AN ONLINE MINDFULNESS-BASED INTERVENTION FOR PERFECTIONISTS

Transcription

1 AN ONLINE MINDFULNESS-BASED INTERVENTION FOR PERFECTIONISTS By HANNA SUH A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA

2 2016 Hanna Suh 2

3 To my family and friends 3

4 ACKNOWLEDGMENTS I thank everyone who has supported and challenged me through this journey. First and foremost, I would like to thank Laurie for her endless support throughout the past four years. Your expertise in intervention studies led me to become interested in how to adapt mindfulness interventions to the population of my interest. Also, our biweekly lab meetings and processing made me grow into a better researcher, therapist, and a person. Second, I would like to thank Dr. Rice for his continuous mentoring even after leaving to another school. Your expertise in perfectionism research and commitment to science has helped me become a critical researcher and has opened my eyes to the new world of methodology. I also thank Drs. Ratliff and Ardelt for their valuable input in making this dissertation relevant and meaningful. I am also thankful for all my previous supervisors at the Alachua Country Crisis Center, University of Florida Counseling and Wellness Center, and University of Pennsylvania Counseling and Psychological Services. You all were so kind, encouraging, and genuine in your support of me. I am indebted to pay back the training that I have received from all of you. Finally, I feel extremely fortunate to have had my amazing UN cohort and internship cohort. This journey would have been a very lonesome one without y all. Thank you so much! 4

5 TABLE OF CONTENTS 5 page ACKNOWLEDGMENTS... 4 LIST OF TABLES... 7 LIST OF FIGURES... 8 ABSTRACT... 9 CHAPTER 1 INTRODUCTION AND REVIEW OF THE LITERATURE Introduction Perfectionism Perfectionism as a Multidimensional Construct Subtypes of Perfectionism Theories of Perfectionism Latent Classes of Perfectionism Perfectionism and Psychological Adjustment Perfectionism and Emotion Regulation Perfectionism and Intervention History and Definition of Mindfulness Mindfulness and Well-being Mindfulness-Based Interventions Mindfulness and Emotion Regulation Purpose of the Study METHOD Phase 1: Prescreening for Eligibility Participants Procedure Measures Data Analysis Phase 2: Intervention Phase Participants Procedure Data Analysis RESULTS Phase 1: Prescreening Descriptive Statistics Latent Profile Analysis... 74

6 Phase 2: Intervention Descriptive Statistics and Preliminary Analyses Main Effect Analyses DISCUSSION Subtypes of Perfectionists Effectiveness of Mindfulness-Based Intervention Limitations Implications for Research and Practice Conclusion APPENDIX A ALMOST PERFECT SCALE REVISED B EMOTION REGULATION QUESTIONNAIRE C DEPRESSION ANXIETY STRESS SCALE D SATISFACTION WITH LIFE SCALE E DIFFICULTIES WITH EMOTION REGULATION SCALE F FIVE FACET MINDFULNESS SCALE G POSITIVE AND NEGATIVE AFFECT SCALE H THREE DIMENSIONAL WISDOM SCALE I DEMOGRAPHIC INFORMATION LIST OF REFERENCES BIOGRAPHICAL SKETCH

7 LIST OF TABLES Table page 3-1 Sample Characteristics Overview of Daily Sessions Final Number of Participants Descriptive Statistics for Prescreening (N = 438) Fit indices for One- to Four- Class Models Correlations, Means, Standard Deviations (Phase 2) Number of Participants Responding to Treatment Engagement Questions Functions of Time and Treatment Effects on Variables (n = 67) Summary of Support of Hypotheses

8 LIST OF FIGURES Figure page 2-1 Timeline of the Study Flowchart of Participation Latent Profile Graph for Recruitment Latent Profile Graph for Recruitment Latent Profile Graph for Recruitment

9 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy AN ONLINE MINDFULNESS-BASED INTERVENTION FOR PERFECTIONISTS Chair: Laurie B. Mintz Cochair: Kenneth G. Rice Major: Counseling Psychology By Hanna Suh August 2016 Perfectionism is a personality characteristic that encompasses setting extremely high standards and experiencing self-criticism for not reaching performance expectations. Particularly, maladaptive perfectionists experience highest levels of psychological distress and lowest levels of subjective well-being and psychological wellbeing. Many intervention efforts have found targeting perfectionists difficult due to the cognitive rigidity and shame that impedes help-seeking and maintaining being involved. Mindfulness-based intervention can be a promising alternative to intervening to this population, especially given that cultivating mindfulness stabilizes emotion dysregulation process which often exacerbates the stress that maladaptive perfectionists experience. The present study examined whether an online mindfulness-based intervention shows effectiveness in decreasing psychological distress and increasing subjective and eudaimonic well-being among maladaptive perfectionists. A total of 438 participants initially responded to prescreening questionnaires and a final sample of 67 maladaptive perfectionists was identified through latent profile 9

10 analysis. Participants engaged in a five-day online psychoeducation and experiential activities addressing mindfulness (intervention) or stress management (active control). Results suggested three latent classes of perfectionists: adaptive perfectionists, maladaptive perfectionists, and non-perfectionists showing similar profile characteristics mirroring previous literature. More substantively, maladaptive perfectionists in both conditions showed significant improvement in emotion dysregulation, mindfulness, satisfaction with life and significant decrease in negative affect, depression, anxiety, and stress. However, no changes were observed on both groups on positive affect and wisdom. Second, and more central to this study, there were no group differences between mindfulness and stress management conditions in the rate of change over time on most variables (except negative affect). This indicated that the effectiveness of the mindfulness-based intervention was generally not supported. Implications for future mindfulness intervention research and practice are discussed. 10

