One clear healthcare path paved by the Affordable Care Act and the Obama administration’s Department of Health and Human Services (HHS), across all of health, is the idea of recovery. Acute treatment is out; long-term recovery is in. Many believe that nowhere is this more appropriate and glaringly overdue than in the field of addiction treatment.

But who will “staff” the growing recovery industry, and how they will be paid, is a critical question, according to recovery researcher Alexandre Laudet, Ph.D., writing in “Promoting Recovery in an Evolving Policy Context: What Do We Know and What Do We Need to Know About Recovery Support Services?” in press at the Journal of Substance Abuse Treatment.

Anticipated increased demand for recovery support services due to insurance expansion under the ACA will require an increased workforce, and it is “promising and desirable” to rely on the experience of the recovery community to help meet that need, writes Laudet, who is senior staff with National Development and Research Institutes in New York City.

Roles in recovery

Peer-based recovery support is nonprofessional, nonclinical assistance to help people in recovery on a long-term basis, and is provided by people who have experienced substance use disorders (SUDs) themselves, and are either volunteers or paid, according to Laudet. Peer services can be delivered in recovery community centers, faith-based institutions, jails and prisons, mental health and addiction treatment programs, health and social service centers, and other community venues.

Recovery coaching involves a peer mentoring the individual seeking recovery, helping with setting recovery goals, for example. Peer recovery coaching can also involve helping negotiate employment and other supports. Peer recovery coaching has not yet been evaluated, said Laudet. However, reports on broader recovery-oriented efforts are promising, she said.

Sober residences are homes that are also peer-based, offering financially self-sustaining, self-governed (in the Oxford House example) or sometimes run by treatment programs or others. These residences have been associated with greater abstinence rates as well as improvements in other parts of life, such as housing and employment, according to Laudet. Operators, depending on the level determined by the National Association of Recovery Residences, may be clinicians or peers (see ADAW, December 17, 2012).

Different from treatment

“We like to think of peers as transformative, rather than an add-on,” said Tom Hill, director of programs for Faces & Voices of Recovery. “These new peer service roles do shake things up a little bit.”

Peers are not just a part of treatment, he said. For example, they may be able to help people who are reentering society from the criminal justice system stabilize their recovery, he said.

But when peer services are embedded in treatment programs, it’s important that they not be put into “inappropriate services roles, like junior counselors,” Hill told ADAW. “They are there to help the clinicians.”

Treatment will always be needed, said Hill. “This needs to be developed in a comprehensive way so that everybody knows their role,” he said.

‘Behavioral’ workforce at SAMHSA

The Substance Abuse and Mental Health Services Administration (SAMHSA) has promoted recovery, in accordance with the HHS philosophy, but not surprisingly, there is some confusion about the distinctions between recovery from mental illness and recovery from addiction.

Paolo del Vecchio, director of SAMHSA’s Center for Mental Health Services (CMHS), is the point person in charge of workforce at SAMHSA — and since his perspective is mental health, we asked him how recovery from mental illness is distinguished from recovery from addiction, in terms of workforce. Specifically, are peers in recovery from addiction appropriate to help people with mental illness, and are peers in recovery from mental illness appropriate to help with people with SUDs? “We’re inclusive in how we approach the recovery workforce,” he told ADAW. “We’re inclusive of recovery coaches for addiction, and peer specialists for mental health” — meaning that the term “recovery coach” is viewed as more for addiction, while “peer specialists” is for mental health. Nevertheless, del Vecchio said that SAMHSA’s approach is a broad one that comprises behavioral healthcare.

Addiction recovery researcher Laudet offered this clarification: “Because each chronic condition requires condition-specific lifestyle changes, triggers and challenges, and self-care strategies, it’s not intuitively desirable or logical that a person managing the symptoms be assigned to assist somebody managing the symptoms of another chronic illness, be it diabetes, mental illness or addiction.”

Del Vecchio added that in the proposed budget announced earlier this month (see ADAW, April 15), a peer professional workforce development program was announced, which includes substance abuse peers.

SAMHSA’s problems in delineating an addictions workforce were seen clearly in its workforce report to Congress, delivered a year late, last month (see ADAW, April 1). That report was requested by the Senate Appropriations Committee and was supposed to be only about the addictions workforce; however, SAMHSA, citing lack of information about the addictions workforce, focused on the behavioral workforce.

Accreditation

SAMHSA is advancing the Recovery-Oriented Systems of Care (ROSC) model, which has as goals: (1) early intervention with people with SUDs, (2) supporting sustained recovery from SUDs and (3) improving the health and wellness of people and families affected by SUDs. However, ROSCs go far beyond peer supports, including education and job training, housing, childcare, transportation, spiritual support and case management, as well as SUD-specific services such as relapse prevention, recovery support, SUD education for family members, and peer and coaching services.

Faces & Voices of Recovery has long seen a need to have quality standards for the recovery field, and recently issued a set of guidelines to accredit Recovery Community Organizations (RCOs), with site visits for the pilot due to start this summer. Peers — people with experience with SUDs themselves — will be staffing many recovery organizations that will be accredited by Faces & Voices.

SAMHSA is developing core competencies for the peer workforce that include both mental health and addiction, said del Vecchio. “What’s important is the training of those providers to be in recovery-oriented approaches,” he said. For the last five years, SAMHSA has developed the concept of “recovery to practice,” working with the American Psychological Association, American Psychiatric Association, NAADAC, the Council on Social Work Education, the American Psychiatric Nurses Association and the National Association of Peer Specialists to develop curricula on recovery-oriented practices, he said.

From the beginning, the strategy of Faces & Voices has been to build an accreditation system, said Hill. “If they meet our standards, and get accredited, then they would be authorized entities,” he said. Faces & Voices would only accredit the organizations, and the peers who work there would have to be supervised.

The recovery industry has outliers, like the $1,000-per-day recovery coaches who market their services to corporate executives and celebrities, said Hill. “It’s not necessarily bad,” he said. “But there is this whole industry that has been growing in parallel with the peer movement.” Some of them call themselves “life coaches” with a recovery focus, he added. “But what they’re doing is rebuilding a life that may have been devastated,” he said.

Bottom Line…

Healthcare reform will open up access to treatment and recovery supports. Peers — people in recovery from addictions — will be called on to help. But their exact roles and how they will be paid are still unclear.