**5. Interventions for psychosocial adjustment**

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

#### **5.1. Individual psychotherapy**

#### *5.1.1. Grief therapy*

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

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

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

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 situa-

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"

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

equally important impact on the reactions of an individual [20].

with the disability, as well as on his/her behavior [23].

tion, or when confronting the reactions of others.

**4.3. Prejudice by interaction with others**

that had changed.

100 Causes and Coping with Visual Impairment and Blindness

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

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 accomplish was presented, their depression might be intensified.

#### *5.1.2. Cognitive therapy: maladjusted belief*

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 unique psychological constitution (e.g., blind people had to be either gifted or defective in their intellectual functioning); (3) blind people had a special relationship with other people and society in general; and (4) there were magical circumstances about blindness (e.g., blindness would be cured by a new scientific discovery, or new products of engineering would solve the problems of blindness).

clarification, problem-solving skills, and self-modification. Control group participants were involved in group counseling focusing on personal feelings and adjustment to disability. PAS group (*n* = 16) and control group (*n* = 18) were randomly assigned. The participants in PAS group

Psychosocial Adaptation to Visual Impairment http://dx.doi.org/10.5772/intechopen.70269 103

Van der Aa et al. conducted a meta-analysis of 22 studies of psychological intervention implemented between 1981 and 2015 [5]. These studies included group-based cognitive-behavioral intervention, self-management programs, problem-solving treatment, psycho-education, relaxation training, and behavioral activation. Fourteen studies were randomized control trials (RCTs), while in 15 studies, the participants' mean age was over 60. The studies demonstrated that intervention reduced depressive symptoms significantly, but anxiety symptoms, mental fatigue, psychological stress, and psychological well-being were not improved significantly. Given the higher age of participants, the effects on depressive symptoms, psychologi-

Considering the interaction of personal factors, environmental factors, and behavior in the psychological adaptation of persons with acquired visual impairment, we implemented a structured group counseling program as part of a Living Skills Training Program [52]. A quasi-experimental study design was used to compare the outcomes of a 6-month group counseling program with and without individual cognitive therapy, which included a control group. The group counseling program was based on weekly 90-min sessions consisting of three components: (1) talking about experiences and feelings; (2) psycho-education about dis-

Individual cognitive therapy was scheduled once a week for 45 min. Clients talked mostly about how they felt and what they thought during the group counseling sessions, and compared other group participants' responses to their own expectations and beliefs. When distorted negative cognitions were identified, these were explored and modified during indi-

The control group was taken from the participants of the Living Skills Training Program. This program consisted of orientation and mobility training, writing and reading Braille, house cleaning, cooking, sports, recreation, and computer training. The programs were held 5 days per week, and the course ran for 6 months. The results indicated that participants in skills training alone (*n* = 32) improved significantly in acceptance and attribution style, while also showing a trend of improvement in tension anxiety and self-esteem. However, participants with high levels of psychological distress (who indicated a *T*-score of Profile of Mood States Test over 60, *n* = 10) did not show any such improvements. Nevertheless, highly distressed participants that participated in group counseling (*n* = 18) showed significant improvement in their attitudes toward visual impairment and reported decreased anxiety. Moreover, participants that chose to engage in individual therapy in addition to group counseling (*n* = 9) also showed a decrease in depressive mood, fatigue, and confusion, as well as significantly

showed significantly higher self-esteem and goal achievement than the control group.

cal stress, and psychological well-being were small.

increased acceptance of their visual disability.

*5.1.4. Structured group counseling combined with individual cognitive therapy*

ability, eye diseases, and social resources; and (3) relaxation and meditation.

vidual therapy sessions based on the actual attitudes of the other participants.

Additionally, they suggested that maladjusted beliefs mentioned earlier about blindness could affect and limit the lives of visually impaired people. The mythologies and irrational beliefs about visual impairment were part of our general culture and were just as prevalent among sighted as among visually impaired people. This meant, therefore, that any single irrational belief statement that had a potential to cause much unhappiness for a visually impaired person would become the self-defeating thought that could limit their living. Hence, the appropriate intervention included uncovering an individual's irrational beliefs by direct inquiry, knowing their peer group's different capabilities, and seeking views on their impairment in rehabilitation settings or in psychotherapy.

