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Getting off the fence:
Journal of Substance Abuse Treatment, Vol. 14, No. 5, pp. 467472, 1997 Copyright © 1997 Elsevier Science Inc. Printed in the USA. All rights reserved 0740-5472/97 $17.00 + .00
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Getting Off the Fence: Procedures to Engage Treatment-Resistant Drinkers
ROBERT J. MEYERS, MS* AND JANE ELLEN SMITH, PhD'~ *Center on Alcoholism, Substance Abuse, and Addictions (CASAA), University of New Mexico, Albuquerque, NM, tPsychology Department, University of New Mexico, Albuquerque, NM
Abstract-Historically there have been few options for individuals seeking help for treatment-resistant loved ones with substance abuse problems. This article describes a program with empirical backing called Community Reinforcement and Family Training (CRAFT). This cognitive-behavioral treatment teaches the concerned significant other how to use behavioral principles to reduce the loved one's drinking and to encourage the drinker to seek treatment. Additionally it assists the concerned significant other in alleviating other types of stress and in introducing meaningful reinforcers into his or her own life. © 1997 Elsevier Science Inc.
Keywords-alcohol treatment; community reinforcement; treatment engagement; treatment resistant; substance abuse treatment.
THE YEARS it has become clearly evident that a loved one's alcohol abuse can seriously affect the lives of family members and friends (Collins, Leonard, & Searles, 1990; Orford, 1994; Orford & Harwin, 1982; Paolino & McCrady, 1977). Spouses of individuals with alcohol dependence show higher levels of depression, anxiety, and somatization than normal controls (Kogan & Jacobson, 1965; Moos, Finney, & Gamble, 1982), and lower levels of self-confidence (Dominguez, Miller, & Meyers, 1995). Additionally, these significant others report elevated levels of both personal and marital distress (Thomas & Ager, 1993). Some of the ongoing stressors for these families that contribute to the development of
these problems include social embarrassment, verbal assaults, theft, and physical violence (Velleman et al., 1993). Unfortunately, it is not unusual for individuals with substance-abuse problems to be opposed to getting treatment. Substance-abuse facilities regularly receive calls from desperate friends and family members, but historically there have been few options for individuals seeking help for their treatment-resistant loved ones. This is regrettable, given that many significant others have proven to be influential in prompting drinkers into treatment (Hingson, Mangione, Meyers, & Scotch, 1982; Room, 1987). Facilities' traditional responses to the significant other have been offers of Al-Anon (A1-Anon Family Groups, 1965) or the Johnson Institute Intervention (Johnson, 1986). The former teaches family members to "detach," because a family member is viewed as powerless to control or change the drinker or the drinking behavior. The Johnson Institute Intervention encourages involvement, but it is unappealing to many since it is in the form of a confrontational "surprise" family meeting with the drinker.
OVER
This work is being further tested and supported by NIAAA grant (#AA09774) and NIDA grant (#DA08896). William R. Miller is the principal investigator for each of these grants, and Robert J. Meyers is the co-investigator. Requests for reprints should be addressed to Robert J. Meyers, Center on Alcoholism, Substance Abuse, and Addictions (CASAA), 2350 Alamo SE, Albuquerque, NM 87106; E-mail: [email protected]
Received October 8, 1996; Revised March 28, 1997; Accepted April 22, 1997.
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A third approach, Community Reinforcement Training, was introduced 10 years ago (Sisson & Azrin, 1986) and modified recently (see Meyers, Dominguez, & Smith, 1996). Known now as Community Reinforcement and Family Training (CRAFT), it is an outgrowth of a behavioral treatment for individuals with substance abuse problems called the Community Reinforcement Approach (Azrin, 1976; Azrin, Sisson, Meyers, & Godley, 1982; Hunt & Azrin, 1973; Meyers & Smith, 1995). In several successful clinical trials the Community Reinforcement Approach has shown the spouse or family member to be a crucial collaborator in treatment (Azrin, 1976; Azrin et al., 1982). CRAFT asserts that these Concerned Significant Others (CSOs) can have a substantial impact both on the drinker's use of alcohol and the important decision to enter treatment. The purpose of this paper is to provide a brief overview of CRAFT procedures. (For a more detailed description, see Meyers et al., 1996). CRAFT involves: 1. Teaching the CSO to recognize the potential for domestic violence as behavioral changes are introduced at home, and introducing precautions to reduce the risk of harm. 2. Utilizing a functional analysis to outline the drinker's triggers for using alcohol as well as the consequences. The latter includes the CSO's coping responses. 3. Motivating the CSO to make some difficult changes through reminders about the specific reasons for starting treatment in the first place, and the potential worthwhile gains. 4. Demonstrating more effective ways to communicate with the drinker. 5. Teaching the appropriate use of positive and negative reinforcement to discourage a loved one's harmful using behavior. 6. Providing instruction in how to reduce other types of stress that are experienced by the CSO, and in how to introduce meaningful "rewards" into his or her own life. 7. Preparing the CSO to suggest treatment to the drinker at the most appropriate time and in a manner that is most likely to succeed. 8. Arranging to have treatment available for the drinker at the time the decision is made to enter therapy, and preparing the CSO to support the drinker during treatment.
