Antony, Master Clinician

23 Pages·2015·0.99 MB·English

by  Martin Antony

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
Outline
Anxiety and Depression Association of America
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
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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 “A pervasive pattern of preoccupation
emotional and physical health.
with orderliness, perfectionism, and
§  A graphic artist constantly seeks reassurance that his work
is of the highest quality, and that he is well respected and mental and interpersonal control, at
well-liked by others.
the expense of flexibility, openness,
§  A student constantly strives to meet excessively high
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
§  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., 2011
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Pathways to Perfectionism
§ Learning
§ Cognitive factors
CAUSES OF § Biological factors
§ Other factors (e.g., stress, personality,
interpersonal factors)
PERFECTIONISM
Learning and Perfectionism Modeling
1.  Reinforcement of Perfectionism Factors Affecting Modeling
2.  Modeling § Attractiveness
§ Similarity (e.g., values)
2. Other Learning Pathways
§ 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
§ Biased memory
failure. If I eat one cookie, I may as well have eaten ten
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
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Cognitive Model of Perfectionism Cognitive Biases
§ Dichotomous (all-or-nothing / black and white)
Self-Worth Overly Dependent
on Striving and Achievement thinking
§ Shoulds and musts
Performance-Related
Cognitive Biases Inflexible Standards Behaviors § Selective attention (noticing the negative;
discounting the positive)
§ Overgeneralization
Temporarily Meets Fails to Meet Avoids Trying to Meet
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)
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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
Maladaptive Evaluative Concerns
Self-Oriented Perfectionism
§ 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
Positive Striving
§ I seldom criticize my friends for accepting second best.
§ 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
overly disappointed or angry when my
§ Am I able to meet my standards? Do I get
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
§ What would be the benefits of relaxing a specific
don’t meet my standards?
standard or ignoring a rule that I have?
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Evidence-Based Strategies
INTRODUCTION TO Cognitive Strategies for Perfectionism
§  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)
§  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)
§  Frequency of sessions?
§  Progressive muscle relaxation (chronic worry)
§  Focus on perfectionism vs. focus on one or
§  Medications (anxiety disorders, OCD, depression)
more specific disorders (e.g., depression,
OCD)
Introducing the Treatment Sample 11-Session Protocol
§  Understanding perfectionism (e.g., 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.  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
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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
Components of Relapse Prevention
§  Develop an action plan, emphasizing strategies
CHANGING
that have been most helpful
§  Discuss realistic and compassionate expectations
PERFECTIOINISTIC
§  Catch problems early
§  Identify triggers for lapses and setbacks
§  Strategies for dealing with lapses and setbacks THINKING
§  Practice self-compassion
Egan, Wade, Shafran, & Antony, 2014
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, § Designed to promote more flexible,
while the other neighbor feels scared. They have adaptive, and realistic thinking.
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, 2014
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Perfectionism Myths
Cognitive Features
§  The harder people work, the better they will do.
§  To get ahead, you have to be single minded and give § All-or-nothing thinking
up all outside interests.
§ Unrealistic and inflexible standards
§  The more you put into something, the more you get
out of it. § Raising the bar when standards are met
§  People can’t be happy if they’re not successful. § Overestimating likelihood of negative
§  If I avoid it, it tends to sort itself out.
events
§  If a job’s worth doing, then it’s worth doing right.
§ Underestimating one’s ability to cope with
§  People notice every little detail and are quick to form
critical judgments. negative events
§ Being overly focused on details
Egan, Wade, Shafran, & Antony, 2014
Using Emotional Shifts to Elicit Thoughts
Changing Perfectionistic Thinking
Questions to ask oneself
§ Examining the evidence
§ What was going through my mind just
§ Education
before I started to feel this way?
§ Perspective shifting
§ What was I saying to myself?
§ Compromising with self and others
§ What images did I have?
§ Behavioral experiments
§ Changing social comparison habits § What was I predicting would happen in this
situation?
§ Looking at the big picture
§ Tolerating uncertainty and ambiguity § What does this say about me?
Examining the Evidence Examining the Evidence (continued)
§  What facts, data, and experiences support my §  Are there small things that contradict my
beliefs, predictions or interpretation? thoughts that I might be discounting?
§  Have I had any experiences to show that this §  Five years from now, as I look back on this,
thought is not completely true all the time? will I think about it any differently?
§  If my best friend had this thought, what would I
§  Am I blaming myself for something over
tell him or her?
which I have no control?
§  If someone who loved me knew I was thinking
this thought, what would he or she say to me?
§  When I am not feeling this way, does this sort
of situation look different to me?
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Identifying Double Standards
Cognitive Reappraisal
§ Do I have one set of rules for myself, and
§ Pie Chart Technique
another set of rules for other people?
§ Are the rules for myself harder than my
rules for others?
Egan, Wade, Shafran, & Antony, 2014
Challenging Double Standards Identifying Should Statements
§ Is it fair to have harsher rules for myself than for § What runs through my mind when I think of
everyone else? the “to do” list that I have to get through?
§ What is the impact of holding a different set of § How often do I say “should” and “must” to
standards for myself than for others?
yourself when I am thinking of everything I
§ What would Isay to a friend who had a harder set have to do?
of rules for him or herself than others?
§ How does it follow that rules need to be harder
for myself than for other people?
Egan, Wade, Shafran, & Antony, 2014 Egan, Wade, Shafran, & Antony, 2014
Perfectionism Thought Record
Challenging Should Statements
Event Beliefs Feelings Before Disputation Feelings After
What was the What went What was I feeling? What would a How do I feel
event, situation, through my mind? Rate 0 -100% friend say? now?
thought, image or What does it say Is there another
§  How does saying “should” to myself constantly memory? about me as a way of viewing this
person? Am I thought?
make mefeel? In what way does it impact on my using unhelpful
thinking styles?
sense of self? Rate 0 - 100%
! ! ! ! !
§  What impact might it have if I applied the sort of !!
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pressure I apply on myself to a close friend? !
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Egan, Wade, Shafran, & Antony (2014)
Egan, Wade, Shafran, & Antony, 2014
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