“What is the best approach to the supervision of peer recovery support service specialists within the addictions field?” is a question that, at present, remains unanswered.
In earlier communications, I have disseminated papers that outlined the history, theory, and science of peer recovery support services; delineated the roles of addiction counselor, Twelve-Step sponsor, and recovery coach; detailed linkage procedures to recovery mutual aid organizations and other recovery community institutions; depicted the value of peers in pre-treatment outreach and engagement; described the integration of peer recovery support within professional treatment settings and recovery community centers; and reported on the integration of peer recovery support services within allied systems of care. Peer recovery support specialists—people credentialed by lived experience and on-the-job training—are now being integrated into a wide variety of settings and are delivering services across the stages of long-term addiction recovery. But questions remain about how such services are best supervised even as work progresses on defining the core competencies of peer supervision. A recent trend has been the requirement that peers be provided “clinical supervision.”
Traditional clinical supervision within the context of addiction treatment has many components, but at its core, and at its best, it provides oversight of the screening, assessment, diagnosis, treatment planning, and treatment delivery process, with a particular focus on the quality of the helping relationship. Modeled from supervision within the fields of psychiatry, psychology, and social work, addiction professionals and the individuals and families they serve have benefited greatly from this clinical supervision process. So why not extend this same clinical supervision to peer recovery support specialists? Here’s why.
Regardless of title (e.g., recovery support specialist, recovery coach, peer specialist, etc.), peer recovery support services are not a “clinical” activity in the sense that they do not involve processes of clinical assessment, diagnosis, treatment planning, or the delivery of professionally-directed treatment services. Any time they drift into this clinical domain, the peer helper is migrating beyond the boundaries of his or her education, training, and experience in ways that could inflict inadvertent harm to those being served. “Clinical supervision” of peer workers threatens to both turn them into wannabe therapists and pull them from activities for which they are best suited and which could have the greatest impact on long-term recovery outcomes.
My personal concern at the moment is that we as a field are not recognizing the difference between clinical supervision and the type of supervision needed for peer recovery support services. As noted, the former has a primarily intrapersonal focus. In contrast, the latter has a much great focus on the ecology of recovery—removing personal and environmental obstacles to recovery, assertive linkage to recovery mutual aid groups and other recovery support institutions, navigation of the larger culture of recovery, providing stage-appropriate recovery education to individuals and families, conducting ongoing recovery check-ups, and offering guidance to improve the quality of personal/family life in long-term recovery. While all helping roles involve emotional support, peer services are best delivered with an interpersonal focus that nests recovery within the context of family and community—including changing environmental conditions to enhance recovery outcomes. Supervision must help peer helpers forge links between personal needs and community needs—bridging personal/family support with advocacy at the community level and beyond.
Given these differences, I think the misapplication of traditional clinical supervision to the delivery of peer recovery support services will destroy the true potential of this role in supporting long-term recovery. What do you think?

