Working Successfully After Brain Injury Jeffrey S. Kreutzer, Ph.D. Virginia Commonwealth University Medical Center

Working SuccessfullyAfter Brain Injury

Jeffrey S. Kreutzer, Ph.D.

Virginia Commonwealth University

Medical Center

Return to Work for Persons with Severe Traumatic Brain Injury:

A Data Based Approach

P. Wehman, M. West, J. Kregel,P. Sherron, & J. Kreutzer

Virginia Commonwealth UniversityMedical Center

Employment Data Base

Wages and Weekly Hours

all 87 persons were placed 27% were placed into a second

position for both first and second placement

– mean hours worked per week = 31– mean hourly wage = $5.12– mean gross monthly salary = $674


Employment Status

months following program initiationn=87 Employment Data Base

Job Stabilization

staff maintenance time falls below 20% of client’s weekly hours

maintenance rate remains below 20% for 4 consecutive weeks

funding and oversight shifted from rehabilitation agency to extended services funding agency


Service Delivery IntensityMean Values

I IIpre-placement intervention hours 32 37weeks to stabilization 15 20intervention hours placement to 127 139stabilizationweeks employed 37 40weekly intervention hours for extended 2 1servicestotal intervention hours for 47 40extended services

PlacementEmployment Data Base

Staff Intervention Time

0

20

40

60

80

100

1 4 7 10 13 16 19 22 25 28 31 34 37

as a percentage of hours worked by the client

Weeks Following Placement

Nine had been separated from two jobs Months employed before separation = 5.8

avg. Most separations occurred during first 6

months following placement Positions included semi-skilled and

unskilled positions, e.g., clerical, sales, warehouse stock

Nine had been separated from two jobs Months employed before separation = 5.8

avg. Most separations occurred during first 6

months following placement Positions included semi-skilled and

unskilled positions, e.g., clerical, sales, warehouse stock

Analysis of Job Separationsfrom Supported Employment

Analysis of Job Separationsfrom Supported Employment

... 38 separations, from a total of 78 placements by 29 clients... 38 separations, from a total of 78 placements by 29 clients

Journal of Head Trauma Rehabilitation

Primary Reasons for Separation


Layoff - employer related financial difficulties

Interpersonal issues with colleagues and supervisors - social cue misinterpretations, task and non-task related conflicts, verbal sexual and aggressive behavior

Employment setting - change in supervisor or duties, poor match with client’s ability and interest, perceived lack of upward mobilityJournal of Head Trauma Rehabilitation



Mental health - psychological, criminal, or substance abuse difficulties

Other - poor attendance, low motivation, transportation difficultiesIn one case, a client in litigation resigned on

the advice of his attorney to gain a larger settlement


Separation Analysis MethodologySeparation Analysis Methodology

Identify all separations

Obtain information from employment specialist based on direct observation, interviews with client, co-workers, and supervisors

Corroborate by review of incident reports, case notebooks, employer evaluations, records

Organize data thematically and summarize

Grounded theory qualitative approach:Grounded theory qualitative approach:


Primary Contributorsto Job Separations


Factors Contributing to Job Separations

0 10 20 30 40 50 60

Proportion of Separations

Economic Layoff

I nterpersonal

Employment Setting

Mental Health

Other


Common Things Workers

Say After A Brain Injury “Even though I’m a mess, I still

have to support my family.” “I used to make $28/hour. Now,

the only job I can get pays $6.50.”

“I’m not sure what I can do, but I have to do something.”

Some helpful ideas…..

Key PointSuccessful Return to Work

Employers value a “good attitude”

Responsiveness to feedback is critical

1 2 3 4 5

notimportant

veryimportant

Qualities That Count With Employers

NY Times Service

When you consider hiring a new non-supervisory or production worker, how important are the following in your decision to hire?


Factor Rankattitude 4.6communication skills 4.2work experience 4.0recommendations from current employees 3.4industry based credentials certifying skills 3.4

NY Times Service


Factor Rankyears of schooling completed 2.9scores on tests as part of interview 2.5academic performance - grades 2.5reputation of applicant’s school 2.4teacher recommendations 2.1

NY Times Service

Key PointSuccessful Return to Work

Many employers don’t give feedback until after a crisis or prolonged performance downturn

Tips for Being Productive

Find a mentor Try to be sensitive when

you are having difficulty and ask for feedback.

