Introduction
Mental health service provision has transformed dramatically in recent years due to major policy and legislative reform. Since the publication of the Irish Mental Health Act in 2001 and its enactment in 2006, the Mental Health Act has governed how those with a recognised mental health challenge are treated (Kelly Reference Kelly2007; Irish Statue Books 2001; Ramsay et al. Reference Ramsay, Roche and O’Donoghue2013). One of its main responsibilities is to provide a mandate for psychiatrists to take over decision-making authority for service users when they are in crisis and are deemed incapacitated to make informed decisions as a direct result of their mental health challenges (Guy Reference Guy2011). A mental health crisis is defined by both Murphy et al. (Reference Murphy, Irving, Adams and Waqar2015) and Hudson et al. (Reference Hudson, Pariseau-Legault, Cassivi, Chouinard and Goulet2024) as an acute episode of decompensating mental health related to an underlying psychopathology which results in a scenario where a person requires hospitalisation to deal with these difficult and frightening experiences. This scenario often results in the involuntary detention of the individual service user into psychiatric facilities until a tribunal is set to determine whether such detention is lawful and can continue (Kelly et al. Reference Kelly, Curley and Duffy2018). The idea behind such involuntary detention is twofold: (1) protect public safety and (2) keep intact the individual service user’s dignity (O’Mahony Reference O’Mahony2024). It is also sometimes necessary to involuntarily detain someone in order to maintain a person’s dignity in the long term (Kuzman et al. Reference Kuzman, Fiorillo and Beezhold2025; Molloy et al. Reference Molloy, Beckett, Chidarikire, Cutler, Isobel, Murphy and Zugai2025). However, despite this, many have viewed this process, particularly since the enactment of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), as outdated, paternalistic, and harmful to the overall well-being and human rights of service users (Department of Health 2015; Murphy et al. Reference Murphy, McGuinness, Bainbridge, Brosnan, Felzmann, Keys, Murphy, Hallahan, McDonald and Higgins2017; O’Mahony and Morrissey Reference O’Mahony and Morrissey2021). This stance is linked to findings in international literature which suggests that involuntary admission is associated with longer hospital stays, higher readmission rates and an increased likelihood of the person dying by suicide (Akther et al. Reference Akther, Molyneaux, Stuart, Johnson, Simpson and Oram2019). However, such findings are subject to selection bias as people with certain risk factors are more likely to be admitted involuntarily. Additionally, this selection bias is evident as those within marginalised communities are disproportionately detained compared to others in the population and as such are also disproportionately impacted by the negative impacts of such detention. Within such international literature, there has long since been calls to remove such paternalistic practices and instead focus on a more person-centred approach to care. One mechanism that policy has highlighted to achieve this is through the implementation and fostering of the mental health recovery movement within mental health service provision and discourse.
When one observes recovery in mental health, it can be subdivided into three main types. There is the traditional type of recovery which is based on the absolute elimination of signs and symptoms of mental distress (Deacon Reference Deacon2013; Handerer et al. Reference Handerer, Kinderman, Timmermann and Tai2020; Karter Reference Karter2015; Nolin Reference Nolin2022). This aspect of recovery has long since been associated with the biomedical model of mental health. This model considers a somewhat paternalistic perspective of the service user as a passive patient, who relies on the ‘expert’ with positivist knowledge – a position where knowledge stems from observed phenomena in a social world – which stemms from randomised controlled trials amongst other objective literature sources to support them in reaching symptom identification, classification, remission, and subsequent eradication. The next type is that of social recovery which stipulates that recovery is brought about through society and the availability of necessary conditions that allows the individual service user to pick themselves up, brush themselves off, and thrive again within society (Norton and Swords Reference Norton and Swords2020; Swords et al. Reference Swords, Norton and Maddock2025). Finally, personal recovery, which is best defined by Anthony (Reference Anthony1993) as living one’s best life even with the signs and symptoms of mental health challenges. Anthony’s definition of recovery here is most widely accepted by the those embedded in the recovery movement as it allows recovery from mental health challenges to involve more than signs or symptoms but also the attainment of a life of one’s own choosing, regardless of illness. It is the definition utilised here as it fosters within it a sense of personal responsibility – where the individual is also responsible for the attainment of a life of their choosing, which feeds into the following discussion on advanced healthcare directives noted in this paper. Here, professionals do not do onto service users, rather they encourage service users to steer themselves in a direction which reflects a life of fulfilment, hope, and satisfaction – whatever that is for them (Norton and Cullen Reference Norton, Cullen, Norton and Cullen2024; Swords and Norton Reference Swords and Norton2023). It is this type of recovery that is based within mental health policy both in the Republic of Ireland and elsewhere in recent years (Department of Health 2006, 2020; Swords and Norton Reference Swords and Norton2020).
