Mothers’ Experiences of Their Sons’ Appearance-Altering Combat Injuries: Distressed and Unsupported

Abstract

Emerging evidence indicates that combat injuries that change appearance, such as limb loss and physical scarring, can impact psychosocial wellbeing of injured military veterans. Parents of young children with a visibly different appearance may experience emotional distress and consequently have their own support needs, but less is known about the experiences of the parents of veterans with appearance-altering combat injuries. Using a qualitative individual interview design, this study aimed to understand the experiences and support needs of parents of military veterans who sustained appearance-altering combat injuries. Reflexive Thematic Analysis of interviews with six mothers identified two main themes “The distress of my son’s appearance-altering injury” and “I can’t express my distress”. The themes represent the emotional distress, guilt, and social difficulties experienced by the mothers following their sons’ appearance-altering injury, their experience of feeling they should supress their feelings of distress, the limited available support, and barriers to accessing support. This study highlights how the mothers of combat-injured veterans are often overlooked and provides emerging evidence that adjusting to a son’s changed appearance following combat-injury can create additional challenges for mothers, who could benefit from specific support.

Keywords:

• Appearance-altering injuries
• combat-injuries
• veterans
• mothers
• parents
• visible difference
• limb loss
• scarring

Due to the nature of military service, numerous UK personnel have sustained physical injuries during service, including some that resulted in a change to appearance, such as scarring or limb loss (Ministry of Defence, 2021). The exact prevalence of appearance-altering injuries (AAI) among UK military personnel and veterans are not known however, between 2005 and 2021, 10,645 personnel and veterans were in receipt of Armed Forces Compensation for ‘injury, wounds, and scarring’ and in the same period, 374 had sustained traumatic amputations, mostly during deployments in Afghanistan (Ministry of Defence, 2021). Research with civilian populations indicates that having a ‘visible difference’ (i.e., a scar, mark or condition affecting appearance due to injury or medical condition), can be associated with psychological and social difficulties, for example, being stared at, receiving inappropriate comments or being avoided by others (Martin et al., 2017; Rumsey & Harcourt, 2012). The psychological impacts for individuals with a visible difference can include low self-esteem and confidence, worries about the way they look, low mood, and feelings of anger or hostility (Clarke et al., 2014; Lawrence et al., 2006; Rumsey & Harcourt, 2012).

While evidence indicates the potential psychosocial impact among civilians, less is known about the psychosocial impact of having an acquired visible difference, or an ‘appearance-altering injury’ (AAI; e.g., limb loss, scarring) on military personnel and veterans (those who have left military service). A recent literature review found only three papers from the US and one from Turkey investigating this area, provide emerging evidence that combat-injured veterans with an AAI may experience psychosocial challenges similar to civilians with a visible difference, but that military culture may affect some aspects of adjustment and recovery (Keeling et al., 2020). A recent qualitative study with UK veterans who sustained AAI during deployments or training included reports of unwanted public attention (e.g., staring, unsolicited questions) which appeared to affect self-confidence, and for some, lead to a fear of being negatively evaluated by others; several veterans also reported feeling disgust and social anxiety related to their appearance (Keeling et al., 2022). Aligned with the US research, military cultural factors appeared to impact adjustment. This included the benefit of continued camaraderie while recovering with other personnel with similar injuries and perceiving their injuries to represent a badge of honor. Conversely, some injured veterans were concerned that visible injuries could lead to stigmatizing assumptions from others about being mentally unwell or having committed acts of violence (Keeling et al., 2022).

In addition to the impact on the individual, a small but growing body of evidence highlights the potential impact of a visible difference on the psychosocial wellbeing of the parents of those affected. To date, research in this field has focused on the experiences of parents of children under the age of 18 years. A recent UK interview study described parents’ initial shock at their child’s appearance, and disappointment followed by feelings of guilt that their child did not look as they had expected (Ministry of Defence, 2021). Moreover, these parents discussed concerns about the social stigma their children might experience, leading them to feel responsible for building their child’s resilience, and in some cases, led to them concealing their child’s visible difference when in public. Similar appearance-related challenges have been reported elsewhere. For example, parents of children born with cleft lip and/or palate in South Africa spoke about not being comfortable showing their children in public due to stares, hurtful comments and gossiping. When a parent’s child has been injured, any appearance-related challenges may be coupled with the stress associated with their child being harmed. Burn injuries to children can have a significant psychological impact on their parents, including stress, anxiety, low mood, and guilt (Bakker, Van der Heijden & Van Son, 2013). Supporting children going through sometimes lengthy medical treatment and rehabilitation, alongside ongoing responsibilities such as careers and looking after other family members, can be additional significant stressors for parents (Bakker, Van der Heijden & Van Son, 2013). Literature examining the impact of acquired visible differences in adult offspring is sparse. However, a study of parents and other family members, of adults with traumatic brain injury, identified stressors including feeling excluded in health settings due to confidentiality concerns, uncertainty around future prognosis, and poor communication between support services (Holloway et al., 2019).

