Under new influence: changing behavior with individualized management plans.
One means of deliberately attempting to change behavior is the development and use of behavior plans. Behavior plans can range in quality and effectiveness --some may even border on being unethical and, potentially, illegal. In his essay, "Punitiveness as 'Behavior Management,'" Dr. Hans Toch, a social psychologist at the University of Albany, reviewed behavior plans that relied solely on punishment. (1) He described plans typical of this genre, which often include "stripped-down 'baseline' environments devoid of any conceivable need-satisfying amenity." (2) These plans sometimes had an element of food and clothing restriction. Dr. Toch described such plans as intended to inflict pain and suffering on the individual, with the overall theme being repudiation.
The Washington State Department of Corrections (WDOC) has attempted to embrace the concept of behavior management as a multidisciplinary process, valuing front-line staff expertise and partnership with mental health aimed at rehabilitation. This article reviews the current WDOC process for the initiation and development, synthesis of information from team members, team review and implementation of Individual Behavior Management Plans (IBMPs) within the organization.
Process for Initiation and Development
Correctional team staff request IBMPs for inmates who engage in repetitive behaviors that impact the inmate's functioning and health (i.e., repeated smearing of feces or repeated cutting). To begin the IBMP process, the officer, nurse or mental health provider requests an IBMP be developed. Then, the primary therapist (PT) serves as the hub for starting the IBMP process and facilitating the creation of the finalized management plan.
The first step of this process is for the PT to ask all correctional team members to fill out a functional analysis (FA) (See Figure 1) regarding an incident in which the inmate engaged in the problem behavior. For example, a nurse, an officer and a mental health provider might all fill out an FA on an inmate who is repeatedly cutting--they may even write about the same incident. The FA is a short form that takes approximately two to three minutes to complete. It asks the respondent to do five things:
(1.) Identify the problem behavior (smearing, cutting, yelling, refusing, etc.);
(2.) Identify the antecedents of the behavior (anything that took place prior to the behavior: cell move, shift change or bad news from home);
(3.) Identify the hypothesized function of the behavior out of four categories:
a. Communication--when behavior is used to express or get something;
b. Self-regulation--when behavior is used to control a person's feelings;
c. Self-entertainment--when behavior is used to occupy oneself or when a person is bored; and
d. Power/Control--when behavior, often in the form of verbal or physical aggression (or even refusal), is used to forcibly obtain or avoid something in the environment; sometimes, the motivation behind such acts are to simply demonstrate that one possesses power and has some control over their environment.
(4.) Identify the intervention used to try changing the behavior (What did the staff member do--ignore, talk or negotiate?); and
(5.) Identify how the intervention worked (evaluation--did the intervention stop the behavior short term? Long term?).
It is important to note there may be more than one hypothesized function. In addition, even if there is no change in the problematic behavior, or if it increases in frequency, duration and/or intensity, it is still valuable information. It becomes the impetus to review the function, to derive different interventions and to ultimately create a successful plan. The FA of the behavior(s) is perhaps the most important step toward creating a successful IBMP, because the staff's hypotheses and interventions drive the team's decisions.
Synthesizing the Information
Team members are given four days to submit at least one FA to the assigned PT, who compiles this information into the actual IBMP official form. The IBMP form includes
* Name and photo of the inmate;
* Name of the inmate's PT and unit psychologist (may be the same individual);
* Description of the behavior that will be addressed (the behavior that drove the creation of the IBMP);
* History of the behavior (derived from the team and from the available medical record);
* Reasons for the implementation of the plan (Why is this a problem? Why does it need to be changed?);
* Incentive section (details on what the re-enforcers will be used to motivate the inmate); (3) and
* Current behavior/target behaviors. (4)
The target behavior section describes what the replacement behavior for the "current behavior" will be. In addition, this section identifies the behaviors that staff should be reinforcing when they are exhibited by the inmate. All too often, staff miss opportunities to reinforce replacement behaviors. The authors have found that, when completing this section, staff are tempted to simply put the opposite of the behavior in the "current behavior" section. For example, if the "current behavior" is using fingernails to cut arms, then the "target behavior" section includes "will stop using fingernails to cut arms." This approach is problematic because it provides both staff and inmates with very little direction regarding replacement behaviors. Behaviors serve a function, which typically means that making them "stop" does not work. The function still has to be served (via replacement). Instead, it is advisable to go back and relate the "target behavior" to the hypothesized function. In keeping with the same example, if the hypothesized function of the inmates' behavior of using fingernails to cut their arms is for self-regulation, then the "target behavior" section would include some emotion regulation strategies, such as "will use coping skills and dialectical behavior therapy diary card to reduce stress." The "action steps" section details the process to be followed if/when the behaviors described in the "current behavior" are exhibited. Here, again, it is crucial to identify which staff members are responsible for carrying out the interventions. Of course, it is recommended that all interventions in IBMPs are consistent with the policies in your facility and laws of your state.
