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Behavior Modification

Effective Engagement and ResponsesHelen Harberts

Chico CA

helenharberts@gmail.com

Disclosure

• This project was supported by Grant No. 2016-DC-BX-K007 awarded by the Bureau of Justice Assistance. The Bureau of Justice Assistance is a component of the Department of Justice’s Office of Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, the Office for Victims of Crime, and the SMART Office.

• Points of views or opinions in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice.

Consider these facts:

• Helen is driving her car, loses control and slides off the road, hitting a tree. She is impaired by drugs and alcohol.

• Should she be punished?

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Now consider these facts:

• Helen is driving her car, loses control and slides off the road, hitting a tree. She is impaired by drugs and alcohol. Sadly, a small child was near the tree on a tricycle and was killed.

• Should Helen be punished?

•STOP: is there a difference in how you feel when you consider this?

When examined on a brain scan, the answers to these questions varied.

•Decisions on the first scenario: frontal lobe

•Decisions on the second: limbic region.

DON’T DO THIS with responses to behavior. Use research-based principles.

Decisions with the correct region!

Yes! Reason, information

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Team members are human too!

• It is sometimes difficult to stay calm in the storm that is the lives of participants.

• They frustrate us.

• They break our hearts

• They anger us.

• They do dangerous things.

• They go backward, rather than forward.

• They lie.

• They die….and scare us for future decisions.

The ResearchThe baseline of responses to behavior we seek to encourage and discourage.

Why do this strange stuff in Court?

Length of time in treatment is the key. The longer a patient stays in treatment at the correct level of care: the better they do. Coerced patients stay longer.

The purpose of sanctions and incentives is to keep participants engaged in treatment.

Q: What is the problem?

A: Severe SUD, Criminal thinking.

Q: What’s the solution?

A: Treatment!

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The enemy is a difficult opponent

The Basics

The Standard

Adult Drug Court Best Practice Standards Volume I:

Incentives, Sanctions, and Therapeutic Adjustments

www.ndci.orgSearch: Standards

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Essential Elements:

• Certainty and Consistent response.

• Reliable detection of good and bad behavior

• Response associated with the detected behavior.

• Immediacy of response.

Excellent materials to improve your practice!

• Webinar Archives-brown bag lunch

• Judicial Benchbook

• www.treatmentcourts.org

• Materials on the internet with examples

• Single focus trainings.

Punishment is NOT the goal in the Imposition of Sanctions

Changing behavior is the goal.

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Basics of behavior modification:

• Certainty of detection

• Immediacy of detection.

• Detection of desired behavior and reinforcing that is more important in the long run than detecting undesired behavior. Teaching folks WHAT to do is more important…and incentives work better than sanctions in changing behavior.

Consistent Detection(Behavior and Immediate Consequence)

Reliable detection

(Detection allows the gathering of information needed by judge and team to determine appropriate response)

Immediacy of response:

Speeding ex.

Certainty and Immediacy of response!

Supervision

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How do we apply these concepts?

*certainty, swiftness, severity

*positive reinforcement (providing an incentive) & negative reinforcements (removing a sanction)

*proximal & distal behaviors

*punishment teaches what NOT to do & incentives teach WHAT to do.

Question: Which is more effective with our target population: punishment or incentives?

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Essential Elements:

• What about a sanction is more important in shaping behavior: certainty or severity?

• What about severity vs. immediacy?

• And what does this mean to you about delaying responses?

• Giving a second chance with a warning is ineffective!

• Perception of fairness is also a key factor!• Punish the act, not the individual-avoid defiance

• Be fair and appear fair-both are required.

Drug Dependence or Addiction Moderate to Severe SUD

1. Binge pattern2. Cravings or compulsions3. Withdrawal symptoms

Drug Abuse or Misuse Low to moderate SUD

Collateral needs

Co-occurring diagnosisMaslow’s Hierarchy of needs!Homelessness, chronic unemployment Chronic medical condition (e.g., HIV+, HCV, diabetes)

}Abstinence is a distal goal

Abstinence is a proximal goal}Regimen

compliance is proximal

Addicts versus Abusers…Proximal and Distal Goals are not the same!

