Advocacy, Stigma, and the Integrity of Peer Recovery Support Services

Since the beginning of time, individuals and communities have overcome challenges by relying on the support of their friends, families, and neighbors. From natural disasters such as wildfires and floods to pandemics like the coronavirus, we truly count on those who are going through the same things we are to help ease the emotional and physical suffering. Empathy and shared experiences have saved many souls in the depths of despair to help them not only recover, but to come out on the other side stronger and more resilient.

Peer-support workers (i.e., people with shared lived experiences) have been employed or volunteering in all sectors of health and human services for decades. Just add the term “peer support” to your Google alerts and you will find news about peer support in environments such as fire stations, nursing programs, jails and correctional centers, lawyer assistance programs, cancer survivor groups, veteran programs, mental health clinics, and educational settings for parents of children with special needs.

The value of peer support is well documented, yet there are still major hurdles to overcome to achieve optimal outcomes for individuals, families, and our entire health care system. Recovery from addiction is not only possible or probable, but it is also the expected outcome with the right treatment and recovery support services for all individuals. If we believe in this premise, then we must do better to be certain that the stigma of substance use disorders (SUDs) is eliminated, that peer support is adequately funded, and that people with personal experience are at the center of policymaking.

The Integrity of Peer Support

The practice of peer support in the SUD field has evolved over the past several decades into a profession with national standards, core competencies, and certifications on par with clinical professions. The federal government has long recognized peer support as an evidence-based practice. In fact, in 2007 the Center for Medicare and Medicaid Services (CMS) Director Dennis G. Smith provided guidance to all state Medicaid directors, stating, “Peer-support services are an evidence-based mental health model of care which consists of a qualified peer-support provider who assists individuals with their recovery from mental illness and substance use disorders” (CMS, 2007).

Several years later, the Substance Abuse and Mental Health Services Administration (SAMHSA) led an effort to identify the critical knowledge, skills, and abilities needed by those individuals who provide peer-support services to people with or in recovery from a mental health and/or substance use conditions (SAMHSA, 2015). These core competencies are intended to apply to all forms of peer support provided to people living with or in recovery from mental health and/or substance use conditions and delivered by or to adults, young adults, family members, and youth.

Certification of peer-support workers functions as a means of assuring fidelity to the ethical practices of the profession, including adherence to training requirements and supervision. Nearly all fifty states have certification programs for peer-support workers. However, the public, patients, families, providers, state entities, payors, and the health care system itself is likely less aware of the emergence of a national accreditation for the organizations and agencies that employ peer-support workers. For treatment centers and medical settings, the Joint Commission and the Commission on Accreditation of Rehabilitation Facilities (CARF) are the most well-known accrediting bodies for agencies providing clinical services. In the peer-support world, the Council on Accreditation of Peer Recovery Support Services (CAPRSS) has been accrediting organizations since 2013 and is sought after by entities aiming to achieve excellence in their peer recovery support service delivery. As the only accrediting body in the US specifically designed for recovery community organizations (RCOs) and other programs offering addiction peer recovery support services, CAPRSS has accredited organizations in ten states to date and is quickly becoming the north star by which state agencies and payors can rely on to identify and support organizations providing authentic peer recovery support services.

Boots-on-the-Ground: A Safety Net in the Community

Accreditation builds the capacity of RCOs and other programs to provide peer services that reflect the strengths and needs of geographic and cultural communities being served. This includes assertive outreach to minority communities to address racial disparities and injustices as well as improving access to culturally appropriate treatment and recovery support services. While people of color have been disproportionately impacted by COVID-19 at an alarming rate, the health care and justice systems have a long history of inequality and injustice that many peers are grappling with daily. Capacity building in peer work means lifting the voices of people of all life experiences, understanding the intersectionality of race and recovery, and advocating for the elimination of discriminatory policies and practices on every level.

The primary purpose of accrediting organizations that provide peer services is to increase public confidence (and confidence within the field) in the quality of peer services. For individuals and families who are seeking help, knowing that the organization they are receiving services from is accredited provides reassurance that it is a credible and legitimate program from which they can expect high-quality support. Similar to accredited behavioral health treatment providers, accredited organizations demonstrate the ability to ensure ethical practices and supervision; they use promising and evidence-based practices; and they embed quality-assurance and quality-improvement protocols into their service delivery and program management. The CEO of The McShin Foundation shares the following about their experience with accreditation:

The accreditation process was very intense, but worth every second. It helped McShin to be more organized and efficient. Upholding standards and values that are recognized by our field help us to continue to provide quality and value-based services to the recovery community, positively impacting and enriching the community as a whole (H. Liller, personal communication, May 2017).

