Enlisting Family Members to Address Treatment Refusal in Substance Abusers

Clinical trials support CRAFT's ability to engage both alcohol(Drug information on 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.

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

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.

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.