Case Study - Perfectionism

This Case Study is a fictional composite of real cases I have known during the past 8 years. Names and details have been changed, but the concepts are based on true-to-life events.

Case Study – Max – a 43-year old High-functioning man with perfectionism, anxiety, ADHD symptoms, anger issues and interpersonal conflict.

Max was a successful 7-figure guy who ran his own tech company. He was married with 2 children, and an observant Catholic. When he initially came to therapy, he was very proud of the fact that he drove himself very hard; he held himself to extremely high standards. However over the past few years he had been running into increasing problems. One was job related anxiety. He felt significant anxiety over not performing as well as he would like professionally. But in addition, he was very stressed over his personal life as well, about not getting enough exercise, not being a good enough father, and not fulfilling his religious obligations well enough. He was having a good amount of sleeping problems, waking up in the middle of the night with racing thoughts about not being successful enough in his business and having difficulty falling back to sleep.

In addition, Max reported anger issues, mostly a high level of irritability, especially towards his wife.

He had many plans and ideas for things he wanted to do in his family time, and he felt that he absolutely must be successful in carrying them out. But when his wife fell short in helping him implement his intricate plans, he would get very impatient and irritable with her. He would snap at her and criticize her frequently for not doing things exactly the way he needed them to be. For example, Max planned elaborate vacations. He insisted that in the little time he could spare from his business, he and his family needed to experience the most amazing, memorable family retreats. A simple weekend relaxing at a beach house was out of the question, he needed to fly to exciting new destinations, and fill his family’s vacation schedule with elaborate, expensive activities. The problem was since Max was so busy at work, his wife had to carry out all the grunt work of the planning, preparation and packing for these trips, and Max would get very upset with her if everything wasn’t planned perfectly the way he would have like. His wife, Lana, was very dedicated to him and made superhuman efforts to please him, but was very upset by his criticism and his endless pressure to accomplish increasingly amazing and outlandish things. This was generating significant marital conflict.

In addition, Max was impatient with his employees

and held them to very high standards, and would get very irritable and snap at them when they made mistakes. He admitted that this was causing problems at work as well.

Furthermore, Max complained of ADHD-like symptoms. He had difficulty focusing on tasks at work, he would constantly jump from one activity to the next, and be easily distracted. He felt it was affecting his productivity.

Besides the conflict with his wife, he was impatient with his 7 and 9-year old children, who he perceived as making a lot of mistakes and who needed to do better in school and the like. He had significant conflict with his parents who lived nearby. He characterized them as over-controlling and critical.

Over the first few sessions I gradually got to know Max and developed a picture of his overall emotional health.

He was extremely self-critical. He would hit himself over the head for every little mistake or less than perfect performance. He had the idea in his head that less than amazing output in all areas of his life was completely unacceptable. He felt extreme self-imposed pressure to constantly perform up to his own very high standards. When he inevitably did perform less than expected, he admitted feeling terrible shame and low self-worth, even a humiliating defeat, at times. This was all despite the fact that most people would describe him as very successful and competent.

Max attended Mass and confessed regularly. However he felt extremely guilty over what he perceived as himself not living up to the standards that his religion had set for him. In other words, he felt that he was a disappointment to God, that He disapproved of him. No amount of accomplishments and religious observance could rid him of this feeling.

For a fascinating discussion of Perfectionism and Andre Agassi, click here.

It was clear to me that Max was dealing with Perfectionism. When I mentioned the concept to him, he exclaimed, “Isn’t it a great virtue to seek perfection?

Isn’t that the ideal goal that everyone should hold dear?” So I explained to him that there were 2 ways to seek achievement: an unhealthy one, involving self-criticism, self-imposed pressure, shame, anxiety and low self-esteem, and a healthy way involving striving for achievement, but total glad acceptance of less that perfect performance, that is, total contentment with the inevitable, occasional mediocrity. I helped Max see that actually lowering his standards for achievement maybe 10 or 15 percent, would make him much more relaxed, and paradoxically and amazingly actually allow him to perform even better! However relentless pressure to be perfect was stressing him out and creating so many mental health problems which were damaging his productivity. Not to mention, that pressure was making him and his wife miserable!

