“Focusing on the subtle meaning of words—rejecting some while embracing others—is far more than a matter of shallow political correctness. It is about changing the way addicted and recovering people see themselves and are seen by others. It is about changing the language that affects social policies and is in turn affected by those policies. Changing language is a way to personally and culturally close one chapter in history and open another.”
William L. White, The Rhetoric of Recovery Advocacy: An Essay on the Power of Language
Recovery residences provide a vital tool for initiating and sustaining long-term recovery. They are desirable in their emphasis on structure and community in a recovery setting, their service provision over an extended period of time, and their cost-effectiveness.
Outcome studies show that the longer an individual remains in a recovery or treatment environment, the greater are her or his chances of sustaining recovery.1,2 Unfortunately, people in early recovery often are discharged from institutions or programs only to return to the environment where alcohol or other drug use triggers were experienced and addictive lifestyles were supported. Recovery residences provide a safe, healthy, community-based alternative for facilitating recovery at all stages of the recovery process.
Many convergent pathways to recovery exist, ranging from mutual support groups to professional treatment—each of which may be found in various types and levels of recovery residences. The residential spectrum offers a broad variety in terms of types of communities, intensity of structure, and degrees of services offered. Heretofore the field has lacked uniformity and precision of terms necessary to match presenting needs with the appropriate level of residential support.
The National Association of Recovery Residences (NARR) began in response to a call for residential providers across the service spectrum to create a uniform language and standards for all types of recovery residences. This association has attained a broad reach, finding commonality of standards, practice and language for the vast scope of residential operators. A seminal event of 2011 for the association was the adoption of a national standard for recovery residences, to include universal nomenclature.
Today, recovering addicts/alcoholics may engage with a wide spectrum of recovery residences, ranging from the peer-run sober home to the residential treatment program. Historically and geographically, different terms have been used to describe these residences: halfway house, extended care, three-quarter house, sober living, etc. These monikers lack uniformity and clarity, and the meaning of each often depends on the system or area of the country in which one operates.
The myriad of terms and services contributes to significant confusion about matching facilities to individual needs for those seeking recovery residences, affecting potential residents and their families, professionals in behavioral and physical healthcare, criminal justice workers, and coaches and supporters in the recovery community.
Recovery housing is the basic service provided by recovery residences that includes, at a minimum, recovery peer support. “Recovery residence” is an all-encompassing term that accurately describes the residential modality of recovery support, and provides a bridge for a field that historically has been fragmented.
Levels of residential support provide uniform terminology that delineates the range of offerings along the residential continuum. Written operating protocol comprised of community rules, ethical operational and administrative practices, and drug screening procedures are core standards applicable to all recovery residences, regardless of the form of home organization or level of support services offered.
The level titles that have been adopted by NARR are designed to be simple, descriptive and intuitive. Higher numbers correspond to higher degrees of service provision. This new residential matrix will afford those seeking recovery residences the ability to select the modality that best fits presenting needs.
Level 1: Peer-Run
Level 1 recovery residences offer supportive housing in a peer environment. These recovery residences are often referred to as “sober homes,” and are most often found in single-family residences. Oversight of residents is peer-based; residents are self-monitoring and accountable to one another.
The primary criterion for this living environment is a willingness to be abstinent from mood-altering substances. Self-help meetings and outside recovery support services are encouraged and utilized. Democratically elected leadership and weekly house meetings are a standard component of this level; chores and overall house functioning are processed within the community.
While there is no paid staff at this level of support, there is often an overseeing officer who facilitates admission to and discharges from the home, and is available in cases where house issues cannot be resolved internally. There are no in-house services offered at this level, except the benefit of living in a supportive community.
Level 1 peer-run facilities are appropriate for the individual who has physically and psychologically stabilized and who would benefit from a sober environment allowing her/him to implement personal recovery in an interdependent community of support. This level of support is very often one that is highly cost-contained. Length of stay varies and is open-ended, generally ranging from 90 days to several years.
Oxford Houses are the most commonly known example of a Level 1 recovery residence, yet there are many other peer-based and democratically operated sober homes throughout the country.
Level 2: Monitored
Level 2 residences are characterized by peer-based recovery support services overseen by compensated peer staff. These homes utilize a senior resident or a house manager who monitors operations and residents, enforcing structure that is implemented in the form of house rules. There is an emphasis on community and accountability that manifests in a culture of peer support.
The living environment can be any type of dwelling, but most commonly is a single-family residence with shared bedrooms. Like Level 1, this setting often proves to be quite cost-effective.
