Motivational Sanctions in Mental Health Court

1. Motivational Sanctions in Mental Health Court Getting from A to Z, Even with Multiple Detours

2. THE JUSTICE SYSTEM Mental Health Court vs. Traditional Court

3. Traditional Criminal Court • Governmental Mechanisms of Dispute Resolution. • Resolving Disputes Between the Government and Individual Concerning Allegations of Criminal Wrongdoing.

4. Problem-Solving Court • Now, new kinds of problems, many of which are social and psychological in nature, have appeared before the courts. • Problem Solving Courts: • Not only resolve disputed issues of fact, but also • Attempt to solve a variety of human problems that are responsible for bringing the case to court.

5. Comparison • Traditional courts limit their attention to resolving the narrow dispute in controversy. • PSC’s attempt to understand and address the underlying problem that is responsible for the immediate dispute: • Help the individuals involved in the court system to effectively deal with the problem in ways that will prevent recurring court involvement.

6. Common Elements in PSC’s In general, problem-solving courts share some common elements: • Focus on Outcomes. Problem-solving courts are designed to provide positive case outcomes for victims, society and the offender (e.g., reducing recidivism or creating safer communities). • System Change. Problem-solving courts promote reform in how the government responds to problems such as drug addiction and mental illness. • Judicial Involvement. Judges take a more hands-on approach to addressing problems and changing behaviors of defendants. • Collaboration. Problem-solving courts work with external parties to achieve certain goals (e.g., developing partnerships with mental health providers). • Non-traditional Roles. These courts and their personnel take on roles or processes not common in traditional courts. For example, some problem-solving courts are less adversarial than traditional criminal justice processing. • Screening and Assessment. Use of screening and assessment tools to identify appropriate candidates for the court is required.

7. Standard Docket • Sentencing Considerations • State v. Toohill Factors: The four objectives of criminal punishment: (1) protection of society, (2) deterrence of the individual and the public generally, (3) possibility of rehabilitation, and (4) punishment or retribution for wrongdoing. State v. Toohill, 103 Idaho 565, 568, 650 P.2d 707, 710 (Ct. App. 1982) Short-term View Address the Symptoms, not the Problem. What is the “Message” to: Offender Others in the System Public

8. In a Traditional Courtroom Setting: Rehabilitation is a goal with probation, BUT not the main focus of sentencing, which is protection of society and generally a punitive measure. Defendant’s must pay for their crime.

9. In a Mental Health Court Setting: • Not Merely Processing/Resolving the Court Case. • Achieving a Tangible Outcome Associated with Avoiding Reoccurrence of the Problem. • Actively and Holistically Resolve, not just the case, but the problem that created it. • See the law as an instrument for helping people, particularly those with a variety of psychological and emotional problems.

10. Rehabilitation is the Key • Screening Process – Guidelines • Mental Illness Related to Charge; OR • Mental Health Treatment in a court supervised setting can foster recovery and reduce recidivism. • Evaluate for criminogenic risks and needs with the LSI-R prior to final acceptance and should give preference to medium to high criminogenic risk offenders. • Participants should not be excluded from admission solely because of prior treatment failures or a current lack of motivation for treatment. • Mental health courts should implement motivational enhancement strategies to engage participants and keep them in treatment. • The Treatment Model for mental health courts is Assertive Community Treatment (ACT) delivered by the Department of Health & Welfare. . . .

11. Treatment Does Not Need To Be Voluntary To Be Effective. • Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions.

12. Key Components (10) • Element 4—Terms of Participation: Terms of participation are clear, promote public safety, facilitate the defendant’s engagement in treatment, are individualized to correspond to the level of risk that the defendant presents to the community, and provide for positive legal outcomes for those individuals who successfully complete the program. • Element 9—Monitoring Adherence to Court Requirements: Criminal justice and mental health staff collaboratively monitor participants’ adherence to court conditions, offer individualized graduated incentives and sanctions, and modify treatment as necessary to promote public safety and participants’ recovery.

13. Program Goals Mental health courts in Idaho . . . that closely supervise and monitor mentally ill . . . offenders and oversee their treatment will: • Address the mental health needs of offenders; • Reduce recidivism; • Provide community protection; • Ease the caseload of the courts; and • Alleviate the problem of increasing prison, jail and detention populations. Idaho Code 19-5602

14. Recovery Model What is Recovery? “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” SAMHSA 2011

15. Convergence of Two Streams • Procedural Justice Must Exist in Problem Solving Courts as Well as in “Regular” Courts: • Mental Health Court is COURT. • Mental Health Court requires accountability. • The method of achieving change is focused on recovery of the whole person and the changes that hopefully bode well for long-term success.

16. How Do We Achieve THESE Goals Getting from A to Z

17. The Landscape • How do we achieve the goals of MHC with participants who present with very diverse mental illnesses, functional abilities, and criminal behaviors? • Diversity in Presentation. • Diversity of Treatment Approaches • Motivation • Can Incentives/Sanctions be Motivational? • What Will Achieve Results?

18. Motivation We must understand: • Although we can assist people to solve their problems, we cannot solve them. • The individual must confront and solve her own problem and assume the primary responsibility for doing so. • We must help the individual realize this, and, as a team, help the individual to identify and build upon her own strengths and use them effectively in the collaborative effort of solving the problem.

19. Learned Helplessness • Where one has learned to behave helplessly, failing to respond even though there are opportunities for the person to help him or herself by avoiding unpleasant circumstances or by gaining positive rewards. • Clinical depression and related mental illnesses may result from a perceived absence of control over the outcome of a situation. • Learned helplessness can also be a motivational problem. Individuals who have failed at tasks in the past conclude erroneously that they are incapable of improving their performance.

