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THE COMMUNITY REINFORCEMENT APPROACH Development and Effectiveness of CRA an UPDATE of the EVIDENCE the Most Influential Behaviorist of All Times, B

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THE COMMUNITY REINFORCEMENT APPROACH Development and Effectiveness of CRA an UPDATE of the EVIDENCE the Most Influential Behaviorist of All Times, B COMMUNITY REINFORCEMENT APPROACH THE COMMUNITY REINFORCEMENT APPROACH Development and Effectiveness of CRA AN UPDATE OF THE EVIDENCE The most influential behaviorist of all times, B. F. Skinner, largely considered punishment to be an ineffective method Robert J. Meyers, Ph.D.; Hendrik G. Roozen, Ph.D.; for modifying human behavior (Skinner 1974). Thus it and Jane Ellen Smith, Ph.D. was no surprise that, many years later, research discovered that substance use disorder treatments based on confrontation were largely ineffective in decreasing the use of alcohol The Community Reinforcement Approach (CRA), and other substances (Miller and Wilbourne 2002, originally developed for individuals with alcohol use Miller et al. 1998). Nate Azrin already was convinced disorders, has been successfully employed to treat a variety of this back in the early 1970s, when he designed an inno­ of substance use disorders for more than 35 years. Based on vative treatment for alcohol problems: the Community operant conditioning, CRA helps people rearrange their Reinforcement Approach (CRA). Azrin believed that it lifestyles so that healthy, drug­free living becomes was necessary to alter the environment in which people rewarding and thereby competes with alcohol and drug with alcohol problems live so that they received strong use. Consequently, practitioners encourage clients to reinforcement for sober behavior from their community, become progressively involved in alternative non­ including family, work, and friends. As part of this strate­ substance­related pleasant social activities, and to work on gy, the program emphasizes helping clients discover new, enhancing the enjoyment they receive within the enjoyable activities that do not revolve around alcohol, and “community” of their family and job. Additionally, in the teaching them the skills necessary for participating in those past 10­15 years, researchers have obtained scientific activities (see sidebar for a description of CRA procedures). evidence for two off­shoots of CRA that are based on the Research has since supported the premise behind CRA. same operant mechanism. The first variant is Adolescent Studies show that people with substance use disorders report Community Reinforcement Approach (A­CRA), which that they are less engaged in pleasant activities compared targets adolescents with substance use problems and their with healthy controls (Roozen et al. 2008; Van Etten et caregivers. The second approach, Community Reinforcement al. 1998). And other studies found that enriching people’s and Family Training (CRAFT), works through family environment with non–substance­related rewarding alternatives encourages them to reduce their substance use (Correia et members to engage treatment­refusing individuals into al. 2005; Vuchinich and Tucker 1996). Even modern day treatment. An overview of these treatments and their scientific neurobiology has confirmed that components of addiction backing is presented. KEY WORDS: Alcohol use disorders; alcohol treatment should focus on increasing patients’ involvement and other drug disorders; substance use disorders; treatment; with alternative reinforcers (Volkow et al. 2003). treatment methods; Community Reinforcement Approach (CRA); In terms of testing CRA itself, studies suggest that it is Adolescent CRA; Community Reinforcement and Family highly effective. Azrin’s first two studies of the program Training tested its effectiveness among alcohol­dependent inpatients (Azrin 1976; Hunt and Azrin 1973). The results showed that the new CRA program was more effective in reducing he Community Reinforcement Approach (CRA) is drinking than was the hospital’s Alcoholics Anonymous a comprehensive behavioral treatment package that program. Furthermore, the CRA participants had better T focuses on the management of substance­related outcomes with regard to their jobs and family relation­ behaviors and other disrupted life areas. The goal of CRA is ships. Azrin then modified the program slightly to test to help people discover and adopt a pleasurable and healthy it with outpatients at a rural alcohol treatment agency lifestyle that is more rewarding than a lifestyle filled with using alcohol or drugs. Multiple research reviews and meta­ OBERT EYERS H analyses of the treatment­outcome literature have shown R J. M , P .D., is an emeritus associate research professor of psychology in the Psychology Department at the CRA to be among the most strongly supported treatment University of New Mexico, and director of Robert J. Meyers, methods (Finney and Monahan 1996; Holder et al. 1991; Ph.D., and