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Supporting Adaption to Body Image :@! Q Disruption %,,*\O

Joan Norris, PhD RN FMN Stephanie Stockard Spelic, MSN RN CS

Nurses in hospitals, rehabilitation, and community settings ofen provide care for clients who are adjusting to sign$- cant alterations in their physical appearance or function. A grounded theory of reimaging provides guidelines for un- derstanding the process of adaptation and the implications for supportive care afer body image disruptions.

Key words body image change, body image disruption, reimaging

Joan Norris is an associate dean of the Creighton Universi- ty School of Nursing in Omaha, NE. Stephanie Stockard Spelic is an assistant professor of psychiatric mental health nursing at the Creighton University School of Nursing. Ad- dress correspondence to Joan Norris, Associate Dean, School of Nursing, Creighton University, 2500 California Plaza, Omaha, NE 681 78, or e-mail jono@creighton.edu.

Most nurses, at some time in their practice, will provide care for persons who are experiencing significant changes in their physical appearance or functional capabilities. Aside from ad- dressing the person's immediate needs for care, many nurses do not feel competent in supporting the psychosocial process of adapting to these changes. Finding no information on this sub- ject in the literature, we did a grounded theory study of this adap- tation process, using the method described by Strauss and Corbin (1990). 'Tkenty-eight participants were each interviewed 4 times over 18 months, after a body image disruption. The disruptions resulted from surgical or traumatic loss of a body part, paraly- sis, loss of significant function, extensive and visible scarring from bums or accidental trauma, rapid weight gain or loss in excess of 50 pounds from steroid therapy, or gastric surgery for morbid obesity. The description of the basic social process, stages, and influencing factors is based on this study. Readers are referred to the original study by Noms, Kunes-Connell, & Spelic (1 998) for the grounded theory and the methods used to address Sandelowski's ( 1986) criteria of auditability, credibili- ty, fittingness, and confirmability to assure rigor in conducting the study. The purpose of this article is to share information about the stages of reimaging as a social process, and the fac- tors perceived to influence the process and outcomes. Implica- tions for patient support and anticipatory guidance are addressed.

Self-esteem and body image 'Tko key elements associated with the self-concept we body

image and self-esteem. Body image refers to subjective percep- tions of the physical self-appearance and capabilities. It is de- veloped through self-observation, reactions of others, and multi- ple life experiences. Self-esteem is an evaluation of one's self-worth and competence. The factors that build self-esteem are the ability to influence others, being valued by others, being able to perform adequately to meet one's own standads, and behaving consistently with one's values and morals (Coopersmith, 1967).

People who experience losses in physical appearance or func- tioning may perceive themselves as being less valued by oth- ers, less able to perform adequately as an employee or produc- tive member of society, and less influential. These perceptions may be confirmed in reality if they are unable to return to for- mer jobs, or fulfill important family roles, or if people stare at them, or if people with disabilities find that salespersons or wait- ers address their companions rather than speaking directly to them. Prolonged experiences of this nature have the potential to lower self-esteem.

Several cross-sectional studies have reported that groups of persons who experienced body image disruptions because of aging, chronic illness, disability, and disfigurement have lower levels of self-esteem than do comparable groups of persons with- out physical alterations (Antonucci & Jackson, 1983; Drench, 1994; On; Reznikoff & Smith, 1989; Waters,1988.) Situation- al depression, a response to negative life events, is not uncom- mon in persons who have experienced debilitating illness, dis- figurements, or loss of functional abilities. Several participants in the reimaging study, however, reported enhanced feelings of mastery and self-esteem based on their having successfully coped with a life crisis (Norris et al., 1998).

Significance to nursing Nurses are most visibly present during episodes of hospital-

ization, rehabilitation, clinic, and home care. Because of their personal contact and visibility, they are in a position to provide emotional support and anticipatory guidance to clients adapt- ing to body image disruptions, and to their families. Nurses also assess indicators of depression and inadequate coping in clients, and intervene. The reimaging process requires significant time to understand the change, mourn the loss, and adjust to the de- mands of the new situation. Nurses can provide significant sup- port throughout this process.

