when the horse bucks…

horseMy experience on horses is fairly limited. I’ve been on two, and fallen off both – no wait – I’ve been thrown off both. Where I come from that’s called hilarious, unless you’re the one feeling gravity’s pull. Both times things were nice and calm when suddenly the horse became tired of me and introduced me to the ground. In a word, ouch!  This week, I became aware of an interesting parallel between my experiences with horses and the Vision Therapy room.

All doctors and therapists have been there.  You’re in the therapy room and all is calm, when suddenly, your patient has an outburst. The moment can be tense, and part of becoming a strong therapist is learning how to manage the environment, so be prepared to alter the variables at your disposal. When there’s a child sitting across from us, most times our parental instincts kick in and within a minute or two, we’ve diffused the bomb. The same holds true for teenagers, the difference being our inclination to negotiate towards preferred activities in exchange for improved attitudes or approaches may change slightly. In extreme cases we can call or involve parents, but usually our guidance and structure will be much more effective if the patient understands and respects the boundaries we set and enforce ourselves.

But what about our adult patients? In particular, patients who are older than the therapist? Would you feel comfortable discussing behavior with someone that is your mom’s age?  Or even better, my mom’s age?  It can be tough!

Earlier this week, I received a message from a friend, an up and coming Vision Therapist, who came to me for advice.  She wrote:

Have you ever had a patient get extremely upset and verbally aggressive towards you while doing therapy? I have a patient that is 65 years old and he is always really laid back, but today he got very aggressive with me! I ended up cutting our session sort due to his behavior. How do you normally handle situations like that?

Well, calling his mother is probably not an option.

I sat and thought about my tactics for managing my sessions with children versus adults, and by enlarge, they are the same.  The language and voice inflection may vary depending on the audience, and in some cases, preparing your thoughts is as important as preparing your equipment but generally my approach is the same. I think the main idea though has to be that all outbursts are a sign of frustration. Our job is to understand that they are frustrated, understand that frustration is being caused by the relative demand of the activity, understand that it is not ours to judge their reasons for being upset, and we should always do what we can to weather the storm. Remember, it’s not personal.

First and foremost, your safety is paramount.  Never, ever, ever, EVER be in the office alone with a patient whether child or adult. I know we all love our patients, we always think that they are harmless and would never cause any trouble – and you’re welcome to call me paranoid if you like – but it only takes one bad day to ruin things.  Aside from the patient getting angry, there’s always the possibility of incidental contact or a silly comment that is misunderstood which with an office full of people is not a big deal, but one on one might be construed quite differently.  For the 99 patients who are a joy, there’s always 1 who is looking for something to complain about, and gambling that the one you’re in the office alone with is the “sour apple” is just not smart. The risk and reward factors are stacked heavily against us. Trust me, I learned this one the hard way, way back when. It’s sad, but alas, it’s the world we live in.

Assuming our environment is optimal, my first line of defense when patients get angry is to just listen. Not as a passive bystander or casual observer, but as an intent and interested listener. I know, I know, it sounds simple; but you’d be surprised how showing someone you’re really listening helps them overcome their momentary outburst. No one wants to talk to the back of your head or watch you write notes when they’re upset – writing notes  and putting equipment away can be done later. Stop what you’re doing,  sit up straight, hold their eye contact, and use your body language to show that they have your full attention.

Validate their concerns. I wrote in a previous blog post of a gem that Dr. Carl Hillier once offered which explained the value in validating a patient’s thoughts and emotions. It doesn’t mean you have to like what they’re saying, or even agree with them, it just means you express your understanding of their emotions and give them permission to have it. A line I often use when my patients get upset is:

I understand that this activity has made you feel uncomfortable/upset.  It makes sense since this is the first time we’ve reached this level of difficulty.  Do you think we can continue or should we save this one for next time?

