Using Acceptance and Commitment Group Training in Vocational Rehabilitation Programs with Special Needs Veterans

1. 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

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…

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.

4. Population • Polytrauma: TBI, SCI, plus… • OEF/OIF • Acute/ Transitional /Outpatient • Veterans and Active Duty USA solders • Generation X and Y: A new language—Blogs, My space, Texting, Casual, Expectations, Determined, Technology driven.

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

6. Ideas About Success • Over 50% of college students surveyed in 2000 expected to make their first $1 million before age 402 • They strongly believe in the “American Dream” and that success is the product of ambition and individual effort3 • 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

7. Employment4 • 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

8. Self-Esteem & Narcissism4 • 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

9. Social Approval4 • 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

10. Family Upbringing • 75% had working mothers5 • 25% were raised by a single parent5 • Child is the center of the family6 • Families are more democratic and collaborative6 • Parents are highly involved in the lives of their children6 • “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

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.

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.

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.

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” • “I’ve served my country already”

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.

16. Psychological Inflexibility WHO I WAS Dominance of Conceptualized Past I WANT TO DO UNDERWATER DEMOLITION Lack of Values Clarity REJECTING WORK PROGRAMMING OR INCREASING JOB HOURS Experiential Avoidance I AM GOING TO GET WORSE Cognitive fusion I’LL BE A STAY AT HOME DAD/WORK ALONE Avoidant/Inaction Impulsivity IF I CAN’T DO MY MOS, I WON’T BE IN THE ARMY Attachment to conceptualized self

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 • Dog’s life • Raisin activity

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

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 • Don’t trust your brains • Mind chatter • Milk, milk, milk • Don’t think about… • Take mind out for a walk/ride

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

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

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

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.

24. Goals of ACT on L.I.F.E. Group (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.

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.

26. ACT on L.I.F.E. Outline: T.B.I. Transitional Don’t 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 “can’ts” 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.

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: Don’t trust your brain: Board of directors; the can’ts 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

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 didn’t know”

29. ACT on L.I.F.E. Spinal Cord Injury (Lifting Individuals for Future Employment) Group Materials and Clinician Manual Minneapolis VA Medical Center

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

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

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

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.

35. Experiential Exercise:Employee of the Year

36. References • Wiley, Andre L.  (2008).  Generational challenges for army transformation (unpublished master’s thesis).  U.S. Army War College , Carlisle Barracks, PA. • Shepherdson, N. (2000). Life’s a beach 101. American Demographics, 22, 56-60. • Abowitz, D. A. (2005). Social mobility and the American dream: What do college students believe? College Student Journal, 39, 716-728. • 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. • Welc, K. (2009, June 5). Who is Gen Y, and what do they want? The Daily Record. • Tapscott, D. (2008, December 15). Focus on the net gen family. BusinessWeek.