Four tips for building psychological resilience

Life is often stressful. These stresses can come in all shapes and sizes, from the burden of financial debt to the hassle of a fender-bender; from the heartache of a sick parent to the irritation of a late train. The bottom line is that whatever form it comes in, we can’t avoid stress. So what can we do about it? One obvious suggestion is to reduce the amount we’re exposed to: pay that bill a.s.a.p. and be careful to avoid other cars when parking in multi-storey car parks. This is good advice, but the reality is that not all stress can be avoided. For these types of stresses, it can help to increase our capacity to cope: our ‘psychological resilience’. But how can we do this? Here, I offer four tips based on research I have conducted into the factors that confer resilience.

1. Know your strengths: build your confidence. My research has shown that having high self-esteem helps people be resilient to stressful events. In a previous blog post, I outline one evidence-based technique for building self-esteem. Briefly, this works by encouraging you to consider your personal ‘strengths’ and then getting you to think of specific pieces of evidence which show that you have this strength. For example, if your strength is that you’re a good listener, a piece of evidence might be that a friend from work confided to you about their recent break-up last week. 

First though, you have to be willing to allow yourself to do this. When I deliver resilience training, many people I speak with are embarrassed to acknowledge the things they’re good at, for fear of appearing egotistical or narcissistic. This belief is both misleading and detrimental, as some individuals who are highly narcissistic in fact report low levels of underlying self-esteem. The reality is that knowing your strengths can help you to build a quiet confidence that will improve the way you work, and will not make you appear egotistical.

resilience

2. Learn to let yourself off the hook. Being a perfectionist is one of the worst things you can do for your mental health. It’s linked with higher levels of depression, anxiety and self-harm and it’s terrible for psychological resilience. What this tells us is that reducing our perfectionism could boost our psychological wellbeing and levels of resilience. There are misconceptions around perfectionism though, with people sometimes fearing that being less perfectionistic could make them less effective or high achieving. This isn’t the case. Perfectionism is about rigidity: it’s when people push themselves hard, no matter what. Being less perfectionistic involves self-awareness. It’s about knowing when to strive and push forward, and when to let yourself off the hook. If you’re a fitness enthusiast, this might involve knowing when it’s time to take a couple of days off training. If you’re a dedicated student, it might be knowing when it’s time take the afternoon off revision to see friends. For detailed suggestions on tackling perfectionism, see my previous blog post.

3. Focus on the future. When the present is no fun, it’s important to have things to look forward to, and research shows that having hope for the future can help us be more resilient. These don’t have to be big things, but they need to be clear in your mind. For example, you might enjoy going for a coffee and reading the paper, going for a walk in a park, or reading books. This practice is often incorporated into cognitive-behaviour therapy (CBT), and is called ‘pleasant event scheduling’. A recent study which tested the impact of pleasant event scheduling when done in isolation, without any of the other aspects of CBT, found it was effective in reducing risk of depressed mood. It’s not rocket science though – you can easily do this yourself by making a list of things you’d like to do and then scheduling these in your diary.

resilience

4. Don’t beat yourself up when things go wrong. There are three main ways that we explain negative events in our lives. First is how much we blame ourselves, compared with other people or the situation. Second is how permanent our explanations are: whether the problem that caused this one event is likely to keep on causing negative events in our future. Third is how all-encompassing are explanations are: whether this cause is going to make trouble in other areas of our life, as well. For example, if we were to fail an exam, we could think, “This is all down to my own general stupidity. I knew I’d never get through it”. This explanation is negative as we’re taking the blame entirely on ourselves. We’re also doing it in a permanent, all-encompassing way: if we’re stupid, it’s probably going to affect everything we do, forever.

The way we tend to explain events is habitual and it’s called ‘attributional style’. Resilient people explain events in a way that is more positive. In an exam failure situation, a resilient person would acknowledge any stress they’re under, or any other factors that could have affected their performance. Furthermore, they’ll do this in a way that doesn’t leak into other areas of their life and gives them hope for the future. In this example, a resilient person might think, “It was a stressful time with my mum being ill. I haven’t had to manage this kind of situation before, and the result was that I didn’t allow enough time to revise. I’ve learned for the future though: I know what I’ll do differently next time”. Not only will this person feel less bad about the exam failure, they’re also more likely to pass next time. It’s possible to change the way that you explain events with cognitive-behaviour therapy. For a do-it-yourself approach to improving your attributional style, I’d encourage you to ask yourself three questions when you know you’re beating yourself up about something:

