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a School of Social Work, Simmons University, Boston, MA, USA.
*Corresponding author: E-mail: therapy@clairissa.org;
Chapter 6
Print ISBN: 978-93-48119-22-3, eBook ISBN: 978-93-48119-50-6
The Role of Rehabilitation Medicine in the
Psychological Etiology of Blindness or
Visual Impairment: A Critical Synthesis
Clairissa G. Richardson a*
DOI: https://doi.org/10.9734/bpi/dhrni/v6/859
Peer-Review History:
This chapter was reviewed by following the Advanced Open Peer Review policy. This chapter was thoroughly checked to
prevent plagiarism. As per editorial policy, a minimum of two peer-reviewers reviewed the manuscript. After review and
revision of the manuscript, the Book Editor approved the manuscript for final publication. Peer review comments, comments
of the editor(s), etc. are available here: https://peerreviewarchive.com/review-history/859
ABSTRACT
Background: Most research and subsequent treatment interventions operate
dichotomously in the conceptualization of causality regarding mental health among
people with BVI, advancing the conclusion that such problems are either related
to physical impairment or social structure. Roughly 3 million adult Americans have
a visual impairment or blindness, and over 4 million adults aged 40 and older.
Despite data demonstrating an elevated prevalence of mental health symptoms in
people with BVI, this population remains largely untreated. The relatively low rates
of mental health care service initiation are particularly concerning because
individuals with BVI frequently interact with many systems of rehabilitative
treatment intended to enhance quality of life.
Aim: The present study highlights the Role of Rehabilitation Medicine in the
Psychological Etiology of Blindness or Visual Impairment.
Patients and Methods: A comprehensive literature review was conducted. The
literature review utilized a critical systems typology, whereby relevant literature
was selected, reviewed, and analyzed intra and extra-organizationally. In addition,
a thorough discussion of disability-related factors was provided, lending a socio-
political lens to the problem.
Results: Considerable data indicates that short-term mental health care services
for people with BVI are ineffective treatment methods, albeit primarily employed in
health-rehabilitative processes. Multiple studies offered data indicating the
presence of diverse and entangled mental health issues relative to vocational
rehabilitation services, mobility tool utility, and emotional reactions to vision loss.
Many studies suggested that disability identity work be integrated into health-
rehabilitative processes for people with BVI. A critical forum or podcast can provide
a means of educative introspection that aids people with BVI to recognize the
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power that is given, not necessarily power held. Reality therapy, then, can be an
organized effort to incorporate into clinical settings which people with BVI are
cognizant of, and may specifically request, during assessment or evaluative
procedures.
Conclusion: To improve the utility of mental health care services for people with
BVI, a reenergization of the mental health care needs of this population must
occur. Future mental health policy and practice for individuals with BVI can be
improved with the help of a podcast or forum that critically examines and educates
listeners about the health-rehabilitation issues that impact the provision of mental
health care services. In order to improve understanding of this demographic and
their particular mental health needs, disability researchers must expedite
qualitative, community-based techniques and develop research on integrating
critical perspectives in treatment with persons with BVI.
Keywords: Blindness; visual impairment; critical theories; vocational
rehabilitation; mental health; orientation and mobility; rehabilitation;
vision loss.
1. INTRODUCTION
The role of a rehabilitation psychologist in working with individuals who have visual
impairments is crucial in addressing the multifaceted challenges they encounter.
Rehabilitation psychologists utilize a variety of assessment techniques to evaluate
the impact of disability on an individual's functioning and to identify areas of
strength and areas in need of improvement. These assessments may include
standardized tests, interviews, observations, and self-report measures to gain a
comprehensive understanding of the individual's psychological, emotional,
cognitive, and social functioning [1]. According to the World Health Organization
(WHO) [2], as many as 2.2 billion people have impaired vision worldwide. Of these
individuals, 39 million are blind, and an estimated 246 million have visual
impairments [2]. Vision loss can have detrimental effects on many aspects of a
person's life, including psychological, social, economic, and physical functioning.
This can lead to a decrease in overall quality of life. Common effects of vision loss
include decreased self-esteem and social status, progressive decline in motor and
functional abilities, and limited career opportunities. As a result, household income
may decline [3]. In the United States, almost one-third of people with blindness or
visual impairment (BVI) experience subclinical depression and anxiety, while
around 5% to 7% have a major depressive disorder and 7% have an anxiety
disorder, with a significantly higher percentage compared with those having a
healthy vision [4]. Numerous other studies have demonstrated a link between
vision impairment and depression specifically (eg, [5-7]). People with BVI
experience a range of mental health issues, including reduced quality of life [8,9],
accidental injuries [10], mental fatigue [11], and poor social contact [12], which can
induce feelings of loneliness [13]. With age-related eye diseases being the leading
cause of disability among aging adults in the United States (eg, [14,15]), these
findings are a personal and national issue [16,9].
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Most research and subsequent treatment interventions operate dichotomously in
the conceptualization of causality regarding mental health among people with BVI,
advancing the conclusion that such problems are either related to physical
impairment (eg, [7,17]) or social structure (eg, [18,19,9]). However, a recent
literature review performed by Demmin and Silverstein [16] indicated that despite
a high prevalence of clinically significant anxiety and depression reported by
individuals with age-related eye diseases, up to 91% are not receiving treatment
for these mental health issues (see also [20–22,9]). In this same study, findings
were mixed regarding the prevalence, rates, and origins of mental health issues,
suggesting that improved assessment of the mechanisms that contribute to the
onset and maintenance of mental health issues among people with BVI is a better
predictor [16]. Despite these results, Demmin and Silverstein [16] acknowledged
the tendency for vision loss to be most commonly conceptualized as a medical
problem, reducing the condition of visual impairment to lacking psychological
recognition; this is a common conclusion of many disability scholars (eg, [23–
26,9]). To better understand the current state of mental health utility in the lives of
people with BVI, an examination of disability as a social-political category and
narrative must first occur [9]. The following section consolidates what is known
regarding the prevalence and predictors of mental health issues for people with
BVI, separated by context, disability, and definition. Past and current trends related
to mental health issues for people with BVI are also discussed.
2. HISTORY AND BACKGROUND
2.1 Disability Attachment: Past and Current Trends
The primary efforts of rehabilitation following the aftermath of World War I were
concerned with integrating people with disabilities (PwD) into ordinary life and work
[25,27]. Despite this moral obligation to occupy discourse surrounding rights for
PwD, institutional welfare arrangements were born, shifting from notions of rights
to privilege [25,27]. The evolution of rehabilitation as medical and paramedical
expertise, finding root in the struggle for professional control over injured bodies
during the First World War, piloted the formation of disability as a concern of the
state [23,25,28,9]. This new definition of health rehabilitation insinuated the
general notions of replacement, substitution, and compensation, which
progressively were applied to all impairments, including congenital and acquired
conditions [23,28]. The spread of health rehabilitation and intervention by the state
has been assisted by welfare institutions, legislation, business interests,
professional specializations, and medical diagnoses [25,29,9]. Such
endorsements encompassed political interests relative to the redistribution of
support for PwD [25,29]. Medical professionals selected by the state were
burdened with dictating who is entitled to the rights of financial support and relative
services [25,29]. This practice of dividing the deserving from the undeserving is
both a historical and current problem [9].
Over the years, research in this area has documented a mixed report of work-
related disability [30] among US adults [31]. Going as far back as 1962, Oi [32]
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reported that work-related disability had increased from 7% in 1962 to 11% in
1973, then declined to 9% in 1984. Between the years 1981 and 1988, there was
no significant trend; however, the fluctuation across time suggests the difficulty of
defining and measuring the population of PwD. More recently, The United States
Department of Labor [33,9] (DOL) conducted an annual labor survey of 60,000
households, to which 31,000 adults were categorized as having data indicative of
a disability [37]. Results showed that from 2021 to 2022, the unemployment rate
for PwD decreased from 10% to 7%, roughly, with inconsistent trends reported
from prior years; however, results from this data also indicated that employed PwD
was more likely to be self-employed, and when compared with those people
without a disability, the rate of unemploy- ment for PwD were twice as high [34,9].
This review of the history and evolution of disability bears implications to the
prevalence of mental health issues among people with BVI. For instance, as
people with BVI interact with specific work-related legislation [35], including
programs that focus on vocational rehabilitation (eg, see [36]), it can be suggested
that reliability in work- related disability and thus security affects mental health
symptomology. It is difficult to conclude that the definition of health rehabilitation
pertaining to disability and its associated measures are reliable amidst the
fluctuating estimations of work-related disability [9].
2.1.1 Definitions and interactions with mental health
Thomas Szazs [37], a Hungarian American scholar and psychiatrist, was the first
to propose the dilemma of mental health being interspersed with medical
conditions. With the publication of his first book, The Myth of Mental Illness:
Foundations of a Theory of Personal Conduct, Szasz [37] called for the
amelioration of medicine from mental health study, critically exposing the interplay
between categorizing matters of the mind as medical diagnoses and social-political
power. Szasz [37] believed the role of medication should not be a privileged
intervention over the complexity of normal human life. Rather, his theory of
personal conduct suggested people only behave according to the effects of their
social and relational lives, attributing individual circumstances of life predictive of
personal conduct [37,9]. Thus, for Szasz [37], “mental illness” as a disease, is a
myth as it pertains to matters of thought and cognition, not the physical body.
Szasz [37] defined illnesses with respect to deviation from a norm, and in the case
of physical illness, the norm refers to the structural or functional integrity of the
body or some aspect of it. Illnesses, then, can be characterized as physical
diseases, such as Lyme disease or rheumatoid arthritis. His definition excluded
mental illnesses as diseases because they lacked relevancy to the physicalist
framework of traditional medicine [37,9].
Szasz’s [37] theory of mental illness contains components that have since been
accepted, rejected, and combined to elucidate working definitions of mental illness
by many other theorists and scholars akin to the social and behavioral sciences.
Like Szasz [37], mental illness is a myth that inappropriately pathologizes
“problems of living” such as relational distress, poor financial situations, and job-
related stress [38,9], which can be improperly applied to behavioral and intellectual
disabilities [39]. Alternatively, and more recently, mental illness is a disease with
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both medical and social causes such as genetic vulnerability, peer influence, and
level of social skills [40,41] that should not be distinguished from medicine, yet
included to consider a more nuanced view of disease. Unlike the traditional
physicalist framework (eg, [42]), the latter definition provides a more holistic
perspective of mental illness, which helped to expand both the definition and
concept of disability through an anti-reductionist lens, impacted social institutional
reform [38,39,43,9], and the assessment of mental illness in the United States.
Despite the definition of mental illness taking many forms across decades, the
origins of its interest lie within the medical model of disability, to which the social
model of disability countered. The social model of disability, a concept that breaks
the causal link between impairment and disability…the reality of impairment is not
denied but is not the cause of disabled people’s economic and social disadvantage
is valued in most social and behavioral professions over the medical model, which
is a more prominent value in mainstream US health care, particularly rehabilitation
[44,9]. The social model points to how, and to what extent, society restricts
opportunities resulting in dependency [45]. The emergence of the social model of
disability and the renewed perspective of mental illness helped to orchestrate
global social reform by introducing frameworks and strategies that include
multifactorial approaches to disability (eg, [46–48]). The WHO [49] was the
harbinger behind this effort, responding with a tool and framework that has since
been utilized by researchers to improve understanding of disability and propose
well-targeted solutions. The International Classification of Functioning, Disability,
and Health (ICF) [49,9] is a non-traditional health indicator that measures the
livelihood of PwD in consideration of relationships between health conditions and
environments, including mental health functioning. The ICF [49] framework
positions itself multidimensionally to deter- mine health-related inequities for PwD.
As such, it holds value for medical practice, law, and social policy to improve the
overall treatment of PwD [49,9].
Community-Based Rehabilitation and the World Health Organization’s (WHO)
Definition of Mental Illness Community-based rehabilitation (CBR) matrix [50] is a
framework that was developed and supported by the WHO [50] to input a
comprehensive lens to health rehabilitation for PwD; the ICF is the tool, while the
CBR matrix is the framework. The ICF [49] has been shown to provide construct
validity across various medical conditions, such as osteoarthritis [51], lymphedema
[52], and even serious mental illnesses [53,9]. Relating specifically to people with
BVI, a single study [54] was found that assessed the content validity of the ICF
[49]. In this same study, results reported that it had high content validity, as part of
a quantitative, cross-sectional survey; however, this study occurred in Brazil. To
date, there are no research studies that have been conducted in the United States
relative to the validity of the ICF [49] for people with BVI. The aggregation of
disability bears implications for the maintenance of mental health issues among
people with BVI [9].
Throughout this review, the definition of mental illness utilized by the WHO is
adopted [9]:
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A mental disorder is characterized by a clinically significant disturbance in an
individual’s cognition, emotional regulation, or behavior. It is usually associated
with distress or impairment in important areas of functioning. There are many
different types of mental disorders [55].
It is important to note, that while there exist many definitions of “mental illness”, the
WHO’s [55] definition is one of the few that is inclusive of broader conditions to
which mental illness may be affixed. For instance, according to the WHO [55],
psychosocial disability and mental states associated with significant distress,
impairment in functioning, or risk of self- harm are inclusive of mental illness [55,9].
Given that most research surrounding mental illness and BVI varies in professional
and organizational interpretation (eg, [16,56]), this definition is best suited for this
review. During this review, the term mental health is utilized to refer to subject
matter that encompasses the WHO’s [55] definition of mental illness, or otherwise,
mental disorder. To increase understanding of how disability eclipses mental
health issues for people with BVI, it must also be appropriately framed within the
contexts to which it is most often addressed [9].
2.2 The Role of Vocational Rehabilitation (VR), Orientation and
Mobility (O&M), and Care Practitioners
The state-federal vocational rehabilitation (VR) system serves PwD in preparing
for and securing employment, as well as attempting to retain their jobs or advance
in their careers [35]. It is one of the most integral statues in the United States and
supports vocational development and competition for PwD (for a review, see [57]),
operating in partnership with the DOL [33], Department of Education (DOE) [58],
and Health and Human Services (HHS) [59,9]. Formally established in 1920, the
VR system evolved with the changing needs of people injured following the
aftermath of World War I and beyond. The Rehabilitation Act of 1973 [60] was the
most influential piece of legislation for PwD, as it provided a legal basis for
opposing discrimination due to disability, including work-related discrimination.
Calls for equality within disability helped to pass the Americans with Disabilities
Act of 1990, which defines disability as a person who has a physical or mental
impairment that substantially limits one or more major life activities [61,9].
Today, the WIOA [35], initially passed in 2014, is designed to provide work-related
services to eligible PwD with the goal of job security and retention.
Despite the importance of facilitating work-related services for PwD, some
research has questioned the credibility and effectiveness of the VR program. One
study seeking to assess the construct validity of VR-related services specific to
mental health found variations in return across client characteristics [62,9],
suggesting that clients with specific mental health- related needs have negative
long-run rates of work-related returns. Specific to people with BVI, a more recent
study asserted that people with BVI have unique stressors that lack critical
examination, thereby impacting work-related security and retention [63].
Numerous research argues similarly (eg, [64–66,9]). Considering the history of
social-political interests pertaining to disability, VR efforts appear to prioritize
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reintegration and economic sustainability, and thus may not necessarily consider
the emergence of mental illness as a cause for concern indiscriminately. According
to data from the Annual Disability Statistics Compendium [67], sourced by the DOL
[33], DOE [58], and the HHS [59], the VR system served 4013 people with BVI in
2016, with 1431 of those cases closed without employment (see also [68]). Due to
changes in the reporting and data collection of state VR agencies, such data is not
readily available, with the most recent data provided to the public in 2016 [67,9]. It
is suggested that people with BVI are underserved as prospects for mental health
services under the VR system
.
Orientation and mobility (O&M) training is provided to people with BVI to assist
with maintaining travel competency and independence [69]. It teaches people with
BVI new orientation and mobility skills to compensate for reduced visual
information [69] and is a typical provision by state VR agencies. O&M specialists
are professionals (eg, [70]) with training and certification (eg, [71]) who provide
rehabilitation services to people with BVI across the life span [69,9]. A recent study
performed by Keay et al. [72] seeking to assess the cost-benefit of O&M training
for people with BVI concluded that the services offer substantial benefits toward
objective functioning and thus are worth the cost of providing. However, according
to the National Federation of the Blind [73], only an estimated 2% to 8% of people
with BVI utilize mobility tools (eg, cane, guide dog) [9]. While this percentage does
not appear significant, when considering the overall benefit of O&M training, it is
difficult to conclude that another variable does not exist. For instance, an older
study [74] questioned the lack of subjective outcome measures to assess the
effects of O&M training for people with BVI, such as quality of life. It is suggested
that mental health issues for people with BVI may include components of O&M [9].
Research on the relationships between care practitioners intimately involved in the
lives of people with BVI is lacking in the current literature (eg, [16]). In Demmin and
Silverstein’s [16] recent literature review, 15 studies were identified that included
experimental mental health interventions conducted with people with BVI.
However, none of the treatment approaches within these studies identified
mechanisms of change, such as increased hope for the future or recovery of self-
esteem; such mechanisms are indicative of long-term outcomes.13,163 In the
absence of a theoretical or conceptual frame that centers people with BVI, it is
difficult to conclude that mental health issues are being appropriately targeted.
Research indicates relationships with care practitioners are often interspersed in
aggregate with other health professionals, such as rehabilitation psychologists and
social workers. Therefore, for this reason, I adopt the term “care practitioner” to
refer to all proposed professionals within the current literature with specific training
in mental illness and who have past or present involvement in the lives of people
with BVI. To maintain a focus on the circularity of care for people with BVI, it is
important to solely examine those care practitioners who are most involved in the
related systematic processes (eg, [75,9]). The following section will examine the
contrasting and related terms specific to mental health between the VR system
and those generally utilized.
