I was hit by a drunk driver.

I fell o a ladder cleaning the gu ers.

I tripped and hit my head.

I had encephali s.

I was shaken by the babysi er.

I was assaulted leaving work.

The Brain Injury Handbook An Introductory Guide to Understanding Brain Injury for Vocational Rehabilitation Professionals
BrainInjuryAssocia onofOregon,Inc.www.biaoregon.org18005445243

I sustained a blast injury in Iraq.

My exboyfriend beat me up.

I had a heart a ack.

TheBrainInjuryHandbook2011 AnIntroductoryGuidetoUnderstandingBrainInjuryforVoca onal Rehabilita onProfessionals BrainInjuryAssocia onofOregon,Inc. POBox549,MolallaOR97038 8005445243www.biaoregon.org ThesematerialswerefundedbytheOregonStateRehabilita onServicesGrant #131350.
ThesematerialsareadaptedinpartfromTheBrainInjuryHandbook:AnIntroductoryGuideto UnderstandingBrainInjuryforVoca onalRehabilita onProfessionals,madepossiblethrougha grantfromtheU.S.DepartmentofHealthandHumanServicesHealthResourcesandServices Administra on,MaternalandChildHealthBureauincoopera onwiththeHenryH.Kessler Founda on.WithpermissionfromtheN.J.DepartmentofHumanServices,DivisionofDisability Services.

Table of Contents
TableofContents...........................................................................................................................................i I.THENATUREOFBRAININJURY.................................................................................................................. 1 HowDoestheBrainWork?....................................................................................................................... 1 WhatisBrainInjury?.................................................................................................................................5 DiuseInjury.............................................................................................................................................5 ConcussiveDamage..................................................................................................................................6 Coup/ContrecoupInjury.......................................................................................................................... 7 SecondaryDamageinClosedBrainInjury................................................................................................ 8 BlastInjury................................................................................................................................................9 II.FUNCTIONALCHANGESAFTERBRAININJURY........................................................................................ 12 PhysicalChanges.....................................................................................................................................12 Arousal....................................................................................................................................................12 A en onandConcentra on.................................................................................................................. 13 Memory..................................................................................................................................................13 AbstractThinkingandConceptualiza on............................................................................................... 14 Execu veFunc oning............................................................................................................................. 14 InterpersonalandPsychosocialChanges ................................................................................................ 15 CommonIssuesFollowingBrainInjury................................................................................................... 16 MildBrainInjuries...................................................................................................................................16 Diagnos cs..............................................................................................................................................17 NeuropsychologicalConsult/Evalua on................................................................................................. 17 Voca onallyRelevantQues onsfortheNeuropsychologist.................................................................18 III.COGNITIVEREHABILITATION................................................................................................................. 19 IndicatorsofNeed..................................................................................................................................19

RoleofCogni veRehabilita oninVoca onalTraining.......................................................................... 2 0 Compensa ngforCogni veDecitsontheJob..................................................................................... 2 0 Cri calFeaturesofCogni veRehabilita on....................................................................................... 2 0 IV.THEVOCATIONALREHABILITATIONPROCESS....................................................................................... 2 1 DeterminingtheAppropriatenessoftheReferral.................................................................................. 2 1 IntakeInterview...................................................................................................................................... 2 1 Voca onalCandidatesArrival................................................................................................................ 2 2 ReadilyObservedBehaviors.................................................................................................................... 2 2 SignicantOthers.................................................................................................................................... 2 3 FormingaVoca onalProle................................................................................................................... 2 3 MedicalInforma on............................................................................................................................ 2 3 LeisureTimeAc vi es......................................................................................................................... 2 3 PostInjuryWorkHistory..................................................................................................................... 2 3 PostInjuryEduca on.......................................................................................................................... 2 4 GoalsandSelfPercep on................................................................................................................... 2 4 HistoryPriortoInjury.......................................................................................................................... 2 4 PreInjuryHealthHistory..................................................................................................................... 2 4 PreInjuryEduca on............................................................................................................................ 2 5 PreInjuryWorkHistory ....................................................................................................................... 2 5 CourseofRehabilita on/Reports........................................................................................................ 2 5 ReferralforPreVoca onallyRelevantServices.................................................................................. 2 6 WorkingwiththeVoca onalRehabilita onClient................................................................................. 2 6 Issue:Dicultyrememberinginforma on......................................................................................... 2 6 Issue:Dicultyfocusingandpayinga en on................................................................................... 2 7 Issue:Dicultywithini a on............................................................................................................. 2 7 Issue:Dicultywithorganiza onandplanning................................................................................. 2 8

iI

Issue:Dicultywithdecisionmaking................................................................................................. 28 Issue:Dicultyinsocialsitua ons..................................................................................................... 28 Issue:Dicultycontrollingemo ons................................................................................................. 29 Issue:Dicultywithselfawareness................................................................................................... 30 V.EMPLOYMENTOPTIONS......................................................................................................................... 30 Tradi onalVoca onalRehabilita onSe ng......................................................................................... 30 Limita onsofTradi onalVoca onalEvalua on.................................................................................... 30 GraduatedPlacements ............................................................................................................................ 32 SupportedEmployment.......................................................................................................................... 32 UseofaJobCoach..................................................................................................................................33 TheRoleoftheJobCoach....................................................................................................................... 34 JobPlacementConsidera ons................................................................................................................ 35 Selec vity............................................................................................................................................35 JobAnalysis.........................................................................................................................................35 PlacementwithEduca onandTraining............................................................................................. 35 OngoingSupports.............................................................................................................................. 36 JobAccommoda ons.......................................................................................................................... 36 Memory: ..........................................................................................................................................36 Othermemorystrategies:............................................................................................................... 37 MaintainingConcentra on:............................................................................................................ 37 PlacementRedened...................................................................................................................... 39 VI.INVOLVINGTHEFAMILYINTHEVOCATIONALPROCESS....................................................................... 40 FamilyExpecta onsandValues.............................................................................................................. 40 EectsonFamilyStructure..................................................................................................................... 40 Denial......................................................................................................................................................41

iIi

BargainingandSplinteredSkills.............................................................................................................. 4 1 Depression............................................................................................................................................... 4 2 VII.CONCLUSION......................................................................................................................................... 4 3 VIII.REFERENCES......................................................................................................................................... 4 4

iv

I. THE NATURE OF BRAIN INJURY

Personswithbraininjuryareachallenginggrouptoservewithinthevoca onalrehabilita on (VR)system.Theseindividualshaveneedsthatareuniquetotheirdisabilityandsymptomsthat arefrequentlybaing.Thishandbookprovidesanoverviewofbraininjuryandits consequences,aswellasstrategiesandresourcesthatmaybebenecialinworkingwithpeople whohavebraininjuries.ThishandbookwascreatedtohelpVRcounselorsprovideappropriate servicesforpeoplewithbraininjuriesintheireortstoreturntowork. Individualswithbraininjuryareuniqueasservicerecipients.Theirpar culardisabilitydiers fromanyotherdisabilitygroupthecounselormayhaveencountered.Personswithbraininjuries simplydonotexhibitdisablingcondi onsinthesamewayasotherdisabilitygroups,anditis thisnonconformitythatsetsthemapart.Whencounselorsa empttousetradi onalmethods toassessthevoca onalpoten alofmembersofthischallenginggroup,theireortscanresult inafailuretoservetheseclients.Inordertoeec velyprovideservicestothispopula on,the rehabilita oncounselormustrstacquireabasicknowledgeofhowthebrainfunc ons.Only thencanthecounseloradequatelyappreciatethecomplexityoftheclientwithbraininjury.Itis ofparamountimportancethatthecounselordevelopafamiliaritywiththenatureand consequencesofbraininjuryandbeginstounderstandtheinterac onamongthemyriadof problemsapersonmayencounter.Oncehavinggainedfamiliaritywithbrainmechanismsand theclientslocusofinjuryfrommedicalreports,thecounselors llshouldexerciseextreme cau oninplacinglabelsonan cipatedareasofdysfunc on.Thereareindividualdierencesin theorganiza onofeachhumanbrain,andthesedierencesmayinpartaccountfor unan cipatedfunc onalachievementsinsomeclients,eventhoughseveredecitsand, therefore,limitedpoten al,hadbeenobservedinaneuropsychologicalexamina on. Conversely,subtledecitsnotedduringtes ngproceduresmaybequiteseriousobstaclesto successinavarietyofvoca onalspheres.Voca onalcounselorsshouldbeawarethatdispari es betweentestresultsandactualtaskperformancewillsurfacecon nually. Insummary,providingservicestopeoplewithbraininjuriesrequirescrea vityandexibility.It ishopedthatasthereadergoesthroughthishandbook,issuestoucheduponbrieyinthis introductorysec onwillgrowinclarity. onsofthebodyand allowsustothink,learnandremember.Itismadeupofbillionsofnervecellsthatwork togethertocontrolemo on,behavior,movementandsensa on.Tobe erunderstandwhat canhappentoanindividualwhenthebrainisinjured,itishelpfultoknowaboutthedierent partsofthebrainandwhattheydo.Therearethreemainsec onsofthebrainthecerebral hemispheres,cerebellumandbrainstem.Thebrainisdividedintotwohalves.Thesehalvesare thele andrightcerebralhemispheres.

How Does the Brain Work?Thehumanbraincontrolstheac

Eachpartofthebrainisresponsibleforspecicfunc ons.Thele cerebralhemisphere controlstherightsideofthebodyandisresponsibleforspeech,analy calthoughtand memory.Therightcerebralhemispherecontrolsthele sideofthebodyandis responsibleforcrea vethinking,expressionofemo onsandvisuospa alabili es. Specicpartsofthebraincontrolspecicfunc ons,likevision(OccipitalLobe),balance andcoordina on(Cerebellum),heartrateandbreathing(BrainStem),smell(underthe frontallobe),orhearing(temporallobe).Thus,whathappenstoapersonwhenthe brainisinjuredwilldierdependingonthepartofthebrainthatwasaected.

erbirtharecalledacquiredbrain injuries.Anacquiredbraininjurycanbetheresultofamedicalcondi on.Someofthese condi onsincludestroke,encephali s,aneurysm,anoxia(lackofoxygenduringsurgery,drug overdose,orneardrowning),metabolicdisorders,meningi s,orbraintumors.Acquiredbrain injuriescanalsooccurwhenanoutsideforcestrikestheheadhardenoughtocausethebrain tomoveinsideoftheskullanddamagethebrain.Thistypeofinjuryiscalledatrauma cbrain injury,andcanbecausedbycarcrashes,falls,beinghitonthehead,oranyphysicalviolence. Thistypeofbraininjuryisreferredtoasaclosedbraininjury,meaningthatthebrainhasnot beenexternallypenetrated.Whenthebrainispenetrated,suchaswithagunshotwound,the injuryiscalledanopenbraininjury. Theseverityofsuchatrauma cbraininjurymayrangefrommild,i.e.,abriefchangein mentalstatusorconsciousness,toseverei.e.,anextendedperiodofunconsciousnessor comaa ertheinjury.O enthereissomeperiodofunconsciousnessfollowingatraumatothe brain.However,therearethoseindividualswhodonotloseconsciousnessbutwillnonetheless exhibitsymptomsofbraininjury.Asaresultoftrauma cbraininjury,thebrainsustains damagethatmaybeeithertemporaryorpermanent. Theconsistencyofthebrainhasbeencomparedtogela norcustard.Undernormal condi ons,thisso mass,gentlycushionedbycerebralspinaluid,oatswithinthevaults formedbythemembranesthatlinetheskullandtheprotec veboneoftheskullitself.When thebrainisinjured,threeprimarytypesofdamagemayoccur:diuse,concussiveandcoup/ contrecoup.Thesethreetypesofinjuryarediscussedindetailbelow.

