“CRAFT Connect: Engaging families in recovery of their loved one from substance use and or mental health disorders” conference presentation
Let’s talk about Behavioral Health. Recovery from a substance use and or mental health disorder is a process of change through which individuals improve their health and wellness, live independently and strive to reach their full potential. Watch this group of 22-to-25-year old’s cry out for help.
Watch: https://www.youtube.com/watch?v=CTsB-llTzyc
In a December 2020 interview with The Sunday Times when asked if The Beatles experienced behavioral health issues, Paul McCartney (age 78) responded: “Yes, I think so. But (we) talked about it through (our) songs.”
YOUR CONCERNED SIGNIFICANT OTHERS (CSOs) ACTIVITY
Step 1: Think about the people in your life – parents, partners, spouses, siblings, children, friends, co-workers or members of the community -- you feel a particularly strong connection with, who support you “when you are feeling down and help you get your feet back on the ground.” These could be people you spend holidays or birthdays with. Whose praise or encouragement makes you feel good. Who regularly text, phone or email you. People you “appreciate being around.” These are your Concerned Significant Others (CSOs).
Step 2: Identify why you feel close to them.
Step 3: Write down one-word qualities these relationships have in common.
Step 4: Share those qualities with the group.
(If you need help identifying who your CSOs are, turn to the “Social Support Worksheet” at the end of this session.)
1. Chronic diseases can be managed. There is hope. Treatment has made wellness and recovery a reality for people living with substance use and or mental health disorders. Recovery is not about getting rid of our or our loved one’s mental health or substance use problems but seeing beyond them, recognizing and fostering their abilities, interests and dreams. These are chronic conditions. Relapsing to unwanted behaviors is not only possible but also likely with symptom recurrence rates similar to diabetes (20% to 50%), hypertension (50% to 70%) and asthma (50% to 70%). (NIDA, July 2019, U.S. HHS, 2016, p. 4-15).
2. “Clinical” Recovery involves diagnosis, objective measures of symptom management and remission, and psychosocial functioning, as rated by behavioral health professionals. (Davidson & Roe, 2007; Slade, 2009). “Personal” Recovery is an ongoing, lifelong, and highly subjective process. Key concepts in the recovery process include hope, personal responsibility, self-advocacy, and wellness); empowerment and self-determination); and acceptance (Deegan, 1996a); (Mead & Copeland, 2000); (Ahern & Fisher, 1999, 2001; Fisher, 1999; Frese & Davis, 1997; (Spaniol, 1997).
3. Our relationships and how happy we are in those relationships have a powerful influence on our physical and mental health. Connecting with friends, family and community is an indication of a return to basic functioning and underlines the importance of social relationships in recovery. Being supported by others, “Relational” Recovery, is critical for those trying to live interdependently in the community. (Young and Ensing , 1999, (Jacobson and Greenley, 2001), (Schon, 2009) , (Davidson et al., 2005)
Watch this video of Harvard’s 75-year study of Adult Development. (05:50 to 08:00), https://www.youtube.com/watch?v=8KkKuTCFvzI&t=531s
4. A promising pathway. CSO engagement and involvement in recovery offers a promising pathway toward better-quality health care, more-efficient care, and improved population health for those with behavioral health disorders. The way forward lies in developing, promoting and implementing approaches that properly acknowledge the irreducibly relational nature or “connectedness” of recovery. (Rhys, P-R et al, 2016 & 2018)
5. Strategic shift from a traditional model of care where…
• Trained professionals make all the decisions and are expected to ‘fix’ clients
• “Experts” give CSOs advice about what to do
• CSOs are viewed as a source of the problem or obstacles to recovery
• CSO client relationships have a narrow focus
• Formal systems, independent of CSOs, are built to support clients’ success
• An individualist worldview underpins many conceptualizations of recovery
6. To a family model of care. A collaborative strategy that ensures treatment and recovery related programs, services, facilities, and activities are responsive and supportive of CSO’s engagement and involvement, and are based on their loved one’s needs, preferences and goals. A model that energizes and reframes the connection between providers, clients and CSOs into a “therapeutic alliance” that places CSOs closer to the heart of recovery. (See “Collaboration Models Handout” for information on existing collaboration programs.)
