Living with disfigurement can constitute a psychologically challenging position for both adults and young people alike. The affected individual may face socio-psychological difficulties in adjusting to their disfigurement, particularly when this occurs as a result of a sudden event such as an accident (Rumsey and Harcourt 2004). In particular, the stigma of disfigurement may have negative outcomes for self-esteem, self-confidence and interpersonal relations with others. There has been some important empirical research into the interface of disfigurement and identity, with attention to the individual’s adjustment to disfigurement (Moss and Carr 2004; Thompson and Kent 2001) and coping (Thompson and Broom 2009). However, there has been no investigation of the potential impact of disfigurement for identity processes, in particular. It has been observed that a key to understanding the processes underlying identity formation lies in understanding how individuals respond to threatened identity (Breakwell 1983, 2010). The theoretical assumption of this short essay is that an understanding of how individuals with disfigurement might respond to threatened identity will provide insight into their identity development and psychological well-being. Accordingly, the present paper aims to address this issue by exploring the potential for identity threat among individuals with disfigurement, with particular attention to the potential antecedents of and responses to threat. It is argued that there is much heuristic value in applying identity process theory, a socio-psychological theory of identity threat, to the domain of disfigurement. Firstly, the paper outlines those identity principles, likely to be susceptible to change as a result of disfigurement. Secondly, it considers strategies which may be implemented by the individual as a means of coping with identity threat associated with disfigurement, as well as the efficacy of these strategies. It is proposed that a scholarly consideration of the central tenets of identity process theory may assist health care institutions to realise their goal of supporting young people’s socio-psychological adjustment to disfigurement.

Identity process theory (Breakwell 1986; Jaspal and Cinnirella 2010; Vignoles et al. 2002) provides an integrative theory of identity threat and coping, by outlining (i) the necessary components of a positive identity; (ii) social situations likely to ‘threaten’ identity and (iii) the strategies likely be implemented by the individual in order to cope with the threat. It is argued that the individual needs to perceive appropriate levels of self-continuity across time (continuity); uniqueness and differentiation from relevant others (distinctiveness); competence and control over their lives and future (self-efficacy); feelings of personal worth (self-esteem); significance and purpose within their lives (meaning); belonging within social groups (belonging); and compatibility and coherence between elements of their identities (psychological coherence). The theory holds that if the individual cannot perceive appropriate levels of these principles, identity is threatened, which is aversive for psychological well-being. Although it is possible that all or most of these principles may be threatened as a result of living with disfigurement, the present paper considers those principles, which are most susceptible to threat, namely (i) continuity; (ii) self-esteem; (iii) distinctiveness; and (iv) self-efficacy. A key tenet of the theory suggests that the individual will seek to minimise and alleviate threat by engaging in intrapsychic coping strategies, which function at the level of the individual; interpersonal strategies, which involve interaction with other individuals; and intergroup strategies, which refer to group-level behaviour. Some coping strategies are inherently more efficacious than others (Breakwell 1986). The present paper offers fresh insights into the interface of disfigurement and identity threat by considering disfigurement through the lens of identity process theory.

Identity Threat

Self-esteem

The concept of stigma is vital in understanding how facial disfigurement might affect the lives of individuals living with this condition. Crocker et al. (1998, p. 504) argue that a stigmatised individual is ‘devalued, spoiled, or flawed in the eyes of others’. Clearly, stigmatisation on the basis of one’s facial disfigurement, which may be difficult or impossible to conceal, is unlikely to be conducive to a positive self-conception, since the stigmatised individual may come to perceive decreased personal worth (Goffman 1963). Indeed, Ginsburg and Link (1989) argue that feeling ‘flawed’ indicates one dimension of the stigma associated with disfigurement. Crucially, it has been argued that stigmatisation and self-esteem are negatively correlated, which suggests that increases in stigma will induce decreases in self-esteem (Jaspal 2011). Empirical research attests to the vulnerability of the self-esteem principle among people with disfigurement. For instance, in a cross-sectional survey study with a convenience sample (Rumsey et al. 2004), participants completed standardised measures of anxiety and depression, which revealed significantly higher levels of psychological distress among participants with a disfigurement than participants from the normative group. The authors argued that the majority of psychological difficulties were related to problems experienced in social situations, which suggests that depression may be associated with social stigma. Similarly, Valente (2004) argues that disfigurement, in particular, may be conducive to severe depression. The interpersonal dimension of threats to self-esteem cannot be underestimated; the individual’s perception that others hold a negative perception of him/her may well result in threats to self-esteem. This negative perception need not necessarily relate to overt name-calling or ridicule from others (cf. Krishna 2009; Partridge 1997), but may be expressed in more subtle ways. For instance, the individual’s perception that others are wary of engaging in interpersonal contact with him/her due to a disfigurement or the perception that one is given (unfavourable) attention due to their disfigurement may lead to a negative self-conception and hence decreased self-esteem.

