**3. Personality and adaptation**

#### **3.1. Anxiety**

There were some studies that have focused on the relationship between personality traits and adaptation to visual impairment. These studies were called disposition (or trait) theories. The first personality trait that affected rehabilitation was anxiety. As stated above, Dover recognized that denial was a defense to ward off anxiety; in the phase of anxiety, people with visual impairment often did not participate in rehabilitation, or reject to participate. They denied visual impairment of themselves because of anxiety [15]. Moreover, anxiety resulted in lowered attention spans and decreased the ability to use cues of environment, influenced learning, and performance in personal rehabilitation [17]. In addition, the learning of the person with high anxiety was slower, and the retention of what was learned was less [18]. That was why treating anxiety was significant in rehabilitation for visual impairment in which Braille, mobility techniques, and the techniques of daily living were acquired.

#### **3.2. Self-concept and self-esteem**

Self-concept was defined as "a collection of thoughts and feelings one about oneself," [19] and self-esteem had been used as an affective dimension of the self-concept [20]. The reason that self-concept was related to rehabilitation and adaptation was that human beings tend to initiate behavior to reduce the discrepancy between "the present self" and "the ideal possible self" [21], and seek feedback that was consistent with their self-concept, but avoided information that was contradictory [22]. Therefore, the self-concept idea related to whether the individual with visual impairment could initiate new behavior and how he/she could adjust to their new life. In other words, psychological reactions might differ depending on how much his/ her self-concept was defeated. If a person shaped negative self-concept by acquiring visual impairment, and resisted change, it could become very difficult to advance toward the goals of a more independent self in rehabilitation [23].

Tuttle had produced many examples of possible discrepancies that persons with visual impairment might encounter between the way they saw themselves and how they were seen by significant others [20]. These discrepancies needed much effort to resolve and had major impacts on their personal adjustment [23]. This was why there were some studies that had made considerable efforts to establish empirical evidence of the differences in self-concept and self-esteem between people with vision loss and sighted people [24]. However, these studies produced contradictory results because they involved confounding variables, such as inappropriate measuring instruments, the length of time that people with visual impairment had experienced vision loss, and the diverse range of coping strategies they used [23]. Still, self-concept and self-esteem were not closed traits in an individual. Also, their relationships with the people around them should not be ignored. We will discuss this issue later.

#### **3.3. Self-efficacy**

integrity, (2) confidence in the remaining senses, (3) reality contact with environment, (4) visual background, (5) light security, (6) mobility, (7) techniques of daily living, (8) ease of written communication, (9) ease of spoken communication, (10) informational progress, (11) visual perception of the pleasurable, (12) visual perception of the beautiful, (13) recreation, (14) career, vocational goal, job opportunity, (15) financial security, (16) personal independence, (17) social adequacy, (18) obscurity, (19) self-esteem, and (20) loss of total personality organization. Since a blind person lost such a lot, Caroll emphasized that reha-

Caroll's loss model had been further developed. A stage model, which insisted that emotional psychological reactions to trauma occur in stages, was one such development. This theory explained that the psychological reactions experienced after acquired visual impairment might pass through the stages of (1) shock, (2) depression, and (3) recovery [1, 13]. Another stage model proposed by Allen suggested three adaptation processes: (1) pre-impact phase,

Related to the stage models, there were some studies of the impact of denial on the process of adaptation. Dover recognized the importance of denial as a defense to ward off anxiety [15]. She emphasized that denial was frequently manifested through a search for new medical discoveries and magical treatments. Shulz, in distinguishing between denial of the severity of the condition and denial of the affective content or meaning of the visual loss, considered that

