Although diabetes management is considered primarily a medical issue, it has long been acknowledged that health outcomes can also be influenced by psychological and behavioral variables that affect self-care. This article discusses one such variable, perfectionism, as it influences diabetes care for the better and for the worse.

Pathological levels of perfectionism are associated with psychiatric disorders, such as bulimia,1 anorexia nervosa,2 depression,3 and obsessive-compulsive disorders.4 With the focus on food and on behavior control, psychiatric problems such as these develop in people with diabetes5 and greatly complicate treatment. Lower levels of perfectionism, which are more common, can both facilitate and interfere with diabetes care.

"Innies" and "Outies"
There are generally two types of perfectionists. In the first group, the drive toward being perfect or getting things "just right" is inwardly focused ("Innies"). These are sometimes called self-oriented perfectionists.6

Innies expect a great deal from themselves and are concerned about what others think of them. They can be very detail-oriented, structured in their routines, conservative in their ways, organized, and responsive to the evaluations of others. Although they are eager to do well and to please their doctors, deep inside Innies think that they will never be good enough.7

Some clinicians would consider Innies to be ideal patients. They can be, as long as things in their lives remain consistent, stable, and routine. Problems arise when life stress intervenes.

Some clinicians are also inwardly focused perfectionists. They are careful and detailed in their work, orderly, structured, neat, and conscientious.7 Innies are sometimes dietitians and nurses, as well as physicians. They have high expectations for themselves, including expectations for how they manage their own lives and the goals they set for how they want to help patients manage their disease.

The second group consists of more outwardly focused perfectionists ("Outies"). These are sometimes referred to as other-oriented perfectionists6 because their drive toward perfection is most noticeable in their expectations of others.

Outies not only expect a great deal from other people in their lives, but also have little tolerance for people’s seemingly poor quality work or lack of effort. Like Innies, Outies have

a good eye for detail and are structured in the important areas of their lives. Although Outies have high expectations of others, they do not always trust others to do a good job. Some-times, Outies believe that it is better to do a job themselves than to entrust it to someone less conscientious.7

Some clinicians are also Outies. They expect a lot from their patients and their co-workers. They set good examples for others, work hard, and are diligent. Although they can be encouraging of their patients, they can also choose to withhold praise as a way of attempting to motivate others to continue to do well.

When displeased, Outies express their disapproval or dissatisfaction with poor performance in both direct and indirect, or nonverbal, ways. Sometimes, Outie clinicians leave their patients feeling that they will never be good enough.

Deep inside, most Outies have a little Innie in them who has self-doubt and is concerned about what others think of them. In fact, most perfectionists have a mix of Innie and Outie characteristics, depending on the situation.

To determine whether you are a perfectionist and, if so, whether you are an Innie or an Outie, fill out the scale in Table 1. Higher scores suggest a level of perfectionism that could cause you trouble.

The Error of Oversimplification:
A Case Study
The drive toward metabolic perfection can be a particular challenge for people with diabetes. By definition, their blood glucose control cannot be as "perfect" as it might have been before the illness began because it is now under "artificial" control.

The goal of treatment may be to normalize blood glucose levels, to the extent that it is possible, for the majority of the time. This means that external algorithms must be used to adjust activity, food choices and amounts, and insulin doses to compensate for lapses in patients’ biologically driven algorithm.

For perfectionist patients and their clinicians, the goal of perfect metabolic control is likely to be unrealistic and the pursuit frustrating. A characteristic of perfectionism that fuels this frustration is called "oversimplification."7 Oversimplification is a way of looking at blood glucose control in absolute terms; either it is under control or it is not.

When goals for the treatment of diabetes are not clearly defined, perfectionists will assume that there is an absolute standard that they are expected to achieve (i.e., perfect control). This might include having perfect blood glucose levels, watching their diet closely, performing consistent blood glucose monitoring, and engaging in regular exercise and foot care. While it could be argued that perfect control is a great goal, most people with diabetes find it impossible to consistently achieve.

Looking at diabetes control in an oversimplified, all-or-nothing way leaves perfectionists with only two possible outcomes. Either they succeed in achieving their goals, or they fail. For a perfectionist, anything short of complete success can feel like a failure. Almost is not usually good enough. If the perfectionist is the clinician, almost may not be good enough for them, either. Some patients will get so frustrated with their inability to achieve perfect control that they will give up altogether. This is when perfectionism can be a problem, as illustrated in the following case study.

