Strategies for Teaching Use and Integration of Non-Visual Information

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"Joe" walked with a blindfold for several blocks from the bus stop and found his home independently with no problem. He walked a few steps into his driveway and took off his blindfold, pleased with his success. But then he couldn't find the sidewalk that led from the driveway to his porch. It was only a few feet away from where we had been standing, but he passed it and continued walking without realizing he had gone way too far and without noticing the dramatic echolocation cue when he walked along the side of his two-story house, finally realizing his mistake when he reached the end of the driveway in his back yard. We talked about continuing to use non-visual information when his blindfold is off, as he certainly would have found his sidewalk easily with the blindfold on.

On his lesson the next day, he did very well with a blindfold walking from his home to a destination several blocks away, including walking along a highway across a very wide entrance to a parking lot, using his cane to detect the edge of the street and using his hearing, kinesthetic information, and tactual cues to maintain his orientation. Later that day, he walked the same route with the blindfold off. When he got to the wide parking lot entrance, he was unable to recognize where he was in relation to the highway, nor could he identify what his cane was detecting.

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This incident, excerpted from my progress notes, typifies what often happens when training people who have functional vision and are accustomed to relying on it and ignoring everything else. They can usually learn to use non-visual information easily with a blindfold but it is a challenge to teach them to use it when the blindfold comes off. However, it can be done -- "Joe" eventually learned to do it after enough training using some of the strategies listed below:


• intermittent occlusion;
• partial occlusion; and
• drawing people's attention to non-visual information without any occlusion.
  
  
These strategies have proven to be very effective for teaching visually impaired people to use non-visual information and techniques, but only for those who want to wean themselves from reliance on visual information and be able to notice and use non-visual information for everyday situations. The strategies are not as likely to help those who are not motivated to use non-visual information, such as those who feel that their vision provides them with sufficient information in all conditions, and/or those who are doing the exercises merely to please an instructor who has convinced them it is best to learn to use non-visual information in preparation for the possibility of losing vision later.

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Strategy 1: Intermittent Occlusion

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With intermittent occlusion, the clients perform tasks visually, then repeat with a blindfold or with their eyes closed to help them notice the non-visual information, then repeat the task again without visual occlusion while using the non-visual information that they had noticed previously. Some examples are:



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(1) During an O&M lesson in a residential area with many fallen leaves after a recent rain, a man walked along a sidewalk adjacent to the street, with no grass between the sidewalk and the street. When he saw a bright yellow garbage can in a driveway ahead, he walked around the can but at the bottom of the driveway he entered the street unaware. He walked along the street for a while and then wandered back onto the sidewalk without noticing he was stepping up onto the curb (the curb's height was only about two inches there, and the gutter was piled with leaves). When I approached him, he said he was not aware he had ever been in the street. I did the following:


• Have him go back and walk the same area with his eyes closed. This time, with no visual distraction, he found the garbage can with his cane and used the cane to search the sidewalk to see where it was clear to walk around the can. He again entered the street, but this time he was able to notice it even though the gutter was subtle because he could feel with his feet that the surface sloped down and then up (weeks ago, he had learned to notice even subtle gutters with his feet by shutting his eyes while I guided him across the gutters and report when he entered the street). He then resumed his way around the can without stepping into the street.
  
  
• We went back to the beginning and I had him shut his eyes while I guided him the same way he had originally walked (around the can, into the street, and back onto the sidewalk). With no visual distractions, he easily recognized when we entered the street by noticing the slopes, and recognized when we stepped back up on the curb.
  
  
• With his eyes open, I guided him again along the same route down the driveway and into the street and back onto the sidewalk, and asked him to notice those same slopes and curb that he had noticed earlier. This time, even though he was again distracted with vision, he was able to notice the non-visual information of the slopes and curb.
  
  
• Finally I had him walk it again himself, with eyes open but noticing the wealth of information from the cane and feet. He negotiated the can and the driveway beautifully.
  
  
Lest you think that the skill of using non-visual information can be taught with one incident such as this, you should know that this man continued to ignore good non-visual information most of the rest of that lesson. He would hesitate, lean forward to see better, sometimes doing well and sometimes making mistakes with faulty visual information. Each time I saw him trying to rely on his vision, I waited until he negotiated the area and then, regardless of whether he had negotiated it successfully or not, I had him do it again with eyes closed to notice the non-visual information. This was followed by doing it again with eyes open so that, while he was distracted or misled by the vision, he could notice and use that non-visual information, and not rely only on vision that is often insufficient or even faulty.

