family member, family members, CRAFT, Functional Analysis, relative, the CRAFT, positive reinforcement, Community Reinforcement Approach, behaviour, Meyers, Alcohol, Robert Meyers, Substance Abuse Treatment, Community Reinforcement and Family Training, Community Reinforcement, negative consequences, health care, non-drinking, alcohol treatment programs, Violent behaviour, Indigenous communities, Indigenous Australians, communication skills training, Substance Dependence, Indigenous health services, Indigenous Health and Family Workers, alcohol addiction, Indigenous Health Workers, Miranda Rose, Community, alcohol intervention, primary health care, J.C. Saunders, Alcohol Services South Australia, Turning Point Alcohol and Drug Centre, Cannabis Youth Treatment
Miranda Rose, Bianca Calabria, Julaine Allan, Anton Clifford, Anthony P. Shakeshaft Aboriginal-specific Community Reinforcement and Family Training (CRAFT) manual NDARC Technical Report No. 327
Working with families with substance misuse problems Community Reinforcement and Family Training (CRAFT) Manual
Aboriginal-specific Community Reinforcement and Family Training (CRAFT) Manual Miranda Rose, Bianca Calabria, Julaine Allan, Anton Clifford, Anthony P. Shakeshaft Technical Report Number 327 ISBN: 978-0-7334-3444-0 © NATIONAL DRUG AND ALCOHOL RESEARCH CENTRE, UNIVERSITY OF New South Wales
, SYDNEY, 2014 This work is subject to copyright protection. Except as permitted under the Copyright Act 1968 and this notice, no part of this work may be reproduced, stored in a retrieval system, communicated or transmitted in any form or by any means without prior written permission from the owner. Healthcare practitioners, clinicians and healthcare agencies and services who/which have purchased this work, may reproduce the appendices of this work in hard copy only, solely for their use in clinical practice. All other rights are reserved. Requests and enquiries concerning reproduction and other rights should be addressed to the Information Manager, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia.
Table of Contents Introduction................................................................................................................................ 2 About This CRAFT Manual .......................................................................................................... 2 How To Use This Manual............................................................................................................ 3 Section 1: Introduction to CRA and CRAFT ................................................................................ 6 Section 2: CRA and CRAFT In Communities ............................................................................. 12 Section 3: Community Reinforcement and Family Training Procedures ................................. 18 Session 1: Introducing CRAFT to family members ................................................................... 22 Sessions 2, 3 and 4: CRAFT procedures.................................................................................... 34 Skills Training............................................................................................................................ 61 Engagement into treatment..................................................................................................... 72 Section 5: Glossary ................................................................................................................... 88 Useful Resources and Contacts ................................................................................................ 92 1
Introduction There is substantial evidence that Indigenous Australians are more likely to drink alcohol at risky levels and to suffer a higher burden of physical, social and psychological alcohol-related harms than other Australians. This is presented in research which shows Indigenous people have higher rates of hospital admissions for alcohol related conditions such as acute intoxication, liver disease, and dependence, while communities experience more alcohol related social problems such as family violence and incarceration (SCRGP 2009 p 10.14). At the same time, there is little evidence to show which strategies might work best to reduce these harms (Gray, Saggers, Sputore, Bourbon. 2000). In trying to change this situation UNSW is working with a number of community health organisations to trial and evaluate a comprehensive family based approach for alcohol problems adapted for use with Indigenous people. Called Community Reinforcement and Family Training (CRAFT), this approach has already been used in a number of settings with different population groups (Viet 2007,). The approach includes two components; the Community Reinforcement Approach (CRA) for working with individuals who are at risk of alcohol related harm and Community Reinforcement and Family Training (CRAFT) for working with their families and friends (Smith & Meyers 2004 p x). Evaluations suggest this two-sided approach is more effective for encouraging individuals into alcohol treatment and for assisting family members to feel less depressed, anxious and angry (Meyers, Miller, Smith, & Tonigan 2002, Hendrik, Roozen, Ranne de Waart & Petra van der Kroft 2010). Most importantly CRAFT appears to fit well with Indigenous views of health and health care that are holistic and dedicated to `... the social, emotional and cultural well-being of the whole community in which each individual is able to achieve their full potential as a human being thereby bringing about the total well-being of their Community' (NACCHO 2006). There are two manuals that describe the two parts of the CRAFT approach. One manual provides a guide to the Community Reinforcement Approach (CRA) and is designed for workers assisting individuals who have been assessed as at risk for alcohol related harm. The information provided here in this manual is a guide to Community Reinforcement and Family Training (CRAFT). This manual is for workers who will use Community Reinforcement and Family Training (CRAFT) to assist families who are affected by their relative's/loved one's alcohol use. About This CRAFT Manual Community Reinforcement and Family Training (CRAFT) as it is described in this manual has been adapted from a comprehensive explanation of the approach as published in Smith and Meyers (2004) Motivating Substance Abusers to Enter Treatment, Working with Family Members. This adapted CRAFT manual is designed for Indigenous Health and Family Workers1 and other workers within Australian Indigenous community settings to support the 1 In this manual the term Indigenous Health and Family Workers and other generalist and specialist Indigenous Health Workers will hereafter be referred to as workers. 2
families and friends of people who are at risk for alcohol related harm. It is likely that workers using this CRAFT manual will have a variety of qualifications. Consequently some will have more knowledge and experience of alcohol related issues than others, including an understanding of the information in this manual. Some may also have completed the CRAFT training workshop conducted by Dr Robert Meyers in Orange in May 2011. But it is the view of the project team that this manual should take an equitable approach to ensure all workers are similarly equipped with the specialist skills and knowledge they need to confidently use CRAFT with Indigenous people. For this reason the manual acknowledges the range of existing skills and knowledge that workers might bring to this field. It also recognises the useful resources that already address alcohol issues as they affect Indigenous communities and does not attempt to duplicate them. Rather the manual focuses on information specific to the CRAFT approach as it might be used and adapted by all workers who provide health care to Indigenous people. The manual is written in plain English but uses technical and specialist terms when necessary. Detailed explanations and a glossary of terms and acronyms aim to ensure meanings are clear. The manual has six sections as follows: Section 1 outlines CRAFT's structured approach to assist people who misuse alcohol and help their families. It includes a brief overview of some of the research evidence showing that CRAFT is particularly effective for supporting families who are dealing with alcohol related issues. Section 2 describes the physical and social related harms that affect individuals who drink as well as those affecting their families and communities. It describes how CRAFT fits well with Indigenous health services and their holistic approach to health care provision, primary health care (PHC) and community development. The section concludes by describing the roles of individual and team health practitioners, families and the community in CRAFT. Section 3 focuses on the Community Reinforcement and Family Training (CRAFT) component of CRAFT and describes the CRAFT procedures for assisting the families and friends of people who experience alcohol related harms. Section 4 include appendices outlining sample CRAFT session plans, a glossary of useful technical terms and concepts used to talk about alcohol in health service settings and a list of helpful contacts and additional information to support the delivery of CRAFT. Section 5 is a glossary that lists and explains useful technical terms and concepts used to talk about alcohol in health service settings. Section 6 lists helpful contacts and additional resources to support the delivery of CRAFT. How To Use This Manual There are a number of ways to use this manual. For experienced workers it can be used to refresh, reflect on and extend existing skills and knowledge about alcohol dependence and the strategies used in the CRAFT approach. For those with less experience the manual 3
provides theoretical and practical information about alcohol addiction and a detailed explanation of CRAFT. This includes a step by step session guide that shows workers how to plan and deliver CRAFT to families and teach them the skills and knowledge they need to more effectively manage their relative's 2 drinking. The manual's intention is to reinforce what workers learnt in the CRAFT training workshop delivered by Dr Robert Meyers in Orange in 2011. Although the manual is set out in a particular order it is designed to offer workers some flexibility to choose the sections that meet their requirements and those of family members participating in the CRAFT sessions. This last point is really important, as family members may have different needs or be dealing with different issues, while some may require more support than others. 2 The term relative is used in this manual to refer to the person who drinks. This person may also be a close friend or intimate partner
of families/friends who are participating in CRAFT. 4
Section 1: Introduction to CRA and CRAFT This section includes information about: the definition of Community Reinforcement And Family Training (CRAFT) research evidence for CRAFT Leah's Story Leah is at her wits end. She has lost count of how many times she has tried to persuade her 18 year old son Jason that he should go to the Drug and Alcohol Centre to get support for his out of control drinking. Leah has tried talking, getting angry and even pleading with Jason to understand how much damage he is doing to himself and to his family. Jason's grandmother and aunties have also tried. But Jason thinks it is his legal right to drink as much as he likes, especially on weekends when he can spend Friday and Saturday nights with his mates drinking at different clubs in town. He also thinks that because he is still going to footy training every week that his drinking is not having a bad effect on his health. Anyway, as Jason tells his mother, at the weekend he has access to his father's car and the beer is cheap, so its only fair that he and his mates should be able to charge up, hang out and have a good time. Leah sees things differently and has noticed Jason is becoming aggressive and his behaviour unpredictable, so much so that when she recently caught him taking money from her wallet he threatened to hit her. These days Jason is also more, secretive and distancing himself from his sisters and brothers. The situation is making Leah so sad and angry she is thinking of telling Jason to move out of the house. She feels really bad about this but doesn't know what else to do or who to turn to. 1.1 What is CRA and CRAFT? Community Reinforcement And Family Training, or CRAFT as it is known, is a structured but flexible approach to support people who are negatively affected by alcohol. This includes: people like Jason who are at risk of harm as a result of their unhealthy patterns or levels of drinking, and family members like Leah (Jason's mother) and other relatives, for example Jason's grandmother and aunties, intimate partners or close friends To ensure that both groups of people receive the support they need, CRAFT has two parts. These are: 1. Community Reinforcement (CRA) for individuals whose drinking impacts on their health. 2. Community Reinforcement and Family Training (CRAFT) for the families and friends of the people who drink. Both the CRA and CRAFT parts of CRAFT use strategies and procedures that aim to: remove positive rewards for drinking; strengthen positive rewards for abstinence (not drinking); encourage the participation and wellbeing of family, friends and other relatives. 6
In general these strategies and procedures are based on changing the way people think about and behave towards alcohol and towards their relatives or friends who misuse it. In technical terms, this focus on changing people's behaviour is a type of `cognitive-behavioural therapy' or CBT. These strategies and procedures aim to support and encourage people to think about the positive aspects of their personal lives and living environment to improve their health and wellbeing. Strategies also include teaching people the skills they need to achieve these outcomes. Relating the CRAFT approach to Leah's story we can see that CRA would be useful for supporting her son Jason to think about his drinking behaviour and its negative health impact. It would also be useful for assisting Jason to learn how to strengthen the positive parts of his life that would reinforce non-drinking behaviour. We can also see that the CRAFT part of CRAFT could help Leah and others in Jason's family to think about how they might assist him to enter treatment for his alcohol use at the same time as they learn the skills they need to strengthen their own wellbeing. An important advantage of CRAFT is that it is a standardised approach with a set program but is also flexible so it can be adapted to people's personal stories and individual needs. This includes taking more or less time to assist people to achieve their goals. The following section explains each part of the CRAFT approach in more detail. 1.2 What is CRA? The Community Reinforcement Approach or CRA is the part of CRAFT that is for people who: `feel a strong need to drink so that drinking is given priority over other behaviour that they had previously found much more important. This will include people whose dependence on alcohol may range from mild to severe. People with severe dependence, drink regularly at high-risk levels, find it hard to limit how much they drink, and generally have marked tolerance to the effects of alcohol.' (2009 NHMRC Australian Guidelines to Reduce Health Risks from Drinking Alcohol) This includes people whose alcohol consumption has resulted in: diseases such as cardiovascular, cancer, diabetes, liver disease, mental health conditions, foetal alcohol syndrome, malnutrition, obesity and/or alcohol related injury such as assault, vehicle accident, drowning, violence, sports injury, falls, recreational injury, self-harm, poisoning. and/or social problems such as relationship difficulties, family problems, time off work or school and money troubles. The main goal of CRA is to help people whose alcohol consumption is impacting on their health and wellbeing to `discover and adopt a pleasurable and healthy lifestyle that is more rewarding than a lifestyle filled with using alcohol or drugs' (Meyers, Roozen Smith 2011). The approach focuses on the elimination of positive reinforcement for drinking, and 7
enhancing positive reinforcement for reduction or abstinence. If we apply CRA to Jason's story described earlier, we can see that if Jason did not have such easy access
to his father's car on the weekends and if his football was used as a positive reinforcement then perhaps his alcohol use and alcohol related behaviour would decrease. 1.3 What is CRAFT? The Community Reinforcement and Family Training or CRAFT part of CRAFT is designed for the family members and intimate partners of individuals whose alcohol consumption results in problems. In CRAFT, family members and loved ones are the clients. CRAFT has three main goals: 1. to assist families to get their alcohol dependent relative into treatment 2. to support families to provide their relative with social support, promote positive behaviour change and decrease their relative's alcohol use 3. to promote health and wellbeing of families through reducing the negative impact their relative's drinking is having on their wellbeing There are a number of advantages to CRAFT that make it equally as important as CRA. Firstly, CRAFT priorities and addresses the emotional and social wellbeing of family and friends because it is often as much at risk as that of the person who misuses alcohol. Secondly, CRAFT acknowledges that families can influence how their relative uses alcohol. Thirdly, CRAFT includes skills training to increase the knowledge and skills of families who are caring for a relative who is alcohol dependent. This training ensuring that families are better equipped to deal with issues as they may arise. Finally, CRAFT is designed to help improve outcomes for families who may also drink by assisting them to reduce the negative effects of their own alcohol use. There are also advantages for workers using CRAFT. For example, CRAFT sessions provide workers with an opportunity to get to know family members and their needs. This in turn means workers are better able to develop trusting relationships and teach families the skills and knowledge they need to assist their relatives who drink. training session
s are also an opportunity for workers to motivate family members and encourage them to share the care and support that their alcohol dependent relative requires. Applying CRAFT to the case study at the beginning of this section, it's possible to see that Leah and Jason's aunties could benefit from CRAFT. For example, their participation in CRAFT might assist them to change their behaviour by not confronting Jason and finding more positive ways to talk to him. If this was achieved it might improve family communication and reduced family conflict. This in turn could benefit the whole family including Leah as well as Jason's grandmother and aunties. It might also motivate Jason to reconsider the effects of his drinking behaviour. 1.4 Evidence to support CRA and CRAFT Although Indigenous populations in Australia generally suffer much more from the physical, social and psychological harms caused by alcohol, there is little reliable research evidence to 8
show which are the best ways to reduce such harms. While research conducted in Indigenous communities has mainly evaluated individual (e.g. education), and community-based (e.g supply reduction) interventions, other research has shown that the way people use alcohol is commonly influenced and reinforced by different factors within the family. This is particularly relevant to Indigenous communities where family relationships have a central role in defining their member's identity (Memmot, Long Thompson 2006), maintaining their sense of connectedness to kinship and in protecting family wellbeing. As a result, CRAFT's twopronged approach to strengthen families and to support individual drinkers to quit drinking, may be more effective for use with Indigenous communities. CRAFT is well supported by international research which has compared it to other approaches such as Alcoholics Anonymous (AA). This research evidence shows That CRAFT is more effective for encouraging alcohol dependent people to enter and commit to treatment and for improving the overall functioning of families. Research also shows that CRAFT works well in a range of settings with diverse populations for example: inpatients and outpatients, culturally diverse groups, those refusing to seek treatment for substance abuse, homeless people and adolescents (Smith, Meyers, Miller 2001, Meyers, Roozen Smith 2011). In addition, other studies have evaluated individual components of CRAFT and reported advantages on at least some outcome measures. For example, because CRAFT is significantly better at engaging resistant problem drinkers into treatment within the 6 months following the intervention there is a lessening of the physical and psychological symptoms experienced by family members (Copello, Velleman, Templeton 2005). An equally important outcome is that family members participating in CRAFT experience direct and personal benefits whether or not their relatives do or do not enter treatment (Meyers, Miller, Hill, Tonnegan 1998 p 304). This evidence suggests CRA and CRAFT are likely to be an effective approaches for use with Indigenous clients and families, particularly if it is implemented according to clear guidelines and supported with strong training and supervision. Community Reinforcement and Family Training (CRAFT) for Aboriginal Australians in rural New South Wales (NSW) A survey of 116 Aboriginal people
