Adolescent Community Adolescent Community Reinforcement ApproachReinforcement Approach

A-CRAA-CRA

Robert J. Meyers, Ph.D.Robert J. Meyers, Ph.D.Jane Ellen Smith, Ph.D.Jane Ellen Smith, Ph.D.

University of New MexicoUniversity of New Mexicoandand

Chestnut Health SystemsChestnut Health Systems

Presented by:Presented by:Jennifer Smith Ramey, LPC, LMHPJennifer Smith Ramey, LPC, LMHP

Meet Gage……Meet Gage……

17 year old male17 year old male Abused alcohol, marijuana, heroinAbused alcohol, marijuana, heroin Family history of mental illness Family history of mental illness

(father committed suicide)(father committed suicide) Strained relationship with motherStrained relationship with mother

First CRA Therapist ManualFirst CRA Therapist Manual

Adolescent Community Adolescent Community Reinforcement Approach Reinforcement Approach

(A-CRA)(A-CRA)

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Treatment Series

Volume 4

Godley, S.H., Meyers*, R.J., Smith*, J.E., Godley, M.D., Titus, J.C., Karvinen, T., Dent, G., Passetti, L.L., & Kelberg, P. (2001).Chestnut Health Systems Bloomington, IL USA, and*University of New MexicoAlbuquerque, NM USA

Percent of Days Abstinent Percent of Days Abstinent from Alcohol or Other from Alcohol or Other

DrugsDrugs

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10%

20%

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Observation Wave

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Non-comorbid

Internalizing

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Results of HLM growth model analyzing group differences percent of days abstinent

Conclusion: AbstinenceConclusion: Abstinence

Adolescents with COD have greater Adolescents with COD have greater magnitudes of increase in abstinence magnitudes of increase in abstinence than non-comorbid youth than non-comorbid youth

Adolescents with COD maintain their Adolescents with COD maintain their treatment gains out to 12 monthstreatment gains out to 12 months

Emotional Problems ScaleEmotional Problems Scale

0.00

0.05

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0.35

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Observation Wave

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Low

Moderate

Figure 3. Results of HLM growth models analyzing group differences for the Emotional Problems Scale.

Conclusion: Emotional Conclusion: Emotional ProblemsProblems

Adolescents with COD have greater Adolescents with COD have greater magnitudes of decrease in emotional magnitudes of decrease in emotional problems than non-comorbid youth problems than non-comorbid youth

Youth with both externalizing and Youth with both externalizing and internalizing MH problems show the internalizing MH problems show the greatest reduction of emotional greatest reduction of emotional problems.problems.

A-CRA at Horizon A-CRA at Horizon Behavioral HealthBehavioral Health

““Effectiveness of A-CRA/ACC in Treating Adolescents with Effectiveness of A-CRA/ACC in Treating Adolescents with Cannabis-Use Disorder” published in Community Mental Cannabis-Use Disorder” published in Community Mental Health Journal, November 2012Health Journal, November 2012

Enrolled 147 adolescents ages 12-18Enrolled 147 adolescents ages 12-18 Assessed at baseline, 3, 6, and 12 monthsAssessed at baseline, 3, 6, and 12 months More than two-thirds reported quitting marijuana by 12 More than two-thirds reported quitting marijuana by 12

monthsmonths Days of marijuana use in the last 90 days decreased Days of marijuana use in the last 90 days decreased

significantly from the first follow-upsignificantly from the first follow-up Grade completed in school increased one grade comparing Grade completed in school increased one grade comparing

baseline and 12 monthsbaseline and 12 months Average days of missing school decreased significantly Average days of missing school decreased significantly

from baseline to end of treatmentfrom baseline to end of treatment

If punishment worked, there would be few, if any, alcoholics or drug addicts…

Meyers & Smith, 2006

What is the goal of CRA?What is the goal of CRA?

“…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)

Meyers & Smith, 2006

A-CRA’s General GoalsA-CRA’s General Goals Goals: Sessions with

clients Abstinence Participation in pro-

social activities Positive relationships

with family Positive relationships

with peers

Goals: Sessions with caregivers Motivate their

participation Promote the client’s

abstinence Provide information

about effective caregiving

A-CRA Session StructureA-CRA Session Structure

10 individual sessions with the adolescent 4 sessions with the caregiver

2 individual sessions with the caregiver 2 sessions with the caregiver and the

adolescent In the office or home and community

Positive ReinforcerPositive Reinforcer

What is a reinforcer?

How do I find one?

Does everyone have reinforcers?

How can I use them to help?

