Standard 4: Incentives, Sanctions, and Therapeutic Adjustments Truth or Consequences Standard 4: Incentives, Sanctions, and Therapeutic Adjustments

The Bottom Line Consequences for participants’ behavior are predictable, fair, consistent, and administered in accordance with evidence – based principles of effective behavior modification.

The Background Based on scientific theories and research that dates back to the beginning of the 20th century Behavior Modification via Operant Conditioning Our response (or lack of response) to participant behavior will make the behavior more or less likely to reoccur Contemporary studies applying behavioral learning science to criminal justice populations, including Drug Courts, have led to researched- based principles for success -John Watson, B.F. Skinner are early 20th century researchers whose names most attendees will remember from their Psychology 101 classes. They were behaviorists who helped develop the early theories that form the foundation of what we now know as incentives and sanctions. Learning Theory Classical Conditioning and Operant Conditioning (Conditioning means learning) Classical Conditioning involves something occurring that triggers behavior in a participant (e.g., a trigger leading to drug use; or being in court triggering anxiety) Operant Conditioning involves responding after a behavior has occurred in a way that either makes the behavior more or less likely to occur. (e.g., imposing a sanction after a missed group; or giving an incentive after a clean drug test.) Extinction: means that a particular behavior is no longer reinforced in any way, therefore it extinguishes (e.g. when an antagonist medication like naltrexone blocks euphoria of heroin use thereby making it less likely the individual will return to heroin use)

The Basics This is an introductory slide that signals the transition to a number of slides that deal with some of the basic, essential elements of behavior modification.

The Response Categories Sanctions Therapeutic Adjustments Incentives

Two Ways to Reward, Punish, or Treat Give Take

Therapeutic Adjustments Incentives Positive Reinforcement Negative Reinforcement Sanctions Punishment Response Cost Therapeutic Adjustments Enhancements Reductions Let attendees know why this matters! The reason we describe the different ways to respond to behavior is to assist teams when they are brainstorming how to add responses to their menu of options. Realizing that we can reward, punish, and treat by both adding and removing (i.e., give and take) can help them generate ideas. Positive Reinforcement: Providing something desirable (i.e. positive) as a rewarded for compliant behavior. (verbal praise, applause, tokens, gift certificates, barrel drawings.) Negative Reinforcement: Removing something undesirable (i.e. negative) as a reward for compliant behavior. (later curfew, requiring fewer court appearances, waiving fees) Punishment: Imposing something undesirable as a punishment for non compliant behavior. (community service, verbal reprimand, early curfew, flash incarceration) Response Cost: Removing something desirable as a punishment for non compliant behavior. (Replacing an earned late curfew with an earlier curfew; collecting a fine; deducting points earned in a token economy incentive program) Therapeutic enhancements: (additional treatment groups, new assessment, additional AA meetings, treatment workbook, residential treatment, adding a trauma recovery group) Therapeutic reductions (fewer treatment groups, moving from intensive outpatient to outpatient treatment,)

Positive Reinforcement Rewarding Behavior Positive Reinforcement Verbal Praise Applause Tokens Gift Certificates Fish Bowl Drawings Negative Reinforcement Later Curfew Waiving Fees Reduced Court Appearances (as part of phase advancement) These are examples. Not an exhaustive list.

Punishing Behavior Punishment Response Cost Verbal Reprimand Early Curfew Community Service Jury Box Flash Incarceration Response Cost Collecting fines (removing money) Losing Points Return to More Frequent Court Appearances Replacing a Late Curfew with an Earlier Curfew These are examples. Not an exhaustive list.

Treating Behavior Enhancements Reductions New Assessment Adding Trauma Groups Additional Treatment Groups Additional AA Meetings Moving from Intensive Outpatient to Residential Treatment Reductions Moving from Intensive Outpatient to Outpatient Fewer Treatment Groups Replacing Treatment Groups with Job Training Based on recommendations by treatment provider. These are examples. Not an exhaustive list.

Associated with Behavior Essential Elements Certainty Reliable Detection Associated with Behavior Immediacy Certainty: Consistently responding to positive and negative behavior facilitates learning and behavior change. Reliable Detection: Detecting and responding to both positive and negative behavior requires us to notice when a person is doing well, improving, doing poorly, or declining. Associated with Behavior: This is essential for the learning to occur. It can be accomplished by reliable detection, responding as close as practicable to when the behavior occurred, and by verbally associating the behavior with our response. Immediacy: The most powerful way to ensure that that the behavior and our response is associated.

www.ndcrc.org The Standard Search: Standards Adult Drug Court Best Practice Standards Volume I: Incentives, Sanctions, and Therapeutic Adjustments www.ndcrc.org Search: Standards Hyperlink to NDCRC . Encourage everyone to download a copy of both Volumes of the Standards at the NDCRC website. (They can also do so from the allrise.org site.) For some trainings, such as the Drug Court Planning Initiative and Operational Tune Ups, a PDF of the Standards will be included on the disc/flash drive they receive at the training.

