Title How can mental health services support self management ? The experience of Support Time and Recovery workers in promoting WRAP

Aims and method Supporting self-management is a core ambition of progressive mental health services, but little is known about how to achieve this. Support time and recovery (STaR) workers are routinely taught the Wellness Recovery Action Plan (WRAP). This study explores their capacity to support self-management using WRAP. Results The audited STaR trainees had introduced an average of nine service users each to WRAP. There was a trend for those with personal experience of mental illness to introduce more clients to WRAP and even more so for those who had used WRAP themselves. Qualitative analysis suggested a range of factors that may mediate whether people engage with self-management or not. Clinical implications The capacity of STaR workers and others to support people in self-management may depend on more than knowledge of self-management methods and having personal experience of mental health problems and services. Important factors may also include specific experience of the methods introduced, ongoing training, accountability and supervision.


Laura Hill Glenn Roberts Wilson Igbrude
'Give a man a fish, feed him for a day, Teach a man to fish feed him for his life' Lao Tsu 600 BC The wisdom of supporting people in becoming skilled at looking after themselves has been understood from ancient times and was recently reaffirmed as 'one of the key pillars of the NHS Improvement Plan's vision for a patient-centred care system'. 1 There is growing evidence in physical healthcare that people with long-term conditions find self-care and selfmanagement to be effective in improving quality of life and promoting appropriate use of services. 2pporting self-care is a specific work stream arising from the National Service Framework for Long Term Conditions linked to the Expert Patient Programme (EPP). 3,4Self-care and self-management have an established role in recovery based practice, 5 and are a fulfillment of the expectations in both the white paper 'Our Health, our care, our say' and 'Supporting people with long-term conditions to self care. 6,7Additionally the Royal College of Psychiatrists, along with other 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', 8 and the last 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 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. 9The need identified in FAIR DEAL 10 for 'further research on successful methods of supporting self management and recovery (p27) 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 11 and although there is a large and growing body of anecdotal reports of benefit 24,12,13 it is largely unresearched.One of the few studies of outcome from participation in using WRAP reported beneficial changes (significant improvement in self reported symptoms, recovery, hopefulness and self advocacy) but was uncontrolled and described self reported outcomes over a very limited time (one month). 14Another 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. 15AP is a structured approach that is written, owned and used by the individual.It is constantly updated in the light of a persons 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 wellbeing.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 Future Vision Coalition 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'. 16Following 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 17 and forms the core of Personal Recovery Planning at South West London and St George's. 18It has also influenced other illness specific approaches such as Recovery In-Sight for bipolar disorder 19 and there is currently a major national training programme aimed at developing a cohort of WRAP trainers in Ireland, funded by their Department of Justice. 20AP originated from a service user perspective and is largely delivered by peers.The benefits of peer delivered services and supports have been summarised as including. 21Positive role modelling -'if you can maybe I can' • Emotional and social support and empathic connection • Authenticity of the trainers having experience of using methods they are teaching • Practical and usable information and strategies from those who have used them • 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 ministers to consider the implications of National Service Framework for Adult Mental Health. 22For the first time a group of workers were explicitly recruited for their personal qualities rather than professional qualifications, which included valuing their personal experience of mental health problems and services.It was intended that they would work in a variety of statutory and non-statutory settings, provide practical support, promote independence and support services users in self-care with the aim of empowering them to lead 'ordinary lives'.STaR 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. 23,24von was an early adopter of the national STaR training initiative and has one of the most well developed networks of STaR workers.Over 300 people from a wide variety of backgrounds have so far participated in training which was offered free on an unselected basis to all who were interested and could make use of it.This included service users and carers, workers for voluntary and third sector agencies, housing support workers and unqualified workers in statutory services undergoing conversion to become STaR workers (see STaR section of www.recoverydevon.co.uk).There was no specific offer or expectation that people who did STaR training would subsequently be employed as STaR workers.The STaR programme offered an entry level experience for people engaged with or contemplating mental health work and strongly represented the values and principles of recovery oriented approaches which are being broadly promoted in Devon. 25e STaR initiative in Devon therefore provided an opportunity to see how training unqualified health care workers in a specific self management tool converts to people using WRAP and what helped and hindered that learning.We hypothesised that people with STaR training who also had personal experience of using WRAP, and therefore worked as peers, would be more able to offer that support to others.The present study was commissioned by the Devon STaR steering group to provide feedback and understanding on this issue to inform further engagement in supporting self-management.

Method Setting
Devon is a largely rural county covering 2700 square miles with a population of just over one million.It has been recognised nationally as a leading area for innovations in recovery oriented practice, including development of the STaR role 5,10,26 .The authors worked with the Devon STaR steering group to design and deliver the study to trainees who were geographically dispersed and worked for a wide range of statutory and non-statutory employers, were unemployed or independent.

Sample
The questionnaire was sent with a self-addressed return envelope to all participants in the first two years of STaR training in Devon (n = 128).The initial posting was followed by a reminder letter and further copy of the questionnaire.The request to participate was signed by the lead for STaR training in Devon, who was known personally to all participants.A subsequent phone check revealed that only 71 were still contactable at the addresses they had originally given.Our analysis is therefore based on returns expressed as a proportion of 71.

