The Family Journal

The Family Journal http://tfj.sagepub.com/

Evidence-Based Approaches for the Treatment of Substance Abusers by Involving Family Members Robert J. Meyers, Timothy R. Apodaca, Sharon M. Flicker and Natasha Slesnick The Family Journal 2002 10: 281 DOI: 10.1177/10680702010003004 The online version of this article can be found at: http://tfj.sagepub.com/content/10/3/281

Published by: http://www.sagepublications.com

On behalf of:

International Association of Marriage and Family Counselors

Additional services and information for The Family Journal can be found at: Email Alerts: http://tfj.sagepub.com/cgi/alerts Subscriptions: http://tfj.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations: http://tfj.sagepub.com/content/10/3/281.refs.html

>> Version of Record - Jul 1, 2002 What is This?

Downloaded from tfj.sagepub.com at Moshi University on October 11, 2013

JOURNAL: COUNSELING Meyers THE FAMILY et al. / EVIDENCE-BASED TREATMENTS AND THERAPY FOR COUPLES AND FAMILIES / July 2002

Evidence-Based Approaches for the Treatment of Substance Abusers by Involving Family Members Robert J. Meyers Timothy R. Apodaca Sharon M. Flicker Natasha Slesnick Center on Alcoholism, Substance Abuse and Addictions and University of New Mexico

There is now a variety of replicable, empirically supported familybased treatments for substance use disorders. Unfortunately, the gap between evidence-based substance abuse treatment methods and treatment as usual remains wide. Disseminating evidence-based treatments into practice is of obvious importance as the overall effectiveness of health care depends on transferring best practices into routine standards of care. This article seeks to identify empirically supported interventions to substance use so that practitioners may then seek further information or training in one or more of these modalities. Three approaches to involving family members in substance abuse treatment are identified: community reinforcement and family training, marital/couples therapy, and family therapy.

A

lcohol and drug abuse incurs tremendous social costs, yet our society continues to be at odds on how to best alleviate problems caused by substance abuse. Unfortunately, the gap between science and practice continues to grow despite impressive research progress made in the addictions field. Many treatment programs use techniques and strategies that have little, if any, empirical corroboration (Miller & Hester, 1995). It has been widely acknowledged in the substance abuse treatment field that there is a discrepancy between the most commonly provided treatments and those with the strongest evidence for effectiveness (Holder, Longabaugh, Miller, & Rubonis, 1991; Miller & Hester, 1986). McCrady (1991) pointed out that in many cases, the therapist’s own clinical experiences govern his or her beliefs about treatment. Couples and family therapy requires special training, which requires time and financial resources that many agencies and/or therapists are unable or unwilling to provide. Without empirical validation of treatment outcome, many therapists may believe that the therapy they provide is effective, and therefore, there is no need for additional

training in new protocols. In part, due to these factors, integration of empirically tested treatments into practice remains difficult. Although psychological and biological research and treatments have been one major focus of research, the study of social and environmental factors has also been shown to be important in bringing about positive changes in substance use behaviors. Recent meta-analyses of alcoholism treatment outcome literature have pointed to several treatment modalities that are consistently shown to be among the most empirically effective (Finney & Monahan, 1996; Holder et al., 1991; Miller et al., 1995; Stanton & Shadish, 1997). Marital and family therapy and the community reinforcement approach (CRA) are among the top five treatments in one or more of these meta-analyses. In addition, family therapy has been found to be particularly effective at engagement and retention of problem drinkers, as well as adolescent substance abusers (Waldron, 1997). Please see Table 1 for a listing of all topranked treatments in these meta-analyses. Findings from these analyses clearly indicate the importance of involving significant others and family members of individuals suffering from substance abuse problems in treatment. We will focus on three approaches to involving family members: the community reinforcement and family training (CRAFT) approach, marital/couples therapy, and family therapy. First, we will review the theoretical rationale behind using each of these approaches. Next, we will highlight the effectiveness of these three treatment modalities in engagement, retention, and treatment outcome, with particular emphasis on the population for which each approach is most effective. CRAFT works to engage treatment-refusing substance abusers into treatment (Meyers, Miller, Hill, & Tonigan, 1999; Miller, Meyers, & Tonigan, 1999). Marital

THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES, Vol. 10 No. 3, July 2002 © 2002 Sage Publications

281-288

281

282

THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES / July 2002

TABLE 1 Top-Ranked Treatments in Three Recent Meta-Analyses Rank

Holder, Longabaugh, Miller, and Rubonis (1991)

1 2 3 4 5 6

Social skills training Self-control training Brief motivational counseling Behavioral marital therapy CRA Stress management training

Miller et al. (1995) Brief intervention Social skills training Motivational enhancement CRA Behavior contracting Aversion therapy

Finney and Monahan (1996) CRA Social skills training Behavioral marital therapy Disulfiram implants Marital therapy, other Stress management training

