The Gift That Keeps On Giving

In the course of working on something else, I came across Chapter 8 of the manual used in the CITT, on file with the OSU College of Optometry as one of its investigational sites.  It reminded me of what a huge undertaking the CITT was, and why its conclusion is a gift that keeps on giving.


The section on Therapist Instructions is taken almost verbatim from the General Principles and Guidelines for Vision Therapy from Scheiman & Wick’s Clinical Management of Binocular Vision.  That text cites Marty Birnbaum’s influence, and I hear these principles embedded in the coursework from Bob & Linda Sanet.  The Principles and Guidelines might just as well be laminated as “The Therapist’s Credo”, a gift to all those who embrace it.  Read on …

Therapist Instructions

It is important to understand that there are general principles and guidelines that apply to all binocular vision and accommodative techniques. Vision therapy is similar in many ways to other types of therapy that involve learning and education. If we look at other types of learning it becomes clear that there are specific guidelines to facilitate learning and success. Since vision therapy can be considered to be a form of learning and education, similar principles and guidelines are used to achieve success. Therapists should adhere to the following guidelines:

Determine a level at which the subject can perform easily

Working on this level makes it easier for the subject to become aware of the important feedback cues, strategies, and objectives involved in vision therapy. It also builds confidence and motivation.

Be aware of frustration level

Signs of frustration include: general nervous and muscular tension, hesitating performance, and possibly a desire to avoid the task.

Use positive reinforcement

The subject should be rewarded for attempting a task, even if it is not successfully completed. Reinforcements can be verbal praise, tokens that can be exchanged for prizes, or participating in a task that the subject enjoys.

Maintain an effective training level

Start at the initial level at which the task is easy and gradually increase the level of difficulty, being very careful to watch for signs of frustration. Vision therapy should be success-oriented, that is, build on what the subject can do successfully as opposed to giving tasks that are too difficult.

Emphasize to the subject that changes must occur within his or her/her own visual system

A key to success in vision therapy is teaching the subject to internalize changes in visual function, as opposed to just achieving certain criteria for specific techniques. Often, as subjects go through a vision therapy program, they gain the impression that it is the instrumentation, lenses, or prisms that affect the change in their visual system. Unless told otherwise, a subject may believe that these external items are the keys to their success in vision therapy.

It is important to stress that the subject must be made aware that the changes actually occur internally, within the visual system, and not externally in the instruments and paraphernalia utilized in vision therapy. To accomplish this objective the language used in communication between the therapist and subject is critical.


When performing a fusional vergence technique the therapist might say “Try and keep the picture single.”

The problem with this instructional set is that while the subject is asked to try, the instructions are given in terms of what happens to the targets rather than what changes the subject must make internally to achieve the desired result.

Try the following approach instead.

Explain to the subject that if the picture is double it is because he or she is looking too far or too close in space. In order to make it single he or she needs to look nearer or farther; he or she needs to make adjustments within him or herself, in where he or she is pointing his or her eyes in space, and then the picture will become single.

The underlying important concept is that it is not just the specific technique that leads to success in vision therapy. Rather, the key factor is to get the subject to take responsibility for creating internal change.

Make the subject aware of the goals of vision therapy

The subject must know why he or she is in vision therapy. He or she should be able to explain what his or her problem is, how it affects performance and the goals of vision therapy. Even with a young child, the therapist should try to establish some understanding on the part of the child about what is wrong with his or her eyes and why vision therapy is necessary. For each therapy technique the child should be able to explain what he or she needs to do to accomplish the desired task.


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