A-CRA

Adolescent Community Reinforcement Approach

“…to rearrange the vocational, family, and social reinforcers of the alcoholic such that time-out from these reinforcers would occur if he began to drink.” (Hunt & Azrin, 1973)

AbstinenceParticipation in pro-

social activitiesPositive relationships

with familyPositive relationships

with peers

Motivate their participation

Promote the client’s abstinence

Provide information about effective care giving

A-CRA’s General Goals

10 individual sessions with the adolescent

4 sessions with the caregiver2 individual sessions with the

caregiver2 sessions with the caregiver and

the adolescentIn the office or home and community

Described basic objectives (help find healthy, reinforcing lifestyle…)

Outlined several procedures (communication skills, problem solving)

Set positive expectations (scientific base)Described duration of treatment (time

limited)Started to identify reinforcers

An interview that examines the antecedents and consequences of a behavior

“Roadmap”F.A.s can be used for 2 kinds of

behaviors: A problem behavior A healthy, fun behavior

Objective: To work toward decreasing or stopping the problem behavior

Outline individual’s triggers for substance use

Clarify consequences (positive & negative) of substance use for client

External triggersWho, where, when

Internal triggersThinking, feeling (emotionally,

physically)Short-term positive consequencesLong-term negative consequences

Provide a rationaleDetermine which episode to focus on:

Ask for a description of a common/ typical substance-using episode OR

Ask for a description of a recent or specific episode & make sure it is common/typical

Show client the F.A. chart

Gave rationaleStarted by asking for description of commonepisode/behavior

Common problems: selecting a suitable episode, mixing several episodes together

Outlined triggers (external, internal)Clarified the using (or non-using) behaviorOutlined positive and negative consequences of

the behaviorSummarized findings & gave examples of how

the information would be used Common problems: forgetting this item altogether,

summarizing but not offering examples

Provide rationale: Allows the client to see how satisfied

he/she is with different areas of life Identifies areas the client wants to

address in treatment Monitors progress over time

Give instructions (include: circle use or nonuse)

Review some ratings

Substance useRelationship w/

girlfriend/boyfriendRelationship w/

friendsRelationship w/

caregiversSchool (work)School activities

Social life/recreationPersonal habitsLegal issuesMoney managementFeelingsCommunicationJobGeneral happinessOther

Goals of Counseling contains the categories on the Happiness Scale

Guide the client’s selection of a categoryIn general, set short-term goals that are

scheduled to be completed in about a monthDevelop a step-by-step weekly strategy for

reaching each goalAddressed obstacles to completing the goalsThe strategy = the “homework” for the week

Guidelines for Goal Setting

Brief (uncomplicated) Positive (what will be done) Specific behaviors (measurable) Reasonable Under the client’s control Based on skills the client already has

Treatment Plan/Goals ofCounseling Checklist

Used Happiness Scale to select goal category Set goal/strategy using guidelines (e.g.,specific) Common problems: mostly obstacle-related(forgetting to ask about them, identifying

them butnot solving them, not probing enough) Checked on progress of goals

Functional Analysis for Pro-social(Healthy) Behavior

Looks at a pro-social (fun) behavior that’s occurred at least once in the last 6 months Objective: Increases the likelihood that the

individual will choose this non-using activityover substance use

Clarifies negative consequences (barriers toengaging in it) & positive consequences of thehealthy behavior for the individual

Introducing the Pro-Social F.A.

Provide a rationale Ask for a description of an enjoyable activity

that the client is: engaging in currently – but only infrequently OR not engaging in currently, but has done so at least once in the last 6 months

Check to be sure that substance use isn’t usually a part of the activity

F.A. for Pro-Social Checklist

Give rationale Started by asking for description of common

fun/healthy behavior Common problem: finding a fun behavior that is

recent Outlined triggers (external, internal) Clarified the behavior Outlined positive and negative consequences of the

behavior Summarized findings & gave examples of how the

information would be used Common problem: forgetting to make the assignment

explicit, forgetting to ask about/address obstacles

Sobriety Sampling: The Rationale

Select the ones that are most relevant to your client when offering the rationale and make the link to the client’s specific situation:

Enables client to set reasonable and attainable goals

Teaches self-efficacy when goals are reached

Sobriety Sampling (cont’d)

Provides “time-out” from drinking/using so client can experience sensation of being clean/sober

Disrupts old habits, giving chance to replace with new positive coping skills

Builds family support and trust Identifies relapse-prone areas

The Negotiation

Suggest a LONG period (90 days?) Tie in reasons for such a period (high relapse

time; client’s reinforcers?) Expect that the client will negotiate

downward Settle on a period of time: be sure it extends

at least to the time of the next session but don’t make it unreasonably long!