7. CRAFT Connect Family Support model. A respectful, loving, non-confrontational set of principles and skills that teaches CSOs how to encourage their loved one to make choices that lead to progress and healing. CRAFT Connect is a ‘unilateral’ family therapy practice that doesn’t involve clients. It is
Focused on behavior change that has been proven to help everyone.
Based on group learning experiences that have been proven around the world to help people improve their lives.
Provides practical online or in person services that augments
o any recovery pathway a client or loved one may choose,
o existing inpatient or outpatient treatment program, or
o community-based recovery organization efforts.
8. CRAFT Connect is a combination of Evidence-Based-Practices. CRAFT (Community Reinforcement and Family Training), Peer Support, Dialectical Behavioral Therapy (DBT), Wellness, Motivational Interviewing (MI), Expressive Writing and Mindfulness. CRAFT Connect helps CSOs connect
With a loved one struggling with a behavioral health disorder
Their loved one with treatment and support for their recovery
Once again with pleasurable activities that have been disrupted by their loved ones unwanted behaviors.
To other CSOs who are living the same experience
With real-world skills and principles that help them and their loved one
To community and professional resources that address their challenges
9. The Pyramid of Family Care framework is used to incorporate CRAFT Connect services into everyday practice. Framework also used by the United Kingdom, Canada, Australia, New Zealand and other non-U.S. governments around the world for CSOs and their loved ones who struggle with behavioral health disorders.
(See diagram)
10. If CSOs have their basic support needs met, then only a small proportion will require more specialized, more expensive services. Foundational principle, ‘minimal sufficiency’, or do what is needed. (Cohen 2008, Evidence Exchange Network for Mental Health and Addictions, 2017, Slade, 2007). The bottom three levels include orientation to services, CSOs basic need for information about their loved ones’ disorders and support for those dealing with psychological disturbances. It is within the scope and competence of generalist substance use and mental health service front line workers to assess, engage, and address the basic needs of most CSOs. The top level represents complex needs for interventions such as family therapy, referred out during consultation level. The intensity of intervention increases as you move up the pyramid, while the number of CSOs who are likely to require the intervention decreases. (Pyramid of Family Care: A framework for family involvement with adult mental health services. Mottaghipour Y. & Bickerton A., 2018)
11. CRAFT Connect model is an “off the shelf” scalable model that meet the needs of CSOs, providers and community organizations. All programs are based on written curriculum, available on line 24/7. Groups work like a council, there is no teacher or expert. Peer facilitators follow the materials as written and trust in the group. Designed to also work in self-directed individual CSO study. Current CRAFT Connect partners include:
12. CSOs self-report a real skills and confidence deficit:
• I have the skills needed to improve my family's well-being, only 15% agree
• I often think I can't do anything to improve my family's well-being, only 25% agree
• I know how to improve my family's well-being, only 21% agree
• I am confident I can improve my family's well-being, only 39% agree
13. CSOs struggle with their family and loved one. On a regular basis CSOs report:
• Some behavior of my loved one is upsetting – 73%
• Upset to find the person I care for has changed so much from his/her former self – 67%
• I feel completely overwhelmed – 47%
• Poor family emotional/mental well-being -- 50%
• Poor family relationship well-being -- 41%
• Poor family physical well-being -- 38%
14. Caring for loved ones is difficult. On a regular basis CSOs report there have been:
• Emotional adjustments – 77%
• Family adjustments – 63%
• Changes in personal plans – 61%
• Financial strains – 57%
• Work adjustments – 48%
• Physical strains – 36%
Watch this video advice from someone in long term recovery to you and your CSOs.
15. CRAFT Connect services help CSOs with
Support Group programs (peer-to-peer support+ skills training)
o Family Support Group, 15 sessions
o Share & Self-Care Group for Women
Skills Training programs
o DBT Goes to the Movies, 15 sessions
o Skills for a Life Worth Living, 12 sessions
Non clinical one-on-one peer coaching
Curated resources
o Online
16. Family Support Group. How to create compassionate connections with loved ones who have behavioral health disorders. Offers support, education and guidance for CSOs living with these challenges. Family Support Group session are divided into Check-In, Learn, My Commitments and Group Sharing sections where CSOs can share expertise based on their own lived experience. Group meetings provide a safe place for honest sharing.
