“Addiction is an adaptation,” says Lisa Neumann, CPC life skills and recovery coach and author of Sober Identity: Tools for Reprogramming an Addictive Mind. “It’s the cage we built to function in the world, yet we don’t see we are both architect/builder and architect/destroyer. My job is to ask questions that make my client think—deeply—about the meaning of their life, their philosophy and their purpose for being on Earth.”
“Recovery coach,” “sober coach,” “sober companion,” “recovery manager,” “recovery support specialist,” “recovery guide”—peer recovery support professionals go by many names. Their paid services, meant to help initiate and sustain recovery efforts, are provided by non-clinicians whose primary credential is their personal experience—with plenty of attendant controversy.
The sharing of recovery experience is deeply rooted in addiction treatment, but the specialization of this kind of support has undergone rapid growth in the past decade. It has remained largely unregulated, and there is no way to determine exactly to what degree the field has grown; but indicators include the rapid increase in peer recovery support schools, programs, organizations and associations, and in recent years, the emergence of regulating boards in hospitals and state governments.
The field is also firmly established in tabloids and popular culture.
A slew of celebrities—Owen Wilson, Robert Downey Jr. and Lindsay Lohan—have allegedly hired sober companions to help them stay off drugs. Starting in 2012, Lucy Liu began depicting a recovery coach on the hit CBS show Elementary (pictured above). Media stories—Live-In Sober Coaches Offer Wealthy Expensive New Way To Stay Clean; Why Sober Coaches Earn $1000 A Day; A Companion To Protect Addicts From Themselves—have largely portrayed these roles as overpaid babysitters. But peer recovery support specialists may assist people with goal-setting, education, employment, healthcare, housing, daycare, transportation and legal support.
This kind of support has previously been provided by outreach workers, case managers, volunteers and clinically trained professionals. Yet amid increasing demand for personalized, affordable treatment services, the peer-to-peer support business has mushroomed.
As the role’s myriad names suggest, recovery coaching has diverse definitions, applied very differently around the country—and this flexibility is arguably one of its strengths.
“There are many pathways to recovery,” says Jill Petsel, executive director of Minnesota Recovery Connection, one of five Recovery Community Organizations (RCOs) accredited by the Council on Accreditation of Peer Recovery Support Specialists (CAPRSS). “The philosophy we are using around recovery coaching, which is also where the state of Minnesota is going as this becomes a paid position, is to ensure that the person is at the center of the program. The coach’s role is to help that person navigate the system—if they are in the initial stages of recovery, what kind of treatment are they looking for?”
This personalized approach can make recovery coaching an appealing option for people struggling with addiction. “I did the inpatient rehabs, the outpatient rehabs, the sober houses—all of it,” says Stephanie, a 32-year old New Yorker who identifies as a recovering alcoholic. “My recovery coach did not have all the credentials my doctors had, but she was the first person I came across who didn’t make me feel like an addicted cog in a one-size-fits-all wheel.”
Rehabs and other recovery services frequently come under scrutiny for offering exclusively 12-step-oriented services. So recovery coaches, whose role is to adapt to various stages and modalities of recovery, as well as to individual preferences, are potentially filling an important demand for alternatives—despite the fact that they are not treatment providers, nor intended to exist in lieu of treatment.
“We put the person in the middle,” Petsel adds. “Instead of saying ‘Here’s the program and you have to fit into it,’ we say, ‘Here’s the individual—let’s find out what is going to work for them, and then navigate whatever barriers exist.’”
Like Stephanie, I first encountered the idea that the traditional 12-step trajectory—progressive consequences, rock bottom, sudden moment of clarity, spiritual awakening—was not the only valid recovery method from a recovery coach: Lisa Neumann.
“It seems like you’re struggling with this,” I remember her telling me, just three weeks after I asked her to be my 12-step sponsor. “Would you be open to trying something new?”
Lisa worked with me on a sliding scale, and for a period completely pro bono. We tried a few things. What I vividly remember, however, is that the focus of our work was not at all about my powerlessness. Our conversations centered around what I wanted to achieve in life, and the many things I could offer the world. She invited me to think really big, and not to feel guilty or naive for that. She also invited me, a bratty “addict” she hardly knew, into her home and to her young children’s sports games. She offered me an opportunity not to play the role of a drug addict for a few hours every week. This was not something I could possibly have ever gotten from a hospital-based inpatient program, or a 12-step meeting.
Of course there is no way to ensure that all, or even most, recovery coaches will act so kindly, or will even be open to the idea of 12-step alternatives. But the demand is there. “My job is to bring them to a sober/recovered world that is infinitely better than anything they could possibly have imagined,” Lisa says.
In a treatment system largely focused on acute needs, the provision of longer-term support into the context of people’s daily lives makes perfect sense. More than 50% of people discharged from addiction treatment resume their substance use within one year (most within 30-90 days), and peer support has been shown to help mediate this transition.
When ethical lines are crossed
Recovery coaching emerged as a form of service work done between close members of recovery communities. But today, coaches operate in a wide range of organizational settings. Some individual consultants cater to wealthy clients; others work within state hospitals and treatment centers. Some operate within the criminal justice system, and others still work for specialized social service agencies. These environments all have different cultures, funding sources and perspectives. So ensuring the consistent ethical delivery of peer recovery support can be challenging.
“There are a lot of people out there who are promoting themselves as recovery coaches but what they are actually doing is serving in a sponsorship role and getting paid for it,” Petsel says.
Although the roles of traditional sponsor and recovery coach have similarities, a sponsor works exclusively within the framework of a 12-steps program. A paid recovery coach should follow the client’s wishes regarding choice of program, and altogether play both a more practical and holistic role in that person’s life.
