E m p l o y m e n tafter Traumatic B r a i n I n j u r y

Living with Brain Injury

This brochure was

developed for

friends, family

members, and

caregivers of

persons with brain

injury. It also may

be used in

discussions with

health care

professionals and

others about the

problems one may

face when living

with brain injury.

Employment after Brain Injury

James F. Malec, PhD & Rachel A. Scanlan, MS, CRCMayo Clinic, Rochester, MN

Contents:

Barriers to Employment after Brain Injury

Vocational RehabilitationServices

Social Security Administration (SSA)

Ticket to Work

The Vocational Rehabilitationand Employment Program forVeterans

Resources

About the Author’s

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Barriers to Employment after Brain Injury

Brain injury (BI) can leave anindividual with a number of persistentimpairments that interfere with finding andkeeping a job. These problems may becognitive (for example, difficulties withattention, memory, communication,reasoning, and problem-solving), physical(such as weakness or lack of coordinationin arms or legs, impaired vision, fatigue,sleep problems), emotional problems (forexample, vulnerability to depression,difficulty controlling anger or anxiety), orbehavioral (for instance, being impulsive,difficulty initiating or sustaining behavior).

There are other social barriers togetting a job after BI. Many peopleincluding employers and co-workers do notunderstand BI and may have fears orconcerns about employing or working witha person with BI. If a person with BI cannotdrive, alternative transportation to and fromwork may not be available. Although theVocational Rehabilitation (VR) system inthe U.S. can be an important resource, theVR system was designed to help peoplewith primarily physical disabilities.Consequently people with less visiblecognitive, emotional, or behavioralimpairments may have difficulty convincinga VR counselor that they are sufficientlydisabled to qualify for services. Thetraditional VR system depends on theperson applying for services to be"motivated" to work. Most people with BIthat apply for VR services are verymotivated to work. However, their cognitive,emotional, and behavioral problems maymake them appear unmotivated or evenhostile at times, resulting in their casebeing dismissed by the VR counselor.

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A number of special projects overthe last 20 years have shown thatsupported employment services can makea dramatic difference for people with BI toget and keep jobs. However, funding forsupported employment services is often notavailable, again because many people inthe U. S. do not understand BI. Somepeople feel that those who want to workwill "pull themselves up by their bootstraps"and get a job. Such people fail toappreciate that BI weakens people's"bootstraps" and that, for the price ofrelatively inexpensive supportedemployment services, people with BI canbe given the boost they need to get workand contribute to society in ways that morethan offset the cost of these services.

Because of these barriers, mostpeople with BI are not able to find andmaintain paid employment. Some peoplewith BI have such severe disabilities thatthey will never be able to work. For others,volunteering, education, or other unpaidactivities may be rewarding options.However, special projects and programsshow that many people with BI who werepreviously thought to be unemployable canbe employed-if the system works for them.A person with BI with the help of theirsignificant others or other advocates maybe able to make the system work for themand overcome barriers to employment. Therest of this booklet will briefly explain howthat can be done.

Vocational Rehabilitation Services

Each State has an agency to helppeople with disabilities find work. TheseState Vocational Rehabilitation Services(VR) have different names in differentStates. All are funded in part by the Federal

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government and in part by the Stategovernment. People who are disabled byBI are entitled to apply for VR.

The first obstacle that must beovercome in accessing State VR servicesis proving that one is sufficiently disabled torequire these services. State VR agenciesare required to serve people with the mostsevere disabilities first. VR agencies mayhave order of selection criteria to makesure that they are serving those who havethe most need. The most severeimpairments that people with BI have areoften not physical and consequentlyinvisible. If a question about severity ofdisability interferes with accessing VRservices, evaluations by a rehabilitationphysician and neuropsychologist areusually very helpful in proving thatimpairments resulting from BI are severeand extensive enough to meet criteria foradmission to VR services.

Once they are qualified for services,people with BI are best served by VRcounselors who have experience workingwith people with BI. Experiencedcounselors know and use a number ofspecial procedures that are critical forsuccess in VR with people with BI. In someareas of the country, BI is uncommon anda VR counselor with BI experience may notbe available. The person with BI, theirsignificant others, or other advocates willneed to help the VR counselor understandthe special needs of people with BI.Educational materials, such asUnderstanding Brain Injury: A Guide forEmployers (see Resources), may help VRcounselors who have limited experiencewith BI as well as prospective employers tounderstand what kinds of things areneeded for people with BI to be successfuland productive workers.

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Briefly, the most important elementsof successful VR with people with BI are:

Early intervention. The sooner aperson with BI starts thinking about andplanning to work, the better-even if therewill be months of rehabilitation before theyare realistically able to go to work.

