Cognitive-Behavioral Therapy for Perfectionism Presented by Martin M. Antony, PhD, ABPP Department of Psychology, Ryerson University Website: www.martinantony.com E-mail: [email protected] Handouts and slides from this presentation may not be reproduced without permission of the presenter April 9, 2015 ©2015 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 Anxiety and Depression Association of America Outline Cognitive-Behavioral Therapy for § Overview of perfectionism Perfectionism § Causes of perfectionism § Assessment of perfectionism April 9, 2015 § Introduction to cognitive-behavioral therapy Martin M. Antony, PhD, ABPP § Changing perfectionistic thinking Professor and Chair, Department of Psychology, § Changing perfectionistic behavior Ryerson University, Toronto § Mindfulness and acceptance-based Director of Research, Anxiety Treatment and approaches Research Centre, St. Joseph’s Healthcare, Hamilton § Emerging research on treating perfectionism www.martinantony.com § Recommended books and DVDs Definition of Perfectionism Perfectionism is a disposition to regard anything short of perfection OVERVIEW OF as unacceptable PERFECTIONISM Merriam Webster Dictionary Definition of Clinical Perfectionism Historical Perspectives “The overdependence of self- § “Tyranny of the shoulds” (Horney, 1950) evaluation on the determined pursuit § “Musterbation” (Ellis & Harper, 1961) (and achievement) of self-imposed, § Normal vs. neurotic perfectionism personally demanding standards of (Hamacheck, 1978) performance in at least one salient domain, despite the occurrence of adverse consequences.” Shafran, Cooper, & Fairburn, 2002 2 Examples of Perfectionists Perfectionism in the Context of OCPD § 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 pervasive pattern of preoccupation § A graphic artist constantly seeks reassurance that his work with orderliness, perfectionism, and is of the highest quality, and that he is well respected and well-liked by others. mental and interpersonal control, at § A student constantly strives to meet excessively high the expense of flexibility, openness, academic standards, and who is devastated when she and efficiency” 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. DSM-5 Definition of Obsessive-Compulsive Personality Disorder (OCPD) Egan, Wade, Shafran, & Antony, 2014 Obsessive-Compulsive Obsessive-Compulsive Personality Disorder Personality Disorder § Excessive concern with order, rules, § Overconscientious, inflexible about lists, and trivial details matters of morality, ethics, values § Perfectionism that interferes with task § Unable to discard worn or objects completion § Reluctance to delegate tasks to others § Excessively devoted to work (at the § Miserly expense of leisure, friendships) § Rigid and stubborn Domains of Perfectionism Transdiagnostic Nature of Perfectionism § Performance at work or school § Social and performance anxiety § Worry and generalized anxiety disorder § Relationships, friendships and family life § Obsessive-compulsive disorder § Leisure and recreation § Obsessive-compulsive personality disorder § Neatness and aesthetics § Eating disorders § Organization and ordering § Body dysmorphic disorder § Writing § Chronic fatigue § Speaking § Problem anger § § Physical appearance Depression § Suicidal ideation § Health and personal cleanliness Egan et al., 2011 3 Pathways to Perfectionism § Learning § Cognitive factors § Biological factors CAUSES OF § Other factors (e.g., stress, personality, PERFECTIONISM interpersonal factors) Learning and Perfectionism Modeling 1. Reinforcement of Perfectionism Factors Affecting Modeling 2. Modeling § Attractiveness 2. Other Learning Pathways § Similarity (e.g., values) § Observing a model being rewarded for § Direct traumatic experiences a particular behavior § Observational learning § Informational/instructional learning Albert Bandura Cognitive View of Perfectionism Cognitive View of Perfectionism § Perfectionism stems from biased beliefs, Other contributing factors include: assumptions, and predictions, for example: § Biased attributions - Anything less than sticking to my diet perfectly is a failure. If I eat one cookie, I may as well have eaten ten § Biased memory cookies. § Biased attention - 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. Adapted from Antony & Swinson, 2009 4 Cognitive Model of Perfectionism Cognitive Biases Self-Worth Overly Dependent § Dichotomous (all-or-nothing / black and white) on Striving and