Special Commentary: How to Recognize and Work with Destructive Perfectionism
Margaret Robinson Rutherford, Ph.D.
“If it’s worth doing, it’s worth doing well.” How many times did I hear that growing up? Basically, my parents were attempting to teach me (just in case I hadn’t absorbed it from their own actions) that striving for excellence was valuable. They were teaching what’s now termed constructive perfectionism – where enjoyment and fulfillment in life can be found in doing things as well as you potentially can. In constructive or “positive” perfectionism, the focus is process-oriented; if you fall, you get back up again and learn from the experience.
Yet perfectionism can have a much darker side. Brené Brown, a premier researcher in shame and vulnerability, defined perfectionism in her first book, The Gifts of Imperfection, as… “a self-destructive and addictive belief system that fuels this primary thought: If I look perfect, live perfectly, and do everything perfectly, I can avoid or minimize the painful feelings of shame, judgment and blame” (2010, pg. 57). This facet of perfectionism, which is fueled by the need to quell intense and persistent voices of inner shame, isn’t fulfilling. It’s far from enjoyable. Rather, it’s an exhausting race to exceed your own expectations as well as expectations that others might have of you.
This is destructive perfectionism. The goal is achievement. It’s driven. It’s pressured. And it’s a growing mental health problem.
Many perfectionistic people will fall somewhere on a spectrum between the two poles. But there’s another issue. Ironically, destructive perfectionists may not even recognize themselves as perfectionists; they don’t believe their best is good enough. There’s always the next achievement. And then the next. And the next.
Within the last decade or more, I’ve treated more and more people who don’t quite know why they’ve come to therapy. They describe moderate anxiety, or fatigue. If asked if they were depressed, I’d hear a firm denial. “I have too many blessings in my life.” If questioned whether or not their childhoods provided safety and security, they’d laugh and deny or discount any kind of problem. Or sometimes they’d become very quiet and look out the window, as if they wished they were anywhere but my office.
Yet, as they unveiled stories of families where sadness wasn’t tolerated or parents who screamed they’d never amount to anything, it became apparent that there was little access, if any, to hurt or pain. They were completely zipped up. These clients were destructive perfectionists who were running out of steam but not sure what, if anything, was wrong. Their emotional pain was expertly, and often unconsciously, hidden.
Yet as they returned for one more session and then another, they’d slowly risk sharing one shame-filled secret after another. The pathos of their stories would timidly seep out, as a seemingly impenetrable cloak of silence would slip off to reveal tremendous loneliness and despair.
And yes, depression.
What peaked my own curiosity in perfectionism?
In 2014, I was writing my usual weekly blogpost and thought the work I’d done with clients who had the traits and behaviors described above. I picked a term out of the air and entitled the post, “The Perfectly Hidden Depressed Person: Are You One?” The post went viral, which had never happened to me. The next day, it was published by HuffPost. In a 24 hour period, hundreds of emails swamped my inbox. “It’s like you’re in my head.” My curiosity was peaked as I read each and every one of them. I began researching myself, curious to see what existed in the popular literature about perfectionism, shame, and fear of vulnerability. I found the wealth of research and knowledge of Brené Brown, the much earlier thoughts on covert depression by Terrance Real, Kristin Neff’s treatise on self-compassion. There were workbooks talking about how to become more comfortable with imperfection which were of course helpful. But what was available to the general public about the relationship between perfectionism and a potentially deadly depression? I couldn’t find anything.
Then I turned to academic sources and found a wealth of information.
The academic research on destructive perfectionism…
Perfectionism has long been identified as a potentially destructive character trait. Sidney Blatt was one of the first to amass research findings on perfectionism, its links to depression and suicide, and its implications on treatment. He suggested that certain types of depression should be identified through what someone’s lived experience was, rather than if their symptoms fit official criteria for classic depression. “This approach to understanding depression from a phenomenological, rather than a symptomatic, perspective has emerged as a major trend in both psychology and psychiatry over the past two decades…. Investigators have increasingly sought to understand depression not as a series of symptoms but as a complex phenomenon that emerges from two major classes of disruptive life events: (a) severe disruptions in interpersonal relations (e.g. loss of separation) or (b) profound threats to feelings of self-esteem and self-worth.” (pg. 12)
So, perfectionism can become destructive when its birthplace wasn’t a place of support, safety and nurturing. But where instead, trauma or familial/cultural dynamics required a mandatory strategy for emotional survival , where vulnerability was disdained.
Currently, there are researchers worldwide that are investigating perfectionism’s causes, be they cultural, political, familial, social or an interaction of all four of these factors. There’s some disagreement on whether or not perfectionism can be adaptive at all or if it’s almost always maladaptive. There are many people who view striving for excellence as a process, a situation where you learn as you go, where mistakes are tolerated and even expected. Yet a very recent meta-analysis found that perfectionistic concern (trying to reach external goals/expectations set by others) and perfectionistic striving (pushing yourself to perfection) are both linked with depression, are significantly linked to social disconnection, and the first is further associated with greater stress.
There are growing reasons to be concerned about the rate of perfectionism in younger generations as well, with studies showing it’s measurably getting out of hand. And when perfectionism is researched by itself, a certain type of perfectionism called socially-prescribed perfectionism (similar to perfectionistic concern) is not only on the rise, but is significantly correlated with the risk of suicide.
And as these rates soar, tragically so does the quest for the perfect-looking life, fueled by everything from helicopter parenting to social media.
The birth of perfectly hidden depression..
So, I started to ask questions and to write about the traits of people with “perfectly hidden depression.” I spoke with over 60 interviewees who identified with PHD, and who volunteered anonymously to come forward with their own stories. A brain surgeon, a motivational speaker, a dentist, an advertising exec. All successful. And all wanting to help others to not recreate lives similar to theirs.
I took their stories, as well as the ones from people I myself had treated, and tried to describe what this dangerous kind of depression might look like in someone’s life – “phenomenologically” to use Sydney Blatt’s words. How could someone who scored low on a depression inventory be living with secrets that ultimately might destroy their will to live? And clinicians like you and me might to think outside of the diagnostic box, and to pick up on these traits. A recent article by Scottish psychiatrist Dr. Rebecca Lawrence stated this very thing: “It takes a conscious effort to remind myself of a fact that psychiatrists know very well on an intellectual level but should perhaps recognize more: a cheerful demeanor can be profoundly misleading.”
I wanted to describe and offer a working model of what this kind of dangerous perfectionism might look like in daily decision-making and behavior. So, shame-based perfectionism - destructive perfectionism - became the first trait of the syndrome “perfectly hidden depression.”
These traits have not been empirically validated. Yet, they mirror my clinical experience, and likely, will reflect yours as well. As one clinician said to me, “You’ve given a name to something we all know exists.”
The ten traits of perfectly hidden depression…
· You are highly perfectionistic, fueled by a constant, critical inner voice of intense shame or fear.
· You demonstrate a heightened or excessive sense of responsibility and look for solutions.
· You have difficulty accepting and expressing painful emotions, remaining more analytical or “in your head.”
· You discount, dismiss or deny abuse or trauma from the past, or the present.
· You worry a great deal (but hide that habit) and avoid situations where you’re not in control.
· You are highly focused on tasks and others’ expectations, using accomplishment as a way to feel validated.
· You have an active and sincere concern for the well-being of others, while allowing few (if any) into your inner world.
· You hold a strong belief in “counting your blessings” and feel that any other stance reflects a lack of gratitude.
· You have emotional difficulty with personal intimacy but demonstrate significant professional success.
· You may have accompanying mental health issues that involve anxiety and control issues, such as OCD, GAD, panic, eating disorders or high-functioning substance use/abuse.
