**2. Psychosocial problems**

Though visual impairment might differ depending on country and age, there was still a paucity of empirical research concerning psychosocial adaptation to acquired visual impairment [4, 5].

#### **2.1. Demographic variables, degree of visual loss, personality, and adaptation**

Some studies had investigated client adaptation to these problems, as well as the associated features of clients, including their demographic and personality characteristics, and their degree of vision loss. Though some studies showed that psychological reactions differ depending on the degree of visual loss, the studies, which suggest that there was a positive correlation between residual vision and adaptation, were those by Fitzgerald et al., Lukoff and Whiteman, and Wulsin et al. [6–8]. Against these studies, Teitelbaum et al. failed to find such a relationship [9].

Bauman examined the relationships between psychological adaptation and a client's visual, medical, personal, social, educational, and vocational histories, through structured interviews incorporating a comprehensive test battery [10]. The segmented data from this study showed that their well-adjusted group (37% of 400 persons) was (a) independence, (b) mostly mobile, (c) maintained satisfactory home and community activities, and (d) had a successful work history. On the other hand, their identified maladjusted group (29%) was (a) dependence, (b) mobility-dependent on others, (c) engaged in only limited home and community activities, and (d) had no recorded work history. They were also able to show that the welladjusted group demonstrated higher scores on intelligence, manual dexterity, emotional stability, and realistic acceptance of their visual impairment, and attained higher educational levels than the maladjusted group. However, no differences were found between these two groups on the degree of vision loss, health indices, or the level of social interaction. A followup study carried out 14 years later showed that these characteristics had been retained [11].

Joffe and Bast examined the relation of ego functioning and adaptation of 101 men with a visual impairment using the California Psychological Inventory (434 items' questionnaire that include 18 scales. Each scale measures interpersonal adequacy, character, intellectual efficiency, interests, etc.) and extensive structured interviews [12]. In this study, occupational status and mobility were used as the index of adaptation. No differences were found between the employed and the unemployed groups on measures such as educational level, age, degree of vision, and several psychological attributes such as defense and coping. However, by combining occupational status with mobility, the study examined the differences between accommodators (employed and high-mobility skills) and non-accommodators (unemployed and poor mobility skills). The researchers found that accommodators used extensive coping strategies, such as mature, adaptive, flexible, purposive, present-oriented, and reality-based behaviors. Accommodators also included objectivity, intellectualization, suppression, and tolerance of ambiguity as techniques to overcome visual impairment problems. By contrast, non-accommodators tended to rely on defensive strategies such as immature, non-adaptive, rigid, past-oriented, and irrational reactions, and used projection, regression, fantasy, displacement, rationalization, and doubt in their reactions.

#### **2.2. Individual factors of emotional and psychological reactions to visual impairment**

The individual variables that acted in specific situations to exacerbate or reduce the differences in each of these reactions, and determined the degree of further psychological adaptation, had been explained from the various viewpoints of different schools of thought. A sketch of this material is discussed in the next section.

### *2.2.1. Psychoanalytical and psychodynamic models*

focused on the acquired visual impairment that occurs in adults. In this discussion, we provided an overview of the theories and empirical studies relating to the psychosocial problems

Visual impairment might result in serious difficulties, because human beings depended on visual perception to get most of their information from the world around them. It might also trigger a psychological crisis that could promote an intention to seek "death," as Carol described [3]. In Japan, an approximately 310,000 people suffered from visual impairment. However, this number was only those who had a certified disability; there were more people suffering from visual impairment than were on official lists. Visual impairment was brought about by various causes such as eye disease, systemic disease, encephalopathy, and traumatic injury. Eye diseases include glaucoma, retinitis pigmentosa, optic atrophy, macular degeneration, retinopathy of prematurity, and so on, while systemic diseases include diabetic retinopathy and Behcet disease. Encephalopathy includes visual impairment caused by brain injuries,

The aspects of psychological distress resulting from these situations were different, depend-

Though visual impairment might differ depending on country and age, there was still a paucity of empirical research concerning psychosocial adaptation to acquired visual impair-

Some studies had investigated client adaptation to these problems, as well as the associated features of clients, including their demographic and personality characteristics, and their degree of vision loss. Though some studies showed that psychological reactions differ depending on the degree of visual loss, the studies, which suggest that there was a positive correlation between residual vision and adaptation, were those by Fitzgerald et al., Lukoff and Whiteman, and Wulsin et al. [6–8]. Against these studies, Teitelbaum et al. failed to find

Bauman examined the relationships between psychological adaptation and a client's visual, medical, personal, social, educational, and vocational histories, through structured interviews incorporating a comprehensive test battery [10]. The segmented data from this study showed that their well-adjusted group (37% of 400 persons) was (a) independence, (b) mostly mobile, (c) maintained satisfactory home and community activities, and (d) had a successful work history. On the other hand, their identified maladjusted group (29%) was (a) dependence, (b) mobility-dependent on others, (c) engaged in only limited home and community

**2.1. Demographic variables, degree of visual loss, personality, and adaptation**

ing on the time of onset and the type of visual impairment experienced.

that were commonly experienced by the visually impaired.

and postoperative impairment from brain tumors.

**1.1. Causes of visual impairment**

94 Causes and Coping with Visual Impairment and Blindness

**2. Psychosocial problems**

ment [4, 5].

such a relationship [9].

One of the earliest theoretical approaches that emphasized the importance of vision in personality development and later adult life was developed by psychoanalysts. Blank maintained that reactions to visual impairment could often be traced to the unconscious significance of (1) the eye as a sexual organ, (2) the eye as a hostile, destructive organ, and (3) blindness as a punishment for sin (like castration) [13].

Traditional psychodynamic models emphasize the importance of concepts such as loss, mourning, and grief. In this context, Caroll maintained that the losses forced on the blinded person were many [3]. They interlocked; they overlapped one another. Any one of them was severe enough in itself. Together, they made up the multiple handicaps that were blindness. Each loss involved a painful farewell (a "death"), then, and Caroll identified 20 types of losses from blindness in his classic writing. These were (loss of) (1) physical 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 rehabilitation had to provide effective substitutes.

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

Psychosocial Adaptation to Visual Impairment http://dx.doi.org/10.5772/intechopen.70269 97

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.

"our expectations have effect on our motives and behavior" [26].

(improvement of self-concept, sense of mastery, and self-control) [27].

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

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

of a more independent self in rehabilitation [23].

**3.3. Self-efficacy**

#### *2.2.2. Stage model*

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

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