Editor’s Note: This article was adapted from an article that ran in the Journal of Substance Abuse Treatment (JSAT), in accordance with a partnership agreement between Counselor Magazine and JSAT,  to bridge the gap between research

Underutilization of evidence-based treatment practices for addictive disorders represents a longstanding problem for the field, as well as for the public health of our nation. The Addiction Technology Transfer Center of New England (ATTC) at Brown University has adapted and implemented an organizational change strategy intended to support addiction treatment organizations and providers in the adoption and implementation of new treatment practices. 

Since 2003, the ATTC has worked with numerous community-based addiction treatment agencies in New England using this model, which is called the Science to Service Laboratory (SSL) (Gumbley, Duby, Torch & Storti, 2005; Squires, Gumbley & Storti, 2008). Survey data regarding satisfaction with the quality, organization and utility of the SSL have been highly favorable, and many of these agencies have successfully adopted new clinical practices. However, interesting organizational differences are apparent between agencies that have completed the SSL and those that have not. We discuss these differences, along with other results and future directions for the SSL. 

The science to service laboratory
The SSL is based, in part, on a model for transferring research to practice (Simpson, 2002; 2007), and is consistent with guidelines from The Change Book: A Blueprint for Technology Transfer (ATTC, 2004). A primary goal of the SSL is to enhance the perceived benefits of adopting new practices by working collaboratively with organizations and practitioners, while reducing issues of complexity (Rogers, 2003). It incorporates comprehensive training and support that relies heavily on interpersonal strategies; outside consultation; innovation “champions” who promote the benefits of change from within agencies; and collaborative problem solving around implementation issues. 

Principles of the Science to Service Laboratory. To improve attitudes about adopting evidence-based addiction treatment practices and to increase the corresponding knowledge and skills among stakeholders, the SSL is founded on several core principles detailed in The Change Book: agency interventions must be relevant to existing needs; introduction of interventions should be timely with respect to current needs; the process to communicate interventions should be clear (i.e. not complex); proponents of interventions should be ­credible; intervention efforts should be multifaceted (i.e. active and interpersonal); efforts to adopt interventions must be reinforced until they become routine; and communication between proponents of interventions and potential adopters should be bi-directional in order to facilitate issues and concerns that may arise during transfer efforts.

Collaboration with Technology Transfer Specialists. One key component of the SSL is the provision of a Technology Transfer Specialist (TTS) to provide ongoing technical assistance during the process of implementing a new evidence-based treatment approach. The primary role and responsibility of the TTS is to serve as an ongoing advisor to agency management and staff with the goal of increasing the likelihood of successful change efforts. A TTS at (or trained by) the ATTC meets several criteria, including: a minimum of a Masters Degree in counseling, education or related field; a minimum of five years of professional experience in either clinical and educational program development, implementation and management and/or supervision; demonstrated under­standing of the application of evidence-based practices; and experience working with state and federal agencies, academic institutions, community treatment programs and researchers in problem identification and resolution.

In-House Innovation “Champions”. In addition to close, ongoing collaboration with a TTS, and consistent with the noted importance of internal change agents located within organizations (Backer, 1995; Backer, Liberman, & Kuehnel, 1986; Rogers, 2003), the SSL emphasizes the importance of a point person, or innovation “champion” to serve as an internal catalyst for change within organizations attempting to adopt new technologies. Working hand-in-hand with the TTS, the innovation champion helps to harness and coordinate internal agency resources needed to support the SSL objectives.

Staff Training. Working in conjunction with the in-house innovation “champion,” the TTS facilitates staff trainings to cover the basics of learning and adopting a new clinical practice. Treat­ment staff is first provided with a basic ­introduction to the following topics: general characteristics of evidence-based practices, in general; a review of theories of change; a brief overview of the technology transfer process; and the importance of balancing fidelity and adaptation. One purpose of this training is to empower staff by actively involving them in the process of considering new practices. Second, and consistent with the idea of “bi-directional communication” between researchers and consumers of evidence-based practices as put forth by National Institute on Drug Abuse (NIDA), the SSL actively employs researchers from academic environments to conduct clinical training workshops and to provide follow-up consultative support to treatment agencies and their staff with respect to specific evidence-based clinical practices for which they have noted expertise.

Ongoing Support. Once all initial training is complete, a TTS continues to work closely with the agency to provide the following components: detailed follow-up information about the process of technology transfer; a forum in which issues relating to barriers, resistance, etc., can be addressed; assistance in the development of an implementation plan; and general support for the agency personnel who are serving as internal change agents.

Group Problem Solving. Research has shown that collaborative interpersonal contact can be critical in promoting the adoption of innovations (Backer, 1995; Backer et al., 1986). Therefore, the SSL also encourages and facilitates opportunities for individuals both within and across treatment agencies to engage in ongoing collaborative problem solving around issues of implementation.

Application of the Science to Service Laboratory
As part of an initial pilot project, the ATTC worked with 54 treatment agencies across all six New England states (CT, MA, ME, NH, RI, VT) to deliver the SSL. Each of the participating agencies initially submitted an application to participate, and were invited to attend a one-day “exposure” meeting to determine if the SSL would be relevant and timely for their agency’s needs.

Engaging Organizations. During the exposure meeting, participants were given a brief overview of the technology transfer process, which emphasized foundational concepts and rationale for the model.  In addition, they received a brief overview of a specific evidence-based practice for substance abuse treatment that would be used to model the training approach of the SSL. The evidence-based practice used for this purpose was contingency management (CM), and the initial presentations on this topic were given by a noted innovator in the field, Dr. Nancy Petry. CM was selected as a model intervention for the SSL based on it being a comparatively simple clinical method to employ with broad applicability across many treatment settings and substances of abuse (Budney, Higgins, Radonovich, & Novy, 2000; Higgins, Alessi, & Dantona, 2002; Petry & Martin, 2002).
Following the exposure meeting, agency directors were asked to designate three-member implementation teams for the project, and the director was asked to sign a statement committing the necessary staff and agency resources to complete the project for a period of up to nine months.
Technology Transfer Specialists. TTSs for the SSL included ATTC senior staff, or other individuals trained by the ATTC to fulfill this role with agencies in specific states. They were involved with or responsible for recruitment of participating agencies; conducting and/or coordinating all trainings; organizing inter-agency workgroups; and supervision throughout the duration of the SSL.

Bi-Directional Communication. Once the application and selection process was completed, regional staff trainings were scheduled to provide a one-day clinical workshop on CM, given by Dr. Petry. The CM workshop training provided staff with both an introduction to the principles and techniques of CM, and how to develop an implementation plan. Dr. Petry also worked with each TTS to develop clinical and supervisory skills related to CM. Agencies were encouraged to send members of their implementation teams (including the in-house innovation “champion”) and other staff considered significant to the implementation of the intervention to the regional trainings.

Organizational Work Groups. As noted, organizational workgroups have become an integral component of the SSL and the TTS has worked closely with innovation “champions” within each participating agency to establish a collaborative forum among staff to promote open communication and problem solving regarding the implementation of CM.  This venue also provided treatment staff with an opportunity for group supervision regarding fidelity of the intervention with both the innovation “champion” and the TTS. A particularly valuable aspect of the work groups was that they frequently included participants from multiple agencies, which promoted “cross-fertilization” of ideas. Finally, the TTS also worked closely with members of the organizational work groups to develop a written implementation plan (based on methods outlined in The Change Book).

