An official website of the United States government
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Incorporating Peer Support Into Substance Use Disorder Treatment Services [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2023. (Treatment Improvement Protocol (TIP) Series, No. 64.)
Peer workers perform their job based on the principles that recovery is possible for everyone and there are many pathways to recovery.
Providing recovery support and helping to build or enhance the recovery community are the two primary functions peer workers perform.
Lived experience with problematic substance use, behavior change, and recovery is the foundation on which peer workers’ knowledge, values, skills, and abilities are built.
Peer specialists recognize not only the value of their services, but also the limits of their roles.
Communication with an individual in recovery requires listening and learning with kindness, curiosity, and encouragement.
A strengths-based assessment is central to the notion of recovery capital and to peer services.
Peer specialists have a role in both identifying and actively linking individuals in recovery to resources in the local community that are recovery friendly, culturally and linguistically relevant, and accessible. Peer specialists can also help individuals identify personal relationships that will support their recovery.
Peer specialists are a key element of recovery-oriented systems of care (ROSCs).
Advocacy can promote recovery and build community. Peer specialists advocate for themselves, for the peers they serve, and for ROSC networks as well as for other community organizations in which they work.
Growing evidence shows that peer support services (PSS) improve outcomes for individuals in or seeking recovery from substance use–related problems.264,265,266 Years of experiential knowledge and success stories tell us how peer workers contribute to these positive outcomes.
Being an effective peer specialist requires specific knowledge and technical skills to provide recovery support services as well as an understanding of who peer specialists are in recovery; what they bring to relationships with individuals in or seeking recovery; and how they represent the recovery community to treatment programs, service providers, and the public. A peer specialist's values and attitudes about recovery and what it means to help or support others, along with their willingness to be curious, caring, authentic, empathetic, and culturally responsive are also important. Simply put, peer recovery support is about genuinely caring for and connecting with other human beings and supporting improvements in the quality of their lives.
“Core skills required of peer staff include intangibles that relate to their worldview, interpersonal style, and effective use of self.”267
Peer specialists bring their lived experience of recovery, personal strengths, and shared values to their relationships with individuals in or seeking recovery. The recovery support and community-building skills they develop in training and the time they spend under supervision are also highly important.
Chapter 3 of this Treatment Improvement Protocol (TIP) explores the core activities and responsibilities of peer specialists and the knowledge, values, skills, and abilities they need to function effectively in a range of treatment settings. The foundation of a peer specialist's work is their lived experience with problematic substance use, behavior change, and recovery. This is a key factor in what makes recovery support effective.268
Chapter 3 of this TIP discusses two core peer specialist functions: recovery support and community building (i.e., helping to build or enhance the recovery community by connecting to and networking with local organizations and services). It describes the knowledge, values, skills, and abilities needed to perform each function. Chapter 3 is for peer specialists working as integrated members of substance use disorder (SUD) treatment program staff as well as for peer specialists providing PSS in community-based recovery settings who may collaborate with, provide linkages to, or otherwise support the work of SUD treatment programs.
Chapter 3 provides the following information:
The first section describes two core functions of peer specialists and the Substance Abuse and Mental Health Services Administration's (SAMHSA) core competencies for peer specialists.
The second section addresses the knowledge, values, skills, and abilities peer specialists need to support individuals in or seeking recovery from substance use–related problems.
The third section discusses the knowledge, values, skills, and abilities peer specialists need to engage in building and enhancing the recovery community.
The chapter appendix presents sample recovery and wellness plans and identifies resources to support the efforts of peer workers. Additional resources can be found in Chapter 8.
This chapter also includes brief examples of interactions between peer specialists and individuals in or seeking recovery. These examples are simplified for demonstration purposes and may not reflect the complexities or nuances of actual peer relationships. Exhibit ES.1 in this TIP's Executive Summary provides definitions of key terms that appear in this and other chapters.
Exhibit 3.1 shows the overall framework for the work that peer workers do. The core functions of the peer worker are recovery support and community building, at the center of the pyramid. The knowledge (i.e., awareness and understanding of key recovery issues and information), values (i.e., recovery-oriented attitudes, beliefs, and ethical principles), and skills (i.e., learned skills and natural abilities that support recovery) a peer worker needs to be effective in performing these core functions are the building blocks that complete the pyramid. The base of the pyramid represents their lived experience with problematic substance use, behavior change, and recovery. It is the foundation of a peer specialist's work, supporting their knowledge, values, skills, and abilities.
EXHIBIT 3.1. Peer Worker Core Functions.
Peer workers perform many different activities and work in many different settings. Some functions and activities that are “core” to their work may be more or less common in a given setting or even in a certain state because different states certify peer specialists to perform different activities. To be fully aware of the range of core components involved in peer work, this chapter covers as many skills and activities as possible for all peer workers.
Peer workers take on many different roles, including educators, resource navigators, facilitators, and role models. (Chapter 2 includes more information about peer worker roles.)
The main functions of a peer worker are providing recovery support to individuals in or seeking recovery from problematic substance use and helping to build or enhance the recovery community.
This work begins with building a solid service relationship with the individual in or seeking recovery, then acting as a bridge to their family, friends, treatment providers, community-based services, and the larger recovery community. The relationship of a peer worker with an individual in or seeking recovery is based on mutual learning and is guided by the principles of hope, collaboration, respect, self-responsibility, and self-determination (i.e., the ability to live life the way a person chooses). An individual new to the recovery community needs support in building and enhancing that community. This is an ongoing process of support and growth that requires a peer-to-peer relationship that is grounded in trust. Peer workers participate directly in building and enhancing the recovery community by connecting people to and participating in recovery activities as well as advocating for more recovery resources in the local community.
Depending on the work setting, a peer worker may be more focused on individual recovery support, or they may be more focused on community building. Regardless of the primary focus, a peer worker will be called upon to perform both activities. A peer worker's job is to stay involved in the recovery community even when they're physically located in a non-community–based setting (e.g., a jail, emergency department [ED], college, SUD treatment program).
SAMHSA's Core Competencies for Peer Workers.
This section reviews the knowledge, values, skills, and abilities needed to support individuals throughout their recovery from substance use–related problems. Recovery support focuses on establishing and maintaining long-term recovery and is based on recovery principles such as:270,271
Recovery is an ongoing process of change, not a one-time event.
Recovery is fluid; goals and interventions change as recovery evolves.
Recovery involves the need to learn new skills and behaviors for overcoming substance use–related problems, including many different life stressors.
Recovery is person driven and holistic.
Recovery can be achieved through multiple pathways.
In addition to their own experience and self-reflection, peer workers need specific knowledge, values, skills, and abilities to help an individual in or seeking recovery start and maintain recovery over time. Recovery is individual. Not all substance use–related problems, environments, and personal circumstances are the same; therefore, not all recovery pathways are the same. The amount and types of support that people in or seeking recovery need will vary. Recovery support always includes strengths-based and person-driven support. That means a peer worker should focus on the individual's strengths, abilities, and resources. This process is driven by the individual's needs, goals, recovery capital, and hopes for the future.
SUPPORTING, NOT STEERING: HELPING INDIVIDUALS IN RECOVERY NAVIGATE THE JOURNEY TO RECOVERY.
Peer workers will benefit from having core recovery knowledge. This includes learning the definitions and history of recovery, the multiple pathways and evolution of recovery, relational styles in recovery, the influence of cultural contexts on recovery, and recovery across the life cycle. The following sections describe important areas of knowledge.
Problematic substance use can lead to physical, emotional, cognitive, and social consequences for individuals and their families. A peer specialist's personal experience with a particular substance may differ from the individual in or seeking recovery's experience with the same or another substance. Peer specialists should not make comparisons or be judgmental of individuals in or seeking recovery because they can likely relate to feelings of hopelessness and helplessness that can occur for an individual who has problematic substance use.
For example, if a peer specialist's personal experience is with problematic alcohol use and they are working with someone engaged in problematic use of opioid pain medication, the peer specialist needs to be aware of the specific consequences problematic opioid medication use has on that person, the risk of overdose, health and medical complications, and recovery supports in the community. Peer specialists also need to be familiar with the resources available to individuals who take medication to support recovery, which includes opioid agonists (i.e., medications like methadone or buprenorphine that bind to opioid receptors but don't produce euphoria) and opioid antagonists (i.e., medications like naltrexone that block the effects of opioids).
Although peer specialists don't need to be an expert in every effect that substances can have on the brain or in all the health, mental, emotional, or social effects of problematic substance use, they will be more effective at supporting people in or seeking recovery if they understand why these effects occur and how they relate to an individual's ability to initiate and sustain change. To accomplish this, peer specialists should have general knowledge about the following:
Effects of substance use and substance use–related practices on the brain and the body
Health-related effects of substance use, including the link between problematic substance use and infectious disease
Effects of problematic substance use on family and social relationships
The link between problematic substance use and co-occurring mental illness
The link between problematic substance use and negative life events (e.g., criminal justice involvement, experiencing homelessness or housing instability, trauma, being a victim of a crime)
The link between social determinants of health and substance use–related issues
RESOURCE ALERT: MEDICATIONS TO SUPPORT RECOVERY.
RESOURCE ALERT: SCIENCE-INFORMED SOURCES OF ALCOHOL AND DRUG INFORMATION.
Peer support providers work with individuals in or seeking recovery who have experienced trauma or have a mental illness. Diagnosing and treating mental illness are outside a peer worker's scope of practice, even if they have the same mental illness or have experienced trauma. However, understanding the impact of co-occurring disorders and trauma on individuals in or seeking recovery and using a trauma-informed approach in their work ensures that they're providing a safe environment to offer PSS.
