Automatic Self Recriminations: Development and Validation of a Measure of Self-Condemnatory Internal Dialogue.

This article introduces a measure of self-condemnatory internal dialogue as an element of the relationship with the self: The Automatic Self-Recrimination Scale (ASRS). Using the construct validation approach to test construction, we describe the initial development of items and report on findings from a clinical and nonclinical sample showing the ASRS is best understood as a multidimensional measure of self-critical internal dialogue composed of one higher-order factor and four lower-order facets: Not Mattering, Self as Failure, Undeserving Self, and Loathsomeness. The overall scale and four subscales demonstrated acceptable internal consistency and test-retest reliability. Moreover, there was evidence of good convergent and incremental validity of the ASRS subscales with measures of perfectionism, self-criticism, and dysfunctional attitudes. Overall, the ASRS appears to be a reliable and valid measure of an automatic self-recriminatory internal dialogue.

A comparison of the effect of two types of brief psychodynamic group therapy on perfectionism-related attitudes, self-relatedness, and self-esteem.

Objective: This randomized controlled trial investigated the efficacy of dynamic relational group therapy (DRT) relative to group psychodynamic supportive therapy (PST) in improving perfectionism-related attitudes and components of the perfectionistic self-relationship. Method: Based on a comprehensive conceptualization of perfectionism, 80 community-recruited, highly perfectionistic individuals were randomly allocated to 12 sessions of group DRT (n = 41; 5 groups) or group PST (n = 39; 5 groups). Patients completed measures of dysfunctional attitudes, self-criticism, self-esteem, and self-reassurance at pre-, mid-, and post-treatment, and six months post-treatment. Results: Multigroup latent growth curve modeling revealed significant (p < .05) decreases in dysfunctional attitudes, concern over mistakes, two types of self-criticism, and self-esteem problems, along with a significant increase in self-reassurance, from pre-treatment to six-month follow-up in both DRT and PST. Moderate-to-large between-group differences favoring DRT over PST were found for dysfunctional attitudes and self-reassurance. A majority of patients in both conditions maintained reliable improvement at six-month follow-up in dysfunctional attitudes, concern over mistakes, and self-criticism focused on inadequacy. Conclusion: Findings provide evidence for the use of psychodynamic group therapy approaches in treating perfectionism-related attitudes and self-relational elements of perfectionism, and support the relative efficacy of DRT for dysfunctional attitudes and self-reassurance.

Dynamic-relational treatment of perfectionism: An illustrative case study.

OBJECTIVE: Perfectionism has been described as a multidimensional core vulnerability factor in various forms of dysfunction and disorders. Recently, we described our empirically supported-dynamic-relational treatment for perfectionism. This treatment integrates psychodynamic and interpersonal principles to reduce perfectionism and symptoms and enhance relationships with others and self by focusing on underlying relational patterns. METHOD: We discuss this approach and present Azure, a 27-year-old woman who completed our group treatment and subsequent individual therapy as a follow-up. RESULTS: Azure underwent a comprehensive psychological pretreatment assessment, the results of which were used to develop a working formulation that guided the group and individual psychotherapy. A description of the formulation and her experience in therapy are discussed and pre- and post-treatment data illustrate changes in Azure's perfectionism and symptoms. CONCLUSIONS: We discuss changes that occurred over the course of treatment.

Pathological narcissism's impact on psychodynamic group therapy for perfectionism.

Several decades of theory suggest that pathological narcissism (PN) may limit psychotherapy success, but empirical evidence for such theories is limited and mixed. In addition, it has been proposed that individuals with high levels of PN may benefit more from supportive compared to interpretive psychodynamic therapies, but no studies thus far have investigated this question empirically. As such, our study aimed to extend past research by investigating (a) whether higher levels of pretreatment PN predict poorer treatment outcome and (b) whether the type of psychodynamic therapy (supportive or interpretive therapy) moderates these findings, in a sample of patients undergoing group psychodynamic psychotherapy for perfectionism. The sample was drawn from the University of British Columbia Perfectionism Treatment Study II (Hewitt et al., 2023) and consisted of 80 treatment-seeking adults with elevated perfectionism. Contrary to expectations, multilevel and multiple regression analyses showed that pretreatment PN did not significantly predict posttreatment changes in symptom severity, life satisfaction, or work and social impairment. We also did not find that either grandiose or vulnerable narcissism predicted likelihood of patient dropout. Finally, treatment type did not moderate the relationship between pretreatment PN and treatment outcome, suggesting that, contrary to our hypotheses, PN does not impact treatment outcome regardless of the interpretive nature of the psychodynamic group therapy. These results, taken together with past findings, suggest that PN may not be associated with poorer psychotherapy outcomes in certain contexts, such as in the case of supportive or interpretive psychodynamic group psychotherapy for perfectionism. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The efficacy of group psychotherapy for adults with perfectionism: A randomized controlled trial of dynamic-relational therapy versus psychodynamic supportive therapy.

