John Merladet, PhD, John P Billig, PhD, ABPP, & Diane Acord, MA, CRC, CBIS ACBS World Conference 8...
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Using Acceptance and Commitment Group Training in Vocational Rehabilitation Programs with Special Needs Veterans John Merladet, PhD, John P Billig, PhD, ABPP, & Diane Acord, MA, CRC, CBIS ACBS World Conference 8 Reno, Nevada June 2010
John Merladet, PhD, John P Billig, PhD, ABPP, & Diane Acord, MA, CRC, CBIS ACBS World Conference 8 Reno, Nevada June 2010
John Merladet, PhD, John P Billig, PhD, ABPP, & Diane
Acord, MA, CRC, CBIS ACBS World Conference 8 Reno, Nevada June
2010
Slide 2
Disclosure Information We have no financial relationships to
disclose We will not be discussing any off-label and/or
investigational use of medications in our presentation. .though we
may discuss use of off-label and investigational use of
meditation
Slide 3
Objectives Learn how to apply ACT in a vocational
rehabilitation setting with consumers presenting with chronic
disabilities Learn how ACT can improve on increasing psychological
flexibility and outcomes for reemployment. Learn to assess right
time to engage consumer in ACT process.
Slide 4
Population Polytrauma: TBI, SCI, plus OEF/OIF Acute/
Transitional /Outpatient Veterans and Active Duty USA solders
Generation X and Y: A new languageBlogs, My space, Texting, Casual,
Expectations, Determined, Technology driven.
Slide 5
Younger Soldiers 1 According to DOD, almost half of active duty
service members are between the ages of 22 and 30 (avg 28) 37% of
active duty Marines are 18-21 years old Jamie Lindberg, Psy.D,
Postdoctoral Resident, VAMC, Minneapolis, MN
Slide 6
Ideas About Success Over 50% of college students surveyed in
2000 expected to make their first $1 million before age 40 2 They
strongly believe in the American Dream and that success is the
product of ambition and individual effort 3 Those who work hard
earn their advantages, and those who do not succeed simply did not
work hard enough Have been told that they can have it all Tend to
disregard the role of innate abilities in achieving success and
more likely to have unrealistic expectations Jamie Lindberg, PsyD,
Postdoctoral Resident, VAMC, Minneapolis, MN
Slide 7
Employment 4 Tend to expect meaning and fulfillment in their
work Place more value on quality of life and demand balance in
their personal-professional lives Need more feedback hearing that
they are valued and do a good job Tend to seek out direction and
dislike ambiguity Value authenticity in their leaders Dislike
conformity and have been encouraged to think outside the box More
likely to job-hop Jamie Lindberg, PsyD, Postdoctoral Resident,
VAMC, Minneapolis, MN
Slide 8
Self-Esteem & Narcissism 4 Self-esteem of young people has
increased substantially, especially between 1980 and 1994 By the
mid-1990s, the average Gen Y male had higher self- esteem than 86%
of college men in 1968 Average college student in 2006 scored
higher in narcissism than 65% of those in the early 1980s Some
attribute this pattern to the self-esteem movement Jamie Lindberg,
PsyD, Postdoctoral Resident, VAMC, Minneapolis, MN
Slide 9
Social Approval 4 College students need for social approval has
stabilized at a historically low level This may be apparent in
physical appearance, dress, preference for innovation, and greater
tendency to take risks Jamie Lindberg, PsyD, Postdoctoral Resident,
VAMC, Minneapolis, MN
Slide 10
Family Upbringing 75% had working mothers 5 25% were raised by
a single parent 5 Child is the center of the family 6 Families are
more democratic and collaborative 6 Parents are highly involved in
the lives of their children 6 Helicopter parents sometimes to the
point of rushing to prevent any harm or failure from befalling the
child Jamie Lindberg, PsyD, Postdoctoral Resident, VAMC,
Minneapolis, MN
Slide 11
Challenges for Voc Rehabilitation Initial stages of adjustment
to disability Preoccupied with return to past performance. Limited
exposure to occupational information. Early foreclosure in career
maturity before service. Pre morbid factors. Myths about having a
disability with rule laden thoughts about themselves and what they
could accomplish. Entitlement. Rehabilitation staff.
Slide 12
Challenges (continued) Push for rapid employment. Not returning
to work right away: Active Duty. Reporting they did not want to
return work. Teams assumed voc was about returning to work and
disability focused, so why refer them? Impairment levels.
