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. Author manuscript; available in PMC: 2022 Nov 1.
Published in final edited form as: Drug Alcohol Depend. 2021 Sep 8;228:108971. doi: 10.1016/j.drugalcdep.2021.108971

An Examination of Abstinence Social Support Among Recovery Home Residents with Psychiatric Comorbidity

John M Majer a, Leonard A Jason b, Ted J Bobak b
PMCID: PMC8595772  NIHMSID: NIHMS1739875  PMID: 34508961

Abstract

Background

Although social support is a resource that helps persons in their recovery from substance use disorders, it is not clear whether specific types buffer the effects of stress and optimize outcomes for those with psychiatric comorbidity. This investigation examined two types of social support in relation to lengths of stay to identify mechanisms related to retention among individuals with psychiatric comorbidity living in community-based settings.

Methods

Baseline rates of social support (abstinence specific and general types) and stress were examined in relation to follow-up lengths of stay (at four-months and beyond) among individuals (N = 368) with psychiatric comorbidity (n = 90) and no psychiatric comorbidity (n = 278) living in community-based settings (Oxford Houses) in the U.S. The psychiatric severity index of the Addiction Severity Index was used as a proxy measure of psychiatric comorbidity. Moderated mediation analyses were conducted to test the potential mediating effects of abstinence social support and general social support on the relationship between stress and lengths of stay, and whether these were influenced by psychiatric comorbidity.

Results

A full mediating effect was observed for abstinence social support for residents with psychiatric comorbidity, whereas a partial mediating effect for general social support was observed for all residents.

Conclusions

Findings demonstrate qualities of social support have differential effects, substantiating the notion that specific components of social support optimize outcomes for those with psychiatric comorbidity living in recovery homes.

Keywords: psychiatric comorbidity, social support, stress, retention, Oxford House, moderated mediation

1.1. Introduction

Although the benefits of social support among persons recovering from substance use disorders (SUDs) have been well documented, there is a need to critically examine characteristics of this recovery resource to determine which ones might optimize therapeutic outcomes, particularly among those who have psychiatric comorbidity living in recovery homes. Most investigations have examined qualities of support that are either general (e.g., sources that provide tangible or psychological support) or specific to abstinence (e.g., networks comprised of recovering peers/abstainers, those supportive of recovery). General types of social support include having informal networks (Golder et al., 2015), positive/negative and functional supports (Gabrielian et al., 2018), types of actual or perceived support (Cohen et al., 1986), and having network members to confide in (Warren et al., 2007). Examples of abstinence social support include (professional) peer support in treatment settings (Chinman et al., 2014), support from others who are supportive of one’s abstinence and/or recovery (Brown et al., 2013), and network members who are themselves are in recovery or abstinent (Zywiak et al., 2009; Majer et al., 2016a).

Although social networks are mixed in terms of members who misuse/do not misuse substances upon treatment admission (Tracy et al., 2016), abstinence social support networks tend to develop early in recovery with increases in abstinent members and decreases in non-abstinent members over time (Litt et al., 2009; Tracy et al., Zywiak et al., 2009). However, there is a dearth of studies that have compared abstinence social support to general types of social support among persons with psychiatric comorbidity and there is a need to understand how social support types promote therapeutic gains for those living in recovery homes. Although research evidence suggests abstinence social support through involvement in 12-step groups (i.e., AA/NA) improves substance use outcomes whereas general social support might mitigate mental health and substance use severity outcomes, such therapeutic gains are likely compromised by unsupportive living environments (Haverfield et al., 2019). Recovery homes are home-like environments that are necessary for some individuals seeking recovery (Jason & Ferrari, 2010; Wittman & Polcin, 2014) and there is a need to identify factors that engage residents in these settings.

