# Motivation and emotion/Book/2019/Burn survivor emotion

* Multimedia presentation (3 min)

## Overview

This chapter focuses on the emotional consequences of a burn injury, the theories surrounding these emotions and the tools and techniques burn survivors use to confront these emotions.
* Focus questions:
* What are the different types of burns?
* What are the emotions associated with burn survivors?
* What are some theories of emotion that help explain the emotions burn survivors experience?
* How do burn survivors deal with their emotions?

## Burns

There are four main types of burns, four main stages of burns and there are many different treatments for burns (Stanford Health Care, 2019). These are as follows:

### Types of burns

* Thermal burns
* Chemical burns
* Electrical burns
* Radiation burns

### Stages of burns

* First degree (superficial)
** Only involve the epidermis layer of the skin and appear red without blisters. (Wikipedia, 2019)
** First degree burns are also considered mild compared to other burns ("Types Of Burns & Burn Pain Treatment | Cleveland Clinic", 2019).
* Second degree (partial thickness)
** Extends into either the papillary dermis or the reticular dermis. They appear either red with a clear blister or yellow or white with a possible blister (Wikipedia, 2019).
* Third degree (full thickness)
** These burns involve the entire dermis and appear to be stiff and white/brown. Figure 1 is an example of a third degree burn (Wikipedia, 2019).
* Fourth degree
** These burns involve not only the skin, but fat, muscle and bone. They appear to be black and charred and require excision (Wikipedia, 2019).

### Treatments

* Plastic surgeons
** Skin grafts
** Remove burned skin
* Orthopaedic surgeons
** In cases where bones are involved, usually third and fourth degree burns
* Infection disease specialists
* Rehabilitation nurses
* Psychologists/psychiatrists
** Emotional therapy
Quiz
1
Which of the following is also known as a full thickness burn?
First degree
Second degree
Third degree
Fifth degree
2
What is a different name for a first degree burn?
Partial thickness
Superficial
Basic
Full thickness :

## Emotions associated with burn survivors

Emotions can be separated into three categories: basic, self-conscious and cognitively complex. The current research doesn't take into account any emotions that the burn survivor may have been feeling before the accident (Patterson et al. 1993).

### Basic emotions

Basic emotions are cognitive responses to important life events (Neill, 2019). Of the seven basic emotions, burn survivors experience four. These emotions are:
| Emotion | Definition / Causes (Neill, 2019) | Examples |
| Fear | Comes from determining a situation to be unsafe 2 types: situational and perceived vulnerability Initiates flight or fight response | Uncertain about survival (Badger, 2001; Watkins et al., 1988) Can manifest in the form of flashbacks of the accident or the subsequent surgeries (Badger, 2001) Can occur when being discharged from hospital. Can occur when having to return to work or school (Wiechman, & Patterson, 2004). Burn survivors are often hyper-vigilant and alert after the accident and this can cause them to feel fear (Macleod et al., 2016). |
| Anger | Caused by something impeding an individual's ability to achieve their goals. An acute response that may occur within the first 24-72 hours (Badger, 2001). | Can be caused by the frustration of being dependent on others and feeling helpless (Watkins et al., 1988). Can be triggered by seeing their scars and by other people's reactions to their scars (Macleod et al., 2016). Can be caused by the psychological pain they experience (Watkins et al., 1988). |
| Disgust | According to Neill (2019), disgust is a "primitive emotion" that causes us to remove or move away from an object that is contaminated or is deemed to be offensive. | Can be experienced when the burn survivor sees their scars (Badger, 2001). |
| Sadness | Comes from "separation or failure" (Neill, 2019). Promotes self-reflection | Burn survivors may experience sadness when they see their wounds and begin to understand the impact they will have on their future (Badger, 2001) They also may feel sad and lonely and as they may feel socially isolated due to their scars (Badger, 2001). Making little progress with recovery may induce sadness (Watkins et al., 1988) The physical changes, which are reminders of pain, can make a burn survivor experience sadness. (Blakeney et al., 2009) The verbalisation of the acceptance of loss can make an individual feel sad (Watkins et al., 1988). Can also be caused by the psychological pain they experience. |