Help others to give you constructive feedback.

Help Others to Give You Helpful Feedback

Explain how their feedback can help you get better.

Explain how feedback can help you avoid mistakes, failing, and feeling frustrated.

Remind people that you want to know about the good as well as the bad.

Demonstrate receptiveness, avoid defensiveness.

Show your willingness to change.


Learn effective and comfortable ways to ask for help.

Asking for help ...

lets others know you care about your performance

shows recognition of your limitations provides an opportunity to build

relationships with helping people gives you a chance to be part of a

team allows you an opportunity to reduce

your frustration, and to be and feel more effective


Avoid the challenge of hiding your injury.

Learn what to tell people who ask you about going back to work.

Learn what to tell people about your brain injury.

Tips for Being Productive Recognize and avoid the trap of

doing too much. Cut down on responsibilities outside

of work for at least 4-8 weeks after starting a job.

Begin with a part-time schedule, build more hours as you feel comfortable.

The Best Way to Protect Your Job for the Long Haul

honestly acknowledge your limitations

convey reasonable expectations

tell people that you are not yet back at 100%

show a good attitude and give good effort

Helping Clients Keep Jobs

A Problem-Focused Approach to Intervention

Jeffrey S. Kreutzer, Ph.D., ABPPVirginia Commonwealth University,

Medical Center

Physical ProblemsFatigue, Slowness, Difficulty Lifting

promote sleep hygiene provide sleep medications schedule regular breaks work during periods of peak energy complete challenging tasks during

peak energy periods


Physical ProblemsFatigue, Slowness, Difficulty Lifting

organize work environment for efficiency

encourage pacing and adequate time for transition between tasks

comply with schedule and weight restrictions

set realistic timelines for task completion


Cognitive ProblemsPoor Attention and Concentration

work on one task at a time minimize noise and distractions work slowly and regularly check

work use self-talk to improve focus for incomplete tasks, keep a

record of where client left offHelping Clients Keep Jobs

Cognitive ProblemsSlow Learning, Forgetfulness

list and review steps for task completion

encourage rehearsal, paraphrasing, use of imagery, mnemonics

use memory notebooks, calendars, checklists, alarms, “to do” lists


Cognitive ProblemsSlow Learning, Forgetfulness

tape record instructions for later playback

emphasize learning by doing break tasks down into small steps,

introduce new steps with mastery


Cognitive ProblemsCommunication

encourage use of paraphrasing speak slowly and ask others to do

so seek clarification to avoid

misunderstandings


Cognitive ProblemsCommunication

model optimal listening and speaking skills

ask others to simplify, clarify instructions

use synonyms, descriptions when word finding problems encountered


Cognitive ProblemsSlow Processing

divide complex tasks into smaller, simpler components

allow ample time for learning and task completion


Cognitive Problems -Planning and Organization

assist in mapping out strategies monitor performance,

encourage self-monitoring use an alarm as a cue for

error checking and review teach structured

problem solvingHelping Clients Keep Jobs

Major Depressive Disorder Symptom Domains

Mood depressed

mood diminished

interest or pleasure

feelings of worthlessness

Somatic weight change sleep

disturbance psychomotor

retardation oragitation

decreased energy

Cognitive diminished

thinking ability recurrent

death thoughts

Proportion of Patients ReportingSymptoms in Five or More

Categories

N = 722

total = 42%

Major Depression Following Traumatic Brain Injury

Conclusion Major depression is a frequent

complication of TBI that hinders patients recovery. It is associated with executive dysfunction, negative affect, and prominent anxiety symptoms.

Jorge, Robinson, Moser, Tateno, Crespo-Facorro, & Arndt, Archives of General Psychiatry, 61, Jan 2004.

Psychiatric Illness Following TBI in an Adult HMO Population

Results Prevalence of any psychiatric illness

in the first year was 49% following moderate to severe TBI, 34% in the comparison group.

Fann, Burington, Leonetti, Jaffe, Katon, & Thompson, Archives of General Psychiatry, 61, Jan 2004.