A basic understanding of mental illness and trauma will help peer workers recognize when these conditions become potential barriers to recovery, how individuals can use their strengths to support their recovery from problematic substance use and co-occurring mental illness and trauma, and when to link individuals to behavioral health services and other resources in the community. Peer workers can benefit from having a basic understanding of:
Common signs of trauma (e.g., flashbacks or intrusive memories, extreme watchfulness or anxiety).
Effects of trauma and co-occurring mental illness on recovery, including the increased risk of developing substance use–related problems again.
Local behavioral health services and community-based recovery resources and the best ways to access those services.
How trauma affects everyone differently and requires professional assessment.
How the meaning of recovery can differ in substance use and mental illness recovery communities. (The “Resource Alert: Trauma and Co-Occurring Disorder Awareness” provides links to more information about trauma, co-occurring disorders, and distinctions between recovery in the contexts of mental health and SUDs.)
RESOURCE ALERT: TRAUMA AND CO-OCCURRING DISORDER AWARENESS.
Culture consists of the beliefs, behaviors, objects, and other characteristics shared by groups of people. Cultural responsiveness refers to service providers—including peer specialists—respecting, accepting, and being responsive to the health beliefs, practices, and values of diverse populations. Service providers who are culturally responsive also explore the effects of ethnocentrism and racism on their treatment or service delivery.
Broadly speaking, cultural responsiveness in behavioral health includes:272
Connecting with individuals and building positive relationships with them using cross-cultural communications (e.g., speaking clearly; using plain, nontechnical terms).
Making sure individuals understand treatment processes and services.
Working as a team member (i.e., including individuals in treatment planning) throughout the treatment and service provision process.
Including culturally relevant themes and information in the services (e.g., asking about individuals’ cultural identity and acculturation experiences, avoiding making assumptions about a person because of their culture, exploring individuals’ cultural beliefs about the treatment of substance use–related problems and mental illness).
For treatment providers, conducting culturally sensitive interviews and selecting screening and assessment tools that align with individuals’ cultural views about problematic substance use.
Matching culturally similar peers to communities with which they identify.
When necessary and appropriate, enlisting the aid of a culture navigator—someone of the same culture with lived experience who is grounded in SUD treatment and recovery from substance use–related problems.
WHAT DOES CULTURAL RESPONSIVENESS MEAN?
Although peer workers can benefit from learning the common values, customs, beliefs, rituals, and worldviews of different cultures, they can best provide culturally responsive recovery support by learning about each individual's own experiences and what culture means to them.274 The kinds of cultures and pathways of recovery with which individuals might identify include:
Ethnicity, race, class, gender and gender identity, age, sexual orientation and identity, and disability cultures and identities. Many different types of cultures and backgrounds shape each person's worldview. This can lead to bias when peer workers support people in or seeking recovery from different cultures and backgrounds. They should read books, watch films, attend cultural events, and talk with local community leaders to learn about the specific beliefs and needs common to various cultural groups.
Community culture. The location where someone lives can significantly impact their worldview, values, and how they or their local community view substance use treatment and recovery support. People living in rural areas, for example, may experience stigma about seeking SUD treatment, including taking medications for problematic substance use.275 Peer workers should ask the individual in or seeking recovery questions so they can gain a better understanding about where the individual grew up, where they are currently living, and how they or those they are close with feel about problematic substance use. Being culturally responsive requires that peer workers respect the values of those they are working with, regardless of their own worldviews.
Cultures of recovery. These might include mutual-help programs (e.g., 12-Step recovery groups, non-12-Step recovery groups), mental illness recovery groups, recovery community centers (RCCs), sober houses, criminal justice recovery programs, spiritual recovery programs, military and veteran programs, family support groups like Al-Anon, gender-specific programs, and collegiate recovery programs. Values, beliefs, and practices regarding abstinence; taking medications during recovery; and risk-reduction practices may vary by type of recovery support and setting. Peer workers should understand the customs, values, and beliefs of different treatment and recovery settings and their rules on abstinence, taking medications to support recovery, and risk-reduction practices like syringe services programs. Cultural responsiveness means that peer workers honor and respect diverse recovery pathways as well as the individual's choice of recovery pathway.
Spiritual and religious beliefs and cultures. Research shows that spirituality, religious activities, and active involvement in 12-Step mutual-help programs can support long-term recovery.276 However, there is a wide variety of spiritual and religious beliefs about problematic substance use and recovery, spiritual practices that support recovery, and faith-based groups and communities (e.g., Celebrate Recovery®; Millati Islami; Buddhist Recovery Network; Jewish Alcoholics, Chemically Dependent Persons, and Significant Others) with different views on spirituality, substance use–related problems, and recovery.
Some individuals won't consider spirituality or religion to be an important part of their recovery. Peer workers should be knowledgeable about nonreligious alternatives for recovery support.
A peer worker should be aware of and respect the variety of nonreligious (e.g., Self-Management and Recovery Training [or SMART] Recovery®), spiritual, and religious groups providing support for recovery from problematic substance and alcohol use.
Chapter 8 provides a list of faith-based and non-faith-based mutual-help programs.
DELIVERING PEER SUPPORT IN RURAL AREAS.
Learning how to “walk in someone else's shoes.” Peer workers should explore their own culture and biases and cultivate an open-minded approach to others’ cultures. This includes participating in training about stereotypes, implicit bias, microaggressions (i.e., subtle, often unintentional statements or actions of prejudice against a person or group), and stigma. Peer workers should remember that people are diverse, including within cultures, so whatever they learn about an entire group may not apply to a specific individual.
The “Resource Alert: Cultural Competence” contains more information about cultural responsiveness.
CAN PEER SPECIALISTS HELP REDUCE HEALTH INEQUITIES?
RESOURCE ALERT: CULTURAL COMPETENCE.
Motivational interviewing (MI) is widely used in the SUD treatment field as an evidence-based practice for helping people address mixed feelings about changing behaviors and strengthen their motivation to change behaviors, including substance use–related behaviors.295 MI is also a philosophy of care that focuses on compassion and respect for individuals’ independence. (A link to more on this approach can be found in the “Resource Alert: Using the MI Philosophy of Care.”) Using MI as a treatment approach takes additional study and training beyond the scope of this TIP. However, many peer specialist training programs include information on MI, and understanding how to use the MI philosophy can help peer specialists develop a person-centered, team-based, empathetic approach and communication style.296 Using the MI philosophy as a peer specialist means expressing or showing:297
Partnership—Working with individuals as teammates rather than telling them what to do
Acceptance—Respecting the worth and independence of individuals through affirmations and empathetic listening
Compassion—Valuing the well-being of individuals
Evocation—Asking individuals about their thoughts and ideas
Using an MI philosophy shows individuals in or seeking recovery that peer specialists:
Know when to speak, when to listen, and when to ask questions.
Genuinely care about them and listen to them.
Understand ambivalence and resistance.
Are truly accepting and respectful.
Offer encouragement and hope.
Want to understand their experiences and feelings.
RESOURCE ALERT: USING THE MI PHILOSOPHY OF CARE.
OARS: THE KEY TO EFFECTIVE COMMUNICATION IN MI.
There are many recovery pathways, and each person will experience this journey differently. Recovery for one person may include abstinence from substance use, whereas another person may focus on reducing their use. For some individuals, recovery may mean abstinence from one substance, but not from all substances. A person's recovery experience may vary by the type of recovery, how recovery is initiated, their recovery identity, relationships supporting recovery, and the stability of recovery, among other factors.299 Some individuals may not want to embrace a recovery identity. Rather, they embrace any positive change. Understanding that each person builds their own recovery journey is important to meeting them where they are and understanding the challenges they are facing. Most importantly, peer specialists should respect an individual's choices as they navigate this process.300
RESOURCE ALERT: UNDERSTANDING DIFFERENT RECOVERY JOURNEYS.
The transtheoretical model of the stages of change illustrates how people change health risk behaviors.301 The stages of change theory is often used as a clinical tool and may be used as part of the treatment services delivered by the peer specialist's agency as well as their work.302 (The “Stages of Change” box contains more details.) Awareness of the stages of change may help peer specialists understand the mindset of individuals as they move through the recovery process. Remember, an individual in or seeking recovery may be in a different stage of change for different risk behaviors (i.e., in the action stage around their problematic alcohol use but in precontemplation around their drug use). Different stages of change require different responses to support that stage.
STAGES OF CHANGE.
Although there is no specific timeline for achieving recovery, research indicates that it is a progressive process that leads to improvements in quality of life, self-esteem, and happiness over time.304 In a nationally representative sample of U.S. adults who identified as being in recovery, measures of happiness and self-esteem appeared to drop during the first few months of recovery; however, this was followed by a gradual increase in these areas beginning 6 to 12 months into recovery.305 Quality of life, happiness, and self-esteem also improved significantly during the first 6 to 11 years in recovery. The same study found that it takes approximately 15 years of recovery, on average, to reach the same quality of life as the general population.306 Among those who continue to stay in recovery, recovery capital appeared to increase over time up through 40 years of recovery.307
Initiating recovery and maintaining change over time may be a long-term process. Although a counselor may work with an individual mainly at the start of recovery, peer specialists may also work with that individual throughout the full process of recovery.
SUPPORTING A PERSON's INDIVIDUAL RECOVERY JOURNEY.
