CRA and CRAFT: Behavioral approaches to treating substance-abusing individuals.

Abstract

The Community Reinforcement Approach (CRA) and Community Reinforcement and Family Training (CRAFT) are behavioral treatments for substance abuse problems that have received widespread empirical support. CRA, a treatment intended for the drinker him- or herself, was introduced 30 years ago (Hunt & Azrin, 1973). It is based on the belief that a drinker's community (e.g., family, social and job environment) plays a critical role in supporting or discouraging drinking behavior. Consequently this environment needs to be restructured such that a sober lifestyle is more rewarding than a drinking lifestyle. CRAFT, an outgrowt h of CRA, is a highly successful method for working with concerned family members in order to get a treatment-refusing substance abuser to enter treatment (Meyers & Wolfe, 2004; Sisson & Azrin, 1986). The components of both CRA and CRAFT are outlined in this paper, and the scientific support is summarized. Keywords: Community Reinforcement Approach (CRA); Community Reinforcement and Family Training (CRAFT); alcohol treatment; behavioral treatment ********** The Community Reinforcement Approach (CRA), a comprehensive operant program that was started in the 1970s (Hunt & Azrin, 1973), is one of the most highly effective treatments for alcohol use disorders to date. Its companion program, CRAFT (Community Reinforcement and Family Training), grew out of the recognized need for a method of working through motivated family members of treatment-refusing substance abusers. Both treatments are based on the belief that an individual's environment plays a critical role in recovery. This environment, or community, is comprised of family, friends, work, social activities, and sometimes spiritual affiliations that reinforce drinking or nondrinking behaviors. The goal of CRA is to influence various aspects of a person's environment such that a sober lifestyle becomes more rewarding than one involving alcohol. And although ultimately CRAFT shares the same goal, the major purpose of CRAFT is to get a treatment-resistant drinker or drug user to enter treatment. Both CRA and CRAFT rely on behavioral principles and motivational procedures instead of confrontation. How efficacious are CRA and CRAFT? Given that CRAFT does not work directly with the drinker, it has not been included in meta-analytic reviews of controlled alcohol treatment studies. Nevertheless, individual studies have found it to be highly effective at engaging resistant alcohol and drug abusers into treatment (see Scientific section for CRAFT). CRA, on the other hand, is intended for the drinker him- or herself, and it consistently has been ranked among the best alcohol treatments. In the two most recent reviews, CRA was rated as the top program in a cost-effectiveness analysis (Finney & Monahan, 1996), and it tied for fourth place among 48 different treatment modalities in a review by Miller and colleagues (Miller, Wilbourne, & Hettema, 2003). Although CRA also has been used in combination with contingency management programs to treat illicit drug use (Higgins & Abbott, 2001), this paper focuses only on the pure CRA program for alcohol use disorders. CRA Procedures A description of the components of CRA follows (see Meyers & Smith, 1995 for a more detailed account). It should become apparent that several aspects of the CRA program are similar to the behavioral clinical approach called Positive Behavioral Support (PBS), which is appearing increasingly in the literature. PBS is rooted in behavioral analysis, and is defined by its person-centered approach to planning, reliance on a functional assessment of the problem, and multifaceted and environmentally-focused treatment strategies (Carr & Sidener, 2002). As shown below, CRA has been applying these principles to problem drinkers for over 30 years. CRA Functional Analyses A recent paper reviewed 277 studies that utilized functional analyses for problem assessment and treatment prescription. …