Personal recovery, which was manifested as part of the anti-psychiatry, civil-rights movement of the 1960s and 70s is only now being implemented into practice by – for example the Health Service Executive (HSE) through their ‘National Framework for Recovery in Mental Health’ (HSE 2024; Ostrow and Adams Reference Ostrow and Adams2012). One of the central principles of this framework is the co-production of recovery promoting services between all stakeholders (HSE 2018, 2024), which is inclusive of service users, their family members/carers and supporters (Norton Reference Norton2022). Within Irish mental health service provision, personal recovery is being implemented through a number of means including the incorporation of lived experience as knowledge through peer workers (Hunt and Byrne Reference Hunt and Byrne2019; Mahon Reference Mahon2024; Norton Reference Norton2023, Reference Norton2024; Norton et al. Reference Norton, Clabby, Coyle, Cruickshank, Davidson, Greer, Kilcommins, McCartan, McGuire, McGilloway, Mulholland, O’Connell-Gannon, Pepper, Shannon, Swords, Walsh and Webb2026; O’Brien et al. Reference O’Brien, Murphy, Hunt, Dwyer and Hunter2024; Pachowicz and Goffe Reference Pachowicz and Goffe2024; Watson and Medding Reference Watson and Medding2019). However, the ethos encapsulated from such work is relatively new (Norton and Swords Reference Norton and Swords2021). One such notable legislative influence of the recovery movement within Irish mental health services is through the publication and subsequent enactment of ‘The Assisted Decision Making (Capacity) Act 2015’ (Irish Statue Books 2015; Norton and Sweeney Reference Norton, Sweeney, Donnelly and Gleeson2021). An act that advocates for the personal autonomy of an individual even when that same individual does not have capacity to make decisions regarding their own life and care they receive. Keeping this in mind, the focus of this paper is to introduce the concept of advanced healthcare directives in mental health discourse and how a recovery, self-management tool can be used as a suitable template for constructing an advanced healthcare directive here. However, before exploring this, legislation relative to advanced healthcare directives will now be discussed in more detail.
The Assisted Decision Making (Capacity) Act 2015: A brief introduction
The Assisted Decision Making (Capacity) Act (Irish Statue Book 2015), came into law at the end of 2015 and was subsequently enacted in April 2023 (Law Society of Ireland 2023; Quinn et al. Reference Quinn, Henry, O’Neil, Duggan, Cawley, Dwane, O’Sullivan, Griffin and Lombard2017). It replaces the Lunacy Regulation (Ireland) Act of 1871 with the primary focus of moving away from ‘best interest’ to upholding the ‘will and preference’ of the service user even when mentally and legally incapacitated to do so, so that such individuals can still make decisions about their own care and treatment (Curtis et al. Reference Curtis, Fatoki, McGuire and Cullen2022; Davidson Reference Davidson2022; Kelly Reference Kelly2017; Murphy et al. Reference Murphy, Gulati, Whelan, Dunne and Kelly2020; Usher and Stapleton Reference Usher and Stapleton2018). The Assisted Decision Making (Capacity) Act, which provides the statutory basis for advance healthcare directives for the first time in Irish law, supports this through two types of future planning: advance healthcare directives and enduring power of attorney (see Figure 1) (Kelly Reference Kelly2017; Murphy et al. Reference Murphy, Gulati, Whelan, Dunne and Kelly2020). However, for the purposes of this paper, the focus will centre on the advance healthcare directive and how it can be used in mental health care.
Decision-making practices with the enactment of the Assisted Decision Making (Capacity) Act 2015.
