Foundations of Orientation and Mobility

Third Edition
Volume I
History and Theory

William R. Wiener, Richard L. Welsh, and Bruce B. Blasch, Editors

CHAPTER 6

Psychosocial Dimensions of Orientation and Mobility

Richard L. Welsh

LEARNING QUESTIONS

 What is the connection between a person's adjustment to vision loss and his or her success
in orientation and mobility?

 How do the seven stages of adjustment to vision loss developed by Tuttle and Tuttle affect
the timing for the introduction of orientation and mobility (O&M) instruction?

 What is the interactive effect of a person's level of self-esteem and his or her success in
orientation and mobility?

 What are the components that contribute to the development of self-efficacy?

 How does a person's lack of mobility or success in mobility impact the attitudes of the
person's family toward her?

 Does the ability of a person with low vision to conceal his or her visual impairment from the
public contribute to the person's self-esteem, or does the use of a long cane help by
clarifying the person's true situation?

Orientation and mobility without vision or with severely limited vision involves the physical actions of
movement and the cognitive components of orientation. It also requires that a traveler who is blind
or visually impaired receive input from the remaining senses and understand how such perceptions
contribute both to safe movement and to orientation. This chapter, however, focuses on the impact
of the psychological and social experiences of a person who is blind or visually impaired and how
these experiences caninfluence and be influenced by the physical, cognitive, and sensory components
of orientation and mobility. Chapter 6 in Volume 2 focuses on methods that mobility specialists can
use to harness or circumvent these psychological and social factors in helping individual students
learn to be more effective and independent in moving through the environment.

THE INFLUENCE OF PSYCHOLOGICAL AND SOCIAL FACTORS

Psychological and social factors frequently interact and affect one another. As they interact, they are
referred to as psychosocial factors (in this chapter and elsewhere). The impact of psychological and
social variables on physical and cognitive behaviors is broadly accepted. Most people believe that a
fear of failure or a firm expectation of success can influence a student's answers on an examination
(Elliot, 1999; Murray, 1938). People typically agree that extreme anxiety or a strong desire to win
may affect an athlete's performance (Martens, Vealey, & Burton, 1990). Similarly, while parents
travel to their children's sporting events to encourage their success, the hostile crowd at the
opponent's venue can negatively impact an athlete's performance (Hackfort & Spielberger, 1989).

The research of a number of disciplines has demonstrated the interactions between emotions and
the mind and body. Medical research has established the reality of psychosomatic illnesses (Shorter,
1993). Studies of perception have shown how the decisions of others can influence the perceptual
judgments of subjects (Conway, 2004; Fiske & Taylor, 1991). Experimentally induced fear has
demonstrated the impact of that variable on a wide range of physical and cognitive behaviors
(LeDoux, 1996).

The performance of any physical, cognitive, or perceptual skill can be influenced positively or
negatively by psychological and social factors. While this is true as a general statement, it is especially
true of practical life skills that are carried out in real-world circumstances, as happens in orientation
and mobility for people with vision loss. An adult's experience of a disability usually has a significant
impact on his or her feelings and personal attitudes. A partial or complete loss of vision can interfere
with basic life functions, and these disruptions can have a negative impact on a person's self-concept
and self-esteem. Therefore, any effort to overcome these losses and restore some of the diminished
self-esteem can contain emotional challenges beyond those that accompany any new learning by an
adult.

Similarly, the presence of other people and their attitudes can have an impact on a person with a
disability who is trying to learn new skills. The parents of a child with a visual impairment may not
feel comfortable with their child's learning to become more independent. The development of this
skill may activate new fears and worries in the parents or may threaten their roles in the child's life.
These feelings can be conveyed to the child in direct or subtle ways that complicate the child's
motivation for learning these skills. Similarly, patronizing or uninformed attitudes of people on the
street can influence feelings of confidence during the learning process or afterward.

The process of traveling independently with reduced vision or with total loss of vision must include
the mastery of the psychological and social aspects of this skill in addition to the motor, perceptual,
and cognitive elements. Traveling without vision includes more than cane skills and hearing skills. It
requires more than the use of environmental concepts and cognitive maps. It depends on confidence
and courage. It requires that people believe in their ability to solve problems that arise. It calls for
being comfortable with the use of help from other people when necessary. It requires the ability to
interact effectively with other pedestrians, some of whom may be appropriately helpful while others
may be extremely insensitive. It is influenced by the understanding and the support of family
members and friends and by the lack of such support.

UNDERSTANDING PSYCHOSOCIAL FACTORS AND ORIENTATION AND MOBILITY

In spite of the important role played by psychosocial factors in orientation and mobility, there is
comparatively little information in the literature on these factors. There is even less research and
substantiated data directly related to this topic. While the information produced by the various
subdisciplines of psychology and sociology is vast and expanding dramatically, anyone who wishes to
understand the interaction of psychosocial factors with orientation and mobility typically has to
extrapolate information from more general theories and research and apply it to orientation and
mobility. The applied disciplines directly involved with blindness and visual impairment are based
primarily in education and counseling. Within these disciplines there is, generally, a lack of expertise
for relating the impact of emerging knowledge from the fields of psychology and sociology to the
issues and challenges of learning to function without vision or with impaired vision.

Theories of Psychosocial Functioning

In the literature of personality psychology, most theories and studies reflect specific perspectives and
touch on only one factor in a broad array of possible factors that may be involved in O&M behaviors.
When these limited viewpoints are considered along with the difficulty for researchers to identify
representative populations of people who are blind or visually impaired, the likelihood is quite small
that personality psychology will contribute specific information that will directly help O&M specialists
understand how individuals who are visually impaired cope with the psychosocial factors that impact
on orientation and mobility. However, each of the primary theoretical approaches seems to offer
some concepts that can be useful.

While this chapter does not review the primary theories of personality psychology in detail, a brief
summary of each is helpful in setting the stage for the discussion to follow. Sidebar 6.1 reviews each
of the four major theories of personality.

Eclectic Use of Theories

For these reasons, people who are visually impaired and O&M practitioners end up as eclectics in
regard to theories and research to help them understand the interaction of psychosocial factors and
orientation and mobility. Because there are no specific theories related to these matters and very
little in the way of substantiated data, relevant information about this topic is drawn from many
different sources that relate more or less directly to this topic. Many of the theories and findings
discussed in this chapter reflect this author's belief that they are useful in understanding the
interaction of psychosocial factors and orientation and mobility, even though they do not, in
themselves, represent a unified theory about this topic. It is the author's hope, however, that this
discussion of related theories may help to spur more focused and productive research and specific
theory building in the future.

Great Promise in Interactionism

One of the important trends in the field of personality psychology offers great promise when it
comes to understanding how psychosocial factors impact O&M behavior. Beginning with the theories
of Rotter (1954, 1972), an awareness emerged that it was not only the reinforcement value of certain
outcomes that influenced behavior, but also the person's expectancy that such outcomes could be
achieved by the behavior. His theory came to be centered around the concept of locus of control.
This understanding was later advanced by Mischel (1979), who theorized that behavior could be
understood through a combination of cognitive schemas that the person possessed, the impact of
past social-learning environments, and other personal variables. The latter included the person's
competencies, the person's interpretation of the situations and rewards being faced, and certain self-
imposed goals and standards that the person brought to the situation. Probably the most prolific
advocate for this approach to understanding how a number of factors come together to help explain
behavior was Bandura (1977, 1997). Bandura's social-learning theory emphasizes and attempts to
explain how the reciprocal interaction of personal variables, environmental variables, and the
person's behavior itself impacts behavior. This theory also suggests ways to study complex behavior
and change it.

Any effective study of the psychosocial factors of orientation and mobility will draw from the
interactionist perspective. "Interactionism" refers to a comprehensive framework for personality
research in which individual behavior is seen as resulting from the reciprocal interaction between
personal qualities and the features of the situation (Krahe, 1992). Research has to focus on the
interaction of personal traits and experiences and circumstances in order to understand a person's
psychological and social influences and how to harness them or change them. As Ekehammer (1975)
described it, neither the "psychic structures" of the person nor situational and environmental factors
can adequately explain behavior by themselves. The interaction of these factors is more likely to
explain individual behaviors.

The mobility specialist who tries to understand the psychosocial reactions of students to mobility
situations will not learn much from research that is tightly focused on a study of the frequency of
certain dispositions or traits in certain populations. Nor will she benefit from studies that exclusively
describe a range of situations that a person may have to face. Rather, the O&M specialist has to be
more concerned about the responses of an actual student who possesses certain traits in specific
situations. To this extent, the interaction of these matters is of much more practical value in
orientation and mobility.

Differences among People Who Are Blind or Visually Impaired

The second set of complications in studying and cataloguing the psychosocial factors that impact on
orientation and mobility is the great variety of people who experience blindness and visual
impairment. While individual differences are responsible for qualifying so much of what is known
about human functioning, especially in the psychosocial area, there is sometimes the expectation
that all people who are blind are alike. Before even considering the many differences in the ways that
people respond to emotional and social situations, there are differences in more elementary
characteristics that have an impact on psychosocial factors.
One of the most significant differences is the time when visual loss occurs. Some people are
congenitally blind. Their vision loss occurred at birth or prior to the time when they would have had
useful visual memories. The psychosocial factors that impact this subpopulation of people with visual
impairment are very different from those that affect people who had useful vision and lost it (Tuttle
& Tuttle, 2004; Welsh & Tuttle, 1997). Persons who are congenitally blind do not have to get used to
a new set of circumstances. They grew up depending on their other senses. While they will have
other psychosocial challenges similar to those of other children and young adults, learning to adjust
to a loss of vision is not one of them. Some people with congenital impairments have particular
adjustment challenges associated with the sense that they have always felt different from most of
their peers because they cannot see and most of their peers can.

In contrast, the trauma associated with losing vision can play a significant role in a person's
adjustment to blindness. In some of these situations, especially when vision loss is sudden and total,
the emotional impact of this new reality can greatly affect a person's ability to cope. When a person
has seen, has visual memories, and has had successful life experiences, the person has assets on
which to build during the adjustment, but getting started and developing the motivation to do so can
be a challenge.

Among those who had vision and lost it— a group that is frequently referred to as the
"adventitiously blind"—there are other timing issues. A young adult who loses vision while coping
with the many other challenges of establishing an adult identity faces psychosocial issues that are
different from those faced by an adult who already has a family, a career, and responsibilities to
other people. These issues are also different from those faced by the largest group of adventitiously
impaired people, those who lose vision in their senior years. For this latter group, the psychosocial
factors of vision loss dovetail with other social and emotional issues related to retirement, serious
health impairments, and end-of-life issues.

Another set of psychosocial factors relates to the onset of vision loss. In some cases, vision loss is
quick and unexpected. This may happen when vision is lost as a result of an accident or a wartime
injury. From a psychological point of view, this loss is very different from the more common
experience of gradual loss over a period of time. While the latter experience can be very difficult, it is
usually preceded by an opportunity to learn to function with less and less vision and to alter one's
identity slowly.

Another significant difference that affects the psychosocial experiences of certain individuals is the
degree of loss. For some people—approximately 10 to 20 percent of the total population of people
with severe visual impairment—the loss of vision is total. This results in obviously significant
challenges to adjustment. In contrast, people who experience partial loss of vision may appear to
have a less significant challenge in that they still have some remaining useful vision. The reality is,
however, that people with low vision frequently face more serious psychosocial challenges than do
people who are totally blind. When a person functions with vision in some situations but is not able
to use vision in others, it presents a confusing stimulus to those with whom she interacts. This may
result in significantly greater psychosocial stress for the person with low vision. In addition, an
individual's perception of the seriousness of the loss does not always correspond to an objective
measurement of the loss itself. A somewhat lesser loss in acuity or field can have a more traumatic
impact on one individual than can a more serious loss on another.
Still other psychosocial differences result from the cause of vision loss and whether or not there are
other impairments related to the loss. A person who loses both vision and hearing faces extremely
difficult psychosocial issues. A person whose vision loss is accompanied by neuromuscular
impairments, as in some forms of multiple sclerosis, faces a different set of psychosocial variables.
These factors are also different for people with visual impairments who have cognitive deficits
caused by developmental disabilities or age-related dementia.

