The community reinforcement approach, alcohol research and health, volume 33, number 4

Development and Effectiveness of CRA
The most influential behaviorist of all times, B. F. Skinner,largely considered punishment to be an ineffective method Robert J. Meyers, Ph.D.; Hendrik G. Roozen, Ph.D.; for modifying human behavior (Skinner 1974). Thus it was no surprise that, many years later, research discoveredthat substance use disorder treatments based on confrontationwere largely ineffective in decreasing the use of alcohol The Community Reinforcement Approach (CRA),
and other substances (Miller and Wilbourne 2002, originally developed for individuals with alcohol use
Miller et al. 1998). Nate Azrin already was convinced disorders, has been successfully employed to treat a variety
of this back in the early 1970s, when he designed an inno- of substance use disorders for more than 35 years. Based on
vative treatment for alcohol problems: the Community operant conditioning, CRA helps people rearrange their
Reinforcement Approach (CRA). Azrin believed that it lifestyles so that healthy, drug-free living becomes
was necessary to alter the environment in which people rewarding and thereby competes with alcohol and drug
with alcohol problems live so that they received strong use. Consequently, practitioners encourage clients to
reinforcement for sober behavior from their community, become progressively involved in alternative non-
including family, work, and friends. As part of this strate- substance-related pleasant social activities, and to work on
gy, the program emphasizes helping clients discover new, enhancing the enjoyment they receive within the
enjoyable activities that do not revolve around alcohol, and “community” of their family and job. Additionally, in the
teaching them the skills necessary for participating in those past 10-15 years, researchers have obtained scientific
activities (see sidebar for a description of CRA procedures).
evidence for two off-shoots of CRA that are based on the
Research has since supported the premise behind CRA.
same operant mechanism. The first variant is Adolescent
Studies show that people with substance use disorders report Community Reinforcement Approach (A-CRA), which
that they are less engaged in pleasant activities compared targets adolescents with substance use problems and their
with healthy controls (Roozen et al. 2008; Van Etten et caregivers. The second approach, Community Reinforcement
al. 1998). And other studies found that enriching people’s and Family Training (CRAFT), works through family
environment with non–substance-related rewarding alternativesencourages them to reduce their substance use (Correia et members to engage treatment-refusing individuals into
al. 2005; Vuchinich and Tucker 1996). Even modern day treatment. An overview of these treatments and their scientific
neurobiology has confirmed that components of addiction backing is presented. KEY WORDS: Alcohol use disorders; alcohol
treatment should focus on increasing patients’ involvement and other drug disorders; substance use disorders; treatment; with alternative reinforcers (Volkow et al. 2003).
treatment methods; Community Reinforcement Approach (CRA); In terms of testing CRA itself, studies suggest that it is Adolescent CRA; Community Reinforcement and Family highly effective. Azrin’s first two studies of the program tested its effectiveness among alcohol-dependent inpatients(Azrin 1976; Hunt and Azrin 1973). The results showedthat the new CRA program was more effective in reducing TheCommunityReinforcementApproach(CRA)is drinkingthanwasthehospital’sAlcoholicsAnonymous a comprehensive behavioral treatment package that program. Furthermore, the CRA participants had better focuses on the management of substance-related outcomes with regard to their jobs and family relation- behaviors and other disrupted life areas. The goal of CRA is ships. Azrin then modified the program slightly to test to help people discover and adopt a pleasurable and healthy it with outpatients at a rural alcohol treatment agency lifestyle that is more rewarding than a lifestyle filled withusing alcohol or drugs. Multiple research reviews and meta-analyses of the treatment-outcome literature have shown ROBERT J. MEYERS, PH.D., is an emeritus associate researchprofessor of psychology in the Psychology Department at the CRA to be among the most strongly supported treatment University of New Mexico, and director of Robert J. Meyers, methods (Finney and Monahan 1996; Holder et al. 1991; Ph.D., and Associates, Albuquerque, New Mexico Miller et al. 1995, 2003). This article briefly discusses thescience behind CRA, and provides an overview of the treat- HENDRIK G. ROOZEN, PH.D., is a clinical psychologist ment program. In addition, it discusses two novel variants and senior researcher in the Department of Research and built upon the CRA foundation. These interventions Development, Novadic-Kentron Treatment Services, Vught, include an adolescent version of CRA called Adolescent the Netherlands, and Erasmus University Medical Centre, Community Reinforcement Approach (A-CRA), and a Department of Forensic Psychiatry, Rotterdam, the Netherlands. program called Community Reinforcement and FamilyTraining (CRAFT), which is designed to engage treatment- JANE ELLEN SMITH, PH.D., is professor of psychology in the refusing substance-abusing individuals into treatment by Psychology Department at the University of New Mexico, (Azrin et al. 1982). He and his colleagues, again, found vouchers to participants who submitted drug-free urine CRA to be superior to the comparison condition.