Figure 1. Long description
The flowchart illustrates the decision-making process for mental health service provision based on the Assisted Decision Making (Capacity) Act 2015. It starts with the presumption of capacity and follows guiding principles in the 2015 Act, providing appropriate supports. The first decision point checks if the individual can comprehend and retain the treatment information, weigh up the pros and cons of treatment or treatment refusal, and communicate the decision. If yes, capacity is present. If no, even with supports, capacity is absent. If capacity is absent, the flowchart checks for an advance directive. If an advance directive is present, respect the directive. If no advance directive is present, it checks for a Power of Attorney governing healthcare matters. If a Power of Attorney is present, healthcare decisions can be made by the attorney except for the refusal of life-sustaining treatment and decisions that conflict with any advance directives. If no Power of Attorney is present, the flowchart branches into three paths: decision-making assistant, co-decision-maker, and court-appointed decision-making representative. Each path outlines specific conditions and processes for decision-making.
Taken directly from Murphy et al. (Reference Murphy, Gulati, Whelan, Dunne and Kelly2020). An advance healthcare directive is a legally binding document that is designed to allow individuals to make decisions about their future care which is enacted when a person is deemed incapacitated, for whatever reason, and cannot communicate such preferences to healthcare providers (Morrissey Reference Morrissey2022; Srebnik and La Fond Reference Srebnik and La Fond1999). Since Srebnik and La Fond defined what advance healthcare directives are, an increasing interest has been observed for same within multiple jurisdictions including the United Kingdom, Germany, Belgium, New Zealand, Canada, Australia, India, and Ireland (Zelle et al. Reference Zelle, Kemp and Bonnie2015). This interest has intensified since bodies such as the United Nations and World Health Organization have both called for legislation to become more aligned with human rights-based principles as laid out in the UNCRPD (Lenagh-Glue et al. Reference Lenagh-Glue, Dawson, Potiki, O’Brien, Thom, Casey and Glue2022; Redahan et al. Reference Redahan, Kelly and Gergel2024; Wilson Reference Wilson2025) Given this longing for a human rights focused service, advanced healthcare directives are effective in this endeavour as they promote autonomy, ensures that a person receives treatment in line with their own will and preferences as well as enhancing service user–psychiatrist communication and service users long-term recovery outcomes (Crooks et al. Reference Crooks, Rizk, Simpson-Greene, Hopwood, Smith, Seddon and Hudson2025; Dowling et al. Reference Dowling, Kennedy and Foran2020; Malhotra et al. Reference Malhotra, Shafiq and Batcagan-Abueg2022). In addition, advanced healthcare directives were seen to have a significantly positive effect on marginalised communities if these communities had access to appropriate education interventions (Jones et al. Reference Jones, Luth, Lin and Brody2021). Consequently, a recent scoping review on advanced healthcare directives in marginalised communities found that such educational interventions were not evident in such populations because of the lack of knowledge these groups of people had towards such directives (Macedo et al. Reference Macedo, Rego and Nunes2023). However, uptake of advance healthcare directives in jurisdictions is sparse at best due to the lack of legislative reform and educational awareness of this option for those suffering with mental health challenges (Kelly Reference Kelly2025). One such method to increase the education around the steps to take when unwell along with a possible document that can, in part, form an advance healthcare directive is the Wellness Recovery Action Plan (WRAP) (Norton and Sweeney Reference Norton, Sweeney, Donnelly and Gleeson2021).
However, before we proceed with exploring WRAP’s potential as an advanced healthcare directive, first we shall explore other such templates and frameworks across jurisdictions. According to Rodado et al. (Reference Rodado, Sanchez and Grifo2021) in the European union, there is no standardised instrument used for advanced healthcare directives, with the authors reporting that the situation between countries remaining heterogeneous. Psychiatric advanced healthcare directives tend to be more strictly regulated with a restricted scope, but less forceful than medical advanced healthcare directives across regions (Gloeckler et al. Reference Gloeckler, Scholten, Weller, Keene, Pathare, Pillutla, Andorno and Biller-Andorno2025). The same document in the United States tends to have greater weight there than in Europe and the UK (Buchanan Reference Buchanan1999). In terms of content, A recent systematic review into the content of advanced healthcare directives noted that six key elements are in such directives, including: signs of crisis, general treatment approaches, preferences on treatment setting, treatment, coercion, and social instructions (Gaillard et al. Reference Gaillard, Braun, Vollmann, Gather and Scholten2022). However, even these elements vary between jurisdictions, which often leads to their dismissal during a mental health crisis (Stewart Reference Stewart2025).
