Reviewing Illness Self-Management Programs: A Selection Guide for Consumers, Practitioners, and Administrators

Recovery is the paramount goal of mental health services (1), focusing on building hope and engaging personal agency to promote healing, change, and growth (2,3). Illness self-management (ISM) programs endeavor to help consumers pursue recovery by nurturing nascent hope and fostering self-regulated learning to develop effective recovery strategies. Given the unique and personal nature of recovery, providers and consumers have an enormous task of assessing which interventions will best meet overall needs and preferences. Selection of ISM programs should broadly maximize the fit between consumer interests, provider endorsement and skills, agency culture, and resources available for adoption, implementation, and maintenance. This article guides the selection of ISM programs for consumers, providers, and administrators by reviewing their structure, value orientation toward recovery, methods of teaching, educational content, and empirical evidence.

ISM Programs

ISM programs provide a framework for consumers to enhance capabilities for self-management, focusing on controlling the disorder, maximizing overall health and wellness, and ameliorating the psychosocial sequelae of illness (4). Traditionally, health professionals have conceived of ISM training as unidirectional, didactic education (5); however, skepticism has grown about clinician-centered approaches that tacitly demand adherence to plans created by health care professionals (6). Although providers have specialized education and knowledge, consumers are experts on the lived experience of pursuing health with a given disorder. Consumers, therefore, often prefer a “decentralized” approach to self-management, wherein the power and authority traditionally and wholly ascribed to providers diffuses and is shared by consumers. Thus, rather than learning to adopt prescriptive strategies from providers, consumers may learn effective self-management strategies best from personal trial and error in the context of daily life (5). Such an approach promotes self-regulated learning (7) and fosters self-agency in the process of discovering personally effective recovery strategies (4–6).

The purpose of ISM programs extends beyond learning a constellation of strategies; these programs offer a framework for personal exploration to (re)discover or (re)construct a stable sense of self as an “active and responsible agent” (8). Davidson and Strauss (8) suggest four such topics that underlie consumer priorities when they pursue recovery: discovering the possibility of an active sense of self; identifying strengths, weaknesses, and possibilities for change; initiating action and integrating the results of those behaviors into one’s construction of actual capabilities; and using the resources of one’s sense of self to provide refuge from illness and pernicious elements of one’s social environment. ISM programs that provide structure for such personal exploration most closely align with consumer preferences and may maximize engagement and resulting benefits of the intervention.

Five of the most popular ISM programs have been selected for this review: Pathways to Recovery (PTR), The Recovery Workbook (TRW), Building Recovery of Individual Dreams and Goals through Education and Support (BRIDGES), Wellness and Recovery Action Planning (WRAP), and Illness Management and Recovery (IMR). Derivations of these programs, such as the IMR adaptation known as Wellness Self-Management (9), were not included to enable a more focused, concise guide to ISM programs. Readers who identify other programs can use our framework to evaluate them against the five presented here.

PTR

PTR is a self-help workbook focusing on strengths (10). Although the workbook is primarily intended for individual use, support groups have used the content of the program to supplement individual work. PTR promotes in-depth assessment of multiple dimensions of a holistic framework for recovery, from housing, career development, and financial asset management to sexuality, intimacy, and spirituality. Each topic includes a framework for assessment of strengths, resources, goal identification, and obstacle analysis. PTR focuses on reducing stress and encouraging enactment of strategies to pursue goals in a variety of life domains. PTR suggests that by pursuing goals, reducing stress, and experiencing success, the impact of illness diminishes while recovery naturally emerges and grows. Accordingly, the program purposefully omits content on symptom management, referring participants to WRAP to learn strategies to manage symptoms serious enough to overtake one’s recovery journey.

TRW

TRW is a self-help workbook, ideally initiated with a chosen support person and sometimes offered in a group format for which a facilitator manual is available (11). TRW claims recovery is a process of critical self-reflection that begets a new self-identity as a person capable of actualizing goals. Identity naturally transforms while the person learns to cope and attends to recovery-supporting activities, and the person becomes aware of strengths, limitations, and new priorities from which meaningful goals can be identified. The program provides structured activities for self-reflection directed at feelings, reactions, and goals in the process of emerging identity development while encouraging unstructured reflection in the form of journaling. TRW focuses on strengths and simultaneously explores the impact of and strategies for improving four areas affecting identity and recovery: impairment, dysfunction, disability, and disadvantage. TRW relies minimally on providing guidance and concrete strategies for self-management and instead emphasizes self-directed exploration and reflection—reinforcing consumer competence and expertise. TRW does not purposefully exclude or consistently embrace medical and diagnostic language, choosing instead to acknowledge a spectrum of preferences.

