Community Reinforcement Approach Susan Harrington Godley Chestnut Health Systems Bloomington, IL Funded by: Center for Substance Abuse Treatment (TI11894 TI13356) National Institute on Drug Abuse (R01 DA ) Based on slides by Robert J. Meyers, Ph.D. and Jane Ellen Smith, Ph.D. University of New Mexico

Goals of Presentation Supporting Research What is CRA?

Hunt & Azrin 1973 Inpatient Alcoholics job finding counseling behavioral/marital therapy social/leisure counseling reinforcer access counseling social club home visits [total 50 hrs per client]

Results: 6 month follow-up

Azrin 1976: New & Improved CRA inpatient alcoholics disulfiram w/compliance protocol problem prevention buddy system early warning mood monitoring ~70% as aftercare home visits [Average 30 contact hrs]

CRA new & improved: Results

CRA Outpatient Study (1982) Azrin, Sisson, Meyers, & Godley 43 outpatient alcoholics 3 groups: (1) traditional tx (2) traditional tx + disulfiram compliance (3) CRA + disulfiram compliance increased use of positive reinforcement sobriety sampling drink refusal training +/- functional analysis job club phone contacts [Average: 5 sessions]

6 Month Follow-up (1982) CRA + disulfiram compliance % days abs = 97% Traditional + % days abs = 74% disulfiram compliance Traditional % day abs = 45%

CRA with Homeless Alcohol- Dependent Individuals CRA Group Sessions Problem-Solving Communication Skills Drink-Refusal Independent Living Skills Goal Setting Meeting Social Club Disulfiram Compliance (for a sub-group) Individual Sessions Job Finding Case Management STANDARD TREATMENT Day Treatment 12-Step Counselor Job Service Program VA Benefits Advisor

Drinks Per Week By Condition Follow-Up Period 2 Month 4 Mont 6 Month 9 Month 12 Month Median SECs --- Standard --- CRA

Percent Homeless By Condition CRA Standard Follow-up Periods 2 Month 4 Month 6 Month 9 Month 12 Month Percent

Evidence of Effectiveness: Meta-analyses & Reviews Holder et al. (1991)Miller et al. (1995) Social skills trainingBrief intervention Self-control trainingSocial skills training Brief motivational txMET Behavioral Marital tx CRA CRABehavioral contract Stress managementAversion tx

Evidence of Effectiveness (cont’d) Finney et al., 96Miller et al., 03Miller et al., 05 CRABrief InterventionCognitive-Behavioral Social skills trainingMETCRA Behavioral Marital txAcamprosateMI Disulfiram Implants CRARelapse Prevention Other marital txSelf-Change Social Skills Training Stress Management NaltrexoneBehavioral Marital Ther.

CRA Clinical Trials Hunt & Azrin, ‘73 (inpatient alcohol dependent) Azrin, ’76 (inpatient alcohol dependent) Azrin et al., ‘82 (outpatient alcoholic) Higgins et al., ’91 (cocaine) Budney et al., ‘91 (cocaine) Higgins et al., ’93 (cocaine) Smith et al., ’98 (homeless alcoholics) Abbott et al., ’98 (methadone/heroin addicts) Roozen et al., ’00 (opioid dependent individuals) Schottenfeld et al., ’00 (opioid & cocaine dependent individuals) Meyers & Miller., ’01 (outpatient alcoholics) Godley, et al., ’02 (Adolescent aftercare mj & alc) Azrin, ’04 (outpatient adolescent patients) Roozen et al., ’06 (nicotine dependent individuals) Slesnick, et al., ’07 (homeless, street living youth) De Jong et al., ’07 (opioid dependent individuals) DeFuentes-Merillas, & De Jong ’08 (opioid & cocaine dependent individuals)

What does not work! Educational films and lectures General alcoholism counseling Process psychotherapy (individual or group) Confrontational counseling Antipsychotic medication Insight therapy

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

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)

CRA Session Structure Been tested in clinical trials for 3-month period, but designed to be open-ended based on individual needs Can be combination of individual/group sessions Frequency of sessions based on client’s motivation and progress Assessment and treatment planning used for all; skills training as needed

CRA Induction: First Session Build rapport, build rapport, build rapport Stay client-focused Use positive reinforcement Provide an overview of the basic CRA objectives Begin to establish “reinforcers” (motivators)

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

Functional Analysis (F.A.) An interview that examines the antecedents and consequences of a behavior “Roadmap” F.A.s can be used for 2 kinds of behaviors: A problem behavior A healthy, fun behavior

Sobriety Sampling Provide the rationale (Step 1) The negotiation (Step 2) Plan for Time-Limited Sobriety (Step 3)

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 Develop a step-by-step weekly strategy for reaching each goal. The strategy = the “homework” for the week

