How do concerned significant others experience Community Reinforcement and Family Training (CRAFT) – a qualitative study.

doi:10.21203/rs.3.rs-198798/v1

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Research Article

How do concerned significant others experience Community Reinforcement and Family Training (CRAFT) – a qualitative study.

https://doi.org/10.21203/rs.3.rs-198798/v1

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Journal Publication

published 01 Dec, 2021

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Introduction: In the last 20 years, there has been growing evidence that heavy drinking causes serious harm, not only to the person who drinks but also to the person’s relations and concerned significant others (CSOs). Several interventions have been developed to help CSOs of persons with substance abuse e.g., Community Reinforcement and Family Training (CRAFT). The aim of this study was to investigate what the CSOs who participated in a CRAFT intervention aimed for, when they sought help, what they found helpful from the intervention, and which elements of the interventions they utilized. Furthermore, we wanted to investigate how the CSOs managed to apply the components to their life.

Method: This is a qualitative study is based on data from 11 interviews with help-seeking CSOs of individuals with alcohol problems. The participants were recruited from an RCT study of various formats for delivering CRAFT (by means of group sessions + written material, individual sessions + written material or self-delivered CRAFT with written material only). Semi-structured interviews were conducted, audio-recorded, and transcribed. The analysis was based on the Interpretative Phenomenological Analysis.

Results: The results describe how the CSOs experienced the intervention and the format that CRAFT in which was delivered, what they felt they gained, and, lastly, how the CSO experienced that it affected their life after the intervention.

Conclusion: CSOs who participated in CRAFT intervention, felt helped by the CRAFT components, regardless of the format through which the intervention was delivered. Written material on CRAFT was considered helpful alongside the interventions and may, even for some, function as a useful intervention, albeit probably not as effective. The “Communication-element” from CRAFT, positive reinforcement, and knowledge about the disorder seemed particularly helpful.

Health Economics & Outcomes Research

Health Policy

General Practice

Community Reinforcement and Family Training

CRAFT

Concerned Significant others

relatives

alcohol

alcohol use disorder

alcohol problems

substance use disorder

addiction.

Alcohol problems have serious consequences for the people who suffer from them; but also people close to the drinking person, especially family members, are seriously affected by alcohol problems (1). Families are often affected by marital problems, financial troubles, and a general feeling of insecurity because of the life in a stressful environment; factors that, in sum, increase the risk of physical and mental illness (2) in addition to experiencing a lower quality of life (Qol) (3).

Being related to a heavy drinker is associated with suffering from negative self-reported health, and the correlation is positively associated with the degree of proximity to the heavy drinker (Bloomfield 2019). In particular, spouses and partners of substance abusing individuals seem to experience more physical violence and aggression compared to parents of substance abusing individuals (4); and women seem to experience more harm than men (4–7).

Individuals close to a person suffering from alcohol problems, have been named in various ways throughout the literature. In the present paper, we will use the term “Concerned Significant other (CSO)” when we refer to family members, partners, ex-partners or individuals who have friends with alcohol problems. We will use the term “Identified Patient (IP)” to describe the individual who are drinking excessively and who are reluctant or uncapable to seeking treatment for the drinking problem.

CSOs, who respond to the alcohol problems of the IPs by suppressing their emotions and own needs, have been found to experience more family dysfunction and have a lower Qol (8). Still, often the CSOs find it challenging to search for help in stressful situations (9). However, help-seeking might not only be helpful for the CSO themselves; CSOs are also considered a motivating factor for the IP to seek treatment and to potentially have a significant impact on the IP’s alcohol intake because they often spend more time with the IP than professional treatment providers (10). Several interventions have been developed in order to help families and CSOs of persons with substance abuse, including alcohol use disorder. Orford et al. divide the interventions into three broad categories: 1) Interventions aimed at the needs of CSOs him or herself. 2) Interventions aimed at involving the CSO in the treatment of the IP. 3) Interventions aimed at helping the CSOs to motivate the IP to seek treatment (11). In the first group, the 5-step method (12) and 12-step programs such as Al-Anon and Nar Anon (13) have been the main intervention for many years. The last two emphasize the CSOs to focus on their own needs and do not encourage them to seek solutions for the IP (10). In the second category, we find Family Treatment (14, 15) and Behavioral Couple Therapy (16–18), where the CSO takes an active part in the treatment of the IP. In the third group, we find interventions like the Johnson Institute Intervention (19) which uses a “surprise party” in order to force the IP to choose between the family or their substance abuse (10), and we find that the Community Reinforcement and Family Training (CRAFT)suggests offering the CSO strategies and tools to use during the daily contract with the IP. The overall aims of CRAFT are to increase treatment engagement for the IP, reduce the IPs’ misuse, and increase Qol of the CSO regardless of whether the IP enters treatment or not (Meyers 1999, Meyers 2011, Smith 2004).

