PSYCHOSOCIAL INTERVENTIONS IN TREATING SUBSTANCE ABUSE
Empirically-supported Psychosocial Interventions in Treating Substance Abuse
The Citadel Graduate College
PSYC 540 – Alcohol and Substance Abuse Counseling
March 2019
CWID 10623262
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PSYCHOSOCIAL INTERVENTIONS IN TREATING SUBSTANCE ABUSE
With over 130 people dying from opioid overdose in the United States every day, the opioid
crisis has propelled its way to the center of national attention in recent years. The abuse of and
addiction to opioids has incited a profound effect not only on public health, but on the social and
economic well-being of our nation as well, incurring an estimated burden of $78.5 billion a year
by the Centers for Disease Control and Prevention. The NIH reports that approximately 21-29%
of individuals receiving opioids for chronic pain misuse their prescriptions and between 8-12% go
on to develop an opioid use disorder. Furthermore, 4-6% of those who misuse opioids switch to
using heroin and has been linked to increases in the spread of HIV and hepatitis C 6. These rising
rates of abuse and overdose necessitate the urgent development of effective treatment interventions
and preventative measures.
The focus of this report is to investigate several empirically-supported psychosocial
interventions that have demonstrated positive outcomes in the treatment of substance use and
dependence. These strategies not only provide support and training to the substance-abusing
individuals, but also assess the contributing social and environmental factors that lead to relapse
and incorporate family members and concerned loved ones affected by their drug use. These
interventions have demonstrated promising results for engaging individuals who are resistant to
treatment, reducing rates of drug use, and increasing family cohesion and functioning.
Furthermore, some of these interventions have also generated results that suggest they may be
effective in preventing future drug use in a variety of at-risk populations.
1. Brigham et al., 2014
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PSYCHOSOCIAL INTERVENTIONS IN TREATING SUBSTANCE ABUSE
The goal of this randomized clinical trial was to determine whether or not the addition of
Community Reinforcement and Family Training for Treatment Retention (CRAFT-T) would
increase treatment retention rates and reduce drug use in adult patients voluntarily participating in
opioid detoxification followed by outpatient treatment. The CRAFT model incorporates the
involvement of concerned significant others (CSOs) by teaching them behavior principles to help
motivate substance-abusing individuals to engage in treatment. In several previous randomized
clinical trials, CRAFT has exhibited a robust effect, however, it is unclear whether CRAFT can be
used to prevent dropout and to support risk-reduction in other ways. This clinical trial evaluated a
modified version of the CRAFT model that differed in several key ways: it worked with CSOs of
identified patients (IPs) who were already involved in treatment; the CSOs were selected by the
IP; retention in treatment was targeted; the IP participated with the CSO in the first two sessions;
and it additionally aimed to reduce HIV-risk behavior.
This randomized clinical trial included 52 dyads with one identified patient (IP) and one
concerned significant other (CSO). IPs were recruited during their participation in a detox program
and those interested specified the contact information for a CSO, who then was presented with the
study and provided their own consent. In order to participate, IPs had to meet DSM-IV criteria for
opioid dependence as determined by a Clinical Structured Interview, be planning to attend
outpatient treatment following detox, and have a willing CSO. CSOs could be a spouse, relative,
intimate partner, or someone planning to live with the IP. Exclusion criteria included a history of
violence between IP and CSO, current suicidal or homicidal intent, any medical or psychiatric
disorder that would impede participation, and a court order to complete treatment. Participants
were randomly assigned to one of two groups, the treatment as usual (TAU) control group or the
CRAFT-T treatment group. IPs in the TAU group received the standard services provided by the
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PSYCHOSOCIAL INTERVENTIONS IN TREATING SUBSTANCE ABUSE
detox treatment program and CSOs in the TAU group were invited to attend a support group and
provided an informal referral to self-help resources. The CRAFT-T treatment group involved 12
weekly, 1-hour sessions, in addition to two additional optional sessions, that worked primarily
with the CSO to learn and implement behavioral techniques intended to improve the IPs retention
to treatment and reduce drug use. The IPs in the CRAFT-T group attended the initial two sessions
with the CSO. Participants were primarily evaluated on the IP’s first cessation of 30 or more days
from treatment, as recorded in the clinic’s electronic health record. Other measures involved a
timeline follow-back (TLFB) procedure that was employed to record the IP’s daily use of drugs
and alcohol and a urinalysis was conducted and evaluated at each IP’s subsequent research visits.
