Face IT@home

Online Support Tool For People With A Visible Difference

Information for Health Professionals About Face IT@home

Brief Overview of the Face IT Project

Research over the past decade has identified the psychological and social difficulties experienced by a significant number of people with a visible difference and their need for easily accessible, psychosocial interventions to help them lead a full and happy life. There are however very few evidence-based interventions available to meet their needs and psychological support resources can be limited. In collaboration with people who have a visible difference and the charity Changing Faces, researchers at the Centre for Appearance Research have therefore developed an easily accessible eight week web-based support program called Face IT@home, for adults aged 18 years and up.

It aims to address some of the key concerns of people with disfigurements, such as anxiety, depression, low self-esteem and appearance-related distress, and provides self-management skills via social skills training and cognitive behavioural therapy techniques. The content of Face IT@home is based on another adult intervention called Face IT, which has already been evaluated and found to be successful in improving the quality of life of adults with a visible difference. Following rigorous evaluation, we plan for Face IT@home to be administered with minimal supervision from health professionals and made available via the NHS and lay-led specialist organisations throughout the UK.

Background Reading

What is a visible difference?

A visible difference or disfigurement can result from:

  • Skin conditions, for example: Birthmarks, vitiligo, acne, ichthyosis, eczema, or other conditions that affect the texture of the skin, such as neurofibromatosis and epidermolysis bullosa.
  • Scarring resulting from an accident, surgery or burn.
  • Medical treatments, for example hair loss, skin or weight changes as a result of chemotherapy, radiotherapy or steroid therapy.
  • A condition that has been present from birth, such as a cleft lip or other craniofacial condition.

The Psychosocial Impact of a Visible Difference

Recent figures estimate that in excess of 1.3 million people in the UK have a significant disfigurement to the face or body (Changing Faces; 2010), including birthmarks, burn scarring, skin conditions such as vitiligo, acne, eczema and psoriasis, cleft lip and palate and other craniofacial conditions. In addition there are around one million presentations to hospital for treatment associated with some form of facial injury as a result of accidents, falls or assaults (Cartwright & Magee; 2006)

Although many adjust well, some individuals struggle to come to terms with their visible difference and irrespective of whether present at birth or acquired later in life, their appearance can have a profound psychological and social impact (Rumsey & Harcourt; 2007).

Appearance is also a highly sensitive and private subject and one which many people are reluctant to raise as a concern; particularly those with the perception that their concerns will be minimised or disregarded as trivial or vain and secondary to issues of physical well-being or even survival (Bessell et al, 2010). Health professionals who are aware of the potential psychosocial impact of a visible difference therefore have a vital role to play in validating and de-stigmatising appearance concerns among their patients. By being proactive and providing opportunities to discuss appearance, they can encourage their patients to express and identify their appearance–related worries and if necessary help them access specialist support.

Although the range of psychosocial difficulties experienced by those with a visible difference may vary from condition to condition, there are more similarities than differences. Common difficulties are discussed below.

Social Discrimination and Stigma

We live in a culture that values beauty, places a high degree of importance on appearance and has a tendency to mock or denigrate those deemed unattractive. Those who have assimilated these cultural norms into their own belief system are likely to find it difficult to accept their visible difference (Rumsey; 1997) and many of the problems faced by people with a visible difference are related to social situations and their experience of discrimination and stigma.

From an early age, the use of beautiful heroes and heroines (such as snow white) in Fairy Tales fighting against ugly villains (such as the wicked witch) teaches us to respond to physical differences with suspicion and uncertainty. These stereotypes continue into adulthood with the idea of beauty representing good being a running theme throughout many films and television programs.

There is often a great deal of uncertainty when people view something different, or out of the ordinary. This can lead to some of the negative responses you may experience from other people.

Research studies that have investigated the impact of our appearance, specifically how others see us have identified that when forming first impressions we tend to predict people's behaviour (both personality and intelligence) based upon their looks. These impressions can change on further contact.

There can also be problems in areas such as employment (Stevenage & McKay, 2009), with individuals with physical differences being less likely to be chosen for employment despite their qualifications or previous experience.

Permanently on Public Display

Staring from members of the public is one of the most common problems experienced by those with a visible difference (Rumsey et al; 2004) and is frequently combined with unsolicited questioning or comments about appearance, often in inappropriate settings. Members of the public may also feel the need to offer words of pity or sympathy for their plight or alternatively advise the person that their appearance is not actually that noticeable (Partridge; 1994). Again these comments are usually unsolicited.

Responses such as staring or questioning are not always intended to cause distress or offence (Bernstein; 1976). They can result from a lack of understanding about disfigurement and reflect concern or curiosity and a desire to seek explanation for the cause of the visible difference, or the individual's past experiences of treatment and treatment intentions (Partridge; 1994). But, irrespective of the motives behind these public responses, they can increase an individual's sense that they are permanently on public display, heightening feelings of self-consciousness and negatively impacting upon self-confidence.

Similar difficulties can arise as a result of "institutional gaze", a term used to describe an individual's experience of the intense scrutiny and constant involvement of health professionals in their lives (Hearst & Middleton; 1997). For example an individual who has scarring as a result of a road traffic accident, may undergo numerous surgeries over a long period of time which requires repeated trips to hospital and multiple assessments. This can be even more intense in the case of individuals with craniofacial abnormalities, who may undergo assessments and surgery over many years. This regular and repeated focus on the 'difference' may be unwelcome.

Psychological Distress

Being labelled as 'different' and experiencing social discrimination can have a wide variety of negative psychological consequences. Individuals may experience anxiety, depression, and low self-esteem. Some can feel angry about the reactions of others or angry and resentful that they have a visible difference or an appearance-altering condition (Kent; 2000, Newell & Clarke; 2000, Kent & Thompson; 2002, Lawrence et al; 2006, Blakeney et al; 2008).

Body Image Dissatisfaction

'Body image' refers to an individual's perception of how they look (Schilder; 1935) and is affected by an individual's emotions, attitudes and cognitions (Slade; 1994). According to Higgins' (1987) self-discrepancy theory, there are three components to body image:

  • Actual self (one's objective appearance)
  • Ideal self (how an individual would like to look)
  • Ought self (how one feels they ought to look)

For any individual, irrespective of whether they have a disfigurement, a discrepancy between the ideal self (body ideal) and the actual self can lead to body image dissatisfaction, low self-worth and distress (Altabe & Thompson; 1996, Rumsey; 1997). For those with a congenital or acquired visible difference, the risk of body image dissatisfaction is greater because their actual self may not match up to social norms (Gilbert; 1997) or, for those with an acquired difference, because their actual self no longer resembles their self-schema: their internal perception of how they think they look (Moss; 2005).

These outcomes will very much depend on the content and organisation of the individual's self-concept (Moss & Carr; 2004). If an individual values appearance highly and invests a lot of time and energy in their looks whilst investing less in other aspects of themselves, they are more likely to experience body image dissatisfaction and distress associated with having a visible difference (Lawrence et al; 2006).

Avoidant behaviour

Fear of negative reactions to their appearance by other people can lead to increased social anxiety (Langley et al; 2005). Social anxiety can then distort the focus of their attention and interpretation of events (Rapee & Heimberg; 1997). This can result in a heightened awareness of negative reactions, a tendency to look for and attend to such responses and heightened sensitivity to any reactions that may be perceived as negative (Kent & Keohane; 2001).

Newell's (1999) fear avoidance model suggests that if an individual finds that they can successfully reduce their anxiety by removing themselves from the anxiety-provoking situation, this (avoidant) behaviour will become reinforced and will be more likely to be used again in the future if the individual fails to manage their anxiety. This avoidant behavioural response can lead to self-imposed social isolation (Kent; 2000).

