A review of current strategies and trends for the enhancement of vocational outcomes following brain injury.

Traumatic brain injury results from a physical trauma to the head (McAlees, 1987) and is not a new disability, although it has become more prevalent in the public's eye over the last ten years. More than 700,000 Americans sustain brain injuries each year (Burke, Michael, & Wesolowski, 1988). This does not account for brain damage which occurs from near drowning, heart attacks, aneurysms, lung problems, infections, and chemical and drug reactions. These cases produce residual effects similar to those seen in traumatic brain injury even though the mechanisms of damage are different (Swiercinsky et al., 1987).

Whether damage to the brain is sustained traumatically through an open or closed head injury, or by a cerebrovascular accident such as an aneurysm or stroke, primary damage occurring at the time of injury or accident can result in secondary damage as a result of edema (swelling of the brain), hemorrhage, or the formation of a hematoma (sac filled with blood) (Falvo, 1991; Namerow, 1987; Rehab Brief, 1989).

Given the recent advances in the emergency medical services and operating room procedures for treatment of individuals with brain injuries mortality has decreased and morbidity has increased (McAlees, 1987). This increased morbidity has resulted in an increased need for access to specialized rehabilitation (DeJong & Batavia, 1989). In conjunction with this has come a rise in consumer activism and family support groups demanding state-of-the-art community-based rehabilitation services which will enhance the vocational and independent living outcomes of individuals who have sustained brain injuries. These value driven services promote full-inclusion community living and the development and facilitation of individual supports which are inherent to all working and living environments.

Possible Residual Effects Following a Brain Injury

The successful rehabilitation of individuals who have sustained a brain injury can be a difficult task (Cohen, 1985). Labels do not define people, using a term such as "head injured" when referring to an individual is a great disservice and preempts the individuality of a person.

Individuals who have sustained brain damage as a result of traumatic injury or cerebrovascular accident often experience changes in ability (residual effects) which may affect physical and cognitive abilities and emotional and behavioral capacities (Burke, Weslowski & Guth, 1988; Namerow, 1987; Peck et al., 1984; Swiercinsky, Price, & Leaf, 1987; and Whyte & Rosenthal, 1986). Table 1 further expands on the areas within these more general classifications.

Kreutzer, Wehman, Morton, and Stonnington (1988) stated that vocational status has become one of the most important outcome variables in head injury rehabilitation and research. Recent legislation including the Americans with Disabilities Act of 1990, the Amendments to the Rehabilitation Act of 1973, and final Federal Supported Employment Regulations promote the concepts that all individuals, regardless of severity of disability, have the ability to work, given they are motivated and have individually developed supports. Outcome studies over the last ten years document that the proportion of consumers who return to work varies greatly, partially due to factors such as length of coma, severity of injury, locale of injury, extent of residual effects, availability of community-based and integrated vocational services, and longevity of follow up. These studies reflect a diverse range of return to work percentages following a brain injury from 48 to 99 percent (Brooks, McKinley, Symington, et al., 1987; Humphrey & Oddy, 1980; and Peck, Fulton, & Cohen, 1984). Hurt (1991) reported six critical factors for consideration in the vocational rehabilitation of this population including:

1) remediation of cognitive deficits and development of compensatory strategies; 2) increased/improved acceptance of limitations posed by residual effects of the brain injury; 3) an increase in physical endurance/work tolerance; 4) the individual should participate in a real work trial prior to re-entering competitive employment; 5) increased tolerance for frustration; 6) the worker should be provided intensive follow-up services when they return to employment to ensure success.

The Traditional Vocational Rehabilitation Continuum

Vocational Rehabilitation for individuals with disabilities in the United States has classified its provision of services as a continuum through which consumers have accessed: diagnostic vocational evaluation, personal adjustment, and work adjustment services resulting in sheltered employment and/or community-based employment (Fawber & Wachter, 1987). This sequence of services is typically orchestrated by state-appointed vocational rehabilitation counselors, and services are purchased from providers who may or may not have the specific expertise to meet the selective needs of certain populations which may be required to maximize of vocational potential and community integration. This model presupposes that the consumer is capable of generalizing skills learned in one setting (often simulated or artificial) to another. Some individuals who have sustained a brain injury have difficulty generalizing skills (Fawber & Wachter, 1987) e.g., generalizing or transferring skills learned in a cognitive therapy session to a job setting. This difficulty in generalization limits the potential effectiveness of this delivery system for enhancing community-based vocational outcomes for individuals who have sustained a brain injury.