There were some studies that have focused on the relationship between personality traits and adaptation to visual impairment. These studies were called disposition (or trait) theories. The first personality trait that affected rehabilitation was anxiety. As stated above, Dover recognized that denial was a defense to ward off anxiety; in the phase of anxiety, people with visual impairment often did not participate in rehabilitation, or reject to participate. They denied visual impairment of themselves because of anxiety [15]. Moreover, anxiety resulted in lowered attention spans and decreased the ability to use cues of environment, influenced learning, and performance in personal rehabilitation [17]. In addition, the learning of the person with high anxiety was slower, and the retention of what was learned was less [18]. That was why treating anxiety was significant in rehabilitation for visual impairment in which Braille,

Self-concept was defined as "a collection of thoughts and feelings one about oneself," [19] and self-esteem had been used as an affective dimension of the self-concept [20]. The reason that

bilitation had to provide effective substitutes.

96 Causes and Coping with Visual Impairment and Blindness

(2) impact phase, and (3) learning to live with impairment [14].

the latter could interfere with the process of adaptation [16].

mobility techniques, and the techniques of daily living were acquired.

**3. Personality and adaptation**

**3.2. Self-concept and self-esteem**

*2.2.2. Stage model*

**3.1. Anxiety**

Another concept that is related to rehabilitation and adaptation was self-efficacy. In the past, the concept of confidence and motivation was widely used in the field of rehabilitation, because one of the problems rehabilitation personnel had been struggling with was low confidence or unmotivated clients. However, since the widely used concept of motivation was so simple, Dodds outlined the usefulness of the concept of self-efficacy for rehabilitation [25]. The concept of self-efficacy, originally proposed by Bandura, was based on the notion that "our expectations have effect on our motives and behavior" [26].

Moreover, Dodds et al. developed an adjustment structural model comprising anxiety/depression, self-esteem, self-efficacy, locus of control, acceptance of disability, attitudes toward blindness, and attributional style by using the LISREL (linear structural relation) model (the statistical methods to formulate theoretical model for manifest variables and latent variables from collected data) [27]. Additionally, two factors, which were not assessed directly but appeared in latent form, were identified. These factors were "self as agent" and "internal selfworth," and seemed to explain the high interrelationships found among above seven factors assessed by the adjustment structural scale (**Figure 1**). Based on this, Dodds et al. asserted that successful adaptation was multidimensional and includes (1) low levels of anxiety and depression, (2) high levels of self-esteem and self-efficacy, (3) a high sense of personal responsibility for recovery, (4) a positive attitude toward visual impairment, and (5) acceptance of one's own visual disability. They also suggested that the process of adaptation was inclusive of changes in both negative aspects (decreasing anxiety and depression) and positive aspects (improvement of self-concept, sense of mastery, and self-control) [27].

socio-environmental influences such as prejudice and interactions with others also had an

Psychosocial Adaptation to Visual Impairment http://dx.doi.org/10.5772/intechopen.70269 99

Cutsforth, a blind psychiatrist, was the first to assert the influence of society on such reactions [28]. He stated that the characteristic of emotional disturbances was that they were evoked from the social situations that blindness created and not from the sensory deprivation itself. Thus, it was difficult to find any evidence that blindness itself was productive of emotional disturbances. Chevigny and Braverman described that society included the beliefs, feelings, and consequent expectations that sighted persons inflicted upon the blind person [29]. They stated that every blind person reacted to this environment, either consciously or unconsciously, and resentment was a primary reaction that emerged from this social situation. Thus, a major issue in other people's reactions to blindness was "lack of understanding and misconceptions." The core of the self-concept of persons with visual impairment was the stereotypical attitudes and expectations of sighted people around them, which became the rules by which persons with visual impairment sculpted their thoughts, feelings, and daily actions. It was thus impossible for persons with visual impairment to ignore these beliefs, and they had no choice but to respond to them. The result was a feeling of shame, inadequacy, and self-derogation [30, 31]. Though empirical studies had been conducted to discover how other people regard visual impairment, the findings were confounded. This was caused by the variety of using psychological tests, different eliciting stimuli, and confusion regarding whether the research was measuring people's attitudes toward visual impairment, or toward people with visual impairment [32]. However, many of the confusing and discrepant findings suggested that people's attitudes toward visual impairment were not unidimensional, but were instead multidimensional [23]. Whiteman and Lukoff [33] identified five dimensions of other people's attitudes toward visual impairment or people with visual impairment: (1) personal attributes reflecting a negative view of the emotional life and general competence of people with visual impairment; (2) social attributes reflecting a readiness for interaction with people with visual impairment, and a positive view of the social competence of people with visual impairment; (3) evaluation of visual impairment that showed the degree to which visual impairment was perceived as threatening and uniquely frustrating to one's self and others; (4) non-protectiveness, reflecting a lack of protectiveness and sympathy; and (5) interpersonal acceptance, reflecting an emotional acceptance of people with visual impairment in interpersonal