Sally is a 40-year-old mother of two with a 5-year history of type 1 diabetes. Her husband and children tease her by calling her a perfectionist because she is so fussy about how the house looks, her personal appearance, and the way she organizes her shelves and her life. She tries very hard to be a good homemaker and mother, and she takes care of her health.

Sally is currently in college to complete a master’s degree in special education. She does not want her schooling to interfere with taking care of her family, so she takes the time to prepare hot breakfasts in the morning, packs the kids’ lunches, and makes dinner every night. She attends all school functions and helps her children with school projects.

Because she knows that her education is placing a financial burden on her family, she wants to do her best at school so that they "get their money’s worth." For Sally, this means getting straight A’s.

This semester, Sally is taking a full load of courses and is having a difficult time keeping up with all of her responsibilities. She cannot stand the idea of doing less than her best at school or "short-changing" her family, so she works hard day and night to keep up.

Unfortunately, she has less time for herself. She skips meals, checks her blood glucose less frequently, and stops exercising. Although she is testing less frequently, she "knows" that her blood glucose levels are "out of control." She skips her next doctor’s visit because she does not want to hear the usual lecture.

When Sally cannot take care of her diabetes the way she thinks she "should," she gives up, eats unhealthy foods, checks her blood glucose levels only when she thinks she is too high, and overeats when she compensates for the lows. For Sally, as for most perfectionists, when she cannot be completely successful with her diabetes care, she feels like a failure. This leads to giving up the pursuit at least until she can be 100% successful again. When she cannot do it all, she does nothing.

Correcting Oversimplification
To help people like Sally, clinicians must first help them recognize this all-or-nothing pattern of thinking. Point out how they either keep their self-care behaviors "right on track," or they fall apart. Help patients see that these are only two choices of how to manage their diabetes and that they represent two ends of a continuum. There are lots of other choices besides doing it all or doing nothing. Rather than seeing their self-care in black-and-white terms, patients need to choose shades of gray.

The second step is to help patients reconceptualize their diabetes management as a process rather than an outcome. This means that their self-care behaviors and blood glucose control must be viewed as an ongoing process with the goal of doing as well as possible as often as possible. Perfectionists tend to view control as an accomplishment or an endpoint (e.g., "My diabetes is under control") rather than looking at their current level of control as a point on a continuum (e.g., "I am managing my diabetes well right now").

Perfectionists tend to equate diabetes control with success. When they are unable to reach a good level of blood glucose control, it feels like failure. This generates negative emotions (e.g., sadness, frustration, anger), all of which serve to reduce motivation.

Sally thought she was a failure with regard to her diabetes management, and she felt very guilty. Because she could not keep up, she put her diabetes management "out of her mind." This kept her from having to feel guilty and think about her failure.

Clinicians may oversimplify diabetes management in their own minds, as well. They know logically that diabetes care is a long-term process that will have lots of ups and downs. Nonetheless, when a patient does well, it may feel like a personal success for them. Similarly, when a patient does not do well, it can be very frustrating because at some level it feels like a personal failure for the clinician. Innie clinicians may tend to personalize the failure (e.g., "What’s wrong with me?") and feel badly inside, whereas Outie clinicians will get angry or irritated because a patient did not meet their expectations.

The third step is to try to help patients set realistic expectations for themselves, particularly those you suspect are perfectionists. Although they may approach their self-care with great enthusiasm, do not let them set unreasonable goals.

This is especially important early in the course of treatment. Set goals that may be a bit lower than they can achieve so that they can have positive experiences in managing their diabetes. At the next visit, let the patient set another goal that may be slightly higher.

Rather than setting goals for perfect blood glucose levels 100% of the time, target improvements in areas that may be troublesome, such as reducing the frequency or degree of late-afternoon low blood glucose or after-dinner high blood glucose levels. Sometimes the goal will be to alter the treatment so that it matches a patient’s lifestyle or eating habits, rather than the reverse.

In the way that you help patients set goals, you can communicate that diabetes care is a process that will change as patients’ schedules, life-styles, and bodies change. The goals you set today may be quite different from the goals of treatment next year. The general plan is to help patients adapt to the fluctuations in their lives and in their disease.