General outcomes
Overall, more than half of the agencies (28) that began the project ended up completing all components of the SSL. Of those, 26 of the completer agencies (93 percent) adopted and implemented CM into clinical practice by the end of the roughly nine-month training period. Of the remaining agencies that did not complete the full SSL, most dropped out early in the process (following initial exposure and/or attempts to establish bi-directional communication), while the remaining agencies discontinued participation later in the SSL process (after having identified an internal innovation champion, but prior to developing and implementation plan). None of the dropout agencies implemented CM.

Satisfaction Surveys Regarding Participation in the SSL. A satisfaction and feedback survey was sent to staff members from each of the participating agencies, including those from dropout agencies. The purpose of the survey was to assess the perceived quality and utility of the SSL, as well as to solicit feedback about useful components and areas in need of improvement. Overall, 40 individuals (58 percent) from SSL completer agencies, and 16 individuals (43 percent) from SSL dropout agencies returned the survey within the requested timeframe. Re­sponses in terms of overall satisfaction with the SSL training, instruction, materials and experience were positive for both SSL completers and dropouts, and did not differentiate completer and dropout agencies. 

Additional Agency Characteristics. To further investigate why some agencies completed the SSL and successfully implemented CM, while others did not, despite universally favorable appraisal of the training model, we conducted a second survey designed to examine additional characteristics of completer and dropout agencies along two dimensions. The first dimension addressed how many, and which SSL components (exposure, commitment, bidirectional communication, identifying an innovation champion, training of implementation teams, development of an im­ple­ment­ation plan) dropout agencies completed before withdrawing from participation. The second dimension evaluated agency characteristics, including: management or staff turnover; personnel resources; financial resources; and whether or not there was turnover in the TTS assigned to a given agency. The purpose of the second dimension was to explore differences between completer and dropout agencies.

On average, dropout agencies completed only three of the six SSL components. As can be seen in Figure 1, there was a predictable decline in participation as time and required investment increased. While all dropout agencies participated in the initial exposure meeting, about two-thirds dropped out before identifying an internal innovation champion (see Figure 1). By definition, none made it to the final component of developing an implementation plan for CM.

We also compared the organizational characteristics data between the completer agencies that successfully adopted and implemented CM, and the remaining agencies that either failed to follow through with implementation despite completing the SSL; or dropped out altogether. As can be seen in Table 1, differences were largely in the expected direction. Non-adopter agencies reported higher rates of turnover (50 percent), with respect to an organizational management position key to the SSL effort (e.g. CEO, Program Director, Clinical Director) than did adopter agencies. Non-adopter agencies also reported a higher percentage of critical personnel (e.g. the internal innovation champion) turnover (42 percent vs. 31 percent), and TTS turnover (25 percent vs. 8 percent) than did successful adopter organizations. Unexpectedly, adopter organizations were more often observed as having insufficient financial resources (15.4 percent vs. zero) than non-adopter agencies; and there was virtually no difference between reports of adopter and non-adopter agencies’ general personnel resources (15 percent vs. 17 percent, respectively).

Adopter Agency Preferences. Finally, in the interest of exploring how we might further refine the existing SSL model, we conducted a six-question survey of directors across the 26 agencies that completed the SSL and implemented CM.  Each question had several choices that could be selected and ranked according to what would be most helpful. Of the adopter agencies queried, 16 returned completed surveys in the requested timeframe of two weeks. The questions and highest ranked choice for each were as follows:
1. What sources of information would be most helpful in identifying new evidence-based practices likely to meet the agency’s needs? Fifty percent of respondents endorsed “Professional conferences/workshops/seminars.” 
2. What aspects of new evidence-based clinical practices are most important to the agency?  Sixty-nine percent of respondents endorsed, “Relative advantage over existing practice.” 
3. What would be most useful to the agency in selecting a new evidence-based practice to adopt? Eighty-eight percent of respondents endorsed,
“A menu of practice options.”
4. What type of support would be most helpful in implementing a new evidence-based practice once one is identified? Forty-four percent of respondents endorsed, “Introductory skill training workshops,” with a range of three to 12 months of follow-up support. 
5. What types of follow-up information would be most helpful in evaluating the success of change initiatives? fifty-six percent of respondents endorsed, “Patient outcome data.”
 6. What areas are you interested in targeting for change within the organization?  eighty-one percent of respondents endorsed, “Adopting evidence-based clinical practices.”     

Discussion
Participants from all agencies (adopters and non-adopters) indicated a consistent and high level of satisfaction with the SSL. There were, however, several notable differences between adopter and non-adopter agencies in other areas. Most notably, non-adopter agencies had more frequent turnover in an organizational management position key to the SSL effort than adopter agencies (50 percent vs. 15 percent, respectively). Even among agencies that completed the SSL, the only two that did not actually adopt CM had experienced turnover in a position key to the effort, while the remaining 26 that adopted upon completion did not.

In addition to greater turnover among critical organizational management, non-adopter agencies also were rated as more likely than adopters to experience turnover among internal innovation champions (42 percent vs. 31 percent, respectively) and TTSs (25 percent vs. eight percent, respectively). Un­expect­edly, adopter agencies were more often assessed as having insufficient financial resources as compared to non-adopter agencies (15 percent vs. zero, respectively). This, however, may have been related to the nature of CM, in that adopter agencies were more likely to face financial challenges en route to implementing a viable CM protocol. Finally, while all of the adopter agencies signed a commitment letter confirming their initial intentions to complete the SSL, eight of the non-adopter sites failed to do so. While it remains unclear to what degree this reluctance was related to staffing instability or other factors, the finding is consistent with similar work done by Squires and Hester (in press) where initial agency willingness to sign a letter of commitment predicted retention in training.

Finally, questions designed for agency directors provided guidance on how the SSL might be refined in the future. Answers to these questions indicated that directors clearly preferred professional conferences, workshops or seminars as an initial means of identifying new evidence-based practices to be considered for future adoption. On the question of perceived advantages of new evidence-based practices, nearly 70 percent of directors endorsed “relative advantage over existing practice” as a first choice. This was not surprising given that relative advantage of new practices has been identified as a principal factor in determining adoption (Rogers, 2003).

When asked what would be most helpful to their organization in selecting a new evidence-based clinical practice to adopt, agency directors overwhelmingly (88 percent) selected a menu of practice options as their first choice. This finding is consistent with the literature on individual change, which has shown that a menu of change options, or offering more than one avenue to accomplish a goal, promotes positive outcome (Miller & Rollnick, 2002; Miller & Sanchez, 1994).  Once a new practice has been identified, nearly half of directors surveyed indicated a first choice preference of “introductory skill training workshops” to help in implementing the practice.  Beyond the first choice reported above, clinical treatment manuals, administrative technical support, and clinical supervision training/resources where also endorsed by over 50 percent of the sample.  Perhaps more than any of the others, the diversity of rankings on this item reflect the complexities involved in successfully adopting and implementing a new clinical practice, and they mirror the current literature on the topic. 

Finally, once change initiatives are undertaken, over half of directors surveyed indicated that “patient outcome data” was their number one choice in determining the success of implementing a new evidence-based practice, and that adopting evidence-based practices was the number one priority for change within their agency.

Conclusion
The adoption and implementation of new clinical practices in treatment agencies is a complicated, multi-faceted process.  Of all the findings reported, perhaps the most significant is the apparent and critical importance of staffing stability.  Given the high rates of staff turnover common in agency settings, it may be helpful for agencies considering significant change to identify and target a core group of committed individuals for any change initiatives.  It may also be helpful to offer specific incentives for participating staff to promote active, long-term involvement in the effort.  Our data also supports the potential value of expanding the range of options for practice choices, training experiences and follow-up support, and highlight the value of clearly identifying and communicating the relative advantage of new practices and how they relate to clinical outcomes.

