Core Competency 2 Wellness Recovery Action Plan (WRAP)

What is WRAP?

The Wellness Recovery Action Plan® or WRAP®, is a self-designed prevention and wellness process that anyone can use to get well, stay well and make their life the way they want it to be. It was developed in 1997 by a group of people who were searching for ways to overcome their own mental health issues and move on to fulfilling their life dreams and goals. It is now used extensively by people in a variety of circumstances, and by health care and mental health systems all over the world to address a wide spectrum of physical, mental health and life issues.
WRAP has been studied extensively in rigorous research projects and is listed in the National Registry of Evidence-based Programs and Practices.

WRAP will help you...

Discover your own simple and safe wellness tools
Develop a list of things to do every day to stay as healthy as possible
Identify upsetting events, early warning signs and signs which indicate things have gotten worse and, using wellness tools, develop action plans for responding at these times
Create a crisis plan
Create a post-crisis plan

Overview

• Wellness Toolbox – A list of resources used to develop your WRAP. It includes things like: contacting friends and supporters, peer counseling, focusing exercises, relaxation and stress reduction techniques, journaling, affirming activities, exercise, diet, and getting a good night’s sleep.

• Daily Plan – Describe yourself when you are well, and list things you need to do every day to maintain wellness.

• Stressors– External events or circumstances that, if happen, may make you feel uncomfortable. These are normal reactions, but if we don’t deal with them in some way, they may actually cause us to feel worse.

Overview

• Early Warning Signs – Internal, subtle signs that let you know you are beginning to feel worse. Reviewing Early Warning Signs regularly helps us to become more aware of them and allow us to take action before they worsen.

• When Things are Breaking Down – List signs that let you know you are feeling much worse, like feeling sad all the time, or hearing voices. Using your Wellness Toolbox, develop a powerful action plan to help you feel better as quickly as possible and prevent an even more difficult time.

Components of WRAP

• Developing a maintenance plan • Triggers• Early Warning Signs• When things are breaking down • WRAP crisis plan

Lets Make Our Own WRAP

Supplies Needed

a three-ring binder, one inch thick
a set of five dividers or tabs
a package of three-ring filler paper
a writing instrument of some kind
supporter to give you assistance and feedback

Developing a Maintenance Plan

On the first tab write Daily Maintenance List. Insert it in the binder followed by several sheets of filler paper.
On the first page, describe, in list form, yourself when you are feeling alright.
On the following page make a list of things you need to do for yourself every day to keep yourself feeling comfortable.
On the next page, make a reminder list for things you might need to do. Reading through this list daily helps keep us on track.

Triggers

External events or circumstances that, if they happen, may produce serious symptoms that make you feel like you are getting ill. These are normal reactions to events in our lives, but if we don't respond to them and deal with them in some way, they may actually cause a worsening in our symptoms.
On the next tab write "Triggers" and put in several sheets of binder paper.
On the first page, write down those things that, if they happened, might cause an increase in your symptoms. They may have triggered or increased symptoms in the past.
On the next page, write an action plan to use if triggers come up, using the Wellness Toolbox at the end of this handout as a guide.

Early Warning Signs

Early warning signs are internal and may be unrelated to reactions to stressful situations. In spite of our best efforts at reducing symptoms, we may begin to experience early warning signs, subtle signs of change that indicate we may need to take some further action.
On the next tab write "Early Warning Signs". On the first page of this section, make a list of early warning signs you have noticed.
On the next page, write an action plan to use if early warning signs come up, using the Wellness Toolbox at the end of this handout as a guide.

When Things are Breaking Down or Getting Worse

In spite of our best efforts, our psychiatric symptoms may progress to the point where they are very uncomfortable, serious and even dangerous, but we are still able to take some action on our own behalf. This is a very important time. It is necessary to take immediate action to prevent a crisis.
On the next tab write, "When Things are Breaking Down". Then make a list of the symptoms which, for you mean that things have worsened and are close to the crisis stage.
On the next page, write an action plan to use "When Things are Breaking Down" using the Wellness Toolbox at the end of this handout as a guide.

