The Pathology of Perfectionism How to Tame the Inner Critic

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1 The Pathology of Perfectionism How to Tame the Inner Critic Presented by Martin M. Antony, PhD, ABPP Department of Psychology, Ryerson University Website: E- mail: Handouts and slides from this presentation may not be reproduced without permission of the presenter. Sponsored by Institute for Brain Potential PO Box 2238, Disclosure Statement: Dr. Antony is the author of several leading books on the topic of anxiety and related problems. In this program, Dr. Antony will recommend a number of books related to anxiety disorders, including some of his own. COURSE OBJECTIVES Participants completing this program should be able to: 1. Describe the origins and forms of perfectionism. 2. Distinguish between realistic and maladaptive beliefs that underlie perfectionism. 3. Identify common perfectionistic behaviors. 4. List effective evidence- based interventions that health professionals can apply to help protect and enhance their health when working with people with unrealistic standards in medical, dental, and behavioral practices Martin M. Antony, PhD Professor and Chair, Department of Psychology, Ryerson University, Toronto Director of Research, Anxiety Treatment and Research Center, St. Joseph s Healthcare, Hamilton 1

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3 Customer Service IBP Contact Info Registration Department (e.g., payments) Outline Overview of perfectionism Descriptive models of perfectionism Causes of perfectionism and related problems Assessment of perfectionism Introduction to cognitive-behavioral therapy Research on CBT for perfectionism Cognitive strategies Outline (continued) Behavioral strategies Mindfulness and acceptance-based strategies Dealing with perfectionists Treatment challenges Concerns about treatment Motivational interviewing for perfectionism Group treatment OVERVIEW OF PERFECTIONISM Examples of Perfectionists A woman struggles to be a perfect parent, a perfect wife, and a perfect employee, often to the detriment of her own emotional and physical health. A graphic artist constantly seeks reassurance that his work is of the highest quality, and that he is well respected and well-liked by others. A student constantly strives to meet excessively high academic standards, and who is devastated when she receives a grade that is less than perfect. An individual spends hours planning every aspect of every day, and who becomes very distressed when things don t go according to his plans. Definition of Perfectionism Perfectionism is a disposition to regard anything short of perfection as unacceptable Merriam Webster Dictionary Egan, Wade, Shafran, & Antony, in press 2

4 Definition of Perfectionism A perfectionist is someone whose standards are high beyond reach or reason and who strain compulsively and unremittingly toward impossible goals and who measure their own worth entirely in terms of productivity and accomplishment. Definition of Clinical Perfectionism The overdependence of selfevaluation on the determined pursuit (and achievement) of self-imposed, personally demanding standards of performance in at least one salient domain, despite the occurrence of adverse consequences. David Burns (1980) Shafran, Cooper, & Fairburn, 2002 Definition of Perfectionism in the Context of OCD Perfectionism is the tendency to believe there is a perfect solution to every problem, that doing everything perfectly (i.e., mistake-free) is not only possible, but also necessary, and that even minor mistakes will have serious consequences. OCCWG, 1997 Perfectionism in the Context of OCPD A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency DSM-5 Definition of Obsessive-Compulsive Personality Disorder (OCPD DSM-5 OC Personality Disorder DSM-5 OC Personality Disorder A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four or more of the following: 1. Preoccupation with details, rules, lists, order, organization, schedules 2. Perfectionism that interferes with task completion 3. Excessive devotion to work and productivity 4. Overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values Continued 5. Inability to discard worn-out or worthless objects 6. Reluctance to delegate tasks or to work with others 7. Miserly spending style toward both self and others 8. Rigidity and stubbornness 3

5 Dimensions of Clinical Perfectionism Extreme overdependence on achieving selfimposed high standards of performance when evaluating the self (Shafran et al.) Preoccupation with order, rules, lists, and control (OCPD) Each of these can be directed at the self, at others, or both. Categorical vs. Dimensional Views Taxometric research suggests that dimensional conceptualizations best fit the data. Broman-Fulks et al., 2008 Domains of Perfectionism Work (58%) Bodily hygiene (54%) Studies (43%) Physical appearance (40%) Social relationships (38%) Presentation of documents (37%) Spelling (36%) Dress (33%) Stoeber & Stoeber, 2009 (109 college students indicated yes/no to whether they were perfectionistic in each domain) Domains of Perfectionism Way of speaking (28%) Romantic relationships (28%) Eating habits (25%) Health (23%) Domestic chores / cleanliness (18%) Time management / punctuality (17%) Correspondence / mail (17%) Leisure activities (17%) Oral presentations (17%) Domains of Perfectionism Although some perfectionists exhibit perfectionism across many domains, most exhibit perfectionism only in a small number of selected domains. Stoeber & Stoeber, 2009 Transdiagnostic Nature of Perfectionism Social and performance anxiety Worry and generalized anxiety disorder Obsessive-compulsive disorder Obsessive-compulsive personality disorder Eating disorders Body dysmorphic disorder Chronic fatigue Problem anger Depression Suicidal ideation Egan et al.,

