Addiction professionals are painfully aware that addiction treatment is all too often followed by relapse, re-addiction and readmission to treatment. Of those individuals currently entering addiction treatment in the United States, 52 percent already have one or more prior admissions to specialty-sector addiction treatment, and 20 percent have three or more prior admissions (for those with opiates as a primary dependency, the figures are 74 percent and 42 percent respectively; OAS, 2007).

Of those discharged from addiction treatment, more than half will resume alcohol and/or drug use in the following 12 months, and 50 percent will be readmitted to addiction treatment within two to five years (For an extensive review of this data, see White, 2008). When clients, family members, referral sources, funding authorities and members of the larger community ask for an explanation of this cycle, they are often told that this pattern marks the very essence of a chronic, relapsing disorder. “Relapse is part of the disease” is prominently featured in the new litany of addiction treatment.

But a growing number of addiction professionals and recovery advocates are asking whether relapse is an inherent quality of addiction or the product of a design flaw in how addiction is treated and managed, or more specifically, treated and not managed. It has been suggested that relapse rates might decline precipitously if individuals who initiate recovery within the context of addiction treatment were afforded access to sustained monitoring, recovery support services and a post-treatment environment that is supportive of recovery maintenance. 

For more than three decades, men and women seeking recovery have been involved in a living experiment that has tested this very proposition. This article will describe how Oxford Houses function as recovery support institutions, and review what scientific evaluations have concluded about the relapse and long-term recovery outcomes of Oxford House residents.

Oxford House history

Oxford Houses are self-run, self-supported recovery houses. Once voted in, residents can stay as long as necessary, as long as they do not drink or use drugs, pay their monthly share of expenses and expel any house member who uses drugs or alcohol.  Started in 1975 by a group of men whose stay in a county-run halfway house was abruptly ended when the county decided to close the house, there are now more than 1,300 Oxford Houses providing recovery housing. 

The first person voted into Oxford House was Jim Spellman. Like most of the other men in the first Oxford House, Jim attended a lot of recovery support meetings and was a popular speaker at open meetings. He would often tell a story — perhaps apocryphal — about Blue Cross-Blue Shield hiring one of the leading consulting firms to study the best solution for the alcoholism/drug addiction problem. He would describe all the surveys they conducted and the experts they consulted, and then he would announce the major finding of the study: “If you don’t drink alcohol, you won’t get drunk, and if you don’t use drugs, you won’t get high.” Everyone hearing Jim’s story would laugh, knowing the truth of the observation and the difficulty in achieving it. For Jim and tens of thousands of others who followed, the difficulty of becoming comfortable enough in sobriety to avoid relapse was overcome by living in an Oxford House. 

In 1988, Congress recognized that Oxford Houses worked and included a section based on the Oxford House model in the Anti-Drug Abuse Act of 1988 (Section 2036 — Group Homes for Recovering Substance Abusers, now codified in the United States Code as 42 USC 300x-25). That law, along with a minimal amount of technical assistance provided by trained outreach workers, served as a catalyst for the expansion of Oxford Houses throughout the country. The network of Oxford Houses has grown from a handful of houses in the Washington, D.C., area in 1988, to more than 1,300 houses with a collective daily capacity of 9,922 recovering people across 44 states. As of November 2008, 314 of the homes are for women, and 54 are designed specifically for women and children.

The Oxford Houses are residential single-family houses segregated by gender.  They are located in stable neighborhoods. In most cases, trained outreach workers employed by Oxford House, Inc. — the national nonprofit umbrella organization — help establish new houses and train the initial residents to use the time-tested system of disciplined democratic operation and self-support. These trained outreach workers also organize local clusters of houses into mutually supportive chapters and statewide associations. 

Growth of the network of Oxford Houses over the last decade shows that clusters of Oxford Houses can be replicated readily at minimal cost. Since all Oxford Houses are rented, there is no need for substantial capital investment. Experience has shown that mass expansion requires utilization of trained residents and alumni to effectively establish clusters of houses in new geographic areas. A single outreach worker can open between three to five houses per year.