Additionally, Level 2 homes very often work collaboratively with outpatient programs and/or recovery providers to offer comprehensive recovery management services. This systemic, rehabilitative community model is quite desirable for the structure and support provided in both residential and outpatient treatment settings. It allows for an increased ability to access services over a longer period of time due to the affordability of these service models. Like Level 1 homes, length of stay in Level 2 varies and is open-ended.
Level 3: Supervised
Level 3 recovery residences offer peer-based residence plus extended-care programming with an emphasis on (re)habilitative life skill development, overseen by professional staff. Guidance is provided toward the establishment of life and recovery sustaining activities (i.e., employment, self-help, physical health, etc.). Case management and clinical services are contracted in or accessed in the outside community. On-site staff promote and sustain the recovery environment. Average stays vary from 90 days to a year or more.
The residence itself can be quite varied, from a single-family residence to a grouping of apartments or townhomes to a large dorm-like dwelling. Licensing requirements vary from state to state regarding this type of recovery residence.
This environment is ideal for an individual who is stabilizing and establishing a recovery lifestyle after a residential treatment stay.
Level 4: Service provider
This type of recovery residence provides peer-based services plus life skills, and clinical programming. It is most often aligned or attached with a licensed treatment provider, and overseen by an appropriately credentialed and qualified management team. This level is characterized by a high degree of daily structure. Licensed and credentialed staff members provide in-house program services.
The residential facility is typically part of the continuum of care for an overseeing institution. All types of residences and occupancy numbers can be found at this level, depending on the program. Average stays vary from several weeks to several months, depending on the acuity of the individual. Emphasis is placed on equipping the individual for the next phase of recovery, be that another residential level or independent living.
Fees and demographics associated with this residential level vary considerably. Insurance is far more likely to cover costs at the residential treatment level (vs. Levels 1 to 3) at the present time.
The levels of recovery residence provide definition for the broad spectrum of residential services, while the national standard specifies best practices for each Level. Recovery residence levels of support and the standard establish uniform operational practices and performance criteria that enhance potential residents’ and referral sources’ knowledge of the offerings of a particular recovery residence. Objective descriptors facilitate appropriate placement in the residential continuum. Recovery residences now can operate with a degree of practice that elevates a field long in need of professional legitimacy.
Common language creates a precise framework for communications about critical issues. The recovery residence field is now poised to be a key participant in discussions regarding the service delivery system under healthcare reform, criminal justice reform and placement, and evidence-based practice.
Significant changes regarding the nature of services available to persons with substance abuse disorders are expected as a result of the Mental Health Parity and Addiction Equity Act and the Patient Protection and Affordable Care Act. There will be greater access to services through the healthcare system, longer-term monitoring and maintenance strategies, and efforts toward teaching and promoting self-care, all of which complement recovery residence services.
High-quality recovery residences provide affordable choices that support outpatient and other forms of community-based treatment. As recovery services shift from an acute care model to sustained recovery management, it is important that the recovery residence field be visible and vocal in discussions regarding funding and reimbursement issues.
Recovery residences have proven to be effective in reducing homelessness for persons with substance use disorders.3 The community model inherent in all levels facilitates access to sustaining recovery practices, while offering a preferable alternative to traditional shelters.
Recovery residences also offer a positive option for the criminal justice system. Community-based alternatives such as recovery residences are poised to curb the flow of people into jails and prisons via drug court and other front-end programs, while also serving as key re-entry resources for inmates, of whom 75% report that substances were associated with their incarceration.
NARR supports implementation of evidence-based practices for diverse populations of providers and residents. Clear terminology codifies recovery residences, and the national standard creates a process for identifying best practices. NARR is dedicated to the transfer of concrete knowledge about recovery residences.
Individual housing providers need valid, actionable information about the operation of successful recovery residences. The public wants accurate information about recovery residences’ program characteristics and qualities when matching an individual’s recovery goals with socioculturally suitable programs. Policy-makers and healthcare professionals require dependable information about the potential impacts of recovery residences when incorporated effectively into comprehensive healthcare planning. In short, everyone benefits from research that identifies the practices that improve recovery outcomes.
It is an exciting and dynamic time for the recovery residence field. Your input in the dialogue is welcome as language, best practices and policies continue to evolve.
Beth Fisher, LCSW, LCAS, MAC, CCS, is President of the National Association of Recovery Residences (NARR; www.narronline.com). She is also Founder and Executive Director of Hope Homes, Inc., a Level 3 supervised recovery residence organization in Atlanta and Charlotte, N.C. (www.hopehomesrecovery.org). Her e-mail address is email@example.com.