When is perfect, perfect enough?
Perfectionism is not about excellence or healthy development but a rather sophisticated bio-psycho-social mechanism that internally sounds something like this: ‘if I deliver at 100% all the time and if I look perfect all the time and if I achieve 100% academically all the time, I shall no longer feel ashamed, embarrassed and will no longer be judged for underperforming – everyone will love and accept me then’.
Striving for a specific ‘reward’, whether material, professional or academic, is wired into our neurological system and can be healthy for both the mind and body. However when suffering from low mood and low self-esteem, perfectionism is usually turned into an unhealthy obsession by constantly shifting the goal posts or aiming for unrealistic or even impossible standards.
According to Roz Shafran (2002) “the overdependence of self-evaluation on the determined pursuit (and achievement) of self-imposed, personally demanding standards of performance, in at least one salient domain, despite the occurrence of adverse consequences”, explains the mechanism behind perfectionism.
This obsessive drive forward is often misread by significant others (usually immediate family and close friends) as ambition. There is a threshold nonetheless, observable to the trained eye, by the experienced clinician who understands the blurring line between pathological tendencies that reinforce anxiety and depression, and a healthy motivation to achieve.
Mary, a case of clinical perfectionism
This article follows Mary’s NA-CBT treatment for clinical perfectionism, and it is part of a handout offered to students on doctoral training in CBT; as such certain details have been changed in order to maintain anonymity; the article includes specific questions at various crucial points ‘[in square brackets]’ raised by the author which are meant to trigger further enquiry and insights into the treatment.
For further training opportunities in Clinical Perfectionism, click on this link: Treating the Perfectionist: CBT for Perfectionism Workshop – with Daniel Mirea, BABCP Accredited Psychotherapist – The UK College of Hypnosis and Hypnotherapy – Hypnotherapy Training Courses (ukhypnosis.com)
Mary did not present to NA-CBT because she wanted help with perfectionism, but because she felt low, and was sick and tired of feeling isolated. She also wanted to feel less anxious and improve her sleeping; socially she needed a better connection with people on the one hand but on the other hand, she was very good at pushing them away As such she was depressed much of the time, pessimistic, cynical and generally unsatisfied.
Focusing on the main complaint (in her view, the social isolation), I directed the specific exploration towards the how she is usually pushing people away (a functional analysis). Mary enjoyed a senior position at work and explained that she was by her own admission intolerant and naturally so, given the circumstances, since most people surrounding her are slow and stupid. As I was sitting across from her, tried to really concentrate on what would be like to work for someone like Mary and be made to ‘feel stupid’; and thus imagined being one her colleagues feeling inadequate as a result of an interaction with Mary [the imagery method used is termed: emphatic mentalisation]. I asked her… do you ever feel that you’re stupid or is it just other people or is this perhaps just another stupid question? She immediately responded… Oh no, I could be stupid, and I hate that even more, because deep down, I actually know I’m pretty smart, so if I do something stupid it’s even worse, there are no excuses for me…
I pressed on and asked for an example of her being stupid and she said… Well, I binge on alcohol and sugar you know, not so often now, but I waste a lot of money on drinks and sweets and that is pretty stupid in my books. Mary had been binge drinking and indulging with sweets for a long period of time; naturally this felt enjoyable in the moment, but this process provided also an excellent platform for launching a series of self-blaming thoughts and self-criticism which will relentlessly follow [these reinforcing activities would later be explored in simple ABC type formulas – explore the concept functional chain analysis and vicious cycles]. Her occasional all-or-nothing attitude to drinking or eating was carried over destructively to other parts of her life; her mind was set to self-criticism and her being stupid inventory was off charts… if someone says the wrong thing that’s it, I feel like I just don’t want anything to do with them anymore… everybody gets one chance and if they blow it that’s it [Mary].
