17-TIP 64 Incorporating Peer Support Into Substance Use Disorder Treatment.pdf

Incorporating Peer Support Into Substance Use Disorder

Treatment Services

TIP 64

TREATMENT IMPROVEMENT PROTOCOL

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Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi The Need for a TIP on Integrating PSS Into SUD Services. . . . . . . . . . . . . . . . . . . . . . . . . . xii

Scope of This TIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

TIP Development Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv Consensus Panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv

Stakeholder Meeting Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv

Field Reviewers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvi

Publication Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxix

Chapter 1—Introduction to Peer Support Services for People With Substance Use–Related Problems (For Peer Workers, Providers, and Administrators)

Benefits of PSS

Role of Peer Workers in SUD Treatment and Recovery

Settings for PSS

Integration of Peer Positions Into SUD Treatment Settings

Background and Concepts

Recovery Capital

Diversity, Equity, Inclusion, and Accessibility

Evolving Ways To Deliver PSS

Challenges of Providing PSS Within SUD Treatment Programs

Conclusion

Chapter 2—Roles of the Peer Worker (For Peer Workers, Supervisors, and Administrators)

Why Integrate Peer Specialists Into SUD Treatment Programs?

What Are Peer Specialists’ Functions in SUD Treatment Programs?

What Challenges Do Peer Specialists in Treatment Programs Face?

What Core Knowledge, Values, Skills, and Abilities Do Peer Workers Need?

Conclusion

Chapter 3—Peer Worker Core Functions in Substance Use Disorder Treatment and Recovery Support (For Peer Workers)

Core Functions

Recovery Support

Community Building

Conclusion

Appendix

Resources

TIP 64 Incorporating Peer Support Into Substance Use Disorder Treatment Services iv

Chapter 4—Why and How To Integrate the Peer Specialist Position Into Substance Use Disorder Treatment Programs (For Administrators)

Service Models for Integrating the Peer Specialist Position

PSS: Background and Benefits

Introducing PSS Into SUD Treatment Program Settings

Workforce Development and Retention

Sustainability

Ensuring Access to PSS

Conclusion

Chapter 5—Supervision of Peer Specialists (For Supervisors and Administrators)

Basics of Supervising Peer Specialists

Supervision Competencies

Challenges and Solutions

Conclusion

Chapter 6—How To Become a Peer Specialist (For People and Families in Recovery)

Who Are Peer Workers?

Is Being a Peer Specialist Right for People and Families In Recovery?

Steps to Becoming a Peer Specialist

Becoming a Family Peer Specialist

Conclusion

Appendix

Additional Resources

Chapter 7—How Family Peer Specialists Can Help Families Affected by Problematic Substance Use (For SUD Treatment Providers)

Effects of Problematic Substance Use on the Family

Family Support Needs

Educating Families About the Benefits of PSS

Family Peer Specialists and PSS for Families

Conclusion

Appendix

General Resources

Chapter 8—Resources (For All Audiences) Community-Related Resources

Implementing and Integrating Peer Support Services

Peer Support Services in Specific Settings

Resources for Peer Specialist Workforce Development

Resources for Peer Providers v

Tools for Peer Specialists

Resources for Peer Specialist Supervisors and Administrators

Tools for Supervisors and Administrators

Resources for People In or Seeking Recovery

Resources for Families of People In or Seeking Recovery

Selected State Resources

References

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Exhibits Exhibit ES.1. Key Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv

Exhibit ES.2. What a Peer Worker Is and Is Not. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii

Exhibit 1.1. Defining Features of SUD-Focused PSS

Exhibit 1.2. SAMHSA’s 10 Guiding Principles of Recovery

Exhibit 2.1. The Four Types of Recovery Support

Exhibit 3.1. Peer Worker Core Functions

Exhibit 3.2. Peer Boundaries

Exhibit 3.3. An Example Peer Worker Ethical Decision-Making Process

Exhibit 3.4. Recognizing When a Peer Specialist Is Out of Their Lane

Exhibit 3.5. Self-Care Tips for Peer Workers

Exhibit 3.6. Three Parts of Storytelling for Peer Workers

Exhibit 3.7. Recovery-Focused CBAM of Maine

Exhibit 4.1. Division of Responsibilities Among Three Outpatient Staff Members

Exhibit 4.2. Interviewing Peer Worker Candidates

Exhibit 5.1. Strategies for Supportive, Strengths-Based Supervision of Peer Support Staff

Exhibit 5.2. Peer Supervisor Roles and Responsibilities

Exhibit 6.1. Peer Certification Requirements From NAADAC and IC&RC

Exhibit 6.2. Family Peer Specialist Certification

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Foreword

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the U.S. Department of Health and Human Services agency that leads public health and service delivery efforts that promote mental health, prevent substance misuse, and provide treatments and supports to foster recovery while ensuring equitable access and better outcomes. An important component of SAMHSA’s work is focused on dissemination of evidence-based practices and providing training and technical assistance to healthcare practitioners on implementation of these best practices.

