The Art and the Science of WRAP

Judith A. Cook, Ph.D.,    Professor of Psychiatry,    University of Illinois at Chicago, Director, Center on Mental Health Services Research & Policy

I’ve been conducting research on mutual support and self-help groups in mental health before it was accepted as a good idea or even as something you could study. But our research not only put WRAP on the map as an evidence-based practice, it showed that you can conduct a randomized controlled trial (RCT) of a peer-to-peer intervention that strengthens it rather than diminishes it.

Offering the Highest and Best WRAP

I first heard Mary Ellen Copeland talk about WRAP at several conferences, and she never failed to inspire. I approached her about studying WRAP and made clear that in order to rigorously test the outcomes of WRAP for people with serious mental health problems, we had to be certain we offered the intervention in the exact same way—every time, everywhere, to every participant. RCT studies produce the highest level of evidence, but also require the highest level of annoying, persnickety detail. This meant we had to develop an intervention version of WRAP—not one that was different in any substantive way from the original, but one that could be repeated by anyone who taught it. Mary Ellen took a bit of time to think this over.

Eventually, we established a mutual level of trust with one another. The research team trusted that Mary Ellen would be able to build on WRAP best practices to create a measure of fidelity. She trusted that we would honor the original intent of WRAP and provide the best and most supportive experience for participants.  We followed the model of participatory action research described by William Foote Whyte by involving participants in all stages of the study, from design to publication.

Our first RCT of WRAP was conducted in five waves across five cities in Ohio over three years. This was a massive undertaking. Individuals who were similar on all key demographic characteristics were randomized into two groups, one that received the intervention and one put on a “waiting list,” able to receive WRAP when the study was over. We could do this because WRAP was not widely available in Ohio at the time, and most individuals were willing to wait to receive WRAP training.

Facilitators, all of whom were in recovery from serious mental health problems, were trained on how to deliver WRAP down to the minute—what to say and when to say it, what handouts to use, what examples to offer. In essence, this was WRAP as it was developed and intended to be taught. To eliminate differences that might result from facilitators telling their own stories, they shared Mary Ellen’s experiences and how WRAP made a difference in her life.

Our study coordinators, Carol Bailey Floyd and Walter Hudson, recruited and trained facilitators, enrolled participants, coordinated data collection, and organized meetings. Throughout our research, we consulted with Mary Ellen about suggested changes we thought might ensure fidelity across study sites. Sometimes she agreed, and sometimes she explained why a change would harm the integrity of WRAP. Always, we were aware that WRAP was not ours—it belongs to the people who created it.

Data Reveal WRAP’s Power

The results speak for themselves. Our data revealed that individuals who received WRAP during the study experienced increased hope and self-perceived quality of life. They felt empowered to move forward with their recovery. Even though WRAP isn’t about symptom reduction, study participants reported a decrease in their psychiatric symptoms. These findings held even though some 10 percent to 15 percent of participants enrolled in the experimental condition never showed up for even one WRAP class.

Some have criticized our research for what they perceive as coercion. To ensure that our data would be valid, we encouraged study participants to complete the sessions by sending reminders and offering to help with transportation. But far from being harmful, facilitators found these strategies so useful, they decided to continue them after the study was over. They did so, they told me, because when people complete WRAP, something “magical” happens.

Studying the Future of WRAP

I next studied WRAP in Illinois, where we found that, compared to study participants who were enrolled in a nutrition class, those who received WRAP used fewer individual and group mental health services. This is powerful testament to the impact WRAP has on facilitating recovery.

WRAP is now considered an evidence-based practice, but I’m not done studying it. Mary Ellen and I have talked about creating and testing a version of WRAP that pays as much attention to overall health as it does to emotional wellness. To further my research in vocational rehabilitation and supported employment, I dream of helping develop and test WRAP for work—to help people with mental health problems get and keep a job.

I’m honored to have been able to help prove with concrete data what millions worldwide know deep in their hearts—that WRAP promotes healing, supports recovery, and empowers people to be their best selves. Mary Ellen will always be the life force behind WRAP, and I wish her well in the next chapter of her remarkable life.

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