Employment After Traumatic Brain Injury:
Predictors, Challenges and Interventions
July 27, 2011
(Q & A Session)
>> M. DEMAYA: Good afternoon. Welcome to our Question & Answer Session
today for our recent pre-recorded webinar on "Employment After Traumatic Brain
Injury: Predictors, Challenges and Interventions" with Dr. Lynne Davis. I am Marisa
Demaya with the DBTAC Southwest ADA Center here at ILRU. Today's Q&A session is a
follow-up to the pre-recorded webinar that was posted on our website earlier this week.
We will be talking with Dr. Davis and asking her questions regarding her recent work.
Before we begin I'll go over a few housekeeping issues. For those of you tuning
in, you may submit your questions to us by typing them into the text chat area located
on the right side of your screen and under the emoticons there. Just remember to press
the <ENTER> key when you've finished typing to submit your question to us. You may
also email us your questions at any time during today's session at swdbtac@ilru.org.
Lastly, I will remind everyone that a copy of Dr. Davis' PowerPoint presentation along
with the written transcript and recording of her webinar is posted on our website for
you to access at any time. To do so just visit: www.ilru.org and click on Webinar
Calendar.
Now, I'd like to introduce Dr. Lynne Davis. Welcome, Dr. Davis.
>> L. DAVIS: Thank you, Marisa. Thanks for having me.
>> M. DEMAYA: Sure. I'm going to go ahead and just dive into these questions.
The first one is:
For your study, can you elaborate a little bit more about the demographics you
used as far as age - can you explain what you mean by inverse relationship between age
and return to work?
>> L. DAVIS: Sure. For the study that we're conducting right now on trying to
help people with TBI get back to work after their injuries, the age range that we're
looking at is 18 to 65, and we chose those beginning and end points because we really
wanted to capture the folks who are most likely to be seeking employment after their
injuries. So we figured that those who were over 65, or many fewer of them, are going
to be likely to want to return to work, and those under 18 are more likely to be involved
with school and not wanting to focus on employment as their main goal. So
that's -- those are our limits for our study, and when we do have all of our data
collected, which will take another couple of years, but when we do have it all compiled,
we will be able to look at the relationship between age at injury and employment
outcome. We will have all of those data available to us, and that is something that we
will look at.
A lot of previous work has been done looking at age and how does it relate to
employment outcomes, and overall, most studies show that those who are injured the
at -- later on in life tend to have poorer employment outcomes, those who are kind of
the cut point or rule of thumb that some investigators have identified as that those who
are, say, over age 40 tend to be less likely to return to competitive employment than
those who are younger at the time that they were injured. But I do think it's important
to point out that this is kind of speaking in general terms. So although the majority of
studies have found this to be so, you know, that older folks may have a tougher time
getting back to work after traumatic brain injuries, it's not going to be true for
everybody, naturally. And also I would like to emphasize that predicting return to
work is just so complicated. So something like age and other Democrat graph are just
a small part -- demographics are a small part of the constellation of factors that predict
returning to work. So the outcome for any given person is going to be dependent
upon so many different factors beyond age.
>> M. DEMAYA: Okay. I think that kind of tackled our next question, but maybe
I can -- there is a second part to this question from one of our listeners. It says:
To work is? If not, do you know of any research that has been done or is currently
being done on this? Aside from your own, of course.
>> L. DAVIS: I can suggest there is a really good review article that looked
at -- kind of summarizing a number of studies that have been done looking at age and
employment outcomes. This is a really recent study by Mary STURGOIKIT,
STERGIOU-KITA. So she has done a lot of work in this area and just published earlier
this year in 2011 a review article looking at -- where she summarizes the research
literature on the whole, what it has shown with regard to various predictors much
employment outcomes after TBI, and age is a whole section that she has in that article,
and she looked at, I think it was, 30 studies that did examine age and how it relates to
employment outcome, and she has a nice summary of what the findings have shown.
But there has been a lot of work that's been done looking at age and employment and
TBI over the past 20 years or so. But -- I mean, she found out the majority of the
studies that she looked at, the majority of those studies, did show this pattern of older
individuals having -- being less likely to return to competitive employment after their
injuries.
