‘On the Face Of It’ – new training course for assessing mental health of aesthetic patients

Associate Professor Gemma Sharp, Head of the Body Image and Eating Disorders Research Program and Senior Clinical Psychologist from the Department of Neuroscience at Monash University, has developed an online short course called ‘On the Face of It’ – Understanding AHPRA’s guidelines on mental health assessment of cosmetic patients.

Why is assessing mental health in aesthetic patients important?

The drivers for aesthetic requests are generally psychological in nature, so if you’re not asking those questions then you’re not really understanding the patient’s motivations as comprehensively as you could be.

I’ve dedicated the past 10-plus years of my career looking at the psychological motivations and outcomes of people seeking aesthetic procedures. I’ve published my own research and read the research from others and we have all shown the importance of psychological drivers. Patients can benefit from these treatments both psychologically and physically, but it is very important to assess their mental health in order to achieve the best outcomes.

How did you become involved in the development of the short course in assessing mental health in aesthetic patients, ‘On the Face of It’?

This goes back a little way. In 2018 I was asked to work with the Australian Psychological Society (APS) on what ended up being the world’s first clinical practice guide for mental health assessments of patients seeking cosmetic procedures for mental health professionals such as psychologists. This was the result of 2016 guidelines by the Medical Board of Australia (MBA) recommending that clinicians should be assessing mental health. In 2023 there was more discussion between the Australian Health Practitioner Regulation Authority (AHPRA) which resulted in the MBA and the APS updating their guidelines recommending the MBA to mandate the assessment of mental health conditions in patients seeking cosmetic procedures.

So as you can see I’ve been working in this space for quite a while, particularly from a guideline and policy aspect. I started thinking do clinicians in aesthetic medicine actually know how to do these mental health assessments with confidence? Psychologists, psychiatrists and other mental health professionals do this sort of assessment all the time. Unfortunately, education in medical school and nursing school may not be as comprehensive as it could be and I wanted to help practitioners upskill on their mental health assessments so that they would abide by the new guidelines, but also to understand their patients better.

We wanted to partner with an organisation and decided to team up with the Cosmetic Physicians College of Australasia (CPCA). We decided that an online short course was a really easy, accessible way to educate a large group of people quickly and share all the knowledge that we’ve accumulated over the past 10-plus years.

Can you give a brief outline of ‘On the Face of It’?

‘On the Face of It’ is a five-module online course. It will take learners between four and five hours to complete. It consists of a webinar for each module, which has points of reflection as well as short videos. There is an assessment at the end of each module to test your skills, as well as practice questions along the way. At the end of the course, a certificate of completion is awarded.

In terms of content, Module One is about the basics, such as why should we perform mental health assessments of cosmetic patients. It cites a lot of the research that we’ve done at Monash over the past 10 years looking at how body image concerns and other anxieties really drive those requests. Module Two is a summary of the various guidelines in Australia. We go through each different policy and guideline and highlight the most relevant parts for cosmetic practitioners.

Module Three is about the different types of assessment that can be performed. I suppose people are very familiar with patient self-report questionnaires, but we also talk about mental health history and clinical interviewing, and how all of these are important to really understand the patient’s mental health profile. Module Four is the largest module, which focuses on the various mental health conditions that can play a role in people requesting cosmetic procedures. Body dysmorphic disorder comes first to mind for everyone, but really that’s only one relevant condition. We talk about the influence of eating disorders, OCD, mood disorders, anxiety disorders, personality disorders, as well as neurodivergence such as autism. It really opens people’s eyes up to the way different mental health conditions can present and interact.

Module Five is about applying this knowledge. It has case studies and it asks our participants what they would do in certain situations, which may, for example, be about making a referral to a mental health professional. It discusses why they should make a referral, the process of doing so and what the outcome will likely be.

Most participants are able to claim CPD hours for completing the course, but I believe you’ve added an optional part at the end, if people want to get some of those difficult Measuring Outcome CPD hours as well?