Psychosocial factors that have an impact on orientation and mobility might be related to the life
experiences and cultural influences that each person brings to his or her encounter with vision loss. A
person raised in a supportive family where members readily help one another will face different
psychosocial challenges than a person who has grown up in a family where all are expected to pull
their own weight and be independent. A person who grows up in a culture that easily looks to public
or private agencies and programs for support will respond differently to the need for help when
compared to a person who comes from a culture that emphasizes caring for its own family members
who have special needs.

Common Factors versus Individual Differences

For all of the reasons discussed previously, there is no singular theory about vision loss and how
people respond to it. There is no unified "psychology of blindness" (Kirtley, 1975; Lowenfeld, 1981;
Schulz, 1980; Tuttle & Tuttle, 2004). There is very little in the research literature that can help the
O&M specialist understand and prepare in advance for the unique psychosocial needs and abilities of
the individuals who will require O&M instruction. There is no alternative to the need to assess each
person in relation to the psychosocial factors that may impact the ability to learn to be independent
in orientation and mobility. What is available in the theoretical and research literature about visual
impairment and orientation and mobility can be helpful in suggesting hypotheses about what a
person may be feeling or what may be causing the appearance of being unmotivated for O&M
training. The literature is useful in suggesting possible approaches to helping a person develop the
confidence to travel independently. In determining the psychosocial factors that may by blocking an
individual's progress in orientation and mobility or what strengths can be harnessed to facilitate
learning, there is no shortcut to directly assessing the needs, abilities, and experiences of each
student and taking those factors and their interaction into consideration in efforts to improve each
person's ability to travel independently.

The discussion that follows reviews theories and research that will help the O&M specialist in
assessing the range of psychosocial factors that may impact on O&M training for individual students
and in planning activities that will help the mobility specialist to assist students in coping with such
factors.

ADJUSTMENT AND VISION LOSS

Just as there is no psychology of blindness, there is a broad range of opinions about what constitutes
adjustment to vision loss. Once again, this reflects the great variety of people, life circumstances, and
visual characteristics among the population of people who are considered to be blind or visually
impaired. It also reflects, to some extent, the philosophy or orientation of those who have theorized
about this matter, researched it, or provided adjustment services to people who have lost their
vision.

As Kirtley (1975) described it,

On the one hand there are those who see blindness as a virtual disaster. This group stresses the
physical, psychological, and social limitations associated with blindness and considers it a tragic fate
that can never be substantially overcome without superior ability and/or unusually favorable
environmental circumstances. The blind person is seen as essentially different from the seeing
individual…. At the opposite pole, there are those who assess blindness as nothing more than a
physical nuisance or practical inconvenience. They contend that the problems traditionally linked to
blindness are almost totally the product of social prejudice and discrimination, that blindness, in
itself, is at most only a minor handicap. Indeed the proponents of this view resent the very use of
such words as handicap, disability, and impairment in connection with blindness…. The first view
tends to be pessimistic and defeatist, fostering in those blind who accept it an unproductive
orientation toward passivity, gloomy resignation, and childlike dependency on the seeing. On the
other hand, the second position involves an unrealistic degree of optimism, for certain obvious
handicapping effects of blindness are simply denied or ignored. (pp. 137–138)

Cutsforth (1950) and Scott (1969) attributed the first view to many of those who ran schools for the
blind and agencies for the blind before World War II. These two authors seemed to suggest that
schools and agencies held few if any expectations of independence for blind people and were
content to provide everything they needed. The second viewpoint seems to be similar to the
perspective often proposed by members of the National Federation of the Blind (Jernigan, 1965).
Even though this organization emphasizes the use of specialized tools such as the long cane and
braille as being necessary to help blind people succeed, they attribute most problems that blind
people experience to the misunderstandings and misconceptions of sighted people resulting in
discrimination against people who are blind. It is easy to understand how the proponents of either of
these extreme viewpoints would define adjustment to blindness quite differently.

Delafield (1976) summarized the different approaches cited above in this way:

Does adjustment to blindness mean coming to terms with being blind in a sighted world and acting in
a way expected of the stereotyped blind, or does it mean trying as far as possible to act as a normal
sighted person does? Also, will either of these definitions be adequate for all blind people? There is
no assurance that those behavior patterns which are construed as being "adjusted" by one blind
person will be considered so by others…. Any comprehensive assessment of adjustment must not
be misled into pursuing the notion that it is a single generalizable trait. A definition of adjustment
must incorporate the views of the individual (p. 65).

Tuttle and Tuttle (2004) represent the reasonable conclusions reached by many authors over the
years who have emphasized that vision loss is similar to many other traumas or losses that people
experience in the course of their lifetimes. As is true in relation to these other losses, each person
brings to the process of adjusting to vision loss his own personal characteristics, life experiences,
family supports, interpersonal skills, feelings about himself, and plans for the future. Regardless of
the organizational philosophies of service organizations or consumer organizations, each person's
adjustment to vision loss will reflect primarily who that person is and how he responds to adversity
and challenge. Tuttle and Tuttle also added the helpful perspective that this adjustment is not a
static, one-time accomplishment. Rather it is an ongoing process. For this reason, they titled their
book Self-Esteem and Adjusting with Blindness (emphasis added).

The Tuttles' viewpoint blends well with the perspective of interactionism in the study of personality.
Loss of vision, either total or partial, happens to many different individuals. Each person responds in
a way that reflects his own personality, skills, goals, personal supports, and life situation. If the
response proves to be helpful to the person in coping with the impact of vision loss in his life, the
value of the response is reinforced and the person most likely experiences an improvement in
feelings about himself. This may contribute to improved self-confidence and to a willingness to try
similar responses or to take additional risks. If, however, the first responses are not successful, this
may result in the person redefining his sense of self or feelings about his visual impairment. A
constant process of adjustment takes place as a person copes with vision loss in his life.

Orientation and Mobility and Adjustment

Does a person have to adjust to vision loss before she is able to learn to travel independently? Or
does success in learning to travel result in adjustment to vision loss? Or does the process of learning
to travel successfully contribute to the ongoing process of adjusting with vision loss?

Cutsforth (1950) believed that helping the individual adjust to the environment required that service
providers revise their concept of the disability involved in blindness. While he felt that the schools
and agencies did a good job in teaching skills and in providing socialization opportunities, there was a
more important psychosocial issue to address: "As early as possible when such a condition is
encountered in an individual, young or old, he should be acquainted with the true nature of his
disability; namely that his self-regarding attitudes are a greater incapacitation to him than the
physical restrictions imposed by blindness. He should be taught that his major task is not that of
conquering the world, but that it is one perhaps equally as great. It is the task of perceiving and
refusing to employ as tools his feelings of inadequacy, insecurity, and lack of self-assurance" (p. 187).

Lowenfeld (1947) presented a very articulate view about the most significant problems caused by
blindness. He listed three such problems: (1) restriction in the range and variety of concepts about
the world; (2) restriction in the ability to get about; and (3) restriction in the control of the
environment. He felt that adjustment and rehabilitation activities needed to focus on these three
restrictions and on helping people with vision loss cope with these restrictions. According to
Lowenfeld, "As in all extreme experiences, 'personality' determines the way in which the individual
reacts to the onset of blindness. By personality, we understand the psycho-physical organization of
the individual as modified by his life experiences. In spite of the gravity of the reaction to the onset of
blindness, human nature is, in most cases, strong enough to recuperate and begin adjustment" (p.
42).

As Lowenfeld saw it, the personal and environmental restrictions and attitudes could be overcome by
the person's achieving insight into his own resources and being willing to use them. This adjustment
could be supported by the relearning of skills in special rehabilitation centers or from trained
rehabilitation personnel. This training would have to be combined with general psychotherapeutic
principles and specialized knowledge in the training of certain skills such as getting around, doing
personal and household tasks, and reading and writing.

Even though Lowenfeld had described a practical and functional approach to coping with vision loss,
there were still writers and theorists who emphasized the overwhelming psychological implications
of blindness. Carroll (1961) characterized adjustment to blindness in extreme terms when he
described loss of sight as dying and adjustment as being reborn as a blind person. He analyzed the
many losses that a person experiences subsequent to loss of vision, and he advocated for
comprehensive rehabilitation programs that addressed all areas of a person's life where such losses
occurred. According to Carroll, "The restoration of total personality organization is, in a sense, the
whole goal of rehabilitation, and how to bring it about is the whole problem. Personality loss is the
effect of all the other losses, but restoration does not come about simply as the effect of
rehabilitation in other areas. By the regaining of abilities and skills, much of the strain on the
personality is removed, but help is also needed to repair the damage done to the emotional structure
itself" (p. 231).

Carroll, however, did not believe that this restructuring of personality had to take place before
rehabilitation could begin. He believed that the rehabilitation process should begin at the hospital
bedside during the first period of shock resulting from the realization of blindness. The
comprehensive rehabilitation center program that Carroll structured called for the teaching of
mobility skills as an integral part of the process even as the client worked on the required restoration
of the other losses as a part of the total rehabilitation process.

Carroll was writing in an era when a psychoanalytic approach to blindness and many other problems
dominated. Psychoanalytically oriented psychiatrists introduced the concept of a staged adjustment
to the onset of blindness, which would have implications for the timing with which training in specific
skills, such as orientation and mobility, should be introduced. Cholden (1958) contended that "[t]he
adult who loses his sight faces a task that can be succinctly stated as one of internal reorganization to
the fact that he is now a different person. His capacities, his interests, his social position, his body
image, his aspirations are all affected if not completely changed. And it is important to know that
until he accepts the fact that he is this different person—a blind person—rehabilitation, or the
relearning necessary for adjustment to blindness, cannot proceed" (p. 73).

Based on his experience with many patients who were blind, Cholden observed, "If an adult suffers
the loss of sight with any degree of suddenness, he will usually react with a state of psychological
immobility that can best be described as a state of shock…. We can think of this shock stage as a
period of protective emotional anesthesia which is available to the human organism under such
stress." Cholden further believed that a person's ability to cope with this initial shock depends on his
or her ego strength and maturity: "The way an individual has learned to cope with his major life
problems and emergencies antedating his blindness will largely determine his ego-recovery capacity
as far as blindness is concerned" (p. 74).

Cholden also felt that no readjustment effort would be effective during this withdrawn state and that
the shock state can be reintroduced by raising and then dashing hopes for the return of vision. This
shock stage then leads to a state of "reactive depression," which is characterized by "feelings of self-
recrimination, feelings of hopelessness, self-pity, lack of confidence in meeting problems, suicidal
thoughts and psychomotor retardation" (p. 75). At this point, the blind person recognizes the loss of
his vision and begins a period of mourning. Even Cholden, who makes a strong case for a person
necessarily passing through the stages of shock, depression, and dependence, recognizes the value of
the client beginning to work with teachers who can begin to introduce success experiences in
developing the skills of coping with the loss.

As true eclectics, Tuttle and Tuttle (2004) have drawn on these basic psychoanalytic concepts
proposed by Cholden, Carroll, and others, and joined them to other concepts advanced by cognitive
theorists, especially the concepts of self-acceptance and self-esteem. They have proposed a
comprehensive model of the stages a person is likely to experience in the process of adjusting to life
with blindness.

Phases of Adjustment

The personal adjustment model proposed by Tuttle and Tuttle (2004) views adjusting with blindness
as a normal process similar to the process of accommodating life's many traumas and crises. The
phases they have described are "sequential, not hierarchical; they are overlapping, not distinct."
While most people who experience a severe trauma will experience some if not all of the phases
described, individuals who are visually impaired may find that they are unable or unwilling to
continue further and may remain in a particular phase indefinitely. "Every time individuals confront
another trauma (an unresolved discrepancy or an unfamiliar situation), they may recycle through
some or all of the adjusting phases before regaining some measure of self-acceptance and self-
esteem."

 Phase One: Trauma, Physical or Social. Trauma is a crisis precipitated by the consciousness of
a significant change or irreconcilable discrepancy which introduces an overwhelming threat
to the self or the self-concept, upsetting a person's equilibrium and endangering a sense of
adequacy. The sudden and unexpected onset of blindness can be very traumatic, especially if
a person's occupation or avocation depends on vision or if his preblindness attitudes toward
vision loss were particularly negative. It may also be very negative for family and friends or
close associates. For many congenitally blind people, the realization that others can see and
they cannot comes more gradually, like a puzzle that is solved over time. For some it may be
traumatic and emotional when a skill cannot be obtained or when a social stigma is first
realized.

