Enlisting Family Members to Address Treatment Refusal in Substance Abusers

Anyone who is close to someone who abuses alcohol or drugs knows all too well that substance abusers do not typically seek treatment until they have experienced years of substance-related problems.¹ During the first year after onset of a diagnosable substance use disorder, only 1 of 5 alcohol-dependent persons and 1 of 4 drug-dependent persons receive treatment.¹ The situation is even grimmer considering the percentage of persons with substance use disorders (regardless of duration) who seek treatment during any 12-month period: only 6% of those with alcohol use disorders and 16% of those with drug use disorders will begin treatment.² In addition, when explicitly offered a treatment referral, only 20% of substance abusers will accept it.³

Finding and understanding how to reduce treatment refusal is paramount, given that efficacious substance abuse programs are certainly available.^4,5 Besides the obvious benefits that substance abusers receive from treatment, concerned loved ones have much to gain as well. These affected families suffer from a host of substance-related negative consequences, including financial difficulties, poor family cohesion, and domestic violence.^6-8

Even though there are specific treatment strategies designed to increase motivation in substance users who attend at least 1 session (eg, motivational interviewing), many substance users refuse to go anywhere near a clinic or counselor.⁹ A willingness to try treatment is significant, since persons who initiate treatment are more willing to reenter it if a relapse occurs. ¹⁰

More than 20 years ago, a group of alcohol researchers were testing a behavioral treatment called the Community Reinforcement Approach^11,12 and recognized that family members could be a valuable resource in getting substance-abusing persons to enter treatment who had previously refused. In subsequent years, the idea of encouraging substance abusers to begin treatment by working with family mem- bers was pursued.Treatment involving family members of a substance abuser is termed unilateral family therapy (UFT).¹³ The most empirically supported UFT is Community Reinforcement and Family Training (CRAFT)--an outgrowth of the Community Reinforcement Approach. CRAFT attempts to get treatment-refusing substance abusers (referred to as identified patients) to enter treatment by working with their concerned significant others (CSOs).¹⁴

Using family members to facilitate treatment entry

UFTs such as CRAFT capitalize on the powerful influence that family members have over each other's behavior.^15,16 Despite feeling unsure of what to do, family members are often eager to help their loved one. These family members typically report a wide variety of mental and physical problems themselves, making their own treatment vital as well.¹⁷ The CRAFT program teaches CSOs skills to help decrease the identified patient's abuse and to increase the likelihood of treatment entry, while at the same time assisting CSOs in enhancing their own psychological functioning.

Although widely used programs such as Al-Anon¹⁸ and the Johnson Institute Intervention¹⁹ also focus on family members, CRAFT is unique in its positive, nonconfrontational approach. CRAFT's reliance on a reinforcement-based approach is especially noteworthy, because many family members are unwilling to use confrontation. ²⁰ Unlike Al-Anon, CRAFT teaches CSOs that they can help their loved one without being "lovingly detached." In addition, CRAFT is culturally sensitive to the needs of ethnically diverse clients who often prefer less confrontational modes of communication.²¹

Research supporting CRAFT

Clinical trials support CRAFT's ability to engage both alcohol- and substance-using identified patients in treatment. The earliest study found CRAFT- trained CSOs to be significantly more successful at identified patient treatment engagement (86% engaged) than the CSOs who attended disease-concept- based sessions and received referrals to Al-Anon (0% engaged).¹² In the first large CRAFT study, researchers recruited 130 CSOs of treatment-refusing alcohol-dependent individuals (Figure 1).²² CSOs were randomly assigned to a maximum of 12 hours of CRAFT, Al-Anon facilitation (ie, the delivery of Al-Anon in an individualized format), or the Johnson Institute Intervention. At 6-month follow-up, CRAFT demonstrated a superior engagement rate. Specifically, CRAFT-trained CSOs engaged 64% of identified patients, those using the Johnson Institute Intervention engaged 30%, and CSOs receiving Al-Anon facilitation engaged only 13% (Figure 2). Preliminary support for the effectiveness of CRAFT across diverse populations was shown, since nearly half of the CSOs were members of ethnic minorities and CRAFT engagement rates did not vary by ethnicity. More studies with ethnic minorities are needed.

CRAFT is highly successful in engaging treatment-refusing illicit drug users in treatment as well. One study enrolled 32 CSOs in a 10-week program of either CRAFT or 12-step meetings.²³ CRAFT-assigned CSOs demonstrated superior identified patient engagement (64% engaged) compared with the 12-step-assigned CSOs (17% engaged). In a larger but uncontrolled trial, CRAFT-trained CSOs engaged 74% of treatment-refusing identified patients.²⁴ A recent controlled trial with drug- abusing identified patients found significantly higher engagement rates for CRAFT-trained CSOs (67%) compared with the rates of CSOs who received Al-Anon/Nar-Anon facilitation therapy (29%).²⁵

In the CRAFT studies, the psychological functioning of CSOs tended to improve independently of treatment conditions or identified patient engagement status. Also, an average of fewer than 5 sessions with a CRAFT-trained CSO was required before the identified patient began treatment. Furthermore, identified patients who began treatment did not typically terminate quickly. On average, they attended more sessions than did those attending many state drug programs.

The theory behind CRAFT

CRAFT is rooted in behavioral principles, specifically the belief that one's environment plays a key role in reinforcing alcohol and drug use.²⁶ For example, substance use may be associated with overt social rewards, such as the companionship of drinking or drug "buddies." It has been recognized that CSOs can play a powerful role in creating or maintaining contingencies associated with an identified patient's substance use. This is notto suggest that CSOs are responsible for the identified patient's use, but CSOs may inadvertently behave in a way that makes it easier for the identified patient to abuse. Examples include the CSO who gives special attention to a relative whenever that person is intoxicated, or the CSO who routinely heats up dinner when the identified patient comes home late and inebriated. CRAFT teaches CSOs how to alter their own behavior in a manner that rewards sober behavior and withdraws rewards during times of substance use. For instance, the CSO who spends extra time with an intoxicated relative will learn to spend time with him or her only when he or she is sober, and will learn to communicate the reason for this new behavior in a caring manner.

Loving CSOs also sometimes remove the negative consequences of substance use, such as paying an identified patient's bills so as not to incur late fees. CRAFT might teach these CSOs to inform the identified patient in advance that they will happily assist with the bill paying but only at times when the person is substance-free. If limited clean/sober periods mean that time does not get set aside for paying bills, the CSO would be taught to let them go unpaid, thereby allowing the identified patient to face the consequence of a late fee. Thus, CRAFT shows CSOs how to shift rewards that may have unwittingly been linked with drug and alcohol use (ie, "enabling") to positive identified patient behaviors instead.¹⁶

Overview of key CRAFT techniques

Motivating and supporting the CSO. Although CSOs are highly invested in seeing the identified patient's behavior change, their motivation sometimes wavers when they discover that they have to initially do all the hard work. An excellent way to energize CSOs for the difficult road ahead is to discuss CRAFT's success rate and to explain how CRAFT focuses not only on identified patient treatment engagement but also on helping CSOs become more satisfied with their own lives. The latter is addressed throughout therapy, as CSOs are encouraged to set personal goals across different life areas and progress toward the goals is monitored and reinforced.

Functional analysis. In order to help CSOs find healthy behaviors that serve the same function as the identified patient's substance abuse, one must first understand the context in which the identified patient's substance abuse normally occurs. This functional analysis asks CSOs to describe the identified patient's pattern of use, starting with external triggers (people, places) and internal triggers (thoughts, feelings). The CSO learns to develop options for influencing the identified patient to respond to these triggers with a healthy behavior. CSOs also identify the positive consequences of the substance use as experienced by the identified patient--namely, the factors that are maintaining the substance use. The CSO generates healthy methods of serving these same purposes and develops a plan for introducing them to the identified patient. The negative consequences of the substance use are also identified, because these "damaging" reinforcers may serve as motivators for the identified patient to alter his behavior.

Learning to reward only nonusing behavior. The functional analysis often reveals examples of CSOs' unwitting support of the identified patient's substance use. Suppose a CSO regularly participates in an enjoyable activity with the identified patient, but often during times when the identified patient is high. CRAFT teaches that even inadvertent pairings of rewards (ie, the CSO's presence during a pleasant activity) with the identified patient's abusing behavior helps to maintain the substance use. CRAFT provides specific and safeways for CSOs to withdraw such reinforcement (eg, only joining the identified patient for the activity when he is not high). As identified patients lose rewards that were associated with their substance abusing behavior, they gradually become more interested in reducing their use and starting treatment.

Introducing rewards for nonusing behaviors is a natural complement to withdrawing rewards for using behaviors. CRAFT helps CSOs determine simple rewards that can be offered at times when the identified patient is clean/sober (eg, compliments, small favors), as well as new pleasant drug-free activities to sample when the identified patient is not under the influence. The decision about whether the CSO should communicate the purpose of these new behaviors depends on the particular CSO and identified patient.

Allowing the negative consequences of use to occur. Individuals with substance use disorders invariably experience a number of negative conse- quences associated with their use (eg, social difficulties, financial problems). CRAFT teaches CSOs that by protecting the identified patient from these consequences, they are increasing the likelihood that the identified patient will use again. Within reason, and while considering safety precautions, CSOs are encouraged to refrain from protecting the identified patient from the consequences of alcohol or drug abuse.

Positive communication training and treatment invitations. A positive communication style is essential for all of the CRAFT procedures. Understandably, years of substance-related problems may have fueled a CSO's anger toward the identified patient, and yet angry communication is not successful in getting the identified patient into treatment. Thus, the CSO is taught a "gentle" way of communicating, both as a way of explaining the new CSO behaviors as they are introduced and as a way of presenting the invitation for the identified patient to enter treatment. Furthermore, practicing good communication skills is vital because substance users with more positive and stable family relationships enjoy more successful treatment outcomes.¹⁵

Preparation for extending a treatment invitation entails not only learning how to make a request but when to make it. Still, the invitation itself is a small part of why CRAFT is so effective. The foundation is laid in the weeks of carefully planned behavior change that the CSO has introduced and the new relationship dynamics that have resulted.

Conclusion

CRAFT engages treatment-refusing alcohol and drug users in treatment by working with family members or friends. Its effectiveness has been supported by clinical trials and extends across ethnic groups. More widespread use of CRAFT could increase the number of alcohol and drug users willing to enter treatment, as well as help their families enjoy a more positive lifestyle. Of course, placing an identified patient on a long waiting list for treatment would almost certainly sabotage the engagement efforts, thus, practical issues would need to be addressed in advance.

Miller WR, Meyers RJ, Tonigan JS. Engaging the unmotivated in treatment for alcohol problems: a comparison of three strategies for intervention through family members.

J Consult Clin Psychol.

1999;67:688-697. Meyers RJ, Miller WR, Smith JE, Tonigan JS. A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others.

J Consult Clin Psychol.

2002;70:1182-1185.

For more information on setting up a CRAFT program or on receiving CRAFT training, please contact Robert J. Meyers, PhD, via his Web site, www.robertjmeyersphd.com.

Dr Meyers is research associate professor, Ms Austin is a graduate student in clinical psychology, and Dr Smith is professor in the psychology department and the center on alcoholism, substance abuse, and addictions at the University of New Mexico, Albuquerque.

The authors report that they have no conflicts of interest concerning the subject matter of this article.

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