Holly Whittenburg, Jenn McDonough
In this paper, we will describe how customized employment (CE) can be used to support return to work for individuals with traumatic brain injury (TBI). Increased understanding of the CE process will allow medical and rehabilitation professionals to consider it as an option when planning collaboratively with patients, families, and rehabilitation professionals for return to work. We will also highlight ways in which medical and rehabilitation professionals can contribute to and participate in CE.
In 2010, the year for which the most recent statistics are available, traumatic brain injury (TBI) accounted for approximately 2.5 million emergency department visits, hospitalization, and deaths for individuals in the United States (Centers for Disease Control and Prevention, 2015). While this statistic highlights the severity of medical problems for individuals experiencing TBI, challenges are often far-reaching and affect other critical areas such as employment, independent living, and personal relationships. TBI-related symptoms, including memory issues, attention deficits, problems with executive functioning, and emotional dysregulation, can make a successful return to work post-injury challenging, with recent reported employment outcomes for individuals with TBI ranging from to 42.5% to 55% (Grauwmeijer et al., 2017; Scaratti et al., 2017). While previous research has extensively documented personal factors associated with return to work (i.e. severity of injury, cognitive functioning, educational attainment, employment status pre-injury; Ahonle et al., 2020; Mani et al., 2017; Scaratti et al., 2017; Wehman et al., 2005), we know less about service models that support a successful return to work.
Supported employment (SE) is an evidence-based practice that has been used since the 1980s to facilitate competitive, integrated employment outcomes for individuals with significant disabilities, including persons with TBI (Wehman et al., 2005). It is characterized by the use of qualified employment specialists who work with individuals with disabilities to get to know them, identify potential employment opportunities that match individuals’ interests, augment employer-provided training and implement needed workplace supports once hired, and promote job maintenance through regular contacts with the individual and employer (Wehman et al., 2018). More recently, CE has emerged as a new pathway to competitive, integrated employment for individuals with significant disabilities. CE focuses on the relationship between the job seeker and employer and meeting both parties’ needs. It does this through informal observations/assessments to identify the individual’s strengths and interests and negotiating employment opportunities using job creation, job carving, and job sharing techniques (Jorgensen Smith et al., 2017). While these two service models are similar in some respects, they also differ substantively in their approaches. Table 1 provides descriptions of the essential features of SE and CE service models.
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CE offers a new and promising approach in facilitating return to work for individuals with TBI for several reasons. First, it seeks to identify the job seeker’s strengths and interests, and then match the job seeker with businesses who have unmet needs that align with those strengths and interests. This approach changes the emphasis from searching for existing job openings to developing customized positions that are good fits for the job seeker and the business. In this way, CE opens up opportunities for successful employment for individuals with TBI who may not be able to perform all the essential functions of a standard position. Second, CE explicitly rejects the premise that individuals need to demonstrate they are ready for work before seeking employment, and instead focuses on providing individuals with the long-term supports and training they need to be successful within competitive, integrated work settings. This type of ongoing support and problem-solving may be helpful in addressing challenges individuals with TBI may experience over time after they return to work. Finally, CE has been used successfully with populations who have historically been excluded from employment, or who have been deemed “unemployable” through traditional vocational assessments. Individuals with moderate to severe TBI, who may have had similar assessment experiences post-injury, can benefit from this highly individualized and supportive approach to facilitating return to work.
Customized Employment and Return to Work
CE includes five essential, sequential components: discovery, vocational profile development, job development, job negotiation, and support after employment (Wehman, 2020). Each of these components can be utilized with individuals with TBI to support a successful return to work.
Discovery is the first step in CE, and it utilizes a qualitative approach to identify the job seeker’s strengths and interests. In contrast to traditional vocational assessments, discovery activities focus heavily on natural conversations with the job seeker and important people in their life and informal, but extensive, observations of the person in authentic settings in their community and neighborhood (Jorgensen Smith, 2017; Riesen et al., 2019). Qualitative data related to the job seeker’s hobbies, strengths, and interests obtained from these activities are used to identify vocational themes, which drive the development of the vocational profile and subsequent job development and negotiation.
When the discovery process is implemented with individuals with TBI, it shifts the focus from traditional, deficit-based vocational assessment to an individualized understanding of the person’s strengths and interests. Data obtained from interviews and observations in authentic settings the person frequents (e.g., favorite stores and restaurants, leisure activities, community organizations) are used to identify areas of career interest. This approach can be particularly helpful for individuals with TBI, who may have new interests post-injury, who may not know or be unable to convey their career aspirations, or who may be unsure about returning to work and could benefit from seeing how personal interests can be aligned with employment possibilities.
Vocational Profile Development
The next step in the CE process focuses on development of the vocational profile. The vocational profile is a document that is created using the data obtained during discovery. It highlights the job seeker’s strengths and interests, describes the ideal conditions for employment, and identifies several vocational themes (Riesen et al., 2019). These vocational themes form the basis of the plan for achieving employment (Jorgensen Smith et al., 2017) and can encompass specific areas of interest (e.g., health and nutrition, films, automobiles) and/or specific job seeker strengths (e.g., organizing, customer service, database management).