6 Perfectionism and Psychological Functioning When the discrepancy between personal standards and actual academic performance increases (in high school students), depression increases and self-esteem decreases. Perfectionism Self- Help Readings Antony, M.M., & Swinson, R.P. (2009). When perfect isn t good enough: Strategies for coping with perfectionism, second edition. Oakland, CA: New Harbinger Publications. Burns, E.F. (2008). Nobody s perfect: A story for children about perfectionism. Washington, DC: magination press. Shafran, R., Egan, S., & Wade, T. (2010). Overcoming perfectionism: A self-help guide using cognitive behavioral techniques. London, UK: Constable & Robinson. Accordino et al., 2000 Professional Books and DVDs Antony, M.M. (2008). Cognitive behavioral therapy for perfectionism over time (DVD Video). Washington, DC: American Psychological Association. Egan, S.J., Wade, T.D., Shafran, R., & Antony, M.M. (in press, to be published in 2014). Cognitive-behavioral treatment of perfectionism: A clinician s guide. New York, NY: Guilford Press. Flett, G.L., & Hewitt, P.L. (2002). Perfectionism: Theory, research, and treatment. Washington, DC: American Psychological Association. DESCRIPTIVE MODELS OF PERFECTIONISM Hewitt & Flett s Multidimensional Model Three Dimensions Self-oriented perfectionism (SOP) Other-oriented perfectionism (OOP) Socially prescribed perfectionism (SPP) Frost & Colleagues Multidimensional Model Six Dimensions Concern over mistakes (CM) Doubts about actions (CA) Personal standards (PS) Parental expectations (PE) Parental criticism (PC) Organization (O) 5

7 Positive and Negative Perfectionism Historical Perspectives Tyranny of the shoulds (Horney, 1950) Musterbation (Ellis & Harper, 1961) Normal vs. neurotic perfectionism (Hamacheck, 1978) Positive and Negative Perfectionism Psychometric Approaches Factor analyses of Frost s and Hewitt & Flett s dimensions suggest two higher order dimensions: - Maladaptive Evaluation Concerns: concern over mistakes, doubts about actions, parental expectations, parental criticism, social prescribed perfectionism - Positive Achievement Strivings: Personal standards, organization, self-oriented perfectionism, other oriented perfectionism These dimensions (adaptive/healthy/normal vs. maladaptive/neurotic/clinical/unhealthy) have been confirmed by various investigators using a variety of scales. Pathways to Perfectionism CAUSES OF PERFECTIONISM, & RELATED PROBLEMS Interpersonal factors Personality factors Learning Cognitive factors Biological factors Interpersonal Factors Maladaptive perfectionists report having both perfectionistic parents and critical parents, whereas adaptive perfectionists only report having perfectionistic parents (Enns et al., 2002) Adaptive perfectionists report having more balanced, cohesive, and adaptable families (and nurturing parents) than maladaptive perfectionists and nonperfectionists (DiPrima et al., 2011) Note that most research findings reflect only the participants perspective (family members are not assessed) Interpersonal Factors Athletes perceptions of their parents perfectionism is more predictive of perfectionism among athletes than was the parents actual levels of perfectionism. Appleton et al.,

8 Interpersonal Factors Peer Victimization Recalled history of indirect peer aggression (exclusionary acts, gossiping, rumor spreading) in childhood predicts perfectionism in adults, whereas recalled history of direct aggression (e.g., physical, verbal) does not. Personality and Perfectionism Among adolescents (ages 14-19), the trait of conscientiousness predicts longitudinal increases in self-oriented perfectionism 5 to 8 months later. Although the trait of neuroticism is associated with socially prescribed perfectionism, it does not predict longitudinal increases in this trait. Miller & Vaillancourt, 2007 Stoeber, Otto, & Dalbert, 2009 Learning and Perfectionism 1. Reinforcement of Perfectionism 2. Other Learning Pathways Direct traumatic experiences Observational learning Informational/instructional learning Learning and Perfectionism Mediating Variables Genetics Neurotransmitter dysfunction Individual differences (e.g., personality) Previous experiences (e.g., family influences) Previous exposure to triggering situation Subsequent exposure to triggering situation Context of the negative experience Cognitive View of Perfectionism Perfectionism stems from biased beliefs, assumptions, and predictions, for example: - Anything less than sticking to my diet perfectly is a failure. If I eat one cookie, I may as well have eaten ten cookies. - I always need to look perfect in front of other people. - If I don t get an A+ in this course, I don t deserve to be in this program. - My reports are never good enough. - I seem to be the only person in this house who knows how to clean things properly. Cognitive View of Perfectionism Other contributing factors include: Biased attention Biased memory Biased attributions Adapted from Antony & Swinson,

