introductory brain injury handbook for v/r. professionals

8/22/2019 Introductory Brain Injury Handbook for V/R. Professionals

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I fell offa ladder cleaning the guers.

My exboyfriend beat me up.I sustained a blast injury in Iraq.

I tripped and hit myI was hit by a drunk driver.

I had encephalis.

The Brain Injury Handbook

An Introductory Guide toUnderstanding Brain Injury

for Vocational Rehabilitation Professionals

BrainInjuryAssociaonofOregon,Inc. www.biaoregon.org 18005445243

I was assaulted leaving

I had a heart

I was shaken by the babysier.


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TheBrainInjuryHandbook2011

AnIntroductoryGuidetoUnderstandingBrainInjuryforVocaonal

RehabilitaonProfessionals

BrainInjuryAssociaonofOregon,Inc.

POBox549,MolallaOR97038

8005445243www.biaoregon.org

ThesematerialswerefundedbytheOregonStateRehabilitaonServicesGrant

#131350.

ThesematerialsareadaptedinpartfromTheBrainInjuryHandbook:AnIntroductoryGuideto

UnderstandingBrainInjuryforVocaonalRehabilitaonProfessionals,madepossiblethrougha

grantfromtheU.S.DepartmentofHealthandHumanServicesHealthResourcesandServices

Administraon,MaternalandChildHealthBureauincooperaonwiththeHenryH.Kessler

Foundaon.WithpermissionfromtheN.J.DepartmentofHumanServices,DivisionofDisabilityServices.


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TableofContentsTableofContents........................................................................................................................................... i

I.THENATUREOFBRAININJURY.................................................................................................................. 1

HowDoestheBrainWork?....................................................................................................................... 1

WhatisBrainInjury?................................................................................................................................. 5

DiffuseInjury............................................................................................................................................. 5

ConcussiveDamage.................................................................................................................................. 6

Coup/ContrecoupInjury.......................................................................................................................... 7

SecondaryDamageinClosedBrainInjury................................................................................................ 8

BlastInjury................................................................................................................................................ 9

II.FUNCTIONALCHANGESAFTERBRAININJURY........................................................................................ 12

PhysicalChanges..................................................................................................................................... 12

Arousal.................................................................................................................................................... 12

AenonandConcentraon.................................................................................................................. 13

Memory.................................................................................................................................................. 13

AbstractThinkingandConceptualizaon............................................................................................... 14

ExecuveFunconing............................................................................................................................. 14

InterpersonalandPsychosocialChanges................................................................................................ 15

CommonIssuesFollowingBrainInjury................................................................................................... 16

MildBrainInjuries................................................................................................................................... 16

Diagnoscs.............................................................................................................................................. 17

NeuropsychologicalConsult/Evaluaon................................................................................................. 17

VocaonallyRelevantQuesonsfortheNeuropsychologist................................................................. 18

III.COGNITIVEREHABILITATION................................................................................................................. 19

IndicatorsofNeed.................................................................................................................................. 19

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RoleofCogniveRehabilitaoninVocaonalTraining.......................................................................... 20

CompensangforCogniveDeficitsontheJob..................................................................................... 20

CricalFeaturesofCogniveRehabilitaon....................................................................................... 20

IV.THEVOCATIONALREHABILITATIONPROCESS....................................................................................... 21

DeterminingtheAppropriatenessoftheReferral.................................................................................. 21

IntakeInterview...................................................................................................................................... 21

VocaonalCandidatesArrival................................................................................................................ 22

ReadilyObservedBehaviors.................................................................................................................... 22

SignificantOthers.................................................................................................................................... 23

FormingaVocaonalProfile................................................................................................................... 23

MedicalInformaon............................................................................................................................ 23

LeisureTimeAcvies......................................................................................................................... 23

PostInjuryWorkHistory..................................................................................................................... 23

PostInjuryEducaon.......................................................................................................................... 24

GoalsandSelfPercepon................................................................................................................... 24

HistoryPriortoInjury.......................................................................................................................... 24

PreInjuryHealthHistory..................................................................................................................... 24

PreInjuryEducaon............................................................................................................................ 25

PreInjuryWorkHistory....................................................................................................................... 25

CourseofRehabilitaon/Reports........................................................................................................ 25

ReferralforPreVocaonallyRelevantServices.................................................................................. 26

WorkingwiththeVocaonalRehabilitaonClient................................................................................. 26

Issue:Difficultyrememberinginformaon......................................................................................... 26

Issue:Difficultyfocusingandpayingaenon................................................................................... 27

Issue:Difficultywithiniaon............................................................................................................. 27

Issue:Difficultywithorganizaonandplanning................................................................................. 28

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Issue:Difficultywithdecisionmaking................................................................................................. 28

Issue:Difficultyinsocialsituaons..................................................................................................... 28

Issue:Difficultycontrollingemoons................................................................................................. 29

Issue:Difficultywithselfawareness................................................................................................... 30

V.EMPLOYMENTOPTIONS......................................................................................................................... 30

TradionalVocaonalRehabilitaonSeng......................................................................................... 30

LimitaonsofTradionalVocaonalEvaluaon.................................................................................... 30

GraduatedPlacements............................................................................................................................ 32

SupportedEmployment.......................................................................................................................... 32

UseofaJobCoach.................................................................................................................................. 33

TheRoleoftheJobCoach....................................................................................................................... 34

JobPlacementConsideraons................................................................................................................ 35

Selecvity............................................................................................................................................ 35

JobAnalysis......................................................................................................................................... 35

PlacementwithEducaonandTraining............................................................................................. 35

OngoingSupports.............................................................................................................................. 36

JobAccommodaons.......................................................................................................................... 36

Memory:.......................................................................................................................................... 36

Othermemorystrategies:............................................................................................................... 37

MaintainingConcentraon:............................................................................................................ 37

PlacementRedefined...................................................................................................................... 39

VI.INVOLVINGTHEFAMILYINTHEVOCATIONALPROCESS....................................................................... 40

FamilyExpectaonsandValues.............................................................................................................. 40

EffectsonFamilyStructure..................................................................................................................... 40

Denial...................................................................................................................................................... 41

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BargainingandSplinteredSkills.............................................................................................................. 41

Depression............................................................................................................................................... 42

VII.CONCLUSION......................................................................................................................................... 43

VIII.REFERENCES......................................................................................................................................... 44

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I.THENATUREOFBRAININJURY

Personswithbraininjuryareachallenginggrouptoservewithinthevocaonalrehabilitaon

(VR)system.

These

individuals

have

needs

that

are

unique

totheir

disability

and

symptoms

that

arefrequentlybaffling. Thishandbookprovidesanoverviewofbraininjuryandits

consequences,aswellasstrategiesandresourcesthatmaybebeneficialinworkingwithpeople

whohavebraininjuries. ThishandbookwascreatedtohelpVRcounselorsprovideappropriate

servicesforpeoplewithbraininjuriesintheireffortstoreturntowork.

Individualswithbraininjuryareuniqueasservicerecipients.Theirparculardisabilitydiffers

fromanyotherdisabilitygroupthecounselormayhaveencountered.Personswithbraininjuries

simplydonotexhibitdisablingcondionsinthesamewayasotherdisabilitygroups,anditis

thisnonconformitythatsetsthemapart.Whencounselorsaempttousetradionalmethods

toassessthevocaonalpotenalofmembersofthischallenginggroup,theireffortscanresult

inafailuretoservetheseclients.Inordertoeffecvelyprovideservicestothispopulaon,the

rehabilitaoncounselormustfirstacquireabasicknowledgeofhowthebrainfuncons.Only

thencanthecounseloradequatelyappreciatethecomplexityoftheclientwithbraininjury.Itis

ofparamountimportancethatthecounselordevelopafamiliaritywiththenatureand

consequencesofbraininjuryandbeginstounderstandtheinteraconamongthemyriadof

problemsapersonmayencounter.Oncehavinggainedfamiliaritywithbrainmechanismsand

theclientslocusofinjuryfrommedicalreports,thecounselorsllshouldexerciseextreme

cauoninplacinglabelsonancipatedareasofdysfuncon.Thereareindividualdifferencesin

theorganizaonofeachhumanbrain,andthesedifferencesmayinpartaccountfor

unancipatedfunconalachievementsinsomeclients,eventhoughseveredeficitsand,

therefore,limitedpotenal,hadbeenobservedinaneuropsychologicalexaminaon.

Conversely,subtledeficitsnotedduringtesngproceduresmaybequiteseriousobstaclesto

successinavarietyofvocaonalspheres.Vocaonalcounselorsshouldbeawarethatdisparies

betweentestresultsandactualtaskperformancewillsurfaceconnually.

Insummary,providingservicestopeoplewithbraininjuriesrequirescreavityandflexibility. It

ishopedthatasthereadergoesthroughthishandbook,issuestoucheduponbrieflyinthis

introductoryseconwillgrowinclarity.

HowDoestheBrainWork?Thehumanbraincontrolstheaconsofthebodyandallowsustothink,learnandremember.Itismadeupofbillionsofnervecellsthatwork

togethertocontrolemoon,behavior,movementandsensaon.Tobeerunderstandwhat

canhappentoanindividualwhenthebrainisinjured,itishelpfultoknowaboutthedifferent

partsofthebrainandwhattheydo.Therearethreemainseconsofthebrain thecerebral

hemispheres,cerebellumandbrainstem.Thebrainisdividedintotwohalves.Thesehalvesare

thele andrightcerebralhemispheres.

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Eachpartofthebrainisresponsibleforspecificfuncons. Thele cerebralhemisphere

controlstherightsideofthebodyandisresponsibleforspeech,analycalthoughtand

memory.Therightcerebralhemispherecontrolsthele sideofthebodyandis

responsibleforcreavethinking,expressionofemoonsandvisuospaalabilies.

Specificpartsofthebraincontrolspecificfuncons,likevision(OccipitalLobe),balance

andcoordinaon(Cerebellum),heartrateandbreathing(BrainStem),smell(underthe

frontallobe),orhearing(temporallobe).Thus,whathappenstoapersonwhenthe

brainisinjuredwilldifferdependingonthepartofthebrainthatwasaffected.

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WhatisBrainInjury?Braininjuriesthatoccuraerbirtharecalledacquiredbraininjuries.Anacquiredbraininjurycanbetheresultofamedicalcondion.Someofthese

condionsincludestroke,encephalis,aneurysm,anoxia(lackofoxygenduringsurgery,drug

overdose,orneardrowning),metabolicdisorders,meningis,orbraintumors.Acquiredbrain

injuriescanalsooccurwhenanoutsideforcestrikestheheadhardenoughtocausethebrain

tomoveinsideoftheskullanddamagethebrain.Thistypeofinjuryiscalledatraumacbrain

injury,andcanbecausedbycarcrashes,falls,beinghitonthehead,oranyphysicalviolence.

