Does an intervention for concerned significant others increase treatment seeking for treatment resistant young adults?
Treatment engagement is particularly low among young adults. Community Reinforcement Approach and Family Training (CRAFT), a program designed to help concerned significant others (e.g., spouses) improve the chances of treatment entry is proven to be useful for adults, but little is known about whether it can work with this more challenging young adult population. This study examined this very question pitting the CRAFT intervention against an active control condition.
Young adults use alcohol and other drugs at a greater rate than any other age demographic . As a result, young adults experience the highest rates of alcohol and drug related harms. Approximately 14% of young adults in the United States meet criteria for a substance use disorder. However, only 10% of of these actually seek treatment in any given year. This may be, in part, due to the fact that young adults report lower motivation and/or perceived need for treatment, on average, compared to older adults. Attempts to increase motivation to reduce substance use and engagement with services, such as brief motivational interventions, demonstrate small to medium effect size reductions in substance use but still require the individual to make contact and engage with a mental health professional.
Often, close significant others such as parents, romantic partners, or adult children may experience secondhand harms, or witness firsthand harms, from their loved one’s substance use. The accompanying worry about harm to their loved one also motivates them to try to help their young adult loved one to get help.
Community Reinforcement Approach and Family Training (CRAFT) is a treatment approach designed specifically for concerned significant others to learn how modifying their own behavior can change the behavior of their loved one. There are three main goals in CRAFT: (1) to improve the quality of life of the concerned significant other; (2) to decrease substance use of the relative; and (3) to promote help-seeking behavior in the relative. CRAFT was developed in part as a person-centered alternative to the once Johnson Institute intervention (popularized by the TV show Intervention) in which family and friends participate in confronting the individual, using their relationships with the loved one as leverage to encourage them to go attend treatment. Randomized clinical trials have demonstrated that CRAFT is helpful at increasing the likelihood of treatment attendance compared to other interventions such as the Johnson Institute Intervention and Al-Anon facilitation . Despite these effects for concerned significant others of adults with substance use disorder, there have been no studies examining the utility of CRAFT for parents of young adults experiencing harms from substance use disorder.
The aim of the current RCT was to study the effect of CRAFT for parents of treatment-refusing young adults with hazardous substance use compared to counseling, with treatment entry for the young adults as the primary outcome and substance use for the young adults, relationship happiness, parental mental health, psychological flexibility, and quality of life as additional (secondary) outcomes.
HOW WAS THIS STUDY CONDUCTED?
This study used a randomized controlled parallel-group design to compare an 8 session CRAFT intervention to a 6-session active control comparison condition. The researchers included 113 parents (92% female) of young adults (87% male) in the study, with 58 randomized to the CRAFT condition and 55 randomized to the comparison condition.
Parents completed a survey at baseline (prior to randomization), 6 weeks (“mid-treatment”), 12 weeks (“post-treatment”), and 24 weeks. All young adult outcomes are based on parent report. The primary outcome measure was the rate of young adult “help seeking” at the 24 week follow up.
Young adults were considered help seeking if they engaged with any addiction treatment services, mutual-help groups such as Alcoholics or Narcotics Anonymous (AA or NA), primary care psychiatry, telephone support lines, or engaged with internet- or text-based content related to reducing substance use. Secondary outcomes included young adult substance use separated by alcohol and other drug use, young adult substance use severity separated by alcohol and other drug use, parent depression, anxiety, and stress, parent quality of life, parent relationship satisfaction, parent self-efficacy, psychological flexibility, and treatment satisfaction.
The CRAFT intervention was 8 sessions (45-60 minutes) long. Content included motivational enhancement, functional analysis of their loved one’s substance use, positive communication skills, managing own (parent) well-being, managing reward and consequences for young adult’s substance use, and role-playing discussion about treatment entry with child. The comparison condition included 5 individual 45-minute sessions and 1 group psychoeducational session. Content included young adult social network mapping, analysis of positive and negative responses to young adult substance use and understanding relational mapping of the family.
Participants were only included in the study if they were a parent (or had a similar relationship) to a young adult with hazardous substance use who refused to participate in treatment, they had contact (face-to-face or telephone) with the young adult at least 50% of days per week, and they self-declared a strong desire for the young adult to enter treatment. Concerned significant others were excluded if they met criteria for any substance use disorder (except nicotine) according to DSM-5 criteria, self-reported frequent use of illicit substances or psychological or cognitive impairments, participated in support intervention during the previous 3 months. The concerned significant other was also excluded if by their report the young adult: participated in treatment for substance use during the previous 30 days, met criteria for severe psychiatric conditions such as psychotic disorder, or behaved violently towards parent during the last year.
