Counselling for sight loss: Using systematic case study research to build a client informed practice model

Abstract

There is compelling evidence to suggest that acquired sight loss negatively impacts on emotional well-being. Despite increasing recognition of the need to provide emotional support for people with sight loss, we still do not fully understand what counselling interventions help and why they help. The aim of this study was to examine the process and outcome of counselling for a 70-year-old client who had experienced complete, irreversible, post-operative sight loss in order to gain a deeper understanding of client-defined helpful aspects of therapy. A Hermeneutic Single-Case Efficacy Design study was undertaken having received ethical approval from the University’s Research Ethics Committee. The client received six sessions of counselling from a vision-impaired counsellor working within a pluralistic framework. Measures were completed by the client at every session, as well as at pre- and post-counselling. All sessions were recorded and transcribed. The client also participated in pre- and post-counselling interviews. Data formed a rich case record that was analysed by a quasi-judicial enquiry team. Results suggested that this was a successful outcome case. Client-defined helpful aspects of therapy were (1) feeling understood; (2) being able to express emotions around the loss of sight; (3) finding a new identity; (4) finding ways to cope with fear, loss, dependency, and other people’s perceptions; (5) exploring the possibility of a positive future without sight; (6) making sense of things; and (7) finding ways to become more socially connected. Relevant therapeutic tasks are proposed, and four key aspects of therapy are identified, which may have implications for the development of a practice model.

Keywords

Case study counselling helpful aspects of therapy Hermeneutic Single-Case Efficacy Design study outcomes sight loss

Introduction

With an ageing demographic, the prevalence of acquired sight loss is rising. Nearly 2 million people in the United Kingdom are blind or partially sighted (Royal National Institute of Blind People [RNIB], 2012b). There is growing recognition of the need to provide emotional support for people with sight loss (RNIB, 2012b; UK Vision Strategy, 2008) as the diagnosis of an eye condition can be devastating and can lead to anxiety, worry, and uncertainty about the future (Norowzian, 2006; RNIB, 2012a; Stephens, 2007), with shock and grief being common accompanying reactions (Baus, 1999; Evans, 1983). There is a clear link between sight loss and emotional distress (Scott, Schein, Feuer, Folstein, & Bandeen-Roche, 2001), with many people fearing sight loss more than loss of any other sense (Baker & Winyard, 1998; De Leo, Hickey, Meneghel, & Cantor, 1999). There is a well-documented link between sight loss and depression (Black, 1999; Burmedi, Becker, Heyl, Wahl, & Himmelsbach, 2002; Carabellese et al., 1993; Emerson, 1981; Hodge, Barr, & Knox, 2010; Horowitz & Reinhardt, 2000; Upton, Bush, & Taylor, 1998). There is evidence that sight loss negatively affects quality of life (Hassell, Lamoureux, & Keeffe, 2006; Williams, Brody, Thomas, Kaplan, & Brown, 1998) and can lower morale (Branch, Horowitz, & Carr, 1989). There is convincing evidence that people with sight problems are more likely to feel lonely (Barron, Foxall, Von Dollen, Jones, & Shull, 1992) and lack social support (Bruce, Harrow, & Obolenskaya, 2007; Davis, Lovie-Kitchin, & Thompson, 1995; Percival, 2003). The issue of isolation and the importance of social support for blind and partially sighted adults are a recurring theme in the research literature (Bruce et al., 2007; Burmedi et al., 2002; Cimarolli & Boerner, 2005; Percival & Hanson, 2007; Percival, Hanson, & Osipovic, 2005; Pey, Nzegwu, & Dooley, 2007).

The literature on the emotional impact of sight loss is weighted towards quantitative studies, although there is a growing body of qualitative research that gives voice to the experience of living with sight loss (Dale, 2008, 2010; Thurston, 2010; Thurston, Thurston, & McLeod, 2010). However, little is known about effective counselling interventions for people experiencing sight loss. To date, there is scant, robust evidence about the process and outcomes of counselling and emotional support for this client group (Nyman, Gosney, & Victor, 2010), and there is no conclusive evidence as to what therapeutic interventions would provide positive effects in this client group. To design effective counselling services for people with sight loss, there is a need to establish an evidence-based understanding of what therapeutic interventions help and why they help.

Case studies have the potential to play an important role in the development of theory and practice (McLeod and Elliott, 2011), particularly in relation to this specific client group, as they can provide detailed process and outcome evidence. Data presented in the following case study may have the potential to play a role in the development of theory and practice, particularly in relation to the development of client-defined therapeutic tasks (McLeod, 2007; McLeod & McLeod, 2011) for this specific client group. This case study is interesting, in that positive change appeared to occur within only six sessions. This study is part of a broader programme of study using a series of systematic case studies to develop a practice model for counselling for sight loss.

Methods

The client

Silvia (name and identifying information have been changed to preserve anonymity) lived alone, supported by a professional carer, who lived with her on a 2-week rotation. An agency allocated each carer, so she was not able to specify her choice of carer and she was unsure who would be allocated to her at the start of each new 2-week rotation. She had two sisters and a niece who lived near her and ‘did what they could’. She had two close friends who were Christians. She had a large circle of contacts, but no one confidant. She felt she was always on the periphery.

Silvia had a carotid artery health problem, which led to her sight loss. In January, she visited an optician because of ‘misty vision’. Four weeks later she was referred to an eye clinic. She had an aneurysm lying on an optic nerve. In July, she underwent an operation to stabilise the aneurysm. She woke up the next day with no useful sight. Several weeks later she was released from hospital and referred to social services. She received a visit from the local blind society and rehabilitation officer for mobility. She did not recall having emotional support, but the general practitioner (GP) was ‘a good listener’. He prescribed antidepressants and referred her to psychiatry. She visited a psychologist fortnightly. Silvia reported persistent low mood and took antidepressants to help.

Silvia described herself as ‘weary’. She reported that she felt negative and lacking in confidence compared to what she used to be. She felt she now had a passive role among her friends instead of an active one. She wanted to be active and confident, but she felt she was not able to be. Before her sight loss, Silvia had described herself as active and fun loving and a social organiser, who specifically liked having friends and going travelling. She enjoyed ‘visiting the lonely’. After her sight loss, she reported that she could not recognise any aspects of her previous life. However, faith in God had always played a significant part in her life and she continued to go to church and to take part in home groups and Bible studies when she was able.