DOMESTIC VIOLENCE PRECAUTIONS Since there is a significant association between alcohol abuse and domestic violence (Coleman & Straus, 1983; Gondolf & Foster, 1991; Leonard & Jacob, 1988; Stith, Crossman, & Bischof, 1991), it is important to ascertain whether violence is already a part of the CSO's relationship, and whether it is likely to escalate when behavior change is introduced. Some clinicians may prefer to broach the topic with a questionnaire that assesses recent
episodes of violence, such as the Conflict Tactics Scale (Straus, 1979). When indicated, it should be followed up with a method for identifying potential triggers, such as by using a functional analysis of the sequence of behaviors involved in a violent episode. Although the CSO usually is all-too-familiar with the antecedents to the drinker's aggressive behavior, often it is not realized that this information can be used to learn to reduce the potential for violence. CRAFT teaches alternatives to arguing with or nagging the drinker, since these actions often increase aggression. For example, assume a CSO describes the following events: "When he comes home and slams the door, that's the first sign of trouble. Then he refuses to eat and starts pacing. Finally he starts to blame me for making a meal that he doesn't like, or that I ' m a lousy housekeeper. When he does that I know he's going to start a fight if 1 say anything at all." With proper training this CSO would learn that these precursors to violence (slamming the door, refusing to eat, pacing, blaming) should never be answered with a verbal response (trigger). Instead the CSO would resort to a safer response, such as ending the conversation and leaving the room, or heading over to a friend's house for the night. In preparing to identify and respond to the buildup to aggression, the CSO must understand that changing his or her behavior may elicit a further negative reaction from the drinker. Therefore, a safety plan is an absolute necessity if there is any threat of violence. F U N C T I O N A L ANALYSIS OF DRINKING P A T T E R N In the first session, it is vital for the therapist to let the CSO express frustration with the loved one's drinking. The therapist should then discuss the importance of the CSO learning to place responsibility for the problem where it belongs, namely, on the drinker. At the same time, the therapist should introduce the notion that because the CSO is in a significant relationship with the drinker, the CSO's behavior toward that individual at drinking and non-drinking times is worth examining. Next, the therapist should help the CSO outline the drinker's pattern of alcohol use. It is necessary for the CSO to be fully aware of the loved one's drinking triggers so that strategies can be taught to alter the CSO's behavior at these times. The therapist then should explore the consequences the drinker experiences for alcohol use. Special attention should be paid to how the CSO responds to the drinking behavior, including watching for efforts aimed at covering up the loved one's drinking. Some therapists supplement this functional analysis with instruments specifically designed to identify spouses' faulty coping strategies, such as the Spouse Enabling Inventory and the Spouse Sobriety Influence Inventory (Thomas, Yoshioka, & Ager, 1994). Finally, the therapist should discuss the CSO's struggle to keep the relationship intact, and all of the hard work that already has
CRAFT Engagement Procedures been undertaken to protect family members from associated negative consequences.
ENHANCEMENT OF MOTIVATION The therapist should determine the precise reasons why a CSO seeks help, so that this information can be used to motivate the CSO. For instance, assume a CSO states that it is important for her children to see their father as a positive role model. The therapist (T) can use this information to motivate the CSO (C) to try a new procedure. An example follows: T: I'm a little confused here. Help me out. You keep telling me that you want your children to see your husband as a good role model, which I agree is important. And you know if your husband isn't home by 6:00, he's usually at the bar. Is that correct? C: Yes, he's usually home by 5:30; no later than 5:45, unless he starts to drink. T: Here's where I need your help, If you know he's been drinking, why do you make your children wait to eat dinner until he comes home'? Maybe on the days you think he's drinking you could serve them dinner at the usual time without your husband present. This would send the message that you're not going to support his drinking by waiting to serve dinner. And the kids won't be eating with him when he's intoxicated. C: 1 guess I could try that. I like the idea of not making the kids wait so long to eat. They get really cranky, and that's hard on me. The therapist uses the C S O ' s "reinforcer"; having the children see their father sober, as the motivation to prompt her to change the old behavior. But in addition to encouraging a CSO to try a new behavior, motivators also may be used to remind a frustrated CSO about the benefits of remaining in treatment. These should include advantages associated with the drinker entering treatment, as well as the potential gains for the CSO even if the drinker never seeks professional help (see section, "Reinforcers for the CSO").
COMMUNICATION TRAINING In attempting to change the C S O ' s relationship with the drinker, typically it is useful to first examine the manner in which the two individuals communicate. C R A F T relies heavily upon the communication skills training outlined in the Community Reinforcement Approach (see Meyers & Smith, 1995, pp. 163-170). The basic communication rules are: (a) be brief, (b) be positive, (c) be specific and clear, (d) label your feelings, (e) offer an understanding statement once the issue has been viewed from the drinker's perspective, (f) accept partial responsibility when appropriate, and (g) offer to help. Assume that the CSO introduced earlier has decided to speak to her husband about his habit of coming home late for dinner. The therapist will utilize the behavioral principles of modeling, behavioral rehearsal, and shaping while teaching the CSO the communication rules. The
469 dialogue begins after the CSO has made her first attempt at the conversation: T: You've been telling me what you don't want your husband to do anymore. Could you change this into a positive statement and talk about what you would like him to do? C: What exactly do you mean? T: Instead of saying, "You really make me mad when you come home late for dinner and don't call," you could say, "I really love it when you come home for dinner on time. Me and the kids love it when you eat with us." Do you see how it states briefly and clearly what you want, and it does so in a positive tone? It even mentions your feelings. That covers the first four rules of a good conversation. Would you like to give it a try'? C: OK. "Jimmy, it's about time you're home. We like it when you eat with us." T: That was a great start. You told him that you and the kids like eating dinner with him. This time let's try to change the first part though, because it had a negative edge to it when you said, "It's about time you're home." You could replace it with something like, "I'm glad to see you." Does that sound comfortable? C: Yes, I see what you mean. "Jimmy, I'm glad you're home in time for supper. You know how the kids and I like to eat supper with you." T: What a great job! Now let's add something a little different. Let's see if we can use an understanding statement, accept partial responsibility and offer to help. For instance you might say, "Jimmy, I understand you like to spend time with your co-workers. And I probably haven't done certain things to make it more enjoyable for you to come home early. Maybe I could give the kids their baths before dinner, because then they'd be calm and it would be easier for you to unwind." Now, do you see how I was understanding, accepted some of the responsibili~ for the problem, and came up with an offer to help? C: That sounds like a lot to say. But I get the idea. He just may be more likely to come home if the kids are calmed down. I'll try it. "Jimmy, I know you like to hang out with the guys, but if you come home for supper, I'll do my best to help the kids be calm and quiet so you can relax at the dinner table." T: Great job. How does that feel'? Is this something you can support? All seven communication rules were demonstrated by the therapist (modeling) and then attempted by the CSO. The CSO would continue practicing the conversation (behavioral rehearsal) and the therapist would reinforce her efforts and offer feedback so that her conversation gradually approximated the therapist's (shaping). In order for these new skills to generalize to outside of therapy they must be practiced regularly during sessions.
