This article is featured in the June 2017 issue of the Substance Dependence Treatment Review
The Community Reinforcement Approach (CRA) is backed by strong evidence for its effectiveness, and is listed amongst the top methods of treatment. Nevertheless, many clinicians who treat alcohol dependency are unfamiliar with the approach. This is despite the fact that CRA was put forth in its first clinical trials over 40 years ago. Since its introduction in 1973 by researchers Hunt and Azrin, CRA has evolved into a treatment approach that includes spouses, family members and drug dependent individuals.1
Hunt and Azrin created the community reinforcement approach as a means to restructure a patient's place in the community, so that a sober lifestyle was more conducive and rewarding. The core idea is that alcohol dependency cuts the dependent drinker off from sources of life satisfaction and fulfillment, namely: home, work, and personal relationships.2
The research team worked under the premise that recovery from alcohol dependency must include changes in a person's social and occupational environment. Some elements in the alcohol dependent person could encourage further alcohol use, and others could discourage it. In the first and subsequent studies, community reinforcement included family, social, occupational, and recreational reinforcers to promote change in the individual's life. The results showed that alcohol dependent people who received community reinforcement drank less, worked more, spent extra time with family and stayed out of institutions, than a control group of alcohol dependent people that were not given CRA.
The approach of community reinforcement is simple: in order to overcome a dependency to alcohol, a person's life must be reconstructed, or rearranged, so that abstinence, which is more rewarding than alcohol dependency, comes back into the forefront. In essence, the objective is to identify and carry out contingencies in which the sober behavior becomes more enjoyable than the drinking behavior. Through re-asserting proper connections and relations in a person's life, sober fulfillment can once again be achieved.
To provide a problem drinker with an incentive to quit drinking, CRA has two objectives:
- The elimination of positive reinforcement for drinking and associative behaviors, and
- The enhancement of positive reinforcement for a sobriety
To reach these objectives, a community reinforcement therapist will construct a plan that includes several treatment strategies, which may include:
- Increasing the patient's motivation to discontinue alcohol consumption,
- Initiating a time, or period, to practice sobriety,
- Performing a functional analysis of the patient's behavior,
- Increasing positive reinforcement through a broad range of practical techniques,
- Practicing newly learned coping mechanisms and behaviors, and
- Encouraging family member and significant others to take part in the therapy.
The outcome of CRA may also reflect upon any treatment components used as well as the therapist's style and intensity of the initial approach. Community reinforcement may also implement interventions, cognitive behavioral therapy and pharmacological assistance. 3
A CRA operant method that involves a voucher based incentive to promote sobriety could be incorporated into treatment. These vouchers, given by the therapist and significant others, are then exchanged for services or retail items.
The Reinforcing Alienation Effects of Alcohol
The effects that a user experiences from alcohol or drugs are highly reinforcing, and may lead to alienation or isolation from sobering sources of fulfillment. As time proceeds, the overall effects can directly motivate the alcohol dependent person to continue drinking. This puts them at further risk for dependency, and other problems. This kind of reinforcement has led to many people asking what could help a dependent drinker to give up their consumption of alcohol, and be okay with that decision.
A common approach to instill the effects or consequences of drinking is through direct, often uncomfortable confrontations, and social violations that attempt to make alcohol less attractive. Aversion therapies, medications, counselling, and an infliction of consequences, may be included in this approach.
However, such approaches might be taken negatively by the alcohol dependent person, and may not be effective in alleviating the problem. In fact it could turn a problem drinker completely away from getting the treatment they need. This is an understandable reaction to a sense of betrayal.
An alcohol dependent person may even go to great lengths to access alcohol, and continue on a dangerous, self-destructive path. Some addiction professionals say that if punishment or harsh confrontations actually worked, there would virtually be no alcohol dependent people. CRA eliminates this mindset, and includes an approach that is based on providing incentives to decrease the drinking, rather than punishment. When practiced, the patient, therapist, and significant others, work together to make healthier, more positive changes in their life, including positive activities, social support, focus on a fulfilling job, encouraging family relations, etc.
Drinking Behaviors Identified by the CRA Therapist
Community reinforcement relies heavily on functional analyses performed by a therapist. First the internal and external antecedents or triggers associated with the desire to drink are identified. Internal triggers can be the person's thoughts and feelings that contribute to the desire to drink. Often it is apparent that alcohol is consumed because it induces positive feelings such as happiness, relaxation or confidence.
