John Powerhouse: An Evidence-Based Vocational Rehabilitation Case Presentation

1. John Powerhouse: An Evidence-Based Vocational Rehabilitation Case Presentation Patrick Waring CPSY 695 January 2013 the author wishes to acknowledge the reliance on Fernelius (2012) in preparing this case presentation.

2. Identifying Information • 61-year-old Caucasian male • Forced into unemploymentfrom being the top project manager about 1 year ago due to health costs and company failure in this economy • Vietnam Era Veteran who was exposed to defoliation chemicals during service in army as an officer and main MOS was as document security officer to several different generals both in the field and outside the field • Main SCD is 100% cancer of the genitourinary tract for the past 2 years

3. Identifying Information • Veteran is eligible for services due to 100% SCD • Veteran is seen to have a serious employment handicap due to age, prior level of experience as an executive, and impact of disability on performance • Veteran is eligible for Vocational Rehabilitation and Employment Services

4. Mental Status • Appearance - The Veteranis average in height and somewhat overweight and reports feeling overweight. His appearance was consistent with chronological age with some signs of fatigue. He is well groomed and has a very professional business presentation. He is well organized and comes to the intake with all documents organized. • Mood – The Veteran was seen 4 times in January. At all meetings the veteran appeared positive and polished but looked fatigued. • Affect: The client’s self-report of affective experience appeared consistent with observations.

5. Mental Status • Thought processes: The client’s thought process were very logical and sequential with good reality testing. On occasion the counselor would need to repeat something twice or three times due to an apparent diminishing of attention. • Thought content: The client’s thought content was appropriate to the situation. • Dangerousness to self or others: Denies ideation, domestic violence or homicidal ideation • Sensorium: The client was alert and oriented to person, place, and time and purpose of the meetings

6. Chief Complaints • Veteran reports surgery for the cancer including rerouting of the ureter which causes pain during seated activities • Secondary to testosterone suppressing treatment, Veteran reports fatigue, weight gain, incontinence, and depressive like symptoms. • Veteran expresses some memory impairment with appointments, times, places and medication management which is primarily assisted with by wife at current time • Patient also expresses frustration with unemployment and also the thought of having to function in a work environment without support staff and relates no computer skills or experience working independently without support staff • Self-referred because wishes to continue to work and make money due to young child at home.

7. Additional Information • Both wife and he have had 3 prior divorces, wife is 48 years old and they have on dependent biological child at home who is 9. • Very little computer skills or clerical skills as has always had a staff to assist him with these tasks. • No history of physical, emotional, or sexual abuse. No history of substance abuse. • Unemployed on intake but given new job exactly 7 days later. • Has many connections in the field but this means these small to medium sized businesses all know of his Dx and cannot afford to hire him or do not wish to hire him. • Tx Goals: Get a job as a independent contractor functioning as a project manager or property buyer. Now keep this new job as a project manager.

8. New Job • Working as an independent contractor for a VA telecom firm as their IN, OH and MI property acquisition manager for telecom antenna sites • Requires 90 days of training at home office in Richmond , VA • Will require lost of time in didactic settings for first 30 days and then 60 days of paired work with a more experienced person. • Has the skill set but does he have the disability coping skills? • Will this aggravate his condition?

9. Evaluation • Purpose of Voc Rehab Evaluation is three fold. • Is veteran eligible and he is as he has more than 30% disability that is SC and he has a serious employment handicap • Is veteran capable of working with support? He is determined to be employable with support, although in the future if conditions worsen he may become unemployable which would make his case an independent living case. • What support services does he need to succeed?

10. Diagnosis • Voc Rehab Counselors do not diagnose in the VA system. We rely on the medical center for all diagnoses. His sole diagnoses is cancer of the genitourinary tract.

11. Impressions in a DSM Model • DSM IV Hypothetically • I.-608.89 Male hypoactive sexual desire disorder due to Prostate Cancer Treatment; 309.9 Adjustment Disorder Unspecified (psychosocial adjustment to CID) • II. N/A • III. Genitourinary cancer • IV. Unemployment • V. GAF 65% GARF 85%

12. The Iterative Process of Evidence-Based Practice • Is it the same for a Psychologist and a vocational rehabilitation counselor?

13. The ICF Model (Stewart & Rosenbaum, 2003)

14. The ICF Model • “Specifically, the ICF paradigm is structured around the following broad components: (a) body functions and structure, (b) activities (related to tasks and actions by an individual) and participation(involvement in a life situation), and (c) severity of disability and environmental factors. Functioning and disability are viewed as a complex interaction between the health condition of the individual and the contextual factors of the environment as well as personal factors.

15. The ICF Model Cont. • The emphasis of the ICF is on function rather than condition or disease and is designed to be relevant across cultures as well as age groups and genders, making it highly appropriate for heterogeneous populations. The ICF model has been embraced by many health care and rehabilitation health researchers, and the voluminous research generated by these health researchers can also be invaluable for rehabilitation counselors. These kinds of EBP information can help the performance of rehabilitation counselors in their case management functions.” (Chan, Tarvydas, Blalock, Strauser, & Atkins, 2009)

16. Asking • What supports are available to increase function in a person within the realities of the environment. • What is the best available research from the entire health professions literature about increasing function in the activity of employment within the context of the disease (cancer), the person and the person’s history, culture, geographic and work environments

17. Accessing • Best Available Research • Unfiltered – EBSCOhost (utilizing PsycInfo, PsycArticles, Academic Search Premiere). • Search for: • Meta-Analyses • Systematic Reviews • Randomized Controlled Trials

18. ICF Component • Disease • Genitourinary Cancer • Group education and Discussion in a RCT of 250 prostate CA survivors resulted in increased rates of employment and decreased sexual concerns in non-college graduates. No effect seen in college grads. (Lepore, Helgeson, Elton, & Schulz, 2003) • M.D.-Regular injections of Testosterone suppressing medicine. • V.R.-Referral for possible prostate CA survivors group as Veteran is a non-college graduate. However, recent employment may prevent participation.

