Skip to main navigation menu Skip to main content Skip to site footer
FrancoAngeli Journals

Regular Articles

No. 2 (2024)

Therapist’s perfectionism as a target of clinical supervision. A case-study

DOI
https://doi.org/10.3280/rpc2-2024oa18926
Submitted
novembre 29, 2024
Published
2025-01-13

Abstract

Perfectionism is characterized by beliefs and feelings that drive individuals to pursue unattainable standards of excellence and impeccability, often at the expense of their psychological and physical well-being. It correlates with many psychopathologies and a heightened suicide risk; and it can be also an aspect of a multiplicity of personality disorders. Perfectionism seems a common phenomenon among psychological practitioners too, and the very few studies that focus on it overall suggest that perfectionism in therapists is negatively correlated with therapy effectiveness, and positively correlated with therapist emotional distress (e.g., negative emotions toward patient characteristics or demands); but it is not clear the mechanism underlying these correlations. In this paper we present a hypothesis on the process underlying the relationship between therapist perfectionism, therapist emotional distress, and ineffectiveness of therapeutic interventions. Starting with a parallel analysis of a clinical case and supervision over it, we show that perfectionism may be part of an overall organization of the meaning of the experience that the therapist brings into the relationship, which we call Prototypical Adaptive Modality of Existence (PAME). We show how the therapist’s perfectionist PAME functions as an automatic process that hinders intersubjective attunement with the patient; finally, we show how a supervisory process focused on the shared exploration of the therapist’s perfectionist PAME, of its developmental genesis, and of its impact on the supervisory relationship can modulate the therapist’s perfectionism, foster attunement with the patient, functionally modify the line of intervention, and foster a positive outcome.

