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I was hit by a drunk driver.

I fell o a ladder cleaning the gu ers.

I tripped and hit my head.

I had encephali s.

I was shaken by the babysi er.

I was assaulted leaving work.

The Brain Injury Handbook An Introductory Guide to Understanding Brain Injury for Vocational Rehabilitation Professionals
BrainInjuryAssocia onofOregon,Inc.www.biaoregon.org18005445243

I sustained a blast injury in Iraq.

My exboyfriend beat me up.

I had a heart a ack.

TheBrainInjuryHandbook2011 AnIntroductoryGuidetoUnderstandingBrainInjuryforVoca onal Rehabilita onProfessionals BrainInjuryAssocia onofOregon,Inc. POBox549,MolallaOR97038 8005445243www.biaoregon.org ThesematerialswerefundedbytheOregonStateRehabilita onServicesGrant #131350.
ThesematerialsareadaptedinpartfromTheBrainInjuryHandbook:AnIntroductoryGuideto UnderstandingBrainInjuryforVoca onalRehabilita onProfessionals,madepossiblethrougha grantfromtheU.S.DepartmentofHealthandHumanServicesHealthResourcesandServices Administra on,MaternalandChildHealthBureauincoopera onwiththeHenryH.Kessler Founda on.WithpermissionfromtheN.J.DepartmentofHumanServices,DivisionofDisability Services.

Table of Contents
TableofContents...........................................................................................................................................i I.THENATUREOFBRAININJURY.................................................................................................................. 1 HowDoestheBrainWork?....................................................................................................................... 1 WhatisBrainInjury?.................................................................................................................................5 DiuseInjury.............................................................................................................................................5 ConcussiveDamage..................................................................................................................................6 Coup/ContrecoupInjury.......................................................................................................................... 7 SecondaryDamageinClosedBrainInjury................................................................................................ 8 BlastInjury................................................................................................................................................9 II.FUNCTIONALCHANGESAFTERBRAININJURY........................................................................................ 12 PhysicalChanges.....................................................................................................................................12 Arousal....................................................................................................................................................12 A en onandConcentra on.................................................................................................................. 13 Memory..................................................................................................................................................13 AbstractThinkingandConceptualiza on............................................................................................... 14 Execu veFunc oning............................................................................................................................. 14 InterpersonalandPsychosocialChanges ................................................................................................ 15 CommonIssuesFollowingBrainInjury................................................................................................... 16 MildBrainInjuries...................................................................................................................................16 Diagnos cs..............................................................................................................................................17 NeuropsychologicalConsult/Evalua on................................................................................................. 17 Voca onallyRelevantQues onsfortheNeuropsychologist.................................................................18 III.COGNITIVEREHABILITATION................................................................................................................. 19 IndicatorsofNeed..................................................................................................................................19

RoleofCogni veRehabilita oninVoca onalTraining.......................................................................... 2 0 Compensa ngforCogni veDecitsontheJob..................................................................................... 2 0 Cri calFeaturesofCogni veRehabilita on....................................................................................... 2 0 IV.THEVOCATIONALREHABILITATIONPROCESS....................................................................................... 2 1 DeterminingtheAppropriatenessoftheReferral.................................................................................. 2 1 IntakeInterview...................................................................................................................................... 2 1 Voca onalCandidatesArrival................................................................................................................ 2 2 ReadilyObservedBehaviors.................................................................................................................... 2 2 SignicantOthers.................................................................................................................................... 2 3 FormingaVoca onalProle................................................................................................................... 2 3 MedicalInforma on............................................................................................................................ 2 3 LeisureTimeAc vi es......................................................................................................................... 2 3 PostInjuryWorkHistory..................................................................................................................... 2 3 PostInjuryEduca on.......................................................................................................................... 2 4 GoalsandSelfPercep on................................................................................................................... 2 4 HistoryPriortoInjury.......................................................................................................................... 2 4 PreInjuryHealthHistory..................................................................................................................... 2 4 PreInjuryEduca on............................................................................................................................ 2 5 PreInjuryWorkHistory ....................................................................................................................... 2 5 CourseofRehabilita on/Reports........................................................................................................ 2 5 ReferralforPreVoca onallyRelevantServices.................................................................................. 2 6 WorkingwiththeVoca onalRehabilita onClient................................................................................. 2 6 Issue:Dicultyrememberinginforma on......................................................................................... 2 6 Issue:Dicultyfocusingandpayinga en on................................................................................... 2 7 Issue:Dicultywithini a on............................................................................................................. 2 7 Issue:Dicultywithorganiza onandplanning................................................................................. 2 8

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Issue:Dicultywithdecisionmaking................................................................................................. 28 Issue:Dicultyinsocialsitua ons..................................................................................................... 28 Issue:Dicultycontrollingemo ons................................................................................................. 29 Issue:Dicultywithselfawareness................................................................................................... 30 V.EMPLOYMENTOPTIONS......................................................................................................................... 30 Tradi onalVoca onalRehabilita onSe ng......................................................................................... 30 Limita onsofTradi onalVoca onalEvalua on.................................................................................... 30 GraduatedPlacements ............................................................................................................................ 32 SupportedEmployment.......................................................................................................................... 32 UseofaJobCoach..................................................................................................................................33 TheRoleoftheJobCoach....................................................................................................................... 34 JobPlacementConsidera ons................................................................................................................ 35 Selec vity............................................................................................................................................35 JobAnalysis.........................................................................................................................................35 PlacementwithEduca onandTraining............................................................................................. 35 OngoingSupports.............................................................................................................................. 36 JobAccommoda ons.......................................................................................................................... 36 Memory: ..........................................................................................................................................36 Othermemorystrategies:............................................................................................................... 37 MaintainingConcentra on:............................................................................................................ 37 PlacementRedened...................................................................................................................... 39 VI.INVOLVINGTHEFAMILYINTHEVOCATIONALPROCESS....................................................................... 40 FamilyExpecta onsandValues.............................................................................................................. 40 EectsonFamilyStructure..................................................................................................................... 40 Denial......................................................................................................................................................41

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BargainingandSplinteredSkills.............................................................................................................. 4 1 Depression............................................................................................................................................... 4 2 VII.CONCLUSION......................................................................................................................................... 4 3 VIII.REFERENCES......................................................................................................................................... 4 4

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I. THE NATURE OF BRAIN INJURY


Personswithbraininjuryareachallenginggrouptoservewithinthevoca onalrehabilita on (VR)system.Theseindividualshaveneedsthatareuniquetotheirdisabilityandsymptomsthat arefrequentlybaing.Thishandbookprovidesanoverviewofbraininjuryandits consequences,aswellasstrategiesandresourcesthatmaybebenecialinworkingwithpeople whohavebraininjuries.ThishandbookwascreatedtohelpVRcounselorsprovideappropriate servicesforpeoplewithbraininjuriesintheireortstoreturntowork. Individualswithbraininjuryareuniqueasservicerecipients.Theirpar culardisabilitydiers fromanyotherdisabilitygroupthecounselormayhaveencountered.Personswithbraininjuries simplydonotexhibitdisablingcondi onsinthesamewayasotherdisabilitygroups,anditis thisnonconformitythatsetsthemapart.Whencounselorsa empttousetradi onalmethods toassessthevoca onalpoten alofmembersofthischallenginggroup,theireortscanresult inafailuretoservetheseclients.Inordertoeec velyprovideservicestothispopula on,the rehabilita oncounselormustrstacquireabasicknowledgeofhowthebrainfunc ons.Only thencanthecounseloradequatelyappreciatethecomplexityoftheclientwithbraininjury.Itis ofparamountimportancethatthecounselordevelopafamiliaritywiththenatureand consequencesofbraininjuryandbeginstounderstandtheinterac onamongthemyriadof problemsapersonmayencounter.Oncehavinggainedfamiliaritywithbrainmechanismsand theclientslocusofinjuryfrommedicalreports,thecounselors llshouldexerciseextreme cau oninplacinglabelsonan cipatedareasofdysfunc on.Thereareindividualdierencesin theorganiza onofeachhumanbrain,andthesedierencesmayinpartaccountfor unan cipatedfunc onalachievementsinsomeclients,eventhoughseveredecitsand, therefore,limitedpoten al,hadbeenobservedinaneuropsychologicalexamina on. Conversely,subtledecitsnotedduringtes ngproceduresmaybequiteseriousobstaclesto successinavarietyofvoca onalspheres.Voca onalcounselorsshouldbeawarethatdispari es betweentestresultsandactualtaskperformancewillsurfacecon nually. Insummary,providingservicestopeoplewithbraininjuriesrequirescrea vityandexibility.It ishopedthatasthereadergoesthroughthishandbook,issuestoucheduponbrieyinthis introductorysec onwillgrowinclarity. onsofthebodyand allowsustothink,learnandremember.Itismadeupofbillionsofnervecellsthatwork togethertocontrolemo on,behavior,movementandsensa on.Tobe erunderstandwhat canhappentoanindividualwhenthebrainisinjured,itishelpfultoknowaboutthedierent partsofthebrainandwhattheydo.Therearethreemainsec onsofthebrainthecerebral hemispheres,cerebellumandbrainstem.Thebrainisdividedintotwohalves.Thesehalvesare thele andrightcerebralhemispheres.

How Does the Brain Work?Thehumanbraincontrolstheac

Eachpartofthebrainisresponsibleforspecicfunc ons.Thele cerebralhemisphere controlstherightsideofthebodyandisresponsibleforspeech,analy calthoughtand memory.Therightcerebralhemispherecontrolsthele sideofthebodyandis responsibleforcrea vethinking,expressionofemo onsandvisuospa alabili es. Specicpartsofthebraincontrolspecicfunc ons,likevision(OccipitalLobe),balance andcoordina on(Cerebellum),heartrateandbreathing(BrainStem),smell(underthe frontallobe),orhearing(temporallobe).Thus,whathappenstoapersonwhenthe brainisinjuredwilldierdependingonthepartofthebrainthatwasaected.

erbirtharecalledacquiredbrain injuries.Anacquiredbraininjurycanbetheresultofamedicalcondi on.Someofthese condi onsincludestroke,encephali s,aneurysm,anoxia(lackofoxygenduringsurgery,drug overdose,orneardrowning),metabolicdisorders,meningi s,orbraintumors.Acquiredbrain injuriescanalsooccurwhenanoutsideforcestrikestheheadhardenoughtocausethebrain tomoveinsideoftheskullanddamagethebrain.Thistypeofinjuryiscalledatrauma cbrain injury,andcanbecausedbycarcrashes,falls,beinghitonthehead,oranyphysicalviolence. Thistypeofbraininjuryisreferredtoasaclosedbraininjury,meaningthatthebrainhasnot beenexternallypenetrated.Whenthebrainispenetrated,suchaswithagunshotwound,the injuryiscalledanopenbraininjury. Theseverityofsuchatrauma cbraininjurymayrangefrommild,i.e.,abriefchangein mentalstatusorconsciousness,toseverei.e.,anextendedperiodofunconsciousnessor comaa ertheinjury.O enthereissomeperiodofunconsciousnessfollowingatraumatothe brain.However,therearethoseindividualswhodonotloseconsciousnessbutwillnonetheless exhibitsymptomsofbraininjury.Asaresultoftrauma cbraininjury,thebrainsustains damagethatmaybeeithertemporaryorpermanent. Theconsistencyofthebrainhasbeencomparedtogela norcustard.Undernormal condi ons,thisso mass,gentlycushionedbycerebralspinaluid,oatswithinthevaults formedbythemembranesthatlinetheskullandtheprotec veboneoftheskullitself.When thebrainisinjured,threeprimarytypesofdamagemayoccur:diuse,concussiveandcoup/ contrecoup.Thesethreetypesofinjuryarediscussedindetailbelow.