New York State Vocational Rehabilitation

In 1985, the New York State Office of Vocational Rehabilitation - OVR (currently the Office of Vocational and Educational Services for Individuals with Disabilities - VESID) responded to the growing awareness of the need to provide improved vocational services to individuals who have sustained a brain injury. They awarded a grant to the New York State Head Injury Association to study the existing delivery of vocational services to individuals who have sustained a brain injury. The Vocational Rehabilitation Task Force (Burns, Kay, & Pieper, 1985) surveyed a sample of 38 OVR counselors, 167 service providers, and 47 individuals who had sustained a brain injury. The major findings of the 252 responses were:

* OVR appears to be doing a very good job of becoming known to, and accessing, this population.

* Approximately 8.5 percent of OVR consumers with brain injuries are ultimately placed into jobs as a result of OVR services.

A large percentage of overall OVR consumers' evaluations and placements were in Community Rehabilitation Programs.(1)

* The consumers surveyed valued one-to-one attention and expressed an overwhelming desire for counselors to understand the unique needs of individuals with traumatic brain injury (TBI).

* The consumers surveyed generally did not understand the evaluation process and it was often experienced as frustrating and humiliating.

* While private programs had a higher rate of successful job placement, OVR remains the only available source of vocational rehabilitation available to this population.

The New York State report concluded that: two-thirds of diagnostic vocational evaluations were purchased through service providers with no special programs for evaluating individuals with brain injuries; 78 percent of all counselors responded they weighed the results of standardized testing "moderately" and "very heavily"; 53 percent of counselors responded they classified consumers with brain injuries with other disabilities; 91.6 percent of counselors reported they "never", "almost never", or only "occasionally" purchase cognitive remedial services for this population; 69 percent of counselors responded that they felt only "minimally" or "somewhat" prepared to deal with the residuals of a brain injury; 83 percent of all counselors responded they used job trials or on-site placements less than 40 percent of the time; 91 percent of the service providers responding did not have programs specifically developed for this population; and service providers only reported an average 11.8 percent "successful job placement" rate (or lower) for individuals with brain injuries treated. Also recognized was the need for intensified staff training to meet the needs of individuals with brain injuries, and need for TBI specialists within OVR offices, and the use of community-based assessment and placement services.

Supported Employment

Since 1987, vocational advances in brain injury rehabilitation have resulted in the development and implementation of community-based vocational rehabilitation techniques which have been proven to enhance the employment outcomes of individuals who have sustained a brain injury. Initial supported employment studies, completed by Wehman, Kreutzer, Stonnington, Wood, Sherron, Diambra, Fry, and Groah in 1987, reported an approximate 79 percent employment retention rate among individuals diagnosed with a brain injury that had received community-based supported employment services.

Supported employment is defined as paid employment in a variety of work settings for individuals for whom competitive employment has not traditionally been available. The purpose of supported employment is to facilitate job placement in competitive employment settings via support provided both on and off site (as needed) by staff referred to as employment specialists, job coaches, or training specialists. These community-based services (job analysis, systematic instruction, career development, and follow-along support services) are provided in competitive employment settings using a variety of strategies, including: individual placements (Stapleton & Parent, 1989); mobile work crews; enclaves; and through entrepreneurial business (Rusch & Hughes, 1990). All approaches to supported employment have incorporated training and supervision by an externally imposed rehabilitation support staff and, until recently, the social integration factors of these models and strategies had not been challenged or assessed.

With the inception of consumer and activist groups for individuals with brain injuries, developments in private sector rehabilitation for this population, supported employment initiatives for development of specialized programs for individuals with brain injuries, and recognition on State Vocational Rehabilitations part for counselors with expertise in the area of brain injury rehabilitation, an increase in provision of community-based employment services for individuals with brain injuries has been observed (Wehman, 1992). Recent studies (Hagner, Rogan, & Murphy, in press; Nisbet & Hagner, 1988; Parent, Kregel, Wehman, & Metzler, 1991) have begun challenging and assessing quality and quantity of social integration in supported employment settings. These studies stress the need for continued valorization and development of the currently embodied supported employment approaches to individually developed support systems to maximize consumer potential. Individuals that have sustained a brain injury are not part of a homogeneous group. Each individual requires a custom-made rehabilitation plan which specifically addresses that person's needs in relation to their values, priorities, and functional capacities (Cohen, 1985).