  1. What range of factors contributed to this event? When things go wrong, they can rarely be pinned on just one thing. List all the things you know contributed to the event, to help yourself create a balanced perspective.
  2. What else has gone right recently? Think about other things that went to plan, no matter how small. This might be, for example, a friend’s birthday that you remembered, a work task that you completed well or a tricky conversation that you handled sensitively. It’s important to remember that this negative event doesn’t define you.
  3. What can you do to reduce the chance that a similar event will occur in future? Think about anything you’ve learned from this. Think about any actions you can take, whether this is personal (e.g., allowing more revision time in future) or external (e.g., asking for input from a tutor).

With all of these tips, it’s important to know that having good relationships with friends or family can help. Talking to others about stress you’re experiencing can help you to realise when it’s time to take action and can help you to change your perspective. Have you ever moaned to a friend about a rough day at work, and appreciated it when they pointed out that it wasn’t all your fault? Well, that’s an example of them helping you to develop a more positive attributional style for that event. The take home message is: talk about it! It’s easier than trying to do it alone.

This article was originally posted on the Psychreg website on 14 June 2019.

Ten tips for aspiring Clinical Psychologists

The competition to become a Clinical Psychologist is fierce. In the UK, the constituent parts of the training are a three-year undergraduate degree which is accredited by the British Psychological Society (BPS), and a three-year taught Clinical Psychology doctorate. The doctorate is full-time; candidates are employed by the NHS and complete a series of six-month placements in addition to coursework and a research project.

Psychology undergraduate students self-fund their degrees and as such, courses have flexibility about the number of students they can enrol. Psychology is consistently the second most popular degree in the UK, with an estimated 13,000 graduating each year. However, until recently, the only places offered on the doctorate were NHS funded, and therefore carefully regulated. Between 2012 and 2018, doctorate courses enrolled around 590 students per year altogether; just 15% of the total number of applicants. While three courses now include self-funded places, these come with a price tag of £20k+ a year, putting them out of reach of most graduates. 

Here, I offer 10 tips for aspiring Clinical Psychologists:

1. Know the bottom-lineIf you are at the point of applying for the doctorate, look at the particular courses you are interested in on the Clearing House website. What are their non-negotiables? Many courses now stipulate that candidates must have a 2:1 or a score above 65% in their undergraduate degree. Others require that applicants have a year’s clinical experience supervised by a qualified psychological therapist. If you don’t meet their stipulations your application will be automatically excluded, even if it is otherwise strong.  It is therefore worth researching each course’s bottom-lines before you apply.

2. Look into placement-year degrees. Several universities including Aston, Bath and Leeds (where I am based) offer applicants the opportunity to undertake a placement year ‘in industry’ between the second and third year. This means that students can gain relevant clinical experiences which can help them to be competitive applicants for graduate jobs. These placements are overseen by the universities, helping to ensure that they provide students with more useful experiences than they may gain through general volunteering. Some placements also offer a contribution towards expenses or a stipend, which volunteer roles generally do not. 

3. Consider the ‘Increasing Access to Psychological Therapies’ (IAPT) initiative for an alternative career as a psychological therapist. IAPT was launched in 2007 to provide greater access to psychological interventions for people with mild-to-moderate anxiety and depression. It is now planned to expand in order to provide therapies to 1.5million adults per year by 2020/2021. There are two main types of psychological therapists working in IAPT: Psychological Wellbeing Practitioners (PWPs) and High-Intensity CBT Therapists (HITs). PWPs are recruited into training positions with IAPT services on an NHS band 4; once they are qualified, they are paid at band 5 and can progress to band 6 (for information on NHS pay bands, see here). Similarly, HITs apply to train with specific NHS services. They train on band 6 and are paid on band 7 once qualified. Sign up to NHS jobs for alerts about these roles. A follow-up of HITs suggested that 79% stay in IAPT services after qualifying, 61% become CBT supervisors and 23% progress to more senior roles. It also possible to self-fund training to qualify as a CBT therapist, by undertaking a postgraduate course accredited as Level-2 by the British Association for Behavioural and Cognitive Psychotherapies (BABCP). 

