Community Reinforcement Approach

Susan Harrington GodleyChestnut Health Systems

Bloomington, ILFunded 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

Goals of Presentation

Supporting Research

What is CRA?

Hunt & Azrin 1973

Inpatient Alcoholics job finding counselingbehavioral/marital therapysocial/leisure counselingreinforcer access counselingsocial clubhome visits [total 50 hrs per client]

Results: 6 month follow-up

0

20

40

60

80

Drink Days Jobless Days Days awayfrom family

Institution Separated/Div

Traditional CRA

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]

CRA new & improved: Results

0

10

20

30

40

50

60

70

Drink Days Jobless Days Days away fromfamily

Institution

Traditional CRA

CRA Outpatient Study (1982)Azrin, Sisson, Meyers, & Godley

43 outpatient alcoholics3 groups:

(1) traditional tx (2) traditional tx + disulfiram

compliance(3) CRA + disulfiram

compliance

increased use of positive reinforcement

sobriety sampling

drink refusal training

+/- functional analysis

job club

phone contacts

[Average: 5 sessions]

6 Month Follow-up (1982)

CRA + disulfiram compliance % days abs = 97%

Traditional + % days abs = 74% disulfiram compliance

Traditional % day abs = 45%

CRA with Homeless Alcohol-Dependent Individuals

CRAGroup Sessions

Problem-SolvingCommunication SkillsDrink-RefusalIndependent Living SkillsGoal Setting MeetingSocial ClubDisulfiram Compliance (for a sub-group)

Individual SessionsJob FindingCase Management

STANDARD TREATMENT

Day Treatment

12-Step Counselor

Job Service Program

VA Benefits Advisor

Drinks Per Week By Condition

Follow-Up Period

0

2

4

6

8

10

12

14

16

18

20

2 Month 4 Mont 6 Month 9 Month 12 Month

Median SECs

--- Standard

--- CRA

Percent Homeless By Condition

0

5

10

15

20

25

30

35

CRA

Standard

Follow-up Periods

2 Month 4 Month 6 Month 9 Month 12 Month

Percent

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

Evidence of Effectiveness (cont’d)

Finney et al., 96 Miller et al., 03 Miller et al., 05CRA Brief Intervention Cognitive-BehavioralSocial skills training MET CRABehavioral Marital tx Acamprosate MIDisulfiram Implants CRA Relapse PreventionOther marital tx Self-Change Social Skills TrainingStress Management Naltrexone Behavioral Marital Ther.

CRA Clinical TrialsHunt & 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)

What does not work!

Educational films and lectures

General alcoholism counseling

Process psychotherapy (individual or group)

Confrontational counseling

Antipsychotic medication

Insight therapy

If punishment worked, there would be few, if any,

alcoholics or drug addicts…

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)

CRA Session Structure

Been tested in clinical trials for 3-month period, but designed to be open-ended based on individual needsCan be combination of individual/group sessionsFrequency of sessions based on client’s motivation and progressAssessment and treatment planning used for all; skills training as needed

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)

Positive Reinforcer

What is a reinforcer?

How do I find one?

Does everyone have reinforcers?

How can I use them to help?

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 behaviorA healthy, fun behavior

Sobriety Sampling

Provide the rationale (Step 1)

The negotiation (Step 2)

Plan for Time-Limited Sobriety (Step 3)

Happiness Scale

Goals of Counseling: Setting Goals

Goals of Counseling contains the categories on the Happiness Scale

Guide the client’s 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

Skills Training

Communications Skills

Problem Solving

Drink/Drug Refusal

Job-Finding Skills

Assigning Homework

Refer to as “practice exercises”? An experiment?

Offer rationale

Get client’s input

Describe agreed-upon specific assignment

Ask about potential obstacles; problem-solve

Identify time for completing assignment

Review homework at next session

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

Drink/Drug Refusal Training

Review high-risk situations

Enlist social support

Refuse drinks/drugs assertively

Additional Relapse Techniques

CRA Functional Analysis for Relapse

Behavioral “chain” of events

Early warning monitoring system

Relationship Counseling

Self-Reminder to Be Nice

Common Mistakes Made When Implementing CRA

Losing sight of client’s 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

Common Mistakes Made When Implementing CRA

Inadequately monitoring the client’s contact with triggers

Not checking for generalization of skills

Being reluctant to suggest the use of appropriate medications

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.

