Academic journal article The International Journal of Behavioral Consultation and Therapy

A Program for Engaging Treatment-Refusing Substance Abusers into Treatment: CRAFT

Academic journal article The International Journal of Behavioral Consultation and Therapy

A Program for Engaging Treatment-Refusing Substance Abusers into Treatment: CRAFT

Article excerpt


Community Reinforcement and Family Training (CRAFT) is a scientifically-supported program for family members who are desperate to get a treatment-refusing substance abuser to enter treatment (Meyers & Wolfe, 2004; Sisson & Azrin, 1986; Smith & Meyers, 2004). CRAFT teaches these family members how to apply behavioral principles at home so that clean and sober behavior is reinforced and substance use is discouraged. CRAFT-trained family members consistently are able to engage their substance-abusing loved one into treatment in nearly seven out of 10 cases. Notably, the program is effective with ethnically diverse populations, across various types of relationships (spouses, parent-adult child), and without regard for the particular drug of abuse (alcohol, cocaine). This paper provides a rationale for working with family members when a resistant individual refuses treatment, and supplies an overview of both the CRAFT program components and the research findings.

Key words: CRAFT, Community Reinforcement and Family Training, substance use, behavioral treatment


Traditional Programs

Imagine the following common clinical scenario: a therapist receives a desperate telephone call from a family member about a loved one who refuses to seek professional help for a substance abuse problem. Until recently, the therapist had few options to offer this family member, aside from traditional programs such as Al-Anon (Al-Anon, 1984) and the Johnson Institute Intervention (Johnson, 1986). In addition to lacking empirical support for getting resistant individuals to enter treatment, each of these programs has characteristics that many Concerned Significant Others (CSOs) find unappealing.

The 12-step programs, such as Al-Anon and Nar-Anon, instruct CSOs to acknowledge their powerlessness over the substance abuser's alcohol or drug problem, to detach, and to focus on themselves. Although CSOs who attend Al-Anon do feel better, they typically are unsuccessful at getting the substance abuser to enter treatment (Barber & Gilbertson, 1996; Dittrich & Trapold, 1984; Meyers, Miller, Smith, & Tonigan, 2002; Miller, Meyers, & Tonigan, 1999; Sisson & Azrin, 1986). Importantly, many CSOs report that they are uncomfortable with the directive to detach from their loved one. A second traditional option, the Johnson Institute Intervention, entails a "surprise party" in which a group of family members and friends confront the substance abuser about his or her problem. When the intervention is carried out, it results in a high rate of treatment engagement. However, since only a small percentage of CSOs actually complete the intervention, treatment engagement rates range from 24%-30% (Liepman, Nirenberg, & Begin, 1989; Miller et al., 1999). CSOs frequently report opposition to the confrontational tactics (Barber & Gilbertson, 1997).

Unilateral Family Therapy

Unilateral family therapy (UFT) is a label often applied to less traditional approaches for CSOs (Thomas & Santa, 1982). UFT is geared toward the individual who agrees to attend treatment; namely, the CSO. The objective is to teach the CSO techniques that will change the problematic behavior of the substance abuser (identified patient; IP) and increase the likelihood that the IP will seek treatment. Thomas and colleagues conducted several of the earliest UFT trials, and obtained rather promising results in terms of engaging resistant drinkers into treatment (Thomas & Ager, 1993; Thomas, Santa, Bronson, & Oyserman, 1987). Yet there were methodological limitations of the studies, including non-random assignment to some of the treatment conditions. A second UFT, Pressure to Change, also showed moderate success in modifying IP drinking behavior and influencing IPs to begin treatment (Barber & Crisp, 1994; Barber & Gilbertson, 1997). A limitation was a confrontational component to the program for the more resistant IPs. …

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