Angie Fiedler Sutton
Welcome to Destination Change the podcast where we talk recovery treatment and more. I'm your host, Angie Fiedler Sutton, with the National Behavioral Health Association of Providers.

Today's guest is Dave Sheridan. Dave Sheridan is the Executive Director of the National Alliance for Recovery Residences, otherwise known as NARR. He is a national speaker and writer with a primary focus on the development and operation of statewide recovery housing. He is also an advocate and resource on fair housing issues.

His professional background is in institutional investments and he currently advises midsize companies on matters including asset management, capital structure, business combinations, new venture financing, and business planning. His behavioral health industry experience includes CFO and COO positions with a prominent Southern California provider. Dave also serves on the board of the Chandler Lodge foundation in North Hollywood, California. And he's also on the advisory team of the National Behavioral Health Association of Providers. Welcome to the podcast, Dave.

Dave Sheridan
Well, thank you very much, Angie. And it's a pleasure to be here. And I need to say up front, I've enjoyed my association with NBHAP.

Angie Fiedler Sutton
Great. Well let's first let's dive into to NARR to begin with and kind of just your history with NARR, how you got involved with them. What about the organization draws you, that kind of thing. So why? Tell me a little bit about the history of NARR. What's the elevator pitch?

Dave Sheridan
Yeah, the elevator pitch is NARR was formed to bring standards and professionalism to a field that had very little of it, which is recovery housing. I got involved in recovery housing generally about 18 years ago. And the most important motivator is that I'm a person in long term recovery myself. And as part of my recovery journey, I had spent some time in a recovery house, got on with my life career, didn't think much of it better or worse at the time.

But through some associations in my own recovery, I got to know some people that were running this little southern California organization that was designed to help operators learn about best practices and agree to operate according to some standards. It was kind of unique. And they needed some people to help them on the board of directors side of things, I agreed to join the board. And I pretty soon realized that recovery houses are the probably the hardest service to deliver in the recovery field that nobody cared about. There was no regulation, there were no national organizations, there was no real network of professionals. And so a few of us got together over the next couple of years. And through a suggestion of a gentleman who at the time was the head of the Center for Substance Abuse Treatment in Washington, we decided to make a go of a national organization that would pull together all of the best practices about how to operate various types of recovery homes, and codify them. And then to develop a best practice standard.

We did that we released the first standard and 2011 and the modeling adopted to introduce this and to see that it could be implemented was rather than NARR being the accrediting body for individual homes and providers, we work with a network of state level organizations, some of which we helped found and some of which pre existed NARR. And that has worked really well. So when we started in 2010, formed our first board in 2011, there was no state that recognized any particular best practice standards or granted any preferential benefits or funding to recovery homes except for Oxford Houses, which is a well known well regarded system that's been around for about 40 years.

We address the need for standards and accreditation for a broader spectrum of recovery housing types. So we went from zero states with recognition or acceptance of standards to now we have affiliates in 30 states. About a dozen of those are directly supporting our state affiliates, and there are benefits to homes that will get certified and the certification process is done at the state level. So it's been a long strange trip, Angie, I know that was a long answer you Question, but no, that's fine.

Angie Fiedler Sutton
So you've been with them since the beginning. And it's all about the recovery. I guess it's an industry. Would you consider it one?

Dave Sheridan
it is in the sense that it's a discrete set of services. Some of the providers also do other things, addiction treatment, mental health. But it's a field at least we always call it a field when you don't really know how to how to slot it. But yes, and so it's it is developing into an industry of sorts, in that providers are getting to know each other. There's a mutual understanding about best practices, which didn't exist before.

Angie Fiedler Sutton
Well, for those of our listeners who may only have a vague idea, kind of give me the standard definition. I know, that's probably not really a standard definition. But what is a recovery house? And how is it different from other types of treatment?

Dave Sheridan
That no, you know, that's a really important question. And it's one that a lot of state local governments wrestle with. So at it's heart, a recovery house has five characteristics.

