July 1st, 2010

Half-finished notebooks

At morning rounds the other day while waiting for something important to record in my recycled, spiral-bound notebook, curiosity nudged me to flip through the filled front pages for a clue about why I kept it in the first place. Considering how much stuff I had to clear out of my old office, it would have been easier to trash this early decade relic than to give it space among the 18 boxes of essentials that accompanied me to my new workplace. My motivation was probably not so noble as stewardship of the earth’s dwindling resources nor so old-fashioned as Benjamin Franklin’s admonition to “waste not, want not.” I had either recorded something really, really important or I just couldn’t bear to discard all those inviting blank pages pointing the way to a future of unimaginable surprises. More likely, it was something in between, considerably less dramatic, the kind of un-named impulse usually captured by the thought that it seemed like a good idea at the time.

What I found was a good set of notes on a conference addressing the issue of the diagnosis and treatment of people with sexually problematic behavior. Here was material directly relevant to my work as a psychologist in a state hospital with clear, practical descriptions of empirically supported techniques to promote attitude and behavior change. The strategies in the front of the notebook could be used exactly as described with some of our patients and adapted to benefit others with different behaviors that they were trying to change. This information was good stuff with lots of possibilities and wasn’t I wise to recognize its value and bring it with me?

Not so fast. If I were truly wise, I would have begun using the information from this lecture at my first opportunity. If it didn’t quite fit the needs of my patients at the time, I might have found ways to adapt the techniques, using what was relevant and shelving the rest for possible future use. By now, nearly 10 years later, all of these good habits of thinking and clinical practice would have been internalized and I would do the right thing in the right situation automatically. As an added bonus, I wouldn’t need the notebook and, probably half of the other things I carted across town when the last hospital closed. At last I would be traveling light. Isn’t life easy?

Not so fast. In a recent review of a new book about life in the age of the Internet (“The Shallows: What the Internet is Doing to Our Brains” by Nicholas Carr), Wen Stephenson (The Boston Globe) argues the merits of striking a balance between the quick consumption of digital information and the contemplative immersion in a subject that books provide. Stephenson describes Carr’s thesis and its growing empirical support that extensive Internet use changes our neural pathways in ways that impair our capacity for complex thought. Carr believes that the online environment promotes “cursory reading, hurried and distracted thinking and superficial learning.” But the Internet, according to the reviewer, did not replace books but took their place alongside them. It is up to us to decide how much time we will spend with each of these very different sources of information. We are the half-finished notebooks we carry with us from place to place, the old information up front and the empty pages waiting for our newer, wiser insights. Like digital information and insights wrestled from contemplative thought, the new does not replace the old but provides opportunities for one to influence the other. While it would have been more efficient to start using the information at the front of my notebook immediately, I am glad to have the opportunity to use it now.

After rounds that morning, I sat with a new admission to our unit. As it is in most psychiatric facilities, our admissions work-up is a routine procedure designed to balance thoroughness with efficiency. In many ways, an admissions interview is more like consulting the Internet than reading a book about our patient. We click on hyperlinks to trauma, substance use and current mental status, giving cursory attention to the deeper story that provides the context. We mine the data, construct the information and strive to extract whatever insights we can. That work begins in earnest if we have the opportunity to engage the person in individual psychotherapy.

Do we discard a half-finished notebook or keep it? Do we learn from the Internet or from books? Do we strive to know our patients in the full complexity of their existence or zero in on the conflicts and behaviors that brought them to our doorstep? As far as possible, we try to do both. The challenge is knowing when to use each strategy and how to integrate and use what we learn from all sources. We don’t learn this in graduate school or in our early years of professional practice. This is the work of a career and then some. This is the work of a lifetime.

Alan Bodnar, Ph.D. is a psychologist at Worcester State Hospital and a consultant in the field of leadership development.

By Alan Bodnar Ph.D.

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