Learning Objectives

After reading this article, you should be able to:

1. Understand the recommended first-line treatment approach for adults with OCD.

2. Recognize the fundamental elements of ERP for OCD and distinguish them from alternative therapeutic approaches.

3. Identify the most suitable type of exposure therapy for clients with obsessive thoughts without rituals, considering factors that may limit the use of in vivo exposure.

CPTR: As a person who worked with a group of people who experienced mental health issues to develop the now evidence-based Wellness Recovery Action Plan (WRAP), how would you describe WRAP?

Dr. Copeland: WRAP is a wellness self-management program. Specially trained facilitators who are usually, but not necessarily, peers assist people with mental health challenges in learning how to personally manage their own lives through a series of interactive facilitated group sessions. People assess their own self-help and wellness resources and then make plans so that they can use these resources, Wellness Tools, to stay as well as possible, and to help themselves feel better during difficult times. In WRAP groups or on their own, people develop a list of their own Wellness Tools, and use those tools to recover and stay well. They do this by identifying the things that upset them and signs they are having difficulty and creating action plans they can use to stay well, and to get through hard times. WRAP includes an advance directive and a postcrisis plan. It encourages people to advocate for themselves and to take charge of their own wellness and recovery (Copeland MD. Overview of Wrap: wellness recovery action plan. Mental Health Recovery Newsletter 2002;3:1-9).

CPTR: How did you develop this program?

Dr. Copeland: In the 1980s, I began collecting information from people who had experienced all kinds of mental health issues and challenges to find out how they coped. We weren’t looking at recovery in particular; in fact, the word recovery wasn’t even used back then. We were told that if you had mental health issues and challenges, you could expect to have them for the rest of your life, and that you needed to take medication for the rest of your life. People were warned that their quality of life would be diminished forever. I learned skills and strategies from hundreds of people who volunteered to be part of my research process. I tried those techniques, and found that I was feeling better and better, that the mood swings that had plagued me for such a long time were becoming less frequent and less intense (Copeland ME. Wellness Recovery Action Plan: A System for Monitoring, Reducing and Eliminating Unwanted or Problematic Physical Symptoms and Medications. Dummerston, VT: Peach Press; 2002). I began leading trainings based on what I had learned. One of these trainings was in Vermont. Participants included people with mental health challenges, social workers, case managers, and family members. I shared with them, over eight days, the skills and strategies I had learned. At the end, one woman said, “You know, this is all really interesting, but I have no idea how to put any of the things you have talked about here into my life.” Other people in the group agreed: this would be far too difficult.

CPTR: Interesting. So what did you decide to do?

Dr. Copeland: We spent the next three days developing what came to be known as the Wellness Recovery Action Plan, WRAP. The group members collectively agreed that we needed to list all of the resources available to us and then we needed to figure out which of these resources—we ended up calling them Wellness Tools—we needed to  use to keep ourselves as well as possible.  It included a description of what we are like when we are well, so we can return to that when we are having a hard time, a Daily Plan. WRAP was developed and evolved into what it is today by a group of people who experienced severe mental health challenges. My role has been to network it and share it.  

CPTR: What evidence supports the value of WRAP?

Dr. Copeland: WRAP is supported by major studies, which is why we are listed in the national registry of evidence-based programs and practices. (Editor’s Note: Further information about studies used to create the evidence base can be found at at https://tinyurl.com/4w6wprmt).

CPTR: WRAP was instrumental in reducing hospitalizations in one study.

Dr. Copeland: Yes, a randomized, controlled study showed a reduction in hospitalizations in severely mentally ill adults who used WRAP (Cook JA et al, Schizophr Bull 2012;38(4):881-891). Participants reported that they used to have repeated hospitalizations, and that now months or years go by when they don’t have hospitalizations because they have learned that when things get hard for them, there are simple, safe, and noninvasive things they can do to feel better.

CPTR: What are some of these simple, safe, and noninvasive things?