In Denmark, CSOs can seek help and advice free of charge in most public alcohol treatment centers, although this is not always particularly advertised and visible to the public. The interventions that the treatment centers offer to CSOs vary throughout the country, but in 2015, a Danish Clinical Guideline noted, based on findings from a meta-analysis (Authority, 2015), that CRAFT was the most effective intervention in helping CSOs to motivate the IP to seek treatment and the Health Authorities thus recommended that CRAFT should be implemented in public treatment institutions (20). Since CRAFT was an intervention strategy previously unknown in the Danish Treatment sector, a cluster-randomized trials was designed to investigate how to implement CRAFT best and disseminate knowledge about CRAFT to staff in the treatment institutions (21). The present study is a qualitative sub-study of this trial.

About Community Reinforcement and Family Training

CRAFT is an intervention based on cognitive-behavioral principles and designed to motivate treatment-reluctant substance-abusing individuals to seek treatment by training CSOs in strategies on how to support a sober lifestyle. Moreover, CSOs are taught how they can improve their own Qol, regardless of whether their IP enters treatment or not (10). The CRAFT intervention consists of eight components:

Motivational strategies: Set positive expectations by describing CRAFT to increase the motivation of the CSO.
Functional analyses: Of the identified patient’s (IP) substance-using behavior. To outline the triggers and consequences of the IP’s use, and to use the tool to plan the CSOs intervention strategies.
Domestic violence precautions: Assessing the potential for violence in relation to the IP.
Communication Training. Teaching and practicing positive communication skills to improve the communication with the IP.
Positive Reinforcement Training: Teaching the CSO how to use small rewards to reinforce clean and sober behavior.
Discouragement of using behavior/Natural consequence: Teaching the CSO how to allow the natural consequences for using and teaching a standard problem-solving strategy.
CSO self-reinforcement training/Life quality: Exploring the CSOs’ dissatisfaction in life and devolving goals and a plan to increase CSOs’ own life quality.
Suggestion of treatment for the IP: Planning the best time for suggesting treatment and give the CSO knowledge about possibilities within treatment (10).

A recently published systematic literature search identified 14 studies on CRAFT involving CSOs of individuals suffering from alcohol and/or drug misuse or gambling problems (Archer 2020). A meta-analysis was performed on 11 of the studies and found, that CRAFT was twice as effective in engaging the IP to treatment as control condition/comparison (22). Archer et. al. (2020), however, also found that the 14 identified studies were of rather low quality. A recent Swedish study on Internet-based CRAFT (iCRAFT) on Alcohol Use Disorder, published after the review by Archer et. al (2020), showed a non-significant difference in treatment engagement between the iCRAFT group and the control group, although a statistical tendency was observed for positive effects of CRAFT. Participants in the iCRAFT group showed improvements on the short-term measures on depressive symptoms, Qol, and relational satisfaction (23).

The intervention-studies on CRAFT have contributed with a significant amount of quantitative data and, thus, strengthened the knowledge about the intervention-effects (22). However, research on how the CSOs experience the CRAFT intervention, what kind of benefits they get from the CRAFT-program, and which process the CSOs are going through is under-investigated and needed. Using a qualitative approach might provide an in-depth understanding of people's experience and understanding of their living life (24, 25). To date, only one qualitative study on CRAFT participation has been performed, and it focused, in particular, on a digital solution. Ocilla et al. (2018) evaluated the feasibility of a web-based adapted version of CRAFT for 12 military CSOs living with a person who was active duty service member or post-9/11-veteran (26). In the study, the participants received four web-sessions of 30–45 minutes. The 12 participants participated in a semi-structured telephone interview after having completed all four sessions. The participants felt that the web-intervention was an advantage in overcoming barriers like stigma and receiving professional help, without anyone else's knowledge (26).

CSOs participating in treatment might reveal different needs and perspectives, as shown in a study on treatment motives (24) and as suggested in a study where CRAFT was offered online and apparently only a small number of CSOs asked their IPs to enter treatment (27), which makes it interesting to find out more about the relative impact of the different treatment modules from a consumer´s perspective (i.e., the CSOs). As mentioned above, the present qualitative study is part of a randomized controlled trial (RCT) of a Danish study on CRAFT (21), and, thus, a sub-study. In order to obtain knowledge about how the intervention was received by the participants, we conducted qualitative interviews with CSOs, who had participated in the RCT (Hellum et. Al 2019). The aim was to investigate what elements of CRAFT that seemed to be the most important and how the different formats of delivering CRAFT was perceived. We thus investigated what the CSOs experienced to receive from CRAFT, which elements of the CRAFT interventions they found particularly helpful and made use of and how satisfied they were with the format that they had received. In particular, we wanted to investigate how the CSOs managed to apply the components to their life after they received the intervention delivered, either as a group-based CRAFT-intervention combined with written material, or individual sessions of CRAFT combined with written material, or by means of the written material describing the CRAFT, only. The latter was considered a minimal control-intervention in the RCT-study.

