Psychosocial Care (BURN)

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\fs24 Psychosocial Care of Persons with Burn Injuries \par\pard\ql \li2284\sb0\s
l-276\slmult0 \par\pard\ql\li2284\sb268\sl-276\slmult0 \up0 \expndtw-4\charscale
x100 Patricia E. Blakeney PhD, Clinical Professor, Shriners Burns Hospital and \
par\pard\ql \li3321\sb1\sl-256\slmult0 \up0 \expndtw-5\charscalex100 University
of Texas Medical Branch, Galveston Texas \par\pard\ql \li2332\ri2087\sb265\sl-28
0\slmult0\tx3321 \up0 \expndtw-5\charscalex100 Laura Rosenberg PhD, Assistant Pr
ofessor, Shriners Burns Hospital and \line\tab \up0 \expndtw-5\charscalex100 Uni
versity of Texas Medical Branch, Galveston Texas \par\pard\ql \li2332\sb0\sl-260
\slmult0 \par\pard\ql\li2332\ri2087\sb17\sl-260\slmult0\tx3321 \up0 \expndtw-5\c
harscalex100 Marta Rosenberg PhD, Assistant Professor, Shriners Burns Hospital a
nd \line\tab \up0 \expndtw-5\charscalex100 University of Texas Medical Branch, G
alveston Texas \par\pard\ql \li2179\sb267\sl-276\slmult0 \up0 \expndtw-4\charsca
lex100 Prof. Dr. A.W. Faber PhD, University of Groningen, Groningen, Netherlands
\par\pard\ql \li1881\sb0\sl-276\slmult0 \par\pard\ql\li1881\sb268\sl-276\slmult
0 \up0 \expndtw-4\charscalex100 Contact Information: \par\pard\ql \li1881\sb0\sl
-260\slmult0 \par\pard\ql\li1881\ri3859\sb18\sl-260\slmult0 \up0 \expndtw-5\char
scalex100 Patricia E. Blakeney PhD \line \up0 \expndtw-5\charscalex100 Clinical
Professor \par\pard\ql \li1881\sb7\sl-276\slmult0 \up0 \expndtw-5\charscalex100
Shriners Burns Hospital \par\pard\ql \li1881\ri3331\sb0\sl-280\slmult0 \up0 \exp
ndtw-5\charscalex100 University of Texas Medical Branch \line \up0 \expndtw-5\ch
arscalex100 815 Market St. \par\pard\ql \li1881\ri4036\sb0\sl-270\slmult0 \up0 \
expndtw-5\charscalex100 Galveston, TX 77550 \line \up0 \expndtw-5\charscalex100
Phone: 409-770-6718 \line \up0 \expndtw-5\charscalex100 Fax: 409-770-6555 \par\p
ard\ql \li1881\sb1\sl-245\slmult0 \up0 \expndtw-5\charscalex100 Email: pblakene@
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rscalex100 \ul0\nosupersub\cf1\f2\fs24 Psychosocial Care of Persons with Burn In
juries \par\pard\ql \li1881\sb264\sl-276\slmult0 \up0 \expndtw-5\charscalex100 I
ntroduction: Why Psychosocial Care Is Important \par\pard\ql \li2592\sb4\sl-276\
slmult0 \up0 \expndtw-5\charscalex100 Treatment of people with burn injuries inc
ludes recovery of optimal \par\pard\ql \li1881\ri1636\sb0\sl-271\slmult0\tx2592
\up0 \expndtw-4\charscalex100 function for survivors to fully participate in soc
iety, psychologically and physically. \line \up0 \expndtw-4\charscalex100 Increa

sed likelihood of physical survival has led to greater concern for potential \li
ne \up0 \expndtw-4\charscalex100 psychological morbidity for the burn survivor.
Surgical and medical technology \line \up0 \expndtw-4\charscalex100 has improve
d to such an extent that now, in most cases, burn care providers \line \up0 \exp
ndtw-4\charscalex100 must assume that the patient will live. They must be aware
, even in the first \line \up0 \expndtw-4\charscalex100 moments of treatment, of
what will be important to the surviving patient. \line \tab \up0 \expndtw-4\cha
rscalex100 Burn survivors experience a series of traumatic assaults to the body
and \line \up0 \expndtw-4\charscalex100 mind which present extraordinary challen
ges to psychological resilience. \line \up0 \expndtw-4\charscalex100 Contrary to
what might be expected, empirical data regarding the long-term \line \up0 \expn
dtw-4\charscalex100 sequelae of burn injury indicate that many burn survivors do
achieve a satisfying \line \up0 \expndtw-4\charscalex100 quality of life and th
at most are judged to be well-adjusted individuals. However, \line \up0 \expndtw
-4\charscalex100 thirty percent of any given sample of adult burn survivors cons
istently \line \up0 \expndtw-4\charscalex100 demonstrate moderate to severe psyc
hological and/or social difficulties.\ul0\super\cf3\f4\fs23 1, 2 \line \up0 \ex
pndtw-4\charscalex100 \ul0\nosupersub\cf1\f2\fs24 Similarly, most pediatric burn
survivors, even those with the most extensive and \line \up0 \expndtw-4\charsca
lex100 disfiguring injuries, adjust well.\ul0\super\cf3\f4\fs23 3-5\ul0\nosupers
ub\cf1\f2\fs24 Empirical studies, as well as clinical \line \up0 \expndtw-4\cha
rscalex100 observations and patient self-reports, suggest that burn care of the
whole person, \line \up0 \expndtw-4\charscalex100 including early and continued
attention to psychosocial aspects of the patient\u8217?s \line \up0 \expndtw-4\c
harscalex100 life, can facilitate positive psychological adaptation to the chall
enges of traumatic \line \up0 \expndtw-5\charscalex100 injury, painful treatment
, and permanent disfigurement. \par\pard\ql \li1881\sb254\sl-276\slmult0 \up0 \e
xpndtw-5\charscalex100 Who Provides Psychosocial Care \par\pard\ql \li2592\sb1\s
l-256\slmult0 \up0 \expndtw-5\charscalex100 Ideally, clinicians who specialize i
n human behavior (psychiatrists, \par\pard\ql \li1881\ri1656\sb0\sl-271\slmult0\
tx2592 \up0 \expndtw-4\charscalex100 psychologists, social workers, psychiatric
nurses or others with similar expertise) \line \up0 \expndtw-4\charscalex100 can
be involved in treatment programs for all burned patients throughout the \line
\up0 \expndtw-4\charscalex100 recovery process, beginning as soon as possible an
d continuing throughout \line \up0 \expndtw-4\charscalex100 rehabilitation.\ul0\
super\cf3\f4\fs23 6\ul0\nosupersub\cf1\f2\fs24 However, there are many location
s in the world where fully trained \line \up0 \expndtw-4\charscalex100 mental he
alth experts are not readily available. Where we talk about the \line \up0 \exp
ndtw-4\charscalex100 \u8220?psychotherapist\u8221? we refer to a person who guid
es and accompanies the other (in \line \up0 \expndtw-4\charscalex100 this case,
the burn survivor) through a journey. Such a person must be gifted \line \up0 \
expndtw-4\charscalex100 with empathy and must like people; other skills can be l
earned, regardless of \line \up0 \expndtw-4\charscalex100 educational background
. However, it is most helpful if ongoing consultation and \line \up0 \expndtw-5
\charscalex100 supervision can be arranged to be provided by a well-trained expe
rt. \line \tab \up0 \expndtw-5\charscalex100 It must be remembered that every pe
rson who interacts with a patient \line \up0 \expndtw-4\charscalex100 impacts th
e psychosocial world of the patient. Any caregiver, including the \line \up0 \ex
pndtw-4\charscalex100 patient\u8217?s family, may be the instrument of psychothe
rapeutic intervention. An \line \up0 \expndtw-4\charscalex100 important role of
the psychotherapist is to consult with caregivers about \line \up0 \expndtw-4\c
harscalex100 psychological and social issues and to suggest therapeutic interven
tions that any \line \up0 \expndtw-4\charscalex100 or all can act upon. Further
more, psychotherapists on a burn team provide direct \line \up0 \expndtw-4\chars
calex100 treatment to patients as appropriate to changing concerns. As needs of
the \line \up0 \expndtw-4\charscalex100 patient evolve, the intensity of direct
psychotherapeutic intervention varies \line \up0 \expndtw-5\charscalex100 accord
ingly.
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l-276\slmult0 \par\pard\ql\li1881\sb68\sl-276\slmult0 \up0 \expndtw-5\charscalex
100 \ul0\nosupersub\cf1\f2\fs24 Cultural Sensitivity \par\pard\ql \li2592\sb4\sl
-276\slmult0 \up0 \expndtw-5\charscalex100 Burn patients come from diverse cultu
res, and care providers must be \par\pard\qj \li1881\ri1668\sb0\sl-272\slmult0 \
up0 \expndtw-4\charscalex100 sensitive to how cultural issues can affect patient
s and families in all the phases \line \up0 \expndtw-5\charscalex100 of the reco
very process. \u8220?Culture\u8221? refers to the socially transmitted expecta
tions, \line \up0 \expndtw-4\charscalex100 beliefs, traditions, and behavioral p
atterns typical of a given community at a point \line \up0 \expndtw-4\charscalex
100 in time. It is influenced by many factors such as geographical location, eth
nicity, \line \up0 \expndtw-4\charscalex100 and socioeconomic background. Care
providers must also be aware of their own \line \up0 \expndtw-4\charscalex100 bi
ases, values and assumptions that stem from their cultures. Individuals\u8217? \
par\pard\qj \li1881\ri1655\sb0\sl-270\slmult0 \up0 \expndtw-4\charscalex100 conc
epts of time and space, appropriate hospitality, importance of greetings, how \u
p0 \expndtw-4\charscalex100 non-verbal gestures are interpreted, and ways of exp
ressing gratitude may differ \up0 \expndtw-5\charscalex100 greatly among culture
s. \par\pard\ql \li1881\ri1683\sb0\sl-271\slmult0\fi710 \up0 \expndtw-4\charscal
ex100 A\ul0\nosupersub\cf4\f5\fs24 cculturation\ul0\nosupersub\cf1\f2\fs24 is t
he process in which individuals from one culture embrace \line \up0 \expndtw-4\c
harscalex100 patterns, customs, beliefs, values, and the language of the dominan
t culture. \line \up0 \expndtw-4\charscalex100 Patients and their families on fi
rst arriving at a burn care facility must rapidly \line \up0 \expndtw-4\charscal
ex100 adapt to the culture of the hospital environment. Even if the hospital is
within \line \up0 \expndtw-5\charscalex100 their own community, they experience
some level of culture shock and \line \up0 \expndtw-5\charscalex100 acculturati
on. This process is even more complicated for those who are \line \up0 \expndtw4\charscalex100 transported for care to communities far removed from their homes
and perhaps \line \up0 \expndtw-5\charscalex100 in another country. \par\pard\q
l \li2592\sb1\sl-243\slmult0 \up0 \expndtw-4\charscalex100 Coping with a multitu
de of unfamiliar experiences in a situation that is \par\pard\ql \li1881\ri1665\
sb0\sl-272\slmult0 \up0 \expndtw-4\charscalex100 traumatic under the best of cir
cumstances presents extraordinary stress that can \line \up0 \expndtw-4\charscal
ex100 inhibit a patient\u8217?s or family\u8217?s ability to participate in the
recovery process. Such \line \up0 \expndtw-4\charscalex100 difficulties correct
ly recognized can be addressed by the burn team so that \line \up0 \expndtw-4\ch
arscalex100 cultural differences are not impediments to recovery. Cultural trad
itions can be \line \up0 \expndtw-5\charscalex100 incorporated into treatment pl
ans to enhance participation toward recovery. It is \line \up0 \expndtw-4\char
scalex100 not necessary for providers to know the beliefs and expectations of ev
ery culture, \line \up0 \expndtw-4\charscalex100 but what is necessary are sensi
tivity and willingness to learn about cultural \line \up0 \expndtw-4\charscalex1
00 differences. Staff can acknowledge their lack of familiarity and pose a ques
tion \line \up0 \expndtw-4\charscalex100 to the patient/family of whether there
is anything the team can do to help meet \line \up0 \expndtw-4\charscalex100 the
ir cultural, spiritual and religious needs. The question conveys respect for \li
ne \up0 \expndtw-4\charscalex100 cultural differences and a desire to help throu
gh the acculturation process. \par\pard\ql \li1881\sb259\sl-276\slmult0 \up0 \ex
pndtw-5\charscalex100 Assisting With Death \par\pard\ql \li1881\ri1733\sb9\sl-27
0\slmult0\fi710 \up0 \expndtw-5\charscalex100 Treatment plans and programs must
be based on an assumption of life \line \up0 \expndtw-5\charscalex100 beyond the
hospital; however death also occurs on the burn unit, and \line \up0 \expndtw-4
\charscalex100 psychosocial treatment planning includes plans for assisting pati
ents in living to \line \up0 \expndtw-4\charscalex100 the cessation of life. As
part of such a plan, the patient\u8217?s family must be aided in \line \up0 \exp
ndtw-5\charscalex100 preparing for and enduring bereavement. In this event, sup
porting and \line \up0 \expndtw-4\charscalex100 enhancing whatever coping streng
ths the family manifests is the primary task for \line \up0 \expndtw-4\charscale
x100 psychotherapy. Most families initially deny the possibility of death, appea
ring not \line \up0 \expndtw-4\charscalex100 to hear an unwanted prognosis. Staf
f can allow the family to maintain hope while \line \up0 \expndtw-4\charscalex10
0 subtly preparing them with honest statements which pose death as an outcome \l
ine \up0 \expndtw-4\charscalex100 which is possible to accept. Comforting the be
reft and helping them to care for \line \up0 \expndtw-4\charscalex100 themselves
, physically and spiritually, are essential elements of a plan that \line \up0 \
expndtw-4\charscalex100 facilitates the family\u8217?s ability to participate in
the process. Keeping the family \line \up0 \expndtw-4\charscalex100 informed ab
out changes in the patient\u8217?s condition and actively supporting,
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100 \ul0\nosupersub\cf1\f2\fs24 sometimes instructing, them in continuing their

