Evidence-Based Treatment Community Reinforcement Approach (CRA) Robert J. Meyers, Ph.D. Jane Ellen Smith, Ph.D. University of New Mexico

Early CRA Studies Hunt & Azrin, 1973 Azrin, 1976 Azrin, Sisson, Meyers, & Godley, 1982

Hunt & Azrin 1973 inpatient alcoholics inpatient alcoholics job finding counseling job finding counseling behavioral/marital tx behavioral/marital tx social/leisure counseling social/leisure counseling reinforcer access counseling reinforcer access counseling social club social club home visits home visits [total 50 hrs per client] [total 50 hrs per client]

Results: 6 month follow-up

Azrin 1976: New & Improved CRA inpatient alcoholics inpatient alcoholics disulfiram w/compliance protocol disulfiram w/compliance protocol problem prevention rehearsal problem prevention rehearsal buddy system buddy system early warning mood monitoring some group tx ~70% as aftercare home visits [Average 30 contact hrs]

CRA new & improved: Results

1 st CRA Outpatient Study (Azrin, Sisson, Meyers, & Godley, 1982) 43 outpatient alcoholics 43 outpatient alcoholics 3 groups: 3 groups: traditional tx only traditional tx only traditional tx + disulfiram compliance traditional tx + disulfiram compliance CRA only CRA only increased use of positive reinforcement sobriety sampling immed. disulfiram drink refusal training +/- functional analysis job club phone contacts [Average: 5 tx sessions]

Results of 1982 study 6 month follow-up Disulfiram only group% days abs = 74% CRA +% days abs = 97% Traditional group% day abs = 45%

CRA with Homeless Alcohol- Dependent Individuals PI: Jane Ellen Smith Co-PI: Robert J. Meyers Funded by:NIAAA

Primary Questions Addressed: Is CRA > a day shelter’s standard program for treating drinking problems among homeless individuals? Is CRA > a day shelter’s standard program for treating drinking problems among homeless individuals? What are the effects of the 2 treatments on the non-drinking variables (employment, housing)? What are the effects of the 2 treatments on the non-drinking variables (employment, housing)?

CRA Group Group Sessions Problem-Solving Problem-Solving Communication Skills Communication Skills Drink-Refusal Drink-Refusal Independent Living Skills Independent Living Skills Goal Setting/Community Meeting Goal Setting/Community Meeting Social Club Social Club Disulfiram Compliance Disulfiram Compliance Individual Sessions Job Finding Job Finding Case Management Case Management Couples Therapy Couples Therapy

Standard Treatment Group Day Shelter Program Day Shelter Program Project Share Project Share Alcoholics Anonymous Meetings Alcoholics Anonymous Meetings 12-Step Counselor 12-Step Counselor Job Service Program Job Service Program VA Benefits Advisor VA Benefits Advisor Project CARE Project CARE

Grant-Provided Housing All participants were housed All participants were housed Normal stay: 3 months Normal stay: 3 months Extended stays: if job and $ saved Extended stays: if job and $ saved Random breathalyzer tests Random breathalyzer tests

Drinks Per Week By Condition Follow-Up Period 2 Month 4 Mont 6 Month 9 Month 12 Month Median SECs --- Standard --- CRA

Percent Homeless By Condition CRA Standard Follow-up Periods 2 Month 4 Month 6 Month 9 Month 12 Month Percent

Percent Employed By Condition CRA Standard Percent Follow-up Period Intake 2 Month 4 Month 6 Month 9 Month 12 Month

Limitations of the Study Not comparable “doses” of treatment Not comparable “doses” of treatment Some CRA participants still drinking heavily Some CRA participants still drinking heavily Only moderate improvement in employment Only moderate improvement in employment Cost of housing Cost of housing

CRA with Homeless Alcoholic Women Why women only? Why women only? Treatments: Treatments: (1) Case Management (2) CRA (3) CRA + contingency-managed computer training

Summaries of Adult Treatment Research for Alcohol Use Disorders Meta-analyses and Reviews

Evidence of Effectiveness: Meta-analyses Holder et al., ’91Miller et al., ’95 Social skills trainingBrief intervention Self-control trainingSocial skills training Brief motivational txMET Behavioral Marital tx CRA CRABehavioral contract Stress managementAversion tx

Evidence of Effectiveness (cont’d) Finney et al., ‘96Miller et al., ’03 CRABrief Intervention Social skills trainingMotivational Enhancement Behavioral Marital txAcamprosate Disulfiram Implants CRA Other marital txSelf-Change (bibliotherapy) Stress Management Naltrexone

CRA for Illicit Drugs: Adult Studies Cocaine Higgins et al. (1991; 1993; 1994; 1995; 2000) Heroin Bickel et al. (1997) Abbott et al. (1998)

Adolescent CRA

Godley et al. (2002) Continuing care study (after residential treatment) Continuing care study (after residential treatment) UCC (usual continuing care) or ACRA + case mgmt UCC (usual continuing care) or ACRA + case mgmt 114 adolescents 114 adolescents 90% = marijuana dependent at intake 90% = marijuana dependent at intake 57% = alcohol dependent 57% = alcohol dependent 82% = involved w/ juvenile justice system 82% = involved w/ juvenile justice system

Results: 3 months ACRA significantly > UCC in terms of: abstinence from marijuana abstinence from marijuana reduced alcohol use reduced alcohol use

Cannabis Youth Treatment (CYT) Study (Dennis et al., 2004) Outpatient treatment for marijuana Outpatient treatment for marijuana Trial 1:MET/CBT5; MET/CBT12; FSN Trial 1:MET/CBT5; MET/CBT12; FSN Trial 2: MET/CBT5; ACRA; MDFT Trial 2: MET/CBT5; ACRA; MDFT 600 adolescents 600 adolescents Hi rate of illegal activities Hi rate of illegal activities

Results: 12 months Measures: (1) days of abstinence (from drugs & alcohol) (2) “in recovery” = living in community (not jail) + no use + no past month substance problems no use + no past month substance problems General Findings: All treatments significantly improved pre-post; no significant tx comparison differences

Best overall “in recovery” rates = ACRA (34%; next best = MET/CBT5 at 27%) Best overall “in recovery” rates = ACRA (34%; next best = MET/CBT5 at 27%) Best # of abstinent days for Trial 2 = ACRA (73% of days during the year; best for Trial 1= MET/CBT5 at 74%) Best # of abstinent days for Trial 2 = ACRA (73% of days during the year; best for Trial 1= MET/CBT5 at 74%) Most cost-effective? ACRA Most cost-effective? ACRA

UNM CASAA’s Street Youth Program: Project STAR

Percent days of substance use Significant interaction between time (pre to 6 months) and group using number of treatment sessions as covariate (F (1, 81) = 9.10, p <.01).

Percentage of days off the street Percentage of days off the street Trend toward interaction between time (pre to 6 months) and group using number of treatment sessions as covariate (F (1, 81) = 3.09, p =. 08).

What does not work! Educational films and lectures Educational films and lectures General alcoholism counseling General alcoholism counseling Psychotherapy Psychotherapy Confrontational counseling Confrontational counseling Antipsychotic medication Antipsychotic medication Psychotherapy, group process Psychotherapy, group process Insight therapy Insight therapy

Why Isn’t CRA Used More? Disease Model Disease Model Limited accessibility Limited accessibility It’s hard to teach an old dog new tricks It’s hard to teach an old dog new tricks “We already do that” “We already do that” CRA isn’t “sexy” CRA isn’t “sexy”