Strategies for Success:
Returning To Work
After Brain Injury
BANCROFT Brain Injury Services
Heads-Up Webinar Series
By Lorraine Myro, MSW, LSW
Clinical Director, Bancroft
Brain Injury Services, New Jersey
Our Mission
Bancroft provides opportunities to children and
adults with diverse challenges to maximize their
potential.
.
Our Vision
A community where every individual has a voice, a
purpose and a rightful place in society.
Our Core Values
Responsible Empathetic Supportive Passionate Empowered Committed Trustworthy
RESPECT
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Re-Cap of May Webinar: Finding
the Perfect Job

Reviewed the significance of volunteer and employment
positions as related to quality of life

Identified Community resources and services available to
support the vocational process

Identified challenges encountered when helping individuals
with acquired brain injuries find their “Perfect Job”

Explored how to utilize brain injury outcome measures (the
MPAI-4) as an effective assessment tool to determine job
compatibility
Today’s Objectives

Identify what percentage of individuals with TBI are
returning to work, as well as the limitations of the research

Identify limiting and facilitating factors for returning to
work

Identify what employers need from us to engage in
successful partnerships

Identify key elements that support successful return to work
programming
People who are employed report . . .

Better sense of well-being
 Better health status
 Greater social integration within the community
 Less health service usage
 More social contacts
 Overall better quality of life
Van Helzen, Van Bennekom, Edelaar, Sluiter, & FringsDresen, 2009
Factors affecting return to
work rates (RTW)
o
o
o
o
o
o
o
Invisibility of injury
Economic conditions
Specific employer hiring strategies
Employer attitudes
Continuing symptoms
Life changes
Lack of information provision, advice and
guidance re: RTW
Van Helzen, Van Bennekom, Edelaar, Sluiter, & FringsDresen, 2009; Hernandez, Chen, Araten-Bergman,
Levy, Kramer, Rimmerman, 2012
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Limitations of research


Reviews published 2007 - 2011
Challenges with the studies
Definition of “return to work”
o
•
•
o




Same job, other job, studies, homemaker
FT/PT
Length of RTW employment to be considered “successful RTW”
Distinguishing ABI vs. TBI
Range of measures (6 months, 1 year, 2 years)
Severity of injury
Contradictory findings
Return to work rates
10 studies, international
TYPE OF INJURY
RATE
MILD (6 weeks – 9 months)
12 – 87.5%
MIXED (> 1 year)
45 – 66%
SEVERE (> 1 year)
18 – 37 %
Shames, Treger, Ring & Giaquinto, 2007
Influence of race/ethnicity on
RTW post ABI

Race/ethnicity independently predicts employment
outcomes after ABI
 Example:


African Americans twice as likely as whites to be
nonproductive 1 year postinjury
Minorities, as a group, more likely than whites to not
be competitively employed at 1 year postinjury
Wehman, Gentry, West, Arango-Lasprilla, 2009
RTW Predictive Factors
 Length
of stay
 ADL functioning
 Injury severity
 Self-awareness
 Motivation
Shames, Treger, Ring, & Giaquinto, 2007;
Van Helzen, Van Bennekom, Edelaar, Sluiter, &
Frings-Dresen, 2009
Qualitative Predictive Factors
Patient’s positive valuation of work
 Flexible and supportive workplace
 Higher scores on neuropsychological screenings


Subscale for Affect discriminated
o
o
o
o
Ability to express an affect with the voice
Interpret facial emotional expressions
Ability to control emotional impulses
Ability to comprehend and express response to
humor
Hofgren, Esbjornsson, & Sunnerhagen, 2010
Most prevalent barrier for RTW

Inappropriate behavior



Behavioral outbursts
Lack of tact
Disinhibition
Shames, Treger, Ring & Giaquinto, 2007
RTW Barriers Continued

Self-report






Tiredness/fatigue
Lack of support from colleagues, supervisors
Recovery time took too long
Unable to drive
Physical consequences (vision, hearing, balance, pain)
Cognitive consequences (aphasia, concentration)
Van Velzen, Van Bennekom, Van Dormolen, Sluiter, &
Frings-Dresen, 2011
RTW Facilitating Factors
 Self-report