11 CHAPTER 1 INTRODUCTION AND REVIEW OF THE LITERATURE Introduction Perfectionism has long been identified as an important risk factor contributing to psychological distress (Stoeber & Otto, 2006). Despite several different conceptualizations of perfectionism, it is generally agreed that perfectionism is a multidimensional construct (Frost, Marten, Lahart, & Rosenblate, 1990; Hewitt & Flett, 1991; Slaney, Rice, Mobley, Trippi, & Ashby, 2001), composed of two fundamental aspects: personal standards (perfectionistic strivings) and self-critical perfectionism (evaluative-concerns perfectionism) (Dunkley, Berg, & Zuroff, 2012; Dunkley, Zuroff, & Blankstein, 2003; Stober & Otto, 2006; Slaney et al., 2001). According to these converging definitions, personal standards perfectionism generally reflects setting high expectations for one s performance. On the other hand, self-critical perfectionism reflects experiencing chronic discrepancy between one s performance and self-set expectations, colored with harsh self-scrutiny and critical self-evaluations. Furthermore, categorical approaches have distinguished qualitatively different subtypes of perfectionists, namely, adaptive and maladaptive perfectionists (Rice Ashby, & Slaney, 1998; Rice & Ashby, 2007). Utilizing such categorical approaches has been supported in several studies (Boone, Soenens, Baret, & Goosens, 2010; Elion, Wang, Slaney, & French, 2012; Grzegorek, Slaney, Franze, & Rice, 2004). For instance, Parker (1997) identified three profiles of adolescents, each referred to as healthy (adaptive) perfectionists, maladaptive (dysfunctional) perfectionists, and non-perfectionists. The key distinction between healthy and maladaptive perfectionists existed in their different levels on evaluative concerns perfectionism. In essence, adaptive perfectionists are 11

12 individuals who are characterized by setting high standards with low levels of evaluative concerns whereas maladaptive perfectionists are individuals who set high standards while concurrently experiencing high levels of self-critically evaluative concerns in meeting those goals. Recently, employing more rigorous methods allowed identifying latent classes of perfectionists that mirror adaptive and maladaptive perfectionist profiles, ensuring additional validity to this distinction (Rice & Richardson, 2014; Rice, Richardson, & Tuller, 2014). Given that perfectionists, especially maladaptive perfectionists, experience pervasive emotional disturbance (Milyavskaya, Harvey, Koestner, Powers, Rosenbaum, Ianakieva, & Prior, 2014), exploring ways in which emotion regulation can be promoted seem appropriate and necessary. However, only a handful of studies explored the process through which perfectionism affects psychological adjustment via emotion regulation. For example, Rice, Vergara, and Aldea (2006) argued that perfectionism is associated with psychological adjustment via cognitive and affective self-regulation process, such that maladaptive perfectionists experience higher levels of perceived stress and dichotomous thinking styles influencing decreased adaptation. Although this study alluded to cognitive and affective self-regulation process, it did not directly incorporate emotion regulation processes of perfectionists. Furthermore, it has been found that different subtypes of perfectionists use different emotion regulation strategies. Richardson, Rice, and Devine (2013) distinguished that adaptive perfectionists tend to engage in healthier emotion regulation (cognitive reappraisal), while maladaptive perfectionists engage in less healthy emotion regulation strategies (emotional suppression). 12

13 According to the Self-Determination Theory (SDT), individuals are intrinsically oriented to regulating themselves. This regulation fulfills basic needs that are facilitative to psychological health (Ryan & Deci, 2000). Furthermore, according to SDT, mindfulness is identified as an important factor that promotes psychological health (Brown & Ryan, 2003). Defined as a characteristic that brings flexibility and objectivity, mindfulness promotes clarity to one s internal processes (Brown & Ryan, 2003). Interestingly, this conceptualization of mindfulness closely mirrors that of emotion regulation. According to Gratz and Roemer (2004), emotion regulation reflects increased awareness and acceptance of emotions. In the present study, mindfulness is conceived as an important process that is related to, and may be facilitative of, effective emotion regulation (Gratz & Tull, 2010; Hill & Updegraff, 2012). Mindfulness-based interventions emphasize developing emotional awareness and clarity via continuous formal and informal experiential practices (for example, Mindfulness-Based Stress Reduction [MBSR: Kabat-Zinn, 1990]). Thereafter, cultivating mindfulness further promotes psychological health (Keng, Smoski, & Robins, 2011). What is still left unclear is whether cultivation of mindfulness through a mindfulnessbased intervention directly generates better emotion regulation, which in turn leads to psychological health. A small number of studies explored the association between mindfulness and emotion regulation utilizing a randomized controlled trial (RCT) (Erisman & Roemer, 2010). To date, no study has examined the longitudinal change process of emotion regulation and its potential function as a mediator between a mindfulness-based intervention and outcome variables. Many researchers articulated the importance of assessing mediation in treatment research (MacKinnon, Fairchild, & 13

