March 1st, 2014

Counting what we do and doing what counts

These days, we count everything in the hospital. On Tuesdays, an email comes to remind me to submit my weekly encounter form by 10 o’clock the next morning. That’s where we count how many patients we’ve seen and how many minutes we spent seeing them. Risk assessments ask us how many times a patient has been arrested, charged with violent crimes, convicted, hospitalized, restrained and secluded. We need to know how many times they’ve run away from home, tortured animals, set fires, skipped school, bullied classmates, sassed teachers, got suspended, expelled or expunged from the rolls of the good and honorable.

Of course, not everyone needs a risk assessment. Some folks are just mentally ill as if that weren’t enough of a challenge. It’s important to distinguish these ordinary folks from the risky ones, to know how many fall into each category of risk and to keep track of how many assessments we’ve done and how many remain to be completed.

If the task sounds daunting, we’ve got it covered with a system of checks and balances to make sure nothing important escapes our attention. We use Form A to tell us how many of each task we need to do and Form B to keep track of everything on Form A to make sure it gets done. With all this counting, we can only be thankful for the invention of numbers. Years ago, I entered an essay contest that challenged participants to make a case for the most important invention of all time. My favorite essay was written by a guy who gave us a picture of a world without numbers. Imagine what life as a psychologist would be like in that world.

I would answer that Tuesday morning email requesting my encounter form by writing that I had seen quite a few patients last week. That’s terrific, the reply would come, commending me for the increase from the good many encounters I logged for the last reporting period. One of my violence risk assessments might describe an individual who skipped school a whole lot until he was expelled sometime during high school after getting caught smoking marijuana in the men’s room plenty of times. Unfortunately he went on to be arrested for larceny a few times and on occasion for assault. The last episode was one too many and the judge threw the book at him.

The number of assessments adds up and every now and then we fall behind. When we’re way behind, we can always get a little help from our colleagues. That’s one of the nicer things about working here – the team spirit that keeps us all ready to help one another get the job done. Glancing at my to-do list, I see that a great many of my patients need risk assessments, up a smidgen from the good number of folks requiring this service last month. The other psychologist on my unit is out for a bit of vacation and not due to return for a while. Thank goodness the interns and trainees are available to pitch in.

We’ve got some of each and they are all required to do a good many risk assessments. It’s a great learning experience especially when we can assign some of each kind to every student. Today we are all in luck. The patient needs a fire setting risk assessment and the trainee on site needs to do a few more of these. She will have to work fast since the patient is scheduled to be discharged sometime soon and we have to leave enough time for the discharge to be reviewed by the medical director. In a hospital as busy as ours, that can take a while.

With our trainee doing the assessment, I am free to turn my attention to other pressing matters. There’s a positive behavior support plan that needs to be reviewed and possibly revised. The patient is demonstrating a bit more appropriate social behavior than he was last week but has still not reached the threshold of the goodly amount needed to earn a bit of extra time with staff in the recreation center. It may be time to lower the bar just a tad to keep his motivation from flagging.

My phone rings and it’s the trainee with a question and an assurance that she will have the assessment done in a jiffy. While speed is always a factor, talk of a jiffy makes me nervous. Some things take time to do right and talking to people about sensitive topics is a prime example. It is important to be thorough and efficient, to explain the purpose of the assessment, and establish rapport sufficient to allow the patient to make an informed decision about whether or not to participate.

If he agrees, the interviewer will give him the opportunity to tell his story, using every tool a good psychologist has at her disposal. Whether we are doing evaluations or psychotherapy, we try to create a safe space where people feel comfortable expressing their thoughts and feelings, grow curious about themselves and commit to meaningful recovery. This process takes more than a jiffy. Numbers remind us that we need to use our limited time and resources wisely. They allow us to count what we do. Doing what counts is up to us.

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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