### Self-conscious emotions

Self-conscious emotions come from an individual's cognitive evaluation of themselves (Neill, 2019). According to Lawrence et al. (2007), self-conscious individuals tend to interpret information in a way that validates their negative opinion of their appearance. They also tend to look for possible "rejection cues" and misinterpret unclear signs (Lawrence et al. 2010). As their levels of self-esteem increase, individuals begin to feel more comfortable in social situations (Lawrence, & Rosenberg, 2007). Four of the five self-conscious emotions are displayed by burn survivors.
| Emotion | Definition / Causes (Neill, 2019) | Examples |
| Guilt | Comes after interpreting one's actions as causing loss or harm to another person. | May experience survivors' guilt (Watkins et al., 1988) Self-recrimination (Blakeney et al., 2009) They may feel guilty because they were responsible for the injury to themselves or others (Watkins et al., 1988). Even though they may not have been responsible for their burn, patients with PTSD feel more guilt than those without PTSD (Patterson et al., 1993). |
| Shame | Comes from a feeling of being inferior. Associated with feeling worthless. | Burn survivors may experience shame as they begin to acknowledge their disfigurement (Badger, 2001). They may feel ashamed of having to change roles at work to accommodate their injuries (Wiechman, & Patterson, 2004). Can be caused by being teased about their disfigurement (Macleod et al., 2016). Can feel ashamed of not being able to perform tasks properly (Watkins et al., 1988). Burn survivors may feel shame because of their burn scars (Lawrence et al., 2007) |
| Embarrassment | Occurs when something goes wrong and the individual needs to conceal or monitor something. | Can feel embarrassed when they're being stared at (Macleod et al., 2016). Can also feel embarrassed because they cannot perform tasks to the standard they used to (Watkins et al., 1988). |
| Pride | Two types: authentic and hubristic Authentic applies to burn victims Associated with success. | Some burn survivors may feel proud of their scars, for example Tess and Carlton from the case studies below. |

### Cognitively complex emotions

Of the eight emotions in the cognitively complex category, according to research, burn survivors only experience two. These are:
| Emotions | Definition / Causes (Neill, 2019) | Examples |
| Hope | Associated with trying to reach a goal | The burn survivor may feel hopeful for the future (Blakeney et al., 2009). |
| Gratitude | A positive emotion Associated with "receiving something of value". | The burn survivor may feel grateful to be alive and to have survived. |

### Other emotions

There are four other emotions that do not fit into the three main categories, but are still experienced by burn survivors. These are:
| Emotions | Definition / Causes | Examples |
| Grief | According to (Wiechman, & Patterson, 2004; Macleod et al., 2016), grief begins in the acute stage of the recovery process. | The individual grieves for their former life, those who may have died in the accident, their losses (e.g. pets and property) The effect their burn injuries will have on their life (Wiechman, & Patterson, 2004; Watkins et al., 1988) The scars act as a permanent reminder of their grief (Macleod et al., 2016). |
| Distress | The Cambridge Dictionary defines distress as "a feeling of extreme worry, sadness, or pain". | The burn survivors may experience distress whilst they are unsure about the likelihood of survival as they undergo many painful surgeries and procedures (Wiechman, & Patterson, 2004). Children experience distress when they are separated from their parents (Wisely et al., 1983). |
| Psychological Pain | Psychological pain is the interaction of physical and psychological pain (Watkins et al., 1988). | Physical causes of psychological pain are "increased catecholamine, increased muscle tension and increased sympathetic neuronal activity" (Watkins et al., 1988). Psychological pain is often suspected when medication isn't effective in controlling emotions (Watkins et al., 1988). |
| Stress | Occurs when an individual is in a challenging situation (Health Direct, 2019). | Stress is a common emotion experienced when in the intensive care unit (ICU) whilst the individual is struggling to survive (Wiechman, & Patterson, 2004). Extreme stress can cause delirium in burn patients (Patterson et al., 1993) |
Quiz
1
Which of the following is NOT a basic emotion?
Sadness
Guilt
Anger
Fear
2
Which of the following is a self-conscious emotion?
Shame
Contempt
Disappointment
Hope :

## Emotion theories

There are two main theories of emotion that can be used to help explain burn survivor emotions. These are:

### Lazarus' appraisal theory of emotion

Lazarus' theory of emotion is based on the idea that emotions aren't caused by events, but an individual's appraisal of that event. This appraisal is split into two stages:
* Primary appraisal
** The aim of the primary appraisal is to explore the personal significance of the event.
* Secondary appraisal
** The aim of the secondary appraisal is to assess the individual's ability to cope with the effects of the event.

