physiotherapy, D ecem ber 1983, vol 39, no 4 101 PSYCHOLOGICAL ADJUSTMENT TO INJURY AND ACUTE TRAUMA H EIN H E L G O SC H O M E R B.A. (H ons) M.A. (Psychology)* SUMMARY Man lives in an ever-changing environment. To maintain a relative state of psychological homeostasis essential for optimal functioning man has to learn how to adapt effectively to the manifold demands made on him by the complex social system in which he lives in. For any adaptive behaviour to be maximally successful a person has to possess clear insights into his capacities, values and self-concept. A simple personality model is outlined to elucidate psychological adaptive behaviour processes and to illustrate what impact injury and acute trauma can have on a person’s functioning. In order to make treatment more incisive physiotherapists have to be aware of the psychological adjustments required to cope with injury and acute trauma. Implications are discussed. j OPSOMMING Die mens leef in ’n altyd veranderende ! omgewing. Om 'n toestand van relatiewe I sielkundige homeostase, essensieel viroptimale j funksionering, te handhaaf, moet die mens leer om effektief aan te pas by die menigvuldige eise j j wat van hom geverg word in die ingewikkelde j sosiale stelsel waarin hy leef. Vir enige aanpassingsgedrag om maksimaal suksesvol te wees, moet 'n persoon duidelike insig in .sy I bekwaamhede, waardes en selfbegrip h§. 'n Eenvoudigepersoonlikheidsmodelwordgeskets | ' om sielkundige aanpassingsgedragsprossesse te verduidelik en om te illustreer watter aanslag besering en akute trauma op 'n persoon se ! funksionering kan, he. Om behandeling meer kragtig te maak, moet fisioterapeute meer bewus wees van die sielkundige aanpassings wat nodig ! is om opgewasse te wees teen besering en akute i trauma. Implikasies word bespreeek. The world a ro u n d us changes all the time. This “ o u te r” world consists of both natural factors, like tem perature and sunlight, and social factors like work dem and and p eergroup composition. H um ans have had to learn to adapt to the changing dem ands o f such a world. Most o f us have learnt to adapt quite effectively. We are the fo rtunate ones with the capacity to make adjustm ents to keep our body and mind working in a balanced way. We m aintain a relative physiological and psychological state o f hom eostasis. We have learnt to cope; we deal with events and their effects. Put in another way, we take actions to prom ote our effectiveness as it is associated with psychological achievements — we are nentally healthy. The adjustm ents dem anded from us to cope with life’s activities som etimes mean that we have to behave in a way to change the environm ent, the outer w orld, to a more compatible one with our goals and aspirations. Most o f the time though, adjustm ents mean change in the inner world in us. The environm ent m aintains its status quo and we adjust to be able to deal with the status quo m ore effectively. We adapt. A daptation may take several form s. Some are more psychologically economical than others. If, for instance, you believe yourself to be at the mercy o f taxing events or aggravating dem ands, you will most probably cope in a reactive way; fight or flight. This coping behaviour is often accom panied by frustrations, self-blame, chronic fatigue, tension o r acts o f self-indulgence, like overeating, excessive smoking o r drug and alcohol abuse. tT a l k delivered at O rthopaedics T raum a Symposium, Physiotherapy Silver Jubilee Week, U CT, 8 April 1983. *Lecturer in the D ept, o f Psychology, U C T and at Medical School in the B.Sc. (Med) (H ons) Sport Science course. Received 20 May 1983. You are far better off when you perceive yourself to be in control o f your own behaviour an d p attern s o f interaction. Active ways of coping denote th a t you are deciding what needs to be changed and how you will im plem ent that change. Problem solving, exercise, relaxation therapy, healthy eating habits and work are all active ways o f coping. Coping takes place unconsciously and consciously. We do no t have to tell ourselves when it gets to 28° outside to sweat. O ur autonom ic nervous system takes care o f the appropriate response here. N either do we really consciously register varied ad ap ta tio n s th at our mind and body go through to deal with the stresses and strains o f daily living. It is when our mind must confront com plicated critical problem s with no simple single obvious solution th a t conscious coping has to take place. F o r this adaptive behaviour to be optim ally successful, we have to possess personal insights into our capacities, values and self-concept. The more accurate our insights, the more precise our assessm ent o f our capacities, the better our self- concept. We are more likely to m ake effective adjustm ents to life’s situations the more defined our self-concept is. A clear self-concept is crucial in determ ining o u r im mediate behaviour and for fu rth er personality developm ent. A clear self-concept includes a definite perception o f one’s basic roles, dispositions and body image. A sense of self emerges gradually th roughout childhood. It forms the fram ew ork into which all past, present and future experiences are integrated. It makes up a m ajor p ari o f the individual’s personality. Personality may be viewed as the sum total o f a perso n ’s characteristics th at indicates his uniqueness and (at the same time) his am algam ation