Linking Clients to Healthcare Services

People experiencing problematic substance use are more likely to have comorbid health conditions, including mental and other chronic illnesses.¹¹⁹¹ People experiencing both problematic substance use and chronic disease may have difficulty accessing or remaining in care, which can result in additional medical complications.¹¹⁹² Chronic conditions, including diabetes, hypertension, chronic obstructive pulmonary disease, HIV, and hepatitis C, require ongoing medical care and, in some cases, medication and medication management. Even individuals who do not have chronic diseases should receive preventive screenings and care to ensure they remain healthy.

Figure

One of a counselor's roles is to connect clients with the healthcare resources they want and that meet their needs, including a primary care provider who can support them in developing a plan to manage chronic illness or receive preventive care. Outlined below are steps counselors can take to help clients receive healthcare services that meet their personal needs.

Identifying Providers and Other Resources for Clients

Identifying providers and other resources is a first step to helping clients access health care. Counselors will want to create a list of providers that take various types of insurance and are accepting patients. The more concrete counselors are about what they are looking for, the more likely they will be able to find providers who will meet the needs of their clients. Counselors may have to make several calls to identify providers.¹¹⁹³ The following organizations, individuals, or programs can be useful resources to contact:

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Physicians or nurses, nurse practitioners, or physician assistants

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Pharmacists

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Dentists

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Department of Veterans Affairs (https://www​.va.gov)

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State, county, and municipal health departments

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Hospitals

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Specialists

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Complementary and integrative care (e.g., acupuncturists, chiropractors)

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Programs that offer recorded health messages or access to trained professionals who can answer questions

To identify providers in the area, counselors can¹¹⁹⁴:

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Research providers online.

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Ask others in their network if they have recommendations for providers that they can include in their database.

As counselors contact providers, they will want to ask the following questions (as applicable):

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Is the provider accepting new patients or patients with specific healthcare coverage?

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Where is their office located and what are the hours?

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Can they accommodate someone with a disability?

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Are they affiliated with a specific hospital?

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Do they have experience working with people who are in recovery?

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RESOURCE ALERT: FIND A LOCAL HEALTH CENTER.

Developing a Database of Providers in the Area

With the information they collect, a counselor can create a database highlighting local healthcare providers that they can share with clients. The database can include information about each provider, including practice location, contact information, specialty, and any other notes the counselor collected during the information-gathering process. Counselors should ensure that they regularly update the database to keep it current. Exhibit 4.1 provides a sample matrix counselors can use to collect and organize information.

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EXHIBIT 4.1. Collecting and Organizing Information on Local Providers.

Understanding and Enrolling in Health Insurance

Clients who do not have health insurance will need information about how health insurance works and how to enroll. Exhibit 4.2 includes basic information about how health insurance works.

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EXHIBIT 4.2. Health Insurance 101.

Counselors can help clients identify and contact their state marketplace, which offers information about health insurance plans, including costs and how to enroll, at https://www.healthcare.gov/get-coverage/. Clients can also find local resources about health insurance, including people who can help them apply and enroll, at https://localhelp.healthcare.gov/#intro. Counselors should familiarize themselves with local resources, such as nonprofits or organizations that can support clients in learning about and obtaining health insurance.

For clients who may qualify for Medicaid, counselors can learn more about eligibility, which differs by state, and how to enroll at https://www.usa.gov/medicaid. The Health Resources and Services Administration's “Find a Health Center” search tool can help counselors identify local health centers that allow clients to pay what they can afford, based on their income. The tool can be accessed at https://findahealthcenter.hrsa.gov/.

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RESOURCE ALERT: PUBLIC LIBRARIES.

Connecting Pregnant People With Problematic Substance Use to Care

Use of substances during pregnancy is increasingly common. The most commonly used substances during pregnancy include alcohol, tobacco, and cannabis.¹¹⁹⁷ Mothers with opioid-related diagnoses documented at delivery increased by 131 percent between 2010 and 2017, while the incidence of babies born with withdrawal symptoms, or neonatal abstinence syndrome, increased by 82 percent over the same period.¹¹⁹⁸ The prevalence of cocaine use during pregnancy is also estimated at 1.1 percent during pregnancy.¹¹⁹⁹

The effects of alcohol use and problematic substance use on both the pregnant person and the developing fetus may be significant. For example, pregnant people with problematic substance use are more likely than pregnant people without problematic substance use to have a co-occurring psychiatric illness and postpartum depression.¹²⁰⁰ Inadequate treatment of substance use disorder (SUD) during pregnancy may also result in poor adherence to prenatal care and poor attention to maternal nutrition, poor oral health, and increased risk for infectious diseases, such as hepatitis and HIV, or overdose and death.^{1201,1202,1203}

Adverse effects of problematic substance use on the fetus are similarly wide ranging. Infants born to mothers with problematic alcohol use can have alcohol-related birth defects, including heart, kidney, bone, or hearing problems; alcohol-related neurodevelopmental disorders; or fetal alcohol spectrum disorders.¹²⁰⁴ Also, infants with prenatal opioid exposure may be smaller at birth and have neonatal opioid withdrawal syndrome, a form of neonatal abstinence syndrome, requiring additional medical care.¹²⁰⁵ Babies born to mothers with problematic cannabis use during pregnancy are at higher risk of being born preterm, having low birth weight, or having long-term brain development issues.¹²⁰⁶

The American College of Obstetricians and Gynecologists (ACOG) and the American Society of Addiction Medicine (ASAM) have outlined effective treatments for SUDs during pregnancy, including the need for early universal screening. Screening is particularly important, given that many pregnant people with problematic substance use may not discuss concerns with their providers because of stigma related to substance use during pregnancy and concerns about child welfare involvement. Additionally, ACOG and ASAM note the importance of offering brief interventions, such as engaging a patient in a short conversation, providing feedback and advice, and referring to specialized care, as needed.¹²⁰⁷ As ASAM notes, pregnancy is a unique opportunity to provide broad and necessary medical care for women, including treatment for SUD. Pregnant people should be given priority access to treatment and prenatal care.¹²⁰⁸ Screening for problematic substance use during the perinatal period is also critical to ensuring that women are connected to recovery support.

Counselors should be aware that some states have laws in place that penalize individuals who are pregnant for actions that are interpreted as harmful to their own pregnancies. These policies may punish people for substance use during pregnancy, which may affect whether pregnant people with problematic substance use seek care; some may not seek care out of fear that they may lose parental rights or face criminal penalties.¹²⁰⁹

Counselors should discuss the importance of receiving ongoing perinatal care and obtaining SUD treatment with pregnant clients. Counselors will want to discuss the benefits of receiving care for both the mother and child as well as any concerns a pregnant client may have.

Simply offering education about problematic substance use can improve the health of pregnant people and their babies. In one study, pregnant women with problematic substance use who were offered prenatal care plus education on the benefits of abstinence were compared with pregnant women who also had problematic substance use but who received standard prenatal care only. The authors found that women who received both prenatal care and education reduced their problematic use, and their infants had fewer medical problems than did infants of those women who received only standard prenatal care.¹²¹⁰ The Resource Alert below contains more information about supporting pregnant people with problematic substance use.

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RESOURCE ALERT: SUPPORTING PREGNANT PEOPLE WITH PROBLEMATIC SUBSTANCE USE.

Connecting Clients to Sexual Health Services

Sexual health services are necessary to support the health of clients, as these services can prevent the transmission of HIV and other sexually transmitted infections (STIs) and potentially reduce the number of unplanned pregnancies. As discussed in Chapter 3, studies have indicated that problematic substance use may put people at higher risk of contracting HIV, STIs, or other infections.¹²¹¹ Clients should receive preventive services, such as screenings for HIV, STIs, and cervical cancer. Key sexual health services include¹²¹²:

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Access to birth control options. Offering birth control options, such as long-acting reversible contraceptives, birth control pills, and other types of contraceptives, is effective in reducing the number of unplanned pregnancies and supporting sexual health.

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Access to condoms. Condom distribution programs have been implemented in communities across the country and have been shown to be effective for preventing the spread of HIV and other STIs as well as reducing the number of unplanned pregnancies.¹²¹³

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Access to HIV prevention methods, such as preexposure prophylaxis (PrEP) and postexposure prophylaxis (PEP). PrEP and PEP are effective medications for preventing HIV transmission and are part of sexual health programs nationwide. These medications can be prescribed by primary care providers, community health centers, and other service providers.