The Impact of the Severity of a Disfigurement on Adjustment

Many assume that the degree of severity or visibility of a disfigurement predicts the extent of psychological distress; that those with a minor disfigurement, or those with conditions that are not very noticeable, will probably adjust more effectively to their appearance than those with a major disfigurement. However, research consistently finds that this is not the case. An individual's subjective assessment of how noticeable the difference is to others tends to be a far better predictor of distress (Moss; 2005). In fact some research has suggested that those with more noticeable differences can learn to adjust more positively, because the responses of others tend to be predictable and individuals know what reactions to expect - they are therefore forewarned and prepared.

In contrast, for those whose visible difference is not always noticeable, perhaps because the condition can flare up or subside over time (for example skin conditions, such as psoriasis or eczema), the unpredictable nature of others' reactions can make it difficult for them to adjust to their altered appearance (MacGregor; 1990, Lansdown et al; 1997).

Rather than relying on objective clinical assessments or personal judgements made by clinicians, it is therefore important to routinely ask young people how they judge and feel about their appearance.

Camouflage and Concealment of Visible Differences

Evidence also challenges the assumption that coping strategies involving the concealment or camouflaging of visible differences are always beneficial. Although they may have short-term benefits, particularly for those with temporary appearance changes (for example during cancer treatments), reliance on these techniques can reduce the likelihood of the individual developing alternative adjustment strategies. They can also increase anxiety and worry about the reactions of others should their difference be accidentally or unavoidably exposed (Coughlan & Clarke, 2002).

The Therapeutic Framework of Face IT

Research has identified the importance of psychosocial support, particularly from health professionals, in helping individuals adjust to an altered appearance and supports the view that individuals need to develop a tool box of self-management skills, rather than a reliance exclusively on medical and surgical solutions (Argyle 1988; Bowden et al; 1980; Cobbs; 1976, Kleve & Robinson; 1999).

The first step in the developmental process of Face IT was therefore to assess the methodological validity of existing psychosocial interventions for young people in this area. A systematic review of the literature by Bessell & Moss (2007) found that there is a lack of evidence-based interventions and support services specifically designed for people with disfigurements. Of the few available for evaluation, most lack methodological rigour.

The authors did however conclude that cognitive behavioural therapy (CBT) and social skills based interventions, delivered within a package of care, are the most promising type of intervention and that this approach is worthy of more systematic investigation.

This view is consistent with and reinforced by the success of Face IT, an online intervention for adults, designed by the Centre for Appearance Research in consultation with the charity Changing Faces and other expert clinicians in the field of appearance psychology (Bessell et al, 2010). Face IT provides self-management skills via social interaction skills training (SIST) and cognitive behavioural therapy (CBT) techniques. In a randomised controlled trial, Face IT was found to be effective at reducing levels of depression, anxiety and appearance concerns when administered in an adult clinic setting and facilitated by an appropriately trained health care professional (Bessell et al, 2012).

In developing an intervention for people that is easily accesible without the need for psychological referral, we believe that the online mode of delivery of the Face IT@home intervention will be particularly appealing. Studies have indicated that many people prefer to seek health-related support and information via the internet, rather than talking directly to healthcare professionals (Weber et al, 2000). Online interventions are available at a time and place convenient for the user and are easily accessible and interactive, a benefit over paper-based material. Online access can also overcome the difficulty of reaching a population people for whom social avoidance is a defining characteristic (Newell, 1999), and a population reluctant to seek help due to the perceived stigma associated with therapy - a perception commonly experienced by those with disfiguring conditions (Wright & Bell, 2003). A systematic review of the computerised cognitive-behavioural therapy (cCBT) literature has also found this mode of delivery to be effective at treating mild-to-moderate levels of anxiety and depression amongst young people (Richardson et al, 2010) and the National Institute for Health and Clinical Excellence recommend its use (NICE, 2005).

The therapeutic content of Face IT@home is therefore based on the Face IT intervention and focuses on a combination of cognitive restructuring and social skills training. With the help of people with visible differences, its visual design, functionality, features and the presentation of its content have been made accessible to people aged between 18 and 91 years of age. The program has a reading age of 12 years.

Theoretical Models That Have Informed the Development of Face IT

There are many different models that contribute to our understanding of the difficulties experienced by young people with visible differences. These include the social anxiety model (Baumeister & Leary; 1995), Goffman's (1968) model of stigma, the social skills model (Bull & Rumsey; 1988) and the model of body image disturbance (Cash; 2001, Cash; 1996). Face IT@home adopts an integrated approach to support that addresses aspects associated with all four models and is largely based on the theoretical approach illustrated by Kent's (2000) Integrated Model of Psychosocial Distress & Intervention for Individuals with Visible Differences.

Social Anxiety Model (Baumeister & Leary; 1995)

This model suggests that social anxiety is a universal occurrence amongst humans. The social nature of the species and our desire to fit in can lead to fears of rejection by others and a fear of being excluded. Young people with visible differences experience social anxiety, at least in part, because they are fearful of being rejected or excluded on the grounds of having an unusual or different appearance (Kent; 2000). The level of social anxiety an individual experiences acts as a mediating factor between the severity of their visible difference (how objectively noticeable the appearance concern is) and their emotional response (Leary et al; 1998). This model promotes the use of interventions that reduce social anxiety by regularly exposing the individual to social situations (Newell & Marks; 2000).

Stigma Model (Goffman; 1963, 1968)

In many ways the stigma model fits with the social anxiety model, but rather than suggesting that social anxiety is simply a universal occurrence, it relates social anxiety to the social stigma of having an unusual appearance. Having a different appearance is a characteristic that is "devalued" by society and as such those with a visible difference are more likely to have real experiences of being excluded, rejected or misjudged. These experiences can undoubtedly lead to social anxiety.

Social Skills Model

Research suggests that those with visible differences can become preoccupied with their own appearance due to high levels of distress (Acton; 2004). When in public, this preoccupation can make individuals appear distracted, anxious or lacking in confidence (Kent; 2000). The social skills model suggests that many of the negative reactions these individuals experience are less to do with stigma and more a reaction to poor social skills that can create tension and inhibit social interactions (Rumsey & Bull; 1988). The social skills model and the stigma model are not mutually exclusive. The reality of the situation for many people with a visible difference is that they do indeed experience some level of rejection and exclusion, but in some cases this effect is exacerbated by inadequate social skills (Kent; 2000). This model therefore promotes the use of interventions that improve social skills (Rumsey et al; 1993).

Body Image Disturbance Model

This model suggests that the high value placed on appearance within certain societies makes body image disturbance (discontent with one's own appearance) relatively commonplace. Individuals with a visible difference may experience additional dissatisfaction with their body image because they do not conform to the cultural norms of attractiveness imposed by their society. Social pressure to look a certain way, alongside a more personal form of stigma (where they themselves feel they should look "normal") can lead to high levels of body image disturbance. Body image disturbance is associated with poorer adjustment (Altabe & Thompson; 1996) particularly among individuals heavily invested in their own appearance (White; 2000). This model suggests that interventions should focus on addressing the way individuals feel about their appearance and the negative assumptions they make about the importance of appearance.

Integrated Model (Kent 2000)

All these models are helpful in describing some of the difficulties faced by individuals with a visible difference, but no one model completely encapsulates the lived experience. Kent (2000) therefore recommends an inclusive model incorporating key features of all four models. Kent's theoretical model has been adopted for Face IT, see Figure 1.

Social interaction skills training (SIST) is proposed to address the inappropriate social skills that some individuals with visible differences may have developed and can help people interact more positively with others and overcome the social stigma attached to looking 'different'.

