It’s as clear as the logo on a designer bag that emotional (patient) support in private elective cosmetic procedures must be integrated into the clinical setting as a routine option for all cosmetic patients. The average patient remains ill-informed against a backdrop of an exploitative industry which either choose not to or refuse to reach out to their patients as individuals. The result of this is emotional confusion rather than emotional intelligence in the clinical cosmetic setting. The final results can lead to chaos and ruin financially and otherwise for both patient and practitioner. These issues can be mostly avoided by integrating independent emotional support. 

For this integration to succeed, independent sources of support must be understood. Patient advisors as they are today are not independent or trained in emotional support. When any psychotherapist who is also selling or recommending products tries to offer emotional support, the process becomes corrupted. The entire reason for emotional support is for the patient to draw his/her own well-informed conclusions based on clear information and emotional understanding. This can’t be achieved when the ‘provider’ is linked to products or other commercial factors. Nor can this be even partially achieved if the support is offered in a public setting such as social media. I do not wish to be insulting but there is a lack of understanding among patients about how to verify the qualifications of the person from whom they are asking life-changing questions. 

Yesterday I met a patient who shared the story of her face-lift and blepharoplasty. Applying the concepts of privacy and confidentiality, this patient will be referred to as Samara. When she turned 50 Samara noticed her face was showing signs of age that she had more than enough financial means to correct. She wanted to hold back the visible signs of ageing as much as possible and she wanted the best possible surgeon to do the job. Samara felt that a facelift and blepharoplasty was relatively straight forward - “…all my friends have already had it done,” she said. Samara did her research by going online to see which clinic looked best. Being easily able to afford the best and considering herself a reasonably well-educated and intelligent woman, Samara decided it was easier to choose a hospital instead of a surgeon. She chose a hospital in a popular London location that she considered looked the best: “good hospitals will have the best surgeons”, she believed.  Samara was happy that she had found a ‘good surgeon’ and was in safe hands. More than a year later, Samara struggles in the summer heat when she wants to tie her long blonde hair in a pony tail because of the tell-tale scars that remain clearly visible. I asked Samara who her surgeon was but she could not remember how to spell his name although she had a vague recollection of his Eastern European sounding name. She tried to google what she thought might be the spelling and nothing came up. Equally, the surgeon was not listed on the particular hospital’s website.  I asked Samara if she knew whether her surgeon was on the GMC list of specialist plastic surgeons and she asked me what that was. This type of response is not uncommon.  I explained the importance of this register and she responded by trying her best to assure me that she had chosen well because she had spent a long time on the internet searching for the best hospital. 

This brief excerpt from a recent case history illustrates why it is not only crucial for patient safety to be brought into line with real patient needs but also conveys the need for appropriately independent cosmetic surgery counsellors. Patient (emotional) support is often confused with information or psychology. It borrows from both but it is neither of the two. Psychology may argue that it is preferable to focus on reporting the findings of scientific research rather than on the results of individual cases. However, history shows us that it is cases like ‘The Wolf Man’ and ‘Anna O’ that make life-long impressions. Patients will remember the encounter (form and content) they have with an intelligent, informative emotional support provider rather than the questionnaire they are asked to fill out in the isolation of a waiting room or with a non-psychologically trained professional. 

It is not just patients who benefit from an independent integrative emotional support system. I have often heard it said among aesthetic surgeons that their patients are “.. the type of people who want the best”. I think it is fair to say that most patients want the best. What that best looks like on a glossy website or other form of marketing is a matter of individual taste. There may be several stores appearing to be selling the same thing.  Why is one drawing more customers than another if they are all playing on the same level playing field? Are surgeons really understanding that their patients make up a cross-section of different financial backgrounds?  There was once upon a time when the myth that plastic surgery was only for Hollywood or the elite and secretive rich, but not any more. All aesthetic professionals must learn to understand who is at the other end of their treatment plan and how to talk to them in a way that they understand. Accepting this aspect of their business does not cheapen it - quite the contrary - it elevates it to a new standard. 

Offering free information and advice, whether it is online or via consultation is a great way to help create well-informed patients and any appropriate method should be encouraged by all cosmetic practitioners wherever possible. 

There appear to be two different types of patient support on the market: independent and commercial. I speak as an independent patient support provider believing this to be the right way to offer support. Independent emotional support can and should  be integrated into the industry while remaining true to its essential ethical principles. Diluting this solution leads to pollution. 