ALWAYS consider the diagnosis! Individualized case plans and management is the rule

Huh? Proximal? Distal?

NOW LATERLATER

• Show up• Try hard• Tell the truth

• Abstain from use• Accept disease• Work program

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For every participant action: please consider the full menu of responses- do a checklist or follow the chart of responses.

Each type of response-every time

by every relevant team member.

3-4 types of responses:

(1) Incentives (positive and negative reinforcement)

(2) Sanctions (punishment or response cost)

(3) Therapeutic and detection responses(a)Treatment responses (determined and delivered by treatment)(b) Supervision responses- more or less detection and support

Understand: this is about them, not you.

Responses are in the eyes of the behaver

What changes your behavior will not work on them!

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JAIL doesn’t change behavior like you hope it does. Indeed, it can make it worse.

• For some, incarceration is NOT the worst punishment• Punishment works best on those who have something to lose by

incarceration.

• Positive reinforcement works on those who have nothing to lose by incarceration.

• Sanctions may be perceived as punishments-communication is the key to explaining the difference.

• The Judge explains, the team repeats and supports!

Responses must be of sufficient intensity

• Too low: no impact

• Too high: damaging

Responses should be delivered immediately

Your team must be able to respond quickly with intermediate responses as needed.

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Undesirable behavior must be reliably

detected

•Abstinence must be reliably detected and a response given. BOTH good and bad.

•Failure to detect puts clients on an intermittent schedule of rewards and sanctions. Sharply less effective.• Consider drug testing and community supervision in

this context.• Consider attorney delays in this context

•Timing is everything-delay is the enemy-how can you as a team work on this issue? As an individual?

• Intervening behaviors may mix up the message.

•Brain research supports behavioral observation-dopamine reward system responds better to immediacy.

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Responses should be delivered for every target behavior.

COUNT the incentives.

Responses must be predictable and controllable

•Written agreements and contracts work.

•Client handbooks work

•Stay within ranges of responses but provide notice of the range with ability to override.

•Certainty of consequence has deterrent effect.

•Learned helplessness can occur when target behaviors are not clear.

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Responses may have unintentional side effects

•Too excessive a punishment, or an inappropriate punishment may cause learned helplessness.• Avoidance, fear, anger, resistance, escape

•Positive reinforcements can have negative consequences if perceived as undeserved.

• Frequency of contact with a Judge needs to be matched with the offender’s needs. High-end need more, low end need less.

• Research: See Judge every two weeks or more at first, never more than a month for HR/HN.

Best intrinsic motivator: praise. There appears to be no ceiling as long as it is sincere.

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Behavior does not change by punishment alone-that is why

our jails are full

-5%-15% -12%

44%37%

142%

1 day 2 days 3-6 days 1 week 2 weeks > 2 weeks

% In

crea

se in

Rec

idiv

ism

Typical # of Consecutive Days in Jail as a Sanction

Courts that typically impose jail longer than 6 days have higher recidivism

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Jail Considerations• Is the behavior dangerous to others? (Or impact the

safety and integrity of the court?)

• What behavior do you want to stop? What is the intended impact of jail?

• What will the impact of jail be on others (employer, family, etc.)?

• What behavior do you want the participant to do instead?

• Are there other responses that might incentivize them to do the behavior you want them to do instead?

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Jail Considerations• Is the behavior dangerous to others? (Or impact the

safety and integrity of the court?)

• What behavior do you want to stop? What is the intended impact of jail?

• What will the impact of jail be on others (employer, family, etc.)?

• What behavior do you want the participant to do instead?

• Are there other responses that might incentivize them to do the behavior you want them to do instead?

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What else do you have?