The most effective model for developing local clusters or statewide networks of Oxford Houses includes the involvement of the state addiction treatment authority in providing funding to pay outreach workers and to administer the recovery home revolving loan fund established pursuant to the provisions of the federal Anti-Drug Abuse Act [42 USC 300x-25]. Most of the existing 1,300 Oxford Houses have received and repaid $4,000 in start-up loans. These loans enable a new Oxford House group to pay a landlord the first month’s rent and security deposit.  These loans are then repaid over 24 months at the rate of $170 a month. 

How Oxford Houses operate

The success of Oxford House is rooted in its simplicity and in the infrastructure that supports it. Oxford Houses provide a place for the recovering individual to heal and transform his or her life from one of destructive addiction to comfortable, productive, long-term sobriety. At the same time, Oxford Houses provide residents considerably more personal liberties (e.g., ability to bring belongings, personal choice of daily schedule, freedom to leave for weekends and “private time” with guests in their rooms) than would be found in therapeutic communities or traditional halfway houses (Ferrari, Jason, Davis et al., 2004). 

First, a group of recovering individuals must get a charter from Oxford House, Inc. to establish and operate an Oxford House. There is no charge for the charter.  Second, the house must be for either males or females — there are no co-ed houses. Third, the group home must have at least six beds. Fourth, the group must agree to the following three conditions:

1. The house must be democratically self-run.
2. The house must be financially self-supporting.
3. The group must immediately expel any resident who returns to using alcohol and/or drugs.

The umbrella organization, Oxford House, Inc., has sole authority to issue charters and initially issues a charter limited to six months. During that period of time, the group must take steps to show that it understands how to operate as an Oxford House by following the operational procedures in the Oxford House Manual© and submitting proof of performance to Oxford House World Services. The proof includes two letters of recommendation from active Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) members. Then it is given a permanent charter and has equal membership in the network of all Oxford Houses. Oxford House Inc. thanks the recommending AA/NA members and asks them to contact World Services if they ever believe that the house has failed to expel a resident who has relapsed. This is but one part of the quality control mechanisms the central Oxford House organization uses to keep houses on track.

The operation of each Oxford House is based upon a standard system of operation, including: weekly house business meetings; election of five officers; and prompt payment of all household bills. Each officer has specific duties within the house and each resident is limited to service of six months in any one office. The forms and procedures are the same for each house. Among other duties, houses post their vacancies on the national website: www.oxfordhouse.org.

Prospective Oxford House residents are selected for membership following completion of an application; participation in an interview with existing house members; and approval by 80 percent of the residents living in the house. In many ways, getting into an Oxford House is similar to getting accepted as a member of a country club or some other exclusive organization. What this process says to the accepted newcomer is that his or her peers want him or her as a member of their family. Being accepted into an Oxford House — in and of itself — is often the new member’s first success along the recovery path.

Once accepted as a member of an Oxford House, the recovering individual has an equal voice in the running of the house, including a vote at the regular weekly business meetings. In these meetings, which are run by disciplined parliamentary procedures, everyone in the house reviews the financial status of the house; discusses and votes on key issues facing the house; and participates in solving problems of daily living that arise within the house. The predictability of everyday events in the house adds to the newcomer’s transition from the turbulence of addiction to the stability of sobriety. The recovery process within the Oxford Houses has been aptly conceptualized as a transition from destructive drug dependencies to a positive dependence on recovering peers (Nealon-Woods, Ferrari & Jason, 1995).   

Nationally, the average number of residents per house is 8.2. The best size house provides room for 8 to12 residents, with most bedrooms accommodating two individuals to help them avoid the isolation that can lead to relapse. Residents pay an average equal share of household expenses (rent to the landlord, loan repayment, utilities and house staples) of about $95 a week (range from $75 per week to $150 per week).  Residents can live in an Oxford House for as long as they stay clean and sober and pay their equal share of expenses. There are no limits on length of residence in an Oxford House. While the average length of stay is about one year, some residents live in an Oxford House for many years. This open-ended residency is possible because when demand exceeds the supply of beds, the group simply rents another house to establish another Oxford House.

Oxford House evaluation studies

When they started the first house, the original group of residents had to prove that ‘the inmates could run the asylum.’ A full-time staff of three ran the traditional halfway house in which they had lived. The remaining houses not closed by the county also relied on a full-time staff who proclaimed that the Oxford House would soon become nothing but a flophouse for drunks and drug addicts. This voicing of doubt by “the Establishment” spurred the new Oxford House residents into a “We’ll show you” attitude. As part of that attitude, the very first Oxford House invited observation by others, made its address public, and kept all records public with regard to its successes and failures. Evaluation was infused within the very bones of the Oxford House culture.

