The Practical Application Of The Science Of Behavior Change

Part 1 Staffing

Shannon Carey, Ph.D.

Helen Harberts, J.D.

Hon. Diane Bull

Hon. Peggy Davis

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• Review and demonstrations of the

principles/best practices of behavior change

• What does the judge and team need to know in

staffing?

• What are effective incentives and sanctions?

OverviewS

What is the purpose of Sanctions?

What is the purpose of Incentives?

What other court responses are there?

Purpose

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Positive ReinforcementINCENTIVES

SANCTIONS

Basic Terminology

Increase or START behavior

Decrease or STOP behavior

Therapeutic Adjustments

Treat sick behavior

Supervision/Drug tests Monitors behavior

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Why do any of this?

Purpose

To Change Behavior

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“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

The Beginning

(Applies to humans as well as rats!)

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Consistent Detection(Behavior and Immediate

Consequence)

Reliable detection

(Detection allows the gathering

of information needed by judge

and team to determine

appropriate response)

Speeding ex.

Certainty

Supervision

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• Urine drug testing at least twice per week

• Random testing all 7 days

• Continuous detection methods (patches, bracelet)

• Electronic monitoring

• Home visits (Extend supervision into natural social environment - work, home, school, street, cell phones)

• Include law enforcement on the team

• Case manager, supervision, treatment

Reliable DetectionH

• Remote responses have no power– and can cause real harm.

• Insist on quality testing and real-time devices.

• Insist on “fresh news.”

–Address lab issues.

–Utilize interlock dashboards with team access.

• Empower CM’s to administer lower level responses (incentives and sanctions) immediately per response matrix.

Achieving ImmediacyD

NOWLATER

LATER

• Show up

• Try hard

• Tell the truth

• Abstain from use

• Accept disease

• Work program

Proximal = Proximate/Close Distal = Distant

Proximal? Distal? What the heck is that?

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Focus on Incentives

Number one incentive is acknowledgment from the judge (“Tinna Quee”)

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WHAT THE TEAM NEEDS

Changing Behavior Requires Information

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STAFFING CONSIDERATIONS

BEHAVIOR RESPONSES:

• WHO are they in terms of risk and need?

• WHERE are they in the program (phase)?

• WHY did this happen (circumstances)?

• WHICH behaviors are we responding to?

– Proximal or distal?

• WHAT is the response choice/ magnitude?

• HOW do we deliver and explain response?

TREATMENT / SUPERVISION CHANGES?

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Staffing Sheets

• Staffing takes time

• CM should have up to the minute info

• CM recommended responses based on response matrix

• CM/ Treatment should have recommended questions/topics for the judge to ask participant

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STATIC INFO

• Name, Case No.

• Program Entry Date

• Offense Charged

• Priors

• Driving Facts, BAC

• Driver’s License Suspension

• Family

• Program Completions

• Phase Promotions

• Response History

DYNAMIC INFO

• Sobriety Date, Phase

• Risk / Needs Level

• Current Barriers

• Client Goals

• Changes in Employment

• New Completions (CS, Tx, etc)

• UA Results, Interlock

• Law Enf. / Field Visit Notes

• Tx Provider Notes & Progress

• Prosocial Accomplishments

• Sober Support Network

• Recs for Incentives, Sanctions, Changes in Tx, Supervision

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WHEN AND HOW TO

EFFECTIVELY

USE THE INFO PROVIDED

You are a

Change Agent!

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WWYD

Roles and Information for the Team

• Each team member has a specific role

• We respect those boundaries!

• Disagreement is healthy and needed.

• We all share common goals:

–Public safety

–Program completion

• Many of our team members face

ethical dilemmas

D/ALL

TEAM DEFENSE ATTORNEY

• Role often described as “murky”

• Represents/ counsels clients as needed

• Advocates for clients-- in a non-adversarial way

• May assist with pleas, documents

• Shares goal of program completion and health and well being of clients.

