Ethical Guidelines for the Delivery of Peer-based Recovery

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Ethical Guidelines for the Delivery of Peer-based Recovery

Transcript Of Ethical Guidelines for the Delivery of Peer-based Recovery

This article will be part of Perspectives on Peer-based Recovery Support Services, the third in a series of monographs on recovery management published by the Great Lakes Addiction Technology Transfer Center (ATTC).

White, W., the PRO-ACT Ethics Workgroup, with legal discussion by Popovits R. & Donohue, B. (2007). Ethical Guidelines for the Delivery of Peer-based Recovery Support Services. Philadelphia: Philadelphia Department of Behavioral Health and Mental Retardation Services.
Ethical Guidelines for the Delivery of Peerbased Recovery Support Services
William L. White, MA
The PRO-ACT Ethics Workgroup: Howard “Chip” Baker, Babette W. Benham, Bill McDonald, Allen McQuarrie, Skip Carroll, John Carroll, Beverly J. Haberle, Heidi Gordon, Kathy McQuarrie, Maura Farrell, Harvey Brown, Marilyn Beiser, Deborah Downey, Esq., Carole Kramer, Fred D. Martin, Leslie M. Flippen, Nadine Hedgeman, D.C. Clark, Jerri T. Jones, Larrissa M Pettit, Darryl Chisolm, LeeRoy Jordon, and Hassan Abdul Rasheed
With a discussion of legal issues by Renée Popovits and Elizabeth Donohue

Prepared for the Philadelphia Department of Behavioral Health and Mental Retardation Services (DBHMRS)
Pennsylvania Recovery Organization—Achieving Community Together (PROACT)


There is a long history of peer-based recovery support services within the alcohol and other drug problems arena, and the opening of the twenty-first century is witnessing a rebirth of such services (White, 2004a). These services are embedded in new social institutions such as

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recovery advocacy organizations and recovery support centers and in new paid and volunteer service roles. These peer-based recovery support roles go by various titles: recovery coaches, recovery mentors, personal recovery assistants, recovery support specialists, and peer specialists. Complex ethical and legal issues are arising within the performance of these roles, issues for which little guidance can be found within the existing literature.
The twin purposes of this article are 1) to draw upon the collective experience of organizations that are providing peer-based recovery support services to identify ethical issues arising within this service arena, and 2) to offer guidance on how these issues can best be handled. Toward that end, we will:
 define the core responsibility of the peer recovery support specialist (here referred to generically as recovery coach);
 provide an opening discussion of key ethical concepts;
 outline a model of ethical decision making that can be used by recovery coaches and those who supervise them;
 discuss vignettes of ethical situations that can arise for recovery coaches related to personal conduct, conduct in service relationships, conduct in relationships with local service professionals and agencies, and conduct in service relationships with the larger community; and
 provide a sample statement of ethical principles and guidelines for recovery coaches.
An appended paper also identifies the extent to which current laws governing roles in addiction treatment (e.g., confidentiality, duty to warn, personal/organizational liability) are applicable to recovery coaches and their organizations.
We have two intended audiences for these discussions: individuals who are in positions of responsibility for the planning, implementation, and supervision of peer-based recovery support services and individuals who are working in either paid or volunteer roles as recovery coaches. This paper is designed to be adapted for use in the training of recovery coaches and their supervisors. The paper will remain in the public domain and may be adapted as a training aid or used without request by other recovery support organizations as a reading resource. We encourage the use of the decision-making model and the ethical case studies in the paper in the orientation and training of recovery coaches.
Recovery support services, as the term is used here, refers to non-clinical services that are designed to help initiate and sustain individual/family recovery from severe alcohol and other drug problems and to enhance the quality of individual/family recovery. The Center for Substance Abuse Treatment’s Recovery Community Support Program identified four types of recovery support services:

1 This section excerpts material from White, W. (2004). Recovery coaching: A lost function of addiction counseling? Counselor, 5(6), 20-22.

