A meta-analytic test of the efficacy of cognitive behavioural therapy for perfectionism: A replication and extension.

Abstract

Meta-analyses conclude that cognitive behavioural therapy (CBT) for perfectionism is efficacious without addressing indices of efficacy such as reliable improvement, deterioration, dropout, and change at follow-up. We addressed this through a reanalysis of the 16 randomized controlled trials included in Galloway et al. (2022), Robinson andWade (2021), andSuh et al. (2019). At posttreatment, small-to-large effects favouring CBT were found for certain perfectionism measures: high standards (g = −0.40), doubts about actions (g = −0.49), personal standards (g = −0.50), concern over mistakes (g = −0.85), and clinical perfectionism (g = −0.97). Small-to-medium posttreatment effects were found for symptoms of eating disorders (g = −0.29), anxiety (g = −0.37), and depression (g = −0.62). In contrast, self-oriented perfectionism (g = −0.60; 95% CI [−1.96, 0.78]), other-oriented perfectionism (g = −0.36; 95% CI [−1.15, 0.43]), socially prescribed perfectionism (g = −0.53; 95% CI [−1.58, 0.51]), perfectionistic cognitions (g = −0.70; 95% CI [−1.57, 0.17]), discrepancy (g = −0.48; 95% CI [−1.83, 0.87]), life satisfaction (g = −0.59; 95% CI [−1.02, 0.01]), and self-esteem (g = −0.53; 95% CI [−1.25, 0.18]) did not differ between treatment and control conditions. Risk ratios for reliable improvement were significant for perfectionistic cognitions (RR = 1.46), concern over mistakes (RR = 2.36), and clinical perfectionism (RR = 3.07). Dropout was 27.0% and higher in treatment than control conditions (RR = 1.78). At follow-up, all between-group effects were nonsignificant. Findings support the efficacy of CBT for certain perfectionism features while underscoring crucial limitations and areas for improvement. Public Significance StatementThe importance of evaluating treatments for perfectionism is crucial given the deleterious effects of this personality variable. Although there are indications that CBT for perfectionism is efficacious, the current work indicates that a substantial proportion of participants do not experience reliable posttreatment improvements. Moreover, for those who experience improvements, it is unclear how much improvement extends beyond posttreatment. Dropout also appears higher in treatment conditions than in control conditions, suggesting that CBT for perfectionism might not be well tolerated by many individuals with perfectionism. Developing and refining treatment for perfectionism is urgently needed.

Towards high standards of evidence for cognitive behaviour therapy for perfectionism: A critique of Smith et al. (2023).

“…The definition of dropout used, that is, "all randomized participants who did not complete posttreatment measures regardless of whether they started treatment or the reason for dropout" (p. 358) combines "decliners" who verbally accept randomization but do not attend the first session (e.g., because they were randomized to a condition they did not like), "dropouts" who had at least one session but fewer than the number of sessions defined as therapy completion, and "no shows" who completed treatment but for various reasons failed to come to postassessment. While study dropout for any reason has been used in some meta-analyses, this reflects dropout, not tolerance, as Smith et al (2023) incorrectly conclude.…”

“…Omission of Studies That Were Included in the Previous Meta-Analyses Which Were Reexamined Smith et al (2023) state that their meta-analysis is a replication and extension of three previous meta-analyses (Galloway et al, 2022;Robinson & Wade, 2021;Suh et al, 2019); however, it is problematic that they omitted two previous randomized controlled trials (RCTs;Pleva & Wade, 2007;Wilksch et al, 2008) that were included in these meta-analyses, despite their footnote that they did not exclude any studies. The three previous systematic reviews Smith et al (2023) aimed to replicate (Galloway et al, 2022;Robinson & Wade, 2021;Suh et al, 2019) applied different inclusion and exclusion criteria across the reviews, searched for studies with different outcomes, searched in different databases, some but not all included the gray literature, and have different search dates. Therefore, simply equating the studies included in independent systematic reviews into one's own review and metaanalysis is not a standardized strategy.…”

Empowering self-critical perfectionistic students: A waitlist controlled feasibility trial of an explanatory feedback intervention on daily coping processes.

“…This randomized controlled feasibility study found further support for the EFI derived from the PCPM (Dunkley, 2017), with individualized feedback delivered in-person and online by student research assistants to individuals with higher SC perfectionism. Considering that longer perfectionism interventions (Shafran et al, 2023) are not well tolerated by many individuals with perfectionism (Smith et al, 2023), our findings suggest that the single-session PCPM-EFI can have broad applicability, conceptual utility, and effectiveness for perfectionistic individuals.…”

“…The single-session EFI might instigate and support important processes of change and allow for more effective tailoring of therapeutic interventions (Schleider et al, 2020), rather than relying on symptom-based, "one size fits all" treatment protocols characterized by extreme comprehensiveness (e.g., CBT). The EFI might also help focus CBT interventions for perfectionism on one to three treatment elements rather than eight or more separate modules, which require sustained effort over several weeks (Shafran et al, 2023), resulting in low engagement and dropout (Smith et al, 2023). The feedback entertaining multiple mechanisms at multiple levels has the advantage of increased flexibility in interventions (e.g., shifting between different mechanisms to align with the situation and/or individual preferences; Kuyken et al, 2009).…”

“…To improve evidence-based practice, it is critical to address person-centered explanatory questions (e.g., “Why does this individual keep having difficulties?”) that are essential to help achieve two overarching therapy goals of reducing clients’ distress and bolstering resilience (Kuyken et al, 2009). Further, single-session interventions (Schleider et al, 2020) might be timely because many participants with perfectionism drop out from interventions with many modules over several weeks, such as cognitive behavioral therapy (CBT) for perfectionism (Smith et al, 2023). The present study tested a single-session, individualized explanatory feedback intervention (EFI), which was derived from the perfectionism coping processes model (PCPM; see Dunkley, 2017).…”