The implications of Posttraumatic Stress Disorder on vocational behavior and rehabilitation planning. (Implications of Posttraumatic Stress Disorder).

With the changing nature of work and the globalization of the economy, workers are having to develop extensive cognitive, interpersonal, and critical thinking skills to successfully compete for and maintain employment in the current labor market (Drucker, 1993; Reardon, Lenz, Sampson, & Peterson, 2000; Ryan, 1995; Wilson, 1997). In a survey of employers, only 5% to 10% of the non-college graduates will have jobs that do not require advanced cognitive and interpersonal skills (Holzner, 1996). In addition to the increased cognitive and interpersonal skills, research has suggested that individuals will change employers multiple times and engage in multiple job searches. Research has found that individuals with psychiatric disorders may lack work experience, have interrupted training and educational opportunities, experience a fragmented work history, and possess very limited knowledge of the labor market and employment opportunities (Ford, 1995). The changes in work environment and the potential vocational limitations may create problems and barriers to successful employment for individuals with psychiatric disorders.

One psychiatric disorder, Posttraumatic Stress Disorder (PTSD), may have particular significance for rehabilitation counselors because research has suggested that individuals with disabilities, especially women, experience higher rates of violence, abuse, and trauma when compared to their non-disabled peers (Watson-Armstrong, O'Rourke, & Schatzlein, 1999). These higher rates may be attributed to financial and social dependence, social isolation, and negative sexual attitudes toward individuals with disabilities (Watson-Armstrong et al., 1999). Among women with disabilities, sexual assault and violence rates tend to be very high, with researchers reporting incident rates ranging from 40% to 70% (Doucette, 1986; Sobsey, Gray, Wells, Pyper, & Reimer-Heck, 1991). The Ontario Ministry of Community and Social Services in a 1987 report indicated that 50% of the women with disabilities reported being sexually abused as a child compared to 34% of the women who did not have a disability. Research has also suggested that children with disabilities are twice as likely to experience physical or sexual abuse (Nosek, 1996).

With the high level of abuse and violence for individuals with disabilities and the increased potential for the development of PTSD, it is important for rehabilitation counselors to understand the vocational implications of the disorder so that they can engage in effective vocational and rehabilitation planning (Keim, Strauser, & Malesky, 2000; Strauser, 2000). The purpose of this article is to provide a brief overview of PTSD and to discuss the vocational implications of this disorder, using the Ecological Model of Vocational Behavior (Szymanski & Hershenson, 1998).

Posttraumatic Stress Disorder

Posttraumatic stress disorder is a condition that can occur at any age and with people who have no predisposing conditions. Individual and contextual factors such as personality variables, social support, and characteristics of the trauma impact the severity and duration of the disorder. Research on PTSD has suggested that the prevalence rate for this disorders ranges from 1% to 14% for the general population. This rate increases to 3% to 58% when one considers individuals who have experienced a traumatic event where death or injury was possible (American Psychiatric Association, 2000). Kessler (1995) reported that 60.7% of males and 51.2% of females report experiencing a traumatic event, of which 25% have developed clinically significant symptoms of PTSD (Keim, Strauser, & Malesky, 2000). Keim, Strauser, and Malesky (2000) also noted that 50% of individuals who have clinically significant symptoms of PTSD go untreated and continue to have symptoms that impact their overall functioning. While there is no specific research addressing the prevalence rate of PTSD for individuals with disabilities, there have been limited studies that have shown general support for the relationship between PTSD and overall physical health (Jankowsi, 2090). Given the high incidence rate of sexual assaults, especially among women with disability, and the strong correlation to the development of PTSD, it is possible that females make up the single largest cohort of individuals who are diagnosed with PTSD (Calhoun & Resnick, 1993; Fong & Silien, 1999). Posttraumatic Stress Disorder is a disabling condition that can be distinguished from other DSM-IV-TR anxiety disorders because the symptoms develop after exposure to an extreme stressor or traumatic event. Symptoms of PTSD vary in terms of severity and may be directly affected by the duration, frequency and intensity of the traumatic event. Personal variables such as age, gender, personality traits, and psychosocial resources have also been found to mediate the severity of PTSD (Keane, 1989; Thomas, 1995). PTSD also tends to be more severe and prolonged in duration if the stressor or traumatic event is caused by another person (Maxman & Ward, 1995; Thomas, 1995). Crime victims are more likely to develop PTSD if the crime involved rape, physical violence, or the cognitive appraisal of a life threat (Otto, Penava, Pollack, & Smoller, 1996).

To assist in the differential diagnosis of PTSD, six symptom criteria have been established by the American Psychiatric Association (APA, 2000). First, the individual is exposed to an event where injury or death was a possibility and invoked feelings of terror and helplessness. Second, the individual re-experiences the traumatic event in at least one distressing manner such as recollections, dreams, and distress at actual or similar cues to those of the traumatic event. Third, the person avoids stimuli associated with the event and experiences an overall numbing of responses, such as avoiding thoughts, amnesia for aspects of the event, detachment, and restricted affect. Fourth, the person has increased arousal, such as insomnia, anger outbursts, and impaired concentration. Fifth, the symptoms must last at least 1 month. Finally, the symptoms must be significant enough to cause impairment in social and occupational functioning. Many times depression and substance abuse accompany PTSD and individuals report an increase in irritability and a decrease in the ability to experience emotion (Maxman & Ward, 1995).

The Ecological Model of Vocational Behavior

Vocational functioning is both directly and indirectly impaired by PTSD. The Ecological Model of Vocational Behavior provides the rehabilitation counselor a means to conceptualize the effect of PTSD on vocational functioning and to implement interventions that are directed at increasing vocational functioning and outcomes. The Ecological Model of Vocational Behavior was developed to address the vocational behavior of people with and without disabilities and of people from diverse ethnic backgrounds (Szymanski, 2000). According to the Ecological Model of Vocational Behavior, an individual's career development is a product of the interaction of five constructs and six processes. Constructs are concepts used for an explanatory purpose and processes are a series of activities or events involved in vocational behavior (Szymanski, 2000). Outlined in the following paragraphs is a brief description of this model. For a more detailed discussion please refer to Szymanski and Hershenson (1998) and Szymanski (2000).

The Ecological Model of Vocational Behavior consists of the following five constructs: individual, contextual, mediating, environmental, and outcome (Syzmanski, 2000). The individual construct is made up of attributes directly connected or related to the person. These attributes would include gender, ethnic background, physical abilities, cognitive traits, and career and vocational interests. The contextual construct consists of characteristics of the environment or situation in which the individual lives or has lived. These characteristics are external to the individual and may include educational structures, living environment, socioeconomic status, legislation, and important events that may have impacted the overall environment such as wars or natural disasters. The mediating construct consists of individual, cultural and societal beliefs that impact the interaction of the individual and the environment. Examples of the mediating constructs include self-efficacy, religious beliefs, and discrimination. The environmental construct includes elements and structures that make up the work environment and other environments that influence an individual's vocational behavior. Examples include the organizational culture, task requirements, and the physical structure of the work place. The final construct is outcome. Outcomes describe the behaviors or states that result from the interaction of the constructs in this model. Outcomes could include the amount of satisfaction from a job, job stress, and organizational productivity.

The major process variables identified in the Ecological Model of Vocational Behavior are congruence, decision-making, development, socialization, allocation, and chance. Congruence is the process of relative match or mismatch between the individual and the work environment. Decision-making is the process in which an individual considers career related alternatives and formulates career decisions. Development describes the process that produces change over time, which is interwoven with characteristics and perceptions of the individual and is reciprocally influenced by the environment. Socialization is the process by which individuals learn to work and learn life roles. Allocation is the process by which society uses and applies external criteria to direct individuals into or away from specific career and vocational directions. Chance is the unforeseen events or encounters that may shape the various constructs that make up this model. The three processes of congruence, decision-making, and development can be conceptualized as primarily internal to the individual and the three processes of allocation, chance and socialization are primarily external to the individual.

