Development of O&M Services and Use of Innovative Approaches
William R. Wiener, Ph.D., COMS, Dean, The Graduate College, Western Michigan University
Dona Sauerburger, MA, COMS, Practitioner and Consultant
This presentation focuses on the following areas of concern:
1) Evolution of certification,
2) the use of visual and non-visual techniques,
3) teaching through individual and group lessons, and
4) the use of guided and discovery learning.
1. Evolution of Certification
Throughout the ages blind people have taught other blind people how to travel. The skills learned by people with visual impairment have been handed down from one generation to the next. The first systematic approach to providing instruction in orientation and mobility came from the efforts of the Veterans Administration at Hines Hospital in an effort to prepare blinded veterans for independence. The program was often imitated but never duplicated in the civilian population. Therefore in 1959 Vocational Rehabilitation sponsored a meeting at American Foundation for the Blind for the purpose of establishing systematic training of instructors. From that meeting the following standards evolved:
training should be on the graduate level, for a minimum of one year, and
all instructors should be sighted.
In 1964 the American Association of Workers for the Blind (AAWB) established a mobility interest group. In 1969 AAWB established a certification program. The standards for certification have evolved over a long period of time with revisions occurring in 1971, 1977, 1995, 1996, and 2001. The early 1969 standards followed the requirements of the 1959 conference and required practitioners to possess corrected visual acuity of 20/20 with no field restrictions. In 1971 the standards were changed to require 20/40 with contiguous field of 120 degrees. In 1977 the standards shifted to a functional abilities approach but required monitoring from as far as several hundred feet. In the 1980's, proposals using vignettes were developed to move toward more functional assessment.
All the while a debate raged regarding whether instructors should be required to possess vision to provide instruction. The professional organization (AER) believed that some amount of vision was needed to allow the instructor to monitor the student from a distance. People who were blind believed that safety could be provided by using alternative means. Both sides were well intentioned and only wanted to do the right thing.
The passage of the ADA in 1990 established new principles that included making a case-by-case determination, job restructuring, job modification, and use of technology in carrying out the duties of the job. Wanting to explore the potential of certification of blind instructors, the Co-Chairs of the AER Orientation and Mobility Division's Certification Standards Committee Elga Joffee of the American Foundation for the Blind and William Wiener of Western Michigan University traveled to the Nebraska Services for the Blind and were taught some of the techniques used by blind instructors to teach O&M. With this experience the AER O&M Division considered the ADA philosophy while proposing a revision to the AER certification standards. In 1995 the O&M Division conducted a Conference on Alternative Approaches to which it invited university educators and blind instructors to explore alternatives that could be used by persons with disabilities to provide O&M instruction. As an outcome of the conference, AER extended certification to university program graduates who could perform essential job functions using whatever means necessary to accomplish the task. As a result, instructors with disabilities were certified and included instructors who are blind, and instructors who use wheelchairs or have other disabilities.
Certification continued to evolve with the development of a certification examination. There was a drive towards equality with other professions. This required establishing a certification body that was independent of the professional association. Inherent in such a movement was the need to establish an objective evaluation of the knowledge of the practitioner. A certification examination was developed through test-writing seminars that were conducted regionally with input from a national consultant responsible for similar efforts for the Commission for Certified Rehabilitation Counseling. The examination was pilot tested by comparing scores from orientation and mobility specialists, teachers of visually impaired children and rehabilitation teachers, and non-vision professionals to find out how different populations would score on the test. An analysis of the test results was used to determine an acceptable score for passage of the test.
The next step in the evolution of our certification program came with authorization for the AER board to separate certification from the organization and establish the Association for Certification of Vision Rehabilitation and Education Professionals (ACVREP). As part of the process, AER transferred all initial and renewable certifications to ACVREP. The ACVREP Certification requires passage of a certification examination and successful completion of internship. The ACVREP infrastructure includes an 11-member board of directors. The majority of board members are ACVREP certified and five are non-certified including one employer, one consumer, and one eye care specialist.
ACVREP received national recognition in October of 2002 by the National Certification Commission (NCC), a non-profit external reviewer of certification programs. NCC granted ACVREP “full registration,” recognizing it as comprehensive, objective, and in compliance with national procedures and more than 20 criteria.
