Integrating Wellness, Recovery, and Self-management for Mental Health Consumers
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- Sterling, E.W., von Esenwein, S.A., Tucker, S. et al. Community Ment Health J (2010) 46: 130. doi:10.1007/s10597-009-9276-6
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Three distinct, yet interrelated, terms—wellness, recovery, and self-management—have received increasing attention in the research, consumer, and provider communities. This article traces the origins of these terms, seeking to understand how they apply, individually and in conjunction with one another to mental health consumers. Each shares a common perspective that is health-centered rather than disease-centered and that emphasizes the role of consumers as opposed to professional providers as the central determinants of health and well-being. Developing approaches combining elements of each construct may hold promise for improving the overall health and well-being of persons with serious mental disorders.
KeywordsSerious mental illnessChronic diseaseWellnessRecoverySelf-management
Historically, the United States’ healthcare system has been oriented toward treating disease rather than promoting health (Adler 2007; McGinnis et al. 2002). However, in recent years, there has been increased interest in approaches focusing on viewing illness, particularly by the healthcare system, as part of a broader continuum. For instance, the World Health Organization defines health as a “state of physical, mental, and social well-being and not merely the absence of disease or infirmary” (World Health Organization 2007a:1).
In addressing this broader goal, three distinct, yet related, concepts—wellness, recovery, and self-management–have gained widespread usage in both the general and mental health fields. These terms have different lineages. Wellness derives from the complementary and alternative medicine field; recovery from the substance abuse and mental health consumer movements; and self-management from the chronic illness and rehabilitation literature. Nonetheless, each shares a common perspective centering on health rather than disease. Likewise, wellness, recovery, and self-management suggest that health and disease are not mutually exclusive, and one can continue to maintain wellness in the midst of disease. All also emphasize the central role of consumers in managing their own health and health care. Still, each term is complex, multifaceted, and often defined differently by various constituencies and stakeholder groups.
In this article, we examine these three distinct terms—wellness, recovery, and self-management. We explore their origins, definitions, and how their meanings do and do not overlap. More specifically, we focus on how these concepts apply to mental health consumers and persons with serious mental illness (SMI)—a group for whom chronicity of illness, comorbidity, and a history of stigma make combining these different approaches particularly relevant. We conclude by providing several current examples of programs seeking to bring together elements of these three constructs to improve the health and well-being among mental health consumers.
In the United States, the general concept of wellness originated in the nineteenth century as a reaction to mainstream medicine. Proponents of complementary and alternative medicine began to highlight the relationships between fitness, the environment, and self-responsibility to overall health largely through religious and cultural movements (Engel 1977; Foss 1989). The actual term wellness is credited to a physician named Dr. Halbert L. Dunn who began to promote the notion of wellness in the 1950s. Initially, Dunn provided a series of lectures on wellness throughout the Washington, D.C. area. His ultimate emphasis included ideas about fitness, the environment, and self-responsibility. These talks later culminated in the 1961 publication of his book entitled High Level Wellness published by Beatty Press of Arlington, Virginia (Dunn 1961).
Over time, Dunn’s ideas were expanded, modified, and given new meanings within an array of health care perspectives. In fact, wellness has evolved into a term commonly referenced in a variety of settings, both within the medical community and outside (Theriot 2001). The term wellness has been applied not only to specific diseases, such as arthritis and diabetes, but also to everyday problems, including stress and lack of energy (Kickbusch and Payne 2003). Wellness is not simply the absence of disease, but instead a separate, orthogonal construct.
This has reflected a shift regarding the way people view health and how health and wellness are marketed to the public. While promoting good health is not a new concept, its popularity is (Davies 1979). As health promotion efforts have extended beyond the health care system, the private sector has embraced wellness as well. Wellness has entered into our popular culture and day-to-day living through numerous article headlines, magazine covers, packaging for nutritional products, pharmaceutical advertisements, health promotion efforts, and even marquees of clinics and health spas (Brown 1999). Although most agree that preventing diseases through healthy lifestyles and self-care is critical, the organizational view of wellness perpetuated by the corporate realm has come to include much more (McGillivray 2005). For instance, many of these products and services tout “alternatives” to the present health care system, some of which are scientifically unacceptable often furthering the skepticism surrounding the concept of wellness as a whole (Davies 1979). Consequently, the overuse of this term wellness creates much confusion among consumers and health care practitioners alike preventing them from actually being able to put wellness into practice (Green 1985).