The results of this study found no significant differences between groups at baseline
assessment. In the CRAFT-T treatment group, on average, IPs attended 1.78 (median=2) of the
two scheduled CRAFT-T sessions and CSOs attended of 7.62 (median=9.5) of the twelve CRAFTT sessions. Of the 52 dyads, 3 dropped out before their initial session. Eight CSOs attended one
of the two additional optional sessions and two CSOs attended both. Participants in the CRAFTT condition demonstrated a longer time-to-dropout (p = .058) and were 57% as likely to drop out
at any given time when compared to the TAU group. While these results are not statistically
significant, CRAFT-T participants with CSOs that were their parents did show a significantly
longer time-to-dropout (p < .01) and were 40% as likely to drop out at any given time. These
results support previous findings by Meyers et al. (1998) which indicate that parents are more
effective in improving IP treatment retention rates compared to spouses. Although relapse rates
and drug use were still high, this study also found that placement in the CRAFT-T treatment group
resulted in fewer days of opioid and drug use.
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PSYCHOSOCIAL INTERVENTIONS IN TREATING SUBSTANCE ABUSE
One of the most important strengths of this study is its randomized clinical trial design that
was built on the foundation of previous empirically supported randomized clinical studies. The
CRAFT-T treatment was also manualized which provides the advantage of reducing the potential
variability associated with different therapists providing treatment. These characteristics lend
themselves to the study’s ability to be replicated in the future and the potential for additional
validation of its results. Some of the limitations of this study were its small sample size which
restricts its generalizability to populations that are not white males and furthermore, its statistical
power. This study also lacks the ability to effectively evaluate the nature of the relationship
between the IP and CSO, which from the results of this study, appears to be a potentially significant
factor affecting an IP’s adherence to treatment. These limitations aside, the results of this study
are important as they illustrate the promising positive impact of biopsychosocial influences on an
IP’s retention to treatment and reduction of drug use. Although this study disqualified participants
who were court ordered, these results provide evidence in support of CRAFT-T as a starting point
for addressing the estimated 2.3 million Americans with an opioid-dependence disorder. This
provides a basis and direction for future studies that might improve our ability to effectively help
those who are actively seeking help with opioid dependence.
2. Manuel et al., 2012
The goal of this randomized clinical pilot study was to identify evidence-based treatment
options that were also low-cost for family members of substance-abusing individuals concerned
with their refusal to engage in treatment. More specifically, this study sought to assess the
effectiveness of Group and Self-Directed Community Reinforcement and Family Training
(CRAFT) modalities to determine if they provided similar results as the individual CRAFT
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PSYCHOSOCIAL INTERVENTIONS IN TREATING SUBSTANCE ABUSE
approach. Researchers hypothesized that concerned significant others (CSOs) in the Group
CRAFT condition would be more effective than Self-Directed CRAFT participants in engaging
identified patients (IPs) in treatment due to increased attention from the therapist and support
provided to the CSOs in the Group CRAFT condition. They also predicted that participants in
both the Group and Self-Directed CRAFT conditions would report meaningful increases in CSO
and family functioning from assessment at baseline to follow-up; and additionally, anticipated that
Group CRAFT participants would report better advancements in CSO and family functioning at
follow-up sessions.
Of the 75 CSOs recruited, 46 met eligibility criteria for the study and 40 were enrolled to
participate after a baseline screening. In the baseline assessment, CSOs reported on their own
psychological functioning and family atmosphere by completing the Beck Depression Inventory
(BDI-II), the Physical Symptoms Scale from the Health and Daily Living Form, the State Trait
Anxiety Inventory (STAI), the State Trait Anger Expression Inventory (STAXI-2), the Family
Environment Scale, and the Center on Alcoholism, Substance Abuse and Addictions Drug
Efficacy Scale. CSOs were then assigned to either the Group CRAFT condition or the SelfDirected CRAFT condition. CSOs in both conditions were provided with the CRAFT self-help
book which provided instructions and guidelines for implementing the CRAFT model. CSOs in
the Group CRAFT condition were offered twelve 1-hour sessions of group CRAFT therapy given
by therapists trained by the developer of the CRAFT approach. CSOs in the Self-Directed CRAFT
condition were only given a copy of the CRAFT self-help book and told that free treatment was
available should their IP decide to engage in treatment. Subsequent interviews to follow up with
CSOs were conducted at 3- and 6-months.
