CRAFT: Family-Based Approaches to Treatment-Resistant Adolescent

Intervention.

It’s a scary word.

It’s also a word most of us associate with another relatively scary word – or phrase, rather: tough love.

We all know what tough love is: tough love is when you tell someone you care deeply about something they don’t want to hear. Examples of tough love run from the trivial – as in you should never wear that color again – to the significant – as in get a job this week or I’m…leaving you, kicking you out of the house, cutting off the money.

 You can practice tough love around virtually any topic, but intervention is almost always associated with alcohol and substance abuse. Families also use interventions for other behaviors considered addictive, such as gambling, disordered eating, and more recently, out-of-control video gaming and problematic internet use.

Let’s back up a moment and make sure we’re on the same page about exactly what we mean by intervention. With regards to alcohol, substance use, and other problem behaviors, The National Council on Alcoholism and Drug Dependence (NCADD) defines an intervention as:

“…a professionally directed education process resulting in a face-to-face meeting of family members, friends, and/or employers with a person in trouble with alcohol or drugs…The goal of an intervention is to present the alcohol or drug user with a structured opportunity to accept help and make changes.”

When most of us think of an intervention, we conjure up emotionally-charged scenes of confrontation between family members and the person they’re trying to get into treatment. Tears, anger, shouting, people storming out of the room and slamming doors – we tend to think conflict happens – and has to happen – in every intervention.

We’ve got news – there’s no unwritten law or evidence-based theory that says it has to be that way. New approaches to treatment and support for treatment-resistant individuals struggling with alcohol and substance use disorders reveal an important fact: intervention does not have to be synonymous with confrontation and conflict.

The CRA Model

In the early 1970s, psychologist Nathan Azrin began exploring avenues of treatment for alcoholism that did not rely on confrontation and conflict as a means to convince resistant individuals to enter and stay in treatment. Instead, he focused on improving the environment, conditions, and relationships that surround the individual, rather than solely focusing on the problem behaviors themselves. He theorized that sobriety was more likely if an individual received positive reinforcement for sobriety from family, friends, and colleagues. He explored different ways of helping individuals with alcohol use disorders find new activities that did not revolve around alcohol and sought to teach them the coping skills required to seek out and engage in these activities as they grew and transformed in their recovery.

Azrin called his model the Community Reinforcement Approach (CRA), an early precursor of what’s now known as the Community Reinforcement and Family Training (CRAFT) model of treatment. Significant evidence exists for the success of CRA-based models as compared to traditional models of intervention and treatment. Since 1973, over thirty published studies with close to three thousand participants have confirmed the effectiveness of the CRA model and its subsequent offshoots in both residential and outpatient treatment settings.

The fundamental elements of the CRA/CRAFT approach are:

  • Changing the environment in which the recovering individual lives, with the goal of positively reinforcing sober and non-drug taking behaviors, while negatively reinforcing alcohol and substance use.
  • Teaching the individual in recovery to identify and seek positive reinforcement through non-drinking and non-drug-taking behaviors.
  • Direct involvement of one or more Concerned Significant Others (CSOs)
  • Training and education of CSOs about the science and treatment of addiction
  • Training and education of CSOs about the problem of enabling behaviors. Enabling is defined as “…actions that typically involve removing or diminishing the naturally occurring negative consequences resulting from substance use.”
  • Training and education of CSOs about the opposite of enabling: positive reinforcement of sober and/or non-substance using activities.
  • Training and education about positive, supportive, non-confrontational communication strategies CSOs can use when communicating with the loved one in question.

Those are the broad strokes: change the environment, involve and educate family (i.e. CSOs), provide positive behavioral reinforcement, and teach productive communications strategies. You may notice these elements place almost equal emphasis on the people and environment that surround the individual with the alcohol or substance use disorder as they do on the individual with the disorder. We highlight those elements because they’re the ones that differ most from traditional approaches. Please understand: the CRAFT approach does not attempt to shift or transfer accountability and personal responsibility from the user to the family and community. The primary work of recovery does and always will rest on the shoulders of the individual in recovery. The CRAFT model does not change this one iota: rather, it seeks to place that individual in a milieu more conducive to recovery and sobriety, which – evidence clearly indicates – increases their chances of long-term health and well-being.

