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| “Where Are They Going to Live?” Why We Need to Study Sober Living Houses |
| Feature Articles - Treatment Strategies or Protocols | |
| Thursday, 30 September 2004 | |
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Where are they going to live?” is one of the most frequent and frustrating questions faced by alcohol and drug professionals. In residential programs, there are often few housing options for clients upon completion of treatment. Although some residential programs have transitional beds in the community that clients can access during an aftercare phase of treatment, they are typically limited and not able to accommodate all of the clients that need them. So clients often have little choice but to reside with substance-using family or friends, or alone in an apartment or hotel room without the necessary social support to maintain the gains made in treatment. Even if they have developed a strong recovery program, continued abstinence from alcohol and drugs without the provision of a long-term clean and sober living environment is difficult.
Why sober living? Drug and alcohol offenders in the criminal justice system face similar challenges. Even if they are motivated to stop using substances, they may have difficulty maintaining motivation in the face of destructive living environments that invite a return to alcohol and drug use and illegal behaviors. Individuals who attempt to establish sobriety solely through self-help groups such as 12-step programs may face similar challenges. Although they may be motivated to make the changes necessary to deal with their addiction, their inability to leave alcohol- and drug-using living environments leaves them vulnerable to relapse. For many individuals, sober living houses (SLH’s) offer an appealing alternative to more intensively structured treatment programs. For example, SLH’s are sometimes used by clients who have completed treatment, relapsed, and want support for reestablishing sobriety without reentering a residential program (Schonlau, personal communication, February 8, 2004). Lack of sober living housing also may be associated with vulnerability to homelessness. Link, Suusser, Stueve, Phelan, Moore, and Stuening (1994) reported that homelessness affected up to 5.7 million people in the U.S. between 1987 and 1993. Conservative estimates of alcohol and drug problems among the homeless suggest that up to 40 percent suffer from alcohol abuse and 15 percent from drug abuse (McCarty, Argeriou, Huebner, and Lubran, 1991). In one California county, Robertson, Zlotnick, and Westerfelt (1997) found that 69.1 percent of the homeless had a lifetime history for a substance use disorder. Many sober housing advocates and addiction professionals would suggest that the rates are even higher. In addition to alcohol and drug problems, these individuals are at higher risk for a variety of health problems, including HIV infection, TB, and sexually transmitted diseases (Milby, Schumcjer, Fredman, Wallace, & Frison 2003). Because they are likely to be treated in publicly funded medical settings, they incur substantial costs to society. Even greater social costs result from their involvement in the criminal justice system (Polcin, 1999). In particular, chronic problems with “nuisance crimes,” such as public intoxication, trespassing, disorderly conduct, and petty theft have been frustrating and costly for many communities. This article suggests that SLH’s have been overlooked as essential recovery resources, resulting in a lack of social environments that support recovery from addiction. After describing SLH’s and their role in the spectrum of recovery services, this article presents a 5-year, National Institute of Alcohol Abuse and Alcoholism (NIAAA) funded study titled “An Evaluation of Sober Living Houses” (see page 38). The study, based at the Haight Ashbury Free Clinics in San Francisco, examines 18 sober living houses in Northern California. The article ends with suggestions for addressing some of the obstacles faced by SLH’s and strategies for developing more support for SLH’s among advocates, professional groups, state and local government officials, and the public.