as a social being. A p erso n ’s distinguishing characteristics are inextricably tied up with the society he lives in. This relationship is a direct consequence of the fact that an individual’s personality R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 102 Fisioterapie, Desember 1983, deel 39 , no 4 develops as a function o f psycho-social adjustm ents. In this process the life-long necessity to balance individual needs and social requirem ents is cardinal. It will be advantageous at this stage to outline a modified form of H o llan d er’s (1967) personality m odel. Personality can be seen to m anifest itself at four distinct levels: 1. The core-concept (a prim al perception o f the person’s life force) 2. The psychological core constructs (values, attitudes, beliefs, interests and motives) 3. T he typical responses (c h a ra c te ristic m an n er in responding to frustration, hum our and anxieties) and 4. The role-related behaviours (behaviour in accordance to perceived social position, status and norms). Schematically this modified model can be represented as four concentric circles inside a social environm ent (Figure 1). The four levels are closely interrelated. Level one and two form what has previously been referred to as self-concept. These levels also contain less conscious effects o f past experiences. T here is an internal and external dim ension to this personality model. W hereas the core-concept is the extrem e internal, the role related behaviours are at the extreme external end o f the continuum . Internal levels are relatively stable and coherent. External levels are subject to change due to their exposure to the social environm ent aro u n d us. SOCIAL ENVIRONMENT Fig. I. SC H EM A TIC REPRESENTATION O F PERSONALITY M O D EL This implies th at there are consistent as well as dynamic com ponents to a personality. The dynam ic com ponent allows for changes due to learning (adaptive behaviour) and the consistent com ponents provide the needed structure (reference point for hom eostatic process) for an individual to function in an ever changing world. Influences from the environm ent act first o f all on the external levels four and three, and depending on how much adjustm ent is required from the individual to deal effectively with the situation, may penetrate to the internal levels. The perm eability o f the levels with respect to the influences of the environm ent decreases rapidly as we ap proach the core-concept. W hen we co m e to e n c o u n te r som eone new, we are usually aw are o f the specific social environm ent in which the meeting takes place. Specific social environm ents m ake us behave d re ss and perceive ev en ts and people around us in specific lights. We d o n ’t behave, dress o r look at people at the State O pera as we do at home. W ithin reasonable limits we tend to conform to the acceptable social norm . We yield to the perceived situational dem and. We register people around us according to the role they seem to play in the given situation. Even when encountering a person in only one given situation, fulfilling a given role, we start generalising excessively ab o u t that p erso n ’s typical personality from just that limited basis. We might have the opportunity to get to know the person better, to talk to him or to see him in more than one situation. We might discover th at our initial ind u ctio n s/d ed u ctio n s were only partly right. We might have been wrong. But only after extensive exposure and interaction with a person do we come to know his psychological core constructs and finally his core-concept. A s the im pact o f influences from the social environment decreases, as we go from the o u ter levels to the inner levels of the person, so does the ability to recognise the inner levels for an o th er person. Back to the processes within the person. Events that dem and adjustm ent are interpreted as stress. Usually a person can cope with these dem ands by making some adjustm ents at the external levels, namely the role- related behaviours or the typical responses. O ur system usually survives the occasional attack on o u r internal levels, viz. o u r core constructs and our core-concept. Here we are talking ab o u t the m entally healthy person. But stress can accum ulate and persist. Highly stressful influences may penetrate right down into the centre, to the core-concept. A ccum ulation and persistence o f highly stressful influences may cause the system to go off balance, i.e. to lose its hom eostatic state. W hen you feel more stress than you can cope with, your m ental health is in danger. The system will dysfunction. Physiological injury and acute traum a are stressful events. N ursing a bruised knee after a social soccer game at the weekend may be ignored. It is irritating, but not interpreted as stress. G oing to work with your leg in plaster may be seen as light stress by a student, not so light by a m anager who has to fly to Europe to clinch an o th er m illion-dollar deal. Playing the role o f injured is usually short-lived ancjj peripheral. The individual does not have to make adjustm ents to his typical responses o r core. One usually has the chance to play the role o f the injured several times during childhood. It is not new and one has some idea in advance ab o u t its requirem ents. Yet there will be the occasional reactive response. On the o ther hand, losing a leg in a car after too much m erry-m