Thistypeofbraininjuryisreferredtoasaclosedbraininjury,meaningthatthebrainhasnot

beenexternallypenetrated.Whenthebrainispenetrated,suchaswithagunshotwound,the

injuryiscalledanopenbraininjury.

Theseverityofsuchatraumacbraininjurymayrangefrommild,i.e.,abriefchangein

mentalstatusorconsciousness,toseverei.e.,anextendedperiodofunconsciousnessor

comaaertheinjury.Oenthereissomeperiodofunconsciousnessfollowingatraumatothe

brain.However,therearethoseindividualswhodonotloseconsciousnessbutwillnonetheless

exhibitsymptomsofbraininjury.Asaresultoftraumacbraininjury,thebrainsustains

damagethatmaybeeithertemporaryorpermanent.

Theconsistencyofthebrainhasbeencomparedtogelanorcustard.Undernormal

condions,thissomass,gentlycushionedbycerebralspinalfluid,floatswithinthevaults

formedbythemembranesthatlinetheskullandtheprotecveboneoftheskullitself.When

thebrainisinjured,threeprimarytypesofdamagemayoccur:diffuse,concussiveandcoup/

contrecoup.Thesethreetypesofinjuryarediscussedindetailbelow.

DiffuseInjury

Thefirsttype,diffuseaxonalbraininjury,resultsfromthestretchingandtearingofnervefibers

(axons)throughoutthebrain. Thisdiffuse,widespreaddamagetothebrainisthetypethat

frequentlyresultsfromamotorvehiclecrash.Whenthemomentumofarapidlymoving

vehicleissuddenlyhalted,withtheheadstrikingastaonaryobjectinsidethecarsuchasa

dashboardorthewindshield,theimpactresultsinrotaonalforcestwisnganddislocangor

shiingthebrainmass.

Whenthebrainissubjectedtotheseviolentmoons,thereisenormousstretchingandpulling

ofthethreadlikenerveconnecons(axons)thatformthenetworkforbrainfunconing.Asthe

axonsarestretched,biochemicalfunconingceasesandthenervesstopfunconing.Axons

thatareseverelystretchedsomemessnap,andthelikelihoodofthesenervesever

funconingagainisremote.Themoresevereandwidespreadthedamage,thegreaterthe

probabilityofanensuinglossofconsciousness(coma).Praccallyallpeopleemergefrom

coma.However,thetypeofinjurydescribedabovevirtuallyalwaysleadstopermanentand

generallyseveredamagetothebrain.

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ConcussiveDamage

Concussivedamageistheresultofthebraincollidingwiththesharpridgesontheinside

frontoftheskull.Theresulngbruisesorcontusionsaremostlikelytooccurinthebase

ofthefrontalandtemporallobesofthebrain.Theselocalizedcontusionsproducetwoof

themostfrequentlyencountereddeficitsfollowingclosedbraininjury. Theyare

execuvedysfunconandimpairedmemoryfuncons.

Sincethetemporallobesareessenaltothesystemthatregisters,storesandretrieves

informaon,damagetothisareaaffectstheabilitytolearnnewmaterial.

Damagetothefrontallobesmayseriouslyimpairthewiderangeofabiliesknownas

execuvefuncons.Individualswithfrontallobeinjuriesareunabletothinkabstractly,

conceptualize,orbeeffecveproblemsolvers.Theyaregenerallyinflexiblethinkerswho

remainconcretelyboundtoapresenngsituaon.Theyareunabletotakeaselfcrical

viewandarethereforefrequentlyunawareofhowtheirbehaviormayaffectothers.

Becauseofapronouncedinabilitytodevelopaplanandiniateanacvity,these

individualsarefrequentlylabeledunmovated.Frontallobeinjuriesarethemost

prevalentinautomobilecrashes.Individualswithfrontallobeinjuriesareoenthemost

difficulttoserveinvocaonalrehabilitaon.

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Coup/ContrecoupInjury

Thethirdtypeofprimarydamageseeninclosedbraininjuryoccurswhentheheadis

struckwithsuchintensitythatitliterallybendstheskullinatthepointofimpact,injuring

thebrainbeneathit(theinialbloworcoup),andthenpropellingthebrainagainstthe

oppositesideofthebrain(thecounterbloworcontrecoup).Thistypeofdamageismost

likelywhenamovingobjectstrikesthestaonaryhead.Itdoesnotnecessarilyoccurinall

closedbraininjuries.Whenitdoeshappen,theimpairmentsthatresultdependonwhich

specificbrainareashavebeendamaged.Arangeoffunconalareasmaybecome

selecvelyimpairedfollowingacoup/contrecoupinjury.Thesemaybeinthemotor,

sensory,perceptualandlanguagedomains.

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SecondaryDamageinClosedBrainInjury

Inaddiontothethreetypesofprimarydamagedescribedpreviously,secondarydamage

isacommonoccurrenceinbraininjury.Thiscanincludebleedingwithinthebrainitself(intracerebralhematoma);orbetweentheskullandthebraincovering(epidural

hematoma);and/orbetweenthebrainandbraincover,(subduralhematoma).Thereis

furtherdamagetothebrain ssueasbloodcollectsandbuildsuppressurethat

compressesthebrain.Intracranialpressureincreasesasthebrainswellswithfluid(edema,

hydrocephalus)orbecomesengorgedwithblood.Sincetherigidityoftheskullallowsno

roomforthebraintoexpand,surgeryisfrequentlynecessarytorepair,stopbleeding,

removeclots,relievepressureand/orpreventherniaon.Whensecondarydamage

occurs,usuallyinseverebraininjury,itcanproducefunconallimitaonsmoresevere

thanoriginallyancipated.

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BlastInjury

Ablastinjuryisacomplextypeofphysicaltraumaresulngfromdirectorindirectexposuretoan

explosion.Blastinjuriesoccurwiththedetonaonofhighorderexplosivesaswellasthe

deflagraonofloworderexplosives.Theseinjuriesarecompoundedwhentheexplosionoccurs

inaconfinedspace. From2000to2010,theDefenseandVeteransBrainInjuryCenterhas

counted178,876casesofTraumacBrainInjury(TBI)amongU.S.Militarypersonnel.

Seventysevenpercentofthosecasesweredeterminedtobemild.Basedonthesenumbers,the

numberofconfirmedcasesofTBIshassurpassedrecordedcasesofPostTraumacStress

Disorder(PTSD)bynearly100,000.

TherearefourtypesofBlastInjuries: Primary(directeffectsofpressure,either

overpressurizaonandunderpressurizaon,suchasruptureoftympanicmembranes,pulmonary

damage,andruptureofhollowviscera);Secondary(effectsofprojecles,causingpenetrang

traumaandfragmentaoninjuries);Terary(effectsofstructuralcollapseandofpersonsbeing

thrownbytheblastwind,causingcrushinjuriesandblunttrauma,penetrangtrauma,fractures

andtraumacamputaons,openorclosedbraininjuries);andQuaternary(burns,asphyxia,and

exposuretotoxicinhalants).

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PrimaryInjuries

Primaryinjuriesarecausedbyblastoverpressurewaves,orshockwaves.Theseareespecially

likelywhenapersonisclosetoanexplodingmunion,suchasalandmine. Theearsaremost

oenaffectedbytheoverpressure,followedbythelungsandtheholloworgansofthe

gastrointesnaltract.GastrointesnalinjuriesmaypresentaeradelayofhoursorevendaysInjuryfromblastoverpressureisapressureand medependentfuncon.Byincreasingthe

pressureoritsduraon,theseverityofinjurywillalsoincrease.

Ingeneral,primaryblastinjuriesarecharacterizedbytheabsenceofexternalinjuries;thus

internalinjuriesarefrequentlyunrecognizedandtheirseverityunderesmated.Accordingtothe

latestexperimentalresults,theextentandtypesofprimaryblastinducedinjuriesdependnot

onlyonthepeakoftheoverpressure,butalsootherparameterssuchasnumberofoverpressure

peaks, melagbetweenoverpressurepeaks,characteriscsoftheshearfrontsbetween

overpressurepeaks,frequencyresonance,andelectromagnecpulse,amongothers.The

majorityofpriorresearchfocusedonthemechanismsofblastinjurieswithingascontainingorgans/organsystemssuchasthelungs,whileprimaryblastinducedtraumacbraininjuryhas

remainedunderesmated.

SecondaryInjuries

Secondaryinjuriesareduetobombfragmentsandotherobjectspropelledbytheexplosion.

Theseinjuriesmayaffectanypartofthebodyandsomemesresultinpenetrangtraumawith

visiblebleeding.At mesthepropelledobjectmaybecomeembeddedinthebody,obstrucng

thelossofbloodtotheoutside.However,theremaybeextensivebloodlosswithinthebody

cavies.Shrapnelwoundsmaybelethalandthereforemanyanpersonnelbombsaredesigned

togenerateshrapnelandfragments.

TeraryInjuries

Displacementofairbytheexplosioncreatesablastwindthatcanthrowvicmsagainstsolid

objects. Injuriesresulngfromthistypeoftraumacimpactarereferredtoasteraryblast

injuries.Teraryinjuriesmaypresentassomecombinaonofbluntandpenetrangtrauma,

includingbonefracturesandcoupcontrecoupinjuries.

Blastinjuriescancausehiddenbraindamageandpotenalneurologicalconsequences.Its

complexclinicalsyndromeiscausedbythecombinaonofallblasteffects,i.e.,primary,secondary,teraryandquaternaryblastmechanisms.Itisnoteworthythatblastinjuriesusually

manifestinaformofpolytrauma,i.e.injuryinvolvingmulpleorgansororgansystems.Bleeding

frominjuredorganssuchaslungsorbowelcausesalackofoxygeninallvitalorgans,including

thebrain.Damageofthelungsreducesthesurfaceforoxygenuptakefromtheair,reducingthe

amountoftheoxygendeliveredtothebrain.Tissuedestruconiniatesthesynthesisand

releaseofhormonesormediatorsintothebloodwhich,whendeliveredtothebrain,changeits

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funcon.Irritaonofthenerveendingsininjuredperipheral ssueand/ororgansalso

significantlycontributestoblastinducedneurotrauma.

Individualsexposedtoblastfrequentlymanifestlossofmemoryforeventsbeforeandaer

explosion,confusion,headache,impairedsenseofreality,andreduceddecisionmakingability.

Paentswithbraininjuriesacquiredinexplosionsoendevelopsudden,unexpectedbrain

swellingandcerebralvasospasmdespiteconnuousmonitoring.However,thefirstsymptoms

ofblastinducedneurotrauma(BINT)mayoccurmonthsorevenyearsaertheinialevent,

andarethereforecategorizedassecondarybrainInjuries.Thebroadvarietyofsymptoms

includesweightloss,hormoneimbalance,chronicfague,headache,andproblemsinmemory,

speechandbalance.Thesechangesareoendebilitang,interferingwithdailyacvies.

