1. A-CRA Adolescent Community Reinforcement Approach

3. “…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. Abstinence Participation in pro- social activities Positive relationships with family Positive relationships with peers Motivate their participation Promote the client’s abstinence Provide information about effective care giving A-CRA’s General Goals

5. 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

6. Described basic objectives (help find healthy, reinforcing lifestyle…) Outlined several procedures (communication skills, problem solving) Set positive expectations (scientific base) Described duration of treatment (time limited) Started to identify reinforcers

7. 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

8. Objective: To work toward decreasing or stopping the problem behavior Outline individual’s triggers for substance use Clarify consequences (positive & negative) of substance use for client

9. External triggers  Who, where, when Internal triggers  Thinking, feeling (emotionally, physically) Short-term positive consequences Long-term negative consequences

10. Provide a rationale Determine which episode to focus on:  Ask for a description of a common/ typical substance-using episode OR  Ask for a description of a recent or specific episode & make sure it is common/typical Show client the F.A. chart

11. Gave rationale Started by asking for description of common episode/behavior  Common problems: selecting a suitable episode, mixing several episodes together Outlined triggers (external, internal) Clarified the using (or non-using) behavior Outlined positive and negative consequences of the behavior Summarized findings & gave examples of how the information would be used  Common problems: forgetting this item altogether, summarizing but not offering examples

12. Provide rationale:  Allows the client to see how satisfied he/she is with different areas of life  Identifies areas the client wants to address in treatment  Monitors progress over time Give instructions (include: circle use or nonuse) Review some ratings

13. Substance use Relationship w/ girlfriend/boyfriend Relationship w/ friends Relationship w/ caregivers School (work) School activities Social life/recreation Personal habits Legal issues Money management Feelings Communication Job General happiness Other

14. 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

15. Guidelines for Goal Setting  Brief (uncomplicated)  Positive (what will be done)  Specific behaviors (measurable)  Reasonable  Under the client’s control  Based on skills the client already has

16. Treatment Plan/Goals of Counseling Checklist Used Happiness Scale to select goal category Set goal/strategy using guidelines (e.g., specific) Common problems: mostly obstacle-related (forgetting to ask about them, identifying them but not solving them, not probing enough) Checked on progress of goals

17. Functional Analysis for Pro-social (Healthy) Behavior Looks at a pro-social (fun) behavior that’s occurred at least once in the last 6 months Objective: Increases the likelihood that the individual will choose this non-using activity over substance use Clarifies negative consequences (barriers to engaging in it) & positive consequences of the healthy behavior for the individual

18. Introducing the Pro-Social F.A. Provide a rationale Ask for a description of an enjoyable activity that the client is: engaging in currently – but only infrequently OR not engaging in currently, but has done so at least once in the last 6 months Check to be sure that substance use isn’t usually a part of the activity

19. F.A. for Pro-Social Checklist Give rationale Started by asking for description of common fun/healthy behavior Common problem: finding a fun behavior that is recent Outlined triggers (external, internal) Clarified the behavior Outlined positive and negative consequences of the behavior Summarized findings & gave examples of how the information would be used Common problem: forgetting to make the assignment explicit, forgetting to ask about/address obstacles

20. Sobriety Sampling: The Rationale Select the ones that are most relevant to your client when offering the rationale and make the link to the client’s specific situation: Enables client to set reasonable and attainable goals Teaches self-efficacy when goals are reached

21. Sobriety Sampling (cont’d) Provides “time-out” from drinking/using so client can experience sensation of being clean/sober Disrupts old habits, giving chance to replace with new positive coping skills Builds family support and trust Identifies relapse-prone areas

22. 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 the next session but don’t make it unreasonably long!

