The UNITS Study: Developing psychosocial support for appearance-altering injuries. Written by Dr Mary Keeling, on behalf of the UNITS team, Centre for Appearance Research, University of the West of England.
Body image is rarely discussed in relation to the psychological impact of battlefield injuries on military personnel and ex-service personnel; that was, at least, until recently. Since autumn 2018, researchers at the Centre for Appearance Research (CAR), University of the West of England, Bristol, have been studying the psychosocial impact of ‘appearance-altering’ injuries (e.g. those that result in scarring and/or limb-loss) among military personnel and ex-serving personnel injured during operational deployments or training for deployment.
The nature of military service means some personnel, especially those serving in combat roles during wartime, have sustained injuries resulting in a change to their body and their physical appearance (e.g. physical scarring, limb-loss). During the First World War (WWI) with the advent of new weapons but the absence of protective equipment, facial injuries were common. Due to negative perceptions and social stigma these injured war veterans were often shunned from society and are rarely represented in wartime literature (Gehrhardt, 2018). A move to airborne warfare during the Second World War (WWII) saw a high volume of severe burn injuries sustained to the hands and face of airmen (Pinney & Metcalfe, 2014). Much like the facially injured veterans of WWI, these injured WWII veterans were subject to negative reactions from the public (Pinney & Metcalfe, 2014).
In more recent conflicts in Northern Ireland, the Falklands, the Gulf War, and in Iraq (since 2003) and Afghanistan (since 2001), new approaches to war and weaponry such as landmines, Improvised Explosive Devices (IEDs), and Rocket Propelled Grenades (RPG), have meant a significant number of military personnel received injuries resulting in limb-loss, and scarring from burns, shrapnel, and gunshot wounds. Between April 2005 and March 2020, more than 10,000 UK service personnel and veterans were in receipt of Armed Forces Compensation due to ‘injury, wounds and scarring’ (Ministry of Defence, 2020b). During the period of recent operations in Iraq and Afghanistan, 336 UK service personnel received injuries that included traumatic or surgical amputation (Ministry of Defence, 2020a). Despite the high number of UK military personnel and veterans with appearance-altering injuries, and evidence from WWI and WWII veterans of the potential public stigma of looking different, little is known about the impact on body image and related psychosocial wellbeing.
The Centre for Appearance Research (CAR) is a centre of excellence for psychological and interdisciplinary, patient-centred research in appearance, disfigurement, body image and related studies. Previous research conducted by researchers at CAR shows that among the general population, people living with an appearance that is noticeably different from culturally sanctioned ideals (sometimes referred to as a visible difference) may experience negative reactions, social stigma, and social rejection (Clarke, Thompson, Jenkinson, Rumsey, & Newell, 2014; Rumsey & Harcourt, 2012). Fear of being negatively judged by others because of their appearance may lead some people with a visible difference to avoidance of social situations, isolation and engagement in activities to conceal scars or prosthetics (Holzer et al., 2014; Levine, Degutis, Pruzinsky, Shin, & Persing, 2005), which may lead to social anxiety (Clarke et al., 2014; Rumsey & Harcourt, 2012). In addition, evidence indicates that trauma symptoms related to the injury may be associated with appearance concerns (Shepherd, 2015).
While existing research highlights the psychosocial challenges of adjusting to a changed appearance following injuries in the general population, less is known about the psychosocial experiences of military personnel who sustained appearance-altering injuries during operational deployments and training.
In 2018, a team at CAR (led by Professor Diana Harcourt and Dr Heidi Williamson) were awarded funding by The Scar Free Foundation, as part of the Centre for Conflict Wound Research, to conduct the UNITS study; a three-year program of work aimed at investigating the psychosocial impact of appearance-altering injuries sustained during operational deployment or training on UK military personnel, ex-service personnel, and their families.
The Understanding Needs and Interventions for the Treatment of Scarring (UNITS) study specifically focuses on understanding how issues and concerns surrounding body image, self-esteem, identity and overall adjustment to an altered appearance, may affect psychological wellbeing. The overall objective of this project is to determine whether existing support interventions designed to provide appearance-related support for the general population would be suitable for supporting military personnel and veterans, or if new interventions tailored to the specific needs of military personnel and veterans with appearance-altering injuries are required. To address these aims and objectives, the UNITS study has comprised four studies, which the team have been conducting since September 2018.
Study 1, a gap analysis, consisted of a review of existing literature and stakeholder engagement to determine what is already known about the experiences, needs, and service provision for this specific group of serving/ex-service personnel. The gap analysis identified just four existing published peer reviewed papers that had specifically investigated the body image and appearance-related concerns of ex-service personnel injured during operational deployments. Three of these papers were from the US and one from Turkey. Within these papers is emerging evidence that much like the general population, military veterans with appearance-altering injuries may experience body image distress, that this is associated with symptoms of depression and lower quality of life, and that they can experience concerns with social relationships, social avoidance, and public stigma (Keeling, Williamson, Williams, Kiff, & Harcourt, 2020). Stakeholder engagement indicated that there are not currently any services or resources focused on providing specific appearance-related support for military personnel and ex-service personnel in the UK.
