Clinical social work

As an intrinsic part of the rehabilitation process, the clinical social worker has a unique role, not only as a member of a distinct discipline, but also as a member of the rehabilitation team. It is the combined functions of the rehabilitation team that c'al with diagnosis, treatment plan, and follow-up care of the disabled patient. Depending on the nature of the diagnosis and its origin and seventy, the treatment plan must always extend into the community, particularly with the involvement of family members and significant others who may have a relationship with the patient.

The developmental stage of the patient (infancy, childhood, adolescence, young adulthood, and old age) greatly influences the prognosis of the disability and governs the determination of suitable or adequate capacity for adaptation and adjustment to he diagnosis. Implicit in this process is the initial assessment of the problem, the patient's reaction to the disorder, the reaction of the family or spouse to the presenting problem, and the availability of resources-financial, emotional, public, or private agencies and services— all of which contribute to the total helping process and the ultimate maximum adjustment to the rehabilitation effort. Beyond the specific physical situation, in other words, there are a host of significant components that must combine in some orderly and systematic fashion if the patient is to receive maximum benefit.

Although social workers have specific training in a variety of helping methods—casework, group work, community activity, and advocacy—the critical element must be an understanding of the clinical problem. All planning and subsequent interventions must be based on a clear clinical understanding of the problem. In addition, the social worker should recognize that all patients are different and cannot be treated routinely if their total treatment plan is to produce successful results. Without individuation of each patient, the treatment effort will be mechanical and guaranteed to create resistance in the patient. Although institutional structures have routine procedures for assessment and standardized approaches to specific diagnoses, they also must identify individual factors such as the critical question of patient and family motivation for adaptation and change, adjustment to rehabilitation methodology, and capacity for dealing with mandatory management expectations.

Definitions

The words "impairment," "disability," and "handicap" are often used interchangeably and convey different meanings to the speaker and the listener. It would be helpful to clarify these terms in order to clarify different aspects of the rehabilitation process and goals. Impairment is a more generic word that literally means to worsen, so it might be applied to stages of disability or handicap or, in a larger sense, to quality of life.

Disability is a loss in personal coping and adaptation ability that causes limitations in daily living. It may include disturbances of the adaptive and adjustment mechanisms that ordinarily permit a relatively stable and healthy reaction of a person to the psychosocial, economic, and physical demands of life.

Handicap is a general term meaning a limitation of bodily motion or circumstances in daily living that prevents or makes a physical activity impossible (for example, missing arm.) Some professionals examine other aspects of handicap such as economic, sociocultural, and vocational factors. These are more sociologic than physical but contribute to total view of person as they contribute to basic physical limitations. In the diagnostic assessment and establishment of realistic goals for a handicapped person, these additional "social" factors cannot be ignored. For example, it may be assumed that a handicapped young black adolescent coming from a poorly educated, financially marginal household will have additional handicaps beyond actual physical limitations. These are the areas in which the expertise and competence of the clinical social worker come sharply into focus.

Having established one of the goals of rehabilitation as restoration of maximal healthful living, it would be helpful to refine the definition of health as mutually understood by members of the rehabilitation team. In the simplest biologic sense, at all stages of normal development health involves a minimum of three essential ingredients:

1. Functional capacity, or the ongoing management of physiologic capacities and adequate psychologic and social behavior, determines the estimated goals or limitations in which the behavior takes place. With aging, psychologic and social behavior are important in helping individuals cope with bodily changes and tolerate mechanical devices and other altering circumstances in the human organism.

2. Adaptive capacity is the capacity to achieve stability or develop compensatory defenses when there are up setting changes in the physical self or the external environment. It is critical in assessing motivation for rehabilitation efforts. The basic adaptive capacity is the most difficult or resistant to change.

3. Organizing capacity reflects the highest order of human expression in regard to optimizing adjustment. It is the effort or ability to match physical conditions or limitation with environmental and social aspirations and expectations. It is this area of activity that most deeply reflects education, culture, family tradition, and a host of nonbiologic or social elements. An area for the expertise of clinical social work is the preparation of a psychosocial history and analysis to help the rehabilitation team develop realistic treatment goals based on past history and family ego strengths, cohesion, and supportive elements available in forms of community resources. (For example, deeply religious families have often found considerable strength and capacity for adaptation through their religious convictions and beliefs.)