community reinforcement approach susan harrington godley chestnut health systems bloomington, il...
TRANSCRIPT
Community Reinforcement Approach
Susan Harrington GodleyChestnut Health Systems
Bloomington, ILFunded by:
Center for Substance Abuse Treatment (TI11894 TI13356) National Institute on Drug Abuse (R01 DA 018183)
Based on slides by Robert J. Meyers, Ph.D. and Jane Ellen Smith, Ph.D.
University of New Mexico
Goals of Presentation
Supporting Research
What is CRA?
Hunt & Azrin 1973
Inpatient Alcoholics job finding counselingbehavioral/marital therapysocial/leisure counselingreinforcer access counselingsocial clubhome visits [total 50 hrs per client]
Results: 6 month follow-up
0
20
40
60
80
Drink Days Jobless Days Days awayfrom family
Institution Separated/Div
Traditional CRA
Azrin 1976: New & Improved CRA
inpatient alcoholics
disulfiram w/compliance protocol
problem prevention
buddy system
early warning mood monitoring
~70% as aftercare home visits
[Average 30 contact hrs]
CRA new & improved: Results
0
10
20
30
40
50
60
70
Drink Days Jobless Days Days away fromfamily
Institution
Traditional CRA
CRA Outpatient Study (1982)Azrin, Sisson, Meyers, & Godley
43 outpatient alcoholics3 groups:
(1) traditional tx (2) traditional tx + disulfiram
compliance(3) CRA + disulfiram
compliance
increased use of positive reinforcement
sobriety sampling
drink refusal training
+/- functional analysis
job club
phone contacts
[Average: 5 sessions]
6 Month Follow-up (1982)
CRA + disulfiram compliance % days abs = 97%
Traditional + % days abs = 74% disulfiram compliance
Traditional % day abs = 45%
CRA with Homeless Alcohol-Dependent Individuals
CRAGroup Sessions
Problem-SolvingCommunication SkillsDrink-RefusalIndependent Living SkillsGoal Setting MeetingSocial ClubDisulfiram Compliance (for a sub-group)
Individual SessionsJob FindingCase Management
STANDARD TREATMENT
Day Treatment
12-Step Counselor
Job Service Program
VA Benefits Advisor
Drinks Per Week By Condition
Follow-Up Period
0
2
4
6
8
10
12
14
16
18
20
2 Month 4 Mont 6 Month 9 Month 12 Month
Median SECs
--- Standard
--- CRA
Percent Homeless By Condition
0
5
10
15
20
25
30
35
CRA
Standard
Follow-up Periods
2 Month 4 Month 6 Month 9 Month 12 Month
Percent
Evidence of Effectiveness: Meta-analyses & Reviews
Holder et al. (1991) Miller et al. (1995)Social skills training Brief intervention
Self-control training Social skills training
Brief motivational tx MET
Behavioral Marital tx CRA
CRA Behavioral contract
Stress management Aversion tx
Evidence of Effectiveness (cont’d)
Finney et al., 96 Miller et al., 03 Miller et al., 05CRA Brief Intervention Cognitive-BehavioralSocial skills training MET CRABehavioral Marital tx Acamprosate MIDisulfiram Implants CRA Relapse PreventionOther marital tx Self-Change Social Skills TrainingStress Management Naltrexone Behavioral Marital Ther.
CRA Clinical TrialsHunt & Azrin, ‘73 (inpatient alcohol dependent)Azrin, ’76 (inpatient alcohol dependent)Azrin et al., ‘82 (outpatient alcoholic)Higgins et al., ’91 (cocaine)Budney et al., ‘91 (cocaine)Higgins et al., ’93 (cocaine)Smith et al., ’98 (homeless alcoholics)Abbott et al., ’98 (methadone/heroin addicts) Roozen et al., ’00 (opioid dependent individuals)Schottenfeld et al., ’00 (opioid & cocaine dependent individuals)Meyers & Miller., ’01 (outpatient alcoholics)Godley, et al., ’02 (Adolescent aftercare mj & alc)Azrin, ’04 (outpatient adolescent patients) Roozen et al., ’06 (nicotine dependent individuals)Slesnick, et al., ’07 (homeless, street living youth)De Jong et al., ’07 (opioid dependent individuals)DeFuentes-Merillas, & De Jong ’08 (opioid & cocaine dependent
individuals)
What does not work!
Educational films and lectures
General alcoholism counseling
Process psychotherapy (individual or group)
Confrontational counseling
Antipsychotic medication
Insight therapy
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 Session Structure
Been tested in clinical trials for 3-month period, but designed to be open-ended based on individual needsCan be combination of individual/group sessionsFrequency of sessions based on client’s motivation and progressAssessment and treatment planning used for all; skills training as needed
CRA Induction: First Session
Build rapport, build rapport, build rapport
Stay client-focused
Use positive reinforcement
Provide an overview of the basic CRA objectives
Begin to establish “reinforcers” (motivators)
Positive Reinforcer
What is a reinforcer?