Study 2 was a qualitative study comprising one-to-one interviews with military personnel (n = 3) and ex-service personnel (n = 20) who had sustained appearance-altering injuries during deployments or training any time since 1969, and with family members of personnel and veterans with appearance-altering injuries (n = 5 mothers; n = 11 female partners). Overall, the results indicated that similar to the general population, military participants experienced challenges adjusting to a changed appearance which could include social stigma, body image concerns, the impact on significant others, and associated psychological distress, thus indicating a potential need for support. However, while challenges were reported, so were coping strategies that helped minimise some of the difficulties faced by personnel, veterans and their families. Consistent with the gap analysis, there was limited evidence of appearance-specific support being formally provided, though many of the military participants expressed a need. Obstacles acknowledging appearance concerns as well as barriers to seeking help and accessing care were identified, which may play a role in the limited availability of appearance-specific support and propensity to use it should it be available. While similarities in the experiences of serving military personnel and veterans and the general population with appearance-altering injuries were evident, nuances related to military culture and context in the challenges, protective experiences, coping approaches, and barriers and preferences for support were highlighted. These differences indicate that appearance and body image support developed for the general population may not be directly transferrable to supporting military populations experiencing appearance distress and body image concerns following appearance-altering injuries. The full paper of this study is currently being prepared for submission to a peer reviewed journal.
The third study was an online quantitative survey study that recruited UK military veterans (n = 121) who had sustained deployment and training related appearance-altering injuries and civilians who had sustained appearance-altering injuries (n = 197). The aim of this study was to determine in what ways the experiences and support needs of ex-service personnel who sustained appearance-altering injuries in a military context differ or are similar to the experiences and needs of individuals without a military background who have sustained similar injuries. The content of the survey was informed by the findings of Studies 1 and 2. The results are currently being finalised but preliminary results support the findings from study one and two, that there appears to be a need for support based on evidence that some veterans do report experiencing appearance and body image related challenges. While many similarities in the data of the veterans and civilians’ experiences are evident, there are also clear differences in terms of some the factors associated with reporting appearance and body image related difficulties. The full paper of this study is also currently being prepared for submission to a peer review journal.
The final phase, intervention development, is currently underway. The combined results from the previous three studies have shown a need for appearance-related support among military personnel and veterans with appearance-altering injuries. Existing interventions and support materials developed for the general population could potentially be effective, but they require adaptations and tailoring in content, delivery and implementation in order to meet the particular needs of former and current military personnel. The UNITS team are currently working with key stakeholders and veteran advisors with a lived experience of appearance-altering injuries to finalise the development of a proposed multi-level intervention.
From the outset, Public and Patient Involvement with veteran advisors with a lived experience of appearance-altering injuries has been a central part of the UNITS study, with regular advisory group meetings contributing to the design of the studies, the interpretation of the results, dissemination, and intervention development.
In addition to the main UNITS study, a project investigating the impact of appearance-altering deployment injuries on romantic relationships was conducted in 2019. This study was developed following evidence that emerged from the UNITS veteran advisors and the interviews with personnel, veterans, and partners (study two) indicating that romantic relationships were a specific area of concern related to appearance-altering injuries. This Combat Injuries, Body Image, and Relationships (CIBIR) study included interviews with injured veterans with appearance-altering deployment injuries and a stakeholder engagement workshop, the outcome of which has been published in an online report. The interviews indicated that military masculine body ideals were an important aspect of how veterans felt about their bodies and changed appearance following injuries, and the impact this had on relationships. Differences between those whose relationships were able to overcome the challenges following injury versus those whose relationships ended were identified, this included the role of dyadic coping (e.g. working together to manage challenges and stressors) when adjusting to life-changing injuries. The full paper of this research is currently under review with an academic journal. Both the stakeholder event and qualitative study provide evidence for a need for further research in this area to inform the development of tailored support.
Over the next three months, the UNITS team will be developing and testing the acceptability of a proposed multi-level intervention and applying for additional funding to test the effectiveness of the intervention, working with key stakeholders to ensure a feasible and accepted implementation of appearance-specific support for injured military personnel, veterans, and their families. Further research specifically focused on the romantic relationships of veterans with appearance-altering injuries and their partners is also planned. To keep up to date with the work of the UNITS team and CAR you can follow both on twitter and Instagram (@unitsstudy / @car_uwe)
Clarke, A., Thompson, A. R., Jenkinson, E., Rumsey, N., & Newell, R. (2014). CBT for Appearance Anxiety: Psychosocial Interventions for Anxiety due to Visible Difference. John Wiley & Sons.
Gehrhardt, M. (2018). Losing Face, Finding Love? The Fate of Facially Disfigured Soldiers in Narratives of the First World War. Litteraria Copernicana; No 3(27)/ (2018): Pierwsza Wojna i (Nie)Pokój. Retrieved from https://apcz.umk.pl/czasopisma/index.php/LC/article/view/LC.2018.032
Holzer, L. A., Sevelda, F., Fraberger, G., Bluder, O., Kickinger, W., & Holzer, G. (2014). Body Image and Self-Esteem in Lower-Limb Amputees. PLOS ONE, 9(3), e92943. Retrieved from https://doi.org/10.1371/journal.pone.0092943
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Ministry of Defence. (2020a). Afghanistan and Iraq amputation statistics: 1 April 2015 - 31 March 2020. Retrieved March 8, 2021, from UK Service Personnel amputations: Financial year 2019/2020 website: https://www.gov.uk/government/statistics/uk-service-personnel-amputations-financial-year-20192020/afghanistan-and-iraq-amputation-statistics-1-april-2015-to-31-march-2020#contents
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Pinney, J., & Metcalfe, A. D. (2014). Sir Archibald McIndoe and the Guinea Pig Club. PMFA News, 1, 21–24.
Rumsey, N., & Harcourt, D. (2012). Oxford handbook of the psychology of appearance. OUP Oxford.
Shepherd, L. A. (2015). A pilot study exploring the relationship between trauma symptoms and appearance concerns following burns. Burns, 41(2), 345–351.
 The Scar Free Foundation Centre for Conflict Wound Research is funded by the Chancellor using LIBOR funds.