Ben: Hello and welcome! My name is Dr. Ben Buchanan, I am a clinical psychologist and we are joined by Dr. Toni Pikoos, whom we are very privileged to have the expertise from tonight.

Both Dr.Toni Pikoos and I have been working at the interface of cosmetic procedures and mental health for a long time, and we’ve learned from cosmetic practitioners about the sorts of psychological complications that come up in practice.

Tonight we are going to be talking about the AHPRA guidelines and how those psychological complications have really informed the AHPRA guidelines about screening for body dysmorphic disorder and other psychological issues. We are interested to see the developments in the AHPRA guidelines that will come into effect on the 1st of July.

So let me introduce Dr.Toni Pikoos Toni has a PhD in clinical psychology, and the intersection of cosmetic procedures, mental health, body dysmorphic disorder and client satisfaction. She is a post-doctoral research fellow at Swinburne University and also a practicing clinical psychologist in Melbourne, and specializes in body dysmorphic disorder.

She is also the co-founder of ReadyMind, the ReadyMind assessment platform.

We have had massive interest in the ReadyMind assessment platform, essentially because it is going to be helping people comply with the AHPRA guidelines.

Toni is also a sought after speaker. She was invited to many national and international conferences, and we are very lucky to have access to Tony’s expertise tonight. Welcome, Toni.

Toni: Thank you so much, Ben and thank you to everyone for coming. I am excited to see so many people here and it definitely speaks to how relevant this topic is. And a lot of questions might come up tonight that you’ve been wondering and are hoping to get answered in the webinar.

Another thing to mention is that I took part in AHPRA’s consultation process when they were developing these new guidelines. So I was the psychological representative speaking about the impacts on patients, patient motivations and expectations. I was quite involved in the development of these new guidelines around screening. So hopefully I will be well positioned to answer some questions around that as well.

So I am going to launch straight into talking about the new guidelines initially, and then we will go on to how to actually implement this in your practice.

AHPRA Guidelines

So the first thing is, who do these new guidelines apply to? The guidelines have been released by the Medical Board of Australia, and they are for medical practitioners performing cosmetic surgery and procedures. Technically these guidelines only apply to medical practitioners registered with the MBA.

However, we know that the cosmetic industry is diverse, that there are lots of different practitioners, cosmetic nurses working in this space. The guidance from the nursing board is that nurses should be aware of these guidelines because they serve an evidence-based framework outlining the conduct and practice expectations that are required.

And so these guidelines, while they might not apply to every single health practitioner working in the cosmetic space, are considered the industry standard and certainly apply to prescribers of injectables. Even if you are not the one that’s prescribing the injectable, you will be working with someone who is bound by these guidelines.

Surgical Guidelines

So in the new guidelines, I am only going to be focusing on the patient suitability aspect of it and the screening requirements. But there were obviously lots of changes that happened in the guidelines around advertising and other elements of your practice. So it is important that you read it so you know how to abide by them.

The guidelines do differentiate between cosmetic surgeries and non-surgical procedures like cosmetic injections. For cosmetic surgery and the assessment of patient suitability, one of the things that has been added is that everyone who needs to undertake cosmetic surgery must have a referral from their GP and that ideally should be the regular GP that they work with.

But if not, it can be from another GP who is independent of the medical practitioner and that GP should not be working in the cosmetic space (administering cosmetic surgery or non-surgical procedures themselves). This is the first element of it.

But the other element which is most relevant to us is that the medical practitioner who is performing a surgery must discuss and assess the patient’s reasons and motivations for requesting the surgery. This includes identifying both external and internal reasons. An external reason for getting a surgery might be a need to please others or a partner who is putting pressure on you to get a procedure or a recent break-up might be an external motivation. An internal motivation is a person who wants to boost their self-esteem, confidence or their own feelings about their appearance and the patient’s expectations must be discussed to ensure that they are realistic.

Patients should also be asked if another practitioner has declined to provide them cosmetic surgery. And the reason for that is a red flag – if somebody else has declined the surgery, then it suggests that they may have picked up on something that stopped them from feeling comfortable with proceeding.

