Addressing Client Perfectionism in Clinical Practice

In this article, we examine the nature of perfectionism, its correlation with various mental health issues, and the interventions and exercises that help clients address and overcome it.

Related articles: Clinical Considerations in Treating High-Functioning Clients, Working with Shame: Interventions for Deep Emotional Healing, Working with the Highly Sensitive Client.

Introduction

Perfectionism, a personality trait characterised by setting excessively high standards, is a widespread issue that many individuals bring to therapy. It involves the relentless pursuit of flawlessness and an accompanying critical self-evaluation. While striving for excellence can be a positive trait, when taken to extremes, perfectionism can lead to significant mental health struggles, including anxiety, depression, and stress-related disorders. In clinical practice, perfectionism often presents as a barrier to progress, hindering clients from experiencing personal growth and well-being. Understanding how perfectionism manifests, its impacts, and how therapists can address it is crucial for effective intervention.

This article explores the concept of perfectionism, its manifestations, and how it correlates with various mental health issues. It also outlines interventions, techniques, and practical exercises that mental health professionals can use to address perfectionism in therapy.

Unpacking perfectionism

Perfectionism is a multidimensional construct that refers to a tendency to set exceedingly high personal standards, coupled with an excessive preoccupation with mistakes or flaws. Perfectionists often have an intense fear of failure and an inner drive to meet unattainably high standards. They may experience frequent self-criticism and dissatisfaction with their performance, even when their achievements are objectively successful.

There are two types of perfectionism that often emerge in clinical settings: adaptive and maladaptive. Adaptive perfectionism involves setting high standards that are achievable and motivating, while maladaptive perfectionism refers to perfectionistic tendencies that are unrealistic and lead to distress (Frost et al., 1990). Maladaptive perfectionism is linked to a range of psychological issues, including anxiety disorders, depression, eating disorders, obsessive-compulsive disorder (OCD), and social anxiety disorder (Shafran et al., 2002).

Perfectionism often serves as a coping mechanism, protecting individuals from feelings of inadequacy or failure. However, when this coping mechanism becomes ingrained and excessive, it can have detrimental effects on a person’s mental health. It leads to an endless cycle of self-criticism and failure, with individuals unable to accept anything less than perfection.

How perfectionism presents in our therapy rooms

In clinical practice, perfectionism can manifest in various ways, often complicating treatment and hindering progress. Some common presentations of perfectionism include:

• Overachieving behaviour: Clients with perfectionistic tendencies may go above and beyond in their professional and personal lives. They may set unrealistically high expectations for themselves and constantly strive to meet them. In therapy, they may present as individuals who appear high-functioning on the surface but are struggling with deep internal dissatisfaction. For more on this, read Clinical Considerations in Treating High-Functioning Clients.
• Fear of making mistakes: Perfectionistic clients may have an intense fear of failure or making mistakes, leading to procrastination or avoidance behaviours. They might delay starting projects or avoid taking risks for fear of not meeting their standards.
• Self-criticism and shame: These clients often engage in harsh self-criticism, internalising mistakes or perceived shortcomings. They may feel shame for not achieving perfection and find it difficult to accept praise or success. For more on working with shame, read Working with Shame: Interventions for Deep Emotional Healing.
• Difficulty delegating tasks: Perfectionists may struggle to trust others with responsibilities, believing that no one else can meet their high standards. This can create problems in work or personal relationships and can result in burnout.
• Constant comparisons: Perfectionistic clients may compare themselves unfavourably to others, leading to feelings of inadequacy and social anxiety. They often focus on the perceived flaws of others, reinforcing their belief that they are not good enough.
• Over-preparation and overworking: These clients may spend excessive time preparing for tasks or overworking themselves, believing that they must do everything perfectly to succeed. This behaviour can contribute to chronic stress and burnout.

The correlation between perfectionism and mental health issues

Research has shown that perfectionism is closely linked to a variety of mental health disorders. It can act as both a precursor and a maintaining factor for conditions such as anxiety, depression, OCD, eating disorders, and social anxiety.