Brief description of the CRAFT intervention and the RCT

CRAFT is an intervention leveled at CSO struggling to get their IP to stop using alcohol and seek treatment. The RCT study was a three-armed cluster randomized controlled trial to investigate the implementation of group-CRAFT, individual-CRAFT, and self-delivered-CRAFT in 24 public outpatient treatment centers in Denmark. The participating treatment centers were randomized to deliver one of the three conditions only when a CSO sought help at the center. The CSOs in group-CRAFT and individual-CRAFT received six sessions and written material on CRAFT (28). The CRAFT groups were organized as open groups with a fixed structure, where each session had a specific headline and content. After having had one individual session primarily consisting of assessing the CSOs situation and information about the intervention, new members could join the group at any point of intervention curriculum until the completion of the full program. The participants who were offered individual group sessions also began with an individual session consisting of assessment and information before starting the CRAFT intervention. The Individual intervention had the same content as the group intervention but was offered in flexible order, depending on the wishes and needs of the CSO. The CSOs in self-delivered-CRAFT only received the individual assessment and information session and the written material on CRAFT (28). If the CSOs in this arm of the study felt that they needed more help after three months, they were encouraged to come back and would then be offered individual sessions. The primary outcome of the RCT study was whether the IP entered treatment, and secondary outcomes were changes in numbers of drinks, and changes in QoL for the CSO, measured by self-reported questionnaires at baseline, three-month and six-month follow-up. The inclusion criteria for the study were; the CSO ≥ 18 years, being a CSO of a person with alcohol problems who were not in treatment, having a regular contact to the IP, willing to maintain the contact for at least 90 days, and being prepared to support the IP into treatment (21). A total of 255 CSOs were enrolled in the CRAFT study from January 2018 to December 2019.

Design of the present qualitative sub-study:

In the present study, we used a qualitative design with semi-structured interviews. We used the Interpretative Phenomenological Analysis (IPA) (Smith et al., 2009) to analyze and interpret the interviews. IPA is a phenomenological approach used to understand how people make sense of experiences in their life—in this study, understanding how CSOs experience the CRAFT intervention, what they gained by the intervention, and how it affected their life after the intervention. IPA also has a hermeneutic approach used in the interpretation of the experiences. The researcher needs to interpret the accounts to understand the participants' experiences. The last phenomenon that characterizes IPA is that it is ideographic- which means that every case is examined in detail to gain knowledge about what this participant experiences precisely. Often IPA only has few participants because it is important to probe into each participant experience (25).

Participants:

Participants for the present study were recruited through the randomized controlled CRAFT-study (21). During the six-month follow-up interview, the participants were asked if they were willing to be contacted again for further questions and information within the next five years. We contacted all the participants, who completed six-month follow-up at a certain time and had given such consent, and we contacted them by mail, telephone or personal digital mail. In total, we invited 40 CSOs by e-mail, personal digital mail or telephone after their given preference. Fifteen CSOs showed interest in participating in the present qualitative study. Three of the participants, however, gave their acceptance after we had completed all interviews and one audio-file was damaged, hence, the present study is based on interviews of 11 CSOs: Four participants, who have received group-CRAFT, five who have received individual-CRAFT, and two who have received self-delivered CRAFT. We gave the participants oral and written information about the study and their rights, after which they signed a statement of consent.

The sample of participants in the present study consisted of 11 female CSOs of persons with alcohol problems. Five CSOs were living together with their drinking boyfriend/husband, three CSOs had a drinking ex-husband (none of them living together anymore), one had a drinking boyfriend (not cohabiting), one had a drinking brother (not cohabiting), and one had a drinking stepson (not cohabiting). All IPs were men. The CSOs were between 29 and 60 years old (mean age: 51). The CSOs had known the IP for 2–43 years (mean: 23,5) and the CSOs had had the supporting role concerning the IP for approximately 2 to 30 years (mean: 12 years).

Interviews:

The semi-structured interview guide consisted of a few demographic questions and a series of open questions within two areas; their lives as CSOs and how they came to need help-seeking (findings reported in another sub-study), and their experience with CRAFT (see Table 1). We performed 11 face-to-face individual interviews in autumn 2019. The interviews took place in the participants’ home, workplace or in the treatment institution, where the participant had received the CRAFT intervention. All interviews started by encouraging the participants to be truly honest about the intervention they had received, since the interviewer took part in planning and evaluating the CRAFT intervention. Thus, if the participants had any experiences that they felt might improve the intervention, they were encouraged to share them with the researcher. Afterwards, the participants were asked about basic demographic information before being encouraged to talk about the experiences of the CRAFT intervention. All interviews were recorded on a digital voice recorder and lasted between 20 and 62 minutes.