What is Brain Injury?Braininjuriesthatoccura

Diffuse Injury
Thersttype,diuseaxonalbraininjury,resultsfromthestretchingandtearingofnervebers (axons)throughoutthebrain.Thisdiuse,widespreaddamagetothebrainisthetypethat frequentlyresultsfromamotorvehiclecrash.Whenthemomentumofarapidlymoving vehicleissuddenlyhalted,withtheheadstrikingasta onaryobjectinsidethecarsuchasa dashboardorthewindshield,theimpactresultsinrota onalforcestwis nganddisloca ngor shi ingthebrainmass. Whenthebrainissubjectedtotheseviolentmo ons,thereisenormousstretchingandpulling ofthethreadlikenerveconnec ons(axons)thatformthenetworkforbrainfunc oning.Asthe axonsarestretched,biochemicalfunc oningceasesandthenervesstopfunc oning.Axons thatareseverelystretchedsome messnap,andthelikelihoodofthesenervesever func oningagainisremote.Themoresevereandwidespreadthedamage,thegreaterthe probabilityofanensuinglossofconsciousness(coma).Prac callyallpeopleemergefrom coma.However,thetypeofinjurydescribedabovevirtuallyalwaysleadstopermanentand generallyseveredamagetothebrain.

Concussive Damage
Concussivedamageistheresultofthebraincollidingwiththesharpridgesontheinside frontoftheskull.Theresul ngbruisesorcontusionsaremostlikelytooccurinthebase ofthefrontalandtemporallobesofthebrain.Theselocalizedcontusionsproducetwoof themostfrequentlyencountereddecitsfollowingclosedbraininjury.Theyare execu vedysfunc onandimpairedmemoryfunc ons. Sincethetemporallobesareessen altothesystemthatregisters,storesandretrieves informa on,damagetothisareaaectstheabilitytolearnnewmaterial. Damagetothefrontallobesmayseriouslyimpairthewiderangeofabili esknownas execu vefunc ons.Individualswithfrontallobeinjuriesareunabletothinkabstractly, conceptualize,orbeeec veproblemsolvers.Theyaregenerallyinexiblethinkerswho remainconcretelyboundtoapresen ngsitua on.Theyareunabletotakeaselfcri cal viewandarethereforefrequentlyunawareofhowtheirbehaviormayaectothers. Becauseofapronouncedinabilitytodevelopaplanandini ateanac vity,these individualsarefrequentlylabeledunmo vated.Frontallobeinjuriesarethemost prevalentinautomobilecrashes.Individualswithfrontallobeinjuriesareo enthemost diculttoserveinvoca onalrehabilita on.

Coup/Contrecoup Injury
Thethirdtypeofprimarydamageseeninclosedbraininjuryoccurswhentheheadis struckwithsuchintensitythatitliterallybendstheskullinatthepointofimpact,injuring thebrainbeneathit(theini albloworcoup),andthenpropellingthebrainagainstthe oppositesideofthebrain(thecounterbloworcontrecoup).Thistypeofdamageismost likelywhenamovingobjectstrikesthesta onaryhead.Itdoesnotnecessarilyoccurinall closedbraininjuries.Whenitdoeshappen,theimpairmentsthatresultdependonwhich specicbrainareashavebeendamaged.Arangeoffunc onalareasmaybecome selec velyimpairedfollowingacoup/contrecoupinjury.Thesemaybeinthemotor, sensory,perceptualandlanguagedomains.

Secondary Damage in Closed Brain Injury


Inaddi ontothethreetypesofprimarydamagedescribedpreviously,secondarydamage isacommonoccurrenceinbraininjury.Thiscanincludebleedingwithinthebrainitself (intracerebralhematoma);orbetweentheskullandthebraincovering(epidural hematoma);and/orbetweenthebrainandbraincover,(subduralhematoma).Thereis furtherdamagetothebrain ssueasbloodcollectsandbuildsuppressurethat compressesthebrain.Intracranialpressureincreasesasthebrainswellswithuid(edema, hydrocephalus)orbecomesengorgedwithblood.Sincetherigidityoftheskullallowsno roomforthebraintoexpand,surgeryisfrequentlynecessarytorepair,stopbleeding, removeclots,relievepressureand/orpreventhernia on.Whensecondarydamage occurs,usuallyinseverebraininjury,itcanproducefunc onallimita onsmoresevere thanoriginallyan cipated.


Blast Injury

Ablastinjuryisacomplextypeofphysicaltraumaresul ngfromdirectorindirectexposuretoan explosion.Blastinjuriesoccurwiththedetona onofhighorderexplosivesaswellasthe deagra onofloworderexplosives.Theseinjuriesarecompoundedwhentheexplosionoccurs inaconnedspace.From2000to2010,theDefenseandVeteransBrainInjuryCenterhas counted178,876casesofTrauma cBrainInjury(TBI)amongU.S.Militarypersonnel. Seventysevenpercentofthosecasesweredeterminedtobemild.Basedonthesenumbers,the numberofconrmedcasesofTBIshassurpassedrecordedcasesofPostTrauma cStress Disorder(PTSD)bynearly100,000. TherearefourtypesofBlastInjuries:Primary(directeectsofpressure,either overpressuriza onandunderpressuriza on,suchasruptureoftympanicmembranes,pulmonary damage,andruptureofhollowviscera);Secondary(eectsofprojec les,causingpenetra ng traumaandfragmenta oninjuries);Ter ary(eectsofstructuralcollapseandofpersonsbeing thrownbytheblastwind,causingcrushinjuriesandblunttrauma,penetra ngtrauma,fractures andtrauma camputa ons,openorclosedbraininjuries);andQuaternary(burns,asphyxia,and exposuretotoxicinhalants).

PrimaryInjuries Primaryinjuriesarecausedbyblastoverpressurewaves,orshockwaves.Theseareespecially likelywhenapersonisclosetoanexplodingmuni on,suchasalandmine.Theearsaremost o enaectedbytheoverpressure,followedbythelungsandtheholloworgansofthe gastrointes naltract.Gastrointes nalinjuriesmaypresenta eradelayofhoursorevendays Injuryfromblastoverpressureisapressureand medependentfunc on.Byincreasingthe pressureoritsdura on,theseverityofinjurywillalsoincrease. Ingeneral,primaryblastinjuriesarecharacterizedbytheabsenceofexternalinjuries;thus internalinjuriesarefrequentlyunrecognizedandtheirseverityunderes mated.Accordingtothe latestexperimentalresults,theextentandtypesofprimaryblastinducedinjuriesdependnot onlyonthepeakoftheoverpressure,butalsootherparameterssuchasnumberofoverpressure peaks, melagbetweenoverpressurepeaks,characteris csoftheshearfrontsbetween overpressurepeaks,frequencyresonance,andelectromagne cpulse,amongothers.The majorityofpriorresearchfocusedonthemechanismsofblastinjurieswithingascontaining organs/organsystemssuchasthelungs,whileprimaryblastinducedtrauma cbraininjuryhas remainedunderes mated. SecondaryInjuries Secondaryinjuriesareduetobombfragmentsandotherobjectspropelledbytheexplosion. Theseinjuriesmayaectanypartofthebodyandsome mesresultinpenetra ngtraumawith visiblebleeding.At mesthepropelledobjectmaybecomeembeddedinthebody,obstruc ng thelossofbloodtotheoutside.However,theremaybeextensivebloodlosswithinthebody cavi es.Shrapnelwoundsmaybelethalandthereforemanyan personnelbombsaredesigned togenerateshrapnelandfragments. Ter aryInjuries Displacementofairbytheexplosioncreatesablastwindthatcanthrowvic msagainstsolid objects.Injuriesresul ngfromthistypeoftrauma cimpactarereferredtoaster aryblast injuries.Ter aryinjuriesmaypresentassomecombina onofbluntandpenetra ngtrauma, includingbonefracturesandcoupcontrecoupinjuries. Blastinjuriescancausehiddenbraindamageandpoten alneurologicalconsequences.Its complexclinicalsyndromeiscausedbythecombina onofallblasteects,i.e.,primary, secondary,ter aryandquaternaryblastmechanisms.Itisnoteworthythatblastinjuriesusually manifestinaformofpolytrauma,i.e.injuryinvolvingmul pleorgansororgansystems.Bleeding frominjuredorganssuchaslungsorbowelcausesalackofoxygeninallvitalorgans,including thebrain.Damageofthelungsreducesthesurfaceforoxygenuptakefromtheair,reducingthe amountoftheoxygendeliveredtothebrain.Tissuedestruc onini atesthesynthesisand releaseofhormonesormediatorsintothebloodwhich,whendeliveredtothebrain,changeits

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func on.Irrita onofthenerveendingsininjuredperipheral ssueand/ororgansalso signicantlycontributestoblastinducedneurotrauma. Individualsexposedtoblastfrequentlymanifestlossofmemoryforeventsbeforeanda er explosion,confusion,headache,impairedsenseofreality,andreduceddecisionmakingability. Pa entswithbraininjuriesacquiredinexplosionso endevelopsudden,unexpectedbrain swellingandcerebralvasospasmdespitecon nuousmonitoring.However,therstsymptoms ofblastinducedneurotrauma(BINT)mayoccurmonthsorevenyearsa ertheini alevent, andarethereforecategorizedassecondarybrainInjuries.Thebroadvarietyofsymptoms includesweightloss,hormoneimbalance,chronicfa gue,headache,andproblemsinmemory, speechandbalance.Thesechangesareo endebilita ng,interferingwithdailyac vi es. BecauseBINTinblastvic msisunderes mated,valuable meiso enlostfor preven vetherapyand/or melyrehabilita on.

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II. FUNCTIONAL CHANGES AFTER BRAIN INJURY


Manyclientswithabraininjuryappeartobeidealvoca onalcandidates.Theytypically possesssubstan alpreinjuryworkrecords;formeremployerswillinglya esttotheirgood workadjustments;andselfreportsofpreinjuryemploymentoreduca onala ainmentsare usuallyinkeepingwiththereportsofothers.Itisimportanttoemphasize,however,thatthe personbeingdescribedinthesereportsisnotnecessarilythesamepersona ertheinjury. Physical,cogni veandpsychosocialchangesasaresultofthebraininjurymayhavesignicant impactontheindividualsabilitytowork.

Physical Changes
Physicaldecits,iftheyexist,arealwaysthemostobviousorno ceablelimita onsinindividuals withbraininjury.Unlikethemoresubtlecogni veimpairments,physicaldecitsaregenerally visibleandfrequentlybecomethecentralissueuponwhichanindividualplacesallresponsibility (blame)forhis/herinabilitytoreturntopreinjuryac vi esandlifestyle. Physicalimpairmentsareusuallytheresultofdamagetothebraincentersthatcontrolmotor func onsratherthandirectinjurytotheextremi es.Decitsmayincludelossofmotor coordina on,spas city,poorbalance,aninabilitytowalkunassisted,andalossofeyehand coordina on.Hemiplegia(paralysisaec ngonesideofthebody)andhemiparesis(weakness ofonesideofthebodyorpartofit)mayfurthercomplicatevoca onalissues,par cularlywhen thesecondi onsaecttheuseofthepreinjurydominanthand. Withinthiscategory,onemustnotethepoten alforseizuredisorders,and,iftheyare prescribed,medica onstakentocontrolseizures.Thestabilityoftheseizuredisorderandthe poten alsideeectsoftheseizuremedica onsmayfurthercompromisevoca onal rehabilita oneorts. Cogni veChangesPersonswithbraininjurymayexhibitproblemsinavarietyofcogni veareas suchasbasicarousal,alertness,a en on,concentra on,memory,abstractthinkingand conceptualiza on,planning,organizing,problemsolving,andjudgment.Peoplealsomayhave difcultyprocessingverbalandvisualinforma on.

Arousal
Signsofarousalproblemsincludeaninabilitytoa endtotheenvironment;alackof(or reduced)alertness;aninabilitytoaccuratelyobserveenvironmentaldetailsandoccurrences; andaseverelyslowedcapacityforinforma onprocessing.Peoplewitharousalimpairments areo enslowinreac ngandrespondingtoothersandarehighlysuscep bletofa gue followingcogni veorphysicalexer on.Theymayappearalmostlostinspaceornotin touch.

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Attention and Concentration


Impaireda en onandconcentra oncanexhibitaseasydistrac bility.Thismaybearesponse tointerferenceeitherbyexternalorinternals muli.Forthepersonwithbraininjury,the inabilitytoscreenoutexternalnoisesmakesitdiculttosustainconcentra on. Environmentalnoiseisfoundinmostworkse ngs,e.g.,conversa onofothers,usualoce trac,hummingofmachinesandthegeneralrelatedbuzzofac vity.Intrusionsbyexternal noisecano enbecontrolledorminimized,andthecapacityforconcentra onwillusually improve. Forthepersonwithbraininjury,anotherpossiblesourceofdistrac ngnoiseistheinternal conversa onwithinhis/herownmind.Intrusiveinnerthoughtsthatlimitproduc vityare exceedinglyhardertomanage.Theybecomevisible(observable)onlywhentheyinterrupt performance.

