Montana’s new efforts to regulate recovery residences

A consortium of addiction treatment experts is trying to bring best practices to the state’s unlicensed industry.

By Mara Silvers MONTANA FREE PRESS

This is the second article in a two-part series about Montana’s recovery residence industry. The first story, about the pathways into recovery residences from the criminal legal system, can be found here.

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Ronald Britt spent 19 of the last 22 years going through the revolving door of the prison system — using methamphetamine, racking up drug-related criminal charges, returning to the men’s prison in Deer Lodge — until relatively recently. Last February, he said, he decided to “do something different” when he was released on parole. Instead of returning to Billings, where many of his friends and family were also using, he took the advice of his therapist and applied to a residential sober living home in Ronan operated by Never Alone Recovery Support Services.

“I kept putting it off for years. And finally, I didn’t have any other options. I was like, I’ve got to do something different,” Britt, 46, said in a recent phone interview. “And to be honest, my life’s been great. Everything isn’t rainbows and unicorns, I’ve had my bad days and good days, but, wow, my life has improved tremendously from, you know, sitting in a cell.”

Since leaving prison, Britt said, he’s earned an associate’s degree in business management, completed a Native cultural wellness and recovery “White Bison” program, and is working to become a peer support specialist to help other people going through recovery. He said December marked his tenth month clean and sober. 

“I couldn’t have done it without the recovery residence over here — the recovery community,” Britt said. “The only thing that made a difference was having some place to go to.”

For Britt and others, recovery residences occupy a unique position in the spectrum of addiction services, helping people transition out of prison, jail or inpatient treatment. But unlike clinical treatment settings, the recovery industry is largely free from state and federal oversight, opening the door for unethical conduct and business practices in Montana and nationwide. Even the number of homes currently operating in Montana, let alone what type of recovery support they offer, is not tracked at a statewide level. 

Against that backdrop, addiction recovery experts in Montana have started pooling their expertise to create a certification process for recovery homes. Their goal is to help residences meet national best-practice standards, protect residents and set more people on the path to long-term recovery.

“Montana has really been dropping the ball on treatment for years. They’ve been trying the same thing for 30 years and expecting different results,” said Don Roberts, a licensed addiction counselor and founder and executive director of Never Alone Recovery Support Services. “They’re just sending people to treatment for 30 days and then telling them to go to outpatient [treatment] when they get released. There’s a whole chunk in there that’s been missed. And so now we’re trying to address that.”

‘TO PROTECT THE RESIDENTS’

Nationwide, addiction recovery experts have spent more than a decade consolidating recommendations for recovery homes under one umbrella organization, the National Alliance of Recovery Residences, and creating standards for a long-unregulated industry. As of December, the organization has affiliates in 30 states, with nine more in development.

Montana is one such state with an “emerging” affiliate called the Recovery Residence Alliance of Montana. The accrediting body, funded through a contract from the state health department awarded in January 2022, operates under the leadership of the Native American Development Corporation.

RRAM representatives are clear that the affiliate is still working out kinks in its operations. It doesn’t yet have a website, and some judges, attorneys and behavioral health workers who refer clients and defendants to recovery programs aren’t yet familiar with the organization’s acronym or purpose. But Roberts and others say that having a group overseeing best practices in Montana’s recovery industry is the start of something important.

“We want to meet certain standards. We want to make sure that the people that are running these programs really have an environment that is recovery-focused,” said Roberts, who’s part of a RRAM subgroup in charge of certifying residences. “We don’t want people just coming in and charging these people all this money and using them and burning them and then kicking them out with no recovery stuff involved.”

Absent state licensure, regulation or third-party certification, the extent of unethical and exploitative sober living practices in Montana is undocumented, though complaints nationally have included allegations of unsafe living conditions, work without pay, false advertising and financial gain for patient referrals, with a patchwork of state and federal enforcement to rein in bad actors. 

As previously reported by Montana Free Press, one of the state’s largest addiction recovery programs, Hope Center Ministries, accepts residents charged with drug-related crimes into residences where Bible study and “vocational training” is mandatory. The program doesn’t allow residents to keep their wages for the majority of the year-long program, a business model that has sparked class-action lawsuits against recovery residences in other states. The Hope Center Ministry program in Montana, the organization’s national office, and two Montana businesses that contract with the ministry did not respond to Montana Free Press’ questions about the resident work program.

Peter Maney, program director for RRAM, would not directly comment on any recovery programs in Montana other than the three organizations that have already gained certification, a cohort that does not include either of the Hope Center Ministries residences in Clancy or Butte. Asked whether the practice of using residents’ wages as revenue aligns with RRAM’s certification standards, Maney said it would depend on several factors, including whether residents have a choice in their work location and hours, as well as whether they can leave the program at any time. 

“If it’s involuntary for me to be there and it’s involuntary for me where I have to work, and it’s involuntary of how much I’m working, that doesn’t sound like a social model [of recovery] to me,” Maney said.

