Back when I worked as a case manager, I worked with a person who was notorious for making decisions that were the opposite of what I would choose. What made this incomprehensible to me was that the choice seemed obvious. Stop spending all your money on alcohol…use that money to pay for rent…stop letting multiple people crash at your place…keep your apartment. Done, goal achieved. Instead, he decided to continue doing all the things that were putting his housing at risk. I felt frustrated and a bit perturbed.
I had worked hard to get him this current apartment, and it took a lot of creative finagling to acquire it, considering his past rental history. These emotions culminated in the thought, “Well, I guess he will have to face the natural consequences of his decisions.” I even admit I experienced a bit of schadenfreude because that would confirm how bad his decisions were and exonerate my efforts to convince him otherwise. I did work through this dissonance, but more on that later.
Before discussing how Strengths Model Care Management approaches consequences, let’s first spend some time dissecting:
• What is occurring on a neurological level when we make decisions?
• What might be occurring internally for us as workers when there are decisions that involve potential consequences?
• What might be occurring internally for clients when there are decisions that involve potential consequences?
Anatomy of a Decision
Our brains love predictability. If we can establish simple predictive models where A leads to B, which leads to C, then we get to bask in self-aggrandizement. Then someone pops our bubble by saying that A might also lead to Z and C could be achieved by completely bypassing B and instead deciding to start with D.
Then our brains start to hurt because we never liked complex logic problems when we were in high school so why would we embrace hypothetical probabilities now. Cognitive rigidity can sometimes make life easier to navigate or even keep us from danger. Like deciding which wild mushroom to eat or which snake to pet. It’s a safer choice to decide not to eat or pet any of them. Brains not only like predictability; they also gravitate to being risk averse.
Decision-making is a complex phenomenon, even if we like to make choices simple. It involves a multitude of neural networks (our superhighways of information processing and communication), including those involved with cognition, perception, memory, and emotions. Basically, at any point in time when making a decision, there is a whole lot of data on the table that our brain quickly processes, and most of this is outside our awareness.
The brain processes an estimated 11 million bits of information per second. Yet, our conscious brain can only handle about 40-50 bits per second at any given moment (NPR, 2020). This means there is a significant amount of data that will influence what we decide to do that is beyond the conversation that is occurring within the room. This includes our past experiences and corresponding associations, our present internal state, and future predictions. Let’s dig below the surface for a bit.
Past associations
No matter how long we have been doing this work, we have had a lifetime of experiences (birth to however old you are now). We start making associations with each new stimulus we encounter from a very early age. The first time we encountered what we now call a ball, we had to associate it with something. Maybe we just made googly eyes at it, marveling at the color. Or tried to communicate with it by babbling nonsensical words. Or tried to eat it.
Whatever you ended up doing, your little brain was spinning around, trying to make sense of it. Over time, the people around us gave us words to name the round object and even showed us a few things we could do with it. More associations. While this is all part of the basic fabric of learning, it takes its shape within social and cultural contexts, which influences how we think, feel, and behave toward that little ball. Do you have good memories of playing catch with your mom? Did your older brother bonk you on the forehead with it? All these experiences are factored into learning.
Now, here we are, employed in a behavioral health organization (or wherever you work), and your brain of today (all grown up now) is preloaded with all your previous associations. All of them (conscious or unconscious), not just ball associations. So, with each experiential encounter we have, our brain fires up its trusty database to look for similar experiences so they can be cataloged accordingly. Person uses meth – that goes here. Person who no shows for half of their appointments – over there.
Person who is angry and agitated at the world – here’s a place for that. Woman of color with a tattoo – here, there, and over there. Person has a diagnosis of personality disorder – special folder right here. Okay, it’s not that perfect of a filing system inside there, but you get my point. Our brains process approximately 11 million bits of information per second, and they move data around quickly.
Remember, our conscious mind only brings 40-50 frames per second to the conversation. So, while we like to think our decisions are based on “just the facts,” the seemingly objective data we are consciously processing is heavily influenced by our subjective categorical associations that we have hardwired into our neural circuitry through years of learning.
Present state
We tend to value rational decision-making (logic and reason) over affective decision-making (how we feel). This is based on outdated views of the brain (still prominently in play today) that portray the brain as having three evolutionary layers: a primitive inner layer that includes the brain stem and basal ganglia (base instincts), a middle layer that includes the limbic system (emotions), and an outer layer that includes the neocortex (cognition, reasoning, etc.) (MacLean, 1990). Through the lens of this theory, it seems to make sense. Our neocortex (our thinking brain) evolved to make us uniquely human and was designed to help us ward off those thoughtless, primitive instincts and emotions.
