Employment After Traumatic Brain Injury

Updated : Nov 19, 2019 in Articles

Employment After Traumatic Brain Injury


Cindy Cai: Hello everyone. I am Xinsheng “Cindy”
Cai of the American Institutes for Research. I’ll be monitoring today’s webcast entitled
Employment After Traumatic Brain Injury. This webcast is offered through the Center on Knowledge
Translation for Disability and Rehabilitation Research, KTDRR, which is funded by the National
Institute on Disability and Rehabilitation Research, NIDRR. The Center on KTDRR has a
sub-grant with American Institutes for Research to develop a series of webcasts and to establish
a community of practice to help promote the understanding and use of evidence-based practices
in the field of vocational rehabilitation or VR. I am the project director of the sub-grant
and my colleagues Anestine Hector-Mason, Emma Hinkens and Prakesha Mathur have been instrumental
in the development of this webcast and related community of practice. I also want to thank
my colleagues Joann Starks and Ann Williams from SEDL in Austin, Texas for their support
of the webcast. Today’s webcast is one of our first collaborative efforts now that SEDL
has joined AIR as an affiliate. Here’s our agenda for today. After an overview
of the webcast topics, I will introduce our presenters and we will have a facilitated
discussion. We’ll then wrap up by letting you know how to become part of this discussion.
In the first webcast, we discussed the issue surrounding the use of practice guidelines
in the VR field. The most recent webcasts have focused on research and practice in motivational
interviewing in VR, supported employment for transition-age youths and returning to work
after burn Injury. In today’s webcast we will follow the same thread by translating research
to informed VR service delivery. We’ll have a dialogue with a researcher, with a VR counselor,
and a state head injury coordinator to discuss employment after traumatic brain injury or
TBI. In our dialogue today, we’ll discuss four
central questions: What is research and its evidence say on employment for individuals
with TBI? What does research say about the key issues that VR practitioners should consider
in supporting clients who return to work after TBI? What are some of the VR practices related
to supporting TBI survivors returning to work? And What is the role of practice guidelines
in supporting VR practitioners to work with clients with TBI? We’re happy to have three presenters with
us today. Dr. Jeffrey Kreutzer is a Professor of Physical Medicine and Rehabilitation, Neurosurgery
and Psychiatry at Virginia Commonwealth University, Medical College of Virginia Campus. Alyssa
Bonser is a VR Specialist at State of Maryland’s Division of Rehabilitation, and Maria Crowley
is the State Head Injury Coordinator for the Alabama Department of Rehabilitation Services. Now I’m going to turn to Dr. Kreutzer to ask
him to comment on the literature base about employment for individuals with TBI to address
the following questions: What is TBI? What are the critical factors related to employment
after TBI? What are key issues that VR practitioners should consider in helping clients with TBI?
What are some interventions or best practices that VR practitioners can use to support TBI
survivors in returning to work? Finally, what are the gaps in the literature base and research
on returning to work after TBI? Dr. Kreutzer, please take over. Jeffrey Kreutzer: Hello and thank you for
inviting me to be part of this very interesting and useful presentation. It’s important in
talking about brain injury to have a common definition, and the definition that myself
and my colleagues often use is that a traumatic brain injury refers to damage to brain tissue
caused by an external mechanical force as evidenced by medically documented loss of
consciousness or post-traumatic amnesia, also called PTA, or by objective neurological findings
on physical or mental status, examination that can reasonably be attributed to traumatic
brain injury, and this definition has been adopted by the traumatic brain injury model
systems of care. Now, I thought it might be very interesting
for people to appreciate some of the early effects of traumatic brain injury and many
times I find that vocational rehabilitation specialists post-acutely don’t really understand
or are confused by the fact that people with brain injury have so many challenges and so
many difficulties that they face and that really understanding brain injury really starts
by understanding what happened to the person early after their injury. So I borrowed an
excerpt from an actual discharge summary to give you a sense of what early on some patients
may face. Primary diagnosis, traumatic brain injury. In the chart, it also lists secondary
diagnosis for this patient, hypertension, methicillin-resistant staphylococcus aureus
pneumonia, otherwise known as a staph infection, right neurosensory hearing loss and left partial
rotator cuff tear. A brief history of patient that you might
see two or three years down the road as a vocational specialist, the patient is a 31-year-old
male admitted after a pedestrian versus car accident with loss of consciousness and an
initial Glasgow Coma Scale of 70 in the emergency room. I told you this was a verbatim discharge
summary and normally when I’m presenting this summary or slide, I would ask people what
it means when a person has a Glasgow Coma Scale of 70. Some people don’t realize this,
but the GCS or Glasgow Coma Scale, the range is actually 3 to 15, and 70 reflects most
likely an error in the chart that was not caught by anyone. You can’t really have a
70 on the GCS, but a 7 on the GCS means that a person had a severe brain injury. Generally
severes are classified as GCS 3 to 8. Head CT shows intraparenchymal hemorrhage, bleeding
in the brain, contusions to the right frontal and left frontal/temporal lobes, so there
was damage. Sometimes people ask me about “Well, what
is damage? What’s typical when you see damage to the right side of the brain or what’s typical
when you see damage to the left side of the brain?” In this particular case and in many
cases, you tend to see damage to both sides of the brain. Subdural hematoma, subarachnoid
and non-displaced right occipital fracture, so you’re seeing a fracture of the skull,
you’re seeing bleeding in the brain and the patient had neurosurgery in the form of decompressive
craniectomy to evacuate the subdural hematoma. Another thing this chart indicates is that
this patient had a partial left temporal lobectomy. Some of you may know that the temporal lobes
are really important, particularly the temporal lobes on the left side because they’re responsible
for language comprehension as well as auditory memory, but this patient was so badly injured
they removed an important part of his brain to save his life, but that will also leave
him with challenges and problems for years to come. The patient also had a non-displaced
left clavicular fracture, which is non-weight bearing. The patient had a tracheostomy. The
patient could not ingest food normally and had a G-tube inserted and the hospital course
