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Using TOC in Clinical Practice

Using TOC in Clinical Practice

A couple of weeks ago I was visiting a colleague on her inpatient addiction treatment unit. We were discussing my use of TOC in clinical practice as opposed to using it in organizational work. She wasn't aware of it being applicable to such things as diagnosis and treatment so we were going through the basics. 

Just as we were getting going, there was a loud ruckus in the hall outside. She said, "This is probably something I have to take care of. Do you mind?" Of course I didn't, so she went out into the hall. A moment later she returned with a sobbing woman complete with running mascara and blotchy face. The patient was disturbed to say the least, and, as she sat down, she began speaking in short sentences between the sobs.

"Nobody wants me here. Nobody will let me smoke a cigarette. I want to smoke a cigarette. I have to leave. I have to be with my daughter who needs me. Nobody here listens to me, nobody understands. Everybody here is horrible. I have to get out of here." From there it got repetitive.

My colleague did a great job of listening and calming the patient. It took about 10 minutes to get the patient to the point where she could listen, and my colleague arranged for the patient to get her a chance to smoke a cigarette and get back into the treatment group. 

When my colleague returned she wanted to pick up where we left off. I said, "Why don't we use that patient as an example?"

I started by asking my colleague how many problems the patient told us about. We brainstormed for a bit and wrote down:

1. Nobody here wants me

2. I need to smoke a cigarette

3. My daughter needs me at home

4. The staff doesn't care about me

5. I'm upset

"So," I said, "the patient told us five problems. How many problems does she really have." 

My colleague answered, "Oh, she has a lot more problem than that."

"No," I said. "She only has one."

I went on to explain the TOC finding that reality is exceedingly simple, and the more complex a problem seems, the more powerful a solution will result when we realize the simple true reality. She didn't buy it so I turned back to the list. "Tell me, can you connect any of the items on this list to each other with cause and effect relationships?"

My colleague answered after a while. "Well, I guess when people are upset they want to smoke. So "I'm upset" causes "I need to smoke."

"That's a good suggestion," I said. "But was she upset before she asked to smoke or did she become upset after the staff told her no?" My colleague answered that it was the latter.

I continued, "And when do people want to smoke?" 

My colleague, who is already well versed in the neurobiology of addiction said, "When dopamine tone is low." 

"Alright," I said. "Let's draw a current reality tree." And so we did. Rather than fill space and waste your time with the conversation and process of drawing the tree, I'll just present the finished project. You can see it below.


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For anyone who isn't familiar with reading a logical tree, read from bottom up. Entities connected by arrows are read as "Because, then," and the conjunctions are added when two or more entities lead to one. Like this: "Because 'Nobody wants me here" and when we feel uncared for or less than we have lowered midbrain dopamine receptor density and lowered dopamine tone, then the patient has lowered midbrain dopamine tone."

Once we had finished doing this logical tree, and it only took us a few minutes, my colleague saw that all the stated problems of the patient stemmed from a single cause, her perception that no one wanted her there. Of course, this begs the question of why the patient perceives that, but now, rather than having 5 things to investigate, my colleague can focus on finding out why the most important thing exists.

"Do you see now why I claim that treatment can be done much faster and is more simple than anyone currently thinks in our field?" Of course, she's still skeptical. She doesn't think we can do a complete treatment in an Intensive Outpatient Program in only a few weeks. But I've seen it done and done it. When my friend has practiced TOC a bit, she'll see it too.


A Patient, a Project, and TOC

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