NOTE: CRA = community reinforcement approach.

therapy has proven effectiveness with adult alcoholics (Meyers & Smith, 1997). Family therapy seems most appropriate for use with teenage substance abusers. These three approaches were chosen because they have been rigorously evaluated and have been identified as effective in metaanalyses for the treatment of substance abuse problems (Finney & Monahan, 1996; Miller et al., 1995; Stanton & Shadish, 1997). CRAFT Clinical research in the area of helping family members of substance abusers was initially sparse but has been on the increase during the past 20 years. Because the vast majority of active substance abusers do not seek treatment, it is important to have an effective way of engaging them into treatment. Community mental health centers, substance abuse agencies, as well as hospitals and clinics receive calls from distressed family members looking for information on how to help substance abusers. Traditionally, assistance for family members has been limited to an Al-Anon–based (1965) approach and the Johnson Institute intervention (Johnson, 1986). Known as the intervention, this surprise meeting entails having the drinker confronted by loved ones about his or her alcohol use and all of the problems created by it (Johnson, 1986). Today, there are many interventions that have shown to be effective at engaging substance abusers without confrontation. Importantly, the behavioral program called CRA (Azrin, Sisson, Meyers, & Godley, 1982; Hunt & Azrin, 1973) always operated with a different view of the role that a concerned significant other (CSO) could play in the treatment of substance abuse. For example, CRA has been shown to successfully enlist CSOs as disulfiram (alcohol-deterrent drug that induces extreme physical upset if alcohol is ingested while on the prescribed medication) monitors, partners in marital counseling, active agents in resocialization and reinforcement programs, and detection monitors for relapse (Azrin, 1976; Azrin et al., 1982; Hunt & Azrin, 1973; Smith, Meyers, & Delaney, 1998). The related CRAFT program was developed with the belief that because family members (CSOs) can make important contributions in other areas of

treatment, they can play a powerful role in helping to engage a resistant loved one into therapy. The CRAFT program further believes that most CSOs can benefit from counseling that teaches them to become more independent and to take better care of themselves. CRAFT uses an overall positive approach and disavows the use of confrontation. The program is similar to CRA in that it emphasizes learning new skills to cope with old problems. In fact, many of the actual skills-training strategies used in CRA are also used in CRAFT (Meyers & Smith, 1995). Some of CRAFT’s basic components include discussing personal safety issues, outlining the context in which substanceabusing behaviors occur, teaching CSOs how to use positive reinforcers for both the substance user and themselves, and emphasizing lifestyle changes for the CSO. Thus, CRAFT emerged as a means to engage treatment-refusing substance abusers, through a CSO. CRAFT is a unique type of unilateral family therapy that does not rely on confrontation. CSOs meet alone with the therapist and receive behavioral skills training designed to influence the identified patient’s use, with the ultimate goal for the identified patient to enter treatment. Implementation of CRAFT procedures requires specific training in the approach and may be conducted by licensed therapists with a variety of educational backgrounds (e.g., licensed marriage and family therapist, licensed professional clinical counselor, Ph.D., licensed independent social worker). Marital/Couples Therapy It is well established that problem drinking is correlated with marital discord (O’Farrell, 1995). Problem drinking in one spouse is associated with higher rates of psychological and physical problems among nondrinking spouses (Moos, Finney, & Gamble, 1985), as well as higher rates of marital aggression, separation, and divorce (Kantor & Strauss, 1990; Leonard & Jacob, 1988). Including spouses in the treatment of alcoholics can help ameliorate the negative impact of the alcoholics’ drinking on the spouses’ lives. Marital factors are also thought to contribute to the development and maintenance of alcohol problems (O’Farrell,

