Annals of the MBC - vol. 2 - n' 3 -
September 1989
THE
PSYCHOLOGICAL RECOVERY OF THE BURN PATIENT: AN INTEGRATED REHABILITATION WORK PROGRAMME
Amico W Colaianni E*, Mosca K*, Masellis
M.
Divisione di Chirurgia Plastica. Ospedale Civico USL
58, Palermo, Italia
* Divisione di Neuropsichiatria. Ospedale Civico USL 58, Palermo
SUMMARY. A programme is proposed
to of the various professional figures involved. the psychological rehabilitation of the
burn patient that takes into consideration the group-work The psychologist is the
essential link between patient, physician, paramedical staff, physiotherapist, social
worker and family. The programme was prepared on the basis of a suitably long period of
observation by these professional figures of the events and the emotional climates in a
Burns Centre.
This programme is based on observations by
psychologists, physicians, physiotherapists and nurses of children and adults admitted to
the Palermo Civic Hospital Burns Centre. In the course of the last year these observations
have intensified, and it has been found necessary to form a clear definition of the
psychological assistance required, with regard to the whole working group.
The patients were observed in particular from certain viewpoints: psychological reaction
to the specific burn pathology, attitude to hospitalization, relationship with medical
staff, family and the outside world.
In working out this programme, it is essential to have weekly meetings of the working
group; this is indispensable in any group wishing to integrate psychological assistance
and to reflect on the operative methods that have been followed, in order to avoid the
overlapping of the disorganized or, worse still, contradictory forms of assistance
frequently found in routine hospital treatment.
The observations of the physicians and nurses and the resulting psychological assistance
vary according to the phase of the patient's burn pathology.
In the early phase, which we may define as the shock phase, the patient is upset by
the sudden realization of his condition. Burns strike individuals who are fully active -
there is no time for gradual acceptance of the pathology. The patient experiences a
reduction of his state of consciousness and his capacity for thought; often he cannot
speak, a condition not always directly due to the severity of actual physical trauma, but
related to the state of post-traumatic shock, with reactions of panic and a psychological
difficulty to accept the situation. It should not be forgotten that the burn pathology is
characterized not only by insidious damage to the internal organs but also by shocking
visible external damage to the body.
During this phase, an attempt must be made to start a dialogue with the patient, although
it must be realized that reactions of refusal must be understood and respected as
indications of his self-protective attempt to adapt to his new condition. Inevitably
during this phase the patient is in intensive care and consequently in a condition of
isolation and lack of physical contact with his family, a condition of detachment from the
outside world. With regards to children, the psychologist has to work on an elaboration of
the trauma with the parents; this elaboration is all the more difficult because it may not
be possible for the parents to communicate with their child and act out their need to help
him in some way. In the case of the adult patient, attention must be paid to stimulating
forms of communication between the patient and his family, and a vigilant watch must be
kept for the appearance of feelings of abandonment or emotional detachment.
In the next phase, the pain phase, the patient begins to take stock of his diseased
condition, and to interact with his environment and the medical staff. The patient is
continually exposed to pain because of the various therapeutic procedures he undergoes -
the insertion of catheters, repeated taking of blood, the venous drip, escharotomy,
bathing therapy and the general treatment of wounds. Subsequently, other procedures -
repeated surgical operations, physiotherapy, the use of splints - continue to provoke a
reactivity to physical pain that, induces various psychological reactions that depend on a
number of interacting psychophysical factors. The predominant mental conditions are
thoughts of death, fear, anxiety, depression, abandonment, isolation, mutilation, change
of image and a feeling of guilt. The patient's attitude towards the medical staff and the
therapy he is receiving ranges from indifferent negativism to anger, intolerance and
extreme restlessness. In all these conditions the psychologist's role must be to suggest
to the medical staff a form of approach that is not critical or condemnatory of the
patient's difficulty of facing pain. There must be respect for the reaction of the
individual patient, also in relation to his personality before the accident and his social
background. It is very important in the case of children that there should be some members
of the working group whose relationship with the children is entirely unconnected with any
painful procedures; they do not therefore provoke reactions of anxiety and they are
experienced as communicative and reassuring figures.
In the third phase, the elaboration phase, the patient has succeeded in preventing
the experience of pain from invading his entire mental space and he is better disposed
towards initiating a direct dialogue with the psychologist. The gradual reactivation of
thinking processes opens the path to the description of the scene which provoked the burn
accident. This elaboration, in the case of children, takes into account the possible
responsibility of the parents or other persons; this responsibility, whether real or not,
in any case leads to a series of unconscious reactions laden with feelings of guilt. In
the case of adults, the clarification of the circumstances, whether fortuitous or not, of
the accident, reveals situations deriving from acts of carelessness, lack of assistance
from other persons present and involvement of family members or others. This promotes
conflicting mechanisms of acceptance of blame, refusal of blame or the laying of blame on
others.
The matter of information to the patient and his family regarding the extent of the burn
and the development of scars is of great importance. This problem involves in different
ways all members of the working group who must be aware that this information does not
consist only of technical and sanitary details but also has psychological, human and
social implications. This approach to integrated information on the part of the whole
group does not minimize the lesions and their eventual outcome, and it does not permit the
patient to withdraw into a depressive state - it must rather aim at inspiring confidence
in the possibility of reconstructive recovery.
In the final phase, the reconstructive phase, the patient is prepared for the
moment of dischar leaving hospital and returning to his home and his place in society. The
psychologist's attention is directed towards the follow-up of the patient in his
repossession of a physical identity often disfigured by scars that modify not only his
physical appearance but also his way of living and thinking. These are physical
disabilities which, depending on the gravity of the burn, entail new ways of life, gradual
physical reconstruction and complex mechanisms of psychological adaptation. During the
long period of hospitalization the psychologist has already assured the non-interruption
of the relationship between the patient and his family, using every means possible
-letters, toys, familiar objects - and he must continue to follow the patient at the
delicate moment of his impact with the outside world. These aspects of the outside world -
family, school, place of work, society in general - can be experienced by the burn victim
as different and strange, compared to the identity they had before. For children the
return to school is the moment of truth, with regard to their response to their new
condition. The psychologist must contact the teachers, whose attitude generally ranges
between frightened pity and anguished detachment. The teachers must be made aware of the
needs of the individual burned children and of the problems deriving from their disease
and their disfigurement.
RÉSUMÉ. On propose un programme
pour la réhabilitation psychologique du brûlé, un programme qui tient en considération
le travail de groupe de tous les opérateurs intéressés. Le psychologue constitue le
trait d'union entre le patient, le médecin, l'infirmier, le physiothérapeute,
l'assistant social et la famille. L'élaboration du programme de travail a été
réalisée après une période convenable d'observation des événements et des climats
émotifs dans un Centre des Brûlés, avec la partécipation de tous les opérateurs
mentionnés.
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