Atlas›Domain II · Behavioural & cognitive›Guide 031
Guide II-031

Community reinforcement approach

Nathan Azrin, George Hunt, Robert Meyers, Jane Ellen Smith1973Illinois
A 22 · L 72 · M 636 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

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 records; CRAFT in the 10-procedure sequence of Smith & Meyers (2023), The CRAFT Treatment Manual for Substance Use Problems. The 1995 and 2016 manuals are not drawn on directly; their content comes from the developers' own summaries and training materials [uncertain where marked].

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 persists because it is reinforced, and it gives way when a sober life holds more reward than using. The aim, in Hunt and Azrin's phrase, is "to rearrange the vocational, family, and social reinforcers" so that drinking costs the client those rewards. The therapist works with the client, and often a partner or family member, to find what use does for the client, to sample abstinence, to build skills, and to add competing rewards from work, relationships and recreation. [source: Meyers, Roozen & Smith 2011; Serna NWATTC webinar 2021 quoting Hunt & Azrin 1973; williamrmiller.net]

CRA has two main offshoots:

  • A-CRA adapts CRA for ages 12 to 24 and adds caregiver sessions.
  • CRAFT (Community Reinforcement and Family Training) treats a concerned significant other (CSO) of someone who refuses treatment. It has three aims: get the loved one into treatment, reduce their use, and improve the CSO's own life. It "decidedly does not pressure these individuals to attend treatment" (Meyers et al. 2011). [source: Meyers, Roozen & Smith 2011; CCSA CRAFT summary 2017]

2. Framework

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. [source: Meyers, Roozen & Smith 2011; NIDA CRA manual 1998]

Adult CRA (alcohol): typical flow. [source: Meyers, Roozen & Smith 2011; CCSA CRA summary 2017; Serna 2021]

  1. 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.
    • Outline the procedures. This also serves as informed consent.
    • Start identifying the client's reinforcers.
  2. Assessment.
    • Gather background and substance use history, with standard instruments and collateral information.
    • Complete a functional analysis of use. Optionally, complete one for a pro-social behaviour.
  3. Sobriety sampling.
    • Negotiate a time-limited abstinence period early, often in session 1 or 2.
    • Plan how the client will get through it.
  4. Treatment plan.
    • Complete the Happiness Scale, then turn low-rated areas into Goals of Counseling.
    • Re-administer both at intervals to track progress.
  5. Skills and reinforcer-building modules, chosen by need. Options include:
    • communication, problem-solving and drink/drug refusal training
    • job skills
    • social and recreational counselling
    • relationship counselling
    • disulfiram with monitoring
    • mood monitoring
  6. Relapse prevention, threaded throughout. Use a functional analysis of each relapse and an early warning system.

Session count is not fixed in the alcohol sources [uncertain]. Sessions are usually weekly, individual, about 60 minutes, and follow a standard format: review homework, teach and rehearse a skill, then assign homework (Serna 2021). Group formats have been used, for example in the homeless CRA trial (Meyers website).

CRA + Vouchers (cocaine; NIDA 1998). [source: NIDA CRA manual 1998]

  • Length and schedule: 24 weeks. Weeks 1–12 have two 60-minute sessions a week. Weeks 13–24 have one session a week.
  • Urine testing: three times a week in weeks 1–12, twice a week after that.
  • Vouchers: cocaine-negative samples earn points that escalate with consecutive negatives. A positive or missed sample resets the value, and five consecutive negatives restore it. Points are exchanged for therapist-approved goods that support a drug-free life.
  • Component order:
    • functional analysis in weeks 2–4
    • then employment, drug refusal, HIV prevention, social/recreational counselling and social skills, sleep and relaxation
    • relationship counselling slotted in where relevant

A-CRA. [source: ACF Prevention Services Clearinghouse; Meyers, Roozen & Smith 2011]

  • Dosage: at least 10 individual adolescent sessions of 60 minutes, two caregiver-only sessions of 60 minutes, and two family sessions of 90 minutes. Sessions are usually weekly over 12–14 weeks.
  • Caregiver-only sessions: cover parenting rules, motivation, and the communication and problem-solving skills the young person is learning.
  • Family sessions: practise positive communication, negotiate relationship goals, and assign problem-solving practice at home.
  • Homework: every session ends with a homework assignment agreed together.

CRAFT. [source: Smith & Meyers 2023 contents; Case Western CRAFT summary 2024; Kane MGH slides; Meyers, Roozen & Smith 2011]

  • Format: individual sessions with the CSO alone, usually 8–12, most commonly 12. Group and self-directed formats also exist (Meyers & Wolfe, Get Your Loved One Sober).
  • How fast engagement happens: loved ones who entered treatment usually did so after 4–6 CSO sessions.
  • Brief version: a 4–6 session treatment-entry training (TEnT) focuses on getting the loved one into treatment.
  • Procedure sequence:
    1. Inform and motivate the CSO, with a violence risk check first.
    2. Functional analysis of the loved one's use.
    3. Positive communication.
    4. Rewarding non-using behaviour.
    5. Functional analysis of the loved one's healthy, enjoyable behaviour (optional).
    6. Withdrawing rewards for use.
    7. Allowing natural negative consequences.
    8. Problem solving.
    9. Enriching the CSO's own life.
    10. Inviting the loved one into treatment.
    11. Then CRA with the loved one, and relationship therapy as early as possible.

Criteria for moving on. The sources set behavioural readiness criteria, not a fixed calendar:

  • Sobriety sampling: the negotiated period runs at least until the next session.
  • Goals: advance when the measurable goals on the Goals of Counseling form are met. Revise them when they stall.
  • CRAFT invitation: invite the loved one into treatment only once the CSO is comfortable with positive communication and with rewarding non-use, a treatment provider is lined up for rapid intake, and a window of opportunity appears.
  • CRA + Vouchers: step down to weekly sessions at week 13.

[source: Serna 2021; Case Western 2024; NIDA 1998]

3. Guiding principles

[source: Meyers, Roozen & Smith 2011; NIDA CRA manual 1998; CCSA CRA summary 2017; williamrmiller.net]

  • Reinforcement, not confrontation. Change behaviour by changing what it earns. Never lecture, label or moralise.
  • Make sobriety more rewarding than use. Every module must add or protect a reward that competes with substance use.
  • Behaviour serves a function. Ask what use does for the client before trying to change it. The functional analysis is the case formulation.
  • Whole-life focus. Work, money, relationships, leisure and mood are all treatment targets, not distractions from "the real issue".
  • Client-chosen, measurable goals. Goals are positive (what the client will do), specific, under the client's control, and countable.
  • Gentle path to abstinence. Negotiate time-limited abstinence instead of demanding lifelong sobriety at intake.
  • Directive but collaborative. Set the agenda, structure sessions and set limits. Hold a confident, can-do stance, as a teacher and coach.
  • Skills are taught behaviourally. Use instruction, modelling, role-play, feedback and homework. Describing a skill is not enough.
  • Shaping and praise. Reinforce small approximations. Give frequent, specific social reinforcement, including for attendance.
  • Flexibility of format. Sequence, spacing, location and length can bend to the client. Tolerate lateness and do outreach.
  • Involve the social network. Partners, family and friends are allies, early warning observers and sources of reward.
  • Respect the client's position. If the client is not ready for a goal, set an alternative and come back to it later.
  • CRAFT: the CSO's wellbeing is a goal in itself. Treatment succeeds partly even if the loved one never enters treatment.
  • CRAFT: safety first. Assess for violence before teaching any procedure that changes how the CSO responds to the loved one.

