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

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

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

Behavioral Couples Therapy Structure: Standard: 15-20 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; 10-20 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)

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; 10-20 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. 158-159 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)

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)

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)

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

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

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

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”

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

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

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

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

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