samples. In turn, they could exchange the vouchers for A larger outcome study conducted in the 1990s had goods, such as dinners. A number of early studies demon- mixed results, though it did show a benefit of CRA on strated that CRA plus vouchers outperformed standard the immediate outcome. (Miller et al. 2001). For this treatment programs (e.g., Higgins et al. 1991, 1993, study, participants had to score in the symptomatic range 1994). Another study showed that CRA plus vouchers on two of four measures, including the Addiction Severity was significantly better than vouchers alone in terms of Index and the Alcohol Use Inventory. The final sample improved treatment retention and employment rates, and consisted of people who met an average of 7 of the 9 reduced cocaine use—at least during the treatment phase criteria for alcohol dependence syndrome as defined (Higgins et al. 2003). The CRA plus vouchers program by the Diagnostic and Statistical Manual of Mental has been used successfully with other illicit drugs as well.
Disorders, Third Edition, Revised (DSM–III–R) (American For example, people receiving opioid detoxification with Psychiatric Association 1980). The study compared CRA buprenorphine had significantly better treatment out- with a “traditional” treatment. However, because this comes if they also received CRA plus vouchers (Bickel et al.
comparison treatment used a CRA procedure as part of 1997). In addition, a recent study with adults who used its protocol—teaching one of the participants’ loved ones cannabis determined that long-term outcomes favored positive communication skills so he or she could administer clients who received CRA in addition to vouchers as disulfiram (Antabuse®) in a supportive and caring way— opposed to just vouchers alone (Budney et al. 2006).
the overlap could have obscured the results somewhat.
Thus, the CRA plus contingency management package Another confounding factor may have been that the appears to be a highly successful program for treating traditional treatment group included more participants individuals who abuse illicit drugs (Bickel et al. 2008; who agreed to take disulfiram in the first place (Miller In a study that delivered CRA in a group format to severely alcohol-dependent homeless individuals in a day The Adolescent Version of CRA: A-CRA
treatment program, CRA produced significantly greater The high rate of illicit substance use among adolescents substance use outcomes than did the standard treatment has been viewed as one of the primary public health problems at the homeless shelter (Smith et al. 1998). Finally, another facing the United States for some time now (Johnston study discovered that people with antisocial personality et al. 2001). According to one report, during a relatively disorder could, in fact, respond successfully to a CRA recent six-year period (1992–1998), the number of 12- to program, even if it highlighted the relationship counseling 17-year-olds who were admitted to public substance use treatment agencies increased by 54 percent (Dennis et al.
The table provides an overview of Community 2003). Consequently, it is more important than ever to Reinforcement studies. The first section highlights the tri- identify effective substance use disorder treatment programs als in which researchers tested “pure” CRA, without any for adolescents. A-CRA is a scientifically-based behavioral additional programs. Several comprehensive reviews and intervention that is a slightly modified version of the adult meta-analyses support the conclusion that CRA is highly CRA program (for descriptions with examples see Godley effective compared with other alcohol treatments (Finney and Monahan 1996; Holder et al. 1991; Miller et al. 1995, To begin with, developers of A-CRA modified several of 1998, 2003, 2005; Roozen et al. 2004). Although it is the CRA procedures, and the forms that accompany them, not readily apparent from the table, CRA has been clini- to make them more developmentally appropriate for ado- cally effective for people with varying degrees of alcohol lescents. For example, the adolescent versions of the Happiness problems and with psychiatric comorbidity, in both rural Scale and the Goals of Counseling form contain additional and urban environments, and for people with goals of categories focused on school and friends (Forehand and either abstinence or reduced use. It also has been modified Wierson 1993). In addition, developers simplified the to expand its reach to people with illicit drug problems, communication skills training procedure and added an to adolescents, and to people resistant to entering treatment, anger management procedure to assist with impulsive, as will be explained in the following sections.
acting-out behavior (Weisz and Hawley 2002).