When Sally finally went to see her doctor, he referred her to the clinical nurse specialist to work out a plan for managing her diabetes until her degree was completed. They identified two or three areas in which Sally could improve and still fit those efforts into her very busy schedule. For example, they worked out a plan for checking her blood glucose at the times of day that she was most likely to have problems. She decided to keep a healthy portable snack in her backpack for those times when she absolutely could not stop to eat a real meal. And they modified her insulin schedule to match these changes.

The fourth step in helping patients avoid oversimplification is to normalize "failure." Specifically, clinicians can help patients to anticipate times when, despite their great efforts, their blood glucose levels will not respond as predicted. In this way, you are communicating to them that it is normal to have difficulty in controlling their blood glucose. When this inevitably happens, the key is not to panic or give up. The key is to try to learn from these events. When patients have difficulties, normalize the process by telling them that everyone struggles with their blood glucose levels.

Sally incorrectly assumed that everyone else was following his or her diabetes regimen without trouble and that she should be able to do so, too. It helped for her to hear that other people have had similar problems with their diabetes management when their lifestyle changed or when they faced competing demands. Rather than feel badly and give up, she learned how to adapt to the inevitable changes in her life. While the modified self-care plan would not ultimately give her the level of control she desired, it was much better than giving up altogether and waiting until her life returned to normal.

Negative Thinking and Diabetes Self-Care
When patients discuss their difficulties in following their self-care plan, listen for emotional reactions such as anger, frustration, or fear. These emotions are a clue that patients have attached negative thoughts to their difficulties (i.e., "I can’t do it," "I’ll never get it right," "The doctor is going to be angry with me," or "I don’t care"). These negative thoughts will directly affect patients’ self-care behaviors.

Try to help patients anticipate how their emotional reactions can affect their self-care by helping them to identify their negative thoughts about their blood glucose control. You can do this by first identifying the type of emotion they experienced (e.g., upset, angry, irritated, or frustrated).

Sometimes, patients will tell you or show you their emotional reaction. If you can hear their frustration or anxiety, tell them what you hear (e.g., "It sounds like that 200 reading really upset you").

When patients do not readily tell you their emotional reactions, ask about them (e.g., "When you saw that 200 on the meter, how did it make you feel?"). Many people will answer that question by telling you what they thought, rather than what they felt. That is O.K., because what you ultimately want to know about is their inner thoughts about their self-care efforts.

If patients tell you about their emotions, as you ask, probe further to find out what was going through their mind when the upsetting event occurred. If a patient has not already told you, you can ask, "What was it about seeing that 200 that upset you the most?"

The final step is to find out how their emotions and negative thoughts affected their actions. You can find out by asking, "When you felt badly and thought to yourself that you could not do it, how did it affect your actions? What did you do?"

Your goal is to draw a connection between feeling badly and doing something counterproductive to their diabetes control. If patients can recognize their emotional reactions and consequent behaviors, then they can learn to ignore the urge to give up the next time they have difficulty with their blood glucose levels. Instead they can choose a more effective plan of action.

These are some of the basic steps in cognitive behavior therapy. The theory is that thoughts, feelings, and actions interrelate.8 Negative thinking arouses negative emotions, and vice versa. Both influence choices of actions. When a person is distressed, negative thoughts often come to mind. There can be a cascading effect, whereby one negative thought seems to open the door for another and another until the person is emotionally overwhelmed. Negative thoughts can lead to a choice of actions that creates more problems. This reinforces the person’s negative thoughts about the situation.

There are underlying beliefs, sometimes called schemas or core beliefs,8,9 that help people to interpret their experiences. Some schemas are very positive and adaptive. Some are negative and dysfunctional. Perfectionists often have schemas or core beliefs that they must be perfect, or something bad will happen.

Sally’s core belief is that if she is not a perfect wife and mother, her family will suffer. Another one of Sally’s core beliefs is "I am capable of getting straight As, therefore I must. Anything less would not be right."

Sometimes, perfectionists believe that if they are perfect something good will happen. This is often more fantasy than reality. For example, "If I am perfect, then everything will turn out just right, I will be happy, or people will accept me." These core beliefs motivate perfectionists to work very hard. Unfortunately, they get upset or depressed when they cannot be perfect or when they achieve perfection and the good things they anticipate do not come to pass.

