1. COMMUNITY REINFORCEMENT APPROACH 윤명숙 MSW, Ph.D. 전북대학교 사회복지학과 October 14, 2011

2. Principles of Effective Treatment 1. No single treatment is appropriate for all 2. Treatment needs to be readily available 3. Effective treatment attends to the multiple needs of the individual 4. Treatment plans must be assessed and modified continually to meet changing needs 5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness

3. Principles of Effective Treatment 6. Counseling and other behavioral therapies are critical components of effective treatment 7. Medications are an important element of treatment for many patients 8. Co-existing disorders should be treated in an integrated way 9. Medical detox is only the first stage of treatment 10. Treatment does not need to be voluntary to be effective

4. 11. Possible drug use during treatment must be monitored continuously 12. Treatment programs should assess for HIV/AIDS, Hepatitis B & C, Tuberculosis and other infectious diseases and help clients modify at-risk behaviors 13. Recovery can be a long-term process and frequently requires multiple episodes of treatment - NIDA (1999) Principles of Drug Addiction Treatment Principles of Effective Treatment

5. Evidence-Based Practices for Alcohol Treatment Brief intervention Brief intervention Social skills training Social skills training Motivational enhancement Motivational enhancement Community reinforcement Community reinforcement Behavioral contracting Behavioral contracting Miller et al., (1995) What works: A methodological analysis of the alcohol treatment outcome literature. In R. K. Hester & W. R. Miller (eds.) Handbook of Alcoholism Treatment Approaches: Effective Alternatives. (2 nd ed., pp 12 – 44). Boston: Allyn & Bacon.

6. Scientifically-Based Approaches to Addiction Treatment Cognitive–behavioral interventions Cognitive–behavioral interventions Community reinforcement Community reinforcement Motivational enhancement therapy Motivational enhancement therapy 12-step facilitation 12-step facilitation Contingency management Contingency management Pharmacological therapies Pharmacological therapies Systems treatment Systems treatment 1. L. Onken (2002). Personal Communication. National Institute on Drug Abuse. 2. Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug Abuse

7. Community Reinforcement Approach Basic assumptions Basic assumptions  Drug and alcohol use are positively reinforced behaviors. They can be reduced/eliminated by proper application of behavioral techniques.  To successfully build an effective intervention, some techniques should focus on reducing drug and alcohol use and others should focus on acquisition of new incompatible behaviors.

8. Community Reinforcement Approach Key concepts Key concepts  Behavioral analysis and teach conditioning information  Positive reinforcement with vouchers for drug free urine samples  Behavioral marriage counseling  Shape and reinforce new behavioral repertoire  Coping skill/Drug refusal skill training  Vocational Counseling  Frequent urine testing

9. 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)

10. Hunt & Azrin 1973 Inpatient Alcoholics Inpatient Alcoholics  job finding counseling  behavioral/marital therapy  social/leisure counseling  reinforcer access counseling  social club  home visits  [total 50 hrs per client]

11. Results: 6 month follow-up

12. Patients in outpatient treatment for alcoholism Patients in outpatient treatment for alcoholism Location: Illinois Location: Illinois Treatment: Community reinforcement approach Treatment: Community reinforcement approach Comparison: Traditional counseling Comparison: Traditional counseling Follow-up: 6 months Follow-up: 6 months Source: Azrin, N. (1976). Improvements in the community reinforcement approach to alcoholism. Behaviour Research and Therapy, 34:339-348. Investigator: Nathan Azrin

13. 6 Month Outcomes (Azrin) Drinking days reduced by 97%

14. 6 Month Outcome: CRA in New Mexico % Alcohol-free days Source: Meyers & Miller (2001). A community reinforcement approach for addiction treatment. Cambridge University Press.

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

16. CRA Outpatient Study (1982) Azrin, Sisson, Meyers, & Godley 43 outpatient alcoholics 43 outpatient alcoholics 3 groups: 3 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]

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

18. Evidence of Effectiveness: Meta-analyses & Reviews Holder et al. (1991)Miller et al. (1995) Social skills trainingBrief intervention Self-control trainingSocial skills training Brief motivational txMET Behavioral Marital tx CRA CRABehavioral contract Stress managementAversion tx

19. Evidence of Effectiveness (cont’d) Finney et al., 96Miller et al., 03Miller et al., 05 CRABrief InterventionCognitive-Behavioral Social skills trainingMETCRA Behavioral Marital txAcamprosateMI Disulfiram Implants CRARelapse Prevention Other marital txSelf-Change Social Skills Training Stress Management NaltrexoneBehavioral Marital Ther.