There are nearly 18,000 estimated recovery homes in the United States (Jason et al., 2020). Recovery homes are part of the continuum of care to help individuals with high needs reintegrate into their communities (National Alliance for Recover Residences, 2019; Substance Abuse and Mental Health Services Administration; SAMHSA, 2015). Recovery home living where involvement in twelve-step groups such as Alcoholics Anonymous and Narcotics Anonymous is practiced engenders residents’ abstinence social support whereas the safe and supportive communal-living setting of recovery homes provide general social support through a sense of community among residents (Jason & Ferrari, 2010). These social supports are likely to buffer stress that threatens recovery home retention for vulnerable residents such as those with psychiatric comorbidity.

Stress has been demonstrated to increase the risk for substance use relapse across investigations (Lijffijt et al., 2014) and have negative effects on psychiatric symptoms (e.g., depressive) independent of substance use (McHugh et al., 2020). High levels of stress and low levels of social support were observed among victimized women who reported high levels of psychological distress (Golder et al., 2015). In addition, high stress levels have been associated with decreased treatment retention (Jaremko et al., 2015) which is prevalent among persons with psychiatric comorbidity (Compton et al., 2007). Low treatment retention rates have been related to deficits in coping skills and social adjustment (Kelly et al., 2014; Moos, 2007) in addition to stress. Thus, a lack of social support, stress, and ineffective social and coping skills probably account for the high rates of relapse for persons with psychiatric comorbidity (Tate et al., 2008), and there is a need to identify social supports that reduce stress and increase recovery home length of stay demonstrated to improve community reintegration outcomes (Belyaev-Glantsman et al., 2009; Jason et al., 2006).

Abstinence social support in professional treatment settings has been estimated to be moderately effective in promoting treatment gains including treatment retention for persons with SUDs who have psychiatric comorbidity (Chinman et al., 2014), thus it seems likely that abstinence social support could buffer the effects of stress and improve length of stay rates in recovery homes for this at-risk population. However, differential effects between social support types have been demonstrated among persons with SUDs, and they have implications for understanding different types of social support among persons with psychiatric comorbidity in community settings such as recovery homes. For instance, differential effects were observed between perceived social support received from friends versus family members among those in continuing care (Lookatch et al., 2019), and substance using women with criminal justice involvement in terms of their perceived tangible social support and abstinence social support (Majer et al., 2015a). Yet it is not clear what types of social support among persons with psychiatric comorbidity buffer the effects of stress, and there is a dearth of literature comparing the effects of different types of social support in relation to length of stay in non-professional settings such as recovery homes.

The present investigation examined whether specific types of social support (abstinence social support, general social support) among recovery homes residents with psychiatric comorbidity would mediate the effects of stress in relation to their length of stay. We hypothesized that abstinence social support would mediate the relationship between stress and length of stay in recovery homes among residents with psychiatric comorbidity, and we explored whether general social support would have a similar mediating effect.

2.1. Material and Methods

2.2. Sample

Participants (n = 368) were persons recovering from SUDs living in recovery homes (Oxford House) in the United States. Oxford Houses are self-run, communal-living settings that are regarded as a Level I recovery residence (National Alliance for Recover Residences, 2019) which is a most common type of recovery home in the US. The present study is a secondary analysis of data from the parent study (Jason et al., 2021) that provides more details on sampling and procedures. About half (51%) of the sample were male with a mean age of 37.0 years (SD = 10.5, ranging from 18 to 70), and reported their ethnicity as White (78.8%), Latinx (10%), African American (8.5%), or other ethnicities (2.7%). Their average length of stay in an Oxford House was 11.4 months (SD = 12.6).

2.3. Procedures

Data were collected from Oxford Houses located in North Carolina, Texas, and Oregon. Oxford House statewide organizations are strong and well-developed in these areas, which facilitated communication with residences about possible participation. Residences from different geographical regions provided some ability to address the generalizability of findings. Recruitment attempts were made to residences after state organizations helped field staff assemble lists of residences to approach. Member-elected house presidents were asked to introduce the study to the residents by reading a description of it from a project-provided script; houses were accepted into the study if the house president and all other members (or all but, at most, one member) agreed to participate. The first thirteen consenting houses from each state were accepted into the study, and three more houses were added for a total of 42. Ninety-three percent of all residents approached agreed to participate and the sample was representative of Oxford House residents in general across many sociodemographic characteristics except for gender as more women were represented in the present investigation. Residents were engaged in a process of informed consent and agreed to participate, and they received $20 for their involvement. Permission to conduct this study was reviewed and approved by the DePaul University Institutional Review Board.

