The Logic of Consequences

I'm part of a large email group of physicians who specialize in Addiction Medicine. Every once in a while the conversation reveals deep differences in underlying assumptions of these physicians about what addiction is and what it responds to. A recent such conversation between two very experienced and highly thought of physicians concerned the role of consequences in addiction treatment.

One of the members of this group opined that many in the field feel the patients "need consequences," and that he felt this was a problem. His counterpart in the conversation replied that in 30 years of experience he had never heard a counselor say that a patient "needed consequences," but went on to say that consequences are real and important to how patients learn. From there, others picked up the conversation and the points became diffuse and diluted. I want to focus, therefore, on the initial exchange.

First, we need a precise definition of a consequence. I propose, "naturally occurring event that follows without outside intervention from a previous action." Such things abound in nature. When a supporting structure holding a bolder in place is removed, the boulder succumbs to gravity and falls to the next level of support. When a super tide rises to the level of the top of a barrier, water flows over the barrier to a previously dry part of the land. Our idea of consequence is based on natural law and physics as we understand it. Subsequently, we see that any person who does not include consequences in their mental model will be run over by the forces of nature. This gives us a clue on how two caring physicians can differ in their underlying assumptions about the use of consequences in addiction treatment.

Those who know the TOC Thinking Processes will recognize the conflict cloud. The wishes of the two parties are expressed as "Wants" on the right hand side. Usually they are connected by a conflict arrow, but here I left it out. When drawing a cloud in order to "evaporate it" and remove the conflict, we start with these conflicting wishes. 

We then continue to the left and add in the necessary conditions that lead logically to those wishes. Because we have two necessary conditions which logically lead to contradicting wishes, we have two contradicting necessary conditions, the TOC definition of conflict. We then continue to the left, adding the common core goal of both parties. Each arrow in the cloud is a logical "if...then" statement, so that we can read from left to right, "If our goal is to provide good treatment for addiction, then we need to align with the patient against the illness."

The process of evaporation then continues by raising the assumptions behind each of these logical connections. For instance, why do we need to align with the patient against the illness? It could be that we assume that only by the patient and treatment team working together can this illness be treated. That is not something we'd assume about, for example, strep throat. Strep only requires an injection of antibiotic that could conceivably be given against the patient's will. No cooperation from the patient is necessary. But in addiction, we assume that such cooperation is important. 

We could see these assumptions as logical conjugations as illustrated below.

This could be read as "If our goal is to provide good treatment for addiction, and cooperation between treatment team and patient is necessary for good addiction treatment, then we need to align with the patient against the illness." And so, we could build out this cloud with multiple injections and make quite a mess of what is a clear definition of the conflict. It's best if we don't do this, but rather just surface the assumptions verbally and see if we can't establish which are erroneous. When I do this with a patient, I usually start with the branch that ends in my wish, and I ask them to surface my assumptions first. I found that if I start with the patient's branch first, they react defensively.

We can use this technique this ourselves when we are looking for a solution to a conflict with someone who won't even participate in the process, but it works even better to do this with the person we're in conflict with. In this case, you, as the reader are a neutral third party, so we'll have to guess at both sides' assumptions. 

I'll just list the ones I came up with. Please add your own. I note that almost always these logical arrows have more than one assumption behind them.

Top first: 1. Cooperation between treatment team and patient is necessary for good treatment of addiction. 2. We exist as a single team treating the illness with one goal as opposed to multiple individuals treating the illness with multiple goals.

Top second: 1. People, even patients, are good and act negatively because of effects of system construction. 2. The treatment team, not the patient, is being paid, and therefore has the responsibility of constructing a safe effective system.

Bottom first:  1. Addiction treatment can only be done well in a group milieu. 2. The treatment team, not the patient, is being paid, and therefore has the responsibility of constructing a safe effective milieu.

Bottom second: 1. A patient, aware of the rules, will interpret a behavioral consequence as coming from nature, not the staff. 2. Patients in addiction treatment are able to shift behavior away from biologically attached behaviors to more positive behaviors determined by cortical executive functioning; that is, they can always respond to consequences. 

There is one final set of assumptions that we need to check. I didn't have a conflict arrow between the wishes, but it too has assumptions behind it. In this case, such an assumption is, "Examining what is missing in the treatment plan and applying consequences are mutually exclusive." Goldratt stated that when we find the underlying assumptions of the conflict arrow to be in error, we often find the most powerful solution.

I'm not going to give my solution to the conflict here. You may find a solution I could not think of, and I don't want to limit you. I'm going to leave this conflict for you and the field of addiction treatment to resolve. Perhaps in your own field you have similar conflicts. The evaporating cloud is one of the most fundamental thinking process of TOC and has been invaluable to me in both administrative and clinical work. Read more about it. It's well worth mastering.