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Mental Disability and Mental Illness: Implications for Mental Health Care Services
While WIOA [35] federally mandates the provision of VR-related services, including
mental health-related services, states have separate regulatory privileges
pertaining to these services. Therefore, the definition of mental illness varies
across states and agencies (eg, [76]). For this review, the state of Florida VR
program and its agencies will be utilized to elucidate the defining terms. Although
terminology in the field is not standardized, mental illness generally refers to
clinically significant dysregulation of a person’s cognition, emotion, or behavior,
whereas mental disability generally refers to a state or condition of mental
impairment (eg, [24,55,9]). The Florida VR program utilizes the latter term to
assess mental impairment and provide mental health services [77]. Additionally,
the term restoration services are utilized to describe the following association:
Physical and mental restoration services are provided to correct or substantially
modify a physical or mental condition that is stable or slowly progressive [77].
While this term can include physical as well as mental impairments, it should be
noted that both psychological services and mental health services are considered
part of restoration services and are often utilized interchangeably within the
literature. The Florida VR program utilizes these interchangeable terms to describe
the following association [9]:
In cases where psychological treatment (including psychotherapy) has been
recommended by a psychologist, psychiatrist or other physicians, a counselor may
authorize the psychologist to provide the treatment. In any case, in which a
physician is providing medical treatment and a psychologist is providing
psychological treatment concurrently, both should be kept informed of any
changes in the individual’s therapeutic regime, which would affect the treatment
process. The local community mental health center should be considered as a
comparable service for long-term psychotherapy, or when an individual no longer
requires services from VR to achieve an employment outcome [77,9].
The term “counselor” in this legal definition refers to “vocational rehabilitation
counselor” and can be interpreted as a case manager for people engaged in VR-
related services. The terms assessment and evaluation are also services that refer
to a person’s eligibility for VR-related services and should not be interpreted as
strictly relating to mental health services. The Florida VR program utilizes these
terms to describe the following association [9]:
Diagnosis of mental health disabilities shall be made by a psychiatrist and/or a
licensed psychologist. Diagnosis by a professional staff with less than an M.D. or
Ph.D. credential is acceptable only if such individual(s) are employed by a
licensed/certified facility with M.D. or Ph.D. oversight [77].
This distinction between mental disability and mental illness is critical to
understand as it distinguishes two terms that allude to differences in professional
treatment. As aforementioned, traditional health rehabilitation categorizes mental
health conditions and/or symptoms as “mental disabilities”, thereby requiring a
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dominant medical lens to treat or restore, which is generally considered short-term
(eg, [25,78]). Therefore, “mental illness” is arguably not considered a disability
because it can be manipulated and improved, albeit often requiring long-term care
[9]. It is suggested that the prevalence of the medical model corresponds to the
determination of mental health services within the Florida VR program. It is
important to note that despite the variability of services across states, many of the
VR-related services are similar in nature (eg, concept and definition) and should
be interpreted with such similarity for the purpose of this review (for a review of
federal similarity, see [79,9]).
The major purpose of the present discussion was to examine what is known about
the prevalence and predictors of mental health issues for people with BVI,
separated by context, disability, and definition. While most of the research
discussed identified connections within VR, O&M, and care practitioner
relationships relative to the conceptualization of mental health issues for people
with BVI, there is a dearth of research about how all these services systematically
influence the provision of mental health services for people with BVI [9]. Therefore,
the aim of this review is two-fold. First, utilizing a critical systems framework, I
provide a comprehensive analysis of the interconnected systems to identify human
activity and interdependencies affecting processes of mental health utility within
the lives of people with BVI. Second, I identify the variables that exist across the
care systems that offer the most influence on the provision of mental health for
people with BVI [9].
Fixsen et al’s [75] research on relational dynamics within organizations suggests
that systems thinking (eg, [80]) must include a critical element, inclusive of the
emergence and interrelatedness of social influences, both intra and extra-
organizationally. This review seeks to utilize a critical systems theoretical
framework [75] to identify and analyze such influences on the nature of mental
health utility and provision for people with BVI. Slusser et al. [81] and Stringfellow
[82] maintain that the dynamics of a system unveil the unique character of
interactivity that translates to output [83]. The analysis of system dynamics, then,
can provide a deep understanding of the social and biological influences that
accumulate systematic activity [82,9]. The outcome of this critical literature review
will assist people with BVI and relevant stakeholders in better understanding how
these systems of care influence and reinforce each other in the presence of mental
health issues. All literature will originate from research conducted within the United
States.
3. METHODOLOGY
A literature search was conducted utilizing the databases Complementary Index,
Academic Search Ultimate, CINAHL Complete, SocINDEX with Full Text,
Business Source Premier, MEDLINE, APA PsycInfo, APA PsycArticles, Social
Sciences Citation Index, and ERIC. Searches included a combination of the
following keywords: “blindness” “visual impairment” “low vision” “mental health”
“orientation and mobility” “vocational rehabilitation” and “mental health
practitioners.” Literature was further identified utilizing the subject identifiers
“depression” “anxiety” “psychology” “quality of life” “social support” “rehabilitation”
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“psychosocial stress” “social stigma” “disability” and “mental health treatment.”
Studies that combined data from adults with BVI and children with BVI in analyses
were excluded from this review [9]. Studies that focused on the medical
consequences of blindness or visual impairment negated a critical lens or those
studies that focused on employment mechanisms solely were also excluded. For
the purposes of this review, the term “blindness” and “visual impairment”
correspond to objective visual acuities of 20/70 to 20/200 or worse, with the latter
acuity indicative of legal blindness (for a review of the current classification system,
see [84,9]). Data retrieved and analyzed from studies in this review utilize either
the current classification system ratified by the WHO [84] or the code of federal
regulations [85] when establishing blindness or visual impairment and
corresponding objective assessment.
This review primarily focuses on people with BVI in the United States; however,
data from people with BVI from other countries are also presented throughout the
article for comparison purposes [9]. Twenty-four studies were identified as meeting
the criteria. All 24 studies had been published since 2010, and thus were further
excluded based on the date of publishing; however, two studies that were first
published in 2011 were included due to their seminal distinctions (eg, [11,86]). The
additional exclusion was to improve the credibility of the included sources. As such,
sources, records, and reports published prior to 2013 were excluded from this
review. Seventeen out of the 24 studies were examined and included in the final
review based on the above criteria. Table 1 shows the representation of the
selected studies in a summary format, with Table 2 showing the excluded studies
and rationale [9].
3.1 Types of Mental Health Issues and Interventions
Although only one study [16] was very specific about the nature of mental illness
and diagnoses were stated (eg, major depressive disorder, generalized anxiety
disorder), a moderate number of research stated that the participants had a high
risk of developing a mental illness (eg, [95,96-103,9]). Still, most stated that the
participants’ prevalence rates were high relative to subclinical depression, anxiety,
and affective disorders, attributing psychological factors such as distress [16,95],
identity conflict [16,97], low life-satisfaction [14,16,86,92–95], vision-specific stress
[14,16], low self-worth [96], and negative social support [14,16,86,91].
Accountability relative to the predictors of mental health issues largely focused on
VR and employer characteristics (eg, [63,90,9]), with a fair number of research that
focused on disability and professional development (eg, [87,88]). Recent
therapeutic interventions were specifically described in a single study [16] with
targeted therapeutic recommendations provided in different research (eg, [87]).
Although few research studies included O&M implications in their conclusionary
findings (eg, [94]), there was no recent research that examined O&M
comprehensively as a training resource [9].
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Table 1. Studies examining interfacing components of VR, O&M, and/or care practitioners and the presence of mental health
issues among people with BVI in the United States
Authors
Sample
Study Design
Interdependencies
Anderson et al.
[87]
VR consumers with marginalized
identities. n = 30. Purposive
sampling
FG; consistent with CBPR
protocol
Themes relative to disability, racial, and
economic stressors/trauma, and poorly
targeted VR-related mental health
interventions
Bourgeois et al.
[88]
VR rehabilitation counselors. n =
83. random sampling
OS with instrument
Forty-three percent of participants reported
high moral distress when providing VR-related
services and poor connection to necessary
external providers
Crudden &
Steverson [63]
People with BVI and employment
history. n = 11. Purposive
sampling
Semi-structured
interviews; consistent with
member checking protocol
Inconsistent narratives related to VR-related
services and employment needs and stress.
Results discussed in terms of generalizable
skills and issues with job retention
Guerette &
Smedema [86]
People with BVI. N = 199.
Purposive sampling
OS with instrument
First study to measure multiple dimensions of
well-being for people with BVI and life
satisfaction, depression, and social support.
Recommendations for VR, O&M, and care
practitioners to employ strategies to promote
skills of assertiveness and conflict resolution
Brennan et al.
[14]
People with BVI, AMD diagnosis,
and who are engaged in VR-
related services. N = 584.
Purposive sampling
Interviews with measures;
consistent with
longitudinal protocol
First study to identify a discrepancy between
objective and subjective assessments of
visual impairment. Recommendations for VR
and care practitioners to address emotional
needs to vision loss and incorporate the family
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Authors
Sample
Study Design
Interdependencies
Giesen &
Hierholzer [89]
RSA-911 data on people with
BVI. N = 3610. Purposive
sampling
Descriptive, factorial, and
multilevel analyses
Evidence of systematic grouping approaches
to VR-related services. Services unrelated to
employment outcomes, such as clinical
counseling, implied a risk
Dean et al. [62]
Virginia DARS, VEC, and
associated SSDI data on people
with BVI who also have an
identified mental illness. N =
1555. Purposive sampling
Novel, multivariate model
Results showed that when combining the
employment and earnings effects together,
apart from diagnosis and evaluation, all
service types had positive long-run effects
Clapp et al. [90]
VR administrative data from
three separate states; N = 1964
Descriptive analysis
Results indicated persistent earnings benefits;
however, there was substantial cross-state
heterogeneity relative to the types of services
offered. Recommendations relative to care
practitioners aiding people with BVI in
cultivating independence and seeking
alternative quality of life outcomes
McDonnall &
Lund [91],
Hiring managers. n = 388.
Purposive sampling
OS with measure;
consistent with CFA
protocol
Results indicated that attitudes relative to
productivity and subjective norms accounted
for over sixty-one percent of intent to hire a
person with BVI. Recommendations for VR
counselors to screen employers’
organizational attitudes toward visual
impairment were offered.
Zapata [92]
People with BVI with RP
diagnosis; N =
183. Purposive sampling
OS with measure; multiple
logistical regression
analysis
Results indicated that individuals with RP who
have elevated levels of Self-efficacy had
higher odds of employment, while those who
utilized a mobility tool had lower odds.
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Authors
Sample
Study Design
Interdependencies
Zapata [93]
People with BVI; N = 180.
Purposive sampling
OS with measure;
consistent with stepwise
logistic regression
Results indicated that employment status was
predicted by higher disability affirmation;
disability acceptance and self-pride were
noted as a psychosocial correlation.
Zapata [94]
People with BVI; N = 212.
Purposive sampling
OS with measure;
consistent with multiple
linear regression
Results indicated that the use of a mobility
tool correlated to higher disability affirmation.
Recommendations for clinicians to consider
the impact of disability identity on mental
health status
Zapata [95]
People with BVI with blindness or
visual impairment group
affiliation; N = 187. Purposive
sampling
OS with measure;
consistent with cross-
sectional design.
Hierarchical linear
regression
Positive group disability attitudes predicted
higher life satisfaction. Isolation from group
disability predicted higher anxiety and
depression
Zapata &
Pearlstein [96]
People with BVI; N = 390.
Purposive sampling
OS with measure;
consistent with
hierarchical linear
regression
Lower disability self-worth, but not lower
personal meaning, was significantly
associated with higher depression and
anxiety. Findings suggest that disability self-
worth may be an important target outcome for
clinical settings.
McDonnall et al.
[97]
RSA-911 data on people with
BVI. N = 8723. Purposive
sampling
Descriptive and
hierarchical linear
modeling
Results indicated that job quality differed
widely across applicants, with advanced
degrees resulting in better job quality. Those
with female gender, African American race,
and economic insecurity were associated with
poorer job quality.
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Authors
Sample
Study Design
Interdependencies
Lund & Cmar
[98]
Nine articles consisting of 14
analyses were reviewed
Use of database, hand,
and ancestral search
strategies to
systematically identify
studies with RSA-911
data; consistent with
researcher member
checking
Factors that consistently predicted lower
employment across studies included the
presence of a secondary disability and legal
blindness
Demmin &
Silverstein [16]
15 current experimental studies
were reviewed, along with
current treatment outcomes
Use of database search
strategies separated by
mental health treatment
modalities
Factors that consistently predicted lower
utilization of mental health resources included
poorly targeted screening, uneducated
practitioners, and ineffective mechanisms of
change.
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3.2 Types of Qualitative Methodologies
One study employed a modified type of grounded theory, and two studies used a
form of content analysis. Anderson et al. [87] combined both inductive and
deductive approaches to their grounded theoretical methodology to encourage the
theoretical
Table 2. Excluded studies
Authors
Justification
Papakonstantinou et al. [99]
Geography
Papakonstantinou [66]
Geography
McDonnall et al. [100]
Focus of Study
Papakonstantinou & Papadopoulos [101]
Geography
Cmar & McDonnall [76]
Population of Study
Koolaee et al. [102]
Geography
Shakespeare & Kleine [56]
Geography
Abbreviations: FG, focus group; OS, online survey; CBPR, community- based participatory
approach; AMD, age-related macular degeneration; RP, retinitis pigmentosa; RSA,
rehabilitation services administration; DARS, department for aging and rehabilitation
services; VEC, Virginia employment commission; CFA, confirmatory factor analysis
constructs of VR personnel involved in their study. It is important to note that
although Anderson et al’s [87] study integrated community-based research
approaches, people with BVI were not explicitly mentioned as part of the
participant pool in this study [9]. Therefore, it is difficult to conclude that the relative
findings can be generalized to this population; findings should be interpreted within
the broader context of VR solely and with caution. Bourgeois et al. [88] deployed
a survey to which 83 rehabilitation counselors were asked to describe both rates
and sources of moral distress, taking a conceptual approach to understanding
patterns and the prevalence of ethical dilemmas involving people with disabilities
engaged in health rehabilitation and/or VR-related services [9]. Like Anderson et
al’s [87] study, people with BVI are not explicitly mentioned as a constituent
demographic in Bourgeois et al’s [88] study, and as such findings should be
interpreted with caution. Crudden and Steverson [63] described their methodology
as an iterative process, whereby data collected through semi-structured interviews
with people with BVI was repeatedly reviewed, recorded, and summarized. The
purpose of Crudden and Steverson’s [63] study was to better understand the
experiences of people with BVI who had prior engagement with VR. It is important
to note that Crudden and Steverson’s [63] study was the sole study in which
participants were explicitly identified as having blindness or visual impairment, and
a qualitative methodological approach was utilized [9].
3.3 Types of Quantitative Methodologies
One study employed a quasi-experimental method, and nine studies pursued a
correlational predictive method. Two studies examined data using only descriptive
methods. Guerette and Smedema [86] used a combination of bivariate and
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hierarchical regression analysis to explore the relationship between perceived
social support and well-being in adults with BVI [9]. Brennan et al. [14] deployed a
longitudinal design to examine cause-and-effect relationships across time for
people with a specific age-related eye disease. Giesen and Hierholzer [89]
described their methodology as multilevel, and purposed to evaluate service
patterns and the impact of VR on employment outcomes for people with BVI
receiving social security benefits [9]. Concentrated on the service structure of VR
for people with BVI and an identified mental illness, Dean et al. [62] formulated a
multivariate model to capture service provision choices and corresponding service
receipts. Clapp et al. [90] added to the literature by providing a descriptive analysis
of a longitudinal data set consisting of cross-state variations of VR-related services
and labor market outcomes for people with BVI. McDonnall and Lund’s [91] study
tested the theory of planned behavior (TPB, see [104,9]) relative to employer
attitudes toward people with BVI using confirmatory factor analysis (CFA).
Zapata’s [92] earliest study used multiple logistic regression to analyze cross-
sectional data to examine correlations between general self-efficacy and
employment in people with a specific age-related eye disease. In the next study
[93], stepwise logistic regression was used to explore the correlation between PDI
and employment status to advance psychosocial correlates of employment for
people with BVI [9]. The following year [94], multiple linear regression was used to
examine the association between impairment-related factors and personal
disability identity (PDI) and group disability
identity (GDI). Zapata’s [95] most recent work utilized hierarchical linear regression
to analyze the association GDI attitudes and mental health indicators. In the same
year, Zapata and Pearlstein [96] conceptualized PDI with disability identity
theoretical constructs, utilizing hierarchical regression analysis to analyze the
association between PDI and disability-related factors [9]. McDonnall et al. [97]
utilized hierarchical linear modeling to investigate job quality as well as predictors
of job quality for people with BVI engaged in VR. Two literature reviews were
conducted; one focused on current mental health treatment and outcomes for
people with BVI (see [16]), and the other, a systematic literature review, focused
on factors related to employment in people with BVI and who are engaged in VR-
related services (see [98,9]).
