Understanding challenges for recovery homes during COVID-19.

Understanding the effects of COVID-19 mitigation for persons in group living environments is of critical importance to limiting the spread of the virus. In the U.S., residential recovery homes for persons with alcohol and drug disorders are good examples of high-risk environments where virus mitigation procedures are essential. The National Alliance for Recovery Residences (NARR) has taken recommendations developed by the Center for Disease Control (CDC) and applied them to recovery home settings. This paper describes how COVID-19 mitigation efforts in recovery homes may be influenced by two factors. First, while some houses are licensed by states with rigorous health and safety standards, others are not licensed and are subject to less oversight. These homes may be more inconsistent in adhering to mitigation standards. Second, to varying degrees, recovery homes use a social model approach to recovery that contrasts with mitigation procedures such as social distancing and stay-at-home orders. This paper provides examples of ways recovery homes have been forced to adjust to the competing demands of mitigation efforts and social model recovery. The paper also identifies multiple questions that could be addressed by provider-researcher coalitions to inform how social model recovery can navigate forward during the era of COVID-19. As we move forward during the era of COVID-19, providers are encouraged to remember that recovery homes have a history of resilience facing adversity and in fact have their origins in grassroots responses to the challenges of their times.

With the rapid onset and severe consequences associated with COVID-19 in the U.S., recovery homes for persons with alcohol and drug problems have needed to make modifications. These homes provide supportive, alcohol- and drug-free living environments using a social model approach to recovery (Borkman, Kaskutas, & Barrows, 1999) that emphasizes peer support and involvement in 12-step recovery programs. Many recovery homes, such as sober living houses (SLHs) in the U.S. state of California and Oxford houses, are entirely peer-operated by persons in recovery from substance use disorders (Wittman & Polcin, 2014). SLHs and Oxford houses do not offer on-site professional services. When residents need professional substance abuse, mental health, or other services, they are encouraged to access them in the local community while they reside in the recovery home. The social model approach used in these homes emphasizes interaction among residents in a shared living space and mutually beneficial relations between recovery homes and the surrounding community (Polcin, Henderson, Trocki, Evans, & Wittman, 2012). Although peer-based recovery homes are most prominent in North America, many aspects of the social model approach are used in conjunction with professional-based residential treatment programs (Polcin, 2015), which are more prevalent in other countries as well as in North America.

Since the onset of COVID-19, recovery homes have been forced to adjust to competing demands. On one hand, there are essential virus mitigation standards that demand attention, such as adhering to social distancing and stay-at-home orders. On the other hand, homes are trying to maintain a social model recovery environment that prioritizes peer interaction, peer support and participation in 12-step recovery groups. For the time being, health and safety considerations have required recovery homes to move forward with virus mitigation procedures without evidence-based recommendations about the best way to concurrently maintain a strong social model environment.

The obvious hope is for a decline in the incidence of new cases nationwide, a lessening of the most stringent mitigation restrictions, and a return to a more functional economy, all of which would allow recovery homes to move toward more normal operations. However, even then, the same questions will remain to some degree because most health scientists predict there will be future waves of COVID-19 (Hiscott et al., 2020). Even when a vaccine is found, scientists are cautioning that we are vulnerable to the spread of new epidemics, which they consider highly likely (Oldstone, 2020). This suggests there may need to be long-term strategies for modifying of how recovery homes operate.

The purpose of this paper is fourfold. First, we briefly review mitigation standards put forward by the National Alliance of Recovery Residences (NARR, 2020) for recovery homes, which are to a large extent based on broader recommendations from the Center for Disease Control (CDC, 2020). Second, we describe ways that the standards present challenges to the practice of social model recovery in recovery homes. Next, we identify critically important questions needing to be studied by researchers. We suggest that integrating house manager and resident input into understanding these questions will be essential. Finally, we suggest it is important to remember that peer operated recovery homes have a history of resilience and innovation in the face of adversity, particularly in the circumstances surrounding their inception. Currently, we have an advantage in that we can draw upon existing provider-researcher coalitions to inform efforts to create new ways of operating in the era of COVID-19 and better prepare us for future epidemics. As describe in previous papers (Polcin, 2015; Polcin, Mericle, Callahan, Harvey, & Jason, 2016), studies to date have involved residents and house managers in research studies in a number of ways: identifying issues impacting recovery, provide input into developing research questions, and strategizing ways to implement study procedures. In addition, our previous projects used researcher-provider coalitions to jointly present findings to consumer and researcher forums and to co-author publications targeting various stakeholder groups (Polcin, Mericle, Howell, Sheridan, & Christensen, 2014).