9 Cognitive Model of Perfectionism Cognitive Biases Cognitive Biases Temporarily Meets Standards Self-Worth Overly Dependent on Striving and Achievement Inflexible Standards Fails to Meet Standards Performance-Related Behaviors Avoids Trying to Meet Standards Dichotomous (all-or-nothing / black and white) thinking Shoulds and musts Selective attention (noticing the negative; discounting the positive) Overgeneralization Double standards Reappraise Standards as Insufficiently Demanding Counterproductive Behavior and Self- Criticism Shafran, Egan, & Wade, 2010 Adapted from Egan, Wade, Shafran, & Antony, in press Performance-Related Behaviors Avoiding situations that may test one s performance (e.g., tests) Procrastination Goal achievement behaviors (e.g., overpreparing) Testing one s performance Reassurance seeking Social comparisons Social Comparison and Perfectionism It is normal to compare oneself to others in order to assess one s performance. Normally, we compare ourselves to others who are similar to us (or slightly better) on a given dimension. People with elevated perfectionism (e.g., people with depression, social anxiety disorder) report unique patterns of social comparison that may help to maintain perfectionism. Adapted from Egan, Wade, Shafran, & Antony, in press Social Comparison and Social Anxiety Commonly compared dimensions included personality characteristics (49% for SAD; 27% for controls), appearance (32% for SAD; 24% for controls), and social skills (38% for SAD; 15% for controls). Social phobic individuals were more likely than controls to make upward comparisons (64% vs. 39%) and less likely to make same level comparisons (11% vs. 18%) or downward comparisons (25% vs. 43%). Social phobic individuals were more likely to make comparisons on a larger number of dimensions, compared to controls. From: Antony, M.M., Rowa, K., Liss, A., Swallow, S.R., & Swinson, R.P. (2005). Social comparison processes in social phobia. Behavior Therapy, 36, Social Comparison and Social Anxiety Upward comparisons (comparisons in which the participant viewed him or herself as inferior) tended to affect mood negatively in both groups. Same level comparisons did not affect mood differently in the two groups. Downward comparisons led to greater positive mood shifts in the social phobia group than in controls. From: Antony, M.M., Rowa, K., Liss, A., Swallow, S.R., & Swinson, R.P. (2005). Social comparison processes in social phobia. Behavior Therapy, 36,

10 Biology and Perfectionism Genetics Studies Perfectionism has been found to be moderately heritable (Moser et al., 2012; Tozzi et al., 2004). Disorders associated with perfectionism (e.g., depression, anxiety disorder, eating disorders) are influenced by genetics. Neurotransmitters No studies in perfectionism Brain Imaging Studies (e.g., PET, fmri) No studies in perfectionism ASSESSMENT OF PERFECTIONISM Assessment Goals To assess the presence, absence, or severity of particular symptoms or behaviors (e.g., procrastination, perfectionistic beliefs) To assess any associated problems (e.g., depression) that may affect treatment To assess the impact of perfectionism on functioning To facilitate the selection of target behaviors To inform the process of collaborative case conceptualization To facilitate the development of a treatment plan To assess the effects of the intervention Adapted from Egan, Wade, Shafran, & Antony, in press Assessment Methods Clinical interview Monitoring diaries Behavioral observation Self-report measures Clinical Interview Behavioral features (e.g., safety behaviors, avoidance, alcohol or drug use) Cognitive features (beliefs, predictions, and cognitive biases) Physical responses (e.g., panic attacks, muscle tension) Adaptive versus maladaptive perfectionism Development and course over time Assessing Behavioral Features Are there things that you do to prevent yourself from feeling anxious about not meeting your standards? What sorts of things do you do to ensure that you meet your high standards? Are there things that you do that others might consider to be perfectionistic behaviors? Are there strategies that you use to prevent yourself from making mistakes that you might regret later? Adapted from Egan, Wade, Shafran, & Antony, in press 9

11 Assessing Cognitive Features What were you thinking just before your anxiety began to increase? What would it mean about you if you didn't do your best, for example if you didn t get the highest grade in the class? What are you predicting might happen if others were to notice your mistakes? Do you hold others to the same standards to which you hold yourself? To what degree do you define your self-worth in terms of your attaining your goals? Adapted from Egan, Wade, Shafran, & Antony, in press Assessing Physical Responses How do you feel physically when your anxiety hits? When you are unable to meet your high standards, do you experience uncomfortable physical sensations, like racing heart, sweating, or dizziness? Are you frightened by any of the physical sensations that you experience when you are feeling anxious? Do you worry that they might lead to some sort of catastrophe? Adapted from Egan, Wade, Shafran, & Antony, in press Assessing Whether Standards are Overly Perfectionistic Are my standards higher than those of other people? Am I able to meet my standards? Do I get overly upset if I don t meet my own standards? Are other people able to meet my standards? Do I get overly upset if others don t meet my standards? Assessing Whether Standards are Overly Perfectionistic Do my standards help me to achieve my goals or do they get in the way (e.g., by making me overly disappointed or angry when my standards are not met; by making me get less work done, etc.)? What would be the costs of relaxing a particular standard or ignoring a rule that I have? What would be the benefits of relaxing a specific standard or ignoring a rule that I have? Adapted from Antony & Swinson, 2009 Adapted from Antony & Swinson, 2009 Assessing Course Over Time What has the course of the problem been over time? Has the perfectionism been stable? Has it worsened or improved over time? Has it waxed and waned? Have changes in the perfectionism coincided with any major life events or other possible triggers? Was there a time when your perfectionism was helpful to you (e.g., rewarded by others, etc.)? What changed over time? Adapted from Egan, Wade, Shafran, & Antony, in press Clinical Interview Diagnostic features Triggers and cues for feelings of distress, sadness, anxiety, especially when standards are not met Variables that affect how triggers and cues influence perfectionism and subsequent emotional responses Focus of apprehension (e.g., internal vs. external) Insight Motivation to change Impact on functioning 10