Post Date December 1, 2017 by Bill White



I have tremendous respect for the work Dr. Alan Marlatt, Dr. Dennis Daley, Terrence Gorski, and others have done pioneering the field of relapse prevention (RP), but I have always been troubled by the relapse language and making RP a focal point in addiction treatment. My concern is threefold. First, the lapse/relapse language is drawn from moral rather than medical discourse and drips with centuries of stigma and contempt that have long been heaped on people experiencing alcohol and other drug-related problems (see earlier blog). Second, characterizing all AOD problems and related disorders as “chronically relapsing” misrepresents the natural course of such problems (grossly underestimating recovery stability and durability) in a way that increases personal, therapeutic, and cultural pessimism regarding the potential resolution of such conditions (see earlier blog). Third, and the focus of the present essay, the RP lens risks inadvertently casting personal and professional attention on deficits and vulnerabilities rather than assets and casting one’s vision backward (to the potential for resurging pathology) rather than forward (toward a flourishing and meaningful recovery). The image is one of running from something (the beast/dragon images often come to mind) rather than being positively drawn toward something of great value of one’s own choosing.
A lens of recovery management (or recovery enhancement) (RM) has advantages not achieved by the RP framework. The RM shift might be cast as “recovering from” to “recovering to,” with the potential for a process of discovery that transcends the recovery experience—a journey traversing from, to, and beyond. The prepositions here are important. We should build on what has been learned within relapse prevention research and practice while focusing on what makes us come alive rather than on what we most fear. At its most practical level, RP and RM are distinguished by a focus on what is not wanted versus what is desired, e.g., debt counseling versus wealth management, disease management (symptom suppression) versus recovery management (facilitation of healing and wholeness), marriage counseling versus marriage enrichment, a focus on correcting defects of character versus expanding character assets, interests, and social contributions. RP might be thought of as “vulnerability (demon) management”; RM might be thought of as “potential management” (e.g., the cultivation and management of a pleasurable, engaged, meaningful, and contributing life).
The RP to RM shift suggested here is part of a larger transition from pathology and treatment paradigms to a recovery paradigm within the AOD policy and service arenas. I am not suggesting that the nuts and bolts of RP be cast aside, only that it be renamed, reframed, and balanced with an emphasis on building personal, family, and community recovery capital. If recovery is more than the removal of alcohol and other drugs from an otherwise unchanged life, then the focus of recovery support interventions should shift from a strict RP focus (a process of problem subtraction) to an RM focus on achieving global health (a process of addition) and increasing one’s potential for a both personal fulfillment and social contribution (a process of multiplication). There is a difference between the prevention of illness and the promotion, achievement, and transcendence of wellness. The field of primary medicine required centuries to discover this simple maxim, and it is still struggling to grasp its full clinical and social implications. Hopefully, the same will not be true for the alcohol and other drug problems arena.
Of Related Interest and Highly Recommended: Krentzman, A. R. (2013). Review of the application of positive psychology to substance use, addiction, and recovery research. Psychology of Addictive Behaviors, 27(1), 151-65.
Post Date November 24, 2017 by Bill White


When that doctor asked me, ‘Son, how did you get in this condition?’
I said, ‘Hey sawbones, I’m just carrying on an ole family tradition.’
–Hank Williams, Jr., Song Lyric, Family Tradition.
