VT Works

On occasion, another Vision Therapist will reach out to me for advice. Sometimes it’s something simple like where to order more Lifesaver Cards, and other times it’s a more complex question, like how do you figure out if your patient is really seeing the Haidinger Brush?

There never seems to be a one size fits all response; a fact which was clearly illuminated when trying to answer a more recent inquiry from a newer Vision Therapist whom I have never met. After a few introductory pleasantries, the body of the email read:

I want to pick your brain about a difficult patient of mine who I cannot get to do anything! He is the typical pissed-off teenager who sits down, pulls down the brim of his baseball cap, crosses his arms, and has a general f*#& you look to him every time we try an activity. I have tried to reach him with kindness and understanding, even asking his parents for help (which only made it worse!), but everything has failed. We have met six times and probably have successfully completed less than three activities in all. His mom and dad seem to have an argument every time they are together, so I understand where this attitude comes from, but I haven’t figured out how to break through. I’m wondering if you have any suggestions?

The first thing I would like to acknowledge is anyone who has worked in Vision Therapy for more than a few weeks has likely been in this spot, so try to take comfort in the idea that you are in good company.  I can’t really say that I have a one size fits all solution, but, here are a few ideas – try them in this order, or not – and see which ones you find useful. I tend to be fairly kinesthetic in these situations, and sometimes just fly by the seat of my pants, so go with what feels right to you.

Here are my ideas:

• Stay Neutral, Stay Present – When a teen’s home life feels like a battlefield, it’s tempting to step in as the referee, or to lean toward one side because you understand where their attitude comes from. For example, “His mom and dad seem to argue every time they’re together, so I get why he’s frustrated.” Totally valid. But here’s the catch: if you start taking sides or voicing opinions about family dynamics, even implicitly, you risk losing the teen’s trust. Your role isn’t to judge or fix the family drama, it’s to be a steady, neutral presence who sees the teen as they are, not just as a product of their circumstances. When you stay out of the parental squabble, you keep your VT room as a space safe. The teen knows they won’t get lectured, dismissed, or caught in crossfire. That neutrality allows them to work and open up in their own time and way. Breaking through doesn’t mean solving the family conflict. It means showing up without bias, without taking sides, and without making their story about your opinions. That’s how you build a bridge and avoid the battle lines.

• Acknowledge and Validate – For me, this is the most important. “I see that you’re unhappy/frustrated about being here, and those feelings you’re having are important.” You’re letting the patient know they’re seen and heard, not ignored or overruled. This doesn’t mean you’re agreeing with their perspective, just that you’re recognizing it. For many kids (and parents), this small step is surprisingly disarming. It lowers the emotional temperature and opens the door to cooperation. You’re essentially saying: “I get it. You’re a human being with real feelings, and I’m not here to bulldoze you.” From here, you can start to build trust, and trust is the foundation for any meaningful progress in therapy.

• Redirect with Purpose – Once you’ve acknowledged their feelings or helped them co-regulate, it can be tempting to jump right into “Okay, let’s get to work.” But teens, especially those who are oppositional, anxious, or just plain exhausted, often need a bridge, not a shove.

  Redirection isn’t about brushing past their emotions; it’s about gently guiding their focus toward something productive or neutral. Try: “Okay, that sounds really frustrating. Do you want to tell me more, or should we see if you can beat your time on the Michigan Tracking from last week?” Either option is acceptable, but both keep the session moving without invalidating the moment.

  The key is purpose. You’re not just distracting; you’re refocusing with intent. You’re saying: “I hear you, and I believe you’re capable of moving forward from here.” That belief, paired with gentle direction, can be surprisingly motivating.

• Empathy, Not Sympathy – There’s a difference, and it matters. With empathy, we try to step into their shoes, to understand and reflect their feelings from their point of view. For example: “Your frustration makes sense. I imagine at your age, you’d rather be anywhere else but here.” Empathy invites connection. It says: “I get you.”
  Sympathy, on the other hand, stays at a distance. It’s more like, “Man, that sucks,” said from the sidelines. It acknowledges the discomfort, but doesn’t really engage with it. It’s not wrong — just not as effective when we’re trying to build trust and rapport with a young patient who already feels misunderstood. Empathy builds bridges. Sympathy just waves from the other side.

• Establish a Shared Goal – This doesn’t have to be lofty. It could be as simple as: “Look, I don’t want to waste your time, and I’m guessing you don’t want me to either. What if we agree to just get through one thing and I promise I’ll keep it short?” You’d be amazed how often this tiny truce shifts the dynamic just enough to get a foot in the door.

  It reframes the session from “something being done to them” into “something we’re navigating together.” Even better, it gives the patient a sense of agency, which is something many frustrated or anxious patients feel they’ve lost. A shared goal doesn’t mean total buy-in, but it does mean cooperation becomes possible. And once that’s in place, everything else gets easier.

  In other words, you’re not saying, “Do this because I said so.” You’re saying, “Let’s make a deal.” And for many teens, especially the oppositional or wary ones, that simple shift in power dynamic can be the difference between a battle and a breakthrough.

• Offer a Sense of Control – Teenagers, especially those coming from chaotic or emotionally unsafe environments, often resist anything that feels like forced compliance. When everything in their world feels unpredictable or imposed, autonomy becomes sacred. So instead of saying, “We’re going to do this now,” try something like, “Would you rather start with something hands-on or something more chill today?” . If you have ever read the Love & Logic series, it’s a concept borrowed from those writings and one I have found incredibly useful. Two choices, both lead to answers you can live with, yet the power to decide which happens first is theirs. It’s a win/win.

  Even this small choice (clearly a low-stakes decision), can have a regulating effect. It signals respect. It says: “You have a say in what happens to you here.” And for many teens, that alone is a novelty.

  You’re not giving up structure or therapeutic intent; rather, you’re just handing over the reins, briefly, in a way that invites cooperation instead of resistance. Sometimes, the illusion of control is enough to restore a sense of safety, and that’s where the real work can begin.

• Co-Regulate First, Then Challenge – If the patient is dysregulated (angry, shut down, anxious, or bouncing off the walls) any cognitive or visual demand will likely feel like an attack, not an exercise. Their nervous system is in survival mode, and asking it to track a moving target or solve a puzzle just adds fuel to the fire.

  Take a beat. Match their energy, or gently ground it. Sit on the floor in silence for a moment. Comment on something neutral and safe in the room: “That lamp has been crooked all day and it’s driving me nuts.” Humor can help. So can quiet. Your goal is to signal: “We’re not in a rush. You’re safe. I’m here with you.”

  Once they’re a bit more regulated (breathing slower, shoulders less tense, eyes less darting) you can begin to layer in challenge. But never before. Regulation isn’t just a prerequisite for learning; it’s the doorway to connection.

• Just Be Real – Teens have an uncanny BS radar. If you pretend to care more than you do, or worse, fake being “cool,” you’ll lose all credibility in zero seconds flat. They don’t need you to be hip, they only need you to be honest.

  Show up as a steady, calm, respectful adult. Someone who’s not thrown off by eye rolls or silence. Someone who can sit through discomfort without making it about themselves. When you see the person, not the resistance, not the diagnosis, not the behavior, but the actual person underneath – it lands most times.

  Being real doesn’t mean oversharing or trying to be their friend. It means being present. Consistent. Human. That’s the kind of relationship that sticks, and it’s the one most likely to make any real therapeutic work possible. Your presence is powerful, don’t underestimate it.

You’re doing good work. Keep showing up!

Cheers!