2. The Use of Visual and Non-visual Techniques
The traditional approach of O&M programs was to teach clients to use non-visual techniques, using blindfolds for clients who have some vision. O&M programs were first developed in the 1940's for young soldiers who were suddenly, completely, and permanently blinded. These programs were anything but route travel -- the soldiers went home and traveled independently in their own communities, using only non-visual techniques that they had learned at the center in Hines, Illinois and transferred to their home environments.
In fact, all the O&M techniques that were taught were non-visual for the first several decades of our profession, even while this traditional core O&M program was adapted to serve children, elderly people, and people with multiple disabilities. Blindfolds were used extensively to help these people learn non-visual techniques, because we only knew how to teach people who were totally blind.
It was not until the mid-60's and early 1970's that some of the more progressive O&M specialists started to question the tradition, and develop programs to teach people to use both visual and non-visual information and techniques to travel efficiently. These programs were resisted by the majority of O&M specialists, and so another decade passed before these innovative programs were published to any extent and started to become accepted as best practice. Thus the “progressive” approach, which was developed slowly over the last half century, is to teach people to use both their vision and non-visual techniques effectively to travel.
There are four challenges for people with functional vision. These people must learn:
1) non-visual techniques and how to trust the non-visual information;
2) how to use vision reliably and efficiently, while
3) not allowing vision to distract them from effective non-visual information; and
4) how to use non-visual and visual information together.
It's been written that clients who have impaired vision just naturally know how to use that vision efficiently, but that's not true. For one thing, people must learn how much of their vision can be used reliably, and also learn the limits of their vision -- that is, learn when they can not rely on visual information, or when they can get the information much more effectively using non-visual techniques.
Many people must also learn how to process the visual information, for example to identify objects and their implications for travel. Visual aids can be very effective for getting certain visual information but again, people need to learn how to use them effectively.
And some people need to learn to use their vision for maximum efficiency. For example people with central scotomas, such as macular degeneration, need to change a lifetime of habit to use their best point of fixation with eccentric viewing. In one illustration of this, a client with macular degeneration was asked if she could see the traffic signal. She looked and said, “No, I can't see the light -- wait! Yes, I can see the light --oh, no, I can't see the light -- yes! I can see the light!” She hadn't learned that if she wants to see something, she shouldn't try to look at it or it will disappear -- it will appear again when she looks away from it. She needed to learn to look just to the side of whatever she wants to see, after determining where is her best point of fixation.
People with peripheral visual loss, such as retinitis pigmentosa, need to learn scanning techniques. For example, when their visual field becomes less than about 5 degrees they need to learn to change their lifetime habits and scan at a certain speed, or they will miss seeing lar”ge objects. Sauerburger realized the importance of this one day when her client who is deaf and has retinitis pigmentosa looked very carefully both ways and saw no cars, and then almost walked right into a speeding car that she hadn't seen because she looked too quickly. Sauerburger developed a 20-minute procedure for teaching these people exactly how to scan so they don't miss any cars. [See Scanning for Cars.]
And people who can see the cars consistently sometimes misjudge how close and how fast those cars are approaching. This was probably the reason that a visually impaired colleague and her husband were killed crossing a street in Maryland about 15 years ago. As a result, there is now a simple procedure for teaching people to accurately judge visually when there is a sufficient gap in traffic.
So methods have been developed to teach people how to scan; how to find the best point of fixation and view eccentrically; how to visually determine whether there is a gap in traffic; how to use visual aids to get information efficiently; and many other skills. It's important to note that 1) these skills don't take long to teach, and 2) the instructor does not need to be sighted to teach these skills -- these teaching methods can be readily adapted, or some of them can be used as is, by O&M specialists who are blind.
Another challenge is learning non-visual techniques. People can learn to notice and use non-visual information when they have lots of experiences where visual information isn't available, such as with blindfolds or real-life situations where the client cannot see well. Blindfolds are a very effective way to teach non-visual techniques because they prevent any distraction from vision, so it is easier for people to notice and use the non-visual information. Real-life situations where people cannot see well are also effective. For example night travel is a great way for people with retinitis pigmentosa to learn to use non-visual information. Many clients say that these real-life situations are essential because blindfolds don't really simulate the situation in which they find themselves -- lights at night can not only be useful, they can also be distracting and misleading. Therefore clients want to apply their skills and practice not only with a blindfold, but also in realistic conditions where they encounter challenges that are not present when they are blindfolded.
