Thoughts on a live debate: is psychological assessment robust enough for patients?

 At the inaugural Clinical, Cosmetic & Reconstructive Expo held in London, a multiprofessional group got together at the 'Great Live Debates' to discuss how patients should be deemed suitable for treatments using psychological assessment. In this article, aesthetic nurse consultant Julie Brackenbury reflects on the key points raised during the discussion and makes recommendations for the future.

The first Clinical, Cosmetic & Reconstructive (CCR) Expo held at London Olympia on 11-12 October was a complete success in the eyes of aesthetic nurses and the event itself exceeded expectations. A true highlight of the event was that members of the medical aesthetic multidisciplinary team had the chance to participate in a live debate to discuss a pertinent issue in the industry - is psychological assessment robust enough for cosmetic patients?

During the debate, all parties agreed that there is nothing wrong with cosmetic procedures. People are and should be as free to pay for treatment for what they see as physical imperfections, or the less attractive consequences of ageing, as they should be free to seek treatment of pain or significant disease. Much of it may have little to do with the treatment of illness, but it is a service that meets a need that people experience (British Association of Aesthetic Plastic Surgeons (BAAPS), 2008).

Psychological benefit or not? During the debate, Nichola Rumsey, Co-Director of the Centre for Appearance Research, University of the West of England, said that literature 'demonstrated cosmetic plastic surgery does not improve patient outcomes and quality of life from a long-term perspective'. This view opposes the opinion of Poole (2012), who commented in retrospect that cosmetic surgery is designed to meet what patients consider to be desirable and may alleviate psychological suffering.

Considering reported motivations to seek cosmetic surgery, such as low self-esteem,
it would seem sensible to have some form of psychological assessment for cosmetic patients. Worryingly, Brunton et al (2013) reported that patients who have suffered from domestic violence, or who have underlying psychological issues are more likely to undergo cosmetic surgery. Further to this, it was reported that their condition may actually worsen rather than improve following surgery. S o it is clear that aesthetic practitioners need to know something of each patient’s psychological history and condition.

The Professional Standards for Cosmetic Practice by the Cosmetic Surgical Practice Working Party (2013) draws particular attention to patients with a history of psychiatric problems, especially eating disorders, body dysmorphic disorder (BDD) or personality disorders.

Concerns about cosmetic gynaecological surgery are also addressed in the standards, and states that: 'High levels of anxiety regarding body image where appearance is within the normal range should trigger psychological referral.' Drummond et al (2013) maintained that it is important that all patients have access to highly specialist services for obsessive compulsive disorder and BDD.

There is clear guidance available from the National Institute for Health and Care Excellence (2005) for health professionals that should be read by all of those working in the medical aesthetic industry. Body dysmorphic disorder Further research examining the long-term outcomes of patients undergoing cosmetic procedures is lacking; however, it is possible that a significant number of patients may experience depression, anxiety and doubts post procedure.

Body dysmorphic disorder is also not uncommon in patients seeking cosmetic surgery. It is estimated that 5-15% of cosmetic surgery patients may be suffering from this disorder (Veale, 2004). Moreover, Crerand et al (2006) suggested that body dysmorphia should be considered a contraindication for aesthetic procedures. Veale and Neziroglu (2010) further stated that psychological treatments are often deemed more appropriate to address patients' needs effectively.

Who is carrying out psychological assessments? It is clear that psychological assessment is needed in medical aesthetics, but who is responsible for doing so? A 2010 report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) suggested that the majority of sites who participated in a survey fell short in evaluating patients for psychological disorders before cosmetic surgery. The report also found that a wide range of health professionals were carrying out the screening, although no evidence was provided as to the quality of this assessment or the method of training of these individuals.

Where an assessment was carried out, it was rare (4% of sites reported as standard) for a patient to see a clinical psychologist. A review of the organisational structures surrounding the practice of cosmetic surgery was carried out by the NCEPOD (2010)
following the report. It recommended that psychological assessment is an important
part of any patient’s cosmetic surgery episode and should be routine; that this part of  a patient’s care must be delivered by those adequately trained; and reliable psychological assessment tools need to be developed.

The national minimum standards which apply to the regulation of private hospitals
offering cosmetic surgery insist that referral to appropriate psychological counselling is
available if clinically indicated before surgery takes place (Poole, 2012).

The future of psychological assessment in aesthetics

Discussing whether psychological assessments are robust enough for cosmetic patients ignited a very relevant and powerful debate. Given that regulation within the industry seems out of reach at the current time, aesthetic practitioners do have the ability to work together to minimise psychological risk and injury to patients who appear
to seek cosmetic procedures for a multitude of reasons. However, it is aesthetic practitioners' duty to ensure that those they treat do not present with existing psychological issues that would lead to future harm.

It is astounding that aesthetic technology is so advanced and new innovations are coming onto the market all the time, yet the field is so far behind on the development of tools and interventions to assess, plan, implement and evaluate psychological support. So, what does the future hold? The University of the West of England’s Centre for Appearance Research is working on the development of tools to assess patients before they undergo cosmetic surgery. However, more importantly, as articulated perfectly by integrative psychotherapist Norman Wright, aesthetic practitioners 'need to look at the person behind the patient'. In the author's opinion, he could not be more right.


British Association of Aesthetic and Plastic Surgeons (2008) Surgeons reveal UK’s largest ever breast augmentation survey. (Accessed 18 October 2013) iStockPhoto\pavlen Brunton G, Paraskeva N, Caird J et al (2013) Psychosocial predictors, assessment and outcomes of cosmetic interventions. A systematic rapid evidence review. (Accessed 18 October 2013) Cosmetic S urgical Practice Working Party (2013) Professional Standards for Cosmetic Practice. (Accessed 18 October 2013) Crerand CE, Franklin ME, Sarwer DB (2006) Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg 118(7): 167e–80e Drummond L, Fineberg NA, Heyman I , Veale D, Jessop E (2013) U se of specialist services for obsessive–compulsive and body dysmorphic disorders across England. The Psychiatrist 37: 135–40 National Confidential Enquiry into Patient Outcome and Death (2010) Cosmetic Surgery: On the Face of It. (Accessed 18 October 2013) National Institute for Health and Care Excellence (2005) Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder. (Accessed 25 October 2013) Poole N (2012) Consent to cosmetic surgery. (Accessed 18 October 2013) Veale D (2004) Body dysmorphic disorder. Postgrad Med J 80(940): 67–71 Veale D, Neziroglu F (2010) Body Dysmorphic Disorder: A Treatment Manual. Wiley Blackwell, Chichest