• Anxiety disorders: Perfectionism often leads to heightened levels of anxiety, particularly when clients fear making mistakes or failing to meet their own standards. This can manifest as generalised anxiety disorder, social anxiety, or performance anxiety (Shafran & Mansell, 2001). The constant need for control and fear of failure creates a cycle of worry and stress.
• Depression: The relentless pursuit of perfection can lead to feelings of hopelessness and inadequacy, which are key symptoms of depression. When clients cannot achieve their perfectionistic ideals, they may experience a profound sense of failure, which can contribute to depressive symptoms (Frost et al., 1993).
• Obsessive-compulsive disorder (OCD): Perfectionism shares common features with OCD, particularly in the form of compulsive checking, organising, or redoing tasks until they are deemed “perfect.” OCD symptoms often revolve around a need for certainty and order, which can overlap with perfectionistic tendencies (Shafran et al., 2002). Related reading: Case Study: Working with Obsessive Compulsive Disorder.
• Eating disorders: Perfectionism is a well-established risk factor for eating disorders, particularly anorexia nervosa and bulimia nervosa. Individuals with these disorders often have excessively high standards for their appearance and engage in rigid, controlling behaviours related to food, weight, and body image (Flett & Hewitt, 2002). Related reading: Case Study: DBT and Bulimia Nervosa.
• Low self-esteem: Perfectionistic individuals often have fragile self-esteem, as their self-worth is contingent upon their ability to meet their own or others’ high standards. When they fall short, they may experience profound self-doubt and negative self-evaluation.

Addressing perfectionism in therapy

In clinical practice, addressing perfectionism involves helping clients recognise and challenge their perfectionistic beliefs and behaviours. Several therapeutic interventions and techniques can be used to address perfectionism, including cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), and compassion-focused therapy (CFT). Below, we explore these approaches in greater detail, including practical case studies and scripts to illustrate their application.

Cognitive behavioural therapy (CBT)

CBT is one of the most effective therapeutic approaches for addressing perfectionism. CBT focuses on identifying and challenging negative thought patterns and replacing them with more balanced and realistic beliefs. For perfectionistic clients, this often involves identifying the unrealistic standards they set for themselves and examining the impact of these standards on their mental health.

Case study 1: John and his fear of making mistakes

John, a 32-year-old accountant, presents with a history of perfectionism. He is constantly worried about making mistakes at work, which leads to significant procrastination and anxiety. John believes that making a mistake will lead to his co-workers thinking he is incompetent, and that he will lose his job. Through CBT, John is encouraged to recognise that this belief is irrational and exaggerated. Here’s an example dialogue between John and his CBT therapist:

• Therapist: “John, let’s examine the thought, ‘If I make a mistake at work, I’ll be fired.’ Can you think of any evidence that supports this thought?”
• John: “Well, I’ve never actually been fired, but I have made mistakes in the past and it has led to criticism.”
• Therapist: “What other factors could contribute to criticism, besides making mistakes?”
• John: “Well, my supervisor said that criticism is part of the learning process.”
• Therapist: “How likely are you to be fired for going through a learning process?”

Through this process, the therapist helps John realise that his perfectionistic thoughts are not grounded in reality. Over time, John learns to challenge these beliefs and become more comfortable with making mistakes as a natural part of his work.

CBT techniques for perfectionism

• Cognitive restructuring: Help clients identify and challenge perfectionistic thoughts, replacing them with more realistic and flexible beliefs.
• Graded exposure: Gradually expose clients to situations where they can make mistakes or not meet their standards, helping them build tolerance to imperfection.
• Behavioural experiments: Encourage clients to test their perfectionistic beliefs by engaging in behaviours that contradict their rigid standards, such as completing a task imperfectly or allowing others to take on responsibilities.

Acceptance and commitment therapy (ACT)

ACT helps clients embrace their imperfections and learn to accept themselves as they are, rather than striving for unattainable standards. The focus is on increasing psychological flexibility, which allows clients to engage in meaningful activities despite the discomfort of imperfection.

Case study 2: Sarah and her obsession with perfect appearance

Sarah, a 25-year-old university student, struggles with perfectionism related to her body image. She constantly compares herself to others and engages in unhealthy dieting behaviours to maintain an idealised appearance. ACT helps Sarah recognise that her self-worth should not be tied to her appearance. Here’s an example dialogue between Sarah and her ACT therapist:

• Therapist: “Sarah, the dimensions of your hips that you’ve just told me are reported in these two size guidebooks as requiring a medium size skirt, yet you maintain that your hips are ‘huge and horrible’. Are those thoughts about your body helpful to you, or even true?”
• Sarah: “Well, ok, perhaps I exaggerate a little, but I feel like that’s the main thing people notice when they see me coming.”
• Therapist: “Is that all they see in you? You told me how kind members of your choir said you are, and how Anne thanked you for being a loyal friend.”
• Sarah: “Yes, people do sometimes tell me that they appreciate my kindness or loyalty, or how I stand up for people being bullied.”
• Therapist: “So, is it fair to say that those thoughts about your hips don’t define who you are as a person?”
• Sarah: “Yes, I guess so, but I still think my hips are way out of proportion.”
• Therapist: “Are there any disadvantages to continuing to think that way about a part of your body?”
• Sarah: “Hmmm. Looking at it now, I can see that these thoughts are causing me distress and maybe keeping me from living my life fully.”

Through ACT, Sarah learns to accept her body as it is and make choices that align with her value of living a full life of growth, rather than trying to meet societal beauty standards of excessive thinness.