Working with someone who identifies with perfectly hidden depression…
In my own work, I’ve identified five stages of treatment that can be helpful to remember, as your own clients take the risk to gently confront their own silence – and learn to express what has long been suppressed.
The stages are consciousness, commitment, confrontation, connection and change.
The First Stage: Consciousness
Consciousness means becoming aware that perfectionism is a problem. Although part of every emotional/mental healing process, this stage may be more complicated for your client because they’ve convinced themselves that those traits are normal. “Isn’t everyone like this?” The answer to that is a resounding no. Yet giving up or tweaking a strategy that’s brought them external success is very difficult.
It’s important to distinguish between PHD and high-functioning depression. In the latter, your client knows they’re depressed, but hide it to the best of their ability.
This is where mindfulness comes into play. Mindfulness authors teach that mindfulness is changing how someone is paying attention. It can deepen the experience of the present. For someone who’s trying to become more aware of how their shame and need for control scream at them in the background of each day, becoming more mindful can allow them to experience and identify that painful inner dialogue.
Here’s one simple mindfulness practice.
“Sit somewhere very comfortable where your body is supported well and set a timer for three to five minutes. Breathe deeply and close your eyes. Stay as focused on your breath as possible, even counting them from one to ten and then starting over. If your mind wanders (which it will), gently let go of those thoughts and refocus on the breath. When the timer goes off, check in with your emotions, your eyes still closed. There could be irritation, relief, feeling silly. Simply notice and watch it dissipate.”
The Second Stage: Commitment
There are five major stumbling blocks to a commitment to challenging perfectionism’s grasp. And as the clinician, you can watch for their presence and help point out how these hurdles are threatening healing.
1) Adopting such a rigid commitment that when you falter or don’t do it perfectly, you’ll quit or simply want to stop thinking about it.
2) Beginning with a goal that’s too hard or too large.
3) Going it alone and not asking for help along the way.
4) Dealing with the fear and shame of giving up your persona with its familiar coping strategies -- while stress that change brings naturally… increases.
5) Other mental issues you might have worsening due to the pressure, such as OCD or an eating disorder.
One of the best strategies here is to alter the goal of “commitment” to that of “intention.” It’s far less autocratic and holds within it much more grace and forgiveness. So, the first two blocks are fairly self-explanatory. Let’s look at the third block; here’s an exercise to try.
“Reflect and write down instances you can remember where you didn’t ask for help, but in hindsight, it would’ve been helpful to do so. Go back and replay what you could’ve said or asked for. Practice those sentences coming out of your mouth and hear yourself say the words. How does doing that cause you to feel? Try to think now of the present, and a situation where you could ask for help.”
The fourth block may be the most difficult. It’s a bit like the client is shedding their armor while in the midst of battle. Journaling here can be highly effective.
The fifth block reminds you that you may need to stop your client’s work for a bit and attend to any symptoms of anxiety or an eating disorder – because an actual mental illness may be co-occurring with destructive perfectionism.
The Third Stage: Confrontation
Let’s talk about the difference between beliefs and rules. Rules govern conduct. Beliefs are something you accept as true. The two are interactive. Beliefs may define the rules you follow. Yet the rules you follow may limit or expand your beliefs. For example, you might have the rule, “I always put a smile on my face, no matter what.” It’s connected with the belief, “People won’t like me if I don’t smile.”
This stage involves helping your client identify the rules they follow – what’s allowed or disallowed, what they should do, must not do, always need to do, never should do. They could be spoken rules from family, from culture, created from real danger or expectations. Some are spoken; some unspoken. So you guide your client in their identification – and then, in whether or not they find them truly helpful now as an adult.
First determine what your spoken and unspoken rules are. Decide whether or not they serve you well (and some will) and will guide you toward a more self-accepting and less shame-filled life. If you decide the rule does not serve you well, write out one that would take its place.
The Fourth Stage: Connection
Looking in control, pleasing others, keeping a foot on the accelerator at all times – all these choices have protected your client. To confront shame head on, to connect with anger, to admit fatigue – that’s an immense amount of exposure.
