A promising recovery housing model for American Indian communities

Abstract

In 2016, two Oxford House (OH) recovery homes were established for the Suquamish Tribal reservation. A group of researchers interviewed house members and key individuals responsible for the creation of these two unique OHs. Because American Indians are an at-risk population for substance use disorders, our study explored whether an OH-type recovery home model could be successfully adapted to this population, given the specific nature of tribal cultures. Findings indicated that the residents, composed of both American Indians and non-American Indians, found these OHs to be supportive of recovery in general and with the values of American Indians. The tribal community’s positive attitudes toward these recovery homes may have been due to similarities between the Suquamish Tribal Government and OH’s democratic structures, with all individuals having a voice in the decision making process. The overall findings suggest that these types of culturally modified recovery settings on American Indian tribal lands could be an important resource for individuals dealing with substance use disorders.

1 |. INTRODUCTION

Among the general population, American Indians have a greater prevalence of alcohol and illicit drug use than other ethnic groups (Gone & Trimble, 2012; Substance Abuse & Mental Health Services Administration, 2007). The National Survey on Drug Use and Health found that 12.3% of American Indians were current users of illicit drugs, compared with 9.5% of whites, 8.8% of Hispanics, and 10.5% of African Americans (U.S. Department of Health & Human Services, 2013). There are complex reasons for these substance use disparities, and these might include both social and cultural factors (e.g., lack of employment opportunities) as well as current practices (e.g., stores selling alcohol next to American Indian reservations; https://www.denverpost.com/2017/09/29/pine-ridge-indian-reservation-whiteclay-nebraska/) and past practices as when European colonists made alcohol easily available to American Indians (Beauvais, 1998) Unfortunately, there have only been a small number of treatment studies for this population, and although some have reported positive treatment outcomes, methodological problems included low follow-up rates and possible selection biases (Greenfield & Venner, 2012). A number of treatment and recovery interventions have been developed that incorporate American Indian culture such as medicine wheels, sweat lodges, and talking circles (Naquin, Trojan, O’Neil, & Manson, 2006), and 12-step programs have been modified as well (Jones-Saumty, 2002). There is a clearly a need for more work on effective recovery options for American Indians (Malcolm, Hesselbrock, & Segal, 2006) such as White Bison which offers sobriety, recovery, and addictions prevention to American Indian communities (see http://www.whitebison.org/), and recovery homes might represent one promising community-based intervention. In this article, we describe results from an exploratory study of two recovery homes located on Suquamish Tribal lands in the Pacific Northwest. The purpose of this study was to determine how the operation of these homes had been modified for their largely (but not exclusively) American Indian residents, how both residents and American Indian tribal members viewed these homes, and how this approach to recovery might be further extended.

The current study occurred in recovery houses, called Oxford Houses (OH), which provide comprehensive social environments for individuals with substance use disorders. OHs are the largest single network of recovery houses in the US, with more than 25,000 individuals living in the over 2,200 houses over the last year (Oxford House Inc, 2017). OHs are rented, single-family homes with a gender-segregated capacity for six to 12 individuals. The houses are usually located in middle-class neighborhoods with access to public transportation and employment opportunities. Because the average rent to stay in an OH is about $100 per week, this network provides sustainable, affordable housing for those with even minimum wage jobs. Each OH operates democratically with majority rule (i.e., >80% approval rate) regarding membership and most other policies (Oxford House Inc, 2011). Residents must follow three simple rules, namely, pay rent, abstain from using alcohol and other drugs, and contribute to the maintenance of the home. Violation of the above rules results in eviction from the House (Oxford House Manual). The OH network which is completely self-run and involves no professional staff provides affordable and safe housing for recovering substance use disorders.

There have been multiple outcome studies of OH recovery homes over the past two decades (Jason, Davis, Ferrari, & Anderson, 2007; Jason, Olson, & Harvey, 2015; Jason, Olson, Ferrari, & Lo Sasso, 2006; Jason, Salina, & Ram, 2016). In general, the findings have shown that the OH model can reduce substance use and increase employment. In addition, specialized OHs have been developed and evaluated. For example, several OHs have been established specifically for Latinos (Jason et al., 2013). Residents in these houses had the option of speaking English, Spanish, or a mixture of both languages. These houses provided a culturally congruent experience by welcoming visits by extended family members and promoting communication styles characterized by an emphasis on relationships and downplaying direct conflict in relationships to preserve harmony and respect. Jason et al. (2013) compared the employment and substance use outcomes of Latinos living in traditional OHs to those living in culturally modified OHs for Latinos. They found that residents of both types of houses had increased rates of income from employment. Those increases were largest for Latinos in culturally modified OHs. These types of culturally modified houses present an opportunity for OH to become more accessible to diverse communities, particularly those who might only be Spanish speaking.

OHs with a focus on hearing impairment have also been studied. Individuals who are deaf and seeking a recovery-oriented living environment are less likely to have access to treatment and aftercare services because of a lack of culturally and linguistically specific programs. Alvarez, Adebanjo, Davidson, Jason, and Davis (2006) recruited a sample of seven deaf members who lived in an OH specifically established for those who were deaf as well three in traditional OHs where they were the only deaf members in the OHs The study found that OH may be a promising deaf-affirmative alternative setting for individuals seeking recovery from substance use disorders.

Beasley et al. (2017) examined the facilitators and barriers to OH entry for individuals who were transgendered, and that study also examined their experiences in OHs in comparison to residents who identified as cisgendered. The researchers conducted semistructured interviews of seven transgendered women and seven cisgendered men, and used descriptive phenomenology to analyze the data. Transgendered participants reported fear and apprehensions upon entry into OH due to initial feeling that OHs might be similar to past settings that were not sensitive to their needs or gender identity. However, these participants reported diminished fear and comfort shortly after transitioning into OHs. Though instances of discrimination were not absent, it appears that participants who were transgendered could work through minor issues by means of discussion and boundary setting.

Only one study to date has examined American Indians living in traditional OHs. Kidney, Alvarez, Jason, Ferrari, and Minich (2011) examined a large sample of OHs, of which 17 residents were American Indian. American Indian residents were more likely to report being on parole or probation, as well as more likely to be referred for aftercare by the legal system. Additionally, American Indian residents reported greater disharmony within their recovery residences than Caucasians, but there were no significant ethnic differences in initial length of stay in OH, length of alcohol or drug sobriety, or substance use outcomes 4 months after the initial assessment. These American Indians did not live in an OH on tribal grounds.

In another article, Jason et al., (2018) describe social network data that were collected among OH residents involving friendship, trust, and mentorship on an American Indian reservation. Findings indicated that residents had a well-integrated network with multiple sources of friendship, trust, and mentors. The current study is different from the prior study in that it provides information about house residents reactions to living in the OHs, as well as how we found out about these OHs, how we approached the OHs to gain their interest in our study, and what we learned about the reasons for opening up these OHs on this American Indian reservation. As American Indians are a particular at-risk population for substance use disorders, and given the specific nature of tribal cultures, our study explored whether an OH-type recovery home model could be successfully adapted to this population. We also investigated whether the OH model offers any particular advantages for an American Indian population and whether the OH initiated cultural adaptations. The goal was to determine the acceptability and feasibility of the OH model on tribal lands. Finally, because non-American Indian tribal were also residents, we were interested in investigating whether cultural mixing created any problems or benefits.

2 |. METHOD

2.1 |. Suquamish tribe

The Suquamish Tribe is located near the city of Seattle WA, and was named for their famous chief Seattle (see http://www2.gvsu.edu/klitzkee/efforts/schoolwork/suquamishindians.htm). The tribe resides on a 7,486 acre reservation, though with only 3,000 acres remaining in trust or under American Indian ownership at the Suquamish Tribe at Port Madison. The tribe harvests as many as 26,000 salmon a year from the Duwamish River, the pollution of which has been a significant source of tension between the tribe and multiple levels of government. The Suquamish Tribal Government is led by a seven member Tribal Council elected by the Tribe’s voting body, known as the General Council. The Suquamish Tribal Government currently employs 345 staff members in the areas of Administration, Human Resources, Community Development, and so forth (https://suquamish.nsn.us/home/careers/).