BRIDGES

BRIDGES is typically offered in a peer-led weekly meeting format over eight to ten weeks (12,13). The goals for each meeting are to increase knowledge about mental illness and recovery strategies while fostering an environment where participants can educate and learn from one another. Worksheets are provided for participants to apply learning by reflecting on personal needs and goals while making recovery plans. BRIDGES emphasizes the emotional and psychosocial impacts of experiencing mental illness and encourages participants to identify as active agents, responsible for actualizing personal recovery goals. The program is largely didactic and psychoeducational, with activities to build skills in problem solving and interpersonal effectiveness. Participants share personal recovery stories, identify barriers to recovery, and engage in collaborative problem solving as a group to simultaneously enhance skills and develop strategies to resolve participants’ real-time barriers to recovery. Companion support groups are intended to concurrently augment the structured programming (tmhca-tn.org). Of the five programs reviewed here, BRIDGES has the most extensive curriculum focused on the physiology of mental illness and the mechanisms of medications.

WRAP

WRAP is commonly delivered in eight weekly group meetings and sometimes through one-on-one interactions, with self-help guides available for individual use. When offered in group settings, WRAP is cofacilitated by trained peers, who identify either as mental health consumers or as WRAP practitioners without regard to mental health status. WRAP encourages participant introspection to identify simple, accessible activities that have been personally effective in the past at supporting wellness (14). Participants are guided through a holistic recovery framework to develop a comprehensive, goal-oriented action plan to promote, maintain, and reestablish wellness with several components: a proactive daily maintenance plan describing wellness tools and activities for everyday use, contingency plans identifying actions to ameliorate triggers and stressful antecedents to decreasing wellness, a crisis plan, a postcrisis plan, and an advance directive to guide care in the event of crisis. Participants can choose to focus with depth on any or all of the components and are referred to additional resources throughout the curriculum. WRAP focuses almost exclusively on strengths and wellness while purposefully excluding diagnostic language and pathology. Facilitators and self-help guides reinforce self-determination and personal agency as the foundation of recovery.

IMR

IMR is a highly intensive program generally offered in weekly individual or group meetings lasting between three and ten months (15). The curriculum focuses on didactic instruction about mental illness as well as management and recovery strategies, and it incorporates structured activities for skills building. Individual recovery goals are identified early in the program and broken down into manageable steps, and progress toward goal attainment is monitored throughout the program. Facilitators are encouraged to use motivational interviewing strategies to elicit consumers’ ideas and motivation for change, often regarding reasons to learn particular information and skills conducive to meeting personal recovery goals. IMR balances collaboration and empowerment with didactic education and skills building, underscoring feedback from the program facilitator, who is typically a professional practitioner. IMR is highly structured, with educational handouts and worksheets to guide homework assignments as participants learn and implement self-management strategies. Skills enhancement activities include problem solving, decision making, social skills, and effective communication.

Comparative Assessment of Programs

Selecting the best-fit program depends on several factors that may be overlooked by traditional reviews but that have important implications for the lived experience of consumers, practitioners, and administrators who utilize the programs in real-world contexts. We systematically reviewed the curriculum and the published literature for each program and identified four major contextual domains that supplement empirical evidence for a more comprehensive evaluation: structure, value orientation toward recovery, methods of teaching, and educational content. Together, these domains provide a framework by which consumers and providers can make informed decisions about program selection. Because ISM programs may be complementary, some consumers choose to access more than one over time; therefore, the best-fit program may actually refer to a combination of programs.

Structure

The structure of programs can be compared in two ways: the selected health domains around which content is built and the manner in which curriculum is disseminated, with accompanying costs of resources for implementation. All five programs provide structured, reflexive content in major health domains to guide construction of holistic recovery plans; the only notable difference is that PTR offers dedicated content on sexuality and culture (Table 1). The primary difference in the structure of the programs revolves around their format and delivery of content.

PTR and TRW are primarily workbooks with optional group components. PTR support groups have grown up organically in various locations; TRW offers a facilitator guide with a recommended 30-session format to structure peer support and cooperative learning.

