Community Reinforcement Approach (CRA)

Robert J. Meyers, Ph.D.

& Jane Ellen Smith, Ph.D.

University of New Mexico

If punishment worked, there would be few, if any, alcoholics or drug addicts…

What is the goal of CRA?

……..”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)

CRA Induction & Overview: 1st Session

Build rapport, build rapport, build rapport

Stay client focusedUse positive reinforcementBegin to establish “reinforcers” (e.g., internal or external

motivators?)

CRA Induction & Overview (cont’d)

Set positive expectations: CRA has proven efficacy (scientific backing)

Explain that treatment is time limited Emphasize independence Clarify assessment information (how

can this be useful in treatment planning?)

Positive Reinforcer

What is a reinforcer?

How do I find one?

Does everyone have reinforcers?

How can I use them to help?

CRA Overview: Clinicians’ Problem Areas

**Refer to CRA Procedures Checklist Giving a clear, concise description of

CRA’s basic objective/theory Starting to identify reinforcers

Functional Analysis (F.A.)

Semi-structured interview that examines the antecedents & consequences of a behavior

A “roadmap”2 kinds of F.A.s

F. A. for Substance-Using Behaviors

Objective: to work toward decreasing or stopping the problem behavior

F.A. Procedure: – outlines individual’s triggers for substance

use– clarifies consequences (positive &

negative) of substance use for client

F. A. of Substance Use: Initial Assessment

External triggers– who, where, when

Internal triggers– thinking, feeling (emotionally,

physically) Short term positive consequences Long term negative consequences

Case Example

22 year-old single male who presented with concern over his Sat. night drinking; appeared depressed over break-up with girlfriend (2 years prior)

External triggers

Who are you usually with when you drink?– Marcello, Dale, & James

Where do you usually drink?– Marcello’s house

When do you usually drink?– Saturday night

Internal triggers

What are you usually thinking about right before you drink?– I need to relax. I deserve some fun for

working so hard. I’ll fit in because I’ll be drinking

What are you usually feeling physically right before you drink?– Exhausted

What are you usually feeling emotionally right before you drink?– Pleased with self. A little sad.

Drinking behaviors

What do you usually drink?

– Beer How much do you usually drink?

– 7-8 12 oz. bottles Over how long a period of time do you

usually drink?

– 3 hours

Short-term positive consequences

What do you like about drinking with (who)?– We laugh a lot. They think I’m funny.

What do you like about drinking (where)?– I don’t have to drive so far. It’s informal; I can be

myself.

What do you like about drinking (when)?– It’s a good way to unwind after working all day.

Positive consequences (cont’d)

What are the pleasant thoughts you have while drinking?– These guys think I’m funny and they like

having me around. What are the pleasant physical feelings you

have while drinking?– I feel relaxed

What are the pleasant emotions you have while drinking?– Feeling “high”, happy, content

Long-term negative consequences

What are the negative results of your drinking in each of these areas:– Interpersonal: “I only seem to have friends

who drink. I haven’t put any effort into finding a romantic relationship lately.”

– Physical: “I don’t sleep well Saturday night and I usually feel terrible Sunday.”

– Emotional: “I feel lonely. I don’t know if it’s related to drinking.”

Negative consequences (cont’d)

Legal: “No problems, but I worry about getting a DWI.”

Job: “The Saturday drinking doesn’t affect this, but my weekday drinking may be starting to.”

Financial: “No problems here.” Other: n/a

Functional Analysis Practice

Partner-up: 2 people Therapist & Client

– Don’t try to do the whole FA form– Client may also have F.A. sheet – Do try to “get the story” rather than just

filling in the blanks– Use your own style of interviewing– Don’t play the client from Hell!

Group Debriefing

Functional Analysis for Substance Use: Clinicians’ Problem Areas

**Refer to CRA Procedures Checklist Giving a rationale for doing a F. A. Remembering to 1st ask for a

description of a common episode Explaining how the information will be

used in treatment planning

Functional Analysis for Pro-Social, Healthy Behaviors

Objective: to work toward increasing the healthy behavior

F. A. Procedure:– outlines the factors that “set the stage” for

the individual to decide to engage in a healthy behavior

– clarifies consequences (negative & positive) of the healthy behavior for the individual

F.A. for Pro-social Behavior (cont’d)

Remember to: Use a pro-social behavior that is

occurring occasionally alreadyUse a behavior that is both healthy

and FUNHelp identify & address roadblocks

before they happen

Case Example (cont’d)

Same client; sometimes he chose to go to his brother’s house for dinner on Sat. nights instead of playing cards & drinking with friends.