Personality and Mood Problems -

Argumentativeness, Anger Control self-monitoring assertiveness training anger management, conflict resolution,

impulse control training frequent, constructive feedback model good anger management and

conflict resolution skillsHelping Clients Keep Jobs


Depression and Anxiety self-monitoring stress and mood stress management, relaxation

training rank order priorities, and focus on

highest priority(ies) recognize the dangers of overly

ambitious expectations, goalsHelping Clients Keep Jobs


Depression and Anxiety develop reasonable goals,

expectations seek outside support and

mental health services regularly provide constructive

feedback


Personality and Mood ProblemsImpersistence, Amotivation,

Adynamia mutually establish goals

and monitor progress incorporate reinforcement systems develop task completion time

frames considering client’s personality

closely monitor performanceHelping Clients Keep Jobs


Interpersonal social skills, communication training self-monitor, solicit feedback role play effective ways to handle

challenging situations provide frequent,

constructive feedback model good interpersonal skills


Relationship BuildingBetween Job Coach and Client

solicit information about client’s goals, interests, expectations

appreciate history of failures, successes

emphasize client’s rolein decision making


Relationship BuildingBetween Job Coach and Client

identify skills, strengths, and their relationship to work success

facilitate development of achievable goals

help client appreciate workplace rules and expectations

help anticipate and avoid problems


Evaluate Work Environments

identify and address health and safety concerns

observe co-worker interactions inquire about job satisfaction

and turn-over identify workplace supports identify potential barriers to success


Provide On-Site Assistance

facilitate adjustment to employment develop and use compensatory

strategies for cognitive impairments identify and address

interpersonal problems apply stress,

anger management skills


What to Tell People About Your Injury

Lee Livingston, Jeff Kreutzer, & Laura TaylorVirginia Commonwealth University

Medical Center

Have People Asked You Questions Like These?

“How did the accident happen?”

“What’s wrong with you now? Why aren’t you working?”

“When can you start driving again?”

“Why do you stay home so much?”

“Will you ever be back to normal?”

Why People are Uncomfortable Talking About

Their Injury Talking about your injury may

bring back painful memories.

Your answer may be a painful reminder that your life used to be much better.

You may feel embarrassed or guilty because you are not working.

Why People are Uncomfortable Talking About

Their Injury You may feel frustrated if you can’t drive

or do things that you used to.

Questions may bring up fears and concerns about the future.

You may also worry about what other people will think about you.

What to Watch Out for When Talking About Your Injury

Feeling mad or frustrated

Giving away too much personal information

Painful memories

Going out of your way to avoid people

Reasons to be Cautious When Talking About Your Injury

Many people have negative stereotypes or don’t know much about disabilities.

They may confuse brain injury and mental retardation.

They may be afraid you’ll have a seizure, pass out, or attack somebody.

They may think people with disabilities are helpless.

Reasons to be Cautious When Talking About Your Injury

Others have bad opinions of people who don’t work or collect disability benefits.

They may think people with disabilities are lazy and don’t want to work. They may think you’re faking your injury to get benefits.

You may worry others won’t keep your information private.

When Deciding Who To Talk to and What to Say About Your

InjuryAsk yourself…..

Is this the right time or place to talk about my injury?

How well do I know this person? What’s my relationship with them?

What do I feel comfortable with them knowing?

When Deciding Who To Talk to and What to Say About Your Injury

Ask yourself…..

Do I trust this person with this personal information?

Will this person use the information in a way that might hurt me?

How would I feel if this person told other people that I am not very close to?

When Deciding Who To Talk to and What to Say About Your

InjuryAsk yourself…..

What is this person really trying to find out about me?

Will I look bad if I share details about my recovery?

Could information I share affect my job, school, or relationships?

Things to Think About Before Responding to People’s

Questions Remember you can make choices

about what to tell people about your injury.

Only tell people what they need to know and what you feel comfortable telling them.

Keep your answers short, simple, and to the point.


Questions Remember you can always change the

topic to something you feel more comfortable talking about.

Politely decline answering or give little information if you do not feel comfortable talking about your injury.

Talk to other survivors about how they deal with difficult questions.


Questions Tell people you trust what you would like to

say about your injury and get their reactions.

Make a list of the questions you find the hardest to answer. Talk to trusted family and friends about ways to answer the questions. Practice saying the answers ahead of time.


Questions Disclose the most personal information

only to people you really trust – like family, close friends, doctors, and therapists.