BRIDGES is offered in a group format and typically cofacilitated by peers who identify as having mental health challenges. Programming varies from a condensed two-day format to a weekly meeting format over eight weeks. To become a facilitator, a person must attend formal training, at which time a practitioner guide is provided, and subsequently take part in periodic refresher trainings.

WRAP is commonly accessed through group programming, although sometimes through one-on-one facilitation. Individuals can access WRAP without formal facilitation through WRAP workbooks, and apps are available for supplemental online support. WRAP group programming is always cofacilitated and typically offered in a weekly meeting format over eight to 12 weeks. To become a facilitator, a person must first develop a personal WRAP plan and subsequently be trained and certified and engage in refresher courses every two years to ensure fidelity to the program model and core values (16).

IMR was initially designed to be facilitated by a practitioner and has since incorporated peer facilitation. IMR can be offered in individual or group formats, usually over three to ten months of twice-weekly to biweekly meetings. All IMR material is free and available on the Web site of the Substance Abuse and Mental Health Services Administration (SAMHSA), with guides for participants and facilitators that are further categorized by group and individual format (15). Although no standardized training or certification is required by the program, facilitation requires proficiency in program content and skills related to motivational interviewing, problem solving, decision making, and setting and monitoring of goals.

Value Orientation Toward Recovery

Values reflect beliefs about the nature of mental illness and health, conceptualizations of recovery, relative emphasis on holistic wellness versus targeted attention to symptom remediation, and the overall approach guiding the most effective route toward recovery. The manuals of programs describe some values overtly, while other values can be inferred as a result of content that is included or omitted, language used, and strategies embedded within program manuals and workbooks (Table 2).

All five programs promote wellness and recovery, but only IMR, BRIDGES, and TRW offer significant content on managing symptoms and controlling one’s disorder—suggesting underlying values of openly addressing illness and prioritizing symptom management. WRAP and PTR eschew language of pathology and illness and focus almost exclusively on strengths as a means to promote wellness and recovery. The other programs include strengths, problems and deficits, and medical and diagnostic language, and they offer explicit content on symptom management. BRIDGES and IMR place overt value on reducing hospitalization and a higher priority on traditional, didactic psychoeducation overall—especially regarding mental illness, medications, and symptom reduction strategies. IMR particularly values regular and systematic assessments of growth in knowledge, skills, and goal attainment, both from provider and consumer perspectives.

Methods of Teaching

One major difference among programs is the strategies they employ to teach curricular information and overall self-management frameworks (Table 3). WRAP and BRIDGES are traditionally peer led and embrace modeling by facilitators and mutual sharing by participants to foster learning from peers. BRIDGES and IMR use role-play and skills-building exercises during group meetings to enhance proficiency in solving problems, engaging others in reciprocal problem-solving processes, implementing plans, communicating effectively, and (for IMR) developing and refining social skills. Given that PTR and TRW are traditionally self-help guides, participants are encouraged to read material, create structured time for self-reflection, and engage in activities independently and with social support. PTR attempts to create peer support in the text by including quotes and anecdotes, some by others pursuing recovery.

Educational Content

Educational content refers to types of knowledge people need about health and decrements in wellness to effectively use strategies to pursue recovery. Two types of knowledge relevant to self-regulated learning in ISM programs are addressed in Table 4 and discussed separately below: propositional knowledge (knowing that) and procedural knowledge (knowing how). Propositional knowledge refers to facts and information that one can know either a priori (without having to first observe something) or a posteriori (through empirical observation and testing after an observation has been made) (7). ISM programs present content in propositional knowledge and encourage self-reflection by participants to discover what is personally relevant. Procedural knowledge refers to knowing how to engage in a behavior or applying information to complete a task (7). It is fostered by providing process-oriented techniques to support implementation of recovery strategies and by encouraging participants to practice and apply strategies both during group programming and individually through trial and error in the context of daily life. Emphasizing application of knowledge and implementation of strategies promotes self-regulated learning as participants discover available strategies and evaluate which are personally effective in promoting recovery.

Content in propositional knowledge.

All five programs offer information about conceptualizing recovery and identifying elements of a holistic approach to pursuing recovery. IMR and BRIDGES also prioritize biological contributions to mental illness and associated etiology, physiology, and psychopharmacology. Varying emphasis is placed on formal, external services and benefits—IMR, BRIDGES, and TRW particularly attend to basic-needs benefits as well as to mental health and general social services.

