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  • David Best, Ph.D.

An ecological model of recovery for recovery residences in the United States

Background

One of the central tenets of recovery is that it is intrinsically and fundamentally social as I outline in my 2019 book, “Pathways to Desistance and Recovery: The Social Contagion of Hope”. This approach is entirely consistent with the ‘social model’ widely promulgated as being at the heart of recovery residence approaches as well as widely used in therapeutic communities. However, what this article will attempt to set out is that, both in terms of the history and evolution of recovery research, and through the lens of recovery capital, we need to extend that thinking to incorporate how the recovery residence is impacted by community factors beyond the walls and what, in turn, the residences do to influence the community beyond their boundaries.


I am writing this as I return home from participating in the “Recovery Housing Expo and Symposium” in Houston, Texas, and where I had the privilege of staying in a recovery residence, the wonderful Hearthstone House (owned and run by the fabulous Tim Carpenter, who was a truly generous and wonderful host).


Moving beyond the social model

The assumption underlying a recovery capital approach is that we are reliant, as Granfield and Cloud initially outlined in 2001, on the breadth and depth or internal and external resources that a person can access. Along with Alexandre Laudet, in 2010, I started attempting to operationalise this into three component parts – personal, social and community capital. Our evidence (Dennis, Scott and Laudet, 2013) would suggest that stable recovery typically takes around five years to achieve (at which point recovery is regarded as ‘self-sustaining’), and our approach was that in this time, people would attain the external supports to develop the bundle of internal qualities needed to sustain recovery in the face of whatever adversities life would throw up. Our original characterisation of those strengths was self-esteem, self-efficacy, coping skills, resilience and communication skills.


Rightly, the focus has primarily been on the social support people need, which Moos (2007) referred to as social learning (copying from role models) and social control (the rules and structures imposed by the group and by peers. Indeed, in our own work on the social components of Alcoholics Anonymous, we came up with a Social Identity Model Of Recovery (SIMOR, Best et al, 2016) where we talked about the transformative capacity of group belonging, where embedding yourself in a new group involves the internalisation of the rules, roles, norms, values and language of that group. We were writing about AA but could just as easily have been writing about accredited recovery residences.


In recent years, the recovery model has been buttressed by an emerging evidence base, largely driven forward by the amazing work of Leonard Jason around Oxford Houses and by the work of Doug Polcin and Amy Mericle on Sober Living Homes. In addition to work on effectiveness (references), there has also been a body of work about the importance of social dynamics and social processes in recovery residences. The evidence is clear – the social process is central to the effectiveness of the recovery residence but more widely is an essential component of recovery more generally.


However, what I will argue for the remainder of this paper, is that the social process of recovery (contagion) is shaped and influenced by creating the conditions in which this social influence occurs (which I will refer to as ‘cascades’) and through the processes that residences and their residents actively engage with the communities in which they are embedded.


Point 1: Social contagion of recovery requires structural cascades of conducive conditions;


Point 2: Recovery residences are not houses on the hill and their engagement with the communities in which they are located is essential;


(Point 3: More speculatively, the structural, fiscal and legal context in which recovery residences operate will also impact on their capacity to create contagions of recovery).


To address Point 1, we are starting to do some pilot work in Michigan and some other international locations to test the question of how peer recovery specialists and champions (including house managers and owners) influence and impact the milieu in which social processes occur. As we strive to understand better the variance in outcomes for recovery communities, it will be essential that we start to frame the role and context of house managers and peer specialists, the interventions they deliver, and the organisational factors that generate congruence and conflict within each residence or cluster of residences. Particularly for residences that operate at Level 2 and Level 3 of the NARR standards, there are hierarchical and structural factors that matter. But this also opens up questions about what additional services are provided (recovery support services and beyond) and what impact they have on wellbeing of each resident and collectively on each house.


In starting to unpack Point 2, the external engagement components of the recovery residence are a recognition of community capital. What are the resources that each residence has access, and crucially what role do the residents play in actively building and enhancing not only the vibrancy of the local recovery community (by boosting mutual aid fellowships, by hosting and participating in recovery events) but also how they engage with the wider community through social enterprise, volunteering and actively participating in various aspects of civic society. How this is done will have an effect on public perceptions, social stigmatisation and collective wellbeing and efficacy in the community. How we will go about measuring these things will be a major challenge for academics but will help to create a genuinely inclusive and comprehensive science of recovery residences (and by translation, for all residential recovery settings).


Finally, in relation to Point 3, there is a wider point here around how NARR affiliates and the broader recovery communities influence the macro conditions of what is achievable through legislation, fundraising and partnership working. At this macro level, recovery is blocked or facilitated through structural change such as the Fair Housing Act and subsequent local implementation. In Virginia in recent years, the NARR affiliate has shown incredible leadership and advocacy and in return there is a trust in the recovery housing system that has been reported previously in the blogs in this series. Again, it is early days for our research, and it will take a considerable period of time to catch up, but this is a crucial component in understanding the macro conditions for creating successful community contagion of recovery.


In summary


First, I would like to thank Don Hall and his colleagues at the Houston Recovery Oriented Systems of Care for the invitation and for his commitment; to Tim Carpenter for his wonderful support, friendship and generosity, and crucially to Jason Howell, Jason Pullin and all of those inspirational figures from Texas who inspired the thinking outlined in this paper.


As always, the science will take a long time to catch up with the innovation and inspiration that I was privileged to witness, but it is critical that we find ways to conceptualise, operationalise and quantify the amazing work that goes on in recovery residences in Texas, and throughout the United States, and that will, at some point, be recognised and replicated internationally.

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