USE OF POSITIVE REINFORCEMENT The CSO often has the unique ability to encourage or discourage the drinker's alcohol use with just a modest change in the C S O ' s own behavior. Typically, ongoing attempts at managing the drinking behavior are unsystematic and ineffective. Examples include pouring alco-
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hol down the drain, nagging the drinker to stop, abusing alcohol to "show them" what it's like, bartering with, pleading with, or even threatening the drinker. As an alternative, CRAFT teaches the CSO to arrange positive consequences for non-drinking behaviors and to avoid contact with the drinker whenever he or she is drinking. The therapist should first explain the concept of a positive reinforcer to the CSO; namely, it is any object or behavior whose presentation increases the rate of the behavior that it follows. The CSO should generate a list of reinforcers that could be introduced when the drinker is not using alcohol, such as preparing the drinker's favorite foods, talking about the drinker's favorite topic, giving small inexpensive gifts, providing praise or support for not drinking, suggesting a romantic encounter, or just spending time with the drinker. The therapist should check to be sure that these "rewards" are indeed things that the drinker would find reinforcing, and that they are powerful enough to be selected over drinking. The next step is to determine the most effective times to introduce the rewards. It is critical, for example, that the drinker is sober and not hungover. Therefore, it often is worthwhile to make sure that the CSO recognizes when the drinker is under the influence of even a small amount of alcohol (see Meyers et al., 1996, p. 277). Finally, the therapist should caution the CSO that the drinker initially may miss the connection between rewards and sober behavior. Since one could guard against this by verbally linking a reward with non-drinking behavior, the CSO should be trained to explain his or her actions. An example may include: "I love you Oliver, and want to spend time with you. I want to cuddle with you on the sofa. And I want to spend this time with you when you're not drinking. If you begin drinking I'll have to excuse myself and leave." Some CSOs are reluctant to use positive reinforcement of non-drinking activities, due to feeling angry and resentful for what they perceive as having to reward someone who has caused so much pain. Other CSOs argue that they cannot do anything special for the drinker, since this could be viewed as enabling or rescuing behavior. The therapist needs to clarify that positive reinforcement is not an enabling behavior when it is introduced only when the drinker is sober. Another way to elicit a change in the CSO's behavior is to use the Community Reinforcement Approach's sampling procedure. This technique encourages a CSO to "sample" a new behavior for a period of time (Azrin et al., 1982; Meyers & Smith, 1995; Miller & Page, 1991; Smith & Meyers, 1995). The following dialogue illustrates CRAFT sampling: T: I understand that you're skeptical about the reward system. It definitely is a new way of interacting, but I believe it will be for your benefit in the long run. I wonder if you'd consider trying positive reinforcement a few times? If it doesn't work, you could stop. C: I don't know. It doesn't seem right to be rewarding him. That's the last thing I feel like doing now. I feel like I've al-
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ready done a lot of nice things for him, and he still drinks. T: And you certainly have a right to feel that way. You have done a lot of nice things for him and he hasn't been very nice to you in the recent past. But remember your ultimate goal: to get him to stop his drinking. I'm sure it feels a little strange, but could you give it a try knowing that it may help you to achieve your ultimate goal? C: l suppose so. T: Good. So, you are sure that sitting next to him on the sofa while he watches TV is something he really likes? C: Oh yes. He's always trying to get me to sit with him. It seems to make him happy. T: Is this something you're willing to do? You could sit with him two or three nights and watch his reaction. But remember, only sit with him if he hasn't been drinking, and leave immediately if he starts. Reward him with your presence only if he doesn't drink. C: 1 guess I'd be willing to try it for a few nights. I'm kind of curious to see his reaction. Before sending the CSO out to actually use positive reinforcement with the problem drinker, the following should have been accomplished: 1. The CSO fully understands the concept and can identify appropriate positive reinforcers. 2. The CSO has demonstrated the capability of delivering suitable reinforcers through practice role plays with the therapist, and ideally with another family member or friend. 3. The CSO has discussed possible resentment for being expected to give rewards to someone who has caused so much pain. 4. The CSO has reviewed the optimal times to apply the reward system: the drinker must be sober, not hungover, and in a pleasant mood (Meyers et al., 1996). 5. A variety of possible consequences of this new behavior have been discussed fully. The CSO has learned the appropriate skills to address any problematic negative reactions. USE O F N E G A T I V E C O N S E Q U E N C E S In addition to being taught how to offer positive reinforcement for non-drinking behavior, the CSO learns how not to reward drinking behaviors. The therapist should gently point out ways in which the CSO may be unintentionally "supporting" the partner's drinking, such as by calling in sick for a loved one with a hangover, reheating dinner for a partner who has stopped at a bar on the way home, and paying bills created by the drinker. These types of CSO responses should be apparent from the consequences section of the functional analysis. To prepare the CSO to apply negative consequences for drinking behavior, five steps should be followed: 1. Have the CSO select one situation in which he or she unknowingly has been supporting the partner's drinking. 2. Consider using positive reinforcement to change the drinking behavior. If this is not feasible or it already
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has been unsuccessful, discuss a planned negative consequence. 3. Select a reasonable, timely, negative consequence, such as avoiding contact with the drinker when he or she is using alcohol, or refusing to clean up alcoholrelated messes. 4. Explore all possible reactions of the drinker to the negative consequence, and prepare a plan to deal with each. 5. Role-play how the negative consequence for the drinking behavior will be delivered and explained (refer to section, "Communication Training"). Assume, for example, that a drinker comes home from a long night of drinking and proceeds to vomit throughout the bathroom. Also assume that the CSO typically has been the one to clean up the vomit. If the CSO is willing to leave the cleaning to the drinker, the drinker will have to suffer the negative consequences of the excessive drinking. As noted, any possible problematic repercussions for this plan will need to be explored in advance.
