Intervention Summary

Community Reinforcement and Family Training (CRAFT)

Community Reinforcement and Family Training (CRAFT) is an intervention designed to help a concerned significant other/family member (CSO) facilitate treatment entry/engagement for a treatment-refusing individual who is abusing drugs or alcohol (the family member). CRAFT was developed with the belief that CSOs, who often have substantial information about their family member's substance abuse behavior patterns, can play a powerful role in helping him/her to enter treatment.

Delivered one on one or in groups of CSOs, CRAFT aims to influence the substance-abusing family member's behavior by changing the way the CSO interacts with him or her. The intervention incorporates the clinical style of motivational interviewing and emphasizes learning new skills to cope with a substance-abusing family member (e.g., using positive reinforcement, letting the loved one face the natural consequences of his or her behavior). CRAFT is also designed to help the CSO become more independent and feel more empowered in his or her relationship with the substance-abusing family member.

The twelve to fourteen 1-hour CRAFT counseling sessions are typically delivered twice weekly for the first 4 weeks and once weekly for the next 6 weeks. However, the CRAFT program moves as fast or as slow as the CSO is able, and the CRAFT therapist may use any procedure at any time. CRAFT therapists are typically counselors with master's degrees who are trained in the intervention.

The sessions cover the following topics:

Handling dangerous situations with the substance-abusing family member
Remembering the family member's positive attributes that were evident before he or she was abusing substances
Communicating with the family member using nonjudgmental feedback and reflective listening, and discontinuing communication that is not effective in positively influencing substance abuse
Using positive reinforcement to support abstinence and increase positive interactions (i.e., scheduling activities the family member enjoys that do not involve substances, participating only when no substances are used that day)
Practicing nonreinforcement of substance abuse (extinction) by ignoring or avoiding the family member when he or she is abusing substances
Suggesting and initiating counseling during opportune times
Developing interests and social supports independent of the family member

Also during sessions, CSOs discuss problems they have encountered with the substance-abusing family member since the last session. Optional counseling sessions with the substance abusing family member or additional family members can be scheduled as needed. In all the studies reviewed for this summary, the majority of CSOs were women.

Descriptive Information

Areas of Interest	Substance use disorder treatment
Outcomes	1: Entry into drug treatment 2: Engagement in alcohol treatment 3: Engagement in drug treatment
Outcome Categories	Alcohol Drugs Treatment/recovery
Ages	13-17 (Adolescent) 18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)
Genders	Male Female
Races/Ethnicities	Black or African American White Race/ethnicity unspecified
Settings	Outpatient
Geographic Locations	Urban Suburban Rural and/or frontier Tribal
Implementation History	CRAFT was first implemented informally in the developer's clinical practice. Since then, CRAFT has been used in 50 sites with more than 2,000 participants in at least 13 States. Internationally, CRAFT has been implemented in Australia, Canada, Ireland, Japan, the Netherlands, and the United Kingdom.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	CRAFT has been adapted in the United States for Native Americans, returning war veterans, and members of the Salvation Army, as well as internationally for Aboriginal Australians. The intervention has been translated into Dutch, Finnish, German, Japanese, Korean, and Spanish.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Kirby, K. C., Marlowe, D. B., Festinger, D. S., Garvey, K. A., & LaMonaca, V. Community reinforcement training for family and significant others of drug abusers: A unilateral intervention to increase treatment entry of drug users. Drug and Alcohol Dependence, 56(1), 85-96.

Study 2

Miller, W. R., Meyers, R. J., & Tonigan, J. S. Engaging the unmotivated in treatment for alcohol problems: A comparison of three strategies for intervention through family members. Journal of Consulting and Clinical Psychology, 67(5), 688-697.

Study 3

Meyers, R. J., Miller, W. R., Smith, J. E., & Tonigan, J. S. A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others. Journal of Consulting and Clinical Psychology, 70(5), 1182-1185.