Data collection
The Devon STaR steering group worked with the authors to formulate a simple questionnaire with quantitative and qualitative elements.The quantitative questions covered basic demographic details, training experience, subsequent confidence in WRAP and experience of introducing WRAP to others.

Analysis
The quantitative results were analysed using SPSS and free text responses were thematically analysed by two researchers (LH & WI) and any disagreements resolved through discussion or categorised as ambiguous (uncoded).We were supported in both analyses by researchers highly experienced in quantitative and qualitative methods.

Demographics
Forty-six out of sixty of the respondents were female (77%) which was representative of the sample as a whole.Forty-four of the respondents were over 40 years old (73%).Just over 40% stated they had personal experience of a mental health problem and 33% used a WRAP plan themselves.Of those respondents who had completed the training, half were subsequently employed in STaR roles, a third of whom reported personal experience.

Training and confidence
Seven respondents had been trained in WRAP within the previous 6 months, 22 within 6-12 months and 25 over 12 months ago.Six respondents stated they had not been trained in WRAP despite this being core to STaR training.A third of respondents described feeling very confident at introducing WRAP to service users and a further half stated they were moderately confident.

Introducing others to WRAP
At the time of the study respondents stated they had introduced a total of 477 service users to WRAP (mean 9, range 0-80) of whom 207 (43%) had taken it up.There was no significant difference between individuals currently employed as STaR workers and others in how many service users they introduced to WRAP and there was no association found between age of STaR worker and numbers introduced.There was a non-significant trend for those who had personal experience of mental health problems to introduce more people to WRAP.Those who used a WRAP plan themselves introduced an average of fourteen people to WRAP compared with six people for those who didn't.

What helped and hindered?
The analysis of the main themes is given in tables 1, 2 and 3.

Limitations
A surprisingly high number of people who had attended STaR courses had moved on from their initial contact address and were subsequently unavailable to comment on their experience.The study may have been more powerful with a control group consisting of those whom had no previous experience of mental health attempting to support others in selfmanagement, but as a naturalistic rather than experimental study this was not possible.The anonymity of the study design did not allow us to clarify the meanings of some of the responses or follow up non-responders.
Neither can we comment on the effectiveness of WRAP as a selfmanagement tool, or compare it with other approaches to self-management but we can comment on the process and results of training unqualified workers to engage people in developing self-management (WRAP) plans which is an initial step and preliminary to any further work.

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 (WRAP) is a simple, sensible and structured tool, and the proposal of supporting people in self-management by introducing them to WRAP is a seemingly straightforward but elusive goal.
In this initial group of STaR trainees there was a wide variation in the experience of engaging people in WRAP, with seven introducing none.It would appear that there is an appreciable gap between giving people a theoretical grounding in a self-management tool and them subsequently introducing it to others and hence a continuing need to understand the obstacles between learning principles and changing practice.There may be clear and practical steps needed by organisations, professions and individuals who wish to make a reality of the cultural shift towards recovery oriented services. 11,27ngaging and supporting people in self-care is a required competency within the emerging core curriculum for psychiatrists and an acknowledged key skill in recovery based practice.It has been observed that for practitioners to support people in self-management we may need to give up some of our power and authority and become skilful and confident in creating more opportunities for personal choice. 28,29There 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.The non-significant trend in this study towards STaR trainees with their own personal WRAP plans being more able to introduce others is consistent with this proposition.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 others. 30This 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. 4It also underpins the ambitious Irish national WRAP training programme (IMHREC) which aims to develop its cohort of WRAP trainers from people who have themselves already learned and used WRAP. 20e 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 (two years) highlights specific workforce issues and has significant implications for turning training into services.Offering training in an open way to unselected applicants with no obligation to subsequently use their training 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 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 and indicate a need to reconsider fidelity issues to the STaR role, as well as ongoing support and supervision.
This 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 selfmanagement 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 is disappointing.However, despite its limitations, it 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.
Outcomes from more extensive studies such as IMHREC will be eagerly awaited as having the potential to answer some of the questions raised here and lead us to successfully utilise tools such as WRAP in everyday practice in mental health settings.

Thanks
To Ann Ley and Tobit Emmens for support in qualitative and quantitative data analysis and to Laurie Davidson STaR lead in Devon.

Tables
(1) What helped engagement with WRAP?Frequency (%) Service users valued the structured approach of WRAP and the identification of triggers 53 Service users with good insight and understanding about their mental health were more likely to participate in producing and using a WRAP plan

30 3 ( 2 )
Offering choice and giving control to the service user made them more willing engage in producing a WRAP plan 28 Support from workers to help the service user 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 service user is able to engage with the process and explore what works for them 5 Uncoded What hindered engagement with WRAP?Frequency (%) 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 Clients concerns 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 Thinking about those who did take WRAP up and use it, what helpedwhat are the key issues?(2) Thinking of those who didn't take it up or use it, what hindered -what are the key issues?(3) If the overall aim is to enable WRAP to be put into practice and to encourage people we are working with to develop their own WRAP plans as a support for self-management -what would enable this to happen -in your opinion what would make a difference?