Received: 26 May 2020 | Revised: 11 July 2020 | Accepted: 5 August 2020

DOI: 10.1002/jclp.23047

CLINICAL CASE REPORT

Struggling with perfectionism: When good

enough is not good enough

James Overholser1 | Giancarlo Dimaggio2

1
Department of Psychology, Case Western
Reserve University, Cleveland, Ohio, USA
2
Center for Metacognitive Interpersonal
Therapy, Rome, Italy
Correspondence
James Overholser, Department of
Psychology, Case Western Reserve
University, Psychology, Cleveland, Ohio,
44106‐7123, USA.
Email: overholser@case.edu
Abstract
Perfectionism includes a tendency for high standards for self
and others with a clear goal of successful performance in a
variety of areas. A perfectionist often reacts with critical
evaluations whenever performance falls below these stan-
dards. Moreover, perfectionists emphasize personal goals to
gauge their worth, neglecting intimate bonds or openness to
new experience. At the core of perfectionism lies a view of
self as weak, flawed, and easily rejected. Perfectionism can
result in chronic tendencies for emotional distress and in-
terpersonal conflict. Treatment aims to explore personal
views of self and others, viewing perfectionism as a form of
maladaptive coping. When clients understand the role of
perfectionism, they can discontinue striving to meet their
extreme goals and unrealistic standards. The authors of
the papers in the issue present their views on how to treat
these maladaptive tendencies according to their preferred
therapeutic orientation.

KEYWORDS
perfectionism, psychotherapy, psychotherapy process

1 | INTRODUCTION

Perfectionism involves the creation of excessively high standards (Shafran & Mansell, 2001) often combined with
high expectations and critical evaluations, resulting in unrealistic standards for performance and outcome.
Perfectionistic tendencies often include setting high standards, striving for excellence, and intolerance of mistakes
(Smith, Sherry, Vidovic, Hewitt, & Flett, 2020). These expectations and evaluations can be directed toward self and
others. Hewitt and Flett (1993) have explored three dimensions of perfectionism and identified patterns related to
the direction of the person's standards and expectations. Some perfectionist attitudes focus on the individual's

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2 | OVERHOLSER AND DIMAGGIO

personal goals, achievement standards, and criteria for evaluating one's accomplishments. Such self‐oriented
perfectionism often pushes the person to strive for excellence in all or most areas. A different type of perfectionist
attitude is directed toward the people in the person's life. Such other‐oriented perfectionism involves setting high
standards and expectations for others, with a tendency toward hostility and blaming others. Finally, socially
prescribed perfectionism involves the belief that other people expect you to be flawless. Socially prescribed
perfectionism is associated with a tendency to attribute blame to external causes (Flett, Hewitt, Blankstein, &
Pickering, 1998). These assorted perfectionistic tendencies can be ego syntonic, as clients believe their high
standards help to improve their functioning, despite causing frequent feelings of distress and inadequacy.
At the core of perfectionism lies a view of self as weak, flawed, and easily rejected. Often implicitly,
persons high in perfectionism may believe that if they fix their flaws, then others will accept them and
recognize their talent. Fearing that others would not accept their true flawed self, they aim for perfection as a
means of gaining acceptance from self and others. When persons are unable to meet these high standards, they
become vulnerable to negative emotions and self‐criticism which may trigger their request for psychotherapy
(Besser, Flett, & Hewitt, 2004).
Perfectionism can be viewed as a kind of dysfunctional coping, used to deal with the idea that others are
criticizing or rejecting them. Adopting perfectionism as a coping strategy has a negative impact on clients, even
when they are sometimes praised for their high level of performance. They may learn they will not be accepted for
who they are but only if they continually appear skilled and flawless. Perfectionism makes a person prone to worry
(Santananello & Gardner, 2007) and other forms or repetitive thinking (Macedo et al., 2015). As the person
struggles to meet their own high expectations, worry triggers a tendency to procrastinate (Rozental et al., 2018)
and avoidnegative experiences (Santananello & Gardner, 2007).
Tendencies for perfectionism may be a transdiagnostic factor involved in assorted emotional problems and
personality disorders. Thus, research has found that perfectionism is involved in the struggles of patients who have
an eating disorder (Dahlenburg, Gleaves, & Hutchinson, 2019; Shafran & Mansell, 2001; Shafran, Cooper, &
Fairburn, 2002), obsessive‐compulsive disorder (Frost & Steketee, 1997), social phobia (Lundh, Saboonchi, &
Wangby, 2008), and panic disorder with agoraphobia (Hewitt & Flett, 1991). Furthermore, perfectionistic ten-
dencies can be seen in obsessive‐compulsive personality disorder (Halmi et al., 2005) and narcissistic personality
disorder (Dimaggio & Attina, 2012). Research suggests that perfectionism is involved in most forms of personality
pathology in both clinical (Dimaggio et al., 2018) and nonclinical samples (Ayearst, Flett, & Hewitt, 2012). Trait
perfectionism has been related to self‐generated stress (Flett, Hewitt, & Nepon, 2020). In contrast, non‐
perfectionists report better scores on measures of health and well‐being (Molnar, Sirois, Flett, & Sadava, 2020).
Perfectionism has been found to play an important role in depression (Hewitt & Flett, 1991; Shahar, Blatt,
Zuroff, & Pilkonis, 2003; Zuroff et al., 2000). Both self‐oriented and socially prescribed perfectionism has been
found predictive of depressive symptoms (Smith et al., 2020). Self‐oriented perfectionism and achievement stress
increase the risk of depression (Hewitt, Flett, & Ediger, 1996), and seem especially related to chronic unipolar
depression (Hewitt, Flett, Ediger, Norton, & Flynn, 1998). Perfectionism may trigger depression through social
disconnection (Smith et al., 2020) and difficulties accepting past negative events (Smith et al., 2020). Depression in
socially prescribed perfectionism involves rumination and difficulty accepting past events (Smith et al., 2020).
Higher levels of perfectionism have been related to hopelessness (O'Connor & O'Connor, 2003), self‐injurious
behaviors (O'Connor et al., 2007), as well as suicidal ideation and attempts (O'Connor, 2007; Smith et al., 2018). As
compared to medical inpatients, suicide attempters reported the belief that others imposed perfectionistic stan-
dards on their behavior (Hunter & O'Connor, 2003) Furthermore, among patients with alcohol dependence, suicide
risk is associated with other‐oriented perfectionism and socially prescribed perfectionism (Hewitt, Norton, Flett,
Callander, & Cowan, 1998).
Results from a recent meta‐analysis (Curran & Hill, 2019) suggest that tendencies for perfectionism have
been increasing over the past 30 years. A recent study (Molnar et al., 2020) found that extremely elevated
levels of perfectionism can be fairly common in college students (14%) and patients with a chronic illness
OVERHOLSER AND DIMAGGIO | 3

