CBT for Clinical Perfectionism

Let's Talk About CBT

Striving for achievement has got to be a good thing, right? But what if it starts to get in the way of our happiness? What if the standards we hold ourselves to are unattainable or unrealistic? What if we feel like we'll never measure up?

In this episode, Sam and Professor Roz Shafran speak to Dr Lucy Maddox about CBT for clinical perfectionism - what it is, what it's not, and how it can be useful.

Show Notes and Transcript

Podcast episode produced by Dr Lucy Maddox for BABCP

For more information here are some resources.

Books

This is Roz's book on Overcoming Perfectionism

https://www.amazon.co.uk/Overcoming-Perfectionism-scientifically-behavioural-techniques/dp/1845297423

Or for a shorter booklet this is also written by Roz and published by the Oxford Cognitive Therapy Centre

https://www.octc.co.uk/product/booklets/changing-perfectionism-2

Other Reading

This is a short article on clinical perfectionism by Roz and colleagues

https://nopanic.org.uk/perfectionism/

For some free ACT resources from Dr Russ Harris check out his website (Sam talked about ACT)

https://thehappinesstrap.com/free-resources/

The bullseye worksheet in these resources is the 4 quadrant image that Sam talks about:

https://thehappinesstrap.com/upimages/The_Complete_Happiness_Trap_Worksheets.pdf

The clinical perfectionism questionnaire is on p39 of this article - it is 12 items long and gives you an idea of the sorts of problems that clinical perfectionism can exacerbate. If you are worried speak to your GP:

https://www.researchgate.net/publication/259530421_The_Clinical_Perfectionism_Questionnaire_Further_evidence_for_two_factors_capturing_perfectionistic_strivings_and_concerns

Some worksheets are available here on clinical perfectionism

https://www.cci.health.wa.gov.au/Resources/Looking-After-Yourself/Perfectionism

Podcasts

Check out other podcast episodes on ACT

https://letstalkaboutcbt.libsyn.com/lets-talk-about-cbt-act-episode

And compassion focused therapy

http://letstalkaboutcbt.libsyn.com/lets-talk-about-cbt-compassion-focussed-therapy-episode-0

Websites

For BABCP accredited therapists visit www.cbtregister.co.uk

For BABCP visit www.babcp.com

Transcript

Lucy: Hi, and welcome to let's talk about CBT with me, Dr Lucy Maddox. This podcast is from the British Association for Cognitive and Behavioural Psychotherapies or BABCP. It's all about CBT, what it is, what it's not and how it can be useful.

In this episode, we'll be finding out about clinical perfectionism, it's a bit of an unusual episode, because clinical perfectionism is not a typical diagnosis. It's a problem which can go alongside many different diagnoses, for example, depression or anxiety.

To understand more, I met with clinical perfectionism expert, Professor Roz Shafran, and Sam, who's experienced CBT for perfectionism. Sam currently studies for a master's in psychology in London. Before this, he worked for a couple of years, and before that studied English at Oxford. Through all of it, he experienced perfectionism-based anxiety, this is where it started.

Sam: So, I think I've always been interested in academics and I know a lot of people aren't. But it meant that at school I enjoyed working hard, but I think the praise I got as a child for doing well became quite addictive. And so, the more I did well, the more I wanted to continue to do well. And then, pressure mounts, and I think I wasn't aware of that as a child.

But suddenly, it wasn't just about doing the best I could in class, but doing the best that could possibly be done, getting full marks. And that's unreasonable, and I think an unhelpful aim. And then, I also felt there was an uglier side of that, which was more comparative, doing better than people around me because I think I found the education system very relative. And it was about being judged against others as well.

And I think while that in itself is stressful, I think what was perhaps most difficult was the way it then grew and eclipsed other aspects of life, resting or doing hobbies, or socialising. Even at a young age was tinged with guilt, or it was in the shadow of the work I could be doing.

Lucy: So, hard to stop?

Sam: Yeah, I think so.

Lucy: How would you describe perfectionism? What does it mean to you?

Sam: So, for me, it's only recently that I’ve viewed it as a potentially bad thing. I think generally it meant to me doing my best at things and striving to feel devoted to things. And I think certain aspects of that feel quite rewarding and energising to feel motivated is good. And I think a lack of that can feel unsettling or depressive.

But recently, especially through therapy, I've started to relate to the more harmful sides of my perfectionism. And the way it relates to my anxiety, and so I feel it's not just about having high standards, but unreasonably high standards and inflexibly high standards. So, it's not just about trying hard, but needing to try my hardest and needing to do my best. Or a conception of my best that is sometimes beyond what I have the energy or the capacity for and that is really draining.

