Partnering in pursuit of truth and recovery

Bill Stauffer recently shared Bill White’s keynote from this week’s Consortium on Addiction Recovery Science.

It’s a great speech and there’s a lot to absorb. I’m sure more will be said about it on this blog.

White frames recovery research as emerging from a gaping hole in professional/clinical and scientific/research knowledge related to recovery. To make matters worse, this gap also constituted a blind spot — knowledge about pathology and brief interventions were believed to be sufficient. (It would be interesting to see analysis of the attitudes and biases that created this gap and blind spot.)

I don’t know whether substance use problems are unique in this respect, but it’s clear that there is an ongoing struggle between kinds of knowledge for dominance. White identifies 4 ways of knowing: 1) experiential knowledge, 2) common or public knowledge—popular folklore or myth, 3) professional/clinical knowledge, and 4) scientific knowledge.

These ways of knowing have been relatively siloed, with each being ignorant of the others and, where they intersect or conflict, each being dismissive or adopting a dominant stance toward the others. The development and pursuit of a recovery agenda has, in part, been an attempt to integrate these ways of knowing rooted in the recognition that each way of knowing is limited and incomplete on its own.

During my first reading of the keynote, this leapt out to me:

In this regard, all recovery research efforts could benefit from earlier work on cross-cultural research and the risk of cultural appropriation. We must scrupulously avoid cultural theft: representing ideas and language drawn from recovering individuals and communities of recovery as our own creation without proper respect, permission, acknowledgement, or explanation of the source and historical and cultural context in which such ideas and language were developed. There are two related issues and strategies of import: 1) the need for recovery representation, and 2) the potential for recovery research coproduction.

Assuring recovery representation within recovery research addresses three concerns: 1) the adequacy of recovery representation (beyond token inclusion), 2) the authenticity of recovery representation (avoiding the problem of “double agentry”—masking of hidden personal/institutional interests behind the claim of recovery status), and 3) diversity of recovery representation (demographic, cultural, and recovery pathway diversity).

Source: White, W. (2024). Frontiers of Recovery Research. Keynote Address, Consortium on Addiction Recovery Science (CoARS), National Institute on Drug Abuse (NIDA), April 24-25, 2024 Posted at https://www.chestnut.org/william-white-papers/

White’s comments are focused on the representation of experiential knowledge in research, but this passage leapt out because of something I’d read recently about peer recovery services. This paper helps illuminate the challenges of integrating these different ways of knowing and avoiding the three traps White identified — tokenism, double agentry, and homogeneity of recovery experience.

PRSs are also unique in the way their professional attitudes are intertwined with their own treatment histories. This study is among the first to quantitatively identify factors that may influence PRSs’ attitudes toward MOUD. Relative to PRSs without histories of MOUD treatment, PRSs with positive or mixed experiences taking MOUD had more positive MOUD attitudes; PRSs who had only negative experiences taking MOUD had more negative attitudes. Twelve-step participation and stigmatizing attitudes toward clients were associated with more negative attitudes toward MOUD. MOUD attitudes also varied by gender and racial-ethnic identity. Findings highlight potential areas for intervention to improve attitudes toward MOUD among the peer workforce.

…Research has shown that individuals currently receiving MOUD can be trained to effectively promote MOUD initiation and recovery support, highlighting a potential strategy for increasing the representation of people with lived experience of MOUD treatment in the peer workforce. In the current study, however, among the minority of PRSs with lived experience of MOUD treatment, about a third indicated their treatment was unsuccessful, and these PRSs reported more negative MOUD attitudes than those without a history of MOUD treatment.

The experiential knowledge that PRSs bring to their work has incredible value; it allows them to quickly build rapport and engage clients in services. At the same time, it is important that PRSs understand their own experience with MOUD is not universal. Popular nonprofessional mutual aid groups for people in or seeking recovery (e.g., 12-step) emphasize one’s own lived experience as their most valuable tool for helping others. However, in work settings, PRSs’ experiential knowledge should be supplemented with professional education, and self-disclosure should be used judiciously. PRSs may need additional training and support as they attempt to balance and integrate experiential, empirical, and professional knowledge. Training should also address considerations for whether and how to use self-disclosure about one’s own recovery pathway.

Pasman, E., Lee, G., Singer, S., Burson, N., Agius, E., & Resko, S. M. (2024). Attitudes toward medications for opioid use disorder among peer recovery specialists. The American Journal of Drug and Alcohol Abuse, 1–10. https://doi.org/10.1080/00952990.2024.2332597

This paper is representative of stances commonly seen from researchers and professional providers. There’s a recognition that experiential knowledge is important. However, when tension emerges between ways of knowing, those developing and advocating scientific or professional/clinical knowledge often assert dominance, seeking submission and conformance to their truths.

White’s three strategies of adequacy, authenticity, and diversity provide a pathway to the integration of experiential knowledge into professional/clinical and scientific knowledge.

