Communal Housing Settings Enhance Substance Abuse Recovery

Abstract

Oxford Houses are democratic, mutual help–oriented recovery homes for individuals with substance abuse histories. There are more than 1200 of these houses in the United States, and each home is operated independently by its residents, without help from professional staff.

In a recent experiment, 150 individuals in Illinois were randomly assigned to either an Oxford House or usual-care condition (i.e., outpatient treatment or self-help groups) after substance abuse treatment discharge. At the 24-month follow-up, those in the Oxford House condition compared with the usual-care condition had significantly lower substance use, significantly higher monthly income, and significantly lower incarceration rates.

SUBSTANCE ABUSE RECIDIVISM after treatment is high for both men and women.1 Under modern managed care, private and public sector inpatient substance abuse facilities have reduced their services dramatically. Thus, there is a need to develop, evaluate, and expand lower-cost, residential, nonmedical, community-based care options for substance abuse patients.

Oxford House, founded in 1975 by Paul Molloy, illustrates a community-based approach toward substance abuse abstinence. The Oxford House model, described in the box on page 3, offers a community where residents live without professional treatment staff and length-of-stay restrictions, unlike traditional hospital care, where trained professionals are necessary, or therapeutic communities, where residents have a maximum length of stay. Because there is no maximum stay, residents may have a greater opportunity to develop a sense of competence toward maintaining abstinence. For more information, see the Oxford House Web page: http://www.oxfordhouse.org.

Similar to those who participate in Alcoholics Anonymous, members of an Oxford House receive abstinence support from peers; however, unlike Alcoholics Anonymous, there is no single, set course for recovery that all members must follow. In fact, residents of Oxford House are free to decide personally whether to seek psychological or substance abuse treatment by professionals or a 12-step organization. In short, Oxford House offers residents the freedom to decide whether to seek and choose which (if any) treatment they desire while receiving constant support and guidance within an abstinent communal setting. The involvement of the individual in the course of treatment may encourage him or her to learn how to cope effectively and independently with stressful situations that promote substance abuse. This sense of competence and self-efficacy may reduce the risk of relapse when the person returns to former high-risk situations.

To be admitted into an Oxford House, applicants fill out an application form and are interviewed by existing residents. Eighty percent or more of the current house members must vote in favor of the applicant’s admission to the house for the application to be accepted. This is an example of how each Oxford House operates democratically with majority rule. Every 6 months, the residents elect officers (e.g., president, secretary) who facilitate the handling of Oxford House clerical responsibilities (e.g., convene weekly meetings, collect rent). Oxford House members maintain financial independence with each resident paying rent and doing chores. Deviations from financial responsibilities to the Oxford House; behaviors that are disruptive, antisocial, or both; or resumption of drug use, alcohol use, or both, result in eviction. The houses are rented, multibedroom dwellings for same-sex occupants. At present, 70% of the facilities house males and 30% house females; 55% of occupants are White, 35% are African American, 5% are Hispanic, and 5% are other.

In 1988, Congress passed the Anti-Drug Abuse Act, which allocated federal funds to any state to establish recovery homes such as Oxford Houses. A group of recovering substance abusers, through the support of an established Oxford House, may request from their state a $4000 interest-free loan to begin a new Oxford House. Payments on the loan are returned to that state’s revolving loan start-up fund so that additional homes can be rented. In the late 1990s, states were no longer required to administer a state loan program, but many states continued to offer these loans to Oxford Houses. This loan program in combination with the Oxford House grassroots movement was instrumental in helping to expand the number of Oxford Houses to more than 1200 in 48 states.

During this expansion, many communities attempted to limit the presence of Oxford Houses in their neighborhoods. In 1995, the US Supreme Court heard the case of City of Edmonds v Oxford House. The purpose of this case was to decide on the Constitutionality of the city of Edmonds’ law that stipulated that no more than 5 individuals who were unrelated biologically or legally could live in a house together. Using this law, the city tried to close down an Oxford House that consisted of 13 residents. The Oxford House organization argued that this law, and others like it, was discriminatory and that the city of Edmonds had failed to make reasonable accommodations for the group home.

KEY FINDINGS.

• Given the high costs of substance abuse disorders to society in general, and to the health care delivery system in particular, the results of this randomized test of the efficacy of a low-cost, self-help housing intervention compared with the usual services provided after inpatient substance abuse treatment have major public health implications.

• Because residents pay all expenses, these types of self-governed settings have important public policy implications for stabilizing individuals with substance abuse histories, especially in an era of cutbacks in funding for a variety of social service programs.

The Supreme Court decided in favor of Oxford House, citing the Fair Housing Amendments Act of 1988 and upholding the 1993 Washington State law stipulating that no Washington State city may enact a zoning ordinance that treats a residential structure housing a collection of individuals with disabilities different than one housing individuals related genetically or by law. Under the Fair Housing Amendments Act, substance abuse was considered a disability, and therefore the city of Edmonds was required to make a reasonable accommodation for Oxford House. This decision had widespread implications for the growth of Oxford House and other existing and future programs of this type.

Since 1992, a team of researchers at DePaul University, in Chicago, has been studying the Oxford House organization.1^–3 In one of the early studies,4 the research team found that Oxford House residents typically were never married (53%), young (early- to mid-30s), White (58%), and male (70%). In another study, individuals who had entered Illinois Oxford Houses were followed up for a 2-year period, and 62% of those interviewed either remained in the house or had left on good terms.5 In a study of individuals in Missouri who had been living in Oxford Houses, 69% were abstinent at a 6-month follow-up interview.6 However, neither study included a control or comparison group. Other studies on Oxford House from the DePaul University research team are available elsewhere.7

In our study, 150 individuals were randomly assigned to either an Oxford House or usual after-care condition (i.e., outpatient treatment or self-help groups) after they had received inpatient treatment for substance abuse. We hypothesized that individuals assigned to the Oxford House would experience lower rates of substance use and criminal activity and higher rates of employment compared with those receiving the usual after-care services.

