Those who fall into substance misuse often create havoc around them among their communities and families.
This is why a range of community and family therapies have been developed, aimed at getting those closest to the substance user to help.
Among these, a method developed in the mid-1980s in the US called Community Reinforcement And Family Training (CRAFT) has risen to the top.
CRAFT has been shown to be almost three times as effective as other approaches.
In this article, we will explore what CRAFT is as well as the Community Reinforcement Approach to sobriety that the system is based upon.
One of the biggest problems associated with substance misuse is that the person involved (sometimes referred to as the Identified Patient or IP) often cannot see that they have a problem.
They will not understand that they are behaving in a threatening, abusive or violent way that is out of character, for example.
They will not always understand that their moods either during or between substance misuse sessions have a real impact on those closest to them.
In some cases, this can lead to their spouse leaving them and family breakdown occurring.
Where there is sufficient strength in the relationship, a family-based approach can be most effective for the substance user as they can have positive reinforcement for their recovery.
The philosophy behind CRAFT is that those closest to the IP will have a very good idea as to the nature of their substance misuse problem.
The Concerned Significant Other (CSO) could be a parent, spouse or adult child of the individual.
It may be someone who lives with them and must put up with the ups and downs associated with substance misuse.
Amongst other common issues the CSO will often experience:
The CRAFT approach teaches the CSO how to look after themselves and to protect themselves from the IP’s wayward behaviour.
This helps them deal with the stress brought about by their loved one’s misuse and can also help strengthen their relationship with the IP for the long term.
In helping them retain and maintain their identity so the training can make life easier for the CSO during the hard road to recovery.
One of the core principles behind CRAFT is that recovery from addiction should not be purely about negative consequences.
The CSO will be trained in offering positive reinforcement for success in tackling the problem, though will also be taught not to shield the substance user from natural consequences of their substance misuse.
At the same time, CRAFT also shows the CSO how to guide the IP in a non-confrontational way toward seeking treatment.
This non-confrontational approach is widely believed to be the reason for the success of CRAFT over other systems such as the Johnson Intervention.
Ultimately, it also shows the CSO how to support the IP on their road to recovery.
The basis of CRAFT is the Community Reinforcement Approach, a system to support the substance user developed in the early 1970s.
Descended from the philosophy of cognitive behavioural therapy (CBT), it is based on the idea that an individual’s social and occupational environment is core to their recovery.
The CRAFT intervention was developed from the CRA system as a base.
Let’s take a look at the seven essential stages of the approach and in the next section, the 14 steps of CRAFT that builds on it:
They consider the positive and negative consequences of substance abuse and come to form a plan of action in recovery.
This stems from the idea that the concept of never-ending sobriety is hard to swallow. Whilst there are plenty of tips to help maintain sobriety, living a life free from substance use is a challenge.
The IP is given fixed and limited periods of sobriety to aim at, and towards the end of each, they are consulted to see whether to continue each time.
Eventually, this will lead to abstinence with no end date.
In this phase, a set of attainable, clear and measurable goals are set for the IP to achieve.
As the programme progresses, the IP will assess where things have gone wrong and how to get around those obstacles in future.
Getting a good job that the IP enjoys. A core tenet of CRA is if the IP has employment they find pleasurable they will make an effort to be sober and to retain it.
All too often the IP will have a vacuum in their lives where substance use once filled. Advice and counselling will be offered as to how to fill this time.
As the programme progresses, the IP will get better at identifying risky situations and learn how to avoid or survive them.
With this concept underpinning the CRAFT approach, we will now look at how it is taught to the CSO to help them help their loved one on the road to recovery.
Here are the 14 sessions of training for the CSO ahead of the CRAFT intervention with brief discussions of each:
This shows the CSO the route they will be taking to help the IP.
Similar to Stage 1 of CRA, the CSO will assess the triggers, feelings, thoughts and consequences around substance use for the IP.
Teaching the CSO how to reward sobriety and avoidance of substance use.
How the CSO can interfere in the IP’s substance misuse. This might be a planned family outing when the IP had planned to have a big substance misuse session, for example.
Taking a neutral, non-confrontational approach to the IP misusing their substance.
Allowing consequences of substance use to happen, for example not bailing them out if in trouble with the police.
How to cease ineffective negative communication with the IP on substance misuse while finding new, natural consequences to substance use.
Finding the appropriate moment to address the issue with the IP. How to communicate when the moment comes.
Suggesting treatment options and having a rapid entry treatment option available to get the IP help before they change their mind.
How the CSO can retain their individuality and not be subsumed in the dramas of the IP’s substance use.
How to look after oneself through the experience and retain the strength to continue.
The trainer will put the CSO through a realistic simulation of what they will face and equip them with the tools and responses needed for discussions around substance misuse.
What the CSO will face during the intervention and good practice techniques to resolve situations as they arise.
Beyond the CSO there will be others very close to the IP who may become involved in the encouragement to get treatment.
These may be parents, spouses, friends or older children.
They will be brought in at this stage so everyone is being consistent in the non-confrontational approach.
For example, if the spouse refuses to bail the IP out of trouble with the police, then so will the mother in this instance.
How to deal with violence and threats of violence during the relationship with the substance misuser.
This will obviously involve putting one’s safety above the relationship and setting red lines that maintain the CSO’s safety.
A review of the course and preparation for the intervention to take place.
Once trained in CRAFT, the support does not stop here.
The treatment provider offering the training will likely offer the CRA based treatment programme to the IP, becoming the rapid entry treatment option described in session 8 above.
At the same time, there is recognition that recovery from substance misuse is rarely successful the first time around.
As such, there will be support for the CSO throughout the addiction/ recovery/ relapse cycle.
This will give them the support they require as they take measures to help their loved one move on from the substance misuse that has blighted their lives.
Since the 1990s when CRAFT was first assessed by scientists, CRAFT has consistently been shown to be the most effective form of family intervention where substance misuse is concerned.
The emphasis on the welfare and safety of those making the intervention, as against more confrontational approaches proposed in other interventions, make it one of the safest ways to intervene.
It also promotes stronger relationships between the CSO and the IP and can lead to far more positive results than allowing the natural consequence of family breakdown to occur.
Community Reinforcement and Family Training (CRAFT) https://www.apa.org/pi/about/publications/caregivers/practice-settings/intervention/community-reinforcement
The Community Reinforcement Approach: History and New Directions https://psycnet.apa.org/record/2005-13277-00F(5
Developing Community Reinforcement and Family Training (CRAFT) for Parents of Treatment-Resistant Adolescents https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4394369/
Community reinforcement and family training and rates of treatment entry: a systematic review https://files.m16.mailplus.nl/user31300425/3706/CRAFT_review_Archer_2020.pdf