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Botox: Filling More Than Lines and Wrinkles?

The rise in Botox in young people might be a symptom of deeper wounds.

Jennifer, a 26-year-old former model, appeared in my office one summer day saying she was thinking of having Botox injections. My first emotional response was surprise. “Why in the world would this beautiful young woman want a cosmetic procedure?”

My second emotional 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 the American Society of Plastic Surgeons, from 2000 to 2016, the number of Botox injections increased by 797%. In 2010, 78,452 botox procedures were done on 20–29-year-old women. In 2018, 109,385 botox procedures were done on 20–29-year-old women. For women, 20 to 29 years of age, Botox procedures have increased 28 percent since 2010. This doesn’t feel right to me.

Yesterday, I saw this add in New York City. I felt my outrage and sadness at the blatant advertising to young women. It is undermining to young women’s self-esteem when subliminal messages tell them they need to alter appearance to be loved or catch the right partner. It is destructive to both men, women, and every gender.

Hilary Jacobs Hendel
Add for Botox with a very young woman featured
Source: Hilary Jacobs Hendel

I am an emotion-centered trauma psychotherapist. I see the trend in plastic surgery as having as much to do with inner insecurities more than anything else. A person feels bad about themselves, they try to feel better, they think Botox will help them feel better, but this doesn’t always happen. When procedures don’t bring relief from insecurities, some women get additional procedures still searching to feel more confident. This road is not a healthy one.

Self-esteem doesn’t improve because there are deeper insecurities that lie underneath and that no amount of Botox or any procedure will change. These deeper insecurities are about inherent self-worth and lovability and they stem from past wounds, not aging. The emotions, however, are triggered by the aging process. Sometimes it’s hard to tell what stems from the past and what is a current stressor. They can feel the same.

“Jen,” I asked during a session, “Let’s imagine in great detail what happens after the Botox procedure?”

I often use fantasy to help patients 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 as would happen in reality. This approach 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 nods) 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.”


“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 smiles 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?”


“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 thought for a moment, “Yes! That is exactly what I think.”


Thinking someone else is having your experience is called a projection. For example, we have a thought and imagine others have the same thought. Or we have a feeling and imagine others have the same feeling. We all project — it is just something our brains naturally do. Being aware of this process helps us think twice and make sure we tune into our own thoughts and feelings. Projections 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.”

“I think you’re right.”

“You know and those are really big and hard issues. Getting older and dating are complicated issues for all of us and they bring up many feelings and conflicts. Can we just take a breath and let that all be for now without doing anything about it.”

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

I said to Jennifer, “If you go through with the Botox, 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 build confidence for you in the long haul. To me, that’s inside work. 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. She didn't realize she could be beautiful and imperfect too. 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 de-emphasized 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 the myriad of 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.

Patient details have been changed to protect confidentiality.


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

Hendel, H. (2018). It’s Not Always Depression: Working the Change Triangle to Listen to the Body, Discover Core Emotions, and Connect With Your Authentic Self. New York: Random House

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

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

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