A randomized controlled trial of acceptance and commitment therapy for clinical perfectionism

doi:10.1016/j.jocrd.2019.100444

Journal of Obsessive-Compulsive and Related Disorders

Volume 22, July 2019, 100444

https://doi.org/10.1016/j.jocrd.2019.100444 Get rights and content

Highlights

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We tested the effectiveness of ACT for clinical perfectionism.
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ACT outperformed a waitlist control on clinical perfectionism and other outcomes.
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Targeting maladaptive processes rather than symptoms may be effective.

Abstract

Clinical perfectionism is characterized by imposing excessively high standards on oneself and experiencing severe distress when standards are not met. It has been found to contribute to the development and maintenance of various clinical presentations including anxiety, obsessive-compulsive, and eating disorders. The present study tested the efficacy of ten weekly individual sessions of acceptance and commitment therapy (ACT) relative to a waitlist control on clinical perfectionism and global outcomes among 53 individuals with clinical perfectionism. ACT is a process-based therapy that targets maladaptive underlying processes (e.g., rigid adherence to unrealistic high standards) rather than symptom topography (e.g., anxiety, depression). Participants completed assessments at pretreatment, posttreatment, and one-month follow-up. Compared to the waitlist condition, the ACT condition led to greater improvements in clinical perfectionism as well as outcomes related to wellbeing, functional impairment, distress, and processes of change. Our study suggests targeting core dysfunctional processes (i.e., clinical perfectionism) rather than symptom topography with treatments like ACT is feasible and efficacious, supporting a shift from symptom-focused to process-based care. We also note potential weaknesses in our treatment protocol and study methodology that should be addressed in future research. Study limitations included a small sample size and high dropout rate (35.7%).

Section snippets

Participants

Participants were recruited from a western U.S. town using newspaper advertisements, flyers posted in the community and on the local university campus, and announcements in university classes. Recruitment materials specified intervention targets as “procrastination, spending a lot of time planning/organizing, and difficulty starting/completing tasks because you need to get them exactly right.” Inclusion criteria were: (1) score of at least five on the Dimensional Obsessive-Compulsive Scale

Screening measure

Dimensional Obsessive-Compulsive Scale (DOCS)—Symmetry (Abramowitz et al., 2010). This five-item subscale assesses severity of avoidance, distress, and interference due to a perceived need to make things “just right” (Abramowitz et al., 2010). Examples of this type of avoidance and/or distress include a perceived need for “symmetry, evenness, balanced, or exactness” and behavioral repetition to obtain a feeling of being “just right” or “balanced.” Given the overlap between rigid pursuit of a

Sample descriptives

Mean age of the sample was 25.4 years (SD = 12.3). The majority of participants identified as female (74%), European American (85%), single (74%), and members of The Church of Jesus Christ of Latter-day Saints (79%; see Table 1 for details). The most common DSM-5 diagnoses assigned were OCPD, GAD, and OCD. There were no significant differences between groups on demographic, outcome, or process variables at pretreatment (see Table 1). There were significantly more participants diagnosed with GAD

Discussion

Our findings indicate ACT was superior to a waitlist control condition on clinical perfectionism, psychological functioning, and processes of change from pretreatment to follow-up. Within-group improvement over time was significant for all outcomes, further supporting the efficacy of ACT with respect to clinical perfectionism and global outcomes. In addition, the observed effect sizes are comparable to those obtained from CBT treatment trials for clinical perfectionism (Egan et al., 2014;

Conflicts of interest

Declarations of interest: none.

Funding source

This study was supported by a grant from the International OCD Foundation.

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Acceptance and Commitment Therapy (ACT) is an empirically supported treatment for a variety of clinical concerns and has over 1000 randomized controlled trials (RCTs). ACT may be a potentially effective treatment for racial, sexual orientation and gender diverse people who experience unique stressors related to their identities and higher rates of psychopathology and have unique mental health considerations. Despite this, there remains a lack of inclusion of reporting and inclusion of these communities in psychological research. This lack of inclusion of minority populations limits the generalizability of the findings of RCTs to those populations. Further, although there is a growing number of minority graduate students and trainees, this increased diversity often does not extend to their principal investigators. The current study reviews racial, sexual, and gender minority inclusion of participants as well as of principal investigators in 75 ACT RCTs performed in the United States (n = 10,914). Of these, 73% were White, 11% were Black, 5% were Latine, 3% were Asian, 2% were Native American, 0.4% were Pacific Islander, 0.1% were Middle Eastern, and 3% were multiracial while 1% were reported as Other and another 1% as Unknown. Of the 75 studies reviewed, 5 reported on sexual orientation and 73% of participants were heterosexual, 7% were gay or lesbian, 5% were bisexual, 2% were pansexual, 4% were asexual, 1% were queer, 1% were questioning, and 1% were reported as Other and 7% as Unknown (n = 297). Only two studies reported on gender identity beyond men and women, with one study including all cisgender participants and one study reporting that 2% of participants were nonbinary. Of the 32 PIs that responded, 94% were White, 2% were Mixed, and 2% were Asian. In terms of sexual orientation and gender identity, one PI was gay, one was asexual, and cisgender women authored 26% of studies. These results indicated that despite Black participants being more accurately represented, Latine and Asian participants were largely underrepresented. Regardless of level of representation, the numbers of racial, sexual, and gender minority participants were still limited and therefore conclusions cannot be made about the generalizability of ACT for these populations. Recommendations for more inclusive practices are provided. We discuss limitations to this review and the implications of PI refusal to report their sexual and gender identity.
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A Randomized Test of Interpretation Bias Modification for Perfectionism Versus Guided Visualization Relaxation Among High Perfectionistic Undergraduate Students
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Clinical perfectionism contributes to the onset and maintenance of multiple psychological concerns. We conducted a randomized, longitudinal test of the efficacy of a web-based intervention for perfectionism (specifically, cognitive bias modification, interpretation retraining; CBM-I), compared to an active treatment comparison condition (specifically, guided visualization relaxation training) for reducing perfectionism and related psychopathology. College students (N = 167) with elevated perfectionism were randomized to one of the two study conditions and were asked to complete their assigned intervention twice weekly for 4 weeks. Participants completed measures of perfectionism and psychological symptoms at baseline, 2 weeks (midway through the intervention period), 4 weeks (at the conclusion of the intervention period), and 8 weeks (1 month follow-up). CBM-I was rated as acceptable overall, though relaxation training was rated slightly more favorably. CBM-I outperformed relaxation training on improving perfectionism-relevant interpretation biases (i.e., increasing nonperfectionistic interpretations and decreasing perfectionistic interpretations), though with small effect sizes and inconsistency across study timepoints. Self-reported perfectionism showed small decreases across time in both intervention conditions. Support was found for a key hypothesized mechanism of CBM-I, such that randomization to CBM-I had a longitudinal, indirect effect on decreasing psychopathology symptom scores through improving perfectionism-relevant interpretation biases. However, in light of small effect sizes, the present study failed to provide compelling evidence that CBM-I for perfectionism contributes meaningfully to the treatment of perfectionism.
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Citation Excerpt :
This unique circumstance could have suppressed well-being scores, even though participants were seeing improvement in perfectionism and psychological skills. Furthermore, previous perfectionism trials reported less change in quality of life measures relative to symptom-focused measures at follow-up assessments (e.g., Egan et al., 2014; Ong et al., 2019), suggesting that well-being may be more difficult to change, especially over shorter periods of time (e.g., length of a research study), in this population. The PBT model requires processes of change to be malleable by available methods and relevant to personally meaningful outcomes.
Process-based therapy (PBT) is model of psychotherapy designed to improve people's ability to use a variety of skills from evidence-based treatments to match environmental needs and personal goals in the moment. This randomized trial tested the effect of an online self-help intervention modeled after PBT principles for participants with perfectionism (N = 77). The intervention comprised two four-session trainings teaching skills from different evidence-based treatments (e.g., cognitive-behavioral therapy, acceptance and commitment therapy) and targeting cognitive and motivational processes: (1) cognitive training and (2) motivational training respectively. Participants completed 17 assessments throughout the intervention and at 3- and 6-month follow-up. Results indicated that the full intervention led to improvement in perfectionism, self-compassion, psychological distress, and cognitive skills targeted by the cognitive intervention (e.g., cognitive defusion; absolute βs = 0.02 to 0.66). In addition, the second four-session training (i.e., training after first four-session training) was associated with improvements in perfectionism, self-compassion, quality of life, and psychological distress (absolute βs = 0.09 to 2.90), suggesting it had incremental benefit. Whereas the cognitive training appeared to specifically impact cognitive processes, the motivational training increased both cognitive and motivational processes. These findings provide initial support for the feasibility and efficacy of a process-based approach, because they show that participants can benefit from learning skills from different orientations and applying them with reference to their goals. However, specific aspects of the PBT model, including whether interventions can precisely improve targeted skills, still need to be empirically tested in larger and more diverse clinical samples.
The acceptability of cognitive analytic therapy (CAT): Meta-analysis and benchmarking of treatment refusal and treatment dropout rates
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Meta-analyses of treatment refusal and dropout rates for other psychotherapies provided comparison benchmarks for the pooled CAT refusal and dropout rates. An electronic search of literature databases for recent meta-analyses of therapy dropout produced five reviews reporting specific therapy pooled dropout rates for CBT (Fernandez et al., 2015), dialectical behaviour therapy (DBT; Dixon & Linardon, 2020), interpersonal psychotherapy (IPT; Linardon, Fitzsimmons-Craft, Brennan, Barillaro, & Wilfley, 2019), schema therapy (ST; Gülüm, 2018) and acceptance and commitment therapy (ACT; Ong et al., 2019). The most recent overall review of dropout from adult psychotherapy and/or pharmacotherapy was also included to provide a general overview (Swift et al., 2017).
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PROSPERO registration CRD4202017081. Systematic searches found CAT treatment studies reporting treatment refusal and dropout rates. Studies were narratively and quantitatively synthesised in a proportional random-effects meta-analysis and moderator analyses were performed. Secondary analyses compared refusal and dropout rates for CAT versus other psychotherapies via direct comparisons in the original studies and via benchmarking these rates against other acceptability meta-analyses for other psychotherapies.
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For these latter outcomes, 5/6 participants experienced gains in the expected direction, indicating relatively less consistent effects on these variables. This finding somewhat contradicts research showing significant improvements in wellbeing and psychological inflexibility following ACT for conditions related to HD (e.g., perfectionism, anxiety; Arch et al., 2012; Ong et al., 2019); this discrepancy may be explained by the experimental nature of the current intervention. More modifications to the current protocol to emphasize flourishing may be needed.
Hoarding disorder (HD) is associated with distress and functional impairment not only for the individual but also for their family members and community. Acceptance and commitment therapy (ACT) already has broad empirical support and may be helpful for treating HD. In this nonconcurrent multiple baseline study (N = 6), we examined the effect of ACT on HD symptom severity, functional impairment, quality of life, co-occurring symptoms, and other outcomes. Participants consistently reported decreases in HD severity, clutter, functional impairment due to clutter, and depression at posttreatment. Scores were maintained at follow-up for two of three participants. Changes in other variables like quality of life and psychological inflexibility were less consistent. Overall, our findings preliminarily support the efficacy of ACT for HD especially for symptom severity, but the reliability of its effect on other outcomes like quality of life and psychological inflexibility is unclear. Limitations include a homogeneous (100% White women) sample.

