A model for the interpretation of personality assessments of individuals with visual impairments.

Individuals with visual impairments experience not only challenges in their physical capacities but also challenges in their psychological capacities to adjust to their disabilities. On the other hand, there is no evidence currently that suggests significant, long-term personality trait differences between individuals with visual impairments and those who are sighted (Foulke, 1972; Vander Kolk, 1981). In a classic study by Bauman (1976) it has been suggested that visual impairments, congenital or adventitious, do not seem to be related to psychopathological personality disorders. Knowing that a person is partially or even totally blind tells us; nothing about that person's personality characteristics or personal adjustment to this physical condition. Consequently, the adjustment to a visual impairment is idiosyncratic. Bauman (1976) has argued against the contention that there is a "blind personality type." Clinical practitioners must investigate the multiple dimensions of the personality dynamics of the individual with visual impairments on a case by case basis to make a determination whether their adjustment is normal or whether there are adjustment problems (Kirtley, 1975).

Some research has shown that individuals with higher measured cognitive abilities may have a more positive adjustment to the visual impairment and that individuals who have had more rehabilitative education experience will also likely have a better adjustment. The factors that have been found to have the greatest impact on an individual's adjustment to visual impairment include the reaction of society, the community, important peer groups, and the personal coping style of the individual. It has been claimed (Lazarus & Strichart, 1986) that individuals with visual impairments have been socialized into a "blindness role" that society and peers expect them to adopt. They criticize social agencies for providing only those services to the blind that fit predetermined expectations of their general needs as a group rather than as individuals. Common reactions of society, the community, peer groups and unsensitized clinical practitioners might include pity, rejection, and stereotyping. All of these reactions are unjustified and could be avoided with knowledge of specific clinical procedures that should be applied in the assessment of individuals with visual impairments.

Individuals with congenital forms of blindness might experience normal adjustment reactions to the experience of being blind. These normal adjustment reactions might include among others, self-consciousness in public places (Tuttle, 1987), lack of socially appropriate behaviors, introversion in the presence of sighted individuals (Lowenfeld, 1981), denial of the difficulties imposed on them by the disability (Cook-Clampert, 1981), distorted body image (Foulke, 1972), feelings of helplessness (Bauman, 1976), and a rich fantasy life (Scholl, 1986). Common reactions of individuals who have been adventitiously blinded might include a need to redefine their self-concepts. Reactions to sudden blindness might parallel those stages often described in the death and dying literature (Kubler-Ross, 1969). If the diagnosis of the ophthalmic problem has a progressive component it may be that the individual will experience anxiety about the future status of his/her vision as well as the potential impacts on his/her lifestyle. While an individual's response to adventitious loss of sight is idiosyncratic and may be highly related to his/her adjustment status as a previously sighted individual, it may not be uncommon for practitioners to observe some of the following psychological reactions. These reactions may include denial, fear, anger, and a fall into helplessness and depression. Psychopathology occurs only when an individual overuses a reaction or uses a defense mechanism beyond the point of its adaptive utility. It is up to the clinical judgement of the rehabilitation counselor to determine when these reactions are no longer adaptive for the individual and should be thought of as an adjustment problem or psychopathlology.

In a national survey of psychologists serving individuals who were blind or visually impaired in public and private schools and agencies, Bauman and Kropf (1979) requested the names, frequency of use, and qualitative ratings of all tests these psychologists used in the past year. Questionnaires were sent to 104 psychologists. The five personality tests most frequently reported being used by these psychologists included some form of the Sentence Completion Test, followed by the Minnesota Multiphasic Personality Inventory (MMPI), Projective Drawings, the Thematic Apperception Test, and the Sixteen Personality Factor Inventory. It is interesting to note that of those psychologists reporting they used the Sentence Completion Test, 47% thought that it was a good test for individuals with visual impairments, 38% thought that it was adequate, and only 11% thought that it would be of questionable utility for individuals with visual impairments. The 45 psychologists using the Sentence Completion Test reported that in the previous year they had administered the test 407 times to individuals who were totally blind and 901 times to individuals who were partially sighted. Similarly, of those psychologists reporting that they used the MMPI in their clinical work, 48% reported that they thought the MMPI would be a good test for individuals with visual impairments; 32% thought that it would be a questionable test to use with individuals with visual impairments. In the previous year, the 31 psychologists using the MMPI reported that they had administered the test 166 times to individuals who were totally blind and 297 times to individuals who were partially sighted. Bauman and Kropf noted that the list of personality inventories and procedures reported in use in their most recent study had changed little from a previous study of over a decade earlier (Bauman, 1967). According to Bauman and Kropf (1979), it would appear that the MMPI is still considered to be one of the recommended measures for the assessment of personality of individuals with visual impairments.

