Psychosocial Recovery and Reintegration of Patients With Burn Injuries

Preinjury Adjustment

Shortly after being admitted to the burn unit, a clinical interview is done to gather information regarding variables that may influence the patient's recovery and treatment. Information about the burn injury, previous stressful events, risk factors, preburn physical and psychological health, coping skills, family and social support, and the family's strengths and weaknesses are important factors to take into account when developing treatment plans. Gathering information about factors that contributed to the circumstances of the burn is emphasized in instances of suspected maltreatment and neglect. Because patients will be dependent to some extent on family during recovery, it is essential to identify risk factors in the family system. Risk factors that may predispose individuals to burn injury and that may affect postburn recovery include physical illness, substance abuse, psychiatric illness, behavioral problems, poverty, inadequate social support, and heightened family disruption. Part of the clinical interview involves initiation of a therapeutic alliance with those who are most likely to be involved in assisting a patient's recovery.

Admission Crisis

When people with burns are admitted to the intensive care unit (ICU), they may be frightened, confused, experience shock and disbelief, have pain and anxiety, and fear dying. While the physiological emergency is treated medically, the psychological crisis must also be addressed. The goals at this time are to establish therapeutic rapport with the patient, decrease anxiety, and assess strengths and needs of the patient. The first two tasks are addressed immediately by orienting the patient, focusing on immediate priorities, and assuring the patient that the burn team is composed of knowledgeable experts who will provide excellent care. The patient's heightened anxiety can be expected to interfere with his or her comprehension, so it is usually necessary to repeat statements of reassurance. To prevent a patient from becoming emotionally overwhelmed, it may be necessary initially to avoid or limit talking about trauma-related content. Children in this early stage of recovery may exhibit signs of cognitive and emotional regression, and it is important to respond to them on that level. Techniques such as deep breathing, relaxation with focused imagery, and hypnotherapy may decrease patients' anxiety.

Family members are often traumatized and may experience difficulty eating, sleeping, or concentrating, and feel a loss of control and a generalized sense of incompetence and helplessness. Providing psychosocial support and education about recovery may facilitate the coping of the family. They may need frequent repetition of information and direction in providing comfort to the patient. The psychotherapeutic goals to be accomplished with the family include establishing a therapeutic relationship and diminishing anxiety. This can be facilitated by assisting with orientation to the hospital, providing information about normal reactions to trauma, and validating that their distress is normal and temporary, which helps communicate empathy and understanding. Learning about the injury and its treatment helps restore the family's sense of competence and provides opportunities for them to experience the reality of their roles in helping the patient. The manner in which an individual and a family will ultimately adjust to the long-term sequelae of a burn is often determined in the early stages of recovery.

Critical Care Phase

This phase involves intensive medical and surgical care until the majority of open wounds are covered, and it is an important phase psychologically. Organic factors resulting from the injury and treatment can contribute to psychological symptoms of disorientation, confusion, sleep disturbance, transient psychosis, and delirium. Helpful interventions include frequent orientation to person, place, time; placing comforting objects in patient's view to see and touch; and making the environment as soothing as possible. Visits from family and friends can provide familiarity, reassurance, and comfort the patient. A schedule that approximates a regular wake–sleep cycle helps patients begin to feel normal.

Reassurance from staff about normal aspects of recovery, the treatment plan, and how staff plans to help improve function can decrease anxiety and provide a sense of hope. When a patient is alert the psychotherapist can facilitate grief work to help the patient adjust to the effects of the burn. Patients with altered mental states may be able to hear although not respond, and discretion should be used regarding what is said near them. Psychological interventions are aimed at diminishing anxiety and increasing comfort instead of correcting the person's perception of reality.

Pain and anxiety management are crucial in this stage of recovery. Providing good pain control enhances psychological recovery. Routine and scheduled assessments of background and procedural pain and anxiety validates a patient's concerns but also set an expectancy of relief. The use of standardized scales provides the message that experiencing a range of pain is normal. When staff assess comfort routinely, patients are less likely to feel anxious about their pain management. Clinicians, researchers, and burn survivors have noted that patient recall of satisfaction with acute pain management in the hospital has indicated the need to improve this salient aspect of burn care. Perhaps this may be accomplished by combining a standard pain medication regimen with individualized adjustments based on behavioral observation and patient-reported pain. Similarly, survivors have voiced dissatisfaction with various aspects of care and aftercare, including pain management and the means by which they observed and coped with their injuries. These are ongoing areas of focus and psychosocial intervention.