20. Adolescent CRA (ACRA): Godley et al. (2002) Continuing care study (after residential tx) Continuing care study (after residential tx) UCC (usual continuing care) or ACRA UCC (usual continuing care) or ACRA 114 adolescents (76% male) 114 adolescents (76% male) 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

21. ACRA Treatment Structure 10 Individual sessions with the adolescent 10 Individual sessions with the adolescent 4 sessions with the caregiver 4 sessions with the caregiver  2 individual sessions with the caregiver  2 sessions with the caregiver and the adolescent ACRA is procedure based, not session based ACRA is procedure based, not session based

22. Assumptions for ACRA For many adolescent marijuana users, their social environment encourages marijuana use For many adolescent marijuana users, their social environment encourages marijuana use The therapist needs to help the adolescent The therapist needs to help the adolescent  recognize that their drug use is incompatible with other short- or long-term reinforcers (e.g., parental approval, staying out of criminal justice system, having a girl/boy friend)  maximize family/peer/community resources and activities to reward non-drug using behavior  increase alternative positive, non-drug related social/recreational activities  developing social skills (e.g., problem solving, drug refusal, etc.) will increase the likelihood of success in these endeavors.

23. Key Concepts Positive and enthusiastic approach Positive and enthusiastic approach Uses lay language Uses lay language Keeps it simple Keeps it simple Flexible Flexible Uses role-playing Uses role-playing Uses homework Uses homework

24. Primary Goals Goals for Adolescents Goals for Adolescents  Promote abstinence  Participation in pro-social activities  Positive relationships with family  Positive relationships with peers Goals for Caregivers Goals for Caregivers  Motivate participation in ACRA  Promote adolescent’s abstinence  Positive communication and problem-solving skills  Promote critical parenting practices

25. Treatment Mechanisms Functional Analysis of Substance Use to identify the internal and external triggers that lead to substance use, document these behaviors and identify consequences of these behaviors. Functional analysis of pro-social behaviors that compete with substance use Skills training in relapse prevention, communication, problem solving, etc. Incorporation of above into a treatment plan Monitoring progress with the “Happiness” scale

26. Adolescent CRA (ACRA): Godley et al. (2002) Continuing care study (after residential tx) Continuing care study (after residential tx) UCC (usual continuing care) or ACRA UCC (usual continuing care) or ACRA 114 adolescents (76% male) 114 adolescents (76% male) 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

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

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

29. Common Mistakes Made When Implementing CRA Losing sight of client’s reinforcers Losing sight of client’s reinforcers Failing to involve concerned others in treatment Failing to involve concerned others in treatment Neglecting to emphasize the importance of having a satisfying social and recreational life Neglecting to emphasize the importance of having a satisfying social and recreational life Not stressing the necessity of having a meaningful job Not stressing the necessity of having a meaningful job

30. Common Mistakes Made When Implementing CRA Inadequately monitoring the client’s contact with triggers Inadequately monitoring the client’s contact with triggers Not checking for generalization of skills Not checking for generalization of skills Being reluctant to suggest the use of appropriate medications Being reluctant to suggest the use of appropriate medications

31. Community Reinforcement Approach Resources Resources  Meyers and Smith 1995  NIDA CRA Manual  Higgins and Silverman 2000

32. More Information on CRA Godley, S. H., Meyers, R. J., Smith, J. E., et al. (2001). The adolescent community reinforcement approach for adolescent cannabis users, Cannabis Youth Treatment (CYT) Series, Vol. 4. DHHS Pub. No. 01-3489. Godley, S. H., Meyers, R. J., Smith, J. E., et al. (2001). The adolescent community reinforcement approach for adolescent cannabis users, Cannabis Youth Treatment (CYT) Series, Vol. 4. DHHS Pub. No. 01-3489. Meyers, R. J. & Smith, J. E. (1995). Clinical guide to alcohol treatment: The Community Reinforcement Approach. New York: Guildford Press. Meyers, R. J. & Smith, J. E. (1995). Clinical guide to alcohol treatment: The Community Reinforcement Approach. New York: Guildford Press. Robert J. Meyers, Ph.D. & Associates, 505-270-6503. Visit webpage at http://robertjmeyersphd.com Robert J. Meyers, Ph.D. & Associates, 505-270-6503. Visit webpage at http://robertjmeyersphd.comhttp://robertjmeyersphd.com