14 Fritz, 2007). MacKinnon et al. (2007) indicate that because meditation analysis provides evidence as to how an intervention achieved its effects, gauging critical components can assist improving the intervention. The current study adapts an online mindfulness-based intervention. Viable reasons exist supporting its relevance and appropriateness. First, although various forms of mindfulness-based interventions exist, mindfulness practice is a rather solitary mental, physical, and emotional activity that is geared towards attuning to one s present inner and outer experiences. Although in-group mindfulness practice is generally suggested (Kabat-Zinn, 1990), paying attention to the private nature of mindfulness meditative practice may not necessitate the physical presence of others. In the present study, participants will individually engage in guided meditations and will not be practicing in a group environment as in traditional MBSR suggests. Second, an online mindfulness intervention has its benefits such as flexible timeframe and ease of access, allowing individuals to have greater autonomy to manage and practice mindfulness. In sum, exploring the applicability and effectiveness of an online mindfulness-based intervention will be a welcomed addition to the literature. Taken together, the current study examines two research objectives. First, latent classes of perfectionists will be identified using measures of perfectionism, emotion regulation, psychological distress, subjective well-being, and eudaimonic well-being. Taking into account these four components is a sensitive and comprehensive approach to capture qualitatively different characteristics and subtypes (or profiles) of perfectionists that has been previously supported (Richardson, Rice, & Devine, 2013; Rice & Richardson, 2014). Second, by employing a randomized controlled trial, the 14

15 effects of a brief online mindfulness-based intervention will be examined over time. Specifically, the present study examines whether mindfulness-based intervention yields significantly different change trajectory compared to an active control condition. Findings from this study will provide information to guide and further tailor efforts in implementing mindfulness-based interventions for perfectionists. This chapter presents a literature review, beginning with theory and research on perfectionism and its effects. Definitions of perfectionism will be presented, followed by critical interpretation on the association between perfectionism and psychological adjustment link, and the role of emotion regulation. Thereafter, research on mindfulness will be included. Effective established mindfulness-based interventions and the association between mindfulness and emotion regulation will then be subsequently introduced. Lastly, the applicability of an online mindfulness-based intervention for perfectionists will be examined. This chapter concludes with stating the purpose of the current study, subsequently followed by specific research hypotheses. Perfectionism While variations exist, it is generally agreed that perfectionism is multidimensional construct that reflects a relatively stable personality style (Enns & Cox, 2002; Hewitt & Flett, 1991; Frost et al., 1990, Slaney et al., 2001). It is characterized by setting excessively high performance expectations for oneself (hereinafter referred to as Standards) coupled with critical self-evaluative tendencies for not meeting those self-set expectations (hereinafter referred as Discrepancy) (Flett & Hewitt, 2002; Rice, Richardson, & Tueller, 2014; Slaney et al., 2001). The characteristics of Standards and Discrepancy are respectively referred as Personal Standards or Personal Strivings and Evaluative Concerns or Self-critical Perfectionism in others studies (Dunkley, Zuroff, & 15

16 Blankstein, 2003; Stoeber & Otto, 2006; Slaney et al., 2001). Such perfectionistic characteristics exhibit relative stability over time, independent from situational mood changes such as depression (Rice & Aldea, 2006). This partially supports the longstanding notion that perfectionism exhibits relative stability over time across various circumstances. Perfectionism as a Multidimensional Construct Several studies (Rice & Ashby, 2007; Slaney et al., 2001) argued Standards and Discrepancy as two integral aspects of perfectionism, combined intricately to generate distinct subtypes or classes of individuals with perfectionistic tendencies. This multidimensional perfectionism characterized by Standards and Discrepancy mostly pertains to intra-individual characteristics, which may or may not develop from, or be maintained by, interpersonal pressures. Often however, individuals with perfectionistic tendencies do report experiencing difficulties in interpersonal communications and social realms (Rice, Leever, Christopher, & Porter, 2006; Slaney, Pincus, Uliaszek, & Wang, 2006), although interpersonal difficulties herein may not be precipitated or maintained by others expectations. On the contrary, some researchers conceptualize perfectionism incorporating interpersonal pressure (Frost et al., 1990; Hewitt & Flett, 1991), although others raise concerns about whether such interpersonal component is perfectionism itself or a cause (or correlate) of perfectionism. For instance, Slaney et al. (2001) made a poignant point indicating that parental, other-oriented and sociallyprescribed perfectionism seem to be based on assumed causes, concomitants, or the resultant effects of being perfectionistic rather than a definition of perfectionism itself (p. 132, see also Shafran et al., 2001, 2002). 16

17 Subtypes of Perfectionism A multidimensional conceptualization of perfectionism has also evolved into delineating qualitatively different subtypes (e.g., categories, classes) of perfectionists. In their review, Stoeber and Otto (2006) outlined adaptive and maladaptive forms of perfectionism that result from distinct combinations of concurrent experiences of performance discrepancy with self-set standards. Specifically, adaptive perfectionists are individuals who strive for high personal standards and are relatively satisfied with current performance (Grzegorek, Slaney, Franze & Rice, 2004; Rice & Ashby, 2007). Adaptive perfectionists are less likely than others to be punitive and chronically dissatisfied with their performance, given that the discrepancy between standards and current performance is minimal (Slaney, Rice, & Ashby, 2002). On the contrary, maladaptive perfectionists endorse high personal standards coupled with a chronic sense of inability and inadequacy to reach the self-set standards (Rice & Ashby, 2007; Rice, Bair, Castro, Cohen, & Hood, 2003). As such, maladaptive perfectionists are likely to exhibit excessive sensitivity to failure cues as well as a tendency to discount success, which makes it difficult to lessen the degree of discrepancy (Ashby & Kottman, 1996; Rice & Dellwo, 2002). Due to different lines of research grounded in different conceptualizations and assessments, followed by subsequent utilization of analytic methods, adaptive and maladaptive perfectionism are also being referred to as active/passive, positive/negative, functional/dysfunctional, healthy/unhealthy, personal standards/evaluative concerns, conscientious/self-evaluative perfectionism in the literature (Stoeber & Otto, 2006). 17