Crisis Planning

In spite of our best planning and assertive action, we may find ourselves in a crisis situation where others will need to take over responsibility for our care. We may feel like we are totally out of control.
Writing a crisis plan when you are well to instruct others about how to care for you when you are not well, keeps you in control even when it seems like things are out of control. Others will know what to do, saving everyone time and frustration, while ensuring that your needs will be met. Develop this plan slowly when you are feeling well.

Crisis Plan

Those symptoms that would indicate to others they need to take action in your behalf
Who you would want to take this action?
Medications you are currently taking, those that might help in a crisis, and
those that should be avoided
Treatments that you prefer and those that should be avoided
A workable plan for at-home care
Acceptable and unacceptable treatment facilities
Actions that others can take that would be helpful
Actions that should be avoided
Instructions on when the plan no longer needs to be used

Advanced Directive for Mental Health Treatment

• Advance directives are designed to establish a person's preferences for treatment if the person becomes incompetent in the future or unable to communicate those preferences to treatment providers. Mental health advance directives are similar to the more commonly used directives for end-of-life medical decisions. A patient must be competent to execute a mental health advance directive, and the directive must clearly express the patient's wishes. Once directives are executed, steps must be taken to ensure compliance, including adequate dissemination to providers, and to ensure that proxy decisions are consistent with the patient's treatment preferences.

• Potential effects of mental health advance directives include enhanced consumer empowerment; improved functioning; improved between consumers, family members, and providers; increased tolerance for consumer autonomy at the organizational level in community mental health agencies; and reduced use of hospital services and judicial proceedings. Issues to be clarified in future research and practice include strategies for increasing awareness of advance directives in mental health, barriers to execution of legally and clinically effective directives, practitioners' concerns, providers' compliance with directives, effects of directives on consumers and providers, effects of managed care on implementation of directives, and stakeholders' perceptions of the value of directives.

• "Advance directive for mental health treatment" or "advance directive" means a written document, or a document in a form consistent with the provisions of the federal Americans with Disabilities Act (ADA), made voluntarily by a grantor in accordance with the provisions of KRS 202A.420 to 202A.432 that provides instructions for mental health treatment.

202A.422 Advance Directive for Mental Health Treatment

An adult may execute an advance directive for mental health treatment that includes one (1) or more of the following:

(a) Refusal of specific psychotropic medications, but not an entire class of psychotropic medications. This refusal may be due to factors that include but are not limited to their lack of efficacy, known drug sensitivity, or previous experience of adverse reactions;

(b) Refusal of electric shock therapy (ECT);
(c) Stated preferences for psychotropic medications;

(d) Stated preferences for procedures for emergency interventions; and

(e) Provision of information in any area specified by the grantor.

202A.422 Advance Directive for Mental Health Treatment

The execution of an advance directive shall be complete when signed by the grantor and:

(a) Signed by two (2) adult witnesses who attest that the grantor: 1. Is known to them;
2. Signed the advance directive in their presence; and
3. Did not appear to be under duress, fraud, or undue influence; or

• (b) Acknowledged before a notary public or other person authorized to administer oaths.

202A.422 Advance Directive for Mental Health

Treatment

The following persons shall not serve as a witness, a notary public, or other person authorized to administer oaths to the signing of an advance directive:

(a) The grantor's current health care provider or a relative of the current health care provider; and

(b) An owner, operator, employee, or relative of an owner or operator of a health facility in which the grantor is a client or resident.

(c) An advance directive shall not override the grantor's right under federal and state law to refuse treatment.

(d) The grantor or the surrogate of the grantor shall be responsible for providing a copy of the advance directive to the grantor's health care provider and health care facility where the grantor is a patient.

202A.422 Advance Directive for Mental Health Treatment

(6) An advance directive for mental health treatment shall be honored in any setting, except a hospital emergency room or a hospital emergency department, that is required to honor advance directives under Title XVIII or Title XIX of the Federal Social Security Act.

