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Share your story

12/7/2016

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This site has some serious blogs that I have written but please don't let that put you off from sharing your own story. We welcome happy stories and sad stories because everyone's experience is unique and worth telling. Even though my own stories are serious, there is always room for light-hearted and upbeat stories so get your pens out and start writing. If you find it hard to write, you can contact me and discuss your story and together we can get it perfect in digital format. 

My own story is that of being a psychotherapist with a passionate interest in cosmetic patient safety. In order to make this industry safer for patients, I have had to attend some difficult meetings and often argue to get my point across. I have often been quite shocked at the lack of regulation in the industry. I am pleased to say that new training qualifications are now being delivered and these include trainings for practitioners to understand patients better. My stories are not the same as your story but all stories are equally welcome here.  I just want to let the public and the professional world know that we have come a long way in improving patient safety but there is much more work to be done. It takes courage, strength and determination to have our patient voices heard but the struggle will be worth it for the next patients still to come. 

I have spent a life-time facing body image and weight issues. These struggles don't finish. They continue. However, it must be understood that each person who faces these issues, faces them at varying degrees and have different ways to resolve them. Putting time and effort into making positive changes is my way of healing myself. It works for me, it may work for you too. Everyone is welcome to join this campaign and make the effort they wish to do at the level they feel comfortable with. 

Sharing your journey, sharing your experience here with others is one way of helping. Mental health issues range from severe mental health disorders to simple every day body image issues but neither end of the spectrum receives enough support from either the NHS or other support groups. Let's do something about that. Body image issues are not trivial and should not be ignored so let's build our own network so that nobody falls through the net again. 

We are always looking for volunteers to help our campaign. You can offer a few hours of your time or more if you have it to spare. The work is always exciting and interesting. ​You can share your story online or in a live support group. You can be-friend someone or accompany someone to a consultation. There are many ways to be productive so JOIN IN now. Click here and let me know how you wish to help:
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Patient Safety in an unregulated industry

17/3/2015

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I recently left a meeting on non-surgical cosmetic interventions with serious concerns over certain aspects of patient safety. Patient safety falls into two categories: (1) practical (as per the ERG remit) and (2) psychological (not in the ERG remit). 

It was a great pity that psychology was not in the ERG remit. Yet, psychologists were members of both the ERG and AG with a psychotherapist also on the ERG. This configuration created conflict and confusion for all members of all groups who were denied the opportunity to fully engage with and understand the role and relevance of independent emotional support for patient safety and how that differs from psychology. The role and relevance of a patient association is crucial given the lack of Ombudsman as per the Keogh recommendations. Powerful industry representatives were not able to engage with the importance of psychological services within their industry for the benefit of patient safety. Without regulation, these safety measures that can be achieved, should be achieved. To ignore them is a tragedy. How many more innocent victims must suffer at the hands of an industry that are too self-absorbed to look at the person behind the profit. 

Members of the the recent meeting would be forgiven for thinking that emotional support undermines practitioners and surgeons. (How could you know otherwise without dialogue?)  In the meeting I was accused of providing emotional support because ‘I thought surgeons are stupid’. This is a remark that bears no resemblance to the reality of my role as patient support provider. Patients are often unable to integrate both practical and emotional support at the same time from the same person. There are many other reasons why emotional support benefits patients and surgeons but time does not permit that here.  I have created an article called The Case for Emotional Support Services in Cosmetic Interventions (which can be supplied on request) to remind you of why independent emotional support services provided by BACP members falls into the Keogh recommendations and is neither psychological screening nor Joint Council or TYCT.

I was criticised for pointing out that patients prefer the word ‘cosmetic’ to the word ‘aesthetic’. I fully appreciate the industry prefers the word ‘aesthetic’ to ‘cosmetic’. However, I must remind industry readers that the original question put to me was: ‘what word do patients use?’. Having provided support as a cosmetic support patient association since 2000, I can say that they use the word ‘cosmetic’ far more than they do ‘aesthetic’. It is the exception to the rule when the word ‘aesthetic’ is used. There is simply no point in blaming me for this. If, as one member suggested, patients should be educated on their terminology then I would suggest the industry provide funding for this because I provide service without funding. Ido not believe patients should have to pay for this additional level of safety that they clearly need. 

I would like to remind readers here that, since its inception in 2000, and often in the face of great challenge, Cosmeticsupport has always offered its total support to the BAAPS and BAPRAS surgeons. Whilst it is true that we are often critical of their marketing, we have not wavered in our support of their surgeons. 

I would suggest that if anyone wants to know why a patient association is important for this industry and what independent emotional support is that they contact me directly rather than jump to conclusions based on chinese whispers. 


Yours sincerely,


Deborah Sandler, MBACP
Co-Founder, Cosmeticsupport
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The Emperor's New Clothes

11/8/2014

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It’s as clear as the logo on a designer bag that emotional (patient) support in private elective cosmetic procedures must be integrated into the clinical setting as a routine option for all cosmetic patients. The average patient remains ill-informed against a backdrop of an exploitative industry which either choose not to or refuse to reach out to their patients as individuals. The result of this is emotional confusion rather than emotional intelligence in the clinical cosmetic setting. The final results can lead to chaos and ruin financially and otherwise for both patient and practitioner. These issues can be mostly avoided by integrating independent emotional support. 

For this integration to succeed, independent sources of support must be understood. Patient advisors as they are today are not independent or trained in emotional support. When any psychotherapist who is also selling or recommending products tries to offer emotional support, the process becomes corrupted. The entire reason for emotional support is for the patient to draw his/her own well-informed conclusions based on clear information and emotional understanding. This can’t be achieved when the ‘provider’ is linked to products or other commercial factors. Nor can this be even partially achieved if the support is offered in a public setting such as social media. I do not wish to be insulting but there is a lack of understanding among patients about how to verify the qualifications of the person from whom they are asking life-changing questions. 

