Building A Positive Self Image In Patients
Mary Point Novotny, RN., MS. *
"Poems are made by fools like me, but only God can make a tree, "
Momentary reflection on this literary work brings into perspective the complex task of rebuilding the image of one who has lost a limb. It is a task which requires not merely the professional and technical abilities of the prosthetist, but also a personal concern for the self image of the patient.
Body image is the constantly changing mental picture one has of his individual, body appearance. It develops through reflected perceptions about one's body and sensations originating from internal and external stimuli as the individual adapts to a kaleidoscopic variety of living activities. All too frequently body image is overlooked in the rehabilitation plans for a patient with chronic disease, disability, or surgical intervention, because physical diagnosis and mechanical advances have become paramount in our fast-paced acute care settings. The concept is so basic, it is not hard to see why it is overlooked; yet, if one begins to examine the personal effect of alterations, such as mastectomy, amputation, colostomy or stroke, we can begin to identify with the grief, anxiety and fear accompanying the loss of a body part and the ensuing alteration in functional ability.
Research of Schilder and others has shown that since body image is primarily a psychological entity, alterations in it are extremely subjective experiences which vary in intensity, dependent on the unique characteristics of each individual, in three distinct categories. These sources of self image include:
Past experiences which are gradually built up through the years from physiologic, psychologic, and social components, organized and integrated by the central nervous system.
Social interactions which include the reaction of significant others and of society to the person's body, as well as his own interpretation of that reaction.
Current sensations, such as perceptions of physical appearance, alterations incurred, and images, attitudes and emotions regarding the body.
Because these components are subject to constant revision, the body image of any individual is constantly changing. Survival of a healthy self image is determined by the amount of flexibility available to adapt to new situations and one's ability to realize that the image he projects to others is the one others see.
The loss or absence of a limb, therefore, has varying consequences dependent on the individual and his stage in the life cycle. Studies have shown that an individual is capable of incorporating a firmly-attached object, such as a prosthesis, cane, etc., into his self image. This seems to be particularly evident with congenitals fitted very early in life, before developing unilateral coordination and functional abilities. Of the acquired amputees, early fitting and functional use of the prosthesis also increases the chances of reconstructing a complete image of one's self. A juvenile amputee, up to 3 years old, is not able to consciously deal with "loss," and congenitals, up to 6 years old, generally do not perceive themselves as "different." Yet amputation in later years results in the patient undergoing the process of grief, which includes feelings ranging from denial, anger and hopelessness, to reorganization and adaptation.
Schilder places a positive emphasis on the necessity for communication of these feelings. He believes we constantly construct, dissolve, and reconstruct our own body image as well as the body images of others. He points out that the tendency to destroy a previous body image is essential to acceptance of a new, altered image.
This appears to be a critical area in successful care of any patient. Because most amputees and their families have limited, if any, exposure to others with similar problems, their greatest fears are of the unknown. Will amputation ruin my personal life?. End my career?. Leave my child handicapped and dependent?. With little factual information in the areas of prosthetics and a body image distortion that has not been reconciled, the patient frequently arrives at the professional door seeking an opportunity to communicate his fears and frustrations to an individual who will, hopefully, aid in the design of a prosthesis and promise for the future. While personal style and approach vary with the needs of individual patients, certain factors should be considered in dealing with an amputee: personality type, expectations, stage of adjustment, support system, and medical conditions.
Recent amputees, for example, would benefit from an opportunity to see and touch a prosthesis, with a complete explanation of the stages of fitting and fabrication to limb completion. Be open and honest with patients, keeping in mind that cosmesis may be a priority for some while function and durability are essential for others. While no prosthesis will ever replicate human functioning, once you determine what a patient expects to achieve through prosthetic usage, you can then fulfill his needs and likewise increase his acceptance of an artificial limb.
Parents of a congenital amputee frequently need much more support than the child who can learn to lead a "normal" life if allowed to develop and achieve, unhampered by "concerned" adults who would treat him "special/different."
Meeting with another amputee who has mastered life with a prosthesis can have a very positive effect on the older child or adult who is attempting to re-adjust his self image. Family members or significant others should be encouraged to be present at such meetings, as the fear of new amputees is generally in direct proportion to the acceptance reaction of those whose opinion he values most. Seeing is believing!, and once normal functioning in everyday living is explained, there will be less chance of the amputee being treated as a "handicapped" individual, which he is not.
Lastly, bear in mind that you are a very important person in the eyes of your patient. This is because you are now the professional most heavily relied on for advice, support and adjustment in the initial period of building a new self image. So grin and bear those minor repairs, etc., keeping in mind that a well-worn prosthesis is your best measure of success. Function and form go hand-in-hand in establishing a sense of completeness in self image.
While you may not have the power of our creator, you can surely have a part in the final design of his creations.
- Fishman, Sidney, "Behavioral and Psychological Reactions of Juvenile Amputees." Reprinted from Limb Development and Deformity: Problems of Evaluation and Rehabilitation, Charles C. Thomas, Publisher, 400-407.
- La Fleur, Jean and Novotny, Mary, "A Study of Human Figure Drawings by Amputee Children and Verbalization of their General Adjustment," Masters' thesis, De Paul University, 1978.
- Schilder, Paul, The Image and Appearance of the Human Body, International Universities Press, Inc., New York, 1950.
- Schilder, Paul "Symposium on the Concept of Body-Image," Nursing Clinics of North America, VII (December, 1972).