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Perfectionism and therapy relationship quality in psychodynamic-interpersonal group psychotherapy Zhang, Lisa 2020

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       PERFECTIONISM AND THERAPY RELATIONSHIP QUALITY IN PSYCHODYNAMIC-INTERPERSONAL GROUP PSYCHOTHERAPY   by  LISA ZHANG  B.Sc., McGill University, 2012 M.A., University of British Columbia, 2014   A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF   DOCTOR OF PHILOSOPHY   in   THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (Psychology)       THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)    June 2020    © Lisa Zhang, 2020       ii  The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled:  Perfectionism and Therapeutic Relationship Quality in Psychodynamic-Interpersonal Group Psychotherapy  submitted by Lisa Zhang  in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Psychology  Examining Committee: Paul Hewitt, Professor, Department of Psychology, UBC Supervisor  Amori Mikami, Professor, Department of Psychology, UBC Supervisory Committee Member  Frances Chen, Associate Professor, Department of Psychology, UBC Supervisory Committee Member Peter Graf, Professor, Department of Psychology, UBC University Examiner Robinder Bedi, Associate Professor, Department of Educational and Counselling Psychology, and Special Education, UBC University Examiner       iii Abstract Perfectionism has been identified as a core vulnerability and maintenance factor in myriad psychopathologies and additionally appears to obstruct the course of improvement from the treatment of that psychopathology. The Perfectionism Social Disconnection Model posits that perfectionism is related to various negative outcomes through the mediating effects of social disconnection. When applied to the therapy realm, one would expect that perfectionism impedes the formation and growth of therapy relationships and that this then leads to worse outcomes from psychotherapy (e.g. less symptomatic improvement). Much of what is known about perfectionism in the context of psychotherapy comes from a series of papers stemming from a single study, the Treatment of Depression Collaborative Research Program (TDCRP, Elkin et al., 1989). These papers support the notion that perfectionism impairs both therapeutic alliance and therapeutic outcomes. This dissertation seeks to evaluate the Perfectionism Social Disconnection Model in the context of psychotherapy and to extend what is known about the relationships between perfectionism, therapy relationship quality, and therapy outcomes beyond the context of individual group treatment of depression using contemporary, empirically validated multidimensional measures of perfectionism. Furthermore, previous studies addressing these issues have mostly conceptualized perfectionism as a static measure. It is unknown if treatments that lead to decreases in perfectionism also improve therapy relationship quality and if those changes account for better therapeutic outcomes. The current paper addresses these questions in a group of 71 patients taking part in a group psychodynamic-interpersonal psychotherapy treatment designed to address issues related to perfectionism. Hypotheses were that 1) pre-treatment perfectionism would be negatively related to initial therapy relationship quality, 2) decreases in perfectionism would be accompanied by increases in therapy relationship quality, and 3) that changes in therapy relationship quality would account for the   iv relationship between decreases in perfectionism and better therapy outcomes. In the current study, these hypotheses were not supported. These null results are discussed in the context of a literature that suggests that perfectionism is related to both worse treatment outcomes and to interpersonal difficulties both in therapy and non-therapy contexts.      v Lay Summary Perfectionism has been associated with many mental health difficulties. There is also evidence that perfectionism is related to treating those mental health difficulties, where individuals high in perfectionism show less improvement from psychotherapy and also have more difficulties in therapy relationships compared to individuals lower in perfectionism. This dissertation investigated the question of whether pre-treatment perfectionism and changes in perfectionism are related to psychotherapy relationship quality and psychotherapy outcomes in a new and different context from where it has previously been studied, in a group psychotherapy treatment for individuals high in perfectionism. The results did not support a relationship between perfectionism and therapy relationship quality. These results are discussed in detail.     vi Preface The data analyzed in this dissertation is based on archival data from a treatment study that took place at the University of British Columbia (see Hewitt et al., 2015). None of the text of this dissertation is taken directly from previously published or collaborative studies. Furthermore, the hypotheses and analyses in this dissertation are unique to this paper.  