12 Assessing Impact on Functioning How does perfectionism affect your day-to-day life? What are the types of situations where it is really important to reach your standards? What are the consequences if you feel you don t reach your standards? Does it affect the way you feel about yourself? Can you please give me a recent example in detail about a time where you set standards for yourself, didn t meet them and how you responded to this? Clinical Interview Treatment history Role of family (e.g., family accommodation) Potential for family members to help with treatment Skills deficits (e.g., social skills, study skills) Family history of the problem Medical history Adapted from Egan, Wade, Shafran, & Antony, in press Monitoring Diaries Situations triggering perfectionism Perfectionistic thoughts Perfectionistic behaviors Consequences of perfectionism Note that the way in which clients complete their diaries and questionnaires can provide clues into their perfectionism Behavioral Assessment Behavioral approach test (BAT) - Client engages in an anxiety provoking practice - Assess whether client can complete practice - Assess client s response to the practice - Cautions about using BATs early in treatment Behavioral observation by others (e.g., family members) Behavioral observation by the therapist Popular Perfectionism Measures Hewitt and Flett Multidimensional Perfectionism Scale (Hewitt & Flett, 1991) Frost Multidimensional Perfectionism Scale (Frost et al., 1990) Hewitt and Flett Multidimensional Perfectionism Scale Self-Oriented Perfectionism When I am working on something, I cannot relax until it is perfect. I demand nothing less than perfection of myself. Other-Oriented Perfectionism I seldom criticize my friends for accepting second best. The people who matter to me should never let me down. Socially Prescribed Perfectionism Those around me readily accept that I can mistakes too. My family expects me to be perfect. 11

13 Frost Multidimensional Perfectionism Scale Concern over Mistakes If I fail at work/school, I am a failure as a person. I hate being less than best at things. Personal Standards I set higher goals than most people. I am very good at focusing my efforts on attaining a goal. Doubts about Actions I usually have doubts about the simple everyday things I do. It takes me a long time to do something right. Frost Multidimensional Perfectionism Scale Parental Expectations My parents set very high standards for me. My parents wanted me to be the best at everything. Parental Criticism As a child, I was punished for doing things less than perfectly. My parents never tried to understand my mistakes. Organization Organization is very important to me. I am a neat person. General Perfectionism Measures Almost Perfect Scale - Revised (Slaney et al., 2001) Behavioural Domains Questionnaire (Lee et al., 2011) Burns Perfectionism Scale (Burns, 1980) Clinical Perfectionism Questionnaire (Fairburn et al., 2003) Consequences of Perfectionism Scale (COPS; Kim, 2010) Multidimensional Perfectionism Cognitions Inventory (MPCI; Kobori, 2006) General Perfectionism Measures Neurotic Perfectionism Questionnaire (Mitzman et al., 1994) Perfectionism Cognitions Inventory (Flett et al., 1998) Perfectionism Inventory (Hill et al., 2004) Perfectionistic Self-Presentation Scale (PSPS; Hewitt et al., 2003) Positive and Negative Perfectionism Scale (PANPS; Terry-Short et al., 1995) Child Perfectionism Measures Adaptive/Maladaptive Perfectionism Scale (AMPS; Rice & Preusser, 2002) (for children) Child and Adolescent Perfectionism Scale (CAPS; Flett et al., 1997) Childhood Retrospective Perfectionism Scale (CHIRP; Southgate et al., 2008) Perfectionistic Self-Presentation Scale Junior Form (PSPS-JR; Hewitt et al., 2011) Domain-Specific Perfectionism Measures Perfectionism in families and relationships Perfectionism in sports and athletics Perfectionism in body image and eating disorders 12

14 INTRODUCTION TO COGNITIVE- BEHAVIORAL THERAPY Evidence-Based Strategies Cognitive Strategies for Perfectionism Recalibrating cognitive biases and correcting unrealistic beliefs and interpretations Behavioral Strategies for Perfectionism Exposure to feared objects, thoughts, situations Prevention of safety behaviors Other Strategies (still unproven in perfectionism) Mindfulness and acceptance-based strategies Motivational enhancement Evidence-Based Strategies Strategies for Targeting Associated Problems Social skills training (social anxiety disorder) Behavioral activation (depression) Progressive muscle relaxation (chronic worry) Medications (anxiety disorders, OCD, depression) CBT for Perfectionism Basic Assumptions Treatment is relatively brief. Therapy focuses on identifying and changing cognitive and behavioral factors that currently maintain the problem, rather than factors that may have initially caused the problem. Treatment procedures based in research. Homework is assigned between sessions. Treatment Decisions Group or individual? Number of sessions? Frequency of sessions? Focus on perfectionism vs. focus on one or more specific disorders (e.g., depression, OCD) Introducing the Treatment Understanding perfectionism (e.g., definitions, causes, features) Adaptive vs. maladaptive perfectionism Setting SMART goals (specific, measurable, attainable, relevant, time-bound) Readiness for treatment; beliefs about treatment Discussion of treatment expectations (number of sessions, attending appointments, arriving on time, completing homework, ongoing assessment, etc.) Overview of treatment strategies Developing a collaborative CBT formulation 13

