Transitioning from “Rehabilitation” to Work Role of the Speech-Language Pathologist (Speech Therapist) 

Janet Hart Mott, PhD, CRC, CCM, CLCP Vocational Rehabilitation Counselor/Case Manager/Life Care Planner, Edmonds, Washington 

The Rehabilitation Team

      In an ideal situation, the pre-employment rehabilitation team includes a speech-language pathologist who is familiar with compensatory strategies that individuals with brain injury often need to use in order to successfully return to work.  In addition to the individual being served and the Speech-Language Pathologist, other members of the employment readiness team may include:

• Physiatrist (Rehabilitation Medicine Physician)
• Neurologist (depending on physical effects of the brain injury, such as seizure disorder)
• Neuropsychologist (pre-employment neuropsychological testing) 
  
• Other Medical specialists as needed
• Primary Care Physician
• Occupational Therapist (OTR/L) 
  
• Physical Therapist (RPT)
• Vocational Rehabilitation Counselor (VRC)
• Collateral Agency workers, e.g. Goodwill, Easter Seals, ILC, etc.) 
  
• Clinical Psychologist “talk therapist”)
• Life Skills Trainer
• Compensatory Skills Trainer 
  
• Home Health Aide
• Pre-injury Employer
• One or more family members 
  
• Case Manager (Internal and/or External)
• Social Worker
• Nurses 
  
• Prospective employer may include co-workers)
• Successfully employed peers with cognitive impairment) 
  

      In early cognitive rehabilitation, the role of the Speech-Language Pathologist may be more clearly defined than it is toward the end of the rehabilitation process, which is typically the point at which individuals prepare to return to work or practice work, as the case may be).  Unfortunately, at this later stage, the services of the Speech-Language Pathologist may have terminated.  This is why the Speech-Language Pathologist who has an opportunity to work with an individual in early rehab would be wise to either incorporate strategies and tactics the individual will likely need on-the-job, or prepare the individual and the family in some other way, even if the expectation is that work is months, or even years, in the future. 

“Cognitive Rehabilitation” Defined

The following definition of “cognitive rehabilitation” is excerpted from an Official Statement of the National Academy of Neuropsychology: 

“…The Brain Injury Interdisciplinary Special Interest Group BI-ISIG) of the American Congress of Rehabilitation Medicine provided a definition of cognitive rehabilitation. Cognitive rehabilitation was defined as a “systematic, functionally-oriented service of therapeutic cognitive activities, based on an assessment and understanding of the person’s brain-behavior deficits.” “Services are directed to achieve functional changes by 1) reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or 2) establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems” Harley, et al., 1992, p.63).  

See http://www.nanonline.org/NAN/Files/PAIC/PDFs/NANPositionCogRehab.pdf 

How the Speech-Language Pathologist can help an individual prepare for returning to work

      With respect to transitioning to work, just as the OT, PT, and/or Prosthetist/Orthotist are in a key position to recommend appropriate physical accommodations, assistive technology support, and orthotics the individual may need in the future, the Speech-Language Pathologist is in a key position to recommend cognitive orthotics which the individual will find useful at work. While items such as “memory books,” day planners, calendars, white boards or PDAs may not typically be thought of in the class of devices known as “orthotics,” these tools are orthotic devices for persons with cognitive impairment, in the sense that they support the individual’s disrupted memory, communication, executive function or other cognitive processes.

      Ideally, the appropriate rehabilitation team members, the individual and the family will work together from the outset.  This model ensures that the tools and skills the individual learns in the early stages of rehabilitation will generalize seamlessly to their home life, reintegration into the community and in the eventual work environment.

       If the ideal model is not possible, as long as the Speech-Language Pathologist is involved at some stage of the rehabilitation process, the Speech-Language Pathologist will be in a position to have a positive impact on the individual’s eventual success when return to work becomes a feasible goal. By virtue of the recommendations for incorporation of compensatory skills training and cognitive orthotics, the Speech-Language Pathologist will be assisting the individual with many aspects of the return to work process.  Likewise, the Speech-Language Pathologist will have the opportunity along with other rehabilitation team members and the individual to communicate with employers, be they former employers or new employers, regarding the implementation of compensatory skills training and cognitive orthotics in the workplace.  

       These are some of the challenges individuals with brain injury typically struggle with early in the return-to-work experience:

• consistently preparing for work at home 
  
• preparing clothing, lunch, etc. 
  