References

  1. Alloy, L. B., Abramson, L. Y., Walshaw, P. D., Gerstein, R. K., Keyser, J. D., Whitehouse, W. G., Urosevic, S., Nusslock, R., Hogan, M. E., & Harmon-Jones, E. (2009). Behavioral approach system (BAS)-relevant cognitive styles and bipolar spectrum disorders: Concurrent and prospective associations. Journal of Abnormal Psychology, 118(3), 459-471. DOI: 10.1037/a0016604.
  2. Aron, A., Paris, M., & Aron, E. N. (1995). Falling in love: Prospective studies of self-concept change. Journal of Personality and Social Psychology, 69(6), 1102-1112. DOI: 10.1037/0022-3514.69.6.1102.
  3. Atwood, G. E., & Stolorow, R. D. (1984). Structures of subjectivity: Explorations in psychoanalytic phenomenology. Analytic Press.
  4. Ayearst, L. E., Flett, G. L., & Hewitt, P. L. (2012). Where is multidi-mensional perfectionism in DSM-5? A question posed to the DSM-5 personality and personality disorders work group. Personality Disorders Theory Research and Treatment, 3(4), 458–469. DOI: 10.1037/a0026354.
  5. Beinart, H. (2014). Building and sustaining the supervisory relationship. In C. E. Watkins, Jr. & D. L. Milne (Eds.), The Wiley international handbook of clinical supervision (pp. 257-281). Wiley Blackwell.
  6. Betan, E., Heim, A. K., Conklin, C. Z., & Westen, D. (2005). Counter-transference Phenomena and Personality Pathology in Clinical Practice: An Empirical investigation. American Journal of Psychiatry, 162(5), 890-898. DOI: 10.1176/appi.ajp.162.5.890.
  7. Blatt, S. J. (1995). The destructiveness of perfectionism: Implications for the treatment of depression. American Psychologist, 50(12), 1003-1020. DOI: 10.1037/0003-066x.50.12.1003.
  8. Borders, L. D. (2014). Best practices in clinical supervision: Another step in delineating effective supervision practice. American Journal of Psychotherapy, 68(2), 151-162.
  9. Bordin, E. S. (1983). A working alliance based model of supervision. The counseling psychologist, 11(1), 35-42.
  10. Bromberg, P. M. (2011). The shadow of the tsunami: And the growth of the relational mind. Routledge.
  11. Carotenuto, A. (1991). Trattato di psicologia della personalità e delle differenze individuali. Raffaello Cortina.
  12. Coltart, N. (1996). The baby and the bathwater: Psychotherapy, care and control. International Journal of Psychoanalysis, 77(6), 1113-1126. DOI: 10.4324/9780429481161.
  13. Cornell, W. F. (2019). Into TA: A comprehensive textbook on transactional analysis. Routledge.
  14. Cruciani, G., Liotti, M., & Lingiardi, V., (2024). Motivations to become psychotherapists: beyond the concept of the wounded healer. Research in Psychotherapy: Psychopathology, Process and Outcome, 27(2), 808. DOI: 10.4081/ripppo.2024.808.
  15. D’Souza, F., Egan, S. J., & Rees, C. S. (2011). The relationship between perfectionism, stress and burnout in clinical psychologists. Behaviour Change, 28(1), 17-28. DOI: 10.1375/bech.28.1.17.
  16. Dimaggio, G., Lysaker, P. H., Calarco, T., Pedone, R., Marsigli, N., Riccardi, I., Sabatelli, B., Carcione, A., & Paviglianiti, A. (2015). Perfectionism and personality disorders as predictors of symptoms and interpersonal problems. American Journal of Psychotherapy, 69(3), 317-330. DOI: 10.1176/appi.psychotherapy.2015.69.3.317.
  17. Dimaggio, G., MacBeth, A., Popolo, R., Salvatore, G., Perrini, F., Raouna, A., Osam, C. S., Buonocore, L., Bandiera, A., & Montano, A. (2018). The problem of overcontrol: Perfectionism, emotional inhibition, and personality disorders. Comprehensive Psychiatry, 83, 71-78. DOI: 10.1016/ j.comppsych.2018.03.005.
  18. Dimaggio, G., Salvatore, G., MacBeth, A., Ottavi, P., Buonocore, L., & Popolo, R. (2016). Metacognitive Interpersonal Therapy for Personality Disorders: A Case Study series. Journal of Contemporary Psychotherapy, 47(1), 11-21. DOI: 10.1007/s10879-016-9342-7.
  19. D’Souza, F., Egan, S. J., & Rees, C. S. (2011). The relationship between perfectionism, stress and burnout in clinical psychologists. Behaviour Change, 28(1), 17 28. DOI: 10.1375/bech.28.1.17.
  20. Egan, S. J., Wade, T. D., & Shafran, R. (2011). Perfectionism as a transdiagnostic process: A clinical review. Clinical Psychology Review, 31(2), 203-212. DOI: 10.1016/j.cpr.2010.04.009.
  21. Ekstein, R., & Wallerstein, R. S. (1958). The teaching and learning of psychotherapy. Basic Books.
  22. Epstein, L., & Feiner, A. H. (1988). Countertransference: The therapist’s contribution to treatment. Contemporary Psychoanalysis, 24(4), 489-513. DOI: 10.1080/00107530.1988.10746272.
  23. Fernández-Alvarez, H. (2016). Reflections on supervision in psychotherapy. Psychotherapy research, 26(1), 1-10.
  24. Fife, S. T., Whiting, J. B., Bradford, K., & Davis, S. (2014). The therapeutic pyramid: A common factors synthesis of techniques, alliance, and way of being. Journal of Marital and Family Therapy, 40(1), 20-33.
  25. Fleming, J., & Benedek, T. (1964). Supervision. A method of teaching psychoanalysis: preliminary report. The Psychoanalytic Quarterly, 33(1), 71-96.
  26. Fleming, J., & Benedek, T.F. (1966). Psychoanalytic supervision. Grune & Stratton.
