1. Integrating Peer and Community-based Addiction Recovery Support Services with Professional Systems of Care: Principles and Implementation Issues ONDCP ROSC Learning Community June 18, 2013 William White, MA Emeritus Senior Research Consultant Chestnut Health Systems

2. Presentation Goals
Discuss the why, when, where and how of professional-peer collaborations within RM/ROSC system transformation efforts
Discuss issues commonly arising within the design and evaluation of professional-peer collaboration efforts
A note on notes:

3. Historical Supports for Addiction Recovery
Natural Support
Limited Generalist Support within the Community
Peer Recovery Support TX

4. Vacuum in Community beyond Peer Support and Specialty Tx
Mutual Aid
Vacuum
Specialty Treatment

5. Historical Tension Between Mutual Aid and Professional TX
History of Maltreatment
Anti-professionalism
Disregard
Condescension
Control

6. Vacuum in Community beyond Peer Support and Specialty Tx
Sanctuary
Stigma
Contempt
Exclusion
Maltreatment

7. Filling the Vacuum beyond Peer Support and Specialty Tx
Expansion, Diversification & Expanding Identity
New Recovery Institutions & Culture of Recovery
Recovery as new paradigm; RM & ROSC; Mainstreaming of Tx & Recovery Support

8. Brief History of Professional-Peer Collaboration
19th century controversies over “reformed men as asylum managers”
Early-mid 20th century “lay therapy” movement
1950s-1970s: paraprofessional alcoholism and ex-addict counselors
1980s-1990s: professionalization of addiction counselor & reduced recovery representation

9. Brief History of Professional-Peer Collaboration
Early 2000s: increased recovery orientation of allied roles, e.g., outreach, case management.
2000s: Re-emergence of peer recovery support roles in context of RM & ROSC
: Increased peer support funding, credentialing and role specialization

10. Collaboration Context: State of Addiction Treatment
Calls for treatment system redesign
Fiscal austerity
Service integration initiatives
Health care reform
Evolution in private practice

11. Collaboration Context: Culture of Recovery
Diversification of Peer-based Recovery Support Societies
New Recovery Advocacy Movement
Spread of Grassroots Recovery Community Organizations & Recovery Support Centers
New recovery support institutions
Recovery culture development

12. New Recovery Support Institutions
RCOs
Recovery Community Centers
Recovery Homes
Recovery Schools
Industries
Recovery
Recovery Ministries
Recovery Cafes

13. Ecumenical Culture of Recovery Beyond Recovery Fellowships
Heroes
History
Values
Symbols
Rituals
Music
Media
Art

14. P-BRSS/Professional Settings
Recovery Community Organizations / Recovery community Centers
Addiction Treatment Programs, including MMT
Harm Reduction Programs
Indigenous Community Organizations, e.g., churches, schools, youth centers
Managed Behavioral Healthcare Organizations
Criminal Justice System
Child Welfare System
Community Hospitals

15. Collaboration Goals Personal Recovery Sustainable abstinence/remission
Improvements in global health
Citizenship (community reintegration)
Family Recovery
Healing across family subsystems
Breaking intergenerational cycles

16. Collaboration Goals Community Recovery Reduced SUDs & related problems
Increased recovery prevalence
Increased community recovery capital
--Recovery resource mapping
Specialty Treatment System Recovery
Infrastructure enhancements
From AC to RM/ROSC toward goals of
-Enhanced attraction
-Improved access, engagement and retention
-Expanded service menu & service dose
-Enhanced post-treatment / long-term recovery rates
-Increased involvement in recovery community resource development

17. Principles of Peer-based Support
Community Connectedness
Wounded Healers
Experiential Knowledge

18. Principles of Peer-based Support
Recovery is Contagious
Role of Recovery Carriers
Helper Principle

19. Historical Elements of Peer Support Relationships
Natural
Reciprocal
Accessible
Potentially enduring
Non-commercialized
Non-regulated

20. Foundational Principles of Professional-Peer Collaboration
Peer/professional complementary rather than opposing paradigms
Search for potent combinations and sequences
Balanced respect for different ways of knowing: science, clinical experience and lived experience
Philosophy of choice

21. Organizational Framework for Collaboration
Defining Structure for Collaboration
-Policy bodies, e.g., major boards
-Recovery advisory committees
-Consumer councils
-Need to define locus for planning and problem solving
Defining Processes for Collaboration (planning, implementation and evaluation)
-Policy Documents (Why & What of Collaboration)
-Blueprints & Practice Guidelines (How of Collaboration)
-Recovery Report Card (at system and program levels)
Managing conflicting agendas between state, providers, RCOs

22. Recovery Representation within Collaborative Models
“Nothing about us without us” (Inclusion as first thought versus afterthought)
Representation of multiple recovery pathways
Authenticity of representation
Avoiding problem of “double agentry”
“Giving back” versus “cashing in”

23. Recovery Representation within Collaborative Models
“Nothing about us without us” (Inclusion as first thought versus afterthought)
Representation of multiple recovery pathways
Authenticity of representation
Avoiding problem of “double agentry”
“Giving back” versus “cashing in”

