Julia E. Leschi
Substance abuse is a public health crisis, with around 20 million adults in the United States struggling with a substance use disorder in 2017 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018). One of the major issues hindering substance abuse recovery is that too few people enter treatment (Cunningham et al., 1993; Kessler et al., 2001; Wang et al., 2004). Of those who do, there is often a treatment delay of at least a decade after identification of the substance use problem, and many do not complete treatment (Cunningham et al., 1993; Kessler et al., 2001; Wang et al., 2004). Research has identified motivation to change as one of the most reliable indicators of treatment readiness and engagement (De Leon et al., 1999; Heather et al., 1993; Hiller et al., 2002). Motivation to change evolves in five stages: pre-contemplation, contemplation, preparation, action, and maintenance (Prochaska & Diclemente, 1984). Where a patient is situated on this continuum at treatment entry has been linked to treatment outcomes and dropout rates (DiClemente et al., 2004; Heather et al., 1993; Klag et al., 2010; Simpson et al., 2002; Simpson et al., 1993). Thus, learning more about the factors leading to an increase in motivation to change is an important step in trying to improve the success of substance abuse treatment.
Families can play an important role in helping loved ones pursue treatment. Research has found that family support plays a considerable role in preventing substance use and in supporting recovering users following treatment (Dishion et al., 2003; Kumpfer et al., 2003). Expressed concern from one’s social network has also been found to greatly increase the likelihood of someone committing to treatment, reinforcing the impact family and friends can have on someone’s desire and ability to change (Pollini et al., 2006; Rapp et al., 2007). These findings all point towards the importance of families in tackling substance use issues, yet few studies have directly explored the association between family support and treatment entry.
Community Reinforcement and Family Training (CRAFT; Meyers & Wolfe, 2004), an intervention program highlighting the use of positive reinforcement from family members (referred to as Concerned Significant Others [CSO]) to get loved ones (referred to as Individual Patients [IP]) into treatment, has shown great promise in recent years (Brigham et al., 2014; Meyers et al., 2002; Roozen et al., 2010). CRAFT is a behavioral intervention aiming to both improve the CSO’s wellbeing and promote the IP’s treatment entry by transforming the IP’s environment (Kirby et al., 2017; Meyers et al., 2011). This happens through changes in the CSO’s communication, the use of positive reinforcement for sober behaviors, and a reduction of the CSO interfering with the consequences of substance use, among others (Meyers et al., 2011). CRAFT has been shown to be significantly more effective at engaging treatment-resistant loved ones than traditional approaches taught in Al-Anon Family Groups, a popular 12-step program for family members and loved ones of substance abusers, which encourages family members to detach from their loved ones and accept their powerlessness in the face of the loved one’s illness (Brigham et al., 2014; Meyers et al., 2002; Roozen et al., 2010). The mechanisms through which CRAFT functions have scarcely been researched, but existing studies suggest that family support and motivation to change could play a significant mediating role (Dishion et al., 2003; Kumpfer et al., 2003; Meyers et al., 2011), since the CRAFT approach depends on the IP having a relationship with their family, and aims to push the IP to seek treatment of their own volition.
The association between family support, motivation to change, and treatment entry must be further researched so that families can further help the recovery of their loved ones. Hence, this study proposes to address the following research questions: What are the differential effects of CRAFT and Al-Anon on family support and motivation to change for individuals struggling with substance use disorders? To what extent is the effect of CRAFT (vs. Al-Anon) on SUD treatment entry mediated by levels of family support and motivation to change?
Proposed Method
Participants
The proposed study will include 300 substance-abusing individuals and their CSOs. All participants will be over 18 years old. CSOs should be a direct relative, spouse, or cohabitating romantic partner of the IP who is in regular contact with the IP. Participating substance users will fit the diagnostic criteria for a DSM-V Substance Use Disorder and not be in therapy or receiving pharmaceutical treatment for addiction. The sample will aim to be as representative of the general population as possible in terms of gender, education level, socioeconomic status, race and ethnicity.
Procedure
Participating CSOs and IPs will be recruited through flyers inviting family members of treatment-resistant substance abusers to participate in a six-month long treatment program, posted in community spaces of towns located in counties with high rates of drug use, as well as on Facebook groups for loved ones of substance abusers. In order to only include CSOs of treatment-resistant IPs, CSOs will be asked their IP’s hypothetical reaction to being asked to enter treatment. CSOs will be excluded if they answer that the IP would already be interested and open to treatment. Participating CSOs will be randomly assigned to either CRAFT, an approach that seeks to transform the IP’s behavior through the family, or Al-Anon therapy, focused on detaching the family from the IP. When their family members commit to the program, IPs will fill out demographics and baseline measures of family support (Multidimensional Scale of Perceived Social Support, or MSPSS), motivation to change (Stages of Change Readiness and Treatment Eagerness Scale, or SOCRATES-8), severity of substance use (Drug Abuse Screening Test, or DAST) and psychological wellbeing to account for variation in depression and anxiety at baseline (Depression and Anxiety Stress Scale, or DASS-21).