In conceptualizing PTSD in terms of the Ecological Model of Vocational Behavior, PTSD resides within the individual construct and is affected by the process variables that in turn influence the interaction between the five construct variables. For example, an individual may have grown up in an abusive home or may have been the victim of sexual or physical abuse at school. This abuse and the resulting PTSD would significantly affect the individual's development and decision making, which in turn would impact the level of congruence established between the individual and the environmental construct. Mediating constructs may also affect the individual's self-efficacy, adherence to religious beliefs, and perceptions of discrimination.

Since a comprehensive discussion of the interactive effect of PTSD on the Ecological Model of Vocational Behavior is beyond the scope of this paper, the primary focus will be on two areas. First, the remaining sections will focus on the effect of PTSD on the individual's ability to perform work-related activities and on the level of congruence between the individual and the work environment. The second focus will be on providing some basic intervention strategies that rehabilitation counselors can use to increase congruence and increase the probability of good rehabilitation outcomes in their work with people who are diagnosed with PTSD.

The Effect of PTSD on the Congruence Between the Individual and Environment

Posttraumatic Stress Disorder can negatively affect congruence between the individual and the environment by creating an inconsistent pattern of behavior, reduced stress tolerance, and decreased energy level. In turn, these symptoms affect an individual's ability to effectively engage in four areas important in vocational functioning: (a) understanding and memory, (b) concentration and persistence, (c) social interaction and (d) adaptation (Fischler & Booth, 1999; Strauser, 2000).

The ability to understand and remember is important to the successful completion of work-related activities that deal with basic work procedures and following instructions. PTSD usually has minimal effect on an individual's ability to remember locations, basic work procedures, and simple instructions. It may however mildly impair the individual's ability to remember detailed instructions. While this impairment is usually not severe enough to cause any significant problems at work, it could diminish an individual's effectiveness in the workplace (Strauser, 2000). Concentration and persistence are important work skills that affect an individual's ability to carry out work-related tasks and to meet production requirements of the job and work environment. Individuals with PTSD usually do not have any difficulty in completing short or simple tasks but tend to experience difficulty when asked to complete tasks and activities that require attention and concentration for extended periods of time. These tendencies may diminish the individual's ability to complete a normal workday or workweek without interruptions. Individuals with PTSD may also experience serious difficulty in working closely with others without being distracted by them. This distractibility may be caused by a fear of being criticized or a fear of confrontation. Distraction could also occur because coworkers may remind the individuals of a traumatic event or stimuli associated with a traumatic event. PTSD may also significantly impact the individual's ability to work quickly, meet deadlines, and effectively handle every day work related stresses (Fischler & Booth, 1999).

PTSD may also impact the individual's ability to engage in effective social interaction on the job. PTSD may limit his or her ability to interact appropriately with the general public, to ask simple questions, to request assistance, and to maintain socially appropriate behavior. Individuals may experience serious and severe impairments in the ability to get along with co workers, to accept instruction, and to respond appropriately to criticism from supervisors (Fischler & Booth, 1999; Strauser, 2000). In an economy requiring more interpersonal skills and increased interaction with both customers and supervisors (Twenty-Fifth Institute on Rehabilitation Issues, 1999), impairments in social interaction reduce the level of congruence between the individual and the job. PTSD tends to have a mild effect on the individual's ability to adapt to a new or changing work environment. While individuals usually do not experience difficulty in identifying normal work hazards, in getting around unfamiliar places, or in using public transportation; mild impairments may be noted in the individual's ability to respond appropriately to changes at work, to set realistic goals, and to make future plans independently of others. Limitations could become more problematic if the individual is required to work independently and to develop realistic goals (Fischler & Booth, 1999).

Vocational Strategies and Accommodations

Rehabilitation counselors working with individuals with PTSD can implement strategies and accommodations to increase congruence between the individual and the work environment and to increase the probability of successful rehabilitation outcomes. First, because individuals with PTSD may have diminished ability to match their skills and abilities to appropriate work settings, rehabilitation counselors may assist the clients in identifying their skills and abilities and their interaction with specific workplace needs. Formalized vocational evaluations and psychometric testing may provide information about the client's work-related abilities. An assessment completed collaboratively with the rehabilitation counselor, including self-exploration exercises, skill checklists, and brief assessments of achievement and aptitude may also be beneficial. Individually reviewing the test results assists in understanding them and the implications for rehabilitation planning.