Memory
Lossofadequatememoryfunc onandtheinabilitytoimmediatelyrecallnewinforma on (anterogradeamnesia)arecommonsymptomsfollowingbraininjury.Whilesignicant improvementinmemoryfunc onmaybenotedduringtheini alperiodofrecovery,this decitiso enobservedinvaryingdegreesformostpeoplewithbraininjury. Inadequatememoryfunc onisoneoftheprimarycomplaintsreportedbypeoplewhohave sustainedbraininjuries.O enitistheirsocialenvironmentthatcausesthemtodevelopan awarenessofthispar cularproblemarea.Thereprimandsofacquaintancesandsignicant othersformissedappointments,appliancesle onorbillsle unpaidcompelthepersonwith braininjurytoacknowledgethathe/sheforgetsimportantthings.Inadequatememoryfunc on remains,unfortunately,unresponsivetoremedialinterven on.However,memoryimpairments canbecompensatedforbyavarietyofmnemonicdevices(memoryaids)suchasthose describedlater. Prac callyallpersonswithbraininjuryretainaclearmemoryofthemselvesastheywere preinjury.Intactoldmemoriesandoverlearnedinforma on(forexample,ridingabikeor performingasequenceofjobtasks)frequentlyrepresentareasofstrength.Thesepreserved skillscano enbedrawnuponwhenhelpingaclientwithbraininjuryredevelopvoca onalgoals. Some mesanindividualmayappeartohaveamemoryimpairment,wheninfactthepersonhas dicultypayinga en onwhenpresentedwithnewinforma onandisthusunableto rememberthisinforma on.Itisessen alfortheclientandthecounselortoknowthe dierence.Theinabilitytoremember,asaresponsetolackofeec vea en on,canbe remediatedfrequently,oratleastsubstan allyimproved,bycogni verehabilita on.

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Abstract Thinking and Conceptualization


Animportantconcernforvoca onalcounselorsiswhethertheclientwithbraininjuryisableto engageinabstractthought.Clientscanremainstuckinoneviewofasitua on.Theymayndit diculttoshi tootheraspectsofaproblemortoreadilysearchforalterna ves.Theymaylack thecapacityforimagina vethoughtandremainpoorproblemsolvers.Problemswithabstract reasoninglimitsthetypesofproduc veac vityanindividualcanpursueautonomouslyand impactsontherange,complexity,andvarietyoftaskstheycansuccessfullya empt. Conceptualiza on,whichisdependentonthecapacitytothinkabstractly,isanotherareain whichtheindividualmayexhibitcogni vedecits.Theabilitytoeec velyconceptualizelies withintherealmofhigherlevelcogni on.Onemustpossessastoreoflearnedmaterialthatis reliablyandreadilydrawnuponinordertoimagineorformamentalpicture,organizethese mentalevents,andbeabletotranslatethiscogni veac vityintoanobservablebehavior/skill. Problemsintheabilitytoconceptualizecansignicantlyimpactthetypesofjobsapersonisable topursue.

Executive Functioning
Decitsinexecu vefunc oningarethedirectresultoffrontallobedamage.Intactexecu ve func onsallowanindividualtoengageinautonomous,independent,wellplanned,eec vely organized,sucientlymonitored,selfregulated,purposefulorgoaldirectedenterprises.When thesecapabili esarediminishedastheresultofbraininjury,theindividualhasdiculty sustaininggainfulemployment,maintainingsa sfactorysocialrela onshipsand,at mes, maintainingadequateselfcare,regardlessofhowwellothercogni vecapaci esareretained. Thepersonwholooksandsoundsgoodandwhosetestresultsonexamina onsofskillsand knowledgeareunimpairedwillhavedicultyfunc oningproduc velywhenexecu veskillsare impaired.Suchclientsremainpoorselfmanagers.Theseclientswhosoo enappearcapableare probablythemostdiculttotreatorevaluatevoca onally.Theyhavelostthemechanismto accuratelymonitortheirabili esandneedfrequentfeedbackinordertounderstandtheimpact theirareasofweaknesshaveontheirabilitytoreturntowork. Thecounselorshouldalsocarefullyassessaclientsabilitytoformulategoals.Whilecapableof engagingincomplexac vi es,thoseimpairedinexecu vefunc oningmaylackthecapacityto developplansorini atepurposefulac vity.Inextremecases,theseindividualsmayappear apathe candunabletoini ateac vityexceptinresponsetoexternals muli.Theabilityto becomeengageddynamicallyininterac veandinten onalbehaviorisbasictoexecu veskills. Asmen onedearlier,whenthiscapacityfalters,personswithbraininjurycanerroneouslybe labeledlazyorunmo vated.

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Interpersonal and Psychosocial Changes


Interpersonalandpsychosocialchangesfollowingbraininjurymaypresentthemostserious impedimenttovoca onalreintegra on.Aclientmaypossessintact,highlevel,func onalwork skillsbutwillbepreventedfromsustainingemploymentbecause,inmostemploymentse ngs, jobreten ondependsonmaintainingthegoodwillofcoworkersandsupervisorysta.Inother words,aclientneedstobeabletointeractwithcoworkersandsupervisorystainawork appropriatemanner;maintainingapleasant,approachableaect,oratleastaneutralone. Peoplewithbraininjurymaybele withmarkedchangesintheirbehavioralrepertoireand exhibitverbalandphysicaldisinhhibi on,poorsocialjudgmentandageneraldecreaseinsocial graces.Someclientsmayexhibitdysfunc onalsocialbehaviorsofsuchmagnitudethattheyare preventedfromengaginginanyconsistenttaskperformance.Whenevenlengthytreatmentand clinicalinterven oncannotmodifyundesirablesocialbehavior,compe veemploymentmay notbeachievable. Ahighdegreeofegocentricityiso enanotherconsequenceofbraininjury.Manyclientshave dicultyinadop ngaexiblestanceandremainxedintheirviewthattheworldonlyrelatesto andrevolvesaroundthem.Clientsmaylackthecapacitytoreadsocialcuesaccurately.Some failtoreaditatall;theyseemoblivioustonuancesofspeechandbodylanguageofothers.They confusetheimpactofsociallyrelayedmessagesandconsistentlyinterpretthemasbeing personallydirected.Forexample,clientsmaymisinterpretacoworkersorsupervisorsangeror disappointmentoverworkproblemsasastrongnega vemessageabouttheirpersonal performance.Inaddi on,construc vecri cismmaybeinterpretedasapersonalassault.The unfortunatebyproductofthistypeofmisinterpreta onisthattheclient,whoperceivesthe angerasdirectedathim/her,generallyrespondswithanger. Oneoftheleastunderstooddysfunc onalinterpersonalskillsisthelossofemo onalcontrol. Clientscanoverreactorbecomeimmobilizedbyatypeofemo onaloodingrarelyobservedin otherdisabilitygroups.Thetypeandextentoftheiremo onalresponse,o enthedirectresultof someinternaldialogue,isnotmeritedbythesitua on.Lossofemo onalcontrolwillusually surfaceunexpectedlyandsome mesbeofsuchmagnitudethatitprecludesanyproduc ve ac vity. Thisemo onalinstabilityischaracterizedbyrapid,exaggeratedmoodoraectswings.Knownas emo onallability,thecondi onistheresultofweakenedorimpairedcontrolinemo onally chargedsitua ons.Becausetheclientsphysicalappearancemaygivenoindica onofadisability, observerstendtomisinterprethis/herstrongemo onalresponses. Anotherissuefacingpeoplefollowingbraininjuryisadecreasedtoleranceforalcoholanddrugs. Smallerdosesproducemorerapideects.Socialdrinkingcanbediculttocontrolandwill interferewithapersonscogni ve,physicalandpsychosocialfunc oning.

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Rela onshipswithinthefamily,thecommunityandtheworkplacewillbecompromisedwhena personisunabletoeec velycontroltheiruseofalcoholordrugs.Thevoca onalrehabilita on processwillbeatjeopardyaswell.Theclientshouldbemadeawareoftheharmfuleectsof thesesubstancesandtheVRcounselorshouldaggressivelymonitorandinterveneifthereisa ques onofimpairmentduetoalcoholordruguse.

Common Issues Following Brain Injury


Cogni ve Changes Memory Problemsolving Decisionmaking Persistence Planning Organiza on Sequencing Processingspeed Judgment Inexibility Concentra on A en onspan Depression Socialskillsproblems Moodswings Emo onallackofcontrol Inappropriatebehavior Impulsivity Lackofresponsetosocialcues Irritability Physical Changes Motorcoordina on Tasteandsmell Hearingand/orvisualchanges Spas cityandtremors Fa gueand/orweakness Balance Mobility Speech Seizuredisorder Paralysisononeorbothsides

Personality and Behavioral Changes Reducedselfesteem Dicultyrela ngwithothers Selfcenteredness Dicultyformingnewrela onships Stress,Anxiety,Frustra on Denial Lackofmo va on Excessivelaughing

Mild Brain Injuries


TheVRcounselorwillbecalledupontoprovideservicesforpersonswhopossessawiderangeof capabili esandlimita onsastheresultofbraininjury.Alongwiththosewhohavemoderateor severebraindamage,therearethoseclassiedashavingmildbraininjuries.Becausepeople withsocalledmildorminorbraininjurydonotexhibitobviousdecits,theyarenotreferredfor rehabilita onservicesun llonga ertheactualinjury.Followingavisittotheemergencyroom, doctorsoce,orabriefperiodinanacutecarefacility,individualswithmildbraininjuries generallyreturnhomeandsubsequentlytowork.Whiletheyo enhavenoawarenessofaltered

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abili es,theirjobperformanceismarkedlydiminishedandtheabilitytoretainemployment suers.Thisgroupofpeopleappearunchangedfrompreinjurystatusandtheirdicul esare furthercompoundedbytheexpecta onsplaceduponthembytheirsocialenvironment.Because theyappearsointact,theseexpecta onsarehighandusuallyincongruentwiththeirreduced capaci es.Whentheemploymentproblemsbecomeobviousandtheindividualisnally referredforvoca onalcounselingorrehabilita on,theoriginalcauseoftheproblemmayremain unrecognized.Ifthisisthecase,theVRcounselorcanbeinstrumentalindeterminingwhethera mildbraininjurymaybeafactorintheemploymentproblemstheindividualisexperiencingand inarrangingforappropriatetes ngbyaneuropsychologisttoaddresstheseproblems.Itshould benotedthatmildbraininjuryisacomplexproblemandiso enaddressedintherehabilita on literatureasaseparateanduniquetopic.Resourceinforma onaboutmildbraininjurycanbe foundontheBrainInjuryAssocia onofOregonswebsite(www.biaoregon.org).

Diagnostics
Duringtheearlystagesoftreatmentandrehabilita onofpeoplewithbraininjury,anumberof neurodiagnos cmeasuresandmentalstatusexamina onsareperformed.Themainpurposeof suchtes ngistomeasurecogni vefunc oningandchartimprovementsastheyoccur.These testsarenotimmediatelyrelevanttothevoca onalrehabilita onprocess.However,later neuropsychologicaltes ng,whichisbestadministeredwhenthepersonwithabraininjuryhas becomemedicallystable,bearsdirectrelevancetovoca onalrehabilita on.

Neuropsychological Consult/Evaluation
Aneuropsychologicalevalua onmaybepartofthecaserecordsthevoca onalcounselor reviewsatthe meofreferral.Thesignicanceoftheresultsmaynotbereadilyapparent,and therefore,maybediculttotranslateintomeaningfulapplica on.Testscoresaretypically reportedastheycomparetoestablishednorms,andaclientsperformanceorlevelof func oningmaybedescribedintermsthattellusonlythathe/sheisdecient,impairedor belowtheaverage.Thesetermsmeanli lewhentheyhavetobeappliedtoajobanalysis. Addi onally,thesereportsmaybewri eninjargonthatfurtherconfusesthevoca onal counselor. Ontheotherhand,awellwri enneuropsychologicalevalua oncanserveasaninvaluabletool tounderstandingthecogni vestrengthsandweaknessesofaclientasitappliestoreturningto work.Ifthevoca onalcounselorismakingthereferralfortheneuropsychologicalevalua on, askingspecicreferralques onsaboutworkfunc oning,accommoda ons,andtreatment recommenda onscanenhancetheinforma onthatisprovidedinthereport.Discussingthe resultsofthetes ngwiththeneuropsychologist,whoseexper seisinbrainbehavior rela onships,isanotherwaytoobtainvoca onallyspecicinforma on.

