The Role of the Therapist in Vision Therapy: Part 2

In Part 1 we introduced the concept that, of necessity, any therapy encounter involves some elements of the patient’s psyche.  When working with adult patients having strabismus, there are some deep underlying issues woven into the fabric of the patient’s condition.  We are used to thinking of the implications of strabismus as related to visual development, something that Patty Lemer addressed very nicely in her DDR blog. But what about the effects on the patient when unraveling all these developmental adaptations and compensations that have developed over time?

I cited Susanna Zaraysky as an accomplished linguist who has highlighted some of these psychological issues in the Adult Strabismic Patients’ Forum  on Sovoto. Holding true to her pledge, Susanna shared her thoughts with me on some of the unmet psychological needs of patients from her point of view.  First a little background, then the points.

In 2006, Susanna read the article, “Stereo Sue” by  Dr. Oliver Sacks and was surprised to learn that she didn’t see like most other people.  Prior to finding out about Susan Barry, she didn’t know that there was something called binocular depth perception, that she didn’t have it, and what the implications were.  After reading  “Fixing my Gaze”, it took her another year and a half to commit to vision therapy.  As soon as she embarked on her journey to 3D, Susanna encountered a number of psychological stumbling blocks both within and outside the doctor’s office.  Consider the following:


1. Being the only patient above 3 feet tall in the waiting room and vision therapy office and having to sign out vision therapy tools (prisms, red-green glasses, etc) as the patient’s parent or guardian can make one feel like the  “odd man out”.  Doctors need to be aware that adults may feel odd looking at clown vectograms while it sounds like the kids around him/her are goofing off and perhaps even having fun.  In Susanna’s words: “These exercises are super hard for us and we may need to be in a quiet atmosphere to concentrate. Having a quiet area available for adults is a wise idea.”

2.  Working through some of the therapy procedures can be very disruptive to one’s visual system.  Patients should be prepared for, and perhaps be counseled on how to cope with nausea, headaches, extreme fatigue, hypersensitivity to sound, double vision, etc.  Some patients will need to spend extra time in the office before feeling secure enough to drive home, or to be prepared to have someone else drive.   When Susanna encountered difficulty for the first time and called the doctor the following day to explain what happened, he told her that her visual confusion was a good sign that her anomalous correspondence was breaking down.  Susanna suggested that we consider how dramatic and disruptive these changes can be.  A list of tips to prepare patients for possible “side effects” of VT, something as simply as closing one eye if encountering temporary double vision or confusion when driving, can be helpful.

3. We emphasize the positive effects of becoming more binocular, and developing stereopsis can indeed be a rhapsodic experience for many patients.  Yet for others the psychic energy expended in rewiring the brain to achieve this may require that that they need to slow down their lives.   While there are many benefits to expanding binocular abilities, prepare patients for potential disruption to their activities of daily living along the way to their ultimate goals.  “No pain, no gain” may need to be counterbalanced by conscious relaxation.

4. How do adult patients undertaking vision therapy explain what they are doing to family, friends, or colleagues?  What if an adult has a spouse or significant other who is un-supportive? When Susanna described to me the sense of frustration and isolation that can occur, it reminded me how important it is to encourage at least one other significant individual in the patient’s life to attend the conference to review findings and recommendations about vision therapy.  Are there effective visual or verbal demonstrations that we can give that help create the critical empathy that would lend support?

5. It takes a significant amount of courage and fortitude to deal with the pain that surfaces when an adult strabismic undertakes vision therapy.  Beyond the doctor, how well acquainted is the therapy staff with these issues?  Fixing My Gaze highlights what a profound impact strabismus can have on one’s life, and when Susanna undertook VT the pain and embarrassment of thick glasses and eye patches that she suffered as a child came flooding back.  Given that there are so few support groups or sources of information available, anything the staff can do to become more conversant with these issues is welcome.  Clearly social networking sites like Sovoto and its adult strabismic patients’ forum are a step in the right direction.

– Leonard J. Press, O.D., FCOVD, FAAO


4 thoughts on “The Role of the Therapist in Vision Therapy: Part 2

  1. Well said. These are important thoughts and considerations for any vision therapy patient, but especially true for the adult strabismic. It’s easy to overlook how much neuro relearning they need to accomplish before results are seen. This also points to the need to converse about how they are feeling as they go through the therapy process. We need to be aware of the enormous shift in visual processing they are being asked to make, not just the clinical findings.

  2. Thank you Len for writing this very important post with a strong message that is often over-looked. Being a former strabismic myself, I am sensitive to your points and those
    of others and work this way with my patients too. Some of these cases are documented in my books, The Power Behind Your Eyes and Conscious Seeing. I am pleased to see this message visible in our Optometric forums. Wonderful.

    • You’re welcome, Roberto. The challenge always has been the context for the discussions, and broadening the vision while maintaining useful constructs from, shall we say, more “conventional” sources. Indeed we are inching closer to your vision.

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