Motivation*
 Strong will*
 Support from colleagues and bosses
 Goodness of fit for job task
 Humor*
 Functional use of upper extremities*
Van Velzen, Van Bennekom, Van Dormolen, Sluiter, &
Frings-Dresen, 2011
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Clinical Implications for
Successful Program Planning

Research identifies complex interactions between
 Pre-morbid
characteristics
 Injury factors
 Post-injury impairments
 Personal and environmental factors
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Programming for Success
 Commitment

from Administrative team
Business Advisory Council
 Support/partnership
with vocational rehabilitation
professionals

Supported Employment/Customized Employment
 Inter-disciplinary

team model
Vocational Grand Rounds
 Utilization

of strengths-based practices
Personal Futures Planning
 Commitment from
Administrative Team:
Business Advisory Council
o
o
Committee of local business representatives who
come together to identify avenues for helping
those with TBI get back into the work force.
Purpose = network
Zuger, Brown, O'Neill, Stack, Amitai, 2002
Why a Business Advisory Council?
Groundbreaking research by Fraser, et al (2009)
explored the hiring intentions and behaviors of
nonprofit and for-profit organizations
 Follow up study identified differences in hiring
strategies

o
o

For-profit  driven by mission to sell
Nonprofit  driven by mission to serve
For-profit organizations: participants involvement
with disability employment committees or
networks seemed to foster hiring of individuals
with a disability
Hernandez, Chen, Araten-Bergman, Levy, Kramer,
Rimmerman, 2012
Critical Elements of BAC




Chair person who can attract and motivate members
Committee members either are decision makers in their
organization or have access to decision makers in local
businesses
Serve as advisors, advocates, liaisons, and educators
Network



Events
Personal meet and greets
Newsletter to the local community
Zuger, Brown, O'Neill, Stack, Amitai, 2002
Benefits of a BAC . . .





Networking
Educate, break down barriers within the business
community
Employers can communicate about trends, their
needs, make recommendations and referrals
Advice about resumes
Invite us to their functions, opportunities for
company exposure, ambassador for clients
Zuger, Brown, O'Neill, Stack, Amitai, 2002
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Benefits for business professionals
on a BAC . . .
 Develop
awareness
 Exposed to cultural and sensitivity
training
 Inspiration
 Opportunity to “shine”
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 Vocational Rehabilitation
Specialists

Comprehensive Evaluations
o

Recommendations based off of evaluations
Situational assessments
 Work trials/Job coaching
 Problem solve, resources
 Therapeutic interventions
 Network, advocate, bridge gaps
Most prevalent barrier for RTW

Inappropriate behavior

Behavioral outbursts
Lack of tact
Disinhibition


Strategic interventions

Tailor the environment
o
o

Quiet, structured, routinized
Structured, routinized, and loud
Opportunity and space to take breaks as
needed
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Examples of strategies/therapeutic
interventions
 Make
building a resume a priority: volunteer and
internships demonstrate individual’s strengths and
capacities
 Modify working tasks/ work times to individual’s
capabilities
 Work less hours/have sufficient time to recover
 Introduce adaptations to improve performance
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Examples of strategies/therapeutic
interventions
 Prolonged
support for individual and employer
 Collaborate with inter-disciplinary team
 Make sure individual has name/# of on-site contact
(and back-up contact) each time he/she goes to
work
 Make sure individual has name/# of contact for
transportation, when it should arrive and what to
do if it doesn’t
Emphasize pre-vocational work
Volunteering
o
Opportunity to practice work skills

Follow a structured schedule
 Build cognitive and physical stamina
 Improve upon skills
 Opportunity to practice accountability
 Opportunity for evaluation in a safe setting
o
Add to resume
What do employers look for
when hiring



Goodness of fit
Compatability/connection
Understand what their needs are:




business practices, trends, and outcomes
their hiring process
what their industry calls for from it’s workers
how a carved out position can help them
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What supports do employers need
from us?