 Phase Two: Shock and Denial. Shock, denial, and disbelief are usually the first reactions to a
major trauma or crisis. Shock can be understood as a breakdown in congruence among
 feelings, thoughts, actions, and beliefs. During shock, which can last anywhere from a few
hours to several weeks, a person is unable to think or feel, almost frozen in suspended time.
According to Wright and Wright (1993), "Shock gives us time to withdraw from the sharpness
of the pain. Our shock turns into emotional anesthesia that helps us develop coping
mechanisms we need to handle the news and survive the assault. This is healthy: it's actually
the first stage in the healing process" (p. 55).
Denial is one of the most common psychic defenses employed during the shock phase. Denial
can be manifested as either a disbelief or a failure to admit that a trauma has occurred, or it
can be an unrealistic expectation that a miracle from God, a medical procedure, or a new
scientific discovery will restore vision. When this persists, the hope for recovery is a major
deterrent to adjustment to blindness (VanderKolk, 1981). Schulz (1980) discussed two
consequences of using denial as a form of adjustment: The first is that the individual refuses
services and aids that could be of benefit. The second is the temptation to engage in foolish
or dangerous activities that require more vision than the person has. Schulz identified three
factors that tend to influence the severity and intensity of the shock (1) the significance of
the loss to the individual; (2) the suddenness or unexpectedness of the event; and (3) the
degree of visual loss.
According to Cholden (1958) the longer the shock state, the more difficult the rehabilitation
will be. It may be counterproductive to try to hasten the person through this stage, and the
professional's role is to simply be available and to provide comfort, support, and
understanding. Shock defenses prevent assimilation of more implications about blindness or
new information regarding rehabilitation. Time is probably more helpful than any direct
intervention by a professional.

 Phase Three: Mourning and Withdrawal. When the effects of shock begin to dissipate, people
begin to mourn their loss. Mourning takes the form of self-pity. It can be described as
feelings of sadness or sorrow for perceived losses of adequacy, self-esteem, equality, or
belongingness in a vague or global sense. As the psychic anesthesia wears off, the individual
may begin to experience apathy, bitterness, fear, boredom, helplessness, despair, and
frustration. Many of these emotions underlie a person's predispositions, which have been
exacerbated by blindness. People may become very egocentric and focus on their own
problems with their loss of sight to the exclusion of everything else. As shock wears off, some
people may withdraw from contact with their physical or social environment. While
temporary withdrawal is a natural consequence, prolonged withdrawal can result in feelings
of isolation and loneliness. Expressions of hostility and anger are also common during the
mourning phase. According to Schulz (1980), if a person never resolves the feelings stemming
from the loss of vision, the hostility may become an integral part of the person's personality.
During the mourning and withdrawal phase, significant others should be good listeners,
acknowledge grief, and allow it to surface. Grieving is essential because it enables people to
separate from their shattered, unrealized dreams so they can establish new dreams. To be
effective, grieving a loss must be shared with others, especially those close to the individual.
During this period, the blind person frequently feels incompetent and inadequate. The
service provider can begin to offer training in some of the simpler and practical skills of
managing the visual loss. This is not yet the time for a complete rehabilitation program, but
companionship, gentle encouragement, support, and advice from another blind person can
 be helpful. The mourning for the global loss often gives way to an increasing awareness of
the many complications resulting from the trauma.

 Phase Four: Succumbing and Depression. Mourning for the global loss is followed by a
gradual process of becoming more and more aware of the specific implications of the loss.
The person itemizes the perceived repercussions of the loss, whether realistic or not. He may
also manifest the "spread effect" by seeing even more losses than are realistic (Wright,
1983). This phase is characterized by the "I can't" reaction. All valued goals seem to be
blocked. The intensification of these feelings of inadequacy and incompetence reinforces low
self-esteem.
Depression, which has been described as despair, despondency, discouragement, disinterest,
and disenchantment with circumstances as they are, is regarded as a natural and normal
response to severe trauma. According to Cholden (1958), the emotions experienced during
the depressive stage are self-recriminations, feelings of hopelessness, self-pity, lack of
confidence when solving problems, and suicidal thoughts. Temporary depression for most
people is a normal therapeutic phase of the adjusting process. According to Blank (1957), the
inner work of mourning must be accomplished before addressing the problems of the
external world. Recent research studies have examined more closely the role played by
depression and the expression of depressive symptoms among older adults with age-related
macular degeneration (Casten & Rovner, 2008). This research points out that while many
persons experience depressive symptoms as a normal and temporary reaction to vision loss,
others may meet the criteria for a major depressive disorder that requires medical or
psychological intervention.

The first four phases outlined represent the student's physical and social reaction to the loss of
vision. This begins the adjustment process. Giving up driving because of a visual impairment is one of
the hardest realities that older adults have to face, and many who do so go through a grieving
process, feeling shock or denial, anger at living longer than they expected, vulnerability, despair and
hopelessness, social isolation as a result of psychological withdrawal, and fear (Orr, 1998).

According to Tuttle and Tuttle (2004), students during these first phases are in no position to "receive
or respond to aggressive and comprehensive intervention by the professional" (p. 178). Therefore,
the role of professionals, family, and friends during these phases is to be passively supportive.

As the person becomes ready to rebuild and to regain feelings of self-esteem, he is likely to
experience the following three phases, described by the Tuttles.

 Phase Five: Reassessment and Reaffirmation. The discouragement, anger, and self-pity of the
mourning phase begin to diminish, and the student begins a period of reevaluation. This
starts the rebuilding process. Individuals reexamine and reconsider the meaning of life: their
basic assumptions, values, beliefs, priorities, and habitual patterns of behavior. They
scrutinize their self-concept and decide that the majority of their personal attributes remain
untouched by the trauma of blindness. This leads to a reaffirmation of life and of self. They
choose to learn to live full and satisfying lives as people who happen to be blind. This
provides a firm foundation for the renewal process. However, this does not happen for
everyone, and some continue to avoid the problem by not resolving the questions they
continue to ask.
 The acceptance of the fact of blindness as one of the many personal attributes in one's self-
concept must occur before any possibility of further adequate adjusting can take place. If the
elements of the former identity return, the former sense of self returns. To the extent that
blindness remains the primary focal point of attention, the individual will continue to feel
different.
The reassessment involves identifying one's assets and limitations, including (1) perceived
limitations that are unrealistic as a result of the spread effect, (2) the temporary limitations
that can be circumvented by learning the proper use of adaptive aids and techniques, and (3)
the more permanent limitations that must be accepted as unalterable.
Reassessment also requires the reconsideration of goals and values. Some goals are blocked,
but others can be substituted. Some can be reached directly, but others need to be reached
through circumventing the barriers that blindness raises. Newly reconstructed goals and
values can be put to the test of everyday living. One can use one's assets to achieve realistic
and attainable goals. This can have a positive impact on one's self-esteem, self-confidence,
and general outlook for the future. Realistic hope can motivate a person to work toward
bettering a situation if one really believes that things can improve (Schulz, 1980).

 Phase Six: Coping and Mobilization. In coping, the emphasis is on what a person can do,
areas of life where she can participate. The person is seen as playing an active role in molding
her life constructively. Negative aspects of life are seen as manageable. Coping requires
making an assessment of residual capacities and the goals and values of the person and
bringing these two sets of factors into a satisfactory relationship with one another. The
student learns to perform lost functions using new tools or techniques and restoring a sense
of competence. Increased proficiency in these coping skills tends to foster a sense of
accomplishment and pride and to enhance the person's self-esteem.
The mobilization aspect of this phase involves the acknowledgment of the need for, the
search for, the recognition of, and the effective utilization of personal, interpersonal, and
institutional resources. Programs that foster maximum adaptive coping behaviors must be
comprehensive and thoroughly planned. To be effective, they must address the three areas
of physical, cognitive, and affective adjustment.

 Phase Seven: Self-Acceptance and Self-Esteem. Successfully meeting the demands of life does
not necessarily result in self-acceptance or self-esteem. The acceptance of one's blindness is
a necessary prerequisite. Schulz (1980) believed that students are affected by what they feel
about themselves and their condition. They may make gains through their training in
adaptive skills, but if they have not resolved their feelings about what has happened, it is
quite possible that they will not use what they have learned. However, if they are given only
psychological support without training to develop appropriate coping skills to restore their
independence and self-confidence, they can never feel that they are adequate individuals.
Self-acceptance does not necessarily mean that a person likes or appreciates all of her
attributes. A blind person does not necessarily need to like the blindness but does need to
internalize blindness as one of many personal characteristics. A person's self-esteem flows
from self-acceptance and represents how she feels about herself. Individuals with high self-
esteem tend to exhibit confidence in their own judgments, expectations of being successful,
an openness to new experiences and change, a sensitivity to the needs of others, less
susceptibility to others' influences and judgments, and relationships characterized by mutual
 feelings of respect, dignity, value and worth. Wylie (1961) observed that studies on self-
esteem of persons who are blind reported a positive correlation between self-regard and
personal adjustment.

Tuttle and Tuttle (2004) concluded that the process of 'adjusting to life's demands with blindness is
the same process as adjusting to any severe trauma. They contended that "there is no fixed state of
'adjustment to blindness' but rather a continuous process of adjusting to daily demands of life with
the added attribute of blindness. The adjusting process involves three components that must be
carefully balanced and orchestrated: the knowledge of the facts involved—cognitive; the behaviors
involved—action; and the feelings involved—affective" (p. 212).

The Timing of O&M Training

The model of adjustment proposed by Tuttle and Tuttle (2004) reflects the psychoanalytic concept of
a person's need to come to grips with the subconscious forces of grief and loss, which can bring on
states of shock and mourning and which may prevent a person from taking positive and logical steps
toward rehabilitation. This model suggests that until the person's ego is able to accept these feelings
and the impact of blindness on his identity, any conscious efforts to encourage the person to learn
rehabilitation skills may be futile. While Tuttle and Tuttle eventually integrated these concepts with
the cognitive-based self theory, their approach has practical implications for the timing of formal
mobility training in the adjustment process.

The experiences of the U.S. Army rehabilitation program during World War II and the Veterans
Administration program since that time represent alternatives to that approach. Bledsoe (1980; see
also Chapter 14) and Williams (Welsh, 2005a) described how wounded military personnel found
themselves in skill-oriented rehabilitation programs within weeks of having lost their vision on the
battlefield. There was neither time nor resources for counseling that focused on grief and loss. As
soon as possible, military personnel who had lost their vision were transported to rehabilitation
hospitals, where training in the techniques of functioning without vision, including orientation and
mobility, were offered as soon as practicable.

Dodds (1989) picked up on this same concept when he suggested that the loss model with its
requirement for grief counseling has had a dominant influence on the thinking of people who deliver
rehabilitation services for people with vision loss. In studying the concepts of perceived self-efficacy
(to be discussed under "Self-Efficacy and O&M Instruction") and internal self-worth, Dodds et al.
(1994) found that acceptance of vision loss was strongly related to the factor "self as agent" but only
weakly to "internal self worth." From this, they concluded that counseling may not directly lead to
measurable improvements in self-worth, but it may lead to improved motivation for the student to
act in ways that will bring about successful outcomes. It is the experience of successful outcomes
that leads to a sense of improved self-worth. As a result, Dodds et al. concluded that "clients who are
obviously severely distressed require additional emotional support, whereas those who appear to be
well motivated and 'together enough' to go straight into skill training should not have to undergo a
'cure' for a condition from which they do not suffer" (p. 494).
COGNITIVE THEORY AND THE SELF-CONCEPT

The model of adjustment to blindness developed by Tuttle and Tuttle (2004) integrates concepts
from psychoanalytic theory with those from cognitive theories. In the latter half of the 20th century,
cognitive theories became more prevalent in attempts to understand why people behave the way
they do. Tolman (1932) is credited with launching the cognitive approach by his observation that
"behavior reeks of purpose," that it appears to be goal directed and based on conscious cognition
and knowledge. Lewin (1936) extended this concept by noting that a person's behavior was not
influenced exclusively by a past history of reinforcement or by subconscious forces, but was also
affected by current judgments of the ability of environmental objects to satisfy present needs. He
viewed the person as an independent actor who could make new decisions that would lead to the
satisfaction of needs in new ways.