What is Brain Injury?Braininjuriesthatoccura

Diffuse Injury
Thersttype,diuseaxonalbraininjury,resultsfromthestretchingandtearingofnervebers (axons)throughoutthebrain.Thisdiuse,widespreaddamagetothebrainisthetypethat frequentlyresultsfromamotorvehiclecrash.Whenthemomentumofarapidlymoving vehicleissuddenlyhalted,withtheheadstrikingasta onaryobjectinsidethecarsuchasa dashboardorthewindshield,theimpactresultsinrota onalforcestwis nganddisloca ngor shi ingthebrainmass. Whenthebrainissubjectedtotheseviolentmo ons,thereisenormousstretchingandpulling ofthethreadlikenerveconnec ons(axons)thatformthenetworkforbrainfunc oning.Asthe axonsarestretched,biochemicalfunc oningceasesandthenervesstopfunc oning.Axons thatareseverelystretchedsome messnap,andthelikelihoodofthesenervesever func oningagainisremote.Themoresevereandwidespreadthedamage,thegreaterthe probabilityofanensuinglossofconsciousness(coma).Prac callyallpeopleemergefrom coma.However,thetypeofinjurydescribedabovevirtuallyalwaysleadstopermanentand generallyseveredamagetothebrain.

Concussive Damage
Concussivedamageistheresultofthebraincollidingwiththesharpridgesontheinside frontoftheskull.Theresul ngbruisesorcontusionsaremostlikelytooccurinthebase ofthefrontalandtemporallobesofthebrain.Theselocalizedcontusionsproducetwoof themostfrequentlyencountereddecitsfollowingclosedbraininjury.Theyare execu vedysfunc onandimpairedmemoryfunc ons. Sincethetemporallobesareessen altothesystemthatregisters,storesandretrieves informa on,damagetothisareaaectstheabilitytolearnnewmaterial. Damagetothefrontallobesmayseriouslyimpairthewiderangeofabili esknownas execu vefunc ons.Individualswithfrontallobeinjuriesareunabletothinkabstractly, conceptualize,orbeeec veproblemsolvers.Theyaregenerallyinexiblethinkerswho remainconcretelyboundtoapresen ngsitua on.Theyareunabletotakeaselfcri cal viewandarethereforefrequentlyunawareofhowtheirbehaviormayaectothers. Becauseofapronouncedinabilitytodevelopaplanandini ateanac vity,these individualsarefrequentlylabeledunmo vated.Frontallobeinjuriesarethemost prevalentinautomobilecrashes.Individualswithfrontallobeinjuriesareo enthemost diculttoserveinvoca onalrehabilita on.

Coup/Contrecoup Injury
Thethirdtypeofprimarydamageseeninclosedbraininjuryoccurswhentheheadis struckwithsuchintensitythatitliterallybendstheskullinatthepointofimpact,injuring thebrainbeneathit(theini albloworcoup),andthenpropellingthebrainagainstthe oppositesideofthebrain(thecounterbloworcontrecoup).Thistypeofdamageismost likelywhenamovingobjectstrikesthesta onaryhead.Itdoesnotnecessarilyoccurinall closedbraininjuries.Whenitdoeshappen,theimpairmentsthatresultdependonwhich specicbrainareashavebeendamaged.Arangeoffunc onalareasmaybecome selec velyimpairedfollowingacoup/contrecoupinjury.Thesemaybeinthemotor, sensory,perceptualandlanguagedomains.

Secondary Damage in Closed Brain Injury

Inaddi ontothethreetypesofprimarydamagedescribedpreviously,secondarydamage isacommonoccurrenceinbraininjury.Thiscanincludebleedingwithinthebrainitself (intracerebralhematoma);orbetweentheskullandthebraincovering(epidural hematoma);and/orbetweenthebrainandbraincover,(subduralhematoma).Thereis furtherdamagetothebrain ssueasbloodcollectsandbuildsuppressurethat compressesthebrain.Intracranialpressureincreasesasthebrainswellswithuid(edema, hydrocephalus)orbecomesengorgedwithblood.Sincetherigidityoftheskullallowsno roomforthebraintoexpand,surgeryisfrequentlynecessarytorepair,stopbleeding, removeclots,relievepressureand/orpreventhernia on.Whensecondarydamage occurs,usuallyinseverebraininjury,itcanproducefunc onallimita onsmoresevere thanoriginallyan cipated.

Blast Injury

Ablastinjuryisacomplextypeofphysicaltraumaresul ngfromdirectorindirectexposuretoan explosion.Blastinjuriesoccurwiththedetona onofhighorderexplosivesaswellasthe deagra onofloworderexplosives.Theseinjuriesarecompoundedwhentheexplosionoccurs inaconnedspace.From2000to2010,theDefenseandVeteransBrainInjuryCenterhas counted178,876casesofTrauma cBrainInjury(TBI)amongU.S.Militarypersonnel. Seventysevenpercentofthosecasesweredeterminedtobemild.Basedonthesenumbers,the numberofconrmedcasesofTBIshassurpassedrecordedcasesofPostTrauma cStress Disorder(PTSD)bynearly100,000. TherearefourtypesofBlastInjuries:Primary(directeectsofpressure,either overpressuriza onandunderpressuriza on,suchasruptureoftympanicmembranes,pulmonary damage,andruptureofhollowviscera);Secondary(eectsofprojec les,causingpenetra ng traumaandfragmenta oninjuries);Ter ary(eectsofstructuralcollapseandofpersonsbeing thrownbytheblastwind,causingcrushinjuriesandblunttrauma,penetra ngtrauma,fractures andtrauma camputa ons,openorclosedbraininjuries);andQuaternary(burns,asphyxia,and exposuretotoxicinhalants).

PrimaryInjuries Primaryinjuriesarecausedbyblastoverpressurewaves,orshockwaves.Theseareespecially likelywhenapersonisclosetoanexplodingmuni on,suchasalandmine.Theearsaremost o enaectedbytheoverpressure,followedbythelungsandtheholloworgansofthe gastrointes naltract.Gastrointes nalinjuriesmaypresenta eradelayofhoursorevendays Injuryfromblastoverpressureisapressureand medependentfunc on.Byincreasingthe pressureoritsdura on,theseverityofinjurywillalsoincrease. Ingeneral,primaryblastinjuriesarecharacterizedbytheabsenceofexternalinjuries;thus internalinjuriesarefrequentlyunrecognizedandtheirseverityunderes mated.Accordingtothe latestexperimentalresults,theextentandtypesofprimaryblastinducedinjuriesdependnot onlyonthepeakoftheoverpressure,butalsootherparameterssuchasnumberofoverpressure peaks, melagbetweenoverpressurepeaks,characteris csoftheshearfrontsbetween overpressurepeaks,frequencyresonance,andelectromagne cpulse,amongothers.The majorityofpriorresearchfocusedonthemechanismsofblastinjurieswithingascontaining organs/organsystemssuchasthelungs,whileprimaryblastinducedtrauma cbraininjuryhas remainedunderes mated. SecondaryInjuries Secondaryinjuriesareduetobombfragmentsandotherobjectspropelledbytheexplosion. Theseinjuriesmayaectanypartofthebodyandsome mesresultinpenetra ngtraumawith visiblebleeding.At mesthepropelledobjectmaybecomeembeddedinthebody,obstruc ng thelossofbloodtotheoutside.However,theremaybeextensivebloodlosswithinthebody cavi es.Shrapnelwoundsmaybelethalandthereforemanyan personnelbombsaredesigned togenerateshrapnelandfragments. Ter aryInjuries Displacementofairbytheexplosioncreatesablastwindthatcanthrowvic msagainstsolid objects.Injuriesresul ngfromthistypeoftrauma cimpactarereferredtoaster aryblast injuries.Ter aryinjuriesmaypresentassomecombina onofbluntandpenetra ngtrauma, includingbonefracturesandcoupcontrecoupinjuries. Blastinjuriescancausehiddenbraindamageandpoten alneurologicalconsequences.Its complexclinicalsyndromeiscausedbythecombina onofallblasteects,i.e.,primary, secondary,ter aryandquaternaryblastmechanisms.Itisnoteworthythatblastinjuriesusually manifestinaformofpolytrauma,i.e.injuryinvolvingmul pleorgansororgansystems.Bleeding frominjuredorganssuchaslungsorbowelcausesalackofoxygeninallvitalorgans,including thebrain.Damageofthelungsreducesthesurfaceforoxygenuptakefromtheair,reducingthe amountoftheoxygendeliveredtothebrain.Tissuedestruc onini atesthesynthesisand releaseofhormonesormediatorsintothebloodwhich,whendeliveredtothebrain,changeits

10

func on.Irrita onofthenerveendingsininjuredperipheral ssueand/ororgansalso signicantlycontributestoblastinducedneurotrauma. Individualsexposedtoblastfrequentlymanifestlossofmemoryforeventsbeforeanda er explosion,confusion,headache,impairedsenseofreality,andreduceddecisionmakingability. Pa entswithbraininjuriesacquiredinexplosionso endevelopsudden,unexpectedbrain swellingandcerebralvasospasmdespitecon nuousmonitoring.However,therstsymptoms ofblastinducedneurotrauma(BINT)mayoccurmonthsorevenyearsa ertheini alevent, andarethereforecategorizedassecondarybrainInjuries.Thebroadvarietyofsymptoms includesweightloss,hormoneimbalance,chronicfa gue,headache,andproblemsinmemory, speechandbalance.Thesechangesareo endebilita ng,interferingwithdailyac vi es. BecauseBINTinblastvic msisunderes mated,valuable meiso enlostfor preven vetherapyand/or melyrehabilita on.

11

II. FUNCTIONAL CHANGES AFTER BRAIN INJURY

Manyclientswithabraininjuryappeartobeidealvoca onalcandidates.Theytypically possesssubstan alpreinjuryworkrecords;formeremployerswillinglya esttotheirgood workadjustments;andselfreportsofpreinjuryemploymentoreduca onala ainmentsare usuallyinkeepingwiththereportsofothers.Itisimportanttoemphasize,however,thatthe personbeingdescribedinthesereportsisnotnecessarilythesamepersona ertheinjury. Physical,cogni veandpsychosocialchangesasaresultofthebraininjurymayhavesignicant impactontheindividualsabilitytowork.

Physical Changes
Physicaldecits,iftheyexist,arealwaysthemostobviousorno ceablelimita onsinindividuals withbraininjury.Unlikethemoresubtlecogni veimpairments,physicaldecitsaregenerally visibleandfrequentlybecomethecentralissueuponwhichanindividualplacesallresponsibility (blame)forhis/herinabilitytoreturntopreinjuryac vi esandlifestyle. Physicalimpairmentsareusuallytheresultofdamagetothebraincentersthatcontrolmotor func onsratherthandirectinjurytotheextremi es.Decitsmayincludelossofmotor coordina on,spas city,poorbalance,aninabilitytowalkunassisted,andalossofeyehand coordina on.Hemiplegia(paralysisaec ngonesideofthebody)andhemiparesis(weakness ofonesideofthebodyorpartofit)mayfurthercomplicatevoca onalissues,par cularlywhen thesecondi onsaecttheuseofthepreinjurydominanthand. Withinthiscategory,onemustnotethepoten alforseizuredisorders,and,iftheyare prescribed,medica onstakentocontrolseizures.Thestabilityoftheseizuredisorderandthe poten alsideeectsoftheseizuremedica onsmayfurthercompromisevoca onal rehabilita oneorts. Cogni veChangesPersonswithbraininjurymayexhibitproblemsinavarietyofcogni veareas suchasbasicarousal,alertness,a en on,concentra on,memory,abstractthinkingand conceptualiza on,planning,organizing,problemsolving,andjudgment.Peoplealsomayhave difcultyprocessingverbalandvisualinforma on.

Arousal
Signsofarousalproblemsincludeaninabilitytoa endtotheenvironment;alackof(or reduced)alertness;aninabilitytoaccuratelyobserveenvironmentaldetailsandoccurrences; andaseverelyslowedcapacityforinforma onprocessing.Peoplewitharousalimpairments areo enslowinreac ngandrespondingtoothersandarehighlysuscep bletofa gue followingcogni veorphysicalexer on.Theymayappearalmostlostinspaceornotin touch.

12

Attention and Concentration

Impaireda en onandconcentra oncanexhibitaseasydistrac bility.Thismaybearesponse tointerferenceeitherbyexternalorinternals muli.Forthepersonwithbraininjury,the inabilitytoscreenoutexternalnoisesmakesitdiculttosustainconcentra on. Environmentalnoiseisfoundinmostworkse ngs,e.g.,conversa onofothers,usualoce trac,hummingofmachinesandthegeneralrelatedbuzzofac vity.Intrusionsbyexternal noisecano enbecontrolledorminimized,andthecapacityforconcentra onwillusually improve. Forthepersonwithbraininjury,anotherpossiblesourceofdistrac ngnoiseistheinternal conversa onwithinhis/herownmind.Intrusiveinnerthoughtsthatlimitproduc vityare exceedinglyhardertomanage.Theybecomevisible(observable)onlywhentheyinterrupt performance.

