1. Community Reinforcement and Family Training: Utilization Across the Treatment Spectrum Carrie Wilkens, PhD – Co-Founder, Clinical Director Nicole Kosanke, PhD - Director of Family Services Center for Motivation & Change www.motivationandchange.com A Workshop For NJAMHAA Annual Conference - April 16 th, 2015

2. Outline of this Workshop Part 1: Overview of CRAFT (purpose, evidence, and elements) Part 2: Non-traditional uses of CRAFT (group, couple, CRAFT-IT) Part 3: CRAFT, Parents and Self-Help: A Novel Pilot Project 2

3. Prevalent Problem We know SUDs are prevalent (1 in 10 over age 12 meet criteria for abuse or dependence) 30% of adults have met criteria in lifetime 12% of high school students meet criteria The majority of people don’t seek treatment (estimates = 11%) 3

4. Collateral Damage: 1 in 4 Families Estimated 5 loved ones for every 1 person with substance use disorder negatively impacted. Family member functioning negatively impacted across domains (financial problems, marital conflict, increased depression and stress, and decreased happiness levels) Due to issues like shame, isolation, and very limited treatment options for the family members themselves, these domains of negative impact often go untreated 4

5. What Is CRAFT? CRAFT is a highly effective, evidence-based approach for working with family members trying to cope with a loved one who is reluctant or refusing to get help for substance abuse problems 5

6. Alphabet Soup CSO: Concerned Significant Other IP: Identified Patient (the substance user) Engagement = Entering Treatment 6

7. Sid and Nancy – A Case Example Sid: Has been binge drinking after work between 2 and 4 x’s a week, sometimes coming home late and calling Nancy, clearly drunk, for a ride home from the train station. When he does come home on time, he will have drink after drink and get belligerent. He often makes no sense and has fallen asleep at the table. 7

8. Sid and Nancy – A Case Example Nancy: “He’s such a good guy… really… but since he got in trouble at work, he drinks in the day and gets wasted a bunch each week. I asked him to talk to somebody, but he tells me I’m over-sensitive cause of my Dad. Yells a lot. And the worst? It’s scaring the kids..and me actually, when I’m not furious.” 8

9. Traditional Approaches for CSOs 12-Step Programs (Al-Anon, Nar-Anon) Johnson Institute Intervention Mental Health Counseling 9

10. 12-step programs (Al-Anon, Nar-Anon) Offers valuable support to CSO, decreases isolation & builds community Goal: Self-care and decreasing enabling Key premise: CSO cannot directly influence changes and needs to focus on self-care “Detach with love”: detach from behaviors not the person Prevalence: Almost 15,000 Al-Anon groups in US 2nd Most common referral made by providers 10

11. CRAFT Contrast & the Evidence Change can be influenced at every stage & CSO’s can have a positive impact Of substances users who seek treatment, family involvement is #1 reason cited Al-Anon is a support system that was never designed to “get someone into treatment” even though that is often CSO goal CSO’s can learn skills beyond that of self-care 11

12. Johnson Institute Intervention Recognizes the powerful influence of the family Goal: Get the substance user to agree to rehab Key Premise: Direct, specific feedback about impact of use (confrontation) is instigator of change Commonly reported success rates = 90% Average cost = $5,500 Broad media support 12

13. CRAFT Contrast & the Evidence Significant evidence that confrontation leads to worse long-term treatment outcome 70% of families fail to go through with the process 13

14. CRAFT: Community Reinforcement & Family Training Utilizes power of family and gives “reasonable & realistic” hopefulness – works unilaterally with CSO to teach skills Goal: 1.Reduce the IP’s harmful substance use/negative behaviors 2.Engage the IP into treatment/change 3.Increase the life satisfaction of CSO Key Premise: IP motivation can be influenced by CSO and reinforcement is more effective than confrontation 14

15. CRAFT Reality CRAFT: Average engage rate of IP into treatment = 68% Parents, adult children and spouses Prevalence: Approx. 5-15 CRAFT providers in the U.S. 15

16. Miller, Meyers et al, 1999 (N=130) (Miller et al., 1999) Treatment Engagement Rates Percentage of cases in which a family member’s participation successfully engaged a substance abuser in treatment. 16