The CRAFT group will meet once a week for six months with a licensed therapist trained in CRAFT who will teach them the primary components of CRAFT: how to identify a loved one’s triggers to use substances, positive communication strategies and reinforcement strategies, identifying appropriate times and ways to suggest treatment, and self-care practices (Kirby et al., 2017). The Al-Anon group will meet at the same frequency with a licensed counselor with a 12-step orientation reflecting Al-Anon’s philosophy. For both groups, if at any point the IP expresses desire to enter treatment, researchers will schedule the IP’s intake session within the next 72 hours, at which point the IP will once again fill out the baseline measures. Entering treatment is operationalized as having completed the intake measures and attended at least three individual treatment sessions. If the IP never expresses interest in treatment, they will fill out the measures again at the end of the study. Referrals to local mental health providers will be shared with all participants so that they may continue or begin to receive therapy after termination of the study. Information about open support groups and psychoeducation materials on substance use disorders will also be available.
Measures
Drug Abuse Screening Test (DAST). The DAST is a 28-item self-report measure for drug use. Research has established the DAST’s high internal reliability (α = .92). Validity was assessed by correlating the DAST with documented frequency of drug use in the last year (p < .05; Skinner, 1982).
Depression and Anxiety Stress Scale – Short Form (DASS-21). The DASS-21 is a 21-item instrument comprised of three reliable subscales measuring depression (α = .88), anxiety (α = .82), and stress (α = .90). The composite score (i.e., combining each of the subscales scores) has also been found to have strong s reliability (α = .93; Lovibond & Lovibond, 1995). The DASS-21 dimensions are correlated (all ps < .01) to the appropriate Positive Negative Affect Schedule (PANAS; Watson et al., 1988) dimensions, demonstrating high construct validity.
Multidimensional Scale of Perceived Social Support (MSPSS). The MSPSS is a 12-item self-report instrument assessing perceived social support from family, friends, and significant others on a seven point Likert-type scale from “Very Strongly Disagree” to “Very Strongly Agree.” Research has found the MSPSS has good internal reliability (α = .88), and moderate construct validity, with the scale being significantly correlated to depression (r = -.25, p < .01; Zimet el al., 1988).
Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES-8). The SOCRATES-8 is a 19-item instrument used to assess change readiness and treatment eagerness in substance users (Miller & Tonigan, 1996). It is scored on a five point Likert scale from “Strongly Disagree” to “Strongly Agree”, and is composed of three dimensions of Recognition, Ambivalence, and Taking Steps. Miller and Tonnigan (1996) found the internal reliability of the SOCRATES-8 to range from 0.85–0.95 for Recognition; 0.60–0.88 for Ambivalence; and 0.83–0.96 for Taking Steps (as cited in Abiola et al., 2015).
Data Analytic Plan
Two regressions will be run to explore whether participation in CRAFT leads to greater changes in perceived family support and motivation to change than Al-Anon (IV: experimental condition; DVs: family support, motivation to change). Baron and Kenny’s (1986) approach will then be followed to test the mediation hypotheses. We will use a logistic regression to show whether CRAFT is correlated with treatment entry status (C pathway), and a linear regression to show whether CRAFT is correlated with family support/motivation to change (A pathway). Then, both CRAFT and family support/motivation to change will be entered as predictors in a last logistic regression to see if the total effect of CRAFT on treatment entry diminishes when controlling for family support/motivation to change (B and C’ pathways). Sobel’s tests will be run to establish if the mediation effects are significant. Covariates (i.e., demographics, depression and anxiety levels, baseline severity of substance use) will be controlled for throughout.
Discussion
Although there is a great deal of research assessing CRAFT’s rates of successful treatment engagement compared to other popular programs for families of substance abusers (Meyers et al., 2011), there are no published studies investigating the steps through which CRAFT is effective. Hence, the proposed study would help fill a gap in the literature. However, this study will be limited by certain selection factors. Indeed, IPs who volunteer to participate in this research study may already be more motivated to change, and therefore to enter treatment, than the general population of substance users. This threatens the study’s external reliability and the generalizability of the findings. Furthermore, the least motivated study participants are more likely to drop out before the end of the study, which could skew the results. Assessing motivation to change levels at baseline will enable partial control for this. Additionally, this study should be adapted to look specifically at group and family-oriented populations, such as Hispanic/Latinx or East-Asian individuals (Corrigan & Lee, 202; Sabogal et al., 1987; Villatoro et al., 2014). These different family dynamics could make CRAFT even more effective, or, on the contrary, more difficult to implement. It is important to investigate if interventions research has deemed successful in the past remain so across ethnic groups.
Understanding how family support and motivation for change influence the efficacy of CRAFT could help improve other interventions’s success rates for treatment entry, strengthening other programs aimed at getting substance abusers to commit to treatment. Demonstrating the importance of family support in relation to treatment entry has implications for research to explore how it could play a role in other treatment modalities, building upon the literature that has explored family support as a tool for addiction prevention or maintaining recovery (Dishion et al., 2003; Kumpfer et al., 2003; Pollini et al., 2006; Rapp et al., 2007). Identifying mediators can also make CRAFT more cost-effective and, therefore, more broadly accessible to the millions of individuals struggling with addiction and their families suffering by proxy, lightening the burden of care.
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