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TEAM DEFENSE ATTORNEY

–Attends staffing and gives input regarding appropriate sanctions / incentives

–Must be mindful of the client’s due process

rights, but encourage client’s honesty and accountability

–Must be careful about client confidentiality—the attorney’s silence often speaks volumes

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TEAM DEFENSE

ATTORNEY: SANDRA

• One of her clients, Amy, has confessed to her that she smoked “K-2/ Spice,” a substance that Sandra knows is not routinely tested for.

• Amy deeply regrets the decision and wants to know if she should be honest and tell the judge.

• The team judge routinely sanctions this type of behavior with 3 days of jail.

• Without Amy’s confession, no one would ever know.

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What would you do?

1. Encourage honesty. Warn her jail is likely. Don’t mention the truth about K-2 testing. Seek permission to disclose to team/advocate.

2. Tell all to Amy: K-2 won’t show up on a drug test. If she’s silent, no one will know. Don’t tell team.

3. Encourage honesty. Don’t tell her about testing and the jail. Ask permission to disclose to team. Advocate hard for lesser sanction.

4. Disclose the K-2 use even if client objects. Advocate for sanction reduction.

D/ALL

TREATMENT COUNSELOR

• Extremely mindful of client confidentiality.

• Will not, and should not, share everything, including positive UAs.

• Participates in staffing

• Monitors progress, makes treatment recs to the Court

• Identifies and provides s a continuum of care for participants

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TREATMENT/ COUNSELOR

• Address barriers that may exist (mental / physical health, language, etc).

• Services could include detox, residential treatment, SOP, IOP, cognitive education, boosters and aftercare.

• If a client has slipped or relapsed, the team must reassess the client’s needs.

• Your treatment partner’s input is essential.

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COUNSELOR: CHERYL

• Client, Rob, is in trouble yet again after many alcohol and drug violations.

• Rob served two terms in Iraq and Afghanistan. A friend was killed next to him by a sniper just before he returned home.

• He has severe anxiety issues, along with a terrible attitude and resistance to treatment.

• Deputy Jones (Sheriff) saw Rob drinking a beer at the rodeo. Rob shot him the bird and chugged it.

• The team unanimouslycalls for termination.

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Cheryl Gets Rob to Open Up

• Cheryl met with Rob. One of Rob’s few redeeming factors is that he is an extremely proud, devoted father who shares custody of his 13-year-old son, Rob, Jr.

• Rob confided days before the incident, he was served with papers, where his son’s mother was seeking full custody.

• It gets worse…

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Rob’s Bad Week

• After a quarrel, his son told him he was a “dope-head loser,” a “horrible father” and he wanted to live with mom.

• Rob’s new girlfriend gave him gonorrhea.

• All of this happened a week after he had finally weaned himself off of his anxiety meds.

• Rob insisted she must not

tell the judge and team.

• Rob expects termination and doesn’t really want to fight it.

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Rob Gives Up. Cheryl Doesn’t.

• Cheryl firmly believes Rob needs to remain in the program to get him through this rough patch.

• These troubling events could be the catalyst for a long-awaited breakthrough for Rob.

• Though clients sign confidentiality waivers, Cheryl is not sure how much she should share.

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What would you do?

1. Tell the team everything; advocate for treatment.

2. Tell the team about everything except the STD. The team doesn’t need to know that.

3. Don’t disclose any confidential info. Say, “There are

some big issues that I’m not at liberty to disclose, but please trust me on this one.”

4. Urge the client to be honest with the team and not

give up. Say little at staffing, but urge all to reconsider termination.

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Incentives and Sanctions

What do you use?

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INCENTIVES

• If you are using not incentives in your program you are hindering your clients progress.

• Keep an incentives history, too.

• Tracking incentives increases use.

• Reinforcers should far outnumber punishers.

• How many incentives is enough?

:

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H/D

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Pro

bab

ilit

y o

f 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%

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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?_____________________________________________________

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What if we have no

budget for incentives?