Wellness Recovery Action Planning (WRAP): An introduction
WRAP is a structured, self-help wellness programme for individuals who want to make positive changes in their lives towards recovery as it postulates that recovery can be lived towards achieving or striving towards one’s own self-defined recovery goals (Canacott et al. Reference Canacott, Moghaddam and Tickle2019; Norton and Flynn Reference Norton and Flynn2021). It is a mental health wellness/recovery programme created specifically for others experiencing mental health challenges (Mak et al. Reference Mak, Tsoi and Wong2024). It was developed through a co-production process with service users from Vermont in the United States in 1997 and has been spearheaded ever since by Mary Ellen Copeland (Horan and Fox Reference Horan and Fox2016). Today, it is delivered as part of the recovery education workstream of the Irish mental health services in order to support the services transition to recovery principles and recovery-orientated care (Keogh et al. Reference Keogh, Higgins, Devries, Morrissey, Callaghan, Ryan, Gijbels and Nash2014). As such, this initiative is in line with principle four of the ‘National Framework for Recovery in Mental Health’ which is Ireland’s framework to support the creation of a recovery-orientated service (HSE 2024).
Composition of WRAP
In general, WRAP consists of four main parts: a set of key concepts, an individualised wellness toolbox along with a six-part monitoring and response system that helps promote individualised recovery (O’Keeffe et al. Reference O’Keeffe, Hickey, Lane, McCormack, Lawlor, Kinsella, Donoghue and Clarke2015). Finally, WRAP concludes with a set of wellness recovery topics. Despite this, this paper will focus on the crisis and post-crisis plan specifically as these are most relevant in the construction of an advanced healthcare directive. However, for the purposes of this paper, these recovery topics are not discussed here. The first part of WRAP is an exploration of the five key concepts: hope, personal responsibility, education, self-advocacy, and support (Copeland Reference Copeland2011, Reference Copeland2018). These five concepts form the foundations of the programme by which all other aspects are built upon. Next is the wellness toolbox – an instrument used by service users (either physically and/or metaphorically) to place mementos or other items of significance into. The idea is that such items can remind the person of what’s important in their life. This is important as recovery is a non-linear process (Erondu and McGraw Reference Erondu and McGraw2021; Jacob Reference Jacob2015; Slade and Longden Reference Slade and Longden2015). As such, when a person feels like they are slipping back into unwellness, this toolbox and its contents can be used to help lift the person out of the slippery slope of unwellness back to a place of wellness.
The next part of the WRAP programme is a six-part monitoring and response system that individuals are trained to use to support their own mental well-being. First, comes the daily plan, which is divided into three subsections. Subsection one examines what a person is like when they are well. Here the service user lists all the characteristics they and others notice about themselves when they are in a place of wellness. This is an important component as it links with subsection one of the crisis plan (to be discussed later). Subsection two explores what a person needs to do daily to maintain wellness. This could be anything from ensuring they dress their bed to taking their medication to gym work to relaxing in front of the television watching a current soap opera. What this consists of differs per person due to the recognised uniqueness of each person in a social world. Finally, subsection three of daily planning lists the things a person needs to do occasionally to maintain wellness. Examples include medical appointments, dental appointments, paying the bills etc. The idea behind subsections two and three is that a person is in control regarding how to maintain their well-being. However, to be proficient at it requires reflection and practice. This section of WRAP is vital as for the sections that follow, a reference will always be made back to daily planning as a core place that signifies wellness for an individual.