Central to most cognitive theories is the construct of the self-concept. The self-concept is defined as
a collection of thoughts and feelings one has about oneself (Ross, 1992). The affective dimension of
the self-concept is referred to as self-esteem (Tuttle, 1984). People acquire a concept of themselves
through their interactions with their physical and social environments. One's self-concept influences
how one acts, and how one acts influences how one perceives oneself. Knowing something about a
person's self-concept is helpful in understanding that person's behavior. The self is a cognitive
structure that reflects a present state of being but is capable of imagining possible future states. In
this regard, a discrepancy between a "present self" and an ideal "possible self" can lead to behavior
designed to reduce the discrepancy between the present self and the ideal possible self (Markus &
Nurius, 1986).

Does the loss of vision change a person's self-concept? Can it have a negative impact on a person's
self-esteem? What impact does lack of vision have on the self-esteem of a person growing up
without vision or with low vision? How can a person's self-concept or self-esteem influence mobility
training? Can the accomplishment of greater independence in travel have a positive impact in a
person's self-esteem? Does the interaction with the general public while traveling have a positive or
negative impact on self-esteem?

According to Tuttle and Tuttle (2004), persons who are visually impaired formulate opinions and
judgments about their personal attributes primarily through interaction with their social
environment. Their personal attributes are the qualities and characteristics they believe to be true
about themselves. They include physical, mental, and emotional traits and abilities, characteristics of
family and peer relations, values and attitudes, hopes and fears. The sum of one's personal attributes
constitutes a person's self-perception or self-concept. The personal attributes may be realistic or
unrealistic; they may be firmly bonded or vague, distorted, and fragmented (p. 80).

The Self-Concept and Blindness

Efforts to establish empirical evidence of a consistent impact of blindness on the self-concept of
people who lose their vision or who grow up without vision when compared with sighted controls
has produced contradictory results (Beaty, 1992; Cowen, Underberg, Verillo, & Benham, 1961;
Francis, 1996; Jervis, 1959; Lifshitz, Hen, & Weisse, 2007; Lopez-Justicia, Pichardo, Amezcua, &
Fernandez, 2001; Meighan, 1971). Such research inevitably encounters confounding variables related
to the measuring instruments, the length of time that the blind subjects have experienced vision loss,
the diverse coping mechanisms they have used, the ability of people to adjust their concepts of
themselves to the conditions in which they find themselves, and the fact that there is no consistent
psychology of blindness. Bandura (1997) contended that there are many dimensions to one's self-
concept and to one's self-esteem. They are not unitary concepts but are multidimensional.
Therefore, a person may have high self-regard as a social being who can get along with other people,
but may not think well of himself as a problem solver who can make decisions. Many of the
assessment instruments used to evaluate self-concept or self-esteem may primarily reflect one
dimension of the self and not others.

Tuttle (1987) summarized four problems facing the person who is blind that relate to the challenge of
developing self-esteem:

1. 1.  To feel competent, the blind person must develop good coping skills and adaptive
behaviors.

2. 2.  The blind person has to maintain a sense of high self-esteem in the face of
predominantly negative reflections from the general public.

3. 3.  The blind person is especially challenged to maintain control over situations, perceive
alternative courses of action, and make decisions or choices regarding events in his life.

4. 4.  The blind person must maintain positive self-esteem even while still having to depend
on others for the accomplishment of some daily tasks.

From this analysis, it is possible to conclude that discrepancies related to self-concept are highly
likely to occur in the lives of blind people, and that the blind person's efforts to resolve such
discrepancies are likely to have a major impact on adjustment and self-esteem.

Elliot and Kuyk (1994) demonstrated that individuals participating in a comprehensive personal
adjustment-to-blindness training program with an O&M component achieved measurable
improvement in their independent functioning, self-image, and self-esteem as a result of their
acquisition of skills and their subsequent application of these skills in their home environments.

Huebner and Wiener (2005) contended that orientation and mobility continues to go unrecognized
as a set of crucial skills that enable independence and self-esteem. The research is clear that
independent orientation and mobility are critical factors in the education and employability of
individuals who are blind, yet it is relegated to the status of a related service too often described by
administrators as an optional or "Cadillac" service (Crudden & McBroom, 1999; Crudden, McBroom,
Skinner, & Moore, 1998).
Self-Efficacy and O&M Instruction

While improved self-esteem is one of the outcomes of increased independence and adjustment to
blindness, as posited by Tuttle and Tuttle (2004), there are other dimensions of the self that play an
important role in the process of learning to travel more independently. One of these is a sense of
self-efficacy.

The concept of self-efficacy, introduced by Bandura (1977) as one particular type of self-referencing
activity, has generated a significant amount of empirical support for its effect on behavior and
motivation (Bandura, 1986, 1997). Efficacy in dealing with one's environment requires not only
knowledge of what to do and the skill to carry out the necessary deeds, but also a belief that one is
up to the task. Bandura (1977) has demonstrated that a person's perceived self-efficacy in relation to
the task at hand plays a major role in performance differences. Perceived self-efficacy is defined as
"people's judgments of their capabilities to organize and execute courses of action required to attain
designated types of performances" (Bandura, 1986, p. 391). In other words, perceived self-efficacy
can be described as a person's belief in what he can do and how strongly he believes it. A person's
beliefs in what he can do determine whether he will try to do it, how hard he will try, and how long
he will keep trying even though obstacles and unpleasant experiences are encountered.

This aspect of self-referencing behavior is relevant to O&M instruction. To be successful in

accomplishing the skills and behaviors required for orientation and mobility, a person with visual loss
would have to believe that he can do it and be willing to work long and hard at the learning task.
According to Bandura (1986, 1997), perceived self-efficacy develops from one or more of four
principal sources: (1) performance accomplishments, (2) vicarious experiences, (3) verbal persuasion,
and (4) monitoring of one's own physiological states.

Performance Accomplishments

The most significant of the four sources of self-efficacy is the direct personal experience of
successfully performing the task at hand. Nothing is more effective in convincing a person that she is
up to handling a challenge than past success at doing so, nor is there anything more motivating for
the future. Successes raise efficacy judgments, and repeated failures lower them, especially if the
failures occur early in the course of events and do not reflect lack of effort or adverse external
circumstances. The extent to which people change their perceived self-efficacy through performance
experiences will depend upon the difficulty of the task, the amount of effort they expend, the
amount of external aid they receive, the circumstances under which they perform, and the temporal
pattern of their successes and failures (Bandura, 1986).

As this relates to O&M instruction, it seems to support the importance placed by O&M specialists on
an appropriate sequence of lessons and challenges providing a pattern of success experiences. If the
task is too easy or too difficult, or if the student receives too much help or too little, success at
handling the task will not have the same effect on her perceived self-efficacy and therefore on her
motivation for going forward and self-confidence in doing so.

Vicarious Experience
The second most important source of perceived self-efficacy is the observation of others performing
the same behavior, what Bandura calls "vicarious experiences." Seeing other people adequately
perform a behavior encourages the observer to feel that he can, too. Vicarious experience also works
the other way: Seeing someone being unable to perform a task can decrease an observer's belief in
his own ability. Bandura's studies (1986) indicate that the impact of the vicarious experience is
stronger if the observer considers the actor to be similar to himself. Also, the less experienced the
observer is in relation to the task, the more powerful the impact of the vicarious experience will be.
In other words, vicarious experience can have a powerful impact on efficacy expectations for
inexperienced observers watching others whom they perceive to be similar to them. Vicarious
experience is less powerful for observers who are watching others dissimilar to themselves.

As they relate to O&M instruction, these findings confirm the value of having beginning mobility
students associate with other students who are also beginning or who are slightly ahead of them in
their training. Frequently, the small accomplishments of similar beginning students can have a more
motivating impact on other students than the smooth and easy skill of the experienced blind person,
who may appear dissimilar to the students.

Verbal Persuasion

A third source for increasing a person's perceived self-efficacy is verbal encouragement from others.
This is a widely used technique by coaches, teachers, parents, employers, and friends. By itself, or
when it is unrealistic, this approach is of limited value in producing lasting changes in a person's
perceived self-efficacy. When the encouragement is realistic, however, it can have the effect of
encouraging the person to mobilize greater sustained effort to succeed. However, the raising of
unrealistic beliefs of personal competence invites failure that will discredit the persuaders and
undermine the recipient's perceived self-efficacy.

In mobility training, the instructor frequently encourages the student and helps him gather the
courage to try his skill in new situations or with less supervision. The quality of the relationship
between the instructor and the student will have an impact on the instructor's effectiveness in
persuading the student to take the next steps. A relationship built on genuine caring and accurate,
concrete feedback is more likely to be effective in its impact.

Monitoring Physiological Feedback

Most people are aware of and influenced by their state of arousal as they approach new or
threatening tasks. They are sensitive to the arousal signals from their autonomic nervous system,
which may include a more rapid heart rate, changes in breathing, sweating, muscle tension, and any
number of idiosyncratic mannerisms. When a person approaches a task for which he does not have a
sense of efficacy, he is not surprised to experience many of these symptoms. An individual's
awareness of these symptoms while approaching a task may alert him to his lessened sense of
efficacy for that task. However, Bandura and Adams (1977) demonstrated that treatments that
eliminate emotional arousal in response to subjective threats can heighten a person's sense of self-
efficacy in approaching the threatening task and lead to corresponding improvement in performance.

The O&M specialist frequently uses this same insight by attending to behavioral manifestations of
nervousness or fear in students who are approaching a new or difficult part of the training. The signal
may be a slower walking pace, a tightened grip on the instructor's arm, a clenched fist, the
appearance of a rocking mannerism, or noticeable tremors. When these signals appear, the O&M
specialist may choose to restructure a lesson, alter the level of difficulty, or make some other
adjustment that keeps the level of challenge appropriate without overwhelming the individual.
According to Bandura's theory, the more these arousal symptoms are managed and kept in check,
the more likely it is that the student will perceive a sense of self-efficacy for the task at hand.

MOTIVATION

In the everyday language of O&M specialists, motivation is probably the psychosocial factor referred
to most frequently. When a student appears to be having difficulty beginning or progressing in
mobility training and there are no other obvious explanations for this difficulty, there is a tendency to
regard him as being not "motivated." Similarly, if a student is progressing very well, he is considered
to be highly motivated.

The tendency to understand a number of psychosocial factors as manifestations of motivation

mirrors an early stage in the understanding of human behavior. In the history of psychology, some of
the earliest theorists, such as William James, Sigmund Freud, and Clark Hull, focused their efforts on
discovering or articulating a grand theory of human behavior, and especially what "motivated"
behavior. These grand theories of motivation were eventually recognized as too simplistic (Reeve,
1992). One term,motivation, was inadequate to explain the complex and varied ways in which
behavior is energized, directed or limited.

What may appear to be a lack of motivation may be the inhibiting influence of fear or anxiety. A
person's lack of interest in O&M instruction may reflect social concerns and the role of dependence
in the dynamics of a particular family. A person's unwillingness to appear in public using a long cane
and making his blindness visible to others may have more to do with social stigma than with
motivation. While these various issues are addressed throughout the chapter, there are some
cognitive approaches to understanding motivation that are helpful.

According to Bandura (1997), most human motivation is cognitively generated. People motivate
themselves and guide their actions through the exercise of forethought: "They form beliefs about
what they can do, they anticipate likely positive and negative outcomes of different pursuits, and
they set goals for themselves and plan courses of action designed to realize valued futures and avoid
aversive ones. Efficacy plays a central role in the cognitive regulation of motivation" (p. 122). Four
theories that relate to cognitive motivators are attribution theory, expectancy-value theory, goal
theory, and learned helplessness.

Attribution Theory
According to Wiener (1985), retrospective judgments about the causes of one's performance have
motivational effect. People who credit their successes to personal capabilities and their failures to
insufficient effort will undertake difficult tasks and persist in the face of failure. In contrast, people
who ascribe their failures to deficiencies in ability and their successes to situational factors will
display low strivings and give up easily when they encounter difficulties. While reasons for past
actions cannot cause future actions, they can affect a person's beliefs about his personal capability,
and these beliefs can motivate future actions. Therefore, people who attribute past failures to not
working hard enough are likely to strive harder. In contrast, people who believe they failed in the
past because they lack the necessary ability are likely to decrease their efforts and become
discouraged.

