CRAFT is the acronym for Community Reinforcement & Family Training. There is also a part of this model called Contingency Management theory, which we will discuss.
This evidence-based approach to addiction treatment is based on operant conditioning and learning. It seeks to find the efficacy of whether or not applied environmental consequences increase voluntary commitment for a person with a substance use disorder.
Environmental consequences are one of the number one predictors of outcomes. To put it in lay terms, does enforcing boundaries, consequences, and tough love help a substance user see the need to change? In other words, should the family apply positive reinforcement and love them to change, or should they take a stronger position?
The answer is it all depends on the person and where they are at in their addiction. It is important to remember that some of the treatment works some of the time for some people. If we look at what an intervention is by way of clinical explanation, it is a specific strategy to meet a specific goal to address a problem or behavior. You could even add to that definition a particular moment in time.
This blog will look at the following:
The CRAFT model can be applied through all 5 stages of change and throughout the intervention and recovery process for both family and substance user.
Here we will discuss applying the CRAFT Model for interventions during the the first two stages of change: pre-contemplation and contemplation.
Most substance users are in the contemplation stage of change, which means they are aware there is a problem. Pre-contemplation is either complete denial or someone unaware there is a problem. Whether the substance user is in the pre-contemplation or contemplation stage, the goal is to move them into the following stages of change.
The following stages are preparation for treatment, taking action by entering treatment and addressing the problem, and recovery maintenance and growth. The substance user must have ambivalence to move out of the contemplation stage. Ambivalence is when the substance user can recognize both sides of the argument.
The goal of a clinician is to help the substance user see a greater need for change than a greater need to stay the same. There are many tools to help a substance user see the benefits of addressing the problem. Some of the earlier approaches before the CRAFT model and, in turn, inspired the CRAFT model include:
Motivational Interviewing – An evidence-based intervention that seeks to evoke change talk by moving the substance user away from the sustained talk. The goal of motivational interviewing is to help motivate the substance user.
The five dimensions of motivation a clinician seeks to receive from the substance user are Desire, Ability, Reasons, Need, and Commitment. Motivational interviewing is still used every day to help motivate clients, as it is an effective communication tool for clinicians.
Assessment Feedback – This is when the clinician will provide feedback to the client based on the assessment performed with the substance user. When the feedback is delivered using Motivational Interviewing, this is considered MET or Motivational Enhancement Theory.
Working through Friends and Family – This is where the “you have to wait for them to want help and hit bottom” theory most likely came from. Working through friends and family, this approach suggested waiting for the addict and alcoholic to hit bottom and ask for help, for the family to go to al-anon, and using the coercive intervention to kick them out. Where this approach failed miserably is you do not have to wait for the addict or alcoholic to want help or hit bottom before taking action.
The coercive intervention approach is said to be linked back to the Vernon Johnson model of intervention. Although his style has been fine-tuned today, he was right about many things. Among many ideas, two things he believed in were disrupting alcohol and drug use and suggesting not to wait for the addict or alcoholic to want help or hit bottom.
Building off the Vernon Johnson approach, also known as the Minnesota Model, the CRAFT model helped families understand that their involvement was essential to the substance user’s successful outcome potential. It helps families understand there are approaches other than simply waiting for their loved one to want help or hit bottom and that the family can help increase the likelihood of the substance user accepting help.
The CRAFT Model helps with this by focusing on operant conditioning and the impact the environment has on the motivation of a substance user to seek treatment rather than continue to use drugs or alcohol.
The CRAFT model seeks to answer whether the operant conditioned behavior is changed by positive reinforcement or tough love and consequences. The answer is that it all depends on where the substance user is.
We can tell from our experience that the positive reinforcement approach becomes less effective as the severity of the addiction increases. In other words, the CRAFT model appears to be most effective when the substance user is either sober and abstinent or early on in their addiction. It is less effective when the addict or alcoholic is in the late stages of addiction.
In the later stages, we see exhausted families who can no longer tolerate the impact of the addiction. When they utilize positive reinforcement, the substance user takes advantage of their kindness and steamrolls past them. When caught early on, we see the opposite effect.
