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Successful Work
Supports for Persons
With Spinal Cord
Injury
Pam Targstt MEd: and paul Wehman PhD
('.Cording to the National Spinal Cord Injury
Statistical Center, there are between 183,000 to 230,000 individuals with spinal
cord injury (SCI) living in the United States. Each year that number increases
by 10,000 people. A number of federal initiatives, like the Americans with
Disabilities Act (ADA Public Law 101-336), have been passed to promote
employment of persons with disabilities. However, unfortunately the vast
majority of people with 'SCI and other severe physical disabilities have not yet
entered the workforce (Revel, Wehman, Kregel, West, & Rayfield, 1994; Yasuda,
Wehman, Targett, Cifu, & West, 2002). They continue to experience high rates
of unemployment and underemployment that far exceed the general
population, even after completing post secondary education and training
programs (Babbitt & Burbick, 1990; Liebert, Lutsky, & Gottlieb, 1990).
Literature reviews related to employment after an SCI indicate employment
rates ranging from 13% to 48% and 13% to 69%, respectively (Trieschmann,
1988; Athanasou, Brown, & Murphy, 1996). A study conducted by the National
Spinal Cord Injury Association indicates that a majority, or 59%, of individuals
with SCI were employed at the time of injury. However, only 29% of individuals
between the same age ranges were employed 8 years after their injury. Research
has indicated that the least successful employment outcomes for persons with
SCI were among minority men, persons over 50 years old at injury, those with
complete quadriplegia, and individuals with less than 12 years of education
(Yasuda et aI., 2002).
CUll till ued
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successful work supports
SUCCESSFUL WORK SUPPORTS
supported employment. This paper will provide a brief
Continued fro III p. 1
overview of this vocational rehabilitation service and
offers some real life examples of effective supports in the
People with disabilities have said that the number
workplace for individuals with SCIs.
one barrier to employment is imposed by their
Supported employment was first introduced into
disabilities. Other barriers to employment identified by a
federal legislation with the Developmental Disabilities
Louis Harris Poll (1995) include the need for personal
Act of 1984, (Public Law 98-527). The Rehabilitation Act
assistance noted by 24%, transportation requirements
Amendments
noted by 24%, 31 % have concerns about losing benefits
"competitive work in integrated work settings for
or insurance, and 42(70 say that employers will not
individuals with the most severe disabilities; (I) for whom
recognize that they can do a good job.
It has been suggested that individuals with SCI can
competitive employment has not traditionally occurred;
or (II) for whom competitive employment has been
return to work when they have access to quality
interrupted or intermittent as a result of severe disability;
vocational services that offer creative and flexible
and (III) who, because of the nature and severity of their
supports to meet their individual needs (Inge, Wehman,
disability, need intensive supported employment services."
defines
supported
employment
as
Strobel, Powell, & Todd, 1998; Dowler, Batiste, &
The meaning of supported employment is further defined
Whidden, 1998).
within the context of these amendments as follows:
The characteristics of quality return to work
programs include:
>-
>-
>-
>-
>-
>-
The term "supported employment services" means
An organizational climate and culture that
ongoing support services and other appropriate
supports anyone who wants to work, encourages
services needed to support and maintain an
success, and focuses on work as an outcome.
individual with the most severe disability in
Practical assistance is provided to facilitate the
supported employment, that (a) are provided singly
person's job search rather than requiring the
or in combination and are organized and made
person to go through many steps in a process
available in such a way as to assist an eligible
prior to job seeking, like skills training.
individual in entering or maintaining integrated,
Emphasis on the job seeker's personal
competitive employment; (b) are based on a
preferences, existing strengths, and belief in the
determination of the needs of an eligible individual,
power of workplace supports.
as
Rapid assistance is provided when one wants to
rehabilitation program; and (c) are provided by the
work; one does not have to be "work ready" and
designated State unit for a period of time not to
assessment focuses on person-centered approaches to
extend beyond 18 months, unless under special
determine employment strengths and interests.
circumstances the eligible individual and the
Flexible and individualized support including
rehabilitation counselor or coordinator jointly agree
ongoing support if needed. Rather than giving
to extend the time in order to achieve the
one kind or level of support to all, assessment
rehabilitation
objectives
of support needs is ongoing in the natural
individualized
written
environment.