15 Questions for Developing a Collaborative CBT Formulation High Standards and Striving In what areas do you set high standards? In which areas of your life do you push yourself and feel that you have to excel? Of these areas, which are the most important for you to achieve your standards? How would you order them from most to least important, or are they equally important? Questions for Developing a Collaborative CBT Formulation Adverse Consequences of Perfectionism What impact has your striving had on your life? What cost to you pay for pushing yourself? What is the effect of striving on your mood? What effect does striving have on your relationships? What effect does it have on your thinking (e.g., rumination over mistakes, poor concentration)? What effect on does it have on your behavior (e.g., counterproductive behaviors, reassurance seeking)? Adapted from Egan, Wade, Shafran, & Antony, in press Adapted from Egan, Wade, Shafran, & Antony, in press Questions for Developing a Collaborative CBT Formulation Self-Evaluation Dependent on Achievement What factors affect how you judge yourself as a person? How much of your self-esteem is made up of how well you are meeting your high standards? Do you base your sense of self-worth on what you do, rather than who you are as a person? Questions for Developing a Collaborative CBT Formulation Setting Inflexible Standards and Rules Do you change your standards and rules when you discover that they cannot be met? Adapted from Egan, Wade, Shafran, & Antony, in press Adapted from Egan, Wade, Shafran, & Antony, in press Questions for Developing a Collaborative CBT Formulation Cognitive Biases Do you tend to perceive your standards as being either completely met or not at all met? When you think about your performance, what do you tend to focus on? How much do you notice mistakes in performance? How much do you notice successes in your performance? How do you react to positive aspects of performance? Questions for Developing a Collaborative CBT Formulation Performance-Related Behaviors Testing performance Do you tend to check repeatedly to assess how well you are doing at things? Comparisons Do you compare your performance to that of others? Reassurance seeking Who do you ask for reassurance about your performance? Adapted from Egan, Wade, Shafran, & Antony, in press Adapted from Egan, Wade, Shafran, & Antony, in press 14

16 Questions for Developing a Collaborative CBT Formulation Evaluation of Standards - Failure to Meet a Standard What do you think when you fail to achieve a goal or standard you have set? What does it mean about you when you fail to achieve a goal or standard? What is the worst part about failing at a goal? What do you do when you don t meet a goal? Do you often fear that you will fail at your goals? Adapted from Egan, Wade, Shafran, & Antony, in press Questions for Developing a Collaborative CBT Formulation Evaluation of Standards Reaction to Meeting Goals and Resetting Standards How do you feel when you meet a goal or standard? Do you feel satisfied? Not satisfied? How long does the feeling last? When you meet your goals, do you discount them as being too easy (e.g., anyone could have done that! )? After you meet your goals, do you set even higher goals for next time? Do you set lower goals, or are your goals more or less the same? Adapted from Egan, Wade, Shafran, & Antony, in press Questions for Developing a Collaborative CBT Formulation Avoidance of Meeting Standards Avoidance What do you avoid doing due to worry about your performance? (e.g., never inviting friends over for dinner, because the meal won t be good enough) Procrastination What do you put off doing because of perfectionism? Do you leave things until the last minute so you will have an excuse if you don t do well? Would you rather delay a task than face doing it less than perfectly? Do you ever delay starting tasks because you know they will take a long time due to your high standards? Adapted from Egan, Wade, Shafran, & Antony, in press Questions for Developing a Collaborative CBT Formulation Self-Criticism and Counterproductive Behaviors Do you criticize yourself over your performance? How do you feel when you make a mistake? What do you say to yourself when you are critical about your standards? What is the result of self-criticism? What effect does it have? Counterproductive behaviors - Is there anything else you do to reduce the impact of your worry about performance (e.g., always making lists before starting work for the day) Adapted from Egan, Wade, Shafran, & Antony, in press Sample 11-Session Protocol 1. Motivational enhancement 2. CBT formulation and monitoring 3. Introduction to changing cognitive biases 4. Introduction to changing maladaptive behaviors 5. Introduction to behavioral experiments 6. Maladaptive patterns of self-evaluation 7. Rigidity, rules, and extreme standards 8. Self-criticism and self-compassion 9. Scheduling pleasant events 10. Problem solving 11. Relapse prevention Adapted from Egan, Wade, Shafran, & Antony, in press Homework Guidelines Amount should be manageable and achievable Instructions should be unambiguous Rationale should be clear to the client Leave enough time to assign homework Homework should be planned collaboratively Ensure clear expectation that homework will be completed Begin each session with review of homework Avoid being punitive for failure to complete homework Homework is often progressive or additive Adapted from Egan, Wade, Shafran, & Antony, in press 15

17 Homework Guidelines Some clients avoid homework (because it cannot be done well enough. Some clients do much more homework than they are asked to do (because they devalue small goals) It is helpful to work through beliefs that clients may have about homework completion Adapted from Egan, Wade, Shafran, & Antony, in press Therapeutic Alliance Clients who perceived their therapist as providing high average levels of positive regard, empathy, and genuineness experienced more rapid reductions in both overall maladjustment and selfcritical perfectionism (Zuroff, Kelly, Leybman, Blatt, & Wampold, 2010) Validation Collaboration Balance of structure and flexibility Therapist expectations Therapist Expectations Therapist Beliefs and Biases In a recent study of client expectations and therapist expectations in CBT for generalized anxiety disorder, it was found that: Therapists are generally unaware of their clients treatment expectations, especially early in treatment. Therapist beliefs about client expectations predict treatment outcome beyond the client s actual expectations. The more a therapist believes in the client (regardless of the client s belief in him/herself), the better the treatment outcome. Therapists need to be aware of their own beliefs and biases that may influence the course of treatment (e.g., beliefs regarding achievement). Seeking supervision can help to keep therapist beliefs in check. Aviram, Westra, Constantino, & Antony, 2013 Components of Relapse Prevention Develop an action plan, emphasizing strategies that have been most helpful Discuss realistic and compassionate expectations Catch problems early Identify triggers for lapses and setbacks Strategies for dealing with lapses and setbacks Practice self-compassion RESEARCH ON CBT FOR PERFECTIONISM Egan, Wade, Shafran, & Antony, in press 16

18 Treatment of Perfectionism A few papers have described or advocated for psychodynamic treatments for perfectionism (e.g., Blatt et al., 1995; Fredtoft et al., 1996), there are no published studies on this approach. A few published studies on cognitive behavioral therapy (CBT) for perfectionism in nonclinical samples (e.g., DiBartolo et al., 2001; Pleva & Wade, 2007; Shafran et al., 2006) A few controlled studies of CBT in clinical samples of individuals with anxiety or depression (Riley et al., 2007) and eating disorders (Steele & Wade, 2008; Wilskch et al., 2008) One controlled study of group CBT for clinical perfectionism (Steele et al., 2013) found that 8 weeks of CBT was superior to a control condition (4 weeks waitlist plus 4 weeks psychoeducation). Does Treatment Work? - Study 1 N = 107 Diagnosis = Social Anxiety Disorder Treatment = 12 sessions of group CBT for social phobia Ashbaugh, A., Antony, M.M., Liss, A., Summerfeldt, L.J., McCabe, R.E., & Swinson, R.P. (2007). Changes in perfectionism following cognitive-behavioral therapy of social phobia. Depression and Anxiety, 24, Does Treatment Work? - Study 1 Measure Pre Post p SPS <.0001 SIAS <.0001 DASS-Depression <.0001 DASS-Anxiety <.0001 DASS-Stress <.0001 From: Ashbaugh, A., Antony, M.M., Liss, A., Summerfeldt, L.J., McCabe, R.E., & Swinson, R.P. (2007). Changes in perfectionism following cognitive-behavioral therapy of social phobia. Depression and Anxiety, 24, Does Treatment Work? - Study 1 Measure Pre Post p Concern over Mistakes <.0001 Doubts about Actions <.05 Personal Standards n.s. Parental Expectations n.s. Parental Criticism n.s. Organization <.01 FMPS Total <.01 From: Ashbaugh, A., Antony, M.M., Liss, A., Summerfeldt, L.J., McCabe, R.E., & Swinson, R.P. (2007). Changes in perfectionism following cognitive-behavioral therapy of social phobia. Depression and Anxiety, 24, Does Treatment Work? - Study 2 N = 20 Participants high scorers on the Clinical Perfectionism Examination and the Clinical Perfectionism Questionnaire (Fairburn, Cooper, and Shafran). CBT treatment vs. a wait-list control condition Treatment = 10 sessions of individual CBT over 8 wks. Riley, C., Lee, M., Cooper, Z., Fairburn, C.G., & Shafran, R. (2007). A randomised controlled trial of cognitivebehaviour therapy for clinical perfectionism: A preliminary study. Behaviour Research and Therapy, 45, CPE Score Does Treatment Work? - Study Immediate Waitlist Pre Post Riley, C., Lee, M., Cooper, Z., Fairburn, C.G., & Shafran, R. (2007). A randomised controlled trial of cognitive-behaviour therapy for clinical perfectionism: A preliminary study. Behaviour Research and Therapy, 45, CPE = Clinical Perfectionism Examination. 17