• allowing sufficient time to get ready for work
• planning transportation to and from work related to physical disorientation, using public transportation, etc. 
  
• knowing, whether by remembering or by noting, the proper day and time to be at work 
  
• getting and staying oriented at work  
  
• knowing or remembering work station location, co-worker’s names, job description (or other “soft” skills related to job tasks and company procedures) * 
  
• communicating effectively with co-workers and supervisor (relating to repeating one’s self or minimizing misunderstandings from incoming communication, forgetting past communications, etc. 
  
• managing troubling feelings (e.g., confusion, frustration, overwhelm, etc.) 
  
• managing physical and cognitive fatigue 
  
• dealing with insecurity and shame (generally with failure of short-term memory) 
  

      While the cognitive orthotic or cognitive orthotic system the individual uses in the rehabilitation setting and at home is important, the tools and skills the individual uses at work are equally important.  Because skills transfer (generalization) is often difficult for persons with brain injury, the cognitive orthotics an individual uses during the early phases of rehabilitation should be similar (or the same) as those he or she will eventually use at the job site.  If not, extra time, training and attention will likely be needed to ensure that new skills training and successful acquisition of these new skills. For example, if scheduling at work is done with an unfamiliar software package and scheduling during earlier phases of rehabilitation or at home has been done with other methods, then time and support staff will be needed to assist the individual with the acquisition of the new skills which will be required for the successful return to work.  

Suggested Strategies for Common Issues/Problems/Barriers

Dr. Robert Fraser’s innovative work in the field of vocational rehabilitation for persons with cognitive impairment is an excellent background resource as a backdrop for a discussion of specific compensatory strategies on-the-job. The following is excerpted from Traumatic Brain Injury Rehabilitation:  Practical Vocational, Neuropsychological and Psychotherapy Interventions, Edited by Robert T. Fraser and David C. Clemmons, © 2000 by CRC Press LLC,

 

*  “Soft skills” are collateral skills not directly related to performing work tasks, for example, punching time clock, turning in time card, knowing where to put one’s lunch, knowing where to sit, knowing who one’s co-workers are, where the lunchroom is, etc.).

 

Boca Raton, Florida.  From Chapter two:  “Specific interventions for cognitive and behavioral problems related to vocational rehabilitation procedures and outcomes,” (p. 117 ff.):

“…Over 50% of workers with head injuries had problems with work performance, which included behaviors such as exercising good social judgment and presentations… The second general dimension related to poor work performance seemed related to cognitive abilities such as learning ability and capacity for self-direction on the job.  Over 40% of clients were found to have difficulty in this area of task orientation, which included the following behaviors:  Work Persistence, Amount of Supervision Require, Work Tolerance.” (page 117)

 

And,

 

“In general, problems with work conformance seemed to be related to social judgment and emotional control, while problems in task orientation were related to cognitive abilities such as sustaining attention, problem solving, mental flexibility and new learning.” (page 117)

 

Later in this chapter, Fraser and Clemmons list a series of useful “interventions and compensations” (page 118 ff.)

 

Specific Interventions

      Besides all the memory, emotional, visual, cognitive, auditory, physical, and other issues a person with brain injury may need to deal with at home and in the community, the same issues arise at work and are often exacerbated, accelerated, and/or magnified by the demands the workplace can put on a worker:  Some compensatory strategies and reasonable accommodations  that have been known to work effectively at the job site have included:

Visual and auditory overload

• For visual “overload,” eliminate or reduce fluorescent lighting, replacing it with incandescent lighting.  Where overhead fluorescent lighting cannot be eliminated, suggest and permit the worker to use a visor, photo-grey or photo-brown glasses or even sunglasses. 
• Visually “busy” environments can compete with fragile attention capabilities for many individuals with brain injury.  These environments may include spinning overhead fans, light streaming through office blinds, “busy” patterns on the floor or walls, and even bulletin boards with too many sticky notes
• Another form of visual overload can occur when an individual works in a busy location where he or she is distracted with people walking back-and-forth in their work space.   Installation of work space partitions or moving to a different location can be helpful to reduce the individual’s need to deal with these kinds of distractions that compete for weakened attention in the first place.
• Some workers find that the color of paper and font size and type affect their ability to work effectively.  Neon paper is generally discouraged.  In general, simplicity and low contrast has been found to work for some individuals.  By using 14 point Arial type on off-white, grey or cream-colored paper has been found to assist workers who are particularly sensitive to visual overload.
• Auditory overload can be in the form of overhead alerts such as those found in many department stores), microwave “done” buzzers, overhead speaker systems or even ordinary speech in a common area can add to an individual’s cognitive overload and stress. Ear protectors, such as those worn by road workers can be helpful to reduce auditory distractions.  Some individuals find that noise-cancelling head phones, ear plugs, or classical music or nature sounds in their ear or in the work space background, can counter these barriers to their effective use of attention and concentration.