Traditionally, vocational rehabilitation programs developed levels of programming, systems or strategies for provision of services which were open ended in principle (Nisbet & Hagner, 1988) although these services were classified into a continuum from which little deviation occurred. These continuum were not challenged or refined because they produced adequate outcome statistics for the general disabled population served. In 1988, Nisbet and Hagner stated the importance of developing support systems and training strategies that were unique to the consumer being served, incorporating not only traditional job coaching services if needed, but also assessing and developing supports which may already be innate in the workplace. Consumers are requesting a mode of vocational rehabilitation that is not intrusive, is community-based, and meets needs on an individualized basis.

Keys to Enhancing Vocational Outcomes

Critical to the vocational success of an individual who has sustained a brain injury is the functional application of therapeutic activities, ongoing assessment, and rehabilitation treatment in actual "real work" settings (Wehman, Kreutzer, Wood, Morton & Sherron, 1988). Given difficulties in skill generalization for individuals who have sustained a brain injury, receiving training in anything but "real work" settings would indicate rehabilitators are assuming the individual will be able to make the transition successfully from "simulated" or "sheltered" settings to the real world of employment. Replicated, simulated, and sheltered environments can only replicate perceived job tasks and often do not account for, and cannot replicate, workplace culture, social integration, and other work-related variables. Given the unpredictability of a brain injury, post-acute, community re-entry and vocational rehabilitation services should predominantly take place in "real" community and employment settings. Campus-based, sheltered, and simulated programs, while successful at protecting individuals who have sustained a brain injury and in modifying behavior in a control led or supported environment fall short of comprehensive and holistic evaluation and training of a person and their ability to live, love, work, or enhance function in an actual integrated community setting.

TABULAR DATA OMITTED

Natural Supports

Nisbet and Hagner (1988) suggest an alternative approach to traditional, externally imposed, habilitation-centered supported employment strategies. They report several problems inherent to this approach which include: (1) difficulty fading the job coach from the job site due to employer and employee dependency on this outside source of expertise; (2) job coach presence may be obtrusive and inhibit members of the work force from behaving in their usual way: (3) the job coach may call undue attention and exaggerate the disability of the supported employees and thus contribute to their stigmatization; (4) the cost-effectiveness of long-term support using a job coach on a one-to-one ratio, Callahan (1991) and Curl, Hall, Chisholm & Rule (in press) stated that the negative impact of these issues can be minimized through the use of natural supports which were defined as those employment and training supports implemented by coworkers already employed where an individual with a disabling condition is being considered for employment Kaplan (1990) provided evidence demonstrating the importance of natural social supports as applied to individuals with brain injuries attaining their optimal level of vocational functioning. With the formation of the following proposed natural worksite support options: (a) the mentor option, (b) the training consultant option, (c) the job sharing option, and (d) the attendant option (Nisbet & Hagner, 1988), new strategies for effectively providing employment supports are upon us. To maximize the effectiveness of these options and other individualized approaches, it is important that they do not become embodied, and perceived as a new continuum of services.

Shafer (1986) suggested using coworkers as change agents in several different capacities: (1) an advocate to ensure supported employees' rights and other protective roles, (2) an observer to aid in assessing performance, and (3) a trainer to aid the supported employee in acquisition of skills. Rusch and Minch (1988) went on to propose that coworkers can also be used to aid in maintaining acceptable work behaviors by reinforcing desired work behaviors. In addition to providing supports for initial training, these roles can also effectively facilitate an ongoing long term support mechanism. Rusch, Johnson, & Hughes (1990) report the additional importance of utilizing coworkers to aid in collecting social comparison information in the employment setting. Powell, Pancsofar, Steere, Butterworth, Itzkowitz, and Rainforth (1991) identified the responsibility for facilitating natural coworker supports as the duty of the employment specialist. The initial role of the employment specialist, prior to placement, is that of evaluator to aid in assessing the social integration, work culture, and supports naturally existent within the employment site. Hagner, Rogan & Murphy (in press) specifically examined previously mentioned aspects of the traditional job coach model of supported employment which ignore or impede the formation of social relationships between supported employees and their co-workers and supervisors. They offer preliminary guidelines which have initially proven effective for maximizing the utilization of natural work supports, including strategies for: securing jobs, assessing work culture and natural supports, building interactions and supports into job designs, and adopting a consultant role to develop co-worker supports.