Before giving out personal information, ask the other person to agree to keep what you say in confidence.

Ways You Can Respond To Specific Questions

Q: “What happened?” A: “I was in an accident a while ago.”

Q: “What type of medical care do you need?” A: “I see my doctors every now and then.”

Q: “How much longer will you need treatment?” A: “My doctors are helping me recover as quickly as possible.”

Ways You Can Respond To Specific Questions

Q: “What are your current symptoms?” A: “I tend to get tired easily.” (or) “I have to pay attention to things more carefully now.”

Q: “How are you doing now?” A: “I’m getting better slowly but surely.”

Q: “When will you be able to come back to work?” A: “We’re working on a plan right now; I hope to know soon.”

Remember most people who ask about your injury are people who care about

you. Think about that before

you reply.

Productivity Options

Jeffrey S. Kreutzer, Ph.D., ABPPVirginia Commonwealth University

Medical Center

Meals and wheelsPartners form team for special deliveries

By Bill LohmannRichmond Times-DispatchTuesday, May 12, 1998

Ken Hearns and David Stevens are, in the great tradition of dynamic duos, a perfect team. Hearns is an amputee, having lost his right leg; Stevens still lives with the effects of a serious brain injury. Neither can work full-time jobs any longer, but both wanted to give something to the com-

unity by volunteering for Meals on Wheels. Separately, each was a puzzle without all the pieces. Together as partners, they form a complete picture. And have a good time doing it. Hearns drives. Stevens delivers. “I’m wheels,” Hearns said, “and he’s meals.”

Their work has not gone unnoticed. The pair were chosen as Richmond-area winners of the annual Meals on Wheels Volunteer of the Year Award and were top 10 finalists among more than a million volunteers for the national award. Hearns and Stevens will be honored at a ceremony tomorrow.

The award is sponsored by ProjectMeal Foundation and Reynolds Metals Co, which will donate $1,000 in their names to Meals on Wheels of Greater Richmond.

Hearns, 49, and Stevens, 42, work two days a week out of the New Covenant Church distribution center in Chesterfield County.

Hearns pulled his modified minivan - with the left foot gas pedal - into the church parking lot yesterday morning. He ambled into the church on crutches and the first thing Stevens did was hop up and go get him a cup of coffee.

“I couldn’t be involved if it weren’t for Ken and visa

versa,” said Stevens, who is unable to drive because of his brain injury. “It’s a teamwork situation.”

Hearns and Stevens did not know each other before they were paired by officials at Meals on Wheels, which delivers food to the sick or disabled who can’t prepare or buy their own meals.

That was less than two years ago. Now they are friends who often go out to lunch after a morning of deliveries. Hearns also gives Stevens rides to other places - the American Red Cross and the YMCA, among them - where Stevens volunteers.

Hearns, who lost part of his leg to infection 13 years ago and the rest of it in 4 years ago, has a personal purpose for volunteering. His elderly mother-in-law had received home delivered meals and he wanted to return the favor.

Typically, Hearns and Stevens start their Meals on Wheels Work at midmorning. Stevens sorts the food, while Hearns plots the delivery route that usually includes a dozen or so stops. Stevens hustles the cooler and bags to Hearns minivan - and the two men take off.

Hearns and Stevens engage in some friendly give-and-take along the way. Although Stevens usually moves quickly in making deliveries, he sometimes stays to chat if the recipient wants to talk.

On cool days that’s fine, Hearns said. On hot days though, with the sun beating down on his green minivan, Hearns has been known to honk the horn to encourage Stevens to get a move on.

“They’re a lot of fun,” said Beth Sacher, site director of the meals program at New Covenant.

“They are very, very devoted to Meals on Wheels.”

As for the award, Hearns calls it “mind boggling.” Said Stevens, “It’s nice to be recognized. But this is such a nice opportunity to help others.”

Therapeutic Curriculum

4. Evaluate the costs and benefits of working

5. Identify viable productive activities as an alternative to work

6. Evaluate the costs and benefits of additional training or schooling

The Costs of Working

Transportation, clothing, child care, taxes

Exhaustion and isolation Decline in physical and mental

health Harm to relationships by

“taking it out” on others Loss of disability benefits and

leisure time

Brain Injury Work SurveyYes, No, or Not Sure? Do I want to work? Do I need to work? Am I able to work? Do I know what my strong and weak points

are? Do I want to go back to my old job? Do I know where to look for work? Will I need help learning or doing my old job

when I return to the workplace?