Meyers et al. / EVIDENCE-BASED TREATMENTS

283

ease. The alcoholism is viewed as a pro1995). O’Farrell (1993) concluded that gressive disease, and family members problematic marital interactions appear of the alcoholic are thought to suffer to stimulate drinking, or to instigate from codependency. Alcoholics and renewed drinking in abstinent alcoholics. This article discusses codependents are treated separately, In one study, alcoholics most frequently wherein family members receive educacited marital events and factors involving empirical evidence tion about alcoholism and codependency, the spouse as the cause of relapse as well as well as individual or group therapy to as the reason for ending the relapse epithat suggests certain improve their own psychological wellsode (Maisto, O’Farrell, Connors, being (McCrady, 1989). McKay, & Pelcovitz, 1988). treatments are more Most family therapy approaches for By including nondrinking spouses of adolescent substance abuse arose out of alcoholics in treatment, therapists hope to productive than family systems theory. Family systems change these maladaptive marital pattheory views substance use behavior as a terns and thereby decrease drinking. others. symptom of the family’s dysfunction Drinkers are often shielded from the natu(Stanton et al., 1982). The presence or rally occurring negative consequences of absence of alcohol or drugs becomes the their drinking by their spouses. By learndefining factor in family interactions. ing how to avoid making the conseSystems theorists hypothesize that as family members adapt quences less aversive or even unintentionally rewarding the to the substance use behavior, they also serve to help maintain drinking behavior, spouses are able to play an important role the substance use. Family systems theory further proposes in the recovery process (Noel & McCrady, 1993). In addition, that individual behaviors occur not in isolation but in the coneven if the marriage does not appear dysfunctional, improvtext of the system in which the individuals find themselves ing the relationship can increase motivation of both spouses (Szapocznik & Kurtines, 1989). Therapy is conducted with to change their drinking-related behaviors (Noel & McCrady, the entire family, to redefine members’ roles, restructure alli1993). ances, and change patterns of communication (McCrady, Spouses also have the potential to make valuable contribu1989). tions throughout the therapy process. Nonalcoholic partners Finally, behavioral family theorists suggest that substance may provide essential information, constructive feedback, abusers from happy families with good communication are and support to the clients (Zweben & Barrett, 1993). Spouses less likely to relapse. Behavioral therapists work with the help the clients to identify high-risk situations and recognize alcoholic and his or her family to build support for sobriety the powerful impact of the situation (McCrady, 1993). In and increase relationship cohesiveness. Family members addition, spouses may be able to prompt coping responses learn communication skills and techniques to reward the when the drinker is having difficulty doing so in high-risk sitdrinkers’ sobriety. According to O’Farrell (1992, 1993), uations (McCrady, 1993). although the family disease and family systems models are Family Therapy popular and influential, their effectiveness has not been as systematically tested as has the behavioral family therapy Family therapy as a treatment for substance abuse has approach. grown in popularity and acceptance over the past two decades. Researchers have reported that addiction often EFFECTIVENESS develops within a family context and can be maintained or worsened by family interactive processes (Heath & Stanton, CRAFT 1998). Problems such as substance abuse are seen as CRA has proven effectiveness with adult substance abusmaladaptive behaviors that reflect dysfunction in the family ers in terms of fewer drinking days, less divorce and separasystem as a whole (Stanton, Todd, & Associates, 1982). As tion, fewer hospitalization days, and more employment days such, many researchers and clinicians consider family ther(Meyers & Smith, 1995). CRA has emerged as an effective apy to be an essential element in successful substance abuse treatment modality by which to engage resistant adult subtreatment and relapse prevention. However, the method of stance abusers into treatment through a CSO. In addition, a intervening with the family differs depending on the cliniclinical trial is currently underway to further evaluate its cian’s theoretical orientation. effectiveness at engaging resistant adolescent substance In general, three major approaches to family treatment of abusers. alcoholism have emerged: family disease model, family sysSisson and Azrin (1986) conducted the first randomized tems theory, and behavioral family theory (McCrady & study examining the viability of using community-based Epstein, 1996). The family disease model proposes that both reinforcement procedures with a problem drinker’s CSO. the problem drinker and his or her family members have a dis-

284


They randomly assigned 12 CSOs to receive either an early version of CRAFT (community reinforcement training [CRT]) or a disease model/Al-Anon approach. In the CRT condition, 6 of 7 resistant alcoholics entered treatment after a mean of 58.2 days and an average of 7.2 CSO sessions. Interestingly, the drinkers already had reduced their mean consumption by more than half by the time they started the program. In contrast, none of the Al-Anon group’s drinkers sought treatment. In a recent trial funded by the National Institute on Alcohol Abuse and Alcoholism, 130 CSOs were randomly assigned into one of three different engagement approaches: (a) AlAnon facilitation therapy, which was designed to encourage involvement in the 12-step program and to get resistant drinkers to enter formal treatment; (b) a Johnson Institute intervention, which prepared the CSO for a confrontational family meeting that led to formal treatment; or (c) the CRAFT approach, which taught behavioral change skills and new strategies for guiding the drinker into treatment. All three therapies were manual based and consisted of 12 hours of planned contact. The CRAFT approach was significantly more effective in engaging resistant problem drinkers into treatment (64%) as compared with the more commonly used Al-Anon (13%) and Johnson Institute (30%) interventions (Miller et al., 1999). In a second randomized clinical trial, 90 CSOs of illicit drug users were randomly assigned to one of three treatments: (a) the CRAFT approach alone, which teaches behavior change skills in an individual format; (b) CRAFT with additional group sessions after the completion of the individual sessions; or (c) Al-Anon/Nar-Anon facilitation in an individual format. All sessions were manual guided, with 12 hours of therapist contact. Excellent follow-up rates were achieved. CRAFT alone engaged 58.6% identified patients, CRAFT with group engaged 76.7%, and Al-Anon/Nar-Anon facilitation engaged 29.0%. In addition, CSOs in all conditions showed similar prereduction/postreduction in depression and increased family functioning (Meyers, Miller, Smith, & Tonigan, in press). Marital/Couples Therapy Marital/couples therapy has been most often investigated and found to be particularly successful in the treatment of adult problem drinkers. After a comprehensive review of the literature concerning marital and family treatment of alcohol problems, O’Farrell (1995) concluded that marital treatment produces better outcomes than individual treatment during the 12 months immediately following termination of treatment. Evidence continues to accumulate showing that marital treatment helps stabilize marital relationships and supports improvements in alcoholics’abstinence during that same time period. Two studies have shown that behavioral marital therapy (BMT), with both an alcohol and relationship focus, may