People with problematic substance use may also engage in some form of sex work. In an examination of substance use among sex workers in 86 studies from 46 countries, more than a third of sex workers reported lifetime problematic substance use.¹²¹⁴ Sex workers who also have problematic substance use may be increasingly vulnerable to infectious diseases, including HIV and other STIs, violence, stigma and discrimination, and exploitation.¹²¹⁵ In order to support continued sexual and reproductive health among individuals in recovery who are involved in sex work, counselors should encourage clients to engage in culturally responsive, trauma-informed health care. (Chapter 3 includes additional information related to substance use and sex work.)

People with problematic substance use may also engage in sexual behavior to avoid uncomfortable feelings, also known as sexual acting out. Problematic substance use may increase or lead to this type of sexual activity. Counselors should be aware of these issues, and ensure that they are connecting clients to sexual health services that can support their unique needs.

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RESOURCE ALERT: SEXUAL HEALTH SERVICES.

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RESOURCE ALERT: RESOURCES TO SUPPORT SEXUAL HEALTH.

Counselors can help clients obtain sexual health and reproductive health care provided by gynecologists and obstetricians (OB-GYNs). To do this, counselors can help educate their clients about how to reach out to and engage with OB-GYN providers. For example, counselors can help them call their insurance company to identify a list of OB-GYNs in their network and encourage them to call providers to make an appointment.

Addressing Barriers to Receiving Sexual Health Services

Clients may face barriers in accessing sexual health services, such as a lack of transportation, limited knowledge about sexual health, and stigma related to problematic substance use. Below is information that can help counselors learn more about these barriers.

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Transportation barriers: Transportation can affect clients' access to healthcare services and can result in missed appointments, increased costs, or overall poorer health outcomes.¹²¹⁶ The following includes information about opportunities and organizations that can help clients address transportation barriers¹²¹⁷:

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Some local health departments, health and social service providers, and volunteer-led organizations offer transportation subsidies for those lacking funds to travel to and from healthcare appointments. Community organizations may also have volunteers available to provide clients with rides to and from appointments.

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Communities may offer free or reduced-cost monthly bus passes; shared van services for seniors, people with language barriers, and individuals with vulnerable legal status; and funds for gas cards for individuals with private vehicles but who are not able to afford gas to attend appointments.

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Some mobility service providers offer programs to address transportation barriers. For example, Uber Health offers rides to women's health appointments for those with no or limited fixed-route transit service.

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Lack of knowledge about sexual health and substance use: Clients may have limited knowledge about the importance of sexual health, including factors that may put people with problematic substance use at higher risk for contracting HIV. Counselors can help clients build their knowledge about sexual health by:

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Connecting them to resources that provide comprehensive sexual education, including HIV and STI prevention and birth control options.

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Additional information and resources on sexual health can be found at https://www​.cdc.gov/sexualhealth​/Default.html.

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Stigma related to problematic substance use affecting sexual health care: Research indicates that some healthcare providers have biases related to people with a history of problematic substance use, which can affect the quality of care they receive.¹²¹⁸ These biases may create barriers for clients to receive sexual health services. Also, reluctance to get tested for HIV and fear of being stigmatized by healthcare providers may result in delays of HIV diagnoses for clients in recovery.¹²¹⁹ Delays in HIV testing can have devastating long-term effects for the client. Counselors can address stigma-related barriers by doing the following:

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Talking with clients about the importance of receiving sexual health services and how they can respond if they have a negative experience with a provider during an appointment

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Helping clients to identify providers who have experience working with people in recovery

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Offering to share information about problematic substance use with providers

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RESOURCE ALERT: SEXUAL HEALTH EDUCATION.

Nutrition

Problematic substance use can compromise an individual's nutritional state and affect their dietary habits.¹²²⁰ Proper diet and nutrition education have been shown to be beneficial for individuals in recovery. As counselors assess a client's nutritional status and eating habits, they should understand the unique ways that various drugs and alcohol can affect an individual's nutritional health, and how these factors can affect the delivery of care.^1221,1222

Guidelines for providing nutrition services in SUD treatment settings have not been standardized.¹²²³ Further, only a small percentage of treatment programs have a registered dietitian nutritionist as part of the treatment team.¹²²⁴ Nonetheless, recommended guidelines are emerging, and this section will summarize the components of assessing a client's nutritional status, the potential impact of specific drugs on nutritional health, and strategies to help clients improve dietary well-being.

Setting Nutritional Goals

With any client, a set of general nutritional goals can help to support treatment planning, including encouraging good hydration and appropriate physical exercise, regulating blood sugar levels, normalizing eating habits and times, and promoting sufficient intake of vitamins and proteins. ^1243,1244

Researchers have recently suggested additional strategies that can help clients improve nutritional health. Offering nutrition education to clients has shown positive results in a variety of settings.¹²⁴⁵ A weekly education session with a group of clients has been recommended as a cost-effective alternative to one-on-one discussions, if a registered dietitian nutritionist can be identified to lead the session.^1246,1247 (The “Resource Alert: Additional Information on Nutritional Assessment” contains a link to a free dietary expert search engine.) Counselors can also advocate for healthier food options within their treatment programs, rather than more popular (but less healthy) options, such as burgers, pizza, sodas, or coffee.^1248,1249

Counselors can encourage clients to alter food and beverage intake patterns if poor nutrition is identified, switching to healthier sources of dietary staples, such as^1250,1251:

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Complex carbohydrates, including whole-grain breads and cereal, whole fruit, potatoes, vegetables, beans, and nuts.

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Healthy fats, including fish, low-fat dairy products, seeds, nuts, and omega fatty-acid supplements.

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Fiber, including oatmeal, nuts, beans, whole wheat bread, brown rice, apples, carrots, and tomatoes.

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Food containing vitamins and minerals, including whole-grain breads and cereal, beans, peas, peanuts, seeds, dairy, fruits, and vegetables.

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Hydration, including water, watermelon, strawberries, cucumbers, soup, low-fat milk, unsweetened plant-based milks, and low-sugar sports drinks.

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Proteins, including fish, chicken, eggs, low-fat dairy products, beans, tofu, lentils, and nuts.

Some clients will not have the resources to readily access healthy foods. These clients may need help accessing programs designed to help them purchase or access nutritious foods. Such programs may include the following:

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Local food banks can offer support to people in need of healthy foods. Counselors can research local food banks through the Feeding America^® database at https://www​.feedingamerica​.org/find-your-local-foodbank.

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The Supplemental Nutrition Assistance Program provides support to families to purchase healthy food. More information can be found at https://www​.fns.usda​.gov/snap/supplemental-nutrition-assistance-program.

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The Special Supplemental Nutrition Program for Women, Infants, and Children provides supplemental foods, healthcare referrals, and nutrition education to low-income pregnant, breastfeeding, and nonbreastfeeding postpartum people, and to infants and children up to age 5. The program is operated through local providers. More information can be found at https://www​.fns.usda.gov/wic.

Researchers have also offered recommendations for approaches to clients undergoing specific types of dietary issues.¹²⁵²

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For clients experiencing loss of appetite, counselors should help them to connect with a provider who can assess for co-occurring nutritional disorders, and encourage clients to focus on healthy snacks and whole-food options.

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If the client is experiencing weight loss or weight gain, counselors should encourage them to attend educational classes to learn about proper meal preparation and eating habits, consider monitoring their dietary intake and their cravings with a food diary, have healthy food and drink options available when they are in the treatment setting, and if possible, refer them to a dietitian or nutritionist to develop a plan for healthier eating. Clients should also follow up with a medical provider to determine underlying causes of weight change.

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In cases of constipation, counselors should encourage clients to increase water intake, along with foods rich in fiber (unprocessed plant-based foods); regular exercise can also help, including walking.

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Sufficient water intake can also help to address dehydration often seen with substance use, as can fluids that contain electrolytes and reducing intake of caffeine.

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For clients with poor oral health issues, fluids are again important for hydration, along with encouraging proper oral hygiene, and possibly considering softer foods. Regular dental care, such as visiting the dentist every 6 months, is important to supporting oral health.

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For clients experiencing cravings, nutritious snacks that contain protein, fruits, vegetables, and complex carbohydrates (whole wheat or whole grain) may be helpful.

