How should families help their loved ones who are struggling with addiction? Should they be accommodating, firm, or confrontational? The Community Reinforcement and Family Training (CRAFT) approach is a good strategy that you should become familiar with.

Before we describe CRAFT, though, you should know about two other frequently used approaches to helping family members intervene: The Johnson Institute intervention and Al-Anon.

The concept of a confrontational “intervention” was originally invented in the 1960s by Vernon Johnson, who was an Episcopal priest and in ­recovery from alcohol. He believed people struggling with addiction are unable to see their own disease clearly unless confronted at a crisis point, and he created the Johnson Institute, a major training site for addiction professionals. Studies of Johnson Institute interventions (Liepman MR et al, Am J Drug Alcohol Abuse 1989;15(2):209–221) have shown success rates over 85% for getting the person into treatment when the intervention does take place. However, confrontational intervention is hard on families, and only about 30% of loved ones follow through with one, yielding an overall success of around 25%.

Al-Anon and Nar-Anon are modeled after the 12 steps of Alcoholics Anonymous—but rather than catering to people using substances, these groups cater to their families and friends. The focus is to promote well-being for group members in dealing with the repercussions of addiction. Getting the person into addiction treatment is often not a stated goal, and studies of Al-Anon that measure treatment engagement are discouraging—as few as 13% of people start treatment over a 1-year period (Miller WR et al, J Consult Clin Psychol 1999;67(5):688–697).

The CRAFT modality was first developed in the 1980s by Robert J. Meyers, PhD and colleagues (for more info, see www.robertjmeyersphd.com/craft.html). The theory behind CRAFT is that people with addiction are more likely to take advice from someone they are already close to than from others, such as clinicians. In the CRAFT jargon, close friends and family are termed concerned significant others (CSOs). The two primary outcomes of CRAFT are getting the loved one into addiction treatment and increasing the well-being of the CSO. CRAFT therapy sessions focus on increasing the CSO’s awareness of how substance use has affected the person’s life (“awareness training”) and on helping the CSO use positive reinforcement strategies to change the person’s behavior (“contingency management”). The CSO is encouraged to provide positive support for healthy behavior and to withdraw that support upon instances of substance misuse. For example, CSOs can plan a positive activity for themselves and their loved ones during a time the person would otherwise spend using substances. If the loved one abstains from substances, then the activity proceeds as planned. But if the person uses, the activity is cancelled.

At the same time as learning positive contingency management techniques, CSOs explore how to increase their own well-being—planning activities for themselves to rest and recharge. The therapist and CSO also work on communication skills, safety planning, when to separate from the relationship and when to reunite, and how to bring the person into treatment when the person is ready. This can take the form of CSOs bringing their loved ones to meet the CRAFT therapist, then linking to the appropriate community resources.

Does CRAFT work?
The CRAFT treatment model has been studied and adapted to various populations and treatment settings. In research trials, the primary outcome is getting the loved one into addiction treatment. The rate often quoted for this outcome with CRAFT is up to 70% over 1 year. A head-to-head analysis of CRAFT, the Johnson Institute intervention, and Al-Anon was performed in 1999 involving 130 total CSO participants with follow-up at 12 months (Miller WR et al, J Consult Clin Psychol 1999;67(5):688–697). All three of the treatment arms showed similar improvements in CSO well-being, but the CRAFT group outperformed the other arms in getting participants into treatment (64% for CRAFT, 30% for Johnson intervention, 13% for Al-Anon). Treatment engagement with participants happened on average after 4–6 sessions, and engagement rates were higher for CSOs who were parents than those who were spouses. Another trial in 2002 compared standard CRAFT individual sessions, standard CRAFT plus group aftercare sessions, and Al-Anon and Nar-Anon facilitation therapy (Al-Nar FT) with 90 randomized CSOs (Meyers RJ et al, J Consult Clin Psychol 2002;70(5):1182–1185). The percentage of participants entering treatment was 58.6% for traditional individual CRAFT sessions, 76.7% for CRAFT plus group aftercare, and 29.0% for Al-Nar FT.

Where to find CRAFT therapy
As more focus is placed on addiction treatment, access to a wide array of therapies has become more important. While Al-Anon and other 12-step style interventions are widespread, certified CRAFT therapists are not as accessible. Even though CRAFT originated 30 years ago in the US, it’s gained more traction internationally. There is an online list of CRAFT therapists in the US and abroad, but only 9 states have any therapists listed. However, there are good self-directed resources available. One of these is a book called Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening (Meyers R and Wolfe B. Center City, MN: Hazelden Publishing; 2003). A 2012 study compared CRAFT group therapy to self-directed therapy with this book and found that 40% in the self-directed group got their loved one into treatment, compared to 60% in the group therapy arm (Manuel JK et al, J Subst Abuse Treat 2012;43(1):129–136). Families can also use online CRAFT courses, available from sites like https://alliesinrecovery.net or www.cadenceonline.com.

Final thoughts
When a family member or friend of a person struggling with addiction comes to you for answers, it’s hard to know how to help. CRAFT interventions have proven effective for families struggling with addiction—both for the caregiver and for the loved one. CRAFT offers a practical, skills-based approach for significant others to implement, with the goal of improving family dynamics and getting their loved one into addiction treatment. Not everyone will have access to weekly in-person therapy sessions, but linking them with either self-directed CRAFT literature or online CRAFT therapy resources is a step in the right direction.

CATR Verdict: CRAFT-style interventions are an effective way for family members to both help themselves and get help for their loved ones struggling with addiction.