1. Empirically-supported treatments involving significant others
Behavioral Couples Therapy
Community Reinforcement Approach
CRAFT
12/6/12

2. Options for Family Members
Al-Anon
Johnson Institute “intervention”
Behavioral Couples Therapy (BCT)
Community Reinforcement Approach (CRA)
Community Reinforcement and Family Training (CRAFT)
Al-Anon: group support, work against “codependency”, enc. “loving detachment” from the drinker; unsatisfactory for some
Johnson Institute Intervention: and a surprise confrontation of the drinker by a group of CSOs
Intervention team created; 3-4 prep training sessions with therapist
Work with therapist to (a) agree on treatment recommendation they will all firmly support, and (b) agree on specific consequences to be applied if drinkers does not enter treatment, and (c) follow through with consequences
surprise confrontation of the drinker by a group of CSOs who share their concerns & feelings in nonjudgmental fashion
Outcomes are disappointing:
only 30% of families trained actually complete the intervention
Leading to only 22% treatment engagement
BCT, CRA, CRAFT all have strong support for efficacy

3. Rationale for including spouse in treatment
Assumption that family interactions reinforce alcohol misuse
Alcohol misuse  relationship discord
Partners experience discord/dissatisfaction, aggression, detachment, enabling, etc.
Relationship discord  maintenance of alcohol misuse
Alcohol misuse  relationship discord
Destructive cycle: Alcohol misuse  relationship discord

4. Behavioral Couples Therapy
Structure:
Standard: outpatient couples sessions, ~6 months
Brief: 6-12 sessions, ~3 months
Optimally effective when:
Only one partner has an alcohol problem
Couple is committed to relationship
No major psychopathology or history of domestic violence
Both can commit to abstinence
Goal #1: stabilize alcohol problem
Goal #2: enlist partner’s support for change
Goal #3: improve interaction patterns
SOC: assume action; sessions
Need for crisis intervention? Job loss, financial, medical, legal problems
contraindicated if there is a risk of severe violence (history or by assessment)
Contraindicated if there is a court-ordered restraining order
Goal #1: controlling alcohol abuse is first priority; identify ineffective alcohol-related interactions that could serve as triggers
nagging/blame (reframe as efforts to protect family)
Ignoring sober behavior
Enabling (cleaning up, excuses)
Illustrate sobriety contract, Antabuse contract in Hester & Miller book
Goal #2: work on interaction patterns so as to create a more positive family atmosphere to support sobriety
address relationship differences unrelated to drinking (increase goodwill, positive feelings) ; illustrate with Catch homework (Hester p. 201)
Teach people to confront and resolve conflicts to reduce relapse (cf. communication skills figure, Hester p. 202)

5. Behavioral Couples Therapy
Recovery contract
Daily abstinence trust discussion between partners
Medication adherence
MHG meetings
Monitoring
BCT sessions
Update on urges and drinking or drug use
Review of homework activities
Skills training and practice
Behavioral assignments
“Catch your partner doing something nice”
“Caring day activity”
Shared pleasant activities
Positive communication
SOC: assume action; sessions
Need for crisis intervention? Job loss, financial, medical, legal problems
contraindicated if there is a risk of severe violence (history or by assessment)
Contraindicated if there is a court-ordered restraining order
Assessing relationship: exchange from Rotgers book p
current psychosis in partner
Partner has current AOD problem
Goal #1: controlling alcohol abuse is first priority; identify ineffective alcohol-related interactions that could serve as triggers
nagging/blame (reframe as efforts to protect family)
Ignoring sober behavior
Enabling (cleaning up, excuses)
Illustrate sobriety contract, Antabuse contract in Hester & Miller book
Goal #2: work on interaction patterns so as to create a more positive family atmosphere to support sobriety
address relationship differences unrelated to drinking (increase goodwill, positive feelings) ; illustrate with Catch homework (Hester p. 201)
Teach people to confront and resolve conflicts to reduce relapse (cf. communication skills figure, Hester p. 202)

6. Behavioral Couples Therapy
Managing relapse
Back to drinking
Back to relationship discord
Anticipate, normalize, reframe
Common
Not a personal betrayal
Not a sign that things will never change
Develop recovery plan
Ongoing activities in support of abstinence
Ongoing activities working on relationship
Relapse contingency plan
Outcomes favor BCT over individualized tx (Fals-Stewart, O’Farrell, & Birchler, 2004):
Reduced drinking
Fewer problems
Happier relationships
Less likely to separate
Reduces IPV (O’Farrell et al. 2004/5? JCCP)
Improves adjustment of children (Kelley & Fals-Stewart, 2002)