reduce marital and/or drinking deterioration during longterm recovery better than individually focused treatment. Investigating behavioral couples therapy (BCT), O’Farrell, Cutter, and Floyd (1985) randomly assigned 36 married couples, in which the husbands had recently begun individual alcohol treatment, to one of three conditions. These conditions were (a) no marital therapy control group (individual alcohol counseling); (b) BCT group, including use of Antabuse, plus individual alcohol treatment (BMT); and (c) an interactional couples therapy (ICT) group that included mutual support, emotional expression, group problem solving, and provision of insight by the therapist and other group members, plus individual alcohol treatment (ICT). The ICT condition was less structured and specified than the BMT condition and did not include commonly used behavioral techniques. For marital adjustment, BMT participants significantly improved on a variety of measures from pretreatment to posttreatment and remained significantly improved at follow-up. ICT couples also improved on several measures from pretreatment to posttreatment but did not maintain all of these changes at follow-up. These outcomes were both better than the control group, which did not improve on any measures. The authors concluded that adding BMT to outpatient alcoholism treatment is superior to no marital treatment and equal to or superior to ICT, a frequently used alternative marital treatment. O’Farrell, Cutter, Choquette, Floyd, and Bayog (1992) later found that BMT couples remained significantly improved on marital and drinking outcomes (71% days abstinent) throughout the 2-year follow-up and continued to show better marital and drinking outcomes than the control group (63% days abstinent) throughout the 2 years as well. McCrady et al. (1986) compared 53 alcoholics who received either minimal spouse involvement (MSI) treatment in which the spouses observed the alcoholics’ individual therapy, alcohol-focused spouse involvement (AFSI) in which the spouse was taught specific skills to deal with alcohol-related situations plus the MSI condition, or AFSI plus BMT (ABMT), which included the MSI and AFSI conditions plus BMT. At the 6-month follow-up, all participants had decreased their drinking and reported increased life satisfaction. ABMT participants were more likely to stay in treatment and maintained their marital satisfaction better after treatment ended than MSI participants. At the 18-month followup, ABMT participants had better drinking outcomes, fewer marital separations, and more improvement in marital satisfaction and subjective well-being than either of the other groups (McCrady, Stout, Noel, Abrams, & Nelson, 1991). Winters, Fals-Stewart, O’Farrell, Birchler, and Kelley (in press) examined BCT compared to individual-based treatment alone for female drug-abusing patients. At 1-year posttreatment, women receiving BCT had significantly more abstinent days and higher relationship functioning scores. Fals-Stewart and O’Farrell (1999) assigned 80 married/ cohabiting men with opioid addiction to either BCT plus indi-


vidual treatment or individual treatment only. Again at 1-year follow-up, those receiving BCT had significantly more abstinent days and fewer drug-related legal and family problems than those who received individual treatment. Marital/couples treatment has shown evidence of efficacy in the treatment of alcohol problems, often demonstrating more evidence of efficacy than individual treatments. BMT appears to be particularly promising. Family Therapy Research generally supports the effectiveness of family involvement at engagement and retention (Noel, McCrady, Stout, & Fisher-Nelson, 1987; Pinsoff & Wynne, 1995). Regarding treatment outcome, there have been more studies examining the effectiveness of family therapy for adolescent as opposed to adult substance abusers. In general, two factors seem to converge to make family treatment for substance abuse more efficacious for adolescents than for adults. First, adolescents usually live with their families of origin. Second, adolescent substance abusers have not been abusing as long as most adult abusers, and the family may be more motivated to help them to change (Pinsoff & Wynne, 1995). Empirical evidence supports the efficacy of family therapy to treat adolescent substance abusers. Two studies of behavioral family therapy have found family therapy to produce greater substance use reductions than non-family-based interventions (Azrin, Donohue, Besalel, Kogan, & Acierno, 1994; Bry & Krinsley, 1992). A third study compared family systems therapy, family drug education, and adolescent group therapy in treating adolescent substance abusers (Joanning, Thomas, Quinn, & Mullen, 1992). Results at posttreatment showed abstinence in 54% of adolescents receiving family therapy, compared to 29% in the family education condition and 17% in group therapy. Henggeler and Borduin (1995) and Liddle (1995) noted that, when dealing with complex social systems that have significant alcohol/drug and related clinical problems, a highly specified treatment approach cannot provide the flexibility that is needed to optimize therapeutic outcome. They noted that therapists must conceptualize behavior problems within a framework that considers the multidimensional nature of the problems, and interventions must be conducted directly in the systems that have been targeted for change. Multidimensional family therapy (MDFT) has been developed and tested over the past 15 years in randomized clinical trials at a variety of different locations in the United States with a population comprising ethnically diverse adolescents with a wide range in problem severity (Liddle, 1999). MDFT has been compared to adolescent group therapy and a family education group in a treatment outcome study. Although all three conditions showed reduced substance use, the greatest and most consistent improvement was found in the MDFT condition (Liddle et al., 1993).