The Plan for Time-Limited Sobriety

IS A WITHDRAWAL PLAN NEEDED?? Load up sessions in the 1st few weeks Don’t rely on past unsuccessful methods Identify biggest threats to sobriety Develop a specific plan for maintaining sobriety Identify and address obstacles Develop a back-up plan Remind client of reinforcers for achieving

sobriety Use positive reinforcement

Sobriety Sampling Checklist

Gave rationale for sampling sobriety (e.g., forces use of other coping strategies)

Negotiated a reasonable period of sobriety Common problems: no real negotiation, final

period of time settled upon was too longDeveloped a specific plan for maintaining

sobriety at least until next session Common problem: obstacles not addressed Developed a back-up plan as well Reminded client of reinforcers for sobriety

Communication Training

Why work on communication?More likely to get what you want Positive communication is “contagious” Will open door to more satisfaction in other

life areas as well (social support)Positive communication is the foundation for

other A-CRA procedures

Positive Communication Skills

Components: Offer an understanding statement Accept partial responsibility Offer to help Explain each and come up with examples

that are relevant to the client

Positive Communication (cont’d)

Start with a reverse role-play? Regular role-play (+ specific feedback,

repetitions)Don’t need all 3 components in the one

conversationDiscuss the best time to have the

conversation

Communication Skills: Vignette

A high school girl is having trouble talking to ateacher. She has had the same teacher in anotherclass and feels as if this teacher has it in for her. Itis a required course, and there are no otherteachers for it.

Introduce positive communication skills (including role-plays) to help this client come up with ways to better communicate.

What other A-CRA technique could you use in this situation?

Communication Skills Checklist(Adolescent and Caregiver)

Discussed why positive communication is important Described/reviewed the 3 positive communication elements Gave examples of good communications Common problem: exclusively reading examples off thehandout Role-played (reinforced, gave specific feedback, repeated) Common problems: not offering specific feedback after eachrole-play Did a reverse role-play Common problems: forgetting to ask client what was learnedabout the other person’s perspective by playing him/her, notpointing out the A-CRA positive communication componentsused

Problem Solving

(1) Define problem narrowly:• Help make it very specific (manageable)(2) Brainstorm possible solutions:• Help client generate them• Don’t critique them; just encourage lots of ideas• Don’t skimp – come up with at least 5(3) Eliminate undesired suggestions:• Have client cross out any unwanted ones (no

explanation)(4) Select one potential solution:• Have client explain step-by-step how it will be done

Problem Solving (cont’d)

(5) Generate possible obstacles:• Assist client; probe for more(6) Address each obstacle:• If obstacles cannot be addressed - select another

solution(7) Assign task:• Be sure the task and the time for it to be done is clear(8) [Next session: Evaluate outcome]:• Have client describe what was done and how well itworked• Determine whether the solution needs to be modified• Discuss obstacles again

Problem-Solving Skills Checklist

Described/reviewed steps of the procedure Common problems: not making the specific

stepsexplicit – but instead just demonstrating them Conducted A-CRA problem solving procedure Common problems: not defining the problemnarrowly enough, not generating enough [5]solutions while brainstorming, not addressing

obstacles adequately

Systematic Encouragement

Encourage client to “sample” a new activityGet the client to make the 1st contact (take

the 1st step) during the sessionHelp the client identify a contact person Role-play the phone call or visit Have the client make the contact during the

session (or take client to the activity)[Review activity attended in next session]

Drink/Drug Refusal Training

Review high-risk situations: Discuss upcoming high-risk situations Identify triggers for use

Enlist social support: Discuss importance of support for abstinence Identify at least 1 supportive person for the situation

being discussed Plan how to ask person for support; practice

Assertive Drink/Drug Refusal

[Always watch body language!] Say, “No, thanks” (without guilt!)Suggest alternativesChange the subjectHold a non-alcoholic drink in handAddress the “aggressor” directlyLeave

Drink/Drug Refusal Skills Checklist

Reviewed high-risk situationsEnlisted social supportCommon problem: not checking to see if the person

can be available during the high-risk time; not exploring exactly how the person could help