Memory
Lossofadequatememoryfunc onandtheinabilitytoimmediatelyrecallnewinforma on (anterogradeamnesia)arecommonsymptomsfollowingbraininjury.Whilesignicant improvementinmemoryfunc onmaybenotedduringtheini alperiodofrecovery,this decitiso enobservedinvaryingdegreesformostpeoplewithbraininjury. Inadequatememoryfunc onisoneoftheprimarycomplaintsreportedbypeoplewhohave sustainedbraininjuries.O enitistheirsocialenvironmentthatcausesthemtodevelopan awarenessofthispar cularproblemarea.Thereprimandsofacquaintancesandsignicant othersformissedappointments,appliancesle onorbillsle unpaidcompelthepersonwith braininjurytoacknowledgethathe/sheforgetsimportantthings.Inadequatememoryfunc on remains,unfortunately,unresponsivetoremedialinterven on.However,memoryimpairments canbecompensatedforbyavarietyofmnemonicdevices(memoryaids)suchasthose describedlater. Prac callyallpersonswithbraininjuryretainaclearmemoryofthemselvesastheywere preinjury.Intactoldmemoriesandoverlearnedinforma on(forexample,ridingabikeor performingasequenceofjobtasks)frequentlyrepresentareasofstrength.Thesepreserved skillscano enbedrawnuponwhenhelpingaclientwithbraininjuryredevelopvoca onalgoals. Some mesanindividualmayappeartohaveamemoryimpairment,wheninfactthepersonhas dicultypayinga en onwhenpresentedwithnewinforma onandisthusunableto rememberthisinforma on.Itisessen alfortheclientandthecounselortoknowthe dierence.Theinabilitytoremember,asaresponsetolackofeec vea en on,canbe remediatedfrequently,oratleastsubstan allyimproved,bycogni verehabilita on.

13

Abstract Thinking and Conceptualization

Animportantconcernforvoca onalcounselorsiswhethertheclientwithbraininjuryisableto engageinabstractthought.Clientscanremainstuckinoneviewofasitua on.Theymayndit diculttoshi tootheraspectsofaproblemortoreadilysearchforalterna ves.Theymaylack thecapacityforimagina vethoughtandremainpoorproblemsolvers.Problemswithabstract reasoninglimitsthetypesofproduc veac vityanindividualcanpursueautonomouslyand impactsontherange,complexity,andvarietyoftaskstheycansuccessfullya empt. Conceptualiza on,whichisdependentonthecapacitytothinkabstractly,isanotherareain whichtheindividualmayexhibitcogni vedecits.Theabilitytoeec velyconceptualizelies withintherealmofhigherlevelcogni on.Onemustpossessastoreoflearnedmaterialthatis reliablyandreadilydrawnuponinordertoimagineorformamentalpicture,organizethese mentalevents,andbeabletotranslatethiscogni veac vityintoanobservablebehavior/skill. Problemsintheabilitytoconceptualizecansignicantlyimpactthetypesofjobsapersonisable topursue.

Executive Functioning
Decitsinexecu vefunc oningarethedirectresultoffrontallobedamage.Intactexecu ve func onsallowanindividualtoengageinautonomous,independent,wellplanned,eec vely organized,sucientlymonitored,selfregulated,purposefulorgoaldirectedenterprises.When thesecapabili esarediminishedastheresultofbraininjury,theindividualhasdiculty sustaininggainfulemployment,maintainingsa sfactorysocialrela onshipsand,at mes, maintainingadequateselfcare,regardlessofhowwellothercogni vecapaci esareretained. Thepersonwholooksandsoundsgoodandwhosetestresultsonexamina onsofskillsand knowledgeareunimpairedwillhavedicultyfunc oningproduc velywhenexecu veskillsare impaired.Suchclientsremainpoorselfmanagers.Theseclientswhosoo enappearcapableare probablythemostdiculttotreatorevaluatevoca onally.Theyhavelostthemechanismto accuratelymonitortheirabili esandneedfrequentfeedbackinordertounderstandtheimpact theirareasofweaknesshaveontheirabilitytoreturntowork. Thecounselorshouldalsocarefullyassessaclientsabilitytoformulategoals.Whilecapableof engagingincomplexac vi es,thoseimpairedinexecu vefunc oningmaylackthecapacityto developplansorini atepurposefulac vity.Inextremecases,theseindividualsmayappear apathe candunabletoini ateac vityexceptinresponsetoexternals muli.Theabilityto becomeengageddynamicallyininterac veandinten onalbehaviorisbasictoexecu veskills. Asmen onedearlier,whenthiscapacityfalters,personswithbraininjurycanerroneouslybe labeledlazyorunmo vated.

14

Interpersonal and Psychosocial Changes

Interpersonalandpsychosocialchangesfollowingbraininjurymaypresentthemostserious impedimenttovoca onalreintegra on.Aclientmaypossessintact,highlevel,func onalwork skillsbutwillbepreventedfromsustainingemploymentbecause,inmostemploymentse ngs, jobreten ondependsonmaintainingthegoodwillofcoworkersandsupervisorysta.Inother words,aclientneedstobeabletointeractwithcoworkersandsupervisorystainawork appropriatemanner;maintainingapleasant,approachableaect,oratleastaneutralone. Peoplewithbraininjurymaybele withmarkedchangesintheirbehavioralrepertoireand exhibitverbalandphysicaldisinhhibi on,poorsocialjudgmentandageneraldecreaseinsocial graces.Someclientsmayexhibitdysfunc onalsocialbehaviorsofsuchmagnitudethattheyare preventedfromengaginginanyconsistenttaskperformance.Whenevenlengthytreatmentand clinicalinterven oncannotmodifyundesirablesocialbehavior,compe veemploymentmay notbeachievable. Ahighdegreeofegocentricityiso enanotherconsequenceofbraininjury.Manyclientshave dicultyinadop ngaexiblestanceandremainxedintheirviewthattheworldonlyrelatesto andrevolvesaroundthem.Clientsmaylackthecapacitytoreadsocialcuesaccurately.Some failtoreaditatall;theyseemoblivioustonuancesofspeechandbodylanguageofothers.They confusetheimpactofsociallyrelayedmessagesandconsistentlyinterpretthemasbeing personallydirected.Forexample,clientsmaymisinterpretacoworkersorsupervisorsangeror disappointmentoverworkproblemsasastrongnega vemessageabouttheirpersonal performance.Inaddi on,construc vecri cismmaybeinterpretedasapersonalassault.The unfortunatebyproductofthistypeofmisinterpreta onisthattheclient,whoperceivesthe angerasdirectedathim/her,generallyrespondswithanger. Oneoftheleastunderstooddysfunc onalinterpersonalskillsisthelossofemo onalcontrol. Clientscanoverreactorbecomeimmobilizedbyatypeofemo onaloodingrarelyobservedin otherdisabilitygroups.Thetypeandextentoftheiremo onalresponse,o enthedirectresultof someinternaldialogue,isnotmeritedbythesitua on.Lossofemo onalcontrolwillusually surfaceunexpectedlyandsome mesbeofsuchmagnitudethatitprecludesanyproduc ve ac vity. Thisemo onalinstabilityischaracterizedbyrapid,exaggeratedmoodoraectswings.Knownas emo onallability,thecondi onistheresultofweakenedorimpairedcontrolinemo onally chargedsitua ons.Becausetheclientsphysicalappearancemaygivenoindica onofadisability, observerstendtomisinterprethis/herstrongemo onalresponses. Anotherissuefacingpeoplefollowingbraininjuryisadecreasedtoleranceforalcoholanddrugs. Smallerdosesproducemorerapideects.Socialdrinkingcanbediculttocontrolandwill interferewithapersonscogni ve,physicalandpsychosocialfunc oning.

15

Rela onshipswithinthefamily,thecommunityandtheworkplacewillbecompromisedwhena personisunabletoeec velycontroltheiruseofalcoholordrugs.Thevoca onalrehabilita on processwillbeatjeopardyaswell.Theclientshouldbemadeawareoftheharmfuleectsof thesesubstancesandtheVRcounselorshouldaggressivelymonitorandinterveneifthereisa ques onofimpairmentduetoalcoholordruguse.

Common Issues Following Brain Injury

Cogni ve Changes Memory Problemsolving Decisionmaking Persistence Planning Organiza on Sequencing Processingspeed Judgment Inexibility Concentra on A en onspan Depression Socialskillsproblems Moodswings Emo onallackofcontrol Inappropriatebehavior Impulsivity Lackofresponsetosocialcues Irritability Physical Changes Motorcoordina on Tasteandsmell Hearingand/orvisualchanges Spas cityandtremors Fa gueand/orweakness Balance Mobility Speech Seizuredisorder Paralysisononeorbothsides

Personality and Behavioral Changes Reducedselfesteem Dicultyrela ngwithothers Selfcenteredness Dicultyformingnewrela onships Stress,Anxiety,Frustra on Denial Lackofmo va on Excessivelaughing

Mild Brain Injuries

TheVRcounselorwillbecalledupontoprovideservicesforpersonswhopossessawiderangeof capabili esandlimita onsastheresultofbraininjury.Alongwiththosewhohavemoderateor severebraindamage,therearethoseclassiedashavingmildbraininjuries.Becausepeople withsocalledmildorminorbraininjurydonotexhibitobviousdecits,theyarenotreferredfor rehabilita onservicesun llonga ertheactualinjury.Followingavisittotheemergencyroom, doctorsoce,orabriefperiodinanacutecarefacility,individualswithmildbraininjuries generallyreturnhomeandsubsequentlytowork.Whiletheyo enhavenoawarenessofaltered

16

abili es,theirjobperformanceismarkedlydiminishedandtheabilitytoretainemployment suers.Thisgroupofpeopleappearunchangedfrompreinjurystatusandtheirdicul esare furthercompoundedbytheexpecta onsplaceduponthembytheirsocialenvironment.Because theyappearsointact,theseexpecta onsarehighandusuallyincongruentwiththeirreduced capaci es.Whentheemploymentproblemsbecomeobviousandtheindividualisnally referredforvoca onalcounselingorrehabilita on,theoriginalcauseoftheproblemmayremain unrecognized.Ifthisisthecase,theVRcounselorcanbeinstrumentalindeterminingwhethera mildbraininjurymaybeafactorintheemploymentproblemstheindividualisexperiencingand inarrangingforappropriatetes ngbyaneuropsychologisttoaddresstheseproblems.Itshould benotedthatmildbraininjuryisacomplexproblemandiso enaddressedintherehabilita on literatureasaseparateanduniquetopic.Resourceinforma onaboutmildbraininjurycanbe foundontheBrainInjuryAssocia onofOregonswebsite(www.biaoregon.org).

Diagnostics
Duringtheearlystagesoftreatmentandrehabilita onofpeoplewithbraininjury,anumberof neurodiagnos cmeasuresandmentalstatusexamina onsareperformed.Themainpurposeof suchtes ngistomeasurecogni vefunc oningandchartimprovementsastheyoccur.These testsarenotimmediatelyrelevanttothevoca onalrehabilita onprocess.However,later neuropsychologicaltes ng,whichisbestadministeredwhenthepersonwithabraininjuryhas becomemedicallystable,bearsdirectrelevancetovoca onalrehabilita on.

Neuropsychological Consult/Evaluation
Aneuropsychologicalevalua onmaybepartofthecaserecordsthevoca onalcounselor reviewsatthe meofreferral.Thesignicanceoftheresultsmaynotbereadilyapparent,and therefore,maybediculttotranslateintomeaningfulapplica on.Testscoresaretypically reportedastheycomparetoestablishednorms,andaclientsperformanceorlevelof func oningmaybedescribedintermsthattellusonlythathe/sheisdecient,impairedor belowtheaverage.Thesetermsmeanli lewhentheyhavetobeappliedtoajobanalysis. Addi onally,thesereportsmaybewri eninjargonthatfurtherconfusesthevoca onal counselor. Ontheotherhand,awellwri enneuropsychologicalevalua oncanserveasaninvaluabletool tounderstandingthecogni vestrengthsandweaknessesofaclientasitappliestoreturningto work.Ifthevoca onalcounselorismakingthereferralfortheneuropsychologicalevalua on, askingspecicreferralques onsaboutworkfunc oning,accommoda ons,andtreatment recommenda onscanenhancetheinforma onthatisprovidedinthereport.Discussingthe resultsofthetes ngwiththeneuropsychologist,whoseexper seisinbrainbehavior rela onships,isanotherwaytoobtainvoca onallyspecicinforma on.

