The CRAFT of Getting Loved Ones Sober
By Brenda L. Wolfe, PhD & Robert J. Meyers, PhD
During much of the last century, people with substance abuse problems were perceived as either willfully ruining their lives, or possessing an inherent weakness of character that made them unable to resist ruining their lives. Regardless of stance, both beliefs led to the inevitable conclusion that the individual was either bad or weak. Hence, the common approach for those who loved substance abusers was to nag them to change, plead with them to change, and threaten abandonment or worse if they failed to comply. Rarely effective, these tactics invariably exhaust the addicted person??Ts significant others, who ultimately feel helpless to make a positive difference in the addict??Ts life.
We have come a long way since rock and roll was the devil??Ts music and the moral model dominated our thinking about addictions. We understand the impact of reinforcement and punishment, and the intrinsic power of relationships to mold behavior ??" just as the behavior of an individual who abuses substances can have a negative impact on the lives of family members and friends (Collins, Leonard, & Searles, 1990; Velleman, Bennett, Miller, Rigby, & Tod, 1993), those same concerned significant others (CSOs) can have a powerful positive impact on the substance abuser (Kirby, Marlowe, Festinger, Garvey, & LaMonca, 1999; Meyers, Miller, Hill, & Tonigan, 1999; Meyers, Miller, Smith, & Tonigan, 2002; Miller, Meyers, & Tonigan, 1999).
Community Reinforcement and Family Training (CRAFT) teaches CSOs to optimize their impact by changing their behavior toward treatment-resistant loved ones. Built on the tradition of unilateral family therapy, Meyers and colleagues (e.g., Meyers, Dominguez, & Smith, 1996; Meyers & Smith, 1997; Smith & Meyers, 2004) have systematized a program that teaches CSOs to analyze and modify the reciprocal effects they and their substance-abusing loved ones have on each other. The resulting approach enables them to gently, but firmly, move loved ones toward sobriety. In addition, CRAFT emphasizes the importance of CSOs attending to their own needs even while helping their loved ones, needs that have too often taken back seat to the demands of loving a substance-abuser.
Empirical foundation of CRAFT
Over the past decade, CRAFT has been refined in federally funded clinical trials, a number of which this article discusses. Compared to traditional interventions, CRAFT has consistently resulted in greater rates of treatment engagement for substance abusers and significantly greater degrees of improvement in the well-being of their CSOs. After learning CRAFT, CSOs report they feel renewed hope as they return to caring for their personal needs, develop problem-solving skills that move them from a reactive to a proactive stance, and take control of their lives by replacing confrontation and battle with analysis and collaboration.
In a large trial funded by the National Institute on Alcohol Abuse and Alcoholism, 130 CSOs (93 percent female; 53 percent white; 39 percent Hispanic) were randomized into one of three treatments: (1) Al-Anon facilitation therapy, designed to encourage CSO involvement in the 12-step program and to get their drinkers into treatment, (2) Johnson Institute Intervention to prepare the CSO for a family meeting designed to push the drinker into treatment, and (3) CRAFT, which taught behavioral change skills and strategies for guiding the drinker into treatment. All three treatments were manual-based and included 12 hours of contact over a six-month period. By the end of the study, CSOs in the CRAFT group were significantly more effective in engaging their resistant drinkers into treatment (64 percent) than were CSOs in the Al-Anon group (13 percent), or the Johnson Institute (30 percent) interventions (Miller et al., 1999).
The effectiveness of CRAFT extends to illicit drug users as well. In a pilot study by Meyers et al. (1999), an engagement rate of 74 percent of drug users was obtained for 62 CRAFT-trained CSOs. Controlled clinical trials with illicit drug users had similar strong outcomes. Kirby and colleagues (1999) produced a 64 percent engagement rate for CRT (an earlier version of CRAFT) compared to 17 percent for a 12-step intervention in a controlled trial with a fairly balanced CSO population of primarily Anglos and Hispanics.