(7) A health care provider, health care facility, surrogate, or other responsible party shall not be subject to criminal prosecution or civil liability if acting in agreement with an advance directive for mental health treatment executed in accordance with KRS 202A.420 to 202A.432 or if acting in good faith without knowledge of the existence or revocation of an advance directive

How do I Write Advance Directives?

House Bill 99 provides a form for people to use if they want to write advance directives for mental health treatment. While it isn’t necessary to use the form, it is a good idea because a valid advance directive must substantially comply with the form provided in the statute.
Either two adult witnesses must sign the advance directive or it must be notarized for it to be finished. Neither the witnesses nor the notary public can be the person’s current health care provider or a relative of the health care provider.
If you would like to get a copy of the entire law complete with the advance directive form, you can find it at http://www.lrc.state.ky.us/record/03rs/hb99.htm. You an also call P&A.
This is only a summary of the House Bill 99 and not legal advice. For legal advice, you may want to contact a private attorney or call P&A.
Call the Kentucky Protection and Advocacy office at 1-800-372-2988 for help

Fill Out Form 30 Min

Self-Care and WellnessHandout: Morbidity and Mortality in People with Serious Mental Illness

Name Your 3 Most Common

Forms of Self Care Read 50 Self Care Ideas

Physical Health Disorders Commonly Diagnosed in Individuals with Serious Mental Illness

Heart Disease

• Heart disease describes a range of conditions that affect your heart. Diseases under the heart disease umbrella include blood vessel diseases, such as coronary artery disease; heart rhythm problems (arrhythmias); and heart defects you're born with ( heart defects), among others. The term "heart disease" is often used interchangeably with the term "cardiovascular disease." Cardiovascular disease generally refers to conditions that involve narrowed or blocked blood vessels that can lead to a heart attack, chest pain or stroke.

Having a serious mental illness significantly increases the risk of premature death from heart disease.
Researchers who analyzed data on more than 3 million patients found significant links between cardiovascular disease and conditions such as schizophrenia, bipolar and major depression.
People with sever mental illness were up to 78% more likely to suffer from damaged hearts and arteries.
The risk of dying from cardiovascular disease was 85% higher in people with SMI’s

Diabetes

Diabetes mellitus refers to a group of diseases that affect how your body uses blood sugar (glucose). Glucose is vital to your health because it's an important source of energy for the cells that make up your muscles and tissues. It's also your brain's main source of fuel.
The underlying cause of diabetes varies by type. But, no matter what type of diabetes you have, it can lead to excess sugar in your blood. Too much sugar in your blood can lead to serious health problems.

People with diabetes are 2 to 3 times more likely to have depression than people without diabetes. Only 25% to 50% of people with diabetes who have depression get diagnosed and treated.
People with chronic psychiatric disorders typically eat poorly, exercise rarely, smoke more, have a lower income and tend to be overweight. This automatically puts this specialized population at a higher risk for diabetes due to lifestyle choices that are often the result of an illness rather than a personal choice. But the primary reason those with psychiatric disorders are vulnerable to the disease is the use of certain antipsychotics that lead to the weight gain associated with diabetes.

HIV/AIDS

Acquired immunodeficiency syndrome (AIDS) is a chronic, potentially life-threatening condition caused by the human immunodeficiency virus (HIV). By damaging your immune system, HIV interferes with your body's ability to fight the organisms that cause disease.
HIV is a sexually transmitted infection (STI). It can also be spread by contact with infected blood or from mother to child during pregnancy, childbirth or breast-feeding. Without medication, it may take years before HIV weakens your immune system to the point that you have AIDS.
There's no cure for HIV/AIDS, but there are medications that can dramatically slow the progression of the disease. These drugs have reduced AIDS deaths in many developed nations.