Presented/reviewed options for assertive refusal (e.g.,changed subject)Role-played (kept brief, reinforced, gave specificfeedback, repeated) Common problems: failing to point out & shape A-

CRArefusal options

A-CRA’s Job Finding

A disciplined, step-by-step approach to helping

clients get and keep satisfying jobs How many sessions?Acceptable to complete with one (thesame) client over several sessionsIf different clients: must be covered in 2sessions maximum for certification

Job Finding Topics

(1) Provide an overview:Discuss rewards associated with a satisfying jobExamples: money, meet people, address boredomDiscuss difficult aspects of the job-finding processExamples: Takes a lot of effort, rejection is

commonExplain job-finding’s “basic premises”Examples: need a lot of contacts and interviews

Job Finding Topics

(2) Help generate job categories: Previous work? Training?(3) Generate/follow-up on leads: Develop a list of contacts Examples: family, friends, internet postings Set up a tracking system (next slide)

Job Leads Log (Tracking System)

1st Contact Date: Company: Contact Person’s Name: Telephone Number: Address: Result of 1st Call: 2nd Call: Date Result 3rd Call: Date Result

Job Leads Log (Tracking System)

(4) Rehearse and make phone calls: Explain telephone inquiry stepsExamples: introduce self, ask about openings(5) Complete applications: Discuss considerations when preparing Examples: discuss client strengths, how to

handledifficult questions Fill out an application if possible

Job Leads Log (Tracking System)

(6) Rehearse interviews: Discuss preparatory points Examples: dressing appropriately, being

punctual Cover important topics Example: how to highlight one’s strengths(7) Plan for job maintenance/satisfaction: Maintenance: reasons for past job problems Satisfaction: evaluate, set goals to enhance

Job Finding Skills Checklist

Provided overview Helped generate job categories Generated/followed-up job leads Rehearsed and made phone calls Completed applications Rehearsed interviews Planned for job maintenance/satisfaction

Engaging Caregivers

Start engagement during the first phone call Spend 10-15 minutes with caregiver during

first client session Continue engagement throughout treatment

Caregiver Sessions: Timing &Format

Total of 4 sessions with the caregiver:2 individual sessions with the caregiver 1st one: after about 5 sessions with the adolescent 2nd one: about 2 weeks later 2 “family” sessions with the caregiver + the

adolescent 1st one: after about 9 sessions with the adolescent 2nd one: about 2 weeks later Note: these are only suggested/average times for

these sessionsBuild in time to make up missed sessions

Caregiver Session 1: Rapport Building

Maintain empathic and positive approach:Use empathy Reinforce attendance Re-label negative behavior Stop the blaming Reinforce discussion & emphasize family (adolescent) strengths - aspects of family lifethat are working well Use “exception” statements Express excitement about working with them

Caregiver Session 1: Overview

Talk about the benefits of A-CRA Discuss purpose of caregiver sessions: Diminish caregiver’s pain Improve communication Improve caregiver-adolescent relationship Provide research-based information about whatcaregiver can do to keep adolescent from

relapsingAssess need for another referral

Caregiver Session 1: MotivationEnhancement

Determine caregiver’s reinforcers: related to the adolescent stopping his/her

substance use specific to caregiver’s own, separate needs or

desires Past failures? Recovery is a process Encourage to “sample” treatment

Caregiver Session 1: Critical Parenting Practices

Explain that research supports 4 parentingpractices which help prevent relapse in teens Describe the 4 parenting practices:

Be good role models (specifically – no alcohol/drugs in front of adolescent)

Increase positive communication Monitor adolescent’s whereabouts Get involved with the adolescent’s social life

Caregiver CommunicationSkill Training (Session 1 or 2)

Provide rationale for learning positivecommunication skills Assess the present quality of communication Describe the three components while

generatingreal-life examples with caregiver: Understanding statement Partial responsibility statement Offer to help

Caregiver CommunicationSkill Training

Role-play exchanges between the caregiverand the client Point out any problems (e.g., blaming andbringing up old issues) Switch roles with the caregiver Process each exchange with the caregiver With the caregiver’s input, come up with anassignment (homework)

Caregiver Problem Solving Training

Teach caregiver the problem-solvingprocedure The problem can be: one that relates to the

adolescent one that has nothing to do with the adolescentMake sure a specific assignment results

