Photo credit--Sergei Melnikov
My 2009 monograph outlined in considerable detail the history, theory and status of peer recovery support services (PRSS) in the United States. In the years since the monograph's publication, voluntary and paid recovery support services have dramatically increased in the US and internationally. Such growth has recently prompted me to reflect on the pre-professional days of addiction counseling in the United States (1965-1975) when people in recovery constituted the core workforce within newly arising addiction treatment programs. The current expansion of PRSS raised the following question: What experiential lessons from this earlier era could inform the present implementation of PRSS? Here are my top 20 answers.
Rich History
1. PRSS flow from a long tradition of "wounded healers"--a tradition based on the discovery that people who have survived a life-altering disorder or experience may acquire through that process special sensitivities, insights and skills that can benefit others in similar circumstances. Experiential knowledge can pose significant threats to prevailing professional/scientific ways of knowing, but much can be gained from an integration of these diverse pathways of understanding.
PRSS and Stages of Recovery
2. PRSS can be effectively delivered across the stages of long-term recovery: 1) precovery, 2) recovery initiation and stabilization, 3) recovery maintenance, 4) enhanced quality of personal/family life in long-term recovery, and 5) efforts to break intergenerational cycles of addiction and related problems. The dominant acute care model of addiction treatment, with its near-singular focus in stage 2, has been marked by a progressive erosion of recovery representation within the treatment workforce. The current resurgence in PRSS marks a resurgence of interest in the other stages of addiction recovery.
3. One of the most potent ingredients of PRSS is continuity of contact and support over time. PRSS are one of numerous vehicles through which acute care models of addiction treatment are being reshaped into models of sustained recovery management.
4. PRSS can serve as an adjunct or alternative to professionally-directed addiction treatment. The adjunctive role is particular valuable for those with the most severe and complex problems; the alternative role is well-suited for those with lower problem severity and greater recovery capital.
Vulnerability for Exploitation
5. The service commitment of recovering people can be exploited within rising or expanding systems of care in ways that undermine both role performance and the personal health/recovery of these workers. The modern system of addiction treatment was built on the backs of people in recovery, many of whom were then discarded through the professionalization and commercialization of addiction treatment.
Role-Person Match
6. Duration of continuous recovery, by itself, is an inadequate criterion for judging who can effectively deliver PRSS.
7. Knowledge and experience with one particular recovery pathway (e.g. 12-Step recovery) does not by itself constitute a credential to facilitate recovery initiation across other pathways of recovery (e.g., secular or religious pathways).
8. Working in the PRSS arena does not constitute an effective program of personal recovery; history is strewn with the bodies of those who believed it was. PRSS are based on the primacy and stability of personal recovery and wellness.
9. The recurrence of alcohol and other drug use and related problems among PRSS specialists is uncommon but does occur and is best responded to in a manner similar to any other health-related issue that affects employee performance, e.g., supervisory support, linkage to assistance, and progressive discipline.
10. Role clarity is essential for the effective implementation of PRSS. Such clarity includes defining boundaries between PRSS roles, professional roles and helping roles within recovery mutual aid organizations.
11. Those working in voluntary and paid roles delivering PRSS can find themselves, because of this role, estranged from the professional community and the recovery community. Support for transition into and sustained performance within this role is essential.
12. Essential elements of support for PRSS include careful selection to avoid role-person mismatch, recognition of legitimacy of PRSS roles within interdisciplinary teams, adequate compensation and benefits for paid PRSS roles, structured orientation and training, regular supervision of critical incidents arising within the service delivery process, and coaching related to career ladder options.
PRSS within Multidisciplinary Teams
13. Early tensions between PRSS roles and other service roles are normal and are usually replaced over time with mutual respect and effective collaboration. That said, there are some persons credentialed by experience who do not work well with professionals credentialed by education and training--and vice versa!
Professionalization of PRSS
14. The professionalization of PRSS can inadvertently diminish critical dimensions of peer recovery support, e.g., loss of recovery carrier role via prohibitions/limits on self-disclosure, reductions in mutual identification and its subsequent effects on engagement and retention, and loss of assertive linkage to communities of recovery.
15. Excessive professionalization and commercialization of PRSS roles can undermine the service ethic within indigenous communities of recovery resulting in long-term harm to the community in which such excesses occur.
Ethics of PRSS
16. The ethical mandate for PRSS roles, like that of all helping roles, is to practice within, and only within, the boundaries of one's education, training and experience.
17. The ethics and etiquette of PRSS need to be informed by core recovery community values and filtered through the cultural context in which such services are being delivered. Rule-based ethical mandates drawn from other professional disciplines cannot be arbitrarily imposed on PRSS roles without compromising their effectiveness. This is particularly true for those PRSS roles involved in assertive outreach and engagement or long-term recovery monitoring and support.
18. The potential for the emotional, sexual and financial exploitation can never be completely eliminated within any helping relationship, but these risks can be minimized within PRSS through effectives systems of screening and selection, orientation and training and rigorous ongoing supervision.
Effectiveness of PRSS
19. Counselors in recovery are not more or less effective than counselors without lived recovery experience; recovery status of the counselor is not in itself a predictor of therapeutic engagement or long-term recovery outcomes within a counseling relationship. That principle has not yet been tested in the delivery of non-clinical recovery support services: persons in recovery may bring special assets to the recovery support process, e.g., experiential knowledge of addiction and recovery, knowledge of local cultures of recovery, etc., but those assets have not yet been catalogued or evaluated in terms of their effects on short- and long-term recovery outcomes.
PRSS and Mobilization of Community Recovery Supports
20. There is a tendency to cast the PRSS role in the mold of a junior counselor or "treatment buddy." While peers can provided substantial support to the intrapersonal processes of addiction recovery, their unique strengths (what they bring that other service roles do not) are their ability to nest personal recovery within a natural culture of recovery and to expand community recovery capital through their efforts to organize and mobilize indigenous recovery supports within the community.