Short summary

It is estimated that 585,000 people in Denmark engage in harmful alcohol use with 140,000 suffering from outright alcohol dependence. However, only 15,000 people seek specialist treatment for their alcohol problem. The National Clinical Guideline for the treatment of alcohol dependence recommends that alcohol treatment centers offer interventions aimed at CSOs (concern significant others), providing them with the support and empowerment that will enable them to motivate the problem drinker to enter treatment. The aim of the present study is to implement and investigate CRAFT (Community Reinforcement and Family Training) in a Danish context and with sufficient sample size. The study is a randomized controlled trial. Consecutive CSOs will through cluster randomization be randomized to receiving either CRAFT in a group format + self-help material, CRAFT in an individual format + self-help material, or a control condition, consisting of self-help material only.

During the preparation phase, the study will be approved by the ethical committees, the therapists will be trained in CRAFT, and a study management structure across participating municipalities will be developed.  A total of at least 405 participants (CSOs) will be enrolled in the study, which will begin enrollment in September 2016, with the analysis of the data expected to conclude in August 2019.

Rationale

Today, systematic support and training for CSOs is not offered by the Danish municipalities, whose responsibility it is to provide treatment for alcohol dependence, free of charge. The national health authority, however, in recently issued national guidelines for the treatment of alcohol dependence, recommends that such empowerment be made available to CSO's. Our proposed study offers a unique opportunity not only to introduce evidence based interventions to CSOs - but also to help implement the intervention and evaluate which format is most efficient and best able to attract drinkers into treatment.  

By conducting our study in functioning treatment centers, the first steps towards for a nationwide implementation of the intervention will have been taken, since the knowledge acquired during the study period will stay in field. As a by-product, our study also introduces supervision for practitioners based on recordings of intervention sessions, a practice that has been shown to be the most efficient way of strengthening and developing social work practices. Hence, our study not only examines the efficacy of Community Reinforcement and Family Training (CRAFT) and how it is delivered, it also introduces and stimulates evidence-based practice among practitioners.

The vision is that all treatment centers in the future should offer not only support to CSOs, but also empower them to motivate their loved ones in a constructive way towards seeking treatment for their drinking problem. Solving the drinking problem in the family is the real goal. 

How big is the problem?

A Danish study found that 79% of the Danish population knows somebody who suffers from alcohol problems, and half of them have suffered from its harmful consequences.  For the majority, the drinker in question is part of the household, and many find it hard to address the problem and even harder to motivate the person to seek treatment (9).

What about the children in the families?

The Danish national health authority estimates that 122.000 children live in families with alcohol problems. Over recent decades, there has been an increased focus on children suffering as a result of their parents' drinking patterns. Several initiatives have been taken to get the professionals around these children to become more aware of them, responding to their worries and notifying social services as appropriate. Addressing drinking in the family may be easier for the professionals around the children, if they can inform CSOs about relevant interventions. 

Why more studies on CRAFT?

Although CRAFT is rather well described and been shown to be effective, CRAFT studies have been carried out solely in the US; and only in relatively small studies and often by the same researchers. Furthermore, the study populations have been tended to be well-functioning CSOs who have themselves responded to advertisements in the newspapers and sought help. How well CRAFT works in real life practice, how it works with a broader group of CSOs, and how it works in Europe remains unknown. Furthermore, to our knowledge no efficacy studies have been conducted, which is essential before large scale implementation is planned. 

CRAFT is not a method used in Denmark at present, partly because the Danish treatment centers have so far had a rather limited focus on CSOs and their role. Consequently, interest in CRAFT has increased, although the Danish treatment centers still need to learn about the method and its implementation. This situation opens up a valuable opportunity to investigate how CRAFT can best be translated into the Danish socio-cultural, which format is most efficient, and how it performs with a broad group of CSOs in a real life setting.

Why the interest in formats?

In addition to the content of the therapy itself, group formats and individual sessions offer different perspectives. Being part of a group creates a sense of mutual recognition, and may lower the feeling of isolation and shame among CSOs. Individual sessions may, however, be easier to attend, offer more flexibility, and may allow the CSO to work more freely with what is felt to be most important. 

Economy is another angle. CRAFT in a group format may be a relatively cheaper solution. However, individual sessions may be easier to organize in smaller facilities, if waiting lists are to be avoided.

Although self-directed therapy by means of a self-help manual may be a very brief intervention, it might, however, turn out to be a sufficient intervention for well-functioning CSOs in particular, and is, of course, even cheaper.

Aim of the study

The aim of this study is to implement CRAFT interventions into Danish alcohol treatment centers and investigate whether individual CRAFT, group-based CRAFT or a control condition, based on self-help material only, is efficient in getting problem drinkers to seek treatment for their alcohol problems - and which of the three interventions is the most effective.

Study design

The study is a cluster randomized trial, carried out in functioning public treatment facilities. The study will include at least 135 CSOs in each intervention condition.

Description of the cohort

Study Population

All participants (CSOs) are enrolled from the ten included alcohol treatment centers in Denmark (see under collaborating departments). The CSOs addressing to the alcohol treatment centers and full the inclusion and exclusion criterias are offered to participate in the study. 

Inclusion criteria (CSOs):

More than 18 years old

Being a concerned significant other to a problem drinker.

Having had regular contact with the problem drinker for the last 90 days (face-to-face contact for several hours on at least a weekly basis) and having the intention to maintain the contact during the next 90 days.

Being prepared support the problem drinker if he/she chooses to seek treatment. 

Exclusion criteria (CSO) 

Suffering from dementia or other cognitive disorders

Not speaking Danish

Being psychotic or otherwise severely mentally ill

Being concerned about a person who mainly use illegal substances

Data and biological material

Data from the continuous CSOs will be collected at baseline (t₀), 3 months (t₁) and 6 months (t₂) by means of IPad (baseline) and by means of a Web-based questionnaire (at follow-ups).  Data on whether and when the drinkers start treatment will be collected from the CSO and from the participating treatment centers in the period under study and 6 months after closure of enrollment of CSOs.

The questionnaire will consist of the following instruments:

• Demographic information
• Self-reported number of days with sick leave within the last 90 days
• CMD-SQ
• Relationship Happiness Scale
• Audit about use of Alcohol
• Self-Report Family Inventory (SFI)
• Quality of life
• Time spend with the problem drinker (TLFB)
• The drinker's use of Alcohol (TLFB) (according to the CSO)
• Information on whether the drinker has sought treatment (primary outcome)
• Satisfaction with the intervention received 

Collaborating researchers and departments

Departments of ten alcohol treatment centers in Denmark: Odense, Århus, Randers, Thisted, Silkeborg, Syddjurs, Esbjerg, Svendborg, Nyborg and Novavi.