Burn injuries are known to be one of the major causes of deaths and disfigurement all over the world and so also in India. It has been suggested by various studies that disfigurement due to burns has far reaching psycho – social impact on patients. The psycho social support after burn injury is identified as very important. Cooper & Burnside,1996,a) There is an agreement that the occasion of a major burn injury warrants the availability of acute and long term psycho social services to support optimal recovery. Many have identified the importance of family and social support as predictors of adaptation. (Doctor, 1992) Modern surgical and rehabilitation medicine has made gigantic steps in the healing and rehabilitation of burn patients. However, there are many patients who, despite the best in burn resuscitation, treatment and rehabilitation: are not able to pull themselves together. They retreat into the ‘closet’ and become nonfunctioning. Even for the patients who show successful surgical and rehabilitation results, things are not always what they seem to be. Healing on outside may not reflect healing on inside. The psychological injuries suffered may soon break through like seething abscesses and what seems to be a recovered burn patient may become a societal drop out, recluse or an addict. (Blumenfield & Schoeps, 1992) There is enough evidence that burn patients who use avoidance coping strategies, who have low problem solving skills, few recreational activities and less social support have tended to be les well adjusted after injury. There is also a high evidence of psychological disorder after burn injury, estimated at 10%- 44%; social factors accounting for 40% of the variance in predicting psychosocial adjustment. (Cooper & Burnside, 1996,b) However, it is an unfortunate fact that despite clear knowledge of the importance of social and psychological factors, little is yet being done in this area.
This paper is an attempt to share some of the experiences in the area of counseling burn patients at the Burn Care Unit of Tata Main Hospital, Jamshedpur, Bihar, where the author was working from 1992-2000.
The objectives of this study are
- To gain understanding into the psychosocial problems of burns patients.
- To develop an insight regarding the specific needs that arise out of the counseling sessions.
- To develop a database for future use.
- To familiarize people at large to the issues and concerns of people with burn injuries.
This is a retrospective study wherein the data initiated during the author’s daily work has been analyzed so as to derive some information that can be of use for counseling burns patients in future. The selection of the patients under study was done on the basis of following criteria.
- Patients, who could communicate verbally.
- Patients, who had significant and obvious disfigurement that is likely to hamper social adjustment.
- Patients, who had showed a definite need for counseling in the initial intake sessions.
METHODS AND MATERIALS:
(I) Intake Interview: The contact with the patients under study began with an intake interview by the author, after the patient was admitted to the BCU( Burn Care Unit) of TMH( Tata main Hospital, Jamshedpur)The intake interview gathered the basic identification data of each patient such as age, sex, education level, income, type and cause of burns, first aid offered etc. It also collected some information on family background, adjustment problems, if any; traits, relationships with significant people etc. The details of these were collected during consecutive sessions.
(II) Social Support Assessment: Mainly three types of supports were assessed.
- Emotional Support through Reassurance, empathy etc.
- Informational support means where one can get various types of
(III) Client strength assessment
– Assessment of client strength was done on a continuous basis. It included the following parameters. Despite the disfigurement whether the patient can do
- To share/ open up
- To identify positive / supportive people / places resources that can be helpful in adjustments due to burn injury
- To accept the problem areas arising due to burn injury
- Has the will to adapt the changes in life style/ functional status etc. due to burn injury
- To make decisions about changes / adaptations
Based on the outcomes of the above-mentioned assessments individual intervention plan was prepared for each patient. The basic interventions offered were
- Counseling – emotion focused
- Counseling – problem focused
- Liasoning with some agencies for getting some engagements / vocational training
RESULTS AND DISCUSSION
The identification data provided the basic information as follows:
It was seen that family was the basic support group for all cases for all types of supports. However, informational support regarding management of burns was provided by hospital staff. There was a significant lack of any formal organization providing any kind of support.
Client strength support:
It was seen that women as a group were more open than men as a group. However, it may be assigned to the fact that the counselor is a female and thus may have gender bias.
Crying and talking out were most commonly used ventilating strategies despite the gender differences.
Social aspects of disfigurement that bothered majority of the patients were:
- a negative / low self image due to physical disfigurement basically because people will point out fingers to ‘odd man out’.
- anxiety about ‘how to manage’ in future the assigned roles one is expected to play in life.
