An exploration of recovery competence among Norwegian peer workers in substance abuse services

ABSTRACT Peer recovery services (PRS) in Norwegian municipalities fill a gap in available care in mental health care and/ or substance abuse treatment. In this qualitative study, we interviewed six peer recovery workers (PRWs). Our aim was to explore how the PRWs understood their competences as vital for carrying out the work in PRS. Through a thematic analysis, we found themes the PRWs recognize as important in their recovery competence. The findings can be of practical relevance to those aiming to develop more recovery oriented mental health distress and substance abuse services.


Introduction
In the Norwegian welfare state, the public sector provides most healthcare services. National guidelines for services aimed at people with mental health distress and/or substance abuse problems emphasize the importance of coordinated efforts among agencies, continuity and high quality in services, user involvement, and real opportunities for users to influence the provision of care (Ministry of Health & Care Services, 2011). Capacity pressure in health services has led to innovations that rely on contributions from civil society to mental health and substance abuse services.
One of these innovations is peer recovery services (PRS). The growth of PRS in Norwegian municipalities has brought opportunities to organizations and institutions that serve people with substance abuse and mental health distress. PRS fill a gap in available care, and the peer recovery workers (PRWs) in PRS provide a wide variety of services that seem to be beneficial in the pathway to recovery and a healthy life in the community (Eddie et al., 2019;Reif et al., 2014).
In this study, all the PRWs working for the PRS for former drug addicts had been trained through a user organization in order to be qualified to work as PRWs. The training provided knowledge of various public systems and treatment options, reflections concerning their roles and own recoveries, and various tools for help in engaging with people recovering from addiction. The training emphasized the role of experience competence, explores boundaries, and identifies possible challenges. Over a three-day course, the PRWs were also provided with knowledge of relevant public health rights. The work of the PRWs was then organized with the help of a program coordinator who followed up a team of several PRWs. This program coordinator has a key role in their training and supervision and is intended to offer guidance and support in both practical work tasks and in challenging situations that may arise.
In previous studies on PRS, the lived experiences of the PRWs are often highlighted as a central part of their competences (Davidson, Chinman, Sells, & Rowe, 2006;Kemp & Henderson, 2012;Kessing, 2021). But how do the PRWs themselves define and understand their competence? The research question in our study was what do PRWs recognize as important when providing services to people with mental health distress and substance abuse problems? How can their knowledge be used to create more recovery-oriented services?
Access to substance abuse treatment needs to be improved, and sustainable and cost-effective strategies for engaging and retain hard-to-reach individuals in care need to be identified (Dara et al., 2016). Knowing more about PRS and the required competence(s) can be a step closer to achieving more efficient and user-friendly services. By identifying what it takes to become a competent PRW, future training of PRWs can become more recovery-oriented, which will benefit both service users and the PRWs themselves.
This qualitative study examines how PRWs understand their own competences, and how their role as PRWs affects their own recovery process. We interviewed six PRWs working as paid employees for a nonprofit PRS and analyzed the interviews thematically, seeking to gain more knowledge of the competences of the PRWs and PRS they work for. This study contributes to the expanding literature on PRS and is aimed at practitioners and peers who work with recovery services in substance abuse and mental health care.

The recovery model and its connection to PRS
Recovery is a complex construct including many interconnected processes and outcomes underpinned by access to personal or social resources (Tew et al., 2015). The recovery model has been put forward as a counterpoint to traditional biomedical models in both mental health care and substance abuse related work and use of this model has led to a broader understanding of mental health and substance abuse issues and promoted social inclusion (Thornton & Lucas, 2011). However, there is little consensus about what "recovery" means, even though the concept has become more familiar in mental health policy, practice, and research (Hummelvoll, Karlsson, & Borg, 2015). We understand the recovery model to include the following characteristics first listed by in a UK policy paper (2011, as cited in Thornton & Lucas, 2011, p. 24

):
• Recovery is about building a meaningful and satisfying life, as defined by the person themself, whether or not there are ongoing or recurring symptoms or problems. • Recovery represents a move away from a focus on pathology, illness and symptoms to a focus on health, strengths and wellness. • Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives ("agency") and by seeing how others have found a way forward. • Self-management is encouraged and facilitated. The processes of selfmanagement are similar, but very different processes might be effective for different individuals. In self-management there is no "one size fits all". • The relationship between a clinician and a patient moves away from being a typical expert/patient relationship to one where the expert is more of a "coach", or where the two parties are "partners" on a journey of discovery. Clinicians are there to be "on tap, not on top". • People do not recover in isolation. Recovery is closely associated with social inclusion and being able to take on meaningful and satisfying social roles in local communities, and recovery cannot happen if services are segregated. • Recovery is about discovering or re-discovering a sense of personal identity that is separate from illness or disability.
Community mental health care and outreach approaches have been established in Norway that draw on the perspectives of the recovery model. These innovative services have often been met by barriers rooted in the more traditional biomedical model, the dominant psychiatric cultures, and bureaucratic administrative procedures (Clossey, Gillen, Frankel, & Hernandez, 2016;Hummelvoll et al., 2015;Karlsson, 2008). Giving people a central position in their own recovering process and challenging the bureaucracies and hierarchies when promoting the ideal of human beings as equals, can be understood as a step away from those professionals' programs and orders (Hummelvoll et al., 2015). The recovery process helps people feel as if they belong in their communities and assists them in establishing identities distinct from their mental distress or substance abuse (Davidson et al., 2006). PRS are effective for promoting feelings of community and empowerment and using PRWs helps to engage others seeking recovery (Brown & Townley, 2015). PRS can be defined as an outreach service for people with mental health distress and/or substance abuse issues, consisting of giving and receiving nonprofessional, nonclinical assistance from individuals with similar experiences, conditions, or circumstances with the goal of achieving long-term recovery from psychiatric, and/or drug-or alcohol-related problems (Tracy & Wallace, 2016). Peer services provide an alternative to inpatient care and can help decrease costs associated with hospitalization or rehabilitation services. Internationally, countries have sought to reform services to maximize the potential of users and patients to have control over health care decisions and throughout their trajectory of care (Ness et al., 2014;Ness, Kvello, Borg, Semb, & Davidson, 2017). A recovery systems orientation involves collaborating with people's personal goals, conveying hopefulness, promoting choice, and focusing on people's strengths (Chinman et al., 2017). These services can be defined as a system of giving and receiving help founded on key principles of respect, shared responsibility, and a mutual agreement about what is helpful for people in similar situations (Mead, Hilton, & Curtis, 2001). Andersson, Otterholt, and Gråwe (2017) found that users in residential addiction institutions in Norway were dissatisfied with the support provided for housing, finances, and employment. A study by Biringer, Davidson, Sundfør, Ruud, and Borg (2017) underlined that recovery is tightly interwoven with personal aims, hopes for future life, and expectations related to practical and financial problems, and that a more comprehensive approach is needed that provides more support with family issues, social life, education, work and financial issues. Hårvik (2018) stated there are challenges related to giving service providers ways to assess the quality of their services, increasing contact and dialogue with users, and gaining insight into user needs.
PRS are diverse and can take many forms and directions, including selfhelp, which is the name of the process of change from being a passive receiver of help to an active participant in life (Sjåfjell & Myra, 2015). Different PRS include help with self-help, where the focus is to identify one's own resources, take responsibility for one's own life, and steer that life in the direction one wants.
In this study, the PRS was performed by a nonprofit user organization for former drug addicts and people with mental health distress, focusing on help with self-help. Our aim was to explore how the PRWs in that PRS defined and understood their competences as contributing to (and perhaps even vital for) carrying out the work in PRS.

