The Clubhouse: Addressing Work-Related Behavioral Challenges Through a Supportive
Social Community
Harvey E. Jacobs, PhD
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Employment remains an often cited but elusive goal for the majority of people who
experience severe disability following brain injury. Two decades of outcome studies
consistently report that only 20% to 30% of all people with severe disability following
brain injury subsequently enter and sustain employment 1-5. Yet, despite
such poor odds it should come as no surprise that employment remains an important
goal.
First, wages remain a primary means of covering the costs of living in the community.
Second, compensated employment is the predominant daily activity pattern for most
adults in our society. Third, work offers important opportunities for socialization,
access to recreation and other avocational venues that may not otherwise be available.
Research has also documented that the incidence of physical and mental illness,
asocial behavior, marital problems and other distressful life events increases following
job loss, even among "non-disabled" populations, but are typically rectified through
the reversal of vocational mis-fortune 6,7.
Whereas physical, cognitive and behavioral disabilities are often cited as the primary
reasons why many people do not attempt employment after brain injury 8,9, interpersonal
skill deficits and behavior dysfunction are the primary reasons identified for people
subsequently losing employment 10-12. Frequent reasons for dismissal include unacceptable
social interaction, poor social awareness, loss of motivation, inflexibility to
changing work demands, anxiety, decreased frustration management, anger, boredom
and isolation. Unfortunately, these descriptors do not fully identify the actual
causes of job loss. Behavior is not its own entity but a product of the interaction
between a person and their environment. It can have many causes, especially in the
work place, with noted "behavior problems" produced by many different factors.
Because half of all traumatic brain injuries occur at age 22 or younger, many people
have little work experience prior to the time of injury. For many younger people,
job placement following brain injury may be their first exposure to work. Here the
challenge is not one of vocational re-habilitation, but of initial vocational training
and job experience (i.e., vocational habilitation). Without proper training and
sufficient experience to integrate skills into daily repertoires, many people are
unable to effectively address the pre-vocational, vocational and social challenges
that inhabit the workplace. It is therefore not surprising when people decompensate
on the job. They are simply doing the best they can with available, but incomplete
abilities.
There is no doubt that persisting brain injury sequelae also contribute to poor
job performance. Impairment related deficiencies of attention and concentration,
problem solving, frustration management, adaptability to changes in response sets
and work situations, stamina and other problems can all challenge work placement
and job maintenance 9, 13. Many people are especially susceptible to changes in
work demands after vocational rehabilitation services have been "successfully" terminated.
Few work sites are stagnant, especially in today's economy as businesses continually
adapt to ever increasing social and market place changes. The position that an individual
was successfully placed and trained in six months ago is unlikely to resemble the
workplace they face today or tomorrow. As businesses change, supports established
during job coaching may no longer be relevant to the work environment. However,
the worker is now on their own and may be unable to successfully manage this challenge.
Inadequate community and psycho-social supports may also impair job performance.
Deficient housing and transportation may make it difficult to get sufficient rest
or arrive to work on time. Instability at home, with family or friends, or in the
community can easily unbalance a delicate social homeostasis previously negotiated
by a job coach or treatment team. Arguments can easily spill onto the job and persisting
problems at home can distract even the most dedicated worker. Those within a person's
supportive network, including family members, may not understand job responsibilities
and schedule competing demands or minimize the accomplishment of staying employed.
Employment efforts may even be sabotaged by people close to the worker who may be
concerned that return to work will upset other needs and benefits, such as disability
payments and medical assistance. Most entry level jobs do not provide such benefits
or adequate salaries to cover these expenses
In rare cases, severe behavioral decompensation may occur at work, but people with
such presentations are usually screened out of job placement efforts early in the
evaluation process. Instead, it is generally the subtle and insidious problems that
build over time which often challenge job tenure.
The dynamics of the vocational rehabilitation service delivery system can also contribute
to "behavioral disruption." Employment opportunities are much more influenced by
the market place than the Vocational Rehabilitation Act. People applying for vocational
rehabilitation assistance may have to wait too long to receive adequate services,
something that is excruciatingly difficult without income or financial reserves.
Many people simply give up or attempt their own solutions with varying results.
Different people also have different service needs. Some may require a comprehensive
continuum of assessment, skills training, job creation and supported employment.
Other people may find their own jobs but require opportunistic support at critical
times, and not according to scheduled therapist availability.
Finally, determination of successful placement after 60 days of independent work,
the famous "26 closure," has been repeatedly demonstrated as inadequate for many
people who experience disability following brain injury. People may require long-term,
intermittent support at critical vocational and life junctures. Follow-along services
attempt to address this issue, but can be exceedingly expensive when delivered under
a traditional treatment model 14. Employment maintenance support groups have variable
success. Most people drop out after a few sessions due to lack of interest and are
unlikely to return at the first signs of job trouble when problems may be more easily
remediated. Once employed, many people do not want to return to the hospital or
treatment center where they may have to more acutely face their disability or return
to past roles as patients. It's hard to come back to a group, hat in hand, when
your principal relationship to other people is based on failure.
When we holistically view these factors it is possible to recognize a wide range
of variables and relationships that contribute to incomplete vocational outcomes
due to "behavior problems."
-
Impairment from brain injury clearly produces a wide range of disabilities that
can directly affect job performance or the ability to even attempt employment.
- Disability and handicap following brain injury changes interpersonal roles, values
and relationships. This often makes the individual attempting work more vulnerable
to the influence of others who may not understand or support the person's
goals, or the means to achieve these goals.
- Up to half of all people who experience severe disability following brain injury
have limited job experience. Technical skill training alone is frequently insufficient
for work stability. Many people also need pre-vocational and social skills training
with sufficient time to integrate these skills (via experience) into their daily
repertoires.
- Vocational services must be responsive to the demands of the job, realities of the
employment market place, and provided when needed and not when convenient to schedule.
- Many people will need long-term, intermittent monitoring and support. The challenge
is how to make such services palatable and affordable.
Present day vocational rehabilitation services are effective for a number of individuals.
But, there is no singular model for everybody. Different people may respond better
to different service delivery models. Once such approach is the Clubhouse, a program
that originated 50 years ago by and for people who experience disability due to
psychiatric impairment 15-17. In the past ten years this model has also
been successfully adapted to meet daily living and vocational challenges for a number
of people who experience disability following brain injury 18-22. Approximately
10 such programs now operate in the United States. Clubhouse design and operations
also appear to programmatically address some of the classic social and interpersonal
"behavioral problems" and service delivery challenges reported when people who experience
disability following brain injury attempt employment.
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