This Presentation prepared by Maryland Department of Health and Mental Hygiene

1. Vocational Issues After Brain Injury 2003 updated 2009 This Presentation prepared by Maryland Department of Health and Mental Hygiene Maryland TBI Implementation Project Brain Injury Association of Maryland

2. Learning Objectives… After this training you should be able to answer the following questions: What is a brain injury? How does brain injury impact daily functioning? Why does brain injury impact a person’s employment status?

3. …Learning Objectives After 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 consumers with brain injury find and keep a job?

4. 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

5. The Challenges of Brain Injury in the Work Environment

6. 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 consumer’s vocational potential

7. Barriers to Employment

8. Barriers to Employment • Possible Impairments After Brain Injury • Physical • Social/Emotional/Behavioral • Cognitive

9. Physical Impairments • Changes after Brain Injury Could Include Mobility Impairments Reduced Coordination Speech Impairments Fatigue Seizures Sensory changes

10. 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 consumer may be on

11. 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 consumer in establishing consistent non-verbal cues for use at workplace • Encourage the use of additional means of communications (email; fax; memos)

12. 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 consumer tolerates • Assist employer and consumer to plan for the gradual increase of working hours and workload • Encourage consumer and supervisor to schedule work breaks • Allow extra time to complete task

13. 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 consumer’s physician and ascertain employer policy • Educate employer, supervisor, other workers as to seizure protocol (w/consumer’s consent) • Assist consumer in obtaining a medical identification bracelet or necklace • Help consumer to establish reminders to take anti-seizure medication as prescribed

14. 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 consumer in the placement of materials for optimal viewing

15. Social-Emotional Impairments • Possible Changes After Brain Injury Irritability/Aggression/Mood Swings Anxiety Communication Difficulties Poor Social Judgment/Skills Denial/Lack of Self-Awareness Rigidity/Inflexibility

16. 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 consumer • Provide cues to re-direct consumer • Modify work load • Increase pace of work assignments gradually

17. 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 consumer to slow down and think through responses. • Outline strategies for controlling temper (count to five….) • Evaluate consumer behavior and review possible alternative responses with client

18. 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 consumer to slow down and think through responses. • Evaluate • Teach relaxation techniques • Explore medication when appropriate

19. Communication: Difficulties with initiating and maintaining conversations; talking too much; talking too little • Encourage consumer to practice expressing thoughts in safe environment • Role play possible conversations with others in the workplace • Encourage consumer to ask for time to organize thoughts • Teach consumer 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 consumer

20. 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 consumer to prompt and redirect as needed • Identify possible problems in real-work situations • Plan and rehearse social interactions • Review workplace interactions with consumer and identify appropriate responses • Assist employer/supervisor to identify difficulties and use feedback in a positive way (privately; calmly; clearly)

21. Denial/Lack of Awareness: Inability to realistically and accurately assess one’s abilities; limited self-awareness and insight • Anticipate consumer’s lack of awareness • Assist consumer in identifying and accepting limitations • Promote questioning by consumer in work situations when they are unsure of what to do • Identify feedback needs and strategies for supervisor • Supportive therapy as available and needed

22. 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

23. Cognitive Impairments • Possible Changes After Brain Injury Executive Functioning deficits Attention and Concentration Comprehension and Memory Self-Awareness Initiating/Motivating

24. A deficit in executive skills might look like the inability to plan and organize or it might look like...(Capuco & Freeman-Woolpert) • Uncooperativeness, stubbornness • Lack of follow through • Laziness • Irresponsibility

25. Executive Functioning:Reduced ability to devise a planof action and systematicallyimplement 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

26. An attention deficit might look like trouble paying attention or it might look like…(Capuco & Freeman-Woolpert) • He keeps changing the subject • She doesn’t complete tasks • He has a million things going on and none of them ever gets completed When she tries to do two things at once she gets confused and upset

27. Attention and Concentration: Easily distracted. Difficulty in attending to tasks, focusing or maintaining attention (may be internal or external) • Identify mentor/colleague to assist consumer • 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 consumer • Modify work load • Increase pace of work assignments gradually

28. A memory deficit might look like trouble remembering or it might look like……(Capuco & Freeman-Woolpert) • She frequently misses appointments-avoidance, irresponsibility • He says he’ll do something but doesn’t get around to it • She talks about the same thing or asks the same question over and over-annoying • He invents plausible sounding answers so you won’t know he doesn’t remember

29. 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

30. 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

31. 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

32. Role of the Vocational Counselor

33. Possible Prevocational or Concurrent Vocational Needs • Psychotherapy • Substance Abuse Program • Cognitive Remediation via Rehabilitation therapies (OT,SLP.PT) and/or a Community re-entry program • Neuropsychiatric/Neuropsychological Evaluations • Work hardening program • Driving evaluation/retraining

34. Substance Abuse & Brain InjuryAlcohol Use & TBI-IncidenceAnalysis of the Literature (Corrigan 1995) • Alcohol, the drug of choice-Corrigan and his colleagues report that for 70% of the individuals they work with who use substances, alcohol is the preferred substance • Intoxication at time of injury-7 studies looked at incidence of intoxication (BAL equal or exceeding 100mg.dL)at time of injury. Intoxication ranged from 36% to 50% • History of Substance Abuse-Findings suggest that for adolescents and adults in rehabilitation following a TBI, as much as 60% of this population have histories of alcohol use or dependence.

35. Substance Abuse & Brain InjuryHow does Incidence and History Impact on Recovery & Outcomes? Studies Suggest….. • Alcohol may negatively affect the process of dendrite profusion thus impede ability of the remaining neurons to compensate for the neurons that have been damaged (Corrigan, NASHIA webcast 2003) • Alcohol use after brain injury may increase the risk of seizure post TBI • Increased brain atrophy observed in patients with a positive BAL and or history of moderate to heavy pre-injury use (Bigler et al 1996 & Wilde et.al 2004)

36. Subsequent Use • 5-10% of those with TBI develop substance abuse problems after their injury(Corrigan 2009) • “A person with a preinjury history of two drinks a day would not have had a reason to seek alcohol-related treatment before his or her accident. But once that same person becomes brain-injured, the continuation of that drinking pattern has the potential to cause major problems” Robert Karol, Ph.D.

37. Taking Advantage of the “Honeymoon” Period • Individual in an inpatient and/or highly structured outpatient setting resulting in detoxification • Physical and cognitive disabilities make access to substances difficult • Families are instructed to provide supervision due to physical needs and judgement concerns • Individual is remorseful over past use, related behavior, blames self for accident and vows to change

38. Screen • CAGE Questionnaire • Brief Michigan Alcoholism Screening Test (BMAST) • AUDIT • According to brain injury researchers, the above tools are appropriate and valid for use with individuals with brain injury

39. ……..and Intervene • Modify 12 Step Program components to accommodate cognitive and behavioral concerns • Incorporate substance abuse education into cognitive remediation, prevocational and employment services • If you ask, they will tell, self report according to researchers is a reliable measure of risk and use • Don’t assume staff can easily identify who is currently using or at risk • Discard old stereotypes e.g. “he has to hit rock bottom before any intervention will work”

40. Characteristics of a Successful Vocational Candidate • Rehabilitation therapies (OT,SLP,PT)- carry over of strategies learned • 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/work ethic • Supportive family/social network • May be years post-injury

41. “I had a job, I had a girl, I had something going mister in this world,I got laid off at the lumber yard, Our love went bad, times got hard. Now I work down at the car wash, where all it ever does is rain. Don’t you feel like you’re a rider on a downbound train”Bruce Springsteen quoted by young man living with a brain injury for over ten years

42. Happy Ending • Six months of outpatient brain injury rehabilitation, received speech, OT, mental health, & group therapy • With a employment specialist’s support, hired at a golf course-grounds keeper • After several years, wanted more money,new challenge, took a job w/ an auto parts company as a delivery truck driver, received a few months of supported employment funded by the Division of Rehabilitation Services

43. Job Loss Factors Lack of Social Skills Poor Executive Functioning Memory Impairments

44. 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

45. 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

46. 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

47. Inappropriate Workplace Behaviors • Being late • Interrupting • Talking too much • Arguing, fighting and yelling • Leaving without permission/notice • Preventing others from getting their work done

48. Appropriate Workplace Behaviors Any of the following may be a possible focus for vocational counseling: • 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

49. The Vocational Counselor Needs to Provide • Structure • Support • Strategies

50. 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)