The community reinforcement approach
The Community Reinforcement Approach
A Guideline developed for the Behavioral Health Recovery Management project
Robert J. Meyers and Daniel D. Squires
University of New Mexico Center on Alcoholism, Substance Abuse and Addictions
The Behavioral Health Recovery Management project is an initiative of
Fayette Companies, Peoria, IL; Chestnut Health Systems, Bloomington, IL;
and the University of Chicago Center for Psychiatric Rehabilitation.
The project is funded by the Illinois Department of Human Services'
Office of Alcoholism and Substance Abuse.
Robert J. Meyers, Ph.D.
is a Research Associate Professor in Psychology at the University of
New Mexico based at the Center on Alcoholism, Substance Abuse and Addictions (CASAA), and
has been involved in research on treatment of alcohol problems for more than twenty-five years.
Originally trained in Nathan Azrin's lab, he was a therapist and collaborator in the first outpatient
trial of the community reinforcement approach (CRA; Azrin, Sisson, Meyers, & Godley, 1982), and
other early outpatient studies of CRA (Mallams, Hall, Godley, & Meyers, 1982). He is senior author
of the only therapist manual on CRA (Meyers & Smith, 1995). Dr. Meyers has been involved in six
NIH-funded clinical trials of CRA-based treatment programs at CASAA, three with NIAAA (Meyers
& Miller, 2001; Miller, Meyers, & Tonigan, 1999; Smith, Meyers, & Delaney, 1998) and three with
NIDA (Abbott et al., 1998; Meyers, Miller, Hill, & Tonigan, 1999; Meyers, Miller, Smith, & Tonigan,
in press). He was also Project Coordinator for the Albuquerque site of Project MATCH. He also
developed the community reinforcement and family training (CRAFT) method for engaging
treatment refusing problem drinkers in treatment via unilateral interventions through a concerned
family member which has been found to be significantly more effective than two more commonly
used methods, Al-Anon and the Johnson Institute intervention (Miller, Meyers, & Tonigan, 1999).
Dr. Meyers has presented over 65 CRA and CRAFT workshops in the USA and abroad, including
Australia, Poland, Sweden, and the Netherlands.
Daniel D. Squires, M.S.
is currently a doctoral candidate in Clinical Psychology at the University of
New Mexico where he is also pursuing a Master's degree in Public Health. His interests within the
field of addictions research and treatment revolve around issues of motivation in the change
process, and he has participated as a therapist in two federally funded studies of CRA and CRAFT
with treatment refusing adolescents. He is also interested in policy issues involving program
evaluation and dissemination, and is currently working with colleagues on developing a series of
computer-based brief interventions for problem drinkers that will be evaluated in a series of
upcoming controlled clinical trials.
Table of Contents
The Community Reinforcement Approach (CRA) is a comprehensive behavioral
program for treating substance-abuse problems. It is based on the belief that
environmental contingencies can play a powerful role in encouraging or discouraging
drinking or drug use. Consequently, it utilizes social, recreational, familial, and vocational
reinforcers to assist consumers in the recovery process. Its goal is to make a sober
lifestyle more rewarding than the use of substances. Oddly enough, however, while
virtually every review of alcohol and drug treatment outcome research lists CRA among
approaches with the strongest scientific evidence of efficacy, very few clinicians who treat
consumers with addictions are familiar with it.
The purpose of this guideline is to introduce clinicians to the use of the Community
Reinforcement Approach with consumers who present for drug and/or alcohol treatment.
Once you complete your review of this guideline, you can expect to be better prepared to
work with consumers using CRA for several reasons. First, by gaining an introductory
understanding of the principles underlying CRA, you will have a theoretical foundation by
which to base your practice of this method. Second, by following the procedures outlined
in the clinical guideline, you will have a number of treatment strategies by which to develop
and structure an effective intervention with a variety of consumers presenting with a
diversity of needs. When learning any new treatment modality, it is essential to bear in
mind that mastery comes only as a result of both study and practice. To that end, we have
also provided you with a resource section that we hope will serve as a useful starting point
in your effort to become more knowledgeable of, and efficient with, the practice of the
Background for The Community Reinforcement Approach
The Community Reinforcement Approach (CRA) is a broad-spectrum behavioral
program for treating substance abuse problems that has been empirically supported with
inpatients (Azrin, 1976; Hunt & Azrin, 1973), outpatients (Azrin, Sisson, Meyers, & Godley,
1982; Mallams, Godley, Hall, & Meyers, 1982; Meyers & Miller, 2001), and homeless
populations (Smith, Meyers, & Delaney, 1998). In addition, three recent meta-analytic
reviews cited it as one of the most cost-effective alcohol treatment programs currently
available (Finney & Monahan, 1996; Holder, Longbaugh, Miller, & Rubonis, 1991; Miller et
The first study to demonstrate the effectiveness of CRA was conducted more than 25
years ago (Hunt & Azrin, 1973). In this study, with 16 alcohol-dependent inpatients and
matched controls, individuals were randomly assigned to either the CRA treatment or a
traditional treatment program that focused on the 12 steps of Alcoholics Anonymous (AA).