Yesterday I met a patient who shared the story of her face-lift and blepharoplasty. Applying the concepts of privacy and confidentiality, this patient will be referred to as Samara. When she turned 50 Samara noticed her face was showing signs of age that she had more than enough financial means to correct. She wanted to hold back the visible signs of ageing as much as possible and she wanted the best possible surgeon to do the job. Samara felt that a facelift and blepharoplasty was relatively straight forward - “…all my friends have already had it done,” she said. Samara did her research by going online to see which clinic looked best. Being easily able to afford the best and considering herself a reasonably well-educated and intelligent woman, Samara decided it was easier to choose a hospital instead of a surgeon. She chose a hospital in a popular London location that she considered looked the best: “good hospitals will have the best surgeons”, she believed.  Samara was happy that she had found a ‘good surgeon’ and was in safe hands. More than a year later, Samara struggles in the summer heat when she wants to tie her long blonde hair in a pony tail because of the tell-tale scars that remain clearly visible. I asked Samara who her surgeon was but she could not remember how to spell his name although she had a vague recollection of his Eastern European sounding name. She tried to google what she thought might be the spelling and nothing came up. Equally, the surgeon was not listed on the particular hospital’s website.  I asked Samara if she knew whether her surgeon was on the GMC list of specialist plastic surgeons and she asked me what that was. This type of response is not uncommon.  I explained the importance of this register and she responded by trying her best to assure me that she had chosen well because she had spent a long time on the internet searching for the best hospital. 

This brief excerpt from a recent case history illustrates why it is not only crucial for patient safety to be brought into line with real patient needs but also conveys the need for appropriately independent cosmetic surgery counsellors. Patient (emotional) support is often confused with information or psychology. It borrows from both but it is neither of the two. Psychology may argue that it is preferable to focus on reporting the findings of scientific research rather than on the results of individual cases. However, history shows us that it is cases like ‘The Wolf Man’ and ‘Anna O’ that make life-long impressions. Patients will remember the encounter (form and content) they have with an intelligent, informative emotional support provider rather than the questionnaire they are asked to fill out in the isolation of a waiting room or with a non-psychologically trained professional. 

It is not just patients who benefit from an independent integrative emotional support system. I have often heard it said among aesthetic surgeons that their patients are “.. the type of people who want the best”. I think it is fair to say that most patients want the best. What that best looks like on a glossy website or other form of marketing is a matter of individual taste. There may be several stores appearing to be selling the same thing.  Why is one drawing more customers than another if they are all playing on the same level playing field? Are surgeons really understanding that their patients make up a cross-section of different financial backgrounds?  There was once upon a time when the myth that plastic surgery was only for Hollywood or the elite and secretive rich, but not any more. All aesthetic professionals must learn to understand who is at the other end of their treatment plan and how to talk to them in a way that they understand. Accepting this aspect of their business does not cheapen it - quite the contrary - it elevates it to a new standard. 

Offering free information and advice, whether it is online or via consultation is a great way to help create well-informed patients and any appropriate method should be encouraged by all cosmetic practitioners wherever possible. 

There appear to be two different types of patient support on the market: independent and commercial. I speak as an independent patient support provider believing this to be the right way to offer support. Independent emotional support can and should  be integrated into the industry while remaining true to its essential ethical principles. Diluting this solution leads to pollution. 



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Breast Implants - a Feminist Issue

29/5/2014

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There are certain conversations that women prefer to have with other women: periods, childbirth and .. *drum-roll* .. breast implants.  I think these three issues make up the core issues of what separates us women from the men-folk. Ever tried discussing any one of those three subjects with a man?  Many prefer to gnaw off their own limbs than endure. Yes, women do talk to men about breast implants but it is more likely to be about cost, logistics and other rational aspects of the procedure. I do not deny these are important parts of a conversation but they are a smaller part of a larger picture that women want (perhaps need) to discuss with other women about breast implant surgery. 

The intimate nature of a conversation about breast implants is less self-conscious when carried out woman to woman.  When it comes to breast implants, not only do women want to talk to other women but they want to meet the kind of women who are not afraid to show them their surgical results.  Many years ago I made a reality tv programme where the film crew saw an example of this. I believe that this is a realistic way for women to visualise and understand the possibilities in store for them. Women are generally honest with whether they think their results are ‘natural’ or ‘hard’ or ‘soft’ or ‘big’ or ‘small’, and what manufacturer their implants came from and what choices they were offered at the consultations. They want to talk about how it made them feel to sit in front of a male surgeon with their breasts out and being felt for surgical assessment. While surgeons may do this every day as part of their job, a woman does not usually get her breasts out for anyone other than one close person. For a woman in a consultation, it is an unusually intimate act in an unusually clinical setting. There are alot of emotions involved for many women in this part of the consultation.  Some patients may be  strippers who are more used to this public situation but may not wish to reveal their profession. This can create conflict when surgeons who don’t know the patient’s profession talk about a ‘natural look’. 

The media encourage our daily chatter by providing us with similar stories from different angles about cosmetic surgery and other issues relating to women. It is impossible to ignore cosmetic surgery in the media any more. We are encouraged to attempt to blow the whistle (on behalf of our sisters) on bad surgeons and results but .. it seems .. only if those bad surgeons or bad surgeries are by way of a cowboy. The truth that life teaches us is that there are still some bad apples on very expensive carts even though manufacturers do their best to make sure that all apples look the same!  Sometimes it is not the surgery that is bad but the way the surgeon deals with the criticism and that makes him/her just as much of a cowboy as .. well .. the cowboys in the eyes of the patients. All surgery carries risks and each patient will bring to the table their own particular risks which keeps the focus of finding a well trained surgeon so crucial. 

The fact that our cosmetic surgery reality is being so tightly controlled by the media makes it even more compelling to discuss experiences without fear. The over commercialisation of surgery that results from control factors like these make it unsafe for patients not to talk openly. Being forced to keep silent when conversation is needed creates a climate of fear for patients. Some would argue that a good open conversation alone is what creates well-informed patients. I am not so sure. Cosmetic surgery (like any other surgery)  is one of the top ten major life events and a conversation (emotional release) is an essential part of the process. Who the patient talks to is crucial. Women prefer to talk to women about breast implants but which woman and why? For some, friends and family will be most appropriate but when it comes to professional emotional support, I believe a female counsellor is best placed to take this conversation. This is especially so if the woman in question has both had breast implant surgery and is trained in psychotherapy and is not afraid to make disclosure when that may be relevant. Counsellors are not their to advise on surgeons or implant manufacturers. 

