Tuesday, 13 August 2013

The psychology behind cosmetic intervention decisions

The great Aristotle said "Personal beauty is a greater recommendation than a letter of reference." This adage today is held so close to the heart! Is it the yearn for everlasting youth? Or the undying wanton of perfection? Is our purpose on this earth as aesthetic practitioners to restore what once was and maintain it? Or rather, is it to remove all traces of facial and bodily imperfections, perceived or actual? Is the needle or the knife always the solution?

Life today, alas is no longer about embracing our imperfections and frailties, rather, about soldiering on in battle to defeat them and proving to the world that we are perfect………… and quite naturally and effortlessly so, needless to say! For every problem known to man, there are self-help books and counselors in plentitude……….. and for those not so confident in their outwardly appearance, we are there! But really, we are all aware that there is a line to be drawn, and it’s not that fine. However, where do we draw it? Is the onus on us, as practitioners equipped with the adequate training, and expertise? When do we say no? And when does it dawn on us that perhaps that very line has already been crossed? Are there any remedial solutions then?

We are all too familiar with the patient who insists on natural looks, yet returns again and again for toxin top-ups until every hint of muscle movement and god forbid wrinkle is well and truly abolished, her forehead thus resembling a polished marble egg. And who of us hasn’t been hailed the new savior by the patient who just walked into the surgery? Five minutes into the consultation, Mrs. Jones is heaping exultation on you, and just knows – she has that innate hunch - that you are astonishingly gifted, and that you will be the restorer and provider of her ravishing youthful looks. This is of course in sharp contrast to the six other aestheticians she’s seen before you, who just happen to be plain stupid, don’t understand her needs, one is an utter butcher, the other couldn’t even hold a conversation, the other left her looking like a chip munk and the last one turned her into the joker from Batman! Any bells of familiarity ringing yet? Well, if the bells aren’t ringing, the red light should be flashing!

Recent studies have shown that a larger proportion of individuals seeking cosmetic interventions suffer from psychological and psychiatric co-morbidities than the general population. One study, Malick et al (Journal of Plastic and Reconstructive Surgery May 1998) states that up to 47.7% of cosmetic patients demonstrate traits of psychiatric co-morbidity. While we have all come across a patient here and there who is blatantly suffering from body dysmorphic disorder and know to tread carefully, many of our patients present more subtly. Many people might come across as ‘doctor shoppers’ and will be extremely savvy with technical terms and might also have a knack for intimidating the practitioner and persuading him into performing a procedure he might deem unnecessary or inappropriate.

Out there, plenty of literature exists exhorting us to learn to love our flaws, as they are not such but marks of individualism, making each of us unique and distinctive! In sharp contrast however, when it comes to the fa├žade we present to the world, things are not quite so. Modern society and celebrity culture repeatedly epitomize the yearn to covet unchanging youth and age-defiant beauty. The contemporary consumerist civilization that defines the noughties and the noughtiers dictates that wants tend to override needs. Whereas most forms of medical and surgical interventions are largely unwelcome necessities, cosmetic treatments are purely elective procedures that a (usually) otherwise healthy individual seeks to undergo as a means to improve appearance and to restore that ‘feel-good’ factor.
Fifteen years ago, facials, Botox and regular trips to the hairdresser’s were emblematic of those with enough disposable income and ample time on their hands. Today the desire to be one of the "beautiful people" has developed into an obligatory tool for success in the professional world too. This in itself is part of the psychology that fuels the industry. Looks matter more than ever before.

In most cases, patients start to notice the appearance of lines on their face when they move the underlying muscles. As these lines morph into a static rhytids, some people dislike the way their skin now looks and opt to restore it to its former appearance. Most of these individuals seek a natural look and are content with the results. A similar theory applies to ‘mummy make-overs’. As the age of motherhood increases (and we largely have our high-flying careers to blame for this), abdominal skin doesn’t quite spring back to its original contours and elasticity so easily. The key point is to seek out the patient’s motivations and expectations. Hence, the invaluable worth of the consultation, especially the initial one.

