Consultant plastic surgeon Mr Ibby Younis discusses the importance of psychological education and training for professionals working in the aesthetics specialty
Cosmetic and aesthetic interventions in the UK are popular treatments. It is difficult to find current non-surgical statistics to reflect this; however, according to the British Association of Aesthetic Plastic Surgeons (BAAPS), 31,000 people went under the knife in 2016. Although this figure was significantly lower than 2015, with 40% more procedures, BAAPS acknowledges that this decrease could be attributed to the rising popularity of non-surgical cosmetic procedures.1
In addition, reports by GBI Research indicate that the global facial aesthetics market will experience rapid growth from $2.5 billion in 2013 to $5.4 billion by 2020, at a compound annual growth rate of 11%.2 Taking these significant developments into account, safety and duty of care have never been more important. However, it’s not just physical safety that should be a priority, but the mental wellbeing of patients too.
It is not unusual for aesthetic practitioners to consult with patients who are showing the signs of depression, psychosis and body dysmorphic disorder (BDD). According to The Body Dysmorphic Disorder Foundation, surveys have suggested BDD affects about 2% of the population3 and studies have indicated that of individuals who seek aesthetic medical treatments, 5-15% suffer from BDD, suggesting that it is common for these types of patients to present for treatment at an aesthetic practice.4,5
It is also not uncommon for symptoms to go undetected until after procedures. According to the Foundation, there has been very little research on the treatment of patients with BDD, however, in a study of 265 surgeons, 84% reported having operated on a patient only to realise postoperatively that they had BDD.5,6 This could be because screening processes are not always rigorous enough and, in some cases, BDD might not be detected until after a number of consultations.
I believe all practitioners offering aesthetic treatments should have extensive, compulsory psychological training and that they should conduct mandatory patient screening before offering aesthetic treatment to patients
The issue is that not all practitioners may recognise that some conditions may appear in different ways according to individual patients and that patients may not show symptoms all at once, so a quick diagnosis can be difficult.
To help avoid such circumstances, I believe all practitioners offering aesthetic treatments should have extensive, compulsory psychological training and that they should conduct mandatory patient screening before offering aesthetic treatment to patients.
Whilst procedures are designed to meet what patients consider as desirable aesthetic outcomes and may, in some cases, alleviate psychological suffering,5 more serious mental health conditions may worsen following intervention.
A small prospective study of cosmetic surgery patients who requested treatment for minimal defects found that the majority of those who had BDD received surgery (seven out of 10 patients) and, at follow-up, most continued to have BDD and had developed new appearance preoccupations.5,7
However, in contrast to this, in a study of 250 people with BDD, 66% of patients had received cosmetic treatment for BDD concerns had no change in BDD severity.8 It is important to note that more severe issues can occur when psychological conditions such as BDD are not recognised. According to a 2007 study by Phillips, global rates of suicidal ideation, suicide attempts, and completed suicide appear markedly elevated in BDD sufferers.9
Medical degrees include compulsory psychology teaching and one of the required clinical rotations for medical students is psychiatry, but psychological issues are not always a huge focus of study. Nearly all nursing degree programmes include some psychology courses,10 whether a basic course in general psychology or specialised courses in patient psychology that focus on the mental states of ill or injured people.
Nurses who are working on an advanced degree will typically take more courses on psychology than those with basic training. I think a key issue is that psychological education, specifically BDD, is not a prioritised point of study in many courses, so when individuals move into their chosen professions, they may not be educated enough in BDD to know how to screen out patients with the condition.
I believe more compulsory psychological training should be provided at education level. There should also be a larger focus on training for such conditions when individuals start their professions and refresher courses offered throughout their careers, which will update professionals on new research and findings, so psychological education can remain as up-to-date as possible.
This would arm practitioners who are performing surgical and non-surgical cosmetic interventions with the knowledge needed to handle difficult consultations, with patients exhibiting poor mental health and BDD.
It would also make them better equipped to spot certain behaviour ‘warning signs’ more quickly and easily, thus enabling practitioners to be more scrupulous about who they consider for treatment.
Another option, which I believe would be beneficial, is for aesthetics professionals to introduce formal screening tools in clinics nationwide, a practice suggested by The University of the West of England’s Centre for Appearance Research.11
Psychiatric questionnaires can offer a way to protect patients from unwarranted medical treatment and to pre-emptively defend practitioners from legal and physical attacks, however I don’t think enough aesthetic practitioners are doing this. Psychological screening can help to speed up the decision-making process, but as articulated by Norman Wright, a psychotherapist who works with cosmetic surgery patients, aesthetic practitioners ‘need to look at the person behind the patient’.12
Consequently, I believe screening is not the only answer. This is mainly because due to the secretive nature of BDD sufferers, some symptoms won’t present themselves until quite a way into the procedure process and may also not present themselves all at once, making it harder to diagnose the conditions. It is also likely that some patients may not be honest about their mental wellbeing, in anticipation of a practitioner refusing treatment.
At the surgical clinic I practise at, MyBreast, we believe the more scrupulous, face-to-face time that surgeons and non- surgical aesthetic practitioners have with the individual, the better. The latest GMC guidelines highlight that all industry professionals must give patients time for reflection and that they need to have the time and information about risks, to decide whether to go ahead with a procedure.13
If unsure about someone’s psychological wellbeing during consultations, all potential patients should be referred to a psychologist or psychiatrist for further evaluation
More guidance aimed specifically at surgeons recommends that they should implement a two-week cooling-off period before any surgery is carried out.14 At MyBreast, individuals are welcome to return to us for additional consultations at no additional cost, to ensure the surgeon and patient are ‘on the same page’ at the end of that journey. We charge a small fee for the first consultation, which we deduct from the overall cost if a patient decides to go ahead with a procedure.
In our experience, two consultations suffice for 80% of cases, the rest may need three. However, it is very important not to waste a patient’s time during the process as well. If we think necessary, we may advise a patient that the treatment may not be for them, if after a certain number of appointments we cannot reach a satisfactory decision.
If unsure about someone’s psychological wellbeing during consultations, all potential patients should be referred to a psychologist or psychiatrist for further evaluation. Of course, care should be taken to ensure the patient fully understands why you are referring them and how seeing a specialist will benefit their overall mental wellbeing. At MyBreast, we use a team of very experienced, fully accredited and highly trained psychologists who specialise solely in body image issues and work closely with surgeons in the NHS.
Specialist cognitive behavioural therapy (CBT) has been demonstrated to be effective for those with BDD, which psychologists tend to specialise in.15 CBT is based on a structured programme to enable patients to learn to change the way they think and act.16
Any procedure that can make someone feel better about how they present themselves to the world is worth considering. Part of that consideration, however, includes the risk/benefit ratio of the procedure.
If practitioners who are conducting medical interventions all have sufficient psychological education, as well as effective screening, unlimited consultations and extensive face-to-face time, it will mean fewer patients with mental health problems will be missed and will receive the appropriate support and treatment they need.
Mr Ibby Younis is a consultant plastic surgeon specialising in breast reconstruction at MyBreast clinic.
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