relationships with the dying \par\pard\ql \li1881\sb4\sl-276\slmult0 \up0 \expnd
tw-4\charscalex100 patient help the patient and family through this difficult ev
ent. At the time of \par\pard\ql \li1881\ri1780\sb0\sl-270\slmult0 \up0 \expndtw
-4\charscalex100 death, the staff can psychologically support the family by assi
sting them through \up0 \expndtw-4\charscalex100 the necessary paperwork (e.g. s
igning consents for release of the body or for \line \up0 \expndtw-4\charscalex1
00 autopsy) and in allowing them quiet, private time with the deceased loved one
\up0 \expndtw-4\charscalex100 before the body is removed. A death occurring in
the context of family \line \up0 \expndtw-4\charscalex100 acceptance is more ea
sily accepted by staff. Nevertheless, death of a patient is \up0 \expndtw-4\char
scalex100 always sad and may elicit a wide range of strong emotions among the me
mbers \up0 \expndtw-4\charscalex100 of the burn team. Structuring a time for de
-briefing and validating the feelings of \up0 \expndtw-4\charscalex100 staff mem
bers who want to talk about their experience can be helpful in \line \up0 \expnd
tw-5\charscalex100 maintaining the morale of the team as a whole. \par\pard\ql \
li1881\sb255\sl-276\slmult0 \up0 \expndtw-5\charscalex100 Assessment And Interve
ntion \par\pard\ql \li2592\sb4\sl-276\slmult0 \up0 \expndtw-5\charscalex100 Our
general approach to assessment and care of burn survivors is a \par\pard\ql \li1
881\sb1\sl-256\slmult0 \up0 \expndtw-4\charscalex100 behavioral approach based o
n learning principles (e.g. operant conditioning, \par\pard\ql \li1881\ri1722\sb
16\sl-266\slmult0 \up0 \expndtw-4\charscalex100 cognitive restructuring, and soc
ial learning theories) where maladjusted behavior \up0 \expndtw-4\charscalex100
itself (rather than intrapsychic phenomena, for example) is the target of \line
\up0 \expndtw-5\charscalex100 intervention.\ul0\super\cf3\f4\fs23
\ul0\nosupe
rsub\cf1\f2\fs24 Assessment and treatment are integrally related and both occur
\up0 \expndtw-6\charscalex100 simultaneously throughout the recovery and rehabi
litation process. \par\pard\ql \li1881\sb266\sl-276\slmult0 \up0 \expndtw-5\char
scalex100 Phases of Recovery \par\pard\ql \li2592\sb4\sl-276\slmult0 \up0 \expnd
tw-5\charscalex100 Psychological healing occurs across time commensurate with ph
ysical \par\pard\ql \li1881\ri1653\sb9\sl-270\slmult0 \up0 \expndtw-4\charscalex
100 healing in a pattern which is relatively predictable and consistent.\ul0\sup
er\cf3\f4\fs23 7\ul0\nosupersub\cf1\f2\fs24 Awareness of \line \up0 \expndtw-4
\charscalex100 this pattern allows caregivers to anticipate the emergence of psy
chosocial issues \line \up0 \expndtw-4\charscalex100 and to prepare a patient fo
r coping with those issues. Predicting problematic \line \up0 \expndtw-4\charsca
lex100 issues for patients enables them to view their concerns in a context of n
ormal \line \up0 \expndtw-4\charscalex100 reactions rather than as symptoms of p
sychological impairment. For convenience \line \up0 \expndtw-4\charscalex100 in
describing this pattern, we have arbitrarily designated four phases of recovery:
\line \up0 \expndtw-4\charscalex100 admission, critical care, in-hospital recup
eration, and, finally, reintegration and \line \up0 \expndtw-4\charscalex100 reh
abilitation. Table 1 outlines typical symptoms of patients at each phase and \l
ine \up0 \expndtw-5\charscalex100 recommended treatments. \par\pard\qj \li1881\s
b0\sl-220\slmult0 \par\pard\qj\li1881\ri2414\sb52\sl-220\slmult0 \up0 \expndtw-1
\charscalex100 \ul0\nosupersub\cf6\f7\fs19 Table 1. Phases of Recovery with ex
pected psychosocial symptoms and suggested \up0 \expndtw-1\charscalex100 treatme
nts\par\pard\sect\sectd\sbknone\cols2\colno1\colw7155\colsr160\colno2\colw4785\c
olsr160\ql \li1881\sb16\sl-218\slmult0\tx4708 \up0 \expndtw-2\charscalex100 Phas
e\tab \up0 \expndtw-1\charscalex100 Expected Symptoms\par\pard\ql \li1881\sb33\s
l-218\slmult0\tx4372 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf7\f8\fs19 A
dmission\tab \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf8\f9\fs15 \ul0\nosup
ersub\cf3\f4\fs15 \ul0\nosupersub\cf7\f8\fs19 Anxiety, Terror\par\pard\ql \li4
377\sb3\sl-218\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf8\f9\fs15
\ul0\nosupersub\cf3\f4\fs15 \ul0\nosupersub\cf7\f8\fs19 Pain\par\pard\ql \li43
77\sb14\sl-218\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf8\f9\fs15
\ul0\nosupersub\cf3\f4\fs15 \ul0\nosupersub\cf7\f8\fs19 Sadness, grief\par\par
d\ql \li1881\sb0\sl-218\slmult0 \par\pard\ql \li1881\sb0\sl-218\slmult0 \par\par
d\ql \li1881\sb0\sl-218\slmult0 \par\pard\ql \li1881\sb0\sl-218\slmult0 \par\par
d\ql \li1881\sb44\sl-218\slmult0\tx4382 \up0 \expndtw-1\charscalex100 Critical C
are Phase\tab \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs19 \u8226?

