Recovery coaching
Sponsor, Recovery Coach, Addiction Counselor:
The Importance of Role Clarity and Role Integrity
The recent growth in peer-based recovery support services as an adjunct and alternative to addiction treatment has created heightened ambiguity about the demarcation of responsibilities across three roles: 1) voluntary service roles within communities of recovery, e.g., the role of the sponsor in Twelve-Step programs, 2) the roles of clinically focused addiction treatment specialists (e.g., certified addiction counsellors psychiatrists, psychologists, and social workers), and 3) the roles of paid and volunteer recovery support specialists (e.g., recovery coaches, personal recovery assistants) working within addiction treatment institutions and free-standing recovery advocacy/support organizations.
New service roles sprout from the soil of unmet need. In the current worlds of addiction treatment and addiction recovery, a new role is emerging to bridge the chasm between brief professional treatment in an institutional setting and sustainable recovery within each client’s natural environment. This role is embraced under numerous titles: recovery coach, recovery manager, recovery mentor, recovery support specialist, recovery guide, personal recovery assistant, and helping healer. This role is specifically peer based and peer led.
The growing popularity of the role of the recovery coach (RC) is evident in both public and private mental health and addiction treatment organizations.Peer-based service models are growing rapidly in the mental health service arena, particularly for clients with co-occurring psychiatric and substance use disorders.
There are several key research findings that underscore the need for sustained recovery
support services and the potential of the recovery coach’s role. A growing number of studies
confirm that addiction recovery:
• begins prior to the cessation of drug use;
• is marked in its earliest stages by extreme ambivalence;
• is influenced by age-, gender-, and culture-mediated change processes; and
• involves predictable stages, processes, and levels of change; and that
• the factors that maintain recovery are different from the factors that initiate recovery
(Waldorf, 1983; Frykholm, 1985; Biernacki, 1986; Grella & Joshi, 1997; Wechsberg,
Craddock & Hubbard, 1998; Klingemann, 1991; DiClemente, Carbonari & Velasquez,
1992; Prochaska, DiClimente & Norcross, 1992; Humphreys, et al., 1995).
These findings suggest that the types of needed clinical and non-clinical recovery support
services differ across clinical populations, and differ within the same individual across the
developmental stages of his or her addiction and recovery careers.
The importance of early and sustained recovery support is further indicated by treatment-related
studies confirming that:
• most people with alcohol- and other drug-related problems do not seek help through
mutual aid or professional treatment (Kessler, 1994; Cunningham, 1999; Cunningham
& Breslin, 2004);
• less than half of those admitted to publicly funded addiction treatment successfully
complete treatment (SAMHSA, 2002; Stark, 1992);
• more than 50% of individuals discharged from addiction treatment resume alcohol and/or
other drug (AOD) use within the following twelve months (Wilbourne & Miller, 2003),
most within 30-90 days after discharge (Hubbard, Flynn, Craddock & Fletcher, 2001);
• recoveries from severe AOD problems are not fully stabilized (the point at which the risk
of future lifetime relapse drops below 15%) until between four and five years of
sustained remission (Vaillant, 1996; Dawson, 1996; Jin, Rourke, Patterson, et al.,
1998) or longer for some patterns (e.g., opiate addiction) (Hser, Hoffman, Grella &
Anglin, 2001);
• the transition from recovery initiation to lifelong recovery maintenance is mediated by
processes of social support (Jason, Davis, Ferrari & Bishop, 2001; Humphreys,
Mankowski, Moos & Finney, 1999); and
• assertive approaches to post-treatment continuing care can elevate long-term recovery
outcomes in adolescents (Godley, Godley, Dennis, et al., 2002) and adults (Dennis,
Scott & Funk, 2003).
Considerable effort is underway to answer key questions related to recovery coaching functions
(e.g., should these functions be integrated into an existing role or offered within a new service
role?) and to determine where in the organization these functions can best be placed (e.g., are
recovery support services best integrated within existing addiction treatment programs or within
free-standing, peer-based recovery advocacy and support organizations?).
The piloting of the recovery coach’s role around the country is triggering such questions and comments as: 1)
“Why do people need a recovery coach if they have access to a Twelve-Step sponsor?” and 2)
“We don’t need recovery coaches. These functions are already being performed by addiction
counselors, outreach workers, and case managers.”