I’ve recognized their emotion, gave permission for it to exist, and offered them the perception that they control what happens next – but I am still managing the environment by offering choices and not allowing the session to stall out on their outburst. No matter their answer, it’s clear we’re going to keep moving.  This is usually 95% of the battle in steering them back on course. Sometimes they want to grit through the activity, and sometimes not.  Even if they say they want to try something else today, I’m really OK with that because I’ve laid the groundwork for next time. They know the tough activity is coming, they’ll have time to process and prepare for it during the week, and they’ve already had a taste of the activity so it won’t be such a shock to the system next time.  I have employed this tactic to diffuse many potential uproars in the VT room, and with a few rare exceptions, it works beautifully.


Be respectful, not intimidated. This one can be tough, especially for the newer therapists, and even with 14 years under my belt I will admit there are moments I still struggle with it too. Respect their space, respect their emotions, respect their thoughts, respect their wishes to avoid failure and respect their understanding (or lack) of the problem in front of them – but don’t fear their response. Even if they get loud and boisterous, don’t let your fear of their reaction dictate your decision as to what’s best for your patient.  This is a fine line, I know, but it’s part of the deal. Don’t fear the tears or the sneers.  Acknowledge and validate them, and keep moving.

Adults get upset with these activities too – a true story. Just because your patient is in their 60’s or older, does not mean that these silly little vectograms won’t remind them of something they’ve been trying to accomplish since they were in the third grade. Imagine having to face that demon in a doctor’s office, in front of a relative stranger, after suppressing the emotion for 50+ years. I’d imagine it would be pretty frustrating and maybe even embarrassing. Different people manifest frustration in different ways. Some become a ball of tears, some become outwardly aggressive, some just sit there and fester on the inside.  Regardless of what their frustration looks like, I’ve never felt like it’s mine to judge. Understand where the emotion is coming from, respect their time and space for the emotion to occur, validate it if you can and suggest another activity. For me, the only mistake you can make here is allowing the patient to become “stuck” on this emotional response.  Switch activities, change directions, allow the patient to recover, and move forward with a successful session.

Control your own emotions – this means you.  It always grates on me a bit when I hear a fellow therapist say a patient made them angry during therapy.   For some patients, getting a rise out of the therapist is the goal, so beware. We can share in their successes and failures, and want to help them improve, but our job is not to join them on the emotional roller coaster.   The best advice I can give you is to stay as level headed as you can during a patient’s emotional moments.  Again, it sounds simple now, but in the heat of the moment it can be challenging.

Reel them in with their goals.  During the first visit, most of us ask out patients for goals for their VT program. Reminding them why we’re doing this and what they are working so hard for is never a bad thing. Often times, patients will reset themselves during this conversation. I believe in reviewing goals constantly, but in particular, during these rough patches.

The doctor is on your team, don’t be afraid to ask for help.  I ask my doctor for help more now than I did 5 years ago. The questions are less in the “how do I do this” realm, and more in the “is this the most beneficial for the patient” areas, but still.  When we start out as therapists perhaps we are trying to prove our worth and go it alone whenever possible, and understandably so.  There is no shame in asking for help on activities, treatment plans, or behavioral strategies. View it as an opportunity to learn something new.  

If you take nothing else from this post, believe me on this point:

Your doctor would much rather you ask and get it right, than have you “make it up” and get it wrong.



Posted on February 1, 2014, in From My Perspective.... Bookmark the permalink. 3 Comments.

  1. Feel, felt, found. ” I understand how you fell, other patients have felt the same way, and what they found was _________, “. Hope this helps


    • Thanks, Jessica. Personally, I tend to veer away from “I understand how you feel”. Emotions and responses are individualized, since we are a sum of our parts, my emotional responses are quite different and so are yours. In reality, we have very little understanding of “how they feel” and instead we understand how we think they feel. It’s a fine line of semantics, but for me, an important one as I hope to never assume anything in VT. Instead, I will say “I understand you’re feeling…..” Thanks for reading 🙂


  1. Pingback: Thought of the Week | Kiss My Tractor

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