18 Theories of Perfectionism Tripartite Model. Grounded in the multidimensional conceptualization of perfectionism, several notable theoretical models exist outlining adaptive and maladaptive perfectionism. Rice and Ashby (2007) described a tripartite model of perfectionism that consists of adaptive, maladaptive, and non-perfectionists. This model is aligned to the traditional viewpoint on perfectionism that delineated normal versus neurotic perfectionism (Hamachek, 1978), but takes a step further by actively acknowledging the positive effects of adaptive perfectionism. Their model challenges the longstanding dominant perspective of defining perfectionism as only maladaptive and problematic (e.g., Burns, 1990; Pacht, 1984; see Flett & Hewitt, 2002 for a review). Provided its conceptual convictions, Rice and Ashby s (2007) study was the first attempt to methodologically explore and confirm distinguishing into three groups by suggesting cut-off scores. Using cluster analysis, three groups were identified where each group approximated to adaptive (40.7% of participants), maladaptive (26.9%), and nonperfectionists (32.4%). Other Models. Along with the tripartite model of perfectionism, several other models exist: Three-factor perfectionism model (Hewitt & Flett, 1991), Six-factor perfectionism model (Frost et al., 1990), Dual-process model (Slade & Owens, 1998), Clinical perfectionism model (Shafran, Cooper, & Fairburn, 2003), and the 2 x 2 model (Gaudreau & Thompson, 2010). A fundamental distinction that separates tripartite model from others lies in their construction of perfectionism structure. Specifically, the way in which subtypes of perfectionism are treated (dimensional vs. categorical) dictates the way in which these models are conceived. For instance, the 2 x 2 model yields four types that simply result from combinations of high and low evaluative 18

19 concerns perfectionism (ECP) and personal standards perfectionism (PSP). Similar dimensional conceptualizations of positive and negative perfectionism can be observed in the dual-process model. All these other models address different degrees of perfectionism, whereas the tripartite model addresses different types of perfectionism. In short, as summarized by Broman-Fulks, Hill and Green (2008), there has been controversy over how to treat perfectionism (dimensional vs. categorical). Notwithstanding the advantages of each approach, the current study will be based on categorical conceptualization of different subtypes of perfectionism. Such notion has been further supported through a set of recent studies that utilized more statistically rigorous methods to distinguish qualitatively distinct subtypes of perfectionists. Latent Classes of Perfectionism Recent advancement in methodology allows utilizing factor mixture modeling (FMM) to identify latent classes of perfectionists. In studies that employed factor mixture modeling to yield latent classes with two dimensions of perfectionism (Standards, Discrepancy), the delineation of adaptive and maladaptive perfectionist classes has been consistently supported (Rice & Richardson, 2014; Rice, Richardson, & Tueller, 2014). Rice, Richardson, and Tueller (2014) pointed out that a purely dimensional model, without latent classes, was not as accurate portrayal of the data as were models that incorporated both dimensional representations of perfectionism (Standards and Discrepancy factors) and categorical or latent class representations of perfectionism (p. 373). Although the measure used in this study was a shorter version of the APS-R, they found three latent classes to be best representative of the data, with each class reflecting characteristics of adaptive, maladaptive, and non-perfectionists based on its relation to criterion variables (e.g., GPA, depression). Rice and Richardson (2014) 19

20 indicate that classifying subtypes of perfectionists based on cluster analysis can be fallible given the subjectivity involved in identifying the number of clusters (Ruscio & Ruscio, 2004). In other words, certain methods such as latent profile analysis may be better at capturing qualitatively different subtypes of perfectionists. Grounded in different theoretical underpinnings and clinical perspectives, the subtypes of perfectionism are construed in multiple ways. This pattern is extended to yielding different measures and treatment approaches as well. Regardless, the general consensus is that adaptive and maladaptive dimensions and/or (latent) classes of perfectionists exist with different implications for psychological distress and well-being. Perfectionism and Psychological Adjustment Research on perfectionism has broadened and advanced over the past three decades, mostly focusing on how it is related to psychological adjustment. Not surprisingly, grounded in the conceptualization of treating maladaptive perfectionism as a negative personality trait, many studies explored the deleterious effects of maladaptive, or self-critical perfectionism on psychological maladjustment and distress (Rice, Tucker, & Desmond, 2008; Stoeber & Otto, 2006). As some argue, such a trend may be attributed to psychology s longstanding interest in maladjustment and problematic adaptation (Flett & Hewitt, 2006). Under this paradigm, perfectionism and psychological adjustment research has largely evolved in two streams. One line of research examined associations between perfectionism and distress by considering both Standards and Discrepancy, and delineating adaptive and maladaptive perfectionists (categorical approach). An advantage of this line of research lies in its potential to examine comparative effects of adaptive versus maladaptive perfectionism. Another line of research adhered to a more 20