Virus Mitigation in Recovery Homes

In terms of mitigating the spread of COVID-19 in recovery homes, Mericle et al (2020) pointed out that the National Alliance of Recovery Residences (NARR, 2020) has taken a leading role in providing recommendations for the health and safety. Virus mitigation standards are particularly important for homes that operate outside the scope of state licensing, such as peer operated SLHs in California. Because these houses are not licensed, they are under less scrutiny in terms of compliance with oversight regulations. This can make them vulnerable to overlooking important mitigation procedures. NARR recommendations include implementing enhanced hygiene procedures that are consistent with those proposed by the CDC and many state departments of public health. Recommendations include suggestions for hand washing, avoiding touching one's face, sanitizing surfaces, not sharing dishes, and social distancing. In addition, NARR cautions against allowing visitors and admitting new residents who show signs of illness. When current residents become ill, the recommendation is to contact their health care provider and isolate the person from other residents.

Mericle et al (2020) described how many states (e.g., California) have stay at home orders that are limiting social interaction outside the houses. To deter isolation, NARR (2020) encourages residents to use electronic forms of communications, such as e-mail, texts, Facetime, and Zoom. Most 12-step meetings are currently only available electronically. The stay at home order also has the effect of limiting commercial activities to only involve essential workers. As a result, an increasing number of residents are having difficulty paying rent and other fees that are required to live in the homes. There is therefore an urgent need for temporary financial support from the federal government to support the continuing feasibility of recovery homes. Payments could be disbursed directly to residents or to house managers who reduce costs for residents in their homes who qualify. The potential benefits of such an investment are obvious considering the roles recovery homes play in providing housing to many persons who otherwise would be in even higher risk environments, such as homeless or residing in criminal justice institutions (Korcha & Polcin, 2012; Polcin & Korcha, 2017). In the meantime, NARR (2020) encourages recovery homes to guide residents to financial resources such as unemployment benefits and other potential sources of financial relief.

Social Model Recovery and COVID-19 Mitigation

The Mericle et al (2020) paper presents essential context for the current paper by clarifying the importance of maintaining recovery housing for persons who are vulnerable to homelessness as well as COVID, identifying NARR as a resource for houses, and identifying some of the essential mitigations procedures needed in recovery house settings. The analysis that follows in the current paper focuses on ways that mitigation standards can conflict with social model recovery principles, which house managers emphasize as critical to recovery Polcin, Mahoney, & Mericle, 2020). We identify some responses that current SLH managers are implementing to address conflicting demands and identify research questions that can provide data to inform how recovery housing moves forward.

While implementation of virus mitigation procedures is essential for the health and safety of residents, they also present challenges for recovery homes, particularly those that are peer operated. Some of the fundamental characteristics of social model recovery used in these settings that make them effective for recovery also make them high risk for transmission of the virus. For example, to counteract isolation, enhance peer support, and decrease the risk of relapse, bedrooms are often shared. Some houses have bedrooms that accommodate three or more persons. To enhance a sense of community, some SLHs have residents cook together and share meals. Most houses require attendance at house meetings where a variety of household issues are discussed.

All of these interactions within a shared living space, while supportive of resident cohesion, also have the potential to fuel transmission of the virus.

Additional COVID-19 related challenges to recovery homes include ways that morale might be affected. Residents may have differences in views of risky behaviors and what steps they are willing to take to mitigate risk. For example, mitigation guidelines suggest increased cleaning activities, but some residents may feel resentful of the increased burden, especially if they struggled with completing house chores prior to COVID-19. There could be resentments that some residents may not be able to work while others may work from home. Some jobs may require interaction with the public, which puts those working in such positions at higher risk, but it also may increase risks for other residents. Different levels of risk tolerance among house residents may mean some may not be willing to take any additional steps to protect themselves and others.

The stress of COVID-19 may also lead to an increase in psychological symptoms for persons who are ill, those who have friends and family who are ill, and those who are at high risk. All of these can make group living situations more difficult (Pfefferbaum & North, 2020). Stress can take away from the building of relationships within the house, thus hurting the dynamic factors of the house that are integral to the social model. While some people may have previously relied on activities outside of the house as stress relievers, they may not have access to these coping mechanisms.

Despite these inherent challenges, house responses to COVID-19 could also strengthen some aspects of the social model. Working together to take risk mitigation steps and spending more time together in the house may lead to a stronger bond among residents. Some SLHs have started holding their own 12-step meetings in the residence because in-person meetings in the community have become rare. Thus, residents in recovery may come to rely more on residents for support in their recovery since their in-person interactions with others in recovery may be limited.