One is its housing as opposed to a care facility. So it's where people live instead of where they go to receive treatment, for example. So they get their mail there, they can register to vote there, they live there. The second thing is, it's an abstinence based community, which means that regardless of what medications you might be taking which are prescribed by your doctor, that's considered abstinence. But you are otherwise abstinent from alcohol and other mind altering substances not taken by prescription. The third thing is it's shared housing. So unlike a lot of the permanent supportive housing that's out there, it ... the residents lived together as a family like household or community. So not a boarding house, not a, you know, any other kind of housing. And the other important thing is that it's based on the social model of recovery, which means residents and staff tries lived experience rather than professional credentials, they're basically helping each other learn how to live without drugs and alcohol in early recovery.

So those are the basics that follow through all of the levels of recovery residences that we've defied. Regardless of what other services are provided, those things are all present.

Angie Fiedler Sutton
Perfect sense. One of the things that Destination Change covers is the journey of recovery. And you said you had your own history of going through the treatment journey. What does it mean for you to go through treatment and recovery? And how is that connected to the recovery housing situation?

Dave Sheridan
That varies widely across individuals. Mine might be typical of a lot of people. I did residential treatment for four weeks. And then on the recommendation of my counselor in that program, I stayed for about three, four months in a recovery house, and then got on with my life.

The reality is that people come into recovery, housing a lot of different ways. So some like myself, it's after an acute or subacute treatment experience. And for others, they may be coming directly from incarceration, or homelessness, some kind of a stabilization program, or that they've been living in the community for some years, possibly having received treatment in the past or living in recovery house in the past. And for one reason or another, they want to be in that environment to support their recovery, which may have been faltering. Or they might have returned to drug or alcohol use, and they want to get back into recovery.

So lots of different ways people come in, there's also a wide variety in the length of time people will live in recovery residence. Higher levels of services, people tend to stay shorter periods of time. But in the lower level of service residences, people can stay one two years, and longer in the case of some. So it's, you know, there's no maximum length of stay in the places where there's no services delivered. And so the environments are there to meet people where they are in their recovery journey. Usually it's fairly early.

Angie Fiedler Sutton
Can you give me an example of what a high level one is versus a low level?

Dave Sheridan
Sure, a very high level what we call an NARR level four would combine that recovery environment with a mix of life skills and clinical treatment services. In a lot of states, those are also licensed as addiction treatment facilities. So they crossed the boundary into clinical services. But that would be something where someone will expect to be in contact with services in the house or associated with the house pretty much all day Monday through Friday and stepped down during the week. So it really is it has the notion of a program as well as that recovery environment.

Angie Fiedler Sutton
What are some of the barriers that you see for people to move forward on that recovery journey?

Dave Sheridan
Wow, there are a lot depending on the person, but the biggest ones. Number one is employment: most of the capacity for recovery housing in this country and self pay. And so in order to be able to stay just like you're paying rent on an apartment, you need to figure out a way to finance your stay. And people in early recovery have often burned a lot of bridges, often also never developed any real skills. And so finding that early recovery, job number one, and then number two, connecting with some kind of a job that might have a career path associated with it that really gets somebody in touch with what could be their long term goals.

Physical health is another big challenge. Most of the homes out there have very limited ability to accept people who have poor physical health that might need nursing attention. A fair amount that will have at least some wheelchair access. But that's a barrier that really needs a more complex form of address than anybody has been willing to come forward with so far. Mental health issues are a challenge. There's a fairly substantial overlap between people with substance use disorders and people with co-occurring mental health condition. And it's important to be able to find a residence and services in the area that can help you address both of those things, if that's what you need. And that's not always easy to do.

Another barrier are parents of small children that want to be able to live with their children, possibly just reuniting with kids for the first time after an incarceration or a separation, but needing that recovery supportive environment. So there are homes that will support parents with children. But they're few and far between. And they require a lot of external support.

Angie Fiedler Sutton
Well, one of the things I probably think would be a barrier as well, especially for recovery, housing is the NIMBY issue, not in my backyard. And that's for those who are unfamiliar with the phrase, it's basically people are fine with with recovery housing, as long as they're somewhere else not, not near me. Do you want to speak a little bit on that, and kind of how some of the things that you've done, or NARR has done to kind of help combat that stigma?