Is there a type of responsibility attached to having breast implants? There are some obvious responsibilities like the fact that implants are not for life. It is surprising how many women tell me that their implants are guaranteed for life. This is because they have been misled to believe that ‘life’ means their (the patient's) life and not the life of the implant which may be anything up to about 20 years maximum. There are some implants that are for life but they are not used in normal circumstances because they are difficult for surgeons to ‘place’ right. 

Feminist or not, most women find that a breast augmentation changes the nature of their relationships with other women. It can change the nature of their relationship with men but that is something that is usually considered before surgery. Many women find it far more difficult to reveal that they have breast implants with a new partner than they ever imagined possible. Some women find the nature of their relationship to other women changes after breast implant surgery. 

Many psychological issues are involved in breast implants surgery and I would argue that those issues are mostly feminist in nature and best understood by another woman. If one of two of those women also happens to be a psychotherapist with experience of breast implants and comfortable with disclosure, so much the better. 




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Westminster Briefing 15.05.14

16/5/2014

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I feel very honoured to be a Member of The Expert Reference Group of Health Education England's NWL Non- Surgical Cosmetic Intervention Review. I am the only psychotherapist on the table. It might seem odd that a psychotherapist should be on the table of a non-surgical cosmetic intervention group but I am there to represent the emotional world of patients. What does that mean? Well, it can be anything from pre-procedure anxiety right through to extreme emotions resulting from physical outcome. The most important part of a cosmetic surgery counselling session is the conversation about expectations. A realistic look in the mirror is not easy for anyone but when it comes to cosmetic interventions this is an unavoidable task. Many people think psychotherapists are there to help people with mental health problems and/or to spend countless weeks, months, years and decades going over the same old ground. Nothing could be further from the truth when it comes to cosmetic surgery counselling. Whether you call it psychotherapy, counselling or emotional support it all amounts to the same thing - the ability to help the patient explore what is going on for them emotionally with reference to a cosmetic intervention. This could be pre-op or post-op. Pre-op is interesting because information and support is of concern to anyone no matter how far away in the distance the possibility of a procedure may be.  Generally, though, it relates someone who is quite near to their procedure date. However, awareness of emotional support assists with the cultural shift away from advertising. Cosmetic surgery brings up emotions in patients that they did not know they could feel. Some will take these emotions in their stride but others do not cope as well. The benefit of cosmetic surgery counselling is that patients do not have to go online to speak to strangers who may or may not have hidden commercial or referral agendas and no training in emotional support. 

As a Member of the Expert Reference Group for the Health Education England/NWL Non-Surgical Cosmetic Intervention Group, I have contributed indicative content for my specialist area of emotional support for cosmetic patients. Unlike the distinction made between the HEE/NWL and The Royal College of Surgeons Interspeciality Committee on Cosmetic Surgery Group, I do not draw a psychoIogical line in the sand between surgical and non-surgical patients.  Experience shows that often the surgical patient is also the non-surgical patient and vice-versa. In other words someone who goes in for a face-lift may also be having an injectable treatment for best effect. 

While a member of the RCSIC Patient Group has a seat on the HEE/NWL Expert Reference Group, no known patient group from the aesthetic/cosmetic world sits on the RCSIC. This is how communication problems start, which is a great pity as one of the central issues everyone is trying to remedy is communication. I have requested a place on the RCSIC group just so that surgical and non-surgical can have consistency in patient feedback. I received a reply to my request explaining the rather complicated procedures of the RCSIC together with their assurances that patient groups would be invited to comment after the meetings!  

Today I was invited to attend a Westminster Briefing Conference which was an opportunity for interested parties to present on their chosen subjects and bring the audience up to speed on Government progress post-Keogh. The distinction between surgical and non-surgical was evident but Westminster Briefing has an open door policy that did not discriminate between surgical and non-surgical attendees.This is the way of open communication.  I spent the day thoroughly absorbed in listening and learning as representatives from surgery, dentistry, nursing, government and industry outlined their aspirations and concerns for the  forthcoming safety measures that will be put in place by both surgical and non-surgical governing bodies. The surgical presentation made little reference to the RCSIC although they did display a lovely photo of the Royal College of Surgeons "in case any of the aesthetic professionals were unfamiliar with it".

Two main themes emerged from today's conference: 

Support

Consent

It is music to my ears as it would be to most interested parties when speakers delicately touch on the winds of change that point towards a reality of more honest dialogue with patients on expectations and peer support among themselves in perhaps achieving this. They are referring to diluting the historically poison advertising. The desire was palpable but so was the recognition that without a radical shift in advertising this may not happen. There was genuine exhaustion from the relentless distortion by the media. There was an unspoken question of whether a group of ethical professionals could ever put the genie back in the bottle without some creative thought.  Without realising it, these professionals were talking about counselling/emotional support. The same subject cosmeticsupport.com has been talking about in blogs and websites for so long.  So have we  (cosmeticsupport.com) finally met the professionals on the same page? 

The feeling in the room was that with honest dialogue and some radical changes in advertising everything will return from distortion to normal again. I would love to believe that this would be true. Patients see practitioners as people who can ‘fix’ them through scalpel or the syringe and anything less is just plain withholding. Patients do not expect either scalpel or syringe from counsellors. It is that distinction that makes the difference in delivering the message. 

Patients need to be well-informed. A consultation with the practitioner should focus on what is going to happen to them physically. This is what they are experts in. Counsellors focus on the mind. The need is there because life-changing alterations to the face or body are emotional. Practitioners attempting to hold a psychological conversation with a patient while also explaining the physical side of the procedure are just overwhelming patients in too many cases. Too much information! 

From my perspective, the duality between surgical and non-surgical is less relevant for emotional support. This technical division is important to assist important technical practicalities. This division may lead us to the assumption that non-surgical is less dangerous from the emotional support perspective.  This is not necessarily the case. A patient looking for a quick injectable treatment may harbour more psychological problems than someone turning up for multiple procedure surgery.