CSAT’s Assertive Adolescent Family Treatment

Susan Harrington GodleyChestnut Health Systems

Bloomington, ILFunded by:

Center for Substance Abuse Treatment (TI11894 TI13356) National Institute on Drug Abuse (R01 DA 018183)

Goals

A-CRA vs. CRA

Assertive Continuing Care (ACC)

Technical assistance provided to grantees to learn the EBTs

Target population

Outcomes

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

Critical Parenting Practices

Good modelingIncrease positive

communicationMonitor the adolescent’s

whereaboutsInvolvement in

adolescent's life outside the home.

Based on the work of R. Catalano, H. Hops, & B.Bry

Similarity of Clinical Outcomes by Conditions

Source: Dennis et al., 2004

200

220

240

260

280

300

Tot

al d

ays

abst

inen

t.

over

12

mon

ths

0%

10%

20%

30%

40%

50%

Per

cent

in R

ecov

ery

.

at M

onth

12

Total Days Abstinent* 269 256 260 251 265 257

Percent in Recovery** 0.28 0.17 0.22 0.23 0.34 0.19

MET/ CBT5 MET/ CBT12

FSN MET/ CBT5 A-CRA MDFT

Trial 1 Trial 2

* n.s.d. effect size f=0.06

** n.s.d., effect size f=0.12

* n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16

Moderate to large differences in Cost-Effectiveness by

Condition

Source: Dennis et al., 2004

$0

$4

$8

$12

$16

$20

Cos

t per

day

of

abst

inen

ce o

ver

12 m

onth

s

$0

$4,000

$8,000

$12,000

$16,000

$20,000

Cos

t per

per

son

in r

ecov

ery

at m

onth

12

CPDA* $4.91 $6.15 $15.13 $9.00 $6.62 $10.38

CPPR** $3,958 $7,377 $15,116 $6,611 $4,460 $11,775

MET/ CBT5MET/

CBT12FSN MET/ CBT5 ACRA MDFT

* p<.05 effect size f=0.48** p<.05, effect size f=0.72

Trial 1 Trial 2

* p<.05 effect size f=0.22

** p<.05, effect size f=0.78

A-CRA did better than MET/CBT5, and both did better than MDFT

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

Assertive Continuing Care Motto:

We can’t help them if we don’t see them!

Continuing Care Linkage and Retention During the 90 day CC Phase

94%

54%

10

2

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percent Linked Median Number of Sessions0

2

4

6

8

10

12

ACC UCC

57% Higher Rate of Continuous Abstinence for ACC (Cannabis)

ACC (n=96)

UCC (n=78)

Perc

ent

Rem

ain

ing A

bst

inent

Days from Discharge

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 30 60 90 120 150 180 210 240 270

Continuing Care Phase Follow-up Phase

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

Unique Components of AAFT initiative

GAIN clinical certificationABS softwareClinical supervisor certification processWeb-based tool for clinical and supervisory certification based on digital technologyImplementation calls paired with monthly implementation progress reportsCultural responsiveness committee

Training & Certification Process for A-CRA

Bi-WeeklyCoaching calls

Upload session recordings & data to the

web;Get expert ratings andnarrative feedback

3.5-day centralized

training session

A-CRA/ACC Technical Assistance

A-CRA/ACC Certification Requirements are clearly delineated & monitored

Record clinical and

supervision sessions

Treatment Manual

and

Knowledge Test

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

Supervisor Certification Requirements

Take a knowledge testAttend the 3.5 day trainingAttend coaching callsProvide local supervision sessionsDemonstrate supervision skills during supervision sessionsDemonstrate ability to rate clinician DSRs

Upload Digital Session

Recordings

Read Reviews

Sample Procedure Rating1 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 practices51. ____ ____ Identified CG reinforcers for continued work

52. ____ ____ Kept discussion (about adolescent) positive

Narrative Comments Are Also Provided

Assigned Homework: The assignment for next week is…. Happiness ScaleGood: 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)…It’s 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. It’s 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, it’s 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…

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

Demographic Profile

10%

5%

5%

81%

6%

16%

32%

21%

31%

16%28%

78%

0% 20% 40% 60% 80% 100%

Outpatient Continuing Care

Long Term Residential

Intensive Outpatient

Outpatient

18 to 25 years old

15 to 17 years old

12 to 14 years old

Hispanic*

Mixed/Other

Caucasian

African American

Female

Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)

*Any Hispanic ethnicity separate from race group.

