Community reinforcement approach and family training

Introduction

The community reinforcement approach (CRA) was "originally developed for individuals with alcohol use disorders, [and] has been successfully employed to treat a variety of substance use disorders for more than 35 years. Based on operant conditioning [a type of learning], CRA helps people rearrange their lifestyles so that healthy, drug-free living becomes rewarding and thereby competes with alcohol and drug use."

"CRA is a time-limited treatment." "In time-limited therapy, a set number of sessions (for example, 16 sessions) or time limit (for example, one year) is decided upon either at the very beginning of therapy or within the early stages of therapy."

Community reinforcement and family training (CRAFT) is CRA that "works through family member." It "is designed to increase the odds of the substance user who is refusing treatment to enter treatment, as well as improve the lives of the concerned family members. CRAFT "teaches the use of healthy rewards to encourage positive behaviors. Plus, it focuses on helping both the substance user and the family."

Adolescent Community Reinforcement Approach (A-CRA) is CRA that "targets adolescents with substance use problems and their caregivers."

Description

Community Reinforcement Approach and Family Training (CRAFT) is a motivational model of family therapy. It is reward-based—based on positive reinforcement. CRAFT is aimed at the families and friends of treatment-refusing individuals who have a substance abuse problem. "CRAFT works to affect [(influence)] the substance users’ behavior by changing the way the family interacts with them."

In the model, the following terms are used:

"CRAFT grew out of the understanding that although individuals who truly need help with substance use problems often are strongly opposed to treatment. On the other hand, the concerned significant others (CSOs) of the substance abuser are commonly highly motivated to get help for them."

Three goals

When a loved one is abusing substances and refusing to get help, CRAFT is designed to help families learn practical and effective ways to accomplish these three goals:

1. move their loved one toward treatment,
2. reduce their loved one’s alcohol and drug use, and
3. simultaneously improve their own lives.

One experiment compared CRAFT against and Al-Anon and Nar-Anon facilitation therapy in their impact on the addict entering treatment and found concerned significant others who participated in Al-Anon and Nar-Anon facilitation therapy engaged 29.0% of addicts whereas those who went through CRAFT engaged 67.2%. Another study compared CRAFT, Al-Anon facilitation therapy designed to encourage involvement in the 12-step program, and a Johnson intervention and found that all of these approaches were associated with similar improvements in concerned significant other functioning and improvements in their relationship quality with the addict. However, the CRAFT approach was more effective in engaging initially unmotivated problem drinkers in treatment (64%) as compared with the Al-Anon (13%) and Johnson interventions (30%).

Family influence

Robert J. Meyers, Ph.D. writes about the influence that concerned family members—called Concerned Significant Others (CSOs)—have in treatment of the substance user, and the benefits for themselves:

The Community Reinforcement Approach and Family Training (CRAFT) intervention … method was developed with the belief that since family members can, and do make important contribution[s] in other areas of addiction treatment (i.e. family and couples therapy), that the CSO can play a powerful role in helping to engage the substance user who is in denial to submit to treatment. In addition, it is often the substance user who reports that family pressure or influence is the reason [they] sought treatment. Also, CSOs who attend the CRAFT program also benefit by becoming more independent and reducing their depression, anxiety and anger symptoms even if their loved one does not enter treatment.

CRA procedures

The following CRA procedures and descriptions are from Meyers, Roozen, and Smith for the substance user:

1. Functional Analysis of Substance
2. explore the antecedents of a client’s substance use
3. explore the positive and negative consequences of a client’s substance use
4. Sobriety Sampling
5. a gentle movement toward long-term abstinence that begins with a client’s agreement to sample a time-limited period of abstinence
6. CRA Treatment Plan
7. establish meaningful, objective goals in client-selected areas
8. establish highly specified methods for obtaining those goals
9. tools: Happiness Scale, and Goals of Counseling form
10. Behavior Skills Training
11. teach three basic skills through instruction and role-playing:
1. Problem-solving
2. break overwhelming problems into smaller ones
3. address smaller problems
4. Communication skills
5. a positive interaction style
6. Drink/drug refusal training
7. identify high-risk situations
8. teach assertiveness
12. Job Skills Training
13. provide basic steps for obtaining and keeping a valued job
14. Social and Recreational Counseling
15. provide opportunities to sample new social and recreational activities
16. Relapse Prevention
17. teach clients how to identify high-risk situations
18. teach clients how to anticipate and cope with a relapse
19. Relationship Counseling
20. improve the interaction between the client and his or her partner