When considering whether to certify a residence, Maney said, RRAM staff will look at a recovery home’s finances, program offerings and physical housing infrastructure, conduct interviews with staff and residents, and go through rounds of written program evaluations to help determine how an organization operates. Maney said organizations will pay a $350 fee when they apply for certification to help offset the staffing and resource costs for RRAM’s evaluation. Once a residence is accredited, residents in the home will have an established avenue for reporting any complaints about program requirements and living conditions, a component Maney said is critical for resident safety and empowerment. Accredited operators will have to reapply annually to keep RRAM’s stamp of approval, Maney said, ensuring that homes have long-term financial and programmatic oversight. Most importantly, Maney said, the process is meant to create better programs for addicts working through recovery.

“There are too many stories where residents get taken advantage of because they’re in a position where they’re vulnerable,” Maney said. For many people coming out of prison, jail or court-ordered treatment, affordable housing is already hard to find, he said. Add a history of substance use and possibly criminal charges, he said, and “the deck just keeps getting stacked higher and higher against them.”

As of December, RRAM has certified three organizations operating 10 residences in Montana, including the Never Alone Recovery Support Services homes run by Roberts in Ronan, Crosswinds Recovery in Missoula and STEP in Billings. Maney said certification ensures that programs’ practices are aligned with a common code of ethics, but doesn’t try to make residences into carbon copies. Programs can be faith-based or culturally informed, have more or less integration with clinical treatment providers, employ licensed staff or be run primarily by residents.

“There’s freedom in what we’ve adopted as the RRAM standards … because people develop addiction in all different ways,” Maney said. “People recover in all different ways. And so what works for me doesn’t necessarily work for somebody else.”

As recommended by the National Alliance for Recovery Residences, Montana’s fledgling certification process for sober living homes is voluntary. The hope, Maney said, is that operators will willingly seek certification in order to keep their programs competitive in the growing recovery business and make sure treatment providers, therapists and others who can refer clients to sober living homes are confident they’re operating with ethical standards. If certified recovery residences start to take up a larger share of the market, he said, uncertified operators may eventually shutter.

THE LEGISLATIVE ARENA

As RRAM continues to certify residences — aiming for 20 more homes by the end of 2023 — reform advocates in state government are considering additional ways to increase oversight of the sober living home industry. 

A bill drafted by the Criminal Justice Oversight Council, a bipartisan group of state lawmakers and law enforcement professionals, would require qualified health care providers, judges and justices of the peace to refer patients and defendants only to certified recovery residences, and suggests the Department of Corrections do the same. The bill would also require the department to issue parolee rental vouchers only to certified residences, and adds reporting requirements to prevent the state from overpaying residences after someone moves out. 

If passed, the bill would raise standards for uncertified residences as well. It instructs the state health department to create the first statewide database of recovery residences, both certified and uncertified. All residences would also have to meet building and safety codes and train participants and staff how to use opioid-overdose medication. Under threat of violating the Montana Consumer Protection Act, the law would also prohibit residences from making “materially false or misleading statement[s]” about the identity of their program and the services it offers, as well as bar kickbacks between health care providers and recovery residence operators for referring or accepting participants.  

Yellowstone County Attorney Scott Twito, a member of the council, said the legislation is designed to set a higher bar for safety and ethics among home operators and help law enforcement recognize different practices between residences. 

“Nobody understood truly what a sober living establishment is supposed to be,” Twito said. Judges, prosecutors and defenders, he said, “could think that they would provide all these services when in actuality they probably don’t provide those services, or at least don’t provide those services appropriately. That’s the whole purpose for why we brought this up to the council.”

The bill, sponsored by Sen. Barry Usher, R-Billings, is scheduled for its first hearing before the Senate Judiciary Committee on Jan. 10. Like most bills, the new proposal will be debated and probably amended through the 90-day Legislature. Other treatment providers, people who have stayed in recovery residences and addiction experts will have the chance to weigh in with recommendations. 

Logan Cook, a clinical assistant professor at the University of Montana School of Social Work, said the legislation is “a start” to reining in the currently unregulated industry. But he said the current bill language doesn’t place any requirements on the state health department to regulate residences after certification. RRAM would continue to be the sole entity with oversight powers. 

“I get that they’re trying to avoid red tape and farm that out to someone else,” Cook said of the state health department. At the same time, he continued, “This is working with a vulnerable population. Regulation exists for a reason.” 

FINDING THE ‘MIDDLE GROUND’ OF REGULATION

Twito, Maney and other advocates hope that RRAM’s approach to certifying recovery residences, coupled with the guardrails suggested by the oversight council, will move the needle for standards and consistency at Montana’s sober living homes. But current strategies for increasing oversight don’t include requiring homes to be licensed, as is required for clinical residential treatment programs such as Rimrock in Billings or Recovery Centers of Montana in Columbia Falls. With licensure comes a list of best-practice responsibilities for treatment providers, the ability to bill insurance for services, and monitoring by state inspectors. As of 2020, only six states required sober living residences to be licensed by a state department or agency, while a few more were considering licensure legislation. 