The Treatment Improvement Protocol (TIP) series contributes to SAMHSA’s mission by providing science-based, best-practice guidance to the behavioral health field. TIPs reflect careful consideration of all relevant clinical and health services research, demonstrated experience, and implementation requirements.

Select nonfederal clinical researchers, service providers, program administrators, and patient advocates comprising each TIP’s consensus panel discuss these factors, offering input on the TIP’s specific topics in their areas of expertise to reach consensus on best practices. Field reviewers then assess draft content, and the TIP is finalized.

The talent, dedication, and hard work that TIP panelists and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, people in need of care and treatment of mental and substance use disorders. My sincere thanks to all who have contributed their time and expertise to the development of this TIP. It is my hope that clinicians will find it useful and informative to their work.

Miriam E. Delphin-Rittmon, Ph.D.

Assistant Secretary for Mental Health and Substance Use Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services xi

Executive Summary

KEY MESSAGES

• Peer support services (PSS) are nonclinical recovery support services that can be used to enhance substance use disorder (SUD) treatment, extend related services, and improve outcomes for people in or seeking recovery. (The term “recovery” is defined in the “Key Terms” section of this summary.)

• PSS are increasingly being integrated into diverse SUD treatment settings as well as in settings that frequently coordinate care with formal SUD treatment programs, such as recovery community organizations, recovery community centers, recovery residences, hospitals, and jails/prisons.

• Peer workers are nonclinical professionals who have lived experience with problematic substance use, behavior change, and recovery. These professionals deliver a range of recovery supports designed to improve the treatment experience of individuals who have problematic substance use and their ability to continue on their chosen recovery pathways before, during, and after treatment.

• Peer workers fill a range of roles, such as providers of recovery support, educators, engagement facilitators, role models and mentors, resource navigators, and recovery advocates. In fulfilling these roles, peer workers serve not just individuals in or seeking recovery but also their families and the community.

• To integrate PSS into SUD treatment programs, administrators should consider their organization’s culture, assess staff on their knowledge and attitudes about recovery and PSS, and examine their organization’s hiring and retention practices.

• Treatment program administrators and supervisors play key roles in helping peer workers integrate successfully into organizations and in helping other staff understand, accept, and respect their peer worker colleagues. This is extremely important because a lack of staff understanding about peer workers’ value and roles can lead to role confusion, role strain, and role drift—all of which make it difficult for peers to enjoy and successfully perform their jobs.

• Supervision is a critical part of all roles to ensure delivery of high-quality services. Because the peer worker role is so different from that of a clinical professional, supervisors will need training focused on how to effectively oversee and work with peer workers.

• Serving as a peer worker can be a fulfilling career for individuals in recovery who want to support individuals with problematic substance use while enhancing their own recovery. Attending specialized training and seeking certification are often the first steps on this career path.

• Families affect, and are affected by, a family member’s problematic substance use, treatment, and recovery. Thus, families too can benefit from PSS. Many family members need support, education, and resources to help them better understand their loved one’s problematic substance use and recovery and how to help themselves and their loved one. Peer workers, in the form of family peer specialists, can help fill these unmet needs.

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Peer support services (PSS) enhance traditional substance use disorder (SUD) treatment and services by connecting people who are experiencing problematic substance use to others who have lived experience with problematic substance use and recovery. SUD treatment program providers, supervisors, and administrators (including clinical/program directors) should offer PSS for problematic substance use and ensure that individuals in or seeking recovery are aware of and can access these services. Any setting that offers care and support for individuals who have problematic substance use should also offer or arrange for PSS. Integrating the peer position into SUD treatment programs should supplement PSS that are offered by recovery community organizations (RCOs) and recovery community centers (RCCs)—not replace them.

PSS are an important part of a recovery-oriented system of care (ROSC) and are associated with improved outcomes. ROSCs are multisystem, strengths-based, person-centered continuums of care in which a variety of coordinated supports is tailored to an individual’s needs and chosen recovery pathway.1

The settings and contexts in which PSS are offered are changing rapidly. This Treatment Improvement Protocol (TIP) supports learning about the key aspects, functions, and uses of PSS in recovery from problematic substance use, which will help providers, supervisors, and administrators in SUD treatment programs better understand and respond to these changes.

