Factors Affecting the Sustainability of Self-Run Recovery Homes in the United States

Abstract

This study examined the sustainability rates of 214 self-run substance abuse recovery homes called Oxford Houses (OHs) over a six-year period. We list five factors needed to sustain an OH: affordable housing, residents following OH principles, resident income, institutional support, and community support. Results indicated a high sustainability rate (86.9%) in which 186 OHs remained open and 28 OHs closed. Reasons for houses closing (N = 14) included lack of affordable housing, which we classified as an external factor. Houses that closed because of internal factors (N = 13) included residents who were unable to adhere to OH rules, and insufficient income of residents. No house-level differences for income, sense of community, average lengths of stay, house age, or neighborhood characteristics were found between the houses that closed versus houses that remained open. Because the OH system relies on residents to sustain individual houses located in ordinary residential neighborhoods, these findings suggest that OH sustainability depends on locale, primarily access to affordable housing and adequate job opportunities for residents.

Many non-professional, community-based health programs require the continued support and participation of their members to ensure the program’s sustainability (Shediac-Rizkallah & Bone, 1998). However, member participation and commitment can only flourish if the ecological context is supportive of the organization – factors often external and beyond members’ control (Archibald, 2007). Here we present a framework of the internal and external factors we propose are needed to sustain a model of self-run substance abuse recovery homes called Oxford House (OH) in the United States. We then tested this framework by calculating the number of OHs that remained open or changed locations, compared to those that closed over a six-year period, and assessed which internal and external factors influenced their closure. Although a number of studies document the success of the OH model in terms of health outcomes (Jason, Davis, & Ferrari, 2007; Jason, Ferrari, Dvorchak, & Groessl, 1997), this is the first study that attempted to determine the factors affecting OH sustainability.

OHs are a housing network operating under a common set of guiding principles and philosophies that emphasize recovery, responsibility, mutual-support, and self-help principles (Oxford House Inc, 2004). In the United States, Oxford Houses are rented, single-family homes large enough to accommodate 7 to 10 same-sex residents (Jason et al., 2003; Oxford House Inc, 2004). OH residents must abide by three basic rules: they must remain abstinent from alcohol and illicit drugs, pay weekly rent, and refrain from behaviors that are disruptive to other residents (Oxford House Inc, 2004). If in compliance with these rules, residents may live in an OH as long as they wish (Ferrari, Jason, Sasser, Davis, & Olson, 2006). It is not uncommon for residents to live in an OH for many years (Oxford House Inc, 2009). There is no professional staff to provide therapeutic services or administer a treatment regimen in OHs (Jason, Davis, Ferrari, & Bishop, 2001; Jason, Olson, Ferrari, & Lo Sasso, 2006). OHs are entirely self-governed; house officers (president, treasurer, comptroller, secretary) are elected among residents every six months by house majority votes and perform administrative duties (Oxford House Inc, 2004). These administrative tasks (paying bills, allocation of cleaning and maintenance duties) are discussed at regular weekly meeting, as are personal issues such as conflict resolution. Policies affecting all residents in an OH are discussed among all house residents, and decisions for their enactment must be decided upon democratically.

OHs share many characteristics with self- and mutual-help groups. These include being self-run, non-professional memberships, and self-financing (Humphreys, 2004). However, OHs differ from self-help groups by providing housing and continuous support (Jason, et al., 2006). In this sense, the OH model has characteristics of a “total immersion” residential therapeutic community (TC) (c.f. De Leon, 2004; Humphreys et al., 2004; Kirby, 2004), but require no licenses, are limited in size, and rely exclusively on the activities of their residents to operate their facilities (Harvey & Jason, 2011). A milieu of mutual reliance, rather than a treatment regimen, means that OH residents become invested in their own recovery and offer camaraderie and recovery support to their housemates, similar to the support from peers in other self-help groups (Moos, 2008).

In the United States, the factors affecting the sustainability of smaller, self-governed social model programs such as the OH system might differ from those factors affecting larger, professionally-run institutional environments (Borkman, Kaskutas, & Owen, 2007; Polcin, 2009). We propose that OHs require, at minimum, five factors for creation, operation, and sustenance in the U.S.: appropriate housing, residents willing to live together and follow OH principles, resident income, institutional support, and community support. Each of these factors vary on a continuum influenced by OH residents directly (“internal” factors), or are beyond the influence of residents (“external” factors).

