Therapy with Teenage Perfectionists

A large proportion of the psychotherapy referrals I receive are for 16 year olds, and of those referrals, a disproportionate number are for girls, many of whom are affected by low self-esteem, which can be fuelled by self-imposed goals of perfection. They crave perfect eyebrows, perfect collarbones, perfect breasts, perfect butts, the perfect thigh gap, perfect clothes, perfect iPhones, perfect families, perfect friends, perfect sex, the perfect number of social media followers and perfect exam results. They might strive for perfection and achieve it in some or all areas, or they might strive for perfection and fail, which is experienced as catastrophic.

This is the ordinary backdrop to being a 16-year-old girl for many of the 16-year-old girls that I meet. And it’s exhausting. They present with headaches, stomach aches, lethargy, disordered eating, disordered sleeping and self-injury. They are self-critical, self-blaming, withdrawn, moody, irritable, hopeless, miserable and tearful. Some of them want to die. This list of characteristics strongly resembles the Royal College of Psychiatrists’ symptoms of childhood depression. I find this troubling because it can lead to the pathologising of ordinary adolescent experiences, which can result in ordinary adolescents being diagnosed with a mental illness and prescribed medication. What the majority need is someone to help them make sense of their longing for perfection within the context of ordinary development. Sometimes that someone is me.

In therapy, young perfectionists present as compulsively compliant. They arrive on time, agree with whatever I say, struggle in the silences and await direction. They need to know ‘the rules’, so they can adhere to them rigidly and ‘get it right’. I work within a psychodynamic frame, in a non-directive way. There are few rules. There’s no right or wrong. It’s about taking risks and getting messy. Psychotherapy is a process; more about the journey than the destination, which might be obscure, and that can be uncomfortable for girls who are aiming for perfection.

My primary function is to make a therapeutic relationship with these young perfectionists, which becomes a container for their thoughts and feelings, so that we can make sense of them together. I acknowledge the real expectations of the external world, the real pressures faced by 16 year olds and the real feelings these pressures and expectations provoke. I don’t tell young people they’re over-reacting or being unrealistic. I tell them it’s great that they’re ambitious and want to be the best version of them. What’s not so great is that they’re suffering for the cause. I show them that I understand their reality.

I also pay attention to my countertransference responses, which might typically include projections of self-criticism, frustration, feelings of failure and of not living up to the ideal of the ‘perfect therapist’. I model rather than direct, to demonstrate what I hope young people will have the courage to do themselves. I share my desire to get it right for them and my sense of not knowing what getting it right might look like. I acknowledge the uncomfortableness of not knowing, and the implicit fear of getting it wrong. I offer a space for reflection and collaborative, creative exploration. I take risks, and in doing so, I risk being imperfect. I acknowledge my own vulnerabilities and support young people to acknowledge and work through their vulnerabilities and imperfections too.

Striving for perfection can lead to low self-esteem which can look a lot like depression. But treating it as such, mislabelling, medicating, or dismissing it as unrealistic is detrimental. Each time I meet a young person who is striving to be perfect, I risk being imperfect so that they can risk being imperfect (but good enough) too.