What exactly is the community reinforcement approach (CRA) and how effective is it?

What exactly is the community reinforcement approach (CRA) and how effective is it? I read about it briefly in your book “Diseasing of America”. I am an Intake Counsellor at a Drop In Crisis Center in Montreal and feel our center could be doing much more to help people develop more positive lifestyles. Thanks ­ and keep up the good work!

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Thank you for the question and for your support.

Aside from Diseasing of America, I write more about the community reinforcement approach and describe its implications and usefulness in The Truth About Addiction and Recovery (New York: Fireside Paperback) (See Chapter 14: Integrating Change Into Your Life).

A. What Is Community Reinforcement Approach?

CRA was developed by behaviorists Nathan Azrin and George Hunt. The basic concept is that therapy should structure all rewards to support the alcoholic’s sobriety. But if you break it out of behaviorism, it says that the therapy should enhance and support the alcoholic’s ability to cope with each major area of his/her life. The fundamental insight here is that alcoholism is prevented and remedied to the extent the individual is capable of and comfortable with the challenges life presents him or her. Therapy is not about internal psychological and biological changes, except in as much as such changes support better coping and comfort with life on the alcoholic’s part.

The original CRA program (with my interpretation of each element) comprised the following components:

• a job club that assists people to find and keep jobs
• reciprocal marital counseling (in which a spouse reinforces sobriety with behavior the alcoholic likes and appreciates and withholds rewards for intoxication)
• social­skills training (such as better communication skills, anger management, ability to take and give feedback, a la assertiveness training)
• time­out and drink­refusal skills (which I call creating a peaceful moment so as to avoid panic and automatic reactions that are usually dysfunctional)
• leisure­time planning (find interests not centered on bars and drinking)
• finding supports in the environment (such as a buddy system or a group that supports sobriety, even when the group is not organized for that purpose)

In its later forms, CRA employed disulfiram (Antabuse), and the buddy or reciprocal marital function was primarily to make sure the alcoholic took Antabuse every morning. For me, this trivializes the approach. If you could implant a time­release capsule for Antabuse (like the birth control Norplant), this would accomplish the entire function of the buddy or spouse ensuring the alcoholic takes his/her Antabuse! This cures alcoholism in the same sense that Norplant cures unhealthy sexual relationships. But buddy, community, and spousal roles can accomplish far more central and important functions than this.

I describe (with Archie Brodsky and Mary Arnold) each of these components in detail in The Truth About Addiction and Recovery.

B. How Effective is CRA Therapy?

The good news is that CRA comes out at the top of a number of lists as the most effective/cost­effective alcoholism therapy (most recently, in J.W. Finney & S.C. Monahan, “The cost effectiveness of treatment for alcoholism: A second approximation,” Journal of Studies on Alcohol, 57:229­243, 1996). The original assessment of CRA by Hunt and Azrin (1973) reported that alcoholics treated with CRA drank on 14% of days compared with drinking on 79% of days by alcoholics in the standard inpatient program. Unemployed days were 12 times as great for the standard hospital patients. Azrin (1976), incorporating Antabuse, showed similar results. (These results are reviewed in Sisson and Azrin’s Chapter on CRA in R.K. Hester & W.R. Miller’s Handbook of Alcoholism Treatment Approaches: Effective Alternatives, New York: Pergamon, 1989). CRA has also been shown in experimental trials to be vastly more effective in producing abstinence from cocaine than 12 step treatment.

The bad news is that not many alcoholics/addicts have been treated with CRA. Indeed (although you can’t determine this by reading the Sisson and Azrin chapter in Hester and Miller), Hunt and Azrin (1973) had 8 alcoholics in CRA and 8 in the standard hospital program, and Azrin (1976) had 9 in each group (see S. Peele, “AA, the tooth fairy, and drug policy,” Paper prepared for Division 28 Symposium, “Contemporary Psychological Perspectives on American Drug Policy,” American Psychological Association Convention, Toronto, Ontario, August 20-24, 1993). Finney and Monahan’s ranking of CRA as far and away number 1 in cost-effectiveness in their 1996 article included only two other studies in addition to these 17 alcoholics who received CRA (Mallams et al., 1982; Sisson & Azrin, 1986), both studies 10 years old!

Clearly, CRA in its official form has not been much utilized. This is not because it is expensive (Finney & Monahan rate its cost medium-low). It simply takes some planning and effort, something that alcoholism treatment in America is apparently incapable of and which treatment centers aren’t forced to do because the useless junk they practice is so widely accepted!

Please note: The second edition of Hester and Miller’s Handbook of Alcoholism Treatment Approaches: Effective Alternatives (2nd ed.), Boston: Allyn and Bacon, 1995, has an updated chapter on CRA by Jane Smyth and Robert Meyers.