The only problem is we don’t have a triune brain; we have one brain with a massive network of neurons that connect and communicate with all our brain regions (Feldman, 2021). Therefore, instinct, affect, and cognition are involved in every decision we make, whether we like it or not. Our present state (how we feel internally at the time) isn’t something we need to repress; however, how we respond to that internal state during a decision is important.
How we feel internally is called affect. We experience it on two levels: a continuum of feeling pleasant to unpleasant and a continuum of feeling calm to aroused (worked up). Everyone likes to feel pleasant and calm. However, it’s difficult to stay in a zen-like state for long periods of time (at work or home).
We had a horrible night’s sleep, missed breakfast, a paperwork deadline is approaching, a person just got evicted from their apartment, etc. It just takes one stimulus to move the affect needle, but of course, we humans like to take our stimuli in bunches. What’s important to note for now is that unpleasant or aroused affect can be impacted by things that occurred prior to meeting with a person or what’s currently going on in the meeting.
Future predictions
All those neurons firing off within us aren’t just passively reacting to a stimulus. They are busy actively making predictions. They are quickly gathering all the data they can from our memories, past associations, the current situation, our perception, and the internal state of the body to predict what might happen next. Oh goody, I love surprises. Well, brains don’t. Remember, they like predictability and risk aversion. Prediction is, therefore, part protection. What will lead us toward a desired outcome and away from less desired outcomes.
Predictions are guesses though, which is why we sometimes make decisions that we predict might yield a positive outcome, and instead bring more discomfort and distress. Of course, the more preloaded neural algorithms we have at our disposal, the higher the likelihood of making a more accurate prediction. Like, what would happen if I touched this blazing red burner on the stove? You know the answer to that one.
People are more complex than hot stoves and some of the decisions we have to weigh in practice are multilayered. So let’s move on.
Enter Consequences
Every decision has a consequence. Some of those are minor. If I choose a sugar cone for my Rocky Road ice cream, then I’m not getting the waffle cone. Other decisions have significant consequences. If I poke this bear and her cub, I might not be on this planet tomorrow. Most are somewhere in between. Decisions are value-based propositions. The value of one option seems greater than the value of other options. I think I would enjoy the sugar cone more than the waffle cone.
Being alive seems better than my urge to provoke a bear. So, you are saying we just want something more than something else? Not quite. Because these values are not always so clear-cut, and furthermore, if we are going to talk about decisions and consequences in the context of Strengths Model practice, we have to remember there are two people in the room (or maybe more if you are on a multidisciplinary team – let’s not get too complex). And what each perceives as the value and consequences of any decision can be completely different. Let’s look at a case scenario.
Sarah is a senior in high school. Her grades have been poor, yet if she can avoid an F in one class, she actually still has a chance to graduate. And then, the possibility of attending community college in the Fall is still in play, which she said is her dream. You are the case manager. You have been working with Sarah through some tough times all year. It hasn’t been easy. You want to see Sarah graduate because you know it will open doors for her future.
You have offered to help her take some steps to complete a few assignments that would help her from failing her most challenging class. And then Sarah misses her next appointment with you. She doesn’t respond to calls or texts. When you finally connect with her you can tell she is high. You ask her if she has been working on her assignments and she tells you no, but she will do them tomorrow. Now she just wants to go home and sleep and watch some shows.
How are you feeling, case manager? A little unpleasant affect? Let’s dissect this a bit and see if we can’t make some points related to decisions and consequences here. For starters, we have a simple dilemma. If Sarah doesn’t get a passing grade in that one class, then she doesn’t graduate with her class. Come on Sarah, just complete the assignments! If not, there are natural consequences.
True enough statements. However, let’s look at some potential neural activity that could potentially be occurring for both Sarah and you (the case manager) that complicates what we view are the decision points and consequences.
Sarah – Sarah knows what will happen if she doesn’t get a passing grade in this class. That in itself is causing a lot of stress. In fact, she’s been told by a few teachers over the course of the school year what will happen if she doesn’t bring up her grades. Sarah has never perceived herself as intelligent. She had been told how “dumb” she was multiple times in foster care and had come to accept that label. She still felt like she was trying, but even her best efforts seemed to produce low grades. She had already been having doubts about college, questioning if she could even handle it. No one in her family had ever been to college. Her mom, with whom she is living, seems more worried about her bringing in money from her part-time job than about graduating from high school. She feels overwhelmed by the assignments she needs to complete, even more so in the face of all her other life pressures. She has learned to deal with stress by shutting down and zoning out. She’s aware of your (case manager) efforts. She ponders why you even care or if you are just another person in a long line of eventual disappointments.