My impression, as a practitioner who’s watched this recovery movement unfold over the last 25 years, is that the failure to develop diversity precipitates a willingness to sacrifice adequacy and authenticity of representation. We talk about the importance of peers and lived experience, but then limit the use of lived experience in ways that sometimes make one wonder about the difference between a peer recovery support and a community health worker.

The message from scientific and professional/clinical people to peers is often something like, “Your lived experience is invaluable and we want to use it in our work. However, we want this dimension of your lived experience, but not that dimension. We don’t want you to universalize your personal experience, so we want you to narrow the use of your lived experience to a poorly defined set of parameters so that it will be aligned with our work and (theoretically) universally applicable.”

A few things grabbed my attention in the passage above:

• The concern about biased peer attitudes rooted in their lived experience without acknowledgment that their inclusion is a response to a bias and blindspot in research.
• The assumption that observed peer attitudes are something to be targeted for intervention by researchers and clinicians.
• The assumption that peers need to learn and integrate empirical and professional knowledge without exploring whether there’s anything to learn from the attitudes of peers and their intersection with race and experience with MOUD.
• The conclusion that self-disclosure should be limited.

Peer roles have evolved (as they should), but it’s noteworthy that self-disclosure was central to early conceptions of the role. And, the place of self-disclosure was considered important, in part, because of the suppression of self-disclosure in clinical and paraprofessional roles.

Use of Self: Where self-disclosure has become increasingly discouraged in the addictions
counselor role, it is an important dimension of the RC role. The use of self (using one’s own
personal/cultural experiences to enhance the quality of service) is an inherent part of both the RC and addictions counselor roles, but the use of self by the latter has changed dramatically over the past four decades. In the “paraprofessional” era of addiction counseling (the 1950s early 1970s), disclosing one’s status as a recovering person and using selected details of one’s personal addiction/recovery history as a teaching intervention were among the most prominent counselor interventions. This dimension of the counselor role was based in great part on the role these dimensions played in successful sponsorship within AA Through the 1980s and 1990s, such disclosure came to be seen as unprofessional and a sign of poor “boundary management.” Where self-disclosure by the counselor has been discouraged or discredited, such self-disclosure has been re-elevated in the role of the recovery coach. The recovery coach uses his or her own story and ability to connect the client to the stories of others as a means of offering testimony to the reality and power of recovery and to offer the recovery neophyte guidance on how to live as a person in recovery.

Citation: White, W. (2006). Sponsor, Recovery Coach, Addiction Counselor: The Importance of Role Clarity and Role Integrity. Philadelphia, PA: Philadelphia Department of Behavioral Health and Mental Retardation Services.

The inclusion of peers in mental health teams was intended to be disruptive to the norms and mental models maintained in clinical teams. Culturally specific groups like White Bison also identified sharing personal stories of recovery as a primary task for recovery coaches.

None of this means that practices shouldn’t evolve or be questioned. It also doesn’t suggest that we should just defer to anyone’s lived experience. But, it’s a good reminder that each way of knowing is incomplete, and we limit our capacity to find truth and help people with addiction when we neglect one or subordinate it to another. So, it’s important to ask “Is this change being driven by peers? Or, is it being driven by pressure from funders, professional partners, research partners, or an effort to seek respectability from others?”

We should expect peers to learn from empirical and professional/clinical knowledge sources.

• In what ways is the span and scope of my recovery experience limited?
• Without diminishing or devaluing my own recovery experience, how can I expose myself to other recovery experiences?
• What knowledge and skills can help maximize my capacity to support the pursuit of recovery for as many people as possible?
• What are the limits of my capacity to help others find their way to recovery? How will I know those limits, and how do I communicate them to colleagues?

We should also expect clinicians and researchers to learn from the lived experience of people with addiction.

• What experiences with medication shaped their beliefs and attitudes?
• What experiences with clinicians shaped their beliefs and attitudes?
• What experiences with systems shaped their beliefs and attitudes?
• What blindspots and gaps in empirical and clinical knowledge do these experiences reveal?
• Do their experiences reveal a lack of pathway diversity among the peer workforce?
• Can their experiences help identify any barriers to developing more pathway diversity within the workforce?
• In what ways is the span and scope of my recovery experience limited?

So… how do we protect peers from tokenism and double agentry? It will require vigilance on the part of clinicians, researchers, and peers. It will also require that we live life on life’s terms — that we respect and embrace the lived experience we have — and resist the impulse to bend it into the lived experience we wish we had. It will also demand similar vigilance and attention to the boundaries of peers roles to ensure that they evolve in ways that respect the origins, strengths, and limitations of the role and the people in it, and avoid the tendency to be shaped by the needs of researchers, clinicians, and systems. Finally, where we lack the pathway diversity we need in the peer workforce, we should seek to understand the reasons for that and develop strategies to address those reasons.