CBT is advised to address negative thoughts about one's own appearance and the assumptions individuals with visible differences make about the behaviour of others towards them (Thompson & Kent, 2001). CBT also offers individuals an opportunity to test out social situations they may be fearful of due to negative past experiences.

The process of exposure is crucial in helping individuals to engage more fully in social situations and to reduce the limitations that they may be imposing upon their own lives (Kent 2002). As research has shown that some individuals do not have the necessary social skills to effectively engage with others (Rumsey et al, 1993), there is a risk that social exposure without first addressing any limitations in social communication skills might lead to more negative experiences and greater social withdrawal. SIST is therefore not only an integral part of Face IT but is also addressed prior to social exposure activities.

The program acknowledges that reducing the social stigma attached to visible differences is an important part of improving the lived experience of people with visible differences. Users are informed and reassured that interventions to raise public awareness and acceptance of appearance diversity by the Centre for Appearance Research (CAR) and other organisations such as Changing Faces are being developed. However these interventions cannot change society overnight. The program therefore emphasises the importance of people developing strategies that can improve their current situation.

A Summary of the Content of Face IT@home

Session 1 Common Problems

The session starts by explaining that the purpose of the program is to provide skills designed to reduce social anxiety and increase adjustment to a visible difference. As research suggests that normalising feelings of distress can help to reduce the stigma associated with seeking psychological help (Rosen; 2003), the common problems faced by people with visible differences are outlined in order to normalise and validate the kinds of difficulties the person could be experiencing. These are often described in the words of other people who have chosen to share their experiences of living with a visible difference.

Research has shown that other people often do react negatively to a person with a visible difference. The reality of these reactions is therefore highlighted in this session to ensure people understand that the program is not belittling or undermining the very real negative experiences that they may well have encountered. The session also touches on the problems of loss and grief associated with acquired injuries (Bradbury; 1996).

This session also introduces some of the misperceptions that can exacerbate feelings of discrimination among people, and the impact that appearance concerns can have on the person's interactions with others. Research has shown that because some individuals are uncomfortable with their appearance, at times there can be transference of this self-perception onto others (Acton; 2004). Individuals assume, sometimes wrongly, that because they have a problem with their appearance others will respond negatively too. This is a common experience amongst those with body image concerns (Cash; 1996) and can cause individuals to assume that others are responding negatively to their appearance, even when they are not (Kleck & Strenta; 1980). Illustrations and a case study are used to clarify this point and help the young person to recognise the importance of not allowing negative assumptions to undermine their social encounters.

Self-consciousness and a negative self-image can also lead individuals to behave anxiously or awkwardly in social situations (Bull & Rumsey; 1998; Moss; 1997). Displaying negative body language, or appearing anxious when in conversations with others, can cause people to feel uncomfortable, stare or respond negatively to individuals, regardless of whether they have a disfigurement or not (Bull & Rumsey, 1998; Moss, 1997). In the case of those with congenital conditions, these behaviours and anxiety can occur because the individual has experienced long-term social withdrawal and may not have developed appropriate social skills (Bradbury, 1997). Those with acquired conditions may find that the skills they used previously are no longer effective (Bradbury, 1997). The person is therefore introduced to the potential impact of an individual's (negative) behaviour on the behaviour of others and the benefits of social skills training. The relationship between thoughts, feelings and behaviour is also relevant at this point and the key messages of the 'Think Good, Feel Good' model (Stallard; 2002) are introduced in preparation for later sessions.

Finally, session one aims to highlight that although many of the responses of others to a disfigurement may be negative, this is not always the intention (Quayle; 2001). Many individuals simply do not have much experience of visible difference and find it difficult to know how to respond appropriately (Bull & Rumsey; 1988). An innate preference for novel stimuli and an attentional mechanism that draws attention towards any information or features that are new, also make it probable that other people will look at a person's unusual appearance (Bull & Rumsey; 1988). As the face is particularly important in communication (Cole; 2001), changes to its characteristics are particularly likely to disrupt social exchanges by detracting attention away from key features involved in subtle nonverbal social cues and towards the disfigurement itself (MacGregor; 1990). Similarly, curiosity and a tendency to want an explanation or to understand a difference can evoke unsolicited questioning or comments about the cause or treatment of the disfigurement, particularly by children (Partridge; 1994).

Although these responses to a visible difference may not always intend to offend, they can leave the young person feeling uncomfortable and unhappy because they assume the worst and make negative interpretations about the reason for the other person’s behaviour. By understanding that some people respond negatively without meaning any harm, young people are introduced to the idea that they can challenge their negative assumptions to prevent them from undermining social encounters.

At the end of the session, the person is asked to complete a brief quiz to provide a baseline assessment of their anxiety, depression and appearance concerns and how confident they feel about socialising. These scores are for the benefit of the young person and will be repeated at the end of the course so that they can evaluate their progress or identify the need for additional support.

Finally people are asked to conduct a short task before session 2, called the "3-2-1" go technique. This technique is often employed by the charity Changing Faces in their group skills workshops (outlined by Blakeney et al; 2008). They are asked to reflect on how they respond to questions about their appearance and what they usually think and do when people stare. The person is encouraged to record these (and responses to other activities) in their personal journal that remains available as a permanent record throughout the program.

Reflective diaries/journals also help young people to express themselves and master newly acquired skills and can improve psychological well being. Cognitive behavioural journaling, writing down thoughts and feelings about previous or current difficult situations or experiences whilst participating in the intervention, can increase an individual's insight and confidence to confront issues and develop coping skills, and can reinforce the skills being taught in the intervention (Murray & Segal; 1994, Smyth; 1998, Lepore; 1997, Graf; 2004, Gortner et al; 2006, Clabby; 2006). Face IT@home therefore, for example, asks people to think about and plan what to say or do in difficult situations.

Homework activities in between therapy sessions are an integral part of Face IT@home. They are designed to encourage people to again reflect on their experiences or to practice social or CBT skills to help them master new techniques and increase their proficiency (Hudson and Kendall; 2002, Cunningham & Wuthrich; 2008). Homework has been used in many successful manual-based interventions for a range of conditions, such as body image problems (Dworkin & Kerr, 1987), generalized anxiety disorder (Barlow et al; 1998), social phobia (Marks, 1995) and social skills training for adults (Bellack et al; 1996, Graves et al; 1992, Pettibon et al; 1996). Research indicates that the level of homework compliance is particularly significant in improving the success of the intervention (Kazantzis et al; 2000, Rapee et al; 2001, Ronan & Deane; 1998).People are therefore encouraged to complete these activities and are provided with feedback and the opportunity to contact the Face IT@home team if they are struggling with the homework activities. A gentle e-mail reminder is automatically triggered if the young person has not entered data relating to the homework activity in their journal within 5 days following their last session.

Session 2 – improve your social skills

The beginning of Sessions 2-7 give the person an opportunity to get feedback on the homework activities and practical hints and tips on how to use the skills and strategies outlined within the course. Those who found the homework too difficult are asked to read the feedback on the activity, try the task again and, if they are still struggling, contact the Face IT@home team.

E-mails will be read by the team throughout the working week. Simple queries can be dealt with and explanations given. Should the team judge that the young person requires intensive support, beyond that which Face IT@home can provide, they will facilitate referral to either Changing Faces, GP or back to the Health Professional that referred them in the first instance with suggestions for further support.

Session 2 introduces the benefits of social skills training - a behavioural technique used to help individuals with social anxiety to employ more positive forms of body language and verbal communication (Wilkinson & Canter; 1982). The self-consciousness experienced by some individuals with a visible difference can lead them to display anxious, awkward and sometimes aggressive behaviours in certain situations (Tebble et al; 2004, Thompson & Kent, 2001) which can increase the likelihood of staring because it usually draws further attention (Moss, 1997). Difficulties with facial mobility associated with certain conditions (such as facial palsies) can compound this effect (Cole, 2001). Social skills training aims to reduce this anxious behaviour and in turn reduce the likelihood of further staring.