285

Although more support exists for the use of family therapy to treat adolescent substance abuse, there is some evidence for the effectiveness of family therapy to treat adult substance abusers. Recently, Stanton and Shadish (1997) conducted a meta-analysis of 13 studies that compared family therapy to nonfamily treatment, both with adolescents and adults. They found family therapy produced significantly better outcomes than non-family-oriented individual counseling, peer group therapy, and various forms of treatment as usual (e.g., agency provided individual or group counseling). Other researchers have found that adding a family intervention component to individual counseling and methadone maintenance led to improved outcomes for adult heroin abusers (McLellan, Arndt, Metzger, Woody, & O’Brien, 1993; Stanton et al., 1982). Finally, Edwards and Steinglass (1995) reported that family-involved treatments are effective at engaging adult alcoholics to enter treatment. Evaluating across four studies involving some form of family treatment, these authors reported alcoholics with a family member involved in some intervention entered treatment at an average rate of 73%, compared to an average rate of 12% engagement for alcoholics without a family member involved in the intervention. They examined the percentage of reduction in drinking and found that those involved in family-based treatment had an average 58% reduction in drinking, as compared to an average 7% reduction among control groups. DISCUSSION There are important gaps between knowledge gained from research, everyday practice in community-based treatment programs, and governmental policies about drug abuse treatment (Institute of Medicine, 1998). Many mental health practitioners have not yet incorporated into their clinical practices new information on evidence-based interventions. One reason may be that many treatment providers do not have access to journals or information on newly tested treatments. Perhaps, with increased access to the Internet, the gap between science and practice will slowly close. After a review of the research literature on populations with substance abuse problems and effective treatments, McCrady and Langenbucher (1996) recommended more training for health care professionals to provide interventions of proven effectiveness and also recommended that health insurers support treatments of demonstrated effectiveness as a way to begin to close the gap between science and practice. CRAFT, BCT, and family therapy are noted by researchers to be underutilized by clinicians. Because this article is specific to addictive behaviors, we looked at several conferences specializing in addictions. Not surprisingly, we found that the number of trainings scheduled for either family therapy, couples therapy, or unilateral therapy ranged from 15% to 33% of the overall conference presentations or workshops. We do not

286


believe that this reflects the addictions communities’ attitude toward using empirically tested nonindividual treatments. We believe that the paucity of training in this area is due to a lack of exposure. In addition, there is a tendency to conceptualize both addictions and intrapersonal problems such as depression as internal, that is, to be treated with individual therapy. However, evidence as presented in this article is accumulating that specific family-based interventions may be more successful at engaging, retaining, and improving outcome than individually focused interventions. CONCLUSION This article discussed empirical evidence that suggests certain treatments are more productive than others. The goal of this article was to provide information on empirically supported family-based interventions for the treatment of substance use disorders. Practitioners may then seek additional training in one or more of these approaches so that best practices may be used in the provision of client care. Among the treatments discussed were CRAFT, BMT, and family therapy. The utility of traditional family approaches for intervening with adolescent and adult substance abuse was also noted. Most practitioners do not have the time or resources to be trained in all models of therapy. Therefore, it is important that the practitioner establish an appropriate referral system for clients who need a specific intervention outside the practitioner’s realm of expertise. For readers interested in further training or information on the approaches discussed in this article, we have provided a recommended reading list, including references for treatment manuals. Most treatment research programs have trainers or consultants who will travel to agencies to conduct on-site training in the treatment protocol. To apply the discussed interventions effectively, specialized training and ongoing supervision are recommended.

