Community Reinforcement and Family Training
Community reinforcement and family training has been shown to have success in getting substance abusers to reduce their use and get into treatment.
Denial is a common theme among those suffering from addiction. If someone is regularly abusing alcohol, prescription drugs, or illicit substances, denial might have them convinced that there is no problem or that any problems are only the perceptions of their loved ones.
Denial can significantly hamper treatment, as someone who's addicted but doesn't think she has a problem may refuse treatment, attend treatment inconsistently, or leave treatment early. This can take an enormous toll on the loved ones of that person as they try to remedy the situation.
Community reinforcement and family training (CRAFT) has been shown to have success in getting substance abusers to reduce their use and get into treatment. It also helps show friends and family how to better communicate with their addicted loved ones.
What Is CRAFT?
CRAFT is a set of therapeutic techniques taken from community reinforcement approach (CRA) and applied to the substance abusing population. Rather than target the person with addiction directly, CRAFT works with the concerned significant others (CSOs) so that they can assist the identified patients (IPs).
CRAFT aids the CSOs by:
- Teaching them to modify their usual behaviors, reactions, and expectations towards the IP.
- Reducing or eliminating current substance use and addictive behaviors in the IP.
- Helping to motivate the IP to seek treatment.
- Showing them the importance of self-care as they manage concerns with the IP to maintain or rebuild feelings of happiness.
The final point is elemental to the goal of CRAFT because CSOs are exposed to high levels of stress and anxiety resulting from the IP's addiction. Some of the hardships associated with being the loved one of someone with a substance use disorder include:
- Increased risk of violence as well as mental, verbal, and physical abuse.
- Higher tendencies towards negative financial situations stemming from attempts to help the IP or the IP stealing money directly.
- Poor relationship satisfaction with the IP.
- Other social and relationship issues with other members of the community.
- Higher mental health complaints like depression, anxiety, and low self-esteem.
- Increased rates of physical health problems.
CRAFT allows CSOs to build feelings of confidence and power to actively assist the IP in moving treatment forward.
Foundation in CRA
Since many of the CRAFT principles are grounded in CRA, it is necessary to have a solid understanding of CRA as well. CRA is a therapeutic style based in the ideas of cognitive behavioral therapy. The thought behind CRA is that rewards and punishments from the IP's life highly influence the level of their substance use. With this being true, CRA works to change the reinforcements and punishments to decrease or end substance use. CRA will inspect aspects of:
- Family relationships.
- Social relationships.
- Work-related supports.
- Other community-based relationships.
Originally developed as a treatment for people abusing alcohol, CRA became a viable option for those with a range of addictions and drug abuse problems. CRA treatment has been effective for inpatient, outpatient, and day treatment populations. It utilizes 8 procedures to adjust the contingencies the client experiences.
8 Procedures to Adjust Contingencies
1. Functional Analysis
This is the process of understanding all of the factors present that trigger or lead to use, the thoughts and feelings during use, and the positive and negative consequences after the use. By gathering this information, the treatment team can begin formulating a plan of action based on the current aspects of use.
2. Sobriety Sampling
Since the notion of lifelong abstinence can be overwhelming and lead to reluctance to enter treatment, the goal of CRA is to establish finite periods for the IP to commit to sobriety. During this time, the systems rewarding addiction are discussed and coping skills are developed. Before the period ends, the team will meet to discuss the positives of continuing the duration of sobriety.
3. Treatment Plan
The IP is given an inventory to rate their happiness, and based on these responses, they establish goals that are attainable, clear, and able to be measured.
4. Behavioral Skills Training
With the information gathered from the previous steps, areas of improvement are identified, and a plan of action is developed. Typical skills include problem-solving, communication, and substance refusal. By developing these skills, the IP will be in a better position to change the contingencies around them.
5. Job Skills
CRA will aid in the process of finding or maintaining employment, but the community-based treatment goes beyond this. In this step, CRA will work to ensure that the job is desirable and pleasurable for the IP.
