Speaker: Carolyn Graham, Mike West
Transcription provided by: Caption First, Inc.
> CAROLYN GRAHAM: Hello, I am Carolyn Graham from Virginia Commonwealth University at the Center for Rehabilitation Science and Engineering, and this is Mike West, my colleague at the Virginia Commonwealth University Rehabilitation Research and Training Center. We are both part of KTER which is funded through NIDRR; it's a knowledge translation grant. And we conducted a systematic review titled Review of Vocational Rehabilitation Interventions for Working Aged Adults with Traumatic Brain Injury: Results and Implications that was funded by NIDRR. I'm going to discuss a little bit about what we found and describe the two interventions that were effective, and then Mike is going to join me in discussing it further in more detail.
The goal of the study was to determine the best evidence-based practices for vocational rehabilitation for adults with traumatic brain injury. And what we did is we examined vocational interventions that had been systematically evaluated and had been published or presented or in some type of white paper. So we looked all across the globe and came up with over 700,000 articles and we whittled it down to 368 that we reviewed. And of that, only two were found to be rigorous and were effective. The two were Holistic Residential and Supported Employment. And of these two, they both used different populations. And I think this is real important, Mike, because Holistic Residential used a military sample and Supportive Employment used a civilian sample. And because there was no civilian sample that had research on Holistic Residential, we can't say that it works for civilians, and because the Supportive Employment was only on civilians, we can't really say that it works for military populations.
First, I will go through the Holistic Residential. It was an active military sample and it occurred at a minimum care military hospital on a military base, and it was because there was a lack of military barracks for the participants to stay in, and it was for those with moderately closed traumatic brain injury. And, again, there has been no research connected on civilian populations that used this. And, again, it's very situated in a very military type context which may have impacted the results. It was an 8 week standardized in-hospital interdisciplinary cognitive rehabilitation similar to Prigatano's milieu oriented approach, but it was modified to fit a military framework that could be done – and I'll talk about that in just a minute – but they did say that this could be modified for an outpatient setting. It included a number of different individual and group therapies: cognitive scales, speech – pragmatic speech, occupational therapy, coping, milieu which focused a lot on neuropsychological, and psychotherapy and community re-entering outings. The unique component of this was the use of both individual and group cognitive therapy. Most studies that have used cognitive therapy with adults with traumatic brain injury have only used either the individual or the group and not the combination, and they felt like this was a unique and important aspect to their intervention. Now these groups, the cognitive scale groups and the other group therapy such as the speech therapy, were run in classrooms and they were run in military style. So these active military folks who were in this treatment also, it was set in the military environment that they were very comfortable with.
The cognitive components of the group therapy were orientation, attention, memory, visual processing, language, executive functioning, abstract reasoning and problem solving. Then they had a planning and organization group therapy and this group was used to address executive functioning components that they found were greatly needed in these folks. And these addressed the setting goals, the planning, organization, initiating, monitoring, completing tasks and time management. In the milieu therapy they addressed daily activities and they discussed any type of actions by the patients or staff that could inhibit the patients growing and developing independence, and so they would gently and directly communicate any types of situations and correct those situations so that the patients would be experiencing situations in which they could develop independence. And for any type of success or achievement or goal attainment that they had during the day, the patients would receive positive feedback for. They also found out that these active military adults with traumatic brain injury also had a lot of speech issues and pragmatic speech issues, so they set up a group therapy for it as well and they addressed non-verbal communication, initiation of conversation, turn-taking, staying on topic, asking for clarification, revising communication to clarify when someone didn't understand what they were saying, verbosity, verbal organization and sociolinguistic sensitivity. Then there was a Work Based Treatment Intervention, and this was based on Ben-Yishay and Burke's work, and every day it incorporated hours of goal-oriented employment type tasks into the therapy schedule.
The active military adults with TBI had a military routine, and this military routine focused on conforming to the military standards, and part of that was having free time in the late afternoon and the evenings. It also included the physical fitness training that all military are required to do. It also included scheduling their study and homework and living environments in a very military-oriented context. So it kept the structure that they were comfortable with. And they were also encouraged to wear their military uniforms. The staff who conducted the intervention included a physiatrist, a neurologist, a neuropsychologist, occupational therapist, speech pathologist, and two rehabilitation assistants. And sometimes when it was, in certain situations, a physical therapist was called to help with the physical fitness training due to comorbid disabilities.
