‘Surgeons are crying out for people to work with them’

Clinical psychologist Dr Alex Clarke and long-time colleague and collaborator Professor Emerita Nichola Rumsey OBE told us that while psychology seems perfectly well placed to improve pre- and post-operative care for patients who opt for aesthetic plastic surgery, very few psychologists are embedded in such services. They are hoping to change that. 'Psychology is to plastic surgery what physiotherapy is to orthopaedics – you wouldn't give someone a joint replacement without being clear you had physiotherapy lined up and someone engaged in their aftercare.' 

Last year Clarke and Rumsey – who have worked together on research at the Centre for Appearance Research based at the University of the West of England for many years – were asked to sit on a working group for the Nuffield Council on Bioethics. While many reports, recommendations and guidelines have been released over the years raising concerns regarding the regulation of surgeons in private practice, the Nuffield Council report also examined wider psychosocial factors behind people seeking out aesthetic procedures.

The report made recommendations at a societal and government level. A diverse range of recommendations were directed towards various official bodies, including government departments of health and education. The need for advertising bodies and social media companies to play a larger role in reducing the rise of body image anxiety was highlighted. The report also pointed to a significant role for psychology in research on the impact of procedures on wellbeing, and potentially screening patients for problems such as body dysmorphic disorder (BDD) prior to surgery.

Rumsey told me the psychological evidence we have within plastic surgery so far is scant and of relatively poor quality. She put this down to several factors: 'Because there's been so little research, because these procedures are carried out in the private sector, and because surgeons and patients seem to be reluctant to take part in research, we don't have an enormous amount of evidence to help us understand what the impacts are.'

There are some suggestions in the literature that the benefits people feel after plastic surgery wear off relatively quickly. There may also be an element of people returning for multiple procedures – but in truth we know very little about the psychology behind plastic surgery, its effects and drivers. 'The media tends to sensationalise cosmetic procedures… you hear about the success stories and also the botch jobs, but we know very little about what happens in the middle.'

There are some established risk factors for poor outcomes in plastic surgery: for example people with BDD may feel they can 'fix' an area of their body via surgery, but afterwards turn their negative attention to another physical feature. This is where psychologists could be key in auditing potential patients, Rumsey said: 'Psychologists would be able to identify risk factors in surgery, such as eating disorders, BDD, and shades of those. They're often talked about as a condition you either have or you don't have, but increasingly we understand because body image dissatisfaction is so prevalent there's lots of disordered eating that hasn't reached the stage of an eating disorder and there's lots of body image distortion that hasn't reached the level of BDD. Some involvement of psychologists in screening and assessing people who might be more at risk would be very beneficial.'

Clarke told me that aesthetic surgery is often offered to people without assessing their expectations from a procedure. People tend to be 'sold' positive psychosocial outcomes that have no basis in reality or evidence: 'The Nuffield report really highlights that whilst we've got this huge burgeoning of body-image anxiety and worry about appearance we need to start trying to understand what predicts body-image wellbeing. It also flagged that surgeons need to be able to recognise psychological issues… not to be able to treat them or become a psychologist, but to at least have the ability to recognise things like body dysmorphic disorder and a need to refer them on.'

The Centre for Appearance Research has been at the forefront of exploring aesthetic plastic surgery in more depth. Rumsey, Clarke and colleague Dr Nicole Paraskeva developed a quick pre-operative assessment aid for surgeons to use with patients to clarify their motivation to undergo the procedure, their expectations of outcome and signs of potential risk factors such as BDD. Yet they were unable to get funding to further their investigations.

Surgeons have responded to the Nuffield report, and one professional body, the British Association of Aesthetic Plastic Surgeons (BAAPS), in association with the Royal College of Surgeons, has developed training that includes a module on psychological issues and risk factors, which Clarke and Rumsey teach. It has also asked them to form a special interest group in psychology; the eventual aim, they told me, is to create a network of practitioner psychologists from health and clinical backgrounds to carry out screening and assessment of potential patients, to act as advisers for surgeons who want to better implement psychology within their practice, to develop auditing methods for patients and to carry out research in this field.

Rumsey said the first stage of setting up the group was to get an idea of how many psychologists are already working with plastic surgeons in the private sector. BAAPS has also offered to extend its surgeon training programme to teach psychologists about surgery and the psychology of the cosmetic surgery patient. 'The hope is that eventually psychologists and surgeons will be offered the training together with specialist sessions within it to allow for more dialogue between both groups. There's a big role for health psychologists in audit research and screening, for clinical psychologists, and possibly counselling psychologists too, for dealing with people before and after procedures who might need additional support.'