Stressors or triggers marks the first phase of potentially becoming unwell. A stressor/trigger is an external event or circumstance that may make one feel very uncomfortable. What this is differs for everyone, but the important element here is that the stressor/trigger is external to the person it effects and may or may not be linked to early warning signs. Examples may be physical or abstract concepts. It could be a priest or could be religion itself. It could be the closing in of the dark evenings or the smell of a candle burning inside a Halloween pumpkin. As seen above, what exactly it is may not be clear due to its potential abstract nature, but it is important for service users to reflect on their life and see what exactly is outside of a person that causes them to feel bad. Once these are identified, WRAP encourages us to create an action plan to help mitigate the stressor/trigger when it occurs. It is important to remember that some stressors/triggers can be avoided but some, like an anniversary of a loved one’s death cannot, but the action plan should help in supporting the person not to be as impacted by the stressor/trigger than they would have been before encountering WRAP.
Next is the early warning signs. This section describes feelings and emotions that are internal to the person and that may or may not be associated with a stressor/trigger. Examples could be a feeling of anxiety to feeling low in mood, to an increase in auditory and visual hallucinations, and so on. The important element here is that such early warning signs are internal. They are the feelings, emotions, and reactions a person can have to a situation which may be known or unknown to the affected individual at time of reaction. Once again, WRAP encourages us to create an action plan to help us deal with these unwanted emotions, feelings, thoughts, and reactions. It is important to note here that at this point, the focus is on supporting the individual back to a place of well-being through the use of their daily plan. As such, at this point, the person is still in control of their own well-being and so the action plan is filled with things the person can do to support themselves back from early warning signs to wellness via daily planning.
Following on from this comes the next phase entitled: when things are breaking down. Despite one’s best efforts, one can still begin to feel worse and may feel closer to a mental health crisis. What this constitutes is different for everyone because of the subjective nature of signs that occur within this phase. In fact, what may be an early warning sign for one person may be a sign that things are breaking down for another. The difference here is that there is usually a time factor associated with these signs. For instance, someone’s early warning sign may be that they had a bad night sleep, but their when things are breaking down is that this has continued to be the case for four out of the past seven nights. As such this represents a clear escalation of signs which requires individuals to make more decisive action to actively prevent a crisis from occurring. Once again, this is carried out through an action plan. However, because of the escalation of signs of unwellness and the closeness this scenario is to a crisis, the action plan needs to be very clear with less would and could statements and more must and will statements. If one has planned their WRAP carefully, they may avoid a crisis, but sometimes despite all the effort put in to avoiding a crisis, it can still occur. Here is where WRAP can truly transform into an advance healthcare directive, which is now discussed.
Crisis planning and post-crisis planning as an advance healthcare directive
The crisis and post-crisis planning sections of WRAP are divided into a number of subsections which allows individuals to construct their own advance healthcare directive in a way that is straight-forward and meaningful to them. In terms of WRAP, crisis is the point where a person has lost control over their well-being due to a build-up of stressors/triggers, early warning signs, and prolongation of these elements to the point where a person becomes overwhelmed and are no longer able to advocate for themselves and self-manage their wellness. In other words, this is the point where others have to take control of their care. However, like an advance healthcare directive, the crisis and post-crisis plans are devised to allow individuals to write and share with their supporters a plan of action when they are well so that when/if they become incapacitated. their will and preferences will be considered and adhered to. The crisis plan is divided into nine components which are highlighted in Figure 2.
The nine steps of crisis planning.
Extracted from Norton (Reference Norton2025) as discussed in Kane and Allen (Reference Kane and Allen2025).
The first subsection of crisis planning involves noting what a person is like when they are well. As noted earlier, this section comes straight from the daily plan, but this time, it is used to give one’s supporters an idea of what wellness looks like for the service user as an individual and not what the supporter believes wellness is for them. This followed closely by signs that others need to step in and take over. Here, based on past experiences, the service user inputs what unwellness or crisis is for them. Crisis is a very subjective term when it comes to mental health as what we constitute as a crisis differs per person. For example, a flat tyre could be a crisis for one person but not another. However, the feeling a crisis can cause within an individual is universal. For instance, anxiety, feeling confused, not knowing what to do, and so on Subsection three: supporters is a designated area in a person’s crisis plan where they can identify a) who they want to support them at this point in their recovery and b) who they do not want involved in their care at this point. This is an important distinction as crisis can often be exacerbated by having to deal with individuals that you do not need to see at this moment in time. In addition, certain individuals could represent or be linked to a past or current trauma which can enhance the feelings associated with the current crisis, making things more difficult for the person in distress. Within WRAP, it is recommended that the service user has at least five supporters they can count on in times of crisis. Who becomes a supporter is based on the individual making the plan and who they find useful and trustworthy during a crisis (A Lust for Life, 2026). This is an essential component of this element of the crisis plan as relying on only one person can put undue pressure on that person, thereby impacting their own wellness. In addition, practically, it is very difficult to rely on one person as each individual has their own life to live which may make such individuals unavailable at different points along the recovery journey, such as when one is in crisis. There are some societal barriers to relying on other people whilst in a mental health crisis including fear of stigmatisation as well as a lack of trust in both oneself and others (Meadley et al. Reference Meadley, Rickwood and Ishikawa2024).