Participants were recruited between October 2018 and May 2021. Independent researchers conducted a pre-planned interim analysis when 70% of the proposed sample had been collected and determined that superiority for one condition over another would not be found within the planned sample size. This led to a premature discontinuation of recruitment, with 70% of the intended sample. Importantly, there were no differences between groups in primary or secondary outcomes. In each condition, four participants did not finish the treatment, and five did not report any data on treatment seeking at the 24 week follow up. The researchers were able to demonstrate that baseline demographic characteristics were not different between those that did and did not complete the study or provide treatment entry data.
Concerned significant others were primarily college educated females in their early 50s who had spent more than three weeks with the young adult on average in the past month. Most concerned significant others were employed (88%). Young adults were primarily males around 20 years of age. Just over half of concerned significant others identified cannabis as the primary problem substance for their young adult; approximately 10% identified alcohol as the primary substance, and the remaining third of concerned significant others identified some other substance as the primary problematic substance.
WHAT DID THIS STUDY FIND?
There was not a significant difference in young adult help seeking for harmful substance use between the CRAFT and comparison conditions at the 24 week follow up. Concerned significant others in the CRAFT condition reported that 19 young adults (33%) engaged in help seeking by the 24 week follow up, whereas 17 young adults in the comparison condition engaged in help seeking behavior by the 24 week follow up. Young adults reportedly used a range of different types of services, though mostly formal treatment, with 29 engaging in municipality or regional addiction treatment services available publicly, 2 joining support groups, 2 receiving private addiction treatment, 1 receiving care through primary care services, and 1 using internet-based approach (one was not specified).
The researchers also did not find differences in parent report of young adult past month drug use days (e.g., cannabis), past month alcohol use days, hazardous drug use scores, or alcohol use scores. Concerned significant others in the CRAFT condition reported a 40.9% reduction in young adult drug use days, whereas those in the counseling condition reported a similar 36.4% reduction. Concerned significant others in the CRAFT condition reported a decrease in alcohol use days, specifically, for both CRAFT (25.5% reduction) and counseling (28.2%) conditions. Although concerned significant others in the comparison condition reported a significant reduction in the quantity of young adult alcohol consumption from baseline to the 24 week follow up, the change was not significantly different from the CRAFT condition.
The researchers found increases in relationship happiness as reported by the concerned significant other from baseline to the 24-week follow up in both conditions (21% increase in the CRAFT condition and a 27% increase in the comparison) though there was not a statistically significant difference in change in relationship happiness between conditions. There were no changes in any other secondary outcome from baseline to the 24-month follow-up, nor were there differences between conditions in secondary outcomes.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
This study found no effect of a CRAFT intervention for concerned significant others in increasing help seeking among young adults relative to an active comparison condition. This is contrary to previous studies that have demonstrated an effect of CRAFT in a more general sample of adults, most of which have been conducted in the United States. There are a number of factors that may explain this finding.
First, the researchers compared CRAFT to an active comparison condition that appeared to contain many of the elements that one might expect to see in a CRAFT intervention. For example, the counseling intervention covered material on functions of young adult substance use, social network mapping (for the concerned significant other and for the young adult), analyzing previous responses to young adult substance use and identifying unsuccessful versus successful strategies to guide future behaviors, and an overview of relational patterns in the family with an emphasis on encouraging joint activities and focusing on positive qualities.
Although the CRAFT intervention provides more detailed content related to understanding the dynamic impact of the concerned significant others’ behavior on the young adult’s substance use (e.g., use of a functional analysis procedure), the similar outcomes may be in part due to the overlap in content. It is important to note that the treatment outcomes observed were primarily formal treatment, so there were unlikely to be additional differences in the potency or dose of treatment that young adults may have engaged in.
