In 1995, Sydney Blatt wrote about the destructiveness of perfectionism with the recommendation that certain types of depression, especially if perfectionism was present, should be identified through what someone’s lived experience was, rather than if their symptoms fit official criteria for classic depression. Ongoing research has further found various types of perfectionism with unique correlations with suicidal thinking. However, the mental health field maintains its reliance on a classic symptom checklist to diagnose depression. I stress the danger of this systemic failure and offer clinical expertise in how to discover someone with destructive perfectionism – what I term “perfectly hidden depression.” (PHD).
What makes someone, who’s quietly gone about the business of being a therapist for many years, decide to try to persuade their profession to recognize a hugely overlooked segment of the population that’s slipping through clinical depression’s diagnostic cracks? Why would a psychologist, relatively unknown on either coast, whose career isn’t enshrined within the walls of Harvard or Stanford, venture to take a stand and use their voice to implore, “We’ve got to pay attention. And we’ve got to pay attention now.”
Because that segment – the people whose external lives seem perfect and far from depressed – is dying. Killing themselves. And no one who knew and loved them knows why (1,2).
Their lives seemed fulfilled, the hours of their days apparently complete, brimming with activity, friendship, and success. Whether they are parents, teenagers, friends, partners – they all seem to be enjoying the fruits of their extensive labors – the perfect-looking life. Yet in a flash, they are no longer alive.
What has happened? It doesn’t seem rational.
Until you listen to their stories. For what you often hear are stories of being born into unhealthy families or cultural environments where vulnerability is scorned, or where there’s a demand that secrets be kept. The child adapts by stowing away their own hurt and pain, at first from others, and then even from themselves. While this is an initially protective adaptation, if maintained in adulthood, it can lead to a silent, toxic despair – what I’ve termed perfectly hidden depression (PHD) (3).
The paths to perfectly hidden depression are diverse. As Dr. Brené Brown’s research has revealed, perfectionism can be initially created as “armor” to protect yourself from rejection and hurt (see video below). Maybe you’re like Richard, a highly successful businessman, whose father constantly screamed at him that he’d never be a success. His secret wish was to spend time volunteering and teaching business skills to people confined by poverty. But he couldn’t. “I hear my dad’s voice; I don’t know if I’ll ever have enough money to get him out of my head.” Maybe you were sexually or emotionally abused; as Lynn explained, “I could never let anyone have any power over me. So, I’ve stayed in control.” Perhaps you were forced to grow up too quickly, assuming an adult protective role in your family. Adam revealed, “I learned I could stop bad things from happening. I could fix it.” Maybe you grew up in a family where superior accomplishment was the only way to struggle through cultural barriers or meet rigid parental expectations. Danita’s words help us understand: “My mom needed me to always be the best. I couldn’t take that away from her.” Or maybe you simply never saw vulnerable emotions being expressed. Nor were they allowed. Kaitlyn explained: “My mother died when I was three. All her pictures were taken down, my dad quickly remarried and any mention of her was banned.”
To cope, to emotionally survive, you shoved away feelings of anxiety, anger, sadness or hurt that would’ve been natural, normal responses to these circumstances. You knew those responses weren’t safe to be expressed. So, they were rigidly compartmentalized, in psychological terms. And that pattern can become entrenched and even unconscious as the years have gone by. As Dr. Lisa Firestone states, “It is ironic that the very defenses that saved us emotionally so long ago are now robbing us of our lives today.”
Yet it can become too much. Too hard. The loneliness is deafening. There seems no way out. And suicide can seem like the answer.
In writing the book, Perfectly Hidden Depression , I interviewed over 60 volunteers who’d lived this kind of life, about half of whom had contemplated suicide or had attempted it. Theirs are the quotes I used above. They’d followed many career paths, and had diverse histories – a brain surgeon, a motivational speaker, an advertising exec, a graduate student. Why did they come forward? “I don’t want anyone else to live the life I’ve lived. It’s so very lonely. You constantly feel trapped by the reputation or persona you’ve created.”
This feeling of being trapped, of no one truly knowing what you’re experiencing, varies from true social isolation, but both have been found to be strongly linked to suicidal behavior (4,5). As I’ve worked with patients who’ve come to me because they’ve identified with perfectly hidden depression, I’ve watched how frightening it is for them to let go of that persona and allow their protective walls to come down.