Building positive social skills can also increase social self-efficacy, enabling young people to take more control over their social situations and moderate the degree of psychosocial distress they experience (Hagedoorn & Molleman, 2006). Social skills training has been used successfully with adults with visible differences (Robinson et al; 1996, Kapp-Simon et al; 1992) to increase self-awareness and empathy, which in turn has had a positive impact on peer acceptance and popularity and enhanced perception of available social support (Kapp-Simon & Simon; 1991).

The features of positive non verbal and verbal skills are addressed. Non verbal skills include good posture, welcoming facial expressions (e.g. smiling) and gestures (e.g. nodding) and the importance of maintaining eye contact during social exchanges (Bull, 2001; Rumsey et al, 1993). Verbal skills include tone of voice, active listening and how to start a conversation.

Tone of voice is important in many ways. Using intonation in speech conveys emotion and can express interest in a topic (Kapp-Simon & Simon, 1991). Conversely, a monotonic voice can be misconstrued as boredom and can be difficult for individuals to understand or concentrate on (Kapp-Simon & Simon, 1991). Pitch can also be important (Kapp-Simon & Simon, 1991). The person is taught the value of speaking loudly so they can be heard and appear more confident, whilst remembering not to talk so loudly that it appears as though they are shouting.

Active listening is an important skill that allows individuals to indicate to others that they are both listening and interested. Techniques involved in active listening include head nodding and utterances (e.g. saying "yes" whilst someone is talking) to indicate that the individual is listening and understands. The person is taught how to use brief comments, and to summarise the information someone has conveyed in order to demonstrate that they have understood the main points of a conversation, a technique known as mirroring (Kapp-Simon & Simon, 1991). They are given tips on how to start a conversation, including examples of open-ended questions that can be used to initiate a dialogue based on hobbies, interests, current events or subjects based on hobbies or activities.

Some people with reduced facial expressions as a result of scarring, nerve damage, surgery or with conditions such as Moebius syndrome, can experience difficulty within social interactions because others struggle to read subtle nonverbal cues (MacGregor, 1989). By capitalising on advanced verbal techniques, individuals with such difficulties can overcome some of their difficulties in these areas (Clarke, 1999). This group, as well as those with speech problems, can select to receive specific information and techniques to help them manage social interactions.

Towards the end of the session the person is given the opportunity to evaluate their own communication skills using a quiz (questionnaire). Again the quiz will be repeated at the end of the course so that the young person can evaluate their progress. The person is then provided with four scenarios, each with optional responses to typical (but testing) social situations that a person with a visible difference might experience. The person is asked to imagine how they would react to this challenge and choose from four responses (non-verbal or verbal) that represent typical responses. Each response results in either a positive or negative outcome for the individual in the scenario. Feedback on the young person's choice is provided. The session ends with the setting of a homework task requesting they practice positive and negative forms of body language, first at home and then in public.

Session 3- Don’t be SCARED, REACH OUT

This session is based on SCARED and REACH OUT, two different social skills acronyms used by Changing Faces in their workshops and self-help booklets (Partridge, 1994). These acronyms represent issues to consider when engaging in social situations, and provide the person with techniques to help them manage the challenges of having a different appearance.

The SCARED framework provides a representation of how both the individual with a visible difference and another person can feel when they are involved in a social interaction.

If you behave....   Other people behave...
Shy S Staring, Speechless
Cautious C unComfortable
Aggressive, Anxious A Awkward, Asking
Retreating R Rude
Evasive E Evasive
Defensive D Distracted

It demonstrates how the behaviour of either individual can affect the behaviour of the other. By illustrating how other people might feel during an interaction, the person can understand why some people respond negatively to those with an altered appearance. The REACH OUT acronym is used to provide people with a "tool box" of techniques to help them cope with difficult social situations (Partridge; 1994). The REACH OUT model applies to both verbal and nonverbal skills.

  • R = Reassurance. Using reassurance to put people at ease.
  • E = Energy, Effort and Enthusiasm. Using positive body language to show people that you are willing to make the effort to be sociable.
  • A = Assertiveness. Sticking up for yourself by letting people know how you feel or what you need.
  • C = Courage. Having the confidence to face up to situations that are difficult
  • H = Humour. Making a joke of things and looking on the funny side is a great way to stop you taking things to heart and to put other people at ease
  • O = Over There. Refers to using ways to get people to stop focusing on your difference.
  • U = Understanding that some people don't know how to deal with visible differences.
  • T = Try Again means not giving up

People are encouraged to consider how the REACH OUT tool box (a combination of positive body language, good verbal skills and other strategies such as pre-prepared questions) can be used in a positive and helpful way to initiate and maintain conversations and manage negative reactions, such as staring, comments and unsolicited questions about their appearance.

For example, the person is advised to approach others with positive body language before initiating a conversation, to use an opening question or comment about a current event, or a statement about themselves (Clarke; 2000). They are also reminded to use open-ended questions to keep the conversation flowing, to speak slowly and clearly, and to use a cheerful tone whilst speaking (Kapp-Simon & Simon; 1991). The session reiterates the importance of active listening skills such as head nodding, agreement, comments and repetition to demonstrate that they are listening and interested when the other person is talking.

When joining conversations that are already taking place the person is given similar hints and tips as outlined above, but additional suggestions are given to help them approach others successfully, such as listening to the current topic of conversation, thinking of a relevant comment or question and waiting for a natural pause in the conversation. By monitoring posture and facial expressions, as well as factors such as tone of voice, it is possible to tell whether the other person is interested in a particular topic of conversation. Additionally, if the other person is not using active listening skills, such as repetition, comments and head nodding, this may suggest that the topic of conversation needs to be changed. After highlighting the signs to look out for, the person is then referred back to the verbal skills required for initiating conversations and advised to utilise these to change the conversation (Clarke; 2000). The person is also advised how to change the subject because they feel uncomfortable with it, or because they are not interested in that particular topic.

This section ends with further hints and tips on the importance of trying to be prepared before entering common social situations, for example by formulating pre-prepared responses to common situations that may arise, such as comments or unwanted questions about their appearance or staring.

The session includes a quiz to help the person determine the extent to which their fear of negative evaluation ('worry about what others think of them') compromises their social lives and interactions. This quiz is designed to help them recognise the potential impact of fear of negative interaction and to help them identify if this is an area they need to focus on in the coming sessions.

To further reiterate the session's messages, the person is invited to watch three short films using young actors with visible differences that illustrate the consequences of using either positive or negative social skills in difficult social situations; for example dealing with intimidating behaviour, managing inappropriate questioning and overcoming social anxiety.

For their homework the person is asked to prepare statements about themselves to use in conversation and to think of questions to ask someone with whom they would like to initiate a conversation. The intention here is to encourage them to prepare for social interactions.

Session 4 – Think, feel, do

An individual's perceptions of their own appearance and the assumptions they may make about the feelings of others towards their visible difference, can have a negative impact on the way in which they interact with others (Rumsey et al, 1993). Session 4 focuses on the difficulties that can arise from negative thinking and making negative assumptions about others. Throughout the session the person is encouraged to consider positive alternatives to negative automatic thoughts ('thinking traps') and to employ a positive voice or 'best friend' to help them challenge negative thinking.

The session starts with an explanation of the relationship between thoughts, feelings and behaviours using Stallard's (2007) 'Think, Feel, Do' model. The relationship between low self-esteem and negative thinking is also explored and illustrated. The SCARED model is used again to illustrate how negative thoughts and assumptions can influence social situations by affecting the way we interpret events and by affecting our behaviour (Beck, 1976).