REINFORCERS FOR THE CSO In addition to focusing on eliminating a treatment-resistant drinker's substance abuse problem, CRAFT emphasizes improving the quality of life for the CSO, regardless of whether the drinker ever enters treatment. This entails helping the CSO find his or her own reinforcers. An examination of the CSO's current satisfaction in various arenas is necessary first. The therapist may discover, for example, that the CSO's social life has suffered dramatically due to the drinker's disruptive influence. In response, the therapist may encourage the CSO to find novel social reinforcers through friendships and activities that are independent of the drinker. Personal reinforcers may take the form of a new hobby or pastime for the CSO. In terms of work-related reinforcers, the therapist should discuss the opportunity for increasing the rewarding nature of a current job, or the value in trying a new position altogether. Not surprisingly, many CSOs are reluctant to venture out on their own in search of personal enjoyment. This is an ideal time for the therapist to present the sampling notion again, for the CSO will need to experiment with a variety of new activities before finding any that feel rewarding and comfortable. Once a CSO develops new social, personal or vocational avenues for reinforcement, much less time is spent dealing with the drinker and the accompanying negative drinking behaviors. Furthermore, as the CSO takes responsibility for improving his or her own life, self-efficacy is enhanced and stress is reduced.
SUGGESTION OF T R E A T M E N T TO THE D R I N K E R The skilled application of the procedures outlined thus far may adequately address some individuals' drinking
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problems, but in most situations professional treatment will need to follow. Knowing precisely when to invite the drinker to attend treatment must be determined caseby-case while considering such factors as the CSO's comfort level and ability. Therapy time also should be devoted to identifying times when the drinker is apt to be more receptive to the invitation. Sometimes a drinker asks curiously about the CRAFF program once it becomes apparent that the CSO is in treatment. It also is common for a drinker to begin to ask questions about why a CSO's behavior has changed. These tend to be ideal times for the CSO to broach the topic of treatment. In the course of doing role-plays in which treatment is suggested, several should be rehearsed in which the drinker flatly refuses therapy. A discussion should follow in which the CSO is taught to accept this as part of the process instead of as a personal failure. RAPID INTAKE P R O C E D U R E It is critical to make arrangements early in the work with a CSO that will allow for a rapid intake of the drinker once the decision to enter treatment is made; namely, within 48 hours. Motivation may dissipate and the chances of treatment beginning at all will drop markedly if the drinker is placed on a waiting list. Once the drinker enters treatment, the Community Reinforcement Approach procedures (Azrin, 1976; Azrin et al., 1982; Hunt & Azrin, 1973; Meyers & Smith, 1995) are recommended. The therapist should convey the expectation that with hard work it is probable that the situation with the drinker will improve. But getting the loved one to enter treatment is only the start, and much more hard work is ahead. The therapist should discuss the need for the CSO to stay involved in the drinker's therapy, but this time as part of a couple who is in need of help. And although one major goal of CRAFT is to enroll the loved one into an appropriate treatment program, the CSO must be prepared for the possibility that the drinker enters treatment only to drop out prematurely. In the event that this occurs, it is imperative to remind the CSO that CRAFT is an ongoing process. When the drinker leaves treatment early, it is just one step in the program, and more work needs to be done to encourage the drinker to return. CONCLUSION Research over the years repeatedly has demonstrated the considerable difficulty in engaging and retaining an individual with substance-abuse problems in treatment (Baekeland & Lundwall, 1975; Ellis, McCan, Price, & Sewell, 1992; Stark & Campbell, 1988). According to Foote and colleagues (1994), "The issues of engagement and retention must assume prominence in the development of new treatment approaches." Two separate trials of CRAFT have been funded, one by the National Institute on Alcohol Abuse and Alcoholism and one by the
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National Institute on D r u g A b u s e (Principal Investigator, W i l l i a m R. Miller; Co-PI, Robert J. Meyers). It appears that C R A F T is substantially m o r e e f f e c t i v e in e n g a g i n g u n m o t i v a t e d p r o b l e m drinkers in treatment than are the two approaches m o s t c o m m o n l y used for this purpose in the U.S. (Miller, W. R. & Meyers, R. J. E n g a g i n g unmotivated individuals in treatment for alcohol problems: A comparison of three intervention strategies. Manuscript in preparation.) Early studies with significant others (Sisson & Azrin, 1986; Thomas & Santa, 1982) and the current ongoing trials suggest that the C R A F T program clearly merits additional scientific and clinical attention.