Language they can understand and relate to,
“The individual sustained an injury from a car accident”





Education about TBI and individual’s capabilities
Commitment from support team to individual’s
success
Availability to provide on-the-spot support
Relationship
Reliability of individual and support team
Supported Employment
 2009
study identified that “finding evidence that
the approach is being utilized on a wide-scale basis
by individuals with ABI is difficult”
 2012 study indicated that “Individualized
placement and the model of supported
employment have been established as one of the
most supported EBPs”
Wehman, Gentry, West, & Arango-Lasprilla, 2009;
Drebing, Bell, Campinell, Fraser, Malec, Penk, &
Pruitt-Stephens, 2012
What is supported employment?

Individualized and intensive support
 Provided by vocational rehabilitation professional
 Identify individual’s abilities and potential work
place needs
 Contact employer to discuss hiring needs,
including job seekers abilities, and specific tasks
that employers need to have done
Wehman, Gentry, West, & Arango-Lasprilla, 2009;
Customized Employment
ODEP explains CE as “individualizing the
employment relationship between employees and
employers in ways that meet the needs of both”
 Predicated on a “negotiation” between the job
seeker (or his/her representative) and the
employer; the means of getting the job differs from
the traditional approach of applying, interviewing,
orienting, and working.

Griffin, Hammis, Geary, & Sullivan, 2008; Griffin &
Keeton, 2009
 Inter-disciplinary team model
Inter-disciplinary team model









Neuropsychologist
Speech therapist
Occupational therapist
Physical therapist
Cognitive rehabilitation therapist
Employment specialists
Vocational Rehabilitation specialists
Person being served, significant others
Physician
Example of how an IDT model
can work . . .
 Case
Example: AC
 38 yo, injured as a child, working at ACME for 10
years
 Lives in residential rehabilitation program, with
full IDT
 Behaviors:
 Asking
customers for puzzles
 Uniform chronically dirty
 Anger outbursts (yelling, cursing, stomping away)
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Strategies used:
•
•
•
•
•
Employment Specialist met with management to assure them team
was addressing issues; followed up to ensure improvement
Bring uniform to Day Program daily, include a clean back-up
uniform that is kept on-site
Staff pre-set AC of expectations
o Change into work clothes right before work
o Do not ask customers for puzzles
Therapy with neuropsychologist
Initial response to interventions: angry outbursts
o Calm, consistent implementation of strategies
o Eventually outbursts ceased
o Problematic behaviors ceased
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AC’S WORK PREPARATION CHECKLIST
Each day that AC works, staff will review this checklist with him. Both AC and staff will
initial the box as they review the item. Our support with this responsibility is critical to
AC keeping his job.
Items to Review
__________
Wearing ACME uniform
__________
Pants are clean
__________
Shirt and Vest are clean
__________
Apron is clean and on
__________
Review reminders
REMINDERS IN ORDER TO STAY EMPLOYED
 WEAR A CLEAN UNIFORM FOR THE FULL SHIFT
 IF THEY ASK YOU TO WEAR YOUR ACME JACKET WHILE YOU ARE
WORKING, BE SURE TO WEAR
 DO NOT ASK CUSTOMERS FOR ANYTHING
 BE RESPECTFUL AND POLITE TO YOUR BOSS
 BE RESPECTFUL AND POLITE TO YOUR CO-WORKERS
 IF YOUR BOSS ASKS YOU TO DO SOMETHING, BE SUPPORTIVE BY SAYING
“YES” AND DOING IT
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Inter-disciplinary team support
o
o
o
o
o
Vocational specialist: liaison between AC, team
and employer; provided on-site support until issues
resolved
Residential program manager  sent clothes in
with AC
Day program manager: trained staff on protocol
Staff: pre-set AC daily
Neuropsychologist: source for AC, support with
pre-setting
IDT: Vocational Grand Rounds



