Community Reinforcement Approach (CRA)

1. Community Reinforcement Approach (CRA) Robert J. Meyers, Ph.D. & Jane Ellen Smith, Ph.D. University of New Mexico

2. If punishment worked, there would be few, if any, alcoholics or drug addicts…

3. 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)

4. 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?)

5. CRA Induction & Overview (cont’d) • 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?)

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

7. CRA Overview: Clinicians’ Problem Areas **Refer to CRA Procedures Checklist • Giving a clear, concise description of CRA’s basic objective/theory • Starting to identify reinforcers

8. Functional Analysis (F.A.) • Semi-structured interview that examines the antecedents & consequences of a behavior • A “roadmap” • 2 kinds of F.A.s

9. F. A. for Substance-Using Behaviors • Objective: to work toward decreasing or stopping the problem behavior • F.A. Procedure: • outlines individual’s triggers for substance use • clarifies consequences (positive & negative) of substance use for client

10. 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

11. 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)

12. External triggers • Who are you usually with when you drink? • Marcello, Dale, & James • Where do you usually drink? • Marcello’s house • When do you usually drink? • Saturday night

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

14. 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

15. Short-term positive consequences • What do you like about drinking with (who)? • We laugh a lot. They think I’m funny. • What do you like about drinking (where)? • I don’t have to drive so far. It’s informal; I can be myself. • What do you like about drinking (when)? • It’s a good way to unwind after working all day.

16. Positive consequences (cont’d) • What are the pleasant thoughts you have while drinking? • These guys think I’m 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

17. 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 haven’t put any effort into finding a romantic relationship lately.” • Physical: “I don’t sleep well Saturday night and I usually feel terrible Sunday.” • Emotional: “I feel lonely. I don’t know if it’s related to drinking.”

18. Negative consequences (cont’d) • Legal: “No problems, but I worry about getting a DWI.” • Job: “The Saturday drinking doesn’t affect this, but my weekday drinking may be starting to.” • Financial: “No problems here.” • Other: n/a

19. Functional Analysis Practice • Partner-up: 2 people • Therapist & Client • Don’t 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 • Don’t play the client from Hell! • Group Debriefing

20. 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

21. 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

22. F.A. for Pro-social Behavior (cont’d) 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

23. Case Example (cont’d) • Same client; sometimes he chose to go to his brother’s house for dinner on Sat. nights instead of playing cards & drinking with friends.

24. F. A. for Pro-social, Healthy Behaviors • What is your non-drinking activity? • Dinner at brother’s house; video afterwards. • How often do you engage in it? • About once a month. • How long does it usually last? • About 3 hours.

25. 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.

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

27. Internal triggers (cont’d) • What are you usually feeling physically right before you (activity)? • I don’t know. Mostly relaxed I guess. • What are you usually feeling emotionally right before you (activity)? • Calm, content, but a little disappointed that I won’t be drinking. Then ashamed for feeling that way.

28. 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 I’m dating… • What do you dislike about (activity, where)? -Nothing • What do you dislike about (activity, when)? -It’s not as much fun as drinking & playing cards.

29. What are the unpleasant thoughts you have while (activity)?-Am I ever going to have my own family? I’m 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

30. 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 nephew’s lives.” • Physical: “It’s 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.”

31. Positive consequences (cont’d) • 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 don’t lose money like I do at cards. • Other: n/a

32. 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

33. 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 experiencesensation of being sober

34. Sobriety Sampling (cont’d) • disrupts old habits, giving chance to replace with new positive coping skills • builds family support & trust • identifies relapse-prone areas

35. The Negotiation • Suggest a LONG period (90 days?) • Tie in reasons for such a period (high relapse time; client’s 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

36. Planning for Time-limited Sobriety • Load up sessions • Don’t 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

37. 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.

38. Sobriety Sampling: Clinicians’ Problem Areas • Discussing several of the advantages of a period of sobriety • Making the plan for achieving sobriety very specific

39. Optional: Supplement CRA with Medications

40. 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

41. Advantages of Disulfiram (cont’d) • improved self-confidence • fewer complicated, agonizing daily decisions • more chances for positive reinforcement • increase in available early warning signs

42. 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”

43. 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

44. Medication Monitoring: Clinicians’ Problem Areas • Setting up a monitoring plan • Bringing in the monitor to practice

45. 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 client’s reinforcers

46. Drinking/sobriety Job/education Money management Social life Personal habits Marriage/family relationships Legal issues Emotional life Communication Spirituality General happiness Happiness Scale

48. 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

50. Guidelines for Goal Setting Goals (and their strategies) should be: • Brief (uncomplicated) • Positive (what will be done) • Specific behaviors (measurable) • Reasonable • Under the client’s control • Based on skills the client already has