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Journal of Groups in Addiction & Recovery
ISSN: 1556-035X (Print) 1556-0368 (Online) Journal homepage: http://www.tandfonline.com/loi/wgar20
Assessing the Impact of American Indian Peer
Recovery Support on Substance Use and Health
Allyson Kelley, Dyani Bingham, Erika Brown & Lita Pepion
To cite this article: Allyson Kelley, Dyani Bingham, Erika Brown & Lita Pepion (2017) Assessing
the Impact of American Indian Peer Recovery Support on Substance Use and Health, Journal of
Groups in Addiction & Recovery, 12:4, 296-308, DOI: 10.1080/1556035X.2017.1337531
To link to this article: https://doi.org/10.1080/1556035X.2017.1337531
Published online: 08 Dec 2017.
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JOURNAL OF GROUPS IN ADDICTION & RECOVERY
, VOL. , NO. , –
https://doi.org/./X..
Assessing the Impact of American Indian Peer Recovery
Support on Substance Use and Health
Allyson Kelleya, Dyani Binghama, Erika Browna, and Lita Pepionb
aAllyson Kelley and Associates PLLC, Sandia Park, New Mexico, USA; bRocky Mountain Tribal Leaders
Council, Billings, Montana, USA
KEYWORDS
American Indian; peer
recovery support; substance
use; urban and reservation
ABSTRACT
Peer Recovery Support (PRS) is emerging as a key intervention
for communities and individuals as they address high rates of
substance abuse and limited recovery resources. American Indian
populations were among the rst people to use concepts of PRS
through abstinence-based revitalization movements and cere-
monies. The present study examined the impact of PRS on sub-
stance use, emotional and psychological problems, and social
connections among urban and reservation American Indian peers
involved in a 3-year PRS program. A total of 224 individuals, 110
male and 114 female completed baseline GPRA. Of these, 65 peers
completed baseline and 6-month follow-up GPRAs. Involvement
in PRS decreased substance use signicantly among peers. Peer
attendance at voluntary self-help groups and support from fam-
ily and friends increased as a result of PRS.
This is a story. It is written in a manner that reects a western scientic paradigm.
This paradigm is often the choice of treatment providers, researchers, academic
journals, and funding agencies. We respect this paradigm and at the same time
we honor the people, communities, tribes, and families involved in the Transi-
tional Recovery and Culture Program (TRAC). There is a spiritual aspect of healing
(recovery) that is dicult to measure by western scientic standards. To begin,
we want you the reader to know who we, the storytellers, are. We want you to
understand our relationship to recovery and to the American Indian communities
involved in this healing journey.
IamarecoveryallyandtheevaluatorfortheTransitionalRecoveryandCultureprogram.
I support sustainability and coalition building eorts through writing and research. The
best part is working with authentic people who believe in recovery and share values of
honesty, trust, hard work, acceptance and spirituality. I am inspired by the resilience and
strength of peers. Through their stories and journey, I have learned how to support people
in recovery and live a more balanced life. – Allyson Kelley, Evaluator
CONTACT Allyson Kelley kelleyallyson@gmail.com Allyson Kelley and Associates PLLC, PO BOX Sandia
Park, NM .
© Taylor & FrancisGroup, LLC
JOURNAL OF GROUPS IN ADDICTION & RECOVERY 297
I spend time with people recovering from substance use disorders, providing support,
encouragement, motivation, information and direction as they feel they need. This entails a
number of dierent activities—usually something the Peer enjoys doing—walking, eating,
having coee, visiting, and sometimes things they don’t enjoy so much such as completing
on-line forms, applications for assistance, going to court or seeing their Parole ocer. - Lita
Pepion,PeerMentorBlackfeet/Athabascan.
