Abstracts – Community Reinforcement

On this page you can find a selection of abstracts regarding studies and books on A-CRA, CRA & CRAFT.

Abbott, P. J., Moore, B. A., Weller, A. B., & Delaney, H. D. (1998). AIDS risk behaviors in opioid dependent patients treated with Community Reinforcement Approach and relationships with psychiatric disorders. Journal of Addictive Diseases, 17, 33-48.

Examined the Community Reinforcement Approach’s (CRA) effect on AIDS risk behaviors and the relationship between comorbid psychiatric disorders and risk for AIDS behavior in opioid dependent patients entering methadone maintenance treatment. Also, AIDS risk behaviors were studied as they related to the Addition Severity Index, Beck Depression Inventory, SCL-90-R, and the Social Adjustment Scale-Self Report. 227 Ss (aged 20-63 yrs) were drawn from a large clinical trial that examined the effectiveness of a CRA for treatment of opioid dependence. Both CRA and standard treatment demonstrated a significant effect on reduction of AIDS risk behaviors. There was no relationship between comorbid psychiatric disorders and the risk for AIDS behavior. However, there were correlations with other psychiatric, social, and substance abuse variables. Multivariate analyses indicated that increased drug and legal ASI composite scores were primary predictors of increased AIDS risk behavior.

Abbot, P. J., Moore, B., Delaney, H., & Weller, S. (1999). Retrospective analyses of additional services for methadone maintenance patients. Journal of Substance Abuse Treatment, 17, 129-137.

Studied the effects of additional treatment service for patients entering a methadone maintenance program who transferred from community methadone treatment programs or who entered off the street and not currently on methadone. There were 83 patients in each group (average age 37 yrs). Additional treatment included standard counseling, community reinforcement approach procedures (problem-solving, communication skills, drug-refusal training, social/recreational training), and relapse prevention. Outcome measures were treatment retention, urinalysis for opiates and cocaine, and composite scores on the Addiction Severity Index (A. T. McLellan et al, 1985) indicating problems in the following areas: alcohol, drug, medical, psychological, employment, legal, and family/social. Patients in the methadone transfer group were using less heroin at intake than patients newly initiated onto methadone, and at 6-mo followup both groups had improved from additional treatment services.

Abbott, P. J., Weller, S. B., Delaney, H. D., & Moore, B. A. (1998). Community reinforcement approach in the treatment of opiate addicts. Am J Drug Alcohol Abuse 1998; 24:17-30.

Studied the efficacy of the community reinforcement approach (CRA) as compared to standard counseling in opiate-dependent patients on methadone maintenance. 180 Ss were randomized to 3 treatment conditions: standard, CRA, and CRA with relapse prevention (CRA/RP). Of these, 151 Ss were followed up 6 mo after intake. Since few of the RP sessions had been concluded at the 6-mo follow-up, the 2 CRA groups were combined for analyses. Weekly urinalysis drug screens and Addiction Severity Index (ASI) scores at intake and 6 mo were compared. The combined CRA groups did significantly better than the standard group in the following areas: consecutive opiate-negative urinalysis (3 weeks), and the 6-mo ASI drug composite score. Results support the benefit of adding CRA strategies to the treatment of patients who are opiate dependent and on methadone maintenance. Because of insufficient treatment exposure to RP at the 6-mo follow-up, the additive effect of RP could not be adequately evaluated; further follow-up will be required.

Allen, J. P., & Mattson, M. E. (1993). Strategies for the treatment of alcoholism. In: T. R. Giles (Ed). Handbook of Effective Psychotherapy. New York: Plenam Press, 379-406.

Addresses three . . . recently developed strategies that have been shown to have promise in the treatment of alcoholism: the community reinforcement approach, social skills training, and patient-treatment matching. Briefly mentions some encouraging work in the area of pharmacotherapy for alcoholism. Focuses on the effectiveness of the intervention on reducing drinking itself.

Azrin, N. H. (1976). Improvements in the community reinforcement approach to alcoholism. Behav Res Ther 14: 339-348, 1976.

Evaluated a modified community reinforcement program for testing alcoholics. The previously tested community reinforcement program included special job, family, social, and recreational procedures and was shown to reduce alcoholism. To increase the effectiveness of the program, the present study incorporated a buddy system, a daily report procedure, group counseling, and a special social motivation program to ensure the self-administration of disulfiram (Antabuse). The 19 male alcoholics who received the improved program drank less, worked more, spent more time at home and less time institutionalized than did their matched controls who received the standard hospital treatment including Antabuse in the usual manner. These results were stable over a 2-yr period, and the program appeared even more effective and less time-consuming than the previous program. Results replicate the effectiveness of the community reinforcement program for reducing alcoholism and indicate the usefulness of the additions to the program.

Azrin, N. H., Sisson, R. W., Meyers, S. B., & Godley, M. (1982). Alcoholism treatment by disulfiram and community reinforcement therapy. J Behav Ther Exp Psychiatry, 1982; 13:105-11

Traditional disulfiram (Antabuse) treatment for alcoholism has often been ineffective because of patients’ failure to maintain usage. The present study, with 43 20-60 yr old alcoholics, compared a traditional disulfiram treatment, a socially motivated Disulfiram Assurance (DA) program, and a DA program combined with reinforcement therapy. About 5 sessions were given for each program. At 6-mo follow-up, the traditional-treatment Ss were drinking on most days and no longer taking the medication. The DA treatment resulted in almost total sobriety for married (or cohabitating) Ss but had little benefit for the single ones. The combined program produced near-total sobriety for single and married Ss. Results indicate a promising integration of chemical, physiological, and social treatments for alcoholism.

Barber, J. G.1992. Relapse prevention and the need for social interventions. J. Subst. Abuse Treat. 9, 157-158

Rejects the cognitive-behavioral treatment advocated by G. A. Marlatt and J. R. Gordon (1985) for substance abusers in favor of approaches that help addicted individuals modify their posttreatment environments. The community-reinforcement program of G. M. Hunt and N. H. Azrin (1973) is described, although its high cost and labor intensity are noted.

Bickel, W. K., Amass, L., Higgins, S. T., Badger, G. J., & Esch, R. A. (1997). Effects of adding behavioral treatment to opioid detoxification with buprenorphine. J Consult Clin Psychol 1997; 65:803-810.

