Names and details have been changed to protect patient confidentiality.

Jennifer, a 26-year-old former model, appeared in my office one summer day saying she was thinking of having Botox injections. My first response was surprise. “Why in the world would this beautiful young girl want a cosmetic procedure?” My second response was curiosity. I asked her if we could explore her desire for injectables until we completely understood her motives and feelings before she acted. She was willing.

According to a report published by PlasticSurgery.org, 6,321,160 people had a Botox procedure performed in 2013, an increase of 703 percent when compared to 2000.

In 2013, there were almost 100,000 documented Botox injections for people between 20 and 29 years of age. This number rises to 1,119,798 for 30-39 year olds. For women between the ages of 40-54 this number almost triples.

I am a psychotherapist. I see the trend in plastic surgery as having more to do with inner insecurities then about one’s looks: A person feels badly about themselves, they think injectables will help them look better and then feel better, but this doesn’t always happen. Their long-term self-esteem doesn’t always change for the better. That is because there are deeper insecurities that lie underneath. These deeper insecurities are about inherent self-worth and lovability.

When procedures doesn’t bring relief from insecurities, some women get additional procedures still searching to feel more confident. This is not a healthy road.

“Jen,” I asked, “Let’s imagine in a very vivid, detailed way what happens after the procedure.” I often use fantasy with my patients to help them get in touch with what they think will happen. The brain doesn’t really know the difference between fantasy and reality, so fantasy can be used to conjure the same emotions and thoughts that would happen in reality. This gives us a chance to have a dress rehearsal before something irreversible is done.

“OK,” she replied.

“OK, so picture your doctor’s office. You have just paid and checked out. You exit the office. Got that picture? (She nodded.) Now what happens? Where does your imagination go?”

“I go straight home to examine myself in the mirror.”

“Great, what happens next?”

“I am home standing in front of my bedroom mirror. The lines are gone. I am pleased.”

“OK, that’s great, but let’s slow it down again so we can flesh it out more. So it feels more real. You are at home and your wrinkles are gone. Now what?”

”Now I go out to meet friends for dinner and I feel prettier and have a nice time because I feel good about myself.”

“OK, I understand. You imagine yourself without lines and you feel better.”

“Exactly.”

“Can we reverse it now? Let’s imagine you don’t have the injectables and you’re out to dinner with friends. What happens that is different?”

“I don’t feel as pretty. I can see the lines on my face.”

“How can you see the lines on your own face?”

She smiled and lets out a little laugh. “Well, I obviously can’t. But I remember what my face looks like in the mirror, and I think my friends see that face.”

“And what do your friends see when they look at your face?”

“They see my wrinkles.”

“Yes, and — I’m going to play devil’s advocate here — so what if they see your wrinkles? What do you imagine they think if they see you have a wrinkle?”

“They think, ‘Jen has wrinkles. She is not as pretty as she used to be.’ Then they think that is why I don’t have a boyfriend.”

“So your friends will think ‘Jen has wrinkles and she is not as pretty as she used to be and that’s why she doesn’t have a boyfriend.’ Does that feel true as I say it back to you?”

“Yes.”

“So I am just wondering,” I say gently and playfully, “Given that, 1) you are not a minder-reader; and 2) people are so busy worrying about what others think of themselves that they hardly notice other people, we actually don’t know what your friends are thinking. But, is that what you think about you?”

Jennifer thinks for a moment. “Yes! That is exactly what I think.”

This is called a projection: we have a thought and imagine others have the same thought. We all project — it is just something our brains naturally do. Awareness helps undo projections since they are subjective perceptions and not objective truth, although they sure feel true.

“So I think what you are telling us is that the only thing we know for sure is that you are really struggling with getting older, changing, and being single right now. Thoughts?”

“I think you’re right.”

“Those are really big and hard issues. They are complicated for all of us and bring up many feelings and conflicts. Can we just take a breath and let that be for now without doing anything about it?”

I know we are not going to solve these issues in one session. In fact, they are not issues to solve. Jennifer is dealing with existential issues around aging and self-worth. We have to struggle over time to resolve these complex issues, not avoid them with a potentially harming quick fix.

I say to Jennifer, “If you go through with the injectables, you might be filling your wrinkle when it is really your confidence that needs some filling. Botox may be great, but I don’t think it can do that. What do you think?”

“I never looked at it that way.”

Jennifer and I worked together for two years after that session. During that time we came to understand how her childhood experiences had a direct effect on her feelings about herself. She came to understand how her mother’s excessive reliance on her beauty made Jennifer feel that is what mattered most. Jennifer didn’t feel valued for her brain or her gentle and kind personality. Jennifer’s mother had cosmetic surgeries and Jennifer remembers her mom crying about aging.

I would bet that if Jennifer’s mother had embraced aging, Jennifer would feel differently. If Jennifer’s mother and father deemphasized looks and emphasized character, Jennifer would feel more confident now. If Jennifer grew up in a home where the family valued one’s unique “imperfections” and “how there is beauty in the humanity of how we age naturally,” I imagine Jennifer would feel quite differently.

The point here is that the feelings we have about our looks are not objective. They are subliminally taught to us by our family’s values, our culture and myriad advertisements for cosmetic procedures and anti-aging products. These influences put our securities into us and cause us to feel shame, both consciously and unconsciously, for what we look like. The truth is we all just look like the humans we are. We are all in this aging thing together. No one is spared. And that is truly beautiful.

References

Fosha, D. (2000). The Transforming Power of Affect. New York: Basic Books.

Fosha, D., Siegel, D., Solomon, M. (2009). The Healing Power of Emotion: Affective Neuroscience, Development & Clinical Practice. New York: W.W. Norton and Company.

Nathanson, D. (1992) Shame and Pride: Affect, Sex, and the Birth of the Self. New York: W.W. Norton and Company.

Kaufman, G. (1996). The Psychology of Shame. New York: Springer Publishing Company.

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