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This Presentation prepared by

Maryland Department of Health and Mental Hygiene

Maryland TBI Implementation Project

Brain Injury Association of Maryland

Vocational Issues

After

Brain Injury2003

DHMH Logo Use Requested

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Learning Objectives…After this training you should be able to answer the following questions:

What is a brain injury?

How do different kinds of brain injury impact the individual’s daily functioning?

Why does brain injury impact a person’s employment status?

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…Learning ObjectivesAfter this training you should be able to answer the following questions:

Why does brain injury impact a person’s employment status?

How can brain injury affect learning, behavior and relationships on the job?

What can be done to help clients with brain injury find and keep a job?

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Presentation Overview

The Challenges of Brain Injury in the Work Environment

Barriers to Employment

Role of the Vocational Counselor

The Successful Vocational Program and Candidate

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The Challenges of Brain Injury in the Work Environment

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Specific Challenges for the Vocational Specialist

Job coaches, vocational counselors and other employment specialists may never have received specific training in brain injury

Individuals with brain injury may have an array of needs making it a challenge to be placed in an appropriate working environment

Brain injuries may be undiagnosed and under-reported

Traditional vocational evaluations may not accurately assess the client’s vocational potential

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Barriers to Employment

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Possible Impairments After Brain Injury

Barriers to Employment

Physical

Social/Emotional/Behavioral

Cognitive

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Changes after Brain Injury Could Include

Physical Impairments

Mobility Impairments

Reduced Coordination

Speech Impairments

Fatigue

Seizures

Sensory changes

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Mobility Impairments & Reduced Coordination:Difficulty with walking, balance, dizziness,

spasticity, paralysis, rigidity,coordination

Review medical records including physical and occupational therapy reports

Determine if adaptive devices may be needed

Re-evaluation of physical and occupational therapy might be necessary

Evaluate accessibility of workplace

Access work hardening program after specifics of employment are known

Ask about medications client may be on

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Speech Impairments: Speech or language pathology that makes it difficult for the person to speak or to be

understood

Review speech/language pathology reports

Request an evaluation if appropriate

Encourage client to speak slowly and repeat as necessary

Assist the client in establishing consistent non-verbal cues for use at workplace

Encourage the use of additional means of communications (email; fax; memos)

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Fatigue: Tiredness related to organic changes in the brain or may be related to over-stimulation. May also result from sleep disturbances common after TBI

Obtain a list of medical restrictions from physician

Reduce length of work day if possible. Gradually increase time as client tolerates

Assist employer and client to plan for the gradual increase of working hours and workload

Encourage client and supervisor to schedule work breaks

Allow extra time to complete task

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Seizures: A medical condition that may occur after brain injury and can be caused by a disruption in brain cell activity

Identify seizure protocol with client’s physician and ascertain employer policy

Educate employer, supervisor, other workers as to seizure protocol

Assist client in obtaining a medical identification bracelet or necklace

Help client to establish reminders to take anti-seizure medication as prescribed

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Possible Sensory Changes:

Vertigo: Minimize visual stimulation. Refer if necessary to a neuropthamologist or behavioral optometrist

Hearing: Evaluation of hearing problems by specialist (Speech/Language Pathologist, Audiologist)

Vision: Accommodate visual deficits. Assist client in the placement of materials for optimal viewing

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Possible Changes After Brain Injury

Social-Emotional Impairments

Irritability/Aggression/Mood Swings

Anxiety

Communication Difficulties

Poor Social Judgment/Skills

Denial/Lack of Self-Awareness

Rigidity/Inflexibility

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Impulsivity: Poor Judgment; Reduced ability to modify or inhibit words and actions

Decrease distractions (partitions, reduce noise…)

Teach strategies to maintain/regain focus (checklists; daily planner)

Break down tasks into smaller steps

Identify mentor/colleague to assist client

Provide cues to re-direct client

Modify work load

Increase pace of work assignments gradually

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Irritability/Aggression/Emotional Lability:

Difficulty in controlling emotions; Mood swings and inappropriate behavior may occur

Provide clear expectations for behavior

Plan and role-play social interactions that might occur at job site

Encourage client to slow down and think through responses.

Outline strategies for controlling temper (count to five….)

Evaluate client behavior and review possible alternative responses with client

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Anxiety: Individuals may have difficulty matching emotions to the situation at hand. This is especially true in novel situations.

Plan

Outline strategies

Provide feedback as soon as possible

Encourage client to slow down and think through responses.

Evaluate

Teach relaxation techniques

Explore medication when appropriate

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Communication:

Difficulties with initiating and maintaining conversations; talking too much; talking too little

Encourage client to practice expressing thoughts in safe environment

Role play possible conversations with others in the workplace

Encourage client to ask for time to organize thoughts

Teach client active listening techniques, such as repeating what they heard from the other person

Educate mentor/supervisor on specific communication difficulties and the way that he or she can assist client

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Social Judgment/Skills: Difficulty in reading social cues and understanding humor. Decreased awareness of social rules and roles. Demonstrates inappropriate manners that may result in isolation from co-workers.

