Is our perfectionism making us ill?

My name is Jo and I’m a perfectionist.

Perfectionism is a big part of who I am. I am grateful to that facet of my personality for many of my achievements, but I can see it has also caused issues in my personal and professional life.

I read comedian Jon Richardson’s book It’s Not Me, It’s You about his search for love as an obsessive perfectionist. While it made me laugh out loud a lot, at times I also found it worryingly close to home, and it reminded me what a pain I must be sometimes.

I suspect everyone in this profession has perfectionist traits, or at least they did when they first graduated – otherwise they would not have been able to arrive at that point. And while my introduction may suggest I liken it to alcoholism, I am fully aware the latter can be a life-threatening disease, while perfectionism is… well, let’s think about that.

Personality trait

Frost and colleagues[1. Frost R O et al (1990). The dimensions of perfectionism, Cognitive Therapy and Research 14(5): 449-468.] defined perfectionism as “the setting of excessively high standards for performance accompanied by overly critical self-evaluation” along with “concern over making mistakes”. It is a behavioural personality trait that is multi-dimensional[2. Hewitt P L and Flett G L (1991). Perfectionism in the self and social contexts: conceptualisation, assessment, and association with psychopathology, Journal of Personality and Social Psychology 60(3): 456-470.], and it can be maladaptive or adaptive[3. Enns M W et al (2001). Adaptive and maladaptive perfectionism in medical students: a longitudinal investigation, Medical Education 35(11): 1,034-1,042.]^,[4. Bieling P J et al (2004). Is perfectionism good, bad, or both? Examining models of the perfectionism construct, Personality and Individual Differences 36: 1,373-1,385.].

Self-oriented perfectionists are described as setting very high standards for themselves, along with an intrinsic need to be perfect and constantly striving for self-improvement. Socially prescribed perfectionism refers to the belief others hold unrealistically high expectations for us, which can cause the individual to become a people-pleaser to avoid negative consequences. Other-oriented perfectionists set very high standards for others.

Maladaptive perfectionism is associated with setting standards impossibly high, a sense of self-worth that is dependent on achievement, and black-and-white thinking involving two possible outcomes – perfection or failure.

The adaptive type, on the other hand, involves setting high, but achievable, standards – a sense of self independent of achievements, and the ability to relax standards in some situations.

Perfectionism has been used as a predictor of mental health[5. Xu J and Roberts R E (2010). The power of positive emotions: it’s a matter of life or death – subjective well-being and longevity over 28 years in a general population, Health Psychology 29(1): 9-19.] and has been found to be associated with depression, anxiety, compulsivity, procrastination, low self-esteem, alcohol abuse and eating disorders, along with high achievement and conscientiousness[6. Frost R O et al (1993). A comparison of two measures of perfectionism, Personality and Individual Differences 14(1): 119-126.]^,[7. Rice K G et al (1998). Self-esteem as a mediator between perfectionism and depression: a structural equations analysis, Journal of Counselling Psychology 45(3): 304-314.]^,[8. Shafran R and Mansell W (2001). Perfectionism and psychopathology: a review of research and treatment, Clinical Psychology Review 21(6): 879-906.]. A correlation has also been found between perfectionism and suicide ideation[9. Hamilton T K and Schweitzer R D (2000). The cost of being perfect: perfectionism and suicide ideation in university students, Australian and New Zealand Journal of Psychiatry 34(5): 829-835.].

People with perfectionist traits are often highly competitive, have a fear of failure and a tendency to feel guilt and self-blame when their high standards are not achieved[10. Hamachek D E (1978). Psychodynamics of normal and neurotic perfectionism (abstract), Psychology: A Journal of Human Behaviour 15(1): 27-33.].

It is important to realise the various perfectionist dimensions can all exist in the same person at the same time, in varying proportions[11. Terry-Short L A et l (1995). Positive and negative perfectionism, Personality and Individual Differences 18(5): 663-646.]. Which type dominates can depend on the external and internal environment in play at any given time[12. Hewitt P L and Flett G L (1993). Dimensions of perfectionism, daily stress, and depression: a test of the specific vulnerability hypothesis, Journal of Abnormal Psychology 102(1): 58-65.]. And it has been found, unsurprisingly, that stress can increase the risk of depression in perfectionists[13. O’Connor R C and O’Connor D B (2003). Predicting hopelessness and psychological distress: the role of perfectionism and coping, Journal of Counselling Psychology 50(3): 362-372.].

Grey areas

As we know, there is a problem of reduced emotional well-being and increased mental ill-health within the veterinary profession. Vets have four times the relative incidence of suicide compared to the general population, and twice that of medical practitioners and dentists[14. Mellanby R J (2005). Incidence of suicide in the veterinary profession in England and Wales, Vet Rec 157(14): 415-417.]. Bartram et al[15. Bartram D J et al (2009). A cross-sectional study of mental health and well-being and their associations in the UK veterinary profession, Soc Psychiat Epidemiol 44(12): 1,075–1,085.] found the 12-month prevalence for all suicide ideation among all vets (life not worth living, death wish, suicidal thoughts) was 29.4%, or 5.5 times higher than the general population.

