Oslo: October 2011
3. Preparation for alternative work
after brain injury
Dr. Andy Tyerman
Consultant Clinical Neuropsychologist / Head of Service
Community Head Injury Service,
Buckinghamshire Healthcare NHS Trust ,
The Camborne Centre, Aylesbury, Bucks. HP21 7ET, England
[email protected]
VA&R–PwLTNC–RfBP :
Referral for vocational rehabilitation (VR)
When a need for vocational rehabilitation ….. is identified
people with a neurological condition should be referred to a
vocational programme appropriate to their needs.
People with complex vocational needs should be referred
(whenever possible) to a specialist programme for people
with a neurological condition in accordance with Quality
Requirement 6 of National Service Framework for Longterm Conditions (Department Health, 2005)
(BSRM, 2010)
VA&R–PwLTNC–RfBP
Preparation for alternative work:
• referral for VA & VR appropriate to individual needs incl.
specialist programmes for those with complex needs
• proactive advice/support from specialist practitioners to
pan-disability providers to explain needs (esp. when risk)
• proactive monitoring of people with complex needs on pandisability programmes
• recommended components of specialist VR (incl. voluntary
work trials and supported placements and ongoing support)
• need for neurological & vocational rehab. expertise/training
(BSRM, 2010)
VA&R–PwLTNC–RfBP : Pan-disability provision
When .... a person with substantial or complex needs has
been referred to a pan-disability programme …… consent
should be sought from the person to contact the relevant
adviser or provider to explain the vocational needs of the
individual and to discuss the most appropriate provision.
When a practitioner is concerned that a course of action
poses a risk to the health or well-being of the person or
any third party, this should be brought to the immediate
attention of the adviser/provider and confirmed in writing.
(BSRM, 2010)
VR–PwLTNC–RfBP: Sharing information
It is usually in the person’s best interests for relevant
background clinical information to be shared and
assessment results pooled across agencies to avoid
duplication and to facilitate full assessment and appropriate
recommendations..... subject to informed consent.
If health professionals have concerns about the risk of
misunderstanding of clinical information they should liaise
directly with the agency undertaking the assessment, supply
additional information by way of clarification and/or attend
the initial assessment of that agency.
(BSRM, 2010)
Vocational rehabilitation
ABI VR programmes should include provision for:
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education / discussion about ABI and work
strategies to manage difficulties in workplace
graded work-related activities (work tolerance/confidence)
vocational counselling to identify suitable job role
psychological therapy to promote coping and adjustment
work tasters to sample alternative avenues of occupation
provision for voluntary work trials / permitted work
assisted job selection, search, application, interview
provision for supported work placements
(BSRM / Jobcentre Plus / RCP, 2004)
ABI: Voluntary work trials / supported placements
• In setting up trials / placements providers need to ensure that:
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requirements of the job match the skills of the client.
needs of the client are communicated to the employer.
Health & Safety, training & insurance provided by employer.
provision for on-site job coaching, when required.
client guided/supported in adapting strategies to workplace.
placement monitored closely – client, employer & relative.
trial does not impact negatively on person or the family.
+ Long-term placements monitored for at least 6 months + F/U
(BSRM / Jobcentre Plus / RCP, 2004)
Working Out Programme - Aims
• To assess vocational needs and potential.
• To provide specialist rehabilitation programmes to
enhance vocational potential.
• To set up and evaluate voluntary work trials to prepare
persons for a return to productive occupation.
• To find, set up and support suitable long-term work
placements.
• To provide specialist job retention interventions for
people in work, education or training.
