Community Reinforcement Approach (CRA) 1980S Among Alcohol Outpatients

THEMATIC REVIEW

THE NEXT STEP Take the network into treatment It’s beginning to look like the most promising way forward for treatment – not more therapists, but harnessing friends, lovers, sons, daughters and workmates to reconstruct the incentives in a client’s life to promote recovery – a form of benevolent social engineering gaining ground here and in the USA.

he community reinforcement approach (CRA) 1980s among alcohol outpatients. Since then there Tis a comprehensive cognitive-behavioural pro- have been larger scale replications and extensions gramme for treating substance abuse problems to other populations. based on the belief that environmental contingen- cies can play a powerful role in supporting or Striking gains after inpatient treatment by Jane Ellen Smith, discouraging drinking or drug use. As such, it uses Using a matched-control design, the first study1 Robert J. Meyers & familial, social, recreational, and occupational randomly assigned one alcohol-dependent member William R. Miller reinforcers to aid recovery. The goal is to rearrange in each of eight pairs to the hospital’s standard of the Department of Psychology an individual’s ‘community’ so that a clean and Alcoholics Anonymous programme (instruction on at the University of New Mexico. sober lifestyle is more rewarding than one domi- the Jellinek disease model of alcoholism6 and 1 Contact Professor Jane Ellen Smith, nated by alcohol and drugs. This it accomplishes in discussions about the typical alcoholic’s behaviour Department of Psychology, a non-confrontational manner by first carefully and problems), or to this plus a community rein- University of New Mexico, Logan identifying the external and internal triggers for an forcement intervention involving guidance on how Hall, Albuquerque, New Mexico 87131, USA, [email protected]. individual’s substance use, and reviewing both its to identify and access non-drinking reinforcers, job positive and negative consequences. The resulting and leisure-time counselling, and relapse preven- Copyright 2001 from “The community reinforcement approach treatment plan embraces many aspects of the indi- tion through home visits and encouragement to to the treatment of substance use vidual’s life believed to be integral to their sub- attend an alcohol-free social club. Married partici- disorders” by Jane Ellen Smith, stance use. Importantly, this often includes the pants also received behavioural couples therapy. Robert J. Meyers and William R. individual’s job and social activities. When skill At the six-month follow-up, on average com- Miller. Reproduced with minor editorial amendments by deficits are noted, behavioural training is intro- munity reinforcement participants had drunk permission of Taylor & Francis, Inc., duced in the relevant areas (eg, drink/drug refusal, alcohol on 14% of follow-up days compared to 79% http://www.routledge-ny.com. communication training, problem-solving). Sig- after standard treatment. Another striking differ- We are grateful to Taylor & nificant others are involved whenever possible.2 ence was that the community reinforcement group Francis and to the authors for Despite somewhat different methodologies, in had been unemployed on an average 5% of days, permission to reprint. each of three recent meta-analytic reviews commu- the standard group 62%. Furthermore, community nity reinforcement ranked as one of the most reinforcement participants were hospitalised on efficacious and cost-effective alcohol treatments only 2% of follow-up days compared to 27% after available. The initial review ranked 33 treatments standard treatment. Despite its small samples, the on the basis of cost and whether in follow-up study was recognised as unique for its reliance on studies they had statistically been proven superior operant reinforcement theory for the conceptuali- to another intervention.3 Community reinforce- sation and treatment of alcoholism and for focusing ment came fifth. The next analysis also took into on outcomes beyond substance abuse. account the methodological quality of the studies.4 Nathan Azrin was involved in the first trial and Among 30 treatments tested in at least three stud- also in the second, in which encouragement to take ies, community reinforcement was placed fourth. disulfiram was added to the standard treatment.7 The final review factored in the probability that a New community reinforcement procedures in- study would yield a significant effect by consider- cluded a compliance programme which monitored ing issues such as sample size, strength of the disulfiram intake and rewarded individuals for comparison treatment, and the number of statisti- taking the medication, an early warning system to cal tests.5 Community reinforcement earned top identify potential relapses, and social support in the position in this ranking of 36 interventions. Re- form of a ‘buddy’ system. Again, at the six-month gardless of the precise manner in which the various follow-up the community reinforcement group analyses were conducted, the findings consistently showed superior outcomes across a variety of areas. suggested that community reinforcement was one On average they had drank on 2% of follow-up of the most effective alcohol treatments available. days compared to 55% after standard treatment, and had been unemployed on 20% compared to Early alcohol studies show promise 56%. None of the community reinforcement Community reinforcement’s efficacy was first participants were institutionalised while on average demonstrated over 25 years ago in a small inpatient patients receiving only standard treatment were sample of alcohol dependents and then in the early institutionalised on 45% of follow-up days.

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When they enter the therapy room clients normally leave behind their relationships with lovers, friends, workmates, sons and daughters. Community reinforcement aims to take these people into the room and to mould their interactions with the client into continually active forces for positive change.

counselling. Reciprocity counselling became a routine part of the community reinforcement package whenever problem drinkers were involved in significant relationships. Another element to have been studied separately is the ‘social club’, an alcohol-free recreational environment typically open at Outpatients also benefit individuals, achieving abstinence rates similar high-risk periods such as Friday and Saturday In the early 1980s Azrin and colleagues to those of the community reinforcement nights.10 The study also tested whether be- conducted the first outpatient trial.8 The aim group. Although this difference was not sig- havioural procedures could motivate attend- was to contrast the CRA disulfiram compli- nificant, patients offered the full community ance. Participants were 35 alcohol-dependent ance programme7 with a traditional di- reinforcement intervention were unem- individuals already in outpatient treatment. sulfiram regime, and to test an abbreviated ployed on just 7% of follow-up days com- They were randomly assigned to a control form of community reinforcement. It pared to 36% after traditional treatment. group simply given information about the showed that this approach could be success- club, or to receive encouragement to attend ful on an outpatient basis and with an average Active ingredients through multiple contacts with a counsellor of only five sessions. Typically, community reinforcement is who also problem-solved attendance obsta- All 43 participants underwent traditional offered as a varied package of measures, but cles and provided membership cards and treatment comprising 12-step counselling some studies have tested selected compo- flyers about forthcoming activities. and disulfiram. Along with their significant nents. The couples component featuring Not only did the ‘encouragement’ group others, a randomly assigned third were also ‘reciprocity counselling’ was first tested in a attend significantly more often than the taught the disulfiram compliance procedure, study focused on marital distress.9 The controls, over the same period they also using communication training and role-play therapy helped couples select and initiate drank significantly less. Though the study to teach the significant other how to admin- new, mutually reinforcing interactions, and could be criticised for its limited information ister disulfiram in a supportive manner. instilled an expectation that a reinforcing act on the participants’ outpatient treatment, Another randomly assigned third received all by one partner would be reciprocated. Dur- nevertheless it offered a promising procedure the previous inputs plus a broader commu- ing the weeks they practised this therapy, the for encouraging a potentially valuable activ- nity reinforcement intervention. This was 12 couples in the study demonstrated signifi- ity. Furthermore, it highlighted the impor- based on the earlier study7 but included new cant improvements in marital happiness tance of addressing recreational life as part of elements such as drink-refusal and relaxation compared to the weeks of ‘catharsis-type’ the recovery process. training and sobriety sampling – a “gently” negotiated contract for an alcohol-free period. The middle condition, essentially 12- step counselling plus CRA disulfiram Golden Bullets compliance procedures, was expected to produce outcomes between the other two. Practice points from this article As predicted, the two groups trained in disulfiram compliance reported the highest The community reinforcement approach aims to rearrange an individual’s social and working life abstinence rates. During the sixth month of so that sobriety is more rewarding than a life dominated by alcohol or drugs. the follow-up, patients in traditional treat- Recent assessments ranked it as one of the most cost-effective alcohol treatments available. ment were abstinent on 45% of days. With It has been found effective as an adjunct to disulfiram treatment of alcoholism, contingency man- compliance training this rose to 74% and to agement and disulfiram regimes for cocaine problems, maintenance treatment of opiate addiction, 97% when the broader community reinforce- and in helping families and friends encourage reluctant substance misusers into treatment. ment elements had also been added. Interest- ingly, in the ‘middle’ disulfiram compliance Active ingredients include medication compliance procedures, alcohol-free social clubs, and job- group, couples performed better than single finding clubs.