recruited through an Aboriginal Community Controlled Health Service (ACCHS) or drug and alcohol treatment agency in rural New South Wales asked about Community Reinforcement and Family Training (CRAFT). Of those surveyed, 90% indicated that CRAFT was acceptable for delivery in their local community. Women were more likely than men to perceive CRAFT as acceptable. Participants expressed a preference for counsellors they knew and trusted, and who had experience working in their local community. CRAFT was deemed most acceptable for delivery to individuals wanting to help a relative or friend start alcohol treatment (Calabria et al., 2013). CRA was tailored for Aboriginal Australians using information collected by this survey and from meetings and interviews with health care providers who would deliver the interventions (Calabria et al., submitted). 9
Notes Page On this page make notes, record your thoughts, ideas or any questions you might have about Section 1 that you would like to share with your team. 10
Section 2: CRA and CRAFT In Communities This section begins with a brief overview of the effects of alcohol on individuals, their families and communities. It includes an outline of principles at the heart of many Indigenous health interventions including CRAFT. The section finishes with a description of the roles of health practitioners who may deliver CRAFT and focuses in particular on the role of Aboriginal Alcohol and Drug 3 and Health and Family Workers. 2.1 Understanding alcohol related harms Drinking alcohol at risky and high-risk levels results in short and long term physical, psychological and social harms that affects the health and wellbeing of individuals, families and communities. Physical Effects People who drink alcohol where the `risk of harm is significantly increased beyond any possible health benefits' (Australian alcohol guidelines: Health risks and benefits NHMRC 2001) may experience a range of negative physical effects. These may include for example: altered brain function e.g: mood swings, memory loss, seizures, dementia gastrointestinal disease; liver disease (cirrhosis, cancer); cardiovascular disease (weakening of heart muscle, heart failure, arrhythmias, high blood pressure, ischaemia, myocardial infarction); peripheral vascular disease (poor blood circulation to the lower parts of the body e.g. legs and arms) ; cancers; diabetes; anaemia (shortage of red blood cells, which can lead to weakness, breathlessness and low levels of energy); osteoporosis (fragile, weak bones); gout (inflamed joints, particularly feet); Foetal Alcohol Syndrome (a disorder affecting the foetus that is caused by alcohol ); accidents, injuries and/or death. Psychological Effects As well as having an impact on physical health, alcohol use also impacts on people's psychological wellbeing. For example some people may use it to feel relaxed, confident and less inhibited in social situations. Others however use it as a self-medication to cope with their distress, emotional or physical pain or symptoms of Mental Health Problems
e.g. depression, anxiety, hallucinations, agitation or panic. Regardless of the reasons why people use alcohol, the problem is that when they do drink at risky and high risk levels they are likely to make their symptoms and/or illnesses worse. For example the heavy use of alcohol has a mood depressant effect that can make the symptoms of clinical depression worse or bring on a depression like condition (Alcohol Treatment Guidelines for Indigenous Australians 3 Referred to hereafter as workers 12
p11.137). In addition heavy alcohol use and depression are also associated with a higher risk of suicide. (Gordon 2008 p 21). This is a particularly important point considering suicide rates for Australian Indigenous people are greater than for the whole population. (SCRGP 2009 p 7.65) There is also a relationship between high risk drinking and anxiety, with both worsening each other (Brady, Tolliver Verduin 2007 p 762). Social Effects In addition to its psychological effects, individual alcohol consumption also impacts on the social wellbeing of immediate and extended families as well as friends. This is especially the case in Indigenous communities where families have close ties and the effects are more likely to take a wider toll and influence the overall functioning of the whole community. In a number of Indigenous communities the excessive use of alcohol by some people can cause social disruption. This is evident in reports of higher rates of family stress, time off work and school, social withdrawal, harmful behaviour, money troubles, community disturbances, increased risk of injury, violence, trauma, motor vehicle accidents, incarceration, and loss of self esteem (Kelly, Kowalyszyn 2003, p 761-767). The CRAFT approach acknowledges that it is just as important to assist families to strengthen their social and emotional wellbeing as it is to support people to address their unhealthy alcohol use. Therefore a primary focus of CRAFT is to teach families the skills and knowledge they need to improve their own lives. Short and Long Term Effects The physical, psychological and social effects of drinking alcohol at risky and high-risk levels maybe short or long term. These are outlined in brief below. A more detailed description can be found in the Alcohol Treatment Guidelines for Indigenous Australians (Department of Health and Ageing 2007) and available for down load at: http://www.alcohol.gov.au/internet/alcohol/publishing.nsf/Content/AGI02 Short term effects For individuals the short term physical and psychological effects of increasing blood alcohol concentration depend on a number of factors such as: the type and quantity of alcohol consumed age, weight and gender body chemistry whether a person has food in their stomach drinking experience and tolerance for alcohol the situation in which drinking occurs whether a person has existing health problems is taking certain medications and/or is undergoing other medical treatments Regardless of these factors however, it is always the case that drinking alcohol above recommended levels, will increase the risk of harm and make any existing conditions worse. 13
The Alcohol Treatment Guidelines for Indigenous Australians (2007) is a helpful resource for workers. It classifies the likely primary effects of alcohol on a non-dependent drinker according to a number of stages as follows: Feelings of wellbeing that may result in a person becoming more talkative, relaxed, confident. Risky state: where a person's attention, judgement and movement become weakened and their shyness is reduced Dangerous state: that results in slurred speech, a lack of coordination and balance, slowed reflexes, weakened visual attention, unstable emotions, nausea and vomiting. Stupor: when a person can no longer stand or walk without help, feels sleepy, has difficulty breathing, cannot control their bladder and becomes unconscious Death: which may follow coma, and shock. Detailed information about how to manage someone experiencing an overdose of alcohol which may be life threatening is described in Part II: Clinical Management of Alcohol Problems Tool Kit of the Department of Health's Alcohol Treatment Guidelines for Indigenous Australians. Long term effects The long term physical and psychological effects of alcohol also impact on individuals and families in different ways. The following descriptions of the long term effects of alcohol consumption provide a broad overview only. More complete information can be found in sources listed in Section 7 at the end of this manual. 2.2 Principles of CRA and CRAFT for Indigenous communities The CRAFT approach for managing the effects of alcohol in Indigenous communities has been designed with three key principles in mind. These are: 1. A holistic approach 2. Primary Health Care 3. Community Development 1. Holistic approach The term `holistic' is commonly used to describe Indigenous health and health care. It is best understood through the National Aboriginal Health Strategy's definition of health and which states that it is "not just the physical well-being of the individual, but the social, emotional and cultural well-being of the whole community. This is a whole of life view and it includes the cyclical concept of life-death-life' (National Aboriginal Health Strategy Working Party 1989). Indigenous people's holistic understanding of health fits well with the CRAFT approach. Firstly because the approach views alcohol related harm not just as a problem for the individual drinker, but also for all those people with whom they share their lives. Secondly, because 14
CRAFT strategies are directed at reinforcing the positive aspects of the lives of both the individual drinker and their families, friends and loved ones. This includes addressing people's whole environment (family, social, recreational, work) rather than just selective parts of it. 2. Primary Health Care Primary Health Care (PHC) was first defined by the World Health Organisation
(WHO) in 1978 as: `... essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community...' To achieve the above, PHC activities work to promote health, prevent ill health, treat illness/disease and rehabilitate people to reduce the long term effects or complications of illness/disease. This means that Primary Health Care activities are those that: people and communities can access and afford encourage everyone in the community to participate so they can look after themselves and each other; bring the care as close as possible to where people live and work; are often the first point of contact that people have with the health care system; are offered by different services working together; use appropriate health care methods (hospitals, community care, homes) are the beginning of a continuing process (WHO 1978.) Activities and programs that are based on the above ideals are the core business of most Aboriginal community controlled health organisations and other community based health services. The CRAFT approach to alcohol treatment is an example of such a program and one that fits within the PHC framework 3. Community Development Community development (CD) is a term used to describe strategies that support individuals and communities to acquire the knowledge and skills they need to bring about change in their own communities. These skills are often developed when groups of people work together to raise awareness about certain issues and to achieve a common goal. Community development (CD) goes hand in hand in with PHC because it is based on many of the same principles for example: fairness, equality, responsibility, opportunity, choice, participation, advocacy, reciprocity and continuous learning. These principles make community development an appropriate foundation on which to base Indigenous community health programs such as CRAFT. A number of CD strategies are used in the CRAFT approach. One strategy is the training workshops that teach people the skills they need to restructure their lives and change their drinking behaviour so they can achieve a healthier lifestyle. Another is the collaboration that is encouraged and which aims to get between services and families working together at the local level. 15
2.3 The CRA and CRAFT health team The CRAFT approach generally requires the involvement of a number of different health practitioners each of whom works as part of a team but who also has a specific professional role to play. The team may include a medical practitioner, psychologist, social worker, Indigenous Health and Family Worker, registered nurse and/or counsellors who have specialised drug and alcohol skills and knowledge. Each practitioner has a role specific to their individual profession and to CRA and CRAFT, although practitioners with similar skills and expertise may have overlapping roles. 2.4 Role Activities All health practitioners who deliver CRAFT will undertake a wide range of activities. These might include: assessing an individual's level of alcohol consumption, patterns of alcohol use, and the causes and consequences of their drinking behaviour as these relate to themselves and others developing and tailoring treatment goals for individuals participating in CRA and family members participating in CRAFT motivating CRAFT participants and assisting them to identify strategies and achieve goals counsel CRAFT participants and assist them to identify and organise social and recreational activities that provide them with positive reinforcement conducting communication, problem solving and drink refusal skills training 2.5 The Roles of Indigenous health practitioners in CRA and CRAFT Indigenous health practitioners including Aboriginal Alcohol and Other Drug Workers, and Health and Family Workers are often the first point of contact for Indigenous people dealing with the health care system. As such, they are vital members of the health care team and critical to the success of CRAFT. Their in-depth understanding and experience in communities, combined with their primary health care qualifications, means Indigenous health practitioners are best placed to: undertake front line practitioner roles in CRAFT; advocate on behalf of individual Indigenous clients, families and communities that are dealing with alcohol related harm; offer advice about Indigenous related alcohol issues to other professionals in the health care team; liaise with organisations and other sectors providing services to Indigenous people contribute to the coordination of health services that support Indigenous people dealing with alcohol related harm contribute to the adaption of CRAFT to ensure it is acceptable to Indigenous people 2.6 Other roles During the CRAFT project other types of health practitioners may become available to deliver the intervention to eligible clients. Following training in CRAFT, these practitioners might contribute to the delivery of CRAFT in a number of ways. The following table outlines these. 16
Practitioner Medical Practitioner Social Worker Nurse
Professional Role diagnose illness/disease manage co-morbidities develop treatment plans prescribe necessary medications specialist referral contribute to case management contribute to CRAFT training support individuals/families in either CRA or CRAFT support other health practitioners provide clinical treatment support and liaise with other health practitioners contribute to the delivery of CRAFT
2.7 The role of family in CRAFT As described earlier, family members have a central role in CRAFT. The focus of the family member's role is to assist their alcohol dependent relative to change their behaviour so they choose to take up activities that are more enjoyable and rewarding than drinking. Research shows that when families are given support they can improve the treatment outcomes for their relatives who are alcohol dependent. They can also help to reduce the negative effects that alcohol misuse might be having on the rest of the family and others. The main way in which CRAFT supports families is through Community Reinforcement and Family Training which was described on page 9. Community Reinforcement and Family Training teaches family members how to motivate their alcohol dependent relative into treatment and provides them with assistance to promote positive behaviour change. More specifically, Community Reinforcement and Family Training teaches family members about: the negative consequences of alcohol misuse the potential personal benefits of treatment for alcohol misuse; strategies for preventing dangerous situations that include family members; how to reinforce non-using behaviour with relatives who misuse alcohol; relationship communication and problem-solving skills; ways to stop relative's alcohol misuse use; how to prepare and start treatment when a relative who misuses alcohol is ready; how to support a relative who misuses alcohol once treatment has begun.
Section 3: Community Reinforcement and Family Training Procedures This manual began by describing the two parts of CRAFT, that is: Community Reinforcement (CRA) for individuals at risk of alcohol related harm and Community Reinforcement and Family Training (CRAFT) for the immediate and extended family, intimate partners and friends of individuals who misuse alcohol. As Smith and Meyers (2004) point out, the role of the family in assisting a relative who misuses alcohol is particularly critical to the success of CRAFT and is a feature that sets the approach apart from other alcohol treatment programs
. This claim is based on reports of people with a substance misuse problem who say that their decision to seek treatment is often influenced by a relative or friend (in Smith and Meyers 2004 p27). This section describes the CRAFT procedures and the role of family members in influencing their relatives to stop drinking. The section begins with a summary of the procedures taught to family members who are participating in CRAFT. This is followed by a description of the behavioural approach that workers use with an individual family member. The section then describes each of the CRAFT procedures and how they might be used during a series of one on one training sessions. Before starting, refresh your knowledge of CRAFT by reviewing Section 1, including: Section 1.3 `What is CRAFT?' 3.1 What are the CRAFT procedures? The different procedures that make up the CRAFT part of CRAFT include those that workers use to assist the immediate and extended families, intimate partners and friends of people who have been assessed as alcohol dependent or at risk for alcohol related harm. The CRAFT strategies are focussed on strengthening the knowledge and skills of family members so they can take action to protect their own wellbeing at the same time as they support their relative who is at risk for alcohol related harm. Some of the procedures in CRAFT are similar to those used in CRA, others are different. They include the following: 1. Motivational strategies to set a positive outlook and raise the awareness of family members about the benefits of CRAFT; 2. Functional analysis of the family member's views about their relative's alcohol use. This includes an analysis of triggers, consequences and the unintended role of the family in maintaining their relative's drinking; 3. Safety plans to prevent and protect the family member from possible violence; 4. Communication training to develop problem solving skills and strengthen relationships between family members and their relatives who use alcohol; 5. Positive reinforcement training so the family member knows how to reinforce their relative's non-drinking behaviour; 6. Training the family member using a range of CRAFT procedures to promote changes in their relative's alcohol use, and influence their entry into treatment; 18
7. Self-reinforcement training, so the family member can explore the unsatisfying areas of their lives, plan to address them and be rewarded more often;
8. Preparing the family member to introduce alcohol treatment to their relative when they appear ready.
3.2 How is CRAFT implemented? Family members will learn how to assist their relatives who misuse alcohol by attending a series of one on one or group CRAFT sessions. These sessions will be led by workers formally trained and certified in the CRAFT approach to ensure that the family member is supported in a professional, considerate and respectful environment.
Sessions are intended to be approximately 2 hours and offered once a week over a 4-6 week period. However this schedule should be adapted to suit the needs of individual participants as some participants may require more time to deal with particular issues. Most importantly workers should inform family members that the more sessions they attend the more they will learn and the better equipped they will be to improve their own wellbeing as well as that of their relative. Family members should also be informed that the main focus of sessions will be on learning new skills and how to use them, so they can change the way they behave and interact thereby influencing their relative's alcohol use. Skills that families might learn include: communication and problem solving skills, how to be more assertive, how to improve their own happiness and `take better care of themselves' (Smith Meyers 2004 p35).