Context of the study
The context of the study was a new collaboration model and mentor program, namely a peer recovery service (PRS), that was organized by a national nonprofit organization. Former drug addicts were engaged as paid support persons (PRWs) for other drug addicts who were in rehabilitation for substance abuse. Many of the service users also struggled with mental health distress. The PRWs, by virtue of their experiences of becoming drug-free themselves, function as a role models, bridges, and translators for the service users. Areas where the service users have had the greatest need for support from a peer have been inclusion in drug-free activities and in drug-free networks. Another important function that the peer served was as a translator and coordinator of public services and treatment facilities. The peer thus appears in this model as a personal, easily accessible "door opener" -a role model and a supporter for the service users (Author 2 & X, 2021). Each PRW is organized by a program coordinator, who establishes contact between the PRW and the person in need of assistance (a service user). The contact between the PRW and the service user is established based common denominators regarding their experience, background, interests, age, and the service users wants and needs. The program coordinators are responsible for follow-up and counseling the PRWs. Typically, PRWs work with their service user for up to two years.
Our hypothesis was that PRW training could be made more user-friendly and recovery oriented if we could explicitly identify the competences that the PRWs themselves thought would be important and useful in their roles as peer helpers.
Data were collected in two different cities in south and east Norway at the beginning of 2020, and interviews were performed by author 1 and 2. We did semi-structured, individual in-depth interviews with six PRWs. In Southern Norway, the PRS had been in operation for years, while in Eastern Norway, the PRS was established in 2018.

Informants and data collection
The informants were six PRWs of both sexes, between the ages of 35 and 55. They all worked in the peer recovery service provided by the same user organization. Some of them had worked in the organization for several years, others for less than one year. They were all recruited through their program coordinators in the nonprofit organization. The PRWs' mental health diagnoses or statuses as former substance abusers were not collected in this study. Information letters were distributed to the informants, and individuals who were interested in participating signed letters of consent. The informants could bring a companion to the interviews if they wanted, and they were asked what language they wanted to use during the interview. All interviews were conducted in Norwegian according to the wishes of the informants. A thematic interview guide was used. The main topics were related to the informants' own experiences with being a peer recovery worker. Most interviews were approximately 60 minutes long. The interviews were digitally recorded, and the sound files were transcribed verbatim. The excerpts from the interviews presented in this paper have been transformed into coherent pieces. This process involved constructing comprehensive, condensed excerpts. Comments or questions from the interviewers were omitted to improve the coherence of the excerpts.
The interviews began with the open question "Can you tell me what made you become a peer recovery worker?" The open questions were designed to elicit a narrative account (Thornhill, Clare, & May, 2004), and the interviewees were invited to speak as freely as possible. The interviews varied in terms of how the informants told their stories. Some told their stories without interruptions, while others needed more prompting. Each new research interview represented new stories and a new storytelling (Author 1 et al., 2013). The study was approved by the Norwegian Center for Research Data in 2020. Ethical challenges in the study were obtaining informed consent, recruiting informants through the PRS program coordinators, participating in the storytelling during the interviews with care and ethical awareness, and asking questions related to the unexpected (Klausen, 2017).

Data analysis
Thematic analysis is one approach used to identify patterns of meaning across a qualitative dataset, and the method can offer great flexibility (Braun, Clarke, & Weate, 2016). The analysis is a product of deep and prolonged data immersion, thoughtfulness, and reflection, a process that is active and generative (Braun & Clarke, 2019). In line with Riessmann (2008), we performed an experience-oriented analysis that allowed the data to drive the analysis rather than attempting to fit the data into a preexisting coding frame or analytical preconceptions ( (Klausen, Karlsson, Haugsgjerd and Lorem, 2016). By performing semi-structured interviews, we concentrated on understanding and accurately representing peer recovery competence among PRWs. As stated by Braun and Clarke (2019), qualitative research is about contextbound, positioned and situated meaning-making, and telling stories, interpreting, creating (but not discovering) the "truth" that is "out there" (or that is to be found in the empirical data). The approach chosen analyzes people's experiences in relation to PRS. We followed the analysis model as developed by Braun et al. (2016) through the following six phases: 1-2) familiarization and coding, 3-5) theme development, refinement, and naming themes, and 6) writing up. The analysis is a recursive process, and we moved back and forth among different phases. We analyzed the PRWs' stories in terms of particular patterns of shared meaning across the datasets rather than summarizing the data in relation to a particular topic (Braun & Clarke, 2019). The thematic analysis demonstrated the informants' complex experiences of being PRWs and contributes to the knowledge related to competences among the peers. The themes are "creative and interpretive stories about the data, produced at the intersection of the researchers' theoretical assumptions, their analytic resources and skill, and the data themselves" (Braun & Clarke, 2019, p. 594). We have strived to make our analysis process transparent, reflexive, and collaborative rather consensus-seeking.