Psychological interventions for pain and anxiety should be used in conjunction with pharmacological management. Anticipatory anxiety may influence a person's perception of pain. Cognitive and behavioral interventions that enhance a patient's mastery or control can decrease pain and anxiety. Patients often tolerate procedures better when the reasons for each procedure are explained. They may feel more comfortable participating in their own care and gain some mastery over pain when they are allowed to remove their own dressings or participate in wound debridement. The presence of a supportive person during procedures can be effective in decreasing pain. Instructing a family member on how to comfort his or her loved one is important during these procedures.

Other effective interventions in decreasing pain and distress associated with burn treatment include deep breathing, progressive relaxation, visual imagery, biofeedback, hypnosis, virtual reality, mindfulness exercises, and relaxed jaw. Hypnosis induces a relaxed and focused state of awareness that can be extremely helpful in facilitating comfort for patients. Hypnotic inductions and suggestions must be modified to facilitate a patient's use of imagery. Some individuals will respond well to suggestions of imagining a “favorite place.” Older children may respond well to storytelling, with suggestions for comfort and mastery interwoven into the story. Survivors may benefit from interventions that redirect their attention away from the painful procedure. Studies found immersive virtual reality, in which individuals' attention was immersed in a computer-generated world, was effective in reducing pain during wound care and in the tub room. This intervention may also be helpful during physical therapy. Mott and colleagues reported augmented reality, where a character viewed on a screen, was effective in decreasing pain ratings of children with burns during prolonged wound care. Music therapy is an excellent adjunct to analgesia during burn care with children. Fratianne and colleagues mentioned that music therapy significantly decreased the perception of pain in children during wound care; whereas a sensory-focused intervention was more effective with adult burn survivors. Child life interventions such as medical play that gives children control by having them role play and manipulate medical equipment, preoperative preparation about procedures or surgeries, and procedural support can facilitate coping in children and adolescents and decrease anxiety during burn care. The child's age and development need to be considered when selecting the intervention.

Although over time family members may become more at ease with hospital routines, they will continue to have difficulty coping, feel anxious, and need updates about their patient's present and future status, and they may develop new concerns as they are given new roles and responsibilities. Being away from support systems can be difficult. It is helpful to provide information about what to expect in the immediate future, to facilitate patient interaction, and provide honest information while allowing family members to protect themselves from overwhelming despair. Staff can find ways to allow family members to nurture their loved one and can assist them in becoming comfortable in caring for their patient's needs. Taking the time to treat the family is a very important part of treating the patient. This facilitates the family's resumption of feelings of competence and control, promotes hope, and encourages them to join with the burn team in the healing and rehabilitation of the patient. Psychotherapeutic work with the family should also identify and plan for management of family issues that may impede a patient's recovery and rehabilitation.

In-Hospital Recuperation Phase

This phase involves burn survivors becoming physically and emotionally stronger as they face new challenges. Patients begin to comprehend the extent of their injury and may experience difficulty adapting to physical limitations and changes in their physical appearance. They may feel apprehensive about the future, continue to grieve losses, experience a loss of control and autonomy due to being dependent on others, and feel ambivalent about resuming self-care. The team can help motivate the survivor to participate in his or her treatment and assume responsibility for recovery. Individuals who desire optimal recovery need to comply with the medical team's instructions, many of which require significant physical discomfort. Pain continues to be a concern as patients become increasingly active in rehabilitative exercises. Pain and anxiety management are important to regain optimal physical functioning, and the interventions mentioned previously can facilitate pain and anxiety management.

Emotional lability and cognitive and behavioral regression may occur with younger children. Children often have difficulty expressing verbally their thoughts and feelings and may exhibit behavioral outbursts. Parents may be relieved to find that such behaviors are normal, and they often require guidance with implementation of treatment plans that target and positively reinforce desirable behaviors. Emotional reactions such as frustration, anger, and feelings of hopelessness can be difficult for family members to cope with. Hopelessness can occur when patients feel a lack of control and eventually give up trying, which can lead to depression. Research found that depressive symptoms may decrease during the initial hospitalization, and depression during hospitalization is associated with physical functioning the first year post burn. Psychotherapeutic work may involve helping the patient experience control, combat feelings of hopelessness and helplessness, facilitate healthy expression of emotions, achieve success, and feel rewarded while progressing through difficult procedures. Early in this phase, as the patient begins to ask about the future, the psychotherapist can describe the predictable pattern of emotional vicissitudes indicating that they are normal and can be endured and managed. Staff can demonstrate positive regard and acceptance of the patient while also helping the patient exercise control over destructive behaviors. Responses to questions should be honest but hopeful regarding the expectations of treatment and recovery. Interventions aimed at facilitating grief work, coping with body image concerns, management of anxiety and depression, and social skills training to facilitate social interactions are helpful.