Of those approached to be part of the study, only 4 refused participation. Sociodemographic variables did not differ significantly between participants assigned to the Oxford House and those assigned to usual-care services. Enrolled participants were interviewed every 6 months for a 24-month period. All 75 individuals assigned to the Oxford House condition gained admission to an Oxford House. When vacancies occurred, our research team was notified, and if an individual had not been voted into one Oxford House, we brought that person to the Oxford House with a vacancy to apply for residency. Using this system, we were successful in placing each individual assigned to the Oxford House condition into an Oxford House. In contrast, those in the usual-care condition went to a variety of settings after discharge from the substance abuse treatment settings.

Overall, participants’ questionnaire completion rates across the 24-month assessment period were comparable for the 2 conditions (at the last assessment, more than 90% of participants had filled out the questionnaires). In addition, to increase the validity of self-report abstinence data, a person in each participant’s support network listed on the final follow-up assessment was required to confirm the participant’s self-reported abstinence at 24 months.

DISCUSSION AND EVALUATION

We found that in important areas such as substance use, criminal activity, and employment, participants assigned to the Oxford House condition showed significantly greater positive outcomes than those assigned to the usual-care condition. At the 24-month follow-up, those in the Oxford House condition compared with the usual-care condition had significantly lower substance use (31.3% vs 64.8%), significantly higher monthly income ($989.40 vs $440.00), and significantly lower incarceration rates (3% vs 9%).

An Oxford House and its residents

The economic data gathered (i.e., productivity and incarceration), which represent only a fraction of the total economic impact of substance abuse,8 shows that Oxford House participants, by month 24, earned roughly $550 more per month than participants in the usual-care group. In a single year, the income difference for the entire Oxford House sample corresponds to approximately $494000 in additional production. In 2002, the state of Illinois spent an average of $23812 per year to incarcerate each drug offender.9 The lower rate of incarceration among Oxford House versus usual-care participants at 24 months (3% vs 9%) corresponds to an annual saving of roughly $119000 for Illinois. Together, the productivity and incarceration benefits yield an estimated $613000 in savings per year, or an average of $8173 per Oxford House member.

Perhaps the recovery-home experience of communal living helped reduce substance abuse problems because residents were able to develop a strong sense of bonding with others who shared common abstinence goals. To remain in the Oxford House, members needed to pay weekly rent; this policy probably encouraged residents to seek and maintain employment. Reduced criminal activity might have been influenced by the structure and location of the homes; houses were rented, multibedroom dwellings located in low-crime, residential neighborhoods.

Our long-term collaborative relationship with Oxford House was a significant factor in ensuring the successful implementation of this evaluation.10 The DePaul University research team had worked with Paul Molloy, the CEO of the Oxford House organization, and the Illinois Oxford House chapter for 9 years prior to initiating this study. Over this time period, Oxford House members and DePaul University researchers collaborated on pilot studies and developed high levels of mutual trust. By involving the Oxford House organization in the planning of the research study, we gained a greater appreciation of the culture and unique needs of the Oxford House community, and this collaborative process led to the self-help members valuing and working cooperatively with the research team. This process is well illustrated by Molloy’s decision to allow the researchers to employ randomization in the experimental design, something that is often difficult to accomplish with self-help groups. The support from the Oxford House organization was critical in enabling the DePaul research team to design a study with the methodological rigor to secure funding from the National Institute on Alcohol Abuse and Alcoholism.

NEXT STEPS

After treatment for substance abuse (e.g., hospital-based programs or therapeutic communities), many clients return to former high-risk environments. For both men and women, returning to these settings without a supportive abstinence network increases the chance of relapse and recidivism. The results of this study suggest that Oxford House may be a promising type of recovery home for individuals attempting to maintain abstinence. Many exoffenders, individuals with psychiatric disorders, and others who are homeless have substance abuse problems, and similar types of community-based housing settings might be effective with these populations.11 The relationship between outcomes and individual differences among residents in Oxford Houses needs further exploration. In addition, it is important to better understand whether residents need a minimum length of stay in Oxford Houses to obtain positive outcomes.

The Oxford House Model.

• The house must be democratically self-run.

• The house membership is responsible for all household expenses. Each house is fully responsible for its own expenses and debts.

• An individual recovering from drug or alcohol addiction can live in an Oxford House for as long as he or she does not drink alcohol, does not use drugs, and pays an equal share of the house expenses. The house must immediately expel any member who uses alcohol or drugs.

• The average stay is a little more than a year, but many residents stay 3 or more years.

• There are men-only houses and women-only houses, but no houses for both groups to live together.

• Any recovering alcoholic or drug addict can apply to get into any Oxford House by filling out an application and being interviewed by the existing members of the house.

• Any group of individuals recovering from alcohol or drug addiction can start a new Oxford House. All they need to do is to find a house to rent in the name of the group and apply to Oxford House Inc for a charter.

• Oxford Houses have 6 to 10 members. A house with fewer than 6 individuals is difficult to maintain because of the small size of the group and the fact that any vacancy causes a greater disruption of the financial welfare of the house. A house must have 6 or more residents to be recognized or chartered by Oxford House.

• There is no time limit on sobriety before coming into an Oxford House. Generally, an individual comes into an Oxford House after a 28-day rehabilitation program or a 5- to 10-day detoxification program.