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Question What are the processes of reimaging that people use as they adapt to an alteration in body appearance or function over a period of 18 months?
Community study in Omaha, Nebraska, USA.
32 adults were recruited through advertisements in newspapers and contact with health professionals. All had a substantial alteration in physical appearance or function (weight change >22.7 kg; loss or paralysis of body parts; ostomies; scarring from burns, surgery, or trauma; surgical reconstruction; or cardiac transplantation). 28 participants completed all aspects of the study. Age range was 19–85 years with a broad range of socioeconomic backgrounds. 89% were white and 75% were women.
Participants were interviewed 3, 6, 12, and 18 months after their alteration in body function or appearance. Interviews were done using a broad interview guide with relevant prompts. The interview focused on participants' perceptions of themselves and their experiences during the study, and their thoughts, feelings, adaptive strategies, and perceptions of the responses of others. Interviews were taped, transcribed, and verified by members of the study team and a grounded theory was developed.
The process of reimaging was complex, highly subjective, unique to each person, forward moving, and occurred simultaneously with grief for the loss of the former appearance or function. The process involved 3 phases: body image disruption, wishing for restoration, and reimaging the self.
4 responses characterised the body image disruption phase: shock and painful awareness; attempts to minimise awareness of the alteration by denial, avoidance, or concealment; painful awareness experienced as depression, anger, and self pity; and grieving the loss.
During the wishing for restoration phase, participants struggled between hopefulness, which prompted them to mobilise personal resources and maximise efforts to improve healing, appearance, or functioning; and intense emotional pain when they faced the reality that restorative efforts were not yielding desired results.
In the reimaging the self phase, participants weighed the value of continued efforts at restoration against the cost in energy, time, and effort. They began to replace idealised expectations with more realistic views of the self and self capabilities. The focus shifted from restoring the body to reimaging the self.
The 3 phases were characterised by 3 ongoing processes: assimilation, the cognitive and emotional process of taking in the change; accommodation, learning ways to live with the change; and interpretation, perceiving the meaning of the change for the self and others. Factors which influenced progression through the phases included the extent to which individuals valued appearance compared with function; self esteem; perceived attitudes of others; and access to and acceptability of medical technology.
Through a reimaging process, most individuals who had a recent alteration in body appearance or function achieved positive outcomes on reconciliation, in which they gradually accepted their new body image, and normalisation, in which they adapted personal goals and lifestyles and learnt to live with the limitations of their changed bodies.
The psychological consequences of altered body states have long been recognised.1 This study by Norris et al identified 3 phases that study participants experienced when adjusting to their body image disruption and 3 ongoing processes that occurred concurrently and were woven through each phase. Each process reflected cognitive, emotional, and behavioural responses to body alterations. The strength of this study is the choice of grounded theory which shows the participants' responses to be complex, subjective, and unique to the individual at the time. The use of 4 interviews over 18 months adds depth to their findings that restoration of self esteem takes a long period of adjustment; most participants took up to a year to adapt to their body change.
The limitations of the study include the use of volunteers with a wide age range and a predominance of women, who typically find expressing their feelings more acceptable.2 The authors do not suggest generalisability but the emergence of a process by which individuals come to establish their self esteem through reimaging. The extent to which an individual valued appearance compared with function was seen as influencing progression through each phase. Younger participants were more likely to value appearance whereas older participants were more likely to value function. The influence of sex and cultural factors, however, should also be explored.
The study supports the importance of nursing interventions in assisting individuals to make sense of their altered body and its possible changed functions. Anticipatory guidance and the facilitation of problem solving skills are nursing roles3 that may help patients and families acknowledge the body alteration and reconcile the effects of the body change on their lives.
This new theory provides nurses with an increased awareness of the process of reimaging which will assist in their assessment and understanding of individual patient responses to body alteration.
Source of funding: National Center for Nursing Research.
For correspondence: Dr J Norris, Professor and Associate Dean, Research and Evaluation, Creighton University, School of Nursing, 2500 California Plaza, Omaha, NE 68178, USA. Fax +1 402 280 2045.