8 Rehabilitation Nursing Volume 27. Number I JanlFeb 2002

Supporting the reimaging process The grounded theory of reimaging identified three stages in

the adaptation process. Although the nature and significance of the physical or functional alteration is unique to the person, it typically requires as long as a year to adapt and accept the re- maining physical changes. Various complications and multiple crises may extend the time required. This process is fluid, rather than strictly lineal, and does not assure a positive outcome. Most participants reconciled in positive ways to the remaining changes after approximately a year and coped with them to redefine or resume what they considered to be a “normal” life. For a few, however, the reconciliation and normalization were less posi- tive; they reconciled to a lower level of functioning than was possible, due to feelings of helplessness and hopelessness. Body image disruption: In the initial stage, participants re-

acted to the changes with shock or surprise, although, in the case of planned surgical procedures, they knew what to expect. Peo- ple vacillated between episodes of painful awareness of the na- ture of the change and attempts to minimize that awareness through denial, avoidance, humor, or positive thinking. A per- son with an amputation reported falling as he instinctively tried to jump to his feet to answer the doorbell. Months after a phys- ical change, several participants reported not initially recogniz- ing their reflection in store mirrors or windows. A young woman who had gained 50 pounds on steroid therapy said “I saw this fat old woman and was depressed all day when I recognized that it was me.” In this stage, observers may see, at different times, both the positive facade and the sadness evoked by mourning the loss.

Wishing for restoration: In the next stage, the predominance of grief is replaced by wishing for, and working toward, restora- tion of the former physical self. Most participants in the reimag- ing study did work to regain their previous body image and func- tion. Some reported doing much more physical therapy than was recommended; others had plastic surgery to reconstruct a breast, then included a “tummy tuck” to be “better than ever.” Some people may remain passive or helpless in the face of the tasks to be accomplished in this stage. They tend not to make progress that is attainable and appear to be “stuck” in the grieving process. They may talk of how much they want to walk or resume vari- ous activities but, in describing their efforts, it is evident that they have made few attempts to follow professional recom- mendations to regain these skills.

Depending on the nature of the physical alteration and avail- able medical technology, some people have limited options. 0th- ers are relatively successful in their restorative efforts but are disappointed because nothing is really the same as before. Breast reconstruction often leaves an individual with little sensation. Scars may fade, but remain visible. Prostheses require skill and persistence to be used effectively; the easy freedom of move- ment is not regained. As efforts continue, there is an inevitable slowing in the degree of progress, and eventually, individuals begin to weigh the costs in time, effort, or money against the re- turn in benefits. A turning point is reached when the residual ef- fects of the physical alteration are perceived to be “as good as it gets.” This decision may be made in discussions with health professionals or made independently based on the person’s

accumulating experience. Once these reality-based expectations are accepted, the participants’ efforts shift from striving for restoration of the former self to reimaging the self.

Reimaging the self: In the third stage, the adaptive tasks and desired outcomes are reconciliation and normalization. Recon- ciliation involves full acceptance of the change in appearance or functional abilities and incorporating the changes into a revised body image. Normalization requires accommodation to any resid- ual disfigurements or disabilities by adapting work or social roles as needed, and redefining lifestyle into the best possible sem- blance of a normal life. For some individuals, this may require education or retraining for a job change, altered role expectations, or overcoming embarrassment and reaching out socially.

Statements such as “‘This is who I am now, I am changed and I will live with it” or, “It could have been worse,” or gentle hu- mor directed at making everyone comfortable with a physical challenge suggest reconciliation. Not all reconciliation is posi- tive; some people may reconcile to a lower level of functioning than what is possible because of fatalistic expectations, pes- simism, depression, or feeling overwhelmed by the demands of the situation.

Normalization is suggested by efforts to return to school or to change jobs, restore former interests or pastimes, and main- tain and build social contacts and supports. It may involve giv- ing up former expectations for division of household labor when a man can no longer do yard work or a wife is unable to per- form some aspects of housework. Focusing on what one can do, and finding flexible ways of accomplishing other valued tasks, is evidence of normalization. Persons who retain their overall perceptions of themselves while accommodating to the changes in their bodies and their lives demonstrate normaliza- tion.

