community reinforcement approach (cra) robert j. meyers, ph.d. & jane ellen smith, ph.d....
TRANSCRIPT
Community Reinforcement Approach (CRA)
Robert J. Meyers, Ph.D.
& Jane Ellen Smith, Ph.D.
University of New Mexico
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 Induction & Overview: 1st Session
Build rapport, build rapport, build rapport
Stay client focusedUse positive reinforcementBegin to establish “reinforcers” (e.g., internal or external
motivators?)
CRA Induction & Overview (cont’d)
Set positive expectations: CRA has proven efficacy (scientific backing)
Explain that treatment is time limited Emphasize independence Clarify assessment information (how
can this be useful in treatment planning?)
Positive Reinforcer
What is a reinforcer?
How do I find one?
Does everyone have reinforcers?
How can I use them to help?
CRA Overview: Clinicians’ Problem Areas
**Refer to CRA Procedures Checklist Giving a clear, concise description of
CRA’s basic objective/theory Starting to identify reinforcers
Functional Analysis (F.A.)
Semi-structured interview that examines the antecedents & consequences of a behavior
A “roadmap”2 kinds of F.A.s
F. A. for Substance-Using Behaviors
Objective: to work toward decreasing or stopping the problem behavior
F.A. Procedure: – outlines individual’s triggers for substance
use– clarifies consequences (positive &
negative) of substance use for client
F. A. of Substance Use: Initial Assessment
External triggers– who, where, when
Internal triggers– thinking, feeling (emotionally,
physically) Short term positive consequences Long term negative consequences
Case Example
22 year-old single male who presented with concern over his Sat. night drinking; appeared depressed over break-up with girlfriend (2 years prior)
External triggers
Who are you usually with when you drink?– Marcello, Dale, & James
Where do you usually drink?– Marcello’s house
When do you usually drink?– Saturday night
Internal triggers
What are you usually thinking about right before you drink?– I need to relax. I deserve some fun for
working so hard. I’ll fit in because I’ll be drinking
What are you usually feeling physically right before you drink?– Exhausted
What are you usually feeling emotionally right before you drink?– Pleased with self. A little sad.
Drinking behaviors
What do you usually drink?
– Beer How much do you usually drink?
– 7-8 12 oz. bottles Over how long a period of time do you
usually drink?
– 3 hours
Short-term positive consequences
What do you like about drinking with (who)?– We laugh a lot. They think I’m funny.
What do you like about drinking (where)?– I don’t have to drive so far. It’s informal; I can be
myself.
What do you like about drinking (when)?– It’s a good way to unwind after working all day.
Positive consequences (cont’d)
What are the pleasant thoughts you have while drinking?– These guys think I’m funny and they like
having me around. What are the pleasant physical feelings you
have while drinking?– I feel relaxed
What are the pleasant emotions you have while drinking?– Feeling “high”, happy, content
Long-term negative consequences
What are the negative results of your drinking in each of these areas:– Interpersonal: “I only seem to have friends
who drink. I haven’t put any effort into finding a romantic relationship lately.”
– Physical: “I don’t sleep well Saturday night and I usually feel terrible Sunday.”
– Emotional: “I feel lonely. I don’t know if it’s related to drinking.”
Negative consequences (cont’d)
Legal: “No problems, but I worry about getting a DWI.”
Job: “The Saturday drinking doesn’t affect this, but my weekday drinking may be starting to.”
Financial: “No problems here.” Other: n/a
Functional Analysis Practice
Partner-up: 2 people Therapist & Client
– Don’t try to do the whole FA form– Client may also have F.A. sheet – Do try to “get the story” rather than just
filling in the blanks– Use your own style of interviewing– Don’t play the client from Hell!
Group Debriefing
Functional Analysis for Substance Use: Clinicians’ Problem Areas
**Refer to CRA Procedures Checklist Giving a rationale for doing a F. A. Remembering to 1st ask for a
description of a common episode Explaining how the information will be
used in treatment planning
Functional Analysis for Pro-Social, Healthy Behaviors
Objective: to work toward increasing the healthy behavior
F. A. Procedure:– outlines the factors that “set the stage” for
the individual to decide to engage in a healthy behavior
– clarifies consequences (negative & positive) of the healthy behavior for the individual
F.A. for Pro-social Behavior (cont’d)
Remember to: Use a pro-social behavior that is
occurring occasionally alreadyUse a behavior that is both healthy
and FUNHelp identify & address roadblocks
before they happen
Case Example (cont’d)
Same client; sometimes he chose to go to his brother’s house for dinner on Sat. nights instead of playing cards & drinking with friends.
