1. The programme at a glance
Indication. The programme is intended for an adult whose personal worth depends almost entirely on the pursuit of high standards they impose on themselves, in at least one area of life that matters to them, and who maintains these standards despite what they cost. This is what the literature calls clinical perfectionism (section 4). It may be the main reason for seeking help, or a process that maintains anxiety, low mood or exhaustion. It assumes that the triage in section 3 has been done: an active eating disorder, obsessive-compulsive disorder, a moderate or severe depressive episode or an acute suicide risk come before it.
Reference model. Cognitive behavioural therapy for perfectionism, derived from the analysis of clinical perfectionism by Shafran, Cooper and Fairburn (2002) and from the protocol that Egan, Wade et al. (2014) drew from it. It rests on a personal formulation, behavioural experiments that put the rules to the test, the reduction of checking, avoidance and putting off, work on evaluation biases and on self-criticism, and the broadening of what the person bases their worth on. The manual describes it through its published principles, without reproducing its authors' materials.
Format. Ten individual 50-minute sessions, the first lasting 75 minutes, once a week, then three booster sessions, at one, three and six months. This format draws on the first controlled trial, which had ten sessions over eight weeks (Riley et al., 2007), and on the reference protocol, divided into ten modules usually delivered over eight weeks (Kothari et al., 2016). The length of the sessions, and of the first one, are choices of this programme. The tasks between sessions are short, and they can be done imperfectly: that is part of the treatment.
Mechanism targeted. The programme does not ask the person to lower their standards everywhere. It aims to detach their worth from their results, to have them check through experience what really happens when they do a little less, to remove the behaviours that prevent this check, and to correct the biased way in which they judge what they have done.
| Session |
Focus |
Session output |
| 1 |
Assess, triage, set the frame |
Triage done, risk assessed, baseline measures, record handed over |
| 2 |
The perfectionism circle |
Personal circle drawn with examples from the week |
| 3 |
What it brings, what it costs |
Four-box balance sheet, three goals, a survey launched |
| 4 |
The first "good enough" experiments |
Two experiments written down, one done in session |
| 5 |
Checking less, avoiding less, putting off less |
Limits in figures, first step of a put-off task dated, interim measures |
| 6 |
The perfectionism glasses |
Three biases spotted in real examples, notebook of what went well |
| 7 |
What their worth rests on |
Current and desired pie chart, two dated actions |
| 8 |
Self-criticism |
Written answer to the critical voice, plan for after a mistake |
| 9 |
Other people, rest and pleasure |
One imperfection shown or dated, two low-stakes moments scheduled |
| 10 |
Review and relapse prevention |
Measures repeated, plan for what comes next written |
What the person takes away. Eight printable worksheets, listed in section 32: a record, their circle, their experiments, their limits, their biases, what their worth rests on, their answer to self-criticism, and their plan for what comes next.
What distinguishes this programme from the other manuals on this site. It treats a process and not a disorder, which obliges it to begin with a broader triage and to say when another manual should take over. It is often addressed to people who function well on the surface and who are attached to what makes them suffer. And it must constantly prevent perfectionism from taking hold of the treatment itself.
2. Before you begin
The four preliminary decisions
Is perfectionism the right entry point? This is the most important question in the manual. Perfectionism is higher in people with eating disorders, anxiety disorders, including obsessive-compulsive disorder and social anxiety, or depression, than in people without them (Egan et al., 2011). When one of these disorders is in the foreground, it is treated first with its own manual, and the work on perfectionism is added to it as a module, at the point that manual provides for it. This order is a precautionary choice of this programme: these disorders have treatments of established efficacy, and the trials of treatment for perfectionism have been conducted mostly in people without a full-blown disorder (section 11). Sections 3 and 8 say how to decide.
Is there a suicide risk? Perfectionism is associated with suicidal ideation, and this risk often hides behind a façade of control (section 9). It is looked for in session 1, then at each measurement point and after every failure or humiliation.
Is there a danger to the body? Standards bearing on food, weight, shape or sport, with weight loss, restriction or vomiting, require a medical opinion before anything else (section 9).
Is the person exhausted? Established burnout changes the order of the work: recovery and the work situation come first, with Burnout (occupational exhaustion): a therapist's manual, and perfectionism is treated afterwards, or in session 5 of this manual, devoted to the rules that exhaust.
What this programme does not treat
It does not treat a full-blown disorder, whether an eating disorder or obsessive-compulsive disorder, which have their own manual and their own treatment (section 8).
It does not treat obsessive-compulsive personality on its own. Ten sessions are too short for a long-standing and pervasive way of functioning; this programme can form part of the longer treatment described in its manual (section 3).
It does not change an environment that genuinely demands perfection. A post where mistakes are sanctioned without nuance, a family that humiliates at every failure, high-level sports competition: therapy helps the person distinguish what depends on them, it does not transform these contexts (section 27).