Table 1: Semi-structured interview guide
Opening question	Can you try to explain what you experienced from the time you realised there was an alcohol problem until you searched for help?
	How did you experience receiving the CRAFT counselling?
	Is it your experience that it has made a difference? What was it that made a difference?
	When did you notice a difference? Was it immediately or after some time?
	What was the best thing you acquired from the counselling?
	Are there some elements from the counselling that you did not find useful?
	What more could you have wished from the treatment?
	What is your experience with the written material (the book)?
To the ones who received individual CRAFT	How did you experience receiving individual counselling?
To the ones who received Group CRAFT	How did you experience being in a group?
To the ones who received the written material only	How did you experience receiving this written material? How did it work out with the written material? Was it sufficient?
	Have you experienced that participating in CRAFT has changed the atmosphere/life together between you and the drinking person? What has changed?
	Do you think the drinking person has experienced a change? Has he/she commented on the changes? What happened?
	Have you received any other kind of help because of the drinking person’s alcohol use? – If so, what kind of help? Have you received help from family, friends, job, social network? What happened?
	Is there anything else of importance that I have not asked about?

Data management and analysis:

The audio files were fully transcribed by the first author and two student assistants in the software program Nvivo 12 PRO. The first author anonymized and quality-controlled all the interviews. Ten participants wished to read the interviews, so the transcriptions were sent to them for validation and comments. None of the participants had comments to the transcriptions. An inductive approach was used for the analysis based on the IPA theory (25). The analyses were completed by two researchers and was based on several steps. First, the interviews were read several times, simultaneously taking notes and making descriptive comments. Afterwards we developed themes by discussing the findings within each interview and searched for connections across the emergent themes. This was done for all interviews and, finally, we looked for patterns across all the interviews (25) The quotations in the results section are followed by an ID number, the role of the CSO (e.g. wife, girlfriend or stepmom), whether they were cohabiting with their IP or not, and the intervention they received (individual, group or self-delivered). The interviewer is marked “I”.

The result of the analysis is presented as a journey, first describing how CSOs met the CRAFT intervention, how they experienced the intervention, what they felt they gained by the intervention, and, lastly, how the CSO experienced that it affected their life after the intervention.

“Entering the CRAFT-program”

Firstly, several of the CSOs were very enthusiastic about CRAFT when they first heard and gained knowledge about it. One of the CSOs explained how she responded when she heard about CRAFT from a friend:

So, I contact the treatment center right away and was completely hooked on it because I was out of my depth, I couldn't find any tools at all to do something. And if I could do something, both for you who are involved with this project here and also for myself, well it was a complete win-win after all. So, I had no doubt that it was something for me.

(11, wife, cohabitant, individual)

Entering the treatment center was transgressive for some of the CSOs and a positive experience since they felt very well received in both the center and when they started on the CRAFT intervention. The CSOs described how they felt comfortable around the treatment providers, which were very important for them. They felt they were met without any prejudice and taboo. For several of the CSOs, it was the first time they ever talked to anyone else about their IP’s alcohol problems; hence just describing their situation out loud felt like a relief. Moreover, they explained how pleasant it was to be met by a person who took their worries seriously, validated their hunches about the alcohol problems, and made them hold on to these feelings.

CSOs in all three intervention groups also mentioned how they realized that they were not alone in their situation. This, in particular, meant a lot, as they had often felt very lonely, as one of the CSOs explained:

9: “But, but they have, perhaps, been good at sharing, the fact that I am not the only one with this issue”

I: Could you try to describe what this means; how has it been having this feeling of standing alone?

9: It’s, it's hard to hang in there all the time, though, and, and, and. You just want to confirm that it's okay. It's okay to, uh, that you, uh, sometimes want to pack it all. And to say F*ck you. This feeling is okay to have too. The feeling of constantly wanting to feel normal.

(9, girlfriend, not cohabitant, self-delivered)

Some of the CSOs had told IP beforehand that they would seek help, but not all the participants had told their IP about entering the CRAFT-intervention. One CSO explained how participating in CRAFT was “her thing”:

“Well I did not tell my husband that I have participated in this. I have not needed to, really”.

(11, wife, cohabitant, individual)

The CRAFT components

The CRAFT-program comprises eight components. In the interviews, the CSOs referred to these components as tools and stated that it was great to receive such new utensils, though they felt that some were more relevant than others. The most valued CRAFT component was “Communication training.” Almost all the CSOs stated how helpful the communication-training was. By learning to communicate clearer and more precise, training through role-play with the therapist before communicating with the IP, and learning how to communicate with the IP, they experienced remarkable improvements in their communication with the IP. One of the CSOs explained how she felt communication with the IP change:

"But then to learn how to speak up also concerning the fact that I, just … when I had to communicate some things to my husband, he just experienced me sitting there beating around the bush, and explain wawawa, and in the end we just got each other wrong because that, it was unbearable to listen to, well. So, so there I kind of found out of the fact that it just pays off in this context to be very precise in voicing what I want”.

(5, wife, cohabitant, individual).

Moreover, the CSOs found that they became able to stay calmer and stay on their own “lane half” when communicating. The effort they laid in the communication training lead to less confrontation, and one CSO noticed how her husband began to take note of the things she said when her communication got clearer. Other CSOs realized that it became easier to talk about difficult subjects and problems. Some CSOs mentioned how they found that their IP got more open when the CSO themselves changed communication into a more positive style. It also became clear to the CSOs that it was challenging to communicate when their IPs were drunk and how they could not persuade them to stop drinking when a drinking session had begun.