Day Reporting Center

Daily drug testing

PBTS Patches

Daily check-ins

Probation Court Treatment

Alternatives to Jail

• Increase supervision• House arrest/GPS

• Increase supervision appointments

• Increased home visits

• Increase court hearings

• Curfew

• Other options (Focus on Learning)

• Community service

• Attend/watch court

• Thought papers

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– Homework/Practice

– Volunteering

– Cost/Benefit

– Behavior Chain

May need to

develop new

resources for

some

alternatives

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Alternatives to JailTherapeutic perspective (Physical and Mental/SUD Health)

• Conduct a medical assessment (health issues) – Our participants are ill with a disease that often leads to criminal behavior

• Include history of medication use

• Assess for medication assisted treatment (MAT)• Work with medical and treatment community• Prescribers• Treatment Providers • Know what’s available in your community and state• Education for the team – take NDCI’s online MAT course –

• Get them into pain management• Meditation, yoga, physical therapy, acupuncture

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May need to

develop new

resources for

some

alternatives

Alternatives to Jail

• Review level of SUD/MH care

• Enhance alliance with treatment and case manager/supervision

• Work with participant to discuss what treatment they will follow

through with

• Work with participant on integrated case plan

• Spend more time with peer support (peer mentor, peer specialist)

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May need to

develop new

resources for

some

alternatives

Therapeutic perspective (Physical and Mental/SUD Health)

•Reinforcement works better in the long run than punishment….(and we’re in this race for the long run.)

•Effects of punishment are temporary, behavior returns when punishment possibility is gone.

•Punishment is MOST effective when used in combination with other behavior modification techniques such as positive reinforcement.

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How the heck do teams do this?

• There is comprehensive training available for day long team training.

• It takes time and significant practice to change OUR behaviors too.

• You need to re-think what you do and focus on changing your routines and your thinking.

• They didn’t train us to do this strange stuff, and it isn’t automatic!

News Flash!Change sucks!

STAFFINGWhere the magic is created.

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Staffing 101

• Get your business done first-BEFORE you enter the staffing session

• Unless you are delivering very late breaking details, there should be no question about facts during staffing.

• Your discussions should be focused on responses to behavior and fine tuning the responses.

• Understand your role, and that of your team members

The Bench

• Cannot delegate decisions

• Should be the predominant voice in the room in Court.

• Should spend three minutes with each person…good or bad.

• Should focus on teachable moments.

• MUST HAVE GOOD INFORMATION

Attorneys• Lawyers are there for legal reasons. Protect the record. Protect the

Constitution. Motivate positively.

• Prosecutor’s are there to assert public safety concerns (with probation, Court and LE)

Share new criminal activity, or old activity just coming in

Associates

Share public safety perspective

• Defense attorneys are there to monitor and ensure due process and may have the hardest job

Share any legal complications

Must negotiate difficult ethical issues

Has a duty to the client that is different than all others

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Attorneys

• Prep for the Staffing! Reports matter

• Work together to address legal issues up front

Counsel’s job is to make the law meet the needs of the treatment team.

Supervision and Case Management • Is responsible for knowing what is happening outside the court and

treatment arenas.

• Home visits are paramount

• Report to team on

Assessments,

Testing results, and working with treatment

Information from case management

• Is in constant communication with treatment

Get your work done up front, meet with treatment, and form consensus, distribute information for rest of team in advance

Treatment• At a minimum, the following data elements should be shared:

Assessment results pertaining to a participant’s eligibility for Drug Court and treatment and supervision needs (Provide a diagnosis)

Attendance at scheduled appointments

Drug and alcohol test results, including efforts to defraud or invalidate said tests

Case management/treatment plan and attainment of goals, such as completion of a required counseling regimen

Homework assignments completed or currently working on

Current level in treatment (and what they need to do to move forward)

Any barriers to progress

Evidence of symptom resolution, such as reductions in drug cravings or withdrawal symptoms

Evidence of treatment-related attitudinal improvements, such as increased insight or motivation for

change

Adherence to legally prescribed and authorized medically assisted treatments

Procurement of unauthorized prescriptions for addictive or intoxicating medications

Menacing, threatening, or disruptive behavior directed at staff members, participants or other persons

• Must follow confidentiality standards (see NADCP’s BP standards for more info), but provide sufficient information to help with the message.

