Functional Analysis of Drinking

CRAAssessment Procedures:

Identification and enhancement of motivation for change

  • Identify internal/external reinforcers.
  • Rapidly complete intake procedures.
  • Set positive expectations.
  • Include significant other.

CRAFunctional Analysis of Drinking/Using Behavior

  • Identify Internal Antecedents (Internal Triggers) to drinking/using.
  • Identify External Antecedents (External Triggers) to drinking/using.
  • Complete comprehensive description of drinking/using behavior.
  • Identify short-term positive consequences to drinking/using.
  • Identify long-term negative consequences to drinking/using.

CRAFunctional Analysis of Non-Drinking/Non-Using Behavior

  • Identify Positive Internal Triggers for Non-Drinking/Non-using Behavior.
  • Identify Positive External Triggers for Non-Drinking/Non-using Behavior.
  • Complete comprehensive description of non-drinking/non-using behaviors.
  • Identify short-term negative consequences to non-drinking/non-using behaviors.
  • Identify long-term positive consequences to non-drinking/non-using behaviors.

SpecificCRA Treatment Procedures:

Sobriety Sampling

  • Obtain clients agreement to sample time-limited sobriety or relative sobriety.
  • Outline a strategy for accomplishing time-limited sobriety or relative sobriety.

Possible disulfiram use

  • Present disulfiram use as an option.
  • Use the CRA-specific monitoring system.

CRATreatment Plan

  • Use the Happiness Scales.
  • Develop the Goals of Counseling.

Behavioral Skills Training

  • Teach communication skills.
  • Teach problem-solving skills.
  • Provide drink/drug refusal training.

Job Counseling

  • Provide skill-based job counseling.
  • Provide solution-oriented job counseling.
  • Give information about Job Club.

Social and Recreational Counseling

  • Provide Community Access.
  • Provide Reinforcer Sampling.
  • Provide Systematic Encouragement.
  • Provide Response Priming.
  • Provide Social Club.

Marital Counseling

  • Provide action-oriented counseling.
  • Provide time-limited counseling.
  • Provide goal oriented counseling.
  • Teach positive communication skills.

Relapse Prevention

  • Perform Functional Analysis of Relapse Behaviors.
  • Analyze Behavioral Chains.
  • Activate Early Warning System.
  • Teach Cognitive Restructuring.

Caregiver Involvement in Adolescent CRA:

Caregiver component

  • Address caregivers motivation to participate.
  • Address caregivers promotion of their adolescents drug/alcohol use.
  • Teach effective parenting skills.

Community Reinforcement Approach (CRA) was not designed to be conducted in a group.

Community Reinforcement Approach (CRA) has been tested for use in a group setting.

1) Dennis, M., et al. (2004). The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27, 197-213.

2) Smith, J.E., Meyers, R.J., & Delaney, H.D. (1998). The community reinforcement approach with homeless alcohol-dependent individuals. Journal of Consulting and Clinical Psychology, 66(3), 541-548.

The recommended group size is: 8-10 with a single therapist, can be larger if 2 therapists are used.

Recommended intensity: 1 session per week.

Recommended duration: The recommended duration is 50-60 minutes. The recommended length of treatment is 12-16 weeks. This is the amount of time that has been shown to be successful in clinical trials. Each program should examine the severity of addiction involved, and let that dictate the length of treatment and length of contact.

Community Reinforcement Approach (CRA) includes a homework component.

Description: Homework is assigned in collaboration with the client after each session and is tailored to address therapeutic needs. Assignments are usually behavioral, such as trying a new activity, and are given within the framework of trying new behavior. Homework assignments are made so the client can be successful in completing them, so they are initially easy tasks to help build self-esteem and self-efficacy.

Community Reinforcement Approach (CRA) is typically conducted in a(n): Community Agency, Hospital, Outpatient Clinic, and Residential Care Facility.

Community Reinforcement Approach (CRA) was designed with a Parent Component.

Community Reinforcement Approach (CRA) addresses the following presenting problems and symptoms: An adolescent in their care who is suffering from substance abuse/dependency.

Community Reinforcement Approach (CRA) was designed with a Child Component.

Community Reinforcement Approach (CRA) addresses the following presenting problems and symptoms: Adolescent substance abuse/dependency

Community Reinforcement Approach (CRA) was not developed for children with developmental delays.

Community Reinforcement Approach (CRA) has not been tested for children with developmental delays.

Community Reinforcement Approach (CRA) was not designed for specific racial/ethnic/cultural groups.

Community Reinforcement Approach (CRA) was not tested in specific racial/ethnic/cultural groups.

There is a manual that describes how to implement this program.

There is training available for Community Reinforcement Approach (CRA).

Training contact: Robert J. Meyers, Ph.D., Phone: 505-270-2650; Fax: 505-925-2351; [email protected];

Number of days/hours: A basic training approach (which is not recommended) involves 3 days of onsite training. The recommended intensive training model involves quarterly onsite training over the course of 1 year with regular conference calls and review of audiotapes.