\ul0\nosupersub\cf7\f8\fs19 as at admission plus..\par\pard\ql \li4387\sb13\sl
-218\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs19 \u8226?\
ul0\nosupersub\cf7\f8\fs19 Acute stress disorder\par\pard\ql \li1881\sb0\sl-21
8\slmult0 \par\pard\ql \li1881\sb0\sl-218\slmult0 \par\pard\ql \li1881\sb0\sl-21
8\slmult0 \par\pard\ql \li1881\sb0\sl-218\slmult0 \par\pard\ql \li1881\sb44\sl-2
18\slmult0\tx4382 \up0 \expndtw-1\charscalex100 In-Hospital Recuperation\tab \up
0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs19 \u8226?\ul0\nosupersub\c
f7\f8\fs19 Increased pain with exercise\par\pard\column \ql \li471\sb16\sl-218
\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf6\f7\fs19 Recommended T
reatments\par\pard\ql \li58\sb33\sl-218\slmult0 \up0 \expndtw-1\charscalex100 \u
l0\nosupersub\cf8\f9\fs15 \ul0\nosupersub\cf3\f4\fs15 \ul0\nosupersub\cf7\f8\fs1
9 Antianxiety Medication\par\pard\ql \li58\sb3\sl-218\slmult0 \up0 \expndtw-1\c
harscalex100 \ul0\nosupersub\cf8\f9\fs15 \ul0\nosupersub\cf3\f4\fs15 \ul0\nosupe
rsub\cf7\f8\fs19 Analgesic Medication\par\pard\ql \li58\sb14\sl-218\slmult0 \up
0 \expndtw-3\charscalex100 \ul0\nosupersub\cf8\f9\fs15 \ul0\nosupersub\cf3\f4\fs1
5 \ul0\nosupersub\cf7\f8\fs19 Psychological Support\par\pard\ql \li548\sb3\sl
-218\slmult0 \up0 \expndtw-2\charscalex100 Reassurance\par\pard\ql \li548\sb14\s
l-218\slmult0 \up0 \expndtw-1\charscalex100 Normalization\par\pard\ql \li548\sb4
\sl-218\slmult0 \up0 \expndtw-1\charscalex100 Relaxation Techniques\par\pard\ql
\li7315\sb0\sl-218\slmult0 \par\pard\ql \li20\sb26\sl-218\slmult0 \up0 \expndtw1\charscalex100 \ul0\nosupersub\cf9\f10\fs19 \u8226?\ul0\nosupersub\cf7\f8\fs19
Antianxiety Medication\par\pard\ql \li20\sb13\sl-218\slmult0 \up0 \expndtw-1\c
harscalex100 \ul0\nosupersub\cf9\f10\fs19 \u8226?\ul0\nosupersub\cf7\f8\fs19 A
nalgesics\par\pard\qj \li20\ri1684\sb0\sl-230\slmult0\tx202 \up0 \expndtw-1\char
scalex100 \ul0\nosupersub\cf9\f10\fs19 \u8226?\ul0\nosupersub\cf7\f8\fs19 Medi
cation targeting acute stress \line\tab \up0 \expndtw-1\charscalex100 disorder s
ymptoms\par\pard\qj \li20\ri1674\sb0\sl-460\slmult0 \up0 \expndtw-1\charscalex10
0 \ul0\nosupersub\cf9\f10\fs19 \u8226?\ul0\nosupersub\cf7\f8\fs19 Continued Ps
ychological Support \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf8\f9\fs15 \ul
0\nosupersub\cf3\f4\fs15 \ul0\nosupersub\cf7\f8\fs19 Targeted administration o
f
}
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}
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{\shp {\*\shpinst\shpleft7171\shptop10512\shpright10867\shpbottom10532\shpfhdr0\
shpbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz279\shplid10
}
}}
{\shp {\*\shpinst\shpleft10867\shptop10512\shpright10876\shpbottom10521\shpfhdr0
\shpbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz281\shplid11
}
}}

}
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}
}}
}
}}
}
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}
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}
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}
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}
g5}{\bkmkend Pg5}\par\pard\sect\sectd\sbknone\cols2\colno1\colw7184\colsr160\col
no2\colw4756\colsr160\ql \li4387\sb0\sl-218\slmult0 \par\pard\ql \li4387\sb0\sl218\slmult0 \par\pard\ql \li4387\sb0\sl-218\slmult0 \par\pard\ql \li4387\sb0\sl218\slmult0 \par\pard\ql \li4387\sb0\sl-218\slmult0 \par\pard\ql \li4387\sb85\sl
-218\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf9\f10\fs19 \u8226?\
ul0\nosupersub\cf7\f8\fs19 anger, rage\par\pard\ql \li4387\sb3\sl-218\slmult0
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf9\f10\fs19 \u8226?\ul0\nosupersu
b\cf7\f8\fs19 grief\par\pard\ql \li4387\sb14\sl-218\slmult0 \up0 \expndtw-1\ch
arscalex100 \ul0\nosupersub\cf9\f10\fs19 \u8226?\ul0\nosupersub\cf7\f8\fs19 de
pressive episodes, rapid\par\pard\ql \li4560\sb4\sl-218\slmult0 \up0 \expndtw-1\
charscalex100 emotional shifting\par\pard\ql \li1881\sb0\sl-218\slmult0 \par\par
d\ql \li1881\sb25\sl-218\slmult0\tx4382 \up0 \expndtw-2\charscalex100 Rehabilita
tion and\tab \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs19 \u8226?\
ul0\nosupersub\cf7\f8\fs19 Adjustment difficulties\par\pard\ql \li1881\sb14\sl
-218\slmult0\tx4382 \up0 \expndtw-1\charscalex100 Reintegration (may be\tab \up0
\expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs19 \u8226?\ul0\nosupersub\cf
7\f8\fs19 Post-traumatic stress\par\pard\ql \li1881\sb4\sl-218\slmult0\tx4555
\up0 \expndtw-1\charscalex100 several years)\tab \up0 \expndtw-2\charscalex100 d
isorder\par\pard\ql \li4387\sb13\sl-218\slmult0 \up0 \expndtw-1\charscalex100 \u
l0\nosupersub\cf9\f10\fs19 \u8226?\ul0\nosupersub\cf7\f8\fs19 Anxiety (includi
ng phobic\par\pard\ql \li4560\sb4\sl-218\slmult0 \up0 \expndtw-1\charscalex100 r
esponse)\par\pard\ql \li4387\sb13\sl-218\slmult0 \up0 \expndtw-2\charscalex100 \
ul0\nosupersub\cf9\f10\fs19 \u8226?\ul0\nosupersub\cf7\f8\fs19 Depression\par\
pard\column \ql \li7344\sb0\sl-218\slmult0 \par\pard\ql \li7344\sb0\sl-218\slmul
t0 \par\pard\ql \li7344\sb0\sl-218\slmult0 \par\pard\ql \li7344\sb0\sl-218\slmul
t0 \par\pard\ql \li7344\sb0\sl-218\slmult0 \par\pard\ql \li202\sb85\sl-218\slmul
t0 \up0 \expndtw-2\charscalex100 analgesics\par\pard\qj \li20\ri1300\sb0\sl-230\
slmult0\tx212 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf8\f9\fs15 \ul0\nosu
persub\cf3\f4\fs15 \ul0\nosupersub\cf7\f8\fs19 Psychotherapy (Cognitive-Behavi
oral \line\tab \up0 \expndtw-1\charscalex100 and Family Therapy)\par\pard\qj \li
20\ri1299\sb0\sl-230\slmult0\tx212 \up0 \expndtw-1\charscalex100 \ul0\nosupersub
\cf8\f9\fs15 \ul0\nosupersub\cf3\f4\fs15 \ul0\nosupersub\cf7\f8\fs19 Pharmacolo
gical treatment of anxiety \line\tab \up0 \expndtw-1\charscalex100 and depressio
n\par\pard\ql \li20\sb1\sl-210\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupe
rsub\cf9\f10\fs19 \u8226?\ul0\nosupersub\cf7\f8\fs19 Re-entry program\par\pard
\qj \li20\ri1443\sb13\sl-220\slmult0\tx212 \up0 \expndtw-1\charscalex100 \ul0\no
supersub\cf9\f10\fs19 \u8226?\ul0\nosupersub\cf7\f8\fs19 Medication targeting
Post-traumatic \line\tab \up0 \expndtw-1\charscalex100 stress disorder\par\pard\
ql \li20\ri1300\sb7\sl-224\slmult0\tx212 \up0 \expndtw-1\charscalex100 \ul0\nosu
persub\cf9\f10\fs19 \u8226?\ul0\nosupersub\cf7\f8\fs19 Psychotherapy (Cognitiv
e-Behavioral \line\tab \up0 \expndtw-1\charscalex100 and Family Therapy, social