Recovery capital refers to the resources that are available to individuals that can help them enter and stay in long-term recovery from substance use–related problems.309,310 These resources can be internal or external. Internal resources include values, knowledge, skills, abilities, self-efficacy (i.e., individuals’ thoughts and beliefs that they are able to achieve a goal or complete a task), and hope. External resources include employment, safe housing; financial resources; access to health care; and social, family, spiritual, cultural, and community supports.311 Recovery capital can fall into several categories:312
Personal recovery capital. This includes “physical recovery capital” such as financial stability; food; access to transportation and safe housing; and physical health as well as “human recovery capital” such as values, knowledge, educational/job skills, problem-solving skills, internal motivation or commitment to recovery, and self-awareness.313
Financial stability is a key source of physical recovery capital. People with problematic substance use who have financial resources have more access to SUD treatment and services than those who don't.314
Poverty and lack of economic resources are some of the factors in health disparities (e.g., mental health, physical abilities, stigma, ethnicity) that can make accessing services difficult for people of diverse genders, classes, sexual orientations, gender identities, and ethnic and racial groups.
Family/social recovery capital. This includes intimate relationships, biological family, family of choice, friends, and social relationships at school, work, faith-based institutions, and community organizations that support individuals’ recovery efforts. Family and social resources often provide emotional support during life crises and help individuals initiate and sustain recovery.315
Community recovery capital. This includes attitudes, policies, and resources available in communities that promote the resolution of recovery from substance use–related problems through diverse pathways.
Cultural recovery capital. This includes the availability of culturally prescribed recovery pathways that help support individuals and their families. Cultural recovery capital also includes the values and beliefs associated with a culture that supports recovery.316 Obstacles to accessing cultural recovery capital can include religious and language barriers.
Peer specialists can help educate individuals about recovery capital and ways to expand their access to resources that support recovery.317 Having greater recovery capital is associated with positive outcomes, such as SUD treatment completion, attendance at follow-up appointments, and meeting one's recovery plan goals.318,319 Talking with individuals about their recovery capital is not only a useful way to explore the many factors that support recovery and the different recovery pathways—it is also at the core of peer work.320
Peer specialists should understand the concept of recovery capital and use it in a strengths-based and person-driven approach to providing recovery support. This includes collaborating with individuals to help them identify, access, and practice using their recovery capital. They also can help their local community boost its recovery capital.
The “Resource Alert: Identifying, Accessing, and Building Recovery Capital” contains more information about how to measure and grow one's recovery capital.
RESOURCE ALERT: IDENTIFYING, ACCESSING, AND BUILDING RECOVERY CAPITAL.
Certain core values and ethical principles of PSS can help peer workers provide effective and ethical services to individuals in or seeking recovery.
Values are qualities or ideas that a person, family, culture, or community supports. Principles are guidelines or standards of behavior based on those values. Principles tell us what action might be harmful or helpful in a situation. For example, honesty is a common value of peer workers. An ethical principle based on that value is that peer specialists don't misrepresent their roles or responsibilities to individuals in or seeking recovery or the public.
Values are the basis of all ethical principles. Peer specialist codes of ethics vary based on state laws and the specific settings in which peer specialists are providing PSS. However, peer specialists share many ethical values, including:321,322,323
Hope. Peer workers inspire hope by showing through lived experience that recovery is possible for everyone. Hope isn't something peer workers can give to another, but they can lend hope to individuals by being a role model.
Authenticity. Peer workers share their stories of lived experience with individuals in or seeking recovery in a thoughtful way, focusing on how those stories benefit individuals. They should accurately represent their own recovery experience.
Honesty. Peer workers should practice honest, direct, and culturally responsive communication. This includes being honest with themselves and others, and doing so with compassion. Being honest includes admitting mistakes, such as misunderstanding how the individual needed help or failing to follow through on a promise to help an individual with a problem.
Cultural responsiveness. Peer specialists provide culturally responsive services to individuals in or seeking recovery and their families. They should be respectful and genuinely curious about cultural beliefs and practices that are different from their own and seek continuing education to expand their understanding of other cultures. Peer specialists should remember that differences occur within cultures. One person within a culture does not necessarily think, behave, or have the same beliefs as others in that same culture.
Respect. Peer workers treat individuals with dignity and honor their unique contributions to their communities and the world. They should practice patience, kindness, and warmth with everyone they encounter.
Open-mindedness. Peer workers are open-minded, nonjudgmental, accepting, compassionate, empathetic, and willing to “walk in someone else's shoes.”
Tolerance. Peer workers support multiple recovery pathways in their work with individuals in or seeking recovery.
Cooperation. Peer workers engage in relationships that are cooperative (meaning both they and the person in or seeking recovery work together). Instead of being an expert that the person looks to for help, peer workers engage in a mutual exchange. Peer workers should be open to learning from the individual in or seeking recovery, be respectful, and honor the relationship, while recognizing the importance of relationship boundaries.
Being clear and open. Peer specialists use plain language and provide clear and understandable information to people about the peer specialist's role and what to expect when receiving PSS. They also provide information about privacy and confidentiality.
Using a person-driven focus. Peer workers honor and respect that there are multiple recovery pathways. They recognize that program clients have fundamental rights to make decisions about their own lives and give those individuals information about their options. Peer workers should always be clear that clients have the final say and respect their clients’ decisions.
Maintaining a strengths-based focus. Peer specialists focus on what is going well—not on what is going wrong. They focus on individuals’ strengths, assets, and options instead of their deficits, challenges, and pathology. Peer specialists should use person-first language to demonstrate their understanding that people are not defined by their problems (e.g., saying “person who is between housing” rather than “homeless person,” “person with substance use–related problems” rather than “an addict” or “a user”). Peer specialists emphasize to individuals in or seeking recovery how PSS and strengths can be used to address problems related to substance use.
Having a holistic recovery and wellness focus. Peer specialists recognize the physical, mental, emotional, relational, and spiritual aspects of recovery. They recognize that recovery can be a life journey and that wellness is a goal for many people in or seeking recovery. Peer specialists should be aware of and open to both spiritual and nonspiritual pathways.
Codes of ethics are important tools that help protect program clients from harm and protect peer specialists by offering guidance on appropriate relationship boundaries and potential conflicts of interest. A peer specialist's vocational role is different from the vocational role of a treatment provider, in part because of factors that may shape their relationships with individuals in or seeking recovery.324
For example, a peer specialist's relationship with an individual in or seeking recovery may last longer than a counselor's or other treatment provider's relationship with that individual, and their services may be delivered in various settings, where there are many more kinds of relationships with individuals, families, and members of the recovery community. Relationship boundaries exist but may be more flexible as well as more complex in community settings than they are in traditional healthcare or behavioral health settings.
Ethics and behavioral standards are broad topics that cannot be fully addressed here. Peer specialists can become better at their job by learning their vocation's ethical guidelines, the ethical guidelines at their organization or agency, and their state's ethical guidelines. They should do this before problems arise so that they already know the best way to respond to ethical problems and difficult situations. Their supervisor can help them navigate specific ethical concerns they may have when working with an individual in or seeking recovery. Chapter 5 contains more information about peer supervision.
ETHICAL PRINCIPLES OF TELEHEALTH-BASED PSS: IMPACT OF THE COVID-19 PANDEMIC.
Chapter 6 and the resources listed below in “Resource Alert: Ethical Guidelines for Peer Specialists” contain discussions of ethical behavior by peer specialists.
RESOURCE ALERT: ETHICAL GUIDELINES FOR PEER SPECIALISTS.
Peer specialist codes of ethics should flow from the needs of individuals in or seeking recovery and the values of local communities of recovery.332 Depending on state laws, their work setting, and funding source requirements, peer specialists may have to follow certain guidelines that sometimes challenge their core values. For example, a peer specialist employed by and supporting an opioid treatment program is working with an individual in recovery. The program has rigid rules about engaging in any other drug use while receiving medication. The individual explains to the peer specialist that they drink one beer along with using a little cannabis daily to assist with falling asleep, but the dose is small enough that it has not shown up on biometric tests. The peer specialist does not see this as a breach of the treatment program rules based on the negative biometric tests and struggles to determine if it is acceptable to keep the information between the individual in recovery and themselves. However, they ultimately decide that the best and most helpful plan is to talk with the program clinical director and together determine next best steps that help the program client fully engage in the program while still feeling supported by the treatment and recovery team.
When a peer specialist faces challenges to their core values, their supervisor or program manager can help. This may include engaging in an ethical decision-making process where the peer specialist looks at all the people who might be affected by their actions and determining whether these actions might harm one or more of them.333 (The “Ethical Decision Making” section contains more information.)
Maintaining good relationships between service providers and service recipients is one of the most challenging aspects of ethical decision making. If the peer specialist's program or organization doesn't have specific ethical guidelines, they should talk to their supervisor about how they can be developed and how ethical problems can be discussed and addressed. Exhibit 3.2 provides an example of guidelines for peer specialist boundaries. These guidelines may not apply in some work settings.
EXHIBIT 3.2. Peer Boundaries.
Although a list of do's and don'ts may be helpful as general guidelines, they never cover every situation where a problem might arise. There isn't always a clear “right” answer to a potential ethical concern. An ethical decision-making process can help a peer specialist find the “best” (not the “right”) course of action in any ethical dilemma. Exhibit 3.3 lists a series of questions that can guide the decision-making process. Peer specialists shouldn't make ethical decisions alone, especially when there is a strong risk of harm to others. Instead, they should first talk with their supervisor or even another peer worker before taking action.
EXHIBIT 3.3. An Example Peer Worker Ethical Decision-Making Process.
Knowing the limits of the peer specialist role is a key ethical principle. A peer specialist is not a counselor, medical provider, mutual-help sponsor, or cleric. Peer specialists serve as resource navigators and recovery guides.336 (Chapter 2 discusses peer specialist roles in greater detail.) Peer specialists should understand their professional boundaries, knowing when they are outside those boundaries, and returning at once to their “lane.” A peer specialist who also holds licensure as a clinician cannot serve in both roles. Clinical and nonclinical roles should always remain separate to avoid ethical conflicts. Peer specialists should work closely with their administrator and supervisor to ensure that their role is clearly defined. Exhibit 3.4 lists some signs that a peer specialist may be crossing their role boundaries.
EXHIBIT 3.4. Recognizing When a Peer Specialist Is Out of Their Lane,.
Seeking out and continuing to receive regular supervision are standards in most codes of ethics. One of the most important ways peer specialists can avoid ethical conflicts is to have regular conversations with their supervisors or participate in a peer supervision group. Peer specialists should think about their supervision meeting not only as a time to discuss specific situations with individuals in or seeking recovery but also as a time to develop their peer specialist skills and career. Professional development includes participating in ongoing continuing education and training. Peer specialists should talk with their supervisor about the kinds of training that might be helpful to them and how their organization can support their participation in these activities. It is also a time for them to talk with their supervisor about professional advancement at their organization. Peer specialists should think of their supervisor as someone who can mentor them about career development, and they should meet with their supervisor regularly to talk about this. (Chapter 5 includes further discussion of peer supervision.)
Other activities peer specialists should talk to their supervisor about include:
Their workload and its impact on their self-care and work–life balance.
Specific concerns they have about individuals with whom they're working.
Next steps for the individuals with whom they're working.
Issues related to cultural responsiveness.
Situations in which they experience reactivation of their own trauma or secondary trauma.
Administrative tasks, such as timecards, documentation, and managing work schedules.
Time management.
Role drift and strain.
Professional goals, strengths, and growth areas.
Unethical behavior that they observe.
Concerns about the organization for which they work.
Coordinating and communicating with colleagues, team members, and staff at other organizations.
These tasks are important pieces of professional development, and their supervisor can help them develop these skills.
Peer specialists can talk with their supervisor about are how they're doing in their role as a peer specialist, resources they have in place to support their own health and wellness, and any suggestions they have for how to help ensure that the workplace culture supports the health and wellness of all staff. For instance, it isn't the peer specialist's job to solve a person's problems, provide mental illness treatment, or answer medical questions. The peer specialist's supervisor can be a valuable resource to help them understand their role and give them feedback when they have questions about relationships with individuals in or seeking recovery and treatment or service providers.
In addition to participating in regular meetings, peer specialists may want to contact their supervisor when:
They receive information about a person's condition or are concerned that they're not trained to address a situation (e.g., sexual assault, mental illness, past trauma, criminal behavior).
They think there is an issue of child or elder abuse or a concern about a person self-harming or hurting someone else.
They start to feel overwhelmed and are concerned that their own recovery is at risk. Their supervisor can help connect them to resources, such as an employee assistance program.
They start to have romantic or sexual feelings for the individual in or seeking recovery. It is common to have some feelings (positive or negative) about the people with whom a peer specialist works. In these cases, a peer specialist should seek their supervisor's guidance early and as needed.
They have feelings of anxiety, anger, or helplessness if the recoveree they're helping is in crisis or has returned to problematic alcohol or substance use.
The person has questions that the peer specialist can't answer on the spot (or at all). Peer specialists should remember that it's okay to say, “I don't know, but I will talk to someone and get back to you.” Peer specialists should follow up with the person as promised.
Peer specialists should work with their supervisor to develop a trusting relationship where they can receive the support they need to do their job effectively. They should advocate for themselves when needed.
Participating in self-care is an ethical principle based on the value of holistic recovery and wellness. Peer specialists should remember that their own recovery comes first. They can't be helpful to another individual in or seeking recovery if they're not taking care of their own recovery. Working in SUD treatment isn't a substitute for one's personal recovery.
“Peer support providers, like other caregivers, need to be aware of stressors commonly associated with the work of a helping role and to take steps to maintain their own wellness in the face of frequently encountered stressors associated with their work.”339
Like all team members, it can be easy for peer specialists to work long hours or ignore their own basic needs, like getting enough sleep or eating well, when the demands of their job take over—especially when they're working with individuals who have co-occurring conditions or have experienced trauma. In addition to their individual job-related demands, a peer specialist's organizational culture may contribute to their job-related stress.
Some common individual- and organizational-level stressors that peer specialists may face and that may affect their well-being include:340,341
Working with coworkers who don't understand their role and value, and therefore do not include them in or make them feel part of the recovery team.
Feeling stigma about their role as someone with lived experience with problematic substance use and recovery.
Being mistreated by coworkers or supervisors, including experiencing discrimination and microaggressions (i.e., subtle, often unintentional statements or actions of prejudice against a person or group).
Being unclear about their role, which can lead to role confusion, role drift, and role strain. (More on role clarity can be found in Chapter 2.)
Not having support and training opportunities to improve their skills as a peer specialist.
Receiving low pay or no pay at all (i.e., working as a volunteer).
Having supervision that doesn't meet their needs or is too infrequent (or even nonexistent).
Finding it hard to incorporate their services into their organization's treatment models or teams.
Not knowing how to stay within ethical boundaries with individuals in or seeking recovery, especially because they must play a dual role of being both a service provider and a confidant to them.
Worrying about their own recovery and emotional and physical health.
Experiencing compassion fatigue (i.e., the physical and emotional stress from caring for another, such as someone with an illness or someone with trauma) or burnout.
Being reminded of their own struggles with substance use–related problems and trauma, including feeling and having to manage “triggers” and re-traumatization.
Having difficulty finding their own space with individuals in and seeking recovery with whom they interact at work and who are also present in their personal mutual-help groups.
Working with individuals who are difficult or with those whose problematic substance use is more severe than what they experienced and are familiar with.
Exhibit 3.5 offers self-care tips and activities peer specialists might want to participate in. The paper “State of the New Recovery Advocacy Movement” contains further discussion about peer worker “rituals” for self-care (https://www.chestnut.org/resources/5cd82f5d-f9cb-4e50-8391-7eadb9700e34/2013-State-of-the-New-Recovery-Advocacy-Movement.pdf).
EXHIBIT 3.5. Self-Care Tips for Peer Workers.
This section looks at the specific skills peer specialists need to support individuals in or seeking recovery.
Being present is a key part of building a successful relationship with an individual in or seeking recovery. Peer workers should both listen to and have empathy for the person in or seeking recovery. It means being aware of, acknowledging, and managing biases as a peer specialist. Peer workers may not need to do more than sit with the person and listen to them without judgment. Peer workers will know that they're present in their conversation with an individual in or seeking recovery when:
Their attention is open and focused on the person's concerns.
They quickly bring their attention back to the person if their mind wanders.
They're genuinely curious about the person's concerns and maintain a nonjudgmental attitude.
They're listening fully, meaning they're listening for feeling and meaning, not just listening to the actual words a person says. They should watch for nonverbal clues like open arms, slumped shoulders, or eye contact. They should also listen for the problem and for possible solutions.
To build a relationship with an individual in or seeking recovery, peer specialists should keep their attention on that person instead of on their own ideas or on another service provider's ideas about what is good for the person. The individual in or seeking recovery should be at the center of the conversation. (At times, the person might want to shift the conversation, because talking about oneself can be hard or uncomfortable.) The box “A Peer Specialist Story: The Art of Connecting” shows an example of this.
THE FIRST MEETING.
A PEER SPECIALIST STORY: THE ART OF CONNECTING.
Genuine curiosity is an important part of person-centered helping. If a peer specialist is curious about the individual in or seeking recovery, they're not thinking about their own ideas or how to direct the conversation. They're thinking, “What's this person's story?” When an individual feels like the peer specialist is truly interested in their story, they naturally become more open and less defensive. The box “A Peer Specialist Story: Being Curious” describes how to show genuine curiosity.
One of the most effective ways for a peer specialist to build a sense of curiosity is to practice mindfulness in their own self-care routine. Mindfulness includes:345
Nonjudgmental awareness.
Paying attention to the present.
Staying aware of experiences as they unfold.
Keeping an open, accepting attitude.
A PEER SPECIALIST STORY: BEING CURIOUS.
“Mindfulness is versatile and can be applied to all states and activities. We can do any number of regular daily activities mindfully: showering, brushing teeth, walking, and eating. What is important is the intent, the focused attention in the present moment, and the attitude.”346
RESOURCE ALERT: LEARNING MINDFULNESS.
Learning to ask questions skillfully, an MI technique, first means knowing the difference between closed questions and open-ended questions. Closed questions ask for short answers or “yes” or “no” responses.347 They ask for specific information. People seeking services can sometimes feel like they are being interviewed if they are asked a lot of closed questions. “Why” questions often feel like complaints or judgments. For example, when an individual in recovery returns to problematic alcohol use, asking, “Why did you start drinking again?” can feel like the peer specialist is judging them even though that is not their intent. Instead, the peer specialist could ask, “How long were you in recovery?” “What was helping you not to drink?” or “What changed?” Questions that start with “how” or “what” feel less judgmental and more open.
