craft - community reinforcement approach and family training.pdf

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The Community-

Reinforcement ApproachWilliam R. Miller, Ph.D., and Robert J. Meyers, M.S.,

with Susanne Hiller-Sturmhfel, Ph.D.

The community-reinforcement approach (CRA) is an alcoholism treatment approach thataims to achieve abstinence by eliminating positive reinforcement for drinking and enhancingpositive reinforcement for sobriety. CRA integrates several treatment components, includingbuilding the clients motivation to quit drinking, helping the client initiate sobriety, analyzing

the client

s drinking pattern, increasing positive reinforcement, learning new copingbehaviors, and involving significant others in the recovery process. These components can beadjusted to the individual clients needs to achieve optimal treatment outcome. In addition,treatment outcome can be influenced by factors such as therapist style and initial treatmentintensity. Several studies have provided evidence for CRA s effectiveness in achievingabstinence. Furthermore, CRA has been successfully integrated with a variety of othertreatment approaches, such as family therapy and motivational interviewing, and has beentested in the treatment of other drug abuse. KEY WORDS: AODU (alcohol and other drug use)treatment method; reinforcement; AOD (alcohol and other drug) abstinence; motivation; AODuse pattern; AODD (alcohol and other drug dependence) recovery; treatment outcome;cessation of AODU; professional client relations; family therapy; motivational interviewing;spouse or significant other; literature review

In nearly every review of alcoholtreatment outcome research, thecommunity-reinforcement approach

(CRA) is listed among approaches withthe strongest scientific evidence of efficacy.

Yet many clinicians who treat alcoholproblems have never heard of it, despitethe fact that the first clinical trial ofCRA was published over a quarter of acentury agoan example of the contin-uing gap between research and practice.

The underlying philosophy of CRAis disarmingly simple: In order to over-come alcohol problems, it is importantto rearrange the persons life so thatabstinence is more rewarding thandrinking. The use of alcohol as well asother drugs can be highly reinforcing:

The user experiences effects that moti-vate him or her to continue drinking,which can lead to alcohol dependence.

What then would make a dependentdrinker want to give up drinking? One

common approach is to

turn up thepainthat is, to confront the personwith unpleasant and costly consequencesof drinking. This approach attempts torender drinking less attractive, and caninclude aversion therapies, pharma-cotherapy with the medication disulfi-ram, confrontational counseling, andinfliction of negative consequences (i.e.,punishment). Such negative approaches,however, frequently have been found tobe ineffective in decreasing drinking andalcohol problems (Miller et al. 1998).

116 Alcohol Research & Health

WILLIAMR. MILLER, PH.D., is directorof research and ROBERTJ. MEYERS, M.S.,is a senior research scientist at the Centeron Alcoholism, Substance Abuse, and

Addiction, University of New Mexico,Albuquerque, New Mexico.

SUSANNEHILLER-STURMHFEL, PH.D.,is a science editor ofAlcohol Research& Health.

The authors gratefully acknowledge thesupport of the National Institute on

Alcohol Abuse and Alcoholism and theNational Institute on Drug Abuse forseveral of the clinical studies summarizedin this report.


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Even seasoned clinicians are often amazedat how much adversity an alcoholic willendure in order to continue drinking.In fact, it has been said that if punishmentworked, there would be no alcoholics.

CRA takes a different approach to

overcoming alcohol problems, one thatis based on providing incentives to stopdrinking rather than punishment forcontinued drinking. To that end, client,therapist, and significant others worktogether to change the drinkers lifestyle(e.g., his or her social support systemand activities) so that abstinence becomesmore rewarding than drinking. Sinceits introduction by Hunt and Azrin in1973, CRA treatment has evolved con-siderably, and the clientele has expandedto include spouses of alcoholics and

users of drugs other than alcohol. Thisarticle summarizes the components ofCRA as well as factors influencing itseffectiveness. In addition, the articlebriefly reviews clinical studies demon-strating CRAs efficacy in treating clientswith alcohol and other drug (AOD)problems.