Think about a turtle. At any sign of danger, the turtle pulls his head back in and waits. So, to consider feeling deeply? To approach painful memories that have been tightly compartmentalized for years? It can be quite frightening.
Terrance Real has a quote in his book, I Don’t Want to Talk About It. He’s talking to a patient about emotional vulnerability, and the guy, who was trying his best to understand why it was important, finally said, “You either feel it or live it, right? The pain. Either feel it or live it. Isn’t that what you’re going to say to me?”
He got it. If you don’t connect with emotional hurt or anger or sadness, it will govern your life in ways that you cannot see.
Obviously, with severe trauma, this step needs to be taken with the prevailing principle that the client go only as quickly (or slowly) as they are able. Breaks may need to be taken.
Here’s the exercise.
Carefully create a timeline, where you divide a horizontal line by years of age. 2. 4. 8. 12. 20. And so on. You’re going to go back to those years and write down both the good and the hurtful things that occurred to you. This is an exercise in acknowledgment. Not blame. Acknowledge the good, the bad, and the ugly. This will also take courage as you confront the denial that may still want to emerge and complain, “Oh… it wasn’t that bad.” You’re not whining. You’re acknowledging the emotional consequences or charge of an event with the same compassion you’d show someone else. You’ll begin to see patterns and connections between events. And hopefully, you will find self-compassion.
The third and fourth stages of healing are where your client is going to find the “why” they began needing to look perfect. And to begin to accept that their vulnerabilities don’t define them any more than their successes do. For the antidote to perfectly hidden depression – is self-acceptance.
The Fifth Stage: Change
In my years as a clinician, I’ve learned that insight is a very helpful thing. If offers context and understanding. But hope comes from behavior change. This stage probably began from the very beginning as baby steps are taken toward healing.
One last exercise.
Go through each of the ten traits and with trusted friends, your partner, a parent or a therapist, think about very specific ways you can begin to put your insight to work and actually risk behavior change. Choose which is the simplest and give it a try. This isn’t something to do perfectly. Remember, you’re on a journey.
The hardest work isn’t making a change; it’s maintaining it. There are so many pulls and tugs from that perfectionistic shaming voice that holding onto a fresh perspective and behavior can be challenging. Sometimes your client may have to end relationships that are too damaging and set appropriate boundaries in the ones that remain.
Two women immediately come to mind as I’m finishing up this article. Both said to me, right before they left therapy, “I had a plan to kill myself when I walked in your door. But I never would’ve told you that… until now.”
They finally feel seen. Understood. Cared for. And they want to remain alive just as they are.
Resources
This material is drawn from my own book, Perfectly Hidden Depression: How to Break Free from the Perfectionism that Masks Your Depression (New Harbinger, 2019).
My gratitude and mention to these researchers and authors:
Blatt, Sydney Ph.D.; 1995. The destructiveness of perfectionism: Implications for the treatment of depression. American Psychologist, 50(12). 1003-1020.
Brown, Brené Ph.D.; 2010. The Gifts of Imperfection. (Hazelden Publishing).
Flett, Gordon Ph.D; Hewitt, Paul, Ph.D. Mikail, Samuel Ph.D; 2017. Perfectionism: A Relational Approach to Conceptualization, Assessment, and Treatment (The Guilford Press).
Lawrence, Rebecca. 2021. When depression wears a smile, even psychiatrists like me can be deceived. The Guardian. Thursday 18 2021.
Neff, Kristin Ph.D.; 2014. Self-Compassion: The Proven Power of Being Kind to Yourself (William Morrow).
Real, Terrance Ph.D.; 1997. I Don’t Want to Talk About It (Scribner).
Williams, Mark, Teasdale, John, Segal, Zindel, Kabat-Zinn, Jon: 2007. The Mindful Way through Depression: Freeing Yourself from Chronic Unhappiness (The Guilford Press).
