Academic journal article Alcohol Research

The Community Reinforcement Approach: An Update of the Evidence

Academic journal article Alcohol Research

The Community Reinforcement Approach: An Update of the Evidence

Article excerpt

The Community Reinforcement Approach (CRA) is a comprehensive behavioral treatment package that focuses on the management of substance-related behaviors and other disrupted life areas. The goal of CRA is to help people discover and adopt a pleasurable and healthy lifestyle that is more rewarding than a lifestyle filled with using alcohol or drugs. Multiple research reviews and meta-analyses of the treatment-outcome literature have shown CRA to be among the most strongly supported treatment methods (Finney and Monahan 1996; Holder et al. 1991; Miller et al. 1995, 2003). This article briefly discusses the science behind CRA, and provides an overview of the treatment program. In addition, it discusses two novel variants built upon the CRA foundation. These interventions include an adolescent version of CRA called Adolescent Community Reinforcement Approach (A-CRA), and a program called Community Reinforcement and Family Training (CRAFT), which is designed to engage treatment-refusing substance-abusing individuals into treatment by working through family members.

Development and Effectiveness of CRA

The most influential behaviorist of all times, B. F. Skinner, largely considered punishment to be an ineffective method for modifying human behavior (Skinner 1974). Thus it was no surprise that, many years later, research discovered that substance use disorder treatments based on confrontation were largely ineffective in decreasing the use of alcohol and other substances (Miller and Wilbourne 2002, Miller et al. 1998). Nate Azrin already was convinced of this back in the early 1970s, when he designed an innovative treatment for alcohol problems: the Community Reinforcement Approach (CRA). Azrin believed that it was necessary to alter the environment in which people with alcohol problems live so that they received strong reinforcement for sober behavior from their community, including family, work, and friends. As part of this strategy, the program emphasizes helping clients discover new, enjoyable activities that do not revolve around alcohol, and teaching them the skills necessary for participating in those activities (see sidebar for a description of CRA procedures).

Research has since supported the premise behind CRA. Studies show that people with substance use disorders report that they are less engaged in pleasant activities compared with healthy controls (Roozen et al. 2008; Van Etten et al. 1998). And other studies found that enriching people's environment with non-substance-related rewarding alternatives encourages them to reduce their substance use (Correia et al. 2005; Vuchinich and Tucker 1996). Even modern day neurobiology has confirmed that components of addiction treatment should focus on increasing patients' involvement with alternative reinforcers (Volkow et al. 2003).

In terms of testing CRA itself, studies suggest that it is highly effective. Azrin's first two studies of the program tested its effectiveness among alcohol-dependent inpatients (Azrin 1976; Hunt and Azrin 1973). The results showed that the new CRA program was more effective in reducing drinking than was the hospital's Alcoholics Anonymous program. Furthermore, the CRA participants had better outcomes with regard to their jobs and family relationships. Azrin then modified the program slightly to test it with outpatients at a rural alcohol treatment agency (Azrin et al. 1982). He and his colleagues, again, found CRA to be superior to the comparison condition.

A larger outcome study conducted in the 1990s had mixed results, though it did show a benefit of CRA on the immediate outcome. (Miller et al. 2001). For this study, participants had to score in the symptomatic range on two of four measures, including the Addiction Severity Index and the Alcohol Use Inventory. The final sample consisted of people who met an average of 7 of the 9 criteria for alcohol dependence syndrome as defined by the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) (American Psychiatric Association 1980). …

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