Content in procedural knowledge.

All programs encourage the three subprocesses of self-regulated learning: self-observations, self-assessment, and self-reactions (7). Guided activities help participants observe and identify their strengths and needs (self-observation), assess the success of coping and wellness strategies employed in the past (self-assessment), and decide whether to retain or develop new strategies (self-reaction). Such self-regulated learning is encouraged in the context of creating plans to proactively maintain and enhance wellness; however, each program uniquely fosters skills to implement recovery strategies.

PTR regularly prompts readers to (re)explore personal needs, abilities, and available resources (internal and external) to guide the selection of priorities, set an appropriate pace, mobilize one’s resources, and select strategies to pursue recovery. Consumers are subsequently encouraged to reflect on how successfully they implemented goal-directed strategies, making adjustments as needed. Thus consumers are guided through the cyclical process of self-regulated learning, focusing on how to implement recovery strategies.

TRW includes unstructured exploration with workbook pages designated for nondirective, open journaling to balance and personalize the otherwise structured program. Such reflection reinforces self-regulated learning, relying heavily on self-reaction about how strategies are working.

Comparatively, WRAP has the predominant focus on developing proactive and contingency plans to promote, maintain, and reestablish wellness. WRAP uses the process of creating plans to engage all aspects of self-regulated learning. Consumers are encouraged to continue self-reaction and amend or create new plans as needed.

IMR and BRIDGES guide consumers through the process of self-regulated learning by developing recovery goals and strategies grounded in past successes; however, they also incorporate structured curriculum to learn and practice a formal problem-solving model to resolve barriers to recovery and facilitate implementation of recovery strategies prospectively. Thus IMR and BRIDGES emphasize formal process-oriented learning of implementation strategies and include structured practice during meetings to reinforce learning.

Empirical Evidence

Empirical support for each program is summarized in Table 5. Studies were identified using PsycINFO, Google Scholar, and Wiley Online Library for Cochrane Reviews, with search terms “pathways to recovery,” “recovery workbook,” “BRIDGES,” “building recovery of individual dreams and goals through education and support,” “WRAP,” “wellness recovery action plan*,” “IMR,” and “illness management and recovery.” Systematic reviews were not included because only one has been completed (17), and each qualifying study was included in this review. Articles were excluded if the focus was exclusively on implementation, fidelity, or consumer satisfaction or if the study employed a qualitative approach only. Although qualitative investigations are vital to understanding consumers’ lived experiences with these programs, the intent was to determine effectiveness. Readers should note that studies often employed a battery of tests, and although outcomes of some measures showed null results, only positive findings are reported here.

In the Assessing the Evidence Base series published in Psychiatric Services in 2014, Dougherty and colleagues (18) summarized criteria for judging the strength of evidence and the effectiveness of interventions. The strength of evidence is measured in three categories—high, moderate, and low—and refers to the overall quality and rigor of research designs of published studies, whereas effectiveness refers to the degree to which a treatment achieves its intended outcomes (18).

To achieve a high level of evidence, interventions must meet a threshold of rigorous research such that further investigations are unlikely to diminish confidence in key findings. Typically, this requires three well-designed randomized controlled trials (RCTs) or two RCTs supported by two quasi-experimental trials—all with satisfactory designs. A moderate level of evidence describes interventions with adequate research to judge efficacy, acknowledging that future investigation could alter conclusions about effectiveness. To obtain this ranking, an intervention may have two RCTs with some methodological weaknesses, two or three quasi-experimental trials, or a combination of one RCT and one or more quasi-experimental trials, depending on the quality of design and general rigor. Finally, a low level of evidence refers to interventions for which some, but insufficient, evidence exists to draw conclusions about efficacy. This level refers to interventions for which the evidence base is primarily from studies with nonexperimental designs, for which there are too few quasi-experimental trials or RCTs, or from studies with significant methodological weaknesses. Using these criteria, we rated the effectiveness of each of the five ISM programs in accordance with the strength of evidence available.

With only one study each (19,20), PTR and TRW have low empirical evidence. Effectiveness is difficult to determine because of a lack of corroborating evidence; however, both studies measured and demonstrated improvement in widely used domains of recovery-oriented research.