If you are living with HIV, it is important for you to be aware that you have an increased risk for developing mood, anxiety, and cognitive disorders. For example, people living with HIV are twice as likely to have depression compared to those who are not infected with HIV.
One of the most common mental health conditions that people with HIV face is depression. Depression can range from mild to severe, and the symptoms of depression can affect your day-to-day life.
In the United States, the prevalence of HIV is substantially higher among adults with serious mental illness (SMI; e.g. psychotic disorder, bipolar disorder, recurrent major depressive disorder, comorbid mood, and substance use disorder) – ranging from 2 to 6% – compared with the general population (0.5%)

Mortality and Morbidity Preventable Risk Factors

Smoking- Cigarette smoking is the leading preventable cause of death in the United States. (Heart Disease)
Obesity- Obesity is a common and preventable disease of clinical and public health importance. It is often a major risk factor for the development of several non-communicable diseases, significant disability and premature death. (Diabetes)
IV Drug Use- People who engage in drug use or high-risk behaviors associated with drug use put themselves at risk for contracting or transmitting viral infections such as HIV/AIDS or hepatitis.

STRESS!!

A physical, chemical, or emotional factor that causes bodily or mental tension and may be a factor in disease causation (Merriam-Webster)

Stress Management Techniques

• Exercise• Relaxation Techniques

• Meditation

• Time Management

• Organizational Skills

• Support Systems

Progressive Muscle Relaxation

Have you ever had an aching back or pain in your neck when you were anxious or stressed? When you have anxiety or stress in your life, one of the ways your body responds is with muscle tension. Progressive muscle relaxation is a method that helps relieve that tension.

In progressive muscle relaxation, you tense a group of muscles as you breathe in, and you relax them as you breathe out. You work on your muscle groups in a certain order.
When your body is physically relaxed, you cannot feel anxious. Practicing progressive muscle relaxation for a few weeks will help you get better at this skill, and in time you will be able to use this method to relieve stress.
When you first start, it may help to use an audio recording until you learn all the muscle groups in order. Check your local library or a bookstore for progressive muscle relaxation audio recordings.
If you have trouble falling asleep, this method may also help with your sleep problems.

Progressive Muscle Relaxation Technique Short Video

https://www.youtube.com/watch?v=kdLTOurs2lA

Long Video

https://www.youtube.com/watch?v=86HUcX8ZtAk&t=29s

Exercise

• Exercise essentially burns away the chemicals like cortisol and norepinephrine that cause stress. At the same time, vigorous exercise releases endorphins into the system. Endorphins are morphine-like hormones that are responsible for the feeling of elation, or well being that distance runners get from running. Other chemicals like dopamine and serotonin are also released in the brain during exercise. Together, these give a feeling of safety and security that contributes to offset some of the "internal" causes of stress, such as uncertainty, pessimism and negative self-talk.

• To benefit from exercise, it needs to be regular. Exercise needs to be part of a daily routine. Instead of working during lunch, why not take the time to go for a brisk walk, a run or workout at a gym? Exercise will reduce stress and reducing stress can increase productivity.

Common Wellness Practices

Benefits of Drinking Water Regularly

• Improve physical performance. During physical activity, our bodies use up a lot of water. So stay hydrated before, during, and after exercise helps to protect your body from harm, and to help you to perform better. Proper hydration can reduce fatigue, improve endurance, lower your maximum heart rate, and more. Drinking water can also help you to be less sore after exercise.[1,3,4]

• Help you to lose weight. Are you having trouble with your weight loss efforts? Increasing your water intake may help you achieve better results. Studies show that people who are on diets lose more weight when they also increase their water intake.[5,6] In one study, people on weight loss diets who drank 500 ml of water before each of their three daily meals for 12 weeks lost 4.6 more pounds on average than people who did not drink the additional water

More Benefits of Drinking Water Regularly

• Boost your mood. People who drink more water also tend to have better moods. One study found that when people who regularly drank less than 1.2 liters of water per day increased their intake to 2.5 liters per day, the participants experienced significantly less confusion, bewilderment, fatigue, and sleepiness. On the other hand, for people who regularly drank two to four liters of water per day who were then restricted to one liter per day, the reduced water intake led negative effects on mood, including decreased contentedness, calmness, and positive emotions.[7]

Wait There's More...

