By Kayla Zebrowski, LCSW and C. Alec Pollard, PhD
This article was initially published in the Winter 2022 edition of the OCD Newsletter.
In the Fall of 2021, the OCD Newsletter featured an informative article by Fred Penzel, PhD, on the nature and treatment of academic perfectionism. In this follow-up article, Kayla Zebrowski and C. Alec Pollard share their recommendations for therapists working with students impaired by this form of OCD.
“Perfectionism” is a term used in many different ways. It can be a compliment applied to someone thought of as conscientious or fastidious. It has also been identified as a set of traits by psychologists studying personality. In this article, however, we discuss a type of perfectionism involving clinically significant impairment. According to Shafran, Egan, & Wade (2010), dysfunctional perfectionism is:
“the setting of, and striving to meet, very demanding standards that are self-imposed and relentlessly pursued despite…causing problems.”
The application of demanding standards to schoolwork is called dysfunctional academic perfectionism (DAP). Students with DAP may stay up all night trying to perfect their homework or put it off indefinitely because completing the task to their standards feels too overwhelming. People with DAP struggle with indecision and procrastination and, as a result, schoolwork is often turned in late. They are highly self-critical and often seek reassurance, which leads to family conflict. DAP can also lead to social isolation and depression.
Evidence suggests that DAP is more prevalent today than ever before. Researchers have identified a steady rise in perfectionism among college students over the past several decades (Curran & Hill, 2019), a finding consistent with our clinical experience. In fact, DAP is the primary treatment focus for at least 25% of the patients in our Intensive Outpatient Program. Though not officially listed as a subtype of OCD, DAP can be reasonably conceptualized as an obsessive compulsive problem. Perfectionistic obsessions typically involve themes similar to those found in OCD, like intolerance of uncertainty and not-right feelings. Similar to people with OCD, students with DAP engage in avoidance and compulsions. When presented with an academic task, they either avoid it by procrastinating or attempt the task while performing perfectionistic compulsions like over-researching, over-editing, over-studying, mental checking, re-writing, and re-reading.
Viewing DAP as a form of OCD has important treatment implications. It has been our experience that evidence-based interventions for OCD, especially exposure and response prevention (ERP), can be successfully used to treat DAP. Other clinicians report similar findings (Hood & Antony, 2015). Nonetheless, DAP presents special challenges for which some therapists are unprepared. We believe a therapist’s ability to address these challenges is crucial in determining whether or not treatment will be effective. Here are 10 tips we hope will assist students, parents, and therapists contending with the challenges of DAP:
- Provide the student with a healthy alternative to perfectionism.
Many perfectionists believe the only alternative to striving for perfection is to become irresponsible and unproductive. It is therefore helpful to show students a functional alternative and how it differs from perfectionism. At our clinic, we use the pursuit of excellence as the alternative to perfectionism. The table below highlights the differences.
|A Pursuer of Excellence…||A Perfectionist…|
|Sets high but flexible standards, that can be adjusted based on experience||Sets excessively high, rigid standards that are not adjusted regardless of experience|
|Focuses on the process and the outcome||Focuses only on the outcome|
|Is driven by positive motivation||Is driven by fear|
|Can be satisfied by a range of outcomes||Can only be satisfied by one improbable outcome|
|Views mistakes as inevitable learning opportunities||Views mistakes as unacceptable failure|
- Help the student establish realistic expectations.
Students with DAP underestimate the amount of time and effort necessary to meaningfully change how they approach academics. It is common for them to expect therapists to get them caught up on incomplete homework from prior classes, avoid getting further behind in current classes, and recover from DAP all at the same time. When presented with such unrealistic goals, the therapist must be the voice of reason. This means establishing realistic expectations and timelines, including the amount of time the student is willing to reserve for therapy. It may also mean discussing unwelcome topics like taking medical leave, attending summer school, scheduling time on the weekends to catch up, and the possibility of being placed back a grade in school.
- Get the parents on board.
Parents often come with the same unrealistic expectations as their perfectionistic son or daughter. As a result, they should be included in at least some of the discussions mentioned in Tip #2 so that their expectations are realistic as well. Furthermore, parents who actively accommodate avoidance (e.g., doing the student’s homework) or who do things that increase the student’s anxiety (e.g., pressuring or lecturing) may need guidance from the therapist regarding how best to support recovery.
- Get the school on board.
The ability of schools to respond effectively to DAP has improved since passage of the Americans with Disabilities Act (ADA) of 1990. Even so, some teachers, school counselors, and administrators struggle to understand DAP. Failure to turn in homework, for example, may be interpreted as laziness or irresponsibility. The therapist should educate school personnel about DAP, establish realistic expectations, and advocate on behalf of the student for temporary accommodations to address the limitations imposed by DAP.
- Look for organizational skill deficits.