BecauseBINTinblastvicmsisunderesmated,valuable meisoenlostfor

prevenvetherapyand/or melyrehabilitaon.

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II.FUNCTIONALCHANGESAFTERBRAININJURYManyclientswithabraininjuryappeartobeidealvocaonalcandidates.Theytypically

possesssubstanalpreinjuryworkrecords;formeremployerswillinglyaesttotheirgood

workadjustments;andselfreportsofpreinjuryemploymentoreducaonalaainmentsare

usuallyinkeepingwiththereportsofothers.Itisimportanttoemphasize,however,thatthepersonbeingdescribedinthesereportsisnotnecessarilythesamepersonaertheinjury.

Physical,cogniveandpsychosocialchangesasaresultofthebraininjurymayhavesignificant

impactontheindividualsabilitytowork.

PhysicalChanges

Physicaldeficits,iftheyexist,arealwaysthemostobviousornoceablelimitaonsinindividuals

withbraininjury.Unlikethemoresubtlecogniveimpairments,physicaldeficitsaregenerally

visibleandfrequentlybecomethecentralissueuponwhichanindividualplacesallresponsibility

(blame)forhis/herinabilitytoreturntopreinjuryacviesandlifestyle.

Physicalimpairmentsareusuallytheresultofdamagetothebraincentersthatcontrolmotor

funconsratherthandirectinjurytotheextremies.Deficitsmayincludelossofmotor

coordinaon,spascity,poorbalance,aninabilitytowalkunassisted,andalossofeyehand

coordinaon.Hemiplegia(paralysisaffecngonesideofthebody)andhemiparesis(weakness

ofonesideofthebodyorpartofit)mayfurthercomplicatevocaonalissues,parcularlywhen

thesecondionsaffecttheuseofthepreinjurydominanthand.

Withinthiscategory,onemustnotethepotenalforseizuredisorders,and,iftheyare

prescribed,medicaonstakentocontrolseizures.Thestabilityoftheseizuredisorderandthepotenalsideeffectsoftheseizuremedicaonsmayfurthercompromisevocaonal

rehabilitaonefforts.

CogniveChangesPersonswithbraininjurymayexhibitproblemsinavarietyofcogniveareas

suchasbasicarousal,alertness,aenon,concentraon,memory,abstractthinkingand

conceptualizaon,planning,organizing,problemsolving,andjudgment.Peoplealsomayhave

difficultyprocessingverbalandvisualinformaon.

Arousal

Signsofarousalproblemsincludeaninabilitytoaendtotheenvironment;alackof(or

reduced)alertness;aninabilitytoaccuratelyobserveenvironmentaldetailsandoccurrences;

andaseverelyslowedcapacityforinformaonprocessing.Peoplewitharousalimpairments

areoenslowinreacngandrespondingtoothersandarehighlysuscepbletofague

followingcogniveorphysicalexeron.Theymayappearalmostlostinspaceornotin

touch.

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AttentionandConcentration

Impairedaenonandconcentraoncanexhibitaseasydistracbility.Thismaybearesponse

tointerferenceeitherbyexternalorinternalsmuli.Forthepersonwithbraininjury,the

inabilitytoscreenoutexternalnoisesmakesitdifficulttosustainconcentraon.

Environmentalnoiseisfoundinmostworksengs,e.g.,conversaonofothers,usualoffice

traffic, hummingofmachinesandthegeneralrelatedbuzzofacvity.Intrusionsbyexternal

noisecanoenbecontrolledorminimized,andthecapacityforconcentraonwillusually

improve.

Forthepersonwithbraininjury,anotherpossiblesourceofdistracngnoiseistheinternal

conversaonwithinhis/herownmind.Intrusiveinnerthoughtsthatlimitproducvityare

exceedinglyhardertomanage.Theybecomevisible(observable)onlywhentheyinterrupt

performance.

Memory

Lossofadequatememoryfunconandtheinabilitytoimmediatelyrecallnewinformaon

(anterogradeamnesia)arecommonsymptomsfollowingbraininjury.Whilesignificant

improvementinmemoryfunconmaybenotedduringtheinialperiodofrecovery,this

deficitisoenobservedinvaryingdegreesformostpeoplewithbraininjury.

Inadequatememoryfunconisoneoftheprimarycomplaintsreportedbypeoplewhohave

sustainedbraininjuries.Oenitistheirsocialenvironmentthatcausesthemtodevelopan

awarenessofthisparcularproblemarea.Thereprimandsofacquaintancesandsignificant

othersformissedappointments,appliancesle onorbillsle unpaidcompelthepersonwith

braininjurytoacknowledgethathe/sheforgetsimportantthings.Inadequatememoryfuncon

remains,unfortunately,unresponsivetoremedialintervenon.However,memoryimpairments

canbecompensatedforbyavarietyofmnemonicdevices(memoryaids)suchasthose

describedlater.

Praccallyallpersonswithbraininjuryretainaclearmemoryofthemselvesastheywere

preinjury.Intactoldmemoriesandoverlearnedinformaon(forexample,ridingabikeor

performingasequenceofjobtasks)frequentlyrepresentareasofstrength.Thesepreserved

skillscanoenbedrawnuponwhenhelpingaclientwithbraininjuryredevelopvocaonalgoals.

Somemesanindividualmayappeartohaveamemoryimpairment,wheninfactthepersonhas

difficultypayingaenonwhenpresentedwithnewinformaonandisthusunableto

rememberthisinformaon.Itisessenalfortheclientandthecounselortoknowthe

difference.Theinabilitytoremember,asaresponsetolackofeffecveaenon,canbe

remediatedfrequently,oratleastsubstanallyimproved,bycogniverehabilitaon.

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AbstractThinkingandConceptualization

Animportantconcernforvocaonalcounselorsiswhethertheclientwithbraininjuryisableto

engageinabstractthought.Clientscanremainstuckinoneviewofasituaon.Theymayfindit

difficulttoshi tootheraspectsofaproblemortoreadilysearchforalternaves.Theymaylack

thecapacityforimaginavethoughtandremainpoorproblemsolvers.Problemswithabstract

reasoninglimitsthetypesofproducveacvityanindividualcanpursueautonomouslyand

impactsontherange,complexity,andvarietyoftaskstheycansuccessfullyaempt.

Conceptualizaon,whichisdependentonthecapacitytothinkabstractly,isanotherareain

whichtheindividualmayexhibitcognivedeficits. Theabilitytoeffecvelyconceptualizelies

withintherealmofhigherlevelcognion.Onemustpossessastoreoflearnedmaterialthatis

reliablyandreadilydrawnuponinordertoimagineorformamentalpicture,organizethese

mentalevents,andbeabletotranslatethiscogniveacvityintoanobservablebehavior/skill.

Problemsintheabilitytoconceptualizecansignificantlyimpactthetypesofjobsapersonisable

topursue.

ExecutiveFunctioning

Deficitsinexecuvefunconingarethedirectresultoffrontallobedamage.Intactexecuve

funconsallowanindividualtoengageinautonomous,independent,wellplanned,effecvely

organized,sufficientlymonitored,selfregulated,purposefulorgoaldirectedenterprises.When

thesecapabiliesarediminishedastheresultofbraininjury,theindividualhasdifficulty

sustaininggainfulemployment,maintainingsasfactorysocialrelaonshipsand,at mes,

maintainingadequateselfcare,regardlessofhowwellothercognivecapaciesareretained.

Thepersonwholooksandsoundsgoodandwhosetestresultsonexaminaonsofskillsand

knowledgeareunimpairedwillhavedifficultyfunconingproducvelywhenexecuveskillsare

impaired.Suchclientsremainpoorselfmanagers.Theseclientswhosooenappearcapableare

probablythemostdifficulttotreatorevaluatevocaonally. Theyhavelostthemechanismto

accuratelymonitortheirabiliesandneedfrequentfeedbackinordertounderstandtheimpact

theirareasofweaknesshaveontheirabilitytoreturntowork.

Thecounselorshouldalsocarefullyassessaclientsabilitytoformulategoals.Whilecapableof

engagingincomplexacvies,thoseimpairedinexecuvefunconingmaylackthecapacityto

developplansoriniatepurposefulacvity.Inextremecases,theseindividualsmayappear

apathecandunabletoiniateacvityexceptinresponsetoexternalsmuli.Theabilityto

becomeengageddynamicallyininteracveandintenonalbehaviorisbasictoexecuveskills.

Asmenonedearlier,whenthiscapacityfalters,personswithbraininjurycanerroneouslybe

labeledlazyorunmovated.

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InterpersonalandPsychosocialChanges

Interpersonalandpsychosocialchangesfollowingbraininjurymaypresentthemostserious

impedimenttovocaonalreintegraon.Aclientmaypossessintact,highlevel,funconalwork

skillsbutwillbepreventedfromsustainingemploymentbecause,inmostemploymentsengs,

jobretenondependsonmaintainingthegoodwillofcoworkersandsupervisorystaff.Inother

words,aclientneedstobeabletointeractwithcoworkersandsupervisorystaffinawork

appropriatemanner;maintainingapleasant,approachableaffect,oratleastaneutralone.

Peoplewithbraininjurymaybelewithmarkedchangesintheirbehavioralrepertoireand

exhibitverbalandphysicaldisinhhibion,poorsocialjudgmentandageneraldecreaseinsocial

graces.Someclientsmayexhibitdysfunconalsocialbehaviorsofsuchmagnitudethattheyare

preventedfromengaginginanyconsistenttaskperformance.Whenevenlengthytreatmentand

clinicalintervenoncannotmodifyundesirablesocialbehavior,compeveemploymentmay

notbeachievable.

Ahighdegreeofegocentricityisoenanotherconsequenceofbraininjury.Manyclientshave

difficultyinadopngaflexiblestanceandremainfixedintheirviewthattheworldonlyrelatesto

andrevolvesaroundthem. Clientsmaylackthecapacitytoreadsocialcuesaccurately. Some

failtoreaditatall;theyseemoblivioustonuancesofspeechandbodylanguageofothers. They

confusetheimpactofsociallyrelayedmessagesandconsistentlyinterpretthemasbeing

personallydirected.Forexample,clientsmaymisinterpretacoworkersorsupervisorsangeror

disappointmentoverworkproblemsasastrongnegavemessageabouttheirpersonal

performance.Inaddion,construcvecricismmaybeinterpretedasapersonalassault.The

unfortunatebyproductofthistypeofmisinterpretaonisthattheclient,whoperceivesthe

angerasdirected

athim/her,

generally

responds

with

anger.

Oneoftheleastunderstooddysfunconalinterpersonalskillsisthelossofemoonalcontrol.