When Bill Spillaine, PhD, started teaching at Catholic University, after retiring  from NIDA, he asked to review the outcome records of individuals who had lived in an Oxford House from its beginning, in 1975, through 1987. Everyone living in all 13 Oxford Houses at that time agreed to cooperate with him. Dr. Spillaine tracked down more than 1,200 former Oxford House residents to learn how many had stayed clean and sober. When he came to the leaders of Oxford House and reported that 80 percent had stayed clean and sober without relapse, the leaders asked, “What are we doing wrong to have 20 percent of our residents relapse?” Dr. Spillaine explained that the normal rate of sobriety without relapse was less than 20 percent and that the Oxford House resident outcome was exceptionally good.

Beginning in 1990, Oxford House residents entered into a sustained collaboration with DePaul University psychologists to evaluate all aspects of the Oxford House network. Since then, Leonard Jason and his colleagues have conducted dozens of studies that tracked residents and alumni and compared outcomes of Oxford House residents and control groups of recovering individuals not living in Oxford Houses. (Many of the DePaul Studies are available at www.oxfordhouse.org.) For the most part, Spillaine’s early findings have held up, showing that sobriety without relapse is the norm for Oxford House residents.

More detailed findings from the studies conducted by Dr. Jason Leonard and his colleagues at DePaul University’s Center for Community Research include the following (excerpted from White, in press): 

• Oxford House residents present a profile of gender and ethnic diversity, high alcohol and drug problem severity and rates of co-occurring psychiatric disorders comparable to addiction treatment populations (Alvarez, Adebanjo, Davidson, et al, 2006; Ferrari, Curtin-Davis, Dvorchak, & Jason, 1997; Jason, Davis, & Ferrari, 2007; Jason, Davis, Ferrari, & Bishop, 2001).
• AA is the dominant framework of recovery for Oxford House residents (76 percent), but other pathways of recovery are respected (e.g., 17 percent report individual psychotherapy as their primary recovery support medium; Nealon-Woods, Ferrari, & Jason, 1995). 
• At two-year follow-up, residents who stayed in Oxford House for a minimum of six months following residential addiction treatment have superior recovery outcomes compared to those placed in traditional aftercare (15.6 percent rate of reported substance use compared to 64.8 percent).  Oxford House residents also achieve higher rates of employment, higher incomes and a lower rate of arrest than do those in traditional aftercare (Jason, Olson, Ferrari et al., 2007; Jason, Olson, Ferrari, & Lo Sasso, 2006).
• The prospects of long-term recovery rise with length of stay in an Oxford House (Jason, Davis, &
Ferrari, 2007).  
• At extended follow-up, 69 percent of residents remain in residence or have left the house as planned in good standing (Majer, Jason, Ferrari, & North, 2002).
• Oxford Houses for women that accommodate children have a positive effect on both the mothers and on other women in the house (d’Arlach et al., 2006).
• The communal environment of the Oxford House has been found to be particularly congruent to African American men and women and members of other groups whose historical experience has created a distrust of authority figures (d’Arlach et al., 2006; Ferrari, Curtin-Davis, Dvorchak, & Jason, 1997).
• Community attitudes toward Oxford House are most positive among neighbors who live closest to the Oxford House (Jason, Roberts, & Olson, 2005).
Subsequent studies of Oxford House confirm the primary finding of the first study: the vast majority of Oxford House residents stay clean and sober without relapse. 

A closing reflection

Congress has just mandated that health insurance companies must cover mental illness and substance abuse with the same standards they use to pay for other illnesses (The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (PL 107- 1434)). Passage of this legislation is, in some ways, a step “back to the future” since many health insurance companies in the 1970s and early 1980s covered addiction treatment as they covered payment for other illnesses. Such reimbursement was restricted or eliminated in the late 1980s and early 1990s because of treatment industry excesses (e.g., inappropriate admissions, excessive lengths of stay) and growing alarm about patterns of chronic relapse and treatment recycling. It is important in the face of this new legislation that the treatment field avoids replication of this earlier history. The use of Oxford Houses and other non-clinical, peer-based recovery support services can enhance the likelihood of recovery without relapse and can help prevent the future loss of the parity that has just been legislatively restored. 