There is a tendency for individuals to process information in a way that confirms their view of the world (Kenny & DePaulo, 1993). If a person has a generally positive outlook on life they will interpret information in a way that maximises the positive aspects but if they are negative, they selectively highlight negative information. This is particularly true in the case of ambiguous information. In this session are therefore encouraged to think about the way they perceive themselves and the reactions of others. They are introduced to the idea that feeling self-consciousness about one's appearance can influence the assumptions made about the thoughts and behaviours of others (Kleck & Strenta, 1980). The session reiterates that although they may experience negative responses from others, there are also times when these responses are not always intended to cause offense (Partridge, 1994). A brief negative thoughts quiz is used to help identify if negative thinking is a habit for them.

The person is then taught techniques to help them 'think positively' using elements of Stallard's (2002) 'Catch it, Check It, Change It' method. They are given tips to help them identify negative thoughts (examples of which are mostly appearance-related) and, using a technique known as creating a "positive voice" , they are encouraged to question and replace negative thoughts with more positive ones (Padesky & Greenberger, 1995).

When employing a 'positive voice' the person is asked to think of positive statements or conversations a trusted friend or family member might use to support them if they are feeling low or to challenge their negative thoughts. This process encourages the young person to identify how they are thinking and feeling in any given situation and then develop an alternative positive rebuttal that is strong, non-judgmental, specific and balanced (Padesky & Greenberger, 1995). An example of a conversation between a person and their 'best friend' is used to illustrate this concept and further examples of this technique are used in relation to combating typical negative thinking traps.

The person is reminded of other strategies to help them feel more positive and increase their self-esteem such as brain training (thinking of three positive events per day, however small), focusing on activities they enjoy, not dwelling on the past and not blaming all negative events on their appearance. They are then asked to view four typical social scenarios that someone with a visible difference might experience (for example, being stared at or asked about their appearance) and select the most positive thought in response to these potentially challenging scenarios from a choice of four thoughts (two are negative and two are positive). Feedback on the person's choice is provided.

Session 4 ends with a homework task. The person is asked to record in their journal any difficult situations with other people (like staring, receiving negative comments or being left out) and how they thought and felt about the situation. For each negative thought they are asked to think of and record 'best friend' statements to make them feel better or challenge their negative thoughts. The aim of this assignment is to assess the reality of the events they report as negative and to challenge their interpretation of the meaning of these events. For example the person may identify that other people are not actually staring at them as often as they were assuming. Alternatively, they may identify that some people do stare, but in these instances this may be a result of curiosity, rather than a negative judgement about them as a person.

Session 5 – SMART goals

Session 5 focuses on the importance of goal setting and having the confidence to try new things, and the difficulties many experience setting realistic goals. Initially the session talks about "social disability" in relation to visible differences. This is based on evidence that some people have low expectations of what a person with a visible difference can achieve (Hughes, 1998) and those with a visible difference tend to choose careers where they are less likely to interact and with others, or avoid opportunities for self-promotion because of low confidence. Having low aspirations can be borne out of a belief that it is possible to protect oneself from stigma by not competing with others (Bradbury, 1997).

The session refers to the general absence of people with noticeable differences in the public eye (Wardle et al; 2008). It provides an extensive list of people of all ages with visible differences who are famous or successful in their chosen career - some of whom have provided Face IT@home with inspirational quotes. These examples are used to challenge the assumption that those with a visible difference will necessarily be prevented from succeeding in 'highly visible' roles. Positive role models demonstrate that high expectations and determination can help people achieve their goals and overcome 'social disability'.

Physical disability is also discussed. Face IT@home is aimed at any person who considers him or herself to have a visible difference and wants help to deal more effectively with the challenges of living with a disfigurement – that includes those with a physical disability. As well as providing support for their appearance concerns these young people may also require help to adapt their aspirations and goals to their current level of physical ability (Chai Hong; 2004). Research has shown that some individuals assume they can still carry out all the tasks that they would normally have carried out before their condition developed (or worsened) or their accident occurred (Chai Hong; 2004). Some of these tasks may not be realistic within the constraints of their new circumstances and therefore their goals need to be redefined. Conversely, some individuals feel like giving up completely when faced with physical disability (Caldwell; 2001). Some of the achievements of individuals who are physically disabled are highlighted.

People are introduced to the SMART model of goal setting (Doran; 1981). The aim of SMART is to provide people with a series of principles to help them achieve their goals. SMART goals must be Specific, Measurable, Achievable, Reasonable and Time-measured.

  • Specific: In order to make goals specific, it is important to set parameters on exactly what the goal will be.
  • Measurable: A goal must also be measurable so that it is possible for the individual to identify when it has been achieved.
  • Achievable is about making sure that the goal is obtainable.
  • Reasonable: A goal may be achievable, but far too difficult to be reasonable in the short term. To make the goal reasonable, a plan of action is needed to address any potential problems that may stand in the way of the goal being implemented or achieved (Doran; 1981).
  • Time-frame: Finally a goal must have a time-frame. For those with busy lives or low self-confidence, it is easy to put off achieving certain goals (Doran; 1981).

The next stage of the session highlights the importance of setting staged goals, or action plans, that have short, medium and long-term milestones built into the process. This strategy makes achieving the final end goal easier because the task is made to appear less daunting. Achieving numerous successes on route to the end goal is also a motivating factor (Doran; 1981) and can result in reinforcement through the process of reward after each stage (Skinner; 1956). The SMART approach to goal-setting is illustrated using appearance–related challenges, for example the end-goal of swimming in public and going back to school following a period of absence and a change in appearance.

In this session people also have the option to access support around appearance - specific romantic concerns (as well as links to websites offering generic advice to young people considering romantic relations). They are given advice on how to manage their concerns using the communication skills discussed in previous sessions and SMART goal setting techniques. They can read examples of positive experiences provided by other people with visible differences.

The homework assignment at the end of this session asks people to access their journal and, using the SMART model, help a fictional character to achieve his goal of wearing shorts in the summer. The user can opt to receive 'quick tips' to help them with this task.

Session 6 – Beating Anxiety

This session focuses on the role of anxiety in preventing successful goal attainment, and anxiety management techniques to help people achieve their goals. It starts by explaining the physiological nature of anxiety (the flight or fight response to a perceived threat) and typical bodily sensations resulting from anxiety (LeDoux; 1994). The user is introduced to a cognitive model of panic (Clark; 1986). We explain that some individuals can misinterpret normal anxiety responses (e.g. such as palpitations, breathlessness, dizziness) as much more worrying and dangerous (e.g. a sign of illness) than they really are and how this response can trigger a panic cycle. The intention here is to encourage people to recognise their own anxiety symptoms in order to help them learn to control their anxiety and prevent escalation into a panic attack.

This is followed by a simple explanation of Newell's (1999) fear-avoidance model of visible difference. This model suggests that social avoidance occurs as a result of individuals experiencing or anticipating negative responses from others. Although avoidance of social situations can be useful in the early stages of recovery from significant change or trauma (Furness, et al; 2006), continued social avoidance is associated with poorer long-term adjustment and increased psychosocial distress. As the tendency to avoid social situations increases, individuals can reduce their opportunities to take part in positive and life-enriching activities (Cochrane & Slade; 1999); opportunities to habituate to the responses and behaviour of other people are also reduced (Newell & Marks, 2000).

