Transcript ARCA Presentation - Florida Alcohol and Drug Abuse Association

Adolescent Community
Reinforcement Approach
A-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)
A-CRA’s General Goals
 Abstinence
 Motivate their
 Participation in pro-
participation
 Promote the client’s
abstinence
 Provide information
about effective care
giving
social activities
 Positive relationships
with family
 Positive relationships
with peers
 10 individual sessions with the adolescent
 4 sessions with the caregiver
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individual sessions with the caregiver
 2 sessions with the caregiver and the
adolescent
 In the office or home and community
 Described basic objectives (help find healthy,
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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 triggers
 Who,
where, when
 Internal triggers
 Thinking, feeling (emotionally,
physically)
 Short-term positive consequences
 Long-term negative consequences
 Provide a rationale
 Determine 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 rationale
 Started by asking for description of common
 episode/behavior
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Common problems: selecting a suitable episode, mixing several
episodes together
 Outlined triggers (external, internal)
 Clarified the using (or non-using) behavior
 Outlined positive and negative consequences of the
behavior
 Summarized findings & gave examples of how the
information would be used
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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 use
 Social life/recreation
 Relationship w/
 Personal habits
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girlfriend/boyfriend
Relationship w/ friends
Relationship w/
caregivers
School (work)
School activities
 Legal issues
 Money management
 Feelings
 Communication
 Job
 General happiness
 Other
 Goals of Counseling contains the categories on the
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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
Guidelines for Goal Setting
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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 of
Counseling 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 but
 not 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 activity
over substance use
 Clarifies negative consequences (barriers to
engaging in it) & positive consequences of the
healthy 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
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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
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of other coping strategies)
Negotiated a reasonable period of sobriety
Common problems: no real negotiation, final period
of time settled upon was too long
Developed 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 conversation
 Discuss the best time to have the conversation
Communication Skills: Vignette
 A high school girl is having trouble talking to a
teacher. She has had the same teacher in another
class and feels as if this teacher has it in for her. It
is a required course, and there are no other
teachers 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 the
handout
 Role-played (reinforced, gave specific feedback, repeated)
 Common problems: not offering specific feedback after each
role-play
 Did a reverse role-play
 Common problems: forgetting to ask client what was learned
about the other person’s perspective by playing him/her, not
pointing out the A-CRA positive communication components
used
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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 it
worked
• 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 steps
explicit – but instead just demonstrating them
 Conducted A-CRA problem solving procedure
 Common problems: not defining the problem
narrowly enough, not generating enough [5]
solutions while brainstorming, not addressing
obstacles adequately
Systematic Encouragement
 Encourage client to “sample” a new activity
 Get the client to make the 1st contact (take the 1st
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step) during the session
Help 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 alternatives
 Change the subject
 Hold a non-alcoholic drink in hand
 Address the “aggressor” directly
 Leave
Drink/Drug Refusal Skills Checklist
 Reviewed high-risk situations
 Enlisted social support
 Common 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 specific
feedback, repeated)
 Common problems: failing to point out & shape A-CRA
refusal 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 (the
same) client over several sessions
 If different clients: must be covered in 2
sessions maximum for certification
Job Finding Topics
(1) Provide an overview:
 Discuss rewards associated with a satisfying job
 Examples: money, meet people, address boredom
 Discuss difficult aspects of the job-finding process
 Examples: Takes a lot of effort, rejection is common
 Explain 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)
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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 steps
 Examples: introduce self, ask about openings
(5) Complete applications:
 Discuss considerations when preparing
 Examples: discuss client strengths, how to handle
difficult 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
sessions
 Build 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 life
that 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 what
caregiver can do to keep adolescent from relapsing
 Assess need for another referral
Caregiver Session 1: Motivation
Enhancement
 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 parenting
practices which help prevent relapse in teens
 Describe the 4 parenting practices:
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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 Communication
Skill Training (Session 1 or 2)
 Provide rationale for learning positive
communication skills
 Assess the present quality of communication
 Describe the three components while generating
real-life examples with caregiver:
 Understanding statement
 Partial responsibility statement
 Offer to help
Caregiver Communication
Skill Training
 Role-play exchanges between the caregiver
and the client
 Point out any problems (e.g., blaming and
bringing up old issues)
 Switch roles with the caregiver
 Process each exchange with the caregiver
 With the caregiver’s input, come up with an
assignment (homework)
Caregiver Problem Solving Training
 Teach caregiver the problem-solving
procedure
 The problem can be: one that relates to the
adolescent
one that has nothing to do with the adolescent
 Make sure a specific assignment results
Caregiver Overview, Rapport
Building, 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’s
reinforcers 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 rate
their happiness with each other in different areas of
their relationship
 A method for setting goals/making changes
 A way to track progress toward relationship goals
Relationship Happiness Scale:
Instructions
 Same basic instructions as for Happiness
Scale, 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 OR
 Asking 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
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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 NOT
needed!!):
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 the
form daily regardless of whether the other
person seems to be doing it as well
 Suggest that they find a good place to keep the
forms so they don’t get lost or forgotten
 Have them generate examples for and practice
1-2 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-Caregiver
Relationship 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 anger
created problems for him/her?
 Explain why it is valuable to recognize the earliest
signs of anger
 Help recognize anger building up:
 Identify high-risk situations and/or triggers for getting
angry
 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 in
a 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 of
view (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 the
advantage of knowing the earliest signs of anger
 Teach taking time to “cool down”
 Teach fostering empathy
 Common problem: not probing sufficiently when
asking about the other person’s thoughts/feelings
 Gave adolescent “Anger Management” handout