REFERENCES Al-Anon Family Groups. (1965). Al-Anon faces alcoholism. New York: Author. Azrin, N. H. (1976). Improvements in the community reinforcement approach to alcoholism. Behavior Research and Therapy, 14, 339-348. Azrin, N. H., Donohue, B., Besalel, V. A., Kogan, E. S., & Acierno, R. (1994). Youth drug abuse treatment: A controlled outcome study. Journal of Child and Adolescent Substance Abuse, 3, 1-16. Azrin, N. H., Sisson, R. W., Meyers, R., & Godley, M. (1982). Alcoholism treatment by disulfiram and community reinforcement therapy. Journal of Behavior Therapy and Experimental Psychiatry, 13, 105-112. Bry, B. H., & Krinsley, K. E. (1992). Booster sessions and long-term effects of behavioral family therapy on adolescent substance use and school performance. Journal of Behavior Therapy and Experimental Psychiatry, 23, 183-189.

Edwards, M. E., & Steinglass, P. (1995). Family therapy outcomes for alcoholism. Journal of Marital and Family Therapy, 21(4), 475-509. Fals-Stewart, W., & O’Farrell, T. J. (1999). Treatment models and methods: Family models. In B. S. McCrady & E. E. Epstein (Eds.), Addictions: A comprehensive guidebook (pp. 287-305). New York: Oxford University Press. Finney, J. W., & Monahan, S. C. (1996). The cost-effectiveness of treatment for alcoholism: A second approximation. Journal of Studies of Alcohol, 56, 229-243. Heath, A. W., & Stanton, M. D. (1998). Family-based treatment: Stages and outcomes. In R. J. Frances et al. (Eds.), Clinical textbook of addictive disorders (2nd ed., pp. 496-520). New York: Guilford. Henggeler, S. W., & Borduin, C. M. (1995). Multisystemic treatment of serious juvenile offenders and their families. In I. M. Schwartz & P. AuClaire (Eds.), Home-based services for troubled children (pp. 113-130). Lincoln: University of Nebraska Press. Holder, H., Longabaugh, R., Miller, W. R., & Rubonis, A. V. (1991). The cost effectiveness of treatment for alcoholism: A first approximation. Journal of Studies on Alcohol, 52, 517-540. Hunt, G. M., & Azrin, N. H. (1973). A community-reinforcement approach to alcoholism. Behavior Research and Therapy, 11, 91-104. Institute of Medicine. (1998). Bridging the gap between practice and research: Forging partnerships with community-based drug and alcohol treatment. Washington, DC: National Academy Press. Joanning, H., Thomas, F., Quinn, W., & Mullen, R. (1992). Treating adolescent drug abuse: A comparison of family systems therapy, group therapy, and family drug education. Journal of Marital and Family Therapy, 18, 345-356. Johnson, V. E. (1986). Intervention: How to help those who do not want help. Minneapolis, MN: Johnson Institute. Kantor, G. K., & Strauss, M. A. (1990). The “drunken bum” theory of wife beating. In M. A. Strauss & R. J. Gelles (Eds.), Physical violence in American families (pp. 203-224). New Brunswick, NJ: Transaction. Leonard, K. E., & Jacob, T. (1988). Alcohol, alcoholism and family violence. In V. B. VanHaaselt, R. L. Morrison, A. S. Bellack, & M. Hersen (Eds.), Handbook of family violence (pp. 383-406). New York: Plenum. Liddle, H. A. (1995). Conceptual and clinical dimensions of multidimensional, multisystems engagement. Psychotherapy: Theory, Research, Practice, Training Special Issue: New Frontiers and New Dimensions, 32, 39-58. Liddle, H. A. (1999). Theory development in a family-based therapy for adolescent drug abuse. Journal of Clinical Child Psychology, 28, 521-532. Liddle, H. A., Dakof, G. A., Parker, K., Diamond, G., Garcia, R., Barret, K., et al. (1993, June). Effectiveness of family therapy versus multi-family therapy and group therapy: Results of the adolescents and families project—A randomized clinical trial. Paper presented at the annual meeting of the Society for Psychotherapy Research, Pittsburgh, PA. Maisto, S. A., O’Farrell, T. J., Connors, G. J., McKay, J., & Pelcovitz, M. A. (1988). Alcoholics’attributions of factors affecting their relapse to drinking and reasons terminating their relapse events. Addictive Behaviors, 13, 79-82. McCrady, B. S. (1989). Outcomes of family-involved alcoholism treatment. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 7, pp. 165182). New York: Plenum.