Recovery home residents were permitted to enter the study at any time during a two-year period, and data were collected every four months across seven assessment intervals (waves). A possible maximum of six follow-up waves were thus available for observing length of stay rates which were determined by each participant’s last reported follow-up wave, whereas some residents completed only one wave of surveys. Of the 602 residents who were recruited throughout the two-year period, 394 participants provided data at two waves (baseline, follow-up). Of these, 26 were excluded from analyses because they did not meet criterion cut-off points for psychiatric comorbidity group placement (described in the following section), resulting in a total of 368 total cases for analysis. A pairwise deletion approach was used to evaluate data and calculate analyses. Participants with missing data (<7%) were excluded from analyses. Little’s MCAR test revealed that cases were missing completely at random, X2 (8) = 9.77, p = .28.

2.4. Instruments

Psychiatric comorbidity.

The psychiatric severity index (PSI) of the Addiction Severity Index-Lite (ASI-Lite; McLellan et al., 1997), was used to assess psychiatric comorbidity. The PSI is calculated by using eleven questions from the psychiatric status section of the ASI, and it is a composite score index based on a variety of psychiatric symptoms experienced in the past 30 days. McLellan et al. (1983) defined high and low psychiatric severity as PSI scores ± 1 SD from the mean. Participants reported a mean PSI of .14 (SD = .18), therefore PSI scores ≥ .32 among those who completed both waves (n = 394) were classified as high PSI (n = 90) and those with scores equal to .00 were defined as no PSI (n = 278); resulting in a total sample of 368 cases for analyses.

Dichotomizing PSI scores in this manner has been used to assess psychiatric comorbidity in previous investigations (Ball et al., 2004; Cridland et al., 2012; Majer et al., 2015b; Majer et al., 2016b). Residents in the high PSI group had a mean PSI score of .39 (SD = .18) which is higher than PSI scores reported among persons diagnosed with co-occurring psychiatric disorders (Carey et al., 1997; Dixon et al., 1996; Franken & Hendriks, 2001; McKay et al., 2002). Therefore, the PSI provided us with a reliable measure of psychiatric comorbidity among those who met the criterion cut-off for placement in the high PSI group. The PSI has good internal reliability across studies (Cronbach’s α ≥ .70; Makela, 2004; McLellan et al., 1983) and very good reliability (Cronbach’s α = .81) in the present study.

Abstinence social support.

The Important People Inventory (IP, Clifford, Longabaugh, & Beattie, 1992) is a measure adapted from the Important People and Activities Inventory (Clifford Longabaugh, 1991) and has been used in previous research to assess abstinence social support (Longabaugh et al., 1995). Participants were asked to describe important persons from their social network within the past 6 months, rating them on a 5-point Likert scale that distinguished substance users and nonusers. This resulted in computing a percentage of the four most important persons by dividing the number of persons identified as being abstinent from alcohol and drugs, or in recovery from substance use, by the sum total of persons identified, consistent with previous investigations (Epstein et al., 2018; Groh et al., 2011; Majer et al., 2015a; Zywiak et al., 2002; Zywiak et al., 2009). The IP has good internal reliability (Cronbach’s α = 80, Longabaugh et al., 1993), and the internal reliability of the IP in the present study was good (Cronbach’s α = 79).

General social support.

The Interpersonal Support Evaluation List (ISEL; Cohen & Wills, 1985; Cohen et al., 1986) measures actual or perceived social support and consists of 12-items measured on a 4-point Likert scale ranging from definitely false to definitely true. The total score of the ISEL was used to provide an overall measure of general social support, with higher scores indicating greater general social support. The ISEL has very good reliability (Cronbach’s α = .87; Cohen et al., 2003), and the internal reliability of the ISEL in the present study was very good (Cronbach’s α = .88).