Disorientation

Disorientation can manifest itself at the outset of either the person’s return to a former place of employment or if they begin a new job in a new location.  Disorientation can also manifest itself over time, when personnel, tasks or other aspects of the job change.

On the first day of a new job, or when a person returns to an old job after an absence, the worker with brain injury may not be able to recall names of co-workers or supervisors, location of work station and other collateral information, such as paydays, procedures for filling out a time card or time sheet, or other information related to breaks, use of the lunchroom, location of restrooms, etc.  It may be helpful for the worker to use the compensatory skill of having a special place in their cognitive orthotic to log and locate this information.

Disorientation over time:  Disorientation can be an issue at anytime during the course of employment.  Tasks change, co-workers come and go, meeting times or deadlines change.  Supervisors change.  Disorientation in the face of change can be as troubling as the kind of disorientation an individual feels on the first day of a new job.  If a worker has learned to use appropriate compensatory skills and cognitive orthotics to orient him/herself to new situations, changes in the workplace will be less stressful to the worker.  Often, something as simple as an “Orientation” section of the person’s cognitive orthotic can be an effective tool for supporting the worker’s need to become and remain oriented over time.

Memory

Short-term memory is often a barrier at work (in some cases, long-term memory has been compromised, as well).  If a neurological assessment has been done, the Speech-Language Pathologist may be able to make recommendations about and/or provide initial skills training for the compensatory strategies an individual will need to support impaired memory.  At the work site, the individual will need strategies for the capture of information in such a way as to facilitate its efficient and effective storage, retrieval, and use.  The strategies of capturing, storing, retrieving, and using information may include writing or recording such things as a supervisor’s instructions, steps for doing various tasks and how to execute all of the “soft skills” related to the performance of a specific job. These skills are typically in the form of “writing and/or recording memory notes,” recording instructions or teaching the individual to ask for written instructions, or a combination of these and other compensatory strategies.

Following instructions

Successful workers are able to follow supervisors’ instructions.  Persons with cognitive impairment may have difficulty following instructions.  The reasons can be related to short-term memory impairment, failure to adequately “memory note” the instruction, auditory processing challenges, difficulty with prioritization or initiation, difficulties with attention and managing distractions, or various executive function challenges.  In order to successfully follow a supervisor’s instructions, the worker (and/or the job coach or skills trainer) would be wise to be mindful of the “four parts of cognition” with respect to capturing, storing, retrieving and using necessary instructional information, as a breakdown in any of these four areas could be responsible for an instruction not being carried out.

Misplacing work tools or papers

Misplaced work tools and “messy” paperwork are larger issues for persons with cognitive impairment than they are for ordinary workers.  Workers who used to be able to find common objects in more-or-less “messy” work environments (items like pens, notes,

staplers or other necessary items) may no longer be able to do so.  To complicate the situation further, keeping a work areas visually clean may be more of a challenge, as well.  Until the worker becomes self-aware about the “new” environment he or she may now need, it is not uncommon for the worker to assume someone has taken or moved lost items.  If the worker, their helpers, and their employer find that clean “visual space” is necessary, strategies and tactics can be set in motion that make it possible for the worker to find necessary items and papers with less discomfort and greater success.  Some simple strategies might be to encourage the worker to create a cue for “starting my shift with a clutter-free work space,” or some such.  Another useful strategy is to encourage the worker to put everything back where it “belongs” after use, to ensure that the individuals residual strengths related to procedural memory (or “muscle memory”) can be relied upon.

Troubling feelings

Persons with brain injury and other cognitive impairment typically experience a range of common troubling feelings.  While these feelings are uncomfortable across-the-board, when they are experienced on the job, they can interfere with successful employment.  The Speech-Language Pathologist may be in a position to suggest strategies and tactics the individual can use – first at home and in the community – and later, on the job, to deal with some of the following:

 

• frustration
• confusion
• anger
  
• feeling overwhelmed
• feeling misunderstood
• feeling of going blank
  
• feeling disoriented
• feeling “stuck” 
• feeling sad or depressed

 

Miscommunication and misunderstandings

One of the most effective communication tools a skills trainer, Speech-Language Pathologist or Occupational Therapist can teach an individual is known as “Clarify/Verify.”  If worker develop the habit to routinely verify communications, they reduce much of the confusion they might otherwise feel at the workplace.