skills) \line \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs19 \u8226?
\ul0\nosupersub\cf7\f8\fs19 Anxiolytics tapered off over time \up0 \expndtw-1\
charscalex100 \ul0\nosupersub\cf9\f10\fs19 \u8226?\ul0\nosupersub\cf7\f8\fs19
Anti-depressant medication \par\pard\sect\sectd\sbknone \ql \li1881\sb0\sl-272\s
lmult0 \par\pard\ql\li1881\ri1706\sb216\sl-272\slmult0\fi710 \up0 \expndtw-5\cha
rscalex100 \ul0\nosupersub\cf1\f2\fs24 Admission Phase: On admission, the primar
y psychological tasks are to \line \up0 \expndtw-4\charscalex100 establish thera
peutic rapport, diminish anxiety, and assess the psychosocial \line \up0 \expndt
w-5\charscalex100 strengths and needs of the patient. The first two tasks are ad
dressed \line \up0 \expndtw-4\charscalex100 immediately by orienting a patient,
by assisting the patient to focus on immediate \line \up0 \expndtw-4\charscalex1
00 priorities, and by assuring the patient that the burn team is composed of \li
ne \up0 \expndtw-4\charscalex100 knowledgeable experts who will provide excellen
t care. The patient's anxiety can \line \up0 \expndtw-4\charscalex100 be expecte
d to interfere with comprehension, so it is usually wise to repeat \line \up0 \e
xpndtw-4\charscalex100 statements of reassurance. Techniques of relaxation with
focused imagery can \line \up0 \expndtw-4\charscalex100 be very helpful in quick
ly assisting a patient to feel more comfortable. \line \up0 \expndtw-4\charscale
x100 Rapport is developed as the patient associates the voice of the therapist w
ith \line \up0 \expndtw-5\charscalex100 increased comfort. \par\pard\ql \li2659\
sb1\sl-257\slmult0 \up0 \expndtw-5\charscalex100 Pre-injury physical and psychol
ogical health, coping skills, and \par\pard\qj \li1881\ri1732\sb13\sl-270\slmult
0 \up0 \expndtw-4\charscalex100 family/social support are closely related to the
behavior, distress and recovery of \line \up0 \expndtw-4\charscalex100 a patien
t. Thus assessment of these factors must be begun as soon as possible \line \up0
\expndtw-4\charscalex100 following admission. Prior stressful events and copin
g strategies, risk factors, as \line \up0 \expndtw-4\charscalex100 well as psych
osocial and economic strengths are included in a good history of a \line \up0 \e
xpndtw-4\charscalex100 patient's premorbid lifestyle. A patient's history and po
sition in the family as well \line \up0 \expndtw-4\charscalex100 as the family's
strengths and weaknesses are often helpful pieces of information \line \up0 \ex
pndtw-4\charscalex100 in guiding plans for treatment.\ul0\nosupersub\cf2\f3\fs24
\ul0\nosupersub\cf1\f2\fs24 Historical risk factors which may predispose \par\
pard\qj \li1881\ri1878\sb11\sl-270\slmult0 \up0 \expndtw-4\charscalex100 individ
uals to burn injury and which foretell poor prognoses are physical illness, \up0
\expndtw-4\charscalex100 substance abuse, psychiatric illness, behavioral probl
ems, poverty, inadequate \up0 \expndtw-5\charscalex100 social support, and heigh
tened family disruption. \par\pard\ql \li2592\sb0\sl-258\slmult0 \up0 \expndtw-5
\charscalex100 The psychotherapeutic tasks to be accomplished immediately with a
\par\pard\ql \li1881\ri1703\sb0\sl-272\slmult0 \up0 \expndtw-4\charscalex100 fa
mily are similar to those for a patient (i.e. to establish a therapeutic relatio
nship \up0 \expndtw-4\charscalex100 and to diminish anxiety). Both tasks can oft
en be initiated by assisting them in \line \up0 \expndtw-4\charscalex100 orienti
ng to the hospital and by providing relevant information about the normal \up0 \
expndtw-4\charscalex100 responses to trauma. Explaining, for example, that peopl
e in this situation often \up0 \expndtw-5\charscalex100 have difficulty for a fe
w days in eating, sleeping, and concentrating, \line \up0 \expndtw-4\charscalex1
00 communicates empathy and validates that their distress is acceptable and \lin
e \up0 \expndtw-4\charscalex100 temporary. Family members are important compone
nts of the therapeutic efforts \up0 \expndtw-4\charscalex100 for the patient, an
d it is important to say this explicitly to the family. This helps to \up0 \expn
dtw-5\charscalex100 return to them a sense of purpose and control. \par\pard\ql
\li1881\sb256\sl-276\slmult0 \up0 \expndtw-5\charscalex100 Critical Care Phase

}
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{\shp {\*\shpinst\shpleft7171\shptop1411\shpright10867\shpbottom1431\shpfhdr0\sh
pbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz142\shplid6
}
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}
100 \ul0\nosupersub\cf1\f2\fs24 From hospital admission until the majority of op
en wounds are covered, \par\pard\ql \li1881\ri1665\sb9\sl-270\slmult0 \up0 \expn
dtw-4\charscalex100 the emphasis in treatment of a burned patient is necessarily
on intensive medical \line \up0 \expndtw-4\charscalex100 and surgical care to r

esolve physiologic crises. This period is psychologically \line \up0 \expndtw-4\
charscalex100 critical as well. A patient experiences great anxiety during much
of this time. Fear \line \up0 \expndtw-4\charscalex100 of death blends into fear
of pain and fear of treatment procedures. A multitude of \line \up0 \expndtw-4
\charscalex100 organic factors stemming from both the injury and its treatment,
as well as \line \up0 \expndtw-5\charscalex100 premorbid conditions, can all con
tribute to psychological symptoms of \line \up0 \expndtw-4\charscalex100 disorie
ntation, confusion, sleep disturbance, transient psychosis and delirium \line \u
p0 \expndtw-5\charscalex100 which are commonly observed among adolescent and adu
lt patients.\ul0\super\cf3\f4\fs23 7,8 \line \up0 \expndtw-4\charscalex100 \ul0\
nosupersub\cf1\f2\fs24 Pharmacological interventions to manage pain and anxiety
should be instituted \line \up0 \expndtw-4\charscalex100 and, along with psychol
ogical interventions can diminish anxiety and confusion. \line \up0 \expndtw-4\c
harscalex100 Repeated statements of orientation to time, place, and person are m
andatory. \line \up0 \expndtw-4\charscalex100 Objects that are familiar and comf
orting can be placed in the patient's view or so \line \up0 \expndtw-4\charscale
x100 that the patient can touch them. The patient's environment should be as soo
thing \line \up0 \expndtw-4\charscalex100 as possible. A schedule which approxim
ates a regular wake/sleep cycle helps a \line \up0 \expndtw-4\charscalex100 pati
ent begin to feel normal. Visits from family and friends can provide familiarit
y \line \up0 \expndtw-5\charscalex100 and reassurance to a patient. \par\pard\qj
\li1881\ri1639\sb0\sl-270\slmult0\fi710 \up0 \expndtw-4\charscalex100 Staff int
eracting with patients during this phase must be willing to listen to \line \up0
\expndtw-4\charscalex100 patients' anxieties and reassure them that the nightma
res and vivid memories are \line \up0 \expndtw-4\charscalex100 normal aspects of
recovery. Staff can help patients focus on the present time in \line \up0 \expn
dtw-4\charscalex100 which they are safe in the hospital and are healing. When a
patient is withdrawn \line \up0 \expndtw-4\charscalex100 or in a coma, staff mus
t remember that the patient may be hearing, although not \line \up0 \expndtw-4\c
harscalex100 responding, and must take care to talk to the patient. They must al
so be discreet \line \up0 \expndtw-4\charscalex100 in what is said within a pati
ent's hearing range. Patients are often listening to \par\pard\qj \li1881\ri1711
\sb10\sl-260\slmult0 \up0 \expndtw-4\charscalex100 determine what will happen to
them; and, in their altered mental states, they may \up0 \expndtw-5\charscalex1
00 attribute unexpected meanings to what they hear. \par\pard\ql \li1881\ri1676\
sb0\sl-271\slmult0\fi1411 \up0 \expndtw-5\charscalex100 During the critical-care
phase, family members usually become at \line \up0 \expndtw-5\charscalex100 eas
e with the routines of the hospital. They may, however, continue to \line \up0 \
expndtw-5\charscalex100 experience some symptoms of acute traumatic stress, such
as intrusive \line \up0 \expndtw-5\charscalex100 thoughts, difficulties with sl
eep, or avoidance behaviors. \ul0\super\cf3\f4\fs23 \ul0\nosupersub\cf1\f2\fs24
It is helpful to provide \line \up0 \expndtw-4\charscalex100 families with inf
ormation about what they may expect to observe with their \line \up0 \expndtw-4\
charscalex100 burned relative in the immediate future and to guide family member
s as they \line \up0 \expndtw-4\charscalex100 respond to the patient. Families n
eed instruction about how they can be helpful. \line \up0 \expndtw-4\charscalex1
00 The staff can find ways to allow family members to nurture their relative and
\line \up0 \expndtw-4\charscalex100 provide instructions so that the family can
begin to become comfortable in caring \line \up0 \expndtw-4\charscalex100 for t
he patient's needs. Staff members of critical-care units are very busy and \line
\up0 \expndtw-4\charscalex100 may, at moments, want to send the family away so
that tasks can be completed \line \up0 \expndtw-4\charscalex100 more efficiently
. However, these instructions encourage the family to join with the \line \up0 \
expndtw-4\charscalex100 burn team in the healing and rehabilitation of the patie
nt and are of critical \line \up0 \expndtw-4\charscalex100 importance to the fut
ure of the patient who needs the expressions of care by \line \up0 \expndtw-4\ch
arscalex100 loved ones. Psychotherapeutic work with the family must also identi
fy and plan \line \up0 \expndtw-4\charscalex100 for management of those family i
ssues that may impede a patient's recovery and \line \up0 \expndtw-4\charscalex1
00 rehabilitation. Management plans must support, to the extent possible, the \l