The intergenerational transmission of addiction and related problems has been documented for more than two centuries. Put simply, the children of alcohol and other drug (AOD) dependent parents are at increased risk of developing such problems, even when raised in alternative environments. Risks are amplified when combined with other factors, e.g., adverse childhood experiences, early age of onset of drug use, co-occurring medical or psychiatric disorders, enmeshment in drug-saturated social environments, and limited problem-solving assets.
In earlier publications, my co-authors and I have addressed the sources of such risks as well as potential strategies for breaking intergenerational cycles (e.g., see HERE and HERE). The challenge we faced in proposing potential solutions is linked to a much larger issue. The AOD research establishment has historically focused on illuminating the psychopharmacology of intoxicating substances, cataloguing the pathologies of acute and chronic drug consumption, and describing and evaluating the short-term effects of educational or clinical interventions designed to alter the course of substance use and substance use disorders (SUD). Absent from this research agenda have been rigorous studies to elucidate the prevalence, pathways, styles, and stages of long-term personal and family recovery across cultural contexts. Without such a recovery research agenda, some of the most important questions facing individuals, families, and communities remain both unasked and unanswered.
If, for example, we followed a large community and clinical sample of parents meeting diagnostic criteria for a substance use disorder (SUD) and examined the prevalence of AOD use, risky use, and SUD among their children, what would we discover with regard to the following five questions?
Does recovery of a parent reduce the likelihood of that parent’s children developing a SUD compared to parents who have not achieved recovery?
Does parental recovery increase the likelihood of recovery for any of their children who experience a SUD compared to children of parents who have not achieved remission?
Does parental involvement in professionally-directed addiction treatment or a recovery mutual aid group affect the intergenerational transmission of SUDs and the recovery prognosis of their children?
Does the participation of a child in his or her parent’s addiction treatment or in a family-focused peer recovery support group affect that child’s future vulnerability for experiencing or recovering from a SUD?
For parents who have experienced a SUD, are there parental actions associated with lower SUD risks for their children?
These are not obscure academic questions—the addictionologist’s equivalent of how many brain cells can dance on the head of a pin. They are instead questions of enormous concern to every parent who has experienced an alcohol or other drug problem and to every parent in recovery. It is time, no, past time, for such questions to be answered. If even partial answers to these questions are available, why have they not been widely disseminated to those most directly affected? Is anyone at the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism listening?
Apparently so. McCutcheon and colleagues have just published a NIAAA/NIDA-funded study in the renowned journal, Addiction, that is among the first to explore the questions raised above. The study examined whether the odds of remission from an alcohol use disorder (AUD) increased depending on the existence of relatives in AUD remission. The likelihood of remission was more than three times greater for those related to someone in AUD remission compared to those related to someone with persistent AUD. What remains unclear is whether this remission advantage is a function of heritable traits that increase remission probabilities (i.e., a form of biological recovery capital) or whether this advantage springs from social contagion (e.g., the influence of one family member in recovery upon another family member in need of recovery.) This is the most definitive report to date on the intergenerational transmission of increased odds of recovery from addiction. We have long known that the risk of addiction runs in families; there is now preliminary evidence that this is also true of addiction recovery. Future research may illuminate how the odds of transmitting such resilience may be increased.
Post Date November 17, 2017 by Bill White