Dave Sheridan
Angie, I'm glad you asked that. And for the small fraction of listeners who love legal drama, there's a big challenge for a lot of recovery services, but particularly recovery housing, where there is an enormous stigma attached to being in recovery. It's one of the few acceptable forms of institutional discrimination that remains.

So what often happens is someone will go to acquire a residence and open it as a recovery house in a the kind of neighborhood that tends to be really conducive for people in recovery: near jobs, near stores, you know, walkable neighborhoods. And when the neighbors find out what's going to happen there, cities often try to put up barriers. And it's a very special kind of NIMBY, because there are all kinds of reasons people will throw up to why they don't want them there. But Angie, you got it pretty much right. We've gotten to the point that even in a lot of progressive communities, they're delighted to see people get into recovery and get through recovery, but they just want us to do it someplace else.

So what the challenge for cities and for us is there's a pretty well established body of federal civil rights law and now case law that suggests that under most circumstances, these residences and the people who live there have to be treated like any other family, and it's very, very difficult to help cities understand that their obligations under federal law mean, they can't put up barriers to this kind of housing. It's just like any other housing. So there have been a series of court fights court cases. Right now the state of California has come the furthest and being clear that governments cannot do that. So they are threatening some pretty serious action against cities that have erected ordinances that will try to force that housing either to operate on a smaller footprint, or operate someplace else.

Angie Fiedler Sutton
So I mean, it's attached to the sigma that's starting to get better, what is NARR and and when you specifically have tried to work on in terms of reducing that stigma, let's talk a little bit more about that.

Dave Sheridan
Well, the stigma, the fight against stigma is going to be a long term thing. We collaborate with organizations like the recovery advocacy roject, Faces & Voices of Recovery on a lot of public information campaigns around stigma more generally.

I'll give you a good example of where, where things were able to turn a page. The state of Massachusetts had contacted us to help them build a system of our recovery housing, and in their state. They have a lot of housing, it just was really variable in terms of quality. And we put a proposal in and they said, "Hey, this looks great. Well let you know, when we're ready to start." And it kind of sat on the shelf, it was during the time that the Affordable Care Act was being implemented, so they had a lot of other things to do. And what happened is when young people on Cape Cod started to die from our fentanyl crisis, then it became a crisis. So something that had been a perennial, ordinary day of the week in south Boston or Philadelphia, as soon as it's happening in nicer communities, wetter communities, then some real resources were are coming to bear on this. And that is helping. There's a lot of communities now that I would say 10 years ago would have been highly resistant to things like recovery, housing or community centers that are now welcoming them because they see in the face of of overdoses.

The other thing we've done is we work with our state organizations representing the housing providers and the people they serve, to do a lot of local level and state level outreach, primarily on the area of stigma, that we want communities to understand that well operated recovery services in their communities are really community assets, number one, and number two, that the people that are being served there are their sons and daughters, their spouses, their relatives, their co workers, that they are us. And there's a lot of great data that can be brought to bear on that, that, you know, addiction doesn't respect class or color, or religion, and that all of our communities have this problem.

Angie Fiedler Sutton
that perfect. Some of the resources that you and NARR use to help your mission statement. Can you go into little detail about some of the things that I mean, obviously, we've talked about community resources, but some of the, like, research and whatnot.

Dave Sheridan
Oh, sure. So let me talk a little bit about research.

One of the biggest barriers to getting funding for recovery housing has been the limited amount of academically blessed evidence that it materially improves recovery outcomes. There had been some studies done in the 1990s by a fairly prominent researcher and team at DePaul University, and it established an evidence base that was really unequivocal, but it was conducted on a fairly limited sample of types of homes.

So one of the things that we've been able to do, along with some researchers we've attracted to our efforts, has been to get the federal government, the National Institutes on Drug Addiction, Drug Abuse, to fund some really good studies -- some of which are under underway now, some of which were completed in the last five, seven years. So we're establishing the evidence base that we're people that will live in recovery residences, and I'll just throw out one benchmark, for at least three months are going to have 40% better outcomes. If you stay six months, there's an 80% chance that you will be abstinent from drugs and alcohol for three years, at least. And more of that research is forthcoming. There's a lot more to be done. But that has been a really important shift.

The other thing that we see happening, and it's partly research based and partly because of advocacy, not just by NARR, but other recovery organizations, if you think about how our nation has addressed addiction for the last 40 years, most people -- a lot of the medical profession think that addressing addiction is synonymous with addiction treatment, and medications. But treatment is a very short term limited time service that someone is in for between a week and if you're in a residential program between one and four weeks, you might be receiving outpatient services for another few months. But addiction is a chronic disease. And that means it works itself out. And remission occurs over a course of years, not weeks or months.

So what we're finally seeing and partly is based on this research, is that focus and funding starting at the federal level, is starting to shift away from it's almost exclusive focus on acute and sub acute care and medications, meaning addiction treatment, and now to fund the rest of the recovery continuum, which we define and other organizations as recovery support services. And recovery housing is one of those services. So that's been a big shift brought about by some of the research that's been done in the last five to 10 years.

Angie Fiedler Sutton
You mentioned your advocacy work, talk a little bit more about that. What kind of advocacy does NARR do on a regular basis? How do they approach advocacy, that kind of stuff.

Dave Sheridan
We take a fairly grassroots level. In other words, we like to see advocacy happen at the state level. That seems to be where a lot of things happen the fastest. Most federal funding for recovery and treatment services flows from Washington DC to states. And then states determine how that money gets spent, usually through either a county or a health care regions system.

So what we've found is that advocacy at the state level for the administrative agencies that manage addiction funding and programming, and with state legislatures, has been pretty effective. We've managed to get legislation introduced in a dozen states now that have recognized recovery housing and are supporting it in some way. How do we do that? Well, we work with our network of state organizations, and with these international organizations that also have some reach into those states. So a lot of collaboration is starting to happen around advocacy.

Angie Fiedler Sutton
Well, speaking of the state associations, you don't have all 50 states yet. If someone was interested in a state that's not got a NARR affiliate thing, how, what is the process? How do they go about becoming an affiliate?

Dave Sheridan
Great question, Angie. And I did want to make sure I mentioned this. So we have state affiliates, but we only have one per state. So if if you're in one of the 20 states where we don't yet have an affiliate, well give us give us a call. I get it reach out to us at info@NARRonline.org. And let us know what state you're in. And that you want to explore starting a NARR affiliate.

Some of our state groups are started at the behest of state agencies or state legislatures who have heard about what we do and they want it and they're willing to fund it. But a whole lot of them started as grassroots efforts by providers and people in the recovery community. We don't have a lot of resources to just pop one in. But we've gotten a lot of experience working with state level funders who are often willing to fund that work. We're working in five states right now where we've got at least limited amounts of state support. So if you're in the Dakotas or Nebraska or Kansas, give us a shout.

Angie Fiedler Sutton
And one of the things that we talk about a lot in this podcast as well as something that NBHAP has really been trying to focus on is the idea of recovery capital. Is that something that you use on a regular basis in the NARR and recovery residences? That's the word.

Dave Sheridan
Yeah. Oh, okay. So before I answer the question, I just want to put a disclaimer out there that Angie, and I did not discuss this in advance. Absolutely. As a matter of fact, one of our biggest successes, and one of those research projects I mentioned, is our Virginia affiliate, which, in partnership with its state addiction agency, has funded a platform that is doing recovery capital assessments and recovery plans for every house in our Virginia system. And there's just incredible results coming out of that.

We are huge proponents of recovery capitalism metric, both as a way to measure recovery progress in the quality of recovery, but also as a set of tools that an individual in early recovery can use to map their own recovery journey. So yeah, we like recovery capital a lot.