Supplementary Materials

McLellan, A. T., Alterman, A. I., Cacciola, J., Metzger, D., & O'Brien, C. P. A new measure of substance abuse treatment: Initial studies of the Treatment Services Review. The Journal of Nervous and Mental Disease, 180(2), 101-110.

Miller, W. R., & Del Boca, F. K. Measurement of drinking behavior using the Form 90 family of instruments. Journal of Studies on Alcohol, 12(Suppl.), 112-118.

Roozen, H. G., de Waart, R., & van der Kroft, P. Community reinforcement and family training: An effective option to engage treatment-resistant substance-abusing individuals in treatment. Addiction, 105(10), 1729-1738.

Tonigan, J. S., Miller, W. R., & Brown, J. M. The reliability of Form 90: An instrument for assessing alcohol treatment outcome. Journal of Studies on Alcohol, 58(4), 358-364.

Outcomes

Outcome 1: Entry into drug treatment
Description of Measures	Entry into drug treatment was assessed using a modified Treatment Services Review (TSR) administered to the participating CSOs. The TSR is a semistructured interview that tracks the services received during drug abuse treatment. CSOs completed a weekly version of the TSR that was modified to determine whether the drug-abusing family member sought or obtained relevant treatment services such as counseling, detoxification, drug or alcohol rehabilitation, self-help, physician treatment, or emergency room treatment. At the 10-week follow-up, CSOs were also asked whether the drug-abusing family member entered counseling, self-help groups, or drug abuse treatment at any time during the 10-week study.
Key Findings	In a randomized clinical trial (RCT), adult CSOs of a drug-abusing family member not in treatment were recruited through newspaper advertisements and randomly assigned to a group participating in CRAFT or a group participating in a 12-step self-help group. To participate, CSOs had to be in contact with the family member at least three times weekly and not be engaged in alcohol or drug abuse themselves. A higher percentage of drug-abusing family members with intervention group CSOs than comparison group CSOs entered a substance abuse treatment program during the 10-week intervention period (64% vs. 17%, respectively; p < .01).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.5 (0.0-4.0 scale)

Outcome 2: Engagement in alcohol treatment
Description of Measures	Engagement in alcohol treatment was defined as scheduling and completing an initial 4-hour assessment and one treatment session. CSOs were given a 24-hour phone number to call when their alcohol-abusing family member was willing to consider treatment. When a phone call was received, an initial appointment was scheduled during which a clinical staff member described treatment options: during the first 6 months of the study, free treatment was available through a follow-up clinical study, and for all 12 months of the study, alternative treatment programs were available in the community. Because treatment could be obtained outside of the follow-up clinical study, information about treatment engagement was also obtained from CSOs using a modified Form 90-C (collateral interview, alcohol section), a semistructured interview that addresses drinking and drug use behavior, employment, treatment, and health care utilization. Form 90-C interviews with CSOs were completed 3, 6, 9, and 12 months after CSO randomization.
Key Findings	In an RCT, adult CSOs of a treatment-refusing family member meeting DSM-III-R criteria for alcohol abuse or dependence were recruited through local news media announcements and randomly assigned to one of three counseling interventions: CRAFT; Al-Anon facilitation therapy, designed to encourage involvement in the 12-step program; and the Johnson Institute intervention, designed to prepare the CSO for a confrontational family meeting with his or her substance-abusing family member. For CSOs to participate, their substance-abusing family members had to be a spouse, unmarried intimate partner, or close relative (parent, child, grandchild, or sibling) who lived with the CSO. CSOs had to be in contact with the family member on at least 40% of the 90 days prior to study entry and not be engaged in alcohol or drug abuse themselves. Findings included the following: During the 6 months following CSO randomization, a higher percentage of alcohol-abusing family members with CSOs assigned to CRAFT than those with CSOs assigned to Al-Anon facilitation therapy or the Johnson Institute intervention were engaged in alcohol abuse treatment (64% vs. 13% and 30%, respectively; p < .0001). The difference in treatment engagement between the two comparison conditions was not significant. During the 12 months following CSO randomization, a higher percentage of alcohol-abusing family members with CSOs assigned to CRAFT than those with CSOs assigned to Al-Anon facilitation therapy or the Johnson Institute intervention were engaged in alcohol abuse treatment (67% vs. 20% and 35%, respectively; p < .0001). The difference in treatment engagement between the two comparison conditions was not significant.
Studies Measuring Outcome	Study 2
Study Designs	Experimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