was complicated by pneumonia and staph infection for which 21 days. So in summary the main point of showing you
this discharge summary is to help you understand that many of these severely-injured patients
have a combination of life-threatening illnesses or injuries and this person, the early chart
would indicate to me � if I looked at this chart today, I would say that this is a person
who’s going to have great difficulty in the long term trying to find and keep a job. So
I tell my students, be aware of the patient’s initial injury and that will give you some
hints as to the degree and type of challenges they’re likely to face employment-wise in
the long term. It’s not simply a brain injury, and here you can see infection, bone fractures,
bleeding in the brain. All these things together comprise the patient’s early status. Now, I thought it would be interesting for
people to see these photographs which actually appeared in a national newspaper and the caption
to these two photographs is “A construction worker who had six nails driven into his head
by a high powered nail gun is expected to make a full recovery.” There’s a reason why
I thought this slide might be interesting. It’s really unbelievable to me that the newspaper
would say that this person is going to make a full recovery. Obviously a person like this
is going to have cognitive deficits and there’s also a psychological trauma and I do think
the public is often misled. The newspaper may print a photo like this because they want
to show drama and they want to interest the readership and the drama is “Look how horribly
this person has been injured,” but despite the horror of this initial injury, this person’s
going to live a perfectly normal life, and as a clinician who has treated some of these
folks with these nail gun injuries to the head, I would say that it’s highly unlikely
that this person’s life will ever be the same. One of the things I think is a challenge for
people with brain injury is the misinformation of the general public and employers about
the true effects of traumatic brain injury in the short and in the long term. Now, part of the way that I’ve been involved
in helping people with brain injury is there’re several different ways. One is actually we’re
to develop supported employment programs and that’s part of what I spent the mid-80s and
early ’90s doing, but I’ve also spent a lot of my time doing research on employment after
traumatic brain injury. I thought it would be interesting for me to see some of the data
we collected on employment stability through the Traumatic Brain Injury Model Systems research
program. Basically we did a study that we published in 2003 in The Journal of Head Trauma
Rehabilitation and we categorized people as stably employed, unstably employed which meant
they’re employed sometime post-injury, and employed sometime and unemployed at other
times, and then there were people who were unemployed at all three follow-ups that we
did in the first three to four years post-injury, but what you can see if you look closely at
the slide, is that admission GCS was fairly similar between stably employed and the unemployed.
These three factors, days unconscious, days in acute care and days in rehabilitation,
can tell us a little bit prognostically about the likelihood that people are going to be
unstably employed and you can see that people who were unemployed had all three follow-up
intervals. They were unconscious for five times longer, they were in acute care for
twice as long as those who were stably employed and they were in rehabilitation more than
twice as many days as those who were stably employed. So what this data told us is that when we
see patients early on, that these three factors – days unconscious, days in acute care, days
in rehabilitation � can give us some prognostic information about a patient’s likelihood to
be stably employed in three to four years post-injury or unemployed for the first three
or four years post-injury. One of the factors in this study of employment stability that
was important as a prognostic is whether a person was able to drive a vehicle independently
or not, and in this case you can see that 63% of people who are stably employed were
able to drive their own vehicle, whereas 10% of these people unemployed at all three follow-up
intervals were able to drive their own vehicle. Education has some prognostic value for predicting
employment stability. You can see that 47% of people who had a college degree – nearly
half of the people we followed who had a college degree – were stably employed whereas if you
look at the high school graduate category, you could see that half as many high school
graduates or less than half as many were stably employed, so it appears that having completed
a college degree or having an advanced degree makes someone much more likely to be able
to find and keep a job in the long term. Now, one of the things that we were interested
in when we first really got started with our research was what are the challenges that
people face who are unemployed 5 to 34 years post-injury? I’ve broken the results of the
study up into several slides, but what we were interested in is systematically identifying
the challenges that people face in the long term with that information giving us some
guidance about the types of interventions and support that people need when they attempt
to return to work, and this is a list � we gave a group of people a questionnaire and
they were basically given a list of challenges or problems and asked to rate how frequently
they encountered those problems. My recollection is that there were 108 items on this problem
checklist. The number one challenge or the number one most frequent problem reported
by people 5 to 10 years post-injury was boredom, and you can see on this slide, listed number
two is moves slowly; number three, frustrated; number four, difficulty lifting; five and
six, reading and writing slowly. So what you can see from this slide is that slowness is
an important issue and the other thing is that you can see that there’s a combination
of motor issues – for example moves slowly. There’s a combination of psychological issues
and there’s a combination of cognitive issues. All three categories of issues combine to
comprise the challenges that people face 5 to 10 years post-injury, people who are interested
in finding employment. Now, there’s very little information on what
happens to people in the long term after traumatic brain injury and for people who are unemployed,
we separated this data into a group of people who are unemployed who were 10 to 34 years
post-injury. The top thing, the most frequent issue reported is frustration, and in my clinical
practice, most of the people that I talked to, both survivors and family members talk
a lot about the frustration of returning to an almost-normal life after brain injury.
The 10 most common problems for people who were 10 to 34 years post-injury are a combination
of psychological, motor issues and cognitive issues, frustration, forget people, forget
what they read. They are impatient with others and call that a psychological or social factor.