If it is to survive, a new service role must stake out its distinctive turf and justify its existence,
and it must do so in the context of other roles claiming the same or adjoining territory. The
recovery coach’s role incorporates and refines some dimensions of existing roles (e.g., outreach
worker, case manager) and is positioned between two other recovery support roles: the
recovery support group sponsor
and the addiction counsellor. The purpose of this essay is to
differentiate between the roles of recovery coach, sponsor, and addiction counsellor and to
discuss the importance of clearly defining and maintaining the boundaries of these roles. We
will begin with a brief history of the evolution of voluntary and paid service roles that have
guided people into and through the process of recovery from severe alcohol and other drug
(AOD) problems.
THE EVOLUTION OF SPECIALIZED RECOVERY SUPPORT AND SERVICE ROLES: A BRIEF
HISTORY
The ancient art of Thebes and Egypt portrays the slaves of those addicted to alcohol caring for
their masters by administering medicines and other physical treatments (Crothers, 1893).
People specializing in helping those recovering from the acute and chronic effects of addiction
are as old as humankind, but these roles have a distinctive history in the United States, dating
from the eighteenth century. As alcohol problems arose among Native American tribes and
within colonial communities, there also arose abstinence-based social and personal reform
movements that contained the first specialized roles whose purpose it was to ignite and sustain
the recovery process. These earliest American recovery movements involved the first recovery
mutual-aid societies and America’s first addiction treatment institutions (inebriate homes,
inebriate asylums, addiction cure institutes, religious missions, and inebriate colonies).
The Washingtonian revival of the 1840s enticed more than 400,000 alcoholics to sign a
temperance pledge and participate in regular “experience sharing” meetings for those who had
pledged to remain sober. The new role of the reformed temperance leader challenged the
authority of physicians and clergy, who had served as the early leaders of the American
temperance movement. Reformed men like John Gough and John Hawkins traveled from
community to community giving charismatic speeches, offering personal consultations to
alcoholics and their family members, and helping establish local recovery support groups. The
financial payment these early recovery missionaries received from donations at their speeches,
or from the salaries they were paid by temperance organizations, became a point of
considerable controversy as mainstream members of these early recovery societies accused
these leaders of profiteering. The Washingtonian societies collapsed within a decade and were
replaced by fraternal temperance societies and ribbon reform clubs (e.g., the Blue Ribbon
Reform Club). Many of these groups lost their vitality over time due to restrictive membership
criteria (limiting membership “only to drunkards of good repute”) and to the loss of their outreach
and community service functions.
Competing with these early recovery support groups for ownership of AOD problems were two
other groups: the physicians who headed the newly formed inebriate asylums and addiction
cure institutes and the lay religious figures who were organizing urban missions and rural
inebriate colonies. Mainstream physicians and clergy looked with suspicion or outright disdain
at the growing numbers of reformed people who were beginning to organize their own
institutions for the care of people with addictions. Controversies over recovering people serving
as paid helpers raged both within recovery mutual-aid societies and within professional
treatment organizations.
Dr. T. D. Crothers, Editor of the Journal of Inebriety, wrote an 1897 editorial attacking the idea
that personal experience of addiction was a credential for understanding and treating addiction.
He claimed that those who cared for inebriates following their own cures were incompetent by
reason of organic defects of the higher mentality, and that caring for inebriates heightened the
recovering person’s vulnerability for relapse. Most of this debate over the source of special
expertise to help people wounded by alcoholism and other addictions was lost in the larger
collapse of addiction treatment institutions in the opening decades of the twentieth century.
From the ashes of this collapse rose an effort in 1906 by the Emmanuel Church in Boston to
integrate religion, psychology, and medicine in the treatment of mental disorders. Quickly
developing a specialty in the treatment of alcoholism, the Emmanuel Clinics pioneered the use
of lay alcoholism psychotherapists, a sober social club (the Jacoby Club), and the use of
“friendly visitors” (established recovering members making home visits with newer members).
Lay therapists such as Courtenay Baylor, Francis Chambers, and Richard Pea-body became
quite well known through their clinical practices and their writings, but lay therapists were
routinely threatened with lawsuits for practising medicine without a license.
