Rpsych

Strong evidence for the efficacy of dialectical behavior therapy (DBT) for patients with borderline personality disorder (BPD) has brought hope to clinicians and patients alike. By including cognitive therapy, behavioral strategies, skills training, and exposure therapy, DBT addresses more than just self-harm and suicidal behavior (Box 1).^1-13 In fact, DBT’s primary interventions—such as skills training in emotion regulation and a straightforward approach to dysfunctional behaviors—could help many people.

Because DBT is so comprehensive and practical, clinicians might be tempted to refer almost anyone who seems even slightly “borderline” for DBT. But some patients—particularly those with mood and anxiety disorders—might benefit more from other treatments. To help you make appropriate evidence-based referrals for DBT and other psychological treatments, this article recommends 4 steps:

• Know what the treatment involves.
• Consider the evidence for the treatment in patients similar to yours.
• Consider why your patient—with unique characteristics and problems—would benefit from these specific interventions.
• Communicate to the patient your reasons for the referral.

Box 1

Step 1. What does DBT involve?

Difficulty with emotion regulation. DBT is based on a biosocial theory of BPD.¹ Within this framework, BPD is caused by the transaction (mutual interplay) of a biologically based vulnerability to emotions with an invalidating rearing environment. The patient with BPD typically experiences strong and long-lasting emotional reactions, often to seemingly small or insignificant events such as a slight look of disappointment on someone’s face or a minor daily hassle. Patients with BPD often are especially attuned to emotional reactions, particularly signs of rejection or disapproval.

Caregivers in an invalidating environment fail to provide the support a highly emotional child needs to learn to manage intense emotions. An invalidating environment:

• indiscriminately rejects the child’s communication of emotions and thoughts as invalid, independent of the validity of the child’s experience
• punishes emotional displays, then intermittently reinforces emotional escalation
• oversimplifies the ease of problem solving or coping.¹

As a result, the fledgling BPD individual learns to mistrust and fear emotions and does not learn how to manage them. A patient with BPD is like a car with a powerful “emotional engine” but lacking brakes.

Team treatment. The standard DBT treatment package is an outpatient program run by a team.¹ Therapists meet weekly for consultation to help them execute DBT according to the manual, prevent burn-out, and improve skills and motivation to treat patients with multiple, severe problems. The team also maintains the DBT program’s integrity and functioning and ensures that all treatment components—including individual therapy and skills training—are in place.

In individual therapy, the therapist and client collaborate to help the client reduce dysfunctional behaviors, increase motivation, and work toward goals. Because persons with BPD often present with many serious life problems, the therapist organizes session time to address 3 main priorities:

• Life-threatening behavior (intentional self-injury or imminent threat of intentional self-injury, including suicidal crises or threats, severe suicidal ideation or urges, suicide attempts, nonsuicidal self-injury or self-injury urges, or similar behaviors).
• Therapy-interfering behaviors (actions by the therapist or patient that interfere with progress, such as angry outbursts, missed sessions, or tardiness).
• Quality-of-life-interfering behavior (behaviors or problems—such as depression, eating disorders, or substance use disorders; homelessness or financial difficulties; or serious interpersonal discord—that make it hard for the patient to establish a reasonable quality of life).

 

Additional priorities include skills deficits and secondary targets.¹ Each week, the client monitors his or her behaviors, emotions, and actions using a diary card. The therapist uses this information to collaboratively prioritize the focus of each individual therapy session.

Skills training typically occurs weekly in group sessions of 1.5 to 2.5 hours with 1 or 2 therapists. This structured, psycho-educational training focuses on skills that persons with BPD often lack:

• mindfulness (paying attention to the experience of the present moment)
• emotion regulation (regulating or managing distressing emotions)
• distress tolerance (averting crises, tolerating or accepting distressing situations or emotions)
• interpersonal effectiveness (maintaining relationships and asserting needs or wishes).

Therapists often use the first half of group sessions to review each patient’s homework and to provide feedback and coaching on effective skill use. The remaining time is spent teaching new skills. The therapist then assigns homework to practice new skills and closes with a wind-down exercise, often involving relaxation training.

Step 2. Consider the evidence

Before you make a referral for DBT (or any psychological treatment), know what the research says about who is likely to benefit from it. For women with BPD, DBT is the only treatment that can be considered “well-established.”^3,14 The literature on DBT includes 10 randomized controlled trials (as well as many uncontrolled trials), and the strongest research supports its use in women with BPD.^2,4-13

Based on a detailed review of the literature on DBT, I recommend a basic, evidence-based priority list for referrals (Table 1).^3,12,13 Patient groups at the top are most likely to benefit from DBT—according to the most solid, rigorous research—and deserve your strongest consideration for referral. Patient groups further down the list—with fewer rigorous studies of DBT—merit less consideration of DBT as the treatment of choice. Of course to use this list, an accurate diagnosis of your patient’s problems is essential.

DBT’s treatment strategies—exposure therapy, skills training, cognitive therapy, emotion regulation training, and mindfulness—can work for other types of patients. I have noticed, however, that some clinicians refer patients with depression, anxiety disorders, or even bipolar disorder for DBT. Despite DBT’s intuitive appeal, sufficient evidence does not yet support its use in patients with these disorders. Other evidence-based treatments may be more suitable for patients with uncomplicated mood and anxiety disorders (Table 2).³

Table 1

Candidates for DBT: An evidence-based referral priority list*

	Women with BPD who are suicidal or who self-harm (without bipolar disorder, a psychotic disorder, or mental retardation). One randomized clinical trial with suicidal individuals with BPD included men. Two studies excluded participants with substance dependence, but the most recent, largest study13 did not.
	Women with BPD and substance use problems (without bipolar disorder, a psychotic disorder, or cognitive impairment)
	Women with bulimia nervosa or binge-eating disorder (without substance abuse, psychotic disorder, or suicidal ideation). Other empirically supported treatments exist for these patients (Table 2).
	Depressed older adults (age ≥60, without bipolar disorder, a psychotic disorder, or cognitive impairment). Investigated treatments included group DBT skills training, telephone consultation, selective serotonin reuptake inhibitor medications, and psychiatric clinical management.12
	Suicidal and nonsuicidal adolescentswith oppositional defiant disorder or bipolar disorder
	Incarcerated men and womenwith or without BPD, in high- and low-security forensic settings
	Couples and families where 1 member has BPDor where domestic violence occurs in an intimate relationship
* Persons at the top of the list are the ones for whom the most solid, rigorous research has demonstrated the efficacy of DBT. Fewer rigorous studies of DBT have been conducted in persons further down the list.
BPD: borderline personality disorder; DBT: dialectical behavior therapy
Source: References 3,12,13

Table 2

When not to refer a patient for DBT: Evidence is stronger for alternate treatments

Diagnosis	Treatments with empirical support
Major depressive disorder	CBT, behavioral activation, interpersonal therapy, antidepressant medication, mindfulness-based cognitive therapy for depressive relapse
Panic disorder/panic disorder with agoraphobia	CBT involving cognitive therapy and exposure-based with agoraphobia interventions
Posttraumatic stress disorder	Prolonged exposure therapy, cognitive therapy, EMDR
Bulimia nervosa	CBT, interpersonal therapy
Primary substance use disorders	CBT, motivational enhancement/motivational interviewing, community reinforcement approach
Psychotic disorders	Medication management, social skills training, family-based interventions
CBT: cognitive-behavioral therapy; DBT: dialectical behavior therapy; EMDR: eye movement desensitization and reprocessing therapy
Source: Reference 3

Step 3: Would this patient benefit?

Would your patient, with unique struggles and characteristics, benefit from DBT? Consider to what degree DBT’s interventions would solve some of your patient’s problems and whether DBT fits your patient’s needs.

DBT’s target problems. In controlled trials, DBT’s pragmatic approach outperforms comparator treatments in reducing suicidal behaviors and self-injury, and DBT therapists monitor and target these behaviors. Thus, because few treatments reduce self-injury,^15,16 you might consider DBT for patients who self-injure even if they do not have BPD.

 

DBT also includes a strong focus on emotions and emotion regulation. Therefore, if difficulty managing emotions is among your patient’s primary problems, DBT may offer some benefit. DBT also includes structured interpersonal skills training that might be useful for patients who lack assertiveness.

Finally, if you have a patient with multiple diagnoses and severe problems—but not psychosis—the DBT approach to organizing and prioritizing treatment targets may be beneficial. Some multi-diagnosis patients may struggle with aspects of DBT (such as learning new skills), but DBT is set up to incorporate other empirically supported treatment protocols for co-occurring Axis I and II disorders.

Does DBT ‘fit’ your patient? DBT is very structured and involves direct discussions of maladaptive behaviors. If your patient prefers or would benefit from a structured approach, you might consider a referral for DBT.

DBT is an outpatient behavioral treatment that focuses on the here and now. DBT might not be the best fit if your patient:

• views his or her problems as resulting primarily from childhood experiences or relationships with parents
• would prefer insight-oriented therapy.

If, however, your patient would like a practical approach focused on problem-solving, DBT could be an effective choice.

DBT is based in part on a dialectical philosophy, and DBT therapists often seek to bring together or synthesize polarized thinking. If your patient struggles with “black or white” thinking, this dialectical philosophy might be helpful. On the other hand, DBT might not be the best fit if your patient is particularly rigid in thinking or seems to require cognitive therapy to address his or her thought patterns.

DBT is not the treatment of choice for all personality disorders. Most of the evidence examines its use for BPD, and few studies have looked at any other personality disorder. Also, keep in mind that being interpersonally “difficult” does not mean that a patient is “borderline” or needs DBT.

Step 4: Communicate reasons for referral to your patient

Finally, communicate to your patient the reasons you are referring him or her for DBT. Patients often walk into my office for DBT, confused about why they are there. If patients understand why they have been referred for DBT and how it may help them, they may be more likely to follow through and realize its benefits.

A sample explanation of referral that I offer to guide this communication (Box 2) includes 3 main points:

• my diagnosis or conceptualization of the patient’s clinical problems
• a brief description of DBT
• a rationale for why DBT would be a good fit, and what kinds of benefits the patient might receive.

Box 2

Related Resources

• Chapman AL, Gratz KL. The borderline personality disorder survival guide: everything you need to know about living with BPD. Oakland, CA: New Harbinger Publications; 2007.
• National Education Alliance for Borderline Personality Disorder. Information for professionals, patients, and families. www.neabpd.org.
• Behavioral Tech, LLC, founded by Marsha Linehan, PhD. DBT training and resources, including a directory of DBT therapists. www.behavioraltech.org.
• Dialectical Behaviour Therapy Centre of Vancouver. www.dbtvancouver.com.

 

Disclosure

The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Strong evidence for the efficacy of dialectical behavior therapy (DBT) for patients with borderline personality disorder (BPD) has brought hope to clinicians and patients alike. By including cognitive therapy, behavioral strategies, skills training, and exposure therapy, DBT addresses more than just self-harm and suicidal behavior (Box 1).^1-13 In fact, DBT’s primary interventions—such as skills training in emotion regulation and a straightforward approach to dysfunctional behaviors—could help many people.

Because DBT is so comprehensive and practical, clinicians might be tempted to refer almost anyone who seems even slightly “borderline” for DBT. But some patients—particularly those with mood and anxiety disorders—might benefit more from other treatments. To help you make appropriate evidence-based referrals for DBT and other psychological treatments, this article recommends 4 steps:

• Know what the treatment involves.
• Consider the evidence for the treatment in patients similar to yours.
• Consider why your patient—with unique characteristics and problems—would benefit from these specific interventions.
• Communicate to the patient your reasons for the referral.

Box 1

Step 1. What does DBT involve?

Difficulty with emotion regulation. DBT is based on a biosocial theory of BPD.¹ Within this framework, BPD is caused by the transaction (mutual interplay) of a biologically based vulnerability to emotions with an invalidating rearing environment. The patient with BPD typically experiences strong and long-lasting emotional reactions, often to seemingly small or insignificant events such as a slight look of disappointment on someone’s face or a minor daily hassle. Patients with BPD often are especially attuned to emotional reactions, particularly signs of rejection or disapproval.

Caregivers in an invalidating environment fail to provide the support a highly emotional child needs to learn to manage intense emotions. An invalidating environment:

• indiscriminately rejects the child’s communication of emotions and thoughts as invalid, independent of the validity of the child’s experience
• punishes emotional displays, then intermittently reinforces emotional escalation
• oversimplifies the ease of problem solving or coping.¹

As a result, the fledgling BPD individual learns to mistrust and fear emotions and does not learn how to manage them. A patient with BPD is like a car with a powerful “emotional engine” but lacking brakes.

Team treatment. The standard DBT treatment package is an outpatient program run by a team.¹ Therapists meet weekly for consultation to help them execute DBT according to the manual, prevent burn-out, and improve skills and motivation to treat patients with multiple, severe problems. The team also maintains the DBT program’s integrity and functioning and ensures that all treatment components—including individual therapy and skills training—are in place.

In individual therapy, the therapist and client collaborate to help the client reduce dysfunctional behaviors, increase motivation, and work toward goals. Because persons with BPD often present with many serious life problems, the therapist organizes session time to address 3 main priorities:

• Life-threatening behavior (intentional self-injury or imminent threat of intentional self-injury, including suicidal crises or threats, severe suicidal ideation or urges, suicide attempts, nonsuicidal self-injury or self-injury urges, or similar behaviors).
• Therapy-interfering behaviors (actions by the therapist or patient that interfere with progress, such as angry outbursts, missed sessions, or tardiness).
• Quality-of-life-interfering behavior (behaviors or problems—such as depression, eating disorders, or substance use disorders; homelessness or financial difficulties; or serious interpersonal discord—that make it hard for the patient to establish a reasonable quality of life).

 

Additional priorities include skills deficits and secondary targets.¹ Each week, the client monitors his or her behaviors, emotions, and actions using a diary card. The therapist uses this information to collaboratively prioritize the focus of each individual therapy session.

Skills training typically occurs weekly in group sessions of 1.5 to 2.5 hours with 1 or 2 therapists. This structured, psycho-educational training focuses on skills that persons with BPD often lack:

• mindfulness (paying attention to the experience of the present moment)
• emotion regulation (regulating or managing distressing emotions)
• distress tolerance (averting crises, tolerating or accepting distressing situations or emotions)
• interpersonal effectiveness (maintaining relationships and asserting needs or wishes).

Therapists often use the first half of group sessions to review each patient’s homework and to provide feedback and coaching on effective skill use. The remaining time is spent teaching new skills. The therapist then assigns homework to practice new skills and closes with a wind-down exercise, often involving relaxation training.

Step 2. Consider the evidence

Before you make a referral for DBT (or any psychological treatment), know what the research says about who is likely to benefit from it. For women with BPD, DBT is the only treatment that can be considered “well-established.”^3,14 The literature on DBT includes 10 randomized controlled trials (as well as many uncontrolled trials), and the strongest research supports its use in women with BPD.^2,4-13

Based on a detailed review of the literature on DBT, I recommend a basic, evidence-based priority list for referrals (Table 1).^3,12,13 Patient groups at the top are most likely to benefit from DBT—according to the most solid, rigorous research—and deserve your strongest consideration for referral. Patient groups further down the list—with fewer rigorous studies of DBT—merit less consideration of DBT as the treatment of choice. Of course to use this list, an accurate diagnosis of your patient’s problems is essential.

DBT’s treatment strategies—exposure therapy, skills training, cognitive therapy, emotion regulation training, and mindfulness—can work for other types of patients. I have noticed, however, that some clinicians refer patients with depression, anxiety disorders, or even bipolar disorder for DBT. Despite DBT’s intuitive appeal, sufficient evidence does not yet support its use in patients with these disorders. Other evidence-based treatments may be more suitable for patients with uncomplicated mood and anxiety disorders (Table 2).³

Table 1

Candidates for DBT: An evidence-based referral priority list*

	Women with BPD who are suicidal or who self-harm (without bipolar disorder, a psychotic disorder, or mental retardation). One randomized clinical trial with suicidal individuals with BPD included men. Two studies excluded participants with substance dependence, but the most recent, largest study13 did not.
	Women with BPD and substance use problems (without bipolar disorder, a psychotic disorder, or cognitive impairment)
	Women with bulimia nervosa or binge-eating disorder (without substance abuse, psychotic disorder, or suicidal ideation). Other empirically supported treatments exist for these patients (Table 2).
	Depressed older adults (age ≥60, without bipolar disorder, a psychotic disorder, or cognitive impairment). Investigated treatments included group DBT skills training, telephone consultation, selective serotonin reuptake inhibitor medications, and psychiatric clinical management.12
	Suicidal and nonsuicidal adolescentswith oppositional defiant disorder or bipolar disorder
	Incarcerated men and womenwith or without BPD, in high- and low-security forensic settings
	Couples and families where 1 member has BPDor where domestic violence occurs in an intimate relationship
* Persons at the top of the list are the ones for whom the most solid, rigorous research has demonstrated the efficacy of DBT. Fewer rigorous studies of DBT have been conducted in persons further down the list.
BPD: borderline personality disorder; DBT: dialectical behavior therapy
Source: References 3,12,13

Table 2

When not to refer a patient for DBT: Evidence is stronger for alternate treatments

Diagnosis	Treatments with empirical support
Major depressive disorder	CBT, behavioral activation, interpersonal therapy, antidepressant medication, mindfulness-based cognitive therapy for depressive relapse
Panic disorder/panic disorder with agoraphobia	CBT involving cognitive therapy and exposure-based with agoraphobia interventions
Posttraumatic stress disorder	Prolonged exposure therapy, cognitive therapy, EMDR
Bulimia nervosa	CBT, interpersonal therapy
Primary substance use disorders	CBT, motivational enhancement/motivational interviewing, community reinforcement approach
Psychotic disorders	Medication management, social skills training, family-based interventions
CBT: cognitive-behavioral therapy; DBT: dialectical behavior therapy; EMDR: eye movement desensitization and reprocessing therapy
Source: Reference 3

Step 3: Would this patient benefit?

Would your patient, with unique struggles and characteristics, benefit from DBT? Consider to what degree DBT’s interventions would solve some of your patient’s problems and whether DBT fits your patient’s needs.

DBT’s target problems. In controlled trials, DBT’s pragmatic approach outperforms comparator treatments in reducing suicidal behaviors and self-injury, and DBT therapists monitor and target these behaviors. Thus, because few treatments reduce self-injury,^15,16 you might consider DBT for patients who self-injure even if they do not have BPD.