Employer Education. Sometimespeople with BI do not want employers ortheir co-workers to know that they havehad a BI. However, if impairments due to BIare severe enough to qualify for VRservices, the person with BI is better offinforming the employer and immediate co-workers about the difficulties resulting fromBI. Most employers will help people withdisabilities once they understand that, withappropriate accommodations, the personwith BI can be a very reliable andproductive employee. A number ofprofessionals, such as a case manager,vocational counselor, social worker,rehabilitation therapist, andneuropsychologist, can assist the personwith BI in educating employers about theperson's specific needs, strengths, as wellas recommended accommodations andcompensation techniques. If a person withBI was a good worker prior to injury, theformer employer is often very supportive ofthe person with BI getting back to work tothe old job or another job for the sameemployer that better accommodates specialneeds resulting from BI. In some cases,employers qualify for financial incentives tohire people with disabilities. The employeewith identified disability may also qualify forwork accommodations under American withDisabilities Act (ADA; see below).

Work Trials. Sometimes it is verydifficult to know whether a person with BIcan do a job because their cognitive,emotional, and behavioral difficulties are so

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complex. Sometimes the person with BIthinks they can do the job and others don't,or vice-versa. The only reason the WrightBrothers got their airplane in the air wasthat, at some point, they decided to take itoff the drawing board and see if they couldlaunch it down on Kitty Hawk beach. Thebest way to know if a person with BI cando a job is to give it a try. If such a worktrial is successful, it can lead to a morepermanent job. If not, a great deal ofvaluable information will be gained aboutthe kind of work that best suits the personwith BI and about needed accommodationsand supports.

Supported Employment.Supported employment services can rangefrom an occasional reminder from a co-worker to having a job coach present tohelp the person with BI learn job skills androutines. Such services are often critical forpeople with BI to find and maintainemployment. Usually the more costlysupported employment services, such asjob coaching are required only until theperson with BI learns the job routine. Thenthe job coach can gradually fade out of thepicture in favor of natural supports, such asa written list of reminders or the occasionalreminder from a co-worker.

Place then Train. TraditionallyState VR help people go to work byinvolving them in training or school to learnjob skills before they find a job. However,people with BI often have troublegeneralizing new learning, that is, applyingwhat they learned in training or school tothe job. For this reason, it is much better toinvolve the person with BI in training on thejob. That is, once they have found a jobthat seems to suit them through work trials,additional training for the job should occuron the actual job site. A job coach may

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provide and involve co-workers to providesuch training.

Long term Follow-up. The mostcommon reason why people with BI losetheir jobs is that a change in the job occursthat interferes with their performance andupsets them emotionally. Such changescan range from a new supervisor to adifferent schedule to relatively minoradjustments in job duties. In some cases,changes may not seem that large toemployers or co-workers who consequentlydo not understand why the worker with BIis suddenly not performing well or isregularly upset at work. This type ofsituation can be quickly remediated by aknowledgeable VR counselor who identifiesthe change and helps the worker with BIaccommodate to it. Although the traditionalVR system does not support long-termfollow-up (that is, follow-up over the courseof years, not months), this type of long-term availability to workers with BI and theiremployers is critical to successful jobmaintenance for people with BI.Americans with Disabilities Act (ADA)

The ADA of 1990 is civil rightslegislation that makes it illegal todiscriminate on the basis of disability inemployment, public services, publicaccommodations, transportation, andtelecommunications. Title I of the ADAaddresses the area of employment andprohibits discrimination against a qualifiedindividual with a disability in the jobapplication process, hiring, firing,advancement, compensation, job training,and other terms, conditions, and privilegesof employment. For the purposes of theADA, an individual with a disability is aperson who:

has a physical or mental impairment that substantially limits

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one or more major life activitiesor has a record of such an

impairmentor is regarded as having such an

impairment.

A qualified employee or applicant with adisability is an individual who, with orwithout reasonable accommodation, canperform the essential functions of the job.

Reasonable accommodations arechanges or adjustments to a job or workenvironment that permit a qualifiedapplicant or employee with a disability toparticipate in the job application process, toperform the essential functions of the job,and to enjoy equal benefits and privilegesof employment.

Examples of reasonableaccommodations for people with BIinclude:

modifying examinations, training materials, or policies (for example, an untimed test or providing a reader or scribe)

modifying work schedulesjob restructuringreassignment to an open position

that better meets the special needs of the worker with BI

Reasonable accommodations canalso include recommendedcompensation techniques, such as:

more frequent breaksreduced distractionwritten instructions and checklistsdividing complex tasks into

smaller stepsa paper or electronic organizer

An employer must providereasonable accommodation for qualified

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applicants or employees with disabilitiesonce the individual's needs are knownunless the accommodations would causethe employer undue hardship. Employersmay be obliged under ADA to support theuse of compensation techniquesrecommended by medical rehabilitationproviders. However, employers are usuallynot required to pay for items like anelectronic organizer. Paying for moreexpensive items like these would usuallybe considered an "undue hardship."