Future directions

Building on findings from this project, we are working to incorporate additional resources into the SSL. First, we are developing comprehensive supervision and follow-up components that will better support clinical supervisors and link practitioners with clinical feedback resources following didactic training for a greater range of evidence-based practices. To that end, we are exploring ways to incorporate Internet-based resources that might include distance learning and interactive on-line supervisory and feedback forums, in addition to live training resources.  Second, we are collaborating with representatives from, and regional users of, the Network for the Improve­ment of Addiction Treatment (NIATx) model on ways to integrate SSL components to more comprehensively address and support organizational change for both business and clinical practices. Finally, we are working with a variety of local, state and regional agencies to integrate the SSL into practice. We also have a research grant from NIDA to experimentally evaluate the SSL as compared to “training as usual.” The study is nearing completion, and preliminary results are promising.

Dr. Dan Squires is a clinical psychologist specializing in addiction treatment, and Assistant Professor of Community Health at Brown University.  Dr. Squires’ academic work focuses on the dissemination of evidence-guided practices for the treatment of addictive behaviors. He is currently the PI/Director for the Addiction Technology Transfer Center of New England, and conducts research designed to evaluate comprehensive organizational change and training models for alcohol and other drug treatment organizations and providers.

Stephen J. Gumbley, MA, LCDP, has been working in addiction education, prevention, treatment and recovery since 1988.  He has served as clinical and programmatic administrator of a wide range of residential, outpatient and medication-assisted treatment programs. He is presently the Co-Director of the Addiction Technology Transfer Center of New England at Brown University.

References
Addiction Technology Transfer Centers. (2004).  The change book. A blueprint for technology transfer.  (2nd Ed.)  Kansas City, MO: Author.
Backer, T. E. (1995). Assessing and enhancing readiness for change: Implications for technology transfer.  In T. Backer, S. David, & D Soucy (Eds.), Reviewing the behavioral science knowledge base on technology transfer (pp. 21–41). (NIDA Research Monograph 155, NIDA Publication No. 95-4035). Rockville, MD: National Institute on Drug Abuse.
Backer, T. E., Liberman, R. P., & Kuehnel, T. G.  (1986).  Dissemination and adoption of innovative psychosocial interventions. Journal of Clinical and Consulting Psychology, 54, 111–118.
Budney, A.J., Higgins, S.T., Radonovich, K.J., & Novy, P.L. (2000). Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. Journal of Consulting and Clinical Psychology, 68, 1051–1061.
Gumbley, S.,  Duby, L., Torch, M. & Storti, S. (2005). ATTC New England science to service laboratory: A comprehensive technology transfer model. (Available from the Addiction Technology Transfer Center of New England, Brown University, Box G-BH, Providence, RI 02912)
Higgins, S.T., Alessi, S.M., & Dantona, R.L. (2002). Voucher-based incentives: A substance abuse treatment innovation. Addictive Behaviors, 27, 887–910.
Miller, W.R., and Rollnick, S.  (2002). Motivational interviewing: Preparing people for change. (2nd ed.). New York: Guilford Press.
Miller, W. R., & Sanchez, V. C. (1994). Motivating young adults for treatment and lifestyle change. In G. Howard (Ed.), Issues in alcohol use and misuse by young adults (pp. 55–81). Notre Dame, IN: University of Notre Dame Press.
Petry, N. M., & Martin, B. (2002).  Low-cost contingency management for treating cocaine- and opiod-abusing methadone patients. Journal of Consulting and Clinical Psychology, 70, 398–405.
Rogers, E.M. (2003). Diffusion of Innovations. (5th ed.).  New York: Free Press.
Simpson, D. D. (2002). A conceptual framework for transferring research to practice. Journal of Substance Abuse Treatment, 22, 171-182.
Simpson, D.D. & Flynn, P.M. (2007). Moving innovations into treatment: A stage-based approach to program change. Journal of Substance Abuse Treatment, 33, 111–120.
Squires, D.D., Gumbley, S.J., & Storti, S.A. (2008). Training substance abuse treatment organizations to adopt evidence-based practices: The Addiction Technology Transfer Center of New England Science to Service Laboratory. Journal of Substance Abuse Treatment, 34, 293–301.
Squires, D.D. & Hester, R.K. (in press). Treatment provider perceptions and utilization of a PC-based brief motivational intervention for problem drinkers: Implications for dissemination.  Addictive Disorders and Their Treatment.

This article is published in Counselor, The Magazine for Addiction Professionals, December 2009, v.10, n.6, pp.30-35. 
 

There is no physical or psychiatric condition more associated with social disapproval and discrimination than alcohol and/or other drug (AOD) dependence (Corrigan, Watson, & Miller, 2006). Addiction-related social stigma constitutes a major obstacle to personal and family recovery, contributes to the marginalization of addiction professionals and their organizations, and limits the cultural resources allocated to AOD-related problems. Efforts to forge “recovery-oriented systems of care” inevitably confront social stigma as a barrier to shaping community attitudes and policies supportive of long-term addiction recovery. The purpose of this article is to highlight some of the modern research on addiction-related social stigma and outline actions addiction professionals can personally take to reduce such stigma within their communities.    

Stigma 101
Stigma Defined: Stigma is the experience of being held in contempt (shunned or rendered socially invisible) because of a socially disapproved status (Sayce, 1998). It involves processes of labeling, stereotyping, social ostracism, exclusion and extrusion—the essential ingredients of discrimination. There are three types of personal stigma:

• enacted stigma (direct experience of ostracism and discrimination, e.g., social rejection; professional disrespect; difficulty acquiring employment, housing or services; denial of governmental benefits—student loans, public housing, small business loans);

• perceived stigma (perception of stigmatized attitudes held by others toward oneself); and

• self-stigma (personal feelings of shame) (Luoma, Twohig, Waltzet al., 2007).    

Stigma and Recovery: Addiction-related social stigma extends to people who have achieved stable recovery from addiction (Tootle, 1987).  
Courtesy Stigma: The social stigma attached to addiction can be experienced by families, organizations (e.g., addiction treatment programs), neighborhoods and whole communities. Goffman (1963) referred to this stigma by association as “courtesy stigma.” The social stigma attached to families affected by addiction carries the implication that the family somehow failed to prevent this problem, contributed to its onset and/or played a role in failing to prevent or inciting relapse episodes. Children may be socially shunned due to the perception that they have been contaminated by the addiction of their parents or siblings (Corrigan, Watson & Miller, 2006).  

Multidimensional Stigma: The weight of addiction-related social stigma is not equally applied. Its burdens fall heaviest on those with the least resources to resist it, e.g., those for whom stigma is layered across multiple conditions (addiction, mental illness, HIV/AIDS, incarceration, minority status, poverty, homelessness) (Yannessa, Reece & Basta, 2008). Persons experiencing such layered, multidimensional stigma are less likely to seek addiction treatment than persons experiencing a single discredited condition (Conner & Rosen, 2008). The most intense social stigma attached to addiction begins at the point of admission to treatment (a social signal of problem severity) and intensifies with multiple treatment episodes (a social signal of treatment failure) (Luoma, Twohig, Waltz et al., 2007).