ine \up0 \expndtw-4\charscalex100 physical and emotional well-being of all the m
embers of the family during a \line \up0 \expndtw-4\charscalex100 period of time
in which the burned patient's needs place unusual and urgent \line \up0 \expndt
w-5\charscalex100 demands on the family system. \par\pard\sect\sectd\fs24\paperw
12240\paperh15840\pard\sb0\sl-240{\bkmkstart Pg7}{\bkmkend Pg7}\par\pard\ql \li2
592\sb0\sl-276\slmult0 \par\pard\ql\li2592\sb0\sl-276\slmult0 \par\pard\ql\li259
2\sb0\sl-276\slmult0 \par\pard\ql\li2592\sb0\sl-276\slmult0 \par\pard\ql\li2592\
sb68\sl-276\slmult0 \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf1\f2\fs24 Ps
ychological factors play a significant role in pain and anxiety \par\pard\ql \li
1881\sb4\sl-276\slmult0 \up0 \expndtw-4\charscalex100 management. Scheduling of
pain and anxiety assessments and the choice of \par\pard\ql \li1881\ri1638\sb0\
sl-270\slmult0 \up0 \expndtw-4\charscalex100 assessment tools have psychological
relevance. Regular, routine assessments of \line \up0 \expndtw-4\charscalex100
discomfort imply to a patient and a patient's family that the medical staff cons
ider \line \up0 \expndtw-4\charscalex100 discomfort a valid issue that will be t
reated. This not only validates a patient's \line \up0 \expndtw-4\charscalex100
concerns, but sets an expectancy of relief when pain or anxiety is a problem. Th
e \line \up0 \expndtw-4\charscalex100 use of standardized scales provides the me
ssage that to experience a range of \line \up0 \expndtw-4\charscalex100 pain and
comfort responses is normal and allows the patient to participate to \line \up0
\expndtw-4\charscalex100 some degree in mastering discomfort. When staff assess
comfort as routinely as \line \up0 \expndtw-4\charscalex100 vital signs and ind
icate that they believe the patients, patients are less likely to \line \up0 \ex
pndtw-4\charscalex100 feel that they must complain loudly in order to convince t
he staff that their need \line \up0 \expndtw-4\charscalex100 for pain relief is
legitimate. They also are less likely to feel hopeless and helpless \line \up0 \
expndtw-5\charscalex100 and become depressed. \par\pard\ql \li1881\sb255\sl-276\
slmult0 \up0 \expndtw-5\charscalex100 In-Hospital Recuperation Phase \par\pard\q
l \li1881\ri1638\sb9\sl-270\slmult0\fi710\tx2592 \up0 \expndtw-4\charscalex100 I
n this phase, patients are just beginning to comprehend the extent of their \lin
e \up0 \expndtw-5\charscalex100 injury and to realize that their bodies are chan
ged forever. Their anxieties now \line \up0 \expndtw-4\charscalex100 are incre
asingly about the future and less about the past and present. Patients \line \u
p0 \expndtw-4\charscalex100 are confronted with new physical limitations imposed
by their injuries; they \line \up0 \expndtw-4\charscalex100 experience their bo
dies now as incompetent and disfigured. Patients involved in \line \up0 \expndtw
-4\charscalex100 this struggle shift rapidly in affective behaviors reflecting r
apid shifts in cognition. \line \up0 \expndtw-4\charscalex100 Much of the time,
patients experience themselves as the 'preburn self' (i.e. the \line \up0 \expnd
tw-4\charscalex100 'real self'). When the body will not move as it did in the pa
st or when the scarred \line \up0 \expndtw-4\charscalex100 skin is viewed, a pat
ient remembers and grieves. Patients become aware of their \line \up0 \expndtw4\charscalex100 changed appearance as they observe the responses of others and n
ote these \line \up0 \expndtw-4\charscalex100 responses invalidate their former
body image. Their pre-morbid identities no \line \up0 \expndtw-4\charscalex100 l
onger exist intact, and new identities must incorporate remnants of the old, as
\line \up0 \expndtw-4\charscalex100 well as changed, physical body. They become
easily fatigued yet must continue \line \up0 \expndtw-4\charscalex100 in a sched
ule of exercises and tasks determined primarily by the burn team, thus \line \up
0 \expndtw-4\charscalex100 reinforcing their feelings of loss of autonomy and la
ck of control. In this highly \line \up0 \expndtw-5\charscalex100 emotional sta
te, patients may be expected to act out anger and fear. \line \tab \up0 \expndtw
-4\charscalex100 Emotional lability and cognitive and behavioral regression are
typically \line \up0 \expndtw-4\charscalex100 observed in patients of all ages d
uring this trying time. Perhaps the most difficult \line \up0 \expndtw-4\charsca
lex100 behavior for patient, family, and staff is the patient's expression of an
ger. \line \up0 \expndtw-4\charscalex100 Patients, of course, have many reasons
to be angry, and they need to express \line \up0 \expndtw-4\charscalex100 that a
nger in order to define and direct it adaptively; however, there are \line \up0
\expndtw-4\charscalex100 significant limitations upon the availability of situat

ions in which they can express \line \up0 \expndtw-4\charscalex100 anger. Patien
ts have almost no privacy, nor can they relieve tension through \line \up0 \expn
dtw-4\charscalex100 physical activities such as running. Typically, family membe
rs and patient care \line \up0 \expndtw-4\charscalex100 staff, having devoted mu
ch time and energy to the patient, are prone to perceive \line \up0 \expndtw-4\c
harscalex100 the patient's angry behavior as a personal and unjust attack by an
ungrateful \line \up0 \expndtw-4\charscalex100 patient. Certainly, the patient w
ill direct rageful temper tantrums toward those \line \up0 \expndtw-4\charscalex
100 who are the safest targets, usually a spouse or parent first and then a nurs
e or \line \up0 \expndtw-4\charscalex100 therapist. Angry attacks are best under
stood as necessary ventilation by the \line \up0 \expndtw-5\charscalex100 patien
t rather than sincere evaluations of family or staff.
}
l-270\slmult0 \par\pard\ql\li1881\ri1664\sb97\sl-270\slmult0\fi710 \up0 \expndtw
-4\charscalex100 \ul0\nosupersub\cf1\f2\fs24 Expressions of rage are not only up
setting to family and staff; they also \line \up0 \expndtw-4\charscalex100 frigh
ten patients who themselves perceive this loss of control as evidence of \line \
up0 \expndtw-4\charscalex100 potential destruction of self or others on whom the
y are dependent. Following an \line \up0 \expndtw-4\charscalex100 outburst, a pa
tient typically feels guilty and fears withdrawal of love and support \line \up0
\expndtw-4\charscalex100 by those who were earlier subjugated to the angry beha
vior. These fears are \line \up0 \expndtw-5\charscalex100 added to the patient's
fears of being rejected because of the changed \line \up0 \expndtw-4\charscalex
100 appearance. Turning anger now toward self, the patient may feel overwhelmed,
\line \up0 \expndtw-4\charscalex100 hopeless, depressed, and even suicidal. If
the hospitalization continues over \line \up0 \expndtw-4\charscalex100 several w
eeks, patients experience repetitive frustrations, and tend to feel \line \up0 \
expndtw-4\charscalex100 hopeless and depressed more often. Hopelessness is more
likely to result when \line \up0 \expndtw-4\charscalex100 patients feel as if th
ey have no control over aversive events and eventually give \line \up0 \expndtw4\charscalex100 up trying to control what happens to them; such hopelessness ove
r time can lead \line \up0 \expndtw-5\charscalex100 to chronic depression. \par\
pard\ql \li1881\ri1637\sb11\sl-270\slmult0\fi710 \up0 \expndtw-4\charscalex100 P
sychotherapeutic work at this phase intensifies and is largely focused on \line
\up0 \expndtw-5\charscalex100 working with the rest of the team to help patients
combat feelings of \line \up0 \expndtw-4\charscalex100 hopelessness and helples
sness. Important toward this end is structuring \line \up0 \expndtw-4\charscale
x100 treatment sessions to promote patients\u8217? experience of control, achiev
ing success, \line \up0 \expndtw-4\charscalex100 and feeling rewarded while prog
ressing through difficult procedures. Positive \line \up0 \expndtw-4\charscalex
100 feelings, generated by achieving the goals one has established, increase one
's \line \up0 \expndtw-4\charscalex100 likelihood of repeating the effort. A ps
ychotherapeutic challenge of this phase is \line \up0 \expndtw-4\charscalex100 t
o accept and validate the patient's emotional demonstrations as normal \line \up
0 \expndtw-4\charscalex100 behaviors in the recovery process while also setting
limits on the ways in which \line \up0 \expndtw-4\charscalex100 the emotional up
heaval will be expressed. Early in this phase, as the patient \line \up0 \expndt
w-4\charscalex100 begins to ask about the future, the psychotherapist can descri
be the predictable \line \up0 \expndtw-4\charscalex100 pattern of emotional vici
ssitudes indicating that, should such occur, they are \line \up0 \expndtw-4\char
scalex100 normal; they can be endured and managed. The staff must demonstrate po
sitive \line \up0 \expndtw-4\charscalex100 regard and acceptance of the patient
while also helping the patient to exercise \line \up0 \expndtw-4\charscalex100 c
ontrol over destructive behaviors. At times, they must impose external limits to
\line \up0 \expndtw-5\charscalex100 protect the patient. \par\pard\ql \li1881\r
i1665\sb0\sl-271\slmult0\fi710\tx2592 \up0 \expndtw-4\charscalex100 Staff can an
ticipate and assist a patient in asking questions about future \line \up0 \expnd
tw-4\charscalex100 disfigurement and functional abilities, including sexual acti
vity. Without evading \line \up0 \expndtw-4\charscalex100 questions, psychothera
pists give honest but hopeful appraisals that emphasize \line \up0 \expndtw-4\ch
arscalex100 ability and minimize deformity and disability. For example, as a pat
ient voices an \line \up0 \expndtw-4\charscalex100 unrealistic belief that time
and/or plastic surgery will return the former \line \up0 \expndtw-4\charscalex10
0 appearance, one can state that burned skin will never look like unburned skin
\line \up0 \expndtw-4\charscalex100 and that there will always be some scarring,
but that appearance will change with \line \up0 \expndtw-4\charscalex100 time.
Allowing patients to hope, even for unrealistic outcomes, protects them \line \u
p0 \expndtw-4\charscalex100 from despair and enables them to continue to believe
that there are reasons to \line \up0 \expndtw-4\charscalex100 endure the pain o
f rehabilitation. Patients and families should be given the \line \up0 \expndtw
-4\charscalex100 information that rehabilitation may require several years to ac
hieve optimal \line \up0 \expndtw-4\charscalex100 satisfaction, but that the pai
nful efforts usually obtain good results. \line \tab \up0 \expndtw-4\charscalex1
00 The therapeutic message to be delivered is that survivors can find ways of \l
ine \up0 \expndtw-4\charscalex100 achieving whatever goals they set for themselv
es; the process is lengthy and \line \up0 \expndtw-4\charscalex100 difficult, an
d survivors will often feel over-whelmed and hopeless. Expressing \line \up0 \ex
pndtw-4\charscalex100 sadness and anger is to be expected and accepted; however,
such feelings can \line \up0 \expndtw-4\charscalex100 never be allowed to stop
a patient from participating in the necessary regimen to \par\pard\sect\sectd\fs
24\paperw12240\paperh15840\pard\sb0\sl-240{\bkmkstart Pg9}{\bkmkend Pg9}\par\par
d\qj \li1881\sb0\sl-280\slmult0 \par\pard\qj\li1881\sb0\sl-280\slmult0 \par\pard
\qj\li1881\sb0\sl-280\slmult0 \par\pard\qj\li1881\sb0\sl-280\slmult0 \par\pard\q
j\li1881\ri2965\sb49\sl-280\slmult0 \up0 \expndtw-5\charscalex100 \ul0\nosupersu
b\cf1\f2\fs24 achieve full recovery. Being burned does not relieve a survivor of
the \up0 \expndtw-5\charscalex100 responsibility of competence. \par\pard\ql \l
i1881\ri1677\sb0\sl-270\slmult0\fi710 \up0 \expndtw-4\charscalex100 Introducing
a recovered survivor to the recuperative burned patient can be \up0 \expndtw-4\c
harscalex100 a very helpful intervention at this point. The more experienced su
rvivor can be \line \up0 \expndtw-4\charscalex100 heard as a trustworthy authori
ty in a way the unburned professional cannot. \line \up0 \expndtw-4\charscalex10
0 Visual images of burn survivors telling their stores and presenting themselves
in \line \up0 \expndtw-5\charscalex100 daily life activities on film or video c
an aid in accomplishing this purpose. \ul0\super\cf3\f4\fs23 \ul0\nosupersub\cf
1\f2\fs24 Groups \up0 \expndtw-4\charscalex100 of patients and/or families of b
urned patients at varying stages of recovery and \line \up0 \expndtw-4\charscale
x100 rehabilitation have been helpful in providing information, emotional valida
tion, \line \up0 \expndtw-4\charscalex100 and support as well as reinforcing the
concept that it is possible to survive burns \line \up0 \expndtw-5\charscalex10
0 and live acceptably happy lives.\ul0\super\cf3\f4\fs23 9 \par\pard\ql \li1881\
sb255\sl-276\slmult0 \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf1\f2\fs24 R
eintegration Phase \par\pard\ql \li1881\ri1666\sb9\sl-270\slmult0\fi710\tx2592 \
up0 \expndtw-4\charscalex100 Although plans for a patient's discharge to outpati
ent status are developed \line \up0 \expndtw-4\charscalex100 from the time of ad
mission, very specific plans must be made in the final days of \line \up0 \expnd
tw-4\charscalex100 hospitalization. A major objective at this time is to facilit
ate a patient's reentry and \line \up0 \expndtw-4\charscalex100 reintegration in