OBJECTIVE: This randomized controlled trial investigated the efficacy of group dynamic-relational therapy (DRT) relative to group psychodynamic supportive therapy (PST) in treating perfectionism and improving psychological functioning. HYPOTHESIS: Psychodynamically informed therapies, particularly DRT, will be efficacious in treating perfectionism and functioning outcomes. METHOD: Based on a comprehensive conceptualization of perfectionism, 80 community-recruited, highly perfectionistic individuals were randomly allocated to 12 sessions of group DRT (n = 41; 5 groups) or group PST (n = 39; 5 groups). Patients completed measures of trait perfectionism, perfectionistic self-presentation, perfectionistic cognitions, symptom distress, life satisfaction, and work and social adjustment at pre-, mid-, and posttreatment and 6 months posttreatment. RESULTS: Multigroup latent growth curve modeling revealed significant (p < .05) decreases in all perfectionism components and improvements in all functioning outcomes from pretreatment to 6-month follow-up in both DRT and PST. Likewise, analyses revealed substantial reliable improvement across conditions for all perfectionism components. Last, moderate-to-large between-group differences favoring DRT over PST were found for self-oriented perfectionism, perfectionistic self-promotion, nondisplay of imperfection, nondisclosure of imperfection, and work and social adjustment. CONCLUSION: Findings provide evidence for the use of psychodynamic approaches in the treatment of perfectionism and support the relative efficacy of DRT for components of perfectionism. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Group dynamic-relational therapy for perfectionism.

The interest in treating underlying core vulnerability factors or transdiagnostic processes has been a focus of much attention. In this paper we describe our application of group dynamic-relational psychotherapy to the treatment of perfectionism, a core personality vulnerability factor associated with various forms and types of dysfunction and disorders that have profound costs to the individual both socially and subjectively. Over the course of the past three decades, we developed an evidence-based integrative group treatment that targets the psychodynamic and relational underpinnings of perfectionism. The treatment is based on an integration of psychodynamic and interpersonal perspectives and therapeutic approaches. In this paper we present our model of perfectionism and describe our group dynamic-relational therapy for the treatment of its pernicious outcomes. By drawing on illustrative case material, we describe the approach as applied to one such group as it progresses through four phases of group development that we have termed engagement and pseudo attachment, pattern interruption, self-redefinition/painful authenticity, and termination. Finally, we present some of the accumulating evidence of the effectiveness and efficacy of dynamic-relational therapy.

Patient perfectionism and clinician impression formation during an initial interview.

OBJECTIVES: The negative impact of pre-treatment patient perfectionism on therapeutic alliance and outcomes has been well documented. However, there is much to learn about how patient perfectionism impacts the development of the therapeutic alliance. Our study addressed this by examining the extent to which trait and self-presentational components of perfectionism influence clinician's perceptions of patients during an initial interview. DESIGN: In a re-analysis of data from Hewitt et al., 2008, Psychiatry, 71, 93-122, participants were 90 treatment-seeking adults (aged 19-64, Mage  = 36.2; 40 men) recruited from outpatient mental health clinics. Each patient had a one-on-one, semi-structured interview with a clinician that lasted approximately 50 min. METHOD: Patients completed self-report measures assessing trait perfectionism, perfectionistic self-presentation, and symptom distress before the interview. Patients were then invited to discuss reasons for seeking treatment and to reflect on the two most challenging situations in their lives in which they had not coped well. Following the interview, clinicians indicated their overall impressions of patients by responding to three self-report questions and rated patients' distress and hostility via nine adjectives. RESULTS: After controlling for patients' symptom distress, other-oriented perfectionism and non-display of imperfection had small positive relationships with clinician-rated hostility; self-oriented perfectionism, socially prescribed perfectionism, and non-disclosure of imperfection had small-to-moderate negative relationships with clinician impressions. Additionally, path analysis revealed other-oriented perfectionism and non-display of imperfection indirectly predicted less favourable clinician impressions through clinician-rated hostility. CONCLUSIONS: Findings highlight the importance of evaluating and addressing trait and self-presentation components of perfectionism early in the therapeutic process. PRACTITIONER POINTS: Higher levels of other-oriented perfectionism and non-display of imperfection were associated with greater clinician-rated hostility during an initial interview. Patient hostility mediated the relationship between patients' other-oriented perfectionism, non-display of imperfection, and less favourable clinician impressions. Our study highlights the importance of assessing and attending to patient perfectionism and displays of hostility during the earliest stages of therapeutic contact.