What Is CRA?

To provide an alcoholic with the incen-tive to quit drinking, CRA has the fol-lowing two major goals:

Elimination of positive reinforce-ment for drinking

Enhancement of positive reinforce-ment for sobriety.

To achieve those goals, CRA thera-pists combine a variety of treatmentstrategies, such as increasing the clients

motivation to stop drinking, initiatinga trial period of sobriety, performing afunctional analysis of the clients drink-ing behavior, increasing positive rein-forcement through various measures,rehearsing new coping behaviors, andinvolving the clients significant others.Other factors, such as therapist styleand initial treatment intensity, also mayinfluence the clients outcome. Thesetreatment components and treatment-related factors are described in the fol-lowing sections.

Building Motivation

The initial step in CRA generally is anexploration of the clients motivationsfor change. Particularly in early versionsof CRA, this process involved the iden-

tification of positive reinforcers (e.g.,praise and shared pleasant events) thatcould serve as effective incentives forthe client to change his or her behavior.The CRA therapist also reviews withthe client the current and future nega-tive consequences of the clients drink-ing patterns. For example, the therapistmay offer an inconvenience reviewchecklista list of frequent negativeconsequences of drinking, such as med-ical problems, marital problems, or dif-ficulties at work. The client then checks

all those negative consequences thatapply to his or her current situation orare likely to occur in the future. Thisassessment can be conducted in anempathic motivational interviewingstyle rather than a confrontational style(Miller and Rollnick 1991), therebyencouraging the client, rather than thetherapist, to voice the advantages ofchange and the disadvantages of his orher current drinking.

Initiating SobrietyOnce the client has identified factorsthat provide the motivation to changehis or her drinking behavior, the thera-pist moves on to setting goals forachieving abstinence. Because manyclients are reluctant to commit them-selves to immediate total and perma-nent abstinence, a procedure calledsobriety sampling can be helpful. Thisprocedure uses various counselingstrategies to negotiate intermediategoals, such as a trial period of sobriety(see Miller and Page 1991). For exam-ple, the therapist may encourage theclient to try not drinking for 1 month,to see how it feels and to learn moreabout the ways in which he or she hasbeen depending on alcohol. Sanchez-Craig and colleagues (1984) foundthat clients who explicitly were givena choice about a trial period of absti-nence were more likely to abstain thanwere clients who were given a firm pre-scription for abstinence.

Analyzing Drinking Patterns

CRA involves a thorough functionalanalysis of the clients drinking patterns.This analysis helps identify situationsin which drinking is most likely to

occur (i.e., high-risk situations) as wellas positive consequences of alcoholconsumption that may have reinforceddrinking in the past. This step, whichis often underemphasized in cognitive-behavioral therapy, is useful in individ-ualizing treatment and in determiningspecific treatment components, ormodules, that are most likely to be suc-cessful for a particular client.

Increasing Positive Reinforcement

Once the analysis of the clients drink-ing patterns is completed, both theclient and therapist select appropriatemodules from a menu of treatmentprocedures to address the clients indi-vidual needs. Many of these treatmentmodules focus on increasing the clientssources of positive reinforcement thatare unrelated to drinking. For example,as people become increasingly depen-dent on alcohol, their range of non-drinking activities (e.g., hobbies, sports,and social involvement) narrows substan-

tially, resulting in increasing isolation.Consequently, an important componentof recovery for the drinker is to reversethis isolation process by becominginvolved with other nondrinking peopleand by increasing the range of enjoyableactivities that do not involve drinking.

