Drug and alcohol use disorders are as far-reaching as they are insidious, undermining the lives of not only the people who are struggling, but also of spouses, parents, siblings and friends. Considering that the Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that 22 million Americans age 12 or older need treatment for substance use, the number of friends, family and others who are touched by addiction is likely in the tens, if not hundreds, of millions.
For decades, loved ones have sought help from Al-Anon and Nar-Anon. Like Alcoholics Anonymous, these programs have a spiritual component and urge participants to recognize that they are powerless to stop the substance use of the person they love, and that they should let go of someone who is not willing to seek assistance. A study on the two programs led by Hendrik G. Roozen, PhD, of Erasmus University Medical Centre, in Rotterdam, the Netherlands, shows that while these methods may improve the well-being of friends and family members, they are not effective in getting the addicted person into treatment (Addiction, Vol. 105, No. 10, 2010).
Another option that's been popular for addressing a loved one's substance use is the Johnson Intervention, the approach commonly depicted in TV shows and movies. Through this approach, family and friends work with a counselor to confront a substance user and urge him or her to get treatment. While the method can get people into treatment, a study led by psychologists Robert Meyers, PhD, and William R. Miller, PhD, of the University of New Mexico, showed that only 30 percent of family members are willing to take part in such confrontations (Journal of Consulting and Clinical Psychology, Vol. 70, No. 5, 2002).
Many families don't go through with the JohnsonIntervention because it's confrontational, rests on one meeting, and requires as many family members and friends as possible to be on board, says Kimberly C. Kirby, PhD, director of the Health and Behavioral Integrated Treatments Research Unit at Rowan University.
But psychologists' research has found strong evidence for another option: Community Reinforcement and Family Training, or CRAFT, a program that recognizes the value of tapping the connection between the substance user and his or her loved ones.
How CRAFT works
CRAFT was developed by Meyers and colleagues at the University of New Mexico. Like Al-Anon and Nar-Anon, CRAFT helps family and friends find ways to take care of themselves. But in addition, the method teaches them how to encourage the substance user to enter treatment.
While other treatment approaches call for either confronting or detaching from a loved one who is a substance user, CRAFT shows how to change one's interactions with the addicted person to reduce or stop his or her substance use and encourage the person to move toward getting help. CRAFT teaches family and friends skills such as how to:
- Care for themselves and take back control of their lives.
- Understand triggers that lead to a loved one's substance use.
- Reward a loved one when he or she does not use substances—and withdraw positive reinforcement when there is unhealthy behavior, such as alcohol intoxication.
- Use positive communication to improve interactions and to maximize their impact.
- Encourage a substance user to seek treatment.
- Spot signs that things might escalate to domestic violence.
The full CRAFT intervention usually takes between 10 and 14 one-hour sessions. The substance user enters treatment after about five sessions. Some loved ones may choose to focus solely on treatment entry, which can be achieved in four to six one-hour sessions. Sessions are ideally scheduled once a week, but people often come in less frequently, and most complete CRAFT in about three months. Sessions are typically one-on-one, though CRAFT is also used in groups and often involves the therapist using role play to teach significant others better communications skills for discussing treatment with the substance user.
Research shows that the model is not only effective in helping people cope with a loved one with a substance use problem, but is also more successful than other approaches at getting the substance user more engaged in treatment. In fact, a recent study led by Kirby that compared the outcomes of CRAFT training with Al-Anon/Nar-Anon showed that CRAFT training resulted in better rates of treatment entry for the individuals with drug or alcohol disorder, even when their loved ones participated in an abbreviated version of CRAFT sessions (Psychology of Addictive Behaviors, advance online publication, Aug. 24, 2017). According to the research, as many as 62 percent of substance users whose loved ones completed 12 to 14 sessions of the full CRAFT training entered treatment. In addition, 63 percent of substance users whose loved ones participated in four to six CRAFT sessions went into treatment. In contrast, only 37 percent of those with substance use disorders whose loved ones underwent the Al-Anon/Nar-Anon interventions sought help.
But surprisingly, while CRAFT has been enthusiastically adopted in Australia, Holland, Ireland and Sweden, the approach is not widely used in the United States. That may be because clinicians are unaware of the model, or because treatment programs are sticking to what is already known, experts say. As for why the media, including TV shows and movies, rarely feature CRAFT, Kirby has a hypothesis: "It's not sexy," she says. "Intervention has a big dramatic moment. Watching a parent or partner get training is not dramatic."
In some cases, resource constraints may dictate how CRAFT is implemented. In his clinic at Massachusetts General Hospital (MGH) in Boston, Brandon Bergman, PhD, usually delivers CRAFT in a group format because of limited resources. "Only the most difficult-to-treat cases receive individual CRAFT," says Bergman, associate director and research scientist at the MGH Recovery Research Institute and an instructor at Harvard Medical School. "I'd say it's a hybrid between psychoeducation and therapy."
Numerous studies have shown that CRAFT is effective for both alcohol and drug use, and several studies have yielded similar success rates, showing that CRAFT interventions led to 64 to 74 percent of substance users entering treatment.
The method also stands up to comparison with other interventions. One early study by Miller comparing Al-Anon and the Johnson approach found that only three out of 10 families assigned to the Johnson approach engaged the substance user in treatment, and barely more than one out of 10 sought treatment under the Al-Anon model. The CRAFT model, however, led to a 64 percent success rate, defined as the user's entry into treatment (Journal of Consulting and Clinical Psychology, Vol. 67, No. 5, 1999). By contrast, a study by Meyers on treatment-resistant drug users found that family and friends trained in CRAFT were able to urge 67 percent of substance users into treatment, compared with 29 percent under an approach based on Al-Anon and Nar-Anon (Journal of Consulting and Clinical Psychology, Vol. 70, No. 5, 2002).
"It doesn't matter what type of drug—cocaine, alcohol, marijuana—the results were remarkably similar," says Kirby.
CRAFT for youths
One population that may particularly benefit from CRAFT is teens and young adults. The model is designed for people who are reluctant to go into treatment, and young people are most likely to fit that category, says James McKowen, PhD, clinical director of the Addiction Recovery Management Service at MGH and an assistant professor in psychology at Harvard Medical School.
Providers who are trained or certified in CRAFT (see list at bottom) teach parents communication skills, collaborative problem-solving, and how to talk with their children in a warm and loving way. Parents get coaching and individual therapy and are encouraged to do couples work.
In a study by Holly B. Waldron, PhD, of the Oregon Research Institute, parents of treatment-resistant adolescents experienced a reduction in negative symptoms after working with CRAFT (Journal of Substance Abuse Treatment, Vol. 32, No. 2, 2007). Furthermore, as many as 71 percent were able to get their kids into treatment. That kind of success stands in sharp contrast to the national treatment rates of teens and young adults with substance use problems: In 2015, only 6.3 percent of teens ages 12 to 17 who needed treatment received help at a specialty facility, according to SAMHSA. Among adults ages 18 to 25 who needed help for substance use, just 7.7 percent received treatment at a facility (National Survey on Drug Use and Health, September 2016).
Preliminary data also suggest that kids stick with treatment longer when the parent participates in CRAFT. "If parents come in with kids, the kids will stay on average three months longer in care," says McKowen. "And more treatment is associated with better outcome."
Where to get CRAFT training
Robert J. Meyers, PhD, and Jane Ellen Smith, PhD
Provide CRAFT training and certification of professionals and institutions.
Allies in Recovery*
A comprehensive e-learning platform for the family and friends of individuals with substance problems. Professional memberships available. The CRAFT method is broken down into easy-to-assimilate modules. Members can also pose questions to in-house experts and get guidance on how to apply CRAFT to their particular situation.
Practical Recovery Services
Blends evidence-based practices such as CRAFT and alternative health services to create a unique treatment plan for each individual.
An online video course that teaches parents CRAFT.
*Editor's Note: This description of Allies in Recovery was revised on April 26, 2018.
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