Clientscanoverreactorbecomeimmobilizedbyatypeofemoonalfloodingrarelyobservedin

otherdisabilitygroups.Thetypeandextentoftheiremoonalresponse,oenthedirectresultof

someinternaldialogue,isnotmeritedbythesituaon.Lossofemoonalcontrolwillusually

surfaceunexpectedlyandsomemesbeofsuchmagnitudethatitprecludesanyproducve

acvity.

Thisemoonalinstabilityischaracterizedbyrapid,exaggeratedmoodoraffectswings.Knownas

emoonal

lability,

the

condi

onisthe

result

ofweakened

orimpaired

control

inemo

onally

chargedsituaons.Becausetheclientsphysicalappearancemaygivenoindicaonofadisability,

observerstendtomisinterprethis/herstrongemoonalresponses.

Anotherissuefacingpeoplefollowingbraininjuryisadecreasedtoleranceforalcoholanddrugs.

Smallerdosesproducemorerapideffects.Socialdrinkingcanbedifficulttocontrolandwill

interferewithapersonscognive,physicalandpsychosocialfunconing.

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Relaonshipswithinthefamily,thecommunityandtheworkplacewillbecompromisedwhena

personisunabletoeffecvelycontroltheiruseofalcoholordrugs.Thevocaonalrehabilitaon

processwillbeatjeopardyaswell.Theclientshouldbemadeawareoftheharmfuleffectsof

thesesubstancesandtheVRcounselorshouldaggressivelymonitorandinterveneifthereisa

quesonofimpairmentduetoalcoholordruguse.

MildBrainInjuries

TheVRcounselorwillbecalledupontoprovideservicesforpersonswhopossessawiderangeof

capabiliesandlimitaonsastheresultofbraininjury.Alongwiththosewhohavemoderateor

severebraindamage,therearethoseclassifiedashavingmildbraininjuries. Becausepeople

withsocalledmildorminorbraininjurydonotexhibitobviousdeficits,theyarenotreferredfor

rehabilitaonservicesunllongaertheactualinjury.Followingavisittotheemergencyroom,

doctorsoffice,orabriefperiodinanacutecarefacility,individualswithmildbraininjuries

generallyreturnhomeandsubsequentlytowork.Whiletheyoenhavenoawarenessofaltered

16

Common Issues Following Brain Injury

Cognive Changes Physical Changes

Memory

Problemsolving

Decisionmaking

Persistence

Planning

OrganizaonSequencing

Processingspeed

Judgment

Inflexibility

Concentraon

Aenonspan

Motorcoordinaon

Tasteandsmell

Hearingand/orvisualchanges

Spascityandtremors

Fagueand/orweakness

BalanceMobility

Speech

Seizuredisorder

Paralysisononeorbothsides

Depression

Socialskills

problems

Moodswings

Emoonallackofcontrol

Inappropriatebehavior

Impulsivity

Lackofresponsetosocialcues

Irritability

Reducedselfesteem

Diffi

cultyrela

ngwith

others

Selfcenteredness

Difficultyformingnewrelaonships

Stress,Anxiety,Frustraon

Denial

Lackofmovaon

Excessivelaughing

Personality and Behavioral Changes


23/51

abilies,theirjobperformanceismarkedlydiminishedandtheabilitytoretainemployment

suffers.Thisgroupofpeopleappearunchangedfrompreinjurystatusandtheirdifficulesare

furthercompoundedbytheexpectaonsplaceduponthembytheirsocialenvironment.Because

theyappearsointact,theseexpectaonsarehighandusuallyincongruentwiththeirreduced

capacies.Whentheemploymentproblemsbecomeobviousandtheindividualisfinally

referredforvocaonalcounselingorrehabilitaon,theoriginalcauseoftheproblemmayremain

unrecognized. Ifthisisthecase,theVRcounselorcanbeinstrumentalindeterminingwhethera

mildbraininjurymaybeafactorintheemploymentproblemstheindividualisexperiencingand

inarrangingforappropriatetesngbyaneuropsychologisttoaddresstheseproblems.Itshould

benotedthatmildbraininjuryisacomplexproblemandisoenaddressedintherehabilitaon

literatureasaseparateanduniquetopic.Resourceinformaonaboutmildbraininjurycanbe

foundontheBrainInjuryAssociaonofOregonswebsite(www.biaoregon.org).

Diagnostics

Duringtheearlystagesoftreatmentandrehabilitaonofpeoplewithbraininjury,anumberof

neurodiagnoscmeasuresandmentalstatusexaminaonsareperformed.Themainpurposeof

suchtesngistomeasurecognivefunconingandchartimprovementsastheyoccur.These

testsarenotimmediatelyrelevanttothevocaonalrehabilitaonprocess.However,later

neuropsychologicaltesng,whichisbestadministeredwhenthepersonwithabraininjuryhas

becomemedicallystable,bearsdirectrelevancetovocaonalrehabilitaon.

NeuropsychologicalConsult/Evaluation

Aneuropsychologicalevaluaonmaybepartofthecaserecordsthevocaonalcounselor

reviewsatthe meofreferral. Thesignificanceoftheresultsmaynotbereadilyapparent,and

therefore,maybedifficulttotranslateintomeaningfulapplicaon. Testscoresaretypically

reportedastheycomparetoestablishednorms,andaclientsperformanceorlevelof

funconingmaybedescribedintermsthattellusonlythathe/sheisdeficient,impairedor

belowtheaverage. Thesetermsmeanlilewhentheyhavetobeappliedtoajobanalysis.

Addionally,thesereportsmaybewrieninjargonthatfurtherconfusesthevocaonal

counselor.

Ontheotherhand,awellwrienneuropsychologicalevaluaoncanserveasaninvaluabletool

tounderstandingthecognivestrengthsandweaknessesofaclientasitappliestoreturningto

work.Ifthevocaonalcounselorismakingthereferralfortheneuropsychologicalevaluaon,

askingspecificreferralquesonsaboutworkfunconing,accommodaons,andtreatment

recommendaonscanenhancetheinformaonthatisprovidedinthereport.Discussingthe

resultsofthetesngwiththeneuropsychologist,whoseexperseisinbrainbehavior

relaonships,isanotherwaytoobtainvocaonallyspecificinformaon.

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VocationallyRelevantQuestionsfortheNeuropsychologist

Whatfunconallimitaonsareevidentwithrespecttomemory,informaon

processing,visualandauditorycomprehension?

Whatisthe

poten

alforfurther

remedia

on?

Whatistheprognosisforlengthoftreatment?

Canyoucommentonspecificstrengthsnotedinthetesngsituaon,e.g.,ease

inreceivingoralinstrucon,persistence,concentraon?

Istheclientdistracble?Externally?Internally?

Canyoucommentonthoseaspectsofpreinjurylearning(i.e.,firmly

entrenched,overrehearsed,repertoireofskills)thathavesurfacedduringthe

currenttesng?

Istherepotenalfornewlearning?

Howmuchsupervisionandenvironmentalsupportwillbeneededatthecurrent

leveloffunconing?

Whatistheclientsbestmethodoflearning?

Whattypeofcompensatorystrategieswouldbebeneficialtoenhancejob

performance?

Whattypeofjobaccommodaonswouldbehelpful?

Whataretheeffectsofinterpersonaldeficitsonvocaonalgoals?

Theresultsofawellfocusedneuropsychologicalevaluaoncantranslateintopraccal

recommendaonsforthevocaonalassessmentprocess.Theseresultsallowthecounselorto

makepreparaonsandtakeancipatorystepstoensureasuccessfulexperiencefortheclient.

Thevocaonalcounselorcanthenbegintodesignthetypesofenvironmentalsupportsystems

thattheclient,givenhis/herstrengthsandlimitaons,willrequireduringthevocaonal

rehabilitaonprocess.

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III.COGNITIVEREHABILITATION

Clientswithbraininjuriesmayneedcogniverehabilitaonastheyarepreparingforthe

vocaonalrehabilitaonprocess.Cogniverehabilitaonisthesystemac,goaloriented

therapeucintervenondesignedtoremediate(improve)arangeofcogniveabilies.Areasaddressedinaprogramofremediaonarehighlyindividualizedandmayincludeaenon,

concentraon,andimpulsecontrol.

Cogniveprogramsalsoaddresslackofawarenessofinjuryimposedlimitaonsandsocialand

emoonalneeds.Memoryimpairmentsareaendedtoandcompensatorystrategiesaretaught.

Cogniveremediaoniscarriedoutincarefullyplannedstagesorsteps.Clientsmovethougha

varietyofhighlystructuredtrainingexercises.Skillacquisionandskillstabilizaonarestressed.

Formostpeoplepossessingtruefunconalmemorydeficits,compensatoryaidsmustbe

establishediftheyaretoreturntoanylevelofoccupaonalproducvity.Compensatory

measuresoentaketheformofenvironmentalcueingsystems.Cueingcanbeassimpleasan

indexcardlisngthealphabetfortheclientwhoisinvolvedinafilingtaskorawrienlistof

sequenalstepsforagiventaskthattheclientusesasavisualreference.Somemesthese

cueingmethodsrequireonlycommonsenseandabitofcreavitytocreate.

Itisimportanttorememberthatenvironmentalcueingsystemsmustincorporatethestepstobe

takeninalogicalsequence.Thisistruewhethertheyarebeingdesignedfortheworkplaceorfor

acviesofdailylivingaccomplishedathome.Thesemightbewrienguidelinesforprocedural

operaons;calendarsandjournalsforpersonalappointments;joblogs,maps,wrienstepby

stepproceduresforgainingaccesstoaparcularplace;andadailyschedulewhichhelpsthe

clienttransionfromoneaspectofthedayorjobtasktothenext.

IndicatorsofNeed

Somemesaclientwithabraininjuryisdeterminedtobeeligibleforvocaonalrehabilitaonyet

demonstratesfunconaldeficitsincogniveskills.Ifthesedeficitslimittheclientspotenalfor

independenceandvocaonalsuccess,thencogniverehabilitaonmaybeindicated. Ifthereisa

discrepancybetweenwhattheclientisabletodoandwhatwillberequiredofhim/heronthe

joborvocaonalplacement,cogniverehabilitaonmaybeappropriate. Ifthejobrequiresskills

thattheclienthasalreadydemonstrated,eitheronaconsistentorerracbasis,orhasthe

potenaltolearn,thencogniveretrainingshouldbeiniated.Thefollowingguidelinesarealso

relevant:

Theclientshoulddemonstratethemovaonandabilitytoacvelyparcipateinthe

learningsituaonanddisplayacapacityforconsistentimprovementonnewlearning.

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Theclientsowngoalsshouldbebothrealiscandcongruentwiththefinalgoalsof

theremediaonandulmatejobplacement.