• You don’t need gift cards! (See handouts!)

• 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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Effective Punishment

“4:1” Only Works if

the “1” is Occurring

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Punishment is NOT the goal

of imposing of Sanctions

CHANGING BEHAVIOR IS

THE GOAL

“What will they

learn from the

sanction?”

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Punishers Often Include:

• Verbal admonishment

• Curfew, house arrest

• Reduced driving privileges

• Confinement in jury box, holdover cell

• Community service, work projects

• Escalating periods of jail: 1 – 5 days max (2-3)

• Others--A note about these:

–Essays, Thinking Reports, Apology Letters

– Increased court appearances

–Do NOT demote to earlier program phases*

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Courts that typically impose jail longer than 6 days have

worse (higher) recidivism

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Jail

• Often not effective

• Can make client’s situation much worse

• Should be reserved for serious

infractions

–Public Safety

– Illegal activity

–Violation of Behavior

contract

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Staffing

Understand: this is about them, not you.

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

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CRAFTING RESPONSES

• Response matrix should have options keyed to clients current level of competence and motivation

• Matrices should have several options– No “one size fits all.”

• 10-20% of the time matrix may not work

• FOCUS ON THE BIG PICTURE AND LOOK FOR PATTERNS

• Consider: “What do you want the

participant learn?”

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CRAFTING RESPONSES - Scenario

• Carol is in Phase 2

• Positive EtG for Alcohol – 3rd positive

• Perfect attendance at treatment and engaged in treatment

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Step 2. Determine the Response Low Moderate High Very High

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

Step 1. Identify the Behavior

Low Moderate High Very High

• Late for Scheduled Event

• Failure to Complete Assignments

• Missed payment

• Risky behavior

• Unexcused Absence tx

• Missed UA

• Failure to follow download procedures

• Alcohol Use

• Drug Use

• Tamper w/ UA or device

• Criminal behavior (new crimes, drinking and driving)

• Arrest

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Remember: The enemy is a difficult opponentWe’re in this for the long run!

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The Practical Application Of The Science Of Behavior Change

Part 2 Court

What Do You Think?

Was “Shawana” hiding the fact that she missed her UA and faking her surprise?

•A. Yes

•B. No

•C. Uncertain

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What Response

• For missing UA?

A. Warning

B. Prepare a calendar and present to Court

C. 24 hours jail

D. Acknowledge mistake and encourage to work on compliance

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What Response

• For completing treatment and getting a job?

–A. Praise

–B. Commemorative Certificate

–C. Gift Card

–D. No incentive

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Background

– “Shawana” scored as high risk/high need on the risk/need assessment.

– She meets the clinical criteria for moderate to severe substance use disorder.

– “Shawana” suffers from depression and PTSD.

–At 27, she has been in and out of the criminal justice system her entire adult life.

– She has been to prison and returned to the community, only to return to the same issues of substance use and criminality.

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Background

• “Shawana” has never before been able to stay consistently involved in treatment.

• She has never held a job.

• “Shawana” just returned to the community after successfully completing ninety days residential treatment.

• She just started working full time at the local dry cleaners.

• On the day she missed the UA she worked a full shift at the dry cleaner and planned to go after work, but forgot.

• She has been compliant with all other conditions of the court and treatment since returning home.

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Does your response change?

• Would you respond with an:

A. Incentive?

B. Sanction?

C. Combination of the two?

D. Neither?

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More Background

• The revelation in court should not have happened, but even in treatment court unexpected issues arise.

• The team staffed this case before the Court session.

• The Judge was not told that “Shawana” had missed her UA.

• Rather the team bragged on how incredibly well “Shawana” was doing.

• The information regarding the miss was thrown in during the Court session.

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Response and Discussion

• If you were the Judge, how would you respond?

A. Stop the proceedings and talk with the team about the additional information? Should “Shawana” be present for the discussion?

B. At a later time, talk with the team or probation officer about best practices and what information must be shared.

C. Suggestion from our experts on the team. Treatment? Supervision? Prosecutor? Defense? Law enforcement?

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SETTING THE STAGE

FOR EFFECTIVE

COMMUNICATION

Establishing Trust, Rapport and Safety

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PUTTING CLIENTS AT EASE

• “Never forget how scary you look.”

• Bad experiences with authority figures, esp.

–Judges, DA’s, Law enforcement,

even Probation

–We have the power to send

them to jail

• Develop Rapport

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Tone matters

• No “Judge Judy”

• No snarky comments

• No shaming or attacking

• Respectful, firm, clear, but not harmful

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Deliver Responses With Care

• Be patient and explain.

• Be consistent.

–When clients treated differently, explain WHY

• Afford Due Process.

–No blindsides

– Listen, give opportunity to explain

–Utilize team attorney

HE

LP

ING

HA

ND

AW

AR

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Presented to

JENNY H.

In thankful re

cognition fo

r

encouraging fellow clients, providing

transporta

tion and moral support!

__________________________

Date: ___________ H

on. Diane Bull, J

udge Presiding

Presented to

ROBIN BROWN

In Recognition for

Achieving and Maintaining Sobriety

For at Least 90 days!

__________________________

Hon. Diane Bull, Judge Presiding

Date: ___________

SHINING STAR AWARD

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ITS ALL IN THE

DELIVERY

“Its not just what we

say, it’s HOW we say it.”

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Understand Who You are

Speaking to

• Addicted and traumatized brains hear, retain, and interpret differently.

• This is a group that yearns for validation.

• What does, “You’re doing great” mean?

• We must be specific.

• They may not yet understand the value of prosocial behavior.

• Clients don’t know what “normal” is.

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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.

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Trauma Impedes Communication

Traumatized clients cannot hear or retain what we are saying.

They will not open up.

They are in “survival mode.”

• Use handbooks that clearly define rules.

• Use detailed forms when clients are sanctioned

• Use MI techniques, ask open-ended questions.

• Create a warm, positive atmosphere.

• Some clients don’t want to be touched.

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PUTTING PARTICIPANTS AT EASE

• Solution: Re-orient the courtroom.

• When clients feel safe, they will

open up.

• Caveat: This will extend your

Court Review!

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C

CM

DA

LE DC

AUDIENCE

WALLS

BENCH

JURY BOX

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Att

J

C

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TargetingS

• Define behavior clearly for team

and participant (both bad and good)

• Point direction (describe positive

behavior you are looking for)

• Target the behavior not the person

(be respectful)

TargetingS

Skill Steps to

Effective Responses

A Magic Formula for Meaningful Conversations:

• Identify behavior to be reinforced/ punished.

• Immediately tell person WHAT behavior you liked/

disliked.

• Tell the person WHY you liked/ disliked it.

• Discuss short and long term costs/ benefits of the

behavior? (Effect on her goals?)

• Pair the approval* / disapproval with an

incentive / sanction.

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The Script

• I really liked how you showed up on time for Tx becauseit shows me you are considerate and responsible; and you won’t miss information that will really help you.

• 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.

WHY WE DO IT

This method helps clients internalize:

• “I’m not just doing this to get off probation.”

• There are more intrinsic reasons for this change:

boss, spouse, teacher, etc.

We must change the internal tape from:

“I need to be on time to treatment

so I don’t get in trouble” to:

“I NEED TO LEARN SO I CAN GET BETTER.”

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Remember that

unaddressed co-occurring

disorders may impede the

client’s ability to

understand your

expectations

Repeat as needed

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Spell out the Details

Then Repeat

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Sanction Script

• It was not appropriate that you fell asleep in treatmentbecause 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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Remember:

• These are all courts of law.

• All that legal stuff still exists– i.e. Due Process!

• And, HOW you conduct the Court matters.

