Social Psychology and the Face

The neurological basis of face perception and recognition is a fascinating area of research whose complexity highlights the importance of the face in the social context. Each of us is unique, although the transfer of facial characteristics to our offspring ensures the family and racial characteristics that underpin the cohesiveness of social groups. The face is an important determinant of our internalized sense of who we are. Just as we are instantly recognized by friends and family, we have an internalized body image that is highly resistant to change. Accepting a change in appearance is not the same thing as habituating to it, and patients often describe shock at catching sight of themselves in a shop window or in a photograph many years after the initial trauma. Adapting to any disfiguring condition, even when the change is minor, can be a very long process, which often is described as one of bereavement with a clear focus on grieving for lost looks.

Physical attractiveness is judged to a significant extent on facial characteristics such as skin texture, size and shape of eyes, and facial symmetry, with vast amounts spent each year on cosmetics that enhance these features. Disfiguring conditions have a huge personal impact in terms of perceived attractiveness, with interesting sex differences. Whereas facial scarring, for example, can exaggerate the sexual stereotype for men (e.g., more macho, aggressive, willing to take risks), for a woman, the stereotype is weakened, and she may appear less feminine and less attractive. This does not mean that disfigurement is less of an issue for men. The largest study of concern about appearance dispelled several myths about which patients are disturbed about appearance. In a sample of 1265 participants recruited from community and clinical settings, gender and age were not powerful predictors of distress, and there was a large amount of variation in the responses. Young men in particular may struggle and may behave in a hostile or aggressive way in social encounters as a result of negative responses from their peer group.

Barriers to sexual activity, such as altered facial sensation and the ability to kiss a partner, can cause enormous distress. Withdrawal from intimacy is a major problem for people with anxiety about their bodily appearance, and gradual avoidance of social activity occurs as the prospect of an intimate relationship is perceived as more remote.

The head, neck, and face provide us with the basis of communication. Laryngectomy and removal of the vocal cords permanently abolishes the ability to speak, with future “speech” achieved through a variety of alternative mechanical means. Cancer and the treatment for invasive disease or significant trauma can have a major impact on appearance, speech, swallowing, and shoulder function after neck dissection.

In addition to providing the neural and muscular basis of speech production, nonverbal signaling, such as eye contact, facial gesture, and blushing, depend on facial structure. These nonverbal behaviors support verbal exchanges, helping to pace and structure conversation and allowing us to express emotion and to indicate personal attitudes. Interruption of these mechanisms, often because patients try to avoid eye contact or smiling when there is a facial palsy, can add to the awkwardness of social encounters. Problems may also occur with swallowing. Ingestion of food, chewing, swallowing, and salivation are frequently affected after maxillofacial trauma, with profound implications for ensuring optimal nutrition and impacting dramatically on the social aspects of eating. Patients can be embarrassed about the difficulties of drooling, spilling food, or using special utensils or straws. Interruption of what is an important social activity may be expected to impact self-esteem. The inability to express personality through speech and social exclusion from activities such as having a drink or a meal with friends can affect self-image as much as an objective change in physical appearance. For patients who experience major surgery or accidental trauma to the face, the psychological impact of facial dysfunction may affect any or all of these areas.

Psychosocial Impact of Facial Disfigurement

Research studies are remarkably consistent in describing the problems that people with a disfigurement encounter. The predominant difficulties lie within the area of social interaction, with people being subjected to unwanted intrusions such as staring or comments. Macgregor’s classic study has not been bettered in terms of summarizing patients’ self-reported data. “In their attempts to go about their daily lives, people are subjected to visual and verbal assaults and a level of familiarity from strangers, including naked stares, startled reactions, double takes, whispering, remarks, furtive looks, curiosity, personal questions, advice, manifestations of pity or aversion, laughter, ridicule, and outright avoidance”.

First impressions are important in our image-conscious society, and adapting to disfigurement, even when minor, can be profoundly difficult. First encounters are particularly stressful, staring and intrusions are common, and social avoidance can rapidly develop as the simplest means of survival. As in other anxiety disorders, avoidance of the feared situation provides only temporary relief and removes the opportunity to learn by experience or build up a repertoire of coping strategies. Confronting social situations becomes increasingly difficult, and one of the components of psychological intervention is graded exposure to eliminate the anxiety response, reframe beliefs about the social environment, and develop positive coping strategies.

