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  1. Home
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  3. A Community Reinforcement Approach to Addiction Treatment
  • Cited by 63
Publisher:
Cambridge University Press
Online publication date:
August 2012
Print publication year:
2001
Online ISBN:
9780511570117
DOI:
https://doi.org/10.1017/CBO9780511570117
Series:
International Research Monographs in the Addictions
Subjects:
Psychiatry and Clinical Psychology, Neurology and Clinical Neuroscience, Medicine, Psychiatry
Information

Book description

The community reinforcement approach (CRA) to treating alcohol and other drug problems is designed to make changes in the client's daily environment, to reduce substance abuse and promote a healthier lifestyle. It is of proven effectiveness, and should be more widely used. This 2001 book presents research on the effectiveness of the CRA for a clinical readership. It includes the original study comparing CRA with traditional treatments of alcohol dependence, and summarizes other trials with alcohol, cocaine and heroin users. The CRA program provides basic guidelines for clinicians, focusing on communication skills, problem-solving and drink-refusal strategies, and addresses the needs of the client as part of a social community. Combining practical advice on such matters with a scientific survey of CRA in use, this book offers a treatment approach to all involved with the support and treatment of those with alcohol and drug problems.

Reviews

‘… a comprehensive, highly informative book that is invaluable to individuals looking to be introduced to the history of this approach and learn the therapeutic techniques involved.’

Source: Psychological Medicine

‘It is very rarely that I read a scientific book of about 200 pages in a rather short period of time, that such a book is not only scientifically sound and well written, but in some parts even exciting in such a way that you do not want to stop reading it … Altogether the book is well written.’

Source: Addiction

‘This is a clear, concise, reflective and most interesting book … this book should not be archived, but viewed as an ‘essential read’ by every clinician in this field.’

Source: European Child and Adolescent Psychiatry

‘I recommend this book … for addiction specialists who want to review the most effective treatments for their client groups …’.

Source: International Journal of Geriatric Psychiatry

‘… this is an easy to read book that presents an evidence base for a psychosocial intervention in the treatment of substance misuse, in a way that is both convincing and appealing. It is worthy of much praise …’.

Colin MacRae Source: Medical Sociology News

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Contents

Contents
  • 1 - Developing the Community Reinforcement Approach
    pp 1-7
  • View abstract

    Summary

    The story of the Community Reinforcement Approach (CRA) begins 30 years ago, when indigent alcohol-dependent individuals in downstate Illinois were routinely admitted to the nearest state mental hospital. CRA was the brain child of George Hunt who worked as a Research Associate in the Behavior Research Laboratory of Dr Nathan Azrin at Anna State Hospital. Mark Godley, a social worker, began a 5-year collaboration with Nathan Azrin when he contacted him in the September of that year, about working together on behavioral alcoholism treatment research. John Mallams had served as a therapist in the second CRA inpatient trial and was especially eager to work in a community outpatient setting. In the course of training and preparation for the first outpatient trial, Mallams and Robert J. Meyers modified the inpatient procedures. To date, every clinical trial has shown that CRA has a better outcome compared with more traditional treatment practices.
  • 2 - Practice and Promise: The Azrin Studies
    pp 8-27
  • View abstract

    Summary

    In the early 1970s, George Hunt and his advisor, Nathan Azrin, developed a theory for describing the etiology and maintenance of alcohol problems and a therapy approach for addressing how to treat them. Azrin and his colleagues designed a series of subsequent studies, testing the relative effectiveness of specific treatment components in order to refine the approach. Community Reinforcement Approach (CRA) was first tested on alcohol-dependent individuals in an inpatient setting, then tailored for use with outpatient populations who might have required residential treatment. As Azrin noted when conducting the 1976 study, disulfiram compliance difficulties were a significant barrier in alcohol treatment programs. The major contribution of the study that followed was a test of the relative importance of the disulfiram compliance procedures and the behavioral CRA components introduced in the previous trial. The effectiveness of the CRA procedures has now been demonstrated with a broader range of participant groups.
  • 3 - The Treatment
    pp 28-61
  • View abstract

    Summary

    This chapter outlines the components of the Community Reinforcement Approach (CRA) treatment program. One of the unique features of the CRA functional analysis is that both drinking and pleasurable, nonproblematic behaviors are examined routinely, with the goal of decreasing the substance-abusing behavior and increasing the nonproblematic behavior. Although functional analyses for drinking and nondrinking behaviors are completed at the beginning of CRA treatment, they are referred to throughout the program and new ones are introduced as needed. Many traditional alcohol treatment programs in the United States use abstinence as their only drinking goal. The CRA program's sobriety sampling procedure approaches the goals of treatment in a much gentler way. The foundation of CRA's behavioral treatment plan is built on two instruments: the Happiness Scale and the Goals of Counseling form. An essential component of the CRA program involves identifying behavioral skill deficits, and then providing training to improve those skills.
  • 4 - A Comparison of CRA and Traditional Approaches
    pp 62-78
  • View abstract