In addition to the existing archival data, I led the process of obtaining observer ratings of therapy relationship quality. This involved selecting observational measures, training a team of six undergraduate coders, ensuring that the coding team reached and maintained an acceptable level of reliability, and obtaining two coders’ ratings for each of 239 unique 90 minute client-sessions. Dr. Paul Hewitt provided supervision on this dissertation.  Otherwise, this dissertation represents original, unpublished, independent work by myself.      vii Table of Contents Abstract  ................................................................................................................................................ iii Lay Summary  ........................................................................................................................................ v Preface  .................................................................................................................................................. vi Table of Contents  ................................................................................................................................ vii List of Tables  ....................................................................................................................................... ix List of Figures  ...................................................................................................................................... xi Acknowledgments  ............................................................................................................................... xii Introduction  ........................................................................................................................................... 1 Overview  ................................................................................................................................... 1 Conceptualization and Assessment of Perfectionism  ............................................................... 4 Perfectionism and Its Links to Distress  .................................................................................. 10 The Perfectionism Social Disconnection Model  ..................................................................... 12 Perfectionism in the Interpersonal Context  ............................................................................. 17 Perfectionism in Psychotherapy  .............................................................................................. 20 Summary of the Research Literature  ...................................................................................... 36 Description of the Current Study  ............................................................................................ 37 Method  ................................................................................................................................................ 40 Participants  .............................................................................................................................. 40 Group Psychotherapy  .............................................................................................................. 41 Measures .................................................................................................................................. 42 Data Collection Procedures ...................................................................................................... 45   viii Statistical Analyses  ................................................................................................................. 47 Study Summary  ....................................................................................................................... 56 Results  ................................................................................................................................................. 57 Descriptive Statistics  ............................................................................................................... 57  Effect of Perfectionism on Intercepts and Slope for Alliance, Cohesion, and   Group Climate .............................................................................................................. 61 Discussion  ........................................................................................................................................... 65 Perfectionism and Therapy Relationships  .............................................................................. 65 Possible Reasons for Null Findings  ........................................................................................ 66 Future Directions and Conclusions  ......................................................................................... 79 Tables  .................................................................................................................................................. 84 Figures ............................................................................................................................................... 100 References  ......................................................................................................................................... 113      ix List of Tables Table 1      Taxonomy of Multilevel Models for Change  ................................................................... 