In the United States, the social stigma attached to illicit drug use varies by drug and method of ingestion, with use of heroin and crack cocaine being the most stigmatized substances and injection the most stigmatized method of ingestion (Surlis & Hyde, 2001). Greater addiction-related stigma may also be extended to people in particular treatment modalities. Stigma is particularly severe for persons whose treatment and recovery is supported by methadone, in spite of the well-established scientific legitimacy and effectiveness of methadone treatment (Joseph, 1995; Murphy & Irwin, 1992; Woods, 2001). Methadone-related stigma generates a wide span of discrimination—spanning employment, child custody, access to other forms of addiction treatment and even denial of the privilege to speak at some recovery fellowship meetings (Hettema & Sorenson, 2009; Joseph, Stancliff, & Langrod, 2000).

Stigma and Long-term Health: Stigma can elicit social isolation, reduce help-seeking and compromise long-term physical and mental health (Ahern, Stuber & Galea, 2007). Social stigma is a major factor in preventing individuals from seeking and completing addiction treatment (Luoma et al., 2007). Social stigma increases the service needs of persons with substance use disorders, but that same stigma decreases access to such services by fostering social rejection and discrimination (van Olphen, Eliason, Freudenberg, & Barnes, 2009).  
Personal Responses to Stigma: In­dividual strategies to deal with stigma include:

• secrecy/concealment  
• social withdrawal
• preventative disclosure
• compensation (using personal strengths in another area to counter the imposed stigma)
• strategic interpretation (comparing oneself to others within the stigmatized group rather than to those in the larger community); and  political activism (Shih, 2004).

Stigma and Cultures of Addiction: Individuals who share the “spoiled identity” of addiction have historically organized their own countercultures marked by distinct language, values, roles, rules (behavioral codes), relationships and rituals (White, 1996). These subcultures provide shelter from stigma; access to drug supplies; social support for sustained drug use; meaningful roles, activities and relationships; and mutual protection. Within these cultures, drug users protect their own identities by stigmatizing other drug users viewed as less in control of their drug use (Boeri, 2004; Simmonds & Coomber, 2009). Such attitudes can get played out within the social pecking order of drug treatment milieus. “Street cultures” also are imbedded with myths designed to inhibit treatment-seeking, contribute to ambivalence about treatment and increase the likelihood of treatment disengagement, e.g., street myths about methadone—“it rots your teeth and bones” (Rosenblum, Magura, & Joseph, 1991).

Strategies to Address Social Stigma: Three broad social strategies have been used to address stigma related to ­behavioral health disorders: 1) protest; 2) education; and 3) contact (Corrigan & Penn, 1999). One major strategy, seeking to inculcate the belief that alcohol and drug addiction is a disease, has not been consistently shown to produce sympathetic attitudes toward those with severe alcohol and other drug problems (Cunningham, Sobell & Chow, 1993). One of the most effective strategies to reduce social stigma is to increase interpersonal contact be­tween mainstream citizens and people in recovery (Corrigan, 2002). Contact between stigmatized and non-stigmatized groups as a vehicle of stigma reduction is most effective when this contact is: between people of equal­ status (mutual identification), personal, voluntary, cooperative and mutually judged to be a positive experience (Couture & Penn, 2003). Social stigma is particularly influenced by social proximity and distance. For example, community attitudes toward Oxford Houses are most positive among neighbors who live closest to these houses (Jason, Roberts & Olson, 2005). Reducing social distance and in­creasing interpersonal contact are important goals of any anti-stigma campaign.

Historical/Sociological Perspectives
Before exploring personal strategies that addiction professionals may use to address addiction/treatment/recovery-related social stigma in their own communities, it may be helpful to set this issue within a larger perspective.

Social stigma toward alcohol and other drug (AOD) addiction may be defined as an obstacle to problem resolution or as a strategy of problem resolution. The stigmatization and criminalization of alcohol and other drug problems in the United States has grown over more than two centuries as an outcome of a series of “drug panics” and resulting social reform campaigns (Jonnes, 1996; Musto, 1973). These campaigns have generated policies of isolation, control and punishment of drug users (White, 1979). Stigmati­zation is not an accidental by-product of these campaigns. It is a reflection of policies that “unashamedly aim to make the predicament of the addict as dreadful as possible in order to discourage others from engaging in drug experimentation” (Husak, 2004). An outcome of this complex social history is that many addiction professionals and recovery advocates see the stigma produced by “zero tolerance” policies as a problem to be alleviated, whereas preventionists see the stigma produced by such policies as a valuable community asset. A key question thus remains, “How do addiction treatment professionals, recovery advocates, and preventionists avoid working at cross-purposes in their educational efforts in local communities?”

Efforts to increase or reduce stigma attached to illicit drug use may have intended or unintended side-effects (Room, 2005). Two examples illustrate this point. First, efforts to decrease illicit drug use by portraying the drug user as physically diseased, morally depraved and criminally dangerous may inadvertently decrease help-seeking behavior by creating caricatured images of addiction with which few people experiencing AOD problems identify. Such strategies may also promote patterns of social exclusion and discrimination within local communities that block the ability of drug-dependent individuals to re-enter mainstream community life. Second, an anti-stigma campaign could inadvertently increase drug use if it normalized illicit drug use, increased non-user curiosity about drug effects, conveyed the impression that addiction treatment is an assured safety net (available and affordable) and that recovery is easily attainable, and glamorized the recovering addict as a heroic figure within cultural contexts in which few heroic models are available.  

Any campaign to counter addiction/treatment/recovery-related stigma must ask the question, “Who profits from stigma?” Efforts by one group to define another group as deviant can serve psychological, political and ­economic interests. Put simply, stigmatizing others often serves to increase the self-esteem of the stigmatizer (Tajfel & Turner, 1979). It elevates oneself as more worthy than the demeaned “other” and defines oneself as an upholder of community health and morality. Social scapegoating of others increases during periods in which personal esteem, security, safety, and social value are threatened. Partici­pation in or support of campaigns to define others as outsiders serves to confirm one’s own insider status. Addiction professionals seeking to reduce social stigma attached to addiction/treatment/recovery must address such issues of esteem, security, safety and social value.

  
Stigma has political utility. Anti-drug campaigns often mask and reflect deeper conflicts of gender, race, social class and generational conflict. Such issues have long been manipulated for political gain. Stigma is often the delayed fruit of anti-drug campaigns waged for the benefit of those seeking to build or retain political power. Anti-stigma campaigns must address the question of how the community and its political leaders can benefit from changes in attitudes toward addiction/treatment/recovery.

Social stigma can be fed by individuals and institutions whose economic interests are served by such attitudes. Changes in attitudes can trigger shifts in cultural ownership of alcohol and other drug problems and, in that process, shift millions of dollars in ways that affect the destinies of individuals, organizations and whole communities. For example, past changes in community attitudes have shifted millions of dollars between community-based addiction treatment and the criminal justice system. Such shifts influence the fate of professional careers, organizations, and in some cases, entire community economies. Similarly, what may be viewed as a problem of “not in my back yard” (NIMBY) prejudice by citizens of a particular neighborhood may actually reflect opinion being manipulated by hidden financial interests, e.g., developers who would profit from future gentrification of a neighborhood targeted for a new addiction treatment facility.

     
Social stigma attached to addiction/treatment/recovery involves complex issues, but each of us may find simple  steps we can take to help create a world in which “people with a history of alcohol or drug problems, people in recovery, and people at risk for these problems are valued and treated with dignity, and where stigma, accompanying attitudes, discrimination, and other barriers to recovery are eliminated” (SAMHSA, 2002).

