Community Reinforcement Approach (CRA)
The Community Reinforcement Approach (CRA) is a psychosocial intervention for individuals with alcohol and other drug use disorders that has been adapted for several populations, including adolescents (the Adolescent-Community Reinforcement Approach; A-CRA) and family members of individuals resistant or reluctant to enter treatment (Community Reinforcement and Family Training; CRAFT).
The focus is to help individuals find healthier, more adaptive ways to meet their social and emotional needs than using substances. It is comprised of a broad group of behavioral interventions that provide or withhold rewards and negative consequences quickly in response to at least one measurable behavior (e.g., substance use as measured by a drug test, also called a toxicology screen).
WHAT HAPPENS IN COMMUNITY REINFORCEMENT APPROACH?
In the Community Reinforcement Approach (CRA), clinicians and patients work collaboratively on identifying individual goals, and conducting a “functional analysis” of substance use (i.e., taking a close look at the function served by the use of substances) and functional analysis of pro-social behaviors (i.e., sober activities).
This is typically done using a “behavior chain”. In functional analyses, clinicians ask patients to explore the internal experiences and external situations that precede their substance use (i.e., often called “triggers”), as well as the short-term rewards and longer-term negative consequences that come after the substance use. In this way, the clinician and patient can identify the thoughts, feelings, and situations that will be central in treatment. The exercise provides real-life change targets and a blueprint for the needs that must be met by finding healthier alternative activities.
Providers may ask patients to include another individual in their treatment with whom they spend a lot of time (e.g., spouse) to help recognize triggers that may be more difficult for the individual to notice (e.g., anger).
During the treatment, the patient learns practical skills to meet his or her goals including communication, problem solving, and assertive drink and drug refusal (i.e., effective ways to comfortably handle direct and indirect pressure to drink or use drugs). Community Reinforcement Approach (CRA) may also incorporate job-hunting skills and social or recreational counseling to identify sober activities. The clinician is likely to take an active role in the treatment, including role playing to help the patient learn and practice skills, and encouraging him/her to sample new activities.
- CRA FOR: ADOLESCENTS
The Community Reinforcement Approach (CRA) has been successfully adapted for the treatment of adolescents (Adolescent-Community Reinforcement Approach, or A-CRA). One unique aspect of A-CRA relative to standard CRA is the inclusion specifically of one or more parents/caregivers – though enlisting family members to aid the treatment was part of even the earliest iterations of CRA.
In Adolescent-Community Reinforcement Approach (A-CRA) parents spend two sessions alone working with the clinician to understand the nature of their loved one’s treatment, and to learn the communication and problem solving skills that the adolescent patient is learning in treatment. A-CRA also includes two sessions with both the parents and the adolescent, to help practice these skills with active participation and guidance from the clinician throughout the role plays.
Regarding scientific evidence for Adolescent-Community Reinforcement Approach (A-CRA), it was among the most cost-effective interventions in a multisite randomized trial of psychosocial interventions for adolescents with cannabis use disorder. More research is needed on its effectiveness for adolescents with other primary drug use disorders. Many state agencies facilitate clinical training in A-CRA, and promote its use in front-line clinical care for adolescents given its empirical support.
- CRA FOR: FAMILY MEMBERS
Community Reinforcement and Family Training (CRAFT) is an intervention for family members of individuals with substance use disorder (SUD) who are resistant or reluctant to engage in treatment, called concerned significant others. In addition to communication and problem solving skills taught as part of other the Community Reinforcement Approach (CRA) models, CRAFT also teaches concerned significant others how to respond thoughtfully to patient’s substance use and sobriety, such that they are rewarding sobriety-related behaviors and failing to reward substance use-related behaviors, consistent with operant condition (see “What is the theory behind CRA?” above).
CRAFT also works with concerned significant others to enhance their own emotional well-being (e.g., scheduling and rewarding themselves for healthy and fun activities). As a clinical strategy to engage individuals in addiction treatment through a concerned significant other, CRAFT has strong empirical support, outperforming other interventions for family members like the Johnson intervention (i.e., the initial standard of care for a family “intervention” with a treatment-reluctant drug using individual) and a professional approach that facilitates involvement in Al-Anon or Nar-Anon, the most popular 12-step mutual-help organizations for family members.
WHAT ARE THE ORIGINS OF THE COMMUNITY REINFORCEMENT APPROACH?
Psychologist Nathan (“Nate”) Azrin developed the Community Reinforcement Approach (CRA) in the 1970s. Over time, an adjunctive plan to take the medication disulfiram (known by its brand name Antabuse), was added to CRA treatment protocols. In 1995, Robert Meyers and Jane Smith published the first treatment manual of CRA designed for clinicians in addiction treatment.
WHAT IS THE THEORY BEHIND THE COMMUNITY REINFORCEMENT APPROACH?
Theory Behind the Community Reinforcement Approach:
- The Community Reinforcement Approach (CRA) is based on the theory of operant conditioning – that behavior is shaped by its consequences, both positive, sometimes called “rewards”, as well as negative (similar to Contingency Management). Consequently, clinicians help patients re-organize their social lives and activities (i.e., their “community”) to reward (i.e., “reinforce”) sobriety. CRA helps patients engage in healthy, adaptive behaviors that provide natural rewarding feelings that can potentially compete with the rewarding feelings from alcohol and other drugs, but without the negative consequences.
- Increased rewards for sobriety is assumed to occur through social relationships and experiences (unlike Contingency Management where rewards for sobriety are often more concrete). Thus, the Community Reinforcement Approach (CRA) facilitates patients’ involvement in sober activities alone and/or with other non-drinkers/drug-users.
- In the spirit of making changes to one’s social environment, each patient brings a different set of needs and challenges. The Community Reinforcement Approach (CRA) offers a range of skill building exercises that can be administered flexibly during treatment (i.e., at different times as needed) to increase chances of success in these new activities.
EVIDENCE FOR THE COMMUNITY REINFORCEMENT APPROACH?
The Community Reinforcement Approach (CRA) has strong scientific evidence in support of its short-term effectiveness relative to treatment as usual (e.g., discussion of the negative consequences of alcohol use disorder, psychoeducation regarding the disease model of addiction, and encouragement to try abstinence). It has rarely been tested against other empirically-supported treatments, however.
That said, it is also worth noting the core principles and strategies associated with CRA are highly related to empirically-supported treatments intended to facilitate social network changes, including Network Support and Social Behavior and Network Therapy, from the United Kingdom Alcohol Treatment Trial (UKATT).
- Hunt, G. M. & Azrin, N. H., (1973). A community-reinforcement approach to alcoholism. Behavior Research and Therapy, 11, 91-104
- Meyers, R. J., and Smith, J. E. (1995). Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach. New York: Guilford Press.
- Dennis, M., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., . . . Funk, R. (2004). The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27(3), 197-213. doi:10.1016/j.jsat.2003.09.005
- Meyers, R. J., Roozen, H. G., & Smith, J. E. (2011). The community reinforcement approach: an update of the evidence. Alcohol Research and Health, 33(4), 380-388
- Miller, W. R., Meyers, R. J., & Tonigan, J. S. (1999). Engaging the unmotivated in treatment for alcohol problems: A comparison of three strategies for intervention through family members. Journal of Consulting and Clinical Psychology, 67(5), 688-697.