17. Sisson & Azrin, 1986 Miller, Meyers, et al 1999 Kirby, et al., 1999 Meyers, Miller, et al, 1999 Meyers, Miller, et al, 2002 Waldron, et al,. 2007 14 CSOs130 CSOs32 CSOs 75% Anglo; 23% AA 62 CSOs 80% Hispanic 90 CSOs 88% female; 49% Hispanic 42 CSOs 48% Hispanic 48% Anglo Alcohol 56% Cocaine 22% Opiate 37% Cocaine 35% Marijuana 16% Stimulants 8% Opiates Marijuana Cocaine Stimulants Marijuana Alcohol Randomized (CRAFT / 12- step) Randomized (CRAFT / JI / Al- Anon) Randomized (CRAFT / 12- step) Non - randomized Randomized (CRAFT / Al- Anon) Non-randomized Tx Engage: 86% vs 0%; CSOs better Tx Engage: 64% vs 23% vs 13%; CSOs better Tx Engage: 74% vs 17%; CSOs better Tx Engage: 74% CSOs better Tx Engage: 67% vs 29%; CSOs better Tx Engage: 71% CSOs better CRAFT STUDIES 17

18. What We Have all Heard Huge historical and cultural bias toward disease model language which is supported by media I need to use tough love I can’t do anything. I can’t change him He won’t change until he bottoms out I don’t want to enable I was told I am enmeshed and need to back up and let my son fail so he can get better I’m co-dependent 18

19. A Motivational Interlude: The Myths Confronting someone about their problems helps them change It usually takes a crisis, or hitting “bottom,” for someone to become motivated to change Motivation hits in one revelatory moment; and once it hits, it sticks Until someone is motivated to change, there is nothing that can be done to help them 19

20. A Motivational Interlude: The Facts Confrontation negatively affects motivation Motivation can occur whenever the costs of a behavior perceptibly outweigh the benefits Motivation is a fluctuating state, based on gradual stages Motivation is facilitated by interpersonal interaction CRAFT is based on the use of reinforcers to facilitate changes in motivation 20

21. CRAFT – The Basics Works to affect the IP’s behavior by changing the way the CSO interacts with them Positive Reinforcement Positive Communication Allowing for Negative Consequences Skills-based program useful to the CSO in multiple life areas (self-care, social support) Collaborative/motivational/positive – therapist modeling is crucial 21

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23. They speak of my drinking, but never of my thirst. -Scottish Proverb 23

24. Functional Analysis: Overview FA is a behavioral analysis of IP’s behavior (neg or pos) conducted with the CSO Premise: Behavior (IP substance use) does not exist in a vacuum, and can be influenced by changes in CSO behavior toward IP ‒Increases awareness of patterns = predictable ‒Increase awareness of ability to influence in positive way Goal: Examining IP use patterns, triggers, and consequences (positive and negative) allows for: ‒Increased empathy, optimism and direction/strategy 24

25. Functional Analysis: Information Gathering Describe the drinking/using behavior what, how much, frequency Identify triggers for the drinking/using who, where, when, thoughts, feelings List consequences the IP experiences for alcohol/drug use (negative and positive) Understanding triggers and reinforcers (pos and neg) allows for alternative plans by CSO; CSO behavior can be more targeted 25

26. Functional Analysis 26

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28. Positive Communication: Rationale for the CSO More likely to get what you want: PC reduces defensiveness in the listener (“You catch more flies with honey…”) PC (e.g., a compliment) can serve as a powerful reinforcer for a loved one PC is “contagious” PC will increase CSO satisfaction in other life areas as well (social support) 28

29. Things that Don’t Work Nagging Pleading Threatening Yelling Lecturing Pouring alcohol down the drain Getting drunk ( to show the drinker what it’s like) 29

30. Positive Communication Skills Be brief ‒lots of info is a turnoff ‒ often includes “old”, emotionally-laden issues Be positive (2 meanings) ‒the words do matter (avoid blaming, name calling, overgeneralizing, accusatory tones) ‒what is wanted as opposed to not wanted 30

31. Positive Communication Skills Refer to specific behaviors ‒vague requests much easier to ignore/leave undone ‒refer to behaviors instead of thoughts/feelings: makes change easier to notice/measure/reinforce Label your feelings ‒brief description of emotional reaction ‒state in calm, non-accusatory manner ‒facilitates empathy and consideration 31