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

Assigning Homework Refer to as “practice exercises”? An experiment? Offer rationale Get client’s input Describe agreed-upon specific assignment Ask about potential obstacles; problem-solve Identify time for completing assignment Review homework at next session

Social/Recreational Counseling Discuss importance of healthy social life Identify areas of interest: Ongoing? Pro-Social F.A. New? 2 x 2 table; Problem-solving; Leisure Questionnaire; goal-setting Encourage “reinforcer sampling” Systematic Encouragement Social Club

Drink/Drug Refusal Training Review high-risk situations Enlist social support Refuse drinks/drugs assertively

Additional Relapse Techniques CRA Functional Analysis for Relapse Behavioral “chain” of events Early warning monitoring system

Relationship Counseling

Self-Reminder to Be Nice

Common Mistakes Made When Implementing CRA Losing sight of client’s reinforcers Failing to involve concerned others in treatment Neglecting to emphasize the importance of having a satisfying social and recreational life Not stressing the necessity of having a meaningful job

Common Mistakes Made When Implementing CRA Inadequately monitoring the client’s contact with triggers Not checking for generalization of skills Being reluctant to suggest the use of appropriate medications

More Information The Community Reinforcement Approach. (Available from the Behavioral Health Recovery Management Project c/o Fayette Companies, P.O. Box 1346, Peoria, IL ; or at 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.

CSAT’s Assertive Adolescent Family Treatment Susan Harrington Godley Chestnut Health Systems Bloomington, IL Funded by: Center for Substance Abuse Treatment (TI11894 TI13356) National Institute on Drug Abuse (R01 DA )

Goals A-CRA vs. CRA Assertive Continuing Care (ACC) Technical assistance provided to grantees to learn the EBTs Target population Outcomes

A-CRA vs. CRA Added caregiver sessions Changed Happiness Scale so that it was relevant for adolescents Samples in treatment manual were based on how one might talk with an adolescent and the issues they would talk about

Critical Parenting Practices Good modeling Increase positive communication Monitor the adolescent’s whereabouts Involvement in adolescent's life outside the home. Based on the work of R. Catalano, H. Hops, & B.Bry

Similarity of Clinical Outcomes by Conditions Source: Dennis et al., Total days abstinent. over 12 months 0% 10% 20% 30% 40% 50% Percent in Recovery. at Month 12 Total Days Abstinent* Percent in Recovery** MET/ CBT5MET/ CBT12 FSNMET/ CBT5A-CRAMDFT Trial 1 Trial 2 * n.s.d. effect size f=0.06 ** n.s.d., effect size f=0.12 * n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16

Moderate to large differences in Cost-Effectiveness by Condition Source: Dennis et al., 2004 $0 $4 $8 $12 $16 $20 Cost per day of abstinence over 12 months $0 $4,000 $8,000 $12,000 $16,000 $20,000 Cost per person in recovery at month 12 CPDA* $4.91 $6.15 $15.13 $9.00 $6.62 $10.38 CPPR** $3,958 $7,377 $15,116 $6,611 $4,460 $11,775 MET/ CBT5 MET/ CBT12 FSN MET/ CBT5 ACRA MDFT * p<.05 effect size f=0.48 ** p<.05, effect size f=0.72 Trial 1 Trial 2 * p<.05 effect size f=0.22 ** p<.05, effect size f=0.78 A-CRA did better than MET/CBT5, and both did better than MDFT

What is Assertive Continuing Care (ACC) A continuing care intervention that was specifically designed for adolescents following residential treatment Increasingly, it is also being used following outpatient or other primary treatment ACC clinicians use A-CRA procedures, but typically provide services in the home and increase case management activities

Assertive Continuing Care Motto: We can’t help them if we don’t see them!

Continuing Care Linkage and Retention During the 90 day CC Phase 94% 54% % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percent LinkedMedian Number of Sessions ACCUCC

57% Higher Rate of Continuous Abstinence for ACC (Cannabis) ACC (n=96) UCC (n=78) Percent Remaining Abstinent Days from Discharge 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Continuing Care Phase Follow-up Phase Two months after residential, 58% in ACC vs. 40% in UCC still clean At 9 months 4 out of 10 in ACC are still abstinent vs. less than 3 of 10 in UCC

Unique Components of AAFT initiative GAIN clinical certification ABS software Clinical supervisor certification process Web-based tool for clinical and supervisory certification based on digital technology Implementation calls paired with monthly implementation progress reports Cultural responsiveness committee

Training & Certification Process for A-CRA

Bi-Weekly Coaching calls Upload session recordings & data to the web; Get expert ratings and narrative feedback 3.5-day centralized training session A-CRA/ACC Technical Assistance A-CRA/ACC Certification Requirements are clearly delineated & monitored Record clinical and supervision sessions Treatment Manual and Knowledge Test

A-CRA Clinician Certification Requirements Take a knowledge test Attend the 3.5 day training Attend coaching calls Participate in local supervision sessions Enter session data Demonstrate competency on 9 core A-CRA procedures through DSR reviews