An employer does not have to hirea person with a disability who is unable toperform all of the essential functions of thejob with reasonable accommodation. Onthe other hand, an employer cannot rejecta person with a disability only because thedisability interferes with performing minorduties that are not essential to the job.

Determining the best moment to tella prospective employer about the need forreasonable accommodation on the job is apersonal decision. Sometimes, applicantsare not aware they need a reasonableaccommodation until they have moreinformation about the job, its requirements,and the work environment. Someapplicants choose to inform an employerduring the application process after theybetter understand the job and itsrequirements. Others choose to wait untilthey have a job offer. It is best to let anemployer know as soon as it is realizedthat reasonable accommodation will beneeded for some aspect of the hiring oremployment process. An employer needsadvance notice to provide manyaccommodations, such as alternativeformats for written documents or adjustingthe time allowed for taking a written testthat is part of applying for a job. For peopleseeking work after BI, disclosure of their

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disability to the employer can be difficult.Individuals are encouraged to weigh thepros and cons of disclosure with someonefamiliar with employment issues, such as avocational counselor. An employer is notrequired to provide reasonableaccommodation until they are informed ofthe need for accommodation.

Social Security Administration(SSA)

The SSA makes disability paymentsunder two programs. While these twoprograms are different in many ways, bothare administered by the Social Securityand only individuals who have a disabilityand meet medical criteria may qualify forbenefits under either program. SocialSecurity Disability Insurance (SSDI) paysbenefits to people with disabilities andcertain members of their families if they areinsured. People are insured who have hadSocial Security taxes taken out of theirpaychecks for a specified period of time.Supplemental Security Income (SSI) paysbenefits to people with disabilities based onfinancial need.

The definition of disability underSSA is different than for other programs.SSA pays only for total disability. Nobenefits are payable for partial disability orfor short-term disability. Disability underSSA requires the inability to work. A personis disabled under SSA rules who cannot dothe same work as before and who cannotadjust to other work because of a medicalcondition. The disability must also last orbe expected to last for at least one year orto result in death. (See Resources abouthow to get an application for SSA benefits.)The law requires that SSA review each

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case from time to time to verify that theperson receiving SSA benefits is stilldisabled. People with disabilities whoreceive SSA benefits are responsible forletting SSA know if their health improves orthey go back to work. Benefits usuallycontinue until the person with a disability isable to work on a regular basis. There arealso a number of special rules, called workincentives, that provide continued benefitsand health care coverage to help peoplemake the transition back to work.

Ticket to Work

The Ticket to Work and Self-Sufficiency Program is an employmentprogram for people with disabilities who areinterested in going to work. The TicketProgram is part of the Ticket to Work andWork Incentives Improvement Act of 1999 -legislation designed to remove many of thebarriers that previously influenced people'sdecisions about going to work because ofthe concerns over losing health carecoverage. The goal of the Ticket Programis to increase opportunities and choices forSSA disability beneficiaries to obtainemployment, vocational rehabilitation (VR),and other support services for employment.Employment services may be obtainedfrom public and private providers,employers, or other organizations.

Under the Ticket Program, theSocial Security Administration (SSA)provides disability beneficiaries with aTicket they may use to obtain employmentservices from organizations calledEmployment Networks (ENs). The Ticketrepresents the fees to an EN for services.The Ticket Program is flexible andvoluntary. SSA beneficiaries are not

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mandated to participate and in most cases,ENs can chose which services they want toprovide, where, and to whom. Beneficiariesreceiving Tickets can contact one or moreENs to discuss services. Once anagreement between the beneficiary and ENis reached, the two work together todevelop a plan to assist the beneficiary inreaching his or her employment goal.

Each State has a Benefits Planning,Assistance, and Outreach (BPAO) Programthat helps Social Security beneficiaries withdisabilities make informed choices aboutwork. The BPAO programs provide workincentives planning and assistance (seeResources). Another offshoot of the Ticketprogram is a new service, called Ticket toHire, developed with the Department ofLabor to help employers locate and recruitskilled employment candidates withdisabilities. Ticket to Hire is a free nationalreferral service for employers to recruitworkers from the Ticket to Work program(see Resources).

The Vocational Rehabilitation and Employment Program for Veterans

The Department of Veterans Affairsoffers a program to help those who havean injury or illness from military service. If aveteran with BI wants and needs help toovercome employment difficulties orachieve more independent living after aninjury or illness from military service, thenhe or she should apply for VocationalRehabilitation and Employment benefits.

