A common phrase around planning tables for scaled-up Peer Recovery Support Services in New Hampshire is, "We're driving the car as we're building it." The field is brand new and rapidly expanding throughout our state and others. Given all of the challenges inherent in building a field of service from grassroots, PRSS in New Hampshire have helped to fill long-standing gaps in Substance Use Disorder care and have given laypersons in our communities an opportunity to serve amid crisis. But where do we go from here? What should the field and state agencies be thinking about as the funding landscape grows and recovery support services begin to 'norm'?
Addiction recovery historian William White offers his considerations here in his latest blog.
Who is Best Qualified to Provide Recovery Support Services?
By William White
The explosive growth of nonclinical recovery support services (RSS) as an adjunct or alternative to professionally-directed addiction treatment and participation in recovery mutual aid societies raises three related questions: 1) What is the ideal organizational placement for the delivery RSS?, 2) What persons are best qualified to provide RSS?, and 3) Are RSS best provided on a paid or volunteer basis?
At present, non-clinical RSS are being provided through and within a wide variety of organizational settings by people with diverse backgrounds in both paid and volunteer roles. While research to date suggests that such services can enhance recovery initiation and long-term recovery maintenance, no studies have addressed the three questions above or the broader issue of the kinds of evidence that should be considered in answering these questions.
I have repeatedly suggested that these questions should be answered by methodologically-rigorous research evaluating whether recovery outcomes differ by variations in delivery setting, attributes of those providing the services, and the medium (paid vs. volunteer) through which such services are provided. There are, however, considerations beyond such outcomes that ought to be considered and factored into decisions on the design and delivery of RSS.
As for organizational setting, I have heard such arguments as follows:
*RSS should be provided by addiction treatment organizations to assure a high level of integration between treatment and post-treatment continuing care.
*RSS should be provided by criminal justice and child welfare agencies to assure the balance between the goals of recovery support, public/child safety, and family reunification.
*RSS should be provided by hospitals and other primary care facilities to assure effective integration of recovery support and primary health care.
*RSS should be provided through public health authorities to assure the integration of prevention, harm reduction, treatment, recovery support, community-level infection control (e.g., HIV, Hep C), and wellness promotion.
*RSS should be provided by behavioral managed care organizations (or insurance companies) to assure coordination and integration of support across levels of care (and potentially multiple service providers) and the effective stewardship of limited financial resources.
*RSS should be provided by private professional recovery coaches who can coordinate support across multiple systems and across the long-term stages of recovery.
RSS are now being piloted through all of the above arrangements, but I think a strong argument can be made for providing RSS through and beyond all of the above settings under the auspices of authentic recovery community organizations(RCOs). Allocating financial resources to deliver RSS through these organizations and to the community at large has the added advantages of: 1) maintaining long-term personal and family recovery as the primary service mission, 2) drawing upon the experiential knowledge within communities of recovery to inform the provision of RSS, 3) contributing to the growth of local recovery space/landscapes (i.e. community recovery capital), 4) financially strengthening the infrastructure of local RCOs, and 5) proving greater peer support to the workers providing RSS.
Similarly, RSS are now being provided by people from diverse experiential and professional backgrounds. I think there are many RSS functions that can be effectively delivered across this diversity of backgrounds, but I think the delivery of these services by people in recovery who have been specifically training for this role offers a number of distinct advantages. Through the delivery of peer-based recovery support services, people in recovery can uniquely offer: 1) recovery hope and modeling (living proof of the reality of long-term recovery), 2) normative information drawn from personal/collective experience on the stages and styles of addiction recovery, and 3) knowledge of and navigation within local indigenous recovery support resources. Such hope, encouragement, and guidance is grounded in more than 200 years of history in which people in recovery (i.e., wounded healers, recovery carriers) have served as guides for other people seeking recovery from severe AOD problems (See Slaying the Dragon, 2014). It offers the further advantage of expanding helping opportunities for people in recovery—creating benefits for both helpee and helper through the helping process. (See discussion of Riesman's Helper Principle). Some of these advantages are limited, however, when the knowledge of the RSS specialist is drawn from personal experience within only one recovery pathway—thus the importance of combing experiential knowledge with rigorous training and supervision.
If we accept the delivery of RSS through recovery community organizations and by people with lived experience of personal/family recovery from addiction, there still remains the question of whether those directly providing RSS should be in paid or volunteer roles. The most prevalent model of delivering RSS is presently through paid roles, with progressively increasing expectations of education, training, and certification—similar to the modern history of addiction counseling. Paying people in recovery to provide RSS has the advantages of expanding employment opportunities for persons in recovery, acknowledging the value and legitimacy of experiential knowledge and expertise, and potentially creating a more stable RSS workforce. That said, the professionalization and commercialization of the RSS role risks undermining the voluntary service ethic within the recovery community, potentially creating an unfortunate future in which people in recovery would expect financial compensation for all service work.
One option is to provide funding to RCOs for the recruitment, orientation, training, and ongoing supervision of RSS, while relying primarily upon trained volunteers to deliver such services. Only time will tell if this option is a viable and sustainable model for the delivery of high quality RSS. If not, great care will need to be taken to avoid the over-professionalization and over-commercialization of recovery support. Questions related to the design and delivery of RSS should be answered primarily through research on RSS-related recovery outcomes, but such research should also examine broader benefits and the potential for inadvertent harm rising from particular models of RSS.