The Need for a TIP on Integrating PSS Into SUD Services Although understanding of PSS for problematic substance use has increased, few resources address this topic. Several manuals, books, monographs, and other materials detail the development, use, and benefits of PSS in mental health services, but not in SUD-related services.

The Substance Abuse and Mental Health Services Administration (SAMHSA) developed this TIP to fill the gap by providing an easily accessible resource that addresses PSS for individuals receiving services for or in recovery from problematic substance use.

PSS can foster recovery in SUD treatment and other settings where individuals with problematic substance use seek services and support. Peer support services have undergone rapid growth and expansion into diverse service settings, providing peer workers with increasing opportunities for employment and professional development.

Accessing pertinent and up-to-date information about PSS is challenging for both peer workers and other professionals working in a continuum of care, which includes the SUD treatment and recovery field. The information and resources provided in this TIP will help address this challenge.

This TIP focuses on PSS provided to people seeking or receiving treatment for problematic substance use, especially from specialized SUD treatment programs. While this TIP includes some discussion of substance use–related PSS provided in settings other than SUD treatment programs, it does not cover the work of peer specialists in the mental health field.

Peer services expand the continuum of care and enrich the services that providers offer to improve recovery outcomes. They should be an active part of the care and resources SUD treatment programs offer. People receiving SUD treatment benefit from connection to activities and individuals who support the positive changes they may have begun. When SUD treatment is time limited, peer services can extend important recovery support beyond discharge.

PSS help individuals with problematic substance use start and stay in recovery long term. This is true whether delivery of PSS occurs in SUD treatment facilities or in other community-based settings.

The evidence base for SUD-focused PSS shows their many possible benefits, some of which include:2,3,4,5

• Reduced recurrence rates.

• Increased treatment motivation.

• Increased treatment engagement.

• Increased treatment retention.

• Improved relationships with treatment providers, family members, and social supports.

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Executive Summary

• Increased satisfaction with the overall treatment experience.

• Increased general self-efficacy.6,7

Peer workers fill a key role in the SUD treatment workforce, which faces ever-increasing demands.

Interested candidates as well as their potential employers can use this TIP as a central resource on the:

• Roles and responsibilities of peer workers in the SUD treatment and recovery process.

• Steps for integrating PSS into SUD treatment programs.

• Important considerations for supervising peer specialists in SUD treatment settings.

• Steps for entering the SUD-focused peer support workforce.

• Role of family PSS in helping families of loved ones in or seeking recovery.

This TIP provides information about problematic substance use–focused PSS to help meet the training needs of peer workers and to support them in entering and succeeding in the behavioral health workforce.

Scope of This TIP This TIP offers guidance on incorporating peer workers and the services they provide directly into SUD treatment and supportive programs.

It also discusses how SUD treatment providers and program administrators can collaborate with community-based PSS and successfully link individuals and families to these services to support ongoing recovery from SUDs.

Audience The primary audiences for this TIP are peer workers and those interested in becoming peer workers as well as the SUD treatment providers (e.g., drug and alcohol counselors, licensed clinical social workers, case managers, psychologists, or physicians and other medical professionals who specialize in SUD treatment) with whom they may work to support people in or seeking recovery. Licensed professional counselors and marriage and family therapists may also find the information useful.

The TIP refers to these audiences collectively as “providers” at times for brevity. Additional audiences for this TIP include SUD treatment program administrators as well as supervisors of peer workers.

Organization The eight chapters in this TIP are tailored to specific audiences.

• Chapter 1 presents an overview of PSS for individuals seeking or already in recovery from problematic substance use. It describes the settings in which PSS may be provided and lays the groundwork for information and concepts presented in later chapters.

• Chapter 2 is primarily for peer workers, although SUD treatment program supervisors and administrators will also benefit from the chapter’s content. The chapter provides basic information about PSS, peer worker core functions, and important peer worker challenges, such as stigma and discrimination and role clarity.

• Chapter 3 explores the core activities and responsibilities of peer specialists and the knowledge, values, and skills (including abilities) needed to function effectively in a range of treatment settings.

• Chapter 4 is directed primarily to SUD treatment program administrators and discusses how to successfully integrate and sustain the services peer workers provide.

• Chapter 5 discusses key elements and challenges of supervising peer specialists and covers the basics of supervising peer specialists, peer supervisor competencies, and the challenges of supervising peer specialists in treatment settings, including solutions to these challenges.

• Chapter 6 is intended to help people who are interested in becoming a peer specialist understand the benefits and challenges of the role as well as the required training, certification, and credentialing processes.