4. RESULTS
4.1 Theme 1: Education and Intervention: The Impact of Educating
Across Long-Term Expectations
Two studies in this review identified the importance of health-related education that
is inclusive of long-term mental health outcomes and strategic therapeutic
interventions that involve the complex lives of people with BVI. In a quasi-
experimental study with a longitudinal design, participants with age-related
macular degeneration (AMD) were interviewed for objective and subjective
severity of visual impairment between the years of 1998 and 2004 [14,9], with an
assessment of corresponding levels of social support (eg, instrumental, and
affective) across time. Out of the participants included in the analysis sample (n =
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242), results indicated that 40% had daily contact with their children and more than
half saw their children at least once a week. Ninety-one percent of participants
reported having other relatives (eg, siblings and grandchildren) with stable weekly
contact at 36%. In this same study [14], a repeated-measures multivariate analysis
of variance (MANOVA) found no significant change in the level of family
instrumental (ranging from an average of 15.6 at the baseline to 16.0 at Time 4)
nor family affective support (ranging from an average of 7.8 at the baseline to 7.2
at Time 4) [9].
A literature review by Demmin and Silverstein [16] indicated several experimental
studies that were effective at reducing psychological distress and improving self-
efficacy and functioning in people with AMD. In introducing self-management
interventions (eg, managing disease progression and related psychological
issues), people with AMD were found to sustain effective results for up to 12 weeks
and 6 months in some studies. However, the replication of self-management
interventions across less specific eye-related diseases has not been done [9]. It
was suggested [16] that the families of prospective clients (ie, patients) require
education specific to the development of eye-related diseases to facilitate support
across time, including self-supportive strategies to manage future mental health
issues. Perhaps the most notable finding within Brennan et al’s [14] study was that
there was no significant main effect for objective visual impairment, but there was
a significant main effect for subjective visual impairment overall (p < 0.001) at each
time of measurement and for the objective and subjective interaction overall (p =
0.009) [9]. That is, the greater severity of subjective visual impairment equated to
greater levels of instrumental support from families; however, those with poorer
visual acuities (eg, 20/70 to 20/199) equated to no change in levels of assistance.
Brennan et al. [14] suggested that the use of social support resources may be
more motivated by an older person’s self-perceptions of the need for help than by
objective criteria of visual function (eg, acuity) [9]. Demmin and Silverstein [16]
note this same discrepancy, reporting that some studies seeking an association
between objective evaluations of visual function and depressive symptoms were
unable to correlate such scores. Rather, higher levels of depressive symptoms
were found when assessing vision-specific distress (ie, emotional reactions to
vision loss) or vision-related tasks (eg, navigation). Demmin and Silverstein [16]
explicitly reported a sizable amount of qualitative data indicating the rate at which
people with BVI develop negative self-perceptions due to societal stigma and
experience feelings of loss, like bereavement. Demmin and Silverstein concluded
that even the perceived loss of vision may generate significant distress and result
in mental health problems [16,9].
The study by Brennan et al. [14] suggested that VR counselors and care
practitioners exploit the stability of family and friend social support in the planning
of rehabilitative needs; however, the authors emphasized the connections
between self- perception and levels of distress by way of family and friends,
encouraging these issues to be addressed through education. While Demmin and
Silverstein [16] did not speak to the sequencing of self-perceptions by way of family
and friends, it was suggested that education and including families is an important
step to better address the long-term impact of mental health issues in the lives of
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people with BVI [9]. Although the study by Brennan et al. [14] is considerably older,
it is the only study that
utilized a longitudinal design to measure how the severity of objective and
subjective visual impairment affects levels of social support with large population
size (N = 384) [9]. It is also the first study to identify the discrepancy between
objective and subjective visual impairment and its implications for mental health
outcomes. To date, no studies have longitudinally assessed levels of social
support in correspondence to objective and subjective evaluations of visual
impairment in the United States. Still, the study conducted by Brennan et al. [14]
did not operate using randomized clinical trials (RCT), making it difficult to
conclude the generalizability of its effects [9].
4.2 Theme 2: Employer Attitudes and Social Support: Differential
Outcomes Between the Quality and Level of Social Support
The study of social support and its influence on the lives of people with BVI was
expanded in two other studies. A quantitative study by Guerette and Smedema
[86] explored the relationship between perceived social support and well-being in
adults with BVI; however, the use of multiple indicators of well-being in adults with
BVI (N = 199) was investigated (eg, physical well- being, psychological well-being,
financial well-being, family and social well-being, and medical well-being), in which
the entire population size was sampled [9]. The participants in this study reported
visual acuities from 20/80 to total blindness. Results of the regression analysis
performed with the five subscales (Sense of Well-Being Inventory [SWBI], see
[105]) were all significant (p < 0.001) for physical, psychological, economic, and
family and social well-being. With respect to psychological well-being, F(6, 192) =
7.14, p < 0.001, age was significantly positively associated with psychological well-
being (β = 0.16, t (198) = 2.26, p < 0.05), and social support was significantly
positively associated with psychological well-being (β = 0.38, t (198) = 5.62, p <
0.001), controlling for demographic and disability characteristics. These results are
contradictory to findings found in Brennan et al’s [14] study, which indicated that
older adults who reported more levels of social support had higher negative
perceptions of their visual impairment and thus more susceptible to distress.
However, like Brennan et al. [14] Guerette and Smedema [86] emphasized the
negative influence of “overprotection” upon people with BVI stemming from a lack
of education and impacting self-perceptions [9].
Most notably, no significant correlations were found in the sense of medical well-
being, F(8, 192) = 0.2.85, p < 0.05, in Guerette and Smedema’s [86] study (p =
0.019). It was suggested that the degree of severity or the age of onset of a
disability may not affect the well-being of people with BVI. Unlike Brennan et al’s
[14] quasi-experimental study with similar variables, the control of confounding
variables such as demographic characteristics (eg, age and employment) and
more flexibility with measuring disability (eg, age of onset of the disability and
subjective feelings on disability) were unmeasured [9]. Thus, the SWBI is a
reasonably valid substitute for measuring subjective visual impairment. Despite the
age of this study, Guerette and Smedema’s [86] work was the first in the field of
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BVI to incorporate a subjective instrument (SWBI) that was specifically designed
for people with disabilities. Additionally, this study was a partial replication of
another study conducted by Cimarolli and Boerner [106], in which the perceived
quality of social support was not measured. Rather, Cimarolli and Boerner [106]
measured perceived levels of social support on a continuum; Guerette and
Smedema’s [86] study is considered seminal [9].
The other study took a different approach to analyzing social support, incorporating
the workplace context. In a quantitative study focused on the explanatory utility of
the theory of planned behavior (TPB, see [104]), McDonnall and Lund [91]
deployed an online survey to hiring managers (n = 388) to examine the construct
validity of a TPB structural model (N = 25,843). The aim of the study was to uncover
employers’ hiring intentions of people with BVI. Originally grounded in psychology,
TPB [104] posits that behaviors are influenced by intentions, which are determined
by three factors: attitudes, subjective norms, and perceived behavioral control. It
is also possible for external factors to directly coerce or intercept behaviors, [104]
regardless of the intention, depending on the extent to which a behavior is
controlled by the individual, and the extent to which perceived behavioral control
is a valid measure of actual behavioral control (see also [107,108,9]).
Research in this area aims to uncover these hidden values and ideas that influence
decision-making using meta-analyses. An extensive body of literature has
supported the utility of the TPB model of behavior intention (for a review, see
[109]). However, this is the first study [91] that has applied and tested the TPB in
relation to employer hiring intentions regarding PwD, specifically, people with BVI.
Developing four unique constructs (eg, subjective norms, perceived behavioral
control, attitudes-productive, attitudes-challenges, and intent to hire), the
researchers reached a significant correlation among them (r = 0.35-0.75) [9]. A
confirmatory factor analysis (CFA) was conducted to ensure factorial structure of
the TPB-related items, improving model fit (r = 0.37-0.90). Results indicated that
paths between intent to hire and subjective norms (β = 0.32), perceived behavioral
control (β = 0.19), and attitudes-productivity (β = 0.39) were all significant (p <
0.001). However, the path between attitudes-challenges and intent to hire (β =
0.07, p = 0.31) was the only insignificant path. Cronbach’s alpha was lower for total
scores in this domain of items (r = 0.39-0.66) [9]. McDonnall and Lund [91]
suggested that the insignificance of this factor may relate to ambiguity, as some
aspects of subjective norms and perceived behavioral control may have accounted
for the variance, resulting in participants not answering correctly and conflating the
items. Both Guerette and Smedema [81] and Brennan et al. [14] found that the
discrepancy between subjective and objective evaluation of visual impairment can
impact mental health, social support resources, and the use of rehabilitation
services [9]. Guerette and Smedema [86] explicitly mention that while objective
measures of quality of life are most often utilized for PwD, it typically includes
criteria such as employment status, marital status, and physical and material
indicators, which have been found to be a deficit of the disability community (eg,
see [25,53]), thereby resulting in lower levels of quality of life. Given these findings,
it is difficult to conclude that the items from the attitudes-challenges domain in
McDonnall and Lund’s [91] study can be answered indiscriminately to these
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perspectives. McDonnall and Lund elucidated, that although prejudice toward
people who are blind in general is typically not seen as socially permissible,
negative attitudes toward potential employees or job applicants who are blind may
be more common and viewed as more permissible [91,9].
A similar perspective is illustrated in Demmin and Silverstein’s [16] recent literature
review of therapeutic interventions, in which they found that many of the current
interventions for people with BVI are focused almost exclusively on improving
functionality through skills training and less on vision-specific distress [9]. This
study’s structural model of TPB accounted for over 61% of the variance in intent
to hire people with BVI. The strongest predictors of intent to hire were attitudes
toward productivity (β = 0.39) followed by attitudes toward subjective norms (β =
0.32). McDonnall and Lund [91] suggested that VR counselors and care
practitioners focus efforts on educating employers about how people with BVI can
effectively manage their jobs as well as assess the subjective norms of the
prospective employers [9].
4.3 Theme 3: Identity: The Relationship Between Disability and the
Self-Concept of Blindness
Five studies emphasized the role of disability identity on mental health in people
with BVI. All five studies were conducted by the same researcher, although one
was co-authored. The first study [92] in chronological sequence was intended to
explore the associations between general self-efficacy (GSE) and employment
status in working-age adults with retinitis pigmentosa (RP) [9]. Demmin and
Silverstein’s [16] most recent literature review found several therapeutic
interventions that measured self-efficacy as an outcome; however, as noted
previously, these experiments lacked orientation to the mechanisms to which such
change occurred, affecting the longevity of treatment outcomes. In comparison,
Zapata’s [92] earliest study concerning disability identity intended to correlate GSE
to employment status in people with BVI, specifically people with RP; in other
words, employment was examined as a mechanism by which GSE may be
manipulated. In a large sample size of (n = 183) participants, multiple logistic
regression was conducted to analyze cross- sectional data [9]. Findings indicated
that individuals with RP who have a bachelor’s degree or higher had significantly
higher odds of being employed (p < 0.01), at 158% higher likelihood, and that
individuals with RP who use a cane or guide dog had significantly lower odds of
being employed (p < 0.01). Most notably, participants who used a cane or guide
dog had an estimated 64% lower odds of having full- or part-time employment,
compared to participants who did not use a cane or guide dog, after accounting for
the other variables in the model [9].
These findings lend to findings from a later study by Zapata, [94] to which results
indicated that the use of a mobility tool (eg, cane, guide dog) reported higher
disability affirmation (eg, personal disability identity [PDI]) in participants (p =
0.001), with younger participants displaying higher reports of connectedness with
the disability community (eg, group disability identity [GDI], p = 0.001) [9].
However, in this same study, disability acceptance, an item such as “I regret that I
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am a person with a disability”, was not significantly associated with any of the
variables, such as age, gender, or impairment-related factors, accounting for only
12% of the variance. The clinical application was suggested by Zapata [94] relative
to O&M to address the social issues inhibiting mobility tool use. Earlier critiques by
Virgili and Rubin [74] stated the same, recommending that O&M providers apply a
subjective measure of quality of life in the assessment of mobility for people with
BVI. Assertiveness training and disability-affirmative case conceptualization were
suggested by Zapata; [94] however, Demmin and Silverstein’s [16] recent literature
review indicated that no such intervention exists [9].
Retreating the earliest study, Zapata [92] controlled for factors previously linked to
employment outcomes for people with BVI (eg, age, gender, education level,
mobility tool use, ability to drive, and age at diagnosis), to which age, gender, and
age at RP diagnosis were not found to be associated with employment status. GSE
was measured on a 10-item unidimensional scale. For every 1-point increase in
GSE, participants had 8% higher odds of having full or part-time employment, with
the odds ration approaching statistical significance (z = 1.82, p = 0.07) [9]. Using
Bandura’s [110] theory of self-efficacy, Zapata [92] suggested that employment
and psychological well-being were connected, with self-perception in ability
connected with self-efficacy levels, an item such as “I can usually handle whatever
comes my way”.
The suggestion that self-perceptions are an alterable cognitive construct and may
be the target of interventions to increase employment outcomes for adults with RP
or other eye conditions is supported by Brennan et al., [14] who found that the
greater severity of subjective visual impairment equated to greater levels of
instrumental support from families, thereby affecting self- perception [9]. Zapata
[92] suggested that self-efficacy expectations are influenced by social
persuasions, such as someone else suggesting that another can cope successfully
in a specific, formerly stressful situation (see also [110]). Self-efficacy was an
outcome target in many of the experimental studies reviewed by Demmin and
Silverstein, [16] and rates of self-efficacy did improve; however, employment was
not linked as a mechanism to which change occurred. Considering what was found
by Zapata [92] on associations of self-efficacy and employment, it is suggested
that therapeutic interventions may not be linking self-efficacy as a social construct,
but in terms of functional mastery [9]. As is elucidated by Zapata, the effect of this
information [social persuasion] on people’s self-efficacy is determined by how they
cognitively appraise the information [92].
Going beyond a mere reference to the concept, Zapata and Pearlstein [96]
incorporated recent theories from earlier studies (eg, see [111,112]) to assess PDI
and its psychological impact on people with BVI. Using two novel attitudinal
subconstructs of PDI (eg, self-worth and personal meaning and disability-related
factors), with corresponding general anxiety and depression measures (Patient
Health Questionnaire [PHQ-4], see [113,9]), lower disability self-worth was
significantly associated with increased depression and anxiety (β = −0.40, p <
0.001). Additionally, this study controlled for demographic and disability-related
factors, allowing for more variance in disability as a mechanism for change in
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mental health and clinical settings for people with BVI. Most notably, findings from
this study indicated that the effects of self-worth (r = −0.47) were greater than
personal meaning (r = −0.23) in the prevalence of anxiety and depression; in other
words, it was the strongest predictor of symptoms of depression and anxiety for
people with BVI in this study [9]. Demmin and Silverstein [16] also reported many
other predictive–correlational studies that found associations between anxiety and
depression and people with BVI [9]; however, predictors identified in this study
included vision adjustment, age at onset of vision loss, low vision acceptance, and
vision-specific distress. Age and gender were also variables in Zapata and
Pearlstein’s [97] study, to which age (β = −0.18, p < 0.001) and gender (β = −0.15,
p < 0.001) were also significantly correlated; males and older adults with BVI who
have high self-worth predicted less anxiety and depression. Given what was found
in Brennan et al. [14] and Guerette and Smedema’s [86] studies regarding the
discrepancies between subjective and objective visual function, and Zapata [92]
and Zapata and Pearlstein’s [96] studies regarding connections between self-
worth and self-efficacy, it is difficult to conclude that such predictions found in
Demmin and Silverstein’s [16] literature review are not inclusive of these and are
simply lacking appropriate measures [9].
A notable strength of this study [93] is the use of a novel PDI instrument to measure
disability self-worth and personal meaning, such that both items encompass
aspects of disability from a subjective perspective rather than objectively. For
instance, for disability self-worth, one item was “I have as much to offer the world
as people without a disability”, and a personal meaning item was “my disability
gives me perspective on what matters in life” [9]. Again, Guerette and Smedema
[86] and Brennan et al. [14] found that discrepancies exist between subjective and
objective evaluations of visual impairment, leading to skewed results, echoing
historical measurements of disability discussed earlier (eg, [31,32,9]).
The final study by Zapata [95] explicitly focused on the association of lower anxiety
and depression in people with BVI relative to GDI. In contrast to earlier studies,
[92,93] this most recent study withdrew correlations to employment specifically,
although implications were indicated. Interested in furthering the concept of GDI
and its association with mental health outcomes, Zapata [95] utilized a cross-
sectional design to examine the associations between two GDI attitudes (disability
integration and disability isolation) and three mental health-related indicators (life
satisfaction, anxiety, and depression) in a large sample of US adult members (n =
187) of BVI community groups [9]. In controlling for demographic and impairment-
related variables, results indicated that participants who reported a higher sense
of connection to the disability community (ie, disability integration) also reported
overall higher life satisfaction (β = 0.25, p = 0.001). Participants who reported a
higher sense of isolation from both the disabled and nondisabled community (ie,
disability isolation) also reported overall lower life satisfaction (β = −0.45, p < 0.001)
as well as higher anxiety (ß = 0.26, p < 0.001) and depression (ß = 0.40, p < 0.001).
The negative association between depression and being employed approached
significance (ß = −0.23, p = 0.004), which correlates to earlier studies regarding
connections between self-efficacy [92] and self-worth [96] and employment [9].
Notably, for integrators, the association between anxiety and gender approached
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significance (ß = −0.19, p = 0.009), and for isolators, gender (ß = −0.21; p = 0.003)
was significantly associated with anxiety. Apart from any demographic or
impairment factors, GDI attitudes (integration and isolation) were the only variables
that reached statistical significance in predicting life satisfaction in this study.
