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Community Reinforcement Approach

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Title: Community Reinforcement Approach


1
Community Reinforcement Approach
  • Susan Harrington Godley
  • Chestnut Health Systems
  • Bloomington, IL
  • Funded by
  • Center for Substance Abuse Treatment (TI11894
    TI13356)
  • National Institute on Drug Abuse (R01 DA 018183)
  • Based on slides by
  • Robert J. Meyers, Ph.D. and Jane Ellen Smith,
    Ph.D.
  • University of New Mexico

2
Goals of Presentation
  • Supporting Research
  • What is CRA?

3
Hunt Azrin 1973
  • Inpatient Alcoholics
  • job finding counseling
  • behavioral/marital therapy
  • social/leisure counseling
  • reinforcer access counseling
  • social club
  • home visits
  • total 50 hrs per client

4
Results 6 month follow-up
5
Azrin 1976 New Improved CRA
  • inpatient alcoholics
  • disulfiram w/compliance protocol
  • problem prevention
  • buddy system
  • early warning mood monitoring
  • 70 as aftercare home visits
  • Average 30 contact hrs

6
CRA new improved Results
7
CRA Outpatient Study (1982)Azrin, Sisson,
Meyers, Godley
  • increased use of positive reinforcement
  • sobriety sampling
  • drink refusal training
  • /- functional analysis
  • job club
  • phone contacts
  • Average 5 sessions
  • 43 outpatient alcoholics
  • 3 groups
  • (1) traditional tx
  • (2) traditional tx disulfiram compliance
  • (3) CRA disulfiram compliance

8
6 Month Follow-up (1982)
  • CRA disulfiram compliance days abs 97
  • Traditional
    days abs 74
  • disulfiram compliance
  • Traditional day
    abs 45

9
CRA with Homeless Alcohol-Dependent Individuals
  • CRA
  • Group Sessions
  • Problem-Solving
  • Communication Skills
  • Drink-Refusal
  • Independent Living Skills
  • Goal Setting Meeting
  • Social Club
  • Disulfiram Compliance
  • (for a sub-group)
  • Individual Sessions
  • Job Finding
  • Case Management
  • STANDARD TREATMENT
  • Day Treatment
  • 12-Step Counselor
  • Job Service Program
  • VA Benefits Advisor

10
Drinks Per Week By Condition
--- Standard --- CRA
Median SECs
2 Month 4 Mont 6
Month 9 Month 12
Month
Follow-Up Period
11
Percent Homeless By Condition
CRA Standard
Percent
2 Month 4 Month 6 Month
9 Month 12 Month
Follow-up Periods
12
Evidence of Effectiveness Meta-analyses
Reviews
  • Holder et al. (1991) Miller et al. (1995)
  • Social skills training Brief intervention
  • Self-control training Social skills training
  • Brief motivational tx MET
  • Behavioral Marital tx CRA
  • CRA Behavioral contract
  • Stress management Aversion tx

13
Evidence of Effectiveness (contd)
  • Finney et al., 96 Miller et al., 03 Miller et
    al., 05
  • CRA Brief Intervention Cognitive-Behavioral
  • Social skills training MET CRA
  • Behavioral Marital tx Acamprosate MI
  • Disulfiram Implants CRA Relapse Prevention
  • Other marital tx Self-Change Social Skills
    Training
  • Stress Management Naltrexone Behavioral
    Marital Ther.

14
CRA Clinical Trials
  • Hunt Azrin, 73 (inpatient alcohol dependent)
  • Azrin, 76 (inpatient alcohol dependent)
  • Azrin et al., 82 (outpatient alcoholic)
  • Higgins et al., 91 (cocaine)
  • Budney et al., 91 (cocaine)
  • Higgins et al., 93 (cocaine)
  • Smith et al., 98 (homeless alcoholics)
  • Abbott et al., 98 (methadone/heroin addicts)
  • Roozen et al., 00 (opioid dependent individuals)
  • Schottenfeld et al., 00 (opioid cocaine
    dependent individuals)
  • Meyers Miller., 01 (outpatient alcoholics)
  • Godley, et al., 02 (Adolescent aftercare mj
    alc)
  • Azrin, 04 (outpatient adolescent patients)
  • Roozen et al., 06 (nicotine dependent
    individuals)
  • Slesnick, et al., 07 (homeless, street living
    youth)
  • De Jong et al., 07 (opioid dependent
    individuals)
  • DeFuentes-Merillas, De Jong 08 (opioid
    cocaine dependent individuals)