• Chapter 7 offers SUD treatment providers information about why families of individuals in or seeking recovery might need family PSS and xiv how family peer specialists working in an SUD treatment program or related service setting can meet families’ needs by linking them with family-based PSS.

• Chapter 8 is a compilation of useful resources on PSS.

Exhibit ES.1 defines key terms that appear throughout the TIP. A breakdown of each chapter’s key concepts and messages follows thereafter.

EXHIBIT ES.1. Key Terms

• Addiction: The most severe form of SUD, associated with compulsive or uncontrolled use of one or more substances despite adverse consequences. Addiction is a chronic brain disease that has the potential for both recurrence of problematic use and recovery.8

• Individuals in or seeking recovery: People who are actively engaged in or seeking recovery (e.g., independently, via mutual-help groups, via health-promotion strategies). This term is synonymous with “people in or seeking recovery.”

• Mutual-help programs: Nonprofessional groups in which members share the same problem, value experiential knowledge, and support one another in recovery from that problem.9 Recovery from problematic substance use is supported by a wide spectrum of mutual-help programs that may be secular (e.g., Women for Sobriety, Secular Organizations for Sobriety, Self-Management and Recovery Training [SMART] Recovery®, LifeRing Secular Recovery), spiritual (e.g., 12-Step programs like Alcoholics Anonymous® [AA], Narcotics Anonymous [NA®], Double Trouble in Recovery), or religious (e.g., Celebrate Recovery®; Jewish Alcoholics, Chemically Dependent Persons, and Significant Others; Millati Islami;

Refuge Recovery). The support one receives through mutual-help programs is not the same as support one receives through peer support services.

• Nonclinical role: A staff role that doesn’t involve diagnosis, clinical assessment, or treatment of a substance use, mental, or other medical disorder.

• Peer support services (PSS): The range of services designed, developed, and delivered by peer workers who have lived experience in recovery from problematic substance use and can fill a range of roles to support other people in recovery.

• Peer worker: In general, any person (or in the case of a family peer worker, a close friend, family member, or other loved one of an individual) with lived experience in recovery from problematic substance use, mental disorders, or both who provides nonclinical support in establishing and maintaining long-term recovery.10 The term peer worker encompasses peers working in professional (employed) or volunteer capacities, regardless of whether their work is tied to formal, organized treatment or recovery services.

Peer workers support people in or seeking recovery, conduct strengths-based outreach and engagement, connect individuals who have problematic substance use with recovery resources, facilitate and lead recovery groups, and help build community, among other activities. They sometimes have such titles as recovery coach, mentor, peer provider, peer navigator, or similar terms. Peer specialists (short for peer recovery support specialists) refers specifically to peer workers with some training, including those working in a professional capacity, whether certified or not. Peer workers who have received certification or credentialing to provide peer support services are commonly referred to as certified peer specialists.

• Problematic substance use: The use of any substance in a manner, situation, amount, or frequency that causes harm to the person using the substance or to those around them; it replaces the outdated terms “substance abuse” and “substance misuse.” In the case of prescription medications, problematic use is any use other than as prescribed or directed by a healthcare professional. For some substances (e.g., heroin, cocaine) or individuals (e.g., those who engage in injection drug use), any use constitutes problematic use. Problematic substance use is a broad term and can include use that constitutes an SUD.

(All people with SUDs have had problematic substance use, but not all problematic use meets diagnostic criteria for an SUD.)

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Executive Summary

• Recovery: SAMHSA defines recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” and acknowledges that recovery can occur via many pathways.11 Recovery occurs when positive changes and values become part of a voluntarily adopted lifestyle.

• Recovery capital: The internal and external resources available to establish and maintain an individual’s recovery (e.g., access to health care, supportive relationships, work/schooling, self-esteem, safe housing).

• Recovery orientation: To be oriented to recovery. See definition of “recovery” above.

• Recovery-oriented system of care (ROSC): A coordinated network of community-based, person-centered services and supports that builds on the strengths and resiliencies of individuals, families, and communities to recover and improve health, wellness, and quality of life for those who engage in problematic substance use or are at risk of experiencing substance use–related problems.

• Recovery support: Recovery support includes a wide range of services (e.g., social, legal, and other services), designed to assist people to enter into and navigate systems of care, remove barriers to recovery, and stay engaged in the recovery process. These services can be offered prior to, during, or after treatment, or to those who are not in treatment but are seeking services.12

• Recurrence: A recurrence of problematic substance use after a period of resolved substance use– related problems. Recurrences are often part of recovery; recovery does not mean an absence of recurrence. This term is preferred over relapse, which appears frequently in the research literature but does not reflect a person-first, recovery-oriented perspective. However, the TIP uses relapse on rare occasions when referring directly to the literature or to a program, service, or resource that itself uses the term.