Max admitted that something needed to change, but he was unsure about how to go about it. I explained to him that there were two basic paths in therapy, and we would use both. One was cognitive, and the other was dynamic.

First we would work cognitively, which means changing his thoughts and values.

Gradually over a few months of sessions, Max would need to adopt the thought patterns that perfection was actually not necessary in order to be an acceptable person! He would need to learn the joy of the mediocre, the freedom to be average! 99 percent of people spend 99 percent of their lives in mediocrity! Amazing or near perfect things only happen at most 1 percent of the time. Demanding such achievement of himself and others is necessarily doomed to fail and create tremendous anxiety. In addition, it separates him from the main bulk of society. It’s lonely at the top! He would need to learn that there is great togetherness, joy and liberation in being a regular, average guy. He would need to learn to shoot for only decent performance, not perfect. He would need to realize that his customers, coworkers, parents, wife, and even God and religion, did not expect perfection from him! They would all be totally satisfied with merely decent performance. Therefore, we worked on a plan for Max to actively shoot for 80 percent performance on a daily basis, and to not even attempt to do better. That means totally accepting than 20 percent of his performance each day is going to be messed up! At first this was hard for Max to accept but he realized that it would actually improve his output in the long run, and result in much less anxiety, anger and interpersonal conflict. It would also allow him to enjoy his life much more.

Understanding the past

At the same time, we would spend 5-10 minutes of each session doing dynamic work. That means going into his past, and finding out the root causes of his perfectionism. At first Max reported he had a happy-go-lucky childhood. But after several sessions, he began to reveal and realize that many of the details were troubled. His parents, although they always stayed together, fought in front of him frequently. In addition, they were very critical and controlling. He reported always feeling that they disapproved and were disappointed in him. Over several months I helped Max to realize that his parents’ marital conflict, combined with their critical, disapproving attitude towards him, created that thought pattern that he was never good enough. He remembered thinking, “If I was better, they wouldn’t fight. If I was a good boy they wouldn’t be mad at me and criticize me.” Max had developed a serious case of low self-esteem, and shame of his very self. We discovered then that he had created a maladaptive solution to those overwhelming feelings, of striving for superior, perfect performance and output. In other words, Max grew up feeling so terrible about himself, that in order to rescue himself from those feelings, he created a strategy of thinking, “I will be such a good boy. I will be so great and accomplished that I will be safely beyond anyone’s criticism. Through endless hard work, I will save myself from these terrible feelings!” This habit became a part of his make-up. Unfortunately, no matter how good he performed as a child and later as a teen, his parents’ criticism and their marital conflict never let up! This only pushed Max further and further towards the quest for perfection and achievement. He began to have vainglorious fantasies of all kinds of amazing accomplishments, but the point is, those deeds weren’t an option, they were necessary for his emotional survival!

As he grew up, he internalized his parents critical voice and it became his own, he became his own harshest critic.

His parents’ present day criticism of him didn’t help things either. In addition he learned to see God as sharing the same disapproving attitude of his parents, and so he felt encompassed by global pressure from which only endless accomplishment could have a hope of rescuing him.

Therefore a first important step in therapy was for Max to realize that although his parents loved him very much and they did the best they knew how for him, they made honest mistakes in raising him, and those mistakes affected him unfortunately for the worse. They also did a lot of wonderful things for him, we are not denying that, the point is however we need to recognize and gain a conscious awareness of their mistakes and their effects as well.

Over several months, Max began to feel intense grief over some of the ways his parents had treated him. He realized that the creation of low self-esteem and childhood shame of his very self was one of the greatest tragedies a person could ever experience. He realized that all his achievements, although notable, were all maladaptive, motivated to heal his shame and low self-esteem. But it was all in vain! No amount of objective accomplishments can cure low self-worth, only therapeutic treatment can. He resolved to from now on seek achievement only in a healthy, balanced moderate way; to learn to be content with only decent, near mediocre performance, and to be content with only occasional excellence.