Vicarious trauma, broadly overlapping with secondary traumatic stress and compassion fatigue, and summarized as empathy-based stress (Rauvola et al., 2019), refer to significant, indirect experiences of distress as a consequence of empathic engagement with individuals subjected to trauma. The consequent risks to partners (Diehle et al., 2017), family members (Barnes, 1998), and healthcare providers (Rauvola et al., 2019), are adverse cognitive, emotional, and behavioral reactions to their personal detriment. Research with healthcare professionals has demonstrated a consistent link between attachment status and empathy-based stress (West, 2015), through the support they provide to the individual subjected to trauma. Adult attachment theory provides a key framework for understanding interpersonal relationships, through the formation of working models of how we relate to ourselves and others (Bowlby, 1982), and specifically how distress may elicit the retrieval of attachment representations in close relationships to regulate distress (Mikulincer & Shaver, 2016). In family members, this may replicate how those representations were formed, which may frustrate either and/or both, veteran subject to AAI and family members.

To date, the appearance-related experiences and concerns of family members of military veterans with combat-related AAI (e.g., limb loss, scarring from burns, gunshot wounds, or shrapnel) has not been the subject of empirical research. Given evidence from the civilian population, and our understanding of empathy-based stress especially in the context of attachment relationships, it is plausible that family members of combat-injured veterans with appearance-altering injuries may experience psychosocial difficulties. To date, research with the families of Wounded Injured and Sick (WIS) military personnel and Veterans (not necessarily with appearance-altering injuries) has primarily focused on the experiences of spouses and romantic partners. Some partners have reported a lack of physical and emotional intimacy, and deteriorating communication with their injured partner (Thandi et al., 2017). A study exploring the impact of traumatic limb loss on military families, primarily partners, found that caring responsibilities could be numerous, and partners could find it difficult to ask for support (Engward et al., 2018). The limited research looking specifically at parents of WIS personnel and veterans has found they experience distress related to their adult child’s injury. Mother-son relationships can be negatively impacted after injury, for example reduced openness with one another and concerns not being disclosed.

While research indicates parents of UK WIS personnel and veterans may experience distress related to their adult child’s injury, evidence suggests that parents and other family members of WIS personnel and veterans have often been overlooked in terms of support provision (Fossey & Hacker Hughes, 2014; Verey et al., 2017). In a qualitative interview study, families of UK WIS personnel reported unmet support needs in relation to their roles as carers (Verey et al., 2017). Families wanted better continuity of support after WIS personnel were discharged from hospital or rehabilitation. Having to juggle caring for their family member, alongside other life responsibilities, meant families desired a more proactive approach to support provision, that acknowledged they often have little time to find support themselves. In addition, they wanted to speak to someone who understood military culture and the needs of families (Verey et al., 2017).

In summary, evidence suggests that for both civilians and veterans, looking different from the ‘norm’ following injuries can affect psychosocial wellbeing. Evidence also indicates that the parents of young civilian children with a visible difference may experience psychological difficulties. In the military literature, evidence suggests that parents of WIS personnel may experience psychosocial challenges, especially related to taking on care giving roles. However, to date, there is limited understanding of the experiences and impact on parents of military personnel/veterans who sustained appearance-altering combat injuries. This study therefore aimed to investigate the experiences, appearance-related concerns, and support needs of parents of veterans affected by combat-related AAI.

Materials and methods

Design

To address the research aims, this study used a qualitative methodology of one-to-one semi-structured interviews analyzed using Reflexive Thematic Analysis (Braun & Clarke, 2019). A critical realist perspective was taken with the intention of gathering direct information about participants’ experiences, while also attending to and acknowledging the social and cultural contexts that contributed to each participants’ nuanced experiences (Fletcher, 2017; Willig, 2013). This philosophical approach can facilitate a deeper and contextual understanding of participants’ experiences.

Ethical approval was granted by the University of the West of England, Bristol.

Participants and recruitment

Eligible participants were parents of British Armed Forces veterans with permanent AAI, such as scarring or limb loss, sustained during or whilst training for operational deployment. Injuries had occurred anytime since 1969 but a minimum of one year prior to the interview. The aim was to recruit a sample of 10 parents to allow for exploration of a narrow topic (Malterud et al., 2016). As this study took a critical realist and exploratory stance, the researchers did not intend to provide a ‘complete’ description of parents’ experiences (Malterud et al., 2016).

Opportunity and snowball sampling were used to recruit participants between March 2019 to October 2019. Study advertisements were shared using dedicated social media pages on Twitter, Instagram, and Facebook. In addition, relevant nonprofit veteran support organizations shared the study information with their service users either directly via an invitation letter or indirectly by sharing the study advertisement on their social media, websites and newsletters. Interested parents contacted the research team and were provided the participant information sheet and eligibility questionnaire, which asked potential participants to confirm details about their adult child including their military service, context under which they were injured (e.g., deployment in Afghanistan), and nature of their appearance-altering injury (e.g., scarring from shrapnel caused by improvised explosive device (IED)). After reading the study information and confirming eligibility, parents gave written informed consent, and a suitable time for the interview was agreed.