4. Intervention inventory

This inventory is grouped into four parts:

  • A. Core CRA procedures
  • B. CRA reinforcer-building and adjunct modules
  • C. A-CRA additions
  • D. CRAFT procedures

Most CRA forms (Happiness Scale, Goals of Counseling, functional analysis charts, Relationship Happiness Scale, Daily Reminder to Be Nice) belong to the developers' manuals. They are described here, not reproduced; get the forms from the manuals or certified training. All example wording is illustrative unless quoted with a citation.

A1. Orientation and CRA rationale (first session)

  • Purpose: build rapport and leave the client feeling treatment has started and things can improve. Set expectations, give informed consent, and begin listing the client's reinforcers. [source: NIDA 1998; Serna 2021]
  • Steps:
    1. Introduce yourself and the session's purpose.
    2. Explore, in the client's own words:
      • current use and what prompted help-seeking
      • past treatment and what helped
      • expectations for treatment
      • perceived pros and cons of using
      • work, family and relationships, including whether a partner might join
    3. Give the CRA rationale with optimism:
      • Use serves purposes.
      • Treatment builds other ways to meet those needs and makes a sober life rewarding.
    4. Outline the procedures likely to be used.
    5. Make a problem list covering:
      • substance use
      • employment
      • family
      • social and recreational life
      • psychological health
      • legal issues
      • medical health
    6. Address urgent practical needs first (housing, transport, money).
    7. Discuss involving a significant other. Raise disulfiram if relevant.
    8. In CRA + Vouchers, also explain the abstinence contract, the testing schedule and the voucher rules, including that one use episode can produce several positive tests.
    9. Book the next session. Give an appointment book for planning activities.
    10. If the client is tired or pressed for time, shorten the session and finish next time.
  • Example language (illustrative): "Drinking has been doing some important jobs for you. Our work is to find other ways to get those things, ways that don't cost you your job or your marriage, and to make the rest of your life worth staying sober for."
  • Watch for:
    • Leaving without a clear next appointment, or with an unaddressed crisis.
    • Working signs: the client names at least one thing they want from life, and returns.

A2. Functional analysis of substance use

  • Purpose: map the antecedents and consequences of typical use episodes. The map is the case formulation and points to treatment targets. It is a structured, non-confrontational interview. Do it early (weeks 2–4 in the NIDA schedule). [source: Meyers, Roozen & Smith 2011; CCSA CRA 2017; NIDA 1998]
  • Steps:
    1. Pick a common use episode. For CRA + Vouchers, also analyse the most recent use.
    2. External triggers: who the client is usually with, where, and when.
    3. Internal triggers: thoughts, physical sensations and emotions just before use.
    4. The behaviour: what is used, how much, and over how long.
    5. Short-term positive consequences: what the client likes about using with these people, in this place, at this time, and the pleasant thoughts, feelings and sensations.
    6. Long-term negative consequences, across areas such as relationships, health, legal, emotional, work and money.
    7. Summarise the chain back to the client.
    8. Mark the triggers to plan around and the rewards that need non-substance replacements. These become goals and skill targets.
    9. Ask the client's permission before involving a partner who can spot triggers the client misses (for example, anger).
  • Example language (illustrative): "So on a typical weekday it starts at about five, driving past the bar, feeling wound up from work. The first beer takes the edge off and the guys make you laugh. Let's write down what it costs you later, too."
  • Watch for:
    • Moralising, or asking "why" in a way that sounds accusatory. Keep the tone curious.
    • Long-term consequences the client names only to please you.
    • Working signs: the client can predict their own high-risk situations and names what use gives them.

A3. Functional analysis of pro-social (healthy, enjoyable) behaviour

  • Purpose: use the same mapping on a sober activity the client enjoys. It shows what already competes with use, its triggers, and what gets in its way. [source: Meyers, Roozen & Smith 2011; Serna 2021]
  • Steps:
    1. Choose an activity the client enjoys and does sometimes.
    2. Map its triggers (who, where, when, thoughts, feelings).
    3. Describe the behaviour (how often and how long).
    4. List its short-term negatives: what makes it hard to do.
    5. List its long-term positives.
    6. Plan to increase the activity by removing the short-term barriers.
  • Example language (illustrative): "When you do get out fishing, what makes it good? And what usually stops you going?"
  • Watch for:
    • Clients who say nothing is fun without using. Then go to social and recreational counselling (B2) to sample new activities.
    • Working sign: the activity's frequency goes up.

A4. Sobriety sampling

  • Purpose: get a time-limited, negotiated trial of abstinence instead of demanding lifelong sobriety. It suits clients aiming for moderation as well as those aiming for abstinence. In the developers' words: "Sobriety Sampling is a gentle movement toward long-term abstinence" (Meyers et al. 2011). [source: Meyers, Roozen & Smith 2011; CCSA CRA 2017; Serna 2021]
  • Steps:
    1. Give reasons that fit the client's reinforcers. A trial:
      • lets the client see what sobriety is like
      • breaks old habits
      • gives room to practise new coping
      • shows the client what they can do
      • rebuilds family trust
      • shows which situations are hardest
    2. Propose a substantial period. 90 days is typical.
    3. Expect a counter-offer. Negotiate to a period that is challenging but achievable. It can be as short as a day, but must last at least until the next session.
    4. Build the plan:
      • Name the biggest threats.
      • Do not rely on methods that failed before.
      • Choose alternative coping for each threat, with a backup plan.
      • Add disulfiram if appropriate and medically supervised.
    5. Remind the client what they stand to gain. Praise the commitment.
    6. At the next session, review the trial. Extend it, or renegotiate after a lapse.
  • Example language (illustrative): "I'm not asking you to quit forever today. How about we test it: 90 days without drinking, and you see what changes? ... Ninety feels too long? What would be a stretch but still doable for you?"
  • Watch for:
    • Agreeing to a period the client privately does not believe in. Check confidence.
    • A period with no concrete plan.
    • Working signs: the client completes the agreed period, then agrees to extend it.

