental distress and who may have used services). The benefits of peer-delivered services and supports have been summarised as including: ^{Reference Perkins and Rinaldi19}

1. • positive role modelling (‘If you can, maybe I can too’)

2. • emotional and social support and empathic connection

3. • authenticity of the trainers having experience of using methods they are teaching

4. • practical and usable information and strategies from those who have used them

5. • a sense of normalcy through interacting with others with shared or common experience.

The inception of support time and recovery (STaR) workers followed recommendations from the Workforce Action Team convened by MPs to consider the implications of the national service framework for adult mental health. ^{Reference Corrigan, Muser, Bond, Drake and Soloman20} For the first time, a group of workers were explicitly recruited for their personal qualities rather than professional qualifications, and their personal experience of mental health problems and services was also valued. It was intended that they would work in a variety of statutory and non-statutory settings, provide practical support, promote independence, and support service users in self-care with the aim of empowering them to lead ‘ordinary lives’. Support time and recovery workers were the first and so far only group of mental health workers to be systematically trained in the ten essential shared capabilities for mental health practice, which included training in recovery and supported self-management with WRAP. ^{Reference Copeland14,21}

Method

Results

What helped and what hindered WRAP take up?

A number of themes emerged during analysis of the free-text responses regarding WRAP take up. The themes and percentage of respondents positively identifying each theme are included in Tables 1, 2, 3. Engagement with WRAP is mediated by a range of factors, but with emphasis on the benefits of a structured approach, introduced with adequate support and at the right time for the individual.

Table 1 What helped engagement with WRAP?

Theme	%
Individuals valued the structured approach of WRAP and the identification of triggers	53
Individuals with good insight and understanding about their mental health were more likely to participate in producing and using a WRAP plan	30
Offering choice and giving control to the individual made them more willing to engage in producing a WRAP plan	28
Support from workers to help the individual produce a WRAP plan	18
A person-centred approach which is tailored to meet the individual's needs	17
Introducing the WRAP at an appropriate time or stage in the illness when the individual is able to engage with the process and explore what works for them	5
Uncoded	3

Table 2 What hindered engagement with WRAP?

Theme	%
WRAP introduced at the wrong time for the individual to find it useful	30
Individual does not believe it will be useful	23
Individual does not seem to have sufficient motivation to create a WRAP	22
Individual lacks understanding as to why a WRAP plan may be beneficial or how to use it	22
Individual is fearful of what will be involved	18
Too few workers to support people with the creation and implementation of their WRAP plans	17
Individual concerned about the implications of recovery through engaging with WRAP – for example, loss of benefits and additional responsibilities	12
Features of the WRAP document such as length and time taken to complete	12
Uncoded	7

Table 3 What could improve engagement with WRAP?

Theme	%
Additional support for the person from individual workers, mental health services and non-statutory organisations	23
Involvement of individuals and peer support to offer advice from lived experience	10
Training and supervision for workers on recovery from long-term conditions and self-management	8
Publicity to raise awareness within the general population and combat the stigma of mental illness	7
Early introduction of WRAP to anyone presenting to psychiatric services	5
Keeping the paperwork, language and concepts simple	5

Discussion

Self-management is not another treatment but a means of people becoming more active in their own recovery, taking up more responsibility for their experience and regaining more authority and control over their lives. The Wellness Recovery Action Plan is a simple, sensible and structured tool; supporting people in self-management by introducing them to WRAP is a seemingly straightforward, if elusive, goal.

In this initial group of STaR trainees there was a wide variation in the experience of engaging people in WRAP, with seven trainees introducing none. It would appear that there is an appreciable gap between providing people with a theoretical grounding in a self-management tool and them subsequently introducing it to others, hence a continuing need to understand the obstacles between learning principles and changing practice. Clear and practical steps may be needed by organisations, professions and individuals who wish to make the shift towards recovery-oriented services. ^{Reference Slade11,Reference Slade23}

Engaging and supporting people in self-care is a required competency within the emerging core curriculum for psychiatrists ^{Reference Shepherd, Boardman and Slade24} and an acknowledged key skill in recovery-based practice. It has been observed ^{25,Reference Roberts and Hollins26} that for practitioners to support people in self-management, we as practitioners may need to give up some of our power and authority and create more opportunities for personal choice. There are strong theoretical grounds for considering that support for self-management may be most effective when offered by those who have experienced and overcome similar problems themselves, a trend that also appeared in our study. There may be reciprocity between self-management and peer support such that those who have found such measures valuable themselves may be more confident and skilled at introducing them to others. ^{Reference Roberts, Dorkins, Wooldridge and Hewis27} This is the guiding premise of the Expert Patient Programme where ‘experts by experience’ rather than (just) ‘experts by training’ may be more effective and acceptable recovery coaches to service users. ⁴ It also underpins the ambitious Irish national WRAP training programme (Irish Mental Health and Recovery Education Consortium), which aims to develop its cohort of WRAP trainers from people who have themselves already learnt and used WRAP. ^{Reference Perkins and Rinaldi19}

The unexpected finding in this study that many of those who had participated in training had moved on from their initial contact address or affiliation with non-statutory groups during the period covered (2 years) highlights specific workforce issues and has significant implications for turning training into services. Offering training in an open way to unselected applicants under no obligation to subsequently use their skills may be seen as a positive contribution to a broad development of a recovery culture but clearly has different implications for workforce planning. Trainees' subsequent performance may also be influenced by the expectations placed upon them, for although STaR trainees were taught WRAP, they were not specifically expected to be ‘WRAP facilitators’ and much was left to individual interpretation of the STaR role in a wide variety of personal and service provider settings. Taking an inclusive and undemanding stance to trainees may fail to deliver the hoped for benefits from training but indicates a need to reconsider fidelity issues to the STaR role, as well as a need for ongoing support and supervision.

Our study also highlights the importance of individualised, person-centred care. Workers identified insight, understanding and motivation as key mediators to participation in WRAP. This is unsurprising given the complexity of WRAP and underlines the advice that formulating a self-management plan is best done when someone is comparatively well and able to reflect on their experience.

Although self-care and self-management are prominent and valued goals of progressive services, the available models and evidence of successful outcome is partial, provisional and largely anecdotal. This study is set at the most superficial and preliminary level - can people who have been taught a self-management tool (WRAP) pass it on? Our findings of the modest transfer of learning from the inaugural cohort of STaR trainees are disappointing. However, despite its limitations, the study usefully highlights some of the complexities that need to be considered if we are to learn how to more effectively engage people as active participants in their own recovery. Additionally, it suggests that considerable care and ongoing attention need to be given to training, support and supervision if the ambitious gains are to be realised in practice.