F. A. for Pro-social, Healthy Behaviors
What is your non-drinking activity?– Dinner at brother’s house; video
afterwards. How often do you engage in it?
– About once a month. How long does it usually last?
– About 3 hours.
External triggers
Who are you usually with when you (activity)?– My brother, Charles, his wife, Jill, and their two
boys.
Where are you usually (activity)?– Their home
When do you usually (activity)?– They invite me most Saturday nights. I go only
occasionally.
Internal triggers
What are you usually thinking about right before you (activity)?– This is a good way to spend the evening.
It’s something to do. It’s nice to get to know my nephews. I hope nobody bugs me about my social life.
Internal triggers (cont’d)
What are you usually feeling physically right before you (activity)?– I don’t know. Mostly relaxed I guess.
What are you usually feeling emotionally right before you (activity)?– Calm, content, but a little disappointed that
I won’t be drinking. Then ashamed for feeling that way.
Short-term negative consequences
What do you dislike about (activity) with (who)?
-It gets really noisy sometimes. Once in a while I get interrogated about whether I’m dating…
What do you dislike about (activity, where)?-Nothing
What do you dislike about (activity, when)?-It’s not as much fun as drinking & playing cards.
What are the unpleasant thoughts you have while (activity)?-Am I ever going to have my own family? I’m getting old and time is passing me by.
What are the unpleasant physical feelings you have while (activity)?-My stomach gets upset sometimes because I eat so much there...
What are the unpleasant emotions you have while (activity)?-Disappointment in myself for not having things together in my life
Long term positive consequences
What are the positive results of (activity) in each of these areas:– Interpersonal: “It brings me closer to my family. I
get to be a part of my nephew’s lives.”– Physical: “It’s healthier than drinking all night. I feel
better in the morning.”– Emotional: “My nephews look up to me and are
always thrilled to see me. That feels really good.”
Positive consequences (cont’d)
What are the positive results of (activity) in each of these areas:– Legal: No chance of a DWI.– Job: My brother and his wife help me sort
out job related problems.– Financial: I don’t lose money like I do at
cards.– Other: n/a
F. A. for Pro-Social Behavior: Clinicians’ Problem Areas
Making sure from the start that the behavior is already occurring and is fun
Giving an explicit homework assignment regarding the pro-social behavior
Sobriety Sampling: Rationale
enables client to set reasonable & attainable goals
teaches self-efficacy when goals are met
provides “time-out” from drinking so client can experience sensation of being sober
Sobriety Sampling (cont’d)
disrupts old habits, giving chance to replace with new positive coping skills
builds family support & trust identifies relapse-prone areas
The Negotiation
Suggest a LONG period (90 days?) Tie in reasons for such a period (high
relapse time; client’s reinforcers?) Expect that the client will negotiate
downward Settle on a period of time; be sure it
extends at least to the time of your next session
Planning for Time-limited Sobriety
Load up sessions Don’t rely on past unsuccessful methods Identify biggest threats to sobriety Select alternative coping strategies Develop back-up plans Remind client of reinforcers Use positive reinforcement
Exercise
Practice Sobriety Sampling (including the part about HOW the client is going to make it to the next session without using) in dyads with 1 person playing the therapist & the other playing the client.
Sobriety Sampling: Clinicians’ Problem Areas
Discussing several of the advantages of a period of sobriety
Making the plan for achieving sobriety very specific
Advantages of Disulfiram
less family worry/ more family trust fewer “slips”better able to address many
triggers at oncemore productive therapy timemore reliance on other coping skills
Advantages of Disulfiram (cont’d)
improved self-confidence fewer complicated, agonizing daily
decisionsmore chances for positive
reinforcement increase in available early warning
signs
Advantages of Naltrexone
effective alternative to disulfiram reduces urges & cravingsblocks the “high” from drinkingno adverse effects while drinking
–some evidence of drinkers experiencing negative physical effects without the “high”
Compliance (Monitor) Protocol
any concerned significant other supportive, not punitive role set time & place, make it a pleasurable
event use positive reinforcement during ritual put in water, dissolve, stir until
thoroughly mixed, give to person, praise one another for involvement
Medication Monitoring: Clinicians’ Problem Areas
Setting up a monitoring plan Bringing in the monitor to practice
Treatment Planning
2 parts: Happiness Scale and Goals of Counseling
Ask the client what she/he wants
Use a positive approach
Keep in mind the client’s reinforcers
Happiness Scale
Drinking/sobriety Job/education Money
management Social life Personal habits Marriage/family
relationships
Legal issues Emotional life Communication Spirituality General
happiness
Goals of Counseling (Treatment Plan)
In general: set relatively short-term goals that are scheduled to be complete in about a month
Then develop a step-by-step weekly strategy (intervention) for reaching the goal
The strategy = the “homework” for the week
Guidelines for Goal Setting
Goals (and their strategies) should be: Brief (uncomplicated) Positive (what will be done) Specific behaviors (measurable) Reasonable Under the client’s control Based on skills the client already has
Goals of Counseling: Potential Problems
Applying the 3 basic rules (brief, positive, specific) to “real life” problems. Designing goals & strategies that are too
complex. Leaving out important steps necessary to
reach goals. Including plans that are not under the client’s
control. Unnecessarily putting the client in a high-risk
situation.