Breaking tasks into steps

Breaking tasks into steps and “chunking” are important skills for many workers.  Persons with memory and other cognitive impairment often need coaching to break a complex task into sufficiently small enough steps in order to execute the task successfully.

 

Role of the Skills Trainer, Job Coach and Job Developer

They are not one and the same, though the same individual may perform the roles of each.  In an ideal situation, the Speech-Language Pathologist and/or the Vocational Rehabilitation Counselor may be in a position to oversee or provide input into the tasks of each of these helpers.

Compensatory Skills Trainer

A relatively new Para-professional function, historically “compensatory skills training” was provided by speech therapists and occupational therapists in the normal course of their treatment while individuals were in early stages of cognitive rehabilitation, typically during residential treatment In early cognitive rehabilitation, the compensatory skills trainer will most likely focus on providing skills training in the area of “activities of daily living” (ADLs).  If the person has work goals, the Compensatory Skills Trainer is in an ideal position to teach skills and provide tools that will resemble those skills and tools the person will also need at work.

 

The chart below illustrates how the compensatory skills trainer’s work can positively impact the skill level when the person he or she is training returns to work.  Note that work-focused skills trainers may need to deliver training services while also functioning as a Job Coach.  This dual function will likely occur in those situations where the work has not had adequate preliminary compensatory skills training in the rehabilitation setting.

               ADL-focused training             Work-focused skills training/job coaching

 
 

Job Coach

      In the ideal situation, the person who has experienced a brain injury and wants to return to work would prepare for work by having and mastering the use of appropriate compensatory tools and cognitive orthotics long before he or she sets foot in the workplace.  Then, at the point where they are ready to return to work (practice job, former job or new compensated employment situation), a skilled ob coach would be available to help the person make the transition to work.  The job coach would make recommendations for job modifications and/or teach and support more refined use of existing compensatory tools and skills.

      Unfortunately, many job coaches – if one is secured at all – do not have the kind of specialized training workers which individuals with brain injury need.  To complicate the situation further, many workers do not come to the return-to-work process with a foundation of compensatory skills they are ready to “transfer” to the work site.  The Speech-Language Pathologist is in an ideal position to make recommendations that will make the return-to-work process more comfortable and successful.

Background

      Historically, the position of “job coach” was developed to support persons with developmental disabilities who were in the process of moving from a sheltered workshop to a community-based “supported” job.  These workers often required “coaching” (work skill practice and/or cueing) in order to be able to successfully execute jobs which are, in general, repetitious and supervised. As the survival rates of persons with brain injury increased, and persons with brain injury attempted to go back to work, this job coaching model was used to support brain-injured workers, as well, even if the work they were returning to was more complex than work that was appropriate for workers with developmental disabilities.  In fact, may job coaches who are assigned to assist workers with brain injury have received their on-the-job training by working with persons with developmental disabilities. The cueing model is should be, but often is not, different.

      State Departments of Vocational Rehabilitation may include a “job coach” in the back-to-work plan for a worker with brain injury.  If a Speech-Language Pathologist is involved in the return-to-work planning process, they are in a key position to guide the job coach with the important challenge of recommending modifications and cognitive orthotics, as well as helping the job coach understand the difference between empowering a worker to use compensatory tools and skills versus “rescuing” a worker by the job coach developing the cues.  This difference (“cue vs. rescuing”) is important and is illustrated by the example below (brain-injured “Worker A” is productively “cued” and empowered to learn to be self-cuing on the job, whereas brain-injured “Worker B” is “rescued.”

Worker A has learned from a compensatory skills trainer to break multi-step tasks into steps and write notes he or she can refer to when memory fails.  The worker keeps all these notes in a special section of their day planner, and knows to look up steps for multi-step tasks in this section. If the worker needs notes, the skilled job coach will cue Worker A to look at the notes they (the worker) has created and by doing so, becomes increasingly self-cuing for doing multi-step tasks.  Importantly, when a new multi-step task needs to be done, the coach will cue the worker to break the task into steps and write notes that the worker can independently refer to later.