Educate co-workers on brain injury aftermath

Identify co-worker who will work with client to prompt and redirect as needed

Identify possible problems in real-work situations

Plan and rehearse social interactions

Review workplace interactions with client and identify appropriate responses

Assist employer/supervisor to identify difficulties and use feedback in a positive way (privately; calmly; clearly)

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Denial/Lack of Awareness: Inability to realistically and accurately assess one’s

abilities; limited self-awareness and insight

Anticipate client’s lack of awareness

Assist client in identifying and accepting limitations

Promote questioning by client in work situations when they are unsure of what to do

Identify feedback needs and strategies for supervisor

Supportive therapy as available and needed

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Rigidity/Inflexibility: Difficulty in accommodating changes in routine and making transitions throughout the day

Break job tasks into small steps

Use a daily schedule to be reviewed prior to and at the end of the day

Assign a specific co-worker or supervisor to be the point of contact

Use alarm watch

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Possible Changes After Brain Injury

Cognitive Impairments

Executive Functioning deficits

Attention and Concentration

Comprehension and Memory

Self-Awareness

Initiating/Motivating

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Executive Functioning:Reduced ability to devise a plan of action and systematically implement it

Create templates of routine work tasks

Stress the need for daily job log

Log should be completed each day and reviewed each night

Questions and/or comments for job coach/boss/co-worker should be written down as well as the answer provided

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Attention and Concentration: Easily distracted. Difficulty in attending to tasks, focusing or maintaining attention (may be internal or external)

Identify mentor/colleague to assist client

Decrease distractions (partitions, reduce noise…)

Teach strategies to maintain/regain focus (checklists; daily planner)

Break down tasks into smaller steps

Provide cues to re-direct client

Modify work load

Increase pace of work assignments gradually

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Comprehension and Memory: Reduced ability to understand, process and recall what is being said or read

Provide written and verbal instruction

Model tasks whenever possible

Encourage the individual to paraphrase instructions back to the speaker

Enter instructions in job log

Use a tape recorder to enter reminders and instructions to review/reinforce later

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Self-Awareness: The inability to take a self-critical stance resulting in an overestimation of skills and abilities

Use of feedback both verbally and written

Videotape for self-observation

The establishment of a pre-agreed upon signal to give feedback if behavior/speech or work efforts are inappropriate or incorrect

Use of a contract prior to placement that clearly states roles and responsibilities

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Motivation/Initiation: Difficulty in initiating a task. May appear disinterested or unmotivated

Observe if individual responds better to visual or verbal cues

Use consistent cues and checklists that foster self-monitoring. Include individual in planning these cues

Teach self-prompting techniques

Use a co-worker to cue behaviors

Use a daily written assignment sheet/job log

Break tasks down into simple steps

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Role of the Vocational Counselor

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Possible Prevocational Needs

Psychotherapy

Psychiatry

Substance Abuse Program

Rehabilitation therapies (OT,SLP.PT)

Community re-entry program

Neuropsychiatric/Neuropsychological Evaluations

Work hardening program

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Role of the Vocational Counselor

Gather information

Develop therapeutic alliance (partnership) with client

Prepare plan of action appropriate for person with a brain injury

Utilize a problem solving format

Be open and maintain communication

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Gather Information

Medical Records

Current Medications (purpose, dose, schedule)

Psychological support

Rehabilitation reports

Neuropsychiatry/Neuropsychological Evaluations

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Therapeutic Alliance

Establish relationship at first contact

Ask them what they are interested in, what they have done before and what they would like to do now

Take the time to observe and get to know the person—Spend time on the vocational intake.

Ask them to bring in samples of their work, projects—something they are proud of

Be open and maintain communication by active listening

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Plan of Action

Clarify client’s needs, interests, abilities, impairments

Assist client in identifying expectations

Identify work-related problems and develop solutions

Identify and refer to other needed vocational services

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Be Open and Maintain Communications

Meet regularly to review progress toward goals

Provide timely feedback regarding performance

Include family and other service providers so the message is consistent

Provide written summaries of meetings

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The Successful Vocational Program and Candidate

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Ingredients of a Successful Vocational Program

Case management/resource coordination

Vocational evaluation

Job coaching

On-the-job training

Job analysis

Simulated job tasks in a clinical setting

Compensatory strategies

Work hardening to increase stamina

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Characteristics of a Successful Vocational Candidate

Rehabilitation therapies (OT,SLP,PT)

Able to manage frustration and anger

Awareness of deficits and the ability to generalize compensatory strategies in a variety of situations

Exhibits a desire to please others

Supportive family/social network

May be years post-injury

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Job Loss Factors

Lack of Social Skills

Poor Executive Functioning

Memory Impairments

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Lack of Social Skills

Dress and/or personal hygiene is inappropriate to the work environment

Egocentric in speech

Discloses personal information

Inappropriate sexual behavior

Unable to modify speech and behavior as appropriate ( too familiar with boss)