4. “Remember at the end of the day, it’s just a job”. This was the best advice I was given before I attended my interviews for the Clinical Psychology Doctorate. A qualified Clinical Psychologist called me to give me some advice, and these words helped remind me that I wasn’t auditioning for the X-Factor: at absolute best, I would become a qualified psychological therapist. Imminent fame, stardom and riches were not around the corner. Being a Clinical Psychologist in the NHS is a wonderful job, but it is not without stress and strain, like any other healthcare related job. So, relax: it’s just a job.

5. Vary your experiences. Working as a research assistant or assistant psychologist will give you great experience for the Clinical Psychology doctorate, but more than a year in any one post will have diminishing returns. While you will always need to balance the opportunity to gain varied experience with the need to pay your rent and bills, it’s worth remembering that having a broad skillset will give you the strongest CV and application.

6. Treat applications like assignments and interviews like exams. You cannot assume that the knowledge and experience you have will naturally shine through: work hard to sell yourself. Consider carefully the range of experiences you have had. For example, what is the range of client groups you have worked with? What experiences have you gathered? Think carefully about the knowledge you have in relation to engaging different client groups, conducting assessments, collecting and storing sensitive data, managing risk, and applying psychological theory to individuals, for example by contributing to formulations or interventions. Also consider carefully the job which you are applying or interviewing for: who is interviewing you, and what is their area of interest? Which client group will you be working with, and what things might you need to be conscious of? Which therapeutic modalities might you be using, such as CBT or psychodynamic approaches? One way to impress your interviewers is to appear prepared for the opportunity they are offering.

7. Consider alternative psychology disciplines. If you have a BPS-accredited undergraduate degree, Clinical Psychology is not your only option for working therapeutically. For example, many posts which are open to Clinical Psychologists are also open to Counselling Psychologists. To train as a Counselling Psychologist, you can either do a self-funded doctorate degree or the BPS qualification in counselling psychology; this involves three years of supervised practice. More information is available here. Alternatively, for psychologists interested in working with forensic populations, Forensic Psychology may offer a fulfilling alternative career to Clinical Psychology. In some secure hospitals, much of the work of Forensic Psychologists involves delivering psychological therapy. To train as a Forensic Psychologist you can either complete a Doctorate in Forensic Psychology or a Masters in Forensic Psychology followed by two years of BPS training and supervised practice. More information on becoming a Forensic Psychologist is available here. It is also worth noting that the University of Birmingham now runs a four-year doctorate which offers candidates a dual qualification in both Forensic and Clinical Psychology (see here). 

8. Look for research opportunities. As an undergraduate I undertook some voluntary work as a research assistant with a professor and lecturer in my department. It was one of the best decisions I made: it paved the way to my Medical Research Council-funded PhD in Resilience to Suicidality and kick-started my love of improvement in healthcare. It also helped me to gather a range of experiences in working with clinical populations, as my PhD involved undertaking psychological assessments with people with psychosis and testing a novel mood-boosting intervention in this group. I would highly recommend seeking research opportunities to aspiring Clinical Psychologists. If you are currently a psychology undergraduate, seek opportunities with clinically-oriented researchers in your department. If you are a psychology graduate, sign up for job alerts at jobs.ac.uk and look for opportunities which would allow you to gain experience working with clinical psychologists and/or researching with clinical populations.

9. Keep your eye on the proposed role for ‘Clinical Associate Psychologists’. This is anticipated to take the form of an apprenticeship which will last 18 months and produce psychology professionals who undertake psychological assessment and formulation, and who deliver psychological interventions. At the moment, it is suggested that each Clinical Associate Psychologist will train on a Band 5 salary and be paid at Band 6 once qualified. The plans are currently in development, but should be in place in the coming year. 

10. Take heart: the need for psychologists is not diminishing. While the sense of competition may feel overwhelming, the demand for psychological therapies is increasing, which is reflected in the introduction of the IAPT initiative and the new role of the Clinical Associate Psychologist. While getting a place on the Clinical Psychology Doctorate may be challenging, if you have a passion for psychological work, the future is bright!

