Statement on Recovery Residences

SCRA is pleased to announce the adoption of our first public policy statement, The Role of Recovery Residences in Promoting Long-term Addiction Recovery. Recovery Residences are lower cost, community-based residential environments that require abstinence from substance use and abuse. The Society of Community Research and Action has developed, with the executive, advocacy and research committees of the National Association of Recovery Residences (NARR), a policy statement on the value of recovery residences in the United States.

 

The Society of Community Research and Action – Community Psychology,

Division 27 of the American Psychological Association

Policy Statement

 The Role of Recovery Residences in Promoting Long-term Addiction Recovery 

Executive Summary

Addiction and the larger arena of alcohol and other drug (AOD) abuse and related problems exact an enormous toll on individuals, families, organizations, local neighborhoods, and whole communities in the United States.  Although a great number of advances have been made in AOD treatment, far too few individuals who could benefit from treatment receive it, and many who do receive treatment will resume AOD use following their discharge from it. New recovery support institutions are emerging beyond the arenas of traditional addiction treatment to support individuals hoping to initiate and to sustain long term recovery from addiction. One promising mechanism is the recovery residence.

Recovery residences (e.g., sober living houses, recovery homes, and Oxford HousesTM) are sober, safe, and healthy living environments that promote recovery from AOD use and associated problems. At a minimum, recovery residences offer peer-to-peer recovery support with some providing professionally delivered clinical services all aimed at promoting abstinence-based, long-term recovery. Recovery residences are sober living environments, meaning that residents are expected to abstain from alcohol and illegal drug use. Each credentialed recovery residence publishes policies on relapse sanctions and readmission criteria and other rules governing group living.  Recovery residences may require abstinence from particular types of medications according to individual policy. Although the exact number is currently unknown, many thousands exist in the United States.

A small but growing body of research supports the effectiveness of recovery residences in sustaining abstinence and promoting gains in a variety of other domains, and the National Association of Recovery Residences has developed guidelines to define levels of care and standards to ensure the quality of care received. Yet, despite these advances, recovery residences face innumerable challenges.  Critical questions regarding the operations and effects of recovery residence participation remain unanswered, and research scientists wishing to study recovery residences face considerable funding challenges given the prevailing funding emphasis on the neuroscience of addiction.  Efforts to establish or relocate recovery residences face challenges with start-up funding and often face considerable neighborhood and political opposition.  Also of importance, many health and human professionals are unaware of recovery residences and their benefits on long-term recovery outcomes.

The Society of Community Research and Action (SCRA) has developed, with the executive, advocacy and research committees of the National Association of Recovery Residences (NARR), a policy statement on the value of recovery residences in the United States.  This policy statement 1) describes the emergence and rapid growth of recovery residences as a new addiction recovery support institution, 2) highlights research to date on the positive effects of participation in a recovery residence on long-term addiction recovery and related outcomes, 3) champions a research agenda that would address many unanswered questions related to such participation, 4) advocates social policies (laws, regulations and funding guidelines) in which recovery residences can flourish, 5) supports programs of education and training to increase referrals to these new resources by health and human service professionals, and 6) promotes programs to educate local political leaders and the public about the value of recovery residences for individuals, families, and communities in the United States.

 Background

Addiction and the larger arena of alcohol and other drug (AOD) and related problems exact an enormous toll on individuals, families, organizations, local neighborhoods and whole communities in the United States.  Since the mid-twentieth century, an elaborate network of professionally-directed addiction treatment programs has been funded to respond to these problems, but more than half of individuals treated in these institutions will resume AOD use following their discharge from treatment—most often in the first 90 days following discharge. Assertive continuing care and support is not a routine component of addiction treatment in the United States and only a small percentage of persons treated participate in post-treatment continuing care, which involves post-treatment monitoring and support. There are growing calls to shift acute care models of addiction treatment to models that emphasize sustained, post-treatment recovery management in order to elevate long-term recovery rates and enhance the quality of personal and family life in long-term recovery. Recovery management is a philosophical framework for organizing addiction treatment services to provide long-term recovery maintenance and quality-of-life enhancement for individuals and families affected by severe substance use disorders.  

New recovery support institutions are emerging beyond the arenas of addiction treatment and recovery mutual aid societies to achieve these goals. By providing a physical and social world to recover within, these new institutions (e.g., recovery residences, recovery schools, recovery industries, recovery ministries, recovery community centers, recovery cafes, etc.), mark a major milestone in the history of recovery in the United States.  One of the earliest to develop and one of the most important of these new institutions is the recovery residence.