Caregiver Overview, RapportBuilding, and Motivation Checklist

Provided an overview of A-CRA Set positive expectations Reviewed research regarding parenting practices Identified Caregiver’s reinforcers for continued

work(repeat #5) Common problems: Focusing on the adolescent’sreinforcers instead of the caregiver’s reinforcers Kept discussion (about adolescent) positive

3 Positive Things Exercise

Give rationale: Helps start session on positive note Have them speak directly to each other (not

to the therapist) Have them repeat the positive comments

they hear Don’t forget to help if they get stuck, & to

praise their efforts

Relationship Happiness Scales:Rationale

Tools for caregiver(s) & adolescents to ratetheir happiness with each other in different

areas of their relationshipA method for setting goals/making changes A way to track progress toward relationship

goals

Relationship Happiness Scale:Instructions

Same basic instructions as for HappinessScale, EXCEPT… Rate happiness with the other person

(caregiver or adolescent) in each area Ask them not to look at the other family

member’s answers [they will be explored later]

Relationship Happiness Scale:Review Ratings

Review several ratings for each person(start with high ratings – to continue the

positive tone)Review consists of:Asking why the particular rating was given

ORAsking what it would take to give it a higher

rating (what would have to change?)

Selecting Goal Categories

Using their Relationship Happiness Scales: help

the caregiver(s) & the adolescent select a category in which they want to make a request for a change in the other person

They can each choose different categories Suggest they choose categories rated

somewhere in the middle of the range (e.g., 4-7)

Making Requests and Setting Goals

Help caregiver (or adolescent) formulate a request following guidelines (brief, positive, specific, measurable)

In preparation for verbalizing the request: It’s a good time to review positive communication skills…

Relationship Therapy:Problem-Solving Skills

Problem-solving needs to be reviewed & used in at least 1 of the family sessions

Best time to introduce problem-solving? When a problem is identified in the session

When are problems often identified in family sessions?

When negotiating goals (assignments) to work on during the Relationship Happiness Scale exercise

When deciding on homework assignments more generally

When addressing a crisis

Daily Reminder To Be Nice: Rationale

Acceptable examples (this exact wording is NOTneeded!!): to jump-start a more positive home atmosphere to serve as a follow up exercise to the 3 Positive

Things exercise to make sure family members keep supporting each

other, even if they don’t really feel like doing that at times

the form contains nice things that some family members automatically do for each other when things are going well in their relationship; and so this can be a reminder to continue doing them

Daily Reminder To Be Nice:Instructions

Ask each person to do at least 1 item from theform daily regardless of whether the otherperson seems to be doing it as wellSuggest that they find a good place to keep theforms so they don’t get lost or forgotten Have them generate examples for and practice1-2 items in session Make homework assignment explicit

Caregiver-Adolescent Sessions*Things to Remember*

Keep session structured Role of therapist/case manager: coach,shape, model, reinforce, praise, and keep

everyone on task Focus on one issue at a time Focus is on skill-building Keep positive tone to session

Caregiver-Adolescent Session Tips

Ask participants to speak to each other throughout the session

Ask participants to repeat things Recognize and praise when they use the

skills naturally If clients are resistant, decrease procedure

jargon

Adolescent-CaregiverRelationship Skills Checklist

Check on homework 3 positive things Relationship Happiness Scale Daily Reminder To Be Nice Communication Skills Problem Solving Skills

Anger Management

Identify reasons to manage anger better: How has the client’s current way of expressing

angercreated problems for him/her? Explain why it is valuable to recognize the earliestsigns of anger Help recognize anger building up: Identify high-risk situations and/or triggers for

gettingangry Help identify early signs of anger coming on Physical signs (clenched jaw) Behaviors (pacing, sarcastic remarks)

Anger Management (cont’d)

Find relevant “cool down” activities: Help client come up with a “cool down” phrase Have client leave situation briefly (if possible) & engage

ina planned activity Have client explain when he/she will return to talk Practice communication skills in the process Focus on empathy:Ask client to imagine situation from other person’s point ofview (reverse role-play?) Ask client what he/she thinks the other person was

thinking& feeling in that situation Give Anger Management handout to take home

Identify reinforcers to manage anger Assist in recognizing anger Common problem: forgetting to ask about theadvantage of knowing the earliest signs of anger Teach taking time to “cool down” Teach fostering empathy Common problem: not probing sufficiently

whenasking about the other person’s thoughts/feelings Gave adolescent “Anger Management” handout