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Women Who Are Visually Impaired or Blind as Psychotherapy Clients: A Personal and Professional Perspective

Mary Harsh

The Blind Woman - Tsvelov Alexey (2006)
The Blind Woman -  Tsvelov Alexey, 2006


SUMMARY. Women who are visually impaired or blind may face specific stressors related to their physical limitations in addition to the stressors that those who are not physically limited face. Several factors may limit this population’s utilization of mental health services including problems with mobility, accessibility of mental health professionals, and attitudes about visual impairment and blindness from both the client and the therapist. Psychotherapists need to acquire knowledge about the various types of visual impairment; the impact these impairments have on daily functioning; and the interactions of these impairments with societal demands to become more effective in working with this population. In addition, therapists need to explore their attitudes about visual impairment and blindness. Historically, blindness has been one of the most feared disabilities. This paper contains practical guidelines for working with women who are visually impaired or blind derived from personal experience as a psychotherapy client, from work as a rehabilitation specialist for the blind and visually impaired, and from work as a student-therapist who is partially sighted.

 

Women who are visually impaired or blind may face specific stressors related to their physical limitations in addition to the stressors that those who are not physically challenged face. Several factors may limit this population’s utilization of mental health services including problems with mobility, accessibility of mental health professionals, and attitudes about visual impairment and blindness from both the client and the therapist.

This paper presents practical guidelines for working in psychotherapy with clients who are partially sighted or blind. This information is derived from my work as a rehabilitation specialist for the visually impaired and blind, from my personal experience as a psychotherapy client who is visually impaired, and from my work in a doctoral program in clinical psychology as a student-therapist who is partially sighted.


PRACTICAL CONSIDERATIONS

Seeking psychotherapy is often a difficult process. When the client is visually impaired or blind, the process can become significantly more difficult. The following is a discussion of practical considerations to be aware of when working with women who are both partially sighted and blind.


Mobility and Office Location

The woman who is visually impaired faces her first potential obstacle to entering therapy when she must physically get to the therapists’ office. This first step may be insurmountable depending upon both the woman’s mobility skills and the location of the office. These two issues need to be addressed in the initial phone contact.

One’s ability to travel independently is not determined by the amount of remaining vision. A woman who is partially sighted could conceivably have more difficulty with mobility than a woman who is totally blind. This could be true for several reasons: (1) the woman who is partially sighted may not use her residual vision efficiently, (2) the woman who is partially sighted may deny how much her vision loss has affected her ability to move about safely, (3) the woman who is partially sighted may be so frightened or anxious about going out on her own that she is unable or unwilling to go someplace new, and (4) the woman who is partially sighted may be significantly affected by changes in lighting (i.e., daylight, shadows, dusk, cloud-cover, and darkness). Intuitively, the therapist might think that the best time of day to arrange an appointment with a woman who is partially sighted is during daylight. This is true not only because it will probably facilitate the use of her remaining vision, but also because this will prevent her from having to be out walking alone at night. However, there are people who are visually impaired who are so impacted by photophobia (sensitivity to light) that an evening hour appointment would be preferable. A good match between therapist and client may initially be determined by the flexibility in the therapists’ schedule and the mobility needs of the client.

The woman who is blind may be impacted by several other factors pertaining to her ability to get to the therapists’ office: whether the woman has received formalized mobility training (i.e., from an Orientation and Mobility Specialist, available in most communities), (2) whether the woman has natural orientation skills, and (3) whether she is frightened or anxious about going out on her own to the point that she is unable or unwilling to go someplace new.

The fear or anxiety a woman who is visually impaired or blind may feel about traveling alone warrants additional comment. The possibility of violence or attack is an issue that all women must deal with when going out alone. Although there are no large-scale studies of women who are blind or visually impaired in relation to this issue, one may easily see how this group of women are at increased risk for violence or attack. Several factors make this group more vulnerable. Many women who are visually impaired or blind need to use a white cane, guide dog, or assistance from individuals with full vision because of their limitations in mobility. These assistive devices and techniques also signal to those around them that they have physical limitations. Their visual limitation also decreases their ability to discern when danger is present. They may not be able to take note that they are being watched or followed, and then to seek assistance. Finally, women who are blind or visually impaired generally must rely on public transportation such as buses and taxis.

Use of these forms of transportation often require waiting alone for long periods, and walking to and from bus stops. All of these factors may make women who are visually impaired or blind more vulnerable targets to perpetrators of crime.

Regardless of how well the woman who is visually limited or blind travels, the first time she travels to someplace new she is likely to elicit significant apprehension, uneasiness, and/or fear.

These feelings can be assuaged by a therapist who is sensitive to these unique issues. During the first phone contact, the therapist needs to give thorough and explicit directions to the office location.