Several treatment modules can helpin this process. For example, social andrecreational counseling is used to helpthe client choose positive activities tofill time that was previously consumedby drinking and recuperating from itseffects. If the client cannot easily decideon such activities, an approach calledactivity sampling can encourage himor her to try out or renew various activ-ities that might be, or once were, funand rewarding. For this strategy, thetherapist and client schedule activitiesthat the client will try between counselingsessions and plan where, when, how,and with whom the client will participatein those activities. Those plans empha-size activities that bring the client into

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contact with other people in nondrinkingcontexts. Such activities might includeinvolvement in a church, attendance of12-step meetings or classes, participationin common-interest clubs (e.g., sportsclubs), visits to alcohol-free establish-

ments, or participation in volunteerprograms. The choice of programs istailored to the clients personal intereststo ensure that the client experiences theactivities as positive reinforcers.

Other components of CRA aredesigned to help clients organize notonly their leisure activities but also, ifnecessary, their regular daily lives. Forexample, a component called accesscounseling addresses practical barriers,such as the lack of information sourcesand means of communication, that stand

between the client and those activitiesthat provide positive reinforcement.Thus, access counseling assists the clientin obtaining everyday necessities, suchas a telephone, a newspaper, a place tolive, or a job. Another approach to help-ing clients find rewarding work involvesjob club procedures (e.g., interview skillstraining and rsumdevelopment), whichhave been shown to be successful evenfor difficult-to-employ people (Azrinand Besalel 1980). The common goalof all these CRA treatment modules isto make the clients alcohol-free life morerewarding and affirming and to re-engagethe client in his or her community.

Behavior Rehearsal

CRA therapists do not just talk aboutnew behavior; instead, they have clientsactually practice new coping skills, par-ticularly those involving interpersonalcommunication, during the counselingsessions. For example, a therapist may

first demonstrate the new behavior(e.g., drink refusal or assertive commu-nication), then reverse roles and guidethe client in practicing the new skill.Again, the therapist gives praise for anyand all steps in the right direction.

Involving Significant Others

Because CRA emphasizes change notonly in the clients behavior but also inhis or her social environment, thistreatment approach emphasizes and

encourages, whenever possible, thecooperation of other people who areclose and significant to the drinker.Significant others, particularly thosewho live with a drinker, can be helpfulin identifying the social context of the

clients drinking behavior and in sup-porting change in that behavior.Consequently, even early versions ofCRA included brief relationship coun-seling (Hunt and Azrin 1973). Ratherthan providing protracted marital ther-apy, this counseling offers practicalskills training to improve positive com-munication and reinforcement betweenthe client and his or her significantother, reduce aversive communication(e.g., arguments), and facilitate thenegotiation of specific changes in the

drinkers behavior (Meyers and Smith1995). In addition, CRA therapistsmay coach significant others on howto avoid inadvertent reinforcement ofdrinking (sometimes called enabling)and increase positive reinforcement forsobrietyfor example, by spendingtime with the drinker when he or she issober and withdrawing attention whenhe or she is drinking.

Factors Influencing CRA

EffectivenessIn addition to the treatment compo-nents previously described, several fac-tors related to treatment delivery mayinfluence treatment effectiveness and,consequently, the patients outcome.Two of those factors are therapist styleand initial treatment intensity.

Therapist Style.An important aspect ofCRA that is sometimes underempha-sized is the therapeutic style with which

this treatment approach is delivered.An optimal CRA therapist is consis-tently positive, energetic, optimistic,supportive, and enthusiastic. Any andall signs of progress, no matter howsmalleven the client just showing upfor a counseling sessionare recog-nized and praised. CRA counseling isprovided in a personal, engaging style,not in the form of a businesslike nego-tiation or impersonal education. Witha therapist who successfully executesthis counseling approach, clients look

forward to coming back for future ses-sions and leave those sessions feelinghopeful and good about themselves.

Although many therapists can deliverCRA, some clinicians might find thisapproach easier to adopt than will

other clinicians. For example, therapistwith generally optimistic or enthusias-tic personalities might be best suitedfor CRA. In contrast, therapists whohave been trained to use a relativelyconfrontational approach in order tobreak down denial may find the CRAapproach more difficult to practice.

Initial Treatment Intensity.Anothercharacteristic of CRA that may con-tribute to the success of this approach isits jump-startquality. Ideally, a client

who is ready for change can schedule anappointment for the same or followingday, rather than being placed on a wait-ing list for 1 or more months. In addi-tion, during the initial treatment phase,counseling sessions may be scheduledmore frequently than once per week.The intervals between sessions can thenbe extended as the clients abstinencebecomes more stable.

Finally, CRA can involve proceduresto initiate abstinence immediately. Forexample, in some cases the client canbe evaluated right away as to whetherhe or she is a candidate for taking disul-firam, an agent that induces unpleasanteffects (e.g., nausea and vomiting) afteralcohol consumption and is used todiscourage drinking. In those cases, amedical staff member of the treatmentfacility can promptly issue and fill adisulfiram prescription, and the clientcan take the first dose in the therapistspresence. If a concerned significantother is willing to help the client, he or

she can be trained along with the clientin procedures to ensure that the clienttakes the medication regularly. Thisprocess also can be used to promotepatient compliance with other medica-tion regimens.

Evidence for CRAsEfficacy

During the past 25 years, numerousstudies have demonstrated the efficacy



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of CRA in the treatment of alcoholism.In the first evaluation, Hunt and Azrin(1973) compared CRA with traditionaldisease-model treatment1 for alcohol-dependent people receiving inpatienttreatment. In that study, the patients

who received CRA fared much betterthan did the patients who received tra-ditional treatmentin fact, almost nooverlap existed in the distribution ofthe two groups on several outcomemeasures at followup. The CRA clientsdrank substantially less and less often,had fewer institutionalized days andmore days of employment, and exhib-ited greater social stability comparedwith patients who were treated withthe traditional approach.

Additional improvements to CRA,

such as monitored disulfiram adminis-tration, mood monitoring, and spousalinvolvement, further increased the differ-ence in outcome between patients whoreceived CRA and those who receivedtraditional treatment (Azrin 1976). Forexample, with these improvements,drinking days in the CRA group droppedto 2 percent of all days during a 6-monthfollowup period compared with 55percent of all days in the standard treat-ment group.

Whereas those initial studies wereconducted in an inpatient setting, CRAsubsequently was shortened and adaptedfor use in outpatient settings (e.g., byinstituting immediate disulfiramadministration). The modified CRAapproach also was considerably moreeffective than traditional outpatienttreatment mirroring the Minnesotamodel (Azrin et al. 1982). As in previousstudies, CRA clients showed substan-tially increased rates of abstinence andemployment and less institutionalization

and incarceration.In another study, researchers assessedthe effectiveness of a social interventionconsistent with CRA. They providedan alcohol-free club where clients couldsocialize and have fun without drinking.Clients given access to this club evidencedbetter outcomes than did clients with-out such access (Mallams et al. 1982).Because these studies employed scien-tifically sound methodology, theyprovided strong evidence for the effec-tiveness of CRA.

Other evaluations of CRAs effec-tiveness have been conducted at theUniversity of New Mexicos Center onAlcoholism, Substance Abuse, andAddictions (CASAA). In one outpatienttreatment study (Meyers and Miller in

press), CRA was found to be more suc-cessful in suppressing drinking thanwas a traditional disease-model coun-seling treatment approach.

After Meyers and Smith (1995)published the first manual delineatingthe components of CRA for therapiststreating patients with alcohol problems,CASAA researchers conducted a studyon CRAs efficacy among homelessalcohol-dependent men and women ata large day shelter. The study foundthat compared with the standard 12-

step-oriented group therapy providedat the shelter, CRA, when implementedas described in the manual, resulted insignificantly improved outcomes dur-ing the 1-year followup period (Smithet al. 1998). As in previous studies,alcohol consumption in the CRA groupwas almost completely suppressed during1 year of followup. In contrast, patientsin the standard care group reporteddrinking on about 40 percent of thedays as well as high levels of intoxication.