7. Community Reinforcement Approach Hunt & Azrin (1973), Meyers & Smith (1995)
Behavioral program helps the drinker build a rewarding and meaningful life without alcohol
Helps to restructure or rearrange person’s social environment to support sobriety
Significant other involvement is encouraged
Highly structured
Daily contact, fading to weekly, etc.
Consistent with behavioral economics : people distribute their activities according to what is rewarding
The most powerful reinforcers are associated with social relationships
Highly structured, effective with people with severe AUD problems, and even with comorbid psychiatric disorders
Two variations are discussed CRA and CRAFT (aimed at spouse, to help get drinker into treatment)

8. CRA Components: Functional Analysis: ABCs of behavior
Antecedents: internal & external triggers
Behavioral patterns: what, where, how much?
Consequences: positive and negative, short- and long-term

9. CRA Components: 2. Sobriety sampling A time-limited period of sobriety
Length determined collaboratively (90 days --> 30 days --> 1 week --> 1 day)
Develop a specific plan
Try out feeling of being sober
An initial “success experience”
Difficulties can illustrate degree of dependence, or where help is needed
Antabuse compliance: regular monitoring, stimulus control, social reinforcement, signifiicant other involvement, consequences for noncompliance

10. CRA Components : 3. CRA treatment plan Problems assessment
Identify areas of discontent
Set goals
Specify methods for achieving goals
Focus on multiple aspects of life, not just drinking.
CF Happiness Scale

11. CRA Components : 4. Behavioral skills training Communication skills
Problem solving
Drink refusal training
Identify any communication problems
Help develop better problem solving skills
Drink refusal training important if exposure to others’ drinking is likely to continue
enlist social support: inform important others that you won’t be drinking
Review high risk situations: generate plans
Refuse drinks assertively, reduce anxiety related to “what will happen”

12. CRA Components : 5. Job counseling for unemployed clients
Meaningful work is important for self-esteem
Finding a job is a full-time job: developing a resume, completing applications, practice for interviews, etc.
Learn how to keep a job
Avoid jobs with high relapse potential!
Assumptions: a satisfying job and financial security are important aspects of daily living; also important sources of reinforcement/competence and often incompatible with excessive drinking (ALTERNATIVE)
Job hardening: learning how to get there on time, consistently, even when you don’t feel like it, how to use good judgment in work settings
ATTENDANCE enters you into a lottery: every week a $20 prize was awarded

13. CRA Components : 6. Counseling re: social/recreational activities
Identify areas of interest
Experiment with alternate activities
Weekly, free social event, with concerned others

14. CRA Components : 7. Relapse Prevention Identify high risk situations
Use functional analysis
Plan coping strategies

15. CRA Components : Relationship counseling
Target specific areas for improvement
Practice communicating and problem solving
Plan to be nice
Re-build abstinent ways of relating

16. Community Reinforcement and Family Training (CRAFT)
Designed to help concerned significant others (CSOs) engage (resistant) drinkers into treatment
The CSO is the client in CRAFT
Understand reinforcement contingencies operating in relationship
Positive approach, no confrontation
CSOs learn how to reward positive behavior and avoid “rescuing” the drinker
Helps CSO cope if drinker doesn’t change
The CRAFT protocol has a growing number of studies supporting its efficacy:
7/10 CSOs who participate in this program get their loved one into treatment
64% Kirby et al (1999)
74% Meyers et al (1999)
Used by spouses, also by parents with substance abusing adolescents (Waldron et al., 2007, JSAT)
Addresses concerns of CSO (negative experiences, automatic thoughts): examples of program components
Understand reinforcement contingencies
functional analysis
Often unintentionally ignore sobriety; positive interactions have dropped out
Participate in planning and practicing activities that are alternatives to substance use
Reinforce abstinence + allow drinker to suffer natural consequences of their behavior
if unintentionally reward drinking behaviors, important to stop rewarding unwanted behaviors (don’t heat up dinner)
note that risk for domestic violence must be monitored is CSO starts behaving differently towards drinker (risk of this can be assessed in advance
The CSO also learns how to care for his/her self even in an unhealthy relationship