F. A. for Pro-social, Healthy Behaviors

What is your non-drinking activity?– Dinner at brother’s house; video

afterwards. How often do you engage in it?

– About once a month. How long does it usually last?

– About 3 hours.

External triggers

Who are you usually with when you (activity)?– My brother, Charles, his wife, Jill, and their two

boys.

Where are you usually (activity)?– Their home

When do you usually (activity)?– They invite me most Saturday nights. I go only

occasionally.

Internal triggers

What are you usually thinking about right before you (activity)?– This is a good way to spend the evening.

It’s something to do. It’s nice to get to know my nephews. I hope nobody bugs me about my social life.

Internal triggers (cont’d)

What are you usually feeling physically right before you (activity)?– I don’t know. Mostly relaxed I guess.

What are you usually feeling emotionally right before you (activity)?– Calm, content, but a little disappointed that

I won’t be drinking. Then ashamed for feeling that way.

Short-term negative consequences

What do you dislike about (activity) with (who)?

-It gets really noisy sometimes. Once in a while I get interrogated about whether I’m dating…

What do you dislike about (activity, where)?-Nothing

What do you dislike about (activity, when)?-It’s not as much fun as drinking & playing cards.

What are the unpleasant thoughts you have while (activity)?-Am I ever going to have my own family? I’m getting old and time is passing me by.

What are the unpleasant physical feelings you have while (activity)?-My stomach gets upset sometimes because I eat so much there...

What are the unpleasant emotions you have while (activity)?-Disappointment in myself for not having things together in my life

Long term positive consequences

What are the positive results of (activity) in each of these areas:– Interpersonal: “It brings me closer to my family. I

get to be a part of my nephew’s lives.”– Physical: “It’s healthier than drinking all night. I feel

better in the morning.”– Emotional: “My nephews look up to me and are

always thrilled to see me. That feels really good.”

Positive consequences (cont’d)

What are the positive results of (activity) in each of these areas:– Legal: No chance of a DWI.– Job: My brother and his wife help me sort

out job related problems.– Financial: I don’t lose money like I do at

cards.– Other: n/a

F. A. for Pro-Social Behavior: Clinicians’ Problem Areas

Making sure from the start that the behavior is already occurring and is fun

Giving an explicit homework assignment regarding the pro-social behavior

Sobriety Sampling: Rationale

enables client to set reasonable & attainable goals

teaches self-efficacy when goals are met

provides “time-out” from drinking so client can experience sensation of being sober

Sobriety Sampling (cont’d)

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

builds family support & 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 your next session

Planning for Time-limited Sobriety

Load up sessions Don’t rely on past unsuccessful methods Identify biggest threats to sobriety Select alternative coping strategies Develop back-up plans Remind client of reinforcers Use positive reinforcement

Exercise

Practice Sobriety Sampling (including the part about HOW the client is going to make it to the next session without using) in dyads with 1 person playing the therapist & the other playing the client.

Sobriety Sampling: Clinicians’ Problem Areas

Discussing several of the advantages of a period of sobriety

Making the plan for achieving sobriety very specific

Optional: Supplement CRA with Medications

Advantages of Disulfiram

less family worry/ more family trust fewer “slips”better able to address many

triggers at oncemore productive therapy timemore reliance on other coping skills

Advantages of Disulfiram (cont’d)

improved self-confidence fewer complicated, agonizing daily

decisionsmore chances for positive

reinforcement increase in available early warning

signs

Advantages of Naltrexone

effective alternative to disulfiram reduces urges & cravingsblocks the “high” from drinkingno adverse effects while drinking

–some evidence of drinkers experiencing negative physical effects without the “high”

Compliance (Monitor) Protocol

any concerned significant other supportive, not punitive role set time & place, make it a pleasurable

event use positive reinforcement during ritual put in water, dissolve, stir until

thoroughly mixed, give to person, praise one another for involvement

Medication Monitoring: Clinicians’ Problem Areas

Setting up a monitoring plan Bringing in the monitor to practice

Treatment Planning

2 parts: Happiness Scale and Goals of Counseling

Ask the client what she/he wants

Use a positive approach

Keep in mind the client’s reinforcers

Happiness Scale

Drinking/sobriety Job/education Money

management Social life Personal habits Marriage/family

relationships

Legal issues Emotional life Communication Spirituality General

happiness

Goals of Counseling (Treatment Plan)

In general: set relatively short-term goals that are scheduled to be complete in about a month

Then develop a step-by-step weekly strategy (intervention) for reaching the goal

The strategy = the “homework” for the week

Guidelines for Goal Setting

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

Goals of Counseling: Potential Problems

Applying the 3 basic rules (brief, positive, specific) to “real life” problems. Designing goals & strategies that are too

complex. Leaving out important steps necessary to

reach goals. Including plans that are not under the client’s

control. Unnecessarily putting the client in a high-risk

situation.