2.2 |. Initial contacts

Consent for using names in this article was received. In May of 2017, Dennis Donovan, learned of the existence of two OHs on Suquamish Tribal lands. He subsequently contacted Judith Arroyo at NIAAA, as she had been concerned about access to treatment resources for substance use disorders among American Indians. She subsequently telephoned George Duncan, a contact person and resident of one of the OHs on Suquamish Tribal lands. After learning more about these first OHs, she then contacted the first author because she knew of his prior NIAAA funded Latino OH study, and also knew that he had been one of the authors of a published study that involved a small OH sample of American Indians residing on non-tribal lands (Kidney et al., 2011). She provided the first author several contacts within the American Indian community, including George Duncan, as well as Marty Selvidge, who worked as a recruiter in the State of Washington, and had opened up these two OHs. The first author then contacted George and Marty, and both were receptive to having our institution conduct a program evaluation of these two OHs. Marty next talked with Sammy Mabe (a member of the Suquamish Tribal Government where the two houses were located), and he was very positive about having a study of these OHs conducted by DePaul University. In addition, George talked to the members of the two OHs, and the residents were receptive to participating in this study.

The first author had a number of phone calls with George and Marty during June and July of 2017, and the first author later had an opportunity to meet Marty and several of the American Indian Tribal members (including George) in August of 2017 at the Annual OH Convention in Washington, DC. In addition, the first author later interviewed others including Sammy Mabe, a tribal council member. During these conversations, the first author learned that the male OH was named Alexis and the female house was named Teresa. The male house had been opened in July of 2016, and the woman’s house in December of 2016. The first author learned that both houses were always filled, and Marty and Sammy had already received phone calls from several local tribes regarding the possibility of establishing OHs on their reservations.

Sammy mentioned that there had originally been staff-run transitional recovery homes on the Suquamish Tribal grounds. But in 2010, the Suquamish Tribal Government decided it was no longer feasible to operate due to costs and somewhat mixed client outcomes. For several years, there was a void in recovery housing for residents of the Suquamish reservation. The two closest OHs were 11 and 23 miles away, which were difficult to reach in this rural area that has limited public transportation. Sammy, who had previously lived in an OH as well as the transitional house, campaigned to be an elected member of the Tribal Council with his plank of providing more multipronged resources for those who were struggling with substance use disorders and homeless.

After being elected to the Tribal Council, Sammy reached out to Marty to establish the two OHs on Suquamish Tribal lands. Sammy and other tribal members informed Marty that the houses needed to be open to any American Indian or non-American Indian member, as long as two beds always were reserved for Suquamish Tribal members. They felt the housing was important for both American Indians and non-American Indians who lived in the area. Sammy said that “we wanted to bring the tribe and non-tribal members in recovery a safe place to live.” Sammy mentioned that since being established, almost all members of the Suquamish Tribe who applied to be a resident have been accepted. In addition, the Suquamish Tribal Government has actually made money on the two OHs over the past year through rent received from residents, as the tribe owns these recovery homes. Marty mentioned that members of the Suquamish Tribal Council had assured him that if house members voted for a resident to be evicted (even if the person was a member of their tribe), the council would not interfere with the house member’s decision. In other words, both houses followed the OH rules.

IRB approval from our institution was obtained for this study and data were collected by two DePaul research assistants in the fall of 2017. During the 2-month study, both houses had nine current members, but during this time, but several members left in each house and several new members became residents. There was more turn over in the women’s house, as three new members arrived and two left (one of whom went to a new OH to start it up). During our 2-month study, we were able to interview eight men and four women.