CRA as Family Therapy

In recent years, CRA also has beenintegrated into a unilateral family therapy(FT) approach in which the personseeking help is not the drinker (whorefuses to get treatment) but a concernedspouse or other family memberresulting in the community reinforce-ment and family training (CRAFT)approach (Meyers and Smith 1997). TheCRAFT treatment approach is based

on studies demonstrating that the involve-ment of family members can help initiateand promote the treatment of peoplewith alcohol problems (Sisson andAzrin 1986).

Without the drinker present, theCRAFT therapist works with the familymember to change the drinkers socialenvironment in a way that removesinadvertent reinforcement for drinkingand instead reinforces abstinence. Thetherapist also helps the family memberprepare for the next opportunity when

the drinker may respond favorably toan offer of help and support and maybe willing to enter treatment.

A recently completed clinical trialfunded by the National Institute onAlcohol Abuse and Alcoholism evalu-

ated the efficacy of CRAFT (Miller etal. in press). In that study, 64 percentof the clients who received CRAFTcounseling succeeded in recruiting theirloved one into treatment following anaverage of four to five counseling sessions.In contrast, two traditional methodsfor engaging unmotivated problemdrinkers into treatmentthe JohnsonInstitute intervention2 and counselingto engage in Al-Anonresulted in sig-nificantly lower proportions of signifi-cant others (30 percent and 13 percent,

respectively) motivating their lovedones to enter treatment. In a parallelstudy sponsored by the National Instituteon Drug Abuse that focused on abusersof other drugs, family members receivingCRAFT successfully engaged 74 per-cent of initially unmotivated drug usersin treatment (Meyers et al. 1999).

CRA in the Treatment of OtherDrug Abuse

CRA also has been used in the treatmentof other drug abuse and dependence.For example, researchers at CASAAconducted a trial in which heroin addictsreceiving methadone maintenancetherapy were randomly assigned toCRA or standard treatment approaches.Although both CRA and the traditionalapproaches resulted in good treatmentoutcomes in this study, CRA was asso-ciated with a modest but statisticallysignificant advantage over the standardcare approaches (Abbott et al. 1998).

Furthermore, researchers studying thetreatment of cocaine addicts foundsubstantially better outcomes for clientswho received CRA combined with pos-

1Traditional disease-model treatment is similar tothe Minnesota model, which posits that alcoholismis a disease characterized by loss of control overdrinking and which emphasizes a 12-step approachto recovery.

2The Johnson Institute intervention entails five ther-apy sessions that prepare the client and his or herfamily members for a family confrontation meeting.

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itive reinforcement in the form ofmonetary vouchers issued when theclients tested drug free compared withclients who participated in an outpa-tient 12-step counseling program(Higgins et al. 1991).

Can CRA Be Used inOrdinary TreatmentSettings?

CRA has sometimes been delivered inrelatively expensive ways (e.g., in inpa-tient programs, through home visits,and in combination with vouchers).However, CRA is also amenable to andeffective in the typical outpatient treat-

ment context, in which the client isseen weekly at a clinic. Furthermore,in outpatient studies that demonstratedgood treatment outcomes with CRA,alcohol-dependent patients receivedan average of five to eight CRA sessions(e.g., Azrin et al. 1982). Similarly, thestudy by Miller and colleagues (in press)demonstrated that approximately fiveCRAFT sessions with a concerned sig-nificant other frequently resulted in thedrinkers entry into treatment. This

treatment duration is well within theguidelines of most managed care systems.Although CRA is based on a compre-

hensive treatment philosophy, its proce-dures generally are familiar to clinicianswho have been trained in cognitive-behavioral treatment approaches. Forexample, CRA involves a functionalanalysis and the individualized applica-tion of specific components chosenfrom a menu of problem-solving pro-cedures. Furthermore, CRA can becombined with other treatment meth-ods. For example, at CASAA, CRA hasrecently been combined with motiva-tional interviewing to form an integratedtreatment. Similarly, CRA is consistentwith involvement in 12-step programs.Finally, combinations of CRA andother treatment approaches can be tai-lored to address the needs of particularclient populations (for an example ofsuch an approach targeted to a specificpopulation, see sidebar, p. 121).