A suggested session schedule might include the following:
Introduction to CRAFT
Describing a Relative's Alcohol Use
CRAFT Functional Analysis of Drinking Behaviour
Session 2, 3 & 4: Reinforcers for Family Wellbeing
CRAFT Functional Analysis of Violent behaviour
Positive Reinforcement of Healthy Non-drinking Behaviour
Functional Analysis of Healthy Non-drinking Behaviour
Time Out from Positive Reinforcement
Problem Solving Allowing the Natural Consequences Setting Goals Engagement into Treatment 3.3 Behavioural approach to working with CRAFT participants. To ensure the effective implementation of CRAFT, Smith and Meyers (2004) explain that workers need to communicate a specific set of attitudes as they interact with family members in CRAFT sessions. In particular they state workers must always show family members empathy, warmth, respect while demonstrating a non-judgemental and accepting approach. Interactions should also be based on a motivational approach that acknowledges people's efforts to change their behaviour and improve their situation. This requires workers to avoid arguments and confrontation, use supportive statements, set positive expectations and reinforce the view that a family member is never responsible for their relative's alcohol use. Smith and Meyers (2004 p 20) also recommend that workers are `directive', particularly with people who may expect that others will take responsibility for fixing their problems. A directive approach means workers should reassure family members that their participation in CRAFT puts them in the best position for doing something about their own problems and encouraging their relative to think about entering treatment. It also means reminding family members that there is significant scientific evidence showing CRAFT is more successful than other alcohol treatment programs. Some of this success is associated with CRAFT's skills based training program that teaches family members how to tackle problems associated with their relative's drinking as well as problems in other areas of their lives. Workers who communicate openly, establish relationships of trust, show absolute support, set positive expectations and who also use a directive approach when it is needed, are more likely to develop a relationship with family members that can assist them to take a more confident, hopeful and effective attitude towards life and their loved ones . The following pages include sample session plans, an introduction and explanation for implementing CRAFT procedures and guidelines for supporting the families of people who have been assessed as being at risk for alcohol related harm. Checklists itemising the components of each CRAFT procedure is also included. These checklists are designed to support workers as they practice the use of each procedure. 20
Session 1: Introducing CRAFT to Family Members Overview The primary aim of the first CRAFT session is to establish a relationship of trust and openness with the family member, ensure they have a sound understanding of CRAFT, encourage their commitment to the program, build their confidence and listen to their story about their relative's alcohol use. To achieve this, workers will outline the CRAFT approach, including its goals, procedures and benefits to family health and wellbeing (see Section 1.3 p 9). In addition workers will assist the family member to complete baseline measures. This will entail a discussion about the family member's own wellbeing and their motivation for seeking CRAFT treatment, their relative's alcohol use and its effects, and the family member's role in encouraging their relative to think about entering treatment. The first session will also address the importance of confidentiality and strategies participants can use to prioritise their personal safety. If there is enough time during this session participants will also be assisted to complete a CRAFT Functional Analysis of their relative's alcohol use and their own behaviour in response to it. Session 1: Plan Workers in Session 1 will support participants to: a. describe their relative's alcohol use and its effects b. understand CRAFT goals and procedures c. complete baseline measures d. think about their motivation for seeking support to change their relative's alcohol misuse e. understand their responsibilities as a concerned family member f. identify their own reinforcers g. identify issues of confidentiality h. prioritise their personal safety i. complete a Functional Analysis of their relative's alcohol use Although the activities associated with the above are discussed here in sequence, the circumstances may not be suitable for workers to complete them in order. If this is the case workers should focus on introducing CRAFT (a) and the collection of baseline measures (b) then decide on the remainder of the session based on the needs of the participant. If there is not enough time in the first session for all activities, the Functional Analysis can be postponed. Each of the above issues are discussed below while a more detailed Session Plan is outlined in Appendix 2. 1. Describing a relative's alcohol use and its affects The very beginning of the session may be one of the most important as it focuses on encouraging participants to begin a conversation and tell a story about their relative's alcohol use and the problems it might be causing. This may include for example the alcohol associated harms that affect the relative's relationships with family and friends, and/or their work/study, economic circumstances, and physical, social and mental health and wellbeing. Encouraging participants to tell a story allows them to express possible negative feelings of anger, sadness, frustration, guilt or hopelessness about their relative's alcohol use. It also 22
allows workers to express empathy for the family's disappointment and frustrations, acknowledge their efforts and encourage them to talk about attempts they may have already made to do something about their relative's drinking. At the same time it allows workers to emphasise that CRAFT is a different approach that can assist the family member to find more fruitful ways of relating, and which will not entail them feeling responsible for their relative's alcohol use. Most importantly it is an opportunity for workers to build a relationship with the family member and motivate them towards thinking about possible solutions to their problems. A more detailed exploration of the family member's perceptions of their relative's alcohol is supported through the use the Functional Analysis procedure. Depending on available time and the issues that family members raise in this session, will determine whether the Functional Analysis is undertaken now or later. 2. Introducing CRAFT goals and procedures In introducing the CRAFT program to participants, workers might begin with a description of the program's goals and procedures. The three main goals of CRAFT as outlined by Smith and Meyers (2004) are to: 1. decrease the relative's alcohol use. 2. get their alcohol dependent relative into treatment 3. to increase their own happiness and wellbeing whether or not their relative enters treatment. Participants should also be informed that CRAFT is a program: 1. for families who want to get their relative who may be refusing support into treatment 2. that differs from other alcohol treatment programs because it relies on the nonjudgmental active involvement of family and not on confrontation or judgement 3. which regards family as the best people to assist because they are likely to have the most contact with and knowledge about their relative, and therefore also highly motivated to assist 4. which takes a particular interest in family responses to their relative's alcohol use and the problems it creates 5. based on behavioural learning principles such as giving and withholding positive reinforcement Finally, participants should be aware that each one on one session in the CRAFT program will include: 1. A combination of procedures delivered over a series of voluntary sessions that family members should be encouraged to attend. 2. Procedures based on the CRAFT approach but which may be adapted to meet the needs of individual family members 3. Training to develop the skills and knowledge family members need to change their behaviour, influence their relative's alcohol use and improve their own happiness. Training may include communication skills
, positive reinforcement for non-drinking and strategies for getting their relative into treatment. 23
3. Collection of baseline measures In this first session workers will administer the CRAFT survey to collect baseline data from participants. In this project the term `baseline data' is used to refer to basic information that is provided by each family member to describe their situation at the very start of the CRAFT program. This information is then compared to data that will be collected after the program has been completed. When the two different sets of information are compared, the effects of the CRAFT approach on families can be measured. Baseline data is collected from family members using the CRAFT survey. This survey is completely confidential and asks questions about family member's experiences with alcohol and how their relative's drinking has affected their social, mental and physical wellbeing. Survey questions will ask family members for information such as their: Personal details e.g. name, age, gender, identity, living circumstances General health and psychological wellbeing Alcohol use Harms from alcohol Other drug use The information collected through the baseline survey will assist health services to put together a program to teach family members the knowledge and skills they might need to support a relative who drinks too much alcohol, to cut down or stop drinking too much alcohol. It will also be used to measure and evaluate how effective the CRAFT program has been in achieving this goal. 4. Motivation for seeking support to change a relative's alcohol use Another key focus in the CRAFT approach is for workers to understand the behaviour of family members. In the early stages of this first session it is therefore important that workers briefly explain to participants that they will be exploring why people are motivated to change their behaviour in order to change the behaviour of their relative who drinks. A brief explanation will ensure family members are not overwhelmed with too much information but still given the opportunity to think about their motivation. At this stage workers should also review any previously completed health assessments and any other available information about the family and their relative. This will enable workers to establish a full understanding of the relative's current and past family circumstances. It is also likely to explain family member's current level of wellbeing and happiness including their social and emotional state as well as their relationship with their relative. 5. Responsibilities of the family member In Section 2.3 (see p 22) we outlined the general role of the family in CRAFT. Within this role, families have specific responsibilities. These include a willingness to participate in skills training, complete homework assignments
, practice new skills and attend follow up referral sessions if their problems require specialist treatment and/or counseling. For example if marriage problems are at the heart of a relative's alcohol use it may be helpful for the family member to be referred for relationship counseling in addition to participating in CRAFT. Also, family members must be prepared to provide the ongoing support their relative will need once they have entered treatment. 24
Most importantly however if a relative's alcohol use creates a risk of physical or emotional violence, then families in CRAFT must first be offered support to ensure they can protect their own safety. 6. Positive expectations and reinforcers Family members participating in CRAFT will bring a varied range of experiences, family situations and problems to their sessions. It is also likely they will come in different emotional states, having developed various survival strategies and expectations about how CRAFT can assist them. Some may have already tried other treatment programs such as Al-Anon, while others may have given up thinking that there could be any solutions to their family's alcohol related difficulties. Therefore a key part of the first session is committed to creating an atmosphere of positive expectations. Workers can encourage positive expectations in the family member by: highlighting the active benefits they will experience from being involved in CRAFT emphasizing their critical role in getting their relative to enter treatment showing an understanding of the their frustrations and problems demonstrating expertise in dealing with their alcohol related problems discussing the different positive outcomes of CRAFT appreciating & reinforcing their willingness to share their problems openly & honestly In addition to bringing different experiences, situations and problems to sessions, the family member may also come with different levels of motivation for seeking professional assistance to deal with their relative's drinking. This means some will be highly motivated while others will be less sure about what motivates them to be in the CRAFT program. We discussed motivation earlier (see point `b' above) and explained that in session 1 workers should support participants to at least begin thinking about their motivation. Similarly workers should also assist participants to start thinking about their `reinforcers'. Reinforcers are those things that are experienced as enjoyable by a person so that he/she is motivated to repeat the behaviour that got him/her the reward in the first place (Smith & Meyers 2004 p 135). Because not everyone enjoys the same things, a reinforcer is not necessarily experienced as a reward by everyone. Examples of different reinforcers are: time spent with people (family, lover, friends) satisfying work study money to spend on needs & wants enjoyable recreational or sporting activities holidays praise/approval/admiration The following story about Jill and Brendan is an example of how the possibility of travel could be used as a reinforcer to encourage healthier non drinking behaviour. 25
Jill and Brendan's story Jill and Brendan have always wanted to travel, but when Jill stopped working to look after their new baby, saving to take a trip anywhere was impossible. Then when Jill went back to work full time she and Brendan agreed they would each save a small amount of money to put towards a trip away. Four weeks after starting and sticking to this plan Brendan gave up saving, and started spending his money drinking with his mates at the pub every night. Jill tried nagging and bargaining but it only made Brendan angry. Now Brendan goes to the pub more often. To make matters even worse the job promotion and pay rise Brendan had been offered at work is now also at risk. Jill's longing to travel has motivated her to seek support to get Brendan into treatment. Jill thinks a trip away could act as a reinforcer/reward that might encourage Brendan to reduce his drinking and get the job promotion with more pay. Jill hopes Brendan's improved job situation could help him to save the money they need to travel. 7. Confidentiality Confidentiality is a key issue in CRAFT as the family member may disclose private and sensitive information that places them at a level of risk. To ensure that possible risks are kept to a minimum and that the family member is protected they must have a full understanding of what it will mean to take part in the CRAFT program. This means that workers must verbally inform CRAFT participants and also provide them with written information about all aspects of the program at the start of each session. In addition participants must also be provided with the official contact details of program coordinators for use in possible cases of emergency. Most importantly before participating in CRAFT all participants must have completed a consent form. 8. Personal Safety The personal safety of the family member is another critical issue considered in the first CRAFT session. This is because it is not uncommon for family violence to occur alongside alcohol use. However, before deciding whether or not to tackle cases that involve family violence workers should consider two issues. Firstly, the possible risks to family members participating in CRAFT. Secondly their own skills, knowledge and confidence to support the family member. As regards the first of these issues, workers need to acknowledge that because CRAFT focuses on the family member's behaviour as way to change their relative's alcohol use it's possible that any behaviour change could trigger a violent response from a relative, particularly if they don't know that their family member is participating in CRAFT. As regards the second issue, if workers believe that they do not have the skills or experience they need to manage the involvement of violence in the family member's situation then they should consider discuss the matter with their supervisor and/or team members. Possible options may be to exclude that family member from participating in the CRAFT program or referring them for specialist support. In their description of the CRAFT approach and precautions for domestic violence, Smith and Meyers (2004) note that most studies of CRAFT excluded family members who stated at the beginning of CRAFT that their relatives had been involved in `domestic violence or criminal assault in the previous 2 years, or ... had ever shown any severe violent behaviour (e.g., use of a weapon, infliction of injuries leading to hospitalisation)'. They also note there have been no studies of the safety of CRAFT for family members involved in ongoing physical abuse (Smith and Meyers 2004 p 78-79). 26
To ensure the personal safety of both workers and family members it is therefore important to make a careful and initial assessment of the situation in the first CRAFT session. This assessment may be undertaken as a component of an initial Functional Analysis of a Relative's Drinking Behaviour to: Assess their risk of contact with violence if they participate in CRAFT Assess their social support network Consider alternative options of support The Functional Analysis of a Relative's Drinking Behaviour is discussed in detail below. If the analysis indicates that violence is a specific and likely risk to the personal safety of the family member then an additional and more specific Functional Analysis of a Relative's Violent Behaviour should be completed. This analysis focuses on the issue of violence in much greater detail. A more detailed explanation and example of this analysis is included In Appendix 1. The CRAFT Functional Analysis of a Relative's Drinking Behaviour is described in detail below. 9. Functional Analysis of a Relative's Drinking Behaviour Workers use the `Functional Analysis of a Relative's Drinking Behaviour' to support family member's to describe their relative's drinking behaviour and its consequences. The procedure may also be referred to as a functional analysis of drinking. It is a major part of CRAFT as it provides workers with therapeutic opportunities for responding to family member's descriptions of the problems they experience and that arise from their relative's alcohol use (Smith & Meyers 2004 p 72). The Functional Analysis form is used to guide workers and family members in this task. The CRAFT functional analysis procedure is based on behavioural theory which proposes that the things that happen in a person's life influence the way they behave. In particular behavioural theory recognises that people's behaviour is: influenced by what has gone on before the behaviour occurs more likely to be maintained over time if the experiences associated with it are positive The Functional Analysis therefore aims to collect information from family members about their relative's problem AND healthy behaviour, its triggers and positive and negative consequences. With this information workers can then support family members to reflect on and alter their own behaviour so that it increases their relative's healthy behaviour at the same time as it decreases their problem behaviour. In a detailed discussion of the CRAFT Functional Analysis, Smith and Meyers (2004 p 41) recommend the Functional Analysis form is used one on one with the family member. However they also note the form may be sent home with people so they can complete it in their own time. Regardless of which action workers choose, Smith and Meyers (2004 p 43) emphasise that all CRAFT participants should be provided with a full explanation of the form before it is completed. This should include explaining: how the functional analysis form is used 27
reasons for using the analysis i.e: to find ways to change a relative's drinking by changing how the family member interacts with them the benefit of the analysis i.e: provides valuable information about the relative's drinking and family member's behaviour there should be no immediate changes to the behaviour of family member at the start of CRAFT that family members are the most appropriate people to complete the analysis as they have a close understanding of their relative's circumstances and ongoing contact that it is likely the analysis will show a relative's alcohol use is more predictable than familymembers realise, which in turn enables them to have a more positive outlook how the analysis identifies triggers for a relative's drinking enabling familymembers to suggest possible actions to deal with them the analysis's estimate of a relative's alcohol use enables progress to be observed over time how the analysis identifies the short-term positive consequences of a relative's drinking and also enables the identification of reinforcers how the analysis identifies the negative consequences of a relative's drinking and enables family members to use this information and encourage their relative to change their behaviour (Smith & Meyers 2004 p43) An example of a CRAFT functional analysis of a relative's drinking behaviour form is provided on the following page. 28
External Triggers Who is your relative usually with when drinking? Where does he/she usually drink?
Sample Form: CRAFT Functional Analysis of a Relative's Drinking Behaviour
Short-term positive consequences
What do you think your relative might be thinking about right before drinking?
What does your relative usually drink?
What do you think your relative likes about drinking with ... (whom)? What do you think your relative likes about drinking at ... (where)?
What do you think he/she might be feeling right before drinking?
How much does he/she What do you think your relative likes about drinking
What pleasant thoughts do you think he/she might have while drinking?
Long-term negative consequences What do you think are the negative results of your relative's drinking in each of these areas (* the ones he/she would agree with)?: interpersonal physical emotional legal work/study financial other
When does he/she usually drink?
Over how long a period
of time does he/she
What pleasant feelings do you think he/she might
have while drinking?
Source: Smith and Meyers, Motivating Substance Abusers to Enter Treatment 2004 p75 29
To enable workers to effectively use the Functional Analysis with a family member it is described as a series of detailed steps below.
Step 1: Introducing and using the functional analysis form Workers introduce the functional analysis form and explain to family members that when they have completed it they will be better able to see the likely connections between their relative's alcohol use and factors that may trigger it. The completion of the form will also enable family members to track their relative's drinking behaviour while they are participating in the CRAFT program.
Workers then ask family members to think about and describe an example of a drinking episode that their relative commonly takes part in. Some prompts may be needed to help those who feel unsure about their answer. Prompts might include asking about: times when their relative most likes to drink the relative most recent drinking episode.
Step 2: Asking about triggers This question refers to external triggers such as people, places, situations, and internal triggers such as the feelings thoughts that activate a person's drinking. Identifying triggers, is an important part of the functional analysis. Firstly, it helps the family member to think about the high risk factors that make it more likely their relative will be tempted to drink. Secondly, at a later stage in CRAFT, it can help the family member to consider how they can encourage their relative to choose healthier alternatives to drinking. The following prompts may assist family members to identify their relative's external and internal triggers.
External Triggers Who drinking partners may include: work or sporting mates/friends/family/lover or
the location where a person drinks is often a specific place e.g pub, club, park, a friends house, back yard, shed knowing when a person drinks assists with developing a more detailed picture of their alcohol use e.g every day after work, weekends only,
Internal triggers Family members may find that internal triggers are more difficult to identify, in which case workers can help prompt by giving examples as follows: Thinking I deserve a drink after a hard days work ...' (indicates the alcohol is used as a reward), or `I need to cool off, sometimes the family is just too much to handle...' ( alcohol as an escape from worry, stress) Feeling First identify physical behaviour that might give clues about feelings. For example if a person appears withdrawn, restless or distracted this might indicate they are feeling anxious or stressed. Similarly if their behaviour is hostile or unfriendly it is likely they are feeling angry.
