Diffusing the Bomb – Managing Oppostion in the VT Room

Opposition is not necessarily enmity; it is merely misused and made an occasion for enmity ~ Sigmund Freud

There was a question posted on the Vision Therapist’s email list recently regarding managing patient behavior; specifically, bad behavior. Now, I’m not a Psychologist nor Psychiatrist, but I’ve been in Vision Therapy for close to 15 years and I’ve had my fair share of challenging patients, misbehaving patients, patients who thought they were in charge, and patients who felt like yelling at me would somehow grease the wheels to success. I even had one young man throw a piece of equipment at me, drop a few F-Bombs, and run out of the office and across a busy street – just to avoid a little convergence activity.

Opposition can be a tough pill to swallow. We know we’re trying to help and we hope it makes everyone happy to see us. In most cases it does, but occasionally, the bomb goes off and we’re chasing our patients down a busy street hoping they don’t get hit by a car (worst day of my VT life, by the way).

As with all challenging situations, an ounce of prevention beats a pound of cure. Here are some of my ideas for managing these situations:

Be Prepared – Our VT sessions are 55 minutes in length and with any luck, we spend 12-15 minutes on each activity. We program four activities per session. Sometimes we complete two, sometimes five, sometimes just one. A lot depends on the level of engagement the therapist can elicit from the patient.  This would seem to be pretty standard across most VT rooms. What is also key, I’ve found, is to have a “go to” activity at the first sign of a meltdown.  My weapon of choice varies, depending on the patient’s age, between the trampoline and the Tootie Launch.  With no rules imposed on this “reset activity” beyond my one core requirement – nobody bleeds – often times this is enough to douse the flames before they spread. This is usually a good time for a pep talk too, keeping in mind that positive breeds more positive.

Love and Logic – The Love and Logic series is great, even if you’re not parenting. The basic premise of the books is learning to offer choices to kids, to empower them, and feed their need to gain control of their surroundings. You offer several choices that you can live with, and then let them believe they are in charge when they make their choice within your parameters. Adapting this idea into the VT room can be just as powerful to in maintaining order when a patient decides to misbehave. One tactic I’ve used often when one of my more challenging patients is scheduled is to start my sessions with a list of items on the white board, like so:

Crazy Balls (Marsden Ball) Note: Be careful with this name if your patient happens to be an 9 year old boy 😉

Box of Rocks (Parquetry Feel Box)

Librarian Training (Michigan Tracking)

Magic Pictures (Vectograms)

Circus Act (Beanbag Catch while patient jumps on the Trampoline)

Hidden Pictures (Hidden Pictures with MAR)

FYI – the portion within the parentheses is for your benefit and not included on my while board

Remember, we shoot to complete four activities. First things first, patient gets to ERASE the two they don’t like. Right off the bat, they are eliminating the “boring things”, and feeling good about it.  Once they narrow your list down to four items, let them number the activities, one through four.  This will be the order in which the activities are accomplished.  I’ll usually throw them a bone too, sharing that if we finish all four activities in that order, they can choose something fun to do at the end. If they seem to be veering off track during the session, remind them of their list, and that we get to ERASE each activity as it is accomplished.  You’re empowering them to self monitor their behavior, and offering an instant “reward” for their hard work will do wonders for their self esteem.

Usually, I’ll come up with exciting names for the things I’m hoping to get done, and incredibly boring names for the “throw away” activities. Even if they erase one activity that you’re hoping to accomplish, three solid activities is still better than an hour long argument. Also, keep in mind that giving these activities “code names” gives you quite a bit of latitude. “Circus Act”, for example, could involve the trampoline (as in my example), the Clown vectogram, something with balloons, something with red/green glasses, ring toss, and so on. Find names that sound fun to the kids and are a bit ambiguous and allow for modification.  It will allow you to move around in your VT room while constantly reminding the patient that we are fun with the activities that they chose.

Truly your session begins with some solid preparation, and a lot of those “fires” can be avoided by offering the proper choices to your patients.

