Running Head: COMMUNITY REINFORCEMENT APPROACH

Community Reinforcement Approach

Health Data by
Sabrina Morton

A Paper
Submitted in partial fulfillment of the requirements for
Health Care Policy and Applied Economics

The Community Reinforcement Approach (CRA) is a comprehensive behavioral program developed by behaviorists Nathan Azrin and George Hunt. The Community Reinforcement Approach (CRA), originally developed for individuals with alcohol use disorders, focuses on the management of substance-related behaviors and other disrupted life areas for treating substance-abuse problems. It is based on the belief that environmental contingencies can play a powerful role in encouraging or discouraging substance abuse. To provide an alcoholic with the incentive to quit drinking, CRA has the following two major goals: (1) Elimination of positive reinforcement for drinking; and (2) Enhancement of positive reinforcement for sobriety.
Accordingly, it utilizes social, recreational, familial, and vocational reinforcers to support change in an individual's drinking or drug using behaviors and assist consumers in the recovery process. The Community Reinforcement Approach (CRA) focuses on the management of substance-related behaviors and other disrupted life areas. In essence, the goal of CRA is to help individuals obtain knowledge of and embrace a meaningful and healthy way of life that is more rewarding than one filled with alcohol or drug misuse. This comprehensive intervention blends operant conditioning with a social systems approach to address multiple problem areas (Meyers, Villanueva, & Smith, 2005) (Meyers, Roozen, & Smith, 2010). For more than 35 years, CRA has been successfully and advantageously directed towards the treatment of various substance use disorders. Based on operant conditioning, CRA helps people transfigure their lifestyles so that wholesome, drug-free living valuable and encouraging, thereby challenging alcohol and drug use. In addition, practitioners encourage participants to progressively become involved in alternate, nonsubstance-related, sociable activities, and to work on enhancing the enjoyment received within their familial and employment “community”. The basic concept is that therapy should structure around incentives to support the alcoholic's sobriety. However, if you isolate it out of behaviorism, it says that the therapy should improve and support the abuser’s capacity to effectively govern each major area of his or her life. The principal perception is that alcoholism is remedied to the extent the individual is capable of and comfortable with the challenges life presents him or her. Therapy is not about internal, psychological, or biological changes in as much as these changes support enhanced coping and comfort with life on the alcoholic's part. The original CRA program procedures include: (1) Functional Analysis of Substance Use. Here, the preceding events along with the negative and positive consequences of a client’s substance use are explored. This allows clinicians to identify reinforcing behaviors that will likewise discourage alcohol and drug use. For example, the client drinks daily after work because it alleviates stress and he enjoys being around people who can empathize and laugh with him about his unfavorable work conditions. It would therefore be critical to help this client find ways to relieve stress, receive empathy, and have fun without drinking. It also would be important to identify the constraining elements of his work environment, and afterwards contend with that straightway through communication skills training or problem solving directives. If he reported concern over a loved one’s feelings about his drinking, it would be important to see what type of role they may play in satisfying these objectives. Importantly, at some level, the client must understand that drinking excessively with these friends every night is not necessarily resolving his work problem. Consequently, he might be willing to “sample” some small changes in his daily pattern to see how they can improve his behavior. (2) Sobriety Sampling. Once the client has identified factors that provide the motivation to change his or her abusive behavior, the therapist can move on to setting goals toward abstinence. Sobriety Sampling is based on the concept that it can be counterproductive for therapists to tell clients that they can never drink again. Because many participants are reluctant to commit to immediate, total, and permanent abstinence, this technique can be helpful. Sobriety Sampling is a gentle movement toward long-term abstinence that begins with a client’s agreement to sample a time limited period of abstinence. The client and therapist negotiate the period of time, and the therapist then helps the client develop a plan and the tools for achieving this goal. For example, the therapist may encourage the participant refrain from drinking for one (1) month, to see how it feels and learn about alcohol and drug dependency. As Milford, Austin, & Smith (2007) mentioned, when successful