Working With Specific Populations

Upon completion of this section, you should be able to:

  • Define diversity, equity, and inclusion and how it can effect your day to day interactions, and
  • Describe strategies to work in different ways with members of some populations.

Diversity, Equity, and Inclusion

In the most basic way, diversity refers to differences in identity. Understanding diversity can help peer support specialists meet the needs of the whole person.

These may include personal, social, linguistic, and cultural subgroups such as race, ethnicity, sex, gender identity, sexual orientation, age, socioeconomic class, physical or intellectual abilities, religions, value systems, national origin, and political beliefs.

Beyond that, it can include people who live in crowded urban centers or remote rural villages. People with mental health and addictive disorders may have experienced homelessness, poverty, and limited work histories, or they may come from economically privileged backgrounds. Recovery is inclusive. Inclusion means everyone is welcome, can feel as though they belong, and are part of a community where all people:

  • are treated fairly and respectfully,
  • have equal access to opportunities and resources,
  • and can contribute fully to their community to the best of their abilities and wishes.

Equity is not the same as equality. Equity often requires ensuring people have resources based on their individual needs and removing barriers specific to certain groups of people.  In the first picture, it is obvious that not all of the characters have an equal opportunity to see the game. The second and third pictures show how making accommodations and removing barriers promote equity and inclusion for all.

Upon completion of this section, you should be able to:

  • Define diversity, equity, and inclusion
  • Give examples of subgroups that often experience barriers to recovery.
  • Discuss the needs of some of the specific populations peer support specialist often work with.

Sex and Gender

Gender refers to a person’s identity formation and presentation as male or female, the ways social institutions respond to a person based on perception of masculinity or femininity and the amount of power a person has. Gender roles influence family and community life, socioeconomic status, and acceptable standards of behavior for men and women.

Sex is tied to biology. Sex-linked differences in the way women metabolize substances apply to all women and girls from every culture. For example, an adolescent girl typically passes out after five drinks of alcohol and a boy after nine due to differences in stomach enzymes, water to fat ratios, etc. Women become physically dependent in a shorter period of time at lower levels of consumption and tend to experience more severe withdrawal (NIDA, 2005).

The Genderbread Person is an educational resource that explains the concepts of sex and gender.

Gender-based social stigma seems to also be universal to women’s substance use across cultures (EMCDDA, 2009) influencing when and where women enter doorways to treatment. Research has shown that women, but not men, commonly report stigma as one of the top reasons they do not seek treatment for substance use disorders (CSAT, 2009)  Mental health and addictive disorders can increase vulnerability to sexual and physical violence against women.

Gender non-conforming, non-binary, and LGBTQIA+ individuals are also more vulnerable sexual and physical abuse in childhood and adolescence and may experience abuse at home and at school. These developmental traumas can contribute to mental health problems and early initiation of substance use, which increases vulnerability to addictive disorders.

Considering Specific Populations

The examples below are just a few of the other equity considerations peer support specialists can expect to encounter. This section also has more detailed information on working with some of the underserves groups that tend to experience specific barriers.

Socioeconomic Status

People with fewer socioeconomic resources are more likely to rely on services that accept Medicaid, publicly funded behavioral health services, or may be uninsured entirely. It may be more difficult to access quality care and supportive services that meet their full range of needs. Often it is impossible to take time off work, pay the cost of transportation and childcare or access the internet for telehealth care. People may not have access to Many rural and urban low-income areas are considered medically underserved and have documented shortages of mental health providers.


Individuals with mental health and addictive disorders from racial and ethnic subgroups often experience discrimination within healthcare systems which can deter them from seeking help. Immigrant and refugee populations may experience discrimination as well as language barriers. They may face stigma within their social networks and communities.


Some religions forbid alcohol and drug use, while others may consider mental illness a punishment for sin or consider it shameful to seek outside help. Religions also have healing traditions that are important an important aspect of recovery for many individuals. Some atheist and agnostics may have a hard time with self-help support groups that have a spiritual component.

Geographical Location/Environment

Many people do not have easy access to treatment and recovery supports based upon where they live. One common challenge is transportation. This is often the case in rural areas but may also be the case in urban communities that lack reliable public transportation.

Working with people involved with the justice system

Having a mental health or substance use problem is not against the law; however, nationally, about half of individuals in state prisons had a diagnosed mental illness, more than a quarter had an addictive disorder, and nearly a quarter had both. The situation in jails is similar with an estimated 44% of people sentenced to jail having been diagnosed with a serious mental illness, 63% with an addictive disorder, and 45% with both conditions.

But the information above doesn’t include the largest segment of the jail population, comprised of people who have not been convicted, are awaiting trial, but cannot make bail. Although jail and prison populations have decreased recently due to the COVID-19 pandemic, the situation in California jails and prisons is much the same as the rest of the country. Because there are such disproportionate numbers of people with mental health and addictive disorders involved with the system, peer support specialists need to be familiar with the different ways people may be involved with the justice system.