2.3 |. Instrument

We asked residents when they moved into the house and collected sociodemographic information including age, level of education, marital status, number of children, employment status, drug of choice, length of sobriety, whether or not they were a member of a tribe, and if so, what was the tribal name. We also asked members to respond to the following questions regarding their reactions to living in an OH: “House members respect my cultural values and traditions” (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree); “I have learned about new cultures and traditions while living in this Oxford House.”(1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). “How do you compare the current Oxford House you are living in to other recovery homes or treatment settings that you have lived in?”(1 = much better, 2 = better, 3 = about the same, 4 = worse, 5 = much worse). “Would you recommend this Oxford House to a friend who is having substance abuse problems?” (1 = very strongly, 2 = strongly, 3 = not sure, 4 = would not recommend Oxford House), “How confident are you that living in an Oxford House can help you achieve a successful recovery?” (1 = very confident, 2 = confident, 3 = not sure, 4 = not confident, 5 = not at all confident) and “Do you have any additional comments or suggestions, or anything else you might like to share?” Quotes used in this article were pulled from field notes and also from this open question.

3 |. RESULTS

3.1 |. Length of stay

The men reported living in the OH from 2 weeks to 14 months (M = 7.5 months), whereas the women reported they had lived in the OH fromone to 2 months (M = 1.5 months).

3.2 |. Sociodemographic characteristics

Among the men, four were tribal members and four were not. Among the women, two were tribal members and two were not. Within each male and female group, half of the American Indians were from the Suquamish Tribe. For men, we learned the following about their drug of choice: three indicated methamphetamine; two indicated alcohol; two indicated a dual preference of methamphetamine and heroin; and one indicated a poly preference of cocaine, methamphetamine, and alcohol. Among the women, two indicated heroin, one indicated methamphetamine, and one indicated a dual preference for methamphetamine and heroin. The men had been sober from one to 48 months (M = 16 months), whereas the women had been sober from one to 4 months (M = 2.8 months). The men had been convicted of a crime from one to 60 times (M = 13.4), whereas the women had been convicted of a crime from 0 to 12 times (M = 5.8).

Four men had never been married, two were divorced, one was separated, and one was widowed. Three of the women had never been married and one was divorced. The men had from 0 to four children (M = 1.5), whereas the women had from 0 to 5 children (M = 1.0). Regarding education, one man had a college education, four had some college, and three had a high school degree; among the women, one had some college and the other three had a high school degree. The men were an average of 39.3 years old (range from 24 to 49), and the women were an average of 33.0 years old (range from 21 to 54). Among the men, one worked full-time, two worked part-time, two were retired, and three were unemployed (but they did mention that they were involved in seasonal fishing). Among the women, one worked part-time and three were unemployed.

3.3 |. Reactions among the OH residents

Overall, positive reactions were obtained from both the men and women residents. Regarding whether house members respected their cultural values and traditions, everyone except one male indicated strongly agree (and that male indicated agree). Regarding whether the residents had learned about new cultures and traditions while living in this OH, everyone indicated strongly agree. When comparing the current OH to other recovery homes or treatment settings, everyone indicated much better. As to whether residents would recommend this OH to a friend who is having substance use disorder, everyone indicated very strongly. Finally, when asked how confident they were about living in an OH can help them achieve a successful recovery, everyone said very confident.

In response to the open-ended item, one male mentioned that when the residents got clean and sober, their mental health began to progress. Another male said: “this OH has helped make it possible to seek medical treatment for neurological issues.” One woman resident said: “it’s a blessing and I’m very grateful; It’s amazing being a part of the first house on a reservation, and it’s my reservation!” Another woman resident said it was a “really tight knit group of girls.”

