9/17/2013 Getting to What This Presentation Hopes to Show: Acceptance Patients’ Commonalities or Psychology of Approaches to LV Care Low Vision Rehabilitation Success is Not (Just) About Optics. Faceted Look at Roadblocks to Success Bennett McAllister, OD, FAAO Diplomate, Low Vision Mostly About People Chief, Primary Care Why Do Patients Definition of Come to ODs? Optometry: Glasses Contacts “The Art and Science of LASER Drops Vision Care” Magnifiers Telescopes Four Tenets of Science of Low Vision: Reciprocal of Vision Optics Measure BVA at 20 feet Reciprocal of Vision Goal of 20/50 Near VA in Reduced Snellen at 40 cm Calculate Ratio of Denominators : BVAd / NVAgoal LogMAR Multiply Result by +2.50D 1 9/17/2013 Four Tenets of Two Cultures of LogMAR Thinking Measure VA Set a VA Goal Physical Science Count Steps Humanities Implement (Diopters, Distance, TS) Cultural Characteristics Cultural Characteristics of Physical Sciences of Humanities Optimistic Pessimistic Impatient Resolved Brash Accepting Nimble Dour Struggling Slow to Change Five Stages of Grief Elisabeth Kubler‐Ross Processing: Denial Anger On Death and Dying Bargaining Depression Acceptance 2 9/17/2013 Denial Used by Almost all Patients Anger! Psychic Buffer from Shock of Bad News Allows time for Alternate Coping Strategies “...people who don’t expect justice don’t have to Transient and Recurring suffer disappointment.” Creates Space for Path to Partial Acceptance Isaac Asimov, The Robots of Dawn Characteristics of the Anger Stage: Bargaining: Rage, Envy, Resentment, Injustice Relatively Short Stage Grievances found Everywhere An Attempt to Postpone Diffuse and Displaced‐Radioactive Promise Made with God and Kept Secret Illusion of Control is Shattered Response to Quiet Guilt Expression moves towards Acceptance Seldom Kept and Often Renegotiated Depression: Reactive Depression: When Denial Can No Longer Be Maintained Cumulative Affect of Great and Multiple Loss 1. Reactive Depression Unrealistic Guilt and Shame 2. Preparatory Depression Responds to Admonitions of Cheer Amenable to Talk Therapy and Reason 3 9/17/2013 Preparatory Depression: Acceptance: Anticipatory Depression Reality Based Recognition of Current Situation, Imagining Impending Future Loss Abilities and Impacts on Life. Looking Ahead Rather than to Past Happiness is Not a Criteria. Quiet and Introspective Processing Necessary and Beneficial for Acceptance Healthy Adjustment and Willingness to Work With What is Available. Three Primary Theories Three Part Structure Regarding Workings of the Mind: of Personality: Psychoanalysis 1. ID ‐ Biological Behaviorism 2. Ego ‐ Psychological Humanism 3. Superego ‐ Social Characteristics of the Characteristics of the ID: Ego: Biological Component of Personality Psychological Component of Personality Source of all Psychic Energy Conscience or Self Subconscious Tip of “Personality Iceberg” Seen by External World Submerged part of the “Personality Iceberg” ID’s conduit to Attain Reality Gratification 4 9/17/2013 Characteristic of the Five Psychoanalysis Defense Superego: Mechanisms: 1. Repression Social Component of Personality 2. Projection 3. Reaction Formation Moral Brake on ID’s Impulses 4. Fixation Viewed as Self’s Conscience 5. Regression Idealized Perfection vs. Pleasure Operate to Deny, Falsify or Distort Reality All Work at the Unconscious Level Freud’s Two Major Features of Behaviorism: Contributions: Objective Method Experimental Precision Intense Single Case Study Without Controlled Atomistic vs. Holistic Experimentation. Minimal Assumptions No Need to Infer Psychic Architecture Validity Determined by Internal Consistency of Patient’s Verbalizations in Free Association and Operant vs. Classical Conditioning Dream Analysis. Simple, Precise, Practical Features of Humanism: Compare and Contrast: Non‐Directive and Client Centered Derived from Psychology, not Medicine Psychoanalysis - Hidden, Dark, Pessimistic Two Constructs: Organism and Self Adjustment Depends on Congruence Behaviorism - Cold, Controlling, Deterministic Forward Moving to Enhance Organism Humanism - Optimistic, Hopeful, Choice Optimistic Faith in Essential Goodness 5 9/17/2013 Current View on Cognitive‐Behavioral Defense Mechanisms: Therapy: Repression Thinking, Feeling, Behavior All Interact Dissociation Effective for Anxiety and Depressive Disorders Delusion Short Term Impact Possible Suppression Positive Impacts Possible in Clinical Setting Minimization LVA Demonstrate Possibilities, Influencing Paradigm Denial What is the Path to Acceptance? Listen with your Heart for Defenses Find where Patient is on the Acceptance Trajectory Thank You! Decide Between Counseling Referral or Self CBT Listen Again for Affirmation in Response to LVA Take What You Can Get Build on Small Successes 6.