The main unique element in A-CRA is that it involves caregivers—namely, parents or other individuals who CRA plus Contingency Management
are ultimately responsible for the adolescent and with Higgins, a researcher who was very interested in using whom the adolescent is living—in the treatment program.
CRA to treat cocaine-dependent individuals, believed that These caregivers attend four sessions: two devoted to the people with cocaine-dependence needed tangible incentives caregiver(s) alone and two set up for the caregiver and to combat strong urges early in recovery. Thus, he developed the adolescent together. Among other things, the caregiver- a contingency management program to supplement CRA alone sessions emphasize parenting “rules.” This is especially for his work with these patients. The program provided relevant because parental rule-setting has been inversely (8) Relationship Counseling focuses associated with adolescents’ alcohol use over time, and often experience profound emotional and relationship dam- even moderates the presence of a genetic predisposition age from living with a person with an untreated substance toward alcohol use (Van der Zwaluw et al. 2009). The use disorder (Kahler et al. 2003; Kirby et al. 2005).
program also teaches caregivers several of the basic skills, Substance use disorders often are associated with intimate including communication and problem-solving, that their partner violence (Fals-Stewart and Kennedy 2005).
adolescent has learned in individual sessions. During the CRAFT was designed to address this problem by targeting sessions with both the adolescent and the caregiver, the people who refuse to seek treatment for substance-abuse therapist guides family members in using positive com- problems. Derived from the operant-based fundamentals munication skills with each other as they address problems of CRA, CRAFT decidedly does not pressure these indi- in their relationship. The group negotiates goals geared toward viduals to attend treatment. Instead, it operates indirectly increasing happiness in the adolescent–caregiver relationship, and gently through a concerned family member, called and adolescents and caregivers practice problem-solving the Concerned Significant Other (CSO) in the program.
exercises that they are asked to continue outside of therapy.
CRAFT therapists show CSOs how to change the home A national study with 600 participants tested the efficacy environment of the treatment-resistant individual to reward of A-CRA, comparing the program with several other behaviors that promote sobriety and withhold rewards treatments, including Motivational Enhancement Therapy/ when the individual is using drugs or alcohol (Smith and Cognitive Behavior Therapy (with two different lengths of treatment), Multidimensional Family Therapy, and For example, assume a husband thoroughly enjoys having Family Support Network (Dennis et al. 2004). The par- his wife (the CSO) join him in some after-dinner activity, ticipating adolescents often had multiple substance use such as watching television or playing cards, and that this disorders, and approximately 70 percent had symptoms routinely occurs after the husband has been drinking.
of co-occurring psychiatric disorders. Although a number After discussing the potential for domestic violence and of the treatments were equally effective statistically, A-CRA teaching positive communication skills, a therapist might was the most cost-effective intervention. More recently, the coach the CSO to have some variation of the following effectiveness of A-CRA was confirmed in a study with conversation with her husband at breakfast: “I wanted to homeless youth (Slesnick et al. 2007).
let you know that I really enjoy sitting and watching ourfavorite shows together in the evening, but I only will doit from now on when you haven’t been drinking. I want Community Reinforcement and Family Training (CRAFT)
to do everything I can to support your sobriety.” The A sizeable group of individuals with substance use disorders message would be modified to suit the particular situation, refuse to engage in treatment (Stinson et al. 2005; Substance and in some cases the CSO might elect to not even com- Abuse and Mental Health Services Administration 2009).
municate with the substance user about the plan in advance.
Even for those who do seek treatment, it may take them Regardless, it is critical that the CSO, in this case the wife, 6–10 years after the initiation of drug use (Joe et al. 1999; follow through with the plan to only join her husband if Wang et al. 2005). This reticence to seek treatment can he was sober, and to get up and excuse herself—again, have tangible consequences. Concerned family members using positive communication skills—if he started to drink.