20. Other Factors • Poor Social Boundaries • Antisocial Thinking

21. Creating Conditions for Change • Motivational Interviewing • Facilitating and engaging intrinsic motivation within the client in order to change behavior. • Project acceptance, rather than censure, freeing the person to change. • Empower the individual to improve their motivation to change. • Stages of change: Pre-contemplation, Contemplation, Preparation, Action, Maintenance, Termination.

22. The Role of Sanctions/Incentives • Incentives/Rewards must be designed to keep participants engaged in treatment. • The longer a participant stays in treatment, the better they do; thus, directed motivational sanctions must be designed to keep participants in treatment longer. • Our Goal: Catch them doing something right – while redirecting undesired behavior.

23. Punishment is NOT the goal in the Imposition of Sanctions Changing Behavior is the Goal

24. Application of Behavioral Management Principles Works • Rewards and sanctions are most likely to change behavior when they: • are certain to follow the targeted behavior; • follow swiftly; and • are perceived as fair. • Use of incentives to reward compliance with court mandates. • Rehabilitation emphasis modeled on principles of restorative justice and therapeutic jurisprudence models.

25. Individualized Approach • Cognition (CBT, CSC, MRT) • Beliefs drive emotions and thinking. Emotions and thinking drive behavior. • Behavioral modification (operant conditioning) • Reinforcementis any event that strengthens or increases the behavior it follows. There are two kinds of reinforcers: • Positive reinforcers are favorable events or outcomes that are presented after the behavior. In situations that reflect positive reinforcement, a response or behavior is strengthened by the addition of something, such as praise or a direct reward. • Negative reinforcers involve the removal of an unfavorable event or outcomes after the display of a behavior. In these situations, a response is strengthened by the removal of something considered unpleasant, e.g., decreasing time in a phase, time off court. • In both of these cases of reinforcement, the behavior improves.

26. Punishment • Punishment, on the other hand, is the presentation of an adverse event or outcome that causes a decrease in the behavior it follows. There are two kinds of punishment: • Positive punishment, sometimes referred to as punishment by application, involves the presentation of an unfavorable event or outcome in order to weaken the response it follows, e.g. community service or jail. • Negative punishment, also known as punishment by removal, occurs when a favorable event or outcome is removed after a behavior occurs, e.g., removal of a privilege. • In both of these cases of punishment, the goal is that the unwanted behavior decreases.

27. Remember the Individual • Responses must be keyed to target behavior. • What is a target behavior in the first 30-60 days? • Don’t reward with something they are intrinsically motivated to do. • Most-valuable reward: immediate and consistent praise that is deserved. • Timing is Everything. • Speed Supports Recovery. • Delay Supports Addiction/Disease.

28. Rewards are Much More Effective • Rewarding positive behavior is more effective in producing long-term positive change than punishing negative behavior. • Punishment alone is an ineffective public health and safety intervention for offenders whose crime is directly related to drug use

29. Positive/Motivational Incentives • Nonmonetary rewards such as social recognition can be as effective as monetary ones. • A graduated range of rewards given for meeting predetermined goals can be an effective strategy. • Contingency management strategies. • Bus tokens, to reinforce abstinence (measured by negative drug tests); or • to shape progress toward other treatment goals, such as program session attendance or compliance with medication regimens. • Most-effective when it closely follows the behavior being monitored.

30. Graduated Sanctions can be Motivational • Less punitive responses for early and less serious noncompliance and increasingly severe sanctions for more serious or continuing problems • Insure accountability. • Must be: • Consistent • Predictable • Clear • Perceived as fair

31. Behavioral Contracting • A behavioral contract is an explicit agreement between the participant and the treatment provider or criminal justice monitor (or among all three) that specifies proscribed behaviors and associated sanctions, as well as positive goals and rewards for success. • Behavioral contracting can instill a sense of procedural justice because both the necessary steps toward progress and the sanctions for violating the contract are specified and understood in advance.

32. Motivational Foundations • Maintain participant accountability through engagement with a dynamic and individualized process; • Focus the need for the participant’s change of attitude and behavior through programing solutions; and • Praise. “I recognize how hard you’re working.” “Thanks for showing up today.”

33. Our Biases • Incarceration is NOT the worst punishment • Jail is about us because we’re mad. • Jail works for the period of time I have my foot on their throat. • Punishment works best on those who have something to lose by incarceration. • Punishment is only temporary – real change comes with rewards. • Pygmalion Effect-Golem Effect • Reality can be influenced by the expectations of others. This influence can be beneficial as well as detrimental depending on which label an individual is assigned. • "Whether you think you can or whether you think you can't, you're right." Henry Ford

34. Team member concerns • Difficult clients • “Nice” clients • Burnout

35. Reliability of the Facts • Undesirable behavior must be reliably detected. • Cannot Sanction or Reward based on rumor. • While we’re “allies,” we must understand our roles. • Make sure the Judge gets it right.

36. The Major Themes • Engagement • Co-occurring disorders • Different risks and needs mean different responses. • Engage • Encourage • Instill HOPE • This is very difficult work for them.

37. As long as they are not harming the public or program integrity, keep them in the court.

38. Scenarios

39. Wrap Up/Take Away • Why do we do this work? • No great hopes of getting wealthy. • Hope that I have made a difference, even for just a few. • Big Picture • Eventually they will be our neighbors • This is a long term effort.