introductory brain injury handbook for v/r. professionals
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I fell offa ladder cleaning the guers.
My exboyfriend beat me up.I sustained a blast injury in Iraq.
I tripped and hit myI was hit by a drunk driver.
I had encephalis.
The Brain Injury Handbook
An Introductory Guide toUnderstanding Brain Injury
for Vocational Rehabilitation Professionals
BrainInjuryAssociaonofOregon,Inc. www.biaoregon.org 18005445243
I was assaulted leaving
I had a heart
I was shaken by the babysier.
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TheBrainInjuryHandbook2011
AnIntroductoryGuidetoUnderstandingBrainInjuryforVocaonal
RehabilitaonProfessionals
BrainInjuryAssociaonofOregon,Inc.
POBox549,MolallaOR97038
8005445243www.biaoregon.org
ThesematerialswerefundedbytheOregonStateRehabilitaonServicesGrant
#131350.
ThesematerialsareadaptedinpartfromTheBrainInjuryHandbook:AnIntroductoryGuideto
UnderstandingBrainInjuryforVocaonalRehabilitaonProfessionals,madepossiblethrougha
grantfromtheU.S.DepartmentofHealthandHumanServicesHealthResourcesandServices
Administraon,MaternalandChildHealthBureauincooperaonwiththeHenryH.Kessler
Foundaon.WithpermissionfromtheN.J.DepartmentofHumanServices,DivisionofDisabilityServices.
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TableofContentsTableofContents........................................................................................................................................... i
I.THENATUREOFBRAININJURY.................................................................................................................. 1
HowDoestheBrainWork?....................................................................................................................... 1
WhatisBrainInjury?................................................................................................................................. 5
DiffuseInjury............................................................................................................................................. 5
ConcussiveDamage.................................................................................................................................. 6
Coup/ContrecoupInjury.......................................................................................................................... 7
SecondaryDamageinClosedBrainInjury................................................................................................ 8
BlastInjury................................................................................................................................................ 9
II.FUNCTIONALCHANGESAFTERBRAININJURY........................................................................................ 12
PhysicalChanges..................................................................................................................................... 12
Arousal.................................................................................................................................................... 12
AenonandConcentraon.................................................................................................................. 13
Memory.................................................................................................................................................. 13
AbstractThinkingandConceptualizaon............................................................................................... 14
ExecuveFunconing............................................................................................................................. 14
InterpersonalandPsychosocialChanges................................................................................................ 15
CommonIssuesFollowingBrainInjury................................................................................................... 16
MildBrainInjuries................................................................................................................................... 16
Diagnoscs.............................................................................................................................................. 17
NeuropsychologicalConsult/Evaluaon................................................................................................. 17
VocaonallyRelevantQuesonsfortheNeuropsychologist................................................................. 18
III.COGNITIVEREHABILITATION................................................................................................................. 19
IndicatorsofNeed.................................................................................................................................. 19
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RoleofCogniveRehabilitaoninVocaonalTraining.......................................................................... 20
CompensangforCogniveDeficitsontheJob..................................................................................... 20
CricalFeaturesofCogniveRehabilitaon....................................................................................... 20
IV.THEVOCATIONALREHABILITATIONPROCESS....................................................................................... 21
DeterminingtheAppropriatenessoftheReferral.................................................................................. 21
IntakeInterview...................................................................................................................................... 21
VocaonalCandidatesArrival................................................................................................................ 22
ReadilyObservedBehaviors.................................................................................................................... 22
SignificantOthers.................................................................................................................................... 23
FormingaVocaonalProfile................................................................................................................... 23
MedicalInformaon............................................................................................................................ 23
LeisureTimeAcvies......................................................................................................................... 23
PostInjuryWorkHistory..................................................................................................................... 23
PostInjuryEducaon.......................................................................................................................... 24
GoalsandSelfPercepon................................................................................................................... 24
HistoryPriortoInjury.......................................................................................................................... 24
PreInjuryHealthHistory..................................................................................................................... 24
PreInjuryEducaon............................................................................................................................ 25
PreInjuryWorkHistory....................................................................................................................... 25
CourseofRehabilitaon/Reports........................................................................................................ 25
ReferralforPreVocaonallyRelevantServices.................................................................................. 26
WorkingwiththeVocaonalRehabilitaonClient................................................................................. 26
Issue:Difficultyrememberinginformaon......................................................................................... 26
Issue:Difficultyfocusingandpayingaenon................................................................................... 27
Issue:Difficultywithiniaon............................................................................................................. 27
Issue:Difficultywithorganizaonandplanning................................................................................. 28
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Issue:Difficultywithdecisionmaking................................................................................................. 28
Issue:Difficultyinsocialsituaons..................................................................................................... 28
Issue:Difficultycontrollingemoons................................................................................................. 29
Issue:Difficultywithselfawareness................................................................................................... 30
V.EMPLOYMENTOPTIONS......................................................................................................................... 30
TradionalVocaonalRehabilitaonSeng......................................................................................... 30
LimitaonsofTradionalVocaonalEvaluaon.................................................................................... 30
GraduatedPlacements............................................................................................................................ 32
SupportedEmployment.......................................................................................................................... 32
UseofaJobCoach.................................................................................................................................. 33
TheRoleoftheJobCoach....................................................................................................................... 34
JobPlacementConsideraons................................................................................................................ 35
Selecvity............................................................................................................................................ 35
JobAnalysis......................................................................................................................................... 35
PlacementwithEducaonandTraining............................................................................................. 35
OngoingSupports.............................................................................................................................. 36
JobAccommodaons.......................................................................................................................... 36
Memory:.......................................................................................................................................... 36
Othermemorystrategies:............................................................................................................... 37
MaintainingConcentraon:............................................................................................................ 37
PlacementRedefined...................................................................................................................... 39
VI.INVOLVINGTHEFAMILYINTHEVOCATIONALPROCESS....................................................................... 40
FamilyExpectaonsandValues.............................................................................................................. 40
EffectsonFamilyStructure..................................................................................................................... 40
Denial...................................................................................................................................................... 41
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BargainingandSplinteredSkills.............................................................................................................. 41
Depression............................................................................................................................................... 42
VII.CONCLUSION......................................................................................................................................... 43
VIII.REFERENCES......................................................................................................................................... 44
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I.THENATUREOFBRAININJURY
Personswithbraininjuryareachallenginggrouptoservewithinthevocaonalrehabilitaon
(VR)system.
These
individuals
have
needs
that
are
unique
totheir
disability
and
symptoms
that
arefrequentlybaffling. Thishandbookprovidesanoverviewofbraininjuryandits
consequences,aswellasstrategiesandresourcesthatmaybebeneficialinworkingwithpeople
whohavebraininjuries. ThishandbookwascreatedtohelpVRcounselorsprovideappropriate
servicesforpeoplewithbraininjuriesintheireffortstoreturntowork.
Individualswithbraininjuryareuniqueasservicerecipients.Theirparculardisabilitydiffers
fromanyotherdisabilitygroupthecounselormayhaveencountered.Personswithbraininjuries
simplydonotexhibitdisablingcondionsinthesamewayasotherdisabilitygroups,anditis
thisnonconformitythatsetsthemapart.Whencounselorsaempttousetradionalmethods
toassessthevocaonalpotenalofmembersofthischallenginggroup,theireffortscanresult
inafailuretoservetheseclients.Inordertoeffecvelyprovideservicestothispopulaon,the
rehabilitaoncounselormustfirstacquireabasicknowledgeofhowthebrainfuncons.Only
thencanthecounseloradequatelyappreciatethecomplexityoftheclientwithbraininjury.Itis
ofparamountimportancethatthecounselordevelopafamiliaritywiththenatureand
consequencesofbraininjuryandbeginstounderstandtheinteraconamongthemyriadof
problemsapersonmayencounter.Oncehavinggainedfamiliaritywithbrainmechanismsand
theclientslocusofinjuryfrommedicalreports,thecounselorsllshouldexerciseextreme
cauoninplacinglabelsonancipatedareasofdysfuncon.Thereareindividualdifferencesin
theorganizaonofeachhumanbrain,andthesedifferencesmayinpartaccountfor
unancipatedfunconalachievementsinsomeclients,eventhoughseveredeficitsand,
therefore,limitedpotenal,hadbeenobservedinaneuropsychologicalexaminaon.
Conversely,subtledeficitsnotedduringtesngproceduresmaybequiteseriousobstaclesto
successinavarietyofvocaonalspheres.Vocaonalcounselorsshouldbeawarethatdisparies
betweentestresultsandactualtaskperformancewillsurfaceconnually.
Insummary,providingservicestopeoplewithbraininjuriesrequirescreavityandflexibility. It
ishopedthatasthereadergoesthroughthishandbook,issuestoucheduponbrieflyinthis
introductoryseconwillgrowinclarity.
HowDoestheBrainWork?Thehumanbraincontrolstheaconsofthebodyandallowsustothink,learnandremember.Itismadeupofbillionsofnervecellsthatwork
togethertocontrolemoon,behavior,movementandsensaon.Tobeerunderstandwhat
canhappentoanindividualwhenthebrainisinjured,itishelpfultoknowaboutthedifferent
partsofthebrainandwhattheydo.Therearethreemainseconsofthebrain thecerebral
hemispheres,cerebellumandbrainstem.Thebrainisdividedintotwohalves.Thesehalvesare
thele andrightcerebralhemispheres.
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Eachpartofthebrainisresponsibleforspecificfuncons. Thele cerebralhemisphere
controlstherightsideofthebodyandisresponsibleforspeech,analycalthoughtand
memory.Therightcerebralhemispherecontrolsthele sideofthebodyandis
responsibleforcreavethinking,expressionofemoonsandvisuospaalabilies.
Specificpartsofthebraincontrolspecificfuncons,likevision(OccipitalLobe),balance
andcoordinaon(Cerebellum),heartrateandbreathing(BrainStem),smell(underthe
frontallobe),orhearing(temporallobe).Thus,whathappenstoapersonwhenthe
brainisinjuredwilldifferdependingonthepartofthebrainthatwasaffected.
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WhatisBrainInjury?Braininjuriesthatoccuraerbirtharecalledacquiredbraininjuries.Anacquiredbraininjurycanbetheresultofamedicalcondion.Someofthese
condionsincludestroke,encephalis,aneurysm,anoxia(lackofoxygenduringsurgery,drug
overdose,orneardrowning),metabolicdisorders,meningis,orbraintumors.Acquiredbrain
injuriescanalsooccurwhenanoutsideforcestrikestheheadhardenoughtocausethebrain
tomoveinsideoftheskullanddamagethebrain.Thistypeofinjuryiscalledatraumacbrain
injury,andcanbecausedbycarcrashes,falls,beinghitonthehead,oranyphysicalviolence.