in achieving the negotiated period of nonuse, clients begin to experience the positive effects of a sober lifestyle, such as support from family members and increased self-confidence, which leads to enhanced motivation for therapeutic work. (3) CRA Treatment Plan begins with the Happiness Scale to let clients know that all aspects of their lives are important, not just their substance using behavior. It also provides the structure for easily identifying areas of discontent and later signs of progress. Many of these treatment modules focus on increasing positive reinforcement that are unrelated to drinking. To further explain, the Happiness Scale is a brief questionnaire that clients complete in order to convey their satisfaction in multiple life areas: substance use, job/educational progress, money management, social life, personal habits, marriage/family relationships, legal issues, emotional life, communication, and spiritually (Meyers & Smith, 1995). Clients select areas from the Happiness Scale to work on, and then use the Goals of Counseling form to establish meaningful, objective goals in these areas, and highly specified methods for obtaining them. These plans help clientele organize their leisure activities as well as their regular daily lives. (4) Behavioral Skills Training uses instruction and role-plays with feedback to teach three basic skills: (a) problem-solving, which breaks overwhelming problems into smaller ones while offering a step-by-step framework for addressing them, (b) communication skills, which teaches a positive interaction style that involves simple constructs such as offering to help and verbalizing empathy, and (c) drink/drug refusal training, which helps identify high-risk situations and then teaches assertiveness. CRA psychoanalysts do not merely talk about new behavior. Instead, they have clients actually practice new coping skills. (5) Job Skills Training provides basic steps for obtaining and keeping a valued job. Having a meaningful job generally is considered a significant source of alternative reinforcement that is incompatible with problematic substance use. (6) Social and Recreational Counseling helps clients discover that they can enjoy life without drugs and alcohol. CRA therapists would help him find an alternative route for satisfying needs by providing them with opportunities to sample new social and recreational activities. In reference to our case earlier, it should be readily apparent that helping him develop a new satisfying social life would be critical for sustained abstinence, as opposed to simply encouraging him to find a substitute activity. Although he was drinking for other reasons as well, the outlet to laugh with friends after a hard day at work was highly encouraging to him. (7) Relapse Prevention teaches clients how to identify high-risk situations. Patients practice various behavioral skills as part of this procedure, including drink/drug refusal training and problem solving. Also, consumers learn to anticipate and cope with a relapse through several specific relapse prevention techniques, such as (a) the early warning monitoring system, which involves enlisting the support of someone to help watch for early signs of an impending relapse, and (b) CRA Functional Analysis of Relapse, which is a functional analysis that focuses specifically on a recent relapse. (8) Relationship Counseling focuses on improving the interaction between the client and his or her partner. CRA programs use a couple’s version of the Happiness Scale along with the Goals of Counseling form, and each spouse requests a minor change from their partner. Again, the couple practices communication and problem-solving skills during this process. Finally, therapists introduce the Daily Reminder to Be Nice as a means for continuously incorporating some of the “pleasantries” back into the relationship, which likely have disappeared. In a more recent and somewhat revised approach, to achieve their goals, CRA therapists combine a variety of treatment strategies, such as increasing the client's motivation to stop drinking, initiating a trial period of sobriety, performing a functional analysis of the client's drinking behavior, increasing positive reinforcement through various measures, rehearsing new coping behaviors, and involving the client's significant others. Some of these components are repetitive of the original CRA procedures. Other factors, such as therapist style and initial treatment intensity, also may influence the client's outcome. These treatment components and treatment-related factors are described in the following sections.
Building Motivation The initial step in CRA generally is an exploration of the client's motivations for change. For example, the therapist may offer an "inconvenience review checklist", a list of frequent negative consequences of drinking, such as medical problems, marital problems, or difficulties at work. The client then checks all those negative consequences that apply to his or her current situation or are likely to occur in the future.