(For details, please see the article: "The Community Reinforcement Approach: An Update of the Evidence" published in the Alcohol Research and Health journal by NIAAA)

CRAFT communication

With CRAFT, families/friends (CSOs) are trained in various strategies, including positive reinforcement, various communication skills and natural consequences. "One of the big pieces that has a lot of influence over all the other strategies is positive communication. "There are seven steps in the CRAFT model for implementing positive communication strategies."

1. Be Brief
2. Be Positive
3. Refer to Specific Behaviors
4. Label your Feelings
5. Offer an Understanding Statement - For example, "I appreciate that you have these concerns, … [or] I understand that you really want to talk right now, and that this feels urgent, … [or] I would love to be there for you."
6. Accept Partial Responsibility - This step "is really designed to decrease defensiveness on the part of your loved one. … It's not about accepting responsibility for things you are not responsible for. … [Rather, it's to] direct you towards the piece that you can own for yourself. … [For example, ] what you can take responsibility for are the ways that you communicate," etc.
7. Offer to help

"The overarching goals for the strategies for communicating are to help decrease defensiveness on the part of the loved one that you are speaking to, and increase the chances that your message is really going to be heard—so, increasing the ability that you have to really get across the message that you want." In fact, the title of Robert J. Meyers' and Brenda L. Wolfe's book based on CRAFT is, Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening.

"Consequences being in place is really important and helpful in terms of communicating your message, but it's also really important, maybe even moreso, to be consistent in following through with those consequences and rewards."

Al-Anon and CRAFT

According to the suggested prologue read at many Al-Anon meetings, Al-Anon holds that, "We believe alcoholism is a family illness and that changed attitudes can aid recovery....Al-Anon has but one purpose: to help families of alcoholics. We do this by practicing the Twelve Steps, by welcoming and giving comfort to families of alcoholics, and by giving understanding and encouragement to the alcoholic." Their suggested welcome clearly states that, "The family situation is bound to improve as we apply the Al-Anon ideas." Al-Anon believes that alcoholism is a family disease, and that as a result of trying, often for years, to cope with the substance abuse related behaviors of others, family members may become, "Irritable and unreasonable without knowing it". Because it is common for family members to exert significant energy on counter-productive interventions with loved ones, Al-Anon's pamphlet on detachment counsels that concerned significant others "detach with love"; this means,"Separating ourselves from the adverse effects of another person’s alcoholism can be a means of detaching: this does not necessarily require physical separation. Detachment can help us look at our situations realistically and objectively." Counter-productive behaviors for family members and their substance abusers include the very behaviors that CRAFT seeks to remedy--yelling, screaming, pleading, engaging the alcoholic while he or she is using, manipulation and counter-manipulation, negativity, defensiveness and anger. The skills Al-Anon seeks to teach, according to their pamphlet on detachment, are:

"IN AL-ANON WE LEARN: • Not to suffer because of the actions or reactions of other people • Not to allow ourselves to be used or abused by others in the interest of another’s recovery • Not to do for others what they can do for themselves • Not to manipulate situations so others will eat, go to bed, get up, pay bills, notdrink, or behave as we see fit • Not to cover up for another’s mistakes or misdeeds • Not to create a crisis • Not to prevent a crisis if it is in the natural course of events

By learning to focus on ourselves, our attitudes and well-being improve. We allow the alcoholics in our lives to experience the consequences of their own actions."

Al-Anon does not currently adopt, hold, or promote the view that concerned significant others (CSOs) can with any certainty make a positive, direct, and active contribution to arrest compulsive drinking; Al-Anon does, however, say that by improving our own attitudes and offering support an encouragement to the alcoholic the "family situation is bound to improve". The premise of CRAFT is that deliberate, positive interactions can increase willingness and decrease resistance. Al-Anon recognizes that while increased willingness and decreased resistance may be a happy by-product of detaching from the adverse behaviors of alcoholics, there are no guarantees that this will occur. Al-Anon is a fellowship with a focus on helping families and friends, themselves, without promoting a direct intervention process for alcoholics (see Al-Anon/Alateen). Because "no one ever graduates" from Al-Anon, it can be viewed as an open-ended program, not time-limited; it is available for concerned significant others as long as they may need it, and there are thousands of Al-Anon meetings around the country held on a weekly basis.

Al-Anon view

Regarding the CSO's relationship to alcoholism and sobriety, the view from the Al-Anon organization can be summarized:

1. Powerlessness. Al-Anon's First Step promotes a powerless view for families and friends, "We admitted we were powerless over alcohol—that our lives had become unmanageable."
2. Disease view. Al-Anon writes, "As the American Medical Association will attest, alcoholism is a disease." Al-Anon also states, "Although it can be arrested, alcoholism has no known cure."
3. Three C's. Al-Anon has a dictum called "the Three C's—I didn't cause alcoholism; I can't control it; and I can't cure it."
4. Loving detachment. Al-Anon "advocates 'loving detachment' from the substance abuser." It is important to note that this is often confused with rejecting or socially isolating the alcoholic; in fact, it simply means that we are responsible for our own actions alone, not the actions of and choices of anyone else. This notion of personal responsibility is particularly important for those who may blame themselves when they are subjected to the domestic violence, emotional harm, financial malfeasance and insecurity, or a myriad of other painful and troubling outcomes often associated with having an substance abuser in the family. It does not mean that we cease to love, care for, encourage, communicate with, or otherwise cease positive interactions with a loved one unless the concerned significant other makes a conscious, thoughtful decision to do so.

1. Family illness. Al-Anon writes, "Alcoholism is a family disease," and "we believe alcoholism is a family illness and that changed attitudes can aid recovery."

Regarding alcoholics, the Al-Anon-recommended approach for CSOs (families/friends) is "detachment with love" and "giving understanding and encouragement to the alcoholic."

No direct impact

As far as the CSOs having a direct and positive impact on another's sobriety, Al-Anon asks itself:

"But surely," we argue, "sobriety is desirable, and there must be something we can do to help! There has to be something we can say that will make a difference, or some sort of help or support or information we can provide that will convince our alcoholic loved ones to get the help they need or to make sure they continue on the path to recovery!"

Al-Anon answers:

Alcoholism is a disease. Would the right word stop the spread of cancer or make chemotherapy more effective? Would our help, good looks, higher income, or cleaner house overcome the progression of Alzheimer's Disease? Our compassion and support might make a loved one's struggle with illness easier to bear, but it is simply not within our power to cure someone else's disease. We are powerless over another's alcoholism.

This answer has these three characteristics:

1. Absolute outcomes. Regarding help, their answer tends toward complete and total outcomes, such as the ability for someone to convince, cure or overcome someone else's alcoholism, or that they could guarantee (make sure) that someone continues on the path to recovery. Although this answer may help dispel the notion that someone has permanent, guaranteed power over another's sobriety, it does not answer the question that someone could provide any measure of direct help or support toward someone else's sobriety or treatment of someone else's addiction.
2. Incomplete analogies. They write that the right word can neither make chemotherapy—a bio-chemical process—more effective nor stop cancer. However, their answer does not address the help or support or information that could make cancer treatment more effective or that could have a positive impact against cancer.
3. Medical opinion. Modern contrary assessments exist that alcohol (and drug) addiction are not (progressive, incurable) diseases, coming from Dr. Gene Heyman and others (see disease theory of alcoholism). In 1960, Bill Wilson—the co-founder of A.A. (his wife Lois was co-founder of Al-Anon)—called alcoholism a malady or illness and did not view it as a disease (see Alcoholics Anonymous § Disease concept of alcoholism). The diagnostic assessment of alcoholism in someone can include an assessment of co-morbidity, mental illness, and domestic violence.