As word of CRAFT??Ts effectiveness has spread, numerous requests for client materials have been received by Dr. Meyers. In response, we have taken the CRAFT techniques, which heretofore have been documented only in clinical manuals, and crafted them (excuse the pun) into an self-help book for the CSO who is tired of nagging, pleading, and threatening and is ready to apply empirically validated strategies to help their loved one achieve sobriety (Meyers & Wolfe, 2004). The balance of this article outlines the elements of CRAFT as taught in Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening.1
Key elements of CRAFT
The heart of CRAFT is CSO empowerment. Sufficient research has shown that the CSO need be neither victim nor helpless bystander to the havoc of substance abuse. Rather, she or he can learn to analyze what appear to be random maddening events into a series of relatively predictable and controllable interactions between the abuser and his or her environment, the latter of which includes the CSO. As central people in substance abusers??T lives, CSOs learn they have the power to change how they interact with their loved ones and, in so doing, move them toward sobriety.
In conjunction with the goal abstinence for the user, CRAFT encourages the CSO to prioritize self-care. Filling the role of caretaker for a high-demand loved one often leaves the CSO drained and neglectful of personal needs. We argue that if the caretaker is not taken care of, it is impossible for him or her to function at an optimum level. Hence, CRAFT helps the CSO embrace self-care and realize the inherent power of the relationship to improve life for both himself or herself and for the loved one.
This realization was poignantly expressed by Liz, who, after a few weeks of using CRAFT commented, ??oEven if I weren??Tt seeing improvement in Larry??Ts drinking, giving up our adversarial roles is such a welcome change. I feel like we??Tre soldiers returning from war.??? CRAFT is empowering those who love substance abusers with alternatives that place them on the same side as the people they love; it provides alternatives to nagging, pleading, and threatening.
Behavioral mapping is the central procedure of CRAFT and the first strategy taught in Get Your Loved One Sober. It is a systematic way of analyzing CSO and substance abuser interactions and determining how those patterns may be modified to achieve different results. Teaching CSOs to map these critical behaviors is accomplished with multiple examples. For instance, Ed has struggled for years with his wife??Ts drinking. Day after day, she comes home from work in a bad mood and heads for the liquor cabinet. Ed tries his best to cajole her into not drinking. In spite of his sincere efforts, Lydia continues to drink. Finally, Ed learns to map their daily struggle and devise an alternate route to follow. His revised map is shown here. The old paths are in (parentheses) and the new behaviors he intends to do are typed in boldface.
Lydia comes home complaining. ??"> (Ed points out he had a rough day too, kids clamor for attention.) Rub her shoulders and tell her how much the kids and I appreciate her. Tell her to take a bath while I fix dinner. Also tell her that the bath will help her relax without a drink so our evening can be more enjoyable. ??"> (Lydia pours herself a drink while beginning to organize dinner.) Lydia takes a bath while I fix dinner. ??"> (Ed asks her if she??Ts going to get drunk again ??"> Lydia tells him to lay off and knocks back the first drink while she continues fixing dinner. ??"> Ed tells her what a poor example she is for the kids. ??"> Lydia pours another. ??"> Ed storms out of the kitchen. ??"> The children start crying. ??"> Lydia, having put something on the stove to heat, pours another and heads to the bedroom to change out of work clothes. ??"> Ed follows her in and apologizes. ??"> She accepts but is now a little tipsy. ??~ Lydia heads back to the kitchen and refills her glass two or three more times. ??"> By the time dinner is ready and the family is gathered round the table, Lydia is drunk, Ed is furious, and the evening is a disaster.) Lydia comes downstairs relaxed and we enjoy dinner. (Meyers & Wolfe, 2004, pp. 35-36.)
Of course, Ed??Ts plan did not come off flawlessly on the first try. However, rather than despairing at the initial lack of desired results, CRAFT helped him see each attempt as data he could use to refine his strategy. Consequently, each time Lydia came home from work in her usual funk, he made a little progress, felt a little more in control, and the evenings became a little less stressful. Eventually, even Lydia began to come home less ready to fight because Ed simply wasn??Tt responding in the old way. His efforts sooner or later resulted in less drinking by Lydia and her willingness to consider abstinence.
