Abstract
First, this chapter provides a summary of the findings of the present studies and an implication for the adaptive and maladaptive aspects of perfectionism. Next, the advantage of the cognitive model of Self-Oriented Perfectionism is presented. This is followed by a clinical implication (treatment guide) for the patients whose central problem is perfectionism. Finally, the limitation of the present doctoral thesis and future direction are presented.
Adaptive and maladaptive aspects of perfectionism
In order to further clarify the relationship of SOP with psychopathology, the present doctoral thesis reports on how Self-Oriented Perfectionism (SOP) is associated with both adaptive and maladaptive consequences. Based on the current findings (see Table7.1), we discuss both the adaptive as well as maladaptive aspects of SOP.
First, Study 1 examined the relationship between SOP and Cloninger’s model of temperament. It was revealed that SOP was not associated with harm avoidance, which is considered to be the vulnerability for the development of mental disorders. The result suggests that SOP is not originally a maladaptive personality trait; however, other factors might be involved when SOP leads to maladaptive consequences.
Second, the cognitive model of SOP was developed to explain the manner in which SOP leads to both adaptive and maladaptive consequences. This model used the formulation of the ‘Dual model of perfectionism’ (Slade and Owens, 1998) and is consistent with the notions of other cognitive behavioural models of mental disorders (e.g. Beck, 1976; Wells & Matthews, 1994; Salkovskis, 1985). It was assumed that (1) in the presence of approach goals, positive perfectionism cognitions emerge from SOP to approach the reward for the individual, and this cognition leads to adaptive consequences and (2) in the presence of avoidant goals, negative perfectionism cognitions emerge from SOP to escape from punishment for the individual, and this cognition leads to maladaptive consequences.
Following this, Multidimensional Perfectionism Cognitions Inventory (MPCI) was developed (Study 2) and its psychometric characteristics were examined (Study 3). MPCI contains one positive perfectionism cognition (the cognition of Personal Standards (PS)) and two negative perfectionism cognitions (the cognitions of Concern over Mistakes (CM) and
Pursuit of Perfection (PP)).
Finally, the mediational role of perfectionism cognitions was investigated in Chapter IV. The results suggest that the cognition of PS would emerge only when individuals with SOP have approach goals, and this cognition would lead to positive affect (PA) and enhance the task performance. Further, the cognition of CM would emerge from SOP, and this cognition would become stronger when individuals with SOP faced avoidant goals (Studies 4 and 5). Study 6 demonstrated that negative perfectionism cognitions, particularly the cognition of PP, emerge from SOP to reduce uncertainty during decision-making and lead to excessive information gathering.
Table 7.1.
Summary of the chapters and the result of each study.
Chap. Contents
I A Brief review of the definition, assessment, adaptive and maladaptive aspects of perfectionism. This is followed by the objective of the doctoral thesis.
II
SOP was associated with low HS, high PS, and slightly high RD. However, SOP was not associated with HA, which is considered to be vulnerability for mental disorders.
In sum, it can be said that SOP is not originally a maladaptive personality trait;
however, certain other factors might be involved in the cases where SOP leads to maladaptive consequences.
III
Chapter III developed a cognitive model of SOP as well as the Multidimensional Perfectionism Cognitions Inventory. Study 2 confirmed the factor structure of the MPCI and obtained three subscales (Personal Standards, Concern over Mistakes, and Pursuit of Perfection). These subscales showed a good internal consistency and test-retest reliability, and the construct validity of the MPCI was confirmed in Study 3.
IV
Chapter IV tested the mediational role of the perfectionism cognition. The cognition of PS would emerge only when the individuals with SOP have approach goals and would lead to positive affect and enhance the task performance. In contrast, the cognition of CM would emerge from SOP, and this cognition would become stronger when the individuals with SOP face avoidant goals (Studies 4 and 5). Study 6 demonstrated that the negative perfectionism cognition, especially the cognition of PP, emerges from SOP and leads excessive information gathering in order to reduce uncertainty.
From these results, it can be said that SOP has an adaptive aspect under appropriate circumstances. For example, the experimental setting of Study 5 actualized circumstances in which the individual was faced with only the approach goals and had nothing to lose.
However, we must be careful while saying that SOP has an adaptive aspect because such circumstances are rare in real life. First, approach goals could turn into avoidant goals depending on various conditions. For example, individuals may set high standards to pursue success in business, but they may end up worrying about making mistakes in the same business after failing to achieve their standards and after being criticized by co-workers. Depression could also affect the perception of their goals by causing them to focus on what will be lost rather than focusing on what will be gained. Second, some approach goals could lead to the cognitions of CM as well as PS. For example, goals that are too high or too abstract (e.g. being loved by everyone or developing a perfect appearance) could be appetitive for the individual, but he or she would focus on mistakes or failures because of the lack of feedback that indicates how close he or she is to the goal. This could be one of the reasons why the present studies found that PS had positive correlations with CM and PP. Finally, we are uncertain whether the cognition of PS reflects a ‘healthy pursuit of excellence’, which is found in normal populations, or a ‘successful meeting of standards’, which leads to the temporal improvement of self-evaluation found in perfectionists with mental disorders (e.g. Shafran et al., 2002). In other words, it remains unclear whether this aspect of SOP is actually functional in the long run because clinical perfectionists re-appraise their standards as being too low and insufficiently demanding and heighten the standards as soon as they successfully meet them (Shafran et al., 2002).
The findings of maladaptive aspects of SOP could shed light on the current controversy with regard to perfectionism. First, Study 5 suggests that individuals with SOP would be more concerned about mistakes than those without SOP, but the magnitude of this concern would be moderated by avoidant goals. This suggests that perfectionists want to be perfect in several life domains (Hewitt et al., 2003), but the magnitude of perfection would be different depending on the importance that individuals attribute to the goals. Thus, for the treatment of perfectionism, it is important that we identify the most important goal of the patient.
Second, although Hewitt et al. (2003) believe that it is vital to distinguish the self-evaluative reactions to failure from the perfectionism construct, Study 5 showed that SOP was not strongly associated with NA but that CM mediated these two variables. In other words, the reaction to mistakes or failures cannot be separated from the perfectionism construct. This notion is similar to clinical perfectionism (Shafran et al., 2002), which emphasizes the impact of self-imposed
standards on self-evaluation. Finally, the interpersonal aspects of perfectionism (e.g., Socially Prescribed Perfectionism) can be understood within the self-oriented perspective. For example, individuals with SOP could set high standards or could be concerned about mistakes in order to win approval from others (approach goal) or to avoid being rejected by them (avoidant goal).
In sum, it can be said that (1) SOP is not an originally maladaptive personality trait, (2) SOP has an adaptive aspect only under appropriate circumstances, and (3) SOP leads to maladaptive consequences mediated by the negative perfectionism cognitions.
Advantage of the cognitive model of SOP
This section documents the advantages of the cognitive model of SOP in comparison with the existing models of perfectionism.
The most acknowledged models of perfectionism are those of Frost et al. (1990) and Hewitt and Flett (1991). Their models are known as personality orientation models (Hewitt et al., 2003) and have corresponding self-report measures. However, as discussed in Chapter I, their models and measurement scales have been criticized due to the concept of perfectionism and clinical irrelevance. Additionally, their models cannot fully explain the adaptive aspects of perfectionism. Although past researches have shown that certain dimensions of perfectionism (e.g. PS, Organization, and SOP) are sometimes associated with adaptive variables, it remains unclear as to how and when perfectionism demonstrates its adaptive aspects; the way in which the adaptive aspects are related to the maladaptive aspects of perfectionism also remains unclear.
With an emphasis on the clinical relevance, Shafran et al. (2002) proposed ‘clinical perfectionism’ and described a variety of processes that maintain this dysfunctional
perfectionism. They defined the concept of clinical perfectionism as ‘the overdependence of self-evaluation on the determined pursuit of self-imposed personally demanding standards of performance in at least one salient domain, despite the occurrence of adverse consequences’. In addition, the cognitive process of clinical perfectionism incorporates not only the adaptive aspects of perfectionism but also the counter result of these adaptive aspects. Although this model has high usability among the clinical populations, it has several limitations: (1) since it is circumscribed within clinical populations (particularly to patients suffering from eating
disorders), the validity and application of the model is also restricted; (2) this model has not been empirically examined partly because it has a number of cognitive processes and the causal relationships are complicated.
The current formulation of perfectionism (i.e. the cognitive model of SOP) has several
advantages in comparison with the above-mentioned existing models.