The therapeutic alliance and use of empathic mentalisation
If I was your colleague and needed your help, I would feel intimated by you – I used empathic mentalisation to picture this narrative like watching it unfold on a stage play that I am part of, and therefore, by default, projected it externally into the therapeutic space. Outwardly, I just looked at her and nodded with a slightly intimidated face… and as if she’d heard my thoughts, she then said… people often find me intimidating… I nodded again, eyebrows raised imitating a little fear and a little surprise… Oh reeally!?… I said and continued to visualise what came up next for me, how I might not immediately turn to Mary for some friendly support as her colleague, If I could avoid it [at this stage try to describe the difference between analytical transference and empathic mentalisation in NA-CBT and what would need to happen next].
Inside Mary was torn [therapist’s or an informed conclusion], since she knew she needed to change; her suffering was pretty clear.… it is rather lonely being perfect especially when you’re not…. But in order to understand that (beyond cognitive reasoning at a prefrontal level), it was important to feel what her colleagues or friends are feeling and try to figure out, why they are avoiding her at an emotional level, only to explore these options with her session.
[It may be important to debate the topic of empathic mentalisation, which is s typical NA-CBT method. What is the alternative approach at this stage? Tip: in traditional CBT we use transference and countertransference as opportunities for an open dialogue]
Mary was lonely because other people irritated her, but she irritated herself even more so [double bind]; work relationships and even friendships had gradually disappeared over the years, usually because other people couldn’t stand the attacks and her constant judgements. The unforgiving standards justified by her believes around mediocracy. She quickly found people’s imperfections not a sign of their humanity but laziness or lack of desire to improve and as such she rejected people right away right away [where would such values be placed in the CBT conceptualisation and what type of beliefs are we faced with at this level].
Having high standards, being solution-focused and driven, can help us achieve wonderful things in life. But for Mary and many others (suffering from pathological perfectionism), this life strategy would be so over-used, it would eventually lead to blocking any sense of achievement or reward usually experienced by taking pleasure in activities that are performed.
Early Years
As a child Mary was a fast learner but as she was quick to give up athletics because she was not the fastest runner, she had also given up ballet, even though she had shown great promise. Mary used to rip up her music sheets when her clarinet practise didn’t go as planned and never went back to any of those activities; there was no sense of achievement or enjoyment. This wasn’t unusual, in fact it was perfectly aligned with the family culture; her parents valued achievement above all else and being the best at everything; if you weren’t the best, move on there’s no point in doing it. She recalls her father’s catch phrase vividly ‘if you don’t do it well, might as well not do it at all’. The father passed on these attitudes to his children including Mary.
Nowadays she also struggles with procrastination, putting things off (until she feels 100% ready), or deleting reports or emails reviewed for hours on end for reasons other people probably couldn’t even see (in her own words).
My life has been full of stops & starts… I hesitate all the time, I am uncertain about the quality of my writing (an email or a report) … if something is wrong or doesn’t fit how I think it should be, I tend to give up on it immediately… I’ve had so many opportunities I should have pursued… I’ve stopped even trying to do stuff I feel maybe hard although I won’t be good at that’s what she told me.
The trap of perfectionism
Mary needed of course to relax her standards and disrupt this (childhood) association that she is not worthy unless she performs extremely well. Cognitive rigidity is a major risk factor for chronic pathologies, research has found links between perfectionism, addictions and eating disorders. Perfectionism is particularly unforgiving to the self! Rigid thinking that characterises maladaptive perfectionism can also contribute to the onset and maintenance of depressogenic thinking. Cognitive biases such as all-or-nothing thinking or minimising successes, maximising failures, act as situational filters that lead to black-and-white conclusions about self and others.
[Taking all of the above into consideration, what would the formulation look like at this stage]
The CBT treatment plan
The focus of Mary’s treatment was around improving interpersonal skills, decreasing social isolation and improving her stress levels; we began building her social and interpersonal skills by role playing [discuss method acting] a variety of case scenarios within the safety of the therapy space, helping her develop compassion and appreciation of herself and other people above and beyond what they were good at!
