Community Reinforcement and Family Training

The 2005 National Survey on Drug Use and Health estimated that only 20% to 25% of individuals with serious substance abuse problems seek treatment within the first year of their diagnosis. One might surmise that access to resources is driving these numbers, but in fact, outright refusal of treatment by substance abusers is the main culprit. Fortunately, recent research has discovered that the family members of treatment-refusing substance abusers can play a critical role in influencing the problem drinker or drug user to enter treatment. An overview of some of the early interventions designed to help these family members is presented first, and a description of a newer program with an impressive scientific base, Community Reinforcement and Family Training (CRAFT), follows.

Traditionally, desperate family members of treatment-refusing substance abusers were offered two options: Al-Anon meetings or the Johnson Institute intervention. Al-Anon teaches family members to detach lovingly from the drinker or drug user. Studies have shown that while Al-Anon is a good source of support for family members, it does not routinely play a role in getting the substance abusers into treatment. The Johnson Institute intervention starts with a series of preparatory meetings with individuals whose lives have been negatively impacted by the substance use and culminates in a "surprise party" at which the substance user is confronted and given a treatment ultimatum. There is a high treatment engagement rate for those families who complete the entire intervention, and yet, the majority of family members drop out prior to the confrontation session.

Unilateral family therapy is an alternative to these traditional options. This unique family therapy involves treating a family member other than the individual with the identified substance abuse problem. The treatment focuses on teaching the concerned significant other (CSO) how to go home and change her or his interactions with the substance abuser so that abstinence is rewarded and alcohol or drug use becomes associated with the withdrawal of rewards. CRAFT is a unilateral family therapy that has outperformed both Al-Anon and the Johnson Institute Intervention in several studies in terms of its ability to get treatment-refusing individuals to engage in (seek and begin) treatment. For instance, in a large alcohol study that directly compared these three programs, CRAFT-trained CSOs successfully engaged 64% of the resistant problem drinkers, whereas the Johnson Institute intervention and an Al-Anon-based individual therapy engaged 30% and 13%, respectively. Studies using CRAFT to engage illicit drug users have been equally successful, with the largest trial demonstrating CRAFT treatment engagement rates of 67% and Al-Anon/Nar-Anon rates of 29%. Importantly, CRAFT has shown similar positive results across various ethnic groups, regardless of whether the CSO is the substance abuser's spouse, romantic partner, parent, or adult child. Furthermore, treatment engagement occurs, on average, after CSOs have attended only five CRAFT sessions. CRAFT also has been highly successful at achieving its second goal, improving the psychological functioning of the CSOs, and this improvement tends to occur regardless of whether CSOs' substance abusing loved one enters treatment.

CRAFT is an outgrowth of the Community Reinforcement Approach (CRA), a program geared directly for the substance abuser and most often associated with the work of Nate Azrin. Both treatments are built on the premise that an individual's environment plays a significant role in rewarding drinking and drug use. CRAFT was developed by Robert J. Meyers, one of the original CRA therapists, when he recognized that CSOs were in a position to exert a powerful influence over their loved one's home environment and that they simply need to learn the skills to do so.

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