Recovery residences have found their home

They still face the sting of unwelcoming neighbors and the stigma from bad-apple operators in their own ranks, but overwhelming evidence suggests that these may be the best times yet for recovery residences in the continuum of services for addictions.

In developments ranging from Ohio legislators' commitment of cash to Florida home operators' rush to embrace standards of quality, sober home operators are changing the language of treatment and recovery. They also are transitioning in many communities from ugly stepchild to bona fide partner with treatment facilities.

To some, the present and future success of recovery residences comes down to simple math. Research strongly suggests that 30 days in treatment does not a recovery make, but public and private payment systems are not positioned to finance extended stays in intensive treatment services. Enter the recovery residence that serves as a bridge between highly supervised treatment and a full return to community living.

“Recovery homes partly have grown out of the fact of limited treatment capacity,” says Lori Criss, associate director of the Ohio Council of Behavioral Health and Family Service Providers, which despite not representing sober homes directly was closely involved in advocating passage of landmark legislation for Ohio sober homes last year. “People need a safe place to extend their recovery.”

Substantial growth

Given that it has been only five years since a small but committed group of sober home leaders formed a national organization for the cause (NARR, the National Alliance for Recovery Residences), the movement is demonstrating significant maturity in its relationships with primary treatment and with policy-makers.

“There is a very active effort on the part of treatment centers to collaborate with us,” says Beth Sanders (the former Beth Fisher), NARR's president emeritus and the executive director of Hope Homes Recovery Services with operations in three Southeast states. “The progressive treatment centers out there are starting with recovery planning from day one.”

In Ohio, treatment organizations under the auspices of the Ohio Council were instrumental in the effort to encourage more housing options for individuals with substance use disorders. Criss says this occurred as part of a three-pronged initiative that also examined employment services and recovery coaching. Research from a state legislative committee identified recovery housing as an important component of what was working in communities to combat addiction, and momentum built for the legislation that was adopted last year.

Under the law, every county in Ohio must have recovery housing as part of its continuum of support for addictions, Criss says. Legislators committed an initial $10 million in funding to assist in the effort, with half devoted to home construction/remodeling and the rest for operations.

Now the state has an organization representing recovery residences, called Ohio Recovery Housing; it has become a NARR affiliate. NARR president Jason Howell, executive director of the Texas-based recovery support and awareness organization SoberHood, says NARR now has 18 state affiliates whose members encompass a total of about 2,500 homes across the country (that of course represents a small fraction of the number of operations calling themselves recovery residences or sober homes, in this largely unregulated sector of the field).

Most of the homes in NARR affiliate chapters operate at the less-intensive Levels 1 and 2 of the four-level classification system that NARR has promulgated to assist providers in matching the level of support to resident need (see descriptions at end of article).

In some ways, the shortage areas for high-quality sober homes mirror the most deficient areas in primary treatment. Howell, who established the first recovery residence for the gay and lesbian population, says other groups that remain underserved in sober living options include women with children, the physically handicapped, and Spanish-speaking populations. Sanders adds that recovery residences remain few and far between in rural communities.

Another prominent trend finds the average age of sober home residents dropping dramatically, believed to be fueled largely by the widespread opioid crisis. Sanders says that in 1996, the average age of Hope Homes residents was 32; last year it was 24. But the programs still serve a wide age range, with Sanders saying the oldest Hope Homes resident ever housed was 84. For all persons served, “We offer the benefit of time,” she says.

Outcome-driven

Recovering individuals have been choosing to live together in an effort to stay sober ever since the early days of Alcoholics Anonymous (AA) members meeting in church basements and building group support. But when the influence of third-party payers began to dominate the treatment field, the emphasis in research and funding gravitated to developing a medical model of support. John Lehman, president of the Florida Association of Recovery Residences (FARR) and a leading advocate of operational standards for recovery homes, believes insurers could serve as a key driver for development of a vibrant recovery residence community nationally.

“Third-party payers are now caring about outcomes,” says Lehman. “They had tools to cap risk before, but with the Affordable Care Act and parity, they don't have that anymore.” Now they will have to encourage strategies that work, but in a cost-effective way.