REFERENCES AI-Anon Family Groups. ( 1965). AI-Anon faces alcoholism. New York: Author. Azrin, N.H. (1976). Improvements in the community reinforcement approach to alcoholism. Behaviour Research and Therapy, 14, 339-348. Azrin, N.H., Sisson, R.W., Meyers, R.J., & Godley, M.D. (1982). Alcoholism treatment by disulfiram and community reinforcement therapy. Journal of Behavior Therapy and Experimental Psychiatry, 3, 105-112. Baekeland, F., & Lundwall, L. (1975). Dropping out of treatment: A critical review. Psychological Bulletin, 82, 738-783. Coleman, D., & Straus, M. (1983). Alcohol abuse and family violence. In E. Gottheil, K. Druley, T. Skoloda, & H. Waxman (Eds.), AlcohoL drug abuse and aggression (pp. 104-124). Springfield, IL: Charles C. Thomas. Collins, R.L., Leonard, K.E., & Searles, J.S. (1990). Alcohol and the family: Research and clinical perspectives. New York: Guilford Press. Dominguez, T.P., Miller, W.R., & Meyers, R.J. (1995). Unilateral intervention with family members of problem drinkers: A comparison of two group therapy approaches. Unpublished master's thesis, University of New Mexico, Albuquerque. Ellis, B.H., McCan, I., Price, G., & Sewell, C.M. (1992). The New Mexico treatment outcome study: Evaluating the utility of existing information systems. Journal of Health Care for the Poor and Underserved, 3, 138-150. Foote, F., Seligman, M., Magura, S., Handlesman, L., Rosenhlum, A., Lovejoy, M., Arrington, L., & Stimmel, B. (1994). An enhanced positive reinforcement model for the severely impaired cocaine abuser. Journal of Substance Abuse Treatment, 11,525-539. Gondolf, E.W., & Foster, R.A. (1991). Wife assault among VA alcohol rehabilitation patients. Hospital and Community Psychiatry, 42, 74--79. Hingson, R., Mangione, T., Meyers, A., & Scotch, N. (1982). Seeking help for drinking problems: A study in the Boston metropolitan area. Journal of Studies on Alcohol, 43, 271-288. Hunt, G.M. & Azrin, N.H. (1973). A community-reinforcement approach to alcoholism. Behaviour Research and Therapy, 11, 91104. Johnson, V.E. (1986). Intervention: How to help those who don't want help. Minneapolis, MN: Johnson Institute. Kogan, K., & Jacobson, J. (1965). Some concomitants of personal dif-
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Getting Off the Fence: Procedures to Engage Treatment-Resistant Drinkers
ROBERT J. MEYERS, MS* AND JANE ELLEN SMITH, PhD'~ *Center on Alcoholism, Substance Abuse, and Addictions (CASAA), University of New Mexico, Albuquerque, NM, tPsychology Department, University of New Mexico, Albuquerque, NM
Abstract-Historically there have been few options for individuals seeking help for treatment-resistant loved ones with substance abuse problems. This article describes a program with empirical backing called Community Reinforcement and Family Training (CRAFT). This cognitive-behavioral treatment teaches the concerned significant other how to use behavioral principles to reduce the loved one's drinking and to encourage the drinker to seek treatment. Additionally it assists the concerned significant other in alleviating other types of stress and in introducing meaningful reinforcers into his or her own life. © 1997 Elsevier Science Inc.
Keywords-alcohol treatment; community reinforcement; treatment engagement; treatment resistant; substance abuse treatment.
THE YEARS it has become clearly evident that a loved one's alcohol abuse can seriously affect the lives of family members and friends (Collins, Leonard, & Searles, 1990; Orford, 1994; Orford & Harwin, 1982; Paolino & McCrady, 1977). Spouses of individuals with alcohol dependence show higher levels of depression, anxiety, and somatization than normal controls (Kogan & Jacobson, 1965; Moos, Finney, & Gamble, 1982), and lower levels of self-confidence (Dominguez, Miller, & Meyers, 1995). Additionally, these significant others report elevated levels of both personal and marital distress (Thomas & Ager, 1993). Some of the ongoing stressors for these families that contribute to the development of
these problems include social embarrassment, verbal assaults, theft, and physical violence (Velleman et al., 1993). Unfortunately, it is not unusual for individuals with substance-abuse problems to be opposed to getting treatment. Substance-abuse facilities regularly receive calls from desperate friends and family members, but historically there have been few options for individuals seeking help for their treatment-resistant loved ones. This is regrettable, given that many significant others have proven to be influential in prompting drinkers into treatment (Hingson, Mangione, Meyers, & Scotch, 1982; Room, 1987). Facilities' traditional responses to the significant other have been offers of Al-Anon (A1-Anon Family Groups, 1965) or the Johnson Institute Intervention (Johnson, 1986). The former teaches family members to "detach," because a family member is viewed as powerless to control or change the drinker or the drinking behavior. The Johnson Institute Intervention encourages involvement, but it is unappealing to many since it is in the form of a confrontational "surprise" family meeting with the drinker.
OVER
This work is being further tested and supported by NIAAA grant (#AA09774) and NIDA grant (#DA08896). William R. Miller is the principal investigator for each of these grants, and Robert J. Meyers is the co-investigator. Requests for reprints should be addressed to Robert J. Meyers, Center on Alcoholism, Substance Abuse, and Addictions (CASAA), 2350 Alamo SE, Albuquerque, NM 87106; E-mail: [email protected]
Received October 8, 1996; Revised March 28, 1997; Accepted April 22, 1997.
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A third approach, Community Reinforcement Training, was introduced 10 years ago (Sisson & Azrin, 1986) and modified recently (see Meyers, Dominguez, & Smith, 1996). Known now as Community Reinforcement and Family Training (CRAFT), it is an outgrowth of a behavioral treatment for individuals with substance abuse problems called the Community Reinforcement Approach (Azrin, 1976; Azrin, Sisson, Meyers, & Godley, 1982; Hunt & Azrin, 1973; Meyers & Smith, 1995). In several successful clinical trials the Community Reinforcement Approach has shown the spouse or family member to be a crucial collaborator in treatment (Azrin, 1976; Azrin et al., 1982). CRAFT asserts that these Concerned Significant Others (CSOs) can have a substantial impact both on the drinker's use of alcohol and the important decision to enter treatment. The purpose of this paper is to provide a brief overview of CRAFT procedures. (For a more detailed description, see Meyers et al., 1996). CRAFT involves: 1. Teaching the CSO to recognize the potential for domestic violence as behavioral changes are introduced at home, and introducing precautions to reduce the risk of harm. 2. Utilizing a functional analysis to outline the drinker's triggers for using alcohol as well as the consequences. The latter includes the CSO's coping responses. 3. Motivating the CSO to make some difficult changes through reminders about the specific reasons for starting treatment in the first place, and the potential worthwhile gains. 4. Demonstrating more effective ways to communicate with the drinker. 5. Teaching the appropriate use of positive and negative reinforcement to discourage a loved one's harmful using behavior. 6. Providing instruction in how to reduce other types of stress that are experienced by the CSO, and in how to introduce meaningful "rewards" into his or her own life. 7. Preparing the CSO to suggest treatment to the drinker at the most appropriate time and in a manner that is most likely to succeed. 8. Arranging to have treatment available for the drinker at the time the decision is made to enter therapy, and preparing the CSO to support the drinker during treatment.