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RESOURCE ALERT: ADDITIONAL INFORMATION ON NUTRITIONAL ASSESSMENT.

Exercise

Research supports the many benefits of even modest exercise, such as walking, for physical and mental health, and physical activity has also been linked to recovery from problematic substance use. Even brief amounts of physical activity (i.e., 10 minutes) can decrease substance use cravings¹²⁵³ and symptoms of withdrawal.¹²⁵⁴ Participation in meaningful and structured activities, such as regular exercise, should be a key part of any long-term recovery plan.

Getting Clients Motivated

The first step to encouraging clients to get more exercise is to talk with them about their own physical activity levels and how regular exercise can support their long-term recovery. To start the conversation, counselors can ask clients the following questions¹²⁶⁶:

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How much physical activity do clients get in an average week? Once counselors have an idea of their clients' current activity level, they can suggest small changes to help them become more active.

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What are some things the client's family or friends like to do together? Counselors can offer tips for getting the whole family more active, like turning commercials into family fitness breaks.

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Are there activities clients would like to be able to do? For example, maybe the client has always wanted to join a pool and learn to swim. Knowing the client's motivations can help counselors work with them to set achievable goals.

Next, let clients know how much exercise they should get each week to remain healthy (Exhibit 4.3).

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EXHIBIT 4.3. How Much Exercise Is Enough?

Offer resources that clients can use to inform them about the benefits of exercise and how to get started.

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RESOURCE ALERT: GETTING STARTED WITH AN EXERCISE PLAN.

Motivational Strategies

Motivation for exercise has been found to be a common barrier to increasing physical activity among individuals who have substance use–related problems.¹²⁶⁸ Clients may describe barriers that they face in starting and continuing an exercise plan. There are several strategies that can increase a client's motivation to exercise. These include:

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Encouraging clients to increase their physical activity through exercise sessions. By connecting clients to opportunities for structured exercise sessions, counselors can encourage clients to exercise regularly, while they receive social support in the process. These activities can also create a measure of accountability, which may increase motivation for clients to exercise. Strategies may include offering counselor-driven, skill-based groups (groups where counselors help clients learn new skills) along with these exercise sessions.¹²⁶⁹ Some communities have “recovery gyms,” which offer physical and social support, including customized exercise programs for those in recovery from problematic substance use. Counselors can research whether there are recovery gyms in their community that can help support clients.

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Providing motivational enhancement therapy (MET). MET can be used to increase client motivation around exercising.¹²⁷⁰ Through this approach, clients mobilize their own internal and external resources to facilitate change. MET uses such approaches as motivational interviewing, open-ended questions, and other common counseling techniques to support clients.^1271,1272

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RESOURCE ALERT: RECOVERY GYMS AS A RESOURCE FOR RECOVERY.

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RESOURCE ALERT: TOOLS FOR TALKING ABOUT PHYSICAL ACTIVITY.

Healthy Sleep Habits

Sleep disturbances are common among individuals who have problematic substance use. In addition to sleep disturbances that result from the effects of substances on arousal levels or as part of withdrawal, substance use–related problems can cause psychological distress that negatively affects sleep.¹²⁷³ For some individuals, sleep disturbances can persist into early recovery.¹²⁷⁴ When working with individuals in recovery, counselors should assess for sleep-related issues and make recommendations about behavioral strategies that clients can implement immediately to address sleep disturbances. They should also refer clients to their primary care doctor to assess for any related medical issues that may be affecting the quality of their sleep, such as sleep apnea.

Educating Clients About Healthy Sleep Habits

Counselors should discuss healthy sleep habits, also known as sleep hygiene, with clients. This can help clients reduce their sleep-related disturbances and improve their sleep efficiency and quality. Exhibit 4.4 provides recommendations for nonpharmacological strategies to enhance sleep that can be given to clients as an educational handout and then explored within the context of a conversation about lifestyle changes that support ongoing recovery. If sleep disturbances are severe, counselors should coordinate a referral with their clients' primary care physician to a sleep medicine specialist. Medical providers who specialize in sleep can evaluate clients for sleep apnea and restless legs syndrome. A counselor trained in cognitive–behavioral therapy for insomnia can help address thoughts, feelings, and behaviors that contribute to sleep difficulties.

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EXHIBIT 4.4. Healthy Sleep Habits^1275,1276.

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RESOURCE ALERT: SLEEP AND SUDS.

Role of Safe and Stable Housing

Access to safe and stable housing supports a person's recovery from problematic substance use. Housing instability, or the inability to pay for housing and the threat of losing housing, results in significant stress that can trigger recurrence of substance use. Additionally, problematic substance use can increase a person's risk of homelessness or housing instability. Studies indicate that SUD is a leading cause of homelessness in the United States.¹²⁷⁹ Those with problematic substance use may have more difficulty obtaining and maintaining stable housing due to discrimination, having a criminal background or poor credit history, and systemic disenfranchisement.^1280,1281 To support clients in this area, counselors should be aware of the barriers clients may face in obtaining stable housing.

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RESOURCE ALERT: ADDRESSING HOUSING BARRIERS FOR CLIENTS WITH A CRIMINAL HISTORY.

For individuals experiencing both homelessness and problematic substance use, it can be difficult to sustain recovery.^1282,1283 Research indicates that those facing housing instability or homelessness may be less likely to continue medications for SUDs¹²⁸⁴ and for psychiatric disorders.¹²⁸⁵ This can include those considered “marginally housed,” or people temporarily staying with relatives, sleeping in their car, or with no current place to stay, though they may not consider themselves homeless. Additionally, people experiencing homelessness who are taking medications for SUDs still experience barriers to housing because of misconceptions about these medications.^1286,1287

Several types of housing models and programs exist that may address the needs of those recovering from problematic substance use.¹²⁸⁸ These models, described below, may focus on people recovering from substance use–related problems or address other needs, such as homelessness or income barriers. Each program has a different philosophical approach and eligibility requirements.

Housing Types Designed for Individuals In Recovery

Recovery housing, transitional housing, and permanent supportive housing programs are designed specifically to meet the needs of those in treatment or recovering from problematic substance use.

Counselors should be aware that some of these models, such as recovery housing, focus on abstinence as the primary pathway to recovery from problematic substance use, and thus, may not be appropriate for all clients.

Recovery Housing

A recovery residence or recovery housing is a safe and healthy, substance-free living environment that supports those in recovery from problematic substance use. The recovery housing approach is based on the belief that individuals who have a history of problematic substance use may benefit from an environment of peer support that emphasizes abstinence.¹²⁸⁹

Recovery housing or residences, regardless of their structure, are centered on peer support and a connection to services that promote long-term recovery. Recovery housing benefits individuals in recovery by reinforcing a substance-free lifestyle and providing direct connections to other peers in recovery, mutual support groups, and recovery support services. Those in recovery residences may take prescribed medications, including medications for SUD, while in the program.¹²⁹⁰

The recovery residence model is based strongly in fostering peer support. In fact, the residences are often peer-led and offer recovery support networks and a strong sense of community.¹²⁹¹ Additionally, some recovery residences that offer higher levels of support also provide life skills development and, in some cases, integrated clinical services. Recovery residences are divided into levels of support based on the type, intensity, and duration of support that they offer.¹²⁹² Exhibit 4.5 contains more information about recovery housing levels of support.

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EXHIBIT 4.5. Recovery Housing Levels of Support.

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RESOURCE ALERT: OXFORD HOUSE™.

In general, recovery housing is regulated by the Fair Housing Law and the Americans with Disabilities Act, which require states to make “reasonable accommodations” for people with disabilities, including people in recovery from problematic substance use.¹²⁹³ The National Alliance for Recovery Residences (NARR) has also developed a national standard that is endorsed by nearly 40 states. NARR also certifies over 3,000 recovery residences according to this national standard.¹²⁹⁴ Also, in 2018, SAMHSA developed best practices for the operation of recovery housing (Exhibit 4.6).

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EXHIBIT 4.6. Best Practices for Recovery Housing.

For more information about how to identify recovery housing in their community, counselors can search for “recovery housing” in their city or state.

Additional sources include local professional organizations, faith communities, social service agencies, and resource manuals.¹²⁹⁶

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RESOURCE ALERT: NARR.

