Recovery coaches offer a crucial link
Recovery coaches are individuals, who may or may not be in recovery themselves, who help people along the path of recovery—either before, during, after, or instead of treatment. That broad definition is based on interviews with and information from Faces & Voices of Recovery, the Substance Abuse and Mental Health Services Administration (SAMHSA), the International Certification and Reciprocity Consortium (IC&RC), NAADAC, the Association for Addiction Professionals (NAADAC), the Medication Assisted Recovery Support (MARS) program, managed care company Optum Behavioral Solutions, and others.
Who a recovery coach is and what his/her roles are varies, depending on the source. But there are some constants in the field's thinking about recovery coaches:
Recovery coaches are not therapists. They do not provide clinical help; rather, they help the person engage with treatment, and also help with various skills needed for recovery.
Recovery coaches are professionals who should be paid for their work. The payer, whether Medicaid or commercial insurance, is likely to make all decisions about role definitions and requirements.
Each state has its own rules for credentialing of recovery coaches.
One of the first groups to make recovery coaches a reality, albeit as volunteers at the time, was the Hartford, Conn.-based Connecticut Community for Addiction Recovery. By setting up telephone recovery support more than a decade ago, CCAR showed how a peer staying in touch with patients helped them meet recovery goals.
“Peer work is done in the community,” says Patty McCarthy Metcalf, executive director of Faces & Voices of Recovery, the Washington, D.C.-based organization representing recovery community organizations and people in recovery. “The model we’re advocating for is that treatment providers and health insurers will contract with peer recovery organizations” to provide recovery coaches, says Metcalf.
Non-clinical focus
Recovery coaches focus on non-clinical issues such as housing, employment, proceeding through drug court, and dealing with probation officers, says Metcalf. Recovery coaches also can help engage people who are waiting to get into treatment. “That’s where we lose so many people,” she says.
Colorado's Faces & Voices affiliate, Advocates for Recovery, has a SAMHSA grant (like many recovery community organizations). So the organization has to record how many people are served. “Right now we are probably serving 200 people,” says Advocates for Recovery executive director Tonya Wheeler, adding that this number includes people served by partners with which her organization (which has only three staff members) collaborates. Advocates for Recovery requires that individuals have a year of uninterrupted recovery before they can be trained as recovery coaches.
Wheeler, sober for the past 25 years, stresses that she was able to maintain her recovery mostly because of support. “I came from the 12-Step rooms; that’s where I got and maintained my recovery,” she says. But she adds that there’s a “huge difference between a sponsor and a recovery coach.” A sponsor is a 12-Step title, for the person who “works the Steps” with the recovering individual, she says.
Tom Coderre, senior advisor at SAMHSA, says the goal of a recovery coach is to help the person sustain recovery. “The entire system of recovery coaches and other peer-type recovery supports has grown organically, because our healthcare system hasn’t always responded to the needs of people with [substance use disorders],” says Coderre, whose roles prior to joining SAMHSA included board chair for Rhode Island Communities for Addiction Recovery Efforts (RICARES). “Our goal is to figure out where those gaps are, and fill them.”
Peers or not?
At IC&RC, the recovery coach credential is called Peer Recovery, and is for both addiction and mental health specialists. “Subject matter experts from both sides came together to develop core competencies and standards,” says Mary Jo Mather, IC&RC executive director.
Ultimately, IC&RC left the decision of whether the recovery coach has to be a peer to the credentialing and licensing board in each state.
In many states, Medicaid determines what the recovery coach will be reimbursed for. About half of the states require credentialed coaches to have a “lived experience” in addiction or mental illness, says Mather. This lived experience is determined by self-report—the “honor system,” she says. There is an assumption that recovery coach training is open only to peers anyway, says Mather—and based on comments from Faces & Voices, that is the case.
Metcalf believes recovery coaches in the addiction field need to be peers. SAMHSA does not include peer status in any formal definition of a recovery coach. However, peer status is required in grant programs such as the Targeted Capacity Expansion Peer-to-Peer grants, which are specifically geared toward peer development. In addition, some of SAMHSA’s Recovery Community Services Program is geared toward peers.
New York state has two separate certifications for recovery coaches—one for addiction and one for mental health. In the addiction arena, the coach does not have to be a peer in recovery. Rather, he/she can be a counselor in a treatment program, or a parent of a child with an addiction, basically anyone with “lived experience” related to addiction, explains Walter Ginter, project director of MARS, which has a project funded by a SAMHSA Recovery Community Services Program grant.
Career ladder
Ginter frequently reassures addiction counselors that recovery coaches aren’t going to steal their jobs. “It’s a different skill,” he says. “Recovery coaches aren’t counselors.”
“Some people want to use recovery coaches as cheap labor, and shame on the agency that does that,” adds Mather. “I am very clear that these are not clinicians.” But she notes that with additional education and training, the peer eventually could become a clinician.
“We’re training a lot of recovery coaches, but very few of them have jobs,” says Ginter. “It was never expected that people would make their living being recovery coaches.” Being a recovery coach is the first step in the career ladder toward being a counselor, he says. “The amount of money they get will be limited. Most people just want to give back. The recovery community is for giving back.”