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A randomized controlled trial of acceptance and commitment therapy for clinical perfectionism

Highlights

Abstract

Section snippets

Participants

Screening measure

Sample descriptives

Discussion

Conflicts of interest

Funding source

Personality and Individual Differences

Behavior Therapy

Behavior Therapy

Behaviour Research and Therapy

Clinical Psychology Review

Behaviour Research and Therapy

The Lancet Psychiatry

Behaviour Research and Therapy

Behaviour Research and Therapy

Clinical Psychology Review

Personality and Individual Differences

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Clinical Psychology Review

Behaviour Research and Therapy

Journal of Contextual Behavioral Science

Eating Behaviors

A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems

Psychotherapy and Psychosomatics

Assessment of obsessive-compulsive symptom dimensions: Development and evaluation of the dimensional obsessive-compulsive scale

Psychological Assessment

Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders

Journal of Consulting and Clinical Psychology

Fitting linear mixed-effects models using lme4

Journal of Statistical Software

The quality of life scale (QOLS): Reliability, validity, and utilization

Health and Quality of Life Outcomes

Perfectionism and treatment outcome in obsessive-compulsive disorder

Cognitive Therapy and Research

Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: Outcomes and moderators

Journal of Consulting and Clinical Psychology

Structured clinical interview for DSM-5 disorders, clinician version (SCID-5-CV)

A research approach to improving our quality of life

American Psychologist