15
What does not work!
  • Educational films and lectures
  • General alcoholism counseling
  • Process psychotherapy (individual or group)
  • Confrontational counseling
  • Antipsychotic medication
  • Insight therapy

16
  • If punishment worked, there would be few, if
    any, alcoholics or drug addicts

17
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)

18
CRA Session Structure
  • Been tested in clinical trials for 3-month
    period, but designed to be open-ended based on
    individual needs
  • Can be combination of individual/group sessions
  • Frequency of sessions based on clients
    motivation and progress
  • Assessment and treatment planning used for all
    skills training as needed

19
CRA Induction First Session
  • Build rapport, build rapport, build rapport
  • Stay client-focused
  • Use positive reinforcement
  • Provide an overview of the basic CRA objectives
  • Begin to establish reinforcers (motivators)

20
Positive Reinforcer
  • What is a reinforcer?
  • How do I find one?
  • Does everyone have reinforcers?
  • How can I use them to help?

21
Functional Analysis (F.A.)
  • 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

22
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23
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24
Sobriety Sampling
  • Provide the rationale (Step 1)
  • The negotiation (Step 2)
  • Plan for Time-Limited Sobriety (Step 3)

25
Happiness Scale
26
Goals of Counseling Setting Goals
  • Goals of Counseling contains the categories on
    the Happiness Scale
  • Guide the clients selection of a category
  • In general, set short-term goals
  • Develop a step-by-step weekly strategy for
    reaching each goal.
  • The strategy the homework for the week

27
Skills Training
  • Communications Skills
  • Problem Solving
  • Drink/Drug Refusal
  • Job-Finding Skills

28
Assigning Homework
  • Refer to as practice exercises? An experiment?
  • Offer rationale
  • Get clients input
  • Describe agreed-upon specific assignment
  • Ask about potential obstacles problem-solve
  • Identify time for completing assignment
  • Review homework at next session

29
Social/Recreational Counseling
  • Discuss importance of healthy social life
  • Identify areas of interest
  • Ongoing? Pro-Social F.A.
  • New? 2 x 2 table Problem-solving Leisure
    Questionnaire goal-setting
  • Encourage reinforcer sampling
  • Systematic Encouragement
  • Social Club

30
Drink/Drug Refusal Training
  • Review high-risk situations
  • Enlist social support
  • Refuse drinks/drugs assertively

31
Additional Relapse Techniques
  • CRA Functional Analysis for Relapse
  • Behavioral chain of events
  • Early warning monitoring system

32
Relationship Counseling
33
Self-Reminder to Be Nice
34
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

35
Common Mistakes Made When Implementing CRA
  • Inadequately monitoring the clients contact with
    triggers
  • Not checking for generalization of skills
  • Being reluctant to suggest the use of appropriate
    medications

36
More Information
  • http//www.robertjmeyersphd.com/
  • 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.

37
CSATs Assertive Adolescent Family Treatment
  • Susan Harrington Godley
  • Chestnut Health Systems
  • Bloomington, IL
  • Funded by
  • Center for Substance Abuse Treatment (TI11894
    TI13356)
  • National Institute on Drug Abuse (R01 DA 018183)

38
Goals
  • A-CRA vs. CRA
  • Assertive Continuing Care (ACC)
  • Technical assistance provided to grantees to
    learn the EBTs
  • Target population
  • Outcomes

39
A-CRA vs. CRA
  • Added caregiver sessions
  • Changed Happiness Scale so that it was relevant
    for adolescents
  • Samples in treatment manual were based on how one
    might talk with an adolescent and the issues they
    would talk about

40
Critical Parenting Practices
  • Good modeling
  • Increase positive
  • communication
  • Monitor the adolescents
  • whereabouts
  • Involvement in
  • adolescent's life
  • outside the home.