Permanent Supportive Housing

Permanent supportive housing is a model used for individuals or families experiencing homelessness who also have a disability or other co-occurring condition, which can include SUDs. This type of housing offers a combination of housing and services designed for clients experiencing chronic homelessness.¹³⁰⁰ Permanent supportive housing is guided by the principles of Housing First, a philosophy and approach differing from that of recovery housing and transitional housing. The Housing First model emphasizes immediate access to housing with supports and case management, but without the preconditions of abstinence or mandatory participation in supportive services (the box below contains more information about Housing First).

Permanent supportive housing models offer housing choices, work to prevent recurrence of use, and reduce discrimination and stigma of individuals experiencing mental illness and SUDs. SAMHSA's Permanent Supportive Housing Evidence-Based Practices (EBP) KIT lists 12 elements of permanent supportive housing programs that form the guiding principles of these programs (the box below also lists the 12 elements).¹³⁰¹

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WHAT IS HOUSING FIRST?¹³⁰².

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ELEMENTS OF PERMANENT SUPPORTIVE HOUSING PROGRAMS¹³⁰³.

People served through the Housing First model are less likely to have a recurrence to use, as compared with clients who engage in programs that require SUD treatment as a condition of housing.¹³⁰⁴

Housing Programs To Prevent or Address Homelessness

Several programs exist to support people who are currently homeless or at risk of becoming homeless, such as homelessness prevention programs, emergency shelters, and rapid re-housing programs. Domestic violence shelters are designed to support clients who are experiencing intimate partner violence. Eligibility requirements differ by program. Counselors should be aware of these programs, including how to identify related resources in their community.

Homelessness Prevention

Homelessness prevention programs exist in every community and are designed to prevent an individual or family from moving into an emergency shelter or living in a public or private place not meant for human habitation.¹³⁰⁵

Homelessness prevention programs typically offer¹³⁰⁶:

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Financial assistance in the form of rental housing subsidies to help individuals and families cover housing costs.

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Eviction prevention programs that are designed to prevent displacement from rental units. These programs may include financial assistance, legal representation, or mediation services.

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Community-based services that aim to help individuals maintain stable housing by linking them to supportive services, such as eviction prevention and short-term financial assistance, education and job placement assistance, benefits enrollment, and childcare assistance.

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Critical time intervention, which uses comprehensive case management to connect individuals who have severe mental illness and who are being discharged from a psychiatric facility with community-based services to support recovery.

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Proactive screening of populations at heightened risk of homelessness. Individuals and their families are offered follow-up services and tailored support to help them maintain stable housing.

Research supports the use of homelessness prevention programs as an effective means of reducing homelessness.¹³⁰⁷

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UNDERSTANDING COORDINATED ENTRY.

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MASSACHUSETTS HOUSING STABILITY PROGRAMS¹³¹⁰.

Intimate Partner Violence

There is a significant need for shelters or housing to support clients who are experiencing domestic violence and intimate partner violence and/or homelessness. Between 47 and 90 percent of women of reproductive age (15–44 years) with an SUD have experienced intimate partner violence, compared to 1–20 percent in non-SUD populations.¹³¹¹

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RESOURCE ALERT: HUD'S FIND SHELTER TOOL.

Shelters and transitional housing are available for those experiencing domestic violence. Common transitional housing models include¹³¹²:

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Scattered site, where survivors live in an apartment in the community.

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Clustered site, where the program owns a building with units for survivors to live in.

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Communal living, where survivors may have their own room but share a common space.

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RESOURCE ALERT: NATIONAL NETWORK TO END DOMESTIC VIOLENCE.

Rapid Re-Housing

Rapid re-housing is an intervention, informed by the Housing First approach, that offers people or families experiencing homelessness with time-limited financial assistance and personalized housing support. It can help people who are living on the streets or in emergency shelters solve an immediate challenge to obtaining permanent housing, while reducing the amount of time they are homeless. Rapid re-housing also works to link people to community resources that enable them to achieve long-term housing stability.¹³¹³

The National Alliance to End Homelessness' Rapid Re-Housing Works page contains more information about rapid re-housing (https://endhomelessness.org/rapid-re-housing-works/?gclid=EAIaIQobChMIs_7msKie-AIVaP_jBx3PnwHgEAAYASAAEgI4mPD_BwE).

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RESOURCE ALERT: FEDERAL HOMELESSNESS RESOURCES.

Affordable Housing Programs

Counselors should work with clients to provide resources or connect them to a case manager or social worker to help them access affordable housing. This can be a challenging task given the lack of affordable housing, particularly for low-income renters.¹³¹⁴ The National Low Income Housing Coalition found that no state has an adequate supply of affordable and available homes for extremely low-income renters. Extremely low-income renters face a shortage of nearly 7 million affordable and available rental homes; only 36 affordable and available homes exist for every 100 extremely low-income renter households.¹³¹⁵ Resources are available for counselors to help them learn more about housing programs and support clients who may be in need of rental support or public housing (the “Resource Alert: Public and Affordable Housing Resources” contains links to affordable housing).

Public Housing

Public housing is designed to provide decent and safe rental housing for eligible low-income families, the elderly, and persons with disabilities. Public housing can range from scattered single-family houses to apartments. Local housing agencies manage this housing for low-income residents.¹³¹⁶

To be eligible, housing agencies review an individual's or family's annual gross income; whether they qualify as elderly, a person with a disability, or as a family; and whether they are a U.S. citizen or have eligible immigration status.

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RESOURCE ALERT: PUBLIC AND AFFORDABLE HOUSING RESOURCES.

Housing Choice Voucher Program

Through the Housing Choice Voucher program, very low-income families, the elderly, and the disabled are provided a voucher allowing them to afford decent and safe housing. Once eligible, the participant can choose any housing that meets the requirements of the program and is not limited to units located in subsidized housing projects. These vouchers are administered locally by public housing agencies.¹³¹⁷

Eligibility for a housing voucher is determined by the public housing agency based on the total annual gross income and family size and is limited to U.S. citizens and certain categories of noncitizens. Income may not exceed 50 percent of the median income for the county or metropolitan area in which the family chooses to live.¹³¹⁸

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RESOURCE ALERT: HOUSING CHOICE VOUCHERS.

Developing Life Skills To Maintain Recovery

Clients may need assistance with independently conducting certain life activities that will help them maintain their recovery. For example, clients may need to learn how to manage a checking account or how to get a state ID. Such activities are sometimes referred to as instrumental activities of daily living (IADLs). The IADLs include:¹³¹⁹

•

Transportation and shopping: Obtaining groceries and personal care items, shopping for clothing and other items required for daily life, and attending events

•

Managing transportation: Driving or arranging other forms of transport

•

Managing finances: Paying bills and managing financial assets

•

Meal preparation: Ensuring that steps required to cook a meal are completed

•

Housecleaning and home maintenance: Cleaning kitchens after eating, maintaining living areas so that they are reasonably clean and tidy, knowing how to do laundry, and keeping up with home maintenance

•

Managing communication with others: Handling communication through various platforms, including electronic communication, telephone, and mail

•

Managing medications: Obtaining medications, taking them as directed, and refilling them in a timely manner

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RESOURCE ALERT: LAWTON-BRODY INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE.

Below are resources that can help counselors as they support clients in learning some of these skills.

Financial Literacy

Counselors can help provide resources to clients so that they can learn how to independently perform certain financial tasks, including how to create and maintain a budget, open a bank account, save money, use credit cards, manage debt, and open a retirement account. Exhibit 4.7 reviews various domains of financial wellness and resources to help support clients as they work toward managing finances independently.

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EXHIBIT 4.7. Reflecting on Financial Wellness.

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RESOURCE ALERT: FINANCIAL LITERACY INFORMATION.

Shopping for Healthy and Nutritious Foods

Some clients will need support and guidance about meal planning and grocery shopping, including how to select nutritious foods and manage shopping on a budget. The Department of Agriculture offers resources on shopping and meal planning that can support clients in this process.

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RESOURCE ALERT: TIPS FOR HEALTHY EATING AND SHOPPING ON A BUDGET.

Other Life Activities

Clients may also benefit from assistance in other key areas of living, including housecleaning and home maintenance. They might need support learning about the importance of cleaning kitchens after eating, maintaining clean and tidy living areas, keeping up with home maintenance, and regularly doing their laundry. Developing a plan ahead of time can help clients take on these tasks.