24. Collaboration Across Stages of Recovery1
Pre-recovery engagement 2
Recovery Initiation and Stabilization 3
Recovery Maintenance 4
Enhanced Quality of Personal/Family Life in Long-term Recovery; Breaking Intergenerational Cycles

25. Collaboration and Personal/Family Recovery
Stages of recovery distress & role of peers/professionals
Brown & Lewis findings on the “trauma of recovery”
Scaffolding and long-term family recovery

26. Professional/Peer Collaboration and Extension of the Traditional Service / Support Continuum
Levels of care support
-Primary prevention
-Early Intervention
-Primary treatment
Role of peers in harm reduction
--reducing morbidity and mortality
--reducing irrevocable burdens brought into recovery process
Role of peers in recovery community resource development
Blending clinical, mutual support and community organization/renewal models

27. Duration of Professional-Peer Support
Defining the set point of recovery
Defining points of greatest vulnerability
The question of family support
Vision: minimum of 5 years of post-treatment monitoring/support via recovery checkups

28. Assertive Continuing Care versus Traditional Aftercare
encompasses all admitted clients/families
responsibility for post-treatment contact is with service organization
capitalizes on temporal & personal windows of vulnerability
individualizes support schedule
utilizes assertive versus passive linkage procedures
incorporates multiple support media
Delivers supports within natural environments
Delivers support via multiple roles
emphasizes continuity of contact over time

29. Professional/Peer Collaboration Issues
7 Key Implementation Questions

30. 1. What is the ideal organizational setting for the delivery of peer support services?
Recovery community organization
Addiction treatment organization
Allied service organization
Managed behavioral health care organizations

31. 2. What key qualities define “peer” and who gets to decide?
Is recovery status critical to provision of recovery support services?
Choice Philosophy: Person being served gets to define “peer”
Volunteer versus paid staffing models of RSS
Adaptation of peer services across cultural contexts

32. 3. What distinguishes peer helper roles from other service roles?
Problems of role definition between mutual aid sponsor, clinical roles & other service support roles
Core knowledge and competence domains
Delineation of best practices (potent ingredients of peer helping)
Certification & credentialing issues
Current confusion over recovery coach role

33. 4. What is the ideal infrastructure for peer recovery support?
Screening, selection, orientation, training and supervision
Defining peer support service capacity
a. Number of people served by each peer specialist
b. Expected frequency of contact
c. Expected duration of contact
d. Scope of contact, e.g., individual, family, social network, community
Supervisory and peer support available to peer specialists
Dangers of applying “clinical supervision” to RSS roles

34. 5. What are the greatest risks to implementing peer recovery supports?
Anti-professionalism
Peer support as political precursor to defunding treatment
Professionalism (colonization of peer recovery support movement; peers as junior counselors)
Commodification & commercialization of peer recovery supports
Risk of exploitation of peer specialists
Risk of long-term injury to indigenous communities of recovery

35. 6. What are the Key Ethical Issues in Professional-Peer Collaboration?
Potential for iatrogenesis (harm in the name of help)
Defining the ethical territory of P-BRSS
Increasing ethical sensitivities (critical incident training)
Models of ethical decision-making
Structures for ethical complaints / redress of ethical violations
Assumption: Ethical guidelines for professionals cannot be indiscriminately applied to RSS roles

36. 7. What is the State of the Science of Peer Recovery Support?
Recovery status does not in and of itself create or compromise clinical effectiveness of addiction counselors as measured by therapeutic alliance or post-treatment recovery outcomes.
Growing support for role of recovery mutual aid in enhanced recovery outcomes but studies with strongest methodologies limited to AA.
Growing support for key peer principles, e.g., helper principle

37. 7. What is the State of the Science of Peer Recovery Support?
Multiple studies supporting role of recovery homes in recovery maintenance but mostly descriptive studies of recovery community centers, recovery schools, recovery ministries.
Only a few studies of recovery coaches—positive to date but most outside treatment system, e.g., child welfare.
Very strong support for key elements performed by recovery coaches, e.g., assertive post-treatment outreach and re-engagement, recovery checkups.

38. Selected References and Resources
Will be posted with slides at
White, W. L. (2006c). Sponsor, recovery coach, addiction counselor: The importance of role clarity and role integrity. Philadelphia, PA: Philadelphia Department of Behavioral Health.
White, W. L. (2009a). Peer-based addiction recovery support: History, theory, practice, and scientific evaluation. Chicago, IL: Great Lakes Addiction Technology Transfer Center and Philadelphia Department of Behavioral Health and Mental Retardation Services.
White, W. L. (2009b). The mobilization of community resources to support long-term addiction recovery. Journal of Substance Abuse Treatment, 36,
White, W. L., Kelly, J. F., & Roth, J. D. (2012). New addiction recovery support institutions: Mobilizing support beyond professional addiction treatment and recovery mutual aid. Journal of Groups in Addiction & Recovery, 7(2-4),