As TRAC program director I have come to understand my own recovery better. I once felt
alone struggling with addictions and trauma; now I am proud to be part of the recovery
movement. The best part of recovery is being centered in spirituality, healing and accep-
tance. – Dyani Bingham, Project Director Blackfeet/Assiniboine/Little Shell/Gros Ventre
I am fortunate to have had the opportunity to support the TRAC program as an
AmeriCorps VISTA member during 2016. I seek to advocate for integrating culture-based
programming wherever traditional Western techniques and approaches fall short of
providing holistic, culturally-responsive services for indigenous people. I am grateful to
have been able to serve the TRAC program and for being given the opportunity to witness
the powerful and important impact of this work. – Erika Brown, TRAC AmeriCorps
VISTA Member
The term American Indian has been used throughout this article, but it is impor-
tant to note that this term does not reect the unique tribal status of the 566 feder-
ally recognized tribes in the United States. We selected this term because it encom-
passes the tribes from the Northern Plains who participated in this program. Also,
the eects of peer recovery support (PRS) may be dierent based on the unique cul-
turaldierencesinAmericanIndianpopulationsandthelocationofurbanversus
reservation environments and how PRS is delivered.
Introduction
An estimated 50% of adults or 25 million people in the United States with substance
use disorders (SUD) are in recovery (White, 2012). Recovery from SUD is a process
of change through which individuals improve their health and wellness, live a self-
directed life, and strive to reach their full potential. Recovery includes four primary
dimensions: health, home, purpose, and community (Substance Abuse and Mental
Health Services Administration [SAMHSA], 2012). Community-based PRS services
are emerging as a key intervention for communities and individuals as they address
high rates of substance abuse and limited recovery resources. PRS (coaching) is a
nonclinical approach that includes mentoring, education, and support services pro-
vided by individuals with the lived experience of recovery to individuals with SUD
or co-occurring substance use and mental disorders (Reif et al., 2014). Individuals
provide PRS in a variety of community and institutional settings, either as volunteers
or paid workers. PRS is eective because it emphasizes social support, empathy, and
therapeutic relationships (White, 2009)—all of which predict successful recovery.
Adults and youth with SUD benet from PRS and services may occur before, after,
or in lieu of treatment (Loveland & Boyle, 2005).
The success of PRS is largely based on the exibility of the approach and the
peer-based mutual help component (Laudet, 2007). However, documenting these
298 A. KELLEY ET AL.
successes has been dicult because the very nature of PRS requires autonomy, self-
directed recovery processes, and exibility. Peer recovery coaching has not been
rigorously evaluated. In one clinical trial involving peer coaches, SUD treatment,
and child welfare services, results demonstrated improved family reunication rates
compared with families who did not receive peer recovery coaching (Ryan, Marsh,
Test a, & L o ud e rm a n, 2006). In another study of PRS, authors report that recovery
coaching and recovery supports were strongly associated with successful outcomes
among drug court participants (Mangrum, 2008). Studies support recovery coach-
ing as an eective intervention for SUD and co-occurring substance use and mental
disorders (Reif et al., 2014; Solomon, 2004). In the meta-analysis of PRS related
studies conducted by Reif and colleagues, there were two randomized control trials,
four quasi-experimental studies, and four pre-/poststudies (2014). None of these
studies targeted American Indian populations and communities (Kelley, Snell, &
Bingham, 2015).
American Indian populations were among the rst people to use concepts of
PRS through abstinence-based revitalization movements and ceremonies including
the Native American Church (Coyhis & White, 2006), societies, kinship systems,
collectivism, and living values that support recovery. Despite widespread assim-
ilation and destruction eorts, many American Indian people and communities
remain resilient and know their language, traditions, stories, ceremonies, and cul-
ture (Gone & Calf Looking, 2011).
Culture is an important concept in recovery because it is the essence of individuals
and communities (Frierson, Hood, & Hughes, 2002). Culture is a cumulative body
of learned and shared behavior, values, customs, and beliefs common to a particular
group.TheroleofcultureinPRSissignicantbecausecultureisconsideredaform
of treatment for SUD (Gone & Calf Looking, 2011). Aspects of culture that may
facilitate healing and recovery within PRS include a balance of physical, emotional,
spiritual, and mental supports. For example, talking circles, sweat lodge, prayer, and
smudging are unique to American Indian populations and are integrated into PRS.