You know, in the old days, metrics really centered around things like self reported abstinence, or criminal recidivism. But what recovery capital does is it measures all of the dimensions of wellness and healing that we look at in our own lives, whether we're in recovery or not, it's somewhat akin to social capitalist concept. But the idea is that recovery really is a multi dimensional thing. It's healing family relationships, and getting back into the workforce and developing community relationships and addressing financial and legal wreckage. And all of the things that lead to really a healthy, well rounded, satisfied life in the community.

We work with one of the prominent academics in recovery capital, Dr. David Best. He is the architect of the version of the of the tool that is embedded in a software platform that we're working with several of our state groups now to implement. The downside, of course, is it's pricey. That, you know, most of the capacity out there, not only is it self pay, it's also very low cost. And so the amount of money that providers can spend on these extra services is limited. But in the case of Virginia and a couple of other states, the state itself has decided that having more knowledge about outcomes is important enough that they are picking up the freight for for these licenses. It's just a wonderful thing.

Angie Fiedler Sutton
Standard five year plan question, what do you and NARR hope to accomplish and then in the future in the next five to 10 years?

Dave Sheridan
Well, one thing get back to some of your earlier questions is we would like to have a strong affiliate in all 50 states. And we would also welcome working with Puerto Rico, Virgin Islands, the other American territories, strengthening that network and making it more capable of serving everybody and its states.

One of the shortcomings in the system we have, for example, is even in a state where we have an organization that's got we've had housing there for 10-15 years. It doesn't address everybody in the state. There are underserved populations. There's underserved geography, and it's very difficult to sustain recovery services in rural communities. So we want to be able now to build that system out.

The second thing is that every one of those residences ought to be able to find in its community the kinds of services that its residents need. So if someone comes into a house and a community of 10,000 people and needs mental health services, making sure that our providers can connect people to those services, or childcare or some kind of job training, easier in some places than others, but very difficult to accomplish now.

On a more mundane administrative level, we want to create some workforce development pieces of collateral. For example, we certify homes right now. We want to create a credential for the people that work in the homes either in an operator role or a peer manager role that someone can earn and take with them. It's not associated with a particular provider or piece of property. And that's going to be a long term, longish term thing in probably in collaboration with some of the organizations that maintain credentials with things like addiction counseling, or marriage and family therapy, that really to create something that is of has value for somebody working in this field.

Angie Fiedler Sutton
I know that that's something that that we've talked about before -- not you and I, but we as in NBHAP -- have has talked about before in terms of possibly embracing on on our end to because we do have that unregulated provider level of membership. And we want to make sure that we cover the recovery residences as much as we cover the treatment facilities as well as the individuals.

In terms of you know, something you touched on a little bit that gave me a new question wins. If someone is going into a recovery housing, what kind of questions should they be thinking about in terms of to make sure that it's the right fit, as well as, alas, there are some bad players out there that it's a, you know, a good resource, a good house as well?

Dave Sheridan
Boy, that's a that's a mouthful. Yes, there's really two questions ther: for fit, and then for ethics and standards of service.

So let's talk about fit, first. People do come in with different needs, different amounts of recovery capital that they already possess, for example. And one thing for sure, is, you also want to find one that fits with your values and your recovery journey. So in the early days, a huge percentage of the homes were all based on 12 Step traditions, because that's all it was out there in the 1940s, the 1950s. And today, we see a variety of recovery pathways, whether they're based on 12 Steps, or faith traditions, or tribal traditions, or things like, you know, Eastern meditation. And our system contemplates that all of those have a place as certified residences. But it's important to ask.

There's a lot of people coming into recovery that are very resistant to 12 Step pathways. And we understand that so important to ask, what are the requirements for being in the house? Is this something where I have to go to a 12 Step meeting? Or can I find equivalent activities to substitute for that in the community? Also the sort of mundane, mundane things like how long have you been there? You know, do you have? What's your relationship with your neighbors like? You know, am I going to have to like, not feel that I belong in this neighborhood, if I live here, that people see us coming in and out of this house, that they understand that we're parts of the community and not just sandbaggers or carpetbaggers, or ...

