Addictions Advisor: Understanding Recovery Residences
By Sue Coyle, MSW
Social Work Today
Vol. 18 No. 3 P. 8

Recovery from addiction is a process. A significant part of that process is treatment—inpatient and outpatient, short-term, and ongoing. As such, much attention is given to it. The increasing and recent media focus on opioids, for example, concentrates a great deal on the need for available, accessible, and quality treatment options.

However, looking only or primarily at treatment is both shortsighted and Sisyphean. Recovery requires a greater system of resources and support for it to be sustainable. This became evident to Beth Fisher Sanders, LCSW, LCAS, MAC, CCS, CEO and executive director of Hope Homes and founding president and current board member of the National Alliance for Recovery Residences (NARR), while working in the field in the mid-1990s. At that time, insurance and other barriers were impacting individuals' treatment options.

"That was when the bottom fell out of addiction services," she says. "The traditional 28-day [stay] went away. I saw a real revolving door—a revolving door of acute care. People would return for two or three weeks, whatever they could get, but they were discharged with no therapeutic place to go. They would relapse."

Sanders founded Hope Homes, an organization that provides recovery residences at varying levels to individuals in Atlanta; Charlotte, NC; and Nashville. And she's not the only one to have done so. Recovery residences are not a new phenomenon. However, until recently, the quality of those residences was difficult to judge from the outside.

For that reason, Sanders and other professionals in the field founded NARR. It, in conjunction with state organizations throughout the country, works to ensure that individuals have a place to go that will support and help maintain recovery.

Recovery Residence Definition
To understand what NARR and its state affiliates aim to accomplish, one must first define a recovery residence. That is, in fact, what NARR set out to do when it was founded in 2010 (many of the state affiliates had been operating for years prior).

Generally speaking, "A recovery residence is a clean, safe, sober environment for individuals who are looking to try to get housing and also a recovery program, to get them back on their feet for self-sufficiency," explains Fred Way, executive director of Pennsylvania Alliance of Recovery Residences (PARR) and treasurer at NARR. Way was also a founding member of the national alliance.

"It's a spectrum," Sanders adds. "It goes from Level 1, which is a peer-based residence for the individual that's very committed to their recovery, that's really wanting sober roommates but no oversight. Level 4 is a facility that would be licensed. Level 2 is sometimes called a sober home where there might be a senior resident who oversees the operation. Level 3 is more life-skill oriented, more staff, more oversight.

"The differentiators are the staffing and the structure," she says. Hope Homes offers Level 2 and Level 3 residences.

These homes should provide safe places for individuals to live temporarily as they continue to work their programs. They do not provide treatment. Residents seek the appropriate level of outpatient care from facilities within the community and have, ideally, already participated in inpatient care if necessary.

The goal of all houses, regardless of level, is to promote long-term recovery—to close the revolving door or at least slow it down.

Advantages
When recovery residences work, there are significant advantages. For one, returning home after inpatient treatment is not always the best option. Environments and individuals can be triggering, particularly as an individual is in the early stages of learning how to use coping mechanisms and other tools to maintain recovery. However, no individual should live in isolation. That, too, impedes recovery.

"What we know about addictions recovery is that it's best done in the community," Sanders says. "In my view, the residential setting—any of the levels of recovery residence—is really about how you develop a healthy family life and environment. We don't get better in isolation. We grow and heal with others. The advantage is a healing environment to grow."

It also provides stability. Without recovery homes, many would not have a place to go. "If you take away recovery residences, where are they going?" Way asks. "You have 2,000/3,000 men or women, some with children. Where do they go? You don't have a shelter system able to absorb that. Recovery residence is key to recovery."

While there, the resident is able to attend treatment, find employment, and save some money. "Then [they can] drop down to a transitional level," Way says. "From there they can go into their own apartment or wherever [they're able to live]." Way notes that many residents have records and thus difficulty finding employment. As such, some stays in recovery residences are longer than others.

Disadvantages
Of course, as with anything, there can be disadvantages to recovery residences. For one, it has to be the appropriate setting and the right point in recovery for the resident. "A lot of times, we are asked to consider people who are really not stable enough [for a recovery residence] because resources, such as benefits, have run out. They need to go somewhere," Sanders says. "So, having somebody come to a residence when they're not ready for that level of care is definitely a disadvantage."

However, "if we are practicing what we preach, then we are working in community with our continuum of care," she continues. "Sometimes, that individual needs a higher level of care. Relapse might indicate that. Or they need to go somewhere else, have a different environment. We are working in collaboration with the community at large—we are not the be all, end all. There is a whole community."

Additionally, going to a home that is less than reputable can mean a significant setback to recovery. Way states that many individuals looking for recovery residences haven't previously known what to look for, what to ask, and what's good or not good in a home. They lacked a clear understanding of what a recovery residence is and, therefore, what expectations they should have for one.

When residents and their families are uninformed it can enable operators to conduct themselves unethically. Sanders describes incidents in which residences are closely connected to outpatient treatment facilities or toxicology labs, and the residents are used to increase business and/or for the compensation that can be garnered through their insurance.

On a more basic level, homes may be lacking in cleanliness, structure, and even sobriety.

Regulations
The degree to which recovery residences could and can vary in quality is a large reason why NARR was formed. "There were no standards for recovery houses," Way says. He worked in the city of Philadelphia for 20 years before helping to create NARR and subsequently PARR. In his career, Way saw the increasing need for such standards, as did all the other founding members, he says. "It's the most egoless group of people I've ever worked with," he adds.

NARR established standards as well as a code of ethics for all recovery residences. Sanders explains that the group started with what not to do and then pulled from already established codes. "Some of us had in our individual states and regions codes of ethics. We looked at all the professional ethics codes—social work, addictions counseling, etc.—and adopted a mode and language that was applicable to us," she says.

For Way, some of the most important guidelines surround administrative responsibilities. "Is it a business entity? Do they have a written code of ethics? Do they comply with state/federal requirements?" he lists by way of example. "A lot of recovery houses [when learning the standards] are like, 'Wow! We never knew.' It's a learning curve for them, and they're really enjoying the fact that they're separated from those other houses."

Residences can apply for certification through state affiliates, such as PARR. Once certified, the houses can be referred to with increased confidence from service providers and other individuals. What's more, the certification helps alleviate fears of the community in which the new residence will be housed. There is sometimes resistance to the idea of a recovery residence from the people already living in the area. Way is able to use the certification process and established standards to ease some concerns. He regularly attends community meetings and events where his goal is to provide education. "Generally, the community is already in an uproar," he says. "We get up and talk about standards—you won't see anyone out front smoking, you won't see anyone harassing [others]—you can feel the anxiety of the room going down."

In addition to creating standards that set the foundation for state-affiliate certification, NARR is working to garner national support and buy-in from all 50 states. Success is coming. NARR has collaborated with organizations like the Substance Abuse and Mental Health Services Administration, and states, such as Pennsylvania, are adopting laws about recovery residence standards.

Both Sanders and Way are hoping and working for continuing growth for NARR and its affiliates. As they do, more and more individuals have the opportunity to find a home that truly supports their recovery.

— Sue Coyle, MSW, is an award-winning freelance writer, a social worker in the Philadelphia suburbs, and a frequent contributor to Social Work Today.