Finally, I want to note that while the cap on funded places for the Clinical Psychology doctorate produces a low success rate at the point of enrolment, I believe it also offers significant benefits. First, the competition that the cap creates means that aspiring Clinical Psychologists need to seek additional experience and training after their undergraduate degrees to strengthen their applications. This experience ensures that all doctoral trainees know the discipline they are working in and can feel confident in their career choice before they sign-up to the three-year course. This is reflected in the high retention rates of courses (99.4%): students rarely fail to complete their doctorate, once they’re on it. Second, it means that once qualified, Clinical Psychologists have good job prospects: 95% are employed in a clinical psychology job within 12 months of graduating. Deregulating the number of doctorate training places could shift this balance, creating the possibility that qualified Clinical Psychologists could become unable to find employment. By ensuring that applicants are experienced and committed, I believe that continuing to fund all forms of postgraduate psychological training offers the best outcome for applicants, healthcare providers and clients.

Reflective practice groups for liaison psychiatry nurses: are they helpful? Our study

Liaison psychiatry nurses have a tough job. They are based in the Emergency Department and work with individuals experiencing acute distress; these patients may have recently self-harmed or attempted suicide and could be at high risk of further harm. Liaison psychiatry nurses contact gatekeepers to other services while under the pressure of national waiting-time targets. They usually have no continuity with patients after they are discharged and may be left wondering how their patients’ situations turned out in the end. Both mental healthcare staff and emergency department staff are high risk groups for burnout (Johnson et al., 2018; Potter, 2006); liaison psychiatry nursing combines each of these elements and so these nurses may experience particularly elevated stress.

In order to provide liaison psychiatry nurses with more support, one hospital introduced reflective practice groups. The groups were a protected hour: the liaison psychiatry nursing team left the department to go to a quiet room in another building where they could not be contacted. The groups were facilitated by a clinical psychologist already employed by the hospital. I particularly liked this feature; too often I hear about outside consultants being paid hefty sums to deliver wellbeing packages with hazy evidence bases, when most healthcare organisations already have a group of highly trained professionals employed in their  psychology department who can do this work. The psychologist enabled dialogue between the team members and facilitated their conversation but did not impose an agenda.

When I was invited to contribute to the evaluation of this intervention I was delighted. We interviewed 13 liaison psychiatry nurses who had attended the group. They identified four main benefits of participating:

  • Sharing and learning. Participants found that sharing their experiences in the group helped them to feel less alone. They realised that other people in their team were experiencing similar challenges and they left the group sessions feeling clearer-minded and lighter.
  • Grounding and perspective. Participants said the group allowed them to take a step back and gain perspective on the difficulties of their work and the risks involved. It reminded them of the value their work has.
  • Space. Participants described the group as a safe space; they felt able to ask for help or to say they were unsure of things and seek advice from their colleagues.
  • Relationships. Participants said the group supported some positive interpersonal experiences between team members. The fact that they had an external facilitator and were guaranteed to be free from interruptions led them to feel they could raise difficult issues with their colleagues, in the knowledge they would be able to resolve these before the conversation ended.

It should be noted that not all nurses found the group beneficial. Some felt that the types of discussions they had during reflective practice were already happening elsewhere and they believed a protected space was not necessary. However, these nurses recognised that some of their colleagues benefited from the group, and were willing to participate in recognition of the overall team benefit.

We weren’t able to quantitatively evaluate the group as the number of participants in the study was too small. However, our qualitative data suggested that overall these groups provided a range of benefits which would have been hard to get from another forum, and some participants believed that sickness absence in the team would have been higher without them.

Practical tips for running reflective practice groups

For anyone wanting to run reflective practice groups, our study suggested a few things should be considered:

  • Groups shouldn’t include managers. The presence of managers changed the nature of the group and inhibited open discussion.
  • Protected time is key. Nurses stated that the groups were the only time they were guaranteed to have a conversation at work without interruption, and this was an absolute necessity for helping them feel able to discuss sensitive issues.
  • The facilitator must be external to the group. Previous research suggests nurses trained in reflective practice can supervise these groups and there can be benefits to having someone of the same discipline provide this facilitation. However, experienced clinical psychologists should be sufficiently trained to offer this in the absence of trained nurses. Our study suggests this is acceptable to nurses and the important thing is that the facilitator works in healthcare but is external to their team.

A practical and cost-effective solution

Further research is needed to establish the effectiveness of reflective practice groups for supporting staff wellbeing. However, the evidence base for burnout reduction interventions in general is still small (see my previous blog on this here), and the best methods for supporting staff are not yet established.  While we wait for evidence-based recommendations, reflective practice groups are a cost-effective form of support for liaison psychiatry nurses: they require no special equipment, no long periods of staff absence from work and can be facilitated by in-house psychologists, so no expensive outside consultants are required.

