Issue Section:
Editorial

Returning to work following an acquired brain injury (ABI, e.g. traumatic brain injury, stroke, infection, hypoxia) is a key aim for many survivors and is a marker of return to normality. For their managers and colleagues at work, there is also good will to support this process. The survivor may have played a pivotal role in the company/organization for many years before the injury, their skills are valuable and also many close working relationships and friendships have been developed over the years (many of us spend more time with our work colleagues than our family or other friends). Many employers are committed to supporting disability in the workplace.

However, this good will can change over time which can be a very confusing experience for all concerned. There are generally five key challenges that are either myths/assumptions held by those supporting survivors back to work. But often these do not hold up over time, or are unspoken ‘elephants in the room’ that challenge all involved.

The first myth is that a phased return-to-work process after ABI is similar to other health conditions. The degree of post-injury recovery of function in the workplace (i.e. the ability for the employee to resume all of their duties, perform well and be satisfied in their role) is dependent on the type of brain injury, the nature of post-injury physical and cognitive disabilities, but also the interaction of these factors with the unique work environment in each organization and the work role itself.

Many employers and occupational health providers are used to incrementally increasing hours and responsibilities during a phased return to work. However, recovery and performance after ABI can be impacted by fatigue from mental stimulation and sensory processing issues. As such the incremental stages of a phased return to work may be shaped by increasing the business of the work environment, contact with other employees, including a key element of home working, or implementing a unique schedule of activity and rest. Importantly, reviewing progress through phases of return to work and making decisions regarding increasing demands need to be guided by experts in neurorehabilitation.

The second common challenge is a myth is that adjustments/supports in the workplace should primarily focus on physical disability. Common adjustments in the workplace for disability may be physically focused such as ergonomic chairs, desks and computer equipment. While these are important, many survivors of ABI find that the more disabling aspects of the environment are noise, lighting, background conversation or how cluttered the workspaces are. Difficulties in processing information quickly and filtering out unwanted information mean that every little thing, object, sign and noise all comes flooding into the mind of a survivor, filling it up and overwhelming them. These needs may have different impacts on the ability to carry out the role, and the adjustments required, depending on if the role is in an office environment, customer-facing, an industrial or construction setting.

Workspace adjustments and changes to working practices for both the survivor and their colleagues may require unusual steps compared to other health conditions, to allow the survivor to allocate all of their mental resources on the job role itself and optimize their performance and contribution to their organization. Some of these changes are counter-intuitive (such as radically different work hours) and require guidance from rehabilitation professionals.

The third myth is that once a survivor has been successfully returned to work, the process is complete. This is a common false assumption and links to the previous myth. Indeed, many government-contracted disability employment agencies are organized around returning a survivor to work without adequate follow-up or retention support. Many people think that there is a final point of recovery for survivors and a return-to-work functioning that requires no further support. Someone who has reached an equilibrium of functioning and performance at work may have done so on a foundation of subtle adjustments and work role/environment conditions/support, many of which are delicate and can be easily undermined.

Like a house of cards, when the initial components of a return to work are put in place and the survivor is doing well for a period of months following this, all actually rest on the delicate balance of needs, conditions and practices that support this success. This fragile balance can be inadvertently disturbed in many ways, the house of cards collapses, and both survivors and employers can be plunged back into a state of crisis, confusion and distress. Changes that disturb the balance can be a physical change in environment (e.g. moving to open-plan office layout, the presence of construction works in the adjacent building), or more commonly work personnel (often a change in a line manager after many successful years can lead to a crisis for the ABI survivor, as their new manager is communicating in a different way or does not have the benefit of accumulated knowledge of supporting ABI in the workplace). A change in the work role itself that may seem to be minor to some may be too drastic a leap for the survivor who is managing cognitive difficulties in memory, attention, or planning/organization.

Change of any kind can be much harder to manage, adjust to, flexibly respond and update for survivors of ABI. Each new change requires a reconvening of the employment support network to plan, support and ideally anticipate guiding the change process in a way that is minimally disruptive for the survivors.

The final two challenges are ‘elephants in the room’. The first is the change in social behaviour for many ABI survivors, and the impact on others. Findings from Yeates et al. [1] are in line with other studies showing that the factors that are associated with loss of a job role or demotion post-ABI are not the core ability to do the technical aspects of the job role itself, or difficulties in physical or memory abilities. Instead survivor executive functioning difficulties in planning and organizing [2–4] and empathy/social behaviour [5–10] for survivors are the key predictors.

These post-injury difficulties can show themselves as not putting things into place that have been verbally agreed, missing deadlines and letting colleagues down. In addition, the job performance may be fine, but during coffee breaks, a survivor may inadvertently make their colleagues feel offended or uncomfortable by saying inappropriate things or invading personal space. Subtle and unspoken rules in the workplace can be easily broken, such as not using a colleague’s mug, or unspoken rules around dress when there is a non-uniform policy. Office politics can be difficult aspect of work to negotiate at the best of times, but for a survivor of ABI, can get out of hand and social transgressions can frequently occur. Sometime, essential strategies used by survivors to manage their time at work can attract negative judgments from others. For example, many survivors use their lunch breaks to leave the office and go somewhere quiet, to manage fatigue. This can often be seen as ‘anti-social’ by others in the workplace.

From the perspective of the survivor, the responses and actions of colleagues (who are offended or uncomfortable but this is not clear to the survivor) can be confusing and unpredictable, and a source of anxiety, distress and feeling powerless to change the situation. For the line manager/employer these issues can be really hard to manage. Having a conversation about socially embarrassing incidents is much harder than talking about an aspect of the job itself.

The final elephant in the room is the problematic process of feedback provision. Survivors of ABI who struggle with both cognitive and interpersonal difficulties in the workplace, require feedback from others to manage such difficulties. However, work colleagues may really struggle to do this, worrying about the feelings of the survivors, or struggling to cross a boundary or work hierarchy and give feedback to someone who is/was in an equal or more senior role. As such in the absence of feedback, problems can persist and get to a point of no-return. Deciding who, and how, to provide feedback, can be complicated, and ideally this should be developed with input from ABI employment experts.

In summary these are five challenges (myths and elephants in the room) that are a continual source of struggle for survivors of ABI, their employers/managers, their colleagues and those who support them.