Consistent with crisis theory, many people find meaning in the reimaging process. The experience of mastering new coping strategies and overcoming threatening events may actually en- hance psychological status (Caplan, 1964). Participants in the reimaging study pointed to various meaningful aspects of their struggle, including developing new insights into themselves and their values, becoming more spiritual, and viewing their mastery of the situation as an achievement-something that many peo- ple would have been unable to do. Table 1 describes specific nursing care for the reimaging process.

Influencing factors Several factors influence the progress and quality of coping

with body image disruptions.

Rehabilitation Nursing Volume 27, Number 1 JarVFeb 2002 9

Body Image Disruption

Body Image Disruption Phase 0 Recognize denial, avoidance, humor, and positive think-

ing as important coping mechanisms. 0 Do not confront denial or avoidance if doesn’t affect at-

tention to physical needs. 0 Avoid false reassurance. 0 Assist to recognize the emotional responses as a normal

part of dealing with changes. 0 Educate about the emotional process of recovery. 0 Reassure that recovery takes time. 0 Support coping strategies that conceal, minimize, or dis-

tract from the physical changes. 0 Support attempts at self-sufficiency and accommodation

using appropriate prosthetics and aids. 0 Listen carefully to conversational cues to mood and

clarify the meaning of these comments. 0 Educate and reassure family! support network about the

process of reimaging.

Wishing for Restoration Phase 0 Encourage rehabilitation efforts including physical ther-

apy, cosmetic and environmental changes. 0 Screen for depression, using assessment of behavior and

verbal cues and instruments such as the Beck Depres- sion Inventory (BDI).

0 Refer for early treatment of depression. Antidepressant therapy may be necessary to enhance mood, increase energy and participation in treatment, and reduce pain.

Reimaging the Self Phase 0 Recognize statements and behaviors that indicate recon-

ciliation to body image changes (adapting function, job retraining, renegotiating roles).

0 Support efforts to adjust lifestyle to changes in function- al abilities through collaboration with educational or support organizations.

0 Encourage significant others to use educational or sup- port opportunities.

These include the unique interpretations of the person, ac- cess to health care technology and services, adequacy of social support, previous life experiences, and self-esteem. These fac- tors have varying degrees of influence, depending upon the avail- ability of effective technology, the unique values and support systems of the person, and their individual perceptions of them- selves and their abilities.

Individual values and interpretations: Individuals may in- terpret a particular physical aspect differently, depending upon their value system, developmental stage, and life choices. Physical changes that impair appearance may be much more threatening to a young woman than to many men, or to elderly persons of either sex. On the other hand, loss of functional ability may be pticularly distressing to men, who value physical strength and aghty, or to elderly persons who fear becoming a burden to their families. Cues

to the nature of the interpretation are evident in statements such as “I’m lucky it’s no worse than it is,” “I’m so ugly I can’t stand to look at myself,” or “I’m no use to anyone now.”

The person’s unique value perspective can only be understood and accepted by the nurse through careful listening. It cannot be altered by well meaning suggestions, but must be worked through by the individual who has experienced the physical alteration. This requires time and may interfere temporarily with the per- son’s efforts to cope with the task of accommodating the change.

Access to healthcare technologies: The quality of care and technological support services available, such as plastic surgery or prosthetics, can make significant differences. For instance, current reconstructive procedures can ameliorate much disfig- urement caused by mastectomies. Prostheses are lighter in weight, easier to manage, and more realistic in appearance. For the stroke patient, there is limited technology to restore function once extensive damage is done, but there are several devices and strategies to help with activities of daily living.

Social support: Social support is sigmiicant to the person who is working through the shock and grief of body image disruption, who is coping with-and accommodating to-the changes, and who needs a buffer for feelings of self-consciousness. This buffer- ing effect was important in the initial stages, when individuals were acutely sensitive about the changes and fearful of the re- sponses of strangers. Family and friends provide additional sources of support-from rearranging the household, to pro- viding transportation or running errands, and in providing emo- tional support. Not everyone has adequate social support. Some study participants divorced during the stresses of the adjustment process; others were isolated by age or personal factors. Lack of effective support makes the tasks of the reimaging process even more difficult, painful, and can, in some instances, result in depression.