In different ways I think I've experienced perfectionism, so I think academia and education particularly flares it for a lot of people, because from such a young age we're rated and ranked. I've certainly felt sorted by the way we perform, and I think that even now is being flared up by being back in education.

Lucy: Roz Shafran is professor of translational psychology at the UCL Great Ormond Street Institute of Child Health. She's been working in the field of perfectionism for a decade and got interested in it first of all in relation to eating disorders.

Could you start off just by explaining what perfectionism is in a clinical sense? Because it's the sort of thing people sometimes say they have in a job interview maybe. But actually, we're talking about something a bit different, aren't we?

Roz: You will get different answers from different people and different researchers. So, I think many people would view perfectionism as a personality characteristic, it's something that's you're born with, you're a perfectionist, and it has that positive context to it of striving for excellence and trying to do well and an eye for detail that can be very helpful to people. But it's long been recognised it's also got a dysfunctional or unhealthy kind of element to it.

And some researchers think about perfectionism in the interpersonal domain, so perfectionism in relation to other people. But when I was beginning my work with Chris Fairburns, Afra Cooper and the team in Oxford, we were working with people with eating disorders. So, the sort of perfectionism that we were seeing was really very self-driven. And we called it clinical perfectionism because it was the type of perfectionism we were seeing in our clinical practice.

That's not to say that other forms of perfectionism can't also be a clinical problem. But the area we focused on was the clinical perfectionism that was around your own striving for success and achievement, and your own reaction to failure.

And the reason that we put it in a CBT context rather than the personality context, really is because we know that the treatments that are successful have taken that approach. And we wanted to have a treatment that worked, so we wanted to have a formulation and a model in terms of maintaining factors, to give us ideas about where to intervene.

So, we took the same approach to perfectionism that had been taken to bulimia nervosa, that had been taken to panic disorder and we saw it in terms of cognitive behavioural maintaining mechanisms.

Lucy: By cognitive behavioural maintaining mechanisms, Roz just means patterns of thinking or behaviour that inadvertently keep a problem going.

How would you recognise perfectionism that's really causing a problem? What sort of problems do people come with?

Roz: So, sometimes people themselves find it very difficult to recognise and it's other people are telling them that they have a problem with perfectionism. But people do recognise it's interfering with their lives, when we started the idea of being the best at losing weight is actually inherently more problematic than necessarily being the best at work or being the best at sudoku or something like that.

So, the domain in which the perfectionism is expressed is important and can raise alarm bells. But it makes people very unhappy, they don't often come in saying, "I'm a perfectionist." But they come in, they're depressed, they're anxious, they're stressed.

And then, it is the common theme for all of that might be that they have these very high standards for themselves, they constantly feel like they're failing. Nothing they do is ever good enough. They're not sleeping because they're spending so much time on various tasks. And it's just not working for them anymore, even if it did work for them in the past.

Lucy: And is it that the standards are too high? That they're unrealistic or unachievable?

Roz: So, for many people, the standards are not necessarily unrealistic or unachievable, for many they are. But for some, they're not, but it's the striving and the effort that needs to go into them that makes it dysfunctional in that way.

So, we do often have very successful people, the work was started at the University of Oxford our patients were often students or staff members at Oxford. So, objectively, they had reached and attained very high standards, so the dysfunction comes in in terms of the reaction to failure and the importance of it to their self-evaluation.

Lucy: So, something about the amount of effort that goes in and something about the reaction if that standard isn't met.

Roz: So, the central point for us was the way we defined it, clinical perfectionism, is that people's self-worth is overly dependent on striving and achievement of personally demanding standards. And you're not a perfectionist on Monday and Wednesday, it's consistent and persistent and people will strive to achieve those despite adverse consequences.

Lucy: For Sam, despite achieving high academic success, he felt trapped in a myth he'd created for himself.

Sam: (Laughs) I had such a tight grip on how hard I tried at everything. I felt that if I stopped gripping so tightly I wouldn't relax, I would melt, I don't know quite what I imagined. As if I'd just halt completely and become comatose and demotivated, that only by incessant, compulsive striving could I keep a grip on regularity and functionality. And it felt like stepping back from perfectionism could be more of a cliff edge than sitting on the sofa.

Lucy: I can imagine it feeling potentially catastrophic to give it up. But it sounds like that didn't come to pass.

Sam: It surprised me how relaxing and relieving it was to loosen my grip. But also, in a way how little changed. It wasn't like pulling the carpet from under my feet, it was actually just twisting the tap slightly, changing the water temperature, just letting myself off the hook slightly. And that those degrees of forgiveness weren't catastrophic, they didn't make me melt, I just felt I had a little more energy and perspective and optimism about ways to enjoy the things I was doing.