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 Emotional support—demonstrations of empathy, love, caring, and concern in such activities as peer mentoring and recovery coaching, as well as in recovery support groups
 Informational support—provision of health and wellness information; educational assistance; and help in acquiring new skills, ranging from life skills to skills in employment readiness and citizenship restoration
 Instrumental support—concrete assistance in task accomplishment, especially with stressful or unpleasant tasks such as filling out applications and obtaining entitlements, providing child care, or providing transportation to support-group meetings and clothing assistance outlets (clothing closets).
 Companionship—helping people in early recovery feel connected and enjoy being with others, especially in recreational activities in alcohol- and drug-free environments. This assistance is particularly crucial in early recovery, when little about abstaining from alcohol or drugs is reinforcing.
Some of the service activities now provided within the rubric of recovery support services include activities performed in earlier decades by people working as outreach workers, case managers, counselor assistants, and volunteers. Recovery support services may be provided by clinically trained professionals as an adjunct to their clinical (assessment and counseling) activities, or they may be delivered by people in recovery who are not clinically trained but who are trained and supervised to provide such support services. They are being provided as adjuncts to other service roles or within specialty roles. Recovery support services are being provided by people working in full- and part-time paid roles and by people who provide these services as volunteers.
Peer-based recovery support roles are growing rapidly in the mental health and addiction service arenas. While there are specific issues related to peer-based services that are distinct within these two fields, the fields have much they can learn from each other.2
Part of what makes the ethical delivery of recovery support services so challenging in the addictions context is that the recovery coach performs so many roles. In service organizations piloting this role, the recovery coach is being described as a(n):
 Outreach worker (identifies and engages hard-to-reach individuals, offers living proof of transformative power of recovery, makes recovery attractive)
 Motivator and cheerleader (exhibits faith in capacity for change, encourages and celebrates recovery achievements, mobilizes internal and external recovery resources, encourages self-advocacy and economic self-sufficiency)
 Ally and confidant (genuinely cares and listens, can be trusted with confidences)
 Truth-teller (provides feedback on recovery progress)

2 Particularly recommended are the following three resources from the mental health field: 1) Mowbray, C.T., Moxley, D.P., Jasper, C.A., & Howell, L.A. (Eds.) (1997). Consumers as providers in psychiatric rehabilitation. Columbia, MD: International Association of Rehabilitation Services; 2) Davidson, L., Harding, C., & Spaniol, L. (Eds.) (2005). Recovery from severe mental illness: Research evidence and implications for practice. Boston: Center for Psychiatric Rehabilitation; and 3) Spaniol. L., Gagne, C., & Koehler, M. (Eds.) (1997). Psychological and social aspects of psychiatric rehabilitation. Boston: Center for Psychiatric Rehabilitation.

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 Role model and mentor (offers his/her life as living proof of the transformative power of recovery, provides stage-appropriate recovery education)
 Planner (facilitates the transition from a professionally directed treatment plan to a consumer-developed and consumer-directed personal recovery plan)
 Problem solver (helps resolve personal and environmental obstacles to recovery)
 Resource broker (links individuals/families to formal and indigenous sources of sober housing, recovery-conducive employment, health and social services, and recovery support; matches individuals to particular support groups/meetings)
 Monitor (processes each client’s response to professional services and mutual-aid exposure, to enhance service/support engagement, reduce attrition, resolve problems in the service/support relationship, and facilitate development of a long-term, sobrietybased support network; provides periodic face-to-face, telephonic, or email-based monitoring of recovery stability and, when needed, provides early re-intervention and recovery re-initiation services)
 Tour guide (introduces newcomers into the local culture of recovery; provides an orientation to recovery roles, rules, rituals, language, and etiquette; opens opportunities for broader community participation)
 Advocate (helps individuals and families navigate complex service systems)
 Educator (provides each client with normative information about the stages of recovery; informs professional helpers, the community, and potential service consumers about the prevalence, pathways, and styles of long-term recovery)
 Community organizer (helps develop and expand available recovery support resources, enhances cooperative relationships between professional service organizations and indigenous recovery support groups, cultivates opportunities for people in recovery to participate in volunteerism and other acts of service to the community)
 Lifestyle consultant/guide (assists individuals/families in developing sobriety-based rituals of daily living, encourages activities (across religious, spiritual, and secular) frameworks that enhance life meaning and purpose)
 Friend (provides sober companionship, a social bridge from the culture of addiction to the culture of recovery) (White, 2004a)
The fact that these functions overlap with other helping roles, including that of the addictions counselor, raises the potential for role ambiguity and conflict. Agencies experimenting with these new roles insist that the recovery coach is NOT a:
 sponsor,  therapist/counselor,  nurse/physician, or  priest/clergy (does not respond to questions of religious doctrine nor proselytize a
particular religion/church) (See White, 2006a,c).