(17.6%). The present manuscript is an attempt to synthesize the published literature with many years
of clinical experience providing cognitive‐behavioral and third‐wave psychotherapy sessions to clients who
report high levels of perfectionism.

2 | T R EA T M EN T O F P E R F EC T I O NI S M

Psychological treatments can be used to reduce perfectionist tendencies as well as the associated psychological
problems (Glover, Brown, Fairburn, & Shafran, 2007; Lloyd, Schmidt, Khondoker, & Tchanturia, 2014). Reducing
perfectionism may bring about a subsequent reduction in the person's secondary psychosocial disturbances
(Rozental et al., 2018). Therapy can help clients to understand the secondary problems that arise from
perfectionism (e.g., periods of moodiness, frequent interpersonal conflict) as a means of motivating them to find
new ways of behaving (Kutlesa & Arthur, 2008). However, with the current state of the field, psychological
treatments seem to have only a modest impact on levels of perfectionism (Rozental et al., 2018). Future research
may improve this situation.
There is room for optimism. Even short‐term approaches to therapy can help to reduce tendencies for
perfectionism (Dodd et al., 2019; Lloyd et al., 2014) though it can be difficult to produce consistent changes
(Chik, Whittal, & O'Neill, 2008). Given the established link between perfectionism and anxiety or depression, one
may ask if therapy must target symptoms or is it better to address the underlying perfectionistic tendencies.
Therapy appears to be more effective when targeting the processes that underlie perfectionism instead of directly
targeting concomitant anxiety or depression (Ong et al., 2019).
Perfectionism is more than a problem per se, as it has been found related to poor psychotherapy outcome
(Shahar et al., 2003; Zuroff, Chen, Smith, Zhang, Habke, Flett & Mikail, 2000), possibly due to disruptions with the
therapeutic alliance (Hawley, Ho, Zuroff, & Blatt, 2006; Hewitt et al., 2020). One study found that other‐oriented
perfectionism played a role in premature discontinuation of treatment for cocaine abuse (McCown & Carlson,
2004). Patients may think they are not doing well and then withdraw, they can expect too much from the therapy
and the therapist and lose trust in the process or harshly criticize the clinician, or ultimately, they do not commit
themselves to useful therapy tasks (e.g., behavioral experiment) either because they think they are not up to them
or because they think the task itself is not valued. Many clients fail to engage with therapy and complete the
assigned tasks, and the less involvement with the treatment strategies, the less improvement seen in client
progress (Shafran et al., 2017). Nonetheless, even when therapy ends prematurely, clients are likely to gain some
improvement from sessions devoted to taming their perfectionist tendencies (Shafran et al., 2017).
The strength of the therapeutic alliance predicts change in perfectionism over the course of therapy
(Hawley et al., 2006). However, the long‐standing characterological nature of perfectionist tendencies makes it
much more difficult to change in therapy (Chik et al., 2008). When clinicians see perfectionistic clientsas hostile or
uncooperative, the therapeutic relationship will suffer and it becomes more difficult to engage the client in the
session dialogue. When clients are reluctant to disclose their imperfections in session, they may be rated poorly
by clinicians (Hewitt et al., 2020), likely being seen as guarded or uncooperative. Furthermore, people with
perfectionistic tendencies are less cooperative with behavioral assignments that cleints are asked tocomplete
between sessions, often starting their “homework” late and being less likely to complete the activity (Kobori,
Dighton, & Hunter, 2020).
Therapy can be guided by a general goal; to improve the client's flexibility and tolerance toward self and others
(Hewitt, 2020). Likewise, treatment of perfectionism can be guided by the “principle of good enough” (Ratnaplan &
Batty, 2009). Clients can be helped to appreciate that in some situations, aiming for the highest standards can be
counterproductive and potentially harmful (Ratnaplan & Batty, 2009). Furthermore, “good enough” is not equated
with mediocre levels of performance, but a rational choice to choose how much energy should be invested in a
project (Ratnaplan & Batty, 2009). Therapy can help clients to establish realistic priorities. Thus, some tasks
4 | OVERHOLSER AND DIMAGGIO