Description of the Five Essential Ingredients in the United States

First, Oxford Houses require accessible, affordable rental housing. Rental housing in suburban and working-class neighborhoods tend to provide stable neighbors, adequate transportation options, and local businesses necessary for daily living, and offer greater flexibility to change locations (Oxford House Inc, 2004). Because OH residents cannot directly influence the pricing of their immediate neighborhoods, we consider this an external factor.

Second, Oxford Houses require individuals in recovery willing to live together, and to adhere to OH rules and principles (Oxford House Inc, 2004). This is an internal factor, as all OH residents are informed of the duties expected of each resident (Jason, et al., 2003; Oxford House Inc, 2004).

The third ingredient for sustainable OHs are opportunities for residents to secure reliable employment and income for the house to become self-supporting (Jason, et al., 2006). OH expenses are shared equally among its residents, which currently averages $100 per week (Oxford House Inc, 2009). As such, securing employment relies on both the internal job-seeking behavior of residents as well as external opportunities in the local job market.

The fourth factor for sustainable OHs consists of institutional support. Examples of essential institutional support in the U.S. (without which OH could not exist) are the Fair Housing Act of 1988, which prohibits discrimination against minority housing. The Act has been cited as protection against localities attempting to restrict or close down OHs via targeted zoning laws (Jason et al., 2008; Miller, 1995). Another institutional support is the Americans with Disabilities Act of 1990 which restricts employers from discriminating against hiring former substance abusers (Zuffoletto, 1992). Important, but supplemental, institutional support includes U.S. state-level revolving loan programs that facilitate creating new OHs (Jason, Braciszewski, Olson, & Ferrari, 2005). This is an external factor, as an OH by itself has limited influence on legislative institutional support.

The fifth and last requirement for sustainable OHs is community support. Although OHs residents and their housing are protected legally in the United States, good relations with neighbors and the surrounding community can help combat NIMBY (not in my backyard) attitudes which can lead to hostile relations between OH residents and the local, non-recovery community (Jason, et al., 2008). Fortunately, after some initial resistance community acceptance for therapeutic group homes can improve over time, indicating older houses might have stronger community support (Zippay, 2007). Additional community support includes the availability of local 12-step meetings such as Alcoholics Anonymous (Groh, Jason, Ferrari, & Davis, 2009). We consider this factor as both an internal and external factor.

Factors Predicted to Impact Oxford House Sustainability

Regarding factor 1, availability of affordable housing, we expected to find that some houses closed because residents could not pay for housing. However, we had no a priori causal hypotheses related to this factor, such as suburban versus urban locations.

Previous research suggests that self-run OHs may function more like self-help groups and family units than staffed treatment environments with a more centralized management and support functions (Davis & Jason, 2005; Harvey & Jason, 2011). Relating to ingredient number 2 (OH residents), we explored whether a sense of community (Sarason, 1974) among house residents might positively influence house sustainability. Also, because OHs have no restriction on maximum length of stay, the overall average length of stay might also positively influence sustainability (Ferrari, Jason, Olson, Davis, & Alvarez, 2002). As such, we expected open houses to report higher house-level sense of community scores that emphasized Mission and Reciprocal Responsibility, and reduced levels of Disharmony, than houses that had closed. We also expected that houses that remained open would report an overall longer house-level length of stay than houses that closed.

Next, we explored differences in factor 3, (Income). Each Oxford House depends on the ability of each resident to contribute financially to cover all house expenses. As such, we hypothesized that aggregate house-level income would be higher in houses that remained open compared to OHs that had closed.

Finally, we explored factors related to factor 5, (Community support) as expressed in house age – the length of time the OH was in operation. Older houses may experience greater community acceptance, support and integration, which are likely to positively affect sustainability. Also, older Oxford Houses tend to have more experienced residents who impart knowledge about the local community, thus giving newer residents greater access to community resources.

Because we were limited to using archival data, we could only analyze four of the five factors; we could not analyze data regarding house-level institutional support, such as being the target of zoning activism, or a house being a recipient of a revolving loan program.

Method

Sample

This study used archival data from a one-year longitudinal study that began in 2001. Data were collected from a total number of 897 OH residents who identified the names of their house, resulting in our study sample of 214 Oxford Houses located in the United States. The number of respondents from each house ranged from 1 to 12 residents. Our sample of 214 OHs was divided into two groups based on the status of the houses in late 2007: houses that remained open or moved to a different location with the same organizational structure in place, and houses that closed. Therefore, we examined the sustainability of the houses over a 6-year period.