Step 3: Outlining the relative's drinking behaviour The answers family members give to the questions in this next part of the functional analysis will help to describe the level of their relative's alcohol consumption (what type of alcohol they drink, how much they drink over what period of time). Answers can be used to show possible connections between the nature of a relative's alcohol use and possible triggers. For example a person may only drink beer at unhealthy levels when they meet with their mates at the pub after work, whereas they may only drink one can/stubby/schooner/middy with dinner at home with family. Step 4: Identifying short term positive consequences The purpose of questions about the short term positive consequences of drinking is to find out about the factors that family members think may influence their relative to maintain their alcohol use. For example perhaps their relative drinks when they're bored, or because they want to escape from problems or emotional pain they cannot deal with. Maybe alcohol boosts their confidence or self-esteem? Other short term positive consequences of a person's alcohol use may be linked to where and who they drink with. For example some people may experience the pub as a great place to drink because it gives a sense of belonging and is a meeting place to share with friends, play a game of pool, listen to music and eat a cheap meal. Step 5: Identifying long term negative consequences The purpose of questions about the long term negative consequences can help family members to identify the positive reinforcers in their relative's life that may have been negatively affected as a result of drinking. During this part of the analysis workers may also find that they can encourage the family member to describe negative consequences that their relative may not be aware of. For example perhaps a relative's marriage (positive reinforcer) is under threat as a consequence of her drinking, even though she is devoted to her husband and children. In another example, perhaps a relative is about to be fired from work (positive reinforcer) because of his drinking, even though it's the best job and pay he has ever had. As some family members describe the negative and unpleasant consequences of their relative's alcohol they may also express strong painful emotions. In these instances workers should check and acknowledge the family member's feelings and be ready to offer their understanding and support. Step 6: Connecting the dots At the conclusion of the functional analysis workers can then assist the family member to connect the dots between the different pieces of information they have provided and also: give family members praise and encouragement for responding openly and honestly check family member's feelings summarise & repeat back the information (positive & negative reinforcers) that family members have provided to check that it is been accurately recorded on the functional analysis form remind family members that their behaviour plays a part in their relative's drinking but reinforce they are not responsible for their relative's problem behaviour. Most importantly also remind family members that changing their own behaviour is the best way to influence their relative's alcohol use. 31
Common issues that may come up with the CRAFT functional analysis of a relative's drinking behaviour. A range of issues that may arise during the CRAFT functional analysis procedure have been reported by Smith and Meyers (2004 p 71). Briefly, these are: a mechanical questioning approach used by workers, whereas an interactive, friendly and flexible approach that shows empathy and support is more effective an inappropriate choice of a `common drinking episode' which does not assist family members to identify triggers or consequences that the functional analysis may show some relatives have a poly-substance misuse problem which may complicate the analysis Activity Read the following case study in which Vicki describes one of her husband Henry's typical drinking episodes. Then practice using the Functional Analysis of a Relative's Drinking Behaviour form, to complete the important information that Vicky provides. To help you get started some parts of the form have been completed. Henry & Vicky's Story Henry and Vicky are a young couple who have been married for 7 years. They have 3 children, with the youngest just 3 months old. They also have a supportive family network, although Henry's mother passed away just before the baby was born which has caused a lot of grief that family members are still dealing with. Henry is unemployed. Vicky who is on maternity leave from her full time job has come to the CRAFT program because Henry's drinking and cannabis use is worrying her and causing problems for the whole family. Vicky describes the problem and a typical drinking episode: `The problem started just after the baby was born. Henry was mostly hanging around with his mates getting wasted. He has time on his hands so he goes to the pub to drink beer and play pool or sometimes the pokies. Or they all hang out at someone's house all day playing the X-box and smoking cones. He's had a few wins on the pokies lately and that's made things even worse. Now Henry goes out earlier and earlier in the morning and comes home when he's really drunk. He's short with the kids and can't be bothered helping out with them or even playing with them like he used to, even though I know he loves them. Even when the kids are at school and it's just me and the baby at home he just keeps to himself, watches TV and drinks. He's really quiet but angry at the same time. I don't understand what's going on, it scares me. I tried asking him if we could do something together during the week but he says he's too tired. I can't talk to him when he's like that, so I just stay out of his way and keep the kids away too'. 32
Sample Form: CRAFT Functional Analysis of Henry's drinking behaviour
External Triggers Internal Triggers
Who is Henry usually with when drinking? Whoever happens to be in the pub when he goes.
What do you think Henry might be thinking about right before drinking?
What does Henry usually drink? beer
Having fun with his mates
Where does Henry usually drink? At the pub, but sometimes at home and at friends. When does Henry usually drink? Most days
What do you think Henry might be feeling right before drinking? Looking forward to getting out of the house
How much does Henry usually drink? Over how long a period of time does Henry usually drink?
Short-term positive consequences What do you think Henry likes about drinking with ... (whom)? What do you think Henry likes about drinking at ... (where)? What do you think Henry likes about drinking ... (when)? What pleasant thoughts do you think Henry has while drinking?
Long-term negative consequences What do you think are the negative results of Henry drinking in each of these areas (* the ones Henry would agree with)?: interpersonal physical emotional legal If he gets caught in fight he could be charged. work/study financial We're trying to save for a car, but his drinking is not helping other
What pleasant feelings do you think Henry has while drinking? Source: Adapted from Smith and Meyers, Motivating Substance Abusers to Enter Treatment 2004 33
Sessions 2, 3 and 4: CRAFT procedures The following section describes CRAFT procedures for use with family members during sessions 2, 3 4 and any others that may follow. These procedures do not need to be followed in a specific order because as we stated earlier each family member participating in CRAFT will have their own unique issues and circumstances to manage. Rather, as workers listen carefully to family member's stories they can decide which CRAFT procedures will best support family members as they work towards improving their wellbeing and encouraging their relative to enter treatment for their alcohol use. The CRAFT procedures are therefore described as a collection of procedures which workers can choose to use at any time according to the needs of family members. We begin the section with a description of how family members can consider their personal lives and environment and use positive aspects of these to improve their health and wellbeing The reason for this is that regardless of whether the family member reduces their relative's drinking or engages them in treatment they will have at least been assisted to improve their own psychological functioning, strengthen support systems and develop a better quality of life. Procedures that are used to assist family members achieve these goals include the following: Functional Analysis of a Relative's Violent Behaviour Happiness Scale Goals for Counseling These procedures and the contexts in which they might be used with family members are described in detail below. Assessing family member's happiness and wellbeing Family members who deal with a relative's drinking are often exposed to a range of stressors associated with alcohol use. These may include for example: verbal or physical aggression, moodiness, relationship difficulties, poor communication, money problems and family dysfunction. Not surprisingly, families are more at risk for increased levels of violence, sadness, depression, anxiety and anger. Assessing and addressing the possibility of violence must be a primary consideration for workers assisting family members to improve their happiness and wellbeing. Earlier we discussed how a Functional Analysis of a Relative's Drinking Behaviour can help to pinpoint triggers for verbal and/or physical violence towards a family member. A functional analysis can also be used to assist the family member assess their relative's violent behaviour. Family members who are assisted to complete a Functional Analysis of a Relative's Violent Behaviour will be better placed to recognise triggers for violence and to learn how to respond safely and more effectively. They will also be better able to think about how else they can strengthen their quality of life and improve their own wellbeing. The following section describes the Functional Analysis of a relative's Violent Behaviour. 34
A Functional Analysis of Violent Behaviour This functional analysis is focused on supporting the family member to decrease their relative's violent behaviour by changing their own responses to it. As a functional analysis form should have already been completed in Session 1, family members will already know how the procedure works so it should not take too long. Beginning with an explanation of the reasons for the analysis, workers should ask the family member to describe: what happens when their relative engages in a typical violent episode the internal and external triggers to the violence their involvement in these episodes As stated earlier in discussions about the use of the functional analysis form, workers should establish a conversational style to build rapport and trust, allowing the family member to tell their story in their own way. This may mean questions on the form are completed out of the order in which they appear. Another point worth noting is that discussions about family violence are sometimes difficult and requires workers to use non-intrusive conversation starters such as: `I know it isn't easy to talk about this, but can you tell me what happens when your uncle flies off the handle and ends up hurting you?' Are you afraid that your sister might hurt you? `Does your husband have trouble with his temper? What happens when he loses it? Describing triggers and the violent behaviour When finding out about what triggers a relative's violent behaviour, workers should start by making the point that there is never any justification for a relative's violence. They should also support the family member to identify possible connections between their behaviour and their relative's violence. Questions to determine what internal and external triggers are associated with a relative's violent behaviour are similar to those on the Functional Analysis of Drinking Behaviour form. Other similar questions are those that ask about what else might be going on just before their relative becomes violent. These may be things that don't actually trigger the violent episode but which may be are a warning sign or `red flag' (Smith and Meyers 2004 p 90). The concept of a `red flag' is that if the family member recognises these warning signs they can respond to their relative in a more effective way. Examples of possible red flags which might indicate that a violent episode is about to occur could include agitated and restless behaviour, a raised voice, or rapid speech. In addition to questions about triggers, attention should also be paid to the violent behaviour itself. This may have already been addressed when the family member was asked to describe a typical violent episode. If not, details of the violence should be recorded now, as indicated in the third column in the table below. 35
Who else is present besides What do you think your relative
you when your relative gets might be thinking about right
before getting violent?
Violent behaviour What does your relative's violent behaviour usually consist of?
Where does the violence What do you think your relative
might be feeling about right
before getting violent?
When does the violence
usually occur (alcohol
What is the last thing your relative
says/does right before getting
violent? *`Red Flag'
Source: Adapted from Smith and Meyers 2004 p106.
Positive and negative consequences of the relative's violent behaviour In addition to exploring the violent behaviour itself, the functional analysis also identifies the consequences of the violent behaviour. The purpose of exploring the consequences of the relative's violent behaviour is to support the family member to consider what contributes to keeping their relative's violent behaviour going and whether it could it be that their relative experiences a positive outcome (consequence) from behaving this way. For example, a relative who threatens to verbally assault or physically intimidate their family members may feel more powerful and in control of themselves when they behave this way. For this reason questions in the functional analysis ask about the positive consequences of the relative's violent behaviour as well as about its negative consequences. These questions are outlined in the table below.
Short term positive consequences of a relative's violent behaviour What do you think your relative likes about getting violent? What pleasant thoughts do you think he/she has during or right after the violence? What pleasant feelings do you think he/she has during or right after the violence?
Long term negative consequences of a relative's violent behaviour What do you think are the negative results of your relative's violence in each of the following areas (*the ones he/she would agree with): Interpersonal Emotional Legal Job Financial Other
Using the functional analysis information to develop a plan. After completing the functional analysis the next step is to work with the family member to use the functional analysis information and develop a plan of action to deal with their relative's violent behaviour. To start the process ask the family member to review their completed functional analysis forms and check their understanding of the triggers, red flags and consequences of their relative's behaviour. A discussion about the relationship between triggers and consequences should then follow. During this discussion workers can emphasise that: the personal safety of family members is the top priority in all circumstances that there is never an excuse for violent behaviour the behaviour of family members is only one factor in the complex interplay of many other factors that result in a relatives' violent behaviour
the contributing role of alcohol should not be underestimated in a relatives' violent behaviour
As regards the appropriate action for tackling the violent behaviour of relatives, the emphasis in developing a plan is on the behaviour of the family member. This may include identifying any extra skills and knowledge that the family member may need, such as improved ways of communicating or solving problems. In these cases, training that meets the needs of the family member should be noted and organised. In the meantime, alternative more effective 37
and safer behaviours for family members can be suggested for each trigger so further violence can be avoided. Some examples of these are outlined below.
New safer response
John, a young father Trish yells at John and In the short term, when the baby cries
threatens to take the Trish could remove him from within ear
aggressive with Trish baby and leave him.
shot of John. Any possible risks of
his partner, when he
increased violence in this situation
has been drinking and
should also be addressed as a priority.
his baby cries
In the long term Trish would be
supported to attend problem-solving
and communication skills training.
When Tom, hides
Tom fights back and
Tom would be advised not to hide his
Steve's, (his 14 year threatens to tell the
brother's alcohol as this will not stop his
old brother) alcohol to police that Steve's an drinking. In the meantime Tom could
try and stop him
underage drinker who is learn to reward Steve's non-drinking
drinking, Steve beats buying grog from the
behaviour. He might also be supported
local liquor outlet with a to attend problem-solving and
communication skills training
When Jenny has been Louise verbally fights
In the short term, when Louise can see
drinking she hits her back but gives in and
Jenny first begin to drink she could leave
daughter Louise when buys the alcohol
the house to stay with a friend. In the
she refuses to go and because she is afraid
long term Louise would be offered
buy her mother more that Jenny might kick her communication skills training to learn
alcohol when asked. out of home.
more effective ways to talk to her
mother about her drinking.
Adapted from Smith and Meyers Motivating Substance Abusers to Enter Treatment 2004 p99-
Family members who find themselves at risk of continuous and/or serious family violence should be supported to also have a plan that enables them to leave immediately. This plan should include: having immediate access to a reliable safe house (family, friend, community) knowing emergency phone numbers keeping an overnight bag of personal and essential belongings ready and easily accessible. This might include a list of contact information for people who can be relied on to offer their assistance knowing the easiest and safest ways to remove themselves from their homes knowing their legal rights
Activity: Functional Analysis of Violent Behaviour Use the following story about John and his brother Steve. Then practice completing the Functional Analysis of Steve's Violent Behaviour Form on the following page. John and Steve's Story John and his younger brother Steve have been sharing a house since they both came to study and look for work in Sydney. John has now been studying at Uni for 12 months and is doing well. Unfortunately Steve has not had as much luck and is working part time as a barman in the city while trying to look for a better job. Up until now, John and Steve have always supported each other, surfing together and going to the pub for a few beers or game of pool. But in the last 3 months John has become more and more annoyed by what he thinks is Steve's laziness around the house which is always in a mess. John has asked Steve to help out a bit more but they always end up arguing. Steve often becomes verbally aggressive and threatening, telling John to `back off from the policeman role'. Recently the neighbours complained to the landlord about the noise and arguing. Although John has talked to his parents about the problem this hasn't helped and now Steve avoids any phone contact with his mother or father. To make matters worse Steve is also deliberately staying back at work to drink rather than coming home. In the last month John has noticed that Steve has been drinking and playing computer games, rather than surfing on his days off. John has been so worried he asked Steve if they could go to the pub for a beer and talk about things. Everything was fine for a while until Steve started to drink rum. When John became upset and asked Steve to leave with him. Steve agreed but became extremely agitated and angry, telling John that he did not need a brother telling him how he should live his life. By the time they arrived home the argument had become worse, then Steve lunged out, hitting, punching and holding his brother in a head lock. 39
Functional Analysis of Violent Behaviour
Who else is present besides you when Steve gets violent?
What do you think Steve might be thinking about right before getting violent?
Where does the violence usually occur?
When does the violence usually occur?
What do you think Steve might be feeling about right before getting violent?
What is the last thing you
say/do right before Steve
Other `red flags'
What is the last thing
Steve says/does before
Adapted from Smith and Meyers 2004
Violent Behaviour What does Steve violent behaviour usually consist of?
Short term positive consequence What do you think Steve might like about getting violent?
Long term negative consequences What do you think are the negative results of Steve's violence in each of these areas (* are the ones she/he would agree with) Interpersonal
What pleasant thoughts do you think Steve might have during or right after the violence?
Job Financial What pleasant feelings do you think Steve might have Other during or right after the violence?
As we have just discussed, addressing family member's personal safety and ensuring they are protected from experiencing the consequences of their relative's potential violent behaviour is the first step in assisting them to strengthen their own health and wellbeing. But family members must also be able to describe other issues they must be addressed to improve their quality of life. An individualised Happiness Scale is a procedure that enables family members to assess their satisfaction with their own wellbeing across different areas of their life. The purpose of the Happiness Scale is to: Show family members that all areas of their lives are important, not just those associated with their relative who drinks Assess family members feelings and thoughts about different areas of their lives that are unrelated to their relative who drinks Identify which areas of the family members life might need attention Set a baseline so changes to family members levels of satisfaction/enjoyment can be measured over time Collect information that family members can use to set goals and plan treatment The Happiness Scale The Happiness Scale is a ten item scale that measures family member's level of satisfaction with ten areas of life. An example of the scale is outlined below (Smith and Meyers 2004 p 223) .
2 3 4 5 6 7 8 9 10
2 3 4 5 6 7 8 9 10
2 3 4 5 6 7 8 9 10
2 3 4 5 6 7 8 9 10
2 3 4 5 6 7 8 9 10
2 3 4 5 6 7 8 9 10
2 3 4 5 6 7 8 9 10
2 3 4 5 6 7 8 9 10
2 3 4 5 6 7 8 9 10
2 3 4 5 6 7 8 9 10
Discussing the use of the Happiness Scale with family members is an important activity, after which they should be given an opportunity to practice using it. workers can begin the activity by explaining that each category on the scale indicates an area of life that can be measured on a scale of 1 to 10. The measurement `1' is equal to no satisfaction or enjoyment whereas 41
the measurement `10' is equal to complete satisfaction or enjoyment with that area of life. Workers can then explain to the family member that the completion of the scale will assist in: sorting out which areas of their life might need more attention monitoring changes in those areas over time. setting goals in the areas of their life that most need changing achieving goals. Activity Give the family member a Happiness Scale to complete and demonstrate how the scale should be completed as above. When the scale has been completed ask the family member to comment how they felt completing it and what it revealed. Assisting family members to set goals and develop plans to achieve them Once the family member has completed the Happiness Scale they are in a position to choose one of the ten areas of their lives to address. Many may want to start working on the area of life that they are most unhappy with. However, these areas of life are also likely to be associated with the most difficulties. So, as CRAFT takes a positive approach it is more effective if the family member chooses a less troublesome area as a starting point. Choosing an area of life which the family member does not feel so unhappy about is likely to give them more chance of success as they deal with its associated issues. Having chosen an appropriate area of life to focus on, the family member can then be assisted to set goals and plans for achieving them. The positive communication guidelines described in detail on p55 are helpful in this task. The guidelines for setting behavioural goals described by Smith and Meyers (2004) will also assist. These are described below. Setting Goals The goal setting procedure described by Smith and Meyers (2004 p 203) suggests that goals and are: stated briefly and simply stated in positive words describing what will be done only specific measurable behaviour designed to be reasonable and achievable under the control of the family member based on the family member's current or planned skills and knowledge A Goals for Counselling form is used to support the task of setting goals and planning strategies. The form is based on the areas of life used in the Happiness Scale and includes a space for the family member to record goals and strategies for each of the ten areas and a space for estimating a time line for their completion. A completed sample form is outlined on the following page. Even with the form, some family members may still have difficulties identifying appropriate goals and strategies. Most of these difficulties are likely to be because the guidelines have not been followed. For example some family members may start by 42
setting a goal that is too big to achieve, is stated in negative terms or includes strategies which they cannot control. Where it is clear that a family member is having trouble setting appropriate goals and strategies, workers may suggest extra one on one support. 43
Sample Goals of Counselling Table Name: .................................................. Date: .................................................. Problem Areas/Goals Strategies 1. In the area of drinking I would like: 2. In the area of job/educational progress I would like: 3. In the area of money management I would like: 4. In the area of social life I would like: 5. In the area of personal habits I would like: 6. In the area of intimate relationships I would like: 7. In the area of legal issues I would like: 8. In the area of emotional life I would like: 9. In the area of communication I would like: Source: Smith and Meyers 2004 p 224.