In a December interview, Department of Public Health and Human Services Medicaid Director Mike Randol and state opioid response grant manager Ki-Ai McBride spoke favorably about the RRAM certification process as an alternative to licensure. While they said the state is interested in promoting quality standards in the industry, as with any health care sector, McBride added that recovery residences don’t provide the same level of medical services as licensed treatment providers.

“Recovery homes are sort of an informal step down for people who have been in residential treatment or people who are going through other sorts of systems,” McBride said. 

Maney, the program director for RRAM, said he doesn’t see state licensure as being particularly efficient or effective for recovery home operators and their residents. Overcoming addiction, he said, is highly personal and might require a range of approaches that don’t fit neatly into rules set by the Legislature or a state agency.

“I think that would be messy. If the point is to produce more quality outcomes, in my opinion, getting the government involved in licensure isn’t the way to do that,” Maney said. “We can’t just let people do whatever they want to, either. I think there needs to be this middle ground, and that’s what certification, accreditation, tries its best to do.”

A few Montana recovery residences are currently providing a level of addiction therapy and counseling to merit licensure from the state. Butte SPIRIT, which runs an eight-bed residence for men and is working to open another for women, is a residential substance use disorder facility subject to state inspection because it meets a 3.1 level of care as defined by the American Society of Addiction Medicine. Founder and Director Demetrius Fassas said that if RRAM had been operating when the Butte organization opened its doors in 2020, his team might have decided to pursue certification instead of licensure to help distinguish the program from other sober living settings. 

As a licensed facility, Fassas said, the SPIRIT home has to stay in compliance with state regulations for staffing levels, available therapeutic services and other administrative requirements. Being a state-approved facility also means Fassas and his team can bill Medicaid for some of the services they offer. But, Fassas said, most of the licensure requirements seem secondary to the core mission of the recovery residence, which is premised on peer support and skill building for long-term recovery.

“From across the country, what we can tell is that transitional housing that’s in a home, not in an institution, but in a home, is what works best for transitioning people into independent living in homes or apartments or wherever they go,” Fassas said. 

On the other hand, he added, employing licensed clinical staff and offering required group therapy sessions also provides beneficial services for residents. The residence provides six hours of mandated recovery-related programming a week, Fassas said, which exceeds the state requirement by an hour and gives residents an opportunity to process “what’s going on in their personal lives, what’s going on in the home, hold each other accountable, learn to set boundaries.” Fassas said those sessions, facilitated by trained counselors or social workers, can help residents develop tools they can take with them when they leave the home. 

“‘How do I manage my emotions, my reactions, without turning to a drink or a drug?’ Being licensed gives us the staff to be able to, in real time, help people come to those answers for themselves of how to cope with life on life’s terms,” he said.

Cook, from the University of Montana, said one potential response to Montana’s growing industry of unregulated sober living facilities would be to encourage the development of more 3.1 level homes like Butte SPIRIT. The standards applied to those residences still require a non-institutional environment, but pair the home-like setting with licensed clinical staff and therapeutic programming, allowing residences to bill Medicaid for some services. If facilities had more reliable financing, including insurance revenue, Cook said homes with lesser standards might not have found such a foothold in the state.

“Whatever happens, I think the priority has to be protecting the community and protecting vulnerable populations. Is it something formal within the treatment continuum of care, where you’re opening up access to 3.1 level programs?” Cook said. “Or are you really going to regulate these recovery residences?”

NEXT CHAPTERS

Fassas, Roberts and Maney talk about the future of Montana’s recovery residence industry with high hopes — they envision the homes as a critical bridge between phases of an addict’s journey toward long-term sobriety. Without that infrastructure, it’s hard to imagine traversing the space between a hospital and independent living, prison and a full-time job, inpatient treatment and sustained recovery. 

Even with the support a recovery residence can provide, overcoming addiction for years and decades is far from guaranteed. Some programs, including Roberts’, continue to check in with participants years after they leave the program, in acknowledgement that time spent in treatment or a peer-support residence is often just one chapter of a person’s recovery story.

“It doesn’t go anywhere. It’s not a ‘fix-it’ issue,” Roberts said of addiction. “This is going to be with people for a long time.”

Fassas said the rise of recovery residences, premised on peer support and resident empowerment, gives him a reason to be optimistic about the direction Montana, and the recovery industry, is moving.

“The value of one addict helping another is unparalleled. And it’s only just starting to be recognized in the broader treatment community,” Fassas said. “It’s changing the clinical model into more of a social model. Into more of a community-based, connection-driven program of recovery.”