Second, neither of these treatments may be potent enough to address the realities of young adult development and related substance use, and given the difference in efficacy relative to adult populations, it may be that CRAFT and the counseling comparison conditions were equally ineffective. Young adults report higher levels of alcohol and illicit drug use relative to any other age demographic. Developmentally, young adults are tasked with specific developmentally appropriate goals, such as achieving independence, identity exploration and formation, developing a social network, and finding a mate. Young adults are more prone to engage in risky behaviors and tend to exhibit lower levels of self-regulation than those in their late 20s or early 30s, as achievement of such developmental goals often require taking risks. Many report that alcohol and other substances can facilitate social connection and given the high rates of substance use in this age demographic, substance use may provide additional opportunities to achieve developmental goals, despite experiencing consequences. It is perhaps no surprise that young adults are the least likely age demographic to seek treatment, as well. Although the overall rates of help seeking at the end of the intervention in this sample are low relative to randomized clinical trials testing CRAFT for adults, these rates may be expected for young adults given the specific nature of this sample.
All young adult data was reported secondhand by the concerned significant other, so it is possible that young adult help seeking or substance use was different than what was reported in the study (e.g., compared to if the young adult reported their own treatment use or substance use).
Therapists were different across conditions. Though we have no reason to believe one set of therapists was more skilled than the other, it remains a possibility. Given that therapist effects can be powerful and each condition had different therapists, this design feature may have influenced treatment outcomes in unknown ways.
BOTTOM LINE
This randomized control trial comparing the efficacy of CRAFT with an active comparison for concerned significant others did not find differences in young help seeking behavior, young adult substance use, or concerned significant other outcomes such as anxiety, depression, or relationship happiness across the two conditions. Elements present in both – e.g., learning adaptive ways of responding to young adult substance use – may account for the lack of observed added benefits in CRAFT found in several other older adult-focused studies. Also, overall young adult treatment seeking was lower than when CRAFT is tested in adults. CRAFT interventions for concerned significant others of young adults may need to be modified to account for young adults’ specific developmental needs and realities that account for their higher levels of alcohol and other drug use.
For individuals and families seeking recovery: CRAFT has been shown to be effective for adults more broadly, but it may not be more effective than other approaches for increasing treatment seeking among young adults. Even so, the content included in CRAFT interventions may still be useful for improving interactions with young adults with harmful substance use. For example, parents’ relationship happiness with their loved ones increased equally in the CRAFT and the comparison treatment groups.
For treatment professionals and treatment systems: In this study, CRAFT for concerned significant others of young adults did not lead to greater rates of treatment seeking or reductions in substance use among young adults relative to another active comparison condition. The active comparison included some content similar to the CRAFT intervention, and it is possible that this accounts for the lack of difference. Even so, the researchers did not compare the results with no intervention, and CRAFT may be more effective than no intervention. Further, this intervention has been shown to be effective for general samples of concerned significant others of people with substance use disorder.
For scientists: The current study did not support CRAFT as an intervention for concerned significant others of young adults relative to counseling. Elements of this study, such as the smaller sample size or the characteristics of the comparison treatment condition, may account for this lack of effect. The low general level of treatment engagement and modest reductions in substance use suggest young adults may require a different approach to increase treatment seeking and to improve substance use outcomes. Studies should continue to understand mechanisms of behavior change among young adults and explore alternatives or adjuncts to CRAFT to increase treatment seeking.
For policy makers: Given that young adults consume substances at a higher rate than any other age demographic, and that substance use during this developmental period is predictive of the development of future substance use disorder, identifying ways to improve young adult treatment seeking is likely to pay substantive public health dividends. More funding in this area would help develop systemic research to enhance CRAFT or other interventions for this particular age population.
Young adults use alcohol and other drugs at a greater rate than any other age demographic . As a result, young adults experience the highest rates of alcohol and drug related harms. Approximately 14% of young adults in the United States meet criteria for a substance use disorder. However, only 10% of of these actually seek treatment in any given year. This may be, in part, due to the fact that young adults report lower motivation and/or perceived need for treatment, on average, compared to older adults. Attempts to increase motivation to reduce substance use and engagement with services, such as brief motivational interventions, demonstrate small to medium effect size reductions in substance use but still require the individual to make contact and engage with a mental health professional.
Often, close significant others such as parents, romantic partners, or adult children may experience secondhand harms, or witness firsthand harms, from their loved one’s substance use. The accompanying worry about harm to their loved one also motivates them to try to help their young adult loved one to get help.