>> M. DEMAYA: Wow. Okay. Switching gears now a little bit, one of our other
questions is:
Regarding motivational levels and individuals returning to work- do you have any
recommendations from your experience that you might share as far as tools that might
prove useful in motivating individuals who wish to return to work?
>> L. DAVIS: I think this is a really, really good question, bringing up the whole
issue of motivation. It's a really important question. I'd like to mention -- actually,
this is another study by the same researcher whose name I just mentioned, and she
did -- and her colleagues conducted a study where they interviewed a number of very
experienced occupational therapists to ask them what do they think were the most
important factors in assessing readiness to return to work, and she and her colleagues
found that motivation was identified by most of the occupational therapists in the study
as being the most relevant factor that needed to be considered for every person
evaluating whether or not they were ready to return to work. So motivation is really
critical.
And as far as trying to improve it, I think probably what's most important to do
first is to figure out, if someone does seem to have lower level of motivation for
returning to work, you got to figure out why that is, and that may be easier said than
done because there can be any number of factors contributing to lower motivation
levels, but it would be important to explore various disincentives to return to work that
may exist. Some of those might include if the person is receiving disability
compensation and maybe is fearful of jeopardizing that. Or if they're reluctant to
return to work because they are convinced that they will not be able to do the same job
that they did before their injury and, therefore, feel like it's less worthwhile. Or if
there are psychologically-based disincentives at play, like are they fearful of failure or do
they have low confident level because they've just been through this really traumatic
injury and really thrown for a loop and feel like they won't be able to do well. Or are
there emotional factors that are causing trouble, for instance, if a person is depressed
after their injury, that would very likely affect their motivation to return to work. So I
think the most important thing would be to try to get to the bottom of what is it that's
causing the motivation to be low, and then when you have that information, you can
work on addressing it, if the person is at a point where they're ready to think about
returning to work, and then also it might be helpful to try and emphasize some of the
benefits of returning to work. I mean, other than, of course, the economic benefit of
getting a paycheck, there's also a number of other things that are -- that people find to
be fulfilling about work. For instance, the social benefits of work, emotional benefits,
just kind of being active and doing something can improve mood. Just also having a
sense of being productive. Of course, paid work is not the only way to be productive,
but having a job can certainly bring that. So that -- I think kind of focusing on some of
those aspects may potentially be able to help somebody's motivation level, because we
do see that people who are employed after their injuries do tend to have better
reports -- they report better satisfaction with life and lower levels of depression. So I
think that work can be a lot more -- can be about a lot more than just having a
paycheck.
>> M. DEMAYA: Okay. That being said, would you -- I guess in your experience,
would you say that a person's family or support network might be instrumental in part
of that motivation for them to return to work?
>> L. DAVIS: Yes. Sorry for interrupting, but absolutely. We definitely find that
to be the case. Someone who is not fortunate to have a strong support network
oftentimes is in a just much tougher position.
>> M. DEMAYA: This is actually another question that came in. This ties into
this. In your study did you find that it was the family members, perhaps, or support
system or the person who initiated that question of returning to work?
>> L. DAVIS: Yes, that is another interesting issue, and with our study, the way
that we approach it is we actually contact people who were hospitalized for traumatic
brain injury at Memorial Hermann hospital, so we're the ones that initiate that contact.
It's not like in some of our studies we post flyers and it's up to people to see them and
contact us, but this study works the opposite way. So we're contacting them as early
as two or three weeks after their discharge to see if they might be interested in this
study, but when we do call them, we it going both ways where sometimes it's the
person with the injury that is more interested in returning to work, whereas maybe their
family is feeling a little hesitant about that or kind of worried about wanting to let them
recover more or feel more comfortable or -- better adjusted after their injury.
Sometimes it's the opposite where it's the family that's want the person to look for
work. I think most of the time it's really the person with injury may be a little more
gung-ho about going back to work, especially if they have some issues with their level of
awareness and they might not -- sometimes they're more enthusiastic because they
might not be fully aware of some of the issues that are going on that might be a little bit
difficult for them to get back to work right then. But we do see it both ways.
>> M. DEMAYA: I think this is another question that kind of ties into that.
They're asking, as far as the person's family or support system, were any of your
participants married? It says: I wondered how supportive the person's spouse, or
spouses, were in the return to work process, if you had any experience with that?
>> L. DAVIS: Yes, we do have some married people in our study. We have some
single, divorced, the whole gamut. But, yes, if the spouse or significant other is -- or
their level of support for the return to work goal is very, very important, because
especially if the injured person has maybe some -- maybe they're not allowed to drive
yet or maybe never will be able to return to driving, and maybe -- you know, Houston is
so spread out that transportation can be difficult, and especially dependent upon
whether their spouse or person will provide transportation, and if that person is not
supportive of the return to work to goal, that will have an impact on the person's ability
to get to work. On the other hand, if the spouse or family member is very supportive,
that makes it so much easier on the person to return to work. And we see this kind of
pattern in other types of studies that we conduct here at our center. I know before
this particular study I was heavily involved in a study where we were trying to improve
social functioning after traumatic brain injury, and we had a number of people who
really wanted to participate, and it required them going on these outings with other
folks that had traumatic brain injury, and there were several instances where the injured
folks really wanted to participate and wanted to set up these outings, but it wasn't
working out, and it sometimes took us a long time to figure out what was the problem.
They seemed to want to go. They seemed to be remembering that these outings were
going to be set up. And they were contacting another person that they were going to
get together with. But then it falls through. And we began to figure out that, okay,
it's the -- it seems that the family is, unfortunately, for whatever reason, they were not
supportive of that, and so it didn't happen.
>> M. DEMAYA: Okay. Were there family members that felt -- I guess, did you
encounter any issues as far as guardianship over the individual? Were there any family
members in your study where they were trying to obtain guardianship or they were the
guardian and they weren't helpful?
>> L. DAVIS: In our study, everyone who participates has to -- we don't -- we
haven't encountered that because they have to be managing their own affairs and be
able to provide consent to participate. So that just hasn't been a factor. And they
have to want -- first and foremost, do they have to want to return to work or take steps
toward getting back to work. So if the person with the injury is not wanting to do that,
they're not going to be in our study. But we certainly have varying levels of support
from family members of people that are in our study, but that particular issue of
guardianship has not come up.
>> M. DEMAYA: Okay. Going back to that one step further, were there family
members who did not want to participate?
>> L. DAVIS: Yes, who didn't want their family member to even think about going
back to work?
>> M. DEMAYA: Right. In the study that weren't helpful in that case.
>> L. DAVIS: Yes, we have had that in some cases when we call the potential
participants, and we're trying to recruit people for this study, sometimes we may not
even get to talk to the person with the injury. Of course, sometimes that's because
they're in a lot of pain or something and we can't talk to them. But sometimes it is the
family that doesn't -- that kind of shuts us down, and they're not wanting to -- the
person to even think about returning to work, so we don't even get to talk to the injured
person himself or herself.
>> M. DEMAYA: Okay. I think this next question kind of -- may tie into that a
little bit as well. Maybe slightly a different direction. One listener is asking:
As far as cultural influence as a variable in RTW- can you describe any challenges
that you may have experienced with participants as far as the background of the
person's family and culture in the return to work process?
>> L. DAVIS: That's another good question and another good point, as far as the
role of culture goes. We have in our study both English speakers and Spanish
speakers, and among the Spanish speakers, our Spanish-speaking case coordinator has
encountered some -- definitely some challenges in working with the folks that she's
following because sometimes there may be some mistrust of the system or fear, they're
not going to help us or they're going to turn us down, so let's not even bother. Or just
seems to be sometimes some mistrust about the motives of the healthcare professional
or any member of the -- kind of the healthcare team. I can think of one case where
she's following a gentleman who is in a very unfortunate situation, he had a really bad
TBI, and he's not back to work yet, although he wants to. That's why he's in the study.