Get your work done up front, meet with supervision and form consensus, distribute information for rest of team in advance

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• The people who are doing direct services are the ones who know what is going on. Their recommendations are paramount.

Unless public safety or due process is compromised, follow their lead.

• If you can live with the consensus, do so.

• Fighting does not occur in open court.

• The worst possible thing? The team is wrong and in two weeks, you can fix it.

When making decisions: consider team dynamics!• Who has the power in the staffing?

• Who has the information in the staffing?

• Who has the DIRECT information in the staffing?

• Who should you be listening to about treatment?

• Who should you be listening to about supervision?

• Who should you be listening to about the law? • Should the lawyers be recommending treatment? Generally…no.

Use Progressive Sanctions and Incentives.

• Use a range of responses that vary in magnitude

• If the task is easy to accomplish, high magnitude sanctions, low magnitude incentives

• If the task is difficult for them: (distal) high magnitude incentives, low magnitude sanctions.

• This relates to who, where, what….

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Checklist for staffing and responses:

1. WHO are they? (risk and need)

2. WHERE are they in the program?

3. WHICH behaviors are we responding to? Are they proximal or distal?

4. WHAT is the response choice magnitude?

5. HOW do we deliver the response and explain it?

6. Is there also a TREATMENT response?

7. Is there a SUPERVISION response?

2. Antisocial Attitudes3. Peer Associations4. Antisocial Personality5. School/Employment6. Substance Abuse7. Living Situation8. Family/Marital

Central 8 Risk Factors

Clients have a variety of Criminogenic needs:

• Subset of risk factors• Dynamic, live and

changeable

Adapted from Iowa DOC training materials 59

1. History of antisocial behavior (Criminal History)

Important, but STATIC

DYNAMICCriminogenic

Needs

What to focus onS

Dynamic Risk Factor (Central 8)

History of antisocial behavior (Criminal History)

Antisocial personality pattern(Check trauma history)

Antisocial cognition

Antisocial associates

Family and/or marital discord

Poor school and/or work performance

Poor living situation

Substance abuse 60

Addressing Risk Factors (Need) in staffing and courtSource: Andrews (2006)

Dynamic risk factors are Criminogenic Needs that can change!

Need/Case management/Services

Build and practice positive/healthy behaviors by addressing the dynamic risk/needs below

Learn problem solving skills, practice anger management

Develop more pro-social thinking

Reduce association with criminal others (learn refusal skills)/increase association with positive peers

Reduce conflict, build positive relationships

Work on good employee/study/performance skills

Find appropriate housing

Reduce use through integrated treatment

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Staffing: Crafting Responses

Understand: this is about them, not you.

Responses are in the eyes of the behaver, not you.

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Model Response Matrix and Checklist

• Email for copy of this is Microsoft Word.

Inappropriate Behavior

Sanction Matrix: “What do we want the participant to learn from this?”

Step 1. Identify the Behavior

Low (Less Immediate) Moderate High (More Immediate) Very High

Late for Scheduled Event

Missed payment

Missed UA Failure to Complete

Assignments

Unexcused Absence tx Alcohol Use Drug Use Tamper w/ UA or device Dishonesty

Criminal behavior (new crimes, drinking and driving)

Arrest

Step 2. Determine the Response Level Low Moderate High Very High

Distal

Prox

Phase 1 Level 1 Level 2 Level 2 Level 4

Phase 2 Level 1 Level 2 Level 3 Level 4

Phase 3 Level 2 Level 3 Level 4 Level 5

Phase 4 Level 3 Level 4 Level 5 Level 5

Phase 5 Level 3 Level 4 Level 5 Level 5

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Step 3. Choose the Responses (paired with Judicial Verbal Disapproval and Explanation)

3a. Sanction/Punishment Responses Level 1 Level 2 Level 3 Level 4 Level 5

Community Service

≤ 4 hrs ≤ 8 hrs ≤ 16 hrs ≤ 24 hrs ≤ 32 hrs

Curfew ≤ 3 days ≤ 5 days ≤ 7 days ≤ 10 days ≤ 15 days

House Arrest ≤ 24 hrs ≤ 72 hrs ≤ 5 days ≤ 7 days ≤ 15 days

Jail ≤ 24 hours ≤ 3 days ≤ 7 days

Other Review Placement

Termination

3b. Therapeutic Responses Level 1 Level 2 Level 3 Level 4 Level 5

Behavior Chain Cost/Benefit Analysis Skill Development Thought Restructuring Homework/Practice Thinking Report