6. Social/Recreational Counseling
If the IP's life was previously built around substance use, abstinence will bring out excessive free time, and IPs may not know what to do with this. CRA helps to identify and encourage appropriate social and recreational activities.
7. Relapse Prevention
Using the identified triggers of use, relapse prevention will focus on predicting risky situations and planning ways to manage these.
8. Relationship Counseling
The IP will work with their CSO to assess the current state of the relationship and identify how they would like it to be in the future. Focus on addressing issues of the past is minimized and replaces with adding daily positive experiences to the relationship.
Components of CRAFT
In CRAFT, the therapist will teach CSOs about the basis of CRA as described above. It can be taught in a support group setting comprised of approximately 7 hour-long sessions. Each session will focus on one of the aspects below.
CSOs will learn to:
- Decide if they are a good match for the CRAFT treatment model. The major factor will be the risk of new or continued violence from the IP towards the CSO if treatment is initiated.
- Appropriately employ a functional analysis as outlined in #1 above. Much of the desired change will come from accurately identifying the triggers and consequences of using, so it is imperative for the CSO to perceive the environment correctly. Many CSOs will have distorted views of their role in the use due to their own rewards and punishments. CRAFT will improve this area.
- Improve their communication style with the IP. Over time, communication with the IP has likely become more aggressive, more passive, or almost absent. This communication training will bring the focus back to assertive communication that is clear, direct, and respectful of all parties.
- Provide positive reinforcement for sober behaviors. Too often, relationships between CSOs and IPs are based on punishments, as the CSO will become upset, yell, or provide guilt regarding use. This will make the relationship less desirable for each. CRAFT works to reverse this trend by encouraging CSOs to consistently deliver reinforcement in the form of tangible rewards or verbal praise. This will rebuild the relationship and increase the likelihood of these behaviors continuing.
- Allow natural consequences for using behaviors. Rather than feeling the need to administer punishment, CRAFT uses the notion of natural consequences to reduce the likelihood of using behaviors. IPs will face issues with the law, health consequences, social issues, and work problems from using. CRAFT believes that this is enough to end the behaviors.
- Begin looking inward to find ways to improve their own life. If the CSO spends too much time interested in the well-being of the IP, they lose their individual identity. CSOs are encouraged to engage in more pleasurable activities and reward their own positive behaviors.
- Identify the best opportunities and measures to mention treatment to the IP. An intervention is based on high levels of pressure to persuade the IP into treatment. CRAFT teaches the CSO to be aware of times and places that reveal an opening for treatment. When a situation presents, the CSO will mention options while having a plan for a "rapid intake" established so treatment can move quickly to avoid doubt in the IP.
- Be prepared and patient. If the IP enters treatment that utilizes family supports, like CRAFT, it will be up to the CSO to remain interested and engaged in the process to act as an aid. Patience is needed at this stage as well since the IP may be reluctant to try treatment or refuse directly. Additionally, the IP may initially agree to treatment only to end it early or ignore recommendations. At this point, the CSO will benefit from reassessing and restarting the process of CRAFT while putting more emphasis on their own needs and well-being.
A problem separating CRAFT from wider success is the limited knowledge of CRAFT by the public and the limited number of therapists that are trained to use the style. It may be a newer model of treatment, but it has already found success in studies done on alcohol use and substance use populations. CRAFT is backed by evidence to make a positive impact on the IP as well as the CSO.
- Meyers, R., Villanueva, M., & Smith, J. (2005). The Community Reinforcement Approach: History and New Directions. Retrieved November 12, 2015, from http://www.springerpub.com/journal-of-cognitive-psychotherapy.html
- Scruggs, Psy.D, S., Meyer, Ph.D., R., & Kayo, Ph.D., R. (n.d.). Community Reinforcement and Family Training Support and Prevention. Retrieved November 12, 2015, from http://www.mirecc.va.gov/visn16/docs/CRAFT-SP_Final.pdf