Lucy: So, what does CBT for perfectionism look like? Here's Roz.

Roz: The key part of it is about understanding your perfectionism, so you've got a maintenance model, understanding what's going on. And it's about having some psychoeducation, so many people have beliefs, “The harder I work, the better I'll do.” But actually, that's not supported by data, it's not just a linear relationship that goes on exponentially and just carries on.

There's some surveys, so understanding where the benchmark is, beginning to set a more realistic standard in that sense. It's not about lowering standards, I think that's probably the key. It's not about we're going to turn you into a slob. Because then people won't engage, and it doesn't need to be that.

And people value achievement, so it's about how can you achieve your standards realistic or adjusted standards in a way that is less detrimental to you? So, essentially, challenging the belief that this is the best way to go about getting self-esteem and self-worth and to build up other domains.

And so, lots and lots of behavioural experiments to test beliefs, lots of behavioural experiments to try things another way, to get the information about the best way that the person wants to live their life in a more balanced, sustainable way.

Lucy: Could you give an example of a behavioural experiment? Because people might not know what that is.

Roz: So, if you're gathering evidence about different ways of thinking then you want to have personal experience of doing it differently.

So, for example, if someone was a perfectionist in the domain of their work, and they were say a university student. They might have two assignments, and the first assignment might encourage them to really do it like they normally would, but even more. Even more intensely, put every effort in, stay up all night, open up all your 20, 30 PDFs, really strive as you normally would, even more so if possible. And record and rate their predictions about how well they think they would do, but also in terms of their emotional wellbeing, how happy do you think you will be with the result, etc.? Whatever the variables are that are important to them.

And then, we might encourage them the next time when they got an assignment to do it in a different way. And we might even create two different assignments for them, if it was too risky for them to do it with a real university piece of work. And in that, not to do it in an hour or something that's completely unrealistic, but to maybe – based on the survey when they find out how much their peers do – to try to do it in a reasonable amount of time, the same sort of time as their peers, maybe with a little bit extra and see how worried and how anxious they were.

And they predict that they'll be much more worried and much more anxious, because it's not what they want to do. But many times that's not the case. And to compare their marks.

And I would like to say that what always happens is they get a much better mark for the second one than they do for the first, but the reality isn't like that. And sometimes they do get better marks for the first, but they've also got the experience of doing it differently.

And they might say, "Well, I know, maybe I got 95 for the first, but actually with the second I predicted I would get 50, and I got 87. So, there was only a seven-point mark in it, but actually there was eight hours difference in it. So, I've decided that actually it's okay to perhaps do a bit less. I might not get exactly the right mark that I want to get, but I won't be as anxious as I thought, I won't be as low as I thought, and I won't be as tired. And I can go out with my friends. So, on the whole, doing it that way is better for me."

So, that would be an example of a behavioural experiment. And just to emphasise these experiments can't go wrong. Because if they really did very badly in that and they were more anxious and more stressed, then we would work together to find a different way of working or a different pattern that was more helpful to that person.

Lucy: So, this behavioural experiment could apply to all sorts of things, music practice, schoolwork, work reports, you can gather data yourself in what's called a contrast experiment. For example, how do you normally clean your kitchen? Try doing it a bit more one day, a bit less another day, and write down how you feel. Repeat it over seven days. What does the data show in terms of mood, anxiety, what works best for you?

Roz: It is about I think trying things differently and testing your beliefs and testing your predictions about it, in the workplace, in the social domain, information gathering to test your beliefs and find out whether or not they fit with reality or if there is a different, better way for the person.

Lucy: I asked Sam what his experience of CBT was like.

You mentioned having had some cognitive behavioural therapy, is that right? Could you say a bit about what that's been like?

Sam: That was a really interesting experience, and it wasn't quite my first experience of CBT. When I was doing my undergrad, I became very, very anxious about lots of things, but I'm sure compounded by the workload. And about again, wanting to judge myself by those standards. And that was low intensity CBT through IAPT and looked at more generalised anxiety, from the way I thought to the way I breathed.

And actually when I went back for CBT more recently, I thought it would also be dealing with more generalised mood things. But it was my CBT therapist who thought a lot of what I had brought to the space was actually being shaped and driven by perfectionism. For example, I was worried that I was quite energised and motivated and almost manic at certain times, and then quite absent and numb in other times.

And so, it felt by chance, for me that suddenly it became perfection-oriented CBT where we were discussing things through the lens of perfectionism. So, it was me when I was feeling fresh, I would max out my energy, my capacity and do as much as possible to meet all of the demands that I'd set for myself in recent memory.

And then, suddenly, I'd feel unsettled and very troubled by being too tired the next day or perhaps two days later, to do more of the same. And it was suggested to me that I was so troubled by feeling tired because I had so many high standards for myself that I wanted to meet, and I was punishing myself at every turn for not meeting them. And that was made worse when I was tired.

So the image that really stuck with me, which I share with friends now as well is that exerting myself so much in those highs and trying to meet my standards and then continuing to do so when I'm exhausted is like trying to run a race after having run a marathon. We just need more rest than we give ourselves time for, or certainly I feel that way.

Lucy: Yeah, that's a really great metaphor. What sort of standards were you holding yourself to in those times when you're working, is that on university work or other stuff, or a mix?

Sam: I think for me, a lot of it is work based, and maybe just because of my past experiences also I worked in office jobs for a couple of years, and I think certainly the businesses I experienced, it's perhaps not in their best interests to make you feel relaxed and rewarded all the time. Those high standards are useful, but I think it was up to me to draw some boundaries and find some space for myself.

But the funny thing is that perfectionism can spread into all sorts of areas of my life, and I get bounced around from one area to the other, so if I strive to feel my work standards are sated, then the next moment I'll realise with alarm that I've neglected my friends, or I'll get ill because I haven't rested, or I'll feel guilty or incomplete for not having practised my hobbies. And it feels like a constant juggling act to stay satisfied perfectionistically about all of those.

Lucy: Maybe impossible.

Sam: Yeah, I think it is impossible, and that was a really helpful image that my therapist gave me, was I think drawing on ACT, actually.

Lucy: ACT is Acceptance and Commitment Therapy, a third wave CBT. If you want to know a bit more about that, have a listen to the earlier podcast episode called Acceptance and Commitment Therapy.

Sam: Russ Harris' four quadrants for life, you have work, I certainly feel I have work. But also, my health and leisure and relationships, your family and friends. And what that image of the circle carved into four made me realise is that if I let one expand to more than a quarter, then the others would shrink. And then, I'd feel that shrinkage and feel guilty, and I'd leap to one of the others and grow that out.

And I think it's impossible to have any of them as large as I wanted them to be. And so, actually, it takes a real I don't know, a courageous kindness to let them be slightly smaller, each quadrant, than I want them to be.

Lucy: Were there particular things that you remember talking through in therapy or particular sessions that stick in your head at all?

Sam: This one session that really sticks in my mind that we had, because it was the only time my therapist was a little firm with me, because she felt I was being resistant to the therapy. I was trying to talk about my mood and this and that and various other things I was worried about. And she just put it to me whether I was attached to my perfectionism (laughs) and finding ways not to confront that.

She gave me the myths of perfectionism that if I'm perfectionistic, if I worked to 100% of my capacity, I would do better. And she urged me to question whether that's true or whether actually I'd burn out. And so, that was an important moment for me, because it showed me that the therapy wasn't just a box of tools or a book of information that she'd share with me. It was actually a process where I was going to have to stand up to beliefs and habits that I'd held for so long and kind of do battle with them a bit.

And again, that left me feeling very disarmed, and out in the cold with new ways of being, and that's scary. And I think for me that was very much the value of therapy, it was having a guide through that, that period of unknown.

Lucy: And what things do you try and do a little bit differently now?

Sam: Well, a lot of it is cognitive for me. Some is behavioural but a lot is cognitive, it's letting myself off the hook. It's noticing when I am worrying and criticising myself. It's actually just changing my internal dialogue and saying, again, more compassionate things to myself.

More practically, the quadrant, where you map out work and relationships and health and leisure. And I try to keep track of which ones I've been enlarging, which I've been shrinking, which I'm feeling guilty about, which I can forgive myself about. I find that a really useful tool for remembering the parts of life that might feel nourishing that I've been forgetting.

And purely behaviourally, I try to rest more. I force myself to see friends when I might continue working. Or to stay in, if I'm feeling perfectionistic about socialising, but actually feel rundown.

That said, I feel it's worth saying that I get a lot of it wrong still. And I think I imagined therapy would be an instant cure and you walk out of it a completely changed person. The habits are very much still there, it's just the perspective and the permission that's changed. I’m now much more aware of what I do. And sometimes I lean on old habits, because it's really tiring to try out new habits.

And now that I’m doing a master's for instance, I sometimes have to lean on old ways because I don't have the cognitive space to do the work and manage the trials of life while also trying to manage my own thoughts and behaviour. But I now have the experience of therapy, and the knowledge of those changes when I have experienced them to fall back on or feel can warn me if I need them.