This trial assessed whether behavioral treatment improves outcome during a 26-week outpatient opioid detoxification. Thirty-nine opioid-dependent adults were assigned randomly to a buprenorphine dose-taper combined with either behavioral or standard treatment. Behavioral treatment included (a) a voucher incentive program for providing opioid-free urine samples and engaging in verifiable therapeutic activities and (b) the community reinforcement approach, a multicomponent behavioral treatment. Standard treatment included lifestyle counseling. Fifty-three percent of the patients receiving behavioral treatment completed treatment, versus 20% receiving standard treatment. The percentage of patients achieving 4, 8, 12, and 16 weeks of continuous opioid abstinence were 68, 47, 26, and 11 for the behavioral group and 55, 15, 5, and 0 for the standard group, respectively. Behavioral treatment improved outcomes during outpatient detoxification.

Budney, A. J., & Higgins, S. T. (1998). A community reinforcement plus vouchers approach: Treating cocaine addiction. Rockville, MD: National Institute on Drug Abuse

Budney, A. J., Higgins, S. T., Delaney, D. D., Kent, L., & Bickel, W. K. (1991) Contingent reinforcement of abstinence with individuals abusing cocaine and marijuana. Journal of Applied Behavior Analysis, 24. 657-665

Demonstrated the efficacy of a treatment package that included contingency management and the community reinforcement approach for increasing cocaine and marijuana abstinence in 2 White males (aged 28 and 35 yrs) seeking treatment for cocaine dependence.

Dennis, M, et al. (2004). The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27(3), 197-213.

This article presents the main outcome findings from two inter-related randomized trials conducted at four sites to evaluate the effectiveness and cost-effectiveness of five short-term outpatient interventions for adolescents with cannabis use disorders. Trial 1 compared five sessions of Motivational Enhancement Therapy plus Cognitive Behavioral Therapy (MET/CBT) with a 12-session regimen of MET and CBT (MET/CBT 12) and another that included family education and therapy components (Family Support Network [FSN]). Trial II compared the five-session MET/CBT with the Adolescent Community Reinforcement Approach (ACRA) and Multidimensional Family Therapy (MDFT). The 600 cannabis users were predominately white males, aged 15-16. All five CYT interventions demonstrated significant pre-post treatment improvements during the 12 months after random assignment to a treatment intervention in the two main outcomes: days of abstinence and the percent of adolescents in recovery (no use or abuse/dependence problems and living in the community). Overall, the clinical outcomes were very similar across sites and conditions; however, after controlling for initial severity, the most cost-effective interventions were MET/CBT5 and MET/CBT 12 in Trial 1 and ACRA and MET/CBT5 in Trial 2. It is possible that the similar results occurred because outcomes were driven more by general factors beyond the treatment approaches tested in this study; or because of shared, general helping factors across therapies that helped these teens attend to and decrease their connection to cannabis and alcohol.

Finney, J. W., & Monahan, S. C. (1996). The cost-effectiveness of treatment for alcoholism: a second approximation. J Stud Alcohol, 57: 229-243.

Provides a 2nd approximation of the cost-effectiveness of treatment modalities for alcoholism. 141 treatment studies were reviewed. The difference between predicted and actual effectiveness score (Adjusted Effectiveness Index [AEI]) was calculated for each modality. Findings showed that the AEIs were consistent with those of H. Holder et al (1991) in suggesting that some of the same modalities (social skills training, community reinforcement approach, behavioral marital therapy, and stress management training) appear to be effective, whereas others (residential milieu treatment, general counseling, metronidazole) show no proof of effectiveness. However, a smaller range of effectiveness across modalities was found. This suggests no significant relationship between cost and effectiveness. Thus, major treatment provision or funding decisions must not be based solely on this type of review.

Finney, J. W. & Moos, R. H. (2002). Psychosocial treatments for alcohol use disorders. In: P. E. Nathan & J. M Gordon (Eds), A guide to treatments that work. New York, NY: Oxford University Press.

(from the chapter) Reviewed studies of psychosocial treatments for alcohol use disorders. The more effective cognitive behavioral treatments (CBTs) include social skills training and the community reinforcement approach. Two recent multisite evaluations suggest that 12-step treatment can be as effective as CBT. With regard to patient-treatment matching, interpersonally oriented treatment appears to be more effective for patients who are functioning better, whereas CBTs seem to work better for more impaired patients. However, some findings may be attributed to multiple test for interaction effects. In general, patients of therapists who are more interpersonally skilled, less confrontational, and/or more empathic experience better outcomes. On the issue of duration and amount of treatment, an effective strategy for many patients may be to provide lower intensity treatment for a longer duration. With respect to treatment setting, there is little or no difference in the outcome between inpatient and outpatient treatment for patients who are clinically eligible for treatment in either setting. Patients who are more severely impaired and/or less socially stable may experience better outcomes following treatment in inpatient or residential settings.

Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R., & Passetti, L. L. (2002). Preliminary outcomes from the assertive continuing care experiment for adolescents discharged from residential treatment. Journal of Substance Abuse Treatment, 23, 21-32.

Developed and experimentally evaluated an Assertive Continuing Care (ACC) protocol for adolescents after their discharge from residential treatment. 114 12-18 yr olds who stayed at least 7 days in residential treatment were randomly assigned to receive either usual continuing care (UCC) or UCC plus an ACC involving case management and the adolescent community reinforcement approach. Baseline and follow-up data were collected through interviews using the Global Appraisal of Individual Needs and the Form 90 version of the Time Line Follow Back interview. Service Contact Logs were developed to track all ACC case management activities. Results indicate that ACC Ss were significantly more likely to initiate and receive more continuing care services, to be abstinent from marijuana at 3 mo postdischarge, and to reduce their 3-mo postdischarge days of alcohol use. Preliminary findings demonstrate an ACC approach designed for adolescents can increase linkage and retention in continuing care and improve short-term substance use outcomes.

Godley, S. H., Meyers, R. J., Smith, J. E., Godley, M. D., Titus, J. M., Karvinen, T., et al. (2001). The adolescent community reinforcement approach for adolescent cannabis users: Cannabis youth treatment (CYT) series, vol. 4 (DHHS Publication No. 01-3489). Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.

Greenstreet, Richard L. (1988). Cost Effective Alternatives in Alcoholism Treatment. Springfield, IL: Charles C Thomas Pub Ltd

(from the jacket) Seeking efficiency in health care delivery, the author herein reviews literature which supports the use of non-hospital-based, cost-effective alternatives to alcoholism treatment. Outpatient and social-setting detoxification approaches are proposed; and subsequent treatment approaches include day clinic, partial hospital, and outpatient treatment. Other pertinent topics examined include: the community reinforcement approach (CRA) to alcoholism treatment, the abuse of alcohol in adolescent and elderly populations, matching alcoholic patients to treatment and therapists, and the overall effectiveness of treatment techniques.

