Braille Monitor                                                    February 2008

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Medical Issues and Special Populations
Providing Training to Students with Mental Health Issues

by Mary Ann Goodwyn

Mary Ann GoodwynFrom Dan Frye: Dr. Mary Ann Goodwyn, associate professor of psychology in the Department of Psychology and Behavioral Science at Louisiana Tech University, provided perspective during the Medical Issues and Special Populations breakout session on working with blind students in residential rehabilitation training centers who cope with issues of acute emotional distress or serious mental illness. Increasingly administrators of residential rehabilitation centers are encountering blind students who need this type of professional support. Conference participants found Dr. Goodwyn�s advice helpful and refreshing. Without being too clinical, she offered commonsense information and strategies on this topic that may be of use to residential rehabilitation center administrators and teachers. Below is a summary of the remarks she delivered:

I am a licensed clinical psychologist in Ruston, Louisiana, where the Louisiana Center for the Blind training center is located. I am also an associate professor in the doctoral counseling psychology training program at Louisiana Tech University. My campus office is down the hall from the Research Institute on Blindness and Dr. Eddie Bell�s office. Dr. Bell is my friend, colleague, and fellow researcher on an ongoing project to examine the effects of a strong sense of self-efficacy in blindness rehabilitation. We recently finished looking at data from two focus groups that we convened last fall. We asked fourteen blind people to help us identify factors that were important in building success in their own lives. (Most of these folks are here at this meeting this week, and they and Dr. Bell and I can talk with you about the success factors at a later time if you�d like that.)

The title �Providing Training to Students with Mental Health Issues� refers in your program to my part of this panel presentation, and I will address the way I understand and serve the needs of students at residential training centers for the blind, specifically the Louisiana Center for the Blind (LCB). My professional contact with the training center is usually limited to one of two roles: (1) a consultant contacted by staff about a specific problem, which we discuss, or (2) a therapist to whom an occasional student is referred. The reason for the referral almost always involves specific problematic behaviors and emotions that are interrupting the student�s progress in the program and possibly delaying the student�s reaching important program or personal goals. I consider this an important referral distinction for us in the mental health profession to understand. Our professional roles are different in different circumstances, and in conjunction with training centers it is the staff members who are responsible for students� exposure to skills training, challenges, and, most important, to a philosophy of success, whereas our role as counselors is to provide supportive adjunct services only if and when needed.

In the case of my clinic associate and me, our services are strictly linked to the goals of the training center. A student is typically referred to me or my associate in the clinic so that we can try to break up what I will refer to as an emotional log-jam which is getting in the way of the student�s being able to take full advantage of the training program. I personally understand my role in this context to be a provider of short-term intervention designed to help a student make progress in the training program. I think it can be done by providing an informed and supportive non-training-center forum for the student to recognize and make whatever mental or emotional adaptation(s) are necessary to become better able to take advantage of all that the training center offers, including (1) skills training, (2) role-models and mentors, many of whom are blind, (3) social opportunities, and (4) planned challenges which trainers model facing with optimism. In our practice our goal is the same as the training center staff�s goal: for the student to succeed in most if not all of the training opportunities while there in Ruston. Most of our work with students from the LCB does not relate specifically to blindness. In our opinion the staff at LCB does an excellent job with that in their program and seminars.

Because I am both a clinician and an academician, I used two resources for this talk: (1) the small amount of empirical literature available out there regarding mental health needs of blind and visually impaired individuals, and (2) my own and my clinic colleague�s experiences and opinions.

Various reputable online sites about blindness, including several links from the U.S. Department of Veterans Affairs site, make it abundantly clear that counseling referral is one of the services offered by rehabilitation case managers. It sounds as though many of these sources may consider that becoming blind or living as a blind person requires a number of mandatory rehabilitative inputs including counseling. This is not my position with regard to counseling (to make it mandatory). I suspect, however, that the degree to which mental health professionals and counseling services are part of a center�s rehabilitation program varies from center to center. My only experience is with the LCB, however, so perhaps program variations are something we can discuss, and you can give me feedback about in a few minutes.

My experience has been that blind individuals in general encounter the same types of intrapersonal and interpersonal stresses and strains that we all encounter, maybe a few more inconveniences regarding necessary adaptations at home, school, and work. Some of them would of course benefit from talking about one or more of these strains, perhaps even benefit from specialized psychological interventions. I also suspect, though, that the percentage of adult students who could benefit from counseling would be approximately the same in matched samples of blind and sighted adults.

With regard to specific counseling needs, however, it is very important to distinguish between two groups of students at blindness rehabilitation centers: those who are congenitally blind and those who are newly blind. Those individuals with lifelong blindness typically present with similar issues as their sighted counterparts with the exception that a proportion of them have been infantilized, overprotected, and shaped into highly dependent individuals. These students are naturally frightened of the expectations and demands for independent functioning that they encounter at their training center. These students typically are well served by becoming immersed in the training center milieu and meeting and engaging with peers and with role models and mentors. A few of them may also respond well to a counseling environment in which they can express their fears, which in some cases have become redirected as anger and irritability at the training demands.