Learning how to appropriately reward clean/sober behavior Meyers 2004) and a self-help book (Meyers and Wolfe is only one aspect of CRAFT, but over time it can become 2004)—outline the differences between appropriate rein- a powerful tool. Importantly, it must be used consistently forcement and enabling, as well as provide comprehensive and applied across a number of different behaviors. Relying descriptions of the other CRAFT procedures.
upon positive communication throughout the process is Along with helping to encourage substance abusers to critical for success. Furthermore, the appropriate use of seek treatment, CRAFT also focuses on enhancing the this procedure requires that CSOs learn the difference happiness of the CSO overall. Therefore, some of its between the reinforcement of clean/sober behavior and procedures help CSOs identify the areas of their lives in enabling. The latter is the CSO’s inadvertent reinforce- which they would like to make changes, and then assist in ment of drinking or drug using (Meyers and Smith 1997).
developing strategies to accomplish their goals. For example, Two CRAFT books—a therapist manual (Smith and assume a mother (CSO) has delayed finishing up her NOTE: The studies included are considered unique published studies and are available in electronic databases such as PubMed and PsychInfo. The effects of each study are appraised as+, statistically significant effect in favor of the experimental condition; =, no statistically significant difference detected; and NA, Not Applicable.
degree at the local college because she has been preoccupied also: thus, discussions about obtaining a job might easily with caring for her substance-abusing 19-year-old daughter.
bring up mandatory urine tests, and talking about enhancing If the CSO noted on her Happiness Scale that she was her social life might introduce the idea of substance-free very unhappy in the job/education category, the therapist activities and friends. Therapists also respond favorably to would explore whether she wanted to set some goals in the basic premise of community reinforcement treatments— that area. A reasonable goal might be to take one college namely, that the emphasis should be on using reinforcement course that semester, and the strategy would involve several to affect behavior change. At the same time, therapists are steps, including finding out which courses she needed to relieved to learn that despite being a non-confrontational graduate, which courses were offered at a convenient time, treatment, CRA/A-CRA/CRAFT therapists are directive, and determining her financial aid status. She would also have clear expectations, and set limits as needed (Meyers identify and address obstacles. For example, she might be and Smith 1995; Smith and Meyers 2004).
reluctant to leave for class on evenings when her daughteris high. Acceptable solutions could vary widely, but mightinvolve asking a neighbor to check on the daughter in her Future Directions
absence, or dropping the daughter at a safe location for Because the scientific evidence has established that com- the evening. A therapist would check progress toward the munity reinforcement treatments are effective, current CSO’s goals weekly, and help modify them as needed.
lines of research have focused on determining state-of-the- Studies (see table) have consistently demonstrated that art methods for training therapists (Garner et al. 2009a) CRAFT is 2-3 times more successful at engaging treatment- and for ascertaining which specific procedures in these resistant individuals in substance abuse treatment than the comprehensive treatment packages are most crucial traditional Al-Anon model and the Johnson Intervention(Johnson 1986). More specifically, studies show that (Garner et el. 2009b). In terms of clinical advances, these CRAFT successfully engaged approximately two-thirds treatments are being adopted in various countries around of the treatment-refusing individuals into treatment, the world, as evidenced by translations of the CRA book regardless of whether they used alcohol or other drugs into German, Dutch, and Finnish, and the CRAFT book problematically (Kirby et al. 1999; Meyers et al. 1999, into German, Finnish, and Korean. In addition, clinicians 2002; Miller et al. 1999; Roozen et al. 2010; Sisson and are considering applying CRA and CRAFT to other diag- Azrin 1986). Furthermore, CRAFT worked across ethnicities noses, such as eating disorders (Gianini et al. 2009), and and various types of relationships, including spouse–spouse, investigating the use of A-CRA for adolescents with parent–child and sibling–sibling. Generally, substance users engaged in treatment after only 4-6 CSO sessions.
Irrespective of whether the substance user engaged in treat-ment, the CSOs reported a sizeable reduction in their Financial Disclosure
own physical symptoms, depression, anger and anxiety(Dutcher et al. 2009; Kirby et al. 1999; Meyers et al. and The authors declare that they have no competing financial 1999, 2002; Miller et al. 1999; Sisson and Azrin 1986).
CRAFT demonstrated similar success rates when usedwith the parents of treatment-resistant adolescents(Waldron et al. 2007).
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Addictions 17:422-435, 2008. PMID: 18770086 Copyright of Alcohol Research & Health is the property of National Institute on Alcohol Abuse & Alcoholism and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
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