Community reinforcement approach and family training


Community Reinforcement Approach and Family Training is a behavioral intervention approach used in the treatment of substance use disorders. The approach involves working with family members of individuals with substance use disorders to improve communication and interaction patterns and to support engagement with treatment services.

Overview

Developed in the late 1970s by Dr. Robert J. Meyers and colleagues, CRAFT is an adaptation of the Community Reinforcement Approach. This approach encourages individuals with substance use disorders to seek treatment by actively involving their family members. By promoting the use of healthy rewards for positive behaviors, CRAFT aims to reduce the individual's resistance to finding support while simultaneously enhancing the family’s well-being.
The approach has three primary goals:
  1. Engage the substance user in treatment.
  2. Reduce substance use behaviors.
  3. Improve the family members' mood and functioning.
CRAFT treatment is time-limited, typically involving a specified number of sessions or a set time frame determined early in the therapy process.
The adolescent community reinforcement approach specifically adapts CRA for adolescents with substance use issues and their caregivers.

Description

CRAFT is a family-based therapeutic model that incorporates principles of positive reinforcement. It was developed to address substance use disorders by modifying interaction patterns between individuals who refuse treatment and their family members or close contacts. The approach aims to support engagement with treatment and to address the impact of substance use on family relationships.
In the model, the following key terms are used:Identified Patient : the individual with the substance use disorder who is refusing treatment.Concerned Significant Others : the relevant family members and friends of the IP.
Meyers reported that concerned significant others participating in CRAFT may experience changes in emotional functioning and independence, regardless of whether the identified patient enters treatment.

CRA and CRAFT procedures

The following CRA procedures and descriptions for the substance user are from Meyers, Roozen, and Smith:
  1. Functional Analysis of Substance
  2. * Explore the antecedents of a client's substance use.
  3. * Explore the positive and negative consequences of a client's substance use.
  4. Sobriety Sampling
  5. * A gentle movement toward long-term abstinence that begins with a client's agreement to sample a time-limited period of abstinence.
  6. CRA Treatment Plan
  7. * Establish meaningful, objective goals in client-selected areas.
  8. * Establish highly specified methods for obtaining those goals.
  9. * Tools: Happiness Scale and Goals of Counselling form.
  10. Behavior Skills Training
  11. * Teach three basic skills through instruction and role-playing:
  12. # Problem-solving
  13. #* Break overwhelming problems into smaller ones.
  14. #* Address smaller problems.
  15. # Communication skills
  16. #* A positive interaction style.
  17. # Drink/drug refusal training
  18. #* Identify high-risk situations.
  19. #* Teach assertiveness.
  20. Job Skills Training
  21. * Provide basic steps for obtaining and keeping a valued job.
  22. Social and Recreational Counseling
  23. * Provide opportunities to sample new social and recreational activities.
  24. Relapse Prevention
  25. * Teach clients how to identify high-risk situations.
  26. * Teach clients how to anticipate and cope with a relapse.
  27. Relationship Counseling
  28. * Enhance the interaction between the client and their partner.

Communication

CSOs are trained to accomplish treatment goals, via positive reinforcement, communication skills, and natural consequences. There are seven steps in the CRAFT model for implementing these 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"
  6. Accept partial responsibility – for example: "It's not about accepting responsibility for things you are not responsible for"
  7. Offer to help
The overarching goals for the strategies for communicating are to help decrease defensiveness on the part of the loved one that the CSO is speaking to, increases the chance that the message is really going to be heard.

CRAFT view

The majority of medical and legal professional bodies, such as the World Health Organization, the American Medical Association, and the American Bar Association, state that alcoholism is a disease, demonstrated by changes in brain chemistry. However, Dr. Gene Heyman and others assert that alcoholism is not a disease. The disease theory of alcoholism—the idea that alcoholism is caused by a disease rather than being a disease itself–asserts this as well. The diagnostic assessment of alcoholism in someone can include an assessment of co-morbidity with conditions such as mental illness and domestic violence.
From SMART Recovery, section: Family & Friends:
The CRAFT program uses a variety of interventions based on functional assessment, including a module to prevent domestic violence.