32. Positive Communication Skills Offer an understanding statement ‒genuine understanding reduces defensiveness Accept partial responsibility ‒“sharing” the problem reduces defensiveness ‒shows other your interest in solving, not blaming Offer to help (specific or general) ‒experienced as non-blaming and supportive 32

33. But first a word about…Role-Playing Acknowledge discomfort Use less difficult scenes first Get adequate description of the scene Demonstrate it for them Keep it brief (2-3 minutes) Reinforce any effort First get client’s specific reactions Then offer supportive, specific feedback (“sandwich” technique) Repeat Try a “reverse” role-play 33

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35. Enabling vs. Positive Reinforcement Enabling: something the CSO does that increases drinking/drug using behavior or allows it to continue CRAFT’s Positive Reinforcement: something the CSO does that increases non-drinking/non-drug using (pro-social) behavior The difference between positive and negative behaviors is at the heart of CRAFT 35

36. Identifying Non-Using Behaviors to Reinforce The behavior to reinforce should be one that: The IP enjoys (pleasurable, ideally inexpensive). Competes with the substance-using behavior in terms of time and function. Occurs fairly often currently, or can occur often in the future (ideally immediately) The CSO also enjoys (if applicable). 36

37. Linking Reinforcement with Non-Using Behavior Timing Potential for violence/negative reaction Use of positive communication skills Improving ability to recognize signs of use (so positive reinforcers can be withdrawn) 37

38. Time Out From Positive Reinforcement Withdrawing of positive reinforcement when IP resumes drinking/using. Identify reinforcers (rewards) to withdraw. Will IP miss the withheld reinforcer? Teach CSO to communicate the rationale for withholding the reward. 38

39. Allowing for Natural Consequences Explore CSO’s unintentional support of the using/negative behavior Refer to F.A. (consequences) if necessary Offer common examples: ‒Reheating dinner for late, intoxicated IP ‒Calling in sick for hungover IP ‒Making excuses to family/friends about IP 39

40. Sample Natural Consequences Wife (CSO) cleans up her husband’s (IP) “accidents” when he’s drunk. Husband (CSO) of an unemployed drug-user (IP) calls his parents for financial help each month. Daughter (CSO) picks up her drunk dad at midnight after his Sat. night card games. 40

41. Increasing the CSO’s Quality of Life: Self-Care Find CSO Reinforcers Assess CSO’s satisfaction in various areas Select one area needing more reinforcers Identify goals and steps to obtain them Problem-solve if necessary Identify activities independent of drinker 41

42. Happiness Scale Legal issues Emotional life Communication General happiness [add your own] Drinking/using Job/education Friendships Money management Social life Personal habits Marriage/family relationships 42

43. Improving the CSO’s Quality of Life: Friendships & Social Support Create or re-create a social circle Find a confidant Ask for help/learn how to Self-help groups Positive communication skills 43

44. Suggestion of Treatment to the IP Prepare for Rapid Intake (for IP to be seen within 24-48 hrs.) Role-play the conversation (use positive communication) Include important motivational “hooks” Discuss windows of opportunity 44

45. Basic Questions to Consider CSO’s past engagement attempts that have been the most successful? Time, place, day the IP is most approachable about requests in general? Most likely reason the IP would enter treatment (for the relationship, kids, to keep his/her job)? Most influential person to talk with IP about treatment? 45

46. Motivational “Hooks” Ask IP to informally meet CSO’s therapist Mention having one’s own (a different) therapist Invite IP to “sample” treatment State that the IP won’t have to do anything he/she doesn’t want to Explain that there’s no confrontation/judgment Mention that IP can focus on topics besides just alcohol/drugs (e.g., job, depression) Tie in IP’s reinforcers 46

47. Windows of Opportunity Is IP approachable when feeling remorseful for a drug- related “crisis”? Is IP acting upset upon overhearing a negative remark about his substance use? Is IP asking about what’s happening in the CSO’s therapy? Is IP inquiring about why the CSO’s behavior has changed lately? 47

48. Examples Identify “hook,” window of opportunity, positive communication component: You’ve been my best friend and partner for over 10 years, and I don’t want that to change. But I’m worried about your drinking. Would you be willing to come down and see if my therapist can find you a counselor? 48