21 narrowly defined conceptualization of perfectionism by examining elevated levels of Discrepancy (or Evaluative Concerns) as an indicator of maladaptive, self-critical perfectionism (Albert, Rice, & Caffee, 2014; Dunkley, Berg, & Zuroff, 2012; Rice, Lopez, Richardson, & Stinson, 2013; van der Kaap-Deeder, Vansteenkiste, Soenens, Verstuyf, Boone, & Smets, 2014). Regardless of the dimensional or categorical conceptualization of perfectionism, studies converge on the deleterious effects of maladaptive (or selfcritical) perfectionism on subjective and eudaimonic well-being. Hence, examining the ways in which maladaptive perfectionists experience distress has been a noteworthy exploration in the perfectionism research thus far. Several notable psychological distress indicators have been identified in relation to maladaptive perfectionism. These include depression (Chang, 2002; Chang & Sanna, 2001; Rice, Ashby, & Slaney, 1998), anxiety (Antony, Purdon, Huta, & Swinson, 1998; Enns & Cox, 1999; Eum & Rice, 2011), perceived stress (Stumpf & Parker, 2000), obsessive-compulsive disorder (Huan, Rice, & Storch, 2008; Rice & Pence, 2006), and post-traumatic disorder. With regards to how research ideas unfolded, earlier studies mostly focused on elaborating the adverse consequences of perfectionism (Flett, Hewitt, Blankstein, & Gray, 1998; Shafran & Mansell, 2001). Thereafter, research expanded by exploring mediation and/or moderation effects in the link between perfectionism and psychological health (for a review, see Stoeber & Otto, 2006). In reviewing the literature pointing to adverse effects perfectionism has on depressive symptoms, we could locate several studies that examined mediation and moderation models. Black and Reynolds (2013) reported optimism to mediate the association between maladaptive perfectionism and depression. Results indicated that 21

22 maladaptive perfectionism influenced less optimism, which in turn was related to increased levels of depression. Self-esteem also functioned as a mediating variable in the aforementioned link, a result that is evidenced frequently in the association between perfectionism and depression (Preusser, Rice, & Ashby, 1994; Rice, Ashby, & Slaney, 1998). As evidenced in these studies, exploring possible mediation effect(s) has been largely limited to cross-sectional mediational analysis. However, according to MacKinnon et al. (2007), causality cannot be inferred from cross-sectional designs due to their inability to establish temporal precedence in the mediational chain. Because the aforementioned studies did not set temporal precedence, nor manipulated independent variable(s) to infer causality, accurately interpreting these results can be quite limited. Moderation models have been also explored. Enns, Cox, and Clara (2005) indicated evaluative-concerns perfectionism (concern over mistakes and doubts about action) to be significantly correlated with concurrent depressive symptoms (rs ranged from.25 to.51). Furthermore, negative life events significantly exacerbated depression and hopelessness via interacting with concern over mistakes and doubts about action. Wei et al. (2004) also explored moderating effect of maladaptive perfectionism in the association between adult attachment (attachment anxiety, attachment avoidance) and depressive mood. Results indicated that particularly for attachment anxiety, it was positively associated with depressive mood, and such effect was exacerbated by maladaptive perfectionism level. In other words, individuals who are at highest risk for experiencing depressive mood were those who exhibited higher attachment anxiety coupled with increased levels of maladaptive perfectionism. 22

23 In sum, studies that investigate the process in which perfectionism is related to depression have incorporated mediators (e.g., optimism) and moderators (e.g., negative life events) that are particularly reflective of emotion-laden personality characteristic and situations. Differential effects of adaptive versus maladaptive perfectionism were also explored when applicable. However, again, all these studies are limited in inferring causality due to the cross-sectional nature of the research design. Given the theoretical underpinning suggesting perfectionism as a risk factor to distress such as depression (Egan et al., 2011), a recent longitudinal study by Sherry et al. (2013) is a welcomed addition to the literature. Using a three-wave longitudinal design, this study found that Discrepancy at time 1 confers to depression at time 2, but not vice versa. In other words, perfectionism as a vulnerability factor to depression was confirmed only after adapting a longitudinal framework. In sum, applying a longitudinal design to perfectionism and distress research seems necessary and critical. Studies that examined the link between perfectionism and anxiety seem to have evolved by focusing on specific clinical populations that exhibit anxiety symptoms. For example, in a mixed sample of individuals diagnosed with anxiety disorders (e.g., panic, obsessive-compulsive, social phobia, and specific phobia) and nonclinical volunteers, elevated levels of evaluative-concerns perfectionism were related to social phobia symptoms (Antony, Purdon, Huta, & Swinson, 1998). Similarly, elevated scores in doubts about action was associated with obsessive-compulsive disorder symptoms. Likewise, Brown and Kocovski (2014) examined anxiety levels among individuals diagnosed with social anxiety disorder, after an anxiety-provoking speech task. They 23

24 found state and trait evaluative-concerns perfectionism significantly associated with rumination after increased anxiety through an anxiety-provoking task. Other studies that explored how perfectionism is related to anxiety symptoms (symptoms that do not meet clinical anxiety disorder criteria) among college student populations report converging results. Maladaptive perfectionists show increased levels of anxiety, compared to adaptive perfectionists and non-perfectionists. For instance, Eum and Rice (2011) indicated that students who endorsed high maladaptive perfectionism showed increased levels of test anxiety, with variations existing dependent upon gender and approach/avoidance goal orientations. Relatedly, some other studies examined links between perfectionism and more general psychological distress (Eddington, 2014; Pirbaglou, Cribbie, Irvine, Radhu, Vora, & Ritvo, 2013; Rice, Sauer, Richardson, Roberts, & Garrison, 2014; Rice, Vergara, & Aldea, 2006). For example, Rice, Vergara, and Aldea (2006) used the Student Adaptation College Questionnaire (SACQ; Baker& Siryk, 1989) that encompasses academic, social and general emotional adjustment to reflect distress among college students. Some utilized the Outcome Questionnaire (OQ-45.2; Lambert et al., 1996) that taps into anxiety-somatization, negative self-worth, and loss of interest, all of which are reflective of frequent distress symptoms and maintenance factors among college students (Rice, Richardson & Clark, 2012; Rice, Sauer, Richardson, Roberts, & Garrison, 2014). Such comprehensive measurement of psychological distress may be especially relevant when examining distress among college students. College students may be experiencing distress symptoms that are elevated and significant enough to be noticed, but that do not meet the diagnostic criteria to be 24