to life at home. Returning home means re-engaging in social \line \up0 \expndtw4\charscalex100 interactions with the larger community of extended family, frien
ds, and strangers. \line \up0 \expndtw-5\charscalex100 Patients as well as famil
y must prepare for those encounters. \line \tab \up0 \expndtw-4\charscalex100 Fa
milies and patients alike are often ambivalent about leaving the safe \line \up0
\expndtw-4\charscalex100 environment of the hospital. Patients, including very
young children, fear social \line \up0 \expndtw-4\charscalex100 rejection or rid
icule because of their changed abilities or appearance. Family \line \up0 \expn
dtw-4\charscalex100 members will probably feel a desire to protect their patient
from rejection or \line \up0 \expndtw-4\charscalex100 ridicule. Family members
may also express concerns about their ability to \line \up0 \expndtw-4\charscale
x100 continue the time-consuming physical care of the patient while resuming the
ir \line \up0 \expndtw-4\charscalex100 usual responsibilities. Patients may doub
t their abilities to resume former \line \up0 \expndtw-4\charscalex100 activitie
s. As discharge approaches, anxieties intensify, and patients can be \line \up0
\expndtw-4\charscalex100 expected to evidence some regressive behaviors that, in
turn, can reinforce the \line \up0 \expndtw-5\charscalex100 family's doubts. \p
ar\pard\ql \li1881\ri1635\sb0\sl-270\slmult0\fi710 \up0 \expndtw-4\charscalex100
Psychotherapeutic activities of this phase involve preparation of patient \line
\up0 \expndtw-4\charscalex100 and family for the difficulties that can be antic
ipated at discharge. Patients and \line \up0 \expndtw-4\charscalex100 families m
ay deny that they will have problems. Rather than accepting their \line \up0 \e
xpndtw-4\charscalex100 assurance that problems will not arise, the psychotherapi
st can characterize such \line \up0 \expndtw-4\charscalex100 events as normal an
d 'usual', and proceed, without condescending or judging, to \line \up0 \expndtw
-4\charscalex100 offer suggestions for developing a repertoire of alternative be
haviors to address \line \up0 \expndtw-4\charscalex100 those problems 'just in c
ase' they do experience difficulties. Issues such as how \line \up0 \expndtw-4\
charscalex100 to respond to people who stare or are rude, recurrence of symptoms
of post-\line \up0 \expndtw-4\charscalex100 traumatic stress, sleep disturbance
, irritability, or fear of resuming sexual \line \up0 \expndtw-4\charscalex100 a
ctivities should be discussed during the days prior to discharge. This \line \up
0 \expndtw-4\charscalex100 preparatory verbal rehearsal enhances the probability
that the patient/family will \line \up0 \expndtw-4\charscalex100 be less reluct
ant to ask for help if problems do occur; if problems do not occur, \line \up0 \
expndtw-4\charscalex100 the staff has the opportunity to congratulate the patien
t/family on their strengths \line \up0 \expndtw-5\charscalex100 or skills in cop
ing. \par\pard\qj \li1881\ri1788\sb0\sl-280\slmult0\fi710 \up0 \expndtw-5\charsc
alex100 Toward the end of inpatient treatment, patients are expected to resume \
line \up0 \expndtw-4\charscalex100 increased autonomy; caretakers are supported
in withdrawing assistance to the \line \up0 \expndtw-4\charscalex100 degree poss
ible. It is helpful at this point to develop with patients/families a daily
}
g10}{\bkmkend Pg10}\par\pard\ql \li1881\sb0\sl-276\slmult0 \par\pard\ql\li1881\s
b0\sl-276\slmult0 \par\pard\ql\li1881\sb0\sl-276\slmult0 \par\pard\ql\li1881\sb0
\sl-276\slmult0 \par\pard\ql\li1881\sb68\sl-276\slmult0 \up0 \expndtw-5\charscal
ex100 \ul0\nosupersub\cf1\f2\fs24 schedule to guide them in accomplishing necess
ary tasks. The burn team \par\pard\ql \li1881\ri1636\sb11\sl-268\slmult0 \up0 \e
xpndtw-4\charscalex100 relinquishes performance of daily care so that the patien

t/family can assume care \up0 \expndtw-4\charscalex100 to the extent that they w
ill be required to conduct it at home. The patient and \line \up0 \expndtw-4\cha
rscalex100 family can benefit from the opportunity to rehearse out-patient care
while still able \up0 \expndtw-4\charscalex100 to consult with the burn team for
direction and support. Rehearsals are \line \up0 \expndtw-4\charscalex100 oppor
tunities for all involved to experience difficulties in a safe environment and \
line \up0 \expndtw-5\charscalex100 to plan corrective actions. \par\pard\ql \li1
881\ri1668\sb12\sl-268\slmult0\fi710 \up0 \expndtw-4\charscalex100 Important amo
ng these rehearsals are those of interpersonal interactions \up0 \expndtw-4\char
scalex100 outside the hospital. Burn survivors have reported their most difficul
t experience \up0 \expndtw-5\charscalex100 at discharge involved observing the r
eactions of others. Patients benefit from the \up0 \expndtw-4\charscalex100 op
portunity to experience such reactions before discharge from the hospital. \line
\up0 \expndtw-4\charscalex100 They may leave the hospital for brief outings and
return to the hospital for \line \up0 \expndtw-5\charscalex100 reassurance, enc
ouragement, and praise. \par\pard\ql \li2592\sb1\sl-258\slmult0 \up0 \expndtw-5\
charscalex100 James Partridge of \ul0\nosupersub\cf4\f5\fs24 Changing Faces\ul0\
nosupersub\cf1\f2\fs24 , an organization dedicated to \par\pard\ql \li1881\sb8\s
l-276\slmult0 \up0 \expndtw-4\charscalex100 assisting persons with facial disfig
urement, recommends a brief social skills \par\pard\ql \li1881\ri1677\sb9\sl-270
\slmult0\tx2592 \up0 \expndtw-5\charscalex100 training program called \u8220?3-2
-1-GO!\u8221? The program can be provided in the hospital \line \up0 \expndtw5\charscalex100 by staff who regularly interact with patients. The patient is
asked to plan for \line \up0 \expndtw-4\charscalex100 uncomfortable social situa
tions by thinking of 3 things to do when someone \line \up0 \expndtw-4\charscale
x100 stares at them, 2 things to say when someone asks them what happened (to \l
ine \up0 \expndtw-4\charscalex100 cause the scars), and 1 thing to think if some
one turns away from them. \line \tab \up0 \expndtw-4\charscalex100 In addition t
o preparing a patient and family for discharge, the burn team \line \up0 \expndt
w-4\charscalex100 may also prepare the 'community' to which a patient will retur
n. The 'community' \line \up0 \expndtw-4\charscalex100 may include extended fami
ly, neighbors, church groups, social clubs, a patient's \line \up0 \expndtw-4\ch
arscalex100 workplace or, in the case of a school-age pediatric patient, the sch
ool. Instructing \line \up0 \expndtw-4\charscalex100 those unfamiliar with burns
in what to say or do to ease a survivor's reentry may \line \up0 \expndtw-5\cha
rscalex100 facilitate reintegration. \par\pard\ql \li1881\ri1667\sb0\sl-270\slmu
lt0\fi710 \up0 \expndtw-4\charscalex100 Reintegration programs for adults and ch
ildren educate the community in \line \up0 \expndtw-4\charscalex100 a developmen
tally sensitive fashion. They address both the intellectual and \line \up0 \expn
dtw-4\charscalex100 emotional aspects of burn injury, provide generic informatio
n about burn injuries \line \up0 \expndtw-4\charscalex100 and burn treatment, an
d emphasize a survivor's abilities as well as clarify the \line \up0 \expndtw-4\
charscalex100 ways in which a survivor may need assistance. Homemade videotapes
can be \line \up0 \expndtw-4\charscalex100 sent to target groups ahead of a pati
ent, thus allowing a community the \line \up0 \expndtw-4\charscalex100 opportuni
ty to see and hear the burn survivor, to anticipate difficulties, and to \line \
up0 \expndtw-4\charscalex100 plan coping responses. Educational information pres
ented in pamphlets or letters \line \up0 \expndtw-4\charscalex100 can be directe
d to those who will play key roles in facilitating a patient's transition \line
\up0 \expndtw-4\charscalex100 from hospital to home community.\ul0\super\cf3\f4\
fs23 \ul0\nosupersub\cf1\f2\fs24 If possible, one or more members of a burn \li
ne \up0 \expndtw-4\charscalex100 team may visit the home community and speak to
targeted groups, answering \line \up0 \expndtw-4\charscalex100 questions which p
eople may be reluctant to ask of the patient or family. \par\pard\ql \li1881\sb0
\sl-276\slmult0 \par\pard\ql\li1881\sb1\sl-276\slmult0 \up0 \expndtw-5\charscale
x100 Rehabilitation Phase, Post-discharge \par\pard\ql \li1881\ri1781\sb0\sl-272
\slmult0\fi710 \up0 \expndtw-4\charscalex100 Discharge from acute inpatient trea
tment does not signify that a patient is \line \up0 \expndtw-4\charscalex100 wel
l. A burn survivor's wounds are covered with sensitive and fragile skin which \l
ine \up0 \expndtw-4\charscalex100 is vulnerable to breakdown and requires specia