84 Table 2      Self-Rated Perfectionism and Outcomes at Pre-Group, Post-Group, and  at Follow-Up  ............................................................................................................... 85 Table 3      Alliance, Cohesion, and Group Climate Means and Standard Deviations Across  Sessions  ....................................................................................................................... 86 Table 4      Pearson Correlations Between Alliance, Cohesion, and Climate Measures  ..................... 87 Table 5      Intraclass Correlations for TPOCS-A and -GC  ................................................................ 88 Table 6      Multilevel Variance in Alliance, Cohesion, and Group Climate  ...................................... 89 Table 7      Hypothesis 1: Multilevel Analyses Examining the Effects of Pre-Treatment  Perfectionism on Initial Status for GCQ Engaged  ...................................................... 90 Table 8      Hypothesis 1: Multilevel Analyses Examining the Effects of Pre-Treatment  Perfectionism on Initial Status for GCQ Conflict  ................................................................... 91 Table 9       Hypothesis 1: Multilevel Analyses Examining the Effects of Pre-Treatment  Perfectionism on Initial Status for GCQ Avoiding  ..................................................... 92 Table 10     Hypothesis 1: Multilevel Analyses Examining the Effects of Pre-Treatment  Perfectionism on Initial Status for TPOCS-A  ............................................................. 93 Table 11     Hypothesis 1: Multilevel Analyses Examining the Effects of Pre-Treatment  Perfectionism on Initial Status for TPOCS-GC  .......................................................... 94 Table 12     Hypothesis 2: Multilevel Analyses Examining the Effects of Change in  Perfectionism on Rate of Change for GCQ Engaged  ................................................. 95 Table 13     Hypothesis 2: Multilevel Analyses Examining the Effects of Change in  Perfectionism on Rate of Change for GCQ Conflict  .................................................. 96   x Table 14     Hypothesis 2: Multilevel Analyses Examining the Effects of Change in  Perfectionism on Rate of Change for GCQ Avoiding  ................................................ 97 Table 15    Hypothesis 2: Multilevel Analyses Examining the Effects of Change in  Perfectionism on Rate of Change for TPOCS-A  ........................................................ 98 Table 16    Hypothesis 2: Multilevel Analyses Examining the Effects of Change in  Perfectionism on Rate of Change for TPOCS-GC  ..................................................... 99       xi  List of Figures Figure 1      Perfectionism Social Disconnection Model ................................................................... 100 Figure 2      Perfectionism Social Disconnection Model in the Psychotherapy Context  .................. 101 Figure 3      Change Trajectories for Alliance, Cohesion, and Climate Variables  ............................ 102 Figure 4      Linear Change Trajectories for GCQ Engaged by Participant  ...................................... 103 Figure 5      Linear Change Trajectories for GCQ Conflict by Participant  ....................................... 104 Figure 6      Linear Change Trajectories for GCQ Avoiding by Participant  ..................................... 105 Figure 7      Linear Change Trajectories for TPOCS-A by Participant  ............................................. 106 Figure 8      Linear Change Trajectories for TPOCS-GC by Participant  .......................................... 107 Figure 9      Change Trajectories For GCQ Engaged for Participants 2, 42, 60, and 106 ................. 108 Figure 10    Change Trajectories For GCQ Conflict for Participants 2, 42, 60, and 106 .................. 109 Figure 11    Change Trajectories For GCQ Avoiding for Participants 2, 42, 60, and 106 ................ 110 Figure 12    Change Trajectories For GCQ TPOCS-A for Participants 2, 42, 60, and 106 ............... 111 Figure 13    Change Trajectories For GCQ TPOCS-GC for Participants 2, 42, 60, and 106 ............ 112          xii Acknowledgements I offer my gratitude to the faculty and staff at UBC, who have supported me throughout my time at UBC. I owe particular thanks to Dr. Paul Hewitt, who guided me through the world of perfectionism research and helped me develop the ideas and content for this dissertation.  I thank my fellow graduate students for your exchange of ideas, your exchange of commiseration, and your many hours of company. Thank you for being with me across years and locations – in offices, coffee shops, in apartments across various cities. I also thank the many friends I’ve made over my time in grad school, who have made this process infinitely easier.  Special thanks are owed to my parents who have supported me throughout my years of education, and who have come to my aid without question time and time again. Thank you for your hard work and sacrifice.   