Behavior Modification and the Seriously Mentally Ill or Functionally Impaired: Special Issues to Consider

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1 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

2 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.

3 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.

4 Consistency, Notice and Fairness Consistent responses, but tailored to the individual Participants should know what to expect handbook Procedural Justice

5 Predictable and Attainable Goals What goals are we seeking? Proximal goals Distal goals Expectations should change over time

6 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

7 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.

8 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.

9 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.

10 #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

11 #9 continued Phases should reflect participants progress Public recognition of progress Number of available incentives should be as broad as sanctions

12 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)

13 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

14 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.

15 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.

16 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

17 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

18 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

19 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)

20 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.

21 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

22 Judicial Responses, continued Unannounced visits Loss of privileges (travel, curfew) Community service More restrictive pre-trial release status (electronic monitoring, etc.)

23 Judicial Responses, continued Bench warrant Jail remand Termination

24 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

25 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?

26 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.

27 Don t forget clinical responses to behavior NA/AA/Double Trouble Clubhouse, other peer support Treatment engagement groups (remand intervention) Hospitalization Voluntary Involuntary

28 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)

29 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?

30 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?

31 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.