The need to focus on perfectionism in suicide assessment, treatment and prevention

Perfectionists are people who not only want to be perfect; they also need to seem perfect. Several decades of global research on perfectionism have identified a host of worrisome realities. First, meta-analytic evidence indicates that perfectionism is on the rise among young people1. Second, perfectionism is associated with mental health problems, but also with physical health issues and early mortality2. Third, perfectionism is associated with heightened risk for suicide3, as illustrated by the results of a comprehensive meta-analysis3. The perfectionistic person who is experiencing psychological pain is at a heightened suicide risk due to a confluence of correlated attributes and tendencies4. These include a proclivity to hide psychache behind a perfect front while also experiencing elevated hopelessness5; a tendency to all-or-none views and cognitive rumination; an unwillingness or inability to seek help; and a degree of planfulness that can turn suicidal urges and plans into completed suicides. Here the voracious information seeking of perfectionists may extend to accessing information on the Internet that enables them to perfect their suicide plans. The risk is especially high for the perfectionist who has attempted suicide and remains suicidal while grappling with the humiliation of having engaged in a failed attempt. The role of perfectionism in suicide is to some extent in the public consciousness. We are all aware of the deaths of highly perfectionistic luminaries such as V. Woolf, S. Plath and E. Hemingway. Public awareness was heightened further when S. Blatt published his seminal paper on the destructiveness of perfectionism, detailing the lives and demises of three well-known highly self-critical perfectionists6. We can add the recent attention given to the suicides of famous people such as director T. Scott in 2012 and fashion designer L'Wren Scott in 2014, as well as highly publicized public inquests investigating the suicides of perfectionists such as N. Worrall and C. Dragun. Unfortunately, clinical case examples of deceased perfectionists continue to mount, including the deaths of people such as K. Spade, M. Evans and L. Breen (the emergency room physician who died as stressors mounted during the COVID-19 pandemic). Sadly, there is also no shortage of deaths due to suicide among perfectionistic adolescents7. Constant additions to the above list are disconcerting, but just as troubling is the lack of evidence that research knowledge and public awareness of the role of perfectionism in suicide are being reflected in practice. Our informal survey of key organizations which provide lists of acknowledged suicide risk factors (e.g., the US Centers for Disease Control and Prevention) found little mention of the role of personality factors in general, and perfectionism in particular. More progress is needed immediately, because it is not hyperbole to state that many lives are in the balance. Education, training and heightened awareness are urgently needed. Accordingly, we are issuing a call for a stronger proactive and comprehensive focus on perfectionism and its various elements in terms of their likely roles in suicide and suicidal tendencies. Perfectionism and its various facets merit extensive consideration and action when it comes to assessment, treatment and prevention of suicidal behavior. It should be seen as a warning sign when someone known to be in psychological pain is also a perfectionist. Similarly, when a perfectionist with stressful experiences that should elicit psychological pain seems to be functioning exceptionally well on the surface, this too is a warning sign. In many of these instances, probing for suicide ideation and intent can be appropriate, along with an assessment of perfectionism using measures that have been linked empirically with elevated suicide ideation and risk. In adults, these include the Hewitt-Flett Multidimensional Perfectionism Scale, the Frost Multidimensional Perfectionism Scale (FMPS), and the Perfectionistic Self-Presentation Scale (PSPS), which have extensive evidence of reliability and validity. In younger people, dimensions of perfectionism can be assessed with the Child-Adolescent Perfectionism Scale and the junior version of the PSPS7. Also, the perfectionistic person with a recent suicide attempt should be closely monitored and frequently evaluated. Close evaluation is especially needed of the perfectionistic person brought to an emergency department due to being suicidal, but whose symptoms almost magically seem to disappear at the hospital. All of the above applies to perfectionists from all backgrounds, but especially to people prone to burnout in exceptionally demanding jobs (e.g., doctors, lawyers). In general, people in roles that can provide experience in concealing symptoms behind a front should be closely scrutinized, in line with our conclusion that perfectionists are over-represented among people who commit a suicide that seems to take place without warning. The association between perfectionism and suicide needs to be examined from a perspective that involves careful consideration of life stressors and transitions. For instance, the work-obsessed perfectionist who is disquieted by and feels forced into retirement may also have heightened risk. Our frustration about the lack of implementing knowledge and putting it into action is balanced by a modicum of hope. What accounts for this hope? First, by and large, perfectionism researchers are dedicated to making the world a better place, and this includes a commitment to sharing vital information with the public, including this topic. Second, there is mounting empirical evidence of the effectiveness of nuanced treatments addressing the complexities inherent in the perfectionism construct. A recent meta-analysis of 15 randomized control trials concluded that cognitive-behavioral therapy focusing on perfectionism is efficacious in reducing depression, anxiety and eating disorder symptoms8. However, a dynamic interpersonal approach to treatment may be preferred, especially for perfectionists who feel under pressure to meet extreme expectations imposed on them by others (i.e., socially prescribed perfectionism) and those with an excessive need to seem perfect that has been hidden behind a perfect front (i.e., perfectionistic self-presentation)9. A strong case can be made for prevention, given that many perfectionists experiencing psychological pain tend to suffer in silence and never come into contact with potential treatment providers7. Specific themes that need to be highlighted in preventive efforts include promoting self-compassion to combat self-criticism; seeing oneself as learning and growing rather than fixed and defective; limiting excessive self-reliance; training in problem-solving and cognitive restructuring; and role-playing responses to mistakes and failures. Prevention efforts should be broad and designed to heighten awareness among not only mental health professionals, but also parents and educators. Efforts should also include a targeted focus on people in roles, or training for roles, in which the pressure to be perfect and never make mistakes can seem unbearable (e.g., elite athletes, medical personnel, lawyers, architects). Prevention is also needed to counter the impact of settings that promote unrealistic and unrelenting pressure to be perfect (e.g., schools and communities where high achievement is prescribed and seems normative). Treatment and prevention offer hope and promise for perfectionists in general, including people experiencing suicidal tendencies that may or may not be openly expressed.

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