17

Vocationally Relevant Questions for the Neuropsychologist

Whatfunc onallimita onsareevidentwithrespecttomemory,informa on

processing,visualandauditorycomprehension?
Whatisthepoten alforfurtherremedia on? Whatistheprognosisforlengthoftreatment? Canyoucommentonspecicstrengthsnotedinthetes ngsitua on,e.g.,ease

inreceivingoralinstruc on,persistence,concentra on?

Istheclientdistrac ble?Externally?Internally? Canyoucommentonthoseaspectsofpreinjurylearning(i.e.,rmly

entrenched,overrehearsed,repertoireofskills)thathavesurfacedduringthe currenttes ng?

Istherepoten alfornewlearning? Howmuchsupervisionandenvironmentalsupportwillbeneededatthecurrent

leveloffunc oning?
Whatistheclientsbestmethodoflearning? Whattypeofcompensatorystrategieswouldbebenecialtoenhancejob

performance?
Whattypeofjobaccommoda onswouldbehelpful? Whataretheeectsofinterpersonaldecitsonvoca onalgoals?

Theresultsofawellfocusedneuropsychologicalevalua oncantranslateintoprac cal recommenda onsforthevoca onalassessmentprocess.Theseresultsallowthecounselorto makeprepara onsandtakean cipatorystepstoensureasuccessfulexperiencefortheclient. Thevoca onalcounselorcanthenbegintodesignthetypesofenvironmentalsupportsystems thattheclient,givenhis/herstrengthsandlimita ons,willrequireduringthevoca onal rehabilita onprocess.

18

III. COGNITIVE REHABILITATION

Clientswithbraininjuriesmayneedcogni verehabilita onastheyarepreparingforthe voca onalrehabilita onprocess.Cogni verehabilita onisthesystema c,goaloriented therapeu cinterven ondesignedtoremediate(improve)arangeofcogni veabili es.Areas addressedinaprogramofremedia onarehighlyindividualizedandmayincludea en on, concentra on,andimpulsecontrol. Cogni veprogramsalsoaddresslackofawarenessofinjuryimposedlimita onsandsocialand emo onalneeds.Memoryimpairmentsarea endedtoandcompensatorystrategiesaretaught. Cogni veremedia oniscarriedoutincarefullyplannedstagesorsteps.Clientsmovethougha varietyofhighlystructuredtrainingexercises.Skillacquisi onandskillstabiliza onarestressed. Formostpeoplepossessingtruefunc onalmemorydecits,compensatoryaidsmustbe establishediftheyaretoreturntoanylevelofoccupa onalproduc vity.Compensatory measureso entaketheformofenvironmentalcueingsystems.Cueingcanbeassimpleasan indexcardlis ngthealphabetfortheclientwhoisinvolvedinalingtaskorawri enlistof sequen alstepsforagiventaskthattheclientusesasavisualreference.Some mesthese cueingmethodsrequireonlycommonsenseandabitofcrea vitytocreate. Itisimportanttorememberthatenvironmentalcueingsystemsmustincorporatethestepstobe takeninalogicalsequence.Thisistruewhethertheyarebeingdesignedfortheworkplaceorfor ac vi esofdailylivingaccomplishedathome.Thesemightbewri enguidelinesforprocedural opera ons;calendarsandjournalsforpersonalappointments;joblogs,maps,wri enstepby stepproceduresforgainingaccesstoapar cularplace;andadailyschedulewhichhelpsthe clienttransi onfromoneaspectofthedayorjobtasktothenext.

Indicators of Need
Some mesaclientwithabraininjuryisdeterminedtobeeligibleforvoca onalrehabilita onyet demonstratesfunc onaldecitsincogni veskills.Ifthesedecitslimittheclientspoten alfor independenceandvoca onalsuccess,thencogni verehabilita onmaybeindicated.Ifthereisa discrepancybetweenwhattheclientisabletodoandwhatwillberequiredofhim/heronthe joborvoca onalplacement,cogni verehabilita onmaybeappropriate.Ifthejobrequiresskills thattheclienthasalreadydemonstrated,eitheronaconsistentorerra cbasis,orhasthe poten altolearn,thencogni veretrainingshouldbeini ated.Thefollowingguidelinesarealso relevant: Theclientshoulddemonstratethemo va onandabilitytoac velypar cipateinthe learningsitua onanddisplayacapacityforconsistentimprovementonnewlearning.

19

Theclientsowngoalsshouldbebothrealis candcongruentwiththenalgoalsof

theremedia onandul matejobplacement.

Thereshouldbeevidencethattheskilldecitsexhibitedbytheclientareretrainablein

therapy.Ifnot,thefocusofthetherapyshouldbeondevelopmentofcompensatory strategies,useofexternalaids,providingmorestructureintheenvironment,andjob support.

Role of Cognitive Rehabilitation in Vocational Training

Goalsforcogni verehabilita onshouldbemadewithregardtothespecicskillsneededinthe clientsvoca onalse ng.Sincetheseneedsmaychangewithdierentvoca onalplacementsor developmentoftheclientsskills,itisimportanttoupdatethegoalsregularly.Forexample,the goalsforcogni verehabilita onmayberelevantforasupportedemploymentsitua on.A er workinginsupportedemployment,theclientmaydemonstratethepoten alforemployment withoutsupports.Theneedforaddi onalcogni verehabilita onmaybeindicatedwithnew goalsforselfsuciency.

Compensating for Cognitive De icits on the Job

Peoplewithbraininjuriesareusuallytaughtavarietyofcompensatorymechanismsduringthe courseofcogni veremedia on.Atissuehereiswhethertheyarecapableofincorpora ngthe learnedcompensatorystrategiesintohome,community,andworkplacese ngs. Peoplewithbraininjuryo enhavedicultytransferringthecompensatorystrategiestheylearn intheclinictorealworldsitua ons.Memorydecitsandproblemswithabstractreasoningmake itdifculttogeneralizeinforma onlearnedinonese ngtoanothersitua on.Thebestwayto teachworkrelevantcompensatorystrategiesisinaworkcontext.Itisonlyinaworkse ngthat thesestrategieshaverealmeaningtomostpeoplewithbraininjuries.

Critical Features of Cognitive Rehabilitation

1.Adequateevalua on,planningandongoingsupervisionbyatrainedprofessional. 2.Dailystructuredtasksthatinclude:

Supervision/Minimaldistrac ons Stepbystepacquisi onofskills Constantsystema cfeedback Maximals mula on

20

Builtinsuccess Repeatedlearning Transferoftrainingtofunc onalse ngs

3.Wri eninstruc onsandnotesbysupervisorofdailytasks:

Cogni verehabilita ontherapist/technician A endant Familymember

4.Regular(e.g.weekly)reviewofprogrambyneuropsychologist. 5.Coordina onofprogramwithotherrehabilita onteampersonnel.

IV. THE VOCATIONAL REHABILITATION PROCESS

Thevoca onalrehabilita onprocessbeginswiththereferralandthecollec onofinforma on tolearnasmuchaspossibleaboutthevoca onalcandidate.TheVRcounselorcreatesaprole ofthepoten alclientbygatheringinforma onthroughwri enandverbalreportsand interviewingtheclient.

Determining the Appropriateness of the Referral

Beforebeginningtheassessmentofreadinesstoengageinthevoca onalrehabilita onprocess, thecounselorshouldbesurethattheclienthasbeenappropriatelyreferred.Oneoftherst considera onsistorecognizethereasonforthereferral.Professionalsinbothmedicaland rehabilita onse ngssome mespushpa entswithbraininjuryintoun mely,andtherefore inappropriate,voca onalrehabilita onintheireortstoengagetheirpa entsinproduc ve ac vity.Thereferralmayalsobeviewedasapossiblewaytocon nuerehabilita onwhenother fundingsourceshavebeenexhausted.Ifthepersonbeingreferredforvoca onalrehabilita onis atastageofrecoverywereaddi onalimprovementisexpected,thentheini a onofthe voca onalrehabilita onprocessisbestdeferred.Inassessingreadinesstoengageinwork, carefulconsidera onofthestageandstabilityofbothcurrentandpoten alimprovementmust bemade.Ideally,the metobeginvoca onalrehabilita oniswhenthepoten alclientwith braininjuryiscomple ngtherehabilita onprocess,hasreintegratedintothehomeand community,andexpressesmo va ontowork.Some mes,clientsdonotappreciatetheneedfor voca onalservices.Theymaybeunabletoassesstheirowncapabili esandfrequentlyare unawareoftheirinjuryimposedlimita ons.Itishelpfulforclientstohaveabasicawarenessand acknowledgementofresidualchangesinarangeofcapaci esbeforebeginningvoca onal rehabilita on.

21

Intake Interview
Theintakeinterviewisactuallytherststepintheprocessofassessingreadinesstoengagein theVRprocessandisprobablythebestini alassessmenttoolavailable.Itisrecommendedthat theVRcounselorallowmore meforini alinterviewswithindividualswithbraininjuriesthan otherclients.Theintakeinterviewservesavarietyofpurposes,includingfactndingandto establishingrapportwiththeclient.Addi onally,itallowsthecounselortomakeclinical observa ons,whichisanotherformofdatacollec on.Iftheclientpresentswithbehaviorsthat aresodysfunc onalthatthecounselorhasconcernsaboutworkingwithhim/her,thereisa strongpossibilitythatthepersonisnotreadyfortheVRprocess.Firstandforemost,the interviewprovidesthecounselorwithanopportunitytoevaluatetheclientsabilitytopar cipate ataverybasiclevel;inotherwords,totesthis/hercapacitytoengagereliablyinatwoway communica on.Didtheclientremembertokeeptheappointment?Wastheclientpunctual?Can theclientsupplyinforma onabouthim/herself?Duringthecourseofconversa on,istheclient focused?Ishe/shea en ve,orhighlydistrac ble?Istheclientorientedto meandplace?Isthe clientimpulsive?Istheclientinterestedinvoca onalrehabilita onservices?

Vocational Candidates Arrival

Twothingstobenotedduringthisrstmee ngare: 1)bywhatmeansoftransporta ondidthecandidatearrive,and 2)didhe/shearrivealoneoraccompaniedbyasignicantother. Theinclusionofthisaddi onalpersonasasourceofbackgroundinforma onanddetailsofinjury isrecommendedwhentheclientcannotreliablyprovidethisimportantinforma on.However, thecounselormustndoutwhetherthepresenceofthisaddi onalperson(s)isinresponsetoa needoftheclientortothatofthesignicantother. Inaddi on,theissueofindependentmobilityandtheavailabilityoftransporta onmustbe addressedduringthevoca onalassessmentprocess.

Readily Observed Behaviors

Thelistofbehaviorsthatarereadilyobservedduringtheinterviewingprocessislengthy,andthe counselormustbeawareofallthosethatwillhaveaposi veornega veimpactinawork situa on.Thecounselorshouldgainknowledgeofspecicbehavioraldecitsthat,unlessthey canbecompensatedfororsucientlyremediated,willprecludecertainjobs.Forexample,note signsofdisinhibi on.Theclientwhoisextremelyuninhibitedmaynotfarewellinmaintaining employmentbecauseahighdegreeofdisinhibi onmakesitdiculttoestablishadequate

22

interpersonalrela onshipsintheworkplace.Oneshouldalsonotewhetherapoten alclienthas physicaldisabili esorproblemswithcommunica on.

Signi icant Others

Duringthisini alphaseoffactnding,thecounselorshouldobtaininforma onconcerningthe constella onofsignicantotherswhocanberelieduponforsupplyingsupport.Thelackofthis typeofsupportsystemcanmaketheprocessmoredicult.Familymembersandfamilialrole modelsmakeameasurablecontribu oninvoca onalrehabilita on.