Time Frame 44
Additional support for family members using the form could include examples of less suitable
goals matched against improved ones. For example:
Less Suitable Goal/Strategy Goal: Spend more social time with my girlfriends. (Area 4) Strategy: Get one of the girls to come out with me Goal: Improve my relationship with my daughter. (Area 6) Strategy: Arrange three activities a week I can share with my daughter Goal: Change my work situation. (Area 2) Strategy: Talk to the boss about my work options Goal: Be less stressed. (Area 5) Strategy: Take some time to play sport
More Suitable Goal/Strategy Goal: Invite one of the girls to come over and watch movies or go out to the movies Strategy: Call Sally and Jessica tonight and ask if either of them can come to the movies on cheap Tuesday next week Goal: Spend quality time with my daughter Strategy: Talk to Sarah about spending half an hour each afternoon helping her with homework Goal: Request to work part time for a period Strategy: Write an application and submit to my boss asking to work part time for a month Goal: Have at least an hour of exercise each day on the weekend Strategy: Contact the local pool to find out about weekend swimming club times
Extending support systems It is not unusual for a family member to lose social contact in the process of dealing with their relative's alcohol use. Consequently this area of their lives is often one of the most neglected. For example, a woman whose partner drinks and behaves unpredictably in social situations may feel afraid to go out with him in public or to accept invitations that are outside their home.
If it is the case that a family member starts to restrict their social activities, it's likely that their Social Network
s will also become more restricted, although some may not even realize that this is what has happened. It is therefore important that the family member is supported to think about gaining some control of this area of their lives, and in particular to consider social activities that are independent of their relative and that will provide them with enjoyment. To support the family member to think about how they can improve their social lives begin by describing the guidelines for `selecting independent social activities (Smith and Meyers 2004 p 217). These guidelines explain that the most suitable social activities for family members are those which: are pleasurable don't cost much are easy to include in their day to day life are ongoing or have been a part of their lives in the past involve other people and in particular those who they already know
If the family member has difficulty choosing social activities that they find enjoyable and that can be undertaken without their relative, a `Problem Solving' procedure might assist. This procedure is described in detail on page 81. In addition to problem solving CRAFT recommends the `Systematic Encouragement' procedure to assist family members who show lots of enthusiasm for improving their social lives but find it difficult to take the first step towards changing their behaviour and doing something differently. The Systematic Encouragement procedure supports family members who are more likely to come up with numerous barriers and additional problems as to why it is not possible for them to begin the social activity they have chosen. The procedure that workers: never take for granted that family members will necessarily be able to take the first step to achieve the social activities they have planned arrange another Family member to provide support and increase the likelihood that the social activity will actually occur review family member's experiences after they have participated in the social activity, including whether they participated, how enjoyable it was and possible obstacles that may have prevented the family member's enjoyment. Activity Ask the family member to consider how they would like to improve their lives. Assist them to consider the 9 areas identified in the Goals for Counseling and then ask them to complete the form as shown in the example on page 53. A positive problem solving approach (see page 81) should be used to assist the family member to think of possible problems, goals and strategies. Positive Communication An important skill that family members learn through participating in CRAFT is how to communicate effectively so they can talk to their relative using a more positive approach. Communication skills are a key part of CRAFT and are included because many studies show that communication difficulties often occur in relationships where alcohol use is an issue (Monti et al 2001, Kadden et al 1994, Marshall 2003,). With other studies showing that communication problems may in some cases, trigger alcohol misuse (Smith and Meyers 2004 p 109) A number of typical communication problems occur in situations where alcohol is a factor. These include for example: blaming others, resentment and negativity. In CRAFT teaching family members positive communication skills will enable them to: increase the influence they have over others improve other areas of their lives extend their social support networks get what they want because people will be more likely to listen to them explain changes in their own behaviour to their relative act as a powerful reinforcer (e.g: a compliment) for the person who drinks invite their relative into treatment when they are ready 46
Guidelines for Positive Communication To teach positive communication skills workers can begin by introducing the seven step set of communication guidelines described by Smith and Meyers (2004 p 111-115). These guidelines will support the family member to communicate positively with their relative. These seven steps in the guidelines are: 1. To be brief 2. To be positive 3. Refer to specific behaviour 4. Label feelings 5. Offer an understanding statement 6. Accept some responsibility 7. Offer to help Before briefly outlining each step and giving examples of how to put them into practice, the family member should be reminded that their goal is to be heard and understood. This means trying their new positive communication style at a time when their relative is not drinking or suffering from a hangover and when everyone is in a good mood. Each of the above steps is described in more detail below. 1. Be brief not long winded When communicating to achieve a positive outcome, it is best that people state their issues as briefly as possible and stick to the main points. This helps the listener to maintain their attention and keeps old and inappropriate information out of the conversation. It is also more likely to keep the conversation quiet and unemotional. 2. Use positive words The use of positive words means no blaming, name calling, or over generalizing, as these are more likely to annoy the listener and make them feel guilty, distrustful, or defensiveness. A positive approach to a conversation will also help to avoid arguments, particularly if the family member talks clearly about what they `would like' rather than what they `don't like'. Stating a request or demand in positive terms to a relative makes it quite clear what the family member wants. 3. Refer to specific behaviour and not to thoughts or feelings Communicating a specific behaviour requires the family member to make absolutely clear which of the relative's behaviour they are talking about. Talking about a precise behaviour is more productive than referring to thoughts of feelings which might be easily misunderstood. 4. Label feelings Family members who label their feelings and avoid using judgmental or critical language when talking about a problem will help convey their message to their relative. 5. Offer an understanding statement This requires the family member to express empathy with their relative. This means trying to put themselves in the position of their relative to understand them. If people are able to 47
adopt a more empathetic approach it is likely the listener will also respond with understanding. 6. Accept partial responsibility Although taking some responsibility for a problem is not easy, a family member will be more likely to get what they want in the long run if they can acknowledge that they are not interested in blaming their relative for problems. 7. Offer to help Family members who offer to help their relative with their problem and who use a supportive, positive and open approach are more likely to get a positive response in return. The following table uses each of the above seven steps to provide examples of negative and positive communication styles. 48
Be brief Be positive Specific behaviour Label feelings Offer understanding Partial responsibility Offer help
You never tell me what you're doing or when you're working late. You're just like the kids running around being completely selfish as if nobody else in the world matters. You could be dead at the side of the road in the middle of the night and I'd be sitting here none the wiser. You're a pain when you've had too much to drink. You're not funny even though you think you are. Nobody ever laughs at your jokes, I don't know why keep telling them if you can't remember the punch lines You said you'd help me with the kids and you still never offer to do anything. I can't stand this anymore, you're sending me round the bend. I can't stand being around you while you're trying to figure out how to manage your drinking. I knew you'd forget we had that appointment. Now it'll take ages to get another one. You're always in a crisis, when is it ever going to change?
Could you call me this afternoon and tell me if you'll be late so I'll know if I have time to pay mum a visit. You're so much better to be around when you're not drinking. That conversation we had tonight was really interesting, I had no idea you knew all that history of the town I need you to bath and feed the children tonight if that's OK, because I `m taking your mother late night shopping When you sleep all day on your days off I feel sad that we're not using the time to do something enjoyable together. I'm sorry that I am keeping my distance from you right now. I know we'll be closer as the effects of the treatment program start to kick in. I'm sorry I didn't remind you about that appointment. I know things are hard for right now, can I do something to help?
Activity Use the communication guidelines above and discuss positive responses to complete the following table.
Be brief Be positive Specific behaviour Label feelings Offer understanding Partial responsibility Offer help
Look, I'm really sick of the way you can never reach a decision about anything. We've been through this problem over and over again. I've told you what I think and you still can't get around to making up your mind. How long am I going to have to wait for the answer to what is a really small problem that you are just making bigger than ever so everyone around you is stressing out? So what's your big contribution to the family day we're trying to plan, that you're doing your best to ignore, just because you think you work harder than anyone else? Steph, you know you're too much for me to handle when we go out with the girls on the weekends. You were so selfish on the weekend when we went out . Of course there won't be any dinner left if you work late and don't tell me. It's not my fault that we're in this mess, you should have thought about what would happen if you just kept spending till there was no money left. I can't believe you're in this situation again.
Using role play to teach positive communication skills Assisting family members to gain the confidence they will need to use a new positive way of communicating with their relative, requires them to have opportunities to practice. Role plays that take place in a confidential CRAFT session are ideal for supporting a family member to practice their communication skills. Role plays are also a key part of CRAFT and an opportunity for workers to observe and assess the family member's communication skills, to give feedback and offer positive reinforcement. For the family member, role plays are an opportunity to practice difficult conversations in a safe environment, to learn new skills and receive realistic feedback and positive reinforcement. The role of workers as facilitators in role plays is to: ask the family member to describe their relative's likely behaviour in a problem situation ask the family member to imagine the situation is real start the role play & model the desired behaviour invite the family member to join in only continue the role play for brief periods ask the family member to comment on their performance (likes & improvements) provide specific feedback using `sandwich technique' (positive comment, constructive criticism, positive comment) repeat the process to allow the family member to adapt their role based on Healthworker feedback repeat the feedback, starting with the Healthworker playing the role of the relative set homework Reverse role play Another CRAFT strategy for teaching positive communication skills is `reverse role plays'. In this strategy roles are swapped, so that the family member takes the part of their relative with the drinking problem. This aim of the reverse role play is to assist the family member to develop an understanding of their relative's experiences. Playing the part of their relative also enables the family member to hear first-hand, what their own positive communication might sound like from the perspective of their relative. Reverse role plays are useful for situations where a family member might feel angry or resentful towards their relative and is struggling to develop an understanding of their problems. 51
Role Play Activity Step 1: Read the following story about Mary and Jill out aloud Step 2: Workers role play Mary and the family member plays the role of Jill. Workers then ask the family member to demonstrate positive communication using the guidelines described earlier. The conversation is focused on Jill talking to Mary about her drinking and the negative effects it is having on their friendship. Step 3: Discuss the role play Step 4: Swap roles and try a reverse role play. Discuss the outcomes. Mary and Jill's Story Mary separated from her husband 6 months ago and is finding it difficult to cope. Before the separation she had been drinking for some time in an effort to manage her difficult relationship. Now that Mary is on her own her drinking has increased, and on most nights she drinks alone at home. Her problem is that once she starts she cannot stop. If she starts just after she gets home at about 5.30pm she often gets through 7 or 8 glasses by the time she's ready for bed. Sometimes Mary doesn't even get to bed, but falls asleep in front of TV, only waking up in the early hours of the morning. Mary is really angry with her husband but is taking it out on other people close to her, including her friends and family. Jill and Mary been friends for 5 years and have become really close. Jill has tried to help Mary as much as she can, taking her out on weekends, listening to Mary's problems over cups of tea and phoning her to check she is OK. Jill noticed Mary's drinking when they went out on one weekend. Jill tried to talk to Mary about it but the conversation ended in a disagreement and Jill left in tears. Now Jill has started to withdraw to avoid having to listen to any more of Mary's problems. This has not made things any better as Mary has started to openly criticise Jill and to make up unpleasant stories about her to tell people around town. Positive reinforcement for non-drinking The CRAFT approach is based on a behavioural principle which proposes that when behaviour is positively reinforced or rewarded the behaviour will be repeated. This principle applies to either unhealthy or healthy behaviour. Some people experience their unhealthy drinking as positive. For example, some may feel that it is relaxing, time-out from worries, a boost to their self-esteem, a reward for working hard, or an activity that gives them a sense of belonging. People who use alcohol to have these positive experiences are more likely to keep on drinking. However, it is equally possible that if people experience their healthy non-drinking as rewarding then they might also choose to continue that behaviour. An aim of CRAFT is therefore to teach family members the skills they need to positively reinforce their relative's nondrinking rather than their drinking behaviour. 52
To teach this skill workers can begin by reminding the family member about the use of positive reinforcers. Smith and Meyers (2004 p25) describe positive reinforcers as: Something (objects, activities, behaviours, comments) that is experienced by a person as pleasurable/enjoyable, and that makes them interested in repeating or increasing the behaviour that resulted in them achieving that pleasure in the first place. Effective positive reinforcers (Smith and Meyers 2004 p138) for family members to use with relatives should be: pleasurable for relatives inexpensive immediately available to give comfortable and easy for the family member to offer Examples of effective positive reinforcers that fit these guidelines and that a family member can use to reward their relative's non-drinking behaviour include: Sharing an enjoyable activity with them e.g. go for a walk, sit in the park garden, visit a friend together, go fishing, Showing appropriate warmth/affectionate feelings e.g. giving a hug, cuddle, touch Giving a compliment e.g. `you're looking relaxed and happy', `it's great/lovely to see you...', `I heard about your exam results, it's a fantastic achievement...' Offering to do something for them e.g cook a meal, mow the grass, take out the rubbish, look after the children, shop, take them to an appointment, drop in for a cup of tea Showing an interest in their lives by asking questions about the things (family, sport, work, study, music, TV show) that are important to them e.g. `how is your mum/dad/friend/ ...?', who won the match on the weekend?', ` how do you find working/studying at ...', `what do you think about Troy Casser-Daley's latest album?' Showing appreciation for the positive things that they may have done for you or others e.g. `that was really kind for you to help Jenny, she really needed it ...', `thanks for not going to the pub the other night, I really liked spending time alone with you...' To check that reinforcers are effective and fit the above guidelines, workers should ensure that the family member thinks carefully about whether their relative will enjoy them. A scale that ranks level of enjoyment from of 1-5 can be used to do this. Using this scale, 1 is equal to `very little enjoyment' and 5 is equal to `tremendous enjoyment'. For example: 53
Some family members might have difficulties choosing which of their relative's alcohol free behaviours they should be reinforcing. As a guide, positive reinforcement should be given to non-drinking behaviour that: 1. a relative enjoys 2. competes with their relative's drinking behaviour in terms of the time it takes and the role it plays in their lives 3. is already happening frequently or which could happen frequently in the future 4. the family/friend's enjoy (Smith and Meyers 2004 p 143) For example, Jeff chooses to reinforce his son Adam's football training by offering to take him to training when he goes once a week. Jeff also stays to watch Adam train and the give him a ride home. As a result, Adam finds football training more enjoyable and much less of a hassle because he doesn't have to worry about getting there or getting home. Adam finds that he also really likes his father's attention so he asks if he has time to give him a lift to training twice a week. In this example football training is an existing healthy non-drinking behaviour that Adam enjoys (1) and which he participates in regularly (3). Also, the time Adam spends at training plays an important part in Adam's general health and wellbeing because it is time out from drinking beer in front of TV (2). Importantly, Adam's father also gets pleasure from watching Adam practice and from the car trips to and from training, during which they get one on one father/son time to talk (4). Reinforcing versus enabling In light of the pain and unhappiness caused by some relative's behaviour, family members might wonder whether showing a relative support by offering rewards, may actually `enable' their alcohol use and make the situation worse. Others may question the logic in reinforcing any of their relative's behaviours particularly if they have tried to support their relative in the past but have never been able to make a difference to their alcohol use. In such situations it is therefore extremely important that workers highlight with the family member that they are only reinforcing their relative's healthy non-drinking behaviour not `enabling' drinking behaviour. If the family member is still not persuaded about reinforcement, workers can ask the family member to trial it for a period of time and then evaluate its effects. Activity Ask the family member to think about their relative's alcohol use, then, using a sheet of paper encourage them to brainstorm at least 5 possible appropriate reinforcers that match the reinforcer guidelines. Finish the activity by assisting the family member to rate each reinforcer on a scale of 1-5, according to how much their relative might enjoy it. 54
A Functional Analysis of a Relative's Healthy Non drinking Behaviour. Positive reinforcement is not a random activity, but is carefully planned and only given by a family member in response to their relative's healthy non-drinking behaviour. If a family member is struggling to select a healthy behaviour to reinforce, then a functional analysis procedure can be used to help. The purpose of a functional analysis in this situation is to gather more information and assess the relative's circumstances and healthy behaviour so the family member can help to increase it. The functional analysis procedure relies on the same approach as previously, although in this situation, the form is slightly modified, so that the negative consequences of a relative's healthy behaviour are addressed first and the positive consequences last. This ensures the analysis finishes on an encouraging note to motivate family members. A functional analysis for assessing a relative's healthy non-drinking behaviour is outlined on the following page (p66). The completed Functional Analysis of a Relative's Healthy Non-drinking Behaviour uses the example of Jeff and Adam described above. The analysis shows how Jeff might answer questions about his son Adam's healthy non-drinking behaviour. 55
Functional Analysis of a Relative's Health Non-drinking Behaviour (Smith and Meyers 2004)
Short term negative
Who is your relative What do you What is your relative's What do you think your relative
usually with when think your
might dislikes about (behaviour)
relative might behaviour
What do you think he/she might
dislike about (behaviour) [where]
Long term positive consequences What do you think are the positive results of your relative's ...(behaviour)? In each of these areas? Interpersonal Physical
How does he/she engage in it?
