Rehabilitation social worker

By its very nature, the rehabilitation setting and process, whether in an acute care setting or a separate rehabilitation facility, exacts a heavy toll on social workers emotionally and professionally. The ethical dilemmas and values of the worker must be enmeshed with those of the team and the philosophy of the setting. They must face their own philosophy of life regarding: What is optimal quality of life? What is possible, desirable, and realistic? In what manner can or should we expect people to function? The severity of the disability and the coping capacity exacted from some patients, spouses, parents is frequently overwhelming. Social workers' maximum effective functioning is impaired if their values conflict with those of the team. This process also involves priority setting. It is not easy to face the parents of a promising young athletic adolescent who has suffered spinal cord injury and will never be able to walk again. The constant pressure of high expectations and limited outcomes creates sources of personal pain and conflict for social work staff. In large complex medical centers, it is possible to transfer and shift workers when they start to evidence and verbalize feelings of ''burnout" and lack of effectiveness.

The staff requires the energy to be patient, creative, and resourceful. Over-identification with the presenting problem and family and social situation can interfere with objective professional functioning. Workers require constant support from their supervisors and administrators. .. They must be able to work comfortably as team members with specific knowledge—frequently without intensive supervision. Their initial diagnostic psychosocial evaluations are critically important to the initial team conference and to generating a realistic plan of care. There will be moments of feeling inadequate and helpless, particularly with patients who do not respond to the process and who must be discharged to home with supports or to another facility.

Medical information (at least the implications of the diagnosis) must be understood, especially to help patients anticipate and plan with physicians and other team members in carrying out their role with families and community agencies. As the major liaison with families, social workers must have the ability to convey the team's thinking about future objectives to the patients and families.

There is no single social work strategy that embodies all modes of intervention: casework, group work, advocacy, education, and consultation. It becomes the social workers' responsibility to report to the team what resources are available and accessible; this information can greatly effect team planning, particularly if treatment goals are not being realized. The team needs to know other options exist for this patient. The social worker's experience with the community is important to the patient and family because community resources change constantly; even more important, eligibility for outside services is a complex and confusing issue. Most families cannot afford the extra items required for patients such as wheelchairs, prostheses, or home care attendants and are not knowledgeable about access to free building modifications to accommodate to the handicap. Many patients and their families must move to other housing if their own housing is crowded, inaccessible, or otherwise not appropriate. This of course is determined by the situation of the patient. One of the most complex and haunting questions is when, if, and how a patient can live independently in the community. This becomes a treatment goal if the patient wants to assume independent functioning apart from the family.

The social worker's role in group education cannot be underestimated. Groups of all kinds—patients, families, children, other professionals—offer considerable support and direct information sharing. During group activity, other team members should be encouraged to contribute information from their own disciplines. Groups of patients with similar diagnoses can be encouraged to work together on creative solutions and mutual understanding. The more aggressive and resilient patients and families are helpful to patients who are frightened and immobilized by the realities of their goals'" and living patterns. The tendency of social workers to find their reward in effecting rapid change stems from the psychiatric model that is part of social work training in psychosocial assessment and counseling. Because rehabilitation is gradual and often lasts a lifetime, it can be frustrating because the gains are slow and gratification is delayed, if it comes at all.

As with other patients, the rehabilitation patient's condition changes over time (especially with the aging process), and the worker must adjust to these changes with new approaches and creative ideas to meet the changing condition. Sooner or later, despite the advantages of independent living, independence may no longer be feasible or practical. Healthy adults also have problems with aging, but the process is even more complicated for the disabled person. With patients requiring skilled nursing home care, complications caused by their disability may create a need for more care than the nursing home can provide. One of the most exciting new developments is the movement of handicapped groups to create advocacy programs for improved services from publicly supported programs such as housing. Most of the larger urban areas have local offices of the handicapped to offer services to these patients and to address their problems in adjusting anr1 surviving in the community.

The team must consider issues such as timing and the patient's readiness for more complex rehabilitation tasks. While treating the patient, the social worker must also consider the community as part of his or her treatment responsibility so that the community can get ready to receive the patient back into its midst. Former routines and activities (such as attending church) must be considered, since the patient may not be as mobile as formerly.

For those patients returning to communities without resources for the disabled, the social worker must use creativity and imagination. One young woman patient was going blind as a result of juvenile diabetes. Her husband worked all night as a truck driver, and they were the parents of newborn twins. They lived in a trailer camp in a very depressed community, and there were no established home care agencies in their community. The social worker, with the patient's permission, suggested placing an advertisement in the local newspaper, and they were subsequently able to get several volunteers locally who came to help the couple.

One of the social worker's special contributions .to the team should be assessing the impact of the patient's psychosocial situation. Some of the most commonly identified psychosocial considerations in regard to disability are similar to those of nonhandicapped persons. The difference is that the health care experience is much longer in rehabilitation than in care for the acutely ill. The most frequently expressed psychosocial concerns focus on the following:

1. Health-care procedures, tests, treatment procedures, length of hospitalization, and sources of financing

2. Loss of status in household or community (the wage earner who can no longer support his. t»r her family) and life-style and financial adjustment.

3. The ability to respond to the needs and demands of others, being dependent on family or others, and becoming a burden on society

4. Initial concerns about ultimate outcome: fear of pain, prolonged discomfort, and of the unknown (death, loss of all functions)

5. Sexuality: loss of sensation, inability to perform sexually and its impact on spouse or partner

6. What to do after leaving the hospital—about managing alone or about remaining in the family if unable to contribute in any way

7. Past interpersonal and family problems, previous occupational problems, and related financial stresses and how these relate to current situation

8. Family members' attitudes toward the patient—expectations and plans or goals for the patient and themselves; the need to examine role readjustments and the ability to create new family systems relationships, power relationships, and decision-making processes

9. What is available in the community for support services: educational, vocational, social, ongoing future health care needs

10. Responses of those who must provide care; conflicts between patients and the health-care team regarding planning