Volunteer Recovery Support: Can College Students Support Adolescents in Recovery?

Treatment for adolescent substance use disorders (SUDs) is effective, but positive outcomes can be compromised by premature dropout and relapse. Continuing care provided by treatment programs has been well-documented by research to improve outcomes. However, these services are offered typically only to clients who “complete” their primary episode of treatment. Of those clients who are referred, there is often difficulty following through due to the need for transportation, potentially long commutes, and the reliance on adolescents and their parents or guardians to attend these clinic-based group or individual counseling sessions over an extended period of time. Furthermore, workforce and funding shortages make the recommended one year or more of recovery support difficult to implement. Other recovery support for adolescents (e.g., youth-oriented mutual-support groups, recovery coaches, recovery residences, recovery high schools, and recovery-focused social clubs) may be helpful, but they are neither widely available nor is there enough rigorous research of these programs.

Moving the Practice of Recovery Support Forward

A novel approach is needed to address the barriers that adolescents experience in connecting with recovery support services. In a previous Counselor article, Godley and White (2011) described the need to test assertive and innovative approaches to recovery support (e.g., continuing care). Questions to explore involved how long such services need to be provided, whether or not we can reliably maintain contact with most clients over a long period of time, who is best to provide these services, and how these services will be funded.

In addition to investigating these questions, Hennessy, Cristello, and Kelly (2019) proposed the “recovery capital for adolescents” model. This model suggests that it is important for recovery support services to help adolescents increase their recovery capital (i.e., the availability and amount of resources that support recovery at the individual, interpersonal, and community levels). Recovery support may be more helpful and effective if it can increase access to substance use, mental health, and other services; improve connection with peers and family who are supportive of recovery; and increase the identification of and engagement in substance-free activities.

This article describes the Volunteer Recovery Support for Adolescents (VRSA) study that begins to shed light on many of these questions and recommendations.

The Volunteer Recovery Support for Adolescents (VRSA) Approach

The VRSA approach is based on the idea that volunteers can be trained and supervised to provide recovery monitoring and support for adolescents after discharge from treatment for substance use problems. At its heart, VRSA focuses on helping adolescents increase time spent with peers who support recovery and increasing participation in recovery-focused activities, including attendance at mutual-support groups and continuing care. This flexible model combines a small subset of procedures from the adolescent community reinforcement approach (A-CRA) with VRSA-specific procedures. A-CRA procedures were selected based on their appropriateness to be delivered by individuals without clinical training.

A-CRA procedures included:

Increasing prosocial/prorecovery behavior (divided into two procedures for VRSA: increasing prorecovery peers and increasing prorecovery activities)
Positive and brief goal setting
Adolescent-directed homework to achieve goals

VRSA-specific procedures included:

General conversation about how things are going
Asking about any use of substances since the last session
Asking about any cravings or opportunities to use substances that were experienced
Identifying any upcoming situations that might present a risk for relapse and problem-solving for how to handle those events
Referral for further treatment services when relapse or mental health problems are reported

Volunteers contact adolescents by telephone immediately after treatment discharge. Over a period of nine months, the goal is to provide weekly recovery support sessions for the first three months. Adjustments in session frequency in months four through nine are made based on client functioning or client request. For example, clients who report no substance use for at least thirty days are offered sessions every two weeks, while clients who report relapse or other difficulties are offered to continue or increase to weekly sessions. Sessions last approximately fifteen to twenty minutes and are conversational in tone. Adolescents are praised for any attempts to maintain abstinence or achieve goals. Volunteers are trained to not give advice and to use procedures that make the most sense for adolescents’ situations during a given session, rather than force the conversation into a rigid format. Text messaging is used to send session reminders, ask for calls to be answered, provide encouragement for or assist in goal completion, provide support on birthdays or after special events (e.g., a job interview), and complete sessions if requested.

The goals of VRSA are for adolescents to report more time spent with prorecovery peers, more participation in recovery management activities, less substance use and related problems, and higher rates of remission.

Testing the Effectiveness of VRSA

Several years ago, the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Substance Abuse Treatment provided funding to the authors to test recovery support approaches for adolescents who have been treated for SUDs. One of the enduring efforts produced by that project was the VRSA model. Our work established that volunteers were successful in completing recovery support telephone sessions with adolescents recently discharged from outpatient or residential treatment for SUDs. The project also demonstrated that volunteers could engage most adolescents in VRSA and that those receiving calls were satisfied with the volunteers, length of sessions, and perceived helpfulness. Results suggested that volunteers could indeed help many youth sustain recovery or minimize relapse and reinitiate recovery (Garner, Godley, Passetti, Funk, & White, 2014).