McCrady, B. S. (1991). Promising but underutilized treatment approaches. Alcohol Health & Research World, 15, 215-218. McCrady, B. S. (1993). Relapse prevention: A couple-therapy perspective. In T. J. O’Farrell (Ed.), Treating alcohol problems: Marital and family interventions (pp. 327-350). New York: Guilford. McCrady, B. S., & Epstein, E. E. (1996). Theoretical bases of family approaches to substance abuse treatment. In F. Rotgers, D. S. Keller, & J. Morgenstern (Eds.), Treating substance abuse: Theory and technique

287

clients who have alcohol problems (pp. 292-314). Springfield, IL: Charles C Thomas. Noel, N. E., & McCrady, B. S. (1993). Alcohol-focused spouse involvement with behavioral marital therapy. In T. J. O’Farrell (Ed.), Treating alcohol problems: Marital and family interventions (pp. 210-235). New York: Guilford. Noel, N. E., McCrady, B. S., Stout, R. L., & Fisher-Nelson, H. (1987). Predic-

(pp. 117-142). New York: Guilford. McCrady, B. S., & Langenbucher, J. W. (1996). Alcohol treatment and health

tors of attrition from an outpatient alcohol couples treatment program. Journal of Studies on Alcohol, 48, 229-237. O’Farrell, T. J. (1992). Families and alcohol problems: An overview of treat-

care system reform. Archives of General Psychiatry, 53, 737-746. McCrady, B. S., Noel, N. E., Abrams, D. B., Stout, R. T., Nelson, H. F., & Hay, W. N. (1986). Comparative effectiveness of three types of spouse

ment research. Journal of Family Psychology, 5, 339-359. O’Farrell, T. J. (1993). A behavioral marital therapy couples group program for alcoholics and their spouses. In T. J. O’Farrell (Ed.), Treating alcohol

involvement in outpatient behavioral alcoholism treatment. Journal of Studies of Alcohol, 47, 459-467. McCrady, B. S., Stout, R. T., Noel, N. E., Abrams, D. B., & Nelson, H. F.

problems: Marital and family interventions (pp. 170-209). New York: Guilford. O’Farrell, T. J. (1995). Marital and family therapy. In R. K. Hester & W. R.

(1991). Effectiveness of three types of spouse-involved behavioral alcoholism treatment. British Journal of Addiction, 86, 1415-1424. McLellan, A., Arndt, I., Metzger, D., Woody, G., & O’Brien, C. (1993). The effects of psychosocial services in substance abuse treatment. Journal of the American Medical Association, 269, 1953-1959. 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, 291-308. Meyers, R. J., Miller, W. R., Smith, J. E., & Tonigan, J. S. (in press). A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others. Journal of Consulting and Clinical Psychology. Meyers, R. J., & Smith, J. E. (1995). Clinical guide to alcohol treatment: The community reinforcement approach. New York: Guilford. 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. Miller, W. R., Brown, J. M., Simpson, T. L., Handmaker, N. S., Bien, T. H., Luckie, L. F., et al. (1995). What works? A methodological analysis of the alcohol treatment outcome literature. In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alterna-

Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (pp. 195-220). Boston: Allyn & Bacon.

tives (pp. 12-44). Boston: Allyn & Bacon. Miller, W. R., & Hester, R. K. (1986). The effectiveness of alcoholism treatment methods: What research reveals. In W. R. Miller & N. Heather

O’Farrell, T. J., Cutter, H.S.G., Choquette, K. A., Floyd, F. J., & Bayog, R. D. (1992). Behavioral marital therapy for male alcoholics: Marital and drinking adjustment during the two years after treatment. Behavior Therapy, 23, 529-549. O’Farrell, T. J., Cutter, H.S.G., & Floyd, F. J. (1985). Evaluating behavioral marital therapy for male alcoholics: Effects on marital adjustment and communication from before to after therapy. Behavior Therapy, 16, 147-167. Pinsoff, W. M., & Wynne, L. C. (1995). The efficacy of marital and family therapy: An empirical overview, conclusions, and recommendations. Journal of Marital and Family Therapy, 21, 585-613. Sisson, R. W., & Azrin, N. H. (1986). Family-member involvement to initiate and promote treatment of problem drinkers. American Journal of Drug and Alcohol Abuse, 8, 371-376. Smith, J. E., Meyers, R. J., & Delaney, H. (1998). The community reinforcement approach with homeless alcohol-dependent individuals. Journal of Consulting and Clinical Psychology, 66, 541-548. Stanton, M. D., & Shadish, W. R. (1997). Outcome, attrition and family-couples treatment for drug abuse: A meta-analysis and review of the controlled, comparative studies. Psychological Bulletin, 122, 170-191. Stanton, M. D., Todd, T. C., & Associates. (1982). The family therapy of drug abuse and addiction. New York: Guilford.

(Eds.), Treating addictive behaviors: Processes of change (pp. 121-174). New York: Plenum. Miller, W. R., & Hester, R. K. (1995). Treatment for alcohol problems:

Szapocznik, J., & Kurtines, W. M. (1989). Breakthroughs in family therapy

Toward an informed eclecticism. In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives

come: A review of randomized trials. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 19, pp. 199-234). New York: Plenum.

