This article is reposted from www.williamwhitepapers.com with permission from the author. William White is the author of Slaying the Dragon: The History of Addiction Treatment and Recovery in America. His collected papers and interviews with leaders in the addictions field can be viewed at www.williamwhitepapers.com.
One of the major clinical innovations in the modern treatment of addiction is the community reinforcement approach and family training (CRAFT) intervention developed by Robert J. Meyers, PhD. CRAFT is an evidence-based, nonconfrontational approach that can be used by concerned significant others (CSOs) to promote help-seeking and recovery initiation for a family member experiencing alcohol- or other drug-related problems. I recently had the opportunity to interview Dr. Meyers about the development, evaluation, and future of CRAFT. Please join us in this engaging discussion.
Personal Background
Bill White: Dr. Meyers, you have a personal story related to your attraction and contributions to the addiction field. Could you begin by sharing that story?
Dr. Meyers: Sure. I think I was destined, in a way, to be in the addiction field. When I was a young child, my father had a horrible drinking problem, and my mother experienced depression and other types of problems related to that. My father wasn’t around to discipline me and my brother, so we ran wild. My mother tried to discipline us with a broom handle or a belt, and it became a real struggle for us to dodge her. I think the reason I was such a good wrestler in high school was because I was so used to scrambling around the floor on all fours and going in and out underneath tables to escape my mother’s tantrums. She died very young at the age of forty-five when I was only twenty-three. It was really hard on my family, particularly on one of my sisters who still lived at home as my father’s drinking worsened over time. By that time, I had escaped into the military. I joined the Navy to avoid going to Vietnam and, of course, that’s where they sent me.
The one thing I learned to do well in the military was use drugs. The home port for my first ship was in Alameda, near San Francisco, and in 1968 when I returned from Vietnam, I went down to Haight-Ashbury and started using drugs with my other shipmates. Before it was all over, I was really addicted to lots of different things. I used marijuana, downers, cocaine, and a variety of opiates. It got so bad, Bill, that when I got out of the Navy and went home, my parents wouldn’t let me stay at the house. They knew I was in crisis with using drugs, so they kicked me out. I was on the street at that point, just hanging out with friends and living with other people who did as many drugs as I did or more.
What then happened was that one New Year’s Eve, which was actually my birthday, I got so high I didn’t know where I was. I ended up running into a friend who said, “My God! You look horrible. What’s wrong? You look crazy.” I said, “I am. I’m scared. I’m using drugs and I don’t know what to do.” And he said, “Hey, you were in the military. I was in the military, too, and I’m going to school on the GI bill. Why don’t you do something like that?” And that’s actually how I started going to college. My first big discovery at school was that I wasn’t very good at anything. I had to get tutors for English and math because of those turbulent high school years. I ended up at Southern Illinois University for my BS and MS. While in the BA social work program, I had to do practicums and my first practicum was at an alcohol treatment center. I was offered and took a job in the addiction field before my BA was completed, but continued my school, completing my bachelor’s and master’s degrees.
Bill White: Your early description of entrance into the field just really intrigues me. We talk about multiple pathways of recovery within the field, but you’re describing a recovery pathway through a combination of epiphany and education. Did you see yourself or identify as a person in recovery at that point?
Dr. Meyers: On that New Year’s Eve, I woke up realizing that I was totally, absolutely out of control and scared. I knew I wasn’t going to do drugs anymore. I stopped doing drugs in this epiphany, “I can’t do this, I’m going to die.” I had no support system around me whatsoever. There was no support to understand a family ravaged by alcoholism, no support to understand being physically abused, no support to address all I had witnessed and experienced in Vietnam. I just turned my back on drugs and never told anybody about this once I started going to college. I had abused drugs. I probably was addicted and would have met several DSM categories. But I never talked about that all through my career until I retired from CASAA. I feared the stigma of the label and I didn’t want to be defined by my problem. I wanted to be defined as a person who was compassionate and a good therapist rather than have my past addiction define me. I was also afraid to tell anybody for fear that they would look at me in a different way or that the University might even find a way to fire me because of my history. At this point in my life, I can disclose this because I no longer worry about any of those things.