Silvia wanted to order her life in a simpler way. She wanted to find a supportive empathic person and to be accepted into a family or group. She wanted to look for groups to go to where she could listen and have coffee. She looked forward to taking part in the research, as she felt it might help give her some purpose in life.

The counsellor

The counsellor (corresponding author) is a British Association of Counselling and Psychotherapy accredited practitioner. She is a lecturer in counselling, and her research interest is the social and emotional impact of sight loss. Prior to becoming a therapist, she had a 20-year career in teaching, which she gave up after she acquired sight loss. She is registered blind but has some residual sight. It should be noted that, although the therapist did not collect the process data from the client, the therapist acted in a research capacity by acting as a reader for the client for the pre-therapy outcome measures. She also assembled the rich case record, helped facilitate the affirmative and sceptic briefs, and chose the judges.

The counselling intervention

The counsellor used a pluralistic approach for counselling. At its heart, this approach values multiple perspectives. Practice centres on a collaborative relationship between the therapist and client in which both work together to identify tasks and methods that can help the client work towards their goal for therapy (Cooper & McLeod, 2007). The client’s view on what is helpful and not helpful in therapy informs the practice; thus, meta-communication (Rennie, 1998) is a distinctive feature of the therapy, with the therapist regularly checking out with the client that things are progressing in a way they find helpful.

Procedure

The client heard about the research project from a friend at church and was keen to participate as she felt it might ‘give her a purpose’. The client participated in a 1-hr pre-counselling assessment interview. The assessment interview was organised around collecting information about personal history and social network and presenting problems and goals for therapy. In addition, the interview functioned as a preparation for entering therapy – the interviewer provided an explanation of how counselling operated and how the client might make use of it. Counselling commenced 1 week following the assessment interview. The client received six weekly 1-hr sessions of individual counselling. The counselling took place in a University setting. The client was invited to complete Clinical Outcomes Routine Evaluation (CORE) outcome measures (orally) at the start of each session along with a goal attainment measure. A full description of CORE is provided in the ‘Measures’ section of this article. Following each session, process measures (the Working Alliance Inventory [WAI] and Helpful Aspects of Therapy [HAT] form) were administered (orally) by a research assistant. The same person administered the process outcomes each week to ensure continuity for the client.

Ethical considerations

The client and therapist completed ethical consent procedures pre-therapy, and the project received ethical consent from the University Ethics Committee. The client was given an information sheet at the pre-counselling meeting and agreed that information could be collected and used in a case study. Each session was recorded with the client’s consent, and she was informed that she could switch off the recorder at any point. Data were stored in a password protected file in a locked office. The client was invited to comment and amend personal details before publication. Care was taken to protect identifying client details.

The research design

The design used was a Hermeneutic Single-Case Efficacy Design (HSCED) (Elliott, 2001, 2002, 2009), in which multiple sources of data, quantitative and qualitative, are collected from each session throughout the course of therapy and assembled into a rich case record to provide a range of evidence about the process of therapy. The rich case record is then analysed in a quasi-judicial way. Opposing readings of the rich case record are developed and argued by a team of affirmatives and a team of sceptics. A panel of judges then considers the arguments and supporting evidence presented by the affirmatives and sceptics and draws conclusions about the outcome and process of therapy as defined in Figure 1.

Figure 1.

Hermeneutic Single Case Efficacy Design (adapted from Stephen, Elliot & McLeod 2011).

The analysis team

The analysis team comprised 22 first- and second-year postgraduate diploma in counselling students. The students were invited to attend a case study research day, hosted by the researchers. The students were divided into groups of four or five. Two groups were tasked with developing an affirmative case from the case study evidence, while three groups were to develop the sceptic case.

Affirmative case

The affirmative case was based on the identification of evidence to support a claim that the client had experienced positive change during the course of counselling and that this change came primarily as a result of the counselling.

Sceptic case

The sceptic case was based on the identification of evidence to support a claim that the client had not experienced positive change during the course of counselling or that change came primarily as a result of non-therapy events.

Rebuttals

Once the case for the affirmative and sceptic had been presented, each side was given time to develop rebuttals in order to provide a detailed and balanced argument.

The judges

Four independent judges were selected to review the findings of the affirmative and the sceptic groups. Each judge was chosen due to them having specific expertise. Judge 1 was a university lecturer in counselling, with expertise in long-term health conditions and in case study methodology. Judge 2 was a narrative researcher with expertise in the field of sight loss. Judge 3 was a counselling practitioner with expertise in the pluralistic approach. Judge 4 was a senior social science researcher who was not a counsellor.

Adjudication

The rich case record, containing the findings of all qualitative and quantitative measures, the counsellor notes, and a transcript of each session, along with the case for the affirmatives, sceptics, and rebuttals, were sent to independent judges for adjudication. The judges were asked to examine the evidence and to provide a verdict as to whether this case was a good outcome case or a poor outcome case. The judges were also asked to comment on whether the therapists’ own experience of blindness had been significant.

Measures

In order to build a rich case record and to compile multiple sources of evidence, Silvia completed a number of quantitative and qualitative measures before and after each counselling session. The therapist also completed detailed, structured session notes. At the pre-counselling assessment, Silvia completed four quantitative measures and one qualitative measure:

Clinical Outcomes Routine Evaluation–Outcome Measure 34 (CORE-OM 34): This is a self-completed 34-item scale, yielding four sub-scales (well-being, psychological symptoms, functioning, and risk) and total score. It is validated and widely used in research into the outcomes of counselling and psychological therapies (Evans et al., 2000). Inter-item reliability for CORE-OM 34 and Clinical Outcomes Routine Evaluation–Outcome Measure 10 (CORE-OM 10), across both clinical and non-clinical samples, is .94, with a test–retest reliability of .90 (Barkham et al., 2001). Each measure is scored on a 5-point Likert scale. This is scored 0 = not at all, 1 = only occasionally, 2 = sometimes, 4 = often, and 5 = most or all of the time. For CORE-OM 34, data are presented as mean score for the instrument. For CORE-OM 10, data are presented as total score for the instrument.

