a-cra adolescent community reinforcement approach
DESCRIPTION
“…to rearrange the vocational, family, and social reinforcers of the alcoholic such that time-out from these reinforcers would occur if he began to drink.” (Hunt & Azrin, 1973)TRANSCRIPT
A-CRA
Adolescent Community Reinforcement Approach
“…to rearrange the vocational, family, and social reinforcers of the alcoholic such that time-out from these reinforcers would occur if he began to drink.” (Hunt & Azrin, 1973)
AbstinenceParticipation in pro-
social activitiesPositive relationships
with familyPositive relationships
with peers
Motivate their participation
Promote the client’s abstinence
Provide information about effective care giving
A-CRA’s General Goals
10 individual sessions with the adolescent
4 sessions with the caregiver2 individual sessions with the
caregiver2 sessions with the caregiver and
the adolescentIn the office or home and community
Described basic objectives (help find healthy, reinforcing lifestyle…)
Outlined several procedures (communication skills, problem solving)
Set positive expectations (scientific base)Described duration of treatment (time
limited)Started to identify reinforcers
An interview that examines the antecedents and consequences of a behavior
“Roadmap”F.A.s can be used for 2 kinds of
behaviors: A problem behavior A healthy, fun behavior
Objective: To work toward decreasing or stopping the problem behavior
Outline individual’s triggers for substance use
Clarify consequences (positive & negative) of substance use for client
External triggersWho, where, when
Internal triggersThinking, feeling (emotionally,
physically)Short-term positive consequencesLong-term negative consequences
Provide a rationaleDetermine which episode to focus on:
Ask for a description of a common/ typical substance-using episode OR
Ask for a description of a recent or specific episode & make sure it is common/typical
Show client the F.A. chart
Gave rationaleStarted by asking for description of commonepisode/behavior
Common problems: selecting a suitable episode, mixing several episodes together
Outlined triggers (external, internal)Clarified the using (or non-using) behaviorOutlined positive and negative consequences of
the behaviorSummarized findings & gave examples of how
the information would be used Common problems: forgetting this item altogether,
summarizing but not offering examples
Provide rationale: Allows the client to see how satisfied
he/she is with different areas of life Identifies areas the client wants to
address in treatment Monitors progress over time
Give instructions (include: circle use or nonuse)
Review some ratings
Substance useRelationship w/
girlfriend/boyfriendRelationship w/
friendsRelationship w/
caregiversSchool (work)School activities
Social life/recreationPersonal habitsLegal issuesMoney managementFeelingsCommunicationJobGeneral happinessOther
Goals of Counseling contains the categories on the Happiness Scale
Guide the client’s selection of a categoryIn general, set short-term goals that are
scheduled to be completed in about a monthDevelop a step-by-step weekly strategy for
reaching each goalAddressed obstacles to completing the goalsThe strategy = the “homework” for the week
Guidelines for Goal Setting
Brief (uncomplicated) Positive (what will be done) Specific behaviors (measurable) Reasonable Under the client’s control Based on skills the client already has
Treatment Plan/Goals ofCounseling Checklist
Used Happiness Scale to select goal category Set goal/strategy using guidelines (e.g.,specific) Common problems: mostly obstacle-related(forgetting to ask about them, identifying
them butnot solving them, not probing enough) Checked on progress of goals
Functional Analysis for Pro-social(Healthy) Behavior
Looks at a pro-social (fun) behavior that’s occurred at least once in the last 6 months Objective: Increases the likelihood that the
individual will choose this non-using activityover substance use
Clarifies negative consequences (barriers toengaging in it) & positive consequences of thehealthy behavior for the individual
Introducing the Pro-Social F.A.
Provide a rationale Ask for a description of an enjoyable activity
that the client is: engaging in currently – but only infrequently OR not engaging in currently, but has done so at least once in the last 6 months
Check to be sure that substance use isn’t usually a part of the activity
F.A. for Pro-Social Checklist
Give rationale Started by asking for description of common
fun/healthy behavior Common problem: finding a fun behavior that is
recent Outlined triggers (external, internal) Clarified the behavior Outlined positive and negative consequences of the
behavior Summarized findings & gave examples of how the
information would be used Common problem: forgetting to make the assignment
explicit, forgetting to ask about/address obstacles
Sobriety Sampling: The Rationale
Select the ones that are most relevant to your client when offering the rationale and make the link to the client’s specific situation:
Enables client to set reasonable and attainable goals
Teaches self-efficacy when goals are reached
Sobriety Sampling (cont’d)
Provides “time-out” from drinking/using so client can experience sensation of being clean/sober
Disrupts old habits, giving chance to replace with new positive coping skills
Builds family support and trust Identifies relapse-prone areas
The Negotiation
Suggest a LONG period (90 days?) Tie in reasons for such a period (high relapse
time; client’s reinforcers?) Expect that the client will negotiate
downward Settle on a period of time: be sure it extends
at least to the time of the next session but don’t make it unreasonably long!