To read this study please see here


Burnout and wellbeing in mental healthcare staff: Our review

It was an article that started life as a conversation. We sat around a table in March 2016, discussing mental healthcare staff wellbeing. Someone pointed out the increase in burnout they had seen in mental health staff in the services they worked with; someone else spoke about the unique demands of working in mental health care settings, and how staff burnout may impact patient care. It felt like we were tapping important issues; etching out a line of argument we had not seen articulated in any academic articles we had read. Then I heard myself pipe up, “This feels like a paper. We should write a paper. I’ll draft it”.

Famous last words. As I left the room my enthusiasm waned a little. Had I really just volunteered to write another review?

Getting into the data
I knew I was going to need to access original data from government sources to build the case, which was new for me. I scoured NHS Digital and other sites, entering the numbers into excel files in order to plot graphs. These told me that the proportion of NHS  staff feeling unwell due to work-related stress had risen by 9% in 8 years (from 28% in 2008 to 37% in 2016; Figure 1a), and double the number of NHS staff had said they were leaving because of poor work– life balance in 2015 compared with 2011 (Figure 1b). I was stunned.

Figure 1

Figure 1. Percentage of staff reporting having felt unwell due to work-related stress on the NHS staff survey. (Source: NHS staff survey data; www.nhsstaffsurveys.com) (A) and number of staff citing poor work-life balance as their reason for leaving their NHS post. (Source: NHS Digital; https://data.gov.uk/dataset/nhs-workforce-reasons-for-leaving) (B).

Are these problems just in the UK?
The NHS has suffered significant underfunding for several years (Kingsfund, 2017) which has been a cause of staff stress, so I wanted to check whether these problems may be NHS-specific or similar in other countries. I found relevant data provided by the US Bureau of Labour Statistics (2017). Given the vast differences between the organisation of UK and USA healthcare provision it was an interesting point of comparison. This data suggested workers in healthcare support occupations take the most sickness absence of all employees, with rates 50% higher than private sector employees. It was clear that these patterns were not UK specific.

Are they any differences between staff working in mental healthcare and other settings?
Curious to compare mental healthcare staff with healthcare staff in other settings, I emailed NHS Digital to get a breakdown of sickness absence rates by trust type. These told me that mental healthcare staff are off work due to sickness on more days than the overall average for healthcare staff, and on more days than those in both acute trusts and primary care (Figure 2). Mental healthcare staff also more frequently cited anxiety, stress, depression and other mental health problems as the reason for this absence.

MH FIg 2

Figure 2. Sickness absence rate by trust type. (Source: NHS Digital: http://www.content.digital.nhs.uk/catalogue/PUB22562).

It occurred to me that the proportion of different types of staff varies across trust type. Some trusts employ relatively more doctors, and others relatively more allied health staff (such as occupational therapists and physiotherapists). What if this variation in staff type explained the variation in sickness absence? To test this, I restricted the analysis to first doctors, then nurses. It didn’t make a difference. In doctors in acute trusts, 17% of absences were in this category, compared with 26% in doctors working in mental health. In nurses in acute trusts, 18% were in this category, compared with 25% in mental health nurses (NHS Digital, 2017). It was quickly becoming apparent that the concerns we had raised in our conversation and the observations of members of the authorship team were backed up by hard data.

Impact on patient care
In order to consider the impact these high rates of stress may have on patient care, my co-authors and I reached into our knowledge of the general healthcare literature. A previous systematic review we had completed (Hall et al., 2016) found that high staff burnout is linked with greater risk of medical errors happening (or poorer patient safety) across healthcare settings. Medical errors can include being prescribed the wrong amount of a medication by your family doctor, being administered a medication you are allergic to by your nurse in hospital, or even being operated on the wrong body part by your surgeon. As expected, when we searched for studies investigating this area in mental healthcare staff a similar pattern emerged. For example, Brady et al. (2012) found that running a mindfulness-based-stress-reduction intervention with mental health staff improved patient satisfaction scores and decreased rates of patient safety events during the 3 months after the intervention. However, there was a disappointingly small amount of research linking healthcare staff wellbeing and burnout with patient care in mental health, and more is needed.

What about interventions?
There were also fewer studies looking at burnout and wellbeing interventions in mental healthcare staff than other staff groups, but I was pleased to find a recent systematic review and meta-analysis by Kimberley Dreison and her colleagues (2018) focused specifically on burnout interventions in mental healthcare staff. This review identified 27 studies. Interventions included stress management workshops, clinical supervision, and staff training. Overall, interventions were effective but only led to small improvements.