19 Does Treatment Work? - Study 3 N = 49 Participants high scorers (84 or higher) on Frost Multidimensional Perfectionism Scale Guided self-help (eight 50-minute sessions) vs. pure self-help (no therapist) Treatment based on first edition of When Perfect Isn t Good Enough (Antony & Swinson, 1998). Pleva, J., & Wade, T.D. (2006). Guided self-help versus pure self-help for perfectionism: A randomised controlled trial. Behaviour Research and Therapy, 45, Does Treatment Work? - Study 3 Results Generally, participants in both groups showed improvement on measures of perfectionism, OCD symptoms, depression, and anxiety. Overall, improvement was greater in the GSH condition than the PSH condition Generally, gains were maintained at 3 month follow-up. % With Clinically Significant Change (pre-treatment to 3 mo. follow-up) Does Treatment Work? - Study CM PS DA GSH PSH Other Findings Providing feedback to perfectionists on their perfectionism can help to reduce psychological distress associated with maladaptive perfectionism (Aldea et al., 2010). Pleva, J., & Wade, T.D. (2006). Guided self-help versus pure self-help for perfectionism: A randomised controlled trial. Behaviour Research and Therapy, 45, GSH = Guided Self-Help; PSH = Pure Self-Help CM = Concern about Mistakes; PS = Personal Standards; DA = Doubts about Actions Aldea et al., 2010 Link Between Thoughts and Emotions COGNITIVE STRATEGIES It is 10 pm and two neighbors hear a loud bang outside their houses. One neighbor feels angry, while the other neighbor feels scared. They have both heard the same noise, so what accounts for them feeling differently? Two women arrive home to a bunch of flowers from their husbands with an attached note that says I love you. One woman immediately feels worried, whereas the other one immediately feels happy. What accounts for the difference in their feelings? Egan, Wade, Shafran, & Antony, in press 18

20 Cognitive Features All-or-nothing thinking / should statements Excessively high or inflexible standards Double standards Probability overestimations Overgeneralizing Being overly focused on details Catastrophic thinking Excessive need for control Biases in attention and memory Perfectionism Myths The harder people work, the better they will do. To get ahead, you have to be single minded and give up all outside interests. Clever people have to work less than stupid people. The more you put into something, the more you get out of it. People can t be happy if they re not successful. If I avoid it, it tends to sort itself out. If a job s worth doing, then it s worth doing right. People notice every little detail and are quick to form critical judgments. Egan, Wade, Shafran, & Antony, in press Goals of Cognitive Therapy Positive thinking? Rational or realistic thinking? Convincing clients that the way they think is wrong, irrational, or too negative? Empowering clients by broadening their choices for how they interpret situations? Structure of a Typical Cognitive Therapy Session 1. Setting the agenda for the session 2. Discussion of the patient s functioning in the previous week 3. Review of the patient s homework for the previous week 4. Psychoeducation (e.g., relationship between thoughts and feelings) 5. Application of cognitive therapy techniques (e.g., examining the evidence, behavioral experiments, etc.). 6. Assigning new homework Questions to Challenge Thoughts Are my thoughts necessarily true? Are my thoughts consistent with the evidence? Are there other ways of thinking about the situation? Education Provide information or evidence to help counter perfectionistic beliefs. 19

21 Changing Cognitive Biases Thought records Changing Cognitive Biases Socratic questioning Identifying Double Standards Do you have one set of rules for yourself, and another set of rules for other people? Are the rules for yourself harder than your rules for others? Challenging Double Standards Is it fair to have harsher rules for yourself than for everyone else? What is the impact of holding a different set of standards for yourself than for others? What would you say to a friend who had a harder set of rules for him or herself than others? How does it follow that rules need to be harder for yourself than for other people? Egan, Wade, Shafran, & Antony, in press Egan, Wade, Shafran, & Antony, in press Identifying Overgeneralization What do you think of yourself as a person overall when you make even just a small mistake? What happens to your self-esteem when your performance has not met your standards? Egan, Wade, Shafran, & Antony, in press Challenging Overgeneralizing How does it follow that someone s worth as a person can be judged from one mistake or one instance of not meeting a goal? What is the universal definition that people in society would hold of a failure? How do you compare to that definition? In what ways are you similar or different? What does your belief that one small makes you are a complete failure do to your self-esteem and mood? Egan, Wade, Shafran, & Antony, in press 20

22 Examples of Should Statements I should always push myself to achieve I should always do things thoroughly I should never waste time I should always be productive I should always be trying to better myself I should leave as little time as possible for tasks so I don t waste time, even if I am late I should work harder I should try to be the best Egan, Wade, Shafran, & Antony, in press Identifying Should Statements What runs through your mind when you think of the to do list that you have to get through? How often do you say should and must to yourself when you are thinking of everything you have to do? Egan, Wade, Shafran, & Antony, in press Challenging Should Statements How does saying should to yourself constantly make you feel? In what way does it impact on your sense of self? What impact do you think it might have if you applied the sort of pressure you apply on yourself to a close friend? Egan, Wade, Shafran, & Antony, in press Identifying Selective Attention When you think about your performance, what do you tend to focus on? How much do you notice mistakes in performance? Do you notice successes? How do you react to positive aspects of performance? How do you feel when you meet a goal or standard? Do you feel satisfied? Not satisfied? How long does that last? Do you discount your goals when you meet them as being too easy, or that anyone could have done that? After you meet your goals, do you set the goals for next time higher, lower or the same? Egan, Wade, Shafran, & Antony, in press Challenging Selective Attention What does focusing in on your mistakes and discounting your successes do to your mood? What is the impact of focusing on your flaws and discounting your positive aspects of performance on how much you base your sense of self-worth on achievement? If you constantly followed around a friend around as a critical judge and pointed out everything he or she did wrong, and never commented on what your friend did well, what do you think would start to happen to your friend s mood and self-esteem? What would the judge actually need to do instead in order for your friend of feel like a success? Egan, Wade, Shafran, & Antony, in press Behavioral Experiments Beliefs rarely change as a result of intellectual challenge, but only through engaging emotions and behaving in new ways that produce evidence that confirms new beliefs (Chadwick et al., 1996) Behavioral strategies offer the most powerful means to cognitive change in cognitive therapy to cognitive change in cognitive therapy (Wells, 1997) The best way to increase the believability of your alternative or balanced thoughts is to try them out in your day-to-day life (Greenberger & Padesky, 1995) Egan, Wade, Shafran, & Antony, in press 21