The Plan for Time-Limited Sobriety
IS A WITHDRAWAL PLAN NEEDED?? Load up sessions in the 1st few weeks Don’t rely on past unsuccessful methods Identify biggest threats to sobriety Develop a specific plan for maintaining sobriety Identify and address obstacles Develop a back-up plan Remind client of reinforcers for achieving
sobriety Use positive reinforcement
Sobriety Sampling Checklist
Gave rationale for sampling sobriety (e.g., forces use of other coping strategies)
Negotiated a reasonable period of sobriety Common problems: no real negotiation, final
period of time settled upon was too longDeveloped a specific plan for maintaining
sobriety at least until next session Common problem: obstacles not addressed Developed a back-up plan as well Reminded client of reinforcers for sobriety
Communication Training
Why work on communication?More likely to get what you want Positive communication is “contagious” Will open door to more satisfaction in other
life areas as well (social support)Positive communication is the foundation for
other A-CRA procedures
Positive Communication Skills
Components: Offer an understanding statement Accept partial responsibility Offer to help Explain each and come up with examples
that are relevant to the client
Positive Communication (cont’d)
Start with a reverse role-play? Regular role-play (+ specific feedback,
repetitions)Don’t need all 3 components in the one
conversationDiscuss the best time to have the
conversation
Communication Skills: Vignette
A high school girl is having trouble talking to ateacher. She has had the same teacher in anotherclass and feels as if this teacher has it in for her. Itis a required course, and there are no otherteachers for it.
Introduce positive communication skills (including role-plays) to help this client come up with ways to better communicate.
What other A-CRA technique could you use in this situation?
Communication Skills Checklist(Adolescent and Caregiver)
Discussed why positive communication is important Described/reviewed the 3 positive communication elements Gave examples of good communications Common problem: exclusively reading examples off thehandout Role-played (reinforced, gave specific feedback, repeated) Common problems: not offering specific feedback after eachrole-play Did a reverse role-play Common problems: forgetting to ask client what was learnedabout the other person’s perspective by playing him/her, notpointing out the A-CRA positive communication componentsused
Problem Solving
(1) Define problem narrowly:• Help make it very specific (manageable)(2) Brainstorm possible solutions:• Help client generate them• Don’t critique them; just encourage lots of ideas• Don’t skimp – come up with at least 5(3) Eliminate undesired suggestions:• Have client cross out any unwanted ones (no
explanation)(4) Select one potential solution:• Have client explain step-by-step how it will be done
Problem Solving (cont’d)
(5) Generate possible obstacles:• Assist client; probe for more(6) Address each obstacle:• If obstacles cannot be addressed - select another
solution(7) Assign task:• Be sure the task and the time for it to be done is clear(8) [Next session: Evaluate outcome]:• Have client describe what was done and how well itworked• Determine whether the solution needs to be modified• Discuss obstacles again
Problem-Solving Skills Checklist
Described/reviewed steps of the procedure Common problems: not making the specific
stepsexplicit – but instead just demonstrating them Conducted A-CRA problem solving procedure Common problems: not defining the problemnarrowly enough, not generating enough [5]solutions while brainstorming, not addressing
obstacles adequately
Systematic Encouragement
Encourage client to “sample” a new activityGet the client to make the 1st contact (take
the 1st step) during the sessionHelp the client identify a contact person Role-play the phone call or visit Have the client make the contact during the
session (or take client to the activity)[Review activity attended in next session]
Drink/Drug Refusal Training
Review high-risk situations: Discuss upcoming high-risk situations Identify triggers for use
Enlist social support: Discuss importance of support for abstinence Identify at least 1 supportive person for the situation
being discussed Plan how to ask person for support; practice
Assertive Drink/Drug Refusal
[Always watch body language!] Say, “No, thanks” (without guilt!)Suggest alternativesChange the subjectHold a non-alcoholic drink in handAddress the “aggressor” directlyLeave
Drink/Drug Refusal Skills Checklist
Reviewed high-risk situationsEnlisted social supportCommon problem: not checking to see if the person
can be available during the high-risk time; not exploring exactly how the person could help
Presented/reviewed options for assertive refusal (e.g.,changed subject)Role-played (kept brief, reinforced, gave specificfeedback, repeated) Common problems: failing to point out & shape A-
CRArefusal options
A-CRA’s Job Finding
A disciplined, step-by-step approach to helping
clients get and keep satisfying jobs How many sessions?Acceptable to complete with one (thesame) client over several sessionsIf different clients: must be covered in 2sessions maximum for certification
Job Finding Topics
(1) Provide an overview:Discuss rewards associated with a satisfying jobExamples: money, meet people, address boredomDiscuss difficult aspects of the job-finding processExamples: Takes a lot of effort, rejection is