Successful facilitation of inherent supports within specific environments requires a support system for the individual that is as custom made as the individuals goals and aspirations for their life. It requires identification of key players in the person's life, identification of their roles and responsibilities, and how they contribute to aid this person in attaining the goals they have set for themself. When facilitating natural supports it is important to remember that they are not "developed", but individually facilitated.

Successful re-integration of an individual who has sustained a brain injury is dependent on the extent to which the consumer, family and service provider are committed to provision of community integrated rehabilitation services. Following is a description of one case in which community-based and natural support strategies were utilized to successfully re-integrate one individual who had sustained a brain injury secondary to an aneurysm. In this case a cognitive therapist, training consultant, and speech language pathologist were utilized to facilitate the compensatory strategies necessary to maximize this persons optional level of vocational functioning. Table 2 follows which outlines guidelines utilized to effect this process.

Case Study

Mr. R is a man in his early 40's who sustained a brain injury secondary to an aneurysm. Mr. R was extensively supported throughout the rehabilitation process by a supportive network consisting of his wife, children, extended family, employer, and treatment team. Initial residual effects of injury included: decreased physical strength and endurance, decreased ability to sustain attention, impaired auditory comprehension, and impaired short term memory when compared to prior abilities.

Prior to his injury Mr. R was employed as an injection molding engineer. His responsibilities included: monitoring machinery, troubleshooting, following production schedules, and providing technical assistance to machinery operators. In addition, the job involved above average stress levels and long work hours.

After the initial eight weeks of acute medical rehabilitation. Mr. R was transferred to a post-acute community re-entry program. From the inception of Mr. R's initial rehabilitation, his employer was kept abreast of all developments and treatment and actively participated in the rehabilitation process. The employer assumed the role of liaison between Mr. R and his coworkers. Upon admission to the post-acute program, the clinical team, in concert with the family and employer, proposed that a situational assessment of functional work abilities was critical to expedite a return to work. His employer was receptive and aided in the completion of an initial job analysis (identification of essential job functions) and design.

Given the stress level in his prior position, it was decided by Mr. R and his employer to complete the initial assessment in a position of the same ranking which Mr. R had performed prior to his most recent job. As a production scheduler, Mr. R would be responsible for following a production forecast, scheduling items to be produced, farming out extra work, quality control as related to work flow, attending daily production meetings, and publishing a daily schedule. Given that primarily cognitive areas were in continued need of remediation, it was decided that a cognitive therapist and speech/language pathologist would act as additional consultants to the job site. The training consultant established the initial return to work to facilitate a two-week situational assessment in conjunction with the employer and Mr. R began his assessment ten weeks post-injury. Weekly meetings were held with coworkers and supervisors responsible for advocacy, observation, and training and Mr. R began his assessment ten weeks post-injury. During the initial assessment a mutual request was made by the employer and clinical consultants for development of a daily tracking form which could be used to aid in identifying areas in need of remediation and development of compensatory strategies. The rating form was developed in conjunction with those parties involved and initially tracked cognitive abilities in several areas: concentration, task completion, interruptions, understanding, memory, organization, problem solving, clarification, communication, writing, reading, and use of compensatory strategies. Initial scores on the rating form reflected moderate impairment since Mr. R's injury in the area of memory (differences noted in work performance but employee still able to perform 61%-75% of essential job functions) and slight impairment in the remaining areas assessed as cited above (differences noted in work performance but employee still able to perform 76%-92% of essential job functions). Mr. R and his coworkers assessed targeted areas at the end of each work day by assessing work completed and reflecting over the days events.