### Cannon-Bard theory of emotion

The Cannon-Bard theory of emotion states that a physical and emotional response occur at the same time. The theory insinuates that the following three steps occur (Lumen Learning):
* Stimulus
* The individual perceives or interprets the stimulus and the consequences of it
* The individual experiences and emotion and physical arousal simultaneously

## Case Studies

There are many burn survivors that share their stories and inspire others. They can help us gain insight into the thoughts, experiences and emotions of burns survivors. Some of these people are:

### Turia Pitt

* In 2011, Turia Pitt was competing in a 100km outback ultra-marathon when a grassfire happened. She has burns to 65% of her body and lost seven fingers. She had to undergo over 200 operations.
* In 2016, Turia managed to compete in the Ironman World Championships.
* Turia has raised millions of dollars and gained a lot of awareness for Interplast Australia and New Zealand
* She has walked along the Great Wall of China, the Inca Trail and the Kokoda Track.
* She has been named Young Australian of the Year and Australian of the Year
* Turia has written 4 books about her experience.

### Sophie Delezio

* Sophie was involved in two accidents as a child. In 2003, Sophie's car crashed into her childcare centre and caught on fire. Sophie had burns on 85% of her body. She lost "most of her skin, her right ear, the fingers on her right hand and her lower legs" (Woman's Weekly, 2016).
* She was then hit by a car in 2006 and suffered from a heart attack, a broken shoulder and a tear to her lung and also caused bleeding in her brain and she lost her sense of smell (Woman's Weekly, 2016; Daily Telegraph,
* Despite having lost the bottom half of both her legs and her fingers on her right hand, Sophie has learnt to drive, and she is also an avid rower and likes to act and dance.
* Sophie and her family also fundraise for an organisation they set up called Day of Difference.

### Skin deep videos series

[Provide more detail]

#### Tamara

* Tamara was in an accident when her younger sister was playing with matches and accidentally dropped the match on Tamara's pyjamas.
* In Tamara's video, she says that she feels self-conscious and embarrassed about her scars. She also said that she loves and hates them.
* Even though Tamara feels judged about her scars and that she has been bullied for having them, she still believes that "you judge yourself the most" (Queensland Government, 2018).

#### Tess

* Tess was in a boating accident where the engine exploded.
* According to Tess, the lowest point is when you first get out of hospital and the hardest part is registering what has happened to you.
* Tess experienced a lot of anger about her burns and the pain she was going through and took it out on her mother.
* Her mother is her biggest supporter and helped her a lot.
* Like Tamara, Tess also felt self-conscious and found it difficult to return to school.
* She owns her scars and says that "my scars are a part of me" (Queensland Government, 2018).

#### Carlton

* Carlton accidentally poured oil from a deep fryer on himself when he was 7 months old and suffered from burns to 70% of his body.
* Does a lot of public speaking and fundraising in Australia and in other countries.
* Mother and father would support him.
* He needed to emotionally and mentally prepare before each procedure.
* Carlton says it is a scary experience, as he had to constantly miss out on periods of school to have procedures.
* His dad says that people are staring at him because he is different, and they want to know what is happening, and that they would do it to anyone else. This brings everything into perspective and can help burn survivors feel less self-conscious.
* Doesn't believe that being burnt is going to hold him back, he is very positive about his burns and owns his scars.

#### Sarah

* Sarah was in a house fire.
* She remembers feeling confused and lonely.
* She believes it's important to have a good support network.
* In the video Sarah says, "it is really good to celebrate the little victories" (Queensland Government, 2018).

