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: 1 st 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 1 st 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 experience sensation 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. Happiness Scale Drinking/sobriety Job/education Money management Social life Personal habits Marriage/family relationships Legal issues Emotional life Communication Spirituality General happiness

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

51. Goals of Counseling: Potential Problems Applying the 3 basic rules (brief, positive, specific) to “real life” problems. Designing goals & strategies that are too complex. Leaving out important steps necessary to reach goals. Including plans that are not under the client’s control. Unnecessarily putting the client in a high-risk situation.

52. What’s wrong with these goals? I don’t want to drink anymore! I’ll apply for 10 jobs tomorrow! I’ll have a job tomorrow! I’ll try harder to save money. I’ll go out on a date with 3 different women next week.

53. What’s wrong with this goal? I am going to attend 1 AA meeting next week - at the St. Agnes church at 8:00 pm on Tuesday night.

54. Exercise Complete a Happiness Scale with your “client” Then with your client select 1-2 categories she/he wants to work on Develop a Treatment Plan using the selected categories Remember the “Potential Problems” when designing a Treatment Plan Debrief with group

55. Happiness Scale & Goals of Counseling: Clinicians’ Problem Areas Providing a rationale for the Happiness Scale Setting goals & strategies that are very specific

56. Skills Training Communication skills/assertiveness training Drink/drug refusal Problem Solving Job-finding skills Anger management

57. Role-Playing Guidelines Acknowledge discomfort Use less difficult scenes first Get adequate description of the scene Start it for them Keep it brief (2-3 minutes) Reinforce any effort Get client’s reactions Offer supportive, specific feedback Repeat

58. Communication Training Why work on communication? More likely to get what you want Positive communication is “contagious” Will open door to more satisfaction in other life areas as well (social support) Positive communication is the foundation for other CRA procedures

59. Positive Communication Skills Be brief Be positive Be specific and clear Label your feeling: “I feel ___” Offer an understanding statement Accept partial responsibility Offer to help

60. Exercise Practice communication in dyads; one plays the therapist & the other plays the client. Be sure to do role-plays as part of the communication training.

61. Communication Skills: Clinicians’ Problem Areas Involving the client in the process when generating examples of each of the 7 components Role-playing! Providing specific feedback, and then repeating the role-play

62. Homework Guidelines refer to “practice exercises” offer rationale for assignment describe specific assignment carefully; their input? ask about possible obstacles, problem-solve identify time for completing assignment review homework at start of next session reinforce any compliance

63. Systematic Encouragement Never assume a client will make 1 st contact independently Practice in session [It gives an opportunity to observe skill level] Use sampling as part of the strategy Locate & speak to a contact person in advance for the activity Review the experience in the next session

64. Drink/Drug Refusal Training Enlist social support Review high-risk situations Refuse drinks/drugs assertively Optional: Restructure negative thoughts

65. Assertive Drink/Drug Refusal [always watch body language!] say, “No, thanks.” (without guilt!) suggest alternatives change the subject address the aggressor directly about the issue leave

66. Group Exercise Practice drink/drug refusal as if you’re in a therapy group.

67. Drink/Drug Refusal: Clinicians’ Problem Areas Taking time to identify social support Providing specific feedback and repeating the role-play

68. Problem Solving (1) Define problem narrowly (2) Brainstorm possible solutions (3) Eliminate undesired suggestions (4) Select one potential solution (5) Generate possible obstacles (6) Address each obstacle (7) Assign task (8) Evaluate outcome

69. Exercise Practice Problem-Solving as if you’re in a therapy group.

70. Problem Solving: Clinicians’ Problem Areas Narrowing down the problem sufficiently Generating potential obstacles & addressing them

71. Social/Recreational Counseling discuss importance of healthy social life identify areas of interest reinforcer sampling community access systematic encouragement reinforcer access response priming social club

72. CRA’s Job Finding a disciplined, step-by-step approach to helping clients get and keep satisfying employment.

73. Job Finding: Key Elements development of a resume instructions on how to fill out a job application utilization of relatives, friends, & phone book to generate job leads instructions in telephone techniques to secure interviews rehearsal on the interview process [video camera if possible] information on how to keep a job

74. CRA’s Relapse Prevention Relapse prevention really starts the 1 st day of treatment There are some specific relapse prevention strategies too

75. Recovery Maintenance Strategies: Marlatt and Gordon RP Model Characteristics of a “high risk” situation Unpleasant emotions Physical discomfort Pleasant emotions Testing personal control Urges and temptations Social problems at work Social tension Positive social situations

76. Marlatt and Gordon Relapse Prevention Model. High Risk Situation Effective Coping Response Ineffective Coping Response Increased Self- Efficacy Decreased Self- Efficacy Less Lapse/Relapse Risk Positive Outcome ExpectancyMore Lapse Risk Increased AVE More Relapse Risk

77. Additional Relapse Techniques CRA Functional Analysis for Relapse Set up an early warning monitoring system Outline the behavioral “chain” of events that leads to a relapse

78. Behavioral Chain bored take a walk go towards park go into park go near friend’s house go into house friend asks you to get high give in

79. CRA Relationship Therapy emphasizes relationships as an integral part of treatment focusing only on the using behavior (while ignoring other interpersonal problems)  less productive therapy

80. Relationship Therapy: Overview Action oriented Time limited Focuses on skills building “Here and now” focus Teaches general relationship skills

81. Relationship Therapy: Introduction Discuss current negative communication style Assure clients that many people in similar situations have shown improvement in their relationships

82. Introduction (cont’d) Explain how they will be taught effective new communication skills Let them know that they will feel less overwhelmed as progress is made

83. Relationship Therapy: Communication Skills Briefly present one issue Speak in a positive manner; no blaming Define issues clearly & specifically; refer to measurable behaviors Clearly state your feelings about the issue

84. Communication Skills (cont’d) Offer understanding statement (try to view issue from partner’s perspective) Accept partial responsibility for any problem raised Offer to help

85. Relationship Happiness Scale Household responsibilities Raising the children Social activities Money management Communication Sex & affection Job or school Emotional support Drinking/drug use General happiness

86. Relationship Happiness Scale

87. “Perfect” Relationship In household responsibilities I would like my partner to: In raising the children I would like my partner to: In social activities I would like my partner to:

88. Reciprocity Learn how to make a request in a positive manner. Each partner gets “something”. Clients’ cannot say “no” to a request, but you don’t have to say “yes” either. Learn how to give in a little (compromise). Try at home, learn independently.

89. Self-Reminder to Be Nice Today….did you: Express appreciation to your partner? Compliment your partner? Give your partner any pleasant surprises? Express visible affection to your partner? Spend some time devoting your complete attention to pleasant conversation w/ your partner? Initiate a pleasant conversation? Make any offer to help before being asked?

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

91. 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

92. Inadequately monitoring the client’s contact with triggers Not checking for generalization of skills Being reluctant to suggest the use of disulfiram/naltrexone

93. More Information The Community Reinforcement Approach. (Available from the Behavioral Health Recovery Management Project c/o Fayette Companies, P.O. Box 1346, Peoria, IL 61654-1346; or at http://www.bhrm.org).http://www.bhrm.org 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.

94. First CRA Therapist Manual

95. Monograph of CRA Research

96. Community Reinforcement and Family Training: CRAFT