Community Reinforcement Approach and Family Training (CRAFT) is a treatment approach designed specifically for concerned significant others to learn how modifying their own behavior can change the behavior of their loved one. There are three main goals in CRAFT: (1) to improve the quality of life of the concerned significant other; (2) to decrease substance use of the relative; and (3) to promote help-seeking behavior in the relative. CRAFT was developed in part as a person-centered alternative to the once Johnson Institute intervention (popularized by the TV show Intervention) in which family and friends participate in confronting the individual, using their relationships with the loved one as leverage to encourage them to go attend treatment. Randomized clinical trials have demonstrated that CRAFT is helpful at increasing the likelihood of treatment attendance compared to other interventions such as the Johnson Institute Intervention and Al-Anon facilitation . Despite these effects for concerned significant others of adults with substance use disorder, there have been no studies examining the utility of CRAFT for parents of young adults experiencing harms from substance use disorder.
The aim of the current RCT was to study the effect of CRAFT for parents of treatment-refusing young adults with hazardous substance use compared to counseling, with treatment entry for the young adults as the primary outcome and substance use for the young adults, relationship happiness, parental mental health, psychological flexibility, and quality of life as additional (secondary) outcomes.
HOW WAS THIS STUDY CONDUCTED?
This study used a randomized controlled parallel-group design to compare an 8 session CRAFT intervention to a 6-session active control comparison condition. The researchers included 113 parents (92% female) of young adults (87% male) in the study, with 58 randomized to the CRAFT condition and 55 randomized to the comparison condition.
Parents completed a survey at baseline (prior to randomization), 6 weeks (“mid-treatment”), 12 weeks (“post-treatment”), and 24 weeks. All young adult outcomes are based on parent report. The primary outcome measure was the rate of young adult “help seeking” at the 24 week follow up.
Young adults were considered help seeking if they engaged with any addiction treatment services, mutual-help groups such as Alcoholics or Narcotics Anonymous (AA or NA), primary care psychiatry, telephone support lines, or engaged with internet- or text-based content related to reducing substance use. Secondary outcomes included young adult substance use separated by alcohol and other drug use, young adult substance use severity separated by alcohol and other drug use, parent depression, anxiety, and stress, parent quality of life, parent relationship satisfaction, parent self-efficacy, psychological flexibility, and treatment satisfaction.
The CRAFT intervention was 8 sessions (45-60 minutes) long. Content included motivational enhancement, functional analysis of their loved one’s substance use, positive communication skills, managing own (parent) well-being, managing reward and consequences for young adult’s substance use, and role-playing discussion about treatment entry with child. The comparison condition included 5 individual 45-minute sessions and 1 group psychoeducational session. Content included young adult social network mapping, analysis of positive and negative responses to young adult substance use and understanding relational mapping of the family.
Participants were only included in the study if they were a parent (or had a similar relationship) to a young adult with hazardous substance use who refused to participate in treatment, they had contact (face-to-face or telephone) with the young adult at least 50% of days per week, and they self-declared a strong desire for the young adult to enter treatment. Concerned significant others were excluded if they met criteria for any substance use disorder (except nicotine) according to DSM-5 criteria, self-reported frequent use of illicit substances or psychological or cognitive impairments, participated in support intervention during the previous 3 months. The concerned significant other was also excluded if by their report the young adult: participated in treatment for substance use during the previous 30 days, met criteria for severe psychiatric conditions such as psychotic disorder, or behaved violently towards parent during the last year.
Participants were recruited between October 2018 and May 2021. Independent researchers conducted a pre-planned interim analysis when 70% of the proposed sample had been collected and determined that superiority for one condition over another would not be found within the planned sample size. This led to a premature discontinuation of recruitment, with 70% of the intended sample. Importantly, there were no differences between groups in primary or secondary outcomes. In each condition, four participants did not finish the treatment, and five did not report any data on treatment seeking at the 24 week follow up. The researchers were able to demonstrate that baseline demographic characteristics were not different between those that did and did not complete the study or provide treatment entry data.
Concerned significant others were primarily college educated females in their early 50s who had spent more than three weeks with the young adult on average in the past month. Most concerned significant others were employed (88%). Young adults were primarily males around 20 years of age. Just over half of concerned significant others identified cannabis as the primary problem substance for their young adult; approximately 10% identified alcohol as the primary substance, and the remaining third of concerned significant others identified some other substance as the primary problematic substance.
WHAT DID THIS STUDY FIND?
There was not a significant difference in young adult help seeking for harmful substance use between the CRAFT and comparison conditions at the 24 week follow up. Concerned significant others in the CRAFT condition reported that 19 young adults (33%) engaged in help seeking by the 24 week follow up, whereas 17 young adults in the comparison condition engaged in help seeking behavior by the 24 week follow up. Young adults reportedly used a range of different types of services, though mostly formal treatment, with 29 engaging in municipality or regional addiction treatment services available publicly, 2 joining support groups, 2 receiving private addiction treatment, 1 receiving care through primary care services, and 1 using internet-based approach (one was not specified).