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Vocationally Relevant Questions for the Neuropsychologist


Whatfunc onallimita onsareevidentwithrespecttomemory,informa on

processing,visualandauditorycomprehension?
Whatisthepoten alforfurtherremedia on? Whatistheprognosisforlengthoftreatment? Canyoucommentonspecicstrengthsnotedinthetes ngsitua on,e.g.,ease

inreceivingoralinstruc on,persistence,concentra on?


Istheclientdistrac ble?Externally?Internally? Canyoucommentonthoseaspectsofpreinjurylearning(i.e.,rmly

entrenched,overrehearsed,repertoireofskills)thathavesurfacedduringthe currenttes ng?


Istherepoten alfornewlearning? Howmuchsupervisionandenvironmentalsupportwillbeneededatthecurrent

leveloffunc oning?
Whatistheclientsbestmethodoflearning? Whattypeofcompensatorystrategieswouldbebenecialtoenhancejob

performance?
Whattypeofjobaccommoda onswouldbehelpful? Whataretheeectsofinterpersonaldecitsonvoca onalgoals?

Theresultsofawellfocusedneuropsychologicalevalua oncantranslateintoprac cal recommenda onsforthevoca onalassessmentprocess.Theseresultsallowthecounselorto makeprepara onsandtakean cipatorystepstoensureasuccessfulexperiencefortheclient. Thevoca onalcounselorcanthenbegintodesignthetypesofenvironmentalsupportsystems thattheclient,givenhis/herstrengthsandlimita ons,willrequireduringthevoca onal rehabilita onprocess.

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III. COGNITIVE REHABILITATION


Clientswithbraininjuriesmayneedcogni verehabilita onastheyarepreparingforthe voca onalrehabilita onprocess.Cogni verehabilita onisthesystema c,goaloriented therapeu cinterven ondesignedtoremediate(improve)arangeofcogni veabili es.Areas addressedinaprogramofremedia onarehighlyindividualizedandmayincludea en on, concentra on,andimpulsecontrol. Cogni veprogramsalsoaddresslackofawarenessofinjuryimposedlimita onsandsocialand emo onalneeds.Memoryimpairmentsarea endedtoandcompensatorystrategiesaretaught. Cogni veremedia oniscarriedoutincarefullyplannedstagesorsteps.Clientsmovethougha varietyofhighlystructuredtrainingexercises.Skillacquisi onandskillstabiliza onarestressed. Formostpeoplepossessingtruefunc onalmemorydecits,compensatoryaidsmustbe establishediftheyaretoreturntoanylevelofoccupa onalproduc vity.Compensatory measureso entaketheformofenvironmentalcueingsystems.Cueingcanbeassimpleasan indexcardlis ngthealphabetfortheclientwhoisinvolvedinalingtaskorawri enlistof sequen alstepsforagiventaskthattheclientusesasavisualreference.Some mesthese cueingmethodsrequireonlycommonsenseandabitofcrea vitytocreate. Itisimportanttorememberthatenvironmentalcueingsystemsmustincorporatethestepstobe takeninalogicalsequence.Thisistruewhethertheyarebeingdesignedfortheworkplaceorfor ac vi esofdailylivingaccomplishedathome.Thesemightbewri enguidelinesforprocedural opera ons;calendarsandjournalsforpersonalappointments;joblogs,maps,wri enstepby stepproceduresforgainingaccesstoapar cularplace;andadailyschedulewhichhelpsthe clienttransi onfromoneaspectofthedayorjobtasktothenext.

Indicators of Need
Some mesaclientwithabraininjuryisdeterminedtobeeligibleforvoca onalrehabilita onyet demonstratesfunc onaldecitsincogni veskills.Ifthesedecitslimittheclientspoten alfor independenceandvoca onalsuccess,thencogni verehabilita onmaybeindicated.Ifthereisa discrepancybetweenwhattheclientisabletodoandwhatwillberequiredofhim/heronthe joborvoca onalplacement,cogni verehabilita onmaybeappropriate.Ifthejobrequiresskills thattheclienthasalreadydemonstrated,eitheronaconsistentorerra cbasis,orhasthe poten altolearn,thencogni veretrainingshouldbeini ated.Thefollowingguidelinesarealso relevant: Theclientshoulddemonstratethemo va onandabilitytoac velypar cipateinthe learningsitua onanddisplayacapacityforconsistentimprovementonnewlearning.

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Theclientsowngoalsshouldbebothrealis candcongruentwiththenalgoalsof

theremedia onandul matejobplacement.


Thereshouldbeevidencethattheskilldecitsexhibitedbytheclientareretrainablein

therapy.Ifnot,thefocusofthetherapyshouldbeondevelopmentofcompensatory strategies,useofexternalaids,providingmorestructureintheenvironment,andjob support.

Role of Cognitive Rehabilitation in Vocational Training


Goalsforcogni verehabilita onshouldbemadewithregardtothespecicskillsneededinthe clientsvoca onalse ng.Sincetheseneedsmaychangewithdierentvoca onalplacementsor developmentoftheclientsskills,itisimportanttoupdatethegoalsregularly.Forexample,the goalsforcogni verehabilita onmayberelevantforasupportedemploymentsitua on.A er workinginsupportedemployment,theclientmaydemonstratethepoten alforemployment withoutsupports.Theneedforaddi onalcogni verehabilita onmaybeindicatedwithnew goalsforselfsuciency.

Compensating for Cognitive De icits on the Job


Peoplewithbraininjuriesareusuallytaughtavarietyofcompensatorymechanismsduringthe courseofcogni veremedia on.Atissuehereiswhethertheyarecapableofincorpora ngthe learnedcompensatorystrategiesintohome,community,andworkplacese ngs. Peoplewithbraininjuryo enhavedicultytransferringthecompensatorystrategiestheylearn intheclinictorealworldsitua ons.Memorydecitsandproblemswithabstractreasoningmake itdifculttogeneralizeinforma onlearnedinonese ngtoanothersitua on.Thebestwayto teachworkrelevantcompensatorystrategiesisinaworkcontext.Itisonlyinaworkse ngthat thesestrategieshaverealmeaningtomostpeoplewithbraininjuries.

Critical Features of Cognitive Rehabilitation

1.Adequateevalua on,planningandongoingsupervisionbyatrainedprofessional. 2.Dailystructuredtasksthatinclude:


Supervision/Minimaldistrac ons Stepbystepacquisi onofskills Constantsystema cfeedback Maximals mula on

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Builtinsuccess Repeatedlearning Transferoftrainingtofunc onalse ngs

3.Wri eninstruc onsandnotesbysupervisorofdailytasks:


Cogni verehabilita ontherapist/technician A endant Familymember

4.Regular(e.g.weekly)reviewofprogrambyneuropsychologist. 5.Coordina onofprogramwithotherrehabilita onteampersonnel.

IV. THE VOCATIONAL REHABILITATION PROCESS


Thevoca onalrehabilita onprocessbeginswiththereferralandthecollec onofinforma on tolearnasmuchaspossibleaboutthevoca onalcandidate.TheVRcounselorcreatesaprole ofthepoten alclientbygatheringinforma onthroughwri enandverbalreportsand interviewingtheclient.

Determining the Appropriateness of the Referral


Beforebeginningtheassessmentofreadinesstoengageinthevoca onalrehabilita onprocess, thecounselorshouldbesurethattheclienthasbeenappropriatelyreferred.Oneoftherst considera onsistorecognizethereasonforthereferral.Professionalsinbothmedicaland rehabilita onse ngssome mespushpa entswithbraininjuryintoun mely,andtherefore inappropriate,voca onalrehabilita onintheireortstoengagetheirpa entsinproduc ve ac vity.Thereferralmayalsobeviewedasapossiblewaytocon nuerehabilita onwhenother fundingsourceshavebeenexhausted.Ifthepersonbeingreferredforvoca onalrehabilita onis atastageofrecoverywereaddi onalimprovementisexpected,thentheini a onofthe voca onalrehabilita onprocessisbestdeferred.Inassessingreadinesstoengageinwork, carefulconsidera onofthestageandstabilityofbothcurrentandpoten alimprovementmust bemade.Ideally,the metobeginvoca onalrehabilita oniswhenthepoten alclientwith braininjuryiscomple ngtherehabilita onprocess,hasreintegratedintothehomeand community,andexpressesmo va ontowork.Some mes,clientsdonotappreciatetheneedfor voca onalservices.Theymaybeunabletoassesstheirowncapabili esandfrequentlyare unawareoftheirinjuryimposedlimita ons.Itishelpfulforclientstohaveabasicawarenessand acknowledgementofresidualchangesinarangeofcapaci esbeforebeginningvoca onal rehabilita on.

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Intake Interview
Theintakeinterviewisactuallytherststepintheprocessofassessingreadinesstoengagein theVRprocessandisprobablythebestini alassessmenttoolavailable.Itisrecommendedthat theVRcounselorallowmore meforini alinterviewswithindividualswithbraininjuriesthan otherclients.Theintakeinterviewservesavarietyofpurposes,includingfactndingandto establishingrapportwiththeclient.Addi onally,itallowsthecounselortomakeclinical observa ons,whichisanotherformofdatacollec on.Iftheclientpresentswithbehaviorsthat aresodysfunc onalthatthecounselorhasconcernsaboutworkingwithhim/her,thereisa strongpossibilitythatthepersonisnotreadyfortheVRprocess.Firstandforemost,the interviewprovidesthecounselorwithanopportunitytoevaluatetheclientsabilitytopar cipate ataverybasiclevel;inotherwords,totesthis/hercapacitytoengagereliablyinatwoway communica on.Didtheclientremembertokeeptheappointment?Wastheclientpunctual?Can theclientsupplyinforma onabouthim/herself?Duringthecourseofconversa on,istheclient focused?Ishe/shea en ve,orhighlydistrac ble?Istheclientorientedto meandplace?Isthe clientimpulsive?Istheclientinterestedinvoca onalrehabilita onservices?

Vocational Candidates Arrival


Twothingstobenotedduringthisrstmee ngare: 1)bywhatmeansoftransporta ondidthecandidatearrive,and 2)didhe/shearrivealoneoraccompaniedbyasignicantother. Theinclusionofthisaddi onalpersonasasourceofbackgroundinforma onanddetailsofinjury isrecommendedwhentheclientcannotreliablyprovidethisimportantinforma on.However, thecounselormustndoutwhetherthepresenceofthisaddi onalperson(s)isinresponsetoa needoftheclientortothatofthesignicantother. Inaddi on,theissueofindependentmobilityandtheavailabilityoftransporta onmustbe addressedduringthevoca onalassessmentprocess.

Readily Observed Behaviors


Thelistofbehaviorsthatarereadilyobservedduringtheinterviewingprocessislengthy,andthe counselormustbeawareofallthosethatwillhaveaposi veornega veimpactinawork situa on.Thecounselorshouldgainknowledgeofspecicbehavioraldecitsthat,unlessthey canbecompensatedfororsucientlyremediated,willprecludecertainjobs.Forexample,note signsofdisinhibi on.Theclientwhoisextremelyuninhibitedmaynotfarewellinmaintaining employmentbecauseahighdegreeofdisinhibi onmakesitdiculttoestablishadequate

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interpersonalrela onshipsintheworkplace.Oneshouldalsonotewhetherapoten alclienthas physicaldisabili esorproblemswithcommunica on.

Signi icant Others


Duringthisini alphaseoffactnding,thecounselorshouldobtaininforma onconcerningthe constella onofsignicantotherswhocanberelieduponforsupplyingsupport.Thelackofthis typeofsupportsystemcanmaketheprocessmoredicult.Familymembersandfamilialrole modelsmakeameasurablecontribu oninvoca onalrehabilita on.