Thereshouldbeevidencethattheskilldeficitsexhibitedbytheclientareretrainablein

therapy.Ifnot,thefocusofthetherapyshouldbeondevelopmentofcompensatory

strategies,useofexternalaids,providingmorestructureintheenvironment,andjob

support.

RoleofCognitiveRehabilitationinVocationalTraining

Goalsforcogniverehabilitaonshouldbemadewithregardtothespecificskillsneededinthe

clientsvocaonalseng. Sincetheseneedsmaychangewithdifferentvocaonalplacementsor

developmentoftheclientsskills,itisimportanttoupdatethegoalsregularly.Forexample,the

goalsforcogniverehabilitaonmayberelevantforasupportedemploymentsituaon.Aer

workinginsupportedemployment,theclientmaydemonstratethepotenalforemployment

withoutsupports.Theneedforaddionalcogniverehabilitaonmaybeindicatedwithnew

goalsforselfsufficiency.

CompensatingforCognitiveDeicitsontheJob

Peoplewithbraininjuriesareusuallytaughtavarietyofcompensatorymechanismsduringthe

courseofcogniveremediaon.Atissuehereiswhethertheyarecapableofincorporangthe

learnedcompensatorystrategiesintohome,community,andworkplacesengs.

Peoplewithbraininjuryoenhavedifficultytransferringthecompensatorystrategiestheylearn

intheclinictorealworldsituaons.Memorydeficitsandproblemswithabstractreasoningmake

itdifficulttogeneralizeinformaonlearnedinonesengtoanothersituaon.Thebestwayto

teachworkrelevantcompensatorystrategiesisinaworkcontext.Itisonlyinaworksengthat

thesestrategieshaverealmeaningtomostpeoplewithbraininjuries.

CriticalFeaturesofCognitiveRehabilitation

1.Adequateevaluaon,planningandongoingsupervisionbyatrainedprofessional.

2.Dailystructuredtasksthatinclude:

Supervision/Minimaldistracons

Stepbystepacquisionofskills

Constantsystemacfeedback

Maximalsmulaon

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Builtinsuccess

Repeatedlearning

Transferoftrainingtofunconalsengs

3.Wri

eninstruc

ons

and

notes

bysupervisor

ofdaily

tasks:

Cogniverehabilitaontherapist/technician

Aendant

Familymember

4.Regular(e.g.weekly)reviewofprogrambyneuropsychologist.

5.Coordinaonofprogramwithotherrehabilitaonteampersonnel.

IV.THEVOCATIONALREHABILITATIONPROCESSThevocaonalrehabilitaonprocessbeginswiththereferralandthecolleconofinformaon

tolearnasmuchaspossibleaboutthevocaonalcandidate.TheVRcounselorcreatesaprofile

ofthepotenalclientbygatheringinformaonthroughwrienandverbalreportsand

interviewingtheclient.

DeterminingtheAppropriatenessoftheReferral

Beforebeginningtheassessmentofreadinesstoengageinthevocaonalrehabilitaonprocess,

thecounselorshouldbesurethattheclienthasbeenappropriatelyreferred.Oneofthefirst

consideraonsistorecognizethereasonforthereferral.Professionalsinbothmedicaland

rehabilitaonsengssomemespushpaentswithbraininjuryintounmely,andtherefore

inappropriate,vocaonalrehabilitaonintheireffortstoengagetheirpaentsinproducve

acvity.Thereferralmayalsobeviewedasapossiblewaytoconnuerehabilitaonwhenother

fundingsourceshavebeenexhausted.Ifthepersonbeingreferredforvocaonalrehabilitaonis

atastageofrecoverywereaddionalimprovementisexpected,thentheiniaonofthe

vocaonalrehabilitaonprocessisbestdeferred. Inassessingreadinesstoengageinwork,

carefulconsideraonofthestageandstabilityofbothcurrentandpotenalimprovementmust

bemade.Ideally,the metobeginvocaonalrehabilitaoniswhenthepotenalclientwith

braininjuryiscomplengtherehabilitaonprocess,hasreintegratedintothehomeand

community,andexpressesmovaontowork.Somemes,clientsdonotappreciatetheneedfor

vocaonalservices.Theymaybeunabletoassesstheirowncapabiliesandfrequentlyare

unawareoftheirinjuryimposedlimitaons.Itishelpfulforclientstohaveabasicawarenessand

acknowledgementofresidualchangesinarangeofcapaciesbeforebeginningvocaonal

rehabilitaon.

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IntakeInterview

Theintakeinterviewisactuallythefirststepintheprocessofassessingreadinesstoengagein

theVRprocessandisprobablythebestinialassessmenttoolavailable.Itisrecommendedthat

theVRcounselorallowmore meforinialinterviewswithindividualswithbraininjuriesthan

otherclients.Theintakeinterviewservesavarietyofpurposes,includingfactfindingandto

establishingrapportwiththeclient.Addionally,itallowsthecounselortomakeclinical

observaons,whichisanotherformofdatacollecon.Iftheclientpresentswithbehaviorsthat

aresodysfunconalthatthecounselorhasconcernsaboutworkingwithhim/her,thereisa

strongpossibilitythatthepersonisnotreadyfortheVRprocess.Firstandforemost,the

interviewprovidesthecounselorwithanopportunitytoevaluatetheclientsabilitytoparcipate

ataverybasiclevel;inotherwords,totesthis/hercapacitytoengagereliablyinatwoway

communicaon.Didtheclientremembertokeeptheappointment?Wastheclientpunctual?Can

theclientsupplyinformaonabouthim/herself? Duringthecourseofconversaon,istheclient

focused?Ishe/sheaenve,orhighlydistracble?Istheclientorientedto meandplace?Isthe

clientimpulsive?Istheclientinterestedinvocaonalrehabilitaonservices?

VocationalCandidatesArrival

Twothingstobenotedduringthisfirstmeengare:

1)bywhatmeansoftransportaondidthecandidatearrive,and

2)didhe/shearrivealoneoraccompaniedbyasignificantother.

Theinclusionofthisaddionalpersonasasourceofbackgroundinformaonanddetailsofinjury

isrecommendedwhentheclientcannotreliablyprovidethisimportantinformaon.However,

thecounselormustfindoutwhetherthepresenceofthisaddionalperson(s)isinresponsetoa

needoftheclientortothatofthesignificantother.

Inaddion,theissueofindependentmobilityandtheavailabilityoftransportaonmustbe

addressedduringthevocaonalassessmentprocess.

ReadilyObservedBehaviors

Thelistofbehaviorsthatarereadilyobservedduringtheinterviewingprocessislengthy,andthe

counselormustbeawareofallthosethatwillhaveaposiveornegaveimpactinaworksituaon.Thecounselorshouldgainknowledgeofspecificbehavioraldeficitsthat,unlessthey

canbecompensatedfororsufficientlyremediated,willprecludecertainjobs.Forexample,note

signsofdisinhibion.Theclientwhoisextremelyuninhibitedmaynotfarewellinmaintaining

employmentbecauseahighdegreeofdisinhibionmakesitdifficulttoestablishadequate

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interpersonalrelaonshipsintheworkplace.Oneshouldalsonotewhetherapotenalclienthas

physicaldisabiliesorproblemswithcommunicaon.

SigniicantOthersDuringthisinialphaseoffactfinding,thecounselorshouldobtaininformaonconcerningthe

constellaonofsignificantotherswhocanberelieduponforsupplyingsupport.Thelackofthis

typeofsupportsystemcanmaketheprocessmoredifficult. Familymembersandfamilialrole

modelsmakeameasurablecontribuoninvocaonalrehabilitaon.

FormingaVocationalProile

MedicalInformation

Relevantmedicalreportsshoulddescribetheinjury,itsseverity,andthecircumstancesunder

whichtheinjuryoccurred.Descriponsofmedicaltreatment,complicaonsduring

convalescence,andeffortsatrehabilitaonshouldalsobepartofthisdatacollecon.Cognive

andphysicaldisabiliesshouldbenoted.Thecircumstancessurroundingtheinjurymayalso

provideinformaonsuchasthepresenceofalcoholordrugsascontribungfactors.

Thepresenceofasurgicallyimplantedshuntshouldbenoted.Theseshuntsareinsertedto

relievebuildupoffluidinthebrain(creangincreasedintracranialpressure)duringtheacute

carestage.Theyusuallyremaininplaceandgenerallyoffernoproblems.However,iftheshunt

becomesclogged,theremustbeasurgicalrevisionorreplacementtocorrectthemalfuncon.A

malfunconingshuntwillcontributenoceablytoasuddendeclineinperformance.

Prescribeddrugsforseizurecontrolorbehavioralmanagementmustalsobenoted.Thesedrugs,

whilehelpfulinmaintainingmedicaland/orbehavioralstability,mayhavesideeffectsthat

impedejobperformance.

LeisureTimeActivities

Leisure meacviesshouldbeexamined.Iftheclientisfortunateandhasremainedsocially

acvefollowingthebraininjury,thecounselorshouldconsiderhowhe/shemaintainsleisure

meacvies.Theskillsneededtomaintainsocialcontactscanbeagoodindicatorofsuccessin

thejobmarket.Thecounselorshouldalsoexploreatthispointwhethertheindividualisinvolved

inbraininjurysupportgroups.(www.biaoregon.org/supportgrp.html)

PostInjuryWorkHistory

Duringtheinterview,thecounselorshouldfindoutwhetherthereisapostinjuryworkhistoryor

whetheraemptstoreturntoschoolorworkweremade.Thequalityoftheworkeffortshould

beexploredindetailwhenpossible.Sincetheclienthasbeenreferredforvocaonalservices,

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previousaemptsatreintegraonmaynothavebeensuccessful.Itisimportanttodetermine

howrealisctheclientsperceponisofwhattranspired,andhis/herselfreportofwork

funconingshouldbeconfirmedinconsultaonwithsignificantothers,formeremployersor

teacherswheneverpossible.

PostInjuryEducationAcademiccreditsordegreesearnedpostinjurymeritspecialaenon.However,thedegree

awardedsomemeshasnoapplicabilityintherealworldandmayhavebeenearnedunder

highlystructuredcondions.

GoalsandSelfPerception

Itisimportantduringthisprocesstoaskthevocaonalcandidateaboutselfpercepons

regardingspecificinjuryinducedproblems. Thecounselorshouldgatherinformaononthe

qualiestheclientpossessesthatmightrepresentstrengths.Usuallypeoplewithbraininjury

willmenonproblemsinmemorybecausetheirsocialcirclehasforcedthemtoacknowledge

thisdeficit.Memoryimpairmentsbecomeselfevident,asdophysicallimitaons,whichclients

areabletoreportreadilyandidenfyastheprimaryreasonfortheirinabilitytogain

employment.