Dr. Copeland: Well, for example, one person said, “When I am feeling bad, if somebody would just make me some macaroni and cheese, I would be fine.” Others have shared things like  relaxation exercises, working on a creative project, going outside, getting physical exercise, eating regular meals, avoiding sugar and alcohol, or talking to a specific friend or family member that might help them feel better and get through the discomfort. It has helped many people get through tough times that might have, in the past, led to hospitalization.

CPTR: There’s a part of WRAP that specifically focuses on helping people recognize and manage crises in their mental health. Please tell us about that.

Dr. Copeland: People have found that, with practice, even in the worst of times, there are things that they can do to help themselves feel better and to prevent a crisis and the possible need for intensive treatment. There is a section of WRAP called “When Things are Breaking Down”. People identify the signs that they are having a very difficult time, things like crying all the time, non-stop pacing for hours and hours, or thinking about abusing substances. Then they make a list of specific wellness tools that they will use then these signs come up to help them feel better and avoid a crisis, that time when the situation is so difficult that others would have to provide them with care. Thepost-crisis plan is a list of questions that help people plan the wellness tools they need to use that will help them be able to, once again, care for themselves (Cook JA, Psychiatr Rehabil J 201;34(2):113-120).

CPTR: WRAP is such a low-tech concept. It is surprising that people didn’t invent it sooner because it’s commonsensical, inexpensive, and highly effective.

Dr. Copeland: I agree. And I think it would be much easier, if the first time somebody goes to the psychiatrist, the social worker, or the case manager, the professional said, “What helps you to feel better? Why don’t we try some simple things that we know have helped you feel better before-when you had a little chocolate, when you went outside and sat on a swing, when you got some exercise, or you talked to a supporter. Let’s look for easy answers first.”

CPTR: So is that really all there is to it, from a professional standpoint? Can I improve a client’s health simply by asking, “What makes you feel better when you’re feeling bad?”

Dr. Copeland: Yes. People can be helped by simple things like drawing, playing a musical instrument, or listening to music. Sometimes it can be a challenge to find what resources help people who are homeless and people who have been in institutions for a long time. But we can. We can look deeply. For these people it might be making their bed, combing their hair, a particular bench they like to sit on or a specific care provider or supporter they like to talk with. We can ask: “Who do you like to sit with? What are the things that feed your soul, that can help you just feel a little bit better and get through this hard time, to get yourself back to feeling better?” Clinicians can walk clients through these first steps, and then refer them to a WRAP group or help them put more of the program into practice (Note: For WRAP resources and information on applying it to your practice, go to https://www.wellnessrecoveryactionplan.com.).

CPTR: What other tips or techniques from WRAP would it be easy for clinicians to apply in their practices?

Dr. Copeland: I think it is critical to validate a person, to acknowledge that prior to having a difficult time, something happened. Ask, “What happened?” And say, “I’m sorry about that. That is very hard; no wonder you are having a difficult time.” Often people feel shamed and blamed when first reaching out for help. The next question could be, “What things can you do that help you feel better?” And begin making a list of them, so they can begin the process of developing their list of personal Wellness Tools and helping themselves to feel better. Also ask, “What do you feel like when you feel well? If they say they can’t remember, ask them what they would like to feel like if they felt well?”

CPTR: Is there anything that you would like to add?

Dr. Copeland: I just want to reiterate that I think we have made dealing with mental health issues way too hard. We have made it so hard that it is inaccessible to many people, so lots of people lose their quality of life, and far too often their health is compromised by invasive treatments. WRAP is a very easy answer, and we have resources available to teach you how to work with it. Clinicians can use WRAP with people who have limited or no education at all and those who have developmental distinctions. We have introduced WRAP to people  all over the world,  people from many different cultures and people from all kinds of backgrounds. We are using it now with children. We have found that WRAP is a process that works and that it has broad applicability.

CPTR: Thank you for your time, Dr. Copeland.