Supporting Healthy Relationships

Family and/or social support are vitally important to long-term recovery. Counselors should encourage clients to develop and maintain healthy relationships with the people they consider to be family or friends. (Chapter 2 contains a discussion on allowing the client to define “family” and “friends.”) The information in the “Resource Alert: Supports for Healthy Family Relationships” can help counselors support clients as they work to grow or strengthen relationships with their children, spouses or partners, other family members, or friends.

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RESOURCE ALERT: SUPPORTS FOR HEALTHY FAMILY RELATIONSHIPS.

Transforming Identity by Rewriting the Narrative

Seeking and maintaining recovery from problematic substance use not only gives individuals the opportunity to improve their physical well-being, but also provides them with a chance to positively establish (or reestablish) their identity, or personal narrative.

An individual's life story exerts significant influence over their memories, choices, and future possibilities.¹³²² Being able to tell one's story of substance use in redemptive terms—that is, a story in which a negative experience led to positive change—is associated with improved psychological well-being and adjustment to a “new normal,” and with the likelihood of sustained recovery.^1323,1324

Research suggests that clients see a discrepancy between their “real” self and who they feel they became because of their substance use, and they may feel a strong sense of purpose to restore or create a new, healthier identity as part of the recovery process.¹³²⁵ Many clients never had a positive identity or never learned this from their family of origin. Counselors have an opportunity to help clients reframe how they see themselves and how they feel they are seen by others.

In terms of self-perception, a key challenge can be helping clients avoid feeling that because they are in recovery from problematic substance use that their substance use defines them; that their identity and narrative is that they are a “substance user.”¹³²⁶ Research indicates that clients may see this in either a positive or negative light. That is, people using substances in a problematic way may:

•

Develop a negative identity association with substance use because it replaced or compromised positive functions and/or relationships in their life; or

•

Develop a positive identity association with substance use because it may have provided a social framework that reduced their feelings of isolation.¹³²⁷

Even in the case of a positive identity association, research suggests that the sense of positivity declines over time, as substance use increases and/or creates more wellness and personal difficulties.¹³²⁸

A positive way to reframe this substance-related identity can be to work with clients to develop a recovery identity by defining recovery as more than simply managing substance use behaviors. Research suggests that other elements include¹³²⁹:

•

Engaging in activities that clients value.

•

Being able to look forward (i.e., have hope).

•

Gaining control or mastery over their substance use.

•

Feeling a sense of connection and belonging.

Each of these factors has been shown to be positively associated with increased self-efficacy and self-esteem^1330,1331 as well as recovery progress and reduced risk of recurrence.¹³³²

Addressing a sense of belonging and connectedness can include fostering the individual's recovery identity with fellow clients, where possible. These relationships can take several forms, from fellow clients in residential treatment to other members of mutual-support groups (i.e., Alcoholics Anonymous^® [A.A.], Narcotics Anonymous [NA^®]). An increased identity with recovery-oriented social connections and reduced identity with social connections related to substance use have been positively associated with longer stay in treatment^1333,1334 and improved well-being at follow-up visits.^1335,1336

In terms of community, positively “rewriting” the way the client feels they are viewed by that community can be difficult. Issues such as stigma, lack of social supports, poverty, and self-exclusion make it challenging for socially marginalized or excluded groups—including those in recovery from problematic substance use—to effectively engage with community resources.^1337,1338 However, research increasingly identifies recovery as a social process, rather than just an individual process,¹³³⁹ spotlighting the importance of connecting individuals in recovery to positive assets in their community.¹³⁴⁰

Asset mapping can be an effective way to link clients to resources they need and can enjoy in their community. In addition to linking clients to community assets, counselors can also help to reframe the way the community views or treats individuals in recovery through informed treatment and advocacy. Although these steps were originally identified for psychologists, they can also have meaning for SUD treatment providers. Counselors can help the community see the individual in recovery differently, which can potentially reinforce the ways in which the individual rewrites their own narrative and finds a sense of purpose on their recovery journey. Counselors can:¹³⁴¹

•

Use acceptance and mindfulness practices to identify and potentially mitigate internalized stigma or bias in themselves or in individuals in recovery.¹³⁴² (Chapter 3 covers more details on effective strategies.)

•

Provide careful support for the individual's disclosure decisions and processes, not only with family and friends, but also in the community (e.g., healthcare providers, employers), and support the individual in the aftermath of these processes.

•

Advocate for policy change in the community (e.g., against policies that criminalize substance use or deny services to these individuals) through appropriate public channels (e.g., face-to-face conversation, social media, op-eds).

•

Advocate against the intentional use of stigma to deter substance use (e.g., public health campaigns that associate substance use with criminality, violence, or unethical behavior).

•

Educate individuals in the community whenever possible about recovery to correct misconceptions and build the knowledge that can break down stereotypes.

•

Discourage stigmatizing language (i.e., counselors should speak up when they hear words like “addict,” “druggie,” “user,” etc.).

Educational Attainment

Another avenue for clients to develop a new or renewed sense of purpose is education. Research has linked educational and vocational attainment to longer periods of abstinence and a more positive life trajectory for individuals in recovery.

At the same time, the individual in recovery must be able to safely pursue education without creating risks for recurrence. There are several points they should keep in mind if they are going to commit to spending significant time on campus and pursuing further education, such as¹³⁴³:

•

Knowing their limits. Many social events on campus will involve substance use. These may be events to avoid if clients feel that they will be tempted or uncomfortable around substance use.

•

Understanding their triggers. Clients should have a plan for alternative activities if they experience something that they feel is a trigger, such as isolation, stress, or seeing others using substances.

•

Finding like-minded friends. Clients should be encouraged to socialize with people who enjoy activities that do not involve substance use.

•

Filling their schedule. Clients should find positive, substance-free activities to fill free time if they tend to feel tempted to use when they are bored or have nothing to do.

•

Creating a plan for well-rounded health. Clients should not forget about mental and physical well-being, and should make time in each day for therapy, self-care, and/or exercise.

Despite the perception of colleges and universities as party environments, many safe and sober initiatives exist on campuses throughout the country. These can be invaluable for individuals in recovery who are returning to education. Collegiate recovery programs (CRPs) include counseling and mutual-help groups and increase the availability of sober living options for those who want to live on or near campus. Sober living programs on campus often offer additional recovery services, such as academic support, 24/7 recurrence assistance, and sober entertainment options.

Exhibit 4.8 identifies components of a CRP.

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EXHIBIT 4.8. Characteristics of a CRP.

The “Resource Alert: Sober Resources for College” contains links to organizations and websites that can guide individuals in recovery to on-campus resources that can help them safely pursue an education while maintaining their own recovery.

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RESOURCE ALERT: SOBER RESOURCES FOR COLLEGE.

Vocational Counseling and Rehabilitation

Gainful employment is strongly linked to better recovery outcomes,¹³⁴⁵ including lower rates of recurrence of substance use and higher rates of abstinence, compared with individuals in recovery who are unemployed.¹³⁴⁶ Obtaining and maintaining a regular job helps clients develop a reliable source of income, structure their time, and improve self-esteem.

Re-establishing employment in recovery can be challenging, however. Compared with the general U.S. population, individuals in recovery are less likely to be employed or retired and more likely to be unemployed and disabled.¹³⁴⁷ Individuals also report perceived employment-related discrimination, including losing a job, being unable to get a job, and being employed but unable to get a promotion.¹³⁴⁸ Additionally, individuals may encounter barriers to hiring such as¹³⁴⁹:

•

Lack of job skills or lower educational attainment.

•

Poor work history.

•

Poor interpersonal skills or motivation to work.

•

Lack of transportation and/or childcare.

•

Lack of identification, such as a birth certificate or driver's license.

•

Continued substance use or recurrence.

•

Criminal history.

•

Employer's lack of understanding about SUD.

•

Scheduling conflicts with probation and treatment requirements.

This section discusses strategies and resources for supporting clients as they reestablish themselves in the workforce.

Navigating the Employment Landscape

Before starting a job search, clients should understand recovery-friendly and recovery-supportive workplaces and workplace-supportive recovery programs.