Therefore Max needed to gain a conscious awareness of his entire childhood history in all its details, and also of his emotional history.

How did he feel when criticized, blamed or put down as a child? How did he feel when his parents fought? Once he became consciously aware of all these stormy feelings that had until now been hidden in his heart, he could mourn and grieve the events causing them, and allow them to fade into the past. Once he had done so, he had defused the cause of his feelings of shame, and therefore his low self-esteem, and therefore would no longer be drives to seek the perfectionistic solution!

In addition I advised Max employ a cognitive technique of writing down in a journal 2 good things he did each day in acts of kindness and personal growth, such as “I called my sister to cheer her up today,” and “I allowed myself to enjoy 20 minutes of sunshine without pressure to accomplish.” At the end of each month he would have 60 mundane, decent accomplishments and we would review then in therapy. Gaining awareness of all the everyday wonderful things he does went light years to improving his self-esteem and reducing the perfectionistic drive.

Releasing Repressed Anger

Max began to realize he was beginning to feel very angry at his parents, especially his father. I helped him see that being honest with his feelings was the wisest course. Until now, that anger had been repressed, where it was causing all sorts of emotional health problems, including irritability at his wife. Therefore he began to spend a short time each day at home crying and validating his anger to himself, as well as speaking about it in therapy.

Approaching the parents

He began to feel relief, but we realized that there was one step left. I guided Max to approach his parents and to tell them that he loved them very much, and he wanted to have a continuing lifelong relationship with them. However he was having some emotional issues, and he would like to ask their help. Approached so respectfully, they expressed their willingness to help. He then explained to them that although he recognizes the many wonderful things they did for him, that they loved him and did their best, they unfortunately made some mistakes which affected him, and it would be immensely healing and helpful to him if they would recognize their mistakes. Thankfully they realized that they had been harsh on him, and expressed regret for verbally mistreating him saying, “I just didn’t realize the effects of what I was saying on you. I’m sorry I hurt you. I hop you get better.” That short conversation was so amazingly helpful! I caused years of shame, anger, and anxiety to melt away! You see, parents of even adult children, possess tremendous power to influence their child’s psychological reality. If they refuse to admit mistakes, it is more difficult for the child to truly be aware of and have his experience validated. He tends to think, “Maybe they never did anything wrong and it’s all my fault” This prevents healing. But a simple admission from the parents is extremely helpful.

To find out about the steps I take clients through in psychotherapy in general, click here.

Over time, Max learned to be more content with more moderate performance, at work and at home.

Sometimes they would take stay-at-home vacations, and just relax together. He learned to be much less critical of his wife, and he actually began to realize what an amazing person she was, and how lucky he was to have her. His children also appreciated his more gentle, easy-going attitude.

His business did not at all suffer from his decreased pressure to achieve.

He began to accept mistakes in stride as part of normal everyday life. He actually began to enjoy his work much more now that he was relieved of so much self-imposed pressure. He reported significantly reduced anxiety, better ability to focus on his tasks, and even improved sleep!

At times, perfectionistic thoughts and attitudes would bubble up again, but he would reframe them by thinking about the beauty of the mundane, the liberation and joy of being an average, regular guy. We would review these thing in therapy, and he moved down from weekly to bi-monthly maintenance sessions.

Altogether it was after 2 years of weekly therapy that Max reported a 75 percent improvement. He considered the time a very wise investment, as now he would have decades left to live of increased happiness, improved family relations, and emotional health.

To find out more about my approach to Perfectionism treatment, click here.

I hope this case study in perfectionism was illuminating.

If you are struggling with this issue, and feel I may be the right therapist for you, feel free to explore the rest of my website, chat with me in the chat box, or call me directly at 646-681-1707 for a complementary 15-minute consultation. I look forward to speaking with you!