[How would you best achieve all of the above? Below there is a brief overview of how NA-CBT helped Mary go from an intolerant to compassionate attitudes towards herself and other people. Consider what is missing from this plan and what else would you have done]
Psychoeducation:
In CBT we start by describing the bio-psycho-social traps, the maintenance formula(s) that keep the perfectionistic mechanism going over the years. Mary like most perfectionists, is a detailed analytical thinker and likes to know why she is even thinking in this way, the origins of it and so on. This is not an intellectual or psychoanalytical exercise, nor a brief overview of her earlier years but rather an exercise of exposing the earlier narrative through a strong hypothesis about the episodic origins (and associated specific memories) of her perfectionism. And more importantly the link between these episodes and the present attitude and life strategies [how would this be achieved].
The origins of her perfectionism were very clear in Mary’s case. It was simply her parents’ personal ambitions, unrelenting goals and high standards imposed to her from a very early age; reading already at the age of three, her parents were very proud of her. Mary’s need to please her main caregivers was backed up (reinforced) over the years by appropriate and timely rewarding (i.e., every time she would get the highest mark, an A+, she would be praised but criticised harshly and compared unfavourably with other peers, when she would bring a lower grade, a B or a C). This was further reinforced and conditioned by her teachers, peers and friends, all too willing to praise and appreciate her efforts. This would eventually lead to a rigid personality and a strong association between self-appreciation and good performance. which would be maintained by specific life strategies (behaviours) and all-or-nothing thinking. Creative diagrams and metaphors were used to explain the nature of negative thinking and all these vicious traps.
[case formulation: diagrammatical explanation or narrative, what would work best in this case]
Cognitive interventions:
I asked Mary to spend some time with her eyes closed (hypnotic state), drawing a world in her mind, in which no mistakes were ever made, where everything was always done entirely correctly, and skills were picked up instantly by everybody… were people were perfect and operating at their full potential without error. She imagined a range of different scenes, involving all sensory modalities (making very real – this is not a fantasy world but a real world, in present tense).
She described this world in detail, just like a perfectionist would, drawing with her mind’s eye, this very detailed perfect world for 15 minutes or longer… and when I asked her what she felt after, on reflection, she said that…. it is silent, too cold, not much fun at all; she noticed no satisfaction from having overcome challenges and in a nutshell, it’s a horrible place.
Chronic perfectionism is always a case of being (unrealistically) too goal and task oriented in parallel with an imminent self-critical mind. As such, we need to directly tackle this aspect, by encouraging a wider context and more psychological flexibility. If we consider experiences within a strict goal-oriented narrative (i.e., the scope is to win or my goal is to be the best), we miss much of the finer details of the process (of winning), for example playing a friendly game with relatives at Christmas or some other get together, is a chance to have fun, to be creative, to laugh and bond with significant people in your life, a chance to help other people feel good when they win, a way of communicating with loved ones, regardless of who wins!
But a chronic perfectionist may miss out on all these wider contextual elements of playing a game, so for instance when I would ask Mary what is the point of a competition, she immediately replied, well to win of course. It was a genuine revelation to her when we explored other possible purposes or by products of a competition; and how she was intrigued to generate new ideas because she’d always thought … in fact, what’s the point was a standard response to any idea or suggestion in therapy, as if everything could be whittled down to one thing. The ‘what’s the point’ syndrome is often a sign that someone’s thinking is too task oriented and too black-and -white.
[the exercise of overcoming perfectionism sharpens perception and makes it more flexible and context aware, while also increasing compassion to oneself and other people – but how can this best be achieved]
Behavioural interventions:
A lot of social experiments at work or at home would be designed based on the above conceptualisation of Mary’s perfectionism. For example, going to a colleague that may be particularly intimidated by her and asking for advice in spite of already knowing the answer. Encouraging relaxation and downtime is remarkably important; all-or-nothing thinking is exhausting as a result of being hyper-aroused, on high alert all of the time, in search for good outcomes and excellent results; no activity feels rewarding unless it’s results driven, so even the immediate time that follows a successful endeavour can feel depressing to the perfectionist; free time isn’t valued or tolerated very well.