l care. Dressing changes, \line \up0 \expndtw-4\charscalex100 exercises, and app
lication of special splints and pressure garments continue. \line \up0 \expndtw4\charscalex100 Patients must confront anew their losses and may experience a de
layed grief \line \up0 \expndtw-4\charscalex100 reaction. Upon leaving the prote
ctive hospital environment, symptoms of post{\shp {\*\shpinst\shpleft1881\shptop12211\shpright5750\shpbottom12231\shpfhdr0\s
}
ex100 \ul0\nosupersub\cf1\f2\fs24 traumatic stress that had remitted in the hosp
ital may recur. A survivor must \par\pard\ql \li1881\sb4\sl-276\slmult0 \up0 \ex
pndtw-4\charscalex100 continue the arduous process of tedious, uncomfortable phy
sical treatments \par\pard\qj \li1881\ri1737\sb0\sl-280\slmult0 \up0 \expndtw-4\
charscalex100 while struggling to comprehend and incorporate the multitude of ch
anges into an \up0 \expndtw-5\charscalex100 image of 'self' which the survivor c
an accept and value. \par\pard\ql \li1881\ri1823\sb0\sl-272\slmult0\fi710 \up0 \
expndtw-5\charscalex100 During this time (which may continue for many months) pa
tients need a \up0 \expndtw-4\charscalex100 great deal of support and encouragem
ent. They need to feel that the difficulties \up0 \expndtw-4\charscalex100 invo
lved in rehabilitation will eventually lead to greater comfort and satisfaction.
\up0 \expndtw-4\charscalex100 They must be reminded of the strengths they have
already demonstrated in \up0 \expndtw-4\charscalex100 surviving in order to enco
urage their continued belief in themselves. And they \up0 \expndtw-5\charscalex
100 need someone to help them appreciate even small successes. \par\pard\ql \li1
881\sb233\sl-276\slmult0 \up0 \expndtw-4\charscalex100 Summary \par\pard\ql \li1
881\ri1765\sb0\sl-272\slmult0\fi710 \up0 \expndtw-4\charscalex100 Outcomes studi
es not only report status of patients post-treatment, but \line \up0 \expndtw-4\
charscalex100 also can provide indicators of those factors that seem necessary o
r important to \up0 \expndtw-4\charscalex100 good recovery. Outcomes studies of
burn survivors have found, somewhat \line \up0 \expndtw-4\charscalex100 surpris
ingly, that the extent of the injury, the depth of the burn, and the area of \li
ne \up0 \expndtw-4\charscalex100 the body burned and/or scarred or even amputati
ons are not determining factors \up0 \expndtw-4\charscalex100 of good psychosoci
al recovery. The age at which the individual was injured also \up0 \expndtw-4\c
harscalex100 has not been shown to relate to later adjustment. Intelligence doe
s not relate \line \up0 \expndtw-4\charscalex100 significantly to adjustment (al
though we mentally retarded individuals have not \line \up0 \expndtw-4\charscale
x100 been included in these studies, and it seems likely that, at that level the
re would \up0 \expndtw-4\charscalex100 be some effect). The immediate emotional
response of the patient and/or the \line \up0 \expndtw-5\charscalex100 patient\
u8217?s family also does not predict adjustment. \par\pard\ql \li1881\ri1695\sb0
\sl-270\slmult0\fi710 \up0 \expndtw-4\charscalex100 There are two important fact
ors that have been found consistently to be \line \up0 \expndtw-4\charscalex100
related to psychological and social adjustment. Fortunately, these two factors
\line \up0 \expndtw-4\charscalex100 can be facilitated by the work of persons sk
illed in psychotherapy. The enduring \line \up0 \expndtw-4\charscalex100 qualit
y of family and social support received by the patient and the willingness on \u
p0 \expndtw-4\charscalex100 the part of the patient to take social risks appear
to play critical roles in the \line \up0 \expndtw-5\charscalex100 adaptation pro