Initiating Sobriety To repeat, this procedure uses a diverse range of strategic counseling to negotiate intermediate goals, such as a trial period of sobriety. Sanchez-Craig and colleagues (1984) found that clients who were expressively given an option about a trial period of abstinence were more likely to abstain than those who were given a firm, prescribed method.
Analyzing Drinking Patterns CRA involves a well-planned, functional analysis of the client's drinking patterns. This analysis helps identify high-risk situations in which drinking is most likely to occur as well as positive consequences of alcohol consumption that may have reinforced drinking in the past. This step, which is often underemphasized in cognitive-behavioral therapy, is useful in individualizing treatment and in determining specific treatment components, or modules, that are most likely to be successful for a particular client.
Increasing Positive Reinforcement Once the analysis of the client's drinking patterns is completed, both the client and therapist select appropriate modules from a menu of treatment procedures to address the client's individual needs. Several techniques can help in this process. For example, the social and recreational counseling module is used to assist the client in choosing favorable, vigorous actions to fill time that was formerly spent drinking and recovering from its effects. If the individual cannot straightforwardly decide on such activities, an approach called activity sampling can persuade him or her to examine or resume different activities that might be, or once were, exciting and rewarding. Such activities might include participation in common-interest clubs, participation in volunteer programs, involvement in a church, attendance of 12-step meetings or classes, or visits to alcohol-free organizations. The choice of programs is fashioned to the client's relative interests to ensure the client experiences the activities as positive conditioning. Access counseling assists the client in obtaining everyday necessities, such as a telephone, a newspaper, a place to live, or a job. As Azrin & Besalel (1980) reports, another approach to helping clients find rewarding work involves job club procedures such as interview skills training and resume writing, which have been shown to be successful even for difficult-to-employ people. The general objective of all these CRA treatment modules is to make the client's alcohol-free life more rewarding and affirming and to re-engage the client in his or her community.
Behavior Rehearsal Behavior Rehearsal is an approach that analyzes and modifies behavior. For example, a psychoanalyst may initially demonstrate the new behavior, for example an aggressive statement or refusing a drink, then reverse roles and give the client directives in practicing the new skill.
Involving Significant Others Since CRA emphasizes change, this treatment approach emphasizes and encourages, whenever possible, the cooperation of other people who are close and significant to the drinker. Significant others, particularly those who live with a drinker, can be helpful in identifying the social context of the client's drinking behavior and in supporting change in that behavior. Consequently, as noted by Hunt and Azrin (1973), even early versions of CRA included brief relationship counseling. Rather than providing extended marital rehabilitation, this counseling recommends practical skills guidance to develop positive communication and corroboration between the client and his or her significant other, diminish aversive communication, and integrate compromise, to promote change in the abuser’s behavior (Meyers & Smith, 1995). In addition, CRA therapists may coach significant others on how to avoid enabling and increase positive reinforcement for sobriety, for example, spending time with the drinker when he or she is sober and withdrawing attention when he or she is drinking (Miller & Meyers, 1999). As you can see, in contrast to other programs, CRA takes a different approach to overcoming alcohol problems, one that is based on providing incentives to stop drinking rather than punishment for continued drinking. To that end, client, therapist, and significant others work together to change the addict’s social support system and actions so that abstinence becomes more satisfying than drinking. Expanding its consumers to include spouses of alcoholics and users of drugs other than alcohol, CRA treatment has evolved significantly since its introduction by Hunt and Azrin in 1973. Consistent with a public health form of mental health, this psychosocial approach is relatively distinctive among treatments in that it is designed to concentrate on the individual within the environmental perspective in which problematic drug or alcohol use occurs, as well as the psychological mechanisms that are involved in the maintenance of the addiction. By working to increase the gratifying effects of the societal, professional, and familial aspects of patients’ lives, CRA seeks to help individuals create non-using lifestyles that are more rewarding than lifestyles involving drugs or alcohol (Hunt & Azrin, 1973; Meyers & Smith, 1995). CRA lives up to the standard of care for mental health services promoted by the Surgeon General’s Report on Mental Health and the APA’s Presidential Task Force Report, as it has been ranked near the top of a list of 46 different treatment modalities for alcohol problems (Miller & Wilbourne, 2002). Additionally, an earlier cost-effectiveness review ranked CRA first in a list of 24 treatments for alcoholism, and labeled CRA’s cost as “medium-low” when compared to other treatments (Finney & Monahan, 1996). From a client’s perspective, it is also easier to understand and commit to a treatment that focuses not just on their substance use, but gives equal weight to a variety of other important areas of life. One way in which CRA accomplishes this is through the use of the Happiness Scale, as aforementioned. Unlike many traditional approaches rooted in the disease model of addiction (Moyers & Miller, 1993), community reinforcement works with the client to develop a unique, reasonable treatment objective (Milford, Austin, & Smith, 2007).