Recovery-friendly workplaces are committed to creating a healthy, safe, and stigma-free work environment for employees in recovery, and to creating internal supports and relationships with local recovery organizations. Recovery-friendly workplace programs are associated with less absenteeism, higher productivity, lower turnover and replacement costs, and lower healthcare costs.¹³⁵⁰

A recovery-supportive workplace “… aims to prevent exposure to workplace factors that could cause or perpetuate an SUD while lowering barriers to seeking care, receiving care, and maintaining recovery. A recovery-supportive workplace educates its management team and workers on issues surrounding SUDs to reduce the all-too-common stigma around this challenge.”¹³⁵¹

Exhibit 4.9 lists specific elements of a workplace-supported recovery program.

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EXHIBIT 4.9. Elements of a Workplace-Supported Recovery Program.

Counselors can help clients identify recovery-friendly workplaces by reaching out to the local recovery community for guidance on employers in their community. Other useful resources include:

•

CareerOneStop, a Department of Labor (DOL) website dedicated to employment recovery (https://www​.careeronestop.org/).

•

National H.I.R.E. (Helping Individuals with arrest and conviction records Reenter through Employment) Network, a resource developed by the nonprofit Legal Action Center to help individuals with criminal records enter the workforce (https://www​.lac.org/major-project​/national-hire-network).

•

Rehabilitation Services Administration, State Vocational Rehabilitation Agencies, including contact information for the department of rehabilitation services in each state (https://rsa​.ed.gov/about/states).

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RESOURCE ALERT: BECOMING A RECOVERY-FRIENDLY WORKPLACE.

Clients may also have questions about their legal rights, specifically with regard to the Americans with Disabilities Act (ADA). Because SUD affects significant life skills, including the ability to work, having a history of SUD may be considered a disability. ADA protections are determined on a case-by-case basis. If clients express concern about specific actions taken by an employer, counselors should refer the client to an attorney.

Steps to Finding Employment

Clients may need help with any, or all, of the following activities related to finding employment. Counselors can provide the following resources to help them with:

•

Resume writing: A professional-looking resume is a prerequisite for applying for certain types of jobs. The website ResumeBuilder.com has a page on resume development, specifically for people in recovery (https://www​.resumebuilder​.com/employment-guide-for-people-in-substance-abuse-recovery/).

•

Searching: Career and employment advertising is almost entirely online. DOL's CareerOneStop has a webpage with links to every state job bank as well as a Job Finder tool for searching four major general-purpose job listing sites: the National Labor Exchange, America's Job Exchange, CareerBuilder, and Indeed.com (https://www​.careeronestop​.org/Toolkit/Jobs/find-jobs.aspx).

•

Applying: The application process has also moved online. Large employers often accept applications exclusively through their websites, and many smaller employers ask for applications via email, a form on their website, or even a Facebook page. Filling out an application and/or uploading a resume can generally be executed with any device—computer, tablet, or smartphone. Once they have applied, jobseekers must be alert for any communications from the employer asking for additional information or offering an interview, and they must be prepared to receive and respond to communications via email, phone, text, or the employer's portal.

•

Interviewing: DOL's CareerOneStop site includes a section on interviewing and negotiating at https://www​.careeronestop​.org/JobSearch/Interview​/interview-and-negotiate.aspx. Clients may need specific interview practice regarding how to address their SUD as it relates to their work history. Under the ADA, it's illegal for employers to ask about disabilities during an interview, including SUD and SUD treatment history. However, if asked, the client should answer honestly; lying creates a legitimate reason for an employer to disqualify the client from consideration. (The applicant's recourse is to file a complaint about the employer's violation.) If offered a job, the applicant is required to disclose any disabilities, if asked.¹³⁵⁵

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RESOURCE ALERT: EVIDENCE OF REHABILITATION.

Volunteerism

Volunteering occupies free time with satisfying activities that turn the volunteer's attention outward. Regular volunteering builds self-respect as the volunteer makes a positive contribution and becomes valued by the organization and fellow volunteers. Volunteering can help develop new skills, structure time, expand social networks, broaden horizons, and give a sense of purpose.

For someone in recovery, one natural way to volunteer is to help others who are also in recovery, or to fulfill other volunteer roles in a treatment center or recovery-related organization. However, when the client is ready, volunteering can also present the opportunity to move beyond a recovery-oriented environment, pursue interests, and explore new areas. Possibilities include:

•

Homeless shelters.

•

Food pantries and meal programs.

•

Community farms or gardens.

•

Animal shelters.

•

Home construction programs (such as Habitat for Humanity^®; https://www​.habitat.org/).

•

Political campaigns or activist organizations.

•

National, state, or local parks.

•

Arts organizations, such as museums or theaters.

Opportunities will vary by location. One place to find them is VolunteerMatch (https://www.volunteermatch.org/), where many organizations nationwide list their volunteer needs. It allows searches by location and category.

It is best to be transparent about a history of substance use and recovery when offering one's services as a volunteer. Some volunteer opportunities will require a background check, particularly if they involve working with children or teenagers, animals, the elderly, or other vulnerable populations. Prior criminal justice involvement may significantly limit volunteer opportunities.

Meaningful Leisure Activities

As with volunteering, finding creative outlets for leisure time can help replace activities and time spent in settings that encouraged problematic substance use. Some studies suggest that creative activities can affect the brain in ways similar to substance use. For example, some types of interactions with music can reduce craving.^1356,1357

Clients may have been exposed during their treatment program to therapies based on art, writing, music, or drama. If they found particular satisfaction in any of these, they may benefit from developing it as a lifelong interest. For example, there are a number of knitting and sewing programs available that offer a creative outlet while supporting recovery.

One word of warning: some creative pursuits have the potential to lead a client into situations that jeopardize their recovery. Though music can heal, a client may associate a certain song or type of music with past substance use, and hearing it may trigger powerful cravings.¹³⁵⁸ Playing in a band may put them in bars and clubs where they encounter substances they are trying to avoid. In developing creative leisure activities, clients should prioritize their recovery.

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RESOURCE ALERT: EMPLOYMENT AND VOCATIONAL SERVICES.

Music

Many aspects of music have been studied for their healing power. For example, evidence shows that group music therapy can reduce pain in people with OUD, and cravings in SUD.¹³⁶² Performing music can be a rewarding leisure activity, both for the act of making music and for the opportunity to share music with others. Group singing, for example, has been shown to have specific beneficial effects on neurotransmitters like oxytocin.¹³⁶³

If clients have experience playing an instrument, taking it up again can connect them with past pleasures and accomplishments. If they are new to music performance, choral singing is an accessible way to start. Many church choirs and community choruses require no more than the ability to carry a tune and will welcome new members.

One option to explore, if available, is a “recovery choir”—a singing group established specifically for people in recovery. Examples include:

•

Harmony, Hope, & Healing, Chicago (https://www​.harmonyhopeandhealing.org/).

•

The Straight and Narrow Choir, Paterson, New Jersey (https://www​.ccpaterson.org/choir).

•

Minnesota Adult & Teen Challenge Choir (https://www​.mntc.org/choir-page/).

Starting a recovery choir requires willing singers, a director (who might be recruited from a church, an elementary or high school, or a college or university with a music department), and a place to rehearse.

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RESOURCE ALERT: HOW THE ARTS IMPROVE HEALTH.

Using Mutual-Help Groups To Support Recovery

Mutual-help group meetings support recovery by focusing on strengthening coping skills and preventing or managing a recurrence to use. Research indicates that some mutual-help groups focusing on the 12 Steps facilitate continuous abstinence and remission and are as effective as other SUD treatment programs in reducing intensity of drinking, alcohol-related consequences, and severity of alcohol addiction.¹³⁷² Mutual-help group programs contribute to these recovery outcomes by focusing on developing and enhancing an individual's self-efficacy and recovery motivation, and in reducing craving—all associated with long-term recovery. These programs are also designed to facilitate positive changes in social networks.¹³⁷³

Counselors can provide information to clients about local mutual-help groups and encourage them to visit a meeting before committing to the program.¹³⁷⁴ These programs may also encourage close mentoring through a “sponsorship” or a recovery coach/mentor who serves as a primary contact, particularly during early recovery.¹³⁷⁵ Counselors can help clients by informing them about the importance of a sponsor and encouraging them to request a sponsor as part of participation. By examining a client's recovery goals, counselors can help to identify a mutual-help group that is a strong fit with their client's needs and values.