Associates, Albuquerque, New Mexico Miller et al. 1995, 2003). This article briefly discusses the science behind CRA, and provides an overview of the treat­ HENDRIK G. ROOZEN, PH.D., is a clinical psychologist ment program. In addition, it discusses two novel variants and senior researcher in the Department of Research and built upon the CRA foundation. These interventions Development, Novadic­Kentron Treatment Services, Vught, include an adolescent version of CRA called Adolescent the Netherlands, and Erasmus University Medical Centre, Community Reinforcement Approach (A­CRA), and a Department of Forensic Psychiatry, Rotterdam, the Netherlands. program called Community Reinforcement and Family Training (CRAFT), which is designed to engage treatment­ JANE ELLEN SMITH, PH.D., is professor of psychology in the refusing substance­abusing individuals into treatment by Psychology Department at the University of New Mexico, working through family members. Albuquerque, New Mexico. 380 Alcohol Research & Health COMMUNITY REINFORCEMENT APPROACH (Azrin et al. 1982). He and his colleagues, again, found vouchers to participants who submitted drug­free urine CRA to be superior to the comparison condition. samples. In turn, they could exchange the vouchers for A larger outcome study conducted in the 1990s had goods, such as dinners. A number of early studies demon­ mixed results, though it did show a benefit of CRA on strated that CRA plus vouchers outperformed standard the immediate outcome. (Miller et al. 2001). For this treatment programs (e.g., Higgins et al. 1991, 1993, study, participants had to score in the symptomatic range 1994). Another study showed that CRA plus vouchers on two of four measures, including the Addiction Severity was significantly better than vouchers alone in terms of Index and the Alcohol Use Inventory. The final sample improved treatment retention and employment rates, and consisted of people who met an average of 7 of the 9 reduced cocaine use—at least during the treatment phase criteria for alcohol dependence syndrome as defined (Higgins et al. 2003). The CRA plus vouchers program by the Diagnostic and Statistical Manual of Mental has been used successfully with other illicit drugs as well. Disorders, Third Edition, Revised (DSM–III–R) (American For example, people receiving opioid detoxification with Psychiatric Association 1980). The study compared CRA buprenorphine had significantly better treatment out­ with a “traditional” treatment. However, because this comes if they also received CRA plus vouchers (Bickel et al. comparison treatment used a CRA procedure as part of 1997). In addition, a recent study with adults who used its protocol—teaching one of the participants’ loved ones cannabis determined that long­term outcomes favored positive communication skills so he or she could administer clients who received CRA in addition to vouchers as disulfiram (Antabuse®) in a supportive and caring way— opposed to just vouchers alone (Budney et al. 2006). the overlap could have obscured the results somewhat. Thus, the CRA plus contingency management package Another confounding factor may have been that the appears to be a highly successful program for treating traditional treatment group included more participants individuals who abuse illicit drugs (Bickel et al. 2008; who agreed to take disulfiram in the first place (Miller Garcia­Rodriquez et al. 2009). et al. 2001). In a study that delivered CRA in a group format to severely alcohol­dependent homeless individuals in a day The Adolescent Version of CRA: A­CRA treatment program, CRA produced significantly greater The high rate of illicit substance use among adolescents substance use outcomes than did the standard treatment has been viewed as one of the primary public health problems at the homeless shelter (Smith et al. 1998). Finally, another facing the United States for some time now (Johnston study discovered that people with antisocial personality et al. 2001). According to one report, during a relatively disorder could, in fact, respond successfully to a CRA recent six­year period (1992–1998), the number of 12­ to program, even if it highlighted the relationship counseling 17­year­olds who were admitted to public substance use aspect of CRA (Kalman et al. 2000). treatment agencies increased by 54 percent (Dennis et al. The table provides an overview of Community 2003). Consequently, it is more important than ever to Reinforcement studies. The first section highlights the tri­ identify effective substance use disorder treatment programs als in which researchers tested “pure” CRA, without any for adolescents. A­CRA is a scientifically­based behavioral additional programs. Several comprehensive reviews and intervention that is a slightly modified version of the adult meta­analyses support the conclusion that CRA is highly CRA program (for descriptions with examples see Godley effective compared with other alcohol
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