## Coping with emotions

Research shows that there are many strategies that burn survivors can employ to help manage their emotions effectively. These strategies can be grouped into seven categories. These are:

### Therapy

Individual therapy is useful for helping the burn survivor by reinforcing that it is okay to feel the way they do and reinforcing the reality of their injuries and the potential consequences (Blakeney et al., 1998). Family therapy is important, as the burn survivor relies heavily on their family members and how their family members perceive their disfigurement. It is important that members of the family are well as the burn survivor relies on them for support (Wisely et al., 1983; Blakeney et al., 1998). Psychiatrists can do early screening to determine if the burn survivor needs therapy, which can help speed up their recovery and cope with their emotions. This screening can also help paediatric burn survivors receive the help they need but may not have the necessary skills or be in a position to ask for (Lawrence et al., 2007). Psychiatrists can help the burn survivor cope with the negative emotions by fostering a sense of hope and other positive emotions (Blakeney et al., 1998). They can also encourage them to identify as survivors, which encourages a more positive evaluation of themselves (Blakeney et al., 1998). Other types of therapy that can be useful include grief therapy, psychotherapy and cognitive therapy (Trief, & Schiller, 2001).

### Socialising

Socialising is an important part of individual development as it helps us gain important life skills. Deficits in social skills caused by burn injuries can be detrimental to a burn survivors' development (Szabo et al., 2017). This deficit can cause psychosocial issues in the individual's future and can ruin future relationships. Screening can be used to test for future social difficulties such as bullying and harassment, which can lead to social isolation (Szabo et al., 2017). According to Badger (2001), daily socialisation with nurses is enough to help maintain a healthy amount of social interaction whilst the individual is recovering.

### Support networks

It is important for burn survivors to establish support networks. These can be family, friends, nurses, or other burn survivors. By attending support groups peer counselling, burn survivors can become more comfortable with their situation and it can help them cope with feelings of sadness and loneliness (Weichman, & Patterson, 2004).

### Organised activities

Organised activities are an important tool for coping with the emotions that can arise from a burn injury as they encourage social interactions between peers of similar ages (Szabo et al., 2017). This is important as we learn social skills and behaviours from others. Organised activities provide a positive and stable opportunity for burn survivors to practice coping strategies (Szabo et al., 2017). It also allows the burn survivor to experience a sense of normalcy.

### Education

Educating peers and public about burn injuries can help the burn survivor to feel more accepted and help them readjust (Wisely et al. 1983). Having a strong level of communication between the hospital, the school and the burn survivor's family is important for paediatric burn survivors. This can help make the transition back to school seamless and can lead to a successful and stress-free reintegration (Blakeney et al., 1998).

### Reappraisal

Burn survivors can reappraise their scars, which can lead them to feeling more comfortable with themselves and help them cope with their emotions, for example disgust and shame. By reappraising their scars, they can begin to feel less self-conscious and resume social interactions (Macleod et al., 2016). By reappraising their trauma, such as the scars being a symbol of courage, they no longer become a reminder of pain, which can help reduce feelings of fear (Blakeney et al., 1998).

### Intervention

Intervention can be divided into seven stages as outlined in Figure 6. The most important of these stages are the validation stage, the legitimisation stage, and the termination stage. The validation stage involves the burn survivor finding their own reasoning for what has happened to them and this theory being confirmed by the people around them. The legitimisation stage involves the support network for the individual confirming that it is okay to feel the way they do and that it is a normal response. Finally, the termination stage involves the individual letting go of their "preburn" life and focusing on their new life and what goals they can achieve (Watkins et al., 1988).

## Conclusion

In conclusion, burns have four main degrees: first, second, third, and fourth. Burn survivors are people who suffer from third and fourth degree burns. The psychological impact of enduring this trauma can lead to a series of emotions. These emotions can be broken down into four categories: basic, self-conscious, cognitively complex and other. These emotions are experienced simultaneously with a physical response and are determined by the personal significance of the event and the individual’s ability to cope with the stressor. There are many examples of burn survivors overcoming these emotions and doing positive things with their lives. Turia Pitt and Sophie Delezio are two good examples of burn survivors managing to make the most of their situation. There are many strategies burn survivors can employ to help cope with their emotions. These are therapy, socialising, support networks, organised activities, education, reappraisal, and intervention. These strategies help support the burn survivor and help reduce the impact of their emotions on their life.