Bill White: It sounds like working in this field was part of your personal destiny.
Dr. Meyers: I was doing a free community workshop in Japan a year ago and one of my interpreters was a Maryknoll Japanese Catholic nun. There were about three hundred people at the community meeting, and it was real hot so I was sweating like a madman, and jet-lagged so I was telling some jokes and stories and the crowd really enjoyed themselves. When it was all over, the nun came walking toward me. I started to bow and she grabbed my neck and pulled me close to her and whispered in my ear, “Bob, this is your calling. You have to keep doing it.” It blew me away; I had to fight back tears. I understood very clearly that from a spiritual perspective, I had to do this. It was my calling.
Early State of the Field
Bill White: Take us back to the first program you worked in. What was it like?
Dr. Meyers: I first worked at a program with Dr. Mark Godley in a community alcohol program, and at one point we collaborated with Anna State Hospital in Southern Illinois. It was at Anna State that I met Dr. Nate Azrin and his team and first learned the community reinforcement approach (CRA) to alcoholism treatment. Mark and I, along with members of Dr. Azrin’s team, helped develop the first outpatient CRA program in the late 1970s. Working with Mark and Nate turned out to be one of the best things I ever did in my life because I really learned addiction treatment, and I learned it in a really positive way. In those days of confrontation within the larger field, I learned not to judge people and to try to find the positive parts of their life that could be built upon—a strength-based and recovery orientation before such language was used.
Bill White: How would you describe the larger field at the time you began working with Mark and Nate?
Dr. Meyers: When I first got into the field, it was dominated by AA. A lot of the people who were working with me at Anna State Hospital during my social work internship were people in recovery who had a long history of using drugs and alcohol. I always thought that was strange in that I was going to school to get a professional credential, but that most of the people I was learning from had no such credentials. Under the influence of Nate Azrin, I was learning about behavioral treatments and what would become behavioral therapy, and it seemed to me that this offered a technology of change beyond what the AA program offered. I believed that there were people who could do really well in AA—people who self-select AA and feel very comfortable in it. CRA and CRAFT are open to anything to help somebody get sober. Community reinforcement means that you use anything in the community to help people get sober and stay sober. The field I entered in the 1970s relied on AA and little else, and there was considerable tension as the field sought to integrate science-based interventions as an adjunct or alternative to AA. In those early years, I had to apologize for being a behaviorist and for not being an AA member, which is interesting since given my history, I could have easily been an AA or NA member.
The Roots of CRAFT
Bill White: How did the early work at Anna State Hospital heighten your interest in families?
Dr. Meyers: It first heightened my understanding of my own family and my own development. I began to understand my mother’s response to my father’s drinking problems. Once I started working with folks who were having problems with substance use, everything just started to click, and I got very interested in family responses to alcoholism. Working with Mark Godley doing community reinforcement for eight years was my training ground. Part of my work was doing the couples counseling section of the community reinforcement approach. As I progressed, I realized that the spouses had potentially far more influence over the drinker than one might expect. It was an influence I never saw growing up. I saw only the arguing and fighting about the drinking. As I worked with spouses, I began to wonder if we could work with spouses and help them learn strategies to get their partners into treatment. My colleagues were egging me on and saying, “You can do it. Let’s try it.” I would process working with the spouse with a colleague from Azrin’s lab named Bob Sisson. We would look at some of those cases and talk about how the CSO—usually a wife or family member—might be able to leverage help-seeking of their husband or other family member. CRAFT began when we started engaging the husbands in treatment through the efforts of their wives. This was all new stuff and we were doing it in the late 1970s and early 1980s.
Bill White: The development of CRAFT goes back much farther than I thought.