This program offers services andassistance to help veterans with service-connected disabilities prepare for, find, andkeep suitable jobs. Suitable employmentmeans employment that is both within a

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veteran's physical and emotional capabilityand that matches his or her pattern of skillsand interests. Depending on their needs,veterans can receive counseling,employment, training, and otherrehabilitation services.

In order to apply for this benefit, aveteran must have a VA establishedservice-connected disability for which he orshe is entitled to compensation. Generally,the disability compensation rating allows acounselor to evaluate whether or not theveteran qualifies for the program. Generallyit must be at least 20%. After a veteranreceives this rating, the vocationalrehabilitation counselor will work closelywith the veteran to gather informationabout his or her unique situation so that theveteran's eligibility can be determined. Thecounselor determines a veteran's eligibilityfor services based on the answer to twoquestions:

Does the veteran need vocational rehabilitation to overcome his or heremployment problems?

Can he or she benefit from the program?

For veterans with service-connecteddisabilities so severe that they cannotcurrently work, services can be provided toimprove their ability to live asindependently as possible. This programworks with veterans to set realistic dailyliving goals, and help them reach thosegoals. These services can lessen the needto rely on others by giving veterans theskills they need to live as independently aspossible at home and in the community.Independent Living services include:

Determining the veteran's independent living needs

Training in activities of daily living

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Guidance and support throughout a veteran's rehabilitation program

Personal adjustment counselingTechnology to help a veteran live

more independentlyIn some cases, services to

improve a veteran's ability to reach a vocational goal

See Resources for sources of moreinformation and an application.

Resources

Understanding Brain Injury: A Guide forEmployers available at:http://mayoresearch.mayo.edu/mayo/research/tbims/

Information on Accommodations and theAmericans with Disabilities Act (ADA):http://www.jan.wvu.edu or call 1-800-526-7234 (for Accommodations) or1-800-232-9675 (for ADA)

Social Security benefits application: call1-800-772-1213, visit a local SSA office, orvisit www.ssa.gov

Information about each State's BenefitsPlanning, Assistance, and Outreach(BPAO) Program:http://www.ssa.gov/work/ServiceProviders/BPAODirectory.html

Ticket to Work:http://www.yourtickettowork.com or call 1-866-968-7842

Ticket to Hire: call 866-TTW-HIRE (1-866-889-4473)

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Information about Veterans Services andapplication (VA form 28-1900, DisabledVeterans Application for VocationalRehabilitation): call 1-800-827-1000 andask for the Vocational Rehabilitation andEmployment program and VA form 28-1900, or visithttp://www.vba.va.gov/bln/vre/index.htm

About the Author’s

James F. Malec, Ph.D. is Director of theNIDRR-funded Mayo TBI Model System inRochester, MN. He is a Co-Chair of theDivision of Tertiary Psychiatry andPsychology in the Department ofPsychiatry and Psychology and a Professorof Psychology in the Mayo Clinic College ofMedicine. He is Board Certified in bothClinical Neuropsychology andRehabilitation Psychology through theAmerican Board of ProfessionalPsychology, and a Fellow of the AmericanPsychological Association and of theAmerican Congress of RehabilitationMedicine. He has received a number ofprofessional recognitions, including theLowman Award from the AmericanCongress of Rehabilitation Medicine forinterdisciplinary contributions torehabilitation, and the Career ServiceAward from the Brain Injury Association ofMinnesota. He remains active in both layand professional groups involved with theconcerns of persons with brain injuries,including the Brain Injury Association, theAmerican Congress of RehabilitationMedicine, and the InternationalNeuropsychological Society. Dr. Malecserves on the Editorial Board ofRehabilitation Psychology. He has over100 publications and continues to conduct

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research in brain injury rehabilitation andother areas of neuropsychology andbehavioral medicine.

Rachel A. Scanlan, M.S., C.R.C. is theVocational Case Coordinator for MayoClinic's Brain Injury Rehabilitation Program.Rachel received her Master of Sciencedegree in Rehabilitation Counseling fromMinnesota State University, Mankato and isa Certified Rehabilitation Counselor. She isan active member of the Rochester BrainInjury Community Committee and theAbilities Unlimited Program AdvisoryCouncil. She also serves on the AcquiredBrain Disorders Committee at Mayo Clinic.Rachel has presented at state and localconferences on the topic of brain injury andis a regional resource for returning to workfollowing brain injury. She is an activemember of the Minnesota RehabilitationAssociation and currently serves the Boardof Directors as District D Co-Representative. She is also a member ofthe National Rehabilitation Association andthe National Rehabilitation CounselingAssociation.

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Notes

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Employment after Traumatic Brain Injury is one in a series ofbrochures on "Living with BrainInjury."

Depression

Employment

Substance Abuse

Information: 1.800.444.6443w w w . b i a u s a . o r g

Published in 2004 by the Brain Injury Association of America