In addition to person to person interactions, social model recovery emphasizes mutually beneficial interactions between programs and the surrounding community. For example, groups of residents often attend 12-step meetings in the community, 12-step related social events, and a variety of recreational activities. Through these and a host of other activities residents derive benefit. Many houses make efforts to reciprocate by contributing to the surrounding community. For example, one group of houses in northern California encourages residents to volunteer to help with community events, such as seasonal festivals, parades, and other celebrations (Polcin et al., 2012). During major holidays, such as Thanksgiving, they open their doors and invite neighbors over to share a meal. In addition, they invite the surrounding community to attend on-site 12-step meetings and social activities organized by the house.

All of these activities contribute to maintenance of a culture of recovery within recovery houses as well as mutually beneficial relationships with the surrounding community. Yet, in the era of COVID-19 they present risks in terms of disease transmission. SLHs and other types of recovery homes are therefore faced with the dilemma of how to adapt to COVID-19 mitigation measures and yet maintain the types of interactions required of the social model approach to recovery within the household and in relation to the surrounding community.

Table 1 indicates some examples of the ways recovery homes have begun to respond to specific challenges presented by COVID-19. The list is not meant to be comprehensive and we encourage researcher-provider coalitions to actively develop additional strategies and develop research studies that assess their efficacy.

Table 1

COVID-19 Mitigation Challenges and Examples of Current Recovery Home Responses.

COVID-19 Mitigation Challenge	Examples of Recovery Home Responses
Enhanced Cleaning	House meetings: discuss as a way to give back/support the household.
Enhanced Personal Hygiene	House meetings: discuss hand washing, not sharing dishes/utensils, use of hand sanitizer.
Social Distancing/ Isolation	Electronic communications. Limit number of persons in bedrooms. House meetings: distance when possible.
Mutual Help Groups	Attendance at on-line meetings. Additional in-house closed meetings for house residents only.
Visitors	Prohibit or limit visitors. Increased monitoring of visitors.
Admission of New Residents	Limit or cease new admissions. Refer applicants who are ill to other services.
Managing Residents with COVID	Isolate from other residents. Assist Access to Healthcare
Loss of Employment	Assist residents with access to unemployment and other benefits. Support efforts of associations (e.g., NARR) to access funding assistance for recovery homes.
RECOVERY HOMES DURING COVID-19
Psychological Stress	House meetings: discuss stress reduction strategies. Maintain connections with mental health resources. With increased time at home, encourage use of peer support and increased bonding.

Note: Examples of recovery home responses are not meant to be comprehensive and required research to assess their efficacy. For additional recommendations see: https://drive.google.com/file/d/1E4uLjz1hRX0I1y2-8S-dD3rt5LIgtywc/view.

Outcome Studies

Studies conducted on peer operated recovery homes demonstrate their value in terms of recovery outcomes and protection of vulnerable populations, such as those with histories of homelessness and criminal justice incarceration. For example, researchers at the Public Health Institute in California studied populations of persons entering SLHs and showed residents in these homes make significant, sustained improvements in multiple areas of functioning, including reduced alcohol and drug use, psychiatric symptoms, arrests, homelessness, and unemployment Polcin & Korcha, 2017; Polcin, Korcha, Bond, & Galloway, 2010; Polcin, Korcha, Bond, & Galloway, 2010). Researchers at DePaul University studied subgroups of persons residing in Oxford Houses and found favorable results for persons who entered residences after leaving incarceration (Jason, Salina, & Ram, 2016) and graduating from a therapeutic community program (Jason, Olson, Ferrari, & Lo Sasso, 2006).

Questions for Research: Compliance with Standards

As recovery home house managers move forward in the era of COVID-19, there are numerous new questions that need to be investigated. Critical to health and safety, is the question of the extent to which these homes are implementing virus mitigation standards consistent with those put forward by NARR (2020). We need to know which standards are and are not being implemented. Studies could help identify areas of vulnerability to disease transmission. Additionally, there are questions about how mitigation procedures are experienced by residents and managers. For example, there are increased demands for improved hygiene in the household as a result of COVID-19. While these can be experienced as an increased burden, skillful development of a social model environment in the house can help these activities be experienced as important contributions to the community. The idea of “giving back” to others is central to 12-step recovery and it would be interesting to know to what extent providers and residents experience additional tasks related to COVID-19, such as increased cleaning, as a way of giving back to their households.

Questions for Research: Maintaining Social Model

Social distancing is a fundamental mitigation procedure that is universally recommended. Yet, many recovery residences encourage interpersonal contact (e.g., hugs, high five's, etc.) as an integral part of peer support. We need to understand the extent to which residents are able to practice social distancing in their homes as well as how interactions are experienced differently from larger distances. As a way to avoid social isolation, NARR recommendations include suggestions for using electronic communication. To what extent does electronic communication work in terms of obtaining the support from friends, family and recovering peers that is necessary for recovery? Most 12-step groups are now conducted remotely. When residents attend these meetings, are they as effective as in-person meetings? One initial investigation suggested electronic meetings may not be experienced as effective as in person meetings (Barrett & Murphy, 2020). Researcher-provider collaborative projects are needed to investigate if there are there ways to make electronic meetings more effective.

Most recovery homes have regular house meetings attended by all residents. These forums provide opportunities to discuss a variety of issues, including issues such as chores, house rules, and social outings. Some houses also use house meetings to celebrate successes (e.g., sobriety anniversaries and employment) and address conflicts. If house meetings are discontinued or substantially altered in response to the social distancing recommendations of COVID-19, how does that affect the social environment in the household and daily operations? In addition, house meetings represent an excellent forum to emphasize the importance of both mitigation procedures and maintenance of a social model approach to recovery. It would be informative to assess the extent to which these discussions occur and the extent to which residents view them as helpful.

A basic tenet in most recovery homes is to keep active and avoid long periods of idle time. This is particularly important in peer operated homes, which do not provide on-site services or a daily schedule of activities. Most peer operated homes therefore require residents to engage in some type of daily activity, such as work, school, job training, volunteer work etc. If large proportions of residents remain in the house most of the day to comply with shelter in place orders, how does that affect the social environment and the quality of interpersonal relationships? Does boredom lead to increased relapse? Do interpersonal conflicts lead to lower retention? Is it possible for residents to have too much time together, particularly when that is not balanced with support received outside the house? In some houses, groups of residents regularly attend social outings or 12-step meetings together. When these activities are not possible, how does that effect the sense of cohesion among residents?

Questions for Research: Financial Stability

A final issue with immediate relevance for the survival of many houses, especially those that serve vulnerable, low income residents, is financial feasibility Mericle et al (2020). Although NARR and its state affiliations are monitoring potential sources of financial support, these may change over time in response to changes in national and state policies Mericle et al (2020). Research can play an important role by summarizing how houses are responding to financial challenges and identifying resources that are experienced as helpful. Longer term research endeavors could use quantitative methods to assess the effects of government fiscal policies on the sustainability of recovery homes. Part of these endeavors could include studies assessing mechanisms of support, such as whether disbursements should be submitted directly to residents or to house managers.

Conclusions and Considerations for Moving Forward

For recovery homes to survive and maintain their essential characteristics, significant innovation may be required. However, it should be noted that peer operated recovery homes have a long history of adapting to adverse circumstances and their origins are rooted in responses to adversity. In the late 1940’s Alcoholics Anonymous (AA) was rapidly expanding throughout the U.S. However, in Los Angeles, significant numbers of AA members lacked affordable housing that supported abstinence. In response, longtime members of AA members rented out low cost rooms and eventually entire houses to these individuals. These “twelve-step houses” eventually became known as sober living houses (Wittman & Polcin, 2014). There are now more than 800 of these homes in California that are members of recovery home associations (e.g., Sober Living Network and California Coalition of Addiction Programs and Professionals) (Wittman & Polcin, 2014). Some estimates suggest there are an equal number of SLHs in California that are not associated with recovery housing organizations and many similar types or residences in other states.

The history of Oxford Houses is similar in that they originated in response to adversity (Jason, Olson, & Foli, 2008). In 1975 a half-way house in Maryland was defunded, leaving the occupants with no place to live. In response, they took over house operations themselves. Other groups of persons with alcohol and drug disorders followed suit and these homes eventually became known as Oxford Houses. Today they number over 2,500 homes.

The circumstances around the inception of peer-oriented recovery homes reveal resilience and innovation. Recognizing that solutions emerged from grassroots movements of recovering persons affected by the challenges of their times should inform our current approach to COVID-19. Additionally, we now have provider-researcher coalitions capable of identifying and investigating the most effective strategies through systematic research. An important first step would be to conduct descriptive studies to depict what house managers are currently doing in response to COVID-19, both in terms of how consistently they are implementing mitigation procedures and the effects of those changes on the houses. Longer term studies could show how specific modifications are associated with transmission of the virus and recovery outcomes.

There is currently no roadmap for the best way for recovery homes to proceed as they face COVID-19. However, the way forward can draw inspiration by recognizing the history of resilience and innovation evident in recovery home communities. In addition, emerging tools, such as provider-researcher coalitions, can help make the next steps forward better informed and potentially help identify new opportunities as well.

Declarations of Interest

There are no conflicts of interest to report. The study was approved by the Public Health Institute IRB.