Cognitive Behavioral Model of Perfectionism (Shafran, Egan, Wade, 2010)

Description

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, despite this having negative consequences (Shafran et al., 2010). Perfectionism can arise in various life domains, including work, appearance, bodily hygiene, social and romantic relationships, eating habits, health, time management, hobbies, leisure activities, sports, orderliness, and several others (Stoeber, & Stoeber, 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 and colleagues (2002) suggest that the perfectionism observed in clinical groups (referred to as ‘clinical perfectionism’) can be distinguished 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”. Thus, clinical perfectionism is associated with four key features (Egan et al., 2014; Riley & Shafran, 2015; Shafran et al., 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. However, 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. Accordingly, perfectionism can be treated in isolation or alongside other presenting problems (e.g., disordered eating; Fairburn, 2008). 

Core symptoms of perfectionism include:

• Pursuit of standards that are highly demanding and potentially unrealistic.
• Intense fear of failure.
• Harsh self-criticism when standards are unmet.
• Use of counterproductive performance-related behaviors (e.g., excessive checking, comparison-making, or reassurance-seeking).
• Task-avoidance and procrastination.
• Marginalization of life-domains that are unrelated to perfectionism.

The high levels of perfectionism observed amongst individuals with eating disorders led Shafran and colleagues (2002) to develop the first cognitive behavioral model of perfectionism. The model was later revised to explain the role of performance-checking behaviors in perfectionism more explicitly (Shafran et al., 2010; see also Egan et al., 2014). Key components of the new 2010 model include the following. 

Self-evaluation which is overly dependent on striving and achievement: Shafran and colleagues (2002) propose that setting high standards for oneself does not account for clinical perfectionism; this is commonplace and can lead to growth and satisfaction. Rather, it is basing one’s self-evaluation on pursuing demanding standards which is maladaptive. The authors suggest this is problematic for two reasons. First, positive self-worth depends on just one 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 unmet (e.g., self-criticism). Second, positive self-worth depends upon achievements in the domain(s) where the individual holds perfectionistic standards (e.g., work), which can lead to emotional and behavioral disturbance in that area (e.g., overworking, occupational stress, and burnout). As a result, individuals with perfectionism pursue their standards relentlessly and have an intense fear of failure. 

Inflexible standards: Individuals with perfectionism pursue standards that are highly demanding. These standards have three core characteristics (Shafran et al., 2002; Shafran et al., 2010):

1. They are self-imposed. The individual views their demanding standards as their own, although they may have originated elsewhere.
2. 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 a less personally significant area, such hygiene or cleanliness.
3. They often take the form of rigid rules about how the individual should or should not perform in the domain where perfectionism exists. Examples might include “I must be at the top of the class” and “I should never make grammatical errors” (see Egan et al., 2014). Because these rules are inherently dichotomous (the rule is either met or not met), they lead to ‘all-or-nothing’ performance evaluations.

Shafran and colleagues (2002) note that while these standards are sometimes objectively demanding, their subjectively demanding nature is more pertinent in perfectionism – the standard is demanding for that individual. It is pursuing standards that are personally challenging that lead individuals with perfectionism to strive to improve and do better.

• Cognitive biases: Given the importance of fulfilling these demanding standards, individuals with perfectionism are strict judges of whether their standards have been met. These evaluations might relate to whether the individual has achieved a specific goal (e.g., being able to run a certain distance) and/or their performance while pursuing the goal (e.g., the amount of physical exertion while running). Shafran and colleagues (2002) 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: the standard is either met or unmet.

Individuals with perfectionism are inclined to believe that have not met their standards due to three cognitive biases (Egan et al., 2014):

• Dichotomous thinking (i.e., evaluating performance in all-or-nothing terms)
• Noticing the negative (i.e., paying more attention to errors)
• Discounting the positive (e.g., dismissing achievements that are less than perfect).

These biases can also apply to evaluations of one’s performance while pursuing a standard (e.g., focusing on times when a recipe was approached imprecisely and discounting instances when it was followed methodically) (Shafran et al., 2020). It should be noted that other cognitive biases also play a role in perfectionism. These include overgeneralization (“I made a spelling mistake, so I am a total failure as a person”) and double standards (“Other people can make spelling mistakes but not me”) (Egan et al., 2004). 

