The feasibility and acceptability of psychology in aesthetics appears reasonably permissible; however, conflict and taboo can still be found within the implementation of this specialism that creates a barrier to true cohesive and effective practice. One explanation for this is that for some practitioners' psychological assessments are considered as deterrents due to the fear of loss of demand for aesthetic services, as well as the notion that asking too many questions about emotions might imply that something is ‘wrong’ with the patient. Either way, it is commonplace to disregard their use or avoid any emotional detailing of a patient, creating a precarious position for the patient and the practitioner, as opportunities are being missed to safeguard through the provision of holistic integrated care. This is increasingly relevant given that, in July 2021, the All-Party Parliamentary Group (APPG) on Beauty, Aesthetics and Wellbeing made specific recommendations that:
- ‘The Government must work with the aesthetics industry on the development of psychological pre-screening tests to cover a range of broader psychological vulnerabilities and make these mandatory prior to a consumer undergoing an aesthetic non-surgical cosmetic treatment
- Education on spotting at-risk individuals, covering a broad range of psychological vulnerabilities, must be included in national minimum standards for the training that practitioners must be required to undertake to be qualified to deliver aesthetic non-surgical cosmetic treatments
- The Government must extend the legal ban on under 18s receiving Botox or fillers to other invasive advanced aesthetic non-surgical cosmetic treatments including PDO cogs and threads’ (APPG on Beauty, Aesthetics and Wellbeing, 2021).
Psychological assessment
With no single accepted psychological assessment tool available for use within the non-surgical aesthetics arena, it is imperative that the sector unites to seek understanding of the effects that psychological tools have on treatment outcomes and patient–practitioner satisfaction. This will assist the Government in developing mandatory psychological pre-screening assessments that include a broad range of emotional and psychological vulnerabilities for all consumers seeking an aesthetic treatment. The limiting view that psychological assessment tools are simply dichotomous diagnostic tools used to identify psychopathology (for example, body dysmorphic disorder (BDD) or major depressive episodes) perpetuates the misunderstanding of psychological application in aesthetics.
All patients must be carefully assessed prior to the provision of any aesthetic treatment to identify emotional or psychological disorders or vulnerabilities that promote inappropriate motivations and/or unrealistic expectations. The BDD Foundation is advancing its case for mandatory psychological assessments in any cosmetic treatment given the precarious misconception that those with BDD will be ‘cured’ by undertaking any number of aesthetic procedures. In fact, the evidence is contrary and firm that appearance dissatisfaction will remain, if not intensify, after aesthetic interventions (BDD Foundation, 2021).
A valid assessment tool used by a suitability equipped assessor has the scope to guide informed consent as an improved and meaningful process of patient selection. This can include offering psychoeducation regarding the divergence in appearance norms, and perhaps challenging patients' beliefs about the role of appearance and self-worth. This refutes the unhelpful view that a self-reporting diagnostic tool will reveal a ‘pass’ or ‘fail’ for treatment access.
Having access to a multidisciplinary care team or referral route for specialist psychological support and intervention is recommended alongside any relevant assessment. Most patients are motivated to seek aesthetic, cosmetic or non-surgical interventions by psychological factors and may, therefore, expect the aesthetic intervention to result in improvements in psychological or emotional health and wellbeing. It could be argued that psychologists should be included as core members of any aesthetic team.
The Joint Council for Cosmetic Practitioners (JCCP) has firmly recommended the inclusion of a psychological assessment to ensure safe patient selection and to distinguish a particular treatment pathway. By definition, the use of a ‘psychometric’ was a factor for an explicitly defined point of assessment and onward treatment journey (JCCP, 2021a). Efforts to find a clear definition of what constitutes a medical, medically related or cosmetic treatment, to be satisfied by law, as proposed in the JCCP 10-point plan, will continue (JCCP, 2021b)..
Psychological vulnerabilities are significantly higher in patients seeking aesthetic treatments
Assessing the vast idiosyncrasies within presentations of appearance dissatisfaction through traditional self-reporting psychological assessment tools give rise to the obvious bias, untruths and secretiveness. With this in mind, any assessment cannot be effectively constructed or implemented in isolation. Achieving an informed understanding of the emotional aspects of an aesthetic treatment is essential and can be achieved and expanded upon by embedding an evidence-based approach to psychological and emotional assessment as an integrated component of clinic management.
Emotional aspects
The Mental Health Foundation, British Beauty Council and the JCCP collectively engaged in June 2020 to consider how to best inform this debate and produced and distributed a range of public and practitioner facing toolkits relating to emotional and psychological health and wellbeing (Mental Health Foundation, 2021). Based on the moving accounts of consumers' lived experiences, these guides proved to be extremely powerful to raise awareness of the significant emotional aspects involved in seeking and undergoing aesthetic, cosmetic or non-surgical treatments.
Acknowledged in the JCCP's 10-point plan (2021b), aesthetic service providers are encouraged to clearly display simple, informative guides on all services provided, including the risks, benefits, costs, qualifications and insurance to members of the public (BDD Foundation, 2021). These small acts of best practice could have a tremendous positive impact in encouraging patients to think more carefully and weigh up the potential risks and benefits of an aesthetic procedure, as intended by these toolkits.