Regarding how the OHs were culturally tailored to Native American culture, we were informed by George and Marty that on some house walls, there were paintings or posters representing Native American themes. In a living room of the men’s house, there was a large drum that was used for casual drumming as well as more formal drumming ceremonies with the house members. The woman’s house used a talking feather that would be passed to residents who next wanted to speak during meetings. The OH residents would also engage in smudging, in which sage is burned during a prayer ceremony. Although residents were required to attend three recovery self-help meetings a week, they could attend a sweat lodge and that would count as one of their required recovery meetings. One male resident mentioned, “For White society, drug use is considered a moral problem, but in this house and on this tribal land, it is considered a health problem and the people have empathy and love for those affected.” Members of the house mentioned that acceptance by the tribe was very high, and the houses were considered part of their community.

3.4 |. Reactions of the tribe

Even though the tribe was weary of outside entities being located on their tribal lands, during discussions with Marty, George, and Sammy, the first author was informed that tribal members liked the idea of the self-run OHs. For example, Marty stated that the “reservation loves it as they liked the idea of the self-run community.” Sammy’s overall evaluation of the OH was that the creation of the two OHs had been “Nothing but positive.” In addition, George mentioned that the tribe was very supportive of the OHs, saying: “Things are working out famously for the tribe because the way business is connected in Oxford Houses, with decisions being made in a very similar (way) to the tribes, where all have a voice in decisions.” Marty stated that tribal members would often drop by the OHs and have coffee with residents on their porch.

As a reflection of the feelings of the tribal community members to these OHs, George said that tribal members honked their car horns when they passed the houses as a way of greeting residents and saying hello. Sammy said that when OH fund raisers occurred such as car washes, many from the tribal community would support these events. George mentioned one of the reasons that the tribes were so accepting of the OHs was that similar norms occurred in both settings, and he added: “Tribal councils are true democracies, and are not individualistic. Tribal people are accepting of people without judgement. They feel that close relationships and helping others is the key.”

4 |. DISCUSSION

Using data from interviews with residents and individuals responsible for the creation of the houses, this article explored how Oxford Houses established on the Suquamish Tribal reservation were adapted for this population and whether residents and the tribal community felt that they were supportive of recovery and the values of American Indians. We highlighted the urgency to address disparities in risk for substance use disorders among American Indians and the potential role for OHs in doing so. The use of mixed-methods interviews with residents and other informal interviews with key stakeholders is was appropriate for a study geared toward establishing feasibility and acceptability of the OH model in a novel setting.

Findings from this study suggests that self-run recovery homes such as OHs may be positively received by tribal and non-tribal individuals with substance use disorders. The findings on this Suquamish Tribe did not uncover any disharmony, which was found in the Kidney et al. (2011) study when Native Americans were in the minority in the OHs on non-tribal lands. In addition, we have anecdotal data suggesting that the Tribal Council perceived these types of recovery homes as very compatible with the values and norms of their communities, possibly because their governance system was democratic with house residents having an equal opportunity to be involved in decision-making.

We also explored whether the OH model offered any particular advantages for an American Indian population. Our study suggested that these OHs were sensitive to the unique needs of the Suquamish tribal community. Tribal culture tends to be communal and this might have some comparisons with the OH model which was specifically designed to be communal, including features such as consensus governing, mutual respect, and mutual responsibility. We found that cultural practices including rituals, ceremonies, and practices (e.g., sweat lodge, talking feather, and drumming circles) appeared to be well accepted by OH residents.

Robinson, Brown, Beasley, and Jason (2017) have written about the importance of using cultural adaptations to guide the transformation of standardized therapeutic interventions (e.g., Bernal, Bonilla, & Bellido, 1995; Castro, Barrera, & Martinez, 2004; Griner & Smith, 2006; Tucker & Herman, 2002). Smith, Rodríguez, and Bernal (2011) have found that culturally adapted interventions are more effective than traditional, non-adapted interventions for the same population. Our study suggests that the experiences of the participants of the two OHs on Suquamish Tribal grounds are consistent with findings in the literature regarding cultural adaptations of interventions. The OH residents, both American Indians as well as non-tribal members, were extremely comfortable in these culturally sensitive settings.

