CRAFTing a response: expanding support options available for families affected by substance use

Author

Heather Fulton PhD RPsyc (biography and disclosures)

Disclosures: The author is a provider of Community Reinforcement and Family Training/Invitation to Change approaches however she has no ownership over such approaches, is not the sole provider of such approaches, nor receives any financial compensation or payments should such approaches be used. The author does receive payments from the Centre for Motivation and Change as a co-trainer offering training in the approach for some health/helping professionals. Access to all resources outlined within this article are educational in nature and the author receives no financial compensation related to their use. Mitigating potential bias: Only published trial data is presented. Recommendations are consistent with current practice patterns. Recommendations are consistent with published guidelines: Family centred care: Families at the centre: Reducing the impact of mental health and substance use problems on families by the Family Mental Health and Substance Use Task Force.¹

What I did before

Approximately one in five Canadians will develop a substance use disorder in their lifetime.² While no similar Canadian data exists, data from the US suggest that 46% of people have a close family member or friend with a substance use disorder.³ Loving someone with a substance use disorder is challenging: family members* often report elevated levels of stress, anxiety, depression, physical health problems^, and financial difficulties amidst interpersonal chaos.^4,5 They face considerable social isolation and stigma, including blame for the substance use challenges themselves.^6,7

As a health-care provider, it can be hard to know how to help an affected family member who presents in your office. Family members’ anxiety, stress, and frustrations often seem very reasonable and proportionate to the complex, challenging situations that they face. Previously, I was aware of approaches such as Al-Anon and Interventions (also known as Johnson Interventions) for families however I was unsure of their evidence base. I had concerns about any approach that advocated hitting rock bottom when research across mental health suggests early intervention is beneficial.⁸ Additionally, approaches that emphasize families detach from the relationship or use confrontation types of strategies with loved ones also seemed at odds with everything I knew from Motivational Interviewing, trauma informed practices, and family-centered care.^1,9-11 In fact, family is often listed as a key reason for entering and maintaining recovery by people with substance use challenges.¹²

_{*For the purposes of this article family refers to both biologically related family members, members of a person’s family of origin, as well as found family such as friends, spouses, partners and other loved ones in a person’s life.}

What changed my practice

Evidence-based approaches for family members impacted by substance use disorders exist — not only to better support a loved one in accessing treatment but to improve their own lives and mental health. Community Reinforcement and Family Training (CRAFT) helps family members change the way they interact with their loved one that makes change more likely while also helping themselves in the process. It has three goals:

1. Improve the quality of life and functioning of the concerned significant other (the family member you are working with);
2. Reduce the loved one’s substance use;
3. Engage the loved one in treatment and support.¹³

It teaches families about behavioral principles of reinforcement (e.g. positive reinforcement), effective communication skills (e.g. listening, how to have conversations about substance use, offer invitations for treatment), setting and maintain boundaries, taking care of themselves and problem solving. There are similar approaches, such as Invitation to Change, which is based on CRAFT but expanded to include more skills from evidence-based psychotherapies such as Motivational Interviewing (to assist family members in supporting behavioral change) and Acceptance and Commitment Therapy (for managing the strong emotions and challenges that come with supporting a person through a change process: grief, pain, self-criticism, etc.).¹⁴

CRAFT is effective: across studies approximately 70% of loved ones entered substance use treatment when family members were trained in CRAFT compared to other approaches such as Al-Anon or Interventions (18-30%).¹⁵ Further, families enrolled in CRAFT attended more sessions and were more likely to complete the treatment compared to the other approaches.¹⁶ People who had family members trained in CRAFT had increased treatment retention and reduced substance use compared to treatment as usual.¹⁷ Often improvements happened after as little as 4-6 sessions.^15,18 It has been found to be effective across different family relationships (parents, siblings, partners) and formats (individual sessions, group sessions and self-help book formats).^19,20 Family members’ mental health is also improved with participation. Research suggests they experience significant reductions in depression, anger, and anxiety, regardless of whether their family member enters treatment or not.¹⁹ It has found to be effective with adolescents and adults and across different types of substances.^15,17,21 Additional research studies are investigating its use for families where the loved one has a psychotic illness in addition to substance use.²²

What I do now

Typical CRAFT or Invitation to Change processes are outlined in The CRAFT Treatment Manual for Substance Use Problems and Invitation to Change: A Short Guide.^13,14 There is flexibility in what supports are offered based on the presenting challenges the family is facing. Typically, the approach includes first talking with the family about their goals, what have they tried already, as well as things that are working well in their relationship with their loved one. Risk for interpersonal violence is assessed as safety of the family members is the highest priority and CRAFT may not be a good fit in such circumstances.