First, the cognitive model used SOP (Hewitt & Flett, 1991). Despite the controversy regarding the concept and measurement of perfectionism, SOP is considered to be close to the construct most often referred to as perfectionism by clinicians and theorists attempting to define the construct (e.g. Blatt, 1995; Burns, 1980; Hamachek, 1978; Hollander, 1965; Shafran &
Mansell, 2001). In addition, the cognitive model of SOP contains perfectionism cognitions (Chapter III). All perfectionism cognitions are ongoing conscious thoughts about the current state of self. In other words, every perfectionism component of the cognitive model reflects current beliefs, behaviours, and thoughts about the self, excluding the past state of self or others’ expectations towards the self. This guarantees that the concept and measurement of the cognitive model is consistent with the appropriate definition and the construct of perfectionism.
Second, the cognitive model of SOP explains the manner in which perfectionism leads to both adaptive and maladaptive consequences: (1) In the presence of approach goals, positive perfectionism cognitions emerge from SOP to approach the reward for the individual, and this cognition leads to the adaptive consequences; and (2) in the presence of avoidant goals, negative perfectionism cognitions emerge from SOP to escape from punishment for the individual, and this cognition leads to maladaptive consequences. These processes were not only theoretically driven (e.g. a dual process model of perfectionism by Slade and Owens) but also feasible for being empirically examined.
Most of the existing models of perfectionism (particularly Frost et al., 1990; Hewitt &
Flett, 1991) consider perfectionism to be a personality trait. In other words, it is an individual difference that is stable across time and space. In other words, individuals with perfectionism attempt to be perfect or perform perfectly at any given time. In contrast, the current cognitive model incorporates situational factors (i.e. goals) and suggests that individuals with perfectionism attempt to be perfect or perform perfectly to some extent, but the magnitude of this perfectionism is moderated by goals. Additionally, the cognitive model of SOP suggests that individuals with perfectionism would experience both adaptive and maladaptive consequences of perfectionism depending on the goals of the person (i.e. approach or avoidant goals). However, in case the person continuously has avoidant goals, he experiences only maladaptive consequences and the adaptive aspect of perfectionism diminishes. In such cases, perfectionism can be observed as a maladaptive trait.
Finally, the interpersonal aspects of perfectionism (e.g. socially prescribed perfectionism) can be understood within the self-oriented perspective. Hewitt et al. (2003) insist that interpersonal aspects are the core features of perfectionism, and patients with perfectionism perceive pressures to be perfect and attempt to win the approval and acceptance of others. In
contrast, Shafran et al. (2002, 2003) returned to the unidimensional approach and circumscribed perfectionism within a clinical construct. They suggest that the intrinsic feature for the maintenance of clinical perfectionism is that personally demanding standards are self-imposed and adopted by the person as their own. In the current cognitive model of SOP, it can be said that individuals with SOP could set high standards or could be concerned about mistakes in order to win approval from others (approach goal) or to avoid being rejected by them (avoidant goal).
In sum, the advantages of the cognitive model of SOP are that (1) it uses an appropriate concept of perfectionism and is formulated based on the theory, (2) it incorporates situational factors and explains the manner in which perfectionism leads to both adaptive and maladaptive consequences, and (3) the interpersonal aspects of perfectionism can be consistently understood within the self-oriented model of perfectionism.
Clinical implication: Treatment guideline for perfectionism
Perfectionism is found in many patients with mood disorders, anxiety disorders, and eating disorders. This section outlines the clinical implication for perfectionism based on the cognitive model of SOP. It also presents a case example (the case is a combination of several patients that the author had seen in psychiatric hospitals; informed consent was obtained from all the patients before disclosing their information). The intervention for perfectionism contains the following five elements (Table 7.2).
1. Psycho-education
First, both the therapist and patient need to agree that perfectionism is a central problem for the patient and that perfectionism maintains his symptom (e.g. depression or anxiety). They also need to agree that cognitive behavioural therapy mainly focuses on perfectionistic cognitions and behaviours. It might be useful to inform patients that perfectionism sometimes leads to adaptive consequences under appropriate circumstances, and thus it is difficult for them to recognize that perfectionism is their central problem. This notion is consistent with the findings of the cognitive model of SOP but is also helpful in enhancing the therapeutic relationship between the therapist and patient. Following this information, patients might disclose to the therapist that they have attempted to be perfect for a long time and that they sometimes had rewarding experience owing to their perfectionism (e.g. academic achievement).