The researchers also did not find differences in parent report of young adult past month drug use days (e.g., cannabis), past month alcohol use days, hazardous drug use scores, or alcohol use scores. Concerned significant others in the CRAFT condition reported a 40.9% reduction in young adult drug use days, whereas those in the counseling condition reported a similar 36.4% reduction. Concerned significant others in the CRAFT condition reported a decrease in alcohol use days, specifically, for both CRAFT (25.5% reduction) and counseling (28.2%) conditions. Although concerned significant others in the comparison condition reported a significant reduction in the quantity of young adult alcohol consumption from baseline to the 24 week follow up, the change was not significantly different from the CRAFT condition.
The researchers found increases in relationship happiness as reported by the concerned significant other from baseline to the 24-week follow up in both conditions (21% increase in the CRAFT condition and a 27% increase in the comparison) though there was not a statistically significant difference in change in relationship happiness between conditions. There were no changes in any other secondary outcome from baseline to the 24-month follow-up, nor were there differences between conditions in secondary outcomes.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
This study found no effect of a CRAFT intervention for concerned significant others in increasing help seeking among young adults relative to an active comparison condition. This is contrary to previous studies that have demonstrated an effect of CRAFT in a more general sample of adults, most of which have been conducted in the United States. There are a number of factors that may explain this finding.
First, the researchers compared CRAFT to an active comparison condition that appeared to contain many of the elements that one might expect to see in a CRAFT intervention. For example, the counseling intervention covered material on functions of young adult substance use, social network mapping (for the concerned significant other and for the young adult), analyzing previous responses to young adult substance use and identifying unsuccessful versus successful strategies to guide future behaviors, and an overview of relational patterns in the family with an emphasis on encouraging joint activities and focusing on positive qualities.
Although the CRAFT intervention provides more detailed content related to understanding the dynamic impact of the concerned significant others’ behavior on the young adult’s substance use (e.g., use of a functional analysis procedure), the similar outcomes may be in part due to the overlap in content. It is important to note that the treatment outcomes observed were primarily formal treatment, so there were unlikely to be additional differences in the potency or dose of treatment that young adults may have engaged in.
Second, neither of these treatments may be potent enough to address the realities of young adult development and related substance use, and given the difference in efficacy relative to adult populations, it may be that CRAFT and the counseling comparison conditions were equally ineffective. Young adults report higher levels of alcohol and illicit drug use relative to any other age demographic. Developmentally, young adults are tasked with specific developmentally appropriate goals, such as achieving independence, identity exploration and formation, developing a social network, and finding a mate. Young adults are more prone to engage in risky behaviors and tend to exhibit lower levels of self-regulation than those in their late 20s or early 30s, as achievement of such developmental goals often require taking risks. Many report that alcohol and other substances can facilitate social connection and given the high rates of substance use in this age demographic, substance use may provide additional opportunities to achieve developmental goals, despite experiencing consequences. It is perhaps no surprise that young adults are the least likely age demographic to seek treatment, as well. Although the overall rates of help seeking at the end of the intervention in this sample are low relative to randomized clinical trials testing CRAFT for adults, these rates may be expected for young adults given the specific nature of this sample.
All young adult data was reported secondhand by the concerned significant other, so it is possible that young adult help seeking or substance use was different than what was reported in the study (e.g., compared to if the young adult reported their own treatment use or substance use).
Therapists were different across conditions. Though we have no reason to believe one set of therapists was more skilled than the other, it remains a possibility. Given that therapist effects can be powerful and each condition had different therapists, this design feature may have influenced treatment outcomes in unknown ways.
BOTTOM LINE
This randomized control trial comparing the efficacy of CRAFT with an active comparison for concerned significant others did not find differences in young help seeking behavior, young adult substance use, or concerned significant other outcomes such as anxiety, depression, or relationship happiness across the two conditions. Elements present in both – e.g., learning adaptive ways of responding to young adult substance use – may account for the lack of observed added benefits in CRAFT found in several other older adult-focused studies. Also, overall young adult treatment seeking was lower than when CRAFT is tested in adults. CRAFT interventions for concerned significant others of young adults may need to be modified to account for young adults’ specific developmental needs and realities that account for their higher levels of alcohol and other drug use.
