Smith, M. M., Hewitt, P. L., Sherry, S. B., Flett, G. L., Kealy, D., …, & Bakken, K. (2023, April 27). A meta-analytic test of the efficacy of cognitive behavioural therapy for perfectionism: A replication and extension. Canadian Psychology / Psychologie canadienne. Advance online publication. https://dx.doi.org/10.1037/cap0000360
Perfectionism is a multidimensional personality factor that can make one vulnerable to mental health problems and can interfere with therapeutic processes like the therapeutic alliance. The bulk of the research for treating perfectionism has focused on cognitive behavioural therapy (CBT), with meta-analyses concluding that CBT is efficacious. However, this research has certain limitations. First, the meta-analyses focus on standard mean differences (SMD) between treatments and control conditions, but SMDs are abstractions that are difficult to translate into real-world practice. What matters most to patients and clinicians is the proportion of patients who reliably improve beyond statistical error or the natural course of the problem. Second, the studies do not consistently report analyses related to drop-out rates. Drop-out is an indicator of the tolerability of a treatment for patients. If patients drop out at a high rate, then the treatment may not be acceptable, and many patients may not benefit. Third, the meta-analyses of CBT for perfectionism do not indicate whether treatment effects at the end of therapy are sustained in the longer term. In this re-analysis and extension of previous meta-analyses, Smith and colleagues look at the critical issues of the proportion of improved patients, drop-outs, and long-term outcomes for those with perfectionism treated with CBT. Like previous meta-analyses assessing SMDs, the authors found moderate to large effects of CBT versus control conditions on several of the dimensions of perfectionism. However, they also found no significant effects for several other dimensions of perfectionism that were more persistent and related to core personality (e.g., self-oriented perfectionism, other-oriented perfectionism, socially prescribed perfectionism, perfectionistic cognitions). Regarding the proportion of reliably improved patients, 13% to 55% of patients showed reliable improvement depending on the dimension of perfectionism that was assessed. But between 7.5% and 24.5% reliably improved without any treatment. So, the added value of CBT beyond no treatment was modest in most cases. Regarding dropouts, 27.0% of patients dropped out of CBT while only 15.7% dropped out of the control conditions. That is, those who received CBT had a 1.89 times increased risk of dropping out compared to those who were in control conditions (95% CI [1.37, 2.60], p = .005). Finally, very few studies assessed the longer-term effects of CBT, and those that did assess longer-term outcomes found that any effects at post-treatment disappeared at the follow-up assessments.
The results of this meta-analysis suggest that it may not be enough to provide CBT to help patients who have the persistent relational aspects of perfectionism (i.e., self-oriented perfectionism, other-oriented perfectionism, socially prescribed perfectionism, and perfectionistic cognitions). It is also unclear if CBT is effective in the longer term as the small amount of evidence that exists does not inspire optimism. CBT may not be tolerable to some patients with perfectionism as evidenced by the moderately high drop-out rate. It may be necessary to adapt CBT or to include other models of treating perfectionism that use interpersonal and dynamic concepts and interventions that explicitly target core personality features of perfectionism.