17. Women’s Share & Self-Care Support Group. For women who are caring for children at home or those at work this one-hour support group for parents and partners is a good match. Topics vary on a weekly basis, support is key. Facilitator provides one-on-one coaching for those enrolled in this group. 12 sessions or a recurring cycle.
18. DBT Goes to the Movies Education Group. Dialectical Behavioral Therapy (DBT) skills training helps individuals change behavioral, emotional, thinking, and interpersonal patterns associated with problems in living and replace them with more skillful, more effective remedies. Combination of readings, activities, discussion, music and movie clips aims to help people create a life worth living.
SKILLS TRAINING EXAMPLE, FAMILY SUPPORT GROUP EFFECTIVE COMMUNICATION SESSION
19. Seven principles of PIUS communication (Positive I statements with Understanding and Support)
1. Be brief. Resist the urge to bring up too much. Keep it simple.
2. Be specific and clear. Focus on one thing.
3. Be positive while communicating what you want. Avoid blaming, name calling and over generalization.
4. Label your feelings. Describe the emotional impact on you in a calm, non-judgmental, non-accusatory way.
5. Offer an understanding statement. Try seeing it from the other person’s point of view.
6. Accept partial responsibility. Share a small piece of the problem.
7. Offer to help.
Discuss
What do you notice about the principles of PIUS communication that might be different from how you have been communicating?
20. Negative “You” vs. PIUS statements. As we read through the following examples of negative “You” and positive “I” (PIUS) statements think about the different messages they deliver.
Negative “You”: You always get drunk and embarrass me.
PIUS: I enjoy being with you when you don’t drink. I know it’s not always easy for you, so that makes it really special.
Negative “You”: You never listen to me when I’m talking to you.
PIUS: I understand that some of our conversations are upsetting, I’d love it if you could help me work them out.
21. Practice, Practice, Practice
Step 1. Write down a verbal/text or email interaction between you and your loved.
Step 2. Using the seven principles re-write what you might say the next time the same situation occurs, to limit defensiveness and not lead to an argument.
I... (HOW DO YOU FEEL?)
when you...(DESCRIBE THE BEHAVIOR OR CONDITION)
because... (WHY DO YOU FEEL THIS WAY?)
I would like... (WHAT DO YOU WANT TO HAPPEN?)
I know... (YOU UNDERSTAND THE OTHER’S POSITION)
How can I help... (YOUR WILLINGNESS TO SHARE RESPONSIBILITY)
Step 3. Share your ”before and after” statements with the group.
22. After completing their CRAFT Connect study CSO skills and confidence improved, CSOs agreeing that:
I have the skills needed to improve my family's well-being. Pre 9% -- Post 53%
I know how to improve my family's well-being. Pre 27% -- Post 64%
I often think I can't do anything to improve my family's well-being. Pre 27% -- Post 18%
I am confident I can improve my family's well-being. Pre 45% -- Post 55%
23. Well supported scientific evidence shows that CSOs, their loved ones and providers all benefit when they develop a “therapeutic alliance” that addresses recovery related issues in an open, collaborative and caring manner. CSOs reported
Increased empowerment to become a positive participant in their loved one’s recovery
Increased self-care. Recognize the importance of taking care of themselves
Improved quality of life by easing the effects of depression, anxiety, anger, physical symptoms, and other problems CSOs may be experiencing because of a loved one’s disorder
Decreased internalized blame
Reduced family isolation
24. Remember the “therapeutic alliance” -- when CSOs are engaged, providers see over 50% improvements in
Positive relationship with clients
Clients’ willingness to discuss and be more “open” about their personal life
Focus on recovery-oriented goals
Overall quality of client’s life
Mental/behavioral health conditions of clients
25. CSO engagement and involvement in recovery benefits clients by
Providing information that helps them develop a quality plan for their recovery
Learning about their behavioral health needs and how to respond in helpful ways
Understanding their goals and how to support efforts to achieve them
Providing information about warning signs and triggers for relapse
Helping meet basic needs, e.g., financial, housing, transportation, etc.