A first session often includes working with a family to increase their own motivation and hope for change. Topics addressed in sessions typically include:

• Understanding a loved one’s substance use based on a functional analysis (i.e. what function do the substances play in their life). The family and therapist identify possible reinforcers that may maintain use, and possible targets for change.
• Behavioral skills training. The therapist and family consider alternate rewards that may meet the same needs of substance use for their loved one. Rewards used are under the family member’s control and are not burdensome to deliver (e.g. small rewards such as offering to pay for a coffee together may be a good fit; offering to pay for a new car may not be a good fit given the cost of this reward and frequency with which it can be delivered). Problem solving strategies and discussions about allowing natural consequences of substance use are also included as part of decreasing reinforcers associated with use (e.g. family members no longer calling into work to cover for a loved one).
• Communication skills training. The therapist and family discuss how to change the dynamic of the relationship with the loved one. Communication skills training includes role playing and feedback (e.g. practicing how to have difficult conversations and how to offer understanding statements), identifying windows of opportunity for discussions regarding substance use, as well as identifying and reducing barriers to treatment engagement.
• Self-care and self-compassion. The therapist and family discuss the rationale and the value of enriching their own lives. Given this is a very challenging and stressful time, exploring practical options to recharge and improve functioning can help the family role model making healthy changes to their loved one, reduce isolation and shame, help more effectively, be happier and have less stress overall.

There are many free or low-cost resources available for people who have a loved one affected by substance use that are based in Community Reinforcement and Family Training and/or the Invitation to Change approach. While there is no one size fits all approach for any family or person who uses substances, CRAFT and its related approaches can be helpful in discussing a menu of options that may be helpful for each family’s unique situation.

Resources for health-care providers

• Canadian Centre on Substance Use and Addiction: The Essentials of Community Reinforcement and Family Training
• Shared Care & UBC CPD’s Child and Youth Substance Use Pathway: a clinical pathway to help you navigate care for children and youth with problematic substance use

Resources for families

Books:

• Beyond Addiction: How Science and Kindness Help People Change introduces CRAFT and related strategies to support your loved one.
• Beyond Addiction Workbook is an interactive and skills focused workbook.
• The 20 Minute Guide (there are versions for parents and partners) – a shortened, free version of Beyond Addiction.

Groups and individual coaching:

• Families for Addiction Recovery Canada has free phone coaching and support groups. Facilitators are familiar with the Beyond Addiction approach (see books above).
• SMART Family and Friends have in person and virtual groups that are based on CRAFT.

Online:

• Helping Families Help is a resource hub for connecting people with CRAFT-based resources as well as providers.
• Centre for Motivation and Change has free resources, videos, blog posts as well as podcasts. The founders of the Centre are also the authors of the books noted above.
• Partnership to End Addiction provides a video summary of CRAFT for families. They also provide a number of free CRAFT-based videos and resources.

Handout for families

View and download the handout that you can provide to people with loved ones using substances. Download PDF.