Dr. John Kelly and colleagues just published (Drug and Alcohol Dependence, 181, 162-169) a landmark survey that measured the prevalence and pathways of alcohol and other drug problem resolution among adults living in the United States. Major findings from this study include the following.
Recovery Prevalence The just-published Recovery Research Institute (Massachusetts General Hospital) survey found that 9.1% of U.S. adults report they “use to have a problem with alcohol or drugs but no longer do.” This prevalence rate is comparable to earlier epidemiologic studies on rates of remission for alcohol and drug use disorders (See here for a review) and would translate to approximately 22.35 million U.S. adults who have resolved alcohol and other drug (AOD) problems. The rate of remission for substance use disorders in earlier surveys ranges from 5.3% to 15.3% of the adult population—an estimated 25 to 40 million U.S. adults (not including those in remission from nicotine dependence alone).
Variability of Problem Severity Approximately half of those who had resolved an AOD problem reported indicators associated with greater problem severity, e.g., early age of onset of AOD use, multiple drug use, and past arrest.
AOD Problem Resolution and Recovery Identity Of those who reported having resolved an AOD problem, only 46% identify as being “in recovery.” This suggests that people embracing a recovery identity (recovered, recovering, in recovery) are a subset of a much larger pool of people who have resolved AOD problems.
Duration of Problem Resolution Of those who had resolved an AOD problem, 35% reported duration of resolution of 5-15 years, and 29% reported having resolved the problem for more than 15 years. There is a substantial population of American adults in stable, long-term recovery from significant AOD problems.
Assisted versus Unassisted Recovery Of U.S. adults who have resolved AOD problems, 46% resolved these problems without professional treatment or peer recovery support and 54% reported using such supports. Significant differences exist between those with unassisted versus assisted pathways of problem resolution, with the latter associated with greater problem severity, problem complexity (e.g., co-occurring psychiatric diagnosis), and more significant consequences (e.g., criminal justice involvement).
Sources of Assistance The most commonly reported resources used to resolve AOD problems were mutual aid groups (45%) and professional treatment (28%), with 9% reporting use of medication support. While the majority noting use of mutual aid reported participation in Alcoholics Anonymous or Narcotics Anonymous, also evident were other Twelve-Step groups and an increasing variety of secular (women for Sobriety, SMART Recovery, etc.) and religious (e.g., Celebrate Recovery) recovery mutual aid groups. Of those who had resolved AOD problems, 22% reported using new recovery support institutions, e.g., sober residences, recovery community centers, and recovery ministries.
For nearly two decades, recovery advocates have championed two kinetic ideas: 1) Recovery is a reality (for individuals, families, and communities) and 2) There are multiple pathways of recovery and ALL are cause for celebration. The research of Kelly and colleagues offers substantive scientific evidence in support of both propositions.
Kelly, J. F., Bergman, B., Hoeppner, B., Vilsaint, C., & White, W. L. (2017). Prevalence, pathways, and predictors of recovery from drug and alcohol problems in the United States population: Implications for practice, research, and policy. Drug and Alcohol Dependence,181, 162-169.
White, W. L. (2012). Recovery/remission from substance use disorders: An analysis of reported outcomes in 415 scientific studies, 1868-2011. Chicago: Great Lakes Addiction Technology Transfer Center; Philadelphia Department of Behavioral Health and Developmental disAbilites; Northeast Addiction Technology Transfer Center.
Related Reading
Arndt, S., Vélez, M. B., Segre, L., & Clayton, R. (2010). Remission from substance dependence in U.S. Whites, African Americans, and Latinos. Journal of Ethnicity in Substance Abuse, 9(4), 237-248.
Calabria, B., Degenhardt, L., Briegleb, C., Vos, T., Hall, W. Lynskey, M., . . . McLaren, J. (2010). Systematic review of prospective studies investigating “remission” from amphetamine, cannabis, cocaine or opioid dependence. Addictive Behaviors, 35(8), 741-749.
Dawson, D. A., Grant, B. F., Stinson, F. S., Chou, P. S., Huang, B., & Ruan, W. J. (2005). Recovery from DSM-IV alcohol dependence: United States, 2001-2002. Addiction, 100(3), 281-292. doi: 10.1111/j.1360-0443.2004.00964.x
Grella, C. E., & Stein, J. A. (2013). Remission of substance dependence: Differences between individuals in a general population longitudinal survey who do and do not seek help. Drug and Alcohol Dependence, 133(1), 146-153.
Price, R. K., Risk, N. K., & Spitznagel, E. L. (2001). Remission from drug abuse over a 25 year period: Patterns of remission and treatment use. American Journal of Public Health, 91(7), 1107-1113.
Spinelli, C. & Thyer, B. A. (2017). Is recovery from alcoholism without treatment possible? A review of the literature. Alcoholism Treatment Quarterly, DOI: 10.1080/07347324.2017.1355219.
White, W. L., Weingartner, R. M., Levine, M., Evans, A. C., & Lamb, R. (2013). Recovery prevalence and health profile of people in recovery: Results of a Southeastern Pennsylvania survey on the resolution of alcohol and other drug problems. Journal of Psychoactive Drugs, 45(4), 287-296.
Post Date November 3, 2017 by Bill White

