Educate social workers about pain and grief

Social workers can play role in pain management

While nurses and physicians have their roles to play in palliative care of dying patients, social workers also have a responsibility for assisting in pain management, experts say.

Social workers need to know more about pain and palliative care because of hospice work as well as work in hospitals that often includes care for people who have life-threatening illnesses, says Terry Altilio, LMSW, social work coordinator in the department of pain medicine and palliative care at Beth Israel Medical Center in New York City.

"Most people see pain as involving physical symptoms, but pain can be very complicated, and so it's not only a physical event," she says. "It has emotions attached to it and thoughts and beliefs and expectations that can be very distressing to patients and families."

Part of a social worker's role is to look at human beings from a multidimensional perspective, Altilio notes.

"When somebody is experiencing serious pain or other symptoms, it becomes important in addition to treating the physical aspect to understand what the symbolism of those symptoms are in their lives," she explains. "For some, it's a physical experience; for some, it's redemptive; and for some, it's a sign of abandonment by God."

So it's important to look at the emotions and beliefs that surround the experience of pain when someone has a life-threatening illness, Altilio points out.

This perspective is an easy one for social workers to adapt since they are trained to look at multidimensional care, she says.

"I teach social workers to extend their skills to pain and symptom management," Altilio says.

Social workers also can be instrumental in helping patients alleviate pain and suffering through cognitive behavioral interventions, including relaxation techniques, she explains.

Social justice is another aspect of pain management, Altilio notes.

"Pain is undertreated in minorities and the elderly and in women, so there are social justice issues that pervade this topic," she says.

Also, political issues, minority health care issues, and many other aspects of pain management make it an amazingly rich topic for social work clinicians, Altilio says.

It's important to note that a patient can have pain, but not have suffering, and vice versa, she says.

"You can have pain from running a marathon, and it's not attached to suffering; it's attached to celebration," Altilio continues.

Alternately, a patient who is in hospice care because of a chronic lung disease or some other illnesses might not experience any pain but does have suffering because of the loss of freedom, mobility, and the prospect of death, she explains.

Dying patients can experience depression and anxiety without experiencing pain, Altilio notes.

"You can have depression that is a consequence of out-of-control pain," she says. "Sometimes, if you manage a patient's pain well enough, the patient's mood improves enormously, and the patient is able to sleep and engage in the world in a different way."

Other times, end-of-life patients who have psychological symptoms may need to be treated with antidepressants or other medication, Altilio says.

Another symptom that can be problematic is delirium, because end-of-life patients can become delirious for a variety of reasons, she says.

"It robs people of the quality of life they could have together in the setting of a serious illness," Altilio explains. "Some deliriums are treatable, and some are not, and some are part of the dying process."

It's very important to help patients who have delirium return to a more normal cognitive state so they can be in touch with their families in a way that is meaningful for them, she adds.

Relaxation techniques and other cognitive behavioral interventions may help patients cope with pain, Altilio says. "Cognitive behavioral interventions are designed to intervene in the relationship between mind, body, and your emotions. There are many different areas of living that are wonderful demonstrations of the relationship between emotions, mind, and body, and one of those is fear. If you can conjure up a fearful thought in your mind, then you can create a physiological reaction," she continues.

Health care providers can help a person who is in pain learn to change their thoughts and experience of that pain through such methods as hypnosis, Altilio explains.

"You use interventions and techniques they are most able to accept and try to teach it to them and help them understand it in a way that makes sense to them," she says. "You can tap into people's ability to use their mind and emotions because it can influence how they experience their body and pain."

Another area of end-of-life care in which social workers can help involves grief and psychological symptoms.

Very few medical professionals have received training in differentiating grief from depression, says Mary Raymer, MSW, ACSW, president of Raymer Psychotherapy and Consultation Services in Acme, MI. "So often a patient's receiving treatment for depression when the person is grieving normally, or vice versa," she says.

There are many differences, but the biggest is that in depression, the symptomology is persistent and pervasive; and in grief, the symptoms waxes and wanes, Raymer says.