Cognitive Behavioral Model Of Clinical Perfectionism (Shafran, Cooper, Fairburn, 2002)
People with perfectionism pursue high standards in one or more areas of their life and base their self-worth on their ability to achieve these standards, even though this has negative consequences (Shafran, Egan, & Wade, 2010). Perfectionism can arise in domains including: work, appearance, bodily hygiene, social and romantic relationships, eating habits, health, time management, hobbies and leisure activities, sports, orderliness, and several others (Stoeber, J., & Stoeber, F., 2009).
Working with perfectionism is complicated by the overlap between positive perfectionism (sometimes referred to as normal, adaptive, or healthy perfectionism) and negative perfectionism (sometimes referred to neurotic, maladaptive, or unhealthy perfectionism). Shafran, Cooper & Fairburn (2002) suggest that perfectionism found in clinical groups (which they refer to as ‘clinical' perfectionism) is distinguishable from the functional pursuit of excellence (positive perfectionism) by an “overdependence of self-evaluation on the detrimental pursuit of personally demanding, self-imposed standards in at least one highly salient domain, despite adverse consequences”. Accordingly, perfectionism is associated with four key clinical features (Egan et al., 2014; Riley & Shafran, 2015; Shafran, Egan, & Wade, 2010):
- Setting excessively high standards for oneself
- Continuous striving to reach goals
- Basing self-worth on meeting these standards
- Significant distress or impairment arising from the above
Perfectionism is not a formal diagnostic category, but it has been associated with multiple forms of psychopathology, including anxiety, depression, eating disorders, and suicidality (Egan et al., 2011; Limburg et al., 2017; Smith et al., 2018). For this reason, perfectionism represents a 'transdiagnostic' factor in the development and maintenance of other disorders. It is treated in isolation or alongside other presenting problems (e.g., disordered eating; Fairburn, 2008).
Core symptoms of perfectionism include:
- Pursuing standards that are highly demanding and potentially unrealistic.
- Being afraid of failure.
- Self-criticizing intensely when standards are unmet.
- Using counterproductive performance-related behaviors (such as excessive checking,
- comparison-making, or reassurance-seeking).
- Avoiding tasks or procrastinating.
- Marginalizing areas of life that are unrelated to perfectionism.
The high levels of perfectionism observed amongst individuals with eating disorders led Shafran, Cooper & Fairburn (2002) to develop the first cognitive behavioral model of perfectionism. The model was later revised to explain more explicitly the role of performance-checking behaviors – such as reassurance-seeking – in perfectionism (Shafran, Egan, & Wade, 2010). Key components of the earlier model include:
- Self-evaluation which is overly dependent on striving to meet standards. Shafran and colleagues propose that standard-setting alone does not account for clinical perfectionism, as this is commonplace and can lead to growth and satisfaction. It is basing one’s self-evaluation on the pursuit of demanding standards which is maladaptive. The authors suggest that this is problematic for two reasons. First, positive self-worth is dependent on a single area of life (i.e., striving and achievement), which leads to an intense fear of failure, continuous striving, and negative self-evaluation when these standards are not met (e.g., self-criticism). Second, positive self-worth depends upon achievements in the domain(s) where these perfectionistic standards are held, which can lead to emotional and behavioral disturbance in that area (such as through overworking, occupational stress, and burnout).
- Setting standards that are excessive. People with perfectionism pursue standards that are highly demanding. These standards have three core characteristics:
- They are self-imposed. The individual views their demanding standards as their own, even if they originated elsewhere.
- They relate to domains which are important to the individual. For example, a painter might pursue demanding standards related to artistry but is unlikely to have equally demanding standards in an area that is less personally significant, such hygiene or cleanliness.
- They often take the form of rigid rules about how the individual should or should not perform in the domain where the perfectionism exists. Examples of this include “I must be at the top of the class”, “I should never make grammatical errors” (Egan et al., 2014). Because these rules are inherently dichotomous (the rule is either met or not met), they lead to ‘all-or-nothing’ evaluations of performance.