Our experience has shown us that when the addict or alcoholic is in active addiction along with destructive behavior, strong boundaries and accountability is the most effective strategy until the substance user accepts help. It is important to note that positive reinforcement appears effective regardless of where the family is in the process. This is also a reminder that there is no one size fits all method.
It is essential to retain professionals who understand when tough love and detachment is a more effective option than positive reinforcement and vice versa. There are also several ways to apply positive reinforcement with boundaries and accountability. You can be firm and kind at the same time. The CRAFT Intervention model applies the most appropriate intervention strategy for the specific problem and behavior.
“No matter the approach, changing the environment is the focus of the CRAFT Model and is the number one predictor of successful outcomes.”
What is CRAFT Intervention Therapy for Alcohol and Drug Addiction?
CRAFT Therapy for alcohol and drug addiction looks at several areas to address the substance user’s environment and provide positive reinforcement. As with any clinical intervention strategy and application, it should be determined by a trained professional when these applications should be executed.
Positive reinforcement is significant and is not always the best course of action in specific situations depending on where the substance user and their family are emotionally and mentally.
The areas of focus with the CRA part of the craft model and one with the contingency management part (CM):
CRA + Vouchers (Use of Time) – In the Community Reinforcement Approach (CRA) part of the Craft Model, drug or alcohol users look at the positives and negatives of drug and alcohol use. By looking at situations that may place the substance user in a vulnerable position, the substance user can identify the people, places, and things to avoid.
The substance user is encouraged to engage in and with new activities, people, places, and things to avoid the negative consequences of drug or alcohol use. They are equally encouraged to focus on the positive reinforcement of these changes.
Many substance users state they use drugs and alcohol because they are bored. Even though this is a minimal reason, it’s a reason, and making better use of their time to fill in potential isolation periods is suggested. There is also a reward that comes with engaging in activities that bring happiness.
The substance user feels a reward from drugs and alcohol, and the goal is to seek rewards from positive activities, people, places, and things as an alternative to the rewards brought from alcohol and drugs.
CRA + Vouchers – In the Contingency Management Approach (CM) part of the Craft Model, substance users are given monetary incentives to comply with their treatment plan and abstain from drugs and alcohol. It is important to note that addicts and alcoholics are never given actual cash as an incentive. This is a controversial approach that is discussed later in this article.
Social Networks & Interpersonal Relationships – Substance users are encouraged to change their unhealthy contacts and relationships to healthy ones to support their recovery. This is one of the many benefits of the fellowship in a 12-step program.
Many sober activities are available to participants of 12-step programs. Those in early recovery need to work on themselves and detach themselves from toxic individuals that could compromise their mental health and increase their stress levels.
Job & Skills Training – Some will return to a job after treatment, and some will have to find a job after treatment. It can be difficult in either case and learning how to navigate the challenges of employment in sobriety may be difficult for some. Some may have never had a job or have criminal backgrounds that prevented them from achieving their employment goals.
Learning how to handle the many challenges of finding the right job could greatly benefit long-term sobriety. Job and skills training can also include encouragement to start pursuing an education or complete an education that may have been put on hold due to alcohol and drug use.
Behavioral Couples Therapy – BCT is an evidence-based treatment that brings the substance user’s spouse or significant other into the recovery process. As part of our intervention process at Family First Intervention, we utilize BCT throughout our curriculum. We witness the positive results of this evidence-based tool.
Although BCT addresses the spouse and significant other only, we see the same results when key family members are brought into the addict or alcoholics recovery process while applying the same principles of BCT.
HIV/AIDS and STD Education – Whether or not someone is in recovery, education on diseases that can be transmitted sexually or by sharing needles is extremely important. Learning the importance of medical care and caring for one’s body is all part of recovery.
Many addicts and alcoholics have not been to a dentist or a doctor in a long time, nor have they been tested for any diseases or STDs. This education is also part of learning how to be unselfish and think of others before engaging in relationships involving sex. It is also about learning how to take care of yourself and consider others in the relationship.