Not surprisingly, this group of people may have very low self-esteem and expectations about life chances. For example, many believe that they need to make compromises in terms of relationships (e.g., take what you can get) or think that they have diminished employment prospects. For children, all the problems of chronic illness, such as repeated hospitalizations, time off from school, and disruption of peer relationships and education, may be compounded by bullying at school and the lowered expectations of teachers and parents. Studies have demonstrated that even in normal classroom situations, sensitivity about appearance can impact behavior, with children unwilling to put up their hands to answer questions if they feel uncomfortable about what they look like.

Although the perceived hostility from other people has led to the description of facial disfigurement as the last bastion of discrimination in the United Kingdom, the situation is not completely one sided. The increased uncertainty, embarrassment, and self-consciousness that people experience when their appearance changes can often prompt changes in behavior that elicit a negative response from other people. Altered posture, avoidance of eye contact, hiding the face with the hand and hair, and overzealous use of cosmetic camouflage and clothing, especially hats, can elicit the very responses that the individual is trying to avoid.

It is easy to see how repeated exposure to negative events can lead to a behavioral change, particularly increasing avoidance of social situations, but the role of individual beliefs is also important. People behave differently in response to someone who is visibly different, and the expectation of a negative response is enough for the visibly different person to perceive and report events differently. Social psychologists have examined the impact of these beliefs about disfigurement. Actors were made up to look disfigured, but under the guise of having fixative added and unknown to them, the experimental group had that make-up removed before being exposed to the experimental situation. Subjects who believed themselves to be scarred reported stronger reactions from other people than the control group. This finding might have resulted from heightened sensitivity leading to the misinterpretation of events or to subtle alterations in the subject’s behavior, such as poor posture or eye contact, producing genuinely stronger reactions from the onlooker. However, sensitivity to the disfigurement and the tendency to attribute all negative experiences to facial appearance, even when unrelated, is a commonly reported problem and a possible explanation for the significance to the individual of apparently only minor disfigurement.

From the clinical perspective, these findings are important because the modification of inappropriate cognitions (i.e., beliefs) and the introduction of more appropriate cognitions and behavior form the basis of effective psychological intervention in this group. Social anxiety and avoidance can be effectively targeted using this well-established approach.

Relatively few studies have attempted to look beyond the description of psychosocial problems in the target population to the factors associated with good adjustment in the long term. There is a strong, erroneous presumption that psychological distress is proportionate to the severity of the disfigurement, a finding that has no basis in research findings but nevertheless drives referral patterns and services. It is instead the individual factors driven by cognitive processes that predict long-term adjustment. Macgregor illustrated this idea many years ago, identifying coping style as important. Those who cope well and report fewer problems tend to use the positive coping strategies summarized in Box 29-1 , all of which allow them to manage social situations. Negative coping strategies are those that facilitate the avoidance response.

Findings of the Appearance Research Collaboration further clarified the factors and processes that are associated with positive adjustment in the long term. They demonstrated that biomedical factors such as the cause, timeline, and severity of the condition do not predict adjustment, although visibility to others is important. The psychological characteristics of those who were positively adjusted included higher levels of optimism, greater feelings of social acceptance and satisfaction with social support, a lack of concern about negative evaluations by others, and a self-system with lower levels of salience and valance afforded to appearance-related information.

This research is important to those working in the maxillofacial trauma field, primarily because it identifies individual behavior, rather than the condition or appearance, as a determinant of successful long-term outcomes. This is encouraging because behavior is learned and can be modified. These ideas provide the basis for psychological management of patients with altered appearance, who do not have to rely solely on biomedical solutions aimed at restoring appearance.

Psychosocial Impact of Facial Disfigurement

Research studies are remarkably consistent in describing the problems that people with a disfigurement encounter. The predominant difficulties lie within the area of social interaction, with people being subjected to unwanted intrusions such as staring or comments. Macgregor’s classic study has not been bettered in terms of summarizing patients’ self-reported data. “In their attempts to go about their daily lives, people are subjected to visual and verbal assaults and a level of familiarity from strangers, including naked stares, startled reactions, double takes, whispering, remarks, furtive looks, curiosity, personal questions, advice, manifestations of pity or aversion, laughter, ridicule, and outright avoidance”.