Newly blind individuals, on the other hand, often present with the additional issue of grieving the loss of sight, a very powerful and entirely understandable set of emotions which can sometimes derail the learning trajectory for that person and make training goals unattainable until the grieving can be turned into a productive force. Grieving is certainly an initial part of losing a significant portion of one�s sensory experience, just as grieving is a significant, probably inevitable, part of losing any part of oneself. The transition from sighted to blind status, especially if it occurs precipitously, certainly poses a significant psychological impact, similar to the transition from any major human functional status (e.g., wife or employee) to a drastically changed status (e.g., widow or unemployed person). Counseling may, indeed, provide invaluable support to these individuals as well as an informed and supportive relationship within which the individual may explore sink holes of immense grief. Within a therapeutic relationship the newly blind student can often regroup and forge ahead in life with a permanently altered set of experiences and with something added to his or her identity. It is this something added to his or her identity, however, that therapists must be mindful of in their work with grieving individuals. We must attempt to assist them in regrouping in a way that the something added enhances their depth and flexibility and not their sense of negativity or hopelessness.

Often the grieving process after a major loss is described as a series of stages, individualized for each person, which include such emotional states as shock, denial, anger, depression, hopelessness, sometimes bargaining, and finally in the most positive outcome coming to a calm place, which includes a sense of acceptance that �this is the way my life is going to be, and now I need to figure out how to go about getting on with it.� Acceptance is hopefully accompanied by input and examples from mentors and role models that life can continue to be joyful, productive, and fulfilling. In coming to terms with grief, an individual must identify the debilitating emotions and acknowledge that they are about the loss and do not necessarily reflect negative personality traits. A counseling setting can be very helpful in this process, again as an adjunct to the training milieu which also is therapeutic if the person can plug into it.

As with all other humans, in blind people anger, depression, and hopelessness are often generalized and redirected onto targets other than the loss of sight, for example, onto an incompetent medical team, or the training center staff and their supposedly too-challenging program, even onto the therapist. Again, some of these students have come to the center from families or environments that have infantilized them. One of the primary aspects of our work with these young people is to help them recognize what my clinic associate is likely to tell them: �You have lost your sight; you didn�t lose your brain.� They are much more capable than they have been told by well-meaning family members and sometimes by other people in the rehabilitation world. They can and will learn to do things on their own; they do not need to be waited on, and they are now at a center staffed by folks who know the beauty in this plan and who are not going to wait on them. Sometimes this new experience takes a while for the student to understand and appreciate.

One question I encountered in the literature about blindness is whether or not counseling should be mandated for all blind individuals, especially the newly blind. My answer is a resounding �no!� I maintain that mandating counseling just because someone is blind is fertile ground for resentment, resistance, and further infantilization. Other therapists disagree with me about this and have found that some reluctant clients change their minds about the benefits of therapy after attending a session or two. Regardless of our beliefs about mandated counseling, we all agree that a referral for therapy is appropriately made by the training center staff when a student�s goal-directed behavior is interrupted or prevented by personal issues. We in Ruston are fortunate to have a center director who is sensitive to the types of mental health issues that can impede a student�s progress in the program, and referrals are appropriate and typically helpful to the few students who are targeted for our services.

The seventeen recent empirical articles I reviewed from the medical and psychosocial literature were fairly evenly split on their opinions about mental health needs and mandatory intervention in this population. Because there is limited space and probably little interest in my reviewing this literature, I will close my talk with an issue I consider very important. It was identified several times in the literature with regard to an individual�s successful adjustment to the progressive loss of visual function with retinitis pigmentosa (RP). The authors of one recent study (Hayeems, Geller, Finkelstein, and Faden, 2005)* found that mastering the progressive functional limitations associated with RP is contingent upon one important factor, the person�s shifting personal identity from that of a sighted person to that of a visually impaired (or blind) person. (It is interesting to note that this was also one of the ten identified factors that supported individuals� success in Dr. Bell�s and my focus groups last fall.)**

The point I will conclude with is that the authors of that study about individuals with RP stated that it is not the physical impairment itself but the impact of the vision loss on the person�s sense of self and life-plan that creates adjustment problems. This is a known phenomenon in the world of mental health--that ultimately our limitations are not external, physical conditions, but are instead our internal psychological states. Or, more simply put, the way we respond to events not the events themselves can create problems.

I recently heard a student from the LCB laughing with some of his fellow students about their misadventures on a particular travel route, and he paraphrased Franklin Roosevelt�s famous statement to them, saying: �All we have to fear is fear itself.� He then turned to me and asked, �Isn�t it?� As mental health professionals our answer to his question will determine the way we understand and serve the needs of students at residential training centers for the blind.

*Hayeems, R., Geller, G., Finkelstein, D., and Faden, R. (2005). How patients experience progressive loss of visual function: A model of adjustment using qualitative methods. British Journal of Ophthalmology, 89, 615-620.

**Bell, E., and Goodwyn, M. (2006). Factors that support the achievement of success in blind adults. Research Institute on Blindness and the Department of Psychology and Behavioral Sciences, Louisiana Tech University. Unpublished manuscript.

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