Measuring Architecture in Recovery Homes: Recovery Home Architecture Scale.

Background: The settings where we live shape our daily experiences and interactions. Social environment and physical setting characteristics may be particularly important in communal living services, such as recovery homes for alcohol and drug disorders. Objectives: This paper describes the measurement and mobilization of architectural characteristics in one type of recovery home, sober living houses (SLHs). The Recovery Home Architecture Scale (RHAS) is a 25-item measure comprised of six subscales designed to assess architecture in SLHs. Results: Using a sample of 528 individuals residing in 41 houses, we found the RHAS had good interrater reliability, factor structure, and internal consistency. The measure also showed modest construct validity. The RHAS was not associated with length of stay (LOS) but did interact with a measure of the social environment that predicted LOS, the Recovery Home Environment Scale (RHES). Conclusions: Future studies should include a more diverse sample of SLHs and assess how house management, recovery capital, and other factors work in concert with architecture.

Social Model Recovery and Recovery Housing.

Recovery housing is an important resource for many in their recovery from alcohol and other drug use disorders. Yet providers of recovery housing face a number of challenges. Many of these challenges are rooted in stigma and bias about recovery housing. The ability to describe the service and purported mechanisms of action vis-a-vis an overarching framework, approach, or orientation could also go a long way in adding credence to recovery housing as a service delivery mechanism. Several aspects of social model recovery are often explicitly built or organically reflected in how recovery housing operates, yet describing recovery housing in these terms often does little to demystify key features of recovery housing. To more fully cement social model recovery as the organizing framework for recovery housing this article aims to: review the history, current status, and evidence base for social model recovery; comment on challenges to implementing the social model in recovery housing; and delineate steps to overcome these challenges and establish an evidence base for social model recovery housing.

Psychometric Properties of the Recovery Home Environment Scale.

BACKGROUND: Recovery homes for persons with alcohol and drug problems provide an abstinent living environment and social support for recovery. Research shows residents in these homes make significant, sustained improvements. However, descriptions of recovery environments within the homes have been limited. PURPOSE: The current study assessed psychometric properties for the Recovery Home Environment Scale (RHES), which assessed social environments within one type of recovery home, sober living houses (SLHs). METHODS: 373 residents were interviewed at entry into the house, 1-month follow-up, and 6-month follow-up. Measures included the RHES, other measures of the social environment, days of substance use, and length of stay. RESULTS: Principal components analysis suggested the RHES was largely unidimensional. Exploratory factor analysis suggested items could be grouped into recovery support (3 items) and recovery skills (5 items). Cronbach's alphas for the full scale and the recovery support and recovery skills subscales were 0.91, 0.89, and 0.87, respectively. As hypothesized, construct validity of the RHES was supported by correlations with other measures of the social environment and predictive validity was supported by associations with length of stay and substance use. CONCLUSIONS: SLHs have been described as "the setting is the service." However, the field has lacked a way to capture characteristics of the social environment. The RHES represents a new way to measure the recovery environment by focusing on social interactions among residents within SLHs and shared activities in the community.

Resident and house manager perceptions of social environments in sober living houses: Associations with length of stay.

AIMS: Studies have shown persons living in recovery homes for drug and alcohol problems make significant, sustained improvements. However, there is limited information about factors associated with outcomes. This study examined how perceptions of social environment of one type of recovery home, sober living houses (SLHs), were associated with length of stay (LOS). METHODS: SLH residents and their house managers (N = 416) completed the recovery home environment scale (RHES) that assessed social model recovery characteristics and the community-oriented program evaluation scale (CPES) that evaluated perceptions of the program environment. RESULTS: Scales completed by residents predicted LOS, but those completed by house managers did not. Larger discrepancies between the two groups were associated with shorter LOS. The RHES was shown to be a stronger predictor of LOS than the CPES. CONCLUSION: Results highlight the importance of the social environment in SLHs, particularly those most closely aligned with social model recovery principles.

House Manager Roles in Sober Living Houses.

BACKGROUND: Alcohol and drug treatment providers are increasingly emphasizing the role of long-term, community-based systems of care. A good example is Sober Living Houses (SLHs), which are peer operated alcohol- and drug-free living environments. Studies show residents of SLHs make significant improvements in multiple areas. However, little attention has been devoted to describing the critically important role of SLH managers who oversee these homes. METHODS: Thirty-five SLH managers completed interviews about the characteristics and operations of their houses, their activities as managers, and ways their own recovery was affected by their work. RESULTS: Managers reported widespread use of some but not all principles of social model recovery. Manager roles varied dramatically in terms of time spent managing houses, activities related to their roles, and training they received. Some reported extensive amounts of time proving support to residents, while others viewed their role as primarily administrative. CONCLUSIONS: Research is needed to understand reasons for manager differences, optimal manager functioning, and manager training needs. Research is also needed to assess whether different house characteristics require different manager roles.

