Community Reinforcement Approach (CRA) - PowerPoint PPT Presentation


Title: Community Reinforcement Approach (CRA)


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 1st 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 (contd)
  • 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 CRAs
    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 individuals 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?
  • Marcellos 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. Ill fit in because Ill 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 Im funny.
  • What do you like about drinking (where)?
  • I dont have to drive so far. Its informal I
    can be myself.
  • What do you like about drinking (when)?
  • Its a good way to unwind after working all day.

16
Positive consequences (contd)
  • What are the pleasant thoughts you have while
    drinking?
  • These guys think Im 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 havent put any effort into finding a
    romantic relationship lately.
  • Physical I dont sleep well Saturday night and
    I usually feel terrible Sunday.
  • Emotional I feel lonely. I dont know if its
    related to drinking.

18
Negative consequences (contd)
  • Legal No problems, but I worry about getting a
    DWI.
  • Job The Saturday drinking doesnt 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
  • Dont 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
  • Dont 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 1st 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 (contd)
  • 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 (contd)
  • Same client sometimes he chose to go to his
    brothers 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 brothers 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. Its
    something to do. Its nice to get to know my
    nephews. I hope nobody bugs me about my social
    life.

27
Internal triggers (contd)
  • What are you usually feeling physically right
    before you (activity)?
  • I dont know. Mostly relaxed I guess.
  • What are you usually feeling emotionally right
    before you (activity)?
  • Calm, content, but a little disappointed that I
    wont 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 Im
    dating
  • What do you dislike about (activity, where)?
  • -Nothing
  • What do you dislike about (activity, when)?
  • -Its 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? Im 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 nephews lives.
  • Physical Its 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 (contd)
  • 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 dont 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 (contd)
  • 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 clients 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
  • Dont 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 (contd)
  • 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 clients 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

47
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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

49
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50
Guidelines for Goal Setting
  • Goals (and their strategies) should be
  • Brief (uncomplicated)
  • Positive (what will be done)
  • Specific behaviors (measurable)
  • Reasonable
  • Under the clients 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 clients
    control.
  • Unnecessarily putting the client in a high-risk
    situation.

52
Whats wrong with these goals?
  • I dont want to drink anymore!
  • Ill apply for 10 jobs tomorrow!
  • Ill have a job tomorrow!
  • Ill try harder to save money.
  • Ill go out on a date with 3 different women next
    week.

53
Whats wrong with this goal?
  • I am going to attend 1 AA meeting next week - at
    the St. Agnes church at 800 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 clients 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 1st 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 youre 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 youre 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
CRAs 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
CRAs Relapse Prevention
  • Relapse prevention really starts the 1st day of
    treatment
  • There are some specific relapse prevention
    strategies too

75
Recovery Maintenance StrategiesMarlatt 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
More Relapse Risk
Increased Self- Efficacy
Decreased Self- Efficacy
Increased AVE
Less Lapse/Relapse Risk
Positive Outcome Expectancy
More Lapse 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 friends 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 (contd)
  • 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 (contd)
  • Offer understanding statement (try to view issue
    from partners 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
    dont have to say yes either.
  • Learn how to give in a little (compromise).
  • Try at home, learn independently.

89
Self-Reminder to Be NiceToday.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 clients 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 clients 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).
  • 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
97
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Community Reinforcement Approach (CRA)

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Title: Community Reinforcement Approach (CRA)


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 1st 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 (contd)
  • 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 CRAs
    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 individuals 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?
  • Marcellos 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. Ill fit in because Ill 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 Im funny.
  • What do you like about drinking (where)?
  • I dont have to drive so far. Its informal I
    can be myself.
  • What do you like about drinking (when)?
  • Its a good way to unwind after working all day.

16
Positive consequences (contd)
  • What are the pleasant thoughts you have while
    drinking?
  • These guys think Im 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 havent put any effort into finding a
    romantic relationship lately.
  • Physical I dont sleep well Saturday night and
    I usually feel terrible Sunday.
  • Emotional I feel lonely. I dont know if its
    related to drinking.

18
Negative consequences (contd)
  • Legal No problems, but I worry about getting a
    DWI.
  • Job The Saturday drinking doesnt 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
  • Dont 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
  • Dont 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 1st 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 (contd)
  • 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 (contd)
  • Same client sometimes he chose to go to his
    brothers 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 brothers 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. Its
    something to do. Its nice to get to know my
    nephews. I hope nobody bugs me about my social
    life.

27
Internal triggers (contd)
  • What are you usually feeling physically right
    before you (activity)?
  • I dont know. Mostly relaxed I guess.
  • What are you usually feeling emotionally right
    before you (activity)?
  • Calm, content, but a little disappointed that I
    wont 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 Im
    dating
  • What do you dislike about (activity, where)?
  • -Nothing
  • What do you dislike about (activity, when)?
  • -Its 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? Im 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 nephews lives.
  • Physical Its 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 (contd)
  • 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 dont 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 (contd)
  • 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 clients 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
  • Dont 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 (contd)
  • 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 clients 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

47
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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

49
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50
Guidelines for Goal Setting
  • Goals (and their strategies) should be
  • Brief (uncomplicated)
  • Positive (what will be done)
  • Specific behaviors (measurable)
  • Reasonable
  • Under the clients 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 clients
    control.
  • Unnecessarily putting the client in a high-risk
    situation.

52
Whats wrong with these goals?
  • I dont want to drink anymore!
  • Ill apply for 10 jobs tomorrow!
  • Ill have a job tomorrow!
  • Ill try harder to save money.
  • Ill go out on a date with 3 different women next
    week.

53
Whats wrong with this goal?
  • I am going to attend 1 AA meeting next week - at
    the St. Agnes church at 800 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 clients 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 1st 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 youre 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 youre 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
CRAs 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
CRAs Relapse Prevention
  • Relapse prevention really starts the 1st day of
    treatment
  • There are some specific relapse prevention
    strategies too

75
Recovery Maintenance StrategiesMarlatt 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
More Relapse Risk
Increased Self- Efficacy
Decreased Self- Efficacy
Increased AVE
Less Lapse/Relapse Risk
Positive Outcome Expectancy
More Lapse 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 friends 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 (contd)
  • 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 (contd)
  • Offer understanding statement (try to view issue
    from partners 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
    dont have to say yes either.
  • Learn how to give in a little (compromise).
  • Try at home, learn independently.

89
Self-Reminder to Be NiceToday.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 clients 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 clients 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).
  • 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
97
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