 

Worker B also has a brain injury and may also have learned to break multi-step tasks into steps which he keeps in a special section of his day planner.  If he fails to reference his notes, or if he needs to write new notes (steps) for a new task, the less skilled job coach will create the cues FOR the worker (posting them on the worker’s desk or a bulletin board perhaps), which has the effect of “rescuing” the worker, as opposed to “empowering” him or her.  And when a new multi-step task presents itself, the less skilled job coach will create the cues or the steps, instead of supporting the worker to become more independent and self-cuing.

 

 

A sure sign that a job coach is inclined toward the rescuing model, as opposed to the more empowering self-cueing model, is when the job coach creates “To Do” lists, task lists, or other reminders, placing them in prominent locations for the worker to see and use.  Because workers with brain injury often struggle with skills transfer (generalization), the mere execution of a particular strategy may not “translate” to new situations – that is, unless generalization is ALSO a skill that has been specifically taught and mastered.  As a result, the use of a “To Do” list or other cues that has been created by a job coach may not trigger the creation of subsequent “To Do” lists or other cues.  In short, the more the job coach “does for” the worker with brain injury, the less the worker is empowered to do for him or herself.

 

Job Developer

Job developers find (or “develop”) appropriate job placements for individuals who are ready to return to work.  In some cases, they develop practice-work situations that are designed to simulate the kind of work the individual will eventually perform.  Skilled job developers communicate well with workers and employers, understand the issues both worker and employers will face, and ideally, are skilled in the art of the “job matching” (finding work, work environments and employers that are well-suited to the individual being served). 

 

The Future of Job Coaching (“best practice”)

 

            The experienced Speech-Language Pathologist is in an ideal position to create a long-term plan that the person’s eventual compensatory skills trainer and job coach will find useful.  This plan would identify those skills and tools (including cognitive orthotics) that the worker will likely need when they return to work.  Ideally, the continuum of care and teaching would be this:

Hospital or residential rehabilitation setting

The person with brain injury would be introduced to a wide range of compensatory skills and tools in the early cognitive rehabilitation process (from the Speech-Language Pathologist and OT team).  These are tools and skills that will eventually translate seamlessly to the work site (especially with respect to writing useable Memory Notes, scheduling tasks and managing troubling feelings).

After discharge

The person would receive sufficient compensatory skills training from a compensatory skills trainer in the outpatient setting, or at home (services could be delivered by a Speech-Language Pathologist, Para-professional or lay person);

Preparing for employment

During the pre-employment stage, the worker-to-be would continue to receive support from a compensatory skills trainer such that he or she will learn to generalize skills to new situations.

Practice Work or Employment

In the practice work phase or when the person is back to work, the job coach would continue to support the use of compensatory skills and tools (including increasingly sophisticated cognitive orthotics).

Sustained Employment

By the time the worker returns to work, he or she has hopefully started networking with other employed workers with brain injury.  Various self-help groups are available locally in larger communities and on the Internet for those workers who are in less populated settings (for example, the TBI-WORKING listserv and the Job Accommodation Network). 

 

Because workers may need on-going support, the Speech-Language Pathologist who gives the future working person and his or her family, access to these on-going supports, will be providing a much needed service, even if the direct services they provide are months or perhaps years away from the actual date the person will return to the workplace.

 

Co-worker as trainer model *

      Dr. Robert Fraser’s innovative work in vocational rehabilitation includes an important development known as the “co-worker as trainer model.”   According to Fraser, “Co-Worker Trainers are Fellow Workers Who:

• (have ) worked the same shift for some time
• (are) highly rated by supervisors
• (are) well-liked by co-workers
• (are) willing to participate in training *

* Presentation at the VOCATIONAL OUTCOMES IN TRAUMATIC BRAIN INJURY, THIRD INTERNATIONAL CONFERENCE, MAY 7 - 9. 2009, Presented by The Training Associates, a division of DJ Magrega and Associates Inc. Empire Landmark Hotel, Vancouver, BC Canada

 

Robert T. Fraser, PhD, CRC

Robert T. Fraser is a professor in the University of Washington’s Department of Rehabilitation

Medicine, jointly with Neurosurgery and Neurology. He is a counseling and rehabilitation

psychologist and a certified rehabilitation counselor. Dr. Fraser is author or co-author of more

than one hundred publications, including the 2000 publication entitled Traumatic Brain Injury

Rehabilitation, Practical Vocational, Neuropsychological, and Psychotherapy Interventions. He has

been awarded numerous federal grants by the Department of Education (NIDRR and RSA) - four

of which have been specific to traumatic brain injury rehabilitation. He was awarded a World

Rehabilitation Fund fellowship to review post-acute traumatic brain injury programs in Israel and

has received two American Rehabilitation Counseling Association Research Awards. He is a past

president of Rehabilitation Psychology, Division 22 of the American Psychological Association and

a Fellow in the Division (EFA), a former Board Member of the Epilepsy Foundation of America,

member of the EFA Professional Advisory Board and recently appointed to the Board of Governors

of the International Consortium of MS Centers.

