Aisha says she knows many people who tried treatment for a substance use disorder; they also tried 12- Step meetings. Neither worked. Her friends are back on the street, still using. Anyway, Aisha doesn’t have time to attend treatment sessions or go to meetings; she has a full-time job and is busy raising her two grandchildren because their mother is in prison.

Roger has just been released from jail. He has been clean for the 90 days of his incarceration, and he thinks he can stay clean if he can just find a job and a place to live with other people in recovery.

Elizabeth tells her treatment counselor that payday is her trigger, and that she needs an alcohol- and drug-free place to go and socialize on Friday evenings. She adds that it would be helpful if she could bring her children.

Luis says he understands that his AA meeting is not the place to discuss the complications he is encountering with his hepatitis C medications. But he needs someone to talk to because managing his response to the medications and his recovery at the same time is just too much for him to handle.

Bodie has been in recovery for a year. He is looking for an opportunity to be of service and to strengthen his recovery by giving back to the community. He loves gospel music and sings in his church choir.

Introduction

What do all these people have in common? Although they are at different points in the process of recovering from a substance use disorder, each is expressing a need for some form of social support to help them through the process. Equally important, each is also a potential source of social support for others.

In this paper on What Are Peer Recovery Support Services, you will be introduced to a new kind of social support services designed to fill the needs of people in or seeking recovery. The services are called peer recovery support services and, as the word peer implies, they are designed and delivered by people who have experienced both substance use disorder and recovery. Through the Recovery Community Services Program (RCSP), the Substance Abuse and Mental Health Services Administration/Center for Substance Abuse Treatment (SAMHSA/CSAT) funds grant projects across the country to develop and deliver these services.

The peer recovery support services developed by the RCSP projects help people become and stay engaged in the recovery process and reduce the likelihood of relapse. Because they are designed and delivered by peers who have been successful in the recovery process, they embody a powerful message of hope, as well as a wealth of experiential knowledge. The services can effectively extend the reach of treatment beyond the clinical setting into the everyday environment of those seeking to achieve or sustain recovery.

Social Support for Recovery

Research has shown that recovery is facilitated by social support (McLellan et al., 1998), and four types of social support have been identified in the literature (Cobb, 1976; Salzer, 2002): emotional, informational, instrumental, and affiliational support. RCSP projects have found these four types of social support useful in organizing the community-based peer-to-peer services they provide to recovering people. (Some typical examples are shown in Figure 1 below.) These four categories refer to types of social support, not discrete services or service models.

For example, a project that is planning social support services to address recovering people’s employment needs might consider whether a job referral (informational support) by itself is adequate, or whether emotional support (such as supportive coaching to prepare for an interview), and/or instrumental support (such as help cleaning up a criminal record) might also be needed. In general, the more robust the types of social support available to address any given recovery concern, the more likely that a person seeking help will walk away with useful information, a new insight or skill, or more confidence to help with the tasks ahead.

Peer Leaders and the Peer Service Alliance

RCSP projects use the term peer to refer to all individuals who share the experiences of addiction and recovery, either directly or as family members or significant others. In a peer-helping-peer service alliance, a peer leader in stable recovery provides social support services to a peer who is seeking help in establishing or maintaining his or her recovery. Both parties are helped by the interaction as the recovery of each is strengthened.

RCSP projects use many other titles besides peer leader and peer to describe the parties to the peer service alliance. On the peer leader side of the equation, titles include recovery (or peer) mentor, guide, or coach; peer services interventionist; firestarter; and peer resource specialist. (Firestarters are peer leaders responsible for building local recovery communities in Native American communities.) The peer who seeks help also is given different titles in different RCSP projects, such as member (of the peer services organization), mentee, or simply peer. Most project leaders have consciously sought to find and use identifying terms that distinguish their peer services and service providers from those in formal, 3 professional treatment programs or in mutual aid groups conducted by lay persons. For this reason, terms such as counselor, case manager, or sponsor, as well as client, consumer, or patient, are avoided.

