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1 Cognitive- Behavioral Therapy for Perfectionism 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 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 Recommended books and DVDs Definition of Perfectionism Perfectionism is a disposition to regard anything short of perfection OVERVIEW OF as unacceptable Merriam Webster Dictionary PERFECTIONISM.

2 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 receives a grade that is less than perfect.

3 And efficiency . 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 Social and performance anxiety Performance at work or school 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 Depression Physical appearance Suicidal ideation Health and personal cleanliness Egan et al.

4 , 2011. 3. Pathways to Perfectionism Learning Cognitive factors Biological factors CAUSES OF Other factors ( , stress, personality, interpersonal factors). PERFECTIONISM. Learning and Perfectionism Modeling 1. Reinforcement of Perfectionism Factors Affecting Modeling 2. Modeling Attractiveness 2. Other Learning Pathways Similarity ( , values). Direct traumatic experiences Observing a model being rewarded for 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.

5 - 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 ( , tests). Disorders associated with perfectionism ( , Procrastination depression, anxiety disorder, eating disorders) are Goal achievement behaviors ( , moderately heritable.)

6 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 ( , 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.

7 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.

8 , 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 ( , by making me Am I able to meet my standards? Do I get overly disappointed or angry when my standards are not met; by making me get less overly upset if I don't meet my own 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 COGNITIVE- and interpretations Behavioral Strategies for Perfectionism BEHAVIORAL Exposure to feared objects, thoughts, situations Prevention of safety behaviors THERAPY Other Strategies (still unproven in perfectionism).

9 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). Behavioral activation (depression). Number of sessions ? Progressive muscle relaxation (chronic worry) Frequency of sessions ? Medications (anxiety disorders, OCD, depression) Focus on perfectionism vs. focus on one or more specific disorders ( , depression, OCD). Introducing the Treatment Sample 11-Session Protocol Understanding perfectionism ( , definitions, 1. motivational enhancement causes, features) 2. CBT formulation and monitoring Adaptive vs. maladaptive perfectionism 3. Introduction to changing cognitive biases Setting SMART goals (specific, measurable, 4. Introduction to changing maladaptive behaviors attainable, relevant, time-bound) 5. Introduction to behavioral experiments Readiness for treatment; beliefs about treatment 6. Maladaptive patterns of self-evaluation Discussion of treatment expectations (number of 7.)

10 Rigidity, rules, and extreme standards sessions , attending appointments, arriving on time, 8. Self-criticism and self-compassion completing homework, ongoing assessment, etc.) 9. Scheduling pleasant events Overview of treatment strategies 10. Problem solving Developing a collaborative CBT formulation 11. Relapse prevention Adapted from Egan, Wade, Shafran, & Antony, 2014. 7. Homework Guidelines Homework Guidelines Amount should be manageable and achievable Some clients avoid homework (because it Instructions should be unambiguous cannot be done well enough). Rationale should be clear to the client Some clients do much more homework than Leave enough time to assign homework they are asked to do (because they devalue Homework should be planned collaboratively small goals). Ensure clear expectation that homework will be completed It is helpful to work through beliefs that Begin each session with review of homework clients may have about homework Avoid being punitive for failure to complete homework completion Homework is often progressive or additive Adapted from Egan, Wade, Shafran, & Antony, 2014 Adapted from Egan, Wade, Shafran, & Antony, 2014.