Intervention

A study examining individuals with substance use disorders who underwent a traditional intervention, commonly known as the Johnson Intervention, found higher relapse rates than those referred to outpatient alcohol or drug treatment through other methods.
Research has also identified practical and emotional challenges associated with the Johnson Intervention. Studies report that although the approach can result in treatment entry when it is carried out, only a small proportion of family members or friends who begin the process complete the intervention. Participants who do follow through often describe the approach as uncomfortable because of its confrontational nature.
By contrast, research suggests that CRAFT has been more effective than the Johnson Intervention or Al-Anon and Alateen approaches in engaging individuals who are resistant to treatment. Al-Anon and Alateen are not designed to directly influence individuals with substance use disorders, but instead focus on supporting family members and others affected by a loved one's substance use.

Development

Robert J. Meyers wrote in an introduction to one of his books that "although my mother was blessed by the support and comfort she found in Al-Anon meetings, she was never able to achieve her most cherished goals of getting my father into treatment and getting him to stay sober". Witnessing this as a child inspired Meyers to seek an approach that was more effective for people with those goals. The origin of CRAFT:
"Dr. Robert J. Meyers and Jane Ellen Smith of the University of New Mexico developed the CRAFT program to teach families how to impact their loved one while avoiding both detachment and confrontation, the respective strategies of Al-Anon, and traditional interventions in which the substance user is confronted by family members and friends during a surprise meeting. While all three approaches have been found to improve family members' functioning and relationship satisfaction, CRAFT has proven to be significantly more effective in engaging loved ones in comparison to the Johnson Institute Intervention or Al-Anon/Nar-Anon facilitation therapy."
Having worked with Nathan Azrin in the early 1970s, whilst Azrin was developing the community reinforcement approach, Meyers started to look into using the process in other settings. CRAFT combines CRA with family training, which equips the families and friends of addicts with supportive techniques to encourage their loved ones to begin and continue treatment and provides them with defenses against addiction's damaging effects on their loved ones.

CRA

The Community Reinforcement Approach, developed by Nathan Azrin in the early 1970s, was originally developed for individuals with alcohol use disorders, but has been employed to treat a variety of substance use disorders.
Azrin's belief that "punishment to be an ineffective method for modifying human behavior" was shared with B. F. Skinner, the "most influential behaviorist of all time," and later research discovered confrontation-based treatments "were largely ineffective in decreasing the use of alcohol and other substances." As such, Arin designed the Community Reinforcement Approach:
"Azrin believed that it was necessary to alter the environment in which people with alcohol problems live so that they received strong reinforcement for sober behavior from their community, including family, work, and friends. As part of this strategy, the program emphasizes helping clients discover new, enjoyable activities that do not revolve around alcohol, and teaching them the skills necessary for participating in those activities."
The CRA technique has "been found to be effective in outpatient setting." It uses operant conditioning based on a functional assessment of a client's drinking behavior and the use of positive reinforcement and contingency management to achieve the goal of non-drinking. When combined with Disulfiram, participants were "abstinent an average of 97% of the days during the last month of the 6-month follow-up, whereas clients treated with a combination of a 12-step program and the CRA Disulfiram compliance training were abstinent an average of 74% of the days." A notable component of the program is the non-drinking club. As of 2007, applications of community reinforcement to public policy have become a focus of study.