Much psychotherapeutic work during this phase is accomplished with patient and family together. Families must learn to assist the patient's adjustment to the new situation, and the family system must accommodate as well. Research suggests it is important to strengthen the family unit, facilitate family closeness, and support attempts to organize their lives to incorporate additional duties involved in providing continued care for the patient. Families will have to adapt to changes in their relationships and in the home environment that are necessary for the patient's recovery and rehabilitation after discharge.

Reintegration Phase

Preparing for a patient's discharge to outpatient status and eventually home begins upon admission to the burn unit. A major objective is to facilitate a person's reintegration to life at home with the family and back to his or her community. Community reintegration is the process of becoming involved in the community, school, work, and leisure activities. Returning home signifies social interactions with the immediate family as well as the extended family, friends, and strangers. Individuals must prepare for those encounters. They often feel anxious, fear social rejection, worry about being accepted, and are concerned about receiving social support. Returning to a cohesive and supportive family environment and loyal friends can make this transition much smoother.

Psychotherapeutic activities involve education and preparation of patient and family about difficulties that may be encountered at discharge. Coping skills that can help should be discussed and practiced. Survivors and families often deny that they will have problems; however, psychotherapists can help prepare patients by offering suggestions to address problems that others have experienced. Issues such as recurrence of posttraumatic stress symptoms, anxiety and pain management, sleep disturbance, irritability, or fear of resuming sexual activities should be discussed prior to discharge.

There are now a spectrum of programs available to the survivor and some for the family. These professional programs help individuals and families through all the phases of recovery from major burn injuries. The Model System Knowledge Translation Center has a large number of print and downloadable forms containing useful information on a wide-range of burn-specific topics available in English and Spanish.

The Phoenix Society for Burn Survivors Inc. is “a non-profit organization dedicated to empowering anyone affected by a burn injury.” This organization has several videos providing information and instruction on new skills, such as social skills, training survivors how to conduct supportive therapy, image enhancement, and school reentry.

Cognitive-behavioral therapists have developed several techniques for treating negative body image and social anxiety related to a physical difference. Likely the most important is teaching a specific set of social skills. Social skills programs are available to facilitate positive reintegration into society, improve social comfort, and increase confidence in social interactions. Social skills include having a short precise answer to explain “what happened,” guiding the topic of conversation, using confident body language and eye contact, and assertively confronting confused and rude behavior. After mastering these skills through in-therapy practice, the survivor is encouraged to practice the skills by engaging in social activities. This practice helps break the social avoidance–depression cycle that may maintain the burn survivor's negative body image.

The program Be Your Best, by Barbara Kammerer Quayle and The Phoenix Society for Burn Survivors Inc., was developed to help burn survivors with community reintegration. The UBelong Social Skills program includes skills to increase social comfort and confidence. Acquiring such skills can make encountering new people and situations and handling stares and unwelcome comments easier. They can help survivors and their loved ones navigate such encounters with added confidence. Additionally Changing Faces , by James Partridge, a program dedicated to assisting persons with facial disfigurement, and recommends a brief social skills training program called 3-2-1-GO! Each of these programs provides strategies to prepare patients and their loved ones to answer questions related to the burn and to deal with staring and stigmatization. The patient may benefit from rehearsal using these skills on brief outings outside the hospital. If difficulties are encountered, the patient can consult with the burn team for direction and support to develop an alternate plan. Support groups for inpatients, outpatients, and their families can be extremely helpful in the process of anticipating difficulties at discharge and rehearsing solutions while also providing emotional support.