It might also be consumed when a person wishes to temporarily avoid dealing with unpleasant thoughts associated with anger, anxiety or sadness. 4 The therapist accepts these drinking-related thoughts and feelings as being valid, but then helps the patient find healthier ways to achieve these objectives without drinking.
Next, the therapist may help the patient to identify external triggers such as people, places, and times of the day which can be linked to excessive drinking. Often considered to be high-risk situations, these situations will be addressed later in treatment, after the patient has begun to feel more comfortable without alcohol.
Once internal and external triggers are discovered, the drinking behaviors are examined. These may include the type and amount of the beverage as well as short-term positive after-effects of consumption, as they are linked to the continuation of the problem.
Finally the negative consequences, both short and long term, of the drinking behavior are examined. Also known as the costs of drinking, these can include the loss of a job, legal problems, relationship woes, and so forth. Once all of these factors are examined, a therapist will work alongside the patient to develop preliminary ideas which can generate new behavioral repertoires that can replace the desire to drink. In general, as the patient understands how drinking reinforces negative behaviors and an overall time out from family, friends, work and social situations, they can begin to explore the benefits of sobriety as well as alternative approaches of reinforcement.
Popularity of Community Reinforcement Approach
Although community reinforcement has been around for several decades, it has never actually gained momentum amongst the addiction treatment community. Many rehab centers prefer to take a 12 step or holistic approach without considering the positive attributes of CRA and how it could act as a complementary treatment method. While it is unknown as to why community reinforcement is largely underutilized, likely to do with limited training opportunities and the idea that many therapists believe they are already implementing CRAs techniques in behavioral therapy sessions.5
In, CRA requires a significant amount of time and dedication from not only the dependent individual, but also the therapist and their loved ones, friends, and possibly workplace. Finally, in the U.S., many alcohol programs do not put too much significance on the social context of dependency. Consequently, social reinforcement contingencies are generally not well regarded.This mindset does not hold true across international borders which is why one can find a small number of CRA practitioners and programs in countries such as Sweden, Germany, England and Ireland. Because this treatment approach has so much success in clinical trials, it is with hope that methods of education and dissemination can be developed. More clinicians should become familiar with and use community reinforcement techniques.
Criticism of the Community Reinforcement Approach
It is difficult to locate direct criticisms of community reinforcement. However, there are noted limitations to the approach. Very little is known about the actual comparative value of elements associated with CRA. For example, it is unclear as to which techniques within CRA are the most effective, which are absolutely necessary, and which have less of an impact. On the other hand, certain kinds of holistic models are difficult to tease apart, and interaction effects may mean the whole is more effective than the sum of its parts.
Similar Treatment Approaches to CRA
Community reinforcement has been used by addiction and mental health professionals to help people find healthier, sober alternatives to drinking. Apart from CRA, other similar therapies have been used to assist alcohol dependent people and their families communicate better and generate a life that is more rewarding than alcohol.
The goal of motivational interviewing is to encourage less drinking (or drug use) and more follow-through treatment. This collaborative approach includes a therapist who will create practical conditions that rapidly motivate patients and help them to become committed to making a positive change. In this treatment, the therapist remains highly empathetic and supports the patient in their own ability to reach goals and aspirations. Motivational interviewing builds upon various optimistic theories about people's capabilities to exercise freedom of choice as well as change through a process of self-actualization. It does not include argumentation or coercive techniques that could be detrimental to a patient's state of mind and willingness to change.
One on One Addiction Therapist
Sometimes an alcohol dependent person, or their family members, will choose to work with an individual addictions therapist. This professional might employ various techniques including cognitive behavioral therapy, life skills, humanistic therapy and integrative therapy to encourage treatment and sobriety. In addition to this, one on one (1-to-1) therapy can address various concerns that arise when dealing with dependency. Depression, stress, anxiety and fear resulting from the situation might be identified and dealt with in the healthiest manner possible. The group model of many inpatient and outpatient addiction rehabs may be inefficient in many cases.