October 19, 2017 -Bill White- RECOVERY AND THE EYE OF HISTORY

I received two emails this week, each posing the question: Are recovery management (RM) and recovery-oriented systems of care (ROSC) dead as organizing frameworks for addiction treatment and recovery support? For 15 years, these conceptual rubrics ascended as promising alternatives to ever-briefer, acute care models of addiction treatment. RM and ROSC were among the most important progeny of efforts to extend the organizing center of the addictions field from its historically dual focus on problems (etiological roots and resulting clinical pathologies) and interventions (competing methods of treatment) to a focus on lived solutions (i.e., lessons drawn from the collective experience of long-term personal and family recovery). Questions regarding the future of RM and ROSC are quite legitimate concerns.
RM pilots (see HERE and HERE) generated promising new approaches to treatment and recovery support spanning the arenas of early identification, engagement, and motivational enhancement; comprehensive and continual assessment protocol; partnership models of recovery planning; assertive linkage to indigenous recovery support institutions; the integration of professional and peer-based recovery support services; and post-treatment personal/family recovery check-ups. Most importantly, RM implementation efforts addressed support needs across the stages of recovery: 1) precovery, 2) recovery initiation and stabilization, 3) transition to recovery maintenance, 4) enhanced quality of personal and family life in long-term recovery, and 5) efforts to break intergenerational cycles of addiction and related problems.
The concept of ROSC provided a rationale and a framework for expanding recovery support resources beyond the treatment setting into the very fabric of local communities. ROSC promoted forging the physical, psychological, and social space (recovery landscapes) within which personal and family recovery could flourish. Adopted and adapted at the federal level under the leadership of Dr. Westley Clark at SAMHSA and drawing inspiration from early ROSC efforts in Connecticut and Philadelphia, significant resources were extended to seed ROSC-focused transformations in addiction treatment in the U.S.
The question at present is whether RM/ROSC-related innovations mark a sustainable shift in addiction treatment and recovery support, or if they are one more flavor of the month to be cast into the waste bin of a field known for such fleeting infatuations. The recovery orientation within national drug policy (at ONDCP, SAMHSA, and to the extent that it existed at NIDA and NIAAA) has rapidly dissipated under a new presidential administration whose drug policy efforts to date are marked by delayed promises, at best, and, at worst, a return to failed drug policies of the distant past. Also of concern is the disengagement of the first wave of RM/ROSC champions (e.g., McLellan, Lewis, Boyle, White, Kirk, Evans, Clark, Nugent, Botticelli, and Murthy) due to the assumption of new roles or retirement. The lost visibility of RM/ROSC initiatives at the federal level and the decreased visibility of RM/ROSC champions at a national level spark fears that these concepts will be relegated to a brief footnote within the field’s history.
But there is another side to the RM/ROSC story. The RM/ROSC initiatives launched at the federal level exerted a potentially enduring influence on the field. Addiction professionals from across the U.S. and around the world visited early RM/ROSC pilots in Connecticut and Philadelphia. The Center for Substance Abuse Treatment’s network of Addiction Technology Transfer Centers embraced RM/ROSC and the resulting RM/ROSC monograph series and related training events stirred innumerable state and local RM/ROSC initiatives. The results of these and related efforts are evident in the following:
Key elements of the RM/ROSC model are being positively evaluated by research scientists, e.g., the positive effects of post-treatment recovery checkups.
A second generation of RM/ROSC leaders is providing training and consultation services focused on RM/ROSC implementation across diverse clinical, cultural, and geographical settings.
New strength-based assessment instruments are being developed, e.g., the Assessment of Recovery Capital.
Peer-based recovery support services are being integrated into addiction treatment and allied health and human service organizations.
Traditional abstinence-based addiction treatment organization and harm reduction organizations are evolving from a state of stale rhetorical warfare to efforts of collaboration and integration—aided by staged models of addiction recovery.
Efforts are increasing to integrate addiction treatment and recovery support services within primary health care, the criminal justice system, and the child welfare system.
New financing models are being piloted that support the transition from acute care interventions to RM/ROSC.
Recovery community building efforts are progressing via the growth and diversification of recovery mutual aid organizations, the rise of new recovery support institutions, and the maturing of a new addiction recovery advocacy movement.
No matter what happens at the federal level, the essence of RM/ROSC will prevail, or if lost, be rediscovered in the future. Historically, when addiction-related systems of care collapse, people in recovery and their families and visionary professionals rise up and forge new systems of care and support.
Recovery is more than a personal and family experience; it is a catalytic idea that can transform addiction treatment, allied service organizations, and the communities in which such professional support is nested. The future of RM/ROSC is being written by heroes who are carrying forward this movement at a grassroots level. And change at the grassroots level is ultimately what RM and ROSC are all about. The stakes are enormously high, and the eye of history is watching.