Now, for an overview of evidence-based CRA/CRAFT procedures adapted from a manual for therapists written by psychologists Robert Myers, Hendrik G. Rozen, and Jane Ellen Smith.

The CRA Method

  1. Functional Analysis of Substance Use: Therapists explore the reasons for addictive behaviors first with CSOs, then with the individuals themselves, with a focus on identifying the positive and negative consequence of alcohol and drug use.
  2. Sobriety Sampling: Therapists introduce the concept of sobriety, guided by the idea that telling someone they can never drink/use again ever may be counterproductive. Instead, they negotiate a limited period of abstinence on a trial basis and collaborate on a plan to implement the trial period.
  3. CRA Treatment Plan: Therapists, CSOs, and individuals create a list of treatment goals and a list of specific, practical, achievable methods for meeting them. To create a goal-setting baseline, clinicians administer a Happiness Scale that measures levels of satisfaction in personal, professional, social, spiritual, and other areas of life.
  4. Behavioral Skills Training: Therapists and individuals focus on three areas:
    1. Problem-solving: Therapists help struggling individuals take overwhelming issues divide them into smaller, manageable pieces that are less intimidating.
    2. Communication: Therapists teach methods of interacting that both the individual and the CSO can use while addressing challenging topics.
    3. Alcohol and substance refusal training: Therapists work with individuals to identify triggers and high-risk situations, then brainstorm and practice strategies to increase assertiveness and say no with confidence.
  5. Job Skills Training: Therapists work with individuals to help them get steady jobs. Azrin proposed that meaningful work functions as a powerful and positive reinforcer for individuals struggling with alcohol and substance use disorders, observing that consistent employment is “incompatible with problematic substance use.”
  6. Social and Recreational Counseling: This element helps individuals in recovery discover ways to enjoy life without alcohol or drugs.
  7. Relapse Prevention: This is two-fold. First, like alcohol and substance refusal training, it teaches individuals in recovery to identify and manage high-risk situations that may lead to relapse. Second, it teaches how to handle a relapse if and when it happens. Therapists will include CSOs in this process, teaching them about person-specific warning signs and the high-risk situations unique to their loved one, so they may offer extra support to help manage risk when it appears.
  8. Relationship Counseling: This element focuses on improving the primary relationships in the life of the individual in recovery and restoring balance to their family unit. Spouses and any relevant CSOs may participate. Anyone directly involved in the day-to-day life of the individual in recovery can help create a new and sober normal for the couple, family, or extended family.

CRA for Adolescents: A-CRA

The success of the CRA model for treating alcohol and substance use disorders in adults prompted mental health professionals to modify and apply the model to adolescents. A steady rise in the prevalence of alcohol and drug use among 12-17 year-olds caused concern in the mental health community, a trend reflected in a fifty-three percent increase in the number of 12-17 year-olds admitted to public substance use programs between 1992-1998. While more and more adolescents entered treatment during this period, the general approach to treatment followed a model designed for adults. A select handful of treatment centers began exploring adolescent-centered models in the late 1960s and early 1970s, altering traditional treatment programs in the following key areas:

  1. Addition of a more robust array of psychological and psychiatric assessments and supports
  2. Increased flexibility with violations of treatment center rules
  3. The use of younger and more educated staff
  4. De-emphasizing confrontation to encourage entry into treatment

Researchers and clinicians folded these adolescent-specific concepts into the CRA model, and further altered techniques to match the psychological, physical, and emotional development of the adolescent population. To make CRA developmentally appropriate, clinicians:

  1. Increased the level of CSO engagement before, during, and after treatment
  2. Tweaked the Happiness Scale to include detailed questions regarding school, friends, and other dynamic social factors relevant to adolescents
  3. Simplified communications skills training, with an emphasis on parent-child or primary caregiver-child interactions
  4. Added anger management modules to address impulse control and acting-out behaviors
  5. Focused parent/caregiver sessions on appropriate rule-setting and consequences
  6. Educated parents/caregivers more thoroughly about the communication and problem-solving skills adolescents develop during treatment
  7. Applied the job-training element to school attendance, homework, and academic pursuits