At the 6-month follow-up, participants in the CRA condition significantly outperformed the
12-step group with the former drinking an average of 14% of the follow-up days and the
latter drinking 79% of the days. Significant differences in favor of CRA were also found for
the number of days institutionalized and employed as well. A second related study of
inpatients by Azrin (1976) again contrasted CRA with a 12 step program-this time with a
larger sample. And, again, CRA proved to be superior at the 6-month follow-up, with the
CRA group averaging 2% of their follow-up time drinking, as compared to 55% for the
those participating in the 12-step program. As before, those treated with CRA were more
likely also to report fewer days of institutionalization and more days employed.
Importantly, the CRA condition's abstention rate at the 2-year follow-up continued to be
Not only was the next study the first to be conducted with outpatients (n=43), but it also
was the first to compare the effects of a disulfiram (Antabuse) compliance program within
both CRA and 12-step programs (Azrin, Sisson, Meyers, & Godley, 1982). The disulfiram
compliance component involved training a concerned family member or friend to
administer the disulfiram to the drinker, and to provide verbal reinforcement. A third
condition involved participation in a 12-step program (AA in this case) and a prescription
for disulfiram, but it lacked the trained disulfiram monitor that was presumed to be an
integral part of the disulfiram compliance protocol. As predicted, the two groups containing
the additional disulfiram compliance component reported the most success during the sixth
month of follow-up, with the CRA program averaging 97% and the 12-step condition
reporting 74% of the days abstinent. It was noteworthy that couples assigned to the
disulfiram condition within the 12-step group performed much better than the group's
single subjects, even to the point of matching the CRA group's outcome on several
variables. In contrast, the 12-step group that received only the disulfiram prescription had
an abstinence rate of only 45% of the days.
In another study the effectiveness of CRA was examined within an alcohol-dependent
population of homeless individuals (Smith, Meyers, & Delaney, 1998). During this 3-month
program all participants were housed in grant-supported apartments. Individuals who were
employed at the end of three months were allowed to remain in the apartments for an
additional month. Housing privileges were suspended temporarily if random breathalyzer
tests detected drinking. In contrast to those in the experimental group who were provided
with housing, Standard Treatment group members had access to resources at a large day
shelter, which primarily included basic meals, clothing, and showers. The shelter also
offered a job program, individual sessions with AA-oriented counselors, and on-site AA
Participants in the CRA condition were treated in a group therapy format, and two
weekly prizes were awarded for good attendance. The focus of most groups was skills
training, primarily in the areas of problem solving, communication, and drink-refusal.
Additionally, a non-drinking social event was held on Friday evenings, which commonly
entailed a group dinner at a local restaurant. Periodically, group sessions were
supplemented with relationship counseling or case management meetings. The latter
were particularly important for the individuals with dual diagnoses (major mental illness +
alcohol dependence) within the sample. At the conclusion of treatment, follow-ups were
conducted every 2-3 months for the next year. The results for this trial showed that
compared with standard care at the shelter, those treated with CRA showed significantly
better outcomes throughout a year of follow-up (Smith et al., 1998).
With respect to the use of CRA with substances other than alcohol, a series of studies
have demonstrated that the combination of CRA and contingency management is an
excellent program for treating cocaine and methadone-maintained heroin abusers.
Contingency management for cocaine abusers entails monitoring cocaine use through
frequent urine samples, and rewarding individuals who turned in clean urines with tokens
that could be traded for prizes. Studies have ranged from a 2-case design (Budney,
Higgins, Delaney, Kent, & Bickel, 1991) to a controlled but nonrandomized trial (Higgins, et
al., 1991), and finally to a controlled and randomized experiment (Higgins, et al., 1993). In
both controlled trials the CRA plus contingency management group participants decreased
their cocaine use significantly more than those in the 12-step (AA philosophy) comparison
condition. Figures for the third study showed that the CRA plus contingency management
group had fewer program dropouts than the control condition (5% versus 42%) and a
greater number of continuous days of cocaine abstinence throughout. Continuous cocaine
abstinence was still found 16 weeks into the trial for 42% of the CRA group and only 5% of
the 12-step group. CRA has also been extended to the treatment of methadone-
maintained heroin addicts, again with an advantage for the CRA-treated clients (Abbott,
Weller, Delaney, & Moore, 1998).
CRA has also been integrated with unilateral family therapy into an approach called the
Community Reinforcement Approach and Family Training (CRAFT), which showed
promising results in a small initial evaluation by Sisson and Azrin (1986). In CRAFT, the
person seeking help is usually the parent or spouse of a problem drinker who refuses to
seek treatment. Without the drinker present, the CRAFT therapist works with the spouse
or parent to change the drinker’s social environment so as to remove any inadvertent
reinforcement for drinking or drug using, and instead to reinforce any and all behaviors
related to abstinence (Meyers & Smith, 1997). They also prepare for the next window of
readiness, when the drinker may respond favorably to an offer of help and support.
In a recently completed clinical trial funded by NIAAA (Miller, Meyers & Tonigan, 1999),
64% of those given CRAFT counseling succeeded in getting their loved one into treatment
following an average of 4-5 counseling sessions, while two other traditional methods for
engaging unmotivated problem drinkers were significantly less successful: the Johnson
Institute family intervention (30%) and counseling to engage in Al-Anon (13%). In a
parallel NIDA study focusing on drug abuse (Meyers, Miller, Hill, & Tonigan, 1999), family
members given CRAFT successfully engaged 74% of initially unmotivated drug users in
treatment. Lending additional support to findings from the NIDA study, Meyers, Miller,
Smith, and Tonigan (in press) compared CRAFT, CRAFT plus aftercare, and Al-Anon/Nar-
Anon facilitation therapy (AFT) for treatment-refusing drug users. CRAFT alone and
CRAFT plus aftercare successfully engaged 59% and 77% (respectively) of initially
unmotivated drug users into treatment, while AFT was successful in only 29% of cases.
