The Age Old Story – Differing Compensations, Differing Expectation in Peer Recovery Workforces – A Review of Alavi et al., 2023

Qualitative studies are essential to understanding the field of addiction and recovery precisely because whether one is talking about the misery of addiction, the liberation of recovery, or the dynamics and experience of those working in the field – at the heart of the field is the question of experiential knowledge and personal accounts of endless varieties. As a researcher, I find the qualitative studies in this field to be on par with the richness of Indigenous, feminist, and Black revolutionary scholarship. For any population that is misunderstood, disabused, exploited, or marginalized, qualitative work unlocks the necessary dimensions of understanding that quantitative science and the study of mainstream Western culture overlook or underestimate. In this spirit, I want to highlight a recent qualitative study on community-based health workers and peer recovery workforce by Alavi et al., 2023.

This post will highlight a few takeaways from the recent article by Alavi, S., Nishar, S., Morales, A., Vanjani, R., Guy, A., & Soske, J. (2023), titled ‘We Need to Get Paid for Our Value’: Work-Place Experiences and Role Definitions of Peer Recovery Specialists/Community Health Workers,‘ which can be found here in the recent addition of Alcohol Treatment Quarterly.

Some Notes on Methods

As part of a study, 21 peer recovery workers (n=21) were interviewed in clinical settings, such as medical and psychological services, instead of the recovery community organizations that had been used in previous research. The authors chose clinical settings over community settings because the stigma of substance use disorder (SUD) and those in recovery is most evident in clinical and professional settings. This was an insightful and deliberate decision on the part of the authors.

The structured interview questions were developed in collaboration with a separate group of current peer workers, adding a participatory research element to the inquiry methods. This approach, derived from indigenous methodology and critical feminist research, is especially relevant for working with stigmatized or exploited populations. The study’s significance lies in its insightful approach and the critical and political-economic nature of the findings, which align with broader labor studies in feminist, Black, and Indigenous scholarship.

The Findings

From the Abstract: “Through semi-structured interviews with 21 CHWs and peer recovery specialists working within substance use disorder treatment and/or traditional health care settings, we identified six prevalent themes: Benefits/Pleasures of the Role; Reciprocity; Challenges; Duality of Lived Experience; Relationships with Medical Professionals and Supervisors; and Defining Metrics. These themes reveal a complex narrative of system failures, organizational hierarchies, and experiential realities in which shared experiences and personal connections with clients undergird both positive and negative aspects of the role. In the words of one study participant: “We have not taken a vow of poverty, we need to get paid for our value.”

I would like to focus primarily on the political-economic features of this study because I see an important feature in this work that is often overlooked – The belief that reciprocal and meaningful work for specific populations is adequate compensation for their labor time. In short – I see the exchange of qualitative benefits of peer work being swapped out for quantitative forms of compensation.

The exploitation of peer recovery workers in healthcare settings is a complex issue rooted in several systemic factors. Firstly, the disparity in compensation arises from the nature of their qualifications, which are based more on lived experience than formal education, leading to lower wages compared to other healthcare roles. This undervaluation of their expertise and emotional labor constitutes a clear form of exploitation. Additionally, many organizations employing these workers face budget constraints, contributing to the wage gap. The general perception of peer recovery work as more supportive than medical further undermines its value, resulting in inadequate financial recognition of the workers’ significant contributions.

Another major issue is the lack of robust union representation for peer recovery workers, which limits their ability to negotiate for fair wages and working conditions. This absence of collective bargaining power places them in a vulnerable position, making them more susceptible to exploitation. The nature of their work, often requiring flexibility to cater to clients with addiction or mental health issues, means they frequently work outside of the typical 9-5 schedule, including off-hours and late nights. However, this demanding and irregular schedule is not compensated at a rate higher than standard working hours, highlighting a significant area of exploitation.

The conflict between the need to maintain professional boundaries and the requirements of their clients exacerbates this situation. Peer recovery workers are often advised to set working hour boundaries, yet the needs of their clients, who live lives asynchronous to societal norms due to the nature of addiction or mental illness, conflict with these boundaries. This often results in workers extending their availability without corresponding compensation, further contributing to the emotional and physical toll on the workers.

Ultimately, mitigating the exploitation of peer recovery workers involves acknowledging and compensating them adequately for their unique contributions, including the challenges of working non-standard hours. This requires sector-specific changes and a broader reevaluation of how society values different types of labor, particularly those associated with caregiving and emotional support.

Labor issues aside, this swapping out of the qualities of the work for the quantified extends beyond just labor time and compensation. In fact, it is built into the very metrics of the peer recovery position. To quote, “The majority of participants did not believe grant metrics (which pay their wages) captured the often messy and non-linear progress made by clients or the most valuable work they performed.”

My Take

So here we have a pattern that emerges which only a study of this kind can truly elucidate – The interplay between the qualities of the job, and the quantitative mechanisms by which the job is compensated and by which the efficacy of the work is evaluated.

This fact is at the heart of the problem – Not just in peer recovery work, but as part of a broader systemic shortcoming of marketized systems of care that seeks to quantify cost-benefit of all things relational, nurturing, and human. The fact that this economization of care work happens to fall upon vulnerable, gendered, and minority populations is intentional to capitalist systems rather than a bug. Hence, there is a political element that must be placed front and center in the discussion of peer recovery systems – We must ask if recovery-supportive systems should allow for the reproduction of exploitation we see elsewhere in society and whether that jives with the principles and values of recovery as well as the professional ethics of clinicians. Personally, I believe such exploitative conversions of qualitative to marketized quantities should be eradicated from recovery-specific venues based on recovery principles alone, but I may be in the minority in this opinion.

If we agree that, at least in this sphere of recovery, such inherent exploitation is contradictory to the overarching aim of recovery systems, then each of us must make a specific and deliberate stand to prevent the current exploitative trends from becoming further entrenched in the status quo of daily operations and systems. If we do not act now to specifically address this, it will only become the standard practice that is widely and unfairly accepted by funders, organizations, and even laborers who will have no collective say in the matter. We have seen this episode before, countless times, throughout the history of capitalism. Are we going to let it encroach on this space? This is a question we all must answer.