 

DBT also includes a strong focus on emotions and emotion regulation. Therefore, if difficulty managing emotions is among your patient’s primary problems, DBT may offer some benefit. DBT also includes structured interpersonal skills training that might be useful for patients who lack assertiveness.

Finally, if you have a patient with multiple diagnoses and severe problems—but not psychosis—the DBT approach to organizing and prioritizing treatment targets may be beneficial. Some multi-diagnosis patients may struggle with aspects of DBT (such as learning new skills), but DBT is set up to incorporate other empirically supported treatment protocols for co-occurring Axis I and II disorders.

Does DBT ‘fit’ your patient? DBT is very structured and involves direct discussions of maladaptive behaviors. If your patient prefers or would benefit from a structured approach, you might consider a referral for DBT.

DBT is an outpatient behavioral treatment that focuses on the here and now. DBT might not be the best fit if your patient:

• views his or her problems as resulting primarily from childhood experiences or relationships with parents
• would prefer insight-oriented therapy.

If, however, your patient would like a practical approach focused on problem-solving, DBT could be an effective choice.

DBT is based in part on a dialectical philosophy, and DBT therapists often seek to bring together or synthesize polarized thinking. If your patient struggles with “black or white” thinking, this dialectical philosophy might be helpful. On the other hand, DBT might not be the best fit if your patient is particularly rigid in thinking or seems to require cognitive therapy to address his or her thought patterns.

DBT is not the treatment of choice for all personality disorders. Most of the evidence examines its use for BPD, and few studies have looked at any other personality disorder. Also, keep in mind that being interpersonally “difficult” does not mean that a patient is “borderline” or needs DBT.

Step 4: Communicate reasons for referral to your patient

Finally, communicate to your patient the reasons you are referring him or her for DBT. Patients often walk into my office for DBT, confused about why they are there. If patients understand why they have been referred for DBT and how it may help them, they may be more likely to follow through and realize its benefits.

A sample explanation of referral that I offer to guide this communication (Box 2) includes 3 main points:

• my diagnosis or conceptualization of the patient’s clinical problems
• a brief description of DBT
• a rationale for why DBT would be a good fit, and what kinds of benefits the patient might receive.

Box 2

Related Resources

• Chapman AL, Gratz KL. The borderline personality disorder survival guide: everything you need to know about living with BPD. Oakland, CA: New Harbinger Publications; 2007.
• National Education Alliance for Borderline Personality Disorder. Information for professionals, patients, and families. www.neabpd.org.
• Behavioral Tech, LLC, founded by Marsha Linehan, PhD. DBT training and resources, including a directory of DBT therapists. www.behavioraltech.org.
• Dialectical Behaviour Therapy Centre of Vancouver. www.dbtvancouver.com.

 

Disclosure

The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Strong evidence for the efficacy of dialectical behavior therapy (DBT) for patients with borderline personality disorder (BPD) has brought hope to clinicians and patients alike. By including cognitive therapy, behavioral strategies, skills training, and exposure therapy, DBT addresses more than just self-harm and suicidal behavior (Box 1).^1-13 In fact, DBT’s primary interventions—such as skills training in emotion regulation and a straightforward approach to dysfunctional behaviors—could help many people.

Because DBT is so comprehensive and practical, clinicians might be tempted to refer almost anyone who seems even slightly “borderline” for DBT. But some patients—particularly those with mood and anxiety disorders—might benefit more from other treatments. To help you make appropriate evidence-based referrals for DBT and other psychological treatments, this article recommends 4 steps:

• Know what the treatment involves.
• Consider the evidence for the treatment in patients similar to yours.
• Consider why your patient—with unique characteristics and problems—would benefit from these specific interventions.
• Communicate to the patient your reasons for the referral.

Box 1

Step 1. What does DBT involve?

Difficulty with emotion regulation. DBT is based on a biosocial theory of BPD.¹ Within this framework, BPD is caused by the transaction (mutual interplay) of a biologically based vulnerability to emotions with an invalidating rearing environment. The patient with BPD typically experiences strong and long-lasting emotional reactions, often to seemingly small or insignificant events such as a slight look of disappointment on someone’s face or a minor daily hassle. Patients with BPD often are especially attuned to emotional reactions, particularly signs of rejection or disapproval.

Caregivers in an invalidating environment fail to provide the support a highly emotional child needs to learn to manage intense emotions. An invalidating environment:

• indiscriminately rejects the child’s communication of emotions and thoughts as invalid, independent of the validity of the child’s experience
• punishes emotional displays, then intermittently reinforces emotional escalation
• oversimplifies the ease of problem solving or coping.¹

As a result, the fledgling BPD individual learns to mistrust and fear emotions and does not learn how to manage them. A patient with BPD is like a car with a powerful “emotional engine” but lacking brakes.

Team treatment. The standard DBT treatment package is an outpatient program run by a team.¹ Therapists meet weekly for consultation to help them execute DBT according to the manual, prevent burn-out, and improve skills and motivation to treat patients with multiple, severe problems. The team also maintains the DBT program’s integrity and functioning and ensures that all treatment components—including individual therapy and skills training—are in place.

In individual therapy, the therapist and client collaborate to help the client reduce dysfunctional behaviors, increase motivation, and work toward goals. Because persons with BPD often present with many serious life problems, the therapist organizes session time to address 3 main priorities:

• Life-threatening behavior (intentional self-injury or imminent threat of intentional self-injury, including suicidal crises or threats, severe suicidal ideation or urges, suicide attempts, nonsuicidal self-injury or self-injury urges, or similar behaviors).
• Therapy-interfering behaviors (actions by the therapist or patient that interfere with progress, such as angry outbursts, missed sessions, or tardiness).
• Quality-of-life-interfering behavior (behaviors or problems—such as depression, eating disorders, or substance use disorders; homelessness or financial difficulties; or serious interpersonal discord—that make it hard for the patient to establish a reasonable quality of life).

 

Additional priorities include skills deficits and secondary targets.¹ Each week, the client monitors his or her behaviors, emotions, and actions using a diary card. The therapist uses this information to collaboratively prioritize the focus of each individual therapy session.

Skills training typically occurs weekly in group sessions of 1.5 to 2.5 hours with 1 or 2 therapists. This structured, psycho-educational training focuses on skills that persons with BPD often lack:

• mindfulness (paying attention to the experience of the present moment)
• emotion regulation (regulating or managing distressing emotions)
• distress tolerance (averting crises, tolerating or accepting distressing situations or emotions)
• interpersonal effectiveness (maintaining relationships and asserting needs or wishes).

Therapists often use the first half of group sessions to review each patient’s homework and to provide feedback and coaching on effective skill use. The remaining time is spent teaching new skills. The therapist then assigns homework to practice new skills and closes with a wind-down exercise, often involving relaxation training.

Step 2. Consider the evidence

Before you make a referral for DBT (or any psychological treatment), know what the research says about who is likely to benefit from it. For women with BPD, DBT is the only treatment that can be considered “well-established.”^3,14 The literature on DBT includes 10 randomized controlled trials (as well as many uncontrolled trials), and the strongest research supports its use in women with BPD.^2,4-13

Based on a detailed review of the literature on DBT, I recommend a basic, evidence-based priority list for referrals (Table 1).^3,12,13 Patient groups at the top are most likely to benefit from DBT—according to the most solid, rigorous research—and deserve your strongest consideration for referral. Patient groups further down the list—with fewer rigorous studies of DBT—merit less consideration of DBT as the treatment of choice. Of course to use this list, an accurate diagnosis of your patient’s problems is essential.

DBT’s treatment strategies—exposure therapy, skills training, cognitive therapy, emotion regulation training, and mindfulness—can work for other types of patients. I have noticed, however, that some clinicians refer patients with depression, anxiety disorders, or even bipolar disorder for DBT. Despite DBT’s intuitive appeal, sufficient evidence does not yet support its use in patients with these disorders. Other evidence-based treatments may be more suitable for patients with uncomplicated mood and anxiety disorders (Table 2).³

Table 1

Candidates for DBT: An evidence-based referral priority list*

	Women with BPD who are suicidal or who self-harm (without bipolar disorder, a psychotic disorder, or mental retardation). One randomized clinical trial with suicidal individuals with BPD included men. Two studies excluded participants with substance dependence, but the most recent, largest study13 did not.
	Women with BPD and substance use problems (without bipolar disorder, a psychotic disorder, or cognitive impairment)
	Women with bulimia nervosa or binge-eating disorder (without substance abuse, psychotic disorder, or suicidal ideation). Other empirically supported treatments exist for these patients (Table 2).
	Depressed older adults (age ≥60, without bipolar disorder, a psychotic disorder, or cognitive impairment). Investigated treatments included group DBT skills training, telephone consultation, selective serotonin reuptake inhibitor medications, and psychiatric clinical management.12
	Suicidal and nonsuicidal adolescentswith oppositional defiant disorder or bipolar disorder
	Incarcerated men and womenwith or without BPD, in high- and low-security forensic settings
	Couples and families where 1 member has BPDor where domestic violence occurs in an intimate relationship
* Persons at the top of the list are the ones for whom the most solid, rigorous research has demonstrated the efficacy of DBT. Fewer rigorous studies of DBT have been conducted in persons further down the list.
BPD: borderline personality disorder; DBT: dialectical behavior therapy
Source: References 3,12,13

Table 2

When not to refer a patient for DBT: Evidence is stronger for alternate treatments

Diagnosis	Treatments with empirical support
Major depressive disorder	CBT, behavioral activation, interpersonal therapy, antidepressant medication, mindfulness-based cognitive therapy for depressive relapse
Panic disorder/panic disorder with agoraphobia	CBT involving cognitive therapy and exposure-based with agoraphobia interventions
Posttraumatic stress disorder	Prolonged exposure therapy, cognitive therapy, EMDR
Bulimia nervosa	CBT, interpersonal therapy
Primary substance use disorders	CBT, motivational enhancement/motivational interviewing, community reinforcement approach
Psychotic disorders	Medication management, social skills training, family-based interventions
CBT: cognitive-behavioral therapy; DBT: dialectical behavior therapy; EMDR: eye movement desensitization and reprocessing therapy
Source: Reference 3

Step 3: Would this patient benefit?