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The job club component has received was roughly comparable to the earlier studies drinking outcomes. Marked improvements repeated research attention. It aims to help (ie, six months), so too were the findings, in in employment and housing status were participants obtain satisfying employment two ways. First, community reinforcement noted but with one exception did not signifi- which reinforces non-drinking through was superior to traditional treatment in terms cantly differ across the groups. The exception enhanced self-esteem, financial rewards, and of drinking outcomes. Second, when di- was better housing at four months in the opportunities for pleasant social interaction. sulfiram compliance training was added to community reinforcement group. The skills outlined in the Job Club Counselor’s traditional treatment, outcomes were raised Manual11 include developing CVs, complet- to a level similar to those achieved by com- Beyond alcohol to illegal drugs ing job applications, generating job leads, and munity reinforcement – an effect detected As with many of the alcohol studies, when rehearsing interviews. Its success was first earlier, though only for married clients.8 applied to clients dependent on illicit drugs, demonstrated in populations who were not community reinforcement has usually been necessarily substance users.12 One study Homeless drinkers also respond well allied with other treatments. involved referrals from probation officers The most recent study was conducted by and the state hospital as well as from sub- Jane Ellen Smith and colleagues, notable for Cocaine abstinence reinforced stance abuse centres.13 At the six-month its cost-effective group format and high In the treatment of cocaine dependence, follow-up, 95% of participants randomly follow-up and low drop-out rates. It involved community reinforcement has typically been assigned to the job club were employed but 106 alcohol-dependent men and women supplemented by a contingency management only 28% in the control group. They had also recruited from shelters for the homeless.17 programme which rewards clean urines with acquired higher-paying positions and done so They were randomly assigned to the shelter’s vouchers which can be exchanged for com- faster. Impressive benefits were also apparent standard treatment (including access to 12- modities. Financial reinforcers were added to in a study of welfare recipients.14 As noted step counsellors, on-site AA meetings, and a address the high early drop-out rates of above, the job club was also quite successful job programme) or to a community rein- cocaine-dependent individuals and to have a as part of the complete community reinforcement programme modified for the tool early in treatment which can compete forcement package.1 7 8 homeless. Modifications included group with cocaine’s powerful reinforcing effects. delivery, small incentives for attendance, Several trials have established the efficacy Later studies confirm early work using the project nurse as the disulfiram of this community reinforcement/voucher These seminal studies have since been ex- monitor, and independent-living skills combination. In one randomised study, 58% tended to larger sample sizes and different groups. All participants received abstinence- of participants given this combination com- drinking populations, with essentially the contingent grant-supported housing during pleted 24 weeks of treatment but only 11% in same positive results. the three-month programme. standard counselling.18 Also, 68% and 42% In terms of drinking outcomes, the overall respectively maintained eight and 16 weeks With and without disulfiram average number of drinks per day dropped of continuous abstinence from cocaine A large-scale (237 participants) replication from 19 before treatment to about four at 12 compared to only 11% and 5% in standard and extension of Azrin’s work was conducted months. As predicted, participants in the counselling. Urinalyses documented signifi- by William Miller and colleagues. It ad- community reinforcement condition significantly greater cocaine abstinence in the dressed many of the earlier methodological cantly outperformed those in the standard community reinforcement/voucher group at limitations such as small sample sizes.15 The condition, with the differences most consist- the nine- and 12-month follow-ups. first three conditions were similar to those in ent across the various drinking variables More recent studies have attempted to first outpatient study:8 traditional treatment through to the nine-month follow-up. tease out the unique contribution of the including disulfiram; traditional treatment Other predicted effects did not emerge. contingent vouchers part of the combination. plus disulfiram compliance training; di- Neither initial willingness to take disulfiram Some found that the significant extra benefit sulfiram compliance plus a broader commu- nor its actual use were associated with better gained by vouchers during treatment persists nity reinforcement package. A fourth condition, community reinforcement without disulfiram, was added to determine whether disulfiram was critical to the CRA package. Manuals and practice guides In terms of their drinking, during follow- up months one to six patients generally did Despite its research pedigree, community reinforcement has not been widely adopted significantly better in the community rein- in the UK or in its US homeland, perhaps because it seems a more complex way of way forcement conditions.16 The most pro- of engaging with a client’s life than focusing exclusively on them and their substance nounced contrast was between the misuse problem. However, a similar approach (social behaviour and network therapy) proportion of drinking days, just 3% versus has been implemented as part of the UK’s national alcohol treatment trial (UKATT) and 19% in traditional treatment. However, when has proved feasible when adapted for drug users attending a community drug service.1 disulfiram compliance training was added to Two of the authors of the present review have gathered together relevant research traditional treatment, the combination was as in one of the prestigious International Research Monographs in the Addictions.2 This effective as community reinforcement. At readable volume also includes examples of community reinforcement in action. There later follow-ups over a year after treatment also two readily available manuals, one covering alcohol treatment,3 the other cocaine.4 intake there were no significant differences 1 Williamson E. et al. “Implementing and evaluating social behaviour and network therapy between the groups. in routine service provision in the UK.” Presented at the Society for the Study of Addiction The study also included patients ineligible Annual Symposium 2003, 6–7 November 2003. 2 Meyers R.J, Miller W.R., eds. A community reinforcement approach to addiction treat- for or who refused disulfiram. They were ment. Cambridge University Press, 2001. Copies through bookshops. assigned either to community reinforcement 3 Meyers R.J. et al. Clinical guide to alcohol treatment: the community reinforcement or to traditional treatment. The only differ- approach. New York: Guildford Press, 1995. Copies through bookshops. ence was a much lower drop-out rate in 4 Budney A.J. et al. A community reinforcement plus vouchers approach: treating cocaine addiction. US National Institute on Drug Abuse, 1998. Download from www.nida.nih.gov/ community reinforcement – 9% compared to DrugPages/Treatment.html or contact US National Clearinghouse for Alcohol and Drug 41% of controls. Information, fax 00 1 301 468 6433, e-mail [email protected]. In summary, when the follow-up period