Unable to pick up nonverbal social cues

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Executive Functioning

Work space is messy and unorganized

Unable to work on several projects/tasks concurrently

Get caught up in extraneous details

Unable to modify a solution to a problem as the situation changes and shifts

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Memory Impairments

Unable to retain coworkers names

Unable to recall work routines

Unable to generalize knowledge/routines

Inconsistently able to utilize notes to support memory

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Inappropriate Workplace Behaviors

Being late

Interrupting

Talking too much

Arguing, fighting and yelling

Leaving without permission/notice

Preventing others from getting their work done

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Appropriate Workplace Behaviors

Show others respect

Address supervisors and other superiors appropriately (Sir, Ms)

Listen when someone is talking

Avoid interrupting

Maintain focus—don’t go off on tangents

Be prompt (check watch and map out plan to get to work on time)

Notify supervisor if going to be late

Any of the following may be a possible focus for vocational counseling:

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The Vocational Counselor Needs to Provide

• Structure

• Support

• Strategies

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Remember

“Success at work requires two basic components: The Skills necessary to perform the job, and the proper attitude, motivation , awareness, and consistency of behavior to function effectively on the job apart from and in addition to the particular skills required.”

Saralyn Silver (1988)

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Additional Resources on Brain Injury

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Additional Resources…

Print MaterialsCurrent Books

Understanding Brain Injury A Guide for Employers by Mayo Clinic (2000) www.mayo.edu

Vocational Rehabilitation for Persons with Traumatic Brain Injury by Paul Wehman & Jeffrey S. Kreutzer (Eds.) (1990)

Many other titles are available online and at your bookstore

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…Additional Resources…

WebsitesBrain Injury Association of America

www.biausa.org

Dana Foundation

www.dana.org

Half the Planet

www.halftheplanet.org

Also use web search engine terms “brain injury”, “traumatic brain injury”, or “acquired brain injury”

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…Additional Resources…

Organizations

Brain Injury Associationof Maryland(BIAM)

To contact BIAM: Call: (410) 448-2924 Toll Free in Maryland: (800) 221-6443Email: info@biamd.org Write or visit: BIAM

2200 Kernan Drive Baltimore, MD 21207

Website: www.biamd.org

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…Additional Resources

Organizations

Division of Rehabilitation Services (DORS)

Prepares individuals with disabilities for employment and independence

To contact DORS: Call: (410) 554-9385Toll Free (in MD) (888) 554-0334 TTY: (410) 554-9411Email: dors@dors.state.md.usWrite or visit: DORS

2301 Argonne DriveBaltimore, MD 21218

Website: www.dors.state.md.us

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Acknowledgements

The Maryland Traumatic Brain Injury Project wishes to thank the following individuals for their contributions to this vocational training:

Sharon Cullinane Anastasia Edmonston

Fran Forstenzer Jerri Fowler

Stefani O’Dea Diane Triplett

Amy Welch

 

Special thanks and acknowledgement to Saralyn Silver MS CRC formerly of the New York University Head Trauma Program and Patricia Price of the Florida Brain Injury Demonstration Project for their contributions to the field brain injury and vocational rehabilitation.

Alice Marie Stevens, PhDc, Editor, Vocational Issues After Brain Injury 2003 and Director, Maryland TBI Implementation Project, Baltimore, MD

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Acknowledgements

This training and its associated training materials are supported in part by the TBI State Grant Program, Grant Number 4 H21 MC 00008-04-03, from the Department of Health and Human Services (DHHS) Health Resources and Services Administration, Maternal and Child Health Bureau. The contents are the sole responsibility of the authors and do not necessarily represent the official views of DHHS.

Disclaimer: Information given within this training does not imply endorsement by BIAM or DHMH or any other party associated with this training. Listings in this training may not represent all the possible services or resources available.

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References

Ezrachi., O., Ben_Yishay., Kay, T., Diller, L., Rattok, J. (1991). Predicting Employment Brain Injury Following Neuropsychological Rehabilitation. Journal of Head Trauma Rehabilitation, 6(3), 71-84.

Jacobs, H. (1997). The Clubhouse: Addressing Work-Related Behavioral Challenges Through a Supportive Community. Journal of Head Trauma Rehabilitation,12(5), 14-27.

Kay, T., Silver, S. (1989). Closed Head Trauma: Assessment for Rehabilitation. In M. Leazak (Ed.), Assessment of the Behavioral Consequences of Head Trauma. (pp.145-170). New York: Alan R. Liss, Inc.

Malaec, J., and Basford, Jr. (1996). Postacute Brain Injury Rehabilitation. Archives of Physical and Rehabilitation Medicine, 77, 198-207.

Osborn, C. (2000). Over My Head: A Doctor’s Own Story of Head Injury From the Inside Looking Out. New York: Andrews McMeel Publishing.