Luckily Sadie, one of those volunteers, risked allowing herself to be seen: “I was seconds away from driving my car into the path of a tractor trailer. What stopped me was seeing the driver’s face. I realized he would think he’d killed me, and my pain would only be transferred to him. I couldn’t be responsible for that. The next day I went to my doctor and, for the first time ever, spoke freely about what I learned later was anxiety and depression. I’d been seeing her for over fifteen years. I remember the pain in her eyes as she said, ‘I had no idea. Why didn’t you say anything?’”
Research shows us that suicide rates are exponentially rising, and certain perfectionist tendencies are highly correlated with suicidal potential (6). But are all kinds of perfectionism dangerous? What’s being recognized is the vast difference between constructive perfectionism and its far more ominous cousin – destructive perfectionism (7).
Think of perfectionism as existing on a spectrum. The more constructive type seeks to do their best and can handle making mistakes. The process of striving for excellence is fulfilling. This is the swimmer who wants to beat their personal best or is working on their stroke. They can take success or disappointments with a grain of salt and keep both in perspective.
On the opposite end of the spectrum, destructive perfectionism can be found, where one is driven by the consistent accomplishment of exceeding personal expectations as well as the expectations of others – where mistakes simply cannot happen. It’s not the process that’s fulfilling. It’s reaching the first goal. And then the next. And the next. Any feelings of fulfillment quickly evaporate.
In even more detail, researchers also divide perfectionism into three categories, those three being self-oriented (expecting perfection from yourself), other-oriented (expecting perfectionism from others) and socially-prescribed (needing to meet and exceed the expectations of others) (8). Speaking of the latter’s higher correlation with the potential of suicide, premiere researcher Dr. Gordon Flett stated in an interview, “the reason for that… socially prescribed perfectionism has an element of pressure combined with a sense of helplessness and hopelessness …The better I do, the better I’m expected to do.” Ironically, this helplessness reflects that no one has control over the expectations of others; thus, socially-prescribed perfectionism is found by most studies to hold the most suicidal danger. It’s as if you’re on a treadmill which keeps going faster and faster. The pressure can be immense.
Michael Phelps and other Olympians, in the recent documentary The Weight of Gold (see video below), talk about the intense and volatile pressure brought on by being a highly praised Olympic athlete. Your total identity and worth is tied into being an Olympian. And then, when it’s over, there’s nothing left, no more accolades or affirmation. The emotional turmoil is terribly hard to handle.
Yet even if they decide to seek help or some kind of answer, too many in the mental health profession roll out their classic symptom checklist, where two criteria are required by the Diagnostic and Statistical Manual, the diagnostic standard in psychiatry (9), for a diagnosis of depression. First, a “depressed mood that’s noticeable to self or others and is a noticeable change from previous functioning” (9), and/or second, “anhedonia (not enjoying previously pleasurable things)” (9). Someone with a perfect-looking smile and life wouldn’t fit, and a clinician who too stiffly follows this symptom checklist could easily smile and say, “You’re not depressed. You’re just tired. Overworked. You need a vacation. Look at all you’ve got going on. Here are some vitamins.” (10)
However, as early as 1995, Sydney Blatt wrote a treatise on perfectionism – and within it he stated, “These findings suggest the value of considering psychopathology, especially depression, from a psychological rather than a symptomatic perspective” (11). What does that mean? He goes on to state, “This approach to understanding depression from a phenomenological, rather than a symptomatic, perspective has emerged as a major trend in both psychology and psychiatry over the past two decades […] Investigators have increasingly sought to understand depression not as a series of symptoms but as a complex phenomenon…” (11) His words suggest that, especially when perfectionism is present, a person should be evaluated for depression from a wider and far less specific perspective, rather than trying to measure their level of pathology or illness by the classic checklist.