Where does she usually...(behaviour)?
What do you think your relative might be feeling about right before ...(behaviour)?
What do you think she might dislike about (behaviour) [with when]
What unpleasant thoughts do you Job/study think he/she might have while ...(behaviour)? Financial
What unpleasant feelings do you think he/she might have while ...(behaviour)?
When does she usually ...(behaviour)?
How long a period does it last?
Functional Analysis of Adam's healthy non-drinking behaviour as completed by his father Jeff (Adapted from Smith and Meyers 2004)
External Triggers Who is Adam usually with when he goes to footy training? The footy team. Where does Adam usually go to footy training? At the local footy field in town. When does Adam usually go to footy training? Currently he goes once a week on a Wednesday evening.
Internal Triggers What do you think Adam might be thinking about right before footy training? Great to be getting away from study to kick a ball and keep buff What do you think Adam might be feeling about right before footy training? Energetic, a bit revved up, maybe frustrated by study demands..
Enjoyable, health behaviour What is Adam's enjoyable healthy behaviour Football and footy training. How does Adam engage in it? Goes to training once a week and plays a match most weekends during the season. How long a period does it last? For the whole of the footy season and a few weeks before the season starts.
Short term negative consequences What do you think Adam dislikes about footy training with the team? Not everyone turns up. What do you think Adam dislikes about footy training at the footy field in town? It's difficult to get to training from where he lives. What do you think Adam might dislike about footy training once a week? It's not enough practice to improve his game. What unpleasant thoughts do you think Adam might have while footy training? I hope I don't miss the bus home or someone can give me a lift. What unpleasant feelings do you think Adam might have while at footy training. Worry about transport home
Long term positive consequences What do you think are the positive results of Adam's footy training? In each of these areas? Interpersonal Improved relations with his father. Physical Keeps fit & healthy Emotional Learns to manage his own feelings more effectively, can take some of his frustration out on the ball Legal N/A Job/study Winning matches helps to keep up Adam's motivation for study. Financial N/A Other Keeps Adam away from the grog
Tips for implementing a Functional Analysis of a Relative's Healthy Non-drinking behaviour To ensure the functional analysis is used as effectively as possible some extra tips for addressing each of its specific areas are described below. These tips are based on the sample functional analysis for Adam on the previous page. External Triggers To make the most of a relative's external triggers for their healthy non-drinking behaviour, a family member can either: Increase the triggers for the behaviour OR Make the triggers more of a top priority for their relative so they are more likely to choose the behaviour. For example, in the above functional analysis Jeff identifies football training as an external trigger for Adam's healthy non-using behaviour. To make the trigger more of a priority for Adam and thereby positively reinforce the behaviour, Jeff decides to take more of an interest in his son's training and to make it easier for him to get to and from training. Internal Triggers The aim here is for the family member to try and strengthen the links between the internal triggers that pave the way for their relative's healthy non-drinking behaviour. Using the above sample functional analysis, Jeff could try to be aware of when Adam was feeling frustrated by his study and `revved up'. He might then use this trigger to suggest that he and his son kick the footy ball around the yard. In this way Jeff would be strengthening the links between Adam's energetic feelings and/or frustration and the healthy action that would follow. It's possible that over time, when Adam he was feeling frustrated or energetic he would then choose to practice his footy skills independently. Negative consequences The short term negative consequences for healthy non-drinking behaviour are a barrier to a relative choosing healthy non-drinking behaviour. However, CRAFT teaches the family member that they have a role in helping their relative to overcome these challenges. The functional analysis is a framework that family members can use to recognise which negative consequences are likely to be the most serious challenges. When the negative consequences are addressed, that family member makes it easier for their relatives to choose non-drinking behaviour. Again if we look back at Adam's situation and the short term negative consequences that his father identifies in the functional analysis, we can see that Adam's concern about getting to and from footy training is a key obstacle that could risk his attendance. Because Jeff recognises transport is a problem that has potential negative consequences for Adam's non-drinking behaviour he decides the best way to overcome the problem is to give Adam a lift to and from training. Positive consequences As Smith and Meyers (2004 p 146) point out, the long term positive consequences of a relative's healthy non-drinking behaviour are those things that are already helping to sustain 58
the behaviour. To make sure this healthy behaviour continues it is the role of the family member to look for ways to reinforce the positive consequences. In Adam's situation for example, Jeff has created opportunities to strengthen his relationship with his son as well as making it easier for Adam to stay fit and healthy and mange his study more effectively . Verbally linking a positive reinforcement/reward with non-drinking behaviour Some family members may prefer to give a relative positive reinforcement for their nondrinking behaviour without telling them what they are doing or why. For example a family member may not want to tell their relative that they are participating in CRAFT, while others may prefer to see if their relative even notices any change in their behaviour or will respond to their positive reinforcements. However, If a family member changes their behaviour towards their relative's healthy non-drinking behaviour without discussing what they are doing it is possible their relative may become suspicious. For this reason, it is important that a family member who wants to explain and verbally link their offers of positive reinforcement and rewards should know the best way to go about it. The family member who wants to verbally link a positive reinforcement to their relative's non drinking behaviour will need to know how to communicate effectively. There are seven communication steps to take that will assist the family member to talk effectively about positive reinforcement and to link it to their relative's non-drinking behaviour. These steps are the same as those used in the positive communication guidelines (described on page 55). They require the family member to: 1. be brief 2. be positive 3. refer to specific behaviours 4. label their feelings 5. offer understanding statements 6. accept partial responsibility 7. offer help Other suggestions to assist the family member to talk to their relative about their healthy non-drinking behaviour and positive reinforcement include: Making sure their relative is sober and not drinking when the conversation takes place Avoiding arguments or confrontation Making positive statements Taking the conversation slowly Activity Read the following story about Betty. Then with one person playing the part of Betty and the other playing either Robbie or Lisa, role play the conversation Robbie/Lisa might have to show how positive reinforcement can be used to link Betty's non-drinking behaviour. 59
Betty's Story Betty is an older woman who has retired. Betty's husband passed away so she has gone to live with her eldest son Robbie, his wife Lisa and their three young children
. The family thought this was a good idea and that Betty could help with the kids. Betty loves the kids but finds them a handful on her own. Mostly she loves spending time with the women she has met at a craft group that she goes to when she can. The group is really friendly, and they sometimes even use the community bus to organise extra outings. Robbie and Lisa know Betty drinks too much because when Robbie's father was alive he used talked to them about its effects on her health. But Robbie and Lisa mostly ignored the issue. Now Betty has come to live with them they can't ignore it any more, particularly when they come home from work and find Betty drunk and the kids running wild after school. Robbie and Lisa decided to encourage Betty to attend the craft group more often because they knew how much she enjoyed it and also noticed that on the days she went that she didn't drink. Robbie and Lisa also decided to give Betty more support to get involved in other activities outside the home. To achieve these outcomes Lisa has arranged to take Betty to the craft group every week. Robbie has started to get his mother to help him when it's his turn to look after the kids after school. Lisa and Robbie have also arranged for a local community volunteer group to visit Betty once a week. Checking family/friend's readiness to deliver positive reinforcers After completing this activity workers can assist the family member to reflect on what they have learnt about offering their relative positive reinforcement for their healthy non-drinking behaviour. Using a check list can help to ensure that the family member is ready to deliver positive reinforcement to their relative. The list includes making sure the family member can: describe a positive reinforcer to increase a relative's non-drinking behaviour describe the difference between `reinforcing' and `enabling' non-drinking behaviour express any feelings of resentment they may have about rewarding a relative even though their relative may have caused them pain and suffering make a list of possible reinforcers according to the reinforcer guidelines select a healthy non-drinking behaviour to reinforce for their relative recognise and manage any negative consequences that may result from trying to reinforce their relative's healthy behaviour recognize the signs of their relative's are unhealthy drinking behaviour demonstrate how to link a reward with non-drinking behaviour through a role play plan how to handle problem 60
Skills Training The following section explains skills training that workers can use to assist family members to: change the way they think about and behave towards their relative's unhealthy alcohol use A detailed plan describing the strategies and procedures that are part of this training is outlined in Appendix 4. Using negative consequences If the family member makes a decision not to intervene in a relative's unhealthy drinking behaviour that relative is likely to experience a range of natural negative consequences. Sometimes however, family members unintentionally reward their relative's drinking in which case their relative is unlikely to experience any negative outcomes. For example, a mother may positively reinforce her son's non drinking behaviour by giving him money at the end of the week if he does not go to the pub. The money goes into her son's bank account so he can buy a new car. The son has been given the money regularly for several months because he has stopped going to the pub. But he now drinks at his friends' houses where his mother can't see what he is doing. The son thinks that this way he still gets to drink and get the money. In this case the mother will need to know when her son is drinking before she can stop rewarding it by giving him money. When she stops giving her son money he will then be able to experience the negative consequences of his drinking The CRAFT Procedures that allow a person to experience the `negative consequences' of their drinking behaviour are for the family member to use along with strategies for reinforcing their relative's healthy non-drinking behaviour. The first of the negative consequence procedures is `time out' from positive reinforcement. The second is allowing the `natural consequence' of a relative's drinking to take its natural course (Smith and Meyers 2004 p 165). These procedures may be particularly useful in instances where relatives have continued to use alcohol over a long period of time regardless of any alcohol interventions, and/or where they have taken their family member's support for granted. Although these two procedures sound simple to implement the family member may still find them difficult. This is because it is not easy to refuse to give a relative the support they may have come to expect and rely on. Also because the family member may be afraid of how their relative will react when faced with such refusal. Each of the two procedures are described in detail below. 1. `Time out'-from positive reinforcement' Time out from positive reinforcement is a procedure that involves the family member withdrawing or withholding a reinforcer/reward from their relative during a drinking episode and thereby creating `time out' from that positive reinforcement. To be able to use the `time out' procedure workers can assist the family member to: consider how they might have been unconsciously rewarding their relative's drinking. 61
describe appropriate times to introduce `time out', consider types of reinforcers/rewards to withdraw use a positive approach to explain the `time out' process to their relative. Successfully implementing this procedure requires the family member to be able to: identify the difference between their relative's unhealthy drinking and healthy nondrinking behaviour link new rewards with their relative's non-drinking behaviour so they can also withhold these rewards when their relative drinks select the appropriate circumstances when their relative is drinking to apply the `time out' procedure change their own behaviour to affect their relative's drinking Appropriate situations for introducing `time out' It may not be easy to choose an appropriate situation for withdrawing a reinforcement so a relative experiences `time out', so workers should assist the family member family in this task. Situations that are more likely to be appropriate for `time out' are those: that are ongoing and/or when a relative is drinking in the presence of their family member, so the family member can make an immediate response and withdraw the reinforcer at that moment, thereby beginning the `time out' procedure in which the family member usually respond with a positive approach, so when the reinforcer is withdrawn their relative becomes aware of its absence thereby experiencing `time out'. Types of reinforcers to withdraw A set of guidelines has been developed to make it easier for family members to select appropriate reinforcers for withdrawal (Smith and Meyers 2004 p 168). These guidelines state that the most effective types of reinforcers for a family member to with draw are those that: 1. their relative thinks are valuable and that they will miss when withdrawn 2. can be reintroduced when the relative is not drinking or hung over 3. consider easy to withdraw 4. feel safe to withdraw 5. are able to withdraw as close to the time as possible that the alcohol is being used. Examples of effective reinforcers that could be withdrawn are described below: 62
A father who drives his son to a friend's place and the son gets drunk, can stop taking him there A son tells his recently widowed mother that she can only come to visit him and his family when she has not been drinking and when she is not hung over. After trying to help his work mate come to terms with his divorce, a man explains to his friend that he will not take him fishing on weekends if he is hung over. The mother and father of a young 18 year old tell him that they will only help to pay her car repayments on those weeks when she does not binge drink. How to explain `time out' to relative's using a positive approach Another important consideration for workers is to discuss with the family member how they will explain the `time out' procedure to a relative using a positive approach. This discussion should explain that it is more effective if the family member talks about `time out' with their relative: before they take any action so the procedure does not come as a surprise and give them time to change their behaviour in response to the withdrawal of the reinforcer when everyone is in a good mood and relatives have not been drinking nor are hung over In some situations family members may find that their relative continues to drink despite the introduction of time out. This may mean that the family member will have to consider choosing a stronger and more influential reinforcer to withdraw. Withdrawing a stronger reinforcer is likely to result in more serious or stronger negative consequences. However this might cause some unexpected challenges, in which case family members need to think carefully about when to withdraw the reinforcer and if they are going to reintroduce it. For example, the withdrawal of a stronger reinforcer may be more effective if the family member arranges it to happen as soon as they have had a chance to explain what they are going to do, rather than waiting for when their relative is drinking. In some situations it may be necessary to withhold a reinforcer indefinitely, rather than only withdrawing it at the time of a drinking episode. The purpose of this is to show that the old ways of relating between a family member and their relative is no longer working and may even be encouraging the drinking behaviour to continue. (Smith and Meyers 2004, p173). The following activity offers family members an opportunity to practice how to explain the `time out' procedure to a relative. Activity Read the case study below. Then with the family member role playing the part of Justine and the worker playing Sally practice a conversation in which Justine explains the `time out' procedure to Sally. The conversation should demonstrate a positive approach to give an explanation of the reinforcer being withdraw (babysitting), for how long it will be withdrawn, and the circumstances in which it will be withdrawn (you will need to make this up). Record: when the conversation took place 63
the key points of the conversation (the reinforcer being withdraw, how long withdrawn, circumstances in which it will be withdrawn, key words to show style of language used) any difficulties that were encountered At the completion of the activity discuss the outcomes. Justine and Sally's Story Justine has been looking after her grandchildren four afternoons and evenings a week. This involves picking them up from school, helping them with their homework, cooking their dinner and putting them to bed so that her daughter Sally who is a single mum can work some overtime and earn more money. While Sally does work the extra hours, she frequently also uses the money to go to the club to drink with her girlfriends and often comes home drunk. Justine tried to talk to Sally about the problem, but Sally told her it was the only time she had to get away from `being a mum' and working. Justine is concerned that if she stops babysitting that Sally will get really angry and take it out on her or the kids. However, Justine decides to explain to Sally that she is no longer willing to keep looking after her grandchildren and that if Sally wants to keep drinking after work she will have to pay for a babysitter. Justine is hoping that when Sally realizes just how much a babysitter costs she might stop drinking. Also, although Justine is worried that Sally might be angry at the start, she is also confident that her daughter will eventually see that her drinking behaviour is unhealthy and unreasonable. 2. Natural Consequences The second procedure for linking a person's drinking to its negative consequences entails teaching family members how to allow their relative's drinking to take its natural course. This procedure includes a description of guidelines for allowing the natural consequences of a relative's drinking to occur. It also includes assistance for the family member as they select which natural consequences will be most effective as a deterrent for drinking. As the family member learns how to problem solve they will develop the skills to handle any difficulties that might result from the negative consequences. Each of these procedures are now described in more detail. The `natural consequences' procedure is used by the family member to link a negative effect with their relative's alcohol use. In this procedure the family member makes no attempt to prevent or fix the negative outcomes that are likely to result from their relative's alcohol use. In other words they allow the negative consequence of their relative's drinking to take its natural course. Family members who allow the natural negative consequences of unhealthy drinking to occur can assist their relative to learn to control their drinking. Learning how to allow the natural negative consequences of unhealthy drinking to occur requires the family member to: recognize that when they protect their relative from experiencing the negative effects of their drinking they are unintentionally behaving in a way that shows their relatives they approve of their alcohol use. change their behaviour and stop protecting their relatives so that the natural negative consequences of their relative's drinking are allowed to occur. Showing a family member how their behaviour may actually be playing a part in maintaining their relative's drinking is a key part of CRAFT. 64
Read the following scenario to gain an idea about how natural consequences can work. Gracie's Story Gracie has been asked to stay home during the week to help her mother look after her sick auntie who has come to stay with them. Gracie ignores her mother's requests because she is more interested in having fun and going out to drink with her girlfriends. It is not unusual for Gracie to come home very drunk on these occasions and to vomit and make a mess in her bedroom which she knows her mother will clean up. Gracie's mother is getting fed up with always cleaning up after her daughter and is considering leaving it for Gracie to clean up. But Gracie's mother is also ashamed about Gracie and worried that her auntie will see the mess and think that she is a hopeless housekeeper and mother. A natural consequence to target Choosing possible times for when to allow the natural consequences of a relative's drinking to occur are often obvious during a functional analysis when the family member describes a typical drinking episode or the short term positive consequences of drinking. If occasions are not obvious then workers should ask the family member to think about their relative's alcohol use and to describe a situation when they have tried to prevent the natural negative consequences from occurring. Identifying such situations will enable the family member to identify the natural consequence that might be targeted. In the scenario above for example we can see that when Gracie's mother cleans up Gracie's mess she is preventing Gracie from learning about the negative consequences of her drinking. The mess that Gracie leaves in the bathroom could be an effective natural consequence that Gracie's mother could target. All Gracie's mother needs to do is to change her own behaviour and stop cleaning up after her daughter. Guidelines for allowing natural consequences Family members who may be uncertain about allowing the natural consequences of their relative's alcohol use to occur should have opportunities to discuss their feelings and concerns with the worker during the CRAFT session. They should also have time to practice the natural consequence procedure in a role play before trying it out at home. In addition, other issues that could impact on the family member as a result of implementing the procedure can also be discussed. Such issues include: What might be likely to happen if the family member changes their usual behaviour and lets their relative experience the natural consequences of alcohol use? What their relative might do? Whether there is any chance the relative could become aggressive? How the changes might impact on the family member and other relatives? A summary of the key points for the family member to consider when allowing the natural negative consequences of drinking occurring are listed below. These include: 1. that the negative consequence allowed to occur must be a result of the relative's alcohol use 65
2. that family member's discuss feelings (anger, resentment, shame) about previously blocking a consequence 3. relative's recognise the consequence is negative 4. ensuring that the negative consequence is likely to contribute to a decrease in their relative's alcohol use 5. ensuring it is safe to allow the negative consequence to occur 6. discussing how any other problems which may arise for the family member as a result of the consequence can be sorted out 7. family members knowing how and when to explain their plan for changing their behaviour, choosing which consequence to target, allowing it to occur and managing issues that may arise Some examples of situations that are appropriate for allowing the natural consequences to occur are outlined below. Activity Ask the family member to think about a situation in which their relative's drinking behaviour is of concern. Then ask them to imagine stepping in to that situation to prevent their relative from experiencing the negative consequences of their drinking. Brainstorm the following issues: The circumstances of their relative's drinking episode (who were they with, where were they drinking, when were they drinking) All the natural negative consequences that their relative might have experienced if they had not intervened What the family member did to interfere The relative's reaction/s to their family member's interference Using the same sample drinking episode ask the family member to imagine they changed their behaviour and did not prevent one of the natural consequences occurring. Ask the family member to briefly describe: the natural consequences was considered appropriate to target the explanation they would give to their relative about letting that negative natural consequence occur how they felt about changing their behaviour their feelings about allowing the negative consequence to occur 66