commonExplain job-finding’s “basic premises”Examples: need a lot of contacts and interviews
Job Finding Topics
(2) Help generate job categories: Previous work? Training?(3) Generate/follow-up on leads: Develop a list of contacts Examples: family, friends, internet postings Set up a tracking system (next slide)
Job Leads Log (Tracking System)
1st Contact Date: Company: Contact Person’s Name: Telephone Number: Address: Result of 1st Call: 2nd Call: Date Result 3rd Call: Date Result
Job Leads Log (Tracking System)
(4) Rehearse and make phone calls: Explain telephone inquiry stepsExamples: introduce self, ask about openings(5) Complete applications: Discuss considerations when preparing Examples: discuss client strengths, how to
handledifficult questions Fill out an application if possible
Job Leads Log (Tracking System)
(6) Rehearse interviews: Discuss preparatory points Examples: dressing appropriately, being
punctual Cover important topics Example: how to highlight one’s strengths(7) Plan for job maintenance/satisfaction: Maintenance: reasons for past job problems Satisfaction: evaluate, set goals to enhance
Job Finding Skills Checklist
Provided overview Helped generate job categories Generated/followed-up job leads Rehearsed and made phone calls Completed applications Rehearsed interviews Planned for job maintenance/satisfaction
Engaging Caregivers
Start engagement during the first phone call Spend 10-15 minutes with caregiver during
first client session Continue engagement throughout treatment
Caregiver Sessions: Timing &Format
Total of 4 sessions with the caregiver:2 individual sessions with the caregiver 1st one: after about 5 sessions with the adolescent 2nd one: about 2 weeks later 2 “family” sessions with the caregiver + the
adolescent 1st one: after about 9 sessions with the adolescent 2nd one: about 2 weeks later Note: these are only suggested/average times for
these sessionsBuild in time to make up missed sessions
Caregiver Session 1: Rapport Building
Maintain empathic and positive approach:Use empathy Reinforce attendance Re-label negative behavior Stop the blaming Reinforce discussion & emphasize family (adolescent) strengths - aspects of family lifethat are working well Use “exception” statements Express excitement about working with them
Caregiver Session 1: Overview
Talk about the benefits of A-CRA Discuss purpose of caregiver sessions: Diminish caregiver’s pain Improve communication Improve caregiver-adolescent relationship Provide research-based information about whatcaregiver can do to keep adolescent from
relapsingAssess need for another referral
Caregiver Session 1: MotivationEnhancement
Determine caregiver’s reinforcers: related to the adolescent stopping his/her
substance use specific to caregiver’s own, separate needs or
desires Past failures? Recovery is a process Encourage to “sample” treatment
Caregiver Session 1: Critical Parenting Practices
Explain that research supports 4 parentingpractices which help prevent relapse in teens Describe the 4 parenting practices:
Be good role models (specifically – no alcohol/drugs in front of adolescent)
Increase positive communication Monitor adolescent’s whereabouts Get involved with the adolescent’s social life
Caregiver CommunicationSkill Training (Session 1 or 2)
Provide rationale for learning positivecommunication skills Assess the present quality of communication Describe the three components while
generatingreal-life examples with caregiver: Understanding statement Partial responsibility statement Offer to help
Caregiver CommunicationSkill Training
Role-play exchanges between the caregiverand the client Point out any problems (e.g., blaming andbringing up old issues) Switch roles with the caregiver Process each exchange with the caregiver With the caregiver’s input, come up with anassignment (homework)
Caregiver Problem Solving Training
Teach caregiver the problem-solvingprocedure The problem can be: one that relates to the
adolescent one that has nothing to do with the adolescentMake sure a specific assignment results
Caregiver Overview, RapportBuilding, and Motivation Checklist
Provided an overview of A-CRA Set positive expectations Reviewed research regarding parenting practices Identified Caregiver’s reinforcers for continued
work(repeat #5) Common problems: Focusing on the adolescent’sreinforcers instead of the caregiver’s reinforcers Kept discussion (about adolescent) positive
3 Positive Things Exercise
Give rationale: Helps start session on positive note Have them speak directly to each other (not
to the therapist) Have them repeat the positive comments
they hear Don’t forget to help if they get stuck, & to
praise their efforts
Relationship Happiness Scales:Rationale
Tools for caregiver(s) & adolescents to ratetheir happiness with each other in different
areas of their relationshipA method for setting goals/making changes A way to track progress toward relationship
goals
Relationship Happiness Scale:Instructions
Same basic instructions as for HappinessScale, EXCEPT… Rate happiness with the other person
(caregiver or adolescent) in each area Ask them not to look at the other family
member’s answers [they will be explored later]
Relationship Happiness Scale:Review Ratings
Review several ratings for each person(start with high ratings – to continue the
positive tone)Review consists of:Asking why the particular rating was given
ORAsking what it would take to give it a higher
rating (what would have to change?)