• Performance-related behavior: Shafran and colleagues (2002) originally proposed that individuals with perfectionism engage in ‘hypervigilant monitoring’ regarding whether they have reached their standards, which contributes to biased appraisals of performance (e.g., repeatedly checking work which raises awareness of minor flaws). They suggested that monitoring often takes the form of checking behaviors which can be overt (e.g., re-reading a draft assignment over and over) or covert (e.g., scrutinizing one’s speed or performance while writing an assignment). In their revised model of perfectionism, Shafran and colleagues (2010) separated hypervigilant monitoring from dichotomous evaluations of performance and replaced it with ‘performance-related behaviors’. These behaviors aim to assess whether standards are being met and support goal attainment. Examples include goal achievement behaviors (e.g., spending hours searching for the perfect word for an essay), performance testing (e.g., repeatedly redoing tasks), comparison-making, and reassurance-seeking (Egan et al., 2014):
• Failing to meet standards. Individuals with perfectionism are inclined to think that they haven’t met their standards due to biased appraisals of performance. This leads to intense self-criticism and overgeneralizing perceived failures to their entire self, reinforcing the idea that self-worth depends on striving and achievement.
• Avoid trying to meet standards. For some individuals, trying to meet demanding standards and the fear of failure is so anxiety-provoking that it leads to avoidance, procrastination, and giving up. These behaviors are likely to lead to actual or perceived failures, which also intensifies self-criticism and thoughts about the need to strive. Once again, the belief that self-worth is contingent on meeting high standards is reinforced.
• Using counterproductive behaviors and self-criticism. Counterproductive behaviors aim to reduce concerns about performance but often have negative consequences. Examples include excessive preparation (e.g., rehearsing a speech to the point that it becomes monotonous), being overly thorough (e.g., answering an examination question in such detail that there isn’t enough time for the others), and list-making (e.g., spending so long preparing lists that tasks are delayed). While it could be argued these are essentially “safety” behaviors, Egan and colleagues (2014) suggest the term “counterproductive” is more appropriate because their judicious use can be helpful. Similarly, perfectionistic individuals engage in self-criticism in the belief that is functional (e.g., “criticizing myself will help me avoid future mistakes”). However, self-critical appraisals reinforce the view that self-worth depends upon striving and achievement, which leads to continued striving.
• Temporarily meeting standards. Individuals with perfectionism often discount their successes (“anyone could achieve that”), which leads them to ‘set the bar higher’. In this way, meeting demanding standards does not lead to personal satisfaction or feeling good enough, reinforcing the need to pursue ever more demanding self-expectations. Moreover, resetting standards at higher and higher levels increases the risk of perceived or actual failures.
• Other maintenance factors. The original and revised models of perfectionism highlight other factors that can perpetuate perfectionism:
  • Perfectionism is sometimes reinforced by its positive consequences (e.g., praise, rewards), which outweigh or disguise its negative consequences. Perfectionism might also be encouraged or condoned within the individual’s social environment (e.g., by parents with high expectations; Shafran et al., 2002).
  • Perfectionism requires a significant amount of self-control (e.g., limiting or denying pleasurable activities which interrupt the attainment of goals). This might have the perceived benefit of simplifying the individual’s life and providing a sense of structure and direction (Shafran et al., 2002).
  • Perfectionism can have adverse consequences such as a social isolation and narrowed interests which reinforce it (e.g., increasing the time available for scrutinizing one’s performance).
  • Core beliefs and early maladaptive schemas (EMS: Young et al., 2003) are not discussed in the cognitive behavioral model of perfectionism but may be an important predisposing and perpetuating factor. For example, 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 (i.e., abandonment/instability, defectiveness/shame, emotional deprivation, mistrust/abuse, and social isolation/alienation; Maloney et al., 2014). In other words, early experiences lead to the formation of negative core beliefs, which perfectionism compensates for. This might be expressed as intermediate beliefs such as, “If I achieve certain standards, 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 model’s components fit together to maintain their perfectionism.
• Openly discussing and enhancing motivation to change perfectionism.
• Self-monitoring to help clients understand and become more aware of their perfectionism in relevant domains.
• Tailored psychoeducation related to perfectionism, such as the curvilinear relationship between stress and performance, and counter-perspectives on the common myths that maintain perfectionism (e.g., “the harder you work, the better the results”).
• Addressing cognitive biases and perfectionistic thinking using cognitive techniques. These include labeling common thinking errors in perfectionism (e.g., selective attention, double standards, overgeneralizing), disputing perfectionistic thoughts, and learning to notice the positive aspects of performance.
• Devising idiosyncratic behavioral experiments. Potential targets include addressing all-or-nothing patterns of thinking (e.g., testing out the effects of approaching tasks with flexible guidelines rather than rigid rules), evaluating the use of performance-related behaviors (e.g., reducing the use of checking behaviors), decreasing procrastination, and surveying others about beliefs and experiences that relate to the client’s perfectionism (e.g., “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.
• Procrastination and poor time management are common in perfectionism. These issues are addressed using cognitive techniques (e.g., thought records for challenging procrastination-related thinking), behavioral experiments, behavioral interventions (e.g., planning pleasurable or restorative activities), and relevant skills training (e.g., problem-solving, ‘chunking’ tasks, and improving time management through scheduling).
• Relapse prevention and future planning for a more balanced life.