• Prevent headaches. Water deprivation is a very common cause of headache. In most cases, rehydrating can provide relief from a headache. For some people, dehydration can also trigger a migraine, so be sure to keep your water intake regular if you are prone to getting migraines or headaches.[1]

• Protect against disease. One of the most important answers to the question “Why is water important?” is its role in disease prevention. Proper hydration may be a useful tool in preventing a variety of health conditions and diseases. Staying hydrated may protect against kidney stones, constipation, asthma, urinary tract infections, coronary heart disease, and even possibly some cancers.

What about Caffeine?

• Anxiety

• Insomnia

• Digestive Issues

• Muscle Breakdown

• Addiction

• High Blood Pressure

• Rapid Heart Rate• Fatigue

Nicotine?

Nicotine is the fundamental cause of addiction among tobacco users. Nicotine adversely affects many organs as shown in human and animal studies. Its biological effects are widespread and extend to all systems of the body including cardiovascular, respiratory, renal and reproductive systems. Nicotine has also been found to be carcinogenic in several studies. It causes resistance to the chemotherapeutic agents. Nicotine replacement therapy (NRT) is an effective adjunct in management of withdrawal symptoms and improves the success of cessation programs. Any substantive beneficial effect of nicotine on human body is yet to be proven. Nicotine should be used only under supervision of trained cessation personnel therefore its sale needs to be strictly regulated.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363846/

Core Competency 2 Wellness Recovery Action Plan (WRAP)

What is WRAP?

WRAP has been studied extensively in rigorous research projects and is listed in the National Registry of Evidence-based Programs and Practices.

WRAP will help you...

Discover your own simple and safe wellness tools

Develop a list of things to do every day to stay as healthy as possible

Identify upsetting events, early warning signs and signs which indicate things have gotten worse and, using wellness tools, develop action plans for responding at these times

Create a crisis plan

Create a post-crisis plan

Overview

• Wellness Toolbox – A list of resources used to develop your WRAP. It includes things like: contacting friends and supporters, peer counseling, focusing exercises, relaxation and stress reduction techniques, journaling, affirming activities, exercise, diet, and getting a good night’s sleep.

• Daily Plan – Describe yourself when you are well, and list things you need to do every day to maintain wellness.

• Stressors– External events or circumstances that, if happen, may make you feel uncomfortable. These are normal reactions, but if we don’t deal with them in some way, they may actually cause us to feel worse.

Overview

• Early Warning Signs – Internal, subtle signs that let you know you are beginning to feel worse. Reviewing Early Warning Signs regularly helps us to become more aware of them and allow us to take action before they worsen.

• When Things are Breaking Down – List signs that let you know you are feeling much worse, like feeling sad all the time, or hearing voices. Using your Wellness Toolbox, develop a powerful action plan to help you feel better as quickly as possible and prevent an even more difficult time.

Components of WRAP

• Developing a maintenance plan • Triggers• Early Warning Signs• When things are breaking down • WRAP crisis plan

Lets Make Our Own WRAP

Supplies Needed

a three-ring binder, one inch thick

a set of five dividers or tabs

a package of three-ring filler paper

a writing instrument of some kind

supporter to give you assistance and feedback

Developing a Maintenance Plan

On the first tab write Daily Maintenance List. Insert it in the binder followed by several sheets of filler paper.

On the first page, describe, in list form, yourself when you are feeling alright.

On the following page make a list of things you need to do for yourself every day to keep yourself feeling comfortable.

On the next page, make a reminder list for things you might need to do. Reading through this list daily helps keep us on track.

Triggers

External events or circumstances that, if they happen, may produce serious symptoms that make you feel like you are getting ill. These are normal reactions to events in our lives, but if we don't respond to them and deal with them in some way, they may actually cause a worsening in our symptoms.

On the next tab write "Triggers" and put in several sheets of binder paper.

On the first page, write down those things that, if they happened, might cause an increase in your symptoms. They may have triggered or increased symptoms in the past.

On the next page, write an action plan to use if triggers come up, using the Wellness Toolbox at the end of this handout as a guide.

Early Warning Signs

Early warning signs are internal and may be unrelated to reactions to stressful situations. In spite of our best efforts at reducing symptoms, we may begin to experience early warning signs, subtle signs of change that indicate we may need to take some further action.