Recent studies on A-CRA demonstrate its effectiveness in treating adolescents with alcohol and substance use disorders, as well as those with co-occurring psychiatric disorders. A close examination of the elements of A-CRA listed above reveals their influence on contemporary best-practices for adolescent alcohol and substance use treatment: virtually every adolescent-specific treatment program across the country – with the exception of punitive approaches such as boot camps – highlights family involvement, comprehensive psychiatric assessment, social skills training, contingency management, anger management, communication training, and relapse prevention – all core elements of the CRA and A-CRA approaches to treatment.

Interventions: CRAFT-ing The Environment

We’ll now bring the discussion back full circle to the topic addressed in the first line of this article: intervention. The intervention style we discussed there, which reached public consciousness through televisions shows like “Intervention” on the A&E network, is based on what’s known as The Johnson Model. This model relies on orchestrating a confrontation between family members, loved ones, and the individual struggling with alcohol and substance use. A distinguishing feature of The Johnson Model is that all preparations for the intervention are made without the knowledge of the target individual. When the intervention occurs, it’s a surprise. The individual is often invited to the meeting under misleading pretenses, to discover what’s really going on: a group of the people closest to them directly confronting them about the negative effects their alcohol or drug use has had on everyone present.

Therapists advise non-emotional detachment from the situation and a strict adherence to consequences of not entering treatment for the individual: parents inform teens of significant loss of privileges, spouses inform spouses of actions they may take if the offer of treatment is ignored, and parents of young adults inform their children they’ll have to leave the home if the offer of treatment is denied. This non-emotional component is similar to other intervention strategies proposed by organizations such as Al-Anon.

However, though both Johnson and Al-Anon style interventions can and do work, there’s a confounding element: the ambush factor. To break from the somewhat academic tone of this article for a moment, and talk directly to parents on a practical level, we pose this question:

In general, how well do you think adolescents respond to surprise confrontation?

We’ll let you answer that question or yourself, based on your personal experience. We’ll offer our answer in the form of the following data:

  • Al-Anon style interventions have a 20% success rate
  • Johnson style interventions have a 30% success rate
  • CRAFT style interventions have a 71% success rate

While Al-Anon and Johnson style approaches emphasize confrontation and extreme consequences for treatment-resistant adolescents, CRAFT interventions – like CRA and A-CRA approaches to treatment –emphasize education, understanding, positive communication, problem solving, and creating positive reinforcement strategies that both the target individual and concerned loved ones can implement to change the environment and lead to increased chances of long-term abstinence and/or sobriety.

Research on the CRAFT approach shows an added bonus: it reduces stress and improves quality of life for the family members of the struggling individual, as well – an often-ignored component of recovery that’s essential to restoring balance to the family unit and establishing a new approach to life that works for everyone.

Tough Love, or Tough to Love?

The process of getting a treatment-resistant adolescent the help they need does not have to be miserable. It does not have to involve surprise meetings engineered to precipitate conflict and confrontation. While it’s true that there are times when adolescents need a proverbial kick-in-the-pants to get them to change their behavior, the latest studies show non-confrontational models like CRAFT and A-CRA are two to three times more effective than confrontational models at getting resistant teens into treatment. This aligns with recent developments in the science of addiction, wherein addiction is viewed as a chronic disease as opposed to a moral failing, character flaw, or lack of personal and family discipline. If a teenager develops a chronic disease other than addiction, it’s unlikely a family would attempt to tough-love them into treatment for the disease. Evidence shows that the more we treat alcohol and substance use disorders like other chronic diseases, the more progress we make in treating them.

It can be tough to love someone who’s in active addiction. It can be heartbreaking and frustrating. Yet love, compassion, knowledge, and understanding – without enabling – appear to be key elements to voluntary engagement in treatment and essential components to successful treatment outcomes. This approach allows parents to follow their most basic instinct, which is to offer love and support to their children, and leave the shouting, tears, and door-slamming to the television shows designed to create drama and increase viewership.