Recovery Home Environment Characteristics Associated with Recovery Capital.

BACKGROUND: Recovery capital refers to internal and external resources that facilitate recovery from alcohol and drug disorders. Examples include support from friends and family, access to health and other services, stable housing and finances, and internal assets, such as self-esteem and motivation. Recovery capital is receiving increased emphasis as an integral component of addiction services. However, there are a limited number of studies assessing recovery capital in different settings. METHODS: The current study assessed recovery capital among 363 individuals entering sober living recovery homes (SLHs) and showed how recovery capital was associated with individual and social environment characteristics of the houses. Individual characteristics were assessed shortly after residents entered the house (mean=17 days, sd=9.0). Approximately one month later, individuals were interviewed about their perceptions of the social environment within the household. We hypothesized residents' perceptions of social model characteristics within the household would be associated with higher recovery capital. RESULTS: Study findings showed individual characteristics associated with recovery capital included motivation, support from friends and family, and 12-step involvement. Perceptions of the social environment assessed by four subscales on the Community Oriented Program Evaluation Scale and a measure of social model characteristics were correlated with recovery capital. Regression analyses controlling for individual characteristics showed modest, but consistent associations with recovery capital. CONCLUSION: Even after relatively short periods of time in SLHs, resident perceptions of the social environment show associations with recovery capital. Additional research is needed to understand causal dynamics of this relationship and associations with outcome.

Recovery in context: Sober living houses and the ecology of recovery.

Sober living houses (SLHs) are an increasingly common element of the recovery support services landscape, yet little is known about their neighborhood context. This study describes neighborhoods in which SLHs are located and examines differences by house characteristics. SLHs in Los Angeles County (N = 297) were geocoded and linked with U.S. Census, alcohol outlet, recovery resources, and accessibility data. Regression analyses tested differences by house characteristics. Co-ed houses were in neighborhoods that were less ethnically diverse and farther away from recovery resources. Larger house capacity was associated with increased density of off-premise alcohol outlets but also increased proximity to treatment. Higher fees were associated with lower neighborhood disadvantage and off-premise alcohol outlet density but the greater distance from treatment programs and other recovery resources. House characteristics are associated with neighborhood factors that both support recovery and place residents at risk.

Improving Recovery Outcomes among MSM: The Potential Role of Recovery Housing.

BACKGROUND: Gay, bisexual, and other men who have sex with men (MSM) face unique recovery challenges. Recovery housing may play an important role in improving outcomes among MSM, but little is known about their experiences in these settings. METHODS: This study examined 3-month outcomes among MSM (N=22) living in a group of recovery residences in Texas, one of which is a home specifically designated for gay and bisexual men. Upon intake, adult MSM were recruited to participate in the study, which involved a baseline and 3-month phone interview and allowing study staff to access records maintained by the program about their stay. RESULTS: At follow-up, only two (9.1%) reported used of any substances in the past 30 days. The vast majority (73%) had attended outpatient substance use treatment in the past three months, and 86% reported working for pay during the past 30 days. All participants reported attending four or more 12-step meetings in the past 30 days. Use of dysfunctional coping strategies significantly decreased, however so did scores on health-related quality of life. CONCLUSIONS: MSM have complex treatment needs. Recovery housing may help improve outcomes among MSM by bridging formal substance use treatment with community-based recovery support.

"I have more support around me to be able to change": A Qualitative Exploration of Probationers' and Parolees' Experiences Living in Sober Living Houses.

Persons in the U.S. who are incarcerated for drug offenses are increasingly being released into the community as a way to decrease prison and jail overcrowding. One challenge is finding housing that supports compliance with probation and parole requirements, which often includes abstinence from drugs and alcohol. Sober living houses (SLHs) are alcohol- and drug-free living environments that are increasingly being used as housing options for probationers and parolees. Although a few studies have reported favorable outcomes for residents of SLHs, little is known about resident experiences or the factors that are experienced as helpful or counterproductive. This study conducted qualitative interviews with 28 SLH residents on probation or parole to understand their experiences living in the houses, aspects of the houses that facilitated recovery, ways residence in a SLH affected compliance with probation and parole, and ways the houses addressed HIV risk, a widespread problem among this population. Interviews were audiotaped and coded for dominant themes. Study participants identified housing as a critically important need after incarceration. For residents nearing the end of their stay in the SLHs, there was significant concern about where they might live after they left. Residents emphasized that shared experiences and goals, consistent enforcement of rules (especially the requirement of abstinence), and encouragement from probation and parole officers as particularly helpful. There was very little focus in HIV issues, even though risk behaviors were common. For some residents, inconsistent enforcement of house rules was experienced as highly problematic. Research is needed to identify the organizational and operational procedures that enhance factors experienced as helpful. This paper is the first to document the views and experiences of persons on probation or parole who reside in sober living recovery houses. These data can be used by SLH operators to develop houses that are responsive to factors experienced as helpful and counterproductive. The significance of this paper is evident in the trend toward decreasing incarceration in the U.S. of persons convicted of drug offenses and the need for alcohol- and drug-free alternative living environments.

Motivational Interviewing Case Management (MICM) for Persons on Probation or Parole Entering Sober Living Houses.

The failure of incarceration as a response to drug offenses has resulted in new policies supporting community-based alternatives. One challenge has been finding appropriate housing for persons on probation and parole. Sober living houses (SLHs) are alcohol- and drug-free living environments that are increasingly being used as housing options for these individuals. The current study examined 6- and 12-month outcomes for 330 persons on probation or parole who entered 49 SLHs. Residents in 22 houses (n = 149 individuals) were randomly assigned to receive a "Motivational Interviewing Case Management" (MICM) intervention and residents in the other 27 houses (n = 181 individuals) received SLH residency as usual. At 6-and 12-month follow-up, both study conditions showed significant improvement relative to baseline on substance abuse, criminal justice, HIV risk, and employment outcomes. For persons who attended at least one MICM session, there were better criminal justice outcomes compared to the SLH as usual group.

Housing Status, Psychiatric Symptoms, and Substance Abuse Outcomes Among Sober Living House Residents over 18 Months.

Studies show individuals entering sober living recovery houses (SLHs) make significant, sustained improvement on measures of substance abuse problems, employment, and arrests. The current study assessed changes in housing status among SLH residents over 18 months and the relative influences of housing status and psychiatric distress on substance abuse outcomes. Two hundred forty one men and 58 women, all age 18 and older, were interviewed within their first week of entering 20 SLHs and again at 6-, 12-, and 18-month follow-up. Between entry into the SLHs and 18-month follow-up homelessness declined from 16% to 4%, marginal housing declined from 66% to 46%, and stable housing increased from 13% to 27%. Psychiatric severity was generally mild to moderate in severity, but nevertheless showed improvement over the 18-month study period. Multivariate models showed worse substance abuse outcomes for residents with higher psychiatric distress and unstable housing. Relative to persons with stable housing, those who were homeless or marginally housed had worse outcomes and those in SLHs had better outcomes. Overall, we conclude that individuals entering SLHs show improvement in housing status and psychiatric distress, both of which are associated with better substance abuse outcomes.

Social Support Influences on Substance Abuse Outcomes Among Sober Living House Residents with Low and Moderate Psychiatric Severity.

Social support and psychiatric severity are known to influence substance abuse. However, little is known about how their influences vary under different conditions. We aimed to study how different types of social support were associated with substance abuse outcomes among persons with low and moderate psychiatric severity who entered Sober Living Houses (SLHs). Two hundred forty-five individuals entering 16 SLHs were interviewed at baseline and 6, 12, and 18 months. The Brief Symptom Inventory assessed psychiatric symptoms and the Important People Instrument and a modified AA Affiliation Scale assessed social support. Social support variables predicted substance abuse outcomes for persons with low and moderate psychiatric severity. However, they were the strongest and most consistent predictors for the low severity group.

Changes in psychiatric symptoms among persons with methamphetamine dependence predicts changes in severity of drug problems but not frequency of use.

BACKGROUND: Few studies have examined how changes in psychiatric symptoms over time are associated with changes in drug use and severity of drug problems. No studies have examined these relationships among methamphetamine (MA)-dependent persons receiving motivational interviewing within the context of standard outpatient treatment. METHODS: Two hundred seventeen individuals with MA dependence were randomly assigned to a standard single session of motivational interviewing (MI) or an intensive 9-session model of MI. Both groups received standard outpatient group treatment. The Addiction Severity Index (ASI) and timeline follow-back (TLFB) for MA use were administered at treatment entry and 2-, 4-, and 6-month follow-ups. RESULTS: Changes in ASI psychiatric severity between baseline and 2 months predicted changes in ASI drug severity during the same time period, but not changes on measures of MA use. Item analysis of the ASI drug scale showed that psychiatric severity predicted how troubled or bothered participants were by their drug us, how important they felt it was for them to get treatment, and the number of days they experienced drug problems. However, it did not predict the number days they used drugs in the past 30 days. These associations did not differ between study conditions, and they persisted when psychiatric severity and outcomes were compared across 4- and 6-month time periods. CONCLUSIONS: Results are among the first to track how changes in psychiatric severity over time are associated with changes in MA use and severity of drug problems. Treatment efforts targeting reduction of psychiatric symptoms among MA-dependent persons might be helpful in reducing the level of distress and problems associated with MA use but not how often it is used. There is a need for additional research describing the circumstances under which the experiences and perceptions of drug-related problems diverge from frequency of consumption.