It is the reduction in anxiety which results from avoiding certain situations that can reinforce the avoidant response (Marks; 1987). However, a physical reaction to threat can only be sustained for a short period of time and if the person can stay in the fearful situation long enough, their anxiety will reduce and any association between running away and anxiety reduction can slowly be broken (Newell; 1999). They will find it easier to remain in similar situations in the future because they have the opportunity to learn that their feared scenario is not as threatening as they feared. For someone with a visible difference who is anxious about going to a social gathering, it is therefore important that they remain exposed to that social situation until their adrenaline has reduced. Once they reach this point the association between attending an event and the social anxiety will slowly start to be extinguished. The fear avoidance model outlines the importance of increasing exposure to social situations in order to reduce avoidance (Newell & Marks; 2000).

Based on the concept of exposure therapy (which aims to systematically desensitise individuals to their feared event, Wolpe; 1958) young people are then introduced to a strategy called 'testing the water'. They are taught the benefits, in terms of anxiety-reduction, of a graduated approach to anxiety-provoking situations using the concept of a "fear ladder" (Marks; 1987). A score of one is assigned to the least anxiety-provoking situation and ten to the most difficult situation that the person wants to achieve. The session provides examples of fear ladders used for exposure to spiders and overcoming an appearance-related anxiety.

To help manage potentially high levels of anxiety whilst becoming habituated to stressful situations, the person is provided with a selection of practical relaxation techniques. These are a deep breathing exercise (Bernstein & Borkovec; 1973), progressive muscle relaxation (Jacobson; 1938), visualisation (Cousins; 1993), a positive association technique known as anchoring (Williamson; 2008) and finally mind games and distraction (Patel; 2006). They are also provided with some helpful tips to consider when developing and using their own fear ladder. They are advised to take the process slowly, and even start by just observing other people carrying out a task that they consider to be anxiety provoking. This is known as vicarious exposure and can also have a positive effect on reducing the intensity of anxiety (Vincelli; 1999). During these observations they are encouraged to take notes of all the things they might need or any behaviour that may help them. Facing unexpected difficulties can set back progress considerably during exposure therapy (Marks; 1987, Butler et al; 1984), users are therefore encouraged to anticipate some of the things that could go wrong as they attempt each 'rung' of their fear ladder and to consider how they could deal with these.

Monitoring thoughts, emotions and progress in their journal is an important part of using fear ladders. People are shown how to use an anxiety diary, which involves monitoring how fearful they feel (on a scale from one to ten) , both before being exposed to a situation and after the exposure session has finished. This helps them assess whether desensitisation has been achieved and acts as a record of achievement.

The importance of engaging social support is emphasised and the person is reminded that they can ask friends or family members to accompany them during exposure sessions if they do not wish to take on the process alone. However the aim, once confidence builds, is to approach these situations alone and only seek support in the early stages if necessary.

For homework, participants are asked to construct their own fear ladder for an anxiety-provoking situation they might currently be experiencing. They are also encouraged to practice the relaxation techniques at home. Relaxation strategies take time to learn, and practice will give the person the opportunity to identify which techniques they can work with. Participants are then asked to attempt the first rung of their ladder, and are encouraged to practice this stage until their anxiety has reduced to around three or less out of ten before moving onto the next rung (Marks, 1987; Butler et al, 1984).

Session 7- looking at your progress

This session provides a review of all the information disseminated over the previous six sessions. It starts with a comprehensive debriefing from the exposure task (testing the water) performed by the person since the last session. This may take up to 20 minutes.

The person is asked to rate on a visual analogue scale how difficult they found the task on the first rung of their fear ladder. If scores are high, it is suggested that they revisit their fear ladder and find a task that is not quite so fear-provoking to try instead. Some clinical psychologists use a rating scale of one to ten to identify how fearful their patients are of certain situations. Generally, a score of one to around three indicates that they have become used (habituated) to this item and are ready to proceed to the next stage (Marks, 1987). However a score of four to seven suggests more practice may be required before moving on and a score of eight or above suggests that they may need to rethink their ladder and they are advised to find a less anxiety-provoking situation to try (Marks, 1987).

The person is finally asked to rate their anxiety about progressing up to the second rung of their ladder. Again a low score means they are ready to carry on, whilst higher scores suggest more practice is needed. If their score is above eight they should be advised to rework their ladder to include another step.

At the end of the session the person is asked to revisit the anxiety, depression, appearance, socialising and negative thoughts questionnaires. They are provided with feedback on their scores and if scores are high they are asked to revisit the relevant sections within the programme and are reminded to seek further support from their family, GP or Changing Faces.

Six weeks following the completion of the seven sessions in Face IT@home, the person will be asked to complete an online quiz, which tests their knowledge of the core content of Face IT@home. Those who are struggling to answer questions are given clues and, if difficulties persist, the programme directs them back to the relevant content within Face IT@home to refresh their memories.

The inclusion of booster sessions within face- to- face cognitive behavioural interventions has long been employed as a strategy to increase and maintain newly acquired skills and improve post intervention outcomes (Clarke et al; 1998, Spence & Shortt; 2007, Weisz et al; 2006, Whisman; 1990, Clarke et al; 1999; Spence et al; 2000; Riedel et al; 1986). Although very few studies have conducted controlled trials investigating the effects of including booster sessions in online support interventions, a recent review of computerised CBT for preventing and treating anxiety and depression in children and adolescents by Richardson et al (2010) suggests that including a booster session has the potential to maintain treatment effects and also yield significant improvements in outcomes.

Outcome Measures Used in Face IT

Session 1

Anxiety

The question below asks you to rate your feelings of anxiety on a scale of 1 to 10, where 1 is not really anxious at all and 10 is really very anxious indeed.

Do you experience anxiety related to social situations?

Scale 1 to 10

You scored:

A score between 1-3 represents low anxiety. If you rated your anxiety from 1-3, it is unlikely that this is causing you a problem.

A score between 4-7 indicates slightly high levels of anxiety. Although not necessarily a problem, you may find some of the techniques to reduce social anxiety useful to help you cope more effectively

A score of 8 or over indicates high levels of social anxiety. This is an area that may be causing you difficulty, and if it hasn't already, it could make you avoid stressful situations. This is what Face IT is here for. The program will help to learn to manage your anxiety more effectively, and will help you to get along much better.

Depression

The question below asks you to rate your feelings of depression on a scale of 1 to 10, where 1 is not really depressed at all and 10 is really very depressed indeed.

Do you experience depression associated with your appearance?

Scale 1 to 10

You scored:

A score between 1-3 represents low depression. If you rated your depression from 1-3, it is unlikely that this is causing you a problem.

A score between 4-7 indicates slightly high levels of depressive symptoms. Although not necessarily a problem, you may find some of the techniques to reduce negative thinking and isolation useful to help you cope more effectively.

A score of 8 or over indicates high levels of depressive symptoms. This is an area that may be causing you difficulty, and if it hasn't already, it could prevent you living your life to the full. This is what Face IT is here for. The program will help to learn to manage your depression more effectively, and will help you to get along much better. If you feel you need more help please speak to your GP who will be able to help you.

Appearance

The question below asks you to rate your feelings about your appearance on a scale of 1 to 10, where 1 is not really concerned at all and 10 is really very concerned indeed.

Are you concerned about the way you look?

Scale 1 to 10

Do you think others are concerned about your appearance?

Scale 1 to 10

Have you experienced negative responses from others due to your appearance?

Scale 1 to 10

You scored:

A score between 1-10 represents low appearance-related concerns. If you rated your appearance concerns from 1-10, it is unlikely that this is causing you a problem and that you feel that other people generally respond well to your appearance.

A score between 11-20 indicates slightly high levels of appearance concerns. Although not necessarily a problem, you may find some of the techniques in Face IT useful to help you cope more effectively. This score indicates that you tend to feel that people are bothered by your appearance. Although not necessarily a problem, this is an area that needs addressing, as there are many ways to help you to overcome your concerns about the responses of others and your feelings of social stigma.