While SUD prevention and treatment have benefited from an immense body of research, there remains little research on peer recovery support services for SUDs. Accredited programs provide an excellent opportunity to highlight the quality, efficacy, value, and/or scientific basis of peer services while establishing an empirical base for peer-based practices. With more states requiring accreditation for programs that deliver peer services, there is now a greater number of models available to research the positive recovery outcomes for people with SUDs, and thereby increase public confidence in peer services.

An Advocacy Movement Led by People in Recovery

Advocates nationwide have played a significant role in the evolution of peer support within the SUD field. Led by those with a passion for helping others and the desire to legitimize peer support as a critical component of recovery-oriented systems of care, recovery advocates are amplifying their voices to elevate the urgency our nation faces during the dual pandemics of COVID-19 and the addiction crisis. Fortunately, the new recovery advocacy movement has the capacity to mobilize individuals and groups to influence policymaking on the local, state, and national level. From sitting on local committees and councils, to meeting with lawmakers, to launching public awareness campaigns, the organized recovery community continues to be an effective constituency of consequence.

As a recovery advocate and woman in long-term recovery, my involvement with recovery advocacy began when I was the executive director of Friends of Recovery-Vermont from 2003 to 2013, then an affiliate of the Association of Recovery Community Organizations (ARCO). During this time, many RCO leaders realized that we needed to address the most effective ways to ensure the highest quality of care while keeping intact the values, principles, and contexts that were the underpinnings of our work and that would give integrity and fidelity to peer-recovery practice.

In January 2011, SAMHSA convened a group of RCO representatives and allies to consider the possibilities of establishing a program or body that would accredit programs and organizations providing peer recovery support services. The meeting participants considered a range of issues, including the primary goals and purposes of an accrediting body and the domains to be addressed by an accreditation process. Two accreditation consultants were hired to assist with the development of working documents for the advisory council and its subcommittees. Staff and consultants researched different accreditation and peer-review models as well as the range of peer- and other recovery-support services that were available. This work resulted in the framework for the accreditation of peer recovery support service programs that exists today.

At that time, there was a rapidly growing national network of RCOs that were almost entirely built around the need to address the gaps in their communities by helping individuals and families on their path to long-term recovery. They did this by recruiting people in recovery to serve as peer-support workers to help individuals and families with a variety of self-determined goals, such as having a recovery plan, accessing treatment and harm-reduction services, finding a safe place to live, returning to the workforce or higher education, and so much more. Peer-support workers in RCOs are surrounded by colleagues who are immersed in the best practices and core competencies of the specialized practice of peer recovery support. RCOs are founded by peers to help peers. The majority of staff and board members of RCOs are people in recovery. They are the hub of recovery activity in communities across the nation. They are well connected to the local community and many of the program staff have navigated the local systems of care themselves, or with friends and family members. They know about availability, eligibility, payment, waiting list requirements, and also how to coach those who are having a tough time getting the services they need. They have been there and know the way out. This is what we mean by “authentic” peer recovery support; it is local, it is grassroots, and it is led by people with shared life experiences of addiction and recovery who are making life better for people in their community.

“The Behavioral Health Workforce Report” released by SAMHSA last year indicates there is a need for over 2 million more peer-support workers to serve the over 20 million Americans in need of treatment and recovery support services for mental health and SUDs (SAMHSA, 2020). Currently, tens of thousands of trained peers with lived experiences of addiction and recovery are working in a wide variety of settings—recovery community centers, child welfare agencies, recovery courts, law enforcement agencies, housing programs, emergency departments and other medical settings—that were not included in the recent report, making 2 million a conservative estimate. The challenge in many settings is that confusion often exists regarding peer roles and duties. This confusion has led to inappropriate tasks and roles, which has led to tension in the workplace and ineffective peer support. Misunderstandings have also led to worker burnout. Stigma, defined herein as “negative attitudes,” brings even greater complexities.

Reducing the Stigma Faced by Peer Workers

One challenge peer-support staff may face on the job is a lack of acceptance and underlying negative attitudes from their colleagues when they are employed at agencies other than RCOs. There are still many people who believe that people with SUDs can or should be denied housing, employment, social services, and health care. Discriminatory beliefs like this can exist in employment settings where peers may face stereotypes that can manifest in any number of ways. SUD is among the most stigmatized conditions in the US and around the world. Some health care providers, falsely believing that SUDs are within a person’s control, cite feelings of frustration and resentment when treating patients with SUDs. This is especially troubling for peers working in emergency departments and other health care settings where these negative attitudes may exist. There may also be an underlying fear that peer staff will return to using substances, resulting in suspicion and lack of confidence in peer workers’ fitness for work duties. Examples of policies based on stigma include directing peer-support staff to use client restrooms instead of staff restrooms; excluding peer-support staff from team meetings; addressing nonpeer colleagues as “Mr.” or “Mrs.” while addressing peer-support staff by their first names; and referring to peer-support staff as “addicts” or other stigmatizing terms that characterize people by their disorders (Resources for Integrated Care, 2015). The word “addict” carries heavy negative connotations and advocates are urging counselors and agencies to replace the word with person-first language such as a “person with a substance use disorder.”