(Rehabilitation Act Amendments of 1992).
specified
III
an
individualized
identified
rehabilitation
written
III
the
program
about vocational preferences is by working in
As described above, supported employment is an
ongoing service for persons with severe disabilities who,
real jobs, is embraced and job termination is
without these services, would be unable to obtain or
not viewed as a failure but as an opportunity
to find a better career match or move to a
maintain competitive employment. This long-term
enduring support to both the employer and employee
better job.
with a disability is a unique feature of supported
The idea that the best way for a person to learn
employment (Wehman,
1988). The individualized
One vocational rehabilitation strategy that embraces
placement approach to supported employment has
these practices best and represents a major paradigm
proven to be effective for individuals with a wide range of
shift in traditional vocational rehabilitation services is
severe disabilities, including SCI (Inge et aI., 1998).
6
successful work supports
disability related topics like the ADA, accessibility in the
The essence of supported employment is defined by
a number of critical characteristics (Brooke, Inge,
workplace, disability etiquette, and ideas for employee
Armstrong, & Wehman, 1997) that can be used as a
accommodation or workplace supports. It is also
measure of a program's success such as the following:
important to note that services are provided in a way that
~
Real work for real pay: Workers with disabilities
complement the employer's existing practices and uses
are employed in "real community based jobs"
existing workplace supports when possible. The
following case studies will further illustrate this process.
earning wages that are in alignment with the
pay of others performing the work.
~
~
~
~
~
CASE STUDY f
Full integration in the workplace: The worker
with the disability works, eats, and participates
Luther is a middle-aged man who sustained a C-6 to C-7
in after work activities along side other workers.
SCI as the result of an automobile accident when he was
There are no special facilities or areas for
19 years old. At the time of injury, he was employed as a
workers with disabilities.
construction worker. He attempted to return to work one
Job search assistance and on the job support:
Individuals are offered assistance with
time after his injury. A vocational rehabilitation counselor
referred him to a sheltered workshop. He attended the
conducting their job search and support is
workshop for a couple of weeks, but then stopped going
provided on the job. Learning how to do the
because he did not like the setting and stated that it made
job and becoming a valued employee can be
him feel unproductive. Nearly 30 years later, Luther was
accomplished in the real workplace.
referred back to the State Department of Vocational
Zero rejection: Supported employment is for
Rehabilitation Services by a physician working in
persons with the most severe disabilities. No
a SCI clinic at a local hospital. The doctor strongly
one should be denied access due to the severity
recommended
of disability.
Individualized, flexible, and customer-driven
employment services.
When Luther met with the employment specialist he
supports and services: Supports and services are
stated that he did not know what type of work he would
individually determined and can include
like to pursue, so several activities took place to help him
whatever is needed to help the person to be
define work activities that he liked and those that he
successfully employed.
Choice: Services are geared toward offering the
disliked. This included discussions that revealed that he
that
Luther
receive
supported
support needed to enable the recipient to
preferred to work -part-time and would use specialized
transportation services to get to and from his job,
exercise choice.
requiring a work schedule that accommodated the
transporter's hours of operation. The employment
The individual placement model of supported
specialist also learned that he enjoyed being around
employment generally involves four phases: career
people, listening to music, and that religion played an
important role in his life. Luther's strengths were also
planning, job search, on the job support, and job
retention services. It is important to note that a
noted: he was mobile, had movement in both wrists,
professional known as an employment specialist
elbows and shoulders, and was friendly and motivated to
performs numerous tasks to support the individual in
work. Some of his challenges were related to his limited
each phase of service delivery. The specific tasks will vary
work history and slowed movements. He and the
from person to person, however, the following types
employment specialist began to look for entry-level work
of activities listed in Table 1 are usually provided.
opportunities and discovered that a local bookstore and
Nonetheless, it is important to keep in mind that new
coffee shop needed a cashier.
Initially, the employment specialist met with the
and creative types of support may also be developed
to meet the person's individual needs.
employer
In addition to offering services to the person with the
to
commitment
discuss their hiring needs and gage their
to
accommodating
individuals
with
disability, the service provider offers business services
disabilities in the workplace. The company was very
too. This may include, but is not limited to, the following:
interested in diversifying its workplace and felt that all
referral of job applicants, education and training on
employees needed support and a person with a disability
7
successful work supports
Table 1. Supported Employment Activities.