Forming a Vocational Pro ile

Medical Information
Relevantmedicalreportsshoulddescribetheinjury,itsseverity,andthecircumstancesunder whichtheinjuryoccurred.Descrip onsofmedicaltreatment,complica onsduring convalescence,andeortsatrehabilita onshouldalsobepartofthisdatacollec on.Cogni ve andphysicaldisabili esshouldbenoted.Thecircumstancessurroundingtheinjurymayalso provideinforma onsuchasthepresenceofalcoholordrugsascontribu ngfactors. Thepresenceofasurgicallyimplantedshuntshouldbenoted.Theseshuntsareinsertedto relievebuildupofuidinthebrain(crea ngincreasedintracranialpressure)duringtheacute carestage.Theyusuallyremaininplaceandgenerallyoernoproblems.However,iftheshunt becomesclogged,theremustbeasurgicalrevisionorreplacementtocorrectthemalfunc on.A malfunc oningshuntwillcontributeno ceablytoasuddendeclineinperformance. Prescribeddrugsforseizurecontrolorbehavioralmanagementmustalsobenoted.Thesedrugs, whilehelpfulinmaintainingmedicaland/orbehavioralstability,mayhavesideeectsthat impedejobperformance.

Leisure Time Activities

Leisure meac vi esshouldbeexamined.Iftheclientisfortunateandhasremainedsocially ac vefollowingthebraininjury,thecounselorshouldconsiderhowhe/shemaintainsleisure meac vi es.Theskillsneededtomaintainsocialcontactscanbeagoodindicatorofsuccessin thejobmarket.Thecounselorshouldalsoexploreatthispointwhethertheindividualisinvolved inbraininjurysupportgroups.(www.biaoregon.org/supportgrp.html)

PostInjury Work History

Duringtheinterview,thecounselorshouldndoutwhetherthereisapostinjuryworkhistoryor whethera emptstoreturntoschoolorworkweremade.Thequalityoftheworkeortshould beexploredindetailwhenpossible.Sincetheclienthasbeenreferredforvoca onalservices,

23

previousa emptsatreintegra onmaynothavebeensuccessful.Itisimportanttodetermine howrealis ctheclientspercep onisofwhattranspired,andhis/herselfreportofwork func oningshouldbeconrmedinconsulta onwithsignicantothers,formeremployersor teacherswheneverpossible.

PostInjury Education
Academiccreditsordegreesearnedpostinjurymeritspeciala en on.However,thedegree awardedsome meshasnoapplicabilityintherealworldandmayhavebeenearnedunder highlystructuredcondi ons.

Goals and SelfPerception

Itisimportantduringthisprocesstoaskthevoca onalcandidateaboutselfpercep ons regardingspecicinjuryinducedproblems.Thecounselorshouldgatherinforma ononthe quali estheclientpossessesthatmightrepresentstrengths.Usuallypeoplewithbraininjury willmen onproblemsinmemorybecausetheirsocialcirclehasforcedthemtoacknowledge thisdecit.Memoryimpairmentsbecomeselfevident,asdophysicallimita ons,whichclients areabletoreportreadilyandiden fyastheprimaryreasonfortheirinabilitytogain employment. Thisinterviewwouldalsobewellspentindiscussingtheclientspersonalgoalsandassessing howrealis ctheyarewhencomparedwiththeclientsabili es.Thecounselorshouldbeableto observewhethertheselfreportisbiasedbyanxietyduetotheinterviewsitua onorwhether theclientwhopresentsasunrealis cissimplyrespondingtoasocialneedforapproval,thatis, tolookgoodintheeyesofthecounselor.

History Prior to Injury

Informa ongatheredduringtheintakeinterviewmaybeincompleteor,insomecases,not totallyaccurate.Thecounselormustnowassemblethoseelementsofpreinjuryhistorythatcan bedocumentedbywri enrecord.Inthisway,thecounselorcon nuestocreateaportraitofthe personwhoisabouttobeginthevoca onalrehabilita onprocess. Counselorsmustbeawareoftheinjuryproducedphysical,cogni ve,andpsychosocialchanges, butmustalsokeepinmindthatwhoapersonwasbeforeinjuryiso enakeydeterminantof whohe/shewillbecome.Thetragiccircumstanceofabraininjurymaybluntaspectsofbehavior or,conversely,exacerbatethem.Armedwithpreinjuryinforma on,thewellpreparedcounselor canbegintoan cipatestylesofbehaviorthatmaybringsuccessinpar cularworksitua ons.

PreInjury Health History

Itisimportanttoobtainapreinjuryhealthhistorybecausepreexis ngmedicalailmentso en complicatebraininjury.Bothearlierinjuriestothecentralnervoussystemandcongenital anomaliesmayimplicatetherehabilita onprocess.Thepersonprohibitedsincebirthfromthe

24

developmentofafullrangeoffunc onalcapaci espresentsaspecialchallenge,dierentfrom thatofonewhohadnosignicantproblemspriortoinjury. Ahistoryofsubstanceabuseorpsychiatricdisabilityalsomaycompromiseprospectsfor successfulvoca onalrehabilita on.Preinjurydrugabuseandalcoholismaddressapersonsstyle ofsocialadjustment.Themeresugges onofthispredilec onshouldalertthecounselortothe factthatthepoten alforthisbehaviorwillhavetobecloselymonitoredthroughouttheVR process.

PreInjury Education
Levelofpreinjuryeduca onala ainmentmustbeobtainedand,whenpossible,thequalityof educa onalperformance.Anyindica onofalearningdisabilitythatinterferedwiththenormal progressionofeduca onalachievementshouldbenoted.Thepresenceofalearningdisability maycomplicatetheVRprocess. Clientswithadvancedacademicorprofessionaldegreeswillo enpossessagreaterrangeof voca onalop ons.Sinceindividualswithbraininjuriesfrequentlyexhibitproblemswithrecent memory,thelengthof methathaspassedsincethedegreewasobtainedandtheamountof mespentinapplyingwhatwaslearnedmaybeveryrelevant.Mostpeopleretainmemoryfora repertoireofoverlearnedskillsdevelopedbeforetheinjury.

PreInjury Work History

Incompilingapreinjuryworkhistory,thecounselorshouldnotetheskillsthatweredemanded inpreinjuryoccupa ons.Theseskills,o enretained,suggestfurtherareasforvoca onal explora on.Thecounselorshouldalsolooktothejobtrainingexperiencesaswellasformal trainingrequiredforpreinjurywork.Retrievableskillsfromsuchtrainingmayexistandmay suggestfurtherareasforvoca onalrehabilita on.

Course of Rehabilitation/Reports
Withawarenessthatthecourseofrehabilita onishighlyindividualizedanddependentupona rangeofvariables,theVRcounselorshouldgatherallavailablerecordsfromthevarious repor ngdisciplines.Inmostcases,thismeansnursing,physicaltherapy,occupa onaltherapy, psychologyandneuropsychology,speechandlanguageservice,socialservicesandrecrea onal therapy.Thesereportstypicallydocumentfunc onalskillsacrossagamutofcommunityand workrelateddomains.Whenitisdeterminedthattheclienthastheappropriatedegreeof readinesstobegin,thecounselor,inconsulta onwithaneuropsychologistifpossible,should designtheindividualizedvoca onalrehabilita onplan. Someindividualsmayneverhavepar cipatedinconven onalrehabilita onprogramspriorto theVRinterview.Ifthisisthecase,theonlymeansofevalua ngthecurrentstatusof neurologicalandphysicalimprovementsistoacquirethemostrecentreportsofthemedical

25

professionalswhocaredforthem.Thecounselorsprimaryconcerninreviewingtheserecords shouldbethestabilityofgainsmade.Thestabilityofimprovement,bothneurologicallyand physically,isadeterminingfactorinjudgingthe melinessofvoca onalinterven on.

Referral for PreVocationally Relevant Services

Whenwri enandorallydeliveredreportsaswellasobserva onmadeduringthecourseofa personalinterviewdonotindicatereadinesstoengageintheVRprocess,theVRcounselor shouldhavetheop onofreferringtheclientforfurtherservicesthatwouldenhancevoca onal readiness.Theseservicesmightincludetherapiesinanyoftherehabilita ondisciplines, programsthatwouldenhancecommunityindependence,volunteeringexperiences,oralternate choicesasnecessary. Thetypeofprogramorservicetowhichtheclientisbeingreferredshouldbeatthediscre onof thevoca onalcounselorwhohasmadethedetermina onthattheclientisnotready.For example,theclientwithproblemsina en onmayprotfromaperiodofcogni veremedia on designedtoamelioratethisspecicdecit.Eortsmadetoengagepeoplewithbraininjuriesin theVRprocessbeforetheyarereadyarenevercosteec veandmayservetodiscouragethe clientunnecessarily.

Working with the Vocational Rehabilitation Client

InorderforaclientwithbraininjurytogetthemostbenetfromtheVRprocess,thecounselor mayneedtoprovideaccommoda onsforsomeofthecogni veandpsychosocialchallenges facedbytheclient.Apointtorememberisthattheclientsa en onspanisshortandtheymay havelimitedmemory.Theirprocessingisdelayed.Therearuleofvetofollow:haveyour sentencesbenolongerthanveworks,pauseforvesecondsbetweeneachsentence,and havethelistbenolongerthanvesentences.Thefollowingissuesandstrategiesmayassistthe clientinge ngthemostoutoftheservicesoered.

Issue: Dif iculty remembering information

Aclientmayhavedicultyrememberingtasksfromdaytodayorinstruc onsprovidedbythe VRcounselor.He/shemayalsohavedicultyrememberingnewinforma on,whichimpacts learning.He/shemightforgetscheduledinterviewsorfollowupappointmentswiththeVRsta. Strategies:
Providewri eninforma onwheneverpossible. Encouragetheclienttowritedowninforma oninavoca onalrehabilita on

notebook.
Remindtheclienttorefertothenotebooko en.

26

Encouragetheuseofadayplannerorcalendarforrecordingappointmentdates

andtaskstobeperformed.
Encouragetheclienttohaveafamilymemberorfriendprovideareminder

aboutappointments.
Calltheclientonthemorningofascheduledappointment.

Issue: Dif iculty focusing and paying attention

AVRagencyorprogramisabusyplacewithlotsofdistrac ons.Itiseasyforaclientwithabrain injurytohavedicultypayinga en oninthiskindofenvironment.Theclientmayappear uninterested,butinfactishavingproblemsfollowingconversa ons. Strategies:
Workinanareawithlimiteddistrac ons. Beawareofsurroundingnoisesthatmayinterferewithconcentra on,suchas

radios,otherpeopletalking,etc.Trytolimitthesenoisesasmuchaspossible.
Asktheclienttorepeatinforma onthatwasjustheardtomakesurethe

conversa onorinstruc onswereunderstood.

Besuretohavetheclientwriteinstruc onsdowninanotebookorjournal. Besuretohavetheclientsa en onbeforestar ngaconversa on. Refocustheclientsa en onifhe/shebecomesdistracted.(Forexample,John,

letmerepeatthatpointagain.Itsimportant.)
Reschedulethesessionforanother me;perhapsearlyinthedaywhenthe

clienthasmoreenergy.
Asktheclientifthereissomewayyoucanhelp.Forexample,John,youappear

distracted.IstheresomethingIcandotohelp?

Issue: Dif iculty with initiation

Asaresultofabraininjury,aclientmayhavedicultybeginningac vi es.Itmayappearthat he/sheisnotinterestedormo vated,butinsteadhe/sheneedsassistancetobeginworkingon tasks. Strategies:
Establishastructuredrou neofdailyac vi es.

27

Breakdownac vi esintosimplersteps.Encouragetheclienttocompleteonetaskata

mebeforebeginningthenext.
Makeachecklistofac vi esthatneedtobecompletedeachday.Checkoeachtask

thatiscompleted.
Establish meframesinwhicheachtaskshouldbecompleted. Useaclockorwatchthatcanbeprogrammedtoringorvibratetoindicatethe

startofatask.
Provideremindersandencouragement.

Issue: Dif iculty with organization and planning

InordertobesuccessfulintheVRprocess,aclientmustbeabletosuccessfullycarryoutthe plan.Thismaybedicultforapersonwithabraininjurywhohasproblemswithorganiza on andplanning. Strategies:
Developawri enplanandincludetheclientinthedevelopmentoftheplan. Breakdowntheplanintosimplersteps,withclearanddetailedinstruc onsofhowto

completeeachstep.
Assigndierentac vi esforeachdayoftheweek.Forexample,onSundaylookinthe

wantadsandcirclejobleads,onMondaymakephonecalls,onTuesdaysendout resumes,etc.
Developachecklisttoensurethateachstepoftheplangetsaccomplished. Reviewtheplano entomakesurethatitisunderstoodandthatitisworking. Oerpraiseforajobwelldone.