Numerous alternatives to 12-Step meetings have emerged over the years based on individual and cultural needs. Most mutual-help groups tend to fall within the following categories: 12 Step, religious, secular, harm reduction, family, and supportive of medications for OUD (MOUD), among others. Select examples of these groups are described below.

12-Step Mutual-Help Groups

Founded in 1935, the first 12-Step mutual-help group, A.A., aided its membership in overcoming alcohol use disorder. Since that time, dozens of organizations have been formed from the A.A. program and use a version of A.A.'s suggested 12 Steps, first published in 1939. Alcoholics Anonymous, commonly known as the “Big Book,” provides information about the program and contains stories from the cofounders and other members of A.A. who have achieved and sustained recovery. Steps are put forth as suggestions, and the only requirement for membership is a desire to seek abstinence or an end to harmful behaviors. Clients can locate information about problematic substance use and the 12 Steps as well as links to local meetings on the websites for various mutual-help groups.

Examples of 12-Step groups include:

•

A.A. A.A. is a fellowship of individuals who are focused primarily on supporting people who identify as having difficulties resolving problematic alcohol use and achieving sobriety. (https://www​.aa.org/)

•

Anorexics and Bulimics Anonymous (ABA). ABA is a fellowship of individuals whose primary purpose is to find and maintain recovery in their eating practices, and to help others gain recovery. (http://aba12steps​.org/about/)

•

Co-Dependents Anonymous (CoDA). The CoDA program encourages members to follow the 12 Steps and 12 Traditions for developing honest and fulfilling relationships with themselves and others. (https://coda​.org/)

•

NA^®. NA^® is a global, community-based organization focused on supporting people who identify as having difficulties resolving problematic drug use—including alcohol. NA^® members use a 12-Step program that includes regular attendance at meetings to help individuals achieve and sustain recovery. (https://na​.org/)

•

Cocaine Anonymous^® World Services, Inc. (CA). CA emerged to provide affiliational support to individuals who have experienced problematic cocaine use. Although the name implies a drug-specific focus, today's CA is for anyone wishing to resolve cocaine and all other problematic drug and alcohol use; however, individuals who had problematic cocaine use may identify more strongly with the culture of CA. (https://ca​.org/)

•

Crystal Meth Anonymous^® (CMA). CMA is a fellowship of individuals who strive to achieve and sustain recovery from crystal meth. Group members share the process they used to achieve recovery and the ways that they have applied a new outlook to their lives. The 12 Steps of CMA were adapted from A.A. and were founded on the belief that people who use crystal meth relate best to others seeking recovery from crystal meth because they understand the darkness, paranoia, and compulsions of this addiction. (https://www​.crystalmeth.org/)

•

Drug Addicts Anonymous^® (DAA). DAA is a fellowship of individuals who have resolved problematic drug use using the 12 Steps outlined in A.A. It provides support for individuals experiencing problematic drug use who may have greater affiliation with A.A. than with NA^®. (https://daausa​.org/)

•

Eating Disorders Anonymous (EDA). EDA is a 12-Step fellowship of individuals who share their experiences, strengths, and hopes with each other that they may solve their common problems and help others to recover from their eating disorders. (https:​//eatingdisordersanonymous.org)

•

Emotions Anonymous^® (EA). The EA membership is composed of people who come together in weekly meetings for the purpose of working toward recovery from emotional difficulties. (https:​//emotionsanonymous.org)

•

Gamblers Anonymous^®. Gamblers Anonymous^® is a fellowship of men and women who share their experiences, strengths, and hopes with each other that they may solve their common problem and help others to recover from a gambling problem. (https:​//gamblersanonymous​.org/ga/content/about-us)

•

Marijuana Anonymous (MA). MA is a fellowship of people who share their experiences, strengths, and hopes with each other as part of their recovery from problematic marijuana use. It is based on the 12 Steps of A.A. (https:​//marijuana-anonymous.org/)

•

Nicotine Anonymous^® (NicA). NicA is a nonprofit 12-Step fellowship of people helping each other live nicotine-free lives. (https://www​.nicotine-anonymous.org/)

•

Overeaters Anonymous^® (OA). OA is a community of people who support each other to recover from compulsive eating and food behaviors. (https://oa​.org/)

•

Sex Addicts Anonymous (SAA). SAA is a fellowship of individuals who share their experiences, strengths, and hopes with each other so they may overcome their sexual addiction and help others recover from sexual addiction or dependency. (https:​//saa-recovery.org/our-program/)

•

Sexaholics Anonymous (SA). SA is a 12-Step recovery peer support program based on the same model as A.A. but with sexual addiction in mind. (https://www​.sa.org)

•

Sex and Love Addicts Anonymous (S.L.A.A.). S.L.A.A. is a 12-Step, 12-Tradition-oriented fellowship based on the model pioneered by A.A. Services are supported entirely through the contributions of its membership and are free to all who need them. (https://slaafws​.org/)

•

Sexual Compulsives Anonymous (SCA). SCA has adapted the 12 Steps of A.A. to recovery from sexual compulsion to create a safe space for members to discuss their compulsive sexual behaviors without shame, and to work toward recovery. (https:​//sca-recovery.org/WP/)

•

Wellbriety. These mutual-support circles follow the Red Road, Medicine Wheel Journey to Wellbriety to become sober and well in a Native American cultural way. The indigenous experience adds a dimension of acknowledging sociopolitical causes of addiction, without removing an individual's need to do the hard work it takes to heal. (https://www​.wellbriety.com/map.html)

Religious Mutual-Help Groups

These mutual-help meetings often focus broadly on individual concerns or problems using a spiritual or religious framework. Some may be structured more formally (e.g., format, readings, step work), or they may be less formal. Some are aligned with a specific religion, whereas others may be more holistic or nondenominational. Examples of religious mutual-help groups include:

•

Celebrate Recovery^®. Celebrate Recovery^® is a Christ-centered, 12-Step program focused on supporting people experiencing SUDs to process addictions, anger, codependency, and more. General meetings involve worship, testimonies, and lessons connected to the 12 Steps, and often feature co-ed fellowship meals and gender- and issue-specific groups. Meetings are offered both in person and online. (https://www​.celebraterecovery.com/)

•

Recovery Dharma. Recovery Dharma uses the Buddhist practices of meditation, self-inquiry, wisdom, compassion, and community as tools for recovery and healing. The program is based on Buddhist teachings and practices, with the belief that anyone can benefit from this wisdom, regardless of whether one identifies as a Buddhist. Meetings include readings, guided meditation, and discussion. Both online and in-person meetings are available. (https:​//recoverydharma.org/)

•

Refuge Recovery. The main inspiration for the Refuge Recovery program is the guiding principles of Buddhism. Buddhism recognizes a nontheistic approach to spiritual practice. The program of recovery consists of the Four Noble Truths and the Eightfold Path. Refuge Recovery groups provide help from others in recovery and offer an ongoing support network. Meetings are structured to include readings of guiding principles, 20-minute guided meditation, and open shares. Meetings are available in person and online. (https://www​.refugerecovery.org/)

•

Millati Islami. Millati Islami is a fellowship of men and women, joined together on the “Path of Peace.” They share experiences with one another and look to Allah on this pathway of recovery to become rightly guided Muslims. Meetings are available in person and online. (https://www​.millatiislami.org/)

Secular Mutual-Help Groups

Secular mutual-help meetings embrace a clear separation from any religious or spiritual framework; however, these programs do not discourage engagement in religious or spiritual activities. They are largely based on self-awareness and modification of thoughts, actions, and behaviors.

Examples of secular mutual-help groups include:

•

LifeRing^® Secular Recovery. LifeRing^® Secular Recovery is an organization of people who share practical experiences and sobriety support. Many LifeRing^® members attend other kinds of meetings or recovery programs, and members honor those decisions. LifeRing^® respectfully embraces what works for each individual. (https://lifering​.org/)

•

Self-Management and Recovery Training (SMART). SMART Recovery^® is a global community of mutual-support groups. At meetings, participants help one another resolve problems with any addiction (to drugs or alcohol or to activities such as gambling or overeating). Its meetings are free and open to anyone seeking science-based, self-empowered addiction recovery. (https://www​.smartrecovery.org/)

Harm Reduction, Moderation, and MOUD-Supportive Mutual-Help Groups

People who use drugs, practice moderation in their recovery, or take MOUD (e.g., methadone, buprenorphine) benefit from the community aspect of mutual-help meetings but may not always feel welcome. Though not always widely available, there are many opportunities—some in person, but mainly digital.