Thisinterviewwouldalsobewellspentindiscussingtheclientspersonalgoalsandassessing

howrealisctheyarewhencomparedwiththeclientsabilies.Thecounselorshouldbeableto

observewhethertheselfreportisbiasedbyanxietyduetotheinterviewsituaonorwhether

theclientwhopresentsasunrealiscissimplyrespondingtoasocialneedforapproval,thatis,

tolookgoodintheeyesofthecounselor.

HistoryPriortoInjuryInformaongatheredduringtheintakeinterviewmaybeincompleteor,insomecases,not

totallyaccurate.Thecounselormustnowassemblethoseelementsofpreinjuryhistorythatcan

bedocumentedbywrienrecord.Inthisway,thecounselorconnuestocreateaportraitofthe

personwhoisabouttobeginthevocaonalrehabilitaonprocess.

Counselorsmustbeawareoftheinjuryproducedphysical,cognive,andpsychosocialchanges,

butmustalsokeepinmindthatwhoapersonwasbeforeinjuryisoenakeydeterminantof

whohe/shewillbecome.Thetragiccircumstanceofabraininjurymaybluntaspectsofbehavior

or,conversely,exacerbatethem.Armedwithpreinjuryinformaon,thewellpreparedcounselor

canbegintoancipatestylesofbehaviorthatmaybringsuccessinparcularworksituaons.

PreInjuryHealthHistory

Itisimportanttoobtainapreinjuryhealthhistorybecausepreexisngmedicalailmentsoen

complicatebraininjury. Bothearlierinjuriestothecentralnervoussystemandcongenital

anomaliesmayimplicatetherehabilitaonprocess.Thepersonprohibitedsincebirthfromthe

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developmentofafullrangeoffunconalcapaciespresentsaspecialchallenge,differentfrom

thatofonewhohadnosignificantproblemspriortoinjury.

Ahistoryofsubstanceabuseorpsychiatricdisabilityalsomaycompromiseprospectsfor

successfulvocaonalrehabilitaon.Preinjurydrugabuseandalcoholismaddressapersonsstyle

ofsocialadjustment.Themeresuggesonofthispredileconshouldalertthecounselortothe

factthatthepotenalforthisbehaviorwillhavetobecloselymonitoredthroughouttheVR

process.

PreInjuryEducation

Levelofpreinjuryeducaonalaainmentmustbeobtainedand,whenpossible,thequalityof

educaonalperformance. Anyindicaonofalearningdisabilitythatinterferedwiththenormal

progressionofeducaonalachievementshouldbenoted. Thepresenceofalearningdisability

maycomplicatetheVRprocess.

Clientswithadvancedacademicorprofessionaldegreeswilloenpossessagreaterrangeof

vocaonalopons. Sinceindividualswithbraininjuriesfrequentlyexhibitproblemswithrecent

memory,thelengthofmethathaspassedsincethedegreewasobtainedandtheamountof

mespentinapplyingwhatwaslearnedmaybeveryrelevant.Mostpeopleretainmemoryfora

repertoireofoverlearnedskillsdevelopedbeforetheinjury.

PreInjuryWorkHistory

Incompilingapreinjuryworkhistory,thecounselorshouldnotetheskillsthatweredemanded

inpreinjuryoccupaons.Theseskills,oenretained,suggestfurtherareasforvocaonal

exploraon.Thecounselorshouldalsolooktothejobtrainingexperiencesaswellasformal

trainingrequiredforpreinjurywork. Retrievableskillsfromsuchtrainingmayexistandmay

suggestfurtherareasforvocaonalrehabilitaon.

CourseofRehabilitation/Reports

Withawarenessthatthecourseofrehabilitaonishighlyindividualizedanddependentupona

rangeofvariables,theVRcounselorshouldgatherallavailablerecordsfromthevarious

reporngdisciplines. Inmostcases,thismeansnursing,physicaltherapy,occupaonaltherapy,

psychologyandneuropsychology,speechandlanguageservice,socialservicesandrecreaonal

therapy.Thesereportstypicallydocumentfunconalskillsacrossagamutofcommunityand

workrelateddomains.Whenitisdeterminedthattheclienthastheappropriatedegreeof

readinesstobegin,thecounselor,inconsultaonwithaneuropsychologistifpossible,should

designtheindividualizedvocaonalrehabilitaonplan.

Someindividualsmayneverhaveparcipatedinconvenonalrehabilitaonprogramspriorto

theVRinterview.Ifthisisthecase,theonlymeansofevaluangthecurrentstatusof

neurologicalandphysicalimprovementsistoacquirethemostrecentreportsofthemedical

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professionalswhocaredforthem.Thecounselorsprimaryconcerninreviewingtheserecords

shouldbethestabilityofgainsmade.Thestabilityofimprovement,bothneurologicallyand

physically,isadeterminingfactorinjudgingthe melinessofvocaonalintervenon.

ReferralforPreVocationallyRelevantServices

Whenwrienandorallydeliveredreportsaswellasobservaonmadeduringthecourseofa

personalinterviewdonotindicatereadinesstoengageintheVRprocess,theVRcounselor

shouldhavetheoponofreferringtheclientforfurtherservicesthatwouldenhancevocaonal

readiness.Theseservicesmightincludetherapiesinanyoftherehabilitaondisciplines,

programsthatwouldenhancecommunityindependence,volunteeringexperiences,oralternate

choicesasnecessary.

Thetypeofprogramorservicetowhichtheclientisbeingreferredshouldbeatthediscreonof

thevocaonalcounselorwhohasmadethedeterminaonthattheclientisnotready.For

example,theclientwithproblemsinaenonmayprofitfromaperiodofcogniveremediaon

designedtoamelioratethisspecificdeficit. Effortsmadetoengagepeoplewithbraininjuriesin

theVRprocessbeforetheyarereadyarenevercosteffecveandmayservetodiscouragethe

clientunnecessarily.

WorkingwiththeVocationalRehabilitationClient

InorderforaclientwithbraininjurytogetthemostbenefitfromtheVRprocess,thecounselor

mayneedtoprovideaccommodaonsforsomeofthecogniveandpsychosocialchallenges

facedbytheclient. Apointtorememberisthattheclientsaenonspanisshortandtheymay

havelimited

memory.

Their

processing

isdelayed.

There

arule

offi

vetofollow:

have

your

sentencesbenolongerthanfiveworks, pauseforfivesecondsbetweeneachsentence,and

havethelistbenolongerthanfivesentences. Thefollowingissuesandstrategiesmayassistthe

clientingengthemostoutoftheservicesoffered.

Issue:Dificultyrememberinginformation

Aclientmayhavedifficultyrememberingtasksfromdaytodayorinstruconsprovidedbythe

VRcounselor. He/shemayalsohavedifficultyrememberingnewinformaon,whichimpacts

learning.He/shemightforgetscheduledinterviewsorfollowupappointmentswiththeVRstaff.

Strategies:

Providewrieninformaonwheneverpossible.

Encouragetheclienttowritedowninformaoninavocaonalrehabilitaon

notebook.

Remindtheclienttorefertothenotebookoen.

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Encouragetheuseofadayplannerorcalendarforrecordingappointmentdates

andtaskstobeperformed.

Encouragetheclienttohaveafamilymemberorfriendprovideareminder

aboutappointments.

Calltheclientonthemorningofascheduledappointment.

Issue:Dificultyfocusingandpayingattention

AVRagencyorprogramisabusyplacewithlotsofdistracons.Itiseasyforaclientwithabrain

injurytohavedifficultypayingaenoninthiskindofenvironment.Theclientmayappear

uninterested,butinfactishavingproblemsfollowingconversaons.

Strategies:

Workinanareawithlimiteddistracons.

Beawareofsurroundingnoisesthatmayinterferewithconcentraon,suchas

radios,otherpeopletalking,etc.Trytolimitthesenoisesasmuchaspossible.

Asktheclienttorepeatinformaonthatwasjustheardtomakesurethe

conversaonorinstruconswereunderstood.

Besuretohavetheclientwriteinstruconsdowninanotebookorjournal.

Besuretohavetheclientsaenonbeforestarngaconversaon.

Refocustheclientsaenonifhe/shebecomesdistracted.(Forexample,John,

letmerepeatthatpointagain.Itsimportant.)

Reschedulethesessionforanother me;perhapsearlyinthedaywhenthe

clienthasmoreenergy.

Asktheclientifthereissomewayyoucanhelp.Forexample,John,youappear

distracted.IstheresomethingIcandotohelp?

Issue:Dificultywithinitiation

Asaresult

ofabrain

injury,

aclient

may

have

diffi

cultybeginning

acvies.Itmay

appear

that

he/sheisnotinterestedormovated,butinsteadhe/sheneedsassistancetobeginworkingon

tasks.

Strategies:

Establishastructuredrouneofdailyacvies.

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Breakdownacviesintosimplersteps.Encouragetheclienttocompleteonetaskata

mebeforebeginningthenext.

Makeachecklistofacviesthatneedtobecompletedeachday.Checkoffeachtask

thatiscompleted.

Establish meframesinwhicheachtaskshouldbecompleted.

Useaclockorwatchthatcanbeprogrammedtoringorvibratetoindicatethe

startofatask.

Provideremindersandencouragement.

Issue:Dificultywithorganizationandplanning

InordertobesuccessfulintheVRprocess,aclientmustbeabletosuccessfullycarryoutthe

plan.

This

may

be

diffi

cult

for

a

person

with

a

brain

injury

who

has

problems

with

organiza

on

andplanning.

Strategies:

Developawrienplanandincludetheclientinthedevelopmentoftheplan.

Breakdowntheplanintosimplersteps,withclearanddetailedinstruconsofhowto

completeeachstep.

Assigndifferentacviesforeachdayoftheweek.Forexample,onSundaylookinthe

wantadsandcirclejobleads,onMondaymakephonecalls,onTuesdaysendout

resumes,etc.

Developachecklisttoensurethateachstepoftheplangetsaccomplished.

Reviewtheplanoentomakesurethatitisunderstoodandthatitisworking.

Offerpraiseforajobwelldone.

Issue:Dificultywithdecisionmaking.

Followingabraininjury,aclientmayhavedifficultymakingdecisions. Idenfyingwhichjobto

pursue,deciding

what

towear

foraninterview,

oranswering

interviewers

ques

ons

may

be

difficult. Aclientmayactimpulsivelyandnotthinkthroughtherelevantopons.

Strategies:

Helptheclientidenfywhattheoponsaretoaparcularproblem.

Discusswiththeclienttheadvantagesanddisadvantagesofeachopon.

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Havetheclientwritedown(orassisthiminwring)thepossibleopons,alongwiththe

prosandconstoeach.

Encouragetheclienttostopandthinkbeforemakingadecision.