DOMESTIC VIOLENCE PRECAUTIONS Since there is a significant association between alcohol abuse and domestic violence (Coleman & Straus, 1983; Gondolf & Foster, 1991; Leonard & Jacob, 1988; Stith, Crossman, & Bischof, 1991), it is important to ascertain whether violence is already a part of the CSO's relationship, and whether it is likely to escalate when behavior change is introduced. Some clinicians may prefer to broach the topic with a questionnaire that assesses recent
episodes of violence, such as the Conflict Tactics Scale (Straus, 1979). When indicated, it should be followed up with a method for identifying potential triggers, such as by using a functional analysis of the sequence of behaviors involved in a violent episode. Although the CSO usually is all-too-familiar with the antecedents to the drinker's aggressive behavior, often it is not realized that this information can be used to learn to reduce the potential for violence. CRAFT teaches alternatives to arguing with or nagging the drinker, since these actions often increase aggression. For example, assume a CSO describes the following events: "When he comes home and slams the door, that's the first sign of trouble. Then he refuses to eat and starts pacing. Finally he starts to blame me for making a meal that he doesn't like, or that I ' m a lousy housekeeper. When he does that I know he's going to start a fight if 1 say anything at all." With proper training this CSO would learn that these precursors to violence (slamming the door, refusing to eat, pacing, blaming) should never be answered with a verbal response (trigger). Instead the CSO would resort to a safer response, such as ending the conversation and leaving the room, or heading over to a friend's house for the night. In preparing to identify and respond to the buildup to aggression, the CSO must understand that changing his or her behavior may elicit a further negative reaction from the drinker. Therefore, a safety plan is an absolute necessity if there is any threat of violence. F U N C T I O N A L ANALYSIS OF DRINKING P A T T E R N In the first session, it is vital for the therapist to let the CSO express frustration with the loved one's drinking. The therapist should then discuss the importance of the CSO learning to place responsibility for the problem where it belongs, namely, on the drinker. At the same time, the therapist should introduce the notion that because the CSO is in a significant relationship with the drinker, the CSO's behavior toward that individual at drinking and non-drinking times is worth examining. Next, the therapist should help the CSO outline the drinker's pattern of alcohol use. It is necessary for the CSO to be fully aware of the loved one's drinking triggers so that strategies can be taught to alter the CSO's behavior at these times. The therapist then should explore the consequences the drinker experiences for alcohol use. Special attention should be paid to how the CSO responds to the drinking behavior, including watching for efforts aimed at covering up the loved one's drinking. Some therapists supplement this functional analysis with instruments specifically designed to identify spouses' faulty coping strategies, such as the Spouse Enabling Inventory and the Spouse Sobriety Influence Inventory (Thomas, Yoshioka, & Ager, 1994). Finally, the therapist should discuss the CSO's struggle to keep the relationship intact, and all of the hard work that already has
CRAFT Engagement Procedures been undertaken to protect family members from associated negative consequences.
ENHANCEMENT OF MOTIVATION The therapist should determine the precise reasons why a CSO seeks help, so that this information can be used to motivate the CSO. For instance, assume a CSO states that it is important for her children to see their father as a positive role model. The therapist (T) can use this information to motivate the CSO (C) to try a new procedure. An example follows: T: I'm a little confused here. Help me out. You keep telling me that you want your children to see your husband as a good role model, which I agree is important. And you know if your husband isn't home by 6:00, he's usually at the bar. Is that correct? C: Yes, he's usually home by 5:30; no later than 5:45, unless he starts to drink. T: Here's where I need your help, If you know he's been drinking, why do you make your children wait to eat dinner until he comes home'? Maybe on the days you think he's drinking you could serve them dinner at the usual time without your husband present. This would send the message that you're not going to support his drinking by waiting to serve dinner. And the kids won't be eating with him when he's intoxicated. C: 1 guess I could try that. I like the idea of not making the kids wait so long to eat. They get really cranky, and that's hard on me. The therapist uses the C S O ' s "reinforcer"; having the children see their father sober, as the motivation to prompt her to change the old behavior. But in addition to encouraging a CSO to try a new behavior, motivators also may be used to remind a frustrated CSO about the benefits of remaining in treatment. These should include advantages associated with the drinker entering treatment, as well as the potential gains for the CSO even if the drinker never seeks professional help (see section, "Reinforcers for the CSO").