Rachel confided in me about halfway through her treatment, “I got up one night around 2:00 am. I’d known something was wrong in my gut, but I couldn’t think of what. I looked up depression – and didn’t find myself there. At that point, all I felt was shame that I’d even considered it.” Rachel’s story? She’d grown up in a loving family, but a very superficial one – where she was considered the independent one – the child who could take care of herself. She had been through years of infertility treatment without ever crying or grieving, suffering miscarriage after miscarriage. She and her husband finally adopted, but then she found herself totally confused. When alone, huge sobs ripped through her. “I should be over the moon with happiness,” her inner critical voice chided. Yet becoming a parent had opened up the bleeding chasm of ten years of pain – and she even admitted thoughts of dying. That’s when she came to me. She’d been perfectly hiding depression.
So, what’s the answer? How can a therapist or doctor, a parent or a partner, figure out what could possibly be underneath that smile?
We need to follow Dr. Blatt’s advice. And we can learn something from our medical colleagues in the cardiology field.
Prior to cardiovascular researchers identifying that a woman’s warning signals for a heart attack could be very different that a man’s, those symptoms were misunderstood and misdiagnosed – until that blind spot was corrected; until medical professionals realized they needed to look for and respond to another pattern of symptoms.
That same change can happen in mental health. With a different rubric, with an understanding that not every person with depression is going to actually look depressed, (in fact, their lives may look “perfect,”) we can begin to confront psychology’s own blind spot in its consideration of the diagnosis of depression.
In an attempt to provide that very rubric and honor Sydney Blatt’s recommendations of using a more systemic view of depression when perfectionism was present, I put together ten common traits of PHD. What this set of traits offers to not only the people who identify with PHD, but to the medical providers and/or clinicians that they might turn to for help, is a behavioral yardstick that can help reframe someone’s “perfect-looking life” as potentially filled with rigidly compartmentalized pain that they are secretly, even unconsciously, struggling to bear.
As a clinician for almost thirty years, I hope these practical suggestions are helpful – and will help you “see” what I term perfectly hidden depression. These proposed directions are directly tied into the ten core traits of this syndrome – and can lead to the armor or the mask or the defense strategy slowly being released. As many people have written to me, “It’s like you’re in my head.” The relief of discovery – of being seen – can be immense. And yet, learning to find self-acceptance and reveal those tightly held emotions is very hard and at times frightening work. If severe trauma is involved, then working with a trauma therapist is vital for safe healing.
So, if you identify with perfectly hidden depression or can see that your perfectionism has turned destructive, the first step can be to simply tell a trusted friend or a therapist, “I’m not who I seem to be.” That’s where you start. You begin exactly where you are. And you talk about your fear of revealing more, one step at a time.
If you are someone who suspects their partner or friend struggles with destructive perfectionism or perfectly hidden depression, you also approach gently, with the understanding that one of their primary fears may be someone uncovering their truth – even though they may yearn for just that. Perhaps by sending them this article, or simply telling them what you’ve noticed, your concern could be absorbed. “I realise that we’ve been married for over a decade and I love you. But I don’t feel at times that I really know you very well.” Or ask them more about their childhood. Recognize that perhaps you count on them being overly responsible, or that you may avoid conflict as well. Suggest going to therapy together. The point is to try and break the silence around emotional pain and make it something that you can talk about together.
If you’re a parent and your child is tending toward perfectionism, be sure you’re modeling the importance of revealing vulnerabilities in a way that your children can emulate. Be open (as is age-appropriate) with what your own struggles are. Look carefully at what you’re teaching your children by your own behavior – as they will mimic what they experience. Don’t make the mistake of only seeing their strengths. If they put a lot of pressure on themselves, try not to minimize the impact of them doing so.
And if you’re a mental health or medical professional, here’s a more extensive list of suggestions to help you identify what could be a tragedy waiting to happen.
- Ask more varied questions that would reveal problems with vulnerability. Instead of only asking, “Do you ever feel hopeless?” an added question might be, “If you felt hopeless, would you tell someone?” When asking about their support system, ask who knows them really well or who they turn to when overwhelmed. Their answers will offer clues. For example, if their friends are all out of town, then that may be a clue that they don’t let people in who are nearby.
- Trust may be more difficult to build with these patients. They’re watching to see you handle small admissions of vulnerability. And they may fear letting go of their persona to the point they may avoid revealing too much. Realize they may not be ready to share suicidal ideation, so gently bring these kinds of topics up at a later time.
- Ask them questions about how they handle the tremendous responsibilities they have taken on (as a rule). What do they give up when taking on a new one?