Closed questions can make people feel like they are supposed to have the right answer or any answer at all. For example, “How are you feeling?” often leads to a one-word answer or an “I don't know” response. This question is very hard for individuals to answer in early recovery when they may be feeling alone or confused. Peer specialists don't need to avoid closed questions all the time. Sometimes they need to use closed questions to get specific information to provide services or review progress, such as “When was the last time you drank?” If a peer specialist needs to ask closed questions, they should try not to ask two or three in a row.
Open-ended questions invite people to tell a story. These questions help individuals in or seeking recovery feel like what they have to say is important. (“A Peer Specialist Story: Asking Questions Skillfully” provides a clear example of skillful questioning.) Another kind of open-ended question that invites storytelling is a “Tell me about …” statement. For example, instead of asking the person, “When was the last time you drank?” peers might say “Tell me about the last time you drank.”
Learning how to ask open-ended questions is an important part of asking questions skillfully. Skillful questioning techniques include:
Asking “how” or “what” questions from a place of true curiosity.
Avoiding the question “How are you feeling?” which usually leads to a one-word answer or an “I don't know” response.
Avoiding “who,” “when,” or “why” questions unless there is a need for specific information.
Using “Tell me about …” or “Tell me more about …” to elicit a story from the individual in or seeking recovery.
Avoiding asking several closed questions in a row.
Being open and nonjudgmental when asking questions.
Being curious and asking questions that you don't already know or think you know the answer to.
Remembering to ask questions in ways that help the person tell a story instead of giving a short answer.
More Examples of Skillful Questions.
A PEER SPECIALIST STORY: ASKING QUESTIONS SKILLFULLY.
Empathetic listening is also called active listening or reflective listening. The most important principle of empathetic listening is, “Listen more, talk less.” Peer specialists can become more empathetic listeners if they practice these listening skills:349
Paying attention. Paying attention requires practice and focusing on the person's concerns rather than on the peer specialist's thoughts. When their mind wanders, peer specialists should take a breath and refocus their attention on the individual in or seeking recovery.
Looking for nonverbal signs. Does the person the peer specialist is speaking with seem uncomfortable? Nervous? Impatient? Upset? Peer specialists should look for the individual's nonverbal behaviors and learn about cultural differences in how people express themselves nonverbally. For example, in American culture, eye contact is seen as a positive sign that a person is paying attention. In some cultures, though, it is a sign of disrespect.
Using reflective listening strategies:350
Simple reflections. Peer specialists should listen to what the person says, then either repeat back or summarize what they heard. This is the simplest form of reflective listening and shows the person that the peer specialist is listening.
Complex reflections. Peer specialists should listen to the statement, make a guess about either the feeling or meaning of the statement, then share that best guess with the individual in or seeking recovery. Peer specialists should be open to the possibility that they may be wrong, so they may need to ask the person to explain what was meant.
Summarizing and focusing. When the person has talked about several different issues, the peer specialist should summarize what they heard. They should then ask if it would help to focus on one item and which one to start with.
Reflecting the positive. It's imperative to listen carefully for the smallest sign of what is going right in the person's life. This includes talk about changing attitudes and behaviors, solutions to problems, ways the person has coped, strengths, abilities, and hopes for the future. Peer specialists shouldn't ignore the problems, but they should spend more time talking about the positive in their reflective listening responses.
Allowing silence. When people are uncomfortable with silence, they tend to talk or ask questions to fill up the space. Peer specialists should practice being silent in their conversations with the individual in or seeking recovery. Silence helps the person self-reflect and lets them tell a story.
Avoiding roadblocks to listening. When someone comes to a peer specialist with a problem, their first reaction might be to try to fix it. Instead of doing that, peer specialists should first listen to the person. Once the individual in or seeking recovery feels fully heard, the peer specialist can move on to brainstorming and trying to find solutions. Common roadblocks to effective communication can include:351
Ordering or directing.
Warning or threatening.
Moralizing or preaching.
Giving advice or providing solutions.
Persuading with logic, arguing, or lecturing.
Judging, criticizing, or blaming.
Name-calling, ridiculing, or labeling.
Analyzing or diagnosing.
Diverting, using sarcasm, or withdrawing.
Focusing the conversation on the peer specialist rather than the individual in or seeking recovery.
Some of these practices may be okay to use sometimes. For example, praising an individual in or seeking recovery for successfully completing a recovery goal might be helpful. However, if the peer specialist tends to praise or give advice a lot, they may need to start listening again and shift the focus back to the individual in or seeking recovery.
One study found that emotional support in the form of empathy and encouragement was the type of peer worker support most mentioned by individuals as being important to their recovery.352 Peer specialists can be more encouraging by:
Supporting people who are identifying their values, strengths, skills, and abilities. Many people, especially in early recovery, have a hard time knowing what their strengths and abilities are. Helping people discover what is important in their lives and recognize their abilities can give them hope and shift their attention to what is positive instead of what is negative about their life or experience.
Showing that they have faith in the individual's capacity for change. This means knowing that all people can change their attitudes and behavior to have a better life for themselves and their families. Sometimes a simple statement like, “I know this change is hard, but I know you can do this” or “things do get better” can show that the peer specialist has faith in them.
Offering affirmations skillfully. Affirmations are different than praise. When a peer specialist offers an affirmation to people, they remark on a strength or a value that is helping them move forward in recovery. For example, they might say, “You're really committed to getting to meetings. When you set your mind to something, nothing can stop you.” Avoid praising with general statements like “Great job.”353
Celebrating the individual's efforts and reaching their goals. Remember to celebrate the individual's efforts to start and stay in recovery. No success is too small to celebrate. For example, in 12-Step groups, a 24-hour chip/key tag is a way to recognize and celebrate 1 day of not drinking or using drugs.
One of the primary tools peer workers already have is sharing their story with individuals in or seeking recovery. When they share their story strategically, peer workers can inspire hope by letting individuals see the possibilities for a life in recovery that might not have been available before. Peer workers should be careful to avoid supporting any one idea of what recovery should look like based on their own experience. They shouldn't assume their experience with problematic substance use and recovery will be the same for others.
Peer workers should recognize when and how to share their personal recovery stories. General guidelines for sharing their story include:
Knowing when, where, how, and why to open up. Peer workers should use their story to create rapport and enhance hope. They should be clear about the specific reason behind sharing their story and why they're sharing it at that time.354 They should ask themselves, “Does my story:355
Focus on recovery and not active use?”
Relate to and express empathy for the individual's circumstances?”
Enhance connection and mutual identification?”
Elicit hope and express the value of long-term recovery?”
Normalize the individual's experiences in recovery?”
Model recovery language?”
Benefit the individual in or seeking recovery?”
Being brief. When a peer worker goes on at length, the focus shifts from the individual in or seeking recovery to them.
Connecting the peer worker's story to the experience of the individual. Peer workers should match their story to the person's stage of change and recovery journey. They can highlight parts of their story relevant to the individual at that time in their recovery.
Being culturally responsive. A peer worker's story should demonstrate respect for the diversity of recovery and cultural experiences of the individual. They should be open for the person to respond with a different experience than their own356 or to not respond at all.
Recognizing boundaries around sharing personal information. Peer workers should recognize that their boundaries may be different when sharing with an individual in or seeking recovery or when sharing their story as part of an educational group or community outreach effort. For instance, there may be personal details that are appropriate for them to share with someone in one-on-one conversations that they would not share with an entire group. Peer workers should share what they feel comfortable sharing. They should remember that sharing their story is intended to inspire hope rather than serve as an opportunity for them to process specific details about their experiences in recovery. Peer workers should ask themselves if they're willing to let others know about:357
What happened and any feelings about difficult times in their lives, including periods of active problematic substance use.
Which attitudes and approaches did not help their recovery.
Which plans, supports, and resources helped them in recovery.
How their life has changed in recovery.
Where they see themselves in the future.
Being prepared for follow-up questions. After sharing their story, the individual in or seeking recovery may ask the peer worker additional questions about their recovery journey. Again, peer workers should share what they feel comfortable sharing.
Exhibit 3.6 defines the three parts of telling a recovery story.
EXHIBIT 3.6. Three Parts of Storytelling for Peer Workers.
THINKING ABOUT STORYTELLING.
Physical and emotional safety are necessary for successful recovery. Within the appropriate limits of their role, peer specialists can support individuals’ physical, mental, and emotional safety.361 Ways to do this include:
Maintaining a trauma-informed focus. Peer workers need to recognize that people with substance use–related problems have often experienced trauma. Peer workers should be kind and avoid confrontation and other actions that might remind program clients of previous traumatic events.
Focusing on their basic needs first. Peer workers should help individuals in or seeking recovery take care of basic needs such as food and safe housing. When a peer specialist meets with people, they should be offered food and water, if possible. And they should be met in safe locations in the community.
Recognizing that risk behaviors (e.g., self-harm, problematic substance use) are often a way of coping. Peer specialists should try to be open instead of judgmental and listen genuinely and with care and concern. They should be respectful and help program clients discover other ways to reduce stress that have worked for them in the past or introduce them to new ways to reduce stress.
Knowing and discussing with supervisors the signs of and risk factors for being in crisis. If a peer specialist notices that individuals in or seeking recovery are acting differently or appear to be stressed, they should tell their supervisor what they're observing. They shouldn't be afraid to ask people direct questions about thoughts and plans to harm themselves or others. Peer specialists should be aware that individuals in or seeking recovery may have experienced institutional trauma (i.e., trauma resulting from action or inaction by an institution that the individual depended on and trusted), which can be made worse when crisis support is used incorrectly. They should help individuals create a “crisis card” with names of and contact information for support people who can be contacted in an emergency. Peer specialists should know how to link individuals in or seeking recovery to crisis or mental health resources in their community. This may include providing them with information about the 988 Suicide & Crisis Lifeline. Also, peer specialists should learn the situations in which they may need to call 911.