Target complaints (TC) rating is a self-completed form through which clients describe up to three problems for which they are seeking help and rate each of them on a 10-point scale of severity. These problems and ratings as applied to this client were scaled and scored from Scale a – extent to which blindness is bothering me from 0 = not bothering me to 9 = bothering me, Scale b – extent to which the blindness is important to how I am feeling from 0 = not important to me to 9 = important to me, and Scale c – expectation of change as a result of counselling from 0 = not expecting change to how I feel to 9 = expecting change to how I feel. It is validated by Deane et al. (1997). In a sample of 138 clients, this measure significantly correlated with measures of anxiety, psychological distress, symptom severity, and client satisfaction.

The State Hope Scale (goals scale for the present). This is a six-item scale that measures feelings of hope in the ‘here and now’ measured on a 7-point Likert scale from 1 = extremely negative, 2 = somewhat negative, 3 = slightly negative, 4 = neutral, 5 = slightly positive, 6 = somewhat positive, and 7 = extremely positive (validated by Snyder et al., 1996). When validated with a group of 240 students over a 30-day period, the scale showed Cronbach alpha values between .83 and .95. Data are presented as a total score for the instrument.

Client Pre-counselling Interview (CPCI): This is a semi-structured interview that explores (a) reasons for seeking counselling/description of problems, (b) previous assistance sought for problems, (c) length of time suffered from problems, (d) theory of change ‘What do you believe will help you best with the difficulties and problems you have at present?’, (e) social network/participation in social life/use of community resources – family, work, other (leisure, religion, etc.), (f) feelings about taking part in research, and (g) perceptions of the counselling centre environment.

Before each session, Silvia completed two outcome measures:

CORE-OM 10: This is a self-completed 10-item scale, yielding four sub-scales (well-being, psychological symptoms, functioning, and risk) and total score. It is validated and widely used in research into the outcomes of counselling and psychological therapies (Evans et al., 2000).

TC rating: This is a self-completed form through which clients describe up to three problems for which they are seeking help and rate each of them on a 10-point scale of severity, validated by Deane et al. (1997). Both these forms were read out by the researcher and completed orally due to the participant’s blindness.

During each session, Silvia consented to an audio recording of the session. After each session, Silvia completed two process measures:

Working Alliance Inventory–Short Form (WAISR): This is a self-completed 12-item scale that measures three dimensions of the relationship between counsellor and client: bond, task, and goal. The revised short form of the WAI provides better psychometric properties than previous versions (Hatcher and Gillaspy, 2006). This scale is employed in this study as an index of the quality of counselling being delivered.

HAT form. This is a 2-page instrument, used by clients to describe the most helpful and most hindering events that took place during the preceding counselling session, developed by Llewelyn (1988).

At the end of counselling (1 week after final session), Silvia completed two quantitative outcome measures and one qualitative process/outcome measure:

(a) CORE-OM

(b) State Hope Scale (Snyder et al., 1996)

(c) Change interview. This is a semi-structured counselling follow-up interview, widely used in counselling and psychotherapy research. It invites the client to identify changes that have occurred as a result of counselling, developed by Prof Robert Elliott, Strathclyde University (Elliott et al., 2001).

Results

The counselling sessions

This section is based on segments of session transcripts and describes the various themes and topics that emerged during counselling, significant moments, and turning points.

In the first session, Silvia described the experience of multiple losses due to her blindness.

I feel I’m sort of in the world, but I’m not here. I don’t really see any colour now at all. There is no laughter now. There really isn’t any control from me. I actually can’t think of much being the same at all. I feel that my life, quite honestly, has been taken away from me.

The counsellor primarily used self-disclosure to address the underlying issue of Silvia’s perceived isolation and to help build a relationship with her where she could feel someone identified with her situation and understood the issues she faced.

Sessions 2 and 3 explored the difficulty Silvia had in expressing the pain she felt about her blindness and the tension this caused her.

I’ve been trying to be positive. I don’t want to make people miserable. I don’t like this covering up, ‘cause it is a strain. No, I may not look it, but I’m cracking up inside. I don’t think there is very much of me left, because, erm, to be me was sort of free and you know, to laugh. I can’t see any forward. That’s the way I feel at the moment, I feel completely powerless to do anything.

The counsellor invited Silvia to express her feelings of pain openly in the counselling room and helped her identify inner resources that might form the basis of her ‘forward’.

Session 4 explored the unbearable nature of the profound changes enforced on Silvia because of her blindness and her belief that, at 70, she was too old to start a new life.

I can’t be what I was before, and yet, that’s what I would like to do, because that’s how I related to people, I was interested in them. I’m 70 . . . I’ve lived all my life being somebody else. I do quite wish that I was dead I do. I mean I don’t have plans to end my life, but that is my weekly wish. I think a lot for me is bound up with purpose, having a purpose, because at the moment I feel I don’t have a purpose.

Session 5 responded to the tension Silvia felt about returning home having spent 3 weeks living with friends. ‘It’s difficult to say anything positive here at the moment because I’m so tense. I just feel so tense because . . . you know I’m going home today’. The exploration of this highlighted Silvia’s negative self-concept as a consequence of having to be dependent on others.

Now, because I am blind, I’m demanding and I’m much harder work, so that people think ‘oh that’s the way she is, that’s her character’, when actually it was never my character. It’s very difficult being an adult and maintaining myself as an adult, and yet being so dependent on people you almost have to act like a child. I found it is a difficult balance to keep especially when I have carers who are caring for me and yet I’m meant to be the employer in a way and I’m meant to be in charge. I suppose that’s why I constantly hark back on how it was, because then I was an individual and I knew who I was and the person that God made me to be, as it were. Now I feel I’m covering up such a lot, not really being the real me, in that I was never somebody that was really very demanding. I tended to be somebody that wanted to help people rather than being demanding. I don’t really have many people that I can be real with, and this is what makes it a big issue for me. I have nobody that I can specifically rely on to remind me that I’m a person, to remind me that I’m somebody valuable or somebody that’s the same. I’m the same. I suppose that’s the hard thing for me.

During this session, the counsellor strongly challenged Silvia’s negative self-concept, inviting her to consider adopting a different, less self-critical view point.

Session 6 was a pivotal session in which Silvia reviewed her experience of counselling:

For me, (counselling’s) been actually, almost a lifeline, because I found there’s somebody that I can just touch base with every week, and I can talk about things that have been difficult or worrying and, to me, that’s actually very important. I haven’t really had that since I became blind last year.

Silvia also reflected on the positive impact of her new carer ‘J’:

I can sort of relax, and she sort of anticipates things and says ‘okay would you like this?’ It’s just a more natural, normal relationship. I’ve been doing lots of normal things with J, you know like going places . . . J is so interested in where she is and it just makes all the difference. J trusts me . . . as an adult, as somebody that sort of knows what she’s talking about, whereas the others didn’t.