Based on the work of R. Catalano, H. Hops, B.Bry
41
Similarity of Clinical Outcomes by Conditions
Trial 2
Trial 1
300
50
.
280
40
.
Percent in Recovery
over 12 months
at Month 12
260
30
Total days abstinent
240
20
220
10
200
0
MET/ CBT5
MET/
FSN
MET/ CBT5
A-CRA
MDFT
CBT12
269
256
260
251
265
257
Total Days Abstinent
0.28
0.17
0.22
0.23
0.34
0.19
Percent in Recovery
n.s.d. effect size f0.06
n.s.d., effect size f0.06
n.s.d., effect size f0.16
n.s.d., effect size f0.12
Source Dennis et al., 2004
42
Moderate to large differences in
Cost-Effectiveness by Condition
Trial 2
Trial 1
20
20,000
16
16,000
12
12,000
Cost per person in recovery
at month 12
Cost per day of abstinence
over 12 months
8
8,000
4
4,000
0
0
MET/
MET/ CBT5
FSN
MET/ CBT5
ACRA
MDFT
CBT12
4.91
6.15
15.13
9.00
6.62
10.38
CPDA
CPPR
3,958
7,377
15,116
6,611
4,460
11,775
plt.05 effect size f0.48
plt.05 effect size f0.22
plt.05, effect size f0.72
plt.05, effect size f0.78
Source Dennis et al., 2004
43
What is Assertive Continuing Care (ACC)
  • A continuing care intervention that was
    specifically designed for adolescents following
    residential treatment
  • Increasingly, it is also being used following
    outpatient or other primary treatment
  • ACC clinicians use A-CRA procedures, but
    typically provide services in the home and
    increase case management activities

44
Assertive Continuing Care Motto
  • We cant help them if we dont see them!

45
Continuing Care Linkage and Retention During the
90 day CC Phase
94
10
54
2
Percent Linked
Median Number of Sessions
ACC
UCC
46
57 Higher Rate of Continuous Abstinence for ACC
(Cannabis)
100
Two months after residential, 58 in ACC vs. 40
in UCC still clean
At 9 months 4 out of 10 in ACC are still
abstinent vs. less than 3 of 10 in UCC
90
80
70
60
Percent Remaining Abstinent
50
ACC (n96)
40
30
UCC (n78)
20
10
0
0
30
60
90
120
150
180
210
240
270
Continuing Care Phase
Follow-up Phase
Days from Discharge
47
Unique Components of AAFT initiative
  • GAIN clinical certification
  • ABS software
  • Clinical supervisor certification process
  • Web-based tool for clinical and supervisory
    certification based on digital technology
  • Implementation calls paired with monthly
    implementation progress reports
  • Cultural responsiveness committee

48
Training Certification Process for A-CRA
49
Treatment Manual and Knowledge Test
A-CRA/ACC Technical Assistance
A-CRA/ACC Certification Requirements are clearly
delineated monitored
Record clinical and supervision sessions
Bi-Weekly Coaching calls
50
A-CRA Clinician CertificationRequirements
  • Take a knowledge test
  • Attend the 3.5 day training
  • Attend coaching calls
  • Participate in local supervision sessions
  • Enter session data
  • Demonstrate competency on 9 core
  • A-CRA procedures through DSR reviews

51
Supervisor Certification Requirements
  • Take a knowledge test
  • Attend the 3.5 day training
  • Attend coaching calls
  • Provide local supervision sessions
  • Demonstrate supervision skills during supervision
    sessions
  • Demonstrate ability to rate clinician DSRs

52
Upload Digital Session Recordings
53
Read Reviews
54
Sample Procedure Rating
1 2 3
4 5



poor needs satisfactory
very excellent

improvement good
Caregiver Overview, Rapport Building, and
Motivation 48. ____ ____ Provided an overview
of A-CRA 49. ____ ____ Set positive
expectations 50. ____ ____
Reviewed research regarding parenting
practices 51. ____ ____ Identified CG
reinforcers for continued work
52. ____ ____ Kept discussion (about adolescent)
positive
55
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56
Narrative Comments Are Also Provided
Assigned Homework The assignment for next week
is. Happiness Scale Good You gave a nice
rationale for the happiness scale! You explained
that he would rate his happiness in different
areas of his life and that his ratings would be
used to make short-term goals. It was great that
you mentioned that he would do several scales and
they would be used to assess progress. Good You
gave good directions for the scale. You explained
that he should rate his current happiness for
today on a scale from 1-10 (1-low, 10-high)Its
also good to mention that he should rate the
categories independently from one another. It was
good that you reviewed some of the ratings! For
legal issues and emotional life, you asked him
why he rated it the way he did. For emotional
life, you asked him what could improve his
ratings. Its important to do this with a number
of categories (a few that are rated very high,
some that are rated moderately, and some that are
rated very low). For each category, its
important to ask why he rated it the way he did
and what could improve his rating. Also, this
procedure should only take 15 minutes or so. It
seemed like you got stuck while going over the
emotional life category and spent the rest of the
session discussing this. Overall Stayed
Within ACRA Protocol You were behavioral,
supportive, and positive Overall Introduced
ACRA Procedures at Appropriate Times You
assigned homework General Clinical Skills You
were warm, nonjudgmental, and supportive
57
AAFT Performance Data
  • 2,137 Adolescents have been open to the project
  • 25,463 Sessions have been posted to EBTx
  • 2,726 Of DSRs have been rated with feedback to
    clinicians
  • 88 Clinicians have been certified
  • 31 Supervisors have been certified
  • Average of DSRs to certification is 21 range
    9 - 49
  • Average of months to certification is 9 range
    2.2 - 19
  • 261 of fidelity checks conducted 51 pass on
    first check, and 72 pass on the second check