“We're getting that 30 days [in treatment] is not sufficient time, but we also can't pay $90,000 for 90 days,” Lehman says. He believes insurers will need to embrace a collaborative effort to determine how to extend the available dollars most effectively across the continuum of support, and how best to assess where each individual in need belongs on the continuum.

Sanders says the maturation of recovery homes in the continuum of support means that terms such as “life skills” and “recovery support” have become part of the common language in addiction services. “Social model” may become the next term to take prominence. At NARR's inaugural Best Practices Summit last fall, Howell and Dave Sheridan of Southern California's Sober Living Network unveiled their paper on using social model principles in residential settings. Recovery home leaders are beginning to define more clearly the factors that will make a recovery residence successful.

“You don't just throw a bunch of people in early recovery together and hope it happens,” says Lehman. He explains that the characteristics of a high-quality recovery home tend to be the opposite of those that work in a treatment center—which makes sense given that they are serving individuals at different stages along the continuum.

While a clinician in a treatment center must maintain a professional relationship with boundaries, a peer support specialist in a recovery residence seeks to break barriers and create a one-on-one recovery partnership with the resident. “If you're in a recovery residence and you're in a 12-Step program, I don't have a behavioral tech take you to your meeting. I take you to my home group,” Lehman says.

Successful recovery homes are about recovery planning, not treatment planning, and about creating a community of equals. “The homes that are intentional about community are the ones that stick around,” Sanders says.

Barriers remain

Leaders in the recovery residence community still have to fight potential obstacles to their success on many fronts. On the public-sector side of the service system, many would like to establish safe recovery housing environments for individuals who are homeless or at risk of homelessness, but they have run up against a policy direction contrary to that aim.

The “Housing First” approach to addressing homelessness that has taken hold at the U.S. Department of Housing and Urban Development (HUD) and in local communities emphasizes housing as the precursor to supportive services. That can potentially work for some chronically homeless individuals, but it means that some housing communities turn out not to be safe, drug-free environments for people in early recovery.

Howell says leaders are investigating whether federal housing money could be used to establish safe and peer-supportive living environments. Some of the housing units operated by Portland, Ore., multi-service organization Central City Concern offer a glimpse at the possibilities.

Around 30% of the addiction and mental health services organization's client base would be considered chronically homeless, and heroin addiction is prevalent. The organization operates or manages around 1,600 units of housing, including transitional housing that sometimes is a client's immediate stop after sub-acute detox services. Executive director Ed Blackburn says that a year after spending several months in transitional housing, the vast majority of Central City Concern's clients show positive recovery outcomes and live in permanent housing.

Blackburn is working with a number of organizations to define the essential components of a service model for the highest-need populations, such as peer case management and direct access to treatment when required. “There is a need to describe what valid recovery housing looks like,” he says. “People need to know what they're funding.”

Another obstacle for recovery residences continues in the form of roadblocks erected by municipalities, even in states such as California where sober living has a long history of performance. Two lawsuits were filed late last year against the city of Costa Mesa after it adopted an ordinance regulating the bed capacity and location of sober homes in the city (various estimates have the current number of recovery homes in Costa Mesa at anywhere from 60 to 200).

The lawsuit plaintiffs contend that the city's ordinance violates provisions of the Fair Housing Act, the recovery residence community's main protection that allows it to overcome municipal opposition and locate homes in residential neighborhoods. Solid Landings Behavioral Health, which operates treatment programs as well as recovery residences, is a plaintiff in one of the challenges. It is not commenting publicly on the lawsuit while it proceeds, but it would like more harmonious relations at the local level.

“Our number one wish is that we would work together with the municipalities that we work in and for,” says Solid Landings co-founder and executive vice president Elizabeth Perry. “It's not enough to be a non-disturbing neighbor—we want to be a good neighbor.”

Howell says that in most cases, the home dwellers who are initially the object of scorn in neighborhoods end up being the ones praised for helping neighbors with chores. But all acknowledge that the actions of a minority of unscrupulous providers who are in business just to collect rent—or insurance reimbursement for excessive drug testing—continue to tarnish the field's reputation. “Like in any industry, there are folks who cut corners,” says Perry.