My Back Pocket – A great friend of mine who is a Marriage and Family Counselor once taught me this technique, which she calls “my back pocket”. The idea is, at the first sign of trouble, to divert attention with an anecdote unrelated to the task at hand – which essentially dissolves the argument and does not acknowledge the opposition – while you subtly transition to a more favorable activity. The diversion will take their mind off of their discontent, and hopefully will keep the session moving in a positive direction. Keep a funny story or “in your back pocket” – which for me was the time I went bungee jumping and pee’d my pants half way down – don’t ask. This sounds very simple, but the idea is when a patient fires the “first shot”, do not “return fire” or even respond. Instead, do the unexpected. Tell a funny story and move on.

Diamond in The Rough – This one is the most important to me, personally. By the time they get to us, most patients have been labeled, called stupid, told they are somehow less than their peers, told they need to try harder, told things should be easy, considered for medication, and felt the stress at home of their parents as they try to figure out how to help.  Every adult this child runs into is focused, serious, intent on finding a solution. Very few adults, it seems anyway, take the time to identify with the child and listen to their story. Maybe even try to befriend them.  There is so much power in being that adult, being the one “grown up” in the kid’s life who understands.  Be their diamond in the rough – the one adult who doesn’t treat them like the rest.

Good Cop/Bad Cop – This tends to be my last resort, but does occasionally occur. If you’re in an office with another therapist, trade patients without warning.  Sometimes the “change of scenery” is enough to reel in the patient.  Worst case scenario, get your doctor.  The perception of the “higher authority” usually rights the ship. At the very least, it gives you an opportunity to catch your breath and maybe even have the doctor offer some encouragement.

Linda-ism –  One of the finest moments of my Vision Therapy career was the day I realized that when patients get frustrated and/or act out in VT, it is the truest compliment they could give me.  It shows that they are comfortable enough to let their true colors show, it shows that they are engaged in what I am asking for, and it demonstrates that they are telling me by way of body language that we are on the proper path. If it was all easy, everyone would succeed all the time. But it isn’t.  The good news is you’ve discovered a weakness and now have an opportunity to help. Remember to ask yourself “what skills are necessary to achieve this goal?” and see if you can discover the missing link. Full credit to Linda Sanet for teaching me this 🙂

Let Them Show Off – Many kids we see have failed so much that they rather have rusty needles inserted into their eyeballs than fail again. When you come across something they’re good with, even marginally, get their parents, get other staff, get the doctor (if available), and get the other patients and let your patient have a moment to shine. This is so incredibly powerful with their overall cooperation, willingness and success.  Few people in their lives champion what they can do, but you should be one of them. Help them feel good about succeeding

You Are Not Them – When patients resist an activity, or deliberately perform badly, there is usually a reason. Maybe they’re seeking attention, maybe they’d rather look silly than stupid (class clown like), or maybe they don’t like your shoes. It’s important to remember that no matter what their reason is, it is theirs, and it’s to be respected. Even if it sounds ridiculous to us. Pass no judgments. Just work the problem.

Overcome Your Frustration – Working in the Vision Therapy room can be tough, but the return is incredible. Remember that the challenging times are an opportunity to grow, to be creative, to step outside your own comfort zone, and to learn from your mistakes.  Consider that the frustration you experience while working with your most challenging patient is but a fraction of what that person experiences all day, every day.

Keep It Fun – Life is hard enough, both theirs and yours. Keep your VT fun.

Give Yourself a Break – Vision Therapy to me is very kinesthetic, and I often “go with my gut” when managing behavior and motivating patients. Usually it works out, but sometimes not.  Many of my judgment calls on how to maneuver in the VT room are based on some colossal failure over the last 15 years that I’ve learned from.  You are not perfect and nor am I. The good news is that no matter what happens, the sun will come up tomorrow, and we can try again.

All of us can. 🙂


Posted on May 18, 2014, in From My Perspective.... Bookmark the permalink. 3 Comments.

  1. Very practical insights Robert!!


  2. williamsandmintod

    While your suggestions are wonderful, the exposure that these problems are common in the therapy room is just as important. The Networking of therapists has raised the level of therapy in many offices. When therapists understand and don’t engage with the patient’s reaction, patients improve and we all are doing better and feeling better.


  3. Hi Robert,
    Thanks for the kind words – they made my day 🙂


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