Generally, the woman will be traveling by public transportation (i.e., bus or taxi). Beyond basic information about major crossstreets and street numbers, detailed descriptions of the area are often useful or necessary. These details may include size and shape of the building, number of buildings from the nearest cross-street, number of driveways and/or pathways from the nearest cross-street, side of building to enter, location of door, layout of floor plan, and description of waiting area. In addition, the therapist should ask the client if she needs any other information to facilitate travel to the office.

At times, efficient travel skills and detailed descriptions of the office location will not be enough. I was once referred to a therapist who had her office in the local foothills. I was assured by the referring therapist that there was bus service to the area. When I called the transit system, I learned that the one bus for that area made only three trips per day. The logistics made it unfeasible for me to see this therapist.


The First Session

During the first session, several unique issues arise when working with a woman who is visually impaired or blind. The first one involves determining whether the client would like to move into the office independently or whether she needs or wants physical or verbal assistance.

The easiest way to determine the level of assistance the client needs is to ask. The most appropriate way to physically assist a client who is visually impaired is through what is known as ‘sighted guide technique.’ This technique involves the person who is visually impaired holding onto the arm of the person who is sighted right above the elbow. This position is most helpful because the person who is sighted is a half step in front of the guided person, which allows for advanced warning of turning or elevation changes (i.e., stairs or slopes). Unfortunately, well-intentioned people often automatically grab the arm of the person who is blind to do the guiding.

Instead of being helpful, this position can feel as though the person who is visually impaired is being pushed or pulled rather than guided. In addition, it leaves the person who is visually impaired less in control of her own movement and body.

A commonly used question in formalized mobility training is ‘‘Would you like to take my arm?’’ (from the individual who is fully sighted), or ‘‘May I take your arm?’’ (from the individual who is visually impaired or blind). If the answer is yes, the person who is sighted needs only to touch the back of her hand to the hand of the person who is visually impaired. This physical contact will enable the person who is visually impaired to locate the guide’s arm. This process can be very natural and quick, and can help to avoid an embarrassing or awkward situation in the first few minutes of the session.

Some therapists may have strong reservations about having physical contact with their clients. Physical contact between therapist and client is a complex clinical and ethical issue that has gained considerable attention in recent years (Holub & Lee, 1990). Physical contact is a very different kind of experience from verbal or visual contact. Touching between therapist and client may lead to misunderstandings or inappropriate behavior, and it may elicit sexual feelings in the therapist or client. Women are at particular risk for sexual exploitation by therapists. Holroyd and Brodsky (1980) found that a higher frequency of erotic physical contact occurs between male therapists and their female clients. In addition, these male therapists advocated nonerotic physical contact only with opposite- sex clients indicating a sexist therapy practice. It may be difficult to determine where nonerotic touching ends and erotic touching begins. Therapists need to remember that the sighted guide technique is an accepted and appropriate method of providing necessary physical assistance to individuals who are visually impaired and blind. However, a discussion of the impact and relevance of touching on the therapeutic relationship is necessary given the complexity of engaging in physical contact with clients.

Once inside the office, information that is helpful will differ depending upon whether the woman is partially sighted or blind.

For the client who is blind, it can be useful to describe the layout of the room in terms of size and positioning of the furniture. This may also be helpful to clients who are partially sighted. The client may want to practice moving from the waiting area to the inner office independently, or to review this process verbally. These issues will vary from woman to woman. An awareness of these issues can enhance the therapists’ effectiveness and ease in working with women who are visually impaired or blind. In addition, the degree of comfort and familiarity the therapist has with issues relating to sight loss will likely signal an acceptance of the woman and her disability.


Lighting and Distance

Two key elements of the physical environment in the therapists’ office can have a profound effect on the comfort level of the client who is partially sighted. Both artificial and natural lighting may impact how well the woman is able to see the therapist, and how physically comfortable the environment feels to her. In addition, the seating arrangement in terms of proximity may impact the communication between therapist and client.

Many people who are visually impaired are affected by glare and lighting/illumination. For example, the glare coming from a window can actually prevent the individual who is partially sighted from seeing the features of another person’s face who is positioned in front of the window. The glare can also cause physical discomfort and lead to headaches and/or muscle strain from squinting. For some, even sitting with the window to one’s side causes too much discomfort. If closing drapes or blinds does not cut down on enough of the glare, the furniture may need to be arranged so that the client is able to have her back to the window.

Illumination from ceiling lights and table lamps can also impact the comfort level of the client who is partially sighted. People with some types of visual impairments require bright light to enable them to use their residual vision most effectively. Others may need relatively low and indirect lighting to function well visually. Recognition of this important issue, and flexibility on the therapists’ part will help to create a more comfortable environment for the woman who is partially sighted. One therapist I saw demonstrated this type of sensitivity. First, she showed an interest and willingness to understand how lighting affected my ability to see. We then explored ways to modify the office environment to make it visually more comfortable for me. This involved shutting blinds and turning off a lamp close to my chair. In addition, she moved her easy chair away from the glare of the window. What I found so impressive was that she remembered to make these changes each week. These actions served to facilitate the building of our rapport during the early stages of therapy more than any other comment or action I can recall.

