On International Overdose Awareness Day 2018, Dean LeMire sat in the New Hampshire woods with Jim Wuelfing, pondering a dilemma. The peer recovery coaching movement to which they belonged had grown exponentially—filling gaps in care and igniting changes in the systems that help people with substance use disorders—but it wasn’t working as well as it should be.
Drug-related deaths were continuing to rise, and LeMire and Wuelfing saw limited effectiveness in the peer-support arena. Sometimes this was due to coaches’ unchecked biases, as well as a lack of education about effective alternatives. LeMire and Wuelfing felt compelled to do more, and their conversation spurred an exciting new development.
Not to be confused with a sponsor from a 12-step group, a peer recovery coach is a person who provides non-clinical assistance to support long-term recovery from substance use disorders. Tens of thousands now operate in the US.
Coaches bring their lived experience, combined with training and supervision, to assist others in initiating and maintaining recovery. They are typically available in primary care settings and community organizations. Given their accessibility and flexibility, recovery coaches come into contact with many people who can’t, or don’t want to, access other recovery supports—often due to continued drug use and/or lack of resources. (Although unfortunately, like most healthcare options, coaches are also more available to people with financial resources.)
Substance use disorders (SUD) are incredibly complex. There are strong links with childhood trauma and poverty, and as many as half of all people with SUD also have co-occurring mental health disorders, requiring an individualized and multifaceted approach. But the options proposed by mainstream treatment and recovery support systems—including clinicians, mutual-aid groups and peer coaches—typically have one simple goal: abstinence.
Many coaches have personal roots in a 12-step program and can sometimes allow their own experience of abstinence to cloud—and even dismiss—overwhelming evidence that for many people, harm reduction approaches are more successful. LeMire and Wuelfing recognized this dissonance. Many coaches claimed they supported all pathways to recovery, yet did not do so in practice.
“I saw a lot of that paternalistic and infantilizing behavior … it seemed nearly universal in the systems of care around me.”
“I missed opportunities to be helpful and not harmful,” Dean LeMire told Filter of his own time peer coaching. “It was never malicious, and I was never consciously protecting an ideal over a person in need. But until challenged and corrected, my recovery paradigm became as much a weapon as it was a shield for my own wellness.” LeMire now runs a company that trains peer coaches, and is a founding member of New Hampshire Harm Reduction Coalition and co-founder of Hand Up Health Services, a multi-county syringe services program.
“There were many times when I would draw lines in front of people who had asked me for help either personally or professionally, and I’d pull my support after they stumbled over that arbitrary line,” he continued. “I’d get angry at the person for stumbling, and in a lot of cases I wasn’t able to recognize the process and progress within the missteps. After my thinking about recovery transformed, I saw a lot of that paternalistic and infantilizing behavior in my brief history of service delivery, and it seemed nearly universal in the systems of care around me.”
He pointed out the logical and philosophical flaw of many service systems that ask, “What’s wrong with this person?” without real curiosity, and further reinforce identified problems with punitive action. “What’s more harmful than kicking someone out of substance use disorder treatment or recovery services for demonstrating the very symptom for which they sought help?”
A Harm Reduction Curriculum Is Born
Jim Wuelfing is the lead author of the nation’s most prolific recovery coach curriculum (CCAR Recovery Coach Academy). He and LeMire observed that most recovery coaches working in a huge array of service settings, sometimes available for free, represented only a narrow sliver of recovery experience—one that doesn’t accurately reflect how most people recover.
“When we consider the huge variety of recovery experience, and the majority of people who resolve their problematic drug use, abstinence and 12-step paradigms are still hugely over-represented in service design and delivery in the United States,” concluded LeMire.
Coaches, like many in the SUD field, often fail to appreciate that abstinence is just one point on a continuum of ways to reduce harms. “A common misconception with an abstinence-based recovery is that abstinence is not harm reduction,” Amber Sheldon of Glide Harm Reduction told Filter. ”Abstinence is a great harm reduction strategy for many people, but not everyone.”
“Harm reduction understands that the path to recovery looks different for each individual and in most cases is not linear,” she continued. “Forcing one’s own judgment feels stigmatizing even when given with the best intentions.”
This attitude also has the potential to cause great harm, Sheldon warned. Abstinence-only recovery programs “add to people’s trauma, and for the vast majority, 12-step-based programs fail and can leave people feeling defeated. Harm reduction meets people where they are and allows for change at the pace of the individual. Humans are unique, and so is recovery.”
“Harm reduction is a basic cultural competency that’s largely missing in the structures that house and deploy recovery coaches,” said LeMire. “It may be that most recovery coaches trained and employed at the height of an overdose epidemic are ill-prepared to serve a huge portion of the people they come in contact with.”