Ratings were averaged on a weekly basis to track current level of performance in essential job functions and the format of the weekly meeting focused on reviewing progress charted by Mr. R and his coworker responsible for training. Weekly meetings were also utilized for development of compensatory strategies needed to remediate barriers posed during training. After the initial two-week assessment Mr. R had increased hours worked from two hours per day to eight hours per day and was performing approximately 100 percent of work tasks assigned, which only comprised 25 percent of essential job functions. Mr. R was having no difficulties with writing, communication, organization, auditory comprehension, asking for clarification or using compensatory strategies once the strategies were developed.

The cognitive therapist and speech/language pathologist aided Mr. R in increasing effective use of a daily planner as a memory strategy to increase recall of meetings attended and other reference information in off-site therapeutic sessions. Also developed were strategies for aiding Mr. R in tracking while reading, and being able to return to what he was working on after an interruption. These strategies were developed in conjunction with Mr. R and utilized tools already available within the work environment. During the eight-week assessment/training program Mr. R gradually demonstrated his ability to perform 100 percent of all essential functions required for this position. All areas initially posing barriers to Mr. R's ability to independently perform his job were remediated through use of compensatory strategies developed. Mr. R maintains his competitive employment and has recently returned to working successfully in his pre-injury capacity as an injection molding engineer, independent of externally imposed rehabilitation intervention.

Conclusion

As already established (Callahan, 1991; Hagner, Rogan & Murphy, in press; Nisbet & Hagner, 1988; Rusch & Minch, 1988) there is a general need for movement away from a continuum model of services to an array of integrated, individualized services and supports offered for all individuals with disabilities. Given the hererogenous nature of individuals with brain injuries and the individuality of each consumer, we can no longer afford utilization of a model which dictates progression towards integration based on the attainment of skills acquired at a previous level and generalized to the next.

Strategies for provision of vocational rehabilitation services should be perceived as a la carte items which can be combined to create customized employment opportunities to maximize and enhance the employment outcomes for persons who have sustained a brain injury.

Areas for Continued Research

This article has documented the application of strategies for work re-integration for individuals who have sustained a brain injury utilizing supports which occur naturally in most work environments. Areas identified for continued research, development and evaluation include: long term effectiveness of natural coworker supports as applied to training and retention; cost effectiveness; indices of consumer satisfaction in relation to provision of natural coworker supports strategies; and continued development and dissemination of information and research pertaining to new types of support options, training, and follow-along services for supported employees.

1 Language reflects current usage. Community Rehabilitation Programs has replaced the outdated terminology Rehabilitation Facility.

References

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Burns, P.G., Kay, T., & Pieper, B. (1986). A Survey of the Vocational Service System us it Relates to Head Injury Survivors and Their Vocational Needs. (Grant No.0001229). New York State Head Injury Association.

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ABILITIES AND CAPACITIES OFTEN EFFECTED AS A RESULT OF BRAIN INJURY

COGNITIVE ABILITIES

Attention

Concentration

Memory

Basic Academics

Money Management

Follow Through

Reasoning

Problem Solving

Thought Processes 

Ability to Say What is Meant

Initiation

Ability to Understand What is Heard

Following Directions

Time Management

Insight

Ability to Sequence

Organization

Ability to Prioritize 

Ability to Handle Multiple Stimuli

Meta-Cognition

Meta-Memory

PHYSICAL ABILITIES

Endurance and Strength

Walking

Coordination and use of body and limbs

Vision

Olfactory Sensation

Taste

Visuospatial Perception

Hearing

Feeling and Sensation

Bowel and Bladder Control

Speech Intelligibility 

Swallowing and Feeding

Other Medical Areas : i.e. seizures

BEHAVIOR AND EMOTIONAL CAPACITIES

Ability to Monitor and Control Anxiety, Irritability, Depression, Temper, Anger, and Impulsivity.

Tolerance for Frustration

Ability to Regulate Emotional and Energy

Social Interactions and Skills

Ability to Maintain Relationships

Ability to Control Behavior in Social Situations

Substance Abuse

Ability to Control Sexual Inhibitation

Thomas P. Golden, Cornell University, The Program on Employment and Disability, New York State School of Industrial and Labor Relations, 105 I.L.R. Extension, Ithaca, NY 14853-3901.

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