The founding of Alcoholics Anonymous (AA) in 1935 led to the emergence of several new
service roles in the 1940s. The AA sponsor’s role and the core of today’s sponsorship rituals
emerged from the explosive growth of AA in Cleveland following a series of local newspaper
articles on AA published in 1939
; AA physicians and nurses worked with new “AA Wards” in
hospitals in Akron, New York, and Philadelphia; in the 1940s, AA members offering peer
support to others with alcohol problems led to paid positions as the first industrial alcoholism
specialists (the precursor to today’s employee assistance programs); and AA entrepreneurs
began opening “AA Farms” and “AA Retreats.”
The tension between peer support and professional care was played out repeatedly in this early
history in response to such events as AA co-founder Bill Wilson’s offer to work as a lay therapist
at Charles Towns Hospital in New York City. There were impassioned debates over the
distinction between and relative importance of psychological treatment on the one hand and AA
spirituality and fellowship on the other.
The result was a delineation of guidelines (particularly
AA’s Twelve Traditions) governing how AA members should and should not perform certain
roles within a re-emerging alcoholism treatment industry. Other Twelve-Step programs and
alternative recovery support groups also utilized or emulated these AA guidelines. However,
such guidelines did not completely eliminate the personal and professional double-bind that
recovering people experienced working in the treatment field.
There were several threads in the emergence of the modern addiction counsellor’s role. There
was the continuation of the lay therapist tradition with such model programs as the clinics
operated by the Yale Center for Studies in Alcohol in the 1940s and 1950s. There was the
codification of the “ counsellor on alcoholism” role within the “Minnesota Model” of alcoholism
treatment pioneered at Pioneer House, Hazelden, and Willmar State Hospital. There was the
“community alcoholism consultant’s” role of those working within the 1960s anti-poverty
programs and within some State programs (a role that focused more on community resource
development than on clinical assessment and treatment). There were the ill-defined roles of
those working within the rising halfway house movement of the 1950s and 1960s. And there
were the “ex-addict counsellors” working within the growing network of therapeutic communities
and methadone maintenance programs. As funding first increased for treatment services in the
1960s, a lively debate ensued over the question of whether formal education or recovery
experience better qualified one to treat the alcoholic and addict (see Krystal & Moore, 1963).
While this debate was going on in professional circles, recovery support societies raised
concerns that the quantity and quality of their own service work was weakening in tandem with
the growth of the professional treatment industry.
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The “paraprofessional” roles of “alcoholism counsellor” and “drug abuse counsellor” of the 1970s,
birthed within the earlier lay therapy tradition, were rapidly professionalized and modelled on the
roles of psychiatrist, psychologist, and psychiatric social worker. Education and training
requirements rapidly escalated in tandem with certification and licensing systems, as addiction
counsellors defined themselves as a “new profession.” Personal recovery became de-emphasized and many programs prohibited recovering counsellors from sharing that status with
their clients. The same was true for recovering people serving other professional roles in the
treatment field, e.g., physicians, nurses, psychologists, and social workers. As the percentage
of treatment professionals in recovery declined, recovering people continued to work in other
non-clinical service roles within the treatment field, e.g., those of outreach workers, case
managers, house managers, residential aides, detox technicians, research assistants (trackers,
interviewers, and case managers), and follow-up workers.
The emergence of the recovery coach’s role in the past decade has emerged from the
recognition of the need to reconnect addiction treatment to the more enduring process of
addiction recovery, to effectively link clients from treatment institutions to indigenous
communities of recovery, and to address complex co-occurring problems that inhibit successful
recovery. These recognitions are part of a larger shift in the design of addiction treatment from
a focus on acute bio psychosocial stabilization to a focus on sustained recovery management.
The recovery coach is a:
• motivator and cheerleader (exhibits bold faith in individual/family capacity for change;
encourages and celebrates achievement),
• ally and confidant (genuinely cares, listens, and can be trusted with confidences),
• truth-teller (provides a consistent source of honest feedback regarding self-destructive
patterns of thinking, feeling, and acting),
• role model and mentor (offers his/her life as living proof of the transformative power of
recovery; provides stage-appropriate recovery education and advice),
• problem solver (identifies and helps resolve personal and environmental obstacles to
recovery),
• resource broker (links individuals/families to formal and indigenous sources of sober
housing, recovery-conducive employment, health and social services, and recovery
support),
• advocate (helps individuals and families navigate the service system, ensuring service
access, service responsiveness, and protection of rights),
• community organizer (helps develop and expand available recovery support resources),
• lifestyle consultant (assists individuals/families in developing sobriety-based rituals of
daily living), and
• friend (provides companionship).
