CRA is a broad-spectrum behavioral treatment approach for substance abuse problems. It was developed to utilize social, recreational, familial, and vocational reinforcers to aid clients in the recovery process. CRA acknowledges the powerful role of environmental contingencies in encouraging or discouraging use, and attempts to rearrange these contingencies such that sober behavior is more rewarding than using behavior. The overall philosophy is to use individuals and the community to reward non-using behavior so that the clients make healthy lifestyle changes.CRA has been shown effective in clinical trials. Typically there are 12 individual sessions, but also parts of CRA have been used in group format.
The CRA induction is a motivational method for introducing the CRA program to the client. It demonstrates from the start that CRA is based upon positive reinforcement instead of confrontation. It is set up to help the client work toward getting whatever is important to him or her.
The CRA Functional Analysis: The therapist and client examine the triggers (thoughts, feelings, and behaviors) leading up to behavior and the immediate and long-term consequences of this behavior. The CRA Functional Analysis is unique in its additional emphasis on examining non- behavior. The client also is helped to recognize the chain of events that lead to enjoyable activities not involving alcohol consumption. By highlighting the long-term positive consequences of a particular non- activity, the therapist encourages the client to engage in the activity more often and experience its rewards.
CRA works to replace a client’s maladaptive behaviors with new coping strategies. Sobriety Sampling is a technique that teaches the client to abstain from alcohol for a mutually agreed-upon limited amount of time. This lets the client experience sobriety and to reflect on how sobriety may be a positive experience. Sobriety sampling operates on the assumption that you can be more successful in engaging clients in treatment by not overwhelming them with rigid rules and frightening expectations about never being able to drink again for the rest of their lives.
An addition to the CRA program is the use of Disulfiram or Naltrexone. The assessment as to whether this will be helpful to the client will be made early in treatment with the primary therapist. Proper use of these medications brings additional benefits to the treatment program, including:
1) reduction in worry about future episodes,
2) an increase in family trust, since their utilization demonstrates a commitment to stop,
3) a reduction in “slips” that result from impulsive,
4) an increase in productive use of therapy time, since the client can now deal objectively and constructively with other current life problems,
5) a necessary increase in the reliance on new coping skills, since is no longer an option,
6) a reduction in complicated, agonizing daily decisions about about substance using behaviors, and
7) an increase in opportunities for positive reinforcement, since at the very least the client will be praised daily by the Concerned Other who is monitoring “the taking of the pill”. Typically a spouse or close friend is trained as a “monitor” to aid in consistent drug administration and to praise the problem drinker for his or her efforts.
Communication Skills Training is an important component of CRA behavioral skills training. It helps the client increase positive interchanges with loved ones. Clients also are taught to develop more appropriate strategies for coping with their stressful environments with resorting to alcohol use through Problem Solving Training. The therapist works with the client to define the problem, generate alternatives for action, decide on a solution, and evaluate the outcome. Drink Refusal Training aids the client with his or her assertiveness skills by teaching several ways to refuse a drink. Trigger situations are avoided, and thought substitution is used to replace the types of thoughts and feelings that lead to episodes with new thoughts.
Additional methods for encouraging and rewarding sobriety may also be employed. Job finding procedure aid the client in finding and keeping a meaningful job, which can serve as a powerful, positive reinforcer. Social and Recreational Counseling is a critical part of CRA, since many clients have great difficulty replacing their lifestyle with a non- one when it comes to free time. CRA encourages clients to change to peer reference groups who will less likely be engaging in activities involving alcohol consumption and to develop healthier alcohol-free social outlets. If the client is married or has a significant relationship, the spouse or significant other is typically is brought in for Marital/Couple Therapy. The purpose is to enhance many aspects of the couple’s relationship, and to teach the spouse/other to reinforce non- behavior.
Relapse Prevention is an integral component of many phases of the CRA program. One of the skills taught within CRA is learning to recognize when temptation is building or a slip is close. Slips typically do not occur in response to just one trigger, but after a sequence of triggers. This set of events is called a Behavioral Chain. The therapist shows the client where costly negative decisions were made surrounding a slip. Cognitive restructuring and problem solving would be introduced again to train appropriate ways to cope. Early Warning System is a specific relapse prevention self-monitoring procedure designed to track the behaviors of clients that appear to be the antecedents, or triggers, to using behavior. The system is most successful when a concerned other is trained in the procedure along with the client. In addition to providing valuable input regarding triggers, the concerned other can often recognize the earliest signs of an impending relapse before the client.
One of the unique aspects about CRA is its compatibility with many other approaches to substance abuse treatment. It is appropriate for individuals who are striving for either lifelong abstinence or moderation. CRA’s positive, motivational approach has much to offer in the struggle to gain full cooperation from clients.