Following on from this comes the section on medication and supplements. In America, where WRAP is more fully developed and utilised within mental health systems, individuals can select the medications they wish to use whilst in crisis. However, within an Irish context, this is currently not possible. Despite this, this section can be used to list the current medications a person is on, any allergies, and any medications that have not worked for them in the past. All of which are helpful for both supporters and clinicians to know about to optimise this time in one’s recovery. Next comes treatments and complimentary therapies. What this addresses is the treatments that one may wish to be offered whilst in crisis. For example, is electroconvulsive therapy (ECT) an option that one would consider in this situation. Once again, this is very subjective with some including this in their plan, where others would strongly object to undergoing such treatment. This also relates to other, more complimentary treatments like yoga, art therapy, music therapies, sound bathing etc. The idea here is that this subsection of the plan identifies the wholeness of the person and how each element of what constitutes a person should be considered when making an advance healthcare directive. This moves us on to the sixth element of crisis planning which centres around home/community/respite. Here, the individual making the advance healthcare directive can choose where they wish to be at in times of crisis. Do they want to be under the care of a Home-Based Treatment Team or within a crisis house/peer respite or actually within an inpatient environment. Now, there are caveats to this that individuals making this plan should be aware of including the fact that (a) not all jurisdictions have these resources available and (b) these decisions are dependent somewhat on the level of suicidality in an individual at time of crisis (Amering et al. Reference Amering, Stastny and Hopper2018; Hough Reference Hough2025; Swartz and Swanson Reference Swartz and Swanson2026; Zelle et al. Reference Zelle, Kemp and Bonnie2015).
If a treatment facility is identified – ideally by the individual in crisis – as appropriate, the individual then has another decision to make: public or private. Again, this is subject to financial status of a person within a community, but where this is an option, the person can add this into their crisis plan/advance healthcare directive. After this, subsection eight examines help from others. This is another important milestone in the crisis plan as here is where one gets to tell their supporters what they need them to do whilst in crisis. This can range from advocating for their best interests, to feeding the dog, to paying the electricity bill, and so on. Whatever that task is, it is dependent on the person, but it is essential that the person names what supporter to do what task. For example, for an individual, they may choose their mother over their father for sitting with them and talking to them about their experiences. But, if this individual needed someone to fix the car or feed the dog, then the father may be chosen over the mother for that task. As such, this requires the service user to think about their supporters – what are their given strengths and shortcomings and assigning tasks based on same. The final aspect of the crisis plan is entitled: signs a crisis plan is no longer needed. Here, the service user can identify the signs within themselves when the crisis has past and it is time to start rebuilding. That could be when one is less occupied by their hallucination experiences or are able to read the newspaper again without getting distressed. Once again, knowing when this is is subjective to the person and often requires them to have experienced a crisis before so that they can know when their place in recovery has changed from acutely unwell to rebuilding a sense of self beyond mental illness towards recovery (Norton and Cullen Reference Norton, Cullen, Norton and Cullen2024a; Watts Reference Watts2025).
Post-crisis planning
Post-crisis planning is another aspect of WRAP that should be somewhat included in an advance healthcare directive. However, within WRAP, the post-crisis plan is the only section of the plan that is not pre-planned. It is simply not possible to pre-plan a post-crisis plan as it relies on knowledge that can only truly be ascertained once a person has gone through a crisis. Although post-crisis planning is unique and differs from person to person, the general idea behind post-crisis planning is the gradual reuptake of responsibility in order to return to using a daily plan. In WRAP this is not possible without utilising the five key concepts of which WRAP is based on as bench markers towards daily planning (see Figure 3).
