Clinical Guide to Alcohol Treatment
Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach
RJ Meyers, JE Smith
New York: Guilford Press; 1995. 215 p
Robert Meyers from the Centre on Alcoholism, Substance Abuse and Addictions (CASAA) and Jane Smith from the Department of Psychology, both from the University of New Mexico, have authored a pragmatic “how-to” instruction book on the Community Reinforcement Approach (CRA) to alcohol treatment. CRA is listed in the US Institute of Medicine’s report on alcohol problems as a contingency management approach designed to provide focused behavioral training to persons with chronic alcohol problems (Institute of Medicine 1990). This approach remains unfamiliar to many clinicians in the field although several grants from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and National Institute on Drug Abuse have been provided to enrich its research basis.
The 1 st chapter outlines the approach’s empirical pedigree dating back to the work of NH Azrin and his group in 1973. The reinforcers used were access to family, to jobs, and to friends, which were contingent on sobriety. In a series of trials, CRA procedures improved the outcome of traditional 12-step programs, monitored disulfiram compliance, and enhanced an alcohol-free recreational environment as well as the involvement of concerned others. These procedures have also been applied to the management of cocaine and heroin abusers and, more recently, to an alcohol-abusing homeless population.
The book’s main contribution lies in the next 10 chapters. Five chapters provide detailed instruction in the CRA assessment procedure, an intriguing approach to facilitating a client’s acceptance of the need for sobriety through a contractual “time-limited sampling” period, the optimal use of disulfiram, and the planning of a treatment protocol using a quality of life scale and identification of counselling goals. The remaining chapters describe procedures to be used for behavioral skills training as well as coping strategies at work, in one’s social interactions and significant relationships, and in relapse prevention.
The highlights of the book for me were the tables appended at the end of each chapter that could be readily adapted by therapists to their own practice. The book is a good primer for those interested in developing their cognitive-behavioral skills with substance abusers. Some procedures may be more controversial or dated than others. For example, recent studies have provided mixed evidence regarding the usefulness of disulfiram (Institute of Medicine 1990). Will the use of naltrexone replace disulfiram as a preferred pharmacotherapy?
As highlighted by the Director of the Research Division at CASAA, Dr WR Miller, many of the procedures included in the original CRA trials, such as motivational preparation and early relapse prevention strategies, have become important elements in today’s treatment programs and have gained more recognition than their predecessors. Elements of the CRA have been incorporated as part of the cognitive-behavioral intervention to be tested in Project MATCH (1994), the current NIAAA-funded multisite clinical trial of patient-treatment matching.
This book’s content is suitable for a multidisciplinary team dedicated to the field of addiction and for the psychiatric resident or psychiatrist searching for ways to enhance his or her skills with this challenging population. The cost of the book is reasonable.