Based on a Need to Know Fact Sheet by Doug Marlowe, J.D. Ph.D./NDCI Incentives and Sanctions: Practical Application of the Science of Behavior Change Shannon M. Carey, Ph.D. Based on a Need to Know Fact Sheet by Doug Marlowe, J.D. Ph.D./NDCI

Purpose What is the purpose of Sanctions? What is the purpose of Incentives? What other court responses are there?

Overview Brief review of the science of behavior change Research on application in drug courts Sample incentives, sanctions and treatment responses (guidelines) Implementing incentives and sanctions (Review and discuss videos)

Certainty 1:1 Schedule for initiation Reliable detection “Trust but verify”

*Or use continuous detection methods Reliable detection Urine drug testing at least twice per week* Do not decrease frequency of testing until last phase Do tests with short detection windows in field Random testing all 7 days Extend supervision into natural social environment (work, home, school, street, cell phones) Include law enforcement on the team *Or use continuous detection methods

Reliable detection Cell Phone Transcript from Phone during Court Session - 1 SF B Chic Nov 18 3:29pm R u getting anything in la?   SF B Chic Nov 18 3:35pm Can we go in on the deal. If I got 4 would u get 2 so we could do the 540 SF B Chich Nov 18 3:45pm Toats

Reliable detection Cell Phone Transcript from Phone during Court Session - 2 ?? Nov 18 6:47pm If you need a source for tina Hit up 714-647-0410 Tell them dan sent ya..Good stuff…  AM Nov 18 6:48pm How lomng doles xaanax stay in system  ?? Nov 18 6:48pm 72hrs to a week   AM Nov 18 6:49pm anyway to clear em out  ?? Nov 18 6:49pm Do you ever get swabbed!!!???????  AM Nov 18 6:50pm Occasionally ans I no it doesn’t test for that  ?? Nov 18 6:50pm Well if ur dirty dirty.. Always check urself into the ER for a panic attack or something.. do that day of probation..Walk outta there with a hospital/dr ltr  

Reliable detection Participant in his outpatient substance abuse group  AM Nov 18 6:22pm Plzbring tibaasement pLII  AM Nov 18 6:23pm Theyre randomly testing me tnite  AM Nov 18 6:25pm IM in grop  AM Nov 18 6:27pm Plese bring to basement bathroom  AM Nov 18 6:27pm Plzzzzzzzzzzzzz  S Nov 18 6:29pm Ok  AM Nov 18 6:29pmHit me up when ur down there ill walk out  AM Nov 18 6:30pm How long bro  S Nov 18 6:30pm Like 20  AM Nov 18 6:34pm Im in the bathroom in the basement plz hurry im trippin out  S Nov 18 6:35pm Leavin hollies rite now  AM Nov 18 6:36pm Shit whats ur eta from there

Reliable detection Participant in his outpatient substance abuse group (cont)  S Nov 18 6:37pm 15  S Nov 18 6:38pm Shuld I wait in basement bathroom  AM Nov 18 6:38pm Plz tell me u gotta vial to pissi in S Nov 18 6:38pm Ya  AM Nov 18 6:42pm Put the vial of piss in bathrroom trashcan  AM Nov 18 6:42pm I gotta go bak to geoup9 hit me up when its dun  S Nov 18 6:54pm Its in the trash

Timing is Everything

Timing is Everything Effects degrade exponentially New behaviors interfere Status hearings every two weeks the first few months Bring non compliant participants in sooner Catch them doing something right, provide incentive sooner Continue hearings monthly until participants have engaged in continuing/after care plans

Keep Centered EFFECTIVENESS Habituation Effects Effective Zone Ceiling SEVERE MINIMAL MODERATE

Keep Centered NDCI Handout http://ndcrc.org/content/list-incentives-and-sanctions

(Procedural Fairness) Do Due Process (Procedural Fairness) Allow participants to explain Explain judge/team decision Be respectful (and expect respect) Have written incentive/sanction guidelines Allow reasonable discretion The brain and decisions about punishment

Sanctions or Treatment Responses? Abuse or dependence (mild, moderate or severe substance use disorder)? Proximal or distal behaviors

Abstinence is a distal goal Needs Substance Dependence or Addiction Binge pattern Cravings or compulsions Withdrawal symptoms Abstinence is a distal goal }

Abstinence is a distal goal Needs Substance Dependence or Addiction Binge pattern Cravings or compulsions Withdrawal symptoms Substance Abuse Abstinence is a distal goal }

Abstinence is a distal goal Abstinence is a proximal goal Needs Substance Dependence or Addiction Binge pattern Cravings or compulsions Withdrawal symptoms Substance Abuse 1. Still enjoyable 2. No Cravings or compulsions 3. No withdrawal symptoms Abstinence is a distal goal Abstinence is a proximal goal } }