COMMUNICATION TRAINING In attempting to change the C S O ' s relationship with the drinker, typically it is useful to first examine the manner in which the two individuals communicate. C R A F T relies heavily upon the communication skills training outlined in the Community Reinforcement Approach (see Meyers & Smith, 1995, pp. 163-170). The basic communication rules are: (a) be brief, (b) be positive, (c) be specific and clear, (d) label your feelings, (e) offer an understanding statement once the issue has been viewed from the drinker's perspective, (f) accept partial responsibility when appropriate, and (g) offer to help. Assume that the CSO introduced earlier has decided to speak to her husband about his habit of coming home late for dinner. The therapist will utilize the behavioral principles of modeling, behavioral rehearsal, and shaping while teaching the CSO the communication rules. The
469 dialogue begins after the CSO has made her first attempt at the conversation: T: You've been telling me what you don't want your husband to do anymore. Could you change this into a positive statement and talk about what you would like him to do? C: What exactly do you mean? T: Instead of saying, "You really make me mad when you come home late for dinner and don't call," you could say, "I really love it when you come home for dinner on time. Me and the kids love it when you eat with us." Do you see how it states briefly and clearly what you want, and it does so in a positive tone? It even mentions your feelings. That covers the first four rules of a good conversation. Would you like to give it a try'? C: OK. "Jimmy, it's about time you're home. We like it when you eat with us." T: That was a great start. You told him that you and the kids like eating dinner with him. This time let's try to change the first part though, because it had a negative edge to it when you said, "It's about time you're home." You could replace it with something like, "I'm glad to see you." Does that sound comfortable? C: Yes, I see what you mean. "Jimmy, I'm glad you're home in time for supper. You know how the kids and I like to eat supper with you." T: What a great job! Now let's add something a little different. Let's see if we can use an understanding statement, accept partial responsibility and offer to help. For instance you might say, "Jimmy, I understand you like to spend time with your co-workers. And I probably haven't done certain things to make it more enjoyable for you to come home early. Maybe I could give the kids their baths before dinner, because then they'd be calm and it would be easier for you to unwind." Now, do you see how I was understanding, accepted some of the responsibili~ for the problem, and came up with an offer to help? C: That sounds like a lot to say. But I get the idea. He just may be more likely to come home if the kids are calmed down. I'll try it. "Jimmy, I know you like to hang out with the guys, but if you come home for supper, I'll do my best to help the kids be calm and quiet so you can relax at the dinner table." T: Great job. How does that feel'? Is this something you can support? All seven communication rules were demonstrated by the therapist (modeling) and then attempted by the CSO. The CSO would continue practicing the conversation (behavioral rehearsal) and the therapist would reinforce her efforts and offer feedback so that her conversation gradually approximated the therapist's (shaping). In order for these new skills to generalize to outside of therapy they must be practiced regularly during sessions.
USE OF POSITIVE REINFORCEMENT The CSO often has the unique ability to encourage or discourage the drinker's alcohol use with just a modest change in the C S O ' s own behavior. Typically, ongoing attempts at managing the drinking behavior are unsystematic and ineffective. Examples include pouring alco-
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hol down the drain, nagging the drinker to stop, abusing alcohol to "show them" what it's like, bartering with, pleading with, or even threatening the drinker. As an alternative, CRAFT teaches the CSO to arrange positive consequences for non-drinking behaviors and to avoid contact with the drinker whenever he or she is drinking. The therapist should first explain the concept of a positive reinforcer to the CSO; namely, it is any object or behavior whose presentation increases the rate of the behavior that it follows. The CSO should generate a list of reinforcers that could be introduced when the drinker is not using alcohol, such as preparing the drinker's favorite foods, talking about the drinker's favorite topic, giving small inexpensive gifts, providing praise or support for not drinking, suggesting a romantic encounter, or just spending time with the drinker. The therapist should check to be sure that these "rewards" are indeed things that the drinker would find reinforcing, and that they are powerful enough to be selected over drinking. The next step is to determine the most effective times to introduce the rewards. It is critical, for example, that the drinker is sober and not hungover. Therefore, it often is worthwhile to make sure that the CSO recognizes when the drinker is under the influence of even a small amount of alcohol (see Meyers et al., 1996, p. 277). Finally, the therapist should caution the CSO that the drinker initially may miss the connection between rewards and sober behavior. Since one could guard against this by verbally linking a reward with non-drinking behavior, the CSO should be trained to explain his or her actions. An example may include: "I love you Oliver, and want to spend time with you. I want to cuddle with you on the sofa. And I want to spend this time with you when you're not drinking. If you begin drinking I'll have to excuse myself and leave." Some CSOs are reluctant to use positive reinforcement of non-drinking activities, due to feeling angry and resentful for what they perceive as having to reward someone who has caused so much pain. Other CSOs argue that they cannot do anything special for the drinker, since this could be viewed as enabling or rescuing behavior. The therapist needs to clarify that positive reinforcement is not an enabling behavior when it is introduced only when the drinker is sober. Another way to elicit a change in the CSO's behavior is to use the Community Reinforcement Approach's sampling procedure. This technique encourages a CSO to "sample" a new behavior for a period of time (Azrin et al., 1982; Meyers & Smith, 1995; Miller & Page, 1991; Smith & Meyers, 1995). The following dialogue illustrates CRAFT sampling: T: I understand that you're skeptical about the reward system. It definitely is a new way of interacting, but I believe it will be for your benefit in the long run. I wonder if you'd consider trying positive reinforcement a few times? If it doesn't work, you could stop. C: I don't know. It doesn't seem right to be rewarding him. That's the last thing I feel like doing now. I feel like I've al-
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ready done a lot of nice things for him, and he still drinks. T: And you certainly have a right to feel that way. You have done a lot of nice things for him and he hasn't been very nice to you in the recent past. But remember your ultimate goal: to get him to stop his drinking. I'm sure it feels a little strange, but could you give it a try knowing that it may help you to achieve your ultimate goal? C: l suppose so. T: Good. So, you are sure that sitting next to him on the sofa while he watches TV is something he really likes? C: Oh yes. He's always trying to get me to sit with him. It seems to make him happy. T: Is this something you're willing to do? You could sit with him two or three nights and watch his reaction. But remember, only sit with him if he hasn't been drinking, and leave immediately if he starts. Reward him with your presence only if he doesn't drink. C: 1 guess I'd be willing to try it for a few nights. I'm kind of curious to see his reaction. Before sending the CSO out to actually use positive reinforcement with the problem drinker, the following should have been accomplished: 1. The CSO fully understands the concept and can identify appropriate positive reinforcers. 2. The CSO has demonstrated the capability of delivering suitable reinforcers through practice role plays with the therapist, and ideally with another family member or friend. 3. The CSO has discussed possible resentment for being expected to give rewards to someone who has caused so much pain. 4. The CSO has reviewed the optimal times to apply the reward system: the drinker must be sober, not hungover, and in a pleasant mood (Meyers et al., 1996). 5. A variety of possible consequences of this new behavior have been discussed fully. The CSO has learned the appropriate skills to address any problematic negative reactions. USE O F N E G A T I V E C O N S E Q U E N C E S In addition to being taught how to offer positive reinforcement for non-drinking behavior, the CSO learns how not to reward drinking behaviors. The therapist should gently point out ways in which the CSO may be unintentionally "supporting" the partner's drinking, such as by calling in sick for a loved one with a hangover, reheating dinner for a partner who has stopped at a bar on the way home, and paying bills created by the drinker. These types of CSO responses should be apparent from the consequences section of the functional analysis. To prepare the CSO to apply negative consequences for drinking behavior, five steps should be followed: 1. Have the CSO select one situation in which he or she unknowingly has been supporting the partner's drinking. 2. Consider using positive reinforcement to change the drinking behavior. If this is not feasible or it already
CRAFT Engagement Procedures
has been unsuccessful, discuss a planned negative consequence. 3. Select a reasonable, timely, negative consequence, such as avoiding contact with the drinker when he or she is using alcohol, or refusing to clean up alcoholrelated messes. 4. Explore all possible reactions of the drinker to the negative consequence, and prepare a plan to deal with each. 5. Role-play how the negative consequence for the drinking behavior will be delivered and explained (refer to section, "Communication Training"). Assume, for example, that a drinker comes home from a long night of drinking and proceeds to vomit throughout the bathroom. Also assume that the CSO typically has been the one to clean up the vomit. If the CSO is willing to leave the cleaning to the drinker, the drinker will have to suffer the negative consequences of the excessive drinking. As noted, any possible problematic repercussions for this plan will need to be explored in advance.