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after the vouchers are withdrawn,20 others resistant alcohol-dependent individuals in CRAFT consistently outperforms other inter- that it is lost across the follow-up.19 treatment.26 Six of the seven drinkers whose ventions in engaging resistant problem alco- Disulfiram compliance training is one of associates received CRAFT training entered hol or drug users in treatment. the original community reinforcement com- treatment, but none of the five whose associ- ponents which has been examined separately ates received traditional counselling. In a Challenge now is dissemination in cocaine trials. Initially introduced to de- large study of 130 problem drinkers con- The evidence strongly supports the use of crease alcohol consumption, for various ducted by William Miller and colleagues, community reinforcement and CRAFT in the reasons disulfiram has great promise in associates assigned to CRAFT engaged signifi- treatment of substance use disorders. Azrin’s cocaine treatment as well. Two randomised cantly more of their loved ones in alcohol initial findings have been replicated by sev- trials have found that cocaine-dependent treatment (64%) than those assigned to either eral research groups across culturally diverse patients who as part of their treatment re- the Johnson Institute intervention (30%) or populations. Typically, community rein- ceived disulfiram and disulfiram compliance to Al-Anon (13%).27 forcement has been compared with standard training evidenced significantly greater co- Similar results have been found with approaches in randomised trials, providing a caine and alcohol abstinence than individuals illicit drug abusers. An uncontrolled trial stringent test of relative efficacy. Importantly, who did not receive these elements.21 22 involving 62 associates discovered that after every study to date has found an advantage CRAFT training 74% successfully engaged the for community reinforcement on at least Opiate addiction pharmacotherapy resistant user in treatment.28 A randomised some outcome measures. Pharmacotherapies for opiate addiction are study detected significant differences when With increasing concern for cost contain- enhanced by effective psychosocial interven- the engagement rates of CRAFT-trained ment, it is also noteworthy that outpatient tions.23 Among those which have been tested associates (64% engaged) were compared to community reinforcement is relatively inex- is community reinforcement. In one study, those of associates who had attended 12-step pensive and has been successfully learned 39 patients undergoing buprenorphine de- meetings (17% engaged).29 The latest study and applied by less experienced therapists.31 toxification were randomly assigned to either was conducted by our unit in Albuquerque CRAFT, an outgrowth of community rein- a community reinforcement plus vouchers with 90 associates. Again it discovered sig- forcement, successfully targets the common condition or to standard drug counselling.24 nificantly better engagement rates for those obstacle of lack of motivation for treatment. The voucher regime was unique in that half randomly assigned to CRAFT (67%) versus The principal challenge now is to dissemi- the vouchers could be earned for opiate-free those assigned to individual twelve-step nate this well-supported approach into urines and half for engaging in activities facilitation therapy (31%).30 In summary, clinical practice. ‘prescribed’ as part of the treatment. Just over Nuggets 4.8 4.5 half the community reinforcement/vouchers REFERENCES LINKS patients completed the 24-week detoxifica- 1 Hunt G.M. et al. “A community-reinforcement approach 17 Smith J.E. et al. “The community reinforcement ap- tion but only a fifth of counselling patients, a to alcoholism.” Behaviour Research and Therapy: 1973, 11, proach with homeless alcohol-dependent individuals.” J. statistically significant difference. p. 91–104. Consulting and Clinical Psychology: 1998, 66, p. 541–548. Another statistically significant effect was 2 Meyers R.J. et al. Clinical guide to alcohol treatment: the 18 Higgins S.T. et al. “Achieving cocaine abstinence with a community reinforcement approach. Guildford Press, 1995. behavioral approach.” American Journal of Psychiatry: 1993, noted in a study which used community 3 Holder H. et al. “The cost effectiveness of treatment for 150, p. 763–769. reinforcement without vouchers to treat 181 alcoholism: a first approximation.” Journal of Studies on 19 Higgins S.T. et al. “Outpatient behavioral treatment for methadone-maintained patients.25 Of those Alcohol: 1991, 52, p. 517–540. cocaine dependence: one-year outcome.” Experimental and 4 Miller W.R. et al. “What works? A methodological analysis Clinical Psychopharmacology: 1995, 3, p. 205–212. assigned to community reinforcement (with of the alcohol treatment outcome literature.” In: Hester R.K. 20 Higgins S.T. et al. “Contingent reinforcement increases or without additional relapse prevention et al, eds. 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