Research in the United States shows that reluctance to enter treatment is a common issue, with fewer than 10-20% of those diagnosed with SUD entering treatment (Tucker & King, 1999). Further, the reason given by 95.4% of those who did not receive treatment was that they did not believe they needed it (Lipari, et al., 2016). A recent study in India that sought to find both reasons for seeking treatment and reasons for not seeking treatment found that 88% of participants did not seek treatment because they believed treatment was not needed (Arun, et al., 2004). Results of a European study found the top reasons given for not seeking treatment were they did not believe they had a problem (55.3%), stigma or shame (28.6%), barriers to treatment (22.8 %), and participants preferred to cope alone (20.9%) (Probst, et al., 2015). In addition to non-seeking or refusal of treatment being a universal issue internationally, it occurs across age groups. One study of college students, for instance, found that of 548 college student participants diagnosed with SUD, just 3.6% thought they needed treatment and just 8.8% of those sought help (Caldeira, et al., 2009).
Evidence from another study supported not only difficulty engaging persons with SUD in treatment, but also its impact on participants’ overall health, revealing that people with alcohol use disorder (AUD) are more likely to miss medical outpatient appointments than people without AUD (Fortney, Booth, Blow, Bunn and Cook (1995). What if there was a method for getting people into treatment that really worked and that also helped them to maintain recovery long enough to realize the healthy and fulfilling lives they were meant to live? Research evidence shows that such programs do exist and are being used successfully to move people with SUDs and AUDs into treatment and help them maintain recovery by using and bolstering the support of their families, social environments, and work environments.
Community Reinforcement Approach (CRA) and Community Reinforcement and Family Training (CRAFT)
CRA is a treatment methodology designed to manage behaviors related to substance use disorder (SUD) and areas of life that are disrupted by it. CRAFT is an evidence-based outpatient intervention for substance use disorder that was subsequently developed as a strategy for using family members to help treatment refusing substance clients with SUD or AUD engage in treatment (Hunt and Azrin 1973). The theory behind the method was the concept of operant conditioning, a method for learning new behaviors that was first written about by Skinner in 1939. This approach works primarily through the use of rewards and consequences for certain behaviors. Dr. Robert Meyers began working with CRA in 1976 and helped to develop many of the procedures used in both CRA and in the adolescent version of CRA (A-CRA) and the CRAFT intervention programs. Adolescent CRA (A-CRA) is the model that was developed in the late 1990s for use with adolescents. CRAFT is the most recent model, using a cognitive-behavioral approach and is based on research from the two previously created models showing that the employment of environmental contingencies are crucial to encouraging sobriety for substance dependent clients. All three of these treatment methodologies employ the positive aspects of community, familial, recreational, and occupational environments, using them to reward sober behavior to make the lives of people with alcohol use disorder more satisfying and enjoyable when they are sober than when they are drinking (Meyers, Villanueva, & Smith, 2005).
What the Research Base Tells Us about this Treatment Modality
Research into CRA and CRAFT shows effectiveness and a variety of strengths, including the following results:
- CRA is more effective than existing standard treatment for alcohol dependence (Azrin, 1976; Azrin, Sisson, Meyers, & Godley, 1982; Hunt & Azrin, 1973).
- Effectiveness in ethnically diverse samples (Smith, Meyers, & Delaney, 1998).
- In the four meta-analytic reviews of treatments for alcoholism conducted over the past 12 years, CRA has consistently placed among the top programs. Depending on the review, it has been ranked from the first to the fifth position out of a group of 30–50 interventions (Finney & Monahan; 1996; Holder, Longabaugh, Miller, & Rubonis, 1991; Miller et al., 1995; Miller, Wilbourne, & Hettema, 2003).
- CRA has a more recent history of being used in conjunction with contingency management programs to treat illicit drug abusing populations, with very successful results in treating persons with SUD who use illicit drugs (Meyers, Roozen, and Smith, 2011).
- CRA also evolved into a format (i.e., CRAFT) that could be used with the concerned significant others (CSOs) of treatment-resistant substance abusers (Meyers, Roozen, and Smith, 2011).