Factors Influencing CRA Effectiveness In addition to the treatment components previously described, several factors related to treatment delivery may influence treatment effectiveness and, consequently, the patient's outcome. Two of those factors are therapist style and initial treatment intensity. Therapist Style. An important aspect of CRA that is sometimes underemphasized is the therapeutic style with which this treatment approach is delivered. An optimal CRA therapist is consistently affirmative, full of life, optimistic, compassionate, and enthusiastic. Any and all signs of progress, no matter how small, even the client just showing up for a counseling session, are acknowledged and congratulated. CRA counseling is not provided in the form of a businesslike negotiation or impersonal education. With a therapist who successfully executes counseling in a personal, engaging approach, clients leave those sessions feeling positive and good about themselves and look forward to coming back for future sessions. Although many therapists can deliver CRA, some clinicians might find this approach easier to adopt than others. For example, therapists with optimistic or enthusiastic personalities in general might be best suited for CRA. On the other hand, psychotherapists who have been trained to use a confrontational approach in order to battle denial may find the CRA approach more difficult to practice. Initial Treatment Intensity. Another contributing factor to the success of this approach is its "jump-start" quality. Rather than being placed on a waiting list for one (1) or more months, a client who is ready for change can schedule an appointment for the same or following day. In addition, during the initial treatment phase, counseling sessions may be scheduled more frequently than once per week. The intervals between sessions can then be extended as the client's abstinence becomes more stable. Finally, CRA can involve procedures to initiate abstinence immediately. For example, in some cases the client can be evaluated right away as to whether he or she is a candidate for taking disulfiram, an agent that induces unpleasant effects after alcohol consumption and is used to discourage drinking. In those cases, a medical staff member of the treatment facility can promptly issue and fill a disulfiram prescription, and the client can take the first dose in the therapist's presence. If a concerned significant other is willing to help the client, he or she can be trained along with the client in procedures to ensure that the client takes the medication regularly. This process also can be used to promote patient compliance with other medication regimens. In conclusion, CRA is a comprehensive, individualized treatment approach designed to initiate changes in both lifestyle and social environment that will support a client's long-term sobriety. CRA focuses on finding and using the client's own intrinsic reinforcers in the community and is based on a flexible treatment approach with an underlying philosophy of positive reinforcement. Those characteristics make CRA, with certain modifications, applicable to a wide range of client populations. Although CRA is based on a comprehensive treatment philosophy, its procedures generally are familiar to clinicians who have been trained in cognitive-behavioral treatment approaches. For example, CRA involves a functional analysis and the individualized application of specific components chosen from a menu of problem-solving procedures. Furthermore, CRA can be combined with other treatment methods. For example, at the Consumer Advocates for Smoke-Free Alternatives Association (CASAA), CRA has recently been combined with motivational interviewing to form an integrated treatment. CRA is also consistent with involvement in 12-step programs. Finally, combinations of CRA and other treatment approaches can be tailored to address the needs of particular customer populations (Milford, Austin, & Smith, 2007).

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