Since the MMPI and MMPI-2 are considered by clinicians to be two of the most useful measures of personality for use with individuals with visual impairments it may be helpful to briefly describe the purposes of each instrument. The MMPI and MMPI-2 were designed to provide comprehensive assessments of a number of psychiatric syndromes and personality characteristics manifested by persons with various types of psychological disorders. The MMPI consists of 550 self-reference statements, 16 of which are repeated, bringing the item pool total to 566 items. Persons usually respond to the items by marking "true" or "false" or "cannot say" on an answer sheet. Standard scoring procedures generate a test profile composed of four validity indications and ten clinical or personality scales, which have come to be known both by abbreviations of the scale names and by code numbers used interchangeably. The MMPI-2 represents the restandardizition of the original MMPI. The purpose of the restandardization was to improve wording of existing items that were culturally outmoded or psychometrically unsound. The MMPI-2 has 567 "true-false", self-report items. Like the MMPI, the MMPI-2 has ten clinical scales and four validity scales. No norming data or validity data is available on either instrument for individuals with visual impairments or for those who are blind.

In a recent study on the potential for bias and misinterpretation in personality assessment with individuals who are visually impaired (Harrington, McDermott & Triggs, 1992), three Ph.D. level psychologists independently reviewed the items contained on the MMPI and MMPI-2 for item content potentially biased toward individuals with visual impairments. The bias categories were irrelevant content, discriminatory content, or confounding content. Irrelevant approaches involve assessments which are meaningless in the context of the client's visual impairment.

Discriminatory approaches include those approaches that by their very nature penalize the client by an appearance of maladjustment that is nothing more than an artifact of their visual impairment. Confounding approaches are techniques in which the client's personality functioning is confused with the physical and psychological reality of the client's visual impairment. When all three raters agreed that an item contained biased content based upon one of these three criteria that item was determined to be a "symptom item." A total of fifty-eight items were identified as symptom items on the MMPI and 57 items were identified as symptom items on the MMPI-2. In the second part of the study, these researchers demonstrated the effects of content bias in these two instruments through a case study analysis of test results of the MMPI and MMPI-2 taken by a "normal," 31-year-old, adventitiously, legally blind male diagnosed with diabetic retinopathy at age 23 but sighted until that time. In the first condition the subject responded to the MMPI and the MMPI-2 as if he were sighted. In the second condition, the subject responded to both instruments under his present visually impaired condition. Significant scale score increases were noted on both the MMPI and MMPI-2 under the visually impaired condition. On both the MMPI and MMPI-2 the greatest elevations were on the Depression (D) and Social Introversion (SI) scales. Contrary to Hathaway's (Hathaway & McKinley, 1940; 1943) original contention that item content of the MMPI is of little relevance and that only response patterns are important, it might be concluded from this study that the response patterns of clients with visual impairments should always be reviewed for potential bias.

Model Development

The purpose of this article is to describe a model for personality assessment of individuals with visual impairments. This model contains specific clinical techniques that examiners using measures of personality might employ to help them avoid the potential bias in personality assessment described previously and that the Standards for Educational and Psychological Testing (American Psychological Association, 1985) require be avoided.

In the proposed model of personality assessment of the visually impaired four stages in the assessment process are identified similar to the general stages of assessment specified by Sattler (1988) in his work on intellectual assessment. A flowchart of the proposed model is shown in Figure 1.