As the lesson progressed, he started actively searching with the cane and using the non-visual information without pausing and bending forward to try to look. However, near the end of the lesson, he crossed an unfamiliar street while relying on his vision, but with the sun's glare on a street filled with puddles, broken pavement, and leaves, he crossed with a lot of hesitation, moving left and right, and ended up missing the other corner and walking along the parallel street. In previous lessons he had crossed similar streets very well with his eyes closed. On this occasion, when he did it so badly with eyes open, I chastised him saying, "I KNOW you can cross this street easily with your eyes closed!" So I guided him back, had him close his eyes and use one of the non-visual techniques he had learned for aligning, then cross with his eyes still closed. His crossing was perfect and, when crossing, he appeared to be confident rather than hesitant as he had with his eyes open. I then had him do it again with eyes open, and he was able to line up again with the same non-visual technique, and cross with confidence even though the vision in that situation gave him nothing but distraction and misleading information.

Still, I knew from experience with other clients that this man's progress in developing the skill of using non-visual information in his daily travels would be slow and would have to be reinforced many times with more intermittent occlusion before it would become a natural habit for him to use the non-visual and visual information together. If I had trained him predominantly with a blindfold, I know he'd be able to do it well with a blindfold, but I also know that without the training with intermittent occlusion, he would never learn to use the vision and non-visual information together, and when the blindfold came off he would not be the skilled traveler that he eventually learned to become.



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(2) A woman received instruction in cane and orientation skills almost exclusively with her vision fully occluded, and became proficient and confident. However, on her first lesson where she walked without the blindfold, she approached a stairway where she could see an electric cord draped over some of the steps. She almost bent over double, straining to see the cord and where to step. I had her start again but with her eyes closed and using her cane find the cord and the clear steps. She did this easily. I then had her ascend again with eyes open, using the cane to find the cord rather than straining to use vision that was insufficient in this case, and she did well.



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(3) The following scenario was repeated by numerous people with low vision. They had learned to use the cane well indoors, sometimes with occlusion and sometimes without, and had achieved the fourth (most advanced) stage of cane proficiency. This scenario happened when they were on one of their first lessons outside and approaching a curb. They each leaned forward and strained to see where the edge was. I let them find the edge that way, then had them close their eyes while I guided them back so they wouldn't know how far from the edge they were, and approach the curb again with eyes closed. They always did well, as they had done indoors, and found the edge with confidence. I then guided them back (again, confusing them as to how far from the curb they were) and had them approach the edge under normal conditions (i.e. with eyes open), using the cane as they had done before. They each did well, and this time found the curb without straining or struggling.

Most of these students needed to repeat this experience because the next few times they approached an edge, they again strained to see it, rather than remembering to rely on the non-visual information from their cane. After enough of these experiences of intermittent occlusion, they started to notice and use the cane to detect the curb with confidence without further prompting.



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(4) A woman who had learned to use the cane without any occlusion was traveling along an unfamiliar sidewalk in her neighborhood. She approached a stair that she didn't realize was there because the sidewalk looked flat. However as soon as the cane went over the edge, she stopped* and then leaned forward, trying to see the edge [see photos below]. Normally, when people ignore cane information and try to rely on their ineffective vision I allow them to struggle before having them do it with eyes closed but in this case I had her stop, since walking in that position made her balance precarious and I felt it was dangerous to allow her to continue in such a position. So I asked her to step back and close her eyes and use the cane to find the edge and negotiate the stairs nonvisually. She did well. I then had her return to descend the stairs again, this time with eyes open. She again leaned forward straining to see the edge, but I told her to look ahead, and use the cane to find the edge, paying attention to the cane while looking ahead. She did it well. Most people need more than one experience like this to help them use the non-visual information automatically, and she was no exception -- she did the same thing several more times and needed this experience of intermittent occlusion each time before she finally started to use the non-visual cane information without prompting.

* The fact that she stopped as soon as her cane dropped over the unexpected stair verified that even though she had not had any partial or intermittent occlusion during her training, she was functioning in the fourth and final level of cane proficiency -- that is, she noticed the cane information reliably and recognized there was a step there, even when distracted with misleading visual information. However, once she noticed the edge, she went into "vision mode" and tried to rely on her vision to negotiate the stairs while ignoring the cane, demonstrating the need to learn to use non-visual information when the visual information is unreliable and insufficient. Intermittent occlusion was effective for helping her achieve this.

