The Community Reinforcement Approach to Addiction Treatment

The Community Reinforcement Approach (CRA) is a broad-spectrum addiction treatment method originally developed by Nathan Azrin and his colleagues in Illinoisduring the early 1970’s.  Azrin’s

group demonstrated, in three well-designed studies, that the CRA was superior to standard alternative treatment procedures.  In one stringent test (Hunt & Azrin, 1973), alcohol dependent people receiving traditional inpatient treatment were assigned at random to receive or not receive CRA.  The CRA program yielded such large main effects that by 6-month follow-up there was little overlap between outcomes of the experimental and control groups (e.g., 14% vs. 79% of days spent drinking,

a 12-fold difference in days unemployed, and a 15-fold difference in days).  In a second evaluation (Azrin. 1976), also with inpatients, a CRA-treated group again showed highly superior outcomes

relative to a randomly assigned control group receiving standard treatment alone (e.g., 2% vs. 55% of days drinking).  At 12, 18, and 24 month follow-up, the CRA group was still retaining over 90% abstinent days, with no cases lost to follow-up.  An outpatient application of the CRA was no less successful (Azrin, Sisson, Meyers, & Godley, 1982).  Enormous outcome differences were observed between groups of alcohol dependent patients assigned at random to standard outpatient alcoholism treatment, compliance treatment, or full CRA.  Alcohol dependent people receiving standard treatment again reported over 50% of days drinking, and about one-third of days intoxicated and unemployed.  The  disulfiram compliance program reduced these rates by about half, but the full CRA program

resulted in almost total suppression of drinking (Mean = 0.9 days/month), intoxication (0.4 days/month), and unemployment (2.2 days/month).  In all three studies, those receiving standard treatment showed almost total relapse within 3 months following intervention, whereas CRA patients evidenced extremely low relapse rates.

The CRA consists of a broad treatment philosophy and a specific set of clinical procedures.  The overall philosophy is that in order to compete with the reinforcing effects of addictive substances, it is important

to help people establish a rewarding lifestyle with regular positive reinforcement that does not depend on the use of drugs.  Both individual skills and the environment are shaped, as possible, to remove

reinforcement for alcohol/drug use, and instead to reinforce sobriety.  Specific clinical procedures are used as appropriate to the needs of the individual, and have included the following.

1. Sobriety sampling – Trying out at least short periods of abstinence
2. Disulfiram compliance – Involving family members to ensure client adherence to disulfiram medication as a deterrent to drinking
3. Functional analysis – A detailed analysis of high-risk situations for alcohol/drug use
4. Job-finding counseling – Clients learn skills to find meaningful employment.
5. Problem-solving training – Clients receive training in problem-solving skills,with strategies and behavioral rehearsal directed toward their individual problem situations.
6. Behavioral  marital therapy – For clients who are experiencingproblemswithin a marital or other intimate relationship, reciprocity counseling (Azrin, Nastor & Jones, 1973) focuses on increased positive communication and exchange of reinforcement within the relationship.
7. Social counseling – Clients are assisted in scheduling rewarding activities, developing hobbies or recreational pursuits, taking advantage of community resources, seeking the company of nondrinking companions and friends who support their sobriety.  This is emphasized particularly for clients who are socially isolated, or who need social activities to compete with and replace substance use time.
8. Reinforcer access counseling – This is encouragement and practical assistance in obtaining access to common sources of information and reinforcement: a radio or television, newspaper and magazines, a driver’s license, a telephone, a computer, etc.
9. Mood monitoring – Clients are taught to monitor mood on a daily basis, as an early warning system to detect signs of impending relapse.  Clients are instructed, on observing warning signs, to resume contact with the counselor.
10. Refusal training – to help clients resist peer pressures for alcohol/drug use

CRA in New Mexico

The community reinforcement approach (CRA) was brought to CASAA in the 1980s by Robert J. Meyers, who had been part of Azrin’s research group in Illinois.  We collaborated over the years in a series of grant-funded research projects sponsored by NIAAA and NIDA.  The first of these (reported by Meyers & Miller, 2001), was a randomized trial seeking to replicate the Azrin studies by testing comparing traditional disease-model treatment for alcohol dependence (with or without the CRA disulfiram compliance procedure) with full CRA treatment.  We had separate study arms for clients who were (or were not) candidates for disulfiram medication.  Thus the four groups in this study for disulfiram-eligible clients were:

1.  Traditional disease-model treatment
2. Traditional disease-model treatment plus CRA disulfiram compliance procedure
3. CRA with disulfiram compliance
4. CRA without disulfiram

Clients ineligible for or unwilling to accept disulfiram were randomized to:

5. Traditional disease-model treatment              or
6. CRA without disulfiram

We maintained 84% interview completion rates to 24 months of follow-up.  Among disulfiram-eligible clients, those receiving CRA showed a significantly lower rate of drinking relative to the traditional treatment group (without CRA disulfiram compliance procedure).  Adding CRA disulfiram compliance did improve drinking outcomes among those receiving traditional disease-model treatment.  However, among clients receiving full CRA, the addition of disulfiram compliance did not improve outcome.  Clients who were too ill to take disulfiram or refused to do so had similar (and poorer) outcomes regardless of whether they received CRA or traditional treatment.  Thus within the disulfiram-eligible arm, we did replicate the superiority of CRA, although the difference from traditional treatment was much smaller than had been reported by Azrin’s group.  This is most likely due to the fact that in our study, traditional treatment was provided by highly experienced counselors who were committed to a disease-model perspective, whereas in Azrin’s studies the same behavioral therapists provided both treatments.