A5. Happiness Scale

  • Purpose: show that all life areas matter, find areas the client wants to improve, and give a baseline for the treatment plan. [source: Meyers, Roozen & Smith 2011; Serna 2021]
  • Steps:
    1. The client rates current satisfaction in each life area on a 1–10 scale. The areas are:
      • drinking/sobriety
      • job or education
      • money management
      • social life
      • personal habits
      • marriage/family
      • legal issues
      • emotional life
      • communication
      • spirituality
      • general happiness
    2. Ask what would raise each low score by one point.
    3. Choose one to three areas to work on first.
    4. Re-administer periodically to track change.
  • Notes:
    • The area list comes from training slides (Serna 2021). Check the scale range against the 1995 manual [uncertain].
    • A-CRA adds school and friends.
    • Couples use a relationship version (B4).
  • Example language (illustrative): "Your social life is at a 3. What would a 4 look like this month?"
  • Watch for:
    • Rating everything 10 or 1. Anchor the ratings to the past week.
    • Working sign: scores rise in targeted areas.

A6. Goals of Counseling (treatment plan)

  • Purpose: turn Happiness Scale areas into goals that are specific, measurable, positive and under the client's control, each with concrete methods. [source: Meyers, Roozen & Smith 2011; CCSA CRA 2017]
  • Steps:
    1. For each chosen area, state the goal briefly and positively: what the client will do, not what they will stop.
    2. Make it measurable and achievable within weeks.
    3. List specific interventions or steps, with timeframes.
    4. Link methods to CRA skills, for example problem solving or job skills.
    5. Review the goals at every session. Revise if stalled.
    6. In CRA + Vouchers, graph progress each session:
      • cumulative negative tests
      • attendance
      • target behaviours, as bar charts with a goal line
  • Example language (illustrative): "'Be less lonely' is hard to measure. What's one thing you could do twice this week that would count?"
  • Watch for:
    • Vague goals, or goals that depend on someone else changing.
    • Working signs: methods are actually done between sessions, and the graphs move. [source: NIDA 1998 for graphing]

A7. Systematic encouragement

  • Purpose: make sure first steps toward new reinforcers, such as calling a club, a job lead or a self-help group, actually happen. The sources treat this as a CRA technique; the principle is to never assume the client will take a new step alone. [source: named among A-CRA procedures in training materials; Meyers & Smith 1995 not drawn on — steps below are my reconstruction] [uncertain]
  • Steps:
    1. Encourage the specific step.
    2. Start it in session, for example by having the client make the phone call from the office.
    3. Problem-solve and rehearse what to say.
    4. Get details: time, contact person, transport.
    5. Review how it went at the next session. Problem-solve if it didn't happen.
  • Example language (illustrative): "Let's call the climbing gym right now while you're here. I'll sit with you. What do you want to ask them?"
  • Watch for:
    • Steps that stay talk and never get done.
    • Working sign: the client attends the new activity at least once.

A8. Communication skills training

  • Purpose: replace critical or coercive exchanges with positive, assertive, empathic ones. This raises the chance of being heard and of getting rewards from others. [source: Meyers, Roozen & Smith 2011; Kane MGH slides; Case Western 2024]
  • Steps:
    1. Explain the rationale and get a recent example of a difficult conversation.
    2. Teach the core elements:
      • Be brief.
      • Be positive: say what you want, not what you don't.
      • Refer to specific behaviours.
      • Label your own feelings.
      • Offer an understanding statement.
      • Accept partial responsibility, for the situation, not for the other person's use.
      • Offer to help.
    3. Model a statement.
    4. The client rehearses it in role-play while you play the other person realistically.
    5. Give specific praise and one correction. Repeat.
    6. Assign real-life practice and review it next session.
  • Notes: the CRA and A-CRA core is the three-part sequence: understanding statement, partial responsibility statement, offer to help. A-CRA uses a simplified version.
  • Example language (illustrative): "I know you've had a brutal week at work (understanding). I probably haven't made evenings easy either (partial responsibility). Could we go for a walk after dinner instead of the pub? I'd really like that time with you (positive request). Is there anything I can do to help that happen (offer to help)?"
  • Watch for:
    • "You" statements, sarcasm, and bringing up past failures.
    • Working sign: the client reports fewer arguments and more requests granted.

A9. Problem-solving training

  • Purpose: break overwhelming problems into steps the client can carry out. It is also used whenever a goal stalls. [source: Case Western 2024 (CRAFT version); Meyers, Roozen & Smith 2011; NIDA 1998]
  • Steps:
    1. Define the problem narrowly and specifically.
    2. Brainstorm without judging. You may add ideas.
    3. The client eliminates options they won't or can't do.
    4. Choose one solution.
    5. Identify likely obstacles.
    6. Plan how to handle each obstacle.
    7. Make the solution an assignment with a time.
    8. Evaluate the outcome at the next session, and repeat if needed.
  • Example language (illustrative): "Let's shrink 'my money's a mess' to one piece we can solve this week. Which bill is most urgent?"
  • Watch for:
    • Therapist-generated solutions the client hasn't chosen.
    • Problems defined too broadly.
    • Working sign: the assignment is completed, or obstacles are identified for the next round.

A10. Drink and drug refusal training

  • Purpose: prepare the client for direct and indirect social pressure in high-risk situations found in the functional analysis. [source: Meyers, Roozen & Smith 2011; CCSA CRA 2017; NIDA 1998]
  • Steps:
    1. Identify the people and situations where pressure is likely.
    2. Plan social support for sobriety, for example a partner or friend who knows the plan.
    3. Teach assertive refusal behaviours:
      • say no clearly
      • suggest an alternative activity or drink
      • change the subject
      • use firm body language and eye contact
      • ask the person to stop offering
      • leave if pressure continues
    4. Role-play escalating pressure, with you playing a persistent friend.
    5. Coach, then assign real-world use and review it.
  • Notes: the refusal behaviours above follow common CRA training presentations; the 1995 manual's exact list is not drawn on [uncertain].
  • Example language (illustrative): client practising: "No thanks, I'm not drinking. Grab a coffee with me instead?" Therapist: "Good. Now I'm going to push harder, the way Mike would."
  • Watch for:
    • Apologetic or vague refusals, or over-long excuses.
    • Working sign: the client reports refusing in a real situation.

B1. Job skills training (Job Club method)

  • Purpose: help the client get and keep satisfying work. Work is a major competing reinforcer and structures time away from use. [source: Meyers, Roozen & Smith 2011, which refers to Azrin & Besalel's Job Club Counselor's Manual; NIDA 1998]
  • Steps:
    1. Set an employment goal on the Goals of Counseling form.
    2. Build job-seeking behaviours:
      • find leads through friends, relatives and other contacts
      • prepare a résumé or application
      • rehearse phone calls to employers and interview answers, including how to handle gaps and a record
    3. Set daily contact goals and graph them.
    4. Address barriers by problem solving: transport, childcare, clothing.
    5. Once in work, work on job retention and on avoiding jobs with heavy drinking cultures.
  • Notes: the specific job-search steps paraphrase the Job Club approach as summarised in secondary training sources. The Job Club manual is not drawn on [uncertain].
  • Example language (illustrative): "Let's aim for five employer contacts tomorrow. Who in your family knows someone hiring?"
  • Watch for:
    • Applications only to jobs that keep the client around use.
    • Working signs: daily contact counts rise, and interviews and offers follow.