And the next bit which has changed most substantially is that the medical practitioner who performed the surgery must assess the patient for underlying psychological conditions such as body dysmorphic disorder (BDD) which might make them an unsuitable candidate. The practitioner doing this needs to use a validated psychological screening tool. The process and the outcome of the assessment needs to be documented in the patient’s record for all patients seeking cosmetic surgery.

Every patient that is getting cosmetic surgery needs to have a BDD screening documented on their file. If you detect that they are an unsuitable candidate because of psychological issues or because they have screened positive for BDD, then they need to be referred on for further assessment. The guidelines say that further evaluation can be done by a psychologist, psychiatrist or general practitioner. This person should work independently of the medical practitioner who performs the surgery after that.

Non-Surgical Guidelines

For non-surgical procedures like cosmetic injectables, the guidelines are quite similar in terms of the changes. Again, the medical practitioner who is either performing the cosmetic procedure or prescribing, must assess the patient for underlying psychological conditions such as BDD. The difference here is that they do not specify that it has to be a validated BDD questionnaire but that is probably the easiest way to go about doing this.

For cosmetic injections, it is the same recommendation that if a patient has these underlying psychological conditions or if they have body dysmorphic disorder, then they should be referred on for further assessment before doing any kind of treatments on them. Another thing interesting to note with these changes is that the medical practitioner performing the procedure should also discuss other options with the patient. And that includes mentioning that there is an option not to have the procedure and that there are treatments offered by other healthcare practitioners.

I think that becomes quite relevant when you are working with patients who are struggling with body image or self-esteem, or they might have body dysmorphic disorder, to note that there might be psychological treatments that could help them instead of or as an adjunct to cosmetic treatment. And that could be one of the options you actually discuss with your patients.

Key Changes

So essentially the key change is that the wording has changed from ‘should’ to ‘must’. So instead of it just being a recommendation, now you must assess the patient’s motivations, expectations and psychological state. The recommendation to refer for further assessment was always there but again, the wording has been strengthened. So instead of a ‘should’, it’s now a ‘must’ for surgery only, so not the injectable space. You need the GP referral to get cosmetic surgery to have the initial consultation. And for surgery only they have specified the validated BDD assessment tool.

Body Dysmorphic Disorder (BDD)

So why BDD in particular? Some people might have that question when reading the guidelines because it does say assess underlying psychological conditions but then specifies one condition in particular.

So body dysmorphic disorder is a psychiatric condition where someone becomes preoccupied with perceived flaws in their physical appearance. So they see it as being a significant problem like their nose, skin or worry about scarring, wrinkles that seem really noticeable and substantial to them, but other people might not be able to see it at all or it might appear very subtle.

Usually people with BDD are spending lots of time worrying about and thinking about these concerns in their appearance, often in excess of an hour a day. But for many people it is actually a lot more than that. So the average is people spending between three to eight hours a day worrying about their appearance and they often have a real distorted perception of what they actually look like. And there have been neuroimaging studies with brain scans done on patients with BDD, which show differences in the visual processing areas of their brain so that

when they are looking at themselves, they are often over focusing on small details and not always seeing the big picture.

So this picture on the slide of Danielle is a great example of where there’s nothing unusual that stands out to me. She is very attractive, she is very symmetrical, but when Danielle sees herself, she sees that she has this broad face and protruding chin. So if Danielle were to come into your practice and ask for a facelift or injectables to balance out her facial proportions, you are going to have a really challenging time doing that because what you might be seeing is something very different to what Danielle is seeing. So it is hard to satisfy and meet her expectations.

The other thing about patients with BDD is that they are a very vulnerable group of consumers. So often they are experiencing high levels of distress about their appearance and it significantly interferes with their ability to function. They might have trouble socializing, going on dates or going to work. In extreme cases, sometimes people with BDD really are not leaving the house at all. And we know that BDD has one of the highest rates of suicide out of any mental health issue. 80% of people with BDD experience suicidal ideation at some point and 30% of people with BDD actually attempt suicide.

People with BDD also engage in repetitive behaviors in response to their appearance. So often they will be engaging in things to try to fix, check or hide the way that they look. They might be spending lots of time looking at their appearance in the mirror from all sorts of different angles, taking lots of photographs or in different lightings, they might be avoiding mirrors altogether or avoiding photographs. And when it comes to cosmetic procedures and cosmetic surgery, often people with BDD might be seeking these treatments as a way to feel better about their appearance.