Another CRAFT element made a particularly big impression on the CSOs, namely the “Positive Reinforcement Training.” The rationale behind the strategy of making a sober life more attractive than life when drinking was realized by some of the CSOs before entering the CRAFT intervention, but it was a kind of revelation for others. One CSO explained how she realized that she had previously dissociated herself from her stepson and how she now practiced giving him more positive attention when he was sober:

“So, I have practiced being present for him and paying attention to what interests him. And he is talented in many ways, and many things work for him. And by creating distance, I achieve nothing at all”.

(6, stepmom, not cohabitant, group)

Other CSOs realized that, for a long time, they had almost entirely had focus on the negative aspects of their life together with the IP. Most found that by focusing on the positive things and praise them, they could increasingly also value and embrace the more positive sides of their IP. A few, however, found it to be difficult to affirm the positive sides and sober actions of her husband when he had also caused his family so much harm and sorrow. Another CSO described how her boyfriend was taken aback when she began to praise his sober sides.

The CRAFT-component "Focusing on own life quality" was also emphasized and found helpful by the CSOs. The focus on the CSO's own quality of life was surprising to some of the CSOs. Still, most explained how they became better at prioritizing themselves and doing something for themselves due to the intervention. One CSO explained how she realized that it was important to her to be loaded with positive things:

“… This…having the energy to think about, what can you do that’s good for yourself. So, you can get filled up with some energy, and also be better empowered to stand up to him, if you can say it that way. I've probably been too bad at doing that”.

(11, wife, cohabitant, individual)

The CRAFT-component “Negative consequences” was also explored during the interview with the CSOs. Most had found that allowing natural negative consequences of the drinking to happen made a huge impression on their IP, for instance no longer being able to see their children or grandchildren when drinking. Several of the CSOs had begun to simply withdraw from their IP when he was drinking, and a CSO explained how she began to communicate clearer to the IP, how unpleasant he was to be together with when drinking:

11: Yes and of course change my behavior and make it clear to him. When was he nice to be with and when was he not nice to be around. And pick or reject him.

I: Can you try to explain how you did that?

11: Well, it was to put into words, not just leave when he came home or came in and was under the influence, but also to explain why I left

(11, wife, cohabitant, individual).

However, not all CSOs found it easy to make use of natural negative consequences of drinking, in particular, consequences that affected their common home. As one of the CSOs noted, she had to be able to live in the home as well.

The CRAFT component “Function analysis” was overall found to be very helpful and contributed with a better sense and understanding of the drinking situation, and, thus, help to give the CSOs a kind of map describing when it was possible to intervene. One CSO, though, did not find it helpful at all.

The CRAFT-intervention

How the CRAFT-intervention was delivered was also addressed in the interviews. Overall, the five CSOs who received “Individual CRAFT sessions” were satisfied with the intervention. They appreciated that the program was flexible and met their needs. One CSO did not feel that there was enough time to work through all her problems and feelings, and some CSOs would have liked to discuss issues with other CSOs in similar situations.

The four CSOs who received CRAFT in group sessions were overall satisfied, but one CSO would have preferred individual sessions of CRAFT because she needed more focus on her own situation. Still, they also mentioned that they would have wished for more group members (her group consisted of only a few members). The CSOs who had received CRAFT in group sessions appreciated conversing with and seeing CSOs, who suffered from the same kind of problem since this left them with feeling less alone with their challenges. It also contributed to a more varied picture of alcohol problems. The participants found the open-group format advantageous since there was no waiting time before being allocated to the group and because the group thus got even more diverse. Several of the CSOs experienced that other CSOs were way worse off than themselves and that put their own experiences in perspective, as one CSO explained:

“I felt better about myself, the days when the other one was with me. Because I could hear that she was much worse off than me. I could go home and think wow, okay it might not be so bad here at home.

(3, girlfriend, cohabitant, group)

Some CSOs found it easier to help solve the other group members' problems in the sessions than propose solutions to their own problems. When entering the group, some of the CSOs were anxious to meet somebody familiar in the group. Simultaneously, the CSOs had taken firm decisions about being honest about their situation, for once. One CSO explains:

“It was my experience that what is said here stays in this room. And if I am not honest in this room…. And I can totally trust that the people who hear this, of course they are also bound by confidentiality, which was mutual regarding the woman who sat opposite me”.

(6, stepmom, not cohabitant, individual,)

Two of the CSOs participating in the present study received the written material as the only source of information and help. Both expressed that the written material was helpful and supportive:

“I have that book next to my bed and um. I read it often. Probably it is also, both to get the advice from it. And just like being confirmed in that what I do is actually good enough, or it is fine enough. In that way, I think it is really great”.

(9, girlfriend, not cohabitant, self-delivered)

The CSOs felt a positive change very quickly after reading the book:

“Well, I think it happened pretty quickly. Because it read it immediately after I got it. Eh. It didn’t take me long. And that’s where I started, just like – to be able to see things and do things”.