A score of 21 or over indicates high levels of appearance concerns. This is an area that may be causing you difficulty. This is likely to cause you real problems in social situations. Face IT will help you to learn to manage your appearance concerns so that you can get along much better.

Social Interaction

The question below asks you to rate your difficulties in relating to other people on a scale of 1 to 10, where 1 is not really any difficulties at all and 10 is very severe difficulties indeed.

Do you have difficulties interacting with other people?

Scale 1 to 10

Do you experience anxiety about going out?

Scale 1 to 10

Do you feel very cut off from other people?

Scale 1 to 10

You scored:

A score between 1-10 represents low levels of social interaction difficulties; it is unlikely that this is causing you a problem.

A score between 11-20 indicates slightly high levels of social interaction difficulties. Although not necessarily a problem, you may find some of the techniques to increase your social skills useful to help you cope more effectively.

A score of 21 or over indicates high levels of social difficulty. This is an area that is really causing you difficulty. This is what Face IT is here for. The program will help you to learn effective social skills so that you can meet new people and increase your social support.

Goal Setting

The question below asks you to rate your ability to set realistic goals for yourself on a scale of 1 to 10, where 1 is not really very successful at all and 10 is really very successful indeed.

Are you successful at setting realistic goals for yourself?

Scale 1 to 10

You scored:

A score between 1-3 represents low success at goal setting. This is an area that may really be causing you difficulty. Don't worry though, that's what Face IT is here for. The program will help to learn to set realistic, achievable goals for yourself which will help to build your confidence.

A score between 4-7 indicates reasonable levels of success when it comes to goal setting. Although not necessarily a problem, you may find some of the techniques rating to realistic goal setting useful to help you to build your confidence further.

A score of 8 or over indicates high levels of success with goal setting. This indicates that you are confident in your ability to set achievable and realistic goals for yourself.

At the end of the session, individuals are asked to conduct a short task during the week between sessions called the “3-2-1-Go” technique, often employed by the charity Changing Faces in their group skills workshops (outlined by Blakeney et al, 2008), which can be seen at the end of session 1 of Face IT.

Session 2 quiz: Communication Skills Questionnaire: Part 1

Below are a series of items relating to communication skills. Please consider your ability to do the following in social situations and rate the items on the scale.

Statement Poor Fairly Poor Sometimes Good Almost Always Good Always Good
1 2 3 4 5
Maintaining Eye Contact
Using Gestures
Showing Enthusiasm
Good Appearance
Speaking Clearly
Choosing Suitable sentences

You scored:

If your score was between 6 and 13, this indicates that your non-verbal communication skills could be improved. By going through the pages and exercises in these sessions you will learn to improve your communication skills.

A score between 14-21 indicates adequate social skills. If you scored within this range, this indicates that your social skills are alright, but could do with some improvement. You may find the following pages useful in enhancing your social skills.

A score of 22 or over indicates high levels of social skills. This is an area that you already feel very confident with. You may not be experiencing any difficulties, but the following pages may still provide you with useful hints and tips.

Session 3 Quiz: Communication Skills Questionnaire: Part 2

Below are a series of items relating to communication skills. Please consider your ability to do the following in social situations and rate the items on the scale.

Statement Poor Sometimes Good Almost Always Good
0 1 2
Greeting people
Asking a question
Finding communication hints during conversation
Speaking about your own opinion or situation
Expressing positive feelings to other people
Active listening
Saying yes to other people's requests
Saying no to other people's requests
Asking someone for something
Starting a conversation
Continuing the conversation when other people speak to you
Counting the good points of others
Joining other people's conversation
Ending the conversation politely
Explaining your own situation
Negotiating With other people who have a different opinion
Expressing negative feelings to others
Ignoring others when they blame you for something that isn't your fault
Letting other people know that they are mistaken

Session 4: The Negative Automatic Thoughts Questionnaire

Below are a series of statements relating to negative thoughts that many people experience. Please read each sentence carefully and then report how frequently those thoughts have crossed your mind during the past week, using the scale provided.

Statement Not at All Not Often Sometimes Often All the Time
1 2 3 4 5
I'm no good
I don't think I can go on
I'm so disappointed in myself
Nothing feels good anymore
I can't stand this anymore
I can't get started
What's wrong with me?
I'm worthless
I'll never make it
I feel so helpless
Something has to change
There must be something wrong with me
My future is bleak
It's just not worth it
I can't finish anything

You scored:

A score of 15-34 represents low levels of negative thinking. This is an area that you already feel very confident with. You clearly are not experiencing any difficulties, but the following pages may still provide you with useful hints and tips.

A score between 35-54 indicates average negative thoughts. If you scored within this range, this indicates that you do experience some trouble with negative thoughts, but no more than many other people. You could find some improvement in your thinking style by examining the following pages.

A score of 55 or over indicates high levels of negative thinking. If your score fell in this range, this indicates that you are prone to think very negatively about yourself and your present situation. By going through the following pages in these sessions you will learn to think more positively, which in turn will help you to feel more confident and content. If you are feeling negative about yourself, it may be worth talking to your GP or contacting someone for support.

Session 5 Quiz: The Hope Scale

Below are a series of items relating to your ability to set goals. Please read each item carefully and select the option that best describes you.

Statement Definitely False Mostly False Mostly True Definitely True
1 2 3 4
I can think of many ways to get out of a tricky situation (belief)
I energetically pursue goals (determination)
I feel tired most of the time (not scored)
There are a lot of ways around any problem (belief)
I am easily beaten in an argument (not scored)
I can think of many ways to get the things in life that are most important to me (belief)
I worry about my health (not scored)
Even when others get discouraged, I know I can find a way to solve the problem (determination)
My past experiences have prepared me well for my future (belief)
I've been pretty successful in life (determination)
I usually find myself worrying about something (not scored)
I meet the goals that I set for myself (determination)

You scored (Determination towards goals)

If your score was between 4 and 7, this indicates that you do not have much determination towards completing goals successfully. This may be because you have found goals difficult to achieve in the past. By going through the following pages in these sessions you will learn to improve your ability to set goals.

A score between 8-11 indicates adequate determination. If you scored within this range, this indicates that your determination to successfully complete goals is quite good, but could do with some improvement. You may find the following pages useful in enhancing your goal setting abilities.

A score of 12 or over indicates high levels of determination. This is an area where you already feel very confident. You clearly are not experiencing any difficulties, but the following pages may still provide you with useful hints and tips.

You scored (belief in your own ability to set goals)

If your score was between 4 and 7, this indicates that you do not have much confidence in your ability to succeed when it comes to goal setting. You may find that this section of the program and the section on thought processes will help you to improve your belief in yourself.

A score between 8-11 indicates adequate self-belief. If you scored within this range, this indicates that your belief in your own ability to set goals is quite good, but could do with some improvement. You may find the following pages useful in enhancing your goal setting abilities.

A score of 12 or over indicates high levels of self-belief. This is an area that you already feel very confident with. You clearly are not experiencing any difficulties, but the following pages may still provide you with useful hints and tips.

Session 6 Quiz: Fear of Negative Evaluation Questionnaire

Below are a series of items relating to the fear of negative evaluation. Please rate each item using the scale below to indicate the response that best represents the extent to which you agree with the item. If any of the items concern something that is not part of your experience, answer on the basis of how you think you might feel if you had such an experience. Otherwise answer all items on the basis of your own experience.

