Question 1

How do you conceptualize perfectionism?

Martin Antony · Accepted Answer

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 (Shafran, Cooper, & Fairburn, 2002).

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 (American Psychiatric Association, 2013).

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 (for a review, see Egan, Wade, Shafran, & Antony, 2014).

Finally, definitions of perfectionism vary with respect to their focus. Some definitions assume that perfectionism is always self-focused (e.g., Shafran, Cooper, & Fairburn, 2002), whereas other definitions assume that perfectionistic standards can be focused on the self or others (e.g., Hewitt & Flett, 1991).

Question 2

How do you help a person who wants to hold onto their perfectionism because they view that it motivates them and fear that they will become lazy (but it is causing them some problems)?

Martin Antony · Accepted Answer

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 out 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.

Question 3

What are the main differences between clinical perfectionism and OCPD? Could we assume that all OCPD people are also perfectionists?

Martin Antony · Accepted Answer

OCPD is the only problem in DSM-5 that includes perfectionism in the diagnostic criteria (American Psychiatric Association, 2013). 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 (Shafran, Cooper, & Fairburn, 2002).

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.

Question 4

I am curious about online resources for CBT treatment for  Perfectionism.

Martin Antony · Accepted Answer

Anxiety Canada’s website has a helpful article regarding CBT strategies for dealing with perfectionism . You can find it here: https://www.anxietycanada.com/articles/how-to-overcome-perfectionism/

Question 5

How do you know when you should focus on perfectionism in therapy?

Martin Antony · Accepted Answer

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 (e.g., anxiety over not looking perfect and being judged by others for his imperfections, as well as low mood focused on not being able to meet his standards).

Question 6

Can you give an example or ideas for behavioral experiments for exposing a client to their fear of failure?

Martin Antony · Accepted Answer

Our book, Cognitive-Behavioral Therapy for Perfectionism (Egan, Wade, Shafran, & Antony, 2014), 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 (e.g., excessive checking, reassurance seeking, spending too long on a project, etc.). We would then identify the thoughts underlying these behaviors (e.g., “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.

Question 7

Should we be looking for perfectionism when someone presents with depression?

Martin Antony · Accepted Answer

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.

Question 8

What are the best techniques to help the patient being more flexible?

Martin Antony · Accepted Answer

The most studied treatment for perfectionism is Cognitive-Behavioral Therapy (CBT). It includes teaching people strategies for identifying and challenging perfectionism-related thinking and for changing behaviors that maintain perfectionism over time. My self-help book, When Perfect Isn't Good Enough (https://www.amazon.com/When-Perfect-Isnt-Good-Enough/dp/157224559X), describes these strategies in detail, as does my book for therapists, Cognitive Behavioral Therapy for Perfectionism (https://www.amazon.com/Cognitive-Behavioral-Treatment-Perfectionism-Sarah-Egan/dp/1462527647). There is also emerging evidence supporting mindfulness and acceptance-based strategies (e.g., https://www.amazon.com/Anxious-Perfectionist-Perfectionism-Driven-Acceptance-Commitment/dp/1684038456) and relational therapy approaches (e.g., https://www.amazon.com/Perfectionism-Relational-Conceptualization-Assessment-Treatment/dp/1462528724).

Question 9

Do perfectionists lack self-compassion and therefore is self-compassion an antidote to perfectionism? Does CBT have interventions to increase self-compassion?

Martin Antony · Accepted Answer

People with high levels of perfectionism may lack self-compassion. Our book, Cognitive-Behavioral Therapy for Perfectionism (Egan, Wade, Shafran, & Antony, 2014), has a chapter on self-evaluation and self-criticism that includes a section on facilitating self-compassion. https://www.amazon.com/Cognitive-Behavioral-Treatment-Perfectionism-Sarah-Egan/dp/1462527647

Question 10

Is CBT effective for perfectionism aimed at others? In other words, can it be used to alter the behavior of a person with unreasonable expectations of those around them?

Martin Antony · Accepted Answer

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 (e.g., CBT) 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.

Question 11

How would you address excessive perfectionism in elementary-age children?  Particularly if it involves comparing themselves with older children or adults doing the same task.

Martin Antony · Accepted Answer

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 Siquiland have done a number of trainings on the topic (you can find one of their presentations here: https://www.youtube.com/watch?v=mi_befBKW8w&t=59s). There is not much out there in terms of clinical materials or research on treatment of perfectionism in children. However, there is a new book coming out soon on developmental factors in perfectionism, called Perfectionism in Childhood and Adolescence (https://www.amazon.com/Perfectionism-Childhood-Adolescence-Developmental-Approach/dp/1433833093).

Question 12

How can CBT help someone who is socially anxious due to perfectionism (i.e. fears judgement when things are not perfect)?

Martin Antony · Accepted Answer

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 to 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 (https://www.amazon.com/When-Perfect-Isnt-Good-Enough/dp/157224559X), describes these strategies in detail, as does my book for therapists, Cognitive Behavioral Therapy for Perfectionism (https://www.amazon.com/Cognitive-Behavioral-Treatment-Perfectionism-Sarah-Egan/dp/1462527647).

Question 13

How do you approach treatment for perfectionism via a CBT model (i.e. where do you start)?

Martin Antony · Accepted Answer

The CBT approach begins with developing a collaborative case formulation to help identify the cognitive and behavioural factors that cause, trigger, and maintain the client’s perfectionism. One can use a general CBT case formulation approach to identify the “five ps” (i.e., presenting problem, predisposing factors, precipitating factors, perpetuating factors, protective factors), or a more perfectionism-specific approach, as described in our book for therapists, Cognitive Behavioral Therapy for Perfectionism (https://www.amazon.com/Cognitive-Behavioral-Treatment-Perfectionism-Sarah-Egan/dp/1462527647).

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