Life experiences and self-esteem: People bring extensive histories of life experiences into any new and challenging situ- ation. These experiences, attitudes, and self-perceptions influ- ence their coping and expectations. In turn, the experience of the injury or illness, the related body image disruption, and the reimaging process will add to those life experiences and may affect future self-esteem. Consistent acceptance and caring by the nurse can be comforting and reassure a person about his or her inherent worth.

Summary: Based on the grounded theory and basic social process of reimaging, a case study and two tables of supportive nursing interventions are presented. The story line in the case study has been altered to protect participant identity, but retains the typical stage issues and influencing factors in adapting to sig- nificant body image disruption. Table 1 presents nursing care appropriate to the various phases of reimaging. Recognition of behaviors in each phase, and appropriate interventions, will fa- cilitate movement through the phases. Table 2 illustrates sup- portive interventions that promote positive adaptation based upon influencing factors. The interventions suggested are based in the study participants’ experiences, and in principles from anticipa- tory guidance and crisis theory (Caplan, 1964). Psychosocial s u p port from friends, family, and healthcare providers can signifi- cantly contribute to positive adaptation in the reimaging process.

10 Rehabilitation Nursing Volume 27, Number 1 Jan/Feb 2002

Body Image Disruption

Individual Values and Interpretations 0 Recognize that individual values and interpretations

about appearance and function may vary based on gen- der, spiritual and moral beliefs, life stages, and previous life choices.

0 Listen actively and validate feelings. 0 Avoid well-meaning suggestions and allow client to work

Access to Healthcare Technologies 0 Assess financial coverage and identify nonreimbursable

0 Coordinate with other health care providers as appropriate. 0 Refer clients to resources for items that are not reim-

through the process.

needs.

bursed in health care plan.

Social Support 0 Identify capacity and willingness of the network to pro-

vide support. a Assist in mobilizing available support as appropriate to

needs. 0 Identify and help educate sources of emotional or affec-

tive support to the need for active listening, acceptance and availability.

0 Assist with problem solving, sorting out options, and making decisions without interjecting personal bias.

0 Encourage interaction with individuals or support groups who have undergone similar body image changes.

prior L i e Experience and Self-Esteem 0 Recognize that the reimaging process is consistent with

grief and crisis theory, in which restoration to prior level of functioning, or better, is desirable.

0 Discuss new insights and the meaning of the experience with the person.

0 Help the person identify new coping mechanisms that have promoted reconciliation and normalization.

References Antonucci, T. &Jackson, J . (1983). Physical health and self-esteem. Family

and Community Health, 6(1), 1-9. Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic

Books. Coopersmith, S. (1967). Antecedents of self-esteem. San Francisco: Free-

man. Drench, M.E. (1994). Changes in body-image secondary to disease and in-

jury. Rehabilitation Nursing, 19, I , 31-6. Noms, J., Kunes-Connell, M., & Spelic, S.S. (1998). A grounded theory of

Reimaging. Advances in Nursing Science, 2q3). 1-13. Om, D.A.. Reznikoff, M., & Smith, G. (1989). Body image, self-esteem,

and depression in bum injured adolescents and young adults. Journal of Bum Care and Rehabilitation, 10,454-61.

Sandelowski, M. (1986). The problem of rigor in qualitative research. Ad- vances in Nursing Science, 8(3), 21-37.

Strauss, A., & Corbin, J . (1990). The basics of qualitative research: Grounded theory procedures. Newbury Park, CA: Sage.

Waters, H.H.F. ( 1 988). The relationship among self-concept, coping, social support and psychosocial adjustment. Unpublished doctoral dissertation, Catholic University of America, Washington, DC.

Continuing education (CE) articles dis- cuss current trends and issues affecting re- habilitation nursing. This CE offering (code number RNC- 188) will provide 1 contact hour to those who read this article

38. This independent study offering is ap- propriate for all rehabilitation nurses. By reading this arti- cle, the learner will achieve the following objectives: 1 . Describe phases with characteristic behaviors in the

process of reimaging the body following body image disruption.

2. Identify supportive approaches or interventions to fa- cilitate the process of adaptation to the body image disruption.

3. Recognize phase-specific indicators of adaptation, out- comes of reconciliation and normalization, and ban-i- ers that require intervention or referral.

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"@j * and complete the application form on page 94C&,O

12 Rehabilitation Nursing Volume 27, Number I JanlFeb 2002