Higgins, S. T. (1999). Potential contributions of the community reinforcement approach and contingency management to broadening the base of substance abuse treatment. In: J.A. Tucker, D. M. Donovan, & A. G. Marlatt (Ed.). Changing addictive behavior: Bridging clinical and public health strategies. New York, Guilford Press, pp. 283-306.

The purpose of this chapter is to discuss some potential contributions of the community reinforcement approach (CRA) and contingency management to broadening the base for substance abuse treatment. In so doing, I describe the conceptual foundations of CRA and results of clinical trials supporting its efficacy in treating alcohol dependence. More recently, CRA was combined with contingency-management procedures to treat cocaine and, to a more limited extent, opioid dependence. Those innovations and the results of clinical trials supporting their efficacy are described as well. Last, I suggest some additional ways that CRA and contingency-management interventions might be used to increase treatment utilization in clinic settings and extend services to other settings and populations.

Higgins, S.T., et al. (1991). A behavioral approach to achieving initial cocaine abstinence. American Journal of Psychiatry, 148, 1218-1224.

Assessed the efficacy of a behavioral treatment program (BTP) for achieving initial cocaine abstinence in adults enrolled in outpatient treatment for cocaine dependence. 13 Ss participated in the BTP consisting of contingency management procedures and the community reinforcement approach. 12 Ss participated in treatment with 12-step counseling. 11 Ss in the BTP were retained for 12 wks of treatment, compared with 5 of the Ss given 12-step counseling. 10 Ss in the BTP achieved 4 wks of continuous cocaine abstinence, compared with only 3 Ss given 12-step counseling. Six Ss in the BTP achieved 8 wks of abstinence, and 3 achieved 12 wks; none of the Ss in the 12-step program achieved 8 wks abstinence.

Higgins, S. T., Sigmon, S. C., & Budney, A. J. (2002). Psychosocial treatment for cocaine dependence: The community reinforcement plus vouchers approach. In S. G. Hoffman & M. C. Tomson (Eds), Treating chronic and severe mental disorders: A handbook of empirically supported interventions. New York, NY: Guilford Press.

Significant scientific advances have been made in understanding cocaine’s myriad effects during the past 15 yrs, including the development of efficacious treatments for cocaine dependence. This includes the Community Reinforcement Approach (CRA) plus vouchers, which is the focus of this chapter. This treatment combines therapy based on an adaptation of the CRA, originally developed as a treatment for severe alcohol dependence, with a voucher-based incentive program derived from prior contingency-management interventions used with heroin and other forms of drug abuse. There are no controlled trials supporting the efficacy of inpatient care for cocaine dependence, and the few available comparisons of outpatient vs inpatient treatment have revealed higher costs and no outcome advantage for the latter. Thus, the emphasis of this chapter is outpatient care, with a focus on behavioral interventions, since there is not yet a reliably efficacious pharmacotherapy for cocaine dependence. Although the chapter focuses on the CRA plus vouchers model, the authors have attempted to mention all available information regarding efficacious treatment practices for cocaine dependence.

Higgins, S. T., Sigmon, S. C., Wong, C. J., Heil, S. H., Badger, G. J., Donham, R., Dantona, R. L., & Anthony, S. (2003). Community reinforcement therapy for cocaine-dependent outpatients. Arch Gen Psychiatry 2003; 60: 1043-1052

Objective: To examine the contributions of community reinforcement therapy to outcome in the community reinforcement approach (CRA)+ vouchers outpatient treatment for cocaine dependence. Methods: One hundred cocaine-dependent outpatients were randomly assigned to one of 2 treatment conditions: CRA+vouchers or vouchers only. All patients earned incentives in the form of vouchers exchangeable for retail items contingent on cocaine-free urinalysis results during treatment weeks 1 to 12. Incentives were combined with a 24-week course of CRA therapy designed to promote healthy lifestyle changes in the CRA+vouchers condition, while incentives represented the primary treatment in the vouchers-only condition. Patient drug use and psychosocial functioning were assessed at intake and at least every 3 months for 2 years after treatment entry. Results: Patients treated with CRA+vouchers were retained better in treatment, used cocaine at a lower frequency during treatment but not follow-up, and reported a lower frequency of drinking to intoxication during treatment and follow-up compared with patients treated with vouchers only. Patients treated with CRA+vouchers also reported a higher frequency of days of paid employment during treatment and the initial 6 months of follow-up…

Higgins, S. T., Wong, C. J., Badger, G. J., Ogden, D. E., & Dantona, R. L. (2000). Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up. J Consult Clin Psychol 2000; 68: 64-72

This study assessed whether contingent incentives can be used to reinforce cocaine abstinence in dependent outpatients. Seventy cocaine-dependent outpatients were randomized into 2 conditions. All participants received 24 weeks of treatment and 1 year of follow-up. The treatment provided to all participants combined counseling based on the community reinforcement approach with incentives in the form of vouchers exchangeable for retail items. In 1 condition, incentives were delivered contingent on cocaine-free urinalysis results, whereas in the other condition incentives were delivered independent of urinalysis results. Abstinence-contingent incentives significantly increased cocaine abstinence during treatment and 1 year of follow-up compared with noncontingent incentives.

Hunt, G. M., & Azrin, N. H. (1973). A community reinforcement approach to alcoholism. Behaviour Research and Therapy, 11, 91-104

Employed an operant reinforcement approach to develop a new procedure that rearranged community reinforcers (e.g., the job, family, and social relations of the alcoholic) such that drinking produced a time-out from a high density of reinforcement. Results show that Ss who received this community-reinforcement counseling drank less, worked more, and spent more time with their families and out of institutions than did a matched control group who did not receive these procedures. This new approach is concluded to be an effective method of reducing alcoholism. An analysis in reinforcement terms is presented of the etiology, epidemiology, and treatment of alcoholism.

Kadden, R. M. (2001). Behavioral and cognitive-behavioral treatments for alcoholism: Research opportunities. Addictive Behaviors, 26, 489-507.

This status report on behavioral and cognitive-behavioral treatments for alcoholism is based on an article commissioned by the National Institute on Alcohol Abuse and Alcoholism for a review of its treatment research priorities. Additional work on cue exposure is needed to identify the most potent cues for drinking, and strategies for reducing the impact of drinking cues. Regarding contingency management, there is need for further studies with alcoholics, investigation of reinforcement schedules, and exploration of maintenance factors. With respect to the community reinforcement approach, research should identify its most effective elements and ways to sustain gains following treatment. The mediating role assigned to coping skills in the cognitive-behavioral model needs to be substantiated, and the effectiveness of various coping skills components must be determined. Further studies of relapse prevention are needed to improve the system for classifying relapse episodes, and to identify the most effective interventions for each type of episode. Finally, given the overlap among these approaches, it is likely that research along the lines suggested will impact several of them and lead to a consolidation of their most effective elements into a common treatment package.

