Community Reinforcement Approach (CRA) - Detailed Report

CRA Assessment Procedures:

Identification and enhancement of motivation for change

• Identify internal/external reinforcers.
• Rapidly complete intake procedures.
• Set positive expectations.
• Include significant other.

CRA Functional Analysis of Drinking/Using Behavior

• Identify Internal Antecedents (Internal Triggers) to drinking/using.
• Identify External Antecedents (External Triggers) to drinking/using.
• Complete comprehensive description of drinking/using behavior.
• Identify short-term positive consequences to drinking/using.
• Identify long-term negative consequences to drinking/using.

CRA Functional Analysis of Non-Drinking/Non-Using Behavior

• Identify Positive Internal Triggers for Non-Drinking/Non-using Behavior.
• Identify Positive External Triggers for Non-Drinking/Non-using Behavior.
• Complete comprehensive description of non-drinking/non-using behaviors.
• Identify short-term negative consequences to non-drinking/non-using behaviors.
• Identify long-term positive consequences to non-drinking/non-using behaviors.

Specific CRA Treatment Procedures:

Sobriety Sampling

• Obtain client's agreement to sample time-limited sobriety or relative sobriety.
• Outline a strategy for accomplishing time-limited sobriety or relative sobriety.

Possible disulfiram use

• Present disulfiram use as an option.
• Use the CRA-specific monitoring system.

CRA Treatment Plan

• Use the Happiness Scales.
• Develop the Goals of Counseling.

Behavioral Skills Training

• Teach communication skills.
• Teach problem-solving skills.
• Provide drink/drug refusal training.

Job Counseling

• Provide skill-based job counseling.
• Provide solution-oriented job counseling.
• Give information about Job Club.

Social and Recreational Counseling

• Provide Community Access.
• Provide Reinforcer Sampling.
• Provide Systematic Encouragement.
• Provide Response Priming.
• Provide Social Club.

Marital Counseling

• Provide action-oriented counseling.
• Provide time-limited counseling.
• Provide goal oriented counseling.
• Teach positive communication skills.

Relapse Prevention

• Perform Functional Analysis of Relapse Behaviors.
• Analyze Behavioral Chains.
• Activate Early Warning System.
• Teach Cognitive Restructuring.

Caregiver Involvement in Adolescent CRA:

Caregiver component

• Address caregiver's motivation to participate.
• Address caregiver's promotion of their adolescent's drug/alcohol use.
• Teach effective parenting skills.
  

Smith, J.E., Meyers, R.J. & Delaney, H. D. (1998). The community reinforcement approach with homeless alcohol-dependent individuals. Journal of Consulting and Clinical Psychology. 66(3), 541-548.

Homeless alcohol-dependent individuals were randomly assigned to receive either the Community Reinforcement Approach (CRA) or the standard treatment (STD) at a large day shelter. Ninety-one men and 15 women participated. The majority of participants were White (64%), but both Hispanic (19%) and Native American (13%) individuals were represented as well. Overall, the decline in drinking levels from intake through follow-ups was significant. As predicted, CRA participants significantly outperformed STD group members on drinking measures across the 5 follow-ups, which ranged from 2 months to 1 year after intake. Both conditions showed marked improvement in employment and housing stability.

Smith, J.E., Meyers, R.J., & Miller, W.R. (2001). The community reinforcement approach to the treatment of substance use disorders. The American Journal on Addictions, 10(Suppl.), 51-59.

Summary: Review of empirical support is presented for the Community Reinforcement Approach (CRA), a broad-spectrum cognitive-behavioral treatment for substance use disorders. At the core of CRA is the belief that an individual's environment can play a powerful role in encouraging or discouraging drinking and drug use. Consequently, it attempts to rearrange contingencies so that sober behavior is more rewarding than substance-abusing behavior. Originally tested in the early 1970s with a small sample of alcohol-dependent inpatients, it has repeatedly proven to be successful over the years with larger, diverse populations. Empirical backing is also presented for a new variant of CRA that works through family members to engage treatment-resistant individuals into substance abuse treatment.

Smith, J.E., Milford, J.L., & Meyers, R.J. (2004). CRA and CRAFT: Behavioral approaches to treating substance-abusing individuals. The Behavior Analyst Today, 5(4), 391-403.

Summary: The Community Reinforcement Approach (CRA) and Community Reinforcement and Family Training (CRAFT) are behavioral treatments for substance abuse problems that have received widespread empirical support. CRA, a treatment intended for the drinker him- or herself, was introduced 30 years ago. It is based on the belief that a drinker's "community" (e.g., family, social and job environment) plays a critical role in supporting or discouraging drinking behavior. Consequently this environment needs to be restructured such that a sober lifestyle is more rewarding than a drinking lifestyle. CRAFT, an outgrowth of CRA, is a highly successful methodfor working with concerned family members in order to get a treatment-refusing substance abuser to enter treatment. The components of both CRA and CRAFT are outlined in this paper, and the scientific support is summarized.

Wolfe, B.L. & Meyers, R.J. (1999). Cost-effective alcohol treatment: the community reinforcement approach. Cognitive and Behavioral Practice, 6, 105-109.

Summary: Introduces the Community Reinforcement Approach (CRA), one treatment modality which is well-supported by the literature. CRA is a cost-effective behavioral and social-learning-based treatment protocol. Its menu-driven approach to substance abuse also integrates several other cost-effective treatments to make a comprehensive package for the clinician. An overview of CRA is provided with the objective of helping the clinician increase his or her cost-effectiveness with alcohol abusing and dependent clients.

Azrin, N.H., Sisson, R.W., Meyers, R.J., & Godley, M. (1982). Alcoholism treatment by disulfiram and community reinforcement therapy. Journal of Behavior Therapy and Experimental Psychiatry, 13(2), 105-112.

Summary: Compared traditional disulfiram treatment, socially motivated disulfiram treatment and reinforcement therapy with disulfiram. Latter group produced "near-total" sobriety. N=43, 6-month follow-up. (Adult male and female participants.)

Hunt, G.M. & Azrin, N.H. (1973). A community-reinforcement approach to alcoholism. Behavior Research & Therapy 11, 91-104.

Summary: Initial study showing that participants in CRA drank less, worked more, spent more time with families and less time in institutions than matched control who did not receive this treatment. (Adult male participants).

Meyers, R. J. & Smith, J. E. (1995). Clinical guide to alcohol treatment: The Community Reinforcement Approach. New York: Guildford Press.

Meyers, R.J. & Miller, W.R. (2001). A Community Reinforcement Approach to the treatment of addiction. Cambridge, UK: University Press.

Miller, W.R. & Meyers, R.J. (1999). The Community Reinforcement Approach. Alcohol Research and Health, 23(2), 116-120.