As the prior discussion of self-efficacy theory indicates, people who attribute their success to their
own ability are likely to experience even greater beliefs about their own self-efficacy, which in turn
predicts improved performance. Efforts to change a person's attributional style have not been very
successful (Bandura, 1997): "If people believe that their difficulties stem from internal but
changeable factors, the net result may be self-blame rather than heightened motivation when the
personal impediments do not lend themselves readily to modification. Conversely, if difficulties are
attributed to external changeable factors, people have less incentive to build their competencies and
they fall back on situational excuses if their situations do not change for the better" (p. 125).
Changing causal attributes can temporarily raise motivations, but the improvement will not last for
long in the absence of true efficacy-enhancing accomplishments.

Outcome Expectancy Theory

While perceived personal efficacy as described by Bandura refers to a person's judgment of how well
she can perform a particular behavior, outcome expectations refer to the person's assessment of how
likely a particular behavior is to produce a particular outcome. Both elements are important to
understanding motivation. People are more likely to pursue goals that, in their view, they can
accomplish and, once accomplished, have a high probability of leading to a desired outcome. An
outcome is the consequence of a performance and not the measured performance itself.

According to Bandura (1986, 1997) outcome expectations take three major forms. Within each form,
the positive expectations serve as incentives and the negative ones as disincentives. One form of
outcomes is positive and negative physical effects that may accompany behavior. Positive effects
include pleasant sensory experiences or physical pleasures; negative effects include aversive sensory
experiences, pain, or physical discomfort. Another form of outcomes is social reactions to behaviors.
Positive social reactions include expressions of interest, approval, social recognition, monetary
compensation, and conferral of status and power. Negative social reactions include disinterest,
disapproval, social rejection, censure, deprivation of privileges, and imposed penalties. The third
form of outcomes is self-evaluation, a cognitive notion. Positive outcomes include self-satisfaction, a
sense of pride, and self-worth. Negative outcomes include self-dissatisfaction, self-devaluation, and
self-censure.
An efficacy expectation is a person's estimate of how likely it is that she can perform an act, whereas
an outcome expectation is a person's estimate of how likely certain physical, social, and self-
evaluative outcomes will occur once the behavior is accomplished. Both have to be considered. In an
O&M training situation, a person's expectancy that she will receive significant social praise if she can
travel downtown by herself is probably on target and is a great motivator. However, early in her
training, her efficacy expectation that she is not yet able to perform the act of independent travel
downtown may appropriately curtail her motivation to do so.

Reeve (1992) identified four determinants of the strength of outcome expectancies: (1) outcome
feedback, (2) task difficulty, (3) social comparison information, and (4) personality differences.

Outcome Feedback

Past experience of success or failure following the performance of a particular behavior has the most
direct impact on the acquisition or change of an outcome expectancy. Feather (1966) illustrated this
effect by having subjects work on a series of 15 anagrams. For one group, the first 5 were very
difficult, leading to initial failure, and for the other group they were easy, leading to initial success.
For the remainder of the study, all of the subjects worked on the same 10 puzzles, recording their
expectations of success or failure. Data demonstrated that the subjects' expectations were
significantly affected by the experience of initial success or failure. Those who were initially
successful expected to do well, and those who initially failed expected to do poorly even though their
objective performances on the remaining anagrams were about equal. This concept suggests that it is
important for mobility students to experience successful outcomes in their early learning and travel
opportunities, which sets a tone for subsequent activities.

Task Difficulty

Outcome expectations are also determined by perceptions of task difficulty. Each task has specific
salient characteristics that influence the judgment of difficulty. Difficult tasks give rise to low
expectancies of success, and easy tasks generate high expectancies of success. It helps to have
complex tasks understood in terms of manageable subcomponents that appear doable to the
student.

Social Comparison Information

Outcome expectancies are also affected by the observation of the outcomes others have attained on
the task under consideration. This can be a limiting factor for individuals considering mobility training
because of the likelihood that they have no comparison group from which to draw expectancies. In
this case, the opportunity to interact with others who have had successful experiences with
rehabilitation and specifically mobility training may be an essential part of developing appropriate
outcome expectancies.

Personality Differences

Certain personal traits or dispositions can have a significant influence on an individual's outcome
expectancies. Wiener (1974) has shown that persons high in need achievement tend to overestimate
their chances for success and make overly optimistic outcome expectancies. In contrast, persons low
in need achievement tend to be pessimistic in their outcome expectations. McFarlin and Blascovich
(1981) related outcome expectancies to level of self-esteem. Individuals with high self-esteem
overestimated their outcome expectations while those with low self-esteem underestimated their
outcome expectations.

Goal Theory

Another cognitive mechanism of motivation and self-directedness is the ability to challenge oneself
by setting a certain standard and evaluating one's own performance against that goal. Both factors
are necessary: a personal goal and knowledge of one's own performance level in relation to that
goal. The combined influence of goals with knowledge of performance heightens motivation
significantly (Bandura, 1997).

Goal Setting

Goal setting is a process of comparing a present state of affairs with an ideal state. Many studies have
demonstrated the motivational value of explicit goal setting (Weinberg, Bruya, Longino, & Jackson,
1988). To enhance performance, goals need to be specific, difficult, and challenging (Locke, Shaw,
Saari, & Latham, 1981). Goals that are vague and easy are not effective. Locke and Latham (1985)
identified four reasons why goal setting improves performance.

1. 1.  Goals direct a performer's attention to the task at hand.

2. 2.  Goals mobilize effort. The harder the goal, the greater the effort expended.

3. 3.  Goals increase persistence since the performer is less likely to give up until the goal is
reached.

4. 4.  Goals promote the development of new strategies for improving performance until the
goal is reached.

Goals also facilitate the helpful mechanism of feedback. Goal setting works only if there is timely
feedback documenting progress in relation to the goal (Locke et al., 1981).

Vallerand, Deci, and Ryan (1985) clarified the impact of short-term versus long-term goal setting on
the development of intrinsic motivation. They demonstrated that a performer's initial level of
motivation toward a task is the key variable. When performers begin an activity with a relatively low
intrinsic motivation, short-term goals enhance motivation by enhancing the performer's sense of
competence that results from achieving the short-term goals. However, when performers begin an
activity with relatively high intrinsic motivation for the task, short-term goals are considered
intrusive, apparently because feedback about competence is not as important. If the person is highly
motivated, long-term goals provide more of a challenge and are not regarded as controlling.

The O&M specialist should note the strong support for the impact of explicit goal setting on the
motivation of the student for the task at hand. This reinforces the value of having the student
involved in choosing the goals for his own mobility program and the need for individualizing the
development of each person's plan. The goals that people set for themselves at the beginning of an
endeavor are likely to change depending on how they evaluate the progress they are making. They
may maintain the original goal, lower their sights if they are not making headway, or adopt an even
more challenging goal. As people approach or surpass their standard or goal, they often set new
goals for themselves that serve as additional motivators. The higher the self-selected goals, the more
effort invested. People who are assured of their capabilities enlist new challenges as personal
motivators for further accomplishments (Bandura, 1997).

Properties of Goals

According to Bandura (1997), goals do not automatically activate the self-reactions that govern level
of motivation. Certain properties of goals determine how strongly the self-system will become
involved.

1. 1.  Goal specificity. Explicit goals and standards regulate performance by designating the
type and amount of effort needed to achieve them. They also generate self-satisfaction and
build personal efficacy by supplying unambiguous markers of personal accomplishments.

2. 2.  Goal challenge. Strong interest and involvement in activities are sparked by challenge.
When self-satisfaction is contingent on the attainment of challenging goals, more effort is
expended than if one adopts only easy goals.

3. 3.  Goal proximity. The effectiveness of goals in regulating motivation depends to a large
extent on how far into the future they extend. Proximal subgoals mobilize self-influences and
direct what one does in the here and now. The attainment of subgoals also figures
prominently in the development of self-efficacy.

Control Theory

In discussing self-efficacy and outcome expectations, Bandura (1997) added a third critical element,
which he calls control. If the person's self-efficacy leads directly to the desired outcomes, there is
maximum control. In these situations, the individual's perceived self-efficacy accounts for a large
portion of the variation in outcome expectancy. If, however, there is not a direct connection between
the individual's performance and the eventual outcome, perceived self-efficacy does not predict
outcome expectancy.

Locus of Control

Rotter (1966) was the first to identify the existence of reasonably stable characteristic ways in which
people view the source of the outcomes they experience. He called this characteristic the locus of
control and developed a method of measuring it. According to Rotter, a person with a
predominantly internal locus of control views reinforcements or punishments as resulting from her
own efforts. In contrast, a person with a predominantly external locus of control considers that her
reinforcements and punishments are due to outside forces such as luck, chance, or fate, over which
she has no control. Regardless of an objective analysis of the actual source of an outcome, a person's
subjective locus of control affects how she behaves.
People with an internal locus of control, when compared to those with an external locus of control,
tend to be higher in information seeking and achievement, are more cooperative, participate in more
health-promoting behaviors, and experience better psychological adjustment (Phares, 1976). In spite
of these advantages for individuals with an internal locus of control, there are some situations in
which an external orientation can be more adaptive. Felton and Kahana (1974) demonstrated that
among elderly persons in an institution, individuals characterized by an external locus of control
seemed to experience better adjustment and more feelings of satisfaction than did those who had an
internal locus of control. Wolk and Kurtz (1975) found that the reverse was true among a group of
noninstitutionalized elderly people. In that group, internal locus of control was more likely to be
associated with better adjustment and satisfaction.

Research into the effects of locus of control on the behavior of people entering rehabilitation settings
(MacDonald & Hall, 1971) suggested that an internally controlled person may be better motivated
through an appeal to his desire for competence, while an externally controlled person may be
motivated more by praise from people in authority or peer support. Hyman (1972) found that
attributing illness to supernatural causes was one of several factors that impaired the motivation of
persons entering a stroke rehabilitation program.

Learned Helplessness

Bandura (1997) demonstrated how an analysis of the interaction between a person's perceived self-
efficacy and her outcome expectancies could predict behavior and affective states. A high sense of
personal efficacy in a responsive environment rewards valued accomplishments and fosters
aspirations, productive engagement in activities, and a sense of fulfillment. In contrast, people with a
high degree of self-efficacy in an environment that is not responsive to individual accomplishments
can experience frustration. While such people may continue to strive to accomplish their goals, those
who have a low level of self-efficacy may quickly give up when their efforts fail to produce results.

When a person spends too much time in an environment that is not responsive to her efforts, she
can develop learned helplessness. This is a characteristic or attitude that Seligman (1975) described
as the belief that events in one's environment are uncontrollable. The effects of learned helplessness
were described by Alloy and Seligman (1979) as leading to three kinds of functional deficits:
motivational deficits resulting in the person showing an unwillingness to try new behaviors to solve
problems or achieve certain outcomes; cognitive deficits resulting in a person's having a difficult time
learning that a response can have an impact on outcomes in the future; and affective deficits leading
to depressive reactions when it becomes clear that there is nothing that the person can do to control
or predict her situation.

The person who is blind or visually impaired and immobile and who thinks of herself as necessarily
dependent on others may have to be helped to envision a possible self that is more independent.
Embracing the goal of a more independent self may be a risky option for the visually impaired
person, no matter how inconvenient her present dependency. If the person has no success
experience in being effectively responsible for her own performance, she may be very unlikely to
embrace outcome goals built around the value of increased independence. As Reeve (1992)
described it, "If we expect our coping efforts to be futile, we tend to give up and behave listlessly. If
we expect our coping efforts to provide us the means to control our environment, we tend to persist
in coping and actively work to adjust to our surroundings" (p. 205).
The focus of the O&M specialist's intervention is typically on helping the individual develop personal
skills. However, if this person is to be returning to or continuing to function in a nonresponsive
environment, the focus of the O&M specialist may have to expand. If O&M training is being provided
in a school setting where, for policy and liability reasons, the student is never allowed to travel
independently, the O&M specialist may have to pursue advocacy efforts to modify school policy so
that meaningful outcomes can be available to support the student's motivation. Similarly, an adult
who receives training in a rehabilitation center may be prevented by family members from using his
skills upon returning home. Once again, the O&M specialist may have to intervene to educate the
family to reinforce the person's sense of self-efficacy to obtain the expected outcome of independent
travel in the home environment.

FEAR, ANXIETY, AND OTHER TRAITS

A major research focus in personality psychology throughout most of its history has been on the
identification of personal factors that are relatively stable and can explain an individual's consistency
in actions and behavior (Allport, 1961; Cattell, 1965). These factors have been
called dispositions or traits. To the extent that some of the traits of an individual can be known, a
teacher working with that person can understand or predict subsequent behavior and know how
best to approach a learning task.

