Vocational rehabilitation counseling of traumatic brain injury: factors contributing to stress

Journal of Rehabilitation,  April-June, 1993  by Rosalind R. Zuger

• E-mail
• Print
• Link

The vocational rehabilitation of persons with traumatic brain injury can be an arduous and stressful process, likely to place counselors and patients in oppositional roles. Persons with traumatic brain injury persist, often unsuccessfully, in resuming pre-injury vocational objectives, while counselors frequently persist in redirecting patients away from their pursuits, perceived by counselors as unrealistic. The persistence by patients and counselors to pursue their respective and discrepant objectives can place the vocational rehabilitation process at an impasse, exposing counselors to undue stress and exacerbating patient disatisfaction. Counselors need to identify the stressors contributed by both themselves as well as their patients, and reassess their approach in order to reduce the stress they experience and allow the process to advance.

One of the consequences of traumatic brain injury is its often enduring resistance to vocational rehabilitation efforts, specifically competitive placement.

Indeed, much of the available research on vocational outcome suggests that a majority of patients with moderate and severe brain injuries repeatedly fail in vocational endeavors (Wehman, Kreutzer, Sale, West, Morton, & Diambra, 1989). Peck, Fulton, Cohen, et al., (1984), report a 52% unemployment rate for a sample of 60 head injured persons over a 3 1/2 year period. Jellinek, Torkelson, & Harvey (1988), found a 59% unemployment rate for persons with traumatic brain injury, with an average of 4 years post injury. Ben-Yishay, Silver, Piatsesky, et al., (1987), report that less than 3% of head injured individuals treated in vocational rehabilitation programs were able to maintain employment for more than one year. In a study of 101 patients admitted to a head injury unit between 1977 and 1982, Rappaport, Herrero-Backe, Rappaport & Winterfield (1989) noted that 61% of those surveyed were unemployed at time of follow-up, with none returning to a professional level of functioning. This compares with 100% employment for these same individuals pre-injury (Rappaport, Herrero-Backe, Rappaport, & Winterfield, 1989). Jacobs (1988) reports from his survey of 142 randomly selected families from five Los Angeles based rehabilitation centers, that approximately 73% of traumatic brain injured survivors indicated that wages were not their principal source of income (wages were the primary source of income for nearly 78% of these survivors pre-injury).

What is especially noteworthy about these studies is the high percentage of unemployment/vocational inactivity, 6 years (Jacobs, 1988) and 10 years (Rappaport, Herrero-Backe, Rappaport, & Winterfield, 1989), post-injury.

As Burke, Wesolowski & Guth (1988) indicate, unemployment among this population is partly a consequence of diverse personality, behavioral and cognitive changes arising from pathophysiological alterations in the brain following injury. Indeed, Zasler (1989) notes that one of the principal factors limiting return to work is the behavioral/personality changes that commonly occur as a result of traumatic brain injury. Although the professional literature on traumatic brain injury and its sequelae reports unsuccessful vocational outcome, the supported employment model is cited as a successful alternative strategy for this population (Wehman, Kreutzer, Wood, et al., 1989), especially when post-injury placements are consistent with patient's pre-injury employment experiences and/or vocational interests. Thus, "successful" employment outcomes require a qualifier since those with brain injuries who enter or re-enter employment, frequently do so at a level below their previous positions or pre-injury expectations (Stambrook, Moore, Peter, Deviaene, & Hawryluk, 1990). In our experience (white collar/professional), this can be and often is unacceptable to the person with traumatic brain injury.

From our perspective, the vocational rehabilitation process is a partnership between the vocational rehabilitation counselor and the patient, whereby an attainable vocational objective has been targeted. However, for persons with traumatic brain injury with white collar/professional work history or interests, vocational objectives are typically discrepant with those of the counselor's, because patients believe that they can resume their pre-injury vocational pursuits. Thus, resistance to the vocational rehabilitation process replaces a cooperative effort toward rehabilitation. One of the results of this persistent resistance to the vocational rehabilitation process is a stressful impact on vocational rehabilitation counselors.

The purpose of this article is to identify and address the stressors experienced by counselors during the often complex and arduous vocational rehabilitation process of persons with traumatic brain injury.

Let us first look at the stressors with which we, as counselors, are typically presented that stem from the cognitive and affective sequelae of brain injury: