Leonard A. Jason1 , Bradley D. Olson, David G. Mueller, Lisa Walt and Darrin M. Aase
(1)
Psychology Department, Center for Community Research, DePaul University, 990 W. Fullerton Ave., Chicago, IL 60614, USA
Leonard A. Jason
Email: ljason@depaul.edu
Abstract
Over 10,000 people live in recovery homes called Oxford Houses throughout the USA. Among these approximately 1,400 abstinent living environments, residents are provided an unlimited period of time to gain fellowship and support for becoming productive members of society. The evolution of 17 year collaboration between this Oxford House organization and a research team at DePaul University is described. In addition, economic issues are explored including the finding that this recovery community appears to have both low costs and high benefits. Issues involving the sustainability of the Oxford Houses are also presented. The chapter also reviews gender roles and women’s specific issues to highlight how Oxford Houses have the potential to be empowering. Finally, comorbid psychiatric conditions are reviewed in the context of how Oxford Houses can promote not only abstinence among this group, but also improved psychological functioning.
Keywords
Addiction recovery managementRecovery homesAbstinent living environmentRecovery communityLong-term abstinence
The Oxford House Story
This chapter focuses on the history and growth of the Oxford House Movement, and the evolution of a Participatory Action Approach collaboration between this self-help organization and researchers at DePaul University. We begin with a brief description of the origin and nature of Oxford Houses. Subsequently, we explored some of the economic benefits and costs of Oxford Houses as well as issues involving the sustainability of the Oxford Houses. The chapter also reviews gender roles and comorbid psychiatric conditions among residents of these recovery homes.
Origin and Nature of Oxford Houses
Beginning in 1975, Paul Molloy and his fellow house members created one Oxford House. Since that time, this one house has expanded to a network of over 1,400 USA Oxford Houses plus just over 30 Canadian and 8 Australian Houses, each providing support to persons with substance abuse problems. Former substance abusers now rent houses throughout the USA, with no supervision except what they provide on their own. Houses are single-sex dwellings, and some allow residents to live with minor children. Individual members are expected to pay monthly rent and assist with chores. Houses generally have functional kitchens, laundry facilities, and common areas where residents conduct business meetings and spend social time, with 7–12 individuals living in a house and usually sharing bedrooms. Houses are located in multiethnic communities with access to public transportation and employment opportunities. Unlike other aftercare residential programs, such as half-way houses, Oxford House has no prescribed length of stay for residents.
Each House operates democratically with majority rule for most policies and an 80% majority regarding membership [1]. Residents must follow three simple rules: pay rent and contribute to the maintenance of the home, abstain from using alcohol and other drugs, and avoid disruptive behavior. Violation of the above rules results in eviction from the House [1]. Each Oxford House has a President, Treasurer, Comptroller, Coordinator, Secretary, and Building Maintenance person elected to 6-month terms. This process gives all house members opportunities to exert leadership and make sure rules are being followed. The revolving leadership system helps residents inexperienced with financial issues and general management to become more skilled in these areas. Members report that it is easier to follow rules enforced by other house residents, who must also comply with these rules, than by professionals who might be more distant and removed. New members attend eight self-help meetings during this first month. During the first 2 weeks, they are also required to do a “one on one” with all members of the house. This process involves each member sitting down with the new resident to allow the new resident to tell the story of his/her addiction and what he/she is doing to avoid substance use and stay abstinent. Groups of houses in the same geographic area are placed into a chapter. Chapters have officers that are elected and include a Chapter Chairperson, a Vice Chairperson, a Treasurer, a Secretary, and a Housing Service Committee Chairperson.
In 1988, Congress passed the Anti-Drug Abuse Act allocating federal funds to any state for the start-up of recovery homes such as Oxford Houses. A group of recovering substance abusers, through the support of an established House, could request $4,000 from their state in an interest-free loan to begin a new Oxford House. Repayment of loans was returned to the fund for start-up costs of additional Houses in that state. Several states also provided funds to hire Oxford House recruiters to help open Oxford Houses. These actions led to the expansion of Oxford Houses. In the late 1990s, states were no longer required to administer a state loan program, but many states continued to offer these loans to Oxford Houses.
The aspect that is most unique to Oxford House involves the high levels of abstinence-specific social support, which encourages abstinence. The self-governing policies described above help create and nurture these abstinence-specific social support networks. In the absence of professional staff, residents develop rules and policies, learn to self-govern, assume positions of leadership within their Houses, and participate in the bodies that develop, monitor, and assist individual houses.