Trait Clusters

Throughout the history of dispositional research, there have been efforts to identify recurring
patterns or clusters of traits that can account for almost all of the adjectives used to described stable
personality factors. Using factor analysis, numerous research studies have consistently identified
similar clusters of traits. The consistency of these recurring factors has helped to focus dispositional
research and improve efforts to understand the existence and impact of different personality types.
McCrae and Costa (1990) have shown that five factors appear consistently in such research: (1)
neuroticism/stability, (2) extroversion/introversion, (3) openness, (4) agreeableness/antagonism, and
(5) conscientiousness/undirectedness.

Individuals might be assessed for where they fall along theoretical continua relating to each of these
factors. The total distribution of all people on each factor may reflect a bell curve, with most people
falling in a midrange and smaller percentages of people at the extremes of these continua. Sidebar
6.2 shows the ranges of traits that McCrae and Costa found to cluster in their statistical analyses
under each factor they identified.

As methods of assessing these factors continue to progress, research relating them to other personal
and environmental factors and behavior will be better understood. An example of this approach is
contained in the work of Rovener and Casten (2001), who studied the connection between
depression and disability in people who experienced age-related macular degeneration. Rovener and
Casten hypothesized that the Costa and McCrae (1987) factor of neuroticism would correlate highly
with the tendency on the part of people with age-related macular degeneration to respond to their
disability with depression. Their work was based on the theory that people with a high degree of
neuroticism react to problems with a high degree of emotionalism and a tendency to exaggerate the
severity of the physical problems they are experiencing. As a result they tend to consider their visual
impairment in the most negative way, which may then further impair their functioning. Casten and
Rovener (2008) pursued this theory by researching the effect of a problem-solving intervention that
they developed for people with age-related macular degeneration who scored high on measures of
the factor of neuroticism. Their research demonstrated that this problem-solving intervention was
able to prevent depression in the short run, but that these beneficial effects were not sustained over
time.

For now, the Costa and McCrae list of factors serves as a useful way to conceptualize and organize
the characteristics of the student with whom the O&M specialist is working and to hypothesize about
ways to approach the rehabilitation training of students who show high levels of any of these factors.

Dispositional-oriented research by De l'Aune, Lewis, Needham, and Nelson (1977) has attempted to
identify the traits of individuals who are especially successful in coping with blindness. The hope
behind such research was not to select only the most promising clients to receive the services, but to
try to understand how to approach people with different patterns of traits differently in order to
achieve positive rehabilitation outcomes.

Conditional Dispositional Links

One of the most important reasons why research that focuses on personality traits does not show
strong correlations to successful outcomes is related to subsequent developments in this area of
personality psychology and the emergence of the importance of interactionism. Wright and Mischel
(1987) demonstrated the validity of the conditional dispositional construct. This concept suggests
that the most promising way to understand the role of dispositions or traits is to understand the if-
then link between certain clusters of situations and clusters of behaviors. In this view a particular
trait—for example, aggressiveness—in a mobility student would not suggest the likelihood that
this person would behave aggressively across all mobility situations. Instead, it should be understood
as a person's tendency to respond to certain situations, such as being confused or frustrated, with
certain behaviors, such as lashing out verbally. In the absence of the triggering situations, the person
high in the trait of aggressiveness would be no more likely to behave aggressively than the person
who is not high in the trait.

Anxiety
Spielberger (1972) has contributed to this more sophisticated understanding of the role of
personality traits through his work on anxiety, a trait that is frequently a concern of O&M
specialists. Anxiety has been defined as a diffuse reaction to a vague or not clearly perceived threat.
Unlike fear, which is a reaction to a specific threat or danger and usually generates some type of
avoidance behavior such as flight, anxiety is a reaction to a less intense threat in which the reason for
the discomfort is not well understood. Anxiety does not usually result in flight, but usually occurs in
situations where the person cannot escape.

Spielberger proposed a two-factor theory of anxiety, differentiating between state anxiety and trait
anxiety. State anxiety was conceptualized as a transitory experience of unpleasant, consciously
perceived feelings of tension and apprehension. Such an experience affects most people at certain
times to a greater or lesser degree and varies from moment to moment and day to day. In
contrast, trait anxiety was described as a more stable disposition of certain individuals who are prone
to experience anxiety more frequently and more intensely in response to a wider range of situations.

Spielberger's model fueled the criticism of the trait approach to the study of personality in its
conceptualization of anxiety as a unidimensional construct. In effect, Spielberger said that a person's
likelihood of experiencing state anxiety in a wider variety of situations was related to the strength of
the underlying trait of anxiety. However, Endler (1980) cited a number of studies that showed that
individual differences in trait anxiety predicted corresponding differences in state anxiety for only
certain types of situations. There was a high correspondence between trait anxiety and subjects
experiencing the state of anxiety in situations containing threats to self-esteem or interpersonal
threats. However, for other situations, especially those containing physical danger, the level of trait
anxiety failed to predict the intensity of state anxiety.

Endler (1983) went on to develop an interactionist model of anxiety that identified five dimensions of
trait anxiety relating to different types of anxiety-provoking situations. These five dimensions and the
kinds of situations that may provoke them are shown in Sidebar 6.3.

These differentiations can be of particular value to O&M specialists who frequently encounter
anxiety in their students. Sometimes this anxiety prevents a person from beginning mobility
instruction, and sometimes it appears at various points along the way. In the first case, the anxiety
might be a manifestation of "ambiguous anxiety," in which the person reacts to a situation in which
he does not know what is going to happen. In this case the O&M specialist may want to provide more
information about each new step in the training process so that the student has the maximum
amount of information available as he thinks about what comes next. Other students may begin to
show anxiety as they approach stair travel or street crossings, which represent physical dangers. Still
others may show the greatest amount of anxiety as the lessons bring them into interaction with
people on the street. This may suggest a high level of "interpersonal anxiety." These observations can
better focus the O&M specialist's responses to the student.

Anxiety in Orientation and Mobility

Schulz (1977) suggested that anxiety may be, and probably is, the explanation for many of the
difficulties experienced by some mobility students. Students are not necessarily limited in
intelligence because they cannot coordinate the swing of their canes with their steps. Rather, their
thought processes may have been short-circuited because they are afraid they will fall into a hole.
When they veer, it may not be due to a mental inability to walk a straight line; it is quite possible that
tension produced by anxiety causes them to miss available kinesthetic or auditory cues. There are
obvious symptoms of anxiety such as excessive sweating, shortness of breath, and muscle tension.
However, less obvious symptoms may include the inability to grasp simple directions, or poor
orientation that cannot be explained by low intelligence or lack of experience. If the instructor
overlooks anxiety as a possible explanation for specific behavior, he may not be able to take
appropriate remedial action.

Mandler and Sarason (1952) have shown how limited amounts of anxiety can be helpful in assisting
learning and in completing challenging tasks. Generally speaking, however, research suggests that
anxiety interferes with learning and task accomplishment, especially for complex tasks. Easterbrook
(1959) demonstrated that increased anxiety affects learning and performance by decreasing the
number of cues that a person attends to and uses. Fluharty, McHugh, McHugh, Willits, and Wood
(1976) cited research that showed that for highly anxious subjects, learning was slower and the
retention of what was learned was less; judgments of time and distance were distorted; and
efficiency in the performance of complex motor tasks was diminished.

O'Donnell (1988) reviewed the literature related to anxiety and stress in mobility training and travel
situations and advocated the use of modern stress-reduction techniques such as muscle relaxation,
meditation, and biofeedback by students receiving mobility training.

Beggs (1991) proposed that walking speed decreased as a strategic response to stress and lack of
confidence. He investigated the feelings of visually impaired subjects while they were traveling and
devised a questionnaire on the psychological variables important to orientation and mobility. His
analysis showed that various psychological variables, assessed at the time of walking, accounted for
63 percent of the variance in the speed of walking, which was more than the amount of variance
explained by vision variables. The primary psychological variables identified were components of
what he called weak "self-efficacy": lack of confidence, disorientation, and emotional distress.

INDEPENDENCE AND DEPENDENCE

In social cognitive theory, the environment in which a person exists plays a significant role in
determining how a person with certain characteristics responds to specific circumstances. A
particular environment may encourage more or less independence as a result of familial, social, or
cultural factors.

Bandura and Walters (1963) defined dependency as a class of behaviors that are capable of eliciting
positive attending and ministering responses from others. A person's characteristic level of
independence or dependence is not innate but is a learned response that develops from an
individual's past experiences, especially with significant others in the environment.
Vision loss and other disabilities are likely to cause at least temporary disturbances in an individual's
balance between independence and dependence. In some situations, the problems that arise are
quite natural and temporary. In others, they may be pathological and enduring. According to Tuttle
and Tuttle (2004) blindness tends to aggravate or exacerbate latent or preexisting personality traits.
The more dependent people are in general, the more likely they will be to use blindness to
rationalize even greater dependency. Until the person with a disability learns techniques for
functioning without vision, he will have to depend to a greater degree on assistance from others to
perform many tasks of daily living, especially travel. The loss of vision can be the excuse one person
uses to move into a socially acceptable dependent role that he previously was unable to assume.
Other individuals may feel threatened by even the necessary and natural short-term dependency
that accompanies initial vision loss. These persons' responses may be to strongly resist any assistance
and insist that they need neither personal help nor rehabilitation service.

Cholden (1958) observed that "one of the clearest social attitudes toward the dependent state is that
of personal devaluation. This will be felt as a lowering of self-esteem, for the receiving person is often
less valued and less acceptable as a human being" (p. 100). The self-esteem of people who are blind
may also be affected by the recognition that they are not totally self-sufficient, that they are
dependent on the sighted to meet some of their needs even with the best adaptive behaviors and
coping skills. The dependency needs of people who are blind may be more visible or more obvious
than the dependency needs of people with vision, and, as a result, most members of society tend to
share the opinion that the visually impaired are more dependent and thus less worthy (Tuttle &
Tuttle, 2004, p. 19).

While the problem of finding an acceptable balance between independence and dependence is an
issue faced by everyone, it is more serious and more likely for individuals with a disability. They find
themselves in a society that generally encourages independence but discourages it in subtle or
obvious ways for people with disabilities. They may find themselves caught between family, which
encourages and rewards dependence, and their own need for more freedom. Alternatively, family
members and friends may feel burdened by these individuals' dependence, while the individuals
themselves may be reluctant to learn to function on their own.

Rosenblum and Corn (2002) surveyed older people who stopped driving because of visual
impairment and discovered that their top-ranked worries at the time they stopped driving were (1)
being a burden to others, (2) not getting where they wanted to go, and (3) losing their independence.
Corn and Sacks (1994) reviewed the high importance and status that driving brings in our culture.
They cited an observation by Sebald (1983) that a car confers prestige on teenagers, makes their
company more desirable to their peers because of freedom of movement, improves dating and other
social behaviors, and provides them with a sense of control. They also referenced Eisenhandler
(1990), who claimed that elderly people believe "that giving up the ability to drive tacitly marks the
beginning of what might be called a dependency career." He found that "many elderly people
conceded that this wallet-sized card imbued them with a sense of control and independence; they
could decide where to go and what to do." Meier (1992) reported that older people not only need
driver's licenses but see them as symbols of self-worth. They continued to drive to avoid
stigmatization. Corn and Sacks concluded that elderly persons view the right and ability to drive as
critical for autonomy and for avoiding social isolation (p. 54).
Participants in the Rosenblum and Corn survey who used at least one form of public transportation
worried less about feeling old and about feeling isolated than did those who did not use public
transportation. Developing the skills needed to partake in one or more forms of transportation
(buses, taxis, or paratransit services) seems important for maintaining a feeling of involvement and
the ability to perform tasks that age mates can accomplish. Engel, Welsh, and Lewis (2000) found
that the provision of rehabilitation and O&M services to older visually impaired people slightly
increased the participants' confidence in using public transportation. As a result of receiving the
services, the participants felt they had more control over their environment, had greater contact
with their relatives, and participated more in exercise and hobbies. The researchers concluded that
enhanced freedom of movement is an important outcome for maintaining the independence of older
blind adults.