B2. Social and recreational counselling

  • Purpose: replace the social and recreational rewards that use provided by sampling new sober activities and contacts. The aim is to replace reinforcement, not to keep the client busy. [source: Meyers, Roozen & Smith 2011; Serna 2021; NIDA 1998]
  • Steps:
    1. Discuss why a rewarding social life protects sobriety.
    2. List the client's interests, past and possible. A leisure questionnaire can help.
    3. Use a 2×2 grid (free versus costs money, alone versus with others) to generate options that fit the client's means.
    4. Choose an activity to sample. Use the pro-social functional analysis (A3) to anticipate barriers.
    5. Set a measurable goal and use systematic encouragement (A7). Track the hours.
    6. Problem-solve barriers. Model and rehearse the social steps, such as joining or introducing oneself.
  • Options the sources describe:
    • Reinforcer access counselling: help the client get transport, a phone, media and other resources needed to reach rewards.
    • Social club: in some trials, a sober social club or weekly non-drinking social event ran alongside treatment.
  • Example language (illustrative): "Before, Friday nights meant the bar and your mates. What else gave you that feeling of being part of something? Let's find one thing to try this Friday."
  • Watch for:
    • An activity the client picks to please you, or one surrounded by drinking.
    • Working sign: weekly sober activity hours rise and new non-using contacts appear.

[source: williamrmiller.net for reinforcer access counselling; Meyers website for the social club]

B3. Self-management planning (CRA + Vouchers)

  • Purpose: turn the functional analysis into a written plan for each high-risk situation. [source: NIDA 1998]
  • Steps:
    1. Give the rationale.
    2. From the functional analysis, list the high-risk triggers.
    3. For each trigger, plan how to avoid it, how to change it, or an alternative response, including stimulus control: removing paraphernalia and avoiding using contacts.
    4. Write the plan, rehearse it, and assign it.
    5. Review it after any use.
  • Example language (illustrative): "Payday Friday is your biggest risk. What's the plan: direct deposit, cash with your sister, plans at 6pm?"
  • Watch for:
    • Plans that rely on willpower alone.
    • Working sign: high-risk situations come and go without use.

B4. Relationship counselling (CRA behavioural couples work)

  • Purpose: raise the rate of positive exchanges, improve communication and problem solving, and make the relationship a reinforcer for sobriety. [source: Meyers, Roozen & Smith 2011; NIDA 1998; Serna 2021]
  • Steps:
    1. Session 1:
      • Introduce the approach.
      • Each partner completes the Relationship Happiness Scale (the couple's version of the Happiness Scale).
      • Introduce the Daily Reminder to Be Nice. Each partner tracks daily pleasant acts: appreciation, compliments, pleasant surprises, affection, pleasant conversation, offering help unasked.
    2. Session 2:
      • Each partner describes their "perfect relationship" in the low-rated areas.
      • Each partner turns this into positive, specific requests.
      • Each partner asks for one minor change.
    3. Sessions 3–4:
      • Train communication (A8) using the couple's own requests.
    4. Later sessions:
      • Problem solving (A9) on joint issues.
      • Negotiate reciprocal agreements.
      • Keep up the Daily Reminder.
  • Notes: the NIDA manual specifies sessions 1–4; the content of sessions 5–8 was not retrieved [uncertain].
  • Example language (illustrative): "Instead of 'stop ignoring me,' tell her exactly what you'd like her to do, and when."
  • Watch for:
    • Turning sessions into complaint exchanges.
    • Coercion or violence. Screen both partners separately before joint work [synthesis].
    • Working signs: Daily Reminder entries increase, and Relationship Happiness ratings rise.

B5. Disulfiram with monitored compliance (alcohol)

  • Purpose: for suitable clients aiming at abstinence, disulfiram removes the option of impulsive drinking. A supportive monitor raises adherence. The monitored version had the strongest abstinence results in one outpatient study. [source: Meyers website; NIDA 1998; williamrmiller.net]
  • Steps:
    1. Offer disulfiram as an option within sobriety sampling, not as a condition of treatment.
    2. Refer to a prescribing physician for medical screening, consent and monitoring. Prescribing and dosing are medical decisions outside this guide.
    3. With the client's consent, recruit a monitor, usually a partner or family member, or arrange supervised clinic dosing.
    4. Train the monitor in a brief, positive daily routine:
      • observe the medication being taken
      • thank and reinforce the client
      • use positive communication, with no reminders of past drinking
    5. Rehearse what both do if a dose is refused. The monitor responds calmly and informs the therapist.
    6. Review adherence every session.
  • Notes: the CRA + Vouchers manual offers disulfiram where alcohol fuels cocaine use, with limited drinking as an alternative goal.
  • Example language (illustrative): monitor rehearsal: "Thanks for taking it with me this morning. It means a lot to me."
  • Watch for:
    • The monitor using the routine to scold.
    • Covert non-adherence.
    • Working sign: daily adherence is recorded and the couple reports the ritual as positive.

B6. Relapse prevention: functional analysis of relapse and early warning system

  • Purpose: treat lapses as information, and catch the chain early next time. Relapse prevention runs through all of treatment. [source: Meyers, Roozen & Smith 2011; CCSA CRA 2017; NIDA 1998]
  • Steps:
    1. After any use, run a functional analysis of that specific episode:
      • triggers
      • the chain of decisions
      • short-term rewards
      • consequences
    2. Identify the earliest warning signs in the chain.
    3. Build an early warning system:
      • The client chooses someone (partner, friend, family member) and teaches them the warning signs.
      • Agree with that person how they will point out a sign, using positive communication.
      • Agree the pre-planned response.
    4. Update the self-management plan and goals.
    5. Renegotiate sobriety sampling.
  • Example language (illustrative): "Let's treat Saturday as a learning opportunity. Walk me back. When was the first moment you knew the day was heading that way?"
  • Watch for:
    • Shame-driven missed sessions after use. Reach out quickly.
    • Working signs: the client and network notice warning signs earlier, and lapses shorten.

B7. Mood monitoring

  • Purpose: daily mood tracking serves as an early warning of relapse and a target for intervention. [source: williamrmiller.net] Procedure details are not given in the sources [uncertain].
  • Steps (my reconstruction): [synthesis]
    1. The client rates mood daily.
    2. Review the ratings each session.
    3. Link dips to triggers in the functional analysis.
    4. Plan coping or activities for low days.
  • Example language (illustrative): "Your mood ratings dropped on Tuesday and Wednesday. What was happening?"
  • Watch for:
    • Persistent low mood. Assess for depression and suicide risk using standard practice.