Summary

CRA is a comprehensive, individualizedtreatment approach designed to initiatechanges in both lifestyle and socialenvironment that will support a clients

long-term sobriety. CRA focuses onfinding and using the clients own intrin-sic reinforcers in the community and isbased on a flexible treatment approachwith an underlying philosophy of posi-tive reinforcement. Those characteristicsmake CRA (with certain modifications)applicable to a wide range of clientpopulations.

Numerous clinical trials have foundCRA to be effective in treating AODabuse and dependence and in helpingrelatives recruit their loved ones intoAOD-abuse treatment. The trials wereconducted in a variety of geographicregions, treatment settings (e.g., inpa-tient and outpatient), and individualand family therapy approaches. Further-more, the clients in those studies sufferedfrom various AOD-related problemsand included homeless people as wellas people of different ethnic or culturalbackgrounds. Consistently, CRA wasmore effective than the traditionalapproaches with which it was compared

or to which it had been added. Becausethe scope and duration of CRA arecompatible with the guidelines of mostmanaged care services, this approach mayplay an increasingly important role inthe treatment of people with alcoholism.

References

ABBOTT, P.J.; WELLER, S.R.; DELANEY, H.D.;ANDMOORE, B.A. Community reinforcement approachin the treatment of opiate addicts.American Journalof Drug and Alcohol Abuse24:1730, 1998.

AZRIN, N.H. Improvements in the community-reinforcement approach to alcoholism. BehaviorResearch and Therapy14:339348, 1976.

AZRIN, N.H.,AND BESALEL, V.A.Job Club CounselorsManual. Baltimore: University Park Press, 1980.

AZRIN, N.H.; SISSON, R.W.; MEYERS, R.;ANDGODLEY, M. Alcoholism treatment by disulfiramand community reinforcement therapy.Journal ofBehavior Therapy and Experimental Psychiatry13:105112, 1982.

HIGGINS, S.T.; DELANEY, D.D.; BUDNEY, A.J.;BICKEL, W.K.; HUGHES, J.R.;AND FOERG, F.

A behavioral approach to achieving initial cocaineabstinence.American Journal of Psychiatry148:12181224, 1991.

HUNT, G.M.,ANDAZRIN, N.H. A community-reinforcement approach to alcoholism. BehaviorResearch and Therapy11:91104, 1973.

MALLAMS, J.H.; GODLEY, M.D.; HALL, G.M.;ANDMEYERS, R.A. A social-systems approach to resocial-izing alcoholics in the community.Journal of Studieson Alcohol43:11151123, 1982.

MEYERS, R.J.,AND MILLER, W.R., EDS.A CommunityReinforcement Approach to Addiction Treatment.Cambridge, UK: Cambridge University Press, in press.

MEYERS, R.J.,AND SMITH, J.E. Clinical Guide toAlcohol Treatment: The Community ReinforcementApproach. New York: Guilford Press, 1995.

MEYERS, R.J.,AND SMITH, J.E. Getting off the fenceProcedures to engage treatment-resistant drinkers.

Journal of Substance Abuse Treatment14:467472,1997.

MEYERS, R.J.; MILLER, W.R.; HILL, D.E.;ANDTONIGAN, J.S. Community reinforcement and fam-ily training (CRAFT): Engaging unmotivated drugusers in treatment.Journal of Substance Abuse10(3)118, 1999.