Training is obtained: Onsite and regional.

There currently are additional qualified resources for training.

List of additional qualified resources: Robert J. Meyers and Associates (including Drs. Robert J. Meyers, Jane Ellen Smith and John Gardin II) provides comprehensive training in the adult program and the adolescent program.

The typical resources for implementing Community Reinforcement Approach (CRA) are: There are no additional resources required for implementation beyond the counselor/therapist.

All therapists using this approach should be certified as trained by Robert J. Meyers & Associates to ensure that the procedures are being delivered as they were intended. Since this is a psychotherapeutic approach, state laws also govern who should be allowed to serve as a therapist.

Smith, J.E., Meyers, R.J. & Delaney, H. D. (1998). The community reinforcement approach with homeless alcohol-dependent individuals. Journal of Consulting and Clinical Psychology. 66(3), 541-548.

Homeless alcohol-dependent individuals were randomly assigned to receive either the Community Reinforcement Approach (CRA) or the standard treatment (STD) at a large day shelter. Ninety-one men and 15 women participated. The majority of participants were White (64%), but both Hispanic (19%) and Native American (13%) individuals were represented as well. Overall, the decline in drinking levels from intake through follow-ups was significant. As predicted, CRA participants significantly outperformed STD group members on drinking measures across the 5 follow-ups, which ranged from 2 months to 1 year after intake. Both conditions showed marked improvement in employment and housing stability.

Smith, J.E., Meyers, R.J., & Miller, W.R. (2001). The community reinforcement approach to the treatment of substance use disorders. The American Journal on Addictions, 10(Suppl.), 51-59.

Summary: Review of empirical support is presented for the Community Reinforcement Approach (CRA), a broad-spectrum cognitive-behavioral treatment for substance use disorders. At the core of CRA is the belief that an individuals environment can play a powerful role in encouraging or discouraging drinking and drug use. Consequently, it attempts to rearrange contingencies so that sober behavior is more rewarding than substance-abusing behavior. Originally tested in the early 1970s with a small sample of alcohol-dependent inpatients, it has repeatedly proven to be successful over the years with larger, diverse populations. Empirical backing is also presented for a new variant of CRA that works through family members to engage treatment-resistant individuals into substance abuse treatment.

Smith, J.E., Milford, J.L., & Meyers, R.J. (2004). CRA and CRAFT: Behavioral approaches to treating substance-abusing individuals. The Behavior Analyst Today, 5(4), 391-403.

Summary: The Community Reinforcement Approach (CRA) and Community Reinforcement and Family Training (CRAFT) are behavioral treatments for substance abuse problems that have received widespread empirical support. CRA, a treatment intended for the drinker him- or herself, was introduced 30 years ago. It is based on the belief that a drinkers “community” (e.g., family, social and job environment) plays a critical role in supporting or discouraging drinking behavior. Consequently this environment needs to be restructured such that a sober lifestyle is more rewarding than a drinking lifestyle. CRAFT, an outgrowth of CRA, is a highly successful methodfor working with concerned family members in order to get a treatment-refusing substance abuser to enter treatment. The components of both CRA and CRAFT are outlined in this paper, and the scientific support is summarized.

Wolfe, B.L. & Meyers, R.J. (1999). Cost-effective alcohol treatment: the community reinforcement approach. Cognitive and Behavioral Practice, 6, 105-109.

Summary: Introduces the Community Reinforcement Approach (CRA), one treatment modality which is well-supported by the literature. CRA is a cost-effective behavioral and social-learning-based treatment protocol. Its menu-driven approach to substance abuse also integrates several other cost-effective treatments to make a comprehensive package for the clinician. An overview of CRA is provided with the objective of helping the clinician increase his or her cost-effectiveness with alcohol abusing and dependent clients.

Azrin, N.H., Sisson, R.W., Meyers, R.J., & Godley, M. (1982). Alcoholism treatment by disulfiram and community reinforcement therapy. Journal of Behavior Therapy and Experimental Psychiatry, 13(2), 105-112.

Summary: Compared traditional disulfiram treatment, socially motivated disulfiram treatment and reinforcement therapy with disulfiram. Latter group produced “near-total” sobriety. N=43, 6-month follow-up. (Adult male and female participants.)

Hunt, G.M. & Azrin, N.H. (1973). A community-reinforcement approach to alcoholism. Behavior Research & Therapy 11, 91-104.

Summary: Initial study showing that participants in CRA drank less, worked more, spent more time with families and less time in institutions than matched control who did not receive this treatment. (Adult male participants).

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

Meyers, R.J. & Miller, W.R. (2001). A Community Reinforcement Approach to the treatment of addiction. Cambridge, UK: University Press.

Miller, W.R. & Meyers, R.J. (1999). The Community Reinforcement Approach. Alcohol Research and Health, 23(2), 116-120.

Affiliation/Agency: Universtiy of New Mexico’s Center on Alcoholism, Substance Abuse and Addiction