Providing love, companionship and a continuity of relationships that have a positive history
Being an advocate
26. Most important things CSOs learned:
New skills to interact differently with my loved one.
PIUS (positive I-statement) communication skills.
It is “therapeutic” to be in a group.
Self-care.
Didn’t CAUSE, can’t CONTROL, and can’t CURE my loved one’s behavioral health disorder.
27. How CSOs relationships with their family and loved one improved:
My expectations have changed due to knowledge I have gained.
Our communication is calm and very open.
I feel confident in holding a conversation safely, without major blow ups.
I have used my CRAFT Connect skills in relationships successfully. Taught skills to my family as well.
I am able to “self-regulate”.
I think about the choice of words, hence improved relationships.
Thank you. CRAFT Connect would not be possible without the help of our friends at USARA, New Roads Behavioral Health, University of Utah College of Social Work, Family Services and all those we have met in halfway houses, community centers, churches and private agencies while facilitating 100s of face-to-face and online support group meetings. You have been our mentors and become our heroes. Thank you all for sharing your lives with us. Kristin & John Garbett
Social Support Worksheet
These five questions ask about parents, partners, spouses, siblings, children, friends, co-workers or members of the community, the Concerned Significant Others (CSOs) in your life who provide you with help or support. Each question has an (a) and (b) part.
Step 1: For the (a) part, list all the people you know who you can count on for help or support in the manner described. Write the person’s initials and their relationship to you (see example). Do not list more than one person next to each of the numbers beneath the question.
Step 2: For the (b) part, circle how satisfied you are with the overall support you have. If you have no support for a question, circle the words “No one,” but still rate your level of satisfaction. Do not list more than nine people per question. Please answer all the questions the best you can. (Sarason, S. et al, 1983)
Example (a). Who do you know that you can trust with sensitive personal information?
No one
1.) T.N. (brother) 4.) D.N. (father) 7.)
2.) L.M. (friend) 5.) W.T. (employer) 8.)
3.) R.S. (friend) 6.) 9.)
Example (b). How satisfied are you with the support you have in this area?
6–very 5-fairly 4-alittle 3-alittle 2-fairly 1-very
satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied
1(a). Who can you really count on to be dependable when you need help?
No one
1.) 4.) 7.)
2.) 5.) 8.)
3.) 6.) 9.)
1(b). How satisfied are you with the support you have in this area?
6–very 5-fairly 4-alittle 3-alittle 2-fairly 1-very
satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied
2(a). Who can you really count on to help you feel more relaxed when you are under pressure or tense?
No one
1.) 4.) 7.)
2.) 5.) 8.)
3.) 6.) 9.)
2(b). How satisfied are you with the support you have in this area?
6–very 5-fairly 4-alittle 3-alittle 2-fairly 1-very
satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied
3(a). Who accepts you totally, including both your worst and best points?
No one
1.) 4.) 7.)
2.) 5.) 8.)
3.) 6.) 9.)
3(b). How satisfied are you with the support you have in this area?
6–very 5-fairly 4-alittle 3-alittle 2-fairly 1-very
satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied
4(a). Who can you really count on to care about you, regardless of what is happening to you?
No one
1.) 4.) 7.)
2.) 5.) 8.)
3.) 6.) 9.)
4(b). How satisfied are you with the support you have in this area?
6–very 5-fairly 4-alittle 3-alittle 2-fairly 1-very
satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied
5(a). Who can you really count on to help you feel better when you are feeling down-in-the- dumps?
No one
1.) 4.) 7.)
2.) 5.) 8.)
3.) 6.) 9.)
5(b). How satisfied are you with the support you have in this area?
6–very 5-fairly 4-alittle 3-alittle 2-fairly 1-very
satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied
Step 3: To score count the total number of people for each of the odd-numbered items. Add the total together (Max = 54). Divide by 5 per item SSQ Number Score, or SSQN. Add the total satisfaction scores for the 5 even-numbered items (Max = 36). Divide by 5 per item SSQ Satisfaction Score or SSQS. You can also compute a Family score and a Non-Family score by using the method in #1 for all people describes as family members, or not described as family members respectively.