Medication Management & Medication Compliance – Education and understanding the importance of prescribed medication is part of recovery. Often, addicts and alcoholics are given medications to deter them from consuming alcohol or to block the effects of opioids.
Others may be given medications for mental disorders. Many treatment providers put together discharge plans that encourage the substance user and their families to follow a plan to hold the person responsible for their medication compliance. Plans are often put in place as to what to do should the substance user become non-compliant with their medication.
Refusal, Coping, and Sobriety Skills – This includes learning ways to refuse alcohol if offered, even in innocent social situations where the person offering it is unaware the person should not be drinking.
Learning how to communicate with doctors and dentists effectively should the need for opioid pain medication be suggested is also covered. Acquiring coping skills is important for recovery and overall mental health. Sobriety from drugs and alcohol requires many more strategies than just saying no or stopping drug and alcohol use.
Sobriety skills are when one acquires a plan of action to defend themselves from the temptations and obsessions of alcohol and drug use. If addiction recovery were as simple as just quitting alcohol and drugs, many fewer people would struggle to achieve sobriety.
How Does CRAFT Intervention Therapy Work?
The CRAFT model focuses on positive reinforcement instead of negative consequences when the situation warrants it.
CRAFT Therapy works by utilizing positive reinforcement to enhance the substance user’s motivation to change, teach the substance user new coping mechanisms, and educate the family on the positive impact they can have in their loved one’s recovery process.
The thought behind the model is that if it is agreed that rewarding negative behavior and consequences lead to repeating the same behavior, then if you reward the substance user for positive behavior, they will repeat more of that instead. The clinician’s goal is to help the substance user see a greater reward than the reward received from drugs and alcohol.
Earlier, we touched on several areas of focus that can create positive reinforcement for the substance user. All of these things are important to sobriety. The question is, when is it ok to reward positive behavior and still hold the substance user accountable for negative behavior? It starts by connecting the substance user with positive people, places, things, and activities.
At the same time, new connections are being offered and encouraged we also would like them to stay away from activities, people, places, and things that include alcohol consumption or drug use.
CRAFT therapy has proven its efficacy following the clinical trial. It works in conjunction with other clinical intervention instruments. For example, rewarding a substance user for doing well while helping the family understand the importance of healthy boundaries and detachment is an element of CRAFT.
The problem we have faced in real-world applications and outside of clinical trials is families rewarding the substance user when they are still using drugs or alcohol or too soon after they stop. It is common for a family to loosen their boundaries almost immediately after the addict or alcoholic enters treatment or quits. It is always important to remember that it takes a while for the substance user’s behavior to change.
Just stopping drugs and alcohol is worth rewarding and acknowledging, and it is not enough to loosen your boundaries right away. If your child did something wrong, there still have to be consequences.
You can implement those consequences while validating their acknowledgment of what they did and encourage them not to do it again. You can help them see why what they did and how it may be harmful to themselves and others.
Talking to them to help them understand why they did it can lead to positive reinforcement too. You can then provide positive reinforcement as they learn to avoid doing things that may get them in trouble. You do not have to punish them in a way that instills fear forever and makes them feel that they can’t come to you for help later. You also do not want to reward them for bad behavior. This can encourage them to continue bad behavior.
“The biggest challenge we face with the CRAFT model is when families let their guard down and loosen their boundaries too soon. Many families instantly apply positive reinforcement because the substance user stopped using drugs and alcohol, and they forget that the behaviors that caused the drug and alcohol use are still present in the early stage of abstinence and sobriety. Moving too quickly often fails for the family as the substance user takes advantage of the positive reinforcement and uses it against the family as a vulnerability.”
Along with positive reinforcement and teaching the substance user new coping skills, the CRAFT model helps families understand that their actions during and after the substance user’s recovery process can significantly impact both positively and negatively.
A tenant of CRAFT is for families to learn how and when to apply positive reinforcement effectively and still be able to avoid looking the other way at negative behavior. How the family addresses the problem greatly impacts the outcome for both them and the substance user.