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PSYCHOSOCIAL INTERVENTIONS IN TREATING SUBSTANCE ABUSE
The results of this study found that 60% of the CSOs in the Group CRAFT condition were
able to engage their IP in treatment compared to 40% of the CSOs in the Self-Directed CRAFT
condition, although this was not a statistically significant difference (p = .20). However, the
difference between engagement rates of the Group CRAFT CSOs who attended at least one group
session (71%) and the Self-Directed CSOs (40%) did approach significance (p = .06). This lends
itself in support of group CRAFT being a viable, cost-effective substitute for individual CRAFT
treatment.
Although partners had higher engagement rates (62.5%) than parents (52%), the
relationship between the CSO and the IP did not indicate any significant differences. No betweengroup differences were found on any of CSO or family functioning measures except for CSO
efficacy at the 3-month follow-up (p = .044). This may be a result of less individualized attention
due to the group treatment modality.
Within-groups, CSOs did not report significant
improvements in their own psychological functioning at 3-months but reported significant
decreases in anger at 6-months (p = .024). They also reported significant improvements in family
functioning at 3-months (p = .021) and 6-months (p = .018). This may potentially be accounted
for by the tendency for CSOs to be highly motivated.
The results of this study lend themselves in support of Group CRAFT being an effective
modality for the delivery of an evidence-based treatment. One important limitation of this study
is that the group condition was not directly compared to a control group or an individual CRAFT
group. This study also has limited power as the sample size was relatively small. However, the
results suggest that Group CRAFT treatment may provide a more cost-effective option as
individual treatment tends to be more expensive than group treatment. It may also provide
effective treatment that is accessible to a higher volume of people at a faster rate given the sparsity
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PSYCHOSOCIAL INTERVENTIONS IN TREATING SUBSTANCE ABUSE
of clinicians available for individual treatment and high rates of individuals seeking treatment for
drug use.
3. Abbott et al., 1998
This clinical trial aimed to determine the efficacy of the Community Reinforcement
Approach (CRA) in opiate-dependent individuals on methadone maintenance compared to
standard counseling interventions.
Grounded in social learning theory, the Community
Reinforcement Approach involves the identification and reorganization of both personal and
community reinforcers with the goal of avoiding cues that lead to drug use and positively
reinforcing abstinence. Random weekly observed urine drug screens and Addiction Severity Index
(ASI) scores obtained at intake and a 6-month follow up were compared.
Researchers
hypothesized that participants in the CRA treatment condition would yield more effective results
than those receiving standard counseling intervention alone.
Subjects for this study included 180 voluntary participants recruited from a large drug
treatment center. Participants were randomly assigned to one of three treatment conditions:
standard, CRA, and CRA with relapse prevention (CRA/RP). Participants in all conditions were
placed on methadone maintenance protocols before their initial counseling sessions. All were
provided with 20 treatment sessions with the exception of the CRA/RP condition in which
participants received 6 additional relapse prevention sessions. However, due to the limited number
of relapse prevention sessions completed at the 6-month follow-up, the two CRA conditions were
combined for analysis. Sessions were scheduled twice a week for the first two weeks in attempt
to increase engagement and retention rates, and then once a week until the completion of treatment.
The standard treatment condition was modeled after Philadelphia’s Veteran Affairs Medical
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PSYCHOSOCIAL INTERVENTIONS IN TREATING SUBSTANCE ABUSE
Center’s methadone counselors’ manual which entailed a review of the program’s rules,
comprehensive treatment plans, access to methadone maintenance protocols, random weekly urine
drug analyses, AIDS information, and counseling sessions that concentrated on the individual’s
current issues. The CRA treatment condition entailed an initial explanation of CRA and a
functional analysis of specific reinforcers in all areas of the individual’s life as well as drug use
cues to promote abstinence. Subsequent sessions involved the development of problem-solving,
communication, and social skills as well as drug refusal training. Participants with significant
others in this condition were also provided with couples counseling sessions.
The results of this study found that the combined CRA conditions had an average of 22.14
negative drug screens for opiates compared to 20.90 in the standard condition when missing drug
screens were not included. Furthermore, these results were consistent when missing drug screens
were included and considered either negative or positive, indicating a trend favoring the CRA
conditions (p = .076). Between-group differences were also found with ASI drug composite scores
in which the combined CRA conditions indicated a higher degree of improvement than the
standard condition (p = .038). These results support the addition of CRA treatment strategies to
opiate-dependent individuals on methadone maintenance in reducing drug use.
