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Psychiatric Advanced Directives, Peer Support, and WRAP®

Psychiatric Advanced Directives, Peer Support, and the Wellness Recovery Action Plan (WRAP®) have been part of our national public mental health system for over a decade and are growing in application and interest. Although each are distinct resources for individual recovery, they can be combined and coordinated in new and innovative ways that may result in substantial benefits.

A psychiatric or mental health advance directive (PAD) is a legal tool that allows a person to state their preferences for treatment in advance of a crisis. They can serve as a way to protect a person's autonomy and ability to self-direct care. They are similar to living wills and other medical advance planning documents used in palliative care (Substance Abuse and Mental Health Services Administration: A Practical Guide to Psychiatric Advance Directives. Rockville, MD: Center for Mental Health Services. Substance Abuse and Mental Health Services Administration, 2019.)

A PAD is a way to improve access to care, quality of care, and provide a voice for self-directed care. It is a legal document that the person develops indicating what works best and what does not work in their interests. Systems implementation of PAD is also a mechanism for coordination of care, feedback, and holistic advocacy. PAD laws vary state-by-state. The National Resource Center On Psychiatric Advanced Directives provides a directory of current state laws.

Peer Specialists are trained in a core set of competencies to be a peer worker. Peer support workers are people who have been successful in the recovery process and help others experiencing similar situations. Through shared understanding, respect, and mutual empowerment, peer support workers help people become and stay engaged in the recovery process and reduce the likelihood of relapse. One key core competency of a Peer Specialist is Person-Centered, meaning support received by the person is always directed by the person receiving services. This can be difficult to support when a person is in crisis. Peer Specialists can support the creation and implementation of a PAD with the person so that even during a crisis the response is still person-centered. Experts estimate that up to one-quarter of the mental health workforce will be staffed by peer specialists by 2030 (Manderscheid, 2019).

"One key core competency of a Peer Specialist is Person-Centered, meaning support received by the person is always directed by the person receiving services." There is also a dramatic expansion of the peer workforce in U.S. hospitals and medical systems (Center on Health Equity Action for System Transformation, 2019).

The Wellness Recovery Action Plan is an evidence-based practice where trained peers follow a curriculum-based peer-group model. Those groups support the development of individualized strategies to better recognize triggers, signs, and action plans using wellness tools and self-directed support systems. WRAP® includes a crisis plan and post crisis plan that can inform what one might want in their legal Advanced Directive but WRAP® is not an Advanced Directive. WRAP® can support people to avoid the type of crisis where-by a PAD becomes activated by a medical determination of incapacitation or incompetency to make decisions. Over 10,000 WRAP® Co-Facilitators have been trained, spanning every state and US territory.

Peer Specialists trained in the facilitation of WRAP® and PAD can provide a continuity of support and resources to better connect with and assist people to self-manage their recovery, reduce crisis, and increase safety and overall quality of care. Combining PAD, Peers, and WRAP® in a systemic way is an opportunity for real recovery innovation in our system of care!



Manderscheid, R. (2019) The National Association of County Behavioral Health and Developmental Disability Directors.


Center on Health Equity Action for System Transformation. (2019). "Advancing Health Equity through Community Health Workers and Peer Providers: Mounting Evidence and Policy Recommendations." Families USA, November 2019 edition.

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