Thank you to everyone who responded to our November Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
November Quandary: My client sees his perfectionism as an advantage, a positive in his life—but I can see how it ramps up his anxiety, exacerbates his sense of shame, and keeps in him living a very rigid life. He brushes me off every time I’ve brought up examples of this. Last time I said something about it, he grew visibly angry and told me to I was unfairly judging him. How do I point this out to him in a way he might accept? Or do I keep this observation to myself?
1) Put the Perfectionism on Trial
In my own practice, I’ve generally found if I can make a compelling case that perfectionism is different than striving for excellence, being perfectionistic no longer has the same allure that justifies my clients defending it. In the event they still feel their perfectionism is justified, and continue to see it as an advantage, I’d gently confront their take on the behavior, essentially putting the core beliefs on trial. To do this, I might say something about how perfectionism is a similar concept to happiness—in itself, it’s not a sustainable pursuit or goal. Rather, I’d explain that it’s our effort toward reaching our fullest potential that’s more organic and easier to achieve.
There’s a compulsive quality to perfectionism, but not with striving for excellence. In my experience, when I explain this to clients and give them some time, they learn to budge a little and assess their behavior more realistically.
Michael Portman, LCSW
2) Don’t Tell the Client What to Do
I find it interesting when therapists try to convince clients that their perspective is wrong, or that their skewed perception is the source of the very problem they claim to want to solve. It’s our nature to disregard someone when they tell us no or that our perception is off or wrong. On some level, it can even feel threatening—the amygdala gets revved up when this happens, sending us into flight, fight or freeze.
In this scenario, it might be more useful to acknowledge how the client feels and ask him how perfectionism serves him. In what ways is it useful? This is a much better option than simply telling the client that he’s wrong for being so perfectionistic, or that it’s ramping up his anxiety. As therapists, we must remember that defenses serve a purpose, and you can’t take away a defense without replacing it with something else. If the client finds his perfectionism helpful, your job is to find out how it helps. This could open up a larger dialogue about how the client uses his perfectionism in a way that doesn’t cause him to shut down, or damage the therapeutic alliance.
We’re not our clients’ parents, and our job isn’t to tell them what to do. Our purpose is to help them develop awareness as to why mental constructs like perfectionism are useful, and then explore how other types of thinking or mental constructs could produce a preferable outcome.
Laurie Sherman, LCSW-C, MAC
3) Help the Client Adopt a “Good-Enough” Philosophy
It’s interesting that in this client’s narrative, perfectionism is regarded positively. Personally, I think it would benefit this therapist to share his or her own point of view in order to help the client see the ways in which perfectionism is limiting. I find that when you help the client consider another viewpoint, constructive conversations follow.
As a follow up, I might ask questions like, “What are the ways in which perfectionism most helps you?” or “Are there any situations or contexts in which you find yourself limited by it?” I’d also ask whether this client’s perfectionism interferes with the important relationships in his life, or with being timely. I’d ask the client when he first developed this perfectionism, and what he’d think about himself if he did something imperfectly. Importantly, I’d ask what the client’s notion of perfect is, and how he will know when he achieves perfection. That question alone gives the subtle suggestion that any notion of perfection is personal and subjective rather than objective.
The reality is nothing we say or do can ever be truly perfect. There are many kinds of beauty, many ways to act and communicate, and multiple solutions for the same problem. When I work with clients who suffer from OCD, I see how perfectionistic and exhaustive their work can be, even down to little things like crafting an email. Gradually, I try to help these clients experiment with a “good-enough” philosophy that challenges them to accept a less than perfect outcome and see if it helps them save time and worry.
Lisa Friedlander, LICSW
4) Do a Little Therapeutic Judo
I’d use the client's perfectionist thinking to benefit him. That is, I’d accept his acceptance of perfectionist thinking and ask how he could apply it toward his therapeutic goals. For example, perhaps he wants to become a more perfect partner, employee, son, or father. How could he use his thinking to benefit his pursuit? We could explore questions like, What would make you a more perfect partner? What attributes would you like to embody? This would allow him to identify goals, and we could work together to make them achievable, going with what seems to be egosyntonic for him.
David Mensink, PhD, R.Psych
Victoria, BC, Canada
5) Find a Creative Way to Shift the Client’s Perspective
If I was this client’s therapist, I’d explore this issue by asking questions that uncover the thought process behind the perfectionism. There’s an exercise I like to use that achieves this. First, I ask clients to draw a picture of whatever comes to mind, giving them only a few minutes to do so. When they’re done, I ask them to make any corrections to the drawing they’d like. The degree to which they make corrections often exhibits the extent of their sense of perfectionism. Afterward, using a mindfulness technique, I ask the clients to imagine a world where for an hour no mistakes are made and everything is perfect. “What does a perfect world mean to you?” I posit. “How does it make you feel? Is it enjoyable?” Next, I ask them to imagine a world in black and white. “This,” I explain, “is what a perfectly balanced world looks like—one without variation, or color. Which would you prefer—a world in black and white, or one with color?”
An activity like this can drastically shift a client’s perspective. You can also do variations on this exercise, for instance, by asking the client to imagine stumbling in a conversation with a close friend and then laughing about it afterward. The message here is that we’re appreciated and valued by those who matter regardless of our mistakes. Envisioning scenarios like this makes perfectionistic people more comfortable with not always getting things right. Whether you’re using CBT, art therapy, or motivational techniques, there are proven ways to help clients move away from their perfectionism.
Riza Ahmed, psychology program graduate
We'll post a new response to each Clinician's Quandary on the first Tuesday of every month! See how to submit to next month's Quandary here.
December Quandary: I’ve been working for several weeks with a client who was in a serious car crash that left her in a deep depression for years. When she recounts her story, I find myself unusually affected, as if I’m reliving the event with her. At the end of our sessions, I feel exhausted and stressed. I’ve heard a little bit about vicarious trauma but don’t know much about how to deal with it. I plan to work through this with my supervisor, but in the meantime, are there some good, practical ways to protect myself that still allow me to be fully present and empathetic with my client?
Tags: 2019 | Challenging Cases & Treatment Populations | challenging clients | change | changes | chris lyford | Clinician's Quandary | habit | habits | habitual behavior | obsessive compulsive | obsessive compulsive disorder | treatment of obsessive compulsive disorder