Meyers & Smith, 2006

Adolescent Caregiver Adolescent Caregiver sessionssessions

Goal is to improve relationshipGoal is to improve relationship Tools used: Happiness Scale, Tools used: Happiness Scale,

Communication Skills, Problem Communication Skills, Problem Solving SkillsSolving Skills

Positive Focus (3 Positive Things Positive Focus (3 Positive Things exercise, Daily Reminder To Be Nice exercise, Daily Reminder To Be Nice homework assignment)homework assignment)

Caregiver-AdolescentCaregiver-Adolescent (Family) Sessions (Family) Sessions

3 Positive Things Exercise3 Positive Things Exercise

Relationship Happiness ScalesRelationship Happiness Scales

Practice communication and Practice communication and problem-solving skillsproblem-solving skills

Daily Reminder To Be Nice formDaily Reminder To Be Nice form

Four Critical Parenting Four Critical Parenting PracticesPractices

Positive CommunicationPositive Communication

Getting involved in adolescent’s life Getting involved in adolescent’s life outside the homeoutside the home

Be a good role modelBe a good role model

Know the adolescent’s whereaboutsKnow the adolescent’s whereabouts

Communication SkillsCommunication Skills

Foundational in A-CRA modelFoundational in A-CRA model Used in adolescent only sessions, Used in adolescent only sessions,

caregiver only sessions, family caregiver only sessions, family sessionsession

3 parts3 parts Role-playsRole-plays

Treatment PlanningTreatment Planning

Two parts: Adolescent Happiness Scale and Goals of Counseling

Ask the client what she/he wants Use a positive approach Keep in mind the client’s reinforcers

Adolescent Happiness Scale This scale is intended to estimate your current happiness with your life on each of the eleven areas listed. You are to circle one of the numbers (1 -10) beside each area. Numbers toward the left end of the ten-unit scale indicate various degrees of unhappiness, while numbers toward the right end of the scale reflect increasing levels of happiness. Ask yourself this question as you rate each life area: “How happy am I with this area of my life? In other words, state according to the numerical scale (1 -10) exactly how you feel today. Try to exclude all feelings yesterday and concentrate only on the feelings of today in each of the life area. Also try not to allow one category to influence the results of the other categories. 1 = Completely Unhappy (can’t get any worse) 5 = Neutral (not unhappy, not happy either) 10 = Completely Happy (can’t get any better) Unhappy Neutral Happy

Happiness with:

1. Alcohol use/nonuse 1 2 3 4 5 6 7 8 9 10

Marijuana use/nonuse 1 2 3 4 5 6 7 8 9 10

Other drug use/nonuse 1 2 3 4 5 6 7 8 9 10

2. Relationship with:

Boyfriend or girlfriend 1 2 3 4 5 6 7 8 9 10

friends

1 2 3 4 5 6 7 8 9 10

3. Parents or caregiver 1 2 3 4 5 6 7 8 9 10

4. School 1 2 3 4 5 6 7 8 9 10

5. Social activities 1 2 3 4 5 6 7 8 9 10

6. Recreational activities

7. Personal habits 1 2 3 4 5 6 7 8 9 10

8. Legal issues 1 2 3 4 5 6 7 8 9 10

9. Money Management 1 2 3 4 5 6 7 8 9 10

7. Emotional Life 1 2 3 4 5 6 7 8 9 10

8. Communication 1 2 3 4 5 6 7 8 9 10

9. General Happiness 1 2 3 4 5 6 7 8 9 10

10. Add specific 1 2 3 4 5 6 7 8 9 10

Name _______________________________________________ ID ____________________ Date _____________________

Goals of Counseling: Goals of Counseling: Setting GoalsSetting Goals

Goals of Counseling contains the categories on the Happiness Scale

Guide the client’s selection of a category In general, set short-term goals that are

scheduled to be completed in about a month Develop a step-by-step weekly strategy for

reaching each goal Addressed obstacles to completing the goals The strategy = the “homework” for the week

Meyers & Smith, 2006

After Happiness Scales

Guidelines for Goal Guidelines for Goal SettingSetting

Goals and weekly strategies should be: Brief (uncomplicated) Positive (what will be done) Specific behaviors (measurable) Reasonable Under the client’s control Based on skills the client already has

Meyers & Smith, 2006

What’s wrong with these What’s wrong with these goals & strategies?goals & strategies?

I don’t want to drink anymore I’ll get my friend to come into treatment I’ll apply for 10 jobs tomorrow I’ll get a higher-paying job this month I’ll try harder to save money this month I’ll go out on a date with three different

women next weekMeyers & Smith, 2006

What’s wrong with this What’s wrong with this strategy?strategy?

I am going to attend one AA meeting next week, at St. Agnes Church at 8:00 pm on Tuesday night.