B8. Urinalysis feedback and vouchers (CRA + Vouchers)

  • Purpose: reinforce abstinence directly and give objective data on it. [source: NIDA 1998]
  • Steps:
    1. Explain the abstinence contract and get the client's written agreement to the testing schedule.
    2. Collect samples on the schedule (Section 2). Screen randomly for other drugs, and breath-test for alcohol as needed.
    3. Give results promptly:
      • Negative result: brief, warm praise, and record the points.
      • Positive result: record the day and amount of use, refer to the therapist, and give no lecture.
    4. Apply the escalating, resetting and restoring voucher rules consistently.
    5. Approve purchases that support drug-free goals, such as recreation passes or work clothes.
    6. Reduce the reinforcement in phase 2.
  • Notes: vouchers are contingency management. Programmes need their own budget and protocol. This guide gives no amounts [synthesis].
  • Example language (illustrative): "Negative again. That's eight in a row, and your points went up. What do you want to put them toward?"
  • Watch for:
    • Inconsistent rule application, which destroys the contingency.
    • Working signs: the run of consecutive negatives lengthens, and purchases are tied to new activities.

B9. Social skills and assertiveness training (CRA + Vouchers)

  • Purpose: broaden interpersonal skills beyond refusal. [source: NIDA 1998]
  • Steps:
    1. Define the client's usual style: passive, aggressive or assertive.
    2. Teach assertive behaviours.
    3. Role-play the client's real situations.
    4. Set practice goals.
  • Example language (illustrative): "When your boss criticises you, you usually go quiet and then use. Let's practise saying what you need."
  • Watch for:
    • Working sign: the client reports handling a real situation assertively.

B10. HIV and hepatitis risk reduction (CRA + Vouchers)

  • Purpose: reduce infection risk. [source: NIDA 1998]
  • Steps:
    1. Assess knowledge before and after.
    2. Give education and discussion.
    3. Provide materials and condoms.
    4. Offer testing, with results discussed.
  • Example language (illustrative): "Before we finish this part, do you want to get tested here?"
  • Watch for:
    • Working sign: the client reports safer practices.

B11. Adjunct mental health procedures (CRA + Vouchers)

  • Purpose: address problems that drive use or block progress. [source: NIDA 1998]
  • Procedures:
    • Depression: monitor with a standard inventory and assess suicide risk following current risk-assessment practice.
    • Anxiety: relaxation training.
    • Insomnia: sleep diary, sleep hygiene, and stimulus control with sleep restriction.
    • Refer out for problems beyond scope.
  • Notes: the NIDA manual discontinued a structured significant-other reinforcement component after it showed no benefit in a trial.
  • Example language (illustrative): "Your sleep diary shows you're in bed nine hours but sleeping five. Let's try the sleep schedule."
  • Watch for:
    • Rising depression scores or any suicidal ideation. Assess immediately and act on the result.

C1. A-CRA adaptations (adolescent sessions)

  • Purpose: deliver CRA in a developmentally appropriate form to ages 12–24. [source: Meyers, Roozen & Smith 2011; ACF Clearinghouse; Wikipedia A-CRA]
  • Steps:
    1. Use A-CRA versions of the procedures:
      • functional analyses of use and of pro-social behaviour (A2, A3)
      • Happiness Scale and Goals of Counseling with school and friends added (A5, A6)
      • sobriety sampling (A4)
      • pro-social recreation and systematic encouragement (A7, B2)
      • simplified communication training (A8)
      • problem solving (A9)
      • relapse prevention (B6)
      • job-seeking skills (B1)
      • anger management (C2)
    2. End every session with a homework assignment agreed together. Review it at the start of the next session.
  • Notes: the 2016 guide has 19 procedures; the full list is not drawn on, so this list may be incomplete [uncertain].
  • Example language (illustrative): "You said school's a 2 right now. What would make it a 3 by next week?"
  • Watch for:
    • Lecturing, which young people quickly read as adult control.
    • Working signs: homework is completed and new pro-social peers appear.

C2. Anger management (A-CRA)

  • Purpose: manage impulsive, acting-out behaviour that leads to use or conflict. [source: Meyers, Roozen & Smith 2011] Step details are not given in the sources. The steps below are a standard behavioural sequence [synthesis].
  • Steps:
    1. Run a functional analysis of a recent anger episode.
    2. Identify early body and thought cues.
    3. Plan a time-out or calming response.
    4. Rehearse an assertive alternative (A8).
    5. Assign practice.
  • Example language (illustrative): "What's the first sign in your body that you're about to blow?"
  • Watch for:
    • Working sign: fewer incidents reported by the young person and caregivers.

C3. Caregiver-only sessions (A-CRA, two sessions)

  • Purpose: engage the caregivers, teach them the skills the adolescent is learning, and strengthen parenting rules and monitoring. Parental rule-setting is linked to less adolescent drinking. [source: Meyers, Roozen & Smith 2011; Recovery Research Institute]
  • Steps:
    1. Build rapport and validate caregiver stress.
    2. Explain A-CRA, while protecting the adolescent's confidentiality.
    3. Motivate caregivers by linking their participation to the outcomes they want.
    4. Teach positive communication and problem solving, with role-play.
    5. Discuss clear rules and consequences, monitoring, and rewarding positive behaviour.
    6. Plan for the joint sessions.
  • Example language (illustrative): "Your son's practising a way of asking for things without a fight. I'd like to teach you the same skill so you're speaking the same language."
  • Watch for:
    • Caregivers wanting a report on everything the adolescent disclosed.
    • Working sign: caregivers use the skills at home.

C4. Family sessions (A-CRA, two sessions)

  • Purpose: improve family interaction and agree shared goals. [source: Meyers, Roozen & Smith 2011; Recovery Research Institute]
  • Steps:
    1. Each member rates relationship happiness.
    2. Each states positive, specific requests.
    3. Practise positive communication in guided role-play.
    4. Negotiate goals for the relationship.
    5. Problem-solve one issue together.
    6. Assign problem-solving practice at home.
  • Example language (illustrative): "Mum, tell Jamie one thing he did this week that you appreciated. Be specific."
  • Watch for:
    • Escalating blame. Stop and coach the skill.
    • Working sign: the home assignment is completed and conflict is reported as lower.