Participatory Action Approach
In 1992, the first author saw Paul Molloy, the founder of Oxford Houses, interviewed on CBS’s 60 Minutes. Intrigued by the description of these Oxford Houses, he contacted Mr. Molloy and out of that initial conversation grew a long-term collaborative partnership between a university-based research team and a grassroots community-based organization [2]. Mr. Molloy was enthusiastic about a collaborative effort that would examine Oxford Houses.
Our work with the Oxford House organization typifies an action research perspective, one focusing on developing practical knowledge about issues of pressing concern using participatory processes [3, 4]. We used Participatory Action Research (PAR) methods, a community-based model that collaboratively involves multiple segments of the community in research endeavors, and uses approaches that reflect ecological theory and an empowerment agenda [5, 6]. Hill et al. [7] identified themes within an action agenda that include collaboration and action. Collaboration allows all stakeholders within the community to be represented [2].
Shortly after the first author contacted Mr. Molloy, Oxford House decided to establish Oxford Houses in the Midwest. In 1992, the first Oxford House representative, named Bill, was sent from Oxford House, Inc. to Chicago in order to begin the establishment of Oxford Houses in Illinois. Although the Illinois Department of Alcohol and Substance Abuse (DASA) awarded money from the state’s revolving fund to support the opening of the first house, there were funding complications at DASA that left the Oxford House representative without necessary housing and financial support. Somewhat discouraged, Bill found temporary lodging at a local shelter where consequently he was robbed of all his personal belongings. Frustrated and dejected, he was on the verge of leaving Chicago and abandoning his task all together. Congruent with an action-oriented agenda, our research team provided Bill with free accommodations, first at the home of one of the members of the research team and then at the DePaul University priests’ residence, so Bill could proceed with his venture. For several months, we also provided him with office space, a telephone, and other resources to facilitate his efforts. Because of this joint effort, Bill was able to successfully establish the first Oxford House home in Illinois. The home was located near the university and for appreciation of the support provided by our group, it was named the “DePaul House.”
Over the next 7 years, pilot studies were conducted and collaborative work was continued with local and national organizations. As an example, a grant proposal was jointly written to a local foundation to provide funds to hire a recruiter to open two Oxford House homes for women and children in the area. The funded grant was jointly administered by both the DePaul University research team and the Illinois Oxford House organization. DePaul researchers also talked to reporters when members of the press wrote articles about Oxford House. Finally, the research team supplied some of their preliminary research findings to the Oxford House organization during a Supreme Court lawsuit against an Oxford House home in the state of Washington. The suit, based on a zoning law that prohibited more than five unrelated people from living in one dwelling, was representative of some communities’ unwillingness to support Oxford Houses or other recovery homes for fear of reducing their property values. Fortunately, the suit against Oxford House was defeated, and the positive precedent the case set has had an important impact on other Oxford Houses, similar residences, and other halfway houses.
During this time, efforts were undertaken to obtain external federal funding to support larger and more sophisticated research studies on the process of communal living within Oxford House. We submitted multiple federal proposals, but members of a scientific review committee recommended that our team needed to evaluate the effectiveness of Oxford House through a randomized outcome study. We were hesitant to advance a methodology that could potentially upset the natural process of self-selection that occurs within Oxford House. That is, members of each Oxford House interview discuss and vote on whether an applicant should be admitted as a resident in their house. This democratic process is an important cornerstone to the Oxford House approach to recovery, and we did not want to disrupt that process; as doing so would fundamentally change the structure of how Oxford House operates.
When this dilemma was presented to Mr. Molloy, he said that he would support a random assignment design, as this would help out efforts to secure funds to assess in a rigorous way the effectiveness of the Oxford Houses. We developed a protocol that accommodated random assignment within Oxford House’s democratic system of selection. In our study, individuals finishing substance abuse treatment were randomly assigned to either an Oxford House or Usual Aftercare, with follow-up assessments at 2 years. Using this design in our proposal, we secured our first Oxford House focused National Institute on Alcohol Abuse and Alcoholism (NIAAA) grant (to be described below). The prior collaborative relationship with Oxford House helped the DePaul researchers gain the approval of Mr. Molloy, who was able to provide the organizational support and technical expertise for a rigorous randomized outcome study. We later also received a National Institute of Drug Abuse (NIDA) grant to interview Oxford House residents in a national sample over a period of a year.
Community coalitions, such as the one described in this article, address the lack of various services addressing specific social problems [8]. Coalitions often employ an ecological approach and empower community members to facilitate social change. Our work employed collaborative methods throughout, and the ideas for most of our work was generated and guided by our Oxford House partners [9]. As an example of the collaborative nature of our work, at the end of one presentation at an Oxford House annual convention, an Oxford House member approached the first author and suggested that we include the issue of tolerance in our future research. He mentioned that prior to living in an Oxford House, he was very prejudiced against people who were different from him, and he pointed to a woman, who was his girlfriend, noting she was HIV positive. Before living in an Oxford House, he said that he would never even talk to her as he was so prejudiced and narrow minded, and he discriminated against people who were infected with HIV. He then mentioned that it was just as important to measure these types of changes that were occurring among residents as it was to assess abstinence. We took this feedback to our team and later began a study on the development of tolerance among Oxford House members [10].
Coalitions such as the Oxford House/DePaul collaboration foster a sense of community in those individuals within the group by promoting methods of information exchange, support for multiple perspectives, and collaborative activities [9]. This emergence of common experiences enhances the trust and awareness of each other [11]. Because of our collaboration with Oxford House, when the Oxford House organization made several presentations to officials as the US Office of National Drug Control policy, they included us in the meetings. In addition, when a new Illinois governor was elected in 2001, as part of cost saving initiatives, he ended the $100,000 loan program and support of Oxford House recruiters for the state of Illinois. When the findings from our randomized NIAAA-funded Oxford House study [12] were released, we met with the head of DASA in Illinois, and our positive findings led the state to restart both the $100,000 loan program and the recruiter support. Our data also was used in expert testimony by the first author to argue in court cases to stop communities from passing not in my backyard legislation that would prevent Oxford Houses from existing in many towns [13].
When working closely with community partners, there are also challenges to the research relationship that need to be addressed. As one example, an official from a large federal agency was asked to develop a position paper on Oxford Houses. He ultimately recommended that the houses should be substantially expanded. However, as he was finishing writing the position paper, he mentioned to the first author that the Oxford House organization was too disorganized, lacked sufficient infrastructure, and had poor leadership to expand this program. He then suggested that the first author should assume the role of training and monitoring of recruiters to expand the system. Even though such a contract would have involved millions of dollars, the first author refused this offer and informed the leadership of the Oxford House organization of this plan. This action preserved our relationship with the Oxford House organization and prevented one of the federal departments from exerting undue influence on the Oxford House model’s operations. There is an appropriate role for the federal government in helping expand these Oxford Houses, in providing additional loan supports, for helping states hire additional recruiters, and for helping defray legal costs from court expenses of communities trying to prevent Oxford Houses from being established in many neighborhoods. But in providing help, the federal government needs to be wary of usurping the authority or leadership of this grass roots organization.
Economic Issues
In the following section, we will discuss some of the economic potential benefits of the Oxford House model. In Illinois, roughly 900,000 adults and 90,000 youth are candidates for substance abuse treatment services. Not all of these individuals are actually seeking treatment, but on average, 700 individuals are on waiting lists at any one time. In most states, service capacity could reasonably be doubled to fit the need. Treatment for substance abuse is as effective, adherence is greater, and relapse is lower for substance abuse-related problems than for many other serious health conditions such as diabetes and cardiovascular disease [14]. From a public health perspective, a most reasonable goal is to focus on recovery systems that have demonstrated social and economic benefits by providing greater access to effective recovery opportunities, and, according to a particular stage in a person’s recovery.
Yearly costs for the USA associated with alcohol and drug problems are around $500 billion. The Center on Addiction and Substance Abuse (CASA) states that for every dollar spent on social harms, 96¢ is spent on “shoveling up the wreckage” and only 4¢ used to prevent and treat addiction. Studies have found that the economic benefits of treatment range from $1 saved to every dollar invested to $18 saved for every $1 invested [15]. Treatment in itself, particularly when contrasted to incarceration – the common alternative path of substance use, is well worth the amount put up front.
We are not suggesting that the mutual-help residence is the end-all in recovery options – such an argument would go against the NIDA’s principles of effective treatment that suggests that no one intervention works for every individual. However, meeting the dual goals of increasing well-being and effective treatment economics requires a more integrated continuum of care, and Oxford Houses fit in such a model.
If we look at our most commonly used modalities of detoxification and inpatient treatment, we have seen average treatment durations shrink dramatically from 90 to 30 days and sometimes to simply a 3-day detoxification. They are expensive, as are almost all professional modalities. That is not to say they are unnecessary, and whether we are talking about traditional inpatient treatment, therapeutic communities, recovery homes, or individual therapy, we see advances from brief interventions, motivational interviewing, and harm reduction strategies. Randomized studies have shown that, if engaged in early enough, brief interventions can be effective, and of course, reduced time means reduced costs.
Then there are the classic 12-step options such as Alcoholics Anonymous and Narcotics Anonymous. Weekly meetings occur and sometimes individuals attend every day. Strong peer support is provided with no societal/taxpayer costs. Such an approach does quite well because it helps counter those dangerous social networks of family, friends, dealers, bars, and other forms of temptation. Even within the 12-step model, a person may end up returning to homes where these networks and temptations exist. Paul Molloy has observed that some individuals are without a home, but few of these individuals have a home that does not constantly invite drinking and using (through direct temptations and enabling).