They feel like they are misunderstood, they’re bored, they lose train of thought, which can
be considered a cognitive issue. They read slowly, they write slowly, they move slowly
and if you sneak a peek at number 11, they think slowly. So these are the major challenges of people
10 to 34 years post-injury. When we looked at combining the data for 5 to 10 years and
10-plus years, what we found were two major categories of issues. One issue I’m going
to call slowness. People with brain injury move slowly, write slowly, read slowly, think
slowly and learn slowly, and in our society there’s a great emphasis on people doing things
quickly, and the way that employers or industries make lots of money is they get their employees
to work more quickly to speed up their output without increasing their salaries. So speed
is very important to employers in terms of their profit, yet one of the greatest challenges
that people face after brain injury is that they do things slowly. The second issue which is an issue that until
recently has been somewhat neglected is what I’m going to call mood problems or psychological
wellbeing. At least for the first 10 or 20 years, the research on traumatic brain injury
really emphasized the physical and medical aspects of injury, but what we’ve learned
over the last 5 or 10 years is that psychological issues or psychological and emotional concerns
or emotional recovery is also an important issue to appreciate when we’re working with
clients and trying to understand the long term impacts of the injury, so when we surveyed
people who were 5 to 34 years post-injury, in the top 15 list for both groups was the
issue of boredom or inactivity. I used the word “frustration” earlier and that’s a term
commonly used not only by people with brain jury, but also by their family members. People
are described as impatient and people describe themselves as misunderstood. So for the purpose
of being holistic and not missing an important characteristic of people who are many years
post-injury, I wanted to mention the emotional and psychological issues. Now, I thought it would be interesting to
ask people a question and that question is who do you suppose drinks more after injury:
people who are unemployed or people who are employed? Some time ago we did a study looking
at alcohol use patterns in people who were employed and unemployed, and what you can
see in this study that we published in The Journal of Head Trauma Rehabilitation, we
looked at the proportion of people, the percentage of people who were abstinent. Thirty-four
percent of people who were employed were abstinent and 62% of people who were unemployed were
abstinent. So what this means is basically that the rate of abstinence among the unemployed
is twice as great as people who were employed, so if you were among the group of people who
said that the unemployed drink more, these data would suggest just the opposite. In fact,
look at the column for moderate or heavy drinkers. Forty-six percent or nearly half of the people
who were employed were moderate or heavy drinkers. Contrast that to the number of heavy and moderate
drinkers among the unemployed. The rate for employed people is nearly twice as great in
the moderate and heavy category. Now, some of you may be puzzled by this, but
when we began to think about this issue and it reminded me of specific individuals who
were unemployed, I can recall a number of patients or clients that I saw who were unemployed.
They couldn’t drive, they had no money and they were living with their parents. It was
when people became independent, when they had money in their pockets, when they were
working, when they weren’t living and being supervised by their parents or siblings. It
was at the time when people became most independent, when they were able to drive down to the local
liquor store and pick up a pint of liquor. These data strongly suggests that the time
where we need to be most concerned about people with brain injury and their alcoholic consumption
is when they get back to work because that’s when they have much greater access to alcohol
and illicit drugs. So I was asked to think a little bit about
what the research says about the major return to work barriers. On my list is the fact that
employers focus on productivity, which is basically translating into English as how
fast people, can work for the lowest wage. Many work environments are competitive versus
collaborative, and while teamwork may be suggested or encouraged, there is often a great deal
of competition in workplaces, people competing for higher salaries, for higher status positions,
and so the person with a brain injury who may be in a disadvantage may be unlikely to
get as much support as would be ideal if people were working truly as a team. Ignorance and
stereotypes contribute to intolerance of disability. There is a tendency to compare clients to
how they were pre-injury, especially if they return to the jobs they were at before and
I have often had disagreements with people about whether it’s good to go back to a previous
position or not. It may seem comfortable, but what happens is when people go back to
their former position, they are compared to how they used to be and for many people, their
ability to be productive is diminished which encourages other people to be disappointed
� their supervisor, their colleagues to be disappointed and discouraged especially
in their productivity. Transportation is a challenge at least in
the first two or three years post-injury. Many people can’t drive and so they can’t
get to work and the research that we’ve done shows that if you can get yourself around
town, if you can get yourself to work independently, you’re much more likely to be able to hold
a job in the long term. The other thing is a lack of training. People with traumatic
brain injury, because their problems are so complex and diverse as we talked about early
on today, because their problems are so complicated and they’re difficult to see with the naked
eye, it’s really important to have employment specialists who are experienced and wise and
resourceful and there is a lack of trained people to provide support services. Let’s talk briefly about the key issues to
consider when a person is concerned about a client keeping their job in the long term,
and that’s what’s really important � not just finding a job, but keeping that job in
the long term as well. The factors that are important to consider are the person’s expectations
for the timing of their recovery and their ability to carry out the most important aspects
of their job. How much support is there in the workplace? Some workplaces are extremely
competitive where people are competing for wages and higher level positions. The person
who is likely to do best is the person who’s supported by their colleagues. We talked earlier
about how when people become more independent when they’re making more money when they have
greater access to transportation, they’re at greater risk. It’s important to monitor
clients’ alcohol use particularly when they first start to get back at work and start
earning the good paycheck. One important issue to consider is whether
it’s really the best thing for the client to go back to their old position or whether
they should consider a different job where people won’t be comparing them to how they
used to be which can be very painful. One of the things that’s happened over the last
several weeks is the price of gasoline at least in Virginia has been almost cut in half
and an issue that people face sometimes especially when they live in rural areas is the cost
of working. Some people have to buy a car, people have to pay insurance and people have
to pay for gas. That’s going to cost money. Is a person going to make enough money to
justify the expenses that come with working? Let me finish up on the issue of patience
and persistence, which are psychological qualities or character qualities. The people who tend
to do best after the most severe injuries are people who are patient and persistent.
Those two ingredients are clearly important when considering what might need to be done
to support a client in the workplace. What are the best practices if you’re a nurse
psychologist looking to deliver good services to people who’ve had a serious injury? It’s
important to do a thorough assessment of cognitive abilities, academic abilities and emotional
wellbeing to get a sense of the challenges and strains that a person has. It’s important
to appreciate how much support they’re getting from the family and to encourage family members
to be supportive in constructive ways. It’s important to educate clients and families
about the common challenges that people face after they have a brain injury, the cognitive
challenges, the vocational challenges, the psychological challenges, and stress management
is a key ingredient to effectively maintaining employment. We try to teach our clients skills,
how to communicate effectively, how to set reasonable goals, how to solve problems efficiently.