What’s wrong with these goals?

I don’t want to drink anymore!I’ll apply for 10 jobs tomorrow!I’ll have a job tomorrow!I’ll try harder to save money.I’ll go out on a date with 3

different women next week.

What’s wrong with this goal?

I am going to attend 1 AA meeting next week - at the St. Agnes church at 8:00 pm on Tuesday night.

Exercise

Complete a Happiness Scale with your “client”

Then with your client select 1-2 categories she/he wants to work on

Develop a Treatment Plan using the selected categories

Remember the “Potential Problems” when designing a Treatment Plan

Debrief with group

Happiness Scale & Goals of Counseling: Clinicians’ Problem Areas

Providing a rationale for the Happiness Scale

Setting goals & strategies that are very specific

Skills Training

Communication skills/assertiveness training

Drink/drug refusal

Problem Solving

Job-finding skills

Anger management

Role-Playing Guidelines

Acknowledge discomfort Use less difficult scenes first Get adequate description of the scene Start it for them Keep it brief (2-3 minutes) Reinforce any effort Get client’s reactions Offer supportive, specific feedback Repeat

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 CRA procedures

Positive Communication Skills

Be brief Be positive Be specific and clear Label your feeling: “I feel ___” Offer an understanding statement Accept partial responsibility Offer to help

Exercise

Practice communication in dyads; one plays the therapist & the other plays the client. Be sure to do role-plays as part of the communication training.

Communication Skills: Clinicians’ Problem Areas

Involving the client in the process when generating examples of each of the 7 components

Role-playing! Providing specific feedback, and then

repeating the role-play

Homework Guidelines

refer to “practice exercises” offer rationale for assignment describe specific assignment carefully; their

input? ask about possible obstacles, problem-solve identify time for completing assignment review homework at start of next session reinforce any compliance

Systematic Encouragement

Never assume a client will make 1st contact independently

Practice in session [It gives an opportunity to observe skill level]

Use sampling as part of the strategy Locate & speak to a contact person in

advance for the activity Review the experience in the next session

Drink/Drug Refusal Training

Enlist social supportReview high-risk situationsRefuse drinks/drugs assertivelyOptional: Restructure negative

thoughts

Assertive Drink/Drug Refusal [always watch body language!]say, “No, thanks.” (without guilt!)suggest alternativeschange the subjectaddress the aggressor directly about

the issue leave

Group Exercise

Practice drink/drug refusal as if you’re in a therapy group.

Drink/Drug Refusal: Clinicians’ Problem Areas

Taking time to identify social support Providing specific feedback and

repeating the role-play

Problem Solving

(1) Define problem narrowly

(2) Brainstorm possible solutions

(3) Eliminate undesired suggestions

(4) Select one potential solution

(5) Generate possible obstacles

(6) Address each obstacle

(7) Assign task

(8) Evaluate outcome

Exercise

Practice Problem-Solving as if you’re in a therapy group.

Problem Solving: Clinicians’ Problem Areas

Narrowing down the problem sufficiently Generating potential obstacles &

addressing them

Social/Recreational Counseling

discuss importance of healthy social life identify areas of interest reinforcer sampling community access systematic encouragement reinforcer access response priming social club

CRA’s Job Findinga disciplined, step-by-step

approach to helping clients get and keep satisfying employment.

Job Finding: Key Elements development of a resume instructions on how to fill out a job application utilization of relatives, friends, & phone book to

generate job leads instructions in telephone techniques to secure

interviews rehearsal on the interview process [video

camera if possible] information on how to keep a job

CRA’s Relapse Prevention

Relapse prevention really starts the 1st day of treatment

There are some specific relapse prevention strategies too

Recovery Maintenance Strategies:Marlatt and Gordon RP Model

Characteristics of a “high risk” situation Unpleasant emotions Physical discomfort Pleasant emotions Testing personal control Urges and temptations Social problems at work Social tension Positive social situations

Marlatt and Gordon Relapse Prevention Model.