[FIGURE 1 OMITTED]
Reviewing the Plan
WDOC's IBMP form ends with a section for the signatures of the inmate (listed as "patient" on the form) and members of the multidisciplinary team. Before signing the plan, the PT sends out a draft (via email) of the IBMP to the correctional team for review. It is recommended that the IBMP also be presented to a multidisciplinary team (MDT) during an in-person meeting. At WDOC, the meeting includes the unit sergeant and at least one front-line custody staff member. The MDT approves the proposed IBMP to move forward.
A meeting with the inmate includes a review of the plan; the inmate is offered an opportunity to provide feedback and sign the document. The inmate may opt to not attend the meeting and/or not sign the document. If the inmate does not sign the plan, the plan still moves forward. Allowing time for review of the IBMP (described in more detail below) and obtaining signatures can be a time-consuming process; however, it is important if greater communication and consistency are going to be established.
Implementing the Plan
It is recommended that no changes be made for two weeks after the IBMP is implemented (unless there is an emergent need to do so). After two weeks, the IBMP is reviewed in an MDT, with suggested changes solicited (when feasible, review with original MDT). An MDT reviews the IBMP approximately 30 days after the two-week review, and then approximately once every 90 days thereafter. IBMPs are discontinued once they are no longer needed, as determined by an MDT. When an inmate has demonstrated sustained behavior change, the plan should be discontinued and the inmate discussed or praised. This can be an opportunity for a positive interaction.
IBMPs are considered to be "in effect" once signatures are obtained by members of the MDT, and the document is posted on the inmate's cell door or another location. It is recommended that any updates to IBMPs be put in writing and then considered to be in effect once the criteria (described above) are met. It is also recommended that IBMPs be disseminated widely; there should not be any confidential information on these documents. At WDOC, IBMPs are filed in the medical record (an electronic medical record, if available), with copies provided to custody staff, custody staff supervisors, medical staff, on-call personnel and the inmate. (Note: it is important to establish a mechanism for resolving any disagreements.) At WDOC, if there is a significant disagreement regarding an IBMP, then the unit's supervising psychologist reviews available information and meets with management to seek a resolution. The superintendent or designee makes the final decisions regarding an IBMP.
Lessons Learned Throughout the Process
Consistency statewide. Prior to 2014, there had been no official WDOC IBMP form. Of course, the need for such a tool existed, and it led to each facility's developing its own "home-grown" forms. The issues with home-grown forms were numerous, but it led mostly to a breakdown in communication. When an inmate was transferred between facilities, the receiving facility was often unaware that an IBMP existed. Because the IBMP was not an official WDOC form, medical records technicians were removing it from the inmate's medical record. On those occasions when an IBMP did make it to a receiving institution, the staff members at the receiving facility were challenged by the idiosyncrasies of the IBMP form that was created by the sending institution. These breakdowns obviously led to inconsistent behavior management across facilities. This was especially debilitating when it involved inmates who were frequently transferred across the state's restrictive housing units. Another complicating factor was that at some facilities, mental health staff were responsible for the development of IBMPs; while at other facilities, custody staff had that responsibility. Every institution now uses the same form, and because it is official, it can be placed and remain in the inmate's medical record. Mental health staff were identified as the staff responsible for the development of IBMPs.