Abstinence is a distal goal Abstinence is a proximal goal Needs Substance Dependence or Addiction Binge pattern Cravings or compulsions Withdrawal symptoms Substance Abuse Collateral needs Dual diagnosis Chronic medical condition (e.g., HIV+, HCV, diabetes) Homelessness, chronic unemployment Abstinence is a distal goal Abstinence is a proximal goal } }

} } } Needs Collateral needs Substance Dependence or Addiction Binge pattern Cravings or compulsions Withdrawal symptoms Substance Abuse Collateral needs Dual diagnosis Chronic medical condition (e.g., HIV+, HCV, diabetes) Homelessness, chronic unemployment Abstinence is a distal goal Abstinence is a proximal goal } Regimen compliance is proximal } }

Sanctions or Treatment Responses? Abuse or dependence (mild, moderate or severe substance use disorder)? Proximal or distal behaviors Dependent: Expectations change over time (Phases) Abuser: Higher level sanctions sooner Separate status hearings Rely on clinical expertise

Targeting

Targeting Define behavior clearly (both bad and good) Point direction (describe positive behavior you are looking for) Target the behavior not the person (be respectful)

Targeting Don’t expect too much Don’t expect too little Learned helplessness and ratio burden Don’t expect too little Habituation Proximal vs. distal goals Phase specificity What was once distal becomes proximal

Phase Regression An example of response cost Often a sign that services were withdrawn prematurely Temporary regression and remedial plan (accelerated redemption) Avoid the Abstinence Violation Effect (A.V.E.)

Remember that unaddressed co-occurring disorders may impede the client’s ability to achieve abstinence

Incentive and Sanction Highlights Verbal acknowledgement The A Team (being called early/being on the A team) Fish bowl (having your name in the bowl is a reward) Being chosen as a mentor

Incentive and Sanction Highlights A Team Video

Decision Dollars $ $

Incentive and Sanction Highlights Thought Paper or Recording Community Service (giving back meaningfully) Curfew Jury Box Jail

Courts that use jail greater than 6 days have worse (higher) recidivism

Incentive and Sanction Highlights For some, incarceration is NOT the worst punishment – (for some it is trauma) The threat of jail works best on those who have something to lose by incarceration. Positive reinforcement works on those who have nothing to lose by incarceration. Treatment responses may be perceived as punishments-communication is the key to explaining the difference.

Incentive and Sanction Highlights FOCUS ON THE POSITIVE BEHAVIOR People need to know what positive behaviors are - before they can perform them They know what not to do, they need to know what to do instead Bring up the participants doing well first (the A team), and ask them what they are doing that helps them succeed. (This will have the most positive impact on those watching).

Incentive and Sanction Highlights Video 1: Highlighting the positive Video 2: The A Team Videos 3a-3d: Positive UA with jail sanction Video 4: Learning experience with thought paper

Incentive and Sanction Highlights During video, think about whether the judge: Is Respectful Allows the participant to explain Provides a clear explanation of behavior being sanctioned Provides a clear explanation of what to do instead Provides a learning experience for other participants

Sample Incentive and Sanction Schedules http://ndcrc.org/content/list-incentives-and-sanctions http://ndcrc.org/content/incentives-and-sanctions-fact-sheet-0 Other good info on incentives and sanctions: www.drugcourtonline.org

Sample Incentive and Sanction Schedules Washington D.C. Merced, CA Kansas NDCI

Sanction Exercise Behavior First 30 days Question T2: John Abuser T1: Allen Addict Positive for cocaine Proximal or Distal? Sanction low, middle or high? Missed Treatment Session Missed Court Session P D M/H L P P M M P P M M

Incentives Exercise Behavior After 180 days Question T2: John Abuser T1: Allen Addict Negative drug tests for last 30 days Proximal or Distal? Incentive low, middle or high? Made all Treatment Session on time for last 60 days P P M H P P M M

“All Behavior is followed by a consequence, and the nature of that consequence modifies the organisms tendency to repeat the behavior in the future” B.F. Skinner

Patience: we are in this for the long haul. 15 months post abstinence Normal methamphetamine addict 15 months post abstinence

Readings Burdon WM et al (2001). Drug courts and contingency management. Journal of Drug Issues, 31, 73-90. Harrell A & Roman J (2001). Reducing drug use and crime among offenders: The impact of graduated sanctions. Journal of Drug Issues, 31, 207-232. Marlowe DB (2007). Strategies for administering rewards and sanctions. In JE Lessenger & GF Roper (Eds.), Drug courts: A new approach to treatment and rehabilitation (pp. 317-336). New York: Springer. Marlowe DB (2008). Application of sanctions. In Drug Court Quality Improvement Monograph. Alexandria, VA: NDCI. Marlowe DB & Wong CJ (2008). Contingency management in adult criminal drug courts (pp. 334-354). In ST Higgins, K Silverman & SH Heil (Eds.), Contingency management in substance abuse treatment. New York: Guilford. Marlowe DB (2011). Applying incentives and sanctions. In The drug court judicial benchbook (pp.139-157). Alexandria, VA: NDCI.