Thistypeofbraininjuryisreferredtoasaclosedbraininjury,meaningthatthebrainhasnot
beenexternallypenetrated.Whenthebrainispenetrated,suchaswithagunshotwound,the
injuryiscalledanopenbraininjury.
Theseverityofsuchatraumacbraininjurymayrangefrommild,i.e.,abriefchangein
mentalstatusorconsciousness,toseverei.e.,anextendedperiodofunconsciousnessor
comaaertheinjury.Oenthereissomeperiodofunconsciousnessfollowingatraumatothe
brain.However,therearethoseindividualswhodonotloseconsciousnessbutwillnonetheless
exhibitsymptomsofbraininjury.Asaresultoftraumacbraininjury,thebrainsustains
damagethatmaybeeithertemporaryorpermanent.
Theconsistencyofthebrainhasbeencomparedtogelanorcustard.Undernormal
condions,thissomass,gentlycushionedbycerebralspinalfluid,floatswithinthevaults
formedbythemembranesthatlinetheskullandtheprotecveboneoftheskullitself.When
thebrainisinjured,threeprimarytypesofdamagemayoccur:diffuse,concussiveandcoup/
contrecoup.Thesethreetypesofinjuryarediscussedindetailbelow.
DiffuseInjury
Thefirsttype,diffuseaxonalbraininjury,resultsfromthestretchingandtearingofnervefibers
(axons)throughoutthebrain. Thisdiffuse,widespreaddamagetothebrainisthetypethat
frequentlyresultsfromamotorvehiclecrash.Whenthemomentumofarapidlymoving
vehicleissuddenlyhalted,withtheheadstrikingastaonaryobjectinsidethecarsuchasa
dashboardorthewindshield,theimpactresultsinrotaonalforcestwisnganddislocangor
shiingthebrainmass.
Whenthebrainissubjectedtotheseviolentmoons,thereisenormousstretchingandpulling
ofthethreadlikenerveconnecons(axons)thatformthenetworkforbrainfunconing.Asthe
axonsarestretched,biochemicalfunconingceasesandthenervesstopfunconing.Axons
thatareseverelystretchedsomemessnap,andthelikelihoodofthesenervesever
funconingagainisremote.Themoresevereandwidespreadthedamage,thegreaterthe
probabilityofanensuinglossofconsciousness(coma).Praccallyallpeopleemergefrom
coma.However,thetypeofinjurydescribedabovevirtuallyalwaysleadstopermanentand
generallyseveredamagetothebrain.
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ConcussiveDamage
Concussivedamageistheresultofthebraincollidingwiththesharpridgesontheinside
frontoftheskull.Theresulngbruisesorcontusionsaremostlikelytooccurinthebase
ofthefrontalandtemporallobesofthebrain.Theselocalizedcontusionsproducetwoof
themostfrequentlyencountereddeficitsfollowingclosedbraininjury. Theyare
execuvedysfunconandimpairedmemoryfuncons.
Sincethetemporallobesareessenaltothesystemthatregisters,storesandretrieves
informaon,damagetothisareaaffectstheabilitytolearnnewmaterial.
Damagetothefrontallobesmayseriouslyimpairthewiderangeofabiliesknownas
execuvefuncons.Individualswithfrontallobeinjuriesareunabletothinkabstractly,
conceptualize,orbeeffecveproblemsolvers.Theyaregenerallyinflexiblethinkerswho
remainconcretelyboundtoapresenngsituaon.Theyareunabletotakeaselfcrical
viewandarethereforefrequentlyunawareofhowtheirbehaviormayaffectothers.
Becauseofapronouncedinabilitytodevelopaplanandiniateanacvity,these
individualsarefrequentlylabeledunmovated.Frontallobeinjuriesarethemost
prevalentinautomobilecrashes.Individualswithfrontallobeinjuriesareoenthemost
difficulttoserveinvocaonalrehabilitaon.
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Coup/ContrecoupInjury
Thethirdtypeofprimarydamageseeninclosedbraininjuryoccurswhentheheadis
struckwithsuchintensitythatitliterallybendstheskullinatthepointofimpact,injuring
thebrainbeneathit(theinialbloworcoup),andthenpropellingthebrainagainstthe
oppositesideofthebrain(thecounterbloworcontrecoup).Thistypeofdamageismost
likelywhenamovingobjectstrikesthestaonaryhead.Itdoesnotnecessarilyoccurinall
closedbraininjuries.Whenitdoeshappen,theimpairmentsthatresultdependonwhich
specificbrainareashavebeendamaged.Arangeoffunconalareasmaybecome
selecvelyimpairedfollowingacoup/contrecoupinjury.Thesemaybeinthemotor,
sensory,perceptualandlanguagedomains.
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SecondaryDamageinClosedBrainInjury
Inaddiontothethreetypesofprimarydamagedescribedpreviously,secondarydamage
isacommonoccurrenceinbraininjury.Thiscanincludebleedingwithinthebrainitself(intracerebralhematoma);orbetweentheskullandthebraincovering(epidural
hematoma);and/orbetweenthebrainandbraincover,(subduralhematoma).Thereis
furtherdamagetothebrain ssueasbloodcollectsandbuildsuppressurethat
compressesthebrain.Intracranialpressureincreasesasthebrainswellswithfluid(edema,
hydrocephalus)orbecomesengorgedwithblood.Sincetherigidityoftheskullallowsno
roomforthebraintoexpand,surgeryisfrequentlynecessarytorepair,stopbleeding,
removeclots,relievepressureand/orpreventherniaon.Whensecondarydamage
occurs,usuallyinseverebraininjury,itcanproducefunconallimitaonsmoresevere
thanoriginallyancipated.
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BlastInjury
Ablastinjuryisacomplextypeofphysicaltraumaresulngfromdirectorindirectexposuretoan
explosion.Blastinjuriesoccurwiththedetonaonofhighorderexplosivesaswellasthe
deflagraonofloworderexplosives.Theseinjuriesarecompoundedwhentheexplosionoccurs
inaconfinedspace. From2000to2010,theDefenseandVeteransBrainInjuryCenterhas
counted178,876casesofTraumacBrainInjury(TBI)amongU.S.Militarypersonnel.
Seventysevenpercentofthosecasesweredeterminedtobemild.Basedonthesenumbers,the
numberofconfirmedcasesofTBIshassurpassedrecordedcasesofPostTraumacStress
Disorder(PTSD)bynearly100,000.
TherearefourtypesofBlastInjuries: Primary(directeffectsofpressure,either
overpressurizaonandunderpressurizaon,suchasruptureoftympanicmembranes,pulmonary
damage,andruptureofhollowviscera);Secondary(effectsofprojecles,causingpenetrang
traumaandfragmentaoninjuries);Terary(effectsofstructuralcollapseandofpersonsbeing
thrownbytheblastwind,causingcrushinjuriesandblunttrauma,penetrangtrauma,fractures
andtraumacamputaons,openorclosedbraininjuries);andQuaternary(burns,asphyxia,and
exposuretotoxicinhalants).
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PrimaryInjuries
Primaryinjuriesarecausedbyblastoverpressurewaves,orshockwaves.Theseareespecially
likelywhenapersonisclosetoanexplodingmunion,suchasalandmine. Theearsaremost
oenaffectedbytheoverpressure,followedbythelungsandtheholloworgansofthe
gastrointesnaltract.GastrointesnalinjuriesmaypresentaeradelayofhoursorevendaysInjuryfromblastoverpressureisapressureand medependentfuncon.Byincreasingthe
pressureoritsduraon,theseverityofinjurywillalsoincrease.
Ingeneral,primaryblastinjuriesarecharacterizedbytheabsenceofexternalinjuries;thus
internalinjuriesarefrequentlyunrecognizedandtheirseverityunderesmated.Accordingtothe
latestexperimentalresults,theextentandtypesofprimaryblastinducedinjuriesdependnot
onlyonthepeakoftheoverpressure,butalsootherparameterssuchasnumberofoverpressure
peaks, melagbetweenoverpressurepeaks,characteriscsoftheshearfrontsbetween
overpressurepeaks,frequencyresonance,andelectromagnecpulse,amongothers.The
majorityofpriorresearchfocusedonthemechanismsofblastinjurieswithingascontainingorgans/organsystemssuchasthelungs,whileprimaryblastinducedtraumacbraininjuryhas
remainedunderesmated.
SecondaryInjuries
Secondaryinjuriesareduetobombfragmentsandotherobjectspropelledbytheexplosion.
Theseinjuriesmayaffectanypartofthebodyandsomemesresultinpenetrangtraumawith
visiblebleeding.At mesthepropelledobjectmaybecomeembeddedinthebody,obstrucng
thelossofbloodtotheoutside.However,theremaybeextensivebloodlosswithinthebody
cavies.Shrapnelwoundsmaybelethalandthereforemanyanpersonnelbombsaredesigned
togenerateshrapnelandfragments.
TeraryInjuries
Displacementofairbytheexplosioncreatesablastwindthatcanthrowvicmsagainstsolid
objects. Injuriesresulngfromthistypeoftraumacimpactarereferredtoasteraryblast
injuries.Teraryinjuriesmaypresentassomecombinaonofbluntandpenetrangtrauma,
includingbonefracturesandcoupcontrecoupinjuries.
Blastinjuriescancausehiddenbraindamageandpotenalneurologicalconsequences.Its
complexclinicalsyndromeiscausedbythecombinaonofallblasteffects,i.e.,primary,secondary,teraryandquaternaryblastmechanisms.Itisnoteworthythatblastinjuriesusually
manifestinaformofpolytrauma,i.e.injuryinvolvingmulpleorgansororgansystems.Bleeding
frominjuredorganssuchaslungsorbowelcausesalackofoxygeninallvitalorgans,including
thebrain.Damageofthelungsreducesthesurfaceforoxygenuptakefromtheair,reducingthe
amountoftheoxygendeliveredtothebrain.Tissuedestruconiniatesthesynthesisand
releaseofhormonesormediatorsintothebloodwhich,whendeliveredtothebrain,changeits
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funcon.Irritaonofthenerveendingsininjuredperipheral ssueand/ororgansalso
significantlycontributestoblastinducedneurotrauma.
Individualsexposedtoblastfrequentlymanifestlossofmemoryforeventsbeforeandaer
explosion,confusion,headache,impairedsenseofreality,andreduceddecisionmakingability.
Paentswithbraininjuriesacquiredinexplosionsoendevelopsudden,unexpectedbrain
swellingandcerebralvasospasmdespiteconnuousmonitoring.However,thefirstsymptoms
ofblastinducedneurotrauma(BINT)mayoccurmonthsorevenyearsaertheinialevent,
andarethereforecategorizedassecondarybrainInjuries.Thebroadvarietyofsymptoms
includesweightloss,hormoneimbalance,chronicfague,headache,andproblemsinmemory,
speechandbalance.Thesechangesareoendebilitang,interferingwithdailyacvies.