It is worthy to note though, that many patients embark on their cosmetic journey with what we would objectively call a reasonable outlook. This is to look good and more importantly to feel good. It has been proved that these treatments, especially the less expensive, minimal discomfort non-invasive procedures can fuel an addiction. We the practitioners do little to ameliorate this situation. Easy access is granted to our services with most of us offering free consultations. “Is the start of a wrinkle? Oh no!! Nip out to lunch, grab a shot of Botox on the way?” “Ooh it’s Friday, no big plans this weekend. Hmmmm, lips or Dermaroller?” This could evolve into a vicious circle of brow lift here, cheek enhancement there, neck lines next week etc… at an alarming rate.

What do we look out for? How do you detect the metamorphosis of a seemingly sound individual into a dysmorphophobe? When do we start to entertain the thought that the beauty conscious lady (or gentleman) is now leaning towards ‘cosmo-junkie’ status? Are there any other sinister traits we should be on the look-out for? And more importantly, when do we bite the bullet and refuse to treat a patient or delicately refer her for psychological help? While our professional training has left the large part of us immaculately skilled with the knife, needle or drill, our training in such issues is limited to that brief interlude during our under-graduate years, when we merely flirted with the notion of psychiatry for a couple of months. Hence, most of us are rather ill-equipped to diagnose such afflictions and deal with them in a timely and appropriate fashion. It is hardly easy to turn to your loyal patient who has been on the receiving end of your needle for so many years that she’s part of the furniture, and say “Well, I think you might need psychological help”

What happens when one scratches the surface of a simple thought like, "I'd like to look more attractive." yields a whole myriad of different and surprising results. When one begins to deliberate on this idea, subconsciously acknowledging the trouble-free access to a plethora of solutions to the quandary at hand, it is easy to comprehend the nascence of a fixation and it’s development into something more sinister. Underneath that initial thought, all kinds of intuitive messages are rallying for attention.

For people with realistic expectations, cosmetic interventions can positively enhance body satisfaction. It is key to actively seek what the patient is trying to achieve with this treatment, and whether she is happy with her overall appearance. If she is accepting of her face and body but dislikes one particular feature and wants it restored, enhanced or corrected, the chances are that she will benefit from the treatment both physically and emotionally. Setting realistic achievable goals is an imperative part of the consultation. In repeat patients, these questions need to be re-addressed and the patient’s outlook explored to ascertain that no unhealthy trends are developing.

Body image dissatisfaction is inextricably linked with self-esteem issues. While most of the time, cosmetic interventions might go a long way to help to fortify and replenish such self-image wellbeing; it has been shown that extensive procedures may in fact be detrimental to the psyche. Patients suffering from body dysmorphic disorder obsess over inexistent physical flaws or exaggerate barely noticeable defects. In 2006 a study carried out in Germany noted that this affects 2% of the population. The benefit gained from cosmetic interventions tends to be fleeting and effects last only until the patient develops a new focus of obsession. Promise of improvement and change of physical appearance is extremely alluring and expectations rise beyond the attainable. These are the patients who are rarely satisfied with the results of their treatments.

A content patient will very often return with “Doctor, what else do I need?” While this is testament to the quality of the treatment provided and is evidence of a doctor-patient rapport built on trust, it may well be the open-ended beginning of a very slippery slope. Cosmetic treatments per se, are never indicated for health reasons and are largely a matter of opinion. Beauty is in the eye of the beholder, and when in our surgery, the patient herself should be the said beholder, not the holder of the needle!

It isn’t that unusual to come across other difficult personality traits that might be a challenge to manage. Histrionic personalities tend to over-dramatize issues, are confrontational, melodramatic and rather emotionally volatile, especially when met with criticism or disparity of opinion. These are the patients most likely to doctor-hop and heap insult on the poor preceding practitioners. Delicate handling is a must, if not, such patients may well be injurious to an otherwise hard-earned fine professional reputation. This trait is usually commoner among (but by no means exclusive to) the fairer sex. A note of caution to male practitioners: ladies exhibiting these features tend to be rather over-the top and unrestrained in making sexual advances on those they consider to be in a position of superiority to themselves.

