Presentation on theme: "Working Successfully After Brain Injury Jeffrey S. Kreutzer, Ph.D. Virginia Commonwealth University Medical Center."— Presentation transcript:
Working Successfully After Brain Injury Jeffrey S. Kreutzer, Ph.D. Virginia Commonwealth University Medical Center
Return to Work for Persons with Severe Traumatic Brain Injury: A Data Based Approach P. Wehman, M. West, J. Kregel, P. Sherron, & J. Kreutzer Virginia Commonwealth University Medical Center Employment Data Base
Wages and Weekly Hours all 87 persons were placed 27% were placed into a second position for both first and second placement –mean hours worked per week = 31 –mean hourly wage = $5.12 –mean gross monthly salary = $674 Employment Data Base
Employment Status months following program initiation n=87 Employment Data Base
Job Stabilization staff maintenance time falls below 20% of client’s weekly hours maintenance rate remains below 20% for 4 consecutive weeks funding and oversight shifted from rehabilitation agency to extended services funding agency Employment Data Base
Service Delivery Intensity Mean Values III pre-placement intervention hours3237 weeks to stabilization1520 intervention hours placement to127139 stabilization weeks employed3740 weekly intervention hours for extended 21 services total intervention hours for4740 extended services Placement Employment Data Base
Staff Intervention Time as a percentage of hours worked by the client Weeks Following Placement
Nine had been separated from two jobs Months employed before separation = 5.8 avg. Most separations occurred during first 6 months following placement Positions included semi-skilled and unskilled positions, e.g., clerical, sales, warehouse stock Nine had been separated from two jobs Months employed before separation = 5.8 avg. Most separations occurred during first 6 months following placement Positions included semi-skilled and unskilled positions, e.g., clerical, sales, warehouse stock Analysis of Job Separations from Supported Employment... 38 separations, from a total of 78 placements by 29 clients Journal of Head Trauma Rehabilitation
Primary Reasons for Separation Layoff - employer related financial difficulties Interpersonal issues with colleagues and supervisors - social cue misinterpretations, task and non-task related conflicts, verbal sexual and aggressive behavior Employment setting - change in supervisor or duties, poor match with client’s ability and interest, perceived lack of upward mobility Journal of Head Trauma Rehabilitation
Primary Reasons for Separation Mental health - psychological, criminal, or substance abuse difficulties Other - poor attendance, low motivation, transportation difficulties In one case, a client in litigation resigned on the advice of his attorney to gain a larger settlement Journal of Head Trauma Rehabilitation
Separation Analysis Methodology Identify all separations Obtain information from employment specialist based on direct observation, interviews with client, co-workers, and supervisors Corroborate by review of incident reports, case notebooks, employer evaluations, records Organize data thematically and summarize Grounded theory qualitative approach: Journal of Head Trauma Rehabilitation
Primary Contributors to Job Separations Journal of Head Trauma Rehabilitation
Factors Contributing to Job Separations Journal of Head Trauma Rehabilitation
Common Things Workers Say After A Brain Injury “Even though I’m a mess, I still have to support my family.” “I used to make $28/hour. Now, the only job I can get pays $6.50.” “I’m not sure what I can do, but I have to do something.”
Key Point Successful Return to Work Employers value a “good attitude” Responsiveness to feedback is critical
12 3 45 not important very important Qualities That Count With Employers NY Times Service When you consider hiring a new non-supervisory or production worker, how important are the following in your decision to hire?
Qualities That Count With Employers Factor Rank attitude4.6 communication skills4.2 work experience4.0 recommendations from current employees3.4 industry based credentials certifying skills3.4 NY Times Service
Qualities That Count With Employers Factor Rank years of schooling completed2.9 scores on tests as part of interview2.5 academic performance - grades2.5 reputation of applicant’s school2.4 teacher recommendations2.1 NY Times Service
Key Point Successful Return to Work Many employers don’t give feedback until after a crisis or prolonged performance downturn
Tips for Being Productive Find a mentor Try to be sensitive when you are having difficulty and ask for feedback. Help others to give you constructive feedback.