Would your patient, with unique struggles and characteristics, benefit from DBT? Consider to what degree DBT’s interventions would solve some of your patient’s problems and whether DBT fits your patient’s needs.

DBT’s target problems. In controlled trials, DBT’s pragmatic approach outperforms comparator treatments in reducing suicidal behaviors and self-injury, and DBT therapists monitor and target these behaviors. Thus, because few treatments reduce self-injury,^15,16 you might consider DBT for patients who self-injure even if they do not have BPD.

 

DBT also includes a strong focus on emotions and emotion regulation. Therefore, if difficulty managing emotions is among your patient’s primary problems, DBT may offer some benefit. DBT also includes structured interpersonal skills training that might be useful for patients who lack assertiveness.

Finally, if you have a patient with multiple diagnoses and severe problems—but not psychosis—the DBT approach to organizing and prioritizing treatment targets may be beneficial. Some multi-diagnosis patients may struggle with aspects of DBT (such as learning new skills), but DBT is set up to incorporate other empirically supported treatment protocols for co-occurring Axis I and II disorders.

Does DBT ‘fit’ your patient? DBT is very structured and involves direct discussions of maladaptive behaviors. If your patient prefers or would benefit from a structured approach, you might consider a referral for DBT.

DBT is an outpatient behavioral treatment that focuses on the here and now. DBT might not be the best fit if your patient:

• views his or her problems as resulting primarily from childhood experiences or relationships with parents
• would prefer insight-oriented therapy.

If, however, your patient would like a practical approach focused on problem-solving, DBT could be an effective choice.

DBT is based in part on a dialectical philosophy, and DBT therapists often seek to bring together or synthesize polarized thinking. If your patient struggles with “black or white” thinking, this dialectical philosophy might be helpful. On the other hand, DBT might not be the best fit if your patient is particularly rigid in thinking or seems to require cognitive therapy to address his or her thought patterns.

DBT is not the treatment of choice for all personality disorders. Most of the evidence examines its use for BPD, and few studies have looked at any other personality disorder. Also, keep in mind that being interpersonally “difficult” does not mean that a patient is “borderline” or needs DBT.

Step 4: Communicate reasons for referral to your patient

Finally, communicate to your patient the reasons you are referring him or her for DBT. Patients often walk into my office for DBT, confused about why they are there. If patients understand why they have been referred for DBT and how it may help them, they may be more likely to follow through and realize its benefits.

A sample explanation of referral that I offer to guide this communication (Box 2) includes 3 main points:

• my diagnosis or conceptualization of the patient’s clinical problems
• a brief description of DBT
• a rationale for why DBT would be a good fit, and what kinds of benefits the patient might receive.

Box 2

Related Resources

• Chapman AL, Gratz KL. The borderline personality disorder survival guide: everything you need to know about living with BPD. Oakland, CA: New Harbinger Publications; 2007.
• National Education Alliance for Borderline Personality Disorder. Information for professionals, patients, and families. www.neabpd.org.
• Behavioral Tech, LLC, founded by Marsha Linehan, PhD. DBT training and resources, including a directory of DBT therapists. www.behavioraltech.org.
• Dialectical Behaviour Therapy Centre of Vancouver. www.dbtvancouver.com.

 

Disclosure

The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Mr. C is a 50-year-old professional writer who recently made a serious suicide attempt. At his initial session, Mr. C was hesitant to discuss his situation and reason for attending. He did, however, bring a copy of his résumé so the therapist could “get to know him quickly.”

He said he had been depressed for a long time, especially since he found an error in one of his published works. His confidence and writing abilities seemed to decline after this discovery, his career took a downturn, and ultimately he was fired from his position. He described often being at odds with his supervisors at work, whom he saw as critical and condescending. He was mortified by his job loss and did not inform his wife or friends of his firing.

Mr. C had always been a bit of a loner, and after losing his job he further distanced himself from others. He began drinking heavily to avoid the pain of “letting everyone down.” His wife, family, and friends were shocked at the suicide attempt and expressed dismay that Mr. C had not confided in anyone.

Mr. C describes himself as being perfectionistic throughout his life and never being quite good enough in any of his pursuits. This leads to self-recriminations and persistent feelings of shame.

Far from being a positive attribute, perfectionism is a neurotic personality style that can result in serious psychopathology, including relationship problems, depression, anorexia nervosa, and suicide. Determining a patient’s perfectionistic traits is essential when evaluating those who seek treatment specifically for this distressing behavior as well as patients in treatment for other issues who may have a perfectionistic personality. Accurately assessing perfectionism can help you predict and forestall noncompliance, assess suicide risk, determine appropriate treatment and identify circumstances under which a patient might be particularly vulnerable to relapse.

This article describes:

• 3 traits of perfectionism
  
• 3 dimensions of perfectionistic self-presentation
  
• perfectionistic cognitions
  
• useful self-report tools for clinical practice
  
• effective treatments.
  

Characteristics of perfectionism

Although perfectionism initially was viewed as self-related cognitions, recent models suggest it incorporates intrapersonal and interpersonal dimensions.¹ A person with perfectionism has a marked need for absolute perfection for the self and/or others in many—if not all—pursuits that is strongly rooted in his or her intrapersonal and interpersonal worlds. Other characteristics of perfectionism include:

• equating self-worth or esteem with performance
  
• self-punishment in failure and a lack of satisfaction in success
  
• maintaining and needing to strive for unrealistic expectations
  
• unrealistic criteria for success and broad criteria for failure.
  

Some clinicians have suggested that perfectionism may be adaptive,² but “adaptive perfectionism” is more likely a reflection of conscientiousness or achievement striving (Table 1). Although perfectionism can involve rumination, it is much broader than simply having an obsessional cognitive style.

We define perfectionism as a neurotic personality style involving perfectionist traits, self-presentation styles, and cognitions that is a core vulnerability factor for a variety of psychological, physical, achievement, and relationship problems (Table 2).^1,3

3 traits. Three traits of perfectionism reflect the desire for the self or others to be perfect:

• self-oriented perfectionism—a requirement for the self to be perfect
  
• other-oriented perfectionism—a requirement for others to be perfect
  
• socially prescribed perfectionism—a perception that others require perfection of oneself.
  

Each of these traits is associated with different Axis I and Axis II disorders, which we outline below.⁴ In addition to these traits, perfectionism includes interpersonal and intrapersonal expressions.

3 self-presentational dimensions. The interpersonal expression of perfectionism is perfectionistic self-presentation. In our model, the 3 facets of perfectionistic self-presentation are:

• perfectionistic self-promotion—overt displays and statements of one’s supposed “perfection”
  
• nondisplay of imperfections—hiding any imperfections
  
• nondisclosure of imperfections—avoiding disclosure or discussion of any imperfection.³
  

Perfectionistic cognitions. The intrapersonal expression of perfectionism is perfectionistic information processing and ruminative thoughts regarding the need for perfection for the self or others.⁵ This state component reflects the self-related inner dialogue of the patient’s requirement for perfection, recriminations, etc. Perfectionistic cognitions are associated with state levels of distress and symptom severity.

Table 1

How perfectionism differs from conscientiousness

Perfectionism	Achievement striving/conscientiousness
Receives no satisfaction from any performance	Experiences satisfaction with good performance
Experiences no rewards from any performance	Rewards self or others for good performance
Maintains expectations in the face of failure	Alters expectations in the face of failure
Is motivated by fear of failure	Is motivated by desire for success
Shows poor organization	Is organized
Focuses on flaws as indication of self-worth	Focuses less on flaws

 

Table 2

Psychopathologies associated with perfectionism

Perfectionism component	Description	Psychiatric outcomes
Perfectionism traits
Self-oriented perfectionism	Requires self to be perfect	Unipolar depression, anorexia nervosa
Other-oriented perfectionism	Requires others to be perfect	Personality disorders (PDs), relationship problems
Socially prescribed perfectionism	Perceives that others require one to be perfect	Suicidal behavior, general distress
Perfectionistic self-presentational styles
Perfectionistic self-promotion	Overtly promotes one’s ‘perfection’	Narcissistic PD, other dramatic cluster PDs
Nondisplay of imperfections	Avoids demonstrating one’s imperfection	Poor help seeking, treatment nonadherence, anxiety in assessment and therapy
Nondisclosure of imperfections	Hides perceived imperfections from others	Poor therapy alliance, relationship problems
Perfectionistic cognitions	Inner dialogue regarding requirement to be perfect	General distress, severity of depression, anxiety
Source: References 1,3,5

Traits tied to psychopathology

Each of the 3 traits of perfectionism in our model has been associated with psychopathology in multiple studies.