Recovery residences (e.g., sober living houses, recovery homes, and Oxford HousesTM) are sober, safe, and healthy living environments that promote recovery from AOD use and associated problems. The number of recovery residences in the U.S. has grown dramatically in the past 25 years and have helped fill the void of community support between professionally-directed addiction treatment and peer-led recovery mutual aid societies. The purpose of a recovery residence is to provide a safe and healthy living environment to initiate and sustain recovery—defined as abstinence from alcohol and other non-prescribed drug use and improvement in one’s physical, mental, spiritual, and social wellbeing.  Individuals build resources while living in a recovery residence that will continue to support their recovery as they transition to living independently and productively in the community. Although recovery is commonly believed to refer to abstinence and a general sense of quality of life, recovery is by no means a simple construct that has uniform definition (i.e., some individuals define it as abstinence only from their primary drug; or as use of alcohol, but no drugs; or as no use of “hard drugs” but use of marijuana, or allow for use of “medical marijuana.”) 

There is growing consensus that recovery from severe substance use disorders involves three critical components:  sobriety, improvement in global (physical, emotional, relational, spiritual) health, and citizenship (positive community reintegration).  Recovery residences are abstinence-based environments that provide mutual support for these three elements of recovery  -in contrast to "wet housing" that allows residents to use alcohol or other drugs or "damp housing" that discourages but does not exclude persons for using and that do not address these larger recovery processes.

A recent publication, A Primer on Recovery Residences in the United States (Jason,  Mericle,  Polcin, White, & the National Association of Recovery Residences, 2012), released by the National Association of Recovery Residences based on a review of all materials published on recovery residences to date found that:

  • Although the exact number of recovery residences is currently unknown, there are many thousands of such residences  operating in nearly every state across the nation;
  • Recovery residences in the U.S. span from low to high service intensity and meet the needs of residents at various stages of recovery (see figure below):
  • Most individuals in recovery residences have past or current involvement in addiction treatment and participate in 12-Step or other recovery mutual aid organizations during their time in the recovery residence.
  • Participation in a recovery residence decreases in-treatment and post-treatment relapse rates and significantly increases recovery outcomes (using such recovery measures as sustained abstinence rates, improvements in global health and social functioning—e.g., high rates of employment) at up to two-years of follow-up.  Longer-term (5-10 years) follow-up studies have not yet been conducted.
  • These benefits extend to women, women with children, African-Americans, and persons with co-occurring psychiatric diagnoses.   
  • These benefits are contingent on adequate lengths of stay (more than 6 months in level I recovery residences) and a supportive community environment.
  • The cost-effectiveness of recovery residences has not yet been rigorously investigated. However, some recovery residences, such as Oxford and California Sober Living Houses, are self-financed primarily through resident fees.
  • Research to date generally finds that recovery residences do not negatively affect neighborhoods and may even provide benefits to the communities in which they are located.

Some recovery residences are designed specifically for individuals with certain needs (e.g., co-occurring addiction and severe mental illness, veterans, mothers with children); however, some recovery residences may not be equipped to adequately meet these residents’ needs.   Individuals with specific service needs seeking recovery residences should ask the provider about how these needs can (or cannot) be addressed within a particular residence. It is still unclear if outcomes differ for people with co-occurring disorders (mental health, process addictions, major medical issues such as Hepatitis C or HIV) living in recovery residences.

Recovery residences are divided into Levels of Support based on the type as well as the intensity and duration of support that they offer. Services provided span from peer-to-peer recovery support (all recovery residences) to medical and counseling services (recovery residences offering higher levels of support).  The National Association of Recovery Residence Standards defines minimum services for each Level of Support, but additional services may be provided at each level. Section 5 of the National Association of Recovery Residences Standards, included in A Primer on Recovery Residences in the United States, details the minimum required service elements for each Level of Support.   National Association of Recovery Residence-certified recovery residences meet standards addressing safety from an administrative, operational, property, and good neighbors’ perspective. Recovery residences’ internal governance varies across National Association of Recovery Residence Levels of Support. Forms of governance range from democratically run by the residents to oversight by licensed professionals. The regulation of recovery residences vary from state to state, local government to local government, and model to model. In general, states regulate professional services and local governments regulate health and safety standards. Both state and local government regulation must adhere to federal laws and limits, such as the Americans with Disabilities Act and the Fair Housing Act.