Shafran and colleagues note that while these standards are sometimes objectively demanding, it is their subjectively demanding nature that is more pertinent in perfectionism – how demanding the standard is for that individual. Pursuing standards that are personally challenging leads people with perfectionism to strive for improvement.
- Evaluating performance in a dichotomous manner. Given the importance they place upon fulfilling their demanding standards, people with perfectionism are strict judges of whether these standards have been met. These evaluations might relate to whether the individual has achieved a specific goal (such as, being able to lift a certain weight), or their performance while pursuing the goal (such as, their physical exertion while weightlifting). Shafran and colleagues note that individuals with perfectionism sometimes view the negative consequences of striving as evidence that their standards and performance are sufficiently demanding (e.g., viewing physical pain or exhaustion as a sign of having exercised as well as possible). Moreover, the inflexible nature of these standards means that they judged in an all-or-nothing manner: either the standard is met or unmet.
Individuals with perfectionism are inclined to believe that have not met their standards due to two cognitive biases:
- Selective attention to perceived failures (i.e., paying more attention to errors)
- Discounting successes (such as dismissing achievements that are less than perfect)
These biases also apply to evaluations of personal performance while pursuing standards (such as focusing on times when a recipe was approached imprecisely and discounting instances when it was followed methodically).
- Engaging in ‘hypervigilant monitoring’ for whether they have reached their standards (Shafran, Cooper, & Fairburn, 2002), which contributes to biased appraisals of performance (for example, repeatedly checking work raises awareness of minor flaws). In an updated model of perfectionism (Shafran et al., 2010), hypervigilant monitoring was separated from dichotomous evaluations of performance and replaced with ‘counterproductive performance-checking behaviors.’ These behaviors are highly idiosyncratic and are used to assess whether standards have been met, reduce concerns about performance, and support goal attainment. Examples include goal achievement behaviors (such as excessive list making), testing performance (such as repeatedly redoing tasks), making comparisons, and seeking reassurance. While it could be argued that these are essentially safety behaviors, Egan and colleagues (2014) suggest they are better described as ‘counterproductive’, because their judicious use can support performance.
- Failing to meet standards and self-criticism. Selective attention and hypervigilant monitoring can lead to impaired performance, and increase the risk of actual or perceived failures. Failing to meet high standards causes people with perfectionism to engage in intense self-criticism and negative self-evaluation, which reinforces the belief that their self-worth depends on striving and achievement.
- Avoidance. For some people, trying to meet demanding standards and the fear of failure is so aversive that they start using avoidance behaviors, such as delaying tasks (procrastination), giving up, or avoiding activities altogether. Avoidance behaviors are likely to lead to actual or perceived failures, which intensify self-criticism and reinforce the belief that self-worth depends upon meeting standards.
- Meeting standards and subsequently reappraising them. Meeting standards reinforces perfectionism because it leads to short-term improvements in self-evaluation and, in some contexts, social rewards (such as praise, recognition, status, etc.). However, individuals with perfectionism often view their achievements as evidence that their standards are not demanding enough (“If I can meet my standards, they must be too low”), which leads them to ‘set the bar higher’. In this way, meeting these standards does not lead to personal satisfaction, but reinforces the need to pursue ever more demanding standards. Moreover, resetting standards at higher and higher levels will increase the risk of perceived or actual failures.
- Other maintenance factors. The original and revised models of perfectionism describe other factors which perpetuate perfectionism:
- Perfectionism is reinforced by its positive consequences (such as praise and rewards) and functionality, such as simplifying life choices, providing structure and direction, and helping to avoid threats. For example, perfectionistic striving may mean that an individual does not have time to pursue intimate relationships, thereby avoiding the risk of rejection.
- Perfectionism requires a significant amount of self-control, such as limiting or denying pleasurable activities which interrupt the attainment of goals (Shafran, Cooper, & Fairburn, 2002). As such, a relationship may exist between the need for control, intolerance of uncertainty, and perfectionistic striving.