Well Adjusted Long-Term Survivors

Focus more on what they have and less on what other people have

Readily acknowledge personal limitations

Learn to appreciate unpaid activities such as visiting, cooking, gardening, housekeeping, and hobbies

Well Adjusted Long-Term Survivors

Give up trying to be the same person they were before the injury

Don’t get angry at themselves for not doing better

Set attainable goals and build on a foundation of success

Recovery Extension Principles

Develop more effective strategies for doing things

Stop doing things that don’t work Focus on primary goals, monitor

progress, stick with plans that work

See what works for others and what doesn’t

Recovery Extension Principles

Listen to other people’s ideas Exercise your body and mind Learn from mistakes Ask people that care

about you to give feedback

Ideas for Learning Library visits College and high school programs Read newspapers and magazines Surf the web and visit educational

sites Visit parks, museums, historical sites Visit stores that offer educational

demonstrations

Therapeutic Curriculum

Consider the benefits of volunteer work

Understand the types of available vocational services

Identify vocational goals and the potential benefits of vocational services

The People Who Don’t Work QuestionnaireTrue or False?People who don’t work ….

- are lazy- would rather live off other people- are stupid- are worthless- have no faith or values- are mentally ill- are dirty

Volunteer Work

Unpaid, meaningful, diverse work opportunities

Often transitional Placements - schools, health and

rehabilitation organizations, churches, and charities

Based within community agencies, promoting integration

Volunteer Work Situational assessment

opportunities Low cost training provided

by host agency In vivo stress management

and inoculation Difficult to arrange long-

term professional supports

Bad spill saved cyclist’s lifeNow he’s honorary chairman of ride to benefit charity

By Alberta LindseyRichmond Times-DispatchSunday, May 14, 2000

“He was sprawled in the road”

About 2 miles from the end of a 25-mile fund-raiser ride, he sprinted ahead of his friends. Then others started passing him. His arms were tired as he went up the final hill.

‘I thought I could manage the bike with my elbows, I lost control of it,’ said Mike, a fund raising coordinator for a local charity. ‘When I saw the front tire go sharply to the right, I knew I was going down.’

“He was sprawled in the road”His friends around

him couldn’t understand what happened. There were no potholes, no boulders, no apparent reason for the fall, Mike recalled this week.

One side of his helmet was crushed. His shoulder, knee, and wrist hurt.

‘I could only see straight ahead over my nose, but not to the sides. I knew that was a concussion… Thoughts were bouncing around in my head, disjointed and uncontrolled.’

“We see something”

He went to the hospital. After a CT scan, he said a physician told him: ‘It’s fortuitous that you came to us today. For today’s incident, you are fine. We see something else. You have a cyst in the middle of your brain.’

Two weeks after the bike spill, he underwent surgery to remove the cyst. He was in the hospital six days and recuperated six days at home. Four months after the accident, he was bike riding again.

Offered to help

The Lions Club will have another Country Roads Bike Ride on June 11. Not only will Mike ride this year, he will also serve as honorary chairman.

“Everything we do is for charity… Mike was so enthusiastic about the ride saving his life. He offered to help in organizing this year’s ride. He’s given us lots of help in getting out mailings.”

Offered to help

Proceeds will benefit Richmond area ARC and Lions Club programs such as Leader Dog, Inc., the Old Dominion Eye Bank and Hearing Aids for the Needy.

Mike said, “The experience was so incredible, I wanted to use if for some kind of good.”

Whether or Not You are Working You Can Succeed

Be patient and persistent. Get better by learning and

trying. Create or find a supportive

environment. Live according to

your good values. Define success in your own

terms.

Box 980542, Richmond, VA 23298-0542USA PH 804 828-9055

Jeff Kreutzer [email protected]

Virginia Commonwealth UniversityMedical Center

The National Resource Center for Traumatic Brain Injury www.neuro.pmr.vcu.edu

Documents

Working Successfully After Brain Injury Jeffrey S. Kreutzer, Ph.D. Virginia Commonwealth University Medical Center