Now the other intervention is Supportive Employment that we found that was effective, and this was with a civilian population, and there were a number of studies: Ellerd & Moore, Wehman and others. And the basic components of it were, of the Supportive Employment, was an ecological analysis of potential work environments, assessment of client's abilities and limitations, client working with a job specialist or a job coach, job-site training, integrated work setting and then a fading of the job coach or specialist. The employment specialist had a great deal to do in helping these folks with traumatic brain injury find a job and maintain that employment. They determined work preferences, determined how the employment would impact their financial situation or any benefits they had, determined any client expectations, would have to restructure work environment at times, arrange for assistive technology when needed, develop compensatory strategies for the client to use and adapt and help the client adapt to the work environment.
And that is the basic portions of the Supportive Employment. And I want to ask Mike here some questions. He's an expert in Supportive Employment and has worked in employment with people with disabilities for a number of years. Mike, when you think about the Holistic Residential and the Supportive Employment programs, what is the feasibility of each of these programs?
> MIKE WEST: Well, as far as the Holistic Residential program, I think it's important to note that, as you said, these are active military personnel, which means that they are more likely to be very recent injuries.
> CAROLYN GRAHAM: M-hmm.
> MIKE WEST: And as a recent injury, they're much more amenable to improvement.
> CAROLYN GRAHAM: M-hmm.
> MIKE WEST: You know, because there is a healing process after an injury that lasts for, you know, six months to a year before the individual will plateau and this is about as good as they're going to recover physically, cognitively and so forth. With the Supportive Employment model, these are people that have already been through rehabilitation and their symptoms and their problems are, you know, they're adaptable but they're not going to be curable, all right, because they've already – they could be months or even years post injury. The people that are going to come into community rehabilitation programs are, you know, they've already gotten these types of services.
> CAROLYN GRAHAM: Okay.
> MIKE WEST: Okay?
> CAROLYN GRAHAM: Okay. So how effective is Supportive Employment with individuals with traumatic brain injuries?
> MIKE WEST: Okay.
> CAROLYN GRAHAM: Because these are long-lasting traumatic brain injuries. Can you talk about how effective it is?
> MIKE WEST: Sure. Just to start with a little bit of history, our center, the RRTC, began – we're one of the early architects of the Supportive Employment model dating back to the late '70s-early '80s and working primarily with transition age youth and young adults with intellectual disabilities, mental retardation primarily, okay, and that's how we learned and developed the model and that was the first testing. In 1987, when I came to the center, we formed a collaboration with the brain injury unit at the medical college of Virginia to try this model with some of their former patients who had moderate to severe brain injuries.
> CAROLYN GRAHAM: M-hmm.
> MIKE WEST: And, you know, that's defined in a number of different ways, but basically what it means is there are going to be long-lasting issues and problems with them. We've done a number of studies over the years about the effectiveness of the model with this group and largely very positive. They're not very rigorous studies, you know. They're mostly like pre- and post-tests. But we have been able to improve people's employment outcomes using the model, you know, before the service and after the service, and in a lot of cases actually bringing them back almost to the point of where they were working when they had their injury, which is an important aspect of the program. Okay? One of the issues that we ran into early is that we did not know the population. And one of the issues that we ran up against is that, in comparison to the individuals we had been working with before, this group could have a myriad of problems. And you mentioned many of them, you know, the cognitive problems and physical problems, but many of them also have social problems, they may have emotional problems, or behavioral problems such as a loss of inhibitions.
> CAROLYN GRAHAM: M-hmm.
> MIKE WEST: All right? Orvolatility.
> CAROLYN GRAHAM: M-hmm.
> MIKE WEST: And all of those issues are more challenging for us as Supportive Employment providers.
> CAROLYN GRAHAM: M-hmm.
> MIKE WEST: And the other difference that we have is that we are collaborating a lot more with the medical field.
> CAROLYN GRAHAM: Yes.
> MIKE WEST: You mentioned physiatrists, and the neuro-rehab people, and with general practitioners, and therapists, you know, rehabilitation therapists, so it's a much more complex process I think than what we had been engaging in before.
> CAROLYN GRAHAM: Okay. So pretty much, in Supportive Employment, they're getting a lot of what the Residential Holistic is getting previously and different –
> MIKE WEST: And ongoing as well, because most of our clients did continue to see the people in the brain injury unit at MCV.
> CAROLYN GRAHAM: What are some of the support needs and strategies for individuals with traumatic brain injury to be successful in employment?
