Adolescent community reinforcement approach

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The adolescent community reinforcement approach (A-CRA) is a behavioral treatment for alcohol and other substance use disorders that helps youth, young adults, and families improve access to interpersonal and environmental reinforcers to reduce or stop substance use.[1][2]


A-CRA is a variant of the adult CRA model, which has a history of development and effectiveness research starting in the 1970s.[3] A-CRA was adapted to be developmentally appropriate for adolescents, which included adding sessions for parents/caregivers.[4] The goal of A-CRA is to improve or increase access to social, familial, and educational/vocational reinforcers for adolescents to achieve and sustain recovery. That is, therapists assist adolescents with learning how to lead an enjoyable and healthy life without using alcohol or other drugs.[5] The treatment manual describes an outpatient curriculum that is intended for adolescents (ages 12 to 17) and young adults (ages 18–25). with DSM-5 alcohol and/or other substance use disorders.[1][2] A-CRA also has been implemented in intensive outpatient and residential treatment settings.[6][7] A-CRA includes three types of clinical sessions: adolescent alone, parents/caregivers alone, and family (adolescent with parents/caregivers).[1][2] To address the adolescent's needs, goals for treatment, and reinforcers, clinicians select from 19 A-CRA procedures (e.g., communication skills, problem-solving, and participation in positive social activities), all with the goal of improving life areas and supporting abstinence from alcohol and other drugs.[8] Practicing skills during sessions is an important aspect of A-CRA counseling, and every clinical session ends with a homework assignment (mutually-agreed upon by adolescent and clinician) to apply skills learned during the session.[1][4] Clinicians practicing A-CRA are trained in all 19 procedures and complete an extensive certification process.[8] A-CRA has been widely implemented in the U.S.,[8] Canada,[9] and Brazil.[10]

Evidence-based outcomes[edit]

As of 2017, five randomized clinical trials of A-CRA have been published. The Cannabis Youth Treatment (CYT) study, which was funded by the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Center for Substance Abuse Treatment (CSAT), was a randomized controlled study of five manual-guided treatment models for adolescents with cannabis-related disorders.[11] All five models demonstrated significant pre-post treatment improvements in number of days abstinent and the percent of adolescents in recovery during the 12-month follow-up period.[12] Within its study arm, A-CRA was the most cost-effective model; across both study arms, A-CRA was the most cost-effective model to involve parents in treatment.[12] Additional randomized clinical trials have shown A-CRA to be effective for homeless, street-living youth and young adults,[7] youth with juvenile justice involvement,[13] and as a continuing care approach for adolescents after residential treatment.[14][15] Secondary evaluation studies suggest that A-CRA shows potential to be an effective treatment for adolescents with co-occurring psychiatric disorders[16] and youth with opioid use problems.[17]

Treatment cost[edit]

In a 2002 article assessing the economic costs of A-CRA, the average cost per completed treatment event was $1,237 at one site and $1,608 at another site.[18] Using U.S. Bureau of Labor Statistics data to adjust for inflation, the 2017 cost per A-CRA treatment episode ranges from $1,683 to $2,188.[19]

Treatment manual[edit]

The original A-CRA treatment manual was published in 2001.[1] An updated version of the A-CRA manual was published in 2016.[2]

Therapist fidelity to A-CRA treatment manual[edit]

Although therapist fidelity to an evidence-based treatment manual is believed to predict treatment outcome, this relationship has been difficult to prove.[20] A 2017 study found that higher ongoing fidelity (model competence) ratings of 91 A-CRA therapists' clinical sessions predicted improved adolescent substance use outcomes.[21] This finding suggests that the A-CRA model of clinical certification and supervision, which rates A-CRA counseling sessions using a standardized rubric, is a central part of model effectiveness.[21]

See also[edit]