Another common core belief of perfectionists, especially Innies, is that no matter what they do, they will never be good enough.7 Having diabetes can reinforce this self-view of being flawed. By definition, having diabetes makes one imperfect. Therefore, in their minds, they will never be good enough.

Perfectionists can have a difficult time adjusting psychologically to having diabetes because it means that they are just as "flawed" as they imagined. If you do not expect perfection from yourself, you are not as distressed when things go wrong.

Working With Perfectionist Patients
Because perfectionists are often concerned about what others think of them, working with clinicians to manage their diabetes can be very uncomfortable. The fantasy of many perfectionists is that, if other people see their flaws or failures, they will be rejected.

Rejection can take a variety of forms. It can be verbal, such as criticism, or emotional, such as withholding attention or affection. Either form of rejection is intolerable for perfectionists.

Diabetes management opens the door for scrutiny by another person. If patients value their relationships with their health care providers and care what their providers think of them, this scrutiny can be very painful. To be helpful, clinicians have to be able to identify when patients have made errors so that they can help patients to improve. However, for perfectionist patients, making an error means that they have failed, and having to openly admit it means that others have seen their flaws. Therefore, each time the clinician points out an error to the patient, it can cut like an emotional knife.

When people feel criticized or attacked, it is natural for them to behave in a defensive manner. The defense can take several forms. Some people will defend by making excuses for their high blood glucose levels. ("Something is wrong with my glucometer." "I couldn’t figure out how much fat there was in the dish they served, and I couldn’t refuse to eat it. It would not have been proper." "That can’t be right. Maybe the lab made a mistake." "I just have too much to do right now.") It may seem to the clinician that, rather than listening and trying to learn, these patients are caught up in defending their actions.

The clinician can help by not putting patients on the defensive in the first place. This can be accomplished by letting patients self-evaluate ("How do you think you did this month?"). It can also be accomplished by being sensitive to patients’ feelings and monitoring the emotional tone of your message. Monitor your own level of irritation with patients and try not to communicate this to them. It is not generally useful to get angry with patients, criticize, express disapproval, or otherwise make their diabetes a personal issue between you and them.

Your goal is for the patient to self-evaluate, self-correct, and self-manage. You are the coach, not the parent.

Rather than being openly defensive, some patients will be self-critical when they have to openly acknowledge that they made an error in their diabetes management or when they have not reached their self-care goals. The self-criticism may be communicated directly (e.g., "I am so stupid. I am never going to get this right.") or may be an internal thought that shows only in the patient’s affective response (e.g., a discouraged look).

As mentioned above, these thoughts usually arouse a lot of emotion and interfere with self-care. Rather than trying to talk patients out of their self-criticism, clinicians should help these patients focus on what to do about their diabetes care ("What do you want to do about it?").

When Innie Meets Outie
Undoubtedly, the most difficult dynamic in diabetes management is when a patient is an Innie and a clinician is an Outie. The Outie clinician has very high expectations for the patient, just as the Innie patient has high expectations for him or herself.

Innies fear that their clinicians will disapprove of them, and Outie clinicians often show their disapproval. Sometimes the disapproval is direct, whether verbal (e.g., a criticism) or nonverbal (e.g., a scowl). Sometimes the disapproval takes the form of emotional distance. This may not be outwardly unfriendly behavior, but the clinician may seem more distant or detached from the patient, like having an emotional wall between clinician and patient.

Some clinicians may think that this dynamic is useful because they can use their personal approval or disapproval as a way of motivating the patient. While this may be tempting, it is not a useful therapeutic process in the long run. The patient needs to do well for him or herself, not just to please you.

When patients do well, the success must be attributed internally ("Look what I did!"), rather than be attributed to the clinician ("If it were not for you, I couldn’t have done it. I owe it all to you"), despite the fact that it might feel good to the clinician. Remember that, ultimately, you want patients to take full responsibility for their care. You want them to rely on themselves and to not need you.

Perfectionist Clinicians and Nonperfectionist Patients
Nothing is more frustrating for a clinician than knowing what is best for a patient and not being able to get the patient to adhere to the plan. This experience can elicit many different thoughts and feelings in clinicians, some of which might interfere with their ability to be helpful to patients or to be creative in treatment planning.

Some common misconceptions about patient-clinician relationships might contribute to the frustration. ("If my explanations are sufficiently clear, the patient will understand." "If the treatment is good for the patient and the patient says he or she wants to stay healthy, then he or she will follow the treatment plan." "Patients will be honest about their self-care behaviors.") While these ideas might hold for some patients, they do not necessarily apply to all patients.

If these are the clinician’s views and a patient does not cooperate with treatment, the clinician must interpret this behavior in a way that makes most sense. Clinicians who are Innies might tend to blame themselves. ("I was not clear enough." "The treatment was not realistic." "I don’t know what I am doing.") Outie clinicians might blame the patients. ("He’s a jerk." "She doesn’t care." "If he doesn’t care, why should I care?") All of these ideas are probably oversimplifications of the actual problem. They are full of emotion and none of them lead toward a solution to the problem.

If a patient does not follow a treatment plan, then the plan does not work. It does not matter whether it was a great plan, a simple plan, or a clinically ingenious plan. If a patient cannot execute the plan, then the plan does not work. This is not about fault or blame. It means the patient and clinician have to go back to the drawing board to develop a better plan that fits the patient’s lifestyle.

Getting angry with yourself or getting angry with a patient fills your head with emotion. Emotions of this sort interfere with creative problem-solving. The more you think negative thoughts about yourself or about your patient, the worse you feel inside.

By virtue of its chronic course, diabetes management is conducted in the context of a long-term relationship between the patient and the clinician. When a clinician knows someone for a long time and knows a great deal about his or her life, the relationship with the patient becomes part of the treatment. When things do not go well, the relationship becomes tense. What patients do or do not do can feel like a personal triumph or a personal failure to clinicians.

When clinicians get upset, they may be reacting to what their patients’ self-care behaviors mean about the therapeutic relationship. ("He will not listen to me." "She does not care what I say." "He does not believe me." "She is doing this just to irritate me.") To be most helpful, clinicians must avoid reading in these added meanings. Stick with things at a behavioral level. Set smaller goals, and adapt the treatment plan.

Another pitfall clinicians must avoid is putting more mental or emotional energy into helping patients than the patients seem to contribute to their own care. Perfectionists do not do things halfway. They approach tasks with intensity. A job worth doing is a job worth doing well. However, that intensity can work against you in treatment. If you find yourself working harder than your patients, you will always lose. Back off and let them take the lead. They may not make the choices you think are best, but if they take responsibility for and control over their care, they will be more likely to follow through. This is what is best.

Summary
Clinicians typically bring a specific interpersonal style to their work. This style is often modified to match the needs of particular patients. Perfec-tionism may not be obvious to clinicians as a process that influences their interactions with their patients or that influences their patients’ self-care behaviors. The purpose of this article was to draw clinicians’ attention to the concept of perfectionism, both in themselves and in their patients, and to help factor this personality variable into the treatment process.

References

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2Bastiani AM, Rao R, Weltzin T, Kaye WH: Perfectionism in anorexia nervosa. Int J Eating Disorders 17:147-52, 1995.

3Hewitt PL, Flett GL, Ediger E: Perfectionism and depression: longitudinal assessment of a specific vulnerability hypothesis. J Abnormal Psychol 105:276-80, 1996.

4Ferrari JR: Perfectionism cognitions with nonclinical and clinical samples. J Soc Behav Personal 10:143-56, 1995.

5Powers PS, Malone JI, Coovert DL, Schulman RG: Insulin-dependent diabetes mellitus and eating disorders: a prevalence study. Comp Psychiatry 31:205-10, 1990.

6Hewitt PL, Flett GL: Perfectionism in the self and social contexts: conceptualization, assessment and association with psychopathology. J Personal Soc Psychol 60:456-70, 1991.

7Basco MR: Never Good Enough. New York, The Free Press. In press.

8Beck AT, Rush AJ, Shaw BF, Emery G: Cognitive Therapy of Depression. New York, The Guilford Press, 1979.

9Beck JS: Cognitive Therapy: Basics and Beyond. New York, The Guilford Press, 1995.

Monica Ramirez Basco, PhD, is a clinical assistant professor in the Department of Psychiatry, Division of Psychology, at the University of Texas Southwestern Medical Center at Dallas.