Yes, we’ve added this because we know that those hours are sometimes hard to get. It’s not only useful for the participant; it’s also very useful for us to see what actually happens after people complete the course. We ask them to complete a questionnaire after the course to tell us what we’ve done well and what we might need to improve on. Following this we ask them to keep a simple record of consecutive patients noting their age, gender, presenting issue and how they assessed their mental health. At the end, we bring them back for a more comprehensive Zoom interview to discuss what happened with those patients and how they applied their knowledge from the course.

The Medical Board and AHPRA decided in their guidelines to use questionnaires such as a BDD questionnaire. I know a lot of readers are going to ask, well, isn’t a BDD questionnaire enough? Isn’t that all that I’m being asked to do?

I suppose if they’re following the letter of the guideline then, yes, but what I would say is that you’re really relying on the patient having quite a lot of insight into their own mental health. It’s often the case that people with BDD will actually not answer those questionnaires truthfully. They’re not trying to obfuscate; they simply aren’t aware sometimes of what’s going on in their own minds. So while you may have ticked the box and thought, ‘Well, this person does not have BDD,’ they may actually have BDD. It’s only through further assessment that you might ascertain this person does have BDD, but a simple patient self-report screening tool may not be sufficient to detect it.

Psychologists know that self-report questionnaires are not sufficient for diagnosis. In addition, as we were saying earlier, it’s not just BDD that needs to be considered. That’s only one condition. The reason we talk about it so much is that it has been more well studied than other conditions. In fact, eating disorders and OCD can also have negative outcomes in cosmetic patients and these conditions are actually far more prevalent. It’s just that we haven’t done as much research in this space, which is what my team’s addressing at the moment. So looking only at BDD and only doing a questionnaire is really the tip of the iceberg. I think you’re putting not only your patients but also your practice at risk by only doing that.

Considering your research, if you don’t do a complete mental health assessment and understand the psyche of a person, how does that affect their satisfaction at the end of the day? What sort of problems can occur and how often do they occur, especially with regards to complaints and litigation taken against the practitioner or the clinic?

Most patients are happy. However, the unhappy minority can be very powerful and problematic to themselves, the clinician and also the practice. Some of the research I’ve done has shown that about 80% of patients are satisfied and 20% dissatisfied. The predictors of dissatisfaction were not a surprise: they were mental health and life satisfaction markers.

If you’re not doing a comprehensive mental health assessment, you’re going in blind, and you don’t know who that 20% are. In some circumstances they can unfortunately harm themselves or could even complete suicide. That is such a terrible outcome, but it does happen. They can also harm the practice, either through litigation or sometimes physical aggression towards the treating practitioner team. So, it can have really negative consequences if you don’t do your due diligence at the start, because you could have predicted what was going to happen.

So, doing a course like ‘On the Face of It’, potentially could enable someone to have the skill to predict the sort of person that could litigate, be aggressive or write a negative Google review?

Many people come to a cosmetic practice on the basis of a review. Imagine if this person has a huge social media profile and they’re unhappy with your service. This can be really damaging. So, yes, if you have the tools to be able to better identify these people from the start, then you’re protecting yourself and also the patient. This is what this course delivers.

This leads to the next question: who should do this course, Gemma?

We designed the course to have a broad audience, from health practitioners early in their career to very advanced practitioners. There is new information that even experienced practitioners might not be aware of. We also made it cross-disciplinary, so it can be undertaken by physicians, dentists and nurses. Even mental health professionals such as psychologists and psychiatrists would benefit from completing it. Basically, anyone who has anything to do with aesthetic medicine could benefit from this course.

Any final comments?

There’s more research to be done on the mental health impacts of cosmetic surgery requests and cosmetic procedure requests. So that’s something we’re always working hard on in our team, and we also love collaborating with cosmetic practitioners to add to the evidence base. So, our work is really never done here.

I’m glad that there’s a spotlight on the intersection of mental health and aesthetic medicine, because it’s been needed for so long. AHPRA and the MBA has taken these steps and I think there’s going to be more to come, so our job will be to keep educating people with the latest developments and latest research coming through so that they can offer the best services for their patients.

For more information or to sign up see On the Face of It – Understanding AHPRA’s guidelines on mental health assessment of cosmetic patients.