Interaction of Motivation and Social Support on Abstinence among Recovery Home Residents.

BACKGROUND AND AIMS: The impetus to abstain from alcohol and drugs is especially robust when individuals seek help. However, motivation to continue abstinence during ongoing recovery is less understood. The present study assessed how social support interacted with motivation to affect abstinence over an 18-monthe time period. METHODS: A sample of 289 residents entering residential recovery homes were recruited and followed at 6-, 12-, and 18-months. Motivation was measured as the perceived costs and benefits of abstinence. Five social influence measures were used to assess interactive effects with costs and benefits on abstinence. RESULTS: Perceived costs and benefits of abstinence were robust predictors of abstinence over the 18 month assessment period. Two social support factors interacted with perceived benefits to influence abstinence: 12-step involvement and number of persons in the social network. CONCLUSION: Suggestions are made for recovery services to influence perceived costs, benefits, and social network characteristics.

Challenges and Rewards of Conducting Research on Recovery Residences for Alcohol and Drug Disorders.

Although research shows treatment for alcohol and drug problems can be effective, persons without stable housing that supports recovery are at risk for relapse. Recovery residences (RRs) for drug and alcohol problems are a growing response to the need for alcohol- and drug-free living environments that support sustained recovery. Research on RRs offers an opportunity to examine how integration of these individuals into a supportive, empowering environment has beneficial impacts on substance use, housing, and other outcomes, as well as benefits for the surrounding community. Research can also lead to the identification of operations and practices within houses that maximize favorable outcomes for residents. However, research on RRs also presents significant obstacles and challenges. Based on our experiences conducting recovery home research for decades, we present suggestions for addressing some of the unique challenges encountered in this type of research.

Interaction of motivation and psychiatric symptoms on substance abuse outcomes in sober living houses.

BACKGROUND: Studies show residents of sober living recovery houses (SLHs) make improvements in a variety of areas including alcohol and drug use, arrests, and employment. Longitudinal measures of motivation (assessed as costs and benefits of continuing sobriety) have been shown to be associated with alcohol and drug outcomes in SLHs. However, how motivation interacts with other potentially important factors, such as psychiatric severity, is unclear. OBJECTIVE: The present study aimed to assess how perceived costs and benefits of sobriety among residents of SLHs differed by psychiatric severity. The study also aimed to assess how costs and benefits interacted with psychiatric severity to influence outcome. METHODS: Two hundred forty-five residents of SLHs were assessed at baseline and 6, 12, and 18 months. RESULTS: High psychiatric severity was associated with higher severity of alcohol and drug problems and higher perceived costs of sobriety at all data collection time points. Perceived costs and benefits of sobriety were strong predictors of alcohol and drug problems for participants with low psychiatric severity. Perceived costs, but not perceived benefits, predicted outcomes for residents with high psychiatric severity. CONCLUSIONS/IMPORTANCE: High psychiatric severity is a serious impediment for some residents in SLHs. These individuals perceive sobriety as difficult and that perception is associated with worse outcome. Finding ways to decrease perceived costs and challenges to sustained sobriety among these individuals is essential as is collaboration with local mental health services. SLHs should consider whether additional onsite services or modifications of SLH operations might help this population.

How Should We Study Residential Recovery Homes?