23. The Plan for Time-Limited Sobriety IS A WITHDRAWAL PLAN NEEDED?? Load up sessions in the 1st few weeks Don’t rely on past unsuccessful methods Identify biggest threats to sobriety Develop a specific plan for maintaining sobriety Identify and address obstacles Develop a back-up plan Remind client of reinforcers for achieving sobriety Use positive reinforcement

24. Sobriety Sampling Checklist Gave rationale for sampling sobriety (e.g., forces use of other coping strategies) Negotiated a reasonable period of sobriety Common problems: no real negotiation, final period of time settled upon was too long Developed a specific plan for maintaining sobriety at least until next session Common problem: obstacles not addressed Developed a back-up plan as well Reminded client of reinforcers for sobriety

25. 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 A-CRA procedures

26. Positive Communication Skills Components: Offer an understanding statement Accept partial responsibility Offer to help Explain each and come up with examples that are relevant to the client

27. Positive Communication (cont’d) Start with a reverse role-play? Regular role-play (+ specific feedback, repetitions) Don’t need all 3 components in the one conversation Discuss the best time to have the conversation

28. Communication Skills: Vignette A high school girl is having trouble talking to a teacher. She has had the same teacher in another class and feels as if this teacher has it in for her. It is a required course, and there are no other teachers for it. Introduce positive communication skills (including role- plays) to help this client come up with ways to better communicate. What other A-CRA technique could you use in this situation?

29. Communication Skills Checklist (Adolescent and Caregiver) Discussed why positive communication is important Described/reviewed the 3 positive communication elements Gave examples of good communications Common problem: exclusively reading examples off the handout Role-played (reinforced, gave specific feedback, repeated) Common problems: not offering specific feedback after each role-play Did a reverse role-play Common problems: forgetting to ask client what was learned about the other person’s perspective by playing him/her, not pointing out the A-CRA positive communication components used

30. Problem Solving (1) Define problem narrowly: Help make it very specific (manageable) (2) Brainstorm possible solutions: Help client generate them Don’t critique them; just encourage lots of ideas Don’t skimp – come up with at least 5 (3) Eliminate undesired suggestions: Have client cross out any unwanted ones (no explanation) (4) Select one potential solution: Have client explain step-by-step how it will be done

31. Problem Solving (cont’d) (5) Generate possible obstacles: Assist client; probe for more (6) Address each obstacle: If obstacles cannot be addressed - select another solution (7) Assign task: Be sure the task and the time for it to be done is clear (8) [Next session: Evaluate outcome]: Have client describe what was done and how well it worked Determine whether the solution needs to be modified Discuss obstacles again

32. Problem-Solving Skills Checklist Described/reviewed steps of the procedure Common problems: not making the specific steps explicit – but instead just demonstrating them Conducted A-CRA problem solving procedure Common problems: not defining the problem narrowly enough, not generating enough [5] solutions while brainstorming, not addressing obstacles adequately

33. Systematic Encouragement Encourage client to “sample” a new activity Get the client to make the 1st contact (take the 1st step) during the session Help the client identify a contact person Role-play the phone call or visit Have the client make the contact during the session (or take client to the activity) [Review activity attended in next session]

34. Drink/Drug Refusal Training Review high-risk situations:  Discuss upcoming high-risk situations  Identify triggers for use Enlist social support:  Discuss importance of support for abstinence  Identify at least 1 supportive person for the situation being discussed  Plan how to ask person for support; practice

35. Assertive Drink/Drug Refusal [Always watch body language!] Say, “No, thanks” (without guilt!) Suggest alternatives Change the subject Hold a non-alcoholic drink in hand Address the “aggressor” directly Leave

36. Drink/Drug Refusal Skills Checklist Reviewed high-risk situations Enlisted social support Common problem: not checking to see if the person can be available during the high-risk time; not exploring exactly how the person could help Presented/reviewed options for assertive refusal (e.g., changed subject) Role-played (kept brief, reinforced, gave specific feedback, repeated) Common problems: failing to point out & shape A-CRA refusal options

37. A-CRA’s Job Finding A disciplined, step-by-step approach to helping clients get and keep satisfying jobs How many sessions? Acceptable to complete with one (the same) client over several sessions If different clients: must be covered in 2 sessions maximum for certification

38. Job Finding Topics (1) Provide an overview: Discuss rewards associated with a satisfying job Examples: money, meet people, address boredom Discuss difficult aspects of the job-finding process Examples: Takes a lot of effort, rejection is common Explain job-finding’s “basic premises” Examples: need a lot of contacts and interviews