Specifically, disability isolation, but not disability integration, was a significant
predictor of anxiety and depression. Zapata [95] suggested that care practitioners
consider supporting clients’ (ie, people with BVI) mental health and related
outcomes by facilitating their exploration of disability identity attitudes including
feelings of connection to the disability community [9].
4.4 Theme 4: VR Classification and Service Patterns: The Concept of
Risk
Five studies quantitatively explored the factors that predict employment outcomes
for people with BVI, including the assessment of VR service patterns and
classification. The earliest study to investigate was a multilevel analysis by Giesen
and Hierholzer [89], who explored VR service patterns and evaluated the potential
employment outcomes for people with BVI using FY 2011 rehabilitation services
administration (RSA-911) data on consumers (N = 3610) who also received social
security disability income (SSDI) [9]. Results indicated that services are delivered
in clusters, such that the higher correlations of services within clusters inform
services within factors that tend to be received together. Regarding evaluation
services (ie, factor), which are inclusive of mental health services, only two of the
four services in this factor group were related to employment outcomes: VR
counseling and guidance and assessment [89]. Results from this study indicated
that people receiving VR counseling and guidance have 32% higher odds of
competitive employment, whereas assessment services indicated 34% lower odds
of competitive employment. Information and referral services and technical
assistance services were not significantly related to outcome [9].
Dean et al’s [62] study examined the types of services provided to people with BVI
who have an identified mental illness. Results showed that when combining the
employment and earnings effects together, apart from diagnosis and evaluation,
all service types had positive long-run effects. Similarly, Clapp et al’s [90] analysis
of VR-related services indicated persistent earnings benefits; however, there was
substantial cross-state heterogeneity relative to the types of services offered.
Further, in their cost-return analysis, results indicated that diagnosis and
evaluation had a mean service cost of $408 per client and restoration at $2,576; in
order of magnitude, both were less expensive than all the other services. In any
case, it was suggested that such services are considered a “risk” to employment
outcomes [89,9].
Similarly, Lund and Cmar’s [98] recent systematic literature review postulated the
potential “risk” for VR consumers with BVI to have unsuccessful closures due to
poorly targeted supports and interventions, particularly those receiving SSDI [9].
McDonnall et al. [97] also postulated this same risk, stating that people with BVI
who are also receiving SSDI may be at risk for poorer employment quality. Still,
this study [89] found that there exists a holistic, multilevel assessment process that
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operates systematically depending on service needs. However, these needs are
considered a “risk” if not associated with employment outcomes. Despite its age,
this is the first study that offered a systematic lens to VR services for people with
BVI. Giesen and Hierholzer stated the negative link between receipt of assessment
services and competitive employment may involve a more complicated situation in
which the needs of the individuals are not readily apparent [89,9].
The necessity of long-term studies for improved treatment outcomes was echoed
in Demmin and Silverstein’s [16] literature review, and clinically emphasized by the
findings in Zapata’s [92,93] studies relative to the role of psychosocial factors in
employment outcomes [9].
While some studies on this theme did utilize RSA-911 data to explore
characteristics of VR, [87,97] many studies highlighted its limitations [62,89,90,98].
In McDonnall et al’s [86] study, results indicated that job quality indicators were
higher for consumers who were employed at application than for those not
employed at application. Most notably, in terms of VR-related services, receipt of
a certificate, receipt of an associate degree, and receipt of a bachelor’s or higher
degree were positively associated with job quality at VR case closure [9]; however,
receipt of job readiness training and on-The-job supports–supported employment
were negatively associated with job quality. Lund and Cmar’s [98] systematic
literature review highlighted this same weakness in RSA-911 data, finding it limited
to what is contained within the data set (eg, demographic vs consumer rating of
services). Based on findings from Giesen and Hierholzer’s [89] study on the
systematic patterns of VR services and their connections to employment
outcomes, it is suggested that employment outcomes are multidimensional;
therefore, it is difficult to conclude that job quality outcomes are indicative of
objective evaluations solely [9]. Dean et al. [62] and Clapp et al. [90] were the sole
researchers who did not utilize RSA-911 data for their studies. Clapp et al. [90]
asserted that while employment earnings were constant across states, the varied
services are misleading accounts of VR's long-term effectiveness for people with
BVI. All studies on this theme operated under the most current legislation of WIOA,
[35] which emphasizes job retention, not simply job attainment, adding to the
strengths of all findings [9].
4.5 Theme 5: VR Counselor Relationships and Community
Involvement: The Role of Persistence, Morality, and Social
Aggravators Amidst Employment Challenges
Two studies sought to explore the impact of VR-related services from a qualitative
perspective, and one used a mixed-methods approach. The aim of all the studies
on this theme was to examine the personal experiences of people with BVI, VR
counselors, and the impact on their communities and organizations. Crudden and
Steverson [63] conducted semi-structured interviews with people with BVI who had
a history of navigating the VR system (n = 11) to better understand how jobs are
retained [9]. Results were organized under two broad areas: generalizable skills
and issues associated with retention. Generalizable skills included technology,
networking, and persistence. Issues associated with job retention included VR
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support, personal factors, and workplace efficiency. These results correspond with
McDonnall & Lund’s [92] study which found that employer’s strongest predictor of
intent to hire was attitudes toward the productivity of people with BVI. Participants
described the psychosocial stressors (eg, anxiety) associated with job retention;
however, reported benefiting from persistence and support networks [9]. Notably,
the theme of “persistence” emerged as both a generalizable skill and an issue
associated with retention. Specifically, six participants reported persistence as a
skill that assisted them in being successful in their jobs, and three mentioned
persistence was a personal factor that assisted them in retaining their jobs [63].
Regarding VR-related services specifically, five participants expressed concerns
with the timeliness of VR-related services and three stated that VR-related services
are not equipped to provide long-term support [9]. This finding contradicts findings
from Lund and Cmar’s [98] most recent systematic literature review which
indicated that job-related services were the stronger predictor of employment. Job-
related services can be defined as services that prepare people with BVI to obtain
and retain positions. In McDonnall et al, [89] study job-related services were not
correlated with job quality or had a small, negative correlation. These findings are
consistent with other studies in which a negative relationship between job-related
services and job quality was found [114–116,9]. McDonnall et al asserted, that
consumers who require assistance from VR with preparing for or locating
employment, rather than being able to prepare for and find it on their own, are
more likely to obtain lower-quality jobs [89].
Crudden and Steverson’s [63] study utilized an iterative approach to data analysis,
improving the overall credibility of the data. However, the sample size was
incredibly small, affecting the generalizability of the data [9].
Work-related stressors were also experienced by VR counselors. A recent mixed-
method study explored the concept of moral distress from the perspective of VR
counselors. Using a randomized sampling method of (N = 1000) VR
counselors, Bourgeois et al. [88] explored the prevalence and impact of moral
distress within the context of professional work. Moral distress can be defined as
when one knows the right thing to do but institutional constraints make it nearly
impossible to pursue the right course of action [117,9].
It is important to note that in this specific study, Bourgeois et al. [88] distinguish
between moral distress and ethical dilemma, in that the latter constitutes difficulty
in decision-making whereas the former’s effects are relative to external constraints
to a decision. For participants who completed the survey (n = 83), results indicated
that the average rating of moral distress was 4.32 (uncomfortable) out of 10, with
43% reporting a distress rating of 5 (uncomfortable/distressing) or higher [9]. A
notable finding within this study [88] was the theme of “compromised service
delivery”, which emerged as a common source of moral distress for VR counselors.
Specifically, it was found that there was an inability to provide optimal services to
clients due to the following: large caseloads, time constraints, lack of qualified
counselors, a shared finding from Demmin and Silverstein’s [16] literature review,
and lack of training and focus on outcomes and cost control. One participant (#29),
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as cited in Bourgeois et al. stated, I am concerned that my clients are not getting
the good quality care that they need to recover from mental health or substance
abuse problems [88,9].
Cost control was also a theme in Clapp et al’s [90] analysis in which they found
that diagnosis and evaluation services were among the lowest in terms of mean
service cost, while restoration services were much higher; nonetheless, both
services were indicated to have the lowest probability of service receipt. Lund and
Cmar’s [98] systematic literature review spoke to VR focus on employment
outcomes, suggesting that people with BVI who have secondary disabilities or may
need additional support are at “risk” for unsuccessful closures [9].
The strength of Bourgeois et al’s [88] study lies in their methodology, as they used
a consensual qualitative research (CQR) approach, an inductive approach to
describe the phenomenon, adding reliability to this study’s findings. The same
approach was utilized by Anderson et al, [87] in which they examined the
intersection of race and poverty in the engagement of VR-related services [9].
Results indicated that trauma-sensitive and culturally responsive care is needed
to meet the demands of the social-political realities of VR consumers. In Lund and
Cmar’s [98] systematic literature review, they found that African American race
was a significant negative predictor in two (OR = 0.67–0.70) of eight analyses of
competitive employment. McDonnall et al. [89] found that job quality was
negatively associated with African American race, female gender, disability, and
SSDI [9]. Anderson et al. [87] suggested that VR programs identify and address
ongoing racial stressors associated with depression and related mental health
considerations, emphasizing that engagement in VR is impacted by these ongoing
stressors. Demmin and Silverstein’s [16] most recent literature review on
therapeutic interventions indicated no such clinical approaches or assessments
[9].
5. DISCUSSION
Little is known about the multifactorial influence of mental health utilization in the
lives of people with BVI. To address this gap, this review aimed to provide a
comprehensive analysis and synthesis of current literature utilizing a critical
systems framework to examine the social and biological relationships between the
systems most involved in the lives of people with BVI. There are marked contrasts
between VR and people with BVI on what predicts job quality and subsequent
competitive employment for people with BVI, which consequently transcends into
the clinical environment [9]; most interventions fixate on improving occupational
functionality through skills-training, a short-term issue when considering the
multidimensional needs, identities, and experiences of people with BVI.
Intersectionality is greater than the sum of any singular identity and thus must be
considered as part of solutions and affected by social problems [118]. Most
employers rely on the subjective norms of people with BVI and their productivity
levels when considering hiring potential. Consequently, these attitudes are a factor
in the emergence of mental health symptoms, such as anxiety, depression, and
feelings relative to self-efficacy and wellbeing [9]. Furthermore, it is difficult to
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conclude that among these challenges, people with BVI would seek independent
mental health intervention, through employer benefits or otherwise, as much of the
reviewed literature found service delivery congruent with objective evaluations of
visual function rather
than subjective evaluations. Moreover, the discrepancy identified between
objective and subjective reports of visual function, such that self-perceptions of
visual impairment can overrule objective criteria of visual function, only serves to
widen this gap [9]. Without appropriate theoretical and conceptual frameworks that
offer choice, people with BVI may not be provided well-targeted care. The
Diversity, Equity, and Inclusion (DEI) (eg, [119]) tenet of equity emerges here as a
reminder of the importance of fulfilling opportunity through congruent approaches
that are intended to mobilize the most marginalized and not simply fill a need (see
also [118,9]). Other research has documented the work of interventions that offer
choice and incorporate peer power for people with BVI. Koolaee et al’s [102]
experimental study utilized choice theory [120] and a combination of group training
and action strategies to investigate its impact on quality of life and hope in people
with BVI (n = 30) [9]. Utilizing the Quality-of-Life Questionnaire (WHOQOL, see
[121]) to measure multiple effects (eg, physical, psychological) of the training and
therapeutic sessions, results indicated that the training of choice theory concepts
affected the quality of life (F = 22.5, p < 0.001) and hope (F = 35.17, p < 0.001) of
people with BVI. Considering the prior research indicating barriers to the
comprehension of mental health concepts for people with BVI, it seems safe to
conclude that the training of choice theory concepts may improve the quality of life
and hope for people with BVI, thereby improving ecological validity. However, this
study was conducted outside of the United States, and thus more research is
needed [9].
In contrast to the mainstream population, the classification of disability arguably
does not interfere with the conceptualization and utilization of mental health
services. It is inequitable for people with BVI, and their emerging mental health
needs to be conceptualized as more or less complex than the average person
without a disability. Concerning VR, the long-standing impact of disability
attachment and its social-political history may be part of the problem with how VR
is managing mental health, its establishment as a condition, and related services.
Clinicians, specifically, may believe that outreach concerning this population is not
necessary because VR is providing appropriate services, including assessing the
need for mental health services; however, this is inconclusive [9].
5.1 The Power of a Podcast: Building Collective Equity
A critical forum in the medium of a podcast or otherwise collaborative online
discourse may aid in exposing and addressing the underutilization of mental health
in the lives of people with BVI. There exist multiple strengths associated with this
proposal. New digital technologies, such as podcasts, provide socially
marginalized people around the world with a mechanism through which they can
make their voices heard [122]. Despite traditional media’s (eg, television media)
social task to represent the interests of all members of society, marginalized
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people’s injustices and needs are often devalued, with content primarily focused
on and designed for dominant or popular groups [123]. Members of the privileged
class have received criticism for appropriating traditional media to reinforce their
interests and dismissing or misreporting perspectives that go against their interests
[124,9].
In addition to underrepresentation in traditional media outlets, marginalized groups
often face exclusion from government bodies. In considering societal issues,
members from the dominant culture tend to launch communication, and their
recommendations have more power [125]. A podcast that focuses on collaborating
to fuel reparations and reenergize the concept of mental health for people with BVI
does not seek expertise from centuries-old rudimentary processes; it seeks a
renewed understanding and reexamined process [9]. People with BVI have access
to education pertinent to their mental health experiences and issues that are
accessible (ie, they can listen and share for free). In addition, there exists no
academic bias to membership to this podcast or its content; such is the case for
most privileged information in scholarly journals [9].
Rehabilitation professionals can receive contextually relevant education without a
cost; and that is informed by research, testing theory to story, and practice [126].
In addition, busy professionals can listen quickly and easily without scheduling a
conference or taking time off [127,128,9].
There exist limitations to this capstone project that should also be acknowledged.
In many academic circles, podcasts, despite being well-researched and supported,
lack credibility because they are not affiliated with an institution, lab, or research
facility (eg, [126]). As such, there is a possibility that replication of scholarly
suggestions does not occur because they lack peer-review processes. As is
elucidated by Kiernan et al., the listener must rely on their own assessment of the
weight they should give to the supplied content [126].
There exist four theories that have been conceived to inform the need for a critical
forum or podcast: (1) critical disability theory (eg, see [129]), (2) choice theory (eg,
see [120]), (3) theory of self-efficacy (eg, see [110]), and (4) liberation health
theory/framework (eg, see [130,9]).
5.2 Critical Disability Theory
First, critical disability theory can be framed and understood by examining the
earliest works by Max Horkheimer [129] relative to his critique of traditional social
inquiry and order. In his 1937 essay titled, “Traditional and Critical Theory”,
Horkheimer [129] states that critical theory is a social theory oriented toward
critiquing and changing society, in contrast to traditional theory oriented only
toward understanding or explaining it. Critical disability theory, then, can be defined
as a methodology of inquiry that involves scrutinizing not bodily or mental
impairments but the social norms that define particular attributes as impairments,
as well as the social conditions that concentrate stigmatized attributes in particular
populations [26,9].
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Similar definitions have also been ascribed to the theory (eg, [131,132]). When
considering findings from current research, there exists no utility of critical
frameworks nor approaches that examine the mental health issues of people with
BVI; while current research exists surrounding the mental health effects of social
and impairment-related issues relative to this population (eg, see [92–95]), none
of these findings have been replicated since first identified in 2011 (eg, see
[14,86]), with a current practice primarily focused on vision-related mental health
issues (eg, see [16,9]), such as visual function (eg, acuity). A critical forum or
podcast can work to intentionally critique and challenge traditional approaches to
understanding the mental health issues of people with BVI with the goal of
producing new methods of problem-solving, particularly within the centralized and
interconnected relationships between VR, O&M, care practitioners, and people
with BVI.
5.3 Choice Theory
Second, choice theory, as aforementioned within the discussion section of the
literature review, was developed with a proceeding therapeutic approach targeted
toward the education of clients with control-based psychological deficits [120].
According to Glasser, [120] choice theory explains that we are motivated by the
pleasure we experience when we satisfy our five basic needs for survival (ie, love
and belonging, power, freedom, fun, and survival) [9]. Thus, all behavior is an
individual choice, not necessarily a product, or outcome, of someone or something
else. However, when we seek external control (eg, via coercion or threats) to
satisfy any one of these five needs, we experience unpleasant emotions and
mental states simply because we are unable to control others, only ourselves
[120]. Reality therapy, the established therapeutic approach consistent with choice
theory, utilizes cognitive behavioral therapy principles to aid clients in gaining new
perspectives and techniques that will help them manage challenges on their own
[120]. As William Glasser pragmatically explained in a published interview with
Onedera and Greenwalt [9]:
That’s the definition of mental health; it is healthy relationships, especially
relationships that are so healthy that you don’t try to change people around
you…you eliminate the use of what I call ‘external control psychology’ from the
relationship…and so it’s a triple metaphor, mental health equals happiness equals
choice theory [133,9].
When considering the current research indicating the concentration of mental
health resources for people with BVI as a consequence of VR-related assessment
and evaluation (eg, see [89,90]), the relationship between VR (ie, case managers,
counselors) and people with BVI is one that requires a re-establishment of the
notion of locus of control (eg, see [134]). Oppressive and structural systems
challenge social influence thereby impacting social constructions, leading to
recursive effects [25,135–138]. That is, what a person can receive from society
and structures may shape their activity, yet this same activity is voluntary and
continues to shape and affect their social lives [134,9]. A critical forum or podcast
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can provide a means of educative introspection that aids people with BVI to
recognize the power that is given, not necessarily the power held. Reality therapy,
then, can be an organized effort to incorporate into clinical settings which people
with BVI are cognizant of, and may specifically request, during assessment or
evaluative procedures [9]. Further, concepts learned through this podcast project
may assist people with BVI in making sound choices related to seeking privatized
mental health care, disconnected from VR entirely. When considering what was
found in the research by [63] related to the overall discontent with VR-related
services by people with BVI (eg, timeliness, appropriateness), concepts from
reality therapy may be beneficial to reducing the proclivity to “persist” in such
situations, and rather “abandon” attempting to single-handedly control such a
complex structural system; indeed, healthy relationships begin when individuals
can notice the nature and benefit of relationships and their unique role and need
within it, [120] adjusting as necessary (see also [133,9]).
