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

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

3. 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)

4. 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.

5. The Response Categories
Sanctions
Therapeutic
Adjustments
Incentives

6. Two Ways to Reward, Punish, or Treat
Give
Take

7. Therapeutic Adjustments Sanctions Incentives
Enhancements
Reductions
Sanctions
Punishment
Response Cost
Incentives
Positive Reinforcement
Negative Reinforcement
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,)

8. 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.

9. 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.

10. 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.

11. 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.

12. www.ndcrc.org The Standard Search: Standards
Adult Drug Court Best Practice Standards Volume I:
Incentives, Sanctions, and Therapeutic Adjustments
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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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

20. 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.

21. 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

22. 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

23. 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.

24. 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

25. 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.

26. 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)

27. Incentives Magnitude
Lower
Proximal
Higher
Distal

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

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