D1. CRAFT: inform and motivate the CSO, with violence risk assessment and safety planning

  • Purpose: engage the concerned significant other (CSO), give hope and the rationale, and make sure applying CRAFT will not raise the risk of violence. [source: Smith & Meyers 2023 ch. 2; CCSA CRAFT 2017; Case Western 2024]
  • Steps:
    1. Hear the CSO's story with empathy. Do not blame.
    2. Explain CRAFT's three goals: the loved one's treatment entry, reduced use, and the CSO's own wellbeing. Note that it does not use confrontation.
    3. Draw out the CSO's motivations and the rewards of change for them, in a motivational style.
    4. Assess violence risk: history, severity, triggers, red flags and supports.
    5. Where there is risk, build a safety plan:
      • who to call, and whether it is safe to leave messages
      • leaving at the first signs of violence
      • preparing a quick exit and a safe place to stay
      • legal options
    6. Choose which CRAFT procedures are safe to use. Where risk is high, pause CRAFT procedures that change how the CSO responds to the loved one.
  • Example language (illustrative): "You've tried everything you know, and it's worn you out. There's a different approach, one that works with how people respond to rewards and doesn't involve confrontation. First, I need to ask some questions about safety."
  • Watch for:
    • Minimised violence.
    • CSO guilt.
    • Working signs: the CSO returns, and safety is documented.

D2. Functional analysis of the loved one's use (CSO view)

  • Purpose: use the CSO's observations to map the loved one's typical use. This shows where the CSO can change the pattern. [source: Smith & Meyers 2023 ch. 3; Kane MGH slides; CCSA CRAFT 2017]
  • Steps:
    1. Pick a typical use episode the CSO knows well.
    2. External triggers: who, where, when.
    3. Internal triggers: the CSO's best guess at the loved one's thoughts and feelings.
    4. The behaviour: what is used and how much. Include the CSO's own early warning signs that use has happened.
    5. Short-term rewards for the loved one: what they seem to get from using.
    6. Long-term negative consequences that the loved one might care about.
    7. Identify which rewards the CSO could provide for non-use, and which triggers the CSO can influence.
  • Example language (illustrative): "From what you see, what does he get out of those evenings at his brother's? Relaxation? Company? Let's see which of those you could offer when he's sober."
  • Watch for:
    • CSO self-blame.
    • Speculation presented as fact.
    • Working sign: the CSO can name the loved one's patterns and possible competing rewards.

D3. Positive communication training for the CSO

  • Purpose: replace nagging, pleading and threats with communication that is more likely to be heard. The developers call this "critical for success" throughout CRAFT. [source: Meyers, Roozen & Smith 2011; Case Western 2024; Kane MGH slides]
  • Steps:
    1. Get an example of a recent conversation with the loved one that went badly.
    2. Teach the seven guidelines:
      1. Be brief.
      2. Be positive and action-oriented.
      3. Name specific behaviours.
      4. Label your feelings.
      5. Give an understanding statement.
      6. Accept partial responsibility, but not for the use.
      7. Offer to help.
    3. The CSO rewrites the conversation.
    4. Rehearse it in role-play, with you as the loved one, including tough responses.
    5. Assign one low-risk conversation at home.
  • Example language (illustrative): CSO: "I really enjoyed Sunday when we cooked together. I felt close to you. I know weekends are hard for you, and I haven't always made them easy. Would you like to do that again this week?"
  • Watch for:
    • Statements that slip into criticism.
    • Working signs: fewer arguments and more positive interactions.

D4. Rewarding non-using behaviour

  • Purpose: make sober time more rewarding for the loved one than using time. [source: Smith & Meyers 2023 ch. 5; Meyers, Roozen & Smith 2011; CCSA CRAFT 2017]
  • Steps:
    1. Teach the CSO the difference between reinforcing sobriety and enabling. Enabling means unintentionally rewarding use.
    2. From the functional analysis, choose rewards that:
      • matter to the loved one
      • cost little or nothing
      • the CSO is comfortable giving
      • the CSO can give right after non-use Examples: time together, a favourite meal, a compliment, affection.
    3. Agree how the CSO will tell that the loved one is sober.
    4. Rehearse delivering the reward, with positive communication.
    5. Plan consistency across many situations.
    6. Review results and adjust.
  • Example language (illustrative): CSO: "It's really nice having you home and clear-headed tonight. Want to watch the match together?"
  • Watch for:
    • Rewards given while the loved one is intoxicated.
    • Rewards given resentfully.
    • Working sign: sober evenings increase.

D5. Functional analysis of the loved one's healthy, enjoyable behaviour (optional)

  • Purpose: find activities that compete with use and that the CSO can encourage. [source: Smith & Meyers 2023 ch. 6; Case Western 2024]
  • Steps:
    1. Choose an activity the loved one enjoys when not using.
    2. Map its triggers and rewards, and the short-term barriers to doing it.
    3. Plan how the CSO can prompt, join in, or remove barriers.
  • Example language (illustrative): "When does he go cycling? What gets in the way? Could you suggest a ride on Saturday mornings, before he usually starts drinking?"
  • Watch for:
    • Working sign: the activity becomes more frequent.

D6. Withdrawing rewards for using behaviour (time-out from positive reinforcement)

  • Purpose: remove the CSO-delivered rewards that currently follow use. [source: Smith & Meyers 2023 ch. 7; Meyers, Roozen & Smith 2011; CCSA CRAFT 2017]
  • Steps:
    1. Identify what the CSO currently does that makes using more pleasant: company, meals, covering for the loved one, attention.
    2. Choose rewards to withdraw when use occurs. Run a safety check on each one.
    3. Script a brief, calm, positive explanation, and pair it with an exit. For example, the CSO goes with the loved one to an event only if he is sober, and politely excuses herself if he starts drinking.
    4. Role-play the script.
    5. Plan safe responses if the loved one becomes angry.
    6. Pair this procedure with D4 so that the contrast between sober and using time is clear.
  • Example language (illustrative): CSO: "I love spending evenings with you, but when you've been drinking I'm going to read upstairs. I'd love to hang out tomorrow."
  • Watch for:
    • Withdrawal delivered as punishment or a lecture.
    • Any escalation risk. Go back to D1.
    • Working sign: using evenings become less rewarding while sober ones are enjoyed.

D7. Allowing natural, negative consequences of use

  • Purpose: stop the CSO from shielding the loved one from the consequences of use. [source: Smith & Meyers 2023 ch. 8; Kane MGH slides]
  • Steps:
    1. List what the CSO does to cushion use, such as cleaning up, calling in sick for them, or paying debts.
    2. Choose one consequence to stop preventing, where letting it happen is safe and the CSO accepts the cost.
    3. Plan what the CSO will say, using positive communication without blame.
    4. Problem-solve the obstacles (D8).
  • Notes: the CCSA summary says problem solving is introduced in this session.
  • Example language (illustrative): CSO: "I'm not going to call your boss for you tomorrow. I know it's hard, and I'll be glad to help you get to work."
  • Watch for:
    • Consequences that endanger health or safety. Do not let these happen; plan protection instead [synthesis].
    • CSO guilt.
    • Working sign: the loved one faces consequences, and conversations about change open up.