Stress.

The Perceived Stress Scale 4 (PSS-4) is a briefer version of the Perceived Stress Scale (Cohen et al., 1983) as it consists of four items to assess perceived stress within the past month. Items of the PSS-4 are rated on a 5-point scale (never to very often), with two PSS-4 items reverse scored. Higher scores indicate greater perceived stress. The PSS-4 has good internal reliability (Cronbach’s α = .77; Warrtig et al., 2013), and in the present study it had good reliability (Cronbach’s α = .73).

Sociodemographic information.

Information was collected including participants’ age, gender, race/ethnicity, gender, and their length of stay in Oxford Houses at follow-up.

2.5. Data analysis

The data analysis of the present study was not pre-registered. Moderated mediation models were tested to examine whether baseline measures of abstinence social support and general social support mediated the relationship between baseline stress scores and length of stay in a recovery home at participants’ last reported follow-up (four months or more), illustrated in Figure 1. Race/ethnicity was included in these models to control for any potentially extraneous effects in relation to the disproportionate number of cases across racial/ethnic categories. The moderator for these analyses was based on participants’ status in terms of their psychiatric comorbidity (no vs. high PSI groups). Direct and conditional indirect effects of the moderated mediation tests were computed by using ordinary least squares regressions and bootstrapping procedure (Preacher & Hayes, 2004), a preferred and powerful method for testing intervening variables without assumptions regarding the sampling distribution (Hayes, 2009), making this method ideal for testing groups that vary considerably in terms of size.

Figure 1.

Figure 1

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Moderated Mediation Pathways of Analysis of Psychiatric Comorbidity by Social Support Types

The conditional indirect effect reveals the amount by which the total effect of the independent variable (stress) is influenced when the mediator (social support) and moderator (psychiatric comorbidity) are included in the analyses, placing our moderator in the pathway between the independent variable and mediator (PROCESS model 7). A moderated mediation takes place in the form of a significant indirect effect that is contingent upon on the moderator and supported by a significant index of moderated mediation (Hayes & Rockwood, 2019), and significance occurs when 95% confidence interval (CI) values do not cross zero. Unstandardized coefficients (b) are used to indicate predicted changes in the dependent variable (Hayes, 2009; Preacher & Hayes, 2004).

3.1. Results

3.2. Moderated mediation analyses

The first moderated mediation analysis (n = 362), examining abstinence social support as the mediator variable, was conducted using PROCESS model 7, using 5,000 bootstrap samples for bias correction and to establish 95% confidence intervals (Preacher & Hayes, 2004). The main results of this moderated mediation analysis are presented in Table 1. Stress was not a significant predictor of abstinence social support, b = .03, SE = .03 [− .03, .10], p = .31, R2 = .03, p = .026, and the direct effect of stress was significant and predicted decreased length of stay in a recovery home. The moderator variable (PSI group), b = .20, SE = .16 [− .12, .51], p = .22 was not a significant predictor of abstinence social support. Although the interaction term (stress x PSI group), b = − .12, SE = .06 [− .24, − .001], p = .046 was a significant negative predictor of abstinence social support, the conditional effects of the focal predictor at values of the moderator were neither significant for the no PSI group [b = .03, SE = .03, (− .03, .10)] nor the high PSI group [b = − .09, SE = .05, (− .19, .01)], indicating similar effects for both PSI groups.

Table 1.

Moderated Mediation Effects of Abstinence Social Support on the Relationship between Stress and Length of Stay in Recovery Homes

95% CI
Effect Estimate (b) SE Lower Upper
Direct − 4.35 *** .98 − 6.28 − 2.42
Conditional indirect
 No PSI group − .17 .20 − .63 .16
 High PSI group .44 * .29 .01 1.11
Moderated Mediation Index .61 * .38 .03 1.47
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Note.