Dynamic-relational group treatment for perfectionism: Informant ratings of patient change.

Although now there is accumulating research on the effectiveness of psychotherapy for perfectionism, this research has been based almost exclusively on self-report data. In this article, we describe analyses from the University of British Columbia Perfectionism Treatment Study assessing close other informant ratings of change in perfectionism traits and perfectionistic self-presentation. A total of 61 close other informants of patients who participated in a 10-week dynamic-relational treatment for perfectionism completed measures of patient trait and self-presentational facets of perfectionism at pretreatment, at posttreatment, and at a 4-month follow-up. In support of the effectiveness of the treatment, we found that close other measures of patients' self-oriented perfectionism, other-oriented perfectionism, and all three facets of perfectionistic self-presentation were significantly reduced at posttreatment and follow-up. Close other measures of patients' socially prescribed perfectionism did not show change over the course of treatment and follow-up. The findings are discussed in terms of the effectiveness of the dynamic-relational treatment of perfectionism and the utility of extending research by including close other measures of change in treatment-outcome research. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Ruptures and repairs of group therapy alliance. An untold story in psychotherapy research.

Although previous studies investigated the characteristics of therapeutic alliance in group treatments, there is still a dearth of research on group alliance ruptures and repairs. The model by Safran and Muran was originally developed to address therapeutic alliance in individual therapies, and the usefulness of this approach to group intervention needs to be demonstrated. Alliance ruptures are possible at member to therapist, member to member, member to group levels. Moreover, repairs of ruptures in group are quite complex, i.e., because other group members have to process the rupture even if not directly involved. The aim of the current study is to review the empirical research on group alliance, and to examine whether the rupture repair model can be a suitable framework for clinical understanding and research of the complexity of therapeutic alliance in group treatments. We provide clinical vignettes and commentary to illustrate theoretical and research aspects of therapeutic alliance rupture and repair in groups. Our colleague Jeremy Safran made a substantial contribution to research on therapeutic alliance, and the current paper illustrates the enduring legacy of this work and its potential application to the group therapy context.

Specific formulation feedback in dynamic-relational group psychotherapy of perfectionism.

In this article, we describe how individualized feedback, in the form of a clinical formulation, is used in our dynamic-relational group treatment of perfectionism (Hewitt et al., 2015), a core vulnerability or transdiagnostic personality factor. The authors discuss briefly their conceptualization and assessment of perfectionism as well as other aspects of patients' functioning, and the use of both psychodynamic and interpersonal models to derive, for individual patients, their unique formulation or idiosyncratic model of their perfectionistic and related behavior. Moreover, we describe the process of providing the formulation feedback to each patient in preparation for group psychotherapy and, finally, provide an illustrative case. (PsycINFO Database Record

Psychodynamic/interpersonal group psychotherapy for perfectionism: Evaluating the effectiveness of a short-term treatment.

This study sought to determine whether clinically significant improvement could be obtained using a psychodynamic/interpersonal group treatment based on a comprehensive conceptualization of perfectionism. A sample of 71 community-recruited perfectionistic individuals participated in the University of British Columbia Perfectionism Treatment Study. Eighteen of these participants were initially nonrandomly assigned to a waitlist control condition. All participants completed measures of perfectionism traits, perfectionistic self-presentation, and automatic perfectionistic thoughts, as well as measures of distress including depression, anxiety, and interpersonal problems at pretreatment, posttreatment, and at a 4-month follow-up. Multilevel modeling demonstrated that perfectionism levels decreased with large effect sizes and that these decreases were associated with reductions in distress measures. Clinically significant decreases were found in all perfectionism components, and posttreatment scores on most variables were significantly lower in the treatment condition versus the waitlist control condition. The findings suggest that psychodynamic/interpersonal group treatment is effective in treating components of perfectionism.