For individuals and families seeking recovery: CRAFT has been shown to be effective for adults more broadly, but it may not be more effective than other approaches for increasing treatment seeking among young adults. Even so, the content included in CRAFT interventions may still be useful for improving interactions with young adults with harmful substance use. For example, parents’ relationship happiness with their loved ones increased equally in the CRAFT and the comparison treatment groups.
For treatment professionals and treatment systems: In this study, CRAFT for concerned significant others of young adults did not lead to greater rates of treatment seeking or reductions in substance use among young adults relative to another active comparison condition. The active comparison included some content similar to the CRAFT intervention, and it is possible that this accounts for the lack of difference. Even so, the researchers did not compare the results with no intervention, and CRAFT may be more effective than no intervention. Further, this intervention has been shown to be effective for general samples of concerned significant others of people with substance use disorder.
For scientists: The current study did not support CRAFT as an intervention for concerned significant others of young adults relative to counseling. Elements of this study, such as the smaller sample size or the characteristics of the comparison treatment condition, may account for this lack of effect. The low general level of treatment engagement and modest reductions in substance use suggest young adults may require a different approach to increase treatment seeking and to improve substance use outcomes. Studies should continue to understand mechanisms of behavior change among young adults and explore alternatives or adjuncts to CRAFT to increase treatment seeking.
For policy makers: Given that young adults consume substances at a higher rate than any other age demographic, and that substance use during this developmental period is predictive of the development of future substance use disorder, identifying ways to improve young adult treatment seeking is likely to pay substantive public health dividends. More funding in this area would help develop systemic research to enhance CRAFT or other interventions for this particular age population.
Young adults use alcohol and other drugs at a greater rate than any other age demographic . As a result, young adults experience the highest rates of alcohol and drug related harms. Approximately 14% of young adults in the United States meet criteria for a substance use disorder. However, only 10% of of these actually seek treatment in any given year. This may be, in part, due to the fact that young adults report lower motivation and/or perceived need for treatment, on average, compared to older adults. Attempts to increase motivation to reduce substance use and engagement with services, such as brief motivational interventions, demonstrate small to medium effect size reductions in substance use but still require the individual to make contact and engage with a mental health professional.
Often, close significant others such as parents, romantic partners, or adult children may experience secondhand harms, or witness firsthand harms, from their loved one’s substance use. The accompanying worry about harm to their loved one also motivates them to try to help their young adult loved one to get help.
Community Reinforcement Approach and Family Training (CRAFT) is a treatment approach designed specifically for concerned significant others to learn how modifying their own behavior can change the behavior of their loved one. There are three main goals in CRAFT: (1) to improve the quality of life of the concerned significant other; (2) to decrease substance use of the relative; and (3) to promote help-seeking behavior in the relative. CRAFT was developed in part as a person-centered alternative to the once Johnson Institute intervention (popularized by the TV show Intervention) in which family and friends participate in confronting the individual, using their relationships with the loved one as leverage to encourage them to go attend treatment. Randomized clinical trials have demonstrated that CRAFT is helpful at increasing the likelihood of treatment attendance compared to other interventions such as the Johnson Institute Intervention and Al-Anon facilitation . Despite these effects for concerned significant others of adults with substance use disorder, there have been no studies examining the utility of CRAFT for parents of young adults experiencing harms from substance use disorder.
The aim of the current RCT was to study the effect of CRAFT for parents of treatment-refusing young adults with hazardous substance use compared to counseling, with treatment entry for the young adults as the primary outcome and substance use for the young adults, relationship happiness, parental mental health, psychological flexibility, and quality of life as additional (secondary) outcomes.
HOW WAS THIS STUDY CONDUCTED?
This study used a randomized controlled parallel-group design to compare an 8 session CRAFT intervention to a 6-session active control comparison condition. The researchers included 113 parents (92% female) of young adults (87% male) in the study, with 58 randomized to the CRAFT condition and 55 randomized to the comparison condition.
Parents completed a survey at baseline (prior to randomization), 6 weeks (“mid-treatment”), 12 weeks (“post-treatment”), and 24 weeks. All young adult outcomes are based on parent report. The primary outcome measure was the rate of young adult “help seeking” at the 24 week follow up.