LeMire and Wuelfing therefore want to broaden the scope of peer recovery coaching by incorporating some key harm reduction principles:
* You’re in recovery when you say you are.
* There are multiple pathways of recovery.
* We support ALL pathways of recovery.
In collaboration with several leaders in the recovery services and harm reduction movements—including William White, Tom Hill, Michael Gallipeau and Devin Reaves—LeMire and Wuelfing devised a new curriculum, called Recovery Coaching: A Harm Reduction Pathway.
Since June 2019, they have used it to train 220 coaches in multiple states.
Personal Paradigm Shifts
This development is strongly supported by harm reduction-oriented recovery advocates like Brooke Feldman, MSW (who has written for Filter). “Even though peer staff have been trained in principles of recovery-oriented care that should be aligned with the principles of harm reduction—meeting people where they are, embracing multiple pathways of recovery, and supporting people in their self-determined goals—there has been a lack of training around harm reduction principles and practices,” she said.
This has had damaging results, she noted. “The peer workforce has been far better equipped to support people who choose or are coerced into abstinence as the goal than it has been equipped and positioned to support people who currently use drugs.”
Accordingly, building relationships with people who currently use drugs is a critical element of the new training. This includes, as Feldman explained, passing on strategies for safer use, such as how to inject more safely, naloxone administration and how to check drugs. This will also help coaches to engage people in whatever stage of change they’re at in a given moment.
“This training is one key way in which we can move away from the outdated and harmful idea of waiting for people to ‘be ready’ or waiting until they hit some proverbial ‘rock bottom’ in order to receive support, services, compassion and love,” Feldman said. “I absolutely believe that equipping peer staff to effectively engage people who currently use drugs will prevent overdose deaths and support people with making self-determined positive changes.”
“Coaches aren’t learning about communicable diseases … and they are not learning about racism and the racist War on Drugs.”
The new training also centers the lives of those most impacted by drug policy, she added—people who are marginalized and oppressed. “A critical way to bridge the gap between harm reduction and recovery is to educate the recovery community … on how the War on Drugs has been a war on people of color and poor people.”
Devin Reaves, MSW, who helped devise the new curriculum, regards it as a step in the right direction. But the situation is layered, he told Filter. “The entities that authorize certified recovery specialists are state agencies, or quasi-state agencies,” he said, and too often, “they worry about what’s politically best, as opposed to what’s best for their participants.”
Reaves trains peer specialists as part of his work for the Pennsylvania Harm Reduction Coalition, and is very aware of gaps in knowledge. “Coaches aren’t learning about communicable diseases, like hepatitis C or HIV,” he said. “They’re not learning that rates of communicable diseases are drastically up right now. And they are not learning about racism and the racist War on Drugs.”
Reaves said that delivering this training is one small part of the much deeper change required. “We’re suffering from a problem that is a century in the making, and we can’t think that our sluggish action in the last handful of years is going to make a difference.”
“We’ve seen overdose deaths barely reduced, and even then, that’s in the most privileged communities,” he continued. “We’re still seeing overdose death rates among black people going through the roof.”
Being strategic about where we place coaches is a key factor, according to Reaves. Putting a recovery coach in a police station isn’t the answer, especially in cities where law enforcement have been killing black men. “How about barbershops, or beauty salons?” he suggested. “Places where black folks congregate.”
Like the wider struggle for harm reduction and drug policy reform, expanding both the scope and reach of peer recovery coaching services means getting uncomfortable. It means challenging our biases, facing the harsh reality of people who use drugs and the gross inequities that exist among the most oppressed and marginalized communities. Recovery Coaching: A Harm Reduction Pathway is a starting point for people to explore their own paradigms on these issues.
“We get to watch people wrestle with concepts that the trainers only recently embraced.”
“In the United States there are ideas about all of these topics that are so universally held and enforced that they can be invisible,” said LeMire. “So the training puts these and related topics, like racism, into the fore.”
“We get to watch people wrestle with concepts that the trainers only recently embraced, and take them further than we ever would have if we’d just kept our wrestling to private chats,” LeMire said of the trainings held so far.
“When we were writing this curriculum, I had in mind a deep divide between two defined camps—harm reduction and traditional recovery supports,” he explained. “But having watched what some exposure to new ideas and the safety to discuss them can do with each training cohort, I’m convinced that the divide is—happily—rather small.”
“Another element in this perspective shift is not focusing on any ‘camps’ or the divide, but rather on the people naturally filling the middle with their curiosity and motivation to make a better world. That is, after all, where both the harm reduction and peer recovery services movements began.”