Slide 13
Need for a Framework: Literature suggests starting rehab pt
early in voc rehab Framework to help move pt beyond their situation
from a vocational point of view that was rooted where they were at
in the hospital. Focus needed to be on tapping into life as an
internal driver vs struggling with the disability. Help pt move
into space to consider meaningful life activities for the future.
Help pt modulate conflicting internal emotions around self efficacy
and thoughts about ineffectiveness. Needed an intervention that
would not overlap with other psychological interventions.
Slide 14
Avoidance and undervaluing self I want to be a stay at home dad
I want to do on line course work I want to work alone I want to
stay on the couch and channel surf I am only going to get worse Ive
served my country already
Slide 15
Unrealistic Overvaluing abilities Taking too many credits in
return to school. Continuing to chose occupations that are likely
to have long term physical and psychological consequences: police
work, Triple Canopy, underwater demolition, carpentry. Taking on
multiple jobs. I want to start my own business.
Slide 16
Psychological Inflexibility WHO I WAS Dominance of
Conceptualized Past REJECTING WORK PROGRAMMING OR INCREASING JOB
HOURS Experiential Avoidance I WANT TO DO UNDERWATER DEMOLITION
Lack of Values Clarity ILL BE A STAY AT HOME DAD/WORK ALONE
Avoidant/Inaction Impulsivity IF I CANT DO MY MOS, I WONT BE IN THE
ARMY Attachment to conceptualized self I AM GOING TO GET WORSE
Cognitive fusion
Slide 17
Contact with the Present Moment Problems Interventions Stuck on
what was, including premorbid visions of future career Fusion with
need for future to be a return to premorbid jobs, functioning: just
need to pick up where I was prior to the injury Avoidance of
physical condition or parts of body not functioning as they did
Stuck in mourning lost past and future Staying in the zone
Listening to silence Dogs life Raisin activity
Slide 18
Acceptance Problems Interventions Avoidance of functional
limitations and associated feelings, such as loss, grief, survivor
guilt, insecurity, fear, anger: Alcohol, drugs Angry outbursts,
fights Withdrawal, isolation Neglect of self-care Refusal to
address vocational concerns Procrastination or lots of time in
activities such as video games, TV, computer, etc Joe the bum
Setting down the shovel Passengers on the bus Who took the governor
off my engine Purple heart/ruck sack/bootcamp
Slide 19
Defusion Problems Interventions Fusion with long-held views
about career Fusion with premorbid life roles Fusion with thoughts
about feelings, particularly negative feelings Fusion with thoughts
about lost functioning Dont trust your brains Mind chatter Milk,
milk, milk Dont think about Take mind out for a walk/ride
Slide 20
Self as Context Problems Interventions Predominance of self-
conceptualizations and life story Defining self by injury,
condition Defining self by premorbid roles, status Who am I: Man in
the mirror Observer you can hold experiences Eye-to-eye contact
Hitting the wall
Slide 21
Values Problems Interventions Fusion with view that values
underlying previous jobs, roles are gone Equating values with
particular jobs Difficulty distinguishing values from goals,
outcomes, specific behaviors What really counts Employee of the
year Stand and commit
Slide 22
Committed Action Problems Interventions Stuck in actions that
function as experiential avoidance or from cognitive fusion
Difficulty identifying actions associated with work values beyond a
narrow range Avoidance of internal and external barriers that arise
I want it all and I want it now Rolling with your disability Fish
hook and forgiving Your tape measure Passengers on the bus
Slide 23
Vocational Rehabilitation Intervention in Residential Program
Working in very part time supported employment setting with a job
coach. OEF/OIF. mTBI to mTBI/PTSD. Males 20-35. Both active duty
and veteran status. Across the Upper Midwest and South Central
States. Limited work histories with only HS diplomas. Open group.
May not be returning to work any time soon. Early in their
disability.
Slide 24
(Acceptance and Commitment Training for Lifting Individuals for
Future Employment) Expanding exposure Defusing inflexible
cognitions Clarifying values Process: Check-in; work situations and
ah-ha moments, (good-byes), ACT concept/Speaker, Wrap-up and VR
business. Goals of ACT on L.I.F.E. Group
Slide 25
Vocational Experience in Residential Work Therapy/Supported
Employment -Participate in supported hospital/community work
activity. Develops confidence and self understanding. Achieving
success through learning on the job. Clinical Job Coaching
-Providing one-on-one feedback on activity based work; related
strengths and weakness; building endurance, activity tolerance, and
confidence. ACT on LIFE Group: Meet weekly to discuss weekly work
experiences and topics in each of the HEXAFLEX domains. Linked with
a Vocational Rehabilitation counselor.