Issue: Dif iculty with decision making.

Followingabraininjury,aclientmayhavedicultymakingdecisions.Iden fyingwhichjobto pursue,decidingwhattowearforaninterview,oransweringinterviewersques onsmaybe dicult.Aclientmayactimpulsivelyandnotthinkthroughtherelevantop ons. Strategies:
Helptheclientiden fywhattheop onsaretoapar cularproblem. Discusswiththeclienttheadvantagesanddisadvantagesofeachop on.

28

 Havetheclientwritedown(orassisthiminwri ng)thepossibleop ons,alongwiththe

prosandconstoeach.
Encouragetheclienttostopandthinkbeforemakingadecision.

Issue: Dif iculty in social situations

Ge ngalongwithcoworkersandbossesisasimportanttokeepingajobasbeingableto performthejobtasks.A erabraininjury,clientsmaynothaveaclearunderstandingofthe impacttheirbehaviorhasonothers.Theymayhavedicultyengaginginconversa onandmay notalwaysbesensi vetosocialboundaries.Thismaybearoadblocktodoingwellonthejob. Strategies:
Provideclearexpecta onsforappropriatebehaviorsattheVRprogram.Provideposi ve

feedbackforexpectedbehavior.
Encouragetheclienttoconsidertheconsequencesofhis/herac ons. Ifundesiredbehavioroccurs,discusstheissueprivately,inacalm,reassuringmanner.

Reviewexpectedbehaviors.
Beforeanintervieworappointment,discusswiththeclientthetypesofques onsthat

canbeexpectedandgureoutwiththeclientthebestanswerstotheseques ons. Similarly,preparewiththeclientques onsthatshewantstoask.

Roleplaytheinterviewsitua onwiththeclientandgivehonestfeedback.Rehearseun l

theclientappearscomfortableansweringandaskingavarietyofques ons.

Issue: Dif iculty controlling emotions

TheVRprocesscanbepar cularlystressfulforapersonwithabraininjury.Accep ngones limita ons,understandingonesstrengths,anddevelopingnewvoca onalgoalscanbe overwhelming.Inaddi on,a endingnewprograms,mee ngnewpeople,andlearningnew rou nesisachallenge.Asaresultofthebraininjury,apersonmayhavedicultycontrolling emo onsinthesestressfulsitua ons. Strategies:
Expecttheunexpected.Alwaysbepreparedtodealwithasitua on,evenifitisatan

inopportune me.
Trytoremaincalm.Bymodelingcalmbehavior,itcanhelptheclientmodifyhis/her

behaviorandmightpreventthesitua onfromescala ng.

29

Takethepersontoaquiet,moreprivate,area.Givehim/herafewminutestocalmdown

andregaincontrol.
Redirecttheclienttoadierenttopicorac vity. Understandthattheeectsofbraininjurymaypreventtheclientfromfeelingguiltor

empathy.
Provideconstruc vefeedbacka erapersonhasregainedcontrol. Usehumorinaposi ve,suppor veway.

Issue: Dif iculty with selfawareness

Apersonwithabraininjurymayhavedicultyaccuratelyperceivinghis/herstrengthsand weaknesses,par cularlythoseareasthathavechangedsincethebraininjury. Strategies:
An cipatepossiblyskewedselfpercep ons. Asktheclienttodiscussherstrengthsandweaknesseswithpeoplewhoknowhis/her

(familymembers,friendsandrehabilita onprofessionals).
Iftheclientlosthis/herjoba erthebraininjury,discusswithhertheproblemsthatled

uptothedismissal.Iftheclientisunsure,asktheclientifhe/shewouldbecomfortable returningtothepreviousemployeranddiscussingtheissues.
Astheclientgainsmoreinsightintoherstrengthsandweaknesses,discussthis

informa onwiththeclient.Encouragetheclienttokeepajournaloftheseinsights.
Provideposi ve,construc vefeedback.

V. EMPLOYMENT OPTIONS
Traditional Vocational Rehabilitation Setting
Thetradi onalVRservicedeliverymodelforthemajorityofclientsconsistsofvoca onal evalua on,voca onaltrainingandjobplacement,inthatorder.Thismodelassumesthatthe clientiscapableofindependentlytransferringwhathasbeenlearnedfromonese ngto another,e.g.,transferringskillslearnedfromtherehabilita onfacilityortrainingprogramtothe job.However,thedecitsofmanyclientswithbraininjuryincludeimpairedmemory,slow

30

informa onprocessingskills,andimpairedabilitytogeneralizenewlylearnedinforma onthe veryskillsnecessarytocompleteatradi onalvoca onalrehabilita onprogramsuccessfully. Clientswithbraininjuryo enarebe erservedbyaPlaceTrainmodel,asopposedtothe tradi onalTrainPlacevoca onalmodel.

Limitations of Traditional Vocational Evaluation

Tradi onalvoca onalevalua onsystemshavebeenillequippedtomeetthespecialneedsof peoplewithbraininjuries.Standardizedtestsofintelligence,personality,ap tude,interestand achievementtypicallyprovidescoresthatindicatehowanindividualcompareswithnorm groups.Peoplewithbraininjuriesareo encapableofdisplayingareasorpocketsofhigh achievementonthosestructuredtestsofdiscreteskills.Theresultsyieldedbymanyofthese testsarepredicatedonoldlearning,i.e.,awellrehearsedrepertoireofpreinjuryskills.An excellentexampleofascorethatcanmisrepresentthepoten alofaclientisverbalIQ,derived fromintactmateriallearnedbeforetheinjury.Unfortunately,thesetradi onaltoolsandthe evaluatorswhousethemassumeasystemicintegrity,andpeoplewithbraininjuriesdonot conformtothenormalpopula onsuponwhichthesetestswerestandardized.Thecomponent thatpreventstheseinstrumentsfrombeingvalidpredictorsofsuccessistheinabilityofthose withbraininjuriestointegrate,applyandgeneralizemanyoftheskillsthataretested.Most standardizedexamina onsdonotaddress(otherthantheadministratorsobserva ons)ormake allowancesfortheproblemareasthatposethemajorbarrierstosocial,educa onaland voca onalreintegra on.Thatis,theyprovidequan abledatabutmakenoprovisionfor includinginreportsofscoresanassessmentofthequalityofperformance. Tradi onalVRsystems,withagrowingawarenessthatindividualswithbraininjuriesareunable torespondtothesetestsinwaysthataccuratelytranslatetofunc onalskills,arenow recognizingtheneedforalterna vemethodsoftes ngandevalua on. Standardizedvoca onaltes ngmeasuresareusefuliftheyarecarefullyadaptedtoaddressthe skillcapaci esofclientswithbraininjuries.Examiningtestresultswhilerecognizinghowthe clientcompletesthetestandwhatcogni vestrengthsandweaknessesareevidentcanprovide invaluableinforma onaboutlearningandperformanceissues.Whenadministeredcrea velyby acounselorfamiliarwithfunc onalbehaviorscommonlyfoundinthispopula on,theresultscan beusedtodetermineappropriatetypesofentryleveljobplacements. Theintroduc onoftradi onalhandson,situa onalassessments(ashorttermmonitoringof workperformanceinanactualse ngasopposedtoastandardizedtes ngenvironment)asa meansofmeasuringvoca onalpoten alhasmetwithlimitedsuccessinthispopula onwhen appliedinthemannerusedbymostvoca onalworkevalua onprograms.Itislimitedbecause mostclientswithbraininjuriesareillequippedtoengageinonthejobworksitua onswithout somepreparatoryguidance.

31

Mostclientsretainapictureofthemselvesfunc oningatpreinjurylevels.Itisunrealis cto an cipatewholeheartedpar cipa oninasitua onalassessment,whichusuallybeginsatentry level,byclientswhomayclingtoaviewofthemselvesasfunc oningattheircapacitybeforethe injury.Suchpar cipa onispossibleonlyfollowingapersonaladjustmenttodisability;an adjustmentthatincludesabeginningawarenessandacknowledgementofinjuryimposed func onallimita ons.Developingthisessen albasicdegreeofawarenessmustbeaccomplished beforeengagingtheclientwithabraininjuryinanyvoca onalevalua onprocess. Oncetheindividualhasasenseofawarenessofhis/herfunc onallimita onsandawillingnessto accommodatetheselimita onsinaworkse ng,amorerealis cevalua oncanbeconducted. Implementa onofaskillfullydesignedsitua onalassessmentfollowedbyapreparatoryperiod tohelptheindividualbecomeawareoflimita onscanprovidetheVRcounselorwithanexcellent opportunitytoobservethequalita veaspectsofworkbehaviors.Itisthevehiclethatcanallow theVRcounselortodesigncompensatorymeasures,providestructureandsupportsystems,test autonomy,gentlyconfrontinareasthatrequiremodica on,and,ifprovidedwhentheclientis ready,canbetheop malguidetowardvoca onalreintegra on.

Graduated Placements
Thedemandsofacompe vejobaresignicantlygreaterthanthosefoundinmost rehabilita onfacili esandarealmostaquantumleapformanyclientswithabraininjury. However,manyclientscanmakethetransi onifitoccursslowly.Forexample,onemethod mightbeginbyplacingtheclientinavolunteerposi ononapart mebasis,thengradually transferringhim/hertoapart mejob,andul matelytoafull mejob,allunderthedirec onof acommunityreentryspecialist.Anynumberofvaria onsofthistechniqueispossible.Thekeyis tointroducenewdemandsinsmallenoughincrementsfortheclienttohandle.Another advantageofgraduatedplacementsistoincreaseaclientsawarenessthataddi onalskillsare neededbeforefull mecompe veemploymentcanbeseriouslyconsidered.Professionalshave foundthatclientswhoworkonatrialbasisinthecommunityo enreturnwithnewawareness oftheobjec vesoftherehabilita onprogram.Theybecomeawarethattreatmentsugges ons madebytherehabilita onprofessionalmayindeedbenecessaryforsuccessfulvoca onal func oning.Atemporaryplacementcanbeusedtoimproveappropriateworkbehaviors. Frequently,clientswilldemonstratemarketablevoca onalskillsbutwilldisplaybehaviorsthat wouldresultinjobloss.Fortheseclients,avolunteerworksitewithrealworldsupervisorshas provenbenecial.O entheclientmorereadilyacceptssupervisorycri cismfromsomeone outsidetherehabilita onfacility.

Supported Employment
Supportedemploymentisaspecialtypeofplacementthatallowsforcon nuedtreatment throughouttheVRprocessandhasprovenbenecialforclientswithbraininjury.Itisdenedas compe veworkinanintegratedworkse ngwithongoingsupportservices.Theadvantagesof usingasupportedemploymentapproachwithclientswithabraininjuryaremany:

32

Itrestorestheclientsiden tyasaworkerandprovidesnancialcompensa onforreal

work.
Theplaceandtrainapproach,asopposedtothemoretradi onaltrainandplaceVR

model,allowsforimmediatereentryintoarealworkse ngandisthebestwayforthe clientwithabraininjurytolearnworkskillsandappropriateworkbehaviors.

ItenablesVRstatoassessandremediatecogni veandbehavioraldecitsinthereal

workse ng.
ItallowsVRstatodevelopcompensatorystrategiesforthespecicjobtasksthatare

assigned.
Itallowsonsiteadvocacyandinterven onwiththeclientssupervisorwhen

problemsoccur. Manypeoplewithbraininjuryneedthelongterm,ongoingsupportthatsupportedemployment providestobesuccessfulonthejob.Whenstar nganewjob,theclientneedsassistance learningjobtasks,developingcompensatorystrategies,andadjus ngtothenewrou ne.As me goeson,jobresponsibili es,supervisorsand/orcoworkerschange.Thepersonwithabraininjury mayhavesignicantdicultyadjus ngtothenewsitua onorlearningnewrou nes.Without periodicoversightfromthesupportedemploymentteam,thepersonmaybeterminatedbefore realizingthataproblemexists.

