Adolescent Community Reinforcement Approach A-CRA Robert J. Meyers, Ph.D. Jane Ellen Smith, Ph.D. University of New Mexico and Chestnut Health Systems Presented by: Jennifer Smith Ramey, LPC, LMHP

Meet Gage…… 17 year old male Abused alcohol, marijuana, heroin Family history of mental illness (father committed suicide) Strained relationship with mother

First CRA Therapist Manual

Adolescent Community Reinforcement Approach (A-CRA) CYT Godley, S.H., Meyers*, R.J., Smith*, J.E., Godley, M.D., Titus, J.C., Karvinen, T., Dent, G., Passetti, L.L., & Kelberg, P. (2001). Chestnut Health Systems Bloomington, IL USA, and *University of New Mexico Albuquerque, NM USA Cannabis Youth Treatment Experiment Treatment Series Volume 4

Percent of Days Abstinent from Alcohol or Other Drugs Discussion points from manuscript: Adolescents with COD have greater rates and greater magnitudes of increase in abstinence Adolescents with COD maintain their treatment gains out to 12 months Results of HLM growth model analyzing group differences percent of days abstinent 5

Conclusion: Abstinence Adolescents with COD have greater magnitudes of increase in abstinence than non-comorbid youth Adolescents with COD maintain their treatment gains out to 12 months

Emotional Problems Scale Discussion points from the manuscript: Adolescents with COD have greater rates and greater magnitudes of decrease in Emotional problems Figure 3. Results of HLM growth models analyzing group differences for the Emotional Problems Scale. 7

Conclusion: Emotional Problems Adolescents with COD have greater magnitudes of decrease in emotional problems than non-comorbid youth Youth with both externalizing and internalizing MH problems show the greatest reduction of emotional problems.

A-CRA at Horizon Behavioral Health “Effectiveness of A-CRA/ACC in Treating Adolescents with Cannabis-Use Disorder” published in Community Mental Health Journal, November 2012 Enrolled 147 adolescents ages 12-18 Assessed at baseline, 3, 6, and 12 months More than two-thirds reported quitting marijuana by 12 months Days of marijuana use in the last 90 days decreased significantly from the first follow-up Grade completed in school increased one grade comparing baseline and 12 months Average days of missing school decreased significantly from baseline to end of treatment

If punishment worked, there would be few, if any, alcoholics or drug addicts… Meyers & Smith, 2006

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) Meyers & Smith, 2006

A-CRA’s General Goals Goals: Sessions with clients Abstinence Participation in pro-social activities Positive relationships with family Positive relationships with peers Goals: Sessions with caregivers Motivate their participation Promote the client’s abstinence Provide information about effective caregiving

A-CRA Session Structure 10 individual sessions with the adolescent 4 sessions with the caregiver 2 individual sessions with the caregiver 2 sessions with the caregiver and the adolescent In the office or home and community

Positive Reinforcer What is a reinforcer? How do I find one? Does everyone have reinforcers? How can I use them to help? Meyers & Smith, 2006

Adolescent Caregiver sessions Goal is to improve relationship Tools used: Happiness Scale, Communication Skills, Problem Solving Skills Positive Focus (3 Positive Things exercise, Daily Reminder To Be Nice homework assignment)

Caregiver-Adolescent (Family) Sessions 3 Positive Things Exercise Relationship Happiness Scales Practice communication and problem-solving skills Daily Reminder To Be Nice form

Four Critical Parenting Practices Positive Communication Getting involved in adolescent’s life outside the home Be a good role model Know the adolescent’s whereabouts Explain how to introduce these in the session Research based on prevention, but make sense for recovery as well

Communication Skills Foundational in A-CRA model Used in adolescent only sessions, caregiver only sessions, family session 3 parts Role-plays

Treatment Planning Two parts: Adolescent Happiness Scale and Goals of Counseling Ask the client what she/he wants Use a positive approach Keep in mind the client’s reinforcers

Adolescent Happiness Scale

Goals of Counseling: Setting Goals Goals of Counseling contains the categories on the Happiness Scale Guide the client’s selection of a category In general, set short-term goals that are scheduled to be completed in about a month Develop a step-by-step weekly strategy for reaching each goal Addressed obstacles to completing the goals The strategy = the “homework” for the week Meyers & Smith, 2006

After Happiness Scales

Guidelines for Goal Setting Goals and weekly 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 Meyers & Smith, 2006

What’s wrong with these goals & strategies? I don’t want to drink anymore I’ll get my friend to come into treatment I’ll apply for 10 jobs tomorrow I’ll get a higher-paying job this month I’ll try harder to save money this month I’ll go out on a date with three different women next week Meyers & Smith, 2006

What’s wrong with this strategy? I am going to attend one AA meeting next week, at St. Agnes Church at 8:00 pm on Tuesday night. Meyers & Smith, 2006

Demonstration

Skills Training Communications Skills Problem Solving Drink/Drug Refusal Job-Finding Skills Anger Management

A-CRA Certification Recording/uploading A-CRA sessions Will receive narrative review and rating (1 to 5 scale) Must pass 9 core procedures for first level certification

Now, back to Gage Improved communication with mother Goals: completion of high school military enrollment

References Dennis, M.L., Godley, S.H., Diamond, G.S., Tims, F.M., Babor, T., Donaldson, J., Liddle, H.A., Titus, J.C., Kaminer, Y., Webb, C., Hamilton, N., & Funk, R.R. (2004). The Cannabis Youth Treatment (CYT) study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27, 197-213. doi:10.1016/j.jsat.2003.09.005 Godley, S.H., Hedges, K., & Hunter, B. (2011). Gender and racial differences in treatment process and outcome among participants in the Adolescent Community Reinforcement Approach. Psychology of Addictive Behaviors, 25, 143-154. doi:10.1037/a0022179 Godley, S.H., Hunter, B.D., Artamendi, S.F., Smith, J.E., Meyers, R.J., & Godley, M.D. (2014). A comparison of treatment outcomes for Adolescent Community Reinforcement participants with and without co-occurring disorders. Journal of Substance Abuse Treatment, 46(4), 463-471. doi:10.1016/j.jsat.2013.10.013 Godley, S.H., Meyers, R.J., Smith, J.E., Godley, M.D., Titus, J.C., Karvinen, T., Dent, G., Passetti, L.L., & Kelberg, P. (2001). The Adolescent Community Reinforcement Approach (ACRA) for adolescent cannabis users (DHHS Publication No. (SMA) 01-3489, Cannabis Youth Treatment (CYT) Manual Series, Volume 4). Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. Retrieved from http://www.chestnut.org/Portals/14/ PDF_Documents/Lighthouse/CYT/Products/ACRA_CYT_v4.pdf. McGarvey, E.L., Leon-Verdin, M., Bloomfield, K., Wood, S., Winters, E., & Smith, J. (2012). Effectiveness of A-CRA/ACC in treating adolescents with cannabis-use disorders. Community Mental Health Journal, 50(2), 150-157. doi:10.1007/s10597-012-9566-2 Meyers, R.J., & Miller W.R. (Eds.). (2001). A Community Reinforcement Approach to Addiction Treatment. Cambridge, UK: University Press. Meyers, R. J., & Smith, J. E. (1995). Clinical guide to alcohol treatment: The Community Reinforcement Approach. New York: Guildford Press.