> MIKE WEST: Okay. Well, a lot of the support needs that they experience are the same as any other person with disabilities. They need job accommodations. They need an effective employment specialist or job coach who is going to be their advocate in the workplace and outside of the workplace.
> CAROLYN GRAHAM: M-hmm.
> MIKE WEST: And oftentimes they will need supportive work environments. But there are a few things that are not unique but things that they will need more than other people. The first is cognitive rehabilitation, and this can include games and activities that improve their memory and concentration.
> CAROLYN GRAHAM: M-hmm.
> MIKE WEST: It can also be what are called compensatory strategies, like using an agenda that they carry around with them. It can be a written agenda or it could be an electronic device, you know, a smart phone that gives them reminders of what to do when on the job. Another area of cognitive rehabilitation that is becoming increasingly used is based on neuro-feedback, and the specifics of it are beyond me, but, you know, using EEGs, you know, brainwave activity can be monitored. And there are good patterns of brain activity and there are bad patterns of brain activity, and using the EEG and a biofeedback mechanism, people can train their brains to stay in the positive brainwave activity and that helps them concentrate better, helps them remember things better, and also has been shown, in some cases, to reduce problem behaviors that I mentioned before.
> CAROLYN GRAHAM: M-hmm.
> MIKE WEST: Okay? Another support need that they will have is ongoing medical management. You know, a lot of these folks will have continuing medical problems with chronic headaches, dizziness, fatigue and similar types of things, and so ongoing medical intervention is often required because these are problems that will keep people out of the workplace.
> CAROLYN GRAHAM: Okay.
> MIKE WEST: Or make working very difficult for them. And so some of those ongoing medical needs might include PT medications for pain, heat and cold therapies, ultrasound therapies, that sort of thing. There's also a class of medications called neurostimulants which are chemicals that will stimulate the brain and promote more healing and better cognition that can be prescribed by a physician.
> CAROLYN GRAHAM: Okay. Well, what lessons have been learned from serving individuals with traumatic brain injury in supported employment?
> MIKE WEST: You know, well, we've been serving this population since 1987, so we have a long history with them. We did make some mistakes in the beginning, it was a steep learning curve for them, but we have learned some lessons over the years. I'll go over them briefly, okay? The first lesson that we found is that we were more effective if we focused less on finding people jobs and more on creating jobs for people.
> CAROLYN GRAHAM: Okay.
> MIKE WEST: And by creating jobs, it's going into a workplace and carving out a job. That's one of the phrases that's used often is pulling tasks and responsibilities from a lot of people to create a new person, a new position. And what job carving does is it allows us to tailor the job for the individual strengths and avoid some of the negative aspects of their injury. For example, if someone is known to have difficulties with volatility or with violating personal space, we can make sure that his or her job description doesn't include contact with customers.
> CAROLYN GRAHAM: Okay.
> MIKE WEST: So that's basically how we go about creating jobs, you know. For this population, we have found that the typical network of finding jobs, you know, going through the newspaper, want ads, job placement agencies, it just does not work very well because they just don't fit into the typical – they often do not. I don't want to say they never do, but they often need so many accommodations because of the multitude of their impairments and their other challenges.
> CAROLYN GRAHAM: M-hmm.
> MIKE WEST: Okay. The second lesson that we learned is, in the rehabilitation field, we tend to dichotomize the process as finding somebody a job and then keeping them in the job. Okay? And one of the lessons that we have learned is that you can't dichotomize it that much. Job retention begins in the job development phase because you're looking for a workplace that will be accepting of the individual, is flexible and willing to do the job carving and other accommodations that we talked about, and where the individual will fit in socially. Okay? And sometimes it also means finding a workplace where there is a champion for people with brain injuries, you know; maybe somebody, a supervisor, an owner, who has a history with brain injury with a family or friends who have brain injuries, or maybe is concerned about veterans with brain injuries.
> CAROLYN GRAHAM: M-hmm.
> MIKE WEST: Right? And that person is going to be much more willing to do what it takes to keep this person in the job.
> CAROLYN GRAHAM: M-hmm.
> MIKE WEST: Okay? One of the other things that we've found is that it often takes multiple efforts to find people the right job, and we have been blessed over the years to have VR counsellors working with us who are willing to do that for their folks, you know. We have had people that we have placed into five positions, six positions, because part of it is not finding the right job match.