  27. Flett, G. L., & Hewitt, P. L. (2002). Perfectionism and maladjustment: An overview of theoretical, definitional, and treatment issues. In G. L. Flett & P. L. Hewitt (Eds.), Perfectionism: Theory, research, and treatment (pp. 5-31). American Psychological Association eBooks.
  28. Flett, G. L., Hewitt, P. L., & Heisel, M. J. (2014). The destructiveness of perfectionism revisited: Implications for the assessment of suicide risk and the prevention of suicide. Review of General Psychology, 18(3), 156-172. DOI: 10.1037/gpr0000011.
  29. Flett, G. L., Nepon, T., Goldberg, J. O., Rose, A. L., Atkey, S. K., & Zaki-Azat, J. (2022). The Anti-Mattering Scale: development, psychometric properties and associations with Well-Being and Distress measures in adolescents and emerging adults. Journal of Psychoeducational Assessment, 40(1), 37-59. DOI: 10.1177/07342829211050544.
  30. Frost, R. O., & DiBartolo, P. M. (2002). Perfectionism, anxiety, and obsessive-compulsive disorder. In G. L. Flett & P. L. Hewitt (Eds.), Perfectionism: Theory, research, and treatment (pp. 341-371). American Psychological Association.
  31. Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The di-mensions of perfectionism. Cognitive therapy and research, 14, 449-468. DOI: 10.1007/bf01172967.
  32. Frost, R. O., & Di Bartolo, P. M. (2002). Perfectionism, anxiety, and obsessive-compulsive disorder. In G. L. Flett & P. L. Hewitt (Eds.). Perfectionism: Theory, research and treatment (pp. 341-272). American Psychological Association.
  33. Gabbard, G. O. (2001). A contemporary psychoanalytic model of countertransference. Journal of Clinical Psychology, 57(8), 983-991. DOI: 10.1002/jclp.1065.
  34. Gelso, C. (2014). A tripartite model of the therapeutic relationship: Theory, research, and practice. Psychotherapy research, 24(2), 117-131.
  35. Gelso, C. J. (2011). The real relationship in psychotherapy. The hidden foundation of change. American Psychological Association.
  36. Gelso, C. J., & Hayes, J. A. (2002). The management of countertransference. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 267-283). Oxford University Press.
  37. Hayes, J. A., Gelso, C. J., Goldberg, S., & Kivlighan, D. M. (2018). Countertransference management and effective psychotherapy: Meta-analytic findings. Psychotherapy, 55(4), 496-507. DOI: 10.1037/pst0000189.
  38. Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the self and social contexts: conceptualization, assessment, and association with psychopathology. Journal of personality and social psychology, 60(3), 456. DOI: 10.1037/0022-3514.60.3.456.
  39. Hewitt, P. L., & Flett, G. L. (1993). Dimensions of perfectionism, daily stress, and depression: A test of the specific vulnerability hypothe-sis. Journal of Abnormal Psychology, 102(1), 58-65. DOI: 10.1037/0021-843x.102.1.58.
  40. Hewitt, P. L., Flett, G. L., & Mikail, S. F. (2017). Perfectionism: A relational approach to conceptualization, assessment, and treatment. The Guilford Press.
  41. Hewitt, P. L., Flett, G. L., & Turnbull‐Donovan, W. (1992). Perfectionism and suicide potential. British Journal of Clinical Psychology, 31(2), 181-190. DOI: 10.1111/j.2044-8260.1992.tb00982.x.
  42. Hewitt, P. L., Flett, G. L., Sherry, S. B., & Caelian, C. (2006). Trait perfectionism dimensions and suicidal behavior. Cognition and suicide: Theory, research, and therapy (pp. 215-235). American Psychological Association eBooks.
  43. Holden, C. L., & Jeanfreau, M. M. (2021). Are Perfectionistic Stand-ards Associated with Burnout? Multidimensional Perfectionism and Compassion Experiences Among Professional MFTs. Contemporary Family Therapy, 45(2), 207-217. DOI: 10.1007/s10591-021-09605-6.
  44. Horney, K. (1945). Our inner conflicts. Norton.
  45. Horney, K. (1950). Neurosis and human growth. Norton.
  46. Huprich, S. K., Porcerelli, J., Keaschuk, R., Binienda, J., & Engle, B. (2008). Depressive personality disorder, dysthymia, and their relationship to perfectionism. Depression and Anxiety, 25(3), 207-217. DOI: 10.1002/da.20290.
  47. Kleinbub, J. R., Testolin, A., Palmieri, A., & Salvatore, S. (2021). The phase space of meaning model of psychopathology: A computer simulation modelling study. PLoS ONE, 16(4), e0249320. DOI: 10.1371/journal.pone.0249320.
  48. Landt, M. C. S., Claes, L., & Van Furth, E. F. (2016). Classifying eating disorders based on “healthy” and “unhealthy” perfectionism and impulsivity. International Journal of Eating Disorders, 49(7), 673-680. DOI: 10.1002/eat.22557.
  49. Lowyck, B., Luyten, P., Vermote, R., Verhaest, Y., & Vansteelandt, K. (2016). Self-critical perfectionism, dependency, and symptomatic distress in patients with personality disorder during hospitalization-based psychodynamic treatment: A parallel process growth modeling approach. Personality Disorders Theory Research and Treatment, 8(3), 268-274. DOI: 10.1037/per0000189.
  50. McWilliams, N. (2021). Psychoanalytic supervision. The Guilford Press.
  51. McCown, W. G., & Carlson, G. (2004). Narcissism, perfectionism, and self-termination from treatment in outpatient cocaine users. Journal of rational-emotive and cognitive-behavior therapy, 22, 325-336. DOI: 10.1023/b:jore.0000047314.90953.c9.