(7, ex-girlfriend, not cohabitant, delivered)

“Well again, to get to know myself and know and find out what I am willing to be a part of and what I cannot. And also, how I can best help. Um. I think that has actually been good. Because a lot of changes have happened since”.

(9, girlfriend, not cohabitant, delivered)

However, the CSOs who only received the self-delivered CRAFT did feel somewhat left alone and missed more personal contact with the treatment provider or other CSOs. They considered that they would have improved faster if they had had a more personal connection. Despite this, no CSOs returned to the treatment centers after three months to receive additional individual support.

The written material on CRAFT

There was a common satisfaction with the written material on CRAFT which all found very readable and understandable. The CSOs explained how they felt met and affirmed when reading the material. They felt validated in their assumptions of the IP drinking too much, and they felt confirmed in doing the right things when they started using CRAFT. Several CSOs described how they felt recognized in the material, and one CSO said that she could have been the one writing the material. The CSOs felt it was beneficial to read the written material before participating in the sessions as a kind of preparation. Others also used the material to brush up on the components after sessions.

The Research Interviews

Since the participants participated in a research study on how to deliver a CRAFT intervention best, the participants had completed self-reported questionnaires at baseline, after three months (end of intervention), and again at six months follow-up. During the interviews for the present study, several of the participants brought up the questionnaires as s theme in spite that this was not a part of the interview guide. The participants expressed how filling out the questionnaires had reminded them and help them focus during the process. Moreover, they felt that the questionnaires helped them summing up of the intervention and they felt confirmed in doing the right things, as one explained:

“But I also think that, subsequently, the questionnaires I have been given, they helped me to hold on to that it was not a just a course I have attended, but it has actually continued. I have actually thought so. And that is also why I say yes to this (interview red.), because it is not just a course and so it is. After all, it's something for life for sure. It (alcohol red.) is a part of our family”.

(6, stepmom, not cohabitant, group)

Especially the two CSOs from the self-delivered CRAFT talked about the questionnaires as if these had been part of the intervention:

“Well, the questions did mean that you were, like, confirmed in some things. And, and it was not wrong to write, well, no one else would know what I was doing, at all. Nobody would know about it, right? So, I could just write what I wanted to write”.

(7, ex-girlfriend, not cohabitant, self-delivered)

What was gained from the CRAFT intervention, how did it work?

The CSOs had very different experiences on how quickly they could make use of the strategies and components learned from CRAFT, and what they felt worked. One CSO experienced an immediate relief already when stepping into the treatment center and openly described her situation with the treatment provider. Another CSO also noticed immediate changes, because she found the components of CRAFT highly useable, in addition to the support received from the treatment provider. One of the CSOs, who had received self-delivered CRAFT, also described an immediate change after reading the written material, because it helped her improve how the communication with her IP. It took her somewhat longer to master the rest of the CRAFT components. Other CSOs described how it took a few months before they experienced a positive change in their lives. One even described how, after one year, she kept improving. Learning the strategy of focusing on the positive aspects rather than the negative was described as new and helpful. A few CSOs were tempted to give up during the early stages of the intervention due to a deep feeling of hopelessness but began to improve after a few months. Thus, the path of improvement varied among the participants.

A particular benefit from the CRAFT intervention, stressed by the CSOs, was becoming better at withdrawing from the IP. When the CSOs got a better understanding of why the IP behaved like he did, and got an understanding of how the alcohol use disorder functioned, it became easier for them both to see things from the IP’s perspective, and how it differed from their own. For many of the CSOs it was really an eyeopener or a wake-up call to find out what alcohol did to the drinking IP. One of the CSOs explained:

“Yes, that understanding of him, so also the fact that, well I also think it was a revelation, I can remember the one with the scale model and how to find out, well what it is that really motivates him to drink, what is it that motivates him not to drink, so it was also like that and where I just actually hurt inside, because it is like it is, that there is just not very much that motivated him not to drink during that time. So, I can easily see the mechanism, hmm that is part of him and that understanding and see it from his perspective, hmm, it was also pretty good to have, I think”.

(4, ex-girlfriend, not cohabitant, individual)

Getting this understanding of the alcohol use disorder helped the CSOs realize that the IP did not drink because of them, and it was not their fault that they begin drinking (again). This distinction between themselves, the IP, and the alcohol use disorder also made the CSOs become more independent individuals. It became easier for them to distance the drinking behavior and make decisions for themselves. Several CSOs described how it became easier to draw a line or make demands on what was expected in the relationship. One CSO explained how she began to take control:

"Well, I feel that it is like, it has, at least, been an eye opener that was about uh, you cannot control that, my friend. You cannot control me. I am the one who decides what I do”.

(5, wife, cohabitant, individual)

Some of the CSOs experienced that their efforts with CRAFT lead to changes in the IP’s drinking pattern. Hence, they observed that their time together became better and the desire for him increased when he did not drink.

What was the perceived outcome of the CRAFT intervention?