Confusion around these differences has resulted in accusations that recovery coaches are nothing but (unethically) paid sponsors or unqualified healthcare providers. As a result, much of the literature and conversation necessarily centers around what the job is not: A recovery coach is not a 12-step sponsor, therapist, clergy member, nurse or physician.
“Even if they are one of these other things, they have to take that hat off when they are acting as a peer recovery coach,” says Patty McCarthy Metcalf, executive director of Faces & Voices of Recovery. “They have to stay within their expertise and lane, and boundaries can easily be blurred if a peer support specialist is hired within a treatment center. Recovery coaches are not mini-clinicians—they should not be handling paperwork, filing, supervising urine tests or anything else that puts them in a role of authority.”
Recovery coaches are in a unique position to receive sensitive information from people who may feel vulnerable to the significant power differential between themselves and clinical professionals, and the external accountability governing that relationship. It is common throughout medical practice, including around cancer or depression or childbirth, to use peer support in this way; in fact, there is scarcely a specialty where peer support is not recognized as a valuable adjunct to medical interventions.
And the role has the potential to be particularly valuable in the field of addiction—both because the stigma of addiction can make open communication difficult for patients, and because recovery coaches could provide the link between professional clinicians and the larger communities (including sober homes) where recovering people live.
“I have a colleague who works in Hennepin, the largest county in Minnesota, and they began using recovery coaches with their Diversion and Recovery Team (DART),” Petsel says. “This is a clinical team working with the most chronically homeless and addicted. They had a patient they’d been working with for years—the man had been detoxed 36 times and was going to go to prison if he didn’t successfully complete their program. Something suddenly clicked inside of him when he started working with a recovery coach.”
This, of course, is anecdotal. But although research remains limited, there is evidence to show that the role’s essential services are a promising adjunct to clinical practice. Improved outcomes have been especially notable when peer support is provided to people with chronic conditions that require long-term self-management.
Concerns, however, remain: “We’ve all heard stories about the recovery coach who drinks with their clients, or the sober house using rent money for a meth lab,” Stephanie says. “It certainly exists, and I don’t know if there is a way to stop it entirely.”
“It’s common [to come across people who are still in active addiction yet acting as recovery coaches]” Lisa adds. “However, it’s not exclusive to the coaching industry. People can just be full of shit until they aren’t. The best suggestion I can make is for people to do research on a prospective coach. Find someone that has a good reputation amongst their peers and within their community. What organizations, associations, affiliates do they have. What other credentials do they possess?”
Problems of role ambiguity and conflict are inevitable when a job’s duties are not clearly delineated, and when there is no mutual understanding of the expectations. Attempts to standardize peer-based roles have been challenging, and further complicated by efforts to protect certain roles in the field, as well as the personal, institutional, and financial interests embedded within those roles.
“I’ve come across many addiction counselors who fear their job could be replaced,” Petsel says. “But in the case of recovery coaching, it’s in addition to—not in lieu of. Recovery coaches will never replace the need for a licensed addiction counselor or a psychiatrist.”
The debate between experiential authority and formal education has a long history. Although many recovery coaches have some training, it is their personal experience that is their foundation. Efforts to standardize the role, consequently, have been complicated.
“Recovery coach trainings have been happening across the country for some time,” says Patty McCarthy Metcalf. “There was a lot of enthusiasm about the role but no real plan about how these people would be placed in actual service roles. On one level, these trainings were a fantastic opportunity for people with a personal interest to find their peer-group. But since the rest of the system wasn’t in place, many of these people are now trying to do this on their own. The fact is a certificate of completion from a training is not a credential; it just means you went through a training.”
Ad hoc efforts to train recovery coaches came to a head in 2010 when the rapid growth of the role garnered increased scrutiny and pressure for greater organizational hierarchy. Faces & Voices of Recovery saw the need for these systems to be developed by leaders in the recovery community, rather than being imposed on them by a third party. They convened community experts, advocates and allies, and in 2013, the Council on Accreditation of Peer Recovery Support Services (CAPRSS) was established. To date, CAPRSS is the only accrediting body in the country for recovery community organizations (RCOs) and other programs offering addiction peer recovery support services.
Orientation, training, and supervision protocols are still at a relatively early stage of implementation for individual recovery coaches who are operating on their own as well. The states have been tasked with ensuring individual recovery coaches are meeting standards of care. There is variation from state to state, but most have built their certification process around the International Certification & Reciprocity Consortium (IC&RC) standards, trainings and exam. Outside of these systems, there is little accountability for individual recovery coaches.
“Recovery coaches operating on their own and without real training can jeopardize our relationships with treatment service providers, single state authorities, licensing and credentialing boards, and other experts,” McCarthy Metcalf says.
These relationships are critical to the future of the role, as most organizations employing recovery coaches depend on state and local funding and federal block grants. While 36 states offer the ability to bill Medicaid for peer support services around mental health, only a third of those have similar provisions for addiction. These provisions, however, have created precedent for peer recovery support service to be considered reimbursable expenses in other states. The Affordable Care Act’s behavioral health parity requirement, combined with a shortage of traditional clinical providers, has also created increased opportunity for the federal and state funding of peer recovery support specialists.
With new sources for funding on the horizon, specialized peer-to-peer support roles are likely to become increasingly prevalent throughout the addiction field. Some argue that the rapid expansion and commercialization of the job could inadvertently teach coaches to view themselves as the source of their authority, rather than their personal experience and connection with the recovery community.
But if recovery-oriented systems of care do not compromise the role’s essence, the carefully regulated expansion of peer-to-peer specialty roles could bridge the longstanding chasm between clinical treatment providers and the larger recovery community, potentially providing life-transforming help.
Chelsea Carmona is a writer and activist living in Los Angeles. You can follow her on Twitter: @CarmonaChelsea.