What are Sober Living Houses? 1. It is a cardinal rule that alcohol and drug use among residents results in loss of residency. Typically, SLH’s require some period of sobriety before individuals enter, but sobriety requirements vary among houses from several days to several months. 2. SLH’s either mandate or recommend attendance at self-help groups, such as Alcoholics Anonymous. 3. They require that residents pay rent on time and comply with other “house rules.” Requirements such as attending house meetings and participating in house maintenance tasks, such as cooking and cleaning, are nearly universal. 4. SLH’s facilitate some type of “residents council” or residents’ advisory board that plays a powerful role in the management of the house. Although there may be a manager or administrator who is ultimately held responsible for operations, empowerment and involvement of the residents’ council in house operations is a vital part of recovery in SLH’s. Some SLH’s may have additional requirements, such as complying with curfew times, attending house meals, or participating in the residents’ council. It is difficult to gauge an exact number of how many SLH’s exist because they are exempt from any type of state licensing. However, the number of SLH’s that are affiliated with recovery organizations that monitor health and safety standards are increasing. The California Association of Addiction and Recovery Resources (CAARR) reports that 24 member organizations provide sober housing services. The Sober Living Network, based mainly in southern California, reports that more than 250 houses have joined their coalition. Oxford House is an international organization with more than 1,000 houses throughout the United States. The philosophy of recovery in SLH’s is a social model approach, which emphasizes shared, democratic self-governance, peer support, and attendance at self-help groups such as Alcoholics Anonymous or Narcotics Anonymous meetings (Borkman, Kaskutas, Room, Bryan, & Barrows, 1998; Kaskutas, 1999; Polcin, 2001). SLH’s have served a variety of functions within alcohol and drug services systems. For example, they have been used as:
Although some SLH’s are part of alcohol and drug treatment systems and provide housing only for individuals who complete residential programs or participate in outpatient care, other SLH’s are freestanding facilities open to anyone with a drug or alcohol problem. Wittman (2000) has suggested that that SLH’s could play a strong role in helping California’s Proposition 36 succeed. This voter passed initiative in 2000 mandates that individuals arrested for nonviolent drug offenses be offered drug treatment with probation in lieu of incarceration. However, Wittman argues that the success of Proposition 36 will require the state to fund a variety of adjunctive services in addition to formal treatment, such as establishing more clean and sober living environments such as those offered by SLH’s. Without long-term stable housing, the chances of maintaining the progress that clients make in treatment decreases substantially. This could result in poor long-term follow-up results and hinder future funding of criminal justice mandated treatment. Most SLH’s serve individuals who have adequate work and social skills to find gainful employment to meet their financial needs. However, some SLH’s also accept individuals who meet their financial obligations from governmental subsidies such as SSI or general assistance. These facilities usually require those residents who are not able to work to have some alternative structured daily activities (e.g., day treatment, volunteer work) and they are required to comply with all other house rules. A separate but related type of housing is the “supported housing” program. These facilities are designed specifically for the needs of dual diagnosis individuals who suffer from addiction and mental health disorders. Supported housing programs are usually associated with mental health treatment systems that address the wide variety of needs that this population presents. As such, they usually entail substantially more structure and supervision than would be found in a SLH. One of the key strengths of sober houses is that they generally cost little to alcohol and drug delivery systems because residents are expected to pay for all or most of the costs (Polcin, 2001). Some states offer start up loans to individuals or groups developing SLH’s and some SLH’s offer incoming residents loans or stipends to pay costs for the first month or two. However, in general, sober living residents bear the burden of costs. Hence, finding gainful employment is critical to success. SLH’s are often able to provide residents with job leads and helpful advice about finding employment. Individuals who are not able to find employment due to disabling psychiatric conditions may do better in more structured supported housing programs that are part of mental health treatment systems. Because SLH’s are low-cost compared to other residential alternatives (e.g., inpatient hospital, residential, therapeutic community) they are becoming increasingly attractive to funders of recovery services. Clinical and anecdotal reports suggest that SLH’s could play a more prominent role in the continuum of recovery services (e.g., Wittman, Biderman, & Hughes, 1993; Wright, 1990). They have the potential to be especially helpful for the large number of homeless individuals who have alcohol and drug problems. However, relative to the need for sober housing among addicts and alcoholics, the number of SLH’s remains woefully inadequate and only one scientific study has assessed outcome in SLH’s (i.e., Jason, Ferrari, Smith, Marsh, Dvorchak, Groessl, Pechota, Curtin, Bishop, Kot, & Bowdin, 1997). That study was limited to an analysis of retention in sober living homes after a six-month follow-up period and was hampered by a number of technical problems as described by Polcin (2001). First was the study assessed houses for men only, so results cannot necessarily be generalized to women. Second, the study only assessed factors associated with residents’ retention in the houses. No information was provided about level of functioning of the men, such as drug and alcohol use, employment, family relationships, psychiatric status, health problems, or criminal justice involvement. Finally, the men were not followed up after they left the houses, so we do not know how long improvements may have lasted. The main findings included analyses suggesting that dropouts were more likely to be younger and Caucasian. It is not surprising that residents who were more optimistic about the future when they entered the SLH were more likely to remain at least 6 months than residents who were pessimistic. If SLH’s are to be recognized as legitimate recovery resources, outcome data is needed to document ways they are effective as well as any potential limitations. Research findings could be used to highlight the strengths of SLH’s, support the development of more of them, highlight potential weaknesses or problem areas, and provide recommendations for modifications.
