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Community Reinforcement Approach (CRA)

Topic Areas
Scientific Rating
Child Welfare Relevance
Substance Abuse Treatment (Adult)
3  — Promising Research Evidence
Medium

About This Program

Target Population: Individuals ages 18 and over who have a primary diagnosis of any Substance-Related Disorder (DSM-IV-R); individuals with co-occurring disorders also respond well to this approach

Program Overview

CRA is a comprehensive cognitive-behavioral intervention for the treatment of substance abuse problems. CRA seeks to treat substance abuse problems through focusing on environmental contingencies that impact and influence the client's behavior. Developed in accordance with the belief that these environmental contingencies play a crucial role in an individual's addictive behavior and recovery, CRA utilizes familial, social, recreational, and occupational events to support the individual in changing his or her drinking/using behaviors and in creating a successful sobriety. Two other versions of CRA are highlighted on the CEBC: Adolescent Community Reinforcement Approach (A-CRA) and Community Reinforcement + Vouchers Approach (CRA+Vouchers).

Program Goals

The overall goal of Community Reinforcement Approach (CRA) is:

  • Rearrange multiple aspects of an individual's life so that a clean and sober lifestyle is more rewarding than one that is dominated by alcohol and/or drugs

Logic Model

The program representative did not provide information about a Logic Model for Community Reinforcement Approach (CRA).

Essential Components

The essential components of the Community Reinforcement Approach (CRA) include:

  • CRA Assessment Procedures
    • Identification and enhancement of motivation for change:
      • Identify internal/external reinforcers
      • Rapidly complete intake procedures
      • Set positive expectations
      • Include significant other
    • CRA Functional Analysis of Drinking/Using Behavior:
      • Identify Internal Antecedents (Internal Triggers) to drinking/using
      • Identify External Antecedents (External Triggers) to drinking/using
      • Complete comprehensive description of drinking/using behavior
      • Identify short-term positive consequences to drinking/using
      • Identify long-term negative consequences to drinking/using
    • CRA Functional Analysis of Non-Drinking/Non-Using Behavior:
      • Identify Positive Internal Triggers for Non-Drinking/Non-using Behavior
      • Identify Positive External Triggers for Non-Drinking/Non-using Behavior
      • Complete comprehensive description of non-drinking/non-using behaviors
      • Identify short-term negative consequences to non-drinking/non-using behaviors
      • Identify long-term positive consequences to non-drinking/non-using behaviors
  • CRA Treatment Procedures
    • Sobriety Sampling:
      • Obtain client's agreement to sample time-limited sobriety or relative sobriety
      • Outline a strategy for accomplishing time-limited sobriety or relative sobriety
    • Possible disulfiram use:
      • Present disulfiram use as an option
      • Use the CRA-specific monitoring system
    • CRA Treatment Plan:
      • Use the Happiness Scales
      • Develop the Goals of Counseling
    • Behavioral Skills Training:
      • Teach communication skills
      • Teach problem-solving skills
      • Provide drink/drug refusal training
    • Job Counseling:
      • Provide skill-based job counseling
      • Provide solution-oriented job counseling
      • Give information about Job Club
    • Social and Recreational Counseling:
      • Provide Community Access
      • Provide Reinforcer Sampling
      • Provide Systematic Encouragement
      • Provide Response Priming
      • Provide Social Club
    • Marital Counseling:
      • Provide action-oriented counseling
      • Provide time-limited counseling
      • Provide goal oriented counseling
      • Teach positive communication skills
    • Relapse Prevention:
      • Perform functional analysis of relapse behaviors
      • Analyze behavioral chains
      • Activate early warning system
      • Teach cognitive restructuring

Program Delivery

Adult Services

Community Reinforcement Approach (CRA) directly provides services to adults (regardless of whether they are parents or caregivers) and addresses the following:

  • Substance abuse/dependency

Recommended Intensity:

1 session per week

Recommended Duration:

The recommended duration is 50-60 minutes. The recommended length of treatment is 12-16 weeks. This is the amount of time that has been shown to be successful in clinical trials. Each program should examine the severity of addiction involved, and let that dictate the length of treatment and length of contact.

Delivery Settings

This program is typically conducted in a(n):

  • Hospital
  • Outpatient Clinic
  • Community-based Agency / Organization / Provider
  • Group or Residential Care

Homework

Community Reinforcement Approach (CRA) includes a homework component:

Homework is assigned in collaboration with the client after each session and is tailored to address therapeutic needs. Assignments are usually behavioral, such as trying a new activity, and are given within the framework of trying new behavior. Homework assignments are made so the client can be successful in completing them, so they are initially easy tasks to help build self-esteem and self-efficacy.