*

p < .05

***

p < 001.

CI = Confidence Interval.

However, abstinence social support predicted significant decreases in length of stay, b = − 4.99, SE = 1.90 [− 8.72, − 1.25], p = .01, R2 = .07, p = .009. A significant conditional indirect effect was observed only for the high PSI group, demonstrating stress to positively predict lengths of stay for this group. Differences between these conditional indirect slopes were supported by a significant index of moderated mediation. Results from this moderated mediation analysis indicate a full mediation effect whereby stress predicts increases in length of stay in relation to abstinence social support among residents with psychiatric comorbidity, whereas the direct effect of stress predicts decreases in lengths of stay.

The second moderated mediation analysis (n = 367), examining general social support as the mediator variable, was conducted in the same manner using PROCESS model 7 and results of this moderated mediation analysis are presented in Table 2. Stress was a significant negative predictor of general social support, b = − .22, SE = .04 [− .30, − .14], p = .0001, R2 = .19, p = .0001, and the direct effect of stress was significant and predicted decreased length of stay in a recovery home. The moderator variable (PSI group), b = .07, SE = .19 [− .30, .44], p = .72, and the interaction term (stress x PSI group), b = − .10, SE = .07 [− .24, .05], p = .19 were not significant predictors of general social support.

Table 2.

Moderated Mediation Effects of General Social Support on the Relationship between Stress and Length of Stay in Recovery Homes

95% CI
Effect Estimate (b) SE Lower Upper
Direct − 3.37 ** 1.06 − 5.46 − 1.28
Conditional indirect
 No PSI group − .72 * .27 − 1.29 − .25
 High PSI group − 1.04 * .43 − 1.99 − .32
Moderated Mediation Index − .31 .32 − 1.00 .24
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Note.

*

p < .05

**

p < .01.

CI = Confidence Interval.

However, general social support predicted significant increases in length of stay, b = 3.31, SE = 1.57 [.22, 6.40], p = .036, R2 = .06, p = .0001. Although significant conditional indirect effects were observed for both (no/high) PSI groups, differences between these slopes were not significant as indicated by the nonsignificant index of moderated mediation. Results from this moderated mediation analysis indicate a partial mediation effect whereby general social support reduced the negative relationship between stress and length of stay regardless of psychiatric comorbidity status.

Finally, there were no significant findings in either model in relation to race/ethnicity. The results were statistically similar when race/ethnicity were excluded from these analyses. We also controlled for participants’ prior length of stay in their recovery homes (at baseline) in both moderated mediation models and the results were statistically similar.

4.1. Discussion

Results from the data analysis support our hypothesis in that abstinence social support fully mediated the relationship between stress and subsequent length of stay in a recovery home for residents with psychiatric comorbidity. The moderated mediation effect of abstinence social support on this relationship suggests the connection with other recovering peers empowers persons with psychiatric comorbid SUDs to withstand stressors that might otherwise lead to a premature departure, as indicated by the significant and negative direct effect of stress on length of stay. The significant and positive moderated mediation effect is consistent with research evidence that has demonstrated abstinence social support promotes cognitive functioning early in recovery (Buckman et al., 2008), and research that demonstrated improved outcomes including gains in self-regulation associated with increased lengths of stay among recovery home residents with psychiatric comorbidity (Jason et al., 2006).

Findings from the present investigation extend research evidence from a recent cross-sectional investigation (Rudolph et al., 2020) by providing evidence that illustrates the complexity of social support for this population in terms of demonstrating how different domains of social support have differential effects on recovery outcomes over time. The full mediation effect of abstinence social support among residents with psychiatric comorbidity, and partial mediation effect of general social support for all residents, exemplify the importance of examining specific qualities of social support; suggesting that affiliational support comprised of recovering peers is instrumental in connecting those with psychiatric comorbidity with their recovery community (Pantridge et al., 2016; Sells et al., 2006). Our findings support the notion that specific (rather than general) components of social support can optimize outcomes for those with psychiatric comorbidity (Haverfield et al., 2019). In addition, results in the present study suggest the effects of the social environment of recovery homes such as Oxford Houses can serve as a protective factor against interpersonal stress known to predict relapse (McKellar et al., 2006) among residents with psychiatric comorbidity.