aking at the office party is severe stress: the consequences chronic and the implications never thought o f by the m ajority o f people. Such an event has a pervasive effect upon the whole personality o f the individual because o f the totality and persistence o f the psychological as well as physiological adjustm ents the person has to live through. Such a severely stressful event penetrates right dow n to the core-concept. The person has to adjust his outlook on life and living, on his role as a husband/w ife, as a p ro v id er/su p p o rter. His feelings and beliefs will undergo radical changes. C an the person m aintain the role he once played — father, m other, postman, m anager o r nurse? The person who has to live through a trau m a sim ilar to the one outlined above is continually rem inded o f his new position by other individuals’ actions tow ards him , which in turn affect the core o f his personality, R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) physiotherapy, D ecem ber 1983, vo! 39, no 4 103 most notably his self-image, b u t also his attitudes, values and beliefs. , . . G e n e r a l l y speaking, the m ore severe the i n j u r y and the re lasting the consequences from acute traum a, the more stress is felt — and the more psychological adjustm ents have to be made — and the more likely th at the person dysfunctions. Signs o f dysfunction are quite distinct. At the first level coping abilities are clearly reduced. The person talks and laughs too much, loses his tem per too often, feels restless and worries. Loss o f appetite and sleeplessness occur. With quite a bit o f drinking, sm oking and sleeping pills, life can go on. The second level is m arked by a strong sense of anxiety, obsessive-compulsive behaviour, phobias and depression. The person is neurotic. Perceptions o f the real- world remain intact, though, fo r most o f the time. Again, life can go on. On the third level o f dysfunction a person starts to act aggressions out openly. The person is no longer fully in touch with reality. An attem pt is made to seem norm al. This is dropped at the fourth level. A ctions are no longer based on real-world dem ands and needs, behaviour becomes ^unpredictable, aggressive and regressive impulses can no lo n g e r be controlled. This is psychosis — insanity. The individual w ithdraws from the family, friends and work into a fantasy world. W hat is left at the last level, level five, is a marked loss in the will to live and a resolve to end life is made. Suicide. What does all this mean to the Physiotherapist? It is most im portant that the p atien t’s m ental health is m onitored during treatm ent. The more severe the injury o r traum a the EXTENSION O F T H E P R O FE SS IO N The post o f C ontrol Physiotherapist has been created by the Transvaal D epartm ent o f H ospital Services a t Pretoria. This Is the first purely adm inistrative post in the hospital services in South Africa. It is hoped that this will be the start o f greater control o f the profession by physiotherapists themselves. Miss Elsa Smit has been appointed to the position. We wish her luck with her new post and hope th at this is the eginning o f greater things and that posts will be created by e other provinces so that the profession can advance and be recognized in its own right. more you will have to be on the look-out; deteriorating m ental health will prolong o r even prevent physiological recovery. The physiotherapist has to take the p atien t’s fears and anxieties into account. The physiotherapist will benefit and derive more satisfaction from h is/h er work the more h e/sh e is aw are o f the psychological adjustm ent the patient has to process. Be sensitive and assertive at the same time. Severe signs o f dysfunction should be a w arning signal. Severe physical im pairm ent and subsequent adjustm ent are crisis periods — the physiotherapist can provide support and em pathy w ithout attem pting to reconstruct a p a tie n t’s personality. Effective problem solving in the more severe cases means seeking ou t professional help. A productive life is determ ined by the quality o f our m ental health. M ental health is a relative state of functioning. It is the quality o f a person’s usual or integrated intrapersonal and interpersonal relationships. D eteriorating m ental health means p o o r relationships with friends, family and colleagues, as well as the self. These relationships determ ine to w hat extent life is w orthwhile, pleasant, happy and productive. You have a role to play. You can enhance your p atien t’s relationships. References H ollander, EP. Principles and methods o f social psychology New York: O xford University Press, (1967). H ollander, EP. & H unt, R. Current perspectives in social psychology. New York: Oxford University Press, (1967). PORPHYRIA — A DANGEROUS G EN ETIC PU ZZLE A pam phlet has recently been released on this subject by the Public Relations D epartm ent, S.A. M edical Research C ouncil, P.O. Box 70, Tygerberg 7505. This is a fairly widespread genetic disease and the authorities are anxious to trace as m any sufferers o f this condition as possible. Anyone who suspects he may have porphyria should contact their nearest regional office o f the D epartm ent of H ealth an d Welfare fo r tests. Pam phlets are also available from the M RC Porphyria Research U nit at the University o f Cape Town. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )