Perfectionism may reflect loyalty, gratitude, and honour—not just internal pressure or pathology.

Anxiety may arise from fear of disappointing family, shaped by cultural meaning and responsibility.

Attending to content, process, and relationship creates space without invalidating cultural values.

In a recent interview, I was asked: How might filial piety or family duty show up as anxiety or perfectionism in children at international schools?

The question stayed with me. It echoed something I am often asked in clinical teaching: How do we work with the Unrelenting Standards schema in Asian clients?

These questions are clinically relevant—but they also reveal something about how we, as therapists, are already framing what we see.

Over the past two years, I have been writing and teaching about adapting psychotherapy to Asian cultural contexts. Through supervision and training, I have increasingly found ways to help Western-trained therapists adjust not only their techniques, but also their language and clinical stance. Much of this learning has been shaped by supervisees who bring complex and challenging questions into the room.

In the process of preparing to teach, I reflected on and consolidated my clinical learning into the Content–Process–Relationship (CPR) framework—a way of organising our attention in psychotherapy, particularly when working with forms of emotional self-restraint that are not immediately visible.

This work is grounded in an understanding that, as I have written in Culture as Predictive Infrastructure: A Constructionist Account of Emotional Access in Schema Therapy (Ng-Kessler, in press), “culture is not only a context, but part of the predictive system of the brain.” The CPR framework (Ng-Kessler, manuscript under revision) invites therapists to move beyond what is said (content) and also attend to how emotion is regulated (process) and how it is shared within the therapeutic relationship (relationship).

When “Perfectionism” Reflects Something More

Consider a student in an international school who says:

“If I don’t get top grades, I feel like I’m letting my family down. My parents have sacrificed so much for me.”

At first glance, this may be understood as perfectionism or unrelenting standards.

But if we stay only at that level, we may miss something important.

At the process level, there is often a fear of disappointment toward parents and toward oneself. If the child disappoints their parents, they may also experience this as a personal moral failure. Alongside this is a deep anxiety of failure, rooted not only in achievement but in a desire to bring honour to the family.

At the relationship level, the meaning becomes clearer. What appears as pressure is often intertwined with loyalty, gratitude, and a sense of responsibility within a relational system.

Seen this way, what looks like “perfectionism” may not be simply an internal drive, but a relationally organised way of being.

The Risk of Labelling Too Quickly

This is where positionality becomes clinically important.

When we use terms such as “perfectionism” or “unrelenting standards,” we are not only describing the client—we are also revealing our own interpretive lens.

From a therapist’s perspective, these labels may accurately capture what is visible in the room. But they are only useful if the client (or their parents, in the case of adolescents) recognises and agrees with that framing.

Otherwise, the label risks misrepresenting the client’s experience—or worse, invalidating culturally meaningful ways of relating.

This can create not only internal conflict for the client but also tension within the family system.

The issue is not whether we take a clinical stance. The issue is whether we are aware of how that stance shapes the therapeutic process.

Finding the “Wiggle Room”

When therapists begin to work with the CPR framework, something shifts.

They start to notice what I often call “wiggle room.”

Is it necessarily true that the parents would feel as disappointed as the client anticipates?

Or is this expectation amplified by the client’s sense of loyalty and obligation?

At the relationship level, further questions emerge:

What is it like for the client to share these feelings with someone outside the family?

Is there a wish for validation from an authority figure—perhaps to be seen as a “good enough” son or daughter?

At the same time, therapists can begin to explore:

To what extent is the client under pressure?

And to what extent might some of this pressure be self-imposed—and therefore, potentially releasable?

These questions do not dismiss the client’s experience. They create space around it.

And that space is often where change becomes possible.

Beyond Technique: A Shift in Attention

Working in this way requires a shift—not just in what we do, but in how we attend.

The more I teach, the more I become aware of the multiple layers of depth that “process” and “relationship” can hold in therapy. These are not abstract concepts; they are lived, moment-to-moment experiences in the room.

I also recognise that my ability to hold these layers simultaneously has been shaped by years of mindfulness practice, group teaching, and retreat experience. Over time, it has become possible to remain aware—quietly and concurrently—of different layers of experience as they unfold.

This is not about adding more techniques.

It is about seeing more of what is already there.

When working across cultures, what appears as anxiety or perfectionism may carry meanings that extend beyond the individual.

If we slow down and attend not only to content, but also to process and relationship, we may find that what looks like pressure is also an expression of care, responsibility, and belonging.

And in that recognition, therapy can begin from a place that does not require the client to give up who they are in order to change.

For clinicians interested in exploring these ideas further, I write regularly on Substack.

Ng-Kessler, B. (in press). Culture as predictive infrastructure: A constructionist account of emotional access in schema therapy. International Journal of Contemporary Psychotherapy.

Ng-Kessler, B. (manuscript under revision). The Content–Process–Relationship framework: A culturally responsive process model.

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