The website www.oxfordhouse.org contains material showing where Oxford Houses are located; studies showing how local development can take place; research reports verifying best practice for assuring recovery without relapse; and a real-time inventory of vacancies in existing houses. Visit this site to explore how this growing network of Oxford Houses may be of use to your clients who could benefit from such rich recovery support.

J. Paul Molloy was the founder of the first Oxford House and currently serves as CEO of Oxford House, Inc. 

William White, MA is a Senior Research Consultant at Chestnut Health Systems and author of Slaying the Dragon:  The History of Addiction Treatment and Recovery in America.   

References and Recommended Reading

Alvarez, J., Adebanjo, A.M., Davidson, M.K., Jason, L.A., & Davis, M.I. (2006). Oxford House: Deaf-affirmative support for substance abuse recovery. American Annals of the Deaf, 151(4), 418-421.

d’Arlach, L., Olson, B.D., Jason, L.A., & Ferrari, J.R. (2006).  Children, women, and substance abuse: A look at recovery in a communal setting. Journal of Prevention & Intervention in the Community, 31(1/2), 121-131.
Ferrari, J.R., Curtin-Davis, M., Dvorchak, P., & Jason, L. (1997). Recovering from alcoholism in communal living settings: Exploring the characteristics of African American men and women. Journal of Substance Abuse, 9, 77-87.
Ferrari, J.R., Jason, L.A., Davis, M.I, Olson, B.D., & Alvarez, J. (2004). Similarities and differences in governance among residents in drug and/or alcohol misuse: Self vs. staff rules and regulations. Therapeutic Communities: The International Journal for Therapeutic and Supportive Organizations, 25(3), 179-192.
Jason, L., Davis, M., & Ferrari, J. (2007). The need for substance abuse aftercare: Longitudinal analysis of Oxford House. Addictive Behaviors, 32, 803-818.
Jason, L.A., Davis, M.I., Ferrari, J.R., & Bishop, P. D. (2001). Oxford House: A review of research and implications for substance abuse recovery and community research.  Journal of Drug Education, 31(1), 1-27.
Jason, L. A., Olson, B. D., Ferrari, J. R., & Lo Sasso, A. T. (2006). Communal housing settings enhance substance abuse recovery. American Journal of Public Health, 96, 1727-1729.
Jason, L.A., Olson, B.D., Ferrari, J.R., Majer, J.M., Alvarez, J., & Stout, J. (2007). An examination of main and interactive effects of substance abuse recovery housing on multiple indicators of adjustment. Addiction, 102, 1114-1121.
Jason, L.A., Olson, B.D., & Foli, K. (2008). Rescued lives:  The Oxford House approach to substance abuse. New York:  Routledge.
Jason, L.A., Roberts, K., & Olson, B.D. (2005). Attitudes towards recovery homes and residents: Does proximity make a difference? Journal of Community Psychology, 33(5), 529-535.
Majer, J., Jason, L. Ferrari, F.R., & North, C. (2002). Co-morbidity among Oxford House residents: A preliminary outcome study. Addictive Behaviors, 27, 837-845.
Nealon-Woods, M.A., Ferrari, J.R., & Jason, L.A. (1995).  Twelve-step program use among Oxford House residents:  Spirituality or social support in sobriety? Journal of Substance Abuse, 7, 311-318.
Oxford House. (2006). Oxford House Comes of Age:  Oxford House — The Model. Presented at the 8th Oxford House World Convention, Wichita, KS, September 21-24, 2006.
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2007). Treatment Episode Data Set (TEDS) Highlights — 2006 National Admissions to Substance Abuse Treatment Services. OAS Series #S-40, DHHS Publication No. (SMA) 08-4313, Rockville, MD.
White, W. (2008). Recovery management and recovery-oriented systems of care: Scientific rationale and promising practices. Pittsburgh, PA: Northeast Addiction Technology Transfer Center, Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health & Mental Retardation Services.  Available for download at http://www.ireta.org/
White, W. (in press). Peer-based Addiction Recovery Support: History, Foundational Principles, Core Characteristics and Scientific Evaluation. Philadelphia, PA: Philadelphia Department of Behavioral Health & Mental Retardation Services, Great Lakes Addiction Technology Transfer Center, and Northeast Addiction Technology Transfer Center.

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