The physical distance between the client who is partially sighted and the therapist may also affect their communication. However, this is a potentially more difficult issue to resolve. Therapists’ styles differ in terms of their desired distance from the client. Their style is based on personal preference and professional training, and they may not feel comfortable modifying this distance. Yet, the therapist and the client may benefit from a discussion concerning how much detail the client is able to see in terms of the therapist’s facial features and expressions. A small difference in the distance may determine whether the client is able to discern facial expressions or body gestures from the therapist. With other clients, the distance necessary for meaningful visual contact may be uncomfortably close for the therapist and/or the client. An awareness of this potential limitation in their ability to communicate can help the therapist make adjustments in her style of expression. For example, feelings she may convey entirely through facial or bodily gestures may need to be expressed verbally to enable the client to experience or be aware of these feelings.

As noted above, sometimes the physical distance between the therapist and the client is too large to permit meaningful eye contact during the session. However, the client may be able to have this contact when standing closer to the therapist. This adds to the importance of the initial greeting of the client, and the final moments before the session ends. During these moments, the client who is partially sighted may be able to discern more about the therapist’s appearance. This added familiarity may increase the clients’ comfort with the therapist.


PSYCHOLOGICAL CONSIDERATIONS

Therapist Issues

Historically, blindness has been one of the most stigmatized and feared disabilities. Although treatment of the blind and visually impaired has improved, negative attitudes and irrational beliefs about blindness still exist. Recently, I was confronted with such an attitude in a doctoral-level course in clinical psychology. After class one evening, I had a private discussion with the professor describing the difficulty I have in group discussions because I am unable to see facial expressions. He encouraged me to explain the situation to the class the following week. When I did so, one woman in the class exclaimed ‘‘Hmmm, you look like a normal person!’’ She had been unaware that I am partially sighted. Now I was in some way not ‘‘normal’’ in her eyes.

Being ‘differently-abled’ by a visual impairment or blindness is often viewed as being not normal. Unfortunately, being ‘not normal’ usually carries a negative stigma as opposed to being seen as unique. Therapists need to explore their beliefs about what it means to be visually impaired or blind before and during their work with this population.

It is tempting for therapists to assume that the primary issues brought to therapy by women with visual impairments will center around sight loss. In actuality, the range of issues brought to therapy by women who are visually impaired are as diverse as those presented by women who are fully sighted. Therapists need to be alert for any tendency on their part to over emphasize sight loss as an issue.


Client Issues

Loss of vision may not be the major reason a woman with a visual impairment seeks psychotherapy. However, the challenges of living in a visually oriented world can influence many of the concerns typically brought to therapy. The issue of independence versus dependence provides an example.

Regardless of how independent a woman who is partially sighted or blind is, or may want to be, she must still rely on others for help with some aspects of her daily life. This assistance may come in the form of rides to work or to run errands, or help with reviewing her mail. A woman who is visually impaired with a strong need to be in control may find it difficult to accept any help or support for these necessary tasks. This rejection of assistance can add to the stress in her life.

On the other hand, a woman who is visually impaired who has a strong dependency need may focus on the real problems caused by her sight loss rather than explore other reasons for the dependency.

Therapists who have knowledge of the types of skills a sight impaired person can acquire through rehabilitation training will be better equipped to explore this aspect of the client’s coping style.

Vision loss also complicates other aspects of interpersonal relationships.

A woman with a visual impairment must cope with being treated differently, and at times thoughtlessly by people who are uncomfortable or unfamiliar with the disability. Simple social interactions can be complicated by the inability to recognize people’s faces or accurately identify body language and other nonverbal cues.

The specific manner in which the challenges of visual impairment interact with other personal issues varies greatly among clients.

Therapists need to be aware of the challenges faced by women with visual impairments and be willing to explore the nature and degree to which these challenges influence the client’s presenting complaint.


CONCLUSION

This paper has presented some of the basic practical and psychological issues that may arise when working with a woman who is visually impaired or blind in psychotherapy. The therapist’s knowledge and sensitivity concerning these issues will help to promote a more comfortable and therapeutic environment for both the client and the therapist.


REFERENCES

  • Holroyd, J. C., & Brodsky, A. (1980). Does touching patients lead to sexualintercourse? Professional Psychology, 11(5), 807-811.
  • Holub, E. A., & Lee, S. S. (1990). Therapists’ use of nonerotic physical contact: Ethical concerns. Professional Psychology: Research and Practice, 21(2), 115-117.

 

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Women & Therapy | Women Who Are Visually Impaired or Blind as Psychotherapy Clients: A Personal and Professional Perspective

author: Mary Harsh is a Blind Rehabilitation Specialist and Doctoral Candidate in Clinical Psychology

fonte: tandfonline.com

 

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8.Mar.2019
Maria José Alegre