BecauseBINTinblastvicmsisunderesmated,valuable meisoenlostfor
prevenvetherapyand/or melyrehabilitaon.
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II.FUNCTIONALCHANGESAFTERBRAININJURYManyclientswithabraininjuryappeartobeidealvocaonalcandidates.Theytypically
possesssubstanalpreinjuryworkrecords;formeremployerswillinglyaesttotheirgood
workadjustments;andselfreportsofpreinjuryemploymentoreducaonalaainmentsare
usuallyinkeepingwiththereportsofothers.Itisimportanttoemphasize,however,thatthepersonbeingdescribedinthesereportsisnotnecessarilythesamepersonaertheinjury.
Physical,cogniveandpsychosocialchangesasaresultofthebraininjurymayhavesignificant
impactontheindividualsabilitytowork.
PhysicalChanges
Physicaldeficits,iftheyexist,arealwaysthemostobviousornoceablelimitaonsinindividuals
withbraininjury.Unlikethemoresubtlecogniveimpairments,physicaldeficitsaregenerally
visibleandfrequentlybecomethecentralissueuponwhichanindividualplacesallresponsibility
(blame)forhis/herinabilitytoreturntopreinjuryacviesandlifestyle.
Physicalimpairmentsareusuallytheresultofdamagetothebraincentersthatcontrolmotor
funconsratherthandirectinjurytotheextremies.Deficitsmayincludelossofmotor
coordinaon,spascity,poorbalance,aninabilitytowalkunassisted,andalossofeyehand
coordinaon.Hemiplegia(paralysisaffecngonesideofthebody)andhemiparesis(weakness
ofonesideofthebodyorpartofit)mayfurthercomplicatevocaonalissues,parcularlywhen
thesecondionsaffecttheuseofthepreinjurydominanthand.
Withinthiscategory,onemustnotethepotenalforseizuredisorders,and,iftheyare
prescribed,medicaonstakentocontrolseizures.Thestabilityoftheseizuredisorderandthepotenalsideeffectsoftheseizuremedicaonsmayfurthercompromisevocaonal
rehabilitaonefforts.
CogniveChangesPersonswithbraininjurymayexhibitproblemsinavarietyofcogniveareas
suchasbasicarousal,alertness,aenon,concentraon,memory,abstractthinkingand
conceptualizaon,planning,organizing,problemsolving,andjudgment.Peoplealsomayhave
difficultyprocessingverbalandvisualinformaon.
Arousal
Signsofarousalproblemsincludeaninabilitytoaendtotheenvironment;alackof(or
reduced)alertness;aninabilitytoaccuratelyobserveenvironmentaldetailsandoccurrences;
andaseverelyslowedcapacityforinformaonprocessing.Peoplewitharousalimpairments
areoenslowinreacngandrespondingtoothersandarehighlysuscepbletofague
followingcogniveorphysicalexeron.Theymayappearalmostlostinspaceornotin
touch.
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AttentionandConcentration
Impairedaenonandconcentraoncanexhibitaseasydistracbility.Thismaybearesponse
tointerferenceeitherbyexternalorinternalsmuli.Forthepersonwithbraininjury,the
inabilitytoscreenoutexternalnoisesmakesitdifficulttosustainconcentraon.
Environmentalnoiseisfoundinmostworksengs,e.g.,conversaonofothers,usualoffice
traffic, hummingofmachinesandthegeneralrelatedbuzzofacvity.Intrusionsbyexternal
noisecanoenbecontrolledorminimized,andthecapacityforconcentraonwillusually
improve.
Forthepersonwithbraininjury,anotherpossiblesourceofdistracngnoiseistheinternal
conversaonwithinhis/herownmind.Intrusiveinnerthoughtsthatlimitproducvityare
exceedinglyhardertomanage.Theybecomevisible(observable)onlywhentheyinterrupt
performance.
Memory
Lossofadequatememoryfunconandtheinabilitytoimmediatelyrecallnewinformaon
(anterogradeamnesia)arecommonsymptomsfollowingbraininjury.Whilesignificant
improvementinmemoryfunconmaybenotedduringtheinialperiodofrecovery,this
deficitisoenobservedinvaryingdegreesformostpeoplewithbraininjury.
Inadequatememoryfunconisoneoftheprimarycomplaintsreportedbypeoplewhohave
sustainedbraininjuries.Oenitistheirsocialenvironmentthatcausesthemtodevelopan
awarenessofthisparcularproblemarea.Thereprimandsofacquaintancesandsignificant
othersformissedappointments,appliancesle onorbillsle unpaidcompelthepersonwith
braininjurytoacknowledgethathe/sheforgetsimportantthings.Inadequatememoryfuncon
remains,unfortunately,unresponsivetoremedialintervenon.However,memoryimpairments
canbecompensatedforbyavarietyofmnemonicdevices(memoryaids)suchasthose
describedlater.
Praccallyallpersonswithbraininjuryretainaclearmemoryofthemselvesastheywere
preinjury.Intactoldmemoriesandoverlearnedinformaon(forexample,ridingabikeor
performingasequenceofjobtasks)frequentlyrepresentareasofstrength.Thesepreserved
skillscanoenbedrawnuponwhenhelpingaclientwithbraininjuryredevelopvocaonalgoals.
Somemesanindividualmayappeartohaveamemoryimpairment,wheninfactthepersonhas
difficultypayingaenonwhenpresentedwithnewinformaonandisthusunableto
rememberthisinformaon.Itisessenalfortheclientandthecounselortoknowthe
difference.Theinabilitytoremember,asaresponsetolackofeffecveaenon,canbe
remediatedfrequently,oratleastsubstanallyimproved,bycogniverehabilitaon.
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AbstractThinkingandConceptualization
Animportantconcernforvocaonalcounselorsiswhethertheclientwithbraininjuryisableto
engageinabstractthought.Clientscanremainstuckinoneviewofasituaon.Theymayfindit
difficulttoshi tootheraspectsofaproblemortoreadilysearchforalternaves.Theymaylack
thecapacityforimaginavethoughtandremainpoorproblemsolvers.Problemswithabstract
reasoninglimitsthetypesofproducveacvityanindividualcanpursueautonomouslyand
impactsontherange,complexity,andvarietyoftaskstheycansuccessfullyaempt.
Conceptualizaon,whichisdependentonthecapacitytothinkabstractly,isanotherareain
whichtheindividualmayexhibitcognivedeficits. Theabilitytoeffecvelyconceptualizelies
withintherealmofhigherlevelcognion.Onemustpossessastoreoflearnedmaterialthatis
reliablyandreadilydrawnuponinordertoimagineorformamentalpicture,organizethese
mentalevents,andbeabletotranslatethiscogniveacvityintoanobservablebehavior/skill.
Problemsintheabilitytoconceptualizecansignificantlyimpactthetypesofjobsapersonisable
topursue.
ExecutiveFunctioning
Deficitsinexecuvefunconingarethedirectresultoffrontallobedamage.Intactexecuve
funconsallowanindividualtoengageinautonomous,independent,wellplanned,effecvely
organized,sufficientlymonitored,selfregulated,purposefulorgoaldirectedenterprises.When
thesecapabiliesarediminishedastheresultofbraininjury,theindividualhasdifficulty
sustaininggainfulemployment,maintainingsasfactorysocialrelaonshipsand,at mes,
maintainingadequateselfcare,regardlessofhowwellothercognivecapaciesareretained.
Thepersonwholooksandsoundsgoodandwhosetestresultsonexaminaonsofskillsand
knowledgeareunimpairedwillhavedifficultyfunconingproducvelywhenexecuveskillsare
impaired.Suchclientsremainpoorselfmanagers.Theseclientswhosooenappearcapableare
probablythemostdifficulttotreatorevaluatevocaonally. Theyhavelostthemechanismto
accuratelymonitortheirabiliesandneedfrequentfeedbackinordertounderstandtheimpact
theirareasofweaknesshaveontheirabilitytoreturntowork.
Thecounselorshouldalsocarefullyassessaclientsabilitytoformulategoals.Whilecapableof
engagingincomplexacvies,thoseimpairedinexecuvefunconingmaylackthecapacityto
developplansoriniatepurposefulacvity.Inextremecases,theseindividualsmayappear
apathecandunabletoiniateacvityexceptinresponsetoexternalsmuli.Theabilityto
becomeengageddynamicallyininteracveandintenonalbehaviorisbasictoexecuveskills.
Asmenonedearlier,whenthiscapacityfalters,personswithbraininjurycanerroneouslybe
labeledlazyorunmovated.
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InterpersonalandPsychosocialChanges
Interpersonalandpsychosocialchangesfollowingbraininjurymaypresentthemostserious
impedimenttovocaonalreintegraon.Aclientmaypossessintact,highlevel,funconalwork
skillsbutwillbepreventedfromsustainingemploymentbecause,inmostemploymentsengs,
jobretenondependsonmaintainingthegoodwillofcoworkersandsupervisorystaff.Inother
words,aclientneedstobeabletointeractwithcoworkersandsupervisorystaffinawork
appropriatemanner;maintainingapleasant,approachableaffect,oratleastaneutralone.
Peoplewithbraininjurymaybelewithmarkedchangesintheirbehavioralrepertoireand
exhibitverbalandphysicaldisinhhibion,poorsocialjudgmentandageneraldecreaseinsocial
graces.Someclientsmayexhibitdysfunconalsocialbehaviorsofsuchmagnitudethattheyare
preventedfromengaginginanyconsistenttaskperformance.Whenevenlengthytreatmentand
clinicalintervenoncannotmodifyundesirablesocialbehavior,compeveemploymentmay
notbeachievable.
Ahighdegreeofegocentricityisoenanotherconsequenceofbraininjury.Manyclientshave
difficultyinadopngaflexiblestanceandremainfixedintheirviewthattheworldonlyrelatesto
andrevolvesaroundthem. Clientsmaylackthecapacitytoreadsocialcuesaccurately. Some
failtoreaditatall;theyseemoblivioustonuancesofspeechandbodylanguageofothers. They
confusetheimpactofsociallyrelayedmessagesandconsistentlyinterpretthemasbeing
personallydirected.Forexample,clientsmaymisinterpretacoworkersorsupervisorsangeror
disappointmentoverworkproblemsasastrongnegavemessageabouttheirpersonal
performance.Inaddion,construcvecricismmaybeinterpretedasapersonalassault.The
unfortunatebyproductofthistypeofmisinterpretaonisthattheclient,whoperceivesthe
angerasdirected
athim/her,
generally
responds
with
anger.
Oneoftheleastunderstooddysfunconalinterpersonalskillsisthelossofemoonalcontrol.
Clientscanoverreactorbecomeimmobilizedbyatypeofemoonalfloodingrarelyobservedin
otherdisabilitygroups.Thetypeandextentoftheiremoonalresponse,oenthedirectresultof
someinternaldialogue,isnotmeritedbythesituaon.Lossofemoonalcontrolwillusually
surfaceunexpectedlyandsomemesbeofsuchmagnitudethatitprecludesanyproducve
acvity.
Thisemoonalinstabilityischaracterizedbyrapid,exaggeratedmoodoraffectswings.Knownas
emoonal
lability,
the
condi
onisthe
result
ofweakened
orimpaired
control
inemo
onally
chargedsituaons.Becausetheclientsphysicalappearancemaygivenoindicaonofadisability,
observerstendtomisinterprethis/herstrongemoonalresponses.
Anotherissuefacingpeoplefollowingbraininjuryisadecreasedtoleranceforalcoholanddrugs.
Smallerdosesproducemorerapideffects.Socialdrinkingcanbedifficulttocontrolandwill
interferewithapersonscognive,physicalandpsychosocialfunconing.
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Relaonshipswithinthefamily,thecommunityandtheworkplacewillbecompromisedwhena
personisunabletoeffecvelycontroltheiruseofalcoholordrugs.Thevocaonalrehabilitaon
processwillbeatjeopardyaswell.Theclientshouldbemadeawareoftheharmfuleffectsof
thesesubstancesandtheVRcounselorshouldaggressivelymonitorandinterveneifthereisa
quesonofimpairmentduetoalcoholordruguse.
MildBrainInjuries
TheVRcounselorwillbecalledupontoprovideservicesforpersonswhopossessawiderangeof
capabiliesandlimitaonsastheresultofbraininjury.Alongwiththosewhohavemoderateor
severebraindamage,therearethoseclassifiedashavingmildbraininjuries. Becausepeople
withsocalledmildorminorbraininjurydonotexhibitobviousdeficits,theyarenotreferredfor
rehabilitaonservicesunllongaertheactualinjury.Followingavisittotheemergencyroom,
doctorsoffice,orabriefperiodinanacutecarefacility,individualswithmildbraininjuries
generallyreturnhomeandsubsequentlytowork.Whiletheyoenhavenoawarenessofaltered
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Common Issues Following Brain Injury
Cognive Changes Physical Changes
Memory
Problemsolving
Decisionmaking
Persistence
Planning
OrganizaonSequencing
Processingspeed
Judgment
Inflexibility
Concentraon
Aenonspan
Motorcoordinaon
Tasteandsmell
Hearingand/orvisualchanges
Spascityandtremors
Fagueand/orweakness
BalanceMobility
Speech
Seizuredisorder
Paralysisononeorbothsides
Depression
Socialskills
problems
Moodswings
Emoonallackofcontrol
Inappropriatebehavior
Impulsivity
Lackofresponsetosocialcues
Irritability
Reducedselfesteem
Diffi
cultyrela
ngwith
others
Selfcenteredness
Difficultyformingnewrelaonships
Stress,Anxiety,Frustraon
Denial
Lackofmovaon
Excessivelaughing
Personality and Behavioral Changes
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abilies,theirjobperformanceismarkedlydiminishedandtheabilitytoretainemployment
suffers.Thisgroupofpeopleappearunchangedfrompreinjurystatusandtheirdifficulesare
furthercompoundedbytheexpectaonsplaceduponthembytheirsocialenvironment.Because
theyappearsointact,theseexpectaonsarehighandusuallyincongruentwiththeirreduced
capacies.Whentheemploymentproblemsbecomeobviousandtheindividualisfinally
referredforvocaonalcounselingorrehabilitaon,theoriginalcauseoftheproblemmayremain
unrecognized. Ifthisisthecase,theVRcounselorcanbeinstrumentalindeterminingwhethera
mildbraininjurymaybeafactorintheemploymentproblemstheindividualisexperiencingand
inarrangingforappropriatetesngbyaneuropsychologisttoaddresstheseproblems.Itshould
benotedthatmildbraininjuryisacomplexproblemandisoenaddressedintherehabilitaon
literatureasaseparateanduniquetopic.Resourceinformaonaboutmildbraininjurycanbe
foundontheBrainInjuryAssociaonofOregonswebsite(www.biaoregon.org).
Diagnostics
Duringtheearlystagesoftreatmentandrehabilitaonofpeoplewithbraininjury,anumberof
neurodiagnoscmeasuresandmentalstatusexaminaonsareperformed.Themainpurposeof
suchtesngistomeasurecognivefunconingandchartimprovementsastheyoccur.These
testsarenotimmediatelyrelevanttothevocaonalrehabilitaonprocess.However,later
neuropsychologicaltesng,whichisbestadministeredwhenthepersonwithabraininjuryhas
becomemedicallystable,bearsdirectrelevancetovocaonalrehabilitaon.
NeuropsychologicalConsult/Evaluation
Aneuropsychologicalevaluaonmaybepartofthecaserecordsthevocaonalcounselor
reviewsatthe meofreferral. Thesignificanceoftheresultsmaynotbereadilyapparent,and
therefore,maybedifficulttotranslateintomeaningfulapplicaon. Testscoresaretypically
reportedastheycomparetoestablishednorms,andaclientsperformanceorlevelof
funconingmaybedescribedintermsthattellusonlythathe/sheisdeficient,impairedor
belowtheaverage. Thesetermsmeanlilewhentheyhavetobeappliedtoajobanalysis.
Addionally,thesereportsmaybewrieninjargonthatfurtherconfusesthevocaonal
counselor.
Ontheotherhand,awellwrienneuropsychologicalevaluaoncanserveasaninvaluabletool
tounderstandingthecognivestrengthsandweaknessesofaclientasitappliestoreturningto
work.Ifthevocaonalcounselorismakingthereferralfortheneuropsychologicalevaluaon,
askingspecificreferralquesonsaboutworkfunconing,accommodaons,andtreatment
recommendaonscanenhancetheinformaonthatisprovidedinthereport.Discussingthe
resultsofthetesngwiththeneuropsychologist,whoseexperseisinbrainbehavior
relaonships,isanotherwaytoobtainvocaonallyspecificinformaon.
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VocationallyRelevantQuestionsfortheNeuropsychologist
Whatfunconallimitaonsareevidentwithrespecttomemory,informaon
processing,visualandauditorycomprehension?
Whatisthe
poten
alforfurther
remedia
on?
Whatistheprognosisforlengthoftreatment?
Canyoucommentonspecificstrengthsnotedinthetesngsituaon,e.g.,ease
inreceivingoralinstrucon,persistence,concentraon?
Istheclientdistracble?Externally?Internally?
Canyoucommentonthoseaspectsofpreinjurylearning(i.e.,firmly
entrenched,overrehearsed,repertoireofskills)thathavesurfacedduringthe
currenttesng?
Istherepotenalfornewlearning?
Howmuchsupervisionandenvironmentalsupportwillbeneededatthecurrent
leveloffunconing?
Whatistheclientsbestmethodoflearning?
Whattypeofcompensatorystrategieswouldbebeneficialtoenhancejob
performance?
Whattypeofjobaccommodaonswouldbehelpful?
Whataretheeffectsofinterpersonaldeficitsonvocaonalgoals?
Theresultsofawellfocusedneuropsychologicalevaluaoncantranslateintopraccal
recommendaonsforthevocaonalassessmentprocess.Theseresultsallowthecounselorto
makepreparaonsandtakeancipatorystepstoensureasuccessfulexperiencefortheclient.
Thevocaonalcounselorcanthenbegintodesignthetypesofenvironmentalsupportsystems
thattheclient,givenhis/herstrengthsandlimitaons,willrequireduringthevocaonal
rehabilitaonprocess.
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III.COGNITIVEREHABILITATION
Clientswithbraininjuriesmayneedcogniverehabilitaonastheyarepreparingforthe
vocaonalrehabilitaonprocess.Cogniverehabilitaonisthesystemac,goaloriented
therapeucintervenondesignedtoremediate(improve)arangeofcogniveabilies.Areasaddressedinaprogramofremediaonarehighlyindividualizedandmayincludeaenon,
concentraon,andimpulsecontrol.
Cogniveprogramsalsoaddresslackofawarenessofinjuryimposedlimitaonsandsocialand
emoonalneeds.Memoryimpairmentsareaendedtoandcompensatorystrategiesaretaught.
Cogniveremediaoniscarriedoutincarefullyplannedstagesorsteps.Clientsmovethougha
varietyofhighlystructuredtrainingexercises.Skillacquisionandskillstabilizaonarestressed.
Formostpeoplepossessingtruefunconalmemorydeficits,compensatoryaidsmustbe
establishediftheyaretoreturntoanylevelofoccupaonalproducvity.Compensatory
measuresoentaketheformofenvironmentalcueingsystems.Cueingcanbeassimpleasan
indexcardlisngthealphabetfortheclientwhoisinvolvedinafilingtaskorawrienlistof
sequenalstepsforagiventaskthattheclientusesasavisualreference.Somemesthese
cueingmethodsrequireonlycommonsenseandabitofcreavitytocreate.
Itisimportanttorememberthatenvironmentalcueingsystemsmustincorporatethestepstobe
takeninalogicalsequence.Thisistruewhethertheyarebeingdesignedfortheworkplaceorfor
acviesofdailylivingaccomplishedathome.Thesemightbewrienguidelinesforprocedural
operaons;calendarsandjournalsforpersonalappointments;joblogs,maps,wrienstepby
stepproceduresforgainingaccesstoaparcularplace;andadailyschedulewhichhelpsthe
clienttransionfromoneaspectofthedayorjobtasktothenext.
IndicatorsofNeed
Somemesaclientwithabraininjuryisdeterminedtobeeligibleforvocaonalrehabilitaonyet
demonstratesfunconaldeficitsincogniveskills.Ifthesedeficitslimittheclientspotenalfor
independenceandvocaonalsuccess,thencogniverehabilitaonmaybeindicated. Ifthereisa
discrepancybetweenwhattheclientisabletodoandwhatwillberequiredofhim/heronthe
joborvocaonalplacement,cogniverehabilitaonmaybeappropriate. Ifthejobrequiresskills
thattheclienthasalreadydemonstrated,eitheronaconsistentorerracbasis,orhasthe
potenaltolearn,thencogniveretrainingshouldbeiniated.Thefollowingguidelinesarealso
relevant:
Theclientshoulddemonstratethemovaonandabilitytoacvelyparcipateinthe
learningsituaonanddisplayacapacityforconsistentimprovementonnewlearning.
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Theclientsowngoalsshouldbebothrealiscandcongruentwiththefinalgoalsof
theremediaonandulmatejobplacement.
Thereshouldbeevidencethattheskilldeficitsexhibitedbytheclientareretrainablein
therapy.Ifnot,thefocusofthetherapyshouldbeondevelopmentofcompensatory
strategies,useofexternalaids,providingmorestructureintheenvironment,andjob
support.
RoleofCognitiveRehabilitationinVocationalTraining
Goalsforcogniverehabilitaonshouldbemadewithregardtothespecificskillsneededinthe
clientsvocaonalseng. Sincetheseneedsmaychangewithdifferentvocaonalplacementsor
developmentoftheclientsskills,itisimportanttoupdatethegoalsregularly.Forexample,the
goalsforcogniverehabilitaonmayberelevantforasupportedemploymentsituaon.Aer
workinginsupportedemployment,theclientmaydemonstratethepotenalforemployment
withoutsupports.Theneedforaddionalcogniverehabilitaonmaybeindicatedwithnew
goalsforselfsufficiency.
CompensatingforCognitiveDeicitsontheJob
Peoplewithbraininjuriesareusuallytaughtavarietyofcompensatorymechanismsduringthe
courseofcogniveremediaon.Atissuehereiswhethertheyarecapableofincorporangthe
learnedcompensatorystrategiesintohome,community,andworkplacesengs.
Peoplewithbraininjuryoenhavedifficultytransferringthecompensatorystrategiestheylearn
intheclinictorealworldsituaons.Memorydeficitsandproblemswithabstractreasoningmake
itdifficulttogeneralizeinformaonlearnedinonesengtoanothersituaon.Thebestwayto
teachworkrelevantcompensatorystrategiesisinaworkcontext.Itisonlyinaworksengthat
thesestrategieshaverealmeaningtomostpeoplewithbraininjuries.
CriticalFeaturesofCognitiveRehabilitation
1.Adequateevaluaon,planningandongoingsupervisionbyatrainedprofessional.
2.Dailystructuredtasksthatinclude:
Supervision/Minimaldistracons
Stepbystepacquisionofskills
Constantsystemacfeedback
Maximalsmulaon
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Builtinsuccess
Repeatedlearning
Transferoftrainingtofunconalsengs
3.Wri
eninstruc
ons
and
notes
bysupervisor
ofdaily
tasks:
Cogniverehabilitaontherapist/technician
Aendant
Familymember
4.Regular(e.g.weekly)reviewofprogrambyneuropsychologist.
5.Coordinaonofprogramwithotherrehabilitaonteampersonnel.
IV.THEVOCATIONALREHABILITATIONPROCESSThevocaonalrehabilitaonprocessbeginswiththereferralandthecolleconofinformaon
tolearnasmuchaspossibleaboutthevocaonalcandidate.TheVRcounselorcreatesaprofile
ofthepotenalclientbygatheringinformaonthroughwrienandverbalreportsand
interviewingtheclient.
DeterminingtheAppropriatenessoftheReferral
Beforebeginningtheassessmentofreadinesstoengageinthevocaonalrehabilitaonprocess,
thecounselorshouldbesurethattheclienthasbeenappropriatelyreferred.Oneofthefirst
consideraonsistorecognizethereasonforthereferral.Professionalsinbothmedicaland
rehabilitaonsengssomemespushpaentswithbraininjuryintounmely,andtherefore
inappropriate,vocaonalrehabilitaonintheireffortstoengagetheirpaentsinproducve
acvity.Thereferralmayalsobeviewedasapossiblewaytoconnuerehabilitaonwhenother
fundingsourceshavebeenexhausted.Ifthepersonbeingreferredforvocaonalrehabilitaonis
atastageofrecoverywereaddionalimprovementisexpected,thentheiniaonofthe
vocaonalrehabilitaonprocessisbestdeferred. Inassessingreadinesstoengageinwork,
carefulconsideraonofthestageandstabilityofbothcurrentandpotenalimprovementmust
bemade.Ideally,the metobeginvocaonalrehabilitaoniswhenthepotenalclientwith
braininjuryiscomplengtherehabilitaonprocess,hasreintegratedintothehomeand
community,andexpressesmovaontowork.Somemes,clientsdonotappreciatetheneedfor
vocaonalservices.Theymaybeunabletoassesstheirowncapabiliesandfrequentlyare
unawareoftheirinjuryimposedlimitaons.Itishelpfulforclientstohaveabasicawarenessand
acknowledgementofresidualchangesinarangeofcapaciesbeforebeginningvocaonal
rehabilitaon.
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IntakeInterview
Theintakeinterviewisactuallythefirststepintheprocessofassessingreadinesstoengagein
theVRprocessandisprobablythebestinialassessmenttoolavailable.Itisrecommendedthat
theVRcounselorallowmore meforinialinterviewswithindividualswithbraininjuriesthan
otherclients.Theintakeinterviewservesavarietyofpurposes,includingfactfindingandto
establishingrapportwiththeclient.Addionally,itallowsthecounselortomakeclinical
observaons,whichisanotherformofdatacollecon.Iftheclientpresentswithbehaviorsthat
aresodysfunconalthatthecounselorhasconcernsaboutworkingwithhim/her,thereisa
strongpossibilitythatthepersonisnotreadyfortheVRprocess.Firstandforemost,the
interviewprovidesthecounselorwithanopportunitytoevaluatetheclientsabilitytoparcipate
ataverybasiclevel;inotherwords,totesthis/hercapacitytoengagereliablyinatwoway
communicaon.Didtheclientremembertokeeptheappointment?Wastheclientpunctual?Can
theclientsupplyinformaonabouthim/herself? Duringthecourseofconversaon,istheclient
focused?Ishe/sheaenve,orhighlydistracble?Istheclientorientedto meandplace?Isthe
clientimpulsive?Istheclientinterestedinvocaonalrehabilitaonservices?
VocationalCandidatesArrival
Twothingstobenotedduringthisfirstmeengare:
1)bywhatmeansoftransportaondidthecandidatearrive,and
2)didhe/shearrivealoneoraccompaniedbyasignificantother.
Theinclusionofthisaddionalpersonasasourceofbackgroundinformaonanddetailsofinjury
isrecommendedwhentheclientcannotreliablyprovidethisimportantinformaon.However,
thecounselormustfindoutwhetherthepresenceofthisaddionalperson(s)isinresponsetoa
needoftheclientortothatofthesignificantother.
Inaddion,theissueofindependentmobilityandtheavailabilityoftransportaonmustbe
addressedduringthevocaonalassessmentprocess.
ReadilyObservedBehaviors
Thelistofbehaviorsthatarereadilyobservedduringtheinterviewingprocessislengthy,andthe
counselormustbeawareofallthosethatwillhaveaposiveornegaveimpactinaworksituaon.Thecounselorshouldgainknowledgeofspecificbehavioraldeficitsthat,unlessthey
canbecompensatedfororsufficientlyremediated,willprecludecertainjobs.Forexample,note
signsofdisinhibion.Theclientwhoisextremelyuninhibitedmaynotfarewellinmaintaining
employmentbecauseahighdegreeofdisinhibionmakesitdifficulttoestablishadequate
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interpersonalrelaonshipsintheworkplace.Oneshouldalsonotewhetherapotenalclienthas
physicaldisabiliesorproblemswithcommunicaon.
SigniicantOthersDuringthisinialphaseoffactfinding,thecounselorshouldobtaininformaonconcerningthe
constellaonofsignificantotherswhocanberelieduponforsupplyingsupport.Thelackofthis
typeofsupportsystemcanmaketheprocessmoredifficult. Familymembersandfamilialrole
modelsmakeameasurablecontribuoninvocaonalrehabilitaon.
FormingaVocationalProile
MedicalInformation
Relevantmedicalreportsshoulddescribetheinjury,itsseverity,andthecircumstancesunder
whichtheinjuryoccurred.Descriponsofmedicaltreatment,complicaonsduring
convalescence,andeffortsatrehabilitaonshouldalsobepartofthisdatacollecon.Cognive
andphysicaldisabiliesshouldbenoted.Thecircumstancessurroundingtheinjurymayalso
provideinformaonsuchasthepresenceofalcoholordrugsascontribungfactors.
Thepresenceofasurgicallyimplantedshuntshouldbenoted.Theseshuntsareinsertedto
relievebuildupoffluidinthebrain(creangincreasedintracranialpressure)duringtheacute
carestage.Theyusuallyremaininplaceandgenerallyoffernoproblems.However,iftheshunt
becomesclogged,theremustbeasurgicalrevisionorreplacementtocorrectthemalfuncon.A
malfunconingshuntwillcontributenoceablytoasuddendeclineinperformance.
Prescribeddrugsforseizurecontrolorbehavioralmanagementmustalsobenoted.Thesedrugs,
whilehelpfulinmaintainingmedicaland/orbehavioralstability,mayhavesideeffectsthat
impedejobperformance.
LeisureTimeActivities
Leisure meacviesshouldbeexamined.Iftheclientisfortunateandhasremainedsocially
acvefollowingthebraininjury,thecounselorshouldconsiderhowhe/shemaintainsleisure
meacvies.Theskillsneededtomaintainsocialcontactscanbeagoodindicatorofsuccessin
thejobmarket.Thecounselorshouldalsoexploreatthispointwhethertheindividualisinvolved
inbraininjurysupportgroups.(www.biaoregon.org/supportgrp.html)
PostInjuryWorkHistory
Duringtheinterview,thecounselorshouldfindoutwhetherthereisapostinjuryworkhistoryor
whetheraemptstoreturntoschoolorworkweremade.Thequalityoftheworkeffortshould
beexploredindetailwhenpossible.Sincetheclienthasbeenreferredforvocaonalservices,
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previousaemptsatreintegraonmaynothavebeensuccessful.Itisimportanttodetermine
howrealisctheclientsperceponisofwhattranspired,andhis/herselfreportofwork
funconingshouldbeconfirmedinconsultaonwithsignificantothers,formeremployersor
teacherswheneverpossible.
PostInjuryEducationAcademiccreditsordegreesearnedpostinjurymeritspecialaenon.However,thedegree
awardedsomemeshasnoapplicabilityintherealworldandmayhavebeenearnedunder
highlystructuredcondions.
GoalsandSelfPerception
Itisimportantduringthisprocesstoaskthevocaonalcandidateaboutselfpercepons
regardingspecificinjuryinducedproblems. Thecounselorshouldgatherinformaononthe
qualiestheclientpossessesthatmightrepresentstrengths.Usuallypeoplewithbraininjury
willmenonproblemsinmemorybecausetheirsocialcirclehasforcedthemtoacknowledge
thisdeficit.Memoryimpairmentsbecomeselfevident,asdophysicallimitaons,whichclients
areabletoreportreadilyandidenfyastheprimaryreasonfortheirinabilitytogain
employment.
Thisinterviewwouldalsobewellspentindiscussingtheclientspersonalgoalsandassessing
howrealisctheyarewhencomparedwiththeclientsabilies.Thecounselorshouldbeableto
observewhethertheselfreportisbiasedbyanxietyduetotheinterviewsituaonorwhether
theclientwhopresentsasunrealiscissimplyrespondingtoasocialneedforapproval,thatis,
tolookgoodintheeyesofthecounselor.
HistoryPriortoInjuryInformaongatheredduringtheintakeinterviewmaybeincompleteor,insomecases,not
totallyaccurate.Thecounselormustnowassemblethoseelementsofpreinjuryhistorythatcan
bedocumentedbywrienrecord.Inthisway,thecounselorconnuestocreateaportraitofthe
personwhoisabouttobeginthevocaonalrehabilitaonprocess.
Counselorsmustbeawareoftheinjuryproducedphysical,cognive,andpsychosocialchanges,
butmustalsokeepinmindthatwhoapersonwasbeforeinjuryisoenakeydeterminantof
whohe/shewillbecome.Thetragiccircumstanceofabraininjurymaybluntaspectsofbehavior
or,conversely,exacerbatethem.Armedwithpreinjuryinformaon,thewellpreparedcounselor
canbegintoancipatestylesofbehaviorthatmaybringsuccessinparcularworksituaons.
PreInjuryHealthHistory
Itisimportanttoobtainapreinjuryhealthhistorybecausepreexisngmedicalailmentsoen
complicatebraininjury. Bothearlierinjuriestothecentralnervoussystemandcongenital
anomaliesmayimplicatetherehabilitaonprocess.Thepersonprohibitedsincebirthfromthe
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developmentofafullrangeoffunconalcapaciespresentsaspecialchallenge,differentfrom
thatofonewhohadnosignificantproblemspriortoinjury.
Ahistoryofsubstanceabuseorpsychiatricdisabilityalsomaycompromiseprospectsfor
successfulvocaonalrehabilitaon.Preinjurydrugabuseandalcoholismaddressapersonsstyle
ofsocialadjustment.Themeresuggesonofthispredileconshouldalertthecounselortothe
factthatthepotenalforthisbehaviorwillhavetobecloselymonitoredthroughouttheVR
process.
PreInjuryEducation
Levelofpreinjuryeducaonalaainmentmustbeobtainedand,whenpossible,thequalityof
educaonalperformance. Anyindicaonofalearningdisabilitythatinterferedwiththenormal
progressionofeducaonalachievementshouldbenoted. Thepresenceofalearningdisability
maycomplicatetheVRprocess.
Clientswithadvancedacademicorprofessionaldegreeswilloenpossessagreaterrangeof
vocaonalopons. Sinceindividualswithbraininjuriesfrequentlyexhibitproblemswithrecent
memory,thelengthofmethathaspassedsincethedegreewasobtainedandtheamountof
mespentinapplyingwhatwaslearnedmaybeveryrelevant.Mostpeopleretainmemoryfora
repertoireofoverlearnedskillsdevelopedbeforetheinjury.
PreInjuryWorkHistory
Incompilingapreinjuryworkhistory,thecounselorshouldnotetheskillsthatweredemanded
inpreinjuryoccupaons.Theseskills,oenretained,suggestfurtherareasforvocaonal
exploraon.Thecounselorshouldalsolooktothejobtrainingexperiencesaswellasformal
trainingrequiredforpreinjurywork. Retrievableskillsfromsuchtrainingmayexistandmay
suggestfurtherareasforvocaonalrehabilitaon.
CourseofRehabilitation/Reports
Withawarenessthatthecourseofrehabilitaonishighlyindividualizedanddependentupona
rangeofvariables,theVRcounselorshouldgatherallavailablerecordsfromthevarious
reporngdisciplines. Inmostcases,thismeansnursing,physicaltherapy,occupaonaltherapy,
psychologyandneuropsychology,speechandlanguageservice,socialservicesandrecreaonal
therapy.Thesereportstypicallydocumentfunconalskillsacrossagamutofcommunityand
workrelateddomains.Whenitisdeterminedthattheclienthastheappropriatedegreeof
readinesstobegin,thecounselor,inconsultaonwithaneuropsychologistifpossible,should
designtheindividualizedvocaonalrehabilitaonplan.
Someindividualsmayneverhaveparcipatedinconvenonalrehabilitaonprogramspriorto
theVRinterview.Ifthisisthecase,theonlymeansofevaluangthecurrentstatusof
neurologicalandphysicalimprovementsistoacquirethemostrecentreportsofthemedical
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professionalswhocaredforthem.Thecounselorsprimaryconcerninreviewingtheserecords
shouldbethestabilityofgainsmade.Thestabilityofimprovement,bothneurologicallyand
physically,isadeterminingfactorinjudgingthe melinessofvocaonalintervenon.
ReferralforPreVocationallyRelevantServices
Whenwrienandorallydeliveredreportsaswellasobservaonmadeduringthecourseofa
personalinterviewdonotindicatereadinesstoengageintheVRprocess,theVRcounselor
shouldhavetheoponofreferringtheclientforfurtherservicesthatwouldenhancevocaonal
readiness.Theseservicesmightincludetherapiesinanyoftherehabilitaondisciplines,
programsthatwouldenhancecommunityindependence,volunteeringexperiences,oralternate
choicesasnecessary.
Thetypeofprogramorservicetowhichtheclientisbeingreferredshouldbeatthediscreonof
thevocaonalcounselorwhohasmadethedeterminaonthattheclientisnotready.For
example,theclientwithproblemsinaenonmayprofitfromaperiodofcogniveremediaon
designedtoamelioratethisspecificdeficit. Effortsmadetoengagepeoplewithbraininjuriesin
theVRprocessbeforetheyarereadyarenevercosteffecveandmayservetodiscouragethe
clientunnecessarily.
WorkingwiththeVocationalRehabilitationClient
InorderforaclientwithbraininjurytogetthemostbenefitfromtheVRprocess,thecounselor
mayneedtoprovideaccommodaonsforsomeofthecogniveandpsychosocialchallenges
facedbytheclient. Apointtorememberisthattheclientsaenonspanisshortandtheymay
havelimited
memory.
Their
processing
isdelayed.
There
arule
offi
vetofollow:
have
your
sentencesbenolongerthanfiveworks, pauseforfivesecondsbetweeneachsentence,and
havethelistbenolongerthanfivesentences. Thefollowingissuesandstrategiesmayassistthe
clientingengthemostoutoftheservicesoffered.
Issue:Dificultyrememberinginformation
Aclientmayhavedifficultyrememberingtasksfromdaytodayorinstruconsprovidedbythe
VRcounselor. He/shemayalsohavedifficultyrememberingnewinformaon,whichimpacts
learning.He/shemightforgetscheduledinterviewsorfollowupappointmentswiththeVRstaff.
Strategies:
Providewrieninformaonwheneverpossible.
Encouragetheclienttowritedowninformaoninavocaonalrehabilitaon
notebook.
Remindtheclienttorefertothenotebookoen.
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Encouragetheuseofadayplannerorcalendarforrecordingappointmentdates
andtaskstobeperformed.
Encouragetheclienttohaveafamilymemberorfriendprovideareminder
aboutappointments.
Calltheclientonthemorningofascheduledappointment.
Issue:Dificultyfocusingandpayingattention
AVRagencyorprogramisabusyplacewithlotsofdistracons.Itiseasyforaclientwithabrain
injurytohavedifficultypayingaenoninthiskindofenvironment.Theclientmayappear
uninterested,butinfactishavingproblemsfollowingconversaons.
Strategies:
Workinanareawithlimiteddistracons.
Beawareofsurroundingnoisesthatmayinterferewithconcentraon,suchas
radios,otherpeopletalking,etc.Trytolimitthesenoisesasmuchaspossible.
Asktheclienttorepeatinformaonthatwasjustheardtomakesurethe
conversaonorinstruconswereunderstood.
Besuretohavetheclientwriteinstruconsdowninanotebookorjournal.
Besuretohavetheclientsaenonbeforestarngaconversaon.
Refocustheclientsaenonifhe/shebecomesdistracted.(Forexample,John,
letmerepeatthatpointagain.Itsimportant.)
Reschedulethesessionforanother me;perhapsearlyinthedaywhenthe
clienthasmoreenergy.
Asktheclientifthereissomewayyoucanhelp.Forexample,John,youappear
distracted.IstheresomethingIcandotohelp?
Issue:Dificultywithinitiation
Asaresult
ofabrain
injury,
aclient
may
have
diffi
cultybeginning
acvies.Itmay
appear
that
he/sheisnotinterestedormovated,butinsteadhe/sheneedsassistancetobeginworkingon
tasks.
Strategies:
Establishastructuredrouneofdailyacvies.
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Breakdownacviesintosimplersteps.Encouragetheclienttocompleteonetaskata
mebeforebeginningthenext.
Makeachecklistofacviesthatneedtobecompletedeachday.Checkoffeachtask
thatiscompleted.
Establish meframesinwhicheachtaskshouldbecompleted.
Useaclockorwatchthatcanbeprogrammedtoringorvibratetoindicatethe
startofatask.
Provideremindersandencouragement.
Issue:Dificultywithorganizationandplanning
InordertobesuccessfulintheVRprocess,aclientmustbeabletosuccessfullycarryoutthe
plan.
This
may
be
diffi
cult
for
a
person
with
a
brain
injury
who
has
problems
with
organiza
on
andplanning.
Strategies:
Developawrienplanandincludetheclientinthedevelopmentoftheplan.
Breakdowntheplanintosimplersteps,withclearanddetailedinstruconsofhowto
completeeachstep.
Assigndifferentacviesforeachdayoftheweek.Forexample,onSundaylookinthe
wantadsandcirclejobleads,onMondaymakephonecalls,onTuesdaysendout
resumes,etc.
Developachecklisttoensurethateachstepoftheplangetsaccomplished.
Reviewtheplanoentomakesurethatitisunderstoodandthatitisworking.
Offerpraiseforajobwelldone.
Issue:Dificultywithdecisionmaking.
Followingabraininjury,aclientmayhavedifficultymakingdecisions. Idenfyingwhichjobto
pursue,deciding
what
towear
foraninterview,
oranswering
interviewers
ques
ons
may
be
difficult. Aclientmayactimpulsivelyandnotthinkthroughtherelevantopons.
Strategies:
Helptheclientidenfywhattheoponsaretoaparcularproblem.
Discusswiththeclienttheadvantagesanddisadvantagesofeachopon.
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Havetheclientwritedown(orassisthiminwring)thepossibleopons,alongwiththe
prosandconstoeach.
Encouragetheclienttostopandthinkbeforemakingadecision.