• Focus on the team and the message.

• When we battle addiction, we speak

as one. Otherwise we sow

manipulation, uncertainty,

triangulation, and failure.

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Do Due Process

• Allow participants to explain

• Explain judge/team decision

• Be respectful (and expect respect)

• Have written incentive/sanction

guidelines

• Allow reasonable discretion

(Procedural Fairness)

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A Word About Fairness

• Behavior Modification Principle: Humans Need /Expect Fairness

• Commitment increases when the process is perceived as fair.

– If not, clients disengage.

• Young clients and those with MH issues require special attention

• Take the time to explain.

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Fair doesn’t mean the same.H

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Be Positive, Instill Hope

Use MI techniques:

• Avoid argument.

• Roll with resistance.

• Remain solution-focused.

• Help clients see when their

attitudes hamper their goals.

• Praise positive steps clients

take.

OUR CLIENTS WILL LIE,

MANIPULATE US,

PUSH OUR BUTTONS

AND BREAK OUR HEARTS

Try to find something you

like about every client–

some little seed

of potential.

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Studies Show Clients

Respond Best to…

• Warmth

• Genuineness

• Empathy

• Respect

• Flexibility

• Enthusiasm

• Humor

• Optimism

• Commitment to Help

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Capitalizing on Hope at Court Review

• Seeing is believing: New clients need to see it all.

• Take later phases first so new clients will see and hear of the other client’s successes every week.

• Take incentives first– unless a “teachable moment.”

• Utilize mentors or your alumni group.

• Generously use incentives until “natural” reinforcers kick in.

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HOW TO CONVEY HOPE IN A

SANCTION SITUATION

• Acknowledge the things client did right.

• Remind the client:

– We see her progress.

• Ask: “How would you have responded to this 3 months ago?”

– He hasn’t “failed.”

– We will move forward together.

– We are team of recovery professionals.

• This doesn’t mean “we don’t like you.”

• Sanctions are a proven tool to foster recovery.

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• We know from research that the addict will choose immediate rewards over long term goals. They are prone to poor decision making. This is simple biology. It takes time to fix it.

• 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.

• The team must distinguish between sick behavior and criminal behavior, before we sanction or react.

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

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The Long Run

• We want all team members to

–Be professional

–Be consistent

–Be positive

• Find the good and reinforce it!

• Be vigilant and hold clients

accountable!

• Be patient. Healing an addicted

brain takes time.

THIS STUFF WORKS!!

S/All

DELIVERY ONLY

• Respectful (e.g., use formal honorifics “Ms. Smith”)

• Rapport/Trust

• Allows the participant to speak

• Listens to the participant and picks up on new information worthy of attention or praise

• Discusses the collateral impact of the sanction (what is the impact?)

• Provides a clear explanation of behavior being incentivized/sanctioned

• Provides a clear explanation of what to continue doing or do instead

• Provides a learning experience for other participants

Focus on the Delivery

Readings

Burdon WM et al (2001). Drug courts and contingency management. Journal ofDrug Issues, 31, 73-90.

Harrell A & Roman J (2001). Reducing drug use and crime among offenders: Theimpact of graduated sanctions. Journal of Drug Issues, 31, 207-232.

Marlowe DB (2007). Strategies for administering rewards and sanctions. In JELessenger & GF Roper (Eds.), Drug courts: A new approach to treatment andrehabilitation (pp. 317-336). New York: Springer.

Marlowe DB (2008). Application of sanctions. In Drug Court Quality ImprovementMonograph. Alexandria, VA: NDCI.

Marlowe DB & Wong CJ (2008). Contingency management in adult criminal drugcourts (pp. 334-354). In ST Higgins, K Silverman & SH Heil (Eds.), Contingencymanagement in substance abuse treatment. New York: Guilford.

Marlowe DB (2011). Applying incentives and sanctions. In The drug court judicialbenchbook (pp.139-157). Alexandria, VA: NDCI.