Young adults were considered help seeking if they engaged with any addiction treatment services, mutual-help groups such as Alcoholics or Narcotics Anonymous (AA or NA), primary care psychiatry, telephone support lines, or engaged with internet- or text-based content related to reducing substance use. Secondary outcomes included young adult substance use separated by alcohol and other drug use, young adult substance use severity separated by alcohol and other drug use, parent depression, anxiety, and stress, parent quality of life, parent relationship satisfaction, parent self-efficacy, psychological flexibility, and treatment satisfaction.
The CRAFT intervention was 8 sessions (45-60 minutes) long. Content included motivational enhancement, functional analysis of their loved one’s substance use, positive communication skills, managing own (parent) well-being, managing reward and consequences for young adult’s substance use, and role-playing discussion about treatment entry with child. The comparison condition included 5 individual 45-minute sessions and 1 group psychoeducational session. Content included young adult social network mapping, analysis of positive and negative responses to young adult substance use and understanding relational mapping of the family.
Participants were only included in the study if they were a parent (or had a similar relationship) to a young adult with hazardous substance use who refused to participate in treatment, they had contact (face-to-face or telephone) with the young adult at least 50% of days per week, and they self-declared a strong desire for the young adult to enter treatment. Concerned significant others were excluded if they met criteria for any substance use disorder (except nicotine) according to DSM-5 criteria, self-reported frequent use of illicit substances or psychological or cognitive impairments, participated in support intervention during the previous 3 months. The concerned significant other was also excluded if by their report the young adult: participated in treatment for substance use during the previous 30 days, met criteria for severe psychiatric conditions such as psychotic disorder, or behaved violently towards parent during the last year.
Participants were recruited between October 2018 and May 2021. Independent researchers conducted a pre-planned interim analysis when 70% of the proposed sample had been collected and determined that superiority for one condition over another would not be found within the planned sample size. This led to a premature discontinuation of recruitment, with 70% of the intended sample. Importantly, there were no differences between groups in primary or secondary outcomes. In each condition, four participants did not finish the treatment, and five did not report any data on treatment seeking at the 24 week follow up. The researchers were able to demonstrate that baseline demographic characteristics were not different between those that did and did not complete the study or provide treatment entry data.
Concerned significant others were primarily college educated females in their early 50s who had spent more than three weeks with the young adult on average in the past month. Most concerned significant others were employed (88%). Young adults were primarily males around 20 years of age. Just over half of concerned significant others identified cannabis as the primary problem substance for their young adult; approximately 10% identified alcohol as the primary substance, and the remaining third of concerned significant others identified some other substance as the primary problematic substance.
WHAT DID THIS STUDY FIND?
There was not a significant difference in young adult help seeking for harmful substance use between the CRAFT and comparison conditions at the 24 week follow up. Concerned significant others in the CRAFT condition reported that 19 young adults (33%) engaged in help seeking by the 24 week follow up, whereas 17 young adults in the comparison condition engaged in help seeking behavior by the 24 week follow up. Young adults reportedly used a range of different types of services, though mostly formal treatment, with 29 engaging in municipality or regional addiction treatment services available publicly, 2 joining support groups, 2 receiving private addiction treatment, 1 receiving care through primary care services, and 1 using internet-based approach (one was not specified).
The researchers also did not find differences in parent report of young adult past month drug use days (e.g., cannabis), past month alcohol use days, hazardous drug use scores, or alcohol use scores. Concerned significant others in the CRAFT condition reported a 40.9% reduction in young adult drug use days, whereas those in the counseling condition reported a similar 36.4% reduction. Concerned significant others in the CRAFT condition reported a decrease in alcohol use days, specifically, for both CRAFT (25.5% reduction) and counseling (28.2%) conditions. Although concerned significant others in the comparison condition reported a significant reduction in the quantity of young adult alcohol consumption from baseline to the 24 week follow up, the change was not significantly different from the CRAFT condition.
The researchers found increases in relationship happiness as reported by the concerned significant other from baseline to the 24-week follow up in both conditions (21% increase in the CRAFT condition and a 27% increase in the comparison) though there was not a statistically significant difference in change in relationship happiness between conditions. There were no changes in any other secondary outcome from baseline to the 24-month follow-up, nor were there differences between conditions in secondary outcomes.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
This study found no effect of a CRAFT intervention for concerned significant others in increasing help seeking among young adults relative to an active comparison condition. This is contrary to previous studies that have demonstrated an effect of CRAFT in a more general sample of adults, most of which have been conducted in the United States. There are a number of factors that may explain this finding.