The specific psychological characteristics of people seeking aesthetic treatments is an evolving research area. Therefore, before any generalised conclusions can be made, further inquiry is necessary. The Centre for Appearance Research at the University of the West of England Bristol has made notable contributions to research exploring the emotional aspects of aesthetic consumers to reveal a complex picture (Nuffield Council on Bioethics, 2017; Rumsey and Diedrichs, 2018). Findings include the prevalence of psychiatric and psychological vulnerabilities being significantly higher in those seeking treatments when compared to the general population. Such emotional aspects range from body image concerns, mental health issues (such as anxiety, depression and suicidal ideation) and higher levels of alcohol and drug abuse.
To demonstrate the emotional aspects of an aesthetic, cosmetic or non-surgical treatment, it is relevant to share an emerging picture within related research fields, while a full discussion of emotional attributions stretches beyond the purpose of this article. Such indicative examples include:
- Patients seek to better self-esteem, increase confidence, achieve greater happiness, with a desire to feel better. This may be described as a ‘treat’ by the patient
- Treatment demand can be triggered by life events and changes, for example, pregnancy, ageing, menopause, getting married or a new job
- Such life stages or specific events can lead to patient reappraisal where changes are made with an accompanied view of restoring, reversing or eradicating undesirable physical characteristics as a way of coping with the subjective negative impact upon quality of life or the ability to succeed
- Procedures may be carried out to address longstanding emotional conflicts, such as a feature that has been bothersome since childhood
- Patient treatment outcomes are largely concerned with the immediate effect, rather than any consideration of long-term maintenance or future financial costs for repeating procedures
- Attitudes and motivations for seeking and having aesthetic procedures can be conveyed as expectations of psychological and social benefits. Patients may believe that it is possible to achieve such aims through aesthetic interventions. Some patients also experience aesthetics as being life-enhancing, with gains often experienced immediately after treatment, but satisfaction is seldom sustained. Satisfaction rates must not be assumed to equal that of general psychological wellbeing, prolonged life satisfaction or self-esteem
- The pressures associated with the expectation to conform to appearance ideals, such as youthfulness, exist with a heavy emotional load. Advertising and social media standards are implicated here and represent a cause for concern, as cited in the JCCPs 10-point plan (2021b), given the outwardly influenced perceptions of others' assumptions and subsequent perceived judgement of appearance. These become reflections of changing cultural norms that are believed to be widely valued, with the suggestion that an aesthetic procedure is a commodity to enable conformity. Peer groups are highly influential when making decisions about aesthetic treatments.
In view of the current APPG recommendations and the JCCP's 10-point plan for mandatory education and training standards (APPG on Beauty, Aesthetics and Wellbeing, 2021; JCCP, 2021b), it is imperative that training programmes incorporate the emotional and psychological aspects of treatment(s). Improving the understanding of the broader range of psychological factors, vulnerabilities and processes that contribute to appearance-related dissatisfaction and distress, as well as motivations for seeking treatment, identifying those at risk, improving skills for referral and managing complex cases, are all essential features of any emotionally inclusive training package. Any such training package must also be underpinned by safe and ethical practice, which would be welcomed by insurance companies (JCCP, 2021b).
With the relevant competency, incorporating emotionally informed approaches can serve to counter the emotional fallout from treatments that are rushed into or not fully considered due to external clinic practice pressures, including assessment protocols, for example, not honouring cooling off periods. Emotionally aware practices will actively seek to redress any emotional exploitation or maladaptive treatment intentions that have been communicated as an urgency to ‘fix’ body image dissatisfaction or immediately uphold appearance ideals. Therefore, it is important to provide an evidence-based approach to emotional and psychological assessment and the provision of a mandatory cooling off period to enable the patient to consider the benefits, risks and perceived outcomes associated with their elective treatment programme.
Age limits
The case for the inclusion of psychological and emotional aspects of aesthetic treatment can be considered an ethical obligation given the revelations that the cosmetics industry itself may be a contributor to the pervasive dissatisfaction of body image in women and children (House of Commons, 2021). The Botulinum Toxin and Cosmetic Fillers (Children) Act 2021 (legislation.gov. uk, 2021) is a demonstrable success that seeks to safeguard younger people and emphasise the importance of emotional address and understanding to shape the sector. The legal intention to extend this age of access ban to include other aesthetic treatments empowers the discussion and opportunity to develop and implement appropriate psychological assessments in regard to the consideration of emotional aspects of treatment. This poses interesting considerations around the proposed national complications reporting system as a coordinated process for the reporting and analysis of all adverse incidents (JCCP, 2021b).
» Improving the understanding of the broader range of psychological factors, vulnerabilities and processes that contribute to appearance-related dissatisfaction and distress, as well as motivations for seeking treatment, identifying those at risk, improving skills for referral and managing complex cases, are all essential features of any emotionally inclusive training package «
Conclusion
Patient selection processes are complex and should be treated as such. More quality data is required to advance the application of psychological assessment and emotional factors pertaining to aesthetic treatments, attitudes, motivations and satisfactions. Practitioners must be regarded as part of the solution to implement emotional and psychological concepts, principles and assessments successfully in view of their privileged positions of trust with their patients. Once the emotional and psychological profiles of the beneficiaries of aesthetic cosmetic and non-surgical services are fully understood, practitioners will be better positioned to ensure that any prospective patient is afforded appropriate care that is suitable to their individual needs.