The CRAFT Treatment Manual for Substance Use Problems
Also Available Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach Robert J. Meyers and Jane Ellen Smith
The CRAFT Treatment Manual for Substance Use Problems WORKING WITH FAMILY MEMBERS
Jane Ellen Smith Robert J. Meyers Foreword by William R. Miller
THE GUILFORD PRESS New York London
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LIMITED DUPLICATION LICENSE These materials are intended for use only by qualified mental health professionals. The publisher grants to individual purchasers of this book nonassignable permission to reproduce all materials for which permission is specifically granted in a footnote. This license is limited to you, the individual purchaser, for personal use or use with clients. This license does not grant the right to reproduce these materials for resale, redistribution, electronic display, or any other purposes (including but not limited to books, pamphlets, articles, video or audio recordings, blogs, file-sharing sites, Internet or intranet sites, and handouts or slides for lectures, workshops, or webinars, whether or not a fee is charged). Permission to reproduce these materials for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications.
The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication. However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the authors, nor the editor and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained in this book with other sources. Library of Congress Cataloging-in-Publication Data is available from the publisher. ISBN 978-1-4625-5110-1 (paperback) — ISBN 978-1-4625-5111-8 (hardcover)
To my sisters, Susan Paradise, Kathryn Constantine, Judith Hakim, and Maria Ricci. You are each unique in terms of your rich personality, chosen life path, playful pursuits, and creative spirit, but you share our family’s overwhelming capacity for compassion and devotion to each other. I couldn’t love you more. —J. E. S. To my two sons, Nicholas Andrew Meyers and Oliver Joseph Meyers, whom I love with all my heart. —R. J. M.
About the Authors
Jane Ellen Smith, PhD, is Professor of Psychology at the University of New Mexico (UNM). She was the first woman to be tenured in the Psychology Department, to become Director of Clinical Training, and to become Chair of the Department, a role she filled for 12 years. Specializing in both alcohol treatment and eating disorders, Dr. Smith has published over 120 scientific articles and chapters and eight books, and was lead author of the first CRAFT manual in 2004. She is a recipient of the Presidential Teaching Fellowship, UNM’s highest teaching award, as well as the UNM Alumni Association’s Erna S. Fergusson Award for exceptional accomplishments and/or distinguished service to the university. Dr. Smith, with her colleagues, is responsible for a $15.6 million National Institutes of Health grant focused on hiring diverse biomedical faculty to enhance inclusive excellence efforts at UNM. Robert J. Meyers, PhD, is Director of Robert J. Meyers, PhD, and Associates, and is Emeritus Research Associate Professor of Psychology at UNM, where his primary affiliation is with the Center on Alcohol, Substance use, And Addictions (CASAA). An internationally sought speaker who has delivered trainings throughout the world, Dr. Meyers is the developer of CRAFT. He is a recipient of the Dan Anderson Research Award from the Hazelden Betty Ford Foundation and the Early Career Investigator Award from the Research Society on Alcoholism. He has published nearly 100 scientific articles or chapters and 10 books, including the CRAFT self-help book Get Your Loved One Sober.
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The impetus to rejuvenate and refine an early version of the Community Reinforcement and Family Training (CRAFT) approach and fully test it actually came from the front-desk staff of our large public addiction treatment program. “Almost every day we receive these desperate calls from family members who are worried about a loved one’s drinking or drug use. They don’t want to kick the person out, but it’s gotten really bad and they don’t know what to do. What should we tell them?” Back in the 1980s there were three main responses. The first was “I’m sorry, but there is nothing we can do until the person contacts us to ask for help.” Indeed, while insurers might pay to treat the drinker or drug user, there was no coverage to help their distressed family members directly. Having to say that to distraught family members also distressed our staff. A second option was to refer the family members to Al-Anon, a 12-step program where they could receive compassionate support from peers with similar experience. The Al-Anon program encourages family members to detach and accept that they are helpless to influence their loved one. People who attend Al-Anon often do benefit themselves, but for their primary concern the message was the same: “There’s nothing you can do until the person is ready to ask for help.” They didn’t feel detached, nor did they want to wait passively for their loved one to “hit bottom.” Then there was “the Intervention,” originally developed by the Johnson Institute, a kind of surprise party where the person is confronted by a roomful of people concerned about his or her substance use. A specially trained facilitator would work with the family, usually for a fee, preparing them for the eventual confrontation. This normally required weeks or months while they identified and trained the Concerned Significant Others (CSOs) who were willing to participate, and found a treatment program ready to admit the person on the designated date. Usually there would be a vehicle waiting outside to take the person off to treatment, and often some negative consequences would be announced if the person refused to go. About 70% of families ultimately decided not to go through with the Intervention, often for fear of damage to family relationships. And that was it: Wait for the person to suffer enough to be “ready,” go to Al-Anon, or plan an Intervention. Were there no other possibilities? Based on his successful experience with using a community reinforcement method to treat people suffering from substance use disorders, Bob Meyers developed CRAFT vii
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as a very different approach. Invite the CSOs to come in themselves, even if their loved one was unwilling. The message was not one of helplessness but quite the opposite: that “there are things you can do.” Always conscious of safety first, the CRAFT team taught family members how to use positive reinforcement rather than punishment to help their loved one make better choices and hopefully accept help. Families learned how to positively encourage the right stuff and not inadvertently make it any easier for the person to continue using. The clinical procedures described in this manual are clear and doable, and I had the further privilege of witnessing how people were treated: with warmth, encouragement, empathy and, yes, positive reinforcement for every step in the right direction. It sounds good, but the proof was in the outcome. In a definitive clinical trial, CSOs were randomly assigned to receive, without fee, one of three professional treatment methods, each provided by therapists trained and believing in their approach. Some received Al-Anon facilitation therapy, helping them to get engaged in the fellowship and to work the Al-Anon program. Others received an intervention facilitated by therapists trained in the Johnson Institute approach, and a third set of participants were offered CRAFT. Families in all three conditions personally benefited: Their depression, anxiety, and physical symptoms decreased. The major difference was in what happened with their loved ones. In the Al-Anon condition, few CSOs got their loved one into treatment, which is fair enough because influencing the substance user is not a goal in Al-Anon. As usual, 70% of families in the Intervention group decided not to go through with it. In the CRAFT condition, however, two-thirds of families succeeded in getting their loved one into treatment within about 6 weeks on average. CSOs observed that even before beginning treatment, their loved one’s drinking had decreased to about half its previous level. Two subsequent randomized trials found that CRAFT families engaged at least two-thirds of drug users in treatment, and this finding has been replicated by research teams in several other nations. CRAFT works. What you have in this manual from Bob Meyers and Jane Ellen Smith is seasoned professional advice from the very psychologists who have grown and tested the CRAFT approach, based on their decades of clinical experience and research. CRAFT has been successfully delivered in individual, group, and even self-directed formats. The procedures are specific and learnable, offering hope and change for distressed families that are wondering what to do. It is also rewarding work, with some of the most motivated clients you will ever see: the CSOs themselves. We who go into helping professions hope that we can contribute to the alleviation of suffering in the world, and here is a practical and effective way to do it. William R. Miller, PhD Emeritus Distinguished Professor of Psychology and Psychiatry, University of New Mexico