“Evaluation of Sober Living Houses” project
What can be done now? 1) Be informed about the SLH’s in your local area and support their efforts to maintain and expand services. During interactions with your funding sources and local government officials, remind them of the difficulties that you face in your work with regard to finding adequate housing for clients. Discuss the potential benefits of increased SLH’s in your area and attempt to enlist their support. Promote a perspective of recovery among clients, professional peers, funders, and state and local government that emphasizes strategies to improve long term functioning in the community in addition to the well-documented benefits formal treatment. Above all, remember SLH’s as a potential resource for clients with housing problems. 2) Individuals or organizations that are attempting to establish or expand SLH’s should consider the advantages of joining a coalition of SLH’s, such as the organizations listed below. Among other things, they provide health and safety standards, practical strategies for addressing a variety of issues that SLH’s face, and considerations for dealing with NIMBY (not in my back yard). 3) More efforts are needed to systematically study SLH’s and discuss relevant issues among recovery organizations, professionals, researchers, advocates, funders or treatment, and government officials. As a result, the Haight Ashbury Free Clinics’ study of SLH’s (see below) will be presenting its results to a variety of forums to maximize exposure to each of these groups. Douglas L. Polcin, EdD, MFT ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) is a research psychologist at the Haight Ashbury Free Clinics and an instructor in the Alcohol and Drug Abuse Studies Program at the University of California, Berkeley-Extension. Gantt Galloway, PharmD, is Chief of Pharmacologic Research of the Haight Ashbury Free Clinics and Director of Research at New Leaf Treatment Center. His principal area of interest is developing improved pharmacologic and behavioral treatments of drug and alcohol dependencies.
Kristen D. Taylor, BA, completed her degree at the University of San Francisco. She has worked as research Alex Benowitz-Fredericks is a data management specialist at the Haight Ashbury Free Clinics Department of Research, Education and Training and an administrative assistant for the Journal of Psychoactive Drugs.
Acknowledgements
References Five-year Study of Sober Living Houses: Which Residents Will Benefit?Researchers at the Haight Ashbury Free Clinics have received funding from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to conduct a comprehensive, 5-year study of Sober Living Houses (SLH’s) in Northern California. The study, titled “An Evaluation of Sober Living Houses”, will track how well residents function in a variety of areas over an 18-month period. Rather than using dichotomous outcome measures that provide little useful data and can be misleading (e.g., relapse rate), measurement of outcome in the study is conceived broadly and includes multiple areas of functioning. Areas assessed include alcohol and drug use, family and social relationships, employment, legal problems, medical status and psychiatric symptoms. The study also includes three comparisons: 1) sober living residents versus early dropouts from the SLH, 2) clients completing residential treatment who enter sober houses versus those who live elsewhere, 3) and criminal justice offenders referred into sober living houses versus offenders referred into residential treatment. In addition to documenting the strengths of SLH’s, the study will assess potential limitations For example, individuals using the SLH as their sole method of addressing their addiction may have difficulty if they have serious problems in other areas that are not being addressed (e.g., psychiatric, vocational, medical, etc). One of the assessments made in the study is a measure of the services that individuals feel they need when they enter the SLH and a measure of the services that they actually receive (Hser, Polinsky, Maglione, & Anglin, 1999). The hypothesis is that a ratio of services desired to services received will correlate with outcome. Finally, the study tests a new instrument designed to measure the effects of confrontation in the recovery process. Our hypothesis is that the effects of confrontation will vary depending on characteristics of the individual receiving confrontation, the confronter, their relationship, and contextual factors of the social environment. The study will collect data from three organizations that administer sober living SLH’s:
1) Clean and Sober Living
2) Sobriety Through Education and Peer Support (STEPS)
3) Options This article is published in Counselor,The Magazine for Addiction Professionals, October 2004, v.5, n.5, pp. 36-41.              |
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