1 Introduction Overview  There is now a wide body of research linking perfectionism with an array of problems including various forms of psychopathology (e.g. Antony et al., 1998; Bardone-Cone et al., 2007; Cox & Enns, 2003; Egan et al., 2011; Hewitt & Flett, 1991a; Zuroff et al., 2016), physical health problems (Sirois & Molnar, 2016), and suicide ideation and attempts (e.g. Flett et al., 2014; Hewitt et al., 2006). Some argue that perfectionism, rather than being merely linked to negative outcomes, functions as a transdiagnostic risk and maintenance factor for psychopathology as well as a core vulnerability factor for various negative outcomes (e.g. Egan et al., 2011; Hewitt, Flett, & Mikail, 2017). Perfectionism has also been associated with many interpersonal problems, including lower overall adjustment in romantic relationships (Habke et al., 1997; Stoeber, 2012), more negative interpersonal interactions (Flett et al., 1996), a higher degree of conflict in romantic relationships (Mackinnon et al., 2012), and a hostile-dominant personality style (Habke & Flynn, 2002).   The Perfectionism Social Disconnection Model (PSDM; Hewitt et al, 2006; Hewitt, Flett, & Mikail, 2017) argues that perfectionism exerts its harmful effects through interpersonal mechanisms. The PSDM provides a theory of the development and maintenance of perfectionism, as well as the link between perfectionistic behavior, relational behavior, and various negative outcomes. The PSDM proposes that perfectionism develops due to thwarted needs to feel connected that develops following problems with early attachment and throughout the developmental process. These individuals attempt to be or appear perfect in order that others may care for them. However, these perfectionistic behaviors are associated with interpersonal sensitivity, hostility, avoidance of self-disclosure and display of imperfection, and boastful self-  2 promoting behavior, and these behaviors are then aversive to others and generate further disconnection from the social environment. This social disconnection then leads to many of the problems associated with perfectionism (Chen et al., 2012; Hewitt, Flett, & Mikail, 2017; Hewitt et al., 2006). There is now considerable evidence supporting the PSDM, with many studies finding that perfectionism is linked to psychopathology and that this relationship is mediated by social disconnection or poor social support.   In psychotherapy, the relationship between therapist and patient is one of the major pillars supporting successful psychotherapeutic treatment (Sullivan, 1953; Wampold & Imel, 2015). When extended to psychotherapy, the PSDM posits that perfectionists’ behaviors and attitudes lead to social disconnection in the therapy room, i.e. difficulties in therapeutic relationships (Hewitt, Flett, Mikail, Kealy, & Zhang, 2017), which then lead to worse outcomes from psychotherapy, including reduced symptom improvement, clinical functioning, and social adjustment (Blatt et al., 1995; Zuroff et al., 2000). There is some indication that the link between perfectionism and worse outcomes from psychotherapy is partially due to problems in the therapeutic alliance (Hawley et al., 2006; Zuroff et al., 2000). There is also some support for the idea that perfectionism is related to difficulties with social connection in psychotherapy, with various studies finding that individuals higher in some forms of perfectionism are more likely to perceive therapists as threatening (Hewitt et al., 2008), and that therapists find these individuals less likeable (Hewitt, Chen, et al., 2020). However the number of studies posing direct tests of the PSDM in a psychotherapy context remain limited, and many questions remain about the relationship between perfectionism and relationships in psychotherapy.  Much of the literature addressing perfectionism in psychotherapy and most of the findings that support the idea that perfectionism is related to problems in therapy relationships originate from the National Institute of Mental Health Treatment of Depression Collaborative   3 Research Program (TDCRP), a single study examining the effects of various short-term treatments for unipolar depression. Because the majority of what we know about how perfectionism functions in psychotherapy comes from the TDCRP, further evaluation of the relationship between perfectionism and therapy relationship quality is necessary. There remain questions regarding generalizability of the TDCRP findings to other therapeutic contexts. Furthermore, the TDCRP papers use a unidimensional measure of perfectionism based on perfectionistic attitudes, which fails to take into account more current empirically validated multidimensional conceptualizations of perfectionism. Finally, the TDCRP focused on pre-treatment perfectionism, which fails to address the clinically important question of whether reductions in perfectionism may lead to improvements in therapy relationship quality.   The current study evaluates the elements of the PSDM in a psychotherapy context, while also addressing issues in the literature regarding generalizability, measurement of perfectionism, and the impact of reductions in perfectionism on therapy relationship quality. This study took place within the context of psychodynamic-interpersonal group psychotherapy aimed at reducing perfectionism. Seventy-one participants took part in the intervention and 60 participants completed the intervention. Perfectionism was assessed pre- and post-treatment. Therapy relationship quality, including patient-therapist relationship quality and patient-group relationship quality, was assessed at multiple time points over the course of the 10-week treatment. Following the PSDM, hypotheses were that 1) higher levels of pre-treatment trait perfectionism would be related to poorer quality therapy relationships initially, that 2) as individuals displayed decreases in trait perfectionism, therapy relationships would improve, 3) and that improvements in trait perfectionism would then lead to improved outcomes from therapy.    