Distinctiveness

The notion that the individual is given excessive attention as a result of their disfigurement highlights how ‘excessive’ distinctiveness may in fact threaten identity. In the UK, for instance, only one in 111 people has a significant facial disfigurement, which highlights the relative rarity of occupying this position (Changing Faces 2010). Thus, the individual with a disfigurement is automatically differentiated from the majority as a result of their appearance. Breakwell (1986) argues that the individual must perceive ‘appropriate’ levels of distinctiveness. Indeed, it is easy to see how ‘excessive’ distinctiveness might conversely threaten one’s sense of belonging within a social group or society as a whole, which is equally as important for identity (Vignoles et al. 2000). The affected individual may exclude him-/herself from social activities or avoid applying for certain occupations due to the anticipation that they will be excluded by relevant others as a result of their ‘excessive’ distinctiveness (Ginsburg and Link 1989). Thus, while the other principles may be curtailed as a result of disfigurement, the distinctiveness principle may become excessively active in social encounters with members of the general population, resulting in identity threat. Moreover, it has been noted that positive distinctiveness has more favourable outcomes for identity than negative distinctiveness (Tajfel and Turner 1979). In short, the ‘excessive’ and primarily negative distinctiveness associated with disfigurement may be aversive for identity.

Self-efficacy

There is empirical evidence that individuals with disfigurement may experience threats to the self-efficacy principle of identity, given that they may perceive a weak sense of control and competence over their lives and future. In a study on disfiguring burn scars, self-efficacy and self-esteem (Robert et al. 1999), adolescent participants with disfiguring burns reported significantly lower self-competence than the normative group, suggesting that the disfigurement can have negative outcomes for self-efficacy. Individuals with disfigurement may feel less able to realise certain goals in their lives partly as a result of the social stigma surrounding disfigurement. For instance, individuals with disfigurement may regard certain occupations to be ‘off limits’ or attendance at certain social events to be impossible due to their disfigurement. This may inhibit the development of feelings of control and competence, which incidentally constitutes a fundamental human motivation and a defining feature of identity (Codol 1981; Deci and Ryan 2000). Crucially, it is the wish or expectation to accomplish a specific goal coupled with the simultaneous perception that one is unable to accomplish it, which threatens self-efficacy (Jaspal 2011). Thus, it is necessary to explore the wishes and expectations of the individual in order to investigate the effects of disfigurement for self-efficacy and possibly the other identity principles.

Continuity

Individuals who acquire a facial disfigurement later on in life are particularly susceptible to threats to the continuity principle, primarily because these individuals must assimilate within their self-concept an undesirable and, in many cases, unanticipated change (Breakwell 1986). Individuals are required to adjust to changes both in their physical appearance and in interpersonal relations with others (Bradbury 1997). It may be difficult to establish a psychological thread unifying past, present and future, given the suddenness of disfigurement, particularly when induced by an accident, for instance. Moreover, the potential uncertainties associated with living with disfigurement, particularly in relation to securing employment and realising other future goals, may further jeopardise the connection between past and future. In some cases, the threats to continuity may be regarded as being chronic, since the individual living with disfigurement may be exposed to family photographs and other social stimuli evoking memories of their lives prior to disfigurement. The constant, enforced psychological transition between past and present, in the absence of a unifying psychological thread, may render salient the psychological disconnect within one’s sense of self. It is noteworthy that deficits in intrapsychic continuity have become associated with negative affect and, in extreme cases, even suicide (Chandler et al. 2003; Rosenberg 1986).

Coping

The empirical research highlighted in this essay suggests that disfigurement may pose threats to identity. In particular, it seems that continuity, self-esteem and self-efficacy will be threatened, while distinctiveness will be excessively active. According to identity process theory, this will induce coping strategies on the part of threatened individuals. Consequently, threatened individuals seek to cope at three levels of human interdependence: the intrapsychic, the interpersonal and the intergroup.