Such problems have been particularly evident in recent months in Florida, where a state investigation of insurance fraud and other practices in the sober living and treatment industries has led to two well-publicized raids on sober home operators in Palm Beach County since last September. FARR's Lehman points out that observers are speculating as to why no indictments have been issued to this point, wondering whether the reach of the investigation is spreading even farther. If that plays out in future actions, “That message would be a game changer,” he says.

One byproduct of this speculation is consistent interest among many Florida recovery homes in becoming FARR-certified as meeting accepted standards of operation and ethical conduct. Lehman says 50 organizations that operate sober homes in the state have been certified, and around 20 entities a month are applying for certification.

Those numbers could grow further if Florida legislators this year pass a bill that would require state-licensed addiction treatment facilities to refer their transitioning clients to certified recovery residences only, as opposed to any residence in the state. Recovery homes would have one year to achieve certification before the referral provision took effect.

Lehman says he benefited greatly from living in recovery residences where sound social model principles were embedded, though no one was using that term at the time. The effort involves much more than providing a roof and a bed.

“When the residents begin to see their community as more important than their personal wants and desires, you have scored,” Lehman says. “Someone will come in defiant of the rules, and 90 days later that same person is overheard sharing with a new guy why it is so important for new arrivals to adhere to house rules.”

Recovery residence levels of support

Level 1 (peer-run): These least-intensive operations are democratically run homes usually housed in single-family residences, with no paid positions but possibly an overseeing officer.

Level 2 (monitored): These homes are usually run by a house manager or senior resident, with specific policies and procedures in place. Peer-run groups occur on site. As with Level 1, drug screening is included in services.

Level 3 (supervised): These homes, as well as homes operating as Level 4, have an organizational hierarchy, with some certified staff. All types of residential settings are used. Any needed clinical care is accessed in the surrounding community.

Level 4 (service provider): Unlike Level 3, these providers offer clinical services in-house with credentialed staff. Sometimes a Level 4 operation is part of a primary treatment center's care continuum. As with Level 3 homes, there is an emphasis on developing residents' life skills.

The reason for standards comes to life

Lisa Sax's own less-than-ideal experience living in a spartan halfway house environment helped shape her into becoming a self-proclaimed “conservative” sober home operator. Her two Liberty House properties in Fort Lauderdale, Fla., feature staff trained in first aid, regular but not excessive drug testing (including Breathalyzer checks), and a night manager who constantly walks the premises instead of camping out in an office. Sax says convincingly that attention to detail helped save a life when something went awry in one of the homes in January.

A 25-year-old resident of the men's house had locked himself in a bathroom after midnight and wasn't responding to his roommate's pleas. The roommate approached the night manager, who broke open the door and rushed in with a staff member who administered CPR to the man. “He was blue,” Sax says of the resident.

Paramedics arrived quickly and administered a dose of naloxone (Narcan) to the overdosing man. The resident was hospitalized for a couple of days. He could not return to Liberty House because he would not immediately agree to enroll in a treatment program to address his relapse. But while Sax says the eventual outcome for the former resident remains unknown, she knows that a life could have been lost that morning.

Sax believes all recovery homes should have a Narcan kit on premises. “There is not one halfway house that doesn't have ODs,” she says. “I know that's the nature of the game,” given the relapsing nature of the illness. “Transitional housing can do a lot more to prevent that sort of thing.”

Liberty House operates a 20-bed men's residence and a 10-bed women's house, under a Level 2 service model based on the National Alliance for Recovery Residences (NARR) levels of support. It is a member of the Florida Association of Recovery Residences (FARR), a quality-minded organization that Sax wishes more sober home operators in Broward County knew about. She says she would give the average Broward County recovery residence a grade of C-minus.

Unfortunately, Sax says, too many home operators sweep on-premises drug use under the rug, urging their residents not to talk about it either. Her own brother witnessed open use in a program he attended, and Sax proceeded to help move him to a more expensive but safer environment for early recovery.

“This is part of the drug-using culture we grew up in,” says Sax, a recovering heroin addict. “We're trained to think, 'Don't rat. Don't tell.'”