Use sparingly. In terms of the procedures involved with the initiation, development, review and implementation of IBMPs, the following is recommended: Delineate which inmates are in most need of an IBMP. In other words, if a unit has 200 inmates, imagine what it would be like to not only develop 200 IBMPs, but also have the expectation that unit staff will have ready knowledge of all those plans and will be able to implement each plan with fidelity. While the majority of IBMPs may be written for inmates in restrictive housing, at WDOC, IBMPs have been effective in assisting both staff and certain inmates in transitioning, as well, and then managing less restrictive settings successfully. The authors suggest that IBMPs be reserved for those inmates that demonstrate an observable pattern of problematic behavior (i.e., self-harm, refusing cell searches, poor hygiene, difficulty transitioning to general population and food refusal).
It takes a team. While mental health staff are responsible for the development of IBMPs, the first step is to request input and observations from the stakeholders (multidisciplinary) where the inmate is housed. One person cannot change an inmate's behavior, and everyone on the team has valuable insight into how to make improvements.
The short game versus the long game. There will be many obstacles to the initiation, development, review and implementation of IBMPs. Most often, IBMPs are undermined by staff who divert from established action steps, because they have other ideas about how to manage an inmate. In addition, staff may engage in deals with an inmate with the purpose of having a quiet shift (the short game). At best, such interventions represent short-term solutions with long-term problems. These tactics also place staff who want to follow the procedures in an IBMP at risk when an inmate has come to expect different treatment. The best way to address these issues is through an ongoing investment in staff training. Such training would include the basics of behavioral principles (including functional analysis) and explicit discussions regarding the IBMP form and associated procedures. One of this article's authors was humbled when he conducted training on IBMPs at his facility, learning that the majority of custody officers had never seen the form or participated in their development. In facilities experiencing high turnover, more frequent trainings may be necessary. While there may be significant obstacles, the consistent implementation of IBMPs can lead to decreased staff burnout and increased safety (the long game).
Every interaction with an offender has the potential to modify behavior. The correctional worker's response, or lack thereof, can increase, maintain or decrease the frequency of that behavior in the future. In corrections, addressing problematic inmate behaviors is routine. It is the experience of these authors that many attempts at behavior change are doomed from the start because of a lack of input from front-line staff; a lack of consistency with interactions; an absence of communication across disciplines, shifts and institutions; a failure to consider the functions of the behaviors; and an emphasis on the benefit of short-term gains (at the expense of long term benefits).
By following the procedure described above, it is possible to create and implement IBMPs by utilizing the expertise of front line staff to create a consistent and methodological team response to offender behaviors, leading to lasting behavior changes in line with institutional objectives (mainly, danger to self, danger to others and/or threat to the orderly operation of the facility). Of course, even when the procedure is followed and an IBMP is in place, behavior management is hard work. Observed changes in behavior are often small and require a substantial amount of time. The successful implementation of IBMPs requires ongoing effort, communication, consistency and patience.
(1) Toch, H. 2008. Essay: Punitiveness as "behavior management." Criminal Justice and Behavior, 35(3):388-397. Albany, N.Y.: State University of New York.
(3) The incentive section utilizes front line staff's ideas on how to intervene and mental health expertise in behavior management. It is imperative to identify which staff members will be responsible for delivering the incentives, including contingency plans, if an identified staff member is absent. If specific staff are mentioned in the plan, it is essential that they are aware of this, aware of their limitations (availability) and agree to participate. This section can often present a challenge, because most systems face very real budget constraints. In the experience of these authors, however, there are a number of incentives that are cost neutral (that do not underestimate the power of attention, for example). Attention, when delivered consistently and contingent upon the demonstration of replacement behaviors, can have a great impact. It is also important to note that the incentives should be based on what actually reinforces the inmate, not simply on what is thought to be reinforcing.
(4) In the current behavior section, there is a concrete description of a behavior or constellation of behaviors. As one of the authors often encourages, be descriptive and not conclusive in this section. When the information is simply described, staff will know how to immediately identify the problem behavior exhibited. Terms such as "acting out," "ramping up" and "melting down" are to be avoided.
By Dr. Rain Carei and Dr. Ryan Quirk
Rain Carei, Ph.D., is psychologist IV at the Washington Corrections Center for Women of the Washington State Department of Corrections. Ryan Quirk, Ph.D., is psychologist IV at the Monroe Correctional Complex of the Washington State Department of Corrections.
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|Author:||Carei, Rain; Quirk, Ryan|
|Date:||May 1, 2016|
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