• Remission: A medical term for the disappearance of signs and symptoms of a disease or disorder.

• Role confusion: Occurs when there is not a clear understanding of and communication about a peer specialist’s role.

• Role drift: When a peer specialist performs tasks outside the scope of their job (e.g., tasks more suited to a case manager or licensed SUD treatment provider). Role drift may result from role confusion.

• Role strain: Stress or tension a peer specialist may experience within their role. Role strain often results from experiencing role confusion, role drift, or both.

• Substance use–related problems: The range of undesirable issues that may result from problematic substance use, including poor job performance or unemployment; troubled friend, family, or intimate partner relationships; financial difficulties; accidents; mental, physical, or behavioral problems; criminal justice involvement; child custody disputes; homelessness; and so forth. The harm these ensuing problems cause may continue beyond the period of active substance use. This term is synonymous with substance use–related issues, issues or problems related to substance use, and similar terms.

• Substance use disorder (SUD): A medical illness associated with repeated, problematic use of a substance or substances despite adverse consequences. According to DSM-5-TR,13 SUDs are characterized by a cluster of cognitive, behavioral, and physical symptoms that can impair health, social function, and control over substance use. SUDs range from mild to severe and from temporary to chronic.

They typically develop gradually over time with repeated misuse, leading to changes in the brain that affect reward, stress, and executive functions like decision making and self-control. Multiple factors influence whether and how rapidly a person will develop an SUD. These factors include the substance itself; the genetic vulnerability of the person using the substance; and the amount, frequency, and duration of use.

• Treatment: Compensated services delivered in clinical or acute-care settings by providers who are trained in specific treatment approaches. Often, individuals with problematic substance use must meet specific diagnostic criteria to receive treatment.

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The TIP may use the term “program client” to refer to an individual receiving services at or from an SUD treatment program. However, a peer worker generally doesn’t refer to someone they work with as their “client,” as the nature of this relationship differs from that between a treatment provider and a person receiving SUD treatment. Often, a peer worker will refer to someone they work with as a “peer” instead, reflecting key aspects of the relationship, particularly mutual learning and the shared experience of problematic substance use.

Chapter 1: Introduction to Peer Support Services for People With Substance Use– Related Problems Chapter 1 of this TIP introduces PSS and its potential benefits and challenges. The chapter also discusses the role of peer workers in SUD treatment and recovery, the integration of peer positions in treatment settings, and evolving ways to deliver PSS, and introduces key concepts, including diversity, equity, and inclusion.

In Chapter 1, readers will learn that:

• PSS play a key role in helping people with problematic substance use achieve long-term recovery. PSS are also associated with other important and beneficial outcomes, like increased treatment motivation and retention, lower rates of recurrence, improved social supports, and increased satisfaction with the treatment experience.

• The main function of peer workers is to provide recovery support to individuals who have problematic substance use, which they do by drawing on their lived experience as individuals who have successfully changed their behavior and achieved recovery from problematic substance use. Many peer workers also have specialized training, with many completing a certification process.

• The use of PSS can increase an SUD treatment program’s ability to conduct outreach to and engage with otherwise hard-to-reach people with substance use–related problems.

• The history of PSS in SUD treatment settings can be traced back to the rise of sobriety-based mutual-help societies, including the Washingtonian Society and Sons of Temperance, which came about during the mid-19th century.

• One important development in the recent history of PSS was the creation of SAMHSA’s Recovery Community Support Program in 1998 and its inclusion of PSS.

• Growing acceptance of SUDs as chronic conditions is transforming the field. Similarly, knowledge of what recovery means and requires also has evolved. This expanded view of recovery highlights the need for and importance of PSS in helping individuals in or seeking recovery achieve successful outcomes.

• Peer workers reflect principles of recovery, serve many roles, and provide a range of services in diverse SUD treatment settings as well as other settings. These include RCOs, RCCs, healthcare settings, justice settings, emergency shelters, recovery residences, and harm reduction programs. PSS delivery now also includes telehealth platforms.

• Implementation of PSS into SUD treatment systems can be challenging, in part because of such factors as a lack of provider understanding about the value and role of peer workers, the need for more peer worker training and certification efforts, a lack of acceptance of peer workers by SUD treatment providers and other staff, and a lack of appropriate compensation.

• PSS provide an opportunity for SUD treatment programs to promote an inclusive atmosphere in which people with diverse backgrounds and life experiences feel welcome, and to improve program clients’ engagement with recovery resources.