Recovery peers in professional settings could be considered abstinence social support in that they themselves are in “recovery.” It is likely that their own recovery experiences are instrumental in connecting with their patients to help them achieve treatment objectives such as reduced psychiatric symptoms (Cook et al., 2010), and findings in the present investigation are consistent in this respect by demonstrating the therapeutic value of abstinence social support for those with psychiatric comorbidity extends to those living in community settings such as recovery homes. In addition, our findings extend research that found social support to buffer the effect of stress (Laudet et al., 2006) by demonstrating that qualities of social support have differential effects on outcomes.

Length of stay rates among participants in the present study are consistent with those from a national longitudinal investigation of Oxford House residents (Jason et al., 2007), lending to the generalizability of our findings. The average length of stay of 11.4 months reported at baseline in the present study most likely accounted for follow-up attrition as residents typically live in an Oxford House for just under a year and many participants left their recovery homes by the four-month follow up interval. The negative relationship between abstinence social support and length of stay in an Oxford House probably represents a ceiling effect of abstinence social support which develops early in recovery (Litt et al., 2009, Zywiak et al., 2009). This relationship might reflect a trend whereby some residents transition into their communities in part after they have solidified their social support networks to sustain their ongoing recovery. Of course, such a claim can only be verified by additional research.

Although general social support buffered the effects of stress for all participants, abstinence social support was demonstrated as having a greater effect among those with psychiatric comorbidity. Our findings underscore the importance of having recovering peers in one’s social network to maximize outcomes for those with psychiatric comorbidity. Future investigations that include a focus on specific types of stress related to social supports and treatment retention such as psychological distress (Ali et al., 2017; Golder et al., 2015) would further our understanding of recovery components for such a vulnerable population.

Although examining different types of social support in relation to length of stay in recovery homes among persons with psychiatric comorbidity has important research and treatment implications, there are some limitations to the present investigation. Examining qualities of abstinence social support networks (e.g., those who also have psychiatric comorbidity), and whether residents lived in recovery homes with other residents who have psychiatric comorbidity (who may/may not be identified as an abstinence social support network member) would inform us as to whether homophily effects are meaningfully related to this type of social support. It is possible that persons with psychiatric comorbidity in the present study were high functioning and not necessary representative of those who have severe levels of psychopathology. Relatedly, although the present study used a well-established and reliable measure as a proxy for assessing psychiatric comorbidity, future investigations consisting of community samples comprised of residents with diverse diagnostic categories in addition to assessing psychiatric symptom severity are needed to further our understanding of how Level 1 recovery homes facilitate community reintegration among a vulnerable population.

4.2. Conclusions

Recovery homes such as Oxford Houses are supportive social environments that help residents with psychiatric comorbidity cope with stressors that threaten their recovery. The effects of stress among residents with psychiatric comorbidity are likely to be lessened when residents’ social support networks include others who are in recovery. Clinicians should encourage patients with psychiatric comorbidity to develop social support networks consisting of other recovering peers (in addition to developing other sources of support) to facilitate their ongoing recovery, and to considering recovery homes such as the Oxford House model as part of a continuing care plan.

Highlights.

  • Specific types of social support were examined in relation to stress and retention.

  • Psychiatric comorbidity was examined as a moderator in analyses.

  • Outcomes were length of stay rates in community-based settings.

  • Abstinence social support had greater effects for those with comorbidity.

  • General social support had lesser effects among all participants.

Funding

This work was supported by the National Institute on Alcohol Abuse and Alcoholism (grant number AA022763).

Role of Funding Source

Nothing declared

Footnotes

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All work related to this investigation was done within the United States of America.

The authors declare no conflicts of interest.

Conflict of Interest

No conflict declared

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