- Positive metacognitive beliefs maintain self-critical responses to perceived failures. For example, individuals may believe that self-criticism will prevent them from repeating mistakes or motivate them to improve their performance.
- Core beliefs and early maladaptive schemas (EMS) are not discussed in the cognitive behavioral model of perfectionism but may be an important predisposing and perpetuating factor (Young, Klosko & Weishaar, 2003). Research suggests that perfectionism is associated with high parental expectations and criticism, and that this relationship is mediated by EMS in the domains of rejection and disconnection such as cases of abandonment or instability, defectiveness or shame, emotional deprivation, mistrust or abuse, and social isolation or alienation (Maloney et al., 2014). In other words, early experiences lead to the formation of negative core beliefs and, subsequently, compensatory perfectionism in the form of intermediate beliefs (e.g., “If I achieve certain standards, then I am lovable as a person”).
Interventions that form part of CBT for perfectionism include:
- Helping clients develop specific and measurable goals for therapy.
- Developing an idiosyncratic version of the formulation, and helping clients understand how the components of the model fit together to maintain their perfectionism.
- Openly discussing and enhancing the client’s motivation to change perfectionism.
- Self-monitoring to help clients understand and become more aware of their perfectionism in relevant domains.
- Giving tailored psychoeducation related to perfectionism, such as the curvilinear relationship between stress and performance, and counter-perspectives on the common myths that maintain perfectionism (such as “the harder you work, the better the results”).
- Addressing cognitive biases and perfectionistic thinking using cognitive techniques. These include labeling thinking errors commonly found in perfectionism (such as selective attention, double standards, or overgeneralizing), disputing perfectionistic thoughts, and learning to notice the positive aspects of the client’s performance.
- Devising idiosyncratic behavioral experiments. Potential targets include addressing all-or-nothing patterns of thinking (e.g., by testing out the effects of approaching tasks with flexible guidelines rather than rigid rules), evaluating the use of performance-related behaviors (e.g., by reducing the use of checking behaviors), decreasing procrastination, and surveying others about beliefs and experiences that relate to the client’s perfectionism (e.g., asking “Do other people make mistakes at work and how do they feel about themselves when they do this?”).
- Broadening the ways in which individuals evaluate themselves. This might include examining the costs and benefits of basing self-evaluation on achieving standards, exploring the origins of this scheme for self-evaluation, and developing a new scheme for judging self-worth.
- Reducing performance-related self-criticism. The cognitive behavioral model suggests that self-criticism perpetuates perfectionism by undermining self-esteem and reinforcing the need to maintain self-worth through striving and achievement. Self-criticism is addressed by exploring its negative consequences, re-evaluating positive beliefs about self-denigration, and developing compassionate responses.
- Addressing procrastination and poor time management directly. These issues are common in perfectionism, and can be addressed using cognitive techniques (such as thought records for challenging procrastination-related thinking), behavioral experiments, behavioral interventions (such as planning pleasurable or restorative activities), and relevant skills training (such as problem-solving, ‘chunking’ tasks, and improving time management through scheduling).
- Preventing relapses and planning for a more balanced life in future.
“It would be helpful if we could explore and understand how your perfectionism has developed and what is keeping it going. Could we explore some of your thoughts, feelings, and behaviors, to see what kind of pattern they follow?”
1. Set standards.
Help the client identify one or two life domains in which they set high standards for themselves. If the client struggles to do this, explore some of the general areas in their life where high standards might exist (such as work, relationships, appearance, weight, finances, etc.) or where difficulties are reported. Next, help the client specify some of their high standards in each domain. Perfectionistic standards usually take the form of strict and inflexible ‘should’ or ‘must’ rules related to achievement and performance.
- Can you tell me about one or two areas of your life where you set yourself high standards?
- In what situations does your perfectionism seem strongest?