High Risk SituationHigh Risk Situation

Effective CopingEffective CopingResponseResponse

Ineffective CopingIneffective CopingResponseResponse

Increased Self-Increased Self-EfficacyEfficacy

Decreased Self-Decreased Self-EfficacyEfficacy

Less Less Lapse/Relapse RiskLapse/Relapse Risk

Positive OutcomePositive OutcomeExpectancyExpectancy

More More Lapse RiskLapse Risk

Increased AVEIncreased AVE

More Relapse RiskMore Relapse Risk

Additional Relapse Techniques

CRA Functional Analysis for Relapse

Set up an early warning monitoring system

Outline the behavioral “chain” of events that leads to a relapse

Behavioral Chain bored take a walk

go towards park go into park

go near friend’s house go into house

friend asks you to get high give in

CRA Relationship Therapy

emphasizes relationships as an integral part of treatment

focusing only on the using behavior (while ignoring other interpersonal problems) less productive therapy

Relationship Therapy: Overview

Action orientedTime limitedFocuses on skills building “Here and now” focusTeaches general relationship skills

Relationship Therapy: Introduction

Discuss current negative communication style

Assure clients that many people in similar situations have shown improvement in their relationships

Introduction (cont’d)

Explain how they will be taught effective new communication skills

Let them know that they will feel less overwhelmed as progress is made

Relationship Therapy: Communication Skills

Briefly present one issueSpeak in a positive manner;

no blamingDefine issues clearly & specifically;

refer to measurable behaviorsClearly state your feelings about the

issue

Communication Skills (cont’d)

Offer understanding statement (try to view issue from partner’s perspective)

Accept partial responsibility for any problem raised

Offer to help

Relationship Happiness Scale

Household responsibilities

Raising the children

Social activities Money

management

Communication Sex & affection Job or school Emotional support Drinking/drug use General

happiness

Relationship Happiness ScaleThis scale is intended to estimate your current happiness with your marriage on each of the eleven areas listed. Ask yourself the following question as you rate each area:How happy am I with my partner in this area? Then circle the number that applies.

Numbers toward the left end of the ten-unit scale indicate various degrees of unhappiness, while numbers toward the right end of the scale reflect increasing levels ofhappiness. In other words, state according to the numerical scale (1-10) exactly how you feel today. Try to exclude all feelings yesterday and concentrate only on thefeelings of today in each of the life area. Also try not to allow one category to influence the results of the other categories.

1 = Completely Unhappy (canÕt get worse)5 = Neutral (not unhappy, not happy either)10 = Completely Happy (canÕt get better)

Unhappy Neutral Happy

Happiness with:

1. Household Responsibilities 1 2 3 4 5 6 7 8 9 10

2. Rearing of Children 1 2 3 4 5 6 7 8 9 10

3. Social Activities 1 2 3 4 5 6 7 8 9 10

4. Money Management 1 2 3 4 5 6 7 8 9 10

5. Communication 1 2 3 4 5 6 7 8 9 10

6. Sex & Affection 1 2 3 4 5 6 7 8 9 10

7. Job or School 1 2 3 4 5 6 7 8 9 10

8. Personal Independence 1 2 3 4 5 6 7 8 9 10

9. Spouse Independence 1 2 3 4 5 6 7 8 9 10

10. Spiritual Life 1 2 3 4 5 6 7 8 9 10

11. General Happiness 1 2 3 4 5 6 7 8 9 10

Name _______________________________________________ ID ____________________ Date _____________________

“Perfect” Relationship

In household responsibilities I would like

my partner to: In raising the children I would like my

partner to: In social activities I would like my partner

to:

Reciprocity

Learn how to make a request in a positive manner.

Each partner gets “something”. Clients’ cannot say “no” to a request,

but you don’t have to say “yes” either. Learn how to give in a little

(compromise). Try at home, learn independently.

Self-Reminder to Be NiceToday….did you:

Express appreciation to your partner? Compliment your partner? Give your partner any pleasant surprises? Express visible affection to your partner? Spend some time devoting your complete

attention to pleasant conversation w/ your partner?

Initiate a pleasant conversation? Make any offer to help before being asked?

Positive Reinforcer: Review

What is a reinforcer?

How do I find one?

Does everyone have reinforcers?

How can I use them to help?

Common Mistakes Made When Implementing CRA

Losing sight of client’s reinforcers Failing to involve concerned others in

treatment Neglecting to emphasize the importance

of having a satisfying social and

recreational life Not stressing the necessity of having a

meaningful job

Inadequately monitoring the client’s contact with triggers

Not checking for generalization of skills Being reluctant to suggest the use of

disulfiram/naltrexone

More Information

The Community Reinforcement Approach. (Available from the Behavioral Health Recovery Management Project c/o Fayette Companies, P.O. Box 1346, Peoria, IL 61654-1346; or at http://www.bhrm.org).

Meyers, R.J. & Miller W.R. (Eds.). (2001). A Community Reinforcement Approach to Addiction Treatment. Cambridge, UK: University Press.

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

First CRA Therapist Manual

Monograph of CRA Research

Community Reinforcement and Family Training: CRAFT