The Standard Advance Notice Opportunity to be Heard Equivalent Consequences Professional Demeanor Progressive Sanctions Licit Addictive or Intoxicating Substances Therapeutic Adjustments Incentivizing Productivity Phase Promotion Jail Sanctions Termination Consequences of Graduation & Termination This slide previews the sub-topics within this standard. Do not describe each one. Simply display. The subsequent slides will elaborate on each sub topic.

Advance Notice Provide to participants and team members written policies and procedures regarding program response strategy. Include range of possible responses for various behaviors, not precise response for each infraction. Allow reasonable degree of discretion to modify usual response due to unique circumstances.

Opportunity to be Heard Provide participant opportunity to explain their perspective regarding factual controversies and program responses. Explain to participants the justification for why a particular response is or is not imposed.

Equivalent Consequences Participants with similar risk/need levels, phase, etc. receive consequences that are equivalent to those received by others who are in engaged in comparable conduct. Equivalent does not necessarily mean identical. Equivalent means similar value, severity, magnitude, or intensity.

Professional Demeanor Sanctions are delivered without expressing anger or ridicule. Participants are not shamed or subject to foul or abusive language. Drug Court judges can learn from Judge Judy. The Drug Court judge’s demeanor should be the opposite of Judge Judy’s in nearly every respect.

Progressive Sanctions Drug Courts have a range of sanctions of varying magnitudes that may be administered in response to infractions. For goals that are especially difficult for participants to accomplish (i.e., distal goals), sanctions increase gradually and progressively in magnitude. For goals that are somewhat easier to achieve (i.e., proximal goals), higher magnitude sanctions may be administered after only a few infractions. Be sure participants understand the distal versus proximal goal designations. Clarify that proximal goal may not be easy, but are doable, even if challenging for participants.

Magnitude: Staying Centered Utilize Wide Array of Intermediate Magnitude Sanctions EFFECTIVENESS Habituation Effects Ceiling Effects Effective Zone Sanctions tend to be least effective at the lowest and highest magnitudes and most effective within the intermediate range. Sanctions that are too weak can precipitate habituation, in which the individual becomes accustomed, and thus less responsive, to punishment. Sanctions that are too harsh can lead to resentment, avoidance reactions, and ceiling effects, in which the team runs out of sanctions before treatment has had a chance to take effect. Practice Pointers Develop a wide and creative range of intermediate-magnitude rewards and sanctions that can be ratcheted upward or downward in response to participants’ behaviors. Avoid overreliance on sanctions that are low or high in magnitude. High LOW MODERATE MAGNITUDE OF SANCTION

Expectations Attend Distal Proximal Abstain Accept Admit Adhere Attempt Proximal Abstain Accept Adhere Distal This applies exclusively to high need individuals—i.e., those whose addiction severity and/or mental illness render some goals extremely difficult to consistently achieve in the early phases of the program. Behaviors that are proximal should be incentivized with low magnitude incentives and sanctioned with intermediate and high magnitude sanctions. Behaviors that are distal should be incentivized with higher magnitude incentives and sanctioned with lower magnitude sanctions until much later in program when treatment providers assess that participant has sufficient ability to maintain abstinence. These are examples—not and exhaustive list of all proximal and distal behaviors. Proximal: Attend (Show Up) = complying with program requirements to show up for treatment, testing, and court Admit (Tell Truth)= telling the truth regarding drug use and other matters. Self reporting use before testing positive. This is difficult for most addicted individuals, but is possible and should be expected from day one. (Normally you incentivize proximal behavior with lower lever incentives. However, self reported use may be incentivized during earlier phases with moderate magnitude responses, instead of low magnitude ones, because of its centrality to addiction recovery) Attempt (Make an Effort)= show evidence of trying to comply with requirements (including distal goals) Distal: Abstain= Consistently avoiding unauthorized alcohol and drug use Accept=Accepting reality that I have a substance use disorder/addiction or mental health disorder; commitment to lasting change; internal motivation Adhere: Those with mental health or co-occurring disorder may not be able to successfully manage their disorder 100% of the time, including fully adhering to their mental health medication regimens right away, until they gain more motivation, skill, and insight.

