The Science of ITC
The Invitation to Change Approach: a model based in science and kindness.
So, what about the science?
Introduction
The ITC is founded on the idea that behavior does not exist in a vacuum—and that instead, the best way to support a loved one who is struggling is to see their behavior as part of a bigger picture. This means looking at the person’s context: historical (their unique experiences and journey) and social (the relationships that surround them).
A number of psychological studies have shown that social connection plays a vital role in a person’s change process, highlighting that the tone and quality of interactions within close relationships have a significant impact on a person’s outcomes. That is why the ITC focuses on what family members (and other close connections) can do, learn, and say to increase the chances that their loved one changes their behaviors—because it actually makes a difference!
The concepts and strategies included in the ITC are also found in three evidence-based approaches—Community Reinforcement Approach and Family Training (CRAFT), Motivational Interviewing (MI) and Acceptance and Commitment Therapy (ACT)—all of which have been used to address substance use in a loved one and help people stay connected to what they value in the presence of emotional pain. Research studies that have included both professionals and real families have shown that CRAFT, MI, and ACT have been effective in the following ways:
- helping loved ones seek treatment (CRAFT)
- improving communication between family members in ways that that help individuals navigate their ambivalence about making changes (MI),
- increasing the likelihood for engaging in more meaningful and healthy behaviors (MI, ACT)
- improving the tone of family interactions (CRAFT)
helping family members navigate the emotional challenges and pain that can come along with - helping a loved one who is struggling (ACT; CRAFT)
—and it is the studies supporting the use of these processes (science), the impact of supportive social connectedness (kindness), and collaboration with families that led us to develop the Invitation to Change Approach, housing all these concepts and strategies under one roof.
Assessing and Evaluating Our Approach
As an organization, we are dedicated to systematically collecting information that can help us better understand how our work is being received by the individuals we serve—we want to know how the ITC impacts those actively applying it to their own lives.
Following several years of development and refinement, we evaluated the use of the Invitation to Change Approach in the context of a peer-to-peer support service for parents concerned about their child’s substance use in a collaborative effort with the Partnership to End Addiction. This evaluation was conducted in two ways. First, we wanted to know if ITC training would be rated as acceptable and helpful to parents who had lived experience of supporting a child with a substance use disorder and wanted to help other parents experiencing the same challenges. Second, we wanted to evaluate how conversations about ITC skills and strategies in the context of parent-to-parent peer support would impact the lives of those parents reaching out to get help from a peer parent coach.
We trained 228 parents who wanted to be peer support specialists in ITC based workshops and over 95% of the parents reported that their understanding of evidenced-based ways of helping were enhanced and that they would recommend the ITC training to other parents. Importantly, over the course of 15 months, we also surveyed 279 parents who called in with concerns about their child’s substance use and spoke with one of the parent coaches trained in the concepts and skills in the ITC. These parents were asked questions about their emotional well being and how they were communicating and responding to their child before the coaching calls and then were asked the same questions after the coaching calls. Among the parents included in the study, a significant majority reported improvements in how they communicated with and responded to their child, as well as lower levels of emotional distress – compared with a small minority who reported no improvements. This initial study was published in the journal Addictive Behaviors, 2020 (click here for the our first published study)
Current Research Priorities
Our efforts to systematically collect data on the acceptability, feasibility, and potential impact of the ITC model has been extended to include community-based support groups and professional treatment services, both of which are vital for supporting families affected by substance use.
These efforts have fostered collaborative relationships between community-based group leaders, professionals in treatment centers, and researchers. These collaborative efforts are critical for navigating the challenges associated with the assessment of community-based support services, and developing useful procedures for containing this work is a priority at CMC:Foundation for Change.
*Note to Research Institutions: Please contact Kenneth Carpenter, our Director of Training, at [email protected] if you have interest in collaborating in research testing the efficacy or effectiveness of this model.
What are the evidence-based approaches that the ITC draws on?
The Invitation to Change Approach is supported by evidence demonstrating the importance of relationships when making changes in substance use. Studies further highlight the positive impact that family relationships can have.
Ariss, T., & Fairbairn, C. E. (2020). The Effect of Significant Other Involvement in Treatment for Substance Use Disorders: A Meta-Analysis. Journal of Consulting and Clinical Psychology, 88, 526-540. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228856/
Dekkers A, De Ruysscher C, Vanderplasschen W. Perspectives on addiction recovery: focus groups with individuals in recovery and family members. Addiction research & theory. 2020;28(6):526-536. doi:10.1080/16066359.2020.1714037
Substance Abuse and Mental Health Services Administration. Substance Use Disorder Treatment and Family Therapy. Treatment Improvement Protocol (TIP) Series, No. 39. SAMHSA Publication No. PEP20-02-02-012. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2020.
The Community Reinforcement and Family Training approach (CRAFT; Smith and Meyers, 2004) is a behavioral and motivational treatment for families based on the empirically supported Community Reinforcement Approach (CRA). It has been studied extensively in randomized controlled trials among a variety of populations (e.g., different socio-economic groups, racial/ethnic groups, types of substance used) and has been found to be more effective for helping loved ones engage in treatment compared to other formal intervention programs and avenues of family support (like Al-Anon).
CRAFT has two goals: engaging the substance user in treatment through behavioral training for the family members, and enhancing family member self-care. It helps family members create an environment where abstinence/change behaviors are positively and incrementally reinforced and recognizes the family as powerful collaborators in effecting change instead of encouraging them to detach or use confrontation to impact their loved one.
In clinical trials, when family members are trained in the concepts and skills in CRAFT 64% – 74% of their loved ones engage in treatment. Families reported significant improvements in their own happiness and sense of family cohesion as well as reduced anxiety, depression, and anger. Further, their loved ones also significantly reduced their substance use, regardless of whether they entered treatment.
Many studies have been conducted over the years supporting the behavioral, communication, and self-care strategies embedded in the CRAFT model.
Archer M, Harwood H, Stevelink S, Rafferty L, Greenberg N. (2020). Community reinforcement and family training and rates of treatment entry: a systematic review. Addiction, 115(6):1024-1037.
Brigham, G., Slesnick, N., Lewis, D., Guo, X., Somoza, G., & Winhusen, T. (2014). A randomized pilot of Community Reinforcement and Family Training for treatment retention in opioid dependence. Drug and Alcohol Dependence, 138, 240-243.
Dutcher L.W., Anderson R., Moore M., Luna-Anderson C., Meyers R.J., Delaney H.D., Smith J.E. (2009). Community reinforcement and family training (CRAFT): An effectiveness study. Journal of Behavior Analysis in Health, Sports, Fitness and Medicine, 2(1):82–93.
Godley, S. H., Smith, J. E., Meyers, R. J., & Godley, M. D. (2009). Adolescent Community Reinforcement Approach (A-CRA). In D. W. Springer & A. Rubin (Eds.), Substance abuse treatment for youth and adults: Clinician’s guide to evidence-based practice (pp. 109–201). John Wiley & Sons Inc.
Miller, W.R., Myers,R.J., & Tonigan, J.S. (1999a). Engaging the unmotivated in treatment for alcohol problems: a comparison of three strategies for intervention through family members. Journal of Consulting and Clinical Psychology, 67, 688-697.
Meyers, R. J., Miller, W. R., Hill, D. E., & Tonigan, J. S. (1999b). Community reinforcement and family training (CRAFT): Engaging unmotivated drug users in treatment. Journal of Substance Abuse, 10(3), 1-18.
Meyers, R. J., Roozen, H. G., & Smith, J. E. (2011). The community reinforcement approach: an update of the evidence. Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism, 33(4), 380–388.
Smith, J.E., & Meyers, R.J. (2004). Motivating Substance Abusers to Enter Treatment: Working with Family Members. New York: the Guilford Press.
Motivational Interviewing (MI; Miller and Rollnick, 2013) is a collaborative conversational and counseling style for strengthening a person’s own motivation and commitment to change. It has been particularly helpful in highlighting the presence of ambivalence in the change process and providing meaningful ways to interact with individuals who are struggling with their motivation to make changes in their substance use and other health related behaviors. MI pays particular attention to the relational stance between individuals (e.g. building a respectful and empathetic environment) and offers guidance on how to build and navigate collaborative conversations that help individuals resolve their ambivalence.
Many studies support the utility of Motivational Interviewing and the relational and communication components that are embedded in this conversation style that together help create a context for change.
Frost H, Campbell P, Maxwell M, O’Carroll RE, Dombrowski SU, Williams B, et al. (2018) Effectiveness of Motivational Interviewing on adult behaviour change in health and social care settings: A systematic review of reviews. PLoS ONE 13(10): e0204890.
Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20(2), 137–160.
Miller, W.R., & Rollnick,(2013). Motivational interviewing: Helping People change. New York: The Guilford Press.
Smeerdijk M, Keet R, Dekker N, van Raaij B, Krikke M, Koeter M, de Haan L, Barrowclough C, Schippers G, Linszen D. (2012). Motivational interviewing and interaction skills training for parents to change cannabis use in young adults with recent-onset schizophrenia: a randomized controlled trial. Psychological Medicine, 42(8), 1627-1636.
Smeerdijk M, Keet R, van Raaij B, Koeter M, Linszen D, de Haan L, Schippers G. (2015). Motivational interviewing and interaction skills training for parents of young adults with recent-onset schizophrenia and co-occurring cannabis use: 15-month follow-up. Psychological Medicine, 45, 2839-2848.
Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, and Wilson, 2016) is a treatment approach that focuses on helping individuals establish a set of processes that can help foster greater psychological flexibility and well being. Developing psychological flexibility can be facilitated by mindfulness strategies, commitment and behavior-change strategies, as well adopting an openness to the emotional and psychological experiences that arise when moving towards one’s chosen values. Numerous investigations have supported that these methods are beneficial for a broad range of individuals and positive psychological goals across the areas of mental and behavioral health, and social wellness areas.
Byrne, G., Ghráda, Á.N., O’Mahony, T. & Brennan, E. (in press). A systematic review of the use of acceptance and commitment therapy in supporting parents. Psychology and Psychotherapy: Theory, Research, and Practice.
Hayes, S.C., Strosahl, K.D., & Wilson, K.G. (2016). Acceptance and Commitment Therapy, Second Edition: The Process and Practice of Mindful Change. New York: The Guilford Press.
Hoseininezhad, N., Alborzi, M., & MamSharifi, P. (2022). Effectiveness of cognitive behavioral counseling based on acceptance and commitment therapy (ACT) for psychological flexibility in drug-abusing mothers. Journal of Psychological Science, 20(107), 2011- 2025.
Ii, I., Sato, H., Watanabe, N., Kondo, M., Masuda, A., Hayes, S. C., & Akechi, T. (2019). Psychological flexibility-based interventions versus first-line psychosocial interventions for substance use disorders: Systematic review and meta-analyses of randomized controlled trials. Journal of Contextual Behavioral Science, 13, 109-120.
Rivera, C.E., Coyne, L.W., Daigle, K.M., Guzick, A., Reid, A., & Shea, S. (2022). Mindfulness, parenting behavior, and children’s mental health: An investigation among diverse, low-income mothers of preschool aged children. Journal of Contextual Behavioral Science, 24, 79-86
Varra, A.A., Hayes, S.C., Roget, N., Fisher, G. (2008). A randomized control trial examining the effect of acceptance and commitment training on clinician willingness to use evidence-based pharmacotherapy. Journal of Consulting and Clinical Psychology, 76, 449–458.
Whittingham, K., Sanders, M., McKinlay, L., Boyd, R.N. (2014). Interventions to reduce behavioral problems in children with cerebral palsy: an RCT. Pediatrics, 133(5), e1249-e1257.