Self-oriented perfectionism is often involved in Axis I disorders, including unipolar depression. This trait is elevated among adults and children diagnosed with major depressive disorder and may be pernicious in the presence of stressors, particularly achievement-related ones.⁶ In other words, self-oriented perfectionism appears to be a risk factor for unipolar depression.^7,8

It also is elevated in women with anorexia nervosa compared with normal and psychiatric controls.⁹ Individuals with anorexia nervosa appear to have the highest levels of self-oriented perfectionism among clinical groups.

Other-oriented perfectionism is associated with antisocial and narcissistic personality disorders.^10,11 It also is related to interpersonal problems and difficulties with marriage and intimate relationships.¹²

Socially prescribed perfectionism is highly elevated in patients with social phobia¹³ and narcissistic¹¹ or borderline personality disorder.¹⁰ It also is associated with severity of depression, anxiety, and symptoms of hostility.⁷

Perhaps most important, determining a patient’s level of socially prescribed perfectionism can aid in assessing suicide risk. Socially prescribed perfectionism has been shown to be highly relevant in suicide ideation, ratings of suicide risk, and moderate- to high-intent suicide attempts in adults,¹⁴ adolescents, and children.¹⁵ Socially prescribed perfectionism has been found to be a unique predictor of suicide behaviors even after controlling for common predictors such as depression severity and hopelessness.

Self-presentation. Fewer studies have evaluated a potential link between perfectionistic self-presentation and psychopathology. However, levels of all 3 dimensions of this style—self-promotion of perfection, non-display of imperfection, and nondisclosure of imperfection—appear to be higher in patients with anorexia nervosa than in normal and psychiatric controls.⁹

In addition, perfectionistic self-presentation appears to impair patients’ ability to access and benefit from treatment. Researchers (Hewitt PL, Lee-Baggley D, Sherry SB, et al., unpublished data, 2007) have found that the various dimensions of perfectionistic self-presentation are associated with:

• difficulty in seeking help for psychological problems
  
• increased distress in clinical interviews
  
• fears of psychotherapy and psychotherapists
  
• early termination of treatment.
  

Assessing perfectionistic behavior

A variety of brief self-report measures of perfectionism components—and at least one interview measure—can aid your assessment. These are brief instruments and take only a few minutes to complete. Each self-report measure assesses different aspects of perfectionism, such as traits, self-presentational styles, or cognitions (Table 3). The interview can be used as an alternative to the self-report tools.

Mr. C’s scores on several of these measures appear in Table 4. Interpretive information is available from the authors (see Related Resources). Empirical evidence supports the reliability and validity of these measures in clinical samples of both adults and children/adolescents.

Table 3

Perfectionism self-report assessment tools

Traits or trait components
Hewitt and Flett Multidimensional Perfectionism Scale (for adults)
Flett and Hewitt Child and Adolescent Perfectionism Scale
Frost Multidimensional Perfectionism Scale (for adults)
Perfectionistic self-presentation
Hewitt and Flett Perfectionistic Self Presentation Scale (for adults)
Hewitt and Flett Perfectionistic Self Presentation Scale Junior (for children and adolescents)
Perfectionistic cognitions
Flett and Hewitt Perfectionism Cognitions Inventory (for adults)
Dysfunctional Attitude Scale (one subscale measures perfectionism; for adults)

Table 4

Interpreting scores on perfectionism self-reports

Measure	Mr. C’s score	Possible outcome
MPS: Self-oriented perfectionism	2 SD above normative mean	Depression symptoms
MPS: Other-oriented perfectionism	0.5 SD above normative mean
MPS: Socially prescribed perfectionism	1 SD above normative mean	Suicide behavior
PSPS: Perfectionist self-promotion	1.5 SD above normative mean
PSPS: Nondisplay of imperfection	1.5 SD above normative mean	Shame, avoidance
PSPS: Nondisclosure of imperfection	2 SD above normative mean	Withdrawal from others, nondisclosure
PCI: Perfectionistic cognitions	.75 above normative mean
MPS: Hewitt and Flett Multidimensional Perfectionism Scale; PCI: Hewitt and Flett Perfectionism Cognitions Inventory; PSPS: Hewitt and Flett Perfectionistic Self-Presentation Scale; SD: standard deviation

Limited data on treatments

Few treatments for perfectionistic behavior have been systematically evaluated. Numerous studies have attempted to assess changes in perfectionism as the result of treatment for a specific Axis I disorder, but few have addressed treatment for perfectionism as a clinical entity.

Overall, it seems reasonable to expect that because perfectionism is a personality style, improvement would require fairly intensive, long-term treatment that explicitly emphasizes reducing dimensions of perfectionism.

 

Psychodynamic treatments focus on perfectionism’s underlying mechanisms and attempt to alter the patient’s personality structure. Studies suggest that intensive psychotherapy is most appropriate.

One of the first treatment evaluations from a reanalysis of Menninger Clinic data found the greatest improvements in patients receiving intensive psychoanalytically oriented treatment, compared with short-term psychotherapy or other treatments.¹⁶ More recent evaluations suggest that highly perfectionistic individuals can be treated effectively only with intensive, long-term psychodynamically oriented treatment¹⁷ and short-term interpersonal, cognitive, and medication therapies do little to alter perfectionistic behavior.

In our experience [PLH] perfectionistic individuals can improve significantly with long-term intensive treatment. On the other hand, we recently completed a study of the efficacy of a short-term, intensive psychodynamic/interpersonal group approach for treating perfectionism and its sequelae.

In this study,¹⁸ we focused on treating the interpersonal precursors or causes of perfectionism, such as attachment styles; interpersonal needs for respect, caring, acceptance, and belonging; and need to avoid rejection, abandonment, and humiliation. In 70 patients with high levels of perfectionism, this treatment significantly decreased perfectionism, symptoms of depression and anxiety, and interpersonal problems. These symptoms continued to be reduced from baseline 6 months later.

Cognitive-behavioral approaches. Several researchers’ findings suggest that cognitive restructuring, bibliotherapy, role-playing, coping strategies, homework assignments, and relaxation may help reduce the cognitive component of perfectionism.^19,20 Other work indicates that cognitive interventions can reduce perfectionism. One study linked reductions in socially prescribed perfectionism to concomitant reductions in depression.²¹

Yet other data show that patients with perfectionism traits experience residual depression even when treatment reduces perfectionism.²² This is consistent with findings that patients with social phobia who did not respond to treatment had slightly diminished but still relatively high perfectionism levels.²³

Cognitive interventions can reduce perfectionistic concerns about mistakes and doubting actions, but other aspects of perfectionism—such as perceived parental unrealistic standards and criticisms—remain elevated and appear more treatment-resistant.²⁴

Collectively, these data suggest that some treated patients may be at risk for relapse because persistent perfectionism contributes to a vulnerability to distress.

Medication. No studies have specifically assessed whether medications might reduce perfectionism. Imipramine did not have a significant effect on perfectionistic attitudes when used in the medication protocol of the National Institute of Mental Health Collaborative Study on Depression.¹⁷ Amitriptyline has alleviated some dysfunctional attitudes in depressed patients but not perfectionism.²⁵

Research is needed to evaluate the efficacy of various treatments. At this early stage, it appears that:

• short-term gains might be achieved by reducing symptoms
  
• long-term, intensive psychodynamic treatment may be required to change the perfectionistic personality and its vulnerability effects.
  

Changing a patient’s characterologic aspects tends to be difficult, however, and perfectionistic individuals often seem intransigent (Table 5).

Table 5

Treating perfectionism: Common patient challenges

Transference characterized by extreme hostility, need to be a perfect patient, or extreme supplication, depending on the kind of perfectionism Countertransference characterized by intimidation, anger, deflation, pressure to perform Suicide risk Patient attributes accomplishments to perfectionistic behavior and does not want to relinquish perfectionism Perfectionistic appraisals of treatment efficacy and pressure to see quick changes Early termination, noncompliance, missed sessions Demands for therapist to be perfect, difficult therapeutic alliance Nondisclosure, prevarication, extreme anxiety in session

Related resources

• Flett GL, Hewitt PL. Perfectionism: theory, research and treatment. Washington, DC: American Psychological Association; 2002.
  
• Greenspon T. Freeing our families from perfectionism. Minneapolis: Free Spirit Publishing; 2002.
  
• For more information on interpreting self-report measures of perfectionism, contact Dr. Paul Hewitt, phewitt@psych.ubc.ca; 604-822-5827.
  

Drug brand names

• Amitriptyline • Elavil, Endep
  
• Imipramine • Tofranil
  

Acknowledgment

The authors thank Jonathan Blasberg for his help with this paper and the Social Sciences and Humanities Research Council of Canada for supporting this work.

Mr. C is a 50-year-old professional writer who recently made a serious suicide attempt. At his initial session, Mr. C was hesitant to discuss his situation and reason for attending. He did, however, bring a copy of his résumé so the therapist could “get to know him quickly.”