23 The Builder s Apprentice What would happen if Joe let go of the wall? How can Joe find that out for himself? Why wasn t the passer s-by comment enough? What is the similarity with your situation? Adapted from Salkovskis et al., 2010 Behavioral Experiments General Principles Make sure rationale is clear. Be clear about the belief to be tested (as well as the alternative or helpful belief). Ensure that perceived risk is low, and that experiment is likely to yield useful information. Design experiment collaboratively. Ensure that predicted outcomes are specific and measurable. Egan, Wade, Shafran, & Antony, in press Behavioral Experiments Steps Identify belief to be tested. Collaboratively brainstorm possible experiments. Elicit predictions and design a method to assess the outcome. Anticipate problems and brainstorm solutions. Conduct the experiment. Review the experiments (and predictions) and draw conclusions. Egan, Wade, Shafran, & Antony, in press Behavioral Experiments Variables to Manipulate Test the effects of breaking a rule Test the effects of preventing safety behaviors Test the effects of behaving imperfectly Test the effects of exposure to a feared situation that was previously avoided Behavioral Experiments Target Cognition: Allowing people to see me blush will show I am weak. Alternative Perspective: Blushing is not the most important thing about me. Most people blush. Experiment:?? Behavioral Experiments Target Cognition: I must always be busy. It is wrong not to be busy. I could not tolerate being idle. Belief rating = 100%. Alternative Perspective: It s okay to be idle sometimes. Experiment:?? Adapted from Butler & Hackmann, 2004 Egan, Wade, Shafran, & Antony, in press 22

24 Behavioral Experiments Target Cognition: If I keep focusing on myself and on how I come across, I ll find a way out of this. Alternative Perspective: If I allow myself to become absorbed in my work, then I won t feel as self conscious. Experiment:?? Behavioral Experiments Target Cognition: If I don t work all the time, I will fail and be miserable. Alternative Perspective: Scheduling pleasurable activities will make life more enjoyable and may even help to focus better when I am working. Experiment:?? Adapted from Butler & Hackmann, 2004 Adapted from Butler & Hackmann, 2004 Behavioral Experiments Target Cognition: If I don t plan and monitor everything I say, it will come out wrong. Alternative Perspective: It is only necessary to plan a few key points, and best to focus on the other person. Experiment:?? Adapted from Butler & Hackmann, 2004 Generating Behavioral Experiments I need to check over and over to make myself sure that I haven t missed any mistakes and so that I can go to sleep at night. Multitasking is efficient and the only way I will manage all the many tasks I have to do I am stupid; if I don t make lists I will forget what I need to do My paper is not ready to send off yet. If I send it off and it is rejected, I will be devastated unable to eat, work or sleep again Egan, Wade, Shafran, & Antony, in press Surveys Rate your belief in each of the following sentences (0 10) If someone saw me blush, they would assume it was a visible sign of anxiety. People think it s strange for a man to blush People think someone should have outgrown blushing by the age of 30 People see blushing as a sign of inadequacy Adapted from Butler & Hackmann, 2004 Surveys I should be available for work phone calls at all times (even evenings, weekends, and vacations). Possible Survey Questions How often do you take your work phone with you on vacation? What do you think of people who do take their work phone away on vacation? What do you think of people who do not take their work phone away on vacation? Do you answer your work phone at night and on weekends? What do you think of people who do answer their work phone at night and on weekends? What do you think of people who do not answer their work phone at night and on weekends? Egan, Wade, Shafran, & Antony, in press 23

25 Surveys I make more serious mistakes than other people at work. Possible Survey Questions How many mistakes have you made at work in the past year? How many of these mistakes were serious? What examples do you have of serious mistakes you have made at work? What were the negative consequences of your serious mistakes? What is the worst consequence you have ever had due to serious mistakes? Changing Cognitive Biases Pie Chart Technique Egan, Wade, Shafran, & Antony, in press Pie Chart Technique Example David recently gave a presentation (along with his boss and two coworkers) to representatives from another company with the goal of making a big sale. The company chose not to purchase from David s group. Why? David assumed that it was because of his performance during the presentation Perspective Shifting Involves considering the event from a different perspective. Examples: What would you tell a loved one who was having the same thought as you? What might someone without anxiety be thinking in this situation? Egan, Wade, Shafran, & Antony, in press Coping Statements Coping statements may be useful in moments of high distress, when it may be difficult to step back from one s thoughts and consider the evidence. Examples Other people are not as focused on my mistakes as I am It s normal to be anxious during a job interview Core Beliefs Represent the deepest level of cognition Typically deduced rather than identified explicitly Most difficult to change, and require close attention Often adaptive or understandable under the circumstances they were formed 24