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Nurses in a counseling role, clinical nurse specialists, occupational therapists and maxillofacial
technicians frequently find themselves in a setting where they spend time with patients as part
of their physical treatment. They are ideally placed to deliver a psychosocial intervention at this
third level of the PLISSIT model. The training days for health professionals at Changing Faces
have included this tier for health professionals working in head and neck cancer. Ideally,
supervision from expert staff such as psychologists should be available.
Computer-based interventions such as FaceIT, developed by Bessell and colleagues, are a
recent addition to psychological treatment and the evaluation of this approach indicates that it is
extremely effective (Bessell et al, 2008). FaceIT could be part of an intervention provided by a
non-psychologist, but has been evaluated as part of package where it is supervised rather than
standing alone. It could also be a very useful addition or first step to an intensive treatment
offered by a psychologist or person with a recognised training in CBT. It offers the enormous
advantage that the intervention can be completed remotely.
Level Four: Intensive Treatment
This final level of intervention relies on specialised training in psychological therapy. The CBT
model outlined in Chapter 6 should be delivered by someone with a relevant qualification in
psychology or training in CBT.
This stepped care model suggests that a non-specialist can provide the first three levels of
intervention to include behavioural approaches to managing problems of visible difference. They
must be provided with additional training; resources and clinical governance arrangements
should be in place to ensure supervised practice. This level of intervention can be effective
when there is:
• Good agreement between objective and subjective assessment of visibility
• Clear evidence of intrusion from other people with concrete examples
• Inadequate social skills, particularly poor eye contact
• Visible safety behaviours – baggy clothes, hats and camouflage, unkempt appearance
• Inability to deal comfortably with staring and questions about appearance
• Preoccupation with appearance is situation specific rather than constant
An intensive intervention provided by a psychologist or other specialist is more appropriate
when there is:
• A mismatch between subjective and objective visibility of appearance
• Multiple appearance-related concerns
• Past history of or current body image concerns
• External shame is assumed in the absence of concrete examples (“no-one actually says
anything but I know what they are thinking”)
• High frequency of checking particularly in the form of reassurance elicited from other people
• Safety behaviours are more internalised
• Preoccupation with appearance is continuous
• High levels of anticipatory anxiety and post event analysis
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