Session 1: Common Problems

The session starts by explaining that the purpose of the programme 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 young person could be experiencing. These are often described in the words of other young 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 young person with a visible difference. The reality of these reactions is therefore highlighted in this session to ensure young people understand that the programme 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) and highlights the difficulties that young people can experience such as bullying and social exclusion (Lovegrove & Rumsey; 2005).

Research suggests that when people feel they have little control over the teasing or bullying that they experience, learned helplessness may occur. They may then give up and feel powerless (Peterson & Seligman; 1983). At this point in the session the young person is provided with a definition of teasing and bullying, and is encouraged to take control and take action if they feel they are being mistreated or feel threatened. Users have the option to access more detailed information about bullying, including how to manage it and how to get specialist support. They are also provided with the contact details of numerous support groups where they can get more condition-specific advice and more intensive support, for example through counselling services provided by the charity Changing Faces.

This session also introduces some of the misperceptions that can exacerbate feelings of discrimination among young people, and the impact that appearance concerns can have on the young 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 young 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 young 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 young 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 young 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 young person is encouraged to record these (and responses to other activities) in their personal journal that remains available as a permanent record throughout the programme.

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). YP Face IT therefore, for example, asks young 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 YP Face IT. They are designed to encourage young 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 with both adults and adolescents 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).Young people are therefore encouraged to complete these activities and are provided with feedback and the opportunity to contact the YP Face IT 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 young 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. Ten minutes should be put aside at the beginning of each session to go over the homework. 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 YP Face IT 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 YP Face IT can provide, they will facilitate referral to either Changing Faces, the Young Person's 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 and adolescents 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). Being friendly and pro-social can also be a protective factor against bullying and teasing (Tani et al; 2003)

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 young 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 young 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 school activities.

Some young 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 young 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 young person is then provided with four scenarios, each with optional responses to typical (but testing) social situations that a young person with a visible difference might experience. The young 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 young 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.

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 young person can understand why some people respond negatively to those with an altered appearance. The REACH OUT acronym is used to provide young 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 = Humor. 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

Young 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 young 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 young 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 young 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 young 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 young 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 young 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 young 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 young 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 young 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 young people 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 young 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 young 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 young 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 young 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 young person's choice is provided.

Session 4 ends with a homework task. The young 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 young 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 young 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 YP Face IT 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 young people achieve their goals and overcome 'social disability'.

Physical disability is also discussed. YP Face IT is aimed at any young 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.

Young people are introduced to the SMART model of goal setting (Doran; 1981). The aim of SMART is to provide young 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 young 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 young people with visible differences.

Information and advice regarding romantic issues is based on the findings of a study by Griffiths, Williamson & Rumsey (2012), specifically designed to inform this section. Adolescents, with a range of visible differences, were given the opportunity to express romantic concerns related to their visible difference, comment on what support they would like to ameliorate these concerns and express their views on how they would like to receive the support. Although many young people in the study had no more romantic concerns than one would typically expect of any young person, a significant number expressed appearance-related distress that resulted in low self-esteem and a lack of confidence around initiating romantic relations and intimacy. Many felt unattractive to others because of their difference and therefore felt any efforts to pursue romantic relations would be fruitless. They wanted advice on when and how to tell their partner about their visible difference and were concerned about what their partner thought about their difference. Participants suggested that online access to the experiences of young people with a visible difference or an experienced psychologist / counsellor would be the preferred sources of support.

The homework assignment at the end of this session asks young 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 young 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 young 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 young 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 young 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 young 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. Young 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 young 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 young 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 young person since the last session. This may take up to 20 minutes.

The young 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 young 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 young 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.

Session 8: Booster Quiz

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