Forming a Vocational Pro ile


Medical Information
Relevantmedicalreportsshoulddescribetheinjury,itsseverity,andthecircumstancesunder whichtheinjuryoccurred.Descrip onsofmedicaltreatment,complica onsduring convalescence,andeortsatrehabilita onshouldalsobepartofthisdatacollec on.Cogni ve andphysicaldisabili esshouldbenoted.Thecircumstancessurroundingtheinjurymayalso provideinforma onsuchasthepresenceofalcoholordrugsascontribu ngfactors. Thepresenceofasurgicallyimplantedshuntshouldbenoted.Theseshuntsareinsertedto relievebuildupofuidinthebrain(crea ngincreasedintracranialpressure)duringtheacute carestage.Theyusuallyremaininplaceandgenerallyoernoproblems.However,iftheshunt becomesclogged,theremustbeasurgicalrevisionorreplacementtocorrectthemalfunc on.A malfunc oningshuntwillcontributeno ceablytoasuddendeclineinperformance. Prescribeddrugsforseizurecontrolorbehavioralmanagementmustalsobenoted.Thesedrugs, whilehelpfulinmaintainingmedicaland/orbehavioralstability,mayhavesideeectsthat impedejobperformance.

Leisure Time Activities


Leisure meac vi esshouldbeexamined.Iftheclientisfortunateandhasremainedsocially ac vefollowingthebraininjury,thecounselorshouldconsiderhowhe/shemaintainsleisure meac vi es.Theskillsneededtomaintainsocialcontactscanbeagoodindicatorofsuccessin thejobmarket.Thecounselorshouldalsoexploreatthispointwhethertheindividualisinvolved inbraininjurysupportgroups.(www.biaoregon.org/supportgrp.html)

PostInjury Work History


Duringtheinterview,thecounselorshouldndoutwhetherthereisapostinjuryworkhistoryor whethera emptstoreturntoschoolorworkweremade.Thequalityoftheworkeortshould beexploredindetailwhenpossible.Sincetheclienthasbeenreferredforvoca onalservices,

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previousa emptsatreintegra onmaynothavebeensuccessful.Itisimportanttodetermine howrealis ctheclientspercep onisofwhattranspired,andhis/herselfreportofwork func oningshouldbeconrmedinconsulta onwithsignicantothers,formeremployersor teacherswheneverpossible.

PostInjury Education
Academiccreditsordegreesearnedpostinjurymeritspeciala en on.However,thedegree awardedsome meshasnoapplicabilityintherealworldandmayhavebeenearnedunder highlystructuredcondi ons.

Goals and SelfPerception


Itisimportantduringthisprocesstoaskthevoca onalcandidateaboutselfpercep ons regardingspecicinjuryinducedproblems.Thecounselorshouldgatherinforma ononthe quali estheclientpossessesthatmightrepresentstrengths.Usuallypeoplewithbraininjury willmen onproblemsinmemorybecausetheirsocialcirclehasforcedthemtoacknowledge thisdecit.Memoryimpairmentsbecomeselfevident,asdophysicallimita ons,whichclients areabletoreportreadilyandiden fyastheprimaryreasonfortheirinabilitytogain employment. Thisinterviewwouldalsobewellspentindiscussingtheclientspersonalgoalsandassessing howrealis ctheyarewhencomparedwiththeclientsabili es.Thecounselorshouldbeableto observewhethertheselfreportisbiasedbyanxietyduetotheinterviewsitua onorwhether theclientwhopresentsasunrealis cissimplyrespondingtoasocialneedforapproval,thatis, tolookgoodintheeyesofthecounselor.

History Prior to Injury


Informa ongatheredduringtheintakeinterviewmaybeincompleteor,insomecases,not totallyaccurate.Thecounselormustnowassemblethoseelementsofpreinjuryhistorythatcan bedocumentedbywri enrecord.Inthisway,thecounselorcon nuestocreateaportraitofthe personwhoisabouttobeginthevoca onalrehabilita onprocess. Counselorsmustbeawareoftheinjuryproducedphysical,cogni ve,andpsychosocialchanges, butmustalsokeepinmindthatwhoapersonwasbeforeinjuryiso enakeydeterminantof whohe/shewillbecome.Thetragiccircumstanceofabraininjurymaybluntaspectsofbehavior or,conversely,exacerbatethem.Armedwithpreinjuryinforma on,thewellpreparedcounselor canbegintoan cipatestylesofbehaviorthatmaybringsuccessinpar cularworksitua ons.

PreInjury Health History


Itisimportanttoobtainapreinjuryhealthhistorybecausepreexis ngmedicalailmentso en complicatebraininjury.Bothearlierinjuriestothecentralnervoussystemandcongenital anomaliesmayimplicatetherehabilita onprocess.Thepersonprohibitedsincebirthfromthe

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developmentofafullrangeoffunc onalcapaci espresentsaspecialchallenge,dierentfrom thatofonewhohadnosignicantproblemspriortoinjury. Ahistoryofsubstanceabuseorpsychiatricdisabilityalsomaycompromiseprospectsfor successfulvoca onalrehabilita on.Preinjurydrugabuseandalcoholismaddressapersonsstyle ofsocialadjustment.Themeresugges onofthispredilec onshouldalertthecounselortothe factthatthepoten alforthisbehaviorwillhavetobecloselymonitoredthroughouttheVR process.

PreInjury Education
Levelofpreinjuryeduca onala ainmentmustbeobtainedand,whenpossible,thequalityof educa onalperformance.Anyindica onofalearningdisabilitythatinterferedwiththenormal progressionofeduca onalachievementshouldbenoted.Thepresenceofalearningdisability maycomplicatetheVRprocess. Clientswithadvancedacademicorprofessionaldegreeswillo enpossessagreaterrangeof voca onalop ons.Sinceindividualswithbraininjuriesfrequentlyexhibitproblemswithrecent memory,thelengthof methathaspassedsincethedegreewasobtainedandtheamountof mespentinapplyingwhatwaslearnedmaybeveryrelevant.Mostpeopleretainmemoryfora repertoireofoverlearnedskillsdevelopedbeforetheinjury.

PreInjury Work History


Incompilingapreinjuryworkhistory,thecounselorshouldnotetheskillsthatweredemanded inpreinjuryoccupa ons.Theseskills,o enretained,suggestfurtherareasforvoca onal explora on.Thecounselorshouldalsolooktothejobtrainingexperiencesaswellasformal trainingrequiredforpreinjurywork.Retrievableskillsfromsuchtrainingmayexistandmay suggestfurtherareasforvoca onalrehabilita on.

Course of Rehabilitation/Reports
Withawarenessthatthecourseofrehabilita onishighlyindividualizedanddependentupona rangeofvariables,theVRcounselorshouldgatherallavailablerecordsfromthevarious repor ngdisciplines.Inmostcases,thismeansnursing,physicaltherapy,occupa onaltherapy, psychologyandneuropsychology,speechandlanguageservice,socialservicesandrecrea onal therapy.Thesereportstypicallydocumentfunc onalskillsacrossagamutofcommunityand workrelateddomains.Whenitisdeterminedthattheclienthastheappropriatedegreeof readinesstobegin,thecounselor,inconsulta onwithaneuropsychologistifpossible,should designtheindividualizedvoca onalrehabilita onplan. Someindividualsmayneverhavepar cipatedinconven onalrehabilita onprogramspriorto theVRinterview.Ifthisisthecase,theonlymeansofevalua ngthecurrentstatusof neurologicalandphysicalimprovementsistoacquirethemostrecentreportsofthemedical

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professionalswhocaredforthem.Thecounselorsprimaryconcerninreviewingtheserecords shouldbethestabilityofgainsmade.Thestabilityofimprovement,bothneurologicallyand physically,isadeterminingfactorinjudgingthe melinessofvoca onalinterven on.

Referral for PreVocationally Relevant Services

Whenwri enandorallydeliveredreportsaswellasobserva onmadeduringthecourseofa personalinterviewdonotindicatereadinesstoengageintheVRprocess,theVRcounselor shouldhavetheop onofreferringtheclientforfurtherservicesthatwouldenhancevoca onal readiness.Theseservicesmightincludetherapiesinanyoftherehabilita ondisciplines, programsthatwouldenhancecommunityindependence,volunteeringexperiences,oralternate choicesasnecessary. Thetypeofprogramorservicetowhichtheclientisbeingreferredshouldbeatthediscre onof thevoca onalcounselorwhohasmadethedetermina onthattheclientisnotready.For example,theclientwithproblemsina en onmayprotfromaperiodofcogni veremedia on designedtoamelioratethisspecicdecit.Eortsmadetoengagepeoplewithbraininjuriesin theVRprocessbeforetheyarereadyarenevercosteec veandmayservetodiscouragethe clientunnecessarily.

Working with the Vocational Rehabilitation Client


InorderforaclientwithbraininjurytogetthemostbenetfromtheVRprocess,thecounselor mayneedtoprovideaccommoda onsforsomeofthecogni veandpsychosocialchallenges facedbytheclient.Apointtorememberisthattheclientsa en onspanisshortandtheymay havelimitedmemory.Theirprocessingisdelayed.Therearuleofvetofollow:haveyour sentencesbenolongerthanveworks,pauseforvesecondsbetweeneachsentence,and havethelistbenolongerthanvesentences.Thefollowingissuesandstrategiesmayassistthe clientinge ngthemostoutoftheservicesoered.

Issue: Dif iculty remembering information


Aclientmayhavedicultyrememberingtasksfromdaytodayorinstruc onsprovidedbythe VRcounselor.He/shemayalsohavedicultyrememberingnewinforma on,whichimpacts learning.He/shemightforgetscheduledinterviewsorfollowupappointmentswiththeVRsta. Strategies:
Providewri eninforma onwheneverpossible. Encouragetheclienttowritedowninforma oninavoca onalrehabilita on

notebook.
Remindtheclienttorefertothenotebooko en.

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Encouragetheuseofadayplannerorcalendarforrecordingappointmentdates

andtaskstobeperformed.
Encouragetheclienttohaveafamilymemberorfriendprovideareminder

aboutappointments.
Calltheclientonthemorningofascheduledappointment.

Issue: Dif iculty focusing and paying attention


AVRagencyorprogramisabusyplacewithlotsofdistrac ons.Itiseasyforaclientwithabrain injurytohavedicultypayinga en oninthiskindofenvironment.Theclientmayappear uninterested,butinfactishavingproblemsfollowingconversa ons. Strategies:
Workinanareawithlimiteddistrac ons. Beawareofsurroundingnoisesthatmayinterferewithconcentra on,suchas

radios,otherpeopletalking,etc.Trytolimitthesenoisesasmuchaspossible.
Asktheclienttorepeatinforma onthatwasjustheardtomakesurethe

conversa onorinstruc onswereunderstood.


Besuretohavetheclientwriteinstruc onsdowninanotebookorjournal. Besuretohavetheclientsa en onbeforestar ngaconversa on. Refocustheclientsa en onifhe/shebecomesdistracted.(Forexample,John,

letmerepeatthatpointagain.Itsimportant.)
Reschedulethesessionforanother me;perhapsearlyinthedaywhenthe

clienthasmoreenergy.
Asktheclientifthereissomewayyoucanhelp.Forexample,John,youappear

distracted.IstheresomethingIcandotohelp?

Issue: Dif iculty with initiation


Asaresultofabraininjury,aclientmayhavedicultybeginningac vi es.Itmayappearthat he/sheisnotinterestedormo vated,butinsteadhe/sheneedsassistancetobeginworkingon tasks. Strategies:
Establishastructuredrou neofdailyac vi es.

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Breakdownac vi esintosimplersteps.Encouragetheclienttocompleteonetaskata

mebeforebeginningthenext.
Makeachecklistofac vi esthatneedtobecompletedeachday.Checkoeachtask

thatiscompleted.
Establish meframesinwhicheachtaskshouldbecompleted. Useaclockorwatchthatcanbeprogrammedtoringorvibratetoindicatethe

startofatask.
Provideremindersandencouragement.

Issue: Dif iculty with organization and planning


InordertobesuccessfulintheVRprocess,aclientmustbeabletosuccessfullycarryoutthe plan.Thismaybedicultforapersonwithabraininjurywhohasproblemswithorganiza on andplanning. Strategies:
Developawri enplanandincludetheclientinthedevelopmentoftheplan. Breakdowntheplanintosimplersteps,withclearanddetailedinstruc onsofhowto

completeeachstep.
Assigndierentac vi esforeachdayoftheweek.Forexample,onSundaylookinthe

wantadsandcirclejobleads,onMondaymakephonecalls,onTuesdaysendout resumes,etc.
Developachecklisttoensurethateachstepoftheplangetsaccomplished. Reviewtheplano entomakesurethatitisunderstoodandthatitisworking. Oerpraiseforajobwelldone.