Working Out Programme (2010)
Community Head Injury Service, Aylesbury
JOB
RETENTION
INITIAL
ASSESSMENT
WORK
PREPARATION
(REHAB. TEAM RETURN TO WORK)
FULL VOCATIONAL
ASSESSMENT
JOB RETENTION
ASSESSMENT
WORK
PREPARATION
JOB RETENTIONS
INTERVENTIONS
VOLUNTARY
WORK TRIAL
ONGOING
REVIEW / SUPPORT
SUPPORTED
PLACEMENT
Working Out: Vocational assessment 1
• Initial assessment (client & relative)
-
Personal, family, social & work history
Clinical history & rehabilitation
Current problems (self & relative)
Self-concept, anxiety / depression
• Formal assessments
- Neuropsychological Assessment
- Occupational Therapy Assessment
- Other assessment (i.e. medical, physiotherapy & speech
& language), as required
Working Out: vocational assessment 2
• Practical assessments
-
Worksite observation / feedback - employers
Feedback from previous jobs / placements
Work preparation group
Community vocational rehabilitation activities
Individual project work and/or
• Vocational rating scales (self & staff):
- Functional Assessment Inventory
- Work Personality Profile
• Vocational guidance assessment
Functional Assessment Inventory (FAI)
• 30 items of vocational strengths & weaknesses rated ‘0’
(normal/average) to 3 (severe impairment) across 7 factors:
 Adaptive Behaviour
 Motor Functioning
 Cognition
 Physical Condition
 Communication
 Vocational Qualifications
 Vision
• standardised on 1716 persons with disability attending vocational
counsellors in the USA
(Crewe & Athelstan, 1984)
Functional Assessment Inventory: CH
Percentile
100
75
50
25
Self rating
Staff rating
0
Behaviour
Motor Cognition Phys.C. Commun. VocQual
Vision
Work Personality Profile (WPP)
• 58 items - 'work attitudes, values, habits & behaviours' rated
from ‘4’ (a definite strength, an employability asset) to ‘1’ (a
problem area which will definitely limit ... employment)
• Five factors:
 Task Orientation
 Social Skills
 Work Motivation
 Work Conformance
 Personal Presentation
• standardised on 243 persons with disability attending for
vocational rehabilitation in the USA.
(Bolton & Roessler, 1986)
Work Personality Profile : CH
100
Percentile
75
50
25
Self rating
Staff rating
0
Task Orient.
Social Skills
Motivation Conformance
Presentation
CHIS Working Out Programme (2010)
VOCATIONAL
ASSESSMENT
WORK PREP.
GROUP
COMMUNITY
VOC. ACTIVITIES
EDUCATION
PROGRAMME
COGNITIVE
REHAB. GROUP
IND. / GROUP
PROJECT WORK
PSYCHOLOGICAL
SUPPORT GROUP
VOCATIONAL
COUNSELLING
PSYCHOLOGICAL
THERAPY
VOLUNTARY
WORK TRIAL
EDUCATION /
TRAINING
PLACEMENT
SUPPORT GP.
JOB SEARCH /
JOB CLUB
SOCIAL
ENTERPRISE
PLACEMENT
SUPPORT/REVIEW
LONG-TERM
PLACEMENT
SUPPORT FOR
EMPLOYER
Work Preparation Group – Aims
• To help people to re-evaluate their strengths and
weaknesses after brain injury.
• To consider the implications of brain injury for reemployment (and re-training).
• To explore issues relating to brain injury and
interpersonal skills in the workplace.
Vocational rehabilitation activities
• Group activities with voluntary agencies
(e.g. Workaid, Waddesdon Manor, Oxfam Milton Keynes Hub)
• Individual projects in the workplace
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Objectives:
To facilitate further recovery and adjustment
To develop and evaluate coping strategies for work
To assess work potential
To promote more accurate self-appraisal
To foster positive work attitudes and behaviours
Vocational counselling
• Help clients to develop a clear understanding of:
- vocational interests, aptitudes and resources
- vocational limitations arising from brain injury
- current vocational opportunities and prospects
• Explore realistic future vocational direction:
- careers guidance
- job matching
- discussing voluntary work trials (and job tasters)
Brain injury education programme
(15 X 2 hr. sessions)
• To increase awareness and understanding of nature and
effects of traumatic and other forms of acquired brain injury:
1. Brain function/ brain injury
3. Sensory deficits
5. Cognitive – executive
7. Behavioural difficulties
9. Personal adjustment
11 Leisure & social difficulties
13/14 Videotape case examples
2. Physical disability
4. Cognitive difficulties – general
6. Communication difficulties
8. Emotional difficulties
10. Vocational adjustment
12. Family adjustment
15. Brain injury services
Cognitive rehabilitation group
(10 X weekly 2 hr. sessions)
• To educate clients about their cognitive difficulties and
how to manage them:
– attention, memory, executive skills, communication
• To provide a supportive environment in which clients can:
– share coping strategies
– practice and improve group communication skills
• To highlight long-term rehabilitation needs
Psychological support group
(One hour weekly for 6 months)
• To provide a contained weekly space for clients to
work together to support their adjustment, coping
and social relationships post-injury
• For group members to draw on relationships with
others with the input of the facilitators to increase
awareness of difficulties and interpersonal patterns
Psychological therapy
• Neuropsychological counselling : e.g.