Level 1 plus: LOC Review

Level 1, 2, plus: Referral Medication

Eval Treatment Team

Review/Round Table

Level 1, 2, 3, plus: Re-Assessment

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3c. Supervision Responses Level 1 Level 2 Level 3 Level 4 Level 5

≤ 1 additional report days/week

Official Letter in File

≤ 2 additional report days/week

Home Visit Curfew

Continuous Testing GPS/Electronic

Monitoring ≤ 3 additional report

days/week Home Visit Increase frequency UA

Test Contingency Contract Additional Court Report Case Conference

≤ 4 additional report days/week

Contingency Contract Electronic Monitor

Device Case Conference Curfew

Positive Behavior

Incentive Matrix: “What do we want the participant to learn from this?” Step 1. Identify the Behavior

Easier/Proximal Moderate Difficult/Distal

Attendance at treatment

Attendance at other appointments

Home for home visits

Report to UA

Timeliness

Payment

Honesty

Testing Negative

Participating in Prosocial Activities

Employment

Progress toward Tx Goals

Progress in Tx

Complete Tx LOC

Extended Abstinence/Neg. Tests

Treatment Goals Completed

Phase Goals Completed

Program Goals Completed

Step 2. Determine the Response Level Easier/Proximal Moderate Difficult/Distal

Distal

Prox

Phase 1 Small Medium Large

Phase 2 Small Medium Large

Phase 3 Small Large

Phase 4 Small Large

Phase 5 Small Medium

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Step 3. Choose the Responses (Paired with Judicial Approval/Verbal Praise)

3a. Incentive Response Small Medium Large

Fish Bowl

Decision Dollars

Example for other participants in

court

Handshake

Candy

≤ 1 day reduction of curfew

Any small and/or:

≤ 3 day reduction of curfew

Choice of Gift Certificate

Supervisor Praise

Written Praise

Positive Peer Board

Certificate

Reduction in CS hours

Reduction in program fees

Any small, medium or:

Framed Certificate

Travel Pass

Larger Gift Certificate

Position as Mentor to New

Participants

Reduction of Curfew

3b. Therapeutic Response Phase 1 Phase 2 Phase 3 Phase 4

Single Event

Behavior Chain Cost/Benefit

Analysis

Behavior Chain Cost/Benefit

Analysis

Behavior Chain Behavior Chain

Continued Progress

Change in LOC Aftercare Fqcy Re-evaluate

Pharmacological Interventions

Aftercare Fqcy Re-evaluate

Pharmacological Interventions

3c. Supervision Responses

Phase 1 Phase 2 Phase 3 Phase 4

Change in Curfew Status

Reduced Contacts Reduction in Home

Visits

Reduced Contacts Reduce Home Visits Reduce in External

Monitoring Devices

Reduced Contacts Decreased Drug

Testing

Step 3. Choose the Responses (Paired with Judicial Approval/Verbal Praise)

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The CourtWhere the work of staffing and case work creates the magic of change.

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The team is made up of scary folks, in a scary situation. NEVER forget how scary you are.

• Develop trust with the Court and team

• Develop rapport with the participant

• Develop a sense of safety with the team.

• Use respect, patience, and positive regard for these folks.

• Meet them where they are…NOT where you are.

• Instill hope. Focus on hope. Be kind.

Tone matters

• No “Judge Judy”

• No snarky comments

• No shaming or attacking

• Respectful, firm, clear, but not harmful

Your face matters

• Watch for “leaking” body language

• Listen for the positive

• Watch your own patterns of thinking –including labelling

“Druggie, dopehead, perp, offender”

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“This person is ill and is a human being.”