- Do you set yourself high standards in relation to your [work / studies / appearance / eating / weight / exercise or fitness / relationships / cleanliness / interests or hobbies]?
- What rules help you achieve your standards in that area?
- What must you do (or not do) in that aspect of your life to achieve your standards?
2. Explore how striving to meet these standards affects the client’s self-evaluation.
People with perfectionism base their self-worth largely (or solely) on striving to achieve their standards. Once the client has identified some of their high standards, work ‘up’ the formulation and explore how their pursuit of these standards is linked to their self-evaluation. This will often take the form of conditional assumptions (such as “If I don’t succeed at work, I am worthless”) or overvalued beliefs (such as “Feeling good about myself depends upon being a perfect parent”) which relate self-worth to striving and achievement. Alternatively, the Multidimensional Perfectionism Cognitions Inventory (Stoeber et al., 2010) can help clients identify underlying beliefs and assumptions related to perfectionism.
- What makes achieving your standards so important?
- How much does your self-esteem seem to depend on meeting your standards?
- What would it say about you if you didn’t meet your standards?
- Can you finish the following sentence for me: “If I don’t to meet my standards, it means…”.
3. Highlight dichotomous evaluations of performance.
Strict and inflexible standards lead people to make dichotomous judgments about whether they have achieved their standards. The therapist’s task is to demonstrate how the client evaluates their standards in an extreme, ‘black-or-white’ manner: the standard is either met or not met. Note that clients’ evaluations may relate to meeting certain standards, or their performance when attempting to do so (e.g., how hard they worked to achieve their goal). When you’re trying to meet your standard, how do you judge your performance?
- Do you judge yourself and your performance in a success-or-failure kind of way?
- Are you strict on yourself when you think about whether you’ve met your standards, or how hard you’ve worked?
- When you believe you’ve failed, have other people ever said anything different?
4. Explore the client’s selective attention to failure and hypervigilant monitoring.
This part of the model describes two processes which reinforce the client’s dichotomous performance evaluations: selective attention (noticing the negative and discounting the positive) and hypervigilant monitoring of performance (such as checking behaviors). These information processing biases may increase the risk of actual (objective) failures and perceived (subjective) failures to meet standards (Shafran, Cooper, & Fairburn, 2002). If the client is unaware of their performance-related behaviors, the therapist can describe some which might be relevant (e.g., “Do you ever [check/scrutinize/compare/seek reassurance] when attempting to meet your standards?”). Alternatively, the behavioral domains questionnaire (Lee et al., 2011) describes common perfectionistic behaviors, including excessive checking, preparation, and comparison-making. Note that checking and other performance-related behaviors can be overt (such as repeatedly re-reading a piece of work), or covert (such as replaying a conversation multiple times to assess one’s social performance).
- Do you find it easier to notice things you have done well? Or things that you have done badly? How does that affect your judgments about whether you’re meeting your standards or not?
- Do you find it easy to notice the good parts of your performance?
- How do you make sure you’re doing things to a high standard? Do you have ways of checking or monitoring your performance? Do you ever compare yourself to other people or ask for reassurance? Are you very detailed or excessively thorough in your approach to tasks and activities?
- Do the things you do to monitor your performance ever seem to interfere with your performance, or make you more worried that you’re not meeting your standards? How do you feel about yourself when that happens?
5. Examine the effect of failing to meet these standards and criticizing oneself.
Demanding standards, biases in information processing, and counterproductive performance-related behaviors increase the risk of actual or perceived failures. Help the client explore how they react when their high standards have not been met (or when they think that they have not been met). These will usually take the form of self-critical thoughts that undermine the client’s self-esteem, and reinforce the idea that positive self-worth depends upon achieving high standards.
- Can you think of a recent time when you failed to meet your standards? What went through your mind? How did you react?
- What do you say to yourself when you don’t meet your standards? Are you hard on yourself?
- How does self-criticism make you feel about yourself?
