Community Reinforcement Approach (CRA)

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Community Reinforcement
Approach (CRA)

• Robert J. Meyers, Ph.D.
• Jane Ellen Smith, Ph.D.
• University of New Mexico

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

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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)

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CRA Induction Overview 1st Session

• Build rapport, build rapport, build rapport
• Stay client focused
• Use positive reinforcement
• Begin to establish reinforcers
• (e.g., internal or external motivators?)

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CRA Induction Overview (contd)

• 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?)

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Positive Reinforcer

• What is a reinforcer?
• How do I find one?
• Does everyone have reinforcers?
• How can I use them to help?

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CRA Overview Clinicians Problem Areas

• Refer to CRA Procedures Checklist
• Giving a clear, concise description of CRAs
  basic objective/theory
• Starting to identify reinforcers

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Functional Analysis (F.A.)

• Semi-structured interview that examines the
  antecedents consequences of a behavior
• A roadmap
• 2 kinds of F.A.s

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F. A. for Substance-Using Behaviors

• Objective to work toward decreasing or stopping
  the problem behavior
• F.A. Procedure
• outlines individuals triggers for substance use
• clarifies consequences (positive negative) of
  substance use for client

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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

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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)

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External triggers

• Who are you usually with when you drink?
• Marcello, Dale, James
• Where do you usually drink?
• Marcellos house
• When do you usually drink?
• Saturday night

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Internal triggers

• What are you usually thinking about right before
  you drink?
• I need to relax. I deserve some fun for working
  so hard. Ill fit in because Ill 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.

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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

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Short-term positive consequences

• What do you like about drinking with (who)?
• We laugh a lot. They think Im funny.
• What do you like about drinking (where)?
• I dont have to drive so far. Its informal I
  can be myself.
• What do you like about drinking (when)?
• Its a good way to unwind after working all day.

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Positive consequences (contd)

• What are the pleasant thoughts you have while
  drinking?
• These guys think Im 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

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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 havent put any effort into finding a
  romantic relationship lately.
• Physical I dont sleep well Saturday night and
  I usually feel terrible Sunday.
• Emotional I feel lonely. I dont know if its
  related to drinking.

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Negative consequences (contd)

• Legal No problems, but I worry about getting a
  DWI.
• Job The Saturday drinking doesnt affect this,
  but my weekday drinking may be starting to.
• Financial No problems here.
• Other n/a

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Functional Analysis Practice

• Partner-up 2 people
• Therapist Client
• Dont 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
• Dont play the client from Hell!
• Group Debriefing

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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

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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

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F.A. for Pro-social Behavior (contd)

• Remember to
• Use a pro-social behavior that is occurring
  occasionally already
• Use a behavior that is both healthy and FUN
• Help identify address roadblocks before they
  happen

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Case Example (contd)

• Same client sometimes he chose to go to his
  brothers house for dinner on Sat. nights instead
  of playing cards drinking with friends.

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F. A. for Pro-social, Healthy Behaviors

• What is your non-drinking activity?
• Dinner at brothers house video afterwards.
• How often do you engage in it?
• About once a month.
• How long does it usually last?
• About 3 hours.

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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.

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Internal triggers

• What are you usually thinking about right before
  you (activity)?
• This is a good way to spend the evening. Its
  something to do. Its nice to get to know my
  nephews. I hope nobody bugs me about my social
  life.

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Internal triggers (contd)

• What are you usually feeling physically right
  before you (activity)?
• I dont know. Mostly relaxed I guess.
• What are you usually feeling emotionally right
  before you (activity)?
• Calm, content, but a little disappointed that I
  wont be drinking. Then ashamed for feeling that
  way.

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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 Im
  dating
• What do you dislike about (activity, where)?
• -Nothing
• What do you dislike about (activity, when)?
• -Its not as much fun as drinking playing
  cards.

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• What are the unpleasant thoughts you have while
  (activity)?-Am I ever going to have my own
  family? Im 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

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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 nephews lives.
• Physical Its 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.

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Positive consequences (contd)

• 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 dont lose money like I do at cards.
• Other n/a

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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

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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

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Sobriety Sampling (contd)

• disrupts old habits, giving chance to replace
  with new positive coping skills
• builds family support trust
• identifies relapse-prone areas

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The Negotiation

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

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Planning for Time-limited Sobriety

• Load up sessions
• Dont 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

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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.