Equally important, the RC is NOT a:
• sponsor (does not perform AA/NA service work on “paid time”),
• therapist (does not diagnose or probe undisclosed “issues”; does not refer to his or her
support activities as “ counselling” or “therapy”),
• nurse/physician (does not make medical diagnoses or offer medical advice), or a
• priest/clergy (does not respond to questions of religious doctrine or proselytize for a
particular religion/church) (Excerpted from White, 2004b).
The words most frequently used to describe what the RC does include the following: identify,
engage, encourage, motivate, share, express, enhance, orient, help, identify, link, consult,
monitor, transport, praise, enlist, support, organize, and advocate. The fact that the RC fulfils
all of these functions is a strength and vulnerability of the RC’s role.
Recovery coaching is a form of strengths-based support for persons with addictions or in recovery from all substances, codependency, or other addictive behaviours Recovery coaches work with persons with active addictions as well as persons already in recovery. Recovery coaches are helpful for making decisions about what to do with your life and the part your addiction or recovery plays. Recovery coaches help clients find ways to stop addiction (abstinence), or reduce harm associated with addictive behaviours Recovery coaches can help a client find resources for harm reduction, detox, treatment, family support and education, local or on-line support groups; or help a client create a change plan to recover on their own.
Recovery coaches do not offer primary treatment for addiction, do not diagnose, and are not associated with any particular method or means of recovery. Recovery coaches support any positive change, helping persons coming home from treatment to avoid relapse, build community support for recovery, or work on life goals not related to addiction such as relationships, work, education etc. Recovery coaching is action oriented with an emphasis on improving present life and reaching goals for the future.
Recovery coaching is unlike most therapy because coaches do not address the past, do not work to heal trauma, and there is little emphasis on feelings. Recovery coaches are unlike licensed addiction counsellors in that coaches are non-clinical and do not diagnose or treat addiction or any mental health issues.
Brief history of recovery coaching
Recovery Coaching was first developed in 2003 as a professional life-coaching niche by Alida Schuyler, a coach credentialed by the International Coach Federation (ICF) and a woman in recovery from addiction. Ms. Schuyler wrote the first recovery coach certification training program specifically aimed at training students to coach persons with addictions. She also created the first special interest group for recovery coaches, and she co-founded the non-profit Recovery Coaches International with Andrew Susskind.[1]
William L. White used the term “recovery coach” in his 2006 paper Sponsor, Recovery Coach, Addiction Counsellor but later changed adopted the term “Peer Recovery Support Specialist” to emphasize a community-based peer model of addiction support. Alida Schuyler developed a professional model of life coaching for addiction recovery by blending the Minnesota Model and Harm Reduction model with the core competencies of the International Coach Federation (ICF). Schuyler believes that recovery coaches need to understand Harm Reduction as well as 12-step recovery because life coaches “follow the client’s agenda” for coaching goals and topics and not all are ready for abstinence.
Recovery coaching and addiction recovery support groups
Recovery coaches encourage (but most do not require) participation in groups such as Alcoholics Anonymous, Narcotics Anonymous, Al-Anon or non 12-step groups such as SMART, Women for Sobriety, Life Rings, etc. Recovery coaches do work with individuals who dislike groups to help them find their own path to recovery.
Niches within recovery coaching
There are also niches within recovery coaching such as food addiction, sex addiction, criminal addiction, codependency, under-earning, even coaches who specialize in such areas as recovery from divorce. Recovery coaches start wherever the client wants to start and support all forms of progress including abstinence, moderation, or using other forms of the harm reduction model.
