Clinical perfectionism: when striving for excellence gets you down

We all know a perfectionist – the person we live with, share an office with, or are friends with, who has agonisingly high standards and is disappointed when things fall short. It might even be you. It’s often harmless enough.

But for some people, this perfectionism is taken to an extreme level, and interferes with their ability to work, study or maintain relationships. This is known as clinical perfectionism.

Clinical perfectionists constantly strive for ambitious goals and judge their self-worth on the achievement of these goals. Not meeting these goals, whether realistic or not, is met with a barrage of self-criticism and loathing.

Some clinical perfectionists avoid or procrastinate because they fear not being able to meet their desired standards.

Clinical perfectionism is not listed as a disorder per se in the diagnostic manuals, but it can increase the risk for a number of disorders, including depression, anxiety and eating disorders.

How common is it?

We don’t know the prevalence among adults, but we have some data for young people.

One in four Australian adolescents are self-critical when standards are not met. Around 1.6% of boys and 3.4% of girls experience clinical perfectionism most or all of the time.

When should you get help?

Clinical perfectionists often don’t see themselves as perfectionists because they believe they can’t do anything perfectly. So, they’re surprised at how well the description fits them.

Take Lisa, for example, who presented for treatment for an eating disorder. She had been kicked out of university for repeatedly failing all her subjects and not responding to a “please explain” letter.

Lisa feared not doing her work perfectly and not being the perfect student, so she had not handed in work she had done and had avoided attending tutorials. She didn’t withdraw from her subjects, as that would be an acknowledgement of failure.

She found it impossible to respond to the “please explain” letter as she felt she could not explain her situation eloquently enough.

Around 3.4% of girls have clinical perfectionism. Matej Kastelic/Shutterstock

Another example is Daniel, a health professional with a busy private practice. He would schedule long appointments with clients to make sure he didn’t miss any important details, and stayed back for hours after everyone else left to complete detailed case notes.

Daniel often came into work the next day tired, and was unable to keep up with the same client load as his colleagues. This led to an unpleasant staff meeting where he was accused of not pulling his weight, and was threatened with dismissal.

It’s human nature to delay getting help until the situation has become intolerable. But in situations such as these, or when perfectionism is leading to low mood, suicidal thoughts, intense anxiety states, or disordered eating, it’s time to get help.

How is it treated?

Clinical perfectionism is treated with specific type of cognitive behaviour therapy (CBT).

This first involves educating the person about the difference between useful and clinical perfectionism, the damaging aspects of clinical perfectionism, and how it can actually make it less likely people will achieve their goals.

Each person then develops a personalised case plan. From this, goals are set collaboratively with the therapist.

Therapists encourage clients to experiment with different ways of approaching their goals, and to have flexible standards and self-compassion rather than self-criticism. They also try to eliminate procrastination and avoidance.

The therapist helps the client compare the outcomes of approaching goals in this new way compared to the old way. There is also an emphasis on developing self-worth that is not completely contingent on achievements.

This approach has been shown to reduce clinical perfectionism and mental health problems when done in group format, one-to-one therapy, or guided self-therapy.

Among adults who were already in treatment for a variety of mental health problems, one study found that group therapy not only reduced clinical perfectionism, but also significantly reduced levels of self-criticism, anxiety, depression and stress.

Where to start

If you think you’re experiencing clinical perfectionism and it’s leading to psychological difficulties, talk to your general practitioner, who can refer you to a psychologist who has expertise in cognitive behaviour therapy.

Alternatively, a self-help book is available, which you can work through on you own or with a counsellor.