Emotional issues can be a problem in the workplace. We’ve talked about frustration. Helping clients
manage and control their anger and other intense emotions in the workplace is often critical
to them keeping a job in the long term. For employment specialists, it’s important for
them to be unobtrusively involved in training work-related skills. Teaching clients compensatory
strategies is extremely important as is promoting positive collegial and supervisor relationships.
The value of stress management can’t be overstated. It’s important to help clients solve problems
on their own. It’s easy to tell clients what to do and give them advice, but the long-term
goal is to help clients learn to solve their problems independently. Less time with the
employment specialist over time is what’s going to happen as people begin to learn their
jobs, as clients begin to learn their jobs, and when the employment specialist is phased
out, what other types of long-term supports are available in the workplace, especially
to address changes in the workplace which inevitably occur? I wanted to read a quote from an article we
published in the Archives of Physical Medicine and Rehabilitation that helps give you a sense
of best practices. From our prospective research, what we’ve learned is that the earnings reported
by people with traumatic brain injury in supported employment far exceed the cost associated
with employment services. Supported employment services are effective when provided by well-trained
staff. Staff training is a key factor dedicated to understanding the needs of the people served
as well as the business. Many programs are not adequately prepared to serve people with
TBI at this time. Clearly people with severe brain injury can face many challenges and
present as a challenge to the rehabilitation team. Perhaps the most important conclusion
that can be drawn from our research on supported employment is that people with severe injuries
and their families should not be led to believe that returning to work is impossible, and
when we talk about the attributes of the situation, the motivation of the individual and his or
her family, acceptance of limitations as people appreciating the new challenges they face
after their injury and supportive assistance from the rehabilitation agency are the key
elements of success. Let’s briefly talk about the gaps in the literature,
and it’s been interesting as someone who’s done research on employment for probably more
than two decades. There are still many gaps in the literature. What we need to understand
now is what are the best strategies for getting people back to work? To what extent can people
be self-employed? How well do people do in temporary staffing situations? What are the
most effective return-to-work models? Are their preventative interventions that we can
do that don’t require people to lose their jobs before we can serve them? One of the
biggest challenges has been getting people back to work in higher level positions. What
of the most efficacious models for getting people back to work in high level positions?
Thank you. Cindy Cai: Thank you, Dr. Kreutzer. Now, we’re
going to turn to Alyssa Bonser who will share her experiences as a VR counselor in supporting
employment for individuals with brain injury. Her discussion will address how VR practices
are guided by research in the state she works in, what interventions and strategies she
and her colleagues have used to support clients with TBI, what is the knowledge base for supporting
clients with TBI, what are the challenges in working with TBI survivors and what help
do VR counselors need to support TBI survivors who return to work. Alyssa? Alyssa Bonser: Thank you, Cindy, for inviting
me to participate in this presentation. Today I’m going to spend some time discussing how
Maryland’s employment initiative with acquired brain injuries came about and has been guiding
VR counselors’ practice in Maryland with the population. In Maryland, our practice is guided
by research when providing vocational rehabilitation services to individuals with acquired or traumatic
brain injuries. Historically in Maryland, rehabilitation counselors developed relationships
with community rehabilitation providers to facilitate employment services for individuals
with traumatic brain injuries. In 2006, Maryland advocates identified that
there was a lack of comprehensive services for individuals with acquired or traumatic
brain injuries. This research was reported to the Maryland Department of Disabilities
which resulted in funding being allocated to Division of Rehabilitation Services, also
referred to as DOR,S for us to take the lead on developing specialized employment services
for individuals with acquired brain injury. As a result of receiving this specialized
funding, DORS formed a steering committee consisting of stakeholders around the state.
ABI rehabilitation counselors were then designated and distributed around various state offices.
Services were determined based on best practices such as neuropsychological evaluation, cognitive
rehabilitation and long-term supported employment. Based on research, five phases of service
delivery were identified and individualized based on the consumer’s needs. The phases
consisted of assessment, compensatory strategies, work readiness, assistance with job development
and job coaching or supported employment. Supported employment job coaching is unique
to our agency as it allows us to provide long-term job coaching to this population, broader than
a 90-day follow-up period. In order for individuals to participate in this program, they must
meet the agency’s federal eligibility criteria just as other disability populations do. Under
the order of selection, the individual must be categorized as category one which is most
significantly disabled. Also, the primary cause of the disability must be a brain injury
to participate in the program. The final criterion is that the individual must not be actively
abusing substances or they must be committed to recovery. The ABI consortium was developed in partnership
with providers and practitioners to meet on a quarterly basis and review the progress
made by DORS consumers participating in this research study. The research study was launched
in 2006 and funded for the first five years. Now it’s currently funded through DORS. The
purpose was to expand employment opportunities for persons with significant disabilities.
Members included DORS administration and VR counselors, community provider representatives,
advocates from the Brain Injury Association of Maryland and the research team, which was
from University of Maryland. The research team was implemented to analyze the efficacy
of the specialized service delivery model and effectively meet the individualized needs
of consumers with brain injuries in securing and maintaining competitive employment. The
confidentiality of participants was protected with data collection maintained on an aggregate
basis only. This slide indicates that the research team
found that the majority of the individuals identified in this study were Caucasian males.
When looking at this next slide, more than three quarters of the study participants had
a high school education or above when receiving services. Results of the study also identified
a majority of participants to have a traumatic brain injury as the result of a motor vehicle
accident followed by cerebrovascular accidents being the second most common cause of traumatic
brain injury. As of September 2011, it had been determined that 84 study participants
were successfully rehabilitated while 51 were posed as unsuccessful due to various reasons. Interventions that I use with my traumatic
brain injury consumers vary based on the individual needs of the consumer. I used interventions
such as cognitive rehabilitation to improve concentration, memory and processing speed,
and sometimes I do this in conjunction with individual psychotherapy to allow the individual
insight into their strengths and deficits. Compensatory strategies are often determined
in collaboration with the VR counselor, the community rehab provider and the individual. Vocational assessment and work adjustment
training are beneficial to this population to determine realistic employment goals and
improve the individual’s work attitudes, social skills and provide exposure to work simulation
activities prior to reentering the workforce. Individualized job development is provided
to assist the individual in developing a resume, complete applications, follow-up on job leads,
practice mock interviewing, determine appropriate accommodations and follow up on interviews
with employers. Job coaching is also provided to assist the individual in learning job duties,
develop compensatory strategies to compensate for deficits and assist the individual in
maintaining appropriate relationships with supervisors and coworkers. I find it as imperative
to provide an ongoing assessment of the individual’s throughout their services to facilitate long-term
job retention. Collaboration and partnership is also imperative on working with this population.