The National Association of Recovery Residences, established in 2011, currently represents approximately 1,500 residences through its local organizational affiliates. The National Association of Recovery Residences advocates for recovery residences and their residents at the national and local levels. Members of the National Association of Recovery Residence maintain standards for recovery residences of all kinds across the four National Association of Recovery Residence Levels of Support, from Level 1 peer-operated residences to Level 4 residences offering a wide variety of treatment and recovery support services. Three additional recovery residence organizations exist with a national scope. The oldest is the Association of Halfway House Alcoholism Programs, founded in 1958, and all are now affiliated with the National Association of Recovery Residences. The members of the Association of Halfway House Alcoholism Program include all of the National Association of Recovery Residences Levels of Support.  The Association of Halfway House Alcoholism Program’s residences operate in accordance with social model recovery principles.  Oxford House Inc. was established in 1975 and supports Oxford Houses internationally. Oxford Houses are National Association of Recovery Residence Level 1, with each residence operated solely by the residents in accordance with Oxford House guidelines. Oxford House Inc. supports and promotes its model for peer-operated recovery residences through training, technical assistance, and access to startup financing. They also advocate for recovery housing rights and provide legal support to Oxford Houses involved in disputes with cities and towns over their right to exist.  Treatment Communities of America (formerly Therapeutic Communities of America) represents more than 600 residential addiction treatment programs in the United States.

Recovery residences face innumerable challenges in spite of their rapid growth and positive findings on their effects on recovery outcomes.  Critical questions regarding the operations and effects of recovery residence participation remain unanswered, and research scientists wishing to study recovery residences face considerable funding challenges given the prevailing funding emphasis on the neuroscience of addiction.  Efforts to establish or relocate recovery residences face challenges with start-up funding and often face considerable neighborhood and political opposition.  Also of importance, many health and human professionals are unaware of recovery residences and their benefits on long-term recovery outcomes.

Recommendations

In light of these findings and circumstances, the Society of Community Research and Action (SCRA):

1)    Recommends that national, state, and local agencies support local networks of recovery residences.  Specially, the SCRA calls upon:   

  • The Substance Abuse and Mental Health Services Administration to develop funding mechanisms to support the development, sustainment, and expansion of recovery support services specific to housing.
  • The Department of Housing and Urban Development to develop funding mechanisms to support the development, sustainment, and expansion of housing services specifically for individuals in recovery from behavioral health disorders.  
  • The National Association of Recovery Residences to disseminate national standards for recovery residences and to provide technical assistance for local organizations to meet these standards as a means of improving the quality of local recovery residences in the United States.  This is of particular importance in order to deal with a perception by some that relapse is common among residents in recovery homes, they are often in unsafe neighborhoods, and many are disorganized and even exploitive of residents. 
  • Single State Authorities on alcohol and other drug problems to establish loan funds and other mechanisms that will support the development of recovery residences where the need for such resources has been established.
  • The National Conference of State Legislatures, the United State Conference of Mayors, and the National League of Cities to develop policy documents and host webinars and conferences related to the issues surrounding the development of supportive housing for recovering individuals in local communities.

2)    Recommends enhanced funding for critical research related to recovery residences.  The SCRA calls upon: 

  • The National Institutes of Health (the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse) to fund research related to recovery residences, including randomized clinical trials, long term outcome studies, cost-effectiveness studies, and studies that isolate the most potent ingredients of the recovery residence model of recovery support. We need recovery outcome and cost savings data across the Levels of Support for various populations (including co-occurring, re-entry with criminal mindsets, etc.) recovering from a diversity of chemical substances in comparison to or in combination with alternative approaches. Without published research and evidence-based practice designations, licensed professionals and policymakers will continue to question the legitimacy of recovery residences and peer-based recovery.
  • The Substance Abuse and Mental Health Administration’s Center for Substance Abuse Treatment to fund evaluations studies related to the integration of recovery residences and related recovery support institutions (e.g., recovery community centers, recovery schools, recovery industries, recovery ministries) within the network of health care initiatives being launched by state and federal government.  
    • Federal, state, and local funding sources to prioritize recovery residence research studies that address 1) the effects of participation in a recovery residence on treatment retention/completion and post-treatment relapse and recovery rates as well as measures of global health and social functioning—e.g., high rates of employment) at longer-term (5-10 years) intervals, 2) the degree of benefits living within recovery residences extends to women, women with children, African-Americans, and persons with co-occurring psychiatric diagnoses, 3) the degree to which benefits are contingent on adequate lengths of stay (more than 6 months in level I recovery residences) and a supportive community environment, 4) the relative cost-effectiveness of recovery residences, and 5) the effects of recovery residences on neighborhoods and communities in which they are located. These are all high priority areas for research that is needed to develop a more solid basis for our understanding of recovery residences and their impacts on residents and communities.
  • National Association of Recovery Residences to increase their presence at key national conferences (National Association of Addiction Treatment Providers, the American Society of Addiction Medicine, and the American Association for the Treatment of Opioid Dependence) to engage the research community on the need for research on recovery residences.
  • Editors of addiction-related professional and trade journals to continue to publish studies and reviews and special issues on the effects of participation in a recovery residence on long-term recovery outcomes.

