1 Clinical Psychologist and Health Psychologist
2 Clinical Psychologist, Psychotherapy Team
SUMMARY. The psychotherapy team at São José Hospital has been collaborating with the Burns Unit since 1985, and the type of co-operation is presented. A study was designed to assess in-patients’ emotional reactions and the subjective meanings of their illness, treatment, and coping process while in the burns unit. We used a methodology based on a qualitative assessment provided by a semi-structured interview designed for the purpose and a quantitative assessment provided by two self-rating scales that assessed anxiety and depression. Twenty-four in-patients were assessed. We present the results and discuss their implications to our clinical practice with burn in-patients and to our role within the burn unit health team.
A brief historical introduction regarding our co-operation with the burns unit
Our co-operation with the São José Hospital Burn Unit in Lisbon started in 1985, with Dr Luzia Travado, because of the psychological needs of a group of thirteen teenagers who were burned in a school accident involving a gas explosion. The patients were receiving intensive care in the Unit (the work with this population receiving psychological help until 1992 has been presented elsewhere; see Bibliography). From 1985 until 1991 Dr Travado followed a series of two-weekly visits to the in-patients in this unit and participated in weekly case discussion meetings with the staff. During that time, she was invited to share her work and experience with the burns patients with other professionals. She presented “Psychological problems of burn patients and their integration in society” in 1987, “Psychological sequelae in a group of teenagers following a gas explosion” in 1992, and “Excessive emotional reaction prevention in the burn patient. Social and family re-integration” in 1995.
In 1995 the old unit was totally rebuilt and gave way to a new and modern unit. Since its reopening a more thorough system of psychological assessment and psychotherapy has been initiated by the first author and her recently created psychotherapy team. What we do
Since 1995 our work in the unit has consisted of: a) daily visits to the burns unit; b) emotional support to all burn patients; c) selection of cases in need of a specific psychotherapeutic approach; d) individual psychotherapy; and e) co-operation with out-patient follow-up.
Goals of the psychotherapeutic approach to burn patients
The goals of our psychotherapeutic approach to burn in-patients are as follows:
When we were invited to present the subject of “Psychological assessment of the burn patient”, we decided that we wanted to bring something more than just our experience followed by a review of the literature or old studies. We therefore decided to carry out a study of our in-patient population in order to review some issues that we thought might be interesting.
We thus designed a study whose main goals were:
1. Methodology of the study
Procedure and timing. The study ran from March to September 1999. Each patient was interviewed after 10 days in the burn unit infirmary.
In-patient assessment was performed in two ways: 1. by a quantitative assessment, in which we used two scales, one to assess the in-patient’s anxiety (Self-Rating Anxiety Scale, Zung, 1975), and one to assess depression (Self-Rating Depression Scale, Zung, 1965); and 2. by a qualitative assessment, in which we used a semi-structured interview designed specifically for this study (based on previous research performed by the first author) to assess the patients’ subjective interpretations of their emotional reactions and the process of recovery, in order to fulfil our goals referred above.
Population. We interviewed 24 subjects, aged between 20 and 54 yr (mean age, 32.9 yr). We eliminated one patient from the study because of insufficient data; we were thus left with 15 men (mean age, 32.0 yr) and 8 women (mean age, 34.6 yr). Ten patients had suffered accidents at work, ten had had domestic accidents, and two vehicle accidents; thirteen had been burned by fire, six by high temperature, two by electric shock, and two by friction. About one-third of our population had a previous history of problems of psychosocial adjustment.
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2. Results and comments
Quantitative data. The results we obtained with scales used yielded a total mean anxiety score of 35.3 and a mean score by gender is 33.6 for men and 38.4 for women; the total mean score for depression was 37.7, and the mean by gender 34.9 for men and 42.9 for women (Table I).
As the cut-off score for a significant clinical level of depression is above 36.25 and for anxiety above 37 (see references), our results show that women had higher and clinically significant levels of depression and anxiety than men, who had clinically nonsignificant levels for both depression and anxiety.
The quantitative analysis of our data led to the following conclusions (it should be noted that all the patients received psychological support from our team on entering the burns unit, as a routine procedure, and this may have affected the data):
Qualitative data
The qualitative analysis of the interviews, the main focus of this study, revealed some important information. We will analyse this on the basis of by each thematic question in the interview:
a. Physical symptoms. With regard to physical symptoms, we found that the patients mainly reported three different symptoms:
Other less significant symptoms were also reported: loss of appetite, oedema, high fever, and complaints related to the anaesthesia used in the procedures, such as vomiting, dizziness, and sleepiness.
b. Emotional reactions. The most important emotional reactions reported were sadness and anxiety. Sadness was related to perceived loss (functional, aesthetic, professional), loneliness, longing for significant other persons, and a sense of guilt. Anxiety was related to pain, slow recovery, treatment, consequences for daily life, sequelae, uncertainty about the future, and fear of facing others.
c. Identity and perceived seriousness of the health problem. All the patients knew the nature of their problem, and perceived it as being very serious (3, in a scale from 0 to 4). Men perceived their problems to be more serious than women did, probably because of their job and family responsibilities. The patients with lower levels of anxiety perceived their problem as being less serious.