Dr. Meyers: Most people don’t know this early story. It began with Bob Sisson, Mark Godley, and I doing what we called the “Concerned Significant Others Program.” We started it, but didn’t have the wherewithal at that time to do anything like a clinical trial.
New Mexico and CASAA
Bill White: What was the next milestone in your career?
Dr. Meyers: After eight years into the work with Mark in Southern Illinois, I decided to move to New Mexico, where my brother and his family lived. There, I worked in different programs, including serving as director of a three-county mental health center, where I continued to develop addiction treatment services. Eventually, I was recruited to work as deputy director in what was then called “The Alcohol and Drug Programs of the Mental Health Center” of the University of New Mexico—later The Center on Alcoholism, Substance Abuse, and Addictions (CASAA)—run by the medical school and main campus.
One of the first people I met there was Dr. Bill Miller, who has become a lifelong friend and is one of the best human beings I’ve ever met in my life. The second time I ran into him, he said, “Hey, you’re that Bob Meyers that did that CRA study down there with Dr. Azrin, aren’t you?” When I acknowledged this past work, he asked if I was interested in writing a grant to study CRA, to which I quickly agreed. That was the beginning of our work together in 1987.
After some years at CASAA working with the medical school and main campus staff, there was a separation from the medical school, who took the treatment section out of CASAA and started a new program called Albuquerque Substance Abuse Programs or (ASAP), and left us researchers to continue on with the name CASAA. The medical school was on the north campus with the nursing school and the pharmacy school, while Bill and a lot of the people from psychology and sociology who contributed to what would continue to be CASAA were all from the main campus. There was a shuffle of deans and provosts and we ended up eventually divorcing the medical school to become CASAA. Bill Miller came on board full-time even though his affiliation was with the Department of Psychology. I switched to CASAA because I believed in Bill and what we were doing. In that process, I went from hard money onto soft grant money. That meant we were awarded grants or I wouldn’t have a job. I took a leap of faith going on to soft research money, but it did have a happy ending.
CASAA played an important role in the development of CRAFT. While we were still working on Project Match, I told Bill about working with families within what was then community reinforcement therapy (CRT). I still remember diagraming what CRAFT would look like as a clinical trial on a whiteboard in Bill’s office and Bill’s eyes lighting up. I could tell he was excited. By the next day, he’d already written a small proposal to the CASAA executive committee describing what he and I would like to do. We changed the title to CRAFT for the added family training component. They gave us the green light, and that’s how we started getting the CRAFT grants at CASAA.
Bill White: Now, the approach you and Bill Miller were proposing was still very different from the mainstream field at this point, correct?
Dr. Meyers: Absolutely. The mainstream family approaches were Al-Anon and the Johnson Institute model of intervention. In our first randomized controlled studies of CRAFT, the control groups that we used were Al-Anon and the Johnson Institute Intervention. The latter were the two helping models for families used by most treatment centers.
What Bill and I were trying to do was provide a broader range of treatment goals and methods to address the whole spectrum of alcohol and drug problems. In the field at that time, there was no alternative to the abstinence now and for life stance for all people seeking treatment. For example, when I first started at the state hospital in Anna, Illinois back in 1975, they said I had to say these words when I saw my client: “You’re in here because you’re an alcoholic and that means you can never, ever drink again as long as you live.” Now sometimes I was saying that to a twenty-five or thirty year-old young man who’s looking at you with that “You’ve got to be kidding me” expression on his face. There was no harm reduction perspective in those days, no incremental models of change, no models of client choice, and no alternatives to the confrontation approaches to therapy. I was convinced that we had to figure out ways to help people gravitate toward sobriety because they were finding things they liked about their life while not using rather than begrudgingly have abstinence forced on them by others. It would be nice if everyone with a drinking problem had a great epiphany—what Bill Miller called “quantum change”—and never drink again, but that’s not usually how it works, and small epiphanies can help people find things in their life that are meaningful and fun and exciting that do not involve alcohol and drug use. What we do in the treatments that I have helped develop over the years is help people find what things in their life that they can gravitate toward that will help them moderate or stop using alcohol and other drugs.
