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InPsych 2016 | Vol 38

Cover feature : Psychology innovation in the public sector

Beyond flames: Pioneering a psychology role in a State-wide burns service

Being burnt alive touches upon one of our most archetypal fears and the sheer horror of sustaining a burn injury is often followed by a lengthy, painful and challenging recovery process.

Although little has been published about psychology’s role in a burns service, its contribution is critical and unique (Bryant & Touyz, 1996).

The Victorian Adult Burns Service (VABS) is a multi-disciplinary State-wide specialist provider of burns care at the Alfred Hospital in Melbourne. Each year, VABS assists about 300 inpatients and 1000 outpatients. The majority of burn injuries are caused by flames (60%), followed by scald, contact, chemical and electrical burns. Although more than 70% of burns survivors are young males, burn injuries vary widely and affect all ages and social groups.

While there was limited general access to psychology previously, a small burns psychologist position was created following the Victorian Black Saturday bushfires. Over the past five years, this role has grown and increasingly evolved into a specialist service.

There is now substantial evidence that burn injuries are associated with a plethora of psychological sequelae, with up to 50% of burns patients reporting ongoing psychological problems and a strong need for psychological treatment and support. This is most evident in the persistent pain, scarring, body image dissatisfaction, fear of social stigmatisation and other interpersonal issues, difficulty returning to work and the reduced overall quality of life that characterises burns survivors. These impacts are typically compounded by an over-representation of posttraumatic stress, substance abuse and sleep disorders (Pfitzer et al., 2014, Wallis et al., 2006).

Additionally, a high proportion of burns patients (up to 60%) present with a pre-existing history of mental illness (Palmu, Suominen, Vuola, J, & Isometsä, 2010). Between two and six per cent of patients present with self-inflicted burns (Castana et al., 2013). Furthermore, a significant proportion of burn injuries are sustained as a result of low premorbid functioning, chaotic lifestyles and poor decision making. Both pre-existing mental health issues and poor coping constitute significant challenges to burns treatment. Nevertheless, the range and type of post-burn experiences are likely to also create multiple entwined challenges to psychological and physical recovery in well-adjusted individuals.

Psychology in Practice

Case vignette

David is a 33 year old male who sustained an electrical burn injury at work when he accidentally touched a power line with one of his tools. He experienced an electric shock and found himself on fire. Trapped on a travel tower, he could not escape the situation and suffered severe burns to his face, hands, arm, chest, flank and back. He was subjected to multiple surgeries, painful procedures and additional aversive experiences, such as delirium and anxiety provoking side effects of medication.

Despite staff repeatedly raising concerns about David’s mental health, it wasn't until about five months after his injury that David referred himself to psychology while suffering a panic attack.

David presented with PTSD characterised by frequent intrusive recollections of his electrical shock, high levels of physiological arousal, insomnia, hyper-vigilance, intense anxiety, and difficulty in using electrical devices. He also reported secondary stress as a result of injury related complications, adverse medical procedures and inconsistent communication of recovery risks. All of these experiences reinforced his perceived loss of control and a profound sense of helplessness at the time of his injury. In addition, David felt constantly reminded of his accident by his scars, ongoing experiences of pain, hospital visits, and the burns care itself. The psychological interventions involved regular secondary consultation with staff members and 12 sessions of trauma focused therapy. After a long recovery process, David currently reports feeling much improved.

The psychologist’s role within the burns unit

As can be seen by the case vignette above, David was not only impacted by the burn injury but his post-injury experiences, many of which were occurring in the hospital environment.

The psychologist’s role in this specialist burns unit included:

  • Helping to raise awareness and understanding amongst relevant hospital staff of the potential impact of the hospital and its procedures / processes on the burns patient from an individual case formulation perspective,
  • Increasing knowledge, e.g. of trauma reactions and trauma treatments, and effective communication of psychological models in general (as these can be quite different from approaches in an acute medical setting),
  • Helping staff members to tolerate a patient’s anxiety and stress reactions,
  • Keeping the door open and offering psychological support beyond the acute stage of burns treatment from the point of view that it may take some time for the patient to seek help (as in the case of David), and
  • Providing evidence-based psychological treatment as well as burns specific interventions (e.g. management of pain, itch, scarring and aversive procedures)

Conclusion

A psychologist’s role in a public health burns service is multi-faceted and reaches way beyond the dousing of the initial flames. While the role holds great potential for developing expertise in this context, it is fundamentally systemic and an integral part of a service that takes a leadership role in burns research, education and prevention.

The author can be contacted at b.pfitzer@alfred.org.au

References

  • Bryant, R. A., Touyz, S. W. (1996). The Role of the clinical psychologist on a burn unit in a general teaching hospital. Journal of Clinical Psychology in Medical Settings, 3(1), 41-55.
  • Castana, O., Kourakos, P., Moutafidis, M., Stampolidis, N. Triantafyllou, V., Pallantzas, Ath, Filippa, E., Alexandropoulos, C. (2013). Outcomes of patients who commit suicide by burning. Annals of Burns and Fire Disasters, vol XXVI, n. 1, 36-39.
  • Palmu, R., Suominen, K., Vuola, J., Isometsä, E. (2010). Mental disorders among acute burn patients.Burns, 36(7),1072-1079. doi: 10.1016/j.burns.2010.04.004.
  • Pfitzer, B., Katona, L. J., Lee, S. J., O’Donnell, M., Cleland, H., Wasiak, J., & Ellen, S. (2014). Three years after black Saturday: Long-term psychosocial adjustment of burns patients as a result of a major bushfire. Journal of Burn Care and Research, 37(3), e244-253.
  • Wallis, H., Renneberg, B., Ripper, S., Germann, G., Wind, G., & Jester, A. (2006). Emotional distress and psychosocial resources in patients recovering from severe burn injury. Journal of Burn Care and Research, 27(5), 734-741.

Recommendations for key reading:

  • Blakeney, P. E., Rosenberg, L., Rosenberg, M., Faber, A. W. (2008). Psychosocial care of persons with severe burns. Burns, 34(4), 433-40.
  • Bryant, R. A., Touyz, S. W. (1996). The role of the clinical psychologist on a burn unit in a general teaching hospital. Journal of Clinical Psychology in Medical Settings, 3(1), 41-55.
  • Fauerbach, J. A., McKibben, J., Bienvenu, O. J., Magyar-Russell, G., Smith, M. T., Holavanahalli, R., Patterson, D. R., Wiechman, S. A., Blakeney, P., Lezotte, D. (2007). Psychological distress following major burn injury. Psychosomatic Medicine, 69, 473-482.

Disclaimer: Published in InPsych on June 2016. The APS aims to ensure that information published in InPsych is current and accurate at the time of publication. Changes after publication may affect the accuracy of this information. Readers are responsible for ascertaining the currency and completeness of information they rely on, which is particularly important for government initiatives, legislation or best-practice principles which are open to amendment. The information provided in InPsych does not replace obtaining appropriate professional and/or legal advice.