1. Self Esteem and Body Image
This presentation will focus on self esteem and body image. Arguably a frequently forgotten area when working with our patients. The presentation will go through how to spot difficulties emerging with self esteem and body image and go on to look at how we can assess and support our patients struggling with these difficulties
Identity and Relationships after Stroke

2. Introduction
After a stroke, an individual’s body image can be severely affected which can then have a negative impact on self esteem.
Problems with body image are most often brought up as an issue by working aged adults who suffer a stroke, although older adults do experience this too.
As we know, stroke can cause many physical effects, leaving some people with a body which seems very different to the body they had before their stroke – often with many more limitations.
They may feel very conspicuous when out and about, leading them to stay at home more and avoid social activities.
After a stroke, an individual’s body image can be severely affected which can then have a negative impact on self esteem.
This can, in turn, have serious implications on rehabilitation as a patient questions their self-worth and often slips into low mood and/or depression. Problems with body image are most often brought up as an issue by working aged adults who suffer a stroke, although older adults do experience this too.
As we know, stroke can cause many physical effects, leaving some people with a body which seems very different to the body they had before their stroke – often with many more limitations. Younger adults in particular may find it hard to reconcile their “new, post-stroke” body, with the body that they had before which can have a big impact on the way that they view themselves. They may feel very conspicuous when out and about, leading them to stay at home more and avoid social activities.
Recently I was working with a lady in her mid 70’s, and she still regularly had her legs and eyebrows waxed, had manicures, dyed her hair, and wore make up every day. Being in hospital prevented her from doing this and she said that it made her feel as though she wasn’t herself. Upon being discharged, the first thing she did was to book an appointment at her local beauty salon and hairdressers!

3. How to Spot Problems
The issue of body image is rarely brought up with patients after stroke, especially in an acute setting as ensuring that an individual is medically well takes priority.
However, at an appropriate time, usually when someone is getting close to discharge, it can be an idea to bring the topic up if you feel as though it could be an issue.
In the toolkit, you will find a screening tool called the distress scale which asks patient’s if they are distressed about their appearance.
There is also a self esteem scale which can be used to screen for any problems. It consists of 10 simple questions so can be carried out quickly and easily by any member of staff.
The issue of body image is rarely brought up with patients after stroke, especially in an acute setting as ensuring that an individual is medically well takes priority.
However, at an appropriate time, usually when someone is getting close to discharge, it can be an idea to bring the topic up if you feel as though it could be an issue.
In the toolkit, you will find a screening tool called the distress scale which asks patient’s if they are distressed about their appearance.
There is also a self esteem scale which can be used to screen for any problems. It consists of 10 simple questions so can be carried out quickly and easily by any member of staff.
1. I feel that I am a person of worth, at least on an equal plane with others.
2.I feel that I have a number of good qualities..
3.All in all, I am inclined to feel that I am a failure.
4.I am able to do things as well as most other people.
5.I feel I do not have much to be proud of.
6.I take a positive attitude toward myself
.7.On the whole, I am satisfied with myself.
8.I wish I could have more respect for myself.
9.I certainly feel useless at times.
10.At times I think I am no good at all.

4. Activity In the toolkit, there is a copy of the self esteem scale.
In pairs, complete the self esteem scale with each other, either as yourself or “in character” as a patient.
Think of ways you could use the scale to open up a conversation about self esteem.
Do you like the self esteem scale? What are it’s good points? What are it’s negative points? Could you see yourself using the scale with patients?

5. How Can You Help? Explore Values
In the toolkit, there is a worksheet that looks at values, and explores what a person values in their life.
By looking at an individual’s values, we can help to show them that despite any physical/cognitive changes that they have experienced, they can still live up to their values in many different ways.
The values worksheet in the toolkit looks at a person’s values in different areas of their lives – for example, parenting, spirituality, marriage, physical wellbeing and employment.
A female patient may hold the value that she wants to be a caring wife. After a stroke she may be unable to fulfil some of the caring roles that she carried out before (e.g. making dinner for her husband) however you can help her to explore some of the other things that she does that make her a caring wife (e.g. asking her husband how his day has been or ordering groceries online to save him having to go to the supermarket). By showing people that there are many ways they can live up to their value, we can help them feel good about themselves and boost their self esteem.
Explore Values
In the toolkit, there is a worksheet that looks at values, and explores what a person values in their life.
By looking at an individual’s values, we can help to show them that despite any physical/cognitive changes that they have experienced, they can still live up to their values in many different ways.
The values worksheet in the toolkit looks at a person’s values in different areas of their lives – for example, parenting, spirituality, marriage, physical wellbeing and employment.

6. Activity- Case Study
Mr L has been very low and feeling distressed following his stroke as he no longer feels that he can be a good parent or grandparent. His stroke has left him with mobility problems which mean that he needs help with many aspects of his personal care and he can no longer get around independently.
Mr L feels as though roles have been reversed and this his son now acts like his parent. He also feels like a bad grandparent as he can no longer get out to watch his grandson play football after school.
On the values worksheet – Mr L indicated how important it was for him to be a good dad and a good grandad. How else can Mr L live up to these values?
Mr L has been very low and feeling distressed following his stroke as he no longer feels that he can be a good parent or grandparent. His stroke has left him with mobility problems which mean that he needs help with many aspects of his personal care and he can no longer get around independently.
Mr L feels as though roles have been reversed and this his son now acts like his parent. He also feels like a bad grandparent as he can no longer get out to watch his grandson play football after school.
On the values worksheet – Mr L indicated how important it was for him to be a good dad and a good grandad. How else can Mr L live up to these values?

