M. Jackson Group Update – August 2014 – Cognitive Rehabilitation Reprise
In looking at past postings, I found a couple discussing the April, 2005 Vocational Outcomes in Traumatic Brain Injury conference, and particularly a Pre-Conference Workshop by Dr. Catherine Mateer and (now Dr.) Claire Sira on Cognitive and Emotional Consequences of Brain Injury: Intervention Strategies for Vocational Rehabilitation. What particularly drew me to re-posting this is how it laid out the key practical issues in working with TBI in a way that continues to be relevant at present. I have combined 2 previous postings.
During the initial portion of this talk, Dr. Mateer examined the research on various predictors of return to work following a traumatic brain injury. These predictors included:
Client age. Findings show poorer vocational outcomes for individuals aged 7 or younger, or after age 40. Older clients are less likely to return to work due to reduced adaptability, as well as the unwillingness of employers to employ a person with deficits and a reduced working life.
Speed of return to work. Findings show that the highest rates of return to work occur between 1 and 6 months post-injury, although it is likely that this finding correlates with severity of injury, medical and emotional complications, and so forth. Clients who return to work within 2 years are more likely to be working at follow-up.
Severity of injury (coma duration, amnesia). Interestingly, but perhaps not surprising for those who work with clients with TBI, findings in this regard are mixed. Some research does show decreasing return to work with more severe injuries, while other research does not. Severity may be more related to survival following injury and neuropsychological deficits, than the concrete outcome of return to work. Most of us can think of clients who had “mild” injuries that have left them very impaired, while others with more “severe” injuries go on to accomplish more than we might have expected. The relationship of our usual measures of severity to outcome is not clear cut or reliable.
Duration of acute rehabilitation. Again, the findings are mixed here, but a longer stay in hospital may be associated with a poorer employment outcome. This may be due in part to complications due to other injuries that further erode employability.
Post-acute emotional adjustment. Emotional reaction to injury is as powerful a predictor with TBI as it is with other disabilities. Clients who are depressed, anxious/helpless, and have PTSD are less likely to return to work. While clients who show less effective coping and higher levels of hopelessness are less likely to be employed, it is often not clear whether this led to lack of work, or was a result of it. Sometimes, in my experience, it seems to be both.
Awareness and acceptance of deficits. Willingness to change and accept guidance from others following TBI is positively related to return to work. Conversely, poor awareness/insight regarding deficits may reduce the likelihood of return to work.
Functional status. In looking at the research, the presenters noted that physical, cognitive, and emotional status is best assessed at discharge from initial rehabilitation. It is this level of functioning that is more reliable in predicting return to work than are severity of injury indices.
Neuropsychological factors. It is noted that global intelligence, attention, memory, and language skills all predict return to work at a moderate level. Importantly, executive functioning (concept formation, divided and selective attention, mental flexibility, mental programming, planning) is the most reliable predictor of return to work.
Preinjury psychological adjustment. Research and practice consistently shows that preinjury substance abuse reduces the likelihood of return to work.
Preinjury work status. Clients with higher preinjury qualifications are more likely to return to work, partially as they have had stable work prior to the injury. The most disadvantaged group in this regard is those 40 years of age and older who have no pre-existing qualifications.
Educational attainment. Education is not consistently a reliable factor in predicting return to work, although in some studies, having completed High School is associated with a higher likelihood of return to work.
Litigation and insurance status. The findings in this regard, as in other areas of disability, are mixed. There are some findings that say that clients involved in litigation are less likely to return to work, and other findings that indicate that clients seeing or receiving compensation take longer to return to work. However, there is other literature showing that compensation/litigation makes very little difference. In my opinion, this issue is likely to be more about the specifics of the groups being examined in the particular studies, and less about the issue of compensation per se.
It can be helpful to get a feel for employment issues by looking at predictors and outcomes. However, it is often unclear how these kinds of findings inform our work with particular individuals who represent a sometimes confusing combination of many factors, and whose presentation can change over time. I conceptualize research findings as often showing us almost a sociological view of what groups of people with disabilities look like as a culture, or as they proceed into and out of rehabilitation. Again, that is relevant, but if I am working with 41 year old Susan with a particular profile of abilities and impairments, rehabilitation rapidly becomes about individual differences and creativity of intervention, rather than general research findings or predictors.
The most common cognitive and behavioural difficulties following brain injury include the following:
- Poor memory – This can adversely affect retention particularly of new work skills, requiring reminder systems and multiple presentations.
- Concentration difficulties – Problems with sustained attention, and particularly divided attention may direct us to quieter work environments and less complex information where the client does not have to grasp everything with only one pass.
- Irritability/impatience/anger – Some TBI’s result in irritability due to some combination of changes in the brain and the frustration of disability (see below), the latter of which is more easily addressed.
- Fatigue – In my experience, while we take care to assess the cognitive sequelae, the uncompromising consequences of fatigue may not be fully appreciated. For many clients, part-time education/work may be necessary in order for them to have other aspects to their life.
- Slowness in thinking and moving – A general slowing may again result in the need for multiple passes at information, as well as work environments where speed is not a critical issue.
- Problems with initiating (i.e., “getting going) – Clients may want to do things and make promises, but find themselves having a hard time getting going. Cuing systems and schedules may help.
In terms of the most common emotional consequences of brain injury, traumatic brain injury survivors may become:
- Depressed – across disabilities, including TBI, there is the recurring finding of 50% of individuals experiencing depression. In the case of TBI, this may be delayed pending increased insight into their limitations.
- Socially withdrawn – It is common to hear clients talk about being overwhelmed by the information in social settings, tiring of answering questions about their TBI, and not wanting to socialize if they cannot keep up with others.
While some of these emotional consequences may have “organic” causes, in other words may be the direct result of damage to the brain, they are also described by Dr. Mateer, “as a reaction to the disruption in their lives, their losses, and the chronic frustration associated with acquired disabilities.”
Given both the research literature and what we know as clinicians, issues to consider in vocational rehabilitation following traumatic brain injury include:
- Actual vs. stated motivation for return to work – Motivation is a single word masking a very complex web of issues. TBI survivors may have vague or even fanciful ideas that they may not have the tools or energy to pursue. Others show a tenacity that is remarkable and exceed all expectations.
- Client’s cognitive abilities – These need to be assessed on an individual basis and may evolve to some degree over time.
- Client’s emotional functioning – As above.
- Client’s physical deficits/limitations – Vocational rehabilitation following TBI can be very complex, with cognitive limitations compounded by physical limitations, and generalized factors such as pain adversely affecting cognitive, emotional, and physical functioning.
- Client’s general medical stability – Clients may passionately wish to proceed with their rehabilitation, but there may be pending medical issues that stall rehabilitation. Waiting for maximum medical improvement, including maximum cognitive and emotional improvement, can be a very problematic time if there are no rehabilitation interventions in place.
- Presence or absence of neurological symptoms or seizures
- Family support and interactions – There is a huge literature on the family’s response to TBI. Some do everything they can to structure and support the client’s rehabilitation, while others blame their symptoms on them and expect full and complete recovery of the persons role responsibilities. A rehabilitation plan that includes the family is essential.
- Self-esteem and self-concept – Naturally, all individuals vary in these domains, but some will be more resilient to the changes brought on by TBI than others. Some will react to a severe injury by making a new plan to the best of their ability, while others will respond to a milder impairment by focusing on how they are permanently “broken.”
- Client’s work ethic – This and the following 3 issues relate to the fact that a TBI does not occur in a vacuum. For those who have always been keen workers, we may even find ourselves almost trying to hold them back, while their residual skill set may be quite broad. For those who bounced around from job to job, a TBI is unlikely to improve their situation and they may have trouble with the structure and multiple helpers they encounter in their rehabilitation.
- Client’s work history
- Preinjury work characteristics
- Current and preinjury personality factors – There are a host of issues here. Generally speaking, existing personality attributes may be exaggerated by a TBI, while others may change, with the individual becoming notably different to their family. Changes in the direction of passivity, indecisiveness, or brittle anger are not uncommon.
- Adjustment to disability – This is a recurring theme here. Again, while some adapt, others fight their changes, while others have limited insight as to their limitations or try to simply ignore them.
- Transferable skills – As you probably know, this refers to skills that can still be applied following the onset of a disability. For clients who had a limited skill set prior to the accident, and now have their ability for new learning compromised, rehabilitation can be very difficult. Others, may have a broad range of skills and associate preserved knowledge, but may require a specific work environment with specific accommodations.
- Employment index of client’s area – The combination of TBI and physical injuries in a rural setting can be very challenging, whereas urban centres may have a broader range of post-injury options to consider.
- Employee prejudices of brain injury – Deciding what to tell co-workers and how to manage their response is a significant issue in vocational rehabilitation with TBI. I generally advise to manage this, rather than to send the client back and hope for the best, but this has to be determined on a case by case basis. In one case I was involved in, it eventually became clear that the employees were embarrassed that a former high level manager would be among them and this became an issue to deal with.
- Litigation – I personally feel that too much is made of the impact of litigation on individuals’ participation in their rehabilitation. Having said that, litigation can seem to put things on hold, produce an array of competing commitments, and put everything into the optic of figuring out just how “damaged” or not the client is, rather than the more desirable goal of attaining the best rehabilitation outcomes possible.