Chapter 2: Roles of the Peer Worker Chapter 2 of this TIP discusses the main roles of peer workers in SUD treatment settings. The chapter also briefly describes some of the core skills needed to fulfill these roles (this is discussed in greater detail in Chapter 3).

xvii

Executive Summary

In Chapter 2, readers will learn that:

• Peer workers fill a critical need in SUD treatment settings because their lived experience with substance use–related problems, behavior change, and recovery gives them a unique ability to empathize with, relate to, and provide hope to others on the path toward recovery. This experience, combined with their training, helps peer workers successfully engage, support, educate, and guide individuals who have problematic substance use on their chosen recovery pathways.

• Peer workers in SUD treatment programs perform many different roles, all of which are important to helping people with SUDs or with problematic substance use enter and stay in recovery. These roles include role model and mentor, educator, resource navigator, engagement facilitator, advocate, and outreach worker.

• Peer workers face several challenges serving in their many roles. For instance, stigma and discrimination can result from providers and administrators not understanding PSS and the role and value of peer workers. Low pay and limited career advancement opportunities are also challenges.

• Role confusion, unclear boundaries, and lack of knowledge about and resources for peer workers can pose challenges when integrating PSS into SUD treatment programs. To overcome these challenges, organization-wide training on PSS, appropriate peer specialist training, and ongoing supervision are essential. Because peer workers are both providers to and peers of individuals in or seeking recovery with whom they work, they can experience problems maintaining boundaries within the peer-to-peer relationship. This can create ethical dilemmas.

To address this, treatment program supervisors and administrators are responsible for ensuring their organization provides access to national guidelines or develops agency-specific guidelines for ethical behavior of peer specialists. Ethical delivery of PSS should be enhanced by conducting training on ethical standards and decision making, incorporating ethical issues into supervision and performance evaluation processes, and encouraging self-care activities for PSS staff, which help them maintain role clarity.

• To perform their roles successfully, peer workers need to acquire a certain set of knowledge, values, and skills (including abilities). For instance, peer workers need to develop knowledge about biopsychosocial aspects of SUDs, the many pathways of recovery, cultural and spiritual aspects of SUDs, and different types of treatments and services available in their community, including medications for SUDs.

• Core skills of successful peer workers include active listening skills, storytelling, recovery planning, and facilitating groups.

Exhibit ES.2 summarizes what a peer worker is and is not.

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EXHIBIT ES.2. What a Peer Worker Is and Is Not

recovery.

person’s role, family, and community.

living, like housing and work.

Source: Adapted with permission.14

Chapter 3: Peer Worker Core Functions in Substance Use Disorder Treatment and Recovery Support Chapter 3 of this TIP explores the core activities and responsibilities of peer specialists. The chapter describes in depth the knowledge, values, and skills (including abilities) needed to effectively perform these activities and responsibilities in SUD treatment settings.

In Chapter 3, readers will learn that:

• The two main functions of peer workers are providing recovery support to individuals who have problematic substance use and helping to build or enhance the recovery community by connecting to and networking with local organizations and services. Peer workers need to develop certain knowledge, values, skills, and abilities to support each of these functions.

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Executive Summary

• Recovery support knowledge includes understanding the physical, mental, emotional, and social effects of problematic substance use, how to be culturally responsive in providing PSS, and how to use the motivational interviewing philosophy in working with individuals who have problematic substance use.

• Core values of providing recovery support include inspiring hope, being authentic, treating individuals in recovery with respect, being open-minded and culturally responsive, and taking a strengths-based, person-centered approach to providing PSS.

• Peer workers also need to learn the ethical principles designed to protect themselves and the individuals in or seeking recovery with whom they work from harm. These principles include maintaining proper boundaries with individuals in or seeking recovery, using ethical decision-making processes, and engaging in supervision.

• Skills needed to successfully provide recovery support include knowing how to encourage building relationships and assisting individuals with problematic substance use with recovery and wellness planning.

• Helping to build or enhance the recovery community includes learning about types of recovery communities (e.g., RCCs, RCOs) as well as their unique cultures and services.

• Core values to help build or enhance the recovery community include supporting the belief that recovery is possible for everyone and that peers’ lived experience is valuable to the recovery community.

• The skills that peers need to help build or enhance the recovery community include:

- Engaging in training to learn how to identify gaps within community resources and existing community supports for individuals in or seeking recovery.

- Recognizing and managing biases when working with individuals in or seeking recovery.

- Mapping community-based recovery assets.

- Supporting local, state, and federal policies that enhance SUD treatment and recovery.

- Creating leadership development opportunities within the recovery community.

- Helping individuals in or seeking recovery become more involved in the local community.

• Advocacy can be an important part of a peer specialist’s role. Peer specialists advocate for themselves, the individuals in or seeking recovery they work with, and other community organizations.

Chapter 4: Why and How To Integrate the Peer Specialist Position Into Substance Use Disorder Treatment Programs Chapter 4 of this TIP offers guidance for administrators on how to make PSS a part of their treatment programs. The chapter reviews the ways in which PSS are implemented in SUD treatment settings, important aspects of workforce development and retention, how to sustain PSS in SUD treatment programs, and how to make PSS accessible to individuals in or seeking recovery.

In Chapter 4, readers will learn that:

• PSS can be used in many different types of SUD treatment settings, including inpatient and outpatient programs, medically managed withdrawal facilities, opioid treatment programs, and residential treatment programs.

• PSS benefit SUD treatment programs by enhancing the scope of services in the continuum of SUD care, such as conducting outreach and advocating for individuals in or seeking recovery. This allows programs to take a long-term recovery approach (rather than an acute, episodic care approach) to recovery and connect individuals who have problematic substance use with individuals who inspire hope, offer support, and model what successful recovery can look like.

• Introducing PSS into an SUD treatment program may require a shift in organizational culture to one that focuses on recovery and values peers as a part of the recovery process.

• Administrators play a key role in championing the value of PSS and their inclusion in SUD treatments and services, which can help gain xx buy-in from staff and make an organization’s implementation of PSS easier.

• Peer workers should have opportunities to discuss experiences, ideas, and challenges with each other. Administrators can create space for this peer-to-peer sharing and learning by holding regular peer-only staff meetings;

programs with a small number of peer workers should consider holding a regular telephone or videoconference call with their peer workers and peer workers from other programs.

• Readiness assessments help administrators learn more about staff knowledge and attitudes about PSS. This information can be used when training nonpeer workers in the organization to make sure they understand the roles that peer workers will play in their setting.

• Learning from organizations that have already integrated the peer specialist position can be helpful for organizations new to these roles.

• Before hiring peer workers, administrators need to make plans for supervision, set hiring objectives, develop job descriptions and compensation packages, and think about recruiting strategies. Nonpeer staff members also need training on PSS-related topics, including on the role that peer workers will assume, before an organization introduces the peer specialist position.

• Workforce development and retention strategies are very important to hiring effective peer workers and ensuring that they continue to develop professionally and want to remain on staff. Two strategies are to have ongoing training opportunities in place for peer workers and to establish a career pathway for peer workers at the organization.

• SUD treatment programs can help make sure PSS remain a part of their organization by showing that staff and leadership are committed to PSS, having consistent access to PSS funding, and gathering information about the value of PSS and sharing it with the community.

Chapter 5: Supervision of Peer Specialists Chapter 5 of this TIP helps supervisors in behavioral health settings, especially SUD treatment settings, understand the supervision needs of peer workers and how to implement supervision successfully. The chapter describes supervision basics, competencies, and challenges.

In Chapter 5, readers will learn that:

• Peer supervisors play a critical part in making sure peer workers provide quality services to individuals in or seeking recovery; helping peer workers develop a career path of their choosing; supporting peer workers in understanding their ethical responsibilities and the importance of staying within their scope of practice; advocating for peer workers’ rights and needs within an organization; and ensuring that the work of peer workers is meaningful and well-coordinated within the organization.

• Effective supervision of peer workers involves helping them build their skills through regular meetings and constructive feedback; working with peers to set goals, identify their strengths and areas for growth, and resolve any ethical dilemmas; helping peer workers to maintain and expand their own recovery experience;

encouraging peer workers to practice self-care and to create healthy boundaries; and teaching nonpeer workers about the importance and role of peer workers within the organization.

• Supervisors should be aware of their state’s requirements for certified peer specialists and should help the peer specialists they supervise achieve and maintain certification, as appropriate. (The chapter also notes the challenge posed by the lack of reciprocal recognition of certification across all states.)

• Although most already receive training on and are experienced in clinical supervision, supervisors also need additional training focused specifically on the supervision of peer workers. Moreover, peer supervisors need to be aware of national practice guidelines and state licensure requirements regarding the supervision of peer workers.

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Executive Summary

• Supervisors need to develop certain competencies in understanding the peer worker role; recovery promotion, recovery management, and ROSCs; the principles of recovery; how to support and advocate for peer workers so that they have a meaningful role within an organization; and the importance of addressing trauma, social inequities, and health disparities affecting individuals in or seeking recovery, including peer workers.