Addiction is a chronic and treatable health condition, but using words such as “abuse” and “substance abuser” implies that addiction is a character flaw. Exposure to the terms “substance abuse” and “substance abuser” have been shown to increase stigmatizing and discriminatory attitudes toward individuals suffering from drug and alcohol problems both in the general population and among clinicians (Kelly, Saitz, & Wakeman, 2016; Kelly & Westerhoff, 2010). Stigmatizing terminology still exists in local, state, and national agencies with the term “substance abuse” in their names. Advocacy groups, including Faces & Voices of Recovery, have done a lot of work to eliminate stigmatizing language in the addiction workforce and are now urging Congress to change the names of federal institutions with the word “abuse” in them. The “Change the Name: End the Stigma” petition (Faces & Voices of Recovery, 2020) was prompted by the July 2020 brief entitled “End the Fatal Paradox: Change the Names of our Federal Institutes on Addiction” (Kelly & Earnshaw, 2020) published by the Society of Behavioral Medicine.

The value of peer support is well documented, yet there are still major hurdles to overcome to achieve optimal outcomes for not only individuals and families, but for our entire health care system.

Stigmatizing language is almost non-existent in RCOs where modeling appropriate use of recovery-positive terms and language is of utmost importance. RCOs maintain the integrity of peer support through the adoption of standards and best practices. Led by the recovery community, RCOs use a peer participatory process that places core values of equity, access, dignity, and respect in highest regard. At the core of the peer participatory process is a deep belief that participation from a wide range of community members with varied and valuable insights to offer and gifts to “give back” is absolutely one of the most important elements of how we heal together. Negative attitudes towards people based on their addiction history is rare in an RCO setting—in fact, the very opposite is true. Peer workers thrive because they routinely receive strengths-based and nonjudgmental support from their coworkers, and they celebrate the success of the organization and the positive impact it has in the community.

In the RCO framework, those affected by programs, policies, and procedures are an integral part of decision-making in the organization. Community members are involved at all levels and policies and procedures are routinely audited to ensure use of non-stigmatizing practices and language. Simply having community input on programming is not sufficient. The peer participatory process requires meaningful peer participation, including day-to-day procedures and activities, ongoing assessments, determining how program funding is distributed, developing policies, and serving on the board of directors and other advisory capacities. The key to success for an RCO is to embrace a culture where staff and peers collaboratively identify when and how peers are involved in decision-making. This is central to the peer participatory process, where peers are respected as experts in their own lives and learn from others who share similar experiences.

A Call to Action

RCOs across the nation have led essential stigma-reduction efforts by putting a face and a voice on recovery and normalizing the reality of recovery from addiction for over 20 million Americans. Recovery messaging and storytelling has helped tens of thousands of people in recovery, as families and allies share their advocacy messages of hope through strategies such as social media campaigns, billboards, podcasts, and blogs. Personal narratives, which are a component of peer-support work, have an important role in overcoming stigma (Jenkins & Carpenter-Song, 2008).

Now is the time to invest in the necessary infrastructure for RCOs across the nation to provide peer recovery support services. RCOs are adding immense value to local communities and doing boots-on-the-ground, lifesaving work to help people recover their lives during both the addiction epidemic and the COVID-19 pandemic. Accreditation is key to sustainability; it will help peer programs attract the recognition of funders and other stakeholders while establishing and legitimizing peer-recovery positions in the SUD workforce. Accreditation preserves the integrity of peer services while increasing the ability of organizations to generate sustainable revenue, including through third-party reimbursement. The executive director of FAVOR Greenville shares the following:

The CAPRSS accreditation process has benefited our organization and has provided clear guideposts as we move forward in the expansion of peer-recovery services in South Carolina. It is certainly a worthwhile endeavor. We look forward to ongoing collaboration with the CAPRSS team and we know we will continue to learn from them as we grow as an organization (R. Jones, personal communication, June 2017).

With the new Congress and administration underway, now is the time to advance the recovery policy agenda on the state and national levels.