 

Worker Resources

       tools run the gamut from the simple “Memory Book” an individual may have been issued in the early stages of cognitive rehabilitation or a “dime store” spiral notebook, to sophisticated PDAs, and everything in between.  Commercial day planners such as those published by Day-Timer, Day Runner^® and Franklin Covey^® are commonplace.  Tape and digital recording devices are often tried.  Cognition-specific compensatory devices and systems are also available, and can be used on-the-job, depending on the individual’s needs, funding sources and budget.  These include products such as BRAIN BOOK^® Work Manager System, Day-Timer’s BIRK (Brain Injury Recovery Kit) and the electronic PEAT product (Attention Control Systems).  Work-specific supports are few and far between, though some are in development both paper-based and electronic

 

A Word about Funding

      Any discussion of compensatory systems and training would include information about funding sources and budgets. While the Speech-Language Pathologist may not be directly involved in funding issues, a general understanding of funding resources and options may be helpful.

State VR Agencies (The State-Federal Vocational Rehabilitation Program)  

The U.S. Department of Education’s Office of Special Education and Rehabilitative Services (OSERS) administers the State-Federal Vocational Rehabilitation (VR) programs through the Rehabilitation Services Administration (RSA).  RSA provides funding, legislative interpretation and monitors program operation for the VR programs located in each of the states.  Through direct service provision, purchase of services or a combination of the two, the VR program provides individuals with disabilities, including individuals with TBI, a strong partner in their employment efforts.  Eligibility for services is based on the following requirements:  (a) the presence of a physical or mental impairment, (b) determination that the physical or mental impairment results in a substantial impediment to employment, (c) presumption that the applicant can benefit in terms of an employment outcome from the provision of vocational rehabilitation services, and (d) determination that the applicant requires vocational rehabilitation services to prepare for, enter into, engage in, or retain gainful employment. 

States differ in their methods of service provision, but all provide individualized rehabilitation services based on the consumer’s identified vocational goal and IWRP, and their strengths, resources, priorities, abilities and informed choice.  State VR programs partner with the consumer, other state and local programs, community-based service providers and employers in helping individuals reach their employment goals.  Some, but not all, state VR programs employ rehabilitation counselors or case managers who specialize in planning for the unique challenges of returning to work with TBI.  For many individuals with TBI, the state-federal vocational rehabilitation program is their primary source for assistance in returning to work or entering the workforce for the first time.

Center for Independent Living (CIL)  

A Center for Independent Living (CIL) is typically a private, non-profit agency which provides training in the skills needed for living independently in the community.  Some CILs may offer driver’s evaluation and training in addition to individual coaching in activities of daily living, money management and budgeting, community transportation options, etc.  CILs are often connected to a state’s Medicaid Waiver programs, offering service coordination and referral to community-based services for eligible individuals with significant disabilities.  For some individuals who are not quite ready to pursue competitive employment, a CIL can bridge the gap, helping to regain independence, confidence, and the “soft skills” necessary for success at work.

Workers Compensation

In the United States the first Workers’ Compensation laws were enacted in 1911 and over the next thirty years spread throughout the states.  Inclusion of benefits for medical coverage for the industrially injured worker occurred over the years.  Extension, elaboration and improvement of medical as well as vocational rehabilitation benefits have continued to the present day.

Workers’ Compensation benefits are administered in three ways:  State Funds, private insurance carriers, and self-insured employers.  The manner in which benefits are administered may vary from state to state.                   

Industrially injured workers who have sustained brain injuries may have assigned vocational rehabilitation counselors, case managers, and other rehabilitation service providers including, but not limited to, physicians and speech-language pathologists.  Within the context of Workers’ Compensation any service provider must always be mindful of the complex  dual accountability to the client who is the injured worker and the customer who is the funding source.