• Peer supervision can be performed by an experienced peer provider or a specially trained treatment provider. A peer can also receive dual supervision from some combination of an experienced peer provider, a treatment provider, and an administrator.

Supervisors can help organizations achieve better role clarity and ensure peer workers don’t experience role confusion or role drift.

For instance, supervisors should review peer worker job descriptions with peers to make sure both parties are aware of what roles and tasks are expected. Supervisors should also revisit the job description with peer workers regularly, updating it as necessary so that it accurately reflects the work assigned.

Supervisors can promote mutual respect between peers and nonpeers by treating peer specialists as experts on recovery who can educate nonpeer staff on the challenges of recovery and on how to relate to people at various stages of recovery. Supervisors can emphasize that peer specialists are a vital part of SUD care and recovery, explaining that peer specialists benefit the SUD treatment program by improving outcomes, enhancing access to community resources, encouraging engagement in treatment and recovery activities, and instilling hope in individuals in or seeking recovery.

Chapter 6: How To Become a Peer Specialist Chapter 6 of this TIP offers guidance for people who want to become peer specialists. The chapter provides an introduction to what peer workers do and where they work; the benefits and challenges of being a peer worker; and peer specialist training, certification, and credentialing requirements.

In Chapter 6, readers will learn that:

• Peer workers perform many different roles and have a wide range of day-to-day responsibilities in engaging, supporting, and educating individuals in or seeking recovery and their families.

• Peer workers can be found in many types of settings besides SUD treatment programs, including RCCs, RCOs, emergency departments, inpatient hospital units, primary care and other physical health clinics, jails/prisons, mobile crisis units, harm reduction centers, social service centers, and high school and college recovery programs.

• Deciding whether to become a peer specialist requires thinking about such factors as what one hopes to get out of the role, why one is interested in becoming a peer worker, how one’s life or own recovery might be affected by serving in this role, and how one feels about working with individuals who have problematic substance use who are on different pathways to recovery.

• Individuals in recovery interested in becoming a peer specialist need to learn about both the rewards and the challenges of performing peer work. This will help them make more informed decisions about whether to enter this line of work. Advantages include offering a critical service to those in or seeking recovery, giving back to the recovery community, and the opportunity to enhance one’s own recovery.

Challenges can include low pay, few career options or opportunities for advancement, the need for more training opportunities, problems setting boundaries with work colleagues, burnout or stress associated with the position, and difficulty getting hired with a past criminal history.

• Being a peer specialist can be—but does not have to be—a steppingstone to a career in the SUD treatment and recovery field. Peer work can open doors to other related jobs either within or outside the behavioral health field.

• Individuals in recovery interested in becoming peer specialists need to learn about the training and certification requirements in their state or in an organization of interest.

Meeting these requirements may require taking xxii courses, gaining more job experience, or meeting a minimum length of time in recovery.

Although no single peer certification is accepted nationwide, some states recognize certifications from other states.

Chapter 7: How Family Peer Specialists Can Help Families Affected by Problematic Substance Use Chapter 7 of this TIP addresses what families of individuals in or seeking recovery need to know about PSS and how they can benefit from working with a family peer specialist.

The chapter also offers information about how families can engage with peer workers as well as a clinical vignette demonstrating how a family of an individual in or seeking recovery might benefit from family PSS.

In Chapter 7, readers will learn that:

• Problematic substance use is a major stressor for families, potentially causing significant problems with physical and behavioral health, work and education, finances, housing, and social relationships. Families can benefit from family PSS as part of their own recovery process.

• Many family members need—and don’t receive—support, education, and resources to help them better understand their loved one’s problematic substance use and how to help themselves and their loved one.

• Individuals in or seeking recovery have a right to privacy and confidentiality, and some may not want peer workers or other members of their treatment team to share certain information with their family members.

• Family peer specialists help family members access recovery support resources and other services that will be helpful to them during an individual with problematic substance use’s treatment and recovery. This can help improve quality of life for all family members—including the individual in or seeking recovery. Family peer specialists also have firsthand knowledge they can share about how to cope with the effects of substance use–related problems on families.

• Families may not be aware of what family PSS are and therefore may not know how to access them or whether to ask for them.

• When family members understand who peer workers are, what they do, and how they can help, they may feel more empowered, more knowledgeable about their loved one’s problematic substance use and recovery process, and less alone in their loved one’s recovery journey.

• Working with families can be complicated.

Some families have unhealthy communication patterns, whereas others might have negative relationships with one another. Some family members may have negative attitudes about SUD treatment. Family members can develop unhealthy behaviors as a result of the stress of a loved one’s problematic substance use.

Other family…