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Sobriety Sampling Clinicians Problem Areas

• Discussing several of the advantages of a period
  of sobriety
• Making the plan for achieving sobriety very
  specific

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Optional Supplement CRA with Medications
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Advantages of Disulfiram

• less family worry/ more family trust
• fewer slips
• better able to address many triggers at once
• more productive therapy time
• more reliance on other coping skills

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Advantages of Disulfiram (contd)

• improved self-confidence
• fewer complicated, agonizing daily decisions
• more chances for positive reinforcement
• increase in available early warning signs

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Advantages of Naltrexone

• effective alternative to disulfiram
• reduces urges cravings
• blocks the high from drinking
• no adverse effects while drinking
• some evidence of drinkers experiencing negative
  physical effects without the high

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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

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Medication Monitoring Clinicians Problem Areas

• Setting up a monitoring plan
• Bringing in the monitor to practice

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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 clients reinforcers

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Happiness Scale

• Drinking/sobriety
• Job/education
• Money management
• Social life
• Personal habits
• Marriage/family relationships

• Legal issues
• Emotional life
• Communication
• Spirituality
• General happiness

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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

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Guidelines for Goal Setting

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

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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 clients
  control.
• Unnecessarily putting the client in a high-risk
  situation.

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Whats wrong with these goals?

• I dont want to drink anymore!
• Ill apply for 10 jobs tomorrow!
• Ill have a job tomorrow!
• Ill try harder to save money.
• Ill go out on a date with 3 different women next
  week.

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Whats wrong with this goal?

• I am going to attend 1 AA meeting next week - at
  the St. Agnes church at 800 pm on Tuesday night.

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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

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Happiness Scale Goals of Counseling
Clinicians Problem Areas

• Providing a rationale for the Happiness Scale
• Setting goals strategies that are very specific

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Skills Training

• Communication skills/assertiveness training
• Drink/drug refusal
• Problem Solving
• Job-finding skills
• Anger management

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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 clients reactions
• Offer supportive, specific feedback
• Repeat

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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

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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

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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.

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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

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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

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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

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Drink/Drug Refusal Training

• Enlist social support
• Review high-risk situations
• Refuse drinks/drugs assertively
• Optional Restructure negative thoughts

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Assertive Drink/Drug Refusal

• always watch body language!
• say, No, thanks. (without guilt!)
• suggest alternatives
• change the subject
• address the aggressor directly about the issue
• leave

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Group Exercise

• Practice drink/drug refusal as if youre in a
  therapy group.

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Drink/Drug Refusal Clinicians Problem Areas

• Taking time to identify social support
• Providing specific feedback and repeating the
  role-play

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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

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Exercise

• Practice Problem-Solving as if youre in a
  therapy group.

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Problem Solving Clinicians Problem Areas

• Narrowing down the problem sufficiently
• Generating potential obstacles addressing them

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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

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CRAs Job Finding

• a disciplined, step-by-step
• approach to helping clients get and keep
  satisfying employment.

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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

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CRAs Relapse Prevention

• Relapse prevention really starts the 1st day of
  treatment
• There are some specific relapse prevention
  strategies too

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Recovery Maintenance StrategiesMarlatt 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

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Marlatt and Gordon Relapse Prevention Model

• .

High Risk Situation
Effective Coping Response
Ineffective Coping Response
More Relapse Risk
Increased Self- Efficacy
Decreased Self- Efficacy
Increased AVE
Less Lapse/Relapse Risk
Positive Outcome Expectancy
More Lapse Risk
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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

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Behavioral Chain

• bored take a walk
• go towards park go into
  park
• go near friends house go into house
• friend asks you to get high
  give in

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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

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Relationship Therapy Overview

• Action oriented
• Time limited
• Focuses on skills building
• Here and now focus
• Teaches general relationship skills

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Relationship Therapy Introduction

• Discuss current negative communication style
• Assure clients that many people in similar
  situations have shown improvement in their
  relationships

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Introduction (contd)

• Explain how they will be taught effective new
  communication skills
• Let them know that they will feel less
  overwhelmed as progress is made

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Relationship Therapy Communication Skills

• Briefly present one issue
• Speak in a positive manner
• no blaming
• Define issues clearly specifically refer to
  measurable behaviors
• Clearly state your feelings about the issue

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Communication Skills (contd)

• Offer understanding statement (try to view issue
  from partners perspective)
• Accept partial responsibility for any problem
  raised
• Offer to help

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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

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Relationship Happiness Scale
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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

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Reciprocity

• Learn how to make a request in a positive manner.
• Each partner gets something.
• Clients cannot say no to a request, but you
  dont have to say yes either.
• Learn how to give in a little (compromise).
• Try at home, learn independently.

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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?

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Positive Reinforcer Review

• What is a reinforcer?
• How do I find one?
• Does everyone have reinforcers?
• How can I use them to help?

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Common Mistakes Made When Implementing CRA

• Losing sight of clients 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

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• Inadequately monitoring the clients contact with
  triggers
• Not checking for generalization of skills
• Being reluctant to suggest the use of
  disulfiram/naltrexone

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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.

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First CRA Therapist Manual
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Monograph of CRA Research
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Community Reinforcement and Family Training CRAFT
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