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Peer-Based Addiction Recovery Support: History, Theory, Practice, and Scientific Evaluation Executive Summary

Authors:

Abstract

The history of addiction treatment and recovery in the United States contains a rich "wounded healer" tradition. For more than 275 years, individuals and families recovering from severe alcohol and other drug problems have provided peer-based recovery support (P-BRS). Formal peer-based recovery support services (P-BRSS) are now being delivered through diverse organizations and roles and are emerging as a critical component of "recovery management" and "recovery-oriented systems of care." For the past year, I have researched the history and status of peer recovery support in the United States. The results of this review are now available in a new 250+ page monograph published by the Center for Substance Abuse Treatment"s Great Lakes Addiction Technology Transfer Center and the Philadelphia Department of Behavioral Health and Mental Retardation Services. A PDF of the monograph is available for downloading and hard copies for purchase are both available at www.glattc.org. This issue of Counselor provides an executive summary of the new monograph. I hope it will stimulate much discussion about the history of the role of addiction counselors and the emergence of new models of peer-based recovery support.
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William L. White, MA
Great Lakes Addiction Technology Transfer Center
Philadelphia Department of Behavioral Health and Mental
Retardation Services
i
Dedication
This monograph is dedicated to:
Barbara Weiner and Rebecca Rowe of Hazelden Library,
and to Stephanie Merkle and Christopher Roberts, research
assistants at Chestnut Health Systems. This monograph
was possible only through their tenacious efforts to procure
hundreds of historical documents, scientific studies, trade
journal articles, posted papers, conference presentations,
and other unpublished manuscripts. Barbara, Rebecca,
Stephanie and Christopher, and their counterparts around
the country receive far less acknowledgment for their
contributions to the field than they deserve.
Thomasina Borkman, for her pioneering work on experiential
learning and peer-based recovery support organizations.
Those working on the front lines of peer-based addiction
recovery support services. Thank you for opening your lives
and your organizations to me.
ii
iii
Table of Contents
Welcome from Lonnetta Albright and Michael Flaherty, PhD................................ 1
Foreword by Arthur C. Evans, PhD and Beverly J. Haberle, MHS........................ 3
Abstract .................................................................................................................. 7
Introduction
Summary of Key Points.......................................................................................... 9
The Recovery Management Monograph Series .................................................... 9
Purpose of the Current Monograph ..................................................................... 11
A Note on Language ............................................................................................ 12
A Caution to the Reader....................................................................................... 12
Acknowledgments ................................................................................................ 13
Chapter One: Defining Peer-based Recovery Support Services
Summary of Key Points........................................................................................ 15
Defining Peer Recovery Support ......................................................................... 16
Distinguishing Professional and Peer Support .................................................... 19
Core Characteristics of P-BRSS Specialists........................................................ 22
Varieties of Peer Recovery Support Services...................................................... 25
Core Functions..................................................................................................... 27
Treatment Adjunct or Alternative ......................................................................... 29
Chapter Two: The History of Peer-Based Recovery Support Services
Summary of Key Points........................................................................................ 31
Solo Practitioners ................................................................................................. 34
Peer Recovery Support and Religious/Cultural Revitalization Movements......... 35
Secular Recovery Mutual-aid Societies ............................................................... 36
Spiritual Recovery Mutual-aid societies ............................................................... 37
Religious Recovery Mutual-aid societies ............................................................. 37
Family-Focused Recovery Support Societies...................................................... 38
Occupation-based Recovery Support Groups ..................................................... 38
Shared Characteristics of Recovery Support Groups.......................................... 38
Recovery Support for Special Populations ..........................................................39
Gender-specific mutual-aid groups........................................................................... 39
Age-specific recovery support .................................................................................. 40
Recovery mutual aid and advocacy in communities of color.................................... 40
Recovery support for and within the LGBT community ............................................ 41
Recovery support for people with co-occurring disorders......................................... 41
Recovery support for people embedded within the criminal justice system.............. 41
Recovery mutual aid in rural communities................................................................ 42
Geographical Accessibility of Recovery Mutual-aid Groups................................ 42
Internet-based Recovery Support ........................................................................ 47
Recovery Community Service Institutions and Organizations............................. 47
Recovery Social Clubs ......................................................................................... 48
Recovery Advocacy Organizations ...................................................................... 49
Recovering People Working in Non-professional Support Roles in ....................50
Addiction Treatment
Recovering People Working in Professional Roles in Addiction Treatment ........ 53
Current Recovery Coaching Practices in the Public and Private Sectors ........... 62
iv
Chapter Three: The Theoretical Foundations of Peer-Based Recovery
Support
Summary of Key Points........................................................................................ 67
“Nothing about us without us” ..............................................................................69
The Wounded Healer Tradition............................................................................ 71
The Power of Calling (Amends in Action) ............................................................ 73
Experiential Knowledge........................................................................................ 74
Chronic Illness and Peer Support ........................................................................ 78
Charisma and Recovery....................................................................................... 80
Spirituality and Recovery .....................................................................................84
Storytelling and the Power of Mutual Identification.............................................. 85
Stigma and The Dynamics of Help-seeking......................................................... 88
Sharing Recovery Capital ....................................................................................92
The Helper Therapy Principle ..............................................................................93
Individual, Community, Culture ............................................................................ 94
Cultures of Addiction and Recovery..................................................................... 96
Preventing Harm in the Name of Help ................................................................. 97
Stewardship of Community Resources................................................................99
The Threats of Anti-professionalism and Professionalism ................................ 100
Primacy of Personal Recovery and Importance of Self-Care ............................ 103
Role of Risk in Recovery.................................................................................... 105
The Value of P-BRSS ........................................................................................105
Criticism of P-BRSS........................................................................................... 107
Testing the Theoretical Foundations of P-BRSS ............................................... 109
Chapter Four: Scientific Evaluation of Peer-based Support:
Studies of the Effects of Participation in Recovery Mutual-aid
Societies
Summary of Key Findings.................................................................................. 113
Limited Scope of Research on Recovery Mutual-aid Societies......................... 115
Role of Mutual Aid in Recovery Outcomes ........................................................ 117
Variability of Response ......................................................................................119
Effectiveness across Diverse Populations......................................................... 120
Cost-effectiveness.............................................................................................. 125
The Question of Harm (Iatrogenesis)................................................................. 126
Potent Ingredients of Recovery Mutual Aid ....................................................... 128
Additive Effects of Professional Treatment and Mutual Aid............................... 130
Timing of Participation........................................................................................ 131
Linkage Procedures and Participation Rates..................................................... 132
Linking Adolescents to Recovery Support Groups ............................................ 133
Early Drop-out Rates.......................................................................................... 134
Dose and Intensity of Participation Effects ........................................................136
Frequency of Participation .................................................................................136
Duration of Participation..................................................................................... 137
Role of Internet-based Recovery Support.......................................................... 138
Relationship between Helping and Helper Recovery Outcomes ...................... 139
Studies of Family Support Groups ..................................................................... 140
v
Chapter Five: Scientific Evaluation of Peer-based Services:
Studies of the Effects of Participation in other Recovery
Community Institutions
Summary of Key Findings.................................................................................. 145
Recovery Social Clubs....................................................................................... 146
Recovery Community Centers ........................................................................... 147
Recovery Homes................................................................................................ 149
Recovery Colonies ............................................................................................. 154
Recovery Schools ..............................................................................................155
Peer-based Occupational Recovery Support .................................................... 158
Recovery Ministries/Recovery Churches........................................................... 160
Other Recovery Support Structures...................................................................162
Chapter Six: Scientific Evaluation of Peer-based Services:
Studies of Recovering People Working in Addiction Treatment
Summary of Key Findings.................................................................................. 165
Science versus Stereotypes .............................................................................. 166
Recovery Representation in Addiction Treatment .............................................167
The Role Transformation of Addiction Counselors in Recovery........................171
Demographic Profile of Counselors in Recovery ............................................... 174
Prior Treatment/Recovery Experience of Counselors in Recovery ...................174
Pre-service Educational Functioning of Counselors in Recovery...................... 175
Educational Levels of Recovering People Working as Addiction Counselors... 175
Certification, Licensure, and Clinical Effectiveness ........................................... 176
Compensation of Recovering Counselors versus Counselors Without a .......... 178
History of Addiction
Personality Characteristics of Recovering Addiction Counselors...................... 178
Beliefs and Attitudes of Recovering Addiction Counselors................................ 179
Attitudes and Behaviors of Recovering Counselors Related to Evidence-........ 184
based Practices
Role Perceptions of Recovering Addiction Counselors ..................................... 186
Recovery Status and Client Perceptions of Credibility and Effectiveness......... 186
Counselor Recovery Status and Therapeutic Alliance ......................................188
Counselor Recovery Status and Ethical Decision-making................................. 189
Counselor Recovery Status and Client Recovery Outcomes ............................ 191
Recovery Status and General Job Performance Factors ..................................196
Vulnerability to Relapse among Counselors in Recovery ................................. 196
Influence of Recovery Status on Supervisory Relationships ............................. 197
Evaluation of Treatment Models Staffed by Recovering People ....................... 198
Evaluation of Recovery Volunteer Programs Linked to Addiction .....................202
Treatment or Medical Treatment
Relevant Studies on Peer-based Services from Allied Fields............................ 204
Commentary on Lack of Distinctive Findings..................................................... 207
vi
Chapter Seven: Recent Studies of Recovery Coaching
and P-BRSS
Summary of Key Findings.................................................................................. 209
The Recovery Community Services Program (RCSP) ...................................... 209
The Access to Recovery (ATR) Program........................................................... 211
Studies of Service Elements related to P-BRSS ............................................... 213
Chapter Eight: A P-BRSS Research Agenda
Summary of Key Findings.................................................................................. 217
Toward a Recovery Research Agenda.............................................................. 217
Communities of Recovery as Ethno-cultural Communities................................ 218
Research on Recovery Mutual-aid Groups........................................................ 220
Participation in Other Recovery Community Institutions.................................... 221
Recovery Representation in Professional Treatment ........................................ 221
Person-specific Factors Affecting Recovery Outcomes..................................... 222
P-BRSS and Stages of Recovery ...................................................................... 223
P-BRSS Service Roles....................................................................................... 223
Service Ingredients and Recovery Outcomes ................................................... 224
Interaction Between P-BRSS and Professional Treatment ...............................225
P-BRSS and Family/Community Recovery Outcomes ...................................... 226
Organizational Contexts and P-BRSS Outcomes.............................................. 227
Concerns About P-BRSS................................................................................... 228
Chapter Nine: Summary and Conclusions ...................................... 231
A Preview .............................................................................................. 235
Appendix
Table 12: Changing Recovery Representation in the Addiction....................... 237
Treatment Workforce
List of Tables
Table 1: Professional and Peer Models of Helping............................................. 20
Table 2: Defining Characteristics of P-BRSS ..................................................... 22
Table 3: Defining Characteristics of Organizations Delivering P-BRSS............. 26
Table 4: Geographical Dispersion of Addiction Recovery Mutual-aid ................ 43
Groups in the United States
Table 5: Paradigms of “Paraprofessional” and Professional Addiction ..............59
Counseling
Table 6: Academic Theories on Mutual Peer Assistance ...................................68
Table 7: Performance Measures and P-BRSS Core Ideas ..............................109
Table 8: Demographic Characteristics of Recovery Mutual-aid societies ........123
Table 9: Al-Anon Membership Characteristics in the United States,.................141
1984 and 2006.
Table 10: Recovery Representation Among Counselors Working in ...............168
Addiction Treatment: 1960-2007
Table 11: Concerns about P-BRSS Raised by Addiction Professionals, ........228
Treatment Administrators, and Members of the Recovery Community
Table 12: Changing Recovery Representation in the Addiction....................... 237
Treatment Workforce
vii
Program Profiles
Program Profile 1: Peer Group Facilitation Training........................................... 47
(previously called “How to Start Your Own Self-help Group”)
Program Profile 2: PRO-ACT Philadelphia ......................................................... 48
Program Profile 3: Recovery Walk 2008 ............................................................ 50
Program Profile 4 : Telephone Recovery Support .............................................. 63
Program Profile 5: New Pathways Project.......................................................... 64
(Assertive Street and Community Outreach)
Program Profile 6: Recovery Advisory Committee .............................................. 69
Program Profile 7: Recovery Foundations Training.............................................70
Program Profile 8: Peer Leadership Academy .................................................... 70
Program Profile 9: A New Day: A Celebration of Recovery................................ 71
Program Profile 10: Amends in Action ................................................................. 74
Program Profile 11: Storytelling Training ............................................................. 88
Program Profile 12: Taking Recovery to the Streets ...........................................92
Program Profile 13: Vermont Recovery Center Network ................................... 148
Program Profile 14: Philadelphia Recovery Community Center........................149
Program Profile 15: Recovery Home Survey..................................................... 153
Program Profile 16: Connecticut Community of Addiction Recovery’s..............153
Recovery Housing Project
Program Profile 17 : Recovery Oriented Employment Services........................ 159
Program Profile 18: NET Consumer Council ..................................................... 163
Program Profile 19: Peer Specialist Initiative..................................................... 170
viii
1
Welcome
Lonnetta Albright, Executive Director
Great Lakes Addiction Technology Transfer Center
Michael T. Flaherty, PhD, Principal Investigator
Northeast Addiction Technology Transfer Center
We welcome you to this, the sixth effort in our monograph series
designed to explore in depth the theoretical and practical aspects of peer-based
addiction recovery support services and recovery-oriented systems of care.