Languages

Community Reinforcement Approach (CRA) has materials available in languages other than English:

Dutch, German

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

A counselor/therapist

Manuals and Training

Prerequisite/Minimum Provider Qualifications

All therapists using this approach should be certified as trained by Robert J. Meyers & Associates to ensure that the procedures are being delivered as they were intended. Since this is a psychotherapeutic approach, state laws also govern who should be allowed to serve as a therapist.

Manual Information

There is a manual that describes how to deliver this program.

Training Information

There is training available for this program.

Training Contact:
Training Type/Location:

Onsite and regional

Number of days/hours:

A basic training approach (which is not recommended) involves 3 days of onsite training. The recommended intensive training model involves quarterly onsite training over the course of 1 year with regular conference calls and review of audiotapes.

Additional Resources:

There currently are additional qualified resources for training:

Robert J. Meyers and Associates (including: Drs. Robert J. Meyers, Jane Ellen Smith and John Gardin II) provides comprehensive training in the adult program and the adolescent program.

Implementation Information

Pre-Implementation Materials

There are no pre-implementation materials to measure organizational or provider readiness for Community Reinforcement Approach (CRA).

Formal Support for Implementation

There is formal support available for implementation of Community Reinforcement Approach (CRA) as listed below:

CRA has a system to teach and certify qualified therapists. After a two-and-a-half day training, they have the option to send in audio tapes to an encrypted system and have their tapes coded by professionally trained coders which will lead to certification. There is a system in place to also certify CRA coders, supervisors, and trainers.

Fidelity Measures

There are fidelity measures for Community Reinforcement Approach (CRA) as listed below:

Sessions are coded for fidelity purposes and then reviewed with the therapist. To be a coder, the professional must become certified as a therapist before beginning the coder, supervisor certification process. To move onto becoming a supervisor, one must pass all protocols so that they are able to properly code any type of treatment session that comes their way. The coder will listen to and rate at least one therapist tape per week, when possible, using the rating form and criteria provided and maintain 80% agreement with expert rater for a minimum of 5 tapes. Tapes will be rated by RJM & Associates staff as well for inter-rater reliability.

Implementation Guides or Manuals

There are implementation guides or manuals for Community Reinforcement Approach (CRA) as listed below:

These 2 books with step-by-step information on all protocols and examples are available on www.amazon.com:

  • Meyers, R. J. & Smith, J. E. (1995). Clinical guide to alcohol treatment: The Community Reinforcement Approach. Guildford Press.
  • Meyers, R. J. & Miller, W. R. (2001). A Community Reinforcement Approach to the treatment of addiction. University Press.

Research on How to Implement the Program

Research has not been conducted on how to implement Community Reinforcement Approach (CRA).

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Hunt, G. M., & Azrin, N. H. (1973). A community reinforcement approach to alcoholism. Behavioral Research and Therapy, 11(1), 91–104. https://doi.org/10.1016/0005-7967(73)90072-7

Type of Study: Other quasi-experimental
Number of Participants: 16

Population:

  • Age — Control: Mean=36.75 years; CRA: Mean=39.87 years
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants were patients admitted to a State Hospital for treatment of alcoholism.

Location/Institution: Rural Midwest

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the effectiveness of the Community Reinforcement procedure [(now known as Community Reinforcement Approach (CRA)] with hospitalized alcoholics. Participants in the CRA treatment group of alcoholics were matched with a control group based on employment history, family stability, previous drinking history, age, and education. Measures utilized include the Marriage Adjustment Inventory. Results indicate that the percent of time spent drinking, unemployed, away from home, or institutionalized was than twice as high for the control group as for the CRA group. Limitations include a lack of long-term follow-up period and lack of randomization to groups.

Length of controlled postintervention follow-up: 6 months.

Azrin, N. H., Sisson, R. W., Meyers, R., & Godley, M. (1982). Alcoholism treatment by disulfiram and community reinforcement therapy. Journal of Behavior Therapy & Experimental Psychiatry, 13(2), 105–112. https://doi.org/10.1016/0005-7916(82)90050-7

Type of Study: Randomized controlled trial
Number of Participants: 43

Population:

  • Age — 20–60 years
  • Race/Ethnicity — Not specified
  • Gender — 83% Male
  • Status — Participants were outpatients of a rural community alcoholism treatment clinic.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the disulfiram assurance component and compare it with a traditional method of dispensing disulfiram, and with a combined community-reinforcement and Antabuse assurance treatment. Participants were randomly assigned to one of three treatments: 1) Traditional disulfiram treatment including five structured counseling sessions. 2) Disulfiram Assurance group (same services as traditional group plus training on how to help assure that the drug was taken regularly for the subject and their significant other, such as a spouse or friend), and 3) Behavior Therapy group (received the same training as the Disulfiram Assurance group plus the training specified in the Community Reinforcement Approach (CRA) program. Measures utilized include developer measures that allowed participants to describe mean number of days drinking and mean number of days intoxicated, as well as whether the participants would take the traditional disulfiram treatment medication. Results indicate that all participants in the traditional disulfiram group resumed drinking by the 6-month follow-up. The Disulfiram Assurance group was sufficient to stop drinking for married participants, but not for single ones. The Behavior Therapy CRA plus Assurance program was effective for both single and married participants. Limitations include the small sample size and findings in a rural setting that may not transfer to other populations.