References

1. Government of British Columbia. Families at the centre: reducing the impact of mental health and substance use problems on families. Family Mental Health and Substance Use Task Force. July 2015. Accessed March 18, 2024 (View PDF)
2. Pearson C, Janz T, Ali J. Mental and substance use disorders in Canada. Health at a Glance. November 27, 2015. Accessed February 15, 2024 (View)
3. Financial well-being, personal characteristics and lifestyles of the political typology. Pew Research Center. October 24, 2017. Accessed February 15, 2024 (View)
4. Shamsaei F, Baanavi M, Hassanian ZM, Cheraghi F. The impact of addiction on family members mental health status. Curr Drug Res Rev. 2019;11(2):129-134. doi: 10.2174/2589977511666190319162901 (View)
5. Maina G, Ogenchuk M, Phaneuf T, Kwami A. “I can’t live like that”: the experience of caregiver stress of caring for a relative with substance use disorder. Subst Abuse Treat Prev Policy. 2021;16(11):1-9. doi: 10.1186/s13011-021-00344-3 (View)
6. Mardani M, Alipour F, Rafiey H, Fallahi-Khoshknab M, Arshi M. Challenges in addiction-affected families: a systematic review of qualitative studies. BMC Psychiatry. 2023;23(1):439. doi: 10.1186/s12888-023-04927-1 (View)
7. Jackson D, Usher K, O’Brien L. Fractured families: parental perspectives of the effects of adolescent drug abuse on family life. Contemp Nurse. 2014;23(2):321-330. doi: 10.5555/conu.2006.23.2.321 (View with UBC)
8. Colizzi M, Lasalvia A, Ruggeri M. Prevention and early intervention in youth mental health: is it time for a multidisciplinary and trans-diagnostic model for care? Int J Ment Health Syst. 2020;14(23):1-14. doi: 10.1186/s13033-020-00356-9 (View)
9. Danda MC. Learning to meet my patient where they are at – how letting go changed my practice. This Changed My Practice (TCMP) by UBC CPD. October 10, 2018. Accessed Feb 21 2024 (View)
10. Government of British Columbia. Healing families, helping systems: a trauma-informed practice guide for working with children, youth and families. Ministry of Child and Family Development. January 2017. Accessed March 21, 2024 (View PDF)
11. McCrady BS, Flanagan JC. The role of the family in alcohol use disorder recovery for adults. Alcohol Res-Curr Rev. 2021;41(1):1-19. doi: 10.35946/arcr.v41.1.06 (View)
12. McQuaid RJ, Malik A, Moussouni K, Baydack N, Stargardter M, Morrisey M. Life in recovery from addiction in Canada. Canadian Centre on Substance Use and Addiction. May 2017 (View PDF)
13. Smith JE, Meyers RJ. The CRAFT Treatment Manual for Substance Use Problems: Working with Family Members. Guilford Press; 2023 (View on WorldCat)
14. Foote J, Carpenter K, Wilkens C, Higgs S. The invitation to change: a short guide. Centre for Motivation and Change. 2021 (View on invitationtochange.com)
15. Roozen HG, de Waart R, van der Kroft P. Community reinforcement and family training: an effective option to engage treatment-resistant substance-abusing individuals in treatment [published correction appears in Addiction. 2010 Nov;105(11):2040]. Addiction. 2010;105(10):1729-1738. doi: 10.1111/j.1360-0443.2010.03016.x (View with UBC)
16. Kirby KC, Marlowe DB, Festinger DS, Garvey KA, LaMonaca V. Community reinforcement training for family and significant others of drug abusers: a unilateral intervention to increase treatment entry of drug users. Drug Alc Depend. 1999;56(1):85-96. doi: 1016/s0376-8716(99)00022-8 (View with UBC)
17. Brigham GS, Slesnick N, Winhusen TM, Lewis DF, Guo X, Somoza E. A randomized pilot clinical trial to evaluate the efficacy of community reinforcement and family training for treatment retention (CRAFT-T) for improving outcomes for patients completing opioid detoxification. Drug Alcohol Depend. 2014;138:240-243. doi: 10.1016/j.drugalcdep.2014.02.013 (View)
18. Kirby KC, Benishek LA, Kerwin ME, et al. Analyzing components of community reinforcement and family training (CRAFT): is treatment entry training sufficient? Psychol Addict Behav. 2017;31(7):818-827. doi: 10.1037/adb0000306 (View)
19. Dutcher LW, Anderson R, Moore M, et al. Community reinforcement and family training (CRAFT): an effectiveness study. J Behav Anal Health Sports Fit Med. 2009;2(1):80-90. doi: 10.1037/h0100376 (View)
20. Manuel JK, Austin JL, Miller WR, et al. Community reinforcement and family training: a pilot comparison of group and self-directed delivery. J Subst Abuse Treat. 2012;43(1):129-136. doi: 10.1016/j.jsat.2011.10.020 (View)
21. Waldron HB, Kern-Jones S, Turner CW, Peterson TR, Ozechowski TJ. Engaging resistant adolescents in drug abuse treatment. J Subst Abuse Treat. 2007;32(2):133–142 (View)
22. McCarthy JM, Wood AJ, Shinners MG, et al. Pilot development and feasibility of telehealth community reinforcement and family Training (CRAFT) for early psychosis and substance use. Psychiatry Res. 2022;317:1-22. doi: 10.1016/j.psychres.2022.114804 (View)
23. Child and youth substance use pathway. Shared Care and University of British Columbia Continuing Professional Development. June 13, 2024. Accessed June 26, 2024 (View PDF)

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