Preassessment

In the first stage, called preassessment, the goal is to ascertain What clinical procedures should be followed in exploring and defining the referral question prior to an formal assessment. Psychological assessment is distinguished from psychological testing in that psychological assessment requires the examiner to take into consideration the unique characteristics and the relevant context of the client who is being assessed while psychological testing may involve a psychometrist administering a standard test battery with little consideration of the unique needs and abilities of the client. To realize this goal, the examiner should engage in the following activities. A determination should be made regarding the purpose of the referral. What is the reason for which this individual has been referred? How will the clinical results be used? Who will have access to the clinical evaluation? How will confidentiality be maintained? For example, is the assessment being conducted for the purpose of determining employment eligibility, to determine the presence of psychopathology, to evaluate adjustment to life stress, or to determine the client's ability to adapt to daily responsibilities, to evaluate responsiveness to a treatment regimen or to predict recovery potential; or possibly to evaluate potential performance in an academic situation? Each of these reasons for referral can be used to help the examiner bring focus to the evaluation.

Following a clear statement of purpose for the evaluation, the examiner should obtain a statement of the referral question from both the referral agent and the client. Comparisons should be made between the referral questions of the referring agent and those of the client and differences should be noted in continuing the evaluation process. The identified problem should be behaviorally specified in terms of its frequency, intensity and duration so that the examiner is able to clearly specify the behaviors of concern.

Next, a careful assessment of the medical history and current visual functioning of the client should be undertaken to determine the impact of the impairment on the client's ability to function in a visual world and to determine his/her ability to respond to the personality assessment instruments you are considering. Sattler (1988) states that if the visual handicap is not severe, then an unadapted, standard measure may be used but if the handicap is severe then only measures with verbal items may be used. Sattler does conclude that a subject's ability to answer even verbal items may be diminished if the content of the item requires visual experience, but provides no recommendations on how to proceed under these circumstances. For example, it is important for an examiner to determine the client's visual acuity; is the field of vision restricted; are there differential problems in near and distant vision; what is the quality of the client's usable vision? Is the visual problem congenital in origin or is it adventitious? If the problem is adventitious, what is the psychological status of the client in adapting to the visual impairment? Is the client in a stage of denial, anger, bargaining, depression, acceptance (Kubler-Ross, 1969). Once this information has been gathered, the examiner should determine what other specific problems the referred individual is facing that might interact with the psychodiagnostic evaluation. For example, is the individual unemployed, undergone a recent divorce or separation, experienced a death in the family or any of the major stress factors identified by Holmes and Rahe (1967)? Following a case history review, the examiner should consider any prior assessment results that might assist the examiner in identifying a pattern of client behavior and determine whether the behaviors of concern are in a phase of exacerbation or remission.

Clinical skills involved in the collection of data in this first stage of the assessment model would include consultation, personal interviews, case history review, and the ability to synthesize the preassessment information to choose from the following decision-making options. Once the preassessment phase is completed and based upon the results of the preassessment as described above, the clinician needs to determine whether there is a clear reason for referral or whether further information needs to be gathered. Furthermore, the clinician needs to determine whether the client would be best served by a referral to another professional specialist such as an ophthalmologist, psychiatrist, or clinical psychologist to collect further preassessment information, or determine whether some forms of data collection including personality measurement might assist in answering the original referral problem.

Data Collection

In the second stage of the assessment process, called data collection, the goal is to decide what informal and formal data collection approaches should be utilized to further investigate the referral problem. In order to make the best selection of an appropriate assessment technique, the examiner must know the nature of the client's visual impairment and the extent that there may be residual vision. This determination is important for two reasons. First, it is important to know whether the client has sufficient vision necessary to be administered the assessment in a standardized, unmodified manner. Second, it is important to have reviewed the background case history to determine whether the onset of the visual impairment has been congenital, hereditary, or adventitious because it has been suggested that there may be differences in cognitive development (Bigelow, 1983) as well as patterns of personality development (Bauman, 1967) in individuals with visual impairments and individuals who are sighted. Overall, the few studies available on cognitive development of individuals with visual impairments appear to be quite consistent in suggesting that persons who are blind do eventually reach the cognitive levels attained by those who are sighted. The only exception to this finding seems to be those with visual impairments resulting from a disease process such as maternal rubella in which the client also may be mentally retarded (Chess, Korn, & Fernandez, 1971). The available evidence on the social-emotional interpersonal development of individuals who are blind suggests the existence of divergent developmental pathways that are not always most adaptable for the individual. For example, they may be viewed as more dependent, less socially interactive, more passive, and have delays in the development of self-concept (Adrian, Miller, & de L'Aune, 1982). These data suggest that the focus of assessment should be more on social-emotional rather than cognitive factors, as the area of personality development appears to be the area of greater risk.

