Improve Access to Recovery Coaches for Parents of Newborns

Introductory Paragraph

New motherhood is an incredibly stressful period of life for women. They must heal from the birth, adjust to the physical and mental demands of caring for a newborn, and make peace with their new lifestyle. There are a myriad of outside factors that influence this new phase, and new life hurdles are exacerbated for mothers with a substance use disorder who are trying to get to or maintain sobriety on top of having a new baby. During the first year after their baby is born, the relapse rate for new mothers is incredibly high at 80%. Becoming sober and maintaining sobriety is no easy feat by itself, just as new motherhood is not. The combination of both circumstances is one which clinicians need to address with the utmost care, respect, and diligence. This critical time period can be profoundly improved by the addition of a recovery coach to the new mother's support team. SUDs are one of the main contributors to child removal and failed reunification of the child and parent, and the help of recovery coaches in reaching and maintaining sobriety has been shown to greatly impact the outcomes of parental-child cohabitation. The effectiveness of the lived experience and the training of the recovery coach cannot be understated in its value to comprehensive SUD treatment for new mothers.

Key Information

The Definition of a Recovery Coach.

The NC Pregnancy and Opioid Exposure Project defines a recovery coach as a “paraprofessional who assists parents in obtaining needed benefits, coordinates child welfare and substance abuse treatment staff, and connects the family with treatment providers.” While they are independent of these agencies, they will often be at home visits with agents from child welfare and substance abuse treatment programs.

The U.S. Department of Health and Human Services, Office of Planning, Research, and Evaluation (OPRE) describes recovery coaches who work in the child welfare system as those who work with parents who have had a child or are at risk of having a child removed from their care due to SUD. They, “increase access to and engagement in treatment and other services to support parents’ recovery, coordinate with child welfare agency staff, and ensure treatment and recovery progress is incorporated into plans to either maintain children with their families of origin or place them with other permanent families.”

The specific responsibilities of recovery coaches will vary from program to program. Some programs may require a bachelor’s degree. Many others employ peer recovery coaches who have lived experience, whether they have had success in SUD recovery and new parenting or have been directly involved with a loved one in that situation.

SAMHSA has published ethical guidelines for peer-based recovery when the recovery coach is not a licensed clinician. These guidelines provide a clear-cut picture of the competencies and responsibilities of a recovery coach and are intended to prevent any role confusion and potential unqualified treatment, because many programs presents overlapping duties between recovery coaches and other treatment players. According to these guidelines, employed peer recovery coaches are meant to provide emotional, informational, and instrumental support along with companionship in recovery. A recovery coach following these guidelines fulfills a mix of the following roles:

• Outreach worker
• Motivator and cheerleader
  • Offers a living example of hard work/recovery success
  • Encourages & celebrates recovery milestones
  • Encourages & models self-advocacy and self-sufficiency
• Ally & confidant - can be trusted, cares, and listens
• Truthteller - provides honest, constructive feedback on recovery progress
• Role model & mentor
• Planner
• Problem solver
• Resource broker
• Monitor
• Tour guide
• Advocate
• Educator
• Community organizer
• Lifestyle consultant/guide
• Friend

The SAMHSA guidelines note that a recovery coach is NOT a sponsor, therapist/counselor, nurse/physician, or a member of the clergy. Tasks that fall into the wheelhouse of these professions should not be permitted and always referred out by the recovery coach.

Substance use disorder and postpartum depression are commonly identified as having comorbidity, regardless of which condition came first. It is important that the recovery coach not blur the lines in giving clinical advice regarding postpartum depression and maintain services that align to their training. However, the co-occurrence of the two conditions may indicate a greater need for the recovery coach, as they can alleviate some of the burdens of finding resources while providing social support which is critical for those with depression.

Role of Recovery Coaches in the Postpartum Period.

Sobriety during pregnancy is an important goal, and about 85% of pregnant women with a substance use disorder are able to maintain abstinence from at least one substance while they are carrying their baby. However, the first year of postpartum is very dangerous for women who struggle with SUD. Mothers who have an SUD face challenges which may propel them towards relapses, such as food insecurities, legal troubles, the threat of infant removal, and domestic turmoil. Resources to aid the new mother in her recovery need to extend beyond birth and be tailored to the unique situations these mothers face with their addiction. Mothers with an SUD are a priority for substance treatment while pregnant, as the continued use can have a major impact on the fetus. However, many women, regardless of insurance status, see their treatment options dwindle postpartum, as the shift of medical attention goes from the mother to the infant.

Programs implementing recovery coaching have seen success with achieving and maintaining postpartum sobriety because the coach has unique, lived experience which they provide to help navigate these struggles. With so much stigma surrounding new mothers with an SUD, a primary goal of recovery coaching is to empower the mother without judgment. The coach’s lived experience can bring a sense of hope and trust to the new mother, upon seeing a peer who has gone through similar circumstances have success in maintaining sobriety. Because the recovery coach has had life experience coupled with paraprofessional training, they provide a unique and knowledgeable insight into the ins and outs of recovery and all the agencies and resources involved with recovery and child welfare.