Many surgeons have said to me: ‘we need someone on site who can be there when we need them to talk to the patient’. Counselling just does not work this way. This is why so many clinics hire ‘patient advisors’ who are to hand when needed but this is nothing like counselling. It is another distortion. 

Patients gain no benefit in rushing from a detailed conversation about the physical to the emotional. Patients need time to digest thoughts and feelings. Most psychotherapists favour comfy surroundings rather than a clinical environment to practice in. Cosmeticsupport offers online help as well as phone help and various other options. The object is not to dilute the therapy but to make it as comfortable for the patient as it can be. Counselling is not supposed to give pain - it is supposed to take it away. What better way is there than in the comfort of your own home or in a therapists warm cozy environment to share your secrets? The recognition of the need for options is an important part of our service. The option to choose how you see a counsellor and when you see a counsellor as an integrative holistic part of an elective private cosmetic procedure must surely be gaining currency. 

The second theme of the day was consent. I was itching to point out the close connection between support and consent at today’s conference but often feel that the industry is not yet open enough to understand counselling. The world of the practitioner is different to the world of the patient even though both patient and practitioner may often be one and the same.

They talked about patients being disappointed with results even though they sign a physical consent form. And there’s the rub. My previous blog was about emotional consent. Disappointment is not physical. It is emotional. Talking about happiness, sadness, disappointment or any one of a host of other emotions related to cosmetic procedures is a conversation about emotions. This is a conversation that should happen with a counsellor in a cool-off period with the request of a signature for emotional consent. 

Surgeons, dentists and nurses are all concerned for patients when it comes to the reality of results. Too much advertising coupled with a lack of solid fact has led to distorted expectations from cosmetic interventions. Practitioners are aware of this but how many want to really challenge the source? In their enthusiasm for best practice they want to help patients understand disappointment but this is not the role of the practitioner. This is the role of the cosmetic surgery counsellor as cosmeticsupport repeatedly points out. 

This is not the first time I have written about emotional consent.  I wrote a blog for Consulting Room on this subject last year because it is of concern to me too. Aesthetic practitioners can be brilliant and some can create miracles with a scalpel or a syringe but that does not make them counsellors who are trained in the emotional welfare of a patient qua consumer.

cosmeticsupport.com was set up in January 2000 as an independent, non-profit counselling and psychology site for patients to talk honestly about their wishes, hopes and expectations from cosmetic interventions. Peer support alone has little value without an ethical boundary to support it. As members of BACP and BPS respectively, we offer independent, non-profit support driven by ethical guidelines to cosmetic patients. Unlike many other support groups, we do not endorse or sell products.  To do so would be a conflict of interest. 




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Blogs 

20/8/2013

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Whose Body Is It Anyway - Psychotherapy Today

17/7/2013

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Picture
  • News feature: Whose body is it anyway?
  • by

  • Catherine Jackson


  • ‘I think, over the years, women have a battle with their bodies as they change, different ages – they struggle with trying to accept it… and the fact that you can, it’s like, “Wow, so what, it’s a bit of money, let’s just change ourselves.”’

    This woman, interviewed for a survey commissioned to support the recent independent review of cosmetic surgery, speaks for many millions of women, judging by the rapidly rising use of cosmetic surgery worldwide. A 16-year-old schoolgirl, also interviewed for the review, may be similarly speaking for her generation: ‘It’s your body and you can do what you want with it.’

    The Review of the Regulation of Cosmetic Interventions, led by Sir Bruce Keogh, Medical Director of NHS England, for which the surveys were conducted, was commissioned by the Government in the wake of the PIP breast implant scandal. The review highlights widespread concerns among the public and the medical profession about the standards and regulation both of surgical/medical practices and the marketing techniques used by the cosmetic surgery industry. It calls for national standards and tighter controls on both and the Government is expected to publish its response to the recommendations this autumn.

    Global surveys show a worldwide surge in demand for cosmetic surgery: from South Korea (leading the field in the number of cosmetic surgery procedures per head of population) to India (the least), women – and increasingly men – are buying new breasts and noses, having fat sucked from various parts of their bodies and injected into others, getting tummies tucked, eyes widened, jaw bones ‘shaved’ and vaginas ‘rejuvenated’. In 2011, according to the most recent figures from the International Society of Aesthetic Plastic Surgeons (ISAPS), 15 million people worldwide had cosmetic surgery or non-invasive procedures such as laser skin resurfacing, hair removal, botox and chemical peels. The UK ranked 16th, with just over 95,000 procedures; the US came top, followed by Brazil, China, Japan, Mexico and Italy. The most popular procedures by far are lipoplasty and breast augmentation, followed by blepharoplasty (eyelids), abdominoplasty (tummy tucks) and rhinoplasty (nose jobs). The American Society of Aesthetic Plastic Surgeons (ASAPS) reports a 64 per cent rise in vaginal rejuvenation procedures between 2011 and 2012.

    The latest stats from the British Association of Aesthetic and Plastic Surgeons (the wonderfully acronymed BAAPS) show a slight leveling off in activity recently in the UK: procedures performed by its members in 2012 were just 0.2 per cent up on 2011, compared with a 5.8 per cent rise between 2010 and 2011, although the industry is still projected to reach a £3.6 billion turnover by 2015. 

    Cosmetic surgery has historically been less common among black and ethnic minority people. In the US, black people reportedly make up just 30 per cent of clients, but the numbers are growing fast.1 In South Africa, there has been a 780 per cent rise in non-invasive interventions and 128 per cent increase in breast procedures in the last 10 years, according to the Association of Plastic and Reconstructive Surgeons of Southern Africa – fuelled, it argues, by cheap prices.2 Growing affluence among black people is also likely to have played a part.

    The cosmetic surgery industry is frequently criticised for its marketing tactics, which include claims that its procedures can deliver direct psychosocial benefits. A cosmetic surgery company’s website will typically promise (often without reference to any evidence other than anecdotal feedback from their own patients) ‘added self-confidence’, ‘increased self-esteem’, ‘much more confidence and a more fulfilling sex life’ from their procedures. The empirical evidence for such claims is, at best, mixed.