But it doesn’t tend to do that. It only provides a brief sense of relief before that wears off. And so cosmetic surgery is one way that the repetitive behaviors actually manifest in BDD. So when you might see a patient with body dysmorphic disorder coming into your practice, the tip of the iceberg is really the appearance concern that they are expressing to you. They might be pointing out one wrinkle or they might be pointing out something about their nose that they are not happy with or their skin. And you might see that and think, there’s something I can do to help this person. I can  see what they are talking about and I could provide a treatment that they might benefit from.

But unfortunately we know with BDD that the appearance concern is really just the tip of the iceberg. There are a whole lot of other things going on beneath the surface that are part of that person’s condition and have predisposed them to develop BDD in the first place.

And we often think about the causes of BDD from a biopsychosocial framework. So we know that there are neurobiological components to it, like the brain, the visual processing regions of the brain. We know that there is a genetic component that people who have a family member with BDD are more likely to experience it themselves. A large proportion of people with body dysmorphic disorder have also experienced some kind of childhood trauma, bullying or abuse in the past.

Often they are hoping that the cosmetic surgery or procedure might address that for them, and undo the effects of the trauma. But usually, unfortunately that takes a little bit more work than just a cosmetic procedure. There are often high rates of perfectionism with people with body dysmorphic disorder and there are also societal impacts. So we know social media plays a big role as well, particularly in seeing lots of filtered photos and these images of people who look perfect that aren’t necessarily realistic. And when we are constantly comparing ourselves to those standards, we can often start to feel really self-conscious and start to develop a distorted perception of what we look like.

This highlights why sometimes the patients with BDD might be the ones that even though you have done everything right, a great treatment or a great surgery and afterwards you think they look fantastic, they are still not quite satisfied because there are so many other things going on.

Why is BDD specified?

So why is BDD specified? Now, it is not because BDD is the only important contraindication that you need to be aware of or the only important condition to be aware of in patients seeking cosmetic treatments. But there is an enormous body of research which supports the fact that patients with BDD do not tend to do as well when they get cosmetic procedures. And that is the only reason why that was the condition specified because other mental health issues, which there is literature around, is less consistent or a bit more murky whereas the BDD literature is quite consistent.

And what we see is that in up to 91% of cases, people with BDD do not experience any change in their symptoms after getting cosmetic treatment. For 82% of them, they actually continue to worry about the area that was treated. And sometimes that worry just takes on a different form. So beforehand, they might have come in requesting an anti-wrinkle treatment to address this one line that they are worried about on their forehead. And you might do the treatment and remove that line that was concerning them. But then they might start to worry, now does my forehead look strange now that I have removed that line? Maybe it looks weird and maybe people are going to notice that I have had a treatment done. And so they continue to worry about the area but just in a slightly different way to what it was before the procedure.

In 17% of cases, they actually start to develop new appearance concerns. So you might address the one thing that they were worried about but then the fixation shifts to a new area and they might request another treatment to address that. In 16% of cases, the BDD symptoms actually deteriorate and their condition gets worse through cosmetic treatment.

There have also been reports, particularly in cosmetic surgery settings of a greater risk of complication and the request for revision surgeries or reoperation is much higher in patients with BDD. We also know that there is potential for addiction to develop and they might begin to kind of rely on these procedures as a source of their self-esteem or confidence. And so you might find that as patients get close to needing another treatment or when they feel like they need another surgery, that they stop living their lives, struggle to leave the house or go to work or socialize or engage in romantic relationships until they have had this next surgery or this next procedure. So they really become reliant on it for their wellbeing.

So there are lots of potential risks to the patient themselves but there has also been quite a large body of work on the risks to the practitioner as well. So there was a study of about 265 plastic surgeons in America and 29% of them reported that they had experienced complaints, threats or litigation from patients that they had seen with body dysmorphic disorder. So there is the risk that a patient who is dissatisfied might then take legal action or they might go online and start leaving reviews and potentially cause some reputational damage when they are not happy with the treatment.