In sum, thus far CRA has been found in at least ten clinical trials to be effective in
treating alcohol and other drug problems, and in helping relatives get their unmotivated
loved ones into substance abuse treatment. In most but not all cases, it has also been
found to be more effective than traditional approaches with which it has been compared, or
A successful CRA therapist must have sound, fundamental counseling skills.
Supportiveness, empathy, and a genuinely caring attitude are key to establishing the
consumer-therapist relationship. However, CRA also requires that the therapist be
directive, energetic, and engaging. Indeed, CRA-therapist trainees are often encouraged
to consider themselves cheerleaders as well as therapists! It is their enthusiasm and
motivation that facilitates the same in the consumer. As a behavioral program, CRA
makes extensive use of modeling, role-playing, and shaping. Such an action-oriented
approach implies that the CRA therapist does not submissively wait for the therapy session
to move on its own. Rather, the therapist engages the consumer and works with him or
her to solve problems. In line with this, problems are always defined as the property of
both the consumer and the therapist. For instance, whereas another therapist might point
out to the consumer, “Communication skills training could really benefit you,” the CRA
therapist says, “It looks like we
really need to do more work in the area of communication
skills. Where do you think we
Rooted in operant principles, CRA uses positive reinforcement for each step, no matter
how small. Consequently, a CRA therapist must be willing to look continually for
opportunities to reinforce consumers. For example, if a consumer arrives 20 minutes late
for a session, the CRA therapist might say something along the lines of, “I’m glad you
made it today. I’m sorry we don’t have the whole 60 minutes to work together, but I’m just
glad you’re here and we have 40 minutes together. Thanks for coming.” In addition to
reinforcing a consumer’s attempts at change, a CRA therapist must be committed to
helping the consumer identify potential positive reinforcements in the community. By
helping the consumer find “payoffs” for learning new skills and trying new behaviors, the
consumer creates his or her own motivation for change. Common examples are found in
the willingness of consumers to modify their communication styles to minimize
interpersonal conflict with significant others in their lives. Other examples include
situations in which individuals learn assertiveness to bolster their self-esteem, or practice
interviewing skills in order to eventually enjoy the pleasures of a job and a paycheck.
Finally, substance abuse is not viewed as an isolated behavior independent of the rest
of the individual’s life. Instead, it is seen as intertwined with many aspects of the
consumer’s life, and attention must be given to the context in which the substance abuse
occurs. As a result, the CRA therapist must also possess the skills to work with couples,
or in some cases, act as a case manager. Knowing community resources and being
willing to actively help consumers address problems other than those that are purely
substance abuse related is essential.
Although several randomized clinical trials have shown CRA to be effective within a
relatively short 3-month period, it is structured in an open-ended format. Given the
objective of helping consumers master a specific set of skills necessary to achieve their
goals, therapy is not complete until those skills are mastered and a reasonable degree of
progress has been made toward obtaining their goals. With this in mind, the amount of
time that is required varies from individual to individual.
In addition to consumer variables affecting the length of therapy, the therapist’s ability
to structure successes early in treatment is also a factor. By carefully selecting initial
treatment goals well within the consumer’s capability (e.g., showing up for the next
session), self-efficacy is enhanced, the therapeutic relationship is strengthened, and the
consumer continues to attend. In turn, the therapist has the opportunity to help the
consumer learn to identify his or her behavioral contingencies and to begin to increase the
number of pro-social behaviors in his or her repertoire, while decreasing drinking or drug
Treatment frequency is dictated by the consumer’s motivation and progress. Although
a CRA therapist normally would have sessions once weekly, the decision may be made to
hold several sessions within the first week or two of treatment if the consumer is
ambivalent or if there is concern about an impending relapse. During this period it would
be important to apply proper positive reinforcement so as to make attendance and
compliance with homework as rewarding as possible. As already noted, by structuring
early successes, the therapist increases the likelihood that the consumer will be around for
later ones! As therapy progresses and both therapist and consumer agree that the
consumer is ready to become more independent, a “weaning” process is introduced.
Essentially, sessions are scheduled every two weeks, then once a month, and so on. In
this fashion the consumer-therapist relationship remains strong, and the consumer feels
welcome to resume the regular sessions if difficulties arise.
As for session duration, an hour is usually adequate for an individual treatment session.
If CRA is offered in a group format, duration runs easily to 1½ hours per session.
Typically, only the first individual session runs as long as 1½ – 2 hours. During this time,
assessment material is obtained, the program is explained, and strategies for maintaining
sobriety until the next session are planned.
The specific components of the CRA program will now be addressed. While the
assessment and treatment planning techniques are utilized with everyone, only those skills
training procedures needed to address a consumer's specific deficits would be introduced
CRA Functional Analysis
This structured interview outlines both the antecedents (triggers) for the drinking
behavior and the consequences. Antecedents are broken down first into external triggers:
people and places that typically precede drinking episodes. Internal triggers include
common thoughts, physical sensations, and emotions. This information allows the
therapist to point out high-risk situations for the problem drinker or drug user that set the
stage for the introduction of alternative behaviors. Next a description of the type and
amount of alcohol or other substance typically consumed is outlined so that progress can
be monitored. Finally, the consequences for an individual's use are examined. The highly
reinforcing but short-lived immediate consequences are identified first, such as the
reported ability to relax and socialize more easily when drinking or using drugs. Eventually
the therapist would assist in finding non-using ways for the individual to obtain these same
feelings. Then the negative, long-term consequences of the using behavior are
highlighted, including problems in interpersonal relationships, health, job, legal issues, and
finances. Improvements in these areas typically accompany abstinence, and reminders of
this can motivate the individual throughout treatment.
Although traditional functional analyses stop here, the CRA Functional Analysis
examines the antecedents and consequences of several types of pleasurable, non-
behaviors as well. Strategies for increasing the frequency of these behaviors can
be introduced, and any obstacles to their implementation can be tackled through problem-
solving efforts (For a complete description see Meyers & Smith, 1995, pp. 20-41).
Upon first entering treatment, most consumers are resistant to the message that they
can never drink or use drugs again. So even in cases in which abstinence may clearly be
the best option, the notion of "sampling" sobriety for a limited period of time is much less
threatening. The therapist proceeds by reviewing some of the naturally occurring benefits
of a period of abstinence, including renewed support from family members and the
motivation to address other related problems. Once the consumer has agreed to a period
of abstinence, the therapist usually asks for a 90-day commitment. Most individuals resist
this, and consequently the negotiation process begins. Regardless of whether 60 or 6
days is settled upon, the therapist assists with a plan for accomplishing this. Since the
necessary skills have not yet been taught, the therapist returns to the high-risk triggers
outlined on the functional analysis and helps identify temporary competing behaviors for
those times (For a complete description see Meyers & Smith, 1995, pp. 42-56).
Disulfiram Use with a Monitor
Frequently, the use of disulfiram (Antabuse) can provide an added benefit to many
consumers who are seeking behavioral treatment for alcohol abuse. Since disulfiram is a
medication that makes individuals very sick if they drink alcohol while taking it, it can be a
useful deterrent for impulsive drinking-especially with those consumers who have a history
of chronic alcohol dependence. In describing the disulfiram option to a consumer it is
important to outline the many advantages of its use, such as reductions in "slips", family
worry, and agonizing daily decisions about whether or not to drink. If a consumer agrees
to try disulfiram, the therapist explains that a supportive monitor (for taking the medication
daily) is critical for ensuring success. The therapist would then meet with the consumer
and monitor jointly so that role-plays of the administration procedure could be rehearsed
(For a complete description see Meyers & Smith, 1995, pp. 72-77).
CRA Treatment Plan
The Happiness Scale is the first of two instruments that form the foundation of the
treatment plan. It asks the consumer to rate current happiness for each of 10 life
categories: drinking (or drug use), job, money management, social life, personal habits,
family relationships, legal issues, emotional life, communication, and general happiness.
This provides a quick overview of the severity of problems in a variety of areas. The Goals
of Counseling chart follows readily, as the same 10 categories are listed again. This time
the therapist assists in defining specific goals and strategies for achieving them in these
areas, while adhering to behavioral guidelines and keeping in mind that the overall goal is
to increase satisfaction in non-drinking areas, so that the role of alcohol and/or drugs as
the major determinant of an individual's happiness is diminished.
In formulating these goals, three basic rules are taught: keep them brief, specific
(measurable), and use positive terms (stating what the consumer will do, as opposed to
what he or she will not do anymore). In the process of identifying strategies for achieving
the goals, it often becomes clear that the consumer does not yet possess some of the
necessary skills. These interventions are typically marked with an asterisk (*) to serve as
a reminder to the therapist that the skills need to be taught. Sample items from the Goals
of Counseling form are presented below. These represent the goals that a given
consumer might begin working on immediately (For a complete description see Meyers &
Goals of Counseling
Behavioral Skills Training
Much of CRA is devoted to teaching new skills in areas of deficits, such as
communication, problem-solving, and drink refusal. Communication skills training focuses
on three components of a good conversation: 1) giving an understanding statement, 2)
accepting partial responsibility for problems, and 3) offering to help. The therapist models
the use of these across a variety of situations, and the consumer then rehearses through
role-plays. Problem-solving training is a step-by-step procedure for addressing specific
problems, such as combating urges to drink, developing non-drinking friendships, or
developing new ways to relax. It begins with defining the problem precisely and
brainstorming until a number of possible solutions are generated. Next the consumer
selects one potential solution, outlines the manner in which it will be executed, and
addresses anticipated obstacles. Finally the consumer commits to attempting the solution
during the week, and the therapist reviews the outcome at the next session. The third
major skill area, drink refusal, essentially involves assertiveness training that is also role-
played (For a complete description see Meyers & Smith, 1995, pp. 102-120).
In the interest of finding multiple ways to increase the reinforcers in a consumer's life, it
is very important to examine the individual's job satisfaction. A good job is often the
source of many reinforcers, such as positive self-esteem, pleasant social interactions with
coworkers, and obvious financial incentives. The CRA job program teaches the necessary
skills for obtaining a job (See Azrin & Besalel, 1980, for a complete description) and
keeping it, or for simply improving satisfaction with a current position. The latter two issues
are, again, addressed primarily through problem solving (For a complete description see
Meyers & Smith, 1995, pp. 121-126).
Social and Recreational Counseling
Typically a new consumer's friendships and social activities revolve around drinking.
Given the importance of having satisfying social activities that compete with alcohol use
and support sobriety, this issue must be addressed. The CRA therapist spends
considerable time helping the individual identify new sources of non-drinking recreation,
and using problem solving to overcome obstacles to participation (For a complete
description see Meyers & Smith, 1995, pp. 138-146).
CRA's Marital Therapy
Although many relationships improve with the elimination of excessive drinking,
interpersonal difficulties will often persist. The CRA therapist attempts to involve the
partner of the drinker in treatment, so that relationship problems can be addressed and the
partner's support for the drinker can be enlisted or, in some cases, re-enlisted. These joint
sessions begin with a couples' version of the CRA assessment and treatment planning
instruments. These provide information about designated problem areas in the
relationship, reasonable goals, and viable strategies for initiating the necessary changes.
Throughout this process the couple is taught basic communication skills, as well as
techniques for gradually increasing the number of pleasant interactions they have with
each other on a daily basis (For a complete description see Meyers & Smith, 1995, pp.
CRA Relapse Prevention
Relapse prevention actually begins when high-risk situations and triggers are first
identified on the initial functional analysis. CRA also trains partners in an Early Warning
System, whereby old precursors to drinking are recognized, and a preplanned strategy is
set into motion if they surface. In the event that a client does have a relapse, a relapse
version of the CRA Functional Analysis is completed. Effective coping strategies for
dealing with the triggers in the future are also devised (For a complete description see
Meyers & Smith, 1995, pp. 180-195).
Frequently Asked Questions
Once aware of the primary components of CRA, there are some specific questions that
should guide the clinician's development of an overall CRA treatment plan. Listed below
are 15 general considerations with brief descriptions that the therapist might find helpful
when engaged in the process of formulating and carrying out an effective CRA treatment
1. What are the therapeutic goals for the consumer? Which are primary, and
which are secondary goals?
These aspects are best accomplished via the Happiness Scale and Goals of
2. What further information would you want to have to assist you in
structuring the consumer’s treatment? Are there specific assessment tools
you would use (i.e. data to be collected)? What would be the rationale for
using those tools?
The main assessment instruments for the CRA program are the two functional
analyses. The first one examines drinking behavior, so that the antecedents and
consequences for alcohol and drug use can be outlined, while the CRA functional analysis
for pleasurable non-drinking behaviors demonstrates that the client already is engaging in
enjoyable activities that do not involve alcohol. Other assessment instruments that the
therapist finds routinely helpful in his or her clinical work (e.g. MMPI-II, NEO-PI-R, SCL-90,
BDI, etc.) may also be used in an effort to obtain a thorough assessment of overall
functioning. Having such information is useful with regard to the next question.
3. What is your conceptualization of the consumer’s personality, behavior,
affective state, and cognitions?
A consumer's developmental history, pattern of substance abuse, treatment, and
relapse, as well as the results of psychological testing all point to consistent patterns that
suggest a certain cognitive style. CRA is particularly appropriate for individuals whose
testing indicates an overall cognitive style that reflects poor problem solving or planning
capacity. Fortunately, these are the skills explicitly trained in the comprehensive format of
4. What potential pitfalls would you envision in this therapy? What would the
difficulties be and what would you envision to be the source(s) of the
Problems associated with the successful implementation of CRA come from two
possible sources: the consumer or the therapist. Consumer difficulties arise when he or
she is uncomfortable with CRA’s action-oriented style. Particularly passive consumers
who look outside themselves for answers and are incapable of joining the therapist in
active problem solving may feel overwhelmed. Therapist-centered difficulties tend to arise
when therapists become overly focused on the CRA “techniques” to the exclusion of other
important issues. First and foremost is the problem that occurs when a poorly trained
therapist confuses the behavioral component of the therapy for the whole therapy.
Specifically, an over-emphasis on implementing operant principles without equal emphasis
on the human aspects of counseling (i.e., warmth, empathy, unconditional positive regard)
relegates the therapy to just another skills-training program. It is the combination of
compassion and skill that makes the CRA therapist effective.
5. To what level of coping, adaptation, or function would you see a consumer
reaching as an immediate result of therapy? What result would be long-term
subsequent to the ending of therapy (i.e. prognosis for adaptive change)?
While other approaches to substance abuse treatment may view consumer's previous
"failed" attempts as a poor prognostic indicator, CRA does not. Given the CRA emphasis
on harm reduction, more prolonged periods of abstinence and abbreviated relapses can be
reframed as evidence that the consumer has the capacity to attain sobriety and that the
focus needs to be shifted to maintaining that goal.
6. What would be your time line (duration) for therapy? What would be your
frequency and duration of the sessions?
Aspects of the time frame and duration of therapy are discussed at length at the
beginning of the clinical guideline section.
7. Are there specific or special techniques that you would implement in the
therapy? What would they be?
Two of CRA’s key techniques have already been explained in some detail: CRA
Functional Analyses and Sobriety Sampling. The remaining techniques that would be
most useful for these consumers fall into the behavioral skills training category: Problem-
solving, communication skills, and drink/drug-refusal. Problem solving is a step-by-step
method for defining a problem, generating potential solutions, and devising a specific plan
for implementing the desired solution. The procedure can be applied to virtually any type
of problem by following these 7 steps: 1) Define the problem, 2) Brainstorm potential
solutions (therapist does not criticize any), 3) Eliminate any undesired solutions (ones that
the consumer cannot picture themselves trying in the upcoming week), 4) Select 1-2
potential solutions and determine if feasible, 5) Identify any obstacles to implementing the
solutions, 6) Address each obstacle, and 7) Check on the outcome at the next session.
