Social problem solving, cognitive defusion and social identification in wellness recovery action planning

Abstract

Objective: The concept of recovery has become an integral part of modern mental health care. Understanding the outcomes and underlying mechanisms of key recovery interventions, such as Wellness Recovery Action Planning (WRAP), is essential in order to expand the theoretical understanding of recovery and inform how to target recovery in treatment. Therefore a systematic review of the literature was conducted to evaluate the mental health outcomes of WRAP for adults. The empirical study then explored three constructs in relation to WRAP and recovery. These were social problem solving, cognitive defusion and social identification. Method: The systematic review of the mental health outcomes of WRAP was conducted by searching four databases, contacting the authors of WRAP research and seeking evaluative information from organisations that deliver WRAP. Fourteen relevant studies met the inclusion criteria. Whereas, the empirical study recruited participants on a trans-diagnostic basis from across Scotland. Using a quantitative cross sectional design, 109 participant’s completed 5 self-report questionnaires. These were the Knowledge, Attitudes and Beliefs about WRAP Questionnaire (WRAP beliefs), the Recovery Assessment Scale – Short (RAS-S), the Social Problem Solving Inventory - Revised - Short (SPSI-R-S), the Four Item Measure of Social Identification (FISI) and the Cognitive Fusion Questionnaire (CFQ). Correlation, regression and mediation analysis were used to explore relationships, and in particular, the predictors and mediators of recovery. Results: The systematic review provided strong evidence that WRAP has a significant positive impact on hope and also reduces the symptoms of mental illness. However, whether WRAP improves personal levels of recovery was unclear and a possible risk of disempowerment was found. Promising preliminary mental health outcomes in the areas of confidence in managing mental health, quality of life, service use, self-advocacy and knowledge attitudes and beliefs about recovery were highlighted. Only studies that did not use peer facilitators failed to find significant increases in hope compared to treatment as usual control groups. In the empirical study, the results indicated that all the constructs examined were correlated to recovery. In the regression analysis, WRAP beliefs, social problem solving and cognitive defusion also demonstrated a predictive relationship with recovery. Mediation analysis indicated that, social problem solving mediated two distinct relationships. One between WRAP beliefs and recovery, and another between cognitive defusion and recovery. The social problem solving subscales also showed how the two predictors relate to recovery through social problem solving in different ways. Social identification with the WRAP group did not significantly predict or mediate recovery. Conclusions: The systematic review indicated having peer facilitators delivering WRAP is key to helping participants foster hope and that a further randomised control trial could help clarify if improved personal recovery is an outcome of WRAP. It additionally suggested how the relationship between WRAP beliefs and recovery could be explored, as per the design of the empirical study. Findings from the empirical study implied that improving participants’ social problem solving and cognitive defusion should be specifically targeted in WRAP delivery. The studies combined indicate that to achieve the best recovery results interventions, like WRAP, should target inspiring hope through peer support, improving knowledge, attitudes and beliefs about recovery and cognitive defusion from unhelpful thoughts.