Measures

We analyzed house-level and demographic data collected from the Addiction Severity Index-Lite (ASI-L) (McLellan, Kushner, Metzger, & Peters, 1992), an abbreviated version of the Addiction Severity Index (McLellan, et al., 1992). Because we used the ASI-L to gather demographic variables (e.g., gender, age, income, length of stay at OH, housing location and costs), no reliability characteristics were calculated. We used this measure to assess factor 1 (affordable housing), factor 2 (resident characteristics in terms of gender, house age), factor 3 (house income), and factor 5 (community support, as assessed by house age and location).

The Perceived Sense of Community Scale (PSOC) is a three-factor measure of sense of community (Bishop, Chertok, & Jason, 1997). A house mean was calculated for house-level analyses (Graham, Jason, Ferrari, & Davis, 2009). We used this as an internal measure of factor 2 (Residents). A factor analysis of the Perceived Sense of Community Scale by Bishop, et al (1997) identified three factors: Mission, Reciprocal Responsibility, and Disharmony. Mission refers to being actively engaged with others toward a common goal; Reciprocal responsibility acknowledges one’s membership in a group, and Disharmony represents the dissatisfaction with aspects of the community experience. In our study, the factor Disharmony was reverse scored and referred to as “Harmony.” The coefficient alpha for the entire scale (r = .95) and the subscales [Mission (r = .93), Reciprocal Responsibility (r = .96), and Disharmony (r = .95)] indicated good reliability (Bishop, et al., 1997).

Procedure

We searched for the names of the 214 OHs from the archival data in the 2001 study to the most-current listing of OHs on the Oxford House website. We also consulted a representative from Oxford House, Inc., to obtain the status of the OH, and to obtain reasons for their closure or move, as appropriate. As this data were reported to us, the OH in the dataset was then coded as either “open” or “closed” until the status of all 214 OHs was determined. If closed or moved, houses were also coded with a reason for closure or relocation.

Results

Frequency of Open and Closed Houses

Of the 214 houses in the sample, 186 houses remained open and 28 houses closed. This represents an overall sustainability rate of 86.9%. Of the 186 houses that remained opened, 14 houses (7.5%) had moved to a different location with the same organizational structure in place. Reasons for moving to a new location included: owner sold property (n = 4, 1.9%), landlord did not maintain the house (n = 4, 1.9%), residents wanted a bigger house (n = 3, 1.4%), old house/needed repairs (n = 1, 0.5%), inconvenient location (n = 1, 0.5%), and members’ financial trouble/low membership (n = 1, 0.5%).

Reasons for Closure

In this sample, 28 of the 214 homes closed permanently (13.1%). Reasons for closure were assessed as closing for external reasons or houses that closed for internal reasons based on our framework. One house closed for an unknown reason. Houses that closed for external reasons (n=14): landlord lost home to foreclosure/sold property (n = 5, 2.3%), house located too far from transportation or other OHs (n = 5, 2.3%), landlord did not maintain the house (n = 3, 1.4%), and fire (n = 1, 0.5%). Houses that closed for internal reasons (n=13): members’ trouble paying rent/low membership (n = 8, 3.7%), and residents did not follow OH guidelines/members had relapsed (n = 5, 2.3%). Of the 28 closed houses, none were significantly different in resident male (n=15) vs. female (n=8) vs. unknown (n=4); or neighborhood characteristics: urban (n=6), inner city (n=8), suburban (n=9), unknown (n=4).

Houses that closed for external or internal reasons were compared on all outcome variables. There were no significant differences between these groups on overall PSOC scores (external: M = 3.78, SD = .53; internal: M = 3.97, SD = .53); house age in years (external: M = 6.91, SD = 3.92; internal: M = 8.45, SD = 3.96), and monthly income (external: M = $948, SD = $589; internal: M = $743, SD = 360). As such, they were combined into one overall group of 28 closed houses, including the house that closed for an unknown reason.

House Age

There was no significant difference between age in years of houses that were open (M = 6.99, SD = 3.77), versus houses that closed (M = 7.46, SD = 3.96); t(157) = 0.55, p > .05. The average house age in years for this sample (M = 7.06, SD = 3.79) suggested similar stability and community support.

