By: Shelley A. Wiechman, PhD, ABPP
Body image is a complicated, multidimensional concept, but, simply, it refers to an
individual’s thoughts, feelings, and behaviors related to their physical appearance. Tom Cash, one of the world’s experts in body image, has identified different aspects of body image,  including:
- Body image evaluation, which refers to the level of satisfaction or dissatisfaction with our appearance. Satisfaction is largely dependent upon the degree of discrepancy between our view of ourselves and our ideal. Studies have consistently shown that more than half of the U.S. population struggles with body image issues. Very few people believe that they meet the expectations of the ideal body image that is promoted in our society, whether we have burn scars or not.
- The degree of investment that we place on our appearance, including the extent to which we define ourselves by our appearance, or, how important our appearance is to us. The development of our body image is influenced by many different factors, including social influences (such as the media), our own interpersonal experiences with family and peers, our personality traits, and any physical changes that we experience.
Clearly, how a person looks on the outside does not always determine how the person feels on the inside.
What We Can Learn From Research
Most studies have found that the degree of importance that a person places on their body image (investment) is more important than the degree or location of scarring. Women and those with larger burns also tend to struggle more with body image changes. We have also found that body image tends to improve over time as we get used to a “new normal” and take steps to adapt to a new image. [2,3]
Adolescence is difficult for anyone, but it is especially difficult if a person has any visible differences. Studies by Blakeney, et al  have found that adolescents who adjust positively to a burn injury are more extraverted (outgoing, social), are more willing to take a social risk, and have good family support. Teasing and bullying from peers can affect body image for years. Unfortunately, the more open and extroverted a person is about their burn, the more they open themselves up to teasing—which is why it is so important that adolescents learn how to deal with questions, staring, and teasing.
Effective interventions include the following components:
- Rehearsing responses/exposure – Getting out there and practicing interacting with the public.
- Psychoeducation – Being informed of how our body image is formed and what factors influence our body image.
- Self-monitoring – Learning how to pay attention to our reactions to others and noting when we are being critical or negative of ourselves.
- Cognitive restructuring – Learning how to actively change what we think and say, and how we view ourselves.
- Desensitization – Getting used to stares and questions.
Adolescence is difficult for anyone, but it is especially difficult if a person has any visible differences.
One exciting study by Egan and colleagues  interviewed 12 participants who had adjusted positively to a visible difference. They found that this group of individuals had turned their visible difference into a positive influence and had used the experience to develop important skills. For example, when faced with adverse or negative events, they were more resilient, were more resourceful, and had a calmer approach to daily hassles. They had also found new interests to pursue. Their coping strategies included having an overall positive outlook on life; they were able to actively solve a problem and take control over a difficult situation; they used humor when appropriate, had more of a spiritual outlook, and had good family support. All of these skills can be learned and are not necessarily traits that a person is born with. Following are examples of burn survivors who have learned a variety of these skills and techniques to cope with their burn injury:
“Rachel” is a 30-year-old woman who had a burn injury when she was 15 that resulted in two scars on her upper arm and back that she could hide and cover when she wanted. She was from a culture where scarring was considered a disgrace and constantly heard messages from her mother that no man would find her attractive if they knew about her scars and that she should cover them whenever possible. Her father never spoke to her about this issue and remained silent. She grew her hair very long and never wore a bathing suit or a sleeveless shirt. She was from a warm climate, so this was uncomfortable for her in the summertime and she gave up her favorite activity—swimming. After graduating from high school, she left home and started college. She found a great group of friends who were supportive of her and very positive, but she never told them about her scars, fearing that they would not like her if they knew about them. She began dating and was always uncomfortable with intimacy, insisting that lights were always off and hiding the scars when she could. She fell in love with a man and told him about her scars and he did not seem to care. They married and she had a baby.
Five years into her marriage, she found out that her husband was having an affair and was leaving her. She immediately withdrew from society, secluding herself in her home, only leaving to take her daughter to school and back. She found a job that she could do from home. She was terrified to start dating again and was adamant that her husband had left her because of her scars. After a couple of years, she realized how depressed she had become and wanted a better quality of life so she sought out counseling with a cognitive behavior therapist. They worked together on monitoring her selftalk and challenging her negative thoughts. She began to realize that her past relationships had ended because of other issues and the characteristics of the men she had chosen, and had nothing to do with her burn scars. She also began to look at the messages that she received from her family members regarding the stigma of scars and how that has influenced her body image. Those perceptions were challenged and, although much harder to change, she is realizing that not all cultures view scars as stigmatizing and there may be other ways to look at her scars. Finally, she has realized that, although she is more accepting of her scars, she still does not like them. She is continuing to pursue surgical options and follows any new technology and products that may become available to improve the appearance of her scars. She is slowly gaining the courage to start dating again and that is a goal that she has set for herself for this next year.