Powerful as behavioral mapping is in its own right, CRAFT further equips the CSO with cognitive and behavioral tools that help to move the loved one toward sobriety at the same time the CSO addresses his or her quality of life.
Before the CSO makes any changes to life with the substance abuser, a safety plan is established. In addition to the usual advice to pack an emergency bag and identify a safe house, CRAFT clients are taught to recognize red flags of violence. Using behavioral mapping, they not only see violence coming but develop safe, effective means of responding to it. Although getting their loved ones sober is a central objective for our clients, doing so at the expense of broken bones and traumatized children is not acceptable.
The CSO has the ??oright???
Perhaps most critical to implementation of CRAFT is helping the CSO to truly believe that taking charge of the relationship is right. As we tell readers in Get Your Loved One Sober, ??oTaking the driver??Ts seat requires that you do two things. One is that you believe you have the right to drive. The other is that you believe you have the power to steer??? (Meyers & Wolfe, 2004, p 83). Because it is often the case that substance abusers repeatedly blame their problems on CSOs, it is common for CSOs to believe that if only they were somehow better (smarter, kinder, more beautiful, richer, the list goes on!), the drinker would be better too. CRAFT utilizes the CSO??Ts motivation, born of this belief, to help him or her become better at taking care of him- or herself and teaching the CSO to use the power inherent in the relationship to gently move the loved one toward abstinence.
The power inherent in the relationship is anchored in psychological principles of learning. CRAFT clients learn to use positive and negative reinforcement, punishment, and extinction to variously reinforce and discourage target behaviors. Within this context, chronic patterns of enabling and fixing are identified and modified. Clients first learn to recognize these patterns in others, as in the case of George who attempts to prevent his wife from driving drunk by stocking her favorite liquor at home, ??oAfter all,??? he says, ??oshe is going to drink so better she does it at home where she can??Tt kill herself in a car wreck??? (Meyers & Wolfe, 2004; p 112). From recognizing enabling in others, readers learn to carefully review their own ??ofixing??? behaviors and come to grips with the need to allow their loved ones to experience the natural consequences of their behavior.
To enhance the CSO??Ts ability to implement behavioral techniques and disengage from harmful fixing patterns, the CRAFT method also teaches communication skills and systematic problem-solving. Perhaps most important, however, we teach clients engagement techniques that have been shown to result in a higher rate of treatment enrollment by substance abusers than the more traditional methods. In particular, the CSO is oriented to the magnitude of the demand placed on the loved one by treatment. Although from the CSO??Ts perspective, giving up a problematic drug is a good thing, for the user it can be a hugely sad thing. The CSO is sensitized to the emotionally loaded place the substance occupies in the user??Ts life and the importance of helping him or her to develop other means of filling that life space. Relapse prevention is best served when the substance abuser had already tasted, so to speak, non-intoxicating sources of enjoyment.
Treatment selection for the loved one is also not left to the vagaries of what therapist happens to have an opening when the drinker is ready to engage. To the contrary, CSOs are guided in exploring the various treatment options available in their communities, comparing treatment models to idiosyncrasies of their loved ones, and pre-arranging for the ??obest matched??? therapist to be available the moment the substance abuser indicates willingness to meet him or her. Along these lines, the CSO is also given guidelines to figure out the best time, circumstances, and manner in which to suggest treatment to his or her loved one. After what often feels like a lifetime of arguing over alcohol/drug use and begging the loved one to ??ogo to a program,??? CSOs are relieved to finally have a means of suggesting treatment that does not result in a battle and often does result in an agreement.
Needless to say, things do not change immediately just because the CSO has a new set of strategies. It typically takes multiple attempts to follow the new maps before even the CSO can reliably not slip into the old arguments, but each attempt provides data for behavioral mapping and the CSO develops an increasingly refined strategy and skill set. In the end, even if the substance abuser does not make important changes, the CSO has the peace of mind of knowing she or he has exerted a best effort and any critical decisions about the relationship can now be made with a clear conscience.