Slide 26
ACT on L.I.F.E. Outline: T.B.I. Transitional Dont trust your
brains (Diffusion /role of language). Veterans with TBI arrive
fused with/in their situations; relaying on old scripts about who
they should be now; the cants Who am I: Man in the Mirror (Self as
context). Lowered self esteem and feelings of inadequacy about self
and capacity to accomplish/achieve like before. Who took the
governor off my engine (Acceptance/Willingness). Accepting the
confusion and uncertainty. Struggling with anger/ depression/ about
current circumstances. What really counts (Values). Have lost touch
of what was important. Hyper focus on family and getting support
wherever they can. I want it all and I want it now (Willingness
with barriers to committed action) Multiple setbacks and barriers;
stuck and confused. Staying in the Zone (Ways of being in the
moment with TBI). Encourages the veteran to stay in touch with the
present moment. And to got with their experience in the here and
now.
Slide 27
Unique Metaphors that Arose Contact with the Present Moment:
Staying in the Zone: what does your experience say.
Acceptance/Willingness: Who took the governor off my engine 1 :
Boot camp, Ruck Sack 1, Purple Heart. Defusion: Dont trust your
brain: Board of directors; the cants you tell yourself. Self as
Context: Man in the mirror: Drawing your thoughts in your brain;
looking in a mirror and describe themselves vs a group buddy.
Values: What really counts: the chair. Committed Action: I want it
all and I want it now: impulsivity/inaction/struggle. 1 Developed
by Steve Anderson, MS, OTL/R CWT Job Coach
Slide 28
Results Quantitatively Qualitatively 8 AAQs were available. -5
showed increases in PF. -3 showed mild decreases in PF. (2/3 showed
inc. in older, 7-Item AAQ questionnaire) It helped me manage my
time and learn areas that need improvement Exceeded my expectations
I feel more confident Hire more job coaches Conversations with
people I didnt know
Slide 29
ACT on L.I.F.E. Spinal Cord Injury (Lifting Individuals for
Future Employment) Group Materials and Clinician Manual Minneapolis
VA Medical Center
Slide 30
SCI Demographic Older Veteran, non combat Spinal cord and MS
disorders All wheelchair bound Closed group Had been living with
the disorder for many years Not working, but had had prior work
histories Engaged vocational counselor, Ms. Acord in PVA Multiple
medical issues and lack of proper adaptive skill set to be in
competitive community placements BUT with expressed interested in
returning to work and beginning process
Slide 31
ACT on L.I.F.E. Group Outline Introduction to ACT and Telling
Your Story Conceptualized self Employment Barriers and Cost of
Avoidance Experiential avoidance, struggle Work Values and self
acceptance Values Clarity especially around work and disability
Managing Rejection/Hitting the Wall Inaction/ Conceptualized self
Mind Games Role of language and attachment to conceptualized past
Listening to the Silence Observer You Present moment, self as
context Commitment: Healing Stories Committed action Booster
Slide 32
Unique ACTributes Retelling your story activity Employee of the
Year Listening to silence Take mind out for a walk Role model in
work force to speak of journey
Slide 33
Slide 34
Results Quantitatively Qualitatively Only two AAQs were
available. Both showed increase in ratings of PF. Older, 7-Item AAQ
Questionnaire, also showed increase or stayed same. Returned to old
employer to ask if alternative jobs were available and settled on
returning to school to get MBA. Good Dragon skills but moving out
of state; stated he would return to work if staying in MN. Waiting
on transportation; began exploring help with marketing T- shirts
for bands he works with. Expressed desire to return to his home
town and return to local factory where he successfully worked with
same disability in the past doing assembly work.
Slide 35
Slide 36
References 1. Wiley, Andre L. (2008). Generational challenges
for army transformation (unpublished masters thesis). U.S. Army War
College, Carlisle Barracks, PA. 2. Shepherdson, N. (2000). Lifes a
beach 101. American Demographics, 22, 56-60. 3. Abowitz, D. A.
(2005). Social mobility and the American dream: What do college
students believe? College Student Journal, 39, 716-728. 4. Twenge,
J. M., & Campbell, S. M. (2008). Generational differences in
psychological traits and their impact on the workplace. Journal of
Managerial Psychology, 23, 862-877. 5. Welc, K. (2009, June 5). Who
is Gen Y, and what do they want? The Daily Record. 6. Tapscott, D.
(2008, December 15). Focus on the net gen family.
BusinessWeek.