Kalman, D., Longabaugh, R., Clifford, P. R., Beattie, M., Maisto, S.A. (2000). Matching alcoholics to treatment: Failure to replicate finding of an earlier study. Journal of Substance Abuse Treatment, 19, 183-187.

The purpose of the present study was to investigate whether sociopathic alcoholics respond differentially to different types of treatment. An earlier study (R. Longabaugh et al, 1994) found that alcoholics with antisocial personality disorder had somewhat better outcomes if treated in individually focused versus relationship-focused cognitive-behavioral treatment. The present study was designed to attempt to replicate these findings. 149 alcoholics (42 of whom scored high on a measure of sociopathy) were randomly assigned to receive either individually focused cognitive-behavioral treatment or a relationship-focused community reinforcement approach. Follow-up evaluations were conducted every 4 months for 2 years. Results failed to support the study hypothesis. Drinking outcomes were similar for sociopathic alcoholics in both treatment conditions. Directions for future research are identified.

Kirby, K. C., Marlowe, D. B., Festinger, D. S., Garvey, K. A., & LaMonaca, V. (1999). Community reinforcement training for family and significant others of drug abusers: A unilateral intervention to increase treatment entry of drug users. Drug and Alcohol Dependence, 56, 85-96.

Thirty-two concerned family members and significant others (FSOs, aged 28-70 yrs) of drug users (DUs) were randomly assigned to a community reinforcement training intervention or a popular 12-step self-help group. Problems arising from the DU’s behavior, social functioning of the DU and FSO, and mood of the FSO were measured at baseline and 10 wks later. The FSOs’ treatment attendance and treatment entry of the DUs were also monitored. The treatment groups showed equal reductions from baseline to follow-up in problems and improvements in social functioning and mood of the FSO. However the community reinforcement intervention was significantly better at retaining FSOs in treatment and inducing treatment entry of the DUs.

McCrady, B.S. (1991). Promising but underutilized treatment approaches. Alcohol Health & Research World, 15, 215-218.

Discusses some promising but underutilized alcoholism treatment approaches including (1) the Community Reinforcement Approach (CRA), (2) Behavioral Self-Control Training (BSCT), (3) Unilateral Family Therapy (UFT), (4) Behavioral Marital Therapy, and (5) “brief intervention.” CRA produces impressive outcomes in clinical trials of inpatients who are long-term alcoholics and outpatients with less severe problems. It is comprehensive, deals with many areas of functioning, and provides an alternative to traditional approaches. BSCT teaches people to monitor both drinking and urges to drink and to set goals for rate reduction. The UFT and the Behavioral Marital Therapy approaches involve the family in treatment. The brief intervention approach provides limited treatment to persons with mild or noncontinuous drinking problems.

Meyers, R. J. & Godley, M. J. (2001). Developing the community reinforcement approach. In R. J. Meyers & W. R. Miller (Eds.), A Community Reinforcement Approach to Addiction Treatment. New York, NY: Cambridge University Press.

The story of the community reinforcement approach (CRA) begins 30 yrs ago, when indigent alcohol-dependent individuals in downstate Illinois were routinely admitted to the nearest state mental hospitals. Although at the time it was not a common practice, some state hospitals did have special programs for substance abusers. It was the Alcohol Treatment Program at Anna State Hospital that CRA was born. This chapter explains the development of the community reinforcement approach

Meyers, R. J., & Miller, W. R. (Eds.). (2001). A community reinforcement approach to addiction treatment. New York, NY: Cambridge University Press.

Reviews literature concerning use of the community reinforcement approach (CRA) in treating substance use disorders. In 3 recent meta-analyses, CRA was ranked as 1 of the most efficacious and cost-effective alcohol intervention treatments available. Early inpatient and outpatient alcohol studies, individual CRA component investigations, and more recent large outpatient and homeless population studies demonstrated that CRA was superior to traditional treatment for drinking outcomes. In combination with vouchers for cocaine and opiates, CRA resulted in significantly better overall results than did traditional treatments. A CRA variant, Community Reinforcement and Family Training (CRAFT), targets individuals refusing to seek treatment, by working through significant others. This treatment has also been successfully used to treat both alcohol and drug-abusing populations. Empirical evidence strongly supports CRA and CRAFT use in substance abuse disorder treatment.

Meyers, R., Miller, W., Hill, D., & Tonigan, J. (1999). Community reinforcement and family training (CRAFT): engaging unmotivated drug users in treatment. Journal of Substance Abuse, 10, 291-308

Meyers, R. J., Miller, W. R., Smith, J. E., & Tonigan, J. S. (2002). A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others. Journal of Consulting and Clinical Psychology, 70, 1182-1185

In a randomized clinical trial, 90 concerned significant others (CSOs) of treatment-refusing illicit drug users were assigned to either (a) community reinforcement and family training (CRAFT), which teaches behavior change skills; (b) CRAFT with additional group aftercare sessions after the completion of the individual sessions; or (c) Al-Anon and Nar-Anon facilitation therapy (Al-Nar FT). All protocols received 12 hr of manual-guided individual treatment, Follow-up rates for the CSOs were consistently at least 96%. The CRAFT conditions were significantly more effective than Al-Nar FT in engaging initially unmotivated drug users into treatment. CRAFT alone engaged 58.6%, CRAFT + aftercare engaged 76.7%, and Al-Nar FT engaged 29.0%. No CSO engaged a treatment-refusing loved one once individual sessions had been completed.

Meyers, R. J., & Smith, J. E. (1995). Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach. New York: The Guilford Press.

This book is [a] guide to implementing the Community Reinforcement Approach (CRA), an empirically based, highly effective cognitive-behavioral program for treating alcohol problems. CRA acknowledges the powerful role of environmental contingencies in encouraging or discouraging drinking, and attempts to rearrange these contingencies so that a non-drinking lifestyle is more rewarding than a drinking one. The approach utilizes social, recreational, familial, and vocational strategies to aid clients in the recovery process. This . . . manual is a hands-on guide to applying these therapeutic procedures.

Each chapter provides detailed instructions for conducting a procedure, describes what difficulties to expect, and presents strategies for overcoming them. Sample dialogues between clients and therapists, annotated by the authors, further illuminate the treatment process.