J helped Silvia feel normal again, and this positive relationship gave Silvia hope that she could still be valued by others. This directly addressed the issues that had been discussed in the previous counselling session. Silvia identified that feeling normal was of paramount importance to her as indicated in the following quote from her, ‘Looking on me as normal, sort of, yes that is a very big thing I think. Whenever I sit down for a chat with somebody then I feel normal, I feel I’m on the level’. There was a marked change in Silvia’s demeanour. She seemed much more positive. There was even a hint of playfulness about her. This appeared to be the result of Silvia feeling human again, having spent time with a carer who made her feel like a friend instead of a demanding child. This carer brought fun back into Silvia’s life. She reminded Silvia that she still had something to contribute to a relationship. She gave Silvia a quality of life that she had not thought possible. Silvia was able to make sense of this change within the counselling session.

Outcome data

Quantitative pre-and post-counselling measures can be seen in Table 1. Sylvia’s pre-counselling scores and post-counselling scores both lay within clinical parameters, although the post-counselling scores were generally reduced. Silvia’s mean well-being scores remained unchanged at 2.75. The Problem Rating Scale measured the client’s perception of her problem. Her perception of how much the problem was bothering her decreased from a mean score of 2.16 to 1.75, her risk also decreased from 0.5 to 0.31 during counselling, indicating a small positive shift in her thinking and a decrease in her risk of suicide or self-harm.

Table 1.

CORE-OM 34 mean sub-scale scores pre-counselling (Week 0) and post-counselling (Week 7).

	Well-being	Problem	Functioning	Risk
Boundary score between clinical and non-clinical populations	>1.77	>1.62	>1.3	>0.31
Week 0,Silvia’s mean score pre-counselling	2.75	2.16	2.66	0.5
Week 7, Silvia’s mean score post-counselling	2.75	1.75	2.0	0.31

CORE-OM 34: Clinical Outcomes Routine Evaluation–Outcome Measure 34.

Weekly outcome data

Table 2 shows a summary of the weekly outcome data collected. Sylvia’s CORE-OM 10 scores showed general improvement throughout the course of counselling, and by Week 7, it had reduced below clinical parameters (clinical cut-off point is scored 15). The Problem Rating Scale measured the client’s perception of her problem. Her perception of how much the problem was bothering her decreased from 9 to 5 during counselling, indicating a small positive shift. There was no change in the client’s perception of how important this issue was in relation to her life as a whole. It stayed at 9 throughout. There was no overall change in perception of how much change the client expected to make during the course of counselling (except for a slight decrease during counselling in Week 4). This could be explained by the realisation that the course of counselling was coming to a close or that the client’s problem could not be solved by six sessions of counselling.

Table 2.

Summary of weekly outcome data (CORE-OM 10, Problem Rating Scale).

Session number	CORE-OM 10 raw score	Problem Rating Scale 0–9	Problem Rating Scale 0–9	Problem Rating Scale 0–9
	Clinical boundary > 15	Bothering me?	Important to me?	Expecting change?
Week 1	27	9	9	3
Week 2	20	6	9	3
Week 3	20	9	9	3
Week 4	18	8	9	2
Week 5	18	7	9	3
Week 6	12	5	9	3

CORE-OM 10: Clinical Outcomes Routine Evaluation–Outcome Measure 10.

The WAI

The WAI was used to assess the quality of the therapeutic relationship. Analysis of WAI data showed that Silvia appeared to have formed a successful working alliance with the counsellor during the course of counselling. The WAI Scale invites clients to rate aspects of the alliance on a 7-point scale. At the end of counselling, all items received a 5 or 6 rating, which reflects a strong alliance. After the first session, three items received a rating of 3, indicating areas of difficulty in the therapeutic relationship, but received 5/6 ratings from Session 3. The items that showed this pattern were the following:

I feel that the things I do in counselling will help me accomplish the changes that I want

What I’m doing in counselling gives me new ways of looking at my problem

As a result of these sessions, I am clear as to how I might be able to change

Hope State Scale

The Hope State Scale measured on a scale from 7 to 42, and measuring the client’s feeling of hope in the here and now showed a change. Silvia’s score on this scale increased from 11 to 18, indicating a small, positive shift in her feelings of hopefulness.

Process data

These measures were completed (orally) after sessions – the client was interviewed by an independent research assistant, who read out the measures and scribed the client’s responses. Sylvia appeared to have formed a successful working alliance with the counsellor during the course of counselling (see Table 3). The quality of the relationship between the counsellor and the client may have contributed to the positive outcome of the case.

Table 3.

Summary of the short-form Working Alliance Inventory (1–7 scale, where 7 indicates a positive alliance).

	I feel that the things I do in counselling will help me accomplish the changes that I want	What I’m doing in counselling gives me new ways of looking at my problem	I believe my counsellor likes me	My counsellor and I collaborate on setting goals for my therapy	As a result of these sessions, I am clear as to how I might be able to change	My counsellor and I are working towards mutually agreed upon goals	I feel that my counsellor appreciates me	We agree on what is important for me to work on	My counsellor and I respect each other	I feel that my counsellor cares about me even when I do things that he/she does not approve of	We have established a good understanding of the kind of changes that would be good for me	I believe the way we are working with my problem is correct
Week 1	3	3	6	6	3	5	6	6	6	–	5	6
Week 2	4	3	6	5	4	3	6	4	6	6	4	6
Week 3	5	5	6	5	3	5	6	5	6	6	4	5
Week 4	5	5	7	7	4	6	7	6	7	6	5	6
Week 5	5	5	7	7	4	7	7	6	7	7	6	6
Week 6	6	6	6	6	5	5	6	6	6	6	5	6

HAT data

The HAT form, completed weekly, functioned as a source of information about Sylvia’s sense of what had been helpful or unhelpful for her within each counselling session.

The aspects of counselling she felt had been most helpful were the following:

(a) Feeling understood:

I’m in a fog, I feel in the world but not of it. It’s the way I feel all the time and it was good to share with someone who understands and listens. It made me feel more relaxed because I shared it with someone who was listening

I was able to share honestly and openly with M since she also struggles with blindness and is able to understand in a way sighted people are unable to fully understand the many related problems and frustrations.