    Summary

    The degree of methodological control in Nathan Azrin's early studies and the surprisingly large treatment effects that were obtained established the Community Reinforcement Approach (CRA) as one of the more promising interventions for alcohol problems. With a larger sample of clients, the authors tested CRA in an ongoing public outpatient treatment program, the University of New Mexico Center on Alcoholism, Substance Abuse, and Addictions (CASAA), the largest public provider of addiction treatment services in New Mexico. A range of outcome measures was included to document drinking, alcohol-related problems and dependence, psychological adjustment, employment, and institutionalization. The authors have replicated Azrin's outpatient study by reproducing the same three treatment conditions: traditional treatment alone, traditional treatment plus disulfiram compliance, and full CRA. To these they added another group, who received CRA without disulfiram, in order to determine the extent to which disulfiram contributes to the overall effectiveness of the CRA.
  • 5 - Community Reinforcement and Traditional Approaches: Findings of a Controlled Trial
    pp 79-103
  • View abstract

    Summary

    This chapter contains the primary report of findings from the comparison of the Community Reinforcement (CRA) and traditional approaches. Study participants completed a comprehensive assessment at intake that included measurement of numerous demographic characteristics, motivation for change, psychological functioning, drinking history, and current drinking practices. The taking and monitoring of disulfiram were important distinguishing aspects of the treatment groups. The a priori treatment contrasts were made at proximal and distal follow-up points using three primary dependent measures. The three outcome measures were total standard drinks consumed during the assessment period, number of drinking days per week, and estimated peak blood alcohol concentration (BAC) for the assessment period. Traditional and CRA groups also had similar outcomes among the disulfiram-ineligible clients. The chapter concludes with a confessional litany of some errors the authors made along the way, in the hope of saving colleagues from similar pitfalls.
  • 6 - CRA with the Homeless
    pp 104-122
  • View abstract

    Summary

    In considering the suitable options for a substance-abuse treatment program for the homeless, one solid choice was the empirically based behavioral intervention called the Community Reinforcement Approach (CRA). CRA offers a comprehensive approach to substance-abuse treatment that addresses many of the needs of homeless men and women. The traditional CRA program was modified to better suit the needs of the homeless population. The study presented in this chapter was a controlled comparison of CRA and a day shelter's standard treatment for alcohol-dependent homeless individuals. The CRA condition outperformed the standard treatment (STD) on all three Brief Drinker Profile (BDP) drinking measures and across all follow-ups. The promising results were obtained while using a cost-effective group format by relatively inexperienced therapists. Future studies should focus on women's responses to the CRA program so that the necessary adaptations can be instituted.
  • 7 - CRA and Treatment of Cocaine and Opioid Dependence
    pp 123-146
  • View abstract

    Summary

    This chapter reviews positive results from a series of well-controlled clinical trials supporting the efficacy of Community Reinforcement Approach (CRA) treatments for cocaine and opioid dependence. It presents a brief description of the rationale for adding the voucher-based incentives to CRA. In developing this treatment for cocaine dependence in the late 1980s, the goal was to develop an intervention to treat cocaine dependence in outpatient settings. More substantially, the trial by Abbott and colleagues with opioid-dependent individuals did not involve vouchers and yet the CRA treatment resulted in greater reductions in opioid use than standard drug-abuse counseling. Delivered with or without vouchers, CRA represents an efficacious treatment that can enhance treatment outcomes with cocaine and opioid-dependent patients. Recognizing the importance of reinforcement to substance dependence and integrating systematic use of that principle into clinical efforts to reduce cocaine and opioid dependence has the potential to substantially improve treatment outcomes.
  • 8 - Community Reinforcement and Family Training (CRAFT)
    pp 147-160
  • View abstract

    Summary

    The Community Reinforcement and Family Training (CRAFT) program was developed with the belief that since family members can make important contributions in other areas of treatment, they can play a powerful role in helping to engage a resistant loved one into therapy. Some of CRAFT's basic components include discussing personal safety issues, outlining the context in which substance-abusing behaviors occur, teaching concerned significant others (CSOs) how to utilize positive reinforcers for both the substance user and themselves, and emphasizing lifestyle changes for the CSOs. Two CRAFT projects, one sponsored by National Institute on Alcohol Abuse and Alcoholism (NIAAA) and a second by National Institute on Drug Abuse (NIDA), have shown that engaging and retaining an individual in treatment with substance-abuse problems is not only possible, but probable. A treatment development study is being conducted to explore the effectiveness of CRAFT with substance-abusing adolescents and their families.
  • 9 - Summary and Reflections
    pp 161-170
  • View abstract

    Summary

    This conclusion presents some closing thoughts of the concepts discussed in the book A Community Reinforcement Approach to Addiction Treatment. The book deals with the story of the Community Reinforcement Approach (CRA) from its very beginning in the late 1960s through current research at the start of a new century. The studies have involved nearly a thousand clients treated with CRA for alcohol and illicit drug problems. CRA-based treatments have been tested, not against untreated or waiting list control groups, but in comparison with the most common, state-of-practice treatments available. It seems to be applicable across cultural differences, having been applied with affluent and poor, rural and urban, and minority populations including Hispanics and African-Americans. CRA procedures that have been applied effectively to increase disulfiram compliance could also be used to promote adherence to other pharmacotherapies. Reinforcement-based treatment procedures have been effective in managing pain, depression, and marital/family distress.

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