What type of interventions are most effective?
Interestingly, when interventions that focused on individual staff members (e.g., psychological therapy) were compared with those that focused on organisational changes (e.g., introducing staff support groups), individual-focused interventions were more effective. However, when staff training and education interventions were separated out from other types of organisational interventions, they led to greater improvements than individually focused interventions for overall burnout scores. This suggests that training and education interventions may be the best place for future research into burnout reduction in mental healthcare staff to focus on. It also suggests that simple comparisons between individually-focused and organisationally focused interventions could be misleading.

What now?
The purpose of the review was to produce recommendations for moving research and practice in this area forward. In the end, there were 4 of these:

  1. Ground interventions in the research literature: When developing burnout interventions, first understand what the causes of burnout are. Design your intervention to address this. Overall, the research literature suggests that poor staffing ratios, the emotional demands of caring for complex patients, lack of leadership and lack of training are all burnout contributors. Furthermore, draw on what the research tells us is likely to be effective. The best evidence at present suggests that staff training interventions may be particularly effective for reducing overall burnout.
  2. Increase the value of interventions: We know that staff burnout is consistently linked with quality and safety of patient care. It is also likely that these two operate in a feedback loop; not being able to provide high quality care is probably detrimental to staff burnout. Developing interventions which simultaneously reduce staff burnout and enhance care quality may meet two needs at once and be self-reinforcing. Again, staff training interventions would tick this box.
  3. Build bridges between universities and healthcare organisations: Partnerships between universities and healthcare organisations can help identify new and relevant topics for research, ensure studies meet current service and patient needs and help results to have a greater impact in the real world.
  4. Engage healthcare staff by emphasising the positives: There is a perceived stigma linked with admitting poor mental wellbeing in healthcare staff. Staff may fear that disclosure could cause career damage or put their professional registration at risk. As such, rather than offering burnout interventions as a fix for those who are struggling, emphasise the additional benefits that participants may reap. These include increased job satisfaction, life satisfaction, relaxation, and improved physical health. Be clear that interventions are not for the suffering but those who want to thrive in their work.

 

The article is published in the International Journal of Mental Health Nursing. To read the paper, follow this link.

 

References

Brady, S., O’Connor, N., Burgermeister, D. & Hanson, P. (2012). The impact of mindfulness meditation in promoting a culture of safety on an acute psychiatric unit. Perspectives in Psychiatric Care, 48, 129–137.

Bureau of Labor Statistics (2017). Absences from Work of Employed Full‐Time Wage and Salary Workers by Occupation and Industry. US Department of Labour. [Cited 18 November 2017]. Available from: https://www.bls.gov/cps/cpsaat47.htm

Dreison, K. C., Luther, L., Bonfils, K. A., Sliter, M. T., McGrew, J. H., & Salyers, M. P. (2018). Job burnout in mental health providers: A meta-analysis of 35 years of intervention research. Journal of Occupational Health Psychology, 23(1), 18-30.

Hall, L. H., Johnson, J., Watt, I., Tsipa, A. & O’Connor, D. B. (2016). Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PLoS ONE, 11, e0159015.

NHS Digital (2017). Sickness Absence Full Time Equivalent Days Lost by Staff Group, Organisational Type and Reason for Absence. Dataset provided by the Health and Social Care Information Centre on request on 24th April 2017.

Building psychological resilience 2: how to reduce perfectionism and enhance flexible thinking

What is perfectionism?

We often use the term ‘perfectionist’ in a light-hearted way, to refer to a friend or colleague who’s being that bit too fussy about something. However, research suggests that having higher levels of perfectionism as a personality trait is one of the strongest factors which can reduce our resilience and make us vulnerable to stress (Johnson et al., 2011). At its heart, perfectionism describes the tendency to hold rigid, unrelenting, high standards. These are the kind of high standards that don’t bend in response to stress and don’t allow for excuses. It has been suggested that there are three types of perfectionism: self-oriented perfectionism, where we impose strict and high standards on ourselves, other-oriented perfectionism, where we impose strict and high standards on others, and socially prescribed perfectionism, where we believe that other people demand overly high standards from us (Hewitt and Flett, 1991). These three types of perfectionism cluster together – that is, if you are high in one, you are likely to be high in others.