8. Are there special cautions to be observed in working with this consumer
(e.g. danger to self or others, transference, counter-transference)? Are there
any particular resistances you would expect and how would you deal with
Aspects related to safety concerns would be identical to other types of clinical treatment
and should be addressed in a manner appropriate to standard ethical codes and
considerations. With regard to resistance, the fact that CRA will represent a very new, and
hopefully refreshing, approach to treatment, it is common for consumers to respond with
less resistance than may typically be present in other types of treatment. However, even
where resistance is encountered, CRA does not attack such behavior "head-on." There is
ample evidence to suggest that a confrontational style does little but to increase resistance
on the part of consumers (Miller & Rollnick, 1991; in press). Instead, CRA focuses on
looking at the meaning of the resistance as it relates to the functional analysis of the
9. Are there any areas that you would choose to avoid or not address with the
Although CRA is designed to handle virtually any problem area, certain issues may
temporarily be avoided until some basic skills are taught. For example, if an individual
decides that they want to try a new social activity, but the therapist is convinced that
communication and drink-refusal skills need to be taught first, the consumer could be
advised to put this plan on hold temporarily.
10. Is medication warranted for the consumer? What effect would you hope
to expect the medication to have?
The use of medication to address withdrawal symptomatology during alcohol
detoxification for all but the most severe cases is controversial. In a comprehensive review
of both the psychiatric and psychological literature on the effectiveness of medication
versus cognitive-behavioral therapy, which would include CRA, (Antonuccio, Danton, & De
Nelsky, 1995), it was determined that medication should not be the first line treatment
approach. As already discussed, one medication that might be considered, however,
would be disulfiram (Antabuse). Another medication to consider at the point of aftercare is
Naltrexone, since this opioid antagonist has shown some promise in reducing binges if an
individual starts to drink again (O’Malley, et al., 1992; Volpicelli, Alterman, Hayashida, &
O’Brien, 1992). To date, it has not been utilized in a controlled trial with CRA.
11. What are the strengths of the consumer that can be used in the therapy?
Let's say, for example, that a given consumer's major strength is the pride they take in
their work, and the fact that they have been viewed by co-workers as fair, hard working,
and conscientious. Since the individual experiences a sense of dignity and self-esteem
associated with work, their job would be considered a powerful reinforcer for them.
Consequently, a CRA therapist would link the consumer's efforts toward sobriety with
doing well at work. Similarly, the consumer could be reminded that they stood to lose
something of great value to them (their job) if they continued to drink.
12. How would you address limits, boundaries, and limit setting with the
In terms of setting limits and boundaries within the therapeutic relationship, CRA
operates in accordance with most standard clinical treatments. This includes establishing
clear expectations for starting and ending sessions on time, and for paying in a timely
fashion. The professional nature of the therapeutic relationship is also discussed. If a
consumer violates any of these boundaries, the CRA therapist would raise the issue,
discuss it with the individual in an effort to understand his or her feelings and motives, and
then move toward a positive solution of the problem.
13. Would you want to involve significant others in the treatment? Would
you use out-of-session work (homework) with this consumer? What
homework would you use?
CRA always has viewed problem users' significant others as important collaborators in
the treatment of substance abuse, and has included them successfully as disulfiram
monitors, partners in marital counseling, active agents in re-socialization and
reinforcement programs, and relapse or problem detectors (Azrin, et al., 1982; Meyers,
Dominguez, & Smith, 1996; Meyers & Smith, 1995; 1997). At some point during treatment
the therapist should try to work on relationship issues between the consumer and his or
her significant others. There are three CRA tools that may be useful for such work. They
include the Marriage/Relationship Happiness Scale (see UNM CASAA website or Meyers
& Smith, 1995; page 171 for entire form), the Perfect Marriage/Relationship form (which
allows for specification of behavioral goals and strategies) (see Meyers & Smith, 1995; pp.
174-176 for entire form), and the Daily Reminder To Be Nice chart (see Meyers & Smith,
Out-of-session homework is essential to CRA, since only 1–2 hours of therapy a week
will not change a pattern that has taken years to develop. Assignments are often written
onto the Goals of Counseling form in the strategies column (example of partial form given
on pp. 14-15 of this guideline; see Meyers and Smith, 1995; pp. 98-99 for entire form). A
basic consideration when assigning homework is to make sure that the consumer has the
skills to be successful. In the event that he or she did not complete an assignment, the
CRA therapist would explore the reason, as opposed to questioning commitment. Next,
problem solving may be utilized, or the assignment might be tackled during the session
14. What would be the issues to be addressed in termination? How would
termination and relapse prevention be structured?
Relapse prevention work is critical in any case, as the period after acute care is
problematic for most people. The integration of relapse prevention throughout all CRA
interventions is implicit. In general, it will be important to see that the consumer has been
trained in the necessary behavioral skill areas, and that he or she utilizes these new skills
appropriately in the community (job, home). Since continued use of those skills is
dependent upon being reinforced for doing so, the CRA therapist must check on this
An additional issue in the termination process is the importance of establishing positive
expectations for treatment success, with a clear understanding of what this would mean
specifically for the consumer. CRA strongly emphasizes that recovery is an ongoing
process, and that while slips are not desired, they can be used as a source of valuable
information in the determination of unforeseen high-risk situations.