Materials

An eligibility questionnaire collected demographic information of those who took part, such as age and gender.

A semi-structured interview schedule was developed drawing on relevant past literature and the research team’s expertise in appearance and military health research. The schedule covered the following topic areas: military background and injury; impact of injury on their adult child’s appearance; the parent’s adjustment to their child’s injury and changed appearance; acceptance of the injury and change to appearance; and appearance-related support experiences.

A public involvement (NIHR, 2019) advisory group (PI AG) comprising two British Armed Forces veterans who had lost limbs from injuries sustained during deployments in Afghanistan, informed the development and conduct of the research. The PI AG members reviewed all materials for their acceptability, clarity, and language. They suggested minor changes to language use and confirmed the acceptability of the interview schedule for the target sample.

Data collection

Interviews were offered face-to-face, via telephone or by video call. All participants chose telephone interviews and were conducted and audio-recorded by the lead author. Interviews lasted between 47 and 85 min. Recordings were transcribed verbatim by the second author and checked for accuracy against the recordings by the lead author.

Analysis

Initial analysis of the interview transcripts was conducted by the second author under the supervision of the lead author, and later discussion with the wider team. Reflexive thematic analysis is a qualitative methodology used to identify and interpret patterns or themes of shared meaning within the data (Braun & Clarke, 2019). It was used taking an inductive approach, thus the analysis was driven by the data and participants’ experiences rather than any pre-defined or pre-determined theory or framework. Analysis was conducted at a latent level focusing on exploring the underlying and implicit meaning of the data This involved six phases: data familiarization where the second author listened to the interview recordings to immerse themselves in the data, followed by initial coding and code generation which was conducted using NVivo v12© software. The second author then searched for themes among the codes leading to the generation of candidate themes and sub-themes which were discussed with the first author. This reviewing led to the candidate themes and sub-themes being refined and then presented and discussed with the wider team. Master themes and sub-themes were then agreed upon, leading to theme definition and labeling, and the production of the report.

Reflexivity and researcher positioning

Reflexivity is key to qualitative research, critical realism (Finlay & Gough, 2003) and reflexive thematic analysis (Braun & Clarke, 2020). The researchers reflected on their personal experiences and how they might affect data collection and analysis. None of the authors had served in the military and neither the first or second author who conducted the interviews and led the analysis were mothers. The last author is a mother. Throughout the analysis, the interview transcripts were reexamined to ensure themes were grounded in the data. To improve credibility and trustworthiness (Tracy, 2010), initial themes were discussed with two family members of injured veterans, a spouse and a mother. These member reflections aided exploration of the data (Given, 2008).

Sample characteristics

Six mothers were recruited and interviewed. Two were recruited via a nonprofit charitable organization, and four via snowballing from one of the participants. The mothers were all white British and aged between 59 and 69 years (M = 64).

Characteristics of participants’ adult children

The mothers’ injured veterans were all male who had sustained blast injuries from improvised explosive devices (IEDs) during deployments in Afghanistan between 2009 and 2010. Five of the sons had served in the Army and one in the Marines. One son had scarring, two a single lower limb amputation, one had a double lower limb amputation, and two had a triple traumatic amputation (e.g. one arm and both legs).

Results

Reflexive thematic analysis identified two master themes that represented the mother’s experiences of their sons’ appearance-altering injuries. While the themes described in this article reflect the appearance-related experiences, concerns and support needs of the mothers in this study, it should be noted that this was only part of their experience of having an injured son. The overall experience was life changing, including the lifetime stressors of health and mobility challenges for their son post-injury, the loss of their son’s career, the trauma of seeing their son injured, and witnessing a change to family relationships between their son and his children. Some mothers also noted that having to juggle other life responsibilities alongside the stresses and caring for their son could be challenging. These injury-related experiences dominated much of the interviews with mothers. Thus, while appearance-related concerns were an important part of the participants’ experience, they formed only part of the overall story of having an injured, military son.

Nevertheless, an overall feeling of distress at their son being scarred and/or losing one or more limbs was evident throughout the interviews, along with a feeling that there were barriers to expressing and processing their emotions and concerns. These experiences were captured across two main themes: ‘The distress of my son’s appearance-altering injury’ and ‘I can’t express my distress’. Each theme is represented by sub-themes, supported by quotes from the interviews, that demonstrate the detail and depth of the mothers’ experiences.