What’s this got to do with resilience?

If having more of this trait makes us vulnerable to stress, what can this tell us about resilience? Well, every positive factor has a negative opposite – and every negative factor has a positive opposite. So if more perfectionism is bad, then less is good; and if perfectionism describes rigid, high standards, then the other end of this spectrum is mental flexibility (Figure 1).

perfectionism 1

It’s not high standards that are the problem

Let’s be clear, reducing perfectionism isn’t about lowering high standards. Having high standards is often a strength, driving people to make great achievements. The problem is not the standards themselves, but the fact that they are rigid and inflexible. Aiming high when you’re feeling strong can be positive, but insisting on reaching the same standard when you’re under unusually high pressure can be exhausting. There’s a need to maintain personal equilibrium, to adjust standards in response to what is manageable, given the situation. Doing this can ensure that you bend without breaking, and feel ready to return to full strength when your situation changes. On the other hand, piling on the pressure to meet overly high standards at all times is a recipe for burnout. 

Types of inflexible thinking

There are different thinking habits we can fall into that feed perfectionist thinking and reduce our ability to be flexible. These kinds of thinking habits are inflexible, rigid and demanding. Some examples are:

  • Black-and-white thinking. This is where you lose sight of the grey areas, and go into a mode which is ‘all or nothing’. The kind of thoughts you might have are “Anything less than the best is unacceptable” and “Asking for help makes me a failure”.
  • Catastrophic thinking. This is where you blow up the consequences and believe that if something goes wrong then it will be unmanageable. Some catastrophic thoughts are “If I fail the exam, my life is over” and “If I don’t get it right, I’ll never be able to face my parents”.
  • Probability overestimation. This is where you overestimate the likelihood of bad outcomes. Some thoughts you might have are “Although I revised for the exam all week, it won’t be enough”, and “There’s no point in entering the competition, because I’d never win”.
  • Should statements. This is where you put yourself under a tyranny of rules. These are rigid, and do not adapt or relax when under times of pressure. Some thoughts you might have are “I should always be polite”, and “I should always foresee potential problems”.

 

Some ways to enhance mental flexibility

  1. Develop self-awareness

Notice when you are falling into these thinking habits and pushing yourself too hard. Some useful questions to ask yourself are:

  • Am I feeling more irritable or distracted than usual?
  • Am I showing any physical signs of stress – am I more tired than usual, or struggling with sleep?
  • Is anyone else telling me that I’m pushing myself too hard to meet these standards?

It may be useful to keep a brief diary. Write down the events of the day, your thoughts/interpretations of these, and how you feel emotionally at the end of the day. This will help you understand your own patterns of behaviour, how you interpret events and how this effects you emotionally. For example:

Event Thoughts/interpretations Emotions
Passed exam, but with a lower grade than predicted

 

I should have seen this coming. That module was tough and I’m just not up to it. I’ll have to work twice as hard next time, if I want to stand any chance of having a successful future. Worried, embarrassed, downhearted.
Saw Mary, went for a drink It was great to catch up, it’s been too long. Sounds like she’s doing really well. Had forgotten some of those times we chatted about! Happy, hopeful.

 

  1. Do something to lift your mood

Negative emotions narrow the focus of our attention (Fredrickson and Joiner, 2002). This means that we are more likely to get stuck thinking about our problems, and lose sight of the bigger picture. By contrast, positive emotions can open the scope of our attention. They help us to think more broadly and to find different ways of looking at our situation. Perfectionistic thinking is closely linked with negative emotion: it is unrelenting and demanding, and rarely helps us to feel good. A good first step in tackling this can be to do something that makes you feel more positive. This might be doing something you enjoy, like seeing friends or going to a film or something active, like exercise. You might also want to engage in the Broad-Minded Affective Coping Procedure (BMAC), a therapeutic exercise designed to boost mood (for an example of this see https://www.youtube.com/watch?v=RXLhtkHck78 ). The key thing is to do something that will give you a quick lift, as this will help you to think of things that can help you and implement change in the longer run.