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Role Boundary Integrity: The RC is NOT a: Sponsor (or equivalent)

You are moving beyond the boundaries of the recovery
coach role if you:
 Perform AA/NA or other mutual-aid group service work in your RC role
 Guide someone through the steps or principles of a particular recovery program
 Diagnose  Provide counseling or refer to your support activities as
“counseling” or “therapy”  Focus on problems/“issues”/trauma as opposed to
recovery solutions
 Suggest or express disagreement with medical diagnoses (including psychiatric diagnoses)
 Offer medical advice  Make statements about prescribed drugs beyond the
boundaries of your training and experience
 Promote a particular religion/church  Interpret religious doctrine  Offer absolution or forgiveness (other than forgiveness
for harm done specifically to you)  Provide pastoral counseling

People serving as recovery coaches, rather than being legitimized through traditionally acquired education credentials, draw their legitimacy from experiential knowledge and experiential expertise (Borkman, 1976). Experiential knowledge is information acquired about addiction recovery through the process of one’s own recovery or being with others through the recovery process. Experiential expertise requires the ability to transform this knowledge into the skill of helping others achieve and sustain recovery. Many people have acquired experiential knowledge about recovery, but only those who have the added dimension of experiential expertise are ideal candidates for the role of recovery coach. The dual credentials of experiential knowledge and experiential expertise are bestowed by local communities of recovery to those who have offered sustained living proof of their expertise as recovery guides (White & Sanders, 2006). The recovery coach works within a long tradition of wounded healers—individuals who have suffered and survived an illness or experience who use their own vulnerability and the lessons drawn from that process to minister to others seeking to heal from the same condition (White, 2000a,b; Jackson, 2001).

Recovery coaching at its best offers dimensions of recovery support not available from other service roles. We asked individuals from three states (Pennsylvania, Connecticut, and Texas) who had experienced recovery coaches what these recovery coaches contributed to their early recovery experiences. Here are some of their responses.

My recovery coach builds me up and makes me feel like I am someone and I can accomplish anything I set my mind to. He provides his experience in recovery and his strength and hope.

Support. It's comfortable to have someone behind me—I don't think I could do it on my own. They always help me to look at things differently.

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My recovery coach is 100% real. She has been there and done that. She understands me and knows where I’m at in this point in my life. She knows exactly what to say and do for me to build me up and keep me strong. It's like we are on the same level and she is here to help me move on and get to the next step in my recovery and in my life.
He gave me a little self-esteem. He asked me, was I ready? I was able to share my past. He helped place me in the Mentor Plus program. He walked me through. He told me it would not be easy.
Recovery coaching has helped me set goals in my life. It has also taught me to be accountable for my actions. The coach didn’t really give advice, more like guidance to make better decisions on my own.
She helped me paint a picture that I am not alone, and that there are a lot of recovering addicts out there and they actually have a lot of clean time. I didn't know that before.
I wanted to become a responsible daughter and mother and a respected and productive member of the community. I started doing anything and everything for my recovery. One of the most important things was that I got mentors for the Mentor Plus program. They came to see me every week, eventually twice a week. They gave me direction and were there to support me.
His demeanor of recovery showed me I could get what he has.
Recovery coaches, particularly those serving in this capacity as volunteers, are also quite explicit in what they get out of this service process.
I like working with people and being able to offer encouragement and support. It’s very rewarding to see people start getting their lives back. Sometimes I see people who don’t make the right choices, and that can be frustrating, because I remember what that was like and I feel for them. It helps me to remain grateful for how much better my life is now that I’m in recovery, and I try to pass that message on to them. I am a part of a wonderful process, and helping others helps me more than I can say.
In helping individuals build and rebuild recovery capital, I have learned, not only a lot about these people, but a lot about myself.
Today I know that I don’t know. In letting someone in on that secret, it reassures them that it is okay not to be all knowing and all powerful.
In being a recovery coach, I am able to make a small dent in the world around me and a huge change in my own life.
Personally, I love what I do. I have been helping people in recovery since the beginning of my recovery in 1989. I have been blessed to have such a great appreciation for helping others that it has become a part of me. There is no greater feeling than to help someone out of the gutter where I came from and see them grow.
I feel I am giving back by helping assist others in their recovery process. By practicing what I preach, I am able to build and nurture areas of spiritual growth in my life. I am

