John Merladet, PhD, John P Billig, PhD, ABPP, & Diane Acord, MA, CRC, CBIS

ACT on L.I.F.E. Lifting Individual for Future Employment

Using Acceptance and Commitment Group Training in Vocational Rehabilitation Programs with Special Needs Veterans

John Merladet, PhD, John P Billig, PhD, ABPP, & Diane Acord, MA, CRC, CBIS

ACBS World Conference 8

Reno, Nevada

June 2010

Disclosure Information

We have no financial relationships to disclose

We will not be discussing any off-label and/or investigational use of medications in our presentation.

.though we may discuss use of off-label and investigational use of meditation

Objectives

Learn how to apply ACT in a vocational rehabilitation setting with consumers presenting with chronic disabilities

Learn how ACT can improve on increasing psychological flexibility and outcomes for reemployment.

Learn to assess right time to engage consumer in ACT process.

Population

Polytrauma: TBI, SCI, plus

OEF/OIF

Acute/ Transitional /Outpatient

Veterans and Active Duty USA solders

Generation X and Y: A new languageBlogs, My space, Texting, Casual, Expectations, Determined, Technology driven.

Younger Soldiers1

According to DOD, almost half of active duty service members are between the ages of 22 and 30 (avg 28)

37% of active duty Marines are 18-21 years old

Jamie Lindberg, Psy.D, Postdoctoral Resident, VAMC , Minneapolis, MN

Ideas About Success

Over 50% of college students surveyed in 2000 expected to make their first $1 million before age 402

They strongly believe in the American Dream and that success is the product of ambition and individual effort3

Those who work hard earn their advantages, and those who do not succeed simply did not work hard enough

Have been told that they can have it all

Tend to disregard the role of innate abilities in achieving success and more likely to have unrealistic expectations

Jamie Lindberg, PsyD, Postdoctoral Resident, VAMC , Minneapolis, MN

Employment4

Tend to expect meaning and fulfillment in their work

Place more value on quality of life and demand balance in their personal-professional lives

Need more feedback hearing that they are valued and do a good job

Tend to seek out direction and dislike ambiguity

Value authenticity in their leaders

Dislike conformity and have been encouraged to think outside the box

More likely to job-hop


Self-Esteem & Narcissism4

Self-esteem of young people has increased substantially, especially between 1980 and 1994

By the mid-1990s, the average Gen Y male had higher self-esteem than 86% of college men in 1968

Average college student in 2006 scored higher in narcissism than 65% of those in the early 1980s

Some attribute this pattern to the self-esteem movement


Social Approval4

College students need for social approval has stabilized at a historically low level

This may be apparent in physical appearance, dress, preference for innovation, and greater tendency to take risks


Family Upbringing

75% had working mothers5

25% were raised by a single parent5

Child is the center of the family6

Families are more democratic and collaborative6

Parents are highly involved in the lives of their children6

Helicopter parents sometimes to the point of rushing to prevent any harm or failure from befalling the child


Challenges for Voc Rehabilitation

Initial stages of adjustment to disability

Preoccupied with return to past performance.

Limited exposure to occupational information.

Early foreclosure in career maturity before service.

Pre morbid factors.

Myths about having a disability with rule laden thoughts about themselves and what they could accomplish.

Entitlement.

Rehabilitation staff.

Challenges(continued)

Push for rapid employment.

Not returning to work right away: Active Duty.

Reporting they did not want to return work.

Teams assumed voc was about returning to work and disability focused, so why refer them?

Impairment levels.

Need for a Framework:Literature suggests starting rehab pt early in voc rehab

Framework to help move pt beyond their situation from a vocational point of view that was rooted where they were at in the hospital.

Focus needed to be on tapping into life as an internal driver vs struggling with the disability.

Help pt move into space to consider meaningful life activities for the future.

Help pt modulate conflicting internal emotions around self efficacy and thoughts about ineffectiveness.

Needed an intervention that would not overlap with other psychological interventions.

Avoidance and undervaluing self

I want to be a stay at home dad

I want to do on line course work

I want to work alone

I want to stay on the couch and channel surf

I am only going to get worse

Ive served my country already

Unrealistic Overvaluing abilities

Taking too many credits in return to school.

Continuing to chose occupations that are likely to have long term physical and psychological consequences: police work, Triple Canopy , underwater demolition, carpentry.

Taking on multiple jobs.