“Jane” is a 50-year-old female who was burned 25 years ago when she was in a car accident with her husband. They had been married only a year, but he was devoted to her and cared for her during her long recovery. He never seemed to care about her scars. Some of her scars were visible, but the severe scars were on her torso where she could choose to cover if she wanted to. She and her husband went on to have a happy marriage and raised a family, and she had a successful career. She also had many close friends who did not seem to notice her scars. Despite the fact that she noticed people staring at her over the years and had experienced numerous questions from strangers (some of them quite rude), it had not really bothered her or affected her body image. Tragically, her husband passed away a couple of years ago after a long illness. She is now thinking about dating again, but is suddenly more aware of her scars and, for the first time, is self-conscious about how another man might respond to her scars. She is struggling with when and how to tell a man about her more extensive scars, and is worried about what his reaction might be. After several sessions with a counselor and numerous talks with her girlfriends, she realizes that most women are self-conscious about different aspects of their body, especially at age 50. She recognizes that she is not alone in facing the challenges of dating later in life. She has also come to realize that she has many strengths and talents that she relies on in social situations, many that have come about as a result of her coping with her burn trauma. She has a dynamic personality and is a good conversationalist. She is interesting and has many hobbies and activities that she enjoys talking about. The men she has dated have found her engaging and exciting. She has decided to trust her instincts on when it is the right time to tell a man about her scars and trusts that his response will also help her determine whether or not he is the right person with whom to be in a relationship.
It is important for you to surround yourself with positive people.
“Jessie” is a 16-year-old boy who, at age 9, was burned after tripping and falling into a campfire. The first several years after his burn injury were confusing and very challenging for him. His scars are all visible. When he first returned to school, he received a lot of support from his classmates and peers who were very nice to him and helped him out whenever he needed it. After a couple of years, he went to middle school and met a new group of peers who were not always supportive. Some of them were very mean and he was teased a lot about his scars. He withdrew and pretended that their teasing did not bother him, but, deep down, he was sad and embarrassed by his scars. He stopped hanging out with friends, dropped out of activities, and usually came home from school and locked himself in his bedroom and engaged in more solitary activities (reading, playing the guitar). His parents became worried and started to force him into activities. Against his wishes, they signed him up for a camp for kids with burn injuries. He went reluctantly, but while there, made some new friends, opened up, and realized that he was not alone. He also realized that everyone at his age gets teased about something, whether or not they have a burn scar. At camp, he learned some great, funny responses to deal with questions and teasing. His true personality started to shine. He was funny and could make anyone laugh. He was also really good at playing the guitar and could entertain his cabin mates. When he returned to school in the fall, he realized that if he could make people laugh they forgot about his scars. He became the “class clown” and, for the most part, teachers enjoyed having him in class and found him very engaging. He also joined a band and continued to pursue his talent as a guitar player. He again realized that he was receiving more attention for his talent than his scars and had a lot to talk about with friends that had nothing to do with his scars. He recently asked a girl to the prom and is excited that she said “yes.”
Body image is a complicated concept. A person’s body image can be affected by their gender, societal influences, age and time of life when they are burned, and whether or not their scars are visible or can be hidden. But all burn survivors who have adjusted well have had to learn how to interpret information from their social world in adaptive ways. So any intervention that focuses on teaching skills and garnering strong social support networks can make a positive difference on a person’s body image. It is important to surround yourself with positive people. Take an inventory of your life. Are there people in your life that give you energy and you walk away from your time with them feeling confident and positive? Are there people in your life that drain you of energy and confidence? When looking for a therapist or counselor, ask if he or she uses cognitive-behavioral techniques and has experience in teaching skills aimed at improving body image.
Take a look at the Phoenix Society’s new Online Learning Community, accessible through the Society’s website, http://www.phoenix-society.org. There you will find the following very helpful resources, developed by Barbara Kammerer-Quayle, that have been adapted and expanded to an online learning format:
• Beyond Surviving: Tools for Thriving After a Burn Injury, which includes information on supporting burn survivors with techniques to feel confident in social situations
• Creative Cosmetics, An Image Enhancement Program for Improving Body Image
For additional resources visit: https://www.phoenix-society.org/resources/resource-center/
1. Cash TF. The Body Image Workbook: An Eight-Step Program for Learning to Like Your Looks. Oakland, CA: New Harbinger Publications; 2008.
2. Lawrence JW, Fauerbach JA, Thombs BD. A test of the moderating role of importance of appearance in the relationship between perceived scar severity and bodyesteem among adult burn survivors. Body Image.2006;3:101-111.
3. Thombs BD, Notes LD, Lawrence JW, Magyar-Russell G, Bresnick MG, Fauerbach J. From survival to socialization: A longitudinal study of body image in survivors of severe burn injury. Journal of Psychosomatic Research. 2008;64:205-212.
4. Blakeney P, Thomas C, Holzer C 3rd, Rose M, Berniger F, Meyer WJ 3rd. Efficacy of a short-term, intensive social skill training program for burned adolescents. J Burn Care Rehabil. 2005;26:546-555.
5. Egan K, Harcourt D, Rumsey N. A qualitative study of the experiences of people who identify themselves as having adjusted positively to a visible difference. J Health Psychology. 2011;16: 739-749.
Shelley Wiechman, Ph.D., ABPP (Rp), is a clinical psychologist who is board certified in rehabilitation psychology. She has been the psychologist for the University of Washington Burn Center at Harborview for the past 12 years. She is part of the multidisciplinary burn team and provides individual therapy for burn survivors. She also is a coordinator for the Phoenix Society’s SOAR program. Her research has focused on studying both acute and chronic pain after burn injuries, and improving long term outcomes (including body image) of burn survivors. She has a theoretical focus on positive psychology, which examines the coping strategies and attributes of those who have adjusted positively to adverse situations.