Then services, this is often done in collaboration with a referral source like a counselor or you know, somebody from a program. If the person needs some kind of specialized service, like there really needs to be somebody around the house all the time. Also, if you're on particular medications that have been prescribed for opioid use disorder, making sure that that house is geared to accommodate you with your medications, their homes that are still out there that are resistant to allowing people to come into homes with certain medications like methadone and buprenorphine. And that's a challenge, but you want to know upfront.

On the ethics side, is the operator telling you everything you are answering all your questions? Are there written documents, including the house rules? T\he reasons you you might be asked to leave, and all of the financial policies, you know, if if they charge a deposit, how do you get that back? Making sure that all your obligations are spelled out in writing.

And another thing if you're already a participant in that local recovery community, local meaning geographic, maybe you go to 12 step meetings already ask her out, is this a reputable house? You know the seals of approval in states where we have really healthy participation, easy to find the are they NARR certified or are they a chartered Oxford house? Those are the houses that have some sort of oversight and adhere to some kind of a standard. If they don't fall into those two categories, maybe you're in a location that just doesn't have any of those. But those would be two things to look for, particularly in a state that has a strong NARR and Oxford House presence, that you want to try to find someone who's gone that extra mile to prove that they operate according to somebody else's standards and not just their own.

Angie Fiedler Sutton
Now you're a professional speaker. I've seen you speak at conferences myself. Do you have a favorite special topic? Other I mean, recovery residents, obviously, but in in under that that you'd like to talk about most?

Dave Sheridan
Yes, I, what I really enjoy, and this just happened last week, I was part of an all day workshop at NATCon, which is the National Council for Mental Wellbeing's big four day convention in downtown LA. We did this program for state addiction agencies who had people coming to the conference for the next four days. And so got to talk about how to build systems and make them better. And these were with the decision makers and funders. And that's really boring to a lot of people because it's all process and policy stuff. And that's just the geek, kind of geek I am. But I love to see things grow and flourish. And it's a lot of that behind the scenes stuff that makes the magic possible.

Angie Fiedler Sutton
Was there anything else that you wanted to talk about that you or you thought we were going to talk about that we haven't that we still need to cover?

Dave Sheridan
Yeah, just thought I'd mentioned a couple of milestones along the way. You know, already talked about the idea that we're moving from a world where we focus our resources and attention in addiction on the first three months to where we're starting to look at the whole continuum. The President's National Drug Control Strategy, for the first time, the first year of the Biden administration, lays out for some growth and performance goals for recovery separate from treatment. Wonderful first step.

Dave Sheridan
Another big milestone that happened more recently is that NARR has been working with the American Society of Addiction Medicine, and who is rewriting their what they call their ASAM criteria. And what those do is define the various levels and services of addiction clinical addiction treatment in America. And they're used as the Bible by a lot of third party payers, insurance companies, state Medicaid programs to define the treatment landscape. But up until now, their continuum has only included clinical services. And for the first time there are going to include recovery residences. And their version four that will be coming out sometime this summer. And that means people will be able to see how recovery dovetails with treatment, and how recovery housing is the natural part of that continuum. We're pretty excited about it.

Angie Fiedler Sutton
Great. Sounds like great news. Now for anyone who's interested in learning more about NARR or wants to talk to you directly how is the best way they can get a hold of you?

Dave Sheridan
The best way to get me is email at Dave.Sheridan@NARRonline.org. And you can always email just general NARR at info@narronline.org, and NARROnline.org is our website. We will also if you want to learn much more about recovery housing, want to get involved in it. We're having a big national conference October 9 through the 11th, this year in Dearborn, Michigan. And we'll have that information up on our website.

Angie Fiedler Sutton
You've been listening to Destination Change, a podcast where we talk about recovery, treatment and more. Our guest today was Dave Sheridan. Thank you very much for being here. Our theme song was "Keta" by Sun Nation and used via Creative Commons licensed by the Free Music Archive. Please consider rating and reviewing the podcast on Apple podcasts so we can get more listeners. In the meantime, you could always see more about the podcast including show notes and where else to listen on our website www.nbhap.org. If you have any questions for the podcast, please email us at info@NBHAP.org. Thanks for listening.