The role and functions of the Speech-Language Pathologist with respect to industrially injured workers who are covered by the Workers’ Compensation may include:

•   Provision of speech-language therapeutic services
• 
  
•   Identification of the client’s need for compensatory skills training and cognitive orthotics
• 
  
•   Implementation of compensatory skills training and use of cognitive orthotics with the client, family members, other rehabilitation team members, and workplace personnel
• 
  
•   Specifically assist with the job analysis process in regards to communication and cognitive functions required of the client
• 
  
•   Making recommendations regarding necessary and appropriate job-related accommodations

Workers’ Compensation rules and regulations may vary from state to state.  Consequently the speech-language pathologist will need to develop a method for obtaining the necessary information to effectively provide services for industrially injured workers within a given geographical location. In a similar manner the speech-language pathologist will need to develop an understanding of the process for obtaining authorization for the provision of services via the State Fund, insurance carriers, and self-insured employers.

Private Pay situations

Occasionally the services of a speech-language pathologist may be obtained on a private pay basis.  Sources of private payment may be family members, self-pay, or Trust funds including Special Needs Trusts.  In this context the professional and business ethics of the service provider first and foremost determine how, when, why, where, and at what cost services will be provided.  If the funding entity is a Trust, then the legal structure of the Trust will determine to some extent the provision of services.  Rules and regulations such as those required by public agencies are far less likely to come into play when private pay arrangements have been made.

 

The “Cognitive Loop” and the Four Parts of Cognition

For the purpose of helping individuals with cognitive challenges return to work, perhaps the most important role the Speech-Language Pathologist can play, especially if his or her role is not a prominent one in the later return-to-work process, is to help the individual, the family and other helpers fully understand the importance of the “cognitive loop” in the return-to-work process.  While closing the cognitive loop matters at home, because a person’s family is not available for support when the individual returns to work, knowing how the individual needs to be empowered to “close the cognitive loop” at work can be the difference between success or failure on-the-job.

The cognitive loop consists of the following four components:

•   Information capture
•   Information storage
•   Information retrieval
•   Information use.

In life generally, and particularly on the job, if ANY of the parts of the cognitive loop are missing or have “glitches,” the person’s functional success is jeopardized.  The role of the worker’s helpers is to be mindful of which part of the cognitive loop may be giving the individual difficulty, and then working together to craft an empowering solution.

 

Information Capture

Workers with memory impairment need to have skills for capturing information, particularly with respect to task-related instructions, for example, “Joe, I need you to make three widgets an hour, box them up and put them in the mail room at the end of each day.”  Similarly, the employer may need to know that this kind of instruction may not be accessible to the worker unless the worker captures the instruction in some fashion.  The working situation is likely to be successful when workers capture needed information effectively, and supervisors and co-workers are sensitive to one or more of the special needs the worker may have in this area. 

 

Information Storage

The worker will likely need to know how/where to store information they have captured.  Typical storage “devices” include, but are not limited to day planners, notebooks, PDAs, digital recorders, and software.  In some cases, information is best stored in written form, as provided by the employer or supervisor.

 

Information Retrieval

Given the massive amount of work- and non work-related information a worker with brain injury needs to capture and store throughout the work day, the worker will likely need a system that empowers him or her to consistently retrieve all the information bits he or she needs throughout the work day.  Information retrieval is often a major challenge for the worker with brain injury.  The Speech-Language Pathologist’s contribution in this area would be greatly beneficial.

 

Information Use

Memory Notes that are written down for the purpose of capturing information, stored effectively and later found when needed, cannot be used effectively if they lack sufficient meaning, context, detail, or are deficient in some other important way.  The notes the worker writes, or the memo he or she reads, needs to have enough detail to cue memory (if the individual is cueable), or they need to be “useable” in some other respect.  The Speech-Language Pathologist is in a position to help the worker, the family, other helpers and the employer understand the need for the entire “cognitive loop” to be respected, such that the information the worker needs comes full circle in such a way that information can be used to execute the necessary work tasks..

 

Summary

The role of the Speech-Language Pathologist is be a valuable one, given that the Speech-Language Pathologist is in a key position to identify the likely barriers an individual may face at work, the person’s residual strengths, as well as the options, tools and skills for overcoming likely challenges. The Speech-Language Pathologist is in a key position to recommend cognitive orthotics and cognitive compensatory skills training, and will hopefully be able to advise other members of the team on ways to access and coordinate the expertise and resources the worker will likely need in order to be a successful worker.