(b) Being able to freely express emotions around the loss of sight:

We talked about fear, fear of the future and problems of being honest in relationships and problems in relationships as a result of my blindness . . . I was able to talk about my situation now without holding back.

Just to be able to look at it objectively with M and to have freedom to share honestly, without any fear of the person I was sharing with feeling threatened by my emotions or their own emotions.

We talked about comparing the old Silvia with the new Silvia, how they were similar and how the different now

(d) Finding ways to cope with fear, loss, dependency, and other people’s perceptions:

We talked about ways of coping when I have that feeling of suffocation as a result of living constantly in this grey mist.

It was helpful to talk about other people’s reactions to me. (I’m now a non-person)

Unravelling my thoughts and feelings that I had become a burden as a result of the sudden change from sight to blindness, from independence to dependence and needing a lot of help in daily life.

(e) Exploring the possibility of a future without sight and a life purpose without sight:

M said she had hope for me, because I was saying there was no hope for the future that I could see. It encouraged me to go on. I suppose I also felt she believed in me and in my present situation as a blind person Working on taking the initiative and daring to speak when I meet people. This has given me courage

(f) Making sense of things that had happened:

Being objective. Seeing the whole picture not just from my point of view.

Sorting things out

(g) Having a blind counsellor:

I was hopeful because the counsellor was blind – she could understand. I was ready. I needed somebody.

M being blind was helpful. I learned so much about myself, around attitudes to blindness. I could be honest. I knew that she would not just tell me to ‘snap out of it’ (which is what sighted people would do).

Unhelpful aspect of therapy data

Silvia identified some ways in which therapy had not been helpful:

(a) The amount, duration, and timing of therapy:

Not enough sessions. It would have been better if I had been able to choose the amount of sessions

Not sure about the timing of it in relation to my sight loss.

(b) Her need to explore her painful feelings in more depth:

I haven’t gone deep enough, but I’m reluctant to go any deeper.

Answering the scored questionnaires was hard.

Client’s use of cultural resources

Silvia identified things outside the counselling sessions that had been significant over 6 weeks:

(a) Having faith in God:

Faith in God and attending a church home group. There is a special caring, but lack of understanding.

(b) Having a positive relationship with her carers:

Carers have been a positive part in my life. I can speak to some of them.

I can speak to some friends. With others the relationship is not deep enough – They can’t handle the emotion.

Positive changes

Silvia identified some positive changes after six sessions of counselling:

(a) Getting back to her old self:

People have noticed I look more like myself

(b) Feeling more connected:

I feel less lonely and isolated (I can relate to M’s struggle). There is at least one person who understands

I have an incentive to find groups that I feel I can be part of and contribute to.

I feel a little bit more hopeful about having a useful future. Counselling gave me a purpose.

(d) Using coping strategies:

I can look at things more objectively.

Suggestions

Silvia made suggestions about how to improve services for blind people in future:

(a) Recommendations for counselling provision:

Counselling takes time. You need more sessions. The person should be in control of the number of sessions

You need to have a blind person involved (in the counselling)

Counselling should be linked to RNIB (Scotland).

(b) Recommendations for carer agencies:

There should be more guidance and training for carers, including the distinctive needs and issues of blind people along with the emotional factors

The key elements of change experienced by Silvia during counselling are summarised in Table 4. This gives an indication that Silvia was not expecting therapy to help but identified it as a factor that helped her change significantly. Despite other positive changes in Silvia’s life that ran in parallel to the therapy, Silvia reported that she attributed significant importance to change as a direct result of the therapy.

Table 4.

Change interview summary.

Change	Change was 1 – expected, 3 – neither, 5 – surprised by	Without therapy: 1 – unlikely, 3 – neither, 5 – likely	Importance: 1 – not at all, 2 – slightly, 3 – moderately, 4 – very, 5 – extremely
Feeling less lonely	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5
More hopeful	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5
Incentive to find groups	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5

Note: Bold typeface indicates client response on scale.

The quasi-judicial enquiry team data analysis

The affirmative arguments

The case for the affirmative presented the following arguments based on analysis of the data:

(a) Outcome and process data:

There was steady improvement both in the CORE scores and in the Problem Rating Scale throughout therapy. There was also general improvement in the pre-/post-counselling CORE scores. In the change summary, Silvia attributed positive gains to counselling.

(b) Silvia’s report of her experience of counselling:

Silvia reported counselling was her lifeline and it gave her a purpose. In the counselling room, she felt she became a person who was understood (outside of counselling, she reported she felt like a person who did not exist). She could be honest about her feelings and she developed new ways of looking at her problems.

The sceptic arguments

The case for the sceptics presented the following arguments:

(a) Outcome and process data:

There was only minimal variation in core statistics. Silvia’s CORE score improved post Session 5 when she got a new carer. This carer had a positive impact, not the counselling. It was likely Silvia wanted to please the counsellor in the WAI.

(b) Peer/human support:

It was M as a person with a sight impairment that helped rather than M as a counsellor. Vision-impaired groups could have helped.

Faith had helped her in the past. She had a home church group, which helped. Her antidepressants had kicked in. Her family wanted to listen to her and support her. Her new carer had a positive influence.

(d) Taking part in the study:

The client needed a purpose in life. Taking part in the study gave her purpose, not the counselling.

Affirmative rebuttal of sceptic evidence

The teams presenting the affirmative case prepared following rebuttals of sceptic arguments.

(a) Although the carer had a positive impact on Silvia’s life (Session 6), the counselling enabled Silvia to make use of this. Client felt understood by the counsellor. Pleasing her was incidental.

(b) Counselling skills were used throughout. These are not used in pure peer support. The client did not get anything out of the visually impaired groups that she had attended, so it was not just that the counsellor was visually impaired.

(c) There is no positive or negative evidence about antidepressants. The assumption is that antidepressants worked for this person – ‘they took the edge off’ – there was no more mention.

(d) Taking part in counselling helped Silvia to find a purpose in life, not just the research.

Sceptics’ rebuttal of affirmative evidence

The teams presenting the sceptic case prepared following rebuttals of affirmative arguments.

(a) Improvement in pre-/post-counselling CORE data was negligible.

(b) The relationship between the counsellor and the client was a genuine relationship but not specific to counselling.