First impressions are important in our image-conscious society, and adapting to disfigurement, even when minor, can be profoundly difficult. First encounters are particularly stressful, staring and intrusions are common, and social avoidance can rapidly develop as the simplest means of survival. As in other anxiety disorders, avoidance of the feared situation provides only temporary relief and removes the opportunity to learn by experience or build up a repertoire of coping strategies. Confronting social situations becomes increasingly difficult, and one of the components of psychological intervention is graded exposure to eliminate the anxiety response, reframe beliefs about the social environment, and develop positive coping strategies.

Not surprisingly, this group of people may have very low self-esteem and expectations about life chances. For example, many believe that they need to make compromises in terms of relationships (e.g., take what you can get) or think that they have diminished employment prospects. For children, all the problems of chronic illness, such as repeated hospitalizations, time off from school, and disruption of peer relationships and education, may be compounded by bullying at school and the lowered expectations of teachers and parents. Studies have demonstrated that even in normal classroom situations, sensitivity about appearance can impact behavior, with children unwilling to put up their hands to answer questions if they feel uncomfortable about what they look like.

Although the perceived hostility from other people has led to the description of facial disfigurement as the last bastion of discrimination in the United Kingdom, the situation is not completely one sided. The increased uncertainty, embarrassment, and self-consciousness that people experience when their appearance changes can often prompt changes in behavior that elicit a negative response from other people. Altered posture, avoidance of eye contact, hiding the face with the hand and hair, and overzealous use of cosmetic camouflage and clothing, especially hats, can elicit the very responses that the individual is trying to avoid.

It is easy to see how repeated exposure to negative events can lead to a behavioral change, particularly increasing avoidance of social situations, but the role of individual beliefs is also important. People behave differently in response to someone who is visibly different, and the expectation of a negative response is enough for the visibly different person to perceive and report events differently. Social psychologists have examined the impact of these beliefs about disfigurement. Actors were made up to look disfigured, but under the guise of having fixative added and unknown to them, the experimental group had that make-up removed before being exposed to the experimental situation. Subjects who believed themselves to be scarred reported stronger reactions from other people than the control group. This finding might have resulted from heightened sensitivity leading to the misinterpretation of events or to subtle alterations in the subject’s behavior, such as poor posture or eye contact, producing genuinely stronger reactions from the onlooker. However, sensitivity to the disfigurement and the tendency to attribute all negative experiences to facial appearance, even when unrelated, is a commonly reported problem and a possible explanation for the significance to the individual of apparently only minor disfigurement.

From the clinical perspective, these findings are important because the modification of inappropriate cognitions (i.e., beliefs) and the introduction of more appropriate cognitions and behavior form the basis of effective psychological intervention in this group. Social anxiety and avoidance can be effectively targeted using this well-established approach.

Relatively few studies have attempted to look beyond the description of psychosocial problems in the target population to the factors associated with good adjustment in the long term. There is a strong, erroneous presumption that psychological distress is proportionate to the severity of the disfigurement, a finding that has no basis in research findings but nevertheless drives referral patterns and services. It is instead the individual factors driven by cognitive processes that predict long-term adjustment. Macgregor illustrated this idea many years ago, identifying coping style as important. Those who cope well and report fewer problems tend to use the positive coping strategies summarized in Box 29-1 , all of which allow them to manage social situations. Negative coping strategies are those that facilitate the avoidance response.

Findings of the Appearance Research Collaboration further clarified the factors and processes that are associated with positive adjustment in the long term. They demonstrated that biomedical factors such as the cause, timeline, and severity of the condition do not predict adjustment, although visibility to others is important. The psychological characteristics of those who were positively adjusted included higher levels of optimism, greater feelings of social acceptance and satisfaction with social support, a lack of concern about negative evaluations by others, and a self-system with lower levels of salience and valance afforded to appearance-related information.

This research is important to those working in the maxillofacial trauma field, primarily because it identifies individual behavior, rather than the condition or appearance, as a determinant of successful long-term outcomes. This is encouraging because behavior is learned and can be modified. These ideas provide the basis for psychological management of patients with altered appearance, who do not have to rely solely on biomedical solutions aimed at restoring appearance.

Psychological Aspects of Maxillofacial Trauma