How to use it
Read the whole thing before the first session, in particular sections 3, 5, 9 and 26: the triage, the circle that maintains perfectionism, safety, and behavioural experiments. These are the four places where a mistake costs the most. Three warnings are specific to this request.
The person is attached to what makes them suffer. Their standards have often earned them successes, esteem, a place. Telling them from the outset that these standards are a problem triggers a defence, and that is legitimate. The programme begins by looking with them at what the standards bring them and what they cost, and it is the person who decides what they want to change (session 3).
Perfectionism enters the therapy. The record is kept with extreme care, the worksheet is recopied neatly, the "good enough" experiment is prepared for three hours. You spot it, you name it with humour and without reproach, and you make it something to work on (section 14).
Your own perfectionism matters too. Wanting to deliver this programme to the letter, correcting every worksheet, never letting a session run over: you would be modelling exactly what you are asking the person to let go of. A therapist who acknowledges a mistake without making a fuss about it teaches more than an argument does.
3. Four presentations not to be confused
Four situations present under the word "perfectionism", and they do not call for the same course of action.
1. High standards that help
What you observe. A person aims high, likes work done well, commits strongly, and draws satisfaction from it. A mistake annoys them, then they move on. Their worth is not replayed with every result.
What points the way. The absence of fear of mistakes, the ability to stop when it is enough, and a low cost to sleep, relationships and pleasure. Research speaks here of perfectionistic strivings, less linked to suffering than perfectionistic concerns, which are made up of fear of mistakes and doubt (sections 4 and 8).
What this implies. No treatment. If the person consults for something else, their standards are not something to work on.
2. Clinical perfectionism, without a full-blown disorder
What you observe. The person's worth depends almost entirely on their results in one or several areas. Failure triggers harsh self-criticism; success does not reassure, because it is immediately judged too easy and the bar goes up. The person checks, redoes, puts off, avoids, and pays for it in time, in sleep, in relationships.
What points the way. The cost, the rigidity of the rules, and this movement with two exits in which failure and success alike maintain the system (Shafran et al., 2002). Anxiety, low mood or fatigue may accompany it without forming a disorder in the foreground.
What this implies. This is the programme described here.
3. Perfectionism in the service of a disorder
What you observe. The same mechanisms, but at the heart of a disorder that has its own logic: the dietary restriction of anorexia, the checking of OCD, the constant worry of generalised anxiety, the fear of being judged in social anxiety, the self-criticism of a depressive episode.
What points the way. What organises the person's life. If it is the disorder, the disorder is treated first. Perfectionism is then a factor that maintains the disorder and that predicts a poorer response to the treatment of OCD, social anxiety and depression (Egan et al., 2011).
What this implies. The manual for the disorder first (section 8), with this programme as a module, or afterwards, when perfectionism remains high once the disorder has improved.
4. Obsessive-compulsive personality
What you observe. Perfectionism that is part of a long-standing and pervasive pattern: preoccupation with order, rules and lists, difficulty delegating, throwing things away or spending money, moral rigidity, emotions kept at a distance, standards imposed on those close to them.
What points the way. The long duration, the extension to all areas, and the fact that the person often experiences their traits as virtues and attributes the difficulties to others.
What this implies. Obsessive-compulsive personality: a therapist's manual, in a longer course of treatment.
The three other things to have ruled out
Autism spectrum disorder. The need for rules, the search for exactness and the difficulty changing one's way of doing things may stem from it. What points the way: difficulties in social communication and restricted interests present since childhood. Autism in adults: a therapist's manual describes the assessment.
Burnout. It may be the price of untenable standards, whether imposed or chosen (section 8).
And a genuinely demanding environment. A person who checks a dosage three times on a hospital ward, or a structural calculation, is not showing clinical perfectionism: the question is whether the checking reduces a real risk, and at what price (section 27).
The three triage questions
"What happens inside you when you don't reach what you had set yourself?" It isolates the dependence of self-worth on results, and self-criticism.
"And when you do reach it?" It isolates the second movement of the circle: success erased, the bar raised.
"Do your standards concern food, weight, your body or sport? Do you ever have to check or redo something until it feels just right, even when you know it is pointless?" It looks for the two disorders that change the course of action the most.
4. The dimensions of perfectionism
Perfectionism has been described in several ways, and these descriptions do not overlap. Knowing them helps you read the studies, choose a measure and recognise what the person is going through.
Three directions: towards oneself, towards others, from others
Hewitt and Flett (1991) distinguished three dimensions. Self-oriented perfectionism consists in imposing high standards on oneself and judging oneself harshly. Other-oriented perfectionism consists in demanding perfection from those around one. Socially prescribed perfectionism is the conviction that others expect perfection from you and will accept you only on that condition. This third dimension belongs to perfectionistic concerns, those most linked to distress (section 8), and it is the one that predicts an increase in suicidal ideation over time (Smith et al., 2018).