CRAFT view

From SMART Recovery, section: Family & Friends:

The work of Robert Meyers' CRAFT Community Reinforcement Approach and Family Training program … differs significantly from Al-Anon in that it is a behavioral program which advocates that the CSO [Concerned Significant Other] can have a positive impact on the substance abuser. The CRAFT program has been demonstrated in Meyers' research to be more effective than the Vernon Johnson type intervention or Al-Anon, with less negative side-effects and better outcomes, whether or not the substance abuser enters treatment.

The CRAFT program uses a variety of interventions based on functional assessment including a module to prevent domestic violence.

Intervention and CRAFT

"There are questions about the long-term effectiveness of interventions for those addicted to drugs or alcohol. A study examining addicts who had undergone a standard intervention (called the Johnson Intervention) found that they had a higher relapse rate than any other method of referral to outpatient Alcohol and Other Drug treatment" (see Intervention, section: Controversy).

Smith, Campos-Melady and Meyers describe the Johnson Institute intervention as a "surprise party" that is uncomfortable for many CSOs (families/friends):

The Al-Anon approach’s emphasis upon detaching from the substance abuser is unappealing to many CSOs. On the other end of the spectrum is the Johnson Institute Intervention: a “surprise party” in which the IP is confronted by family members and a therapist with the objective of getting the IP to enter treatment. When the intervention is actually carried out, it often results in a high rate of engagement in treatment, and yet only a small number of CSOs who begin the program ever follow through with the intervention (Liepman, Nirenberg, & Begin, 1989; Miller et al., 1999), and many report feeling uncomfortable with its confrontational nature (Barber & Gilbertson, 1997).

Research suggests that CRAFT has had much more success than the Johnson Intervention method or Al-Anon/Alateen as far as engaging loved ones in treatment.

CRA

The community reinforcement approach has considerable research supporting it as effective. Community reinforcement has both efficacy and effectiveness data. Started in the 1970s, community reinforcement approach is a comprehensive operant program built on a functional assessment of a client's drinking behavior and the use of positive reinforcement and contingency management for non-drinking. When combined with disulfiram (an aversive procedure) community reinforcement showed remarkable effects. One component of the program that appears to be particularly strong is the non-drinking club. Applications of community reinforcement to public policy has become the recent focus of this approach.

Outpatient

"The Community Reinforcement Approach has been found to be extremely effective in outpatient settings as well. In one study, clients treated with CRA and the disulfiram compliance component were abstinent an average of 97% of the days during the last month of the 6-month followup, whereas clients treated with a combination of a 12-step program and the CRA disulfiram compliance training were abstinent an average of 74% of the days. For those clients who received a 12-step program and a prescription for disulfiram, an average of only 45% of the comparable days were abstinent (Azrin, Sisson, Meyers, & Godley, 1982)."

CRAFT (and Al-Anon, intervention, etc.)

An offshoot of the community reinforcement approach is the community reinforcement approach and family training. This program is designed to help family members of substance abusers feel empowered to engage in treatment. Community reinforcement approach and family training (CRAFT) has helped family members to get their loved ones into treatment. The rates of success have varied somewhat by study but seem to cluster around 70%. CRAFT is one of the only family-aimed treatments with proven results for getting people with drug or alcohol problems into treatment. The program uses a variety of interventions based on functional assessment including a module to prevent domestic violence. Partners are trained to use positive reinforcement, various communication skills and natural consequences.

Alcohol abusers intervention

From an article on the American Psychology Association (APA) website about the success of CRAFT in substance abuse treatment and intervention, these are the success outcomes for engaging drinkers into treatment:

1. 64% - CRAFT
2. 23% - Johnson Intervention
3. 13% - Al-Anon

From the article:

Sisson and Azrin (1986) recruited 12 adult women with an alcoholic husband, brother, or father and randomly assigned them either to an early version of CRAFT or to a traditional intervention. Results indicated that CRAFT was considerably more successful in getting the persons with substance abuse into treatment and reducing their alcohol consumption in comparison to the Al-Anon group. Miller et al. (1999) conducted a controlled comparison of CRAFT, the Johnson Intervention, and Al-Anon facilitation (TSF) that randomized 130 caregivers of problem drinkers to receive 12 hours of contact in one of the three conditions. CRAFT and TSF had better retention than the Johnson Intervention. Consistent with previous studies, participants tended to drop out of the latter intervention in order to avoid the family confrontation with the drinker. The CRAFT intervention also engaged substantially more drinkers into treatment (64% vs 23% Johnson and 13% TSF).

Drug abusers intervention

From the same article on the American Psychology Association (APA) website about the success of CRAFT in substance abuse treatment and intervention, these are the success outcomes for persons abusing drugs to enter treatment (the success outcomes were nearly the same as the alcohol abuse outcomes):

1. 64% - CRAFT
2. 17% - Caregivers' Twelve-step Self-help Group (TSG)

From the article:

Kirby et al. (1999) randomly assigned 32 caregivers of drug users to CRAFT or a 12-step self-help group (TSG). Caregivers who were assigned to CRAFT attended more sessions than those in TSG and were more likely to complete a full course of counseling during which the persons abusing drugs were far more likely to enter treatment (64% vs 17%). Reductions in drug use occurred during the study, but there was no group x time interaction. Meyers et al. (2002) replicated and extended those findings with drug users with similar positive effects on engagement of the drug abusing family members in treatment.

Note: When the articles states "there was no group x time interaction," it simply means the CRAFT outcome (64%) and the TSF outcome (17%) remained the same over time, even though there was a reduction in drug use during the study.

(For details, please see the American Psychological Association (APA) article: "Community Reinforcement and Family Training (CRAFT)", published by the APA)

Parallel study

"In a parallel study sponsored by the National Institute on Drug Abuse that focused on abusers of other drugs, family members receiving CRAFT successfully engaged 74 percent of initially unmotivated drug users in treatment (Meyers et al. 1999)."

History

CRA was designed by Nate Azrin in the early 1970s:

The most influential behaviorist of all times, B. F. Skinner, largely considered punishment to be an ineffective method for modifying human behavior (Skinner 1974). Thus it was no surprise that, many years later, research discovered that substance use disorder treatments based on confrontation were largely ineffective in decreasing the use of alcohol and other substances (Miller and Wilbourne 2002, Miller et al. 1998). Nate Azrin already was convinced of this back in the early 1970s, when he designed an innovative treatment for alcohol problems: the Community Reinforcement Approach (CRA). Azrin believed that it was necessary to alter the environment in which people with alcohol problems live so that they received strong reinforcement for sober behavior from their community, including family, work, and friends. As part of this strategy, the program emphasizes helping clients discover new, enjoyable activities that do not revolve around alcohol, and teaching them the skills necessary for participating in those activities.

The origin of CRAFT:

Drs. Robert J. Meyers and Jane Ellen Smith of the University of New Mexico developed the CRAFT program to teach families how to impact their loved one while avoiding both detachment and confrontation, the respective strategies of Al-Anon (a 12-Step based approach), and traditional (Johnson Institute-style) interventions in which the substance user is confronted by family members and friends during a surprise meeting. While all three approaches have been found to improve family members' functioning and relationship satisfaction, CRAFT has proven to be significantly more effective in engaging loved ones in comparison to the Johnson Institute Intervention or Al-Anon/Nar-Anon facilitation therapy.

2009

Up to 2009, CRAFT and CRA programs were not widespread amongst addiction counselors. Instead, many addiction counselors were tied to a twelve-step model that had much less research support. Recent trends by the National Institute on Drug Abuse (NIDA) have been to help deploy these intervention techniques. In 2007, CRAFT was being used in 25 clinics in the United States.

Association for Behavior Analysis International

The Association for Behavior Analysis International (ABAI) has a special interest group in clinical behavior analysis and behavioral counseling ABA:I. The association is developing a special interest group for behavioral pharmacology and addictions. The association serves as the core intellectual home for behavior analysts. The ABAI sponsors two conferences per year—one in the U.S., and one internationally.

Association for Behavioral and Cognitive Therapies

The Association for Behavioral and Cognitive Therapies (ABCT) also has an interest group in behavior analysis, which focuses on clinical behavior analysis. In addition, ABCT has a special interest group on addictions.