Reviewing related research studies, Tuttle and Tuttle (2004) observed that "dependent persons rely
on others for approval, are insecure and uncertain, lack confidence in their own decisions, seek help
and constant companionship, and crave the companionship and recognition of others. On the other
hand, independent persons are self-directed and self-sufficient, detached from the influence of
others, free to choose their own course of action, demonstrate initiative, persistence and curiosity,
are able to solve their own problems, tend to be assertive or even aggressive, and may be more
socially isolated" (p. 59). The expectations of others are a prime molder of the blind individual's own
view of independence. The more dependent visually impaired persons are, the more they will
attempt to comply with the expectations of others. The more independent they are, the more they
are likely to defy or withstand others' expectations regarding their dependency (Lukoff & Whiteman,
1970).

For the person who initially responds to dependency with comfortable acceptance, the movement
toward greater independence may begin with the experience of "dependency dissatisfaction"
(Havens, 1967). This occurs as the person discovers that depending on others leads to outcomes that
are dissatisfying. In the area of mobility, dependent persons may find that they have to adjust their
schedules to meet the schedule of the person or persons on whom they depend for transportation.
In other cases, the person who is supposed to provide a ride forgets and leaves the blind person
stranded or late for a critical appointment. A sufficient number of such experiences may eventually
convince the person to learn to function on his own. Corn and Sacks (1994) documented the lifestyle
changes that result when people with visual disabilities must depend on other people for
transportation. They recommended strategies that can be used to lessen some of the frustrations
that result from not driving.

Long, Boyette, and Griffin-Shirley (1996) found that even though there were no differences between
a group of seniors with unimpaired vision and a group of seniors who were visually impaired on the
combined frequency of assisted and independent travel, members of the visually impaired group
were significantly less satisfied than were the sighted participants with the number of opportunities
they had to leave their homes. This dissatisfaction seemed to be based on a subjective sense that
their ability to travel was limited because they had to be accompanied by another person. Their
dissatisfaction with opportunities to travel may have reflected their dissatisfaction with their levels of
independence and their relatively high degree of dependence on others.
According to Lowenfeld (1975), persons who are visually disabled responding to the dependency
aspects of blindness tend to react with hostility and aggression, with submissiveness and compliance,
or with a more balanced willingness to accept needed assistance when the circumstances of a given
situation seem to warrant the help. The last of the three alternatives demands considerable ego
strength and a self-concept that is positive enough to induce resistance to dependency (p. 265).
Tuttle and Tuttle (2004) suggested that "an analysis of the 'offering self' of others and the 'seeking
self' of the visually impaired person provides some insights into the dynamics of the relationship
between perceived dependency and the blind individual's self-esteem. The manner in which
assistance is offered by others impacts directly on the blind person's sense of value and worth. The
manner in which the assistance is received by the visually impaired person reveals something of that
individual's self-esteem needs. When blind persons learn to understand their own feelings and
reactions, they are in a better position to minimize the negative effect on their own self-esteem" (p.
61).

A standard of absolute independence for a traveler who is visually impaired is neither feasible nor
desirable. Inevitably, the individual will encounter situations in which assistance will have to be
obtained. When this happens, the student may have to learn that the judicious use of help is not a
threat to independence.

THE SOCIAL ENVIRONMENT AND ATTITUDES TOWARD BLINDNESS

Attitudes of the General Public

Do the attitudes of the general public make it difficult for a person who is blind to travel
independently? Does the success of travelers who are blind have an impact on the attitudes of the
general public? Is the impact of the attitudes of the public different for people with low vision?

Among the most salient features of the environments in which people with visual disabilities must
learn to function are the attitudes of other people toward vision loss and toward people who are
visually impaired. These attitudes influence much of the feedback that the person with a visual
impairment receives and uses in the development and refinement of self-concept and perceptions of
self-efficacy. These attitudes can influence the person's judgments of the attainability of desired
outcomes, and they affect the quality and the amount of help offered during travel. Their effect is
pervasive in the blind person's life, and the power of their influence should not be underestimated.

Monbeck (1973) summarized the long history of attitudes toward blindness and toward people who
are blind as reflected in centuries of literature. Most of the reactions and attitudes have been
negative or demeaning. Blindness elicits pity, sympathy, fear, and avoidance responses. Some people
project misery and unhappiness on blind people, while others feel that blind people are helpless.
There are a few examples in the literature of positive attitudes toward blindness. These include the
association of special abilities with visual impairment, and the desire to help blind people and to be
associated with them. Tuttle (1984) and Tuttle and Tuttle (2004) generated a similar list of attitudes
culled from the literature containing mostly negative reactions but with some positive biases as well.

Empirical efforts to discover how people regard blindness have been confounded by a variety of
measuring instruments, different eliciting stimuli, and confusion regarding whether the research was
measuring attitudes toward blindness or toward people who are blind (Lukoff, 1972). Many of the
confusing and discrepant findings might also be explained by the fact that attitudes toward blindness
are not unidimensional, as some measuring instruments suggest, but multidimensional.

Whiteman and Lukoff (1965) identified five factors or dimensions of attitudes toward blindness. The
names of these factors or dimensions as well as the general content of each are shown in Sidebar
6.4.

The attitudes, knowledge, and fears of people with visual impairments were comparable to those of
the general population, which suggests that visually impaired individuals have internalized society's
generally negative stereotypes about vision loss (Horowitz, Reinhardt, Brennan, & Cantor, 1997).

Interactions and Attitudes

Travelers who are blind, as perceived by the general public, may be regarded as incompetent and
unable to function on their own, or they may be regarded as exceptionally talented even though, in
their own mind, they are performing routinely. One thing is certain: Blind travelers are a strong
stimulus to other people, and as a result, they have to be ready and able to respond to a wide variety
of reactions.

Regardless of the attitudes that exist within a particular culture or social setting, some of the
interaction problems that develop between people with visual impairments and others are traceable
to the interactions themselves. Some sighted acquaintances occasionally speak of the person who is
visually impaired as they would an object, referring to the person as "it." Others converse as if the
visually impaired person were not present or invisible (Branden, 2001), totally ignoring and excluding
the blind individual from conversation.

Assuming the accuracy of Whiteman and Lukoff's five characteristics of people that influence their
interactions with people who are blind, four of which appear to be negative, it is easy to see how
such attitudes can create a barrier to normal interactions and have a negative impact on the blind
person's self-confidence. The already strained interactions are also sometimes disrupted by the blind
person's lack of eye contact, atypical gestures and facial expressions, and inability to pick up on visual
conversational cues used by the sighted person (Monbeck, 1973).

According to Tuttle and Tuttle (2004), when the blind person is considered remarkable and unusual
for performing very ordinary and routine tasks, such as eating, telling time, or telephoning, it has one
of two possible consequences: (1) The self-esteem of the blind person is unrealistically inflated or (2)
the person who is visually impaired recognizes the facade as masking the more generalized
demeaning and devaluating attitude toward people who are blind. A sighted person's initial reactions
to a person with a visual impairment may be based on prior direct personal experience with other
persons who are visually impaired and the manner in which the visually impaired person presents
himself. The Tuttles pointed out that the higher the levels of preoccupation among people with visual
impairments with solving the problems that new situations demand, or the higher the levels of
anxiety over anticipating new and different situations, the more ineffective they may become in their
social interactions. This reduced effectiveness has two potential consequences: (1) Others may
misunderstand and, perceiving social distance, may withdraw or become oversolicitous, and (2) the
visually impaired person may allow the temporary, situationally reduced effectiveness to be
generalized to a lowered self-esteem (p. 88).

Some people who are blind feel that their ability to travel has an especially positive impact on how
they are perceived by other people. Gitlin, Mount, Lucas, Weirich, and Gramberg (1997) reported
that the participants in their study felt that the social benefits of using a travel device were the most
important. They believed that being able to travel independently afforded them a level of social
integration and connection that they could not have achieved otherwise. They felt that being able to
go outside the home and participate in work and leisure activities had a direct impact on the quality
of their lives. This was reinforced by Leary, who observed that self-esteem is inherently tied to
interpersonal processes and, thus, is understandably affected by interpersonal events, other people's
appraisals, and the individual's perceptions of his or her personal characteristics (Leary, 2002, p.
156).

According to Heller, Swindle, and Dusenbury (1986), social support from social networks can buffer
stress and improve coping in all stages of life through different forms of helping behavior: emotional,
informational, practical, and appraisal. In addition, support is protective and improves well-being
through the psychological effects of the mere presence of others, which prevents isolation; of being a
valued part of a network; of receiving signs of love and understanding; and of being sure of receiving
help when needed. These effects foster not only self-esteem and self-assurance, but also feelings of
security and control over oneself and the environment.

Stigma and Passing

Many people who are visually impaired are stigmatized when they travel in public. In this
context, stigma does not refer to its primary meaning as a "mark of infamy," but rather to a more
general sense of a label or behavior that indicates some deviation from a norm or standard. Some
persons are stigmatized because of their appearance, perhaps resulting from the eye condition that
led to the vision loss. Others may be stigmatized because of the equipment they use or the behaviors
they adopt to cope with the vision loss. Some persons with low vision become stigmatized only when
they are forced to solicit assistance in a situation where a person with unimpaired vision would be
able to function independently (Emerson, 1981; Wainapel, 1989).

Goffman (1963) and Freidson (1965) theorized about the effects of stigma on human interactions. In
their theories, it is clear that the problem does not reside with the person who possesses the stigma
or with the persons who react to the stigma, but with the interaction between these two sets of
actors. People who are stigmatized elicit atypical, though often predictable, reactions and behaviors
from the general public. These reactions can impact the self-concept of the people with the disability
as well as their behavior. Wright (1960) pointed out that the reactions that an impaired person has to
an exchange with members of the public can go a long way toward making the exchange worse,
controlling it, or even turning it into a positive experience and changing the attitude and future
behavior of both parties.

New Psychological Situations

Three long-standing concepts are useful in understanding these interactions: A new psychological
situation (Barker, Wright, Meyerson, & Gonick, 1953; Lewin, 1936) is one in which the location of
positive goals and the path by which they can be reached are not clearly perceived by a person.
Entering a new psychological situation both attracts and repels a person, because of the uncertain
location of the positive goals. A person will engage in trial-and-error behavior and will experience
frustration as a result of the searching. The person will feel conflict in simultaneously trying to reach
the goal of the new situation and then withdrawing to the safety of the old.

Persons who are visually impaired and people with other visible disabilities more frequently
experience new psychological situations than do persons without disabilities (Barker et al., 1953).
This is often because persons with a visual impairment lack a necessary tool for dealing with
situations, usually a tool that is closely related to the disability. Without vision as a tool, individuals
who are visually impaired enter more situations in which they may not have information about social
or physical changes that have taken place in those situations.

Other situations are "new" for the person with a disability as a result of the stimulus value that the
disability represents for others in the situation. According to Meyerson, "Disability has many
meanings to others. The disabled person often does not know when he enters a social situation
whether he will be an object of curiosity or be pitied, sympathized with, helped, patronized,
exhibited, praised for his spunk, avoided, or actively rejected" (Meyerson, 1963, p. 41). What is
reasonably certain is that the disabled person will elicit a strong reaction of some sort. What is
uncertain is the direction and type of reaction to expect.

Overlapping Roles

The concept of overlapping roles arises from the realization that each person simultaneously belongs
to many different groups and must play multiple roles (Meyerson, 1963). There are four types of
overlapping roles. First, many overlapping roles are compatible and can be handled simultaneously.
Second, others may be interfering and can be resolved simply by choosing one or the other. Third,
some overlapping roles are antagonistic, and responding to one automatically rules out the other.
Frequently persons who are visually impaired have to choose between the antagonistic roles of a
dependent person who relies on help and an independent person who functions without help.
Sometimes it is difficult to get just a little help without being compelled to take more than is actually
needed.

A fourth type of overlapping role is that of excluding roles. The disabled person finds himself torn
between the roles of the disabled person and a physically normal person. Stonequist (1937) was one
of the first to identify this situation, which he described as the condition of the "marginal man." This
referred to an individual whose salient identity has elements that are burdensome or put the
individual at a disadvantage. Consequently, this marginal individual may have ambivalent feelings
about his identity, and he may wish to reject it. If a person acts appropriately for a disabled person in
a situation—for example, using a cane for mobility—he will automatically surrender the possibility
of being considered a nondisabled person. This conflict frequently surfaces in social situations where
the rewards for being a "normal" person are greatest and the negative effects for deviating from the
norm are most potent.