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able to maintain a sense of integrity and character. Working as a recovery coach has helped me evaluate strengths and weaknesses and improve my listening skills. I feel trusted and valued as a mentor when people allow me to help them reach their goals. I feel special.
When that ‘light’ comes on, it is so exciting to witness. I do recovery coaching for selfish reasons…I’m looking for more ‘light.’
Recovery coaching is in its frontier stage. The role is being defined differently around the country based on the unique needs of particular communities and particular client populations. That variability is both a source of strength (responsiveness to the particular needs of individuals, families, and communities) and a source of vulnerability (the lack of consistent role definition and prerequisites). Orientation, training, and supervision protocols for recovery coaches are in an early stage of development.
The excitement about the recovery coach’s role is tempered by concerns about potential conflicts with other service roles, and concerns about harm that might come to recipients of recovery support services due to incompetence or personal impairment on the part of the recovery coach—concerns that apply to all health and human service roles. There are several characteristics of recovery support services that influence the vulnerability of consumers and providers of peer-based recovery support services.
First, recovery support needs span the periods of pre-recovery engagement, recovery initiation, recovery stabilization, and recovery maintenance. As such, these service relationships last far longer than the counseling relationships that are the core of addiction treatment, are far more likely to be delivered in the client’s natural environment, and often involve a larger cluster of family and community relationships.
Second, recovery support relationships are less hierarchical (less differential in terms of power and vulnerability) than the counselor-client relationship, involve different core functions, and are governed by different accountabilities. Given these factors, the ethical guidelines that govern the addiction counselor are often not applicable to the recovery coach. Efforts to impose ethical standards from traditional helping professions might inadvertently lead to the overprofessionalization and commercialization of the role of recovery coach and recreate the very conditions that created the need for peer-based recovery support services. Ethical guidelines for recovery coaches must flow directly from the needs of those seeking recovery and from the values of local communities of recovery.
Third, individual consumers of peer-based recovery support services differ in the kind of nonclinical support services they need, and it is not uncommon for the same person to need different types of support services at different stages of his or her addiction and recovery careers. This requires considerable care in evaluating support service needs, delivering those services within the boundaries of one’s knowledge and experience, and knowing how and when to involve people in other service roles.
Fourth, peer-based recovery support services can constitute an adjunct to addiction treatment (for those with high problem severity and low recovery capital) or an alternative to addiction treatment (for those with low or moderate problem severity and moderate or high recovery capital). This requires considerable vigilance in determining service needs and providing services only within the boundaries of one’s competence, and skill in making necessary referrals in a timely manner.

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All of these conditions underscore the need for a clear set of ethical values and standards to guide the delivery of peer-based recovery support services.
The topic of ethics may be a relatively new one for recovery coaches who have never worked within or received services from an addiction-related service agency. Before proceeding to a discussion of how best to make decisions in the face of ethical dilemmas, we must further enhance our understanding of what we mean when we say that an action of a recovery coach is ethical or unethical. At its most primitive level, aspiring to be ethical involves sustained vigilance in preventing harm and injury to those to whom we have pledged our loyalty. This meaning is revealed through four terms: Iatrogenic, Fiduciary, Boundary Management, and Multi-party Vulnerability.
Iatrogenic means unintended, treatment-caused harm or injury. It means that an action taken to help someone, possibly with the best of intentions, actually resulted in injury or death. Can you think of an example of such an action? There is a long history of such insults in the history of addiction treatment, e.g., mandatory sterilizations, withdrawal using chemo- and electroconvulsive shock therapies, psychosurgery (e.g., lobotomies), and all manner of drug insults (e.g., treating morphine addiction with cocaine). It is easy today to look back on such “treatments” and wonder “What were they thinking?!” And yet history tells us that it is hard to see such potential injuries close-up. Given the new frontier of recovery coaching, we must be vigilant to quickly weed out well intended actions that harm one or more parties. This potential for harm also underscores the importance of seeking guidance from other recovery coaches and from supervisors.
Fiduciary—a word whose roots are linked to those of the word “faith”—describes relationships in which one person has assumed a special duty and obligation for the care of another. This word is a reminder that the relationship between the recovery coach and those to whom he or she provides services is not a relationship of equal power: It is not solely a supportive friendship. “Fiduciary” implies that one person in this relationship enters with increased vulnerability requiring the objectivity, support, and protection of the other—like a relationship we would have with our own physician or attorney. While the power differential between the recovery coach and those whom he or she coaches is less than that between a surgeon and his or her patient, the recovery coach can still do injury through what he or she does or fails to do. And so these relationships are held to a higher level of obligation and duty than would be friendships that are reciprocal in nature.
Boundary Management encompasses the decisions that increase or decrease intimacy within a relationship. This is an area of potentially considerable conflict between recovery support specialists and traditional service professionals. Where traditional helping professions (physicians, nurses, psychologists, social workers, addiction counselors) emphasize hierarchical boundaries and maintaining detachment and distance in the service relationship, peer-based services rely on reciprocity and minimizing social distance between the helper and those being helped (Mowbray, 1997). While addiction professionals and peer-based recovery support specialists both affirm boundaries of inappropriateness, they may differ considerably in where such boundaries should be drawn.