Judgement 1: the verdict

Judge 1 was a university lecturer in counselling, with expertise in long-term health conditions and in case study methodology. Based on the evidence presented by the affirmative and sceptic cases, along with her own reading of the data, she ruled that it had been a ‘moderately successful case’. She felt an important factor was the client was a reliable observer on her own life. She had been a professional before her retirement, and she was eager to take part in the project because she wanted to be helped. She was not eager to please everyone. She explained in great detail why some people had not been helpful to her. Judge 1 commented on the CORE scores saying that she would expect functioning and problem scores to change first. She felt the risk score was not relevant because it was low anyway and that the well-being score was always the last to change. She noticed that Silvia’s goal problem rating had shifted a lot.

She had arrived at a limited success verdict mainly because six sessions were not long enough. Although there were a lot of cultural resources at the beginning, the counsellor helped Silvia to make use of them, for example, when J (her positive carer) arrived. What was helpful (in terms of building up a model) was the counsellor helped her to say painful things that she would not have been able to say to anyone. In addition, the counsellor also conveyed hope – ‘you can get through this’. It would have been a better outcome, if there had been more than six sessions and the counsellor had been more pluralistic and collaborative (e.g. the counsellor never asked the client if her self-disclosure was helpful or what the possibilities were for more sessions).

Judgement 2: the verdict

Judge 2 was a researcher with expertise in narrative practices. She read the rich case record looking for ‘talk that sings’ (Bird, 2004), noting the arguments put forward by the previous adjudicator and the affirmative and sceptic diploma students. These arguments plus her own experiences as a visually impaired counsellor, interested in socially constructed realities, led her to examine the text with specific reference to the therapeutic alliance and the difference the person of the counsellor (including her blindness) made. Because of Silvia’s narrative she judged that the counselling had been successful and that the counsellor’s own experience of blindness had been central to this success, particularly around Silvia’s ability to be honest and to learn about herself and attitudes to blindness. She summed up her adjudication using Silvia’s own words:

Counselling gave me a purpose

M being blind was helpful

I learned so much about myself,

around attitudes to blindness.

I could be honest.

Judgement 3: the verdict

Judge 3 was an accredited counselling practitioner with expertise in the pluralistic approach to counselling. He felt it would be hard to support the sceptical view as the balance of the evidence (outcome data, client testimony, and a reading of the transcript from a counselling-informed perspective) supported the view that this was a good outcome case in which both counsellor expertise and the shared experience of sight loss were significant (though these two factors were supported by different kinds of evidence). Although it could be called ‘moderately successful’ because of the time limit (six sessions), alternatively it could be called a ‘significant outcome’ given the limitations of the resource available. It empowered the client to become an active ‘self-counsellor’ after the conclusion of counselling (longer-term follow-up would help to confirm whether this was the case). He questioned whether a ‘pure’ counselling outcome, separate from other factors, was possible or useful to identify, as from an ‘active client’ perspective, the distinction between ‘counselling’ and ‘peer support’ was perhaps irrelevant. The premise here was that the client was more able to trust, to open up, explore, and ‘use’ the counselling productively because they could assume some shared understanding. Similarly, one sceptical view seemed to be that the client was gaining a sense of purpose from contributing to the research, rather than benefiting from ‘counselling’ as such. However, one of the client’s goals was to ‘be more positive’, and during counselling, she identified purposefulness as a key positive factor in her life story. If she was able to identify a positive sense of purpose with the counselling – to move from thinking of herself as someone with a ‘problem’ that required expert assistance, to thinking of herself as an expert witness to the problem, then it was a good counselling outcome (and a collaborative, ‘pluralistic’ one, even if the counsellor was not practising in an explicitly pluralistic way).

Judgement 4: the verdict

Judge 4 was a senior social science researcher. He was chosen because, although he was interested in sight loss, he was not a counsellor. It was hoped that he might be able to view the findings with some impartiality, despite his relationship with the counsellor.

He supported a successful outcome verdict. He felt there was evidence of positive client outcomes. He noted improvement in CORE scores, particularly the client’s perception of functioning and problem. He noted clear shifts in client’s ability to accept help, for example, from ‘being cared for’ (negative) to ‘I have confidence in my carer’ (positive). He also noted changes in the client’s description of her mood, for example, ‘tense’ and ‘numb’ to ‘giggly’ and ‘relaxed’.

Discussion

The findings of this study are consistent with reports on the emotional impact of sight loss (Norowzian, 2006; RNIB, 2012a; Scott et al., 2001; Stephens, 2007; Thurston, 2010). This client experienced persistent low mood (Black, 1999; Burmedi et al., 2002; Carabellese et al., 1993; Emerson, 1981; Hodge et al., 2010; Horowitz & Reinhardt, 2000; Upton et al., 1998) and she felt socially isolated (Bruce et al., 2007; Davis et al., 1995; Percival, 2003). The loss of sight had negatively affected her identity (Dale, 2011; Thurston, 2010; Thurston et al., 2010) and how she felt perceived by others (Thurston, 2010). Finding a life purpose was important to Silvia. This theme emerged in a study by Marques-Brocksopp (2012). In terms of the Transition from Sight to Blindness Model (Thurston et al., 2010), we can conceptualise Silvia’s sudden sight loss as a point of impact, necessitating an enforced life style change and engagement with social services and rehabilitation interventions. This was immensely emotionally challenging for her.

This case study provided systematic evidence about the process and outcome of counselling for a blind client. Nyman et al. (2010) advocated a move towards robust academic evidence about the effectiveness of emotional support within the sight loss sector. The main finding to emerge from this case study was that short-term pluralistic counselling was an effective intervention for a client who had experienced sudden sight loss. The data collected, particularly the client-identified helpful aspects of therapy, provided us with insight into effective aspects of the counselling process.

Limitations of this study

The main limitation of this study is that N = 1. This was one therapist’s work with one client; therefore, it is impossible to generalise conclusions despite the rich data collected. More research of this type is needed to enable cross case analysis. When we have an idea of what might constitute effective therapy for this client group, then quantitative study might enable further generalisation. Another limitation to the study was the possibility of judge bias. There was a possibility that judges may have responded more positively to evaluation of outcomes to try to please the researcher. Judges were provided with both affirmative and sceptic arguments. It should be noted that the manuscript also reports views as opinions. Therefore, conclusions and judgements should be treated with caution, but as a true representation of opinion.