Within the therapeutic milieu (rehabilitative or psychological), the person with visual impairment should be regarded as a student and a learner rather than as a patient, be contacted with objective and realistic attitudes of their condition, and be able to test the accuracy or inaccuracy of their own beliefs. It was possible to bring about cognitive changes through such interventions. Modifying maladjusted beliefs by effective intervention (cognitive therapy) and acquiring coping techniques for visual impairment (e.g., mobility technique, Braille, daily living technique) would make it possible for visually impaired persons to engage in a limited but many activities, to have dreams that lend themselves to real fulfillment, and to experience the pleasures that were indeed possible even though they were blind. It was important for the therapist to know what mythology existed and what could be accomplished to change this through rehabilitation.

#### *5.1.3. Group counseling*

In contrast to the paucity of information regarding the efficacy of individual psychotherapies for the visually impaired, more information was available regarding the usefulness of group counseling. In general, group treatment approaches had been more effective than individual treatment [44]. However, group treatment had been even more effective when used concurrently with individual counseling [45].

This tradition began with Choldon [1], followed by Herman [46], Ross and Anderson [47], Goldman [48], Manaster [49], Roessler [50], and McCulloh et al. [51]. Group counseling approaches were not uniform, however, and had different theoretical bases, goals, and intervention techniques. Moreover, there could be differences in economic status and educational level between clients. These differences could influence original adaptation level of the clients. Furthermore, in nearly all the studies, outcomes were evaluated based solely on therapists' impressions. Only Roessler used a control group while evaluating outcomes using objective indicators such as the standardized self-esteem scale and the locus of control scale [50]. The structured group counseling that he named "Personal Achievement Skills Training (PAS)" included communication skills, value clarification, problem-solving skills, and self-modification. Control group participants were involved in group counseling focusing on personal feelings and adjustment to disability. PAS group (*n* = 16) and control group (*n* = 18) were randomly assigned. The participants in PAS group showed significantly higher self-esteem and goal achievement than the control group.

Van der Aa et al. conducted a meta-analysis of 22 studies of psychological intervention implemented between 1981 and 2015 [5]. These studies included group-based cognitive-behavioral intervention, self-management programs, problem-solving treatment, psycho-education, relaxation training, and behavioral activation. Fourteen studies were randomized control trials (RCTs), while in 15 studies, the participants' mean age was over 60. The studies demonstrated that intervention reduced depressive symptoms significantly, but anxiety symptoms, mental fatigue, psychological stress, and psychological well-being were not improved significantly. Given the higher age of participants, the effects on depressive symptoms, psychological stress, and psychological well-being were small.

#### *5.1.4. Structured group counseling combined with individual cognitive therapy*

unique psychological constitution (e.g., blind people had to be either gifted or defective in their intellectual functioning); (3) blind people had a special relationship with other people and society in general; and (4) there were magical circumstances about blindness (e.g., blindness would be cured by a new scientific discovery, or new products of engineering would

Additionally, they suggested that maladjusted beliefs mentioned earlier about blindness could affect and limit the lives of visually impaired people. The mythologies and irrational beliefs about visual impairment were part of our general culture and were just as prevalent among sighted as among visually impaired people. This meant, therefore, that any single irrational belief statement that had a potential to cause much unhappiness for a visually impaired person would become the self-defeating thought that could limit their living. Hence, the appropriate intervention included uncovering an individual's irrational beliefs by direct inquiry, knowing their peer group's different capabilities, and seeking views on their impairment in

Within the therapeutic milieu (rehabilitative or psychological), the person with visual impairment should be regarded as a student and a learner rather than as a patient, be contacted with objective and realistic attitudes of their condition, and be able to test the accuracy or inaccuracy of their own beliefs. It was possible to bring about cognitive changes through such interventions. Modifying maladjusted beliefs by effective intervention (cognitive therapy) and acquiring coping techniques for visual impairment (e.g., mobility technique, Braille, daily living technique) would make it possible for visually impaired persons to engage in a limited but many activities, to have dreams that lend themselves to real fulfillment, and to experience the pleasures that were indeed possible even though they were blind. It was important for the therapist to know what mythology existed and what could be accomplished to change this