There have been two research studies of BRIDGES, and the evidence comes close to, but does not quite achieve, a moderate level. The findings from one large-scale RCT with a robust research design (21–23) and one pre-post study (24) support claims of moderate treatment effectiveness. Researchers measured a broad range of recovery goals that improved after individuals participated in the BRIDGES intervention, including perceived recovery and empowerment.

WRAP’s efficacy (25–34) is supported by numerous nonexperimental studies (25,26,31,33), one quasi-experimental study (32), and two RCTs (27–30). Both RCTs recruited relatively large samples (519 and 143 participants) with good retention rates, utilized blind assessors to administer standardized instruments of recovery outcomes, and delivered the intervention comparably to similar populations. Although the use of blind assessors reduces the potential for bias, the creator of WRAP was a coauthor in articles reporting results of both RCTs, an indicator of decreased evidential strength (18). Furthermore, the RCT that included an active control group of nutrition education revealed improvements in both conditions but no statistically significant differences between groups in symptom severity and perceived recovery (30). The remaining RCT demonstrated relatively modest changes in outcomes (28,29). The overall strength of evidence for WRAP, therefore, is moderate, with equally moderate claims about its effectiveness regarding perceived recovery and symptom severity.

The most widely researched of the five programs is IMR (35–50). Like WRAP, several studies included researchers who were also involved in the development of the program. Randomization was utilized in seven studies with varying degrees of rigor (36,39,41,42,45,48,50). One trial randomly selected two of four ACT teams to add IMR (minimal randomization), with less than 26% of participants receiving any IMR and less than 4% completing the program (48). Two RCTs investigated only abbreviated versions of IMR, each offering fewer than half of the total modules (42,45).

The remaining four RCTs utilized IMR in its entirety, and all used IMR scales developed to assess the construct of psychiatric self-management with 15 Likert items measuring progress in IMR modules and rated by both consumers and providers who facilitated programming. Authors from one study in Israel reported a dropout rate of 28%, with no details on attendance rates of remaining participants (39). Measurement was limited to IMR scales only. Although providers’ total ratings on IMR scales showed significant improvement over the control condition, only two consumer-rated items improved significantly: knowledge about mental illness and progress toward personal goals. Providers’ ratings, however, may be biased toward improvement given their dual role as program facilitators and evaluators of progress. The trial in Sweden showed significant improvement in IMR scales for provider and consumer total scores (36). Improvements were found in suicidal ideation and psychiatric symptoms assessed by clinicians blinded to condition, and findings related to coping strategies were mixed: three of eight subscales improved for the IMR group and one for the control condition. Perceived recovery and quality of life did not change significantly.

Of the two remaining RCTs, one showed improvement in the IMR condition, compared with a waitlist control group, in psychiatric self-management (measured by IMR scales), psychosocial functioning, and one of two instruments measuring symptoms (41). The other remaining RCT found improvement in both conditions but no significant difference between IMR and an active control group that used nonstructured problem-solving group support; however, participation in both conditions was limited, with more than half of the sample attending less than 50% of meetings (50).

The major quasi-experimental study occurred in Israel (38). Only IMR scales were used, and two of the 15 items were excluded, along with the associated module covering drug and alcohol use. Only participants who attended at least the first three IMR sessions were included in the final analysis. The two other studies that utilized quasi-experimental designs lacked rigor in identifying comparison groups, contributing to methodological weaknesses that diminished confidence in internal validity (37,40). The retrospective study limited outcomes to hospitalization rates and emergency department visits, with no reports on recovery-related outcomes (49).

One final RCT of a program variant, “Integrated IMR,” assessed the efficacy of integrating IMR content with generalized medical illness self-management strategies for adults with serious mental illness and co-occurring general medical conditions (35). Total scores for provider- and consumer-rated IMR scales improved for the experimental condition over the usual-care control group, and diabetes self-management improved. No significant results were found related to self-management of the other general medical disorders studied or standardized measures of symptoms and community functioning. Perceived recovery was not assessed.

IMR studies typically contend with issues related to participation, sometimes discussed as penetration, attrition, attendance, and completion rates. A low penetration rate refers to minimal exposure to the intervention (48), and attrition and noncompletion rates, sometimes exceeding 50% (47), refer to persons who discontinue participation in the study and in the intervention, respectively. Studies with relatively high penetration and retention rates may not have consistently high attendance. Bartels and colleagues (35) reported that 75% attended at least one-third of the sessions with the IMR clinician, with a mean attendance of just over half. Efficacy may be unrelated to attendance rates beyond a certain threshold; however, in a qualitative investigation, participants who discontinued the program noted that program content and the other participants were below their level of education and knowledge about mental illness (41), underscoring the range of abilities and needs for potential consumers.

