Evidence-Based Evidence-Based TreatmentTreatment

Community Reinforcement Community Reinforcement Approach (CRA)Approach (CRA)

Robert J. Meyers, Ph.D.Robert J. Meyers, Ph.D.

Jane Ellen Smith, Ph.D.Jane Ellen Smith, Ph.D.

University of New MexicoUniversity of New Mexico

Early CRA StudiesEarly CRA Studies

Hunt & Azrin, 1973Hunt & Azrin, 1973

Azrin, 1976Azrin, 1976

Azrin, Sisson, Meyers, & Azrin, Sisson, Meyers, & Godley, 1982Godley, 1982

Hunt & Azrin 1973Hunt & Azrin 1973

inpatient alcoholicsinpatient alcoholics job finding counselingjob finding counseling behavioral/marital txbehavioral/marital tx social/leisure counselingsocial/leisure counseling reinforcer access counselingreinforcer access counseling social clubsocial club home visitshome visits [total 50 hrs per client][total 50 hrs per client]

Results: Results: 6 month follow-up6 month follow-up

0

20

40

60

80

Drink Days Jobless Days Days awayfrom family

Institution Separated/Div

Traditional CRA

Azrin 1976: New & Azrin 1976: New & Improved CRAImproved CRA

inpatient inpatient alcoholicsalcoholics

disulfiram disulfiram w/compliance w/compliance protocolprotocol

problem problem prevention prevention rehearsalrehearsal

buddy systembuddy system

early warning early warning mood monitoringmood monitoring

some group txsome group tx ~70% as ~70% as

aftercare home aftercare home visitsvisits

[Average 30 [Average 30 contact hrs]contact hrs]

CRA new & improved: CRA new & improved: ResultsResults

0

10

20

30

40

50

60

70

Drink Days Jobless Days Days away fromfamily

Institution

Traditional CRA

11stst CRA Outpatient Study CRA Outpatient Study (Azrin, Sisson, Meyers, & (Azrin, Sisson, Meyers, &

Godley, 1982)Godley, 1982) 43 outpatient 43 outpatient

alcoholicsalcoholics 3 groups:3 groups: traditional tx onlytraditional tx only traditional tx + traditional tx +

disulfiram disulfiram compliancecompliance

CRA onlyCRA only

increased use of increased use of positive positive reinforcementreinforcement

sobriety samplingsobriety sampling immed. disulfiramimmed. disulfiram drink refusal trainingdrink refusal training +/- functional analysis+/- functional analysis job club job club phone contactsphone contacts [Average: 5 tx [Average: 5 tx

sessions]sessions]

Results of 1982 studyResults of 1982 study

6 month follow-up6 month follow-up

Disulfiram only groupDisulfiram only group % days abs = % days abs = 74% 74%

CRA +CRA + % days abs = % days abs = 97%97%

Traditional groupTraditional group % day abs = % day abs = 45%45%

CRA with Homeless CRA with Homeless Alcohol-Dependent Alcohol-Dependent

IndividualsIndividualsPI: PI: Jane Ellen SmithJane Ellen Smith

Co-PI: Co-PI: Robert J. MeyersRobert J. Meyers

Funded by:Funded by: NIAAANIAAA

Primary Questions Primary Questions Addressed:Addressed:

Is CRA > a day shelter’s standard Is CRA > a day shelter’s standard program for treating program for treating drinkingdrinking problems among homeless problems among homeless individuals?individuals?

What are the effects of the 2 What are the effects of the 2 treatments on the treatments on the nonnon-drinking -drinking variables (employment, housing)?variables (employment, housing)?

CRA GroupCRA Group

Group SessionsGroup Sessions Problem-SolvingProblem-Solving Communication SkillsCommunication Skills Drink-RefusalDrink-Refusal Independent Living SkillsIndependent Living Skills Goal Setting/Community MeetingGoal Setting/Community Meeting Social ClubSocial Club Disulfiram ComplianceDisulfiram ComplianceIndividual SessionsIndividual Sessions Job FindingJob Finding Case ManagementCase Management Couples TherapyCouples Therapy

Standard Treatment Standard Treatment GroupGroup

Day Shelter ProgramDay Shelter Program Project ShareProject Share Alcoholics Anonymous MeetingsAlcoholics Anonymous Meetings 12-Step Counselor12-Step Counselor Job Service ProgramJob Service Program VA Benefits AdvisorVA Benefits Advisor Project CAREProject CARE

Grant-Provided HousingGrant-Provided Housing

All participants were housedAll participants were housed Normal stay: 3 monthsNormal stay: 3 months Extended stays: if job and $ savedExtended stays: if job and $ saved Random breathalyzer testsRandom breathalyzer tests

Drinks Per Week By Drinks Per Week By ConditionCondition

Follow-Up Period

0

2

4

6

8

10

12

14

16

18

20

2 Month 4 Mont 6 Month 9 Month 12 Month

Median SECs

--- Standard

--- CRA

Percent Homeless By Percent Homeless By ConditionCondition

0

5

10

15

20

25

30

35

CRA

Standard

Follow-up Periods

2 Month 4 Month 6 Month 9 Month 12 Month

Percent

Percent Employed By Percent Employed By ConditionCondition

0

10

20

30

40

50

60

CRA

StandardPercent

Follow-up Period

Intake 2 Month 4 Month 6 Month 9 Month 12 Month

Limitations of the StudyLimitations of the Study

Not comparable “doses” of Not comparable “doses” of treatmenttreatment

Some CRA participants still drinking Some CRA participants still drinking heavilyheavily

Only moderate improvement in Only moderate improvement in employmentemployment

Cost of housingCost of housing

CRA with Homeless CRA with Homeless Alcoholic WomenAlcoholic Women

Why women only?Why women only? Treatments:Treatments:

(1)(1) Case ManagementCase Management

(2)(2) CRACRA

(3)(3) CRA + contingency-managed CRA + contingency-managed computer trainingcomputer training

Summaries of Adult Summaries of Adult Treatment Research for Treatment Research for Alcohol Use DisordersAlcohol Use Disorders

Meta-analyses and ReviewsMeta-analyses and Reviews

Evidence of Effectiveness: Evidence of Effectiveness: Meta-analysesMeta-analyses

Holder et al., ’91Holder et al., ’91 Miller et al., ’95Miller et al., ’95Social skills trainingSocial skills training Brief interventionBrief intervention

Self-control trainingSelf-control training Social skills trainingSocial skills training

Brief motivational txBrief motivational tx METMET

Behavioral Marital txBehavioral Marital tx CRA CRA

CRACRA Behavioral contractBehavioral contract

Stress managementStress management Aversion txAversion tx

Evidence of Effectiveness Evidence of Effectiveness (cont’d)(cont’d)

Finney et al., ‘96 Miller et al., ’03CRA Brief InterventionSocial skills training Motivational

EnhancementBehavioral Marital tx AcamprosateDisulfiram Implants CRAOther marital tx Self-Change

(bibliotherapy)Stress Management Naltrexone

CRA for Illicit Drugs: Adult CRA for Illicit Drugs: Adult StudiesStudies

CocaineCocaineHiggins et al. (1991; 1993; 1994; Higgins et al. (1991; 1993; 1994;

1995; 2000)1995; 2000)

HeroinHeroinBickel et al. (1997)Bickel et al. (1997)Abbott et al. (1998)Abbott et al. (1998)

Adolescent CRAAdolescent CRA

Godley et al. (2002)Godley et al. (2002)

Continuing care study (after Continuing care study (after residential treatment)residential treatment)

UCC (usual continuing care) or ACRA UCC (usual continuing care) or ACRA + case mgmt+ case mgmt

114 adolescents114 adolescents 90% = marijuana dependent at intake90% = marijuana dependent at intake 57% = alcohol dependent 57% = alcohol dependent 82% = involved w/ juvenile justice 82% = involved w/ juvenile justice

systemsystem

Results: 3 monthsResults: 3 months

ACRA significantly > UCC in ACRA significantly > UCC in terms of:terms of:

abstinence from marijuanaabstinence from marijuana reduced alcohol use reduced alcohol use

Cannabis Youth Treatment Cannabis Youth Treatment (CYT) Study (Dennis et al., (CYT) Study (Dennis et al.,

2004)2004)

Outpatient treatment for Outpatient treatment for marijuanamarijuana

Trial 1:MET/CBT5; MET/CBT12; Trial 1:MET/CBT5; MET/CBT12; FSNFSN

Trial 2: MET/CBT5; ACRA; MDFTTrial 2: MET/CBT5; ACRA; MDFT 600 adolescents600 adolescents Hi rate of illegal activitiesHi rate of illegal activities

Results: 12 monthsResults: 12 months

Measures: Measures: (1) days of abstinence (from drugs & alcohol) (1) days of abstinence (from drugs & alcohol) (2) “in recovery” = living in community (not (2) “in recovery” = living in community (not

jail) +jail) + no use + no past month substance no use + no past month substance

problemsproblems

General Findings: All treatments General Findings: All treatments significantly improved pre-post; no significantly improved pre-post; no significant tx comparison differencessignificant tx comparison differences

Best overall “in recovery” rates = Best overall “in recovery” rates = ACRA (34%; next best = MET/CBT5 at ACRA (34%; next best = MET/CBT5 at 27%)27%)

Best # of abstinent days for Trial 2 = Best # of abstinent days for Trial 2 = ACRA (73% of days during the year; ACRA (73% of days during the year; best for Trial 1= MET/CBT5 at 74%)best for Trial 1= MET/CBT5 at 74%)

Most cost-effective? ACRA Most cost-effective? ACRA

UNM CASAA’s Street Youth UNM CASAA’s Street Youth Program: Project STARProgram: Project STAR

EngagementConsent

Eligibility ScreenBaseline Assessment

Treatment as UsualN = 90

Community Reinforcement Approach(CRA, 12 sessions),

HIV prevention (4 sessions)N = 90

3-month follow-up6-month follow-up

Percent days of Percent days of substance usesubstance use

67

34

63

55

30

35

40

45

50

55

60

65

70

CRA (N = 44) SAU (N = 40)

Baseline6 months

Significant interaction between time (pre to 6 months) and group using number of treatment sessions as covariate (F (1, 81) = 9.10, p < .01).

Percentage of days off Percentage of days off the streetthe street

28

41

26 25

20

25

30

35

40

45

CRA (N = 44) SAU (N =40)

Baseline6 months

Trend toward interaction between time (pre to 6 months) and group using number of treatment sessions as covariate (F (1, 81) = 3.09, p =. 08).

What does What does notnot work! work!

Educational films and lecturesEducational films and lectures General alcoholism counselingGeneral alcoholism counseling PsychotherapyPsychotherapy Confrontational counselingConfrontational counseling Antipsychotic medicationAntipsychotic medication Psychotherapy, group processPsychotherapy, group process Insight therapyInsight therapy

Why Isn’t CRA Used Why Isn’t CRA Used More?More?

Disease ModelDisease Model Limited accessibilityLimited accessibility It’s hard to teach an old dog new It’s hard to teach an old dog new

trickstricks ““We already do that”We already do that” CRA isn’t “sexy”CRA isn’t “sexy”