- These patients will frequently state: “I don’t really know why I’m here,” or, “I feel silly. I have so many blessings in my life.” Huge flag! Comfort them at this time and help them drop the comparisons with others. That’s shame talking.
- Notice incongruity between the patient’s affect and the content of their story.If someone smiles brightly at you as they’re recounting what would be for most a traumatic event, such as a rape or the death of a sibling, note that incongruence. I’ll frequently say to this patient, “If I could turn down the sound of this session and watch the last few minutes, I might think you were talking about what you had for lunch, rather than being raped.” This can be a kind of “a-ha” moment for your patient, as they are – perhaps for the first time – gently confronted with their lack of self-compassion or even ability to express painful emotions.
- Do a complete family of origin evaluation. Ask how grief or anger was expressed in the family. Ask about the roles different siblings played. Always ask about what was allowed and what wasn’t allowed in the family and how conflict was handled.If you hear, “I had a great family,” continue asking questions rather than accepting that as fact.
- Realize that they may not see their perfectionism as any kind of problem – at all. And to even consider seeing it that way can be highly agitating. So, this work is slow. And you need to let them know they’re in control of how fast it goes. This is very similar to working with abuse victims (and they may have abuse in their background, whether they’ve shared that with you or not). If they admit that it’s hard to be in your office, congratulate them for taking the risk.
- Do a relationship assessment. Look for over-functioning roles or being paired with someone with narcissistic traits. Or someone who also doesn’t know how to express pain.
- Notice how often they use shaming rule-bound language toward themselves and /or others: “I should, I must, I have to, I can’t, I should always, I can never…”
- If you suspect destructive perfectionism, there are well-founded psychological assessments to measure that. And I have a questionnaire that I’ve formulated – only from clinical experience, it’s not empirically validated – that speaks more to what destructive perfectionism might look like in real life.
- As unprofessional as this sounds, I’ve had more than one patient tell me that a helping professional has said to them, “You don’t look depressed. You’re so pretty (or handsome or well-dressed) and you’re so engaged.” And then dismissed their concerns. What someone looks like is important information. But remember the “armor” Brené Brown describes. That armor is strapped on very tightly.
- Look for other clinical problems that suggest control as an issue for the patient. Eating disorders and anxiety disorders are two that can be discovered, as well as an overuse of substances that can be used for escape.
We can save lives, but only if we see what needs to be seen, notice the silence, ask better and deeper questions, look underneath that perfect-looking life, and try to connect with the despair that’s hidden. Don’t throw away the symptom checklist; it’s accurate for many people who suffer with more classic depression. But recognize that its usefulness dims when perfectionism is hiding its own version of depression.
Margaret Robinson Rutherford
- Hamilton, T.K., Schweitzer, R.D., “The Cost of Being Perfect: Perfectionism and Suicidal Ideation in University Students,” Australian and New Zealand Journal of Psychiatry, 2000.
- Martin, J. “Suicidal Behavior, Thoughts Associated with Perfectionistic Tendencies,” Psychiatry Advisor, 2017.
- Rutherford, M.R. Perfectly Hidden Depression: How to Break Free From The Perfectionism That Masks Your Depression. (New Harbinger Publications, 2019.)
- Stravynski, A., Boyer, R. “Loneliness in relation to suicide ideation and parasuicide: a population-wide study,” Suicide Life Threat Behavior, Spring 2001.
- Trout, D.L. “The role of social isolation in suicide,” Suicide Life Threat Behavior, Spring 1980.
- Flett, G., Hewitt, P. Heisel, M. “The Destructiveness of Perfectionism Revisited: Implications for the Assessment of Suicide Risk and The Prevention of Suicide.” Research Gate. Spring 2014
- Jarrett, C. “Perfectionism as a risk factor for suicide – the most comprehensive test to date.” Research Digest. 2017.
- Khazan, O. “The Problem with Being Perfect.” The Atlantic. November 2018.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM V. 2013.
- Lawrence. R. “When depression wears a smile, even psychiatrists like me can be deceived.” The Guardian. March 2021.
- Blatt, S. “The destructiveness of perfectionism: Implications for the treatment of depression.” APA PsychNet. 1995