Contrary to what some people believe, blindfolding and night travel aren't the only ways that people can learn non-visual techniques. It is emphatically not true that people will never learn to use non-visual information if a blindfold is not used. People can also learn non-visual techniques if the instructor prompts them to notice and use non-visual information while they travel normally.
For example, Sauerburger once started working with a middle-aged man who had been visually impaired all his life. They approached the building where they were going to begin training, and Sauerburger asked the client to ring the doorbell. He put his face inches from where the button was and took about 3 minutes before he finally found it and then reached for it. Sauerburger then asked him to step back and scan the wall with his hand, and he found it very quickly. The next day -- and every day from then on -- he matter-of-factly approached the door and found the button by scanning with his hand, as if he had always done it that way. He never again pressed his face up to the door to find it visually, even though he had never worn a blindfold to make him aware of how effective non-visual techniques can be.
Another example is a woman who was on her first lesson outside when she suddenly saw that the sidewalk seemed to end. She got very disconcerted and asked if she was at the corner yet, and where the sidewalk was. When she was asked to relax and listen to the cars, she noticed that they stopped at the corner about half a block ahead. She asked what happened to the sidewalk, and the instructor encouraged her to think about how she could find out. After a few moments of thinking, she probed with her cane. She found that it had turned toward the building, and she continued on her way.
So people can learn these non-visual techniques without blindfolds. Although it's more of a challenge to teach it that way, it is also more realistic and becomes more meaningful and immediately applicable to their real life.
The third challenge is to learn to use non-visual and visual information together. This is one of the biggest challenges for the client as well as for the instructor, but it can be taught using partial occlusion and intermittent occlusion.
With partial occlusion, the bottom half of the clients' vision is covered so that they can't see what's on the ground in front of them. They must rely completely on the non-visual information that the cane provides while, at the same time, they are looking around and getting information visually. This isn't easy to do, but it's an important part of real-life travel, and partial occlusion has been shown to be extremely effective for enabling people to notice and use their cane information at the same time that they notice and use visual information.
With intermittent occlusion, the clients perform tasks visually, then repeat with a blindfold, then repeat the task again without the blindfold while using the non-visual information that they had noticed with the blindfold on. For example sometimes after clients have learned to use and trust the cane, when they go outside and approach the curb they pull the cane back and lean forward, straining to look down and find the edge, walking very cautiously. They are allowed to struggle and find the curb, then they are asked to come back and approach the curb again, but this time find the curb with a blindfold. They usually do so as efficiently as they had done similar tasks earlier in their training. Then they take the blindfold off and approach the curb again, but this time they are asked to consciously keep their eyes on something across the street while letting the cane find the curb as quickly as they had just done with the blindfold. Most clients only need to do this once or twice before they stop searching visually for the curb, and approach it confidently using non-visual information from the cane.
Again, these techniques -- partial occlusion and intermittent occlusion -- can be used by instructors who are blind as well as sighted.
The last challenge is to learn not to allow vision to distract from non-visual information. When using a blindfold for training, clients are prevented from being distracted by vision but when the blindfold comes off, many people will revert back to their old habits and let the vision interfere with their ability to notice and use the non-visual information. Thus, no program is complete unless the client learns to notice and use the non-visual information when the blindfold comes off.
Effective strategies to help the client learn to do this are partial occlusion, and having the client perform tasks where sufficient information isn't available visually, with prompting to notice non-visual information if needed. For example, one of Sauerburger's clients had become proficient and very confident with a cane after training with a blindfold. On her first lesson with the blindfold off, the client approached some stairs with her cane and saw some wires hanging over the stairs. She panicked, and almost literally got onto her hands and knees to see those wires and crawl up the stairs, but it wasn't enough -- she still couldn't see the wires clearly even when she was doubled over. Sauerburger had her relax and calm down, and told her she could get all that information with the cane, just as she had when she was blindfolded. With prompting and encouragement, the woman straightened up and probed with the cane, found clear spaces and went up the stairs, trusting the cane to tell her where to step. All the training with the blindfold hadn't prepared her to ignore the ineffective vision and use the more reliable non-visual information -- this needed to be taught to her by practicing without a blindfold.