Post Date October 19, 2017 by Bill White

October 13, 2017 -Bill White- DENIAL OF RECOVERY

The social stigma attached to addiction and addiction recovery inflicts innumerable harms to individuals, families, organizations, and communities. Two people in recovery recently emailed me sharing quite different dilemmas—each flowing from stigma-induced caricatures of addiction and recovery.
In the first instance, people had no difficulty believing the individual’s addiction story because of his numerous, and quite public, drug-related falls from grace. Yet these same people withheld belief in his recovery status years into his stable recovery. Rumors periodically spread that he was using again—rumors that seemed impossible for him to source or stop. Normal sicknesses triggered suspicions of drug use. Any time anything went temporarily missing at a family gathering or at his workplace, suspicion immediately turned to him. Job promotions were withheld on the grounds that he might not be able to handle the stress of added responsibilities. People, as if walking on eggshells, perceived him as fragile and that the least stressor might plunge him into his past. He discovered that he was charged more for health insurance and denied life insurance because of answering truthfully about his past treatment for addiction. In all these situations, his addiction status was believed because he fit many of the preconceived notions of what an “addict” looked like, but his recovery status was denied because people believed that permanent recovery from addiction was not possible (e.g., “Once an addict, always an addict”), at least in his case.
In the second instance, a woman reported that she was denied recovery status because people would not believe that she had ever been addicted due to her impeccable appearance, high level of social and professional functioning, and her lack of common addiction consequences (hospitalizations, arrests, etc.). Family and friends attributed any perceived excessive alcohol and drug use on her part to transient job stress, depression, or marital strain and were most uncomfortable seeing her life in terms of addiction and recovery. Professionals in her life (e.g., her physicians, clergy, and varied psychotherapists) all discounted her need for support specific to addiction recovery. Ironically, she encountered similar responses from some members of the recovery mutual aid societies through which she sought help. Many there doubted her addiction status because of the shorter duration of her drug use and the absence of late-stage addiction consequences. Denial of her addiction and thus her recovery status all flowed from the fact that she did not look like or talk like the dominant, socially misconstrued images of an “addict,” nor did her style of recovery match those who lived their lives cloistered within a closed recovery culture.
So you finally achieve what everyone around you has been hoping for only to have few believe that you are actually there, or you spend far too long transcending your own denial or minimization of addiction only to have others convince you that alcohol and other drugs were not your REAL problem. Such are the quandaries and paradoxes people experience in their journeys from addiction to recovery.
That is also why being nested within a community of shared experience, mutual respect, and reciprocal support can be such an important dimension of the recovery process. For some, it takes a village to safeguard the journey out of brokenness to a place of healing and wholeness. The scales of sustained addiction versus sustained recovery are as likely to be tipped by the availability of such healing sanctuaries as by personal characteristics. Part of the job of recovery advocates is creating such sanctuaries and educating the larger community about the real potential for permanent recovery and the growing varieties of recovery experience.

Post Date October 13, 2017 by Bill White

October 6, 2017 -Bill White- PATHWAYS TO FREEDOM

The smallest incidents can illuminate the processes of addiction recovery. My condominium building has long hallways on each floor that extend from each elevator, with the first sections upon exiting the elevators consisting of windows overlooking the marina community and the middle areas of the hallways marked by railings and no windows. The design protects people exiting the elevator from occasional winds and rain, but birds sometimes fly into the hallways and become disoriented and trapped behind the glassed areas. This morning, I found two beautiful woodpeckers, one adult and one very young, repeatedly flying against the glass in their failed efforts to escape. Both, seeing their desired destination through the glass entrapment, were unaware that their path to freedom existed only 15-20 feet away. Marks on the window and feathers on the floor offered testament to their futile efforts. Using a towel, I caught first one and then the other and carried them to the open area of the hallway. The adult woodpecker immediately and speedily flew to the North as it was released from the towel, but the youngster rested on the railing for some time before finally taking less graceful flight to the South. It seemed that the younger bird looked back at me as it flew away. Or did I imagine that?
I later contemplated my encounter with these two beautiful creatures and how their dilemmas were similar to those shared by people seeking recovery from addiction.
Being able to see the desired destination is not assurance that one can or will get there. Like birds repeatedly flying into glass, the risks of injury or death do not deter those addicted from the failed strategies of the past nor do they quell the ultimate hunger to escape.
When we feel most trapped, the paths to freedom can often be found only a few steps away. When we finally escape, we sometimes realize that the path of escape had always been there, but that we could not see it.
Timing matters. Escape comes in its own time. For some, a period of respite to gather strength may be needed before the flight to freedom. One’s personal fate may hinge on the availability of sanctuaries to provide such respite.
There are multiple paths to freedom and they can lead in quite different directions.
For those who would help, it is best to offer informed choices, respecting when and in what direction escape occurs. Your help may or may not be acknowledged.
Am I reading too much into my woodpecker encounters? I will let you decide.
Post Date October 6, 2017 by Bill White