While there are wide variations in how wellness is used and understood, consumers and practitioners should concentrate on the commonalities that do exist. Overall, wellness promotes good health and positive lifestyles (Schuster et al. 2004). Wellness seeks to provide an integrative approach bringing together aspects of prevention, education, and health promotion. This encourages a healthier population and a higher quality of life regardless of disease status. There is also consensus that wellness is multidimensional. Wellness includes a number of different lifestyle and mindset elements such as a strong sense of personal responsibility, physical fitness, good nutrition, a positive outlook, a strong interest in critical thinking, and openness to new discoveries (Ardell 1985). Additionally, wellness affects a number of distinct facets: mental, emotional, physical, social, intellectual, environmental, and spiritual wellness (Mackey 2000). Difficulties in any of these areas can make it challenging to maintain a high level of well-being (World Health Organization 2007b). At the most basic level, wellness focuses on the individual and his or her specific needs, recognizes that the locus of control for a healthy lifestyle lies within each individual, and provides strategies that assist an individual in gaining control over his or her life.
Traditionally, the medical community has encouraged the use of the scientific approach to diagnose and treat disease. Illness, whether mental or physical, has been the primary focus (Adler 2007). These common clinical features do not adequately convey the personal responsibilities and connections to disease and illness as seen with the broader issue of wellness (Jones 2006). With the rise of modifiable risk factors, such as smoking, poor diet, and lack of physical activity, which leads to a number of chronic diseases, the concept of wellness is becoming more prominent in discussions about health care. Wellness has become an integral term in health and is recognized as far more than just encouraging certain lifestyle changes. (Chodosh et al. 2005). Instead, wellness is described as the constant and deliberate effort to stay healthy and achieve the highest potential for total well-being (Hoeger 1989).
More recently, the term wellness has begun to migrate into the mental health community, further extending its usage to apply to both mental and physical wellness. For example, Mental Health America, one of the nation’s oldest mental health advocacy groups, recently began an initiative titled “Bringing Wellness Home.” This initiative focuses on establishing mental health as an integral part of everyone’s overall healthy lifestyle and well-being (Mental Health America 2007). Through better understanding and expanding this conceptualization of health and wellness by the mental health community, there exists the possibility of improving health status outcomes (Saylor 2004).
Given the growing evidence on the excess morbidity, mortality, and adverse health behaviors of mental health consumers, the interactions between the mental and physical dimensions of wellness have become of increasing interest for persons with SMI. The National Association of State Mental Health Program Directors concluded that persons with SMI are dying at faster rates compared to those in the general population (Parks et al. 2006). This is especially critical because the increased death rates among persons with SMI are often associated with modifiable risk factors, such as smoking, obesity, diabetes, high cholesterol, and hypertension. As a result, the specific physical health needs of mental health consumers should be addressed in order for well-being to be optimized.
While wellness grew out of a complementary and alternative medicine perspective, the concept of recovery has its roots in the addiction and mental health consumer movements. The founding of Alcoholics Anonymous (AA) in 1935 marks the beginning of modern addiction recovery. For the first time, recovery removed the blame for the disease or condition from the individual and empowered people to take control over their own lives and health. Eventually, recovery became a much broader movement seeking to shift the focus from symptom suppression to overall health and well-being (White et al. 2003).
More recently, the notion of recovery has clearly moved into the mental health consumer field (Davidson et al. 2005, 2006). Until this point, persons with SMI were generally thought to be incurable with very limited treatment options available that might help relieve the symptoms (Ralph and Corrigan 2005). In the 1980s, mental health consumers began to challenge the notion that mental health is a chronic condition without a cure and the best one can hope for is stability. Instead, Anthony (1993:13) explains, “[Recovery] is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.” Drawing from the principles utilized in addiction recovery, the mental health community recognized that there are multiple outcomes associated with mental health and one could certainly move beyond just stability (Harding et al. 1987; Magura et al. 2007; Sullivan 1997).