12 personal strategies
Addiction professionals and recovery advocates in the City of Philadelphia are engaged in a sustained conversation about addiction-related stigma. We are exploring how to best shape community attitudes and policies to transform the city into a true community of recovery. Some of the ideas we are hearing about how addiction professionals and recovery advocates can contribute to this effort include the following.
 1. Assess Yourself. Explore (self-inventory) how addiction-related stigma may have inadvertently influenced your personal (and your program’s) attitudes, beliefs and practices.
 2. Stay Recovery Focused.  Keep your own batteries charged by staying in touch with individuals and families in long-term recovery, e.g., attending open meetings of local recovery fellowships and/or recovery celebration events.
 3. Build Respectful Partnerships. Cultivate service relationships marked by respect, choice, and continuity of support.  
 4. Make Amends. Acknowledge and correct mistakes and shortcomings in your relation­ships with people who are seeking or in recovery.      
 5. Be a Recovery Carrier/Witness. Tell stories of individual and family recovery at every opportunity. The most singularly important thing you have to offer individuals, families, and your community is hope.
 6. Walk the Walk. Conduct yourself in the community as an ambassador of the recovery movement, conveying as best you can such core recovery values as humility, honesty, gratitude, respect, tolerance, responsibility and service. Never forget that people will judge those you serve, your organization and your profession by how you conduct yourself in the community.
 7. Model Non-stigmatizing Language. Use language that is medically descriptive rather than moralistic, e.g., “addiction,” “drug dependence,” or “substance use disorder” rather than “drug abuse.” Refrain from language that equates methadone with heroin, e.g., avoid references to methadone treatment as a “substitution therapy” or “replacement therapy” (Maremmani & Pacini, 2006). Use “person first” language in inter-professional and community-level communications, e.g., “person with a substance use disorder” or “person experiencing drug-related problems” rather than “substance abuser” or “addict.” Confront language in the treatment milieu that demeans and objectifies, e.g., references to persons re-admitted for treatment as “frequent flyers” or “retreads.”    
 8. Educate Yourself. Seek educational opportunities to increase your knowledge about addiction, treatment,and recovery—particularly on subjects about which you have great passion but little education. Passionate opinion in the absence of knowledge is not an admirable trait of the addictions professional or recovery support specialist.  
 9. Be an Educator. Seek out opportunities to educate allied professionals, other community service workers, and the larger community about addiction, treatment, and recovery. Use encounters with addiction/treatment/recovery stereotypes in the community as educational opportunities, but be careful to speak only within the boundaries of your education, training, and experience. It is far better to declare, “I don’t know” than to convey an ill-informed opinion.
10. Extol the Honor of Service Work. When talking about your work with other professionals and members of the community, emphasize points that will enhance optimism about long-term recovery and the importance of, and personal satisfaction that can be drawn from, professional/personal support of long-term recovery efforts.
11. Be an Advocate. Speak out against stigma-related discrimination, e.g., in housing, employment, government benefits, access to health and human services and in stigma-shaped policies/practices within addiction treatment.
12. Embrace and Promote Diverse Pathways for Recovery. Avoid polarized “either/or” debates about the way to treat addiction or the way to recover. Our best message is: There are many pathways to addiction recovery, and all are cause for celebration.  Help people see that there are others like themselves in recovery who share their world view, whether that view reflects a secular, spiritual or religious orientation.  
13. Challenge Institutions. Don’t assume that institutions in the treatment field or that should otherwise “know better” don’t stigmatize people in the same way that the broader society does.  Stigma is pervasive and the attitudes of even well-meaning individuals and institutions may unconsciously reflect such stigma.  
14. Join the Movement. Participate in local recovery advocacy organizations and grassroots anti-stigma campaigns. Contribute your time, talent, and money to support such efforts.  (See www.facesandvoicesofrecovery.org)

Closing reflection
The social stigma attached to addiction exists at cultural, institutional, interpersonal and intrapersonal levels; potential antidotes to such stigma must work at these same levels (Woll, 2005).  

Too many of us hide within our own professionally and socially cloistered worlds while boldly challenging our clients to re-enter the life of communities from which we have long been disengaged. We need to re-enter those communities and stand in partnership with those we serve to confront the social stigma attached to addiction/treatment/recovery. It is not enough to personally help each client initiate a recovery process. We need to assure a community/world that welcomes and nourishes such recoveries.   

As part of our larger recovery-focused systems transformation process, the City of Philadelphia is exploring development of a long-term strategy to reduce the stigma attached to addiction/treatment/recovery. Other communities across the country are involved in similar efforts. We hope this opening discussion will stimulate your own thinking about how you can contribute to this movement.   

William White, MA is a Senior Research Consultant at Chestnut Health Systems and author of Slaying the Dragon:  The History of Addiction Treatment and Recovery in America.   

Dr. Arthur Evans, Jr. is Director of the Philadelphia Department of Behavioral Health and Mental Retardation Services (DBH/MRS).

Roland Lamb is the Director of the Office of Addiction Services, Philadelphia DBH/MRS.  