Earlier on, we discussed the two reasons why interventions fail. The first was when a coercive approach was used, and the second was when the family was not involved in the recovery process for themselves and the substance user.
Study after study shows that when family members change their position and attitude, it directly affects the substance user’s alcohol and drug use. Substance users are more likely to decrease their use and or engage in complete abstinence when family members are engaged in a new way of addressing the problem and are engaged in their own recovery efforts.
Examples of changes using CRAFT concepts for families are:
- Validate growth and positive changes in behavior. Remember, this does not mean letting your guard down or loosening your boundaries.
- Handle objections and excuses from the substance user. Examples could be comments such as, “What about my job? Who will take care of my pets or my house while I am away in treatment?” The family should come together and discuss removing any excuses that would prevent the substance user from entering a treatment program.
- Always remember that “Unconditional love does not mean unconditional approval of bad behavior.”
Who Benefits from CRAFT Intervention Therapy?
The real answer is everyone. Any model that brings a substance user out of their addiction and away from destructive behaviors helps many people, places, and things. When you think about it from a long-range perspective, an addiction can disrupt or at least affect many people’s lives.
When addicts or alcoholics stop using drugs and drinking, they often become productive members of society. When this happens, you take the strain off of many areas that were being affected.
Families reunite, children become less affected, there are fewer overdoses and deaths, impairment on the road is no longer a threat, self-harm reduces, employers have a productive employee, and law enforcement is not pulled away from other areas to tend to the addict’s legal problems, there is less divorce and strains on relationships, courtrooms, and hospitals are less full, the overall financial strain on society decreases, and the list goes on and on.
Substance users and families benefit from a new way of living, and the CRAFT model can help bring both sides there. Evidenced-based treatment works and has proven efficacy.
When family members and substance users reunite and are a happy family again, that is a huge victory. Addiction is not a victimless crime; it affects many people, not just the substance user and their immediate family.
Families can benefit from the CRAFT model even when the substance user does not stop using drugs or alcohol. Families do not have to wait for their loved one to want help or hit bottom to address their concerns over the addiction. As we stated earlier, substance users are more likely to reduce their alcohol and drug consumption or stop altogether when families get better.
Does the CRAFT Intervention Method Work?
The book Evidence-Based Treatment, edited by Peter M. Miller, Copyright 2009, states, “The specific content of CRA will vary depending on the population being treated” We start by answering this question with this citation because, as we stated above, in our experience, the CRAFT model appears to be less effective as the severity of the addiction increases.
One of the most talked about chapters in the book of Alcoholics Anonymous is Chapter 8, To Wives. If anyone has ever been to an Alcoholics Anonymous meeting when this chapter is being discussed or read, you will find out why. The founder of Alcoholics Anonymous, Bill Wilson, decided to write this chapter instead of allowing his wife Lois, who was enormously impacted by Bill’s alcoholism, to write this chapter.
Almost every Alcoholics Anonymous member states Bill should have stayed out of this one and that he got it wrong. Most members laugh at its content and discuss how ridiculous it is.
The biggest laughs of the Alcoholics Anonymous members come from the sentence on page 113 where it states, “Cheerfully see him through more sprees.” This is stating for the family and spouse or significant other to be ok with the destructive behavior of the alcoholic (and drug addict) and accept it.
In reading this chapter, almost every single member of AA states that if their loved ones treated them the way Bill suggests, they would all be dead or still drinking. What is our point? The chapter is about positive reinforcement and validation of destructive behavior while actively drinking alcohol or using drugs. So if almost every sober alcoholic, the key word being sober, believes this to be highly ineffective with real experience to back it up, then how is the CRAFT model showing efficacy today?
The answer is it isn’t.
The CRAFT model does not encourage this when the addict or alcoholic is actively drinking or using drugs. We make this point because codependent people read it that way. People often tell us they read that the only way to help someone is by enabling them or being nice. When active addiction or destructive behaviors are present, Bill’s way did not work in Chapter 8, and the CRAFT model does not imply this either.