Reintegration of the patient into the family is also an area where the burn team can provide assistance. Patients are usually pleased to go home, but upon arrival, may find that their role in the family has changed significantly. The spouse–partner or parent–child relationship may now be one of survivor–caregiver, and the patient may feel helpless or burdensome. Staff can offer advice to families on ways to make the transition home go more smoothly. Tips such as spending time listening to the patient and trying to better understand his or her burn and hospital experience, limiting visitors so the patient can rest, working through feelings of guilt or blame, asking for help from friends and family, and utilizing relaxation techniques for pain management can aid both the patient and family in an easier return home.

The burn team may also prepare the community to which a patient will return. Instructing those unfamiliar with burns in what to say or do to ease a survivor's reentry may assist with reintegration. Variables that may affect burn survivors' ability to return to work once they are discharged from the hospital include size and severity of burn, duration of hospitalization, location of burn, physical impairment, pain, prior employment history, lack of vocational training, work environment impediments, and psychosocial difficulties. Variables found to assist with return to work were psychosocial support, positive thinking, and vocational training. Quinn and colleagues found that 66% of burn survivors returned to work within the first 2 years post burn. In a study of young adults who sustained burns during childhood, Meyer and colleagues found 65% of the sample were employed either full- or part-time. Individuals who do worked reported improved quality of life.

Factors that affect adults returning to work can also influence school reentry for children. Staley and colleagues reported that children with small burns returned to school within the first week or month post burn, and most performed well academically. However pediatric burn survivors often require assistance to return to school so they can learn, develop, and form peer relationships. Many burn centers in the United States have developed school reentry programs. These programs are designed to educate staff and students about aspects of burns, provide generic information about treatment and recovery, emphasize the child's abilities and needs, clarify ways in which the child may require assistance, address the importance of normalizing school activities, and providing peer support and acceptance. Working with the family and the school, a burn professional develops a plan to integrate the child back into school. Usually, part of the process includes the burn professional visiting the child's classroom, explaining the nature of burns and rehabilitation, engendering compassion and support for the survivor, and answering questions. Burn professionals running school reentry programs have received a good deal of positive feedback from schools and families, but the long-term efficacy of school reentry programs has not been empirically demonstrated. A few studies found interventions such as on-site school visits and educational videos/DVDs are beneficial. The Journey Back , by The Phoenix Society for Burn Survivors, is a comprehensive program providing generic materials designed to help pediatric burn survivors, families, and school communities with the re-entry process. Another program, developed by Shriners Hospitals for Children–Cincinnati, is the Remember Me Program, which keeps the pediatric burn patient in touch with his or her classmates during the lengthy burn-related hospitalization. A teddy bear is placed in the child's seat while he is absent, and communication with and from classmates is encouraged.

Rehabilitation Phase, Postdischarge

When survivors transition to the outpatient setting and home, they continue to have physical and psychosocial needs. Rehabilitation may require several months to years, wounds may be vulnerable to breakdown, and individuals may need to use special splints and pressure garments' and continue to exercise. Grief work often continues as survivors cope with losses and delayed grief reactions can occur. Symptoms of posttraumatic stress may recur upon leaving the protective hospital environment. Body image concerns may become more acute as survivors confront stigmatizing reactions from others. Family's social and emotional resources may become taxed as the family transitions into becoming the patient's primary caregivers.

The ratings of significant others on a standardized behavioral scale suggested that young adult survivors of childhood burns who were an average of 14 years post burn were doing well. However on standardized psychiatric interviews, a high percentage of survivors reported experiencing psychiatric disorders specifically related to social situations, and personality disorders warranting diagnoses. Similar results were found in a study of adolescents who were an average 10 years post burn. In these studies survivors were rated by a physical therapist to have no physical limitations that prevented caring for themselves and participating in ordinary activities, their anxieties were severe enough to limit their achievement to full capacity. Even if most burn survivors eventually function satisfactorily by external criteria, clinically, they may be suffering significant distress that is not easily observable. A psychosocial goal is to understand the sources of survivors' distress and to develop interventions that enable survivors to become full participants in society. It would be extremely valuable to patients leaving the hospital, as well as to their social network, employers, and care providers, if there were a set of predictors that could reliably estimate when and to what degree functional improvement could be expected over time. Fauerbach and colleagues evaluated functional impairment of survivors from discharge and across 2 years and found psychological impairment was predicted by prior alcohol abuse, psychological distress, and psychological function both before the burn and at discharge. These data can inform providers and adult patients about factors that could be modified to effect more desirable outcomes.