First, the researchers compared CRAFT to an active comparison condition that appeared to contain many of the elements that one might expect to see in a CRAFT intervention. For example, the counseling intervention covered material on functions of young adult substance use, social network mapping (for the concerned significant other and for the young adult), analyzing previous responses to young adult substance use and identifying unsuccessful versus successful strategies to guide future behaviors, and an overview of relational patterns in the family with an emphasis on encouraging joint activities and focusing on positive qualities.
Although the CRAFT intervention provides more detailed content related to understanding the dynamic impact of the concerned significant others’ behavior on the young adult’s substance use (e.g., use of a functional analysis procedure), the similar outcomes may be in part due to the overlap in content. It is important to note that the treatment outcomes observed were primarily formal treatment, so there were unlikely to be additional differences in the potency or dose of treatment that young adults may have engaged in.
Second, neither of these treatments may be potent enough to address the realities of young adult development and related substance use, and given the difference in efficacy relative to adult populations, it may be that CRAFT and the counseling comparison conditions were equally ineffective. Young adults report higher levels of alcohol and illicit drug use relative to any other age demographic. Developmentally, young adults are tasked with specific developmentally appropriate goals, such as achieving independence, identity exploration and formation, developing a social network, and finding a mate. Young adults are more prone to engage in risky behaviors and tend to exhibit lower levels of self-regulation than those in their late 20s or early 30s, as achievement of such developmental goals often require taking risks. Many report that alcohol and other substances can facilitate social connection and given the high rates of substance use in this age demographic, substance use may provide additional opportunities to achieve developmental goals, despite experiencing consequences. It is perhaps no surprise that young adults are the least likely age demographic to seek treatment, as well. Although the overall rates of help seeking at the end of the intervention in this sample are low relative to randomized clinical trials testing CRAFT for adults, these rates may be expected for young adults given the specific nature of this sample.
All young adult data was reported secondhand by the concerned significant other, so it is possible that young adult help seeking or substance use was different than what was reported in the study (e.g., compared to if the young adult reported their own treatment use or substance use).
Therapists were different across conditions. Though we have no reason to believe one set of therapists was more skilled than the other, it remains a possibility. Given that therapist effects can be powerful and each condition had different therapists, this design feature may have influenced treatment outcomes in unknown ways.
BOTTOM LINE
This randomized control trial comparing the efficacy of CRAFT with an active comparison for concerned significant others did not find differences in young help seeking behavior, young adult substance use, or concerned significant other outcomes such as anxiety, depression, or relationship happiness across the two conditions. Elements present in both – e.g., learning adaptive ways of responding to young adult substance use – may account for the lack of observed added benefits in CRAFT found in several other older adult-focused studies. Also, overall young adult treatment seeking was lower than when CRAFT is tested in adults. CRAFT interventions for concerned significant others of young adults may need to be modified to account for young adults’ specific developmental needs and realities that account for their higher levels of alcohol and other drug use.
For individuals and families seeking recovery: CRAFT has been shown to be effective for adults more broadly, but it may not be more effective than other approaches for increasing treatment seeking among young adults. Even so, the content included in CRAFT interventions may still be useful for improving interactions with young adults with harmful substance use. For example, parents’ relationship happiness with their loved ones increased equally in the CRAFT and the comparison treatment groups.
For treatment professionals and treatment systems: In this study, CRAFT for concerned significant others of young adults did not lead to greater rates of treatment seeking or reductions in substance use among young adults relative to another active comparison condition. The active comparison included some content similar to the CRAFT intervention, and it is possible that this accounts for the lack of difference. Even so, the researchers did not compare the results with no intervention, and CRAFT may be more effective than no intervention. Further, this intervention has been shown to be effective for general samples of concerned significant others of people with substance use disorder.
For scientists: The current study did not support CRAFT as an intervention for concerned significant others of young adults relative to counseling. Elements of this study, such as the smaller sample size or the characteristics of the comparison treatment condition, may account for this lack of effect. The low general level of treatment engagement and modest reductions in substance use suggest young adults may require a different approach to increase treatment seeking and to improve substance use outcomes. Studies should continue to understand mechanisms of behavior change among young adults and explore alternatives or adjuncts to CRAFT to increase treatment seeking.
For policy makers: Given that young adults consume substances at a higher rate than any other age demographic, and that substance use during this developmental period is predictive of the development of future substance use disorder, identifying ways to improve young adult treatment seeking is likely to pay substantive public health dividends. More funding in this area would help develop systemic research to enhance CRAFT or other interventions for this particular age population.