So there are lots of reasons why BDD should be screened for and referred for further evaluation before doing any treatments. If you do not pick up on it before treatment, then it has the potential to create a problem that really could have been avoided.

Other Psychological Concerns

So what other psychological concerns do you need to be aware of? In the guidelines, it does mention other psychological concerns too. And depending on the procedure, the setting that you’re working in, you might come across patients who are experiencing anxiety and depression, obsessive compulsive disorder, health anxiety. So just a real kind of tendency to obsess or worry about various health conditions. Often they are researching lots of things that could be going wrong with them. And so that might be something that you see, particularly after someone has had a surgery or a cosmetic procedure.

Patients with eating disorders, especially with body sculpting treatments or liposuction, might be something that comes up at a higher rate. And personality disorders as well are quite prevalent across the whole range of cosmetic procedures. And all of these mental health conditions have been spoken about in the research before. And we know that of patients seeking cosmetic treatment, about 50% of them actually meet criteria for a mental health condition. Now that does not mean that everyone with a mental health condition should not be

getting cosmetic treatment at all, but there are certain risks that can come with that.

So these conditions can complicate the recovery process, particularly if someone is very anxious in the recovery time after a procedure or surgery, they might be really fixating on any symptoms or side effects that they are experiencing and catastrophizing, maybe blowing them out of proportion and becoming quite overwhelmed by them. It can also potentially create some physical health risks, particularly with something like OCD where people might have behaviors like hand washing or obsessive showering or compulsive showering or washing. And so if there is a surgery that they have had and they have been directed not to shower or not to wash their hands afterwards, that might be a really difficult recommendation to follow through with.

And then we actually see increased risk of infection and physical health concerns after the treatment, after the surgery. We know that some of these conditions can decrease a person’s satisfaction with the treatment and it might also exacerbate their psychological vulnerability. So they are already a vulnerable group because they are struggling with their mental health. And so if a procedure does not necessarily go to plan, that can make them feel worse and actually worsen their mental health. The other thing is that these treatments, with patients who are struggling with their mental health, raises a number of ethical questions that are quite complicated sometimes to address. It raises the question of patient autonomy. So we know that people have a right to make choices about their bodies and about the treatments and the surgeries that they want to undergo.

That is one of the questions that has come up a lot about these guidelines. Should we just be giving people the choice? If they think they want a procedure, they should be able to get it. But the other aspect of that is sometimes these mental health conditions and certainly body dysmorphic disorder can impact a patient’s competency. So their ability to actually make decisions about their treatment can be called into question. If someone is really desperate to get a treatment because they are feeling so terrible about themselves and their appearance, or they have been really depressed and they think this is gonna be the solution, they might be so desperate to get that treatment that they ignore the risks or don’t think about the risks.  So they might not be considered competent enough to actually provide informed consent.

And the other ethical principle that we need to consider is beneficence as well, that we need to make sure that we are doing no harm, that we are acting in the best interest of our patients.

And sometimes acting in the best interest of the patients means not doing the treatment or at least getting a further assessment and preoperative counseling so that they are more likely to get the benefits from it.

Assessing Motivations & Expectations

Motivations and expectations is another area that cosmetic practitioners already do really, really well. We are developing tools, easy screening tools that you will be able to give to your patients to quickly characterize their motivations and expectations. But some questions that you might be able to use if you are not already doing this in your consultation to assess, to meet your guidelines might be to ask your patient:

What prompted you to consider this treatment?

What got you thinking about it in the first place? And why now?

Why now is a really crucial question when assessing a patient’s motivation because they might have been thinking about it for a long time because their friends were getting it or they were seeing it on social media or they had noticed things that they did not like about themselves. But why they made the appointment at that point in time usually has a more interesting response. And it could be because of an upcoming event or maybe they have been struggling to get a job and they think it is gonna give them a competitive edge or potentially they have just undergone a breakup and now is the time that they have thought to come and get the procedure.

You could also be asking if anyone else has influenced their decision at all, to try to identify if they are doing this purely for themselves or if somebody might be pushing them to do it either directly or indirectly. Sometimes it is not someone making direct comments to them but they’ve noticed maybe their partner doesn’t seem as attracted to them anymore. And so they are thinking that this procedure might help them regain that attraction.