In addition to these studies, there were researchers who insisted that the attitudes of other family members had a strong impact. Versluys [34] and Featherstone [35] noted that families who communicated positive attitudes helped stabilize their visually impaired relative's selfconcept. Large noted that the attitudes of family members, especially parents, had a powerful influence and, depending on whether the influence was positive or negative, had lasting effects [36]. The reason why the family had such a strong influence was that it served as the major source of interpersonal influences that affected what visual impairment meant to the

Vision loss was likely to cause disturbances in an individual's balance between independence and dependence. The affected person had to now depend to a greater degree on others to

person suffering from this, and what he/she did with it [37].

impact on psychological adjustment.

situations.

**Figure 1.** LISREL structural model with path coefficients (\**P* < 0.05). Reprinted with permission of the publisher from Dodds et al. [27]. Copyright © 1994 by American Foundation for the Blind. All rights reserved.

Furthermore, based on the results of the LISREL analysis, they suggested that these factors might influence rehabilitation practice. For example, attritional style had a direct effect on "internal self-worth," and "internal self-worth" was related to anxiety/depression and selfesteem. Acceptance of sight loss was also strongly related to "self as agent." "Self as agent" reflects a belief in one's ability to control future goals and tasks, was related to self-efficacy and recovery locus of control, and directly related to "internal self-worth." From these results, Dodds et al. concluded that, while counseling might not directly lead to measurable improvements in self-worth, it might improve the motivation for an individual to act in ways that brought about successful adjustment outcomes [27].

### **4. Social factors**

#### **4.1. Socio-environmental influences**

These theories and studies mentioned earlier had been developed from the standpoint that emotional and psychological reactions and adaptation varied according to the individual factors. However, there were studies from the alternative standpoint that the reactions of individuals with visual impairment were the consequence of influence from other people. Thus, socio-environmental influences such as prejudice and interactions with others also had an impact on psychological adjustment.

Cutsforth, a blind psychiatrist, was the first to assert the influence of society on such reactions [28]. He stated that the characteristic of emotional disturbances was that they were evoked from the social situations that blindness created and not from the sensory deprivation itself. Thus, it was difficult to find any evidence that blindness itself was productive of emotional disturbances. Chevigny and Braverman described that society included the beliefs, feelings, and consequent expectations that sighted persons inflicted upon the blind person [29]. They stated that every blind person reacted to this environment, either consciously or unconsciously, and resentment was a primary reaction that emerged from this social situation. Thus, a major issue in other people's reactions to blindness was "lack of understanding and misconceptions." The core of the self-concept of persons with visual impairment was the stereotypical attitudes and expectations of sighted people around them, which became the rules by which persons with visual impairment sculpted their thoughts, feelings, and daily actions. It was thus impossible for persons with visual impairment to ignore these beliefs, and they had no choice but to respond to them. The result was a feeling of shame, inadequacy, and self-derogation [30, 31].