Encouraged by the initial study, we applied for and received funding from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to carry out a large-scale randomized controlled trial of VRSA. Working with our partners at the University of Arizona, led by Dr. Alison Greene, we recruited youth with SUDs who were admitted to two residential treatment programs in Arizona and two in Illinois. With the collaboration of treatment staff, we were successful in recruiting 403 adolescents to participate. Informed consent was obtained from each adolescent’s parent or guardian. One adolescent was never discharged from a controlled environment during the course of the study. Ultimately, 201 adolescents were randomly assigned to receive services as usual (SAU) after residential treatment, and 201 were randomly assigned to receive VRSA in addition to SAU.

Adolescents enrolled in the study were 16 percent female, 49 percent white, 18 percent African American, 14 percent Hispanic, and 19 percent other/multiracial. Most (79 percent) were between fifteen and seventeen years old. Eighty-four percent were involved with the juvenile justice system and 29 percent reported being victimized in the past year. The majority (85 percent) reported weekly substance use, mainly alcohol and marijuana. Sixty-eight percent had received prior mental health treatment. There were no significant differences between adolescents assigned to VRSA or SAU on any demographic or clinical intake measure.

Participating adolescents were interviewed at admission to residential treatment and again at three, six, nine, and twelve months after residential treatment discharge. Adolescents were interviewed using the Global Appraisal of Individual Needs (GAIN) at intake and follow-up. The GAIN has been used in hundreds of adolescent studies and is well-known for its validity and reliability in measuring alcohol and other drug use and related problems as well as co-occurring psychiatric, legal, and life health risk areas. Urine screens were administered to increase the accuracy of self-reported substance use, and a low percentage of adolescents reported not using substances despite having a positive urine screen (2.4–3.1 percent, depending on condition assignment). This information is important because it established the validity of the outcome data upon which all our findings were based and interpreted. Additional outcome instruments measured the extent to which adolescents increased participation in prorecovery activities or association with prorecovery peers or family (Longabough, Wirtz, Zywiak, & O’Malley, 2010). Remarkably, our research assistants in both Arizona and Illinois succeeded in interviewing over 94 percent of adolescents assigned to each condition at every follow-up time point, further increasing confidence in our findings.

Because so little well-controlled research with volunteers has been reported in the treatment recovery literature, we thought it was vital to understand how well every volunteer (a) reached adolescents at or near the target date for each expected recovery support session, (b) followed VRSA intervention procedures during each session, and (c) responded to ongoing supervision (i.e., was there improvement in (a), (b), or both if needed). Assessing this information is straightforward in clinical supervision of office-based treatment providers, but not so easy with student volunteers who worked remotely and did not often have transportation to the research office. Technology provided effective solutions. Digital audio recorders were used to record telephone sessions (with the consent of adolescents and parents). A secure/encrypted website was developed that allowed volunteers to enter key information about each recovery support session and upload session recordings. Research staff members listened to recordings, provided written feedback through the website, and met weekly with each volunteer by Skype or telephone to review session completion rates and fidelity to the VRSA model. Each supervision meeting resulted in constructive coaching and praise for work well done.

Study results show that the processes developed for volunteer training and supervision were implemented effectively. Forty-one out of fifty-three volunteers recruited (77 percent) fulfilled their semester-long commitments, and nine of these forty-one continued to make calls for multiple semesters. Over the course of the VRSA project, volunteers completed 51 percent of all expected recovery support sessions with adolescents, which compared favorably to session completion rates reported in other studies of telephone-based recovery support (Garner et al., 2014; Godley, Coleman-Cowger, Titus, Funk, & Orndorff, 2010; McKay et al., 2011). The majority of adolescents (63 percent) completed their first recovery support session within two weeks of discharge from residential treatment, compared with 36 to 60 percent in other studies of continuity of care after residential treatment (Garner, Godley, Funk, Lee, & Garnick, 2010; Garnick et al., 2002). This finding is notable because research has demonstrated that rapid initiation of continuing care services for adolescents predicts a greater likelihood of remission from all substance use at three months following discharge from residential treatment (Garner et al., 2010).

Additional implementation findings revealed that 92 percent of youth completed one or more recovery support sessions. At discharge from VRSA, the average number of completed support sessions for all adolescents was 10.62. Based on standardized ratings across all procedures delivered and rated, volunteers were able to deliver the intervention with a higher than average degree of fidelity to the VRSA manual. It was gratifying to learn that over 90 percent of adolescents stated that they liked receiving calls from volunteers, found the volunteers helpful, and were satisfied with their recovery support sessions.

How Did VRSA Do?

Well before the VRSA experiment started, a significant amount of time was invested in testing VRSA with volunteers making recovery support calls to adolescents after treatment for substance use disorders. This work led us to our first research hypothesis that adolescents receiving VRSA would participate in more prorecovery activities and spend more time with prorecovery peers. Results from this study confirmed this hypothesis. Compared to adolescents receiving SAU, adolescents receiving VRSA participated in more recovery management activities, like attending Twelve Step mutual-support meetings, when interviewed at three months following residential discharge. They were also more involved in activities related to Twelve Step meetings, such as doing Step work and meeting with a sponsor.

