1. 1 This Presentation prepared by Maryland Department of Health and Mental Hygiene Maryland TBI Implementation Project Brain Injury Association of Maryland Vocational Issues After Brain Injury 2003 DHMH Logo Use Requested

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

3. 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 clients with brain injury find and keep a job?

4. 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. 5 The Challenges of Brain Injury in the Work Environment

6. 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 client’s vocational potential

7. 7 Barriers to Employment

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

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

10. 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 client may be on

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

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

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

14. 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 client in the placement of materials for optimal viewing

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

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

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

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

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

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

21. 21 Denial/Lack of Awareness: Inability to realistically and accurately assess one’s abilities; limited self-awareness and insight Anticipate client’s lack of awareness Assist client in identifying and accepting limitations Promote questioning by client 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. 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. 23 Possible Changes After Brain Injury Cognitive Impairments Executive Functioning deficits Attention and Concentration Comprehension and Memory Self-Awareness Initiating/Motivating

24. 24 Executive Functioning : Reduced ability to devise a plan of action and systematically implement 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

25. 25 Attention and Concentration: Easily distracted. Difficulty in attending to tasks, focusing or maintaining attention (may be internal or external) Identify mentor/colleague to assist client 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 client Modify work load Increase pace of work assignments gradually

26. 26 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

27. 27 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

28. 28 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

29. 29 Role of the Vocational Counselor

30. 30 Possible Prevocational Needs u Psychotherapy u Psychiatry u Substance Abuse Program u Rehabilitation therapies (OT,SLP.PT) u Community re-entry program u Neuropsychiatric/Neuropsychological Evaluations u Work hardening program

31. 31 Role of the Vocational Counselor Gather information Develop therapeutic alliance (partnership) with client Prepare plan of action appropriate for person with a brain injury Utilize a problem solving format Be open and maintain communication

32. 32 Gather Information Medical Records Current Medications (purpose, dose, schedule) Psychological support Rehabilitation reports Neuropsychiatry/Neuropsychological Evaluations

33. 33 Therapeutic Alliance Establish relationship at first contact Ask them what they are interested in, what they have done before and what they would like to do now Take the time to observe and get to know the person—Spend time on the vocational intake. Ask them to bring in samples of their work, projects—something they are proud of Be open and maintain communication by active listening

34. 34 Plan of Action Clarify client’s needs, interests, abilities, impairments Assist client in identifying expectations Identify work-related problems and develop solutions Identify and refer to other needed vocational services

35. 35 Be Open and Maintain Communications Meet regularly to review progress toward goals Provide timely feedback regarding performance Include family and other service providers so the message is consistent Provide written summaries of meetings

36. 36 The Successful Vocational Program and Candidate

37. 37 Ingredients of a Successful Vocational Program Case management/resource coordination Vocational evaluation Job coaching On-the-job training Job analysis Simulated job tasks in a clinical setting Compensatory strategies Work hardening to increase stamina

38. 38 Characteristics of a Successful Vocational Candidate Rehabilitation therapies (OT,SLP,PT) 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 Supportive family/social network May be years post-injury

39. 39 Job Loss Factors Lack of Social Skills Poor Executive Functioning Memory Impairments

40. 40 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

41. 41 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

42. 42 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

43. 43 Inappropriate Workplace Behaviors Being late Interrupting Talking too much Arguing, fighting and yelling Leaving without permission/notice Preventing others from getting their work done

44. 44 Appropriate Workplace Behaviors 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 Any of the following may be a possible focus for vocational counseling:

45. 45 The Vocational Counselor Needs to Provide Structure Support Strategies

46. 46 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)

47. 47 Additional Resources on Brain Injury

48. 48 Additional Resources… Print Materials Current Books Understanding Brain Injury A Guide for Employers by Mayo Clinic (2000) www.mayo.edu Vocational Rehabilitation for Persons with Traumatic Brain Injury by Paul Wehman & Jeffrey S. Kreutzer (Eds.) (1990) Many other titles are available online and at your bookstore

49. 49 …Additional Resources… Websites Brain Injury Association of America www.biausa.org Dana Foundation www.dana.org Half the Planet www.halftheplanet.org Also use web search engine terms “brain injury”, “traumatic brain injury”, or “acquired brain injury”

50. 50 …Additional Resources… Organizations Brain Injury Association of Maryland (BIAM) To contact BIAM: Call: (410) 448-2924 Toll Free in Maryland: (800) 221-6443 Email: info@biamd.org Write or visit: BIAM 2200 Kernan Drive Baltimore, MD 21207 Website: www.biamd.org

51. 51 …Additional Resources Organizations Division of Rehabilitation Services (DORS) Prepares individuals with disabilities for employment and independence To contact DORS: Call: (410) 554-9385 Toll Free (in MD)(888) 554-0334 TTY: (410) 554-9411 Email: dors@dors.state.md.us Write or visit: DORS 2301 Argonne Drive Baltimore, MD 21218 Website: www.dors.state.md.us

52. 52 Acknowledgements The Maryland Traumatic Brain Injury Project wishes to thank the following individuals for their contributions to this vocational training: Sharon Cullinane Anastasia Edmonston Fran Forstenzer Jerri Fowler Stefani O’Dea Diane Triplett Amy Welch Special thanks and acknowledgement to Saralyn Silver MS CRC formerly of the New York University Head Trauma Program and Patricia Price of the Florida Brain Injury Demonstration Project for their contributions to the field brain injury and vocational rehabilitation. Alice Marie Stevens, PhDc, Editor, Vocational Issues After Brain Injury 2003 and Director, Maryland TBI Implementation Project, Baltimore, MD

53. 53 Acknowledgements This training and its associated training materials are supported in part by the TBI State Grant Program, Grant Number 4 H21 MC 00008- 04-03, from the Department of Health and Human Services (DHHS) Health Resources and Services Administration, Maternal and Child Health Bureau. The contents are the sole responsibility of the authors and do not necessarily represent the official views of DHHS. Disclaimer: Information given within this training does not imply endorsement by BIAM or DHMH or any other party associated with this training. Listings in this training may not represent all the possible services or resources available.

54. 54 Thank you for participating! Please complete your evaluation form and leave it with your speaker

55. 55 References Ezrachi., O., Ben_Yishay., Kay, T., Diller, L., Rattok, J. (1991). Predicting Employment Brain Injury Following Neuropsychological Rehabilitation. Journal of Head Trauma Rehabilitation, 6(3), 71-84. Jacobs, H. (1997). The Clubhouse: Addressing Work-Related Behavioral Challenges Through a Supportive Community. Journal of Head Trauma Rehabilitation,12(5), 14-27. Kay, T., Silver, S. (1989). Closed Head Trauma: Assessment for Rehabilitation. In M. Leazak (Ed.), Assessment of the Behavioral Consequences of Head Trauma. (pp.145-170). New York: Alan R. Liss, Inc. Malaec, J., and Basford, Jr. (1996). Postacute Brain Injury Rehabilitation. Archives of Physical and Rehabilitation Medicine, 77, 198- 207. Osborn, C. (2000). Over My Head: A Doctor’s Own Story of Head Injury From the Inside Looking Out. New York: Andrews McMeel Publishing.