As mentioned, Get Your Loved One Sober is our response to therapist requests for client material to use with CRAFT treatment. Thus, it has been structured to lend itself to facilitation of formal treatment.
Although the structure of Get Your Loved One Sober allows the reader to use the contents in whatever sequence best meets his or her needs, we have found that having a manual to share with clients helps therapy better retain its focus. Thus, the book can be used by therapists to help structure treatment and avoid the circuitous path sometimes dictated by the crises-filled lives of CSOs.
Get Your Loved One Sober teaches CRAFT techniques in the language and tone of CRAFT therapists and thus provides consistent at-home review of concepts taught in session. By having the therapist??Ts voice, so to speak, accompany the CSO in written form between sessions, concepts are reinforced and generalization outside of the therapy room facilitated. Rationales and techniques can be reviewed if the CSO gets stuck, and ideas generated for modifications to plans that fall short of the mark. Moreover, the case histories woven throughout the technical material help to keep the CSO motivated while facing the challenge of changing long-standing patterns. In essence, Get Your Loved One Sober helps you help CSOs move their loved ones onto the path of sobriety.
Brenda L. Wolfe, PhD is a Clinical Psychologist specializing in the treatment of eating disorders and substance abuse. In addition to private practice, she is involved in research and corporate consulting, and is active in various professional organizations. Her works have appeared in both the popular and professional press.
Robert J. Meyers, PhD is an Associate Professor of Psychology at the University of New Mexico and Associate Director of the Clinical Research Branch of the Center on Alcoholism Substance Abuse and Addictions. The creator of CRAFT, he has worked in substance abuse for more than 27 years and has published extensively.
> SEE THEIR BOOK:
Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening
1 A CRAFT therapist manual by Smith and Meyers (2004) appears in the Reference list.
Collins, R.L., Leonard, K. & Searles, J. (Eds.) (1990 ). Alcohol and the family. New York: Guilford Press.
Kirby, K.C., Marlowe, D.B., Festinger, D.S., Garvey, K.A., & LaMonca, V. (1999). Community reinforcement training for family and significant others of drug abusers: A unilateral intervention to increase treatment entry of drug users. Drug and Alcohol Dependence, 56: 85-96.
Meyers, R.J., Dominguez, T.P., & Smith, J.E. (1996). Community reinforcement training with concerned others. In Van Hasselt, V.B., & Herson, M., Sourcebook of psychological treatment manuals for adult disorders (pp. 257-294). New York: Plenum Press.
Meyers, R. J., Miller, W.R., Hill, D. E., & Tonigan, J. S. (1999). Community reinforcement and family training (CRAFT): Engaging unmotivated drug users in treatment. Journal of Substance Abuse, 10(3): 291-308.
Meyers, R.J., & Smith, J.E. (1997). Getting off the fence: Procedures to engage treatment resistant drinkers. Journal of Substance Abuse Treatment, 14 (5), 467-472.
Meyers, R.J., Miller, W.R., Smith, J.E., & Tonigan, J.S. (2002). A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others. Journal of Consulting and Clinical Psychology, 70(5), 1182-1185.
Meyers, R.J., & Wolfe, B.L. (2004). Get your loved one sober: Alternatives to nagging, pleading, and threatening. Center City, MN: Hazelden Press.
Miller, W.R., Meyers, R.J., & Tonigan J.S. (1999). Engaging the unmotivated in treatment for alcohol problems: A comparison of three intervention strategies. Journal of Consulting and Clinical Psychology, 67(5): 688-697.
Smith, J.E. & Meyers, R.J. (2004). Motivating substance abusers by treating their loved ones: The CRAFT Program. Guilford Press: New York, NY.
Velleman, R., Bennett, G., Miller, T., Rigby, K. & Tod, A. (1993). The families of problem drug users: A study of 50 close relatives. addiction, 88: 1281-1289.
This article is published in Counselor,The Magazine for Addiction Professionals, June 2004, v.5, n.3, pp. 57-60.