Clarke, who previously worked with the charity Changing Faces and within the Royal Free Hospital with people who had had reconstructive surgery, said there's even a lack of psychologists in NHS burns units and other plastic surgery centres where one may expect to find them. She said there may be a slight reluctance for clinical psychologists, who usually train in the NHS and remain there, to work within the private sector.

'The surgeons are crying out for people to work with them to put a better process into place. We suspect there's people out there who'd be interested but haven't got any background, haven't done any training or who are slightly wary of taking this on. But Nicky and I are happy to provide some central input and training so we can get it going.'

While there are so many challenges facing mental health services at present, Clarke said, some psychologists may be put off working in an area that is lower priority in the eyes of funding bodies, but psychologists remained vital. 'There's a lot of really treatable mental health issues in this area. There's the very severe BDD which affects about 1 per cent of the population, but in plastic surgery and dermatology we see much, much higher levels, up to 15 per cent. Also, a lot of people have social anxiety or they come for surgery just when they've had a divorce or lost their jobs and it's the worst time to be making a lifelong decision. There's nothing to stop people bringing children in either – while you can't get a tattoo until you're 18 you can get cosmetic surgery… we don't rule that out and it's ridiculous.'

Clarke emphasised that there was a role for all practitioner psychologists within the special interest group: 'We'd like to get people together and hammer it out. This is about establishing what we think would work, what's pragmatic, how it happens and how we embed it in BAAPS so a BAAPS surgeon can say "I think I have an issue here" or even better "I'm setting up a private practice and need a psychology pathway – who can I talk with to put it into place so it's there if I have issues with patients?".' Eventually, Clarke said, she hopes it becomes accepted among patients that having a cosmetic procedure will often require a visit to a psychologist, which may lead to an intervention prior to surgery, for example. She emphasised, however, that psychologists would not act as gatekeepers to surgery.

On the RCS professional skills masterclass, surgeons are taught about the growth in body-image anxiety and what has driven it, and how to spot patients who may not have a good outcome from surgery. 'It's terribly important people are able to identify body dysmorphic patients and people who are pretty unlikely to do well. It's about flagging up how these people present themselves. You can read in a paper about signs and symptoms, but what do you look for when someone comes in the door and sits down and you start to have a conversation, what are the things about them that make you think "I'm not quite sure I'm going to be able to meet this person's expectations?",' Clarke said.

Surgeons are also taught about managing consultations, how to help patients who are upset, identifying whether motivation for surgery comes from the patient themselves or someone else, and looking for other potential red flags. Clarke added: 'I teach people not to jump in too soon. If you have a quiet patient who doesn't quite seem to know what they want done, to try and explore what sits behind that, asking them things like – if your nose was different and you were more comfortable with it – what would be different about your life? Trying to get at some of the psychosocial reasons behind it.'

In these sessions Clarke also emphasises that there's very little relationship between a person's objective appearance and their psychosocial distress or satisfaction: 'You often can't quite pin down what a person doesn't like about their appearance, or they sit down and you think "I see what the problem is here they've got an enormous chin", and they'll say "I'm really worried about my breasts"… what you perceive as an onlooker often has nothing to do with a person's worries, so you've got a real challenge in thinking about your goals for surgery. You aren't seeing what you're patient is seeing.'

When surgeons are explaining procedures and potential outcomes, Clarke said, they need to be very careful: 'You can say generally breast reduction surgery has a very good outcome – or the best outcomes out of the range of procedures. People's neck pain tends to be improved but it's still quite scarring and you can get numbness, so it has downsides and potential risks. But in terms of the other procedures we have very little evidence and particularly little evidence on psychosocial outcomes.'

For psychologists the training would help to teach them about common aesthetic procedures, what is known about the outcomes of these, their common pitfalls and how to prepare people for surgery. 'When I first started in this area people were very suspicious about being sent to a psychologist, but that had shifted by the time I left the Royal Free. People can't believe there's no psychology in a lot of services and it should definitely be there. Not everyone needs to see a psychologist, it's a lifestyle choice for a lot of people who've gone into it, have thought about it, are perfectly capable of making their own decisions, are very clear about their expectations and I would suspect have a good outcome. But surgeons need to know that in their populations are a growing number of vulnerable people and we need to take better care of them.'

- If you are actively involved in working with plastic surgeons, or are interested in doing so, and would like to get involved with this special interest group, please e-mail Rumsey and Clarke on [email protected]