(2nd ed., pp. 1-11). Boston: Allyn & Bacon. 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, 688-697. Moos, R. H., Finney, J. W., & Gamble, W. (1985). The process of recovery from alcoholism II: Comparing spouses of alcoholics and matched community controls. In E. M. Freeman (Ed.), Social work practice with

with drug-abusing and problem youth. New York: Springer. Waldron, H. B. (1997). Adolescent substance abuse and family therapy out-

Winters, J., Fals-Stewart, W., O’Farrell, T. J., Birchler, G. R., & Kelley, M. L. (in press). Behavioral couples therapy for female substance-abusing patients: Effects on substance use and relationship adjustment. Journal of Consulting and Clinical Psychology. Zweben, A., & Barrett, D. (1993). Brief couples treatment for alcohol problems. In T. J. O’Farrell (Ed.), Treating alcohol problems: Marital and family interventions (pp. 353-380). New York: Guilford.

288


RECOMMENDED READINGS

(Eds.), Home-based services for troubled children (pp. 113-130). Lincoln: University of Nebraska Press.

Abbott, P. J., Weller, S. B., Delaney, H. D., & Moore, B. A. (1998). Community reinforcement approach in the treatment of opiate addicts. American Journal of Drug and Alcohol Abuse, 24, 17-30. Azrin, N. H., Sisson, R. W., Meyers, R. J., & Godley, M. D. (1982). Alcoholism treatment by disulfiram and community reinforcement therapy. Journal of Behavioral Therapy and Experimental Psychiatry, 13, 105-112. Higgins, S. T., Budney, A. J., Bickel, W. K., Hughes, J. R., Foerg, F., & Badger, G. (1993). Achieving cocaine abstinence with a behavioral

Liddlle, H. A., Dakof, G., & Diamond, N. (1991). Adolescent substance abuse: Multidimensional family therapy in action. In E. Kaufman & P. Kaufman (Eds.), Family therapy with drug and alcohol abuse (pp. 120171). Boston: Allyn & Bacon. Marlatt, G. A., & Gordon, J. R. (Eds.). (1985). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford. Meyers, R. J., & Smith, J. E. (1995). Clinical guide to alcohol treatment: The community reinforcement approach. New York: Guilford.

approach. American Journal of Psychiatry, 150, 763-769. Higgins, S. T., Delaney, D. D., Budney, A. J., Bickel, W. K., Hughes, J. R., Foerg, F., et al. (1991). A behavioral approach to achieving initial cocaine

National Institute on Alcohol Abuse and Alcoholism. (1995). The physi-

abstinence. American Journal of Psychiatry, 148, 1218-1224. Miller, W. R., & Meyers, R. J. (1999). The community reinforcement approach. Alcohol Research and Health, 23, 116-121.

No. 95-3769). Bethesda, MD: Author. O’Farrell, T. J. (1993). Treating alcohol problems: Marital and family inter-

O’Farrell, T. J., & Fals-Stewart, W. (2000). Behavioral couples therapy (BCT) with alcoholism and drug abuse. Journal of Substance Abuse Treatment, 18, 51-54. Smith, J. E., Meyers, R. J., & Miller, W. R. (2001). The community reinforcement approach to the treatment of substance use disorders. American Journal of Addictions, 10(Suppl.), 51-59.

TREATMENT MANUALS Budney, A. J., & Higgins, S. T. (1998). National Institute on Drug Abuse therapy manuals for drug addiction: Manual 2. A community reinforcement approach: Treating cocaine addiction (NIH Publication No. 98B4309). Rockville, MD: U.S. Department of Health and Human Services. Godley, S. H., Meyers, R. J., Smith, J. E., Karvinen, T., Titus, J. C., Godley, M. D., et al. (in press). Adolescent community reinforcement approach (ACRA) for adolescent cannabis users. Volume 4 of the cannabis youth treatment manual series. Rockville, MD: U.S. Department of Health and Human Services, Center for Substance Abuse Treatment. Henggeler, S. W., & Borduin, C. M. (1995). Multisystemic treatment of serious juvenile offenders and their families. In I. M. Schwartz & P. AuClaire

cians’ guide to helping patients with alcohol problems (NIH Publication

ventions. New York: Guilford.

Robert J. Meyers is a research associate professor of psychology at the University of New Mexico. He has been involved in addiction treatment and research for more than 25 years and has served as a senior research scientist at the Center on Alcoholism, Substance Abuse, and Addictions (CASAA) for the past 15 years. He is one of the original collaborators on the Community Reinforcement Approach (CRA) and the originator of Community Reinforcement and Family Training (CRAFT). Timothy R. Apodaca is a doctoral candidate at the University of New Mexico. Sharon M. Flicker is a doctoral student in the department of psychology at the University of New Mexico. Natasha Slesnick is a research assistant professor of psychology at the University of New Mexico’s Center on Alcoholism, Substance Abuse and Addictions. Her research and clinical work has focused primarily on adolescent substance abuse and family treatments, homelessness, juvenile delinquency and depression. She is principal investigator on four federally funded projects which examine treatment outcome with runaway and homeless youth and their families.