Though empirical studies had been conducted to discover how other people regard visual impairment, the findings were confounded. This was caused by the variety of using psychological tests, different eliciting stimuli, and confusion regarding whether the research was measuring people's attitudes toward visual impairment, or toward people with visual impairment [32]. However, many of the confusing and discrepant findings suggested that people's attitudes toward visual impairment were not unidimensional, but were instead multidimensional [23]. Whiteman and Lukoff [33] identified five dimensions of other people's attitudes toward visual impairment or people with visual impairment: (1) personal attributes reflecting a negative view of the emotional life and general competence of people with visual impairment; (2) social attributes reflecting a readiness for interaction with people with visual impairment, and a positive view of the social competence of people with visual impairment; (3) evaluation of visual impairment that showed the degree to which visual impairment was perceived as threatening and uniquely frustrating to one's self and others; (4) non-protectiveness, reflecting a lack of protectiveness and sympathy; and (5) interpersonal acceptance, reflecting an emotional acceptance of people with visual impairment in interpersonal situations.

Furthermore, based on the results of the LISREL analysis, they suggested that these factors might influence rehabilitation practice. For example, attritional style had a direct effect on "internal self-worth," and "internal self-worth" was related to anxiety/depression and selfesteem. Acceptance of sight loss was also strongly related to "self as agent." "Self as agent" reflects a belief in one's ability to control future goals and tasks, was related to self-efficacy and recovery locus of control, and directly related to "internal self-worth." From these results, Dodds et al. concluded that, while counseling might not directly lead to measurable improvements in self-worth, it might improve the motivation for an individual to act in ways that

**Figure 1.** LISREL structural model with path coefficients (\**P* < 0.05). Reprinted with permission of the publisher from

Dodds et al. [27]. Copyright © 1994 by American Foundation for the Blind. All rights reserved.

These theories and studies mentioned earlier had been developed from the standpoint that emotional and psychological reactions and adaptation varied according to the individual factors. However, there were studies from the alternative standpoint that the reactions of individuals with visual impairment were the consequence of influence from other people. Thus,

brought about successful adjustment outcomes [27].

**4. Social factors**

**4.1. Socio-environmental influences**

98 Causes and Coping with Visual Impairment and Blindness

In addition to these studies, there were researchers who insisted that the attitudes of other family members had a strong impact. Versluys [34] and Featherstone [35] noted that families who communicated positive attitudes helped stabilize their visually impaired relative's selfconcept. Large noted that the attitudes of family members, especially parents, had a powerful influence and, depending on whether the influence was positive or negative, had lasting effects [36]. The reason why the family had such a strong influence was that it served as the major source of interpersonal influences that affected what visual impairment meant to the person suffering from this, and what he/she did with it [37].

Vision loss was likely to cause disturbances in an individual's balance between independence and dependence. The affected person had to now depend to a greater degree on others to assist him/her in performing the many tasks of daily living and especially for help in travel until he/she learned techniques for functioning without vision. Therefore, this could lead to serious problems if an individual had dependency conflicts throughout his/her life [23]. Thus, we needed to understand the influence of the family from the viewpoints of dependence and independence, and the roles in the family formerly occupied by the visually impaired person that had changed.

might have ambivalent feelings about his/her new identity, such as "Am I an independent per-

Psychosocial Adaptation to Visual Impairment http://dx.doi.org/10.5772/intechopen.70269 101

Then, there was the concept of "passing," which often affected persons with low vision, not those with total visual impairment. They were passed up the fact of vision loss by people around them in almost all living situations. This might have an impact on the identity of the

As described earlier, the difficulties in, and the complexity of, the psychological adaptation of people with visual impairment were caused by the interaction of personal factors, environmental factors, and individual behavior. Therefore, the methods of support intervention had also varied, depending on the differences in the understanding of the cause of psychological

Treatments that were effective against the psychological reactions to acquired visual impairment had not been widely empirically demonstrated [4]. Grief work had been one commonly