Results
The analyses were performed with the intention to provide rich descriptions from the breadth and complexity of PRWs' experiences, and four themes emerged. The themes can be understood as steps toward better knowledge about the skills required of a PRW and, in chronological order, describe the development of recovery competence. In the PRWs' experiences, knowledge is needed of 1) one's own experience with substance abuse. After that, knowledge is needed 2) to gain distance from one's own illness. Next, knowledge is needed about 3) recovery as a joint challenge, and 4), flexibility as a prerequisite for recovery services.

Theme 1) one's own experience with substance abuse
All the informants underlined the importance of their own experiences with substance abuse when working with the PRS, and they applied this expertise in different ways. One of the informants, a man that had been struggling with alcohol addiction for many years, explained that he can connect and relate to a service user on a different level than social workers, by virtue of his own experiences. He intentionally uses his own experiences to establish trust and destigmatize the service users' behaviors. Another PRW, a man who had been a drug addict for 25 years, had started as a peer four months before the study started. He said he wanted to use his painful self-experience to do something useful: I feel that is a good feeling in a way . . . to be the one . . . be sober and, to be a role model for somebody else . . . But I don't know. I am done with drugs, so that's not a . . . But it gives me energy, of course, and courage and that sort of thing -to see people changing themselves.
One peer, a man who had been a broker for years, had used drugs and alcohol until he couldn't cope anymore. He likes being a PRW and using his own experiences in the work made him realize how far he has come in his own recovery: Another informant stressed the importance of having personal experiences with substance abuse: But I also think that the whole mentoring scheme and how it works is great. I could probably have had more than three [i.e., service users] . . . It's an idea that's really great. Because we also -the group of recovery workers at the guidance meetings -we have a competence, and we can look each other in the eyes in a COMPLETELY different way than you will ever understand.
The PRWs highlight several elements connected to own experience in the interviews. Connecting to service users in ways other than as professionals is defined as basic for establishing trust and destigmatization. Destigmatizing the service users means adding nonprofessional, but equally important, perspectives regarding addiction, illness, and care to the services. Using their experiences was seen as one way of expressing the PRWs' roles as experts on illness, substance abuse and the need for care.

Theme 2) gaining distance from one's own illness
The informants expressed development within themselves as they worked as PRWs. They got more practical knowledge of "what works" while working with people who are currently using drugs.
A man who had struggled with alcohol abuse for many years said he had quit his job as an accountant to start working with the PRS services. At the time of the interview, he had been a PRW for six years. He wanted something else in his life, and now he has gained competence in what he was doing: The PRWs expressed that having distance from one's own substance abuse is vital for peer work, and sometimes they needed to concentrate to remind themselves of that. At the same time, it was important for the PRWs to accept that service users might be using drugs while still in a treatment process. In this way, the PRWs may expand the existing limited understanding of drug rehabilitation and contribute to alternative approaches to drug rehabilitation.