In our experience, the biggest reason why the CRAFT model shows efficacy for some and not for others goes back to the quote from the evidence-based book.
Most members of Alcoholics Anonymous were late-stage alcoholics who would have been most likely diagnosed with a severe alcohol use disorder. Their families tried the positive reinforcement approach to no avail while they were drinking and/or engaged in negative and destructive behavior.
These alcoholics will tell you that they are sober because they were made aware of the problem while being held accountable with tough love and stiff consequences. They almost always concede that if you validated or rewarded them at any time for anything while they were drinking, they would have pounced on your kindness and taken full advantage of you.
For these alcoholics, positive reinforcement would not have been effective. In our experience, that would be our feedback, with the exception of very few specific cases and situations.
“Almost every severely diagnosed alcoholic and drug addict who is sober will state that they needed stiff consequences and tough love in order to see the need for treatment. Many go on to say that they didn’t decide to stop drinking or drugging when things were going well. They almost always say they needed negative consequences as a reason to stop. The reason to stop rarely, if ever, occurred when things were going well and while others were validating their efforts of trying to reduce their alcohol or drug consumption or stop altogether.”
When we have clients’ families who call early, in other words, before it is a dire situation, the CRAFT model is very effective and is almost always suggested as the first course of action. In our experience, it is very effective for this population of clients. Unfortunately, almost every call we receive for intervention is past this stage, and all efforts of positive reinforcement and validation have failed.
The majority of families we encounter are at a point where they are unable to bring themselves to the point of accepting things the way they are while exercising positive reinforcement and kind strategies to hold on to another day.
As effective as the CRAFT model is for clients who can benefit from it, there is one component that we have never once seen be effective. In fact, we have not only seen it be ineffective; we have only seen it make matters worse for our clients.
It may be effective in the early stage of addiction and the later stages of sobriety for some, and it is one of the most ineffective strategies we have ever witnessed across the board. We have never once seen it work.
We are referring to the Contingency Management (CM) approach of the CRAFT model, also known as CRA + Vouchers. This is different from the CRA + Vouchers strategy on the Community Reinforcement side of CRAFT. With this approach, substance users, either in very early recovery or still using drugs and alcohol while trying to reduce their alcohol and drug intake, are given monetary rewards to positively reinforce their efforts.
Although these rewards are never in physical cash, they are in a way that can be converted into cash, such as gift cards or other forms that an intelligent substance user is able to navigate in their favor to spend on drugs and alcohol.
We understand the science behind the model. Provide substance users with a reward for abstaining from drugs and alcohol that feels better than the reward received from using drugs or alcohol. This model would most likely be very effective in a world of social drug and alcohol users.
An example would be someone who can just stop because they had a child or because they got a new job. In other words, someone who can just quit without any help other than their own willpower.
Substance users diagnosed as severe or moderate have lost the power of choice and cannot just say no. For this reason, when you are faced with a severely diagnosed substance use disorder, this model fails utterly in our experience. The vulnerability and the obsession with using or drinking again while trying to reduce alcohol or drug use or in the early stage of abstinence or sobriety are just too high.
The tools of recovery are just not strong enough yet to overcome the thought of drinking alcohol or using drugs. The manipulative behaviors to convert the rewards to cash have not yet left the substance user in these early stages.
Most people are unaware of what drives addiction. It is often believed that when the alcohol and drugs are gone, the substance user will return to “normal.” This is not the case. It takes quite a while to address the reason and behaviors that drive the addiction.
People in early recovery are rarely in a position to see things differently, even when alcohol and drug use has stopped. Working with professionals can help a family understand what strategies and why could be most effective for specific situations.
“The family may not always know when the addict or alcoholic is using alcohol or drugs. They will almost always no when they are not. This is because the behavior of the substance user will have changed for the better.”
How to Start the CRAFT Method for Drug and Alcohol Addiction
The CRAFT method starts with a Functional Analysis. A functional analysis of alcohol and drug use looks at the events and causes that lead to consequences. Most people believe that the drugs and alcohol itself are the cause of the problems.