There is a different possible explanation for what occurred as a formal adaptation may not have been attempted by the residents of these OHs. Instead of cultural symbols and ceremonies (e.g., talking circle, smudging, and sweat lodge) might have been incorporated more organically into the process of administering and living in the OHs. In fact, there is competing literature on the value of cultural adaptions of mental health interventions with American Indians (Gone, 2011, 2013a,2013b) with American Indian peoples claiming “our culture is healing.” In this sense, the OH residents may have chose on their own to embody this notion—as they inherently incorporated cultural traditions in their OH as healing elements.

We also explored whether mixing American Indian tribal and American Indian non-tribal individuals in the same OHs created any problems or benefits. We did not find suspicion or enmity among the American Indian tribal and American Indian non-tribal residents. American Indian non-tribal individuals appeared to benefit by learning about another culture. The OHs appeared to be an integral part of the larger Suquamish Tribal community, and this is evidenced by the way that some tribal members made an effort to acknowledge and even visit the houses. OHs are designed to be supportive, abstinent communities, and the added social support of a larger community may have positively affect the experiences of the residents. Study findings suggest that members of the house felt that their cultural values and beliefs were respected, regardless of their American Indian or non-American Indian background.

It is possible that the non-American Indians provided a type of meso-system “validation” for the tribal residents’ personal change. This is a complicated issue as we usually seek validation from our “own people,” but perhaps in these houses, the non-American Indian residents were seen in a more positive light than the majority culture. We only have some anecdotal evidence from conversations with several of the American Indian residents who often felt excluded, marginalized, and anything but accepted by mainstream culture, and this was different from their very positive experiences with the non-American Indian residents.

However, this idea of ‘validation’ is derived from Best, Irving, and Albertson (2016), who suggested that recovery involves change in personal identity that requires not only internal changes in values, but also recognition by the surrounding social environment. One corollary of this might be that the broader such recognition is (i.e., across social settings and subcultures), the better; therefore, recognition from both fellow American Indian tribal and other non-American Indian residents could have been particularly beneficial for the tribal residents.

Self-governance might have been one critical element for the positive reception of the OH among tribal residents and the larger tribal community. Governance operationalizes the structure and rules by which the setting operates, forming the boundaries for expected individual actions within the setting, and providing norming of recovery attitudes and behaviors. Governance structure most likely affects perceptions of involvement. For example, because OH settings are self-run and require residents to perform duties normally handled by staff in more traditional recovery residences, these settings may increase resident interdependence. Governance is revealed through social control mechanisms, activated through the bonds formed among individuals in recovery settings while living together under a common system of rules and regulations. OH house residents had considerable involvement in such matters as who is admitted into the program, whom they room with, or whether or not a peer is active in a recovery program. Embedding, the result of bond forming, is likely to result in the emergence of a natural social control through residents’ investment in their social ties. Self-governance can thus promote the development of self-reliance and responsibility; within OHs, an individual recovering from substance use disorder cannot escape accountability. Self-governance is more likely to give rise to group interdependence, which, in turn, tends to create cohesion (Gully, Devine, & Whitney, 1995) and higher self-efficacy (Kelly & Greene, 2014). Moreover, actions perceived as voluntary—emerging through mechanisms of social responsibility versus simple rule adherence—are more likely to be attributed to one’s self rather than external exigencies, thus promoting personal change and learned recovery skills.

These types of inexpensive community supports are important not just for American Indians, but for our entire society. It is now clear that the system of care for alcohol and substance use disorders produces unnecessary costs, re-treatments, and individual suffering (Institute of Medicine, 2015). The National Drug Control Policy (2013) prioritized the further development of recovery support services and recovery-oriented service systems. A supportive, cohesive setting following addiction treatment is known to improve outcomes (Moos & Moos, 2006). Recovery homes currently provide such settings for thousands of individuals annually (Jason, Olson, & Foli, 2008), especially benefitting those with the least resources and the highest risk of relapse (Jason et al., 2007; Polcin, Korcha, Bond, Galloway, & Lapp, 2010). A growing empirical literature (e.g., Laudet, Becker, & White, 2009; Schaefer, Cronkite, & Hu, 2011) supports the expectation that improved access to posttreatment housing and recovery support is a low-cost, high-potential opportunity to help those with substance use disorders sustain their recovery.