Whereas women are more apt to displaying signs and symptoms of emotional or psychological instability, men are by no means exempt from either of the above-mentioned conditions. More common to the male sex is the narcissistic personality disorder. This seldom manifests as a full-blown personality disorder, but as a characteristic that one might come across while speaking to the individual. This group of people comes across as egotistical and self conceited with little regard or empathy, if any at all, for those around them. An air of grandiosity and self-importance is an accompanying factor.

Increasing attention has been drawn to the psychological implications of cosmetic interventions. This is perhaps in part due to the rising toll of medico-legal litigation. Various guidelines are in place, facilitating a more straightforward method of comprehensively integrating psychoanalysis in the initial consultation. Questions pertaining to social behavior, past psychiatric issues (especially depression, anxiety or eating disorders), patient self-assessment on perceived physical flaws should be asked as open-ended questions, and where deemed necessary, probed further. The patient’s motivational factors bringing her to seek treatment should be explored and elucidated, together with obtaining an idea as to whether the patient can afford the treatment, or is she taking out a loan. Is this a last means of desperation for her? Does the patient fully grasp the ensuing consequences of the procedure in question, and its risks? Does she have the necessary education and maturity to rigorously follow post-procedure protocol? Are the patient’s emotional reactions appropriate to the circumstances? This list is by no means exhaustive, but such questions provide insight to a patient’s psyche, and might be useful in staving off potential disasters.

The mere suggestion of cognitive behavioral therapy is rarely met with pleasure and gratitude, rather with hostility and “who do you think you are?” Numerous diverse methods of approaching this situation and conveying your professional concern exist. Perhaps the thorniest challenge is refusing to perform the treatment in question. When placed in a situation where our misgivings cause us to be ill at ease performing any procedure, the astute practitioner would deem it prudent to wait it out, make clear to the patient (in plain words) his concerns, and ask the patient to reconsider her choices. At the end of the day, a cosmetic treatment is never an emergency.

While it is important to recognize our role as clinicians with a duty to our patients, it is important to ensure the patient acknowledges her responsibility in taking this decision to be treated on a voluntary and elective basis, with no causal factor other than as aspiration for the improvement of appearance.

Although many cosmetic clinics are under pressure to keep the business afloat, and most of us do thoroughly enjoy applying our manual skills, at the end of the day it is our responsibility to respect the Hippocratic Oath, “first do no harm”. The wellbeing of the patient, cosmetic or otherwise is imperative to the integrity of our practices. The relevance of psychological issues in the undertaking of aesthetic treatments is well recognized. In repeat treatments, the patient can be in and out within ten minutes. This begs the question “Is this good medical practice?” It’s not as simple as hello this is the explanation, these are the risks, sign the consent form, treatment – there you go - and see you in a fortnight! The key take-home point is ensuring that the patient’s expectations are realistic and that a thorough consultation identifies actual or potential problems. When signing the consent form, the patient should be well versed in the potential risks and anticipated outcomes. Expectation management is an integral part of our communication skills. An element of the aesthetic practitioner’s expertise is his aptitude as a discerning psychoanalyst. A patient is never a blank canvas, but an exclusive inimitable sculpture, which has already weathered some storms and displays the signs of the times. While this fleshy envelope, which we present to the world, succumbs to genetic and environmental factors and insults, the will to maintain the illusion of youth and beauty persevere.

Most of us are certainly extremely talented in our field. Alas, this does not translate into “we are omni- and totipotent”. Knowing when to say no and when a referral to our psychiatric colleagues is warranted is part and parcel of what makes a good doctor a brilliant one. At the end of the day, it is better to turn away a patient, than to disappoint her. A happy patient tells five people. An unhappy patient tells a staggering twenty!!

1 comment:

  1. This is an informative post. Aesthetic doctors which provide aesthetic services should have proper training from reputed institute like http://www.theharleystreet.com/ which provides professional training by experts.