- How do you try to feel better when you don’t meet your standards? Does striving harder to meet them next time seem to be the solution?
6. Explore how the client reacts when they meet their standards.
When standards are met, individuals with perfectionism tend to discount these achievements (e.g., “Anyone could do that”) and view their standards as insufficiently demanding (e.g., “It was too easy”). Consequently, they reset their standards at higher and higher levels. Explore how the client reacts in situations where their standards have been met, perhaps using a recent example. Did they feel satisfied and able to relax? Or did they set the bar at a higher level? Illustrate how discounting successes and resetting standards contributes to feelings of not being good enough, and perpetuates striving. Note that some individuals may not have had the experience of meeting their standards.
- Can you think of a time when you did meet your high standards? What went through your mind? How did you react?
- Did you accept and celebrate your achievement, or discount it as too easy, unimportant, or think that anyone could do it?
- How does discounting your achievements affect your standards? Do you feel like setting the bar even higher for yourself the next time around?
7. Examine the effects of avoidance.
Demanding standards sometimes make tasks so unpleasant to complete, or create such intense worry about failure, that they lead to avoidance behaviors. These might take the form of delaying tasks (such as procrastination), abandoning them prematurely, or avoiding them entirely. Unfortunately, avoidance can increase self-criticism and the client’s worries about failing, and reinforce the value they place on meeting high standards to feel worthy.
- Do you ever avoid, delay, or give up on things because you’re worried you might fail or get them wrong?
- How do you feel about yourself when that happens? Does it make your self-criticism or worries about failing better or worse?
- When you avoid meeting your standards, does it seem more or less important that you achieve them in the future?
- Egan, S. J., Wade, T. D., & Shafran, R. (2011). Perfectionism as a transdiagnostic process: A clinical review. Clinical Psychology Review, 31, 203-212.
- Egan, S. J., Wade, T. D., Shafran, R., & Antony, M. M. (2014). Cognitive-behavioral treatment of perfectionism. Guilford Press.
- Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford Press.
- Lee, M., Roberts-Collins, C., Coughtrey, A., Phillips, L., & Shafran, R. (2011). Behavioral expressions, imagery and perfectionism. Behavioural and Cognitive Psychotherapy, 39, 413-425.
- Limburg, K., Watson, H. J., Hagger, M. S., & Egan, S. J. (2017). The relationship between perfectionism and psychopathology: A meta-analysis. Journal of Clinical Psychology, 73, 1301-1326.
- Maloney, G. K., Egan, S. J., Kane, R. T., Rees, C. S. (2014). An etiological model of perfectionism. PloS One, 9, e94757.
- Riley, C., & Shafran, R. (2005). Clinical perfectionism: A preliminary qualitative analysis. Behavioural and Cognitive Psychotherapy, 33, 369-374.
- Shafran, R., Cooper, Z., & Fairburn, C. G. (2002). Clinical perfectionism: A cognitive-behavioral analysis. Behaviour Research and Therapy, 40, 773-791.
- Shafran, R., Egan, S., & Wade, T. (2010). Overcoming perfectionism: A self-help guide using cognitive behavioural techniques. Constable and Robinson.
- Smith, M. M., Sherry, S. B., Chen, S., Saklofske, D. H., Mushquash, C., Flett, G. L., & Hewitt, P. L. (2018). The perniciousness of perfectionism: A meta-analytic review of the perfectionism-suicide relationship. Journal of Personality, 86, 522-542.
- Stoeber, J., Kobori, O., & Tanno, Y. (2010). The Multidimensional Perfectionism Cognitions Inventory – English (MPCI-E): Reliability, validity, and relationships with positive and negative affect. Journal of Personality Assessment, 92, 16-25.
- Stoeber, J., & Stoeber, F. S. (2009). Domains of perfectionism: Prevalence and relationships with perfectionism, age, gender, and satisfaction with life. Personality and Individual Differences, 46, 530-535.
- Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. Guilford Press.