Team meetings consisting of the individual, VR counselor, other medical or rehabilitation
professionals, family members and other advocates supporting the individual should also be included. My knowledge base for supporting this population
is mainly provided by an ongoing training program through the DORS ABI consortium meetings.
In addition to training, I am also a second year graduate student at George Washington
University majoring in rehabilitation counseling. I’ve worked with the brain injury caseloads
since 2008 and have been with the state of Maryland since 2005. Strategies I have used
to support this population to overcome barriers to employment are to make the job as procedural
and repetitive as possible, also involving the individual in all the aspects of planning
and always maintain open communication. Multiple modalities for learning should also be provided
depending on the individual’s needs. I also encourage the individual to use external aides
in their personal and professional life to assist with planning and memory deficits. Low-tech external aides can be inexpensive
and as simple as pencil-paper systems to help organize the individual. Some common ones
that I use are checklists, wall calendars, notebooks, timers and medication dispensers.
On the other side of the coin are more high-tech and costly external aides. Most of these aides
consist of electronic devices. I find smartphones to be the most efficient if the individual
has access to one because they combine several useful features such as alarms, calendars
and timers. Finally, some other useful strategies that I use with consumers to benefit them
are behavioral plans when necessary, maintaining a close relationship with the consumer supervisor
to educate them on working with this population, providing feedback to the consumers in the
present and helping them to maintain a work environment that is free from distraction. I would say the number one challenge I have
working with this population is impaired self awareness. Consumers that I have worked with
tend to have reduced awareness and overestimate their abilities while underestimating their
problems. Other challenges that are frequently presented in this population are impulsiveness
or poor judgment. In my opinion, VR counselors need partnerships with community providers
specializing in traumatic brain injury and cross-training among agencies. Additional
community rehab providers that specialize in TBI are also needed in many counties. Communication
with employers is also key when helping traumatic brain injury survivors return to work. My
main goal in working with employers is to promote an interdisciplinary team approach
while ensuring that all team members are consistent in utilizing the same strategies for targeting
behaviors or goals leading to a successful employment outcome. Overall my experience
with the supported employment model has been very successful. Cindy Cai: Thank you so much, Alyssa. Now
we’re going to turn to Maria Crowley. As a state head injury coordinator, Maria, can
you describe any trends you’ve noticed related to persons who have TBI and their quest for
gainful employment? Also, we’d like to learn what approaches has your agency used to support
clients with TBI to return to work? In your experience, which critical information that
VR practitioners need that’s missing in current research is related to supporting the employment
of persons with TBI?, and how do you believe research could help to advance the field regarding
supporting employment of persons with TBI? Maria? Maria Crowley: Thank you, Cindy, and thank
you for the opportunity to participate in this webinar. We’ve heard such useful and
accurate information already from the other two speakers from a research perspective and
from a direct service perspective. As someone who started out on the frontlines as a job
coach and now coordinates the program for the state of Alabama with brain injury, my
view is very similar to what we’ve already heard in terms of what a lot of those trends
and issues involve related to brain injury. I would also go a step further to say that
other states have the same experiences in working and collaborating with those other
states within my program and with some of the organizations that I belong to, they express
the same issues and concerns. Before I tell you a little bit about what some of the trends
are within our own department, I thought I would let you know a little bit about what
happens here and how our program is organized. Our lead agency for brain injury in Alabama
is located within the Department of Rehabilitation Services, specifically within Vocational Rehabilitation.
We’ve had a long history of providing community-based services to individuals with TBI, cognitive
stimulation, recreation, social support, housing, respite care, attendant care, and last but
not least, employment services. We’ve got a network of prevocational and vocational
rehabilitation counselors and I’ll tell you a little bit more about the prevocational
program here as it’s unique to Alabama. We have a network of job coaches and employment
specialists that have expertise in brain injury. We have an outside source for long-term support
for supported employment here which is a little unique, and then we’ve got some strong partnerships
with our brain injury association here with the Independent Living Program, with the Children’s
Program, with our model system certainly and with the hospital statewide, and all of that
together make for the ability for us to maximize success for individuals with TBI here with
employment as much as we can. Other states are organized very differently, but ever state
has to do what works best for its own state constituents. There are very wonderful things
happening in Virginia and in Maryland and in other states related to employment as well,
but they’re all very different and customized as things need to be for individuals with
brain injury. Although every brain injury is unique, as
you know, there are a lot of similar challenges and barriers that those with brain injury
encounter or engage in that we’ve noted here as well. I would like to start sharing a little
bit about self-awareness or the lack of self-awareness, as Dr. Kreutzer has touched on already, and
decision-making. Often we find that that is an indicator as to whether or not someone’s
going to do well with employment. Individuals who have difficulty in terms of brain injury
with remembering or learning new information, who are inconsistent with their performance,
who may have poor judgment and decision-making abilities who lack difficulty generalizing
current and old information to new situations and new job environments, who also have a
lack of awareness of these difficulties often have a difficult time with employment. That
creates a lot of frustration for the individual, for the service provider or the vocational
rehabilitation counselor and for that individual support system. Speaking of family support, that’s something
else that we find that’s so important, and the lack of family supports are certainly
a challenge in terms of employment. It doesn’t seem to matter what level of severity that
brain injury is. Without good family supports, individuals are not as successful with employment.