deserve the client's full attention aiming for high‐quality performance, while many other responsibilities can be
handled with a modicum of effort.
Perfectionism often results in interpersonal difficulties, as the client usually sets high standards for their own
behavior as well as the actions of other people. For example, an adult client treated by one of us (J.O.) had
struggled with a series of failed romantic relationships. These romances often ended because the client became
dissatisfied with a string of minor annoyances. In session, the client was asked to rate how well things were going
with her current boyfriend. She replied, “80% of it seems pretty good, but the other 20% is still a struggle.”
Throughout the rest of the discussion, she was encouraged to see that 80% is a good score, no matter what is being
rated. However, if she continued to focus on the 20% where she was dissatisfied, her perspective would act like a
magnifying glass, creating an image that appeared much larger than reality. She was encouraged to see that she
had the power to control her view, and to realize that even a good, strong, lasting romantic relationship will
continue to have areas of disagreement or discord.
Perfectionistic clients often identifylofty personal goals and high standards for their performance. Setting high
standards becomes a problem when it reaches the level of a demand and an unwillingness to accept a less than
perfect outcome (Lundh, 2004). Therapy can increase the client's awareness of common problems associated with
perfectionism (Kutlesa & Arthur, 2008). A cost–benefit analysis can be used to highlight the assorted costs of high
standards (Rozental et al., 2017). Clients can learn to switch from an idealistic view to a more pragmatic stance,
realizing that different chores deserve different levels of investment. For many chores, it can be useful to do it
quickly and be done with it instead of setting high standards that require extensive time and effort.
Therapy can aim to confront and reduce a client's tendency for repetitive and unconstructive thoughts about
self (Smith et al., 2020). Some perfectionists display a tendency to spend excessive time reviewing past situations
that reveal personal imperfections and then ruminating about mistakes (Flett et al., 2020). Clients with perfec-
tionism tend to review prior struggles and mistakes, or they worry about how to avoid future criticism. In both
cases, this paves the way toward obsessions and compulsions and many other aspects of psychological distress
(Macedo et al., 2015). These perfectionistic automatic thoughts have been found to influence subsequent de-
pressive symptoms (Besser, Flett, Sherry, & Hewitt, 2020). Therapy can help clients become more aware of their
automatic thought processes and gain control over these negative habitual reactions.
Clinicians from a cognitiveorientation suggest that important attitudinal changes can be triggered through
thoughtful and provocative questions. Some questions can be used to confront different standards across different
locations. For example, in this cognitive perspective, clients can be asked: “Do you hold similar high standards at
work and at home?”; “Are you something of a perfectionist when it comes to schoolwork?”; “How about when
playing sports with friends?”; “Is there any area where you usually take a more laid‐back approach?” It can be useful
to help clients to respect the negative consequences that arise from their perfectionist tendencies (Egan, Pick,
Dyck, Rees, & Haggar, 2013). Questions can be used to adjust the perceived magnitude of a situation. For example,
clients can be asked: “Is this situation worth an argument?”; “Is this situation really worth getting a headache?”; “Is
it worth the risk of possibly having a stroke over it?”; “Is it likely that this situation is big enough that it will make it
on the evening news?”; “If we let things go as they are going now, it likely that someone will end up in the hospital
or the morgue, or could everything end up okay?” Questions can be used to confront different values, varying the
perception by person. For example, clients can be asked: “Do you know other people who have similar high
standards?”; “Do your friends and family members agree that you need to set your goals this high?”; “If your son or
daughter were struggling with this issue, what would you say to them?”; “What might your best friend tell you to do
in this situation?” Finally, questions can be used to change the perspective across time. For example, clients can be
asked: “How much will it matter in five days?”; “Do you think you will even remember this situation in five years?”;
“If we jump ahead 50 years, when you are old and sickly, maybe even on your death bad, how much will these
things matter?” Another way to work at a cognitive level involves helping the client see the potential humor in a
challenging situation by carrying the expectations out to extreme levels, thereby highlighting the flawed logic that
underlies most perfectionist beliefs.
OVERHOLSER AND DIMAGGIO | 5