And he's got a wife and two or three kids, and they're about to be evicted, and he really,
really needs to work, but he has been reluctant to even apply for some of the services
that he qualifies for. Not that they're always easy to get, because they're not, but he
has not even really wanted to pursue them because he said, well, they won't give it to
me anyway, so why bother. So our case coordinator with him has really had to kind of
push him and say, well, like, you know, there's no harm in trying. You have nothing to
lose and potentially a lot to gain. So she has been helping him with some applications
for various services that hopefully he can qualify for. And she's having to work against
those kind of negative assumptions that are at play, but we do see that, cultural factors
coming into play where people are less likely to want to reach out or take advantage of
some services that may be in place.
>> M. DEMAYA: Okay. As far as -- this kind of goes back into some of that as
well. They're asking: Did you work with or consult the Job Accommodation Network
at all during your research? I wondered if you had any experience with this
organization, as far as if they were helpful or if you even worked with them in this
process?
>> L. DAVIS: We, for this study, have not worked with them. So, unfortunately I
can't give any personal suggestions or -- about that organization. However, I will say
that our colleagues Al DARS, the department of assistive and rehabilitative services
which is the state agency within Texas that has vocational rehab services to try to help
folks with disabilities get back to work, we closely with DARS, and I know that the
vocational rehabilitation counselors who work for DARS oftentimes do consult the Job
Accommodation Network to get information about accommodations for the folks that
they're working with. They don't have a formal relationship -- or DARS doesn't have a
formal relationship with the Job Accommodation Network, but they do recommend the
Job Accommodation Network and consider them to be a great resource, very helpful,
and I know that they work with the employer side of the coin and also just individuals
who are looking for assistance. So it's not just one or the other. And one thing to
look out for that I learned from one of our DARS colleagues was that you have to kind of
be mindful that just because a certain resource is suggested by the Job Accommodation
Network that doesn't mean there's going to be funding for it. So he cautioned
against -- when individuals call looking for possible services, and they might get really
hopeful because such and such service is recommended by the Job Accommodation
Network, but you need to -- they need to make sure there is going to be the funding for
that. But I am told it is a very helpful resource.
>> M. DEMAYA: Okay. Our next question is: Can you discuss some of the
significant conclusions from your study, just kind of briefly touch upon some of those?
>> L. DAVIS: Unfortunately I can't do that at this point because we're still early on
in this study. We began recruiting last fall. So right now we have about 20 or so
participants in the study, and we follow them for a really long time. We follow them
for up to a year. Our case coordinators call them every couple of weeks for up to a
year and then we do follow-up assessments with them up to 18 months after they
enroll. So we have another couple of years to go before we're going to have our data
and are in a position to analyze the data. So right now all we have is kind of our overall
impressions, so far, which is that people in our study are by and large having a pretty
difficult time figuring out how to get services from DARS and they need a lot of help.
>> M. DEMAYA: Okay. The next person is asking, going back to, I guess, the
issue of the reasonable accommodation, they're asking, is it not the obligation of
employers to pay for the reasonable accommodation? I think we talked a little bit
earlier about DARS.
>> L. DAVIS: That was my understanding as well. I mean, they have to comply
with the ADA, certainly, but I think -- maybe that's in reference to the Job
Accommodation Network when we said that the -- one of our colleagues at DARS said
that it's not always funded. I think they can help with a number of type -- they can
suggest a number of different resources that are not necessarily specific
accommodations in the work setting -- of course, that's a big part of what they do, but
they can suggest other things that might be helpful that wouldn't necessarily be funded
by a person's employer. That's just something to watch out for and make sure you
know where the funding is coming from.
>> M. DEMAYA: Right. I think, going back to earlier when you were talking
about how your study is still ongoing, another person is asking: Are you still seeking
participants? And, if so, where might they find more information about your study?
Is there a web address? I think you gave me a web site during our prerecorded
webinar.
>> L. DAVIS: We do have a web site, but for this particular study, we are -- the
way it's set up is that we're recruiting through Memorial Hermann Admissions. So, we
Dee have a number of studies where it's fine for -- we have fliers and are very pleased
when people call and want to enroll, but this one is structured a little bit different such
that -- because we're wanting to -- we're specifically recruiting from a Level 1 trauma
center which is Memorial Hermann. So we're not in a position to enroll folks who
maybe had treatment elsewhere, unfortunately, for this particular study. But we do
have a web site that describes our -- some of our ongoing and past studies, and that
web site is www.tbicommunity.org. That's all one word.