D8. Problem solving (CRAFT)

  • Purpose: work through obstacles to any CRAFT plan. [source: Smith & Meyers 2023 ch. 9; Case Western 2024]
  • Steps: the same eight steps as A9, applied to the CSO's situation:
    1. Define the problem narrowly.
    2. Brainstorm.
    3. Eliminate options.
    4. Select one.
    5. Identify obstacles.
    6. Address the obstacles.
    7. Assign the solution as homework.
    8. Evaluate.
  • Example language (illustrative): "So the snag is his mates turning up on Fridays. Let's brainstorm, no idea too silly."
  • Watch for:
    • Working sign: the CSO uses the steps independently.

D9. Helping the CSO enrich their own life

  • Purpose: improve the CSO's happiness and functioning whatever the loved one does. It also builds the CSO's independence and the CSO's model for the loved one. [source: Smith & Meyers 2023 ch. 10; Meyers, Roozen & Smith 2011; CCSA CRAFT 2017]
  • Steps:
    1. Complete the CRAFT Happiness Scale.
    2. Choose an area to work on.
    3. Set a specific goal and strategy. Plan for obstacles, such as childcare.
    4. Report back weekly.
    5. Widen the CSO's social support.
  • Example language (illustrative): "You've put your life on hold for two years. What's one thing just for you this week?"
  • Watch for:
    • A CSO who feels selfish. Reframe self-care as part of the plan.
    • Working signs: lower depression, anger and anxiety, and goals met.

D10. Inviting the loved one into treatment

  • Purpose: suggest treatment at a moment when the loved one is most open to it. [source: Smith & Meyers 2023 ch. 11; Case Western 2024; CCSA CRAFT 2017]
  • Steps:
    1. Check readiness: the CSO is confident with positive communication and with rewarding non-use.
    2. Line up treatment in advance:
      • Choose a provider and arrange a rapid intake.
      • Consider the options that fit the loved one: harm reduction, outpatient, intensive.
    3. Identify windows of opportunity, for example when the loved one:
      • asks about the CSO's sessions
      • asks why the CSO has changed
      • shows remorse after a substance-related incident
    4. Script the invitation, using positive communication and motivational hooks that address the loved one's own concerns. Points the CSO can offer:
      • the loved one can have their own therapist
      • they can meet the CSO's therapist informally first
      • they can shape their own goals
      • they can sample a few sessions
    5. Rehearse the invitation, and the responses to refusal.
    6. If refused, either:
      • plan and rehearse a later invitation, or
      • shift focus to the CSO's goals and set a time to revisit
    7. If the loved one does not already know the CSO is in treatment, tell them at this stage.
  • Example language (illustrative): CSO: "You've seemed down since the accident, and I'm worried about you. I've been seeing a counsellor and it's helped me. You could see someone of your own, just a couple of sessions to see if it's useful. I'd be glad to drive you."
  • Watch for:
    • An invitation given during intoxication or an argument.
    • Long gaps between the yes and the appointment.
    • Working sign: the loved one attends intake.

D11. After engagement: CRA with the loved one and relationship therapy

  • Purpose: keep the loved one in treatment and continue the CSO's support. [source: Smith & Meyers 2023 ch. 12; CCSA CRAFT 2017]
  • Steps:
    1. Prepare the CSO for possible early drop-out, with a planned response.
    2. Start CRA with the loved one (Parts A and B), and start couples or relationship therapy (B4) as early as possible.
    3. Continue the CSO's own goals.
  • Example language (illustrative): "If he misses a session, how will you respond in a way that makes going back easier?"
  • Watch for:
    • Working signs: the loved one is retained and the relationship ratings rise.

5. Handling problems

Items tagged [source] come from the NIDA manual or the developers' summaries. Items tagged [synthesis] are my own guidance, consistent with CRA principles but not stated in the primary sources.

Attendance and engagement

Missed sessions. [source: NIDA 1998]

  • Call the client straight away. Visit the home if there is no phone and it is safe to do so.
  • Offer transport, or reschedule as soon as possible.
  • If you cannot reach the client within 2 days, send a warm, empathetic letter.
  • When the client returns, problem-solve how to prevent future absences.
  • In the research protocol, five consecutive missed urine tests marked dropout. Before discharge, the protocol required letters, calls and visits offering continued treatment or referral.

Lateness or leaving early. [source: NIDA 1998]

  • Never punish lateness.
  • Praise the client for coming, and run as full a session as time allows.

Motivation and goals

Ambivalence, resistance, or not ready for abstinence. [source: NIDA 1998; CCSA CRA 2017; Serna 2021]

  • Do not confront or argue.
  • Accept the client's position and set an alternative goal the client will work on. Return to the original goal later.
  • Shorten the sobriety sampling period, even to one day, and build on success by shaping.
  • Tie each goal to the client's own reinforcers from the functional analysis and Happiness Scale.
  • In CRA + Vouchers, limited drinking can be an alternative goal for alcohol.

Homework not done. [synthesis, built on systematic encouragement and problem solving]

  • Treat non-completion as data, not defiance. Ask what got in the way and problem-solve that obstacle.
  • Start the task in session, for example by making the call now.
  • Shrink the task to a smaller step.
  • Check the task is the client's own goal, not yours.
  • Praise any partial attempt.

Stuck: nothing rewards the client but using. [synthesis, from CRA reinforcer logic]

  • Use the 2×2 activity grid and the pro-social functional analysis.
  • Use reinforcer access counselling: transport, phone, passes.
  • Lower the bar to sampling a single activity once.
  • Screen for depression and anhedonia. Treat or refer, and use mood monitoring.

Overwhelm: many urgent life problems. [source: NIDA 1998 for practical needs first; the rest is synthesis]

  • Deal with urgent practical needs first: housing, money, legal.
  • Then pick one Happiness Scale area and one narrowly defined problem at a time, using problem solving.
  • Use graphs so the client can see small gains.

Problems within sessions

Crises taking over sessions. [source: NIDA 1998]

  • Link the crisis to the treatment plan if possible.
  • Otherwise, either defer it until abstinence is established, or protect 10–20 minutes at the end of the session after the planned work.

Client arrives intoxicated. [source: NIDA 1998; additions are synthesis]

  • End the session in a caring but firm way and reschedule.
  • Before the client leaves, assess immediate safety and arrange safe transport [synthesis].
  • At the next session, do a functional analysis of that episode [synthesis].

Lapse or positive test. [source: NIDA 1998; Meyers, Roozen & Smith 2011]

  • Respond without lecturing. Use is why the client is in treatment.
  • Run a functional analysis of the episode.
  • Update the self-management plan and the early warning system.
  • Renegotiate sobriety sampling.
  • Keep the voucher rules consistent, and remind the client that points already earned are never lost.

