Behavior Modification and the Seriously Mentally Ill or Functionally Impaired: Special Issues to Consider Hon. Peggy Fulton Hora (Ret.) NDCI Senior Judicial Fellow Hon. Christine Carpenter

The Basics of Incentives and Sanctions

We are trying to modify behavior. Rewards and Sanctions are both necessary for

better outcomes. Rewards increase desirable behavior. Sanctions reduce undesirable behavior.

Certainty and Immediacy Certainty is the most effective response. Threats do not work. Certainty should be applied in response to

reliable reporting. The closer in time the response to the

behavior, the more effective it can be. Certainty and Immediacy are more important

than magnitude.

Consistency, Notice and Fairness

Consistent responses, but tailored to the individual

Participants should know what to expect – handbook

Procedural Justice

Predictable and Attainable Goals

What goals are we seeking? Proximal goals Distal goals Expectations should change over time

Graduated Incentives and Sanctions Proximal goals – lower magnitude reward,

higher magnitude sanction. Distal goals – lower magnitude sanction,

higher magnitude reward. Too low – habituation Too high – ceiling effect

Summary

Responses to behavior should be consistent with the supervision requirements and treatment plan and reflect both short and long term objectives for each participant.

Terminology Old MHC language: Incentives and Sanctions,

Compliance New MHC language: alliance, motivation and

engagement Ongoing judicial monitoring/relationship to

motivate engagement in treatment, pro-social activities and civil society.

The Essential Elements of a Mental Health Court

Essential Element #9 Individualized, graduated incentives and

sanctions and treatment modifications to promote public safety and participants’ recovery.

#9 continued

Imposed “with great care” and with input from mental health professionals

Develop specific protocols for jail as a sanction

Ad hoc praise and rewards are helpful and important incentives

#9 continued

Phases should reflect participants’ progress Public recognition of progress Number of available incentives should be as

broad as sanctions

Judicial Monitoring Vital Role Role more subtle and nuanced than other

treatment courts Informed listening Engagement is key

“The Role of the Judge in Treatment Monitoring”, JLI Newsletter 2:1 (2006)

Motivating Engagement Seriously mentally ill participants often have

impoverished lives and few successes to celebrate.

Celebrate accomplishments; avoid more failure

Coordinate judicial and clinical responses Don’t confuse treatment and services with

rewards and punishment

Motivating Engagement Phases are not as rigidly defined as other

treatment courts. Responses to behavior should be more

flexible with this population. Be aware that effects of psychotropic medications, symptoms of withdrawal, symptoms of mental illness, changes or problems with housing, family or treatment may all contribute to failure to comply with court requirements.

Motivating Engagement Your reward = my punishment! Be supportive rather than confrontational. Articulate: If you change this (fill in the

blank), this (fill in the blank) will happen”. Link volunteer work with something client

like to do (work with animals, etc.) Frequent court appearances at regular

intervals also establish structure and routine.

Motivating Engagement More frequent court appearances for this

population will ensure the response is close in time to the behavior which establishes a clear connection between the behavior and the response

Lots more carrots than sticks Engagement strategies will reflect the style of

the Judge and the court team

Judicial Responses to Engagement and Progress

Recognition: praise, honor roll, applause,

showcase talent (art work, music) Less frequent appointments with court staff Status hearings: priority in order or

appearance or seating Certificates for phase completion

Judicial Responses, continued Presents, gift certificates Participation in court sponsored events Less restrictive pre-trial release conditions Less frequent drug testing Granting privileges (travel, later curfew) Charge reduction/dismissal

Incentives promote abstinence Addiction changes the brain in ways that

make individuals more responsive to short term rewards and less able to forego them in the interest of longer term benefits.

Incentives weaken over time but can show benefits for 1-2 years.

Volkow, Nora D., M.D., “Incentives Promote Abstinence”, NIDA Notes 23:3 (2011)

Abstinence Expectations of sustained abstinence may

need to be amended to more realistic goals. Graduated responses should be flexibly

applied after considering effect of mental illness on ability to achieve sustained abstinence.

Caveat: Being mentally ill does not mean participants should not be held accountable for behavior and choices.

Judicial Responses to Non-Adherence and Non-Engagement Reprimand, disapproval More frequent appointments with court staff More frequent status hearings Penalty box Writing assignments Workbook assignments

Judicial Responses, continued

Unannounced visits Loss of privileges (travel, curfew) Community service More restrictive pre-trial release status

(electronic monitoring, etc.)

Judicial Responses, continued

Bench warrant Jail remand Termination

Jail considerations Use jail sparingly so medication regimes are

not compromised. Possible loss of SSI or other benefits Length of time in custody Strip search Segregation Victimization Look for creative alternative to jail

Strategies to consider Behavior is tied to people, places and things. Those are what need to change. How can we make this population see the

connection between needed behavior change and the choices of people, places and things?

Include the Team Develop responses to behavior with the team

and realize the relationship between the participant and their probation officer or case manager and treatment providers is different from the relationship with the Court. The Court ultimately has the control and responsibility to create boundaries and mandate compliance. Blend care with control.

Don’t forget clinical responses to behavior NA/AA/Double Trouble Clubhouse, other peer support Treatment engagement groups (remand

intervention) Hospitalization Voluntary Involuntary

Clinical responses, continued Detox/drug rehabilitation facility Transfer to different provider, same service

but better fit Transfer to more or less restrictive housing or

treatment program Other groups (MRT, money management,

anger management, family counseling, parenting classes)

Food for thought Can we expect behavior modification to help

achieve desired outcomes? What else needs to happen to help achieve

desired outcomes? How appropriate is it to use incentives and

sanctions to motivate treatment compliance when available treatment may not be effective?

More Food What treatment and services should severely

mentally ill participants be receiving? Is there “criminal justice informed treatment”

available? What is the appropriate judicial response to

non-engagement in treatment, but no further criminal behavior?

In Closing Balance public safety with therapeutic

response to encourage recovery and rehabilitation

Delivery of the response is as important as the response. An explanation of the response may help create an atmosphere of fairness, which may lead to better future compliance.