Issue:Dificultyinsocialsituations
Gengalongwithcoworkersandbossesisasimportanttokeepingajobasbeingableto
performthejobtasks.Aerabraininjury,clientsmaynothaveaclearunderstandingofthe
impacttheirbehaviorhasonothers.Theymayhavedifficultyengaginginconversaonandmay
notalwaysbesensivetosocialboundaries.Thismaybearoadblocktodoingwellonthejob.
Strategies:
ProvideclearexpectaonsforappropriatebehaviorsattheVRprogram.Provideposive
feedbackforexpectedbehavior.
Encouragetheclienttoconsidertheconsequencesofhis/heracons.
Ifundesiredbehavioroccurs,discusstheissueprivately,inacalm,reassuringmanner.
Reviewexpectedbehaviors.
Beforeanintervieworappointment,discusswiththeclientthetypesofquesonsthat
canbeexpectedandfigureoutwiththeclientthebestanswerstothesequesons.
Similarly,preparewiththeclientquesonsthatshewantstoask.
Roleplaytheinterviewsituaonwiththeclientandgivehonestfeedback.Rehearseunl
theclientappearscomfortableansweringandaskingavarietyofquesons.
Issue:Dificultycontrollingemotions
TheVRprocesscanbeparcularlystressfulforapersonwithabraininjury.Accepngones
limitaons,understandingonesstrengths,anddevelopingnewvocaonalgoalscanbe
overwhelming.Inaddion,aendingnewprograms,meengnewpeople,andlearningnew
rounesisachallenge.Asaresultofthebraininjury,apersonmayhavedifficultycontrolling
emoonsinthesestressfulsituaons.
Strategies:
Expecttheunexpected.Alwaysbepreparedtodealwithasituaon,evenifitisatan
inopportune me.
Trytoremaincalm.Bymodelingcalmbehavior,itcanhelptheclientmodifyhis/her
behaviorandmightpreventthesituaonfromescalang.
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Takethepersontoaquiet,moreprivate,area.Givehim/herafewminutestocalmdown
andregaincontrol.
Redirecttheclienttoadifferenttopicoracvity.
Understandthattheeffectsofbraininjurymaypreventtheclientfromfeelingguiltor
empathy.
Provideconstrucvefeedbackaerapersonhasregainedcontrol.
Usehumorinaposive,supporveway.
Issue:Dificultywithselfawareness
Apersonwithabraininjurymayhavedifficultyaccuratelyperceivinghis/herstrengthsand
weaknesses,parcularlythoseareasthathavechangedsincethebraininjury.
Strategies:
Ancipatepossiblyskewedselfpercepons.
Asktheclienttodiscussherstrengthsandweaknesseswithpeoplewhoknowhis/her
(familymembers,friendsandrehabilitaonprofessionals).
Iftheclientlosthis/herjobaerthebraininjury,discusswithhertheproblemsthatled
uptothedismissal.Iftheclientisunsure,asktheclientifhe/shewouldbecomfortable
returningtothepreviousemployeranddiscussingtheissues.
Astheclientgainsmoreinsightintoherstrengthsandweaknesses,discussthis
informaonwiththeclient.Encouragetheclienttokeepajournaloftheseinsights.
Provideposive,construcvefeedback.
V.EMPLOYMENTOPTIONS
TraditionalVocationalRehabilitationSetting
ThetradionalVRservicedeliverymodelforthemajorityofclientsconsistsofvocaonal
evaluaon,vocaonaltrainingandjobplacement,inthatorder.Thismodelassumesthatthe
clientiscapableofindependentlytransferringwhathasbeenlearnedfromonesengto
another,e.g.,transferringskillslearnedfromtherehabilitaonfacilityortrainingprogramtothe
job.However,thedeficitsofmanyclientswithbraininjuryincludeimpairedmemory,slow
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informaonprocessingskills,andimpairedabilitytogeneralizenewlylearnedinformaon the
veryskillsnecessarytocompleteatradionalvocaonalrehabilitaonprogramsuccessfully.
ClientswithbraininjuryoenarebeerservedbyaPlaceTrainmodel,asopposedtothe
tradionalTrainPlacevocaonalmodel.
LimitationsofTraditionalVocationalEvaluation
Tradionalvocaonalevaluaonsystemshavebeenillequippedtomeetthespecialneedsof
peoplewithbraininjuries.Standardizedtestsofintelligence,personality,aptude,interestand
achievementtypicallyprovidescoresthatindicatehowanindividualcompareswithnorm
groups.Peoplewithbraininjuriesareoencapableofdisplayingareasorpocketsofhigh
achievementonthosestructuredtestsofdiscreteskills.Theresultsyieldedbymanyofthese
testsarepredicatedonoldlearning,i.e.,awellrehearsedrepertoireofpreinjuryskills. An
excellentexampleofascorethatcanmisrepresentthepotenalofaclientisverbalIQ,derivedfromintactmateriallearnedbeforetheinjury.Unfortunately,thesetradionaltoolsandthe
evaluatorswhousethemassumeasystemicintegrity,andpeoplewithbraininjuriesdonot
conformtothenormalpopulaonsuponwhichthesetestswerestandardized.Thecomponent
thatpreventstheseinstrumentsfrombeingvalidpredictorsofsuccessistheinabilityofthose
withbraininjuriestointegrate,applyandgeneralizemanyoftheskillsthataretested.Most
standardizedexaminaonsdonotaddress(otherthantheadministratorsobservaons)ormake
allowancesfortheproblemareasthatposethemajorbarrierstosocial,educaonaland
vocaonalreintegraon.Thatis,theyprovidequanfiabledatabutmakenoprovisionfor
includinginreportsofscoresanassessmentofthequalityofperformance.
TradionalVRsystems,withagrowingawarenessthatindividualswithbraininjuriesareunable
torespondtothesetestsinwaysthataccuratelytranslatetofunconalskills,arenow
recognizingtheneedforalternavemethodsoftesngandevaluaon.
Standardizedvocaonaltesngmeasuresareusefuliftheyarecarefullyadaptedtoaddressthe
skillcapaciesofclientswithbraininjuries.Examiningtestresultswhilerecognizinghowthe
clientcompletesthetestandwhatcognivestrengthsandweaknessesareevidentcanprovide
invaluableinformaonaboutlearningandperformanceissues.Whenadministeredcreavelyby
acounselorfamiliarwithfunconalbehaviorscommonlyfoundinthispopulaon,theresultscan
beusedtodetermineappropriatetypesofentryleveljobplacements.
Theintroduconoftradionalhandson,situaonalassessments(ashorttermmonitoringof
workperformanceinanactualsengasopposedtoastandardizedtesngenvironment)asa
meansofmeasuringvocaonalpotenalhasmetwithlimitedsuccessinthispopulaonwhen
appliedinthemannerusedbymostvocaonalworkevaluaonprograms.Itislimitedbecause
mostclientswithbraininjuriesareillequippedtoengageinonthejobworksituaonswithout
somepreparatoryguidance.
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Mostclientsretainapictureofthemselvesfunconingatpreinjurylevels.Itisunrealiscto
ancipatewholeheartedparcipaoninasituaonalassessment,whichusuallybeginsatentry
level,byclientswhomayclingtoaviewofthemselvesasfunconingattheircapacitybeforethe
injury.Suchparcipaonispossibleonlyfollowingapersonaladjustmenttodisability;an
adjustmentthatincludesabeginningawarenessandacknowledgementofinjuryimposed
funconallimitaons.Developingthisessenalbasicdegreeofawarenessmustbeaccomplished
beforeengagingtheclientwithabraininjuryinanyvocaonalevaluaonprocess.
Oncetheindividualhasasenseofawarenessofhis/herfunconallimitaonsandawillingnessto
accommodatetheselimitaonsinaworkseng,amorerealiscevaluaoncanbeconducted.
Implementaonofaskillfullydesignedsituaonalassessmentfollowedbyapreparatoryperiod
tohelptheindividualbecomeawareoflimitaonscanprovidetheVRcounselorwithanexcellent
opportunitytoobservethequalitaveaspectsofworkbehaviors.Itisthevehiclethatcanallow
theVRcounselortodesigncompensatorymeasures,providestructureandsupportsystems,test
autonomy,gentlyconfrontinareasthatrequiremodificaon,and,ifprovidedwhentheclientis
ready,canbetheopmalguidetowardvocaonalreintegraon.
GraduatedPlacements
Thedemandsofacompevejobaresignificantlygreaterthanthosefoundinmost
rehabilitaonfaciliesandarealmostaquantumleapformanyclientswithabraininjury.
However,manyclientscanmakethetransionifitoccursslowly.Forexample,onemethod
mightbeginbyplacingtheclientinavolunteerposiononapartmebasis,thengradually
transferringhim/hertoapart mejob,andulmatelytoafullmejob,allunderthedireconof
acommunityreentryspecialist.Anynumberofvariaonsofthistechniqueispossible.Thekeyis
tointroduce
new
demands
insmall
enough
increments
forthe
client
tohandle.
Another
advantageofgraduatedplacementsistoincreaseaclientsawarenessthataddionalskillsare
neededbeforefullmecompeveemploymentcanbeseriouslyconsidered.Professionalshave
foundthatclientswhoworkonatrialbasisinthecommunityoenreturnwithnewawareness
oftheobjecvesoftherehabilitaonprogram.Theybecomeawarethattreatmentsuggesons
madebytherehabilitaonprofessionalmayindeedbenecessaryforsuccessfulvocaonal
funconing.Atemporaryplacementcanbeusedtoimproveappropriateworkbehaviors.
Frequently,clientswilldemonstratemarketablevocaonalskillsbutwilldisplaybehaviorsthat
wouldresultinjobloss.Fortheseclients,avolunteerworksitewithrealworldsupervisorshas
provenbeneficial. Oentheclientmorereadilyacceptssupervisorycricismfromsomeone
outsidetherehabilitaonfacility.
SupportedEmployment
Supportedemploymentisaspecialtypeofplacementthatallowsforconnuedtreatment
throughouttheVRprocessandhasprovenbeneficialforclientswithbraininjury. Itisdefinedas
compeveworkinanintegratedworksengwithongoingsupportservices.Theadvantagesof
usingasupportedemploymentapproachwithclientswithabraininjuryaremany:
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Itrestorestheclientsidentyasaworkerandprovidesfinancialcompensaonforreal
work.
Theplaceandtrainapproach,asopposedtothemoretradionaltrainandplaceVR
model,allowsforimmediatereentryintoarealworksengandisthebestwayforthe
clientwithabraininjurytolearnworkskillsandappropriateworkbehaviors.
ItenablesVRstafftoassessandremediatecogniveandbehavioraldeficitsinthereal
workseng.
ItallowsVRstafftodevelopcompensatorystrategiesforthespecificjobtasksthatare
assigned.