Because the population in this study was primarily Hispanic (78.9%), this study is limited
in its ability to generalize to other ethnic groups. Another limitation includes the additional
counseling sessions provided to the CRA/RP condition, although they only attended an average of
1.06 additional RP sessions. However, this study did include and account for individuals with
comorbid psychiatric disorders, who are often screened out, and the results suggest potential
improvements in abstaining from drug use in these populations.
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PSYCHOSOCIAL INTERVENTIONS IN TREATING SUBSTANCE ABUSE
4. Robbins et al., 2011
The goal of this multisite randomized trial was to determine the efficacy of brief strategic
family therapy (BSFT) compared to treatment as usual (TAU) that is standard in adolescent
outpatient programs for drug abuse. BSFT is an evidence-based family therapy that has been
previously demonstrated to be an effective treatment for adolescents with substance use and
behavior problems. The goal of BSFT is to reduce problematic behavior in adolescents by
improving relationships within the family system, improving relationships between the family
system and other important systems in the adolescent’s life, like school and peers, and to increase
engagement rates. BSFT has been shown to be effective in increasing rates of engagement and
retention to treatment, reducing substance use in adolescents, and improving family functioning.
As such, researchers hypothesized that the BSFT condition would be more effective in its ability
to engage and retain participants in treatment, reduce substance use, and also in improve family
functioning compared to the TAU condition.
Participants in this study included 480 adolescents between the ages 13 and 17 years old
and their family members that were recruited from 8 different outpatient community treatment
centers located across the United States and U.S. Territories. Enrollment required that adolescents
self-report the use illicit drugs other than tobacco and alcohol within 30 days prior to baseline
assessment or be referred from an institution for drug abuse treatment.
Participants were
randomized to groups following baseline assessment. Drug abuse was assessed using the Timeline
Follow-Back (TLFB) and urinalysis, both administered at baseline and 12 monthly follow-up
sessions. Family functioning and parenting style was assessed using the Parenting Practices
Questionnaire from the Chicago Youth Development Study. Family cohesion and conflict were
measured using the Family Environment Scale. The BSFT condition involved multiple family
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members engaging in 12 to 16 hour-long sessions given over a period of 4 months. The TAU
condition varied across treatment centers but included individual and/or group therapy, parent
training, case management, and non-manualized family therapy at least once per week.
Results analyzing participants’ engagement, retention, and attendance showed that the rate
of failure to engage in the BSFT condition was 11.4% compared to 26.8% in TAU (p < .001). The
rate of failure to retain in treatment in the BSFT condition was 40.0% compared to 56.6% in TAU
(p < .02). Finally, the BSFT condition showed 48.6% of cases with unexpected terminations
compared to 70.2% in TAU. Attendance was also significantly higher in the BSFT condition
compared to TAU (p < .02). No significant differences were found in engagement or retention by
ethnicity or gender. Interestingly, independent of condition, when compared to Whites, African
Americans were more likely to fail to engage and Hispanics were less likely to fail to engage.
Analysis of drug use showed that compared to the BSFT condition, the median number of drug
use days was significantly higher in TAU and living with both biological parents was associated
with lower drug use by self-report over time. Finally, adolescent participants in both treatment
conditions reported significant improvements in family functioning over time.
The results of this study support the effectiveness of BSFT in engaging and retaining
adolescents in treatment compared to TAU. Some strengths of this study include its randomized
clinical design and larger sample size compared to other studies which make these results more
generalizable. One notable limitation was the low rate of drug use reported by participants which
may have been a result of the referral process because adolescents that enrolled directly from a
residential program would not likely have had opportunities to use drugs before participating.
However, the results of this study indicate a need for future studies to investigate more effective
interventions for engaging and retaining African American adolescents with substance abuse
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issues in treatment as only 25% retained in treatment in the TAU condition and 50% in the BFST
condition.
5. Brody et al., 2019
The goal of this longitudinal randomized controlled trial was to determine the effectiveness
of the Strong African American Families (SAAF) program compared to a control condition in
reducing drug use and body mass index (BMI) in young African American adults from low
socioeconomic status (SES) environments. The SAAF program was designed with the intent of
improving the supportive caregiving process which in turn promotes positive socio-emotional
development in adolescents. This is achieved by improving the relationship between adolescents
and their caregivers, structuring home environments so that they are more predictable and routine,
training parents to be consistent in how they discipline their children, and also facilitating parenting
practices that are not harsh. Previous studies have shown that improvements in these caregiving
processes have favorable outcomes for adolescents as far as their ability to self-regulate and be
achievement-oriented, inhibit not only drug use, but also issues with conduct and association with
negative peers during adolescence. Furthermore, it is conceptualized that improvements in
supportive parenting techniques will aid in buffering the negative impact of life stress on these
individuals which has been associated with self-medicating behaviors later in adulthood, namely,
increased drug use in African American men and higher BMI in African American women.