Implications for practice

This case study was interesting in that positive change appeared to occur within only six sessions. The client’s perception was that the counsellor’s own experience of blindness would allow her to be understood. This is a significant point, as it is not the researchers’ intention to assert that a sighted counsellor would not be able to understand issues presented by a blind client or be less effective. The assertion is the client has a perception about the counsellor’s capacity to understand the issues that might predispose positive engagement in the counselling relationship. It might be that a sighted counsellor would have to address the client’s distrust of their ability to understand the issues of blindness in order to build an effective counselling relationship.

By examining client-defined helpful aspects of therapy, we have the basis on which to construct possible therapeutic tasks for this client group (McLeod, 2007; McLeod & McLeod, 2011; Weaks, McLeod, & Wilkinson, 2006). Therapeutic tasks based on this client’s experience are as follows:

(a) Telling the story of what has happened (having time and space to reflect on events),

(b) Feeling understood (feeling that someone understands the impact of sight loss),

(b) Expressing difficult emotions (fear, despair, and loss of hope),

(d) Examining and challenging negative self-concepts (being a burden and being useless),

(e) Exploring the possibility of a future without sight (finding a purpose in life), and

(f) Identifying helpful cultural resources (local groups, carers, relationships, and religion).

A cross case analysis of HAT data, from a series of systematic case studies, would enable the sector to start building an evidence-based practice model for counselling for sight loss. Once there is a body of evidence about what clients find helpful in therapy, further controlled quantitative studies to validate evidence on a broader scale would be required.

As well as identifying possible therapeutic tasks, from these data we can also identify four key elements of a bigger picture, which have implications for the development of a practice model. These are as follows:

(a) Counselling offered a space for the person to talk, to show their feelings, and to reflect on what has happened.

(b) Counselling was used as a means to maximise the value of other resources.

(d) Counselling brought some degree of structure and meaningfulness to a life in which most social routines had been stripped away.

Comment from Silvia

Silvia was invited to comment on the draft version of this article. She noted that the methodology was interesting, as there were ‘sighted people analysing and judging it’. She felt that might have added impartiality to the findings. She was happy with the way the findings had been reported, ‘The sessions have been so helpful. They have been an anchor to keep me working on things nearly a year and a half later’.

Conclusion

The findings from this study showed that a blind client experienced positive change after six sessions of pluralistic counselling with a blind counsellor, although the client reported that it would have been helpful for her to be able to determine the timing and duration of the counselling sessions. More studies of this type are needed to further our understanding of the process and outcomes of counselling with this specific client group, particularly in relation to designing an effective, evidence-based model of counselling and informing future counselling and emotional support services.

Footnotes

Acknowledgements

The researchers wish to extend their grateful thanks to ‘Silvia’ for her invaluable contribution to this project and to acknowledge the contribution of the following people, whose time and thought, so generously given, helped inform and enrich the data analysis: Linda Beech, Christine Bowie, Susan Dale, Philemon Eva, Christina Ford, Helen Gilfillan, Amanda Hawkins, Emer Hefferman, Alison Henderson, Lorraine Lojko, Stewart Macarthur, Carol Macdonald, Donald MacKay, Arlene Malcolm, Myke McKay, Julia McLeod, Denis O’Hara, Kara Mathieson, Anastasia Robertson, Monica Stewart, Rona Stewart, Laura Swarbrigg, Jillian Taylor, Gerard Tierney, Ellen Tilley, Catherine Wallace, and Kathleen Watt.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

Baker

Winyard

(1998). Lost vision: Older visually impaired people in the UK. London, England: Royal National Institute for the Blind.

Barkham

Margison

Leach

Lucock

Mellor-Clark

Evans

. . .McGrath

(2001). Service profiling and outcomes benchmarking using the CORE-OM: Toward practice-based evidence in the psychological therapies. Journal of Consulting and Clinical Psychology, 69, 184–196.

Barron

C. R.

Foxall

M. J.

Von Dollen

Jones

P. A.

Shull

K. A.

(1992). Loneliness in low vision older women. Issues in Mental Health Nursing, 13, 387–401.

Baus

(1999). Commentary: Psychological aspects of visual impairment. The British Journal of Visual Impairment, 17, 41–44.

Bird

(2004). Talk that sings. Aukland, New Zealand: Edge Press.

Black

S. A.

(1999). Increased health burden associated with core morbid depression in all their diabetic Mexican Americans. Results from the established population for the epidemiologic study for elderly survey. Diabetes Care, 22, 56–64.

Branch

L. G.

Horowitz

Carr

(1989). The implications for everyday life of incident self-reported visual decline among people over age 65 living in the community. The Gerontologist, 29, 359–365.

Bruce

Harrow

Obolenskaya

(2007). Blind and partially sighted people’s perceptions of their inclusion by family and friends. The British Journal of Visual Impairment, 25, 68–85.

Burmedi

Becker

Heyl

Wahl

H.-W.

Himmelsbach

(2002). Emotional and social consequences of age related low vision: A narrative review. Visual Impairment Research, 4, 44–71.

10.

Carabellese

Appollonio

Rozzini

Bianchetti

Frisoni

G. B.

Frattola

Trabucchi

(1993). Sensory impairment and quality of life in a community of elderly population. Journal of the American Geriatrics Society, 41, 401–407.

11.

Cimarolli

V. R.

Boerner

(2005). Social support and well-being in adults who are visually impaired. Journal of Visual Impairment & Blindness, 99, 521–534.

12.

Cooper

McLeod

(2007). A pluralistic framework for counselling and psychotherapy: Implications for research. Counselling and Psychotherapy Research, 7, 135–143.

13.

Dale

(2008). Knitting in the dark: Narratives about the experiences of sight loss in a counselling setting. The British Journal of Visual Impairment, 26, 269–278.

14.

Dale

(2010). Songs at twilight: A narrative exploration of the experience of living with a visual impairment, and the effect this has on identity claims. The British Journal of Visual Impairment, 28, 204–220.

15.

Dale

(2011). Songs at twilight: A narrative exploration of the experience of living with a visual impairment, and the effect this has on identity claims. Newcastle upon Tyne, UK: Cambridge Scholars.

16.

Davis

Lovie-Kitchin

Thompson

(1995). Psychosocial adjustment to age related macular degeneration. Journal of Visual Impairment & Blindness, 89(1), 16–27.

17.

Deane

F. P.

Spicer

Todd

D. M.

(1997). Validity of a simplified target complaints measure. Assessment, 4, 119–130.

18.

