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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,

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Presentation on theme: "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,"— Presentation transcript:

1 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

2 Neurological Vocational Services  Dave Clemmons  washington.edu  (206)  Harborview Hospital th Avenue MS / Clemmons Seattle 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 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 ??

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

51 Why Doesn’t the Coworker Model get used??  It’s easier to go generic ??  Lack of creativity ??  Lack of provider skill / training ??  Lack of skill in employer contact ??

52 What can Brain Injury Associations do?  Promote “Teaming” in VR efforts * significant others * state rehabilitation counselors * advocates  Develop effective employer advisory boards.

53 What can Brain Injury Associations do?  LOBBY for ABI specialists in state VR agencies  Lobby for more sophisticated services

54 What can Brain Injury Associations do?  Lobby for conceptual changes in Vocational Rehabilitation services  Lobby for quick access to VR services, or....

55 What can Brain Injury Associations do?  Take over some traditionally state VR functions ???

56 What can “consumers”, SO’s, Parents, etc. do?  Know the basic issues  Don’t hesitate to question agency decisions  Ask for purchase of specialized services

57 What can “consumers”, SO’s, Parents, etc. do?  Lobby !  Become involved with relevant “consumer” associations  Become an advocate (i.e. informed, direct, consistent action)

58 FINAL EXAM Following are some common ABI counseling “dead ends” There are strategies for dealing with these concerns without making them major issues. If you can’t do this, you may not be a very effective ABI service provider

59 Counseling Dead Ends & Editorial Comments  Client is not “motivated” *Do you mean organic problems with initiation or problems with laziness ??  Client is “in denial” *Does this refer to a cognitive inability to understand the situation, or to denial as a psychological defense? (Or both ?)  Client is “in denial” *You’re in denial too. We’re all in denial abut things. It’s your job to not let it get in the way.

60 Counseling Dead Ends & Editorial Comments  Client has “unrealistic expectations” *Don’t act so surprised: that’s part of the problem.  Client won’t accept her/his disability *So what ? Work around it.  Client does not “follow though” *What does the NP data tell you how you could change your approach ?

61 Counseling Dead Ends & Editorial Comments  Client does not “follow through” * Have you ruled out memory problems ? * Have you ruled out attentional problems? *Are there subtle language problems ? * Does your verbal / written communication accommodate decreases in cognitive efficiency ?

62 References / Citations  Clemmons DC, Fraser RT, Getter A, Johnson KL. (2004) An abbreviated neuropsychological battery in multiple sclerosis (MS) vocational rehabilitation. Rehabilitation Psychology, v4,#2, 2004.

63 References / Citations  Curl, R., Fraser, RT, Cook, R., Clemmons, D. (1996). Traumatic brain injury vocational rehabilitation: Preliminary findings from the Co-Worker as Trainer Project. Journal of Head Trauma Rehabilitation, 11,

64 References / Citations  Fraser, RT, Clemmons, DC, Bennett, F., eds Multiple sclerosis: A vocational workbook for the rehabilitation counselor and other allied health rehabilitation professionals. New York: Demos (2002) pp (120 hour job try-out)

65 References / Citations  Fraser RT, Cook R., Clemmons DC, Curl RM (1997). Work access in traumatic brain injury rehabilitation: A perspective for the psychiatrist and allied health team. Physical Medicine and Rehabilitation Clinics of North America, 8,

66 References / Citations  Curl, R., Fraser, RT, Cook, R., Clemmons, D. (1996). Traumatic brain injury vocational rehabilitation: Preliminary findings from the Co-Worker as Trainer Project. Journal of Head Trauma Rehabilitation, 11,

67 Neurological Vocational Services  Dave Clemmons  washington.edu  (206)  Harborview Hospital th Avenue MS / Clemmons Seattle WA 98104

68 SEVEN AREAS EXPLORED IN NEUROPSYCHOLOGICAL TESTING FOR VOCATIONAL REHABILITATION COUNSELING  Sensorimotor Ability:  -Do the areas of the brain responsible for controlling the body's muscles function efficiently? Does the brain efficiently process input from the sensory organs?  Attention and Concentration:  -The ability to attend to individual stimuli. The ability to focus attention on a stimulus in the presence of distractions or for an extended period of time.

69  ** Memory:  -Visual-spatial memory; verbal memory; long- and short- term memory; "incidental" memory vs memory for rehearsed or practiced items.  Language Ability:  -The ability to understand language and to use language to express ideas.  Spatial Ability:  -Ability to deal with two and three-dimensional formats, perceive whole/part relationships, perceive field-background relationships.

70  ** Cognitive Efficiency: -The ability to efficiently perform simultaneous tasks, or tasks in the presence of competing stimuli. The ability to screen out extraneous stimuli.  ** Executive Function: -Abstraction, Problem-solving, Self-regulation, Initiation. _______________________________________________ _________________________ This outline is intended as a model for describing various areas important in the vocational rehabilitation of brain- injured persons. The areas listed above are not necessarily independent entities, and may overlap.


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