Authors' reply

We welcome Dr Butler's comments and endorse the call for further research in the area of psychological difficulties following disfigurement. While we accept the call for caution, given the heterogeneous nature of our sample, we believe our conclusions are appropriately modest. We do not suggest either that phobic avoidance is the sole element of psychological distress following disfigurement, or that “all social anxiety” in such people has the “ same psychopathology as social phobia”. Indeed, the role of multiple contributing factors to such distress has been emphasised by one of us (Newell, 1991), and we noted our awareness of, but inability to investigate, the role of stigma. Moreover, Newell (1991) stresses the importance of sensitivity when advising of exposure exercises, precisely to reduce the potential for reinforcing negative thoughts and increasing anxiety, as Dr Butler suggests. More generally, the need for individualised treatment has been repeatedly stressed in behaviour therapy and cognitive therapy, although self-help methods (which, of necessity, give general prescriptions of advice which clients modify themselves) show promise. In the context of disfigurement, a simple self-help leaflet (Newell & Clarke, 2000) produced modest benefits relative to untreated controls and of a level roughly similar to those found in a group social skills intervention (Robinson et al, 1996).

Although the nature of the sample is important, it is difficult to obtain participants from this group, as previous studies have found. However, findings regarding gender differences among disfigured people with respect to psychological disturbances have been equivocal, and findings tend to suggest that level of disfigurement is a poor predictor of psychological adjustment.

Exposure therapy is obviously not a panacea, but rather a promising approach to psychological disturbance following disfigurement where social anxiety is present. Dr Butler rightly draws attention to the need for flexible, individually tailored treatment, although this is questioned by some results (Schulte et al, 1992). There is likewise a need to avoid the inclusion of poorly supported interventions, and to build an appropriate evidence base. For example, we know of no studies that demonstrate the effectiveness of grief work among people with disfigurement, and there is likewise little evidence of the effectiveness of other interventions for psychological difficulties following disfigurement, despite the size of the problem.