REINFORCERS FOR THE CSO In addition to focusing on eliminating a treatment-resistant drinker's substance abuse problem, CRAFT emphasizes improving the quality of life for the CSO, regardless of whether the drinker ever enters treatment. This entails helping the CSO find his or her own reinforcers. An examination of the CSO's current satisfaction in various arenas is necessary first. The therapist may discover, for example, that the CSO's social life has suffered dramatically due to the drinker's disruptive influence. In response, the therapist may encourage the CSO to find novel social reinforcers through friendships and activities that are independent of the drinker. Personal reinforcers may take the form of a new hobby or pastime for the CSO. In terms of work-related reinforcers, the therapist should discuss the opportunity for increasing the rewarding nature of a current job, or the value in trying a new position altogether. Not surprisingly, many CSOs are reluctant to venture out on their own in search of personal enjoyment. This is an ideal time for the therapist to present the sampling notion again, for the CSO will need to experiment with a variety of new activities before finding any that feel rewarding and comfortable. Once a CSO develops new social, personal or vocational avenues for reinforcement, much less time is spent dealing with the drinker and the accompanying negative drinking behaviors. Furthermore, as the CSO takes responsibility for improving his or her own life, self-efficacy is enhanced and stress is reduced.
SUGGESTION OF T R E A T M E N T TO THE D R I N K E R The skilled application of the procedures outlined thus far may adequately address some individuals' drinking
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problems, but in most situations professional treatment will need to follow. Knowing precisely when to invite the drinker to attend treatment must be determined caseby-case while considering such factors as the CSO's comfort level and ability. Therapy time also should be devoted to identifying times when the drinker is apt to be more receptive to the invitation. Sometimes a drinker asks curiously about the CRAFF program once it becomes apparent that the CSO is in treatment. It also is common for a drinker to begin to ask questions about why a CSO's behavior has changed. These tend to be ideal times for the CSO to broach the topic of treatment. In the course of doing role-plays in which treatment is suggested, several should be rehearsed in which the drinker flatly refuses therapy. A discussion should follow in which the CSO is taught to accept this as part of the process instead of as a personal failure. RAPID INTAKE P R O C E D U R E It is critical to make arrangements early in the work with a CSO that will allow for a rapid intake of the drinker once the decision to enter treatment is made; namely, within 48 hours. Motivation may dissipate and the chances of treatment beginning at all will drop markedly if the drinker is placed on a waiting list. Once the drinker enters treatment, the Community Reinforcement Approach procedures (Azrin, 1976; Azrin et al., 1982; Hunt & Azrin, 1973; Meyers & Smith, 1995) are recommended. The therapist should convey the expectation that with hard work it is probable that the situation with the drinker will improve. But getting the loved one to enter treatment is only the start, and much more hard work is ahead. The therapist should discuss the need for the CSO to stay involved in the drinker's therapy, but this time as part of a couple who is in need of help. And although one major goal of CRAFT is to enroll the loved one into an appropriate treatment program, the CSO must be prepared for the possibility that the drinker enters treatment only to drop out prematurely. In the event that this occurs, it is imperative to remind the CSO that CRAFT is an ongoing process. When the drinker leaves treatment early, it is just one step in the program, and more work needs to be done to encourage the drinker to return. CONCLUSION Research over the years repeatedly has demonstrated the considerable difficulty in engaging and retaining an individual with substance-abuse problems in treatment (Baekeland & Lundwall, 1975; Ellis, McCan, Price, & Sewell, 1992; Stark & Campbell, 1988). According to Foote and colleagues (1994), "The issues of engagement and retention must assume prominence in the development of new treatment approaches." Two separate trials of CRAFT have been funded, one by the National Institute on Alcohol Abuse and Alcoholism and one by the
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National Institute on D r u g A b u s e (Principal Investigator, W i l l i a m R. Miller; Co-PI, Robert J. Meyers). It appears that C R A F T is substantially m o r e e f f e c t i v e in e n g a g i n g u n m o t i v a t e d p r o b l e m drinkers in treatment than are the two approaches m o s t c o m m o n l y used for this purpose in the U.S. (Miller, W. R. & Meyers, R. J. E n g a g i n g unmotivated individuals in treatment for alcohol problems: A comparison of three intervention strategies. Manuscript in preparation.) Early studies with significant others (Sisson & Azrin, 1986; Thomas & Santa, 1982) and the current ongoing trials suggest that the C R A F T program clearly merits additional scientific and clinical attention.
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