49. Examples I know you’re really stressed at work and that you use drugs to unwind. But I bet there’s a healthier way to deal with your stress. I know that therapists let you work on all sorts of things, including stress. You wouldn’t have to just talk about drugs. 49

50. IP TREATMENT Considerations Evidence-based treatment Program that’s compatible with CRAFT (cognitive- behavioral?) Able to do couples work too? Waiting list? Cost, insurance, length, frequency? 50

51. The work isn’t over….. Prepare CSO for a treatment refusal, or a treatment dropout Encourage CSO to get involved in IP’s treatment Instills sense of broad need for skill development across family & learning perspective Open door policy 51

52. CRAFT IS A WIN / WIN APPROACH CSOs improve their psychosocial functioning whether the substance user enters treatment or not. In 7 out of 10 cases the substance user enters treatment. 52

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54. Non-Traditional Uses of CRAFT In group format With couple (two parents learning CRAFT) When IP is already in treatment With trained lay-people as coaches 54

55. Increasing Usability for CRAFT Group is primary treatment modality for clinics treating substance use disorders (group CRAFT) Parents’ eagerness for options utilizing helping strategies (couples CRAFT) Introduction of CRAFT systemically where treatment is provided (CRAFT-IT; when IP in treatment) 55

56. CRAFT Group Logistical considerations: Closed/open group CSO type (men/women, partner/parent, spouse/boyfriend/girlfriend) CSOs with own substance use CSOs with IP’s of differing degrees of substance use disorder severity 56

57. CRAFT Group Clinical considerations Normalizing difficulty of CRAFT Normalizing CSO experience via peers More “real life” behavioral practicing and learning from examples Normalizing ambivalence (of IP and CSO) More accountability with homework and self-care goals Being able to help others 57

58. CRAFT with Couples Both parent CSOs of a child IP Considerations: -Alignment -More options for brainstorming/problem-solving -Accountability in homework/self-care -An additional strategist/perspective on priorities for behavioral interventions re both IP behaviors and CSO self-care needs 58

59. CRAFT - IT When IP already in treatment, goals shift from treatment entry to maintaining engagement Project of changing interactional patterns between CSO and IP can be practiced in on-going way Complexity of managing information flow between IP and CSO treatment providers When treatment is inpatient vs outpatient 59

60. CRAFT, Parents and Self-Help: A Pilot Project A collaboration between: The Center For Motivation and Change and The Partnership For Drug-Free Kids Mission: To develop a national self-help, peer-to-peer network for parents based on CRAFT principles for helping families of loved ones struggling with substances 60

61. Core Concepts of Training Parents 20 Minute Guide Manualized, parent-friendly CRAFT-informed workbook CRAFT concepts + MI communication skills Concepts plus worksheets “Waterfall” – LOVE skills for leading LOVE skills for parent caller 61

62. 20 Minute Guide 62

63. “LOVE” Communication Skills MI communication skills in digestible form Listening using OARS from MI o Affirmations as central Offering using “information sandwich” from MI/CBT Validating Empathizing 63

64. 20 Minute Guide Topics Self-Care Normalizing stress Managing emotions Isolation 64

65. 20 Minute Guide Topics Communication Red and green lights of communication LOVE skills Positive communication skills 65

66. 20 Minute Guide Topics How to Help One size doesn’t fit all Parent collaboration Reinforcement: why use makes sense Natural consequences Understanding ambivalence 66

67. CRAFT BOOKS Get your loved one sober: Alternatives to nagging, pleading and threatening. Meyers, R. J. & Wolfe, B. L. (2004). A self help book published by Hazelden Pubs. Motivating substance abusers to enter treatment: Working with family members. Smith, J.E. & Meyers, R.J. (2004). Guilford Press: New York NY. Beyond Addiction: How Science and Kindness Help People Change. Foote, Wilkens & Kosanke, 2014. Scribner: New York NY. The Parent’s 20 Minute Guide: A Guide For Parents About How to Help Their Child Change Their Substance Use. CMC Staff, self-published (2014). The Partner’s 20 Minute Guide: A Guide For Partners About How to Help Their Loved One Change Their Substance Use. CMC Staff, self-published (2014). 67

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70. Beyond Addiction 70

71. Parent’s 20 Minute Guide 71

72. Parent’s 20 Minute Guide 72