Rupture: the client feels pushed or judged. [synthesis]

  • CRA's directive style can be heard as control.
  • Name it, and own your part. This models the partial-responsibility statement.
  • Return choice to the client: offer a menu of procedures and let the client pick.
  • Ask for feedback at the end of each session.

Service and clinical boundaries

Requests for extra sessions or more contact. [source: NIDA 1998]

  • Consult a supervisor.
  • Consider tying extra contact to goal progress, using a contract.

Concurrent treatment. [source: NIDA 1998]

  • The research manual advised avoiding other professional substance treatment during CRA.
  • AA or NA attendance was encouraged but not required.
  • In routine practice, coordinate care rather than forbid it [synthesis].

Serious danger or no progress. [source: NIDA 1998]

  • Consider termination or referral only after careful clinical review and supervisor consultation.
  • Refer to a more intensive level of care where indicated.

Safety

Withdrawal risk at the start of abstinence. [synthesis; not addressed in the sources]

  • Before sobriety sampling, screen for physiological dependence on alcohol, benzodiazepines or opioids.
  • Arrange medical assessment or withdrawal management first. Unsupervised abrupt cessation of alcohol or benzodiazepines can be dangerous.

Suicide risk. [source: NIDA 1998 for monitoring; the rest is synthesis]

  • Monitor depression and ask directly about suicidal thoughts.
  • Follow current standard risk-assessment practice: assess ideation, intent, plan, history and protective factors, then make a collaborative safety plan.
  • Use lethal-means counselling: secure or remove firearms and stockpiled medications, with a family member's help where appropriate.
  • Intoxication raises acute risk. Include substance use in the safety plan.

Disulfiram declined or medically unsuitable. [synthesis]

  • Do not press. It is optional.
  • Strengthen other parts of the sobriety plan and the early warning system.
  • Medication decisions belong to the prescriber.

A-CRA

Caregivers will not attend, or disagree with each other. [synthesis]

  • Offer flexible times, phone sessions or home visits.
  • Start with one caregiver.
  • Use positive communication with caregivers themselves.
  • Problem-solve their barriers.

Confidentiality. [synthesis]

  • Agree at the outset what will and will not be shared with caregivers. Safety risks are always the exception.
  • Restate this agreement before every joint session.

CRAFT

The CSO fears violence, or violence occurs. [source: CCSA CRAFT 2017; Case Western 2024]

  • Safety comes first. Reassess the risk and update the safety plan.
  • Pause reward withdrawal and natural-consequence procedures.
  • Refer to domestic violence services where needed.
  • CSOs may need to stop CRAFT procedures for a period.

The loved one refuses the invitation. [source: Case Western 2024]

  • Plan and rehearse a later invitation for the next window of opportunity, or switch focus to the CSO's own goals and agree when to revisit.
  • Remind the CSO that their own gains count whatever the loved one does.

The loved one enters treatment then drops out. [source: CCSA CRAFT 2017]

  • Prepare the CSO in advance with a planned, positive response.
  • Resume reinforcement of non-use, and re-invite at the next window.

The CSO does not follow through, or applies the plan inconsistently. [synthesis]

  • Run a functional analysis of the CSO's own non-adherence. Common reasons are fear, guilt, and the loved one's reaction.
  • Shrink the plan to one reward or one withdrawal.
  • Rehearse more.
  • Check the plan is safe and comfortable for the CSO.

The CSO wants confrontation, or an ultimatum-style intervention. [source: Meyers, Roozen & Smith 2011, for CRAFT's non-confrontational stance and outcomes; framing is synthesis]

  • Validate the CSO's frustration.
  • Explain that rewarding sobriety and choosing the timing of the invitation engaged more loved ones in trials than confrontational or Al-Anon-facilitation approaches.
  • Agree to try the CRAFT plan for a set number of weeks.

The CSO uses substances heavily, or is in crisis. [synthesis]

  • Address the CSO's own use or mental health through the self-enrichment goals, or refer them to their own treatment.
  • CRAFT procedures depend on the CSO being able to deliver rewards consistently.

The loved one wants to see the CSO's therapist. [synthesis]

  • The sources say the loved one may meet the CSO's therapist informally, or have their own therapist.
  • Decide the arrangement in advance, with clear consent and confidentiality agreements for both.

Fidelity

Fidelity drift. [source: CCSA CRA and CRAFT 2017; Wikipedia A-CRA; ACF Clearinghouse]

  • Use certified training and coded, recorded-session supervision.
  • A-CRA requires a 2.5-day workshop and review of recorded sessions for certification.

Sources

Sources

Further reading (not drawn on)

  • Hunt, G. M., & Azrin, N. H. (1973). A community-reinforcement approach to alcoholism. Behaviour Research and Therapy, 11, 91–104.
  • Azrin, N. H. (1976). Improvements in the community-reinforcement approach to alcoholism. Behaviour Research and Therapy, 14, 339–348.
  • Azrin, N. H., Sisson, R. W., Meyers, R., & Godley, M. (1982). Alcoholism treatment by disulfiram and community reinforcement therapy. Journal of Behavior Therapy and Experimental Psychiatry, 13, 105–112.
  • Azrin, N. H., & Besalel, V. A. (1980). Job Club Counselor's Manual. University Park Press.
  • Meyers, R. J., & Smith, J. E. (1995). Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach. Guilford.
  • Budney, A. J., & Higgins, S. T. (1998). A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction. NIDA Therapy Manuals for Drug Addiction, NIH Pub. 98-4309.
  • Meyers, R. J., & Miller, W. R. (Eds.) (2001). A Community Reinforcement Approach to Addiction Treatment. Cambridge University Press.
  • Godley, S. H., et al. (2001). The Adolescent Community Reinforcement Approach for Adolescent Cannabis Users (CYT Manual Series Vol. 4). SAMHSA/CSAT.
  • Godley, S. H., Smith, J. E., Meyers, R. J., & Godley, M. D. (2016). The Adolescent Community Reinforcement Approach: A Clinical Guide for Treating Substance Use Disorders. Chestnut Health Systems.
  • Smith, J. E., & Meyers, R. J. (2004). Motivating Substance Abusers to Enter Treatment: Working with Family Members. Guilford.
  • Smith, J. E., & Meyers, R. J. (2023). The CRAFT Treatment Manual for Substance Use Problems: Working with Family Members. Guilford.
  • Meyers, R. J., & Wolfe, B. L. (2004). Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening. Hazelden.
  • Miller, W. R., Meyers, R. J., & Tonigan, J. S. (1999). Engaging the unmotivated in treatment for alcohol problems. Journal of Consulting and Clinical Psychology, 67, 688–697.
  • Kirby, K. C., et al. (2017). Analyzing components of CRAFT: Is treatment entry training sufficient? Psychology of Addictive Behaviors, 31, 818–827. [uncertain: page range]
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