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.
  

Community Reinforcement Approach (CRA) is rated a "3 - Promising Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The practice must have at least one study utilizing some form of control (e.g., untreated group, placebo group, matched wait list) establishing the practice's benefit over the placebo, or found it to be comparable to or better than an appropriate comparison practice. For more information on the rating of a “3 – Promising Research Evidence,” please see the Scientific Rating Scale.

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

Type of Study: Non-randomized, matched control group.
Number of participants: 16
Population:

Age Range: Control: 36.75 on average; CRA: 39.87 on average
Race/Ethnicity: Not given
Status (e.g., foster care, CW) Patients admitted to a State Hospital for treatment of alcoholism.

Location/Institution: Rural Midwest
Summary: (To include comparison groups, outcomes, measures, notable limitations) The Community Reinforcement Approach (CRA) treatment group of alcoholics was matched with a control group based on employment history, family stability, previous drinking history, age, and education. Results showed that the percent of time spent drinking, unemployed, away from home, or institutionalized was than twice as high for the control group as for the CRA group. This study is limited by a lack of long-term follow-up period and lack of randomization to groups.
Length of post-intervention follow-up: 6 months.

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

Type of Study: Randomized controlled trial
Number of participants: 43
Population:

Age Range: 20 to 60
Race/Ethnicity: Not given
Status (e.g., foster care, CW): Outpatients of a rural community treatment clinic.

Location/Institution: Not given
Summary: (To include comparison groups, outcomes, measures, notable limitations) Participants in this study were required to agree to take disulfiram (Antabuse). Those assigned to the traditional disulfiram treatment received the drug and five structured counseling sessions. Those in the Disulfiram Assurance group, along with their significant other, such as a spouse or friend, received the drug plus training on how to help assure that the drug was taken regularly. The Behavior Therapy group received the same training as the Assurance group plus the training specified in the Community Reinforcement Approach (CRA) program. Results showed that all participants in the traditional disulfiram group resumed drinking by the 6-month follow-up. Dilsulfiram Assurance was sufficient to stop drinking for married participants, but not for single ones. The CRA plus Assurance program was effective for both single and married participants.
Length of post-intervention follow-up: 6 months.

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.

Type of Study: Randomized Controlled Trial
Number of participants: 106
Population:

Age Range: 18 to 69 years
Race/Ethnicity: 64% White, 19% Hispanic, 13% Native American, and 4% African American.
Status (e.g., foster care, CW): Chronic homeless individuals recruited from a day shelter.

Location/Institution: Albuquerque, New Mexico
Summary: (To include comparison groups, outcomes, measures, notable limitations) At intake, participants were diagnosed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. They were randomly assigned to receive standard treatment, including access to shelter services and on-site Alcoholics Anonymous meetings, or to the Community Reinforcement Approach (CRA) condition. In addition, those who were medically eligible received disulfiram (Antabuse). However, analysis indicated that there was no difference in outcomes for those taking the drug and those not taking it, so in subsequent analysis the distinction between those groups was ignored. Results showed that participants in the standard shelter treatment and the CRA condition improved over follow-up. However, CRA participants outperformed those in the standard treatment condition. The authors note that the lowest post-treatment drinking levels were in the earliest stages of follow-up and recommend periodic booster sessions of treatment.
Length of post-intervention follow-up: 1 year.

De Jong, C. A. J., Roozen, H. G., van Rossum, L. G. M., Krabbe, P. F. M., & Kerkhof, J. F. M. (2007). High abstinence rates in heroin addicts by a new comprehensive treatment approach. The American Journal on Addictions, 16, 124-130.

Type of Study: Post-test only
Number of participants: 272
Population:

Age Range: Not given
Race/Ethnicity: Not given
Status (e.g., foster care, CW): Patients recruited from methadone maintenance programs.

Location/Institution: The Netherlands
Summary: (To include comparison groups, outcomes, measures, notable limitations) Treatment with the Community Reinforcement Approach (CRA) resulted in abstinence rates of 28% and 32% at 10 and 16 months after detoxification. The authors note this rate as significantly higher than expected with traditional treatment approaches such as methadone tapering. This study is limited by the absence of a comparison group.
Length of post-intervention follow-up: 16 months after detoxification.

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.