Infraction Response Magnitude Considerations in Responding to Participant Behavior 1)WHO are they in terms of risk and need? 2) WHERE are they in the program (i.e., what phase)? 3) WHICH behaviors are we responding to (i.e., are they proximal or distal)? 4) WHAT is the response choice magnitude? 5) HOW to deliver and explain the response? This applies exclusively to high need individuals—i.e., those whose addiction severity and/or mental illness render some goals extremely difficult to consistently achieve in the early phases of the program. Behaviors that are proximal should be incentivized with low magnitude incentives and sanctioned with intermediate and high magnitude sanctions. Behaviors that are distal should be incentivized with higher magnitude incentives and sanctioned with lower magnitude sanctions until much later in program when treatment providers assess that they have sufficient ability to maintain abstinence. Proximal: Adhere= adhering to program requirements to show up for treatment, testing, and court Admit= telling the truth regarding drug use and other matters. Self reporting use before testing positive. This is difficult for most addicted individuals, but is possible and should be expected from day one. (Self reported use may be incentivized during earlier phases with moderate magnitude responses, instead of low magnitude ones, because of its centrality to addiction recovery) Distal: Abstain= Consistently avoiding unauthorized alcohol and drug use Accept= Accepting presence of addiction; commitment to lasting change; internal motivation

Infraction Response Magnitude Intermediate and High Magnitude Sanctions Proximal Treatment Responses or Low Magnitude Sanctions Distal This applies exclusively to high need individuals—i.e., those whose addiction severity and/or mental illness render some goals extremely difficult to consistently achieve in the early phases of the program. Behaviors that are proximal should be incentivized with low magnitude incentives and sanctioned with intermediate and high magnitude sanctions. Behaviors that are distal should be incentivized with higher magnitude incentives and sanctioned with lower magnitude sanctions until much later in program when treatment providers assess that they have sufficient ability to maintain abstinence. Proximal: Adhere= adhering to program requirements to show up for treatment, testing, and court Admit= telling the truth regarding drug use and other matters. Self reporting use before testing positive. This is difficult for most addicted individuals, but is possible and should be expected from day one. (Self reported use may be incentivized during earlier phases with moderate magnitude responses, instead of low magnitude ones, because of its centrality to addiction recovery) Distal: Abstain= Consistently avoiding unauthorized alcohol and drug use Accept= Accepting presence of addiction; commitment to lasting change; internal motivation

Licit Addictive or Intoxicating Substances Sanction the unauthorized, non-medically indicated use of intoxicating and addictive substances even if legal. Use of potentially intoxicating or addicting medications should only be authorized if prescribed by a physician who concludes there are no safe and effective alternative treatments. Encourage participants to utilized physicians knowledgeable in addiction medicine. In order to determine if a physician has concluded that there are no safe and effective alternatives to an addicting medication, the program needs to have participant sign a release for a team member, preferably the treatment provider, to communicate with the physician. The team member must ensure that the physician is aware that the patient has a substance use disorder and is involved in treatment. The physician should be asked directly if there are alternative non-addictive medications that can be prescribed to address the medical issue. If the physician indicates that there are no alternatives, then the participant must be allowed to use the medication as prescribed and may not be sanctioned for such use.

Therapeutic Adjustments Recommended and delivered by treatment professionals. For the drug addicted individual, respond with adjustments to treatment requirements and sometimes with lower magnitude sanctions in response to unauthorized drug use in the early phases of program. Sanction participants who willfully fail to comply with treatment attendance and participation requirements. Do not give augmented sentences, or otherwise punish participants who have to be discharged because adequate treatment is not available and accessible to them. Applies to the high-need –i.e., addicted participant

Incentivizing Productivity Place as much emphasis on incentivizing productive behaviors as on responding to infractions. Criteria for phase progression and graduation should include evidence that participant is engaged in productive activities likely to support recovery and reduce recidivism.

Incentivizing Productivity Realistic & Achievable Desirable to Participant Tangible and Intangible Opportunity for Reward Incentives: Should be realistically achievable Should be desirable to participant, but not extravagant Should be tangible and intangible Can involve the mere opportunity for reward (fishbowl; even the opportunity for reward is reinforcing)

Incentives Magnitude Lower Proximal Higher Distal

Phase Promotion Predicated on achievement of defined behavioral objectives. Sanctions for infraction for behavior previously deemed to be distal may become more stringent. Incentives for positive behavior may decrease. Treatment, supervision, and court requirements may decrease. Drug testing frequency remains constant until the final phase and only after all other requirements have decreased and team determines that those reductions have not triggered relapse. Treatment decreases as participant progress in treatment only after it is determined clinically that such reductions will not lead to relapse. Such individuals are in stable short or long term recovery and are well-integrated into the larger, peer-directed recovery community.

Jail Sanctions Are imposed judiciously and sparingly. Are used only after numerous lesser sanctions have been attempted and failed, unless an immediate risk to public safety exists. Are definite in duration and typically last no more than 3 to 5 days. Participants have access to counsel and a hearing when facing jail.

Terminations Participants are terminated if they can no longer be managed safely in community; or if they repeatedly fail to comply with treatment or supervision requirements. Participants are not terminated for continued use if they are otherwise compliant with treatment and supervision. Participants terminated because adequate treatment is not available (through no fault of their own), do not receive augmented sentence or disposition for failing to complete program.