Testimonials from mothers on the impact of their coach on their recovery document the importance of building a strong relationship with mutual understanding and unwavering support -- outside the stressors of therapies and agencies. Recovery coaches play an integral role in building esteem, giving support, and providing inter-agency resources. This helps to bolster the effects of treatment for new mothers and gives them the tools to work towards sobriety.

Relevant Research

There is not a lot of statistical research on the effectiveness of recovery coaches postpartum. One reason is that many mothers have access to these programs while pregnant, but lose it postpartum due to insurance restrictions. Thus, some of the information provided below is not specific to postpartum recovery coaching, but on the impact of recovery coaching on aiding SUD treatment. Research is needed on the effectiveness of recovery coaches during pregnancy and could provide a springboard for advocacy in postpartum treatment.

• An evidence-based review of an Illinois program found that parents with their baby removed from care who had access to a postpartum recovery coach had a 15% increase in parent-child reunification and a 14% increase in having foster-care cases closed. It is important to note that there was no evidence of adverse impact in the increased and quicker reunifications and case-closures.

• This article highlights the high risk of relapse (28.3%) in the first three months postpartum, especially amongst those with comorbid mental illness.

• The U.S. Department of Health and Human Services, Office of Planning, Research, and Evaluation (OPRE) made a comprehensive review of nine recovery coaching interventions. OPRE evaluated the replicability, success, and readiness of the programs and documents the strengths, weaknesses, and evidence-based practice implications of each model.

• This article provides a systematic review of peer recovery support services and recovery coaching. It highlights the potential of recovery coaching in SUD treatment. It recommends that more extensive research be done to empirically support the inclusion of recovery coaching and to provide a clear role definition.

• This article evaluates an intervention delivered by peer recovery coaches in a medically underserved community in Baltimore City.

• This article examines the cyclical effects of postpartum depression, both unrelated and related to substance use.

Impactful Federal, State, and Local Policies

Federal. Recovery support services, including recovery coaches, were included in the Comprehensive Addiction Recovery Act (CARA), but not funded. There is not a federal definition of recovery services.

States. Implementation access requirements vary from state to state.

• 17 states discontinue Medicaid coverage 60 days postpartum. Those people who do retain their coverage face challenges in navigating postpartum coverage changes, in finding new doctors to give them SUD treatment referrals, and in dealing with new and confusing paperwork.
• One state-level policy advance is reflected in Virginia, which provides a scholarship to help cover fees in becoming a Certified Peer Recovery Specialist.

Available Tools and Resources

SAMHSA provides a state-by-state directory of training and certification programs for peer recovery coaching. It was generated in 2018 by BRSS-TACS (Bringing Recovery Supports to Scale Technical Assistance Center Strategy).

SAFE Project has a dedicated website for Addiction and Mental Health Resources for Women that includes a number of support resources during and after pregnancy.

"Supporting Substance-Using Caregivers: Pregnancy, Birth, and Early Childhood" is a Harvard Kennedy School Government Performance Lab written report that explores ways to better support substance using caregivers and their families on the journey to recovery.

The National Center on Substance Abuse and Child Welfare has published a guide, “The Use of Peers and Recovery Specialists in Child Welfare Settings.” This covers models, implementation, funding, qualifications/training, supervision, and much more. It is a good tool for those wishing to implement recovery coaches and peer support.

KFF formerly know as the Kaiser Family Foundation, provides a breakdown of postpartum Medicaid coverage state-by-state. It addresses gaps, disparities, and needs. Medicaid coverage greatly impacts new mothers with an SUD, who are more likely to need continuity of coverage to aid in their recovery.

The Montgomery County Office of Mental Health has published its recovery coaching guidelines. It is a comprehensive guide on how to effectively implement recovery coaching in the community to address a wide array of vulnerable populations.

Promising Practices

California. The Sobriety Treatment and Recovery Teams (START) is an intensive child welfare program for families with substance use and child abuse or neglect. START is built on cross-system collaboration and integrated service delivery. It utilizes peer recovery coaches in long-term recovery in conjunction with families, treatment providers, and court systems to provide a “system-of-care and shared decision-making approach.” This program is both child welfare and SUD treatment centered and uses trauma-informed care to help maintain safety, reduce child-removal-of-care, achieve and maintain parental sobriety, improve parenting skills, and improve inter-agency collaboration. The site includes program goals, their logic model, components, delivery, training/manuals, implementation, and published research.

Georgia. The Certified Addiction Recovery Empowerment Specialist (CARES) program was developed by the Georgia Council on Substance Abuse. CARES provides training, examination, and continuing education to maintain a strengths-based approach in peer recovery support services that builds on client’s strengths. CARES has an emergency department that provides recovery coaches to those experiencing an overdose or other substance-related incident and in need of immediate aid. They also offer a warm line -- a call line to aid those are struggling and need to talk to someone but want to remain anonymous.