15. What do you see as the hoped-for mechanisms of change for the
consumer, in order of importance?
The most important mechanism of change for any consumer being treated with CRA is
the individual's own set of reinforcers, most of which are inaccessible as a result of his or
her use of substances. The second mechanism of change is inherent to CRA's non-
confrontational format. At no time should the consumer be told that they are required to
quit drinking or using drugs. The choice to change is always up to the individual. In
essence, the most powerful mechanism of change; whether accessed through CRA or
another approach; is the set of natural consequences of positive behavior. This is true
across a wide range of behaviors, across persons of different personalities and cognitive
styles, and regardless of previous failed attempts to change. It is at the foundation of any
change strategy such as CRA that is based on a thorough understanding of behavioral
CRA is a comprehensive, individualized treatment approach designed to initiate
changes in lifestyle and the social environment that will support a client’s long-term
sobriety. It has a strong track record of effectiveness in clinical trials that span geographic
regions, inpatient and outpatient treatment, individual and family approaches, alcohol and
other drug problems, homelessness, and cultural-ethnic differences. CRA teaches the
therapist how to find and use the consumer's own intrinsic reinforcers. This is a unique
and necessary part of CRA therapy process. Its flexibility of approach and philosophy of
positive reinforcement are likely to be applicable, with modification, across a broad range
Azrin, N. (1976). Improvements in the community-reinforcement approach to alcoholism.
Behaviour Research and Therapy,
Higgins, S. T., Delaney, D. D., Budney, A. J., Bickel, W. K., Hughes, J. R., Foerg, F. &
Fenwick, J. W. (1991). A behavioral approach to achieving initial cocaineabstinence. American Journal of Psychiatry, 148, 1218–1224.
Hunt, G. M. & Azrin, N. H., (1973). A community-reinforcement approach to
alcoholism. Behavior Research and Therapy, 11, 91-104.
Meyers, R.J., & Miller, W.R. (2001). A community reinforcement approach to addiction
treatment. Cambridge, UK: Cambridge University Press.
Meyers, R.J., Smith, J.E., & Waldorf, V.A. (1999). Application of the community
reinforcement approach. In E. Dowd & L. Rugle (Eds.), Comparative treatments ofsubstance abuse. New York: Springer Publishing Company
Miller, W.R. & Meyers, R.J. (1999). The Community Reinforcement Approach. Alcohol
Sisson, R. W. & Azrin, N. H. (1986). Family-member involvement to initiate and promote
treatment of problem drinkers. Journal of Behavior Therapy and ExperimentalPsychiatry, 17, 15–21.
Smith, J. E. & Meyers, R. J. (2000). CRA: The community reinforcement approach for
treating alcohol problems. In M. Dougher (Ed), Clinical behavioral analysis:Research and theory. Context Press.
Wolfe, B. L., & Meyers, R. J. (1999). Cost-effective alcohol treatment: The community
reinforcement approach. Cognitive and Behavioral Practice. 6, 105-109.
Recommended Assessment and Treatment Manuals
Budney, A. J. & Higgins, S. T. (1998). National Institute on Drug Abuse therapy
Manuals for drug addiction: Manual 2. A Community Reinforcement Approach:treating cocaine addiction.
(NIH Publication No. 98–4309). Rockville, MD: U.S.
Department of Health and Human Services.
Godley, S.H., Meyers, R.J., Smith, J.E., Karvinen, T., Titus, J.C., Godley, M.D., Dent,
G., Passetti, L., & Kelberg, P. (in press). Adolescent Community ReinforcementApproach (ACRA) for Adolescent Cannabis Users. Volume 4 of the CannabisYouth Treatment Manual series. Center for Substance Abuse Treatment (CSAT),U.S. Department of Health and Human services (DHHS).
Meyers, R. J., Dominguez, T. & Smith, J. E. (1996). Community reinforcement training
with concerned others. In V. B. Hasselt & M. Hersen's (Eds.) Source ofpsychological treatment manuals for adult disorders. New York: Plenum Press.
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.
Meyers, R.J., Smith, J.E., & Waldorf, V.A. (1999). Application of the community
reinforcement approach. In E. Dowd & L. Rugle (Eds.), Comparative treatments ofsubstance abuse. New York: Springer Publishing Company.
National Institute on Alcohol Abuse and Alcoholism. Assessing Alcohol Problems
Treatment Handbook Series 4. J.P. Allen, & M.Columbus (eds.). NIH Pub. No. 95-3745. Rockville MD: National Institute on Alcohol Abuse and Alcoholism, 1995.
Robert J. Meyers, Ph.D.
UNM Center on Alcoholism, Substance Abuse and Addictions (CASAA)2350 Alamo SE, Bldg 2Albuquerque, NM 87106(505) [email protected]
Jane Ellen Smith, Ph.D.
Department of PsychologyLogan HallUniversity of New MexicoAlbuquerque, NM 87131(505) [email protected]
If you are looking for assessment instruments, or information on a variety of other relatedtopics, you can find them on the University of New Mexico Center on Alcoholism,Substance Abuse, and Addictions (CASAA) website at
Also listed below are two other websites containing helpful information about theCommunity Reinforcement Approach.