How do I find one?
Does everyone have reinforcers?
How can I use them to help?
Functional Analysis (F.A.)
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 behaviorA healthy, fun behavior
Sobriety Sampling
Provide the rationale (Step 1)
The negotiation (Step 2)
Plan for Time-Limited Sobriety (Step 3)
Happiness Scale
Goals of Counseling: Setting Goals
Goals of Counseling contains the categories on the Happiness Scale
Guide the client’s selection of a category
In general, set short-term goals
Develop a step-by-step weekly strategy for reaching each goal.
The strategy = the “homework” for the week
Skills Training
Communications Skills
Problem Solving
Drink/Drug Refusal
Job-Finding Skills
Assigning Homework
Refer to as “practice exercises”? An experiment?
Offer rationale
Get client’s input
Describe agreed-upon specific assignment
Ask about potential obstacles; problem-solve
Identify time for completing assignment
Review homework at next session
Social/Recreational Counseling
Discuss importance of healthy social life
Identify areas of interest:Ongoing? Pro-Social F.A.New? 2 x 2 table; Problem-solving; Leisure
Questionnaire; goal-setting
Encourage “reinforcer sampling”
Systematic Encouragement
Social Club
Drink/Drug Refusal Training
Review high-risk situations
Enlist social support
Refuse drinks/drugs assertively
Additional Relapse Techniques
CRA Functional Analysis for Relapse
Behavioral “chain” of events
Early warning monitoring system
Relationship Counseling
Self-Reminder to Be Nice
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
Common Mistakes Made When Implementing CRA
Inadequately monitoring the client’s contact with triggers
Not checking for generalization of skills
Being reluctant to suggest the use of appropriate medications
More Information
http://www.robertjmeyersphd.com/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.
CSAT’s Assertive Adolescent Family Treatment
Susan Harrington GodleyChestnut Health Systems
Bloomington, ILFunded by:
Center for Substance Abuse Treatment (TI11894 TI13356) National Institute on Drug Abuse (R01 DA 018183)
Goals
A-CRA vs. CRA
Assertive Continuing Care (ACC)
Technical assistance provided to grantees to learn the EBTs
Target population
Outcomes
A-CRA vs. CRA
Added caregiver sessions
Changed Happiness Scale so that it was relevant for adolescents
Samples in treatment manual were based on how one might talk with an adolescent and the issues they would talk about
Critical Parenting Practices
Good modelingIncrease positive
communicationMonitor the adolescent’s
whereaboutsInvolvement in
adolescent's life outside the home.
Based on the work of R. Catalano, H. Hops, & B.Bry
Similarity of Clinical Outcomes by Conditions
Source: Dennis et al., 2004
200
220
240
260
280
300
Tot
al d
ays
abst
inen
t.
over
12
mon
ths
0%
10%
20%
30%
40%
50%
Per
cent
in R
ecov
ery
.
at M
onth
12
Total Days Abstinent* 269 256 260 251 265 257
Percent in Recovery** 0.28 0.17 0.22 0.23 0.34 0.19
MET/ CBT5 MET/ CBT12
FSN MET/ CBT5 A-CRA MDFT
Trial 1 Trial 2
* n.s.d. effect size f=0.06
** n.s.d., effect size f=0.12
* n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16
Moderate to large differences in Cost-Effectiveness by
Condition
Source: Dennis et al., 2004
$0
$4
$8
$12
$16
$20
Cos
t per
day
of
abst
inen
ce o
ver
12 m
onth
s
$0
$4,000
$8,000
$12,000
$16,000
$20,000
Cos
t per
per
son
in r
ecov
ery
at m
onth
12
CPDA* $4.91 $6.15 $15.13 $9.00 $6.62 $10.38
CPPR** $3,958 $7,377 $15,116 $6,611 $4,460 $11,775
MET/ CBT5MET/
CBT12FSN MET/ CBT5 ACRA MDFT
* p<.05 effect size f=0.48** p<.05, effect size f=0.72
Trial 1 Trial 2
* p<.05 effect size f=0.22
** p<.05, effect size f=0.78
A-CRA did better than MET/CBT5, and both did better than MDFT
What is Assertive Continuing Care (ACC)
A continuing care intervention that was specifically designed for adolescents following residential treatment
Increasingly, it is also being used following outpatient or other primary treatment
ACC clinicians use A-CRA procedures, but typically provide services in the home and increase case management activities
Assertive Continuing Care Motto:
We can’t help them if we don’t see them!