The RCSP projects’ attention to language reflects the need to clearly distinguish the role of the peer leader from the role of the treatment counselor or other professional and the 12-Step sponsor (White, 2006). RCSP projects are intended by CSAT to enhance—not duplicate, replace, or compete with— valuable services already available in a community. Thus, in addition to using language which is not associated with treatment or mutual aid programs, axioms such as the following are commonly heard: “Peers do not diagnose;” “Peers do not provide therapy;” “Peers do not give advice.” Similarly, it is common to hear, “You need to ask your sponsor, not me, for help working the 12-Steps,” or “That’s a question for the doctor or nurse.”

Peer Recovery Support Service Activities

The RCSP peer recovery support service projects have developed a variety of peer services. Not all programs provide all services, and some peer leaders may provide more than one service. The following is a useful overview of the four major types of recovery support services emerging in RCSP projects: (1) peer mentoring or coaching, (2) recovery resource connecting, (3) facilitating and leading recovery groups, and (4) building community.

Peer Mentoring or Coaching

Although the name given to this service activity varies from project to project, the terms mentoring or coaching refer to a one-on-one relationship in which a peer leader with more recovery experience than the person served encourages, motivates, and supports a peer who is seeking to establish or strengthen his or her recovery.

The nature and functions of mentoring or coaching vary from one RCSP project to another. Generally, mentors or coaches assist peers with tasks such as setting recovery goals, developing recovery action plans, and solving problems directly related to recovery, including finding sober housing, making new friends, finding new uses of spare time, and improving one’s job skills. They may also provide assistance with issues that arise in connection with collateral problems such as having a criminal justice record or coexisting physical or mental challenges.

The relationship of the peer leader to the peer receiving help is highly supportive, rather than directive. The duration of the relationship between the two depends on a number of factors such as how much recovery time the peer has, how much other support the peer is receiving, or how quickly the peer’s most pressing problems can be addressed.

RCSP projects distinguish the role of the peer mentor or coach from that of a 12-Step sponsor in several ways. For example, the sponsor works within the 12-Step framework and is expected to help the person in early recovery understand and follow the specific guidance of the 12-Step program. The typical RCSP recovery mentor or coach, on the other hand, is often described as helping peers in early recovery make choices about which recovery pathway(s) will work for them, rather than urging them to adopt the mentor’s or coach’s own program or any specific program of recovery. The mentor or coach is often described as devoting a greater amount of time than the typical 12-Step sponsor to connecting the person in early recovery to community health, employment, housing, educational, and social services and resources and often has more specific knowledge about a larger range of available services and resources.

Peer Recovery Resource Connecting

The service activities of peer leaders in connecting peers to recovery resources might be likened to case management in substance use disorder treatment. The purpose of resource connecting services is to connect the peer with professional and nonprofessional services and resources available in the community that can help meet his or her individual needs on the road to recovery. The peer leader working in a peer setting to provide recovery resource connecting services often has had personal experience navigating the service systems and accessing the resources to which referral is being made, and can bring those personal experiences to bear.

Peer recovery support services provided in RCSP projects typically can help peers with their most pressing early recovery needs—finding a safe place to live and a job. Thus, peer leaders are likely to refer peers to safe housing or to sources of information about housing and to a wide variety of resources and services that provide assistance in developing job readiness or finding jobs. Peer leaders also help peers navigate the formal treatment system, advocating for their access and gaining admittance, as well as facilitating discharge planning, typically in collaboration with treatment staff.

Peer leaders also encourage and support participation in mutual aid groups and provide specific information about the various groups that exist in the community. They encourage and facilitate participation in educational opportunities. Depending on the particular needs of the population they serve, they also may focus on developing linkages to resources that address specialized needs, such as agencies providing services related to HIV infection or AIDS, mental health disorders, chronic and acute health problems, parenting young children, and problems stemming from involvement with the criminal justice system.

Facilitating and Leading Recovery Groups

In addition to conducting one-on-one coaching or mentoring and resource connecting activities, many peer leaders facilitate or lead recovery-oriented group activities. Some of these activities are structured as support groups, while others have educational purposes. Many have components of both.

The group activities that are structured as support groups typically involve the sharing of personal stories and some degree of collective problem-solving. Many of these groups are formed around shared identity, such as belonging to a common cultural or religious group, or shared experience related to the substance use disorder, such as the need to re-enter the community following incarceration, being HIV positive, or facing challenges in parenting. Many, but not all, group activities conducted by peer leaders have a spiritual component.