Recent developments

As of 2009, CRAFT and CRA programs were not widespread among addiction counselors. The adoption of evidence-based treatments has been slow. Instead, many addiction counselors were tied to a twelve-step model. The National Institute on Drug Abuse, a federally funded organization aiding scientific research into addiction, has supported CRAFT intervention techniques among others. In 2007, CRAFT was being used in 25 clinics in the United States.
However, CRAFT has been adopted by a number of commercial and self-help organizations in the United States. Meyers and the Treatment Research Institute worked with Cadence Online to create a Parent CRAFT course where parents pay a one-off fee for a series of videos presenting the CRAFT process, aimed at teaching them skills to meet the risks of substance use in their adolescent children. An undisclosed "major share" of the revenues goes to TRI. Meyer's work was partially funded with a grant from NIDA. provides a series of videos, eBook, blog, live calls, and other services to families of people with addiction based on the CRAFT method. The states of Massachusetts, Rhode Island, and Mississippi are providing free access for all residents to the Allies in Recovery service. Based in Rhode Island, Resources Education Support Together is a peer-led mutual aid group that uses CRAFT and the Allies in Recovery service for its members.
Founded in 2018, began focusing on supporting families and clinicians in addressing substance use disorders through the evidence-based Community Reinforcement and Family Training approach. Founded by, the organization collaborates with Dr. Robert J. Meyers, to provide for families and professionals. We The Village's work is supported by funding from the National Institute on Drug Abuse, ensuring its programs are rigorously tested and accessible online.
We The Village is currently conducting a fully powered Randomized Controlled Trial, funded by NIDA, to compare two digital interventions: CRAFT-A and PEER support. The trial aims to assess outcomes such as treatment entry and retention, family members' well-being, and knowledge of CRAFT principles.

Research and outcomes

CRAFT compared with other approaches

An offshoot of the community reinforcement approach is the community reinforcement approach and family training. This program is designed to help family members of people who use substances feel empowered to engage in treatment. Community reinforcement approach and family training has helped family members to get their loved ones into treatment. The rates of success have varied somewhat by study but seem to cluster around 70%. CRAFT is one of the only family-aimed treatments with proven results for getting people with drug or alcohol problems into treatment. The program uses a variety of interventions based on functional assessment including a module to prevent domestic violence. Partners are trained to use positive reinforcement, various communication skills and natural consequences.

Intervention for alcohol use

From an article on the American Psychological Association website about the success of CRAFT in substance use treatment and intervention, these are the success outcomes for engaging drinkers into treatment:
  1. 64% – CRAFT
  2. 23% – Johnson Intervention
  3. 13% – Twelve-Step Facilitation
Elsewhere, Robert Meyers has clarified that Twelve-Step Facilitation used in the Miller et Al's comparative study of 130 caretakers of problem drinkers was a control group structured to "simulate the kind of care and guidance CSO's would traditionally receive from attending Al-Anon meetings... treatments were delivered one-on-one and included up to 12 hours of therapy."

Comparisons

One experiment compared the two psychotherapy approaches of CRAFT and Twelve-step facilitation therapies, for their impacts on addicts seeking to enter treatment. The finding was that concerned significant others who participated in facilitation therapy engaged 29.0% of addicts into treatment, whereas those who went through CRAFT engaged 67.2%. Another study compared CRAFT, Al-Anon facilitation therapy, and a Johnson intervention. The study found that all of these approaches were associated with similar improvements in the functioning of concerned significant others and improvements in their relationship quality with the addicts. However, the CRAFT approach was more effective in engaging initially unmotivated problem drinkers in treatment as compared with the facilitation therapy and Johnson interventions.

Intervention for substance use

From the same article on the American Psychological Association website about the success of CRAFT in substance use treatment and intervention, these are the success outcomes for persons abusing drugs to enter treatment :
  1. 64% – CRAFT
  2. 17% – Caregivers' Twelve-step Group
From the article:
Note: When the articles states "there was no group x time interaction," it simply means the CRAFT outcome and the TSF outcome remained the same over time, even though there was a reduction in drug use during the study.
Parallel study
In a parallel study sponsored by the National Institute on Drug Abuse that focused on people who use other substances, family members receiving CRAFT successfully engaged 74 percent of initially unmotivated drug users in treatment.

Professional organizations

CRAFT is a model of clinical behavior analysis which is of interest to the following professional organizations.
  1. The Association for Behavior Analysis International has a special interest group in clinical behavior analysis.
  2. The Association for Behavioral and Cognitive Therapies also has an interest group in behavior analysis, which focuses on clinical behavior analysis. In addition, ABCT has a special interest group on addictions.