Community reinforcement approach

Domain II · Behavioural & cognitive · Nathan Azrin, George Hunt, Robert Meyers · 1973 · Illinois

What it is

The Community Reinforcement Approach (CRA) is a behavioural treatment for alcohol and drug problems. Nathan Azrin and George Hunt developed it in Illinois (Hunt & Azrin, 1973), and Robert Meyers and Jane Ellen Smith later manualised it in New Mexico. Its idea of change is operant: substance use…

Format

• CRA is a menu of procedures, not a fixed sequence of sessions. The therapist picks and orders procedures from the functional analysis and the client's goals. The structure below is the one the sources describe.
• Orientation and motivation (session 1). Build rapport and give the CRA rationale: your use serves purposes, and treatment will help you meet those needs in other ways.

Who practises it, and how they are trained or regulated

• Skills and reinforcer-building modules, chosen by need. Options include: communication, problem-solving and drink/drug refusal training
• Brief version: a 4–6 session treatment-entry training (TEnT) focuses on getting the loved one into treatment.
• Version followed: adult CRA as set out in Meyers & Smith (1995), Clinical Guide to Alcohol Treatment, as summarised by its authors in Meyers, Roozen & Smith (2011), plus the NIDA manual A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction (Budney & Higgins, 1998) for drug use; A-CRA as in Godley, Smith, Meyers & Godley (2016), with the dosage the federal Prevention Services Clearinghouse…

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Does it involve any substance, plant preparation, remedy or supplement? Has your doctor or prescriber been told, especially about any medication you take?
• Does it involve intense or unusual breathing? Have you been told about the medical conditions for which that is not advised?
• Does it involve fasting, a special diet or 'detox'? Have you discussed this with your doctor?
• Is it a group, retreat or community? How do they respond if someone wants to leave or raises a concern?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• Working sign: the client reports safer practices.
• Working sign: the activity becomes more frequent.
• Working sign: the CSO uses the steps independently.
• Working sign: the client reports handling a real situation assertively.
• Working sign: fewer incidents reported by the young person and caregivers.

Problems the guide addresses

• Attendance and engagement
• Motivation and goals
• Problems within sessions
• Service and clinical boundaries
• Safety
• A-CRA
• CRAFT
• Fidelity

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.