 

  1. Set yourself some new, realistic and flexible standards

It can be useful to write yourself a new list of standards and statements, and to read these when you know you are pushing yourself too hard. Some examples of these are:

  • It’s not possible to be perfect all the time, and that’s ok
  • My own wellbeing is more important than my achievements
  • It’s ok to say the wrong thing sometimes, I’m only human
  • It’s not possible to be in a good mood all the time
  • I can only do my best, I can’t control all possible outcomes

 

  1. Think about your fears from someone else’s perspective

Confide your worries and fears to close friends or family who care about you and whose opinions you find helpful. Later on, when you are stressed and you think you may be pushing yourself too hard, you can then draw on these conversations in your mind. Think back to them and try and see your current situation from their perspectives. Ask yourself questions like:

  • If I told [friend or family member] how I had failed to achieve my usual standard, what would they say?
  • What advice would [friend or family member] give me about my current worry?
  • What advice would I give [friend or family member] if they had this same problem?

 

  1. Test your fears

Sometimes we need to change how we behave to change our thinking. In particular, it can be useful to challenge our fears in small ways. For example:

  • If you insist on always being early, try arriving at an event 10 minutes late.
  • If you hold very high standards about your appearance, wear something that is old, creased or has a stain on it.
  • If have a very strict exercise regime, try doing no exercise for a week
  • If you have very high standards for how you behave socially, try saying something you would normally not allow yourself to do so

Before you test out your fear, write down a list of what you are worried will happen. What do you think will go wrong as a result? Then rate each fear on i) how likely you think it is to happen (from 0 [not at all likely]-100 [will definitely happen]) and ii) how bad the impact will be (from 0 [I’ll barely notice it] to 100 [it will affect every area of my life for good]). After you’ve completed the test, read your list of fears. Did they happen? For those that happened, how bad was the outcome in reality? Rate it again from 0-100. Compare your ‘before’ and ‘after’ lists. For example:

 

First list (before the test)

Feared event What I’m worried will happen How likely is it to happen? How bad will the impact be?
Wearing clothes with a mark on Other people will notice 100% 70%
  Other people will judge me, and give me funny looks 100% 80%
  I’ll be so embarrassed I’ll go bright red 100% 90%
  I won’t be able to think straight and get my words out 90% 100%
  I won’t be able to face them again 80% 100%

 

Second list (after the test)

Feared event What was worried would happen To what extend did this happen? How bad will the impact be?
Wearing clothes with a mark on Other people would notice 20% 0%
  Other people would judge me, and give me funny looks 0% 0%
  I’d be so embarrassed I’d go bright red 60% 20%
  I wouldn’t be able to think straight and get my words out 20% 40%
  I wouldn’t be able to face them again 0% 0%

 

When we do this we often realise how bad our fears were before we started. Afterwards, even though we may still be afraid of reducing our high standards, we see how that fear has been reduced. In CBT, we call this a ‘behavioural experiment’. For a video example of one of these in a therapy setting, please see: https://www.youtube.com/watch?v=ExNs8o8A4fI

Evidence for reducing perfectionism and enhancing flexibility

Enhancing flexible thinking is a key feature of most cognitive-behavioural interventions, but recent years have seen the development of some interventions focused specifically on developing this. There is now a strong body of evidence to suggest that these interventions are both successful in reducing perfectionism, and also in boosting overall mental wellbeing. A recent meta-analysis and systematic review identified 8 studies that had investigated this and reported a large-effect sizes for studies reducing perfectionism, and found evidence that these interventions also reduce anxiety and depression in participants (Lloyd et al., 2015).

 

FREDRICKSON, B. L. & JOINER, T. 2002. Positive emotions trigger upward spirals toward emotional well-being. Psychological Science, 13, 172-175.

HEWITT, P. L. & FLETT, G. L. 1991. Perfectionism in the self and social contexts: Conceptualization, assessment, and association with psychopathology. Journal of Personality and Social Psychology, 60, 456-470.

JOHNSON, J., WOOD, A. M., GOODING, P., TAYLOR, P. J. & TARRIER, N. 2011. Resilience to suicidality: The buffering hypothesis. Clinical Psychology Review, 31, 563-591.

LLOYD, S., SCHMIDT, U., KHONDOKER, M. & TCHANTURIA, K. 2015. Can psychological interventions reduce perfectionism? A systematic review and meta-analysis. Behavioural and cognitive psychotherapy, 43, 705-731.

For more information on some of these techniques and other ideas for overcoming perfectionism, see https://www.anxietybc.com/adults/how-overcome-perfectionism

 

This blog post was first published on 24th November 2016 at  https://www.psychreg.org/enhancing-self-esteem/