Income

There was no significant difference in monthly income between houses that remained open (M = $1045, SD = 672) and houses that closed (M = $840, SD =487). These figures approached, but were not significant, t(44.24) = −1.96, p = .057 (unequal variances assumed due to violation of Levene’s test).

Perceived Sense of Community

There were no significant differences in Perceived Sense of Community (PSOC). Houses that closed had similar total PSOC scores (M = 3.86; SD = .52) to houses that were still open (M = 3.87; SD = .43), t(212) = −.19, p = .85. Additionally, there were no significant differences between groups on the PSOC subscale averages for Harmony [open houses (M = 3.41; SD = .56), closed houses (M = 3.49; SD = .55), t(212) = .77, p = .45], Mission [open houses (M = 3.95; SD = .43), closed houses (M = 3.90; SD = .53), t(212) = −.51, p = .61], or Reciprocal Responsibility [open houses (M = 4.03; SD = .49), closed houses (M = 3.99; SD = .56), t(212) = −.36, p = .72].

Discussion

Findings from the present study indicated an impressive percentage of Oxford Houses (86.9%) remained open over a period of six years, thus suggesting that OHs in the United States are relatively stable systems. None of our predictions were supported. We found no specific differences between opened and closed OHs in terms of the demographic characteristics of the residents, the location or age of the house, or the aggregate sense of community, nor did we find any differences among the OHs that closed for internal or external reasons. However, we were able to document for the first time in the U.S. the reasons these houses closed and whether these factors reflected internal or external reasons for closure. These included factor 1 (Housing), reported as lack of affordable housing/landlord issues (an external factor); factor 2 (OH residents) reported as not in compliance to OH principles (an internal factor); and factor 3 (Income), reported as insufficient membership and/or incomes (both internal and external factors). Although not tested directly, none of the closures reported for lack of factor 4, institutional support.

The present study had a number of significant limitations. First, this study relied on archival data for our house-level comparisons, and was thus restricted to these pre-determined constructs. For example, we were not able to examine specific whether institutional supports or the number of 12-step meetings influenced houses that closed versus those that remained open. It was often difficult to determine the detailed, historical reasons for the closing of houses or to determine exactly when the OH closed. Further, it is unknown whether other recovery homes depending on similar configurations (rented properties, residents working in a local job market, etc.) would be similarly affected. More systematic research is needed to explore the variables that affect sustainability of OHs versus similar programs in greater detail. For example, using a Geographical Information Systems (GIS) approach could provide a much more thorough analysis of the local conditions which Oxford Houses depend on to sustain themselves. The 2001–2007 time period of this study was determined by archival data gathered in a previous study, not by any particular study rationale.

Although the house data in this study did not represent the OH organization as a whole, some of our results are in line with the theoretical underpinnings of self-help organizations. Amburgey et al. (1993) posits that a single event could not predetermine whether an organization succeeded or failed; rather, it is often the net effect of independent ecological factors lead to success or failure. We proposed that the five factors are “essential ingredients” necessary for an OH to exist in the United States; any event that seriously affected or eliminated certain factors (e.g. affordable housing) would surely be catastrophic to sustaining an in individual OH. Likewise, changes in institutional support in the U.S. could jeopardize the entire OH system. Though this is not a revolutionary insight, it does distinguish OH from larger-capacity facilities such as a TC which obtain operational rights through commercial and clinical licensures.

We acknowledge this study and these results are unquestionably U.S.-centric; the specific details and implementations of the five factors are likely to be significantly different in other counties. For example, large single-family homes common to the U.S. might be unavailable, impractically small, or overly costly in either Western or Eastern Europe. Preserving the communal processes that likely make OH living effective – e.g. communal decision making, mutual reliance – in individual apartments or group housing on a smaller scale might be challenging, but is certainly possible. Likewise, institutional and legal protections against housing and job discrimination might be radically different (or non-existent) elsewhere and might necessitate differing levels of residents’ disclosure of their recovery status. Despite these differences, we assert that the five ingredients for self-run recovery homes are probably essential regardless of locale. Hopefully, this study might be useful by providing a broad framework for assessing the feasibility for creating and sustaining self-run recovery homes different countries.

In sum, in the U.S., it is likely that location plays a major role whether an OH can sustain itself. Because low-cost residential settings represent an important community-based source of support for people in recovery (SAMHSA, 2011), policy makers in the United States who are charged with creating Oxford Houses and other similar environments would be wise spend considerable efforts to ensure the selected location offers affordable housing and employment opportunities for residents to be self-sustaining.