    Deborah Sandler, who describes herself as a cosmetic surgery counsellor, is open about having had surgery herself; indeed, it was her personal experience that led her to launch an information and peer support website (see www.cosmeticsupport.com). Advertising has, she says, ‘taken cosmetic surgery out of the medical world and placed it in the world of luxury goods. It has trivialised it.’ More importantly, it also promises what it cannot deliver. 

    People have to go into surgery with realistic expectations, she believes. ‘People imagine that happiness and confidence will come more easily post-surgery. They expect other people to notice, to love them more, to give them that compliment they’ve never had. But that love has to come from within, in the form of self-love, self-acceptance.

    ‘Counselling can unblock this for them. It’s a journey and some realise they have to go on it and others don’t.’

    She particularly decries the high-pressure sales tactics that offer cheap deals if people sign up immediately for surgery. She thinks there should be a statutory ‘cooling off period’ between having an initial consultation and making the decision to proceed, with at least one session of impartial counselling pre- and post-surgery. ‘It’s a life-changing intervention. People think they just need to take 10 days off work and everything will be fine but there are other things that need to be gone through to make that happen. Patients need to consent to the emotional as well as physical risks.’

    Cosmetic surgery can be beneficial if the person’s expectations are realistic. ‘You need to go into surgery thinking you will look the best you can. I don’t subscribe to the notion that you have to live in your body, to accept decay. I would be having a face lift today if I had the money. But it wouldn’t make me happier; it would make me look less old and if I looked less old I would feel less old and that would make me happier. If something is decaying or not looking as good as you feel it could, then fortunately we live in a world where we can do something about it.’

    Evidence for benefits
    The Keogh review commissioned a systematic review of the published evidence on psychosocial factors in relation to cosmetic interventions. The review team, at the Institute of Education, could draw only the weakest of conclusions as the quality of the primary research was so poor, and some studies were very dated. Overall, dissatisfaction with body image and improving self-esteem and confidence were frequent motivations for seeking surgery, but the pre-procedure self-esteem levels reported in the studies were no different from the general population. Post-surgery, evidence to suggest improved self-esteem and decreased anxiety was ‘limited’ and claims of positive psychological and social outcomes rendered suspect by the quality of the studies. 

    A very recent Norwegian study,3 published in 2012 and conducted by researchers at NOVA, the Norwegian social research institute, and the Norwegian Institute of Public Health, followed up some 1,500 men and women over 13 years, from school-age into adulthood, and found higher levels of anxiety, depression and suicidal feelings both before and after the intervention among the 4.9 per cent of women who had undergone cosmetic surgery. Their mental health problems and distress continued post-procedure, and sometimes got worse. 

    But another study, from Germany and reportedly the largest ever such comparative trial of the psychological effects of cosmetic surgery, found the opposite.4 The 544 first-time cosmetic surgery patients in the study declared themselves 80 per cent satisfied that the procedure had delivered what they wanted. Also, in comparison with 264 people who had considered but decided against surgery, they reported higher wellbeing, better quality of life, less anxiety and greater sense of attractiveness and body satisfaction. The researchers found no evidence of negative psychological effects post-surgery; indeed, there was a small decrease in depression and social phobia and findings to suggest, they say, that patients were ‘less preoccupied with their looks’. The study was funded by a large German cosmetic surgery company.

    It has even been proposed that having botox can actually combat depression. According to Dr Eric Finzi, author of The Face of Emotion, dubbed by the New York Times as ‘the first authorized biography of botox’, paralyzing the muscles in 
the forehead can not only smooth the furrowed brow but also prevent people’s faces from expressing negative emotions such as sadness, fear, anger and distress. And, as Darwin argued back in the 17th century, facial muscles not only express emotion but also govern them: if we can’t physically frown, we don’t feel sad. Another dermatologist, Dr Patrick Bowler, has tested this, and found that the women who had botox were indeed ‘measurably less negative than their non-botoxed counterparts’.5 

    Moral judgments
    Cosmetic surgery remains a subject of deeply divided opinion, not least among counsellors and psychotherapists. While some cross their legs and wince at the thought of vaginal rejuvenation, others are more pragmatic. Sexual and relationship therapist Paula Hall says it isn’t a question of morality: ‘We shouldn’t make value judgments about people’s ideals of beauty. The days when people raised their eyebrows about boob jobs are long past; genital surgery is just the next stage. Men have been able to compare themselves with each other since time immemorial. 

    ‘Women should have choice but it needs to be informed choice. It’s important that women explore what they believe will make them happy and that they don’t have false expectations that vaginal surgery will make them feel better about themselves or that it’s going to be a relationship fix.’

    Researchers at the Centre for Interdisciplinary Gender Studies at the University of Leeds have just released preliminary findings from a two-year study of cosmetic surgery tourism titled Sun, Sea, Sand and Silicone. Led by Professor Ruth Holliday, the research team interviewed over 100 patients from the UK, Australia and China and 100 cosmetic surgery providers to explore people’s reasons for travelling overseas for cosmetic surgery. Principally it was cost: they simply couldn’t afford to have it done in their home country, she says. 

    ‘There’s this media construction that cosmetic surgery tourists are glamour pusses who are only interested in looking sexy forever; that they’re all young women wanting really enormous breasts and doing whatever they can to get them. We found very few of them were like that. Mostly they are very ordinary people who have one thing they don’t like about their appearance and are desperate to sort it out.’

    Her subjects worked in administration, nursing, care work; they were hotel porters, hairdressers, beauticians, students, police officers and teachers. Less than one in 10 had a higher education qualification. Most said they would otherwise have spent the money on holidays or home improvements. 

    ‘Mostly they simply wanted to look normal,’ Professor Holliday says. ‘There’s a lot of talk about the “designer vagina” but some of the people we talked to had some very nasty birthing injuries. Vaginal tightening can be the same technique used to repair prolapse. These things are very ambiguous. If you lose 10 to 15 stone, that’s lots of skin and it has an enormous impact on your body.’

    People seeking anti-aging interventions were often motivated by the need to keep on top of their work. A woman prison officer had cosmetic dentistry because ‘she said she couldn’t look like someone’s granny if she was to keep her status with the prisoners’. Men were having hair transplants ‘to stay competitive at work’. For the Chinese patients travelling to South Korea to have their jawbones shaved and their eyes widened, cosmetic surgery was seen as an economic necessity to improve their career prospects and employability.