A one on one approach elicits change through direct help from a professional who is well versed in helping people with alcohol or drug dependencies. Sessions can also identify emotional and mental stressors that could be a contributing factor to using. An addiction therapist may not be able to help family members and the likelihood of CRA or CRAFT being used is uncertain.
CRA in the Treatment of Drug Abuse
The community reinforcement approach has been used to treat dependency to drugs including opiates. Researchers at CASAA carried out a trial in which heroin addicts receiving methadone maintenance therapy were divided into two groups.6 One group received CRA treatment and the other traditional therapy. Both resulted in positive outcomes; however, the CRA treatment statistically had a significant advantage. Further studies on the effects of CRA on cocaine dependency also found better outcomes in sobriety when compared to those receiving standard treatment.
CRA for Family Members - CRAFT
An alcohol dependent person is not the only one who may benefit from the community reinforcement approach. Family members can partake in a subsidiary method called CRAFT, or Community Reinforcement and Family Training. CRAFT is an intervention model for the significant others who are reluctant to engage in treatment.7
In addition to improving communication and problem solving skills, a CRAFT therapist teaches family members how to mindfully respond to a loved one's dependency and sobriety. For instance, they will learn to reward any behavior associated with sobriety and fail to reward those related to substance use. This approach is consistent with operant conditioning and also prevents the family from enabling the drinking behavior.
CRAFT was pioneered and developed at the University of New Mexico by Robert Meyers, Ph.D. and his team of colleagues. Their initial research shows approximately 70% of families that had been taught the CRAFT model were able to get their alcohol dependent loved one into treatment within one year.8
CRAFT also works with family members to enhance their own emotional and mental well being by rewarding themselves for participating in healthy, fun activities. As a treatment method overseen by a CRAFT therapist, it offers empirical support and has been found to outperform other methods such as a standard family intervention, Al-Anon and Nar-Anon.
Advantages of CRAFT
- CRAFT has been well researched and shows consistent results
- It teaches practical skills
- CRAFT takes a proactive approach to helping a loved one get treatment
- Family members are not required to detach from the dependent person
- CRAFT is positive and focuses on what family members and the alcohol abuser is doing right rather than wrong
Disadvantages of CRAFT
- CRAFT is not ideal for people who believe harsh confrontation is the best way to help someone
- The philosophy of CRAFT is very different from many 12 step approaches which can turn certain people away from the treatment model
- CRAFT does not offer weekly support meetings
- Learning CRAFT takes time and dedication, and often requires individual sessions with a therapist which could be a financial burden to some
Integrating CRA into Aftercare Treatment
Currently there is very little information, particularly backed by research, that addresses community reinforcement in aftercare. It is safe to say however that because this method is very successful, it could be a useful complementary therapy to ward off any triggers or desires to engage in drinking. An individual in recovery may benefit from attending private CRA therapy sessions that are guided by a trained therapist. Typically lasting between 60 and 90 minutes, these sessions would address issues such as:
- Improving communication skills
- Improving problem solving skills
- Improving social and familial relationships
- Improving job skills
- Learning how to refuse alcohol (or drugs)
- Creating a better, happier, sober life
- Building a strong network of support
- Boosting confidence and self esteem
By refining these basic, yet important, life affairs, the recovering individual can learn how to enjoy sobriety. Moreover, he or she will have the confidence to embrace such matters without irrational fears or objectives. Ideally, the outcomes of implementing the CRA framework into an aftercare program should be further tackled by professionals within the field of study.
Conditions for Effective CRA-Based Treatment
Community reinforcement is most ideal when a dependent person has the desire to discontinue their drinking behaviors. While they do not necessarily have to know how to do this, there should be a will to change. A lack of this mindset could make it difficult to get the individual to realize and understand the social impact of their drinking.
It will also be advantageous for the alcohol dependent person to have some kind of support; either from family, close friends or even co-workers. Working with these people is an integral part of CRA, and lacking it, could hinder the effectiveness of the treatment.
That being said, community reinforcement might benefit any problem drinker who is in need of improving their overall confidence within society. Therefore, it is a method of therapy which should be heavily considered by anyone wishing to reconstruct their life in a more positive manner, and without the need or desire to drink.
This article is featured in the June 2017 issue of the Substance Dependence Treatment Review
Miller, Meyers, & Tonigan: Engaging the Unmotivated in Treatment for Alcohol Problems ↩