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Remember: the person in front of you is not the enemy: the disease is

• We know from research that the addict will choose immediate rewards over long term goals. They are prone to poor decision making.

• We need to catch and redirect undesired behavior, and we need to detect desired behavior and reward, reward, reward…to teach what they should be doing.

• This target shifts over time for them, and for us, requiring the ultimate in competence and proficiency.

• Perceived unfairness=defiance. Need to articulate differences between sanctions and the team must reinforce.

• Communication & empathy crucial

• Utilize motivational interviewing.

• The power of a smile from a Judge or authority figure has more power than we think…..

Have your heard folks get fixated on “fair”?

• In staffing?

• In group?

• In individual sessions?

• In the Hallway?

We have the solution for you!

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Fair doesn’t mean the same.P

Fair

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Do prizes change behavior?

• Tangible rewards only???• Most valuable rewards you’ve heard of?

• The power of immediate and consistent praise that is deserved is immense.

• Target behaviors?• What is a target behavior in the first 30 days….60…year….

• Are the target behaviors tied to assessments and the case plan? Who knows what the targets are? How many at a time?

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How to execute in Court or field?

• Examples of skill steps from other courts

• Examples of motivators.

Skill Steps to Effective Reinforcement

• Identify behavior to be reinforced.

• Immediately tell person WHAT behavior you liked.

• Tell the person WHY you liked it.

• Discuss short and long term benefits of the behavior? (Goals?)

• Consider pairing the approval with an incentive.

Template• I really liked how you showed up on time for your

OV because it shows me you are considerate and responsible.

• Right now, how do you think this behavior has or will help you?

• Can you see where it might have any long-term benefits for you?*

• I’m going to give you a raffle ticket for this behavior.

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Sanction Script• It was not appropriate that you fell asleep in treatment

because it’s disrespectful and you missed important information that could help you succeed.

• Right now, how do you think this behavior has or could hurt you?

• Can you see where continuing the behavior might cause any problems for you down the road?

• Let’s discuss what you could’ve done instead, and how that would’ve looked (thoughts/ behavior).

• I’m going to give you a 8:00 p.m. curfew for 5 days. I recommend an early bedtime so this doesn’t happen again.”

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Presented to

EMILY C.

In Recognition for Achieving and Maintaining Sobriety For at Least 30

days!

__________________________ Hon. Diane Bull, Judge Presiding

Date: ___________

SHINING STAR AWARD

HELPING HAND AWARD

Presented to

JEROME H.

In thankful recognition for encouraging fellow clients, providing transportation and moral

support!

__________________________ Date: ___________ Hon. Diane Bull, Judge Presiding

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The charts change to meet specific goals for clients at the appropriate time. So they may be generic, or they may be specific to each client’s 14 day period.

E.G.: If the client needs more social activities, they can be added into the grid and get a “check off” for that.

How Do We Know What Rewards Work?ASK THEM!

13. What are your favorite incentives? (Circle all that apply)

Fish Bowl Spin the Wheel Praise, positive feedback

Gift Card Bus Passes CSR Voucher

Skype report Candy, treats Certificate (Sobriety, etc.)

Praise, positive feedback Other: (Specify)______________

14. What are some fun things you do that help you stay sober?_____________________________________________________

H/D

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1:10 1:08 1:06 1:04 1:02 2:01 4:01 6:01 8:01 10:01

Pro

bab

ilit

y of

IS

P S

ucc

ess

Ratio of Rewards to Punishments

Goal: 70 – 80%

Completion rate

Ratio of Rewards to Punishments and Probability of Success on Intensive Supervision

Widahl, E. J., Garland, B. Culhane, S. E., and McCarty, W.P. (2011). Utilizing Behavioral Interventions to Improve Supervision Outcomes in Community-Based Corrections. Criminal Justice and Behavior, 38 (4).

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Does an Emphasis on Incentives Really Make a Difference?

• State of Texas DWI Ct Program Completion Rate: 69%

• Harris Co. SOBER DWI Ct Program Completion Rate: 87%

H/D

What if we have no budget for incentives?

• You don’t need gift cards!