3)    Recommends strategies to educate and train addiction treatment professionals and allied health and human services professionals on the value of recovery homes. The SCRA calls upon:   

  • The APA to disseminate this policy document to all APA members as well as to other major related professional associations (e.g., the American Psychiatric Association, the National Association of Social Workers) with the recommendation that the latter develop and disseminate policy statements on recovery residences and related recovery support institutions.
  • College and university addiction studies programs, independent addiction counselor training programs, and educational and training programs for psychiatrists, psychologists, and social workers to integrate information on recovery residences within their respective curricula.
  • The national network of Addiction Technology Transfer Centers to disseminate information on recovery residences, including assertive referral procedures that can be used to access such resources and how recovery residences can be integrated into a continuum of care supporting long-term personal and family recovery from substance use disorders.
  • The major addiction professional certification bodies [including NAADAC: The Association of Addiction Professionals, the International Certification & Reciprocity Consortium (IC&RC), the American Board of Addiction Medicine, and state addictions counselor certification boards] to integrate questions related to recovery residences into certification exams and their respective continuing education programs.  
  • The American Society of Addiction Medicine to formally recognize recovery residences as a level of care within its Patient Placement Criteria.

4)    Recommends public education strategies that will address the stigma and misconceptions often attached to recovery homes and their residents.  The SCRA calls upon:      

  • The National Association of Recovery Residences to develop a public education campaign on recovery residences aimed at state and local civic leaders and media representatives.
  • The National Association of Recovery Residences’ regional and state recovery residence consortia to collaborate with such leading recovery advocacy organizations as Faces and Voices of Recovery to incorporate issues related to recovery housing within larger recovery advocacy and anti-stigma campaigns.
  • The Legal Action Center to develop a kit for local recovery residences on how to respond to NIMBY hysteria and discrimination related to recovery housing regulations and their enforcement.
  • The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Association of Recovery Residences co-develop a recovery residence press kit and a webinar that could be incorporated into SAMSHA’s 2013 Recovery Month activities.

Having reviewed the available scientific evidence on recovery residences, we believe these actions will play a significant role in elevating long-term addiction recovery outcomes in the United States and contribute to the quality of life of individuals, families and communities throughout the country.

The proposed policy statement was written by the National Association of Recovery Residences (NARR) research committee and approved by the NARR executive committee before submission to the SCRA.  The NARR research members include Leonard A. Jason, PhD, Director, Center for Community Research, DePaul University; Amy A. Mericle, PhD, Research Scientist, Treatment Research Institute; Douglas L. Polcin, EdD, Senior Scientist, Alcohol Research Group; and William L. White, MA, Senior Research Consultant, Chestnut Health Systems.

Resources 

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Jason, L. A., Groh, D. R., Durocher, M., Alvarez, J., Aase, D. M., & Ferrari, J. R. (2008).

Counteracting “Not in My Backyard”: the positive effects of greater occupancy

within mutual-help recovery homes. Journal of Community Psychology, 36(7), 947-

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Jason, L.A., Mericle, A.A., Polcin, D.L., White, W.L. & the National Association of Recovery Residences (with Fred Way serving as Liaison with Research Committee).  (2012). A Primer on Recovery Residences in the United States.

 

Jason, L. A., Olson, B. D., Ferrari, J. R., & Lo Sasso, A. T. (2006). Communal housing settings enhance substance abuse recovery. American Journal of Public Health, 91, 1727-1729.

 

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residents: Does proximity make a difference? Journal of Community Psychology,

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Kelly, J. & White, W.  (Eds., 2011) Addiction recovery management: Theory, science and practice.  New York:  Springer Science.

 

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White, W. (2008).  Recovery management and recovery-oriented systems of care:  Scientific rationale and promising practices.  Pittsburgh, PA:  Northeast Addiction Technology Transfer Center, Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health & Mental Retardation Services

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