Continuing Care Linkage and Retention During the 90 day CC Phase
94%
54%
10
2
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percent Linked Median Number of Sessions0
2
4
6
8
10
12
ACC UCC
57% Higher Rate of Continuous Abstinence for ACC (Cannabis)
ACC (n=96)
UCC (n=78)
Perc
ent
Rem
ain
ing A
bst
inent
Days from Discharge
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 30 60 90 120 150 180 210 240 270
Continuing Care Phase Follow-up Phase
Two months after residential, 58% in ACC
vs. 40% in UCC still clean
At 9 months 4 out of 10 in ACC are still abstinent vs. less than 3 of 10 in UCC
Unique Components of AAFT initiative
GAIN clinical certificationABS softwareClinical supervisor certification processWeb-based tool for clinical and supervisory certification based on digital technologyImplementation calls paired with monthly implementation progress reportsCultural responsiveness committee
Training & Certification Process for A-CRA
Bi-WeeklyCoaching calls
Upload session recordings & data to the
web;Get expert ratings andnarrative feedback
3.5-day centralized
training session
A-CRA/ACC Technical Assistance
A-CRA/ACC Certification Requirements are clearly delineated & monitored
Record clinical and
supervision sessions
Treatment Manual
and
Knowledge Test
A-CRA Clinician CertificationRequirements
Take a knowledge test
Attend the 3.5 day training
Attend coaching calls
Participate in local supervision sessions
Enter session data
Demonstrate competency on 9 core
A-CRA procedures through DSR reviews
Supervisor Certification Requirements
Take a knowledge testAttend the 3.5 day trainingAttend coaching callsProvide local supervision sessionsDemonstrate supervision skills during supervision sessionsDemonstrate ability to rate clinician DSRs
Upload Digital Session
Recordings
Read Reviews
Sample Procedure Rating1 2 3 4
5| | | |
|
poor needs satisfactory very excellent improvement good
Caregiver Overview, Rapport Building, and Motivation:
48. ____ ____ Provided an overview of A-CRA 49. ____ ____ Set positive expectations
50. ____ ____ Reviewed research regarding parenting practices51. ____ ____ Identified CG reinforcers for continued work
52. ____ ____ Kept discussion (about adolescent) positive
Narrative Comments Are Also Provided
Assigned Homework: The assignment for next week is…. Happiness ScaleGood: You gave a nice rationale for the happiness scale! You explained that he would rate his happiness in different areas of his life and that his ratings would be used to make short-term goals. It was great that you mentioned that he would do several scales and they would be used to assess progress.Good: You gave good directions for the scale. You explained that he should rate his current happiness for today on a scale from 1-10 (1-low, 10-high)…It’s also good to mention that he should rate the categories independently from one another. It was good that you reviewed some of the ratings! For legal issues and emotional life, you asked him why he rated it the way he did. For emotional life, you asked him what could improve his ratings. It’s important to do this with a number of categories (a few that are rated very high, some that are rated moderately, and some that are rated very low). For each category, it’s important to ask why he rated it the way he did and what could improve his rating. Also, this procedure should only take 15 minutes or so. It seemed like you got stuck while going over the emotional life category and spent the rest of the session discussing this.
Overall – Stayed Within ACRA Protocol: You were behavioral, supportive, and positive…Overall – Introduced ACRA Procedures at Appropriate Times: You assigned homework…General Clinical Skills: You were warm, nonjudgmental, and supportive…
AAFT Performance Data
2,137 Adolescents have been open to the project
25,463 Sessions have been posted to EBTx
2,726 Of DSRs have been rated with feedback to clinicians
88 Clinicians have been certified
31 Supervisors have been certified
Average # of DSRs to certification is 21; range 9 - 49
Average # of months to certification is 9; range 2.2 - 19
261 of fidelity checks conducted: 51% pass on first check, and 72% pass on the second check
Demographic Profile
10%
5%
5%
81%
6%
16%
32%
21%
31%
16%28%
78%
0% 20% 40% 60% 80% 100%
Outpatient Continuing Care
Long Term Residential
Intensive Outpatient
Outpatient
18 to 25 years old
15 to 17 years old
12 to 14 years old
Hispanic*
Mixed/Other
Caucasian
African American
Female
Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)
*Any Hispanic ethnicity separate from race group.