Length of controlled postintervention follow-up: Estimated 8–12 weeks.

Smith, J. E., Meyers, R. J., & Delaney, H. D. (1998). The Community Reinforcement Approach with homeless alcohol-dependent individuals. Journal of Consulting and Clinical Psychology, 66(3), 541–548. https://doi.org/10.1037/0022-006X.66.3.541

Type of Study: Randomized controlled trial
Number of Participants: 106

Population:

  • Age — 18–69 years
  • Race/Ethnicity — 64% White, 19% Hispanic, 13% Native American, and 4% African American
  • Gender — 86% Male
  • Status — Participants were chronic homeless individuals recruited from a day shelter.

Location/Institution: Albuquerque, New Mexico

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to compare the Community Reinforcement Approach (CRA) with services as usual in a shelter setting. Participants were randomly assigned to receive standard treatment, including access to shelter services and on-site Alcoholics Anonymous meetings, or to the CRA condition. In addition, the participants who were medically eligible received disulfiram (Antabuse). Measures utilized include the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. Results indicate that there was no difference in outcomes for those taking the drug and those not taking it, so in subsequent analysis the distinction between those groups was ignored. Results also indicate that participants in both the standard shelter treatment and the CRA condition improved over follow-up. However, CRA participants outperformed those in the standard treatment condition. The authors note that the lowest posttreatment drinking levels were in the earliest stages of follow-up and recommend periodic booster sessions of treatment. Limitations include differences in the amount of services received between the two groups, the use of routine breathalyzers in the CRA group, and self-selection by subjects.

Length of controlled postintervention follow-up: Estimated 8–9 months.

Secades-Villa, R., Sánchez-Hervás, E., Zacarés-Romaguera, F., García-Rodríguez, O., Santonja-Gómez, F. J., & García-Fernández, G. (2011). Community Reinforcement Approach (CRA) for cocaine dependence in the Spanish public health system: 1 year outcome. Drug and Alcohol Review, 30(6), 606–612. https://doi.org/10.1111/j.1465-3362.2010.00250.x

Type of Study: Randomized controlled trial
Number of Participants: 82

Population:

  • Age — Mean=30.7–32.1 years
  • Race/Ethnicity — Not specified
  • Gender — 83–89% Male
  • Status — Participants were cocaine-addicted adults.

Location/Institution: Catarroja Addictive Behaviors Clinic, Spain

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to determine the effectiveness of the Community Reinforcement Approach (CRA) for cocaine dependents at an outpatient clinic within the Spanish public health system. Participants were randomly assigned to one of two treatment conditions: Standard Treatment or CRA. Measures utilized include the European version of the Addiction Severity Index. Results indicate that of the patients who received CRA, 55% completed 6 months of treatment, versus 40% who received Standard Treatment. At the 12 month follow up, patients assigned to the CRA condition achieved higher rates of abstinence (95.2%) by comparison with Standard Treatment (69.2%). In the CRA group, 27% of the patients achieved continuous cocaine abstinence, versus 21% in the Standard Treatment group. The CRA group also obtained lower scores than the Standard Treatment group in all Addiction Severity Index composite scores. Limitations include twice-weekly urine tests during treatment potentially allow for some cocaine use to remain undetected, small sample size, high attrition rate, Spanish only sample, and a largely male sample.

Length of controlled postintervention follow-up: 6 months.

Additional References

Meyers, R. J., & Smith, J. E. (1995). Clinical guide to alcohol treatment: The Community Reinforcement Approach. Guildford Press.

Meyers, R. J., & Miller, W. R. (2001). A Community Reinforcement Approach to the treatment of addiction. University Press.

Miller, W. R., & Meyers, R. J. (1999). The Community Reinforcement Approach. Alcohol Research and Health, 23(2), 116-120. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6760430/

Contact Information

Robert Meyers, PhD
Agency/Affiliation: University of New Mexico's Center on Alcoholism, Substance Abuse and Addiction
Website: www.robertjmeyersphd.com
Email:
Phone: (505) 270-6503
Fax: (505) 925-2351

Date Research Evidence Last Reviewed by CEBC: July 2023

Date Program Content Last Reviewed by Program Staff: October 2018

Date Program Originally Loaded onto CEBC: August 2006