Why I Stopped Talking to Practitioners About Patient Mental Health Safeguarding

I came into the medical aesthetics industry as a patient. A few years ago I had the same cosmetic surgery twice because nobody told me about Body Dysmorphic Disorder (BDD) or mentioned psychological risks, nobody explained that I might not see the change, and nobody warned me that my mental health could get worse afterwards. It did, and it was one of the darkest periods of my life. When I eventually understood what I had been through and why, I wanted to use my lived experience to make sure fewer patients have to go through the same thing.

I spent two years trying to improve patient mental health safeguarding in aesthetic medicine. What I actually learned was how an industry protects itself from the very changes it claims to want.

The first thing I learned is that the medical aesthetics industry has perfected the performance of caring. Every conversation I had with practitioners was positive. Genuinely, enthusiastically positive. “Yes, this is so important.” “Yes, this needs to happen.” “Yes, I want to get involved.” And then nothing. Not when it required actual change. Not when it cost anything. Not even when cost and effort were removed from the equation entirely. The fear of it affecting the business bottom line was always there underneath the enthusiasm, and eventually the enthusiasm disappeared. I stopped being surprised by the gap between what people said and what they did. It is industry-wide and not accidental. It is a comfortable place to sit. Vocal enough about patient welfare to seem like you care, non-committal enough to never have to prove it.

The second thing I learned is that the status economy in this industry is almost entirely fake, and people know it and participate anyway. KOL titles are bought. That is not a conspiracy theory, it is how it works. Reach a minimum order threshold with a pharma or device company and the title follows. It is a commercial transaction presented as recognition. The same logic runs through much of the awards culture. I have personally been offered several awards packaged inside a marketing spend. Somebody else’s business model, sold as prestige. People accept them because the industry has decided that visibility equals credibility, and titles and trophies are the fastest route to visibility. The charities operating in this space are not always immune either. Ambassador roles and board positions often correlate with commercial relationships rather than any clear track record on patient outcomes.

The loudest voices in aesthetics are not the best practitioners. I want to say that plainly because I saw it consistently over two years. The people doing the most careful, genuinely patient-centred work were almost never the ones on panels or dominating Instagram. They were quietly doing their jobs well. The ones speaking most about patient safety were often the same ones who, on closer look, had never examined whether their own practice reflected it.

Then there are the organisations. I had conversations with leaders and trustees of industry bodies, the people meant to set and enforce standards. What I found was a mix of insularity and unrealistic thinking. In one recent conversation, I raised the medico-legal reality that administering and interpreting formal psychological screening tools without the right qualifications creates legal exposure for practitioners. The response was not to engage with that concern. It was to argue that practitioners should use screening tools anyway, as though moralising over the issue makes the legal exposure any less real. As if acknowledging the legal risk and dismissing it is a responsible position for someone in governance.

That conversation clarified how these organisations function. They are not interested in input from outside their circle. They are interested in maintaining it. Who gets platformed, protected, or ignored has little to do with the quality of someone’s work and a lot to do with proximity to the right relationships. I watched organisations that talk constantly about standards ignore breaches by their own board members and ambassadors. The enforcement is selective in ways that are too consistent to be coincidence.

The hardest thing to contend with has been the dogmatism. Not the politics or the commercial incentives, but the confidence with which people speak about things they do not properly understand. Dogmatism is what lets people overestimate their competence and shut down scrutiny. It's what makes the problem unfixable from within.

I had practitioners tell me they can spot a BDD patient instantly. I had people argue for screening tools adapted for cosmetic settings, as though changing the branding changes the underlying problem. In a commercial setting, patients are motivated to pass whatever sits between them and treatment. Self-report does not work here. Not because patients are dishonest, but because the conditions make honest disclosure unlikely. There is shame, lack of insight that is part of the condition, and awareness that the wrong answer leads to rejection. That is not something you fix with a better questionnaire. I have had this argument with mental health professionals who have built careers around these tools and will not engage with that reality.

The irony is that the same practitioners who criticise non-medics for claiming injectable expertise after a short course will attend a one-hour webinar on BDD and consider themselves equipped to manage psychiatric risk. The double standard is obvious and rarely acknowledged.

Here is the position I have come to, and the point I want to be clear on so this does not read as a general grievance: the answer to patient mental health safeguarding is not better screening; the answer is disclosure. Patients should be given the relevant information about BDD, about how it affects expectations and outcomes, and about what research shows regarding cosmetic results in people with high appearance distress. Then they should be trusted to make a decision with that information. A practitioner can still decline treatment if they are uncomfortable. That is their unquestionable right. But the patient should not leave a consultation without being told what they need to know to make an informed choice. That is basic, yet at the moment, it is almost entirely absent.

If I had been told before my surgery what BDD is, how it affects people, how I might feel afterwards, and why the appropriate next step in that situation is psychological support rather than another procedure, it would have changed so much. Not necessarily my decision at the time, because insight is not reliable with this condition. But I would have understood what was happening when things became difficult. I would not have felt misled. Someone would have done their job properly. Duty of care would have been met.

That's where I'm at now. Psychological risk disclosure is a basic part of informed consent in aesthetic medicine, and it is not being treated as one. The practitioners who could drive that change are commercially tied to the current model, socially insulated, and confident in their ability to read patients. The organisations that could enforce it are constrained by the same relationships.

I’m no longer directing my energy there. The people with a structural incentive to take this seriously, the ones who carry the financial exposure when inadequate consent processes lead to claims, are insurers and brokers. They understand risk. They work with data. There is no performance of ethics, only the cost of getting it wrong. Practitioners had every opportunity to lead on this, and they chose not to. Now the people who price their risk will make that change for them.

If you want to understand more about why I’ve reached that point, and the research behind it, you can read the rest of my writing here. Stay tuned for more!