Consequences of Graduation & Termination Graduates avoid criminal record, avoid incarceration, or receive reduced sentence or disposition as an incentive for completion. Participants who are terminated unfavorably receive a sentence or disposition for the underlying offense. Participant and program outcomes are poor if minimal consequences are imposed for withdrawing from or failing to complete program. Participants are informed in advance of the circumstances which may lead to their receiving an augmented sentence for failing to complete Drug Court.

Examples of I/S www.NDCRC.org If internet connection is available, hyperlink is provided that links to the Incentives and Sanctions list on website. www.NDCRC.org

Standard 4: Incentives, Sanctions, and Therapeutic Adjustments Truth or Consequences Standard 4: Incentives, Sanctions, and Therapeutic Adjustments

Table Top Exercise: In Theaters Now or Coming Attractions?

Proximal or Distal Behavior? Target Behavior Phase 1 Proximal Distal Phase 4 Abstinence/clean drug tests    Attendance at treatment sessions (individual and group)  Attendance at court hearings   Candor with the court  Compliance with supervision check-in requirements  Compliance with drug testing reporting requirements  Involvement with peer support groups  Utilizing ancillary services or activities such as employment readiness, school, GED training, parenting classes as designated by the participant’s treatment plan  Positive participation and engagement in treatment (e.g. extra effort, positive attitude, etc.)   Proximal or Distal Behavior? Each team works together to determine answers as a group. This is not a group exericise. Don’t assume any facts not provided. Make decision based on the information provided Allow for discussion, once we reveal our recommended answers. Acknowledge that in the real world, there are other factors to consider and greater complexity in determining whether or not a behavior is proximal or distal. Phase is often a good indicator of what we can expect, but it is not the entire picture. Reference the list of questions on the back of the “Johari Window” laminated card to expound on some of the other factors that determine whether a behavior is proximal or distal.

The Answers

Table Top Exercise: Marty and Jane

Low, Medium, or High; and/or Treatment Response? Marty in Phase 1 Behavior for Marty Risk Level Need Level Phase Response Intensity High 1 Low, Medium, or High; and/or Treatment Response? 3rd positive drug Test 2nd Missed Group 1st clean drug test Week of perfect treatment attendance Each team works together to determine answers as a group. Based on provided risk level and phase information, decide on the appropriate level of response. Don’t assume any facts not provided. Make decision based on the information provided Allow for discussion, once we reveal our recommended answers. Acknowledge that in the real world, there are other factors to consider and greater complexity. Reference the list of questions on the back of the “Johari Window” laminated card to remind them of other questions that must be answered to determine appropriate response.

Low, Medium, or High; and/or Treatment Response? Marty in Phase 3 Behavior for Marty Risk Level Need Level Phase Response Intensity High 3 Low, Medium, or High; and/or Treatment Response? 3rd Positive Drug Test Absconded from Treatment Week of clean drug tests Got job Each team works together to determine answers as a group. Based on provided risk level and phase information, decide on the appropriate level of response. Don’t assume any facts not provided. Make decision based on the information provided Allow for discussion, once we reveal our recommended answers. Acknowledge that in the real world, there are other factors to consider and greater complexity. Reference the list of questions on the back of the “Johari Window” laminated card to remind them of other questions that must be answered to determine appropriate response.

Low, Medium, or High; and/or Treatment Response? Jane in Phase 1 Behavior for Jane Risk Level Need Level Phase Response Intensity High Low 1 Low, Medium, or High; and/or Treatment Response? 3rd Positive Drug Test 2nd Missed Court Hearing 1st clean drug test Month without curfew violation Each team works together to determine answers as a group. Based on provided risk level and phase information, decide on the appropriate level of response. Don’t assume any facts not provided. Make decision based on the information provided Allow for discussion, once we reveal our recommended answers. Acknowledge that in the real world, there are other factors to consider and greater complexity. Reference the list of questions on the back of the “Johari Window” laminated card to remind them of other questions that must be answered to determine appropriate response.

Low, Medium, or High; and/or Treatment Response? Jane in Phase 3 Behavior for Jane Risk Level Need Level Phase Response Intensity High Low 3 Low, Medium, or High; and/or Treatment Response? 3rd Positive Drug Test Failed persistently to enroll in mandated job training class Week of clean drug tests Got job Each team works together to determine answers as a group. Based on provided risk level and phase information, decide on the appropriate level of response. Don’t assume any facts not provided. Make decision based on the information provided Allow for discussion, once we reveal our recommended answers. Acknowledge that in the real world, there are other factors to consider and greater complexity. Reference the list of questions on the back of the “Johari Window” laminated card to remind them of other questions that must be answered to determine appropriate response.

The Answers