Help Others to Give You Helpful Feedback Explain how their feedback can help you get better. Explain how feedback can help you avoid mistakes, failing, and feeling frustrated. Remind people that you want to know about the good as well as the bad. Demonstrate receptiveness, avoid defensiveness. Show your willingness to change.
Tips for Being Productive Learn effective and comfortable ways to ask for help.
Asking for help... lets others know you care about your performance shows recognition of your limitations provides an opportunity to build relationships with helping people gives you a chance to be part of a team allows you an opportunity to reduce your frustration, and to be and feel more effective
Tips for Being Productive Avoid the challenge of hiding your injury. Learn what to tell people who ask you about going back to work. Learn what to tell people about your brain injury.
Tips for Being Productive Recognize and avoid the trap of doing too much. Cut down on responsibilities outside of work for at least 4-8 weeks after starting a job. Begin with a part-time schedule, build more hours as you feel comfortable.
The Best Way to Protect Your Job for the Long Haul honestly acknowledge your limitations convey reasonable expectations tell people that you are not yet back at 100% show a good attitude and give good effort
Helping Clients Keep Jobs A Problem-Focused Approach to Intervention Jeffrey S. Kreutzer, Ph.D., ABPP Virginia Commonwealth University, Medical Center
Physical Problems Fatigue, Slowness, Difficulty Lifting promote sleep hygiene provide sleep medications schedule regular breaks work during periods of peak energy complete challenging tasks during peak energy periods Helping Clients Keep Jobs
Physical Problems Fatigue, Slowness, Difficulty Lifting organize work environment for efficiency encourage pacing and adequate time for transition between tasks comply with schedule and weight restrictions set realistic timelines for task completion Helping Clients Keep Jobs
Cognitive Problems Poor Attention and Concentration work on one task at a time minimize noise and distractions work slowly and regularly check work use self-talk to improve focus for incomplete tasks, keep a record of where client left off Helping Clients Keep Jobs
Cognitive Problems Slow Learning, Forgetfulness list and review steps for task completion encourage rehearsal, paraphrasing, use of imagery, mnemonics use memory notebooks, calendars, checklists, alarms, “to do” lists Helping Clients Keep Jobs
Cognitive Problems Slow Learning, Forgetfulness tape record instructions for later playback emphasize learning by doing break tasks down into small steps, introduce new steps with mastery Helping Clients Keep Jobs
Cognitive Problems Communication encourage use of paraphrasing speak slowly and ask others to do so seek clarification to avoid misunderstandings Helping Clients Keep Jobs
Cognitive Problems Communication model optimal listening and speaking skills ask others to simplify, clarify instructions use synonyms, descriptions when word finding problems encountered Helping Clients Keep Jobs
Cognitive Problems Slow Processing divide complex tasks into smaller, simpler components allow ample time for learning and task completion Helping Clients Keep Jobs
Cognitive Problems - Planning and Organization assist in mapping out strategies monitor performance, encourage self-monitoring use an alarm as a cue for error checking and review teach structured problem solving Helping Clients Keep Jobs
Major Depressive Disorder Symptom Domains Mood depressed mood diminished interest or pleasure feelings of worthlessness Somatic weight change sleep disturbance psychomotor retardation or agitation decreased energy Cognitive diminished thinking ability recurrent death thoughts
Proportion of Patients Reporting Symptoms in Five or More Categories N = 722 total = 42%
Major Depression Following Traumatic Brain Injury Conclusion Major depression is a frequent complication of TBI that hinders patients recovery. It is associated with executive dysfunction, negative affect, and prominent anxiety symptoms. Jorge, Robinson, Moser, Tateno, Crespo-Facorro, & Arndt, Archives of General Psychiatry, 61, Jan 2004.
Psychiatric Illness Following TBI in an Adult HMO Population Results Prevalence of any psychiatric illness in the first year was 49% following moderate to severe TBI, 34% in the comparison group. Fann, Burington, Leonetti, Jaffe, Katon, & Thompson, Archives of General Psychiatry, 61, Jan 2004.