Selecting Goal Categories
Using their Relationship Happiness Scales: help
the caregiver(s) & the adolescent select a category in which they want to make a request for a change in the other person
They can each choose different categories Suggest they choose categories rated
somewhere in the middle of the range (e.g., 4-7)
Making Requests and Setting Goals
Help caregiver (or adolescent) formulate a request following guidelines (brief, positive, specific, measurable)
In preparation for verbalizing the request: It’s a good time to review positive communication skills…
Relationship Therapy:Problem-Solving Skills
Problem-solving needs to be reviewed & used in at least 1 of the family sessions
Best time to introduce problem-solving? When a problem is identified in the session
When are problems often identified in family sessions?
When negotiating goals (assignments) to work on during the Relationship Happiness Scale exercise
When deciding on homework assignments more generally
When addressing a crisis
Daily Reminder To Be Nice: Rationale
Acceptable examples (this exact wording is NOTneeded!!): to jump-start a more positive home atmosphere to serve as a follow up exercise to the 3 Positive
Things exercise to make sure family members keep supporting each
other, even if they don’t really feel like doing that at times
the form contains nice things that some family members automatically do for each other when things are going well in their relationship; and so this can be a reminder to continue doing them
Daily Reminder To Be Nice:Instructions
Ask each person to do at least 1 item from theform daily regardless of whether the otherperson seems to be doing it as wellSuggest that they find a good place to keep theforms so they don’t get lost or forgotten Have them generate examples for and practice1-2 items in session Make homework assignment explicit
Caregiver-Adolescent Sessions*Things to Remember*
Keep session structured Role of therapist/case manager: coach,shape, model, reinforce, praise, and keep
everyone on task Focus on one issue at a time Focus is on skill-building Keep positive tone to session
Caregiver-Adolescent Session Tips
Ask participants to speak to each other throughout the session
Ask participants to repeat things Recognize and praise when they use the
skills naturally If clients are resistant, decrease procedure
jargon
Adolescent-CaregiverRelationship Skills Checklist
Check on homework 3 positive things Relationship Happiness Scale Daily Reminder To Be Nice Communication Skills Problem Solving Skills
Anger Management
Identify reasons to manage anger better: How has the client’s current way of expressing
angercreated problems for him/her? Explain why it is valuable to recognize the earliestsigns of anger Help recognize anger building up: Identify high-risk situations and/or triggers for
gettingangry Help identify early signs of anger coming on Physical signs (clenched jaw) Behaviors (pacing, sarcastic remarks)
Anger Management (cont’d)
Find relevant “cool down” activities: Help client come up with a “cool down” phrase Have client leave situation briefly (if possible) & engage
ina planned activity Have client explain when he/she will return to talk Practice communication skills in the process Focus on empathy:Ask client to imagine situation from other person’s point ofview (reverse role-play?) Ask client what he/she thinks the other person was
thinking& feeling in that situation Give Anger Management handout to take home
Identify reinforcers to manage anger Assist in recognizing anger Common problem: forgetting to ask about theadvantage of knowing the earliest signs of anger Teach taking time to “cool down” Teach fostering empathy Common problem: not probing sufficiently
whenasking about the other person’s thoughts/feelings Gave adolescent “Anger Management” handout