Alexandre Laudet, PhD, senior staff member with New York City-based National Development and Research Institutes and one of the country’s top recovery researchers, says that the pioneering work done by CCAR in Connecticut is now being picked up by others. “Now that people realize there’s money to be made, the big organizations are jumping on it,” Laudet says.
She says it’s understandable if people, and agencies, want to get paid for the work they do. But she adds that helping people is also therapeutic to people in recovery. “It’s the embodiment of what Riessman called ‘helper therapy,’” Laudet says, referring to the work of Frank Riessman, first published in Social Work in 1965. “The peer is getting something out of it, too.”
Treatment provider's programs
There are two recovery support programs at the Hazelden Betty Ford Foundation, coming out of the two separate treatment organizations that merged. Nell Hurley, manager of recovery support with Hazelden Betty Ford, is in charge of the two programs: the Connection program and the MORE (My Ongoing Recovery Experience) program. Both are staffed by licensed alcohol and drug counselors (who also may be in recovery, but it’s not required), and both are for people who went through the Hazelden Betty Ford treatment program.
Connection is an 18-month monitoring program that includes random urine testing. The counselor, referred to as a recovery coach, calls the person on a weekly, biweekly or monthly basis depending on the stage of recovery. All contact occurs over the phone, in contrast to the recovery coaching that is happening face to face in the community.
“This is more like an extended case management program,” says Hurley. Hazelden Betty Ford sends a report every month to employers or other interested parties to indicate whether the person is following his/her continuing care plan. The patient—or sometimes the employer—pays for the Connection program, which insurance doesn’t cover. Currently there are about 190 active participants, says Hurley.
MORE is an online and over-the-phone recovery support program that is much less intensive than Connection, but is offered free of charge to anyone who goes through treatment at Hazelden Betty Ford.
Both programs reflect the movement in treatment toward recovery management, says Hurley. “We know that treating someone for 28 days or even 60 days and telling them, ‘Go to AA, and good luck’ doesn’t work all that well,” she says. Having only a continuing care plan doesn’t work either, she says. “People don’t follow the plan, until it’s hardwired, they know they feel better, and their lives are better,” she says.
The Medicaid dilemma
Advocates for Recovery, like most other community-based recovery organizations, targets “the population that doesn’t have a lot of money,” says Wheeler. This often means the people who can’t afford to pay for treatment that their insurance won’t cover. And most often, it means that Medicaid would be the most likely payer.
But Medicaid reimbursement is focused on states, and many states want a blended recovery coach—someone who can help both mental health and addiction clients.
Medicaid reimbursement remains on the distant horizon in Colorado, where certification is still nonexistent for addiction recovery coaches. To be reimbursed by Medicaid, the coach under current rules would have to be part of a behavioral health organization in the state, which poses another barrier.
“This is a lot of work,” says Wheeler. “I wish we had more people, and the grant doesn’t cover the rent.” For the first nine years, Advocates for Recovery operated without a geographic location.
“But you need a place to serve people, so it’s critical to have that space,” Wheeler says. “It’s somewhere someone can show up and say, 'I can’t find a job.’” For some, that job may end up being a recovery coach.
Alison Knopf is a freelance writer based in New York.
Managed care payer embraces recovery coaching
One of the first managed behavioral healthcare organizations to take an interest in recovery coaches is Optum Behavioral Solutions. This makes sense, with former Faces & Voices of Recovery director Dona Dmitrovic there running the recovery coaching network. The company currently contracts with two entities in the network to provide recovery coaching—one in Maryland and one in Rhode Island.
Optum relies on state credentialing requirements for recovery coaches that include state certification; if a state does not have certification available, it recognizes established programs such as that run by the Connecticut Community for Addiction Recovery (CCAR) in lieu of state certification.
“As a health plan, what can we do to support people making that long and difficult path to recovery?” says Martin Rosenzweig, MD, regional medical director for Optum and head of the substance use disorder treatment initiative across the behavioral health business. “You have to give individuals choices about how they will take that path.”
Some of the people being coached may still be using drugs or drinking, says Rosenzweig. “There are stages along the way to recovery, and we need to meet people where they’re at, and support them.” With substance use disorders, there is so much stigma that it’s hard for people to ask for support. “If you have cancer, people don’t blame you for it,” Rosenzweig says. “But with SUDs, people say you can control it—but you can’t, because it’s a disease.”
Physicians don’t have time to offer the kind of recovery support that coaches can give, says Rosenzweig. And support groups such as 12-Step fellowships and SMART Recovery may be difficult for some individuals who are “socially phobic” and have a hard time standing up in front of strangers, he says.
Recovery coaches are not babysitters
Some celebrities seek out “sober coaches” who are basically “paid to babysit,” says leading recovery researcher Alexandre Laudet, PhD. Nell Hurley of the Hazelden Betty Ford Foundation also uses the word “babysitter” to describe these individuals.
“Sometimes they’re called sober escorts,” says Hurley. They accompany the person—for a high price—and are often not licensed counselors or certified for anything, because they don’t get paid by Medicaid.