I’ve spent a lot of time in Europe, and the European countries have a greater harm reduction orientation than we see here in the US. They have more relaxed and flexible options for treating substance use disorders. Like there, I think sometimes we need to give people a little more slack as opposed to judging them for not immediately achieving the now and forever abstinent goal that we impose. I think it is clinical arrogance to see clients for an hour or so and then say, “Okay, you have to do X, Y, and Z.” I’ve suggested a much slower process of giving each client the opportunity to talk to us and help us learn from them about what approach might work best for them. After all, this process is about them, not about us.
The CRAFT Approach
Bill White: For readers unfamiliar with CRAFT, could you describe this approach?
Dr. Meyers: The CRAFT approach is based on trying to help family members learn more positive, effective ways to interact with one another. So, let’s just take a husband and a wife who have been married for ten years and have a certain way they interact with one another. If he’s been drinking copiously and getting in trouble, she likely has ways of discussing that with him that includes such things as getting angry and saying negative things about his drinking. What we teach family members to do in response to intoxication is to not yell or nag, but to say, “Well, I can see you’re having a hard time, Bill. I love you so much and it hurts me to see you this way. I think I need to go to bed now. We can talk in the morning if you want.” The goal is to disengage from the intoxication to eventually help extinguish this behavior. We’re not condemning them, we’re not judging them. We’re just explaining our own feelings—saying it hurts us and walking away. At the same time, we teach the spouse and other family members to reinforce the positive behavior when the husband comes home sober and in a good mood. The wife, without overdoing it, might say, “I understand it’s been difficult for you, but I think you look really great today. I love being with you when you haven’t been using.”
When the drinker or the drug user says to the wife, “What are you doing? Something’s different about you. What’s going on?” we teach them to say, “I’m going to therapy to help myself. I’m going to therapy to try to help our relationship and our family. We don’t bring up alcohol and drugs; we just talk about relationships.” Then, if he says, “Well, if you think I’m going to quit my drinking, forget about it,” she says, “You don’t have to do anything you don’t want to do or that you’re not ready to do, but I really would like you to visit my therapist once to see what we do down there.” The idea of having somebody come in one time to talk about whatever they want to talk about is quite different than saying, “You have to enter a thirty-day alcohol and drug treatment program.” The CRA approach avoids such extremes and often begins with a procedure called sobriety sampling and sampling of other alcohol and drug-free activities. CRAFT with family members dramatically increases the odds that the person with a substance use disorder will enter and sustain their involvement in treatment.
CRAFT Evaluation Studies
Bill White: And there have been several studies of CRAFT?
Dr. Meyers: Correct. Some were done by Bill Miller, Jane Smith, and myself and others from CASAA, and several studies of CRAFT have been done by other people, including the Treatment Research Institute in Philadelphia (TRI) and the Oregon Research Institute (ORI).
Bill White: Have there been any surprises related to who the CRAFT model works best with?
Dr. Meyers: There was one surprise. We found in our studies that mothers of adult children do extremely well at getting those individuals into treatment using CRAFT, which is very strange in that this was not our original target group for this approach. I see these mothers come in to our treatment programs and they’re depressed, they’re anxious, they’re angry, and they have a lot of negative physical symptoms, like migraine headaches, cramps, stomachaches, vomiting, and others. What our studies have shown us is that these symptoms decline through their participation in CRAFT and continue to decline after they leave treatment. A lot of women, Bill, come into our studies from around the world all thinking they did something wrong—that if they were a better mother or wife, their son or daughter or husband wouldn’t have this problem. The first thing CRAFT does is get rid of all those myths. We let them know how courageous they are for staying with and trying to support their family. We acknowledge their efforts and their fortitude. We make them feel good about themselves.