In the remainder of the introductory chapters of this paper, I elaborate on the conceptualization and assessment of perfectionism and the PSDM, which acts as the guiding theoretical framework for the study. In order to sketch out how perfectionism may impact   4 relationships and outcomes in psychotherapy, I briefly review the relationship between perfectionism and psychopathology, physical health, and other outcomes. I then discuss the interpersonal expression of perfectionism and the social worlds of perfectionists, and their characteristic interpersonal styles. I then discuss the role of therapy relationships in general in psychotherapy. Afterwards, I review the literature to date on perfectionism in the context of psychotherapy, and the relationship between this personality style and both outcome (i.e. improvement in psychopathology symptoms and functioning) and therapy relationship quality in psychotherapy. Finally, I provide an overview of the literature as a whole and provide a description of the current study, including study hypotheses.  Conceptualization and Assessment of Perfectionism Perfectionism refers to a personality characteristic defined by the requirement of perfection of the self or others accompanied by overly critical evaluations of one’s behavior. Although in the popular imagination perfectionism is often thought of as a unidimensional construct consisting of self-directed requirements for perfection, there is now general consensus from decades of clinical observation, theoretical work, and empirical work that perfectionism is a multidimensional personality style with multiple components (e.g. Hewitt & Flett, 1991b, Hewitt, Flett, Besser, et al., 2003; Sirois & Molnar, 2016; see Flett and Hewitt’s (2002) review of definitional and conceptual issues in the field of perfectionism for more on this topic).  It should also be noted that there is a clear distinction between perfectionism and merely having high standards. Blasberg and colleagues (2016) argue that perfectionism reflects a disabling all-or-nothing approach aimed at attaining perfection. In support of this, these authors found that when using modified measures of perfectionism that emphasize attaining perfection rather than excellence, these measures consistently correlated to a number of negative outcomes, including depression and anxiety symptoms. Similarly Gaudreau (2019) makes a distinction between perfectionism and what he calls “excellencism”. He argues that perfectionism involves,   5 rather than just a pursuit of excellence, a tendency to “aim and strive toward idealized, flawless, and excessively high standards in a relentless manner”.  Unidimensional Conceptualizations of Perfectionism Notable unidimensional conceptualizations of perfectionism include Shafran and colleagues’ unidimensional model of clinical perfectionism, and attitudinal self-critical perfectionism, as derived from the Dysfunctional Attitudes Scale (DAS; Weissman & Beck, 1978). Shafran and colleagues (2002) describe a unidimensional construct which they name clinical perfectionism, which refers to self-evaluative tendencies that are overly dependent on achieving excessively high standards despite adverse consequences.  Attitudinal self-critical perfectionism derives from the DAS (Weissman & Beck, 1978), which is designed to assess cognitions related to depression. Factor analysis results yielded two DAS factors: need for approval, and self-critical perfectionism or DAS perfectionism (Imber et al., 1990). Because DAS perfectionism derives from factor analysis rather than from theory, it is unclear where it stands in relation to other conceptualizations of perfectionism. Some authors assert that the DAS perfectionism subscale is characterized by self-directed thoughts regarding high standards and a need for perfection (Brown & Beck, 2002), which bears some resemblance to dimensions of perfectionism in some multidimensional models of perfectionism. However, there remains considerable debate about how to situate DAS perfectionism in relation to multidimensional models of perfectionism and whether DAS perfectionism reflects state-like cognitions versus trait-like personality factors (Brown & Beck, 2002; Dunkley et al., 2004). One criticism of both DAS perfectionism and Shafran and colleagues’ “clinical perfectionism” is that these conceptualizations of perfectionism are unidimensional, whereas most researchers argue that perfectionism is more accurately captured as a multidimensional construct, both according to   6 theory and extensive factor analysis work, though researchers differ on the specific dimensions of perfectionism they believe are most relevant (Dunkley, Blank stein, et al., 2006; Hewitt, Flett, Besser, et al., 2003). Multidimensional Conceptualizations of Perfectionism  Multidimensional conceptualizations of perfectionism include Slaney and colleagues’ model based on the Almost Perfect Scale-Revised (APS-R; Slaney et al., 2001) and two multidimensional models that originated around the same time based on separate measures both named the Multidimensional Perfectionism Scale (MPS): Frost and colleagues’ multidimensional perfectionism and Hewitt and Flett’s multidimensional perfectionism. (Frost et al., 1990; Hewitt & Flett, 1991b). The latter two address interpersonal aspects of perfectionism including demands of perfectionism from others and criticisms of lack of perfection from important others.  