He said he had been depressed for a long time, especially since he found an error in one of his published works. His confidence and writing abilities seemed to decline after this discovery, his career took a downturn, and ultimately he was fired from his position. He described often being at odds with his supervisors at work, whom he saw as critical and condescending. He was mortified by his job loss and did not inform his wife or friends of his firing.

Mr. C had always been a bit of a loner, and after losing his job he further distanced himself from others. He began drinking heavily to avoid the pain of “letting everyone down.” His wife, family, and friends were shocked at the suicide attempt and expressed dismay that Mr. C had not confided in anyone.

Mr. C describes himself as being perfectionistic throughout his life and never being quite good enough in any of his pursuits. This leads to self-recriminations and persistent feelings of shame.

Far from being a positive attribute, perfectionism is a neurotic personality style that can result in serious psychopathology, including relationship problems, depression, anorexia nervosa, and suicide. Determining a patient’s perfectionistic traits is essential when evaluating those who seek treatment specifically for this distressing behavior as well as patients in treatment for other issues who may have a perfectionistic personality. Accurately assessing perfectionism can help you predict and forestall noncompliance, assess suicide risk, determine appropriate treatment and identify circumstances under which a patient might be particularly vulnerable to relapse.

This article describes:

• 3 traits of perfectionism
  
• 3 dimensions of perfectionistic self-presentation
  
• perfectionistic cognitions
  
• useful self-report tools for clinical practice
  
• effective treatments.
  

Characteristics of perfectionism

Although perfectionism initially was viewed as self-related cognitions, recent models suggest it incorporates intrapersonal and interpersonal dimensions.¹ A person with perfectionism has a marked need for absolute perfection for the self and/or others in many—if not all—pursuits that is strongly rooted in his or her intrapersonal and interpersonal worlds. Other characteristics of perfectionism include:

• equating self-worth or esteem with performance
  
• self-punishment in failure and a lack of satisfaction in success
  
• maintaining and needing to strive for unrealistic expectations
  
• unrealistic criteria for success and broad criteria for failure.
  

Some clinicians have suggested that perfectionism may be adaptive,² but “adaptive perfectionism” is more likely a reflection of conscientiousness or achievement striving (Table 1). Although perfectionism can involve rumination, it is much broader than simply having an obsessional cognitive style.

We define perfectionism as a neurotic personality style involving perfectionist traits, self-presentation styles, and cognitions that is a core vulnerability factor for a variety of psychological, physical, achievement, and relationship problems (Table 2).^1,3

3 traits. Three traits of perfectionism reflect the desire for the self or others to be perfect:

• self-oriented perfectionism—a requirement for the self to be perfect
  
• other-oriented perfectionism—a requirement for others to be perfect
  
• socially prescribed perfectionism—a perception that others require perfection of oneself.
  

Each of these traits is associated with different Axis I and Axis II disorders, which we outline below.⁴ In addition to these traits, perfectionism includes interpersonal and intrapersonal expressions.

3 self-presentational dimensions. The interpersonal expression of perfectionism is perfectionistic self-presentation. In our model, the 3 facets of perfectionistic self-presentation are:

• perfectionistic self-promotion—overt displays and statements of one’s supposed “perfection”
  
• nondisplay of imperfections—hiding any imperfections
  
• nondisclosure of imperfections—avoiding disclosure or discussion of any imperfection.³
  

Perfectionistic cognitions. The intrapersonal expression of perfectionism is perfectionistic information processing and ruminative thoughts regarding the need for perfection for the self or others.⁵ This state component reflects the self-related inner dialogue of the patient’s requirement for perfection, recriminations, etc. Perfectionistic cognitions are associated with state levels of distress and symptom severity.

Table 1

How perfectionism differs from conscientiousness

Perfectionism	Achievement striving/conscientiousness
Receives no satisfaction from any performance	Experiences satisfaction with good performance
Experiences no rewards from any performance	Rewards self or others for good performance
Maintains expectations in the face of failure	Alters expectations in the face of failure
Is motivated by fear of failure	Is motivated by desire for success
Shows poor organization	Is organized
Focuses on flaws as indication of self-worth	Focuses less on flaws

 

Table 2

Psychopathologies associated with perfectionism

Perfectionism component	Description	Psychiatric outcomes
Perfectionism traits
Self-oriented perfectionism	Requires self to be perfect	Unipolar depression, anorexia nervosa
Other-oriented perfectionism	Requires others to be perfect	Personality disorders (PDs), relationship problems
Socially prescribed perfectionism	Perceives that others require one to be perfect	Suicidal behavior, general distress
Perfectionistic self-presentational styles
Perfectionistic self-promotion	Overtly promotes one’s ‘perfection’	Narcissistic PD, other dramatic cluster PDs
Nondisplay of imperfections	Avoids demonstrating one’s imperfection	Poor help seeking, treatment nonadherence, anxiety in assessment and therapy
Nondisclosure of imperfections	Hides perceived imperfections from others	Poor therapy alliance, relationship problems
Perfectionistic cognitions	Inner dialogue regarding requirement to be perfect	General distress, severity of depression, anxiety
Source: References 1,3,5

Traits tied to psychopathology

Each of the 3 traits of perfectionism in our model has been associated with psychopathology in multiple studies.

Self-oriented perfectionism is often involved in Axis I disorders, including unipolar depression. This trait is elevated among adults and children diagnosed with major depressive disorder and may be pernicious in the presence of stressors, particularly achievement-related ones.⁶ In other words, self-oriented perfectionism appears to be a risk factor for unipolar depression.^7,8

It also is elevated in women with anorexia nervosa compared with normal and psychiatric controls.⁹ Individuals with anorexia nervosa appear to have the highest levels of self-oriented perfectionism among clinical groups.

Other-oriented perfectionism is associated with antisocial and narcissistic personality disorders.^10,11 It also is related to interpersonal problems and difficulties with marriage and intimate relationships.¹²

Socially prescribed perfectionism is highly elevated in patients with social phobia¹³ and narcissistic¹¹ or borderline personality disorder.¹⁰ It also is associated with severity of depression, anxiety, and symptoms of hostility.⁷

Perhaps most important, determining a patient’s level of socially prescribed perfectionism can aid in assessing suicide risk. Socially prescribed perfectionism has been shown to be highly relevant in suicide ideation, ratings of suicide risk, and moderate- to high-intent suicide attempts in adults,¹⁴ adolescents, and children.¹⁵ Socially prescribed perfectionism has been found to be a unique predictor of suicide behaviors even after controlling for common predictors such as depression severity and hopelessness.

Self-presentation. Fewer studies have evaluated a potential link between perfectionistic self-presentation and psychopathology. However, levels of all 3 dimensions of this style—self-promotion of perfection, non-display of imperfection, and nondisclosure of imperfection—appear to be higher in patients with anorexia nervosa than in normal and psychiatric controls.⁹

In addition, perfectionistic self-presentation appears to impair patients’ ability to access and benefit from treatment. Researchers (Hewitt PL, Lee-Baggley D, Sherry SB, et al., unpublished data, 2007) have found that the various dimensions of perfectionistic self-presentation are associated with:

• difficulty in seeking help for psychological problems
  
• increased distress in clinical interviews
  
• fears of psychotherapy and psychotherapists
  
• early termination of treatment.
  

Assessing perfectionistic behavior

A variety of brief self-report measures of perfectionism components—and at least one interview measure—can aid your assessment. These are brief instruments and take only a few minutes to complete. Each self-report measure assesses different aspects of perfectionism, such as traits, self-presentational styles, or cognitions (Table 3). The interview can be used as an alternative to the self-report tools.

Mr. C’s scores on several of these measures appear in Table 4. Interpretive information is available from the authors (see Related Resources). Empirical evidence supports the reliability and validity of these measures in clinical samples of both adults and children/adolescents.

Table 3

Perfectionism self-report assessment tools

Traits or trait components
Hewitt and Flett Multidimensional Perfectionism Scale (for adults)
Flett and Hewitt Child and Adolescent Perfectionism Scale
Frost Multidimensional Perfectionism Scale (for adults)
Perfectionistic self-presentation
Hewitt and Flett Perfectionistic Self Presentation Scale (for adults)
Hewitt and Flett Perfectionistic Self Presentation Scale Junior (for children and adolescents)
Perfectionistic cognitions
Flett and Hewitt Perfectionism Cognitions Inventory (for adults)
Dysfunctional Attitude Scale (one subscale measures perfectionism; for adults)

Table 4

Interpreting scores on perfectionism self-reports

Measure	Mr. C’s score	Possible outcome
MPS: Self-oriented perfectionism	2 SD above normative mean	Depression symptoms
MPS: Other-oriented perfectionism	0.5 SD above normative mean
MPS: Socially prescribed perfectionism	1 SD above normative mean	Suicide behavior
PSPS: Perfectionist self-promotion	1.5 SD above normative mean
PSPS: Nondisplay of imperfection	1.5 SD above normative mean	Shame, avoidance
PSPS: Nondisclosure of imperfection	2 SD above normative mean	Withdrawal from others, nondisclosure
PCI: Perfectionistic cognitions	.75 above normative mean
MPS: Hewitt and Flett Multidimensional Perfectionism Scale; PCI: Hewitt and Flett Perfectionism Cognitions Inventory; PSPS: Hewitt and Flett Perfectionistic Self-Presentation Scale; SD: standard deviation

Limited data on treatments

Few treatments for perfectionistic behavior have been systematically evaluated. Numerous studies have attempted to assess changes in perfectionism as the result of treatment for a specific Axis I disorder, but few have addressed treatment for perfectionism as a clinical entity.