The cause of the problems is the behaviors, past experiences, and events that lead to the drug and alcohol use that leads to the problems and consequences. Either way, the functional analysis looks at the antecedents, in other words, what is the precursor to the consequences.
In most cases, substance users put themselves in a position to be hurt. Many do not want to look at that or are unable to realize that they are the cause of what happens to them. If you get arrested, that is a consequence. Many addicts blame everything else on the police officer before they own that their actions put them in handcuffs. In summary, the antecedent is almost always the person and their choices.
The functional analysis also explores triggers that prompt people to use drugs and alcohol. Some clinicians can use a payoff matrix to help a substance user see the advantages and disadvantages of using or not using drugs and alcohol.
Positive change begins to happen when the ability to see the positives outweigh the negatives of not using drugs or alcohol. This goes back to creating ambivalence in the contemplation stage of change and enhancing motivation.
The payoff matrix can help someone who has stopped using drugs or alcohol see the benefits of identifying triggers and help those start the recovery process. An analysis of consequences and triggers is part of the functional analysis to start the CRAFT Method.
In theory, you can start the CRAFT model at any time. It is never too late to start educating a family on what they can do differently and when they should apply the principles of positive reinforcement.
Learning how to detach and love at the same time can start as soon as the family is ready. Positive reinforcement can start as soon as the addict or alcoholic does something that allows them to be rewarded.
As we stated several times, and as the CRAFT model suggests, if the substance user is in active alcohol or drug use or is acting out with destructive behavior, it is recommended to detach and withdraw. It is never too late to stop enabling, and it is never too late to start any of the suggestions in the “How does CRAFT Therapy Work” Section above.
Family First Intervention’s CRAFT Model
Many treatment centers and clinicians are jumping on the bandwagon of the CRAFT model, even though it has been around since the late 1970s. More and more people are inquiring about its effectiveness and its approach.
Family First Intervention has been applying many components of the CRAFT model since 2009. We do not believe in coercion, and we believe in the power of family education. We believe in this so much that we are one of the few intervention companies offering a structured family recovery program after the intervention.
We help families understand the why.
It is easy for someone to tell you why you should not give an addict or an alcoholic $50. We all know what they are going to do with it. We help families understand why they feel the need to give the addict or alcoholic $50. Our approach allows families to make informed decisions after they are educated.
We believe in boundaries and holding the addict and alcoholics accountable. We also believe that positive reinforcement is necessary when it is effective. Sometimes it is not, and the substance user will take advantage of your kindness. An untreated substance user knows no other way to act, nor does an untreated codependent enabler.
We help families understand the importance of boundaries while detaching and still loving the substance user. As the behaviors change and improve for the substance user and the family, so do the methods and intervention strategies. Each family, substance user, and case is different, and so are the suggestions to achieve the best chance of positive outcomes.
Study after study indicates why interventions fail, and they are primarily for two reasons. The first is the model used. When interventions are conducted using coercion, they are often ineffective. Many interventionists who operate by themselves use the paid glorified 12-step call. They come in and state the obvious outcomes of enabling while telling families to “cut the substance user off.” This is not an intervention; this is a paid 12-step call.
The second reason interventions fail is that many interventionists do not follow through with the family after the intervention. This is where the CRAFT model shines. When a family understands how to hold boundaries and detach from the addiction, positive outcomes are achieved far more often than not. The family can learn when to be firm and when to apply positive reinforcement.
If someone talks or coerces a substance user into treatment and provides the family little to know support afterward, it is almost inevitable that things will return to the way they were. This is why it is vital to retain a professional interventionist who knows the various clinical strategies to achieve positive outcomes.
You don’t want a one size fits all interventionist coming in and thundering through a paid 12-step call which is not well versed in the various clinical intervention instruments. You need an interventionist who understands which specific strategies to address the problem or behavior to achieve the goal of correcting the problem or behavior.
“Interventions fail for two reasons. When the wrong approach is used and when there is no follow through with the family after the intervention.”