Achievement thinking § Shoulds and musts Performance-Related Cognitive Biases Inflexible Standards Behaviors § Selective attention (noticing the negative; discounting the positive) Temporarily Meets Fails to Meet Avoids Trying to Meet § Overgeneralization Standards Standards Standards § Double standards Reappraise Standards Counterproductive as Insufficiently Behavior and Self- Demanding Criticism Shafran, Egan, & Wade, 2010 Adapted from Egan, Wade, Shafran, & Antony, 2014 Performance-Related Behaviors Biology and Perfectionism § Avoiding situations that may test one’s Genetics Studies performance (e.g., tests) § Disorders associated with perfectionism (e.g., § Procrastination depression, anxiety disorder, eating disorders) are § Goal achievement behaviors (e.g., moderately heritable. overpreparing) § The trait of perfectionism has been found to be moderately heritable (Moser et al., 2012; Tozzi et al., § Testing one’s performance 2004). § Reassurance seeking Neurotransmitters § Social comparisons § No studies in perfectionism Brain Imaging Studies (e.g., PET, fMRI) § No studies in perfectionism Adapted from Egan, Wade, Shafran, & Antony, 2014 Popular Perfectionism Measures § Frost Multidimensional Perfectionism Scale (Frost et al., ASSESSMENT OF 1990) § Hewitt and Flett Multidimensional PERFECTIONISM Perfectionism Scale (Hewitt & Flett, 1991) 5 Frost Multidimensional Frost Multidimensional Perfectionism Scale Perfectionism Scale Concern over Mistakes Parental Expectations § If I fail at work/school, I am a failure as a person. § My parents set very high standards for me. § I hate being less than best at things. § My parents wanted me to be the best at everything. Personal Standards Parental Criticism § I set higher goals than most people. § As a child, I was punished for doing things less than perfectly. § I am very good at focusing my efforts on attaining a goal. § My parents never tried to understand my mistakes. Doubts about Actions Organization § I usually have doubts about the simple everyday things I do. § Organization is very important to me. § It takes me a long time to do something right. § I am a neat person. Hewitt and Flett Multidimensional Positive and Negative Perfectionism Perfectionism Scale Self-Oriented Perfectionism Maladaptive Evaluative Concerns § When I am working on something, I cannot relax until it is perfect. § Hewitt & Flett MPS: SPP § I demand nothing less than perfection of myself. § Frost et al MPS: CM, PE, PC, DA Other-Oriented Perfectionism § I seldom criticize my friends for accepting second best. Positive Striving § The people who matter to me should never let me down. § Hewitt & Flett MPS: SOP, OOP Socially Prescribed Perfectionism § Frost et al MPS: PS, OR § Those around me readily accept that I can mistakes too. § My family expects me to be perfect. Bieling et al., 2004; Frost et al., 1993 Questions to Determine Whether Questions to Determine Whether Standards are Overly Perfectionistic Standards are Overly Perfectionistic § Are my standards higher than those of other § Do my standards help me to achieve my goals people? or do they get in the way (e.g., by making me § Am I able to meet my standards? Do I get overly disappointed or angry when my overly upset if I don’t meet my own standards are not met; by making me get less work done, etc.)? standards? § What would be the costs of relaxing a particular § Are other people able to meet my standard or ignoring a rule that I have? standards? Do I get overly upset if others don’t meet my standards? § What would be the benefits of relaxing a specific standard or ignoring a rule that I have? 6 Evidence-Based Strategies Cognitive Strategies for Perfectionism INTRODUCTION TO § Recalibrating cognitive biases, encouraging flexible thinking, and correcting unrealistic beliefs and interpretations COGNITIVE- Behavioral Strategies for Perfectionism § Exposure to feared objects, thoughts, situations BEHAVIORAL § Prevention of safety behaviors Other Strategies (still unproven in perfectionism) THERAPY § Mindfulness and acceptance-based strategies § Motivational enhancement Evidence-Based Strategies Treatment Decisions Strategies for Targeting Associated Problems § Group or individual? § Social skills training (social anxiety disorder) § Number of sessions? § Behavioral activation (depression) § Progressive muscle relaxation (chronic worry) § Frequency of sessions? § Medications (anxiety disorders, OCD, depression) § Focus on perfectionism vs. focus on one or more