There are a number of limitations to the current study. Only residents of two OHs were involved, which limits the generalizability of the findings. Until the study is replicated with more OHs located on tribal lands, the results should be interpreted with some caution. In addition, the female sample was particularly small, in part due to the turnover in the female house. It is still unclear why the women had fewer days living in the OH than the men, and it does appear that their time in sobriety was briefer and they had less employment. In addition, the implications for the longer-term outcomes of the residents is unclear, but at least we found that the overall reactions of living in these settings was extremely positive. We hope that in the future, long-term studies are conducted to help answer critical questions regarding why residents leave OHs and where they go when they leave OHs.

We were informed that the non-American Indian residents were from the greater Washington community, and were seeking a sober living environment. However, the exact reasons for these non-American Indians wanting to live on the reservation were not assessed, and future studies are needed to explore this issue. It should be noted that this study occurred in just one tribal community, which limits generalizability, as there is substantial variation across tribes. Therefore, while the tenets of OH seem consistent with many of the tribes’ values, it is still unclear about the feasibility and acceptability of OHs on other tribal lands. It should be noted that over the past year, a number of local American Indian tribes have visited these OHs, and there are currently plans to open other OHs on other American Indian tribal lands.

It could also be argued that the use of OH’s policies on rules, policies and regulations could take away decision making and autonomy from the Suquamish Tribal Government. The OH rules stipulate that all residents pay their fair share of the rent, not use any alcohol or drugs, and contribute to the maintenance of the home. If those rules are followed, residents can remain in the houses as long as they want. It does appear that the Suquamish Tribal Government feels comfortable with these rules, and they have not reported any loss of autonomy due to implementing these OH policies.

It is possible that George Duncan and other residents of the OHs, who are in recovery, could have been subjected to undue influence to participate with this study. As these are vulnerable populations, and as they are likely facing high levels of poverty, it is possible some residents could have felt that their housing may be at risk if they did not participate in this study. We were aware of this possible concern, and we tried to allow residents to chose whether to participate of not, and we repeatedly emphasized that there would be no negative consequences if they did not participate in the study.

It is important to clarify the positionality of the research team, that is whether the direction of this study/evaluation was representative of Indigenous/American Indian/Alaska Native/First Nations community perspectives, beliefs and traditions, or that of Euro-Settler (White) perspectives. We did seek and were provided the permission of the tribe to use their name in this article. In addition, we did ask several community members from the tribe to review our article, and they have felt that we have appropriately interpreted and described their tribe from a cultural context. Clearly, attempts at conceptualizing traditional beliefs, ceremonies, and spiritual artifacts and symbolism from a Western and Eurocentric perspective could be problematic. While Mayra Guerrero is Latinx, the other authors are White, the authors did try to educate themselves about the American Indian perspective. It is important to recognize that there are benefits that did accrue to the authors, as they were able to become authors on a publication which continues their line of investigation demonstrating how recovery homes can meet the needs of different groups of individuals (as discussed in the introduction). The tribe also derived benefits from participation in the research, as the first author has been told that the research described in this article has been shared with other American Indian tribes, and that this information has proved useful helping other tribes better understand the use of this OH model on tribal reservations.

In summary, this study suggests that community-based, culturally supportive recovery settings may play an important role on American Indian tribal communities in addressing substance use disorders. Given findings on the acceptability and feasibility of the OH model in tribal communities, a more formal study with follow up assessments are essential for better understanding the maintenance of abstinent lifestyles over time. Our findings on these first OHs on American Indian tribal grounds are promising and could have real world, policy implications for housing those vulnerable to substance use disorders.