I want to start my own business.

Psychological Inflexibility

WHO I WAS

Dominance of Conceptualized Past

REJECTING WORK PROGRAMMING OR INCREASING JOB HOURS

Experiential Avoidance

I WANT TO DO UNDERWATER DEMOLITION

Lack of Values Clarity

ILL BE A STAY AT HOME DAD/WORK ALONE

Avoidant/Inaction

Impulsivity

IF I CANT DO MY MOS, I WONT BE IN THE ARMY

Attachment to conceptualized self

I AM GOING TO GET WORSE

Cognitive fusion

Click to edit Master text styles

Second level

Third level

Fourth level

Fifth level

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Contact with the Present Moment

Problems

Interventions

Stuck on what was, including premorbid visions of future career

Fusion with need for future to be a return to premorbid jobs, functioning: just need to pick up where I was prior to the injury

Avoidance of physical condition or parts of body not functioning as they did

Stuck in mourning lost past and future

Staying in the zone

Listening to silence

Dogs life

Raisin activity

Vocationally this meant that I am not good at anything any more. Why bother trying.

17

Acceptance

Problems

Interventions

Avoidance of functional limitations and associated feelings, such as loss, grief, survivor guilt, insecurity, fear, anger:

Alcohol, drugs

Angry outbursts, fights

Withdrawal, isolation

Neglect of self-care

Refusal to address vocational concerns

Procrastination or lots of time in activities such as video games, TV, computer, etc

Joe the bum

Setting down the shovel

Passengers on the bus

Who took the governor off my engine

Purple heart/ruck sack/bootcamp

Did not even want to try supported employment

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Defusion

Problems

Interventions

Fusion with long-held views about career

Fusion with premorbid life roles

Fusion with thoughts about feelings, particularly negative feelings

Fusion with thoughts about lost functioning

Dont trust your brains

Mind chatter

Milk, milk, milk

Dont think about

Take mind out for a walk/ride

Self as Context

Problems

Interventions

Predominance of self-conceptualizations and life story

Defining self by injury, condition

Defining self by premorbid roles, status

Who am I: Man in the mirror

Observer you can hold experiences

Eye-to-eye contact

Hitting the wall

Values

Problems

Interventions

Fusion with view that values underlying previous jobs, roles are gone

Equating values with particular jobs

Difficulty distinguishing values from goals, outcomes, specific behaviors

What really counts

Employee of the year

Stand and commit

Committed Action

Problems

Interventions

Stuck in actions that function as experiential avoidance or from cognitive fusion

Difficulty identifying actions associated with work values beyond a narrow range

Avoidance of internal and external barriers that arise

I want it all and I want it now

Rolling with your disability

Fish hook and forgiving

Your tape measure

Passengers on the bus

Vocational Rehabilitation Intervention in Residential Program

Working in very part time supported employment setting with a job coach.

OEF/OIF.

mTBI to mTBI/PTSD.

Males 20-35.

Both active duty and veteran status.

Across the Upper Midwest and South Central States.

Limited work histories with only HS diplomas.

Open group.

May not be returning to work any time soon.

Early in their disability.

(Acceptance and Commitment Training for Lifting Individuals for Future Employment)

Expanding exposure

Defusing inflexible cognitions

Clarifying values

Process:

Check-in; work situations and ah-ha moments, (good-byes), ACT concept/Speaker, Wrap-up and VR business.

Goals of ACT on L.I.F.E. Group

Vocational Experience in Residential

Work Therapy/Supported Employment -Participate in supported hospital/community work activity. Develops confidence and self understanding. Achieving success through learning on the job.

Clinical Job Coaching -Providing one-on-one feedback on activity based work; related strengths and weakness; building endurance, activity tolerance, and confidence.

ACT on LIFE Group: Meet weekly to discuss weekly work experiences and topics in each of the HEXAFLEX domains.

Linked with a Vocational Rehabilitation counselor.

ACT on L.I.F.E. Outline: T.B.I. Transitional

Dont trust your brains (Diffusion /role of language). Veterans with TBI arrive fused with/in their situations; relaying on old scripts about who they should be now; the cants

Who am I: Man in the Mirror (Self as context). Lowered self esteem and feelings of inadequacy about self and capacity to accomplish/achieve like before.

Who took the governor off my engine (Acceptance/Willingness). Accepting the confusion and uncertainty. Struggling with anger/ depression/ about current circumstances.

What really counts (Values). Have lost touch of what was important. Hyper focus on family and getting support wherever they can.

I want it all and I want it now (Willingness with barriers to committed action) Multiple setbacks and barriers; stuck and confused.

Staying in the Zone (Ways of being in the moment with TBI). Encourages the veteran to stay in touch with the present moment. And to got with their experience in the here and now.

Unique Metaphors that Arose

Contact with the Present Moment: Staying in the Zone: what does your experience say.

Acceptance/Willingness: Who took the governor off my engine 1: Boot camp, Ruck Sack 1, Purple Heart.

Defusion: Dont trust your brain: Board of directors; the cants you tell yourself.

Self as Context: Man in the mirror: Drawing your thoughts in your brain; looking in a mirror and describe themselves vs a group buddy.

Values: What really counts: the chair.

Committed Action: I want it all and I want it now: impulsivity/inaction/struggle.

1 Developed by Steve Anderson, MS, OTL/R

CWT Job Coach

27

Results

Quantitatively

Qualitatively

8 AAQs were available.

-5 showed increases in PF.

-3 showed mild decreases in PF.

(2/3 showed inc. in older, 7-Item AAQ questionnaire)

It helped me manage my time and learn areas that need improvement

Exceeded my expectations

I feel more confident

Hire more job coaches

Conversations with people I didnt know

ACT on L.I.F.E.

Spinal Cord Injury

(Lifting Individuals for Future Employment)

Group Materials and Clinician Manual

Minneapolis VA Medical Center

Click to edit Master text styles

Second level

Third level

Fourth level

Fifth level

SCI Demographic

Older Veteran, non combat

Spinal cord and MS disorders

All wheelchair bound

Closed group

Had been living with the disorder for many years

Not working, but had had prior work histories

Engaged vocational counselor, Ms. Acord in PVA

Multiple medical issues and lack of proper adaptive skill set to be in competitive community placements BUT with expressed interested in returning to work and beginning process

ACT on L.I.F.E. Group Outline

Introduction to ACT and Telling Your Story

Conceptualized self

Employment Barriers and Cost of Avoidance

Experiential avoidance, struggle

Work Values and self acceptance

Values Clarity especially around work and disability

Managing Rejection/Hitting the Wall

Inaction/ Conceptualized self

Mind Games

Role of language and attachment to conceptualized past

Listening to the Silence Observer You

Present moment, self as context

Commitment: Healing Stories

Committed action

Booster

Unique ACTributes

Retelling your story activity

Employee of the Year

Listening to silence

Take mind out for a walk

Role model in work force to speak of journey

Results

Quantitatively

Qualitatively

Only two AAQs were available. Both showed increase in ratings of PF.

Older, 7-Item AAQ Questionnaire, also showed increase or stayed same.

Returned to old employer to ask if alternative jobs were available and settled on returning to school to get MBA.

Good Dragon skills but moving out of state; stated he would return to work if staying in MN.

Waiting on transportation; began exploring help with marketing T-shirts for bands he works with.

Expressed desire to return to his home town and return to local factory where he successfully worked with same disability in the past doing assembly work.

Experiential Exercise:Employee of the Year

References

Wiley, Andre L. (2008). Generational challenges for army transformation (unpublished masters thesis). U.S. Army War College , Carlisle Barracks, PA.

Shepherdson, N. (2000). Lifes a beach 101. American Demographics, 22, 56-60.

Abowitz, D. A. (2005). Social mobility and the American dream: What do college students believe? College Student Journal, 39, 716-728.

Twenge, J. M., & Campbell, S. M. (2008). Generational differences in psychological traits and their impact on the workplace. Journal of Managerial Psychology, 23, 862-877.

Welc, K. (2009, June 5). Who is Gen Y, and what do they want? The Daily Record.

Tapscott, D. (2008, December 15). Focus on the net gen family. BusinessWeek.

Chart1Baby BoomersGen XGen Y
Series 1

2007 Army Officers by Generation (in Thousands)

13

28

23

Sheet1Series 1Baby Boomers13Gen X28Gen Y23To resize chart data range, drag lower right corner of range.

Self as

Context

Contact with the

Present Moment

Defusion

AcceptanceCommitted

Action

Values

Documents

John Merladet, PhD, John P Billig, PhD, ABPP, & Diane Acord, MA, CRC, CBIS