Illustrations of this example:


BELOW: Even though the sidewalk looked flat to her, this woman was able to notice the edge of the stair as soon as the cane went over the edge. However, as she approached it, she leaned forward and looked down to try to see the stair edge and railing.



BELOW: In contrast, when she closed her eyes to approach the edge, she appeared poised and well-balanced, and relied completely on the non-visual cane information.


BELOW: After this experience, she descended the stairs again but with her eyes open, intentionally looking forward rather than looking down, and worked hard to ignore the vision and concentrate on the non-visual information.

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Strategy 2: Partial Occlusion

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Partial occlusion typically occludes only the bottom part of the vision, so that the students are still able to see ahead of them and look around, but they are unable to see anything on the ground directly in front of them. The only way they can know what is on the ground is to use their cane. This gives students the experience of being distracted with vision while having to rely for their safety on non-visual information from the cane. It is effective for simulating situations where the vision is functional but insufficient or unreliable, to help students reach the fourth and last stage of learning to use a cane -- that is, be able to notice and use the cane information regardless of the distraction of visual information.

Partial occlusion should ideally be introduced after the students have reached the third level of cane proficiency (that is, after they are able to move the cane correctly without concentrating) for several reasons:
• Until they reach this level, the instructor should avoid distracting students with other tasks while they concentrate on learning to use the cane.
• More importantly, partial occlusion is intended to develop a trust of cane information and, if they don't have reliable cane protection (as was the case with a woman who fell off the subway platform while using her cane because she hadn't become proficient with it), partial occlusion may backfire and students develop, with good reason, a distrust of the cane that will be difficult to overcome.
  
  
NOTE: When students begin working with partial occlusion to develop trust and awareness of the cane information, they should be aware of the three things that the cane may not detect, so they are prepared and not disillusioned when they realize that it doesn't protect them from everything.

There is a secondary benefit of partial occlusion for students (such as those with retinitis pigmentosa) who tend to focus all their attention on scanning the ground visually to detect obstacles and edges, often walking with their head lowered and oblivious to what is around them. Experience with partial occlusion often helps them realize how much they are relying on their vision, and realize they can rely on the cane instead so it is not necessary to look down.

There are several ways to partially occlude the vision (shown to the right):
• Glasses or sunglasses with paper taped to the bottom half of the lenses;
• Goggles with material (cardboard, plastic) filling the bottom half of the lens openings.
  
  
    BELOW: (left) view without occlusion; (right) view with partial occlusion



The student can become accustomed to relying on the cane for surface information by wearing the partial occlusion while walking through various familiar and unfamiliar routes with stairs or curbs, or by walking in an area where low obstacles have been set up. Throughout these exercises, the instructor is prepared to provide for safety if the student keeps walking toward stairs or curbs without noticing that the cane has dropped over the edge.

Basketball dribbling goggles


Partial occlusion is used in sports as well as O&M, for many of the same reasons. Kathy Clarrage, COMS shared information about "basketball dribbling goggles" (Korney Board's dribble specs are shown to the left). These goggles, according to a promotional video of "Heads Up" by Hoops King, block the lower field of vision to help players develop "better ball control and sensitive hands, increase awareness of the court" (by not having to look down to watch the ball), and increase confidence. The Hoops King spokesman says in the video that "even advanced players rely on seeing the ball; you take that away and it becomes totally touch that they rely on, and that's what you want to become the best basketball player that you can possibly be." The same can be said about the goal for partial occlusion in O&M!
Basketball dribbling goggles probably don't occlude as much vision as your student needs to be blocked, but they definitely make partial occlusion look cool!


Example of Partial Occlusion

The video to the right shows Katsura Fukuda re-enacting her experience with partial occlusion (during the actual experience, I was standing next to her, ready to stop her if she didn't notice the stairs). Katsura is deaf and has a restricted visual field. As she was learning to use the cane, she said she was concerned about whether the cane would help her avoid falling down unexpected stairs.

I shared her concern -- many people who are learning to use the cane continue to rely on their vision and ignore information from the cane. When that happens, they fail to notice stairs or obstacles that they didn't see, even though the cane detected them. We needed to make sure Katsura reached the fourth level of proficiency with the cane, which means that she can notice information from the cane even when her vision misleads her.

I suggested that after she had improved her cane technique, we would have her practice using her vision and the cane information together, at the same time. We would do this by occluding the bottom half of her vision, so she could see the buildings and people around her, but not the ground -- that way, she could use her vision to figure out where to go, but would have to rely on the cane to know about obstacles and stairs in her path.