Use of a Job Coach

Aprincipleunderlyingthemeofsupportedemploymentistoprovideongoingsupportatthejob sitetohelpclientsfunc oninanintegratedworkse ng.Thepersonwhoprovidesthissupportis o encalledajobcoachorjobcoordinator.Thisindividualprovidesongoingsupportaslong asneeded.Astheclientlearnsthejob,thecoachwillspendless meinonthejobsupport. Ongoingsupportmayincluderetraining,jobmodica onsandmee ngswithsupervisorsandco workers. Ajobcoachiso envitaltothesuccessfulplacementofclientswithbraininjuries.He/shemust beawareofthestrengthsandweaknessesoftheclientandwhat,ifany,compensatory techniquesareusedbytheclienttoovercomecogni vedecits.Thejobcoachmayneedto developspecicstrategiesatthejobsitetoassisttheclientinperformingtheessen al componentsofthejobandmonitoringworkbehaviors.He/shemustalsobeabletointerveneif problemsariseatthejobsite. Itisessen althejobcoachfunc onasaneducatoroftheemployerandotheremployeesatthe site.Onecannotemphasizetoostronglytheneedtoeducateemployersaboutbraininjuryin generalandaboutthespecializedneedsoftheindividualclientinpar cular.Forexample,the

33

employerhastobeawareofthestrengthsandneedsoftheclienttoavoidunrealis c expecta onsorrequiringmorethantheclientscapabili eswillallow. Thejobcoachisalsoinanidealposi ontosetupnaturalsupportsatthejobsitetoincrease theclientschanceforsuccess.Thejobcoach,withtheapprovaloftheclient,canenlistthehelp ofwillingcoworkersandmanagerstoprovidesupporttotheclientasneeded.Thisinvolves educa ngtheselectedcoworkerand/ormanageraboutthetypesofcompensatorystrategies thatcanhelptheclientbestperformhisjob,andteachingthemhowtocuetheclientto implementthesestrategiesasneeded.Theseindividualsshouldalsoknowtocontactthejob coachwithanyques onsorconcerns,par cularlyiftheyseeadeclineintheclientsjob performance.

The Role of the Job Coach

1. Establishtrust Establishrela onshipswiththeclient,thefamily,andtheemployerthatarebased ontrustandhonesty. 2. Respectothers

Respectthevaluesandinterestsoftheclient,thefamily,andtheemployer.Always maintainarespec uldemeanor. 3.Communicate

Constantcommunica on,bothoralandwri en,withtheclient,familyand employeriskeytosuccess.Donttakeanythingforgrantedwriteeverythingdown andsharetheinforma onwithallpar es. 4.Evaluateskillsandbehaviors Performsitua onalassessmentsinavarietyofenvironmentsandusingavarietyof taskstounderstandtheclientsstrengthsandweaknesses.Evaluatewhattypeof compensatorystrategiesworkbest. 5.Makegoodjobmatches

Findajobthatmeetstheinterests,abili es,andtoleranceleveloftheclient. 6.Doathoroughjobanalysis Learneverythingaboutthedemandsofthejobsbeforeplacement.Reviewyour ndingswiththeemployertoensurethatthejobtasksareunderstood.Provide everythingtotheemployerinwri ng.

34

7.Establishastructuredworkdayanddependablerou ne

Unplannedchangesinjobdu escanprovedisastrousforapersonwithabrain injury.Educateemployersabouttheneedtomakechangesslowlyandin consulta onwiththejobcoach. 8.Developcompensatorystrategies

Developcompensatorystrategiesthatworkfortheclientinperformingthejob tasks.Astheclientbecomesfamiliarwiththejoborasjobtaskschange,make adjustmentstothestrategies. 9.Bewatchfulofbehavioralissues

Inappropriatebehaviorscancausemajorproblemsonthejob.Useacollabora ve approachtoiden fybehaviorsthatneedtobemodiedandenlistthecoopera on oftheclienttomakenecessarychanges. 10.Monitorstamina

Fa guecaninterferewithjobperformance,memoryandbehaviors,especiallyona newjob.Workwiththeemployertoadjustworkschedulesasneeded. 11.Providelongtermsupports Longtermfollowalongservicesforclientswithbraininjuryareessen altomonitor performancelevelandprovideinterven onasneeded.Encouragetheclientandthe employertocontactthejobcoachattherstsignofaproblem.

Job Placement Considerations

ThefollowingstepsshouldbetakenbytheVRcounselorpriortoplacingaclientwithabrain injuryonaworksitetoavoidaninappropriatematchandasitua onthatpoten allysetsthe clientupforfailure.

Selectivity
Theplacementmustbeconsistentwiththeclientscogni ve,physical,andpsychosocial strengthsandweaknesses.Moreover,theclientsinterests,abili esandap tudesmustalsobe considered.

Job Analysis
Thereareavarietyoftechniquesdesignedtoorganizeandevaluateinforma onrelevanttothe performanceofajob.Fortheclientwithabraininjury,thatanalysismustcontaininforma on

35

withrespecttothephysical,emo onal,andcogni veelementsnecessarytoperformthejobat theobservedsite.Thedemandsofthejobcanthenbecomparedwiththestrengthsand weaknessesoftheclientpriortoplacement.

Placement with Education and Training

Theemployerandworksitesupervisorsmustbefullyawareofaclientsstrengthsand weaknesses.Aninformedsupervisorislesslikelytomisunderstandbehaviorsthatonthesurface mayappeartobewillfulanddeliberate.Forexample,aataectduetoneurologicalfactorsmay bemisinterpretedasalackofmo va on.Equallyimportantiseduca ngtheemployerthat sa sfactoryperformanceononetypeofjobdoesnotnecessarilyimplythattheclientshouldbe promotedtohigherleveljobs.Again,thenewjobshouldbeanalyzedtodeterminewhetherthe clientiscapableofperformingitsindividualcomponents.

Ongoing Supports
Eec veplacementassumestheavailabilityofanongoingsupportsystem.Longterm coordina onbetweentheVRteam,theemployerandtheclientisessen altoensurethat necessarysupportsfortheclientareinplace.

Job Accommodations
Thekeytoasuccessfuljobplacementistheprovisionofnecessaryjobaccommoda onsandthe developmentofcompensatorystrategiesatthe metheplacementismade.Eachclientwitha braininjuryisuniqueandwillrequirestrategiesthataddressthespecicstrengthsand limita onsthathe/shepresents.Wheneverpossible,consultwiththerehabilita onteamandthe neuropsychologisttoassistinestablishingthebestpossibleaccommoda ons.Belowisalistof accommoda onsthatcanserveasastar ngpointinconsideringwhataclientmightneed.

Memory:
Usenotebooks,calendars,ors ckynotestorecordinforma onforeasyretrieval. Providewri enaswellasverbalinstruc ons. Allowaddi onaltraining me. Providewri enchecklists. Provideenvironmentalcuesforloca onsofitems,suchaslabels,colorcoding,orbulle n

boards.
Postinstruc onsoverallfrequentlyusedequipment. Taperecordmee ngs,conversa ons,andinstruc ons. Useelectronicorganizers(PDAs,handheldcomputers,voiceorganizers,watches,andcell

phones).AnonlineCatalogofPortableElectronicDevicesforMemoryandOrganiza on canbefoundontheBrainInjuryAssocia onofAmericaswebsiteatwww.biausa.org/

36

pda.html.ThebestresultscomefromusingtheiTouchwhichusespicturesratherthan morecomplexinstruc onsthatfrequentlyarenotrememberedcausingfrustra on.

Other memory strategies:

Usemnemonictechniques(anorganiza onalstructureonverbalinforma ontocue

recallofseveralelements.) Example:Aclericalassistantrecallshersequenceofjobdu esbyrememberingtheword CODE. C=clockin O=openmail D=delivermail E=enterdata

Useimagerytechniques(theprocessofusingmentalpictures/imagesforinforma onto

berecalled.) Example:Aclericalassistantvisualizesherselfwalkingaspecicroutetoassistin rememberingtheroutefordeliveringthemail.

Usenumbergrouping(recallingnumbersbyreorganizingthemintofewerelements.)

Example:Aclerkworkingatanautosupplycompanyneedstoremembertopullitems basedonafourdigitcode.Helooksatacodingbookandseesfournumberssuchas9,5, 3,2.Insteadofrememberingthenumbersindividually,herecallstheinforma onas95 and32.

Useofverbalrehearsal(repea ngoutloudkeyinforma ontohelprecallingthe

informa on.) Example:Adataentryoperatorcomestoworkandsetsupherworksta onbysaying aloud:Turnoncomputer.Turnonmonitor.Entermypassword.Hitenter3 mes,etc.

Maintaining Concentration:
Reducedistrac onsinworkareas(whitenoisesoundmachinesorlisteningto

instrumentalmusicmaybehelpful).
Providespaceenclosuresoraprivateofce.

37

Reduceclu erintheworkenvironment. Simplifylargeassignmentsbybreakingthemintosmallertasks. Changeligh nginworkarea(eithermoreorlesslightdependingonneeds). Arrangeforuninterruptedwork me.

Organiza on:
Makedailytodolistsandcheckoitemsascompleted. Useacalendarsystemtomarkmee ngsandtaskdeadlines. Useelectronicorganizers(PDAs,handheldcomputers,voiceorganizers,watches,and

cellphones).AnonlineCatalogofPortableElectronicDevicesforMemoryand Organiza oncanbefoundontheBrainInjuryAssocia onofAmericaswebsite: www.biausa.org/pda.html.

Establishaneec velingsystem. Planrou nemee ngswiththesupervisor,reviewworkprogress.

ProblemSolving:
Providewri enschema csofproblemsolvingtechniques(i.e.owcharts). Restructurethejobtodecreasetheamountofproblemsolvingrequired. Assignasupervisororcoworkerwhoisavailabletoanswerques onsandreviewwork

progress.
Allowextra metoaccomplishjobtasks.

Fa gue/Stamina:
Scheduleperiodicrestbreaks. Allowaexibleworkscheduleanduseofleave me. Allowworkfromhome. Reduceworkplacestress,reducephysicalexer on.

Stress:
Providesensi vitytrainingtocoworkersandsupervisors. Allowbreakstousestressmanagementtechniques. Providepraiseandencouragement. Refertocounselingoravailableemployeeassistanceprograms. Evaluatewhetherjobdemandscanbechangedtoreducestresslevel.

38

VisionImpairment:
Providewri eninforma oninlargeprint. Changeligh ngandincreasenaturalligh ngwheneverpossible. Provideglareguardforcomputermonitors. Consultwiththerehabilita onteamoravisionspecialistforspecicrecommenda ons.

WorkingEec velywithSupervisors:
Providewri enjobdescrip onswithclearlydenedresponsibili esthatarereviewed

frequently.
Reviewjobperformancefrequently. Provideposi vefeedbackandpraiseforgoodwork. Clearlydeneinwri ngtheconsequencesofpoorjobperformanceorinappropriate

workbehaviors.

Placement Rede ined

Full me,compe veemploymentmaybetheidealobjec ve,buttherealityisthatmany clientswithabraininjuryareincapableofachievingit.Therefore,abroaderdeni onof placementishelpfulwhenaddressingtheneedsofthispopula on.Jobplacementcanbe redenedascommunityreentry,includingfull meorpart mecompe veemployment, supportedemployment,andvolunteeremployment.Integra onoftheclientintothe communityandtheprovisionofsuppor veservicesareongoingneedsthroughoutthedura on oftheclientsplacement.Jobplacementcannotbeanal,nonsupportedstepforthis popula on.Specializedtreatmentthroughouttheen rerehabilita onprocess,includinglong term,followalongservicesa erplacement,mustbemadeavailabletoclientswhohave sustainedbraininjuries.

39

VI. INVOLVING THE FAMILY IN THE VOCATIONAL PROCESS

Whilefamilyinvolvementinthevoca onalprocessisanimportantfactor,itmustbepointedout thatnotallfamiliesproduceaposi veinuenceinthevoca onalprocessoftheirlovedone. Familiesmaypushforunrealis cvoca onalgoalsorbeunabletocarryoutaplanofac onto producethebestvoca onaloutcomefortheindividual.Familydynamicsaswellasthefamilys valuesystemplayimportantrolesindeterminingtheresponsetoprojectedvoca onalgoals.