- CRA has been shown effective with clients having anywhere from mild to severe alcohol problems, and with goals of either reduced drinking or abstinence (Meyers, Roozen, and Smith, 2011).
- CRA has been successful in inpatient, outpatient, and day treatment settings, as well as in both rural and urban environments (Azrin, 1976; Azrin et al., 1982; Hunt & Azrin, 1973; Smith et al., 1998).
- A major strength of CRA is its flexibility. The program contains a menu of procedures that can be selected from and tailored to meet a client’s background and goals. For example, an unemployed client would likely find the job-training component to be of immediate value. A client whose social relationships are rapidly deteriorating due to alcohol abuse might benefit from CRA’s communication skills training, or its relationship therapy (Meyers, Roozen, and Smith, 2011).
A description of some of the primary procedures included in most CRA programs is provided below:
- CRA Functional Analysis: This is a process where the client and therapist work together to identify what people, places or times (external conditions) and thoughts or feelings (internal conditions) occur prior to occurrences of drinking or drug use. They then work together to list all elements of using behavior and both positive and negative consequences that occur. Only by knowing both positive and negative results of use can factors be identified that help create psychological and environmental conditions that prevent use and reinforce and maintain sobriety (Azrin, 1976; Hunt & Azrin, 1973).
- Sobriety Sampling: This process is an alternative to telling clients that they can never drink or use again, news which sometimes has the effect of causing clients to feel overwhelmed and end treatment. Instead, a negotiated time-limited period of abstinence is agreed upon (Azrin et al., 1982). This initial period of abstinence is used to teach behavioral skills, and the properties of a drug-free lifestyle are highlighted. Disulfiram with oversight of a trained monitor is occasionally used to help maintain abstinence (Azrin, 1976; Meyers & Smith, 1995, pp. 57–77). Upon completion of this trial period of sobriety, the therapist and client discuss the advantages of extending the sober period (Smith & Meyers, 2001, pp. 41–42).
- CRA Treatment Plan: Two documents are foundational for the CRA treatment plan, The Happiness Scale and the Goals of Counseling. The Happiness Scale allows the client to estimate current satisfaction in ten areas of life on a scale of one to ten. The therapist uses the Goals of Counseling results of the Happiness Scale to help the client to set positive, specific, and measurable goals in the same ten areas of life, such as job, education, and relationships. Then for each goal, strategies and timelines are established with a plan for attaining each goal (Meyers & Smith, 1995, pp. 80–101; Smith & Meyers, 2001).
- Behavioral Skills Training: During the initial assessment and treatment plan development, the need for behavioral skills to prevent relapse will usually emerge. Patients learn to recognize and anticipate risky situations that put them at risk for relapse and practice skills such as refusal training and problem solving. To prevent clients from becoming overwhelmed from such a situation, they are taught to methodically reduce it into smaller, more manageable steps, implement a plan of action, and assess outcomes for future reference (Meyers, Roozen, and Smith, 2011). Communication skills and job skills training are also provided.
- Social/Recreational Counseling: Rather than assuming that clients with SUD or AUD can easily replace unhealthy social and recreational behaviors with healthy ones, CRA trained counselors help them to identify new activities and behaviors and assist them in trying new ones by helping them to deal with their concerns about functioning while sober (Meyers, Roozen, and Smith, 2011).
- Relationship Counseling: CRA trained counselors use a couple’s version of the Happiness Scale and the Goals of Counseling form to begin the process of improving the interactions between them. Other aspects of relationship counseling include each partner asking for a small change from the other, practicing of communication and problem solving skills, and a Reminder to Be Nice for re-establishing common courtesies and good natured small talk to the relationship (Meyers and Smith, 1995; Smith, et al., 2008).