In addition to the above considerations, clinicians should view the assessment of individuals with visual impairments from a multifaceted and multisourced perspective. In other words, they should consider assessing the individual's current personality functioning in multiple settings using multiple data collection techniques involving a variety of sources of information. The purpose of the multifaceted and multisourced approach to data collection is to ensure reliability of data collection results and not to place full confidence in any one assessment technique. Another reason that this technique is advocated is so that the clinician is able to compare personality data from individuals representing varying perspectives on the referral problem to determine whether the referral issue is a generalized problem or is setting specific.

The following types of personality approaches have been included in the array of personality assessment techniques that have been offered for the examiner interested in conducting a multifaceted and multisourced assessment: the clinical interview, behavioral observation, rating scales and checklists, and projectives. While each technique is based upon a different set of assumptions about the measurement of personality functioning and each technique may lead to potentially different intervention plans these data collection techniques should contribute in unique ways to understanding the multiple dimensions of the individual's personality functioning. If reliable and valid data collection techniques are selected from each of these representative approaches, it may be possible to gain a holistic view of the individual with visual impairments (Harrington, 1984).

With this philosophical orientation in mind, examiners should employ the following guidelines in the process of selection of data collection techniques. Reliability and validity are the cornerstones of personality assessment. There is a paucity of available personality assessment approaches that have been designed specifically for individuals with visual impairments and that are both reliable and valid for these individuals. Examiners should be careful to review each data collection technique to determine whether the technique is fair and unbiased given the visual impairment of the client. They should compare the physical capabilities of the client with the requirements of the assessment and review the potential instruments to determine whether special norms or adapted assessment procedures are needed.

Scholl and Schnur (1976) state that the MMPI and MMPI-2 are the major approaches recommended for use with individual with visual impairments. Bauman (1976) cautions that examiners should be careful to review each data collection technique to determine whether the technique is fair and unbiased given the visual impairment of the client. In a content validity study of the MMPI and MMPI-2 mentioned previously Harrington, McDermott and Triggs (1992) described three categories of potential item bias. These forms of bias in personality assessments included irrelevant approaches, discriminatory approaches, and confounding approaches. While this research on potential bias in the MMPI and MMPI-2 has not been applied to the other representative personality assessment approaches mentioned above, it would seem that good clinical practice would require the clinician to guard against these three potential sources of bias.

Cross-validation

In stage three, called cross-validation, the goal is to integrate the informal and formal assessment results into a holistic view of the client and to verify that the assessment results for this individual are representative of his/her current adjustment. Previous research has shown differential responding patterns to "symptom" and "non-symptom" items for individuals who are sighted and those who are visually impaired on the MMPI and MMPI-2. Physical disabilities such as visual impairments should be considered as independent factors that can influence the validity of the MMPI and MMPI-2 interpretations. For example, Scale 2 Depression (D) and Scale 0 Social Introversion (SI) were the most significantly affected for both the MMPI and MMPI-2 (Harrington, et al., 1992). It was found that increases for individuals with visual impairments on these two scales could be high enough so that they could make an otherwise normal MMPI or MMPI-2 personality profile appear elevated in the psycho-pathological range. Furthermore, misinterpretation of these false findings could result in the development of inappropriate treatment regimens for the client. In addition, the physical symptoms associated with visual impairments appear to cause increases on other clinical scales that have been wrongfully interpreted as personality variables. If one uses the criteria of five or more "symptom items" per scale, then there are enough "symptom items" on Clinical Scales 1, 2, 3, 7, 8 and 0 to elevate the T-scales on the MMPI and MMPI-2 from 5 to 14 points.

What seems to be clear is that there is much opportunity for misinterpretation and overinterpretation of the MMPI and MMPI-2 with individuals with visual impairments. The clinician, however, can guard against these inappropriate interpretations by cross-validating the assessment results using interview techniques, third-party reports, personal observations, case history data and projective techniques.