Supervisor Certification Requirements Take a knowledge test Attend the 3.5 day training Attend coaching calls Provide local supervision sessions Demonstrate supervision skills during supervision sessions Demonstrate ability to rate clinician DSRs

Upload Digital Session Recordings

Read Reviews

Sample Procedure Rating | | | | | poor needs satisfactory very excellent improvement good Caregiver Overview, Rapport Building, and Motivation: 48. ____ ____ Provided an overview of A-CRA 49. ____ ____ Set positive expectations 50. ____ ____ Reviewed research regarding parenting practices 51. ____ ____ Identified CG reinforcers for continued work 52. ____ ____ Kept discussion (about adolescent) positive

Narrative Comments Are Also Provided Assigned Homework: The assignment for next week is…. Happiness Scale Good: You gave a nice rationale for the happiness scale! You explained that he would rate his happiness in different areas of his life and that his ratings would be used to make short-term goals. It was great that you mentioned that he would do several scales and they would be used to assess progress. Good: You gave good directions for the scale. You explained that he should rate his current happiness for today on a scale from 1-10 (1-low, 10-high)…It’s also good to mention that he should rate the categories independently from one another. It was good that you reviewed some of the ratings! For legal issues and emotional life, you asked him why he rated it the way he did. For emotional life, you asked him what could improve his ratings. It’s important to do this with a number of categories (a few that are rated very high, some that are rated moderately, and some that are rated very low). For each category, it’s important to ask why he rated it the way he did and what could improve his rating. Also, this procedure should only take 15 minutes or so. It seemed like you got stuck while going over the emotional life category and spent the rest of the session discussing this. Overall – Stayed Within ACRA Protocol: You were behavioral, supportive, and positive… Overall – Introduced ACRA Procedures at Appropriate Times: You assigned homework… General Clinical Skills: You were warm, nonjudgmental, and supportive…

AAFT Performance Data 2,137 Adolescents have been open to the project 25,463 Sessions have been posted to EBTx 2,726 Of DSRs have been rated with feedback to clinicians 88 Clinicians have been certified 31 Supervisors have been certified Average # of DSRs to certification is 21; range Average # of months to certification is 9; range of fidelity checks conducted: 51% pass on first check, and 72% pass on the second check

Demographic Profile Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415) *Any Hispanic ethnicity separate from race group.

Pattern of Weekly Use (13+/90 days) Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)

Co-Occurring Psychiatric Problems Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)

Past Year Violence & Crime Notes: \a Dealing, manufacturing, prostitution, gambling (does not include simple possession or use); \b 14 or more days on probation/parole with urine monitoring Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)

Count of Major Clinical Problems at Intake\a Note: \a Based on count of self reporting criteria to suggest Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415) Median = 4 Problems

No. of Problems\a by Severity of Victimization Severity of Victimization Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415) Note: \a Based on count of self reporting criteria to suggest Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity. OR=Odds Ratio relative to Low

Performance (goal): Recruitment and Monitoring Notes: \a based on done divided by due minus expected, plus same percent expected of those still pending in window Source: CSAT February 2009 AAFT Management Report (n=2,415)

A-CRA/ACC Certification Progress

Performance (goal): Treatment Received Source: CSAT February 2009 AAFT Management Report (n=2,415) Targeted Improvement over general practice

Performance: Change Over Time in Selected Outcomes Source: CSAT February 2009 AAFT GAIN Data set with 1+ Follow-up (n=1,732)

Outcome Status at Last Wave Source: CSAT February 2009 AAFT GAIN Data set with 1+ Follow-up (n=1,732)

Comments from Therapists thanks... the team has been awesome!! Brandi was always responsive and the web-based system was user friendly. I gave some feedback on our last conference call re: possibly having separate calls for supervisors... other than this...TOP NOTCH! Will be in touch if any issues should arise moving forward. Be well and thanks again... Thank you so much; you all have helped me greatly with this process. I really appreciate the time and care you provide for all of us undergoing ACRA/ACC certification. I want you all to know that I felt fully supported from the beginning and I still feel that way today. There was always someone available to answer all of my questions and I never felt like I was alone in this process. I am very proud of this accomplishment and it is a wonderful feeling to be a part of the ACRA/ACC program. I am seeing first hand the opportunities and client empowerment this program provides for our youth, their families, and our community and it's amazing.

Summary The CSAT Adolescent Treatment program has demonstrated the ability to replicate A- CRA and ACC approaches in community based settings Both the GAIN and the A-CRA/ACC training and certification processes appear to be working well in AAFT based on numbers of staff achieving certification Adolescents appear to like the intervention Outcomes to date compare favorably to previous CSAT replication efforts and other CSAT funded initiatives

Monograph of CRA Research

Community Reinforcement and Family Training: CRAFT