Practical Applications of CRAFT
An excellent working example of how the CRAFT model can be used to great benefit in addressing issues of treatment avoidance or refusal may be found at Utah Support Advocates for Recovery Awareness (USARA), located in Salt Lake City, Utah. USARA’s mission is to “celebrate, advocate, support, and empower people in all stages of addiction recovery through connecting to resources, building community, and raising awareness that long term recovery is possible.” In pursuit of its mission, USARA has several programs in addition to the CRAFT Family Support program, including Addiction Recovery Coaching in Healthcare & Emergency Settings (ARCHES), Addiction Recovery Management for Families (ARM), Recovery Leadership Initiative (RLI), and Telephone Recovery Support (TRS).
Darlene Schultz is a Family Support Facilitator with an extensive knowledge of addiction and recovery through lived experience. To quote Ms. Schultz, the three goals of CRAFT in simple language are to:
- “Reduce your loved one’s harmful substance misuse.
- Engage your loved one into treatment.
- Improve you and your family functioning (emotional, physical, relationships)”
The CRAFT program at USARA focuses on these three goals to help families whose loved ones are struggling with a substance use disorder while providing support for family and friends as they make life changes to improve those relationships. This positive approach helps to create an environment that encourages their loved ones to move toward recovery. CRAFT recovery works not only for adults over 18, but also for minors with parental consent.
Benefits of the CRAFT Modality
Ms. Schultz has witnessed many benefits of implementing CRAFT as part of a comprehensive treatment plan: “The great news about CRAFT is that it can be used by family members, friends, coworkers or anyone interested in learning a new approach to helping someone they love move toward recovery by learning motivational strategies for interacting in a positive, supportive and non-confrontational way. When using the skills and techniques reinforced by this program, not only do they find ways to help their loved one engage into treatment, they can also benefit both emotionally and physically even if their loved one does not enter treatment.”
One of the major strengths of CRAFT is that family members and friends of persons with SUD or AUD are encouraged and supported in treating their loved ones with kindness and respect to support positive changes. This relieves them of the inclination to use a “tough love” style, which is often in conflict with how family and friends really feel. USARA has implemented a peer-facilitated Family Recovery Coach approach with a modified CRAFT model that is tailored for the group setting. The peer facilitators are trained in the evidence-based model to enable them to use their own lived experience to facilitate the family support groups. The Peer Family Support Facilitators developed a CRAFT workbook in 2017 to provide specific instruction following the “Get Your Loved One Sober” book by Robert J. Meyers and Brenda L. Wolfe, and trained facilitators provide the books and workbooks for program participants.
The USARA program is being tracked for effectiveness through the University of Utah. To maintain fidelity, the USARA implementation of CRAFT requires training of both volunteer and paid staff facilitators following the “peer-to-peer” model. The requirements for facilitator/coaches are to attend 3-6 existing CRAFT Family Support Group (FSG) meetings, attend the 2 1/2 -day CRAFT FSG Facilitator Training, and attend follow-up facilitator trainings either in-person, through Zoom, or webinar format. Early survey results after family support group sessions 1, 6, and 12 have been very encouraging. Family members’ perceptions of having the knowledge, skills, and confidence to improve the well-being of their families have increased, as have ratings of emotional well-being for both the person with SUD or AUD and the family members supporting them in recovery.
With group meetings in Utah held at USARA, libraries, hospitals, treatment centers, and local authorities, CRAFT can be used collaboratively with a variety of partners. The USARA implementation has had success in interfacing with health departments in Utah and with the Utah Division of Substance Abuse and Mental Health (DSAMH). In addition, USARA works with the Church of Jesus Christ of Latter-day Saints (LDS) Hospital Dayspring Intensive Outpatient program, providing trained facilitators who facilitate the weekly groups for their program with Dayspring purchasing all books and materials required.
To sum up in the words of Darlene Schultz at USARA, “Families are often excluded collaborators in recovery when they can actually make very positive contributions by empowering their loved ones and influencing change. I feel it is important to get the word out that CRAFT model is available. USARA and those who have participated in CRAFT Family Support Groups…have endorsed the CRAFT model as the most impactful solution they have come across. Together we can overcome the stigma of addiction, encourage hope for recovery and provide support to families who through a proven approach that can benefit both the loved one and their family members.”
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