Second, through career counseling or consultation with the employer, rehabilitation counselors should address the individual's need to have a structured work environment. The level of structure needed in the work environment is dependent on the severity of the individual's PTSD and the possible stimulus events associated with the trauma. In moderate to severe cases, it is important to have a work environment that is predictable and provides the option of working independently (Strauser, 2000). Modifying the individual's workspace, schedule, and work pace may be beneficial in reducing the level of anxiety and fear at work and increase productivity.

Third, it is important for the individual to receive social support outside of the work environment (Fischler & Booth, 1999). The combination of individual counseling and participation in support groups may be beneficial in reducing the vocational implications of PTSD. For example, individual sessions with the client during the follow-up stage of job placement are important. In counseling, the rehabilitation counselor should focus on increasing the (a) individual's knowledge about the range of mental health services available locally and strategies for accessing those services, (b) awareness of his or her symptoms, and (c) ability to self-identify when he or she may need additional rehabilitation or mental health services. Consumer support groups, if available, may also help the client process any fears or anxiety that they may experience on the job.

Fourth, the counselor needs to work with the client to determine whether it would be beneficial to disclose his or her disability to an employer in order to increase the probability of a successful vocational outcome. The obvious drawback of disclosure is that the individual may be discriminated against or be perceived as incompetent even when he or she is able to perform the essential functions of the job. The benefit of disclosure to appropriate supervisors and co-workers is that it may bring about support and assist the employer in furnishing accommodations that may beneficial to the individual. For example, the employer may find it unusual that an individual may need a certain accommodation regarding the structure of the work setting and may be initially reluctant to provide the accommodation. However, if the employer understands the circumstances and issues surrounding the request, he or she may be more likely to provide the accommodation, especially if it increases the potential for retaining an employee find maintaining productivity. Three questions can guide the applicant in deciding whether to discuss his or her disability. First, if the disability will require the employer to provide reasonable accommodations, the applicant should mention it and then explain the nature of the accommodation needed and how the accommodation will enable the applicant to do the job. Second, if the disability is obvious but will not require accommodations and the employer probably would have concerns or doubts about whether the applicant can do the job, then the applicant should discuss his or her disability and how he or she can do the job. Finally, if the disability is not obvious and will not affect one's ability to do the job, then the applicant should not bring discuss his or her disability (Pimental, Bell, & Lotito, 1993).

Recommendations

Posttraumatic Stress Disorder is an anxiety disorder that has particular relevance for consumers and rehabilitation counselors because of the increased likelihood of comorbidity for individuals with disabilities. With this in mind, several suggestions are offered to increase the effectiveness of rehabilitation counselors working with individuals with disabilities who are at higher risk for experiencing a traumatic stressor. First, counselors can probe for life experiences that may involve a traumatic event in the consumer's life. If it appears that this event has the potential for development of PTSD, then it is appropriate to refer the individual for formal assessment. Assessment and therapy for PTSD can increase the effectiveness of the rehabilitation counselor's services directed at adjustment and vocational development. Second, rehabilitation counselors can pursue training about the assessment and treatment of PTSD during or after graduate study. It may be appropriate to place more of an emphasis on PTSD and psychopathology in CORE accredited curriculums. Third, although research suggests the comorbidity of PTSD and other disabilities, it is unclear whether the experience of a disability places an individual at increased risk for experiencing a traumatic event or whether the experience of PTSD places an individual at increased risk for development of a disability, physical or psychological. Further research into the etiology of PTSD and into its vocational implications is warranted. Finally, if individuals with disabilities are more likely to experience a traumatic event due to their increased vulnerability, then it is appropriate for rehabilitation counselors to suggest strategies and to advocate for services that protect the consumer from experiencing abusive situations.

References

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David R. Strauser
Daniel C. Lustig
The University of Memphis

David R. Strauser, Ph.D., CRC, Center of Rehabilitation and Employment Research, The University of Memphis, Campus Box 526010, TN 38152-6010. Email: [e-mail]