Community Reinforcement Approach
Community Reinforcement Approach is a behavioral program for treating substance abuse problems such as alcoholism. This treatment is based on the belief the environment an alcohol dependent is in has a powerful impact on encouraging or discouraging alcohol abuse. It was developed over 30 years ago by behaviorists [Nathan Azrin and George Hunt in _1973_](http://www.bhrm.org/guidelines/CRAmanual.pdf). The aim of community reinforcement is to make a sober lifestyle more rewarding than one that includes the use of substances. It is considered among the best alcohol treatments available.
Community Reinforcement – Coping with Real Life
Community reinforcement works to enhance and support the recovering alcoholics ability to deal with the real world. Patients receive extensive support through social and family networks and skills are developed which can include job counselling, lifestyle planning, and family counselling. Because the treatment is based on the belief that the environment or community is critical for recovery, life skills are considered essential to the success of any addict getting help and making long term changes. This environment or community is defined as the family, friends, work, social life, spiritual affiliations and physical setting that an alcoholic revolves in.
Variety of Treatment in Community Reinforcement
When a therapist engages a patient under a community reinforcement approach, there are a [number of treatments that will be used](http://pubs.niaaa.nih.gov/publications/arh23-2/116-121.pdf). Building positive motivations for quitting drinking is the first step which is then followed by encouraging abstinence. It can be daunting to some patients to give up alcohol for good, so a treatment called _sobriety sampling_ is often initiated whereby trial periods or intermediate goals to reduce consumption are set. Analysis of the drinkers triggers or drinking patters is also done which establishes the further development of treatments that a participant should be involved in. This may include attendance at a 12-step meeting, family and marital counseling, skills training or drug therapy. The most common prescribed medication is Disulfiram (Antabuse) which causes a severe reaction to alcohol. Patients who take this medication and drink will have a reaction from mildly sick to requiring immediate medical treatment. Each patient will have a different multi-treatment program set depending on their own situation.
Analyzing Triggers for Drinking
Examination of the context which encourage or support an individuals desire or need to drink is central to community reinforcement. These triggers may be internal or external and once they are identified, the correct focus for treatment can be developed.
The community reinforcement approach believes that there are 2 key reasons that people abuse alcohol. These are positive reinforcement _Type P Drinkers_ and negative reinforcement _Type N Drinkers._ Therapists believe both Type P and Type N drinkers have valid reasons for drinking and there are appropriate treatments for helping both.
Type P Drink
Associating drinking with feeling happy, social and relaxing is considered Type P Drinking. External triggers such as going to a party, being with certain people, social settings and celebrations will encourage or validate a person to drink alcohol. Treating Type P Drinking begins with establishing times and situations that a person has felt happy when they have not had a drink and finding healthier ways to be happy.
Type N Drinker
If a patient states that they drink to avoid something such as sad or angry feelings or anxiety, this is categorized as Type N drinking. Avoiding an unpleasant memory or situation does little to resolve the issue and the associated drinking often escalates the issue. Treatment for a Type N Drinker will often involve extensive counseling and identifying high risk situations to be avoided.
Positive Outcomes in Community Reinforcement
Patients under a community reinforcement therapy are encouraged to develop positive outcomes for themselves that do not include drinking. Many people who are alcohol dependent will state positive outcomes for their drinking, but these are usually short term. With a therapists support, new behaviors and activities are generated to replace drinking. Therapists will also explore the long-term, negative consequences of a patient’s drinking which will include the health and financial costs.
Involvement of Family and Friends in Community Reinforcement
Because community reinforcement focuses on changing the environment which encourages the patient to drink, partners, family members and significant others are involved during all stages of the treatments. This may include getting family members to identify problem drinking triggers or participating in skill training so that they are not reinforcing drinking behaviour. This _enabling_ behaviour needs to be altered so that support for drinking is not given – a person will be not engaged with if they are drinking for example.
Background and Research in Community Reinforcement
Community Reinforcement is a successfully demonstrated alcohol abuse treatment program. It is well supported by drug and alcohol workers and behaviourists since it was first developed in the 1970′s. It is considered one of the most [cost-effective alcohol treatment programs](http://casaa.unm.edu/crainfo.html).
The original study by Hunt & Azrin in 1973 compared community reinforcement with a 12 step program. This research found that with at 6 months follow up, those who were treated with a community reinforcement approach significantly outperformed those who were treated by the 12 step program. Patients under the community treatment drank on average 14% of the follow up days compared with 79% on follow up days. At the 2 year follow up, community reinforcement abstinence rate was reported at 90% (http://www.robertjmeyersphd.com/cra.html).
These positive outcomes has been repeated by other behavioural researchers since. One study performed by [Smith, Meyers & Delaney](http://www.robertjmeyersphd.com/cra.html) in 1998 found similar outcomes when studying alcohol-dependent homeless people. In this instance, individuals were housed in apartments for three months during which time they were treated with either a community reinforcement approach or a standard care approach. Those the standard care group had access to resources in a day shelter and Alcoholics Anonymous meetings and counselling while those in the community reinforcement group had group therapy, job and relationship counselling and skill training. The study found that those in the community reinforcement group had significantly better outcomes in the preceding year.
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