Statement Very little A Little Some Much Almost Always
1 2 3 4 5
Sometimes I think I am too concerned with what other people think
I worry about what kind of impression I make on people
I am afraid that people will find fault with me
I am concerned about other people's opinions of me
When I am talking to someone, I worry about what they may be thinking of me
I am afraid that others will not approve of me
I am usually worried about the kind of impression I make
I am frequently afraid of other people noticing my shortcomings
I worry what other people will think of me even when I know it doesn't make a difference
It bothers me when people form an unfavourable opinion of me
I often worry that I will say or do the wrong things
If I know that someone is judging me, it tends to bother me

You scored:

A score of 12-27 represents low levels of fear of negative evaluation. This is an area that you already feel very confident with. You clearly are not experiencing any difficulties, but the following pages may still provide you with useful hints and tips.

A score between 28-43 indicates average fear of negative evaluation. If you scored within this range, this indicates that you do experience some fear of being negatively evaluated by others, but no more than many other people. The following pages could help you to feel more confident in social situations.

A score of 44 or over indicates high levels of fear of negative evaluation. If your score fell in this range, this indicates that you do tend to worry too much about what other people think of you. By going through the following pages in these sessions you will learn to act more positively, which in turn will help you to feel more confident.

Session 7 quizzes

Anxiety

The question below asks you to rate your feelings of anxiety on a scale of 1 to 10, where 1 is not really anxious at all and 10 is really very anxious indeed.

Do you experience anxiety related to social situations?

Scale 1 to 10

You scored:

A score between 1-3 represents low anxiety. If you rated your anxiety from 1-3, it is unlikely that this is causing you a problem.

A score between 4-7 indicates slightly high levels of anxiety. Although not necessarily a problem, you may find some of the techniques to reduce social anxiety useful to help you cope more effectively

A score of 8 or over indicates high levels of social anxiety. This is an area that may be causing you difficulty, and if it hasn't already, it could make you avoid stressful situations. This is what Face IT is here for. The program will help to learn to manage your anxiety more effectively, and will help you to get along much better.

Depression

The question below asks you to rate your feelings of depression on a scale of 1 to 10, where 1 is not really depressed at all and 10 is really very depressed indeed.

Do you experience depression associated with your appearance?

Scale 1 to 10

You scored:

A score between 1-3 represents low depression. If you rated your depression from 1-3, it is unlikely that this is causing you a problem.

A score between 4-7 indicates slightly high levels of depressive symptoms. Although not necessarily a problem, you may find some of the techniques to reduce negative thinking and isolation useful to help you cope more effectively

A score of 8 or over indicates high levels of depressive symptoms. This is an area that may be causing you difficulty, and if it hasn't already, it could prevent you living your life to the full. This is what Face IT is here for. The program will help to learn to manage your depression more effectively, and will help you to get along much better. If you feel you need more help please speak to your GP who will be able to help you.

Appearance

The question below asks you to rate your feelings about your appearance on a scale of 1 to 10, where 1 is not really concerned at all and 10 is really very concerned indeed.

Are you concerned about the way you look?

Scale 1 to 10

Do you think others are concerned about your appearance?

Scale 1 to 10

Have you experienced negative responses from others due to your appearance?

Scale 1 to 10

You scored:

A score between 1-10 represents low appearance-related concerns. If you rated your appearance concerns from 1-10, it is unlikely that this is causing you a problem and that you feel that other people generally respond well to your appearance.

A score between 11-20 indicates slightly high levels of appearance concerns. Although not necessarily a problem, you may find some of the techniques in Face IT useful to help you cope more effectively. This score indicates that you tend to feel that people are bothered by your appearance. Although not necessarily a problem, this is an area that needs addressing, as there are many ways to help you to overcome your concerns about the responses of others and your feelings of social stigma.

A score of 21 or over indicates high levels of appearance concerns. This is an area that may be causing you difficulty. This is likely to cause you real problems in social situations. Face IT will help you to learn to manage your appearance concerns so that you can get along much better.

Social Interaction

The question below asks you to rate your difficulties in relating to other people on a scale of 1 to 10, where 1 is not really any difficulties at all and 10 is very severe difficulties indeed.

Do you have difficulties interacting with other people?

Scale 1 to 10

Do you experience anxiety about going out?

Scale 1 to 10

Do you feel very cut off from other people?

Scale 1 to 10

You scored:

A score between 1-10 represents low levels of social interaction difficulties; it is unlikely that this is causing you a problem.

A score between 11-20 indicates slightly high levels of social interaction difficulties. Although not necessarily a problem, you may find some of the techniques to increase your social skills useful to help you cope more effectively.

A score of 21 or over indicates high levels of social difficulty. This is an area that is really causing you difficulty. This is what Face IT is here for. The program will help you to learn effective social skills so that you can meet new people and increase your social support.

Goal Setting

The question below asks you to rate your ability to set realistic goals for yourself on a scale of 1 to 10, where 1 is not really very successful at all and 10 is really very successful indeed.

Are you successful at setting realistic goals for yourself?

Scale 1 to 10

You scored:

A score between 1-3 represents low success at goal setting. This is an area that may really be causing you difficulty. Don't worry though, that's what Face IT is here for. The program will help to learn to set realistic, achievable goals for yourself which will help to build your confidence.

A score between 4-7 indicates reasonable levels of success when it comes to goal setting. Although not necessarily a problem, you may find some of the techniques rating to realistic goal setting useful to help you to build your confidence further.

A score of 8 or over indicates high levels of success with goal setting. This indicates that you are confident in your ability to set achievable and realistic goals for yourself.

At the end of the session, individuals are asked to conduct a short task during the week between sessions called the “3-2-1-Go” technique, often employed by the charity Changing Faces in their group skills workshops (outlined by Blakeney et al, 2008), which can be seen at the end of session 1 of Face IT.

Making a referral to Face IT@home

Using CAR's tiered approach to psycho-social support provision, which recognises that interventions should be available at different levels of intensity to meet various levels of need (see Figure 3), we intend Face IT@home to be a Level 1-2 intervention. It therefore does not require supervision. The Face IT online tool (www.faceitonline.org.uk) in a level 3 intervention and therefore requires supervision from a psychologist, counsellor or suitably trained health professional. If you have a patient that you think might benefit from Face IT@home or FaceItonline, please contact us: Tel: 0117 328 3967 Email: info@faceitonline.org.uk

CAR Framework

Who can refer people to Face IT@home?

People can be referred to Face IT@home by Health Professionals (for example: psychologists, social workers, specialist nurses, hospital doctors and GP's) and by charitable organisations who currently provide psychosocial advice and support for appearance-related conditions, for example Changing Faces. People can also self-refer.

Who can use Face IT@home?

The program has been designed for:

  • People aged 18+ years.
  • Those expressing appearance concerns or appearance-related anxiety.
  • Those with a condition known to alter appearance, for example:
    • Skin conditions: for example vitiligo, acne, ichthyosis eczema, or other conditions that affect the texture of the skin, such as neurofibromatosis and epidermolysis bullosa.
    • Scarring: resulting from an accident, surgery or burn.
    • Medical treatments: for example hair loss, skin or weight changes as a result of chemotherapy, radiotherapy or steroid therapy.
    • A condition that has been present from birth, such as a cleft lip or other craniofacial conditions.
  • Those who are fluent in speaking English with normal or corrected to normal vision. However the program does have an audio option for those who struggle to read text.

The program is not suitable for those:

  • With a history of clinical depression or psychosis.
  • With an eating disorder.
  • With post traumatic stress disorder (PTSD).
  • With a learning disability severe enough to compromise informed consent.

For further information please contact Alyson Norman, Lead Researcher.

E-mail: alyson.norman@plymouth.ac.uk.

Tel: 01752 584844

Or Emma Thomas, CAR Research administrator

E-mail: emma7.thomas@uwe.ac.uk

Tel: 0117 3283967

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