The group educational activities tend to focus on a specific subject or skill set, and may involve the participation of an expert as well as peer leaders. Typical topics and activities include training in job skills, budgeting and managing credit, and preventing relapse, as well as courses particularly targeted to people in recovery, such as conflict resolution grounded in recovery skills.

Building Community

A person in early recovery is often faced with the need to abandon friends and/or social networks that promote and help sustain a substance use disorder, but has no alternatives to put in their place that support recovery. Peer recovery support service providers can help such peers make new friends and begin to build alternative social networks. Peer leaders in RCSP projects often organize recovery-oriented activities that range from opportunities to participate in team sports to family-centered holiday celebrations and to payday get-togethers that are alcohol- and drug-free. These activities provide a sense of acceptance and belonging to a group, as well as the opportunity to practice new social skills.

Volunteer and Staff Peer Leaders

Peer recovery support services capitalize on the often recognized desire among many in recovery to “give backî to their communities by providing services to others. Most of the RCSP peer leaders who give back by providing peer recovery support services have done so as volunteers. In some projects, however, peer leaders are paid for their services as staff. In a few projects, peer leaders are not staff, but receive stipends for their work.

All recovery support programs require effective management and all peer leaders, irrespective of their status as paid staff, volunteers, or recipients of stipends, require effective supervision. The range of supervisory tasks may vary, however, depending on the status of the peer leaders as paid or unpaid volunteers or staff. Recruiting and retaining effective volunteers, for example, requires somewhat different techniques than hiring and keeping effective paid staff. The tenure of volunteers may be shorter than that of paid staff, requiring constant recruiting and training of volunteers. A project that relies on volunteers may use community organizing strategies to develop a strong volunteer base, while a project that relies solely on paid staff will be more likely to use standard employee recruitment processes. Moreover, staff time is typically allocated differently in a volunteer-oriented organization. Little staff time is devoted to direct service; staff effort is primarily directed at recruiting, training, and supervising peer leaders; developing and maintaining an organizational culture that incorporates principles of selfcare; and various other tasks related to organizational development, stakeholder development, and sustainability.

Whether the project uses paid or volunteer peer leaders also may affect how the project translates the range of peer leader direct service roles and functions into specific job or volunteer position descriptions. The project that relies primarily on volunteers who can dedicate 20 hours of service each month may distribute peer service roles and functions into volunteer positions that are narrower in scope than the roles and functions included in job descriptions developed by a project that relies primarily on peer leaders in fulltime staff positions. A paid peer leader, for example, might be expected to provide one-on one mentoring and facilitate groups; a volunteer position might include mentoring or facilitation, but not both.

The Adaptability of Peer Recovery Support Services

One strength of peer recovery support services has been their adaptability to many stages and modalities of recovery, as well as to different service settings and organizational contexts. This adaptability makes them an effective vehicle for extending support for recovery beyond the treatment system and into the communities where people live and to people following different pathways to recovery. On the other hand, because of the variations in settings, organizational contexts, and recovery stages and pathways, identifying commonalities in peer recovery support services can be challenging.

Different Recovery Stages and Approaches

Peer leaders can provide social support services to individuals at all stages on the continuum of change that constitutes the recovery process. The Prochaska, Norcross, and DiClementi (1995) stages of change model has identified the stages of precontemplation, contemplation, determination/preparation, action, maintenance, and relapse. Whether peers are familiar with these stages of change or not, most can relate to the idea that recovery takes place in stages. RCSP projects have developed peer recovery support services that meet needs of people at different stages of the recovery process. The services may:

• Precede formal treatment, strengthening a peer’s motivation for change
• Accompany treatment, providing a community connection during treatment
• Follow treatment, supporting relapse prevention
• Be delivered apart from treatment to someone who cannot enter the formal treatment system or chooses not to do so.

Furthermore, peer services can provide social support within the context of many different pathways to recovery, including pathways that are predominantly religious, spiritual, or secular; involve medication assistance; or focus on cultural survival and renewal as avenues to recovery.