Outcome 3: Engagement in drug treatment
Description of Measures	Engagement in drug treatment was defined as completing a baseline assessment, signing an informed consent, and scheduling a treatment session. When the drug-abusing family member agreed to seek treatment, the CSO or family member telephoned the project officer or the pager to schedule a screening and baseline assessment for free treatment through a follow-up clinical study. Because treatment could be obtained outside of the follow-up clinical study, information about treatment engagement was also obtained from CSOs using a modified Form 90-C (collateral interview, drug section), a semistructured interview that addresses drinking and drug use behavior, employment, treatment, and health care utilization. Form 90-C interviews with CSOs were completed 3, 6, 9, 12, and 18 months after CSO intake, although only data from the first 6 months were used in the analysis.
Key Findings	In an RCT, adult CSOs of a treatment-refusing adult family member meeting DSM-IV criteria for a psychoactive substance use disorder other than alcohol were recruited through newspaper advertisements and randomly assigned to one of three treatment conditions: CRAFT only, CRAFT plus aftercare, and Al-Anon and Nar-Anon facilitation therapy. For CSOs to participate, their substance-abusing family members had to be a first-degree relative, spouse, or intimate partner or someone who lived with the CSO. CSOs had to be in contact with the family member on at least 40% of the 90 days prior to study entry and not be engaged in alcohol or drug abuse themselves. During the 6 months following CSO intake, a higher percentage of drug-abusing family members with CSOs assigned to CRAFT plus aftercare than those with CSOs assigned to CRAFT alone or Al-Anon and Nar-Anon facilitation therapy were engaged in treatment (76.7% vs. 58.6% and 29.0%, respectively; p < .01). Compared with engagement in the Al-Anon and Nar-Anon facilitation therapy condition, engagement was significantly greater in the CRAFT plus aftercare condition (p < .01) and the CRAFT-only condition (p < .02). Engagement did not differ significantly between the CRAFT plus aftercare and CRAFT-only conditions.
Studies Measuring Outcome	Study 3
Study Designs	Experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	13-17 (Adolescent) 18-25 (Young adult) 26-55 (Adult)	77.4% Male 22.6% Female	68.8% White 25% Black or African American 6.2% Race/ethnicity unspecified
Study 2	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	Data not reported/available	Data not reported/available
Study 3	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	Data not reported/available	Data not reported/available

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Entry into drug treatment	2.5	2.5	2.3	2.5	2.0	3.0	2.5
2: Engagement in alcohol treatment	2.5	2.5	3.6	3.9	3.3	3.9	3.3
3: Engagement in drug treatment	2.5	2.8	3.8	4.0	3.4	4.0	3.4

Study Strengths

Treatment engagement was measured in two studies using highly replicable criteria (completing a baseline assessment [both studies], signing an informed consent [one study], scheduling treatment [both studies], and attending one treatment session [one study]) and collateral interviews with Form 90-C, an instrument with previously demonstrated reliability, face validity, and high convergent validity in the Project MATCH multisite clinical trial of alcohol treatment. The manual-guided intervention was typically delivered by master's-level counselors who were under the ongoing supervision of a doctoral-level behavioral analyst and a licensed clinical psychologist in one study or the developer of the intervention in two other studies. In two studies, all treatment sessions were videotaped and at least a random selection of sessions and all difficult sessions were reviewed by the supervisor(s), with corrective action taken when necessary. Across all three studies, the target intervention condition had very high follow-up rates and very little missing data. Random assignment was used in all three studies to control for many potential confounds. An appropriate statistical approach was used in the one study with a small sample size, with more sophisticated statistical modeling used in the two studies with larger sample sizes.