58
Demographic Profile
Any Hispanic ethnicity separate from race group.
Source CSAT February 2009 AAFT GAIN Data Set
(n2,415)
59
Pattern of Weekly Use (13/90 days)
Source CSAT February 2009 AAFT GAIN Data Set
(n2,415)
60
Co-Occurring Psychiatric Problems
Source CSAT February 2009 AAFT GAIN Data Set
(n2,415)
61
Past Year Violence Crime
Notes \a Dealing, manufacturing, prostitution,
gambling (does not include simple possession or
use) \b 14 or more days on probation/parole
with urine monitoring
Source CSAT February 2009 AAFT GAIN Data Set
(n2,415)
62
Count of Major Clinical Problems at Intake\a
Median 4 Problems
Note \a Based on count of self reporting
criteria to suggest Alcohol, cannabis, or other
drug disorder, depression, anxiety, trauma,
suicide, ADHD, CD, victimization, violence/
illegal activity
Source CSAT February 2009 AAFT GAIN Data Set
(n2,415)
63
No. of Problems\a by Severity of Victimization
Severity of Victimization
Note \a Based on count of self reporting
criteria to suggest Alcohol, cannabis, or other
drug disorder, depression, anxiety, trauma,
suicide, ADHD, CD, victimization, violence/
illegal activity. OROdds Ratio relative to Low
Source CSAT February 2009 AAFT GAIN Data Set
(n2,415)
64
Performance (goal) Recruitment and Monitoring
Notes \a based on done divided by due minus
expected, plus same percent expected of those
still pending in window
Source CSAT February 2009 AAFT Management
Report (n2,415)
65
A-CRA/ACC Certification Progress
66
Performance (goal) Treatment Received
Targeted Improvement over general practice
Source CSAT February 2009 AAFT Management
Report (n2,415)
67
Performance Change Over Time in Selected Outcomes
Source CSAT February 2009 AAFT GAIN Data set
with 1 Follow-up (n1,732)
68
Outcome Status at Last Wave
Source CSAT February 2009 AAFT GAIN Data set
with 1 Follow-up (n1,732)
69
Comments from Therapists
  • thanks... the team has been awesome!! Brandi was
    always responsive and the web-based system was
    user friendly. I gave some feedback on our last
    conference call re possibly having separate
    calls for supervisors... other than this...TOP
    NOTCH! Will be in touch if any issues should
    arise moving forward. Be well and thanks
    again...
  • Thank you so much you all have helped me greatly
    with this process. I really appreciate the time
    and care you provide for all of us undergoing
    ACRA/ACC certification. I want you all to know
    that I felt fully supported from the beginning
    and I still feel that way today. There was
    always someone available to answer all of my
    questions and I never felt like I was alone in
    this process. I am very proud of this
    accomplishment and it is a wonderful feeling to
    be a part of the ACRA/ACC program. I am seeing
    first hand the opportunities and client
    empowerment this program provides for our youth,
    their families, and our community and it's
    amazing.

70
Summary
  • The CSAT Adolescent Treatment program has
    demonstrated the ability to replicate A-CRA and
    ACC approaches in community based settings
  • Both the GAIN and the A-CRA/ACC training and
    certification processes appear to be working well
    in AAFT based on numbers of staff achieving
    certification
  • Adolescents appear to like the intervention
  • Outcomes to date compare favorably to previous
    CSAT replication efforts and other CSAT funded
    initiatives

71
(No Transcript)
72
Monograph of CRA Research
73
Community Reinforcement and Family Training CRAFT
74
(No Transcript)
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