The first of the multidimensional measures described here, the APS-R, divides perfectionism into three dimensions: Standards, Discrepancy, and Order. Standards reflects the setting of high standards of performance, and Order reflects a tendency towards organization. Discrepancy refers to the discrepancy between one’s ideal self and one’s actual self; a high degree of Discrepancy indicates a belief that one is not meeting one’s personal standards, and is thought to be the defining negative aspect of perfectionism according to Slaney and colleagues (2001). Some researchers argue that the APS-R fail to capture the all-or-nothing nature of perfectionism and instead represents a construct more similar to conscientiousness rather than perfectionism (Blasberg et al., 2016). Frost and colleagues’ (1990) model contains six attitudinal dimensions characterized by the content and origin of the perfectionism in question. The two most studied dimensions in this model are Concern Over Mistakes and Personal Standards. Frost and colleagues define Personal   7 Standards as setting excessively high standards of performance, but conclude that this is not necessarily maladaptive. Instead, their research suggests that Concern over Mistakes is more central to the concept of perfectionism, which involves overly critical self-evaluation upon failing to meet standards of perfection (Frost et al., 1990). Additional subscales include Doubts About Actions (doubts about the quality of one’s performance), Organization (concerns over order and precision), Parental Expectations (perceptions of high standards from parents), and Parental Criticism (perceptions of high levels of criticism from parents). Frost and colleagues conceptualize perfectionism as a primarily self-directed phenomenon; however, they do include interpersonal components in their model, including the perception of high standards and criticisms from others in their model.  Comprehensive Model of Perfectionistic Behavior  The current study uses the model proposed by Hewitt, Flett, and colleagues. The Comprehensive Model of Perfectionistic Behavior (CMPB) is a multidimensional model of perfectionism including trait, self-presentational, and self-relational components (Flett et al., 1998; Hewitt, 2020; Hewitt & Flett, 1991b; Hewitt, Flett, Sherry, et al., 2003; Hewitt, Flett, & Mikail, 2017). According to this model, perfectionistic traits are internal qualities thought to drive and energize perfectionistic behavior, perfectionistic self-presentation constitutes the interpersonal expression of perfectionism, and perfectionistic automatic thoughts reflect the intrapersonal expression of perfectionism.  Perfectionistic Traits. According to this model, perfectionistic traits are internal, stable qualities thought to drive and energize perfectionistic behavior (Flett et al., 1998; Hewitt & Flett, 1991b; Hewitt, Flett, Sherry, et al., 2003; Hewitt, Flett, & Mikail, 2017). Hewitt and Flett (1991b) break down trait perfectionism into three relatively stable components differentiated by   8 the direction of demands for perfection. Individuals high in self-oriented perfectionism (SOP) require perfection of themselves, individuals high in other-oriented perfectionism (OOP) demand perfection from others and stringently evaluate others’ failures, whereas individuals high in socially prescribed perfectionism (SPP) perceive that others have unrealistically exacting standards for them.  SOP is associated with high standards, self-criticism and self-blame; OOP is associated with blame of others, authoritarianism, and dominance; and SPP is associated with demand of approval from others and fear of negative evaluation (Hewitt & Flett, 1991b). This third trait component of perfectionism (SPP) has been identified as one of the most harmful forms of perfectionism and has robustly been associated with mental health difficulties (e.g. Egan et al., 2011; Hewitt, Flett, & Mikail, 2017). Hewitt and Flett’s (1991b) theory predicts that individuals high in SPP are deeply concerned with meeting others’ perceived-to-be excessive standards, fear that they will not be able to meet those standards, and therefore experience fears of negative evaluation by others.  