MILLER, W.R.,AND PAGE, A. Warm turkey: Otherroutes to abstinence.Journal of Substance AbuseTreatment8:227232, 1991.

MILLER, W.R.,AND ROLLNICK, S.MotivationalInterviewing: Preparing People to Change AddictiveBehavior. New York: Guilford Press, 1991.

MILLER, W.R.; ANDREWS, N.R.; WILBOURNE, P.;ANDBENNETT, M.E. A wealth of alternatives: Effectivetreatments for alcohol problems. In: Miller, W.R.,and Heather, N., eds. Treating Addictive Behaviors:Processes of Change. 2d ed. New York: Plenum Press,1998. pp. 203216.

MILLER, W.R.; MEYERS, R.J.;AND TONIGAN, J.S.Engaging the unmotivated in treatment for alcoholproblems: A comparison of three strategies forintervention through family members.Journal ofConsulting and Clinical Psychology, in press.

SANCHEZ-CRAIG, M.; ANNIS, H.M.; BORNET, A.R.AND MACDONALD, K.R. Random assignment to

abstinence and controlled drinking: Evaluation of acognitive-behavioral program for problem drinkers.

Journal of Consulting and Clinical Psychology52:390403, 1984.

SISSON, R.W.,ANDAZRIN, N.H. Family-memberinvolvement to initiate and promote treatment ofproblem drinkers.Journal of Behavior Therapy andExperimental Psychiatry17:1521, 1986.

SMITH, J.E.; MEYERS, R.J.;AND DELANEY, H.D.Community reinforcement approach with homelessalcohol-dependent individuals.Journal of Consultingand Clinical Psychology66:541548, 1998.



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Community-Reinforcement Approach

The community-reinforcement approach (CRA) is ahighly flexible treatment approach that allows therapistsand clients to choose from an extensive menu of treatmentoptions to meet the specific needs of the client. Thisflexibility also enables CRA to be adapted easily to clientpopulations with special needs, such as ethnic or culturalminorities. For example, CRA has been adapted creativelyat the Nanizhoozhi Center, Inc. (NCI) in Gallup, NewMexico, a treatment facility that primarily serves the Dine(Navajo) Native Americans. The NCI staff has developedan intensive, 16-day residential program for alcohol-dependent Native Americans who have not respondedto treatment programs based on the Minnesota model,

which emphasizes a loss-of-control disease methodologyand a 12-step approach to recovery.Among the Dine, clan ties remain strong even when

the trust between the drinker and his or her family hasbeen broken repeatedly. Accordingly, when treating

clients from this cultural group, alcoholism treatmentprofessionals should work with both the family andcommunity networks using traditional Native Americanceremonies and extended clan ties. The NCI programconnects or reconnects the clients with Native Americanspirituality through the Hiinaah Bitsos(Eagle Plume)Society. For example, traditional practices, such as thetalking circle (i.e., the passing of an object that designateswho is speaking while all others listen) and the sacreduse of tobacco, are integrated into the treatment program,replacing alcohol with the Dineway of seeking harmonywith all of creation (i.e., walking in beauty). A special

compound built adjacent to the Nanizhoozhi Centerincludes ceremonial grounds, tepees, and sweat lodges.For many NCI clients, the path into this program

has been long and painful. Most clients are unemployed,destitute, hopeless, physically ill, and depressed aftermultiple treatment failures. Researchers have begun toevaluate the effectiveness of the modified CRA approachpracticed at the NCI in this challenging patient popula-tion. Preliminary results indicate that at the 6-monthfollowup, a substantial portion of clients have achievedcontinuous abstinence and many other clients are freeof alcohol-related problems, despite occasional drinking,or have improved considerably even if they have experi-

enced some ongoing problems. These initial indicationsof effectiveness bear witness to the Hiinaah BitsosSocietys motto, Against all odds, we walk in beauty.

William R. Miller and Robert J. Meyers withSusanne Hiller-Sturmhfel

CRA and Special Populations

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