You’ve heard a lot already about addiction issues with alcohol and drugs. When individuals
are not in control of those substances, they’re often not in control of their employment situation
as well. Also when you think about addiction issues, that is an added stressor on an already
stressed support system with the family. Stamina and fatigue, individuals who have a difficult
time making it through a full work day or keeping up a pace in an employment situation
that that business is asking them to do also complicates things in terms of employment.
It’s very important to find out what an individual’s optimal times are for study or for work tasks
in terms of work, very important for a vocational rehabilitation counselor to take a look at. One of the most important issues or barriers
can be the ability or the inability to form and maintain relationships. Social skills
and social disconnects are often much more of an impairment than sometimes the actual
functional limitations that an individual may have due to brain injury. It’s a fact
people and business hire who they like. So much of who we are is what we do in our jobs
and individuals with brain injury are no different. We make friendships with the people that we
work with. We want to be satisfied with the employment that we have and that job satisfaction
is often closely linked to the relationships that individuals make there. Most people want
to have friends in the workplace and if someone has a difficult time with forming relationships
or having good, strong social skills due to behavior dysfunction, that makes things very
challenging. The availability or the lack of availability of resources in a community,
transportation specifically, but not just limited to that, often the availability of
resources in terms of job coaches, job placement specialists, physicians, practitioners, certainly
neuropsychologists and neuropsychiatrists, having a shortage of those in a state makes
for a lot of difficulty in getting good information and good support where someone is, and we
know that’s key to provide those things where someone is. Last but not least, just the variability of
the individual consumers that we work with. Everyone is so different. It’s difficult to
create one solution that’s going to be successful for every single person, and when you overlay
all of these barriers with the fact that brain injury is a hidden disability and people want
to deal with what they see � Dr. Kreutzer also mentioned to you that employer expectations
are high in terms of production and someone’s ability to fit in – it makes for a mix of
lots of difficulties if these things aren’t addressed. In terms of service providers and their level
of expertise, it’s important that not only placement specialists and job coaches and
VR staff are well versed with all the nuances that come along with brain injury. It’s also
important that the mental health system, physicians, educators, psychologists, all are well-versed
as well. Just because someone has a medical degree or a nursing degree does not mean that
they know how to treat brain injury. We see that time and again. Often assumptions are
made or the brain injury gets missed because it’s a hidden disability and that creates
a lot of difficulty for the individual that’s out there trying to go to work. The more awareness
that we can create about brain injury leads to more success for that individual and their
employment and for more funding so that we can do what works as that is an issue in almost
every state, the lack of funding. In terms of looking at successful approaches
and strategies that we have implemented here, I’ll come back to what I mentioned before,
which is the prevocational program that we have. It’s an interactive community-based
model. It’s a network of vocational rehabilitation counselors that focus on an individual from
the time they get home from the hospital to help them transition back into community involvement
and then gradually ease into the world of work. We find that making a nice, smooth transition
from home to community back to work creates the most successful situation here in terms
of employment. Not only is it successful, it’s also highly
cost-effective. In providing prevocational services, we reduce the cost of post-acute
care here, we reduce the time of referral to vocational rehabilitation overall to well
below the national average and it contributes to increasing wage averages when someone participate
in a pro-vocational program once they’re successful and going to work. Without that, we find that
people often fall through the cracks. Good neuropsychological assessment and feedback
is so important. We have very high expectations here because of the work that’s been done
at the TBI model system with UIB and Dr. Novak and his staff there. They have set the bar
very high in terms of getting good, accurate, functional information from a neuropsych assessment
and we use that time and again with individuals with TBI that work for. We get a lot of customized
information from those and the vocational rehabilitation counselors have been trained
on what to ask and how feedback is structured to get the most out of that for the individual
and the family. We find that “starting low and building slow”
has become a motto within our VR system for brain injury. Often where individuals with
traumatic brain injuries start, it’s not usually where they end up and they find that frustrating.
That’s hard for some individuals, but easing back into school or work is best. We believe
that that works here. If at all possible, we encourage individuals to participate in
a lengthy college prep course that’s offered by our community rehabilitation programs here.
We do a lot of auditing of classes. We work a lot on part-time employment before engaging
in longer, more competitive employment. We utilize volunteer experiences or unpaid work
experience, a good deal. We find it very helpful and that’s certainly allowed by the Department
of Labor and we carry liability insurance for businesses to feel more comfortable. Having
someone in a position that’s unpaid, it gives the counselor an idea of what someone can
do and it gives the individual and idea of what they can do and what they can’t do. Again,
kind of coming back to that lack of awareness of skills and deficits, it really helps if
they can get used to working before they commit to working by either volunteering or by doing
something that’s unpaid for a limited amount of time. We do a lot of long-term follow-up before
closure here. The rules and regulations that govern vocational rehabilitation dictate 90
days before closure after someone goes to work. Often with a case that involves traumatic
brain injury, that is going to be six months or more and it depends solely on how that
individual is doing, and there’s a lot of follow-up all along the way and beyond that
time, and that’s for someone that’s not in a supported employment caseload. We have TBI-specific
vocational rehabilitation counselors here in Alabama. They consistently have the highest
wage averages statewide of the other VR counselors. I like to brag on them a little bit. The reason
for that, we believe, is because they know those consumers, they have smaller caseloads,
they spend a lot more time with those individuals, they can afford to do that because the caseload
size is small, they do a lot more evaluative measures which takes more time on the frontend,
but it gets good results on the backend, and then that waiting to close a case before they
feel like someone’s ready happens here. We aren’t able to have a specialty TBI caseload
everywhere in Alabama, but we do for the areas where there’s a higher population of individuals
with brain injury and we see that it works. Alyssa’s already delineated a number of very
successful strategies in terms of helping people compensate for changes that have occurred
for them. I’d like to point out that a lot of accommodations that she mentioned that
we teach to service providers, job coaches and businesses that work well for individuals
with brain injury also work well for other types of disabilities as well. Learning disabilities,
disabilities that involve attention and social skills and neurobehavioral issues, mental
health issues can benefit from the same kinds of accommodations that happen for individuals
with TBI, and often that’s a selling point within vocational rehabilitation. Limiting
distractions, redirecting when someone’s focus is lost, encouraging them to capture information
in several formats when they go on an interview and when they’re starting work, providing
several solutions to a problem, those kinds of things, keeping things structured in the
workplace. Those work well for lots of different types of disabilities too. In terms of looking at critical information
that’s needed to support employment and traumatic brain injury, having good evidence-based community
outcomes from work that’s done and sharing that information is key. We’ve gathered lots
of good information here related to employment and those core recurring issues from the model
systems and the work that the model systems have done, specifically the work that Dr.