39. Job Finding Topics (2) Help generate job categories: Previous work? Training? (3) Generate/follow-up on leads: Develop a list of contacts Examples: family, friends, internet postings Set up a tracking system (next slide)

40. Job Leads Log (Tracking System) 1st Contact Date: Company: Contact Person’s Name: Telephone Number: Address: Result of 1st Call: 2nd Call: Date Result 3rd Call: Date Result

41. Job Leads Log (Tracking System) (4) Rehearse and make phone calls: Explain telephone inquiry steps Examples: introduce self, ask about openings (5) Complete applications: Discuss considerations when preparing Examples: discuss client strengths, how to handle difficult questions Fill out an application if possible

42. Job Leads Log (Tracking System) (6) Rehearse interviews: Discuss preparatory points Examples: dressing appropriately, being punctual Cover important topics Example: how to highlight one’s strengths (7) Plan for job maintenance/satisfaction: Maintenance: reasons for past job problems Satisfaction: evaluate, set goals to enhance

43. Job Finding Skills Checklist Provided overview Helped generate job categories Generated/followed-up job leads Rehearsed and made phone calls Completed applications Rehearsed interviews Planned for job maintenance/satisfaction

44. Engaging Caregivers Start engagement during the first phone call Spend 10-15 minutes with caregiver during first client session Continue engagement throughout treatment

45. Caregiver Sessions: Timing & Format Total of 4 sessions with the caregiver: 2 individual sessions with the caregiver 1st one: after about 5 sessions with the adolescent 2nd one: about 2 weeks later 2 “family” sessions with the caregiver + the adolescent 1st one: after about 9 sessions with the adolescent 2nd one: about 2 weeks later Note: these are only suggested/average times for these sessions Build in time to make up missed sessions

46. Caregiver Session 1: Rapport Building Maintain empathic and positive approach: Use empathy Reinforce attendance Re-label negative behavior Stop the blaming Reinforce discussion & emphasize family (adolescent) strengths - aspects of family life that are working well Use “exception” statements Express excitement about working with them

47. Caregiver Session 1: Overview Talk about the benefits of A-CRA Discuss purpose of caregiver sessions: Diminish caregiver’s pain Improve communication Improve caregiver-adolescent relationship Provide research-based information about what caregiver can do to keep adolescent from relapsing Assess need for another referral

48. Caregiver Session 1: Motivation Enhancement Determine caregiver’s reinforcers: related to the adolescent stopping his/her substance use specific to caregiver’s own, separate needs or desires Past failures? Recovery is a process Encourage to “sample” treatment

49. Caregiver Session 1: Critical Parenting Practices Explain that research supports 4 parenting practices which help prevent relapse in teens Describe the 4 parenting practices:  Be good role models (specifically – no alcohol/drugs in front of adolescent)  Increase positive communication  Monitor adolescent’s whereabouts  Get involved with the adolescent’s social life

50. Caregiver Communication Skill Training (Session 1 or 2) Provide rationale for learning positive communication skills Assess the present quality of communication Describe the three components while generating real-life examples with caregiver: Understanding statement Partial responsibility statement Offer to help

51. Caregiver Communication Skill Training Role-play exchanges between the caregiver and the client Point out any problems (e.g., blaming and bringing up old issues) Switch roles with the caregiver Process each exchange with the caregiver With the caregiver’s input, come up with an assignment (homework)

52. Caregiver Problem Solving Training Teach caregiver the problem-solving procedure The problem can be: one that relates to the adolescent one that has nothing to do with the adolescent Make sure a specific assignment results

53. Caregiver Overview, Rapport Building, and Motivation Checklist Provided an overview of A-CRA Set positive expectations Reviewed research regarding parenting practices Identified Caregiver’s reinforcers for continued work (repeat #5) Common problems: Focusing on the adolescent’s reinforcers instead of the caregiver’s reinforcers Kept discussion (about adolescent) positive