25 measured by specific symptomatic measures. Additionally, measuring psychological distress as an overarching construct allows the researchers to be sensitive to comorbid symptoms of depression, anxiety, and stress that are not easily compartmentalized especially in the nonclinical population. Lastly, comprehensively assessing psychological distress may be a better approach especially when exploring the effects of perfectionism. This is because an earlier viewpoint proposed perfectionism as an underlying factor responsible for comorbid psychopathology (Bieling, Summerfeldt, Israeli, & Antony, 2004). Egan et al. (2011) further consolidated this argument by proposing perfectionism as a transdiagnostic process that precipitates and maintains psychological distress. In other words, if perfectionism is a transdiagnostic factor that underlies psychological distress, its effect will be present across multiple symptoms (or disorders) exhibited concurrently and consistently across different symptomatic domains. Conversely, if focal point is on specific clinical population or certain symptoms, effects of perfectionism will only be exhibited in these limited measurements, which may not be an accurate representation of the data. Maladaptive perfectionism has been identified in general samples of college students (Chang, 2002; Chang & Sanna, 2001; Rice, Ashby, & Slaney, 1998) and further witnessed within specific subgroups such as honors students (Rice, Leever, Chiristopher, & Porter, 2006), gifted students (Wang, Fu, & Rice, 2012) and international graduate students (Rice, Choi, Zhang, Morero, & Anderson, 2012; Wei, Heppner, Mallen, Ku, Liao, & Wu, 2007). As evidence suggests, maladaptive perfectionism has traditionally received much attention in populations characterized by high-achievement tendencies (e.g., college students, honors students, Asian 25

26 international students) and in settings (e.g., academic settings) where effects of perfectionism can be most amplified. Not surprisingly, it is believed that one-fifth to onethird of student samples exhibit maladaptive perfectionistic tendencies (Boone et al., 2010; Rice & Ashby, 2007). Coupled with the argument that perfectionism is a rather stable personality characteristic, the pervasiveness of perfectionism and its chronic deleterious effects exhibited within the college population is alarming, and necessitates studies to further identify mediating and moderating factors that can disconnect or alter the magnitude of the link between perfectionism and psychological adjustment. The association between perfectionism and psychological distress can be understood in a theoretical framework of the diathesis-stress model (Chang, 2000; Chang & Rand, 2000; Hewitt, Flett, & Ediger, 1996; Rice, Leever, Christopher, & Porter, 2006), although inconsistent results have been reported. This framework posits that while the distinctions may exist between adaptive and maladaptive perfectionism (see Rice, Leever, Christopher, & Porter, 2006 for a more detailed explanation), perfectionism functions as a protective or risk factor to psychological distress. Consequently, the link between perfectionism and psychological distress will be more or less be attenuated in certain (stressful) conditions. Correlational studies that applied the diathesis-stress model of perfectionism converge to support that perfectionism is a risk factor to distress, amplified by stress. For example, Rice, Leever, Christopher, and Porter (2006) reported that when perfectionism is coupled with stress or other factors, it can be a proxy to psychological problems including depression and hopelessness. Similarly, Chang, Watkins, and Banks (2004) also identified stress as a partial and full mediator in the associations 26

27 between maladaptive perfectionism and affect, life satisfaction, and suicide ideation. Likewise, Dunkley, Zuroff, and Blankstein (2003) found that maladaptive perfectionism was associated with greater stress, and that stress partially mediated the link between perfectionism and negative affect. Application of the diathesis-stress model expanded to incorporate behavioral indicators as well. Rice and Van Arsdale (2010) reported that maladaptive perfectionists show more alcohol-related problems. Maladaptive perfectionists exhibited higher levels of stress, but also showed a greater tendency to drink in order to cope as compared to adaptive perfectionists and non-perfectionists. While some studies examined the differential effects of stress on adaptive and maladaptive perfectionism (Chang et al., 2004; Dunkley et al., 2003; Rice et al., 2006), other studies only focused on stress among maladaptive perfectionists. This trend is noteworthy but also somewhat expected given that only maladaptive perfectionism is suggested to be deleterious, exacerbated in the face of stress. In fact, after reviewing literature evidencing differential effects of adaptive and maladaptive perfectionism to adjustment, Rice et al (2006) pointed out that high standards might be best considered adaptive, regardless of stress [author italicized], unless Discrepancy scores are also elevated for the individual (p. 531). Stress, especially in perfectionism research, has been assessed via various means. Correlational studies that incorporated stress as an influential factor mainly examined perceived stress (e.g., Rice, Vergara, & Aldea, 2006). Perceived stress reflects the degree to which situations in one s life are appraised as stressful in a given time frame. Specifically, it reflects how unpredictable, uncontrollable, and overloaded life feels. Perfectionists hold stringent self-set expectations, in part attributable to 27