Study Weaknesses

In the absence of specific study sample psychometrics, the reliability and validity of the TSR and Form 90 versions used in the studies were weakened by unspecified modifications to the instruments, use of only some portions of the instruments, and use of the instruments with indirect sources (CSOs). None of the studies employed any psychometrically tested fidelity instrument to monitor implementation. For one study, the researchers defined the minimum acceptable dose of the intervention but not the full dose. Potential confounding factors were pronounced in only one of the three studies. In this study, the two conditions being compared used different modalities (one-on-one vs. group delivery), treatment session lengths, program content, and requirements for CSO session attendance that constituted a completed treatment week. One study did not use an intent-to-treat approach; two studies did not correct for the experimentwise error rate by adjusting the alpha significance level for multiple statistical contrasts; and none included prospective power analyses, an issue that was particularly problematic in the study with a small sample size.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Godley, S. H., Garner, B. R., Smith, J. E., Meyers, R. J., & Godley, M. D. A large-scale dissemination and implementation model for evidence-based treatment and continuing care. Clinical Psychology, 18(1), 67-83.

Meyers, R. J. CRAFT: Community Reinforcement and Family Training. Unpublished manuscript.

Meyers, R. J., & Smith, J. E. CRAFT: Community Reinforcement and Family Training [PowerPoint slides]. Albuquerque, NM: University of New Mexico, Center on Alcoholism, Substance Abuse, and Addictions.

Meyers, R. J., Smith, J. E., Serna, B., & Belon, K. E. Community Reinforcement Approaches: CRA and CRAFT. Unpublished manuscript.

Meyers, R. J., & Wolfe, B. L.. Get your loved one sober: Alternatives to nagging, pleading, and threatening. Center City, MN: Hazelden.

Participant worksheets:

Communication Worksheet
Goals of Counseling
Index Card for Communication Assignments
Perfect Relationship
Problem Solving Worksheet

Quality assurance documents:

Certificate of Completion
Certification Process
CRAFT Assessment Package
CRAFT Coder Supervisor [supervisor requirements]
CRAFT Functional Analysis of a Loved One's Drinking/Using Behavior
CRAFT Functional Analysis of a Loved One's Rewarding, Healthy Behavior
CRAFT Procedures [fidelity checklist]
Functional Analysis of a Loved One's Violent Behavior
Happiness Scale

Smith, J. E., & Meyers, R. J.. Motivating substance abusers to enter treatment: Working with family members. New York, NY: Guilford Press.

Smith, J. E., & Meyers, R. J. Working with family members of treatment-resistant substance abusers: What independent practitioners should know. Independent Practitioner, 29(3), 175-179.

Smith, J. E., & Meyers, R. J. Community Reinforcement and Family Training (CRAFT) therapist coding manual--individual session version. Bloomington, IL: Lighthouse Institute.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
3.3	3.8	3.5	3.5

Dissemination Strengths

The book Motivating Substance Abusers To Enter Treatment: Working With Family Members contains sample scripts, treatment plans, and case examples to highlight program components. The implementation training is comprehensive and includes a combination of in-person instruction, telephone consultation, and review of audiorecorded clinical sessions. A certification process is in place for counselors and supervisors. The program Web site provides current training information and support resources. Quality assurance is supported through comprehensive tools for monitoring fidelity and client progress as well as training and coaching for both clinicians and supervisors on the use of these tools.

Dissemination Weaknesses

The procedural steps listed in the fidelity checklist are not consistent with the required steps described in the implementation guidance. Implementation, training, and quality assurance materials are not ideally organized to maximize accessibility and ease of use.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Motivating Substance Abusers To Enter Treatment: Working With Family Members (book)	$27.63 each	No
Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening (book)	$13.26 each	No
2.5-day, on-site training (includes all other materials and forms, consultation, and review of recorded sessions)	$425 per person	No