Once again, we have had the benefit of William L. White’s expertise and passion
in the conception and execution of this document.
After all the dedication, skill, and care that addiction professionals devote
to our clients’ well being, we all too often see our best work erode as fragile
people return to the same circumstances and environments that fostered their
illness. The peer-based recovery support model has arisen to nourish and
protect the recovery that in many cases starts in professional treatment, and from
the beginning William L. White has been one of its strongest champions.
As someone who has spent most of his career working toward the
professionalization of the addiction treatment field—drawing the best from us and
advocating the best for us—Mr. White is in a unique position to explore the value
of services that extend beyond professional treatment. In his travels and studies,
he has absorbed an encyclopedic knowledge of recovery systems and services,
from potential to pitfalls.
In earlier documents, Mr. White and colleagues have explored the need
to understand addiction’s potential as a chronic illness requiring continuing care,
the implications of recovery management for treatment systems and for the field
as a whole, the critical role of professional treatment in initiating recovery, and
the science—existing and recommended—that we need for better understanding
and support of recovery. In this volume, he turns his attention to the peers who
provide ongoing recovery support services before, around, and beyond
professional treatment. To dispel the myths that say this model has not been
tested or evaluated and is not supported by scientific evidence or the literature of
our profession, the monograph provides 19 program profiles and includes more
than 850 scientific and professional references.
As an added benefit of this exploration, Mr. White presents and clarifies
two very distinct but complementary roles, that of the professional provider of
treatment services and that of the peer providing recovery support services.
People in these two roles might be thought of as working in partnership, sharing
a common interest in the well being of the same individuals, guarding their
medical safety, employing best practices, and promoting long-term recovery.
Both roles are essential, and each completes the other. In many cases the
exploration of these roles will not describe two distinct bodies of people, but
2
rather describe varying sets of skills that people use to guide their work, with
some people combining skills from both roles.
It is our hope that addiction professionals and peer support providers
alike will find this monograph valuable. May you find in it a little more clarity,
many new ideas, a stronger sense of determination, and a far greater
appreciation for the work that you and your counterparts do.
We wish to acknowledge and thank the Substance Abuse and Mental
Health Services Administration (SAMHSA), Center for Substance Abuse
Treatment (CSAT) for its ongoing support of these efforts and the opportunity to
publish this important work. We also extend our gratitude to the Philadelphia
Department of Behavioral Health and Mental Retardation Services, the Great
Lakes Addiction Technology Transfer Center’s partner in the publication of this
document.
And our highest thanks go to our indefatigable author, William L. White.
For the past 11 years, he has dedicated his life to seeing that this model—and
the people whose lives depend upon it—have a chance for success. We are
honored to do what we can to follow and support this quest.
3
Foreword
Arthur C. Evans, Jr., PhD, Director
Philadelphia Department of Behavioral Health and Mental Retardation
Services
Beverly J. Haberle, MHS, Executive Director
Bucks County Council on Alcoholism and Drug Dependence
Bill White has once again given readers a wonderful opportunity to walk
through history and learn the healing power that is unleashed when Communities
of Recovery work together for the common good. This monograph provides a
foundation for those newly engaged in peer-based addiction recovery support
activities. It also creates an opportunity for those already involved in providing
these services to expand their thinking by exploring the diverse and innovative
varieties of peer-based activities that are emerging in the field.
In Philadelphia, as in much of the nation, we are currently witnessing a
reawakening of hope, vision, and purpose, as stakeholders call for and strive to
implement sweeping changes in the manner in which addictions services are
delivered. These changes go far beyond developing new programs or tweaking
the ways in which existing services are structured. Recovery transformation is
about creating more holistic systems of care that are consistent with what both
scientists and people in recovery tell us works. Transformation moves us beyond
efforts at short-term stabilization to helping individuals achieve sustained
recovery, find meaningful roles in their communities, and fulfill their highest
potential.
This monograph can be used as a tool kit to guide the design and delivery
of peer-based support services in the context of Recovery Oriented Systems of
Care. Included in this work are cautions, questions of ethics, and areas for
further exploration. It also provides reassurance and validation that the hard
work and careful planning required to implement peer-based and peer-delivered
services can pay off in remarkable ways. Sometimes the simplest gesture of
kindness and support at the right time by a peer produces tremendous positive
change.
This monograph provided for us an opportunity to walk down “memory
lane” and reflect on what has transpired during the past few years within the City
of Philadelphia. To say, “Recovery is alive and well in the City of Brotherly Love”
is an understatement. Philadelphia’s recovery transformation process has
employed a participatory, collaborative approach at all levels, including full
engagement of local community members, including people in recovery, in
strategic planning and program development. Individuals and families in
recovery have contributed their time and talents to identify unmet needs, solve
problems, provide trainings, put a positive face on recovery to reduce stigma,
4
and deliver one-on-one services. Collectively, these efforts are expanding
opportunities for individuals to initiate and sustain long-term recovery.
The Program Profiles are a highlight of this Monograph. These profiles
outline different types of peer-based activities, projects, and services. In doing
so, they not only provide readers with opportunities to visualize what the services
look like and to explore their potential benefits, but they also help promote the
development of a learning community by providing contact information so that
readers can access additional information about any particular activity. This is an
invaluable resource for communities starting peer-to-peer services. Sometimes it
is difficult to grasp how peer-based services and activities actually operate. Bill
White's Program Profiles give readers a glimpse of actual services and allow
them to benefit from others’ experience in creating new roles and functions. It is
a testimony to the hard work of all involved in the Philadelphia Recovery
Transformation that fifteen of the Program Profiles describe activities occurring
within the City of Philadelphia. This would not be possible if it were not for the
forward-thinking members of the recovery community and the tremendous
collaboration that they have had with city officials and providers. This
monograph reinforces the importance of having a broad-based approach that
addresses the implementation of peer support services from multiple
perspectives.
From a system administration perspective, this work is enormously
important. Bill White has long championed the need for the field to shift from a
professionally directed, acute-care model, with its focus on isolated treatment
episodes, toward a sustained recovery management approach. In doing so, he
has contributed significantly to the sense of urgency and energy that is currently
stirring in the field. In this new monograph, White lays another critical building
block in the foundation of system-transformation efforts. He masterfully
describes how peer-based recovery support services (P-BRSS) can be used
prior to, during, and following acute treatment to achieve the fundamental goal of
care: recovery and a meaningful life in the community for everyone. Equipped
with this monograph, leaders of the recovery community, providers, policy
makers, and system administrators—that is, all those who grapple with how to
make the vision of recovery a reality—now have access to the burgeoning
scientific evidence that supports the critical role of peer-based recovery support
services in addiction recovery.
System administrators and policy makers will find this monograph to be
an invaluable resource. In addition to being armed with the scientific rationale to
inform their decision-making, they will also have a better understanding of the
infrastructure supports that will be necessary to create a seamless continuum of
integrated P-BRSS and treatment services. Currently, many stakeholders are
keenly aware of the tensions that naturally emerge between P-BRSS specialists
and addiction professionals as concerns regarding roles and credibility challenge
efforts at collaboration. By outlining the rich history and tradition of peer support
within the addiction field, White reminds all stakeholders of the unique
contributions that peer-directed services offer. In addition, his vivid Program
Profiles take the concept of collaborative P-BRSS and professionally directed
services from the realm of abstract aspirations to that of concrete strategies.
5
Finally, White’s recommendations regarding a research agenda for P-
BRSS represent some of the most urgent challenges confronting the field. He
argues that the current pathology-focused research agenda needs to be
expanded to include an exploration of the factors that promote recovery. While
the research base for P-BRSS continues to grow, there remain significant gaps in
what is known about how people recover, and specifically the role of P-BRSS in
supporting recovery. To be successful in transforming our service systems, we
will need to build learning communities based on relevant research, trust, mutual
respect, and an understanding that the goal of recovery is not just important for
people with substance use challenges and their families. Rather, the hope and
realization of recovery touches every individual, family, and organization in our
community. In this, another seminal work, Bill White tears down the walls that
have existed between those providing peer-based recovery support and those
offering professional treatment and, in doing so, charts a course toward more
effective care, and more sustained recovery, for all.
The genius of this work is that it simultaneously speaks to the broad
range of stakeholders in the addictions field, from those in the recovery
community who are inspired to “give back,” to systems administrators who are
seeking to ensure the highest possible standard of service delivery.
6
7
Abstract
Peer-based Addiction Recovery Support:
History, Theory, Practice, and Scientific Evaluation
William L. White, MA
The history of addiction treatment and recovery in the United States
contains a rich “wounded healer” tradition. For more than 275 years,
individuals and families recovering from severe alcohol and other drug
problems have provided peer-based recovery support (P-BRS) to sustain
one another and to help those still suffering. Formal peer-based recovery
support services (P-BRSS) are now being delivered through diverse
organizations and roles. The goals of this monograph are to 1) define P-
BRS and P-BRSS, 2) present a brief chronology of P-BRS in the United
States, 3) discuss the theories and principles that guide the design and
delivery of P-BRS services, 4) illustrate the current varieties of P-BRSS,
and 5) review the scientific studies that have evaluated P-BRS and
specialized P-BRSS. The monograph closes with a discussion of the
strengths and vulnerabilities of peer-based recovery support and
professionally directed addiction treatment services.
Key Words: Recovery mutual aid, recovery support services, recovery-oriented
systems of care, recovery management, paraprofessional, ex-addict, recovery
coach, peer, guide, recovery community, communities of recovery, sponsorship,
recovery homes, recovery schools, recovery ministries, outreach.
Recommended Citation: White, W. (2009). Peer-based addiction recovery
support: History, theory, practice, and scientific evaluation. Chicago, IL: Great
Lakes Addiction Technology Transfer Center and Philadelphia Department of
Behavioral Health and Mental Retardation Services.
8
9
Introduction
SUMMARY OF KEY POINTS
The organizing principle for providing care for people with alcohol and
other drug problems is shifting from pathology and intervention paradigms
to a long-term recovery paradigm.
Evidence of this shift is seen in a shift in emphasis within addiction
treatment from models of biopsychosocial stabilization to models of
sustained recovery management.
Recovery management models include assertive interventions to shorten
addiction careers, lengthen recovery careers, and enhance the quality of
individual/family life in long-term recovery.
Peer-based recovery support (P-BRS) and formal peer-based recovery
support services (P-BRSS) constitute central recovery management
strategies and a core component of recovery-oriented systems of
behavioral health care—with system here defined as a macro-level
organization of a community, state, or nation.
This monograph reviews the history, operational principles, service
practices, and scientific status of P-BRS and P-BRSS and their future
relationship with professionally directed addiction treatment.
THE RECOVERY MANAGEMENT MONOGRAPH SERIES
This is the seventh in a series of monographs on recovery management
(RM) and recovery-oriented systems of care (ROSC). The first monograph,
Recovery Management,1 describes the emergence of recovery as an organizing
paradigm for behavioral health services, reviews the varieties of recovery
experience, outlines recovery management principles, and discusses recovery
management within communities of color. The second monograph, Special
Report: A Unified Vision for the Prevention and Management of Substance Use
Disorders,2 applies principles of chronic disease management to the treatment of
severe alcohol and other drug (AOD) problems. The third monograph, Linking
Addiction Treatment and Communities of Recovery,3 details empirically grounded
strategies for linking addiction treatment clients to indigenous communities of
recovery. The fourth monograph, Perspectives on Systems Transformation,4 is a
1 White, W., Kurtz, E., & Sanders, M. (2006). Recovery management. Chicago: Great Lakes
Addiction Technology Transfer Center.
2 Flaherty, M. (2006). Special report: A unified vision for the prevention and management of
substance use disorders.
3 White, W. & Kurtz, E. (2006). Linking addiction treatment and communities of recovery: A
primer for addiction counselors and recovery coaches. Pittsburgh, PA: IRETA/NeATTC.
4 White, W. (2007). Perspectives on systems transformation. Chicago: Great Lakes Addiction
Technology Transfer Center.