Ultimately, conclusions about IMR’s effectiveness are difficult to make given the variability of research designs, modifications to the program, variation in outcome measures used, and varying degree of attrition and participation. Despite the methodological concerns limiting comparability of research studies, the overall strength of evidence appears to be moderate, as does IMR’s effectiveness at increasing knowledge about illness and improving self-management strategies as indicated by IMR scales.

Discussion

Philosophically and theoretically, ISM programs embody the spirit of the recovery movement and have potential to reduce reliance on the service delivery system. Taken collectively, the body of empirical literature illustrates the efficacy of ISM programs. Although SAMHSA recognizes IMR and WRAP as evidence-based practices, empirical evidence alone does not provide overwhelming support for any one program over the others. All five programs have some evidence supporting their effectiveness at enhancing recovery, and all would benefit from additional research.

The current state of research provides strong evidence that recovery is a unique and personal process, and ISM programs provide a framework by which participants can engage in self-regulated learning to develop effective, personalized recovery strategies. Selecting the intervention or interventions with the best fit can be guided by consumer and practitioner needs and priorities, agency culture, and personal preference.

For providers and consumers seeking inexpensive programs with relatively less structure and more self-guided reflection, PTR and TRW might best support personal introspection about identity transformation and the development of recovery strategies. Whereas groups for PTR develop organically and maintain flexible structures, TRW offers a manual to guide implementation in a group setting, adding structure to the otherwise flexible program.

WRAP maintains the decentralized values of PTR and TRW while increasing program structure. WRAP may be the best-fit program for providers and consumers interested in developing comprehensive action plans to address various decrements of wellness. WRAP helps consumers build a toolbox for maintaining, enhancing, and managing threats to wellness and recovery. Because it is the most widely used ISM program, WRAP may support continuity of care for consumers seeking services at multiple agencies. Agency administrators should note the required capital investment for providers to engage in regular training and certification. Providers make significant personal investment: they must use WRAP to qualify for facilitator training and to maintain a vibrant sense of practicing WRAP.

IMR requires less initial capital outlay, because all materials are free; however, it requires significant organizational investment of staff time devoted to training and implementation of the intensive three- to ten-month program. IMR offers a relatively more structured intervention, prioritizing skills-building activities and didactic education in addition to personal exploration of recovery strategies. IMR might be the best-fit program for consumers interested in a comprehensive, structured program offering regular interaction with and feedback from facilitators; however, consumers need to commit to a relatively longer time frame to fully complete the program.

BRIDGES similarly prioritizes didactic psychoeducation and structure but is shorter than IMR and requires less time commitment from participants and providers. Like WRAP, it requires some capital commitment from agencies to ensure proper training and certification for implementation. BRIDGES may be the best program for consumers interested in structured education that concurrently reinforces decentralized power, with opportunities for personal and interpersonal skills building and with process-oriented problem-solving skills for managing recovery strategies within dynamic personal contexts.

Conclusions

Exercising personal agency and (re)building a healthy, stable identity are vital components of recovery; programs that support personal exploration and self-regulated learning reinforce positive identity development. The natural range and variation of consumer needs and goals underscore the necessity for multiple self-management frameworks and programs. Endorsing the universal adoption of any single protocol of self-management strategies is contraindicated for the provision of recovery-oriented services, which seek to meet individualized needs within complex social environments. The five programs described in this article reflect current popular trends in ISM interventions, and nuances of each should be matched to consumer needs and preferences when selecting the best-fit program or programs. Similarly, consideration must be given to agency culture, priorities, and resources to ensure compatibility with extant services and staffing as well as long-term sustainability of programming.

Empirical evidence is only one of many criteria on which to base decisions about program selection, and it may not address the most salient concerns of consumers, practitioners, or administrators. This article provides a systematic framework to evaluate other domains, important in real-world contexts laden with competing priorities and preferences. Given the equivocal nature of empirical evidence, program selection may ultimately be determined by relatively few components of other domains, including requisite personnel and expertise, program length, breadth and depth of content, language, or alignment with a medical or recovery orientation. Future research and systematic reviews should consider the relevance and necessity of including contextual domains to offer a more comprehensive evaluation of meaningful evidence.