19. ICF Component • Body Structure and Function • Removal of the prostate, rerouting of the ureter, Pain upon sitting needs to sit on the side of his glutes, Incontinence, zero testosterone levels in a male, sexual dysfunction, • Best available evidence seems to be in prostate cancer discussion lists as no results from Google scholar or EBSCO on point. Generally pain is normal but medical follow-up is needed for pain after 4 weeks. Incontinence should also be diminishing but is not. • Group education and Discussion to increase employment retention and decrease sexual side effects. (Lepore et al., 2003). • Referral to primary physician for evaluation of pain and incontinence and possible treatment

20. ICF Component • Environment • Initially job involves training courses and paired site evaluations with current employee. Worry about appearances and need for bathroom etc. Hesitant to draw attention to problem for fear of discrimination. Unsure, what do you think? • New Job involves driving to different sites and evaluating them for possible purchase for telephone towers. Two concerns are need for bathrooms readily available and sitting for extended periods. Plus is that Veteran is somewhat independent of others and has freedom to stop when needed. • Already addressed in MD referral and group education referral

21. ICF Component • Person • Stoic, lacks computer skills, fatigue and memory problems post treatment • Best evidence • Group education and discussion(Lepore et al., 2003). • Training by video superior than tutorial type training in older adults (Gist, Rosen, & Schworer, 1988) • Best evidence is for cognitive orthotic developed for younger people with TBI and other organic cognitive difficulties, generalizability unknown in older populations (Bharuka et al., 2009)

22.  Person Cont. • Plan Made • Referral to a CA support group that is psychoeducational and includes discussions (Lepore et al., 2003). • Because of new employment cannot send to physical training, recommended video training for computer usage. Provide computer and Printer. (Gist, Rosen, & Schworer, 1988) • Referral to Speech Pathology for cognitive orthotic training, provide IPad and case. (Bharuka et al., 2009)

23. ICF Component • Participation • Has new Job • Plan called forComputer and printer and Video Training for computer use • Apple IPad for cognitive assistance and SP referral for use of tech as cognitive assistive device • Referral to M.D. for pain evaluation and possible supportive seating device or other treatment.

24. Participation continued • Recommendation for group support • Regular check in by phone and email so as to meet any problems immediately to support Veteran in new employment. • Referral to Richmond VA for problems arising during training • Meeting upon return from 90 days training in Richmond.

25. Evaluating the Iterative Process • Asking – appropriate background questions, formulating a meaningful, relevant PICO question. • Accessing – demonstrated through screen shots and rationale for literature. • Appraising – Literature and clinical supervision/expertise • Translating – the best available research and theoretical literature Integrating – best available research, clinical expertise, and patient characteristics.

26. Personal Reflections and process notes • Should this Veteran be working or should we work on adjustment to disability and retirement? • Will he be successful with new employer even because of his stoic attitude, lack of disability identity and obvious signs of disability or at least difference. • How do you balance need for treatment with opportunity for employment that came out of no where? • Will he be able to function without wife in VA? • What will be the psychological fallout if he fails? • I found myself under his persuasive spell a bit, guy is a born shmoozer, would I be as effective with a mean clients? • How to balance need to reinforce its ok to ask for help to ensure success with my own need for his success and his independence?

27. References • Bharuka, A. J., Anand, V., Forlizzi, J., Dew, M. A., Reynolds, III, C. G., Stevens, S., & Wactlar, H. (2009). Intelligent Assistive Technology Applications to Dementia Care: Current Capabilities, Limitations, and Future Challenges. American Journal of Geriatric Psychiatry, 17(2), 88-104. doi:10.1097/JGP.0b013e318187dde5 201301281053301113994360 • Chan, F., Tarvydas, V., Blalock, K., Strauser, D., & Atkins, B. J. (2009). Unifying and Elevating Rehabilitation Counseling Through Model-Driven, Diversity-Sensitive Evidence-Based Practice. Rehabilitation Counseling Bulletin, 52, 114-119. doi:10.1177/0034355208323947 201301280926281092203736 • Fernelius, S. (2012). Daniel Plainview: An Evidence-Based Practice Case Presentation [PowerPoint slides]. • Gist, M., Rosen, B., & Schworer, C. (1988). The influence of training method and training age on the aquisition of compter skills. Personnel Psychology, 41, 255-265. 201301281041091570357204 • Lepore, S. J., Helgeson, V. S., Elton, D. T., & Schulz, R. (2003). Improving quality of life in men with prostate cancer: A randomized controlled trial of group education interventions. Health Psychology, 22, 443-452. doi:10.1037/0278-6133.22.5.443 20130128100649519249439 • Stewart, D., & Rosenbaum, P. (2003). The International Classification of Functioning, Disability, and Health (ICF): A Global Model to Guide Clinical Thinking and Practice in Childhood Disability. Retrieved January 28, 2013, from http://www.canchild.ca/en/canchildresources/internationalclassificationoffunctioning.asp 20130128091652780532122