10
collection of interviews with federal, state, and local leaders who are pioneering
ROSC. The fifth monograph, Recovery Management and Recovery-oriented
Systems of Care,5 defines and distinguishes recovery management and
recovery-oriented systems of care, describes the changes in service practices
that accompany the shift from acute care to sustained recovery management,
and reviews the scientific evidence supporting the recovery management model.
The sixth monograph, Building the Science of Recovery, outlines the scientific
questions that must be answered to guide the future design of recovery-oriented
systems of care.6
Collectively, these monographs portray an acute-care system of addiction
treatment that has helped transform the lives of countless individuals and
families, but whose potential benefits are often limited by serious design flaws.
These design flaws can:
inhibit client attraction, engagement, retention, and treatment completion;
limit the scope and duration of professional services and recovery support
provided during and following addiction treatment;
fail to assertively link individuals and families to indigenous communities
of recovery support;
minimize the duration and intensity of post-treatment continuing care;
and, as a result,
generate high rates of post-treatment relapse and treatment re-
admission.
Peer-based recovery support services (P-BRSS) are being designed to
extend the current acute-care model of addiction treatment toward the singular
goal of elevating long-term recovery outcomes. The strategies to achieve this
goal broadly include pre-treatment, in-treatment, and post-treatment P-BRSS.
Infrastructure support for these efforts include peer program standards
development, peer training and certification initiatives, and regulatory changes
that allow reimbursement of P-BRSS through Medicaid and Medicare and private
managed behavioral health care entities.7 These activities are a product of the
broader interest in the use of “community guides” to lead marginalized individuals
and families back into full participation in community life.8
5 White, W. (2008). Recovery management and recovery-oriented systems of care. Chicago:
Great Lakes Addiction Technology Transfer Center, Northeast Addicton Technology Transfer
Center and Philadelphia Department of Behavioral Health and Mental Retardation Services.
6 Laudet, A., Flaherty, M. & Langer, D. (2009). Building the science of recovery. Pittsburgh, PA:
Institute for Research, Education and Training and Northeast Addiction Technology Transfer
Center.
7 Goldstrom, I.D., Campbell, J., Rogers, J.A., Lambert, D.B., Blacklow, B., Henderson, M.J., et al.
(2006). National estimates for mental health mutual support groups, self-help organizations,
and consumer-operated services. Administration and Policy in Mental Health and Mental
Health Services Research, 33(1), 92-103. White, W. (2008). The culture of recovery in
America: Recent developments and their significance. Counselor, 9(4), 44-51.
8 Davidson, L., Tondora, J., Staeheli, M., O’Connell, M., Frey, J., & Chinman, M. (2005).
Recovery guides: An emerging model of community-based care for adults with psychiatric
disabilities. In A. Lightburn & P. Sessions (Eds.), Community based clinical practice (pp.
476-501). London: Oxford University Press. Loveland, D. & Boyle, M. (2005). Manual for
11
PURPOSE OF THE CURRENT MONOGRAPH
This seventh monograph provides a synthesis of current knowledge about
the history, theoretical foundations, methods, and scientific status of peer-based
recovery support services. This monograph is written primarily for those directly
involved in planning, funding, delivering, supervising, and evaluating peer-based
recovery support services. It is hoped that it will also find an audience among
policymakers, purchasers of care, treatment program administrators, and
addiction counselors and other service professionals. With such diverse readers,
every effort has been made to present information in a clear and accessible
language and to document meticulously the sources upon which conclusions and
recommendations are based. The monograph introduces the reader to a lost
body of literature on peer recovery support. I hope the unedited voices of these
early pioneers will resonate with the contemporary reader. Program profiles are
also included, most of them illustrating the varieties of peer recovery support
services unfolding within one city (Philadelphia) as part of a larger recovery-
focused behavioral health system-transformation process.
Also noteworthy is what is not included in this monograph. First, recovery
advocacy as a medium of peer support is not addressed in this monograph
because its recent history has been detailed in the author’s book, Let’s Go Make
Some History: Chronicles of the New Addiction Recovery Advocacy Movement.9
Second, by focusing on peer recovery support for those with the most severe and
complex alcohol and other drug (AOD) problems, this monograph does not
extensively address the role of family and peer support in resolving AOD
problems of lower severity and duration that are often resolved without formal
professional or peer recovery support services. Readers interested in the role of
peer support in the resolution of subclinical AOD problems are encouraged to
explore the growing literature on natural recovery, spontaneous remission,
maturing out, autoremission, and self-initiated change.
recovery coaching and personal recovery plan development. Retrieved August 18, 2008 from
http://www.bhrm.org/guidelines/RC%20Manual%20DASA%20edition%207-22-05.doc.
Ungar, M., Manuel, S., Mealey, S., Thomas, G., & Campbell, C. (2004). A study of
community guides: Lessons for professionals practicing with and in communities. Social
Work, 49(4), 550-561. White, W. (2004). Recovery coaching: A lost function of addiction
counseling? Counselor, 5(6), 20-22. White, W. (2006). Sponsor, recovery coach, addiction
counselor: The importance of role clarity and role integrity. Philadelphia, PA: Philadelphia
Department of Behavioral Health.
9 White, W. (2006). Let’s Go Make Some History: Chronicles of the New Addiction Recovery
Advocacy Movement. Washington, D.C.: Johnson Institute and Faces and Voices of
Recovery.
12
A NOTE ON LANGUAGE
The development of recovery-oriented systems of care for individuals,
families, and communities experiencing severe alcohol and other drug problems
rests on new ideas, new policies, and new service practices. The shift in focus
from pathology and intervention to long-term recovery is generating a new
language that fills the monographs in this series. Our work to-date rests on the
belief that words are important. Great care has been taken in selecting and
defining such terms as recovery, family recovery, recovery management,
recovery-oriented systems of care, recovery capital, pathways of recovery, styles
of recovery, recovery priming, and recovery coaching—to name just a few.10
The present monograph presents two key terms. Peer-based recovery
support, which will be designated by the acronym P-BRS, is a broad term
referring to any form of mutual assistance directed toward the goal of long-term
recovery from alcohol and other drug problems. Such assistance can and often
does occur informally, particularly within recovery mutual-aid societies. Peer-
based recovery support services, which will be designated by the acronym P-
BRSS, is a narrower term for assistance toward the same goal that is delivered
through more specialized roles with more formal resources, service protocols,
and safeguards. The key distinction here is the term services, which implies a
more formal structure though which recovery support is delivered. Discussions
of P-BRS will focus primarily on recovery support provided through recovery
mutual-aid societies and abstinence-based religious and cultural revitalization
movements. Discussions of P-BRSS will focus primarily on recovery support
provided through recovery community organizations other than recovery mutual-
aid societies and through addiction treatment programs and allied health and
human service agencies.
A CAUTION TO THE READER
There are many critical research questions about peer recovery support that
have yet to be studied. Answers to-date for many questions are also tentative.
This is a dynamic period in the development of these services. Caution is in
order regarding the review of scientific studies of peer recovery support. Many of
the cited studies suffer from methodological problems: convenient samples,
small samples, lack of control groups and randomization, lack of follow-up, short
periods of follow-up, and low follow-up rates, to name just a few. As with all
research studies, the findings presented are best viewed as probationary,
pending new studies of greater methodological sophistication.
10 White, W. (2001/2002). The rhetoric of recovery advocacy; An addiction recovery
glossary: The languages of American communities of recovery. In: White, W.
(2006). Let’s Go Make Some History: Chronicles of the New Addiction Recovery
Advocacy Movement. Washington, D.C.: Johnson Institute and Faces and Voices of
Recovery.
13
Those on the front lines delivering peer support services and the
individuals and families receiving these services do not have the luxury of waiting
for needed studies. They must make the best decisions possible today based on
what is now known. While this monograph seeks to convey present knowledge,
it is crucial to recognize that this “best knowledge” is a living, evolving entity.
Peer-based and other recovery support services, like professionally directed
clinical services, are evolving in tandem with new scientific findings and the
changing needs of those served. I look forward to the day when a fulfilled
recovery research agenda will render this monograph obsolete.
Bill White
Senior Research Consultant
Chestnut Health Systems
Port Charlotte, Florida
January, 2009
ACKNOWLEDGEMENTS
Support for work on this monograph was provided by the Philadelphia
Department of Behavioral Health and Mental Retardation and the Center for
Substance Abuse Treatment’s Great Lakes Addiction Technology Transfer. My
thanks to those organizations and to two of their funding sources, the Substance
Abuse and Mental Health Services Administration (SAMHSA), Center for
Substance Abuse Treatment (CSAT) and the National Institute on Alcohol Abuse
and Alcoholism.
Jim Russell of Oklahoma Faces and Voices of Recovery assisted in
locating surveys of recovery representation in the addictions treatment workforce
and in updating membership profiles of recovery mutual-aid societies in the
United States. Andrew Finch, Association of Recovery Schools, and Mandy
Baker, Center for the Study of Addiction and Recovery at Texas Tech University,
provided assistance in locating research on recovery schools. Paul Molloy
provided critical background on the national network of Oxford Houses. Rod
Funk of Chestnut Health Systems analyzed data on the changing recovery
representation in the field and prepared the table displaying this change from
1970-2008. I am indebted to the following people for helping prepare the
program profiles that illustrated the growing varieties of peer-based recovery
support: Mark Ames, Eugenia Argires, Jennifer Dorwart, Ellen Faynberg, Bev
Haberle, Michelle Khan, Joan King, Patty McCarthy, Seble Menkir, Tom O’Hara,
Phil Valentine and Fred Way. The following individuals provided needed
encouragement and helpful suggestions through the early drafts of this
document: Ijeoma Achara-Abrahams, Lonnetta Albright, Mike Flaherty, Ben
Bass, Brian Coon, David Dan, Ellen Faynberg, Tom Hill, Steve Hornberger, Keith
Humphreys, Leonard Jason, Ben Jones, Merlyn Karst, John Kelley, Joan King,
Seble Menkir, Garrett O’Connor, Lora Passetti, Fraser Ross, Mark Sanders,
Jason Schwartz, Richard Simonelli, Laura Sklansky, and Pat Taylor. My
14
previous collaborations with Ernie Kurtz provided the foundation for this present
work. I would also like to thank Pam Woll for lending her skilled touch to the final
editing and layout of the monograph.
I offer particular thanks to Lonnetta Albright, Arthur Evans, and Mike
Flaherty and their respective organizations: the Great Lakes Addiction
Technology Transfer Center, the Philadelphia Department of Behavioral Health
and Mental Retardation Services, and the Northeast Addiction Technology
Transfer Center. This monograph series is a testament to their sustained
commitment and leadership in the development of recovery-oriented systems of
care.
15
Chapter One
Defining Peer-based Recovery Support
Services
SUMMARY OF KEY POINTS
Peer-Based Recovery Support:
Peer-based recovery support (P-BRS) is the process of giving and
receiving non-professional, non-clinical assistance to achieve long-term
recovery from alcohol and/or other drug-related problems.
Peer-based recovery support is provided by people who are experientially
credentialed.
There are substantial differences between models of peer recovery
support and models of professionally directed addiction treatment.
P-BRS can be delivered through a variety of organizational venues and a
variety of service roles (including paid and volunteer recovery support
specialists).
The governance structures of P-BRS vary in the span and degree of peer
control (for example, peer-owned, peer-directed, and peer-delivered).
Peer-Based Recovery Support Services:
Peer-based recovery support services (P-BRSS) are a form of P-BRS
delivered through more formal organizations and through more
specialized roles.
Asset allocation schemes for P-BRSS include entrepreneur models
(excess assets returned to private owner/investors), institutional models
(excess assets reinvested in development of the organization), and
stewardship models (excess assets reinvested in recovery community
development).
The core functions of P-BRSS span the stages of recovery
initiation/stabilization, recovery maintenance, and enhancement of quality
of life in long-term recovery and may encompass support at individual,
family, neighborhood, and community levels.
P-BRSS are distinguished by their recovery focus; mobilization of
personal, family, and community recovery capital to support long-term
recovery; respect for diverse pathways and styles of recovery; focus on
immediate recovery-linked needs; use of self as a helping instrument;
and emphasis on continuity of recovery support over time.
P-BRSS may serve as an adjunct or alternative to professionally directed
addiction treatment.
16
DEFINING PEER RECOVERY SUPPORT
There has been a recent proliferation of new forms of peer-based support
to assist individuals and families in initiating and maintaining recovery from
alcohol and other drug problems and enhancing the quality of personal/family life
in long-term recovery. The advent of expanding sources of peer-based recovery
support (P-BRS) and new roles specializing in the delivery of peer-based
recovery support services (P-BRSS) calls for increased definition of these
functions and roles. The following definition of P-BRS is offered as a starting
point for discussion.
Peer-based recovery support is the process of giving and receiving non-
professional, non-clinical assistance to achieve long-term recovery from
severe alcohol and/or other drug-related problems. This support is
provided by people who are experientially credentialed to assist others in
initiating recovery, maintaining recovery, and enhancing the quality of
personal and family life in long-term recovery.
This definition contains several critical elements.
Peer-based means that the supports and services are drawn from the
experience of individuals who have successfully achieved addiction recovery
and/or who share other characteristics (for example, age, gender, ethnicity,
sexual orientation, co-occurring disorders, prior prison experience, family
experience, or other identity-shaping life experiences) that enhance the service
recipient’s sense of mutual identification, trust, confidence, and safety. What
constitutes peer is defined by each individual, rather than by an organization.
The reference to peer-based implies that services are provided by peers and that
peers play an important role in the design, development, delivery, and evaluation
of services. To further clarify this point, individuals seeking recovery may receive
peer support within a therapy group led by a professional therapist within an
addiction treatment organization, but this would not be considered a peer-based
recovery support service.
Recovery support distinguishes the singular goal toward which all efforts
are directed. Recovery, as used in this monograph, involves three critical
elements: 1) sobriety (abstinence from alcohol, tobacco, and unprescribed
drugs), 2) improvement in global health (physical, emotional, relational, and
ontological—life meaning and purpose), and citizenship (positive participation in
and contribution to community life).11 Support involves the provision of
informational, emotional, social, and/or material aid.
Process implies that the assistance is not a single event or activity and is
relational rather than mechanical, and that continuity of support over the time is
central to the desired outcome of long-term recovery.
11 For discussions about the role of citizenship in recovery and the meaning of recovery, see: The
Betty Ford Institute Consensus Panel (2007). What is recovery? A working definition from
the Betty Ford Institute. Journal of Substance Abuse Treatment, 33, 221-228; White, W.
(2007). Addiction recovery: Its definition and conceptual boundaries. Journal of Substance
Abuse Treatment, 33, 229-241.
17
Non-professional means that the P-BRS relationship is closer to the
reciprocity of friendship than the fiduciary relationship one has with a physician,
lawyer, banker, psychologist, or social worker. The power differential in the
relationship between peers is minimal compared to the power differential that
characterizes professional service relationships. Many P-BRSS specialists are
also indigenous non-professionals, meaning that they claim membership and are
viewed as members of the group being served, and their activities are valued
because of their personal history and social position within a constituent
community.12 P-BRSS specialists see those they serve, not as different from
themselves, but as one of “my people”—“brothers and sisters” to whom they are
connected by a “kinship of common suffering”13 and a kinship of gratitude, hope,
and shared purpose.
Non-clinical distinguishes P-BRS from clinical services that involve
diagnosis and treatment by health care professionals. Addiction professionals
and other professionals in recovery—christened “bridge people” by Bissell14
may volunteer to provide P-BRSS, but they are not acting in their professional
capacity or providing professional services when they are in this role.
Professional, clinically-based services may have a peer quality to them when
they are delivered by physicians, nurses, psychologists, social workers, or
addiction counselors who are in recovery. However, such services are not
considered P-BRSS as defined in this monograph. Non-clinical, in addition to
designating who is providing the service, also denotes what is being provided:
the more general categories of informational, emotional, social, and instrumental
(practical assistance such as transportation) support.15 Two other distinctions
are noteworthy. Where clinically oriented addiction treatment often values the
experience of emotional catharsis, P-BRS extols the value of emotional control.
Where clinically oriented addiction treatment services may focus inward on
personal wounds, P-BRS involves a focus outward—on connecting with
resources and relationships beyond the self.
The phrase experientially credentialed means that the knowledge drawn
on to provide P-BRS is acquired through life experience rather than formal
education. It is first hand rather than second hand. It means that peer support
specialists understand long-term recovery as a “lived experience” and can offer
12 Pearl, A. (1981). The paraprofessional in human service. In S. Robbin & W. Wagonfeld (Eds.),
Paraprofessionals in the human services. New York: Human Science Press. Reiff, R. &
Reissman, F. (1965). The indigenous nonprofessional: A strategy of change in community
action and community mental health programs. Community Mental Health Journal,
Monograph No. 1. Ungar, M., Manuel, S., Mealey, S., Thomas, G., & Campbell, C. (2004).
A study of community guides: Lessons for professionals practicing with and in communities.
Social Work, 49(4), 550-561.
13 Alcoholics Anonymous (1957). Alcoholics Anonymous comes of age. New York: A.A. World
Services, Inc.
14 Bissell, L. (1982). Recovered Alcoholic Counselors. In E. Pattison & E. Kaufman (Eds.),
Encyclopedic Handbook of Alcoholism (pp. 810-817). New York: Gardner Press.
15 Solomon, P. (2004). Peer support/peer provided services underlying processes, benefits, and
critical ingredients. Psychiatric Rehabilitation Journal, 27(4), 392-401; Emerging peer
recovery support services and indicators of quality: An RCSP Conference report, September
2006, Substance Abuse and Mental Health Services Administration.
18
guidance on the nuances of this experience as it unfolds over time. Their
authority, sometimes referred to as “street credentials,” comes from their own
healing journey, their history of recovery service work with others, and their
tenured membership within a community of recovering people. Most, but not all,
persons providing P-BRS have experienced recovery personally or as a family
member.
Experiential knowledge comes from having experienced, lived with, or
done battle with addiction and from having participated in one’s own or
other’s recovery. This does not explicitly require that all volunteer or paid
support staff be recovered or recovering, but it does require that they
have learned about addiction and recovery from close proximity.
Experiential expertise requires the ability to use this knowledge to affect
change in self or others. This latter credential—granted through the
community “wire” or “grapevine” (community story-telling)—bestows
credibility that no university can grant. It is bestowed only on those who
offer sustained proof of their expertise as a recovery guide within the life
of the community. Such persons may be professionally trained, but their
authority comes, not from their preparation, but from their own life history,
character, relationships, and performance within the community.16
Experiential knowledge does not mean that the P-BRSS specialist does not need
training or supervision, but it does affirm life experience as the foundational
source drawn upon in the helping process.
Assistance implies a broad spectrum of support activities—whatever it
takes—rather than the more specialized service menus offered by professional
helpers. Non-clinical, peer-based recovery support can be delivered through the
framework of a recovery mutual-aid society or a community-based service or
advocacy organization, or within a larger religious or cultural revitalization
movement.
The phrases long-term recovery and in initiating recovery, maintaining
recovery, and enhancing one’s quality of life in recovery underscore the vision of
P-BRSS as long-term availability and support, as opposed to brief, crisis-oriented
biopsychosocial stabilization. The implicit focus is on moving beyond reducing
addiction-related pathology to building sustainable personal, family, and
community recovery capital. This is a vision of global health (wellness), life
meaning and purpose, and enhanced service to community. It reflects the view
that long-term recovery is far more than the alleviation of alcohol and drug
problems from an otherwise unchanged life.
The phrase from alcohol and/or other drug-related problems defines the
boundaries of experiential competence and suggests that the support services
offered may not be appropriate for individuals and families experiencing
problems outside this arena. It also conveys that P-BRSS encompass the whole
16 White, W. & Sanders, M. (2008). Recovery management and people of color: Redesigning
addiction treatment for historically disempowered communities. Alcoholism Treatment
Quarterly, 26(3), 365-395.
19
spectrum of AOD-related problems and not just those that meet criteria for
severe alcohol or drug dependence.
In speaking of peer-based recovery support services (P-BRSS), the term
service as used in this monograph will reflect a unit of activity provided by a
formal helping institution rather than the “service work” that is a common
dimension of personal recovery across religious, spiritual, and secular pathways
of recovery. Peer-based recovery support (P-BRS) is used as an umbrella term
for all forms of mutual recovery support, including those provided informally or
through a recovery mutual aid group. Peer-based recovery support services (P-
BRSS) will be used to designate those peer supports that are organized into
formal services and delivered through more formal organizations. The distinction
will be important as we later attempt to distinguish the recovery support provided
by an addiction counselor or a 12-Step sponsor from that provided through the
role of a recovery coach or other recovery support specialist.
DISTINGUISHING PROFESSIONAL AND PEER SUPPORT
Robert Emrick, a sociologist who has investigated peer support groups,
notes the “natural antithesis between the philosophies of self-help and
professional health care.”17 Emrick and others see several crucial differences
between peer and professional models of support. Some of these key
differences and the vulnerabilities resulting from them are briefly summarized in
Table 1.18 These represent generalizations about opposite models/philosophies
that exist at either end of a long continuum. For any given individual or
organization, actual modes of operation may lie anywhere along that continuum.
However, an understanding of these two poles helps us understand some of the
forces that have helped shape these services and the vulnerabilities they have
created.
17 Emerick, R.E. (1990). Self-help groups for former patients: Relations with mental health
professionals. Hospital and Community Psychiatry, 41(4), 401-407.
18 This table is based on the work of the following: Emerick, R.E. (1990). Self-help groups for
former patients: Relations with mental health professionals. Hospital and Community
Psychiatry, 41(4), 401-407.; Gartner, A.J. (1997). Professionals and self-help. Social Policy,
27(3), 47-52; White, W. (1998). Slaying the dragon: The history of addiction treatment and
recovery in America. Bloomington, IL: Chestnut Health Systems.
.
20
Table 1: Professional and Peer Models of Helping
Helping
Dimension Professional Vulnerability Peer Vulnerability
Source of
Knowledge
Scientific knowledge
presented in form of
theories, empirical
studies, and
objective analysis.
Mistake
knowledge
gained from
limited studies
within a single
paradigm for the
whole truth.
Experiential
knowledge drawn
from historical
and personal
experience.
Mistake limited
personal
experience for the
whole truth.
Control of
Knowledge
Knowledge carefully
controlled, often
presented in arcane
language, and
protected.
Danger of closed
ideological
system
investigating only
questions that
will not threaten
the system and
whose answers
are already
known;
pathology-
focused
language
contributes to
social stigma.
Knowledge freely
available and
widely shared.
Anti-
intellectualism;
folk knowledge
can be hijacked,
corrupted, and
commercialized
by external
institutions.
Role
boundaries
Extreme separation
of helper and helpee
roles; emphasis on
professional
distance and
objectivity.
Under-
involvement;
detachment and
clinical
abandonment.
Helper and
helpee roles are
reciprocal;
emphasis on
relational
connection and
personal
involvement.
Over-
involvement;
injury to helpee
and helper
through excessive
intimacy.
21
Helping
Dimension Professional Vulnerability Peer Vulnerability
Structure of
helping
Significant power
differential between
helper and helpee;
extensive legal,
regulatory, and
ethical guidelines
govern relationship;
high external
accountability;
extensive record-
keeping; limited
accessibility; fees
attached to services;
considerable
organizational
hierarchy; helping
as a commodity.
Helping
procedures and
personal and
institutional
interests can
become more
important than
helping
relationship and
helping
outcomes.
Minimum power
differential
between helper
and helpee;
helping
relationship
governed only by
internal
guidelines and
group
conscience;
minimal if any
records; low
external
accountability;
high accessibility;
services
available without
fees; minimal
organizational
hierarchy;
helping as a
commitment.
Exploitation of
power inequities
is possible in the
peer context with
no mechanisms
for redress; over-
extension of the
helper; risk of
organizational
collapse; range
of services limited
by lack of
financial
resources.
Helping
focus
Clinical orientation
emphasizes “getting
into oneself”;
clinician is in control
of degree of
intimacy.
Approach can be
personally
invasive;
tendency to
define problems
and solutions
solely in personal
rather than
political or
cultural terms.
Support focus is
often on “getting
out of oneself”—
connecting with
resources and
relationships
beyond the self;
helpee controls
degree of
intimacy.
Those groups that
emphasize
politicizing their
members may
provide
inadequate
personal support.
It can be seen from this table that the differences between professional and peer
models of helping are extensive. Steve Hornberger of the National Association
for Children of Alcoholics suggests this professional/peer tension is similarly
evident within efforts to move from provider-driven service models to family-
driven service models.19 Many reviewers of this monograph aptly noted that the
distinctions between peer and professional models have blurred within the
addiction field over the past four decades, and that this influence is reciprocal,
with professional treatment exerting considerable influence on the content and
style of recovery support meetings and recovery support fellowships exerting
considerable influence on addiction treatment and addiction counseling. Such
19 Steve Hornberger, personal communication, January, 2009; also see: Osher, W. and Osher, D.
(2002). The paradigm shift to true collaboration with families. Journal of Child and Family
Studies, 11(2), 47-60.
22
reciprocity of influence might be viewed as a healthy synergy or as a corruption
and loss of the unique dimensions of both forms of helping.20
CORE CHARACTERISTICS OF P-BRSS SPECIALISTS
Looking at the ideal characteristics of a P-BRSS specialist (someone who
provides P-BRSS) is one way to think about what distinguishes people providing
these non-clinical services from outreach workers, case managers, or addiction
counselors, as well as from recovery mutual-aid sponsors. The defining
characteristics of P-BRSS are illustrated in Table 2. This Table further implies
some of the potential differences between peer models of recovery support and
professional models of addiction treatment.
Table 2: Defining Characteristics of P-BRSS
Role Dimension Defining Characteristics of P-BRSS Specialist
Recovery Orientation Focus on long-term recovery rather than brief biopsychosocial
stabilization; focus on full recovery rather than remission;
working across multiple (religious, spiritual, secular, cultural)
frameworks of recovery rather than within a particular
framework; emphasis on a person’s self-determination and
service philosophy emphasizing personal choice.
Strengths-based Focus on individual strengths and enhancement of recovery
capital via enmeshing individuals/families in a “culture of health”
rather than focusing on disease and disability;21 orientation
toward potential rather than toward problems.22
20 For concerns about negative influence of professional treatment on AA, see: Kurtz, E. (1999).
The Collected Ernie Kurtz. Wheeling, WV: The Bishop of Books, pp. 131-141; For
concerns about negative influence of AA on professional treatment , See Kalb, M. & Proper,
M.S. (1976). The future of alcohology: Craft or science. American Journal of Psychiatry,
133(6), 641-645.
21 Mead, S., Hilton, D., & Curtis, L. (2001). Peer support: a theoretical perspective. Psychiatric
Rehabilitation Journal, 25(2), 134-41.
22 Rhodes, C. & White, C., with Kohler, M.F. (1974). The role of the so-called paraprofessional in
the six years of IDAP. In E. Senay, V. Shorty, & H. Alksne (Eds.). Developments in the field
of drug abuse (pp. 1051-1066). Cambridge, MA: Schenkman.
23
Role Dimension Defining Characteristics of P-BRSS Specialist
Ecology of Recovery Focus more interpersonal than intrapersonal; emphasis on
building individual, family, and community recovery capital;
assertive efforts to design and deliver family-focused P-BRSS.
Core Knowledge Pathways, styles, and stages of long-term recovery; ecology of
recovery; organizational structure, core ideas, language, and
meeting rituals of local communities of recovery; service
protocols of recovery community institutions; indigenous and
formal support within larger community.
Core Skills Engagement, motivational enhancement, recovery planning;23
liaison with communities of recovery; assertive linkage between
indigenous and formal recovery supports; lapse and relapse
intervention; recovery education; recovery checkups and
coaching; recovery resource development; reputation
maintenance within communities of recovery; ability to access
mainstream institutions; generalist rather than specialist role in
recovery support.
Temporal Orientation Focus on the present, next steps, and near future rather than
focus on feelings about past personal experience.
Motivational Fulcrum Hope-based rather than pain-based motivational strategies,
attracting people to recovery based on what recovery can add to
one’s life rather than on what painful consequences can be
escaped.
Use of Self Strategic use of one’s own story; making recovery contagious
via energy and example; relating, not out of a position of
expertise, superiority, or objectivity, but out of mutual
identification and humility (“there but for the Grace of God go
I”);24 striving for invisibility while deflecting praise and
leadership opportunities to others in the community.
Service Vision Long-term personal/family/community recovery; growth of
individual/family/community recovery capital.
23 See Borkman, 1998, for distinction between recovery planning and treatment planning.
Borkman, T. (1998). Is recovery planning any different from treatment planning? Journal of
Substance Abuse Treatment, 15(1), 37-42.
24 Bissell, L. (1982). Recovered alcoholic counselors. In E. Pattison & E. Kaufman (Eds.),
Encyclopedic Handbook of Alcoholism (pp. 810-817). New York: Gardner Press.
24
Role Dimension Defining Characteristics of P-BRSS Specialist
Roles of Professional
Treatment and
Community in Recovery
Professionalized services not viewed as the first line of
response to need, but as a safety net for needs that cannot be
met by natural community (relationships that are non-
hierarchical, enduring, and non-financial); P-BRSS specialist
immersed in community life; community invited to support
individuals/families in recovery.
Community Education Every opportunity used to educate the community about
addiction recovery at personal, family, and community levels;
shifts pathology-focused discussions within the community to
solution-focused discussions; raises awareness of the
approximately 90% of persons with AOD problems not seen in
professional treatment.
Community Development Role combines personal/family recovery support functions with
recovery-focused community organization and cultural
renewal/revitalization functions.
Advocacy Assertive advocacy on recovery-related issues that transcend
personal, professional, and institutional interests.; advocacy to
reduce/eliminate service disparities; reduce/eliminate
stigma/discrimination; and make addiction treatment more
responsive, effective, and efficient.
Empowerment Recovering people play key roles in governance of service
organizations; emphasis on voluntary consent for participation
in P-BRSS; choice and self-determination highly valued; P-
BRSS role seen as non-hierarchical and catalytic rather than
directive; support for advocacy on one’s own behalf; linkage to
recovery leadership development opportunities; self-monitoring
to avoid “freezing clients in dependent roles.”25
Degree of Personal
Involvement
High degree of personal involvement: “There are things he [the
indigenous nonprofessional] can do which the professional is
not able to do and should not do.…He can be invited to
weddings, parties, funerals and other gatherings—and he can
go.”26
Fidelity and Endurance Continuity of contact with individuals, families, and community
institutions over a sustained period of time.
25 Dhand, A. (2006). The roles performed by peer educators during outreach among heroin addicts
in India: ethnographic insights. Social Science of Medicine, 63(10), 2674-85.
26 Reiff, R. & Reissman, F. (1970). The indigenous nonprofessional. Community Mental Health
Journal. Monograph No. 1.
25
VARIETIES OF PEER RECOVERY SUPPORT SERVICES
P-BRSS are being delivered within a variety of organizational contexts,
including recovery mutual-aid societies; addiction treatment programs; recovery
community organizations; and allied health, child welfare, and criminal justice
systems. These service-delivery organizations—spanning volunteer, not-for-
profit, and for-profit entities—vary widely in their degree of connection to local
communities of recovery.
Governance of organizations that provide recovery support involves
control of organizational policies and the ways in which organizational assets are
best invested to increase recovery outcomes. P-BRSS may be provided through:
entrepreneur models in which excess assets of the organization are
returned to private owner/investors in the form of profit,
institutional models in which excess assets are reinvested in development
of the organization, or
recovery community development models in which excess assets are
reinvested in projects that enhance the service work of local communities
of recovery.
People performing P-BRSS roles are being variably referred to as
sponsors, peer helpers, peer specialists, peer educators, peer mentors, outreach
workers, residential managers, community guides, recovery coaches, recovery
assistants, recovery support specialists, recovery escorts, recovery consultants,
prosumers, recovery mentors, ombudsmen, and behavioral health
paraprofessionals. While titles such as peer counselor or counseling aid are also
sometimes used, they can be confusing because they heighten the level of
ambiguity in the demarcation between professional treatment services and non-
clinical recovery support services. As will be evident as we proceed through this
monograph, it is important to distinguish clearly the roles of the P-BRSS
specialist, the recovery mutual-aid sponsor, and the addiction counselor.27
Table 3 (following page) summarizes some of the key dimensions of peer
recovery support and how these dimensions vary dramatically from organization
to organization. We will return to some of these dimensions shortly for a more in-
depth discussion.
27 Clark, H.W. (1987). On professional therapists and Alcoholics Anonymous. Journal of
Psychoactive Drugs, 19(3), 232-42. Doyle, K. (1997). Substance abuse counselors in
recovery: Implications for the ethical issue of dual relationships. Journal of Counseling and
Development, 75, 428-432. White, W. (2006). Sponsor, recovery coach, addiction
counselor: The importance of role clarity and role integrity. Philadelphia, PA: Philadelphia
Department of Behavioral Health.
26
Table 3: Defining Characteristics of Organizations Delivering
P-BRSS
Dimension Varieties
Repsource Accrual and
Allocation
A. Assets accrue as profits to owner(s)/investor(s)
B. Assets are fed back into organization to support and expand
support activities
Governance
A. Peers make major organizational decisions,, with accountability
to one or more communities of recovery
B. Peers can advise on organizational decisions; no
accountability to communities of recovery
C. Peers have no role in organizational decisions; accountability
to communities of recovery
Problem Perception A. Rooted in the person (Intrapersonal Model)
B. Rooted in disturbed relationships (Interpersonal Model)
C. Rooted in historical trauma/environmental conditions (Social
Change Model)
Ideological Orientation
A. Religious
B. Spiritual
C. Secular
D. Mixed
Method of Problem
Resolution
A. Abstinence-based
B. Moderation-based
C. Medication-assisted
Relationship with
Professionals
A. Professional Leadership (professionals serve as founders and
group leaders)
B. Professional Consultation (group is led by peers but has
professionals available for consultation and support)
C. Professional Collaboration Model (group is led by peers but
works with other professionals in the community)
D. No professional leadership
E. Anti-professional
External Relationships
A. Closed System (thick organizational boundaries, aggressive
gatekeeping, strict membership criteria to enhance mutual
identification, isolation from community, expectation of
confidentiality, anonymity at level of press)
B. Open System (diffuse organizational boundaries, minimal
gatekeeping, loose and evolving membership criteria, high
levels of community interaction, leaders and members visible to
larger community)
Internal Relationships
A. Face-to-face
B. Telephone-based (voice and/or text)
C. Internet-based
D. Mixed
Service Roles
A. Peer support provided on a volunteer basis
B. Peer support provided on a paid basis
C. Peer support provided through a combination of volunteer and
paid roles.
What distinguishes quality of peer recovery support services has been a
focus of increasing discussion. In a 2005 meeting of the Center for Substance
27
Abuse Treatment’s Recovery Community Services Program, 28 grantees defined
12 criteria they viewed as quality indicators.
1. Peer recovery support services are clearly defined in ways that
differentiate them from professional treatment services and from
sponsorship in 12-Step or other mutual-aid groups.
2. The programs and peer recovery support services are authentically peer
based (participatory, peer led, and peer driven) in design and operation.
3. The peer recovery support program has well delineated processes for
engaging and retaining a pool of peer leaders who reflect the diversity of
the community and of people seeking recovery support.
4. The peer recovery support program has an intentional focus on
leadership development.
5. The peer recovery support program operates within an ethical framework
that reflects peer and recovery values.
6. The peer recovery support program incorporates principles of self-care,
which are modeled by staff and peer leaders, and has a well considered
process for handling relapse.
7. The peer program and peer recovery support services are
nonstigmatizing, inclusive, and strengths-based.
8. The peer recovery support program honors the cultural practices of all
participants and incorporates cultural strengths into the recovery process.
9. The peer recovery support program connects peers with other community
resources irrespective of types of services offered.
10. The peer recovery support program has well established, mutually
supportive relationships with key stakeholders.
11. The peer recovery support program has a plan to sustain itself.
12. The peer recovery support program has well documented governance,
fiscal, and risk management practices to support its efforts.28
CORE FUNCTIONS
The functions of the P-BRSS specialist vary widely by role, clientele, and
organizational setting, but collectively reflect the following functions:
Assertive outreach to identify and engage those in need of recovery—
what Malcolm X referred to as “fishing for the dead”29 and Reiff and
Riessman30 called “reaching the hitherto unreached”
28 Kaplan, L., The role of recovery support services in recovery-oriented systems of care. DHHS
Publication No. (SMA) 08-4315. Rockville, MD: Center for Substance Abuse Services,
Substance Abuse and Mental Health Services Administration, 2008, pp. 19-20.
29 Myers, W.D. (1993). Malcolm X: By any means necessary. New York: Scholastic.
30 Reiff, R. & Reissman, F. (1970). The indigenous nonprofessional. Community Mental Health
Journal, Monograph No. 1.
28
Minimization of harm to self, family, and community in the transitions
through identification, engagement, destabilization of addiction, and
recovery initiation
Recovery capital/needs assessment for individual/family/community
Recovery education and coaching for individual/family (normative
recovery information, encouragement, support, and companionship;
enhancement of recovery self-management skills), often delivered in the
natural environment of the individual/family
Community-level recovery education
Recovery resource identification, mapping, and development, including
volunteer recruitment
Recovery resource mobilization (activating a state of readiness to
respond to the needs of an individual/family at a particular point in time)
Community-level recovery resource development
Assertive linkage to communities of recovery (support groups and support
institutions)
Assertive linkage to and systems navigation within addiction treatment
and allied human services
Liaison (bridging, brokering/negotiating, partnering) between individual,
family, organization, and community
Recovery-focused skill training aimed at full community participation
(education, employment, housing, leisure, worship and pro-recovery
family and social relationships)
Companionship and modeling of recovery lifestyle, including participation
in leisure activities that would be judged a breach of ethics for addiction
counselors, e.g., eating together at a restaurant, attending or participating
in a sporting event, attending a social event such as a concert or recovery
celebration event31
Problem-solving to eliminate obstacles to recovery, e.g., linkage to
resources for child-care, transportation, community re-entry from
jail/prison
Recovery check-ups (sustained monitoring, support/companionship, and
recovery promotion)
Recovery advocacy for individual/family needs (empower individuals and
family members to assert their rights and needs)
Recovery advocacy for aggregate community needs
Recovery leadership development
Conducting a regular self-inventory of personal and organizational
performance via reflection, dialogue with service constituents, and
analysis of recovery-focused service benchmark data
31 Wolf and Kerr (1979) recommended such activities under the rubric of “companionship
therapy,” as a means of lowering post-treatment relapse rates. Wolf, K. & Kerr, D.M. (1979).
Companionship therapy in the treatment of drug dependency. In B. S. Brown (ed.), Addicts
and aftercare (pp. 183-209). Beverly Hills, CA: Sage.
29
These core functions can be divided into four overlapping stages of
recovery support: 1) pre-recovery engagement, 2) recovery initiation and
stabilization, 3) recovery maintenance, and 4) enhancement of quality of life in
long-term recovery. (One advantage of this staged view of recovery is that it
provides a way to transcend the traditional polarization between harm reduction
and treatment interventions.) These same functions also encompass different
“zones of action and experience” in recovery: physical, psychological
(cognitive/emotional), relational, occupational/leisure, and ontological
(spirituality/life meaning and purpose).32
TREATMENT ADJUNCT OR ALTERNATIVE
As noted, P-BRSS can constitute an adjunct or alternative to
professionally directed addiction treatment. The former is often demarcated by:
pre-treatment P-BRSS (services aimed at identification, relational
engagement, motivational enhancement, and treatment entry),
in-treatment P-BRSS (services aimed at enhancing service quality,
continued participation, and treatment completion), and
post-treatment P-BRSS (services focused on post-treatment recovery
checkups, stage-appropriate recovery education, assertive linkage to
communities of recovery, early re-intervention, and coaching for
enhanced quality of personal/family life in long-term recovery).
Although P-BRSS will never and should never fully replace professionally
directed treatment as a means of initiating recovery, P-BRSS can serve as an
alternative to treatment for people with low to moderate problem severity and
high levels of personal, family, and community recovery capital.33 P-BRSS may
also serve as an alternative for relapsed clients with multiple prior treatment
episodes who have mastered the art of initiating recovery through the vehicle of
professional treatment but are unable to sustain recovery within their natural
environments following discharge from treatment.
Recovery support in the professional literature is very much focused on
treatment, but pre-recovery engagement entails far more than the question of
how to link someone to treatment, and post-treatment peer support services
involve far more than maintaining the improvements made in treatment. P-BRSS
involve a larger spectrum of life concerns than those typically addressed in
addiction treatment, including basic necessities of living, reconstruction of
32 There are many staged models of recovery that are reviewed by White & Kurtz, 2006, but
Rossi’s depiction of these as sobriety, happy sobriety, and healthy sobriety is as apt here as
any. White, W. & Kurtz, E. (2006). The varieties of recovery experience. International
Journal of Self Help and Self Care, 3(1-2), 21-61. White, W. (1996). Pathways from the
culture of addiction to the culture of recovery. Center City, MN: Hazelden.
33 White, W. & Cloud, W. (2008). Recovery capital: A primer for addictions professionals.
Counselor, 9(5), 22-27.
30
personal lifestyle, sober fellowship and leisure activities, restitution and
community service, and life meaning and purpose. Where treatment focuses on
the problems that can be subtracted from the client’s life, P-BRSS focus on what
can be added during long-term recovery.
In the next chapter, we will explore the history of peer-based addiction
recovery support from the mid-1700s to the present.
31
Chapter Two
History of Peer-Based Recovery Support
Services
SUMMARY OF KEY POINTS
Addiction recovery mutual-aid societies and the specialty sector of
addiction treatment emerged in response to the social stigma attached to
AOD problems34 and the history of service exclusion, service extrusion,
and ineffective and harmful interventions35 that individuals and families
experienced in their encounters with mainstream health and human
service institutions.
Addiction recovery mutual-aid societies have experienced substantial
growth (membership size and geographical dispersion of local meetings),
pathway diversification (secular, spiritual, and religious recovery
societies), specialization (meetings focused on age, gender, drug choice,
and special needs), and new support media (growth of telephone- and
Internet-based support).
A growing number of religious and cultural revitalization movements are
embracing abstinence, creating unique cultural and religious pathways of
recovery initiation and recovery maintenance.
People in recovery have sought service roles as a natural extension of
the service ethic within communities of recovery and as a backlash
against ineffective and disrespectful professional interventions.
The services recovering people have provided to individuals and families
suffering from AOD problems have emphasized service relationships that
are natural, equal, reciprocal, voluntary, sustained (potentially life-long),
non-bureaucratic, and non-commercialized.
P-BRSS constitute an effort to recapture dimensions of support lost in the
professionalization of addiction counseling and the weakening of the
34 For information on how this stigma influenced attitudes of mainstream service professionals,
see: Goodyear, R. (1983). Patterns of counselors’ attitudes toward disability groups.
Rehabilitation Counseling Bulletin, 1, 181-184. Grob, G. (Ed.) (1981). Nineteenth-Century
medical attitudes toward alcoholic addiction. NY: Arno Press. Haberman, P.W. &
Sheinberg, J. (1969). Public attitudes toward alcoholism as an illness. American Journal of
Public Health, 59, 1209-1216. Hayman, M. (1956). Current attitudes to alcoholism of
psychiatrists in southern California. American Journal of Psychiatry, 112, 485-493.
Schneider, C. & Anderson, W. (1980). Attitudes toward the stigmatized: Some insights from
recent research. Rehabilitation Counseling Bulletin, 23(4), 299-311.
35 For a recent review of the harm done in the name of help within the history of addiction
treatment, see White, W.L. & Kleber, H.D. (2008). Preventing harm in the name of help: A
guide for addiction professionals. Counselor. 9(6), 10-17.
32
service ethic within communities of recovery that accompanied the rise of
an “alcohol and drug abuse industrial complex.”36
People in recovery have been cyclically included and excluded from
leadership and service roles within addiction treatment and the broader
arena of recovery support services.
Recovering people are awakening politically and culturally and are
generating new recovery support institutions that complement and, in
some circumstances, compete with professionally directed addiction
treatment.
New recovery support institutions include grassroots recovery community
organizations, recovery homes and colonies, recovery industries,
recovery schools, recovery ministries and recovery churches, recovery-
focused media (radio, television, cinema), and recovery arts (music,
literature, film, comedy).
Recovering people are again moving into a broad range of service roles
within addiction treatment and allied health care, human service, and
criminal justice agencies.
Recovery support services are being rapidly privatized and
professionalized—a trend with unclear long-term consequences.
The history of peer-based recovery support in the United States spans
the services of solo practitioners, recovery support within larger religious/cultural
revitalization movements, formal recovery mutual-aid societies, recovery social
clubs, recovery community service institutions, recovering people working in non-
professional support roles in addiction treatment and prevention organizations,
recovering people working in professional roles in addiction treatment, and
recovering people working in allied service organizations. This history has been
presented elsewhere in considerable depth.37 For purposes of this monograph,
we will provide a brief summary of peer-based recovery support structures in the
United States.
It is important to put this in context. There would be no history of
recovery mutual-aid societies, and no history of addiction treatment, if people
36 Hughes, H. (1974, December). Address before the North American Congress on Alcohol and
Drug Problems. San Francisco, CA.
37 White, W. (1998). Slaying the dragon: The history of addiction treatment and recovery in
America. Bloomington, IL: Chestnut Health Systems. White, W. (2000a). The history of
recovered people as wounded healers: I. From Native America to the rise of the modern
alcoholism movement. Alcoholism Treatment Quarterly, 18(1), 1-23. White, W. (2000b). The
history of recovered people as wounded healers: II. The era of professionalization and
specialization. Alcoholism Treatment Quarterly, 18(2), 1-25. White, W. (2000c). The role of
recovering physicians in 19th century addiction medicine: An organizational case study.
Journal of Addictive Diseases, 19(2), 1-10. White, W. (2004a). The history and future of
peer-based addiction recovery support services. Prepared for the SAMHSA Consumer and
Family Direction Initiative 2004 Summit, March 22-23, Washington, DC. Posted at:
http://www.facesandvoicesofrecovery.org/pdf/peer-based_recovery.pdf. Coyhis, D. & White,
W. (2006). Alcohol problems in Native America: The untold story of resistance and
recoveryThe truth about the lie. Colorado Springs, CO: White Bison, Inc.
33
seeking recovery had found support for recovery within their natural communities
and if they had received respect and effective professional help from other health
and human service institutions. Historically, recovery mutual-aid movements rise
in the absence, under-funding, ineffectiveness, or collapse of professional
systems of care.
It is under such circumstances that recovering people turn to one another,
discover that they can do together what they are failing to do alone, and conclude
that their methods are superior to other methods. The source of any subsequent
failure is viewed as rooted within the person rather than in the program.38 The
anti-professionalism that sometimes characterizes recovery mutual-aid
movements is rooted in recovering peoples’ experience of contempt, service
exclusion, service ineffectiveness, and harm done in the name of help within
mainstream health and human service institutions.39
This collective experience of people with AOD problems set the stage for
the rise of addiction recovery support groups and the specialized field of
addiction treatment.40 Historically, traditionally trained helping professionals
(physicians, psychiatrists, nurses, psychologists, social workers) enter the field of
addiction treatment in large numbers only during periods of increased funding
and heightened professional status. When the stigma attached to addiction
treatment and recovery rises again, with resulting cutbacks in funding and status,
traditional professionals tend to abandon the addictions field for more financially
and socially attractive opportunities.
When systems of support and care for addiction recovery collapse, it is
recovering people and their families and a small cadre of committed
professionals who join together to birth new systems of support and care. In
each cycle, such care and support evolve from peer-based to professional-based
models, resulting in transition periods of mixed peer/professional characteristics.
The therapeutic community, for example, began as a purely peer-based model of
recovery and evolved into a professional treatment that retained strong peer
elements. The stigma experienced by people in medication-assisted recovery
(particularly persons enrolled in methadone maintenance) when they seek
involvement in traditional recovery support groups (e.g., Narcotics Anonymous)
has led to alternative support groups that mix peer and professional support
characteristics.41 Similarly, SMART Recovery® is usually referred to as a peer
38 Pattison, E. (1973). A differential view of manpower resources. In G. Staub & L. Kent (Eds.),
The para-professional in the treatment of alcoholism (pp. 9-31). Springfield, IL: Charles C.
Thomas Publisher. Toch, H. (1965). The social psychology of social movements.
Indianapolis: Bobbs-Merrill.
39 White, W. (1998). Slaying the dragon: The history of addiction treatment and recovery in
America. Bloomington, IL: Chestnut Health Systems.
40 For a discussion of the aversion to alcoholics/addicts among mainstream service professionals,
see: Googins, B. (1984). The avoidance of the alcoholic client. Social Work, 29, 161-166.
White, W. (2003b). A history of contempt: Countertransference and the dangers of service
integration. Counselor, 4(6), 20-23.
41 Nurco, D.N., Stephenson, P., & Hanlon, T.E. (1991). Contemporary issues in drug abuse
treatment linkage with self-help groups. In R. W. Pickens, C. G. Leukefeld, & C. D. Schuster
(Eds.), Improving drug abuse treatment (NIDA Research Monograph, 106; pp. 338-348).
Rockville, MD: National Institute on Drug Abuse.
34
recovery support program but continues to use professional facilitators for many
of its meetings.
The following discussions outline the history of peer-based models of
recovery support.
SOLO PRACTITIONERS
People recovering from alcohol and other drug addictions have a long
history of reaching out to others similarly afflicted. Solo practitioners pursue this
outreach in relative isolation from other organized frameworks of recovery
support. Most often, they do so to bolster their own recovery and to fulfill a
newfound calling to help others. In the nineteenth century, such persons traveled
from town to town giving temperance lectures, providing personal consultations
to inebriates and their families, organizing local recovery support meetings, and
maintaining a prolific correspondence with those seeking recovery.