Issue:Dificultyinsocialsituations

Gengalongwithcoworkersandbossesisasimportanttokeepingajobasbeingableto

performthejobtasks.Aerabraininjury,clientsmaynothaveaclearunderstandingofthe

impacttheirbehaviorhasonothers.Theymayhavedifficultyengaginginconversaonandmay

notalwaysbesensivetosocialboundaries.Thismaybearoadblocktodoingwellonthejob.

Strategies:

ProvideclearexpectaonsforappropriatebehaviorsattheVRprogram.Provideposive

feedbackforexpectedbehavior.

Encouragetheclienttoconsidertheconsequencesofhis/heracons.

Ifundesiredbehavioroccurs,discusstheissueprivately,inacalm,reassuringmanner.

Reviewexpectedbehaviors.

Beforeanintervieworappointment,discusswiththeclientthetypesofquesonsthat

canbeexpectedandfigureoutwiththeclientthebestanswerstothesequesons.

Similarly,preparewiththeclientquesonsthatshewantstoask.

Roleplaytheinterviewsituaonwiththeclientandgivehonestfeedback.Rehearseunl

theclientappearscomfortableansweringandaskingavarietyofquesons.

Issue:Dificultycontrollingemotions

TheVRprocesscanbeparcularlystressfulforapersonwithabraininjury.Accepngones

limitaons,understandingonesstrengths,anddevelopingnewvocaonalgoalscanbe

overwhelming.Inaddion,aendingnewprograms,meengnewpeople,andlearningnew

rounesisachallenge.Asaresultofthebraininjury,apersonmayhavedifficultycontrolling

emoonsinthesestressfulsituaons.

Strategies:

Expecttheunexpected.Alwaysbepreparedtodealwithasituaon,evenifitisatan

inopportune me.

Trytoremaincalm.Bymodelingcalmbehavior,itcanhelptheclientmodifyhis/her

behaviorandmightpreventthesituaonfromescalang.

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Takethepersontoaquiet,moreprivate,area.Givehim/herafewminutestocalmdown

andregaincontrol.

Redirecttheclienttoadifferenttopicoracvity.

Understandthattheeffectsofbraininjurymaypreventtheclientfromfeelingguiltor

empathy.

Provideconstrucvefeedbackaerapersonhasregainedcontrol.

Usehumorinaposive,supporveway.

Issue:Dificultywithselfawareness

Apersonwithabraininjurymayhavedifficultyaccuratelyperceivinghis/herstrengthsand

weaknesses,parcularlythoseareasthathavechangedsincethebraininjury.

Strategies:

Ancipatepossiblyskewedselfpercepons.

Asktheclienttodiscussherstrengthsandweaknesseswithpeoplewhoknowhis/her

(familymembers,friendsandrehabilitaonprofessionals).

Iftheclientlosthis/herjobaerthebraininjury,discusswithhertheproblemsthatled

uptothedismissal.Iftheclientisunsure,asktheclientifhe/shewouldbecomfortable

returningtothepreviousemployeranddiscussingtheissues.

Astheclientgainsmoreinsightintoherstrengthsandweaknesses,discussthis

informaonwiththeclient.Encouragetheclienttokeepajournaloftheseinsights.

Provideposive,construcvefeedback.

V.EMPLOYMENTOPTIONS

TraditionalVocationalRehabilitationSetting

ThetradionalVRservicedeliverymodelforthemajorityofclientsconsistsofvocaonal

evaluaon,vocaonaltrainingandjobplacement,inthatorder.Thismodelassumesthatthe

clientiscapableofindependentlytransferringwhathasbeenlearnedfromonesengto

another,e.g.,transferringskillslearnedfromtherehabilitaonfacilityortrainingprogramtothe

job.However,thedeficitsofmanyclientswithbraininjuryincludeimpairedmemory,slow

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informaonprocessingskills,andimpairedabilitytogeneralizenewlylearnedinformaon the

veryskillsnecessarytocompleteatradionalvocaonalrehabilitaonprogramsuccessfully.

ClientswithbraininjuryoenarebeerservedbyaPlaceTrainmodel,asopposedtothe

tradionalTrainPlacevocaonalmodel.

LimitationsofTraditionalVocationalEvaluation

Tradionalvocaonalevaluaonsystemshavebeenillequippedtomeetthespecialneedsof

peoplewithbraininjuries.Standardizedtestsofintelligence,personality,aptude,interestand

achievementtypicallyprovidescoresthatindicatehowanindividualcompareswithnorm

groups.Peoplewithbraininjuriesareoencapableofdisplayingareasorpocketsofhigh

achievementonthosestructuredtestsofdiscreteskills.Theresultsyieldedbymanyofthese

testsarepredicatedonoldlearning,i.e.,awellrehearsedrepertoireofpreinjuryskills. An

excellentexampleofascorethatcanmisrepresentthepotenalofaclientisverbalIQ,derivedfromintactmateriallearnedbeforetheinjury.Unfortunately,thesetradionaltoolsandthe

evaluatorswhousethemassumeasystemicintegrity,andpeoplewithbraininjuriesdonot

conformtothenormalpopulaonsuponwhichthesetestswerestandardized.Thecomponent

thatpreventstheseinstrumentsfrombeingvalidpredictorsofsuccessistheinabilityofthose

withbraininjuriestointegrate,applyandgeneralizemanyoftheskillsthataretested.Most

standardizedexaminaonsdonotaddress(otherthantheadministratorsobservaons)ormake

allowancesfortheproblemareasthatposethemajorbarrierstosocial,educaonaland

vocaonalreintegraon.Thatis,theyprovidequanfiabledatabutmakenoprovisionfor

includinginreportsofscoresanassessmentofthequalityofperformance.

TradionalVRsystems,withagrowingawarenessthatindividualswithbraininjuriesareunable

torespondtothesetestsinwaysthataccuratelytranslatetofunconalskills,arenow

recognizingtheneedforalternavemethodsoftesngandevaluaon.

Standardizedvocaonaltesngmeasuresareusefuliftheyarecarefullyadaptedtoaddressthe

skillcapaciesofclientswithbraininjuries.Examiningtestresultswhilerecognizinghowthe

clientcompletesthetestandwhatcognivestrengthsandweaknessesareevidentcanprovide

invaluableinformaonaboutlearningandperformanceissues.Whenadministeredcreavelyby

acounselorfamiliarwithfunconalbehaviorscommonlyfoundinthispopulaon,theresultscan

beusedtodetermineappropriatetypesofentryleveljobplacements.

Theintroduconoftradionalhandson,situaonalassessments(ashorttermmonitoringof

workperformanceinanactualsengasopposedtoastandardizedtesngenvironment)asa

meansofmeasuringvocaonalpotenalhasmetwithlimitedsuccessinthispopulaonwhen

appliedinthemannerusedbymostvocaonalworkevaluaonprograms.Itislimitedbecause

mostclientswithbraininjuriesareillequippedtoengageinonthejobworksituaonswithout

somepreparatoryguidance.

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Mostclientsretainapictureofthemselvesfunconingatpreinjurylevels.Itisunrealiscto

ancipatewholeheartedparcipaoninasituaonalassessment,whichusuallybeginsatentry

level,byclientswhomayclingtoaviewofthemselvesasfunconingattheircapacitybeforethe

injury.Suchparcipaonispossibleonlyfollowingapersonaladjustmenttodisability;an

adjustmentthatincludesabeginningawarenessandacknowledgementofinjuryimposed

funconallimitaons.Developingthisessenalbasicdegreeofawarenessmustbeaccomplished

beforeengagingtheclientwithabraininjuryinanyvocaonalevaluaonprocess.

Oncetheindividualhasasenseofawarenessofhis/herfunconallimitaonsandawillingnessto

accommodatetheselimitaonsinaworkseng,amorerealiscevaluaoncanbeconducted.

Implementaonofaskillfullydesignedsituaonalassessmentfollowedbyapreparatoryperiod

tohelptheindividualbecomeawareoflimitaonscanprovidetheVRcounselorwithanexcellent

opportunitytoobservethequalitaveaspectsofworkbehaviors.Itisthevehiclethatcanallow

theVRcounselortodesigncompensatorymeasures,providestructureandsupportsystems,test

autonomy,gentlyconfrontinareasthatrequiremodificaon,and,ifprovidedwhentheclientis

ready,canbetheopmalguidetowardvocaonalreintegraon.

GraduatedPlacements

Thedemandsofacompevejobaresignificantlygreaterthanthosefoundinmost

rehabilitaonfaciliesandarealmostaquantumleapformanyclientswithabraininjury.

However,manyclientscanmakethetransionifitoccursslowly.Forexample,onemethod

mightbeginbyplacingtheclientinavolunteerposiononapartmebasis,thengradually

transferringhim/hertoapart mejob,andulmatelytoafullmejob,allunderthedireconof

acommunityreentryspecialist.Anynumberofvariaonsofthistechniqueispossible.Thekeyis

tointroduce

new

demands

insmall

enough

increments

forthe

client

tohandle.

Another

advantageofgraduatedplacementsistoincreaseaclientsawarenessthataddionalskillsare

neededbeforefullmecompeveemploymentcanbeseriouslyconsidered.Professionalshave

foundthatclientswhoworkonatrialbasisinthecommunityoenreturnwithnewawareness

oftheobjecvesoftherehabilitaonprogram.Theybecomeawarethattreatmentsuggesons

madebytherehabilitaonprofessionalmayindeedbenecessaryforsuccessfulvocaonal

funconing.Atemporaryplacementcanbeusedtoimproveappropriateworkbehaviors.

Frequently,clientswilldemonstratemarketablevocaonalskillsbutwilldisplaybehaviorsthat

wouldresultinjobloss.Fortheseclients,avolunteerworksitewithrealworldsupervisorshas

provenbeneficial. Oentheclientmorereadilyacceptssupervisorycricismfromsomeone

outsidetherehabilitaonfacility.

SupportedEmployment

Supportedemploymentisaspecialtypeofplacementthatallowsforconnuedtreatment

throughouttheVRprocessandhasprovenbeneficialforclientswithbraininjury. Itisdefinedas

compeveworkinanintegratedworksengwithongoingsupportservices.Theadvantagesof

usingasupportedemploymentapproachwithclientswithabraininjuryaremany:

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Itrestorestheclientsidentyasaworkerandprovidesfinancialcompensaonforreal

work.

Theplaceandtrainapproach,asopposedtothemoretradionaltrainandplaceVR

model,allowsforimmediatereentryintoarealworksengandisthebestwayforthe

clientwithabraininjurytolearnworkskillsandappropriateworkbehaviors.

ItenablesVRstafftoassessandremediatecogniveandbehavioraldeficitsinthereal

workseng.

ItallowsVRstafftodevelopcompensatorystrategiesforthespecificjobtasksthatare

assigned.

Itallowsonsiteadvocacyandintervenonwiththeclientssupervisorwhen

problemsoccur.