It seemed like the CSOs got different outcomes of participating in CRAFT depending on their role as a CSO (wife, girlfriend, stepmom) differed, and the format for the CRAFT intervention differed. Some of the CSOs were able to use the CRAFT strategies to motivate their IP for treatment, improve on their quality of life, the relationship with the IP independently of whether he entered treatment or not. Four of the CSOs participating in the present study described a positive outcome of CRAFT despite that they had also realized that their loved one probably would never quit drinking.

Another group of CSOs decided to leave their drinking husband or boyfriend, either immediately before or after the CRAFT intervention. Even though their relationship with the IP came to an end, they felt they achieved a higher satisfaction with life, and that the relationship with their ex-husband or boyfriend was improved due to the CRAFT intervention, as one explains:

“So, I think I already had, I have some good tools for how, even when we were apart, how… well I think it actually ended up fine and we have always been able to cooperate, also with our son, it has been very constructive”.

(4, ex-girlfriend, not cohabitant, individual)

Overall, almost all participants stated the CRAFT intervention as helpful:

It has been a gift to receive CRAFT (2)

There is an intention with CRAFT (5)

CRAFT made me arrive at where I am today (7)

So, I got surplus energy. So, it has helped (10)

Suggested improvements of the CRAFT intervention

Several of the CSOs suggested a kind of follow-up session with a treatment provider after four months following the intervention and considered that it should be either face to face performed as a telephone/video call. It was suggested that such follow-up or after-care session would prevent a feeling of being left alone; helpful when addressing new challenges that have emerged which would be nice to discuss, but also helpful to simply be confirmed in doing the right things. The CSOs who had younger children would have appreciated more focus on how to best support the children in their families. One CSOs felt that the program was too focused on getting the IP into treatment which she already had realized was not a possibility.

Model on the CRAFT components

Based on the analysis of the interviews above, we created a tentative model of how the different CRAFT strategies and components may function regarding treatment-seeking of the IP and increasing the quality of life for the CSO. Elements such as “Domestic violence precaution” were not mentioned during the interviews despite that this element was always part of the CRAFT intervention and stressed in the written material. The present group of CSOs was not facing violent behavior, and this strategy is thus not included in the figure. “Motivational strategies” were neither directly addressed during the interviews as a theme, probably since the motivational methods instead are encompassed in the therapist style and initial session introducing the CSO to the intervention. They are essential for goal clarification in relation to the needs of the CSOs and to clarify what the CSO can expect from the intervention.

The “Functional analysis” was only referred to by a few participants and described as creating an overview useful in applying other CRAFT strategies. “Life-quality,” “Positive reinforcement,” and “Negative consequences” were appropriate strategies for the CSOs, and their experience was that some of them were easy to implement and worked immediately, where others were more complicated to use and harder to learn as “Positive Reinforcement.”

Overall, we found that the CSOs considered the communication component of CRAFT as a particularly helpful part of the intervention. Our findings, thus, confirm a previous qualitative study of CRAFT participation (26). It was while changing communication and focusing on the positive aspects with the IP that the CSOs experienced positive changes in relation to their IP and life in general. CSOs also found it helpful to get an understanding of their IP’s disorder. This finding is in line with the review of Gammage et al. (2020), who found that people living with persons with mental health problems reported better Qol, better communication, and better family relationship when having a more profound knowledge of the disorder of the relative, for instance through psychoeducation. Increased health literacy was associated with improvements in understanding, coping, and stigma reduction for the relatives (29), in accordance with the reports from the participants in the present study. Improving the quality of the family relationship is essential since it seems to impact the substance problems and is related to positive treatment outcomes (1, 30).

In the present study, it was also a central finding that the CSOs, through their participation in the CRAFT intervention, learned to separate themselves to a greater extent from the IP. Gammage et al. (2020) also found that when CSOs focus more on personal relationships than the caregiving relationship, the CSOs reported higher personhood (29). Copello et al. (2005) explain that “A family member cannot stop individuals from drinking, but they can change their own behavior in a way that will help the IP recognize that behavior is problematic and make it favorable to change behavior” (1). This might explain why changes may happen even when the focus in the interventions aimed at the CSOs does not have treatment entry of the IP as an immediate goal. The changes may occur when the CSO changes behavior.

CRAFT is a very structured intervention focusing on applicable tools; hence the time for talking freely and in detail may be limited to some extent, a critique that previously has been raised on CRAFT. Orford et al. (2013) criticized interventions such as CRAFT for lacking a clear focus on the CSO's needs (11). However, the CSOs in our study felt that their own Qol was highly prioritized in the CRAFT intervention and written material they received, and they found this focus to be an eyeopener.

The group-CRAFT and the individual CRAFT in our study consisted of 6 sessions, which is a shorter duration of the interventions than what has previously been offered in research studies. Overall, the participants in the present study were satisfied, but some of the CSOs felt that the time allocated to the intervention was too limited. Several of the CSOs suggested a follow-up session after 1-3 months after the conclusion of the intervention. The questionnaires used in the RCT study at baseline, three-months, and six-month follow-up were mentioned several times by the CSOs. The two CSOs from the self-delivered CRAFT, in particular, seemed to gain positively from filling out the self-reported questionnaires. It questions whether the most crucial point is to receive the actual intervention or participate in the study itself. A review by Kramer Schmidt et al. (2018) found that research assessments and, thus, research projects in general, may influence the outcome in studies of psychosocial treatment for alcohol use disorder (31). This may also be the case in studies of interventions aimed at CSOs.

Independent of the intervention condition, all the CSOs reported feeling helped, in some way or another, by the CRAFT program, particularly if the intervention consisted of sessions with a treatment provider. The two CSOs who received self-delivered CRAFT felt adequately helped, but they also felt a bit left alone and missed someone with whom to discuss their problems. This indicated that written material could be a great help to some extent, but for most CSOs, it cannot stand alone.

Some CSOs in the present study were capable of using all the CRAFT-components, while others found it difficult, particularly in the beginning. The ability to use all the CRAFT-components might be linked to how chaotic they perceived the situation. CSOs who were capable of using the CRAFT-components seemed to move on in their own process, either by staying with the IP or ending the relationship. The CSOs seemed to experience an increase in life-quality regardless of whether the IP entered treatment or not, or regardless of whether they stayed with the drinking relative or not. This underlines the importance of a thorough goal clarification when beginning the CRAFT program.

Strengths and limitations of the study

This study is the first qualitative study of CSOs participating in a non-web-based CRAFT-intervention. This study, thus, contributes with important knowledge that can be used in the planning of future interventions aimed at CSOs. We are aware that there are limitations to the study. Of the 40 CSOs from the RCT study that we contacted and asked for a further interview, only 15 said yes. Of the 11 interviews we included in the study, we only ended up having interviews with two CSOs from the control group, i.e. CSOs having received written material only. It is likely that the CSOs who were less satisfied with the treatment, did not sign up for this study. After the interview, several of the CSOs who participated in this study, expressed that they had been pleased with participating and even perceived the interview as a kind of additional session. We cannot rule out that these CSOs had a special interest in doing the interview, because the alcohol problems were still very much present in their lives. Moreover, only female CSOs accepted the additional interview. The two participants who received self-delivered CRAFT were overall satisfied with the intervention. This might not, however, be the overall picture since only two participants from this group were willing to be interviewed. Lastly, the interviewer is part of the research group that planned and evaluated the overall RCT study, and she has, therefore, followed all the phases of the project. However, during the interview the CSOs were continuously encouraged to be honest and express all their thoughts about the CRAFT intervention, which they had received, regardless whether it was positive or negative. It was explained that the thoughts and considerations of the CSOs were of high importance for the future planning of the development of meaningful interventions.

This study showed that the CSOs of people with alcohol problems, who participated in CRAFT intervention and participated in present study, feel helped regardless of whether the CRAFT components are delivered by means of individual sessions or group sessions. Self-delivered CRAFT, in the form of written material, was considered helpful alongside the interventions and may, even for some, function as a helpful intervention, albeit probably not as effective. The “Communication-element” from CRAFT, positive reinforcement, and knowledge about the disorder seemed particularly helpful.

CRAFT: Community Reinforcement and Family Training

CSO: Concerned significant other

IP: Identified Patient

Qol: Quality of life

RCT: Randomized control trial

Ethics approval and consent to participate

The Study is approved by the Danish Data Protection Agency (Region of Southern Denmark 2008-58-0035 project no. 17/46074). All methods were performed in accordance with the relevant guidelines and regulations. The study has been submitted for approval at the Danish Ethical Committee (Project-ID: S-20170148) but was excluded for approval on account of it being a questionnaire survey only. The study was registered at ClinicalTrials.gov Identifier: NCT03281057 the 17/09/2017.

All participants were informed by the interviewer, both orally and in writing, about the procedures for attending the study. The participants signed an informed consent document in order to participate in the study.

Authors contribution

Rikke Hellum, Randi Bilberg, Anette Søgaard Nielsen, and Gallus Bischof have contributed to all sections of the manuscript. Anette Søgaard Nielsen, Rikke Hellum, and Randi Bilberg designed the study. Analyses were performed by Rikke Hellum and Anette Søgaard Nielsen. Gallus Bischoff trained the therapists involved in the study. Anette Søgaard Nielsen supervised the therapists throughout the study period. Anette Søgaard Nielsen wrote the book that functioned as support to the intervention and stand-alone intervention in the self-administered intervention.

Acknowledgements:

Our thanks to the concerned significant others, who contributed to this study by sharing their personal experiences. We also thank Ayat Al and Eirik Singstad Paulsen for their help with transcribing the interviews.

Competing interests:

The authors declare that they have no competing interests.

Funding:

The CRAFT study is funded by Trygfonden, the University of Southern Denmark and the Research Foundation for Psychiatric Research in the Region of Southern Denmark.

Consent for publication

Not applicable

Availability of Data and Materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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No competing interests reported.

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How do concerned significant others experience Community Reinforcement and Family Training (CRAFT) – a qualitative study.

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