Career Planning
~ Recommend career exploration activities
~ Provide support when participating in career exploration activities
~ Gather information on the job seeker's personal abilities and support needs
~ Assist with determining transportation options for employment and provide skills training on use, once
employed, if needed
Job Search
~ Identify potential employers and arrange fClf meetings with them
~ Meet with employers to discuss abilities and qualifications for work
~ Meet with employers to discuss on the job and ongoing support services
~ Refer the job seeker to inten'iews with prospective employers
~ Discuss the pros and cons of particnlar work opportunities with the job seeker
~ Provide assistance with the pre-employment process (i.e., completing job applications, disclosure, testing,
in ten'iewing, etc.)
On the Job Support
~ Provide additional on the job skills training after the new employee has been tanght by the employer
~ Oner ideas fCl!' assistive technology and other types of accolllmodations
~ leach the employee to use assistive devices or technology
~ Provide feedback to the employee on his or her perfclfIuance
~ Model positive interactions with customers, coworkers, and supervisors
~ Promote communication and rapport between the employee with the disability and workplace personnel
~ Facilitate the use of existing workplace supports
Job Retention Services
~ Assist the person with arranging medical appointments outside of work hours
~ 'leach the person what to do if their transportation to work is late or how to make alternative arrangements
~ Teach the person how to ask fc)]' time off from work
~ Provide assistance with hiring and supervising a personal assistant
~ Provide refenal to a benefits specialist to ensure the use of available work incentives
~ Assist the person with resolving workplace problems related to job performance, getting along with coworkers,
or supervisors and so forth
~ Assist the person with identif}'ing and/or requesting new accOllllnod<ltions' {i'om the employer
was not any different. The manager expressed the need
service, bagging merchandise, and calling customers to
for a part-time cashier to work during the midday rush.
pick up orders.
He stressed that he was interested in hiring anyone,
Once Luther was working, the employment specialist
disabled or not, who could get the job done. The
worked with him and the employer to put into place the
employment specialist discussed the job opportunity with
necessary workplace supports and provided training to
Luther. Luther was very interested, but felt apprehensive
Luther as needed. Examples of his workplace supports
about operating the cash register and a computer. The
are listed in Table 2 below.
He worked for over 3 years before retmng. During
employment specialist reminded Luther of how she
would be there with him every step of the way
to
that time, the employment specialist assisted Luther with
help him
learn how to do the job and to put in place any needed
returning to work, training for a new job with new duties,
assistive technology. Luther agreed to go on an interview
operating new equipment, and helped in arranging for
and was hired to work 20 hours a week with a starting pay
needed medical leave. When asked how work has changed
of over $7 an hour. His primary work functions included
his life, Luther said, "I feel financially better and I like
making sales transactions, providing friendly customer
myself more. I feel like my life is moving forward."
_----_............•
8
.:.
.....,.,.
successful work supports
CASE STUDY 2
employment specialist began to look for entry-level work
Jack is a 56-year-old man who sustained a C-5 SCI as the
opportunities and found a local transportation company
result of an assault a decade ago. At the time of injury, he
that was in need of a part-time receptionist. The
had been employed as a construction worker for over 11
employer indicated that he would hire someone with a
years. He was residing in an adult care facility when he
disability, but he had concerns related to workplace
was referred for supported employment services. The
accessibility. The employment specialist explained how
nursing home's social worker had heard about supported
she would be able to assist in arranging for any needed
employment and referred Jack to the vocational
accommodations and described how she would be
rehabilitation services with a strong recommendation for
available to provide training to Jack on their use if
needed. She also explained to the employer the various
this service option.
When Jack met with the employment specialist he
indicated that he was not really sure about what he could
incentives related to removal of architectural barriers and
do. He indicated that he liked to be around other people
employer agreed to interview Jack and he was hired for
the tax credits for hiring a person with a disability. The
and would do anything to avoid spending all day, every
the job. His primary work functions include greeting
day, in the nursing home. He said that he wanted to work
visitors, answering the telephone, taking messages, and
part-time because he was only allowed to keep a certain
dispatching radio calls. He was hired to work 20 hours a
amount of his paycheck. Earnings over a specific amount
were given to his residence to help pay for his care. He
week for $6 an hour.