Lucy: I asked Roz what the evidence base is like for CBT for perfectionism.

Roz: So, there have now been randomised controlled trials. And there have been meta-analyses showing that CBT for perfectionism works both on the perfectionism but can also be helpful for other problems like anxiety and depression. So, that's very encouraging.

Our version, Tracy and Sarah and my way of working with perfectionism, but it hasn't been really compared to more of a Hewitt and Flett's way of treating perfectionism, which is more interpersonal domain type of perfectionism. So, they have a treatment, too.

There haven't been many active comparisons, so it's not like you've got CBT for perfectionism against something else active treatment. So, IPT for perfectionism for example, you haven't got those active treatment comparisons. So, a lot of it is against weightless controls. But the data we have are positive and encouraging. And the qualitative feedback is positive, too, even from our online intervention.

We have to increase its access, I think. It's still quite niche and think about how it can be used when people have multiple difficulties. So, for us, if someone has anxiety and depression, given the state of the data you wouldn't say, "Oh well, I think it's perfectionism holding them together. I'm not going to do treatment for depression or treatment for anxiety, I'm going to go straight in with perfectionism." It can be tempting, if your clinical judgement is that's what's linking them.

But for us, I would recommend saying, "You go with your evidence-based treatment for anxiety, you see the impact. If that doesn't work, if you find that perfectionism is a barrier to change, then you come out of the existing protocol, you treat the perfectionism and then you can see what's left and go back in." So, given the state of the research, I would view the perfectionism treatment as something that you do when it's a barrier to change.

Lucy: Has your attitude towards meeting deadlines and that sort of thing changed at all through doing this work on perfectionism?

Roz: I think no, not in terms of my deadlines. But I think that I'm more forgiving of mistakes. And sometimes I use it as an excuse, I say, "Oh I work in perfectionism and it's funny to make mistakes." And I use humour, but everybody does make mistakes. I find it really difficult to use them as learning opportunities immediately. But when my emotional response to the mistake has settled down, then I'm more accepting.

Lucy: Sam calls this kind of self-forgiveness courageous kindness.

Sam: Any opportunity to forgive myself was really hard to do, but actually I think that the nastier side of perfectionism where it's harmful or dysfunctional or that kind of clinical perfectionism is driven by a kind of self-criticism. A self-punishment, if I don't meet those inflexible standards then I feel really low or angry at myself or at the world. And actually, it's hard work and feels quite crunchy to look at myself and say, "You're doing okay, that's fine." Letting myself off the hook.

I think so much of the world makes me feel that self-compassion is lazy or indulgent. And political attitudes or just I think the attitudes we all soak up, I feel that relaxing is a luxury. But the more I think about helping others, which is a much more rewarding aim for me, the more I feel I can't pour from an empty cup. And actually, forgiving myself is a cleaner, deeper kind of energising myself than this kind of slave-driven perfectionism could be.

Lucy: Thank you. Is there anything else you'd like to add?

Sam: I think for me, one of the advantages of CBT was that it could be quite clear and theoretical. My therapist showed me a map of the different ways I could fall into perfectionistic traps. So, if I met my high standards then I might raise them, and that rang so true that I'd decide they weren't high enough, that what I'd achieved wasn't that great. Or if I didn't meet the standards, which is more likely, then I'd beat myself up about that and feel low.

Or there's another fork in the road, which is not trying in the first place because it feels safer not to take the risk, that somehow adhering to some strict vision of perfectionism keeps me safe when in fact it keeps me boxed in.

And so, the clarity of that map, that I was given was a really good guide along with lots of other diagrams about the values that I felt and what I wanted to act towards.

I think talking to friends and family and reading and thinking and writing diaries and all of that is really helpful and valuable. But I think for me there was something about the complexity of different angles I could take, voices I could hear meant it was really hard for me to look at myself clearly or focus on one track to drive down.

And actually, almost the simplicity of the perfectionism model I was given in therapy, the beauty of that simple diagram – even if it feels reductive, even if some of it resonates more than others – it gave me something to focus on. And I think sometimes we need a clear path.

Lucy: Yeah, lovely. Thank you so much. That's fantastic.

Thank you to both of my experts, Sam and Professor Roz Shafran.

If you'd like more information on CBT for clinical perfectionism have a look at the show notes where I've put links to lots of the resources that Sam and Roz spoke about. I've also put a link to a questionnaire, if you're worried that you might have clinical perfectionism.

For more on CBT in general and for our register of accredited therapists, check out www.babcp.com. And have a listen to our other podcast episodes for more on different types of CBT and other problems it can help with like OCD and body dysmorphic disorder.

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