How You Can Help

• Medicaid: Urge your state Medicaid authorities to make reimbursement for peer services a standard practice and to make RCOs Medicaid-eligible providers. Keep capacity building, integrity, and accreditation conversations front and center. Remember that peer support is provided across the health and human services spectrum, not just in the SUD and mental health field. There is no need to fight a battle about its evidence base because the CMS declared it a Medicaid- and Medicare-reimbursable service in 2007 (CMS, 2007).
• The Value of Peer Support: Educate policymakers and program administrators about the value of peer support. Research shows that peer support is effective in a number of ways, including increasing self-confidence, decreasing substance use and depression, increasing a sense of hope and inspiration, and reducing hospitalizations.
• Sustainable Funding: Advocate for sustainable sources of funding for the programs that provide peer support. Talk with your single state agency (SSA) where funding decisions are made about SUD programs—they manage the Substance Abuse Prevention and Treatment Block Grants (SABG) in your state. Peer-recovery support is an allowable use of SABG dollars and is in fact a required section of the SSA’s application for federal funding. Join Faces & Voices of Recovery in advocating for federal appropriations for peer-recovery support and RCOs. Keep an eye out for action alerts!
• Discriminatory Practices: Speak out against discriminatory practices and racial inequities. The recovery community is as diverse as the pathways of recovery. The voices of black, indigenous, and people of color (BIPOC) and everyone experiencing discrimination and injustice need to be lifted up and heard. Our organizations have a role and responsibility to right the wrongs done; let us come together to speak out.
• Check Language Use: Conduct a stigma and language audit at your agency or practice. Words matter! The language we use can help to eliminate stigma. Start within your own language and the culture in your agency. Reach out for technical assistance and provide training for your staff and community.
• The “Change the Name” Petition: Sign and distribute the “Change the Name” petition (Faces & Voices of Recovery, 2020). It takes an act of Congress to change the names of federal institutions. One million signatures are needed to make this happen, so take five minutes to sign the petition and then share it with your networks.
• Join a RCO: Join a RCO near you as an ally or person in recovery. Grassroots organizations across the nation are making a difference in local communities. Share your time and talents to strengthen the role of peer-support providers in helping even more Americans achieve long-term recovery.

We must do better in our efforts to eliminate negative attitudes and discriminatory practices that create barriers to recovery by supporting the growth of the peer-recovery workforce. Everyone—counselors, peer-support workers, local agency leaders, policymakers, state and federal governments, and members of Congress—has a role to play. Together, we can make a difference.

References

• Center for Medicare and Medicaid Services (CMS). (2007). CMS State Medicaid Director’s letter: Using peer-support services under Medicaid. Retrieved from https://downloads.cms.gov/cmsgov/archived- downloads/SMDL/downloads/SMD081507A.pdf
• Faces & Voices of Recovery. (2020). Change the name: End the stigma petition. Retrieved from https://actionnetwork.org/petitions/change-the-name-end-the-stigma
• Jenkins, J. H., & Carpenter-Song, E. A. (2008). Stigma despite recovery: Strategies for living in the aftermath of psychosis. Medical Anthropology Quarterly, 22(4), 381–409.
• Kelly, J. F., & Earnshaw, V. (2020). End the fatal paradox: Change the names of our federal institutes on addiction. Retrieved from https://www.sbm.org/UserFiles/image/abuse-language-brief20_FINAL.pdf
• Kelly, J. F., Saitz, R., & Wakeman, S. (2016). Language, substance use disorders, and policy: The need to reach consensus on an “addictionary.” Alcoholism Treatment Quarterly, 34(1), 116–23.
• Kelly, J. F., & Westerhoff, C. M. (2010). Does it matter how we refer to individuals with substance-related problems? A randomized study with two commonly used terms. The International Journal on Drug Policy, 21(3) 202–7.
• Resources for Integrated Care. (2015). Tips to reduce negative attitudes faced by peer-support staff. Retrieved from https://resourcesforintegratedcare.com/sites/default/files/Tips%20to%20Reduce%20Negative%20Attitudes%20Faced%20by%20Peer%20Support%20Staff.pdf
• Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Core competencies for peer workers in behavioral health services. Retrieved from https://www.samhsa.gov/sites/ default/files/programs_campaigns/brss_tacs/ core-competencies.pdf
• Substance Abuse and Mental Health Services Administration (SAMHSA). (2020). Behavioral health workforce report. Retrieved from https://www.samhsa.gov/sites/default/files/behavioral-health-workforce-report.pdf

Patty McCarthy

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Patty McCarthy, MS, is the CEO of Faces & Voices of Recovery, a national recovery advocacy organization based in Washington, DC. Prior to joining Faces & Voices, she was a senior associate with the Center for Social Innovation (C4), where she served as a deputy director of SAMHSA’s BRSS TACS initiative. McCarthy served for a decade as the director of Friends of Recovery-Vermont (FOR-VT), a statewide RCO conducting training, advocacy, and public awareness activities. In addition to public policy and education, her work has focused on community mobilizing, peer-based recovery support services, and peer workforce development. McCarthy has been instrumental in the development of a national accreditation for RCOs and in the development of peer-support standards. She holds a master’s degree in community counseling and a bachelor’s degree in business administration, and has been in long-term recovery since 1989.

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