Over a period of time, by teaching them positive communication skills and helping them elicit support from friends, they shed the guilt and shame, and become effective change agents within their own families. Additionally, they break out of the isolation that guilt and shame produced. We teach them strategies about how to go out and reconnect with people in a positive way. The future health of the person with a substance use problem often begins in this way with the increased health of other family members.
CRAFT Dissemination
Bill White: Have you been surprised at the spread of CRAFT internationally?
Dr. Meyers: I have been amazed at how many times I’ve been to six of the seven continents over the last seven or eight years teaching the CRAFT program. I’ve been to Africa, Australia, Canada, Chile, England, Ireland, Japan, Germany, Scotland, the Netherlands, and Wales. For example, there are more trained CRAFT therapists in Ireland than there are in the entire United States. I conduct CRAFT training in the United States, but far less than I do in other countries. CRAFT hasn’t caught on in the US like it has in other countries.
Bill White: What do you think it’s going to take to implement CRAFT as a science-based practice in the United States?
Dr. Meyers: Well, I think things are starting to move in that direction. I’ve recently been contacted by Dr. Joseph Lee, Medical Director for Hazelden Betty Ford, to explore training their staff in CRAFT. I think if people see the Hazelden Betty Ford using CRAFT, and other prominent treatment centers adopting CRAFT that a wider adoption in the field could move rapidly. I think the treatment system in America has to start opening and broadening its approaches as opposed to staying with what we’ve been doing. We now have lots of great evidence-based protocols—most developed here in the United States. It’s time we started using them as standard practices in the field. We are even seeing legislatures and funding bodies demanding use of these practices. That will eventually increase the use of CRAFT.
Bill White: The popular media has been captivated by the drama of confrontation-style intervention, even with its questionable effectiveness. The fact that CRAFT is skill-based and lacks that drama seems to have prevented its acknowledgement in the popular culture.
Dr. Meyers: When CRAFT was first developed, it did get some coverage in the HBO special on addiction, and Oprah actually called, but I never did get on her show. Another person called—I won’t say what show it was—and wanted me to come and have the family member in one room and the addicted person in the other room in some hotel or whatever and have me run back and forth. My response was, “Look. I’m a scientist. I’m not going to prostitute my work and turn it into a circus so you can have a good show.” They hung up on me.
CRAFT Resources
Bill White: Could you highlight some of the key resources for training people in the CRAFT approach?
Dr. Meyers: Of course! All the major books on CRAFT are on my website (www.robertjmeyersphd.com). The one that many people find most useful is Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening. CRAFT is a very accessible method. For example, One of Bill Miller’s graduate students did a study for her dissertation comparing formal CRAFT group therapy with a group who just read Get Your Loved One Sober. They were followed up six months later, and the people who went to the CRAFT group therapy got 71 percent of their loved ones into treatment. What was surprising was that 40 percent of the people who just read the book also got their loved one to go to treatment. The folks from the Center for Motivation and Change in New York City wrote a book called Beyond Addiction that outlines CRAFT and motivational interviewing. They buy cases of Get Your Loved One Sober and give them to all their clients, including the parents of kids who are having trouble with substance use.
My wife Jane, who is chair of the Psychology Department at the University of New Mexico, and I wrote another book entitled Motivating Substance Abusers to Enter Treatment that is a therapist manual. It outlines all of the CRAFT protocols for therapists who want to learn the skills. The books can be supplemented by training and certification where therapists send us audiotapes of their sessions and we critique them using an over two-hundred-page coding manual and additional coaching of the therapist to improve their use of CRAFT. That has helped maintain fidelity to the CRAFT model.
The Future of CRAFT
Bill White: What do you see for the future of CRAFT?
Dr. Meyers: Well, right now I’m working with the Treatment Research Institute in Philadelphia and the Cadence Company to develop an online version of CRAFT. I’m very excited about having an online treatment program for CRAFT. Secondly, the Change Companies has asked me to do a CRAFT interactive journal, so we’ve started working on that. I’ve also written two veterans’ manuals with Bill Miller. They’re called the Coming Home Series and are for returning war veterans. I talk about my own story in this series. I feel I need to give something back to support this latest generation of veterans.
