NASMHPD/NTAC e-Report on Recovery

WRAP, Peer Support and Recovery: Tools for System Change

By Shery Mead, MSW, and Mary Ellen Copeland, MS, MA

Ms. Mead consults nationally on the development of peer run initiatives and resides in New Hampshire. Ms. Copeland is a mental health educator and is the author of Wellness Recovery Action Plan and other mental health resources.

Not too many years ago, I was Mary Ellen Copeland, manic depressive. Because I had this label my family was told not to expect much of me. I learned not to expect much of myself. I became dependent on the mental health system to maintain, at best, a minimal life style. I avoided thinking about the future; the present was bad enough. I saw myself through a mental health system lens that was confining and oppressive. Now I see myself through a different lens, a lens that is Mary Ellen Copeland, educator, author, mother, wife, woman.

- Mary Ellen Copeland

Even in these days, when recovery, peer support and Wellness Recovery Action Planning (WRAP) are buzz words throughout the mental health system, it is not uncommon in many mental health environments, including peer support, to hear people describe themselves as their label and to see themselves through a “mental illness” lens.

In the past, this label and this lens has meant life-long professional care while expecting periodic episodes of difficult times. Now, in the era of recovery we have come to expect that people with a label can learn coping skills and can learn to manage their “symptoms,” if they are medication compliant. They may even be employed and play some role in the larger community. But when will they become people instead of their label? And when will it be commonly accepted that people who, from time to time, have troubling feelings, thoughts, behaviors, and experiences (this might include everyone), can also have control over their own lives, do the things they want to do, and be the way they want to be?

Recovery in mental health is an exciting concept. Even more exciting is the concept of life change and transformation—not returning to a former way of being, but going forward to create a new, exciting, and rewarding life. The service delivery system can inhibit the process if it continues to see people through the “mental patient lens.” But it can support and enhance this process if it is willing to see people through this new lens.

The “mental patient lens” is the one many of us (who have labels of mental illness) have learned to look through every time we are uncomfortable, have intense feelings or experiences, or difficult relationships. It is a lens that reminds us that our feelings and thoughts are different than other peoples' and that we must take care. We must avoid stress, risk-taking, and challenges, assume others know better than we do, and that there is a medication for everything. Recovery without understanding this lens still only means “symptom” management and becoming more “functional” rather than true recovery and transformation.

“Sarah,” a member of a peer program, has been in the system for many years. She lives on Supplemental Security Income (SSI) income and her housing is contingent on her disability. Sarah is hearing her friends and even the clinical staff talking about recovery… What does that mean? She starts talking to others who say they’ve gotten jobs and gotten their high school equivalency or gone on to college. Her case manager has changed her title to recovery counselor and says that instead of doing a treatment plan they will do a recovery plan. Sarah is going to the peer center more often. But she is beginning to feel uncomfortable. If she “recovers,” where will she live? What if her benefits are taken away? Can she really support herself? One day there is some conflict at the center and she starts feeling a bit overwhelmed. Sarah decides she should call her case manager.

Sarah tells her case manager that her symptoms are really bad. Her case manager asks her if she’s taken her medication and asks if she’s safe. Sarah responds by saying that she’s taken her medication but it doesn’t seem to be working and she is not feeling safe… We know the end of the story.

How could a different response have changed the outcome? What if the case manager said, “Help me understand what it means for you when you say my symptoms are really bad,” or, “What’s going on at the peer center,” and, “Maybe that’s a pretty normal reaction to conflict…” Or even, “So what will you do to feel more comfortable?” Responses such as these could lead to potentially very different conversations and ultimately to much less dire outcomes.

Some of the current thinking in peer support and Wellness Recovery Action Planning has much to teach us about “unlearning the mental patient role.” These forums and environments can openly address roles, relationships, assumptions and worldview. New approaches are teaching people to challenge each other when they become aware of stuck roles and relational dynamics. Instead of responding from an assumption of “I’m fragile or sick,” more and more people are helping each other think differently about their experiences.

