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Psychosocial Aspects of the Adjustment Process

Adjusting to vision loss is a sequential process, which follows the same pattern as that of adjusting to any of life's many traumas or crises.

Although there is much more involved when adjusting to vision loss, the Office for the Blind and Visually Impaired (OBVI) would like to provide a simplified explanation based on phases and explain the role of our staff.

Consumers may move through these phases quickly, slowly, or even get hung up in one of them. Each individual moves at their own pace, and may move forward one day and be set back another.

Our role as professionals is not only to provide technical skills that accommodate for their vision loss, but also to facilitate them through these phases of adjustment.

The following is a brief outline of generalized phases, based on Dr. Tuttle's research on self-esteem and adjusting to blindness, and what our role or response might be.

All of the staff with OBVI is equally important in how they interact while an individual is going through the process. Often, the critical element of a person's adjustment and how they see themselves is the way someone interacted with them.

This includes the Rehab Specialists, Associates, Drivers and Volunteers, or anyone else. Please remember that all are important.

Phase one: Trauma, or the "what hit me?" phase. This phase is influenced by the individual's age, their life experiences, how they perceive themselves, and the strength of their self-esteem.

The role of professionals: The news of a vision loss has already been shared with the consumers, and we seldom see individuals at this level.

Our role is not to take away hope, however, but to verify the vision loss with kind and gentle understanding, with direct and simple frankness, and without pity or condescension.

Phase Two: Shock and Denial. The shock reaction is healthy and normal. It shields the individual from being suddenly overwhelmed by the full impact of trauma.

This phase can be expressed as "this is not happening to me" or by what has been described as a "mental numbness." This can also be followed by the belief that an unrealistic miracle, a medical procedure, or some new scientific discovery will restore vision.

"Hope for recovery is a very important therapeutic tool in all other aspects of medicine, but can be a major deterrent to the adjustment to blindness process" (Cholden, 1958, p. 23). We may see individuals in this phase, looking for something that will allow them to see again.

The role of professionals: To interact with individuals in this phase, the OBVI staff should simply make themselves available, provide physical comfort, emotional support, and understanding. At this phase we should not take away hope.

Patiently listening will help. Information should be factual and stated in terms the individual will understand. Expect a great deal of frustration during this phase.

Phase Three: Mourning and Withdrawal. During this time, an individual may have the feeling that all is lost. Morning is a feeling of being sad or sorry for a perceived loss of adequacy, self-esteem, equality, belongingness, or control.

Expressions of hostility and anger are also common during the mourning phase. This may be constant irritability or as an occasional sudden outburst.

Another common phenomenon during this phase is withdrawal or puling back from contact with the physical or social world. Some withdrawal is normal.

Unfortunately, withdrawal can become one's habitual manner of coping (Schulz, 1980). Extreme withdrawal and self-imposed isolation are unnatural and unhealthy.

The role of the professionals: During the mourning phase, part of the role of the professional is being a good, discerning listener. Continue to provide physical comfort, emotional support, and understanding. Individuals may feel incompetent and inadequate during this time.

As a staff, we can counteract these feelings by providing easily mastered practical solutions to personal and social problems. Keep in mind however; some individuals during the mourning phase will resent the well-intentioned encouraging remarks from sighted people.

The individual is not yet ready for lectures on the need for rehabilitation, or advice about how lucky they are, or for sermons about the many other successful people who happen to be visually impaired. Answer questions with direct and simple frankness,

Phase Four: Succumbing and Depression. The "I can't" phase. Some individuals describe this as "giving in" because of their real or perceived loss of personal freedom or independence.

The areas of loss vary, but typically include a loss of: income, travel (in particular is the ability to drive), recreational activities, social interactions, etc.

Depression can also be described as "the D's." This includes despair, discouragement, disinterest, distress, despondency, and disenchantment. Depression may be a common fact of life, however, serious and prolonged depression is not.

With support from staff, family, and friends the depressive states become less intense and less frequent. The individual at risk, however, is one without a support system and is left to deal with bouts of severe depression alone.

Intense despair, despondency, and hopelessness may lead to suicidal thoughts (Hicks, 1979), although most suicidal thoughts and death wishes soon disappear (Fitzgerald, 1970).

The role of the professional: Much of the same approach initiated during the Mourning phase will need to be continued. The individual remains in urgent need of emotional support and understanding. Expressions of resentment, frustrations, and hostility will be common.

(Note: family members who are providing much of the needed support and understanding will often not be able to comprehend just why they have become the targets of this hostility and resentment. Share with them your professional insight).