CRA can be implemented by all clinicians who treat alcohol abusing clients, regardless of orientation. This book is [a] resource for a wide range of practitioners including psychologists, psychiatrists, substance abuse counselors, and social workers.

Meyers, R. J., Smith, J. E., & Miller, E. J. (1998). Working through the concerned significant other. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors (2nd ed., pp. 149-161). New York: Plenum Press.

Research has repeatedly demonstrated the considerable difficulty in engaging and retaining in treatment an individual with substance abuse problems. There is a growing body of evidence that concerned significant others (CSOs) can provide considerable leverage in convincing problem substance abusers to enter treatment. The support of the CSO also has been shown to aid in treatment retention and to increase the likelihood of treatment success. Community Reinforcement and Family Training (CRAFT) was developed for training CSOs of alcohol- or drug-abusing loved ones to use behavioral techniques to decrease substance use and increase sober behavior. This chapter examines the basic components of CRAFT: domestic violence precautions, functional analysis, communication training, use of positive reinforcement, time out from positive reinforcement, natural consequences for using, reinforcers for the CSO, suggestion of treatment to the drinker or drug user, and rapid intake procedures.

Meyers, R. J., Smith, J. E., & Waldorf, A. V. (1999). Application of the community reinforcement approach. In: D. E. Dowd & L. Rugle (Eds.), Comparative Treatments of Substance Abuse. New York, N.Y., Springer Publishing Company.

Presents a community reinforcement approach (CRA) to treatment of a 35-yr-old male with alcohol and cocaine abuse, as previously presented (see record 1999-04136-003). The treatment model (CRA functional analyses, sobriety sampling, monitored disulfiram, CRA treatment plan, behavioral skills training, job skills, social/recreational counseling, CRA’s relationship therapy, and CRA’s relapse prevention), clinical skills or attributes essential to successful treatment, and clinical questions are presented

Meyers, R. J. Villanueva, M., & Smith, J. E.. The Community Reinforcement Approach: History and New Directions. Journal of Cognitive Psychotherapy, Vol 19(3), 247-260.

This article provides an overview of 2 closely linked treatment approaches for the substance abusing client: The Community Reinforcement Approach (CRA) and Community Reinforcement and Family Training (CRAFT). In 1973, Hunt and Azrin created CRA in an attempt to restructure an individual’s “community” so that a sober lifestyle was more rewarding than one dominated by alcohol. One salient CRA premise was that an individual’s substance abuse recovery was heavily influenced by his or her social and occupational environment. Sisson and Azrin (1986) later built upon this premise in their work with a new type of client; the loved one of an alcoholic individual who refused to enter treatment. This program was an early version of CRAFT, which is an intervention that works through a nonusing individual to affect the behavior of a substance abuser. This article provides an empirical review of the evolution of these 2 interventions, including their application to illicit drug using clients. It also outlines the clinical procedures that comprise CRA and CRAFT, and considers future research directions.

Miller, W. R., Brown, J. M., Simpson, T. L., Handmaker, N. S., Bien, T. H., Luckie, L. F., et al. (1995). What works? A methodological analysis of the alcohol treatment outcome literature. In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (2nd ed.). Boston: Allyn and Bacon.

Miller, W. R., Meyers, R. J., Hiller-Sturmhofel, S. (1999). The community reinforcement approach. Alcohol Research and Health, 23, 116-120.

Summarizes the components of the Community Reinforcement Approach (CRA) to alcoholism treatment, which rearranges an addict’s life so that abstinence is more rewarding than drinking. The CRA therapist builds motivation, sets goals for abstinence, analyzes drinking patterns, provides positive reinforcement, and assists the client in practicing coping skills. Often significant others are involved. Research published during the period 1973-1999 has shown that patients who participated in CRA therapy fared better than those in traditional treatments. CRA has also been shown to be effective in family therapy and other drug abuse.

Miller, W. R., Meyers, R. J., & Tonigan, J. S. (1999). Engaging the unmotivated in treatment for alcohol problems: A comparison of three strategies for intervention through family members. J Consult Clin Psychol 1999; 67(5):688-697

In a randomized clinical trial, 130 concerned significant others (CSOs) were offered 1 of 3 different counseling approaches: (a) an Al-Anon facilitation therapy designed to encourage involvement in the 12-step program, (b) a Johnson Institute intervention to prepare for a confrontational family meeting, or (c) a community reinforcement and family training (CRAFT) approach teaching behavior change skills to use at home. All were manual-guided, with 12 hr of contact. Follow-up interviews continued for 12 months, with 94% completed. The CRAFT approach was more effective in engaging initially unmotivated problem drinkers in treatment (64%) as compared with the more commonly practiced Al-Anon (13%) and Johnson interventions (30%). Two previously reported aspects of the Johnson intervention were replicated: that most CSOs decide not to go through with the family confrontation (70% in this study) and that among those who do, most (75%) succeed in getting the drinker into treatment. All approaches were associated with similar improvement in CSO functioning and relationship quality. Overall treatment engagement rates were higher for CSOs who were parents than for spouses. On average, treatment engagement occurred after 4 to 6 sessions.

Miller, W. R., Meyers, R. J., Tonigan, J. S., & Grant, K. A. (2001). Community reinforcement and traditional approaches: Findings of a controlled trial. In R. Meyers & W. Miller (Eds.), A community reinforcement approach to the treatment of addiction. Cambridge, England: University Press.

Miller, W. R., Meyers, R. J., Tonigan, J. S., & Hester, R. K.1992. Effectiveness of the Community Reinforcement Approach: Final Progress Report to the National Institute on Alcohol Abuse and Alcoholism. University of New Mexico, Center on Alcoholism, Substance Abuse, and Addictions, p. 56.

Miller, W. R., & Wilbourne, P. L. (2002). Mesa Grande: A methodological analysis of clinical trials of treatment for alcohol use disorders. Addiction, 97, 265-277.

Reviews 361 clinical trials published through 1998 concerning alcohol use disorders treatment, and provides an update of 59 clinical trials to the ongoing Mesa Grande project. Studies were rated by 2 reviewers regarding 12 methodological criteria, with outcome logic analyzed for the specific treatment modalities tested. Results show that methodological quality of studies was significantly correlated with the reporting of a specific effect of treatment. The strongest evidence of efficacy among psychosocial treatments was for brief interventions, social skills training, the community reinforcement approach, behavior contracting, behavioral marital therapy, and case management. Pharmacotherapies using acamprosate and the opiate antagonists naltrexone and nalmefene also were among the most strongly supported approaches. Least supported were methods designed to educate, confront, shock, or foster insight regarding the nature and causes of alcoholism. It is concluded that treatment methods differ substantially in apparent efficacy and that it is sensible to consider these differences in designing and funding treatment programs.