Each modality (12-step groups and therapeutic communities) has its advantages, but the mutual-help residence has perhaps the greatest strength of having the low societal costs of the 12-step model with the duration, frequency, and intensity that most treatment providers believe is necessary to bring about effective recovery outcomes. Short treatment stays are often their number one attribution for the cycle of relapse and multiple treatment stays.
The economic advantages of Oxford House are attributable to the fact that participants pay their own rent at a low cost due to sharing rental costs. Many residents enter the house unemployed, but are continually encouraged and supported by other members to find employment. Oxford Houses are organized in chapters, which are typically geographic clusters of houses. Members throughout these chapters have many employment connections and tend to build successful relationships with various employers in a particular region.
Economics are relevant to any section of the multilevel treatment scheme provided, but it is clearly tied to federal and state policy. Our research group’s first foray into studying societal costs of opening up Oxford Houses began with us obtaining federal loan information from states and Oxford House main offices in the Washington DC area [16]. This program was an amendment in the anti-drug abuse act of 1988 previously discussed in this chapter. In addition to collecting information from this program, we explored the literature for ranges of inpatient treatment and jail/prison costs to obtain per person and estimated yearly ranges of these costs. In addition, based on a procedure developed by French [17], we utilized data from our large, NIDA-funded national data set related to incarceration and treatment. This approach allowed us to use the past histories of these participants, adjusting their treatment and incarceration costs to be consistent with the Oxford House sample. Annual program costs per person were estimated for Oxford House based on federal loan information and data collected from Oxford House, Inc. In addition, annual treatment and incarceration costs were approximated based on participant data prior to Oxford House residence in conjunction with normative costs for these settings. Societal costs associated with the Oxford House program were relatively low, whereas estimated costs associated with inpatient and incarceration history were high.
In an NIAAA grant-supported study, 150 individuals who completed treatment at alcohol and drug abuse facilities in the Chicago metropolitan area were recruited, with half being randomly assigned to live in an Oxford House, while the other half received community-based aftercare services (Usual Care). A 24-month follow-up [18] found 31.3% of participants assigned to the Oxford House condition reported substance use compared to 64.8% of Usual Care participants, 76.1% of Oxford House participants were employed versus 48.6% of Usual Care participants, and days engaged in illegal activities during the 30 days prior to the final assessment was a mean of 0.9 for Oxford House and a mean of 1.8 for Usual Care participants. Two years after entering Oxford House, 14 of the women assigned to the Oxford House condition had regained custody of their children, while only one woman had lost custody. On the other hand, in the Usual Care condition, only six women regained custody of their children, while two lost custody. Oxford House participants earned roughly $550 more per month than participants in the usual care group. Annualizing this difference for the entire Oxford House sample corresponds to approximately $494,000 in additional production. The lower rate of incarceration in this study among Oxford House versus usual care participants corresponded to annualized savings for the Oxford House sample of roughly $119,000. Together, the productivity and incarceration benefits yield an estimated $613,000 in savings accruing to the Oxford House participants.
In 2007, the Oxford House organization received about $1.6 million in grants from state and local governments to pay outreach workers to develop and maintain networks of individual Oxford Houses in nine States and the District of Columbia. If the Oxford Houses had been traditional, fully staffed halfway houses, the cost to taxpayers would have been $224,388,000 [19].
We can get a better understanding of how well the start-up loan policy fits with the nature of the Oxford House model and the national growth of new houses by considering two methods. The best way to conceptualize the growth of houses is as either (a) a grassroots, house-to-house, or (b) a relatively hands-off top–down policy method.
Oxford Houses started out as a grassroots movement. Paul Molloy describes his recovery home closing down and all of the members saying, “Let’s rent our own house.” They did so, and instead of hiring staff they voted on everything democratically. This approach was successful, and others in recovery heard about the Oxford House success. The original members had built up a savings account, and they decided to loan money to others to open up a second house. This grassroots method continued from there.
Mutual help, in general, has a curious relationship with the obtaining of government funds. Mutual help researchers and mental health consumers alike have believed that government involvement, particularly the providing of funds, can interfere with the sovereignty of a mutual-help group. The fear has often been that once the government gets involved in opening up houses, the government will start to create new rules, standardize each house, and essentially ignore the features that have evolved that ultimately allowed the model to work. What is positive about what happened with the stipulations of the Anti-Drug Abuse Act of 1988 is that it allowed the houses to keep their self-determination and individual responsibility by allowing states to take on a revolving loan fund that would help hire people to open up houses. However, the majority of the funds were to make loans available to anyone in recovery who wanted to open up these houses and begin to pay the state back for these loans, which is exactly why it was called a “revolving loan fund.”
To examine the impact of this policy on the nationwide growth of Oxford Houses – the diffusion of this innovation – we looked at house growth (either grassroots growth or growth in states adopting the policy) in a state-level multiple baseline framework. We therefore essentially treated the policy as a behavioral intervention, tracing the growth of houses in 13 states. On Fig. 9.1, on the y-axis, we have the number of houses. The y-axis shows the number of houses starting at zero and going up to 100. Each line represents one of 13 states. In the top figure, the low number of houses in each state leads up to a point of dramatic growth in each of these states. This date is 1988/89 when the Anti-Drug Abuse act went into effect, and these ten states were among those that had picked up the loan funds and technical assistance involving hiring recruiters. In the figure below, we see when three other states did not use the loan fund and technical assistance, very few Oxford Houses emerged; however, when the states utilized the loan fund and the technical assistance associated with it, growth of Oxford Housed increased with this policy initiative [20].
Fig. 9.1
The growth of Oxford Houses over time
In some of our other examinations of this data [21], we found that these loan funds also increased the number of women’s houses. Perhaps policy makers who were running these funds saw the need for and encouraged more of these types of houses. We also saw some states drop the fund, and nevertheless we still saw the grassroots method of house openings continue in these states, suggesting that the federal loan policy really increased the growth of Oxford Houses.
Sustainability
Our research team recently conducted a study to explore the longevity of Oxford Houses and find patterns of closure among houses. We examined houses that were included in a large NIDA-funded national study that concluded in 2001. We discovered that of the 214 houses included in the study, 172 were still open and 29 were closed [22]. This translates to an 86.9% sustainability rate for houses 6 years after the initial study was completed. On average, houses were open 7.28 years (SD = 3.75), suggesting that houses have considerable longevity.
Sustainability for any organization is important but it is particularly important for nonprofit self-run settings. Shediac-Rizkallah and Bone [23] have identified two important factors in the sustainability of health programs: program/project factors and organization/environment factors. Since the focus of this chapter is on Oxford House, we will continue this discussion through an examination of two important factors that have contributed to the sustainability of Oxford House: volunteers and organizational strength.
Research has found that volunteers are important for sustainability [24, 25]. Clearly, the benefits of volunteers are numerous for both the organization and the volunteer. The organization receives no cost or low-cost labor and a commitment to the project while the volunteer often enjoys self-esteem benefits [24] and develops new job skills and friendships [25]. Oxford House routinely utilizes current residents in the sustainability of the house. For instance, residents with long tenures often volunteer to move into a new house and provide experience and support for new residents [1]. Oxford House alumni often return to Oxford House and provide support or volunteer in the community. In a 2008 study, alumni reported returning to an Oxford House to be involved after moving out. They reported staying in contact and visiting several times per month for several reasons, including conventions, house meetings, and acting as a mentor to current house residents among many other reasons [26].
Organizational strength can be conceptualized in many ways. Evashwick and Ory [27], for instance, report that the number of years the organization has been in existence is one measure. Oxford House has been in existence over 30 years. As mentioned earlier, originally founded in 1975 with one house in Silver Spring, Maryland, it has grown to over 1,400 houses. Today over 10,000 people are living in the network of houses. Alternatively, researchers have found that responding to challenges is another barometer of organizational strength [28, 29]. Oxford House has overcome several challenges including community opposition to groups of unrelated individuals in recovery living together in a home [30, 31]. Several legal cases have found in favor of Oxford House. Additional struggles included starting up new houses, finding sources of funding, and effectively managing the network of houses throughout the USA. Oxford House has overcome each one of these challenges and today stands strong as one of the more successful recovery programs in the country. The visible leadership of key figures such as Paul Molloy and the unsung local champions has significantly contributed to the sustainability of Oxford House as a solution to successful recovery from alcohol and drugs.
While the previous sections in this chapter have dealt with larger, systemic issues such as economics and sustainability, the remainder of the chapter will highlight how individual factors can interact with the Oxford House model to promote recovery. First, a discussion of etiological issues involving gender roles and women’s specific issues will highlight how Oxford Houses have the potential to be empowering and effective despite many complicating societal pressures influencing substance abuse among women. Second, comorbid psychiatric conditions will be discussed in the context of how Oxford Houses can promote not only abstinence among this group, but also improved psychological functioning. While Oxford Houses are not necessarily for everyone, aspects of the model have potential to be an innovative environment for many oppressed groups that often have their specific issues neglected or unintegrated within traditional treatment settings.