Perfectionistic Self-Presentation. Whereas perfectionistic traits are the stable, internal characteristics of perfectionism that energize perfectionistic behavior, perfectionistic self-presentation (PSP; Hewitt, Flett, Sherry, et al., 2003) constitutes the interpersonal expression of those traits. Research has suggested that perfectionists are highly self-conscious and have a strong desire to conceal their mistakes. For example, experimental research shows that people with high levels of perfectionistic concern over mistakes are less willing to reveal mistakes to others (Frost et al., 1995). Within the CMPB, PSP is divided into both the tendency to promote oneself as perfect, as well as the tendency to conceal imperfection from others. Specifically, PSP consists of three facets: perfectionistic self-promotion (proclaiming and displaying one’s perfection), nondisplay of imperfection (avoiding behavioral demonstrations of one’s imperfection), and nondisclosure of imperfection (avoiding verbal admissions of one’s   9 imperfection) (Hewitt, Flett, Sherry, et al., 2003; Hewitt, Flett, & Mikail, 2017). Importantly, PSP uniquely accounts for important differences between individuals with similar levels of trait dimensions of perfectionism (Hewitt, Flett, Sherry, et al., 2003; Roxborough et al., 2012) and differentially predicts distress and the presence of disorders (Flett & Hewitt, 2002; Hewitt, Flett, Sherry, et al., 2003; Mackinnon et al., 2014; Sherry et al., 2007). For example, perfectionistic self-promotion (the promoting aspect of PSP) is uniquely associated with narcissistic personality style (e.g. Sherry et al., 2007), whereas nondisplay and nondisclosure of imperfection (the concealing aspects of PSP) are more associated with withdrawal and fear of social evaluation (Hewitt, Flett, Sherry, et al., 2003; Mackinnon et al., 2014). In addition, consistent with theory, OOP and PSP correlations are lower in magnitude than the correlations between SPP or SOP and PSP, reflecting the idea that OOP individuals are more concerned with other people’s imperfections than their own (Hewitt, Flett, Sherry, et al., 2003).   Perfectionistic Automatic Thoughts. Whereas perfectionistic self-presentation represents the interpersonal expression of perfectionistic traits, perfectionistic automatic thoughts represent the intrapersonal expression of perfectionistic traits. Flett and colleagues (1998) proposed that there are individual differences in the frequency of perfectionistic thoughts, and that these thoughts are associated with psychological distress beyond perfectionistic traits. Whereas perfectionistic traits are seen as stable and dispositional, perfectionistic cognitions are seen as more state-like and variable, and perhaps share more similarity with DAS perfectionism (Flett et al., 1998). Empirical work on both undergrads (Flett et al., 1998), and psychiatric patients (Flett et al., 2007) support the idea that perfectionistic cognitions account for unique variance in levels of anxiety and depression symptoms after removing variance attributable to trait perfectionism.  The majority of previous papers investigating perfectionism and psychotherapy have used unidimensional measures of perfectionistic attitudes, and many of these papers derive from one study analyzed in multiple ways. In contrast, the current study focuses on CMPB trait   10 perfectionism. The CMPB reflects currently empirically validated conceptualizations and measurement of perfectionism. The CPMB includes a distinct interpersonal component, which fits closely with a relational understanding of the development, maintenance, and consequences of perfectionism. I chose to focus on CPMB trait perfectionism for the current study as this has been the most studied aspect of multidimensional perfectionism and has been implicated in various psychopathologies and relational problems.  Perfectionism and Its Links to Distress Hewitt, Flett, and colleagues describe perfectionism as a personality construct that is a core vulnerability factor across different mental health, physical health, achievement, and relationship problems. (Hewitt et al., 2008; Hewitt et al., 2015; Hewitt, Flett, & Mikail, 2017; Hewitt & Flett, 2002). Others have discussed perfectionism as an explanatory construct in the comorbidity of mental disorders (Bieling et al., 2004). In a sample of 345 patients from an anxiety disorders clinic, Bieling and colleagues (2004) found that higher scores on both the Hewitt and Flett and Frost MPS measures were associated with higher levels of comorbidity of Axis I disorders based on assessment on the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I, First et al., 1994). This was true even after controlling for symptom severity (Bieling et al., 2004). Within this group of outpatients, individuals in the top quartile of perfectionism had an average of 3.04 diagnoses, whereas those in the lowest quartile had an average of 1.67 diagnoses. These studies lend credence to the idea that perfectionism functions as a core vulnerability factor across different psychopathologies.  Similarly, Egan and colleagues (2011) conceptualize perfectionism as a transdiagnostic process factor, i.e. a risk factor or a maintaining mechanism across different disorders. With a focus on prospective studies, they cite evidence of elevated rates of perfectionism in individuals   11 with anxiety disorders; depression; and eating disorders compared to healthy controls, as well as research suggesting that perfectionism increases vulnerability for eating disorders, and that perfectionism predicts worse treatment outcomes for obsessive-compulsive disorder, social anxiety, and depression. Campbell and colleagues’ 2018 study also supports perfectionism as a transdiagnostic risk factor. They found that change in perfectionism over time, which they assessed using a composite measure of Frost MPS Concern with Mistakes and Doubts about Actions, was related to changes in both depression and eating disorder symptoms 6 months later (Campbell et al., 2018).  