Ozechowski, T. J., & Liddle, H. A. (2000). Family-based therapy for adolescent drug abuse: Knowns and unknowns. Clinical Child and Family Psychology Review, 3, 269-29

Extends previous reviews of the empirical literature on family-based therapy for adolescents by evaluating existing research on core criteria in contemporary intervention science. One controlled trial and 4 therapy process studies are examined from a treatment development perspective The authors articulate “knowns and unknowns” regarding the outcomes of treatment as well as the components, processes, mechanisms, moderators, and boundaries of effective family-base therapy for adolescent drug abuse. The review highlights areas of progress and future research needs within the specialty of family-based therapy for adolescent drug abuse.

Pantalon, Michael V., Chawarski, Marek C., & Falcioni, Jean. Linking Process and Outcome in the Community Reinforcement Approach for Treating Cocaine Dependence: A Preliminary Report. American Journal of Drug and Alcohol Abuse, Vol 30(2), 2004. pp. 353-367

This preliminary study evaluated the relationship between therapy process variables (mechanistic processes and interpersonal processes), and treatment outcome (i.e., retention and cocaine abstinence) among 16 cocaine-dependent pregnant or postpartum women treated with the Community Reinforcement Approach (CRA). Two new rating scales were developed for this purpose. The Mechanisms of Action Rating Scale (MARS) assesses five CRA mechanistic domains (Big Picture goals, functional analyses of behavior, nondrug-related activities, skills training, and homework). The Interpersonal Variables Rating Scale (IVRS) measures three nonspecific or interpersonal dimensions of psychotherapy (i.e., empathy, response to resistance, and therapeutic alliance). These rating scales were used to rate one, early treatment, videotaped CRA session for each subject. Results indicated that: 1) sessions with patients who achieved three or more consecutive weeks of cocaine abstinence were rated significantly higher on therapist empathy and positive responses to resistance, and total IVRS scores (all of which indicate positive interpersonal processes); and 2) Big Picture goals, positive therapeutic alliance, and total IVRS scores were significantly and positively correlated with number of consecutive weeks of cocaine-negative urine toxicology tests. Only MARS homework scores were significantly and positively associated with number of study weeks completed. Finally, the pattern of interrelationships among the MARS subdomains suggests the coherence of the multifaceted CRA treatment. The findings of this preliminary study suggest the importance of monitoring both mechanistic and interpersonal processes during CRA treatment of cocaine dependence.

Pantalon, Michael V., Ferro, Gonzalo, & Chawarski, Marek C. Voucher purchases in contingency management interventions for women with cocaine dependence.

Voucher-based Contingency Management (CM) has been shown to be effective in treating cocaine dependence, but the relative impact of extensive voucher purchase guidelines has not been evaluated. Consequently, our objective was to investigate the effect of purchase guidelines on voucher purchases. Methods: We evaluated voucher purchases made by 94 cocaine dependent women who were enrolled hi a randomized clinical trial of the Community Reinforcement Approach (CRA) versus Twelve-Step Facilitation (TSF), where extensive purchase guidelines were only part of CRA. Results: In CRA, 70% of the purchases were consistent with the guidelines offered. The most frequent purchases were for social/recreational activities (30%), the participant’s child (non-basic needs; 17%), and household items (15%). There were no significant differences in percentages of purchases between CRA and TSF. Additionally, preliminary findings on the relationship between voucher purchase patterns and cocaine abstinence are presented. The findings suggest that extensive purchase guidelines may not be a critical aspect of voucher reward programs.

Peele, S. (2004). How I found common cause with social workers. Journal of Social Work Practice in the Addictions, 4, 117-119.

Presents an article by Stanton Peele, a psychologist who teaches treatment principles and techniques for substance abuse in the Post-Master’s Program in the Treatment of Alcohol and Drug Abusing Clients at the New York University School of Social Work. He reports that as he began interacting with social workers, he learned that they shared certain perspectives. Social work addresses people in terms of their social situations and resources. Thus, it struck Peele that social workers were in a unique position to employ techniques that he had helped to pioneer, but which had not been traditionally used in the addiction field. Yet client-centered therapy is a social work staple and social workers are not detached diagnosticians, looking to label people’s ailments. The community reinforcement approach (CRA) addresses clients’ skills at coping in the major areas of their lives-in family and intimate relationships, in their work lives, in terms of their social associations and filling their leisure time.

Poldrugo, F., Porpat, C., Montina, G. L., & Pivotti, F. (2002). A community reinforcement approach for smoking cessation. European Psychiatry 17(1):90.

Randall, J., Henggeler, S. W., Cunningham, P. B., Rowland, M. D., & Swenson, C. C. (2001). Adapting multisystemic therapy to treat adolescent substance abuse more effectively. Cognitive and Behavioral Practice, 8, 359-366.

The article illustrates an adaptation of multisystemic therapy (MST) coupled with community reinforcement plus vouchers approach (CRA) to treat adolescent substance abuse and dependency. Key features of CRA enable the MST therapist and adolescent caregiver to more specifically detect and address adolescent substance use. These features include frequent random urine screens to detect drug use, functional analyses to identify triggers for drug use, self-management plans to address identified triggers, and development of drug avoidance skills. To highlight the integration of MST and CRA in treating substance abusing or dependent adolescents, a case example of a 17-yr-old male is provided. Prior to the case example, an overview of clinical and program features of MST and substance-related outcomes is presented.

Roozen, Hendrik G., Boulogne, Jiska J., van Tulder, Maurits W. et al., A systematic review of the effectiveness of the community reinforcement approach in alcohol, cocaine and opioid addiction. Drug and Alcohol Dependence, Vol 74(1), Apr 2004. pp. 1-13

The community reinforcement approach (CRA) has been applied in the treatment of disorders resulting from alcohol, cocaine and opioid use. The objectives were to review the effectiveness of (1) CRA compared with usual care, and (2) CRA versus CRA plus contingency management. Studies were selected through a literature search of RCTs focusing on substance abuse. The search yielded 11 studies of mainly high methodological quality. The results of CRA, when compared to usual care: there is strong evidence that CRA is more effective with regard to number of drinking days, and conflicting evidence with regard to continuous abstinence in the alcohol treatment. There is moderate evidence that CRA with disulfiram is more effective in terms of number of drinking days, and limited evidence that there is no difference in effect in terms of continuous abstinence. Furthermore, there is strong evidence that CRA with ‘incentives’ is more effective with regard to cocaine abstinence. There is limited evidence that CRA with ‘incentives’ is more effective in an opioid detoxification program. There is limited evidence that CRA is more effective in a methadone maintenance program. Finally, there is strong evidence that CRA with abstinence-contingent ‘incentives’ is more effective than CRA (non-contingent incentives) treatment aimed at cocaine abstinence.