Beginning with the 1999 Surgeon General’s Report, this philosophy, which had primarily been a focus within the mental health consumer and advocacy communities, began to make its way into the mainstream of clinical care and mental health policy discussions. Together, two major federal agencies, Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institutes of Health (NIH) acknowledged that mental health is essential for achieving good overall health and well-being and set the stage for the federal government to view mental health recovery a major priority (U.S. Department of Health and Human Services 1999). The 2003 President’s New Freedom Commission Report further legitimized the concept of recovery as a central goal of mental health policy by offering a vision of hope and recovery for people with a SMI and their families (Goldstrom et al. 2006; Schauer et al. 2007).
Despite its common usage, the term recovery has been associated with several meanings as it is applied to persons with SMI. For instance, research such as the Vermont Longitudinal Study suggested that in contrast to previous concepts of psychotic disorders as chronic and deteriorating, a substantial portion could have a complete remission of symptoms over time (Harding et al. 1987). The term recovery as used in the addiction field and subsequently adopted by the mental health consumer movement, however, more closely reflects a person’s ability to live a full and fulfilling life in the face of a disabling illness (Davidson et al. 2006). It is this latter sense of the term that is used in this review, and that may be of particularly relevance to the understanding of wellness and self-management as described in this paper. Still, recovery, especially how it pertains to mental health, is not without its critics. Some mental health practitioners and researchers have raised concerns that the term “recovery” is overused and the case for recovery is overstated. Both of these observations contribute to mental health consumers setting unrealistic expectations as well as experiencing additional stigma if these expectations are not met (Rodgers et al. 2007).
In order to more specifically define recovery, SAMHSA, together with the Interagency Committee on Disability Research, and in partnership with six other Federal agencies derived a consensus statement proposing ten fundamental constructs of recovery. These domains were described as self-directed, individualized and person-centered care, empowering, holistic, non-linear, strength-based, peer supportive, respectful, responsible, and hopeful (Goldstrom et al. 2006; Schauer et al. 2007). While all of these dimensions are important to the entire recovery process, the holistic, patient-centered, and non-linear dimensions are most applicable to connecting recovery to wellness. The holistic principle embraces all aspects of life. Similarly, the patient-centered approach implies responsiveness to individual needs and values and involves them in the decision making process (Pelletier et al. 2005). Co-morbidity in conjunction with other mental, addictive, or medical conditions may partly underlie the nonlinear nature of recovery. Even if a consumer is stable with regard to their mental condition, they may experience difficulties or relapses with other conditions.
Depending on the unique situation of each individual, there are many pathways and varieties of the recovery experience that need to be considered when designing recovery programs for persons with SMI (Humphreys et al. 1995). The establishment of these recovery constructs allows for a more balanced perspective regarding recovery and for developing systems for care that promote recovery among persons with SMI (Rodgers et al. 2007). Overall, recovery-focused work attempts to change the service provision for persons with SMI from an antiquated system focused on force, coercion, institutionalization, and maintenance to an innovative and life-enhancing system on recovery and life transformation (Copeland 2005).
Self-management first originated in the medical rehabilitation and chronic disease literature. One of the first uses of the terms self-management appeared in 1976 in a book written by Thomas Creer on the rehabilitation of chronically ill children. Based on the works of Albert Bandura, Creer and colleagues felt that the term self-management encouraged patients to become active participants in their treatment. Self-management programs are based on the concept of “self-efficacy” or one’s confidence in his or her ability to deal with health problems (Lorig and Holman 2003). Instead of viewing the chronically ill as having a disease that waxes and wanes simply due to physiologic changes within their bodies, self-management emphasizes the natural shifting of perspectives patients have about their illnesses regardless of their physical health. This allows patients to effectively manage their health and well-being in a variety of situations as their lives, diagnoses, treatments, and specific needs change over time (Lorig and Holman 2003). In the past decade, self-management strategies have become more common in the mental health field. It is not only recognized that persons with SMI do recover, but there are also specific things they can to do help themselves feel better, they can learn these things and use them in their own lives, and they often benefit from positive contact with others who have similar life issues (Ralph and Corrigan 2005).
Although critics argue that self-management blames the patient for poor health outcomes (and for some patients poor health outcomes are inevitable), this can be minimized by devising interventions and programs that provide patients with tools and skills needed to address underlying social structural factors which may inhibit their health, as well as their ability to be successful with their self-care behavior (Gordon et al. 2006). Self-management programs emphasize patients’ central role in managing chronic illnesses. By recognizing that the vast majority of a patient’s time is spent outside the physician’s office, self-management offers concrete tools in assisting patients on their own path to well-being. Self-management programs include interventions, trainings, and skills by which patients with a chronic condition, disability, or disease can effectively learn how to take care of themselves and effectively deal with difficult situations. The most critical outcome of any self-management program is to increase the participants’ confidence levels so that they can more effectively cope with their chronic conditions in a variety of situations (Holman and Lorig 2004).