cess. The factors associated with poor prognoses for \line \up0 \expndtw-4\char
scalex100 psychosocial adjustment are, in addition to social shyness of the indi
vidual, an \line \up0 \expndtw-4\charscalex100 acceptance within the family of d
ependence, i.e. a willingness to wait for \u8220?others\u8221? \line \up0 \expnd
tw-4\charscalex100 to provide what is needed, a learned helplessness. A lack of
family cohesion and \up0 \expndtw-4\charscalex100 high conflict within the famil
y are correlated with poor adjustment. These findings \up0 \expndtw-4\charscalex
100 plus clinical experience have led us to develop the following guidelines for
\line \up0 \expndtw-5\charscalex100 psychosocial care of burned persons. \par\p
ard\ql \li1881\sb244\sl-276\slmult0 \up0 \expndtw-4\charscalex100 Guidelines for
Treatment \par\pard\ql \li2236\ri1928\sb0\sl-280\slmult0\tx2592\tx2592 \up0 \ex
pndtw-3\charscalex100 \ul0\nosupersub\cf2\f3\fs24 \u8226?\ul0\nosupersub\cf1\f2\
fs24
The patient is assumed to be a \ul0\nosupersub\cf5\f6\fs24 normal person
\ul0\nosupersub\cf1\f2\fs24 and is expected to fully \line\tab \up0 \expndtw-5\
charscalex100 recover. Full recovery involves going through a difficult proces
s over an \line \tab \up0 \expndtw-6\charscalex100 estimated period of about 2 y
ears. \par\pard\ql \li2236\sb1\sl-232\slmult0 \up0 \expndtw-3\charscalex100 \ul0
\nosupersub\cf2\f3\fs24 \u8226?\ul0\nosupersub\cf1\f2\fs24
Difficulties durin
g the adaptation process are\ul0\nosupersub\cf5\f6\fs24 normal experiences of \
par\pard\qj \li2592\ri1819\sb0\sl-280\slmult0 \up0 \expndtw-5\charscalex100 pers
ons \ul0\nosupersub\cf1\f2\fs24 struggling to develop new lives, new body images
, new ways of \up0 \expndtw-5\charscalex100 feeling good about themselves. \par\
pard\ql \li2236\sb1\sl-242\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub
\cf2\f3\fs24 \u8226?\ul0\nosupersub\cf1\f2\fs24 \ul0\nosupersub\cf5\f6\fs24 T
he family group, however the patient defines \u8220?family\u8221?, must be \par\
pard\ql \li2592\sb10\sl-276\slmult0 \up0 \expndtw-5\charscalex100 included in th
e patient\u8217?s treatment;\ul0\nosupersub\cf1\f2\fs24 in fact, the family (as
a unit \par\pard\ql \li2592\sb4\sl-276\slmult0 \up0 \expndtw-4\charscalex100 in
cluding the individual) becomes the patient for the psychotherapist. Work
}
}}
}
\sl-271\slmult0 \par\pard\ql\li2236\ri1740\sb93\sl-271\slmult0\fi355\tx2592\tx25
92\tx2592\tx2592\tx2592\tx2592 \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf1
\f2\fs24 with the family should promote \ul0\nosupersub\cf5\f6\fs24 autonomy as
well as cohesion\ul0\nosupersub\cf1\f2\fs24 , so that \line\tab \up0 \expndtw-5\
charscalex100 each member can feel valued and supported by the others. \line \up
0 \expndtw-3\charscalex100 \ul0\nosupersub\cf2\f3\fs24 \u8226? \up0 \expndtw-4\
charscalex100 \ul0\nosupersub\cf5\f6\fs24 Training and practice toward self-effi
cacy\ul0\nosupersub\cf1\f2\fs24 , particularly in the domain of \line\tab \up0 \
expndtw-4\charscalex100 social skills and social risk-taking are important eleme
nts of treatment for \line \tab \up0 \expndtw-4\charscalex100 persons with visib
le physical distinctions such as burn scar disfigurement. \line \tab \up0 \expnd
tw-5\charscalex100 They must learn to deal with predictable hurtful reactions fr
om naive \line \tab \up0 \expndtw-5\charscalex100 observers, and learn to make t
hemselves so lovable that people will be \line \tab \up0 \expndtw-5\charscalex10
0 fond of their physical differences. \par\pard\ql \li2236\sb1\sl-257\slmult0\tx
2592 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf2\f3\fs24 \u8226? \tab \up0
\expndtw-5\charscalex100 \ul0\nosupersub\cf5\f6\fs24 The psychotherapist can he
lp the patient in defining a new self-\par\pard\ql \li2592\ri1752\sb16\sl-266\sl
mult0 \up0 \expndtw-5\charscalex100 image.\ul0\nosupersub\cf1\f2\fs24 In the e
arly months or years, the patient may be encouraged to \up0 \expndtw-4\charscale
x100 overcompensate and enjoy a positive identification of "burn survivor". The
\up0 \expndtw-5\charscalex100 survivor is commended for rehabilitation gains and
social \line \up0 \expndtw-5\charscalex100 accomplishments. Each victory is cel
ebrated. \par\pard\ql \li2236\sb6\sl-276\slmult0\tx2592 \up0 \expndtw-3\charscal
ex100 \ul0\nosupersub\cf2\f3\fs24 \u8226? \tab \up0 \expndtw-5\charscalex100 \ul
0\nosupersub\cf1\f2\fs24 As the patient's physical and psychological adaptation
stabilizes, the \par\pard\ql \li2592\sb1\sl-256\slmult0 \up0 \expndtw-5\charscal
ex100 psychotherapist can assist the patient in \ul0\nosupersub\cf5\f6\fs24 resi
sting the temptation to \par\pard\ql \li2592\sb8\sl-276\slmult0 \up0 \expndtw-4\
charscalex100 remain satisfied\ul0\nosupersub\cf1\f2\fs24 with the identity of
"survivor". This role invites the \par\pard\qj \li2592\ri1676\sb18\sl-260\slmult
0 \up0 \expndtw-4\charscalex100 survivor to strive to achieve expectations that
are unrealistic, attempting to \up0 \expndtw-5\charscalex100 deny unhappiness or
anger or pain. \par\pard\ql \li2236\sb3\sl-257\slmult0\tx2592 \up0 \expndtw-3\c
harscalex100 \ul0\nosupersub\cf2\f3\fs24 \u8226? \tab \up0 \expndtw-5\charscalex
100 \ul0\nosupersub\cf5\f6\fs24 Finally, the task of the psychotherapist is to m
ake explicit the \par\pard\ql \li2592\ri1704\sb0\sl-276\slmult0 \up0 \expndtw-5\
charscalex100 expectation that each burn survivor is a human individual who can
\line \up0 \expndtw-5\charscalex100 be strong and competent, optimistic and auto
nomous and also can \line \up0 \expndtw-5\charscalex100 have moments of sadness,
despair, or rage.\ul0\nosupersub\cf1\f2\fs24 The person who has been \line \up
0 \expndtw-5\charscalex100 the "heroic trauma survivor" can become a competent,
interesting \line \up0 \expndtw-5\charscalex100 individual who also once survive
d a serious injury and a terrifying \line \up0 \expndtw-5\charscalex100 experien
ce. \par\pard\ql \li1881\sb232\sl-276\slmult0 \up0 \expndtw-4\charscalex100 A Fi
nal Thought \par\pard\qj \li2236\ri1745\sb9\sl-270\slmult0\fi355 \up0 \expndtw-4
\charscalex100 Many cultures have a social tradition of, on the one hand, overpr
otecting \line \up0 \expndtw-4\charscalex100 individuals with disfiguring condit
ions and, on the other hand, rejecting and \line \up0 \expndtw-4\charscalex100 r
idiculing them. Both of these attitudes are more crippling to the individual \l
ine \up0 \expndtw-4\charscalex100 than the physical condition. Human beings are
remarkable in their creativity; \line \up0 \expndtw-4\charscalex100 they can de
vise ways of achieving their goals when they feel supported and \line \up0 \expn
dtw-4\charscalex100 encouraged. One young boy who recently had lost much of his
hearing and \line \up0 \expndtw-4\charscalex100 had all four limbs amputated fo
llowing a terrible explosion, was asked if he \line \up0 \expndtw-5\charscalex10
0 had any impairments. He answered \u8220?I do not know.\u8221?
Thinking tha
t perhaps \line \up0 \expndtw-4\charscalex100 he did not understand the question
, the psychologist said, \u8220?You know, some \line \up0 \expndtw-4\charscalex1
00 people would think you were impaired by not having your arms and hands.\u8221
? \line \up0 \expndtw-4\charscalex100 He responded, \u8220?I know, but I don\u82
17?t know if I am or not yet.\u8221? That boy is now a \line \up0 \expndtw-4\ch
arscalex100 grown man, living in an apartment by himself with a helper dog, driv
ing his \line \up0 \expndtw-4\charscalex100 own truck, and attending a universit
y. His life has been very difficult, and he \line \up0 \expndtw-4\charscalex100
is not always happy. He always wishes, at some level, that he had his old \par
\pard\ql \li2236\ri1648\sb11\sl-270\slmult0 \up0 \expndtw-4\charscalex100 body b
ack. And, he would be happier if he had found his dream woman. But, \line \up0
\expndtw-4\charscalex100 he has accomplished much; he is optimistic, enjoys fri
ends, and he has hope \line \up0 \expndtw-4\charscalex100 for the future. He ha
s always had the attitude that he does not know what his \line \up0 \expndtw-4\c
harscalex100 limitations are. And the data and clinical experience we have glea
ned, \line \up0 \expndtw-4\charscalex100 teaches us that we also cannot define t
he limitations of human resilience.
}
ex100 \ul0\nosupersub\cf1\f2\fs24 REFERENCES \par\pard\ql \li2236\sb4\sl-276\slm
ult0\tx2592 \up0 \expndtw-7\charscalex100 1. \tab \up0 \expndtw-5\charscalex100
Faber A, Klasen H, Sauer E, & Vuister F. Psychological and social \par\pard\ql \
li2592\sb1\sl-256\slmult0 \up0 \expndtw-5\charscalex100 problems in burn patient
s after discharge: A follow-up study. \par\pard\qj \li2592\ri1809\sb21\sl-260\s
lmult0 \up0 \expndtw-5\charscalex100 Scandinavian J. of Plastic and Reconstructi
ve Surgery 1987; 21(3): 307-\line \up0 \expndtw-6\charscalex100 309. \par\pard
\li2236\sb12\sl-276\slmult0\fi0\tx2592 \up0 \expndtw-5\charscalex100 2.\tab \up0
\expndtw-5\charscalex100 Patterson C, Everett J, Bombardier C, Questad K, Lee V
, & Marvin J.\par\pard\li2236\sb1\sl-267\slmult0\fi355 \up0 \expndtw-4\charscale
x100 Psychological effects of severe burn injuries. Psychological Bulletin 1993
;\par\pard\li2236\sb1\sl-269\slmult0\fi355\tx3473 \up0 \expndtw-5\charscalex100
113(2):\tab \up0 \expndtw-5\charscalex100 362-378.\par\pard\ql \li2236\ri1833\sb
0\sl-270\slmult0\tx2592\tx2592\tx2592 \up0 \expndtw-7\charscalex100 3. \tab \up0
\expndtw-5\charscalex100 Blakeney P, Herndon D, Desai M, Beard S, & Wales-Sears
P. Long-term \line\tab \up0 \expndtw-5\charscalex100 psychological adjustment f
olowing burn injury. J. of Burn Care and \line \tab \up0 \expndtw-7\charscalex1
00 Rehabilitation1988; 9(6): 661-665. \par\pard\ql \li2236\sb2\sl-266\slmult0\
tx2592 \up0 \expndtw-7\charscalex100 4. \tab \up0 \expndtw-4\charscalex100 Blake
ney, P., Meyer, W., III, Robert, R., Desai, M., Wolf, S., and Herndon, \par\pard
\ql \li2592\ri2025\sb0\sl-270\slmult0 \up0 \expndtw-5\charscalex100 D. Long-Term
Psychosocial Adaptation of Children Who Survive Burns \up0 \expndtw-5\charscale
x100 Involving 80% or Greater Total Body Surface Area. J Trauma \line \up0 \expn
dtw-5\charscalex100 1998;44(4):625-32. \par\pard\ql \li2236\sb2\sl-269\slmult0\t
x2592 \up0 \expndtw-7\charscalex100 5. \tab \up0 \expndtw-4\charscalex100 Sherid
an, R. L., Hinson, M. I., Liang, M. H., Nackel, A. F., Schoenfeld, D. \par\pard\
ql \li2592\ri1688\sb19\sl-260\slmult0 \up0 \expndtw-4\charscalex100 A., Ryan, C.
M., Mulligan, J. L., and Tompkins, R. G. Long-Term Outcome \up0 \expndtw-5\char
scalex100 of Children Surviving Massive Burns. Jama-Journal of the American \lin
e \up0 \expndtw-5\charscalex100 Medical Association 1-5-2000;283(1):69-73. \par\
pard\ql \li2236\sb7\sl-276\slmult0\tx2592 \up0 \expndtw-7\charscalex100 6. \tab
\up0 \expndtw-5\charscalex100 Morris, J. and Mcfadd, A. Mental-Health Team on A
Burn Unit -\par\pard\qj \li2592\ri1779\sb0\sl-280\slmult0 \up0 \expndtw-4\charsc
alex100 Multidisciplinary Approach. Journal of Trauma-Injury Infection and Criti
cal \up0 \expndtw-5\charscalex100 Care 1978;18(9):658-64. \par\pard\ql \li2236\r
i1740\sb0\sl-266\slmult0\tx2592\tx2592\tx2592\tx2592 \up0 \expndtw-7\charscalex1

00 7. \tab \up0 \expndtw-4\charscalex100 Watkins, P. N., Cook, E. L., May, S. R.
, and Ehleben, C. M. Psychological \line\tab \up0 \expndtw-5\charscalex100 Stage
s in Adaptation Following Burn Injury: a Method for Facilitating \line \tab \up0
\expndtw-5\charscalex100 Psychological Recovery of Burn Victims. J Burn Care Re
habil \line \tab \up0 \expndtw-5\charscalex100 1988;9(4):376-84. \par\pard\ql \l
i2236\ri1922\sb0\sl-275\slmult0\tx2592\tx2592\tx2592\tx2592 \up0 \expndtw-7\char
scalex100 8. \tab \up0 \expndtw-5\charscalex100 Haynes, B. W., Jr. and Bright, R
. Burn Coma: a Syndrome Associated \line\tab \up0 \expndtw-5\charscalex100 With
Severe Burn Wound Infection. J Trauma 1967;7(3):464-75. \line \up0 \expndtw-7\ch
arscalex100 9. \up0 \expndtw-4\charscalex100 Rivlin, E., Forshaw, A., Polowyj, G
., and Woodruff, B. A Multidisciplinary \line\tab \up0 \expndtw-5\charscalex100
Group-Approach to Counseling the Parents of Burned Children. Burns \line \tab \u
p0 \expndtw-5\charscalex100 1986;12(7):479-83. \par\pard\sect\sectd\fs24}

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on intensive medical \line \up0 \expndtw-4\charscalex100 and surgical care to r

00 rehabilitation. Management plans must support, to the extent possible, the \l

\expndtw-4\charscalex100 significant limitations upon the availability of situat

ate a patient's reentry and \line \up0 \expndtw-4\charscalex100 reintegration in

xpndtw-4\charscalex100 relinquishes performance of daily care so that the patien

ine \up0 \expndtw-4\charscalex100 is vulnerable to breakdown and requires specia

to play critical roles in the \line \up0 \expndtw-5\charscalex100 adaptation pro

i1740\sb0\sl-266\slmult0\tx2592\tx2592\tx2592\tx2592 \up0 \expndtw-7\charscalex1

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