Moreover, they attended more continuing care treatment services and were more likely to spend time with prorecovery peers.
As encouraging as the aforementioned findings were, it was necessary to understand whether VRSA actually “moved the needle” to improve substance use outcomes. Based on our earlier work, our second hypothesis was that relative to adolescents receiving SAU, adolescents receiving VRSA would show significantly greater reductions in their substance use and related problems while showing greater increases in their rates of early full remission (i.e., abstinence from all illicit substance use with no related problems reported in the month prior to the nine- and twelve-month follow-up interviews). We predicted that VRSA would do this directly as well as indirectly through its effects on recovery management activities and prorecovery peers previously described. Because the VRSA intervention ended nine months after residential discharge, the nine-month follow-up measurement point was critical to test the cumulative effects of the VRSA model. The results of our analyses were interesting. We found that VRSA’s path to decreasing substance use and problems and increasing rates of remission was statistically significant, but only by increasing participation in recovery management and time spent with prorecovery peers. This finding is consistent with research on recovery capital and how to measure it, improve it, and diffuse it through communities in order to facilitate recovery (Best et al., 2012; Cloud & Granfield, 2008; Hennessy et al., 2019).

The inclusion of a follow-up interview at twelve months after residential discharge allowed for testing the effectiveness of VRSA beyond the end of the nine-month recovery support call time period. Additionally, it allowed for assessing whether significant improvements in substance use functioning maintained for the three months after VRSA ended. Results showed a similar pattern of significance. Adolescents receiving VRSA were performing better at twelve months due to increased participation in recovery management activities and time spent with prorecovery peers during the early months following residential discharge and improved substance use outcomes at the nine-month follow-up.

The results of the aforementioned analyses generally confirmed our hypotheses and were encouraging, but it was clear that not every adolescent assigned to the VRSA condition received or participated to the same degree. As with most large-scale effectiveness trials conducted in the community, implementation or “dosage” was variable. In fact, almost as many adolescents completed less than half of expected VRSA sessions as those who completed more than half. Therefore, it was important to better understand the relationship between dosage received and clinical response to that dosage. Findings were revealing. In general, we learned that as the rate of completed VRSA sessions increased, so did the rate of full early remission. This information suggested that greater participation in VRSA can play an instrumental role in recovery.

To shed more light on this, we examined data from the sixty adolescents who made up the top 30 percent of VRSA session completers. These adolescents completed more than 70 percent of all expected VRSA sessions, and we found that nearly 50 percent of this subgroup was in early full remission. As can be seen in Figure 1, this percentage is substantially higher than the overall average remission rate at nine months (i.e., about 35 percent). On the other hand, Figure 1 shows a decrease in remission at the twelve-month follow up. Even though VRSA recovery support calls led to increases in recovery capital (in the form of increased amounts of recovery management activities and prorecovery peers) and resulted in significant improvement at the twelve-month follow up, Figure 1 suggests that extending recovery support beyond nine months is indicated. The implication of this and other findings are discussed in the next section of this article.

Takeaways from the VRSA Study and Future Directions

Results of the VRSA study demonstrate that college student volunteers can provide effective recovery support services with training and supervision, and that these services are both feasible to implement and acceptable to adolescents. Additionally, these results were obtained despite the fact that adolescents were not always easy to reach on the telephone for varying reasons such as forgetting appointments, discomfort with talking on the telephone rather than texting, being busy, and running out of minutes on their cell phone plans. Drawing upon findings from prior implementation research, we used effective volunteer training and supervision practices. Readers who are interested in learning more about how we recruited, trained, and supervised VRSA volunteers can find a detailed description of these processes in the Journal of Substance Abuse Treatment (Passetti, Godley, Greene, & White, 2019).

Analyses revealed that higher VRSA session completion rates may lead to improvements in recovery management variables such as attendance at continuing care, mutual-support groups, or other recovery-oriented activities. These improvements could be due to several reasons. For example, short-term goal setting and review of homework during each session were meant to encourage adolescents to increase participation in prosocial activities and to spend time with substance-free individuals. It is also possible that some recovery support calls occurred in close proximity to high-risk substance use opportunities and could have helped adolescents develop concrete plans to avoid relapse and related problems. Additionally, volunteers successfully encouraged some adolescents to return to treatment to address relapse or a mental health issue. Further research is needed into the change mechanisms related to call completion rates and specific intervention procedures, the optimal duration of VRSA calls, and how to increase session completion rates for a broader range of adolescents.