7. How Can You Help? Positive Personal Qualities
In the toolkit, there is a positive personal qualities survey sheet which you can give to patients experiencing low self esteem.
The sheet basically asks family members and friends of the patient to describe the patient positively in three words.
We tend not to tell people as often as we should, what their positive qualities are and why we like/love them as a person.
The positive personal qualities sheet can be
Hearing positive comments, or seeing them written down by those we love can help us to realise that we do have a lot going for us.
Sometimes, we can be surprised that traits which we dislike in ourselves or see as negatives, are seen as positives by others – for example. Someone may think they are too strict as a parent/grandparent – but their children or grandchildren may appreciate the reasons for this and understand that their actions are in their best interests, and may therefore see it as a positive quality.
Positive Personal Qualities
In the toolkit, there is a positive personal qualities survey sheet which you can give to patients experiencing low self esteem.
The sheet basically asks family members and friends of the patient to describe the patient positively in three words.
We tend not to tell people as often as we should, what their positive qualities are and why we like/love them as a person.
The positive personal qualities sheet can be

8. How Can You Help? Negative Self-Evaluations
People with low self esteem or low confidence often get into the habit of looking at their actions in a much more negative light than they look at the actions of others. They tend to be very harsh on themselves, often thinking the worst and feeling as though others will also judge them in this way.
In the toolkit, there is a worksheet that looks at such negative self-evaluations and explores the evidence for evaluation a situation in a certain way, as well as exploring how helpful the evaluation is, and how we would see the situation if another person was in our position.
A person with low self esteem can have negative self-evalutaions. For example, they may cancel a dinner date with friends due to work commitments and then perceive themselves as being a bad friend and that they always let people down, or that they don’t deserve friends. This may also lead them to engage in over-compensatory behaviour – such as offering to pay for the whole meal when they re-arrange the dinner date.
By looking closer at the situation, and looking at the evidence for and against their evaluation of the situation, that person would hopefully be able to consider their good points when it comes to friendship, and realise that they only cancelled as it was unavoidable. They can also think about what they would have thought if it had been their friend who had to cancel due to work commitments – most of the time you will find they would be a lot more forgiving/lenient with their friend than they are with themselves!
Negative Self-Evaluations
People with low self esteem or low confidence often get into the habit of looking at their actions in a much more negative light than they look at the actions of others. They tend to be very harsh on themselves, often thinking the worst and feeling as though others will also judge them in this way.
In the toolkit, there is a worksheet that looks at such negative self-evaluations and explores the evidence for evaluation a situation in a certain way, as well as exploring how helpful the evaluation is, and how we would see the situation if another person was in our position.

9. How Can You Help? Biased Expectations
Similar to negative self-evaluations which we looked at on the previous slide, people with low self esteem tend to expect the worst of upcoming situations.
For example, if they are invited out to a quiz night with friends, rather than thinking about how they will have a good time, and a good laugh – they might worry about not knowing the answers, making a fool of themselves, and letting the team down.
In the toolkit, there is a worksheet that helps to challenge such biased expectations, again looking at the evidence for and against them and trying to help the individual form a more realistic expectation.
Biased Expectations
Similar to negative self-evaluations which we looked at on the previous slide, people with low self esteem tend to expect the worst of upcoming situations.
For example, if they are invited out to a quiz night with friends, rather than thinking about how they will have a good time, and a good laugh – they might worry about not knowing the answers, making a fool of themselves, and letting the team down.
In the toolkit, there is a worksheet that helps to challenge such biased expectations, again looking at the evidence for and against them and trying to help the individual form a more realistic expectation.

10. How Can You Help?
Goals
Work with your patient to ensure the goals that they set are realistic and achievable.
It can be a real knock to self confidence, and self esteem if you seem to be constantly falling short of reaching targets/goals.
One of the best ways of doing this is to break goals down into small steps so that even if an ultimate goal seems a long way away, there are smaller, “mini goals” leading up to that which can give your patient a feeling of achievement.
Seeting Goals
Work with your patient to ensure the goals that they set are realistic and achievable.
It can be a real knock to self confidence, and self esteem if you seem to be constantly falling short of reaching targets/goals.
One of the best ways of doing this is to break goals down into small steps so that even if an ultimate goal seems a long way away, there are smaller, “mini goals” leading up to that which can give your patient a feeling of achievement.

11. Summary
Sometimes a person will experience low self esteem in the short term following a stroke, and with time, as they adjust, their self esteem will improve again.
Other times however, low self esteem can persist and affect an individual’s rehabilitation in all areas of their life. In this situation, it is important that an intervention is in place and that all staff working with the patient, work with this in mind.
Most of us suffer with low self esteem at times during our lives – self esteem is one of the things that sets us humans apart from other animals. Reassure your patient that many people feel the same way after stroke, it’s completely normal for their self esteem to take a knock after such a big change.
In summary
Sometimes a person will experience low self esteem in the short term following a stroke, and with time, as they adjust, their self esteem will improve again.
Other times however, low self esteem can persist and affect an individual’s rehabilitation in all areas of their life. In this situation, it is important that an intervention is in place and that all staff working with the patient, work with this in mind.
Most of us suffer with low self esteem at times during our lives – self esteem is one of the things that sets us humans apart from other animals. Reassure your patient that many people feel the same way after stroke, it’s completely normal for their self esteem to take a knock after such a big change.