Understanding what recovery support looks like for American Indian popula-
tions disproportionately impacted by SUD (Urban Indian Health Institute, 2011)is
an important rst step in addressing this public health epidemic. American Indian
or Alaska Native people are more likely to need treatment and recovery supports for
illicit drug or alcohol use than any other racial or ethnic group (SAMHSA, 2012).
However, the recovery process for American Indian populations is unique. First,
recovery among American Indian populations often includes the entire community
or family as opposed to the individual (Jilek-Aall, 1981). Second, unlike their Euro-
pean American counterparts, American Indian populations are less likely to enter
treatment for SUD and more likely to enter a natural recovery, meaning they quit
using drugs or alcohol without treatment. In one longitudinal study that compared
European Americans and Navajos, the Navajos were more likely to quit drinking
at an earlier age and report that treatment did not help them quit (recover; Kunitz,
Levy, & Andrews, 1994). Most Navajos in this study cited family support, religion,
and spirituality as the key factors in supporting long-term sobriety. Enculturation
JOURNAL OF GROUPS IN ADDICTION & RECOVERY 299
is a key factor for American Indian people in their recovery (Stone, Whitbeck,
Chen, Johnson, & Olson, 2006). Third, previous studies have consistently found
that participation in cultural activities, traditional activities, and spiritual practices
are protective against alcohol misuse (Hazel & Mohatt, 2001;Stoneetal.,2006),
although it is not clear how enculturation actually protects against SUD. New
research focusing on the connections between traditional spirituality and healing
may provide much-needed answers to the role of enculturation and healing for
individuals in recovery (Owen, 2014). We could not locate similar PRS studies
in other indigenous populations (Canada, Mexico, Australia); however, PRS has
worked well in other settings and is a viable option for American Indian populations
because it incorporates culture, spirituality, and connection.
A key dierence in PRS and other peer-based recovery programs like Alcoholics
Anonymous (AA) is that peer mentors provide a variety of recovery options and
support services. AA may be one type of service oered to peers to explore. Another
dierence between PRS and AA is that PRS does not prescribe a set of actions to be
undertaken to achieve and maintain sobriety, such as the AA 12 steps. PRS begins
with a relationship between a peer mentor with the lived experience of recovery and
a peer who seeks recovery. These relationships are advantageous for individuals who
may not be comfortable in group settings like AA. Another dierence between PRS
andAAisthatAAisgroundedinregulargroupmeetingsfacilitatedbyothermem-
bers whereas PRS is not as structured. The exibility inherent in PRS allows the peer
mentor to support the peer in tailoring an approach to achieving and maintaining
sobriety that suits the unique needs of the individual.
In the present study, we compared 6-month change rates for drug and alcohol
use, depression, anxiety, suicide attempts, psychological and emotional impacts,
attendance at voluntary self-help groups, and support from family and friends
among American Indian peers enrolled in the TRAC. Briey, depression may exac-
erbate alcohol abuse (Kishoe, Gopalkrishnan, Bery, & Ghulam, 2015)andanxiety
is often reported by individuals in recovery (Friedmann, Saitz, & Samet, 1998).
Alcohol and drug use are strongly associated with suicide and suicide attempts
(Wojnar et al., 2008; Wilcox, Conner, & Caine, 2004) and individuals in recovery
often report psychological and emotional problems. Voluntary self-help groups and
social support provide a buer between the stresses of everyday life and sustained
long-term recovery.
TRAC
TRAC is a community-driven PRS approach conceptualized in August 2012 after
tribal leaders voiced concerns about substance abuse and the need for more eec-
tive recovery supports (Kelley et al., 2015). The goals of the TRAC program are to
improve sobriety rates in each community, increase community awareness of sub-
stance abuse problems and the need for supporting recovery, and increase commu-
nity support for eorts to create sober communities. A tribal consortium located
in Billings, Montana, received funding in October 2013 from the SAMHSA Center
300 A. KELLEY ET AL.
for Substance Abuse and Treatment. The consortium partnered with tribal Chemi-
cal Dependency Program Directors and tribal leaders to identify communities that
would be willing to pilot the TRAC program. This resulted in a culturally tai-
lored, tribal-specic PRS that was preferred over a Pan-Native American Recovery
approach that fails to recognize the unique traditions, language, and history of a
given tribe (Owen, 2014). Six peer mentors (coaches) provided PRS in three com-
munities, one reservation recovery program and two urban settings. Peer mentors
in this program also served as cultural leaders, elders, healers, advisors, and spiri-
tual teachers. A community advisory board supported the program and included
community representatives from substance abuse/recovery supporting organiza-
tions, cultural programs, traditional knowledge keepers and elders, public and tribal
schools, social service organizations, law enforcement, juvenile justice, community-
based organizations, and others.