Career Reflections
Bill White: Dr. Meyers, as you look back over what to date has been a very long and productive career, what do you feel personally best about as you reflect on these years?
Dr. Meyers: Well, I feel very good about the fact that I kept climbing the ladder. I wasn’t the smartest or the best looking or the best at this or that, but I never stopped trying to find better ways to help people. I persevered in southern Illinois, and I have persevered here in New Mexico and with my work in other countries. I feel best about my contributions in developing adolescent CRA, outpatient CRA, and CRAFT. I found a way to do workshops and trainings around the world that are engaging and informative. I want to help all people affected by substance abuse wherever they may live.
Bill White: You are in a unique position to influence younger people entering the field or considering entering the field. What kind of advice or guidance would you offer to someone thinking about entering the field with hopes of having the kind of influence you have achieved?
Dr. Meyers: I get emails from young people and one of the things I miss the most about retiring from the university is working with young people. I think what young people need to do is to keep their eyes open, to be open to new innovations in treatment, but also to be critical and carefully evaluate what people are telling you to see how it works for you and those you are working with. Another thing I always tell young people is to be aware that you might be over your head doing something and to recognize that and get help from somebody else. Don’t think you can treat every single individual or help every single patient. It really takes more than that; it takes a lot of people to get it right. Do what you’re best at and if you find yourself in trouble, get somebody to help you or take over the case. Keep your eyes and ears open. Evaluate what’s going on and try different treatments. Use the innovations of others, but be yourself. And it’s okay to make a mistake, but it’s also important to find a mentor or supervisor to help you get it right the next time.
Bill White: Dr. Meyers, thank you for taking this time to reflect on your life and work.
Dr. Meyers: It’s been a pleasure, Bill.
Acknowledgements: Support for this interview series is provided by the Great Lakes Addiction Technology Transfer Center (ATTC) through a cooperative agreement from the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Substance Abuse Treatment (CSAT). The opinions expressed herein are the view of the authors and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA or CSAT.
Resources
Dutcher, L. W., Anderson, R., Moore, M., Luna-Anderson, C., Meyers, R. J., Delaney, H. D., & Smith, J. E. (2009). The community reinforcement and family training (CRAFT): An effectiveness study. Journal of Behavioral Analysis in Health, Sports, Fitness, and Medicine, 2(1), 80–90.
Kirby, K. C., Marlowe, D. B., Festinger, D. S., Garvey, K. A., & La Monaca, V. (1999). Community reinforcement training for family and significant others of drug abusers: A unilateral intervention to increase treatment entry of drug users. Drug and Alcohol Dependence, 56(1), 85–96.
Manuel, J. K., Austin, J. L., Miller, W. R., McCrady, B. S., Tonigan, J. S., Meyers, R. J., . . . Bogenschutz, M. P. (2012). Community reinforcement and family training: A pilot comparison of group and self-directed delivery. Journal of Substance Abuse Treatment, 43(1), 129–36.
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(3), 291–308.
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(5), 1182–5.
Meyers, R. J., & Wolfe, B. L. (2013). Get your loved one sober: Alternatives to nagging, pleading and threatening. Center City, MN: Hazelden.
Miller, W. R., Meyers, R. J., & Tonigan J. S. (1999). Engaging the unmotivated in treatment for alcohol problems: A comparison of three intervention strategies. Journal of Consulting and Clinical Psychology, 67(5), 688–97.
Smith, J. E., & Meyers, R. J. (2007). Motivating substance abusers to enter treatment: Working with family members. New York, NY: Guilford Press.
Waldron, H. B., Kern-Jones, S., Turner, C. W., Peterson, T. R., & Ozechowski, T. J. (2007). Engaging resistant adolescents in drug abuse treatment. Journal of Substance Abuse Treatment, 32(2), 133–42.