    The primary drive is self-improvement, says Professor Holliday. ‘For working-class people, who don’t own a house or a fancy car, investment in your body is the only thing you can control. Cosmetic surgery is their way of showing “I am doing the right thing by improving myself and making myself better”. What we call self-esteem is as much to do with feeling you are excluded from the rest of society as it is with low confidence.’

    Body matters
    At the other end of the spectrum of views are psychotherapists like Alessandra Lemma, Visiting Professor of Psychoanalysis at University College London and author of Under the Skin, a psychoanalytic study of body modification, and psychotherapist Susie Orbach, author of Fat is a Feminist Issue and, more recently, Bodies, which similarly explores what drives people to constantly perfect and literally ‘design’ their own bodies.

    Both see the urge as rooted in a discomfort with being in the body, which itself comes from the lack of a positive, loving physical interaction between mother/caregiver and baby – in Lemma’s words, the lack of ‘a (m)other’s loving and desiring gaze’ – that is crucial to our feeling safe, or ‘at home’ in our bodies. 

    Orbach describes a growing epidemic of bodily distress – ‘a hidden public health emergency’. She argues that the internalisation of how a mother feels about her own body is transmitted to her child (her daughter) from birth. Thus her campaign, within the Endangered Bodies global movement (www.endangeredbodies.org) against body hatred, to persuade the Government to require all health visitors and midwives to be trained in body awareness – their own as well as that of the new mother – so they can support women to be more physically holding of their baby. We need ‘a theory of body development just as compelling as our existing theories of the mind’, Orbach argues.

    Holli Rubin, a psychotherapist specialising in body image, works with Orbach on the campaign. ‘Women need to feel good about themselves and their own bodies before they can give that to their child. But many young mothers – not all – have this belief that they need to get back into their skinny jeans and exercise routines immediately after birth. It is symptomatic of the pressures on all women to live up to standards that are not attainable,’ she says.

    She sees this reflected in the increasing popularity of cosmetic surgery. ‘People feel it’s going to make them feel better, be better, be accepted. If someone has a nose that they have wanted to fix for ages and they know it would make them happier about how they look, I have no issue with that. We are lucky enough to be able to do that these days. But for some, when they’ve had their nose fixed, then they don’t like their ears, their chin, their breasts… maybe if they changed that… People are trying to become what they think they need to be and it’s never good enough; the perfectionism gets out of control. As counsellors, we have to look at why.’

    Psychotherapist Rima Sidhpara sees these same pressures within the UK Asian community. She works for the Rutland House counselling and psychotherapy service in Leicester, where there is a large Asian population. ‘The Asian culture has a specific perception of what is beautiful, which for Indian women is being thin, having long, thick hair and being fair skinned. Difference is seen as shameful, even disgusting. There are creams for Asians that promise to make your skin lighter and if you go to Indian beauticians they offer facials to lighten your skin. Mothers worry a lot about their daughters looking beautiful as if they are not, who will marry them? I have had clients choose surgery for weight loss, which was kept hidden from the family. Image is not something that can be spoken about – instead the young woman can be on the receiving end of rejection, anger, shame and humiliation by close family.’

    Young women’s feelings of low self-esteem turn inwards to self-harm. ‘I have found young women experience low self-esteem and huge amounts of shame. They will tend to hide away their bodies and personality. They lack confidence and that affects how they interact and socialise with other people. They do not feel they fit in and can feel very isolated and there tends to be anger that then gets turned inwards on the self. These feelings are very enmeshed.’

    She always felt ‘too dark’ when she was young. ‘It was only when my white friends at university kept telling me how nice my skin was and other compliments that I began to change my own perception of how I looked.’ With clients, she tries to provide that same positive experience. ‘I explore with them what it is like to feel the way they do, the cultural demands made of them and what beautiful means for them. I try to offer the mirroring that was lacking from their parents and family, to provide that corrective emotional experience.’

    Reality check
    In her book Alessandra Lemma proposes that our relationship to our body ‘is probably the most concrete marker we have of how we feel about ourselves and about others’. Her views, she says today, have not changed since she wrote those words in 2009. ‘Body modification is driven by the need to manage a range of unconscious anxieties, about intrusion, dependency on others or lack of desirability,’ she says. ‘As our existential anxieties increase in a world that is perceived as under threat and where we lack the holding structures that we could once turn to within our communities to support each other, the body has become a project that creates an illusion that its modification can be a solution to problems that are less tangible and felt to be completely out of control.’ 

    She argues that normalising body modification allows us to avoid having to think about our motives for having cosmetic surgery. ‘Society reinforces the belief that you can find external solutions to internal psychic pain. It becomes harder to engage people in thinking what lies behind their pursuit of beautifying processes. The psychotherapeutic project is about learning to live within reality and accepting ourselves and our lives and their disappointments. The beauty industry represents the complete opposite. It’s about making the impossible possible and that is very seductive because it speaks so directly to the fantasy of reinventing the self. And it also provides solutions to the difficulty in coming to terms with ageing, and so with death.’

    Lemma’s concerns about cultural normalisation are shared by child and adolescent psychotherapist Jeanine Connor, who is deeply concerned by the subtle cultural grooming of young girls that she sees in the media, from the reality TV show The Only Way is Essex (TOWIE), where the participants flagrantly parade their cosmetic procedures, to computer games. ‘Young people don’t take it seriously because it is so commonplace. I’ve heard of games aimed at under-11s where the aim is to create a perfect body for your avatar. You win points to buy a boob job or hair extensions. That horrifies me. I wouldn’t rule out surgery as an option but, if there is something about a child’s body that has an impact on how they feel about themselves, it is their sense of self that needs to be worked on first, not their body. Cosmetic surgery feels like a superficial response. 

    ‘It’s a solution for families that can afford it and should be a last resort, in the same way that hospital admission or medication should be the last resort when a child is depressed. Paying money to have something physical and permanent changed in your body isn’t a fix-all.’