PRS in practice
TRAC peer mentors provided diverse recovery support activities that highlight the
self-directed nature of PRS and the concept of “many paths to recovery.” Peers are
American Indian and most are from Northern Plains Tribes. Peers represent diverse
backgrounds and histories, some grew up in urban settings and others live on reser-
vations. Many peers have experienced trauma in their lifetime. Peer mentors sup-
ported their peers using a variety of recovery support activities: sweat lodge, weekly
talking circles, weekly Wellbriety meetings, wellness and physical tness, spiritual
gatherings, church, cedaring, feeding and outreach, employment and education
guidance, sober housing support, food and necessities support, spiritual and cul-
tural support, and transportation. Most peer mentors met with peers in-person or
over the phone over a 6-month period.
All study procedures were approved by the Rocky Mountain Tribal Institutional
Review Board. The study hypothesis is as follows: Involvement in PRS decreases
substance use, depression, anxiety, suicide attempts, psychological and emotional
impacts while increasing attendance at voluntary self-help groups and support from
family and friends.
Method
We used a holistic approach based on the medicine wheel framework (Atlantic
Council for International Cooperation, n.d.) to examine outcomes, including work-
ing with peers to review and validate results and enlisting cultural reviewers to
ensure the results were culturally responsive to the unique status of American Indian
populations and their healing process. The medicine wheel framework (Atlantic
Council for International Cooperation, n.d.) served as a guide to implement the
program and interpret the data. The medicine wheel includes four domains: spiri-
tual, mental, emotional, and physical.
JOURNAL OF GROUPS IN ADDICTION & RECOVERY 301
Sample and procedure
Peers were recruited from tribal chemical dependency programs, tribal health pro-
grams, community social service agencies, and through self-referral. Potential peers
were contacted by a member of the TRAC team via telephone. Verbal consent
was obtained for screening to determine eligibility. Written informed consent was
obtained by the peer mentor before peers completed baseline intake using the Gov-
ernment Performance and Results Act (GPRA) tool. The GPRA tool is a federally
mandated data collection and performance tool that all SAMSHA grantees must use
(http://www.samhsa.gov/grants/gpra-measurement-tools).
Peers met with peer mentors over a 6-month period, at the end of which time
the 6-month GPRA follow-up was administered. Peers who completed the 6-month
follow-up assessment received a $25 gift card. All peers discharged from the pro-
gram were encouraged to continue to attend recovery support groups and maintain
positive social connections to support their recovery. GPRA baseline and follow-up
datawerecollectedbytrainedpeermentors.GPRAdatawereenteredintoadatabase
by a member of the program team. Analyses were conducted by the lead evaluator
and rst author at the end of the 3-year program.
Participants
A retrospective review of GPRA data was conducted by the lead evaluator. These
data were collected from participants (N=224) entering the program between
September 2013 and April 2016. Of these, 65 peers completed baseline and 6-month
GPRA interviews. All interviews were anonymous.
Measures
The GPRA includes seven sections: record management/demographics, drug and
alcohol use, family and living conditions, education, employment and invoice, crime
andcriminaljusticestatus,mentalandphysicalhealthproblemsandtreatmentand
recovery, and social connectedness. An example GPRA question is, “In the past
30 days, not due to your use of alcohol or drugs, how many days have you: a) expe-
rienced serious depression, b) experienced serious anxiety or tension, c) attempted
suicide?” Response options are a number between 0 and 30, “refused to answer,” or
“don’t know.” To document the impact of PRS in this study, we selected GPRA ques-
tions with the medicine wheel framework in mind, including drug and alcohol use
(physical domain), depression (emotional domain), anxiety (emotional and mental
domains), suicide (emotional and spiritual domains), psychological and emotional
impacts (emotional, spiritual, and mental domains), attendance at voluntary self-
help groups (physical and spiritual domains), and support from family and friends
(physical and mental domains).
