 
The Blind Woman - Tsvelov Alexey, 2006
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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
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Holroyd, J. C., & Brodsky, A. (1980).
Does touching patients lead to sexualintercourse?
Professional Psychology, 11(5), 807-811.
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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
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