The community reinforcement approach (CRA) is a longstanding behavioral intervention for persons suffering from alcohol use disorder, opioid use disorder, substance use disorders, and even behavioral disorders such as problem gambling or gaming addiction. CRA involves eliminating positive support for substance abuse and increasing positive reinforcement for abstinence.

According to the Recovery Research Institute, CRA begins with a clinical, “functional analysis” of the individual to map the forces driving their behaviors. CRA attempts to create a “behavior chain” exploring how the person feels before, during, and after substance abuse. Some of the traits CRA attempts to identify include:

• the individual’s motivations to use
• their triggers that make them want to use
• the benefits they hope to get from using
• the way they feel when they use and immediately afterward
• the negative consequences of their usage
• the problems they encounter trying to resist the urge to use

Often a trusted friend or family member participates in the CRA treatment program as someone trained to spot signals and situations that are not conducive to abstinence. CRA very often involves not just abstinence but substitution, replacing the problem substance or behavior with a positive, healthier alternative. The Recovery Research Institute describes the CRA treatment program as follows:

During the treatment, the patient learns practical skills to meet his or her goals including communication, problem solving, and assertive drink and drug refusal (i.e., effective ways to comfortably handle direct and indirect pressure to drink or use drugs). The Community Reinforcement Approach (CRA) may also incorporate job-hunting skills and social or recreational counseling to identify sober activities.

CRA can be traced back to Nathan Arzin, a behavioral modification researcher and psychologist perhaps best known for his book, Toilet Training in Less Than a Day. CRA was refined specifically for alcohol abuse treatment with the publication of the Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach by Robert J. Meyers and Jane Ellen Smith in 1995, considered “the first complete guide to implementing CRA for treating alcohol problems.” Topics covered include:

• behavioral skills training
• social and recreational counseling
• marital therapy
• motivational enhancement
• job counseling
• relapse prevention

A brand new study into the effectiveness of CRA in combination with standard substance use disorder treatment took the novel approach of attempting to measure the difference in “quality of life” between those randomly selected for CRA and those not. The study involved 60 patients at a residential drug treatment facility who had already completed detox. 

Each individual in the CRA treatment group received 12 one-to-one sessions ranging from 45 minutes to one hour over the course of three months. The topics covered in those sessions are essentially the same as those in the book by Meyers and Smith listed above. The researchers used a “10-point Likert scale” to assess happiness levels and the “WHOQOL-BREF scale” to assess quality of life including physical and psychological health. The results, according to the researchers, were clear:

The results showed a significant increase in the quality of life of participants in the treatment group with CRA compared with the control group. The findings also indicated that the individuals in the treatment group with CRA had improved levels of happiness.

This study is new and there is no follow-up reporting on whether the improvement persists over time. There are other studies, however, that have shown strong longevity for CRA results. We will continue to report on new developments in this effective, inexpensive treatment for substance use disorders.

Written by Steve O’Keefe. First published April 15, 2024.

Sources:

“Community Reinforcement Approach (CRA),” Recovery Research Institute, retrieved April 11, 2024.

Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach, by Robert J. Meyers and Jane Ellen Smith, published by Guilford Books, 1995.

“The effectiveness of the community reinforcement approach (CRA) in the context of quality of life and happiness among people using drugs,” Frontiers in Public Health, March 2024.

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