  52. O’Connor, R. C. (2007). The Relations between Perfectionism and Suicidality: A Systematic Review. Suicide and Life-Threatening Behavior, 37(6), 698-714. DOI: 10.1521/suli.2007.37.6.698.
  53. Ogden, P. & Fisher, J. (2016). Sensorimotor psychotherapy: interventions for trauma and attachment. W.W Norton.
  54. Orange, D. M., Atwood, G. E., & Stolorow, R. D. (1997). Working intersubjectively: Contextualism in psychoanalytic practice. Analytic Press.
  55. Pozza, A., Casale, S., & Dèttore, D. (2022). Therapists’ emotional reactions to patients with obsessive-compulsive disorder: the role of therapists’ orientation and perfectionism. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 40(4), 879-904. DOI: 10.1007/s10942-022-00443-5.
  56. Presley, V. L., Jones, C. A., & Newton, E. K. (2017). Are Perfectionist Therapists Perfect? The Relationship between Therapist Perfectionism and Client Outcomes in Cognitive Behavioural Therapy. Behavioural and Cognitive Psychotherapy, 45(3), 225-237. DOI: 10.1017/s1352465817000054.
  57. Putnam, F. W. (1997). Dissociation in children and adolescents. Guilford Press.
  58. Putnam, F. W. (2016). The way we are: How states of mind influence our identities, personality and potential for change. IPBooks.
  59. Reich, W. (1942). The function of the orgasm. Orgone Institute Press.
  60. Reich, W. (1949). Character analysis. Orgone Institute Press.
  61. Riddle, M. A., Maher, B. S., Wang, Y., Grados, M., Bienvenu, O. J., Goes, F. S., Cullen, B., Murphy, D. L., Rauch, S. L., Greenberg, B. D., Knowles, J. A., McCracken, J. T., Pinto, A., Piacentini, J., Pauls, D. L., Rasmussen, S. A., Shugart, Y. Y., Nestadt, G., & Samuels, J. (2016). Obsessive-Compulsive Personality Disorder: Evidence for Two Dimensions. Depression and Anxiety, 33(2), 128-135. DOI: 10.1002/da.22452.
  62. Safran, J. D., & Kraus, J. (2014). Alliance ruptures, impasses, and enactments: A relational perspective. Psychotherapy, 51(3), 381-387. DOI: 10.1037/a0036815.
  63. Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. Guilford Press.
  64. Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. Jason Aronson.
  65. Salvatore, G. (2024). Stanghellini, G., Rosfort, R., Rossi, R., & Salvatore, S. (2024). An intersubjective conception of complex trauma in the framework of the semiotic function of affectivity. European Journal of Trauma & Dissociation, 8, 1-13. DOI: 10.1016/j.ejtd.2024.100462.
  66. Salvatore, S., Palmieri, A., De Luca Picione, R., Bochicchio, V., Reho, M., Serio, M.R., Salvatore, G. (2024). The affective grounds of the mind. The Affective C(APER) model. Physics of Life Reviews. DOI: 10.1016/ j.plrev.2024.07.008.
  67. Semerari, A. (2022). Metacognizione e psicopatologia. Raffaello Cortina.
  68. Sherry, S. B., Hewitt, P. L., Flett, G. L., Lee-Baggley, D. L., & Hall, P. A. (2007). Trait perfectionism and perfectionistic self-presentation in personality pathology. Personality and Individual Differences, 42(3), 477-490. DOI: 10.1016/j.paid.2006.07.026.
  69. Slof‐Op’t Landt, M. C., Claes, L., & van Furth, E. F. (2016). Classifying eating disorders based on “healthy” and “unhealthy” perfectionism and impulsivity. International Journal of Eating Disorders, 49(7), 673-680. DOI: 10.1002/eat.22557.
  70. Smith, M. M., Sherry, S. B., Ge, S. Y. J., Hewitt, P. L., Flett, G. L., & Baggley, D. L. (2022). Multidimensional perfectionism turns 30: A review of known knowns and known unknowns. Canadian Psycho-logy/Psychologie Canadienne, 63(1), 16-31. DOI: 10.1037/cap0000288.
  71. Stern, D. B. (1983). Unformulated experience. Contemporary Psychoanalysis, 19(1), 71-99. DOI: 10.1080/00107530.1983.10746593.
  72. Stern, D. B. (2015). Relational freedom. Routledge eBooks.
  73. Stolorow, R. D., & Atwood, G. E. (1992). Contexts of being. Analytic Press.
  74. Stolorow, R. D., Brandchaft, B., & Atwood, G. E. (1987). Psychoanalytic treatment: An intersubjective approach. Analytic Press.
  75. Sullivan, H. S. (1953). The interpersonal theory of psychiatry. Norton.
  76. Wachtel, P. L. (2023). Cyclical psychodynamics and the contextual self. Guilford Press.
  77. Wampold, B. E. (2019). The basics of psychotherapy: An introduction to theory and practice. American Psychological Association.
  78. Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. 2nd ed., Erlbaum.
  79. Watkins, Jr. C. E. (2015). Extrapolating Gelso’s Tripartite Model of the Psychotherapy Relationship to the Psychotherapy Supervision Relationship: A Potential Common Factors Perspective. Journal of Psychotherapy Integration, 25, 143-157. DOI: 10.1037/a003888.
  80. Winnicott, D. W. (1960). Ego distortion in terms of true and false self. In D. W. Winnicott, The maturational processes and the facilitating environment: Studies in the theory of emotional development (pp. 140-152). Hogarth Press.
  81. Wittenberg, K. J., & Norcross, J. C. (2001). Practitioner perfectionism: Relationship to ambiguity tolerance and work satisfaction. Journal of Clinical Psychology, 57(12), 1543-1550. DOI: 10.1002/jclp.1116.

Metrics

Metrics Loading ...