Oxford House and Gender Roles
In one of our studies [32], we explored similarities and differences between women and men, particularly looking at their social support networks and their beliefs that they could remain abstinent from alcohol and drugs. For women, social support networks were directly related to their confidence in remaining abstinent, whereas for men, social support seemed to play a smaller role in determining these beliefs. Belyaev-Glantsman et al. [32] examined employment and sources of income for different genders and ethnic groups residing in our NIDA-funded national Oxford House sample. Men compared with women reported significantly higher mean income from employment as well as total income. African-Americans compared with European-Americans reported significantly more work in the past 30 days; however, the rate of pay between these two ethnic groups was not significantly different. Longer length of stay in Oxford House was related to higher incomes.
In another study [33], participants completed a survey regarding the resources they have gained or lost dealing with substance abuse. Some resources on the survey include the support of family and friends as well as skills to cope with recovery. Women tended to gain more resources then men in recovery; however, men lost less resources during stressful situations. Finally, individuals with more than 6 months in the Oxford House reported significantly less resource loss than those with less than 6 months in the Oxford House. The results of this study show that the Oxford House model may be beneficial to all residents, regardless of their ethnicity or gender.
With a national USA sample of Oxford House members [34], we investigated whether members help others inside and/or outside their community. Women compared with men reported providing more help to housemates over the past 6 months, were more likely to report that they helped others maintain their abstinence as a result of OH, and reported engaging in more reciprocal help related to abstinence in their houses. In contrast, men reported greater rates of helping strangers and acquaintances who did not live in OH than women.
Perhaps one of the most disheartening realizations is that, because women see such a need for the support a romantic relationship can provide they may willingly place themselves in situations where chances of relapse are high. These women may purposely trade an increased risk of relapse and their long-term physical health to create and maintain romantic relationships. Since the first author has been working within the Oxford House association for many years, and the other authors have worked side by side with many former substance abusers (both successful and unsuccessful in their recovery), many of us has had the chance to hear some of the stories linking romance and recovery. These stories caused us to think of two questions: “What can be done to help empower women in recovery? What can we learn from women that have been successful in their recovery?”
In order to try and answer these questions, we began talking with women in recovery that had lived in an Oxford House. When talking with these women, we found a similar storyline lurking beneath the tales of romance and addiction. Women talked about the power of romance, how the romantic relationship was their one source of social support, of comfort. Women also spoke of how their histories of drug abuse had made them “users” of everyone. The literature supports this type of mindset in the recovering substance abuser, and many studies explain that this atmosphere of manipulation places great burdens on available social supports and also causes the expectation that abusers have to watch themselves with everyone [35].
The women particularly talked of their romantic partners, of the roller coaster ride of patterns of drug use, abstinence, and eventual relapse. Many talked about past interpersonal violence and trauma, and the constant fear of victimization. Women talked of not respecting themselves, of not knowing how to respect themselves. This is where the story turns. For many, recovery involves both giving up the “right” to use others and reassuming responsibility for one’s actions thus, similar to what other researchers have reported [36], the women we spoke with spoke of how the Oxford House gave them the opportunity to form new kinds of relationships, to learn new skills, to reconceptualize their ideas of friendship and sex, and to build social supports outside of and independent of romantic relationships.
Because of these anecdotal stories of former Oxford House members, we believe that the Oxford House model may provide a supportive environment that is especially helpful for women in recovery. OH members may provide one another with both general and abstinence-specific social support that can replace the unhealthy support they might each receive from nonrecovery conducive family, friends, and romantic partners. At the same time, Oxford Houses may provide opportunities for the women in recovery to build communication and reasoning skills and establish strong trusting bonds with women that have been through the same experience that they currently have. Oxford House members may serve to modulate the behavior of each other, much as the “romantic female partner modulator” discussed before. The Oxford House model may also provide valuable social support independent of the romantic relationship, and hopefully, this social support will encourage women to be more likely to leave nonrecovery conducive, or abusive partners behind. In addition, we believe the experience of living in a supportive, democratically run environment that provides opportunities to build life skills (by serving in the different positions in the house and learning from other members), women will be able to see beyond the restrictions of strict gender roles and envision sober, self-fulfilled lives in which they hold the power and ability to navigate through.
Currently, we are attempting to address these research questions in a 5-year longitudinal study funded by the National Center on Minority Health and Health Disparities. This 5-year study follows women recently involved with the criminal justice system in substance abuse recovery for 2 years, and randomly assigns them to either the Oxford House or usual aftercare condition. We have added several measures to five time point interviews that investigate the interactions between romantic relationships, different sources of social support, and living environment. We hope to understand the complex relationship between romance and recovery, and possibly be able to identify the OH as an effective self-recovery living environment that may be especially beneficial to women in recovery.
Psychiatric Comorbidity
While recovery programs have often been considered male oriented due to the era that Alcoholics Anonymous originated in and societal norms that have placed disproportionate expectations on women compared to men, they have also often not been integrative for a number of other subgroups of the general population. An organization such as an Oxford House is unique in that, aside from the three basic rules mentioned previously in this chapter, Houses are able to operate with autonomy. Such an organic approach that exemplifies nonstandardization has the potential to look very different from House to House, Chapter to Chapter, and community to community. This flexibility allows each House to establish its own identity and to empower residents to make their own choices and adaptations that promote their individual recovery. One example of a subgroup in the population that may benefit from Oxford Houses is an individual who has comorbid psychological and substance abuse problems.
Psychiatric comorbidity is often reciprocal in nature; experts often disagree about the “chicken and the egg” concept when clearly, different etiologies and interactions between these two health problems are evident. Due to the fact that 33–60% of individuals with substance abuse issues also have a mood or anxiety disorder [37] and that those estimates of comorbidity are higher for other populations such as those with Schizophrenia, the question facing treatment providers is no longer “Which came first?” but “How do we address both problems to avoid these devastating health consequences?”. The unique aspect of Oxford Houses is that because they are organic and self-run (by individuals who are harsher critics on themselves than treatment providers are); they also are equipped to address the complexities that comorbid psychiatric conditions present to recovery. In fact, evidence from prior research and observations from our research team indicate that Oxford Houses function in ways that often prevent the very behaviors and expressions of affect that are commonly associated with relapse.
For example, many researchers have documented how substance abuse is frequently a response to negative emotions [38] (i.e., self medication). Within an Oxford House, individuals are not permitted to exhibit isolative behaviors such as staying in one’s room all day or locking the door, as the residents are well aware that these avoidant behaviors can lead to urges to self-medicate. Furthermore, while the national Oxford House organization does not require Houses to impose external treatment demands on a resident, many local Oxford House affiliates (such as the Illinois State Board for Oxford Houses) require ongoing attendance at AA or NA and encourage individuals to seek outpatient treatment for psychiatric issues. In fact, some Oxford Houses even have developed their own medication administration systems, where psychiatric medications are kept in a lock-box to ensure that they are taken appropriately and within prescription guidelines. Such engagement in the community and attentiveness to treatment adherence helps to deconstruct the behavioral issues associated with internalizing affective problems and develop new behaviors, much like a professional treatment provider would attempt to do in therapy or a treatment setting. The difference in effectiveness, however, lies in the fact that Oxford House residents impose these regulations on each other, who have had similar experiences and share a common bond.
Beyond issues such as depression and anxiety, researchers have often suggested that underlying temperamental features such as impulsivity and “deviant” personality characteristics may be the underlying catalyst for both substance abuse and impulse-control psychiatric disorders. The organizational structure within Oxford Houses as self-governed settings has the innovative potential to subdue opposition to rules and regulations due to the fact that residents are participants in making the rules. For example, while Oxford Houses often allow more personal freedoms among residents, they are also more likely to enforce harsh penalties for disruptive behavior [39]. Penalties might consist of fines or behavioral contracts that are agreed upon by a majority of members living within the House. Furthermore, many behavioral issues are discussed at business meetings and resolutions are agreed upon by the collective group and not an external authority figure [40]. Such contingencies employed among a group of individuals living together are comparable to those that a treatment provider would attempt to internalize within a patient, but are perhaps more effective due to the fact that there is no external authority involved.
Empirical research has demonstrated that Oxford Houses, and specifically living in an Oxford House for a longer period of time, can produce psychological benefits such as improvements in both internalizing affective [41] and behavioral symptoms [42]. Furthermore, although treatment gains still suggest that those with psychiatric comorbidity do not improve as much as those with only substance abuse problems [43], randomized and within-subjects designs with Oxford House residents have suggested that those with psychiatric disorders or problems have similar beneficial outcomes for substance use abstinence compared to those without psychiatric problems [44, 45]. Such findings renew the interest in how these differences occur and not just why they do.
Mutual help as a concept has received an increasing amount of attention in recent years. In fact, dual-focused (both 12-step oriented and focusing on psychiatric issues) self-help groups have emerged that have demonstrated interesting approaches to integrating substance abuse and mental illness care. These innovative concepts rely on social networks, innovative strategies, and the ability to think beyond addiction as the only underlying problem for individuals. Oxford Houses present a unique contingency operation that is organized such that the results are partly influenced by what each individual resident invests in the system – but ultimately is successful because of what each resident gets out of the system reciprocally.
Conclusions and Future Directions
Oxford Houses are unique residential living environments that came to be out of both need and because of the dearth of empowering treatment modalities available historically and currently. These environments are both economical and effective catalysts in promoting abstinence from drug and alcohol use across the country. Despite mixed results from traditional treatment programs, the Oxford House model presents an environment that is economical, practical, and capable of being flexible for specific groups of residents that have different needs. While self-help is somewhat empowering, the Oxford House movement reminds researchers and everyone else that self-reliance and community-building are the foundation to building stronger relationships.
For the next few years, we will continue our exploration of gender issues, leadership, and individual characteristics with support from the NIAAA, the NIDA, and the National Center on Minority Health and Health Disparities. Two of our studies explore how Oxford House settings can aid individuals with substance abuse after being released from jail and prison. In one of our studies, funded by NIDA, ex-offenders are being randomly assigned to either professionally led Therapeutic Communities, Oxford Houses, or usual care postrelease settings, and we are examining program effects (i.e., substance use, criminal and health outcomes), and economic factors associated with these models. The aims of this project are important from a public health perspective as there may be treatment matching, case management, and financing factors that could be manipulated to enhance the cost-effectiveness of community-based substance abuse treatment for offenders leaving prison. Knowledge of the various environments that directly and possibly additively contribute to long-term abstinence could guide public health and criminal justice resource allocation decisions.
In a study funded by the National Center on Minority Health and Health Disparities, which was described in an earlier section with women being released from jail into either an Oxford House or Usual Aftercare, we have established a Community Advisory Board that will link with a network of existing coalitions in Chicago. The Community Advisory Board will further affect community-based changes for formerly incarcerated women by integrating and supporting service networks from which women historically have been isolated. The community advisory board is involved in all aspects of this project leading to more efficient translation of the research findings into practice.
Finally, with funding from NIAAA, we are also in the process of evaluating culturally specific Oxford Houses for Spanish speaking substance abusers. Culturally modified Oxford Houses may be a more effective option for Hispanic/Latino individuals who are Spanish-dominant, less comfortable with USA culture, or identify more strongly with their ethnic culture. Culturally modified Oxford Houses may also provide a more culturally congruent experience such as welcoming visits by extended family members. In addition, residents of culturally modified Oxford Houses are more likely to use culturally congruent communication styles, characterized by an emphasis on relationships, downplaying direct conflict in relationships in order to preserve harmony, and respect. In the present study, we are compare the outcomes of Hispanic/Latino individuals assigned to a culturally modified Oxford Houses to those assigned to a Traditional Oxford House. Within these three current NIH funded studies, we will continue to collaborate with our Oxford House partners and continue to explore the many issues that have been reviewed in this chapter.
This Oxford House model appears to promote the development of long-term abstinence skills to prevent relapse. As residents of Oxford Houses are required to self-govern and assume positions of leadership within their Houses, according to established protocols that foster consistency across houses and create a supportive milieu. This democratic feature of Oxford Houses possibly helps create the abstinence-specific supportive environment. Findings from a series of studies has demonstrated that Oxford House living represents an inexpensive aftercare model that can empower men and women through increased employment and income, and decreased rates of relapse and criminal behaviors [12, 46]. These studies suggest that the Oxford Houses have the capacity to promote personal responsibility and help substance abusers remain abstinent and maintain employment.
Key Points
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Authors’ Notes
We appreciate the support of Paul Molloy and Leon Venable and the many Oxford House members who have collaborated with our team for the past 15 years, including also Bertel Williams, Kathy Sledge, Robin Miller, Bill Kmeck, Makeba Casey, Lester Fleming, Ron Blake, Stephanie Marez, Carolyn Ellis, LaRonda Stalling, Randy Ramirez, and Gilberto Padilla. In addition, our thanks to other colleagues and graduate students for helping us with the studies mentioned in this article including (in alphabetical order): Josefina Alvarez, Christopher Beasley, Peter Bishop, Blake Bowden, Carmen Curtis, Lucia D’Arlach, Meg Davis, Joseph Ferrari, David Groh, Annie Flynn, Gwen Grams, Ron Harvey, Elizabeth Horin, Bronwyn Hunter, Eve Kot, John Majer, Megan Murphy, Olya Rabin-Belyaev, Ed Stevens, Ed Taylor, and Judah Viola. The authors appreciate the financial support from the National Institute on Alcohol Abuse and Alcoholism (NIAAA grant numbers AA12218 and AA16973), the National Institute on Drug Abuse (NIDA grant numbers DA13231 and DA19935), and the National Center on Minority Health and Health Disparities (grant MD002748).
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