PURPOSE: Persons with serious alcohol and drug problems who are attempting to maintain abstinence often lack an alcohol and drug free living environment that supports sustained recovery. Residential recovery homes, called "sober living houses" in California, are alcohol and drug-free living environments that offer long-term support for persons with addictive disorders. They do not offer formal treatment services but usually encourage or mandate attendance at self-help recovery groups such as Alcoholics Anonymous. APPROACH: This paper weighs the strengths and weaknesses of different research designs for studying residential recovery homes. Alternatives to randomized designs that are able to capture "real world" data that are readily generalized are described and understudied topics are identified. FINDINGS: A significant limitation of traditional randomized designs is they eliminate mutual selection processes between prospective residents and recovery home residents and staff. Naturalistic research designs have the advantage of including mutual selection processes and there are methods available for limiting self-selection bias. Qualitative methods should be used to identify factors that residents experience as helpful that can then be studied further. Innovative studies are needed to investigate how outcomes are affected by architectural characteristics of the houses and resident interactions with the surrounding community. PRACTICAL IMPLICATIONS: Use of the recommended strategies could lead to findings that are more informative, intuitively appealing, and interpretable. SOCIAL IMPLICATIONS: Recovery homes and similar programs will be more responsive to consumers. ORIGINALITY: This paper represents one of the first to review various options for studying recovery homes and to provide suggestions for new studies.

A moderating role for gender in racial/ethnic disparities in alcohol services utilization: results from the 2000 to 2010 national alcohol surveys.

BACKGROUND: Few nationally representative studies have examined racial/ethnic disparities in alcohol services utilization. Further, little is known about whether racial/ethnic disparities generalize across genders, and what factors account for these disparities. Thus, we aimed to describe the combined impact of race/ethnicity and gender on alcohol services utilization, and to explore the roles for social influence factors in explaining racial/ethnic and gender disparities. METHODS: Data were pooled across the 2000, 2005, and 2010 National Alcohol Surveys. Outcomes included lifetime utilization of any services, specialty alcohol treatment, and Alcoholics Anonymous. Social influence factors were assessed as lifetime social pressures (i.e., pressures from a partner, friends, and/or family), legal consequences, and work-related consequences. Core analyses included only those with a lifetime alcohol use disorder (AUD). RESULTS: Analyses revealed a pattern of lower services utilization among Latinos and Blacks (vs. Whites) and women (vs. men); further, race-by-gender interactions revealed that Black-White differences were limited to women, and provided some evidence of stronger Latino-White disparities among women (vs. men). Illustrating these patterns, among women, only 2.5% of Latinas and 3.4% of Blacks with a lifetime AUD accessed specialty treatment, versus 6.7% of Whites; among men, corresponding figures were 6.8% for Latinos, 12.2% for Blacks, and 10.1% for Whites. Racial/ethnic differences were typically robust (or stronger) when controlling for demographics and AUD severity. Evidence did not support a role for measured social influence factors in racial/ethnic disparities, but did suggest that these factors contribute to gender disparities, particularly among Whites and Blacks. CONCLUSIONS: Findings for substantial Latino-White and Black-White disparities, especially among women, highlight the need for continuing research on explanatory factors and the development of appropriate interventions. Meanwhile, our evidence for persistent gender disparities and for social influence factors as drivers of these disparities tentatively suggests a need for intensified outreach to female heavy drinkers.

Pressure to change drinking behavior: An exploratory analysis of US general population subgroups.

BACKGROUND: General population studies have shown that pressure from others to change drinking can come from different sources. Receipt of informal pressure (IP) and formal pressure (FP) is known to vary by quantity and consequences of drinking, but less is known about how pressure varies among subgroups of the population. METHOD: This exploratory study utilizes data from the National Alcohol Surveys from 1995-2010 (N=26,311) and examines associations between receipt of pressure and subgroups of drinkers. RESULTS: Increased relative risk of receiving IP and FP were observed for individuals reporting an arrest for driving after drinking and illicit drug use while poverty and lack of private health insurance increased risk of receipt of formal pressures. Regular marijuana use increased IP. CONCLUSION: The subgroups that were studied received increased pressures to change drinking behavior, though disentangling the societal role of pressure and how it may assist with interventions, help seeking, and natural recovery is needed.

Gender and Social Pressure to Change Drinking Behavior: Results from the National Alcohol Surveys from 1984-2010.

OBJECTIVE: Research shows social and institutional pressure influences drinking, yet determinants of who receives pressure are understudied. This paper examines age, time period, and birth cohort (APC) effects on pressure to stop or reduce drinking among U.S. men and women. METHODS: Data were drawn from six National Alcohol Surveys (NAS) conducted from 1984 to 2010 (N=32,534). Receipt of pressure during the past year to quit or change drinking from formal (police, doctor, work) and informal (spouse, family, friends) sources was assessed. RESULTS: Determinants of pressure were similar for men and women but varied in strength. They included younger age, less education, and younger cohort groups. Cohort effects were stronger for women than men. CONCLUSIONS: Cohort effects among women may be due to increased alcohol marketing to younger women and the changing social contexts of their drinking. Future studies should assess associations between drinking contexts, pressures, and outcomes.