Issue: Dif iculty with decision making.


Followingabraininjury,aclientmayhavedicultymakingdecisions.Iden fyingwhichjobto pursue,decidingwhattowearforaninterview,oransweringinterviewersques onsmaybe dicult.Aclientmayactimpulsivelyandnotthinkthroughtherelevantop ons. Strategies:
Helptheclientiden fywhattheop onsaretoapar cularproblem. Discusswiththeclienttheadvantagesanddisadvantagesofeachop on.

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Havetheclientwritedown(orassisthiminwri ng)thepossibleop ons,alongwiththe

prosandconstoeach.
Encouragetheclienttostopandthinkbeforemakingadecision.

Issue: Dif iculty in social situations


Ge ngalongwithcoworkersandbossesisasimportanttokeepingajobasbeingableto performthejobtasks.A erabraininjury,clientsmaynothaveaclearunderstandingofthe impacttheirbehaviorhasonothers.Theymayhavedicultyengaginginconversa onandmay notalwaysbesensi vetosocialboundaries.Thismaybearoadblocktodoingwellonthejob. Strategies:
Provideclearexpecta onsforappropriatebehaviorsattheVRprogram.Provideposi ve

feedbackforexpectedbehavior.
Encouragetheclienttoconsidertheconsequencesofhis/herac ons. Ifundesiredbehavioroccurs,discusstheissueprivately,inacalm,reassuringmanner.

Reviewexpectedbehaviors.
Beforeanintervieworappointment,discusswiththeclientthetypesofques onsthat

canbeexpectedandgureoutwiththeclientthebestanswerstotheseques ons. Similarly,preparewiththeclientques onsthatshewantstoask.


Roleplaytheinterviewsitua onwiththeclientandgivehonestfeedback.Rehearseun l

theclientappearscomfortableansweringandaskingavarietyofques ons.

Issue: Dif iculty controlling emotions


TheVRprocesscanbepar cularlystressfulforapersonwithabraininjury.Accep ngones limita ons,understandingonesstrengths,anddevelopingnewvoca onalgoalscanbe overwhelming.Inaddi on,a endingnewprograms,mee ngnewpeople,andlearningnew rou nesisachallenge.Asaresultofthebraininjury,apersonmayhavedicultycontrolling emo onsinthesestressfulsitua ons. Strategies:
Expecttheunexpected.Alwaysbepreparedtodealwithasitua on,evenifitisatan

inopportune me.
Trytoremaincalm.Bymodelingcalmbehavior,itcanhelptheclientmodifyhis/her

behaviorandmightpreventthesitua onfromescala ng.

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Takethepersontoaquiet,moreprivate,area.Givehim/herafewminutestocalmdown

andregaincontrol.
Redirecttheclienttoadierenttopicorac vity. Understandthattheeectsofbraininjurymaypreventtheclientfromfeelingguiltor

empathy.
Provideconstruc vefeedbacka erapersonhasregainedcontrol. Usehumorinaposi ve,suppor veway.

Issue: Dif iculty with selfawareness


Apersonwithabraininjurymayhavedicultyaccuratelyperceivinghis/herstrengthsand weaknesses,par cularlythoseareasthathavechangedsincethebraininjury. Strategies:
An cipatepossiblyskewedselfpercep ons. Asktheclienttodiscussherstrengthsandweaknesseswithpeoplewhoknowhis/her

(familymembers,friendsandrehabilita onprofessionals).
Iftheclientlosthis/herjoba erthebraininjury,discusswithhertheproblemsthatled

uptothedismissal.Iftheclientisunsure,asktheclientifhe/shewouldbecomfortable returningtothepreviousemployeranddiscussingtheissues.
Astheclientgainsmoreinsightintoherstrengthsandweaknesses,discussthis

informa onwiththeclient.Encouragetheclienttokeepajournaloftheseinsights.
Provideposi ve,construc vefeedback.

V. EMPLOYMENT OPTIONS
Traditional Vocational Rehabilitation Setting
Thetradi onalVRservicedeliverymodelforthemajorityofclientsconsistsofvoca onal evalua on,voca onaltrainingandjobplacement,inthatorder.Thismodelassumesthatthe clientiscapableofindependentlytransferringwhathasbeenlearnedfromonese ngto another,e.g.,transferringskillslearnedfromtherehabilita onfacilityortrainingprogramtothe job.However,thedecitsofmanyclientswithbraininjuryincludeimpairedmemory,slow

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informa onprocessingskills,andimpairedabilitytogeneralizenewlylearnedinforma onthe veryskillsnecessarytocompleteatradi onalvoca onalrehabilita onprogramsuccessfully. Clientswithbraininjuryo enarebe erservedbyaPlaceTrainmodel,asopposedtothe tradi onalTrainPlacevoca onalmodel.

Limitations of Traditional Vocational Evaluation


Tradi onalvoca onalevalua onsystemshavebeenillequippedtomeetthespecialneedsof peoplewithbraininjuries.Standardizedtestsofintelligence,personality,ap tude,interestand achievementtypicallyprovidescoresthatindicatehowanindividualcompareswithnorm groups.Peoplewithbraininjuriesareo encapableofdisplayingareasorpocketsofhigh achievementonthosestructuredtestsofdiscreteskills.Theresultsyieldedbymanyofthese testsarepredicatedonoldlearning,i.e.,awellrehearsedrepertoireofpreinjuryskills.An excellentexampleofascorethatcanmisrepresentthepoten alofaclientisverbalIQ,derived fromintactmateriallearnedbeforetheinjury.Unfortunately,thesetradi onaltoolsandthe evaluatorswhousethemassumeasystemicintegrity,andpeoplewithbraininjuriesdonot conformtothenormalpopula onsuponwhichthesetestswerestandardized.Thecomponent thatpreventstheseinstrumentsfrombeingvalidpredictorsofsuccessistheinabilityofthose withbraininjuriestointegrate,applyandgeneralizemanyoftheskillsthataretested.Most standardizedexamina onsdonotaddress(otherthantheadministratorsobserva ons)ormake allowancesfortheproblemareasthatposethemajorbarrierstosocial,educa onaland voca onalreintegra on.Thatis,theyprovidequan abledatabutmakenoprovisionfor includinginreportsofscoresanassessmentofthequalityofperformance. Tradi onalVRsystems,withagrowingawarenessthatindividualswithbraininjuriesareunable torespondtothesetestsinwaysthataccuratelytranslatetofunc onalskills,arenow recognizingtheneedforalterna vemethodsoftes ngandevalua on. Standardizedvoca onaltes ngmeasuresareusefuliftheyarecarefullyadaptedtoaddressthe skillcapaci esofclientswithbraininjuries.Examiningtestresultswhilerecognizinghowthe clientcompletesthetestandwhatcogni vestrengthsandweaknessesareevidentcanprovide invaluableinforma onaboutlearningandperformanceissues.Whenadministeredcrea velyby acounselorfamiliarwithfunc onalbehaviorscommonlyfoundinthispopula on,theresultscan beusedtodetermineappropriatetypesofentryleveljobplacements. Theintroduc onoftradi onalhandson,situa onalassessments(ashorttermmonitoringof workperformanceinanactualse ngasopposedtoastandardizedtes ngenvironment)asa meansofmeasuringvoca onalpoten alhasmetwithlimitedsuccessinthispopula onwhen appliedinthemannerusedbymostvoca onalworkevalua onprograms.Itislimitedbecause mostclientswithbraininjuriesareillequippedtoengageinonthejobworksitua onswithout somepreparatoryguidance.

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Mostclientsretainapictureofthemselvesfunc oningatpreinjurylevels.Itisunrealis cto an cipatewholeheartedpar cipa oninasitua onalassessment,whichusuallybeginsatentry level,byclientswhomayclingtoaviewofthemselvesasfunc oningattheircapacitybeforethe injury.Suchpar cipa onispossibleonlyfollowingapersonaladjustmenttodisability;an adjustmentthatincludesabeginningawarenessandacknowledgementofinjuryimposed func onallimita ons.Developingthisessen albasicdegreeofawarenessmustbeaccomplished beforeengagingtheclientwithabraininjuryinanyvoca onalevalua onprocess. Oncetheindividualhasasenseofawarenessofhis/herfunc onallimita onsandawillingnessto accommodatetheselimita onsinaworkse ng,amorerealis cevalua oncanbeconducted. Implementa onofaskillfullydesignedsitua onalassessmentfollowedbyapreparatoryperiod tohelptheindividualbecomeawareoflimita onscanprovidetheVRcounselorwithanexcellent opportunitytoobservethequalita veaspectsofworkbehaviors.Itisthevehiclethatcanallow theVRcounselortodesigncompensatorymeasures,providestructureandsupportsystems,test autonomy,gentlyconfrontinareasthatrequiremodica on,and,ifprovidedwhentheclientis ready,canbetheop malguidetowardvoca onalreintegra on.

Graduated Placements
Thedemandsofacompe vejobaresignicantlygreaterthanthosefoundinmost rehabilita onfacili esandarealmostaquantumleapformanyclientswithabraininjury. However,manyclientscanmakethetransi onifitoccursslowly.Forexample,onemethod mightbeginbyplacingtheclientinavolunteerposi ononapart mebasis,thengradually transferringhim/hertoapart mejob,andul matelytoafull mejob,allunderthedirec onof acommunityreentryspecialist.Anynumberofvaria onsofthistechniqueispossible.Thekeyis tointroducenewdemandsinsmallenoughincrementsfortheclienttohandle.Another advantageofgraduatedplacementsistoincreaseaclientsawarenessthataddi onalskillsare neededbeforefull mecompe veemploymentcanbeseriouslyconsidered.Professionalshave foundthatclientswhoworkonatrialbasisinthecommunityo enreturnwithnewawareness oftheobjec vesoftherehabilita onprogram.Theybecomeawarethattreatmentsugges ons madebytherehabilita onprofessionalmayindeedbenecessaryforsuccessfulvoca onal func oning.Atemporaryplacementcanbeusedtoimproveappropriateworkbehaviors. Frequently,clientswilldemonstratemarketablevoca onalskillsbutwilldisplaybehaviorsthat wouldresultinjobloss.Fortheseclients,avolunteerworksitewithrealworldsupervisorshas provenbenecial.O entheclientmorereadilyacceptssupervisorycri cismfromsomeone outsidetherehabilita onfacility.

Supported Employment
Supportedemploymentisaspecialtypeofplacementthatallowsforcon nuedtreatment throughouttheVRprocessandhasprovenbenecialforclientswithbraininjury.Itisdenedas compe veworkinanintegratedworkse ngwithongoingsupportservices.Theadvantagesof usingasupportedemploymentapproachwithclientswithabraininjuryaremany:

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Itrestorestheclientsiden tyasaworkerandprovidesnancialcompensa onforreal

work.
Theplaceandtrainapproach,asopposedtothemoretradi onaltrainandplaceVR

model,allowsforimmediatereentryintoarealworkse ngandisthebestwayforthe clientwithabraininjurytolearnworkskillsandappropriateworkbehaviors.


ItenablesVRstatoassessandremediatecogni veandbehavioraldecitsinthereal

workse ng.
ItallowsVRstatodevelopcompensatorystrategiesforthespecicjobtasksthatare

assigned.
Itallowsonsiteadvocacyandinterven onwiththeclientssupervisorwhen

problemsoccur. Manypeoplewithbraininjuryneedthelongterm,ongoingsupportthatsupportedemployment providestobesuccessfulonthejob.Whenstar nganewjob,theclientneedsassistance learningjobtasks,developingcompensatorystrategies,andadjus ngtothenewrou ne.As me goeson,jobresponsibili es,supervisorsand/orcoworkerschange.Thepersonwithabraininjury mayhavesignicantdicultyadjus ngtothenewsitua onorlearningnewrou nes.Without periodicoversightfromthesupportedemploymentteam,thepersonmaybeterminatedbefore realizingthataproblemexists.