Pattern of Weekly Use (13+/90 days)

55%

14%

43%

2%

4%

6%

1%

52%

22%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Anything

Alcohol

Cannabis

Cocaine

Opioid

Other Drugs

Needle Use

Tobacco

Controlled Environment

Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)

Co-Occurring Psychiatric Problems

70%

51%

49%

39%

26%

12%

64%

46%

38%

20%

8%

42%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any Co-occurring Psychiatric

Conduct Disorder

Attention Deficit/Hyperactivity Disorder

Major Depressive Disorder

Traumatic Stress Disorder

General Anxiety Disorder

Ever Physical, Sexual or Emotional Victimization

High severity victimization (GVS>3)

Ever Homeless or Runaway

Any homicidal/suicidal thoughts past year

Any Self Mutilation

Prior Mental Health Treatment

Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)

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

83%

72%

63%

47%

45%

44%

86%

68%

36%

30%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any violence or illegal activity

Physical Violence

Any Illegal Activity

Any Property Crimes

Any Interpersonal/ Violent Crime

Other Drug Related Crimes \a

Lifetime Juvenile Justice Involvement

Current Juvenile Justice involvement

1+/90 days In Controlled Environment

Probation/Parole with Urine Testing\b

Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)

Three, 14%

None, 6%

Five to Twelve,

46%

Four, 13%

Two, 12%

One, 9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Count of Major Clinical Problems at Intake\a

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 (n=2,415)

Median = 4 Problems

14%

45%

71%

0%10%20%30%40%50%60%70%80%90%

100%

Low (OR 1.0)

Mod.(OR=5.0)

High(OR=15.0)

NoneOneTwoThreeFourFive+

No. of Problems\a by Severity of

Victimization

Severity of Victimization

Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)

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. OR=Odds Ratio relative to Low

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 (n=2,415)

100%

73%

80%

89%

87%

88%

100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Site Data Submission Ok to Good (80%+)

12 Month follow-up (80%+)\a

6 Month follow-up (80%+)\a

3 Month follow-up (80%+)\a

Session 2 Alliance (80%+)\q

Recruitment Rate (80%+)

Sites with 2+ Staff GAIN Certified or In processWithin Window (100% of Sites)

A-CRA/ACC Certification Progress

88

31

19

12

33

7

53

14

0 20 40 60 80 100 120

A-CRA Clinician

A-CRA Supervisor

ACC Clinician

ACC Supervisor

Staff

Certified In Progress

Performance (goal): Treatment Received

97%

87%

88%

86%

57%

100%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sites with 2+ Staff A-CRA Certified orPending (100% of Sites)

Evidenced Based Treatment (80%+) [ACRA 86%, ACC 10%, other 1%]

Treatment Initiation within 2 weeks (80%+)

Treatment Engagement of 4+ weeks (80%+)

Continuing Care for 90+ days (50%+)

ACC Linkage within 14 days (50%+)

Source: CSAT February 2009 AAFT Management Report (n=2,415)

Targeted Improvement over general practice

Performance: Change Over Time in Selected Outcomes

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 3 6 9 12

Months from Intake

Abstinence

No MentalHealth Problems

No IllegalActivity

No FamilyProblems

Source: CSAT February 2009 AAFT GAIN Data set with 1+ Follow-up (n=1,732)

Outcome Status at Last Wave

Source: CSAT February 2009 AAFT GAIN Data set with 1+ Follow-up (n=1,732)

63%

73%

38%

43%

99%

47%

90%

68%

14%

35%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Abstinent

Abuse/Dependence Sx

Physical Health

Mental Health

Nights of Psychiatric Inpatient

Illegal Activity

Arrests

Family/Home Problems

Recovery Environment Risk

Quarterly Cost to Society

Reduced 50% orNo ProblemNo Problem

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.

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

Monograph of CRA Research

Community Reinforcement and Family Training: CRAFT