Theme 3) recovery as a joint challenge
The most significant challenge that all the informants talked about was the need for boundaries in the work as a PRW. Maintaining boundaries was difficult both in relation to maintaining appropriate distances in their emotional connection to the service user, and in relation to drawing boundaries for the amount time spent in peer work. Boundaries could also be an expression of difficulties that they needed to manage in their own recovery processes. Several of the PRWs emphasized the role and support of the program coordinator as significant to their work and well-being. All the informants indicated positive feelings toward their contact with the program coordinator. When asked about the monitoring by the program coordinator, one peer recovery worker said: Another experienced PRW also talked about the danger of co-addiction: One PRW talked about the problem of being too involved: We [i.e., PRWs] have to take care so that we don't get too involved. I know other PRWs; they talk with their service users three times a day. I don't have time or the strength to that. I would have been exhausted.
The PRWs valued guidance from the program coordinators and looked upon the guidance process as a part of their own recovery. Functioning as a PRW within substance abuse services was a part of their own way back to a more normal, drug-free life. The challenges with, and need for, boundaries also created pictures of their own recovery processes. They recognized the potential limitlessness of the service users, which helped them understand the need to set limits for themselves at the same time. So, in many ways, the recovery process is a joint challenge, which is something that the program coordinators, the PRWs and their service users need to be aware of, because they are all taking part in several ongoing recovery processes. In this process, working as a peer may be therapeutic in itself. As a PRW, one not only takes a responsibility for one's own recovery, but also for a service users' recovery.

Theme 4) flexibility as a prerequisite for recovery services
In contrast to most public health services, the PRWs are available outside ordinary working hours and also on the weekends. One PRW emphasized flexibility in the service as a way of creating a feeling of safety and availability for the service user. Several of the peer recovery workers emphasized the benefits of flexible working hours, and that the flexibility in the work facilitated their own adaptation to working life. One of the men said the flexible organization of the PRS was important because it enabled him to better manage his everyday life: It is wonderful that it is so free. I can choose to NOT meet anybody for a whole day and take a day off -I can be my own boss.
Flexibility in how the PRWs approached the service users and how they chose to reach out to them was appreciated by the PRWs and was an opportunity to experience feeling of mastery in their work. The flexibility needed in the services requires an understanding and acceptance of the life of the service users from the PRWs' view. The PRWs emphasized flexibility in terms of freedom by acknowledging that the mutual involvement of the PRWs and the service users may encourage greater social inclusion for both groups.

Discussion
This paper aims to contribute knowledge about PRWs' experiences with the PRS, and what they themselves recognize as important in their competences. People with previous addiction challenges, who act as paid support persons for others with ongoing substance abuse challenges, often feel the need to explain to professionals what they contribute in terms of mental health and substance abuse services (see Mancini, 2018). The thematic analysis revealed that the PRWs have four steps related to their own experiences as former drug addicts that they consider essential for being able to practice and develop as a peer recovery worker. In addition to earlier research literature, focusing on PRWs lived experience (Davidson et al., 2006;Kemp & Henderson, 2012;Kessing, 2021), we understand the PRWs four steps, as articulated in this paper, as prerequisites for practicing as a PRW.
The first theme is about the importance of one's own experience with substance abuse, which allows the PRWs to be experts on a particular illness. The PRWs' notions of their own recovery processes in relation to other people's processes is prominent. The second theme, getting some distance from one's own illness, underlines the importance of developing professional skills as a peer recovery worker. The PRWs in this study have developed a distance to their own substance abuse challenges, and they feel they can handle those challenges in a different way in relation to their service users.
They think about their own security, and they have an ongoing consciousness related to their own way out of addiction. One way of handling a peer's drug abuse is to keep an emotional distance and protect oneself, which is tightly interwoven with the third theme, being recovery as a joint challenge. The informants underlined the importance of not crossing important boundaries. Doing so is seen as a risk, not only to oneself, but also to the service user's recovery process: the PRWs are very aware of the double recovery process that is going on. The fourth and last theme is related to flexibility as a prerequisite to recovery services. "Normal business hours" is not necessarily adjusted to the life and routines that the service users live by, and not necessarily the PRWs' lives either. The PRWs expressed appreciation for being able to have different working hours and for being able to help somebody outside "office hours." Flexibility is also connected to the PRS and its approach to service users. When all these four steps are acknowledged by a PRW, she or he has gained a recovery competence necessary for practicing in PRS.
Our findings contribute to an understanding of the importance of recovery competence in the field of drug rehabilitation. This competence enables the PRWs to have a unique understanding of the service users' situations (Foster, 2011;Greenwood, Habibi, Smith, & Manthorpe, 2015;Kling, Dawes, & Nestor, 2007;Visa & Harvey, 2019). The informants in our study highlight the PRS as advantageous for the wellbeing of both PRWs and the service users. The relation between being a role model and being an expert-by-experience gives the PRWs an additional way to self-recovery while at the same time they are helping their service users. The PRWs give their service users emotional support, which leads to an enhanced ability to cope themselves (Visa & Harvey, 2019). The PRWs know, from their own rehabilitation, how important it is that support be flexible and accessible. To take control over one's own life again, and to stop being controlled by the need for drugs, one needs flexible support. Flexibility, from underneath the umbrella of support, can be thought of as the ribs from which successful rehabilitation derives. Flexibility is, in our view, closely related to mutual trust, trust that is based on the common ground of the peer's own experience with substance abuse.
From our point of view, there are several benefits of the PRWs having recovery competence within the PRS. We have categorized these benefits of competence into six themes: (1) the PRWs are experts on their own illness and need for care, and can therefore approach peers as equals (2) the PRWs have a variety of important perspectives on addiction, illness, and care, (3) the work of PRWs may help everyone better understand drug rehabilitation, (4) the PRWs can contribute alternative approaches to drug rehabilitation (the acceptance of service users being in a process to become drug free), (5) working with peer recovery may be therapeutic in itself, and, finally, (6) mutual involvement from the PRWs and the service users encourages greater social inclusion for both groups.

Limitations of the study
There were some methodological shortcomings to this study. We did not collect the diagnoses from the PRWs and knowing those details could have provided further richness to the findings. Furthermore, the study originally intended to include more interviews with more informants, but due to the Covid-19 pandemic, those plans had to be changed. Conducting the interviews face to face was an important issue for us, so instead of trying to interview people remotely, we decided to start working with the six interviews we had already collected. The study might have benefited from a larger sample, but the six informants reflected multifaceted experiences. The informants were recruited by their own program coordinators, which may have influenced their participation. Lastly, the informants also may have felt a pressure to positively evaluate the rehabilitation model. However, we informed them of our independence of their user organization and secured their anonymity. All the informants said they were happy to take part in the study, and they felt they were contributing to something important for the PRS.

Implications for practice
Our findings contribute to the understanding of how PRWs can supplement community health services and highlight the unique benefits that PRWs and former drug addicts can provide. These benefits can be important to peoples' rehabilitations, and for the wellbeing of PRW and the person in need of assistance.

Conclusions
The findings from this study can be of practical relevance to those aiming to develop mental health distress and substance abuse services, encourage greater patient participation, and further investigate aspects of participatory peer service development. The experiences of users are increasingly recognized as valuable assets and have been built into the development of different services, and co-produced goals have gained a greater focus. At this time, the role of municipal and specialist health services as service providers has diminished, which creates the need for participation in selfhelp and emphasizes the need for peer recovery workers (PRWs) to collaborate with service providers in service development. New organizational solutions promoting sustainable health services, recovery, coping, user involvement, and more efficient peer recovery services (PRSs) are needed to realize this opportunity. Collaborative practices can expand to embrace the active participation of service users (Beresford & Carr, 2016;Karlsson & Borg, 2013). The Norwegian government's policy on PRS underlines the need to ensure user involvement through free treatment options, additional user-driven solutions, and stronger participation in designing the services (Ministry of Health & Care Department, 2016).