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Family Approaches to Addictions Treatment: CRAFT, Intervention And Al-Anon

A. Tom Horvath, Ph.D., ABPP, Kaushik Misra, Ph.D., Amy K. Epner, Ph.D., and Galen Morgan Cooper, Ph.D. , edited by C. E. Zupanick, Psy.D.

Community Reinforcement and Family Training (CRAFT) is a form of counseling. It is intended for people whose lives are intertwined with addicted persons. These people are called Concerned Significant Others (CSO). This model refers to the addicted person as the Identified Patient (IP). The CSO is typically a family member. However, it can be any person whose life is affected by someone else's addiction. This might include boyfriend, girlfriend, and unmarried life partners. CRAFT has three goals: 1) improve the life of the CSO, 2) reduce the IP's addictive behavior, and 3) influence the IP to begin addiction treatment. The primary mechanism of change is the CSO's behavior toward the IP.

family wordCRAFT relies on well-researched behavioral principles. Most people find these principles to be rather common sense. If you reward a behavior, it will most likely increase. Similarly, if a behavior is not rewarded (ignored) or it has a negative consequence associated with it, then the behavior is likely to decrease.

Although every situation is different, the general direction of CRAFT is for CSOs to learn to: 1) ignore using behavior, 2) reward non-using behavior, and 3) discontinue enabling. Enabling refers to the well-intended removal of negative natural consequences that would ordinarily serve to decrease a behavior. For instance, suppose an IP came home drunk, and passes out in the front yard, in his own vomit. It would be tempting for the CSO to go out, help her husband make it inside the house, and proceed to wash him up. The next day he'd have such a hangover that his wife might call his boss and say he has the flu. These well-meaning gestures would be enabling because they remove several, natural and unpleasant consequences from occurring. Imagine instead if the wife (CSO) did nothing (except something medically necessary). The next day, the husband (IP) would eventually awake with a severe hangover. He is lying in his front yard, covered in vomit. One negative consequence is embarrassment. All his neighbors drove off to work seeing him out there like that. Similarly, the IP must drag himself inside, deal with the disgusting task of cleaning himself up. He must also call his boss, all while dealing with a hangover.

Robert Meyers, Ph.D. at the University of New Mexico (Meyers & Wolfe, 2004) developed CRAFT. Typically, therapists meet with one or more CSOs for 12-16 sessions. In order for this therapy to be effective, CSOs should have daily contact with the IP. Ideally, they live with the IP. IP's typically begin their own addiction treatment about half way through the CSO's treatment. As the CSO change their behavior, it prompts the IP to changes theirs by starting treatment.

The underlying principle of CRAFT is that in order to change someone else's behavior, you must first change your own. However, this is not always an easy thing to do. Unfortunately, some CSO's are so angry with the IP that they become unwilling to participate in a type of treatment that requires them to change. It's quite common for CSOs to feel righteous indignation when we ask to them to change. They do not consider themselves the one with the problem. Yet, you most certainly have a problem if you are in a relationship with an addict! CRAFT helps CSO's to understand that even though they are not responsible for the addiction, they can be very helpful by promoting recovery.

You should not confuse CRAFT with the term "Intervention." Intervention became popular because of a reality TV show of the same name. The show has a standard format. Family members and friends form an alliance to confront the addicted person with the aid of a "professional." The ultimate goal is to get the addicted person to agree to go to treatment. This staged alliance and confrontation is termed an "intervention."

These sensationalized TV "interventions" may be harshly confrontational. They often involve some form of deception to trick the unsuspecting addicted person into attending such an unpleasant event. Thus, these interventions are certainly not voluntary. Therefore, they may be harmful rather than helpful.

In contrast, CRAFT is not confrontational, nor does it involve any deception. Across several studies, CRAFT is approximately three times more effective than "interventions" at getting IPs into treatment (Meyers & Smith, 2004). Interventions in turn are slightly more effective than Al-Anon at getting IPs to attend treatment. Al-Anon is 12-step approach for helping people in relationships with alcoholics to "detach with love." There are other -Anon programs specific to certain addictions. They are all based on the 12-step approach to recovery. The emphasis of -Anon programs are for CSOs to stop focusing on the behavior of the addicted person. Instead, they focus on their own behavior. Anon participants help each other to practice self-care. Simultaneously, they allow the addicted persons to enter recovery in their own way.