Post-crisis plan as a path back to daily planning.
Adapted from the work of Rona McBrierty (Unpublished) and Norton (Reference Norton2025) as discussed in Kane and Allen (Reference Kane and Allen2025).
In creating a post-crisis plan, the general principle is that the person is still healing from the crisis and as such, they have yet to have the ability to take full responsibilities back for their own lives. As such, the post-crisis plan would have a supporters element to it, but this is known here as a timetable to take back responsibility. So, for instance, in week one after the crisis, the person may need support with shopping for food, but in week four may be totally able to shop for themselves again. Yet again, this is highly subjective as recovery in itself is subjective. Along with the gradual uptake of responsibility, there should also be a time for the service user to review their WRAP plan as a whole. This is important for two reasons: (1) something did not work because the individual ended up in crisis in the first place and (2) from the crisis, the individual may have learned new tips and techniques and developed new wellness tools that need inclusion in a revised format of their WRAP plan. In addition, the post-crisis plan period is also a time to thank those individuals that supported the service user during the crisis, but also to apologise/offer apologies to anyone that the service user may have upset whilst acutely unwell. This sometimes is not an easy task but is an important step in retaking responsibility for one’s life and the decisions one makes in their life. The post-crisis plan then ends when the individual service user can fully retake control over all aspects of their lives which they were able to do pre-crisis.
The role of peer staff in embedding WRAP in existing practices
Peer staff are essential for embedding WRAP in mental health services (Federici Reference Federici2013). They do this through two means: recovery education and peer support work (Copeland Reference Copeland2016; Doughty et al. Reference Doughty, Tse, Duncan and McIntyre2008; Federici Reference Federici2013; Norton and Flynn Reference Norton and Flynn2021). Recovery education describes a strengths-based approach to learning about mental health and well-being that is underpinned by the values of self-direction, hope, diversity, personal experience, and ownership (O’Brien et al. Reference O’Brien, Murphy, Hunt, Dwyer and Hunter2024). Recovery education is unique to traditional pedagogical education as it is centred around the intentional use of lived experiences within the design, delivery, and evaluation of such programmes (Norton et al. Reference Norton, Gallini-Poole, Little and Zilberberg2025). This is carried out through both the process of co-production and through the employment of those with lived experience as recovery education facilitators and peer educators, whose primary role is to deliver knowledge that provides psychosocial support and improves social learning (Abdi and Simbar Reference Abdi and Simbar2013). One such programme is WRAP where peer staff are trained in the delivery of the programme, drawing on their own lived experiences of utilising the programme for their own mental health needs (Norton and Flynn Reference Norton and Flynn2021). In Ireland, WRAP has been rolled out as a national recovery education programme, endorsed by the HSE Office of Mental Health Engagement and Recovery and supported by Mental Health Ireland. As a result, peer educators and recovery education facilitators are now trained in its delivery and are now considered one of the primary providers of WRAP training in Ireland today.
Additionally, WRAP is also promoted through Peer Support Workers (PrSWs) situated within traditional multi-disciplinary teams. PrSWs are individuals who have experienced mental health challenges themselves and now use this experience to provide encouragement, guidance, and support to others experiencing similar life circumstances or challenges, based on the principles of mutual understanding and empathy (Whyte et al. Reference Whyte, Schols-Flett, Ferrara, Warren, Wenger, Dimitropoulos and Barbic2026). Since their introduction to mental health services, interest in the role has increased exponentially (Jacobson et al. Reference Jacobson, Trojanowski and Dewa2012). Within mental health services in Ireland and internationally, they are now recognised as a professional discipline who actively draw on their lived experiences to support and guide others (Dunkerley and Jordan Reference Dunkerley and Jordan2024; Norton Reference Norton2025a). Such experiences include that of mental ill health and equally as important, their recovery journey from such challenges – which for many, includes the utilisation of WRAP. In practice, PrSWs can support individuals in learning about their mental health challenges, but also various aspects of wellness and unwellness that is brought to life through a structured programme like WRAP. As such, within therapeutic environments, PrSWs can support service users in attending the recovery college for the first time to receive WRAP training. Or indeed, PrSWs can also share their own WRAP plans with service users, demonstrating its usefulness for mental health recovery and further promoting the peer as a role model which is essential for the therapeutic but informal relationship to work (Norton et al. Reference Norton, Clabby, Coyle, Cruickshank, Davidson, Greer, Kilcommins, McCartan, McGuire, McGilloway, Mulholland, O’Connell-Gannon, Pepper, Shannon, Swords, Walsh and Webb2023).