Roozen, Hendrik G., Van Beers, Suzanne E. C.; Weevers, Harm Jan A. Effects on smoking cessation: Naltrexone combined with a cognitive behavioral treatment based on the community reinforcement approach. Substance Use & Misuse, Vol 41(1), 2006. pp. 45-60

A promising option in substance abuse treatment is the Community Reinforcement Approach (CRA). The opioid antagonist naltrexone (NTX) may work in combination with nicotine replacement therapy (NRT) to block the effects of smoking stimuli in abstinent smokers. Effects of lower doses than 50 mg/dd. have not been reported. A study was conducted in Amsterdam in 2000/2001 with the objective to explore the effects of the combination NTX (25/50-mg dd.), NRT, and CRA in terms of craving and abstinence. In a randomized open label, 2×2 between subjects design, 25 recovered spontaneous pneumothorax (SP) participants received 8 weeks of treatment. Due to side effects, only 3 participants were compliant in the 50-mg NTX condition. Craving significantly declined between each measurement and there was a significant interaction between decline in craving and craving measured at baseline. The abstinence rate in the CRA group was nearly double that in the non-psychosocial therapy group (46% vs. 25%; NS) at 3 months follow-up after treatment.

Rothenberg, J. L., Sullivan, M. A., Church, S. H., Seracini, A., Collins, E., Kleber, H. D.,& Nunes, E. V. (2002). Behavioral naltrexone therapy: An integrated treatment for opiate dependence. Journal of Substance Abuse Treatment, 23, 351-360.

Treatment of opiate dependence with naltrexone has been limited by poor compliance. Behavioral Naltrexone Therapy (BNT) was developed to promote adherence to naltrexone and lifestyle changes supportive of abstinence, by incorporating components from empirically validated treatments, including Network Therapy with a significant other to monitor medication compliance, the Community Reinforcement Approach, and voucher incentives. An overview is presented of the BNT treatment manual. In an uncontrolled Stage I trial (N = 47), 19% completed the 6-month course of treatment. Retention was especially poor in the subsample of patients who were using methadone at baseline (N = 18; 39% completed 1 month, none completed 6 months), and more encouraging among heroin-dependent patients (N = 29; 65% completed 1 month, 31 % completed 6 months). Enrolled participants were aged 20-54 yrs. Thus, attrition continues to be a serious problem for naltrexone maintenance, although further efforts to develop interventions such as BNT are warranted.

Schottenfeld, R. S., Pantalon, M. V., Chawarski, M. C., & Pakes, J. (2000). Community reinforcement approach for combined opioid and cocaine dependence: patterns of engagement in alternate activities. Journal of Substance Abuse Treatment 18: 255-261.

Compared outcomes for agonist-maintained patients with combined opioid and cocaine dependence who were treated in an earlier clinical trial with group drug counseling (DC; n = 57) or in a current trial with the Community Reinforcement Approach (CRA; n = 60). The association between engagement in nondrug-related activities and abstinence was also evaluated. There were no significant differences between the treatments in retention or drug use. The total number of hours and average hours per week engaged in nondrug-related activities was significantly higher for CRA-treated patients who achieved abstinence from opioids, cocaine, or both combined than for those who never achieved abstinence. Although CRA was not more effective overall than DC, the finding that engagement in reinforcing community activities unrelated to drug use (e.g., planned pleasurable events or parenting activities) was associated with abstinence suggests that the planning and reinforcement of specific nondrug-related social, vocational, and recreational activities is a crucial component of CRA.

Sisson, R. W., & Azrin, N. H. (1986). Family-member involvement to initiate and promote treatment of problem drinkers. Journal of Behavior Therapy Exp Psychiatry 17:15-21.

12 nonalcoholic females who were concerned about an alcoholic member of their family were given either community-reinforcement counseling or a traditional type of counseling. The reinforcement counseling (including giving positive reinforcement for not drinking and negative reinforcement for intoxication) resulted in more alcoholic persons obtaining treatment than did the traditional type, and a greater reduction in drinking before the formal treatment was obtained; drinking was reduced further during the joint treatment of the family members and problem drinkers.

Sisson, R. W., & Azrin, N. H. (1993). Community reinforcement training for families: A method to get alcoholics into treatment. In T. J. O’Farrell (Ed.), Treating alcohol problems: Marital and family interventions (pp. 34-53). New York: Guilford Press.

Smith, J. E., & Meyers, R. J. (1995). The community reinforcement approach. In: Handbook of Alcoholism Treatment Approaches: Effective Alternatives. R. K.

Reid & W. R. Miller (Eds). Needham Heights, MA., 251-266.

The Community Reinforcement Approach (CRA) is a broad spectrum behavioral treatment approach for substance-abuse problems. It was developed to utilize social, recreational, familial, and vocational reinforcers to aid clients in the recovery process. CRA acknowledges the powerful role of environmental contingencies in encouraging or discouraging drinking, and attempts to rearrange these contingencies such that sober behavior is more rewarding than drinking behavior. CRA emphasizes motivational techniques and uses positive reinforcement rather than confrontation whenever possible. Once the parameters of typical drinking episodes are outlined via functional analysis, a technique called Sobriety Sampling is used to initiate the process of behavior change. An optional part of CRA is a Disulfiram (Antabuse) compliance program. The procedure ensures that the drinker actually takes the Disulfiram and is reinforced for doing so.

Smith, J. E. & Meyers, R. J. (2000). CRA: The community reinforcement approach for alcohol rehabilitation. In: Clinical Behavior Analysis. Michael Dougher (Ed). Reno, NV. Context Press, 207-230.

Examines the Community Reinforcement Approach (CRA), a broad spectrum behavioral program for treating substance abuse problems. CRA is based on the belief that environmental contingencies can play a powerful role in encouraging or discouraging drinking or drug-using behavior. Consequently, CRA utilizes social, recreational, familial, and vocational reinforcers to assist clients in the recovery process. Its goal is to rearrange various aspects of an individual’s “community” such that a sober lifestyle is more rewarding than one involving alcohol and drugs.

