Boundaries, and the family programs nobody mentions

If someone you love is using and refusing help, you are not a bystander in this. That is not encouragement. It is a finding. What the family does is one of the most reliably measured variables in the whole field, and the approach with the strongest evidence behind it is the one almost nobody tells families about.

The trial that should be better known

In 1999, Miller, Meyers and Tonigan published a randomized comparison in the Journal of Consulting and Clinical Psychology of three ways a family member could try to get an unmotivated problem drinker into treatment. 130 concerned significant others were randomly assigned.

The results, by treatment entry:

• Community Reinforcement and Family Training (CRAFT): 64 percent
• Johnson Institute intervention, the confrontational family meeting: 30 percent
• Al-Anon or Nar-Anon facilitation: 13 percent

(Miller, Meyers and Tonigan, 1999)

A later review in Addiction pooled four randomized trials covering 264 family members and found CRAFT produced a relative risk of engagement of 3.25 (95 percent CI 2.11 to 5.02) against twelve-step facilitation, with a number needed to treat of two, and 2.15 (95 percent CI 1.28 to 3.62) against the Johnson intervention, number needed to treat of three (Roozen, de Waart and van der Kroft, 2010). A number needed to treat of two means roughly one additional person enters treatment for every two families trained.

The trials are small and the authors say so. But the direction has held across every replication, and it points somewhere counterintuitive.

What CRAFT is, and what it is not

CRAFT trains the family, not the person using. It teaches how to reinforce non-using behavior, how to withdraw from conflict rather than escalate, how to stay safe, how to recognize and use the windows when someone is briefly open to help, and how to ask in a way that can be said yes to. It is not confrontation, and it is not detachment. It is a third option that most families are never offered because the two they have heard of occupy all the airtime.

Notice which approach came second. The surprise intervention, the version everybody has seen on television, engaged 30 percent. Real, and less than half of CRAFT. If you have been told that confrontation is the only remaining move, the research does not support that. Interventions have a place, particularly where safety is immediate, and they work better when they are planned with the family rather than performed on them. They are not the highest-yield first step.

In defence of Al-Anon, honestly

Thirteen percent is a poor engagement rate, and it is also the wrong measure. Al-Anon does not claim to get anyone into treatment. Its stated purpose is the wellbeing of the family member, and judging it on a goal it never set is unfair.

On its own terms it holds up. Across those trials, all three approaches produced improvement in the family member’s own functioning at six months, measured on depression, anger, family cohesion, relationship happiness and family conflict (CCSA summary of the CRAFT evidence). The CRAFT trials showed significant improvement in depression symptoms on the Beck Depression Inventory over six months.

So the sensible reading is not that one replaces the other. It is that they answer different questions. If your question is how to get someone into treatment, the evidence points to CRAFT. If your question is how to survive the next two years without losing yourself, Al-Anon has decades of people who will tell you it did that job. Most families need both answers.

Boundaries, defined usefully

Families are told to set boundaries constantly and told what one is almost never. A working definition:

A boundary is a statement about your own behavior, not a demand about theirs. “You have to stop using” is not a boundary; it is a wish, and it hands the outcome to the person least able to deliver it right now. “We will not give cash, and we will not pay for the car if there is a positive test” is a boundary, because you control both halves.

Four rules that make them hold.

• Enforceable by you alone. If keeping it requires their cooperation, it is not a boundary.
• Written down. Verbal boundaries drift under pressure, and pressure is the condition they exist for.
• Agreed between the adults first. The most common failure is not the boundary. It is one parent quietly funding around the other. Split households get worked, every time, and nobody has to be malicious for it to happen.
• Few. Three or four you will actually hold beats fifteen you will not. Every boundary you set and abandon teaches that the next one is negotiable.

And the part families flinch at: a boundary is not a punishment and it is not leverage. It is the description of a relationship you can sustain without being destroyed by it. Framing it as a threat invites a negotiation. Framing it as a fact does not.

What we do here

Alongside is a non-clinical service, and we do not diagnose or treat. We work alongside the family: helping decide what the boundaries are before the conversation rather than during it, deciding who says what, keeping the adults aligned when the pressure arrives, and staying present through the weeks afterward, whichever way it goes.

Planned in days, not weeks; with the family, not around them.

If you are somewhere in this, speak with an advisor. For the conversations themselves, Scripts for families gives you actual language, and What an intervention looks like sets out how one is planned when it is the right call.

Sources

• Miller WR, Meyers RJ, Tonigan JS. Engaging the unmotivated in treatment for alcohol problems: a comparison of three strategies for intervention through family members. Journal of Consulting and Clinical Psychology, 1999;67(5):688-697. pubmed.ncbi.nlm.nih.gov/10535235
• Roozen HG, de Waart R, van der Kroft P. Community reinforcement and family training: an effective option to engage treatment-resistant substance-abusing individuals in treatment. Addiction, 2010;105(10):1729-1738. ncbi.nlm.nih.gov/books/NBK79038
• Canadian Centre on Substance Use and Addiction. Community Reinforcement and Family Training, evidence summary, 2017. ccsa.ca