What recovery coaches do
Recovery coaches support the client in achieving and maintaining a solid foundation in recovery, and building upon recovery to achieve other life goals that make recovery worthwhile. William White, pre-eminent scholar on addictions, worked closely with the Philadelphia community based recovery centre PRO-ACT, to prepare a document outlining the “Ethical Guidelines for the Delivery of Peer-Based Recovery Support Services”, (Faces and Voices of Recovery.org, 2007). The document provides a discussion of key ethical concepts as well as reviewing the core competencies of a coach. These guidelines are the definition of coaching roles as they relate to others in the realm of personal conduct and conduct in service relationships with the community service provider or treatment team. This document presents a simple statement of core competencies (Faces and Voices of Recovery.org, 2007)
Recovery approach
A recovery approach to mental disorder or substance dependence (and/or from being labeled in those terms) emphasizes and supports a person’s potential for recovery. Recovery is generally seen in this approach as a personal journey rather than a set outcome, and one that may involve developing hope, a secure base and sense of self, supportive relationships, empowerment, social inclusion, coping skills, and meaning. Other names for the concept are recovery model or recovery-oriented practice.
Originating from the 12-Step Program of Alcoholics Anonymous and the civil rights movement, the use of the concept in mental health emerged as deinstitutionalization resulted in more individuals living in the community. It gained impetus as a social movement due to a perceived failure by services or wider society to adequately support social inclusion, and by studies demonstrating that many can recover. A recovery approach has now been explicitly adopted as the guiding principle of the mental health or substance dependency policies of a number of countries and states. In many cases practical steps are being taken to base services on a recovery model, although a range of obstacles, concerns and criticisms have been raised both by service providers and by recipients of services. A number of standardized measures have been developed to assess aspects of recovery, although there is some variation between professionalized models and those originating in the psychiatric survivors movement.
Elements of recovery
It has been emphasized that each individual’s journey to recovery is a deeply personal process, as well as being related to an individual’s community and society. A number of features or signs of recovery have been proposed as often core elements, however:
Hope
Finding and nurturing hope has been described as a key to recovery. It is said to include not just optimism but a sustainable belief in oneself and a willingness to persevere through uncertainty and setbacks. Hope may start at a certain turning point, or emerge gradually as a small and fragile feeling, and may fluctuate with despair. It is said to involve trusting, and risking disappointment, failure and further hurt.
Secure base
Appropriate housing, a sufficient income, freedom from violence, and adequate access to health care have also been proposed. It has been suggested that home is where recovery may begin. Housing services, if required, need to flexibly involve people and to build on individuals’ personal visions and strengths, instead of “placing” and potentially “re-institutionalizing” people.[7]
Self
Recovery of a durable sense of self (if it had been lost or taken away) has been proposed as an important element. A research review suggested that people sometimes achieve this by “positive withdrawal”—regulating social involvement and negotiating public space in order to only move towards others in a way that feels safe yet meaningful; and nurturing personal psychological space that allows room for developing understanding and a broad sense of self, interests, spirituality, etc. It was suggested that the process is usually greatly facilitated by experiences of interpersonal acceptance, mutuality, and a sense of social belonging; and is often challenging in the face of the typical barrage of overt and covert negative messages that come from the broader social context.
Supportive relationships
A common aspect of recovery is said to be the presence of others who believe in the person’s potential to recover, and who stand by them. While mental health professionals can offer a particular limited kind of relationship and help foster hope, relationships with friends, family and the community are said to often be of wider and longer-term importance. Others who have experienced similar difficulties, who may be on a journey of recovery, can be of particular importance. Those who share the same values and outlooks more generally (not just in the area of mental health) may also be particularly important. It is said that one-way relationships based on being helped can actually be devaluing, and that reciprocal relationships and mutual support networks can be of more value to self-esteem and recovery.[5]
Empowerment and Inclusion
Empowerment and self-determination are said to be important to recovery, including having self-control. This can mean developing the confidence for independent assertive decision making and help-seeking. Achieving social inclusion may require support and may require challenging stigma and prejudice about mental distress/disorder/difference. It may also require recovering unpracticed social skills or making up for gaps in work history.
Coping strategies
The development of personal coping strategies (including self-management or self-help) is said to be an important element. This can involve making use of medication or psychotherapy if the consumer is fully informed and listened to, including about adverse effects and about which methods fit with the consumer’s life and their journey of recovery. Developing coping and problem solving skills to manage individual traits and problem issues (which may or may not be seen as symptoms of mental disorder) may require a person becoming their own expert, in order to identify key stress points and possible crisis points, and to understand and develop personal ways of responding and coping.