54. 3 Positive Things Exercise Give rationale: Helps start session on positive note Have them speak directly to each other (not to the therapist) Have them repeat the positive comments they hear Don’t forget to help if they get stuck, & to praise their efforts

55. Relationship Happiness Scales: Rationale Tools for caregiver(s) & adolescents to rate their happiness with each other in different areas of their relationship A method for setting goals/making changes A way to track progress toward relationship goals

56. Relationship Happiness Scale: Instructions Same basic instructions as for Happiness Scale, EXCEPT… Rate happiness with the other person (caregiver or adolescent) in each area Ask them not to look at the other family member’s answers [they will be explored later]

57. Relationship Happiness Scale: Review Ratings Review several ratings for each person (start with high ratings – to continue the positive tone) Review consists of: Asking why the particular rating was given OR Asking what it would take to give it a higher rating (what would have to change?)

58. Selecting Goal Categories Using their Relationship Happiness Scales: help the caregiver(s) & the adolescent select a category in which they want to make a request for a change in the other person They can each choose different categories Suggest they choose categories rated somewhere in the middle of the range (e.g., 4-7)

59. Making Requests and Setting Goals Help caregiver (or adolescent) formulate a request following guidelines (brief, positive, specific, measurable) In preparation for verbalizing the request: It’s a good time to review positive communication skills…

60. Relationship Therapy: Problem-Solving Skills Problem-solving needs to be reviewed & used in at least 1 of the family sessions Best time to introduce problem-solving? When a problem is identified in the session When are problems often identified in family sessions? When negotiating goals (assignments) to work on during the Relationship Happiness Scale exercise When deciding on homework assignments more generally When addressing a crisis

61. Daily Reminder To Be Nice: Rationale Acceptable examples (this exact wording is NOT needed!!): to jump-start a more positive home atmosphere to serve as a follow up exercise to the 3 Positive Things exercise to make sure family members keep supporting each other, even if they don’t really feel like doing that at times the form contains nice things that some family members automatically do for each other when things are going well in their relationship; and so this can be a reminder to continue doing them

62. Daily Reminder To Be Nice: Instructions Ask each person to do at least 1 item from the form daily regardless of whether the other person seems to be doing it as well Suggest that they find a good place to keep the forms so they don’t get lost or forgotten Have them generate examples for and practice 1-2 items in session Make homework assignment explicit

63. Caregiver-Adolescent Sessions *Things to Remember* Keep session structured Role of therapist/case manager: coach, shape, model, reinforce, praise, and keep everyone on task Focus on one issue at a time Focus is on skill-building Keep positive tone to session

64. Caregiver-Adolescent Session Tips Ask participants to speak to each other throughout the session Ask participants to repeat things Recognize and praise when they use the skills naturally If clients are resistant, decrease procedure jargon

65. Adolescent-Caregiver Relationship Skills Checklist Check on homework 3 positive things Relationship Happiness Scale Daily Reminder To Be Nice Communication Skills Problem Solving Skills

66. Anger Management Identify reasons to manage anger better: How has the client’s current way of expressing anger created problems for him/her? Explain why it is valuable to recognize the earliest signs of anger Help recognize anger building up: Identify high-risk situations and/or triggers for getting angry Help identify early signs of anger coming on Physical signs (clenched jaw) Behaviors (pacing, sarcastic remarks)

67. Anger Management (cont’d) Find relevant “cool down” activities: Help client come up with a “cool down” phrase Have client leave situation briefly (if possible) & engage in a planned activity Have client explain when he/she will return to talk Practice communication skills in the process Focus on empathy: Ask client to imagine situation from other person’s point of view (reverse role-play?) Ask client what he/she thinks the other person was thinking & feeling in that situation Give Anger Management handout to take home

68. Identify reinforcers to manage anger Assist in recognizing anger Common problem: forgetting to ask about the advantage of knowing the earliest signs of anger Teach taking time to “cool down” Teach fostering empathy Common problem: not probing sufficiently when asking about the other person’s thoughts/feelings Gave adolescent “Anger Management” handout