What to Know About CRAFT Therapy for Addiction

Let’s just put this out there: Community Reinforcement and Family Training (CRAFT) is a pretty clunky and vague name for a method of counseling.

That said, this evidence-based approach for families and friends to help loved ones who are drinking excessively or using drugs is well worth knowing about.

In plain language, CRAFT is directed at those closest to the person with substance use issues. It is not a program or a place. It is a counseling method that gives concerned significant others (CSOs) the skills they need to steer their loved ones toward treatment in a loving and non-confrontational way, while also taking care of themselves.

CRAFT is an alternative to what has traditionally been available to CSOs whose loved ones have a substance use disorder.

These options generally have two basic approaches: There are programs like Al-Anon and Nar-Anon, which aim to help families endure the challenges of a loved one’s substance use, even if it means cutting them off and letting them hit rock bottom. And there are Johnson-style interventions like what you see on TV, where a person is confronted and told they can either get treatment or be cut off by friends and family.

“With fentanyl flooding the drug supply, advice about detaching and letting people hit bottom can be a recipe for death,” says Pat Aussem, LPC, LMHC, MAC, assistant vice president at the nonprofit Partnership to End Addiction. “CRAFT is based on the concept that it’s helpful to treat someone with respect and stay attached if you want to have influence over them. In today’s environment especially, this approach may keep some people who use substances alive long enough so they have the chance to move toward a healthier life.”

Robert Meyers, Ph.D., developed the CRAFT approach while counseling people with alcohol use disorder in the 1970s. At the time, Meyers was working under Nathan Azrin, Ph.D., creator of a counseling method called the Community Reinforcement Approach.

CRA is directed at people with alcohol use disorder and uses positive reinforcement (among other strategies) to make sobriety more rewarding than drinking. As part of his CRA work with Azrin, Meyers often saw patients together with their partners.

“Usually, it was a wife who brought in a husband who was drinking. She was gung-ho about getting him to stop but he wasn’t interested,” says Meyers. “So, I began to think, what if I could help the wife learn how to help her partner in a way that used positive reinforcement and wasn’t confrontational? What if I could teach her to interact with her spouse so he’ll start listening, instead of all the yelling and fighting that usually happened? That’s basically where CRAFT began.”

Over the following years, Meyers and other researchers at the University of New Mexico and beyond conducted CRAFT studies.

“Al-Anon, Nar-Anon, none of these programs had hard statistics to show they were effective. CRAFT studies provided evidence that our approach actually worked,” says Meyers.

The numbers are impressive: Research from 2010 published in the journal Addiction shows that CRAFT leads to three times more patient engagement than Al-Anon and Nar-Anon and twice that of Johnson interventions. Depression and anxiety scores are also lower for CSOs who participate in CRAFT, even if their loved ones ultimately don’t seek treatment.

With research to back him, Meyers began publishing CRAFT materials for clinicians as well as consumers. In the 2000s, he started to expand CRAFT’s reach, training other providers in the US and abroad.

“CRAFT is relatively new compared to other approaches. Americans, especially, are more comfortable sticking with what they know,” says Meyers. “But people are getting smart. More counselors are learning the CRAFT approach. It’s being used at major treatment centers like Hazelden Betty Ford. And clinical data point to the fact that CRAFT is an effective way to go.”

CRAFT can be helpful for CSOs with loved ones who are not interested in seeking treatment for their substance use issues. It can also teach families skills they might need to encourage their loved one who has entered treatment and to respond in the event of a relapse.

Another important point: Because CRAFT embraces a “harm reduction approach,” it doesn’t demand abstinence like some other programs do.

“Not drinking or using drugs at all is ideal. But many people with a substance use disorder may not be open to that. Some may never stop using,” Aussem says. “Keeping the conversation and attachment open regardless may help them move in a direction that is less harmful. Over time and with the ongoing influence of friends and family, they may get to point where they are ready to stop.”

Case in point: A mother sought Aussem’s CRAFT counseling after pleading unsuccessfully with her daughter to quit using heroin. At the time, the young woman was living in a nearby New Jersey city and earning money as a sex worker.

“Since the daughter was firm about not stopping her drug use, we brainstormed other possibilities,” says Aussem. The mother and daughter eventually agreed to have lunch together once a week, with the only ground rule being there would be no talk about her substance use.

“It took five years but eventually the daughter told her mom she was ready to get treatment. Keeping the attachment and communication helped make that happen,” Aussem says.

When is CRAFT not an ideal option? Since CRAFT is relationship-based, it “does not work well with people who have an estranged relationship with their loved one or have very little or no contact with them,” says Lara Okoloko, LICSW, a CRAFT-informed family therapist in the Seattle area.