Varied Service Settings

RCSP grant projects deliver peer services in a variety of settings including recovery community organizations, recovery centers, churches, child welfare organizations, recovery homes, drug courts, prerelease jail and prison programs, parole and probation programs, behavioral health agencies, and HIV/AIDS and other medical or social service centers. Peer leaders work in urban and rural communities with many different populations, including those defined by age (e.g., adolescents, elders), race or ethnicity (e.g., Asian/Pacific Islander American, Latino or Hispanic American, Native American, Caucasian), gender (e.g., women) or by co-existing conditions (e.g., HIV/AIDS and other infectious diseases, mental health disorders, homelessness, or a criminal record).

Variations in Organizational Contexts

Some RCSP projects are free-standing nonprofit recovery community organizations operated by members of the recovery community. Others reside within a host agency. These host agencies include those involved in the field of substance use disorders, including treatment providers; agencies that focus on the continuum of social service needs of specific populations, including those related to substance use; and agencies with a primary focus on challenges such as HIV/AIDS, post incarceration re-entry to the community, or children at risk of abuse or neglect. Each type of organizational context has its own culture and perspective on substance use disorders and recovery and presents its own opportunities and challenges in the establishment and operation of a peer recovery support service program.

These stages of recovery, pathways to recovery, service settings, and organizational contexts can present very different challenges to the peer recovery support services program. One project, for example, may be a new free-standing recovery community organization that is faced not only with the task of designing and delivering peer recovery support services, but also with the tasks of building a board of directors and developing the fiscal infrastructure to handle a Federal grant. Another may be housed in a host agency that is a seasoned nonprofit that has been handling Federal grants successfully for years, but is rooted in a service system that is inexperienced with working with people in or seeking recovery. One may work almost exclusively with peers who have completed formal treatment, while another may work with peers who have not yet acknowledged that their substance use is a problem.

Some Important Cross-Project Principles

Notwithstanding important differences among RCSP projects, certain core principles cut across projects. One key principle is having shared values. In the RCSP experience, shared values have, in turn, given rise to other key principles, including a preference for strength-based approaches and a service philosophy that nurtures self-direction, empowerment, and choice.

Shared Values

RCSP project participants have identified core values that inform the task of organizing the recovery community to provide peer recovery support services. These include:

• Keeping recovery first—Placing recovery at the center of the effort, grounding peer services in the strengths and inherent resiliency of recovery rather than in the pathology of substance use disorders.
• Cultural diversity and inclusion—Developing a recovery community peer support services program that honors different routes to recovery and has leaders and members from many groups at all levels within the organization.
• Participatory process—Making sure the recovery community directs or is actively involved in project design and implementation, so that recovery community members can identify their own strengths and needs, and design and deliver peer services that address them.
• Authenticity of peers helping peers—Drawing on the power of example, as well as the hope and motivation, that one person in recovery can offer to another; providing opportunities to give back to the community; and embracing the notion that both people in a relationship based on mutuality can be helped and empowered in the process.
• Leadership development—Building leadership abilities among members of the recovery community so that they are able to guide and direct the service program and deliver support services to their peers.

Many projects have identified additional core values, but virtually all subscribe to at least these five. RCSP projects have used these core values as a platform on which to build codes of ethics and as a guide to their development of practice guidelines for peer leaders.

Focus on Strengths and Resiliencies

A peer recovery support services program that incorporates a strengths perspective builds on people’s resiliencies and capacities rather than providing services focused primarily on correcting their deficits, disabilities, or problems. Emphasis is on uncovering, reaffirming, and enhancing the abilities, interests, knowledge, resources, aspirations, and hopes of individuals, families, groups, and communities. This approach assumes that the ability to recognize one’s own strengths and identify internal and external resources enhances a person’s chances of success in setting and achieving goals and in realizing his or her aspirations.

RCSP peer recovery support service programs have adopted the strengths perspective in multiple contexts. In the relationship between a peer leader and a peer seeking help, for example, recovery planning does not start with a process that identifies deficits and disabilities, but rather with a conversation intended to uncover the peer’s interests, abilities, and goals. One of the peer’s goals is likely to be a sustained change in substance use behavior. Goals are likely to address other life domains as well, such as housing, employment, education, family and social relationships, recreational opportunities, and physical, mental, or spiritual health.

As the individual’s goals become clear, the peer leader can help the peer identify the resources and skills that need to be marshaled to attain the goals. The peer may already possess some of these resources, skills, and talents and may even have demonstrated them during the active stages of a substance abuse disorder; he or she may need help in developing others, in some cases seeking an external source for help in developing new capacities. These ingredients—the articulation of the peer’s own goals and desires, in his or her own words, and an enumeration and affirmation of his or her specific capacities to marshal resources to achieve them—form the foundation of an empowering recovery plan.