You can ask what they are hoping to achieve with this procedure and how they’re hoping to look or feel different afterwards. And then you need to consider whether the treatment that you are offering or the surgery that you’re offering has the ability to meet those expectations.

Now we know that the vast majority of the patients that you see are really happy with the results and they do experience benefits. They are the ones that report their self-esteem and their confidence improves and they feel so much better about themselves after getting these treatments. But the patients who are more vulnerable and more at risk of dissatisfaction are usually the ones who are experiencing body dysmorphic disorder or other psychological issues. And so by screening for that beforehand, you can prevent yourself and your patients a lot of heartache.

Psychological Screening: The Cosmetic Readiness Questionnaire (CRQ)

So we have developed the ReadyMind platform, which includes a range of different assessment tools that you can use. And I am going to speak about one in particular which is our Cosmetic Readiness Questionnaire. It has BDD questionnaires and things that assess depression, anxiety, health anxiety – which you can pick and tailor to the procedures or the setting that you’re working in. But some of the benefits of including screening questionnaires,

rather than just asking questions in an interview, is that it is really time efficient.

So to do a long clinical interview with someone when you’re assessing their mental health can take awhile. A psychologist can take an hour just to assess a patient’s mental health or provide a diagnosis of body dysmorphic disorder. So a questionnaire like this can gather information really, really quickly. It also requires less expertise to do than a clinical interview.

So with our platform, you can give people the questionnaires, it scores it for them. So you do not actually have to think about adding or interpreting any measures. And so there’s a lot less expertise involved. It also ensures that you don’t miss anything.

And so when you are doing a patient consultation and you have so many different things that you have to do and you have to think about and you are assessing, the patient’s aesthetics and the treatment options and what you can achieve, it is very easy to kind of forget to ask a question about the patient’s mental health or forget to ask a question about how they’ve been, if they’ve been preoccupied with their appearance. And you do not want that question that you miss to be the one that then keeps you up at night later.

So by having this screening questionnaire as a routine part of your paperwork, it can ensure that you don’t miss anything. It also means that you’ve got documentation, you’ve got this on the patient’s file. If there is any problem later down the track, if there are complaints, if there are illegal issues or audits that come up, you’ve actually got a screening questionnaire documented. So it might not be enough to say, I asked the patient in the interview and they said, no, I don’t have BDD or any psychological issues. Having a questionnaire like this can add another layer of protection for you.

You can use it as a tool to support your clinical decision making. And I think this is a really important benefit of a screening process because I know from the work that I have been doing with lots of cosmetic practitioners is, you all know how to detect some red flags in your patients. You see them when they come in and they make you a bit uncomfortable and you know that there is something that you don’t necessarily want to work with but sometimes it’s hard to put your finger on what it is and then it’s really hard to redirect that patient elsewhere or to say no if you can’t actually describe what it is that you’ve picked up on. And so by having a questionnaire like this, you can actually fall back on that questionnaire and the new guidelines for being the reason that you’re recommending a referral and assessment rather than just your clinical judgment.

So it provides a safe framework for you to discuss referral or to discuss a reason why you might not be going ahead with a treatment. And the other thing having these questionnaires can do is it facilitates outcome monitoring. So especially if this is something that you might do with patients at baseline and then again, after treatment or after surgery, you can track your own patient outcomes and see how they’re being impacted by a procedure. You can see if it’s making them more satisfied with their appearance, if their moods improved, if their confidence is improving.

And under the new guidelines there are recommendations for professional development that you have to do ongoing continuing professional development. And one of those CPD activities is actually to routinely monitor your own outcomes. And so it’s a really powerful exercise for reflection and professional development. And also you can use that potentially in your marketing when you know the results that your patients are getting. And you can share that because it’s an evidence-based outcome that you can share with people.

So this brings us to the Cosmetic Readiness Questionnaire. So the CRQ was developed from well-validated psychological scales that have existed in the literature and have strong psychometric backing for them. It includes 45 items, which sounds like a lot, but it actually takes less than five minutes to complete. So it’s still a really quick questionnaire to complete. And this questionnaire doesn’t only assess body dysmorphic disorder, it also takes into consideration those other psychological conditions that you should be aware of. So we have a body dysmorphic disorder scale but we also assess for psychological distress. So high levels of anxiety and depression, it assesses people who might be really self-critical and have a tendency to be really hard on themselves, which might or predict how they respond to a surgery or a treatment, they’re less likely to see the benefits but might actually be a bit more

self-critical afterwards. And we also assess how perfectionistic they are – which is if they hold themselves to really high and unrealistic standards.

