Creating change for families: Working with families and substance use disorders

Written by

Jack Sykstus, LMFT, CSAC

You likely either watched this or perhaps experienced this yourself–the all-familiar scene with a group of family members sitting around, letters in hand and tears in eyes. Perhaps there is a facilitator there with a compassionate yet firm face. 

The family is tired. 

It's been months or even years of ongoing addiction and they’ve been at a loss for a long time. In walks their loved one, who has been using substances. They are startled and uncomfortable, yet they sit down and the family starts reading their letters. With hope for the best outcome, the loved one leaves that day and goes off to treatment—but in reality, this often only leads to further ostracization and even continued substance use. 

This family method is better known as the Johnson Intervention in the substance use disorders (SUD) space, and it does not work.

Why the Johnson Intervention won’t work

The Johnson intervention is usually implemented as a “one and done” intervention, leading to several adverse outcomes. In some cases, the person using substances feels overwhelmed and unsafe from the start, then runs away—potentially engaging in substance use to self-soothe. 

In many cases though, the loved one would start treatment but wouldn’t complete it. The problem isn’t getting them in the door: They aren’t motivated to stay

Enter the stage Community Reinforcement and Family Therapy, better known as CRAFT. 

CRAFT is an ongoing solution for an ongoing challenge

Approximately 35 million Americans will experience a SUD in their lifetime. With the average number of households being 2.5 individuals, we can gather that about 52.5 million family members are impacted by SUDs. This number doesn’t include the many other people in our lives such as grandparents, community members, neighbors, coworkers, and support systems—the sprawling number of people that witness first-hand what it means to love and care about someone struggling with a substance use disorder. It’s one of the most prevalent disorders of our lifetime.

So what are loved ones to do? Do they start writing letters, and hire a facilitator for thousands of dollars out of pocket? I have had many people, partners, children, parents, and grandparents come to me  and ask the hardest question a clinician can get: “What do I do?” Fortunately for families going through this, there is a decent amount of information and evidence to support next steps.

CRAFT is a family treatment approach that focuses on the process of building motivation for change. By using behavioral techniques such as reinforcing positive behaviors, CRAFT sets limits specifically around behaviors the family wants to see less of to improve relationships and communication. CRAFT does this exclusively through roleplaying and prescribed tools that the clinician offers the family. 

The approach hinges on families playing a critical role in helping their loved ones build motivation for change. That intrinsic motivation on the part of the individual carries them to complete treatment. In contrast to the Johnson Method, the CRAFT approach’s positive outcomes are empirically supported by research, showing the value of this type of collaborative family therapy.

Your role as a family therapist

You might be curious about how to work with a family, especially if working with families or couples is unfamiliar to you. Here are a couple of tools to help you get started:

  • Set the stage: Create an equal space for everyone by providing session boundaries and encourage all participants to share openly and freely. If you notice someone is struggling to do that, its okay to break apart the family for the first few sessions to meet in the family holons make sense (an example might be meeting with an individual using substances who does not feel they have much familial power alone, and then with a sibling and parent in a different session).
  • Use evidenced-based practices: Using evidenced-based techniques such as CRAFT, MI, and ACT have been shown to lead to positive treatment outcomes, so use them! If you are not sure where to start, the CMC 20-Minute Guide found in the resources below contains great tools for families.
  • Knowing when to refer: For some, the type of substance or intensity of substance use might make them uncomfortable and that’s okay! Find some clinicians that are CRAFT trained near you that are comfortable working in substance use and refer when appropriate


20-minute Guide by Center for Motivation and Change

Provider Training in CRAFT, MI, and ACT

Family Resources at Partnership to End Addiction