  1. ^ a b c d e 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). The Adolescent Community Reinforcement Approach (ACRA) for adolescent cannabis users (DHHS Publication No. (SMA) 01-3489, Cannabis Youth Treatment (CYT) Manual Series, Volume 4). Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. Retrieved from "Archived copy" (PDF). Archived from the original (PDF) on 17 November 2011. Retrieved 9 June 2012.{{cite web}}: CS1 maint: archived copy as title (link)
  2. ^ a b c d Godley, Susan H; Smith, Jane Ellen; Meyers, Robert J; Godley, Mark D (2016). The Adolescent Community Reinforcement Approach: A Clinical Guide for Treating Substance Use Disorders. Normal, IL: Chestnut Health Systems. ISBN 978-0998058009.
  3. ^ Meyers, R.J., Roozen, H.G., & Smith, J.E. (2011). The Community Reinforcement Approach: An update of the evidence. Alcohol Research and Health, 33(4), 380–388.
  4. ^ a b Godley, S.H., Smith, J.E., Meyers, R.J., & Godley, M.D. (2009). Adolescent Community Reinforcement Approach (A-CRA). In D.W. Springer & A. Rubin (eds.), Substance abuse treatment for youth and adults (pp. 109–201). Hoboken, NJ: John Wiley & Sons.
  5. ^ Hunt, G.M., & Azrin, N.H. (1973). A community-reinforcement approach to alcoholism. Behaviour Research and Therapy, 11, 91–104. doi:10.1016/0005-7967(73)90072-7
  6. ^ Godley, S.H., & Kenney, M. (2010). How to implement an outpatient evidence-based treatment in a residential program. The Counselor, 11, 10–16.
  7. ^ a b Slesnick, N., Prestopnik, J.L., Meyers, R.J., & Glassman, M. (2007). Treatment outcome for street-living, homeless youth. Addictive Behaviors, 32, 1237–1251. doi:10.1016/j.addbeh.2006.08.010
  8. ^ a b c Godley, S.H., Garner, B.R., Smith, J.E., Meyers, R.J., & Godley, M.D. (2011). A large-scale dissemination and implementation model. Clinical Psychology: Science and Practice, 18, 67–83. doi:10.1111/j.1468-2850.2011.01236.x
  9. ^ Dave Smith Youth Treatment Centre. (2010). Clinical programs. Retrieved 6 March 2012, from "Clinical Programs - Dave Smith Youth Treatment Centre". Archived from the original on 20 June 2012. Retrieved 9 June 2012.
  10. ^ Carvalho, R., Crepaldi, K., Oliveira, M., Anderson, L., Calfat, E., Mancilha, G., Nascimento, D., Katz, P., Filho, L., & Fraser, J. (April 2012). Strategies for A-CRA implementation in Brazil. Poster presentation at the 2012 Joint Meeting on Adolescent Treatment Effectiveness (JMATE), Washington, DC.
  11. ^ Dennis, M.L., Titus, J.C., Diamond, G., Donaldson, J., Godley, S.H., Tims, F. ... et al. (2002). The Cannabis Youth Treatment (CYT) experiment: Rationale, study design, and analysis plans. Addiction, 97(Suppl. 1), S16-S34. doi:10.1046/j.1360-0443.97.s01.2.x
  12. ^ a b Dennis, M. L., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J. … et al. (2004). The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27(3), 197–213. doi:10.1016/j.jsat.2003.09.005
  13. ^ Henderson, C. E., Wevodau, A. L., Henderson, S. E., Colbourn, S. L., Gharagozloo, L., North, L. W., & Lotts, V. A. (2016). An independent replication of the Adolescent Community Reinforcement Approach with justice-involved youth. American Journal on Addictions, 25, 233–240. doi:10.1111/ajad.12366
  14. ^ Godley, M.D., Godley, S.H., Dennis, M.L., Funk, R.R., & Passetti, L.L. (2007). The effectiveness of assertive continuing care on continuing care linkage, adherence, and abstinence following residential treatment for substance use disorders in adolescents. Addiction, 102, 81–93. doi:10.1111/j.1360-0443.2006.01648.x
  15. ^ Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R. R., Passetti, L. L., & Petry, N. M. (2014). A randomized trial of Assertive Continuing Care and contingency management for adolescents with substance use disorders. Journal of Consulting and Clinical Psychology, 82(1), 40–51. doi:10.1037/a0035264
  16. ^ Godley, S.H., Smith, J.E., Passetti, L.L., Subramanian, G. (2014). The Adolescent Community Reinforcement Approach (A-CRA) as a model paradigm for the management of adolescents with substance use disorders and co-occurring psychiatric disorders. Substance Abuse, 35, 352-363. doi:10.1080/08897077.2014.936993
  17. ^ Godley, M.D., Passetti, L., Subramaniam, G., Funk, R., Smith, J.E., & Meyers, R.J. (2017). Adolescent Community Reinforcement Approach implementation and treatment outcomes for youth with opioid problem use. Drug and Alcohol Dependence, 174, 9-16. doi:10.1016/j.drugalcdep.2016.12.029
  18. ^ French, M.T., Roebuck, M.C., Dennis, M.L., Diamond, G.S., Godley, S.H., Tims, F.M., Webb, C., & Herrell, J.M. (2002). The economic cost of outpatient marijuana treatment for adolescents: Findings from a multisite experiment. Addiction, 97, S84-S97. doi:10.1046/j.1360-0443.97.s01.4.x
  19. ^ U.S. Department of Labor Bureau of Labor Statistics. (2018). CPI Inflation Calculator. Retrieved on February 5, 2018 from
  20. ^ Webb, C.A., DeRubeis, R.J., & Barber, J.P. (2010). Therapist adherence/competence and treatment outcome: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 200-211. doi:10.1037/a0018912
  21. ^ a b Campos-Melady, M., Smith, J.E., Meyers, R.J., Godley, S.H., & Godley, M.D. (2017). The effect of therapists’ adherence and competence in delivering the Adolescent Community Reinforcement Approach on client outcomes. Psychology of Addictive Behavior, 31, 117-129. doi:10.1037/adb0000216

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