- Education, advice & support
- Awareness, understanding & coping strategies
• Specific psychological treatment : e.g.
- Anxiety, anger or pain management
- Managing mood & behaviour difficulties
• Neuropsychotherapy : e.g.
− Exploring/reconciling changes in self & life
− Re-constructing ‘new’ self & plans post-injury
CHIS Working Out Programme (2010)
VOCATIONAL
ASSESSMENT
WORK PREP.
GROUP
COMMUNITY
VOC. ACTIVITIES
EDUCATION
PROGRAMME
COGNITIVE
REHAB. GROUP
IND. / GROUP
PROJECT WORK
PSYCHOLOGICAL
SUPPORT GROUP
VOCATIONAL
COUNSELLING
PSYCHOLOGICAL
THERAPY
VOLUNTARY
WORK TRIAL
EDUCATION /
TRAINING
PLACEMENT
SUPPORT GP.
JOB SEARCH /
JOB CLUB
SOCIAL
ENTERPRISE
PLACEMENT
SUPPORT/REVIEW
LONG-TERM
PLACEMENT
SUPPORT FOR
EMPLOYER
Voluntary Work Trials
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•
•
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•
Provide:
Independent assessment of work potential.
Identification of difficulties in workplace.
Development/evaluation of coping strategies
Re-establishment of work routine / behaviours.
Graded increase in work stamina / tolerance.
Supervised re-building of confidence.
Independent reference for job applications.
Placement Support Group - Aims
• To provide a personnel / welfare function for clients in
work trials / supported placements.
• To help clients to understand and cope with the
complexities of world of work after brain injury.
• To facilitate adjustments required to maximise and
maintain work trials and supported placements.
Supported Placement
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Job search and application (+ job club)
Job selection, set up and induction
Education for employers / employees
Monitoring – client / family / employer
Coping strategies in the workplace
Work adjustments – duties / hours
Placement support group
Individual off-site support / therapy
Formal reviews and trouble-shooting
Long-term follow-up
Example C - Background
• Education history:
– Grammar school up to 18 years
– 4 O levels + 1 A level (Metalwork)
• Occupational history:
– Making guitar strings (mons.) / clerical job (mons.)
– At 18 years joined RAF – 9 years:
• Aircraft Mechanic – Weapons
• Progressed to Junior Technician
• Recommended for promotion to Corporal
C: Motor cycle accident (aged mid 20s)
• Injuries:
– Severe TBI (Post-traumatic amnesia 3-4 weeks)
– # T5 & T6 + neck injury (soft tissue)
– # left and right ulna/radius + dislocation left wrist
• Acute care:
– On admission: conscious but restless, agitated, abusive
– Orthopaedic surgery > intensive care for 2 days > ward:
abusive, hallucinating, agitated, confused, very sleepy
– In hospital for 5-6 weeks.
C: Rehabilitation
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•
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•
•
•
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No early brain injury assessment / rehabilitation
Early physiotherapy (arm function)
Physical restrictions/fatigue > gradual mobilisation
Not aware early on of consequences of brain injury
Seen by neurologist (8 months) - no abnormality detected
At 4 years GP prescribed anti-depressants
At 5 years referred to mental health (irritability/anger)
– Prescribed carbamazepine - ‘not tolerated’ > anti-depressants
– Saw a behaviour therapist with wife for 6 months (at 6 years)
C: Return to previous work
• Return to light duties (tea bar) at 6 months:
– Speed, concentration, memory, difficulties with money
• Return to technician role:
– Major Health and Safety incident – failure to follow
procedure (? due to memory lapse)
• Referred for assessment at 2 years:
– Investigations confirmed left frontal lobe abnormalities
– Neuropsychology– impaired verbal skills / memory
• Medically discharged at 2.5 years:
– Pre-discharge resettlement course - sales and marketing
C: Alternative work
• Over next 5 years: 6 jobs (sales / delivery), all <1 year,
interspersed with period of unemployment:
– Difficulties with organisation, memory, route-finding,
speed, fatigue and back pain
• At 4 years consulted Disability Employment Advisor >
work psychology assessment > local provider for advice
• At 6.5 years Back to DEA > referred to local generic
provider – supported in finding / setting up delivery job
• Ongoing difficulties - advised by G.P. to discontinue
current delivery job due to persistent back pain
C: Referred to Working Out at 7.5 years
• Referred by Solicitor, suggested by case manager (claim)
• Presented with physical, cognitive, behavioural/emotional
difficulties + impact on work, marriage, leisure/social life.