5.4 Theory of Self-Efficacy
Third, the theory of self-efficacy is defined by Albert Bandura as belief in one’s
capabilities to organize and execute the courses of action required to produce
given attainments [110].
Bandura [110] asserted that a person’s belief in their capabilities affects their
initiation and persistence on a given task; this mention of “persistence” was noted
in the current literature as both a “personal factor” and “skill” that assisted i n job
retention [63]. When an individual believes that they can successfully perform a
task that will produce a desired outcome, they will exert more effort in their
performance of that task. Expectations relative to self-efficacy stores rely on a
combination of four sources: performance accomplishments, vicarious
experiences, physiological states, and verbal persuasion [108,9]. When we
consider the current research by Zapata [92] indicating the associations between
self-efficacy and employment outcomes, and how self-efficacy was primarily
utilized as a “skills-based” outcome target in Demmin and Silverstein’s [16] recent
literature review, it can be suggested that the role of self-efficacy as a cognitive
construct is effective at mitigating the emergence of mental health symptoms for
people with BVI. However, based on the current research data regarding the
prevalence of mental health symptomology for people with BVI (eg, see
[95,96,103]), and long- term mental health ineffectiveness (eg, see [16,9]), self-
efficacy may not be a target of mental health treatment outcomes associated with
social aggravators (eg, prejudice). A critical forum or podcast may aid in the
development of clinical treatment approaches, including measures, to
appropriately identify sources of self-efficacy to which deficits may be targeted.
Additionally, the education and collaboration intent of this podcast project may help
current and prospective employers challenge the subjective norms placed on
people with BVI (eg, see [91]) such that “performance” and “productivity” are not
considered the primary “quality” measures to which people with BVI are
categorized [9].
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5.5 Liberation Health Theory
Fourth, liberation health theory, a combination of radical social work (eg, see
[139]), liberation psychology (eg, see [140]), and Paulo Freire (eg, see [141]) and
popular education, focuses on expanding “traditional case work” into actionable
practices that serve to disrupt the interplay of dominant socio-political forces [130].
In a participatory sense, clients become “subjects”, developing a new
“consciousness” that rejects the “passive sense of self”, allowing for meaningful
progress to occur in the context of their problem [130]. Historical trends (eg, see
[23,25,28,9]) relative to the role of disability as a classification measure have been
utilized to conceptualize problems for people with BVI for decades, including the
emergence of mental health issues (eg, see [7,17]), which in turn, impact how
mental health symptoms are managed by VR, O&M, and care practitioners with
mental health expertise. The category of disability arrives with predetermined
outcomes that are socialized and subsequently reinforced by professionalization,
[142–144] eg, deficit, personal tragedy; similarly, PwD assume this identity,
centering their impairment causal to their “suffering” [25,145–149,9]. This causal
sequencing affects problem-solving and perceived action efficacy for PwD,
particularly as it pertains to social or economic needs [143,144]. Within many
health organizations, the medical model is dominant, as it aligns with the
pedagogical truths inherent to most health-rehabilitation professionals. The
presence of the two models inhibits holistic understanding based on discipline-
specific training and promotes conjectures of the need for PwD [142–144,9].
When considering the historical trends denoting the dichotomous processes that
occur when related professionals behave consistent with the medical or social
models of disability (eg, see [25,29]), and current research identifying
discrepancies in the objective and subjective evaluations of vision impairment (eg,
visual function, visual acuity) and correlations to depressive and anxious
symptoms (eg, see [16,9]), two points are suggested: (1) related professionals are
choosing one of the two models of disability, without attempting to learn about the
validity of the other, and (2) people with BVI are lacking subjectivity to the clinical
processes that hypothesize the direction of causality regarding mental health
issues. A critical forum or podcast can work to utilize liberation health theory as a
framework for exposing the dominant discourse (eg, see [150,9]) and relevant
training that helped shape professional knowledge, specifically the knowledge of
VR, O&M professionals, and care practitioners with expertise in mental health
philosophy. By leveling power as neutral and referring to guests and podcast
listeners as “learners”, they can reflect critically on their experiences and
foundational knowledge to enhance their understanding of roles; this work
challenges prior assumptions and critiques the idealism (eg, see [151]) behind
subconscious behavior (eg, ableism and disability diversity), evoking new
consciousness [130] DEI (eg, see [119,9]) reinforces this work, asking for the
transition of knowledge to evolve, embracing complex intersectionalities with the
goal of disrupting dominant knowledge (see also [118]). Finally, by including
people with BVI in such discourse (ie, talking about but not with people), we are
rejecting the traditional processes in which change and reform occur relative to
ameliorating problems of marginalized populations (eg, see [152,9]).
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6. LIMITATIONS
While much of the current literature was discussed to correspond to the
development of an educational podcast, this author acknowledges the limitations
of theory and the impact of researcher bias, particularly when working with
marginalized populations. As such, the limitations of deductive reasoning in such
an enterprise are detailed in the following subsections.
6.1 A Better Methodology
As previously mentioned, critical disability theory (e.g., see Minich, 2016) was
recommended as a critical methodological approach in critiquing the cognitive and
social orientations that center visual impairment as a derivative of associated
problems. The mental health issues of people with BVI are critiqued as more than
disability-specific conjecture, thereby refocusing effort on critiquing the systems of
engagement, including health rehabilitation, that stigmatize such attributes. Such
work serves to reenergize the mental health needs of people with BVI and, thus,
challenge change initiatives to occur. While effective in both the development of a
critical podcast and the reexamination of rehabilitation provider relationships,
critical disability theory may be too general of a concept. Specifically, it can be
argued that as a methodology, critical disability theory lacks specificity to the
experience of vision loss and, thus, may be more effective as a precursor construct
in understanding the mental health issues of people with BVI.
As such, it is recommended that a podcast enterprise adopt a peer-mentoring
approach to improving mental health utilization for people with BVI, whereby
trained peers act as mentors to people with BVI who recently lost their vision or
are experiencing vision-specific distress (i.e., emotional reactions to vision loss).
As vision loss is a complex and unique experience (e.g., see Demmin & Silverstein,
2020), it can be argued that relational approaches (e.g., see Cait, 2016, and Singh
et al., 2020) that aid people with recent vision loss or vision-specific distress to
examine their subjective beliefs (e.g., values, emotions, judgments)
intersubjectively (e.g., see Cait, 2016) is a valuable way to assess their mental
status relative to the vision loss.
The argument relative to vision loss as both a complex and unique experience is
represented within the literature. Two seminal works are highlighted. First, in a
longitudinal experimental study by Brennan et al. (2011), 242 participants with
AMD were interviewed for objective (i.e., visual acuity) and subjective severity (i.e.,
self-perception) of visual impairment between 1998 and 2004 (Brennan et al.,
2011), with an assessment of corresponding levels of social support from families
(e.g., instrumental and affective) across time. The most notable finding within
Brennan et al.’s (2011) study was that there was no significant main effect for
objective visual impairment, but there was a significant main effect for subjective
visual impairment overall (p < .001) at each time of measurement and for the
objective and subjective interaction overall (p = .009). That is, the greater severity
of subjective visual impairment (i.e., self-perception) equated to greater levels of
social support from families; however, those with poorer visual acuities (e.g., 20/70
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to 20/199) equated to no change in levels of assistance. Brennan et al. (2011)
suggested that the use of social support resources may be more motivated by self-
perceptions of the need for help than by objective criteria of visual function (e.g.,
acuity). Although the study by Brennan et al. (2011) is considerably older, it is the
only study to date that utilized a longitudinal design to measure how the severity
of objective and subjective visual impairment affects levels of social support for
people with BVI with a large population size (N = 384). It is also the first study to
identify the discrepancy between objective and subjective visual impairment and
its implications for mental health outcomes. To date, no studies have longitudinally
assessed levels of social support in correspondence to objective and subjective
evaluations of visual impairment in the United States.
Demmin and Silverstein (2020) noted this same discrepancy in their review,
reporting that some studies seeking an association between objective evaluations
of visual function and depressive symptoms were unable to correlate such scores.
Rather, higher levels of depressive symptoms were found when assessing vision-
specific distress (i.e., emotional reactions to vision loss) or vision-related tasks
(e.g., navigation). Demmin and Silverstein (2020) also reported a fair amount of
qualitative data indicating the conditions to which people with BVI develop negative
self-perceptions because of societal stigma and experience feelings of loss, like
bereavement (e.g., see Teitelman & Copolillo, 2005, and Thurston et al., 2010),
albeit older studies. As is elucidated by Demmin and Silverstein (2020), “even the
perceived loss of vision may generate significant distress and result in mental
health problems” (p. 4233).
Second, a quantitative study by Guerette and Smedema (2011) explored the
relationship between perceived social support and well-being in adults with BVI
across multiple indicators (e.g., physical well-being, psychological well-being,
financial well-being, family and social well-being, and medical well-being). Results
of the regression analysis performed with the five subscales (Sense of Well-Being
Inventory [SWBI]; Rubin et al., 2003) were all significant (p < .001) for physical,
psychological, economic, and family and social well-being. With respect to
psychological well-being, F(6, 192) = 7.14, p < .001, age was significantly positively
associated with psychological well-being (β = .16, t(198) = 2.26, p < .05), and social
support was significantly positively associated with psychological well-being (β =
.38, t(198) = 5.62, p < .001), controlling for demographic and disability
characteristics. These results are contradictory to findings found in Brennan et al.’s
(2011) study, which indicated that participants who reported greater levels of social
support had higher negative self-perceptions of their visual impairment and, thus,
were more susceptible to distress. However, like Brennan et al. (2011), Guerette
and Smedema (2011) emphasized the negative influence of “overprotection” upon
people with BVI stemming from a lack of education and impacting self-perceptions.
Most notably, no significant correlations were found in the sense of medical well-
being, F(8, 192) = .2.85, p < .05, in Guerette and Smedema’s (2011) study (p =
.019). It was suggested that the degree of severity or the age of onset of a disability
may not affect the well-being of people with BVI. Despite the age of this study,
Guerette and Smedema’s (2011) work was the first in the field of BVI to incorporate
a subjective instrument (SWBI) that was specifically designed for PwD.
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The mention of “overprotection” in Brennan et al. (2011) and Guerette and
Smedema’s (2011) research as a barrier to self-supportive outcomes was
corroborated in Demmin and Silverstein’s (2020) most recent literature review.
Subjective beliefs relative to vision loss are powerful forces of change and
motivation for aid for people with BVI (e.g., see Brennan et al., 2011, Demmin &
Silverstein, 2020, and Guerette & Smedema, 2011). Conversely, such beliefs can
manifest differently contingent on the character of social support and the type of
well-being introduced (e.g., see Brennan et al., 2011; Guerette & Smedema, 2011).
When considering the lack of research studying vision loss from a trauma-specific
framework, clinical treatment approaches failing to identify mechanisms of change
(e.g., increased hope for the future, recovery of self-esteem) relative to vision loss
(e.g., see Demmin & Silverstein, 2020, Girdler et al., 2010, and Rees et al., 2015),
and clinical assessments largely informed by objective measures of visual
impairment (e.g., see Demmin & Silverstein, 2020), a better methodology is
needed. More research is needed that replicates this literature (e.g., see Brennan
et al., 2011, and Guerette & Smedema, 2011) to aid in the development of a
methodology that better suits the complexity of vision loss as a trauma-related
psychological construct, and so requiring such an approach to understanding the
mental health needs of people with BVI. Despite current literature showing
evidence of the influence of peer support in the lives of people with BVI (e.g., see
Crudden & Steverson, 2022, and McKnight et al., 2021), no research has
examined its utility as a mental-health resource since 2005 and is quite limited
(e.g., see Bradley et al., 2005, and Kleinschmidt, 1999).
6.2 Internalized Ableism: A Mental Health Implication
As previously mentioned, the theory of self-efficacy was recommended for an
educational podcast to aid in the development of discipline-specific treatment
approaches for health rehabilitation professionals and improve the identification of
self-efficacy dimensions relative to health rehabilitation processes for people with
BVI. When considering the malleability of self-efficacy as a psychological construct
(e.g., see Bandura, 1977, 2006) and the effects of self-efficacy on employment
(Zapata, 2020a), self-worth (Zapata & Pearlstein, 2022), and disability identity
(Zapata, 2020b, 2022) for people with BVI, such developments are essential to
increasing understanding of the presence and emergence of mental health
symptoms. While self-efficacy was identified in the literature as influential to action-
efficacy for people with BVI, less research has studied the impact of ableist
ideology (e.g., see Campbell, 2001) on self-efficacy stores and, thus, mental health
for people with BVI, specifically the impact of vicarious experiences that produce
paradoxical effects.
The discussion relative to ableism as both a source of socialized knowledge and
a disabling effect on disability identity development is represented within the
literature. Three studies are highlighted synchronously. Interested in furthering the
concept of group disability identity (GDI) and its association with mental health
outcomes, Zapata (2022) utilized a cross-sectional design to examine the
associations between two GDI attitudes (disability integration and disability
isolation) and three mental health-related indicators (life satisfaction, anxiety, and
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depression) in a large sample of U.S. adult members (n = 187) of BVI community
groups. In controlling for demographic and impairment-related variables, results
indicated that participants who reported a higher sense of connection to the
disability community (i.e., disability integration) also reported overall higher life
satisfaction (β = .25, p = .001). Participants who reported higher sense of isolation
from both the disabled and nondisabled community (i.e., disability isolation) also
reported overall lower life satisfaction (β = -.45, p < .001) as well as higher anxiety
(ß = .26, p < .001) and depression (ß = .40, p < .001). The negative association
between depression and being employed approached significance (ß = -.23, p =
.004), which correlates to earlier studies regarding connections between self-
efficacy (Zapata, 2020a) and self-worth (Zapata & Pearlstein, 2022) and
employment. Notably, for integrators, the association between anxiety and gender
approached significance (ß = -.19, p = .009), and for isolators, gender (ß = -.21; p
= .003) was significantly associated with anxiety. Apart from any demographic or
impairment factors, GDI attitudes (integration and isolation) were the only variables
that reached statistical significance in predicting life satisfaction in this study.
Specifically, disability isolation, but not disability integration, was a significant
predictor of anxiety and depression.
The category of disability arrives with predetermined outcomes that are socialized
and subsequently reinforced by institutions and professionalization (Forber-Pratt
et al., 2019; Kulnik & Nikoletou, 2014; Rebolledo-Sanhueza et al., 2021), e.g.,
deficit, personal tragedy; similarly, PwD assume this identity, centering their
impairment causal to their “suffering” (Brooks, 1991; Brzuzy, 1997; Hahn, 1983;
Hiranandani, 2019; Mackelprang & Salsgiver, 1996; Quinn, 1995). This causal
sequencing affects problem-solving and perceived action efficacy for PwD,
particularly as it pertains to social or economic needs (Rebolledo-Sanhueza et al.,
2021; Kulnik & Nikoletou, 2014). However, few research studies have dared to
disaggregate this phenomenon and focus efforts on concentrated examinations for
varied disabilities, such as BVI, and the mental health implications relative to
internalized ableism as a negative trauma network. More research is needed that
replicates this literature (e.g., see Zapata, 2020a, 2022, and Zapata & Pearlstein,
2022) to aid in increasing understanding of the correlation between independence
as a character trait (i.e., nature) and internalized ableism as a behavior pattern
(i.e., isolation) for people with BVI and how mental health is affected.
6.3 VR as a Dependency
As previously mentioned, VR’s classification and service patterns indicate that VR-
related services are delivered systematically, whereby related needs are factored
into related services, suggesting a holistic and equitable approach to service
provision (e.g., see Giesen & Hierholzer). However, this author suggests specific
data points are negated from measurements of effectiveness related to VR
services and consumers with BVI. In addition, it can be argued that VR’s service
delivery system produces more of a dependency response than one that
encourages independence.
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The discussion relative to the dependency characteristic of VR-related service
provision was highlighted yet not explicitly mentioned within the literature. Five
studies are highlighted synchronously. A multilevel analysis by Giesen and
Hierholzer (2016) explored VR service patterns and evaluated the potential
employment outcomes for people with BVI using FY 2011 rehabilitation services
administration (RSA-911) data on consumers (N = 3,610) who also received social
security disability income (SSDI). Results indicated that services are delivered in
clusters such that the higher correlations of services within clusters inform services
within factors that tend to be received together. Regarding evaluation services (i.e.,
factor), which are inclusive of mental health services, only two of the four services
in this factor group were related to employment outcomes: VR counseling and
guidance and assessment (Giesen & Hierholzer, 2016). Results from this study
indicated that people receiving VR counseling and guidance have 32% higher odds
of competitive employment, whereas assessment services indicated 34% lower
odds of competitive employment.
Dean et al.’s (2017) study examined the types of services provided to people with
BVI who have an identified mental illness. Results showed that when combining
the employment and earnings effects, apart from diagnosis and evaluation, all
service types had positive long-run effects. Similarly, Clapp et al.’s (2020) analysis
of VR-related services indicated persistent earnings benefits; however, there was
substantial cross-state heterogeneity relative to the types of services offered.