Once employed, the employment specialist worked
said that he would like a workplace where he could take
closely with Jack, the employer, and vocational rehabilitation
smoking breaks and that he would use specialized
services to put in to place the needed accommodations
transportation services to get to work. Furthermore, he
and necessary workplace supports. Examples of Jack's
needed to work in the afternoon because it took a lot of
workplace supports are listed in Table 3 below.
Over the years, the employment specialist has
time for him to be assisted with getting up and out in the
assisted Jack with learning new job duties, replacing
mornmgs.
Jack's vocational strengths were also noted and
assistive devices, coping with performance problems, and
included the fact that he is mobile, is able to move his
moving out of the nursing home into his own apartment.
wrists, has good communication skills, and is friendly and
When asked, "how has work changed your life?"
motivated to work. Some of his challenges were that he
Jack stated, "I get up knowing that I have a job to go
had no recent work history, only wanted to work part-
to and I can make a little money."
time, cannot work mornings due to reliance on others for
Jack has been working for over 5 years and continues
activities of daily living, is functionally illiterate, and very
to receive long-term support and follow-up services on
limited in his ability to read and write. He and the
Table 2. \\'or1..pLtce Support,
t(JI
, the job.
Lutlll'l.
Presenting Issue
Solution
Assess existing work area
De,k nlodified a11(1 shelw's relnO\cd
Difficulty operating computel
Uses track ball mouse
Picking up coins
t' 'ies coin change dispen'lT
froill
register
Remembering certaill transaction,
L'ies memory Llnls
Bagging item'i
i\!ounted hooks
Retrieving
"Oil
Oil w~t11
to hold bags open
C< )\\orkel rcrrieves ,\'lIen asked
hold" books
Hanging hags on hook,
Coworker a",isls "hell asked
9
successful work supports
SUMMARY
Both case studies illustrate a number of important points.
First, both men had participated in, but had not been
successful with, traditional rehabilitation programs.
Furthermore, Luther had indicated that participation in
a segregated workshop setting had been demeaning and
had damaged his self-perception. Both men were
involved in occupations that required a high degree of
physical activity prior to their injury, and after their
injury, neither had received information on how their
existing abilities could be used in the workplace. Neither
man felt comfortable with how his disability benefits
might be adversely affected by earned income, although
each had received verbal and written information from
their local social security representative.
Both men lacked confidence in their current abilities
and did not know how their existing skills and attributes
could translate into employment.
Over the years, the lack of encouragement left each
of them believing that they were unable to find or
perform real work. Both men requested assistance in
identifYing their current abilities and possible needed
accommodations, and in completing pre-employment
activities. Both indicated a strong desire to work, but
when asked what they wanted to do, they replied that
they would do anything that they'd be able to do. Both
men also required somewhat intensive intervention and
individualized supports at work, as indicated in the case
studies. The employment specialist played a key role in
securing adaptive equipment in a timely manner once
the individual became employed and afterwards
provided training to the employee on the use of the
accommodations. This is very important, as technology
identified or purchased prior to work is often useless or
abandoned. Furthermore, all accommodations, with the
exception of the ramp, which cost $650, were purchased
for less than $150. Both men relied on existing supports
in the workplace or on their coworkers to provide a little
assistance with performing the job.
Both men received ongoing long-term support from
the employment specialist. This support has proved
beneficial to both of them. For example, the employment
specialist has worked with Luther and the employer to
negotiate a medical leave of absence due to health
problems related to pressure sores. lack received
assistance in resolving issues related to customer
complaints on his telephone skills, arranging
transportation, and wheelchair and accommodation
repairs.
Both men report a number of positive outcomes as
the result of supported employment, which include
improved self-esteem, new relationships with other
people, development of new skills, improved economic
sufficiency, and fuller participation in their communities.
Supported employment programs that are designed to
achieve these types of outcomes are effective.
Finally, both men have some of the characteristics of
those who are least likely to return to work after an SCI.