Being able to move on can mean having to cope with feelings of loss, which may include despair and anger. When an individual is ready, this can mean a process of grieving. It may require accepting pastsuffering and lost opportunities or lost time.
Meaning
Developing a sense of meaning and overall purpose is said to be important for sustaining the recovery process. This may involve recovering or developing a social or work role. It may also involve renewing, finding or developing a guiding philosophy, religion, politics or culture. From a postmodern perspective, this can be seen as developing a narrative.
Concepts of recovery
Varied definitions
What constitutes ‘recovery’, or a recovery model, is a matter of ongoing debate both in theory and in practice. In general, professionalized clinical models tend to focus on improvement in particular symptoms and functions, and on the role of treatments, while consumer/survivor models tend to put more emphasis on peer support, empowerment and real-world personal experience.[10][11][12] Similarly, recovery may be viewed in terms of a social model of disability rather than a medical model of disability, and there may be differences in the acceptance of diagnostic “labels” and treatments.
A review of research suggested that writers on recovery are rarely explicit about which of the various concepts they are employing. The reviewers classified the approaches they found in to broadly “rehabilitation” perspectives, which they defined as being focused on life and meaning within the context of enduring disability, and “clinical” perspectives which focused on observable remission of symptoms and restoration of functioning. From a psychiatric rehabilitation perspective, a number of additional qualities of the recovery process have been suggested, including that it: can occur without professional intervention, but requires people who believe in and stand by the person in recovery; does not depend on believing certain theories about the cause of conditions; can be said to occur even if symptoms later re-occur, but does change the frequency and duration of symptoms; requires recovery from the consequences of a psychiatric condition as well as the condition itself; is not linear but does tend to take place as a series of small steps; does not mean the person was never really psychiatrically disabled; focuses on wellness not illness, and on consumer choice.
A consensus statement on mental health recovery from US agencies, that involved some consumer input, defined recovery as a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential. Ten fundamental components were elucidated, all assuming that the person continues to be a “consumer” or to have a “mental disability”. Conferences have been held on the importance of the “elusive” concept from the perspectives of consumers and psychiatrists.
One approach to recovery known as the Tidal Model focuses on the continuous process of change inherent in all people, conveying the meaning of experiences through water metaphors. Crisis is seen as involving opportunity; creativity is valued; and different domains are explored such as sense of security, personal narrative and relationships. Initially developed by mental health nurses along with service users, Tidal is a particular model that has been specifically researched. Based on a discrete set of values (the Ten Commitments), it emphasizes the importance of each person’s own voice, resourcefulness and wisdom. Since 1999, projects based on the Tidal Model have been established in several countries.
For many, recovery has a political as well as personal implication—where to recover is to: find meaning; challenge prejudice (including diagnostic “labels” in some cases); perhaps to be a “bad” non-compliant patient and refuse to accept the indoctrination of the system; to reclaim a chosen life and place within society; and to validate the self. Recovery can thus be viewed as one manifestation of empowerment. Such an empowerment model may emphasize that conditions are not necessarily permanent; that other people have recovered who can be role models and share experiences; and that “symptoms” can be understood as expressions of distress related to emotions and other people. One such model from the US National Empowerment Center proposes a number of principles of how people recover and seeks to identify the characteristics of people in recovery.
In general, recovery may be seen as more of a philosophy or attitude than a specific model, requiring fundamentally that “we regain personal power and a valued place in our communities. Sometimes we need services to support us to get there”.
Recovery from substance dependence
Particular kinds of recovery models have been adopted in drug rehabilitation services. While interventions in this area have tended to focus on harm reduction, particularly through substitute prescribing (or alternatively requiring total abstinence) recovery approaches have emphasised the need to simultaneously address the whole of people’s lives, and to encourage aspirations while promoting equal access and opportunities within society. From the perspective of services the work may include helping people with “developing the skills to prevent relapse into further illegal drug taking, rebuilding broken relationships or forging new ones, actively engaging in meaningful activities and taking steps to build a home and provide for themselves and their families. Milestones could be as simple as gaining weight, re-establishing relationships with friends, or building self-esteem. What is key is that recovery is sustained.”
FUTUREMOVES 