Further, in their cost-return analysis, results indicated that diagnosis and evaluation
services had a mean service cost of $408 per client and restoration at $2,576; in
order of magnitude, both were less expensive than all the other services. In any
case, it was suggested that such services are considered a “risk” to employment
outcomes (Giesen & Hierholzer, 2016).
Similarly, Lund and Cmar’s (2019) recent systematic review postulated the
potential “risk” for VR consumers with BVI to have unsuccessful closures due to
poorly targeted supports and interventions, particularly those receiving SSDI.
McDonnall et al. (2021) also postulated this same risk, stating that people with BVI
who are also receiving SSDI may be at risk for poorer employment quality. Still,
this study (Giesen & Hierholzer, 2016) found that there exists a holistic, multilevel
assessment process that operates systematically depending on service needs.
However, these needs are considered a “risk” if not associated with employment
outcomes. Despite its age, this is the first study that offered a systematic lens to
VR services for people with BVI. Giesen and Hierholzer (2016) stated, “The
negative link between receipt of assessment services and competitive employment
may involve a more complicated situation in which the needs of the individuals are
not readily apparent” (p. 186). The necessity of long-term studies for improved
treatment outcomes was echoed in Demmin and Silverstein’s (2020) review and
clinically emphasized by the findings in Zapata’s (2020a, 2020b) studies relative
to the role of psychosocial factors in employment outcomes.
While some studies on this theme did utilize RSA-911 data to explore the
characteristics of VR (Giesen & Hierholzer, 2016; McDonnall et al., 2021), many
studies highlighted its limitations (Clapp et al., 2020; Dean et al., 2017; Lund &
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Cmar, 2019; McDonnall et al., 2021). In McDonnall et al.’s (2021) study, results
indicated that job quality indicators were higher for consumers who were employed
at the application than for those not employed at the application. Most notably, in
terms of VR-related services, receipt of a certificate, receipt of an associate
degree, and receipt of a bachelor’s or higher degree were positively associated
with job quality at VR case closure; however, receipt of job readiness training and
on-the-job supports/supported employment were negatively associated with job
quality. Lund and Cmar’s (2019) systematic review highlighted this same
weakness in RSA-911 data, finding it limited to what is contained within the data
set (e.g., demographic vs consumer rating of services). Based on findings from
Giesen and Hierholzer’s (2016) study on the systematic patterns of VR services
and their connections to employment outcomes, it is suggested that employment
outcomes are multidimensional; therefore, it is difficult to conclude that job quality
outcomes are indicative of objective evaluations solely. Dean et al. (2017) and
Clapp et al. (2020) were the sole researchers who did not utilize RSA-911 data for
their studies. Clapp et al. (2020) asserted that while employment earnings were
constant across states, the varied services are misleading accounts of VR's long-
term effectiveness for people with BVI. All studies on this theme operated under
the most current legislation of WIOA (2016), which emphasizes job retention, not
simply job attainment, adding to the strength of all findings.
VR’s short-term focus on competitive employment arguably frames mental health
issues as a co-occurring detriment, which in turn reinforces the subjective norms
placed on people with BVI and related employment potential (e.g., see McDonnall
& Lund, 2019). Relevant studies show evidence that such behavior simply
transcends into the clinical arena, building upon the notion that people with BVI
have short-term problems that require short-term solutions (e.g., see Demmin &
Silverstein, 2020, Nollette et al., 2016, and van der Aa et al., 2015); people with
BVI must effectively choose between mental health or vocational stability. There
exists extensive literature relative to the systematic processes of VR-related
services (e.g., see Clapp et al., 2020, Dean et al., 2017, Giesen & Hierholzer, 2016,
Lund & Cmar, 2019, and McDonnall et al., 2021); additional literature of the same
typology would be unnecessary and arguably poorly resourced considering
relevant literature suggesting the limitations of RSA-11 data (e.g., see Clapp et al.,
2020, Dean et al., 2017, Lund & Cmar, 2019, and McDonnall et al., 2021). More
research is needed in this area that utilizes data from the blind community relative
to case closures (i.e., successfully employed, and unsuccessfully employed), job
quality, and RSA-11 data using a longitudinal design, thereby filling the gap in
subjective knowledge, and addressing the limitations of RSA-11 data. Concerning
an educational podcast enterprise, developers should consider the limitations of
RSA-11 data on the conceptualization of vocational stability and achievement,
particularly regarding the goal of independence for many people with BVI.
7. RECOMMENDATIONS FOR FUTURE WORK
Future work relative to an educational podcast or forum should focus on the goal
of disengaging the traditional milieu by which mental health as a health-related
resource is conceptualized and, thus, remedied for people with BVI. The
concentration of rehabilitation in the lives of people with BVI generates a culture-
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specific framework of professional intervention that disrupts the significance of
mental health symptomology [9]. A podcast’s educative and collaborative
resources must aim to penetrate professional development whereby behavior
change in this area may occur. It is through such learning that anticipates that new
knowledge is integrated into current knowledge, maintaining and improving skills.
Such a goal will require restructuring the learning methodology to meet the needs
of VR counselors, O&M professionals, and care practitioners through knowledge
transition (KT) activities (eg, see [153,154]). Knowledge transition can be defined
as the exchange, synthesis, and ethically sound application of knowledge within a
complex system of interactions among researchers and users [154,9].
The development of a continuing education course (CEC) is an excellent option to
improve the reliability and sustainability of podcast-based education, increasing
the likelihood of penetration in rehabilitation and clinical practice [9]. Rather than
relying on information from a combination of varied research to inform clinical
decisions, health-rehabilitation professionals can receive evidence-based,
multicomponent educative strategies that parallel their respective disciplines (eg,
see [154–156,9]). For instance, three teaching sessions spread over a 12-week
period that incorporates a combination of interactive and didactic learning activities
aimed at developing strategies to gather mental health information from people
with BVI, developing and implementing a plan that integrates vocational
information into clinical information, analyzing and measuring the effectiveness of
knowledge relative to the plan intersubjectively, thereby improving KT [154].
Although evidence shows that CECs can enhance knowledge, [157,158,9] it is less
clear that traditional CECs alone are effective at manipulating professional
behavior or enhancing patient outcomes (eg, see [159,160]). As critiqued by
Schreiber et al, a traditional CEC delivered at a single point in time employs a
lecture-based format and counts hours of learning (i.e., continuing education units)
rather than improved knowledge, competence, and performance [154].
A CEC course that integrates knowledge transition activities can also lead to
improved assessment tools. Taking into consideration the current research by
Zapata, [92] indicating the associations between self-efficacy and employment out-
comes and how self-efficacy was primarily utilized as a “skills-based” outcome
target in Demmin and Silverstein’s [16] recent literature review, it can be suggested
that the role of self-efficacy as a cognitive construct is effective at mitigating the
emergence of mental-health symptoms for people with BVI. However, based on
current research regarding the high prevalence of mental health symptomology for
people with BVI (eg, see [95,96,103]) and current treatment interventions lacking
long-term effectiveness (eg, see [16,9]), self-efficacy may not be a target of mental
health treatment outcomes associated with social aggravators (eg, prejudice,
employer discrimination, disability isolation). Learnings from an educative podcast
or forum may aid in the development of assessment tools that appropriately identify
sources of self-efficacy to which deficits may be targeted. To better demonstrate
this, a novel assessment tool is proposed that utilizes the theory of self-efficacy
(eg, see [110,9]) and its psychological constructs to capture multiple dimensions
of self-efficacy across VR, O&M, and care practitioner contexts. Most salient, the
proposed measure is informed by research pertinent to the limitations of mental
health as a health-related resource for people with BVI (eg, see [16,63,74,91,9]).
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The title of the assessment tool is Blindness, Visual Impairment Self-Efficacy
Scale, and is informed by Bandura’s [161] guide for constructing self-efficacy
scales. The measure is intended to be self-administered and completed on a
recurring basis, as self-efficacy stores are malleable [110,161,9]. As such, Web
Content Accessibility Guidelines [162] should also be followed to promote
respondent equity. It is important to note that the Blindness, Visual Impairment
Self-Efficacy Scale has not been tested and, thus, lacks empirical evidence.
Rather, it is intended to promote scholarly attention and movement toward an
improved design in which multiple self-efficacy dimensions may be captured for
people with BVI, thereby improving experimental study designs and clinical care
targeting for this population [9].
For instance, the Blindness, Visual Impairment Self-Efficacy Scale may be used
as a tool to cultivate structural competency (eg, see [163]) in clinical practitioners
working with people with BVI. For a graphical illustration of the Blindness, Visual
Impairment Self-Efficacy Scale, see Fig. 1 [9].
A CEC course that integrates knowledge transition activities (eg, see [154]) can
also lead to the development of teaching methods relative to the theory of self-
efficacy (eg, see [110]). Such methods can be constructed as questions to which
VR, O&M, and care practitioners may query their clients (ie, people with BVI)
relative to self-efficacy dimensions [9]. The purpose of the questions is to gain a
more concentrated understanding of the disincentives to outcome expectations
unique to clients. This can be better understood when examining Bandura’s [161]
distinction between perceived self-efficacy as a judgment of capability and
perceived self-efficacy as a judgment of outcome expectations, specifically as it
relates to performance accomplishments. According to Bandura [9]:
Perceived self-efficacy is a judgment of the capability to execute given types of
performances; outcome expectations are judgments about the outcomes that are
likely to flow from such performances. Outcome expectations take three different
forms…. they include the positive and negative physical, social, and self-evaluative
outcomes…. the positive expectations serve as incentives, and the negative ones
as disincentives. The outcomes people anticipate depend largely on their
judgments of how well they will be able to perform in given situations [161,9].
This explicative emphasizes that what an individual can do may present vastly
different relative to the outcome depending on the situation and their judgment of
it. When considering earlier research by Virgili and Rubin [74] in which the authors
questioned the lack of subjective outcome measures to assess the effects of O&M
training for people with BVI, such as hope or quality of life, and current research
by Zapata [92] indicating that people with BVI who utilize mobility tools have 64%
greater odds of unemployment, this distinction between perceived self-efficacy as
a judgment of capability and perceived self-efficacy as a judgment of outcome
expectations is imperative for health-rehabilitation professionals working with
people with BVI [9]. In other words, for instance, people with BVI who participate
in O&M training may feel self-efficacious following such training, in terms of
navigation and mobility skills; however, such skill performance may become more
ambiguous and, thus, less efficacious in the presence of specific social situations
or unforeseen physiological problems. With respect to an appropriately framed
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question, the following question is proposed: “Are there any places, circumstances,
or people in particular of which you believe that your O&M skills would be more
difficult to use or employ?” [9].
Fig. 1. This figure displays the blindness and visual impairment self-
efficacy scale. The blindness, visual impairment self-efficacy scale is a
proposed scale and has no empirical strength.
Notes: Used with permission of Information Age Publishing, from Bandura A. Guide for
constructing self-efficacy scales. In: Pajares F, Urdan T, eds. Self-Efficacy Beliefs of
Adolescents. 2006;5:307–337; permission conveyed through Copyright
Clearance Center, Inc [161]
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8. CONCLUSION
In summary, interdependencies related to the provision of mental health services
as a resource exists between VR, O&M, and care practitioners involved in the
health rehabilitation of people with BVI (see Fig. 2) [9]. Multiple studies indicated
long-term support for people with BVI was needed to adequately capture the
diverse and entangled mental health issues experienced relative to VR-initiated
services, mobility tool utility, and emotional reactions to vision loss and associated
prejudice. Disability identity discourse and support was also a recurring theme
within the literature, correlating psychological variables of well-being, self-efficacy,
and self-worth. Such goals require the development of enhanced and appropriately
targeted evaluative measures and approaches that center the multidimensional
lives of people with BVI [9]. VR’s short-term foci on competitive employment
arguably frame mental health issues as a co-occurring detriment, which in turn
reinforces the subjective norms placed on people with BVI and related employment
potential. Relevant studies indicated that such behavior simply transcends into the
clinical arena, building upon this notion that people with BVI have short-term
problems that require short-term solutions; people with BVI must effectively choose
between mental health or vocational stability [9].
This literature review demonstrates that integrating critical systems theory will
illustrate the gap in mental health utility, address areas of social and biological
influence, and promote future innovation in mental health policy and practice for
people with BVI. The proposed dimensions to be explored through critical
discourse to illustrate the current limitations in mental health policy and practice
for people with BVI are as follows [9]: (1) decenter disability as incontestable truths
relative to the concept of mental health as a health-related resource for people with
BVI, including mental health treatment and outcomes; (2) recenter ableism as a
perpetuating social reality and, thus, psychological influence in the lives of people
with BVI; (3) liberate the traditional methodology of psychological assessment for
people with BVI engaged in health-rehabilitation processes, evoking new
consciousness and improved relationships with health-rehabilitation professionals;
(4) alter the self-perceptions of listeners, their roles and beliefs and the self-
concept of people with BVI; and (5) engage in critical discourse through honest
conversation and restructure disability as having subjective power and, thus,
diversity.
The research findings revealed significant deficiencies in the traditional health-
rehabilitation model for people with BVI, particularly as it relates to mental health
resources and services. The limitation of the findings indicated that disability
scholars need to advance research on integrating critical theories in work with
people with BVI and accelerate qualitative, community-based methods to enhance
understanding of this population and their unique mental health needs [9]. An
educational podcast or forum may help spread awareness and facilitate education
on the mental health gap in the lives of people with BVI. A podcast will help to
expand accountability for the underutilization of mental health for people with BVI
by way of establishing a common goal and vision. Much of the literature has
examined mental health issues for people with BVI in organizational isolation.
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Observing an organization in its “wholeness” would simply constitute an
overabundance of energy on a non-linear-natured system; this is general systems
thinking, not critical systems thinking [9]. Thinking of an organization as a
conversation rather than a machine encourages collective equity that is accessible,
collaborative, and designed to evolve knowledge to create new pathways to
problem-solving. DEI (eg, see [118,119]) encourages the sharing and exposure of
new knowledge to create new pathways to problem-solving, impacting collective
equity.
Fig. 2. This figure illustrates the interdependent nature of VR, O&M, and
care practitioners when considering mental health symptoms and
subsequent provision of services for people with BVI.
Notes: Adapted from Demmin DL, Silverstein SM. Visual impairment and mental health:
unmet needs and treatment options. Clin Ophthalmol. 2020; 14:4229–4251. Creative
Commons [16]
DISCLAIMER (ARTIFICIAL INTELLIGENCE)
Author(s) hereby declare that NO generative AI technologies such as Large
Language Models (ChatGPT, COPILOT, etc.) and text-to-image generators have
been used during the writing or editing of this manuscript.
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COMPETING INTERESTS
Author has declared that no competing interests exist.
REFERENCES
1. Brown RL, Barrett AE. Visual impairment and quality of life among older
adults: an examination of explanations for the relationship. Journals of
Gerontology Series B: Psychological Sciences and Social Sciences. 2011
May 1;66(3):364-73.
2. World Health Organization. Blindness and visual impairment; 2022.
Available:https://www.who.int/news-room/fact-sheets/detail/blind ness-
and-visual-impairment
Accessed March 22, 2024.
3. Srivastava N. Physical rehabilitation of the visually impaired and its
implications for tactile modelling. International Journal of Community
Medicine and Public Health. 2024 Mar;11(3):1291.
4. Lundeen EA, Saydah S, Ehrlich JR, Saaddine J. Self-Reported vision
impairment and psychological distress in U.S. adults. Ophthal Epidemiol.
2022;29(2):171–181.
DOI: 10.1080/09286586.2021.1918177
5. Choi HG, Lee MJ, Lee SM. Visual impairment and risk of depression: A
longitudinal follow-up study using a national sample cohort. Sci Rep.
2018;8(1):2083.
DOI: 10.1038/s41598-018-20374-5
6. Mayro EL, Murchison AP, Hark LA, et al. Prevalence of depressive
symptoms and associated factors in an urban, ophthalmic population. Eur
J Ophthalmol. 2021;31(2):740–747.
DOI: 10.1177/1120672120901701
7. Zhang X, Bullard KM, Cotch MF, et al. Association between depression and
functional vision loss in persons 20 years of age or older in the United
States, national health, and nutrition examination survey 2005–2008. JAMA
Ophthalmol. 2013;131(5):573–581.
DOI: 10.1001/ jamaophthalmol.2013.2597
8. Khorrami-Nejad M, Sarabandi A, Akbari MR, Askarizadeh F. The impact of
visual impairment on quality of life. Med Hypothesis Discov Innov
Ophthalmol. 2016;5(3):96–103.
9. Richardson CG. The Underutilization of Mental Health Care Services in the
Lives of People with Blindness or Visual Impairment: A Literature Review
on Rehabilitation Factors Toward Provision. Clinical Ophthalmology. 2024
Dec 31:953-80.
10. Dhital A, Pey T, Stanford MR. Visual loss and falls: A review. Eye.
2010;24(9):1437–1446.
DOI: 10.1038/eye.2010.60
11. Mojon-Azzi SM, Sousa-Poza A, Mojon DS. Impact of low vision on well-
being in 10 European countries. Ophthalmologica. 2008;222 (3):205–212.
DOI: 10.1159/000126085
Disease and Health Research: New Insights Vol. 6
The Role of Rehabilitation Medicine in the Psychological Etiology of Blindness or Visual Impairment: A
Critical Synthesis
105
12. Kempen GI, Ballemans J, Ranchor AV, van Rens GH, Zijlstra GA. The
impact of low vision on activities of daily living, symptoms of depression,
feelings of anxiety and social support in community-living older adults
seeking vision rehabilitation services. Qual Life Res. 2012;21(8):1405–
1411.