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We might view the relationship between recovery coaches and those they serve upon an intimacy continuum, with a zone of safety in which actions are always okay, a zone of vulnerability in which actions are sometimes okay and sometimes not okay, and a zone of abuse in which actions are never okay. The zone of abuse involves behaviors that mark too little or too great a degree of involvement with those we serve. Examples of behaviors across these zones are listed in the chart below. Place a checkmark for each behavior based on whether you think this action as a recovery coach would be always okay, sometimes okay but sometimes not okay, or never okay.

Table 1: Recovery Coaching: An Intimacy Continuum

Behavior of Recovery Coach in Recovery Support Relationship

Zone of Safety
(Always Okay)

Giving a gift Accepting a gift Lending money Borrowing or accepting money Giving a hug “You’re a very special person” “You’re a very special person to me.” Invitation to a holiday dinner Sexual relationship Sexual relationship with a mentee’s family member Giving your cell phone number Using profanity Using drug culture slang “I’m going through a rough divorce myself right now.” “You’re very attractive.” Addressing the person by his/her first name Attending a recovery support meeting together Hiring the person to do work at your home.

Zone of Vulnerability
(Sometimes okay; Sometimes not okay)

Zone of Abuse (Never Okay)

Ethical issues that can arise in situations like those listed above will be explored later in this paper.

Multi-party Vulnerability is a phrase that conveys how multiple parties can be injured by what a recovery coach does or fails to do. These parties include the person receiving recovery support services, that person’s family and intimate social network, the recovery coach, the organization for which the recovery coach is working, the recovery support services field, the larger community of recovering people, and the community at large.

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It is easy for organizations providing recovery support services to make assumptions about ethical behavior and misbehavior that turn out to be disastrously wrong. Let’s consider five such assumptions to open our discussion.
Assumption 1: People who have a long and, by all appearances, high-quality sobriety can be counted on to act ethically as recovery coaches. Fact: Recovery, no matter how long and how strong, is not perfection. We are all vulnerable to isolated errors in judgment, particularly when we find ourselves isolated in situations unlike any we have faced before.
Assumption 2: People hired as recovery coaches will have common sense. Fact: “Common sense” means that people share a body of historically shared experience that would allow a reasonable prediction of what they would do in a particular situation. The diversity of cultural backgrounds and life experiences of people working as recovery coaches provides no such common foundation, and behavior that is common sense in one cultural context might constitute an ethical breach in another.
Assumption 3: Breaches in ethical conduct are made by bad people. If we hire good people, we should be okay. Fact: Most breaches in ethical conduct within the health and human service arena are made by good people who often didn’t even know they were in territory that required ethical decision making. Protecting recipients of recovery support services requires far more than excluding and extruding “bad people.” It requires heightening the ethical sensitivities and ethical decisionmaking abilities of good people.
Assumption 4: Adhering to existing laws and regulations will ensure a high level of ethical conduct. Fact: The problem with this assumption is that what is legal and what is ethical do not always coincide. There are many breaches of ethical conduct about which the law is silent, and there might even be extreme situations in which to do what is legally mandated would constitute a breach of ethical conduct resulting in harm or injury to the service recipient. It is important to look at issues of law, but we must avoid reducing the question, “Is it ethical?” to the question, “Is it legal?”
Assumption 5: Ethical standards governing clinical roles (e.g., psychiatrists, psychologists, social workers, nurses, addiction counselors) can be indiscriminately applied to the role of recovery coach. Fact: There are considerable areas of overlap between ethical guidelines for various helping roles, but ethical standards governing clinical work do not uniformly apply to the RC role. This potential incongruence is due primarily to the nature of the RC service relationship (e.g., less hierarchical, more sustained, broader in its focus on non-clinical recovery support service needs) and to its delivery in a broader range of service delivery sites.
Assumption 6: Formal ethical guidelines are needed for recovery coaches in full-time paid roles but are not needed for recovery coaches who work as volunteers for only a few hours each week. Fact: Potential breaches in ethical conduct in the RC role span both paid and voluntary roles. The question recovery support organizations are now wrestling with is whether volunteer and paid RCs should be covered by the same or different ethical guidelines.

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