You – You sincerely care about Sarah, and you have gone out of your way on multiple occasions to get her out of a bind. You are beginning to feel weary, though. Not just with Sarah but with everything else going on at work. You have been assigned three new clients who all are experiencing significant challenges in the last month, and you are still trying to adjust to some new documentation changes at the organization. And let’s not get started with pressures outside of work. Needless to say, you haven’t been sleeping well lately. You are starting to question Sarah’s motivation and if you are working harder than she is. It’s a familiar feeling that you have experienced periodically with other clients, and even in past relationships outside of work, where you felt you were putting in more effort than the other person. The more you think about Sarah being high and seemingly not taking the situation seriously, the more you want to remove yourself from the problem. You have had to experience natural consequences in your own life, and while painful, you feel like you learned from them. You think maybe this is what is best for Sarah.
Some of you probably feel a little cranky with how I portrayed you as a case manager with vulnerabilities. Sorry about that, but I had to make the case scenario somewhat complex and interesting. The point is, we all have vulnerabilities that surface in the midst of decisions that involve consequences. And we all have internal conversations with ourselves amid that process.
So, how does the Strengths Model guide us in approaching these pivotal points? Before we turn to that, it should be noted that decisions where the consequences involve danger to self or others are special cases that extend beyond the guidance below. These decisions should not be made in a vacuum and should involve your supervisor and others on a multidisciplinary team for the protection and safety of everyone. We should find the following thread of thinking helpful for the majority of decisions that involve consequences that we may face each week.
o Acknowledge that decisions are complex
Our brains are wired to simplify things as much as possible. And for good reason – it’s how we successfully navigate our complex worlds. Effective behavioral health practice, though, requires us to step back and recognize the complexity that exists and guard against the undue influence of implicit bias. We may not be able to control all the factors that are at play; however, at minimum, we must acknowledge they exist.
o Attend to affect (yours and theirs)
Decisions and potential consequences will impact affect (how we feel), and how we feel will impact how we respond to decisions and potential consequences. So attending to these is critical. For us as workers, it begins with awareness and acknowledgment of our internal state (and the shifts that may be occurring). Engaging in mindfulness and deep breathing techniques is helpful. The goal isn’t to miraculously get us to blissful nirvana but to keep ourselves grounded and remind the brain that we are not in a “code red.” If we don’t employ active efforts to keep ourselves grounded, then our brain’s immediate response will be to take the path that most quickly reduces discomfort and arousal. This is where, in the scenario above, we either try to fix it ourselves or throw up our hands and distance ourselves from the decision (neither being useful).
In regard to the client, here is where we employ empathy (our active efforts to understand the other person’s perspective). Part of Sarah’s move toward getting high and zoning on shows is a move away from discomfort and arousal. Part of Sarah’s ambivalence with completing the school assignments is the discomfort and arousal caused by doing them. Part of Sarah not wanting to meet with you is the discomfort and arousal based on the perceived expectations those meetings might place on her. And all this, in turn, increases your discomfort and arousal. So, while it might feel uncomfortable talking about feelings, there’s no way around them. Just make sure to put your oxygen mask on first before trying to assist fellow passengers.
o Let go of the reigns of judgment
OK, you have acknowledged affect. But wait, you still have a hold of something. What’s that I see? Is that a stake in the outcome of this decision? I get it. We all have a preference for what we would like to see occur. The challenge is once we invest ourselves in a particular outcome, then our judgments revolve around any behaviors that move us toward or away from that outcome. And this also impacts our internal affect. We get giddy when people do things we like and cranky when they don’t. Yeah, but I push all my emotions down into the deep regions of my subconscious where no one can detect them. Uh-huh, how does that usually work out? Our behaviors communicate our learnings (in addition to those gaudy reigns you are holding in your hands). I’m not saying don’t care. Just accept your preference and remember the decision is ultimately the other person’s to make (and their consequences). In the above scenario, whatever Sarah decides to do isn’t about you. It’s about her own internal struggle to make the best decision she can for herself.
o Open space to explore potential associations and ambivalence
If we are able to relinquish our ownership of the decision, then we are in a better place to help the other person process their own decisional uncertainties. To do this, we don’t want the focus to be solely on the consequences (the paternal approach). I’m not saying to act like consequences don’t exist. Rather, pursue the areas where real growth and change can occur – associations and ambivalence around the decision itself. Empathy is front and center here, along with a little motivational interviewing. Open ended questions, affirmations, reflective statements, and summaries that capture key values and validate effort are useful approaches.