Leaving university with a veterinary degree, one can be forgiven for thinking veterinary science is black and white, and there is a right way and a wrong way to do everything in practice. It soon becomes clear that is not the case. For me, that was a very stressful learning curve. Our natural tendency is to do everything perfectly – sooner or later that will not happen and a mistake will be made[16. Turner M (2015). Mistakes in veterinary practice: the elephant in the room?, Vet Times 45(17): 22-23.].

I watched an online talk, by Brian Goldman, for the ideas spreading group TED called Doctors Make Mistakes, Can We Talk About That? I recommend Googling it for a fascinating insight into how the perfectionist mind works when mistakes are made, as they inevitably will be[17. www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that].

Everyone hates to feel they have made the wrong decision, but this concern is even greater in perfectionists. Combined with our black-and-white thinking (I need to be perfect or else I am a bad person), the fact mistakes can cause serious consequences for our patients, and a fear of being judged by others, means errors can lead to severe consequences for our mental health.

If the error leads to a complaint to the RCVS, or to litigation, the situation becomes even worse. Anecdotally, it is obvious how much stress these situations can cause, and sometimes that added stress can be the tipping point that ends in suicide.

How can we improve this situation?

I think there are many things we can do, as individuals and as a profession, that can help us be more resilient. This can only be good for our patients and their owners, as well as ourselves.

Be aware

Firstly, be aware we all have perfectionist traits. This trait can make us not only self-critical but also critical of others. A bit more mutual support and understanding would go a long way towards improving the situation.

Ask for help

We need to lower the threshold for asking for help. At the moment, problems are buried and often support is not sought until mental health is seriously damaged. Vets are less likely than the general population to seek help[18. Cardwell J M et al (2013). A cross-sectional study of mental health in UK veterinary undergraduates, Vet Rec 173(11): 266.]^,[19. Platt B et al (2012). Suicidality in the veterinary profession: interview study of veterinarians with a history of suicidal ideation or behaviour, Crisis: The Journal of Crisis Intervention and Suicide Prevention, 33: 280-289.]. It may be we feel it is an admission of failure, are concerned we will be “found out” and judged incapable, or that we simply do not think it will help[20. Allister R (2014). https://veterinarywellbeing.wordpress.com/2014/10/19/reaching-out-and-holding-on/].

Vet Helpline, for example, is there for us – we should use it at an early stage, preferably before we have got to the point of suicidal thoughts.

We need to recognise how stressful clinical veterinary work can be at the coalface. If a complaint is added to that underlying stress, it can be enough to tip the mental health balance. As well as telephoning the professional indemnity provider (and it has to be said Veterinary Defence Society is incredibly supportive in this situation), it should be the accepted norm to telephone Vet Helpline as well.

Open environment

Because we are so concerned about mistakes and have a huge fear of failure, any suggestion we have got something wrong is a blow to our very being. We may react by thinking we are a bad person who should not be doing the job at all, and then our mental health can go into a tailspin. So, we protect ourselves by hiding it inside, not talking about it nor admitting to ourselves or anyone else that perhaps we are not 100% perfect.

We need to change the culture so mistakes are not treated as some sort of guilty secret and to accept they are inevitable in human beings. We must create a personal, practice and professional environment where we can think and talk about things that went wrong and caused a suboptimal outcome for our patient in an open, no-blame way.

In this way, we would realise all blame does not rest on one individual, but other factors will always play a part. It would help us to derive systems that minimise the future incidence of similar mistakes[21. Reid J and Bromiley M (2012). Clinical human factors: the need to speak up to improve patient safety, Nursing Standard 26(35): 35-40.]^,[22. www.newstatesman.com/2014/05/how-mistakes-can-save-lives].

So it may be the comparison with alcoholism is not totally spurious. While not a disease, being a perfectionist can certainly be very bad for our health, and a risk factor for mortality in some individuals. Being aware of its role in our lives may help us to treat ourselves and our colleagues more sympathetically. It is a message we need to tell ourselves every day. Doing our best is good enough, we will never be perfect and that is okay.

And me? Well, I’m still a work in progress. The other day, I was drafting an eight-vet rota, and someone pointed out two minor errors. In the past I would have been furious with myself and, because it was said in a slightly judgemental manner, a bit humiliated as well. On this occasion I was delighted to find I simply smiled, and patted myself on the back for not being a painful perfectionist. There’s a long way to go, but I think I have taken the first small steps.

My fee for this article will be donated to VBF.

References: