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Enlisting Family Members to Address Treatment Refusal in Substance Abusers

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 Approach11,12 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


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