This style of recovery evangelism is well illustrated in the biographies of
nineteenth-century temperance missionaries John Hawkins,42 John Gough,43
Edward Uniac,44 George Dutcher,45 Luther Benson,46 and Thomas Doutney.47
These accounts attest to the special kinship that existed between the “reformed
reformers” and those still suffering addiction to strong drink.48
I can sympathize with and appreciate the condition of the poor
inebriate. Have I not been one of their number? I now have an
object in life—to reform men.49
They [reformed men] understand the whole nature of
intemperance in all its different phases; they are acquainted with
the monster in every shape which he assumes; they know the
avenues to the drunkard’s heart; they can sympathize with him;
they can reason with him; they can convince him that it is not too
late to reform... (from the Mercantile Journal, May 27, 1841.50)
42 Hawkins, W. (1859). Life of John H. Hawkins. Boston: John P. Jewett and Company.
43 Gough, J. (1870). Autobiography and personal recollections of John B. Gough. Springfield,
MA: Bill, Nichols & Company.
44 Berry, J. (1871). UNIAC: His life, struggle, and fall. Boston, MA: Alfred Mudge & Son.
45 Dutcher, G. (1872). Disenthralled: A story of my life. Hartford, Connecticut: Columbian Book
Company.
46 Benson, L. (1896). Fifteen years in hell: An autobiography. Indianapolis: Douglas & Carlon.
47 Doutney, T. (1903). Thomas Doutney: His life, struggle and triumph. Battle Creek, MI: The
Gage Printing Company, Limited.
48 A Member of the Society. (1842). The foundation, progress and principles of the
Washingtonian Temperance Society of Baltimore, and the influence it has had on the
temperance movements in the United States. Baltimore: John D. Toy.
49 Doutney, T. (1903). Thomas Doutney : His life, struggle and triumph. Battle Creek, MI: The
Gage Printing Company, Limited.
50 Hawkins, W. (1859). Life of John H. Hawkins. Boston: John P. Jewett and Company.
35
The relapse rate was high for those not linked to a recovery mutual-aid
society. Luther Benson, like many solo practitioners, relapsed repeatedly during
his career as a temperance missionary. With each relapse, he threw himself
more intensely into the work in the hope it would take the place of alcohol.
Following his admission to the Indiana Asylum for the Insane in 1896, Benson
reflected on this failed strategy.
I learned too late that this was the very worst thing I could have done. I
was all the time expending the very strength I so much needed for the
restoration of my shattered system.51
People who experience recovery outside professional treatment or
mutual-aid groups have continued this recovery missionary tradition as solo
practitioners. There are fewer such solo practitioners today due to the number of
competing recovery support structures, but if such structures should ever
collapse, solo recovery advocates would quickly rise to fill this void.
PEER RECOVERY SUPPORT AND RELIGIOUS/CULTURAL REVITALIZATION
MOVEMENTS
Abstinence-based religious and cultural revitalization movements have
provided a source of shelter and support for people seeking addiction recovery.
When alcohol problems first rose within American Indian communities, a series of
indigenous movements offered cultural pathways of recovery for individuals,
families, and tribes. The earliest of these movements included the Handsome
Lake Movement (1799), the Indian Prophet Movements (1805-1830s), the Indian
Shaker Church (1882), and the Native American Church (1918), and this tradition
continued in the contemporary period through the “Indianization of Alcoholics
Anonymous,” the Red Road, and the Native American Wellbriety movement.52
Outside Native America, people seeking recovery found peer-based
support within the American Temperance movement’s network of temperance
societies, temperance meetings, temperance hotels, and temperance libraries,53
as well as within the larger religious awakening occurring in the United States in
the eighteenth and early nineteenth centuries. The recovery-focused ministries
within these larger religious movements were led by people in recovery.
Recovery-focused ministries span the urban mission movement and religious
51 Benson, L. (1896). Fifteen years in hell: An autobiography. Indianapolis: Douglas & Carlon.
52 Coyhis, D. & White, W. (2006). Alcohol problems in Native America: The untold story of
resistance and recoveryThe truth about the lie. Colorado Springs, CO: White Bison, Inc.
Womak, M.L. (1996). The Indianization of Alcoholics Anonymous: An examination of Native
American recovery movements. Master’s thesis, Department of American Indian Studies,
University of Arizona.
53 Sigorney, L. & Smith, G. (1833). The intemperate and the reformed. Boston: Seth Bliss.
36
inebriate colonies of the late nineteenth century to the current growth of recovery
ministries and recovery churches.54
Recovery support initiatives were also spawned within the larger mid-
twentieth-century civil rights; women’s liberation; and lesbian, gay, bisexual, and
transgender (LGBT) rights movements. The recovery ministry of the Reverend
Cecil Williams and Glide Memorial Church in the Tenderloin District of San
Francisco was a natural outgrowth of the civil rights movement and set a model
for recovery ministries within disempowered communities.55 Women for Sobriety,
founded by Dr. Jean Kirkpatrick in 1975, was a product of the consciousness
raising within the women’s movement.56 At the height of the youth counterculture
movement of the 1960s, young people recovering from dependence on drugs
other than alcohol and heroin felt little identification with the recovery cultures of
AA or NA. They found service roles within indigenous service organizations,
e.g., the Diggers (the service institution within the San Francisco youth
counterculture), folk medicine institutions (“acid rescue”), crisis lines, “crash
pads,” and youth-focused counseling centers. Similarly, recovering people within
the LGBT movement played key service roles within indigenous responses to the
AIDS epidemic and championed LGBT recovery support meetings and LGBT-
sensitive addiction treatment.
Abstinence-based religious and cultural revitalization movements have
been strongest in historically disempowered communities of color in which
alcohol and other drugs are deeply entwined with histories of enslavement and
colonization.57 Hope for personal recovery from addiction for members of a
culturally besieged group is best couched in a larger framework of hope for a
community and a people.58
SECULAR RECOVERY MUTUAL-AID SOCIETIES
Secular recovery frameworks are distinctive in that they extol the power of
personal (rational) will and mutual fellowship rather than God as the source of
strength in overcoming alcohol and other drug problems. Prominent secular
54 White, W. (1998). Slaying the dragon: The history of addiction treatment and recovery in
America. Bloomington, IL: Chestnut Health Systems. White, W. (2008). The culture of
recovery in America: Recent developments and their significance. Counselor, 9(4), 44-51.
Williams, C. with Laird, R. (1992). No hiding place: Empowerment and recovery for
troubled communities. NY: Harper San Francisco. Sanders, M. (2002). The response of
African American communities to alcohol and other drug problems. Alcoholism Treatment
Quarterly, 20(3/4), 167-174.
55 Williams, C. with Laird, R. (1992). No hiding place: Empowerment and recovery for troubled
communities. NY: Harper San Francisco.
56 Kirkpatrick, J. (1978). Turnabout: Help for a new life. Garden City, NY: Doubleday and
Company. Kirkpatrick, J. (1986). Goodbye hangovers, Hello life. NY: Ballantine Books.
57 Coyhis, D. & White, W. (2006). Alcohol problems in Native America: The untold story of
resistance and recovery—The truth about the lie. Colorado Springs, CO: White Bison, Inc.
58 White, W. (2006). Let’s go make some history: Chronicles of the new addiction recovery
advocacy movement. Washington, D.C.: Johnson Institute and Faces and Voices of
Recovery.
37
recovery support societies in the United States have included the
Washingtonians (1840), multiple fraternal temperance societies (1840s to
1890s), the Dashaway Association (1859), the Ribbon Reform Clubs (1870s), the
Business Men’s Moderation Society (1879), Women for Sobriety (1975), Secular
Organization for Sobriety (1985), Rational Recovery (1986), Men for Sobriety
(1988), SMART Recovery® (1994), Moderation Management (1994), and
LifeRing Secular Recovery (1999).59 Secular recovery groups have grown in
number since 1975, but the availability of face-to-face meetings continues to be
geographically limited. This limitation is balanced by the rapid growth in Internet-
based secular recovery support meetings.
SPIRITUAL RECOVERY MUTUAL-AID SOCIETIES
Alcoholics Anonymous (AA) (1935) pioneered a spiritual, 12-Step
program of recovery that has been widely adapted for other problems. Addiction
recovery societies that have adapted AA’s program include Narcotics
Anonymous (1953), Pot Anonymous (1968), Pills Anonymous (1975), Chemical
Dependent Anonymous (1980), Recoveries Anonymous (1981), Cocaine
Anonymous (1982), Nicotine Anonymous (1985), Marijuana Anonymous (1989),
Benzodiazepines Anonymous (1989), Crystal Meth Anonymous (1994),
Prescription Drugs Anonymous (1998), and Heroin Anonymous (2004). Twelve-
Step groups also exist for medication-assisted recovery (Methadone Anonymous,
1991; Advocates for the Integration of Recovery and Methadone, 1991; Mothers
on Methadone, 2005). Twelve-Step groups are the most geographically
dispersed and available recovery support meetings in the United States.
RELIGIOUS RECOVERY MUTUAL-AID SOCIETIES
Some recovery mutual-aid societies use deep religious experiences,
religious ideas and rituals, and enmeshment in a faith community to initiate and
sustain recovery and enhance the quality of personal/family life in recovery.
Societies formed particularly for this purpose include the United Order of Ex-
Boozers (1912); the Calix Society (1947); Alcoholics Victorious (1948);
Alcoholics for Christ (1976); Overcomers Outreach (1985); Jewish Alcoholics,
Chemically Dependent People and Significant Others (1979); Liontamers
Anonymous (1980); Free N’One (1985); Celebrate Recovery (1990); Millati
Islami (1989); and Victorious Ladies (ND). Celebrate Recovery is currently the
fastest growing faith-based recovery support group in the United States, with
groups in more than 10,000 churches.
59 White, W. (1998). Slaying the dragon: The history of addiction treatment and recovery in
America. Bloomington, IL: Chestnut Health Systems. White, W. (2004). Addiction recovery
mutual-aid groups: An enduring international phenomenon. Addiction, 99, 532-538.
38
FAMILY-FOCUSED RECOVERY SUPPORT SOCIETIES
Some recovery support societies support family members affected by
alcohol and drug addiction. The most prominent of these societies have included
the Martha Washington Society (1842), Alcoholics Anonymous Associates and
AA Auxiliaries (1946-1950), Al-Anon (1951), Alateen (1957), Nar-Anon (1968),
Families Anonymous (1971), Adult Children of Alcoholics (1978), Because I Love
You (1982), National Association for Children of Alcoholics (1983), Co-Anon
(1983), Codependents Anonymous (1986), and Recovering Couples Anonymous
(1988). The most accessible family recovery support group in the U.S. is Al-
Anon, with 14,924 groups in the U.S. and Canada.60
OCCUPATION-BASED RECOVERY SUPPORT GROUPS
Recovery support societies (mostly 12-Step-associated groups) have
formed for particular professional groups in recovery, including physicians
(1949), lawyers (1975), women in religious orders (1979), psychologists (1980),
social workers (1981), pharmacists (1983/1984), anesthetists (1984), nurses
(1988), ministers (1988), and veterinarians (1990). These groups provide a very
special form of peer support for people who face special challenges in recovery
(e.g., ready access to drugs) and whose professional practice could be harmed
by the stigma attached to addiction. They often operate in close association with
formal professional assistance programs.
SHARED CHARACTERISTICS OF RECOVERY SUPPORT GROUPS
Much has been made of the differences between recovery support
groups, but less attention has focused on what these groups share in common
that distinguishes them from professionally directed addiction treatment. Such
collective distinguishing characteristics include:
origin and structure (spontaneous, self-governed movements);
recovery context (recovery support is provided while living in one’s own
natural environment; there is no re-entry or concern about transfer of
learning from institutional to natural settings);
organizational context (mutual support provided through the medium of a
community rather than through a professional/business organization);
lack of hierarchy (purpose is to help one another with common
problems—no one has claim to a morally superior position; no dichotomy
between helper and helpee roles);
support relationships guided by “group conscience” rather than codes of
professional ethics or legal regulations;
welcoming (emphasis on warm social fellowship);
60 Al-Anon (2006). Membership Survey Results, Al-Anon Family Groups, Fall 2006. Retrieved
August 30, 2006 from http://www.al-anon.alateen.org/pdf/AlAnonProfessionals.pdf.
39
motivational enhancement via mutual encouragement and celebration of
sobriety birthdays;
practical antidotes to guilt (self-inventory, confession, acts of restitution,
acts of service);
pragmatism (focus on well tested strategies of daily living rather than
theories about or extensive analysis of problem development);
no intake, no diagnosis, no medical record;
a strong service ethic through which members reach out to those still
suffering from addiction;
sustained availability of support during times of heightened vulnerability
(e.g., evenings, nights, and weekends) when professionals are generally
not available;
support not contingent upon personal financial resources or the vagaries
of public funding; and
guidance provided via experience-based suggestions rather than rules or
prescriptions.
RECOVERY SUPPORT FOR SPECIAL POPULATIONS
When individuals struggle to meet their needs within mainstream recovery
support groups or when aspects of their experience are difficult to address within
mainstream groups, recovering people have sought out others like themselves to
share their “experience, strength, and hope” on these issues.