their relative's possible perceptions of the consequence their relative's response to the consequence 67
Problem Solving CRAFT uses a problem solving procedure to support family members as they consider ways to manage with challenges and issues that arise as a consequence of their relative's alcohol use. The procedure includes a series of steps (Meyers and Smith 1995). These are: Step 1: Define the problem in detail In many cases the complex problem that the family member describes is often more likely to be a combination of smaller more easily managed issues. For this reason it is best if the family member can break their complex problem into its more specific and smaller issues. They can then select the one issue they want to tackle first. Choosing one issue can help the family member to feel less weighed down and more optimistic about managing their problem. Step 2: Brainstorm possible solutions In this step the family member is asked to suggest as many solutions as they can think of to address the problem they identified in Step 1. The more solutions generated the better. All solutions should be recorded. Some family members may need reminding that all suggestions are valid. Step 3: Get rid of unwanted suggestions This step requires the family member to review each of the solutions and remove any that they think are unsuitable for any reason. For example, the family member may consider some solutions are difficult, while there may be others they tried that didn't work. This step does not require an explanation for why the solution is being removed as the problem solving process is a positive one. Workers should avoid asking for explanations as it could make the family member feel uncomfortable and take up unnecessary time. Step 4: Choose one possible solution Once all unwanted solutions have been removed, the family member should choose one solution they think is worth trialling. In this step the family member also provides an explanation for how they will put the solution into action. At this point some family members may need support to think carefully about how realistic their plan of action is. For example, some may not have the skills they need to put their plan into action. This means their plan may take them longer while they take time to practice their skills. Step 5: Identify possible obstacles/problem This important next step allows the family member to identify all the possible barriers/problems that could prevent them from being able to achieve the solution they identified in Step 4. Assisting the family member to identify barriers before they occur means they can deal with them in advance. It also helps to reveal problems that could be used as excuses for not proceeding with the solution. Step 6: Plan a way to deal with each obstacle/problem Once obstacles/problems have been identified the family member can then discuss a simple plan of action to deal with them. If obstacles/problems are not possible to deal with in advance then another solution should be chosen. 69
Step 7: Decide on the problem solving action plan and do it When a plan has been developed and possible obstacles/problems addressed the family member should be ready to discuss how they will put their plan into action. This discussion should include a reasonable time frame. If possible this should be before the family member attends their next CRAFT session. Step 8: Review and evaluate the outcome This final step is best carried out after the family member has had a chance to put their problem solving plan into action. When supporting the family member to evaluate the outcomes of their action workers should use a positive rather than judgmental approach. To achieve this, workers can ask the family member whether their plan was carried out as they anticipated, whether it was completed and if the outcome met their expectations. Family members who had problems implementing their plans may need more time with a worker to take a closer look at their experience. In these cases the family member might choose to use a problem solving worksheet to assist them. A sample worksheet is outlined on the next page. 70
Problem Solving Table Problem solving steps 1. Define the problem narrowly 2. Brainstorm possible solutions 3. Get rid of unwanted suggestions 4. Select one possible solution 5. Identify possible obstacles/problems 6. Address each obstacle/problem 7. Decide on the action plan and do it 8. Review and evaluate the outcome
Engagement into treatment The final goal of CRAFT is to assist the family member to invite their relative to enter treatment for their alcohol use. While CRAFT gives equal importance to all of its goals, some family members may consider this one to be the most important and therefore be eager to make it happen as quickly as possible. But as Smith and Meyers (2004) point out, it is unlikely that family members will achieve this goal if they push their relative into treatment before they are ready. For this reason it is critical that workers advise family members to be patient and follow a few key guidelines. This will make success more likely both for themselves and their relatives. These guidelines are described in this section. A possible session plan for assisting family members to invite their relative into treatment is outlined in Appendix 5. When is the right time to ask? Throughout this manual we have outlined CRAFT's emphasis on motivation. In CRA for example a key consideration, is that relatives `... will be motivated to change their substance abusing behaviour if they are reinforced (rewarded) in doing so' (Meyers, Smith 1995 p 17). Whereas, in CRAFT a fundamental issue is the motivation of the family member for wanting to help their relatives to quit drinking and improve their own wellbeing (Smith and Meyers 2004 p 20). Motivation is also a key factor for family members as they consider when to invite their relatives into treatment, particularly as a relative's levels of motivation is likely to rise and fall over time. To maximize chances that a relative will accept their invitation, Smith and Meyers (2004 p230) suggest that the family member chooses to make the invitation at times described as `windows of opportunity'. These times are occasions when relatives may be: showing signs that they feel sorry for causing an alcohol related crisis and may be more open to thinking about treatment. Such times may include when relatives have been charged for an alcohol related offence, have lost money, work, accommodation or a relationship as a consequence of their drinking. troubled or embarrassed by a surprising comment about their alcohol use made by someone who they thought did not know, such as their boss, colleague, sports coach, doctor, parents. interested in their family members participation in CRAFT sessions. For example, relatives may ask leading questions that show they are concerned their behaviour is being discussed with a Healthworker and are wondering whether it helps. curious why their family member's behaviour has changed. They may for example be curious why their family member is positively reinforcing their non-drinking behaviour. Other considerations related to finding the right time to invite relatives into treatment have already been mentioned. These are for example making sure that both the family member and their relative is: in a good mood sober able to use positive communication (see page 55) 72
Some examples of positive communication styles for inviting a relative into treatment and
that use some of the occasions described above are outlined in the following table.
Occasion of invitation
When a relative knows their That's it! I cant stand your drinking Your drinking is so damaging. I love
for another day, get treatment or you and want to help. Please let's
participating in CRAFT &
get out of my life.
figure a way out of this together.
have caused a crisis
What about coming with me to the
When family/friends are
Things might be bad just now but I want you to know that I
telling their relative they
your drinking is the worst thing
understand how bad everything is &
are participating in CRAFT. tearing this family apart. You're so that drinking is your way out. But
bad I've had to get help. But what I've been learning some new ways
about you, why is it always me
of handling things at the AOD family
doing the work?
sessions that are really helping me.
Why don't you think about trying it
out with me?
An unsuspected remark
Yeah, well what do you expect?
That must have made you feel
about their alcohol use
Everyone knows you're a drunk, you terrible. I know you may not be
should get help.
interested but if you want to make
things better for yourself maybe we
could go and see the AOD worker at
Using motivational hooks As described above, relatives will experience different levels of motivation to enter treatment over time. Also, different triggers influence whether or not a relative chooses to enter or refuse treatment. In studies of CRAFT, people gave a range of reasons for their entry to treatment. For example, some described wanting to feel good about themselves, others noticed positive change
s in their family member's behaviour which made them feel they should find out more about CRAFT, while some mentioned the positive rewards that would result from their participation in CRAFT (Smith and Meyers 2004 p 234) .
Encouraging their relative into treatment requires family members to take careful note of the things that might motivate or `hook' them in. As Smith and Meyers note just as a fisherman trying to catch a fish needs to use the right bait, family members can also use a number of motivational hooks (2004 p 236).. These include for example telling a relative: 1. there may be are opportunities to meet with the CRAFT worker. This could be scheduled to occur for a 10 minute period at the end or beginning of each CRAFT session. In this time workers could ask the family member to provide their relative with positive feedback about their participation in CRAFT and its effects; 2. their participation in CRAFT does not have to involve counseling with the same worker supporting their family member. Rather, they can have their own different worker; 3. they can try CRAFT without necessarily having to commit to treatment in the long term;
4. they can make a major contribution to deciding their own treatment goals and that they would not be made to do anything they did not want to do; 5. that their participation in CRAFT will provide them with opportunities to sort out other areas of their lives, e.g. work, study, money management, relationships, mental health, issues. 6. their participation in CRAFT is likely to result in them being rewarded in one way or another What to do after the invitation is made? Even before a relative has been asked or has accepted an invitation to enter treatment the family member should be well prepared with a follow up plan they can immediately put into action. This plan is based on the idea that it is important to act quickly while the opportunity is there and before their relative suddenly changes their mind. The CRAFT approach therefore recommends that people see an AOD counselor no later than 48 hours or 2 days after they have agreed to treatment. Activity This is a role play activity that requires people to work in pairs, with one person playing the role of their relative and the other role playing the part of the family member. Begin the activity together and brainstorm an appropriate time for the family member to invite their relative into treatment. Take 10 minutes to practice the conversation remembering to use the seven steps of positive communication. That is: 1. be brief, 2. be positive, 3. name a specific behaviour, 4. label your feelings, 5. offer understanding, 6. take partial responsibility, 7. offer help. After completing the activity discuss the experience and outcomes. What to do if relative's refuse an offer to sample treatment As stated earlier, although a relative agrees to enter treatment they may not necessarily take action to make it happen. It is not uncommon for example, for people to change their minds and go from accepting an invitation to then rejecting it, especially if this is the first time they have been asked. In these situations, the family member should be encouraged to stay hopeful and keep trying to find other opportunities to make repeat offers when they think the time is right. In addition family member can be reminded that their relative's refusal to enter treatment is not a personal rejection of the family member themselves. A discussion about how family members talk to their relatives and their relative's responses will assist workers to offer advice about how family members might improve the way they interact so repeated invitations to enter treatment are constructive and timed in the most effective way. However, if the family member indicates they are being adversely affected by their relative's repeated rejection of invitations they may need to take a short break. This will give them a chance to review and revise their strategies while working on their own wellbeing. During these times, workers should also ensure the family member knows to continue with the other CRAFT strategies, such as positive reinforcement for non-drinking, and allowing the natural consequences of drinking behaviour. 74
In some circumstances it may be advisable for the family member to stop making invitations to their relative. However, before making this decision, the family member should have a sound understanding of its possible implications. Workers should also ensure that the family member's decision is based on having as much information about their relative as possible. This might include a review of their relative's current alcohol use, relationships between the relative and their family member, and the family member's level of happiness/wellbeing. Initial screening assessments should also be compared with later ones to assess whether any progress has been made. What to do if a relative drops out Just as some people may change their minds about entering treatment, so too some may enter treatment and then drop out. In these circumstances family members should not be discouraged but supported to accept that their relative's treatment is an unfolding process that is likely to involve a number of stops and starts.. This support might begin with a review of reasons why their relative dropped out followed by a new plan to address problems. Sometimes plans may focus on solutions to manage practical problems for example lack of transport to get to treatment. But where problems are more complex, the family member may need extra one on one support with an AOD counselor or referral to a professional in the specialist field in which they need help. For example some family members may need marriage counseling or mental health support. While others may need more time for training and skill development in areas such as problem solving or communication. In all cases the family member should be advised to keep going with their use of CRAFT strategies to support their relatives and to strengthen their own wellbeing. Summary of preparation needed before a family member invites their relative into treatment Before an invitation to enter treatment is made Smith and Meyers (2004 p 230) recommend that the family member: recognises those times when their relative may be motivated to enter treatment knows how to use motivational hooks that may encourage their relative to enter treatment has the necessary positive communication skills to invite their relative into treatment recognises when and where to make an invitation to their relative to enter treatment knows how to respond effectively to problem situations that might arise as a consequence of the invitation has planned and organised in advance at least one workable treatment option for their relative is prepared for their relative's refusal of treatment or early drop out from treatment can provide ongoing support once their relative has commenced treatment. 75
CRAFT Conclusion This concludes the CRAFT program as it has been adapted for use with Aboriginal communities. As described in this manual the program includes a number of procedures to be used by workers formally trained in CRAFT and who will work one on one with a family member of a person who engages in unhealthy alcohol use. The role of workers will be to guide the family member through the information and case studies over a series of sessions. This will give the family member time to rehearse the skills they need to put CRAFT into practice. Although the procedures are presented in a specific sequence they may be adapted according to the needs of participants and services. The following pages present a series of possible CRAFT session plans. The intention of these is to provide workers with a potential framework for implementing CRAFT with a family member. The session plans are not intended to be used as a fixed program but rather as a demonstration of how the different CRAFT procedures might be used across a series of one on one sessions. 76
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Volume 4). Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. Retrieved from http://www.chestnut.org/li/cyt/products/ acra_cyt_v4.pdf. Godley, S.H., Smith, J.E., Meyers, R.J., & Godley, M.D. (2009). Adolescent Community Reinforcement Approach (A-CRA). In D.W. Springer & A. Rubin (eds.), Substance abuse treatment for youth and adults (pp. 109-201). Hoboken, NJ: John Wiley & Sons. Godley, S.H., White, W.L., Diamond, G.S., Passetti, L.L., & Titus, J.C. (2001). Therapists' reactions to manual-guided therapies for the treatment of adolescent marijuana users. Clinical Psychology: Science and Practice, 8, 405-417. Hunt, G.M., & Azrin, N.H. (1973). A community-reinforcement approach to alcoholism. Behavior Research and Therapy, 11, 91-104. Hupp, C.L., Mertig, K., Krall, K.L., Godley, M.D., & Godley, S.H. (2009). Adolescent Community Reinforcement Approach (A-CRA) and Assertive Continuing Care (ACC) supervisor rating manual. Normal, IL: Chestnut Health Systems. Lee, M.T., Garnick, D.W., O'Brien, P.L., Panas, L., Ritter, G.A., Acevedo, A., Garner, B.R., Funk, R.R., & Godley, M.D. (in press). Adolescent treatment initiation and engagement in an evidence-based practice initiative. Journal of Substance Abuse Treatment. Meyers, R.J., Dominguez, T.P., & Smith, J.E. (1996). Community reinforcement training with concerned others. In V.B. Van Hasselt & M. Hersen (eds.), Sourcebook of psychological treatment manuals for adult disorders (pp. 257-294). New York: Plenum Press. Meyers, R.J., & Godley, M.D. (2001). The community reinforcement approach. In R.J. Meyers & W.R. Miller (eds.), A community reinforcement approach to addiction treatment (pp. 1-7). Cambridge, United Kingdom: Cambridge University Press. Meyers, R.J., Miller, W.R., Hill, D.E., & Tonigan, J.S. (1999). Community reinforcement and family training (CRAFT): Engaging unmotivated drug users in treatment. Journal of Substance Abuse, 10, 291308. Meyers, R.J., Miller, W.R., Smith, J.E., & Tonigan, J.S. (2002). A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others. Journal of Consulting and Clinical Psychology, 70, 1182-1185. Meyers, R.J., & Smith, J.E. (1995). Clinical guide to alcohol treatment: The Community Reinforcement Approach. New York: Guilford Press. Meyers, R.J., & Smith, J.E. (1997). Getting off the fence: Procedures to engage treatment-resistant drinkers. Journal of Substance Abuse Treatment, 14, 467-472. Meyers, R.J., & Wolfe, B.L. (2004). Get your loved one sober: Alternatives to nagging, pleading, and threatening. Center City, MN: Hazelden. Miller, W.R., Meyers, R.J., & Hiller-Sturmhofel, S. (1999). The community-reinforcement approach. Alcohol Research & Health, 23, 116-121. 81
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APPENDIX 1: Sample CRAFT Session 1 Plan Session 1 Objectives In session 1 Family members can be supported to: a. describe their relative's alcohol use and its effects b. identify CRAFT and the CRAFT goals and procedures
c. complete baseline measures d. reflect on their motivation for seeking support to change their relative's alcohol misuse e. describe their responsibilities in CRAFT
f. identify reinforcers
g. identify issues of confidentiality
h. prioritise their personal safety
complete a Functional Analysis of their relative's
Worker Activities Guide them in a discussion about: their relative's alcohol use and the problems it causes negative feelings of anger, sadness, frustration, guilt or hopelessness the benefits of CRAFT In session 1 workers will support the family member and: Briefly overview CRAFT goals and procedures including: decreasing the relative's alcohol use. getting their alcohol dependent relative into treatment increasing their own happiness and wellbeing whether or not their relative enters treatment. Administer CRAFT Survey Use a positive and accepting approach to: encourage family/friends at every opportunity support family/friends to reflect on their motivation Inform them about their need to: participate in skills training activities, complete homework assignments, practice new skills and attend follow up referral sessions provide relative's with ongoing and complete support Discuss: positive expectations reinforcers or rewards that will assist them to manage their relative's healthy non-drinking behaviour Discuss: the disclosure of private and sensitive information informed consent Assess: risks for family violence Guide them to: analyse their relative's problem and healthy behaviour, its triggers and positive and negative consequences using a Functional Analysis 83
APPENDIX 2: Sample CRAFT Session 2 Plan Session 2 Objectives In Session 2 family members can be supported to: use positive communication use positive reinforcement to support a relative's healthy non-drinking behaviour
Session 2 Worker Activities In session 2 workers can support the family member to: communicate positively by : being brief being positive Referring to specific behaviour Labeling feelings Offering an understanding statement Accepting some responsibility Offering to help select and describe: appropriate, effective positive reinforcers to use with a relative the difference between reinforcing and enabling a relative's alcohol use
complete a Functional Analysis of a Relative's Healthy Non drinking Behaviour verbally link a positive reinforcement/reward with nondrinking behaviour review their readiness to deliver positive reinforcers for their relative's non-drinking behaviour
describe a relative's non-drinking behaviour and possible: external & internal triggers negative consequences positive consequences describe and demonstrate how to: use positive communication to talk to their relative about rewarding their non-drinking behaviour describe: feelings of resentment about reinforcing a relative's non drinking behaviour a plan for managing any negative consequences that may be a consequence of reinforcing their relative's non-drinking behaviour
APPENDIX 3: Sample CRAFT Session 3 Plan Session 3 Objectives In Session 3 the family member can be supported to plan & implement: negative consequences
Worker Activities In Session 3 workers can assist the family member to describe: ways they might unintentionally reinforce/reward their relative's drinking behaviour links between reinforcing drinking and the possible absence of negative outcomes how time out from positive reinforcement can deter a relative's alcohol use how allowing the natural consequences of drinking may act as a deterrent to drinking
time out-from positive reinforcement
effective reinforcers to withdraw: valuable, easily reintroduced & safely withdrawn
appropriate times to withdraw reinforcers
how to talk to a relative about time out
natural consequences of drinking
the need to change their behaviour to stop protecting their relative from the natural negative consequences of
how to choose a natural negative consequence to target
potential feelings e.g. anger, resentment, fear that may arise as a result of about allowing a relative to experience
the natural negative consequences of drinking
the need to review safety precautions
Defining the problem
Brainstorming possible solutions
Getting rid of unwanted suggestions & choosing one possible solution
Identifying possible obstacles & planning a way to deal with each problem
Deciding on the problem solving action plan and do it
Reviewing and evaluate the outcome
reinforcers that will improve their wellbeing & assist complete:
them to enrich their own lives
the Happiness Scale
Goals for Counselling based on one of the ten areas from the Happiness Scale
strategies for extending support systems
other family/friends to provide support
and review previous social activities & experiences
APPENDIX 4: CRAFT Session 4 Plan Session 4 Objectives In Session 4 the family member will be supported to: identify and select an appropriate time & place when their relative may be ready to enter treatment. use motivational hooks plan at least one easily available treatment option use positive communication to invite a relative to enter treatment develop strategies to manage a relative's refusal of an offer to try treatment
Session 4 Worker Activities In session 3 workers can assist the family member to choose an appropriate time to invite their relative into treatment. For example when a relative shows they are: feeling sorry for causing an alcohol related crisis embarrassed by an unexpected comment about their alcohol use interested in family/friend's participation in CRAFT sessions curious about why family/friends have started behaving in a different way choose incentives to motivate their relative to consider entering treatment, by offering them opportunities: to informally meet the family/friend's CRAFT counsellor to have their own CRAFT counsellor address other problems in their lives trial CRAFT without necessarily committing to it to be rewarded through participating in CRAFT select and organise a possible and appropriate treatment option and: ensure a relative's rapid easy access role play making an invitation into treatment using positive communication and being: brief positive name a specific behaviour labeling feelings offering understanding taking partial responsibility offering help. discuss how to: keep trying and stay hopeful make repeat offers when the time is right. see that a refusal is not a personal rejection
develop responses to manage a relative's withdrawal from treatment provide ongoing support for treatment.
