Lived experience has long been a significant component of addiction treatment and recovery. In recent years, its prominence has only grown as mainstream medicine seeks to infuse lived experience into the standard of care for not only substance use disorder (SUD) treatment, but across the larger behavioral health field. However, as the field evolves, determining what constitutes “sufficient” lived experience for peer specialists and how these experiences should be applied within care models has become increasingly complex, varying across states and healthcare organizations.
Historically, the structured application of lived experience emerged under the Alcoholics Anonymous model of sponsorship.
While the peer support role has been fundamental to community-based recovery support services from the beginning, there is less known around the effectiveness of current wide scale attempts to expand and apply the role more broadly. The expansion of what has traditionally been a grassroots and programmatically defined role has raised numerous questions about the amount, type, transferability, and core mechanism of impact within the role, which has shown effectiveness in decreasing hospitalizations and ED visits, increasing patient retention and engagement, and overall rates of abstinence.
In mainstream health settings, the recovery coach role has frequently been poorly defined, with coaches being tasked with a wide range of responsibilities: care coordination, acting as de facto therapists during extended wait times for trained clinicians, providing on-call crisis response and care, and so on. While there is an increasing need for clearer role definition, the prospect of greater standardization raises concerns around diminishing the authenticity of individual lived experience and the autonomy of peer specialists to build genuine relationships with clients seeking recovery.
As we navigate this complex landscape, three critical questions remain unanswered.
What is ‘Sufficient’ or the ‘Right Kind” of Lived Experience?
The lack of standardization and general research into the broad-ranging activities of the Recovery Coach role has led to a great deal of subjectivity around who is deemed “qualified” to serve as a coach. The unintended implication is that there are certain types of lived experiences that are more relevant or more real than others.
While outwardly most programs acknowledge there are no ‘right’ or ‘wrong’ pathways to recovery, peer selection has often prioritized individuals with more traditional routes to recovery through inpatient or residential treatment. Attitudes around abstinent versus moderation-based approaches, personal beliefs about the effectiveness of different pathways to recovery, and biases towards medications for the treatment of SUD are often mixed into decisions around lived experience qualifications. Anecdotally, it is not unheard of for programs to deny coaching roles based on a perceived lack of ‘sufficient’ negative consequences, as a long-embedded culture of war storying often uses adverse consequences (i.e. the depth of someone’s rock bottom) as a measure of ones lived experience. This focus can disadvantage candidates who may have maintained higher functioning despite their substance use.
Determinations around lived experience qualifications will continue to become even more complex as the definition of being ‘in recovery’ expands to encompass both abstinent and non-abstinent outcomes. This is happening alongside evolving cultural shifts in attitudes towards traditionally classified ‘good’ drugs (e.g., tobacco) and ‘bad’ drugs (e.g., cannabis), creating further ambiguity around who is considered part of the recovery community.
What is More Important to Success: Past Experience or Trained Skills?
Due to a lack of research on the core mechanism of impact within the role, it’s uncertain how to balance the importance of lived experience with skills-based attributes learned during the training and certification process. A multitude of factors beyond lived experience may play a crucial role such as the coach’s ability to apply their experiences, demonstrate compassion, exhibit strong listening skills, maintain robust relationships within the recovery community, possess organizational skills, release personal biases, speak the same language or align culturally or religiously with the patient.
It’s not clear whether the nature of the lived experience and self-disclosure is the key effective mechanism or whether the hard and soft skills acquired during training, such as coaching and organizational skills elicit greater effect on positive patient outcomes. The ideal weighting of these factors, skills and attributes as they contribute to the successful recovery of clients will surely end up depending on the evolving roles and responsibilities of the recovery coach role and responsibilities.
How Similar Does Lived Experience Need to Be for Effective Transfer?
The degree to which a recovery coach’s lived experience needs to align with that of the patient to be effective is a complex question. For example, can someone with lived experience in opioid use disorder effectively support a patient with an alcohol use disorder, or can a coach with a background in medication-assisted treatment work well with someone focused on mutual aid participation?
The exact extent to which a peer specialist’s experience must mirror that of the patient for effective support and connection remains unclear. The field is grappling with whether lived experience can be transferred across different substance use disorders, recovery pathways, and philosophies, or even applied within integrated care settings to address mental health conditions like anxiety, depression, or schizophrenia. Historical resistance to cross training the recovery coach workforce in both addiction and mental health highlights the need for additional research to assess the range of transferability or range of effectiveness for lived experience and address concerns around the potential dilution of lived experience and impact.
Towards A Clearer Understanding
The role of peer specialists in healthcare is a testament to the growing recognition of lived experience as a valuable asset in the treatment of substance use disorders. However, as the field continues to evolve, it is imperative that we address the unanswered questions surrounding the definition of “sufficient” lived experience, the balance between past experience and trained skills, and the degree of similarity in lived experience required for effective transfer. These considerations are crucial for ensuring that recovery coaches can provide the most effective support to those seeking recovery, while maintaining the authenticity and integrity of the role.
The push for greater role standardization and professionalization inevitably creates tension with the community-based and volunteer origins of peer support, which has traditionally been an organic approach to addiction recovery. Continued research into these unanswered questions will be crucial to resolve these tensions and develop clearer standards that facilitate the effective integration of lived experience into healthcare settings and ultimately, save lives.
Recovery Review 