It’s possible to buy The Beyond Addiction Workbook and put CRAFT techniques into practice on your own. But “if you work with a counselor, they can help you figure out how to tailor CRAFT skills to your situation,” says Aussem. “They can also connect you with resources in your area that complement the CRAFT approach.”

If you opt for CRAFT counseling, it can be done one-on-one or in group settings, in-person or virtually.

During their initial session or sessions, CRAFT counselors educate CSOs about the CRAFT approach and learn all they can about the person who is using and their relationship with the family.

“I ask them to tell me everything about their loved one’s substance use,” says Aussem. “Who they use with. How much they use. What they think motivates them to use. Are they trying to relieve anxiety? Depression? Social awkwardness? Sleeplessness? Knowing the ‘why’ behind a person’s substance use is important.”

Moving forward, counselors use this information to help CSOs learn skills and tailor strategies that can help steer their loved one toward treatment, while attending to their own health and well-being.

CRAFT isn’t a rigid treatment regimen that happens over a specific time period. However, a review of four high-quality, randomized studies found that two-thirds of substance users agreed to seek treatment after CSOs attended four to six CRAFT sessions. Typically, CSOs continue with CRAFT counseling for another six or so sessions after this point.

Every situation is different, however. “Some loved ones can take longer to agree to treatment. Some may never agree to treatment. Families often decide they want more support than 10 sessions of skilling building and counseling,” says Okoloko.

The CRAFT approach teaches CSOs a wide breadth of concrete, practicable skills. This includes:

• Unconditional kind and supportive communication.

• Developing an understanding of why their loved one is using or drinking and acting on that information to steer them toward a healthier life.

• Listening empathetically to help cultivate a more respectful, collaborative relationship.

• Talking directly but non-confrontationally with their loved one about their substance use.

• Using rewards to encourage recovery behavior.

• Determining which painful consequences of using or drinking they will allow their loved one to experience and which consequences are too risky or damaging to tolerate; minimizing enabling.

• Identifying opportunities when the subject of treatment might be raised and being prepared to act if their loved one is receptive.

• Identifying triggers for violence and abuse and devising plans for keeping themselves and others safe.

• Valuing and prioritizing their own self-care, especially getting support.

• Acceptance and learning to let go.

Dr. Michael McGee, president of WellMind, Inc., also offers this summation of the CRAFT principles:

• Get help and support: You can’t do it alone.

• Get safe and vital: Take good care of yourself. You’re no good if you’re no good.

• Practice loving communication: Unconditionally at all times (No one does this perfectly).

• Stay connected: Unconditionally. Do not emotionally abandon your loved one.

• Reward recovery behaviors: Make them feel that recovery is a better way.

• Neglect addiction behaviors: Make material rewards and support conditional upon recovery. Remove them in the context of addicting.

• Honor pain: Do not shield your loved one from the natural negative consequences of addicting.

• Set therapeutic expectations: Expect your loved one to do what they can. Hold them accountable.

• Let go: Only the victim of addiction can choose recovery.

• Have hope: Most people recover from addiction. You can help! Never give up!

Licensed psychologists and social workers can be trained in CRAFT and provide it as part of their practice. Substance use and other counselors can be trained in the CRAFT approach as well.

“If you are looking for a few sessions of CRAFT skill coaching, you probably don’t need to see a licensed therapist. There are many coaches out there who are doing a great job,” says Okoloko. On the other hand, if things are more complicated, “licensed therapists are probably better equipped to address issues like [a CSO’s] depression and multi-generational family trauma,” Okoloko says.

Another benefit of seeing a licensed therapist: The cost for CRAFT may be covered by health insurance.

“Even if CRAFT coaching isn’t covered, it can cost less—and is more effective--than a Johnson intervention, which can run thousands of dollars for a few sessions, says Okoloko.

Group CRAFT counseling is a particularly affordable option.

How To Find a CRAFT Counselor

As the number of CRAFT coaches nationwide grows and virtual counseling has become commonplace, finding someone trained in the CRAFT approach has become easier.

You can start by searching the Helping Families Help Directory. The Center for Advanced Recovery Solutions’ website also has information about where to find CRAFT counseling.

CRAFT Resources for Families

• https://alliesinrecovery.net

• www.cadenceonline.com

• "Beyond Addiction: How Science and Kindness Help People Change" by Jeffery Foote et al.

• "Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening" by Robert J. Meyers and Brenda L. Wolfe

Being there for a loved one who is struggling with substance use issues is a marathon, not a sprint. Whether it is CRAFT or another counseling approach you choose to work with, protecting your own mental and physical health and learning how to support your loved one without enabling their destructive behavior is crucial to their recovery and everyone’s well-being.