No program teaching independent travel can be considered complete for people with functional vision unless they have learned to master these four challenges -- using their vision efficiently and understanding when it's more effective to use non-visual information; noticing and using non-visual information and trusting that information; using the vision and non-visual information together; and not letting their vision distract them from using the non-visual information
3. Teaching through Individual and Group Lessons
The standard of practice in orientation and mobility has always been to provide one to one instruction for individuals who are learning to travel outdoors. The reasons for individual lessons focus upon five issues:
1) instruction must be individually designed to meet unique needs,
2) students learning to travel need individualized attention,
3) discovery learning can be better facilitated,
4) student safety is best served when the instructor can direct full attention to a single student, and
5) the student will gain a sense of self reliance. While individual lessons remain the standard of practice, there are many situations in which group lessons are appropriate and advantageous for consumers.
Group lessons should be an option that is chosen by the instructor with concurrence of the consumer and, where appropriate, his or her family. It is best provided when the student has reached a level of proficiency that will allow more independent functioning, and when the instructor has students who have reached similar levels of competence. The instructor must also be able to schedule large enough blocks of time to allow for sufficient travel for each person to have appropriate experience.
There are various advantages that may result from group instruction. Group lessons may increase the motivation of the traveler by developing a sense of shared importance. Peer encouragement helps to support students in the face of frustration. There is recognition that the student is not the only one who has difficulties. Positive competition may result and may help to push the participants to higher functioning. Participants in group lessons will gain an appreciation for their own strengths and the differences between travelers. Teaming skills will develop and lead to group problem solving. Finally, instruction in groups may be a more cost effective way of providing service.
Various types of group lessons can be developed for travelers. Lessons of concept development can be taught in groups. This may include exploring the environment to learn about traffic patterns, accessible pedestrian signals, spatial orientation, geographical directions, etc. Route planning is another skill that can be developed through group activity. Brainstorming and information gathering may be best accomplished in groups. This may include problem solving relating to physical and social barriers, analyzing the environment, and calling for information. Role-playing interactions are also helpful within groups. This may include role-playing situations of soliciting aid, refusing aid, interacting with the public, interacting with bus drivers, and other situations. Sensory training that teaches students to interpret environmental clues such as identification of sounds, use of echo-detection, and identification of changes in textures and terrain can also be done effectively in groups. Travel within a block may present another opportunity for group instruction. Visual training in the identification of critical features of the environment can be taught in groups. Group practice in the use of optical aids can also be of value. Finally, group travel competitions such as finding stores in shopping malls or finding articles during a scavenger hunt may facilitate travel.
4. Guided and Discovery Learning
Guided and discovery learning are a part of traditional orientation and mobility instruction (Jacobson, 1997). In the traditional learning model the learner is presented with guided learning, a cognitive approach that provides solutions to problems. Where fixed responses and fixed cures are needed, guided learning is the most efficient method of instruction. Examples of guided learning to teach cane procedures include touch technique, shorelining, and recovery methods. Guided learning is useful in handling situations where the same response is needed over and over again.
In contrast, with discovery learning, a gestalt approach, the material to be learned is not taught by the instructor but is discovered by the learner while working through a problem. The task given by the instructor is presented as a problem to be solved by the learner. Only minimal information is provided as to the approach to be taken to solve it. Examples of discovery learning include the following: 1) concept development - the student is presented with shapes and asked to determine their salient characteristics; 2) visual training - the student is asked to determine critical features while walking through an environment, 3) cane travel - routes are used that allow students to discover principles and solutions. In cane travel, for example, students are intentionally lost and asked to work their way out of the problem independently. Also in cane travel, routes are set up that force the student to solve problems. The instructor might select routes where sidewalks dead-end or do not go through to the corner, or where alleys and small streets appear unexpectedly.
With the discovery approach, the learning that takes place can be transferred to other tasks in the future. Discovery learning can enhance learning, retention, and transfer but requires increased time and effort. Among learning theorists, there is a debate as to which approach is better. Supporters of discovery learning note that learning from mistakes is best because the learner appreciates the variety of responses that are possible in an unpredictable environment.
Instruction in orientation and mobility often takes place initially through guided learning so that the student can attain proficiency with the fundamental skills. Strategies and tactics, however, are probably best learned through discovery learning.
When the learner knows the fundamental skills the following self discovery techniques can be used and would include
1) hinting at ways the learner might resolve the problem but without being specific and removing the challenge, and
2) suggesting that the learner has all the knowledge needed to solve the problem but has not yet put it together correctly.
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