Strengths and weaknesses of WRAP as a framework for mental health advance healthcare directives
The use of WRAP as a framework for mental health advance healthcare directives has several strengths and weaknesses. Firstly, in terms of strengths, the international recognition of WRAP as a self-management tool is useful here as it provides a step-by-step mechanism by which advance healthcare directives can be created regardless of diagnosis (Eve 2015; O’Keeffe et al. Reference O’Keeffe, Hickey, Lane, McCormack, Lawlor, Kinsella, Donoghue and Clarke2015; Zhang et al. Reference Zhang, Wong, Li, Yeh and Zhao2010). Something that seems to be missing at the present time (Block et al. Reference Block, Smith and Sudore2021). However, despite the ability of WRAP to be universally applied, there are some weaknesses in utilising WRAP as an advance healthcare directive. For instance, it may be difficult to integrate WRAP with the legally binding aspects of advance healthcare directives as WRAP provides the opportunity for individuals to state within their crisis plan that they do not wish to be involuntarily detained if they lose decision-making capacity. However, in practice, this is ethically and legally difficult to enforce given the acute care needs of an individual at that moment in time. Consequently, the addition of Designated Healthcare Representatives may support the alleviation of such concerns as they would be able to advocate for the person’s request and can work with the multi-disciplinary team to put a compromise in place so that the person’s wishes are respected to as much a degree as possible, whilst maintaining ethical and legal requirements. Additionally, as WRAP was constructed in a different jurisdiction, some of the contents of crisis planning alluded to in the programme may not be applicable to an Irish context. Take for example, medication or treatment facilities. Within an American context, the person can state what medication they do not want to be on during a crisis. Equally, they can also state what kind of treatment centre they wish to attend whilst in crisis. Although both are positive developments, they are, within an Irish context, impractical in their current form due to resources and lack of education on moving away from best interest to wills and preferences. This, as stated earlier, is where compromise is required so that the service user’s wishes are respected in so far as possible. It also re-enforces the need for such advance healthcare directives to be created in conjunction with healthcare providers so that decisions inputted into such documents are realistic, applicable to the jurisdiction whilst also adequately representing the will and preference of the individual concerned.
Conclusion
In summary, increasing attention has been given to the idea of advance healthcare directives since the development of the personal recovery movement, as well as more recently, the publication and enactment of The Assisted Decision Making (Capacity) Act 2015. However, until now, the format of what constitutes an advance healthcare directive has been contested with a lot of ambiguity attached to what way this may actually work in mental health services. Such ambiguity is suggested to have resulted from the subjective nature of mental health crises and personal recovery. In this article, the crisis and post-crisis plan within WRAP is proposed as a workable solution to this conundrum given its ease in understandability and how WRAP is now engrained within mental health services both in Ireland and in other jurisdictions internationally. As a result, this paper explored WRAP in detail – particularly crisis and post-crisis planning in order to support the case for these elements of WRAP to form the basis for an advance healthcare directive for those utilising mental health services whilst in crisis. However, there are several structural, systemic, and cultural barriers to the employment of WRAP for this purpose. These barriers include the availability of services within regions as well as jurisdictions, the financial capital required for its implementation, the need for service users to have experienced a mental health crisis before so that they can apply that knowledge to such a documents and the lack of supporters for some service users that are external to service provision. Given these barriers, future empirical research could examine how such barriers can be rectified so that advanced healthcare directives can be respected for all patients, inclusive of mental health service users.
Data availability statement
There is no dataset associated with this work.
Funding statement
The correspondence received no specific grant from any funding agency, commercial or not-for-profit sector.
Competing interests
The author declare that there are no conflicts of interest.
Ethical standards
The author assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
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