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Community Reinforcement and Family Training (CRAFT): Disseminating Evidence‐Based Concepts Beyond Clinical Practice
Jeffrey Foote, Ph.D.
Founder and Executive Director of CMC
David Lane, Psy.D.
Clinical Director, CMC Westchester
NYSPA 76th Annual Convention June 2, 2013
CRAFT – Community Reinforcement and Family Training
• Give an overview of CRAFT
• Review the research behind CRAFT
• Understand CRAFT’s goals, strategies, and techniques
• Discuss dissemination issues and barriers
3
What Is CRAFT?
CRAFT is a highly effective, evidence‐based approach for working with family members trying to cope with a loved one who is reluctant or refusing to get help for substance abuse problems
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Alphabet Soup
CRAFT
CRA
CSO IP
Engagement
Community Reinforcement and Family Training
Community Reinforcement
Approach
Concerned Significant Other
Identified Patient (the substance user)
Entering Treatment
What Is CRAFT?
• A method for working with family members (CSO) to more effectively deal with a loved one (IP) who is refusing to get help
• Promotes the active, positive participation of CSO’s
• Motivational rather than confrontational
CRAFT Overview
• Unilateral therapy working with the “concerned significant others” (CSOs) of a loved one (IP) who is refusing to get help
• Views CSO’s as powerful collaborators
• Promotes the active, positive participation of CSO’s
• Motivational rather than confrontational
• Focus of change: both the CSO and the IP (although the therapy is “unilateral”)
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CRAFT’S 3 MAJOR GOALS
• Reduce loved one’s harmful drinking
• Engage loved one into treatment
• Improve the functioning of CSO
(emotional, physical, relationships)
Why Work with the Family?
• Families promote treatment seeking
• The family has extensive knowledge and contact and will continue to
• The family is suffering and needs help
CRAFT – The Basics
• Works to affect the loved one’s behavior by changing the way the CSO interacts with them
• Skills‐based program useful to the CSO in multiple life areas
• Menu‐driven approach based on CSO needs
• Therapist modeling is critical
3
CRAFT Components (1)
• Introduction and Rationale For CRAFT
• Domestic Violence Precautions
• Functional Analysis of IP’s Behavior
• Communication Training
CRAFT Components (2)
• Positive Reinforcement Training
• Discouraging Use/Negative Behavior
• Self‐Care for the CSO
• Suggestion of Treatment to the IP
Initial Meeting with CSO
Overview
• Listen to the problem/past attempts to help
• Place responsibility where it belongs
• Begin to establish idea of “reinforcers”
• Describe the program: “What is expected”
• Model positive focus and optimism
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Functional Analysis: Developing a Roadmap
• FA is a behavioral analysis of IP’s behavior (neg or pos) conducted with the CSO
• Premise: behavior (IP substance use) does not exist in a vacuum, and can be influenced by changes in CSO behavior toward IP
• Through examining IP use patterns, triggers, and consequences (positive and negative), CSO develops strategies for influencing IP behavior
Functional Analysis:
Procedure
• Describe the drinking/using behavior
(what, how much, for how long)
• Identify triggers for the drinking/using
(who, where, when, thoughts, feelings)
• List consequences the IP experiences for alcohol/drug use (positive and negative)
Functional Analysis of Using Behavior
External Triggers
1. Who is your
loved one usually
with when
drinking/using?
2. Where does
he/she usually
drink/use?
3. When does
he/she usually
drink/use?
Internal Triggers
1. What do you think
your loved one is
thinking about right
before
drinking/using?
2. What do you think
he/she is feeling right
before
drinking/using?
Short-Term
Behavior
Positive Consequences
1. What does
1. What do you think your loved one likes
your loved one
about drinking/using with
usually drink/use?
_______________________________? (who)
How much does
he/she usually
drink/use?
Long-Term
Negative
Consequences
1. What do you think
are the negative results
of your loved one’s
drinking/using in each
of these areas (and
which of these would
he/she agree with):
2. What do you think he/she likes about
drinking /using __________________?
(where)
A. Interpersonal
3. What do you think he/she likes about
drinking /using __________________? (when)
B. Physical
4. What do you think are some of the pleasant
thoughts he/she has while drinking/using?
C. Emotional
3. Over how long
a period of time
does he/she
usually drink/use?
D. Legal
5. What do you think are some of the pleasant
feelings he/she has while drinking/using?
E. Job
F. Financial
G. Other
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Functional Analysis: Behavioral Goals with CSO
• Provide estimate of current use
▫ for behavioral marker of change over time
• Outline IP triggers to use
▫ for CSO planning how & when to influence IP
• Identify IP’s positive consequences of using ▫ for developing healthier pathways for IP
• Identify IP’s negative consequences of using
▫ for appealing to IP about possible change
Functional Analysis:
Process Goals with the CSO
• Help CSO see substance use as more predictable
• Increase CSO sense of optimism and direction
• Increase CSO empathy toward IP
Communication Training
Why work on communication?
• More likely to get what you want
• Positive communication is “contagious”
• Will open door to more CSO satisfaction in other life areas as well (social support)
• Positive communication is the foundation for other CRAFT procedures
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Things that Don’t Work
•
•
•
•
•
•
•
Nagging
Pleading
Threatening
Yelling
Lecturing
Pouring alcohol down the drain
Getting drunk (to show the drinker what it’s like)
Positive Communication Skills
•
•
•
•
•
•
•
Be brief
Be positive
Be specific and clear
Label your feeling: “I feel ___”
Offer an understanding statement
Accept partial responsibility
Offer to help
Positive from Negative
Words Matter
* When you’re drunk, our time together seems miserable.
I enjoy spending time
with you when you’re
sober.
* You make it impossible to
keep track of our bank accounts.
I appreciate it when
you let me help keep
our bank account balanced.
*You never help clean the house.
I know you’re busy, but
I could use your help cleaning the garage Sat.
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Positive from Negative
Actions Matter
• What is wanted vs what is not wanted
• Not “argument language”
• Clear statement of what to do
• Timed appropriately
Positive Communication:
Practice Makes Sort of Perfect
Using “successive approximations”
• First attempt: “That’s it! I can’t take it anymore. Get help or get out!”
• Second attempt: “Your drinking is really stressing me out. I know your job is extra tough these days, but isn’t there another way to handle it?”
• Third attempt: “Your drinking really upsets me. And I miss talking to you. I know work is tough. How about I help you figure out another way to handle the stress? I have some ideas.”
Role‐Playing Guidelines
•
•
•
•
•
•
•
•
•
Acknowledge discomfort
Use less difficult scenes first
Get adequate description of the scene
Start it for them
Keep it brief (2‐3 minutes)
Reinforce any effort
Get client’s reactions
Offer supportive, specific feedback
Repeat
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Using Positive Reinforcement
Promoting Positive Change
What is positive reinforcement?
Why is it important in CRAFT?
Clarifying positive reinforcement vs. “enabling”?
What are the steps involved in this process?
Positive Reinforcement (Rewards)
• More flies with honey
• A reward is only a reward if the person for whom it is intended desires it
Enabling vs. Positive Reinforcement
• Enabling: something the CSO does that increases drinking/drug using behavior or allows it to continue
• CRAFT’s Positive Reinforcement: something the CSO does that increases non‐drinking/non‐drug using (pro‐social) behavior
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Use of Positive Reinforcement
• Discuss CSO’s current responses to substance use (and non‐use).
• Get information from the Functional Analysis (consequences).
• Is it working? Willing to try something
different?
• Explain a positive reinforcer.
Functional Analysis of Healthy Behavior
Identify Positive Reinforcers
Generate a list of 8‐10 positive reinforcers. Are they:
•
•
•
•
Definitely pleasurable for the IP?
Inexpensive or free?
Available to deliver immediately?
Comfortable for the CSO to deliver?
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Identifying Non‐Using Behaviors to Reinforce
Behavior to reinforce should be one that:
• The IP enjoys.
• Competes with the substance‐using behavior in terms of time and function.
• Occurs fairly often currently, or can occur often in the future.
• The CSO also enjoys (if applicable).
Discouraging Use/
Negative Behavior
• Withdrawing of positive reinforcement
when IP resumes drinking/using.
• Identify reinforcers (rewards) to withdraw.
• Will IP miss the withheld reinforcer?
• Teach CSO to communicate the rationale
for withholding the reward. Sample Reinforcers to Withdraw
• Parents (CSOs) have a teenager (IP) who comes home smelling like pot each day. Withdraw _________?
• Wife (CSO) has an alcoholic husband (IP) who always wants her to accompany him to company functions. Withdraw _______?
• Older brother (CSO) has younger brother (IP) who shows up high to assist w/ Little League coaching. Withdraw ________?
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Identifying the Natural Consequences for Using
• Explore CSO’s unintentional support of the drinking/using.
• Refer to F.A. (consequences) if necessary
• Offer common examples:
▫ Reheating dinner for late, intoxicated IP
▫ Calling in sick for hungover IP
▫ Making excuses to family/friends about IP
Sample Natural Consequences
• Wife (CSO) cleans up her husband’s (IP) “accidents” when he’s drunk.
• Husband (CSO) of an unemployed drug‐abuser (IP) calls his parents for financial help each month.
• Daughter (CSO) picks up her drunk dad at midnight after his Sat. night card games.
Allowing the Natural Consequences for Using
• Select one situation
• Consider the natural consequences (negative?)
• Explore potential problems in allowing
them (safe? reasonable?)
• Use problem‐solving if necessary
• Role‐play the communication
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Anticipate Obstacles
• Difficulties experienced by CSOs when attempting to withdraw positive reinforcers or allow for natural (negative) consequences
• Brainstorm options
Examples: • Fear of explicitly linking use with consequences
• Natural consequence is highly aversive to CSO
Problem Solving Guidelines
1.
2.
3.
4.
5.
6.
7.
8.
Define problem narrowly
Brainstorm possible solutions
Eliminate undesired suggestions
Select one potential solution
Generate possible obstacles
Address each obstacle
Assign task
Evaluate outcome
Increasing the CSO’s Quality of Life: Finding CSO Reinforcers
Part 1
• Assess CSO’s satisfaction in various
areas (Happiness Scale)
• Select one area needing more reinforcers
• Identify goals and steps to obtain them
(Goals of Counseling)
• Problem‐solve if necessary
• Some activities independent of drinker?
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Increasing the CSO’s Social Support
Part 2
•
•
•
•
Create or re‐create a social circle
Find a confidant
Ask for help
Self‐help groups?
Guidelines for Goal Setting
Goals should be:
•
•
•
•
•
•
Brief (uncomplicated)
Positive (what will be done)
Specific behaviors (measurable)
Reasonable
Under the CSO’s control
Based on skills the CSO has
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Potential Problems in Goal Setting
• Designing goals & interventions that are too
complex.
• Leaving out important steps necessary to reach
goals.
• Including plans that are not under the CSO’s
control.
• Unnecessarily putting CSO in a high‐risk
situation.
Goals of Counseling Form Excerpt
• In the area of drinking/sobriety I would like to…
• In the area of job/educational progress I would like to…
• In the area of social life I would like to…
Examples of CSO Goals & Interventions
• In Social Life category? (has few friends)
• In Personal Habits category? (wants to lose weight)
• In Emotional Life category? (stressed all the time)
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Suggestion of Treatment to the IP: Overview
• Prepare for Rapid Intake (for IP to be seen within 24‐48 hrs.)
• Role‐play the conversation (use positive communication)
• Include important motivational “hooks”
• Discuss windows of opportunity
Basic Questions to Consider
• CSO’s past engagement attempts that have been the most successful?
• Time, place, day the IP is most approachable about requests in general?
• Most likely reason the IP would enter treatment (for the relationship, kids, to keep his/her job)?
• Most influential person to talk with IP about treatment?
Motivational “Hooks”
•
•
•
•
Ask IP to informally meet CSO’s therapist
Mention having one’s own (a different) therapist
Invite IP to “sample” treatment
State that the IP won’t have to do anything he/she doesn’t want to • Explain that there’s no confrontation/judgment
• Mention that IP can focus on topics besides just alcohol/drugs (e.g., job, depression)
• Tie in IP’s reinforcers
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Windows of Opportunity
• Is IP approachable when feeling remorseful for a drug‐related “crisis”? • Is IP acting upset upon overhearing a negative remark about his substance use? • Is IP asking about what’s happening in the CSO’s therapy? • Is IP inquiring about why the CSO’s behavior has changed lately?
Examples
Identify “hook,” window of opportunity, positive communication component:
You’ve been my best friend and partner for over 10 years, and I don’t want that to change. But I’m worried about your drinking. Would you be willing to come down and see if my therapist can find you a counselor? Examples
I know you’re really stressed at work and that you use drugs to unwind. But I bet there’s a healthier way to deal with your stress. I know that therapists let you work on all sorts of things, including stress. You wouldn’t have to just talk about drugs. 17
Examples
Maybe I should have told you before; I started seeing a therapist a few weeks ago because I was worried about us. It would mean a lot to me if you’d come with me to a session – just one.
Examples
I know how much you love our family, and that’s why I wanted to talk with you about seeing somebody for your stress and drinking. CRAFT BOOKS
Get your loved one sober: Alternatives to nagging, pleading and threatening. Meyers, R. J. & Wolfe, B. L. (2004). A self help book published by Hazelden Publications.
Motivating substance abusers to enter treatment: Working with family members. Smith, J.E. & Meyers, R.J. (2004). Guilford Press: New York NY.
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COMING SOON TO A KINDLE NEAR YOU…..EARLY 2014
CMC’s FAMILY GUIDE TO NAVIGATING YOUR LOVED ONE AND THE TREATMENT SYSTEM
CRAFT as an Evidence‐Based Treatment:
Problems With Dissemination – or ‐
“But Don’t We Need to Do an Intervention Like on TV?”
Examples
“My husband won’t stop drinking, and it’s destroying our family. I’ve tried to get him to check into treatment, but he refuses. What should I do?”
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Traditional Approaches for CSOs
•
12‐Step Programs (Al‐Anon, Nar‐Anon)
‐ Focus of change: family only, not the IP
•
Johnson Institute Intervention
‐ Focus of change: IP, not the family
•
Mental Health Counseling
‐ Focus of change: dependent on counselor
Average Treatment Engagement Rates
100
Percentage of IP's Engaged in Treatment
90
80
68%
70
60
50
40
29.5%
30
20
19%
10
0
Al‐Anon
JI
CRAFT
RCT
CRAFT STUDIES
Sisson &
Azrin, 1986
Miller,
Meyers, et
al 1999
Kirby, et al., Meyers,
Miller, et al,
1999
1999
Meyers,
Miller, et al,
2002
Waldron, et al,.
2007
14 CSOs
130 CSOs
32 CSOs
62 CSOs
90 CSOs
42 CSOs 48%
75% Anglo; 23%
AA
80% Hispanic
88% female; 49%
Hispanic
Hispanic 48% Anglo
Alcohol
Alcohol
56% Cocaine
22% Opiate
37% Cocaine
35% Marijuana
16% Stimulants
8% Opiates
Marijuana
Cocaine
Stimulants
Marijuana Alcohol
Randomized
Randomized
Randomized
Non-randomized
(CRAFT / JI / AlAnon)
(CRAFT / 12-step)
Non randomized
Randomized
(CRAFT / 12-step)
Tx Engage:
86% vs 0%;
Tx Engage:
64% vs 23%
vs 13%;
CSOs better
Tx Engage: Tx Engage:
74% vs 17%; 74%
CSOs better
CSOs better
CSOs better
(CRAFT / AlAnon)
Tx Engage:
67% vs
29%;
CSOs better
Tx Engage: 71%
CSOs better
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Empirical Conclusions
• Initially unmotivated/resistant problem drinkers and
drug users can be engaged in treatment through CRAFT‐trained concerned significant others (CSOs)
• This is true of CSOs who are parents, adult children and spouses
In The Real World…
•
•
•
•
•
Johnson Intervention (i.e., treatment as usual)
Commonly reported success rates: 90% Empirically supported success rate: 29.5%
Prevalence: Approx. 2,000 JIs in 2009 (avg. $5,500 per JI)
Endorsed across media venues (A&E, etc.)
•
•
•
•
Al‐Anon
Empirically supported success rate: 19%
Prevalence: 14,942 Al‐Anon groups in U.S.
Tx providers 2nd most common referral source (26%) to Al‐Anon
• CRAFT (i.e., evidence‐based)
• Empirically supported success rate: 68%
• Prevalence: Approx. 5‐7 CRAFT providers in the U.S. The Problem of the Rarely Practiced EBT
•
•
•
•
•
Reimbursement issues
Organizational constraints
Cost and time associated with training
Challenges of training
Definitions of EBTs
• The philosophical divide: The conflict between
• EBTs and the disease model
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The Tenets of the Disease Model
Medical, spiritual and moral models blended into one (Miller, 1993)
•Tenet I: “You have it or you don’t”
•Tenet II: Biological in origin
•Tenet III: Use is uncontrollable
•Tenet IV: Incurable and irreversible
•Tenet V: Characterized by spiritual and character defects
“You have it or you don’t”
Implications in JI and Al‐
Anon
CRAFT Approach
Assumed “one‐size‐fits‐all”
diagnosis/severity Variety of substance abuse problems and severities; tx/ “tactics” individualized
Disagreement by the “addict” is by definition “denial”
Goal is communication and collaboration with IP
To suggest individual variation is to support the disease
Individualized care and feedback critical to engagement
Language of the Conflict
CRAFT: “How important is this issue to him, and in what ways? “
“How can we talk in ways that will not make him defensive?”
Disease: “He’s an alcoholic… suffering from terminal uniqueness. “
“He’ll never admit it no matter how hard you push.”
“Use is uncontrollable”
Implications in JI and Al‐
Anon
CRAFT Approach
Immediate and complete abstinence are only use goals
Incremental change as a critical path; reduction is positive step
Goal of intervention is always 28 day inpatient care
LOC determined by individual severity/circumstances
“Addict’s” personal choice IP’s personal choice and is irrelevant to the process “buy‐in” are crucial to the process
“Addicts” use because they’re addicts… nothing to talk about”
Substance use is a choice motivated by reinforcements Language of the Conflict
CRAFT: “We can work at having him consider reducing or stopping, but we really need his buy‐in.”