Researchers hypothesized that participants in the SAAF condition would have gender-specific
effects, with reduced drug use in men and reduced BMI in women.
Participants included 667 African American families recruited from rural communities in
Georgia when the adolescents were 11 years old. They were randomly assigned to either the SAAF
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or control condition. Data assessing SES disadvantage and supportive parenting was acquired at
ages 11 and 16 years old. Data assessing drug use and BMI was later collected from 520
participants, randomly selected due to a lack of funding, when the adolescents reached ages
between 19-21 and 25 years old. The SAAF condition entailed 7 group treatment sessions
involving separate youth and parent skills training in addition to a family session in which the
skills learned separately were practiced. These group sessions included role-plays and guided
discussions and were all led by African American group leaders.
For women, the results of this study found a significant association between neighborhood
SES disadvantage at ages 11 and 16 and higher BMI at ages 19-25 in the control group (p < .001)
but not in the SAAF condition (p = .820). For men, there was no significant association between
neighborhood SES disadvantage and BMI in either condition. Concerning drug use, for men, a
significant association was found between neighborhood SES disadvantage at ages 11 and 16 and
increased drug use at ages 19-25 in the control group (p = .003) but not in the SAAF condition (p
= .650).
For women, drug use was not significantly associated with neighborhood SES
disadvantage in either condition. These results indicate more favorable outcomes for individuals
in the SAAF condition compared to the control group and suggest that interventions designed for
improving supportive parenting techniques during adolescence may lead to reductions in drug use
for low SES Black men and reductions in BMI for low SES Black women in adulthood.
One of the most important strengths of this study is its longitudinal design across nearly 14
years that utilized data from a randomly assigned trial. However, this study is limited in its
generalizability to groups in more urban areas.
It also does not examine any prospective
explanations behind the elevated rates of drug use in men and not women and the elevated BMI in
women and not men. However, the results of this study most notably address a significant issue
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previously unanswered in the present literature concerning rates of drug use in African American
individuals and demonstrated, for the first time, that participation in an intervention targeting
supportive parenting mitigated the negative impact of growing up in a low SES environment on
unhealthy behaviors that frequently lead to chronic disease and addiction.
In conclusion, there is encouraging evidence to support the growing body of research
suggesting efficacy of psychosocial interventions on increasing treatment engagement and
retention rates of substance-abusing individuals. The results of these studies suggest that treatment
of not only the individual, but of the entire support system in an individual’s environment may
provide the most advantageous outcomes for individuals in the recovery process. While assessing
individual factors that lead to relapse and training problem solving skills may aid in this process,
incorporating and developing social supports appear to promote more successful outcomes for the
substance-abusing individuals and their families, especially when substance-abusing individuals
are not motivated to adhere to treatment. By educating important individuals within their spheres
of influence on appropriate and effective methods of dealing with their loved one’s behavior, they
might more effectively manage it. Furthermore, these studies provide supportive evidence for
reducing drug use by intervening earlier and addressing the environmental and social stressors that
may lead individuals to use in the first place. While this body of research is by no means
conclusive, it is an assuring starting point in addressing the problematic crisis we face today.
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References
1. Brigham, G. S., Slesnick, N., Winhusen, T. M., Lewis, D. F., Guo, X., & Somoza, E.
(2014). A randomized pilot clinical trial to evaluate the efficacy of Community
Reinforcement and Family Training for Treatment Retention (CRAFT-T) for improving
outcomes for patients completing opioid detoxification. Drug and Alcohol Dependence
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Smith, J. E., & Bogenschiutz, M. P. (2012). Community Reinforcement and Family
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3. Abbott, P. J., Weller, S. B., Delaney, H. D., Moore, B. A. (1998). Community
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Abuse, 24(1), 17-30
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5. Brody, G. H., Yu, T., Miller, G. E., Ehrlich, K. B., & Chen, E. (2019). Preventative
parenting intervention during childhood and young black adults’ unhealthful behaviors: a
randomized controlled trial. The Journal of Child Psychology and Psychiatry, 60(1). 6371. Retrieved from doi: 10.1111/jcpp.12968
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CWID 10623262
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