PPeeeerr--bbaasseedd AAddddiiccttiioonn RReeccoovveerryy SSuuppppoorrtt HHiissttoorryy,, TThheeoorryy,, PPrraaccttiiccee,, aanndd SScciieennttiiffiicc EEvvaalluuaattiioonn William L. White, MA Great Lakes Addiction Technology Transfer Center Philadelphia Department of Behavioral Health and Mental Retardation Services Dedication This monograph is dedicated to: Barbara Weiner and Rebecca Rowe of Hazelden Library, and to Stephanie Merkle and Christopher Roberts, research assistants at Chestnut Health Systems. This monograph was possible only through their tenacious efforts to procure hundreds of historical documents, scientific studies, trade journal articles, posted papers, conference presentations, and other unpublished manuscripts. Barbara, Rebecca, Stephanie and Christopher, and their counterparts around the country receive far less acknowledgment for their contributions to the field than they deserve. Thomasina Borkman, for her pioneering work on experiential learning and peer-based recovery support organizations. Those working on the front lines of peer-based addiction recovery support services. Thank you for opening your lives and your organizations to me. i ii Table of Contents Welcome from Lonnetta Albright and Michael Flaherty, PhD................................1 Foreword by Arthur C. Evans, PhD and Beverly J. Haberle, MHS........................3 Abstract..................................................................................................................7 Introduction Summary of Key Points..........................................................................................9 The Recovery Management Monograph Series....................................................9 Purpose of the Current Monograph.....................................................................11 A Note on Language............................................................................................12 A Caution to the Reader.......................................................................................12 Acknowledgments................................................................................................13 Chapter One: Defining Peer-based Recovery Support Services Summary of Key Points........................................................................................15 Defining Peer Recovery Support.........................................................................16 Distinguishing Professional and Peer Support....................................................19 Core Characteristics of P-BRSS Specialists........................................................22 Varieties of Peer Recovery Support Services......................................................25 Core Functions.....................................................................................................27 Treatment Adjunct or Alternative.........................................................................29 Chapter Two: The History of Peer-Based Recovery Support Services Summary of Key Points........................................................................................31 Solo Practitioners.................................................................................................34 Peer Recovery Support and Religious/Cultural Revitalization Movements.........35 Secular Recovery Mutual-aid Societies...............................................................36 Spiritual Recovery Mutual-aid societies...............................................................37 Religious Recovery Mutual-aid societies.............................................................37 Family-Focused Recovery Support Societies......................................................38 Occupation-based Recovery Support Groups.....................................................38 Shared Characteristics of Recovery Support Groups..........................................38 Recovery Support for Special Populations..........................................................39 Gender-specific mutual-aid groups...........................................................................39 Age-specific recovery support..................................................................................40 Recovery mutual aid and advocacy in communities of color....................................40 Recovery support for and within the LGBT community............................................41 Recovery support for people with co-occurring disorders.........................................41 Recovery support for people embedded within the criminal justice system..............41 Recovery mutual aid in rural communities................................................................42 Geographical Accessibility of Recovery Mutual-aid Groups................................42 Internet-based Recovery Support........................................................................47 Recovery Community Service Institutions and Organizations.............................47 Recovery Social Clubs.........................................................................................48 Recovery Advocacy Organizations......................................................................49 Recovering People Working in Non-professional Support Roles in....................50 Addiction Treatment Recovering People Working in Professional Roles in Addiction Treatment........53 Current Recovery Coaching Practices in the Public and Private Sectors...........62 iii Chapter Three: The Theoretical Foundations of Peer-Based Recovery Support Summary of Key Points........................................................................................67 “Nothing about us without us”..............................................................................69 The Wounded Healer Tradition............................................................................71 The Power of Calling (Amends in Action)............................................................73 Experiential Knowledge........................................................................................74 Chronic Illness and Peer Support........................................................................78 Charisma and Recovery.......................................................................................80 Spirituality and Recovery.....................................................................................84 Storytelling and the Power of Mutual Identification..............................................85 Stigma and The Dynamics of Help-seeking.........................................................88 Sharing Recovery Capital....................................................................................92 The Helper Therapy Principle..............................................................................93 Individual, Community, Culture............................................................................94 Cultures of Addiction and Recovery.....................................................................96 Preventing Harm in the Name of Help.................................................................97 Stewardship of Community Resources................................................................99 The Threats of Anti-professionalism and Professionalism ................................100 Primacy of Personal Recovery and Importance of Self-Care............................103 Role of Risk in Recovery....................................................................................105 The Value of P-BRSS........................................................................................105 Criticism of P-BRSS...........................................................................................107 Testing the Theoretical Foundations of P-BRSS...............................................109 Chapter Four: Scientific Evaluation of Peer-based Support: Studies of the Effects of Participation in Recovery Mutual-aid Societies Summary of Key Findings..................................................................................113 Limited Scope of Research on Recovery Mutual-aid Societies.........................115 Role of Mutual Aid in Recovery Outcomes........................................................117 Variability of Response......................................................................................119 Effectiveness across Diverse Populations.........................................................120 Cost-effectiveness..............................................................................................125 The Question of Harm (Iatrogenesis).................................................................126 Potent Ingredients of Recovery Mutual Aid.......................................................128 Additive Effects of Professional Treatment and Mutual Aid...............................130 Timing of Participation........................................................................................131 Linkage Procedures and Participation Rates.....................................................132 Linking Adolescents to Recovery Support Groups............................................133 Early Drop-out Rates..........................................................................................134 Dose and Intensity of Participation Effects........................................................136 Frequency of Participation.................................................................................136 Duration of Participation.....................................................................................137 Role of Internet-based Recovery Support..........................................................138 Relationship between Helping and Helper Recovery Outcomes ......................139 Studies of Family Support Groups.....................................................................140 iv Chapter Five: Scientific Evaluation of Peer-based Services: Studies of the Effects of Participation in other Recovery Community Institutions Summary of Key Findings..................................................................................145 Recovery Social Clubs.......................................................................................146 Recovery Community Centers...........................................................................147 Recovery Homes................................................................................................149 Recovery Colonies.............................................................................................154 Recovery Schools..............................................................................................155 Peer-based Occupational Recovery Support....................................................158 Recovery Ministries/Recovery Churches...........................................................160 Other Recovery Support Structures...................................................................162 Chapter Six: Scientific Evaluation of Peer-based Services: Studies of Recovering People Working in Addiction Treatment Summary of Key Findings..................................................................................165 Science versus Stereotypes..............................................................................166 Recovery Representation in Addiction Treatment.............................................167 The Role Transformation of Addiction Counselors in Recovery........................171 Demographic Profile of Counselors in Recovery...............................................174 Prior Treatment/Recovery Experience of Counselors in Recovery...................174 Pre-service Educational Functioning of Counselors in Recovery......................175 Educational Levels of Recovering People Working as Addiction Counselors...175 Certification, Licensure, and Clinical Effectiveness...........................................176 Compensation of Recovering Counselors versus Counselors Without a..........178 History of Addiction Personality Characteristics of Recovering Addiction Counselors......................178 Beliefs and Attitudes of Recovering Addiction Counselors................................179 Attitudes and Behaviors of Recovering Counselors Related to Evidence-........184 based Practices Role Perceptions of Recovering Addiction Counselors.....................................186 Recovery Status and Client Perceptions of Credibility