Six facets, including fear of mistakes
Frost and his colleagues (1990) described perfectionism through several facets: concern over mistakes, personal standards, perceived parental expectations and criticism, doubts about one's own actions, and organisation. Concern over mistakes, that is, the fear of getting things wrong and what a mistake triggers, is the main outcome measure of several treatment trials (section 10).
Two broad families: strivings and concerns
By grouping these facets, researchers identified two broad families (Stoeber and Otto, 2006). Perfectionistic strivings bring together high personal standards and self-oriented perfectionism. Perfectionistic concerns bring together fear of mistakes, doubt, socially prescribed perfectionism, and the felt discrepancy between one's expectations and one's results (Smith et al., 2018). This distinction structures most of the meta-analyses cited in this manual.
Perfectionistic self-presentation
Hewitt, Flett, Sherry and their colleagues (2003) added an interpersonal dimension: the need to appear perfect. It has three facets: putting oneself forward as perfect, never letting an imperfection show, and never talking about one. In session, it can explain why a person minimises their difficulties, does not say they are unwell, and hides their suicidal ideation (section 9).
Clinical perfectionism
Shafran, Cooper and Fairburn (2002) proposed a definition designed for clinical work: the overdependence of self-evaluation on the determined pursuit, and the attainment, of high personal standards, in at least one area that matters, despite negative consequences. It does not describe a personality trait, but a mechanism that can be identified and treated. This is the definition used in this manual.
What the person describes
They rarely talk about perfectionism. They describe work that is never finished, emails reread several times, files started at the last minute for lack of being able to do them "properly", leisure activities that have become performances, an inability to enjoy a success, and an inner voice that never takes a holiday. The areas at stake vary: work or studies, the body, sport, the home, parenting, relationships.
5. What maintains clinical perfectionism
The cognitive behavioural model describes a circle that closes whatever the result (Shafran et al., 2002; Egan, Wade et al., 2014). Treatment targets each of its links.
Worth hanging on results
At the centre of the circle is a self-evaluation that rests almost entirely on success in one or a few areas. What is at stake in each task is then not the task, but the person's worth. A meta-analysis of 83 articles found a moderate negative association between perfectionistic concerns and self-esteem, and an almost zero association with strivings, which indirectly supports this model (Khossousi et al., 2024).
Rigid rules
The standards take the form of inflexible rules, often phrased as "I must" and "I have to": "I must reread everything I send", "a mark below 16 out of 20 is a failure", "I can't show unfinished work". Their rigidity means that they are often impossible to keep, and that the slightest deviation counts as complete failure.
Fear of failure and the behaviours that calm it
To avoid the dreaded failure, the person adopts behaviours that relieve them in the moment: they check, redo, compare, seek confirmation, prepare more than necessary, avoid tasks where they might fail, and put off those they cannot do perfectly. Putting things off is a form of avoidance here: a meta-analysis found a small-to-moderate positive association between perfectionistic concerns and procrastination, and a negative association of the same size with strivings (Sirois et al., 2017).
What these behaviours prevent. They prevent the person from discovering what would happen if they did less. Each check that precedes a success is credited with the success; no experience ever shows that the result would have been the same without it. This is the central mechanism, and it is what behavioural experiments come to undo (section 26).
The perfectionist's glasses
The evaluation of what has been done is biased in a predictable way. All-or-nothing thinking classes each result as total success or failure. Selective attention retains the mistake and forgets the rest. Success is disqualified, attributed to the ease of the task or to luck. And the double standard judges harshly in oneself what would be excused in someone else. These biases mean that the person almost always has the impression of having failed.
The two exits from the circle
If the person does not reach their standard, they criticise themselves harshly, feel anxious or dejected, and redouble their efforts and their checking.
If they reach it, the success is disqualified, and the standard is revised upwards, because it was "too easy". It is this second movement that makes clinical perfectionism so costly: there is no result that allows them to stop (Shafran et al., 2002).
Self-criticism
Dunkley and his colleagues (2006) showed, in a sample of students and a sample of patients with binge-eating disorder, that self-criticism accounts for the link between perfectionism and depressive, anxious and eating symptoms, more than the height of the standards does. This is why the programme devotes a whole session to it (session 8).
The narrowing of life
By dint of devoting their time to the areas in which they judge themselves, the person neglects those in which they do not: friends, rest, low-stakes leisure. Their worth then rests on even fewer things, which makes each failure more threatening. And when a leisure activity survives, it often becomes one more performance.
The complete circle
Worth hanging on results imposes rigid rules; the fear of not keeping them drives the person to check, avoid and put off, which prevents them from discovering that a "good enough" result would have sufficed. The biases make them see failure almost everywhere, failure redoubles self-criticism and effort, success raises the bar, and life narrows. This is the circle you draw with the person in session 2.