    Lucy-Jean Lloyd, a counsellor who works with young people in educational settings, argues that the body carries a very particular weight of significance for adolescents, so the decision to have any form of body modification, whether it’s cosmetic surgery or just a tattoo, is likely also to be heavily loaded. ‘One of the tasks of adolescence is differentiating yourself from your parents – that separating out of what is me, what is mine and what is located within me. I think ambivalence about the body may well relate to feelings of ambivalence about those on whom we depend.’

    In adolescence the body changes rapidly, in ways that can feel out of control at a time when so much else is also out of your control. ‘Cosmetic surgery may feel like you are taking charge of the body, almost taking revenge on it for its irreversibility. It gives you an illusion of control, of omnipotence,’ she suggests. She recalls one young client who had surgery to reduce the size of her breasts. ‘She had a very slight frame and they were causing her backache. But she had also had a troubled relationship with her mother. She felt she was not the daughter that her mother had wished for; there was a wish to get away from her. We talked a lot about the aftercare she would receive. There was something about the way she talked about the removal of the bandages that seemed to me to be about being born into herself again, almost reborn; as if she was saying “This is my body, not my mother’s”.’

    Another client, a young woman in her early 20s, had a nose job. ‘She was someone who was full of very aggressive, hating feelings that were difficult for her to acknowledge. I still have a mental image of her face after the operation. It was very shocking; it looked as though she had been attacked. She had previously said that she thought her mother hated her but didn’t ever show it and I remember thinking it might have been a relief for her if her mother had been able to be in touch with her hatred. 

    ‘I sensed she felt triumphant about having the nose job. Winnicott said that triumph is important for adolescents and certainly this young woman seemed to find it liberating. It was as if getting the body that she wanted through shock and force and violence freed her to be who she wanted to be. It felt very shocking but also maybe it felt necessary to her.

    ‘My experience of working with people who have cosmetic surgery has changed my view. Before I used to be more judgmental; now I see it as having a not necessarily negative function: we all seek transformative experiences as a flight from what we experience as unbearable.’

  • References:
    1. http://www.surgery.org/consumers/plastic-surgery-news-briefs/plastic-surgery-growing-black-community-1036892 
    2. http://www.iol.co.za/news/south-africa/young-blacks-opt-for-plastic-surgery-1.1475775#.UdZzd?FO9wpM 
    3. http://cpx.sagepub.com/content/early/2013/03/04/2167702612471660.abstract
    4. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8477649
    5. http://psychcentral.com/blog/archives/2013/03/21/botox-as-a-cure-for-depression/

Picture
Whose Body Is It Anyway - Psychotherapy Today

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Comments 

13/7/2013

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I spend several hours a week just staying up on cosmetic surgery topics and this is the first time I've come across anything on cosmetic surgery counselling. Nice perspective 
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Cosmetic Surgery Counselling 

18/5/2013

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Psychology has always been considered the sexy one-stop shop for answers to questions. It has given rise to things we take for granted like self-help books, talk shows and reality programmes. A call has been made for mandatory psychological screening by patients who complain they were ill- prepared for the reality of cosmetic surgery. These patients recount the misery created by a lack of emotional support in their experience of cosmetic surgery. The call they make to psychology for screening tools will not offer these patients the support they know they need. Counselling may not have the sleek shiny sex appeal of psychology but it does offer the emotional support that these patients are really calling out for.

It is easy to think that counsellors should only be involved when cosmetic surgery goes wrong or if a surgeon believes a patient to be unsuitable for surgery. This dated concept of counselling creates a lost opportunity to increase patient safety and reduce risks involved in surgery. Specifically trained cosmetic surgery counsellors would make a valuable addition to the forthcoming patient safety regulations resulting from the Keogh Review.

Psychology and counselling both owe a great deal to philosophy. Socrates elevated the mind over the body. Rene Descartes deepened the divide with: ‘I think therefore I am’. Sigmund Freud, in his many books wrote about human uffering in ‘Civilization and its Discontents’. Philosophy flagged up the mind/body problem. Existential philosophers and psychotherapists seek to answer this division by exploring how the need to create meaning in everyday living helps well-being. 

The need for meaning was clearly understood by Google and is universally acted out every day on every subject under the sun, online through social media. The human condition is not meant for isolation. Community and conversation in cosmetic surgery has a very important part to play in the role of patient safety.

This need to talk among patients has given rise to patient groups as well as ‘advisory’ groups. Online patient groups are well-meaning but lack the necessary training to really make a difference. Other groups headed by so-called independent experts claim to be independent while having a hidden financial agenda or surgeon preferential scheme. These groups fail to provide the sense of well-being through professional emotional support that their membership craves. In some cases, these groups only add to the suffering of their individual members. Patients reach out to one another in an effort to reduce anxiety created by a lack of hard facts and regulation. Professional patient support groups need transparent approval if the emotional welfare of patients is to be taken seriously. It is not by accident that counselling is considered a ‘talking cure’.

Negative feelings of shame and anxiety are often silently endured by patients pre- and post-surgically and frequently during a consultation. These troublesome feelings arise from the need to undress, discuss and have pre-op photos taken of the body part that creates the most distress for the patient. Many will do their best to hide those feelings and soldier on through but these feelings can interfere with the very important information exchange during the consultation process. Patients undermine their own feelings and perceptions in a bid to control their anxiety and their concentration is compromised.

I am sure I am not alone when I wish that we (as patients) could download a jpg file to a surgeon to show him/her what it is we do not like about ourselves and how it is we want to have it changed in order for us to see ourselves in a better light. This idea highlights the need for a more holistic mind/body approach as a safety net for patients.

Psychology is a big field. Counselling might be considered as the little sister of psychology. Psychologists help with the diagnosis and treatment of mental illness. Cosmetic surgery patients are not generally mentally ill. A counsellor is a person who assists people to develop better understanding about themselves and to support changes in the patient’s life. Counselling owes much to psychology but it is different. Surgeons do their very best to put patients at ease while they explain the reality of what can be achieved. Crucially surgeons explain all about the physical risks of surgery and patients offer their consent accordingly. This is often a great deal for a patient to take in and should be given the time and space required for a patient to take it all in. There is simply not enough time in a surgical consultation to do justice to both mind and body issues. It must be about time that patients had approved counsellors to discuss emotional concerns with. Isn’t it time that patients were asked to consent to the emotional journey too?