Depression
Depression can exacerbate alcohol abuse and many people in recovery report
depressive symptoms (Kishoe et al., 2015). Peers were asked, “In the past 30 days, not
302 A. KELLEY ET AL.
due to your use of alcohol or drugs, how many days have you experienced serious
depression?” Response options were a number between 0 and 30.
Anxiety
Individuals in recovery may experience anxiety which may precipitate relapse
(Friedmann et al., 1998). Results from the National Epidemiologic Survey on Alco-
hol and Related Conditions show strong associations between drug use disorders
and anxiety disorders (Grant & Dawson, 2006). Peers were asked, “In the past
30 days, not due to your use of alcohol or drugs, how many days have you expe-
rienced anxiety or tension?” Response options were a number between 0 and 30.
Suicide attempts
Alcohol and drug use are strongly associated with suicide and suicide attempts
(Wojnar et al., 2008; Wilcox et al., 2004). Peers were asked, “In the past 30 days, not
due to your use of alcohol or drugs, how many days have you attempted suicide?”
Response options were a number between 0 and 30.
Psychological and emotional impacts
The psychological and emotional eects of drug and alcohol addiction and recovery
may include mood swings, depression, decrease in pleasure in everyday life, and
complications of mental illness (Croft, 2016). Peers were asked, “How much have
you been bothered by psychological or emotional problems in the past 30 days?”
Response options were based on a 5-point Likert scale ranging from 1 (not at all)to
5(extremely).
Voluntary self-help groups and social support
Informal social networks provide critical support for individuals in recovery. Previ-
ous studies report that social support, spirituality, and self-help groups buer stress
and enhance the quality of life for individuals in recovery (Buckman, Bates, & Mor-
genstern, 2008). Peers were asked, “In the past 30 days, how many times did you
attend voluntary self-help groups?” Responses options were a number between 1
and 99. Family and friends play a critical role in supporting long-term recovery and
healing. Peers were asked, “In the past 30 days, did you have interaction with fam-
ily and or friends that are supportive of your recovery?” Response options were yes
or no.
Data preparation and analyses
All statistical analyses were performed using SPSS version 21.0. Descriptive frequen-
cies and means for all variables of interest were computed. Bivariate analyses were
conductedtoassesstherelationshipbetweengender,age,andbaselinemeasures
of substance use. Paired samples t-tests were used to examine dierences between
baseline and 6-month follow-up data from the GPRA for all measures. Changes in
continuous data (alcohol use, binge drinking, illegal drug use, combined alcohol
and drug use, depression, anxiety, suicide attempts, and emotional impacts from
substance use) were explored and dierences from baseline and 6-month GPRA
reports are outlined in the results section.
JOURNAL OF GROUPS IN ADDICTION & RECOVERY 303
Tab l e . Demographic characteristics baseline and -month GPRA follow-up (n=).
Interview Baseline Follow-up Change
Housed .%
Employed (full time/part time) .%
Monthly income average $. $. −.%
Health status (excellent or very good) .% .% .%
Results
Demographics
A total of 224 individuals, 110 male and 114 female completed baseline GPRA
intakes throughout the 3-year program. Of these, 65 peers completed baseline and
6-month follow-up GPRAs. The mean age of peers completing 6-month follow-
up GPRA was 36.15 years (SD =13.54), 32 were male and 33 females, and three
were veterans. The follow-up rate was 29.5% and this is signicantly lower than
the SAMSHA required follow-up rate of 80%. SAMHSA requests that all grantees
maintain an 80% follow-up rate and if grantees are unable to maintain this, they can
request technical assistance, additional training, and support. Peers could decline
answering any GPRA question and this accounts for the dierences in total response
rates in the tables that follow. Chi-square analysis revealed no signicant dierences
by gender or age.
Peers reported increased housing (133.3%), increased employment (75%) and
improved health status (71%) from baseline report data. The only characteristic
that decreased at the 6-month GPRA was monthly income ($226.37 vs. $193.75;
see Table 1 ).
Alcohol and drug use
The mean and standard deviations of peer alcohol and drug use in the past 30 days
is presented in Tab le 2. Results show decreases in drug and alcohol use from intake
to 6-month follow-up. Signicant dierences were observed for past 30-day alco-
hol use, M=3.30, SD =8.5, t(64) =3.13, p=.003; illegal drug use days, M=
2.32, SD =7.29, t(64) =2.56, p=.01] and alcohol and drug use days, M=1.09,
SD =4.53, t(64) =1.94, p=.05. Alcohol and drug use days reect responses to
the GPRA question, “During the past 30-days, how many days have you used both
drugs and alcohol on the same day?” There was not a signicant dierence in past
30-day binge drinking days, M=.67, SD =4.05, t(64) =1.34, p=.18.
Tab l e . Alcohol and drug use over the past -days, (n =).
Interview
Alcohol use, mean
days (SD)
Alcohol binge, mean
days (SD)
Illegal drug use, mean
days (SD)
Alcohol and drug use,
mean days (SD)
Intake . (.) . (.) . (.) . (.)
-monthfollow-up .(.)∗∗ . (.) . (.) ∗. (.)
∗p<.. ∗∗p<..
304 A. KELLEY ET AL.
Tab l e . Anxiety, depression, emotional impact, and suicide attempts (n=).
Interview Anxiety, mean days (SD)
Depression, mean
days (SD)
Emotional impact,
mean score (SD)
Suicide attempts,
mean days (SD)
Intake . (.) . (.) . (.) . (.)
-month follow-up . (.) . (.) . (.) ∗∗ . (.)
∗p<.. ∗∗p<..
Psychological and emotional impacts
The mean and standard deviations of anxiety, depression, emotional impacts, and
suicide attempts are presented in Tab l e 3. Six-month GPRA follow-up data show a
signicant increase in how much Peers are bothered by psychological or emotional
problems, M=−2.12, SD =2.17, t(64) =−7.85, p=.00. There was not a signicant
dierence in depression, M=.94, SD =10.5, t(64) =.73, p=.47]; anxiety, M=.55,
SD =11.1, t(64) =.41, p=.69, or suicide attempts, M=.02, SD =.12, t(64) =1.0,
p=.321.
Six-month GPRA follow-up data show slight increases in attendance at voluntary
self-help groups, M=3.20, SD =6.1 vs. M=4.2, SD =6.2, and the number of
peers reporting interactions with family and friends in the past 30 days, M=.74,
SD =.62 vs. M=1.12, SD =1.2.
Discussion
This study was designed to examine the impact of PRS on substance use, emo-
tional and psychological problems, and social connections among American Indian
peers involved in the TRAC program. The study’s hypothesis—Involvement in
PRS decreases substance use, depression, anxiety, suicide attempts, psychological
and emotional impacts while increasing attendance at voluntary self-help groups
and support from family and friends—was partially accepted. Involvement in PRS
decreased substance use signicantly. Involvement in PRS reduced depression and
anxiety, but the decrease was not statistically signicant. Suicide attempts did not
decreaseandpsychologicalandemotionalimpactsincreasedsignicantly.Atten-
dance at voluntary self-help groups and support from family and friends increased
as a result of PRS.
Overall, PRS was eective in this study. This is consistent with previous that found
recovery coaching as an eective intervention for SUD and co-occurring substance
use and mental disorders (Reif et al., 2014; Solomon, 2004). The eectiveness of PRS
inthisstudymayberelatedtotheexibilityandmutualhelpcomponentofPRSthat
hasbeenreportedinpreviousstudies(Laudet,2007).
TRAC adds new information to the literature about PRS and American Indian
populations. Peers reported gains in stable housing, employment, and improved
health during the 6-month TRAC program. An area that requires further review is
theaveragemonthlyincome;despitegainsinemploymentstatus,incomedecreased
during the 6-month period. Peers completing the 6-month TRAC program report
signicant reductions in alcohol and illegal drug use. There were reductions in
JOURNAL OF GROUPS IN ADDICTION & RECOVERY 305
binge drinking and combined drug and alcohol use, although not statistically
signicant. A possible reason for this includes limited frequency at intake (e.g.,
M=1.6daysatintakevs.M=1.0 days at follow-up). Anxiety and depression
also decreased although peers were more bothered by psychological or emotional
problems. To understand more about the emotional impacts reported by peers, the
team asked peer mentors for possible explanations. One peer mentor said, “They are
no longer numbing. … it’s very stressful to build a life with no money, support, clue
or help. I feel for the folks I work with—they are true Warriors who ght a battle
of survival each and every day.” Results show that peers’ attendance at voluntary
self-help groups and meeting with family and friends increased over the 6-month
period. These results are encouraging because both group and healthy relationships
provide support for peers in recovery beyond the PRS model and TRAC program.
However, challenges remain. First, retention of peers is a major challenge. TRAC
served 224 peers over a 3-year period in six communities; of these, only 65 (29%)
completed the program and 6-month follow-up GPRA. However, attrition rates are
a challenge reported by previous authors. In one U.S. study, 75% to 80% of indi-
viduals seeking recovery left at various stages in the referral, intake, and treatment
processes (Loveland & Driscoll, 2014). In a meta-analyses of psychosocial interven-
tions for SUD, nearly one-third of participants left before completing their treat-
ment (Dutra et al., 2008). Possible reasons for attrition in TRAC include the tran-
sient nature of peers, incarceration, relapse, and inconsistent communication due to
lack of resources. The transient nature of peers is often part of the recovery process
as many peers are in transition between locations and experience unstable hous-
ing situations. Peers may be moving back to the reservation or to an urban center.
Some peers are awaiting sentencing and during the 6-month period are incarcer-
ated. Relapse may also contribute to high attrition rates. Alternately, some peers do
not have access to a phone, computer, or transportation that facilitates meetings
and communication with peer mentors and follow-up. Barriers to follow-up will be
explored in future work.
Strengths and weaknesses
A major strength of this study is that it was facilitated by a tribal consortium and
PRS was oered by American Indian people with the lived experience of recovery to
otherAmericanIndianpeopleinrecovery.Thisculturalmatchsupportedtrust,con-
nection, and belonging that is dicult to nd in many recovery/treatment settings
(Gone & Calf Looking, 2011).TRACistherstpilotprogramtoimplementPRSand
reportimpactsonrecoveryinAmericanIndiancommunities.Thisisanimportant
rst step in documenting the types of recovery support that are needed and how
PRS can successfully implemented and achieved in American Indian contexts.
The main weakness of this study, as mentioned previously, relates to attri-
tion and small sample size. Another limitation is that the types of PRS supports
and services delivered to peers were not documented because of the conden-
tial nature of PRS and the exploratory nature of this pilot program. It is possible
306 A. KELLEY ET AL.
that peers were involved in other recovery programs and services that supported
their successes along with the TRAC program. Future work should consider how to
document the kinds of PRS that peers receive, the frequency/duration of PRS, and
the impact of PRS on recovery outcomes.
Conclusion
Previous studies have reported on the eectiveness of PRS (Reif et al., 2014). How-
ever, this is the rst study that documents the impact of PRS in American Indian
populations. American Indian populations were among the rst to utilize concepts
of PRS through kinship systems, values, and support for those in need. Future stud-
ies with American Indian populations may consider evaluating strength-based fac-
tors including resilience, spirituality, identity, and kinship systems that are unique
to American Indian populations.
This is the rst study that quanties the impact of PRS on recovery and key recov-
ery outcomes for American Indian people. Extending PRS to both urban and reser-
vation American Indian peers and peer mentors, rather than focusing on one popu-
lation or the other, increased access to PRS that was not previously available. Future
research should explore the impact of PRS on family relationships, cultural connect-
edness, and community readiness to support recovery. The end goal of PRS is an
improvement in key areas of life that were impacted by substance use. Results from
the TRAC program give hope for individuals and communities who need recovery
resources and promise for future work.
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