Personality and Mood Problems - Argumentativeness, Anger Control self-monitoring assertiveness training anger management, conflict resolution, impulse control training frequent, constructive feedback model good anger management and conflict resolution skills Helping Clients Keep Jobs
Personality and Mood Problems - Depression and Anxiety self-monitoring stress and mood stress management, relaxation training rank order priorities, and focus on highest priority(ies) recognize the dangers of overly ambitious expectations, goals Helping Clients Keep Jobs
Personality and Mood Problems - Depression and Anxiety develop reasonable goals, expectations seek outside support and mental health services regularly provide constructive feedback Helping Clients Keep Jobs
Personality and Mood Problems Impersistence, Amotivation, Adynamia mutually establish goals and monitor progress incorporate reinforcement systems develop task completion time frames considering client’s personality closely monitor performance Helping Clients Keep Jobs
Personality and Mood Problems - Interpersonal social skills, communication training self-monitor, solicit feedback role play effective ways to handle challenging situations provide frequent, constructive feedback model good interpersonal skills Helping Clients Keep Jobs
Relationship Building Between Job Coach and Client solicit information about client’s goals, interests, expectations appreciate history of failures, successes emphasize client’s role in decision making Helping Clients Keep Jobs
Relationship Building Between Job Coach and Client identify skills, strengths, and their relationship to work success facilitate development of achievable goals help client appreciate workplace rules and expectations help anticipate and avoid problems Helping Clients Keep Jobs
Evaluate Work Environments identify and address health and safety concerns observe co-worker interactions inquire about job satisfaction and turn-over identify workplace supports identify potential barriers to success Helping Clients Keep Jobs
Provide On-Site Assistance facilitate adjustment to employment develop and use compensatory strategies for cognitive impairments identify and address interpersonal problems apply stress, anger management skills Helping Clients Keep Jobs
What to Tell People About Your Injury Lee Livingston, Jeff Kreutzer, & Laura Taylor Virginia Commonwealth University Medical Center
Have People Asked You Questions Like These? “How did the accident happen?” “What’s wrong with you now? Why aren’t you working?” “When can you start driving again?” “Why do you stay home so much?” “Will you ever be back to normal?”
Why People are Uncomfortable Talking About Their Injury Talking about your injury may bring back painful memories. Your answer may be a painful reminder that your life used to be much better. You may feel embarrassed or guilty because you are not working.
Why People are Uncomfortable Talking About Their Injury You may feel frustrated if you can’t drive or do things that you used to. Questions may bring up fears and concerns about the future. You may also worry about what other people will think about you.
What to Watch Out for When Talking About Your Injury Feeling mad or frustrated Giving away too much personal information Painful memories Going out of your way to avoid people
Reasons to be Cautious When Talking About Your Injury Many people have negative stereotypes or don’t know much about disabilities. They may confuse brain injury and mental retardation. They may be afraid you’ll have a seizure, pass out, or attack somebody. They may think people with disabilities are helpless.
Reasons to be Cautious When Talking About Your Injury Others have bad opinions of people who don’t work or collect disability benefits. They may think people with disabilities are lazy and don’t want to work. They may think you’re faking your injury to get benefits. You may worry others won’t keep your information private.
When Deciding Who To Talk to and What to Say About Your Injury Ask yourself….. Is this the right time or place to talk about my injury? How well do I know this person? What’s my relationship with them? What do I feel comfortable with them knowing?
When Deciding Who To Talk to and What to Say About Your Injury Ask yourself….. Do I trust this person with this personal information? Will this person use the information in a way that might hurt me? How would I feel if this person told other people that I am not very close to?
When Deciding Who To Talk to and What to Say About Your Injury Ask yourself….. What is this person really trying to find out about me? Will I look bad if I share details about my recovery? Could information I share affect my job, school, or relationships?
Things to Think About Before Responding to People’s Questions Remember you can make choices about what to tell people about your injury. Only tell people what they need to know and what you feel comfortable telling them. Keep your answers short, simple, and to the point.
Things to Think About Before Responding to People’s Questions Remember you can always change the topic to something you feel more comfortable talking about. Politely decline answering or give little information if you do not feel comfortable talking about your injury. Talk to other survivors about how they deal with difficult questions.
Things to Think About Before Responding to People’s Questions Tell people you trust what you would like to say about your injury and get their reactions. Make a list of the questions you find the hardest to answer. Talk to trusted family and friends about ways to answer the questions. Practice saying the answers ahead of time.