Confirmatory factor analysis of a 4-factor model of chronic pain evaluation.

Extending the earlier work of Mikail et al. (1993), a confirmatory factor analysis (CFA; LISREL VII) of a 4-factor model of pain assessment was tested. This model, comprised of the Beck Depression Inventory (BDI) and 13 subscales of the McGill Pain Questionnaire (MPQ) and the West Haven-Yale Multidimensional Pain Inventory (WHYMPI), adequately accounted for the pain experience with minimal overlap. Subjects were 306 outpatient chronic pain patients seen at a multidisciplinary chronic pain clinic. Subscale scores were subjected to CFA procedures that yielded a well-fitting final model that explained 91% of the covariance in the observed data. This final model was derived through an exploratory post-hoc procedure that allowed for correlated errors among subscales of the same instrument. The 4 factors were identified as Affective Distress, Support, Pain Description, and Functional Capacity. Results supported the hypothesis that the MPQ, WHYMPI and BDI are representative of the multidimensionality of the pain experience with minimal overlap among measures. Theoretical and clinical implications of reducing the overlap among existing measures in the assessment of pain patients are discussed.

Alternative diagnostic criteria for major depressive disorder in patients with chronic pain.

Chronic pain is associated with high rates of major depressive disorder (MDD), but somatic symptoms caused by pain may complicate the diagnosis of MDD. Different methods to address this issue include the adoption of an inclusive approach to diagnosis (i.e. including all symptoms when assessing MDD, regardless of their presumed cause), an etiologic approach (i.e. disregarding symptoms that are caused by medical problems), and a substitutive approach (i.e. replacing somatic symptoms with non-somatic alternatives). In this study, 129 patients with chronic pain (56 men and 73 women) underwent semi-structured interviews addressing 23 individual symptoms of MDD. Detailed probing was undertaken into patients' perceptions of the causes of those symptoms that could potentially be brought on by pain. We found that the prevalence of MDD was highest with the inclusive diagnostic method (35.7%), lowest with an etiologic approach that discounted symptoms based on patient attributions (19.4%), and intermediate with the substitutive method (30.3%). Although some symptoms, such as insomnia, fatigue, and difficulty concentrating, were reported by 34--53% of the patients who did not meet criteria for MDD, they were still more common among those who did (85--94%, P<0.001). Patients who met criteria for MDD with the inclusive method, but who did not meet criteria using the etiologic method, had Beck Depression Inventory scores (M=24.5) that were comparable to those of patients who were consistently classified with MDD across methods (M=25.6). These scores were much higher than those of patients who were consistently classified without MDD (M=13.8, P<0.001). In conclusion, excluding criterion symptoms that patients attribute to pain can reduce the observed prevalence of MDD by about 45%. However, this method introduces a problem of false-negative diagnoses that appears to be more significant than the problem of false positives associated with the inappropriate inclusion of somatic symptoms.

Major depression and insomnia in chronic pain.

OBJECTIVES: Insomnia and depression are common problems for people with chronic pain, and previous research has found that each is correlated with measures of pain and disability. The goal of this study was to examine the combined impact of major depression and insomnia on individuals with chronic pain. METHODS: The participants were patients with chronic musculoskeletal pain who underwent evaluation at an interdisciplinary treatment center. On the basis of semistructured interviews, participants were classified in three groups depending on whether they: (1) met criteria for major depression with insomnia (n = 38); (2) had insomnia without major depression (n = 58); or (3) had neither insomnia nor major depression (n = 47). The groups were then compared on self-report measures that included the McGill Pain Questionnaire, the Beck Depression Inventory, and the Multidimensional Pain Inventory. RESULTS: Participants with major depression and insomnia reported the most difficulty on measures of affective distress, life control, interference, and pain severity, although the insomniac patients without major depression also had elevated scores on some measures. In regression analyses, insomnia severity ratings did not contribute uniquely to the prediction of psychosocial problems when depression was controlled, but they did contribute to the prediction of pain severity. CONCLUSIONS: These results suggest that patients with chronic pain and concurrent major depression and insomnia report the highest levels of pain-related impairment, but insomnia in the absence of major depression is also associated with increased pain and distress.