CBT for Perfectionism

There is no single definition of perfectionism.

Some experts define perfectionism as a tendency to have impossibly high standards, combined with a tendency to judge one's worth almost exclusively based on whether these standards are met. This type of perfectionism is sometimes referred to as clinical perfectionism.

We can also think about perfectionism as an obsessive-compulsive personality feature. In this context, perfectionism is not so much about having impossibly high standards. It is about having arbitrary standards, which may show up as a preoccupation with order, perfection, and control over the self, others, and situations. Individuals with this type of perfectionism tend to see things as “right” or “wrong,” may be overly rigid and inflexible, and may be overly focused on rules, details, organization, and lists.

In addition, many experts distinguish between adaptive (or healthy, helpful) perfectionism and maladaptive (or unhealthy, unhelpful) perfectionism. Adaptive perfectionism involves striving for excellence in a way that facilitates success and wellbeing. Maladaptive perfectionism is more likely to be motivated by a fear of failure or disappointing others, may get in the way of getting things done, and is often associated with feelings of anxiety, fear, and depression.

Finally, definitions of perfectionism vary with respect to their focus. Some definitions assume that perfectionism is always self-focused, whereas other definitions assume that perfectionistic standards can be focused on the self or others.

More information is available at the following links:

Clinical perfectionism: a cognitive–behavioural analysis

Perfectionism in the self and social contexts: Conceptualization, assessment, and association with psychopathology

Cognitive-Behavioral Treatment of Perfectionism

First, we try to identify which aspects of an individual's perfectionism are adaptive versus maladaptive. Behaviors that help the person to function are not things that we want to change. On the other hand, maladaptive behaviors (for example, procrastinating frequently or spending so much time on tasks that other important things don't get done) may be behaviors that an individual might want to change.

We help individuals to examine the costs and benefits of changing specific aspects of their perfectionism. We also encourage them to question perfectionistic thoughts and examine the evidence concerning them to help people think more flexibly so that they can make choices that ultimately are more helpful and more aligned with their values. We also encourage people to engage in experiments to test whether their beliefs are true. For example, if somebody was convinced that it would be terrible to be even a minute or two late for an appointment, we might encourage them to try it out and see what happens.

OCPD is the only problem in DSM-5 that includes perfectionism in the diagnostic criteria. In OCPD, individuals have a preoccupation with order, perfectionism, and control of the self, others, or situations. In addition, they need to endorse at least four symptoms from a list of seven. Some examples of these symptoms include a tendency to focus too much on rules, details, organization, and lists; a tendency to focus so much on doing things perfectly that they don't get done; being overly devoted to work at the expense of socializing and having fun; a tendency to be overly conscientious and inflexible when it comes to issues related to morality and ethics; and difficulty delegating tasks to others.

Clinical perfectionism has been described as a tendency to have impossibly high standards, combined with a tendency to judge one's worth almost exclusively based on whether these standards are met.

The question of whether everyone with OCPD is a perfectionist depends on one’s definition of perfectionism. I would say yes, but others might disagree.

More information is available at the following link.

Anxiety Canada’s website has a helpful article regarding CBT strategies for dealing with perfectionism. You can find it here.

I generally recommend focusing on perfectionism when it is causing problems in a person’s life and when it appears to be the individual’s main problem (versus just a feature of some other problem, like depression or an anxiety disorder). I also recommend focusing on perfectionism when the case formulation suggests that perfectionism may be driving one or more other problems. For example, I saw a client with body dysmorphic disorder, depression, and social anxiety disorder, with whom it became clear that problems with perfectionism were the main underlying explanation for all three of these other issues (that is, anxiety over not looking perfect and being judged by others for their imperfections, as well as low mood focused on not being able to meet their standards).

Our book, Cognitive-Behavioral Treatment for Perfectionism, includes an entire chapter on how to design and implement behavioral experiments. For a client who fears failing, we might first identify a specific situation in which the client fears failing, and we would identify perfectionistic behaviors designed to prevent failing in that situation (for example, excessive checking, reassurance seeking, spending too long on a project, and so on). We would then identify the thoughts underlying these behaviors (for example, “If I don’t rehearse my presentation until I can recite it by memory, I will fail miserably”). Next, we would come up with an experiment to test out the belief. In this example, the experiment might be to practice the presentation just once and to rely on one’s point-form notes and slides to get through it. After the experiment is completed, the client would evaluate the outcome.

Perfectionism is common in individuals with depression, so I generally recommend asking questions to assess perfectionistic thinking in individuals presenting with low mood. For example, I might ask the client about the extent to which their low mood is triggered by not being able to meet their high standards, and the extent to which their self-worth is determined by whether they meet their standards.

The most studied treatment for perfectionism is CBT, which includes teaching people strategies for identifying and challenging perfectionism-related thinking and changing behaviors that maintain perfectionism over time. My self-help book, When Perfect Isn't Good Enough, describes these strategies in detail, as does my book for therapists, Cognitive Behavioral Treatment for Perfectionism. There is also emerging evidence supporting mindfulness and acceptance-based strategies, and relational therapy approaches.

People with high levels of perfectionism may lack self-compassion. Our book, Cognitive-Behavioral Treatment for Perfectionism, has a chapter on self-evaluation and self-criticism that includes a section on facilitating self-compassion.

Most of the research on CBT for perfectionism has focused on unreasonably high standards that people hold for themselves. Although there are reasons to assume that psychotherapy may be useful for people with “other-oriented perfectionism,” there are also reasons to believe that it may be less effective. Perfectionism aimed at others is associated with perfectionistic thoughts and behaviors that can be targeted by CBT. However, it is possible that individuals with unreasonably high standards for others may respond less well to therapy compared to those with unreasonably high standards for themselves, especially if they are not distressed by their perfectionism or if they lack insight into the impact that perfectionism has on their lives. More research is needed in the area of other-oriented perfectionism and its treatment.

The strategies for treating perfectionistic children are similar to those used in adults, but they need to be adapted to be developmentally appropriate. Psychologists Deborah Ledley and Lynn Siqueland have done a number of trainings and presentations on the topic (one of which can be found below). There is not much out there in terms of clinical materials or research on the treatment of perfectionism in children. However, there is a great book on developmental factors in perfectionism, called Perfectionism in Childhood and Adolescence.

Relevant CBT techniques include a range of both cognitive and behavioral strategies. From a cognitive perspective, we use Socratic questioning designed to help people identify the assumptions, beliefs, and predictions that drive their perfectionism and consider the evidence supporting both their perfectionism-related thoughts and alternative, more balanced ways of looking at the situation. For example, clients may be encouraged to ask themselves, “What if I don't perform perfectly?” “What if somebody does judge me negatively?” “Is it possible to be liked by everyone?” The goal is to help clients recognize that the consequences of making mistakes and being judged negatively are often less than what we expect.

We also use strategies such as behavioral experiments and exposure, which encourage people to do the things that make them anxious, to take social risks, and to learn through real-life experience whether their perfectionistic beliefs are, in fact, true. My self-help book, When Perfect Isn't Good Enough, describes these strategies in detail, as does my book for therapists, Cognitive Behavioral Treatment for Perfectionism.

The CBT approach begins with developing a collaborative case formulation to help identify the cognitive and behavioral factors that cause, trigger, and maintain the client’s perfectionism. One can use a general CBT case formulation approach to identify the “Five Ps” (that is, the Presenting problem, Predisposing factors, Precipitating factors, Perpetuating factors, and Protective factors), or a more perfectionism-specific approach, as described in our book for therapists, Cognitive Behavioral Treatment for Perfectionism.