Choldon stated that the therapist should be a relatively fixed, nonthreatening, and warm figure [1]. It was fruitful to point out to a patient conscious side which he/she did not accept the disability, and situations where they could avoid the difficulties that visual impairment brought. But as, in the shock stage, any readjustment effort was not effective, it would seem unwise to do so. After this stage, the reactive depression stage began, which was a period of mourning for their eyes, in which the patient had to die as a sighted person and was an important and necessary phase in the reorganization process. The patient needed to experience this depression before they could accept the reality of visual impairment; efforts to prevent or abort it should not be made. In this stage, it was better to let them alone to cry. After this, it was possible to hasten the movement out of the depressed state by the judicious use of activities and training tasks in the rehabilitation. Having successfully accomplished some task believed difficult at first might lift their mood, but if an overambitious task that they could not

Needham and Ehmer categorized the 16 maladjusted belief statements that visual impaired people often made into four categories [43]. These were that (1) blind people were different from sighted people in their self-worth and value (e.g., an individual's worth was dependent upon his/her physical adequacy. So, blind person was of little value); (2) blind people had a

used intervention strategy, although empirical evidence of its efficacy is lacking.

person with low vision and on the decision of when to disclose their visual disability.

son or a dependent person?," and might wish to reject it.

**5. Interventions for psychosocial adjustment**

reactions or of the difference of the purpose of the intervention.

accomplish was presented, their depression might be intensified.

*5.1.2. Cognitive therapy: maladjusted belief*

**5.1. Individual psychotherapy**

*5.1.1. Grief therapy*

#### **4.2. Combination of individual and socio-environmental factors**

There were some researchers who attached great importance to both individual and socioenvironmental factors in addition to these socio-environmental variables. Bauman and Yoder, for example, recognized the impact of both the situation and the reaction of family members, friends, and medical personnel on the adjustment of newly visually impaired person [11]. Roberts stated that visual impairment presented the human organism with one of the most sweeping environmental adaptations conceivable, and the views of other people made it necessary for the visually impaired person to reexamine and often to redefine his/her own self-concept as well as his/her previously established roles and procedures [38]. Yeadon and Gryson stated that reactions to visual impairment steamed for two main sources: the attitudes of the person and others, and the age at the onset of visual impairment [39]. Tuttle also thought that both "physiological loss of vision" and "society's prevailing attitude" had an equally important impact on the reactions of an individual [20].

#### **4.3. Prejudice by interaction with others**

Many visually impaired people were stigmatized when they were living in various locations. In this context, the stigma is referred to "some deviation from a norm or standard" [23]. Persons with visual impairment were often stigmatized by their appearance or by the equipment (white cane, special glasses) they used. The problem of stigma, however, did not reside in the person who possesses the stigma, nor in the persons who reacted to the stigma, but in the interaction between them [40, 41]. People who were stigmatized elicited atypical reactions and behaviors from the public. These reactions could impact on the self-concept of the person with the disability, as well as on his/her behavior [23].

Understanding these interactions, Barker et al. suggested the concept "A new psychological situation" [42]. This was a concept that covered the fact that a person would engage in behaviors that attracted and repelled, trial and error, and experienced frustration, then withdrew to the safety of the old in the situation where the location of positive goals and the path by which they could be reached were clear. Visually impaired persons frequently experienced this "new psychological situation" when lacking a necessary tool for dealing with the situation, or when confronting the reactions of others.

Another concept that might be important was the one of "overlapping roles." If the person with visual impairment had no problems in their limbs, they might find themselves more torn between the roles of independent and dependent than the persons with physical disability. This condition might result in the feeling of being a "marginal man," and this "marginal individual" might have ambivalent feelings about his/her new identity, such as "Am I an independent person or a dependent person?," and might wish to reject it.

Then, there was the concept of "passing," which often affected persons with low vision, not those with total visual impairment. They were passed up the fact of vision loss by people around them in almost all living situations. This might have an impact on the identity of the person with low vision and on the decision of when to disclose their visual disability.