Similar to medical model of grand rounds
Gathering of professionals involved in vocational
rehabilitation that focuses discussion on unique or
problematic cases
Offer expertise from across the spectrum
•
•
•
•
•
•
•
Neuropsychologists
Vocational specialists
Counselors
Funder
Community business leaders
Advocates
Individual *
Zuger, Brown, O'Neill, Stack, Amitai, 2002
Benefits of Vocational Grand Rounds
•
•
•
Outreach
Education
Development/strengthening of
relationships with community
resources
Zuger, Brown, O'Neill, Stack, Amitai, 2002
 Strengths-based Practice:
Personal Futures Planning
o
o
o
o
Person – centered approach to treatment planning
Assumes that vocational goals are defined,
achieved, and retained within a broad context
Focus on vision and action plan to address all
areas of life that are important to individual
Vision and goals are adapted to fit life with
challenges and new reality
Zuger, Brown, O'Neill, Stack, Amitai, 2002
In the words of one client,
“Following my accident, society seemed to say
to me, ‘Drop out of life, take your medication
and maybe we can find you a job in a file room
somewhere.’ PFP helped clear the psychosocial
logjam that inhibited the flow of my personal
development.”
Zuger, Brown, O'Neill, Stack, Amitai, 2002
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Clinical practice going forward:
Using our resources
o
o
o
o
o
Utilize the MPAI to highlight strengths and skill areas
Categorize types of employment, compare with
strengths and weaknesses of MPAI
Implement principles of customized employment
Utilize resources from BAC
Implement previously identified strategies
•
•
•
Comprehensive assessment
Inter-disciplinary treatment
Job coaching, supported employment, job mentor
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MPAI-4 Tool to Assess
Job Compatibility
Extrapolate results from MPAI

Executive Functioning

Memory

Attention

Social Communication

Visuospatial

Physical Ability
MPAI Tool to Assess Job Compatibility
Person Served:
Job Title:
Organization:
Hours:
LOS:
Assessor:
0 None
Date:
MPAI Scoring Rubric
1 Mild problem
2 Mild problem;
3 Moderate
but does not
interferes with
problem;
interfere with
activities 5-24%
interferes with
activities; may
of the time
activities 25-75%
use assistive
of the time
device or
medication
Executive Functioning
Functional Area/Correlating MPAI Rating
PS Rating
11. Novel problem-solving
20. Impaired self-awareness
22. Initiation
Total
Job
3
3
3
2
2
2
9
6
4 Severe
problem;
interferes with
activities more
than 75% of the
time
With Aid?
Y/N
Y/N
Y/N
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MPAI-4 Tool to assess job compatibility
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Treatment Plan



Long term goal: Employment
Short term goal: Reduce MPAI rating for selfawareness from 3 to a 2
Interventions:
•
•
•
•
•
•
•
Cognitive therapy
Speech therapy
Individual psychology sessions
Group psychology sessions
Situational assessment at potential work site
Monthly team meetings to monitor progress
Job coaching at each work sessions
Critical elements of
successful RTW

Network, network, and then network some more!

Commitment from all members of the team, including
administrative team

Defined roles and expectations of anyone involved

Thorough and accurate understanding of individuals injury,
strengths, interests and impairments
o

History, evaluations, situational functioning
Persistence, creativity, and commitment
Zuger, Brown, O'Neil, Stack, Amitai, 2002
Considerations to improve
RTW outcomes





RTW possibility and process should be discussed with family and
team early in postacute recovery
Embrace RTW principle: everyone is employable when provided
with the right opportunities and supports; RTW is a process rather
than event
Increase use of supported employment
Consider alternative forms of employment: tele-work, selfemployment, independent contracting work
Expand efforts to help raise awareness of the centrality of
employment outcomes : RTW should be a primary outcome for
rehabilitative services
Wehman, Gentry, West, & Arango-Lasprilla, 2009;
Debring, Bell, Campinell, Fraser, Malec, Penk & PruittStephens, 2012
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Further research on this topic . . .
•
•
•
•
•
What types of jobs are people “returning to”?
Has the practice of customized employment impacted RTW
rates?
Has the utilization of Business Advisory Councils impacted
RTW rates?
Has the use of assistive technology impacted RTW rates?
Why do minorities have lower RTW rates than whites?
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Questions?
[email protected]
“… no matter how broken or deformed the body of a
human being may be, within that body is a personality, and
it is our business to liberate that body from its prison – to
remove the obstructions that prevent the assertion of
expression of the individuality”
Margaret Bancroft
The Collected Works of Margaret Bancroft, 1915
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