Focusing on the question “How can I help you feel safe today?” Peer specialists should keep their attention on the present. That also helps people stay focused on the here and now. Peer workers shouldn't drift out of their lane. They should help individuals in or seeking recovery find ways to feel safe in the moment, and they should avoid talking about the past or future.
“A Peer Specialist Story: Building Safety” discusses ways that peer workers can stay focused on safety.
A PEER SPECIALIST STORY: BUILDING SAFETY.
A recovery plan is different from a treatment plan. A recovery plan is largely created by the individual in or seeking recovery. The person in or seeking recovery claims ownership of the plan. A treatment plan is a clinical document that is primarily focused on addressing issues associated with a person's diagnosis. However, it may also address other life issues. The treatment program claims ownership of the plan. This is an important distinction. If a recovery plan becomes part of the person's medical record, the recovery plan is still the individual in or seeking recovery's plan. Ideally, the treatment plan and the recovery plan should reinforce one another, with each plan supporting the individual's recovery goals. A peer specialist's job is to support the person as they develop and take ownership of their recovery plan. Encouraging the individual to take ownership of their plan demonstrates the peer specialist's respect for their autonomy and self-determination.
“Recovery and wellness plans integrate all of the information that people have shared during the assessment about their lives, their strengths, and their challenges into a document that helps to guide the focus of the collaboration between peer workers and the people that they serve.”362
Peer workers should remember that individuals in or seeking recovery are the experts in their own lives, and the peer specialist is there to help them set recovery and wellness goals,363 address ambivalence, remove barriers to those goals, focus on tasks, and provide support so that they can meet their specific recovery and wellness goals. A recovery plan helps peer specialists and the individual stay focused and on task. It is a “living document”364 that should be revised often by the individual in or seeking recovery, as goals are met and new ones are created. The recovery plan is a roadmap for action.365
Based on their roles, providers and peer specialists have different ways of supporting an individual in or seeking recovery. For example, a provider and individual may agree to add “improve quality of life” to a treatment plan, and the peer specialist and individual in recovery may add it to a recovery plan. But the ways to meet that goal may look different on each plan. For example, only the peer specialist may drive or accompany a person in or seeking recovery to a recovery-oriented social activity, not a provider.
Ways to help individuals in or seeking recovery create a personally meaningful recovery and wellness plan include:366
Focusing on the person's most serious needs (e.g., finding a doctor to prescribe buprenorphine for opioid use disorder).
Exploring meaningful life goals set by the individual in or seeking recovery (e.g., “I want to get a better job,” “I want a safe and clean place to live,” “I need to stop drinking so I can get my kids back”).
Helping the person set wellness goals and activities that:
Support ongoing recovery from substance use–related problems.
Improve quality of life.
Enhance physical, mental, emotional, relational, and spiritual well-being.
Working with the individual in or seeking recovery to find specific tasks or steps to take to reach the goal (e.g., call a local sober house and find out how to apply for residency).
Talking about the person's strengths, resources, and sources of recovery capital as well as possible barriers to achieving a goal or taking a specific action.
Making sure the steps are realistic and manageable. Peer specialists want to increase the chances that the individual in or seeking recovery will succeed with each step taken to build their confidence and sense of achievement.
Keeping it simple, focusing on one goal at a time.
Maintaining flexibility. Goals may change over time.
Ensuring the person can easily retrieve their recovery plan by helping them store it in a place they access frequently (e.g., on their computer or their mobile device).
The recovery and wellness plan should include the following aspects of wellness, taking into account the individual's circumstances associated with social determinants of health:367
Emotional. Coping effectively with life and creating satisfying relationships
Environmental. Living in environments that support overall health and well-being
Financial. Becoming satisfied with current and future financial situations
Intellectual. Recognizing creative abilities and finding ways to build new knowledge and skills
Occupational. Getting personal satisfaction and self-improvement from one's work
Physical. Recognizing the need for physical activity, healthy foods, and sleep
Social. Developing a sense of connection, belonging, and a well-developed support system
Spiritual. Expanding a sense of purpose and meaning in life
Individuals in or seeking recovery may not have any recovery goals in one or more of these areas. Peer workers should stay focused on what individuals in or seeking recovery identify as their most important goals and help them prioritize which goal to work on first. (Sample recovery and wellness plans are included in the chapter appendix.)
A PEER SPECIALIST STORY: HELPING AN INDIVIDUAL IN RECOVERY DEVELOP A RECOVERY PLAN.
Although individuals are learning recovery skills, such as avoiding high-risk situations that might trigger a recurrence of problematic substance use, many may also need to learn basic life skills, like cooking, banking, and budgeting, basic housekeeping, problem solving, and job seeking.
Peer specialists work together with the person in or seeking recovery to develop a recovery plan. During this process, peer specialists can help the person in or seeking recovery to identify what skills they need to achieve their recovery goals. For example, if a recovery goal for an individual with whom the peer specialist is working is to find a job so he can move out of his parents’ house, he might need help with job-seeking skills, budgeting and banking, and interpersonal communication skills.
Many recovery and life skills are learned through engaging in recovery and recreational activities sponsored by recovery support groups, in life skills groups sponsored by recovery community organizations (RCOs), or in recovery residences or residential programs where people come together to identify and teach one another recovery and life skills. Peer specialists model specific skills in which they have been trained or connect the person in or seeking recovery to skill-building groups or resources in the community. Two of the most import areas of recovery and life skills are emotional/social skills and problem-solving skills.
People in or seeking recovery often need help understanding their problematic substance use and how feelings are part of substance use and recovery. For example, it is common to hear people in early recovery say things like, “When I get mad, I need to drink.” A peer specialist's task is to help individuals identify the feeling and discover other ways to think about or respond to the feeling instead of drinking. They can help people discover alternative reasons for why they feel something by asking an open-ended question like, “That's one way of looking at it. What's another way?”
Emotional skill-building approaches include helping individuals in or seeking recovery:
Identify basic feelings, such as anger, sadness, happiness, and fear. Peer workers should look for patterns.
Learn that it helps to talk about feelings instead of holding them in or acting on them immediately.
Discover other ways to respond to feelings by “thinking through” the feelings instead of engaging in substance use.
Learn to manage stress in different situations that might trigger a return to substance use.
Develop relaxation skills or participate in relaxation activities (e.g., meditation, exercise) to reduce the impact of intense feelings on thinking and behavioral reactions.
Peer specialists should remember to “stay in their lane.” It is easy to slip into the role of counselor when individuals in or seeking recovery are in an emotional crisis. When people experience intense or unfamiliar emotions (e.g., related to trauma or a mental illness) that are outside the scope of a peer specialist's services, the peer specialist should connect them to a behavioral health service provider who can help them manage their emotions. Peer specialists should work with their supervisor to learn how to spot and respond to crisis situations.
Many people in early recovery may not have much experience interacting with others in everyday life while they are not under the influence of alcohol or drugs. A peer specialist's goal is to help people learn effective communication and social skills that build social capital and enhance recovery. These five steps will help individuals in or seeking recovery learn new social skills that enhance recovery:
Identifying. Helping people identify specific social skills they would like to improve
Modeling. Modeling alternative ways of interacting with others
Rehearsing. Using simple role-plays to help people practice new skills
Practicing. Supporting people practice new social skills at home and in other community settings
Evaluating. Engaging people in evaluating the effectiveness of newly acquired skills, revising as needed, and asking, “What worked?” “What didn't work so well?” and “How could you do it differently next time?”
Individuals in or seeking recovery face everyday problems that can increase stress and the risk of returning to substance use. Helping them learn or enhance problem-solving skills can reduce stress, increase a sense of well-being and empowerment, and help them solve future problems more effectively.368 Problem-solving skills and the steps to the problem-solving process are:369
Identifying a specific problem. Peer workers should help the individual break down larger problems into small chunks, then work through creating solutions. For example, if the person says, “I am unhappy,” the peer specialists can ask an open-ended question like, “What are some things that make you unhappy?” This should help to uncover different pieces of the unhappiness problem that the peer specialist can work with, such as, “I don't have a job” or “I have to go to court for a DUI,” and “I don't have a lawyer.”
Creating possible solutions. When brainstorming possible solutions with the individual, peer workers should give the person time to come up with ideas and avoid jumping in too quickly to find the “right” solution. Peer workers can add their ideas, but they should make sure to let the individual in or seeking recovery know their ideas are not necessarily the best ideas.
Weighing the pros and cons. After making a list of possible solutions, peer workers should go through the list and ask the person, “What are the good and not-so-good things about this solution?” or “What are the pros and cons of this idea?” Talking about the pros and cons of each solution helps the individual in or seeking recovery decide which idea might be the best option.
Learning decision-making processes. Peer workers should explore with the person all available solutions to a problem and what they think is the best possible solution to the problem. They should remember that the problem-solving process isn't about finding the “right” answer but finding the “best” solution to the problem based on the individual's situation. If that solution does not work, the person can try the next best solution.
Putting the solution into action. Peer workers should help the person in or seeking recovery break down the solution into small steps. For example, if the problem is that the individual doesn't have a job and the best solution for her is going to a training program to become an auto mechanic, the peer specialist can help her break down the steps to doing this and determine how and when she will take each step. The peer specialist should discuss any problems the program client thinks she might face in putting the solution into action as well as possible ways to address those problems.
Resource navigating involves reaching out to and engaging individuals in community settings, advocating for individuals in or seeking recovery with providers, and actively linking people to treatment, recovery support, and other community resources. Resource navigating is about reaching out to people in or seeking recovery in the community and connecting them with other people in the community who can help. The “Resource Navigator” section in Chapter 2 contains more information.
Advocacy with a small “a” (i.e., advocacy on the person level rather than advocacy on a policy or legislative level) is about speaking up for individuals in or seeking recovery and their families and teaching them how to speak up and advocate for themselves. A peer specialist's role as an advocate is about not only being a “voice for others,” but also empowering them.370 Advocacy is about helping people work on personal and environmental problems that are making their recovery difficult. As peer specialists model self-advocacy, they are teaching individuals in or seeking recovery how to advocate for themselves. They may be called on to advocate on behalf of people with court officials; probation officers; child welfare agencies; employers; landlords; or more commonly, health, behavioral health, and social service providers.
For example, an individual in or seeking recovery might have difficulty talking with her primary care provider about the negative side effects of the medication she is taking. Advocacy in this situation might include:
Role-playing with the person how to have a conversation with the provider, with the peer specialist modeling respectful, assertive communication skills.
Having the person sign a release of information and sending a copy to the provider before making contact.
Calling the provider while the person is with the peer specialist and getting the conversation started.
Going to a medical appointment with the person to be a support.
To be an effective advocate, peer specialists need to know and be trained on:
How different systems (e.g., the healthcare system, the legal system) work.
What questions to ask.
How to communicate respectfully with providers in different settings.
Laws and regulations about confidentiality (e.g., federal laws such as the Health Insurance Portability and Accountability Act of 1996).
What the individual's concerns, needs, and goals are.
How to respectfully start a conversation between the provider and the individual in or seeking recovery.
The use of technology in accessing recovery support.
Experienced peer specialists may be called on to facilitate support groups, which will help them build their facilitation skills and show leadership in peer recovery support groups and community-based settings. The kinds of groups and meetings that peer specialists lead include:371
Recovery support groups.
Addiction recovery educational groups.
Life skills groups.
Peer-run advisory group meetings.
Peer supervision groups.
Community-based meetings.
Outreach presentations.
Focus groups.
Advocacy groups.
Community educational groups.
Recovery check-in groups.
Recovery house meetings.
RESOURCE ALERT: IN-PERSON AND ONLINE RECOVERY SUPPORT GROUPS.
The key to effective group leadership is applying person-centered principles to the workings of the group. This means creating a safer space where all group members can openly share and fully participate.372 In many ways, the guidance for peers who facilitate groups is the same as it would be for any behavioral health worker filling that role. Peer specialists shouldn't take over the conversation or make themselves the center of attention. They may take more of a central role when sharing information in educational groups or community presentations, but their primary job is to help the group discussion, not to be the center of it.
Here are some ways peer specialists can effectively help groups:373
Starting and ending the group on time, and building in time for breaks
Introducing group ground rules at the beginning of each meeting (e.g., whatever is shared in the room stays in the room unless there is a danger to the person or others, no personal criticism or attacks, respect the diversity of group members). The group can take an active role in creating rules to promote buy-in.
Presenting the agenda or asking participants to develop an agenda at the beginning of group, and sticking to the agenda
Focusing on the value and unique viewpoint of all members
Going with the flow of the conversation, but using redirection to bring it back on track when it goes off topic
Making eye contact with group members while they are talking, as appropriate
Demonstrating active listening skills, empathy, and respect for all group members
Using nonverbal communication techniques to get group members to participate in the discussion and show interest in group members’ views
Helping participants interact with one another by using their names and asking skillful questions
Avoiding expressing personal opinions or taking a stand on an issue
Asking permission to give feedback or suggestions. Peer specialists should use “I” statements when they need to offer feedback or suggestions (e.g., “I hear you saying that you're upset because …”).
Seeking guidance from supervisors to improve their group facilitation skills as well as to address group challenges
RESOURCE ALERT: PEER WORKER GROUP FACILITATION GUIDELINES.
Community building is the other main function of peer workers. Recovery community building includes any activity that supports the development of cultural and community resources where individuals in or seeking recovery can find and grow relationships with others who support long-lasting recovery.374 Helping to build or enhance the recovery community may not necessarily be a part of every peer specialist's job; however, this portion of Chapter 3 equips peer specialists with the key knowledge, values, skills, and abilities that can help them add this dimension to their work and take advantage of opportunities to advocate for, help create, and connect to community resources that support ongoing recovery for individuals and their families.375
Communities of recovery—such as RCCs and RCOs—are important parts of recovery-oriented systems of care (ROSCs) that offer a wide range of recovery services, including PSS, prevention and risk-reduction services, supportive housing (e.g., sober homes), and job training.376 RCCs are central sites for recovery support groups, recovery-focused social networking, skill-building, advocacy, and volunteer activities. RCOs are independent, nonprofit organizations led and governed by representatives of local communities of recovery that organize advocacy activities, carry out community education and outreach programs, provide PSS, or a combination of these. These settings offer a safe place for people to pursue their recovery goals and access resources. (More can be learned about these and other community recovery services and bodies in Chapter 1.) A peer specialist's tasks are to understand the different types and cultures of these communities of recovery as well as how they align with individuals’ chosen recovery pathways and cultural backgrounds.
SUPPORTING INDIVIDUALS IN RECOVERY WHO ARE TAKING MEDICATIONS FOR SUBSTANCE USE–RELATED PROBLEMS.
This section describes key values and attitudes that inform peer specialists’ work to build, enhance, and support communities of recovery.
The problematic substance use–recovery movement is a grassroots movement in the United States that brings the ideas about and values of recovery from traditional SUD treatment institutions and mutual-help groups into the larger community.379 This movement promotes key attitudes, beliefs, and values that are useful for guiding a peer specialist's work in community building, including the idea that recovery is possible for everyone, that there are many recovery pathways, and that recovery is a choice.380
Sharing the wisdom gained from lived experience with problematic substance use, behavior change, and recovery is a major job function of a peer specialist and one of the most important aspects of their ability to effectively offer individuals in or seeking recovery support.381 Their lived experience is also valuable to the recovery community. By networking with community-based settings and community outreach programs, peer specialists can increase awareness of substance use–related problems as well as help people access withdrawal management programs, reduce their problematic substance use, increase their use of residential treatment as needed, and reduce their risk of hospitalization.382 Through networking, peer specialists can also create connections and support a warm handoff between individuals in or seeking recovery and treatment providers or recovery communities.
A peer specialist's lived experience also benefits the recovery community by:383
Inspiring hope that recovery is possible and that people in or seeking recovery and recovery communities are strong.
Showing trustworthiness to individuals in or seeking recovery, the recovery community, and society.
Gaining the trust of people who are not ready to start recovery or participate in health and behavioral health services.
Modeling self-care.
Modeling a diversity, equity, and inclusion perspective that lets people know that peer specialists value their chosen path to recovery (even if it differs from their own) and will consider their unique needs when directing them to resources in the community.
Inspiring people to take an active role in their own lives and recovery.
Supporting community togetherness and improved quality of life for individuals in or seeking recovery and their families.
Supporting efforts for long-term wellness for people in or seeking recovery, their families, and communities.
Sharing with individuals in or seeking recovery, their families, and the recovery community the hard-won knowledge and know-how of someone who has successfully faced the challenges of the treatment, healthcare, and human services systems.
This section describes specific skills that peer specialists may use to strengthen their connections to recovery communities.
Training is essential for peer specialists to ensure they have the knowledge and skills to identify community resources and supports for individuals in or seeking recovery. Each community has different resources available; with training, peer specialists can learn how best to access these resources. Training can help peer specialists understand which community resources may be most critical to the person and offer guidance about organizations that offer these resources. For example, with training about how housing programs operate, peer specialists can learn how to access rental assistance—a resource that may be important to some people with whom they are working.
Training can also provide tools to help peer specialists recognize and manage their own biases when working with individuals in or seeking recovery, particularly when connecting them to culturally responsive resources. Related trainings may address such issues as how bias and privilege can affect helping relationships, the principles of cultural responsiveness, how stereotypes and microaggressions can affect relationships, and how culture and stigma may play a role in help-seeking behaviors.
RESOURCE ALERT: IDENTIFYING AND MANAGING BIASES.
A key part of a peer specialist's work is to identify community resources that may support different cultural groups and backgrounds. Examples of some of these resources include:
Safe Project (https://www
Live Another Day (https:
SMART Recovery® (https://www
Faces & Voices of Recovery LGBTQ+ Recovery Resources (https:
One Sky Center (http://www
White Bison's Culturally Based Healing to Indigenous People (https://whitebison
White Bison's Warrior Down/Recovery Coach (https://whitebison
Latino Recovery Advocacy (http://lararecovery
A community-based asset map (CBAM) is like a strengths assessment of an individual, but for an entire community. A recovery-focused CBAM focuses on all the elements of a ROSC that support recovery, wellness, and quality of life for individuals in recovery and their families. The map in Exhibit 3.7 shows a recovery-focused CBAM for resources in the entire state of Maine, not just a community, but the idea is the same: to map out locations of all the services that support recovery, with a goal of building connections among them.
EXHIBIT 3.7. Recovery-Focused CBAM of Maine.