2. Identification of Avoidant Goals
The cognitive model of SOP suggests that the avoidant goal leads to negative perfectionism cognitions and that their magnitude is moderated by SOP (perfectionism personality). The next step is to identify the most salient avoidant goal for the patient. The patient might have several avoidant goals that are equally salient for him. In such a case, the therapist and the patient categorise the areas pertaining to these goals and discuss the goal that is most appropriate to be worked on first. After identifying the avoidant goal, it needs to be elaborated and redefined.
For example, consider the case of a patient in his 30s, a company employee, who was diagnosed as having major depression. Despite being on medication, he repeatedly took sick leave because he felt he could not handle his work assignment. Since it appeared to the therapist that perfectionism was his central problem, the therapist and the patient identified his avoidant goal and found that he wanted to escape the thought of ‘failing in the project’. They also specified the exact meaning of ‘failing in the project’ and redefined it as ‘the situation where he could not handle his assignment efficiently, leading to the cancellation of the project owing to his delay’.
Table 7.2.
Treatment guideline for the patients whose central problem is perfectionism
1. Psycho-education (1) Agree that perfectionism is a central problem for the patient (2) Explain that perfectionism sometimes lead to adaptive
consequences under appropriate circumstances 2. Identification of
Avoidant Goals
(1) Identify the avoidant goal to be worked on first (2) Elaborate and redefine the avoidant goal 3. Examination of the
avoidant goal
Decrease the significance of what the patient avoids (1) Awfulness: How serious if it happens?
(2) Frequency: How often does it happen?
(3) Coping: How do you or others cope with it?
(4) Support: Is there any resource that helps you?
4. Restructuring Perfectionism Cognitions
(1) Examination of the impact of the mistake (2) Restructuring of the standard setting (3) Looking at advantages of making mistakes
(4) Behavioural experiments to confirm alternative cognitions
5. Personality Focused Approach
(1) Identify the time when the patient’s perfectionism started (2) Explore the reason behind perfect behaviour
(3) Remind the patient of the fact that there is no need to be perfect any more
3. Examination of Avoidant Goals
The avoidant goal needs to be examined before working on perfectionistic cognitions and behaviours. This technique applies the simple formulation of anxiety (Beck, Emery, &
Greenberg, 1985). The therapist considers four elements that might be useful in decreasing the significance of the goal. If the avoidant goal is ‘failing in the project’, the therapist may ask the following four questions to decrease the significance of the avoidant goal.
(1) Awfulness: How serious would it be if the project fails? The patient might find that the company has many different projects and that the failure of one project would not be an extremely serious problem.
(2) Frequency: How often do you delay your work and how often does the project fail because of your delay? The patient might remember that most of the time he finishes his work on time and that a project can fail due to many different reasons.
(3) Coping: How do you cope when you handle your work? After consulting with the therapist, the patient will understand how to work efficiently (time estimation, make the work easier by breaking it down into smaller tasks, taking rest when tired, etc.).
(4) Support: Is their any resource that will help you? The patient might find co-workers who can be easily approached with regard to work or who are most familiar with the work. It is sometimes helpful to suggest to the patient that consulting co-workers is beneficial not only for the patients but also for their co-workers and the project.
4. Restructuring Perfectionism Cognitions
The patients might stick to perfectionistic thinking even after the decreased significance of the avoidant goal. For example, they might say ‘now I know that failing in the project does not bother me so much, but I still think that I feel miserable if I make a mistake, so I must do it perfectly’. The therapist should address the following four issues in order to restructure the perfectionistic thinking.
(1) The therapist and patient should examine the impact of mistakes on the patient’s self-evaluation. The therapist may ask questions like ‘how much of an aversive effect does your mistake have on the project’? or ‘how will your co-workers react to your mistake’? The patient might find that making mistakes does not impact his self-evaluation to the extent that he expected.
(2) Next, the therapist and patient should discuss what constitutes a perfect
performance. The patient may define it as the situation where nobody makes a mistake and the project finishes without any delay. The therapist may make the following suggestion: ‘It is just my opinion, but people may think that perfect performance is the situation in which the project ends WITH several mistakes or errors because projects usually allow time for sudden emergency or some margin for errors’. The patient may find that his standard was significantly higher than what others would expect.