The follow-up interviews after discharge from the hospital revealed that patients had a tendency to minimize / avoid social contacts after returning home. This was due to mainly :
- physical pain / functional limitations in movements
- hesitance felt by majority assuming people may ask questions regarding the injuriy
- family members being very protective towards the patient and doing almost all possible things on their behalf
- initially lack of activities that are not physically tiring but provide socialization and engagement and later on getting used to security of the home bound situation.
- lack of self help group with whom they can share the problems and ways of handling them
- anxiety regarding family members taking on added burden of their daily life and not waiting to increase the burden.
The interventions were aimed at counseling for emotion release that would help minimize stress prevent progression of negative feelings and promote positive coping strategies. This was achieved by building a good rapport with the patient, by encouraging ventilation of feelings and focusing on the residual physical and psychological abilities. Most of the time counseling for emotion release and problem solving went hand in hand.
The counseling for problem solving aimed at positive approach. The counselor and the patient and sometimes the family member jointly listed out anticipated future emotions / problems that are likely to be encountered and discussed appropriate responses to them. The patients were also encouraged to think as how they can make conscious efforts to initiate desirable and positive social responses by initiating eye contact or conversation for breaking the ice. The possible ways to satisfy the curiosity of people without hurting one’s own self were discussed where ever felt necessary.
A number of other areas of concern that emerged from these sessions are listed below.
- meeting similar patients: the concept of self help group that can offer sharing of experiences as well as support during hospitalization and after discharge.
- counseling of family members in some cases
- financial help / mobilizing resources for extra assistance for better life.
- home visits in some cases for reassurance.
- information on various issues that may help in taking better care at home: structured home management package for burn survivors.
The continued sessions in most of the cases revealed that the adjustment after burn injury was satisfactory in most of the cases. One case was lost to follow up and the outstation cases (6) were not in touch date. There is no formal assessment of their social adjustment, how ever, rest of the patients who underwent the counseling sessions do seem to be adjusted with life after burn injury. It may be interesting to note that two females who had severe burns (about %) and associated appearance problems and major emotional traumas (abortion / death of husband) have resumed very active role in life within a span of two years from the injury. It must be mentioned that they had a very good family support in both the cases in terms of emotional support and practical help both of them did not have good financial status. Both of them had a very positive personality and had built up a very good rapport with the counselor and thus were in constant touch.
It was also interesting to observe that counseling for other family members was felt as garments etc. were identified as some important issues by the family members, they showed interest in ventilating feelings and working out solutions by discussing these matters with the counselor/ person concerned.
The number of counseling sessions varied from 3-10 as per individual needs. Counseling seems to have been helpful in adjusting to social life after undergoing the trauma of burn injury. There seems to be a great need for self help group that can offer peer counseling during and after hospitalization.
COUNSELLING BURNS PATIENTS FOR BETTER SOCIAL FUNCTIONING
Burn injuries are known to be one of the major causes of death and disfigurement in India. It has been confirmed by various studies that disfigurement due to burns has far reaching psychological impact on patients resulting in difficulties in social functioning. However, not much attention has been paid to cater to such psychological needs so as to make them socially functional and not just medically fit.
The paper is an attempt to share the experiences of providing counseling services to burns patients and their families to facilitate better social functioning.
The discussion is based on the analysis of 20 selected cases from burns care unit of TMH. The cases had significant disfigurement due to burns.
Social diagnosis of such cases was done to identify the issues for counseling. It was observed that interpersonal relationship problem was a major cause for anxiety either pre-injury (11 cases) or due to injury (9 cases). Family was family was a significant lack of any formal organizations offering any kind of social support.
Women as a group were observed to be more open in realizing strengths than men as a group, may be due to the gender bias of the counselor. Crying and talking out were the most common coping strategies despite the gender difference.
The issues for counseling common for all the 20 cases and their families were; acceptance of pain and altered figure, support, ventilation of feelings, identification of changed needs and appropriate behavior, recognition of strengths and willingness to utilize them, anticipation of future emotions/ actions and how to handle them to facilitate social functioning.
The number of counseling sessions varied from 3-10 as per the needs and are still ongoing in some cases. Except one case, that has been lost to follow up, the social functioning is satisfactory in the rest of the cases. The counseling intervention is still on going.
– Anagha Ghosh, Director Shodhana Consultancy