Things to Think About Before Responding to People’s Questions Disclose the most personal information only to people you really trust – like family, close friends, doctors, and therapists. Before giving out personal information, ask the other person to agree to keep what you say in confidence.
Ways You Can Respond To Specific Questions Q: “What happened?” A: “I was in an accident a while ago.” Q: “What type of medical care do you need?” A: “I see my doctors every now and then.” Q: “How much longer will you need treatment?” A: “My doctors are helping me recover as quickly as possible.”
Ways You Can Respond To Specific Questions Q: “What are your current symptoms?” A: “I tend to get tired easily.” (or) “I have to pay attention to things more carefully now.” Q: “How are you doing now?” A: “I’m getting better slowly but surely.” Q: “When will you be able to come back to work?” A: “We’re working on a plan right now; I hope to know soon.”
Remember most people who ask about your injury are people who care about you. Think about that before you reply.
Productivity Options Jeffrey S. Kreutzer, Ph.D., ABPP Virginia Commonwealth University Medical Center
Meals and wheels Partners form team for special deliveries By Bill Lohmann Richmond Times-Dispatch Tuesday, May 12, 1998
Ken Hearns and David Stevens are, in the great tradition of dynamic duos, a perfect team. Hearns is an amputee, having lost his right leg; Stevens still lives with the effects of a serious brain injury. Neither can work full- time jobs any longer, but both wanted to give something to the com- unity by volunteering for Meals on Wheels. Separately, each was a puzzle without all the pieces. Together as partners, they form a complete picture. And have a good time doing it. Hearns drives. Stevens delivers. “I’m wheels,” Hearns said, “and he’s meals.”
Their work has not gone unnoticed. The pair were chosen as Richmond-area winners of the annual Meals on Wheels Volunteer of the Year Award and were top 10 finalists among more than a million volunteers for the national award. Hearns and Stevens will be honored at a ceremony tomorrow. The award is sponsored by ProjectMeal Foundation and Reynolds Metals Co, which will donate $1,000 in their names to Meals on Wheels of Greater Richmond. Hearns, 49, and Stevens, 42, work two days a week out of the New Covenant Church distribution center in Chesterfield County.
Hearns pulled his modified minivan - with the left foot gas pedal - into the church parking lot yesterday morning. He ambled into the church on crutches and the first thing Stevens did was hop up and go get him a cup of coffee. “I couldn’t be involved if it weren’t for Ken and visa versa,” said Stevens, who is unable to drive because of his brain injury. “It’s a teamwork situation.” Hearns and Stevens did not know each other before they were paired by officials at Meals on Wheels, which delivers food to the sick or disabled who can’t prepare or buy their own meals.
That was less than two years ago. Now they are friends who often go out to lunch after a morning of deliveries. Hearns also gives Stevens rides to other places - the American Red Cross and the YMCA, among them - where Stevens volunteers. Hearns, who lost part of his leg to infection 13 years ago and the rest of it in 4 years ago, has a personal purpose for volunteering. His elderly mother-in-law had received home delivered meals and he wanted to return the favor.
Typically, Hearns and Stevens start their Meals on Wheels Work at midmorning. Stevens sorts the food, while Hearns plots the delivery route that usually includes a dozen or so stops. Stevens hustles the cooler and bags to Hearns minivan - and the two men take off. Hearns and Stevens engage in some friendly give-and-take along the way. Although Stevens usually moves quickly in making deliveries, he sometimes stays to chat if the recipient wants to talk.
On cool days that’s fine, Hearns said. On hot days though, with the sun beating down on his green minivan, Hearns has been known to honk the horn to encourage Stevens to get a move on. “They’re a lot of fun,” said Beth Sacher, site director of the meals program at New Covenant. “They are very, very devoted to Meals on Wheels.” As for the award, Hearns calls it “mind boggling.” Said Stevens, “It’s nice to be recognized. But this is such a nice opportunity to help others.”