• Some of the most powerful are free.

• The best , most long-lasting incentives are “natural”: paycheck from a job, diploma, regaining custody, repairing relationships, feeling better, etc.

• Natural reinforcers are the byproduct of good treatment, and will help clients long after probation ends.

• Our responses keep clients engaged until natural reinforcers kick in.

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YOU’RE #1 !GO 1ST AT COURT

REVIEW !

You’ve got it made in the shade!!

Subtract 8 HOURS of community service.

YOU’RE DOING GREAT! YOU EARNED A “LEAVE COURT EARLY” PASS!

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All Star lists, candy bars…whatever you can do to promote engagement, and reward desired behavior.

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The method of delivery of the response is as important as the

response itself.

Dear Judges: SMILE!

Spell out the details of your responses

Then Repeat

Check for understanding

Then: team must reinforce the message

SUSE MOTIVATIONAL INTERVIEWING

UNDERSTAND TRAUMA

• Almost all our clients (veterans and non-veterans, combat or no-combat) have experienced significant trauma– but some may not realize it.

• Traumatized individuals process information differently

• Face significant hurdles and may need “more”.

• Screen at Orientation and design a treatment plan that meets individual needs.

• LISTEN TO TREATMENT!

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You can get sharply better outcomes with placebo-use it.

• Use your skills to engage

• Use your skills to encourage

• Use your skills to instill HOPE

• Sell recovery

• Use every skill you have to keep them coming back in spite of the pain and agony they are enduring.

• Early recovery (up to several years) really stinks.

This is very difficult work for them:

l-------------l--------------l-------------l-------------lSuicidal BAD GOOD VERY GOOD Euphoric

NORMAL BRAIN RANGE

l l l l

l l l l

l------------l------------l-------------l------------lSuicidal BAD GOOD VERY GOOD Euphoric

RECOVERING BRAIN RANGE

Co-occurring disorders-of all types• Separate track for some

• Careful case management, tx accommodation

• Constant assessment

• Thoughtful responses

• Much more patience and room for error over long run-but still a great need to keep on task.

• Longer time in program

• Medication management is proximal-watch jail

• Pro-Active field services are crucial

• Remember that manipulation happens no matter what the disabling disease.

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Remember that unaddressed co-occurring disorders may impede the

client’s ability to understand your

expectationsRepeat as needed

Diagnosis controls!

• Although often fluid, diagnosis controls.

• Harm reduction becomes the rule.

• Being different does not mean incapable!

• Expectations need to respond to reasonable goals and achievements.

• Setbacks are common, and often due to fluctuations in disease severity or external forces.

• Be clear, consistent, but kind.

• BE PATIENT-YOU ARE NOT THE YARDSTICK!

Cover basic needs first

• Incentivize heavily

• Clarify and remind frequently

• Pursue understanding and “report back” to internalize messages.

• Monitor manipulation.

• Expect treatment interventions to take longer

• Be patient, be very patient.

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Reminder:

• Certainty of detection matters

• Swiftness of response matters

• Severity does NOT impact like you think. Indeed it may harm progress.

• Assume: trauma, cognitive problems and criminal thinking.

• Be clear about your expectations.

Disorders impact performance

• Mental Illness is pervasive with drug court populations. Easily over 50%, probably higher.

• Disorders may be pre-existing, may emerge later in life, or may be “triggered” by substance use.

• In each case, the response to participants must be refined to meet current capabilities. If they cannot hear or grasp concepts S-L-O-W down.

• Separate Courts or tracks for acute disorders

Separate tracks for DUI high risk

• Different assessment instruments as well.

• Different responses to behavior in the field• Acute public safety risk• High levels of sociopathy and criminal thinking

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Number one mistake I made:

• Throwing people out too fast.

• I underestimated the power and tenacity of this disease.

• Do not give up until you have to, or if your Court has been affronted.

• Drug Courts are easy to get into, and hard to get out of.

• Be patient and be kind.

• Know that people will sabotage. Don’t let them.

Normal methamphetamine addict 15 months post abstinence

Patience: we are in this for the long haul.

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