In the above case scenario, Sarah needs to first feel that she is understood within the messiness of the situation. The more we can learn about her perspective, looking both inward and outward, the better we can help her navigate options and potential next steps. If we can align with Sarah around her perspective, then we have a better opportunity to discuss the potential consequences of various decisions. Here again though, we are exploring Sarah’s perspective of the consequences. Double-sided reflections are more useful than closed-ended, value-loaded questions. For example, “On one hand, it’s overwhelming thinking about completing these assignments, and on the other hand, you worry about not graduating” versus “Aren’t you worried about not graduating?”
o Extend an invitation to explore options
The key word here is invitation. The options we discuss need to be in line with areas the person is willing to consider. For example, “Are you open to looking at some options we could support you with ____?” or “Is it worth looking at some potential ways you might be able to ____?” Of course, we might get an “I don’t know” or even a “no.” In that event, we are back to processing decisional uncertainty. However, if we get an opening, then we can move forward.
One effective approach is to ask permission to lay out all the potential options we can think of without judgment before evaluating each one. For visual learners (and stressed auditory learners), it can be helpful to write the options down on a piece of paper or whiteboard. It’s also good practice to start by asking the person if there are any options they have already been considering. Remember when you are evaluating options to approach it from the perspective of their pros and cons, not yours. But you already knew that.
o Coming to a decision
I’m not going to go into everything that goes into helping people arrive at a decision (this is already a long blog). Here, I just want to point out that most people don’t like making hard decisions, especially with potential consequences on the line. It makes the tummy and head hurt. So, just recognize it as such. For Sarah, she’s probably not going to get warm fuzzies from any choice she makes. Movement in any direction (or staying exactly where she is) is a potential step into discomfort (unknowns, worries, doubts, fears, etc.). Validating people’s affect is important no matter what they decide to do next. For example, “I know these aren’t easy decisions to make,” or “It’s understandable to still have worries or doubts about what’s next.”
We also need to validate our affect, regardless of what the person decides to do next. Of course, we will be pleased if they decide to move in the direction we want them to. On the other hand, we are going to feel like we stepped in dog poo, if they decide otherwise. So rather than beat up on ourselves, acknowledge you have feelings. And more than likely, it’s because you care about the person and want them to do well. Or it could be because you know you may have to deal with the fallout from that decision. Both can be true.
o Focus on the next immediate step
Regardless of what people decide, there will still be a next step. Even if they run out of your office and tell you to never talk to them again. We run into a few potential pitfalls here. On the “yay, we are going in the direction I feel most comfortable” end of the continuum, there is the danger of overplanning and returning right back to cognitive inertia by overwhelming the person. On the “boo, this is not how I wanted this to turn out” end of the continuum, there is the danger of being passive-aggressive to soothe our own wounds. Of course, you aren’t going to go to either end of the continuum because you released your investment in the outcome in the early steps.
Since your investment is in the person, not the outcome, the most effective approach is to keep your focus on an immediate next step that the person feels comfortable and able to take.
Final Thoughts
We have been talking about decisions and consequences, but what exactly is a consequence? According to Merriam-Webster, it is “a condition or occurrence traceable to a cause.” Fair enough. Two caveats. First, at any specific moment in time, we view a consequence from the present time and look backward. Time continues to move forward, though, and sometimes today’s consequences become a cause for new consequences in the future. Second, we typically associate the word negative with the word consequence. As in, we made a bad decision, and it had a negative consequence. Our individual decisions and consequences are microcosms in a larger dynamic timetable of life.
Remember the guy at the beginning of this blog who was faced with eviction if he didn’t pay his rent? He lost his apartment and went back to living on the streets. It was painful. I even went through all the steps I described above. A few months later, he and I secured another apartment. He lost that one too. A year later, he got into an apartment and there was a shift. He started moving toward sobriety, joined a clubhouse model program and started engaging in social activities, and eventually got a job. Life still had its challenges, but there was a noticeable difference in how he approached those challenges.
It wasn’t the effect of a magic lightning bolt. Who he was now was the culmination of a multitude of experiences, decisions, and consequences (positive as well as negative). Talking with him later in time, he would look back at some of those evictions as painful experiences that led to future growth. So, am I advocating for people to experience natural consequences so they can grow and thrive? Not at all. If I could go back in time and revisit some of those same decision points, I would still hold hope that he would keep that apartment.
The point is – are we willing to remain present and committed to people regardless of an outcome? Are we willing to help people navigate their own decision-making process and explore options as we would for any other person? In Strengths Model practice we don’t want to move away from the person experiencing consequences, we want to move toward them. Moving away is more about our discomfort in how we feel about the choice. Moving toward is our embracing of the person no matter the choice. It is within that space that we increase the likelihood of learning and growth.