On the next tab write "Early Warning Signs". On the first page of this section, make a list of early warning signs you have noticed.

On the next page, write an action plan to use if early warning signs come up, using the Wellness Toolbox at the end of this handout as a guide.

When Things are Breaking Down or Getting Worse

In spite of our best efforts, our psychiatric symptoms may progress to the point where they are very uncomfortable, serious and even dangerous, but we are still able to take some action on our own behalf. This is a very important time. It is necessary to take immediate action to prevent a crisis.

On the next tab write, "When Things are Breaking Down". Then make a list of the symptoms which, for you mean that things have worsened and are close to the crisis stage.

On the next page, write an action plan to use "When Things are Breaking Down" using the Wellness Toolbox at the end of this handout as a guide.

Crisis Planning

In spite of our best planning and assertive action, we may find ourselves in a crisis situation where others will need to take over responsibility for our care. We may feel like we are totally out of control.

Crisis Plan

Those symptoms that would indicate to others they need to take action in your behalf

Who you would want to take this action?

Medications you are currently taking, those that might help in a crisis, and

those that should be avoided

Treatments that you prefer and those that should be avoided

A workable plan for at-home care

Acceptable and unacceptable treatment facilities

Actions that others can take that would be helpful

Actions that should be avoided

Instructions on when the plan no longer needs to be used

Advanced Directive for Mental Health Treatment

202A.422 Advance Directive for Mental Health Treatment

An adult may execute an advance directive for mental health treatment that includes one (1) or more of the following:

(a) Refusal of specific psychotropic medications, but not an entire class of psychotropic medications. This refusal may be due to factors that include but are not limited to their lack of efficacy, known drug sensitivity, or previous experience of adverse reactions;

(b) Refusal of electric shock therapy (ECT);(c) Stated preferences for psychotropic medications;

(d) Stated preferences for procedures for emergency interventions; and

(e) Provision of information in any area specified by the grantor.

202A.422 Advance Directive for Mental Health Treatment

The execution of an advance directive shall be complete when signed by the grantor and:

(a) Signed by two (2) adult witnesses who attest that the grantor: 1. Is known to them;2. Signed the advance directive in their presence; and3. Did not appear to be under duress, fraud, or undue influence; or

• (b) Acknowledged before a notary public or other person authorized to administer oaths.

202A.422 Advance Directive for Mental Health

Treatment

The following persons shall not serve as a witness, a notary public, or other person authorized to administer oaths to the signing of an advance directive:

(a) The grantor's current health care provider or a relative of the current health care provider; and

(b) An owner, operator, employee, or relative of an owner or operator of a health facility in which the grantor is a client or resident.

(c) An advance directive shall not override the grantor's right under federal and state law to refuse treatment.

(d) The grantor or the surrogate of the grantor shall be responsible for providing a copy of the advance directive to the grantor's health care provider and health care facility where the grantor is a patient.

202A.422 Advance Directive for Mental Health Treatment

(6) An advance directive for mental health treatment shall be honored in any setting, except a hospital emergency room or a hospital emergency department, that is required to honor advance directives under Title XVIII or Title XIX of the Federal Social Security Act.

How do I Write Advance Directives?

House Bill 99 provides a form for people to use if they want to write advance directives for mental health treatment. While it isn’t necessary to use the form, it is a good idea because a valid advance directive must substantially comply with the form provided in the statute.

Either two adult witnesses must sign the advance directive or it must be notarized for it to be finished. Neither the witnesses nor the notary public can be the person’s current health care provider or a relative of the health care provider.

If you would like to get a copy of the entire law complete with the advance directive form, you can find it at http://www.lrc.state.ky.us/record/03rs/hb99.htm. You an also call P&A.

(b) Refusal of electric shock therapy (ECT);
(c) Stated preferences for psychotropic medications;

(a) Signed by two (2) adult witnesses who attest that the grantor: 1. Is known to them;
2. Signed the advance directive in their presence; and
3. Did not appear to be under duress, fraud, or undue influence; or