In the course of paper - and - pencil assessments such as the MMPI or MMPI-2, the client may be asked to note those items that caused him/her problems in responding or which the client felt were unfair given his/her visual impairments. In subsequent interviews, the clinician should discuss these items with the client to determine why they caused difficulties for the client and to determine whether they should be considered fair items for the client or whether they should be considered biased items that might have artificially elevated one of the scales on the personality assessment instrument that has been administered. To demonstrate this follow-up interview technique, the MMPI and MMPI-2 were administered to a 31-year-old male who was adventitiously blinded (Harrington, et al., 1992). In responding to these instruments, the individual reported problems in responding to the following items on the Depression scale of the MMPI and MMPI-2: "I am about as able to work as I ever was." "I enjoy many different kinds of play and recreation," and "I prefer to pass by school friends or people I know but have not seen in a long time unless they speak to me first." On the Social Introversion Scale of the MMPI and MMPI-2, a sample of items of concern included the following: "I love to go to dances", "I have often felt that strangers were looking at me critically", and "I have several times given up doing a thing because I thought too little of my ability."

In subsequent interviews, the clinician should inquire what factors may have contributed to their responding in a pathological direction. For example, if a client responded affirmatively to the question on the Social Introversion Scale, "I prefer to pass by school friends or people I know but have not seen in a long time unless they speak to me first," the examiner might ask why the client had noted that item as being problematic given the visual impairment. The examiner might also ask the client how he/she typically responds to individuals who approach him/her on the street or whether he/she makes efforts to foster social relationships and what strategies are employed to foster these relationships. Similarly, if a client responded negatively to an item on the Depression Scale that stated, "I enjoy many different kinds of play and recreation," the examiner might interview the client regarding current leisure time interests and the extent to which they have been curtailed or changed since the visual loss; or if the client is congenitally blind, then the examiner should make a determination whether the recreation and leisure activities seem to be appropriate given the type and degree of visual impairment. If it is determined that the client may be having problems with personal adjustment that are not completely explainable due to transient problems associated with adjustment to visual disorders, then additional observations by knowledgeable third parties or direct observations by the examiner should be incorporated into the holistic interpretation of the client's status. These observations might include evidence of specific instances of depression or social introversion, for example, that have occurred at a sufficient level of frequency, duration or intensity such that they create problems for the individual.

As for the use of projective techniques as an approach that could be used to cross-validate other assessment information, there is some controversy. Bauman and Kropf (1979) state that for clients with moderate vision loss, projective techniques including ink blots, incomplete sentences, and the apperception tests may be utilized. In addition, they have stated that story material may by used with totally blind individuals when presented orally. They have described tactual and auditory projective materials. Examples are the Auditory Projective Test and the Sound Test. These measures do not appear to have any research basis. It would appear that projectives are idiographic techniques that have highly disputed psychometric qualifies for the sighted and that these instruments should probably not be used with individuals who are visually impaired or blind.

Postassessment

In the fourth and final stage of the assessment process, called postassessment, the goal is to evaluate, compare, and interpret all sources of assessment data, to determine whether any further assessment is necessary, to consider whether the client meets eligibility criteria for a particular diagnosis and placement, to make recommendations for intervention, to write a psychological report, and to confer with the adult client or (in the case of a child) with parents, teachers and staff regarding assessment results and recommendations. In cases where there may be some reason to suspect the representativeness of the personality assessment findings, the examiner should carefully consider further assessments in such domains as cognition or adaptive behavior.

The model of personality assessment for individuals with visual impairments that has been described in this paper demonstrates the potential for bias and shows specific techniques that could be applied to make the assessment process fairer and more representative of the personality of the referred individual with visual impairments. Despite the fact that good clinical procedures can be used to reduce the probability of bias in assessment, this does not reduce the responsibility of test developers to standardize personality assessment instrumentation normed on and adapted for use by individuals with visual impairments. In this way, the research on the topic of the personality structure and personality development of individuals with visual impairments can progress beyond its current minimal status.

References

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Robert G. Harrington, School of Education, University of Kansas, Lawrence, KS 66045.