People high in perfectionism may tend to react to failure experiences as a reflection on their overall view of
self (Besser et al., 2004). It can be useful to explore the developmental origins of perfectionist standards (Besser
et al., 2004). Adult clients often report difficulties during their own childhood, when they endured endless criticism
from parents, frequent and harsh comments about school performance, athletic abilities, and musical talent, even if
their performance was actually good. Other memories are instead related to causing suffering to others when they
were less than perfect. An example is a woman in her 40s treated by one of us (G.D.) who held memories in which
her maternal grandmother had serious medical problems. The client described many memories in which she had to
be the “perfect girl” at home and at school. The client wanted to avoid creating further troubles with her mother
who was struggling with depression and caring forthe client's grandmother. The client described how her younger
sister had problems at school and her mother reacted with profound sadness and disappointment, stating:
“I already have a lot of problems and you give me more troubles.” The client developed the belief that she had to
avoid making her mother suffer and creating disappointment like her sister had done. Perfectionism became her
strategy to avoid feelings of guilt, but also created fear when she realized her mother would still become depressed
and shut herself in her room.
Therapy should not simply focus on reducing the client's symptoms (Hewitt et al., 2020). Central to their
struggles, perfectionists often view themselves as inferior, both in terms of performance and moral standards,
which creates a fear of making a mistake or receiving criticism and make them prone to experience shame when
they think their flaws have been unmasked (Jahromi, Naziri, & Barzegar, 2012) or feelings of guilt when they felt
they caused suffering (Dimaggio, Ottavi, Popolo, & Salvatore, 2020). For example, an adult female treated by one of
us (J.O.) struggled with chronic depression. Her mother lived nearby. When the client was at work, the mother
would enter the client's home and leave notes for the client to read later, usually criticizing the cleanliness of the
home or the grades achieved by the children. It was clear that the client had internalized these critical attitudes,
and accepted the criticism without evaluation. It took many examples confronted across numerous sessions before
the client was able to see the long‐standing cognitive patterns and begin to externalize her mother's critical voice.
Once externalized, it became easier to tone down the volume of these critical self‐statements.
Positive reframing can help to shift the perfectionist's view of failures and instead focus on partial accom-
plishments, remember times in which they experienced success or satisfaction, or review activities in which they
did not evaluatethe quality of a performance because theyfelt fulfilled by what they were doing. Clients can be
helped to realize they were able to learn lessons from difficult situations (Stoeber & Janssen, 2011). For example,
an adult client treated by J.O. had a hobby making small woodcarvings he often shared with hisfriends. When he
first ventured into selling his handiwork, he nervously signed up for a local craft show. Upon arrival, while setting
up his stall, he noticed others nearby who were selling similar objects. He told himself “Why bother, I may as well
go home, my stuff looks crummy in comparison.” However, because of prior discussions in therapy, he told himself
that he would stick it out, reminding himself “What do I have to lose? I already paid my registration fee.” Before
long, customers were purchasing his product and congratulating him for his talent. During his next session, he
admitted telling himself “If I had left when I wanted to quit, I would have never believed I could be successful here.”
A different strategy to address perfectionism involves not targeting it directly, but consider it a form of
maladaptive coping connected to core ideas of self as inferior, worthless, neglected or causing suffer to others. In
this vein, the clinician may ask the client to abstain from unproductive coping such as avoidance, workaholism,
procrastination, and self‐sacrifice. Then, the clinician can explore ideas and feelings that may emerge when
blocking these maladaptive tendencies. Very often, the core self‐appraisal re‐emerges, triggering feelings of shame,
guilt, sadness, and anxiety. Then, the clinician canexplore alternative self‐images, ones when the individual is
capable of self‐acceptance, self‐compassion, or is able to connect oneself to one's very own cherished wishes and
preferences and realize he or she does not have to comply with other expectations to have a sense of worthiness
and to deserve love. Individuals may discover than when they devote time to activities they enjoy without
evaluating their skill, accomplishment or performance, they feel more relaxed and content (Dimaggio, Montano,
Popolo, & Salvatore, 2015; Dimaggio et al., 2020).
6 | OVERHOLSER AND DIMAGGIO