The creation of a vocational profile helps insure the interests and strengths of individuals with TBI are at the forefront of job development efforts. The vocational profile provides a roadmap for how strengths and interests will be incorporated into the job development process. It offers a planning tool the team can use to carefully consider the conditions that will be important for employment success (e.g., work hours, necessary training, on-the-job supports, work environment) and where the job search should be focused. This proactive planning facilitates a strong match between the individual with TBI’s strengths and the employer’s needs, which can promote job retention over time.
Once the vocational profile has been created, job development begins. While traditional job development efforts focus on identifying existing job openings and finding candidates who meet the essential skill and knowledge requirements for those positions, job development in CE focuses on matching the job seeker’s strengths and interests with the unmet needs of employers. In other words, CE professionals do not scour websites to see who is hiring in order to find employment possibilities. Instead, they use the vocational profile to identify businesses where people with similar interests work (Griffin et al., 2008). Then they arrange to spend time at those businesses to build relationships, learn more about business needs, and identify how the job seeker can help meet unmet needs of the business through job creation, job carving, and/or job sharing (Jorgensen Smith et al., 2017; Riesen and Morgan, 2018).
This approach has several advantages for individuals with TBI. It continues to ensure that the individual’s strengths and interests are prioritized. Importantly, it also removes barriers that may exist if the job seeker is unable to fulfill all of the essential skills and functions of a standard position in their area of interest. Finally, it provides for a deeper understanding of a specific business’ work processes, culture, and environment; knowledge of which can facilitate a strong employment match and the development of necessary supports for workplace success.
Once a match has been found between the job seeker’s strengths and interests and the unmet needs of an employer, the CE professional negotiates a customized position. This could be for an entirely new created position, a position that focuses on several existing key job tasks, or a position that re-assigns specific responsibilities from other employees. Job negotiation culminates in a written employment proposal, which describes job responsibilities, workplace supports and services, work schedule, job arrangement, and supervision structure for the customized position (Riesen and Morgan, 2018). After the proposal has been reviewed and accepted by the employer and the job seeker, the job seeker is ready to start work.
Support After Employment
Involvement of Medical and Rehabilitation Professionals
Collaborative planning for patient discharge and return to work offers opportunities for medical and rehabilitation professionals to discuss CE with patients, families, and adult service providers. Clinicians may want to consider CE with individuals whose severity of injury precludes them from returning to the same positions they performed pre-injury, who performed poorly on traditional vocational assessments, and/or who may not be able to perform all the essential functions of a standard position. Describing how job creation, job sharing, and job carving can be used in CE to facilitate return to work provides patients and families with critical information to consider as they plan for the future. If patients are interested in learning more about CE, then clinicians should have contact and referral information available for the local offices of their state vocational rehabilitation agency, as these agencies are the entities responsible for evaluating the need for and the provision of CE services.
It is also important for medical and rehabilitation professionals to maintain ongoing communication with teams as individuals are discharged and engage in the return to work process. For individuals with TBI who participate in CE services, continued collaboration between clinicians and service providers is critical. During the discovery process, clinicians can help teams identify the strengths and interests of the individual with TBI, based on their own informal observations of and interactions with the patient. Clinicians can also provide valuable information about any potential work restrictions, help evaluate the reasonableness of negotiated work tasks and responsibilities, indicate when return to work would be appropriate, and share information about possible workplace supports and accommodations (Wehman et al., 2017). Finally, medical and rehabilitation professionals can advocate for and engage in additional research into the use of CE with individuals with TBI. Research is needed that systematically investigates the use of CE with individuals with TBI and identifies best practices for this population in order to improve return to work outcomes for individuals with TBI.
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Holly Whittenburg, Ph.D. is an assistant professor in the Department of Teaching and Learning at Washington State University. Before that, she worked as a research site coordinator for the Virginia Commonwealth University Rehabilitation Research and Training Center. Holly has also worked as a special education teacher, district-level administrator, and employment specialist. Her research interests include interventions for teaching work-related skills to students with developmental disabilities, the effect of federal and state policies on transition services for youth with disabilities, and approaches to improve employment outcomes for young adults with disabilities.
Jennifer Todd McDonough, MS, CRC is a faculty member at Virginia Commonwealth University (VCU) and has been working in the field of employment for people with disabilities for over 20 years. She earned her M.S. from the Medical College of Virginia at Virginia Commonwealth University in Rehabilitation Counseling. Ms. McDonough is the Associate Director of Training at VCU-RRTC. She is also the Project Director for two national research studies related to work and disabilities. Ms. McDonough is a national expert on Social Security Disability Benefits and Work Incentives. She also serves as the Virginia Project SEARCH Statewide Coordinator.