28 cognitive rigidity (Rice, Vergara, & Aldea, 2006). As such, perceived stress may be a more appropriate way to accurately measure stress experiences among perfectionists, distinguishable from an objective assessment of stress via physiological indicators. Furthermore, inconsistent results have been evidenced in physiological indicators of stress in relation to perfectionism. For instance, Richardson, Rice, and Devine (2013) reported perfectionism to be implicated in physiological reactions when faced with social-evaluative stress. Specifically, they employed Trier Social Stress Test (TSST; Kirschbaum, Pirke, & Hellhammer, 1993) to experimentally induce stress and found that maladaptive perfectionism was associated with lower cortisol response, a blunted reactivity pattern indicative of maladaptive stress response. At the same time, individuals who are exposed to prolonged stress (likely perfectionists) may also exhibit exacerbated physiological stress response (Wirtz et al., 2007). To summarize, a typical and common approach to incorporating stress into perfectionism research has been examining psychological effects of perceived stress on distress, in conjunction with perfectionism. Mixed findings of physiological stress response among perfectionists, coupled with an assumptively unique perception of stress among perfectionists, calls the current study to explore perceived stress in relation to perfectionism. Perfectionism and Emotion Regulation Surprisingly, despite an accumulating literature exploring the link between perfectionism and psychological distress in conjunction with potential mediators and moderators, not much attention has been directed to how, or what, emotion regulation strategies are utilized among individuals with perfectionistic tendencies. Multiple explanations exist to elaborate why emotion regulation has not been thoroughly and consistently incorporated in the perfectionism literature. One possibility is that emotion 28

29 processing has been implicitly assumed, most likely in psychological distress symptoms reflective of mood (e.g., negative and positive affect) and mood dysregulation (e.g. depression and anxiety). In other words, psychological distress itself has been assumed to be reflective of emotional dysregulation, rather than a perspective that treats psychological distress as a product of emotion (dys)regulation and vice versa. Only a few studies have examined the emotional process of individuals with perfectionistic tendencies (e.g., Aldea & Rice, 2006; Richardson, Rice, & Devine, 2014), mostly adapting the definition that views perfectionism as reflecting an interplay of standards and discrepancy. Taking into account the considerable amount of literature that evidences psychological distress perfectionists experience, in addition to emotion regulation as a process that undergirds precipitation and maintenance of psychological distress (for a review, see Hoffman et al. 2011), the scarcity of emotion regulation research in relation to perfectionism is quite astonishing. Maladaptive perfectionists by definition chronically carry a sense of inadequacy by failing to meet self-set standards, which consequently puts them at a greater risk to feel discouraged and disappointed, even expanding into self-loathing and self-pity. In this vein, Tangney (2002) articulated that self-evaluative emotions such as shame, guilt, and embarrassment can be easily triggered for perfectionists, in part owning to perfectionists tendency to put a great deal of energy and emphasis on self-scrutinizing. Ashby, Rice, and Martin (2006) in fact found maladaptive perfectionism to influence depression through increased feelings of shame, notwithstanding the limited methodological rigor of this study. 29

30 Adding another layer of complexity, what seems even more problematic is that for perfectionists, positive and satisfactory feelings are often short-lived even after successfully attaining their goals and standards, further reinforcing the vicious cycle to set even higher standards (Egan et al., 2011). Indeed, perfectionism is strongly associated with experiencing pervasive emotional disturbance. The link of perfectionism and negative affect is well-established regardless of stressful environmental cues such as academic demands for college students (Milyavskaya, Harvey, Koestner, Powers, Rosenbaum, Ianakieva, & Prior, 2014). Lo and Abbott (2013) delineated two ways in which perfectionism and negative affect are related. In the short-term, negative affect can be an outcome of endorsing perfectionistic tendencies but failing to meet self-set expectations. In the long-run, endorsing perfectionistic tendencies can increase the likelihood of negative affect, exacerbated by constant feelings of inadequacy and concerns over failure. In short, an intricate association between perfectionism and negative affect was evident both short and long-term. Given the pervasive presence and debilitating effects of negative emotions, several studies examined how to address emotion in the association between perfectionism and distress. Rice, Vergara, and Aldea (2006) recognized cognitive and affective self-regulation as processes through which perfectionism relates to psychological adjustment. Specifically, perceived stress and categorical thinking were conceptualized as affective and cognitive self-regulation strategies respectively, precipitating adverse consequences to emotional well-being. Not surprisingly, they found maladaptive perfectionists to be experiencing increased levels of perceived stress along with a more dichotomous, rigid, and inflexible thinking style about the world. 30

31 These cognitive-affective self-regulation strategies each partially mediated the association between maladaptive perfectionism and psychological adjustment, more consistently among maladaptive perfectionists. Taking into account the relatively stable nature of perfectionism, they suggest a viable future direction perfectionism intervention can tailor: Despite the clinical appeal of helping perfectionists change their selfregulation strategies, correlational studies such as this one do not address whether maladaptive perfectionists are capable of changing their coping and stress management (p. 470). In this vein, employing an RCT that incorporates emotion regulation may be beneficial to target reducing perfectionism and its effects. Rice and Richardson (2014) recently investigated emotion regulation patterns among individuals classified as adaptive, maladaptive, and non-perfectionists using factor mixture modeling. Results indicated adaptive perfectionists were more likely use cognitive appraisal and less likely to use emotional suppression than maladaptive perfectionists. On the contrary but not surprisingly, maladaptive perfectionists were more likely employ emotional suppression than adaptive perfectionists. Gross and John (2003) articulated reappraisal as a proactive and adaptive way to regulate emotion, by changing the meaning of a situation, in order to bring change in emotional effect. Another aspect of emotion regulation is suppression, a tendency to inhibit negative thoughts and feelings. In sum, emotion regulation is starting to be considered as an important process factor, and that differences exist between maladaptive and adaptive perfectionists. Although variations exist in defining emotion regulation, one that is mostly pertinent to perfectionism research seems to be that of Gratz and Roemer (2004). 31

32 Recall that perfectionists, especially maladaptive perfectionists, are more likely to endorse a skewed perspective on self-evaluation, in a way that is critical and judgmental. Likewise, the range of emotions (self-conscious emotions and negative emotions) that maladaptive perfectionists experience is likely limited, not to mention their chronic and rather automatic provocation. Given these characteristics, emotion regulation strategies for perfectionists should address expanding the range of emotional experiences, in addition to developing management skills to inhibit automatic emotional arousal. Gratz and Roemer s definition of emotion regulation precisely points to increasing awareness and understanding of emotions, precipitated by continuous monitoring, evaluating, and if applicable, modifying emotions. Furthermore, they acknowledge the functionality of emotions (see Cole et al., 1994; Thompson, 1994; Thompson & Calkins, 1996 for earlier conceptualizations), in which certain emotions extenuate and continue. As such, they define emotion regulation to involve the ability to use situationappropriate emotion regulation strategies flexibly to modulate emotional responses as desired in order to meet individual goals and situational demands (pp ). This conceptualization opens the possibility to interpret the extensive and stringent standards perfectionists constantly endorse as situational demands that are unchangeable and definite. In other words, building emotion regulation strategies may prepare perfectionists to flexibly respond to meet their goals of being perfectionistic, although this process is expected to conversely lead to less psychological distress via better emotion regulation. 32

33 Perfectionism and Intervention Despite perfectionism s relevance and prominence in psychological and physiological distress among college students, there have been only a limited number of interventions implemented that target reducing perfectionism among college students. Likewise, Rice, Ashby, and Gilman (2007) point out that although there is some recent evidence of treatment research tailored specifically to perfectionism (e.g., Riley et al., 2007), compared with nonclinical research, studies of perfectionism in treatment contexts are relatively rare (p. 575). Since then, an increased number of studies have explored the applicability of various treatment modalities to treat perfectionism and its effects (e.g., Goldstein, Peters, Thornton, & Touyz, 2014; Rice, Neimeyer, & Taylor, 2011; Steele, Waite, Egan, Finnigan, Handley, & Wade, 2013). In exploring possible explanations to understand such trends, several points seem relevant for discussion. First, perhaps such trends are partly due to the conceptualization of perfectionism as a dispositional trait. Rice and Aldea (2006) argue that self-critical perfectionism holds substantial relative stability, free from situational changes, such as mood states evoking or diminishing self-critical perfectionism. As a result, several studies purported to diminish the influence perfectionism has on psychological distress by focusing on mediating and moderating factors. For instance, developing heathier coping strategies (Achtziger & Bayer, 2012; Dunkley, Zuroff, & Blankstein, 2003; Dunkley, Zuroff, & Blankstein, 2006; Rice & Van Arsdale, 2010) and emotional expressive writing (Merrell, Hannah, Van Arsdale, Buman, & Rice, 2011) have been explored for potential intervention points. Second, due to the constant feelings of social inadequacy and punitive self-monitoring, developing and maintaining therapeutic alliance can be challenging for perfectionists (Blatt & Zuroff, 2002; Shahar, 33

34 Blatt, Zuroff, Krupnick, & Sotsky, 2004; Zuroff et al., 2000). Hence, conducting intervention studies for perfectionists have been challenging. Some have examined the effectiveness of group interventions on targeting perfectionism (Fredtoft, Poulsen, Bauer, & Malm, 1996), although self-guided treatment seems worth consideration. Norcross (2006) identifies self-help as a viable and effective modality to a wide array of problems including depression, anxiety, and substance use. Chang (2005) also emphasizes incorporating online based self-help modality to aid client adjustments, especially for college students. In sum, group-based treatments to perfectionism warrant cautionary attention given that they may yield confounding results if they do not account for the therapeutic relationship. Alternatively, self-guided treatment may capture benefits that cannot be addressed via group-based treatments. Treatment studies purported to decrease perfectionism and its associated distress are mostly rooted in cognitive-behavioral approaches (Arpin-Cribbie, Rivine, Ritvo, Cribbie, Flett, & Hewitt, 2008; Kutlesa & Arthur, 2008). Grounded in the assumption that cognition influences emotion, behavior, and well-being (Deale et al., 1997), cognitive-behavior therapy (CBT) aims to improve symptoms by changing dysfunctional cognition, in this case, perfectionism. Variations exist in the format of cognitive-behavioral perfectionism treatments. Pleva and Wade (2007) examined the effectiveness of bibliotherapy using the book When Perfect Isn t Good Enough (updated version, Antony & Swinson, 2009). This book mostly utilized cognitive-behavioral techniques, as reflected in its content on introducing cognitive therapy and exposure-based strategies to overcome perfectionism. Pleva and Wade randomly allocated perfectionists to a pure self-help 34