References
Ahern, J., Stuber, J., & Galea, S. (2007). Stigma, discrimination and the health of illicit drug users. Drug and Alcohol Dependence, 88(2-3), 188–196.
Boeri, M.W. (2004). “Hell, I’m an addict but I ain’t no junkie”: An ethnographic analysis of aging heroin users. Human Organization, 63, 236–245.
Conner, K.O., & Rosen, D. (2008). “You’re nothing but a junkie”: Multiple experiences of stigma in an aging methadone maintenance population. Journal of Social Work Practice in the Addictions, 8(2), 244–264.
Corrigan, P.W. (2002). Testing social cognitive models of mental illness stigma: The prairie state stigma studies. Psychiatric Rehabilitation Skills, 6, 232–254.
Corrigan, P.W., & Penn, D.L. (1999). Lessons from social psychology on discrediting psychiatric stigma. American Psychologist, 54, 765–776.
Corrigan, P.W., Watson, A.C., & Miller, F.E. (2006). Blame, shame and contamination: The impact of mental illness and drug dependence stigma on family members. Journal of Family Psychology, 20(2), 239–246.
Couture, S.M., & Penn, D.L. (2003). Interpersonal contact and the stigma of mental illness: A review of the literature. Journal of Mental Health, 12, 291–305.
Cunningham, J.A., Sobell, L.C., & Chow, V.M. (1993). What’s in a label? The effects of substance types and labels on treatment considerations and stigma. Journal of Studies on Alcohol, 54(6), 693–699.
Goffman, E. (1963). Stigma: Notes on the management of a spoiled identity. Englewood Cliffs:  Prentice-Hall.  
Hettema, J., & Sorenson, J.L. (2009). Access to care for methadone maintenance patients in the United States. International Journal of Mental Health and Addiction. Online publication ahead of print. Re­trieved from http://www.springerlink.com/content/
c5v56125880u2p64/.  
Husak, D.N. (2004). The moral relevance of addiction. Substance Use and Misuse, 39(3), 399–436.
Jason, L.A., Roberts, K., & Olson, B.D. (2005). Attitudes towards recovery homes and residents: Does proximity make a difference? Journal of Community Psychology, 33(5), 529–535.
Jonnes, J. (1996). Hep-cats, narcs, and pipe dreams. New York: Scribner.  
Joseph, H. (1995). Medical methadone maintenance: The further concealment of a stigmatized condition. Unpublished doctoral dissertation, City University of New York.
Joseph, H., Stancliff, S., & Langrod, J. (2000). Methadone maintenance treatment: A review of historical and clinical issues. Mount Sinai Journal of Medicine, 67, 347–364.
Luoma, J.B., Twohig, M.P., Waltz, T., Hayes, S.C., Roget, N., Padilla, M., et al. (2007). An investigation of stigma in individuals receiving treatment for substance abuse. Addictive Behaviors, 32(7), 1331–1346.
Maremmani, I., & Pacini, M. (2006). Combating the stigma: Discarding the label “substitution treatment” in favour of “behavior-normalization treatment.” Heroin Addiction and Related Clinical Problems, 8(4), 5–8.
Murphy, S., & Irwin, J. (1992). “Living with the dirty secret”: Problems of disclosure for methadone maintenance clients. Journal of Psychoactive Drugs, 24(3), 257–264.
Musto, D. (1973). The American disease: Origins of narcotic controls. New Haven, CT: Yale University Press.
Room, R. (2005). Stigma, social inequality and alcohol and drug use. Drug and Alcohol Review, 24(2), 143–155.
Rosenblum, A., Magura, S., & Joseph, H. (1991). Ambivalence toward methadone treatment among intravenous drug users. Journal of Psychoactive Drugs, 23(1), 21–27.
Sayce, L. (1998). Stigma, discrimination and social exclusion: What’s in a word? Journal of Mental Health, 7, 331–343.  
Shih, M. (2004). Positive stigma: Examining resilience and empowerment in overcoming stigma. Annals of the American Academy of Political and Social Science, 591, 175–185.
Simmonds, L., & Coomber, R. (2009). Injecting drug users: A stigmatized and stigmatizing population. International Journal of Drug Policy, 20(2), 121–130.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2002). National Recovery Month helps reduce stigma. Substance Abuse and Mental Health Services Administration. Retrieved June 17, 2009 from http://www.hazelden.
org/web/public/ade20909.page.
Surlis, S., & Hyde, A. (2001). HIV-positive patients’ experiences of stigma during hospitalization. Journal of the Association of Nurses in AIDS Care, 12, 68–77.
Tajfel, H., & Turner, J.C. (1979). An integrative theory of intergroup conflict. In W.G. Austin, & S. Worchel (Eds.), The social psychology of intergroup relations (pp. 33–48). Monterey, CA: Brooks/Cole.
Tootle, D.M. (1987). Social acceptance of the recovering alcoholic in the workplace: A research note. Journal of Drug Issues, 17, 273–279.  
van Olphen, J., Eliason, M.J., Freudenberg, N., & Barnes, M. (2009). Nowhere to go: How stigma limits the options of female drug users after release from jail. Substance Abuse Treatment Prevention and Policy, 4. Retrieved from http://www.substanceabusepolicy.com/content/pdf/1747-597X-4-10.pdf.
White, W. (1996). Pathways from the culture of addiction to the culture of recovery.  Center City: Hazelden.
White, W. (1979). Themes in chemical prohibition. In Drugs in perspective. Rockville, MD: National Drug Abuse Center/National Institute on Drug Abuse.
Woll, P. (2005). Healing the stigma of addiction: A guide for treatment professionals. Chicago, IL: Great Lakes Addiction Technology Transfer Center.
Woods, J. (2001). Methadone advocacy: The voice of the patient. The Mount Sinai Journal of Medicine, 68, 75–78.
Yannessa, J.F., Reece, M., & Basta, T.B. (2008). HIV provider perspectives: The impact of stigma on substance abusers living with HIV in a rural area of the United States. AIDS Patient Care, 22(8), 669–675.

The history of addiction treatment and recovery in the United States contains a rich “wounded healer” tradition. For more than 275 years, individuals and families recovering from severe alcohol and other drug problems have provided peer-based recovery support (P-BRS). Formal peer-based recovery support services (P-BRSS) are now being delivered through diverse organizations and roles and are emerging as a critical component of “recovery management” and “recovery-oriented systems of care.” For the past year, I have researched the history and status of peer recovery support in the United States. The results of this review are now available in a new 250+ page monograph published by the Center for Substance Abuse Treatment’s Great Lakes Addiction Technology Transfer Center and the Philadelphia Department of Behavioral Health and Mental Retardation Services. A PDF of the monograph is available for downloading and hard copies for purchase are both available at www.glattc.org.      

This issue of Counselor provides an executive summary of the new monograph. I hope it will stimulate much discussion about the history of the role of addiction counselors and the emergence of new models of peer-based recovery support. 

The organizing principle for providing care for people with alcohol and other drug problems is shifting from pathology and intervention paradigms to a long-term recovery paradigm. 

Evidence of this shift can be seen in the shift in emphasis within addiction treatment from models of biopsychosocial stabilization to models of sustained recovery management. Recovery management models include assertive interventions to shorten addiction careers, lengthen recovery careers and enhance the quality of individual/family life in long-term ­recovery. Peer-based recovery support (P-BRS) and formal peer-based recovery support services (P-BRSS) constitute central recovery management strategies and a core component of recovery-oriented systems of behavioral health care.  This monograph reviews the history, operational principles, service practices, and scientific status of P-BRS and P-BRSS as well as their future relationship with professionally-directed addiction treatment.  

Defining Peer-Based Recovery Support Services
• Peer-based recovery support (P-BRS) is the process of giving and receiving non-professional, non-clinical assistance to achieve long-term recovery from alcohol and/or other drug-related problems. 
• Peer-based recovery support is provided by people who are experientially credentialed.
• There are substantial differences between models of peer recovery support and models of professionally-directed addiction treatment.
• P-BRS can be delivered through a variety of organizational venues and a variety of service roles (including paid and volunteer recovery support specialists).
• The governance structures of P-BRS vary in the span and degree of peer control (peer-owned, peer-directed or peer-delivered).
• Peer-based recovery support services (P-BRSS) are a form of P-BRS delivered through more formal organizations and through more specialized roles.
• Asset allocation schemes for P-BRSS include entrepreneur models (excess assets returned to private owner/
investors), institutional models (excess assets reinvested in development of the organization) and stewardship models (excess assets reinvested in recovery community development).   
• The core functions of P-BRSS span the stages of recovery initiation/stabilization, recovery maintenance, and enhancement of quality of life in long-term recovery and may encompass support at individual, family, neighborhood and community levels.
• P-BRSS are distinguished by their recovery focus; mobilization of personal, family, and community recovery capital to support long-term recovery; respect for diverse pathways and styles of recovery; focus on immediate recovery-linked needs; use of self as a helping instrument; and emphasis on continuity of recovery support over an extended period of time.     
• P-BRSS may serve as an adjunct or alternative to professionally-directed addiction treatment.

History of Peer-Based Recovery Support Services
• Addiction recovery mutual-aid societies and the specialty sector of addiction treatment emerged in response to the social stigma attached to AOD problems and the history of service exclusion, service extrusion and ineffective and harmful interventions that individuals and families experienced in their encounters with mainstream health and human service institutions.  
• Addiction recovery mutual-aid societies have experienced substantial growth (membership size and geographical dispersion of local meetings), pathway diversification (secular, spiritual, and religious recovery societies), specialization (meetings focused on age, gender, drug choice, and special needs) and new support media (growth of telephone- and internet-based support).
• A growing number of religious and cultural revitalization movements are embracing abstinence and creating unique cultural and religious pathways of recovery initiation and maintenance.
• People in recovery have sought service roles as a natural extension of the ­service ethic within communities of recovery and as a backlash against ineffective and disrespectful professional ­interventions. 
• The services recovering people have provided to individuals and families suffering from AOD problems have emphasized service relationships that are natural, equal, reciprocal, voluntary, sustained (potentially life-long), non-bureaucratic and non-commercialized. 
• P-BRSS constitute an effort to recapture dimensions of support lost in the professionalization of addiction counseling and the weakening of the service ethic within communities of recovery that accompanied the rise of an “alcohol and drug abuse industrial complex” (Hughes, 1974). 
• People in recovery have been cyclically included and excluded from leadership and service roles within addiction treatment and the broader arena of recovery support services. 
• Recovering people are awakening both politically and culturally and are generating new recovery support institutions that compliment, and in some circumstances, compete with, professionally-directed addiction treatment.
• New recovery support institutions include grassroots recovery community organizations, recovery homes and colonies, recovery industries, recovery schools, recovery ministries and recovery churches, recovery-focused media (radio, television, cinema) and recovery arts (music, literature, film, comedy).
• Recovering people are again moving into a broad range of service roles within addiction treatment and allied health care, human service and criminal justice agencies. 
• Recovery support services are being rapidly privatized and professionalized—a trend with unclear long-term consequences. 