Although some students with DAP appear highly organized, many are not. Common deficits include underestimating the time it takes to complete tasks, difficulty establishing priorities, trouble developing and following a schedule, and difficulty organizing an academic project into manageable steps. Therapists should routinely assess the student’s ability to manage and organize study time and address any deficits identified. Many of the strategies used in Behavioral Activation, especially the practice of following a daily schedule, can be helpful for students with DAP. However, the focus here is less on activation and more on completing a planned task (exposure) within the specified time period (response prevention).
- ERP is more than doing schoolwork quickly.
Students with DAP are inefficient because of their efforts to avoid the distress of uncertainty and not-right feelings. ERP is an opportunity to learn how to tolerate those feelings, not a race to get something done. An example of ERP instructions given to one of our students may help illustrate the point:
“Read until you get the urge to re-read a passage in the book, then close the book so you are unable to re-read. Turn on the script we recorded that helps you focus on the feeling of doubt, that you might not have understood the words perfectly. Sit with the doubt while listening to the script for 10 minutes, or until you are confident you will not try to re-read the passage that triggered you. Then resume reading until you are triggered again.”
- Start ERP with low-challenge, non-academic tasks.
A common mistake in treating DAP is targeting schoolwork as an exposure task before the student has demonstrated the ability to follow response prevention guidelines under less challenging conditions. This is an understandable error given the pressure often exerted by everyone involved. However, some students cannot email a friend without repeatedly deleting and re-writing, much less write a whole term paper. Going too far up the exposure hierarchy at the expense of response prevention adherence risks creating the illusion of progress without the requisite learning needed for real progress to occur. Therapists should ensure the student is able to first resist compulsions during low-challenge, non-academic tasks before incorporating schoolwork into ERP.
- Consider incorporating basic start-stop practice.
If a student struggles adhering to time limits in ERP or has difficulty following a study schedule, it may be helpful to assess the student’s fundamental ability to stop and start tasks. For students who have difficulty transitioning between even simple, non-anxiety provoking tasks, basic start-stop practice can be helpful. For example, a student might be instructed to engage in a non-aversive activity (e.g., drawing a picture) for 5 minutes and then practice moving rapidly to the next non-aversive task (e.g., a video game). An alarm or therapist prompt is used to signal the time to move between tasks. Multiple sets of tasks may be included in one practice session. Once the student demonstrates the ability to transition effectively between non-aversive tasks, the therapy can incorporate the more challenging tasks involved in ERP.
- Diversify the student’s sources of self-worth.
Students with DAP derive their self-worth disproportionately from academic achievement, which further magnifies the threat of doing poorly in school. It is helpful to encourage students to look beyond academics when determining their self-worth. This includes helping them clarify their non-academic values, recognize other interests and talents, and increase their participation in non-academic activities (e.g., social interaction, hobbies, paid or volunteer work, etc.).
- Encourage more flexible long-term goals.
It is common for students with DAP to view certain goals as the ultimate goal, for example, fixating on only certain universities, one professional role, or a specific occupational title. Anything short of that is perceived as failure. It is easy to see how goals like this contribute to academic anxiety. The narrower the definition of success, the greater the chance for “failure.” It is therefore helpful to encourage students to broaden their options. Interventions like cognitive restructuring, values clarification, and motivational interviewing can help students expand their list of acceptable options and develop realistic contingency plans in case their preferred options do not materialize.
DAP is a potentially disabling condition, but in the hands of a skilled OCD therapist, it is highly treatable (Szymanski, 2011). We hope we have encouraged more therapists to work with DAP and that the information we have shared improves the quality of the care they provide.
Curren, T., Hill, A.P. (2019). Perfectionism is increasing over time: A meta-analysis of birth cohort differences from 1989 to 2016. Psychological Bulletin, 145, 410-429.
Frost, R.O, Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14, 449-468.
Hood, H.K., & Antony, M.M. (2016). Treatment of perfectionism-related obsessive- compulsive disorders. In E.A., Storch & A., Lewin (Eds.), Clinical Handbook of Obsessive-Compulsive and Related Disorders, pp. 85-97. Springer.
Shafran, R., Egan, S., & Wade, T. (2019). Overcoming perfectionism: A self-help guide using scientifically supported cognitive behavioural techniques (2nd Ed.). London: Robinson Publishing.
Sulkowski, M.L., Jordan, C., Dobrinsky, S.R., & Mathews, R.E. (2018). Chapter 12 - OCD in School Settings. In E.A. Storch, J.F. McGuire, & D. McKay (Eds.), The Clinician's Guide to Cognitive-Behavioral Therapy for Childhood Obsessive-compulsive Disorder (pp. 225-241). Academic Press.
Szymanski, J. (2011). The perfectionist’s handbook: Take risks, invite criticism, and make the most of your mistakes. New York: Wiley Publishing.