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Acquired Brain Injury - Return to Work Dave Clemmons, Ph.D. , C.R.C.

Acquired Brain Injury - Return to Work Dave Clemmons, Ph.D. , C.R.C. 3rd Annual Pacific Northwest Brain Injury Conference September 30-October 1 - Portland, Oregon. Neurological Vocational Services. Dave Clemmons Clemmons@u. washington.edu (206) 744-9132

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Acquired Brain Injury - Return to Work Dave Clemmons, Ph.D. , C.R.C.

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  1. Acquired Brain Injury -Return to WorkDave Clemmons, Ph.D. , C.R.C. 3rd Annual Pacific Northwest Brain Injury ConferenceSeptember 30-October 1 - Portland, Oregon

  2. Neurological Vocational Services • Dave Clemmons • Clemmons@u. washington.edu • (206) 744-9132 • Harborview Hospital 325 9th AvenueMS 359744 / ClemmonsSeattle WA 98104

  3. NVS Objectives • Direct Services to persons with neurological conditions • Teaching, Training, Publication, Internship Programs . . . • Applied research

  4. NVS Research, Publication, etc. • Neuropsychological assessment • Counseling technique • Job development technique • NRSrehab.org (check latest publications, seminars, etc.)

  5. Teaching / Training CURRENT PRACTICES IN NEUROLOGICAL VOCATIONAL REHABILITATION • Two – to - three day clinical symposia in Seattle and nationally • Most recently: August 5,6,7, 2005 • Continuing Education Credits Available

  6. Populations We Serve • ABI • Epilepsy • Multiple sclerosis • “pseudoseizures” • School - to - work • Autism spectrum / Asperger’s • Other neurological . . .

  7. “Direct Services” Focus Is On: • Assessment • Training • Vocational counseling • Psychological counseling • and . . .

  8. Direct Services Focus Is On: • Job Development • Job Development • Job Dev . . .

  9. Important Point !! From a VR standpoint, epilepsy, MS, ABI, many other neurological populations are often quite similar. Difficulties in neuropsychological functioning is the unifying factor.

  10. Important Point #2 Difficulties with Neuropsychological Status are often more important than other symptoms.

  11. “State of the Union” for ABI / TBI Return to Work: • How are we doing ? • How well are we implementing new strategies ? • How well are we using standard strategies?

  12. Overall, How are We Doing in Neurological Rehabilitation ?-R. Fraser, 2003 • Answer: Not Very Well at Present

  13. Why is this still the case?Is it . . . • Fluctuating availability of VR funds • Order of selection • Managed care • “The Economy…” • Challenged consumer associations

  14. Is it . . .All of the above ?Well, yes, probably, but . . .

  15. We need more specialists in Brain Injury Vocational Services

  16. “Generic” VR programs and counselors will frequently have great difficulty in providing quality brain injury VR Services

  17. We need more specialists in Brain Injury Vocational Services

  18. Neurological Vocational Rehabilitation Issues: • Qualitatively different from many other disciplines • Dictate longer timeframes • Impose unique counseling issues • Involve “Hidden” client limitations • Involve “Hidden” client strengths

  19. Who is providing ABI VR services ? • Specialized Training / education ? • Relevant Experience (I.e. internships, supervised work) ? • Accountability ?

  20. Lack of Provider Sophistication in: • ABI Assessment • Counseling techniques and strategies • Appropriate Placement Strategies

  21. Lack of Sophistication in ABI Assessment • The Myth of “Medical Stability” • Planning without Neuropsychological Assessment • Need for Providers to Understand Applied Neuropsychology

  22. When should ABI vocational rehabilitation begin? • On demand ! * prevocational services * day programs * initial goals may change * client engagement may (will) influence recovery

  23. “Treading Water” – Postponing VR Services • Sabotages client motivation • Increases the likelihood of depression • Increases the likelihood of social isolation • Indicates lack of creativity on the part of the service provider

  24. Epilepsy Surgery Example • Pre-planning increases speed to post-surgery VR • Pre-planning decreases anxiety / depression • Pre-planning increases likelihood of eventual job placement

  25. Neuropsychological Assessment • Why is it still hard to convince some providers to obtain NP evaluations ?? • Why is it still hard to convince some providers to obtain NP evaluations ?? • Why is it still hard to convince some providers to obtain NP evaluations ?? • Why is it still hard to convince some providers to obtain NP evaluations ?? • Why is it still hard to convince some providers to obtain NP evaluations ??

  26. Neuropsychological Assessment • Can Identify Hidden Strengths • Can Identify Hidden Weaknesses • Cost Effective • Use of abbreviated NP batteries ? See citations . . .

  27. VR Planning without Neuropsychological Assessment • Misses hidden strengths • Misses hidden limitations • Ethical ??

  28. VR Planning without Neuropsychological Assessment • Situational Assessment ?? • CBA’s ?? • Volunteer situations ?? • Mc Carron Dial ??

  29. Using the Neuropsychological Assessment • ABI service providers need to develop skills that will allow them to work effectively with neuropsychologists. • Service providers need more direct training in neuropsychological concepts. (Hand - out)

  30. Using the Neuropsychological Assessment • Service providers need to develop less reliance on “experts” for vocational applications. • Service providers need to understand the counseling implications of NP status

  31. Counseling strategies in ABI VR • Neuropsychological status will often dictate: ** counseling technique ** counseling strategy

  32. NP –Counseling Implications • How are persons with frontal symptoms “different” in their problem solving ? • Strategies for working with persons with Aphasia ? • Is it memory or attention? Does it matter?

  33. Counseling techniques & strategies • Insight-oriented approaches ? • Logical, “linear” approaches ? • “talk therapy”?

  34. Counseling techniques and strategies in BI VR • Behavioral strategies • “Brief therapies” • “Strategic therapies” • Movement versus insight . . . • Skills in these areas are often undeveloped or used by service providers.

  35. Practitioners often lack skills for: • Dealing with “motivation” • Dealing with “denial” • Dealing with “unrealistic expectations” • Dealing with problematic anger

  36. Lack of Sophistication in Job Development • Reliance on traditional job development strategies (I.e. “self-actualization”, generic job search programs, “outsourcing” Job Development) • Lack of Client Support / Follow-up Strategies (90 days is not the “gold standard” for ABI VR

  37. Lack of Sophistication in Job Development • Under - emphasis on Job Development by providers • Over - emphasis on Job seeking Skills • Lack of a systems approach to Job Development

  38. Lack of Sophistication in Job Development • It’s easier for an individual or an agency to teach “job seeking” skills than it is to develop an effective job placement program. • But it doesn’t put people to work . . .

  39. Lack of Sophistication in Job Development • Job placement should not be an isolated event. • Job placement is an intermediate goal( ! ) . We need more emphasis on job maintenance. • Job placement as a function of a marketing, PR program which maintains ongoing relations with employers.

  40. See citations for L&I supported 120 hour trial work period • Seldom used by many VR agencies • Allows for a no-risk “try out” period • Useful for evaluation, “work hardening”, job sampling . . .

  41. In Relation to Placement, One Size Does Not Fit All! • e.g., Supported Employment

  42. Models of Work Access • Client coached • Selective placement • Supported employment • Natural supports

  43. Job Coach Functions • Consumer assessment • Job placement • On-site training/compensatory strategizing • On-site/off-site advocacy • Transportation/travel interventional & training • Counseling/social skills intervention • Case management/problem monitoring

  44. Natural Supports in the Workplace* • Employer/supervisor / trainer • Co-worker assistance • Co-worker as trainer • May be more desirable than job coach models * State VR Agency OJT support could be coupled with any of these approaches

  45. Coworker as Trainer Model • Curl, et. al, 1996 • Adapted from DD populations • Many advantages over traditional job coach strategies in ABI VR

  46. Why the Coworker as Trainer Model? • Lack of available job coach • Unreceptive to a job coach • Time investment on the part of job coach • Cost of a job coach • Skill level of the job

  47. It can be hard to find the perfect job coach

  48. Some Job Skills are Hard to Train

  49. A Coworker may also be a better social match

  50. Benefits of the Coworker Model • Coworkers are available as needed • Coworkers are cost-effective/provide better training • Interactive relationships build immediately • Coworkers are ongoing models • Supervisors feel in control and responsible • Coworkers are advocates

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