Meyers & Smith, 2006

DemonstrationDemonstration

Skills TrainingSkills Training

Communications Skills

Problem Solving

Drink/Drug Refusal

Job-Finding Skills

Anger Management

A-CRA CertificationA-CRA Certification

Recording/uploading A-CRA sessionsRecording/uploading A-CRA sessions Will receive narrative review and Will receive narrative review and

rating (1 to 5 scale)rating (1 to 5 scale) Must pass 9 core procedures for first Must pass 9 core procedures for first

level certificationlevel certification

Now, back to GageNow, back to Gage

Improved communication with Improved communication with mothermother

Goals:Goals: completion of high schoolcompletion of high school military enrollmentmilitary enrollment

ReferencesReferences Dennis, M.L., Godley, S.H., Diamond, G.S., Tims, F.M., Babor, T., Donaldson, J., Liddle, Dennis, M.L., Godley, S.H., Diamond, G.S., Tims, F.M., Babor, T., Donaldson, J., Liddle,

H.A., Titus, J.C., Kaminer, Y., Webb, C., Hamilton, N., & Funk, R.R. (2004). The Cannabis H.A., Titus, J.C., Kaminer, Y., Webb, C., Hamilton, N., & Funk, R.R. (2004). The Cannabis Youth Treatment (CYT) study: Main findings from two randomized trials. Youth Treatment (CYT) study: Main findings from two randomized trials. Journal of Journal of Substance Abuse TreatmentSubstance Abuse Treatment, , 2727, 197-213. doi:10.1016/j.jsat.2003.09.005 , 197-213. doi:10.1016/j.jsat.2003.09.005

Godley, S.H., Hedges, K., & Hunter, B. (2011). Gender and racial differences in treatment Godley, S.H., Hedges, K., & Hunter, B. (2011). Gender and racial differences in treatment process and outcome among participants in the Adolescent Community Reinforcement process and outcome among participants in the Adolescent Community Reinforcement Approach. Approach. Psychology of Addictive Behaviors, 25, Psychology of Addictive Behaviors, 25, 143-154. doi:10.1037/a0022179 143-154. doi:10.1037/a0022179

Godley, S.H., Hunter, B.D., Artamendi, S.F., Smith, J.E., Meyers, R.J., & Godley, M.D. Godley, S.H., Hunter, B.D., Artamendi, S.F., Smith, J.E., Meyers, R.J., & Godley, M.D. (2014). A comparison of treatment outcomes for Adolescent Community Reinforcement (2014). A comparison of treatment outcomes for Adolescent Community Reinforcement participants with and without co-occurring disorders. participants with and without co-occurring disorders. Journal of Substance Abuse Journal of Substance Abuse Treatment, 46Treatment, 46(4), 463-471. doi:10.1016/j.jsat.2013.10.013 (4), 463-471. doi:10.1016/j.jsat.2013.10.013

Godley, S.H., Meyers, R.J., Smith, J.E., Godley, M.D., Titus, J.C., Karvinen, T., Dent, G., Godley, S.H., Meyers, R.J., Smith, J.E., Godley, M.D., Titus, J.C., Karvinen, T., Dent, G., Passetti, L.L., & Kelberg, P. (2001). Passetti, L.L., & Kelberg, P. (2001). The Adolescent Community Reinforcement Approach The Adolescent Community Reinforcement Approach (ACRA) for adolescent cannabis users (ACRA) for adolescent cannabis users (DHHS Publication No. (SMA) 01-3489, Cannabis (DHHS Publication No. (SMA) 01-3489, Cannabis Youth Treatment (CYT) Manual Series, Volume 4). Rockville, MD: Center for Substance Youth Treatment (CYT) Manual Series, Volume 4). Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. Retrieved Abuse Treatment, Substance Abuse and Mental Health Services Administration. Retrieved from http://www.chestnut.org/Portals/14/ from http://www.chestnut.org/Portals/14/ PDF_Documents/Lighthouse/CYT/Products/ACRA_CYT_v4.pdf. PDF_Documents/Lighthouse/CYT/Products/ACRA_CYT_v4.pdf.

McGarvey, E.L., Leon-Verdin, M., Bloomfield, K., Wood, S., Winters, E., & Smith, J. (2012). McGarvey, E.L., Leon-Verdin, M., Bloomfield, K., Wood, S., Winters, E., & Smith, J. (2012). Effectiveness of A-CRA/ACC in treating adolescents with cannabis-use disorders. Effectiveness of A-CRA/ACC in treating adolescents with cannabis-use disorders. Community Mental Health Journal, 50Community Mental Health Journal, 50(2), 150-157. doi:10.1007/s10597-012-9566-2 (2), 150-157. doi:10.1007/s10597-012-9566-2

Meyers, R.J., & Miller W.R. (Eds.). (2001). A Community Reinforcement Approach to Addiction Treatment. Cambridge, UK: University Press.

Meyers, R. J., & Smith, J. E. (1995). Clinical guide to alcohol treatment: The Community Reinforcement Approach. New York: Guildford Press.