(3) Following this, the therapist should offer the advantages of making mistakes. For example, the therapist may suggest the possibility of people finding new ideas or solutions after making mistakes and the possibility of the project being completed with better results. It is sometimes useful to suggest that making mistakes occasionally makes people likeable.
(4) Finally, the therapist should assign homework to the patient to confirm his alternative cognition in daily life. The alternative cognition might be that ‘it is better not to make a mistake, but I’m not miserable if I make a mistake’. The patient attempts not to be perfect or perform perfectly and examines whether or not the alternative cognition is true. In case of the treatment for the patient with obsessive-compulsive disorder (OCD), Exposure and Response Prevention (ERP) should be introduced at this point. ERP may be carried out in the session room, and the patients should continue ERP on a daily basis in their home.
5. Personality Focused Approach
The final step is to work on the perfectionism personality. This step is taken based on the schema-focused approach (e.g. Young, 1999). In other words, the therapist considers the patients’ perfectionism as a maladaptive schema maintained for a long time since childhood.
The therapist asks patients when they began behaving perfectly. The patients may recall that their perfectionism originated in their childhood. If the therapist probes for the reason behind their perfect behaviour, the patients may disclose that they were criticized or even abused by their parents if they failed to meet the latter’s expectations. They may discover that since then they regarded themselves as bad, unlovable, or incompetent; as a result, they had to be perfect or behave perfectly.
This is when the therapist needs to empathize that children are often assigned roles in families that are not in the children’s best interest but because these roles serve the psychological need of one or both the parents. These roles do not reflect any inherent flaws in the children, but are rather the result of distorted family dynamics. The therapist often examines each family member individually, with the patients’ help, until the therapist can shift the patients’ perspective on their early family experience to a more realistic one. By the end of this process, the therapist hopes that the patients will experience sadness or anger over what
happened to them in childhood but refrain from considering these early experiences as proof of their unlovability, flaw, incompetence, or badness.
Finally, the therapist helps the patients to recognize that the standards imposed by their parents were not realistic and that they have internalized them and also that they continue to maintain these high standards. Following this, the therapist may remind the patients of the fact that they are no longer under the control of their parents and that hardly anyone criticizes or abuses them even if they cannot perform perfectly.
Limitations and future directions
The present research also has limitations, and many important research issues remain open to empirical investigation. First, the sample size was limited to Japanese college students.
Further research should be conducted with larger groups and more diverse populations (e.g.
younger/older generations and other ethnic groups).
Second, little is known about the perfectionism cognitions that differ between patients and normal controls who have similar SOP scores (Antony, Purdon, Huta, & Swinson, 1998).
Future research could examine whether certain types of perfectionism cognitions would differentiate some mental disorders from others.
Third, the interpersonal aspects of perfectionism also need to be examined using the framework of the cognitive model of SOP. For example, individuals with SOP would set high standards in order to win approval from others (approach goal) and would be concerned about mistakes in order to avoid being rejected by them (avoidant goal).
As discussed in the ‘adaptive and maladaptive aspects of perfectionism’ section in Chapter V, it is also important to empirically examine whether some approach goals could be maladaptive (particularly on a long-term basis). Using the experimental method, it should be examined whether (1) approach goals could turn into avoidant goals depending on conditions and (2) whether goals that are too high or too abstract would make the individual focus on mistakes or failures.
Finally, a clinical trial should be conducted in order to examine the clinical validity of the cognitive model of SOP. The treatment guideline presented above would be helpful while working on a wide range of patients whose central problem is perfectionism. Using the treatment guideline, we need to assess the perfectionism cognitions (MPCI) and perfectionism personality (SOP) before treatment and observe how these variables fluctuate with the treatment progress. It is expected that perfectionism cognitions would first begin decreasing with the improvement of the symptom. This would be followed by a reduction in SOP, which is
considered to be the patients’ core belief.
Acknowledgements
I would like to thank and express my heartfelt appreciation to my research supervisor Dr Tanno for his assistance. I am also grateful to our course professors Dr Shigemasu, Dr Hasegawa, Dr Murakami, Dr Hoshino, and Dr Kawashima for their valuable comments and feedbacks. Finally, I take this opportunity to thank Dr Harada (National Centre of Neurology and Psychiatry) for supervising my clinical practice.
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