Now let’s look at another path for Sarah:

Sarah decides to join a group of peers who are working together developing Wellness Recovery Action Plans. She takes a close look at all the resources and strengths she has—her love of hiking, her interest in photography, her ability to write compelling short stories and to keep things well organized. She uses things like this, including other ideas from members of the group, to build her own Wellness toolbox.

She works with them to develop a list of things she can do every day to stay as well as possible. She thinks about things that are upsetting to her and develops a plan of simple safe things she can do to help herself feel better (things from her Wellness Toolbox) when upsetting things happen. She works with others as they all develop lists of signs that they are not feeling so well—signs they formerly ignored. Then, she uses her Wellness Toolbox to develop a list of things she could do to help herself feel better when she is not feeling so well. Next the group discusses those times when you are feeling really bad—very anxious and upset, hearing voices, wanting to abuse substances, thinking about self harm. Sarah says that in the past, when she felt this bad, she would call the crisis line and get herself admitted to the hospital. But others encouraged her to look at her Wellness Toolbox and see if there were some things there she could do instead. She decided that if she spent some time talking to a peer, wrote in her journal about how she was feeling, spent some time diverting her attention with a project, or took her dog for a long walk, she could probably get through this hard time.

The group even worked through the process of developing Advanced Directives that included lists of when people want others to assist them, who they would want to do it, what they want them to do, and what others can do to help. She developed, with the support of her peers, a plan so she could stay at home or in the community, even when she was feeling very bad.

As Sarah began using this—her own recovery plan as a guide to living each day—she realized that along with her plan and the support of her peers she could make choices about her life. She could take risks. She could begin to plan for living in her own apartment, going back to school, getting a job that she would enjoy and perhaps even getting into an intimate relationship. She could see herself through a new lens—the lens of a capable and competent woman.

She also realized in working with others that being “uncomfortable” and having difficult feelings is something she could deal with. She didn’t have to call them symptoms of anything. She could be with these feelings for a time and/or use her strengths and resources to get through it.

As you can see in this example, Sara is changing her lens from mental patient to person. You may also notice another contributing factor to this “unlearning” process—the intentional use of non-medical language. Talking, for example, about our “experiences” and “feelings,” instead of our “symptoms,” as we do when we are developing a WRAP, opens us up to a different conversation in which our lived experience can be explored through multiple lenses.

Implications for Mental Health Services

The recovery movement has challenged the way we think about mental illness and even the concept of mental illness. It has helped many people begin to have hopes and dreams—something they had been discouraged from having in the past.

At its core, recovery challenges the stories that we’ve been told about our experiences and what they mean. It opens up the possibility of discussion about how we can work together in ways that really share power, risk, and expertise. It must be a process in which everyone moves out of old, comfortable roles and begins to talk about mutuality, boundaries, risk, and who gets to define and decide on treatment. For this to happen, everyone involved must challenge his or herself to respond in new ways.

In addition, we need to have inclusive up-front conversations about power and how we perceive power. Although it is nice to say the words “partnership” and “collaboration,” they are empty unless there is some talk about each of our pre-conceived notions and the reality of choice. By speaking directly about who has the power to do what, and what that means in a collaborative relationship, we can establish guidelines and strategies for handling difficult situations and working through potential conflict without coercion.

Finally, if we are to research and evaluate recovery, it is important to understand the cultural shift in mental health. We need to see beyond measuring “how people are doing” and to see beyond getting a job or fewer hospitalizations as meaningful outcomes. Qualitative research that examines people’s stories will help us look at the extent to which relationships, dynamics, and assumptions are changing, and help us to see how they need to change to support recovery and life transformation. We must all hold ourselves truly accountable to meaningful system change, leaving behind the “mental illness lens.” Rather, we must see people as whole human beings who can cope with adversity and determine the course of their own existence.

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