The 4R’s of Referral: When saying ‘no’ is in your patient’s best interest

The 4 ‘R’S of Referral – When Saying No is in your Patient’s Best Interest

Have you ever come across a patient in your practice, who continues to feel dissatisfied or unhappy with the treatment outcomes, even when you thought that the treatment was a success? Every injector will face this scenario at some point in their career.

One possible reason for this dissatisfaction could be body dysmorphic disorder (BDD), a psychiatric condition where individuals hold a distorted perception of their physical appearance, becoming preoccupied with flaws that appear minor or non-existent to others.1 BDD is a condition that’s on the rise, and disproportionately affects people seeking both surgical and non-surgical cosmetic procedures. While only 2.9% of the general population have BDD, this number skyrockets to between 15-20% of patients seeking cosmetic treatment.2 While most people seeking cosmetic procedures experience positive results, such as improvements in body image, self-esteem and confidence, individuals with BDD are at greater risk of dissatisfaction or adverse
events. In up to 91% of cases, people with BDD don’t experience any change in their symptoms, and in 16% of cases, their symptoms actually worsen following cosmetic treatment.3

Patients with BDD are not only more likely to be dissatisfied, but may also make complaints, leave negative reviews or take legal action against the practitioner.4 Beyond BDD, other mental health issues can also increase the risk of poor outcomes from cosmetic treatment, including personality disorders, severe anxiety or depression, obsessive-compulsive disorder and eating disorders.5

For this reason, the Medical Board Guidelines (2016) and the Australian Health Practitioner Regulation Agency (AHPRA) recommend routine mental health screening prior to undertaking both surgical and non-surgical cosmetic procedures. By completing a mental health screen during your consultation, it can help you identify who is most likely to benefit from cosmetic treatment, and who may be at risk of dissatisfaction.

Using my clinical and research experience, I started ReadyMind with Dr Ben Buchanan, an organisation which develops screening tools to help cosmetic practitioners assess the psychological needs of their patients (visit to access these tools). We recommend implementing these questionnaires prior to or during your consultation to protect yourself, your practice and your patients.

But one of the biggest challenges comes after the initial screening stage – you’ve identified that your patient may have BDD or another mental health concern, now what? The research suggests that in these cases, referral to a mental health professional is the most appropriate next step, before proceeding with cosmetic treatment. The mental health professional would further assess the patient’s emotional wellbeing, goals and expectations for cosmetic treatment and facilitate a discussion of whether the procedure is likely to resolve their concerns or if alternative options such as psychological treatment may help. This can support the patient to make an informed choice about whether or not to proceed with cosmetic treatment at that time.’

The 4 ‘R’s
Referring your patients to a psychologist can be a tricky conversation to start – but it just takes a bit of practice to find the right language and build your confidence. Here’s an easy to remember framework to guide your referral called:

The 4 ‘R’s – Relate, Reassure, Refuse, Refer.

Step 1: Relate
Lead with compassion, and connect with your patient on a human level. They probably came in feeling hopeful of getting a treatment that day, and will likely be disappointed if this doesn’t go to plan. Start by expressing your concern and empathy for the distress, anxiety or life circumstances that your patient is currently experiencing. Reflect back to them using their own language, to show that you have truly listened to their concerns. You may also refer back to specific answers that they provided on the mental health screen which elicited your concern.

“Earlier, you told me about how hard it’s been to go to work because you’ve been feeling anxious about your skin. I’m so sorry to hear about how much it has been affecting you – it sounds like it’s been really difficult.”

Step 2: Reassure
Reassure your patient that you have their best interests at heart, and this includes their aesthetic, physical and emotional needs. You might even remind your patient that your salary comes from providing cosmetic treatment, so by recommending against it that day, it shows that you are considering your duty of care and putting their needs before profit.

“I want to make sure that you get the best outcomes for both your physical and emotional wellbeing.”

Step 3: Refuse
Refuse to provide treatment on that day. It can be tempting to offer alternative treatments to the patient, or “something small” to keep them satisfied, however, this can send the message that with enough coaxing you will be willing to provide the treatment they are seeking. For patients with BDD in particular, it is unlikely that they will be satisfied with the treatment that you offer, and therefore it is best to refer on first. You could draw upon the research and your past clinical experience to justify why you are suggesting a referral.

“The research tells us that when individuals are experiencing a lot of stress or anxiety, they may not get the outcomes they are hoping for from cosmetic treatment, so I don’t think we should do any treatments today.”

Step 4: Refer
Explain to your patient that you recommend a referral to a mental health professional to discuss their treatment goals and current life circumstances. Let them know that this is a supportive space where they can explore their motivations and expectations openly, and have a discussion about whether cosmetic treatment is the best option for them, or if other treatment options might help them achieve their goals. In the case of BDD, a course of psychological treatment is effective in significantly reducing symptoms for up to 84% of people.6

Normalise this referral process by reminding your patients that you regularly work alongside psychologists to help your patients get the best outcomes, for both their physical and emotional wellbeing.

“Instead, I’d like to refer you for further discussion with a mental health professional before we proceed. The goal of this will be to discuss your current situation, goals and motivations and discuss whether this treatment will help you to meet those goals right now.”

And a bonus fifth step… reflect! When you refer a patient to a mental health professional rather than providing cosmetic treatment, they may express a
whole gamut of emotions. There might be tears, anger, disappointment, relief… and much more. This can be difficult to sit with, especially when you want your
patients to walk out your clinic smiling! Reflect on what the process of referral felt like for you and debrief with your colleagues if you need to.

Remind yourself that by making the referral, you are practicing ethically and acting in line with the long-term best interests of your patients, rather than providing a quick fix. Mental health assessment and counselling before, alongside or after cosmetic treatment can increase the chances of your patients achieving long-term improvements in their confidence, self-esteem and body image. Happier patients lead to happier practitioners!


Dr Toni Pikoos is a clinical psychologist and postdoctoral researcher in Melbourne, Australia. She conducts psychosocial assessments for clients considering cosmetic surgery or non-surgical procedures. Dr Pikoos is also the Co-Founder of ReadyMind, an organisation which develops
assessment tools and consultation for cosmetic practitioners
who want to assess the psychological needs of their patients.

1. American Psychiatric Association. Diagnostic and statistical manual of

mental disorders – Fifth Edition (DSM-V). 2013;
2. Pikoos TD, Rossell SL, Tzimas N, Buzwell S. Is the needle as risky as
the knife? The prevalence and risks of body dysmorphic disorder in
women undertaking minor cosmetic procedures. Australian & New
Zealand Journal of Psychiatry. 2021/12/01 2021;55(12):1191-1201.
3. Crerand CE, Menard W, Phillips KA. Surgical and minimally invasive
cosmetic procedures among persons with body dysmorphic disorder.
Annals of plastic surgery. 2010;65(1):11.
4. Bowyer L, Krebs G, Mataix-Cols D, Veale D, Monzani B. A critical
review of cosmetic treatment outcomes in body dysmorphic disorder.
Body Image. 2016;19:1-8.
5. von Soest T, Kvalem IL, Skolleborg KC, Roald HE. Psychosocial
changes after cosmetic surgery: a 5-year follow-up study. Plastic and
Reconstructive Surgery. 2011;128(3):765-772.
6. Wilhelm S, Phillips KA, Greenberg JL, et al. Efficacy and posttreatment
effects of therapist-delivered cognitive behavioral therapy vs
supportive psychotherapy for adults with body dysmorphic disorder:
a randomized clinical trial. JAMA psychiatry. 2019;76(4):363-373

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