CRAFT

Like most addiction treatment centers, CASAA received many calls from concerned family members who wanted help for a loved one.  In many such cases, the loved one refused to seek help, and our counselors were struggling with how to respond.  Dr. Robert Meyers developed the community reinforcement and family training (CRAFT) method specifically to work through concerned family members of loved ones who refused to seek help.  CRAFT teaches the family members skills to reinforce sobriety rather than alcohol/drug use, and to encourage the loved one to enter treatment.

In a first clinical trial (Miller, Meyers & Tonigan, 1999), we randomly assigned concerned significant others (CSOs) to one of three treatment conditions: (1) Al-Anon facilitation, to help the CSO become engaged in the fellowship and program of Al-Anon, (2) the Johnson Institute intervention, in which the family plans a meeting in which the family confronts the loved one with the effects of his or her alcohol/drug use and implements pressures to seek treatment, or (3) CRAFT.  Al-Anon referral and the Johnson intervention were the two most common approaches for helping CSOs at the time, and the study provided the first head-to-head comparison of different approaches with this population.  CRAFT in many ways was a mirror opposite to the Al-Anon approach, which teaches CSOs that they are helpless to control the loved one and that they should detach and take care of themselves.  CRAFT, in contrast, emphasizes the substantial influence that family members can have, and teaches specific strategies for using it to move the loved one toward treatment and sobriety.  There were dramatic differences among the three methods in their rate of success engaging the loved one in treatment:  13% in Al-Anon, 30% with the Johnson intervention, and 64% with CRAFT.

Next we modified the CRAFT method to work with family members of loved ones using illicit drugs.  In our first uncontrolled evaluation, 74% of CSOs succeeded in getting their loved one into treatment with CRAFT (Meyers, Miller, Hill & Tonigan, 1999).  We then conducted a randomized trial comparing CRAFT with an Al-Anon/Nar-Anon facilitation approach, and again found a substantial difference in treatment engagement rates:  29% in the Al-Anon group, versus 67% in CRAFT.

Much more information about CRA and CRAFT, including professional and self-help books, is available on Dr. Robert J. Meyers’ website at http://www.robertjmeyersphd.com/.

Miller, W. R. (1985).  Community reinforcement approach.  In A. S. Bellack & M. Hersen (Eds.), Dictionary of behavior therapy techniques (pp. 64-66).  New York: Pergamon Press.

Meyers, R. J., & Miller, W. R. (Eds.) (2001).  A community reinforcement approach to addiction treatment.   Cambridge, UK: Cambridge University Press.

Meyers, R. J., Miller, W. R., Hill, D. E., & Tonigan, J. S. (1999).  Community reinforcement and family training (CRAFT): Engaging unmotivated drug users in treatment.  Journal of Substance Abuse, 10(3), 1-18.

Miller, W. R., Meyers, R. J., & Hiller-Sturmhöfel, S. (1999).  The community-reinforcement approach.  Alcohol Health & Research World, 22, 116-121.

Miller, W. R., Meyers, R. J., & Tonigan, J. S. (1999).  Engaging the unmotivated in treatment for alcohol problems: A comparison of three strategies for intervention through family members.  Journal of Consulting and Clinical Psychology, 67, 688-697.

Miller, W. R., Meyers, R. J., & Tonigan, J. S. (2001).  A comparison of CRA and traditional approaches.  In R. J. Meyers & W. R. Miller (Eds.), A community reinforcement approach to addiction treatment. (Pp. 62-78).  Cambridge, UK: Cambridge University Press.

Miller, W. R., Meyers, R. J., Tonigan, J. S., & Grant, K. A. (2001).  Community reinforcement and traditional approaches: Findings of a controlled trial.  In R. J. Meyers & W. R. Miller (Eds.), A community reinforcement approach to addiction treatment (pp. 79-103).  Cambridge, UK: Cambridge University Press.

Smith, J. E., Meyers, R. J., & Miller, W. R. (2001).  The community reinforcement approach to the treatment of substance use disorders.  American Journal on Addictions, 10 (Suppl.), 51-59.

Meyers, R. J., Miller, W. R., Smith, J. E., & Tonigan, J. S. (2002).  A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others.  Journal of Consulting and Clinical Psychology, 70, 1182-1185.

Smith, J. E., Meyers, R. J., & Miller, W. R. (2004).  Take the network into treatment.  Drug and Alcohol Findings, 10, 4-7.