Behavioral strategies can be used to encourage change through graded exposure (Rozental et al., 2017),
such as when a client is asked to aim for a suboptimal level of performance. Subsequent discussions can elicit
and confront emotions and attitudes when performance falls below the highest standards. Clients can be asked
to include a deliberate flaw, arriving intentionally late for something relatively harmless like fixing dinner or
meeting a friend for coffee. The event is meant to confront and highlight the client's beliefs, allowing closer
scrutiny during the next session. Similar to exposure therapies, clients can be helped to confront feelings
of discomfort in situations they typically avoid and be helped to regulate them without resorting again to
perfectionistic coping. Clients can be helped to discover they can learn to regulate core feelings of guilt, shame,
sadness or anxiety. Useful strategies include ones from mindfulness training (James & Rimes, 2018) and
attention training (Dimaggio et al., 2020).
Therapy can help clients to achieve balance instead of striving for extreme levels of success. When clients
achieve a high level of success at work or school, it often reflects a major investment of their time, which
may be attained at the cost of time spent with family, friends, or enjoyable nonproductive activities. Clients
can be helped to seek balance across work versus home, productivity versus relaxation. Extreme levels of
accomplishment in one area can be used to identify other areas that have been neglecting, reflecting a life that
is out of balance.
Working through perfectionism in the therapeutic relationship may be helpful. In our experience,
therapists' self‐disclosures are particularly beneficial. Therapists may openly tell about their own struggles,
failures or situations when they performed poorly to show they are not defensive in telling these stories
to the client. However, the therapist should be careful that these examples are not misconstrued as
lecturing the client, or misinterpreted as a form of admonishment and superiority (e.g., “My therapist is
better than me at tolerating failure, which shows I'm less than her”). Conversely, clinicians may disclose
personal experiences where they failed at a task or were awkward in a social situation and then experienced
shame or guilt or sorrow and just let the clients express their own opinions. Very often, this helps the client
to appreciate that flaws are part of being human, which is a basis to consider their own mistakes are normal
and acceptable.

3 | C O N CL U S I O N S

With many clients, it can be useful to encourage a tendency to aim high, work hard, and push self toward high
standards for evaluating performance. However, these same standards will be destructive when used too often.
High standards can be adaptive to a point, but most situations benefit from a more moderate approach. Even when
it may not be universally effective, treatment can help to confront and change perfectionistic tendencies in some
clients (Egan & Hine, 2008). Therapy can help clients to focus on self‐improvement, suppress tendencies to be
critical of others and focus on wishes related to autonomy, exploration, connection with others or group belonging
instead that only aiming to reach high goals and unrelenting standards.
Therapy with a perfectionist client can be challenging. Effective therapy requires patience, persistence, and
sometimes a playful attitude to gently provoke a response from the client. It takes time and repetition before
clients can accept the wisdom of “good enough.” However, therapy can be gratifying for client and therapist alike,
especially when “good enough” releases the client from their self‐imposed burden of shame, guilt, and self‐imposed
blame and opens the way to reaching for things they do like and feel as deeply own. At the core of effective
therapy lies a sound and supportive therapeutic alliance, without which the client may never return for subsequent
sessions. Furthermore, a perfectionist client will set high standards for the perceived competency of the therapist.
Thus, it seems important for the therapist to be well‐trained and well prepared for each session, to stay a few steps
ahead of the client. The papers in this issue provide sound guidance for all therapists, and should help improve the
treatment of these challenging clients.
OVERHOLSER AND DIMAGGIO | 7

C O NF L IC T O F IN T E R ES T S
The authors declare that there are no conflict of interests.

ORCID
James Overholser http://orcid.org/0000-0002-4242-2215
Giancarlo Dimaggio https://orcid.org/0000-0002-9289-8756

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How to cite this article: Overholser J, Dimaggio G. Struggling with perfectionism: When good enough is not
good enough. J Clin Psychol. 2020;1–9. https://doi.org/10.1002/jclp.23047