Smith, J. E., & Meyers, R. J. (2004). Motivating substance abusers to enter treatment: Working with family members. New York: Guilford Press.

Filling a crucial need, this book presents an empirically based therapy program for the family members or partners of treatment-refusing substance abusers. Community Reinforcement and Family Training (CRAFT) teaches concerned significant others (CSOs) how to change their own behavior toward their loved ones in order to reward sober behavior, discourage substance use, and ultimately to get the substance abusers into treatment. In the process, CSOs also derive therapeutic benefits themselves. Written in an accessible style, the book provides step-by-step instructions for implementing an array of well-tested motivational, behavioral, and cognitive interventions. Illustrative case examples, reproducible client materials, and many hands-on clinical pointers bring the approach to life for therapists and counselors from a range of backgrounds, regardless of addiction treatment experience.

Smith, J. E., Meyers, R. J., & Delaney, H. D. (1998). Community reinforcement approach with homeless alcohol-dependent individuals. Journal of Consulting and Clinical Psychology 66, 541-548

Homeless alcohol-dependent individuals were randomly assigned to receive either a behavioral intervention (i.e., the Community Reinforcement Approach [CRA]) or the standard treatment (STD) at a large day shelter. Ninety-one men and 15 women participated. The majority of participants were White (64%), but both Hispanic (19%) and Native American (13%) individuals were represented as well. Overall, the decline in drinking levels from intake through follow-ups was significant. As predicted, CRA participants significantly outperformed STD group members on drinking measures across the 5 follow-ups, which ranged from 2 months to 1 year after intake. Both conditions showed marked improvement in employment and housing stability.

Smith, J. E., Meyers, R. J., & Waldorf, V. A. (1999). Covering all bases: Engaging and treating individuals with alcohol problems. In: Alcohol and Alcoholism: Effects on Brain and Development. J. H. Hannigan, L. P. Spear, N. E. Spear, & C. R. Goodlett (Eds). Mahwah, NJ, 229-249.

Summarizes selected findings of several recent reviews, then outlines three alcohol treatment programs supported by them. H. Holder et al (see record 1992-14368-001) presented information on the cost-effectiveness of 33 empirically tested treatment modalities. In the rank ordering of the treatments, the two of interest, Motivational Enhancement Therapy (MET), and Community Reinforcement Approach (CRA), fared very well. Other studies, including those by J. W. Finney and S. C. Monahan (1996), W. R. Miller et al (see record 1995-97702-002), and R. W. Sisson and N. H. Azrin (see record 1987-16795-001) examined the efficacy of the aforementioned treatments or others, such as the Community Reinforcement and Family Training (CRAFT). This chapter first presents an outline of MET as an example of a solid brief intervention, and then CRA as what is argued to be an excellent choice when the needs of the client dictate a more comprehensive program. The final treatment, CRAFT, was included as a promising intervention that works through a concerned family member when a drinker refuses treatment.

Strada, M. J., & Donahue, B. C. (2004). Substance abuse. In: Psychopathology in the workplace: Recognition and adaptation. Thomas, Jay C. (Ed); Hersen, Michel (Ed); pp. 75-91.

(from the chapter) Substance abuse in the workplace setting is an epidemic problem that has led to widespread cost to society. Having recognized the seriousness of substance abuse as a corporate problem, businesses are taking proactive steps to promote drug-free work environments. However, this development has been controversial. There is a wide variety of intervention programs that have been used in the treatment of substance abuse. Some of the more popular empirically supported substance abuse intervention approaches for adults that address job performance include motivational interviewing, social skills training, the community reinforcement approach, family behavior therapy, and some pharmacological approaches. However, research examining the effectiveness of these interventions in workplace settings is limited. Because the majority of individuals who attain abstinence tend to experience lapses and relapses throughout the recovery process, relapse prevention programs appear particularly promising in workplace settings. Steps have been taken in corporate America to prevent, identify, and treat substance abuse in the workplace. However, much work needs to be done in this area.

Tober, G. & Somerton, J. (2002). The search for evidence-based addiction practice in the United Kingdom. Journal of Social Work Practice in the Addictions, 2, 3-13.

This paper examines the case for evidence-based practice and its application to social work. Developments in evidence-based practice in the field of substance misuse treatment that are of particular interest to social workers, such as Motivational Enhancement Therapy (MET), Community Reinforcement Approach (CRA), and Social Behavior and Network Therapy (SBNT) are described.

Wolfe, B. L., & Meyers, R. J. (1999). Cost-effective alcohol treatment: The community reinforcement approach. Cognitive Behav. Pract, 6, 105-109.

Introduces the Community Reinforcement Approach (CRA), one treatment modality which is well-supported by the literature. CRA is a cost-effective behavioral and social-learning-based treatment protocol. Its menu-driven approach to substance abuse also integrates several other cost-effective treatments to make a comprehensive package for the clinician. An overview of CRA is provided with the objective of helping the clinician increase his or her cost-effectiveness with alcohol abusing and dependent clients.

Wong, C. J., Jones, H. E., & Stitzer, M. L. (2004). Community Reinforcement Approach and Contingency Management Interventions for Substance Abuse. In: Handbook of motivational counseling: Concepts, approaches, and assessment. Cox, W. M. & Klinger, E., New York, NY: John Wiley & Sons Ltd., pp. 421-437

Contingency management interventions have been demonstrated to be effective in treating substance-use disorders in various populations, including primary cocaine-dependent and methadone-maintenance patients. Operant principles of reinforcement are at the heart of contingency management interventions. Two of the most effective contingency management interventions for the treatment of substance-abuse disorders have been abstinence reinforcement procedures and the Community Reinforcement Approach (CRA). The primary objective of both treatments is to modify drug-using behavior by increasing the density of alternative reinforcers that are incompatible with the drug-using lifestyle. The primary premise of both treatments is that if sufficient numbers of alternative reinforcers can be made available, they might effectively compete with the pharmacological reinforcing effects of drugs and nondrug reinforcers that are associated with the drug-using lifestyle. The CRA achieves this goal by increasing the number of alternative reinforcers in the drug abusers’ natural environment or community. In contrast, abstinence reinforcement procedures utilize tangible or more contrived reinforcers to reinforce drug abstinence more directly. The purpose of this chapter is to highlight the CRA and abstinence reinforcement procedures. Their conceptual background and rationale are described and seminal studies to support the effectiveness of these interventions are reviewed. The chapter also discusses how to implement these treatments using effective reinforcement contingencies to reward therapeutically desired behaviors, especially drug abstinence.