Disease: “Its his thinking that got him here.”
“This positive support stuff is just enabling his disease.”
“You can wait, but this kid will be coming home in a coffin.”
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Spiritual / character defects are core of “disease”
Implications in JI and Al‐Anon
Break through “denial” by confronting substance user with family’s version of reality.
Unilateral approach is necessary to deal with “disease”
CRAFT Approach
Language of the Conflict
Develop positive family atmosphere conducive to lowered defensiveness; Collaborative engaging with IP’s perception of reality
IP use behavior responds to The “addict” brain is not rational; external mandates are collaborative rationality and only effective path
positive reinforcement
“Addict’s” lack of motivation is a symptom of the disease
IP’s motivation levels affected by interactional principles
“Addict’s” statements, rationale and behaviors not to be trusted: ”it’s the disease talking”
Mandating one path increases resistance… IP will consider change if not backed into a corner
Disease: He hasn’t reached a bottom yet..we’ll bring the bottom to him.”
Disease Model Obstacles to CRAFT
• “This support for the addict is just enabling him.”
• “We have to act NOW. We can’t afford to move slowly, or this kid is coming home in a coffin.”
• “You’re giving them the wrong idea! It’s not her home life that’s making her drink; it’s her disease.”
• “He hasn’t reached his bottom yet..just wait”
• “We need to come at her disease as hard as we can until we break through her denial.”
The Conflict
There is an inherent conflict between disease
model tenets/philosophy and many elements of
evidence‐based treatment
 Multiple paths to substance use problems
 Multiple levels of severity
 Multiple paths to change
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The Conflict (Part 2)
Critical in working on these issues are:
 Empathy
 Choice
 Collaboration
Recommendations From the Field
• Increase graduate and early‐career training
• Consider process of training in addition to structure and content
• Language matters!
• Support qualified clinicians
• Get the motivated public (parents) involved Graduate and Early‐Career Training
• Doctoral programs (Chiert, Gold, & Taylor, 1994)
• 38% offer one course on substance abuse
• 95% of these courses are electives
• Only 30% consider graduate school an appropriate venue for substance abuse training
• Surveyed psychologists (Div 22) (Cardoso, Pruett, Chan, & Tansey, 2006).
• 79% reported treating pts with alc and drug use issues
• 59% rated their training as “very poor” or “poor”
• Frequency of approaches used:
 Referral to self‐help (46%)
 CB Coping skills
(39%)
 Mot Enhance
(17%)
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Consideration of Training Process
ACT Training (Varra et al, 2008): 2‐day training on EB pharmacotherapy for counselors
Conditions
1) 1‐day educational seminar + 2‐day pharm training
2) 1‐day ACT training + 2‐day pharm training
Results ‐ ACT group differed significantly in:
1) Barriers to referral  a) acknowledged more,  b) believed less
2) Psychological flexibility
3) Actual referrals for pharmacotherapy eval
at 3 months
Language Matters!
Stigma effect on clinical judgment (Kelly & Westerhoff, 2009)
• Clinicians read patient vignette – 2 conditions:1) pt described as “substance abuser”
2) pt described as “having a substance use disorder”
• “Substance abuser” group scored pt higher on the perpetrator‐punishment scale
Traditional disease model principles deeply embedded in mainstream treatment language
Language of Traditional Treatment
• “Take the cotton out of your ears and stick it in your mouth”
• “He’s suffering from terminal uniqueness”
• “She’s taking her will back”
• “He needs to get honest”…because “this is a disease of dishonesty”
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Support Qualified Clinicians • 50% annual turnover rates among addiction treatment staff – comparable to fast‐food industry (McLellan, 2006)
• “To be perceived as an attractive opportunity to those who might be able to develop and deliver new addiction interventions, there will have to be greater financial rewards in the addiction intervention business” (McLellan, 2006). Involve the Motivated Public
Partnership at Drugfree.Org and CMC Collaborative project with The Center For Motivation and Change (CMC) to train parents interested in CRAFT to “coach” other parents in “CRAFT‐Lite” strategies
Embeds a different language and approach into the self‐help culture
Community Reinforcement and Family Training (CRAFT): Disseminating Evidence‐Based Concepts Beyond Clinical Practice
Jeffrey Foote, Ph.D.
Founder and Executive Director of CMC
David Lane, Psy.D.
Clinical Director, CMC Westchester
NYSPA 76th Annual Convention June 2, 2013
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