When Your Patient's Partner Is a Drinker in Denial
Support groups and forced interventions aren't the only options to offer a client desperate to address a partner's overdrinking. The little-known CRAFT approach is a valuable toolkit.
It's part of every addiction therapist's routine. A frustrated woman calls you for advice: “My husband says he doesn’t have a drinking problem. But I’m getting desperate. Can you help?”
Many clinicians would refer her to Al-Anon or suggest a Johnson Institute intervention. Al-Anon is a free 12-step peer support group for families of problem drinkers. It offers support and coping skills, but it does not teach a family how to get the drinker to accept help. Al-Anon believes that only the drinker does that. Johnson Institute interventions work on the opposite premise that families (and employers) can influence the drinker. These well-planned interventions are surprise confrontations by those concerned to pressure a resistant drinker to get treatment.
There is a third approach available to you to address this problem. Family members often come to treatment expecting that the focus will be on the drinker. But CRAFT (Community Reinforcement and Family Training) is a set of treatment tools that work indirectly through a family member—often the drinker's partner—to persuade the drinker to get professional treatment. It changes the home environment by showing the partner how to avoid fighting over drinking; how to reward the drinker’s responsible behaviors; and how to withhold rewards when the drinker overuses. As the family member changes his or her behavior, the drinker notices. When this happens, the partner picks the best time and language for suggesting treatment.
CRAFT offers five main therapy tools:
1. Analyzing the drinking behavior. You help the family member identify both the triggers and the negative consequences of the drinker’s misuse. Then you help devise new response strategies designed to encourage safe use or abstinence.
Example: A client reported that his wife drank three nights a week until she fell asleep. Looking more closely at her behavior, he realized that her overdrinking took place only when she was alone at home after work for more than two hours. He used this data to start returning home earlier from work. On nights when this was impossible, he phoned her from his office to say hello and plan their evening together. This attentiveness cut her overdrinking episodes by 60%.
2. Positive reinforcement training. The family member identifies appropriate small rewards for the drinker’s responsible behavior. Then you teach the family member how to use these rewards to reinforce the drinker’s healthy activity.
Example: A client recalled that her husband loved running but had not entered any local races in years. She surprised him with a new pair of his favorite running shoes and signed him up for a race he had once enjoyed running. When he began training for the race, his alcohol consumption dropped by half and he did not have any problem drinking episodes.
3. Discouraging misusing behavior. You show your client how to withdraw reinforcement during and after periods of problem drinking and how to allow the negative consequences to play out. Then you teach problem-solving strategies to discourage misuse.
Example: The parents of a high school student had made many attempts to help him stop drinking. They noticed that they had gotten into the habit of making excuses for him when he got drunk on Friday nights and failed to make his Saturday school play rehearsals on time. They stopped calling the play’s director, and when their son found his role reduced as a result of his repeated lateness, he stopped drinking on Friday nights.
CRAFT changes the home environment by showing the partner how to avoid fighting over drinking, reward responsible behaviors and withhold rewards when the drinker overuses.
4. Family-member self-reinforcement training. You help your client identify areas for improving his or her own life. Then you jointly create a plan to address these areas and help the family member to choose reinforcers.
Example: In one case that lasted over five years, a woman returned to graduate school and changed careers, all the while using other aspects of CRAFT to induce changes in her husband’s heavy drinking. By the time she concluded that his drinking was not going to change, she felt sufficiently satisfied in her life that she initiated a divorce.
5. Suggesting treatment. You and the partner make prior arrangements with another therapist to immediately accept the drinker for treatment immediately and figure out the best time and manner to raise the topic with the drinker. You also help the family member to plan for a possible refusal of treatment.
Example: One client realized that her husband’s working relationship with his boss was going south. She suspected that her husband’s drinking played a role. She and her therapist lined up a psychologist for her husband who was qualified to coach him on these specific problems. When she brought it up, he jumped at the chance. A year later, his drinking had decreased and he had received a promotion.
CRAFT in Action
These abbreviated examples of CRAFT techniques may sound a bit too pat. To illustrate the complexities of working with the method, the following case study from my own practice shows CRAFT in detail. (The names have been changed.)
Laura, a pediatrician, was concerned about her husband, Greg, a former professional athlete and now a motivational speaker. Married seven years with two children and expecting their third, Laura said that she and Greg typically drank nonproblematically at two or three social occasions a month (except during her pregnancy). But four years earlier, when Greg began to lead seminars for sports teams, he also began to overdrink, about five times a year. Greg’s agent would call Laura to say that Greg would be late flying home because he had passed out in his hotel; or Greg would return with dried vomit on his shirt; or he would be unable to remember how he got home.
After Greg overdrank he was tearfully apologetic and would temporarily cut down. Laura was understandably upset. She had talked to Greg many times about this, and she was now experiencing symptoms of anxiety and depression.
Laura and I analyzed Greg’s episodes of problem drinking. I suggested that she stop expressing her distress to her husband. Then I recommended that she find a time to sit down with Greg for a calm and sympathetic talk. She would focus on his feelings (as she understood them): his stress at delivering motivational talks to sports teams and his distress when he subsequently got drunk. She would ask him how she could help him. Did he want her to accompany him on his trips?
Following this single talk, Greg avoided overdrinking for the next ten months. Then he relapsed, again after a sports talk. During this period, I helped Laura to withdraw unintentional reinforcers after Greg’s binges and to boost her own satisfaction with her life independent of Greg. When Greg had previously come home filthy or having blacked out or lost important personal items, Laura would comfort him, clean him up and make up an excuse for their children. Now she greeted him politely and then took herself and the children into another room—but without any fanfare.
At the same time, Laura decided to resume regular swimming. She had been a competitive backstroker in college but had not found time for swimming as an adult. She left her pediatrics practice and moved with Greg and their children to a university to do full-time research. She also started to mend her relationship with her mother.
Gradually, Laura began to feel less depressed and anxious. She asked for books to read about helping Greg. Then she started to leave the books around the house to pique Greg's curiosity.
Thus began a series of discussions between the couple over several weeks. Then Laura asked if Greg wanted to come—just one time—to therapy with her. He said no. But six weeks later, Greg told her that he had found a therapist and had met with her twice.
At present, Greg’s binges have decreased from five times to twice per year. He takes fewer contracts from sports teams, and he has started a new sport, bicycle racing. Laura reports that her relationship with Greg has changed in subtle but satisfying ways.
Greg found his own therapist without input from Laura or me. But it is far more common for a client to ask you to help locate the best-possible clinicians for his or her family member. One of the critical criteria is that the therapist is OK with a client's gradual reduction in use. If the drinker enters therapy and is quickly asked to attempt abstinence—with no possibility of alternatives—he or she is likely to experience the transition as a family betrayal. That is a big problem, since the single-strongest factor in creating and sustaining improvement is family support.
Most drinking problems grow gradually over the course of months or years. So you and your client cannot expect the drinker to turn on a dime once he or she is in treatment. Working with your client to adapt CRAFT’s tools to the drinker’s efforts at gaining control over his or her use lays the groundwork for the future.
Mark R. Edison, PhD, is an addiction psychologist who practices in New York City. He appears as a guest expert on SiriusXM’s national "Doctor Radio" show and chairs the Psychologically Healthy Workplace Awards committee of the New York State Psychological Association. He can be reached at firstname.lastname@example.org or through his website.