RCSP projects also have adopted strengths-based approaches to the recovery community, as well as to the larger community. By engaging the recovery community in all aspects of the identification, planning, and delivery of peer recovery support services, projects have expressly built upon the strengths and insights of those who are working to achieve and sustain their own recovery goals and are willing to give back to the community through the peer recovery support effort. Similarly, they actively work within the larger community to identify and strengthen existing services and resources that can support recovery. Peer services function as a bridge to a larger network of community support. As one project director noted, “We are building our community’s capacity to care.”

Many RCSP projects have benefited from conducting comprehensive community strengths and needs assessments. This type of assessment—which may be ongoing throughout the life of the project—identifies services and resources available both in the recovery community and in the community at large that can support recovery. The assessment creates multiple opportunities for people in and seeking recovery, as well as family members, significant others, and stakeholders, to identify, in their own words, what has worked for them, what they think is needed, and what they can contribute to the peer effort. In addition to helping ensure that a project develops services that fill gaps, rather than competing with services and resources already available in the community, the strengths and needs assessment identifies important resources within the recovery community and the larger community that can contribute to the development of strong peer services and/or provide assistance that recovering people need. The assessment also facilitates the building of important stakeholder relationships and serves as a foundation for effectively connecting people to resources in the community that support recovery.

Self-Direction, Empowerment, and Choice

Embedded in the shared values of RCSP peer recovery support services is a philosophy of self-direction, choice, and empowerment. The many pathways to recovery are acknowledged, the person seeking recovery is assumed to be fully capable of making informed choices, and his or her preferences are respected.

In practice, carrying out the principles of self-direction, empowerment, and choice has sometimes been challenging to peer leaders. In the first place, they have often needed to become well-informed about pathways to recovery different from their own. In some cases, project leaders have had to combat their own misconceptions about, and prejudices against, certain recovery modalities, such as recovery assisted by medication or grounded in religious belief.

Furthermore, the assumption that the person seeking recovery is fully capable of making informed choices may not always fit the circumstances, particularly when neurological impairment is significant or when acute or severe psychiatric symptoms are associated with an active substance use disorder or early recovery. This can require a peer leader to know when to strike a delicate balance between respect for the peer’s rights of choice and a need to keep the recovery process simple for the time being.

The Many Values of Peer Recovery Support Services

Historically, the substance use disorder and recovery field led the way in recognizing the importance of peer support services for a person seeking to come to terms with a life-changing condition. Utilization of peer support is, by now, a common practice in many fields. In the medical world of today, for example, there is scarcely a specialty where peer support is not recognized as a valuable adjunct to professional medical and social interventions. Improved outcomes are particularly notable when peer support services are provided to people with chronic conditions that require long-term self-management. Thus, the peer recovery support services offered by RCSP grant projects and others stand in a long, well-documented, and copied evidence-based tradition.

Peer recovery support services can fill a need long recognized by treatment providers for services to support recovery after an individual leaves a treatment program. In addition, peer recovery support services hold promise as a vital link between systems that treat substance use disorders in a clinical setting and the larger communities in which people seeking to achieve and sustain recovery live. Using a nonmedical model in which social support services are provided by peer leaders who have experienced a substance use disorder and recovery, these services extend the continuum of care by facilitating entry into treatment, providing social support services during treatment, and providing a post-treatment safety net to those who are seeking to sustain treatment gains.

These services are proving to be very adaptable, operating within diverse populations, stages of recovery, pathways to recovery, service settings, and organizational contexts. Notably, they build on resources that already exist in the community, including diverse communities of recovering people who wish to be of service. By serving as role models for recovery, providing mentoring and coaching, connecting people to needed services and community supports, and helping in the process of establishing new social networks supportive of recovery, peer leaders make recovery a presence in their communities and send a message of hope fulfilled.

Citation

Center for Substance Abuse Treatment, What are Peer Recovery Support Services? HHS Publication No. (SMA) 09-4454. Rockville, MD: Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 2009.

This work resides in the public domain, unless otherwise indicated.

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