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The fear-avoidance model: helping patients to cope with disfigurement

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VOL: 98, ISSUE: 16, PAGE NO: 38

Rob Newell, PhD, BSc, RGN, RMN, RNT, CertBehavPsych, is professor of nursing research, School of Health Studies, University of Bradford

Disfigurement causes considerable distress to those experiencing it, so any means of alleviating this suffering is worth pursuing. The fear-avoidance model offers nurses a practical method of intervention that can be incorporated into their daily work. The model is valuable because it is backed by a growing evidence base that confirms the effectiveness of cognitive behaviour therapy (Fonagy and Roth, 1996). The treatments that arise from the model do not rely on specialist therapists and can be delivered by non-experts and as a means of self-help. Furthermore, the model can be applied in a wide variety of situations.

Disfigurement causes considerable distress to those experiencing it, so any means of alleviating this suffering is worth pursuing. The fear-avoidance model offers nurses a practical method of intervention that can be incorporated into their daily work. The model is valuable because it is backed by a growing evidence base that confirms the effectiveness of cognitive behaviour therapy (Fonagy and Roth, 1996). The treatments that arise from the model do not rely on specialist therapists and can be delivered by non-experts and as a means of self-help. Furthermore, the model can be applied in a wide variety of situations.

The fear-avoidance model
I have reviewed the evidence for the fear-avoidance model of psychosocial distress following disfigurement in Body Image and Disfigurement Care (Newell, 2001). While more research is needed, it seems that the behaviour of disfigured people who experience difficulties with body image closely resembles that of socially phobic patients. In particular, they have a tendency to be anxious in social situations and choose to avoid them (Newell and Marks, 2000). This is an important observation, since a readily available set of treatment interventions exists to address problems of fear and avoidance, in the form of cognitive behaviour therapy.

A comparatively simple intervention is exposure therapy. This is where the patient gradually re-enters feared situations and remains until their anxiety fades. It has been used not only by psychologists and specialist nurse behavioural therapists, but also by generalist nurses, self-help groups and through long-distant methods such as self-help books and computer programmes (Marks, 2000).

Given the extremely resilient therapeutic track record of cognitive behaviour therapy in general, and exposure therapy in particular, the possibility of effective help for disfigured patients remains strong.

The nursing role
At the most general level, action to address problems arising from disfigurement can occur at a public health level, both in terms of raising public awareness of the issues surrounding disfigurement, and by introducing and supporting preventive initiatives.

More specifically, general advice can be given to those who are likely to face issues of body image disturbance.

Finally, disfigured patients can be offered specific interventions or referred to the appropriate experts. Nurses can be involved at all these levels.

Providing information
Information given to patients before surgery is often a potent intervention, but what is the best way to do this? Many centres that offer plastic surgery, head and neck surgery or care for burns patients have formed links with Changing Faces, a charity that publishes a range of self-help material. Likewise, nurses caring for patients with breast cancer often have access to large amounts of information and self-help literature.

However, specialties where altered body image has a high profile are merely the tip of the iceberg in terms of the total number of body image issues that affect patients. Any kind of mutilating surgery is likely to alter a patient's body image, as are complaints such as skin diseases and arthritis. Patients in these categories need to be given clear, accessible information.

Nurses are in a key position to deliver such information. As well as ensuring wider public access to appropriate literature on disfigurement and its psychological consequences, nurses can disseminate knowledge by holding seminars for professional colleagues. Organisations such as Changing Faces (many of whose interventions have a marked cognitive behavioural component) can offer help and advice. When designing leaflets and information aids to give to patients before surgery be sure to emphasise how confronting feared situations can contribute to psychological well-being. There are several good self-help books based on the cognitive behavioural approach, most notably Living with Fear by Isaac Marks (1980) and No Panic by Kevin Gournay (1996).

General advice and preparation for surgery
The cognitive behavioural approach can be used when advising a disfigured person, or preparing a patient for surgery that may be disfiguring. The role of avoidance in creating and maintaining anxiety should be described, with special emphasis on three issues:

- First, explain to the patient that it is natural to want to avoid situations that make us feel uncomfortable or anxious, or where we think that others might be looking at us because of our appearance, the way we move or talk, and so on;

- Second, describe how the anxiety passes, as long as we do not avoid the situations that cause it or dwell on frightening thoughts of what others might be thinking about us;

- Third, tell the patient that people who consciously make the effort to confront the situations they fear seem to do better in coping with their disfigurement than those who avoid those situations (Newell, 2001).

Time is often tight on surgical wards, but just a few minutes spent conveying these principles can be tremendously helpful in preparing a patient for some of the feelings they might experience when facing disfigurement. A discussion of how the issues of avoidance and anxiety might specifically affect the individual, and what he or she might do to ensure they do not slip into a pattern of avoidance, would be even more helpful (Box 1).

In the case of patients being prepared for surgery, nurses could also negotiate with the patient how, when and for how long they will first examine the affected area. This could be done as part of the general explanation of what will happen following the operation. It may also be useful to offer appropriate literature along cognitive behavioural lines, including the self-help books mentioned earlier.

Specialist intervention
Inevitably, there will be a small number of patients who will need further, more intensive intervention because of the extent or duration of their difficulties. This is unlikely to be feasible for most nurses, not because cognitive behavioural interventions are particularly complex, but because advising the patient effectively can be time-consuming. Given the time constraints of most busy wards and clinics, this level of input is often not an option as part of our everyday clinical practice. However, appropriate early referral to a self-help group, psychologist or nurse behavioural therapist will often be welcomed and even patients whose difficulties are quite enduring may find the simple advice mentioned earlier helpful.

If you are considering referring a patient for specialist intervention, the following key questions may help in guiding the patient to decide whether or not to seek referral:

- Does the patient avoid situations because of anxiety about how they look, for example, social situations, public situations, particular activities, types of clothing?

- Does the patient have physical sensations of anxiety (racing heart, tremor or rapid breathing) in feared situations or when thinking about how their body looks?

- Does the patient have repetitive negative thoughts about how their body appears to themselves and others?

- How often do the above behaviours, sensations and thoughts occur?

- For how long have they occurred?

- How much do they handicap the patient's life: are there things the patient cannot do but would like to, and/or is the patient distressed?

The responses to the above questions should give the nurse in even the most hard-pressed of clinics or wards a good idea of the degree to which the patient is experiencing problems. The nurse can then decide whether the patient would benefit from a cognitive behavioural approach and referral to a specialist.

Conclusion
Body image as an area of concern in nursing has a high profile. Many courses, both before and after registration, now contain whole modules devoted to its study. In spite of this, as yet we have no clear idea about what material should be covered in such training to best equip nurses to deal with the practical therapeutic issues concerning body image.

The fear-avoidance model offers much in practical terms, since its associated treatment approach (cognitive behaviour therapy) is well-validated and widely applicable. Perhaps most importantly, the model emphasises the normality of psychological distress following disfigurement. It recognises that the threat to body image is present for everyone, nurses as well as patients. In consequence, awareness of our own vulnerability to issues of body image is an important prerequisite for being able to work with disfigured people.

'Living with disfigurement', the first of this two-part series, was published last week (April 9).

- For further information contact Changing Faces, 1-2 Junction Mews, London W2 1PN. Tel: 020 7706 4232; e-mail: info@changingfaces.co.uk

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