Abbott, P. J., Weller, S. B., Delaney, H. D. & Moore, B. A. (1998). Community
Reinforcement Approach in the treatment of opiate addicts. American Journal of Drug andAlcohol Abuse,
Antonuccio, D. O., Danton, W. G., DeNesky, G. Y. (1995). Psychotherapy versus
medication for depression: Challenging the conventional wisdom with data. ProfessionalPsychology: Research and Practice, 26, 574-585.
Azrin, N. H. (1976). Improvements in the community reinforcement approach to
alcoholism. Behaviour Research and Therapy, 14, 339-348.
Azrin, N. H. & Besalel, V. A. (1980). Job club counselor’s manual. Baltimore, MD:
Azrin, N. H., Sisson, R. W., Meyers, R. J., & Godley, M. D. (1982). Alcoholism
treatment by disulfiram and community reinforcement therapy. Journal of BehaviorTherapy and Experimental Psychiatry, 3, 105-112.
Budney, A. J., Higgins, S. T., Delaney, D. D., Kent, L., & Bickel, W. K. (1991).
Contingent reinforcement of abstinence with individuals abusing cocaine and marijuana.
Journal of Applied Behavior Analysis, 24, 657-665.
Finney, J. W., & Monahan, S. C. (1996). The cost-effectiveness of treatment for
alcoholism: A second approximation. Journal of Studies on Alcohol, 57, 229-243.
Higgins, S., Delaney, D., Budney, A., Bickel, W., Hughes, J., & Foerg, F. (1991). A
behavioral approach to achieving initial cocaine abstinence. American Journal ofPsychiatry, 148, 1218-1224.
Higgins, S. T., Budney, A. J., Bickel, W. K., Hughes, J. R., Foerg, F., & Badger, G.
(1993). Achieving cocaine abstinence with a behavioral approach. American Journal ofPsychiatry, 150, 763-769.
Holder, H., Longabaugh, R., Miller, W., & Rubonis, A. (1991). The cost
effectiveness of treatment for alcoholism: A first approximation. Journal of Studies onAlcohol, 52, 517-540.
Hunt G. M. & Azrin, N. H. (1973). A community-reinforcement approach to
alcoholism. Behavior Research and Therapy, 11, 91-104.
Mallams, J. H. Godley, M. D., Hall, G. M. & Meyers, R. J. (1982). A social-systems
approach to resocializing alcoholics in the community. Journal of Studies on Alcohol, 43,1115-1123.
Meyers, R.J., & Miller, W.R. (2001). A Community Reinforcement Approach to
addiction treatment. Cambridge, UK: Cambridge University Press.
Meyers, R.J., Miller, W.R., Smith, J.E., & Tonigan, J.S. (in press). A randomized
trial of two methods for engaging treatment-refusing drug users through concernedsignificant others. Journal of Consulting and Clinical Psychology.
Meyers, R. J., Miller, W.R., Hill, D. E., & Tonigan, J. S. (1999). Community
reinforcement and family training (CRAFT): Engaging unmotivated drug users in treatment.
Journal of Substance Abuse, 10, 291-308.
Meyers, R. J. & Smith, J. E. (1995). Clinical guide to alcohol treatment: The
Community Reinforcement Approach. New York: Guildford Press.
Meyers, R. J., Dominguez, T. P., & Smith, J. E. (1996). Community reinforcement
training with concerned others. In V.B. Van Hasselt, & M. Hersen (Eds.), Sourcebook ofpsychological treatment manuals for adult disorders (pp. 257-294). New York: PlenumPress.
Meyers, R. J. & Smith, J. E. (1997). Getting off the fence: Procedures to engage
treatment resistant drinkers. Journal of Substance Abuse Treatment, 14, 467-472.
Miller, W. R., Brown, J. M., Simpson, T. L., Handmaker, N. S., Bein, T. H., Luckie, L.
F., Montgomery, H. A., Hester, R. K., & Tonigan, J. S. (1995). What works? Amethodological analysis of the alcohol treatment outcome literature. In R.K. Hester & W.R.
Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (2nded.). Needham, MA: Allyn & Bacon.
Miller, W.R., and Rollnick, S. (1991). Motivational interviewing. New York: Guilford
Miller, W.R., and Rollnick, S. (in press). Motivational interviewing. (2nd ed.). New
Miller, W.R., Meyers, R.J., & Tonigan J.S. (1999). Engaging the unmotivated in
treatment for alcohol problems: A comparison of three intervention strategies. Journal ofConsulting and Clinical Psychology, 67, 688-697.
O’Malley, S. S., Jaffe, A. J., Chang, G., Schottenfeld, R. S., Meyers, R. J. &
Rounsville, B. (1992). Naltrexone and coping skills therapy for alcohol dependence: Acontrolled study. Archives of General Psychiatry, 49, 881-887.
Sisson, R. W. & Azrin, N. H. (1986). Family-Member involvement to initiate and
promote treatment of problem drinkers. Journal of Behavior Therapy and ExperimentalPsychiatry, 17, 15-21.
Smith, J.E., Meyers, R.J. & Delaney, H. D. (1998). The community reinforcement
approach with homeless alcohol-dependent individuals. Journal of Consulting and ClinicalPsychology, 66, 541-548.
Volpicelli, J. R., Alternan, A. I., Hayashida, M., & O’Brien, C. P. (1992).
Naltrexone in the treatment of alcohol dependence. Archives of General Psychiatry, 49,876-880.
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