Manypeoplewithbraininjuryneedthelongterm,ongoingsupportthatsupportedemployment

providestobesuccessfulonthejob.Whenstarnganewjob,theclientneedsassistancelearningjobtasks,developingcompensatorystrategies,andadjusngtothenewroune.As me

goeson,jobresponsibilies,supervisorsand/orcoworkerschange.Thepersonwithabraininjury

mayhavesignificantdifficultyadjusngtothenewsituaonorlearningnewrounes.Without

periodicoversightfromthesupportedemploymentteam,thepersonmaybeterminatedbefore

realizingthataproblemexists.

UseofaJobCoach

Aprincipleunderlyingthemeofsupportedemploymentistoprovideongoingsupportatthejob

sitetohelpclientsfunconinanintegratedworkseng.Thepersonwhoprovidesthissupportis

oencalledajobcoachorjobcoordinator.Thisindividualprovidesongoingsupportaslong

asneeded.Astheclientlearnsthejob,thecoachwillspendless meinonthejobsupport.

Ongoingsupportmayincluderetraining,jobmodificaonsandmeengswithsupervisorsandco

workers.

Ajobcoachisoenvitaltothesuccessfulplacementofclientswithbraininjuries.He/shemust

beawareofthestrengthsandweaknessesoftheclientandwhat,ifany,compensatory

techniquesareusedbytheclienttoovercomecognivedeficits. Thejobcoachmayneedto

developspecificstrategiesatthejobsitetoassisttheclientinperformingtheessenal

componentsofthejobandmonitoringworkbehaviors.He/shemustalsobeabletointerveneif

problemsariseatthejobsite.

Itisessenalthejobcoachfunconasaneducatoroftheemployerandotheremployeesatthe

site.Onecannotemphasizetoostronglytheneedtoeducateemployersaboutbraininjuryin

generalandaboutthespecializedneedsoftheindividualclientinparcular.Forexample,the

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employerhastobeawareofthestrengthsandneedsoftheclienttoavoidunrealisc

expectaonsorrequiringmorethantheclientscapabilieswillallow.

Thejobcoachisalsoinanidealposiontosetupnaturalsupportsatthejobsitetoincrease

theclientschanceforsuccess.Thejobcoach,withtheapprovaloftheclient,canenlistthehelp

ofwillingcoworkersandmanagerstoprovidesupporttotheclientasneeded.Thisinvolveseducangtheselectedcoworkerand/ormanageraboutthetypesofcompensatorystrategies

thatcanhelptheclientbestperformhisjob,andteachingthemhowtocuetheclientto

implementthesestrategiesasneeded.Theseindividualsshouldalsoknowtocontactthejob

coachwithanyquesonsorconcerns,parcularlyiftheyseeadeclineintheclientsjob

performance.

TheRoleoftheJobCoach

1. Establishtrust

Establishrelaonshipswiththeclient,thefamily,andtheemployerthatarebased

ontrustandhonesty.

2. Respectothers

Respectthevaluesandinterestsoftheclient,thefamily,andtheemployer.Always

maintainarespeculdemeanor.

3.Communicate

Constantcommunicaon,bothoralandwrien,withtheclient,familyand

employeriskeytosuccess.Donttakeanythingforgrantedwriteeverythingdownandsharetheinformaonwithallpares.

4.Evaluateskillsandbehaviors

Performsituaonalassessmentsinavarietyofenvironmentsandusingavarietyof

taskstounderstandtheclientsstrengthsandweaknesses.Evaluatewhattypeof

compensatorystrategiesworkbest.

5.Makegoodjobmatches

Findajob

that

meets

the

interests,

abili

es,and

tolerance

level

ofthe

client.

6.Doathoroughjobanalysis

Learneverythingaboutthedemandsofthejobsbeforeplacement.Reviewyour

findingswiththeemployertoensurethatthejobtasksareunderstood.Provide

everythingtotheemployerinwring.

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7.Establishastructuredworkdayanddependableroune

Unplannedchangesinjobduescanprovedisastrousforapersonwithabrain

injury.Educateemployersabouttheneedtomakechangesslowlyandin

consultaonwiththejobcoach.

8.Developcompensatorystrategies

Developcompensatorystrategiesthatworkfortheclientinperformingthejob

tasks.Astheclientbecomesfamiliarwiththejoborasjobtaskschange,make

adjustmentstothestrategies.

9.Bewatchfulofbehavioralissues

Inappropriatebehaviorscancausemajorproblemsonthejob.Useacollaborave

approachtoidenfybehaviorsthatneedtobemodifiedandenlistthecooperaon

ofthe

client

tomake

necessary

changes.

10.Monitorstamina

Faguecaninterferewithjobperformance,memoryandbehaviors,especiallyona

newjob.Workwiththeemployertoadjustworkschedulesasneeded.

11.Providelongtermsupports

Longtermfollowalongservicesforclientswithbraininjuryareessenaltomonitor

performancelevelandprovideintervenonasneeded.Encouragetheclientandthe

employertocontactthejobcoachatthefirstsignofaproblem.

JobPlacementConsiderations

ThefollowingstepsshouldbetakenbytheVRcounselorpriortoplacingaclientwithabrain

injuryonaworksitetoavoidaninappropriatematchandasituaonthatpotenallysetsthe

clientupforfailure.

Selectivity

Theplacementmustbeconsistentwiththeclientscognive,physical,andpsychosocial

strengthsandweaknesses.Moreover,theclientsinterests,abiliesandaptudesmustalsobe

considered.

JobAnalysis

Thereareavarietyoftechniquesdesignedtoorganizeandevaluateinformaonrelevanttothe

performanceofajob.Fortheclientwithabraininjury,thatanalysismustcontaininformaon

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withrespecttothephysical,emoonal,andcogniveelementsnecessarytoperformthejobat

theobservedsite.Thedemandsofthejobcanthenbecomparedwiththestrengthsand

weaknessesoftheclientpriortoplacement.

PlacementwithEducationandTraining

Theemployerandworksitesupervisorsmustbefullyawareofaclientsstrengthsand

weaknesses.Aninformedsupervisorislesslikelytomisunderstandbehaviorsthatonthesurface

mayappeartobewillfulanddeliberate.Forexample,aflataffectduetoneurologicalfactorsmay

bemisinterpretedasalackofmovaon.Equallyimportantiseducangtheemployerthat

sasfactoryperformanceononetypeofjobdoesnotnecessarilyimplythattheclientshouldbe

promotedtohigherleveljobs.Again,thenewjobshouldbeanalyzedtodeterminewhetherthe

clientiscapableofperformingitsindividualcomponents.

OngoingSupports

Effecveplacementassumestheavailabilityofanongoingsupportsystem.Longterm

coordinaonbetweentheVRteam,theemployerandtheclientisessenaltoensurethat

necessarysupportsfortheclientareinplace.

JobAccommodations

Thekeytoasuccessfuljobplacementistheprovisionofnecessaryjobaccommodaonsandthe

developmentofcompensatorystrategiesatthe metheplacementismade. Eachclientwitha

braininjuryisuniqueandwillrequirestrategiesthataddressthespecificstrengthsand

limitaonsthathe/shepresents.Wheneverpossible,consultwiththerehabilitaonteamandthe

neuropsychologisttoassistinestablishingthebestpossibleaccommodaons.Belowisalistof

accommodaonsthatcanserveasastarngpointinconsideringwhataclientmightneed.

Memory:

Usenotebooks,calendars,orsckynotestorecordinformaonforeasyretrieval.

Providewrienaswellasverbalinstrucons.

Allowaddionaltraining me.

Providewrienchecklists.

Provideenvironmentalcuesforlocaonsofitems,suchaslabels,colorcoding,orbullen

boards.

Postinstruconsoverallfrequentlyusedequipment.

Taperecordmeengs,conversaons,andinstrucons.

Useelectronicorganizers(PDAs,handheldcomputers,voiceorganizers,watches,andcell

phones).AnonlineCatalogofPortableElectronicDevicesforMemoryandOrganizaon

canbefoundontheBrainInjuryAssociaonofAmericaswebsiteatwww.biausa.org/

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pda.html.ThebestresultscomefromusingtheiTouchwhichusespicturesratherthan

morecomplexinstruconsthatfrequentlyarenotrememberedcausingfrustraon.

Othermemorystrategies:

Usemnemonictechniques(anorganizaonalstructureonverbalinformaontocue

recallofseveralelements.)

Example:Aclericalassistantrecallshersequenceofjobduesbyrememberingtheword

CODE.

C=clockin

O=openmail

D=delivermail

E=enterdata

Useimagerytechniques(theprocessofusingmentalpictures/imagesforinformaonto

berecalled.)

Example: Aclericalassistantvisualizesherselfwalkingaspecificroutetoassistin

rememberingtheroutefordeliveringthemail.

Usenumbergrouping(recallingnumbersbyreorganizingthemintofewerelements.)

Example: Aclerkworkingatanautosupplycompanyneedstoremembertopullitemsbasedonafourdigitcode.Helooksatacodingbookandseesfournumberssuchas9,5,

3,2.Insteadofrememberingthenumbersindividually,herecallstheinformaonas95

and32.

Useofverbalrehearsal(repeangoutloudkeyinformaontohelprecallingthe

informaon.)

Example: Adataentryoperatorcomestoworkandsetsupherworkstaonbysaying

aloud:Turnoncomputer.Turnonmonitor.Entermypassword.Hitenter3 mes,etc.

MaintainingConcentration:

Reducedistraconsinworkareas(whitenoisesoundmachinesorlisteningto

instrumentalmusicmaybehelpful).

Providespaceenclosuresoraprivateoffice.

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Reducecluerintheworkenvironment.

Simplifylargeassignmentsbybreakingthemintosmallertasks.

Changelighnginworkarea(eithermoreorlesslightdependingonneeds).

Arrangeforuninterrupted

work

me.

Organizaon:

Makedailytodolistsandcheckoffitemsascompleted.

Useacalendarsystemtomarkmeengsandtaskdeadlines.

Useelectronicorganizers(PDAs,handheldcomputers,voiceorganizers,watches,and

cellphones).AnonlineCatalogofPortableElectronicDevicesforMemoryand

OrganizaoncanbefoundontheBrainInjuryAssociaonofAmericaswebsite:

www.biausa.org/pda.html.

Establishaneffecvefilingsystem.

Planrounemeengswiththesupervisor,reviewworkprogress.

ProblemSolving:

Providewrienschemacsofproblemsolvingtechniques(i.e.flowcharts).

Restructurethejobtodecreasetheamountofproblemsolvingrequired.

Assignasupervisororcoworkerwhoisavailabletoanswerquesonsandreviewwork

progress.

Allowextra

me

toaccomplish

job

tasks

introductory brain injury handbook for v/r. professionals

Documents