The other thing that the Cosmetic Readiness Questionnaire has – so every time I’ve spoken about the guidelines with people so far without fail, I’ve had a question, won’t people just cheat the screening measure? So if someone with BDD really wants to get a procedure or a surgery there absolutely is a possibility and risk of lying on the questionnaire. So what we’ve put into our questionnaire is an openness scale as well. It is essentially a bit of a lie detector scale and it assesses how open a person has been in their responses to the questionnaire. If someone gets a high score, that suggests maybe they have not been fully open with you and our scores are adjusted based on how open they’ve been in their responses which makes it a lot harder to cheat in the questionnaire.

So what this questionnaire does is it doesn’t only take into consideration body dysmorphic disorder. We know that BDD is actually highly prevalent in patients seeking cosmetic treatments and it can be sometimes up to 20% of patients that are meeting criteria for body dysmorphic disorder. But from the work that Ben and I have done over the last few years when we’ve been doing these assessments for patients, we know that not everyone with BDD is an inappropriate candidate. There are some people who have really well managed BDD, insightful and are doing really well in their lives and in those cases they actually might be more reasonable candidates for surgery or for procedures.

So our screening tool creates a more nuanced decision-making process that doesn’t consider BDD alone, but considers a range of factors and characterizes people as being in the green, yellow or red zone. The automatic report will let you know which category your patient is in. If they’re in the green zone, that means that they’ve got a ready mindset and they’re more likely to be satisfied with the treatment. And 70-80% of patients will be in that green zone.

Now, if they’re in the yellow zone, that’s a patient who’s displayed some risk factors for dissatisfaction with the outcome or they might have some unrealistic expectations and that’s around 10-20% of patients. In those cases, we would be recommending further discussion during the consultation. The screening software will flag areas that you could actually discuss with your patients before going ahead with the treatment to make sure that they’ve really got a good understanding of the procedure of the risks and that you’ve managed any unrealistic expectations. And in turn, they can go on to get treatment and will hopefully be more satisfied after going through that consultation process.

Then we get to the patients in the red zone and these are considered highest risk because they’re flagged with having certain mental health challenges which might reduce their satisfaction with treatment. And it’ll be around 5-10% of patients who would end up in the red zone. They’re the ones who are most at risk of being dissatisfied or having a negative outcome from the cosmetic treatment. So they’re recommended to be referred to a mental health professional for further assessment before going ahead with the procedure. So patients in the red zone – it’s not a no, you can never have treatment. It’s just not just yet. We need further evaluation first before we can go ahead with this.

Scale Validation

Now our scale validation. The scales in our Cosmetic Readiness Questionnaire have all been previously validated. But we’ve validated our questionnaire as a whole and found that it’s highly associated with a body dysmorphic disorder diagnosis based on a clinical interview and the gold standard questionnaires, which means that a patient that’s screening in that red zone is highly likely to have BDD. It’s also associated with greater dissatisfaction with treatment. And so the total score from the Cosmetic Readiness Questionnaire, the Psychological Distress Scale and the BDD scale are all associated with patients who reported having unmet expectations for treatment, saying that they weren’t quite satisfied with the results because it didn’t meet their expectations.

And the other thing we did in the development of this questionnaire is I also did a full assessment with these patients and gave them a rating before I had seen their questionnaire results of whether I would classify them as green, yellow or red based on my clinical expertise and my research expertise. And then we correlated the scale results with my ratings and that was also highly correlated. When you use these questionnaires, it’s like having a psychologist with you in your consultation and so it saves you a step in the process of having to refer them to me except if they’re really high risk.