Kreutzer has done with caregivers, the work that’s gone on in Ohio with Gordon’s research
in substance use and abuse and employment and the work that’s happened at Mt. Sinai
with screening and employment and behavior have been very helpful to us here in Alabama.
The articles that have come from that, the research that’s come from the database from
the model systems has been great for us to have. One of the biggest challenges with vocational
rehabilitation counselors here � and I feel that Alyssa would probably agree with me on
this � is that they often have a big, full caseload and they don’t have a lot of time
for reading research and getting the bigger picture outside their own department about
what’s going on with employment trends and with vocational rehabilitation in other places.
Anything that we can do to help counselors with that would be key, and more interaction
between what happens with research and the service sector I think is also important.
A lot of what happens here is ongoing education. We provide core competencies training to all
of our TBI staff and placement specialists and job coaches annually and quarterly in
lots of different venues so that they can have information about what’s going on and
what’s most successful with employment. There are a lot of wonderful national resources
that have great materials that we use, the Centers for Disease Control certainly. NASHIA,
the National Association of State Head Injury Administrators, does a lot of training and
mentoring to states and state programs brain injury resources and materials, but there
are good things to be had from SAMHSA, from HRSA and a number of other national resources
as well. We also find that if at all possible, if we can get vocational rehabilitation staff
out and collaborating at national events, interagency conferences, other meetings so
that they can gather that information beyond their own states, we find that to be very
helpful as well. Then lastly in taking a look at what is needed
in terms of research and employment, what’s missing that I would like to see that we have
not been able to find much on that I feel the vocational rehabilitation counselors here
would love to have is something related to employment maintenance and social skills and
support post-employment. Once someone goes to work and they’re doing well, how do we
ensure that they continue to do well by providing supports for them while they’re working? Anything related to behavior, as I mentioned
before, behavior and social skills often get in the way much more so than any other deficits
that an individual might be experiencing. Something we tried here that we have found
anecdotally to be very effective for individuals that are already working is a replication
of the emotional regulation study that Dr. Gordon has done at Mt. Sinai, which is an
education and treatment program offered via GoToMeeting for individuals with TBI. We had
run two groups and found that to be very successful and they can receive that education where
they are after work as a group and they have found a lot of comfort and guidance in maintaining
their employment that way, and anything else that we can gather that’s related to research
and employment with associated or with secondary health issues, dementia, obesity, eating lifestyles,
exercise, nutrition, aging, suicide prevention, the things that come along as we live that
also affect individuals with TBIs would be most useful, specifically information for
our aging population and aging labor market. Cindy Cai: Thank you so much, Maria. Now,
we’re going to turn to the topic of practice guidelines. A previous webcast focused on
the potential application of practice guidelines in VR service delivery. Let us pick up that
discussion here. I want to turn to our presenters. Do you believe that practice guidelines or
training guidelines would be a useful tool for VR practitioners in helping them to define
the application of effective intervention or promising practices for TBI survivors to
support their return to work? If so, what are the benefits of having practice guidelines?
Dr. Kreutzer, why don’t you start off our discussion from a researcher’s perspective? Jeffrey Kreutzer: Sure, thank you. That’s
a simple question with a fairly straightforward answer and that’s the kind of question I like.
There are clear advantages to having practice guidelines. Practice guidelines provide empirically-based
information to guide care, it helps shape the expectations that clients and their families
have about the nature of service delivery and likely outcomes and they are also helpful
to train effective vocational professionals and also helpful for developing efficacious
programs. Cindy Cai: Thank you so much, Dr. Kreutzer.
Alyssa, would you please share with us your view about the benefits of practice guidelines
in VR service delivery? Alyssa Bonser: Yes, thank you. I absolutely
agree. I think having the VR practice guidelines is very useful especially to promote a universal
model and it also allows VR counselors to be consistent in the services that we’re providing
to this population. For us in Maryland, ever since we adopted the practice guidelines of
evidence-based employment, it significantly improved our outcome with this population. Cindy Cai: Terrific. So how about Maria, what’s
your perspective? Maria Crowley: Oh, I certainly agree as well.
It would be helpful for training new staff and giving seasoned staff some new ideas and
approaches that would be proven to be successful for those that are working in the field, and
better training will create better services for the individuals that are being served
and should lead to more satisfaction with work, better wages, longer term employment
outcomes. Cindy Cai: Terrific. Thank you so much, Maria.
What type of information should the practice guidelines include? Again, let’s begin with
Dr. Kreutzer. Jeffery Kreutzer: Practice guidelines should
address commonly encountered complex and challenging situations and that I mean by that it should
be no surprise if we see clients who have, for example, issues with substance abuse.
We often find that clients have difficulty managing stress and although going back to
work can be a good thing, it can also challenge people’s stress tolerance and issues of substance
abuse. Guidelines should also address principles and practice. What is it that guides what
we do to serve our clients? Guidelines should include detailed definitions and descriptions
and types of employment services available. People often think they’re talking about the
same thing, but sometimes unless what they’re talking about is well-defined, they’re actually
talking about different issues. Guidelines should provide foundational information on
brain injury, employment, prognostic factors and the benefits of different approaches to
vocational intervention and guidelines should also provide some information on the reliability
and validity of assessment approaches. Cindy Cai: Terrific. Thank you, Dr. Kreutzer.