When people with co-occurring disorders are incarcerated, they are likely to have significantly longer stays as compared to those serving sentences for similar crimes without either disorder, more disciplinary actions while in prison, and more incidents of victimization while incarcerated (Wolf, Shi, & Blitz, 2008). [NM3] When individuals with COD’s are released, they are more likely to be homeless, suicidal, use substances, and not surprisingly, rearrested (Moynahan et. al, 2001; Peters et. al, 2008).

Diversion and alternatives to incarceration

There are several types of justice programs that divert people with substance use and mental health issues from the justice system and connect them to services and supports instead. Peer support specialist often work in or with some of these programs.

The earliest point of justice system contact is usually with police. Many large police departments now have crisis intervention teams (CIT). These are officers with special training that respond to calls that may involve someone with a mental health or substance use and mental problem. In the case of pre-arrest diversion, police take them directly to mental health crisis services instead of arresting them. Sometimes individuals who are arrested are connected to services instead of being booked into jail. Recently, more programs that respond to drug overdose emergencies are also diverting people from arrest to treatment programs.

There are also many types of court diversion programs, including mental health and drug court programs that either do not prosecute people or expunge the record of prosecutions for people who complete a court ordered program.

One of the most common alternatives to incarceration is probation. People may be sentenced to a term of probation, which means they can remain in the community under the supervision of probation if they do not violate certain conditions. Unfortunately, when people who are poor, have mental health issues, or untreated addictive disorders have a hard time meeting these conditions, they may end up in jail for petty offenses that normally don’t warrant incarceration.

Peer support specialists can play a role in helping people who are involved with the justice system remain in the community. This is true for people who are re-entering after spending time in prison or jail. Sometimes people re-enter after serving their entire sentence or they are released early and are on probation or parole. California has very high rates of recidivism, re-arrest, and re-conviction, which suggests re-entering people need a lot of support. Some peer support specialists are trained to work with people involved in the justice system. In some cases, they may even pursue national or regional peer certification that allows them to work with people in custody.

Suicide and overdose risks

The Bureau of Justice Statistics (BJS) has collected data annually on mortality in jails since 2000 and in state & federal prisons since 2001. The graph below is based on reports up until 2019 and does not include the impact of the COVID-19 pandemic. The leading cause of death in jails is suicide, but between 2001 and 2018 deaths due to overdose/drug or alcohol-related causes increased by over 200% in county jails, with most of these deaths taking place during the first few days in custody. Forty-two percent of all (2000–19) deaths due to suicide or drug or alcohol intoxication were among jail detainees who were awaiting trial and had not been convicted. Women in jails died due to drug and alcohol intoxication at nearly double the rate of men (for all years 2000-19).

Moreover, people with serious mental health problems are more likely to be exploited or victimized in jails and prisons. Some researchers believe this contributes to the high rates of suicide in custody. Several studies have shown sexual victimization in custody is a risk factor for suicide (Coles, 2010; Fazel et. al, 2017).

From 2001 to 2018, the number of people who have died of drug or alcohol related causes in state prisons increased by more than 600% (OJP, 2021). The problem is particularly sever in CA state prisons where drug overdose was the number two cause of death in 2019.

The risk of drug overdose is extremely high for people re-entering from a period in custody. One study found the risk of overdose death in the two weeks following release was 129 times the risk among the general population.

Research on prison inmates has shown:

At least 70–80% of prison inmates have witnessed one or more overdose events.
Up to a third have witnessed a fatal overdose.
At least a third have personally experienced an overdose.
A study of recently released prisoners who survived a drug overdose found the two of the most common reasons they gave for the overdose were:

A lack of knowledge about decreased tolerance levels after limited access to drugs, and
The increase in potency levels of street drugs during the time they spent in custody.[2]
People leaving mental institutions, detoxes, and even treatment programs who use drugs, especially opioid drugs, after a period of abstinence are also at elevated risk of overdose. Peer support specialists can provide lifesaving information on these topics to people who are transitioning back into the community.

Individuals with opioid and other substance use disorders are at risk perpetual risk of losing stable/temporary due to poverty, drug use, etc.  Youth may be thrown out of parental homes or may leave on their own.  Some individuals have relapsed, been considered ‘treatment failures’ and have been discharged or expelled from residential programs.

Opening doorways to hope – low threshold services

  • No commitment
  • No cost
  • Immediate access to MAT
  • Basic health & human needs
  • Safety & street outreach
  • Mobile & drop-in services
  • Abstinence not required
  • Syringes & supplies
  • Trauma-informed

Similar to housing first models, promising programs employ harm reduction, low threshold services that reduce barriers and offer a ‘safety first’ approach without requiring an immediate goal of complete abstinence or formal entry into treatment. Recognizing the interrelated nature of the problems helps people find wholistic solutions.


Harm Reduction Fact Sheet – National Health Care for the Homeless Council

Tip Sheet on Consumer Engagement – National Health Care for the Homeless Council

Strategies to Address the Opioid Crisis & Homelessness – Interagency Council on Homelessness