The distress of my son’s appearance-altering injury

There was a great sense of distress from mothers when discussing their sons’ injuries, including the impact of their changed appearance; in particular, the visibility of their son’s injury and initial shock of seeing their wounds, and worry that others might judge him for his injury. In contrast, some mothers spoke about how they made sense of their son’s injury and appearance, that consequently enabled them to accept it more. This theme is represented by three subthemes: The heartbreak and horror of my son’s injury; I don’t want people to think bad things about him; and, It could be worse.

The heartbreak and horror of the wounds

The heartbreak and horror which mothers experienced was both immediately following injury and sustained overtime. For some, the initial experience of seeing their son’s injury caused significant distress. It could be an emotionally overwhelming experience to see their son for the first time after the injury, preceded by anticipatory anxiety concerning the extent of his changed appearance. The severity of the injury, resulting in exposed flesh and bone, was described using particularly graphic language that reflected the horror they felt when seeing it.

I remember thinking as I was going in … oh you know it’ll be fine. I won’t have to see anything because, you know, he’ll be covered up and, I can, just pretend, and, after trying to reassure myself that, I was going to cope alright…well of course he wasn’t, he was lying in bed, with no sheet on, and, um, this red raw, lump of meat.…And I just burst into tears. (Susan)

For two of the mothers, the fact that the injury had happened to the child they had created and nurtured made the experience painful, perhaps related to feelings of guilt around their unfulfilled responsibility to protect him.

…any mother would find it hard to accept that he’s been injured because you know, you produced this child. You had this child and, and, you know it’s, it’s, it’s a glory in itself. And then to sort of send it off with all its hopes and dreams and it to come back in a, you know just sort of a body bag. Um and then for the rest of its life it’s a changed being (Liz)

At the point of interview, which was approximately 10 years post their son’s injury, some mothers reported continued long-lasting feelings of heartbreak and loss, and a sense of mourning for their son’s previous attractiveness and what that may have afforded them. This was especially the case for a mother whose son had been facially injured.

…every time I see him it’s it, you know your heart breaks, full stop. You know and then I, yes I mean every time I, look at him there’s a, it’s, it’s, it’s an absolute tragedy to see his eye, gone, and his ear not working and everything. (Liz)

As a result of this horror and heartbreak, during initial experiences of seeing their son’s injuries and longer-term experiences of adjusting to their changed physical abilities, a couple of mothers found it too challenging to look at their sons. Seeing her son move around without his prostheses by using his hands, buttocks, and residual limbs was distressing for one mother, as demonstrated by her avoidance of witnessing it.

Something that, I know he, has to do, on occasion, but um (pause) I just, either look down, look away, or, if it’s appropriate I, remove myself. But I don’t make a fuss about it. (Kate)

In contrast to the horror and heartbreak, a couple of participants spoke about things that helped them look at and accept their sons’ injuries. One mother shared how she thought that her nursing background had helped her to be somewhat desensitized, so seeing her son injured was not as traumatic for her as it would be for other mothers.

I’m quite happy to, to look at him, and help him and, I’ve never had any problems that way but then I have a medical background. (Sarah)

Being a mother in itself was a protective factor for another participant. For her, the unconditional love she felt for her son meant she would accept him no matter what.

Coming from a mum’s perspective, you just love them to bits, warts and all *laughs*, so it doesn’t matter you know, you’ve got unconditional love as a mum. (Sue).

I don’t want people to think bad things about him

Managing their feelings associated with the unsolicited staring and attention from members of the public in reaction to their son’s noticeably ‘different’ appearance was challenging. Some expressed feelings of anger and frustration about people staring at their son.

You just want to slap them really and say get a grip. The guy’s lost a leg. (Sarah)

In part, the mothers’ distress seemed related to worries that others would misjudge their son, based on his injury and appearance. For example, one mother was fearful that others would stare at and pity her son considering him weak or a source of amusement. Though in later reflection, she said that people had not stared as much as she had expected.

I was sort of, were people going to stare at him? Were people going to feel sorry for him? Were people going to, the sort of things that I, thought would probably he would, he would struggle with. I don’t think they stared as much as I thought they were going to. I do also remember getting quite angry with somebody who was making a joke, about, *injured son* when *injured son* wasn’t there. (Susan)

Some mothers were particularly frustrated when people stared but then failed to engage with their son, for example by asking questions.

I’ve seen people stare…you know and I’m thinking you’re a grown up you know like, actually, do you need to stare so blatantly? Ask him a question. (Maureen)

This may have related to a concern, expressed by some mothers, that others may not realize their son’s different appearance was due to a combat-related injury in the military. This was concerning as they felt proud of their son’s service and sacrifice. Without this knowledge, some worried others might judge their sons more harshly, and assume the injury had been caused carelessly or through disease; something to be embarrassed about or to feel sorry for.

I think, that was probably us as well, wanted people to know that he hadn’t just an accident or had cancer, but he was a soldier and he’d lost it, doing his, job you know. I mean looking back it sounds daft, really to say that. But I think it was, it was kudos. (Sarah)

One mother noted that, while it would be inappropriate to publicly announce how her son had been injured, she wanted people to know how far he had come since his injury and the challenges he had faced in order to achieve his current functionality. Her pride in his achievements meant she wanted her son to receive the respect she felt he deserved.

I feel protective when I see people, sort of looking. And I want to explain to them you know what it, yeah, I’d love to be able to put a placard on him and say, “I’ve been through bloody hell, and look where I am now”. But I mean you can’t do that. And, you know we don’t live like that. We’re not looking for sympathy, but it is you know, you want, you want to explain that you know, just what it is. (Liz)

It could be worse

In contrast to the sense of horror and heartbreak, mothers spoke about how putting the injury in context, and particularly thinking about how the situation could be worse, provided some comfort. For some, this ‘it could have been worse’ mentality focused on the fact that their sons were still alive, and their injuries were not too severe. This was more important than the negatives associated with their injuries, particularly any challenges related to appearance.

I mean, obviously you’d rather he, he didn’t, wasn’t scarred and stuff but, in the grand scheme of things, compared to what could have happened er, I think it’s a, you know, he came out the best, what he could get sort of thing. (Sarah)

Other mothers contextualized ‘appearance’ in relation to other life challenges. For example, some felt that the physical and functional challenges associated with their son’s injuries were of more concern than the appearance of them. Although still struggling to accept their son’s injuries, the initial concern around his appearance was less worrying.

I’m not so worried about, how it, it looks now, I’m more worried about what the future holds for him, and, what, it, you know whether the other foot’s going to go or he’s constantly having to go, back in and get new prosthetics coz they don’t fit properly, you know, all those sorts of, practical things (Susan)

Another mother felt relieved that her son’s injury had not affected his face since, to her, facial injuries would be much worse. While she felt some shame in this relief, it nonetheless was comforting to her as a facial injury would have changed her son’s identity, and possibly her relationship with him.

…this sounds terrible to say this, but when, after he had his accident, I was like, he’s lost three limbs. You know it could be worse. And when people were phoning me up, they were saying, how confident and buoyant you sound. You know how positive you sound because I was thinking yeah, he’s lost three limbs, but he didn’t have any internal injuries. He didn’t have any facial injuries. And that sounds really shallow, doesn’t it? … He wouldn’t have looked like *son’s name* [with facial scars]. There would have been a mask there. You know a different face that wouldn’t have looked like him. The fact that he’s just lost the limbs, I could, I could cope with that. (Sue)

I can’t express my distress

The second theme represents all the mothers’ experiences of the challenges they faced to express and process their distress. Feeling restricted involved external and internalized social pressures and structural barriers to accessing support. This theme is represented by three subthemes: Mothers supress their distress; There’s not a space for mums anymore; and Gatekeepers to support.

Mothers supress their distress

Many of the mothers shared experiences of ways in which they had felt they should not express or share their feelings or distress. For example, on more than one occasion Maureen’s son had asked her to not cry or show that she was upset when seeing him in hospital or to share her opinions on how he managed difficult social situations. This had resulted in her feeling she had to hide her true emotions and ‘take a step back’

She [a little girl] was saying to her mum, “mummy, mummy, look at that man’s legs, look at that man’s legs”. And um, she was quite upset. And I’m saying to *injured son*, “say something. Say something”. And he’s looking at me, and then he’s turned away and I could see his reflection in the mirror coz he’s really angry…he did say to me afterwards, that we’ve decided that we would both, you know, he he, I was right, and he was right, that I, you know I must, take a step back in trying to protect him (Maureen)

While mother’s felt that saying phrases to themselves such as ‘it could be worse’ or ‘lucky he’s alive’ had been helpful, similar platitudes expressed to them by others were experienced as unhelpful, dismissive or minimizing the legitimacy of their feelings.

I get a lot, I get angry when I see…you know when people sort of say things like oh well you know you’re lucky to have him alive. (Liz)

Others trying to immediately fix or find solutions to their feelings of distress was also unhelpful and left one mother feeling that this approach dissuaded her from sharing her feelings further.

Men always want to fix things. So, I couldn’t really talk to my husband very much because, he couldn’t fix it. The fact that you just want to talk through something, you don’t want them to fix anything. But I’m, it just meant I couldn’t, really talk to him. (Kate)

Some mothers shared how they had supressed their true thoughts and feelings about their distress and their sons’ recovery and coping due to feeling a responsibility to be the pillar of strength for the family and not wanting to overly mother their adult son. For mothers who had grown up in a military family, the role of military culture seemed to exacerbate the feeling they should appear strong, and stoical.

I was really scared to see him. I was really scared to see, what he looked like, and would he be able to see that, if I was horrified by his appearance. Would he, I didn’t want him to see that in my face. (Maureen)

…as a mother you’re always picking your children up even though they’re grown up. But, er or you know, you’re, I definitely, I hold back… he’s taking these horrible steroids and, his muscles have got, big on his arm and on his other arm and, yeah, I would normally say don’t be so ridiculous. You look ridiculous. It’s just a fashion thing for God’s sake. It’s daft to try and change your body like that. But, you know what, I don’t. (Liz)

In a sort of, you know, community like the Armed Forces where we’re supposed to just sort of man up and, not express yourselves (Susan)

Consistent feelings of a need to supress their distress meant many mothers felt unable to talk about their experiences; to do so could make them feel worse as their feelings of distress felt minimized or invalidated by others.

I felt like I couldn’t, I mean I didn’t tell people how I was feeling and, after two or three times coz I, it wasn’t worth it. I just felt, unheard and, unimportant and, useless and pathetic and a whole load of other things. Um, so there’s no point talking about it. (Susan)

There’s not a space for mums anymore

Feeling a need to supress their distress in many settings meant it was important to the mothers to have a space where they could talk openly about their experiences. A few spoke of groups they had previously attended with other parents of injured veterans, in the period following their son’s injury. These had been helpful spaces where they felt accepted, validated, and heard. They did not feel a need to explain themselves when talking to other mothers; the groups offered a space to reflect on their experiences of having an injured son.

They had a group called um, the families of injured service personnel, which encompassed, wounded and sick. Um, and that was a great support. Because along the same lines you didn’t have to explain things. You know people knew how you felt. (Kate)

…in touch with another mother, who had been similarly, well, that whose son had been seriously injured, but far more so than [my son] actually. Um, and we, shared and talked, and it was that, that actually began to shift my take on things (Susan)

However, over time, the focus and structure of these groups changed. Groups became broader to include those primarily affected by mental health problems and some allowed children or injured veterans to attend. Mothers no longer had a safe place where they felt understood. They were in a group where they could not discuss their emotions because they were worried about ‘upsetting’ other members or were concerned about being the subject of gossip, consequently they lost a sense of belonging to these groups, and ultimately felt pushed out with no other space to turn to.

…it’s largely geared towards PTSD, and I’ve, I stopped going online because I find that…we weren’t kind of taken seriously being the injured. (Sarah)

…they wanted, you know let the injured come, to our group. No. Children come to our group. No. I want to be able to honest. I want to be able to say, I’d rather my son died at times. Because, I can’t cope with his grief. And I don’t want, so and so to go back and tell so and so, because they all know each other. And I don’t want that child to hear that. (Maureen)

In this quote from Maureen, there is also evidence of an additional concern that acted to silence and put mothers off using available support, which was of the confidentiality within the tight knit WIS military community.

Gatekeepers to support

Gatekeepers could limit access to spaces where mothers might have been able to talk. For example, mothers reported that information about available support was not always openly shared with them,

Nobody told me about, SSAFA (Soldiers, Sailors, Airmen and Families Association), for example. Um, which at that time was the only thing that I think had, some support for family members. But nobody told me about it. And I found that, a bit odd. (Susan)

In some cases, it was felt that if their sons had a romantic partner, the partner would be prioritized for support first, at the detriment of support offered to mothers and other family members. This was a source of frustration for a few of the mothers in this study who, after being made aware that support services exist, were subsequently not offered access.

I think they should, I mean as parents and family, we should have, been given it [support] anyway, immaterial of the girlfriend. And I feel strongly about that. (Sue)

Restrictions and unclear pathways to accessing available support were also reported, as Maureen shared:

I had some counselling and there was a big issue about who I could use. I had some counselling paid for. I had six sessions and my, daughter did too. But it was a bit of a hoo hah, to get the funding, they had to be a member of this that and the other. Which didn’t necessarily, equate to the counsellors that were in my area. And that I would like to see. Who I felt comfortable with. So that was an issue. (Maureen)

Being offered support for appearance-specific concerns was identified as something that would have been helpful after their son had been injured, to help them process their emotions and adjust to their son’s visible difference. In particular, naming and normalizing appearance as a potential concern was discussed by one mother as something which would have helped her accept the injury quicker. Moreover, it might have led her to feel more inclined to share her distress.

…if somebody had named it, and said, you know, how do, how do you feel? And, and wanted to hear it, I think it would have helped me get through it a lot, quick, quicker. Because I could have been, I could be, horrified, disgusted, angry, upset, all of those things without having to, pretend that I wasn’t. (Susan)

Discussion

Reflexive thematic analysis of interviews with six mothers of UK veterans who had sustained appearance-altering combat injuries during deployments to Afghanistan between 2009 and 2010, identified two main themes; My distress of my son’s appearance-altering injury and I can’t express my distress.

An overriding sense of distress was felt from all mothers who took part. Broadly, this was related to the multifaceted challenges of having a son seriously injured during military deployment, but included distressing emotions specific to their son’s changed appearance. Initial shock of the appearance of their sons’ ‘damaged bodies’, as reflected in mothers’ graphic descriptions of their broken flesh and visible bones, was a common experience. For some of the mothers this was compounded by a sense of guilt for not fulfilling their motherly ‘duty’ to protect their child. This seems consistent with research among parents of US military personnel deployed to Afghanistan and/or Iraq, which suggests that when children come to harm parents may experience this as a threat to successful caregiving, and feel a sense of a loss of control over their child’s safety (Crow & Myers-Bowman, 2011). While the mothers’ sons in this study were adults, the experiences they expressed are consistent with reports of parents of young children who sustained burn injuries (Heath et al., 2018) and a range of visible differences ((Thornton et al., 2021), including shock, emotional distress, and guilt.

Mourning the loss of their son’s previous attractiveness and concerns for how this might affect them in the future is consistent with research with parents of young children with a visible difference (Thornton et al., 2021). In an appearance-focused world, loss of physical attractiveness may be concerning for some parents, especially if they have a high level of appearance investment, meaning they consider appearance to be an important and influential factor in one’s life (Cash et al., 2004). The distress experienced by the six mothers ranged in intensity. It is possible that variance in the ability to accept and cope may have been affected by how important the mothers consider appearance to be, as mentioned above in terms of ‘appearance investment’ and as found in research with parents of young children with visible differences (Thornton et al., 2021) However, differences in mothers’ ability to adjust and accept their adult child’s changed appearance following injury requires more investigation. This evidence of both short- and long-term distress provides emerging evidence that the mothers of veterans who sustain AAI may benefit from emotional support, especially in how to adjust to their child’s changed appearance.

Concerns for how others respond and react to their sons are consistent with the experiences of veterans with AAI, who report managing unwanted public attention and fearing being negatively evaluated by others due to their appearance (Keeling et al., 2022). These experiences are consistent with the experiences of civilian adults with a visible difference (Rumsey & Harcourt, 2012) and the parents of young children with visible differences (Thornton et al., 2021). These concerns may reflect a broader societal challenge of an intolerance of difference in appearance and the difficulty of a society which values appearance and the potential detrimental impact of that. UK veterans with AAI have expressed an unmet need for support in how to manage difficult social situations and self-consciousness related to their appearance (Keeling et al., 2022) Since it may be difficult for parents to dissociate themselves from their adult children’s problems, even though doing so can adversely impact their own wellbeing (Crow & Myers-Bowman, 2011), emerging evidence from this study indicates mothers of veterans with AAI may also benefit from such support.

The desire of some of the mothers’ in this study for the public to know that their sons’ injuries are honorable, sustained in the line of duty, are consistent with the experiences of UK veterans who reported that the public perceiving them as injured war veterans might lead to more favorable judgment of their injuries by others, which in turn may alleviate the fear of being negatively evaluated (Keeling et al., 2022). This is consistent with research with US female veterans with traumatic amputation, who considered their prosthetics as a badge of honor which in turn aided coping (Cater, 2012).

Making sense of their son’s injuries by putting them into context through a process of downward social comparison such as stating ‘it could have been worse’, is a known coping strategy to aid self-preservation. This coping strategy is also reported by UK and US veterans with AAI (Cater, 2012; Keeling et al., 2020, 2022) and civilians with a visible difference (Egan et al., 2011). An additional coping strategy evidenced by the mothers in this study and used by veterans with AAI (Keeling et al., 2022) was to focus on physical function rather than appearance. Research with civilians provides evidence that focusing on body functionality can be beneficial to manage body image concerns (Alleva et al., 2018). In the case of the mothers in this study, it may assist those close to the injured veteran to manage any appearance concerns by proxy.

While some mothers in this study found ways of ameliorating distress in response to their sons’ AAI, they still required an outlet for their feelings yet often felt restricted in their ability to express their distress and be supported. Feeling the need to supress their distress was a pertinent experience. Interestingly, this suppression of the experiences of mothers of combat-injured veterans is reflected in the research literature with very few studies including or focusing on the experiences of mothers or parents of combat-injured personnel and veterans (Crow & Myers-Bowman, 2011; Gribble et al., 2020).

These mothers feeling silenced by their son, or their own restraint to protect their son, may have a positive benefit. Evidence indicates that emotional expression and overprotectiveness can negatively impact adults and young children. For example, excessively communicating worries or concerns can be perceived as intrusive or indicative that the parent lacks confidence in the adult child (Spitze & Gallant, 2004). Research with the parents of young children with visible differences also suggests that overprotective parenting styles can be difficult for developing children (Thornton et al., 2021). Despite potential benefits to their injured son from concealing the extent of their distress, the mothers still required support and a space to feel heard. Unfortunately, access to useful informal and formal support was minimal. These mothers found that often peers and well-meaning friends not connected to the military, do not understand the military context and culture and may say things that are received or perceived as dismissive or unhelpful. As reported by family members, including parents, of Canadian veterans with mental health difficulties, not having peers to talk to who ‘know what it’s like’ can feel very lonely (Schwartz et al., 2021). Thus, formal peer support that is sensitive to military culture, where parents can express their distress and gain support from similar others, has the potential to address a key concern of mothers in this study.