Holman and Lorig (2004:242) explain “…[S]elf-efficacy is the confidence that one can achieve a particular goal.” Self-efficacy is typically reinforced through peer-led self-management programs that use the power and influence of peer networks to model physical and social functioning and build self-efficacy (Velente et al. 2007). Despite the limited amount of evidence-based research supporting peer support programs, peer support is still viewed by both consumers and caregivers as a useful intervention for persons with SMI, as well as an important opportunity to improve social networks (Castelein et al. 2008; NAMI 2008). In order to provide more clarity and guidance to states interested in peer support services under the Medicaid program, the Centers for Medicare and Medicaid Services (CMS) Director Dennis G. Smith mentioned in a letter to all CMS Regional Administrators (personal communication, August 15, 2007) that “Peer support services are defined as an evidence-based mental health model of care consisting of a qualified peer support providers who originally assisted individuals with their recovery from mental illness and substance abuse disorders.” As a result, more people are recognizing the experiences of peer support providers, as consumers of mental health services, can be an important component in self-management and the delivery of effective treatment. By establishing national guidelines for creating peer support services, the CMS also recently endorsed the emerging workforce certified peer specialists who provide services that promote wellness, recovery, and self-management (personal communication, August 15, 2007).
Another key to successful self-management programs is that they provide specific tools that can help facilitate both wellness and recovery (Lorig et al. 1994). Patients are empowered to take control of their illnesses through a combination of education about their symptoms and training in individual disease management skills (Lorig 2001). Overall, this process targets several core self-management skills: problem solving, decision making, resource utilization, forming of a patient/health care provider partnership, and taking action (Lorig and Holman 2003). By integrating these concepts into existing health care delivery systems, patients are able to communicate effectively, collect information, analyze options, and make decisions. Self-management does not take the place of traditional medical care, but it allows people to become active participant in their own health care, primarily through (1) Engaging in activities that protect and promote health and reduce risk; (2) Monitoring and managing symptoms and signs of illness; (3) Managing the impacts of illness on functioning, emotions, and interpersonal relationships; (4) Making informed decisions; (5) Adhering to appropriate treatment regimes, including following care plans and managing medications; and 6) Working with health care providers to attain the best possible care and to effectively negotiate the often complex health system (Alfred Workforce Development Team 2005). Self-management programs not only prepare participants to cope with their chronic conditions on their own, but they also encourage them to actively participate as partners with medical professionals and other health care providers (Holman and Lorig 2004).
For persons with SMI, self-management has become a pillar of the consumer and peer movements. Self-management programs provide new skills allowing people to take control over their health condition, maintain their life roles, and manage negative emotions, such as fear and depression which often accompany chronic disease (Lorig et al. 1994). Moreover, self-management, particularly in the context of peer support, allows mental health consumers to become active participants in the recovery process leading them to an overall sense of wellness.
Integrating Wellness, Recovery, and Self-management for People with Serious Mental Illness
It is clear that wellness, recovery, and self-management are all widely used terms within both physical and mental health. By encouraging everyone to live life at their fullest despite any disease, illness, or other health concerns, these concepts have made consumer empowerment a priority. Persons with SMI not only struggle with mental disorders, but also commonly have high rates of co-morbidity and premature death (Parks et al. 2006). Integrating the approaches of wellness, recovery, and self-management in programs targeting persons with SMI provides a unique opportunity to assist these patients in optimizing their health and well-being. In the remainder of this paper, we describe several examples of programs from both real world practice and research that aim to combine elements of wellness, recovery, and self-management for the benefit of mental health consumers.
The WRAP Program—Including Self-management as a Central Element of Recovery
The Wellness Recovery Action Plan (WRAP) program, developed by Mary Ellen Copeland in 1989, is one of the most widely used recovery programs for mental health consumers. WRAP is consumer-directed and centers on identifying internal and external resources for facilitating recovery. Similar to chronic disease self-management programs, participants use these tools to create individualized plans for successful living (Copeland 1997). Using presentations, demonstrations, interactive discussions, and related activities, WRAP facilitators teach participants that to successfully recover from mental illness one must be determined to get better, manage illness, take action, face problems, and make choices. WRAP facilitator’s assist participants in creating a personal “Wellness Toolbox” consisting of simple and easily accessible strategies, including healthy diet, exercise, sleep, and meeting life and vocational goals. The plan also includes the identification of “early warning signs” and how to effectively manage a crisis situation.
Several studies have shown that WRAP participants experienced significant increases in self-reported knowledge of early warning signs of psychosis, tools and skills for coping with prodromal symptoms, preference for using natural supports, support groups, and other people with mental illness for support, use of wellness tools in their daily routines, and hope for recovery. Also found were significant increases in consumers’ self-rated ability to create crisis plans, and to create plans that: expressed their needs and wishes, listed their supporters and people to contact in an emergency, and explained their early warning signs. Similarly, consumers indicated being more comfortable asking questions and obtaining information about community services, and engaging in self-advocacy (Buffington 2003; Harding et al. 1987). Unlike many traditional mental health interventions, WRAP is intended to help people manage a variety of long-term illnesses, whether or not they choose to receive formal services. WRAP shifts the focus of mental health care from symptom control to prevention and recovery. Overall, WRAP further illustrates how both physical wellness and mental wellness are integral components of recovery, and recovery approaches are necessary to achieve wellness.
Mutual Support Programs—Emphasizing the Value of Peers in Recovery and Self-management
Over the past several years, a number of mental health programs have experienced much success by expanding traditional recovery and self-management models to include the benefits of peer support among persons with SMI. In the mid 1990s, Building Recovery of Individual Dreams and Goals through Education and Support (BRIDGES) began to involve peers in teaching courses on recovery as well as facilitating ongoing support groups for mental health consumers (Tennessee Department of Mental Health and Developmental Disabilities 1995). Similarly, the National Alliance on Mental Illness (NAMI) Peer-to-Peer program written by Kathryn Cohan McNulty utilizes peers to assist persons with SMI in establishing and maintaining their recovery through a unique, experimental consumer education and learning program (National Alliance on Mental Illness 2005). The Vet-to-Vet Peer Support Program co-authored by Moe Armstrong and Naomi Armstrong of Vinfen Corporation and the Massachusetts Peer Education Project stresses that meetings should encourage, validate and support recovery in an ongoing fashion. In order to help individuals gain the skills needed to lead more peaceful and productive lives, the Abraham Low Self-Help Systems (the result of a merger between Recovery International and the Abraham Low Institute) also provides a safe place to talk about life’s struggles with others who have experienced similar struggles in their lives.
A weakness of traditional types of recovery-focused models is that they may focus too much on the needs of those consumers who are further along on their road to recovery. In turn, the success of this program depends largely on the degree of disability experienced by the program participants (Frese et al. 2001). The Vet-to-Vet program’s peer support programs challenges this by further explaining these meetings are not “self-help” meetings, but rather mutual support meetings since all people—both leaders and participants–who attend peer support meetings have something to teach and share as well as something to learn (Armstrong 2005). The goal of these types of peer-to-peer programs is to empower mental health consumers to take a more active role in their treatment and recovery. By utilizing peers to deliver these messages, mental health consumers are able to better understand that having a diagnosis of mental illness is not the end of life. Since the peer leaders themselves have experienced a mental health diagnosis, program participants are able to witness firsthand that mental health consumers are capable of empowering themselves and living life to the fullest. Through both sharing and learning within a community of mental health consumers, shame and stigma can be overcome and strength and hope can be shared leading to a stronger sense of well-being.
A Statewide Peer Wellness Initiative—Adding Wellness to Peer Support
The Georgia Statewide Peer Wellness Initiative (SPWI) recently received a SAMHSA grant to further improve the physical and mental well-being for mental health consumers in Georgia. Due to many limitations and gaps in resources, individuals with SMI have reduced ability to address mind, body, and spiritual wellness. In fact, even current peer support programs insufficiently address the importance of good health and wellness habits. As a result, SPWI aims to help communities develop and build effective consumer-run wellness programs.