temporarily withdraw offers to enter treatment discuss : treatment as an unfolding process that may stop and start and that requires perseverance possible reasons for withdrawal discuss and arrange: how to continue support after a relative's treatment has commenced.
Section 5: Glossary This section includes general technical terms and concepts commonly used to talk about alcohol and alcohol related harms and used in this manual. Definitions are based on the two key references on which this manual is based. That is: 1. Smith JE and Meyers RJ (2004) Motivating Substance Abusers to Enter Treatment, Working with Family Members 2. Meyers R J, Smith J E (1995) Clinical Guide to Alcohol Treatment, The Community Reinforcement Approach Terms are listed in alphabetical order. Abstinence To not drink (abstain from) alcohol or take other types of drugs. Alcohol Dependence When someone gives alcohol priority over and above other important things in their lives, for example looking after their family, going to work or school, taking care of their health. Alcohol dependence has biological, psychological and social elements and can range from mild to severe. AUDIT This term stands for the Alcohol Use Disorders Identification Test. The term refers to a health assessment questionnaire that can be used to assess people's risk for hazardous and harmful alcohol consumption. The questionnaire includes ten questions that each gets a score depending on the answer. When the scores are added together the total indicates the person's level of risk for alcohol. The questionnaire can be used by individuals interested in self-checking their alcohol use or used by workers with clients. AUDIT C A similar but much shorter questionnaire used to assess risk of alcohol that includes only 3 questions. The questionnaire is therefore much quicker, more convenient and easier to use. CRAFT A structured but flexible approach to support people who are adversely affected by alcohol. This includes: people who are at risk of harm as a result of their unhealthy patterns of drinking, and family members, other relatives, relatives or close friends.CRAFT has two parts. These are Community Reinforcement (CRA) for individuals who drink and Community Reinforcement and Family Training (CRAFT) for the families and friends of people who drink. CRAFT uses strategies that aim to achieve three goals: 1. remove positive rewards for drinking 2. strengthen positive rewards for abstinence 3. encourage the participation of family and relatives 88
CRA (Community Reinforcement Approach) Is the part of CRAFT for individuals whose alcohol use affects their health. CRA has two key goals. These are to: 1. Remove the positive reinforcements/rewards that maintain a person's alcohol use 2. Strengthen positive reinforcements/rewards that lead a person to reduce or cease their alcohol misuse Evidence based This is a technical term used to describe the use of research for making decisions about the best way to go about a health activity. The evidence for doing things a particular way helps make things clear and assure people that particular health techniques and procedures will provide the best possible interventions or treatments. CRAFT is an evidence based alcohol intervention. This means the intervention is based on evidence that shows it works for treating people affected by alcohol. Read more: Definition of Evidence Based Practice | eHow.com http://www.ehow.com/about_5048440_definition-evidence-basedpractice.html#ixzz1D9PxuaqQ CRAFT (Community Reinforcement and Family Training) The part of CRAFT that is designed for the families, relatives and close friends of individuals who are alcohol dependent or whose alcohol consumption results in problems. CRAFT has three main goals: 1. to assist families/ friends to get their alcohol dependent relative into treatment 2. to support families/ friends to provide their relative with social support to promote positive behaviour change and decrease their alcohol use 3. to promote health and wellbeing of families/ close friends through reducing the negative impact their relative's drinking is having on their health Patterns of drinking This words used in this term are sometimes used interchangeably, i.e. `drinking patterns'. In either case the meaning of the term is the same. The term refers to the level of drinking, that is how much people drink, as well as to all of the other characteristics that are associated with the way people drink. This includes for example: when people drink (e.g. after work, at work, on the weekend) ; where people drink (e.g. club, home, pub, at the footy); who people drink with (e.g. with others, alone, late at night); the number of drinking occasions (e.g. daily, weekly); activities associated with drinking (e.g. sport, poker machines, smoking, parties); personal characteristics of the drinker and his/her friends (e.g. shy, withdrawn, extrovert, sociable); types of drinks (e.g. full/light strength beer, spirits, wine); drinking norms that contribute to a `drinking culture' (for Indigenous people this might be influenced by pub bans, availability) Risk The possible harm that might result to an individual as a consequence of their alcohol use. Although levels of risk associated with drinking alcohol are difficult to quantify they are often referred to as low risk drinking, risky and high risk drinking. Low risk drinking is a level of drinking at which there is only a minimal risk of harm. 89
Reinforcer Those things that are experienced as enjoyable by a person so that he/she is motivated to repeat the behaviour that got him/her the reward in the first place (Smith & Meyers 2004 p 135) Motivational interviewing A technique workers can use to assist people assess their own behaviour and desire to change. In CRAFT, workers can use the technique to motivate or encourage people to make decisions about their alcohol use. Brief motivational interviewing involves workers asking a person about their positive and negative experiences of alcohol. Workers then reflect this information back to the person so they can further explain their situation. 90
Useful Resources and Contacts Government Guidelines and Plans NHMRC Australian Alcohol Guidelines to Reduce Health Risk from Drinking Alcohol National Drug Strategy Aboriginal and Torres Strait Islander Peoples' Complementary Action Plan 2003-2009 National Drug Strategy: Aboriginal and Torres Strait Islander Peoples, Complementary Action Plan 2003-2009: background paper Canberra: Ministerial Council on Drug Strategy The Alcohol Treatment Guidelines for Indigenous Australian (2007) National Indigenous Drug and Alcohol Committee Strategic Plan 2007 -2010 Canberra: National Indigenous Drug and Alcohol Committee Reports Alcohol and other drug treatment services in Australia 200607: findings from the National Minimum Data Set Canberra: Australian Institute of Health and Welfare Australian Institute of Health and Welfare (2007) Statistics on drug use in Australia 2006 Canberra: Australian Institute of Health and Welfare Other Talking about alcohol with Aboriginal and Torres Strait Islander patients - revised edition
flipchart The Grog Book Revised Edition (2005) DVDs Alcohol DVD - Strong Spirit Strong Mind - what our people need to know about alcohol Web Sites http://www.healthinfonet.ecu.edu.au http://www.adca.org.au/ Alcohol and Other Drugs Council of Australia (ADCA) http://www.adf.org.au/ Australian Drug Foundation http://www.ancd.org.au/ Australian national Council on Drugs http://www.health.nsw.gov.au/public-health/dpb/about.htm Centre for Drugs and Alcohol http://ndri.curtin.edu.au/ National Drug Research Institute http://www.nidac.org.au/ National Indigenous Drug and Alcohol Committee http://ndarc.med.unsw.edu.au/ National Drug and Alcohol Research Centre 92
CRAFT Procedures Check List 1. Introducing CRAFT to the Family Member Workers introduce CRAFT and 1 Describe the CRAFT Goals 2 Provide a brief overview of CRAFT principles 3 Provide a brief overview of CRAFT procedures 4 Assist family member to complete baseline measures 5 Discuss family member's motivation to help relative 6 Briefly explain reason for involving family members in CRAFT & positive expectations 7 Outline family member responsibilities 8 Outline issues of confidentiality 9 Discuss family member's personal safety 10 Ask family member to identify their reinforcers 11 Ask family member to describe their relatives alcohol use and its effects 12 Enable family member to express feelings and thoughts 13 Begin identifying problem areas & shows understanding
2. Functional Analysis of a Relative's Alcohol Use Functional Analysis of Alcohol Use 1 Gives family member reason for Functional Analysis procedure 2 Asks family member to describe drinking episode 3 Asks family member to identify internal and external triggers 4 Asks family member to specify drinking behaviour during drinking episode (drinks what, how much, over what time) 5 Asks family member to describe short term positive consequences of relative's drinking 6 Asks family member to describe long term negative consequences of relative's drinking 7 Gives family member examples of how functional analysis information will be used.
Family Violence Precautions Worker.... 1 Uses non-judgmental approach to ask family member about family violence 2 Asks family member about & assesses level of violence 3 Discusses available support 4 Assesses need for additional support 5 Enables family member to express feelings and thoughts 6 Discusses safe responses to possible family violence e.g. women's refuge, extended family/friends 7 Discusses legal options e.g. AVO
3. Analysis of Relative's Violent Behaviour Worker... 1 Gives family member reason for Functional Analysis procedure 2 Asks family member to describe violent episode 3 Asks family member to identify internal and external triggers including `red flags' 4 Asks family member to specify behaviour during violent episode (what) 5 Asks family member to describe short term positive consequences of relative's violent behaviour 6 Asks family member to describe long term negative consequences of relative's violent behaviour 7 Gives family member examples of how functional analysis information will be used.
4. Happiness Scale Worker assesses Family Member's Wellbeing and... 1 Discuss with family members that all areas of their lives are important & reason for focus on family member's wellbeing 2 Assess family member's feelings and thoughts about different areas of their lives that are unrelated to their relative who drinks 3 Identify which areas of the family member's life needs attention 4 Explains to family members that information can be used to measure changes in their happiness over time 5 Explains to family members that information can be used to set goals and plan treatment 6. Goals for Counselling Worker supports family member to describe goals: 1 briefly and simply 2 in positive words describing what will be done 3 in specific measurable behaviours 4 that are reasonable and achievable 5 that they can control & are independent of their relative 6 that are based on their current or planned skills and knowledge 7 and complete the Goals for Counselling Form 8 and provides examples of new activities that can be trialled
7. Positive Communication Skills Worker supports family member and: 1 Discusses reasons why communication skills are important 2 Describes the 7 components of positive communication including: be brief, positive, refer to specific behaviour, label feelings, offer understanding statement, accept some responsibility, offer to help. 3 Gives examples of good and inadequate communication styles 4 Conducts a role play and provides feedback 5 Conducts a reverse role play
8. Positive Reinforcement. Worker... 1 Describes positive reinforcement and its role in CRAFT 2 Describes positive reinforcers as enjoyable, inexpensive, available to give, easy to offer 3 Describes the difference between enabling and positive reinforcement 4 Discusses family member's concerns about positive reinforcement 5 Discusses & supports family member to identify possible reinforcers available to use 6 Checked that family member can recognise when their relative has been drinking Assist family member to identify their relative's healthy enjoyable non drinking behaviour to reinforce Demonstrates linking a reinforcer to healthy behaviour using 7 steps of positive communication Checks possible complications resulting from reinforcer delivery
9. Functional Analysis of Non-Drinking Worker... 1 Gives family member reason for Functional Analysis procedure 2 Asks family member to give general description relative's enjoyable, healthy non-drinking behaviour 3 Asks family member to identify internal and external triggers for enjoyable, healthy non-drinking behaviour 4 Asks family member to specify relative's enjoyable, healthy non-drinking behaviour (what) 5 Asks family member to describe short term negative consequences of relative's enjoyable, healthy non-drinking behaviour 6 Asks family member to describe long term positive consequences of enjoyable, healthy non-drinking behaviour 7 Gives family member examples of how functional analysis information will be used.
10. Time Out from Positive Reinforcement Worker... 1 Gives family member reason for withdrawing reinforcers, rewards 2 Asks family member to name reinforcers for withdrawal using selection guidelines, e.g. safe, easy, valued etc. 3 Asks family member to demonstrate use of positive communication to explain the removal of a reinforcer & linking it to their relative's behaviour
11. Natural Consequences Worker... 1 Explores family member's unconscious support for their relative's drinking 2 Gives family member examples of unconscious support 3 Gives family member reasons for allowing natural consequences 4 Assists family member to choose one situation to use for allowing natural consequences 5 Asks family member family member to demonstrate verbally linking natural consequences with their relative's behaviour 6 Discusses possible difficulties that may result from family member allowing the natural consequences 12. Inviting a Relative into Treatment Worker assists the family member to... 1 identify appropriate motivational hooks for their relative 2 role play inviting their relative using the selected motivational hook and using positive communication 3 consider possible opportunities for extending the invitation into treatment 4 discuss possible treatment provider options 5 participating in organizing `rapid intake' 6 consider their relatives possible refusal or drop out from treatment 7 Demonstrate the use of other methods of inviting their relative into treatment e.g phone call during the session
13. Problem Solving Worker assists family member to use a problem solving worksheet to... 1 explore the components of a complex problem, breaking it down into its different parts/issues 2 choose one issue to address 3 suggest possible solutions 4 get rid of unwanted/unrealistic suggestions 5 choose one possible realistic achievable solution 6 identify possible obstacles to achieving the solution 7 plan a way to deal with each obstacle 8 decide on the problem solving action plan and do it 9 review and evaluate the outcome `
A Clifford, AP Shakeshaft, ACRAT Manual