Therapeutic Curriculum 4. Evaluate the costs and benefits of working 5. Identify viable productive activities as an alternative to work 6. Evaluate the costs and benefits of additional training or schooling
The Costs of Working Transportation, clothing, child care, taxes Exhaustion and isolation Decline in physical and mental health Harm to relationships by “taking it out” on others Loss of disability benefits and leisure time
Brain Injury Work Survey Yes, No, or Not Sure? Do I want to work? Do I need to work? Am I able to work? Do I know what my strong and weak points are? Do I want to go back to my old job? Do I know where to look for work? Will I need help learning or doing my old job when I return to the workplace?
Well Adjusted Long-Term Survivors Focus more on what they have and less on what other people have Readily acknowledge personal limitations Learn to appreciate unpaid activities such as visiting, cooking, gardening, housekeeping, and hobbies
Well Adjusted Long-Term Survivors Give up trying to be the same person they were before the injury Don’t get angry at themselves for not doing better Set attainable goals and build on a foundation of success
Recovery Extension Principles Develop more effective strategies for doing things Stop doing things that don’t work Focus on primary goals, monitor progress, stick with plans that work See what works for others and what doesn’t
Recovery Extension Principles Listen to other people’s ideas Exercise your body and mind Learn from mistakes Ask people that care about you to give feedback
Ideas for Learning Library visits College and high school programs Read newspapers and magazines Surf the web and visit educational sites Visit parks, museums, historical sites Visit stores that offer educational demonstrations
Therapeutic Curriculum Consider the benefits of volunteer work Understand the types of available vocational services Identify vocational goals and the potential benefits of vocational services
The People Who Don’t Work Questionnaire True or False? People who don’t work …. - are lazy - would rather live off other people - are stupid - are worthless - have no faith or values - are mentally ill - are dirty
Volunteer Work Unpaid, meaningful, diverse work opportunities Often transitional Placements - schools, health and rehabilitation organizations, churches, and charities Based within community agencies, promoting integration
Volunteer Work Situational assessment opportunities Low cost training provided by host agency In vivo stress management and inoculation Difficult to arrange long- term professional supports
Bad spill saved cyclist’s life Now he’s honorary chairman of ride to benefit charity By Alberta Lindsey Richmond Times-Dispatch Sunday, May 14, 2000
“He was sprawled in the road” About 2 miles from the end of a 25-mile fund-raiser ride, he sprinted ahead of his friends. Then others started passing him. His arms were tired as he went up the final hill. ‘I thought I could manage the bike with my elbows, I lost control of it,’ said Mike, a fund raising coordinator for a local charity. ‘When I saw the front tire go sharply to the right, I knew I was going down.’
“He was sprawled in the road” His friends around him couldn’t understand what happened. There were no potholes, no boulders, no apparent reason for the fall, Mike recalled this week. One side of his helmet was crushed. His shoulder, knee, and wrist hurt. ‘I could only see straight ahead over my nose, but not to the sides. I knew that was a concussion… Thoughts were bouncing around in my head, disjointed and uncontrolled.’
“We see something” He went to the hospital. After a CT scan, he said a physician told him: ‘It’s fortuitous that you came to us today. For today’s incident, you are fine. We see something else. You have a cyst in the middle of your brain.’ Two weeks after the bike spill, he underwent surgery to remove the cyst. He was in the hospital six days and recuperated six days at home. Four months after the accident, he was bike riding again.
Offered to help The Lions Club will have another Country Roads Bike Ride on June 11. Not only will Mike ride this year, he will also serve as honorary chairman. “Everything we do is for charity… Mike was so enthusiastic about the ride saving his life. He offered to help in organizing this year’s ride. He’s given us lots of help in getting out mailings.”
Offered to help Proceeds will benefit Richmond area ARC and Lions Club programs such as Leader Dog, Inc., the Old Dominion Eye Bank and Hearing Aids for the Needy. Mike said, “The experience was so incredible, I wanted to use if for some kind of good.”
Whether or Not You are Working You Can Succeed Be patient and persistent. Get better by learning and trying. Create or find a supportive environment. Live according to your good values. Define success in your own terms.
Box 980542, Richmond, VA 23298-0542 USA PH 804 828-9055 Jeff Kreutzer firstname.lastname@example.org Virginia Commonwealth University Medical Center The National Resource Center for Traumatic Brain Injury www.neuro.pmr.vcu.edu