Itallowsonsiteadvocacyandintervenonwiththeclientssupervisorwhen
problemsoccur.
Manypeoplewithbraininjuryneedthelongterm,ongoingsupportthatsupportedemployment
providestobesuccessfulonthejob.Whenstarnganewjob,theclientneedsassistancelearningjobtasks,developingcompensatorystrategies,andadjusngtothenewroune.As me
goeson,jobresponsibilies,supervisorsand/orcoworkerschange.Thepersonwithabraininjury
mayhavesignificantdifficultyadjusngtothenewsituaonorlearningnewrounes.Without
periodicoversightfromthesupportedemploymentteam,thepersonmaybeterminatedbefore
realizingthataproblemexists.
UseofaJobCoach
Aprincipleunderlyingthemeofsupportedemploymentistoprovideongoingsupportatthejob
sitetohelpclientsfunconinanintegratedworkseng.Thepersonwhoprovidesthissupportis
oencalledajobcoachorjobcoordinator.Thisindividualprovidesongoingsupportaslong
asneeded.Astheclientlearnsthejob,thecoachwillspendless meinonthejobsupport.
Ongoingsupportmayincluderetraining,jobmodificaonsandmeengswithsupervisorsandco
workers.
Ajobcoachisoenvitaltothesuccessfulplacementofclientswithbraininjuries.He/shemust
beawareofthestrengthsandweaknessesoftheclientandwhat,ifany,compensatory
techniquesareusedbytheclienttoovercomecognivedeficits. Thejobcoachmayneedto
developspecificstrategiesatthejobsitetoassisttheclientinperformingtheessenal
componentsofthejobandmonitoringworkbehaviors.He/shemustalsobeabletointerveneif
problemsariseatthejobsite.
Itisessenalthejobcoachfunconasaneducatoroftheemployerandotheremployeesatthe
site.Onecannotemphasizetoostronglytheneedtoeducateemployersaboutbraininjuryin
generalandaboutthespecializedneedsoftheindividualclientinparcular.Forexample,the
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employerhastobeawareofthestrengthsandneedsoftheclienttoavoidunrealisc
expectaonsorrequiringmorethantheclientscapabilieswillallow.
Thejobcoachisalsoinanidealposiontosetupnaturalsupportsatthejobsitetoincrease
theclientschanceforsuccess.Thejobcoach,withtheapprovaloftheclient,canenlistthehelp
ofwillingcoworkersandmanagerstoprovidesupporttotheclientasneeded.Thisinvolveseducangtheselectedcoworkerand/ormanageraboutthetypesofcompensatorystrategies
thatcanhelptheclientbestperformhisjob,andteachingthemhowtocuetheclientto
implementthesestrategiesasneeded.Theseindividualsshouldalsoknowtocontactthejob
coachwithanyquesonsorconcerns,parcularlyiftheyseeadeclineintheclientsjob
performance.
TheRoleoftheJobCoach
1. Establishtrust
Establishrelaonshipswiththeclient,thefamily,andtheemployerthatarebased
ontrustandhonesty.
2. Respectothers
Respectthevaluesandinterestsoftheclient,thefamily,andtheemployer.Always
maintainarespeculdemeanor.
3.Communicate
Constantcommunicaon,bothoralandwrien,withtheclient,familyand
employeriskeytosuccess.Donttakeanythingforgrantedwriteeverythingdownandsharetheinformaonwithallpares.
4.Evaluateskillsandbehaviors
Performsituaonalassessmentsinavarietyofenvironmentsandusingavarietyof
taskstounderstandtheclientsstrengthsandweaknesses.Evaluatewhattypeof
compensatorystrategiesworkbest.
5.Makegoodjobmatches
Findajob
that
meets
the
interests,
abili
es,and
tolerance
level
ofthe
client.
6.Doathoroughjobanalysis
Learneverythingaboutthedemandsofthejobsbeforeplacement.Reviewyour
findingswiththeemployertoensurethatthejobtasksareunderstood.Provide
everythingtotheemployerinwring.
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7.Establishastructuredworkdayanddependableroune
Unplannedchangesinjobduescanprovedisastrousforapersonwithabrain
injury.Educateemployersabouttheneedtomakechangesslowlyandin
consultaonwiththejobcoach.
8.Developcompensatorystrategies
Developcompensatorystrategiesthatworkfortheclientinperformingthejob
tasks.Astheclientbecomesfamiliarwiththejoborasjobtaskschange,make
adjustmentstothestrategies.
9.Bewatchfulofbehavioralissues
Inappropriatebehaviorscancausemajorproblemsonthejob.Useacollaborave
approachtoidenfybehaviorsthatneedtobemodifiedandenlistthecooperaon
ofthe
client
tomake
necessary
changes.
10.Monitorstamina
Faguecaninterferewithjobperformance,memoryandbehaviors,especiallyona
newjob.Workwiththeemployertoadjustworkschedulesasneeded.
11.Providelongtermsupports
Longtermfollowalongservicesforclientswithbraininjuryareessenaltomonitor
performancelevelandprovideintervenonasneeded.Encouragetheclientandthe
employertocontactthejobcoachatthefirstsignofaproblem.
JobPlacementConsiderations
ThefollowingstepsshouldbetakenbytheVRcounselorpriortoplacingaclientwithabrain
injuryonaworksitetoavoidaninappropriatematchandasituaonthatpotenallysetsthe
clientupforfailure.
Selectivity
Theplacementmustbeconsistentwiththeclientscognive,physical,andpsychosocial
strengthsandweaknesses.Moreover,theclientsinterests,abiliesandaptudesmustalsobe
considered.
JobAnalysis
Thereareavarietyoftechniquesdesignedtoorganizeandevaluateinformaonrelevanttothe
performanceofajob.Fortheclientwithabraininjury,thatanalysismustcontaininformaon
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withrespecttothephysical,emoonal,andcogniveelementsnecessarytoperformthejobat
theobservedsite.Thedemandsofthejobcanthenbecomparedwiththestrengthsand
weaknessesoftheclientpriortoplacement.
PlacementwithEducationandTraining
Theemployerandworksitesupervisorsmustbefullyawareofaclientsstrengthsand
weaknesses.Aninformedsupervisorislesslikelytomisunderstandbehaviorsthatonthesurface
mayappeartobewillfulanddeliberate.Forexample,aflataffectduetoneurologicalfactorsmay
bemisinterpretedasalackofmovaon.Equallyimportantiseducangtheemployerthat
sasfactoryperformanceononetypeofjobdoesnotnecessarilyimplythattheclientshouldbe
promotedtohigherleveljobs.Again,thenewjobshouldbeanalyzedtodeterminewhetherthe
clientiscapableofperformingitsindividualcomponents.
OngoingSupports
Effecveplacementassumestheavailabilityofanongoingsupportsystem.Longterm
coordinaonbetweentheVRteam,theemployerandtheclientisessenaltoensurethat
necessarysupportsfortheclientareinplace.
JobAccommodations
Thekeytoasuccessfuljobplacementistheprovisionofnecessaryjobaccommodaonsandthe
developmentofcompensatorystrategiesatthe metheplacementismade. Eachclientwitha
braininjuryisuniqueandwillrequirestrategiesthataddressthespecificstrengthsand
limitaonsthathe/shepresents.Wheneverpossible,consultwiththerehabilitaonteamandthe
neuropsychologisttoassistinestablishingthebestpossibleaccommodaons.Belowisalistof
accommodaonsthatcanserveasastarngpointinconsideringwhataclientmightneed.
Memory:
Usenotebooks,calendars,orsckynotestorecordinformaonforeasyretrieval.
Providewrienaswellasverbalinstrucons.
Allowaddionaltraining me.
Providewrienchecklists.
Provideenvironmentalcuesforlocaonsofitems,suchaslabels,colorcoding,orbullen
boards.
Postinstruconsoverallfrequentlyusedequipment.
Taperecordmeengs,conversaons,andinstrucons.
Useelectronicorganizers(PDAs,handheldcomputers,voiceorganizers,watches,andcell
phones).AnonlineCatalogofPortableElectronicDevicesforMemoryandOrganizaon
canbefoundontheBrainInjuryAssociaonofAmericaswebsiteatwww.biausa.org/
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pda.html.ThebestresultscomefromusingtheiTouchwhichusespicturesratherthan
morecomplexinstruconsthatfrequentlyarenotrememberedcausingfrustraon.
Othermemorystrategies:
Usemnemonictechniques(anorganizaonalstructureonverbalinformaontocue
recallofseveralelements.)
Example:Aclericalassistantrecallshersequenceofjobduesbyrememberingtheword
CODE.
C=clockin
O=openmail
D=delivermail
E=enterdata
Useimagerytechniques(theprocessofusingmentalpictures/imagesforinformaonto
berecalled.)
Example: Aclericalassistantvisualizesherselfwalkingaspecificroutetoassistin
rememberingtheroutefordeliveringthemail.
Usenumbergrouping(recallingnumbersbyreorganizingthemintofewerelements.)
Example: Aclerkworkingatanautosupplycompanyneedstoremembertopullitemsbasedonafourdigitcode.Helooksatacodingbookandseesfournumberssuchas9,5,
3,2.Insteadofrememberingthenumbersindividually,herecallstheinformaonas95
and32.
Useofverbalrehearsal(repeangoutloudkeyinformaontohelprecallingthe
informaon.)
Example: Adataentryoperatorcomestoworkandsetsupherworkstaonbysaying
aloud:Turnoncomputer.Turnonmonitor.Entermypassword.Hitenter3 mes,etc.
MaintainingConcentration:
Reducedistraconsinworkareas(whitenoisesoundmachinesorlisteningto
instrumentalmusicmaybehelpful).
Providespaceenclosuresoraprivateoffice.
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Reducecluerintheworkenvironment.
Simplifylargeassignmentsbybreakingthemintosmallertasks.
Changelighnginworkarea(eithermoreorlesslightdependingonneeds).
Arrangeforuninterrupted
work
me.
Organizaon:
Makedailytodolistsandcheckoffitemsascompleted.
Useacalendarsystemtomarkmeengsandtaskdeadlines.
Useelectronicorganizers(PDAs,handheldcomputers,voiceorganizers,watches,and
cellphones).AnonlineCatalogofPortableElectronicDevicesforMemoryand
OrganizaoncanbefoundontheBrainInjuryAssociaonofAmericaswebsite:
www.biausa.org/pda.html.
Establishaneffecvefilingsystem.
Planrounemeengswiththesupervisor,reviewworkprogress.
ProblemSolving:
Providewrienschemacsofproblemsolvingtechniques(i.e.flowcharts).
Restructurethejobtodecreasetheamountofproblemsolvingrequired.
Assignasupervisororcoworkerwhoisavailabletoanswerquesonsandreviewwork
progress.
Allowextra
me
toaccomplish
job
tasks