Use of a Job Coach


Aprincipleunderlyingthemeofsupportedemploymentistoprovideongoingsupportatthejob sitetohelpclientsfunc oninanintegratedworkse ng.Thepersonwhoprovidesthissupportis o encalledajobcoachorjobcoordinator.Thisindividualprovidesongoingsupportaslong asneeded.Astheclientlearnsthejob,thecoachwillspendless meinonthejobsupport. Ongoingsupportmayincluderetraining,jobmodica onsandmee ngswithsupervisorsandco workers. Ajobcoachiso envitaltothesuccessfulplacementofclientswithbraininjuries.He/shemust beawareofthestrengthsandweaknessesoftheclientandwhat,ifany,compensatory techniquesareusedbytheclienttoovercomecogni vedecits.Thejobcoachmayneedto developspecicstrategiesatthejobsitetoassisttheclientinperformingtheessen al componentsofthejobandmonitoringworkbehaviors.He/shemustalsobeabletointerveneif problemsariseatthejobsite. Itisessen althejobcoachfunc onasaneducatoroftheemployerandotheremployeesatthe site.Onecannotemphasizetoostronglytheneedtoeducateemployersaboutbraininjuryin generalandaboutthespecializedneedsoftheindividualclientinpar cular.Forexample,the

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employerhastobeawareofthestrengthsandneedsoftheclienttoavoidunrealis c expecta onsorrequiringmorethantheclientscapabili eswillallow. Thejobcoachisalsoinanidealposi ontosetupnaturalsupportsatthejobsitetoincrease theclientschanceforsuccess.Thejobcoach,withtheapprovaloftheclient,canenlistthehelp ofwillingcoworkersandmanagerstoprovidesupporttotheclientasneeded.Thisinvolves educa ngtheselectedcoworkerand/ormanageraboutthetypesofcompensatorystrategies thatcanhelptheclientbestperformhisjob,andteachingthemhowtocuetheclientto implementthesestrategiesasneeded.Theseindividualsshouldalsoknowtocontactthejob coachwithanyques onsorconcerns,par cularlyiftheyseeadeclineintheclientsjob performance.

The Role of the Job Coach


1. Establishtrust Establishrela onshipswiththeclient,thefamily,andtheemployerthatarebased ontrustandhonesty. 2. Respectothers

Respectthevaluesandinterestsoftheclient,thefamily,andtheemployer.Always maintainarespec uldemeanor. 3.Communicate

Constantcommunica on,bothoralandwri en,withtheclient,familyand employeriskeytosuccess.Donttakeanythingforgrantedwriteeverythingdown andsharetheinforma onwithallpar es. 4.Evaluateskillsandbehaviors Performsitua onalassessmentsinavarietyofenvironmentsandusingavarietyof taskstounderstandtheclientsstrengthsandweaknesses.Evaluatewhattypeof compensatorystrategiesworkbest. 5.Makegoodjobmatches

Findajobthatmeetstheinterests,abili es,andtoleranceleveloftheclient. 6.Doathoroughjobanalysis Learneverythingaboutthedemandsofthejobsbeforeplacement.Reviewyour ndingswiththeemployertoensurethatthejobtasksareunderstood.Provide everythingtotheemployerinwri ng.

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7.Establishastructuredworkdayanddependablerou ne

Unplannedchangesinjobdu escanprovedisastrousforapersonwithabrain injury.Educateemployersabouttheneedtomakechangesslowlyandin consulta onwiththejobcoach. 8.Developcompensatorystrategies

Developcompensatorystrategiesthatworkfortheclientinperformingthejob tasks.Astheclientbecomesfamiliarwiththejoborasjobtaskschange,make adjustmentstothestrategies. 9.Bewatchfulofbehavioralissues

Inappropriatebehaviorscancausemajorproblemsonthejob.Useacollabora ve approachtoiden fybehaviorsthatneedtobemodiedandenlistthecoopera on oftheclienttomakenecessarychanges. 10.Monitorstamina

Fa guecaninterferewithjobperformance,memoryandbehaviors,especiallyona newjob.Workwiththeemployertoadjustworkschedulesasneeded. 11.Providelongtermsupports Longtermfollowalongservicesforclientswithbraininjuryareessen altomonitor performancelevelandprovideinterven onasneeded.Encouragetheclientandthe employertocontactthejobcoachattherstsignofaproblem.

Job Placement Considerations


ThefollowingstepsshouldbetakenbytheVRcounselorpriortoplacingaclientwithabrain injuryonaworksitetoavoidaninappropriatematchandasitua onthatpoten allysetsthe clientupforfailure.

Selectivity
Theplacementmustbeconsistentwiththeclientscogni ve,physical,andpsychosocial strengthsandweaknesses.Moreover,theclientsinterests,abili esandap tudesmustalsobe considered.

Job Analysis
Thereareavarietyoftechniquesdesignedtoorganizeandevaluateinforma onrelevanttothe performanceofajob.Fortheclientwithabraininjury,thatanalysismustcontaininforma on

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withrespecttothephysical,emo onal,andcogni veelementsnecessarytoperformthejobat theobservedsite.Thedemandsofthejobcanthenbecomparedwiththestrengthsand weaknessesoftheclientpriortoplacement.

Placement with Education and Training


Theemployerandworksitesupervisorsmustbefullyawareofaclientsstrengthsand weaknesses.Aninformedsupervisorislesslikelytomisunderstandbehaviorsthatonthesurface mayappeartobewillfulanddeliberate.Forexample,aataectduetoneurologicalfactorsmay bemisinterpretedasalackofmo va on.Equallyimportantiseduca ngtheemployerthat sa sfactoryperformanceononetypeofjobdoesnotnecessarilyimplythattheclientshouldbe promotedtohigherleveljobs.Again,thenewjobshouldbeanalyzedtodeterminewhetherthe clientiscapableofperformingitsindividualcomponents.

Ongoing Supports
Eec veplacementassumestheavailabilityofanongoingsupportsystem.Longterm coordina onbetweentheVRteam,theemployerandtheclientisessen altoensurethat necessarysupportsfortheclientareinplace.

Job Accommodations
Thekeytoasuccessfuljobplacementistheprovisionofnecessaryjobaccommoda onsandthe developmentofcompensatorystrategiesatthe metheplacementismade.Eachclientwitha braininjuryisuniqueandwillrequirestrategiesthataddressthespecicstrengthsand limita onsthathe/shepresents.Wheneverpossible,consultwiththerehabilita onteamandthe neuropsychologisttoassistinestablishingthebestpossibleaccommoda ons.Belowisalistof accommoda onsthatcanserveasastar ngpointinconsideringwhataclientmightneed.

Memory:
Usenotebooks,calendars,ors ckynotestorecordinforma onforeasyretrieval. Providewri enaswellasverbalinstruc ons. Allowaddi onaltraining me. Providewri enchecklists. Provideenvironmentalcuesforloca onsofitems,suchaslabels,colorcoding,orbulle n

boards.
Postinstruc onsoverallfrequentlyusedequipment. Taperecordmee ngs,conversa ons,andinstruc ons. Useelectronicorganizers(PDAs,handheldcomputers,voiceorganizers,watches,andcell

phones).AnonlineCatalogofPortableElectronicDevicesforMemoryandOrganiza on canbefoundontheBrainInjuryAssocia onofAmericaswebsiteatwww.biausa.org/

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pda.html.ThebestresultscomefromusingtheiTouchwhichusespicturesratherthan morecomplexinstruc onsthatfrequentlyarenotrememberedcausingfrustra on.

Other memory strategies:


Usemnemonictechniques(anorganiza onalstructureonverbalinforma ontocue

recallofseveralelements.) Example:Aclericalassistantrecallshersequenceofjobdu esbyrememberingtheword CODE. C=clockin O=openmail D=delivermail E=enterdata


Useimagerytechniques(theprocessofusingmentalpictures/imagesforinforma onto

berecalled.) Example:Aclericalassistantvisualizesherselfwalkingaspecicroutetoassistin rememberingtheroutefordeliveringthemail.


Usenumbergrouping(recallingnumbersbyreorganizingthemintofewerelements.)

Example:Aclerkworkingatanautosupplycompanyneedstoremembertopullitems basedonafourdigitcode.Helooksatacodingbookandseesfournumberssuchas9,5, 3,2.Insteadofrememberingthenumbersindividually,herecallstheinforma onas95 and32.


Useofverbalrehearsal(repea ngoutloudkeyinforma ontohelprecallingthe

informa on.) Example:Adataentryoperatorcomestoworkandsetsupherworksta onbysaying aloud:Turnoncomputer.Turnonmonitor.Entermypassword.Hitenter3 mes,etc.

Maintaining Concentration:
Reducedistrac onsinworkareas(whitenoisesoundmachinesorlisteningto

instrumentalmusicmaybehelpful).
Providespaceenclosuresoraprivateofce.

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Reduceclu erintheworkenvironment. Simplifylargeassignmentsbybreakingthemintosmallertasks. Changeligh nginworkarea(eithermoreorlesslightdependingonneeds). Arrangeforuninterruptedwork me.

Organiza on:
Makedailytodolistsandcheckoitemsascompleted. Useacalendarsystemtomarkmee ngsandtaskdeadlines. Useelectronicorganizers(PDAs,handheldcomputers,voiceorganizers,watches,and

cellphones).AnonlineCatalogofPortableElectronicDevicesforMemoryand Organiza oncanbefoundontheBrainInjuryAssocia onofAmericaswebsite: www.biausa.org/pda.html.


Establishaneec velingsystem. Planrou nemee ngswiththesupervisor,reviewworkprogress.

ProblemSolving:
Providewri enschema csofproblemsolvingtechniques(i.e.owcharts). Restructurethejobtodecreasetheamountofproblemsolvingrequired. Assignasupervisororcoworkerwhoisavailabletoanswerques onsandreviewwork

progress.
Allowextra metoaccomplishjobtasks.

Fa gue/Stamina:
Scheduleperiodicrestbreaks. Allowaexibleworkscheduleanduseofleave me. Allowworkfromhome. Reduceworkplacestress,reducephysicalexer on.

Stress:
Providesensi vitytrainingtocoworkersandsupervisors. Allowbreakstousestressmanagementtechniques. Providepraiseandencouragement. Refertocounselingoravailableemployeeassistanceprograms. Evaluatewhetherjobdemandscanbechangedtoreducestresslevel.

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VisionImpairment:
Providewri eninforma oninlargeprint. Changeligh ngandincreasenaturalligh ngwheneverpossible. Provideglareguardforcomputermonitors. Consultwiththerehabilita onteamoravisionspecialistforspecicrecommenda ons.

WorkingEec velywithSupervisors:
Providewri enjobdescrip onswithclearlydenedresponsibili esthatarereviewed

frequently.
Reviewjobperformancefrequently. Provideposi vefeedbackandpraiseforgoodwork. Clearlydeneinwri ngtheconsequencesofpoorjobperformanceorinappropriate

workbehaviors.

Placement Rede ined


Full me,compe veemploymentmaybetheidealobjec ve,buttherealityisthatmany clientswithabraininjuryareincapableofachievingit.Therefore,abroaderdeni onof placementishelpfulwhenaddressingtheneedsofthispopula on.Jobplacementcanbe redenedascommunityreentry,includingfull meorpart mecompe veemployment, supportedemployment,andvolunteeremployment.Integra onoftheclientintothe communityandtheprovisionofsuppor veservicesareongoingneedsthroughoutthedura on oftheclientsplacement.Jobplacementcannotbeanal,nonsupportedstepforthis popula on.Specializedtreatmentthroughouttheen rerehabilita onprocess,includinglong term,followalongservicesa erplacement,mustbemadeavailabletoclientswhohave sustainedbraininjuries.

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VI. INVOLVING THE FAMILY IN THE VOCATIONAL PROCESS


Whilefamilyinvolvementinthevoca onalprocessisanimportantfactor,itmustbepointedout thatnotallfamiliesproduceaposi veinuenceinthevoca onalprocessoftheirlovedone. Familiesmaypushforunrealis cvoca onalgoalsorbeunabletocarryoutaplanofac onto producethebestvoca onaloutcomefortheindividual.Familydynamicsaswellasthefamilys valuesystemplayimportantrolesindeterminingtheresponsetoprojectedvoca onalgoals.