Provider organizations with large caseloads are encouraged to consider several potential advantages of offering VRSA:

Creating a new recovery support service that can reduce the caseload burden of staff clinicians once primary treatment services end
Initiating and sustaining contact with most adolescents for an extended period of time
Improving recovery outcomes
The low cost to implement VRSA relative to costs for long-term clinic-based continuing care in group or individual formats

Provider organizations interested in pursuing this approach would need to allocate a portion of a staff member’s time to recruit, train, and supervise volunteers. Additional support costs are minimal (Passetti et al., 2019).

Conclusion

In closing, VRSA helps adolescents create more recovery capital that competes with and helps them respond constructively to substance use triggers. We believe an important future direction for VRSA is to increase recovery capital in the community domain. Toward this end, we are exploring collaboration opportunities with the Association of Recovery in Higher Education and its member collegiate recovery progkrams (CRP). We are looking at the possibility of recruiting CRP students in stable recovery to provide telephone recovery support to adolescents discharged from treatment. Such an approach may create opportunities for CRP students to give back, do Twelve Step work, and enhance and support recovery for themselves and others. It may also extend the benefits of VRSA for adolescent clients by increasing connections in the recovery community such that both college students in recovery and adolescents just beginning their recovery journey feel connected to one another.

References

Best, D., Honor, S., Karpusheff, J., Loudon, L., Hall, R., Groshkova, T., & White, W. L. (2012). Well-being and recovery functioning among substance users engaged in posttreatment recovery support groups. Alcoholism Treatment Quarterly, 30(4), 397–406.

Cloud, W., & Granfield, R. (2008). Conceptualizing recovery capital: Expansion of a theoretical construct. Substance Use & Misuse, 43(12–3), 1971–86.

Garner, B. R., Godley, M. D., Funk, R. R., Lee, M. T., & Garnick, D. W. (2010). The Washington Circle continuity of care performance measure: Predictive validity with adolescents discharged from residential treatment. Journal of Substance Abuse Treatment, 38(1), 3–11.

Garner, B. R., Godley, M. D., Passetti, L. L., Funk, R. R., & White, W. L. (2014). Recovery support for adolescents with substance use disorders: The impact of recovery support telephone calls provided by preprofessional volunteers. Journal of Substance Abuse and Alcoholism, 2(2), 1010.

Garnick, D. W., Lee, M. T., Chalk, M., Gastfriend, D., Horgan, C. M., & McCorry, F, . . . Merrick, E. L. (2002). Establishing the feasibility of performance measures for alcohol and other drugs. Journal of Substance Abuse Treatment, 23(4), 375–85.

Godley, M. D., Coleman-Cowger, V. H., Titus, J. C., Funk, R. R., & Orndorff, M. G. (2010). A randomized controlled trial of telephone continuing care. Journal of Substance Abuse Treatment, 38(1), 74–82.

Godley, M. D., Passetti, L. L., Hunter, B. D., Greene, A. R., & White, W. L. (2019). A randomized trial of volunteer recovery support for adolescents (VRSA) following residential treatment discharge. Journal of Substance Abuse Treatment, 98, 15–25.

Godley, M. D., & White, W. L. (2011). Telephone recovery checkups: An assertive approach to posttreatment continuing care. Counselor, 12(4), 28–31.

Hennessy, E. A., Cristello, J. V., & Kelly, J. F. (2019). RCAM: A proposed model of recovery capital for adolescents. Addiction Research & Theory. DOI: 10.1080/16066359.2018.1540694.

Longabaugh, R., Wirtz, P. W., Zywiak, W. H., & O’Malley, S. S. (2010). Network support as a prognostic indicator of drinking outcomes: The COMBINE study. Journal of Studies on Alcohol and Drugs, 71(6), 837–46.

McKay, J. R., Van Horn, D., Oslin, D. W., Ivey, M., Drapkin, M. L., Coviello, D. M, . . . Lynch, K. G. (2011). Extended telephone-based continuing care for alcohol dependence: Twenty-four-month outcomes and subgroup analyses. Addiction, 106(10), 1760–9.

Passetti, L. L., Godley, M. D., Greene, A. R., & White, W. L. (2019). The volunteer recovery support for adolescents (VRSA) experiment: Recruiting, retaining, training, and supervising volunteers to implement recovery monitoring and support services. Journal of Substance Abuse Treatment, 98, 1–8.

Editor’s Note: This article was adapted from an article by the same authors previously published in the Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation provides the original source of the article:

Mark D.. Godley, PhD

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Mark D. Godley, PhD, is a senior research scientist at Chestnut Health Systems’ Lighthouse Institute. His research interests include the Adolescent Community Reinforcement Approach (A-CRA) and variations of this model to increase recovery support and recovery capital at the individual and community level.

Lora L. Passetti, MS

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Lora L. Passetti, MS, is a research projects manager at Chestnut Health Systems’ Lighthouse Institute. She is interested in adolescent participation in continuing care and Twelve Step programs as well as the use of technology in treatment and recovery support.