Family Expectations and Values

Theanswertotheques on,Whatareyourexpecta ons?willo enrevealagreatdealof informa onaboutthefamilysystem:theirneeds,values,adjustmenttoandaccommoda onof thefamilymemberwiththebraininjury.O enanindividualsiden tywithinhis/hercommunity andfamilyisdirectlyrelatedtoemployment.Manypeopleformassump onsaboutthelevelof educa on,income,livingenvironmentandlifestyleofanindividualbaseduponthatpersons typeofemployment.Thisa tudereectstheimportanceworkholdsforpeopleintermof addressingstrong,deeplyfeltneedsandvaluesandelici ngpsychologicalprotec ve mechanisms.Itfollowsthatworkservestojus fyonesvalueandiden fyonesworthinsociety. Whilethemostobviouspurposeofworkingisprovidingnancialsupport,mostpeopledonot workfornancialsupportalone,noristhisnecessarilythemajorreasonforchoiceofwork. Rather,mostpeoplechoosecertainjobsbecausetheyfulllcertainneedsandaddressvalues thattheindividualandhis/herfamilyhavedevelopedoveralife me.Itisimportanttoconsider therolesprovidedbyfamiliesintheprocessofadjustmenttowork.Atoneendofthespectrum arefamiliesdeterminedtobeproduc veandselfsuppor ng(describedaspossessingawork ethic).Attheotherendarefamilieswithli leornoinvestmentinworkasawayoflife.These la erfamiliesmaysubtly(orobviously)transfertheira tudetowardworkasnonessen aland valuelesstothememberoftheirfamilythathasabraininjury.Certainlyanindividualwhocomes fromafamilywithrmlyestablishedworkethicsmaybeabe ervoca onalrehabilita on candidatethantheonewhosefamilyisnotmo vatedtowork.Whileprofessionalsshouldnot judgethevaluesystemsofindividualfamilies,includingthosewhoplaceotherrewardsabove thevalueofconven onalwork,itisofpragma cimportancetorecognizetheinuenceofsuch valuesystemsonapersonwithabraininjuryandadjustvoca onalrehabilita onaccordingly.

Effects on Family Structure

Familiesofindividualswithbraininjuriesmustrealizetheinescapableeectsonandchanges withinthefamilystructure.Ifthepersonwithabraininjuryistheincomeprovider,therewill likelybechangesinmarriage/familyrela onships,income,economicstabilityandsocialstatus. Oneormorefamilymembersmaybeforcedtoassumetheroleofprovider.Itisimportantto rememberthatsudden,unexpectedshi sinroles,goalsandresponsibili esa ertrauma cbrain injuryaectallfamilymembers.

40

Denial
Duringthevoca onalrehabilita onprocess,manyfamiliesappeartobestuckina phaseofdenial.Ifthefamilyhasextremedicultyaccep ngtherealityofthereduced voca onalreintegra onplans,thismessageiso enpassedontothepersonwiththe braininjury.Thismayhamperthebeginningofthevoca onalprocessattheentrylevel. Peoplewithbraininjuriesrememberclearlyhowtheyperformedpriortotheirinjury andareo enreluctanttotakeonataskthatisviewedasboringornonchallenging. Familieswillo ensupportthisa tudeandatthesame mereinforceidealized voca onalgoals.

Bargaining and Splintered Skills

Atthestageofadjustmentwhentheindividualismakingsubstan alphysical improvement,he/sheo enfeelsreadytoreturntohis/herpreviouslifestyle,including work.Itisfrequentlyobservedthattheindividualatthispointo endisregardsor minimizestheimpairmentofskillssuchasproblemsolving,reasoning,judgmentand organiza on,allofwhicharecri calforvoca onaladapta onandcommunityreentry. Whilethepersonmayrecognizesomelimita ons,he/shefeelsdeservingofarewardfor achievementinphysicalrehabilita on. Frequently,familymemberswhodesiretoseetheindividualfunc onatahigherlevel willsupportthistypeofthinking.Thisisthepointatwhichbargainingtakesplace,i.e., whentheclientandthevoca onalcounselormustreachanagreementabouttheskills thatcanberealis callyperformedbytheindividual.O enthefamilydoesnotseethat theskillsofitsfamilymemberwithabraininjuryaresplintered.Thepreviously interconnectedskillsarenolongercoordinatedandworkinisola onratherthanthe completesetofskillstheypossessedpriortothebraininjury. Voca onalcounselorsfacethedilemmathatjobsrelyingonsplinteredskillsdonotexist andthattherearefew,ifany,employerswhoarewillingtoredesignjobsthatrelyon oneortwolimitedskills.Evenifthevoca onalcounselorlocatedaperfectjob,the individualwoulds llneedproblemsolving,communica onandinterpersonalskillsin ordertogetalongwithcoworkersandsupervisors. Placingaclientinajobforwhichhe/shedoesnotpossesstherequisiteskillsmaycause embarrassmentorridiculeatthejobsiteoreventuallycausethepersontobe ostracized.Theindividualrisksalossofselfesteem,whichmaytake metorebuild. Also,certainjobscouldexposetheindividualtoharm.Inadangerousenvironment, cogni velimita ons,especiallyavulnerabilitytodistrac onorreducedsafetyjudgment, couldresultinanaccidentorinjury. Anotherdetrimentalresultofplacinganindividualonajobwhenhe/shepossessonlysplintered skillsisthepossibilityofacri calmistakecos ngtheemployermuch me,eortand/ormoney.

41

ThiswouldalsoreectpoorlyontheVRprogramorprofessional.Moreover,avaluable employmentresourcecouldbelost. VRcounselorsmustremainneutralandobjec vetomanageeec velythedelicatesitua onsof familiesa emptedbargaining.Therststepintherightdirec onistohelpthefamilygainan appropriateperspec veontheprogressthathasbeenmade.Thesecondstepmightbeto encouragethemtolisttheprosandconsofcon nuedrehabilita onora emp ngajob placement.Throughdiscussion,thecounselorcanfacilitatemovementtowardacceptanceofthe situa onwhilemaintaininganobjec veandsuppor verole.Iden fyingjobsthatrequirethe skillstheindividualcurrentlypossessescanbeagroupeort.Theindividual,thefamilymembers andtherestoftherehabilita onteamcanhelpthecounselor.TheVRprofessionalmayalsobe preparingalistofjobsinwhichtheindividualmightbesuccessfulwithanexpandedrepertoireof skills.Alistofpoten aljobop onscanhelpallpar esrefocusandremainhopefulthataddi onal jobop onsmaybeappropriateinthefuture.Se ngupshorttermandlongtermvoca onal goalscanhelpboththeclientandthefamilyestablishanappropriatereturntoworkplanwhile s llholdingontothehopeofcon nuedimprovementinabili es.

Depression
Peoplewithbraininjuryo enexperienceadropinselfesteemstemmingfromthelossofa careeroremployment,alossofsocialiden tygenerallydenedbyoneswork,andguiltcreated byreducedearningcapacityandbecominganancialburdenonthefamily.Familymembersas wellastheclientmaybecomedepressedastheyeachan cipatealossofindependenceand individuallyrealizethattheirownfuturegoalsandplanswillhavetobeadjustedto accommodatetheneedsofthefamilymemberwithabraininjury.Voca onalcounselorsneedto usebothsuppor veandexploratorycounselingapproacheswiththedepressedclientandhis/ herfamilymembers.Counselorsshouldhelptheseindividualsreexamineandchallengetheirlong heldideasaboutpersonalaspira onsandgoalstheyhaveestablishedtofeelworthwhile. Counselorsmayalsoneedtoexploretheindividualspreinjuryfeelingsanda tudestoward personswithadisability.Frequently,thesefeelingsarebasedonstereotypicalideassuchas equa ngdisabilitywithhelplessnessandthesick/pa entiden ty.Helpingboththeindividual andfamilymemberstoiden fytheirfeelingsoflosingcontrolcandiminishdepressivereac ons, andsupportthedevelopmentofworthwhile,contribu ngrolesinthehomeandcommunity. Aboveall,voca onalcounselorswillneedtoprovideac velisteningsupportandvalida onas theclientandfamilymembersexpresstheirsadnessabouttheirlosses. Adjustment Thevoca onalprocesscanbeviewedandusedbyprofessionalsasboththeculmina onofa successfulrehabilita onprogramandapsychotherapeu ctooltofacilitatemovementthough stagesofemo onaladjustment.Theskillfuluseofvoca onaltoolsandsitua onsinthe rehabilita onprocessshouldfacilitateemo onaladjustmentstolimita onsresul ngfrombrain

42

injurywhileencouragingtheuseofprac calaccommoda onstrategies.Tosuccessfullyassist individualswithbraininjuryinbecominggainfullyemployed,voca onalcounselorsneedbothto focusonthedesiredoutcomeandalsotobecomeknowledgeableandsensi vetothe adjustmentprocessthatmustrstoccur.TheVRcounselorwillencountermanydierenttypes offamilyinvolvementthoughthevoca onalprocess.Dierentlevelsoffamilyinvolvementmay includetheinvolvedandsuppor vefamily;theinvolvedandunsuppor vefamily;orthe uninvolvedandunsuppor vefamily.Itisimportantforthevoca onalcounselortoconsider, understandandincludeallaspectsofthefamilyduringthevoca onalprocess.Professionals needtobesensi veandskilledinordertodesigninterven onsthatarehelpful, melyand culturallyandenvironmentallyappropriatetothefamilyandtheindividual.Successinthe voca onalrehabilita onprocessiso encommensuratewiththedegreetowhichprofessionals successfullyinvolvefamilymembersasaneededandvaluedpartofthisprocess.

VII. CONCLUSION
Workingwithaclientwithabraininjurycanbeextremelychallengingyetrewardingforthe voca onalrehabilita onprofessional.Thecounselormustunderstandwhotheclientwaspriorto injury,recognizethephysical,emo onal,andpsychosocialchallengestheclientfacesa erinjury, andestablisharealis cvoca onalplan.Thistakes me,knowledgeofbraininjury,and experience.Inaddi ontoworkingwiththeclient,theVRcounselormustbesensi vetothe needsofthefamilyandtheemployerincarryingoutthevoca onalplan.Finally,theskilledVR professionalmustrecognizethatvoca onalrehabilita onforthepersonwithbraininjuryisa slowando en mescomplicatedprocess,requiringpa ence,crea vityandthough ulness.

43

VIII. REFERENCES
DepartmentofVeteransAairs,VeteransHealthIni a ve.Trauma cBrainInjuryA Con nuingMedicalEduca onProgram. EmploymentandDisability,SchoolofIndustrial&LaborRela ons.WorkingEec vely withEmployeesWhohaveSustainedaBrainInjury.CornellUniversity,NewYork,June, 2000. FawberH.,andWachterJ.JobPlacementasaTreatmentComponentoftheVoca onal Rehabilita onProcess,JournalofHeadTraumaRehabilita on(2)Vol.1,1987pp.2733 JobAccommoda onNetwork(JAN).JobAccommoda onsforPeoplewithBrainInjuries. OfceofDisabilityEmploymentPolicy,U.S.DepartmentofLabor,contract#J9M2 0022. MayoClinic.UnderstandingBrainInjury:AGuideForEmployers.Rochester,Minnesota, 2000. McMahon,B.andShaw,L.WorkWorthDoingAdvancesinBrainInjuryRehabilita on. Orlando:PaulM.DeutschPress,1991. OklahomaDepartmentofRehabilita onServices.OklahomaVoca onalRehabilita on TrainingCurriculumforBrainInjury.OklahomaStateDepartmentofHealth,HRSAGrant H21MC06749. Silver,SaralynM.,M.S.,C.R.C.,HeadTraumaProgram,NewYorkUniversityMedical Center.Originalmaterialdevelopedforthishandbook,1991. Silver,SaralynM.,etal.FamilyandReturntoWork,Williams,J.andT.Kay.Head Injury:AFamilyMa er.Bal more:PaulBrookes,1991. Wehman,Paul,etal.SupportedWorkModelforPersonswithTrauma cBrainInjury: TowardJobPlacementandReten on,Rehabilita onCounselingBulle n,Vol31.June 1988. Wehman,Paul,andKreutzer,JereyS.Voca onalRehabilita onforPersonswith Trauma cBrainInjury.Maryland:AspenPublishers,1990.

44

BrainInjuryAssocia onofOregon,Inc. POBox549 MolallaOR97038 Phone:(503)7403155Fax:(503)9618730 Helpline:18005445243 Website:www.biaoregon.org Email:Info@biaoregon.org

45