What’s wrong with these goals?
I don’t want to drink anymore!I’ll apply for 10 jobs tomorrow!I’ll have a job tomorrow!I’ll try harder to save money.I’ll go out on a date with 3
different women next week.
What’s wrong with this goal?
I am going to attend 1 AA meeting next week - at the St. Agnes church at 8:00 pm on Tuesday night.
Exercise
Complete a Happiness Scale with your “client”
Then with your client select 1-2 categories she/he wants to work on
Develop a Treatment Plan using the selected categories
Remember the “Potential Problems” when designing a Treatment Plan
Debrief with group
Happiness Scale & Goals of Counseling: Clinicians’ Problem Areas
Providing a rationale for the Happiness Scale
Setting goals & strategies that are very specific
Skills Training
Communication skills/assertiveness training
Drink/drug refusal
Problem Solving
Job-finding skills
Anger management
Role-Playing Guidelines
Acknowledge discomfort Use less difficult scenes first Get adequate description of the scene Start it for them Keep it brief (2-3 minutes) Reinforce any effort Get client’s reactions Offer supportive, specific feedback Repeat
Communication Training
Why work on communication? More likely to get what you want Positive communication is “contagious” Will open door to more satisfaction in
other life areas as well (social support) Positive communication is the
foundation for other CRA procedures
Positive Communication Skills
Be brief Be positive Be specific and clear Label your feeling: “I feel ___” Offer an understanding statement Accept partial responsibility Offer to help
Exercise
Practice communication in dyads; one plays the therapist & the other plays the client. Be sure to do role-plays as part of the communication training.
Communication Skills: Clinicians’ Problem Areas
Involving the client in the process when generating examples of each of the 7 components
Role-playing! Providing specific feedback, and then
repeating the role-play
Homework Guidelines
refer to “practice exercises” offer rationale for assignment describe specific assignment carefully; their
input? ask about possible obstacles, problem-solve identify time for completing assignment review homework at start of next session reinforce any compliance
Systematic Encouragement
Never assume a client will make 1st contact independently
Practice in session [It gives an opportunity to observe skill level]
Use sampling as part of the strategy Locate & speak to a contact person in
advance for the activity Review the experience in the next session
Drink/Drug Refusal Training
Enlist social supportReview high-risk situationsRefuse drinks/drugs assertivelyOptional: Restructure negative
thoughts
Assertive Drink/Drug Refusal [always watch body language!]say, “No, thanks.” (without guilt!)suggest alternativeschange the subjectaddress the aggressor directly about
the issue leave
Drink/Drug Refusal: Clinicians’ Problem Areas
Taking time to identify social support Providing specific feedback and
repeating the role-play
Problem Solving
(1) Define problem narrowly
(2) Brainstorm possible solutions
(3) Eliminate undesired suggestions
(4) Select one potential solution
(5) Generate possible obstacles
(6) Address each obstacle
(7) Assign task
(8) Evaluate outcome
Problem Solving: Clinicians’ Problem Areas
Narrowing down the problem sufficiently Generating potential obstacles &
addressing them
Social/Recreational Counseling
discuss importance of healthy social life identify areas of interest reinforcer sampling community access systematic encouragement reinforcer access response priming social club
CRA’s Job Findinga disciplined, step-by-step
approach to helping clients get and keep satisfying employment.
Job Finding: Key Elements development of a resume instructions on how to fill out a job application utilization of relatives, friends, & phone book to
generate job leads instructions in telephone techniques to secure
interviews rehearsal on the interview process [video
camera if possible] information on how to keep a job
CRA’s Relapse Prevention
Relapse prevention really starts the 1st day of treatment
There are some specific relapse prevention strategies too
Recovery Maintenance Strategies:Marlatt and Gordon RP Model
Characteristics of a “high risk” situation Unpleasant emotions Physical discomfort Pleasant emotions Testing personal control Urges and temptations Social problems at work Social tension Positive social situations
Marlatt and Gordon Relapse Prevention Model.