De Leo

Hickey

Meneghel

Cantor

. (1999). Blindness, fear of sight loss, and suicide. Psychosomatics, 40, 339–344.

19.

Elliott

Slatick

Urman

(2001). Qualitative change process research on psychotherapy: Alternative strategies. In Frommer

Rennie

D. L.

(Eds), Qualitative psychotherapy research: Methods and methodology. Lengerich, Germany: Pabst Science, pp. 69–111.

20.

Elliott

(2002). Hermeneutic Single Case Efficacy Design. Psychotherapy Research, 12, 1–20.

21.

Elliott

Partyka

Alperin

Dobrenski

Wagner

Messer

Watson

Castonguay

(2009). An adjudicated hermeneutic single-case efficacy design study of experiential therapy for panic / phobia. Psychotherapy Research, 19, 543–557.

22.

Emerson

D. L.

(1981). Facing loss of vision: The response of adults to visual impairment. Journal of Visual Impairment & Blindness, 75(2), 41–45.

23.

Evans

Mellor-Clark

Margison

Barkham

Audin

Connell

McGrath

(2000). CORE: Clinical outcomes in routine evaluation. Journal of Mental Health, 9, 247–255.

24.

Evans

R. L.

(1983). Loneliness, depression, and social activity after determination of legal blindness. Psychological Reports, 52, 603–608.

25.

Hassell

J. B.

Lamoureux

E. L.

Keeffe

J. E.

(2006). Impact of age related macular degeneration on quality of life. The British Journal of Ophthalmology, 90, 593–596.

26.

Hatcher

R. L.

Gillaspy

J. A.

(2006). Development and validation of a revised short form of the Working Alliance Inventory. Psychotherapy Research, 16, 12–25.

27.

Hodge

Barr

Knox

(2010). Evaluation of emotional support and counselling within an integrated low vision service. London, England: Royal National Institute of Blind People.

28.

Horowitz

Reinhardt

J. P.

(2000). Mental health issues in visual impairment: Research in depression, disability and rehabilitation. In Silverstone

Lang

Rosenthal

Faye

(Eds.), The Lighthouse handbook on vision impairment and vision rehabilitation (pp. 1089–1109). New York, NY: Open University Press.

29.

Llewelyn

(1988). Psychological therapy as viewed by clients and therapists. The British Journal of Clinical Psychology, 27, 223–238.

30.

Marques-Brocksopp

(2012). The broad reach of the well being debate: Emotional well being and vision loss. The British Journal of Visual Impairment, 30, 50–55.

31.

McLeod

(2007). Counselling skill. Maidenhead, UK: Open University Press.

32.

McLeod

Elliott

(2011). Systematic case study research: A practice orientated introduction to building an evidence base for counselling and psychotherapy. Counselling and Psychotherapy Research, 11, 1–10.

33.

McLeod

(2011). Counselling skills: A practical guide for counsellors and helping professionals (2nd edn). Maidenhead, UK: Open University Press.

34.

Norowzian

(2006). The emotional impact of diagnosis. New Beacon, 10, 21–23.

35.

Nyman

S. R.

Gosney

M. A.

Victor

C. R.

(2010). Emotional well-being in people with sight loss: Lessons from the grey literature. The British Journal of Visual Impairment, 28, 175–203.

36.

Percival

(2003). Meeting the needs of older people with visual impairment: Social care or social exclusion? London, England: Thomas Pocklington Trust.

37.

Percival

Hanson

(2007). ‘I don’t want to live for the day any more’: Visually impaired people’s access to support, housing and independence. The British Journal of Visual Impairment, 25, 51–67.

38.

Percival

Hanson

Osipovic

(2005). ‘I’m like a tree a million miles from the water’s edge’: Social care and inclusion of older people with visual impairment. British Journal of Social Work, 35, 189–205.

39.

Pey

Nzegwu

Dooley

(2007). Functionality and the needs of blind and partially sighted adults in the UK: A survey. Reading, UK: The Guide Dogs for the Blind Association.

40.

Rennie

D. L.

(1998). Person centred counselling: An experiential approach. London, England: SAGE.

41.

Royal National Institute of Blind People, (2008). UK Vision Strategy. London, England: Royal National Institute of Blind People.

42.

Royal National Institute of Blind People. (2012a). Common feelings about sight loss. Retrieved from http://www.rnib.org.uk/livingwithsightloss/copingwithsightloss/emotionalsupport/Pages/common_feelings.aspx

43.

Royal National Institute of Blind People. (2012b). Sight loss UK 2012: The latest evidence. London, England: Royal National Institute of Blind People.

44.

Scott

I. U.

Schein

O. D.

Feuer

W. J.

Folstein

M. F.

Bandeen-Roche

(2001). Emotional distress in patients with retinal disease. American Journal of Ophthalmology, 131, 584–589.

45.

Snyder

C. R.

Sympson

S. C.

Ybasco

F. C.

Borders

T. F.

Babyak

M. A.

Higgins

R. L.

(1996). Development and validation of the State Hope Scale. Journal of Personality and Social Psychology, 70, 321–335.

46.

Stephen

Elliott

MacLeod

(2011). Person centred therapy with a client experiencing social anxiety difficulties: A hermeneutic single case efficacy design. Counselling and Psychotherapy Research, 11, 55–66.

47.

Stephens

(2007). The emotional well-being of blind and partially sighted people. Draft literature review. Reading, UK: The Guide Dogs for the Blind Association.

48.

Thurston

(2010). An inquiry into the emotional impact of sight loss and the counselling experiences and needs of blind and partially sighted people. Counselling and Psychotherapy Research, 10, 3–12.

49.

Thurston

McLeod

(2010). Socio emotional effects of the transition from sight to blindness. The British Journal of Visual Impairment, 28, 90–112.

50.

UK Vision Strategy. (2008). London, England: Royal National Institute of Blind People.

51.

Upton

L. R.

Bush

B. A.

Taylor

R. E.

(1998). Stress, coping, and adjustment of adventitiously blind male veterans with and without diabetes mellitus. Journal of Visual Impairment & Blindness, 92(9), 656–665.

52.

Weaks

McLeod

Wilkinson

(2006). Dementia. Therapy Today, 17, 12–15.

53.

Williams

Brody

Thomas

Kaplan

Brown

(1998). The psychosocial impact of macular degeneration. Archives of Ophthalmology, 116(4), 514–520.