The Theoretical Foundations of Peer-Based Recovery Support
• Some people who survive a life-altering disorder or experience develop special sensitivities, insights and skills to help others similarly afflicted. 
• The zeal recovering people bring to helping others reflects a deep sense of purpose and destiny, as well as a means of making amends for past addiction-related harm to others.
• Addiction counseling and peer recovery support rest on two overlapping, but potentially conflicting, traditions of authority:  professional knowledge and experiential knowledge.
• The course and outcome of chronic illnesses are profoundly influenced by the peer support available to individuals and families who experience such illnesses. 
• Exposure to the personal stories and lives of people in recovery can serve as a catalyst of personal transformation for people suffering from severe AOD problems.   
• Peer recovery support helps to remedy the inequality of power/authority, perceived invasiveness, role passivity, cost, inconvenience and social stigma associated with professional help for severe AOD problems. 
• Peer helping is reciprocally beneficial: the helper and helpee both draw value from helping exchanges.
• In historically oppressed communities, hope for individuals and families is best framed within a broader vision of hope for a people, e.g., attaining social justice; addressing disparities in health, stigma, and discrimination; and widening doorways of community participation and contribution for all people.
• Understanding the ecology of recovery is crucial to the design of effective P-BRSS in all communities.  
• P-BRSS provide experience-grounded guidance in the journey from cultures of addiction to cultures of recovery.
• As peer-based recovery support movements develop, they face twin risks: anti-professionalism, “incestuous closure,” and implosion; and loss of mission via the forces of professionalization, bureaucratization and commercialization.
• All peer-based recovery support services rest on the primacy of personal recovery.
• P-BRSS constitute a mechanism of long-term recovery support that can enhance recovery outcomes at costs far less than those of services provided through sustained professional care.

Effects of Participation in Recovery Mutual-aid Societies
• Scientific studies regarding the effects of participation in recovery mutual-aid societies on long-term recovery outcomes are limited in scope and methodological rigor.
• Most of what is known about mutual-aid and recovery outcomes is based on studies of the effects of involvement in Alcoholics Anonymous by individuals treated in professionally-directed addiction treatment programs.
• Participation in recovery mutual-aid societies typically enhances long-term recovery rates, elevates global functioning, and reduces post-recovery costs to society among diverse demographic and clinical populations.
• Individual responses to recovery mutual-aid groups are variable, in­cluding those who respond optimally, those who respond partially and those who fail to respond.
• Recovery mutual aid participation has multiple active ingredients, including: motivational enhancement for recovery; reconstruction of personal identity; reconstruction of family and social relationships; enhanced coping skills; and the personal effects of helping others.
• The effects of recovery mutual aid involvement are interdependent with frequency, intensity and duration of involvement.
• Combining recovery mutual aid and professionally-directed addiction treatment has additive effects in clinical populations.
• For clients in addiction treatment, affiliation with and benefits from recovery mutual-aid societies are influenced by counselor attitudes toward mutual aid, the style of linkage (assertive vs. passive, degree of choice, and personal matching), and the timing of linkage (during treatment vs. following treatment).
• The Internet may provide an effective adjunctive or alternative delivery device for peer-based recovery support services.
• The potential positive effects of recovery mutual-aid participation are often not achieved due to weak linkage procedures and high early dropout rates.     

Effects of Participation in other Recovery Community Institutions
• There is a long history of recovery support institutions beyond mutual-aid fellowships (e.g., recovery community organizations, Recovery Community Centers, recovery-oriented social networking sites and other online resources), but very little research exists on the effects of involvement in these institutions on long-term recovery. 
• Participation in recovery social clubs reduces the risk of relapse following addiction treatment.
• Living within the national network of Oxford Houses significantly reduces the risk of relapse and enhances long-term recovery outcomes.
• Participation in recovery high schools and college/university-based recovery communities reduces the risk of relapse, enhances recovery outcomes and elevates academic achievement. 
• Recovery industries and recovery-conducive employment sites have yet to be described or evaluated extensively in the scientific literature.  
• Religion-oriented recovery colonies, recovery ministries, and recovery churches are growing but remain all but invisible to the professional addiction treatment and research communities.
• Recovery support structures organized by and for recovering people within the context of addiction treatment, such as consumer councils and alumni associations, have not been evaluated scientifically.

Recovering People Working in Addiction Treatment
• The portrayal of recovering people working in the addictions field is plagued by misconceptions and ­stereotypes that are contradicted by the available scientific evidence. 
• The percentage of counselors in personal recovery within the specialty sector addiction treatment workforce has declined from nearly 70% in the early 1970s to approximately 30% in 2008.
• Recovery status alone does not predict pre-practice educational performance or performance on addiction counselor certification tests.
• Studies of addiction counselors in the United States have found that recovering addiction counselors are as effective as counselors who are not in recovery, with neither group showing superiority based only on the question of recovery status.
• The key determinants of effectiveness do not include recovery status. The effectiveness of counselors in personal recovery, like that of counselors not in recovery, varies widely from person to person.
• Recovering people working in addiction treatment are paid less than ­people not in recovery for comparable work, even when their educational credentials are equal. 
• Studies of the personalities of recovering men and women working as addiction counselors reveal few differences from counselors without addiction recovery backgrounds.
• Much of what has been attributed to recovering counselors by way of beliefs and attitudes is a function of educational level; as educational levels of people in recovery have increased, differences between recovering counselors and counselors without addiction histories diminish or disappear ­completely.
• Attitudes toward evidence-based practices differ by educational levels but not by recovery status (when education levels are controlled).
• People in recovery do not constitute a homogenous group: attitudes/beliefs, clinical effectiveness, and the quality of ethical sensitivity and decision-making cannot be predicted based on recovery status.
• Studies of the relapse rates of recovering addiction counselors over the past 40 years report relapse rates ranging between 5 and 38 percent, with rates progressively declining through these years.
• The evaluation of treatment models delivered primarily by counselors in personal recovery report recovery outcome rates similar or superior to those of programs whose services are delivered by counselors without recovery backgrounds.
• Volunteer programs in addiction treatment relying primarily on volunteers in personal/family recovery have been evaluated positively; volunteer programs declined in popularity within the field throughout the 1980s and 1990s but are increasing in tandem with renewed calls for peer-based recovery support services. 

Recovery Coaching and P-BRSS
• There are currently two federal programs administered by the Center for Substance Abuse Treatment that fund initiatives that emphasize peer-based recovery support services: the Recovery Community Services Program (RCSP) and the Access to Recovery (ATR) Program.
• Studies have not been conducted to determine the effects of RCSP or ATR services on long-term recovery outcomes.
• There are independent studies of particular peer-based recovery support services that have been linked to enhanced engagement, access, treatment completion, and improved long-term recovery.

P-BRSS Research Agenda
• There are increased calls for a recovery-focused research agenda capable of illuminating the prevalence, pathways, styles and stages of long-term individual/family recovery from severe AOD problems.
• Research on naturally occurring recovery communities is best conducted with the sensitivities and methods recently developed for the study of other ethno-cultural communities.
• A research agenda related to P-BRS and P-BRSS must encompass expanded research on the effectiveness of recovery mutual-aid societies (particularly non-12-Step recovery support groups); the role of other recovery community support institutions in long-term recovery; the influence of recovery representation at board, executive, staff, and volunteer levels on recovery outcomes of service consumers; individual factors affecting the degree of effectiveness of P-BRSS;  the effectiveness of particular P-BRSS across the stages of recovery; the relative potency of key recovery support service ingredients; the relationship of P-BRSS to professional treatment; the effects of P-BRSS on family health and functioning; and the influence of organizational context on the effectiveness of P-BRSS.   
• Research should also identify the major sources of resistance to P-BRSS and the most effective methods of implementing P-BRSS.
• The recovery research agenda must encompass studies of recovery at individual, family, and community levels.

Summary and Conclusions
Specialized addiction treatment grew out of the failure of the mainstream health and human service system to provide effective solutions for individuals and families experiencing alcohol and other drug problems. Today, peer-based recovery support services are growing out of the failure of professionally-directed addiction treatment to provide a continuum of care that is accessible, affordable and capable of helping people with the most severe and complex AOD problems move beyond brief episodes of recovery initiation to stable long-term recovery. P-BRSS are specifically designed to reach people earlier in their addiction careers, enhance recovery initiation and stabilization, improve linkage to recovery mutual-aid groups and other recovery support institutions, facilitate the transition to successful recovery maintenance and enhance the quality of personal and ­family life in long-term recovery.

However, this model is not a panacea. We would do well to avoid the superficial infatuation with P-BRSS that marked the infatuation with recovering alcoholics and ex-addicts in the late 1960s and early 1970s in the rise of modern addiction treatment. The value of P-BRSS is found in identifying what those in recovery specifically bring to the helping process. 

Peer-based models of care can have a transforming effect on larger systems of care and on our society by enhancing long-term addiction recovery outcomes and elevating public and professional perceptions of hope for recovery. However, peer models of recovery support also can be corrupted and devoured by larger systems of care. As peer-based services are integrated into the existing treatment system or offered by free-standing independent organizations, there will be pressure to emulate the ethos of the existing treatment system, including the professional roles of counselors and others.

At the dawn of modern addiction treatment, observers suggested that one of the advantages ex-addict counselors brought to their role was that they were “unencumbered by ‘professionalism’ and entanglement in bureaucracy” and were free to “interact with patients in a less formal, more spontaneous fashion than professionals” (Suchotliff & Seligman, 1974). Care must be taken not to over-professionalize P-BRSS roles and replicate the very conditions out of which these peer-models were spawned. It will be very important to achieve a delicate balance between peer-based and professional service models, to retain the strengths of each, and manage the vulnerabilities inherent in each model.

Delivering P-BRSS can enrich an individual’s own recovery experience, but this work also can be a threat to one’s sobriety. In P-BRSS models, service accessibility, availability in time of crisis, and continuity of contact over time constitute distinctive strengths, but they also provide a potential source of over-extension and burnout for individual workers and their organizations. There is an inevitable strain between accessibility and stewardship of resources as organizations providing P-BRSS define their recovery support capacity (How many people?  How many services?  How long?). P-BRSS are based on the power of mutual identification—a relationship that is personal, reciprocal and prolonged—but these same traits are potential sources of boundary ambiguity, abuse of power and moving beyond the boundaries of personal competence. That is why training, guidelines and supervision are as important for P-BRSS as for professional services. 

Rather than view peer-based and professional-based styles of knowing and doing as antagonistic models that must be judged against one another in terms of superiority and inferiority, it is more helpful to view these approaches as complementary, what one of the field’s pioneers referred to as a “creative fusion of heart and mind” (McGovern, 1992). 

Peer-based recovery support services can help shift the larger treatment system from a focus on brief biopsychosocial stabilization to a focus on the long-term recovery process. Peer-based models can inject a recovery focus—a source of renewal—into treatment institutions whose fear of the current climate of financial scarcity has driven them into excessive preoccupation with paper, profit and professional prestige. P-BRSS specialists can help divert excessive attention from “funding streams,” “product lines” and “bottom lines” and refocus attention on long-term recovery pathways and processes for individuals and families. This must be done in a way that avoids the “us and them” polarizations between peer and professional models of recovery support. 

The addictions field brings one unique quality that separates it from peer models that are rising in allied fields. It has the oldest and largest recovery mutual aid network in the world via the growth of spiritual, secular, and religious recovery mutual-aid groups and new recovery support institutions. We must be very careful that new peer-based models capitalize upon the strength of these communities of recovery rather than undermining or replacing them. Our long-term goal is not to create a larger treatment system or a new profession, but to create the physical, psychological and social space in which recovery flourishes in local communities. 

Note: The monograph summarized here was prepared with the support of the Philadelphia Department of Behavioral Health and Mental Retardation Services and the Great Lakes Addiction Technology Transfer Center under a cooperative agreement from the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Substance Abuse Treatment (CSAT). The opinions expressed herein are the views of the author and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA, or CSAT. 

William White, MA is a Senior Research Consultant at Chestnut Health Systems and author of Slaying the Dragon:  The History of Addiction Treatment and Recovery in America.  

References
Hughes, H. (1974, December).  Address before the North American Congress on Alcohol and Drug Problems.  San Francisco, CA.
McGovern, T. (1992).  Alcoholism and drug abuse counseling:  A personal reflection.  The Counselor, 10(3), 38-46.
Suchotliff, L., & Seligman, E. (1974).  The myth of the ex-addict staff.  Drug Forum, 4(1), 47-51.

The importance of utilizing evidence-based practices (EBPs) has taken over health care in the medical, psychiatric and substance use treatment arenas (Institute of Medicine, 2001). Patients, insurance companies and other payors want to ensure that only treatments that have been shown to be effective through carefully designed research are being used. In some spheres, utilizing EBPs is becoming a requirement to continue to receive funding for the services that are provided. As a result of this wellspring, community treatment programs are being forced to implement such interventions.

For the past decade, I have penned articles for Counselor that called for a fundamental redesign of addiction treatment. That redesign would extend treatment from an acute — an ever briefer — model of biopsychosocial stabilization to a model of long-term recovery management. Through the support of the Northeast Addiction Technology Transfer Center, the Great Lakes Addiction Technology Transfer Center and the Philadelphia Department of Behavioral Health and Mental Retardation Services, I have completed a review of the scientific evidence supporting this recovery-focused transformation of addiction treatment and outlined the changes in clinical practice suggested by this research.

The findings and recommendations are now available in a 138-page monograph that includes a prologue by Arthur C. Evans Jr., PhD, an epilogue by Lonnetta Albright and Michael Flaherty, PhD, and more than 800 research citations. A free PDF of the monograph for downloading and hard copies for purchase are available at www.ireta.org.     

Although neuroscientists have made major contributions over the past several decades in elucidating the brain mechanisms and underlying neurotransmitter systems involved with addictive drugs, there has been insufficient attention paid to possible psychological mechanisms and vulnerabilities that might explain why addictive substances can be so seductive, consuming and destructive. 

Clearly, regular use of addictive substances cause changes in the brain; produce physical dependence; and when an addicted person’s drug is removed or cut off, symptoms of withdrawal ensue. A wide range of distressing symptoms occur characteristic of the drug upon which the person has become dependent. Many argue that it is the acute and prolonged withdrawal symptoms and distress that cause addicted individuals to revert back to their use of addictive substances.