There are certain conversations that women prefer to have with other women: periods, childbirth and .. *drum-roll* .. breast implants.  I think these three issues make up the core issues of what separates us women from the men-folk. Ever tried discussing any one of those three subjects with a man?  Many prefer to gnaw off their own limbs than endure. Yes, women do talk to men about breast implants but it is more likely to be about cost, logistics and other rational aspects of the procedure. I do not deny these are important parts of a conversation but they are a smaller part of a larger picture that women want (perhaps need) to discuss with other women about breast implant surgery. 

The intimate nature of a conversation about breast implants is less self-conscious when carried out woman to woman.  When it comes to breast implants, not only do women want to talk to other women but they want to meet the kind of women who are not afraid to show them their surgical results.  Many years ago I made a reality tv programme where the film crew saw an example of this. I believe that this is a realistic way for women to visualise and understand the possibilities in store for them. Women are generally honest with whether they think their results are ‘natural’ or ‘hard’ or ‘soft’ or ‘big’ or ‘small’, and what manufacturer their implants came from and what choices they were offered at the consultations. They want to talk about how it made them feel to sit in front of a male surgeon with their breasts out and being felt for surgical assessment. While surgeons may do this every day as part of their job, a woman does not usually get her breasts out for anyone other than one close person. For a woman in a consultation, it is an unusually intimate act in an unusually clinical setting. There are alot of emotions involved for many women in this part of the consultation.  Some patients may be  strippers who are more used to this public situation but may not wish to reveal their profession. This can create conflict when surgeons who don’t know the patient’s profession talk about a ‘natural look’. 

The media encourage our daily chatter by providing us with similar stories from different angles about cosmetic surgery and other issues relating to women. It is impossible to ignore cosmetic surgery in the media any more. We are encouraged to attempt to blow the whistle (on behalf of our sisters) on bad surgeons and results but .. it seems .. only if those bad surgeons or bad surgeries are by way of a cowboy. The truth that life teaches us is that there are still some bad apples on very expensive carts even though manufacturers do their best to make sure that all apples look the same!  Sometimes it is not the surgery that is bad but the way the surgeon deals with the criticism and that makes him/her just as much of a cowboy as .. well .. the cowboys in the eyes of the patients. All surgery carries risks and each patient will bring to the table their own particular risks which keeps the focus of finding a well trained surgeon so crucial. 

The fact that our cosmetic surgery reality is being so tightly controlled by the media makes it even more compelling to discuss experiences without fear. The over commercialisation of surgery that results from control factors like these make it unsafe for patients not to talk openly. Being forced to keep silent when conversation is needed creates a climate of fear for patients. Some would argue that a good open conversation alone is what creates well-informed patients. I am not so sure. Cosmetic surgery (like any other surgery)  is one of the top ten major life events and a conversation (emotional release) is an essential part of the process. Who the patient talks to is crucial. Women prefer to talk to women about breast implants but which woman and why? For some, friends and family will be most appropriate but when it comes to professional emotional support, I believe a female counsellor is best placed to take this conversation. This is especially so if the woman in question has both had breast implant surgery and is trained in psychotherapy and is not afraid to make disclosure when that may be relevant. Counsellors are not their to advise on surgeons or implant manufacturers. 

Is there a type of responsibility attached to having breast implants? There are some obvious responsibilities like the fact that implants are not for life. It is surprising how many women tell me that their implants are guaranteed for life. This is because they have been misled to believe that ‘life’ means their (the patient's) life and not the life of the implant which may be anything up to about 20 years maximum. There are some implants that are for life but they are not used in normal circumstances because they are difficult for surgeons to ‘place’ right. 

Feminist or not, most women find that a breast augmentation changes the nature of their relationships with other women. It can change the nature of their relationship with men but that is something that is usually considered before surgery. Many women find it far more difficult to reveal that they have breast implants with a new partner than they ever imagined possible. Some women find the nature of their relationship to other women changes after breast implant surgery. 

Many psychological issues are involved in breast implants surgery and I would argue that those issues are mostly feminist in nature and best understood by another woman. If one of two of those women also happens to be a psychotherapist with experience of breast implants and comfortable with disclosure, so much the better. 

I feel very honoured to be a Member of The Expert Reference Group of Health Education England's NWL Non- Surgical Cosmetic Intervention Review. I am the only psychotherapist on the table. It might seem odd that a psychotherapist should be on the table of a non-surgical cosmetic intervention group but I am there to represent the emotional world of patients. What does that mean? Well, it can be anything from pre-procedure anxiety right through to extreme emotions resulting from physical outcome. The most important part of a cosmetic surgery counselling session is the conversation about expectations. A realistic look in the mirror is not easy for anyone but when it comes to cosmetic interventions this is an unavoidable task. Many people think psychotherapists are there to help people with mental health problems and/or to spend countless weeks, months, years and decades going over the same old ground. Nothing could be further from the truth when it comes to cosmetic surgery counselling. Whether you call it psychotherapy, counselling or emotional support it all amounts to the same thing - the ability to help the patient explore what is going on for them emotionally with reference to a cosmetic intervention. This could be pre-op or post-op. Pre-op is interesting because information and support is of concern to anyone no matter how far away in the distance the possibility of a procedure may be.  Generally, though, it relates someone who is quite near to their procedure date. However, awareness of emotional support assists with the cultural shift away from advertising. Cosmetic surgery brings up emotions in patients that they did not know they could feel. Some will take these emotions in their stride but others do not cope as well. The benefit of cosmetic surgery counselling is that patients do not have to go online to speak to strangers who may or may not have hidden commercial or referral agendas and no training in emotional support. 

As a Member of the Expert Reference Group for the Health Education England/NWL Non-Surgical Cosmetic Intervention Group, I have contributed indicative content for my specialist area of emotional support for cosmetic patients. Unlike the distinction made between the HEE/NWL and The Royal College of Surgeons Interspeciality Committee on Cosmetic Surgery Group, I do not draw a psychoIogical line in the sand between surgical and non-surgical patients.  Experience shows that often the surgical patient is also the non-surgical patient and vice-versa. In other words someone who goes in for a face-lift may also be having an injectable treatment for best effect. 

While a member of the RCSIC Patient Group has a seat on the HEE/NWL Expert Reference Group, no known patient group from the aesthetic/cosmetic world sits on the RCSIC. This is how communication problems start, which is a great pity as one of the central issues everyone is trying to remedy is communication. I have requested a place on the RCSIC group just so that surgical and non-surgical can have consistency in patient feedback. I received a reply to my request explaining the rather complicated procedures of the RCSIC together with their assurances that patient groups would be invited to comment after the meetings!  

Today I was invited to attend a Westminster Briefing Conference which was an opportunity for interested parties to present on their chosen subjects and bring the audience up to speed on Government progress post-Keogh. The distinction between surgical and non-surgical was evident but Westminster Briefing has an open door policy that did not discriminate between surgical and non-surgical attendees.This is the way of open communication.  I spent the day thoroughly absorbed in listening and learning as representatives from surgery, dentistry, nursing, government and industry outlined their aspirations and concerns for the  forthcoming safety measures that will be put in place by both surgical and non-surgical governing bodies. The surgical presentation made little reference to the RCSIC although they did display a lovely photo of the Royal College of Surgeons "in case any of the aesthetic professionals were unfamiliar with it".

Two main themes emerged from today's conference: 

Support

Consent

It is music to my ears as it would be to most interested parties when speakers delicately touch on the winds of change that point towards a reality of more honest dialogue with patients on expectations and peer support among themselves in perhaps achieving this. They are referring to diluting the historically poison advertising. The desire was palpable but so was the recognition that without a radical shift in advertising this may not happen. There was genuine exhaustion from the relentless distortion by the media. There was an unspoken question of whether a group of ethical professionals could ever put the genie back in the bottle without some creative thought.  Without realising it, these professionals were talking about counselling/emotional support. The same subject cosmeticsupport.com has been talking about in blogs and websites for so long.  So have we  (cosmeticsupport.com) finally met the professionals on the same page? 

The feeling in the room was that with honest dialogue and some radical changes in advertising everything will return from distortion to normal again. I would love to believe that this would be true. Patients see practitioners as people who can ‘fix’ them through scalpel or the syringe and anything less is just plain withholding. Patients do not expect either scalpel or syringe from counsellors. It is that distinction that makes the difference in delivering the message. 

Patients need to be well-informed. A consultation with the practitioner should focus on what is going to happen to them physically. This is what they are experts in. Counsellors focus on the mind. The need is there because life-changing alterations to the face or body are emotional. Practitioners attempting to hold a psychological conversation with a patient while also explaining the physical side of the procedure are just overwhelming patients in too many cases. Too much information! 

From my perspective, the duality between surgical and non-surgical is less relevant for emotional support. This technical division is important to assist important technical practicalities. This division may lead us to the assumption that non-surgical is less dangerous from the emotional support perspective.  This is not necessarily the case. A patient looking for a quick injectable treatment may harbour more psychological problems than someone turning up for multiple procedure surgery.

Many surgeons have said to me: ‘we need someone on site who can be there when we need them to talk to the patient’. Counselling just does not work this way. This is why so many clinics hire ‘patient advisors’ who are to hand when needed but this is nothing like counselling. It is another distortion. 

Patients gain no benefit in rushing from a detailed conversation about the physical to the emotional. Patients need time to digest thoughts and feelings. Most psychotherapists favour comfy surroundings rather than a clinical environment to practice in. Cosmeticsupport offers online help as well as phone help and various other options. The object is not to dilute the therapy but to make it as comfortable for the patient as it can be. Counselling is not supposed to give pain - it is supposed to take it away. What better way is there than in the comfort of your own home or in a therapists warm cozy environment to share your secrets? The recognition of the need for options is an important part of our service. The option to choose how you see a counsellor and when you see a counsellor as an integrative holistic part of an elective private cosmetic procedure must surely be gaining currency. 

The second theme of the day was consent. I was itching to point out the close connection between support and consent at today’s conference but often feel that the industry is not yet open enough to understand counselling. The world of the practitioner is different to the world of the patient even though both patient and practitioner may often be one and the same.

They talked about patients being disappointed with results even though they sign a physical consent form. And there’s the rub. My previous blog was about emotional consent. Disappointment is not physical. It is emotional. Talking about happiness, sadness, disappointment or any one of a host of other emotions related to cosmetic procedures is a conversation about emotions. This is a conversation that should happen with a counsellor in a cool-off period with the request of a signature for emotional consent. 

Surgeons, dentists and nurses are all concerned for patients when it comes to the reality of results. Too much advertising coupled with a lack of solid fact has led to distorted expectations from cosmetic interventions. Practitioners are aware of this but how many want to really challenge the source? In their enthusiasm for best practice they want to help patients understand disappointment but this is not the role of the practitioner. This is the role of the cosmetic surgery counsellor as cosmeticsupport repeatedly points out. 

This is not the first time I have written about emotional consent.  I wrote a blog for Consulting Room on this subject last year because it is of concern to me too. Aesthetic practitioners can be brilliant and some can create miracles with a scalpel or a syringe but that does not make them counsellors who are trained in the emotional welfare of a patient qua consumer.

cosmeticsupport.com was set up in January 2000 as an independent, non-profit counselling and psychology site for patients to talk honestly about their wishes, hopes and expectations from cosmetic interventions. Peer support alone has little value without an ethical boundary to support it. As members of BACP and BPS respectively, we offer independent, non-profit support driven by ethical guidelines to cosmetic patients. Unlike many other support groups, we do not endorse or sell products.  To do so would be a conflict of interest. 

Nip’n’Tuck was such a catchy slogan that it became synonymous with any type of cosmetic surgery.  There was even an American television series with that name.  The TV  surgeons were handsome. Their patients idolized them. The drama itself was mostly confined to the personal lives of the surgeons as opposed to surgical side of plastic surgery.  Each week, I was riveted to it.  It readily reflected the commodification and trivialization of plastic surgery. It was fantasy at its best, just as the phrase Nip’n’Tuck is. 

The phrase Nip’n’Tuck trivializes cosmetic surgery. Isn’t it time this phrase was retired? 

Cosmetic surgery is not a nip and a tuck. Cosmeticsupport.com agrees with Rajiv Grover and other BAAPS surgeons who are making the call that cosmetic surgery must be treated as a medical procedure and not a commodity. The review by Sir Bruce Keogh reveals the vulnerability of cosmetic surgery patients.   Why on earth is the phrase Nip’n’Tuck still used as a media byline. How can we take calls to reduce trivialization seriously if there are still elements of trivialisation?  Safety has no room for confusion. 

Why has it taken so long for calls to safety to be made? Thirteen years ago when I set up www.cosmeticsupport.com it was very clear that plastic surgery had been seriously commodified and yet nobody seemed concerned about it. Commercial clinics offering cosmetic surgery renamed their sales people ‘counselors’, abusing that title. Patients were misled and misinformed.  Patients believed they were seeing a counsellor when they were seeing a sales person.  Patients were put under enormous pressure to sign on the dotted line there and then in order to benefit from time-limited discounts. People were almost afraid not to have cosmetic surgery. Where were the calls to patient safety? Why was their voice not heard through all the years of tomfoolery in the industry? It has taken a long time for the call to change advertising to be made. Let’s hope that patients respond faster than they do. The bogus use of the term 'counsellor' is still being used and often under the noses of the very people who have the power to tighten safety. It troubles anyone with any ethics to see this being played out. 

The scandalous drama of the PIP implants has caused everyone to sit up and take notice.  Professor Sir Bruce Keogh, Medical Director of the NHS recently released his review. The enquiry asked the public about their experiences and recommendations for the industry and whether the public wanted the changes to advertising which were being called for by the surgeons. The response I have written to his review can be seen in a separate posting on this Blog. 

Is it really true that in 2013, women are still not to be treated as equal human beings? Given that the PIP scandal affected women, one wonders if women have ever really earned the right to be treated seriously as human beings? How did the PIP scandal come about?  Who was really asleep at the switch? Surely we have enough safety committees in this country to spot an avalanche before it starts? We now know that mattress grade silicone was used to create breast implants when medical grade silicone should have been used.  Clinics who used these cheaper implants refused to take responsibility on behalf of their patients.  Why were so many women allowed to suffer like this? How was this allowed to happen?  It is as a result of the PIP Scandal that surgeons are making calls to change.  Who are they calling to?  Who are they calling for?  Were Pip victims adequately responded to? Who is fully versed at grass roots level where the patient is?  Will a change in regulation be enough to create safety for patients without counselling be added to the mix?  Why didn’t they call out over the many deaths through cosmetic surgery that have gone before?  Many people have died from complications from cosmetic surgery. Some died from badly trained surgeons performing profit-making surgery and some died from other complications, but the important point is that death occurred. Why did it take a disaster of such epic proportion before we heard these surgeons making their calls for safety? I have been offering emotional support, voluntary, independent and non-profit, for 13 years and if this were not needed, I would not be offering it. Why don’t surgeons take more notice of what their patients really need? Protection must be in the mind as much as it is in the body. Support must be emotional as well as physical. Unlike many others offering this support, I am qualified to do so. I am passionate enough to have offered it for free since Jan 2000. 

I believe that surgeons who are making calls for safety would be wise to consider the history of patient support and safety that has gone before this situation in other arenas. For example, before an abortion, counselling is mandatory. This helps the patient put to rest all the issues that have come up for them before and after abortion. Different abortion clinics have different counsellors. Some are pro abortion and some are anti abortion and the patient who winds up with the wrong counsellor might find themselves seriously struggling emotionally for many years to come. However, existentially trained counsellors will not have an opinion on cosmetic surgery either way. These counsellors are trained to help the patient explore their issues, not to explore the counsellors views or issues. There is little religion involved in cosmetic surgery in the way that it is involved with abortion counselling. With the use of appropriate surgical-consent counselling, the message goes direct to where the safety is needed the most, to the patient. Surgeons will benefit by having a patient who is both well-informed surgically as well as personally. 

If all cosmetic surgeons in all clinics are obliged to offer cosmetic surgery counselling with fully qualified cosmetic surgery counsellors only then can patient safety truly be ensured. Patients will understand the different types of qualifications of different types of surgeons and understand what is involved in an informed choice. Some patients may decide to go ahead with their surgery with a better-trained surgeon than the one they have originally chosen.  Patients will have more time to consider all the information that is currently obscured by misleading information. No longer will sales people be allowed to call themselves ‘counselors’. Cosmeticsupport.com fully supports the idea that advertising in cosmetic surgery must change in order to reflect a more realistic perspective on what it is that people are choosing when they consider elective surgery. However, even with those changes in effect, patients still need a place to go where they can find objective support (counselling) to help them explore all the issues that are involved for them. Every patient will have their own set of issues before and after surgery. It would make an enormous difference to all patients if they were helped to explore their issues before and after cosmetic surgery. I believe that existential psychotherapy is the best-suited psychotherapy for this exploration as it is a philosophy concerned with the individual and his/her meaning in the world. Existential psychotherapy allows for an unbiased exploration of the individual’s world-view. 

Cosmetic surgery counsellors will help to produce a more informed, relaxed patient with its search for meaning helping to clarify confusing misinformation.  Patients will also have had the opportunity to explore the realities of a particular type of elective surgery. Every patient has issues before and after a surgery and if the goal of the new regulations are to be heard, then the response must surely be for counsellors to be invited in to answer. 

Let’s nip trivialization in the bud and tuck in patient support.