Peer-based addiction recovery support: history, theory, practice, and scientific evaluation.
White W.L.
Chicago, IL: Great Lakes Addiction Technology Transfer Center and Philadelphia Department of Behavioral Health and Mental Retardation Services, 2009.
This monograph is likely to become the handbook for the growing peer-based recovery movement in the UK. For administrators, the approaches it reviews offer a way to reconcile decreasing per-patient resources with a policy agenda now focused on reintegration and recovery.
Abstract This seventh monograph* in a series on recovery management and recovery-oriented systems of care synthesises knowledge about the history, theoretical foundations, methods, and scientific status of peer-based recovery support for individuals with the most severe and complex alcohol and other drug problems. It was written primarily for people directly involved in planning, funding, delivering, supervising, and evaluating peer-based recovery support services, but will also be of interest to policymakers, purchasers of care, treatment programme administrators, and addiction counsellors and other service professionals. Though rigorously researched, information is presented in a clear and accessible language.
The report focuses on:
• Peer-based recovery support in general, meaning any form of mutual assistance aiming for long-term recovery from alcohol and other drug problems. Such assistance can and often does occur informally. The focus here is primarily on recovery support provided through recovery mutual aid societies and abstinence-based religious and cultural revitalisation movements by people whose credentials rest on personal experience.
• Peer-based recovery support services, a narrower term for assistance directed toward the same goal but delivered through more specialised roles with more formal resources, service protocols and safeguards. The key distinction is the term ‘services’, which implies a more formal structure though which recovery support is delivered. Here the focus is on recovery community organisations other than mutual aid societies, and on peer-based services provided through addiction treatment programmes and allied health and human service agencies. These services are distinguished from other programmes by their: mobilisation of personal, family, and community recovery capital to support long-term recovery; respect for diverse pathways and styles of recovery; focus on immediate recovery-linked needs; use of self as a helping instrument; and their emphasis on continuity of recovery support over time.
After comprehensively reviewing the literature and profiling peer-based recovery support initiatives, the author reached (among others) the following conclusions:

• Peer-based recovery support services are today growing out of the failure of addiction treatment to provide a continuum of care that is accessible, affordable, and capable of helping people with the most severe and complex problems move beyond brief episodes of recovery initiation to stable long-term recovery.

• Their distinctive strategy is to improve linkage to recovery mutual aid groups and other recovery support institutions, and their value is founded in what specifically those in recovery bring to the helping process. As with any effective helpers, those in recovery relate not primarily through techniques, but through humanness. They are able to do so, not because they once experienced addiction, but because they completed their own recovery experiences and emerged as men and women committed to this demanding way of life.

• Peer-based models of care can have a transforming effect on larger systems of care and on our society, but can also be corrupted and devoured when integration in to these systems leads to pressure to emulate the ethos of current professional treatment models. Care must be taken not to over-professionalise the roles of peer helpers, but training, guidelines, supervision and recognising the limits of one’s competence and role, are as important for services based on the power of mutual identification as for professional services.

• Rather than view peer-based and professional-based styles of knowing and doing as antagonistic models rivalling for superiority, it is more helpful to view these approaches as complementary. We need a community in which both professional and peer-based services are available as needed, and are supported and integrated into a seamless system of long-term recovery support.

• One unique quality separates the addictions field from peer models in allied fields: the growth of spiritual, secular, and religious recovery mutual aid groups, and new recovery support institutions, has gifted it the oldest and largest recovery mutual aid network in the world. New peer-based models must capitalise on these strengths rather than undermining or replacing them. The long-term goal is not to create a larger treatment system or new profession, but the establishment of recovery support relationships that are non-hierarchical, non-commercialised, and enduring in recovery-friendly communities.

• The question, ‘Who is most qualified to treat the alcoholic?’ is ill-framed because it assumes a homogeneity within the label ‘alcoholic’ and within the boundaries of particular helping roles or categories of helpers. In terms of recovery status, the question is not whether professional and peer helpers with or without a history of addiction recovery are most effective, but which helper is most effective with which person or family at a particular point in time. There are so many kinds of alcoholics and so many different kinds of alcoholism that a therapist eminently qualified to treat one type may fail completely with another.