Passing

The struggle to manage this conflict can put the person with a disability under considerable strain
and lead to strong resistance to being identified as a disabled person in public, particularly through
the advertisement of a long cane (Wainapel, 1989). The pressures associated with trying to resolve
the conflict of excluding roles may lead to the phenomenon of "passing." Passing has been defined
by Goffman (1963) as behavior designed to conceal a salient aspect of one's identity. According to
Goffman, passing may begin when a person discovers it accidentally, realizing that others have
treated the person as not having a disability that is actually possessed. The person may progress
through the stages of passing for the "fun of it," passing on vacations, passing in situations involving
people with whom she frequently interacts, and finally passing completely and being able to entirely
conceal the disability portion of her identity. Goffman discusses some of the strains associated with
passing. He notes the anxiety associated with always having to be alert to all of the details of a
situation that might be responsible for unveiling the hidden aspect of the identity of the person with
a disability. There is also the strain associated with explaining the ruse when the hidden aspect of the
person's identity comes to be revealed one way or another.

Special Considerations for People with Low Vision

For many persons with low vision, their disability may not be obvious. It becomes apparent in some
situations and not in others. This variability leaves them with decisions to make concerning how they
present themselves. Freeman, Goetz, Richards, and Groenveld (1991) documented the fact that
many of the people with low vision interviewed in their long-term follow-up study rarely or never
used a cane because of their wish to avoid the stigma of being identified as blind and to "pass" as
having unimpaired vision. As a result, many took needless risks in travel in order to maintain a sense
of anonymity. This same study also documented that 40 percent of the responders reported having
been hit by a vehicle on at least one occasion.

The person with low vision frequently has more difficulty with the psychological adjustment. Because
the person with low vision may appear as a person with unimpaired vision, the person's behavior is
more frequently misunderstood. Such misunderstanding produces ambiguities, embarrassments, and
conflicts that lead to personal traumas. From a psychosocial perspective, persons with low vision
tend to find the adjusting process toward self-acceptance and self-esteem more difficult than do
people with no vision at all (Tuttle and Tuttle 2004).
Uttermohlen (1997) described her own difficulty in getting through adolescence as a visually
impaired teenager who wanted to do as much for herself as possible without drawing attention to
her visual impairment even if it meant excessive risk taking. "Balancing the need for reasonable
assistance with the desire to be seen as competent and 'normal' is a struggle that all people with
limitations face." She went on to say,

My sister Lou and I are both adventitiously blind from congenital glaucoma, and during our
respective adolescences, we both had significant visual impairments. We expended a great deal of
energy trying to pass among our peers as though we were sighted. We accomplished two things by
doing so. First, we avoided the societal reactions that surround blindness. Like all adolescents, we
had a sense that we were immortal and had a desire for more freedom than may have been wise.
We were both smart enough to know that if the adults we knew had realized the extent of the risks
we were taking, they would have curtailed our liberty. Second, passing allowed us to perpetuate the
illusion of "normality" in our self-images, which benefited because we each had our own internalized
understanding of what it meant to be blind—and we were pretty sure it was not something that we
would want to be.

On the few occasions when my instincts for self-preservation prevailed and I took the fold-up cane
out of hiding during the day, the pitying glances of some oncoming pedestrians would make me hide
it again as soon as possible. My aversion to the sorrowful reactions I perceived in these well-meaning
passers-by was so strong that I frequently risked my life rather than identify myself as visually
impaired. (p. 313)

The challenge of finding a balance between necessary help and unnecessary risk repeats itself in
most areas of life. Uttermohlen eventually lost the rest of her vision but still would not allow herself
to do any less work on her own than she had been able to accomplish with her vision. "This attempt
to pass may have worked in my favor in some areas, but the benefits came at a high price. Especially
when my expectations were unrealistic, I would deal with them as if they were a brick wall against
which I would throw myself and my sense of self-efficacy until, battered and unsuccessful, I
internalized the failure as a flaw in myself, rather than as a circumstance in which I had not
sufficiently accommodated my vision loss" (p. 313).

FAMILY DYNAMICS

How do family dynamics and blindness interact and affect a person's independent mobility? Does a
person's lack of mobility result in a negative attitude on the part of family members, or does the
family's positive attitude contribute to the person's success in independent travel? Or, are both the
case?

Many of the attitudes toward blindness and toward people who are blind that were identified in the
previous section as being characteristic of the general public are also found among the families of
people with visual disabilities. When the family's attitudes are negative and rejecting, the impact on
the blind person can be especially devastating. Conversely, when they are positive and accepting, the
blind person can be helped tremendously. Tuttle (1986) reviewed the reactions of families to the
visual disability of their members as found in biographies and autobiographies of people with visual
disabilities. According to Warnke (1991, p. 45), when families are able to go through the normal
grieving process along with the family member who has experienced blindness or visual impairment,
both the family and the individual will benefit. In healthy families, the ability to cope successfully
with a devastating experience serves to strengthen the family unit and prepares its members for
future crises.

Similarly, the child who is congenitally blind is not born with a set of attitudes concerning the
condition. The child incorporates the attitudes of his parents. If the parents allow the wide and rich
experience of the environment, if they stress abilities, and help the child to deal realistically with
limitations, a good self-concept is developed. The child knows what can and cannot be done. Self-
expectations and expectations of others in the social milieu are realistic. The child does not
repeatedly attempt things that are beyond his ability, nor does he assume that he is functioning
adequately when in fact he is extremely dependent on those who can see. The parent who makes
excessive demands on a visually impaired child fosters in him a feeling of inferiority. Because he
cannot meet the demands, he fails, and in time develops a concept of himself as a failure. The child
will repeatedly demonstrate such an attitude during the course of mobility training. Because he has
failed so often, he expects to fail, and unknowingly, he meets his own low expectations (Schulz,
1980).

The family of the person with a visual disability is a salient feature of the environment in which
mobility training and independent travel occur, as are that family's dynamics. If family members
understand the practical aspects of travel without vision, and if they are confident in the student's
ability to handle it, they can be a strong positive force in support of the process. Moore (1984)
concluded that the family serves as a major source of interpersonal influences that affect what
blindness means to the person who is blind and what the person does with the blindness. For this
reason, time spent informing family members and encouraging their observation of mobility lessons
is a good investment. In contrast, family members that manifest a lot of anxiety and skepticism about
the student's skill can become formidable barriers to mobility training and independent travel.

As Tuttle and Tuttle (2004) observed, the support of family plays an important role during the
reassessment and reaffirmation phase of adjustment. Family members have to help foster a positive
frame of mind. They have to promote strengths rather than focus on limitations. Frank and factual
information about the person's condition and prognosis has to be shared with the family and
between the family and the person with a disability before adjustment can occur. Sensitive
significant others should be alert to the person's level of acceptance of the disability and of readiness
for an even greater level of acceptance. Family members will want to provide realistic feedback
without being patronizing or condescending. If a blind person is treated by family members as a
person with equal dignity and worth, she is more likely to see herself in a similar manner. Sheltered
or overprotective treatment results in distorted or overinflated estimates of one's personal
attributes.

Large (1982) noted the powerful influence of the attitudes of family members (especially parents but
also spouses, siblings, and children) on their blind relatives. Whether the influences were positive or
negative, he noted similar pivotal experiences reported in the lives of each of the 16 people who
participated in his study. These influences also had apparently lasting effects. Bambara et al. (2009)
stressed the difficulty that families have in balancing offers of assistance with efforts to maximize the
visually impaired person's safe independence. Cimarolli, Reinhardt, and Horowitz (2006)
demonstrated that family members often tend to underestimate the abilities of adults who have low
vision. This can lead to overprotective responses, which, in turn, lead to the family member's poorer
adjustment to the visual impairment, including increased depressive symptoms and decreased
mastery of the environment. Orr and Rogers (2006) have identified the challenge that families face as
they try to ensure the safety of their family member while also encouraging her independence.

Family members and friends want to be supportive and helpful. In some cases, vision loss brings
families closer together. However, many people have never known anyone who is visually impaired,
and they may feel uncomfortable about how to interact and awkward about offering help (Sussman-
Skalka, 2002). Rosenblum and Corn (2002) found that most of the respondents in their survey (132
out of 147) perceived that they received ready support from their families when they had to give up
driving as a result of visual impairment. Also, the participants in the survey advised family members
and friends of new nondrivers to be proactive by volunteering to drive and by encouraging the
nondriver to obtain mobility training.

High levels of emotional support from family members can facilitate successful rehabilitation
outcomes (Dumas & Sadowsky, 1984; Grieg, West, & Overbury, 1986; Moore, 1984). Nixon (1994)
said that families are supportive when they enable their members to gain a sense of control and
related self-worth by making them less uncertain about the meaning of their experience and self.
Support may be provided in a tangible or material form, or in an intangible form, such as information,
affection, approval, empathy, and respect.

Silverstone (2000) has discussed the adjustment that is required of a person with vision loss and her
family as a process that may require the members of the family to change the ways they interact, the
roles that they play, the expectations they have of one another, and the norms that govern their day-
to-day interactions. These changes are required as a family member loses vision and other members
are required to step in and change their expectations and behaviors in various ways. Similar changes
may be required again as the person with a visual impairment learns how to cope with her visual
impairment and other family members have to adjust once again in support of the visually impaired
person's ability to take over some of her former roles in the family, but perhaps not others.

Sussman-Skalka (2002) discussed the special impact of visual impairment on the dynamics of couples.
They noted that it was typical for one member of a couple to struggle over when to offer assistance,
how much to help, and when to encourage the visually impaired partner to do things alone. It can be
very difficult for a person to hold back as the partner undertakes a task that is so much easier and
quicker to accomplish with full sight. However, providing unneeded assistance, or taking over in
order to complete a task, can come at an enormous price, creating feelings of uselessness and
excessive dependency for the person with the visual impairment, and added burdens for the partner.

While there are no simple answers about when, or how much, to help, it is easier when couples talk
openly about this issue. There may be certain things that the partner wants to do on her own, and
other tasks that the couple can do together. There also may be activities that a person would like to
see the visually impaired partner continue, but is not sure it is possible. Unfortunately, many people
mistakenly assume that their visually impaired partner may have to give up many routine tasks or
favorite activities (Sussman-Skalka, 2002, p. 13).
It can be also be frustrating when one's visually impaired partner will not accept help, even when it
appears to be needed. It is difficult for an individual to watch a partner's frustration when struggling
with a task. Rather than immediately offering to handle it, one man in Sussman-Skalka's group
learned to ask, "Is there a way for me to help you to do this?" Another husband commented, "I have
to restrain myself because when she wants to do something, she says, 'I have to do it,' and I don't
want to interfere with that." While a partner may get impatient when things take longer to get
accomplished, it is important to recognize when it is better to back off. One woman in the group
shared how she sets things up so that her husband can use the microwave or washing machine on his
own. Another cleans up a messy kitchen after her husband prepares lunch for himself. Using this
gradual process, success can build on itself (Sussman-Skalka, 2002, pp. 14–15).

Klausner (1969) and Fordyce (1971) highlighted the powerful dynamics that occur in some families
that seem to be held together by the need for family members to care for one "sick" or "dependent"
member. When it begins to appear that the dependent member may no longer need the other
members of the family to fill their caregiving roles, the family feels threatened and behaviors may
occur that are designed, consciously or unconsciously, to sabotage the rehabilitation or education
process. In such a situation, it may be the introduction of mobility training with its strong emphasis
on independence that activates a family crisis. In cases where these dynamics are especially strong or
not conscious, formal counseling, provided by a professionally trained counselor, may be needed to
address them. In less intense situations, empathetic listening and feedback from the O&M specialist
and time to get used to the changing dynamics may be all that is necessary to help the family past
this change.

SUMMARY

The psychological and social factors that influence the mobility behavior of a person with a visual
disability are very significant to the outcome of the process and difficult to understand and control.
The difficulty is explained by the complexity that results from the three-way interaction of personal
factors, environmental factors, and behavior. Although research methodologies that can empirically
describe the reciprocal effect of these factors are not easy to conceptualize and implement, the
commonsense approaches that have been characteristic of formal mobility training since World War
II are effective in helping students cope with these complex psychosocial variables and experience
success in learning to travel. Recent trends in the study of personality, such as the growing focus on
interactionism and the emergence of social cognitive theory, combine the strengths of behaviorism
and cognitive psychology and hold promise for empirically validating the commonsense practice
methodologies of mobility instruction in the future.