The “Perfect” Patient

As a psychologist specializing in perfectionism, I have recognized how this personality trait can find its way into the therapy room. Clients with perfectionism will typically start therapy with a lot of determination to change and eagerness to learn. This kind of client is ideal and makes my job easy and enjoyable! However, clients and other therapists must recognize when perfectionism can be an obstacle in treatment. In this post, I have listed a few observations on how striving to be the “perfect” patient can be more harmful than helpful.

1. Difficulty letting go of emotional control

In my post “Unpacking Perfectionism,” I discuss perfectionists’ difficulties with being willing to feel uncomfortable emotions. Their goal is to feel in control, which means they want to be in emotional homeostasis 24/7. However, as a human with many different emotions, we know this is impossible. Many clients will come to therapy to get “rid” of their anxiety, sadness, shame, etc. They are looking for a way to better “control” their emotions. There is a difference between regulating and controlling emotions. Regulating creates space to feel and explore the emotion in a curious and nonjudgmental way while using skills to help reduce the emotion over time. Controlling leads to avoidance or numbing. We cannot learn to regulate our emotions if we avoid feeling them. The goal of treatment is to learn how to label and process emotions while utilizing strategies to help regulate them. 

      2. “Should” statements around internal experiences

Relating to the theme of control, individuals with perfectionism typically live by the internal rules they have set for themselves through “should” statements. This may sound like “I shouldn’t have that thought” or “I should always feel happy.” These rules are impossible to follow because we cannot control our intrusive thoughts or emotions; we can only control how we respond to them. When one inevitably breaks this internal rule of having a particular thought or emotion, this leads to more internal distress. One example where this is particularly problematic is clients with OCD, who will be bombarded with intrusive thoughts/images they “shouldn’t” have. 

In a way, therapy breaks these rules by encouraging the person to be willing to have uncomfortable thoughts and emotions. There may be some resistance at first, which is understandable given individuals may have spent the majority of their lives trying to avoid discomfort. I also try to normalize the vast spectrum of human emotions and thoughts we will have while breaking societal myths around them. For example, the Happiness Trap in Acceptance and Commitment Therapy (ACT) illustrates the more we believe we “should” always feel happy or are constantly searching to feel it, the less likely we will experience it. We will not always feel happy, and that is OKAY. Happiness will come and go just like any other emotion. My goal is to help clients become aware of these internal rules they are setting for themselves and demonstrate internal willingness and flexibility.

      3. New Skills = New Rules

My approach to therapy will typically start with psychoeducation and then skills tailored to meet my client’s diagnosis. Sometimes, I will notice individuals with perfectionism taking skills and turning these into new rules. The key here is to recognize the urge to control internal experiences is still there. The thought process here is – “If I use these skills, the uncomfortable internal experience (e.g., intrusive thoughts/images, anxiety, shame) will disappear, or “If I do this skill the “right” way, I’ll get rid of this discomfort.” I always remind my clients that skills are not new rules to control emotions and thoughts but tools in our toolbox to help create a different relationship with them.

     4. Want to “fix” themselves

As I stated earlier in this post, individuals with perfectionism will come into treatment with the motivation to change and an eagerness to learn. However, this stems from believing they are broken or worthless and must be “fixed.” I try to show my clients that this is not the case. They do not need to be “fixed.” They need to heal their relationship with themselves through compassion and curiosity about their internal experiences. We also want to understand how this belief of not being “good enough” developed. Then, this insight, paired with cognitive restructuring and compassion, can change the internal belief. Remember, we can learn skills, set realistic goals, AND create a loving relationship with ourselves. 

     5. High expectations for treatment progress

Unsurprisingly, individuals with high expectations for themselves and others would also expect the same within therapy. Some examples of unrealistic therapy expectations are: 

a. The therapist will fix me and eliminate internal experiences I don’t like (e.g., anxiety, intrusive thoughts).

b. Therapy will be efficient and quick.

c. I must do my therapy homework perfectly to see results. 

I quickly debunk these myths and expectations of therapy with my clients while pointing out that we want realistic therapy expectations. I also clarify that therapy is a collaborative relationship; together, we will navigate tough thoughts and emotions while learning to look at them differently. Clients may also experience thoughts of being a “failure” and shame in therapy if progress isn’t as quickly as they hope or if they don’t do homework. It is the clinicians’ role to meet this shame with compassion. I never shame my clients for not doing homework. I do the opposite and compassionately embrace their imperfection while working as a team to help them achieve their realistic goals.

If you’re reading this and some of these examples resonate with you, I want you to try and let go of your unrealistic expectations around your therapeutic growth. Therapy can be messy and uncomfortable, but it can be extremely rewarding and healing with the right therapeutic fit. If you experience perfectionism and are currently working with a therapist, make sure they know how this trait can impede your progress in therapy!