Mary’s life was organised on paper, literally, because keeping notes (including smaller notes about the main notes) was very important [implicit life strategy or one of the ‘musts’: ensuring not to miss anything or make mistakes]. Her calendar, therefore, was packed with ‘essential activities’. Preferred activities were manically cleaning the apartment, crossing tasks off the lists, or rigorous dieting. What she needed in contrast (another behavioural intervention) more rewarding activities and relaxation, were more of respite episodes, which would not include marathon running, which incidentally was a hobby of hers [can you guess why – could it be because it was a task-oriented activity, where the goal posts can easily be shifted upwards… another vicious… Tip: the answer should be in your conceptualisation].
Mary understood why it was important at this stage in therapy to learn how to let go and perhaps even fail. We talked about compassion, self-appreciation and how being human and flawed by design, means also getting comfortable with failure; this in fact could be the first step towards more realistic success, on a social and professional domain. She also needed a break from having to be seen as perfect by other people and the best at everything all the time. Therefore, we agreed on the following behavioural experiment. Mary was asked to meet up with a friend she hadn’t seen for a while [behavioural and social experiments are designed to contradict life strategies, the obligatory should and musts of which are very much part of perfectionist’s life repertoire]. Her friend remained reasonably close to her over years but kept her distance for obvious reasons; eventually they agreed to meet. The challenge was to tell her friend a story of how she [Mary] had failed in some way. During therapy, Mary told me that she completed this task only because after all, she liked to do what she said she would do. And so, she had met up with her friend and told her how she cheated on one of her reports at work. At the time Mary had been mortified but while telling her friend about this episode something suddenly began to happen Mary relaxed and they both laughed at the irony of it all. In the end they were both crying with laughter, and it was wonderful.
Roadblocks and opportunities to successful therapy
A trusting therapeutic relationship is essential and always key to a successful treatment. This is where empathic mentalisation can be useful not only in the earlier stages of therapy in order to authentically relive difficult situations but to continue to support your client feel felt throughout the process [I don’t just understand (cognitively), but I am feeling your pain]. This enhances collaboration and self-efficacy.
Mary admitted that initially when she was exposed to the idea of behavioural experiments, she felt that… She had to carry out the task, because if she hadn’t, she would have failed it and that would be terrible… This is a classic therapeutic challenge when working with perfectionism. The therapist must be aware of such tendencies and expose these types of beliefs also. This type of admission would not be possible outside of a safe and confidential alliance. Therapist must retain a positive attitude and explain such vicious traps and the role of reinforcing mechanisms.
Experiments would have to be creatively enhanced and repeated over several weeks of treatment. I kept asking Mary to make small mistakes and practise laughing about them, tell other people about these mistakes; this is in line with research that shows that people like you more when they see you make small mistakes and own them. Of course, gradually people did seem to respond to her positively as they discovered that they could relax around her and she didn’t make them feel bad.
References:
Daniel Mirea (2019). Is ‘perfectionism’ a deal maker or a deal breaker https://neuroaffectivecbt.com/2019/05/08/is-perfectionism-a-deal-maker-or-a-deal-breaker/
Roz Shafran (2002). Overcoming Perfectionism. Robinson edition.
Further training opportunities in Clinical Perfectionism:
Disclaimer: the intention with all NA-CBT articles is to help and develop knowledge. All case studies described are a combination of facts and very little fiction from different sources including personal clinical experiences. More similar work, great resources for inspiration, can be found on TedX, Treating Perfectionism, Uncommon Practitioners, Roz Shafran, Keith Gaynore and others.
Neuroaffective-CBT 