>> M. DEMAYA: I think that was kind -- that kind of ties into something else that
we wanted to go back and ask here. You may have touched on this a little bit earlier,
but they're asking: Can you talk a little bit more about your use of compensatory
strategies in work motivation? Or if not, do you know where they might obtain more
information about that?
>> L. DAVIS: Yes, so if I understand the question correctly, -- well, I gather the
question is asking how to improve work motivation?
>> M. DEMAYA: Yes, I think so.
>> L. DAVIS: That can be very complex, for sure. Yes, I think it does relate to
some of what we talked about a little bit earlier. So, again, I think that first place to
start is to try to make some effort to determine what's leading to motivation being
lower than expected and kind of pull everything apart that's going on there, which might
be quite a task, if somebody is just saying, I don't think it's going to work out, and it may
be hard to pinpoint what's going on, but if you can try to identify what the obstacles are
with specific questions, even running through a list of questions like, "Are you worried
about not being able to do the job?"
"Or co-workers think of you differently?"
"Or losing disability payments?"
Running through all the reasons that can contribute to the lower motivation, that
can give some insight as to where to start to try to improve it. I would also sort of
again suggest the -- consulting the work of Mary STERGIO-KITA, because the study with
the occupational therapist that specifically talks about some factors that are critical for
assessing readiness to return to work after brain injury, that's a really good article that
she published in 2010, and it does talk about motivation.
>> M. DEMAYA: Another question we've got is, they're asking: How many
occupational therapists did you work with during this study? How many are you
working with?.
>> L. DAVIS: For our study we're not working directly with occupational
therapists. Those who are enrolled in our study are being contacted by our case
coordinators who call them every two weeks to assess for needs that they might have to
give them referrals for services that might help them, and specifically geared toward
helping them return to work so they assess for anything that could be getting in the
work of returning to work, and we're working with DARS on this study, but we're not
specifically working with occupational therapists.
>> M. DEMAYA: Okay. This kind of goes back to some of the stuff we were
discussing at the beginning here. This person is asking about how early would you say
after injury did individuals in your study begin their return to work intervention? Is
there like a mean that you've -- I guess they're asking about how early after that -- was
there a mean that you have come to or does it really depend on the person more?
>> L. DAVIS: Yes, it varies from person to person, but that is a very important
point, this whole issue of early intervention, because the literature has shown that early
intervention is very helpful in leading to successful employment outcomes, but it's all
about meeting the right balance for each particular person. So what we do is call them
pretty darn early after discharge from their acute care hospitalization. So we call them
as early as two to three weeks after they get discharged, and there's a whole of
variability in how people are doing at that point. You know, depends on the severity of
their injury and a um in of other factors, but we see that a number of people are not at
all in a position to be thinking about going back to work at that early time point. They
may be in a lot of pain, maybe still medically unstable and having some upcoming
procedures. They may have had a whole change in their living situation or are trying to
adjust to living somewhere else while they recover. Things can be so upside down that
it's difficult for them to even think about returning to work. So we hear that
sometimes when we approach people to see if they're interested. So people who just
can't even think about it at that point, yet they need to get some other things sorted out
first, we'll ask if it's okay if we check back with them a few weeks later. So if
they -- things start to stabilize for them, then we can enroll them. We have other
people who are just two or three weeks after their discharge and they are ready to get
enrolled. So it is really variable. But I will say we have a lot of people we're checking
back with periodically because they have too much going on for them to even think
about work.
>> M. DEMAYA: Sure. Our next question is: What has your experience been
on the employer side? Have you had any contact with employers? We have not.
Since we are still pretty early on in this study, we have only a few people at this point
who are back to work. So we have not yet had any contact with employers, and our
study is not structured so that we will definitely have contact with the employer
anyway. If an issue came up where the participant in our study who has gone back to
work, if they want us to talk to the employer, we would certainly do so after we get
permission from them -- written permission to do that. We would. But it's not a
structure component of our study. I'm sure that that will happen at some point in the
future, that will most likely come up. We just have not encountered it yet.