ACT techniques for perfectionism

• Defusion: Teach clients to separate themselves from perfectionistic thoughts, recognising that these thoughts do not define who they are.
• Mindfulness: Encourage clients to become aware of their thoughts and feelings without judgment, allowing them to experience imperfections without becoming overwhelmed.
• Values clarification: Help clients identify their core values and encourage them to take action towards those values, even in the presence of perfectionistic thoughts.

Compassion-focused therapy (CFT)

CFT focuses on developing self-compassion as a means of addressing perfectionism. Many individuals with perfectionistic tendencies are highly self-critical and have difficulty showing themselves kindness. CFT helps clients cultivate self-compassion, which can reduce the harmful effects of perfectionism.

Case study 3: Emma and her self-criticism

Emma, a 40-year-old teacher, constantly criticises herself for not being a perfect mother, wife, and teacher. She feels that she is failing in all areas of her life because she cannot meet her own high standards. Through CFT, Emma learns to treat herself with kindness and understand that imperfection is part of being human. Here’s an example dialogue between Sarah and the CFT therapist she is working with:

• Therapist: “Emma, what would you say to a friend who was experiencing the same level of self-criticism you’re feeling right now?”
• Emma: “I would tell them to be kinder to themselves and that they don’t have to be perfect to be loved or valued.”

Through CFT, Emma learns to treat herself with the same compassion that she would offer a friend, reducing her self-criticism and increasing her self-acceptance.

CFT techniques for perfectionism

• Developing a compassionate self: Help clients create a compassionate inner voice that can counterbalance their self-criticism.
• Self-compassionate letter writing: Encourage clients to write letters to themselves expressing kindness and understanding.
• Compassionate imagery: Use imagery to help clients imagine a compassionate figure offering them support and understanding.

Client exercises and interventions

In addition to therapeutic interventions, clients can engage in self-help exercises to address their perfectionism. These exercises can help reinforce the therapeutic work and promote long-term change.

• Journalling: Encourage clients to journal their thoughts and feelings related to perfectionism. This can help them recognise patterns in their thinking and explore the origins of their perfectionistic tendencies.
• Gratitude practice: Help clients cultivate a practice of gratitude to shift their focus from flaws to strengths.
• Perfectionism scale: Use tools such as the Frost Multidimensional Perfectionism Scale to assess the severity of perfectionism and track progress over time.
• Mindfulness meditation: Encourage clients to practise mindfulness to increase awareness of their thoughts and feelings, allowing them to detach from perfectionistic beliefs.

Conclusion

Perfectionism, when maladaptive, can have profound effects on mental health and well-being. Understanding the nature of perfectionism and recognising how it presents in clinical practice is essential for effective intervention. Through approaches such as CBT, ACT, and CFT, therapists can help clients challenge their perfectionistic beliefs, cultivate self-compassion, and lead more balanced lives. With the right support, clients can overcome the negative impacts of perfectionism and embrace their imperfections, leading to greater emotional freedom and resilience.

Key takeaways

• Perfectionism is a complex personality trait that can lead to mental health struggles when it becomes maladaptive.
• It often presents in clinical practice as overachieving behaviour, self-criticism, fear of failure, and difficulty accepting mistakes.
• Perfectionism is linked to a variety of mental health issues, including anxiety, depression, OCD, and eating disorders.
• Therapeutic approaches like CBT, ACT, and CFT offer effective ways to address perfectionism in clients.
• Client exercises such as journalling, mindfulness, and self-compassion can support progress in overcoming perfectionism.

References

• Frost, R. O., Marten, P., Lahart, C. M., & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14(5), 449-468. https://doi.org/10.1007/BF01172967
• Frost, R. O., Heimberg, R. G., Holt, C. S., & Mattia, J. I., & Neubauer, A.L. (1993). A comparison of two measures of perfectionism. Personality and Individual Differences, 14(1), 119-126. https://doi.org/10.1016/0191-8869(93)90181-2
• Flett, G.L., & Hewitt, P.L. (2002). Perfectionism and maladjustment: An overview of theoretical, definitional, and treatment issues. In G.L. Flett & P. L. Hewitt (Eds.), Perfectionism: Theory, research, and treatment (pp. 3-31). The Guilford Press.
• Shafran, R., & Mansell, W. (2001). Perfectionism and psychopathology: A review of research and treatment. Clinical Psychology Review, 21(6), 879-906. DOI: 10.1016/s0272-7358(00)00072-6
• Shafran, R., Cooper, Z., & Fairburn, C. G. (2002). Clinical perfectionism: A cognitive-behavioral analysis. Behaviour Research and Therapy, 40(7), 773-791. https://doi.org/10.1016/S0005-7967(01)00059-6