As he emerged from the grip of addiction three years ago, Derek saw how complicated recovery would be: programs to navigate, calls to make, forms to fill out, court dates to attend. All that on top of the emotional and physical strain of parting with the heroin and alcohol that had ruled his life for a dozen years.
But the 32-year-old counts himself lucky to have had a “recovery coach” guiding him on his journey from treatment to sobriety. The coach, Katie O’Leary, offered a deep understanding, and a motivating example of success: She started her own recovery from heroin addiction seven years ago.
O’Leary, who works for the North Suffolk Mental Health Association, belongs to a new profession whose role is expanding amid the opioid crisis. But as the use of recovery coaches grows, so do the questions: Who are they, exactly? What qualifies them to do this work? What are the boundaries of their practice?
Governor Charlie Baker is the latest to seek answers, with his recent proposal for a commission to look into credentialing recovery coaches, a move that could lead to insurance reimbursement.
For Derek, who asked that his last name be kept confidential in keeping with the customs of Alcoholics Anonymous and Narcotics Anonymous, O’Leary’s help made all the difference.
She told him where to apply for benefits, drove him to his first post-treatment sober house, stayed until he was comfortable there, and took his middle-of-the-night phone calls when worries kept him awake. Today, living in a sober house and working full time, Derek meets with her about once every two weeks.
“When you start to get nervous, you start to fall, the recovery coach is the person who puts their hand out to you,” he said.
For her part, O’Leary, 38, understands the appeal of peer support. “If a clinician told me I have to do something, I would laugh at them and do the exact opposite,” she said. But suggestions carry more weight when they come “from somebody that has the same experience and the same pain.”
Recovery coaches, or “peer support specialists,” have been around for decades, originally as volunteers who had beaten addiction and wanted to help others do the same. In recent years, hospitals, treatment centers, municipalities, and courts have started to pay for their services.
They are seen as peers able to guide and mentor, encouraging people to enter treatment or helping them keep on track in recovery. Usually they are not supposed to provide treatment, and most do not have advanced degrees. But there are no firm statewide rules — and insurance companies do not reimburse for peer recovery services, requiring programs that hire recovery coaches to find other sources of funding. No one even knows how many people call themselves recovery coaches, in Massachusetts or nationwide.
Kristoph Pydynkowski, director of recovery management at the Gosnold treatment center on Cape Cod, said he welcomes the governor’s proposal to credential recovery coaches, part of a wide-ranging plan to battle opioid addiction.
“It’s like the Wild West,” he said. “We do need to come up with some standards and best practices.”
Pydynkowski got his start a decade ago while working as a dishwasher at Gosnold, newly in recovery after a 10-year struggle with heroin. Someone pulled him away from the dishes with a request to talk with a difficult young patient. With his Mohawk haircut and tattooed face, Pydynkowski sat down with the young man — and connected in a way that changed the patient’s life, and Pydynkowski’s.
Gosnold started its peer recovery program in 2012, and now employs 10 recovery coaches to help patients after they leave treatment.
Training and supervision are critical for recovery coaches, Pydynkowski said. “I’ve seen so many people do harm to themselves and others,” he said.
People whose own recovery is too recent can end up getting high with their clients, Pydynkowski said. Some, he said, work around the clock and burn out, endangering their own recovery.
Recognizing the need for education and standards, the state Department of Public Health began offering a one-week Recovery Coach Academy several years ago, and more than 1,000 people have completed the course.
In 2016, the department established a more rigorous program to certify recovery coaches. Applicants must take the one-week course plus additional hours of training in ethics, cultural competency, and motivational interviewing. Then they must complete 500 hours of supervised work as a coach. Starting in June, they will also have to pass an exam.
There is no legal requirement for recovery coaches to become certified, but employers are starting to send their coaches through the program, and may require certification in the future. So far, 16 people have been certified, including several from Gosnold and the North Suffolk Mental Health Association.
But the state has no official definition specifying what recovery coaches can and cannot do — one of the issues that Baker’s commission might address.
More than 20 states have some kind of peer recovery designation or regulation, and most New England states offer certification. But the requirements vary, and there is no national standard.
“We need to unify this discipline, and we need to put together some standards that are national,” said Cynthia Moreno Tuohy, executive director of NAADAC, the Association for Addiction Professionals. In January, the association plans to launch a national credentialing program for “recovery support specialists,” another term for recovery coaches.
The addiction professionals’ group has also worked with the American Professional Agency, a liability insurer, to offer malpractice insurance for recovery support specialists who become credentialed through its program.
One of the top concerns is defining the scope of practice, to ensure that recovery coaches don’t veer into providing treatment and do not try to replace trained addiction clinicians, Moreno Tuohy said.
Do recovery coaches make a difference? Data from Gosnold show that its clients maintain sobriety longer and have fewer admissions to hospitals or addiction treatment centers than before they enrolled in the recovery program.
A review of the research on peer recovery published last year in the Journal of Substance Abuse Treatment found the research very limited, but the few good studies suggest that peer recovery services “make a positive contribution to substance use outcomes.”
The North Suffolk Mental Health Association, where O’Leary works, employs five full-time recovery coaches, paid $31,000 to $35,000 a year, and two supervising coaches, who make $42,000 to $45,000.
It’s a challenging program to manage financially, because insurance companies do not reimburse for recovery coaches as they do for licensed clinicians, said Kim Hanton, the agency’s director of addiction services. Hanton arranges to cover coaches’ salaries through grants and contracts.
Coaches have a special touch when engaging people, including those who may not want treatment. “It’s like magic,” Hanton said. “You see sparkle when you see coaches with individuals.”
Although she wants to protect the integrity of the profession, Hanton said she hopes that credentialing will not make the job too professional. Requirements for college degrees, for example, would cause her to lose some of her best coaches.
“I don’t want them to take away the magic in what they do,” Hanton said.