DOI: 10.1007/s11136-011-0061-y
13. Brunes A, B Hansen M, Heir T. Loneliness among adults with visual
impairment: prevalence, associated factors, and relationship to life
satisfaction. Health Qual Life Outcomes. 2019;17(1):24.
DOI: 10.1186/s12955-019-1096-y
14. Brennan M, Horowitz A, Reinhardt JP, Stuen C, Rubio R, Oestreicher N.
The societal impact of age-related macular degeneration: use of social
support resources differs by the severity of the impairment. J Vis Impairment
Blindness. 2011;105(1):5–19.
DOI: 10.1177/0145482X1110500102
15. Wong WL, Su X, Li X, et al. Global prevalence of age-related macular
degeneration and disease burden projection for 2020 and 2040: A
systematic review and meta-analysis. Lancet Glob Health. 2014;2(2):
e106–e116.
DOI: 10.1016/S2214-109X(13)70145-1
16. Demmin DL, Silverstein SM. Visual impairment and mental health: Unmet
needs and treatment options. Clin Ophthalmol. 2020;14:4229–4251.
DOI: 10.2147/OPTH.S258783
17. Rees G, Tee HW, Marella M, Fenwick E, Dirani M, Lamoureux EL. Vision-
Specific distress and depressive symptoms in people with vision
impairment. Invest Ophthalmol Vis Sci. 2010;51(6):2891–2896.
DOI: 10.1167/iovs.09-5080
18. Chou C-F, Beckles GLA, Zhang X, Saaddine JB. Association of
socioeconomic position with sensory impairment among us working-aged
adults. Am J Public Health. 2015;105(6):1262–1268.
DOI: 10.2105/AJPH.2014.302475
19. Carrière I, Delcourt C, Daien V, et al. A prospective study of the bi-
directional association between vision loss and depression in the elderly. J
Affect Disord. 2013;151(1):164–170.
DOI: 10.1016/j.jad.2013.05.071
20. Holloway EE, Sturrock BA, Lamoureux EL, Keeffe JE, Rees G. Depression
screening among older adults attending low-vision rehabilitation and eye-
care services: characteristics of those who screen positive and client
acceptability of screening. Australas J Ageing. 2015;34(4):229–234.
DOI: 10.1111/ajag.12159
21. Nyman SR, Gosney MA, Victor CR. Psychosocial impact of visual
impairment in working-age adults. Br J Ophthalmol. 2010;94 (11):1427–
1431.
DOI: 10.1136/bjo.2009.164814
22. Senra H, Balaskas K, Mahmoodi N, Aslam T. Experience of anti-vascular
endothelial growth factor therapy treatment and clinical levels of depression
and anxiety in patients with wet age-related macular degeneration. Am J
Ophthalmol. 2017;177:213–224.
Disease and Health Research: New Insights Vol. 6
The Role of Rehabilitation Medicine in the Psychological Etiology of Blindness or Visual Impairment: A
Critical Synthesis
106
DOI: 10.1016/j. ajo.2017.03.005
23. Arluke A, Gritzer G. The Making of Rehabilitation: A Political Economy of
Medical Specialization, 1890–1980 (Comparative Studies of Health
Systems and Medical Care). University of California Press; 1985.
24. Donaldson E. Literatures of Madness: Disability Studies and Mental Health.
Palgrave Macmillan; 2018.
25. Hiranandani V. Towards a critical theory of disability in social work. Crit Soc
Work. 2019;6(1).
DOI: 10.22329/csw.v6i1.5712
26. Minich JA. Enabling whom? Critical disability studies now. Lateral.
2016;5(1).
DOI: 10.25158/L5.1.9
27. Stiker H-J. A History of Disability. University of Michigan Press; 1982.
28. Jürgen H. The Theory of Communicative Action. A Critique of Functionalist
Reason. Beacon Press; 1987.
29. Ingstad B, Whyte SR. Disability and Culture. University of California Press;
1995.
30. Basic definition of disability, 20 C.F.R § 404.1505; 1980.
Available:https://www.ecfr.gov/current/title-20/chapter-III/part-404/subpart-
P/ subject-group-ECFRd3e28073a44a293/section-404.1505
Accessed March 22, 2024.
31. Bonaccio S, Connelly CE, Gellatly IR, Jetha A, Martin Ginis KA. The
participation of people with disabilities in the workplace across the
employment cycle: Employer concerns and research evidence. J Bus
Psychol. 2020;35(2):135–158.
DOI: 10.1007/s10869-018-9602-5
32. Oi WY. Work for Americans with disabilities. Ann Am Acad Pol Soc Sci.
1992;523(1):159–174.
DOI: 10.1177/0002716292523001014
33. United States Department of Labor. Disability resources; 2023.
Available:https://www.dol.gov/general/topic/disability
Accessed March 22, 2024.
34. Bureau of Labor Statistics. Persons with a disability [Data set]. Labor Force
Characteristics. United States Department of Labor; 2023.
Available:https://www.bls.gov/news.release/pdf/disabl.pdf.
Accessed March 22, 2024.
35. Workforce Innovation and Opportunity Act of. U.S.C. § 3101 et seq; 2014.
Available:https://uscode.house.gov/view.xhtml?path=/
prelim@title29/chapter32&edition=prelim
Accessed March 22, 2024.
36. Division of Blind Services. Program Manual. Voc Rehab.
Available:https://dbs.fldoe.org/Voc-Rehab/Manual/
Accessed March 22, 2024.
37. Szasz TS. The Myth of Mental Illness. HarperPerennial; 1961.
38. Albee GW. To thine own self be true. Am Psychol. 1975;30(12):1156–1158.
DOI: 10.1037/0003-066X.30.12.1156
39. Goffman E. Asylums: Essays on the Social Situation of Mental Patients and
Other Inmates. Anchor Books; 1961.
Disease and Health Research: New Insights Vol. 6
The Role of Rehabilitation Medicine in the Psychological Etiology of Blindness or Visual Impairment: A
Critical Synthesis
107
40. Engel GL. The need for a new medical model: A challenge for biomedicine.
Science. 1977;196(4286):129–136.
DOI: 10.1126/science.847460
41. Crow L. Including all of our lives: renewing the social model of disability. In:
Barnes C, Mercer G, editors. Exploring the Divide: Illness and Disability.
Disability Press. 1996;5–9.
42. Benning TB. No such thing as mental illness? Critical reflections on the
major ideas and legacy of Thomas Szasz. BJPsych Bull. 2016;40 (6):292–
295.
DOI: 10.1192/pb.bp.115.053249
43. Wolfensberger W. The Principle of Normalization in Human Services.
National Institute on Mental Retardation; 1972.
44. Oliver M, Barnes C. The New Politics of Disablement. Palgrave Macmillan;
2012.
45. Oliver M. The Politics of Disablement. Macmillan; 1990.
46. Bhattarai J, Bentley J, Morean W, Wegener ST, Pollack Porter KM.
Promoting equity at the population level: putting the foundational principles
into practice through disability advocacy. Rehabil Psychol. 2020;65(2):87–
100.
DOI: 10.1037/rep0000321
47. Herrman D, Papadimitriou C, Green B, LeFlore A, Magasi S. Relationships
at work: integrating the perspectives of disability partners to enhance a peer
navigation intervention. Front Rehabil Sci. 2022;3(1): 876636.
DOI: 10.3389/fresc.2022.876636
48. Iáñez Domínguez A, González Luna B. Disability in the Spanish press: from
the paradigm of rehabilitation to the paradigm of personal autonomy.
Commun Soc. 2019;32(1):77–90.
DOI: 10.15581/003.32.1.77-90
49. World Health Organization. International classification of functioning,
disability, and health. IMB Community Foundation; 2001.
Available:https://www.who.int/standards/classifications/international-
classification-of-functioning-disability-and-health
Accessed March 22, 2024.
50. World Health Organization. Community based rehabilitation guidelines:
CBR: community based rehabilitation. NLM classification: WB 320; 2010.
Available:https://www.who.int/publications/i/item/9789241548052.
Accessed March 22, 2024.
51. Kurtaiş Y, Oztuna D, Küçükdeveci AA, Kutlay S, Hafiz M, Tennant A.
Reliability, construct validity and measurement potential of the international
classification of functioning, disability, and health: ICF. A comprehensive
core set for osteoarthritis. BMC Musculoskelet Disord. 2011;12(255):1–12.
DOI: 10.1186/1471-2474-12-255
52. Devoogdt N, Van Kampen M, Geraerts I, Coremans T, Christiaens MR.
Lymphoedema functioning, disability, and health questionnaire: reliability
and validity. Phys Ther. 2011;91(6):944–957.
DOI: 10.2522/ptj.20100087
53. Pinna F, Fiorillo A, Tusconi M, Guiso B, Carpiniello B. Assessment of
functioning in patients with schizophrenia and schizoaffective disorder with
Disease and Health Research: New Insights Vol. 6
The Role of Rehabilitation Medicine in the Psychological Etiology of Blindness or Visual Impairment: A
Critical Synthesis
108
the mini-international classification of functioning, disability, and health:
ICF-Application: A validation study in Italy. Int J Ment Health Syst.
2015;9(37):1–10.
DOI: 10.1186/s13033-015-0030-x
54. Silva MR, Nobre MI, Carvalho KM, de Montilha R. Visual impairment,
rehabilitation and international classification of functioning, disability, and
health: ICF. Rev Bras Oftalmol. 2014;73(5):291–301.
DOI: 10.5935/0034-7280.20140063
55. World Health Organization. Mental disorders; 2022.
Available:https://www.who.int/news-room/fact-sheets/detail/mental-
disorders
Accessed March 22, 2024.
56. Shakespeare T, Kleine I. Educating health professionals about disability: A
review of interventions. Health Soc Care Educ. 2013;2(2):20–37.
DOI: 10.11120/hsce.2013.00026
57. Mueller S, Weintraub L. The workforce innovation and opportunity act of
2014. Plain Language Series. Issue No. 4. University of Massachusetts –
Boston, Institute for Community Inclusion; 2020.
Available:https://thinkcollege.net/sites/default/files/files/resources/
PL4_WIOA_R.pdf. Accessed March 22, 2024.
58. United States Department of Education. Individuals with Disabilities
Education Act; 2023.
Available:https://sites.ed.gov/idea/
Accessed March 22, 2024.
59. United States Department of Health and Human Services. Programs for
people with disabilities; 2023.
Available:https://www.hhs.gov/ programs/social-services/programs-for-
people-with-disabilities/index.html
Accessed March 22, 2024.
60. Rehabilitation act of 1973, 29 U.S.C. § 794 et seq; 1973.
Available:https://www.govinfo.gov/content/pkg/USCODE-2010-title29/html/
USCODE-2010-title29-chap16.htm
Accessed March 22, 2024.
61. Americans with Disabilities Act of 1990. U.S.C. § 12101 et seq;1990:42.
Available:https://www.ada.gov/pubs/adastatute08.htm
Accessed March 22, 2024.
62. Dean D, Pepper JV, Schmidt R, Stern S. The effects of vocational
rehabilitation services for people with mental illness. J Hum Resour.
2017;52 (3):826–858.
DOI: 10.3368/jhr.52.3.0114-6111R1
63. Crudden A, Steverson A. Job retention: perspectives of individuals with
blindness and low vision. J Vocat Rehabil. 2022;57(2):127–140.
DOI: 10.3233/JVR-221204
64. Bruce I, Baker M. Segmenting and targeting employed and unemployed
people with sight problems. Int Congr S. 2005;1282:1125–1129.
DOI: 10.1016/j.ics.2005.05.054
65. Crudden A, Steverson AC. Job retention and career advancement: A survey
of persons who are blind or have low vision. J Rehabil. 2021;87(2):28–35.
Disease and Health Research: New Insights Vol. 6
The Role of Rehabilitation Medicine in the Psychological Etiology of Blindness or Visual Impairment: A
Critical Synthesis
109
66. Papakonstantinou D. Person-Related factors of people with disabilities
affecting employers’ attitudes toward their vocational integration: A
literature review of the top list. J Rehabil. 2022;88(2):11–20.
67. Annual disability statistics compendium. Vocational rehabilitation—number
of participants served, number of cases closed with and without
employment by State Agency: 2016 [Data set]; 2021.
Available:https://disabilitycompendium.org/compendium/2021-annual-
disability- statistics-compendium-A?page=19
Accessed March 22, 2024.
68. Paul S, Rafal M, Houtenville A. Annual Disability Statistics Compendium:
2021 (Table 14.1). University of New Hampshire, Institute on Disability;
2021.
69. Wiener WR, Welsh RL, Blasch BB. Foundations of Orientation and Mobility.
AFB Press; 2010.
70. University of Alabama in Huntsville. Orientation and mobility concentration;
2023.
Available:https://www.uah.edu/education/depart ments/curriculum-and-
instruction/graduate-programs/master-of-education/orientation-and-
mobility-concentration
Accessed March 22, 2024.
71. Academy for Certification of Vision Rehabilitation and Education
Professionals. Certifications; 2023.
Available:https://www.acvrep.org/ certifications/landing
Accessed March 22, 2024.
72. Keay LJ, Chang KJ, Angell B, Rogers K, Jan S. Cost-benefit analysis of
orientation and mobility programs for adults with vision disability: A
contingent valuation study. Disabil Rehabil. 2022;45(5):857–865.
DOI: 10.1080/09638288.2022.2044523
73. National Federation of the Blind. Blindness statistics; 2019.
Available:https://nfb.org/resources/blindness-statistics.
Accessed March 22, 2024.
74. Virgili G, Rubin G. Orientation and mobility training for adults with low vision.
Cochrane Database Syst Rev. 2010;2010(5):1–23.
DOI: 10.1002/ 14651858.CD003925.pub3
75. Fixsen A, Seers H, Polley M, Robins J. Applying critical systems thinking to
social prescribing: A relational model of stakeholder “buy-in. BMC Health
Serv Res. 2020;20(1):580.
DOI: 10.1186/s12913-020-05443-8
76. Cmar JL, McDonnall MC. Characteristics, services, and outcomes of
vocational rehabilitation consumers who are deaf-blind. J Am Deafness
Rehabil Assoc. 2019;52(2):12–23.
77. Division of Vocational Rehabilitation. Counselor policy manual. Rehab
Works; 2018.
Available:https://www.rehabworks.org/_resources/
docs/policies/manual/counselor-policy-manual.pdf
Accessed March 22, 2024.
78. Shakespeare T. Disability Rights and Wrongs Revisited. Routledge; 2013.
Disease and Health Research: New Insights Vol. 6
The Role of Rehabilitation Medicine in the Psychological Etiology of Blindness or Visual Impairment: A
Critical Synthesis
110
79. Social Security Administration. Vocational rehabilitation providers’
handbook. Social Security Administration; 2020.
Available:https:// yourtickettowork.ssa.gov/Assets/yttw/docs/vocational-
rehabilitation/VR-Providers-Handbook-2020.pdf
Accessed March 22, 2024.
80. Bertalanffy LV. General System Theory: Foundations, Development,
Applications. George Braziller Inc; 1968.
81. Slusser MM, García Luis I, Reed C-R, McGinnis PQ. Foundations of
Interprofessional Collaborative Practice in Health Care. Elsevier; 2019.
82. Stringfellow EJ. Applying structural systems thinking to frame perspectives
on social work innovation. Res Soc Work Pract. 2017;27(2):154–162.
DOI: 10.1177/1049731516660850
83. Gillies DA. Nursing Management: A Systems Approach. W B Saunders;
1982.
84. World Health Organization. List of official ICD-10 updates ratified. World
Health Organization; 2006 [cited February 17, 2024].
Available:https://www.who.int/publications/m/item/icd-10-updates-2006.
Accessed March 22, 2024.
85. Meaning of blindness as defined in the law, 20 C.F.R. § 404.1581; 1980.
Available:https://www.ecfr.gov/current/title-20/section-404.1581
Accessed March 22, 2024.
86. Guerette AR, Smedema SM. The relationship of perceived social support
with well-being in adults with visual impairments. J Vis Impairment
Blindness. 2011;105(7):425–439.
DOI: 10.1177/0145482X1110500705
87. Anderson CA, Hergenrather K, Jones WD. Empowering community voices:
the influences of consumer race, disability, and poverty on public vocational
rehabilitation service engagement. J Rehabil. 2021;87(1):40–47.
88. Bourgeois P, Green K, Hartley M, White M, Clarke B. Moral distress within
rehabilitation counseling. Rehabil Res Policy Educ. 2021;35(2):117–128.
DOI: 10.1891/RE-20-08
89. Giesen JM, Hierholzer A. Vocational rehabilitation services and
employment for social security disability income beneficiaries with visual
impairments. J Vocat Rehabil. 2016;44(2):175–189.
DOI: 10.3233/JVR-150789
90. Clapp CM, Pepper JV, Schmidt R, Stern S. Overview of vocational
rehabilitation data about people with visual impairments: Demographics,
services, and long-run labor market trends. J Vis Impairment Blindness.
2020;114(1):43–56.
DOI: 10.1177/0145482X20901380
91. McDonnall MC, Lund EM. Employers’ intent to hire people who are blind or
visually impaired: A test of the theory of planned behavior. Rehabil Couns
Bull. 2019;63(4):206–215.
DOI: 10.1177/0034355219893061
92. Zapata MA. An exploratory study of general self-efficacy and employment
in adults with retinitis pigmentosa. J Vis Impairment Blindness.
2020a;114(1):18–30.
DOI: 10.1177/0145482X19900715
Disease and Health Research: New Insights Vol. 6
The Role of Rehabilitation Medicine in the Psychological Etiology of Blindness or Visual Impairment: A
Critical Synthesis
111
93. Zapata MA. Disability affirmation predicts employment among adults with
visual impairment and blindness. Rehabil Couns Bull. 2020b;65(2):120–
128.
DOI: 10.1177/0034355220957107
94. Zapata MA. Mobility tool use relates to disability affirmation among adults
with visual impairments. J Vis Impairment Blindness. 2021;115(5):382–392.
DOI: 10.1177/0145482X211046684
95. Zapata MA. Group identity in blindness groups predicts life satisfaction and
lower anxiety and depression. Rehabil Psychol. 2022;67(1):42–52.
DOI: 10.1037/rep0000432
96. Zapata MA, Pearlstein JG. Disability self-worth relates to lower anxiety and
depression in people with visual impairment. J Clin Psychol.
2022;78(7):1491–1499.
DOI: 10.1002/jclp.23308
97. McDonnall MC, Cmar JL, McKnight Z. What predicts job quality of
vocational rehabilitation consumers who are blind or have low vision?
Rehabil Couns Bull. 2021;66(2):100–111.
DOI: 10.1177/00343552211060012
98. Lund EM, Cmar JL. Factors related to employment outcomes for vocational
rehabilitation consumers with visual impairments: A systematic review. J Vis
Impairment Blindness. 2019;113(6):518–537.
DOI: 10.1177/0145482X19885277
99. Papadopoulos K, Papakonstantinou D, Koutsoklenis A, Koustriava E,
Kouderi V. Social support, social networks, and happiness of individuals
with visual impairments. Rehabil Couns Bull. 2015;58(4):240–249.
DOI: 10.1177/0034355214535471
100. McDonnall MC, Cmar JL, McKnight ZS. Beyond employment rates: Self-
employment and other categories of work among people with visual
impairments. J Vis Impair Blind. 2022;116(5):729–735.
DOI: 10.1177/0145482X221128831
101. Papakonstantinou D, Papadopoulos K. Forms of social support in the
workplace for individuals with visual impairments. J Vis Impairment
Blindness. 2010;104(3):183–187.
DOI: 10.1177/0145482X1010400306
102. Khodabakhshi Koolaee A, Mosalanejad L, Mamaghanirad B. The
effectiveness of group training of choice theory on quality of life and hope
in blind people. Iran Rehabil J. 2017;15(3):199–206.
DOI: 10.29252/nrip.irj.15.3.199
103. Haegele JA, Zhu X, Healy S. Behavioral correlates of depression among
adults with visual impairments. J Vis Impairment Blindness. 2021;115(5):
403–413.
DOI: 10.1177/0145482X211046696
104. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis
Processes. 1991;50(2):179–211.
DOI: 10.1016/0749-5978(91)90020-T
105. Rubin SE, Chan F, Bishop M, Miller SM. Psychometric validation of the
sense of well-being inventory for program evaluation in rehabilitation. Prof
Rehabil. 2003;11(2):54–59.
Disease and Health Research: New Insights Vol. 6
The Role of Rehabilitation Medicine in the Psychological Etiology of Blindness or Visual Impairment: A
Critical Synthesis
112
106. Cimarolli VR, Boerner K. Social support and well-being in adults who are
visually impaired. J Vis Impairment Blindness. 2005;99(9):521–534.
DOI: 10.1177/0145482X0509900904
107. Bamberg S, Ajzen I, Schmidt P. Choice of travel mode in the theory of
planned behavior: the roles of past behavior, habit, and reasoned action.
Basic Appl Soc Psychol. 2003;25(3):175–187.
DOI: 10.1207/S15324834BASP2503_01
108. Suntornsan S, Chudech S, Janmaimool P. The role of the theory of planned
behavior in explaining the energy-saving behaviors of high school students
with physical impairments. Behav Sci. 2022;12(9):334.
DOI: 10.3390/bs12090334
109. Hagger MS, Hamilton K. Longitudinal tests of the theory of planned
behaviour: A meta-analysis. Eur Rev Soc Psychol. 2023;1–57.
DOI: 10.1080/ 10463283.2023.2225897
110. Bandura A. Self-efficacy: Toward a unifying theory of behavioral change.
Psychol Rev. 1977;84(2):191–215.
DOI: 10.1037//0033-295x.84.2.191
111. Dunn DS, Burcaw S. Disability identity: Exploring narrative accounts of
disability. Rehabil Psychol. 2013;58(2):148–157.
DOI: 10.1037/ a0031691
112. Putnam M. Conceptualizing disability: developing a framework for political
disability identity. J Disabil Policy Stud. 2005;16(3):188–198.
DOI: 10.1177/10442073050160030601
113. Kroenke K, Spitzer RL, Williams JB, Löwe B. An ultra-brief screening scale
for anxiety and depression: The patient health questionnaire-4.
Psychosomatics. 2009;50(6):613–621.
DOI: 10.1176/appi.psy.50.6.613
114. Chan F, Wang -C-C, Fitzgerald S, Muller V, Ditchman N, Menz F. Personal,
environmental, and service-delivery determinants of employment quality for
state vocational rehabilitation consumers: A multilevel analysis. J Vocat
Rehabil. 2016;45(1):5–18.
DOI: 10.3233/JVR-160806
115. McDonnall MC, Cmar J. Employment outcomes and job quality of vocational
rehabilitation consumers with deaf-blindness. Rehabil Couns Bull.
2019;63(1):13–24.
DOI: 10.1177/0034355218769461
116. McDonnall MC, Cmar JL, McKnight ZS. Service factors and personal
characteristics associated with employment and job quality for vocational
rehabilitation consumers with combined traumatic brain injury and visual
impairment. J Vocat Rehabil. 2020;52(3):223–238.
DOI: 10.3233/JVR- 201073
117. Jameton A. Nursing Practice: The Ethical Issues. Prentice Hall; 1984.
118. Dyer J, Gushwa M. Going Diversity, Equity, Inclusion, Power, Antiracism
DEIPAR Deeper: Developing and Incorporating a Social Justice Curricular
Framework [Manuscript submitted for publication]. DSW Program,
Simmons University; 2023.
Disease and Health Research: New Insights Vol. 6
The Role of Rehabilitation Medicine in the Psychological Etiology of Blindness or Visual Impairment: A
Critical Synthesis
113
119. Arsel Z, Crockett D, Scott ML. Diversity, equity, and inclusion (DEI) in the
journal of consumer research: A curation and research agenda. J Con Res.
2022;48(5):920–933.
DOI: 10.1093/jcr/ucab057
120. Glasser W. Choice Theory. HaperCollins Publishers; 1998.
121. The WHOQOL Group. The Development of the World Health Organization
Quality of Life Assessment Instrument (the WHOQOL). In: Orley J, Kuyken
W, editors. Quality of Life Assessment. International Perspectives.
Springer; 1994.
DOI: 10.1007/978-3-642-79123-9_4
122. Walsh T. A right to inclusion? Homelessness, human rights and social
exclusion. Aust J Hum Rights. 2006;12(1):185–204.
DOI: 10.1080/ 1323238X.2006.11910818
123. Lievrouw L. Alternative and Activist New Media. Polity Press; 2011.
124. Miranda SM, Young AG, Yetgin E. Are social media emancipatory or
hegemonic? Societal effects of mass media digitization in the Case of the
SOPA Discourse. MIS Q. 2016;40(2):303–329.
DOI: 10.25300/MISQ/2016/40.2.02
125. Sunstein CR. The law of group polarization. J Pol Philos. 2002;10(2):175–
195.
DOI: 10.1111/1467-9760.00148
126. Kiernan MA, Mitchell BG, Russo PL. The power of podcasts: exploring the
endless possibilities of audio education and information in medicine,
healthcare epidemiology, and antimicrobial stewardship. Antimicrob
Stewardship Healthc Epidemiol. 2023;3(1):e98,1–3.
DOI: 10.1017/ash.2023.178
127. Tobin SJ, Guadagno RE. Why people listen: Motivations and outcomes of
podcast listening. PLoS One. 2022;17(4):e0265806.
DOI: 10.1371/ journal.pone.0265806
128. Roland D, Thoma B, Tagg A, Woods J, Chan TM, Riddell J. What are the
real-world podcast-listening habits of medical professionals? Cureus.
2021;13(7):e16240, 1–9.
DOI: 10.7759/cureus.16240
129. Horkheimer M. Traditional and Critical Theory. Continuum; 1937.
130. Belkin-Martinez D. The liberation health model: theory and practice. In:
Belkin Martinez D, Fleck-Henderson A, editors. Social Justice in Clinical
Practice: A Liberation Health Framework for Social Work. Routledge.
2014;9–28.
131. Hall MC. Critical disability theory. Stanford Encycl Philos. Metaphysics
Research Laboratory, Stanford University; 2019.
Available:https://plato.stanford.edu/archives/win2019/entries/disability-
critical/
Accessed July 17, 2023.
132. Schalk S. Critical disability studies as methodology. Lateral. 2017;6(1):1–4.
DOI: 10.25158/L6.1.13
Disease and Health Research: New Insights Vol. 6
The Role of Rehabilitation Medicine in the Psychological Etiology of Blindness or Visual Impairment: A
Critical Synthesis
114
133. Onedera JD, Greenwalt B. Choice theory: An interview with Dr. William
Glasser. Fam J. 2007;15(1):79–86.
DOI: 10.1177/1066480706294150
134. Kondrat ME. Actor-Centered social work: Re-Visioning “person-in-
environment” through a critical theory lens. Soc Work. 2002;47(4):435–448.
DOI: 10.1093/sw/47.4.435
135. Adams M. Readings for Diversity and Social Justice [Introduction].
Castañeda C, Hackman H, Peters M, Zúñiga X, Blumenfeld W, editors.
Routledge. 2010;1–5.
136. Adams M, Castañeda C, Hackman H, Peters M, Zúñiga X, Blumenfeld W.
Readings for Diversity and Social Justice. Routledge; 2010.
137. Hardiman R, Jackson B, Griffin P. Conceptual foundations for social justice
education. In: Adams M, Bell L, Griffin P, editors. Teaching for Diversity and
Social Justice. Routledge. 2007;35–66.
138. Freire P. Pedagogy of the Oppressed. Continuum International Publishing
Group Ltd; 1994.
139. Beresford P. Radical social work and service users: A crucial connection.
In: Lavalette M, editor. Radical Social Work Today: Social Work at the
Crossroads. Policy Press. 2011:95–114.
140. Burton M, Kagan C. Liberation social psychology: Learning from Latin
America. Community Appl Soc Psy. 2005;15(1):63–78.
DOI: 10.1002/ casp.786
141. Freire P. Education as the practice of freedom. In: Freire P, editor.
Education for Critical Consciousness. Continuum. 1974;1–78.
142. Forber-Pratt AJ, Mueller CO, Andrews EE. Disability identity and allyship in
rehabilitation psychology: Sit, stand, sign, and show up. Rehabil Psychol.
2019;64(2):119–129.
DOI: 10.1037/rep0000256
143. Kulnik ST, Nikoletou D. A qualitative study of views on disability and
expectations from community rehabilitation service users. Health Soc Care
Community. 2017;25(1):43–53.
DOI: 10.1111/hsc.12180
144. Rebolledo-Sanhueza J, Besoain-Saldaña Á, Manríquez-Hizaut M, Huepe-
Ortega G, Aliaga-Castillo V. Experiencias y percepciones sobre discapa-
cidad y participación social en centros de rehabilitación comunitaria de
Chile. Saúde Soc. 2021;30(2):1–10.
DOI: 10.1590/s0104-12902021200858
145. Brooks NA. Self-empowerment among adults with severe physical
disability: a case study. J Sociol Soc Welf. 1991;18(1):105–120.
DOI: 10.15453/0191-5096.1971
146. Brzuzy S. Deconstructing disability. J Pover. 1997;1(1):81–91.
DOI: 10.1300/J134v01n01_06
147. Quinn P. Social work education and disability. J Teach Soc Work.
1996;12(1–2):55–71.
DOI: 10.1300/J067v12n01_05
148. Hahn H. Paternalism and public policy. Society. 1983;20(3):36–46.
Disease and Health Research: New Insights Vol. 6
The Role of Rehabilitation Medicine in the Psychological Etiology of Blindness or Visual Impairment: A
Critical Synthesis
115
DOI: 10.1007/BF02700073
149. Mackelprang RW, Salsgiver RO. People with disabilities and social work:
Historical and contemporary issues. Soc Work. 1996;41(1):7–14.
DOI: 10.1093/sw/41.1.7
150. Kant JD. Becoming a liberation health social worker. In: Martinez DB, editor.
Social Justice in Clinical Practice: A Liberation Health Framework for Social
Work. Routledge. 2014;29–43.
151. Moya P. What’s identity got to do with it? Mobilizing identities in the
multicultural classroom. In: Alcoff LM, Hames-Garcia M, Mohanty SP,
editors. Identity Politics Reconsidered. Palgrave Macmillan. 2006;96–117.
152. Charlton JI. Nothing About Us Without Us: Disability Oppression and
Empowerment. University of California Press; 1998.
153. Davis D, Evans M, Jadad A, et al. The case for knowledge translation:
Shortening the journey from evidence to effect. BMJ. 2003;327(7405):33–
35.
DOI: 10.1136/bmj.327.7405.33
154. Schreiber J, Perry S, Downey P, Williamson A. Knowledge translation
outcomes following innovative continuing education. J Phys Ther Educ.
2015;29(4):42–51.
DOI: 10.1097/00001416-201529040-00007
155. Rappolt S, Tassone M. How rehabilitation therapists gather, evaluate, and
implement new knowledge. J Contin Educ Health Prof. 2002;22(3):170–
180.
DOI: 10.1002/chp.1340220306
156. Ketelaar M, Russell DJ, Gorter JW. The challenge of moving evidence-
based measures into clinical practice: Lessons in knowledge translation.
Phys Occup Ther Pediatr. 2008;28(2):191–206.
DOI: 10.1080/01942630802192610
157. Taylor JM, Neimeyer GJ. The development of the professional
competencies scale: foundational, functional, and continuing
competencies.Train Educ Prof Psychol. 2022;16(2):112–120.
DOI: 10.1037/tep0000383
158. Luhanga U, Chen W, Minor S, et al. Promoting transfer of learning to
practice in online continuing professional development. J Contin Educ
Health Prof. 2022;42(4):269–273.
DOI: 10.1097/CEH.0000000000000393
159. Kucsera JV, Zimmaro DM. Comparing the effectiveness of intensive and
traditional courses. Coll Technol. 2010;58(2):62–68.
DOI: 10.1080/ 87567550903583769
160. McCluskey A, Lovarini M. Providing education on evidence-based practice
improved knowledge but did not change behavior: A before and after study.
BMC Med Educ. 2005;5:40.
DOI: 10.1186/1472-6920-5-40
161. Bandura A. Guide for constructing self-efficacy scales. In: Pajares F, Urdan
T, editors. Self-Efficacy Beliefs of Adolescents. Information Age Publishing;
2006:307–337.
Disease and Health Research: New Insights Vol. 6
The Role of Rehabilitation Medicine in the Psychological Etiology of Blindness or Visual Impairment: A
Critical Synthesis
116
162. Web accessibility initiative. Web content accessibility guidelines WCAG 2.2;
2023.
Available:https://www.w3.org/TR/WCAG22/
Accessed March 22, 2024.
163. Bourgois P, Holmes SM, Sue K, Quesada J. Structural vulnerability:
operationalizing the concept to address health disparities in clinical care.
Acad Med. 2017;92(3):299–307.
DOI: 10.1097/ACM.0000000000001294
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Biography of author(s)
Dr. Clairissa G. Richardson, DSW, MSW, LCSW
School of Social Work, Simmons University, Boston, MA, USA.
I am a social researcher, studying the ontological conceptualizations pertinent to people with disabilities
and the consequences of structural bias and discrimination, particularly as they apply to complex adaptive
systems. I am dedicated to publishing research that expands the knowledge relative to the socio-political
realities of people with disabilities and how adjusting care approaches can promote inclusion, empathy,
and social change. I have academic and research experience in critical disability studies, critical
psychology, and critical systems studies. My areas of specialization are social theory, policy, and practice
pertaining to people with disabilities. I have published 3 papers in reputed journals.
I am also a devout Christian and licensed clinical social worker, dedicated to illuminating the benefit of
spirituality-based therapies and approaches in clinical practice, with an emphasis on the power of
relationships. My current research interests involve people with blindness or visual impairment and the
mental health disparities relating to care. I am the developer and creator of Canes in the Margins, a critical
discourse podcast series dedicated to elevating the voices of people with blindness or visual impairment
and their mental health experiences. Canes in the Margins facilitate critical discussion, education, and
collaboration pertinent to the diverse and complex lives of people with BVI and the intercession of
rehabilitation, disability, and social and psychological concepts. I am also a developer of a research-
supported education-based critical podcast.
My work is intended to reenergize how mental health is conceptualized for people with BVI, thereby
improving mental health policy and practice. I specialize in the critique and retransformation of age-old
social and psychological theories that govern the lives of people with disabilities, calling for grounded
approaches to theory development and an emphasis on community-based approaches to understanding
the mental health systems that undermine the lived realities of people with disabilities.
___________________________________________________________________________________
© Copyright (2024): Author(s). The licensee is the publisher (BP International).
DISCLAIMER
This chapter is an extended version of the article published by the same author(s) in the following journal.
Clinical Ophthalmology 2024:18 953-980 - Originally published by and used with permission from DoveMedical Press Ltd.
DOI: https://doi.org/10.2147/OPTH.S442430
Peer-Review History:
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