Community Reinforcement Approach and Family Training

Today I’d like to introduce you to one of the most effective treatments/interventions for substance abuse that is rarely used and even-more rarely discussed. It’s called CRAFT and is a behavior therapy approach designed primarily for those with substance abuse issues. Developed by Nate Azrin in the 1970s, his technique focused on operant conditioning to help people learn to reduce the power of their addictions and enjoy healthy lifestyle. CRA was later combined with the FT (…family training), which equips family and friends with supportive techniques to encourage their loved ones to begin and continue treatment, and provides defenses against addiction’s damaging effects on loved ones.

The first part of this acronym – Community Reinforcement Approach (CRA) was originally created for individuals with alcohol issues. Clinicians later went on to apply it to a variety of substance use disorders for more than 35 years. The clinical premise is based on operant conditioning (…type of learning in which an individual’s behavior is modified by its antecedents and consequences), basically, CRA helps rearrange the client’s life so that healthy, drug-free living becomes more interesting/stimulating and thereby competes with substance use.

CRA is designed to be a time-limited intervention. The time limit is decided upon between the clinician and client. For example, a set number of sessions (for example, 16 sessions) or time limit (for example, one year) may be decided upon either at the very beginning of therapy or within the early stages of therapy.

One major goal of CRAFT is to increase the odds of the substance user who is refusing treatment to enter treatment through close support of family members, as well as improve the lives of the concerned family members. CRAFT clinician and participants teach and reinforce the use of healthy rewards to encourage positive behaviors. Additionally,  it focuses on helping both the substance user and the family strengthen their relationships which is often torn apart.

In the model, the following terms are used:

• Identified Patient (IP) – the individual with the substance abuse issues that is refusing treatment
• Concerned Significant Others (CSOs) – the relevant family and friends of the IP.

Three goals

When a loved one is abusing substances and refusing to get help, CRAFT is designed to help families learn practical and effective ways to accomplish these three goals:

1. Move their loved one toward treatment
2. Reduce their loved one’s substance use
3. Improve their own lives

This comprehensive behavioral program accomplishes these objectives while avoiding both the detachment espoused by Al-Anon and the confrontational style taught to families by the Johnson Institute Intervention.

CRAFT and these traditional approaches all have been found to improve CSO functioning and increase CSO-IP relationship satisfaction. However, CRAFT has proven to be significantly more effective in engaging treatment-resistant substance users in comparison to the Johnson Institute Intervention and Al-Anon (or Nar-Anon) facilitation therapy. 

CRA Breakdown of Treatment

The following CRA procedures and descriptions are typical recommended clinical content areas for the substance user:

1. Functional Analysis of Substance
   • explore the antecedents of a client’s substance use
   • explore the positive and negative consequences of a client’s substance use
2. Sobriety Sampling
   • a gentle movement toward long-term abstinence that begins with a client’s agreement to sample a time-limited period of abstinence
3. CRA Treatment Plan
   • establish meaningful, objective goals in client-selected areas
   • establish highly specified methods for obtaining those goals
   • tools: Happiness Scale, and Goals of Counseling form
4. Behavior Skills Training
   • teach three basic skills through instruction and role-playing:
   1. Problem-solving
      • break overwhelming problems into smaller ones
      • address smaller problems
   2. Communication skills
      • a positive interaction style
   3. Drink/drug refusal training
      • identify high-risk situations
      • teach assertiveness
5. Job Skills Training
   • provide basic steps for obtaining and keeping a valued job
6. Social and Recreational Counseling
   • provide opportunities to sample new social and recreational activities
7. Relapse Prevention
   • teach clients how to identify high-risk situations
   • teach clients how to anticipate and cope with a relapse
8. Relationship Counseling
   • improve the interaction between the client and his or her partner

Communication 

With CRAFT, CSOs are trained in various strategies, including positive reinforcement, various communication skills and natural consequences. One of the big pieces that has a lot of influence over all the other strategies is positive communication. 

Here are the seven steps in the CRAFT model for implementing positive communication strategies.

1. Be Brief
2. Be Positive
3. Refer to Specific Behaviors
4. Label your Feelings
5. Offer an Understanding Statement – For example, “I appreciate that you have these concerns, … [or] I understand that you really want to talk right now, and that this feels urgent, … [or] I would love to be there for you.”
6. Accept Partial Responsibility – This step “is really designed to decrease defensiveness on the part of your loved one. … It’s not about accepting responsibility for things you are not responsible for. … [Rather, it’s to] direct you towards the piece that you can own for yourself. … [For example, ] what you can take responsibility for are the ways that you communicate,” etc.
7. Offer to help

Take home message – Help decrease defensiveness on the part of the loved one that you are speaking to, and increase the chances that your message is really going to be heard—so, increasing the ability that you have to really get across the message that you want. 

Consequences with specific limits/expectations being in place is essential in terms of communicating your message, but it’s also really important, maybe even more so, to be consistent in following through with those consequences and rewards.

Al-Anon 

As an organization, Al-Anon does not currently adopt, hold, or promote the view that CSOs can make a positive, direct, and active contribution to arrest compulsive drinking, which is the opposite premise of CRAFT. Al-Anon is a fellowship with a focus on helping families and friends, themselves, without promoting a direct intervention process for alcoholics. Because “no one ever graduates” from Al-Anon, it can be viewed as an open-ended program, not time-limited.

Al-Anon view

Regarding the CSO’s relationship to alcoholism and sobriety, the view from the Al-Anon organization can be summarized:

1. Powerlessness. Al-Anon‘s First Step promotes a powerless view for families and friends, “We admitted we were powerless over alcohol—that our lives had become unmanageable.”
2. Disease view. Al-Anon writes, “As the American Medical Association will attest, alcoholism is a disease.” Al-Anon also states, “Although it can be arrested, alcoholism has no known cure.”
3. Three C’s. Al-Anon has a dictum called “the Three C’s—I didn’t cause alcoholism; I can’t control it; and I can’t cure it.”
4. Loving detachment. Al-Anon “advocates ‘loving detachment’ from the substance abuser.”
5. Family illness. Al-Anon writes, “Alcoholism is a family disease,” and “we believe alcoholism is a family illness and that changed attitudes can aid recovery.”

Summary

CRAFT is not perfect and is not easy to implement partially due to lack of clinician training and also because of having multiple people involved (ie. IP, concerned others, and clinician). Programs, agencies and clinicians may not even be aware of CRAFT if you ask so if you or a loved one are in need of a non-residential approach that’s well researched and effective, find a substance abuse therapist able and willing to use it.