High Risk SituationHigh Risk Situation
Effective CopingEffective CopingResponseResponse
Ineffective CopingIneffective CopingResponseResponse
Increased Self-Increased Self-EfficacyEfficacy
Decreased Self-Decreased Self-EfficacyEfficacy
Less Less Lapse/Relapse RiskLapse/Relapse Risk
Positive OutcomePositive OutcomeExpectancyExpectancy
More More Lapse RiskLapse Risk
Increased AVEIncreased AVE
More Relapse RiskMore Relapse Risk
Additional Relapse Techniques
CRA Functional Analysis for Relapse
Set up an early warning monitoring system
Outline the behavioral “chain” of events that leads to a relapse
Behavioral Chain bored take a walk
go towards park go into park
go near friend’s house go into house
friend asks you to get high give in
CRA Relationship Therapy
emphasizes relationships as an integral part of treatment
focusing only on the using behavior (while ignoring other interpersonal problems) less productive therapy
Relationship Therapy: Overview
Action orientedTime limitedFocuses on skills building “Here and now” focusTeaches general relationship skills
Relationship Therapy: Introduction
Discuss current negative communication style
Assure clients that many people in similar situations have shown improvement in their relationships
Introduction (cont’d)
Explain how they will be taught effective new communication skills
Let them know that they will feel less overwhelmed as progress is made
Relationship Therapy: Communication Skills
Briefly present one issueSpeak in a positive manner;
no blamingDefine issues clearly & specifically;
refer to measurable behaviorsClearly state your feelings about the
issue
Communication Skills (cont’d)
Offer understanding statement (try to view issue from partner’s perspective)
Accept partial responsibility for any problem raised
Offer to help
Relationship Happiness Scale
Household responsibilities
Raising the children
Social activities Money
management
Communication Sex & affection Job or school Emotional support Drinking/drug use General
happiness
Relationship Happiness ScaleThis scale is intended to estimate your current happiness with your marriage on each of the eleven areas listed. Ask yourself the following question as you rate each area:How happy am I with my partner in this area? Then circle the number that applies.
Numbers toward the left end of the ten-unit scale indicate various degrees of unhappiness, while numbers toward the right end of the scale reflect increasing levels ofhappiness. In other words, state according to the numerical scale (1-10) exactly how you feel today. Try to exclude all feelings yesterday and concentrate only on thefeelings of today in each of the life area. Also try not to allow one category to influence the results of the other categories.
1 = Completely Unhappy (canÕt get worse)5 = Neutral (not unhappy, not happy either)10 = Completely Happy (canÕt get better)
Unhappy Neutral Happy
Happiness with:
1. Household Responsibilities 1 2 3 4 5 6 7 8 9 10
2. Rearing of Children 1 2 3 4 5 6 7 8 9 10
3. Social Activities 1 2 3 4 5 6 7 8 9 10
4. Money Management 1 2 3 4 5 6 7 8 9 10
5. Communication 1 2 3 4 5 6 7 8 9 10
6. Sex & Affection 1 2 3 4 5 6 7 8 9 10
7. Job or School 1 2 3 4 5 6 7 8 9 10
8. Personal Independence 1 2 3 4 5 6 7 8 9 10
9. Spouse Independence 1 2 3 4 5 6 7 8 9 10
10. Spiritual Life 1 2 3 4 5 6 7 8 9 10
11. General Happiness 1 2 3 4 5 6 7 8 9 10
Name _______________________________________________ ID ____________________ Date _____________________
“Perfect” Relationship
In household responsibilities I would like
my partner to: In raising the children I would like my
partner to: In social activities I would like my partner
to:
Reciprocity
Learn how to make a request in a positive manner.
Each partner gets “something”. Clients’ cannot say “no” to a request,
but you don’t have to say “yes” either. Learn how to give in a little
(compromise). Try at home, learn independently.
Self-Reminder to Be NiceToday….did you:
Express appreciation to your partner? Compliment your partner? Give your partner any pleasant surprises? Express visible affection to your partner? Spend some time devoting your complete
attention to pleasant conversation w/ your partner?
Initiate a pleasant conversation? Make any offer to help before being asked?
Positive Reinforcer: Review
What is a reinforcer?
How do I find one?
Does everyone have reinforcers?
How can I use them to help?
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
Inadequately monitoring the client’s contact with triggers
Not checking for generalization of skills Being reluctant to suggest the use of
disulfiram/naltrexone
More Information
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.