Family Expectations and Values


Theanswertotheques on,Whatareyourexpecta ons?willo enrevealagreatdealof informa onaboutthefamilysystem:theirneeds,values,adjustmenttoandaccommoda onof thefamilymemberwiththebraininjury.O enanindividualsiden tywithinhis/hercommunity andfamilyisdirectlyrelatedtoemployment.Manypeopleformassump onsaboutthelevelof educa on,income,livingenvironmentandlifestyleofanindividualbaseduponthatpersons typeofemployment.Thisa tudereectstheimportanceworkholdsforpeopleintermof addressingstrong,deeplyfeltneedsandvaluesandelici ngpsychologicalprotec ve mechanisms.Itfollowsthatworkservestojus fyonesvalueandiden fyonesworthinsociety. Whilethemostobviouspurposeofworkingisprovidingnancialsupport,mostpeopledonot workfornancialsupportalone,noristhisnecessarilythemajorreasonforchoiceofwork. Rather,mostpeoplechoosecertainjobsbecausetheyfulllcertainneedsandaddressvalues thattheindividualandhis/herfamilyhavedevelopedoveralife me.Itisimportanttoconsider therolesprovidedbyfamiliesintheprocessofadjustmenttowork.Atoneendofthespectrum arefamiliesdeterminedtobeproduc veandselfsuppor ng(describedaspossessingawork ethic).Attheotherendarefamilieswithli leornoinvestmentinworkasawayoflife.These la erfamiliesmaysubtly(orobviously)transfertheira tudetowardworkasnonessen aland valuelesstothememberoftheirfamilythathasabraininjury.Certainlyanindividualwhocomes fromafamilywithrmlyestablishedworkethicsmaybeabe ervoca onalrehabilita on candidatethantheonewhosefamilyisnotmo vatedtowork.Whileprofessionalsshouldnot judgethevaluesystemsofindividualfamilies,includingthosewhoplaceotherrewardsabove thevalueofconven onalwork,itisofpragma cimportancetorecognizetheinuenceofsuch valuesystemsonapersonwithabraininjuryandadjustvoca onalrehabilita onaccordingly.

Effects on Family Structure


Familiesofindividualswithbraininjuriesmustrealizetheinescapableeectsonandchanges withinthefamilystructure.Ifthepersonwithabraininjuryistheincomeprovider,therewill likelybechangesinmarriage/familyrela onships,income,economicstabilityandsocialstatus. Oneormorefamilymembersmaybeforcedtoassumetheroleofprovider.Itisimportantto rememberthatsudden,unexpectedshi sinroles,goalsandresponsibili esa ertrauma cbrain injuryaectallfamilymembers.

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Denial
Duringthevoca onalrehabilita onprocess,manyfamiliesappeartobestuckina phaseofdenial.Ifthefamilyhasextremedicultyaccep ngtherealityofthereduced voca onalreintegra onplans,thismessageiso enpassedontothepersonwiththe braininjury.Thismayhamperthebeginningofthevoca onalprocessattheentrylevel. Peoplewithbraininjuriesrememberclearlyhowtheyperformedpriortotheirinjury andareo enreluctanttotakeonataskthatisviewedasboringornonchallenging. Familieswillo ensupportthisa tudeandatthesame mereinforceidealized voca onalgoals.

Bargaining and Splintered Skills


Atthestageofadjustmentwhentheindividualismakingsubstan alphysical improvement,he/sheo enfeelsreadytoreturntohis/herpreviouslifestyle,including work.Itisfrequentlyobservedthattheindividualatthispointo endisregardsor minimizestheimpairmentofskillssuchasproblemsolving,reasoning,judgmentand organiza on,allofwhicharecri calforvoca onaladapta onandcommunityreentry. Whilethepersonmayrecognizesomelimita ons,he/shefeelsdeservingofarewardfor achievementinphysicalrehabilita on. Frequently,familymemberswhodesiretoseetheindividualfunc onatahigherlevel willsupportthistypeofthinking.Thisisthepointatwhichbargainingtakesplace,i.e., whentheclientandthevoca onalcounselormustreachanagreementabouttheskills thatcanberealis callyperformedbytheindividual.O enthefamilydoesnotseethat theskillsofitsfamilymemberwithabraininjuryaresplintered.Thepreviously interconnectedskillsarenolongercoordinatedandworkinisola onratherthanthe completesetofskillstheypossessedpriortothebraininjury. Voca onalcounselorsfacethedilemmathatjobsrelyingonsplinteredskillsdonotexist andthattherearefew,ifany,employerswhoarewillingtoredesignjobsthatrelyon oneortwolimitedskills.Evenifthevoca onalcounselorlocatedaperfectjob,the individualwoulds llneedproblemsolving,communica onandinterpersonalskillsin ordertogetalongwithcoworkersandsupervisors. Placingaclientinajobforwhichhe/shedoesnotpossesstherequisiteskillsmaycause embarrassmentorridiculeatthejobsiteoreventuallycausethepersontobe ostracized.Theindividualrisksalossofselfesteem,whichmaytake metorebuild. Also,certainjobscouldexposetheindividualtoharm.Inadangerousenvironment, cogni velimita ons,especiallyavulnerabilitytodistrac onorreducedsafetyjudgment, couldresultinanaccidentorinjury. Anotherdetrimentalresultofplacinganindividualonajobwhenhe/shepossessonlysplintered skillsisthepossibilityofacri calmistakecos ngtheemployermuch me,eortand/ormoney.

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ThiswouldalsoreectpoorlyontheVRprogramorprofessional.Moreover,avaluable employmentresourcecouldbelost. VRcounselorsmustremainneutralandobjec vetomanageeec velythedelicatesitua onsof familiesa emptedbargaining.Therststepintherightdirec onistohelpthefamilygainan appropriateperspec veontheprogressthathasbeenmade.Thesecondstepmightbeto encouragethemtolisttheprosandconsofcon nuedrehabilita onora emp ngajob placement.Throughdiscussion,thecounselorcanfacilitatemovementtowardacceptanceofthe situa onwhilemaintaininganobjec veandsuppor verole.Iden fyingjobsthatrequirethe skillstheindividualcurrentlypossessescanbeagroupeort.Theindividual,thefamilymembers andtherestoftherehabilita onteamcanhelpthecounselor.TheVRprofessionalmayalsobe preparingalistofjobsinwhichtheindividualmightbesuccessfulwithanexpandedrepertoireof skills.Alistofpoten aljobop onscanhelpallpar esrefocusandremainhopefulthataddi onal jobop onsmaybeappropriateinthefuture.Se ngupshorttermandlongtermvoca onal goalscanhelpboththeclientandthefamilyestablishanappropriatereturntoworkplanwhile s llholdingontothehopeofcon nuedimprovementinabili es.

Depression
Peoplewithbraininjuryo enexperienceadropinselfesteemstemmingfromthelossofa careeroremployment,alossofsocialiden tygenerallydenedbyoneswork,andguiltcreated byreducedearningcapacityandbecominganancialburdenonthefamily.Familymembersas wellastheclientmaybecomedepressedastheyeachan cipatealossofindependenceand individuallyrealizethattheirownfuturegoalsandplanswillhavetobeadjustedto accommodatetheneedsofthefamilymemberwithabraininjury.Voca onalcounselorsneedto usebothsuppor veandexploratorycounselingapproacheswiththedepressedclientandhis/ herfamilymembers.Counselorsshouldhelptheseindividualsreexamineandchallengetheirlong heldideasaboutpersonalaspira onsandgoalstheyhaveestablishedtofeelworthwhile. Counselorsmayalsoneedtoexploretheindividualspreinjuryfeelingsanda tudestoward personswithadisability.Frequently,thesefeelingsarebasedonstereotypicalideassuchas equa ngdisabilitywithhelplessnessandthesick/pa entiden ty.Helpingboththeindividual andfamilymemberstoiden fytheirfeelingsoflosingcontrolcandiminishdepressivereac ons, andsupportthedevelopmentofworthwhile,contribu ngrolesinthehomeandcommunity. Aboveall,voca onalcounselorswillneedtoprovideac velisteningsupportandvalida onas theclientandfamilymembersexpresstheirsadnessabouttheirlosses. Adjustment Thevoca onalprocesscanbeviewedandusedbyprofessionalsasboththeculmina onofa successfulrehabilita onprogramandapsychotherapeu ctooltofacilitatemovementthough stagesofemo onaladjustment.Theskillfuluseofvoca onaltoolsandsitua onsinthe rehabilita onprocessshouldfacilitateemo onaladjustmentstolimita onsresul ngfrombrain

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injurywhileencouragingtheuseofprac calaccommoda onstrategies.Tosuccessfullyassist individualswithbraininjuryinbecominggainfullyemployed,voca onalcounselorsneedbothto focusonthedesiredoutcomeandalsotobecomeknowledgeableandsensi vetothe adjustmentprocessthatmustrstoccur.TheVRcounselorwillencountermanydierenttypes offamilyinvolvementthoughthevoca onalprocess.Dierentlevelsoffamilyinvolvementmay includetheinvolvedandsuppor vefamily;theinvolvedandunsuppor vefamily;orthe uninvolvedandunsuppor vefamily.Itisimportantforthevoca onalcounselortoconsider, understandandincludeallaspectsofthefamilyduringthevoca onalprocess.Professionals needtobesensi veandskilledinordertodesigninterven onsthatarehelpful, melyand culturallyandenvironmentallyappropriatetothefamilyandtheindividual.Successinthe voca onalrehabilita onprocessiso encommensuratewiththedegreetowhichprofessionals successfullyinvolvefamilymembersasaneededandvaluedpartofthisprocess.

VII. CONCLUSION
Workingwithaclientwithabraininjurycanbeextremelychallengingyetrewardingforthe voca onalrehabilita onprofessional.Thecounselormustunderstandwhotheclientwaspriorto injury,recognizethephysical,emo onal,andpsychosocialchallengestheclientfacesa erinjury, andestablisharealis cvoca onalplan.Thistakes me,knowledgeofbraininjury,and experience.Inaddi ontoworkingwiththeclient,theVRcounselormustbesensi vetothe needsofthefamilyandtheemployerincarryingoutthevoca onalplan.Finally,theskilledVR professionalmustrecognizethatvoca onalrehabilita onforthepersonwithbraininjuryisa slowando en mescomplicatedprocess,requiringpa ence,crea vityandthough ulness.

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VIII. REFERENCES
DepartmentofVeteransAairs,VeteransHealthIni a ve.Trauma cBrainInjuryA Con nuingMedicalEduca onProgram. EmploymentandDisability,SchoolofIndustrial&LaborRela ons.WorkingEec vely withEmployeesWhohaveSustainedaBrainInjury.CornellUniversity,NewYork,June, 2000. FawberH.,andWachterJ.JobPlacementasaTreatmentComponentoftheVoca onal Rehabilita onProcess,JournalofHeadTraumaRehabilita on(2)Vol.1,1987pp.2733 JobAccommoda onNetwork(JAN).JobAccommoda onsforPeoplewithBrainInjuries. OfceofDisabilityEmploymentPolicy,U.S.DepartmentofLabor,contract#J9M2 0022. MayoClinic.UnderstandingBrainInjury:AGuideForEmployers.Rochester,Minnesota, 2000. McMahon,B.andShaw,L.WorkWorthDoingAdvancesinBrainInjuryRehabilita on. Orlando:PaulM.DeutschPress,1991. OklahomaDepartmentofRehabilita onServices.OklahomaVoca onalRehabilita on TrainingCurriculumforBrainInjury.OklahomaStateDepartmentofHealth,HRSAGrant H21MC06749. Silver,SaralynM.,M.S.,C.R.C.,HeadTraumaProgram,NewYorkUniversityMedical Center.Originalmaterialdevelopedforthishandbook,1991. Silver,SaralynM.,etal.FamilyandReturntoWork,Williams,J.andT.Kay.Head Injury:AFamilyMa er.Bal more:PaulBrookes,1991. Wehman,Paul,etal.SupportedWorkModelforPersonswithTrauma cBrainInjury: TowardJobPlacementandReten on,Rehabilita onCounselingBulle n,Vol31.June 1988. Wehman,Paul,andKreutzer,JereyS.Voca onalRehabilita onforPersonswith Trauma cBrainInjury.Maryland:AspenPublishers,1990.

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BrainInjuryAssocia onofOregon,Inc. POBox549 MolallaOR97038 Phone:(503)7403155Fax:(503)9618730 Helpline:18005445243 Website:www.biaoregon.org Email:Info@biaoregon.org

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