So Alyssa, what is your perspective on this? Alyssa Bonser: I also agree. Again, I think
that they should provide typical issues faced by this population. Basic information on brain
injury is also helpful when training new staff on evidence-based practices, and also I think
the typical challenges such as behavioral issues, substance abuse, mental health issues
should also be addressed in the practice guidelines to help staff in working with this population. Cindy Cai: Wonderful, thank you, Alyssa. So,
Maria, anything to add? Maria Crowley: In addition to what’s been
said, I think really the only thing I would add to that would be something that the practice
guidelines could point out would be difference between serving those with brain injury versus
other kinds of disabilities within the vocational rehabilitation process, in the event that
those who are not working with brain injury daily can have support because that does happen
with states. Expectations within the VR system for defining what a successful outcome is
for somebody with brain injury, because it may look very different than what they would
see with someone with another type of disability. What does job stability and satisfaction look
like for TBI? Then anything that could be in there in terms of employment maintenance
and social support for employment. Cindy Cai: Right. Well, thank you so much,
Maria. Let’s hear from our presenters about who should be involved in developing practice
guidelines. Dr. Kreutzer, what is your thought? Jeffrey Kreutzer: Well, in rehabilitation,
I think one of the things we can pride ourselves in is being inclusive and at least I would
say at the very top of my list would be obviously people with brain injury and their family
members. Maria talked a little bit about the importance of integrating research and clinical
practice. It would be important to have vocational researchers involved as well as service providers,
advocacy organizations such as local brain injury associations and obviously government
which would include state and local agencies. Cindy Cai: Terrific. Thank you, Dr. Kreutzer.
Alyssa, what is your view? Alyssa Bonser: Just to add to that, I would
probably say also a vocational rehabilitation specialist and the employment specialist that
work with these consumers through the community rehabilitation provider. Also professional
organizations that work with consumers and perhaps the educators. Cindy Cai: Thank you so much, Alyssa. Maria,
anything to add? Maria Crowley: I think we’ve hit on everybody,
a representative from every group that we might want to have be involved with that.
I think it would be interesting to possibly survey those providers initially to see what
they view their needs to be, really to do a needs assessment and see what sort of format
might work best for them. Cindy Cai: Wonderful. Thank you, Maria. Well,
thank you everyone. Is there anything else, any topic that we have not discussed that
you would like to share with the listeners? Now, let’s begin with Dr. Kreutzer. Jeffrey Kreutzer: Well, I think one thing
is that we’ve come a very long way in our ability to provide vocational services to
people with traumatic brain injury and it’s interesting because when people early on talked
about vocational rehabilitation, they really spent a lot of time talking about all the
problems, all the negatives, all the things that were wrong with people with brain injury
and the challenges they face, and so one of the things that we’re beginning to learn is
about the importance of focusing on the positive aspects of our clients. So the topics that
I think would be very important to understand are how to recognize the personal strengths
of our clients, the value of patience and persistence as a personality characteristic
that maybe can be modified a little bit. We know that our clients make lots of mistakes
and obviously it’s important for people to learn from mistakes, but it’s not really going
to be much help to encourage our clients to focus on what they’ve done wrong in their
lives. Another issue that I’d like to see addressed
in programs is people’s willingness to ask for help from others and there’s a point in
the middle. Some people ask for help with everything, some clients feel like they can’t
do anything right and some clients don’t want any help and see asking for help as a shortcoming.
So the issue of helping clients decide on who to ask for help and how much to ask or
when to ask for help I believe could be addressed in some of the behavioral and psychosocial
programs. Cindy Cai: Terrific. Thank you so much, Dr.
Kreutzer. Alyssa, other topics that you would like to share with our listeners today? Alyssa Bonser: Just from my perspective and
working with this population to assist them in obtaining employment, I just think involving
the individual directly in the planning process rather than having the team or family members
trying to plan for them by directly engaging them and maintaining that open communication,
I just think that’s key in achieving successful employment outcomes. Also, I think with this
population it’s also important to remember that no two consumers are alike, so services
really do need to be individualized in order for them to achieve success. Cindy Cai: Well, thanks so much Alyssa, that’s
wonderful. Maria, anything from you? Maria Crowley: We have learned so much about
brain injury over the last several years. We have more to learn, but we already have
learned a lot of valuable lessons about what works best with traumatic brain injury. Again,
I would say it cannot be emphasized enough how unique TBI is, how different every individual
is, and that there’s no one-size-fits-all approach for successful vocational rehabilitation
and employment intervention with brain injury. It has to be customized to each individual’s
strengths and challenges and we really need to take a look at really defining what successful
employment is for someone with a brain injury in terms of length of employment and type
of employment. It matters. I guess lastly I would say that the three
of us would be happy, for anyone that participates with the webinar, to share any more information
about resources and materials that we use or the programs that we have. We’d be happy
to do that. Cindy Cai: Terrific. Thanks so much, Maria,
and also, thanks to everyone. Well, that concludes our discussion today. Thank you very much
to all our presenters. We hope that our listeners will find this webcast to be informative.
I want to remind you that today’s event is one of a series of webcasts on knowledge translation
from VR research to service delivery. Also, we intend that these webcasts will foster
the creation of a Community of Practice where this dialogue among researchers, educators,
practitioners, policymakers and other stakeholders can continue to inform and serve those dedicated
to vocational rehabilitation and its goal. To stimulate more discussion, we invite listeners
to contact us to provide your input on today’s webcast, share your thoughts on future webcast
topics and participate in the community of practice to continue the dialogue. We would
really love to hear from you because your views can inform and shape our future work.
You can contact us at the email address shown on the screen, [email protected] We would also appreciate your input about
the webcast by completing a brief online evaluation form. The link is here on the last page of
the PowerPoint slide. Everyone who registers will also get an email with the link to the
evaluation form. Once again, I want to thank Joann Starks,
Ann Williams and our new colleagues at SEDL, and all of the staff here at AIR. We also
appreciate the support from NIDRR to carry out the webcast and other activities. On this
final note, I’d like to conclude the webcast. We look forward to your participation in our
future events. Thanks, everyone.

Leave a Reply

Your email address will not be published. Required fields are marked *