Negativism and depression have a way of perpetuating themselves. Redirect thought patterns onto the good and positive and redirect mental energies toward setting realistic goals, developing social contacts, and other appropriate activities.

Phase Five: Reassessment and Reaffirmation. The "Life is still worth living" phase. This phase is sometimes called "the turning point." This re-evaluation can lead to a reaffirmation of life and its possibilities.

One of the issues to be resolved during this phase is the question of self-identity. If an individual attempts to function "as if" they could see, they will continue to experience uncomfortable discrepancies in life.

This "denial can also take a passive form in which the individual verbalizes acceptance of the vision loss but does nothing to adjust to it" (Dover, 1959, p. 336).

A much more positive situation arises when the individual recognizes themselves as essentially the same person as before the trauma with the majority of personal attributes intact.

They realize, however, that they have to deal with things differently now. The reassessment phase also involves the process of determining the individual's strengths and limitations.

The role of the professional: The support network of family and professionals continues to play an important part during the reassessment and reaffirmation phase. The professional has the responsibility to help foster a positive frame of mind.

Encouraging a positive outlook can be accomplished by setting a positive example and through discussion, as well as allowing the individual to experience success in training.

With respect to the reality of blindness and its implications, all staff must provide frank, factual information about the person's condition and prognosis when asked. The fact of vision loss has to be confronted and accepted before any further adjusting can occur.

This one aspect of providing realistic feedback must be done without any hint of patronizing or condescension. The staff can:

  • assist the individual to cope with their social and physical environment (or, where necessary to restructure it),
  • help establish realistic attainable goals, gain insights into their own strengths and desires,
  • clarify attitudes and feelings, and
  • help determine the motivational factors that contribute to the adjusting process. 

Providing realistic feedback without patronizing or condescension is the key. (Discuss individual consumers you have concerns about with your Rehab Specialist or Field Supervisor)

Phase Six: Coping and Mobilization. The "I can" or the "Some things I do in a different way" phase. Coping refers to the process of learning to manage the demands of one's physical and social environment.

Learning new skills and developing resources. People in the coping phase frequently comment that they feel self-conscious in public. This phase is where all of us as a staff can have the most effect on our consumers by being encouraging and supportive.

Emphasis is on ability, and the individual should be encouraged to take an active part in planning any activity they participate in. A little confidence gained from a successful experience has a way of generating even more confidence.

The role of the professional: Our role in the coping phase is to facilitate the development of appropriate adjustment behaviors and attitudes. This is when the consumers do best in the rehab process.

According to Dr. Tuttle: accurate information about vision loss and its implications MUST be available.

Second, a sequential program to teach the adaptive skills is required for independents.

And third, fostering the development of healthy attitudes and feelings toward the vision loss, self, and others is vital. When interacting with consumers, please remember that:

  • Consumers may demonstrate a fear of failure and need our support.
  • There will be periodic reappearances of anger and frustrations.
  • And the staff need to encourage the three components of the adjustment process:
  1. the knowledge of coping - cognitive
  2. the behavior of coping - action
  3. the feeling of coping - affective

Phase Seven: Self-Acceptance and Self-Esteem. The "I like me" and the "I am somebody" phase. Successfully meeting the demands of life does not necessarily result in, but certainly contributes to, positive self-esteem or self-acceptance.

A self-accepting person is one who has learned to accept all of his or her personal attributes, the strengths along with the limitations, the assets and liabilities. Self-approval and self-respect are all key ingredients of self-acceptance.

This phase is often after we have seen them. With newly acquired skills, self-acceptance and self-esteem of this phase, the individual is ready to relate positively with others and build relationships based on who they are.

This acceptance is a "two way street" however, and is a continuous process for all of us (sighted or blind).

The role of the professional: Consumers with an understanding that an unfamiliar situation or trauma may temporarily throw then back into some earlier phase of the adjustment process, will be in a better position to cope.

During this phase, we can provide feedback that we understand life can be as full and as rich as they want it to be. Defense mechanisms such as denial and repression are no longer necessary.

We can discourage the "as if" or "if only" games, and encourage the cognitive (understanding and awareness) and affective (developing a positive attitude) components of the process.

For all the staff, instilling a desire to continue to grow in self-understanding and problem-solving skills will be key to a consumer's successful adjustment.

During this phase, the consumers is encouraged be less dependent on the staff here and use local resources from the community.

Last Revised: August 17, 2010