A Community Reinforcement Approach (CRA) To Substance Abuse Treatment At Bedrock

The Community Reinforcement Approach (CRA) is a treatment intervention based on operant conditioning.

This treatment is used for individuals with drug and alcohol use disorders and has been adapted for several populations.

The focus of this treatment is to help individuals find healthier ways of meeting their social and emotional needs besides using substances.

CRA utilizes a wide variety of behavioral interventions.

What Is A Community Reinforcement Approach (CRA)?

The Community Reinforcement Approach (CRA) is a substance use disorder treatment that Nate Azrin developed in the 1970s.

In 1995, Robert J. Meyers and Jane Smith published the first treatment manual of CRA for addiction treatment.

CRA aims to achieve abstinence by eliminating positive reinforcement for alcohol or drug abuse and enhancing positive reinforcement for sobriety.

CRA integrates several treatment components, including building motivation, analyzing drug or alcohol abuse, increasing positive reinforcement, learning new coping behaviors, etc.

Another form of CRA is the Adolescent Community Reinforcement Approach (A-CRA), which has been developed to treat young adults living with substance use disorders.

The Core Principles Of A CRA

Treatment planning in CRA begins with the Happiness Scale, a questionnaire that asks the individual to rate life satisfaction based on multiple factors.

The therapist uses the results of this scale to select areas to focus on during therapy.

Once these focus areas are identified, the individual and therapist create specific, achievable, meaningful, and measurable (SMART) goals for treatment.

Sobriety Sampling

Sobriety sampling is a trial period of abstinence. Instead of imposing the expectation of a lifetime of abstinence, CRA clinicians negotiate a trial period, usually 90 days.

The therapist then assists the individual in developing a plan to be successful in maintaining sobriety for this time period.

Behavioral Skills Training

CRA uses modeling, behavior rehearsal, and instruction to help individuals develop or improve social skills to support reaching treatment goals.

Skills training often focuses on communication, problem-solving, and alcohol and drug refusal.

Problem-solving training teaches individuals to break down larger problems into smaller pieces and brainstorm possible solutions.

Substance refusal training helps individuals identify high-risk situations and use role-playing to practice responses that can be used in these situations.

Increasing Positive Reinforcement

CRA emphasizes positive reinforcement through relationships, social and leisure activities, and employment.

This may include encouraging positive relationships with concerned significant others, caregivers, family, or friends, encouraging engagement in outside activities that may prevent substance use, and helping an individual maintain employment.

Relapse Prevention

Relapse prevention is an essential part of CRA. While relapse is an opportunity to learn for many people, it is always accompanied by risk that is better avoided if possible.

CRA uses specific techniques to prevent relapse, such as establishing an early warning system and performing a relapse-specific analysis.

This functional analysis helps to identify triggers and consequences of relapse.

CRA providers then work with the individual to define a chain of internal and external events that led to recent substance use and identify potential signs of relapse.

What Role Does The Community Play In A CRA?

CRA has the central belief that the environment or community can play a crucial role in deterring someone’s substance use by reinforcing alternative behavior.

Community is broadly defined and can include family, friends, hobbies, recreational activities, and employment.

The primary goal of CRA is to improve the environment of the individual using substances so that engagement in other activities is more rewarding than alcohol or drug use.

What Positive Reinforcement Strategies Are Used In A CRA?

CRA focuses on three primary sources of positive reinforcement: relationships, social and leisure activities, and employment.

Relationship therapy in CRA focuses on improving positive interactions between the individual and their significant other, family, and friends.

These individuals are encouraged to join the individual for sessions to improve communication skills and problem-solving.

Meaningful employment is a powerful form of positive reinforcement. CRA uses job skills training to help individuals get and maintain employment.

Social and leisure counseling helps individuals to engage in rewarding recreational activities that aren’t related to substance use.

Evidence For The Efficacy Of A CRA

In one clinical trial, the effectiveness of CRA was trialed as an alcoholism treatment among alcohol-dependent homeless individuals.

During the three-month randomized trial, all individuals were housed in apartments. Those employed at the end of the three months were allowed to remain in the apartment for another month.

One group of individuals was also treated in a group therapy format using CRA and awarded for good attendance, while another group was treated with standard treatment at a shelter.

The alcohol research study found that the individuals receiving CRA treatment showed significantly better treatment outcomes than those treated with standard care at the shelter.

A series of studies have also demonstrated that combining CRA with contingency management is highly effective for treating cocaine and heroin addiction.

What Other Approaches Can Be Combined With A CRA?

Various other approaches can be combined with a CRA, such as family therapy, which is also referred to as community reinforcement and family training (CRAFT), motivational interviewing, behavioral therapy, and other interventions.

Medications such as disulfiram for alcohol use disorders may also be combined with CRA for comprehensive treatment.

Skills Training

CRA treatment can be combined with training for life skills, communication, and other behavioral skills.

There are many opportunities in CRA and CRAFT for training behavioral skills such as positive
communication and problem-solving.

Positive communication skills are taught to support the success of other skills, including positive reinforcement.

Problem-solving is taught by working through high-risk situations to develop viable responses and solutions.

CRA may also be combined with independent living skills training. This may include money management, housing, home management training, risk prevention, career prep, etc.

Therapeutic Approaches

CRA may be combined with a variety of therapeutic approaches, including motivational enhancement therapy (MET) and cognitive behavioral therapy (CBT).

Motivational enhancement therapy (MET) is a therapeutic approach that helps someone identify and resolve their ambivalence related to drug or alcohol use.

Cognitive behavioral therapy (CBT) is a modality used to treat substance use, mental health conditions, and eating disorders (EDs).

CBT helps individuals target and challenge unhelpful thoughts as well as identify new coping skills for high-risk situations where relapse may occur.

How Does A CRA Factor Into Treatment At Bedrock?

CRA is used as an evidence-based therapy at Bedrock for the treatment of substance use disorders, both in inpatient and outpatient treatment.

CRA is used at Bedrock to increase an individual’s engagement in prosocial activities, behaviors, and relationships.

CRA aims to identify positive supports, structures, and goals individuals can use at Bedrock to reduce the risk of relapse during early recovery.

Learn About Addiction Treatment In Massachusetts

If you or a family member are seeking addiction treatment in Massachusetts, we can help.

Contact Bedrock Recovery Center to learn more information about CRA and how we provide this treatment.