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The case against nip/tuck (Deborah Sandler)                      

15/5/2013

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Nip’n’Tuck was such a catchy slogan that it became synonymous with any type of cosmetic surgery.  There was even an American television series with that name.  The TV  surgeons were handsome. Their patients idolized them. The drama itself was mostly confined to the personal lives of the surgeons as opposed to surgical side of plastic surgery.  Each week, I was riveted to it.  It readily reflected the commodification and trivialization of plastic surgery. It was fantasy at its best, just as the phrase Nip’n’Tuck is. 

The phrase Nip’n’Tuck trivializes cosmetic surgery. Isn’t it time this phrase was retired? 

Cosmetic surgery is not a nip and a tuck. Cosmeticsupport.com agrees with Rajiv Grover and other BAAPS surgeons who are making the call that cosmetic surgery must be treated as a medical procedure and not a commodity. The review by Sir Bruce Keogh reveals the vulnerability of cosmetic surgery patients.   Why on earth is the phrase Nip’n’Tuck still used as a media byline. How can we take calls to reduce trivialization seriously if there are still elements of trivialisation?  Safety has no room for confusion. 

Why has it taken so long for calls to safety to be made? Thirteen years ago when I set up www.cosmeticsupport.com it was very clear that plastic surgery had been seriously commodified and yet nobody seemed concerned about it. Commercial clinics offering cosmetic surgery renamed their sales people ‘counselors’, abusing that title. Patients were misled and misinformed.  Patients believed they were seeing a counsellor when they were seeing a sales person.  Patients were put under enormous pressure to sign on the dotted line there and then in order to benefit from time-limited discounts. People were almost afraid not to have cosmetic surgery. Where were the calls to patient safety? Why was their voice not heard through all the years of tomfoolery in the industry? It has taken a long time for the call to change advertising to be made. Let’s hope that patients respond faster than they do. The bogus use of the term 'counsellor' is still being used and often under the noses of the very people who have the power to tighten safety. It troubles anyone with any ethics to see this being played out. 

The scandalous drama of the PIP implants has caused everyone to sit up and take notice.  Professor Sir Bruce Keogh, Medical Director of the NHS recently released his review. The enquiry asked the public about their experiences and recommendations for the industry and whether the public wanted the changes to advertising which were being called for by the surgeons. The response I have written to his review can be seen in a separate posting on this Blog. 

Is it really true that in 2013, women are still not to be treated as equal human beings? Given that the PIP scandal affected women, one wonders if women have ever really earned the right to be treated seriously as human beings? How did the PIP scandal come about?  Who was really asleep at the switch? Surely we have enough safety committees in this country to spot an avalanche before it starts? We now know that mattress grade silicone was used to create breast implants when medical grade silicone should have been used.  Clinics who used these cheaper implants refused to take responsibility on behalf of their patients.  Why were so many women allowed to suffer like this? How was this allowed to happen?  It is as a result of the PIP Scandal that surgeons are making calls to change.  Who are they calling to?  Who are they calling for?  Were Pip victims adequately responded to? Who is fully versed at grass roots level where the patient is?  Will a change in regulation be enough to create safety for patients without counselling be added to the mix?  Why didn’t they call out over the many deaths through cosmetic surgery that have gone before?  Many people have died from complications from cosmetic surgery. Some died from badly trained surgeons performing profit-making surgery and some died from other complications, but the important point is that death occurred. Why did it take a disaster of such epic proportion before we heard these surgeons making their calls for safety? I have been offering emotional support, voluntary, independent and non-profit, for 13 years and if this were not needed, I would not be offering it. Why don’t surgeons take more notice of what their patients really need? Protection must be in the mind as much as it is in the body. Support must be emotional as well as physical. Unlike many others offering this support, I am qualified to do so. I am passionate enough to have offered it for free since Jan 2000. 

I believe that surgeons who are making calls for safety would be wise to consider the history of patient support and safety that has gone before this situation in other arenas. For example, before an abortion, counselling is mandatory. This helps the patient put to rest all the issues that have come up for them before and after abortion. Different abortion clinics have different counsellors. Some are pro abortion and some are anti abortion and the patient who winds up with the wrong counsellor might find themselves seriously struggling emotionally for many years to come. However, existentially trained counsellors will not have an opinion on cosmetic surgery either way. These counsellors are trained to help the patient explore their issues, not to explore the counsellors views or issues. There is little religion involved in cosmetic surgery in the way that it is involved with abortion counselling. With the use of appropriate surgical-consent counselling, the message goes direct to where the safety is needed the most, to the patient. Surgeons will benefit by having a patient who is both well-informed surgically as well as personally. 

If all cosmetic surgeons in all clinics are obliged to offer cosmetic surgery counselling with fully qualified cosmetic surgery counsellors only then can patient safety truly be ensured. Patients will understand the different types of qualifications of different types of surgeons and understand what is involved in an informed choice. Some patients may decide to go ahead with their surgery with a better-trained surgeon than the one they have originally chosen.  Patients will have more time to consider all the information that is currently obscured by misleading information. No longer will sales people be allowed to call themselves ‘counselors’. Cosmeticsupport.com fully supports the idea that advertising in cosmetic surgery must change in order to reflect a more realistic perspective on what it is that people are choosing when they consider elective surgery. However, even with those changes in effect, patients still need a place to go where they can find objective support (counselling) to help them explore all the issues that are involved for them. Every patient will have their own set of issues before and after surgery. It would make an enormous difference to all patients if they were helped to explore their issues before and after cosmetic surgery. I believe that existential psychotherapy is the best-suited psychotherapy for this exploration as it is a philosophy concerned with the individual and his/her meaning in the world. Existential psychotherapy allows for an unbiased exploration of the individual’s world-view. 

Cosmetic surgery counsellors will help to produce a more informed, relaxed patient with its search for meaning helping to clarify confusing misinformation.  Patients will also have had the opportunity to explore the realities of a particular type of elective surgery. Every patient has issues before and after a surgery and if the goal of the new regulations are to be heard, then the response must surely be for counsellors to be invited in to answer. 

Let’s nip trivialization in the bud and tuck in patient support. 

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