Both are minority males and neither of them are high
school graduates. Caution should be taken when
attempting to predict who can and cannot return to work.
When individuals with disabilities have access to
customized employment services then their return to
work is possible, even when it seems to be against
the odds.
~
Table 3. Workplace Supports for.J ack.
Presenting Issue
Solution
Reaching equipment
Uses small slanted table
Answering the telephone
Uses headset, toggle switch, wrist cun: and pointer
Taking messages
Uses tape recorder, wrist cuff, and pointer
Seeing what is going on behind him
Mirror positioned on the wall in front of him
so he can see
Entering and exiting building
Ramp purchased; coworker puts it out and brings it in
Putting on headset
Coworker assists
successful work supports
REFERENCES
Revell, G., Wehman, P., Kregel,
J.
J.,
J.,
West, M., &
& Murphy, G. C.
Rayfield, R. (1994). Supported employment for persons
(1996). Vocational achievements following spinal cord
with severe disabilities: Positive trends in wages, models,
injury in Australia. Disability Rehabilitation, 18, 191-196.
and funding. Education and Training in Mental Retardation
Athanasou,
A, Brown, D.
Babbit, C. E., & Burbick, H. J. (1990). Note on the
and Developmental Disabilities, 29(4), 256-264.
perceived occupational future of physically disabled
Trieschmann, R. (1988). Spinal cord injuries: The
college students. Journal oj Employment Counseling, 27(3),
psychological, social, and vocational rehabilitation. 2nd ed.,
98-103.
Demo Publication: New York.
Brooke, V, Inge, K. J., Armstrong, A
J.,
& Wehman,
Wehman, P. (1988). Supported employment: Toward
P. (1997). Supported employment handbook: A customer-driven
zero exclusion of persons with severe disabilities. In P.
approach Jor persons with significant disabilities.
Wehman & S. Moon (Eds.), Vocational rehabilitational and
Virginia
Commonwealth University, Rehabilitation Research &
supported employment (pp 3-16). Baltimore: Brookes.
Yasuda, S., Wehman, P., Targett, P., Cifu, D. X., &
Training Center on Supported Employment.
Developmental Disabilities Act of 1984, (Public Law
West, M. (2002). Return to work after spinal cord injury:
A review of recent research.
98-527).
Dowler, D., Batiste, L., & Whidden, E. (1998).
NeuroRehabilitation, 17(3),
177-186.
Accommodating Workers with Spinal Cord Injury.Journal
oj Vocational Rehabilitation, 10, 115-122.
Inge, K.
Todd,
J.
J.,
This paper was supported by Grant #HI33NOOOOI5
Wehman, P., Strobel, W, Powell, D., &
(1998).
funded by the United States Department of Education's
Supported employment and assistive
National Institute on Disability and Rehabilitation
technology for persons with spinal cord injury: Three
Research.
illustrations of successful work supports. Journal oj
Pam Targett, MEd, is a collateral faculty member at
Virginia Commonwealth University's (VCU) School of
Education and a research associate for VCU's Medical
College of Virginia's Model Spinal Cord Injury Center,
Richmond, Virginia.
Vocational Rehabilitation, 10(2), 141-152.
Liebert, D., Lutsky, L., & Gottlieb, A (1990).
Post
secondary experiences of young adults with severe
physical disabilities. Exceptional Children, 57(1) 56-63.
Louis Harris & Associates, Inc., & The National
Paul Wehman, PhD, is Professor of Physical Medicine
and Rehabilitation, with joint appointments
in the Department of Curriculum and Instruction and
Department of Rehabilitation Counseling. He is also
Director of the Rehabilitation Research and Training
Center on Workplac,e Supports and Chairman of the
Division of Rehabilitation Research at the Virginia
Commonwealth University, Richmond, Virginia.
Organization on Disability. (1995). The N. O.D./Hams
survey on employment oj people with disabilities. New York:
International Center for the Disabled (lCD).
National Spinal Cord Injury Statistical Center.
(2000). Spinal cord injury:
Facts and figures at a glance.
National
Injury
Spinal
Cord
Statistical
Center:
Birmingham, Alabama.
Rehabilitation Act Amendments. (1992). PL 102-569,
Stat. 4344.
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