• Recovery stages might be broadly conceived in terms of:
• 1 a sudden or unfolding opportunity for change;
• 2 a commitment to recovery experimentation;
• 3 recovery initiation and stabilisation;
• 4 recovery consolidation and maintenance; and
• 5 enhanced quality and meaning of life in long-term recovery.
 Peer-based recovery support services will probably be found most critical in stages 1, 2, and 4. Traditional professionals may be most effective in stages 3 and 5.
Every effort has been made to meticulously document sources, but many critical research questions about peer recovery support have yet to be studied and many studies suffer from methodological problems, so these findings are best viewed as probationary, pending new studies of greater methodological sophistication.
Though written by an advocate of peer-based recovery, this monograph is careful to adhere to the research (more comprehensively reviewed here than in any other publication) and to point out the limitations and risks involved in this route to recovery and the continuing role of professional treatment and other formal services. In it the British reader will find unfamiliar but potentially promising manifestations of mutual aid such as recovery social clubs, recovery community centres, and recovery homes, with profiles of how these have worked in practice and relevant research. Attention is not limited to 12-step based approaches, but extends to mutual aid based on other philosophies and understandings of addiction and recovery. For the growing peer-based recovery movement in the UK, it is likely to become an essential handbook to clarify thinking, offer practical ways forward, identify pitfalls and risks, and to encourage further research.
As the author comments, most of the reviewed research lacks the methodological safeguards of a randomised trial or some other research design capable of eliminating influences on outcomes other than mutual aid or peer support. Typically studies have recorded the degree to which substance dependent individuals participated in mutual aid activities and groups, and then assessed how closely this was associated with substance use and related problems. Such designs leave open the possibility that good outcomes encourage increased mutual aid participation rather than the reverse, or that people who are in any event going to do well also tend to participate in whatever in that society is the accepted route to doing well in terms of recovery from addiction. In the USA, where most studies originate, that route entails 12-step mutual aid.
When (as in a review for the Cochrane Collaboration) the focus is limited to the few randomised or other well controlled trials, there is no convincing advantage for 12-step mutual aid or allied services over other approaches. This review was unable to take in to account an influential later study which randomly assigned patients in formal treatment to standard versus intensive referral to 12-step groups. As intended, intensive referral improved 12-step mutual aid participation and this in turn improved substance use outcomes, confirming that participation was indeed an active ingredient. However, the effects on both participation and substance use were not great. While such studies can demonstrate the value of the extra element of mutual aid participation they ‘artificially’ generate, they say nothing about the value of the bulk of mutual aid participation as it naturally occurs. For this we must turn to the less well controlled studies excluded from the Cochrane review but included in the featured report, yet these are not capable of delivering convincing answers. This bind arises from the fact that mutual aid cannot be imposed or withheld by researchers and the results observed. Rather, it is generated (or not) organically by the nature of the society and of the individuals who choose (or not) to participate. It makes little sense to ask what the recovery chances of that society or those individuals would be if they did not generate or participate in mutual aid, because then they would not be the same societies or individuals. Another limitation of the controlled research is that typically it has studied mutual aid as an add-on to current treatment models, not the thoroughgoing systemic transformation called for in the featured report.
Even if given these difficulties, peer support and mutual aid struggle to demonstrate a superiority, where they can have a distinct advantage is in accessibility and (by reducing resort to public services) cost to society. For administrators in the UK, such approaches offer a way to reconcile increasing numbers in treatment, decreasing per-patient resources, increasing pressure to move patients through and out of treatment, and a policy agenda now focused on secure reintegration and recovery. Formal services seem unlikely to be able to make major advances in the availability to dependent substance users of (among other supports to reintegration and recovery) supported housing, suitable training and education opportunities, sheltered, graduated and attractive employment, and satisfying non-drug focused social and lifestyle options. Within available resources and political and public willingness to redirect these, transformations of the kind described in the featured report may be the only feasible way to create a more recovery-friendly environment which can protect greater numbers of people leaving treatment from repeated relapse.
However, risks of the kind warned about in the report are already apparent in parts of Britain where services concerned to safeguard vulnerable adults and who have clinical responsibility for patients seem reluctant to refer those patients to untried and unqualified mutual aid organisations, leading to pressure for those organisations to implement safeguards and protocols potentially antithetical to their self-help ethos. Such pressures have also been apparent in the UK mental health service-user/survivor movement. There is also a tendency for mutual aid recovery enthusiasts to see formal treatment services and their workers as ‘part of the problem’ rather than collaborators. The result is an imperfect interface between mutual aid and formal services which impedes beneficial complementarity and movement between them. As with other collaborations between organisations with different traditions and agendas, these difficulties will need to be carefully and respectfully worked through if patients are to benefit maximally from the potentially huge reservoir of voluntary effort represented by current and former problem substance users.
In the UK employment of current or former problem substance users in drug and alcohol services may be seriously impeded by the new requirements and powers associated with the advent in 2009 of the Independent Safeguarding Authority and of a similar scheme in Scotland. Among the criteria for banning people working with vulnerable adults (which would embrace many attending drug and alcohol services) are a history of acquisitive crime or fraud, addictive behaviour, or persistent offending. Such histories are common among drug addicted populations who have recovered through treatment and who might be employed as a paid employee or volunteer to offer peer-based support to substance users in contact with services. These problems have been recognised and representations are being made to the authority.
SOURCE: Peer-based addiction recovery support: history, theory, practice, and scientific evaluation.
White W.L.
Chicago, IL: Great Lakes Addiction Technology Transfer Center and Philadelphia Department of Behavioral Health and Mental Retardation Services, 2009.