Overall, it seems reasonable to expect that because perfectionism is a personality style, improvement would require fairly intensive, long-term treatment that explicitly emphasizes reducing dimensions of perfectionism.

 

Psychodynamic treatments focus on perfectionism’s underlying mechanisms and attempt to alter the patient’s personality structure. Studies suggest that intensive psychotherapy is most appropriate.

One of the first treatment evaluations from a reanalysis of Menninger Clinic data found the greatest improvements in patients receiving intensive psychoanalytically oriented treatment, compared with short-term psychotherapy or other treatments.¹⁶ More recent evaluations suggest that highly perfectionistic individuals can be treated effectively only with intensive, long-term psychodynamically oriented treatment¹⁷ and short-term interpersonal, cognitive, and medication therapies do little to alter perfectionistic behavior.

In our experience [PLH] perfectionistic individuals can improve significantly with long-term intensive treatment. On the other hand, we recently completed a study of the efficacy of a short-term, intensive psychodynamic/interpersonal group approach for treating perfectionism and its sequelae.

In this study,¹⁸ we focused on treating the interpersonal precursors or causes of perfectionism, such as attachment styles; interpersonal needs for respect, caring, acceptance, and belonging; and need to avoid rejection, abandonment, and humiliation. In 70 patients with high levels of perfectionism, this treatment significantly decreased perfectionism, symptoms of depression and anxiety, and interpersonal problems. These symptoms continued to be reduced from baseline 6 months later.

Cognitive-behavioral approaches. Several researchers’ findings suggest that cognitive restructuring, bibliotherapy, role-playing, coping strategies, homework assignments, and relaxation may help reduce the cognitive component of perfectionism.^19,20 Other work indicates that cognitive interventions can reduce perfectionism. One study linked reductions in socially prescribed perfectionism to concomitant reductions in depression.²¹

Yet other data show that patients with perfectionism traits experience residual depression even when treatment reduces perfectionism.²² This is consistent with findings that patients with social phobia who did not respond to treatment had slightly diminished but still relatively high perfectionism levels.²³

Cognitive interventions can reduce perfectionistic concerns about mistakes and doubting actions, but other aspects of perfectionism—such as perceived parental unrealistic standards and criticisms—remain elevated and appear more treatment-resistant.²⁴

Collectively, these data suggest that some treated patients may be at risk for relapse because persistent perfectionism contributes to a vulnerability to distress.

Medication. No studies have specifically assessed whether medications might reduce perfectionism. Imipramine did not have a significant effect on perfectionistic attitudes when used in the medication protocol of the National Institute of Mental Health Collaborative Study on Depression.¹⁷ Amitriptyline has alleviated some dysfunctional attitudes in depressed patients but not perfectionism.²⁵

Research is needed to evaluate the efficacy of various treatments. At this early stage, it appears that:

• short-term gains might be achieved by reducing symptoms
  
• long-term, intensive psychodynamic treatment may be required to change the perfectionistic personality and its vulnerability effects.
  

Changing a patient’s characterologic aspects tends to be difficult, however, and perfectionistic individuals often seem intransigent (Table 5).

Table 5

Treating perfectionism: Common patient challenges

Transference characterized by extreme hostility, need to be a perfect patient, or extreme supplication, depending on the kind of perfectionism Countertransference characterized by intimidation, anger, deflation, pressure to perform Suicide risk Patient attributes accomplishments to perfectionistic behavior and does not want to relinquish perfectionism Perfectionistic appraisals of treatment efficacy and pressure to see quick changes Early termination, noncompliance, missed sessions Demands for therapist to be perfect, difficult therapeutic alliance Nondisclosure, prevarication, extreme anxiety in session

Related resources

• Flett GL, Hewitt PL. Perfectionism: theory, research and treatment. Washington, DC: American Psychological Association; 2002.
  
• Greenspon T. Freeing our families from perfectionism. Minneapolis: Free Spirit Publishing; 2002.
  
• For more information on interpreting self-report measures of perfectionism, contact Dr. Paul Hewitt, phewitt@psych.ubc.ca; 604-822-5827.
  

Drug brand names

• Amitriptyline • Elavil, Endep
  
• Imipramine • Tofranil
  

Acknowledgment

The authors thank Jonathan Blasberg for his help with this paper and the Social Sciences and Humanities Research Council of Canada for supporting this work.

Mr. C is a 50-year-old professional writer who recently made a serious suicide attempt. At his initial session, Mr. C was hesitant to discuss his situation and reason for attending. He did, however, bring a copy of his résumé so the therapist could “get to know him quickly.”

He said he had been depressed for a long time, especially since he found an error in one of his published works. His confidence and writing abilities seemed to decline after this discovery, his career took a downturn, and ultimately he was fired from his position. He described often being at odds with his supervisors at work, whom he saw as critical and condescending. He was mortified by his job loss and did not inform his wife or friends of his firing.

Mr. C had always been a bit of a loner, and after losing his job he further distanced himself from others. He began drinking heavily to avoid the pain of “letting everyone down.” His wife, family, and friends were shocked at the suicide attempt and expressed dismay that Mr. C had not confided in anyone.

Mr. C describes himself as being perfectionistic throughout his life and never being quite good enough in any of his pursuits. This leads to self-recriminations and persistent feelings of shame.

Far from being a positive attribute, perfectionism is a neurotic personality style that can result in serious psychopathology, including relationship problems, depression, anorexia nervosa, and suicide. Determining a patient’s perfectionistic traits is essential when evaluating those who seek treatment specifically for this distressing behavior as well as patients in treatment for other issues who may have a perfectionistic personality. Accurately assessing perfectionism can help you predict and forestall noncompliance, assess suicide risk, determine appropriate treatment and identify circumstances under which a patient might be particularly vulnerable to relapse.

This article describes:

• 3 traits of perfectionism
  
• 3 dimensions of perfectionistic self-presentation
  
• perfectionistic cognitions
  
• useful self-report tools for clinical practice
  
• effective treatments.
  

Characteristics of perfectionism

Although perfectionism initially was viewed as self-related cognitions, recent models suggest it incorporates intrapersonal and interpersonal dimensions.¹ A person with perfectionism has a marked need for absolute perfection for the self and/or others in many—if not all—pursuits that is strongly rooted in his or her intrapersonal and interpersonal worlds. Other characteristics of perfectionism include:

• equating self-worth or esteem with performance
  
• self-punishment in failure and a lack of satisfaction in success
  
• maintaining and needing to strive for unrealistic expectations
  
• unrealistic criteria for success and broad criteria for failure.
  

Some clinicians have suggested that perfectionism may be adaptive,² but “adaptive perfectionism” is more likely a reflection of conscientiousness or achievement striving (Table 1). Although perfectionism can involve rumination, it is much broader than simply having an obsessional cognitive style.

We define perfectionism as a neurotic personality style involving perfectionist traits, self-presentation styles, and cognitions that is a core vulnerability factor for a variety of psychological, physical, achievement, and relationship problems (Table 2).^1,3

3 traits. Three traits of perfectionism reflect the desire for the self or others to be perfect:

• self-oriented perfectionism—a requirement for the self to be perfect
  
• other-oriented perfectionism—a requirement for others to be perfect
  
• socially prescribed perfectionism—a perception that others require perfection of oneself.
  

Each of these traits is associated with different Axis I and Axis II disorders, which we outline below.⁴ In addition to these traits, perfectionism includes interpersonal and intrapersonal expressions.

3 self-presentational dimensions. The interpersonal expression of perfectionism is perfectionistic self-presentation. In our model, the 3 facets of perfectionistic self-presentation are:

• perfectionistic self-promotion—overt displays and statements of one’s supposed “perfection”
  
• nondisplay of imperfections—hiding any imperfections
  
• nondisclosure of imperfections—avoiding disclosure or discussion of any imperfection.³
  

Perfectionistic cognitions. The intrapersonal expression of perfectionism is perfectionistic information processing and ruminative thoughts regarding the need for perfection for the self or others.⁵ This state component reflects the self-related inner dialogue of the patient’s requirement for perfection, recriminations, etc. Perfectionistic cognitions are associated with state levels of distress and symptom severity.

Table 1

How perfectionism differs from conscientiousness

Perfectionism	Achievement striving/conscientiousness
Receives no satisfaction from any performance	Experiences satisfaction with good performance
Experiences no rewards from any performance	Rewards self or others for good performance
Maintains expectations in the face of failure	Alters expectations in the face of failure
Is motivated by fear of failure	Is motivated by desire for success
Shows poor organization	Is organized
Focuses on flaws as indication of self-worth	Focuses less on flaws

 

Table 2

Psychopathologies associated with perfectionism

Perfectionism component	Description	Psychiatric outcomes
Perfectionism traits
Self-oriented perfectionism	Requires self to be perfect	Unipolar depression, anorexia nervosa
Other-oriented perfectionism	Requires others to be perfect	Personality disorders (PDs), relationship problems
Socially prescribed perfectionism	Perceives that others require one to be perfect	Suicidal behavior, general distress
Perfectionistic self-presentational styles
Perfectionistic self-promotion	Overtly promotes one’s ‘perfection’	Narcissistic PD, other dramatic cluster PDs
Nondisplay of imperfections	Avoids demonstrating one’s imperfection	Poor help seeking, treatment nonadherence, anxiety in assessment and therapy
Nondisclosure of imperfections	Hides perceived imperfections from others	Poor therapy alliance, relationship problems
Perfectionistic cognitions	Inner dialogue regarding requirement to be perfect	General distress, severity of depression, anxiety
Source: References 1,3,5

Traits tied to psychopathology

Each of the 3 traits of perfectionism in our model has been associated with psychopathology in multiple studies.

