Representative Bureaucracy through Staff with Lived Experience: Peer Co-Production in the U.S. Substance Use Disorder Treatment Field

Background and Purpose. Representative bureaucracy literature concerns service providers’ descriptive representation of marginalized identities of service users and how their representativeness can be translated into more equitable policy and program administration processes. Despite important contributions to our understanding of how providers sharing users’ minority identities can ameliorate inequities in human service administration processes, the literature has major gaps. First, most studies have focused on racial, ethnic, and gender group representation with limited attention to other attributes (e.g., experience of immigration and having a disability that may shape providers’ values and behaviors. Second, few representative bureaucracy studies were done in human service fields where privately-owned organizations assume most human service responsibilities. This exploratory study is an attempt to address these gaps. We use individuals’ lived experience of marginalization and stigma as a core identity that may influence bureaucrats’ perspectives and values and motivate them to serve as representatives of vulnerable service users—the peer co-production mechanism. This study uses the field of substance use disorder (SUD) treatment in the United States as an example, where a significant proportion of the workforce has firsthand SUD experience and the emphasis on responsive services is growing as private organizations offer most of the services.

Methods. Using the data from a nationally representative survey of alcohol and drug use disorder treatment clinics in the United States (2017 National Drug Abuse Treatment System Survey; n=657; 90% response rate), we examine factors associated with descriptive representation (presence of staff with firsthand experience of a substance use disorder in frontline treatment and senior positions) and directors’ perceptions of recovering staff’s potential to serve as user representatives in individual care and organizational decision-making processes. Depending on the characteristics of outcome variables, we used multivariate linear and logistic regression with various environment and organization-level control variables (e.g., located in Medicaid expansion state, revenue sources, staff and patient compositions).

Results. Recovering staff accounted for a third of the field’s workforce, but the majority of clinics did not employ them in senior staff positions. At about a half of the clinics, staff with lived experience are perceived to have relatively less influence over organization-level decisions. Regression results suggest that organizational leaders’ recognition of recovering staff’s unique representation capacities may facilitate greater descriptive representation at both frontline and senior positions, and grant meaningful organizational decision-making authority to recovering staff. Clinics that employed more staff with specialized training and whose clinical supervisor emphasized the medical service field’s normative practice (i.e., patient-centered care) were expected to hire fewer recovering individuals and their directors were less likely to believe in the recovering staff’s potential to represent patients’ concerns.

Conclusions and implications. This study extends the representative bureaucracy literature in multiple dimensions and invites future studies to explore how under-explored identities may influence service providers’ values and behavior and organizational effectiveness in various service settings. The study encourages managers to consider the potential roles staff with lived experience could play in providing more responsive and equitable services (e.g., by advocating users’ concerns and educating other staff members).