A CBAM is more than a list of recovery resources. It is a visual representation of where resources are located and is an important tool for community-building efforts. A recovery-focused CBAM paints a picture of resources in the local community and helps peer specialists organize community members to strengthen or add to those resources.384
Peer specialists should work with individuals in or seeking recovery, family members, allies, and other members of the larger community to draw a CBAM in their area. They should remember that individuals in or seeking recovery are resources and have their own experiential wisdom. Bringing people together to map and organize community resources is itself a community-building action, helping participants feel they are contributing to something of value and experience a sense of hope and renewed energy.385 One study found that engaging recovery community members in a recovery-focused asset mapping project helped them identify gaps in services, develop health and recovery assets, build relationships within the community, and increase social capital to support recovery from problematic substance use.386
Involving recovery community members in the asset-mapping process adds experiential knowledge to the process and supports community-building efforts. Here are some ideas for engaging community members in creating a CBAM:387
Asset-mapping focus groups. Peer specialists can invite members of the recovery community (e.g., people in or seeking recovery, family members, friends, and allies), service providers, and other stakeholders to attend focus groups or asset-mapping workshops. A peer specialist's role is to facilitate conversations and gather feedback about treatment and recovery resources in the community.
Interviews. Peer specialists can conduct informal or semistructured interviews with recovery community members and service providers. They should use open-ended questions and skillful interviewing strategies to develop rapport and allow the interviewee to tell a story about the resource. Peer specialists can get addresses and specific contact information to add to the map.
Surveys. Peer specialists can develop a questionnaire that gathers important information about a local community resource that can be delivered in person, over the phone, or via email. Peer specialists should choose a method that works for them and the audience they're surveying.
Community walks. A community walk is a strategy that helps peer specialists identify a specific neighborhood's resources, like parks, libraries, churches, and recreation facilities, that might not be recovery specific but are assets that can support individuals’ wellness and quality-of-life goals. A community walk is also an opportunity to take pictures or videos (when appropriate) of resources that can be placed on the map, interview interested local community members, and hand out surveys.
Online maps. Peer specialists can use online mapping tools to work with interested recovery community members, service providers, members of peer recovery advisory boards, allies, and members of the local community to plot, map, and view community assets. Multiple users can access the same map to add or edit information. (The “Resource Alert: Online Community Mapping Tool” provides a valuable resource.)
RESOURCE ALERT: ONLINE COMMUNITY MAPPING TOOL.
Advocacy with a big “A” creates a bridge from individuals in or seeking recovery to the larger community (whereas advocacy with a small “a” is about the individual's own personal advocacy efforts). Depending on the peer specialist's work setting, they may be more focused on advocating for individuals; however, they may discover ways to build and increase recovery support resources in the community. For example, helping people register to vote is one way to help them have a voice in shaping laws and regulations around SUD treatment and recovery.
Advocacy in the larger community is about supporting local, state, and federal public policy changes that enhance and expand SUD treatment and recovery resources; advocating for diverse pathways to recovery; lowering barriers to access to services; and changing public attitudes about people with substance use–related problems so that individuals in or seeking recovery can participate fully in community life. Advocacy promotes social and community inclusion and seeks to change negative beliefs about problems linked to substance use and people affected by them.
“Advocacy is about turning personal stories into social action; it is about turning recovery outwards. Advocacy is about acquiring and using power to change the ecology of addiction and recovery.”388
Ways that peer specialists can participate in advocacy with a big “A” include:389
Working with recovery communities to engage in civic and cultural activities that promote recovery.
Providing recovery-focused public and professional education.
Supporting recovery-focused laws and policies.
Lobbying at local, state, and federal levels to promote social policies and programs that support recovery.
Advocating for recovery-focused SUD treatment and mental health services.
Advocating for local, state, and federal laws and policies that support PSS in ROSCs and SUD treatment.
Participating in or organizing national, state, and local recovery celebration events.
ADVOCACY WITH A BIG “A” IN AN RCO.
Advocacy with a big “A” can happen in informal conversations with treatment providers that lead to organizing recovery community members to attend a recovery lobby day event at the state legislature, working with community leaders to start a prevention campaign, or organizing recovery celebration events and inviting the media and state and local legislators, community members, and community leaders. No matter what form advocacy with a big “A” takes, the goal is to encourage prevention and harm reduction efforts, enhance recovery-focused services, provide hope, inform systems, reduce discrimination, and promote inclusion of people in or seeking recovery into civic life. If peer specialists engage in or are already engaged in advocacy work, they should attend advocacy and messaging training. They should also make sure to separate advocacy work they do on behalf of their employer from the advocacy work they do as an individual in recovery.
RESOURCE ALERT: KNOWLEDGE AND UNDERSTANDING OF COMMUNITY BUILDING.
There are many ways for peer specialists to take on a leadership role in the recovery community, including outreach and advocacy. A key leadership function, however, is to promote leadership development opportunities within RCOs, SUD treatment programs, recovery residences, and other community-based organizations, and connect individuals in or seeking recovery and family members to those opportunities.391 When people step into leadership roles, peer specialists can help them:392
Feel empowered and empower others around them early in recovery.
Take control of their treatment and recovery.
Strengthen the sense of community.
Foster personal growth.
A peer advisory council (PAC) is one resource for helping individuals in or seeking recovery to build a recovery community and learn leadership skills. A PAC is a volunteer council of people in or seeking recovery who are receiving services at a peer specialist's organization. Peer specialists can help the PAC get started and mentor people who serve in leadership positions in the PAC.393 If an organization doesn't have a PAC, a peer specialist can advocate for one.
LEADERSHIP IN RECOVERY RESIDENCES.
One thing that is often missing for people in early recovery is healthful social, recreational, and civic activities. A key activity for building or enhancing the recovery community is to provide ways for individuals to get involved in civic community life.
In addition to creating a PAC, peer specialists can develop or link people in recovery to other activities such as:
Volunteer opportunities at an RCC.
Volunteer opportunities in the community (e.g., food pantries, Habitat for Humanity).
Recovery celebrations.
Recovery-focused social and recreational activities (e.g., a substance-free softball team, chem-free dance).
Other social and recreational events (e.g., a hiking club, nature walk, book club, painting event).
Fundraising for nonprofits, charities, or social events.
Faith-based or spiritual activities.
Civic engagement (e.g., voter registration drives, local citizen councils or advisory boards).
RESOURCE ALERT: A GUIDE TO CIVIC ENGAGEMENT.
Recovery support and helping to build or enhance the recovery community are the main functions of peer specialists. These skills make up a wide range of functions peer specialists will perform; however, it isn't likely that they will be able to fulfill all of these duties at all times. Rather, in some settings or in certain situations, peer specialists may only be able to use some of the skills described in this chapter. They are still performing their job in a way that is respectful and values the recovery process as well as the people in recovery they serve.
Whether a peer specialist is sitting with an individual in or seeking recovery and helping them write out their recovery plan or giving a talk about recovery to the staff at a local hospital, they are acting from a place of respect and empowerment for people to shape their own lives. They are being a recovery ambassador and showing that recovery is possible for everyone. In this way, peer specialists give back to and build a healthy community of engaged citizens who will then carry the recovery message to others.
Peer specialists can use these recovery and wellness plans in their work with people in or seeking recovery. Individuals fill out, keep, and are responsible for completing the activities in recovery and wellness plans.
Sample Recovery Plan.
Download PDF (190K)
Download PDF (182K)
Download PDF (187K)
Download PDF (188K)
SAMHSA's Recovery Support Tools and Resources Webpage (www.samhsa.gov/brss-tacs/recovery-support-tools-resources) provides information and links to additional resources on PSS.
California Association of Social Rehabilitation Agencies’ Meaningful Roles for Peer Providers in Integrated Healthcare (https://peerrecoverynow.org/ResourceMaterials/PeerProviderToolkitFinal.pdf) is a guide for peer navigators in integrated healthcare settings.
Illinois Department of Human Services, Department of Alcoholism and Substance Abuse's Manual for Recovery Coaching and Personal Recovery Plan Development (https://chess.wisc.edu/niatx/toolkits/provider/FayetteManual.pdf) provides information for peer workers in integrated behavioral health settings.
The McShin Foundation's Recovery Coach Manual (https://mcshin.org/wp-content/uploads/2019/07/McShin-RCM_for-web.pdf) provides information on SUD treatment and recovery settings.
Philadelphia Department of Behavioral Health and Intellectual disAbility Services’ Peer Support Toolkit (https://dbhids.org/wp-content/uploads/1970/01/PCCI_Peer-Support-Toolkit.pdf) provides information on working in SUD treatment and mental health services.
SAMHSA's Peer Recovery Center of Excellence (https://peerrecoverynow.org/) exists to enhance the field of peer recovery support services by offering help from those who have achieved and maintained long-term recovery to those wanting to enhance or begin PSS in their communities.
Central East Addiction Technology Transfer Center's Anti-Stigma Toolkit: A Guide to Reducing Addiction-Related Stigma (https://attcnetwork.org/sites/default/files/2019-04/Anti-Stigma%20Toolkit.pdf) provides strategies for public education.
Faces & Voices of Recovery (https://facesandvoicesofrecovery.org) is a national recovery advocacy organization. This website provides advocacy resources and publications, and lists of advocacy and recovery celebration events.
A Primer on Recovery Residences: FAQs from the National Association of Recovery Residences (https://narronline.org/wp-content/uploads/2014/06/Primer-on-Recovery-Residences-09-20-2012a.pdf) provides an introduction to recovery residences and answers frequently asked questions about them.
Chestnut Health Systems Blog (https://www.chestnut.org/william-white-papers/) provides articles and current news about PSS and advocacy from leaders in the recovery advocacy movement.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
Your browsing activity is empty.
Activity recording is turned off.
See more...