Examples of harm reduction, moderation, and MOUD-supportive mutual-help groups include:

•

HAMS: Harm Reduction for Alcohol. HAMS is a peer-led and free-of-charge support and informational group for anyone who wants to change their drinking habits for the better. HAMS harm reduction strategies are defined in the 17 elements of HAMS. HAMS offers support via an online forum, a chat room, an email group, a Facebook group, and live meetings. Participants choose their own goal—safe drinking, reduced drinking, or quitting alcohol altogether. (https://hams​.cc/)

•

Moderation Management^™ (MM). MM is a lay-led nonprofit dedicated to reducing the harm caused by alcohol use. MM provides support through face-to-face meetings, video and phone meetings, chats, and its private online support communities, the MM forum, the MM listserv, and the MM private Facebook group. (https://moderation​.org/)

•

Harm Reduction Works. Everyone is welcome in these meetings, especially people who aren't sure what harm reduction is or whether it can help them. People who embrace abstinence, choose moderation, take MOUD, or are just beginning to wonder if alcohol and drugs are a problem are welcome. Friends, families, and allies are also encouraged to attend. (https://linktr​.ee/hrw)

•

Medication-Assisted Recovery Anonymous (MARA).^® Many people who take prescribed MOUD, (e.g., methadone, buprenorphine) sometimes feel unwelcome at traditional recovery meetings. MARA^® believes in recovery from an unsafe lifestyle, and it believes in the value of medications as a means to recovery. (https://www​.mara-international.org/)

Family Mutual-Help Groups

Families, friends, and allies are impacted by their loved ones' problematic substance use, whether their person seeks recovery or not. Family mutual-help group meetings provide free psychosocial supports in many communities, in person and digitally.

Examples of family mutual-help groups include:

•

Al-Anon and Alateen. Al-Anon is a mutual-support program for people whose lives have been affected by someone else's drinking. By sharing common experiences and applying the Al-Anon principles (based on the 12 Steps of A.A.), families and friends of people experiencing problematic alcohol use can bring positive changes to their individual situations, whether or not the person admits the existence of a drinking problem or seeks help. (https://al-anon​.org/; https://al-anon​.org/for-members​/group-resources/alateen/)

•

Grief Recovery After a Substance Passing (GRASP). GRASP was created to offer understanding, compassion, and support for those who have lost someone they love from problematic substance use and overdose. GRASP provides a directory of free, in-person support meetings and tools for coping with loss. (http://grasphelp​.org/)

•

Nar-Anon and Narateen. Nar-Anon is a mutual-support program for people whose lives have been affected by someone else's drug use. By sharing common experiences and applying the Al-Anon principles (based on the 12 Steps of NA^®), families and friends of people who have experienced problematic narcotic use can bring positive changes to their individual situations, whether or not the person admits the existence of a drug problem or seeks help. (https://www​.nar-anon.org/; https://www​.nar-anon​.org/what-is-narateen?rq=narateen)

Other Community-Based Mutual-Help Groups

The numbers and types of mutual-help meetings and the platforms on which they can be accessed continues to grow. Additional community-based meetings include:

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All Recovery Meetings. All Recovery Meetings are discussion groups based on universal recovery topics. They are open to anyone who is challenged by addiction or affected by someone else's addiction, and to supporters of recovery in general. All Recovery Meetings embrace all pathways of recovery. These inclusive mutual-support meetings often are available in person at a counselor's local RCO (https:​//facesandvoicesofrecovery​.org/arco-members-on-the-map/). A full calendar of digital meetings is also available through Unity Recovery (https:​//unityrecovery​.org/digital-recovery-meetings).

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Gay & Sober.^® Gay & Sober's mission is simple—to provide a safe, fun, and enriching experience to the sober LGBTQI+ community. The primary purpose is to encourage unity and enhance sobriety. The website includes online and in-person meetings, events in all U.S. states, and international meetings and events. (https://www​.gayandsober.org/)

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In the Rooms^® (ITR). ITR is a free, membership-based platform designed to give people in recovery access to a diverse menu of live, digital, mutual-support meetings. (https://www​.intherooms.com/home/)

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The Phoenix. The Phoenix takes an innovative approach to recovery by fostering healing through fitness and personal connection. Phoenix offerings include activities for everyone—from weightlifting and boxing to running, hiking, and yoga. The mission of The Phoenix is to help people grow stronger together, overcome the stigma of addiction, and rise to their full potential. The program is free, and the only requirement for membership is 48 hours of sobriety. (https://thephoenix​.org/)

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Seek Healing. Seek Healing provides social health programs to rebuild disconnected communities—healing loneliness, systemic shame, trauma, and addiction. It follows the belief that connection is medicine. Along with in-person mutual-support based in western North Carolina, Seek Healing also offers a full calendar of digital meetings focused on active listening and free from advice. (https://www​.seekhealing.org/)

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RESOURCE ALERT: VIRTUAL RECOVERY RESOURCES.

Using RCOs To Support Recovery

RCOs, along with the services they provide through RCCs and recovery cafés, provide opportunities for long-term support for people in recovery. These organizations encourage ongoing abstinence, for those who choose it, or support to maintain a reduction in substance use, depending on the person's individual needs.¹³⁸⁷ RCCs have been shown to benefit individuals facing significant challenges in recovery with their support for improving quality of life and providing recovery-specific support structures and resources. RCCs have also been successful in supporting increased abstinence, lowering substance-related harms, and improving the well-being of individuals in recovery.¹³⁸⁸

Pros and Cons of Digital Recovery Support

The main advantage of digital recovery support is that it offers social and emotional support for people in recovery that would otherwise not be possible. Digital recovery support offers alternatives for people who cannot or prefer not to use in-person resources, such as rural residents without Internet access, people who do not have transportation, people who need gender- or sexual orientation-specific settings, high-profile community members, and people who cannot leave their homes due to physical limitations or social anxiety.

One disadvantage of digital platforms is the limitation it necessarily places on reading body language and picking up other nonverbal cues. Another disadvantage is difficulty accessing these resources in communities with no or poor technology and broadband access.¹³⁹⁴ Clients also may not have access to devices, such as smartphones, necessary to support these apps. Currently, there is limited clinically validated evidence that many of these apps are effective in supporting treatment or recovery.¹³⁹⁵

Although some digital apps are free, others may be free initially but may have a cost associated with accessing expanded content or with ongoing use. Counselors should research costs associated with digital apps prior to recommending them to clients.

Ethics, Privacy, and Confidentiality Issues

When referring to or recommending digital recovery supports, counselors should address ethical issues as well as those related to client privacy and anonymity. This includes:

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Lack of a “one-size fits all” approach. Referring clients to peer recovery supports requires ethical considerations. Digital support groups are not “one size fits all.” Rather, they cater to people who have different needs, and not every group is appropriate or best for every person in recovery. For example, some groups follow a 12-Step approach, but others do not. Some groups cater to specific groups of individuals based on gender, age, sexual orientation, race, ethnicity, or disability.

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Adherence to ethical principles and guidelines. Professional providers, regardless of the mode of recovery support, must adhere to standard ethical requirements (i.e., do no harm, respect participants' rights to privacy and confidentiality, be culturally sensitive).

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Adherence to privacy regulations. Professionally led digital recovery support services are subject to privacy regulations as outlined in the Health Insurance Portability and Accountability Act of 1996 and 42 CFR Part 2. However, some apps may collect and sell personal information. Counselors should caution their clients about this possibility when using these apps.¹³⁹⁶

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Ability to remain anonymous. Some online platforms allow a degree of anonymity during peer recovery mutual-help meetings (e.g., one can join a meeting using only audio or an alias)—but implementing an anonymous persona is up to the individual.

Using Digital Resources To Support Recovery

When combined with other recovery supports, digital resources can help clients by offering convenient and accessible mechanisms for them to connect with their providers. For example, digital apps can be used by clients who cannot easily access care in their local communities, such as those in rural or remote settings, or those with mobility or transportation issues. These tools may also allow clients to meet with a specific provider or service that is not located in their local area. Digital resources broaden access, make visits with clients more efficient for providers, and can be standardized in format. Digital support can also be cost-effective opportunities for both providers and clients.¹³⁹⁷