Gender-specific mutual-aid groups: Recovery support groups for
women began within the Martha Washington societies of the 1840s, but, like
most groups that would follow, these societies tried to integrate recovering
women into support groups for wives and mothers of alcoholics. The first
sustainable recovery support groups designed specifically for addicted women
were started in the early 1940s within Alcoholics Anonymous. Female pioneers
within AA began meeting together to share experiences and support on issues
they could not raise in mixed-gender meetings. Twelve-Step meetings for
women are now common in communities across the United States.
The second half of the twentieth century witnessed the development of
alternatives to 12-Step groups for women, including Women for Sobriety,
founded by Dr. Jean Kirkpatrick; Charlotte Kasl’s Sixteen Step Groups; and
such faith-based recovery support groups as Women on the Move and Ladies
Victorious.61 Men-only meetings also have risen within AA/NA, and Men for
Sobriety was founded as an alternative recovery support group for men in 1988.
Beyond recovery support groups, gender-specific recovery support
services grew out of efforts to craft an approach to addiction treatment based
61 Kasl, C. (1992). Many roads, one journey. New York: Harper Perennial. Kirkpatrick, J.
(1978). Turnabout: Help for a new life. Garden City, NY: Doubleday and Company.
Kirkpatrick, J. (1981). A fresh start. Dubuque: Kendall/Hunt Publishing. Kirkpatrick, J.
(1986). Goodbye hangovers, Hello life. NY: Ballantine Books. Williams, C. with Laird, R.
(1992). No hiding place: Empowerment and recovery for troubled communities. NY:
Harper San Francisco.
40
specifically on the needs of addicted women. Peer-based outreach services,
mentoring programs, parenting education and coaching, trauma support groups,
child care co-ops, and linkage to educational opportunities were included in these
efforts.62 There have also been recent efforts to blend a recovery home for
women and a women’s community recovery center within the same program.63
Age-specific recovery support: Special support for young people
seeking recovery began in the mid-nineteenth century cadet branches of the
Washingtonians, the Ribbon Reform Clubs, and the Keeley Leagues.64 Young
people’s groups in AA began in the 1940s and led to the founding in 1958 of the
International Conference of Young People in Alcoholics Anonymous—an annual
event that now draws more than 3,000 young AA members from all over the
United States. Alateen, which was founded in 1957, also serves as a source of
support for adolescents who struggle with the alcoholism of a parent, as well as a
pathway of entry into recovery for some of these young people who develop AOD
problems.
Other peer recovery support frameworks that have meetings for youth—
although with far fewer meetings than found in AA—include Narcotics
Anonymous, Alcoholics Victorious, and Teen-Anon.65 There is also a tradition of
“old-timers” recovery support meetings in many communities. These meetings
provide a forum to address later-stage recovery tasks and to address age-related
issues that can pose a special challenge to late-stage recovery (e.g., loss of
spouse, retirement, age-related health problems, physical disability, chronic pain,
terminal illness).
Recovery mutual aid and advocacy in communities of color: As
noted earlier, historical research has placed the beginnings of peer-based
recovery support within mid-eighteenth century Native American tribes. Peer
recovery support was provided within larger, abstinence-based cultural and
religious revitalization movements and was followed by the cultural adaptation of
culturally dominant support structures, e.g., the “Indianization of AA,” or the use
of mainstream religious institutions for support for sobriety.66 According to the
62 Iliff, B, Siatkowski, C., Waite-O’Brien, N., & White, W. (2007). The treatment of addicted
women: Modern perspectives from the Betty Ford Center, Caron Treatment Centers and
Hazelden. Counselor, 8(3), 42-48.
63 Haberle, B. & White, W. (2007). Gender-specific recovery support services: The evolution of
the Women’s Community Recovery Center. Posted at
http://www.facesandvoicesofrecovery.org/pdf/White/white_haberle_2007.pdf.
64 White, W. (1998). Slaying the dragon: The history of addiction treatment and recovery in
America. Bloomington, IL: Chestnut Health Systems.
65 Passetti, L. & White, W. (2008). Recovery meetings for youths. Journal of Groups in
Addiction and Recovery, 2, 97-121. Published simultaneously as: Passetti, L.L. & White,
W.L. (2008). Recovery support meetings for youths: Considerations when referring young
people to 12-Step and alternative groups. In J.D. Roth & A.J. Finch (Eds.), Approaches to
substance abuse and addiction in education communities: A guide to practices that support
recovery in adolescents and young adults. NY: Haworth Press.
66 Coyhis, D. & White, W. (2006). Alcohol problems in Native America: The untold story of
resistance and recovery—The truth about the lie. Colorado Springs, CO: White Bison, Inc.
Womak, M.L. (1996). The Indianization of Alcoholics Anonymous: An examination of
41
research of Crowley,67 Frederick Douglass was the most prominent of early
African Americans in recovery. Douglass spoke openly of a period of
intemperance in his life, signed a pledge of abstinence in 1845, maintained
sobriety the rest of his life, and worked to promote Black temperance groups.
Through his encouragement and example, nineteenth-century African Americans
generated their own temperance and mutual-aid societies, e.g., the Black
Templars. These societies and their pledges framed sobriety within the historical
and cultural context of the post-Civil War years:
Being mercifully redeemed from human slavery, we do pledge ourselves
never to be brought into slavery of the bottle, therefore we will not drink
the drunkard’s drink: whiskey, gin, beer, nor rum, nor anything that
makes drunk come (Temperance Tract for Freedman).68
People of color entered AA in the 1940s, and the first African-American
AA group was established in Washington, DC in 1945. This was quickly followed
by African American groups in St Louis, Valdosta (GA), and Harlem.69 The
history of recovery within Hispanic and Asian communities has yet to be
documented. We will later review the scientific evidence related to the degree of
participation of people of color in mainstream recovery support groups and report
the affiliation rates and recovery outcomes of people of color within these groups.
Recovery support for and within the LGBT community: The first
addiction recovery support group organized specifically for members of the
lesbian, gay, bisexual, and transgender (LGBT) community was an AA meeting
founded for gay men in Boston in 1949. Early LGBT AA meetings existed
without being formally identified in AA meeting lists. The number of cities with
gay AA groups grew from seven in 1975 to more than 300 in 1990.70 Today, in
cities like Chicago, there are more than 50 LGBT-focused AA meetings per
week.
Recovery support for people with co-occurring disorders: People
concurrently recovering from substance use and psychiatric disorders often find
themselves marginalized from mental health support groups and mainstream
addiction recovery support groups. Such marginalization led to the emergence of
three specialty support groups: Dual Disorders Anonymous (1982), Dual
Recovery Anonymous (1989), and Double Trouble in Recovery (1993). (See
later discussion of research on these groups in Chapter Four.)
Native American recovery movements. Master’s thesis, Department of American Indian
Studies, University of Arizona.
67 Crowley, J. (1997). Slaves to the bottle: Gough’s autobiography and Douglass’s narrative. In
D. Reynolds & D. Rosenthal (Eds.), The serpent in the cup: Temperance in American
literature. Amerherst, MA: University of MA Press.
68 Cheagle, R. (1969). The colored temperance movement (Unpublished thesis). Washington,
DC: Howard University.
69 White, W. (1998). Slaying the dragon: The history of addiction treatment and recovery in
America. Bloomington, IL: Chestnut Health Systems.
70 Borden, A. (2007). The history of gay people in Alcoholics Anonymous from the beginning.
New York: Haworth Press.
42
Recovery support for people embedded within the criminal justice
system: Recovery support groups have existed independent of, grown out of, or
spawned inmate recovery counseling programs, e.g., the Addiction Recovery
Counseling program at San Quentin Prison.71 Most of these programs were the
fruit of volunteers from community-based recovery support groups (particularly
AA and NA) carrying recovery messages to local jails and prisons. Winner’s
Circle, a recovery support program for ex-offenders, started in Connecticut in
1988 and was rebirthed and revamped in Texas in 1998. It has developed into a
broader Winner’s Community concept that involves Inner Circle (institution-
based) and Winner’s Circle (community-based) recovery support meetings to
address the special obstacles offenders face in community re-integration and
long-term recovery.72
Recovery mutual aid in rural communities: People seeking recovery
support in rural communities face many obstacles: 1) the absence or scarcity of
mainstream recovery support meetings, 2) the absence of specialty meetings like
those just described, and 3) problems meeting accessibility for those without
driving privileges. These obstacles are being addressed, in part, through
carpooling to access regional recovery support meetings, P-BRSS delivered face
to face in people’s homes, and P-BRSS services delivered via telephone (voice
and text) and Internet.
Summary: Seen as a whole, specialty recovery support groups provide a:
sanctuary of mutual identification and support for individuals estranged
from mainstream community life,
means of making sense of the recovery process through key
developmental transitions,
place of safety and shelter for high-status individuals in recovery whose
careers or social standing could be injured by public disclosure of their
addiction/recovery status,
venue through which stigmatized populations can address their shared
experience and unique obstacles to recovery, and
forum to address recovery from addiction and co-occurring medical or
psychiatric conditions.
If there is a contemporary story of recovery mutual aid, it is that of the
growing varieties of recovery pathways and recovery experiences—all of which
are cause for celebration. A regularly updated directory of this growing network
of addiction recovery mutual-aid groups can be found at
www.facesandvoicesofrecovery.org.
71 De Miranda, J. (2006). Recovery inside San Quentin Prison, training inmate counselors.
Alcoholism & Drug Abuse Weekly, 18(39), 5-5.
72 The first national strategic planning meeting to expand the Winner’s Community nationally was
held in Hartford, CT in July 2008. Personal communication with Steven Shapiro.
43
GEOGRAPHICAL ACCESSIBILITY OF RECOVERY MUTUAL-AID GROUPS
Identification of the growing variety of recovery support groups leaves
open the question of whether these options are really available to people in most
communities in the United States. Table 4 illustrates the geographical availability
of these groups. The founding date of each group is included so that the reader
can estimate the rate of yearly growth of each recovery fellowship.
Table 4: Geographical Dispersion of Addiction Recovery Mutual-
aid Groups in the United States73
Mutual Aid Group Founding
Date
Number and Distribution of Groups and
Meetings in U.S. in 2007-2008
Addictions Victorious 1986 45 meetings in 5 states (MD, NJ, NY, PA, and
WA)
Addicts Victorious 1987 21 meetings in 5 states (IL-8, IO-1, MO-10, &
TX-3)
Adult Children of Alcoholics 1978 1,500+ meetings
Al-Anon/Alateen 1951/1957 14,924 groups in the U.S. and Canada; all 50
states 74
Alcoholics Anonymous 1935 More than 52,500 groups; all 50 states
Alcoholics for Christ 113 groups in U.S.; a particularly heavy
concentration (43) in Detroit.
Alcoholics Victorious 1948 164 groups in U.S.
All Recoveries Anonymous 1981 50 chapters
Anesthetists in Recovery 1984 150+ members; provides phone support and
linkage to support meetings
Benzodiazepines
Anonymous
1989 Currently inactive
Benzo 1999 Online recovery support group for those
withdrawing from benzodiazepines
http://www.benzosupport.org/
Calix Society (adjunct to AA) 1947 27 affiliates in 18 states
Celebrate Recovery 1991 Faith-based peer recovery program in 10,000
churches across all 50 states
Chemically Dependent
Anonymous
1980 65 groups
73 Groups listed in this table were defined as currently inactive if multiple efforts to reach the
group by listed phone and email failed to generate a direct response or information.
74 Al-Anon (2006). Membership Survey Results, Al-Anon Family Groups, Fall 2006. Retrieved
August 30, 2006 from http://www.al-anon.alateen.org/pdf/AlAnonProfessionals.pdf.
44
Mutual Aid Group Founding
Date
Number and Distribution of Groups and
Meetings in U.S. in 2007-2008
Christians in Recovery 1992 All meetings held online
Cocaine Anonymous 1982 2,500 groups; most states
Co-Anon 1985 28 international groups
Co-Dependents Anonymous 1986 1,100 meetings worldwide
Crystal Meth Anonymous 1995 Meetings in all states
Double Trouble in Recovery 1989 250 groups
Dual Diagnosis Anonymous 1998 56 groups; 38 in CA
Dual Disorder Anonymous 1982 48 groups; most in Illinois
Dual Recovery Anonymous 1989 345 groups; 4 states (CA, OH, PA, MA)
Families Anonymous 1971 220 groups in 36 states
Free N’One 1985 55 groups
Heroin Anonymous 2004 35 meetings in Arizona, California, Illinois,
Michigan, Texas, Utah, Washington
Intercongregational
Addictions Program
1979 Support for recovering women in religious orders
through phone, email, and conferences;
membership of 710 plus in IL, Mass., Michigan,
Alabama, California, New York, New Jersey,
and Wisconsin
International Doctors in