d. The main concerns of the burn patient. The main concerns reported by burn patients while in the burn unit were:
e.Factors perceived in the recovery process. We assessed what factors patients considered to be important for a quicker recovery and what factors would delay it. As facilitating or positive factors, the patients mentioned: a) treatment; b) quality of the unit; c) expertise of the health professionals; d) co-operation with the health team; e) time; f) physiotherapy; g) good clinical evolution; h) family support; i) positive attitude; and j) psychological support. As negative or delaying factors they reported: a) clinical complications; b) non co-operation with the health team; c) lack of family support; d) negative attitude; e) pain; f) sleep disturbances; and g) risk of unemployment.
f. Coping skills. The patients reported using a wide variety of coping strategies to deal with their clinical situation and their hospitalization, the most important being:
Comparing the use of coping skills with the patients’ level of depression, we made two interesting observations, which are nevertheless consistent with the literature on the subject:
– patients with higher levels of depression reported using more passive and less compensatory coping strategies, namely, victimization and distraction strategies;
– on the other hand, the patients who showed the lowest levels of depression reported using more active and compensatory coping strategies, namely acceptance and active collaboration.
g. Patient’s role in recovery. The patients reported that the role that they attributed themselves included co-operating with the health team, keeping a positive attitude, distracting oneself, and eating well.
h. Information. Thirteen patients reported needing more information about their clinical situation, against eleven who reported the opposite. Specifically, the patients who needed more information explained that they wanted: a) to be informed continually and gradually about their clinical situation and evolution during hospitalization; b) to receive prior didactic information about the clinical/treatment procedures they were about to undergo ; c) to be given a prediction of the day they could expect to be dismissed from hospital; d) to be informed about the gravity and the consequences of their burns; and e) to be given information about any other associated problems.
i. General evaluation of the experience. In general, the patients rated their experience as “reasonable”, with a mean score of 3.5, on a scale from 1 to 5. However, many patients who rated their experience as “reasonable” explained the rating as the result of a balance between the worst and the best aspects of their experience. The patients with higher levels of anxiety reported their hospitalization experience as more negative than the other patients. We also asked the patients what they found to be the best in their experience as in-patients in the burn unit, to which they referred as follows: a) the health staff’s human and professional qualities; b) the quality of the infrastructures; c) family and social support; d) the food; and e) the availability of room music. When we asked them what was worst in their hospitalization, they referred the following: a) having nothing to do; b) the need to be immobilized; c) limited visits by family and friends; d) the long duration of hospitalization; and e) having pain.
3. Further data from the literature regarding adjustment factors and recovery
The literature reports that various factors are involved in the adjustment and recovery of the burn patient, namely: a) age; b) personality; c) social and family support; d) social and economic status; e) localization, severity, and extent of the burn wound; f) pain; g) attitude of health staff; h) scarring and aesthetic damage; i) functional limitations; and j) coping.
4. Implications for clinical practice
Our results are clearly in touch with our practice as clinical health psychologists with this population. Patients feel and behave because of what they think about what is going on in their lives. So we must all pay attention to the ways our patients are thinking, feeling, and behaving if we are to help them better.
As health recovery is a biopsychosocial process, we as clinical health psychologists should bear in mind that there are two main areas where we play a particular role in the promotion of the psychological aspects of our patients’ recovery: a) firstly, there is our special role with our in-patients, helping them in their adjustment to the new situation in their lives and their problem solving, giving emotional support, fostering their positive attitudes and manner of coping, and playing an active role in the process of their treatment, which will prevent excessive negative emotional reactions and improve compliance and recovery; b) but we must also make a special contribution to the health team by helping them to better understand each patient and his/her needs because if this is adequately done it will prevent later emotional and/or behavioural problems for the patient and also assist the staff in any problem they may have triggered regarding the patients’ well-being.
We have endeavoured to investigate the topic of the importance of assessing the patients’ subjective interpretations of their illness and their coping process and the way these affect their feelings and behaviour. We are sure feel that the use of qualitative methodologies to assess the patients’ subjectivity will provide more clues for clinical practice in further research. We will therefore continue this study with a follow-up of these patients and their quality of life after their dismissal from hospital. This will be our next focus.
Out of curiosity, we looked on the internet for relevant websites aimed at professionals dealing with burn patients and at the patients themselves. Here are some of these sites:
Burn Survivors Online also has a list of suggested readings, namely:
RESUME. L’équipe psychothérapeutique de l’Hôpital São José collabore avec l’Unité de Brûlures depuis 1985, et les Auteurs décrivent cette coopération. Ils ont préparé un protocole pour évaluer les réactions émotionnelles des patients hospitalisés et leur interprétation de la maladie, du traitement et du processus d’affronter la maladie pendant l’hospitalisation dans l’Unité de Brûlures. Les Auteurs ont employé une méthodologie basée sur une évaluation qualitative fournie par un interview semistructuré projeté pour ce but et une évaluation quantitative fournie par deux échelles d’autoévaluation qui évaluaient l’anxiété et la dépression. Vingt-quatre patients hospitalisés ont été évalués. Les Auteurs présentent leurs résultats et considèrent les implications pour ce qui concerne leur activité clinique avec les patients brûlés hospitalisés et le rôle de l’équipe de psychothérapie dans le personnnel médical de l’Unité de Brûlures.