Last week we heard about recommendations that people considering elective cosmetic surgery should first have a psychological assessment. On BBC Radio Nottingham’s Morning Show with Mark Dennison, on Tuesday 12th June, we discussed the possible reasons for this.

Most of us have, at some time, wished we looked ‘better’ eg different, in some aspect(s) of our physical selves – face and/or body. When we are feeling at our lowest or most stressed, such thoughts can become more persistent and intrusive, overwhelming even. Some research has suggested that up to 40% of people being treated for anxiety/depression in mental health settings, are also unhappy with their physical appearance and want to change this. Depression and anxiety are usually, fortunately, a temporary mood condition; once people feel back to their ‘normal’ state of mind, although they may still be dissatisfied with some aspects of physical appearance, they tend to view this from a more philosphical perspective and would not usually attempt to alter it surgically.

This is one of the key reasons why a psychological assessment before elective cosmetic surgery is important. All surgery carries risk – things can, and do, go wrong, sometimes. So it makes sense to only undergo it after careful assessment of the pros and cons, rather than impulsively, whilst in the grip of a depressed mind state where we typically feel pessimistic and think negatively about ourselves. Our mood is destined to improve in weeks, or worst case, months, but the changes we have paid to have made to our appearance will be enduring and difficult to reverse/correct if the outcome was not what we hoped for.

Another good reason to have a psychological assessment (i.e via a counsellor, psychotherapist or, indeed, a psychologist) is to identify Body Dysmorphic Disorder (or orientation towards this). BDD is characterised by

– a preoccupation with an imagined defect in appearance. If slight physical anomaly is present, the person’s concern is markedly excessive

–  the preoccupation causes clinically significant distress or impairment in social, occupational, or other important area of functioning.

– the preoccupation is not better accounted for by another mental disorder (eg dissatisfaction with body shape and size in Anorexia Nervosa).      DSM-1V-TR 2000  300.7

Once people experiencing this psychological difficulty start on the road of elective cosmetic surgery, they keep going, never satisfied with the outcome; there is always just one more alteration to be made before they can be happy….In the worst cases, people will be prepared to self-mutilate to try to achieve the desired self-image.  Research has suggested that 6-15% of patients in cosmetic surgery and dermatology settings, could be clinically diagnosed with BDD.

The problems with undergoing cosmetic surgery in these circumstances are obvious: the chances of satisfaction with the outcome are low (expectations will often be unrealistic). The effect of real or imagined ‘failure’ of the cosmetic surgery (one of the risks), is likely to be devastating. And the person is spending money to live in the future, rather than in the present – things will always be better after this, or that, piece of cosmetic correction has been carried out.

Similarly, it is possible to become addicted to improving personal appearance. Like any addiction, it can only be satisfied by yet one more hit, which needs to increase in intensity. In the case of cosmetic surgery, this would start with a relatively minor ‘improvement’ and graduate to larger-scale interventions.  The addiction process often starts through a person feeling that something is not Ok about life; typically, through therapy, this might be identified as a missing relational need. Erskine (1998) proposed 8 key relational needs which we seek from cradle to grave in our significant relationships. (eg security, the need for validation, to express love, make an impact on the other person, etc…). It makes sense to address this deficit with a talking therapy which will work towards reconciliation of this and self-acceptance without surgery…..

Women have traditionally been more interested in pursuing cosmetic surgery than men; however, there is growing media and peer pressure on men to look ‘fitter’ and more virile. This sometimes draws them towards surgery, but more often tempts them to take supplements, typically steroid-type, and often in combination with circuit/weights training at the gym.  This can quickly become addictive, and has its own risks. Again, following the trend slavishly, succumbing to external pressure, are indicators that the person’s sense of self-worth/acceptance and confidence are not as robust as he might wish.

If depression/anxiety or tendencies to addictive personality or BDD are found during psychological assessment, alternatives to cosmetic surgery can be offered. Typically this would be through a talking therapy programme, often Cognitive Behavioural Therapy which would aim to challenge the negative thinking about self-image, perfectionism etc. Other therapies might seek to uncover suppressed/subconscious deficits in relational needs The object of most talking therapies is for the person to become more self-aware and more self-accepting and compassionate to self. As the French say ‘il faut se faire a son visage’ = we have to learn to like the way we are.