The peer workforce in the treatment of substance use disorders (SUDs) has a venerable history: without it, there would have been no SUD treatment. People in recovery themselves constituted the first treatment programs in the United States, explains Linda Kaplan, director of programs with Faces and Voices of Recovery. However, the “peer” professional, now on the verge of being a recognized professional in the SUD treatment industry, requires training and clinical supervision, said Kaplan, who recently retired from the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration (SAMHSA), where she was the special expert on workforce (she authored SAMHSA’s workforce document that was requested by Congress; see ADAW, March 5, 2012).
“The field started with people in recovery,” Kaplan told ADAW. “That’s part of the culture.” But once someone becomes a professional, that person’s identity is no longer simply as a person in recovery, but as a professional, she said. “Once somebody becomes a professional, gets a degree, becomes certified or credentialed, they are assuming a different role,” she said. This is particularly true for many clinicians in the field — they are in recovery, but they are therapists, not peers, she said.
Peers are a new profession that is going to be essential, especially with the overburdened workforce, said Kaplan. “I think peers are extraordinarily valuable and an integral part of the workforce,” she told ADAW.
It’s important to have peers working in the field who based their work on their own recovery experience, said Kaplan. “We need a full complement of people in the field,” she said, noting that some people with SUDs only want to go to peers, while others need other types of services.
Kaplan, who replaced Tom Hill at Faces and Voices after Pat Taylor suddenly retired this winter (see ADAW, March 3), was executive director of NAADAC, the Association for Addiction Professionals, for 10 years before joining SAMHSA.
IC&RC peer credential
In general, in order to be paid by insurance companies or Medicaid, peers need to be credentialed. The International Certification and Reciprocity Consortium (IC&RC) has a credential for peer recovery professionals, and the demand is growing. So far, 11 IC&RC boards have adopted the peer recovery credential: Arkansas, Canada, Georgia, Illinois, Indiana, Louisiana, Maryland, New Jersey, Oregon, Texas and West Virginia.
“Many more are gearing up to offer it in the coming months,” said Mary Jo Mather, IC&RC executive director. “We have heard from many other states that are getting their infrastructure — the appropriate training — in place so that they can offer the credential in the near future,” she told ADAW in an email. “I believe that the fast-moving approach many states are taking to train and credential peers speaks volumes about the value states are placing on peer recovery services for long-term recovery.”
The peer recovery credential “will provide credibility to the work done by individuals in recovery, members of recovery community organizations and those who work in the substance abuse or mental health field that do not meet the present educational and supervisory criteria for clinical based certifications,” according to the IC&RC. “It is our hope that this certification will open doors for individuals interested in working in the substance abuse or mental health field that possess tremendous knowledge and experience in recovery and would like to use it to help others change their lives.” (Certification is the process by which someone attains a credential.)
The role of the peer, according to the IC&RC, comes from the recognition that substance abuse and mental health treatment need to be connected to “the longer-lasting process of recovery.” The peer is a “role model, mentor, advocate and motivator,” and not a sponsor or therapist.
Peer recovery coaches require no special education, according to the IC&RC, whose minimum standards for the peer recovery credential are:
- Education: High school diploma or jurisdictionally certified high school equivalency.
- Other training: 46 hours specific to the domains, with 10 hours each in the domains of advocacy, mentoring and education, and recovery/wellness support and 16 hours in the domain of ethical responsibility.
- Experience: 500 hours of volunteer or paid work experience specific to the domains.
- Supervision: 25 hours of supervision specific to the domains. Supervision must be provided by an organization’s documented and qualified supervisory staff per job description.
- Examination: Applicants must pass the IC&RC Peer Recovery Examination.
- Code of ethics: The applicant must sign a code of ethics statement or affirmation that the applicant has read and will abide by the code of ethics.
- Recertification: 20 hours of continuing education earned every two years, including six hours in ethics.
IC&RC boards may have more stringent standards, but these are the minimum.
But the people who are serving as peers aren’t all credentialed, noted Kaplan. “There are a variety of different approaches,” she said. “Some people are volunteers and serving as recovery coaches, some are getting paid, but they all need to get some training,” she said. “Just being in recovery does not make you a good recovery coach.”
Some organizations are hiring peers to provide services as part of treatment, said Kaplan. “Sometimes peers are used in pretreatment, getting people engaged in recovery,” she said. “And there’s an enormous need for continuing recovery support, which to me is beyond what we used to call aftercare — it’s to help people deal with and maintain their recovery.”
Importantly, some people with SUDs never go to treatment, said Kaplan. “They may just use recovery support services,” he said.
In particular, Kaplan thinks peers can help with the patients who keep relapsing and returning for repeat treatment. “I think with strong peer support, some of that can be mitigated,” she said. When Kaplan worked with the Recovery Community Services Program when she was at SAMHSA, peers helped intervene early in this cycle, so that patients could stabilize earlier, she said. The recovery coach can make sure the patient has support after treatment has ended. “They can say, ‘Drop in.’ There are all kinds of ways they can provide support for people who may be having trouble maintaining their recovery,” she said.
Kaplan distinguishes between 12-step groups like Alcoholics Anonymous (AA) and peer support. “AA espouses a very specific approach — the 12 steps — and support from sponsors,” she said. “That’s great, but it’s not for everyone,” she said. “Someone who is providing that recovery mentoring or serves as a peer should be working to help people recover in the most important way for that person. It isn’t necessarily doing the steps.”
Peers provide care management in a very specific way, said Kaplan. For example, they help people get other services they may need, such as job training.
In addition, there are now peers working in medication-assisted treatment (MAT), said Kaplan, noting that this is a recognition of the idea that patients in MAT are in recovery. “This has changed significantly,” she said.
Mental health, too?
The IC&RC peer recovery credential is for both mental health and substance abuse. IC&RC had both substance abuse and mental health peers as subject-matter experts (SMEs) who developed the credential, said Mather. “The forward-thinking outcome of this combined group of SMEs resulted in a combined peer credential,” she said. However, states can tailor the IC&RC peer recovery credential toward either substance abuse or mental health if they choose by making the education and training that is required specific to either substance abuse or mental health, she said.
“The four domains that resulted in IC&RC’s development of this credential are broad and applicable to the provision of peer services on either the substance abuse side or the mental health side,” said Mather.
But Kaplan does think it’s important to have addiction-specific peers. In many states, however, the peer process began with mental health peers. “I know some states are looking at expanding these to addiction as well,” she said.
“You have to understand the issues around addiction,” said Kaplan. “There are certainly people who have comorbid issues; you need to understand how the use of alcohol and drugs affects the body.” Addiction and mental illness are different diseases, she said. “They are not one and the same,” Kaplan said. A peer with lived experience with mental illness may not be helpful to a SUD patient; likewise, a peer with an SUD history may not be helpful to a mental health patient. In both circumstances, said Kaplan, training is essential.
Peers — people in recovery from addiction — are key new professionals in the workforce.