One of the main criticisms towards this type of peer approach to wellness is the lack of research necessary to really know what peer mentoring relationships are like, how they develop, and what their outcomes are. Critics say that without extensive training and supervision, the guidance given by peer leaders is left to uncertainly (Nelson et al. 2006; Newbould 2006). The SPWI addresses these concerns by using a structured approach and focusing on the development of (1) Training curricula to train more than 300 mental health peer specialists throughout the state in creating individualized wellness programs; (2) Individualized wellness programs within existing peer support programs; (3) Peer support programs which coordinate services to meet individuals wellness needs; (4) Wellness self-management workbooks for individuals with SMI; and (5) State-wide guidelines for ongoing support of wellness programs for individuals with SMI.
In general, mental health consumers are taught to utilize available treatments and services in a more effective manner, thus reducing hospitalizations and crisis services. By adding these types of specific skill trainings to existing peer-led initiatives, this program will assist consumers in building the self-efficacy and confidence needed to become active participants in their healthcare.
The HARP Project—Adapting a Self-management Program for Persons with SMI
In contrast to the WRAP, peer-to-peer programs, and the SPWI, the Health and Recovery Peer (HARP) Project is formally evaluating the adaptation of an established chronic disease self-management program, the Chronic Disease Self-Management Program (CDSMP), to the specific needs of persons with SMI. The CDSMP is a peer-led self-management program designed to address the needs of persons with a wide range of chronic medical conditions such as diabetes, arthritis, chronic pain, and HIV (Lorig et al. 1994). A series of six group lectures addresses a set of self-management tasks that have been found to be common across chronic conditions; these include becoming a better self-manager, increasing healthy behaviors, and effective use of the health system. The elements of the intervention, grounded in self-efficacy theory, include regular action planning and feedback, modeling of behaviors and problem-solving by participants, reinterpretation of symptoms, and training in specific disease management techniques.
Despite the potential benefits of enhanced self-management programs, critics suggest several possible problems with the presentation and implementation of initiatives like the HARP program. Such problems include the possibility that the effectiveness of peer-led self-management programs can be overstated. Additionally, the varied experiences of those living with mental and chronic illnesses make it difficult to completely know what patients should think and do (Newbould 2006). By working closely with Dr. Kate Lorig, the original developer of the CDSMP, as well as mental health consumers, the HARP Project seeks to adapt the CDSMP to the particular challenges faced by persons with serious mental health conditions, including socioeconomic disadvantage, the need to simultaneously manage mental and medical symptoms, and fragmentation between the mental and medical systems. This approach emphasizes the role of physical health and a healthy lifestyle in mental health recovery. It incorporates many of the core principles of recovery, such as being holistic, patient-centered, and fostering hope. Finally, it teaches specific skills led by peers that promote creative problem-solving and the ability to adapt to changing situations. In order to better assess these issues and how they specifically relate to persons with SMI, a randomized pilot trial of the HARP Project is currently underway in the Atlanta, Georgia metropolitan area.
Because each term has its own unique origins and history, it has been difficult for the mental health community to translate the concepts of wellness, recovery, and self-management into service delivery for persons with SMI. Despite their differences, each concept shares a common focus: the central role of consumers as the primary determinants of their own health and health care. By ignoring these concepts all together or developing initiatives that only incorporate on one of these concepts, the ability to meet the varied and complex mental and physical health needs of persons with SMI is diminished. Because the mind and body are inseparable, wellness must encompass both physical and mental health to ensure overall health and well-being. While recovery allows people the opportunity to grow beyond their diagnoses, self-management offers specific tools to help individuals on their own paths toward recovery. For persons with SMI, there may be particular promise in developing programs that incorporate, and seek to integrate, aspects of each of these different three concepts. Compared to any one strategy alone, these types of integrated programs—drawing on the strengths of wellness, recovery, and self-management—provide a much more powerful vehicle for helping patients develop skills and techniques to enhance self-care of both their mental and physical health.
Unfortunately, few funding opportunities exist to support these types of integrative programs. Wellness, recovery, peer support, and self-management programs are competing with each other for the little money that government and other funding sources are willing to invest. While each individual method has shown both benefits and limitations, research dollars have not been adequately allocated for examining the overall effectiveness of programs seeking to strengthen existing models by combining methods and initiatives. If wellness, recovery, peer support, and self-management programs can further clarify and standardize their models, draw more from each other as resources, and build upon their established strengths, they can become a powerful force in the future design of services for mental health consumers.