Community Reinforcement Therapy

CRA starts from what a person’s week could hold instead of using: paid work, friendships, hobbies and health. A counselor maps what leads to use, agrees a fixed stretch without alcohol or drugs, and rehearses the skills that make those everyday rewards easier to reach. The evidence behind the approach, its versions for teenagers and families, and the questions worth asking a program all build on that one idea.

What Is the Community Reinforcement Approach?

The community reinforcement approach, or CRA, is a behavioral treatment designed to make staying sober more rewarding than a life with alcohol or drugs in it. It builds on rewards a person can reach in ordinary life, such as family, friends and time spent on something they enjoy, so those rewards compete with using. You might also hear it called community reinforcement therapy, or simply reinforcement therapy.

Hunt and Azrin studied 16 people in an inpatient program in 1973, and Azrin followed with a larger sample in 1976. Both were small, early trials, and Meyers and Squires place them in the method’s history rather than in its evidence. Meyers and Smith published the clinician manual in 1995.

CRA differs from contingency management, which gives a tangible incentive, such as a voucher or a prize, for a verified goal. CRA looks for rewards already in a person’s week instead, and CRA plus vouchers combines the two.

Sessions examine the areas a life is built from:

That list follows the life areas of the Happiness Scale, the questionnaire used to see where a person’s life is going well and where it is not.

It belongs to the same behavioral family as CBT for addiction and the other structured forms of addiction therapy.

How CRA Works

CRA starts with a close look at a person’s situation. Counselor and client map what comes before use, what using gives back and what it costs, then map the sober parts of life the same way. Together they show where a change would pay off, and the plan reaches into work, family life and free time. Practice fills the sessions, so skills get tried in the room.

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Meyers and Squires set out the procedures a counselor works through.

Meetings are usually weekly, more often at the start, then every two weeks, then monthly. A typical individual session runs about 60 minutes, and the first one can take 1.5 to 2 hours. A trial-style program for alcohol use disorder lasts 24 weeks. Benefits usually appear within about three months.

Each meeting opens on the previous week’s practice assignment and closes with a new one, with role-play carrying much of the learning.

Some programs add disulfiram (Antabuse) for alcohol use disorder, with a monitor supporting the person taking it; the guideline treats it as an option, not a first-line one. CRA also combines with medication for opioid use disorder, so counseling and medication run side by side.

CRA, A-CRA, CRAFT and CRA Plus Vouchers

The community reinforcement approach comes in four forms, and the differences matter: the original model is for adults, A-CRA adapts it for teenagers, CRAFT aims it at the family members of someone who will not seek help, and the voucher version awards incentives for drug-free urine tests.

A-CRA for teens

A-CRA was written for adolescents, and the way in usually starts with teen substance use at home. A clinician assesses the young person first, then chooses from 17 procedures to shape the sessions. Caregivers join some of those sessions, as they would in family therapy for addiction, and certification takes a 2.5-day training workshop.

CRAFT for families

CRAFT, short for Community Reinforcement and Family Training, works with the family member rather than the person who uses. It teaches them to reward the behavior they want to see, to talk without confrontation and to keep themselves safe, which raises the chance that their loved one agrees to treatment, and the steps themselves are in help a loved one with addiction.

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CRA plus vouchers

How the vouchers work is where this version departs from plain CRA: the reward tracks a run of consecutive negative urine tests, and one positive result costs the whole run.

Does the Community Reinforcement Approach Work?

The community reinforcement approach has strong evidence for alcohol use, though only against the weakest comparison. Trials find it cuts drinking days more than usual care does; results on staying abstinent conflict, and support for pairing it with disulfiram is moderate. Adding incentives strengthens the cocaine case. Against other treatments with a track record of their own, it has rarely been tested at all.

The limits deserve naming. Much of the evidence is old: the Roozen review that anchors the case covers only studies finished before 2004. Early trials were small. Reviews by the approach’s own developers tend to report stronger results than independent ones do.

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The main reviews, unflattering ones included:

Read together, those rows describe a solid short-term record against usual care and a thin one against anything stronger. Talk therapies broadly share that shape, and how well addiction therapy works in general runs into the same missing comparisons. What separates programs is what they actually deliver, so the questions in how to choose an addiction therapist matter more than the label.

Who CRA Helps

CRA suits adults whose daily surroundings tilt toward using: a home where others drink or use, a job that puts them behind a bar, friends who expect them to join in. It also fits someone whose week holds little that is rewarding besides alcohol or drugs, and someone who wants hands-on help rebuilding work, family life and friendships, not just a weekly hour to talk. Teenagers have their own version, A-CRA. Relatives have CRAFT, which works with them directly and does not need the person who is using to attend.

The approach itself does not change with the drug, though the research behind it does. CRA is used for alcohol use disorder, cocaine addiction and opioid addiction alike, and alcohol and cocaine have the most evidence behind them, with less for opioids.

CRA may suit you if:

How to Find CRA or A-CRA

CRA turns up in some outpatient programs and in individual clinicians’ private practices, while A-CRA comes through youth programs whose staff hold certification in it. The reliable way to find either is to ask the program whether it uses community reinforcement at all, and how its staff were trained.

Chestnut Health Systems publishes A-CRA certification information, and Robert J. Meyers publishes CRA and CRAFT training. CRA sits mostly in outpatient care, so an outpatient rehab search is one place to look; FindTreatment.gov searches by location. The Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline, at 1-800-662-HELP (4357), can steer you toward nearby programs. A partner or parent can ask the same questions while trying to help a loved one with addiction.

An intake is also a coverage question, so check your rehab insurance coverage before booking one.

Community Reinforcement Approach FAQs