>> M. DEMAYA: Okay. I guess, lastly, this kind of goes back to the issue earlier
that we discussed about cultural influence. This person is asking, this says: In our
work we often find that patients, clients with a minority background can pose the
highest challenges as far as their motivation being affected. A lot of times it's family
members, if they're from a minority background, the perception I guess they're saying is
that there is -- there is less motivation. Have you experienced any of that currently in
your study?
>> L. DAVIS: Not at this point in our study. I mean, in this study, I should say.
In other studies that we've had here at our Center, we have definitely encountered that.
And I know that the literature shows that members of minority groups have a return to
work outcomes are -- or what's been reported in the literature is that they have been
poorer for members of minority groups, and that can be for a variety of reasons. So, in
general terms, absolutely we have encountered that in our work here at the Brain Injury
Research Center, but not yet in this particular study. But we're early on.
>> M. DEMAYA: Lastly, going back to the issue of age, which, again, I think we
discussed a little bit at the beginning, they're asking if you have encountered or if you
know of any data relating to the issue of a person's age at injury and as far as them
going back to work and how it affects their overall recovery. Do you have positive or
negative aspects to report on that as far as your study so far?
>> L. DAVIS: Not as far as our study so far. I would again kind of highlight what's
been found in the literature but, again, this is not specific to our study at this point.
Most of the people -- because we just have a about 20 or so people enrolled in our
study at this point, and most of them were injured -- well, we have a -- we do have some
folks who have been injured above 50, but most of them have been injured in their 20s
or 30s, and we do not have the data at this point to be able to analyze that relationship,
but the general research literature does suggest that people who are older at the time
that they're injured have a -- are less likely to return to competitive employment but,
again, I would caution against assuming that that would be the case for everyone,
because it varies so much depending upon individual circumstances, and in some cases,
those who are injured at older ages, depending if they had a long work history and a
good relationship with their employer, they might have an easier time going back to
work. So it does vary.
>> M. DEMAYA: Okay. It sound like you've certainly got a lot of work ahead of
you.
>> L. DAVIS: Yes.
>> M. DEMAYA: And our last question, I think, is going to be, basically, our last
question that's come in: When is your study slated to end? I think they're very
interested in seeing your results.
>> L. DAVIS: As are we. We do have another couple of years -- actually, this is
one of our longer timeline studies since we do follow each person for up to a year, and
then our last outcome point is a year and a half from their enrollment in the study. So
we are following them for a very long time. So it will be another, unfortunately, couple
of years before we have all of our data and are able to do the analyses. We'll probably
do some interim analyses along the way when we have -- interim analyses along the way
when we have enough data points but we're not there just yet.
>> M. DEMAYA: Wow, it sounds very interesting, and hopefully when you are
you'll be willing to talk with us again and share some of that info, because I know there's
a lot of interest.
>> L. DAVIS: Oh, I would be more than happy to do so. Absolutely.
>> M. DEMAYA: Well, I think we've just about run out of questions. So I will
reiterate to folks, if there's any question that we did not get to today, if Dr. Davis, if you
don't mind we can e-mail that to you, and if you wouldn't mind answering it we will go
ahead and post it. Again, any questions we'll post along with the archive file of today's
presentation. I do want to thank you again for joining us.
We invite everyone to complete an evaluation- we have the link up on the
webinar page and I believe on the screen there as well. As always, we welcome
Many thanks to our presenter Dr. Lynne Davis for talking with us today. This has
been very informative. I know a lot of people -- we had a couple of people join late so,
of course, we'll remind everyone that the Q&A session for today, along with her
presentation from last week, will be posted up on our web site. Again, if you missed
any part of the presentation, you will be able to have it. We should have that archive
up in about two or three days. Thanks to our audience for joining us today. And
lastly, this session has been sponsored by the
National Institute on Disability Rehabilitation and Research (NIDRR), who funds
your host for today's program - the DBTAC Southwest ADA Center. We would opinions
and views expressed today are those of the presenters and therefore, no endorsement
of the sponsoring agency should be inferred.
Thanks for tuning in everyone. We Hope you will join us again soon.