Indications that the nature of support provision changed over time and was no longer able to meet these mothers’ needs, may reflect the passage of time since injury. Support to address the immediate physical injuries of those returning injured from the Afghanistan conflict (now over a decade ago) has waned and now support focuses on veterans’ longer-term mental health needs, with supporting underpinned by the perception that physical injuries have outwardly healed and mental health difficulties are considered enduring. However, for the mothers in this study the ongoing emotional impact of physical injuries, especially those that affect appearance, have seemingly been overlooked.

As highlighted in a previous report of the family members of WIS personnel’s experiences of support, parents might have benefited from a more proactive approach to being offered and informed of available support (Verey et al., 2017). Additional gatekeepers to support, in the form of their son’s partners being prioritized, is reflected in the paucity of research that has focused on the experiences of parents, often prioritizing understanding the experiences of heteronormative partners (Gribble et al., 2020). Acknowledging the impact of injury on the parents, regardless of the presence of a partner, is important. As Crow and Myers-Bowman (2011) highlight, it is clear that parents of deployed military personnel should be considered and included in policy and support provision for “family members”. This is even more the case when the deployed personnel return home injured.

Consistent with the experiences of UK veterans with AAI, the mothers in this study reported that while they would have benefited from having someone to talk to specifically about the emotional and social impact of adjusting to their son’s changed appearance, appearance-specific support was not available. Consistent with evidence from parents of young children with a visible difference (Thornton et al., 2021), mothers of children of any age, who sustain AAI would most likely benefit from the provision of appearance support.

Strengths and limitations

This study is one of few to focus specifically on understanding the experiences and support needs of the mothers of combat-injured veterans, specifically those with AAI. Taking a qualitative approach has afforded the opportunity to gain in-depth insight into the challenges, coping, adjustment, and unmet needs of this group of military family members. Unfortunately, even though the study recruitment targeted all parents, only mothers chose to take part and therefore the experience of fathers is not represented. While small sample sizes are the norm in qualitative studies, a sample of six is on the smaller side for a reflexive thematic analysis study. Therefore, the results should be interpreted with this in mind. Specifically it is possible that the mothers in this study are outliers representing a smaller sub-set of those who have experienced ongoing challenges adjusting to their child’s injury. The difficulties recruiting parents to take part is reflective of the challenges of reaching family members of injured personnel and veterans, as previously reported by Verey et al. (2017). This study also only includes the experiences of mothers of sons who were injured during a very specific period (2009 -2010) and from deployments in Afghanistan. Due to variance in support provision overtime, including advances in family support provision, and differences in patterns of wounding, these findings may not be generalizable to mothers of veterans injured during different service eras. The sample was all white British mothers of white British sons, and therefore the experiences of mothers and sons of other ethnicities are not represented in this study, nor are the experiences of parents of injured daughters.

Implications

The expressions of distress from these mothers, including feelings of guilt and difficulties accepting and adjusting to their son’s injuries and altered appearance, indicates their unmet support need. This includes support to manage difficult social situations that may arise as a result of their son’s visible difference. Alongside recommendations for the development of support for veterans with AAI (Keeling et al., 2022) this emerging evidence provides early indication of a potential need to develop support for their mothers. Using quantitative methods to develop a further understanding of what differentiates those mothers who have been able to cope and adjust with relatively more ease from those who have experienced enduring difficulties, including the role of appearance salience, could help to inform areas to be targeted in any support that might be developed.

These mothers feeling they must supress their distress, whilst also feeling unsupported, is reflected in the lack of available suitable support as well as in the scarcity of published research literature about mothers’ and parents’ experiences. With emerging evidence indicating that mothers of injured veterans experience emotional distress and have very limited options for support, further research attention on the impact of combat-related injuries on the wider family, including fathers, and when injuries change appearance, is needed. This research evidence could be used to inform the development of evidence-based support.

Conclusion

This study was the first to specifically explore the experiences, appearance-related concerns, and support needs of mothers of veterans with combat-related AAI. Reflexive thematic analysis of interviews with mothers identified two main themes that provide emerging evidence that mothers of veterans with AAI experience distress related to their son’s injury and changed appearance but have limited options for expressing their distress and receiving support to enable adjustment and acceptance. It is suggested that appearance-specific support that can aid adjustment and acceptance and teach skills for managing difficult social situations related to their sons’ visible difference could be beneficial and should be further explored.

Acknowledgments

The authors wish to thank the participants and the study PPI advisors for their time and sharing their experiences. The authors wish to acknowledge the Scar Free Foundation for funding the UNITS Study, which was conducted as part of the Centre for Conflict Wound Injury. The Centre for Conflict Wound Research is funded by the Chancellor using Libor funds.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

Scar Free Foundation