Pattern of Weekly Use (13+/90 days)
55%
14%
43%
2%
4%
6%
1%
52%
22%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Anything
Alcohol
Cannabis
Cocaine
Opioid
Other Drugs
Needle Use
Tobacco
Controlled Environment
Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)
Co-Occurring Psychiatric Problems
70%
51%
49%
39%
26%
12%
64%
46%
38%
20%
8%
42%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any Co-occurring Psychiatric
Conduct Disorder
Attention Deficit/Hyperactivity Disorder
Major Depressive Disorder
Traumatic Stress Disorder
General Anxiety Disorder
Ever Physical, Sexual or Emotional Victimization
High severity victimization (GVS>3)
Ever Homeless or Runaway
Any homicidal/suicidal thoughts past year
Any Self Mutilation
Prior Mental Health Treatment
Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)
Past Year Violence & Crime
Notes: \a Dealing, manufacturing, prostitution, gambling (does not include simple possession or use); \b 14 or more days on probation/parole with urine monitoring
83%
72%
63%
47%
45%
44%
86%
68%
36%
30%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any violence or illegal activity
Physical Violence
Any Illegal Activity
Any Property Crimes
Any Interpersonal/ Violent Crime
Other Drug Related Crimes \a
Lifetime Juvenile Justice Involvement
Current Juvenile Justice involvement
1+/90 days In Controlled Environment
Probation/Parole with Urine Testing\b
Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)
Three, 14%
None, 6%
Five to Twelve,
46%
Four, 13%
Two, 12%
One, 9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Count of Major Clinical Problems at Intake\a
Note: \a Based on count of self reporting criteria to suggest Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity
Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)
Median = 4 Problems
14%
45%
71%
0%10%20%30%40%50%60%70%80%90%
100%
Low (OR 1.0)
Mod.(OR=5.0)
High(OR=15.0)
NoneOneTwoThreeFourFive+
No. of Problems\a by Severity of
Victimization
Severity of Victimization
Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)
Note: \a Based on count of self reporting criteria to suggest Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity. OR=Odds Ratio relative to Low
Performance (goal): Recruitment and Monitoring
Notes: \a based on done divided by due minus expected, plus same percent expected of those still pending in window
Source: CSAT February 2009 AAFT Management Report (n=2,415)
100%
73%
80%
89%
87%
88%
100%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Site Data Submission Ok to Good (80%+)
12 Month follow-up (80%+)\a
6 Month follow-up (80%+)\a
3 Month follow-up (80%+)\a
Session 2 Alliance (80%+)\q
Recruitment Rate (80%+)
Sites with 2+ Staff GAIN Certified or In processWithin Window (100% of Sites)
A-CRA/ACC Certification Progress
88
31
19
12
33
7
53
14
0 20 40 60 80 100 120
A-CRA Clinician
A-CRA Supervisor
ACC Clinician
ACC Supervisor
Staff
Certified In Progress
Performance (goal): Treatment Received
97%
87%
88%
86%
57%
100%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sites with 2+ Staff A-CRA Certified orPending (100% of Sites)
Evidenced Based Treatment (80%+) [ACRA 86%, ACC 10%, other 1%]
Treatment Initiation within 2 weeks (80%+)
Treatment Engagement of 4+ weeks (80%+)
Continuing Care for 90+ days (50%+)
ACC Linkage within 14 days (50%+)
Source: CSAT February 2009 AAFT Management Report (n=2,415)
Targeted Improvement over general practice
Performance: Change Over Time in Selected Outcomes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 3 6 9 12
Months from Intake
Abstinence
No MentalHealth Problems
No IllegalActivity
No FamilyProblems
Source: CSAT February 2009 AAFT GAIN Data set with 1+ Follow-up (n=1,732)
Outcome Status at Last Wave
Source: CSAT February 2009 AAFT GAIN Data set with 1+ Follow-up (n=1,732)
63%
73%
38%
43%
99%
47%
90%
68%
14%
35%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Abstinent
Abuse/Dependence Sx
Physical Health
Mental Health
Nights of Psychiatric Inpatient
Illegal Activity
Arrests
Family/Home Problems
Recovery Environment Risk
Quarterly Cost to Society
Reduced 50% orNo ProblemNo Problem
Comments from Therapists
thanks... the team has been awesome!! Brandi was always responsive and the web-based system was user friendly. I gave some feedback on our last conference call re: possibly having separate calls for supervisors... other than this...TOP NOTCH! Will be in touch if any issues should arise moving forward. Be well and thanks again...
Thank you so much; you all have helped me greatly with this process. I really appreciate the time and care you provide for all of us undergoing ACRA/ACC certification. I want you all to know that I felt fully supported from the beginning and I still feel that way today. There was always someone available to answer all of my questions and I never felt like I was alone in this process. I am very proud of this accomplishment and it is a wonderful feeling to be a part of the ACRA/ACC program. I am seeing first hand the opportunities and client empowerment this program provides for our youth, their families, and our community and it's amazing.
Summary
The CSAT Adolescent Treatment program has demonstrated the ability to replicate A-CRA and ACC approaches in community based settings
Both the GAIN and the A-CRA/ACC training and certification processes appear to be working well in AAFT based on numbers of staff achieving certification
Adolescents appear to like the intervention
Outcomes to date compare favorably to previous CSAT replication efforts and other CSAT funded initiatives
Monograph of CRA Research
Community Reinforcement and Family Training: CRAFT