Self-oriented perfectionism is often involved in Axis I disorders, including unipolar depression. This trait is elevated among adults and children diagnosed with major depressive disorder and may be pernicious in the presence of stressors, particularly achievement-related ones.⁶ In other words, self-oriented perfectionism appears to be a risk factor for unipolar depression.^7,8

It also is elevated in women with anorexia nervosa compared with normal and psychiatric controls.⁹ Individuals with anorexia nervosa appear to have the highest levels of self-oriented perfectionism among clinical groups.

Other-oriented perfectionism is associated with antisocial and narcissistic personality disorders.^10,11 It also is related to interpersonal problems and difficulties with marriage and intimate relationships.¹²

Socially prescribed perfectionism is highly elevated in patients with social phobia¹³ and narcissistic¹¹ or borderline personality disorder.¹⁰ It also is associated with severity of depression, anxiety, and symptoms of hostility.⁷

Perhaps most important, determining a patient’s level of socially prescribed perfectionism can aid in assessing suicide risk. Socially prescribed perfectionism has been shown to be highly relevant in suicide ideation, ratings of suicide risk, and moderate- to high-intent suicide attempts in adults,¹⁴ adolescents, and children.¹⁵ Socially prescribed perfectionism has been found to be a unique predictor of suicide behaviors even after controlling for common predictors such as depression severity and hopelessness.

Self-presentation. Fewer studies have evaluated a potential link between perfectionistic self-presentation and psychopathology. However, levels of all 3 dimensions of this style—self-promotion of perfection, non-display of imperfection, and nondisclosure of imperfection—appear to be higher in patients with anorexia nervosa than in normal and psychiatric controls.⁹

In addition, perfectionistic self-presentation appears to impair patients’ ability to access and benefit from treatment. Researchers (Hewitt PL, Lee-Baggley D, Sherry SB, et al., unpublished data, 2007) have found that the various dimensions of perfectionistic self-presentation are associated with:

• difficulty in seeking help for psychological problems
  
• increased distress in clinical interviews
  
• fears of psychotherapy and psychotherapists
  
• early termination of treatment.
  

Assessing perfectionistic behavior

A variety of brief self-report measures of perfectionism components—and at least one interview measure—can aid your assessment. These are brief instruments and take only a few minutes to complete. Each self-report measure assesses different aspects of perfectionism, such as traits, self-presentational styles, or cognitions (Table 3). The interview can be used as an alternative to the self-report tools.

Mr. C’s scores on several of these measures appear in Table 4. Interpretive information is available from the authors (see Related Resources). Empirical evidence supports the reliability and validity of these measures in clinical samples of both adults and children/adolescents.

Table 3

Perfectionism self-report assessment tools

Traits or trait components
Hewitt and Flett Multidimensional Perfectionism Scale (for adults)
Flett and Hewitt Child and Adolescent Perfectionism Scale
Frost Multidimensional Perfectionism Scale (for adults)
Perfectionistic self-presentation
Hewitt and Flett Perfectionistic Self Presentation Scale (for adults)
Hewitt and Flett Perfectionistic Self Presentation Scale Junior (for children and adolescents)
Perfectionistic cognitions
Flett and Hewitt Perfectionism Cognitions Inventory (for adults)
Dysfunctional Attitude Scale (one subscale measures perfectionism; for adults)

Table 4

Interpreting scores on perfectionism self-reports

Measure	Mr. C’s score	Possible outcome
MPS: Self-oriented perfectionism	2 SD above normative mean	Depression symptoms
MPS: Other-oriented perfectionism	0.5 SD above normative mean
MPS: Socially prescribed perfectionism	1 SD above normative mean	Suicide behavior
PSPS: Perfectionist self-promotion	1.5 SD above normative mean
PSPS: Nondisplay of imperfection	1.5 SD above normative mean	Shame, avoidance
PSPS: Nondisclosure of imperfection	2 SD above normative mean	Withdrawal from others, nondisclosure
PCI: Perfectionistic cognitions	.75 above normative mean
MPS: Hewitt and Flett Multidimensional Perfectionism Scale; PCI: Hewitt and Flett Perfectionism Cognitions Inventory; PSPS: Hewitt and Flett Perfectionistic Self-Presentation Scale; SD: standard deviation

Limited data on treatments

Few treatments for perfectionistic behavior have been systematically evaluated. Numerous studies have attempted to assess changes in perfectionism as the result of treatment for a specific Axis I disorder, but few have addressed treatment for perfectionism as a clinical entity.

Overall, it seems reasonable to expect that because perfectionism is a personality style, improvement would require fairly intensive, long-term treatment that explicitly emphasizes reducing dimensions of perfectionism.

 

Psychodynamic treatments focus on perfectionism’s underlying mechanisms and attempt to alter the patient’s personality structure. Studies suggest that intensive psychotherapy is most appropriate.

One of the first treatment evaluations from a reanalysis of Menninger Clinic data found the greatest improvements in patients receiving intensive psychoanalytically oriented treatment, compared with short-term psychotherapy or other treatments.¹⁶ More recent evaluations suggest that highly perfectionistic individuals can be treated effectively only with intensive, long-term psychodynamically oriented treatment¹⁷ and short-term interpersonal, cognitive, and medication therapies do little to alter perfectionistic behavior.

In our experience [PLH] perfectionistic individuals can improve significantly with long-term intensive treatment. On the other hand, we recently completed a study of the efficacy of a short-term, intensive psychodynamic/interpersonal group approach for treating perfectionism and its sequelae.

In this study,¹⁸ we focused on treating the interpersonal precursors or causes of perfectionism, such as attachment styles; interpersonal needs for respect, caring, acceptance, and belonging; and need to avoid rejection, abandonment, and humiliation. In 70 patients with high levels of perfectionism, this treatment significantly decreased perfectionism, symptoms of depression and anxiety, and interpersonal problems. These symptoms continued to be reduced from baseline 6 months later.

Cognitive-behavioral approaches. Several researchers’ findings suggest that cognitive restructuring, bibliotherapy, role-playing, coping strategies, homework assignments, and relaxation may help reduce the cognitive component of perfectionism.^19,20 Other work indicates that cognitive interventions can reduce perfectionism. One study linked reductions in socially prescribed perfectionism to concomitant reductions in depression.²¹

Yet other data show that patients with perfectionism traits experience residual depression even when treatment reduces perfectionism.²² This is consistent with findings that patients with social phobia who did not respond to treatment had slightly diminished but still relatively high perfectionism levels.²³

Cognitive interventions can reduce perfectionistic concerns about mistakes and doubting actions, but other aspects of perfectionism—such as perceived parental unrealistic standards and criticisms—remain elevated and appear more treatment-resistant.²⁴

Collectively, these data suggest that some treated patients may be at risk for relapse because persistent perfectionism contributes to a vulnerability to distress.

Medication. No studies have specifically assessed whether medications might reduce perfectionism. Imipramine did not have a significant effect on perfectionistic attitudes when used in the medication protocol of the National Institute of Mental Health Collaborative Study on Depression.¹⁷ Amitriptyline has alleviated some dysfunctional attitudes in depressed patients but not perfectionism.²⁵

Research is needed to evaluate the efficacy of various treatments. At this early stage, it appears that:

• short-term gains might be achieved by reducing symptoms
  
• long-term, intensive psychodynamic treatment may be required to change the perfectionistic personality and its vulnerability effects.
  

Changing a patient’s characterologic aspects tends to be difficult, however, and perfectionistic individuals often seem intransigent (Table 5).

Table 5

Treating perfectionism: Common patient challenges

Transference characterized by extreme hostility, need to be a perfect patient, or extreme supplication, depending on the kind of perfectionism Countertransference characterized by intimidation, anger, deflation, pressure to perform Suicide risk Patient attributes accomplishments to perfectionistic behavior and does not want to relinquish perfectionism Perfectionistic appraisals of treatment efficacy and pressure to see quick changes Early termination, noncompliance, missed sessions Demands for therapist to be perfect, difficult therapeutic alliance Nondisclosure, prevarication, extreme anxiety in session

Related resources

• Flett GL, Hewitt PL. Perfectionism: theory, research and treatment. Washington, DC: American Psychological Association; 2002.
  
• Greenspon T. Freeing our families from perfectionism. Minneapolis: Free Spirit Publishing; 2002.
  
• For more information on interpreting self-report measures of perfectionism, contact Dr. Paul Hewitt, phewitt@psych.ubc.ca; 604-822-5827.
  

Drug brand names

• Amitriptyline • Elavil, Endep
  
• Imipramine • Tofranil
  

Acknowledgment

The authors thank Jonathan Blasberg for his help with this paper and the Social Sciences and Humanities Research Council of Canada for supporting this work.