So later in her program, I took Katsura to a shopping center where I knew the sidewalk had stairs that she would not expect (click here for a view of the sidewalk from Google Map). I gave her some sunglasses, and positioned paper inside the lens such that she could see my head and shoulders when I was close, but could not see my feet and the ground until I was at least 15 feet away from her.

I then asked her to walk along the sidewalk. I wanted to make sure she didn't know that the stairs were there, so I walked in front of her to block her view until she got close enough to the stairs (about 10 feet away) that I was sure she couldn't see the ground where they were. However, there was a woman in front of me going down the stairs -- if Katsura had seen the woman descend, she would have realized there were stairs there. So I turned around and stopped to talk with Katsura about her cane technique until the woman was gone.

I then stepped aside and asked her to continue, and she did, walking at her normal pace. The instant that the cane went over the edge, Katsura stopped and looked surprised! She then proceded down the stairs and I congratulated her and discussed her success.

Katsura then continued walking along the sidewalk. There were two more sets of stairs along the sidewalk, but she was now prepared to expect them. However, in certain places there were stairs which she didn't know about between the building and the curb, so several times I stopped and asked her to walk toward my car to get something. The first time that she turned and walked toward the curb, Katsura was surprised by the steps but detected and negotiated them very well. After doing this a few times, I sent her toward the car where the sidewalk was level. Katsura approached cautiously and, when she detected no steps, she demonstrated excellent technique for verifying that there was no drop-off (that is, she dragged the tip of the cane along the ground back to her feet).

After sufficient practice with partial occlusion, we felt confident that Katsura would notice and negotiate any unexpected stairs with her cane when using her vision to walk in unfamiliar places.

I am very grateful to Katsura Fukuda for allowing my to show her videotape and lesson as an example!

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Strategy 3: Drawing attention to the non-visual information without occlusion

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One strategy for teaching the use of non-visual information is to simply draw the students' attention to it and help them understand the implications of the information. When this is done without any occlusion, it can be very effective for helping students learn to notice and use non-visual in their everyday lives. Illustrations below are but a few examples of this teaching strategy, which is a natural part of every effective O&M program for students with low vision.



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(1) After 6 indoor O&M sessions in three weeks (8 hours of training, sometimes with occlusion), a woman with low vision had gained preliminary skills with orientation and had tentatively reached the fourth and final stage of cane proficiency (see "Teaching the Use of a Long Cane Step by Step: Suggestions for Progressive, Methodical Instruction"), and was therefore ready to begin training outside. On her third outside lesson, while walking on a sidewalk along a street with a stop sign at the next corner, the sidewalk seemed to end suddenly, as she could see only grass in front of her and no more concrete. She strained to see the sidewalk but her vision was too limited. She became distressed and asked where the sidewalk was and whether she had reached the corner.

After she calmed down, I asked her to listen to the cars on the street beside her. She heard them pass her and stop about half a block ahead. I asked her to figure out where the corner was, based on the cars' movements. At first she didn't know, but after I asked her to describe the next intersection, she remembered there was a stop sign at the corner. After thinking some more about the traffic movement that she heard, she realized she wasn't at the corner, she was in the middle of the block. When she asked again about the sidewalk, I asked her how she could find it. She was frustrated but thought about it, and then started to search the ground with her cane. She found that the sidewalk had turned toward the buildings, so she followed it for about a car length, and then again she found grass in front of her. This time she did not need prompting to explore with the cane -- she found that the sidewalk had turned again and was going toward the corner.

So in this situation, she was able to experience listening and feeling for the information that was present and use non-visual information to answer her questions without occlusion or closing her eyes.



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(2) The following scenario happened twice when I was working with men with low vision. In each case, as the man and I walked to the building where we would begin our O&M lesson, I told him that there was a doorbell beside the door and asked him to find and push it. He leaned forward, pressing his face within an inch of the wall and searched for the button, unable to find it until after about a minute of searching with his eyes.

In both cases, I let the man struggle till he found it, then asked him to find it again by using his hand to scan the wall instead of straining to use his vision. One of them did it without further prompting but the other man had to be shown how to place his hand on the wall and move it from side to side looking for the button. They each found the button easily using this non-visual technique. I made no comment about which method was better but after that experience, whenever we approached the door each man reached forward with his hand and scanned to find the button instead of peering closely and straining to find it visually.



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