The intrapsychic dimension of coping is undoubtedly the most important, since it involves the individual’s personal meaning-making vis-à-vis disfigurement. On the onset of disfigurement it is possible that the affected individual will engage in the deflection strategy of denial by rejecting the reality of their disfigurement (Bradbury in press; Langer 1999). Breakwell (1986) regards this as a transient coping strategy, which is unlikely to be effective in the long-run. Thus, it is important to facilitate the individual’s acceptance of their disfigurement so that a fundamental change within the identity structure may take place. Continuity, self-esteem and self-efficacy will likely be jeopardised as a consequence of accepting disfigurement, but ‘once the change to identity (i.e. acceptance of one’s disfigurement) is wrought, the threat is passed’ (Breakwell 1986, p. 96). Clearly, this acceptance strategy will be markedly more successful in the long-run if the individual is able to re-interpret their social position (as a person with a disfigurement) and re-define the reasons for occupying the position. For instance, the individual should be assisted in their conceptualisation of their disfigurement not in terms of a ‘flaw’ but rather as an aspect of ‘who one is’ (Goffman 1963). More specifically, the change in appearance should be conceptualised and accepted as an aspect of their identity. Furthermore, the individual must establish that essential unifying thread between past and present by constructing a consistent life-story (Chandler et al. 2003). This is important for coping with major life events such as disfigurement. Thus, the strategies of re-interpretation and re-definition may be conducive to the efficacious acceptance strategy of incorporating fundamental change within identity.

Given the pervasive importance of social relationships in human existence, the individual will try to cope with threat induced by disfigurement at the interpersonal level. Individuals with disfigurement may avoid interpersonal contact by engaging in the strategy of isolation. Identity process theory regards isolation as ‘more of an inaction strategy than an action strategy’ (Breakwell 1986, p. 109). Like denial, this will only be effective in the short-term since, although the principles of self-esteem and self-efficacy may be salvaged by obliterating the source of the threat (i.e. others’ responses to disfigurement), the belonging principle will eventually face threats. The individual needs to feel acceptance and inclusion within social groups and society as a whole (Baumeister and Leary 1995), yet the isolation strategy directly impedes this. The individual who engages in the isolation strategy essentially deprives him-/herself of a source of belonging. The intergroup strategy of group support, which refers to self-inclusion within consciousness-raising or self-help groups, is likely to alleviate the threats to belonging initially posed by self-isolation. This elucidates the immense importance of charitable organisations such as Changing Faces (in the UK), which is committed to providing social support to individuals affected by disfigurement. In these social contexts, individuals are afforded opportunities to establish and develop feelings of self-esteem in a supportive non-stigmatising social environment; self-efficacy through exposure to narratives of success and future possibility; continuity through the collective exploration of past, present and future; and belonging through the latency of enforced distinctiveness.

Implications

Health care institutions committed to the support of individuals with disfigurement must continue to facilitate the acceptance strategy advocated in this short essay. The re-interpretation of what disfigurement means socially will undoubtedly impact the psychological meanings of disfigurement for the affected individual. This hypothesis is supported by theory and empirical research in the social representations theory literature (e.g. Deaux and Philogene 2001; Moscovici 2000). Health care services may help to change the characteristics (i.e. stereotypes) associated with the social position of being disfigured. One means of achieving this is to employ terminology, which is deemed to be sensitive to the needs of individuals living with disfigurement. For instance, Changing Faces acknowledges that some individuals may not feel comfortable with the term ‘disfigurement’ but may prefer ‘visible difference’ and other euphemisms. The appropriate use of terminology is essential for facilitating positive changes in the social representation of disfigurement. This will likely have positive outcomes for self-esteem among affected individuals.

Health care must provide affected individuals with the social and information networks and consciousness-raising groups which are so pivotal in collectively providing individuals with feelings of self-esteem, continuity, self-efficacy and belonging. These groups and networks should initially constitute a collective context for people living with disfigurement. Moreover, the encouragement of positive interpersonal relations and communication between people living with disfigurement and members of the general population (e.g. family members with no disfigurement) would allow affected individuals to engage in overt discussions regarding their disfigurement with others. This could serve to reduce the ‘excessive’ distinctiveness of people with disfigurement, while facilitating feelings of acceptance from others and inclusion within the broader society with positive outcomes for the belonging principle. Moreover, this may contribute to the dismantlement of stigma in the eyes of individuals with disfigurement. Indeed, empirical research has demonstrated that contact can reduce stigmatising attitudes (Alexander and Link 2003). Health care must include the restoration of feelings of self-efficacy particularly in light of previous research, which demonstrates that this principle may be acutely vulnerable to threat among people with disfigurement. Moreover, care services must provide affected individuals with a social context, in which success stories can be shared, elucidating the potential benefits for self-efficacy. Social influence processes may be particularly active among individuals in a similar social situation, with the result that feelings of self-efficacy may be transmitted to one another and thus collectively ‘shared’.

Health care services alone cannot accomplish the task of ameliorating identity processes among young people with disfigurement. Rather, this must be a collective endeavour. The media, for instance, has a crucially important role to play in changing social representations of disfigurement. This will undoubtedly complement the hard work currently being undertaken by social support and health care institutions and, at the social level at least, will have immense clout in improving public attitudes and in obliterating social stigma towards disfigurement.