ReadyMind: How It Works

So how does it work? So at ReadyMind, we’ve really tried to streamline this process. We know that these guidelines have been a bit stressful and we want to make it as easy as possible for you to meet the requirements under the new guidelines. So with our software, the practitioner can send the patient a link to complete the screening questionnaire and that link can be added to your routine paperwork that you send to patients before their consultation. And that same link can be accessed by all patients – they’ll enter their details, the patient will complete the questionnaire on their personal device or at home before they come in, or they can do it at the clinic. The results will be instantly scored and interpreted for you. And that can be emailed to the practitioner or the practice manager or whatever your preference is.

You’ll get an automatic report and then you can use that report to provide feedback to your patient or to determine if it’s safe to proceed with the cosmetic treatment or if they need a referral or you can use it to track their outcomes throughout the surgery process or the procedure.

CRQ Report

And this is an example of what our report ends up looking like. So what you’ll see is that the patient will get an overall rating for their cosmetic readiness if they’re in the green, yellow, or red zone – it’ll break down why they’ve scored in that zone. So it’ll show you, body dysmorphia came up as red and perfectionism came up as red and then it’ll give you some recommendations. So it’ll tell you, because they’re in the red zone, we’d recommend that you refer them on for further assessment by a mental health professional. And it’ll also give you some prompts for the consultation that you might wanna discuss with the patient. It also gives you prompts on sensitive language to use or things that you might need to be careful with when you’re working with a patient who’s in the yellow, green, or red zone, particularly for the red zone.

Scoring Breakdown

And this is what our scoring breakdowns look like in our pilot studies of this questionnaire. So in the guidelines it says to use a BDD questionnaire. Now if you do this, one of the problems that you might run into is that a large number of people start to screen positive. And when we are using the BDD questionnaire alone, we found that 31% of patients would’ve actually scored in the red zone. And that makes sense in a cosmetic setting where everyone getting these treatments has some level of concern about their body image or their appearance. So it’s more likely that they’re going to score on the higher end of a BDD questionnaire.

So with the ReadyMind software, by taking into consideration not only BDD, but also these associated risk factors, we end up with the cosmetic readiness rating where 70% of patients are actually green. 22% might be in the yellow zone and need a little bit of extra care during the consultation process or a bit of extra support. And around 8% of patients are in that red zone – they’re flagged for further referral and those are the patients who need it most. So essentially, by using a more comprehensive measure like the Cosmetic Readiness questionnaire, you’re capturing the people who are most at risk rather than capturing a huge number of people who are just experiencing concerns about their appearance which is why they’ve come to see you in the first place.

How to Refer to a Mental Health Professional

I guess the next thing that might come up for people is how do we actually have this conversation if they do screen positive on the screening measure – what happens next? And this is an area where we’ll be developing more resources, training videos that you can watch and you can practice yourselves because there might be a little bit of discomfort with having these conversations and it’s going to take a bit of practice before you start to get used to it.

But this is kind of a four step framework which I call the Four Rs for how to refer a patient to a mental health professional. And the first thing is to relate to your patient on a human level. They’re obviously going to be disappointed because they maybe wanted to get the procedure that day or make plans for the surgery that day. So I think it’s validating that distress. You can say something like, I can tell how much your anxiety about your appearance has really been impacting you.

The next step is to reassure them. Reassure them that you have their best interests at heart and that means you’ve got their best physical interests and emotional interests, aesthetic interests, all of them. So saying something like, you know, I want you to know that my main priority here is, is your physical and your emotional wellbeing.

Now the next step is to, to refuse to go ahead with any treatments on that day. I think the new guidelines will actually really help with this process. So this Four Rs framework I’ve been talking about for awhile, even before the guidelines were being reevaluated and I think it was harder to do before because then you had to rely on your own clinical intuition as your reason for why you’re referring the patient on. But now you can actually blame the guidelines and the screening questionnaire. So you can say something like, based on your screening results and requirements under the new guidelines, I’m unable to proceed with the treatment today.

And the last step is to refer and or suggest a mental health professional or a psychologist that you’d like them to speak to. And it’ll be a good idea to develop a relationship with someone in particular so that you can really normalize the process. You know, I’d like you to go and have a chat with Toni or with whoever it is to help clarify your motivations and expectations and work out whether cosmetic treatment is gonna be the best way to achieve your goals or if there might be some other options available to you. So really making this process sound, as friendly and neutral as possible and normalizing it that this is not something that’s just happening to them but you’ve done it with lots of patients before and usually patients are more satisfied once they’ve had the opportunity to talk about it with a psychologist first.

So what will the psychologist do next? I know for me personally when I do these cosmetic surgery assessments, it takes at least an hour and this might be time that psychologists have, but other professionals might not. So my preference would be to be referring to a psychologist for an assessment. And we also have guidelines that we have to uphold when we do these assessments. So there are guidelines from the Australian Psychological Society which explains exactly which domains we need to be assessing and considering in a patient to determine their readiness for a cosmetic procedure. After we’ve done that assessment, we would then report back to the referrer, usually just a brief report or a letter with essentially a risk assessment saying, this patient is at high risk of having a negative outcome or being dissatisfied with the treatment.

And so in that case, we might be recommending psychological treatment instead of a cosmetic procedure at that time or before they go ahead with a cosmetic procedure. They might be in the moderate risk zone where it might be okay for them to get the treatment, but we would still recommend some support before and afterwards. Or they might be in the low risk zone where we report back saying, we’ve had a discussion yet they might be experiencing some mental health concerns or they might be experiencing BDD but it’s actually really well managed and they’ve got reasonable motivations and expectations for the procedure and we feel happy for them to go ahead.

And that tends to be the most common response that we would give to people. Most patients will end up being in that green zone with the go ahead and if needed, we would provide or refer them for ongoing treatment. So psychological therapy for whatever mental health condition they’re experiencing. For BDD, we would be recommending psychological therapy and SSRI medication as well.

How do patients actually respond to the psychological screening process? So as part of the research I’ve done earlier this year, I was doing focus groups with patients seeking cosmetic treatments and I asked them about it, how would you feel if you were asked to fill out a psychological screening questionnaire? And eight out of 10 patients had a really positive response to this and would really value a practitioner who could manage their expectations and say no if a procedure wasn’t in their best interests. And they could see how a psychological screening questionnaire could help the practitioner to do that, to understand them better and provide appropriate recommendations.

The other two people didn’t have negative views on it completely. They didn’t think it was a bad idea, but what they did say was that if it wasn’t a routine part of the consultation process, if you just pulled out a screening questionnaire when you were worried you had seen a red flag, they might start to feel targeted. So what that really suggested to me was that these guidelines that recommend screening now for everyone seeking cosmetic procedures and cosmetic surgeries will be really beneficial. I know it might seem like it’s overkill because many of your patients are suitable candidates. But by making this a process for everyone, it really normalizes it so that no one’s getting singled out by the process.

Other Resources on ReadyMind

Ready Mind has developed a number of resources that you might need in implementing these guidelines. So we’ve developed a screening and assessment platform. The main questionnaire that we would recommend is the Cosmetic Readiness Questionnaire because it doesn’t only take into consideration BDD but it considers other factors and it has that openness questionnaire which can assess the risk of a patient bending the truth a little bit. It automatically scores things for you. We’ve also developed scripts and we will be developing more training for you on how to manage these difficult conversations. We’ll be filming role plays and different tools that you might need to get really confident with this process. And other things that you might need, like psychologist referral letter templates or information handouts for patients about these new guidelines and the need for screening.

We would love to hear from you as well. If there are other resources that you feel like you need to feel confident to manage these guidelines, please do reach out and let me know because we’d be more than happy to develop them.

We do have a QR code on the slide here that you can scan and it will take you to the signup page for our Ready Mind software. There is a small fee to use the platform and the only reason we’ve put that in is to cover our costs for the software and the service. We want to make this process as easy as possible. You will get a one month free trial to practice it with a few patients and see if this process works well for you. And after that, it’s only $10 a month for individual practitioners.

What I would recommend to do is to have a go after this webinar at doing the Cosmetic Readiness Questionnaire on yourselves. It’s always an interesting self-reflective exercise to do. Ben and I do it all the time – we’ll often do these mental health assessments on ourselves because it’s really useful to just learn about yourself and see areas where you could develop and grow. And so I think that will be a really important exercise for you to try before you go ahead and give it to your patients as well.

And please feel free to reach out to us if you’ve got any questions or anything else that you might need to navigate the new guidelines.