Good human relationships and social connections are potent protections against both physical and mental ill health. In an analysis involving hundreds of thousands of people researchers looked to see to what extent social relationships influenced the risk of death. They found that those who had stronger relationships were 50% less likely to die early. Loneliness and social isolation have significant negative impacts. You want to live a long and healthy life? Get loads of friends.
In the same way, being connected to pro-recovery social networks improve outcomes in addiction treatment. For a variety of reasons, not least because of stigma, those suffering from substance use disorders are often relatively socially isolated. Guidelines consistently recommend connections to peer groups like mutual aid and LEROs, though this has historically not been a priority for some services. For recovery from alcohol use disorders, being part of mutual aid has an impact at least as great as evidenced psychological therapies like cognitive behavioral therapy.
“The evidence suggests that 42 % of participants participating in AA would remain completely abstinent one year later, compared to 35% of participants receiving other treatments including CBT.”Cochrane Review 2020
Researchers from Massachusetts found in a trial of people with alcohol use disorder that the addition of just one person in recovery to their social network resulted in a 27% increased chance of remaining sober in the following year.
“Network support treatment can effect long-term adaptive changes in drinkers’ social networks and that these changes contribute to improved drinking outcomes in the long term.”Mark Litt and Colleagues 2009
There’s little contention in these findings – they are pretty broadly accepted, yet they don’t seem necessarily to have regularly translated into practice, with odd beliefs persisting about mutual aid and a stigma attaching. I have heard some people in influential and powerful positions say some ill-informed and quite dismissive things about mutual aid and peer support, particularly where these interventions abut on treatment. One commentator recently identified recovery organizations as ‘the biggest risk to current drug users’, when the evidence is clear that connection to such groups mitigates risk. Divisive – right? Why should this be?
In the past it was convenient to say that there was no evidence that mutual aid and peer to peer support made any kind of impact but holding that line now would mean you were willfully evidence-avoidant given the accumulating and emerging research on the topic.
Perhaps the resistance is because some professionals feel their status is threatened when patients and clients become empowered outside of traditional hierarchical treatment settings. Fear of loss of power or influence can be a potent motivator. Perhaps too many of us go into the caring professions for the gain we get when we get to care for individuals – gain that evaporates when they no longer need us. Perhaps being asked to accept that mutual aid and peer to peer support have a significant role to play in helping people recover will reflect badly on our practice to date, which has been built on the premise that ‘professional knows best’. There may be genuine fears about risk that create reluctance. Perhaps being wedded solely to harm reduction rather than valuing a spectrum of approaches results in cynical views towards anything else not in that fold. Who knows? – perhaps it’s all these things or none of these things. Whatever is behind the resistance, it’s not helpful. However, it does get called out.
Lived experience and professionals
For instance, the author and broadcaster Darren McGarvey has some reflections about the issue in his book, The Social Distance Between Us, where in the chapter about addiction he refers to, ‘the complex array of class dynamics, institutional resentments and professional jealousies’ that are relevant, controversially suggesting that someone has ‘as much chance of getting well by following the simple suggestions of other addicts from lower class backgrounds as they do by placing themselves in the care of highly qualified middle class professionals.’
Most people do get better from addiction through natural recovery (‘maturing out’ in a variety of ways) and countless others get well in church halls and other meeting rooms via a variety of mutual aid groups, never having to come near treatment services. However, some whose problems seem intractable, complex or life-threatening need more intensive and structured help. I believe such people do best in a partnership where effective treatment is provided in an alliance between the person with the problem and professionals. I believe treatment is likely to be much more effective when underpinned by peer support and when assertive links are made to mutual aid.
Shared decision making happens when there is a partnership between equals and the person’s goals are understood and prioritized. In more and more treatment settings these days, some of the professionals (like me) have lived experience too. Some of us even come from working class backgrounds! When we eliminate power asymmetries between professionals and service users – accepting that the patient and their family have lived expertise, offer meaningful choice (not only which medication to use), accept that the client’s goals may be different from the clinicians and discuss risks and how to mitigate them, we create a rich and fertile field for growth as well as reducing harms.
Sadly, this is not everyone’s experience and there are obstacles and barriers to progress for some people which do come out of outmoded delivery models where the priorities of the service are not in sync with those of the service user and their family. Peer support can certainly help here:
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 alcohol or other drug problems.William White
In those circumstances, the introduction of peer interventions and mutual aid is a no brainer – introducing hope, role modelling, practical support and vital connections to resources that will build recovery capital and insulate against returning to harmful substance use.
This is not easy. It can take time. John F Kelly, in his paper The Protective Wall of Human Community, points out: “It can take up to 8 years and around 4 to 5 treatment/mutual-help participation episodes before adults treated for alcohol or other drug use disorders achieve initially sustained remission.”
Even then, as Kelly says, it can take another roughly five years of continuous remission before the risk of meeting the criteria for substance use disorder drops to the same level as in the general population. On the surface, this sounds daunting – such a long time – but actually it’s hopeful. Peer recovery workers can help individuals stick with the process and hold out hope over long periods of time.
Practitioners can have low expectations of what their clients can achieve because of the negatively reinforcing experience of seeing people destabilize or come to harm. Michael Gossop called this the treatment fallacy – essentially the belief that people don’t recover because professionals rarely see them recover. Recovered people often move out of services. In my service the place fills up on aftercare days with lots of people in longer term recovery. We get to see positive and enduring changes every week. That makes us hopeful in the same way that, for those of us in recovery, our own recoveries make us hopeful and we transmit that hope to patients.
Sharon Reif and colleagues found, in a 2012 review of peer support impact, that studies ‘demonstrated reduced relapse rates, increased treatment retention, improved relationships with treatment providers and social supports, and increased overall satisfaction with the treatment experience.’ When services have recovering people working in them, then hope becomes integrated and expectations rise. When the practitioner has high expectations, better outcomes ensue and the experience of being in treatment is better. In our service retention in treatment for patients (completion rates) increased significantly in the year following the introduction of a managed peer support program.
Bridging to better outcomes
In our service, we are about to introduce a Peer Bridging Program, funded by the local Alcohol and Drug Partnerships and the Scottish Government. One of the drivers for the program, which aims to improve access, retention and outcomes is the fact that referral rates to rehab can vary significantly between individuals in the same team, between teams and services and geographically.
We want to open the doors as widely as we can and even out those access inconsistencies, but also be as integrated as we can to other services, recognizing that recovery journeys are not linear and risks are best managed in integrated systems of care where harm reduction informs all we do, but is not the sum of all we do, particularly where that system includes both peer recovery support and strong and effective links to mutual aid.
We’ll do that by employing people who are experts by experience to act as bridges for patients with substance use disorder to help with journeys into and out of treatment – facilitators for recovery, catalysts for hope and part of a recovery-oriented system of care.
As I say, evidence is accumulating for the value of peer recovery support. One study found that patients who received support from a recovery support navigator were 23% more likely than patients in the services as usual condition to attend treatment within the first 2 weeks post-detox. Engagement and retention in treatment are associated with better outcomes.
We want to know if our Peer Bridging Project will make a difference – to patients, to services and to the peer workers, so we plan to evaluate this and will report our findings. I hope that the evidence we find will help to both support the argument for more lived experience in treatment settings, but also counter those whose voices are raised against such things.