• Reported major concerns: memory, organisational skills,
lack of initiative, frustration, mood swings, poor
emotional/ behavioural control.
• Noted to have low self-concept, mild anxiety/depression
and to be very despondent …..
“How many times does your head have to be ducked under
water before you give up ?”
C: Vocational assessment
Formal assessments:
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•
•
•
Neuropsychological assessment
Chessington OT Neurological Assessment Battery
Physiotherapy assessment
Speech & Language Assessment
Practical assessments:
• Work preparation group
• Vocational rehabilitation activities
• Vocational ratings scales (FAI / WPP)
C: Vocational assessment – summary
• mild physical restrictions: back pain on lifting/driving
• moderate cognitive/communication difficulties affecting…
verbal memory; attention / speed of processing; executive skills planning/organisation; high level language processing/expression
• good practical work skills:
 highly motivated, responsive to instruction, good team player
 good knowledge / skills in mechanical engineering
 high quality work but slow & meticulous, poor under pressure
• emotional / behavioural:
 anxiety + fluctuating mood/confidence affecting work activities
C: Vocational rehabilitation 1.
1. Work preparation programme:
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–
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work preparation group
cognitive rehabilitation group + individual strategy work
community vocational rehabilitation activity
individual vocational guidance / counselling
individual psychological therapy (long-term adjustment)
2. Voluntary work trial (after 3 mons):
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small company making equipment for ocean yachts:
sheet metal work, drilling and assembly
feedback positive – difficulties manageable - ? job in company
job does not materialise > assisted job search
C: Vocational rehabilitation – 2
3. Supported work placement (making bespoke HiFi speakers):

–
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–

one month full-time voluntary work trial with support
on review: concern about memory + noted to be slow
full-time contract 3 month probationary period
on review: concern over organisation & memory + lifting
transfer to bench work (building circuits/testing speakers) for
further 3 month probationary period
– on review: no major concerns, progressing well
 full time permanent contract in above role + occasional
trouble-shooting role to re-shape faulty components
C: Client feedback - assessment
“ Even after 7½ years, a massive relief, a real feeling
that everybody understood your situation without you
having to sit down and explain it to anyone…. it was
also as much again this labelling process, this
underlining ‘Yes we concur that this problem exists
and it affects you in this way’ - there is a great deal of
comfort in that…… in pinpointing certain other areas
where we were not aware, where we knew we had a
problem, but for you to say ‘Well this is why’ is again,
another major boost ”.
C: Feedback – rehabilitation 1
“ I think it very much heightens your awareness of
what you should and should not get involved
in…..the Working Out programme makes you
aware of the sorts of work that you are going to
have problems with so you can flag that up straight
away .… the awareness of what you can and can’t
do empowers you in a way because .… when you
do take on a job, you are pretty certain that’s the
one you are going to be successful with…..”
C: Feedback – rehabilitation 2
“ It’s a dual thing though because, whilst the Working
Out programme makes me aware and gives ways of
getting around the problems (like diarising things,
making notes and such and looking at different ways
of doing tasks), it also allows you to talk to the people
who are working around you and say, ‘Look, these are
the problems that may crop up, these are the things I
may do when I’m working, look out for them’. And if
you have got the right kind of people around with you
they start to work with you, so you are not just helping
yourself they are helping you as well……”
C: Feedback – rehabilitation 3
“ ..... After a while I remember somebody saying ‘Since you
have been here a while, I think you’re getting better’. You
know you’re not getting better, it’s just the situation is
getting better. The thing is they don’t realise that they are
slotting into you …it’s like a jigsaw … it’s their half that
fits in with your half as much as the other way
round.…before it was just a game of catch-up where you
were just struggling to keep up with things but
now…..you can set things up so that they work for you
rather than you run around trying to make them work”.
TBI-VR programmes / Working Out +
example: further information
Tyerman A, Tyerman R & Viney P (2008).
Vocational rehabilitation programmes
In A Tyerman & NS King (eds.). Psychological
Approaches to Rehabilitation after Traumatic Brain Injury:
p 376-402. Oxford: BPS Blackwell.
and/or
Working Out Information pack for professionals:
[email protected]
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