and Effectiveness.........186 Counselor Recovery Status and Therapeutic Alliance......................................188 Counselor Recovery Status and Ethical Decision-making.................................189 Counselor Recovery Status and Client Recovery Outcomes............................191 Recovery Status and General Job Performance Factors..................................196 Vulnerability to Relapse among Counselors in Recovery .................................196 Influence of Recovery Status on Supervisory Relationships.............................197 Evaluation of Treatment Models Staffed by Recovering People.......................198 Evaluation of Recovery Volunteer Programs Linked to Addiction.....................202 Treatment or Medical Treatment Relevant Studies on Peer-based Services from Allied Fields............................204 Commentary on Lack of Distinctive Findings.....................................................207 v Chapter Seven: Recent Studies of Recovery Coaching and P-BRSS Summary of Key Findings..................................................................................209 The Recovery Community Services Program (RCSP)......................................209 The Access to Recovery (ATR) Program...........................................................211 Studies of Service Elements related to P-BRSS...............................................213 Chapter Eight: A P-BRSS Research Agenda Summary of Key Findings..................................................................................217 Toward a Recovery Research Agenda..............................................................217 Communities of Recovery as Ethno-cultural Communities................................218 Research on Recovery Mutual-aid Groups........................................................220 Participation in Other Recovery Community Institutions....................................221 Recovery Representation in Professional Treatment........................................221 Person-specific Factors Affecting Recovery Outcomes.....................................222 P-BRSS and Stages of Recovery......................................................................223 P-BRSS Service Roles.......................................................................................223 Service Ingredients and Recovery Outcomes...................................................224 Interaction Between P-BRSS and Professional Treatment...............................225 P-BRSS and Family/Community Recovery Outcomes......................................226 Organizational Contexts and P-BRSS Outcomes..............................................227 Concerns About P-BRSS...................................................................................228 Chapter Nine: Summary and Conclusions......................................231 A Preview..............................................................................................235 Appendix Table 12: Changing Recovery Representation in the Addiction.......................237 Treatment Workforce List of Tables Table 1: Professional and Peer Models of Helping.............................................20 Table 2: Defining Characteristics of P-BRSS.....................................................22 Table 3: Defining Characteristics of Organizations Delivering P-BRSS.............26 Table 4: Geographical Dispersion of Addiction Recovery Mutual-aid................43 Groups in the United States Table 5: Paradigms of “Paraprofessional” and Professional Addiction..............59 Counseling Table 6: Academic Theories on Mutual Peer Assistance...................................68 Table 7: Performance Measures and P-BRSS Core Ideas..............................109 Table 8: Demographic Characteristics of Recovery Mutual-aid societies........123 Table 9: Al-Anon Membership Characteristics in the United States,.................141 1984 and 2006. Table 10: Recovery Representation Among Counselors Working in...............168 Addiction Treatment: 1960-2007 Table 11: Concerns about P-BRSS Raised by Addiction Professionals, ........228 Treatment Administrators, and Members of the Recovery Community Table 12: Changing Recovery Representation in the Addiction.......................237 Treatment Workforce vi Program Profiles Program Profile 1: Peer Group Facilitation Training...........................................47 (previously called “How to Start Your Own Self-help Group”) Program Profile 2: PRO-ACT Philadelphia.........................................................48 Program Profile 3: Recovery Walk 2008 ............................................................50 Program Profile 4 : Telephone Recovery Support ..............................................63 Program Profile 5: New Pathways Project..........................................................64 (Assertive Street and Community Outreach) Program Profile 6: Recovery Advisory Committee..............................................69 Program Profile 7: Recovery Foundations Training.............................................70 Program Profile 8: Peer Leadership Academy....................................................70 Program Profile 9: A New Day: A Celebration of Recovery................................71 Program Profile 10: Amends in Action.................................................................74 Program Profile 11: Storytelling Training.............................................................88 Program Profile 12: Taking Recovery to the Streets...........................................92 Program Profile 13: Vermont Recovery Center Network...................................148 Program Profile 14: Philadelphia Recovery Community Center........................149 Program Profile 15: Recovery Home Survey.....................................................153 Program Profile 16: Connecticut Community of Addiction Recovery’s..............153 Recovery Housing Project Program Profile 17 : Recovery Oriented Employment Services........................159 Program Profile 18: NET Consumer Council.....................................................163 Program Profile 19: Peer Specialist Initiative.....................................................170 vii