In contrast to the paucity of information regarding the efficacy of individual psychotherapies for the visually impaired, more information was available regarding the usefulness of group counseling. In general, group treatment approaches had been more effective than individual treatment [44]. However, group treatment had been even more effective when used concur-

This tradition began with Choldon [1], followed by Herman [46], Ross and Anderson [47], Goldman [48], Manaster [49], Roessler [50], and McCulloh et al. [51]. Group counseling approaches were not uniform, however, and had different theoretical bases, goals, and intervention techniques. Moreover, there could be differences in economic status and educational level between clients. These differences could influence original adaptation level of the clients. Furthermore, in nearly all the studies, outcomes were evaluated based solely on therapists' impressions. Only Roessler used a control group while evaluating outcomes using objective indicators such as the standardized self-esteem scale and the locus of control scale [50]. The structured group counseling that he named "Personal Achievement Skills Training (PAS)" included communication skills, value

solve the problems of blindness).

102 Causes and Coping with Visual Impairment and Blindness

rehabilitation settings or in psychotherapy.

through rehabilitation.

*5.1.3. Group counseling*

rently with individual counseling [45].

Considering the interaction of personal factors, environmental factors, and behavior in the psychological adaptation of persons with acquired visual impairment, we implemented a structured group counseling program as part of a Living Skills Training Program [52]. A quasi-experimental study design was used to compare the outcomes of a 6-month group counseling program with and without individual cognitive therapy, which included a control group. The group counseling program was based on weekly 90-min sessions consisting of three components: (1) talking about experiences and feelings; (2) psycho-education about disability, eye diseases, and social resources; and (3) relaxation and meditation.

Individual cognitive therapy was scheduled once a week for 45 min. Clients talked mostly about how they felt and what they thought during the group counseling sessions, and compared other group participants' responses to their own expectations and beliefs. When distorted negative cognitions were identified, these were explored and modified during individual therapy sessions based on the actual attitudes of the other participants.

The control group was taken from the participants of the Living Skills Training Program. This program consisted of orientation and mobility training, writing and reading Braille, house cleaning, cooking, sports, recreation, and computer training. The programs were held 5 days per week, and the course ran for 6 months. The results indicated that participants in skills training alone (*n* = 32) improved significantly in acceptance and attribution style, while also showing a trend of improvement in tension anxiety and self-esteem. However, participants with high levels of psychological distress (who indicated a *T*-score of Profile of Mood States Test over 60, *n* = 10) did not show any such improvements. Nevertheless, highly distressed participants that participated in group counseling (*n* = 18) showed significant improvement in their attitudes toward visual impairment and reported decreased anxiety. Moreover, participants that chose to engage in individual therapy in addition to group counseling (*n* = 9) also showed a decrease in depressive mood, fatigue, and confusion, as well as significantly increased acceptance of their visual disability.

#### *5.1.5. Case example*

Mr. O was a 34-year-old man who had acquired a visual impairment due to pigmentary retinal degeneration and had participated in the Living Skill Training program. Before participating in this program, he had attempted suicide. At first, he had a thought that "there is no meaning in the life with loss of vision." As treatment progressed, he began to clearly recognize the negative beliefs regarding his disability such as "people think that visually impaired person can do nothing." Hearing his peers' thoughts in group counseling, experiencing others attitudes in mobility training, and through cognitive modification in individual therapy, he could modify negative beliefs and have positive beliefs, such as "I'm not so poor." and "I don't want to be back to healthy person. I'm OK as I am now." The outcome was that there was improvement in his depression, attitudes, and acceptance of his disability. After this program, he began to live independently as a practitioner of acupuncture [53].

[5] van der Aa HP, Margrain TH, et al. Psychosocial intervention to improve mental health in adults with vision impairment: Systematic review and meta-analysis. Ophthalmic

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