A large body of literature indicates that perfectionism is related to poorer health, greater psychopathology, and poorer well-being. Perfectionism has been linked to depression (Dunkley et al., 2009; Enns & Cox, 1999; Hewitt & Flett, 1991a, 1993, 1996, 2002; Hewitt, Flett et al., 1998), various anxiety disorders (Antony et al., 1998; Egan et al., 2014; Flett et al., 1989, 2016; Huan et al., 2008; Minarik & Ahrens, 1996; Raines et al., 2019; Rhéaume et al., 1995), eating disorders (Bardone-Cone et al., 2007; Cockell et al., 2002; Izydorczyk, 2014; Machado et al., 2014; McGee et al., 2005), personality disorders (Dimaggio et al., 2015; Hewitt et al., 1992), and suicidal behavior (Enns et al., 2003; Hewitt et al., 2006; Hewitt et al., 1997; Hewitt, Norton et al., 1998; O’Connor, 2007; Roxborough et al., 2012).  Overall, there is a strong body of evidence supporting the idea that perfectionism functions as a risk factor and maintenance factor for and is associated with many forms of psychopathology and other dysfunction. This is the case across Axis I disorders, Axis II disorders, physical health concerns, and suicidal behavior, suggesting that perfectionism is an important personality characteristic to consider in the context of psychopathology and the treatment of psychopathology. See Sirois & Molnar, 2016 for an in-depth overview of the effect   12 of perfectionism on health outcomes and Limburg et al., 2017, for a meta-analysis of the relationship between perfectionism and psychopathology. The Perfectionism Social Disconnection Model (PSDM) The PSDM is a conceptual model that combines both the interpersonal and intrapersonal experiences of perfectionists. The PSDM includes a developmental model of perfectionism from an attachment and self-development (e.g. Baker & Baker, 1987) framework, as well as an extension of an earlier model explicating how perfectionism functions in creating and maintaining dysfunction. The developmental potion of the PSDM proposes that perfectionism develops due to thwarted needs to feel connected due to asynchrony between the individual’s needs and the responses of significant figures in the individual’s early life and throughout that individual’s development. This gives rise to insecure attachment and a lack of a cohesive and resilient self. The individual’s needs for connectedness are not met, and the individual learns that important others will not respond to their needs, and that others do not value them. In hopes that their needs for connectedness might be met, individuals high in perfectionism then learn that they must be perfect and appear perfect to others, and they will not disclose or display their imperfections. The PSDM views perfectionism as an unconsciously learned way of coping that aims to compensate for the damaged self and to manage interpersonal anxiety. A perfectionist may feel on some level that if he or she is perfect or perceived to be perfect, then he or she will finally be worthwhile and accepted.  The second part of the PSDM addresses the mechanisms of perfectionism in generating and maintaining distress. The PSDM theorizes that the perfectionistic behaviors fall within two categories: problematic interpersonal behaviors (including self-concealment, hostility, excessive reassurance-seeking, and social disengagement) and interpersonal sensitivity (characterized by   13 fears of evaluation which then leads to perceptions of others as uncaring or unsupportive, and hypersensitivity to perceived criticism or rejection). Although these perfectionistic behaviors function as a bid for social connection, they actually generate further disconnection from the social environment as others are kept at a distance, perceived as threatening, or actively rejected by perfectionists. A sense of alienation and lack of belonging, perceived lack of social support, and hopelessness about future interpersonal relationships characterize the resultant social disconnection. These perfectionistic individuals feel intense shame and humiliation, and experience themselves as defective. These internal experiences are then theorized to lead to many of the problems associated with perfectionism, including depression, anxiety, other mental health difficulties, suicide risk, suicide attempts (Chen et al., 2012; Hewitt et al., 2006; Roxborough et al., 2012; Hewitt, Flett, & Mikail, 2017), and health problems (Molnar & Sirois, 2016). See Figure 1 for a visual summary of the PSDM.   A growing body of empirical evidence provides support for the PDSM. For example, in a study of 513 undergraduates, Chen and colleagues (2015) found that socially prescribed perfectionism and perfectionistic self-presentation were associated with higher levels of needing to belong, experiences of shame, and insecure attachment; and that the association between insecure attachment and these aspects of perfectionism was mediated by a strong need for belongingness and shame. Similarly, Chen and colleagues (2012) found that perfectionistic self-presentation facets were correlated with lower participant perceptions of social connectedness, and that nondisclosure of imperfection partially mediated the relationship between insecure attachment and feelings of social disconnection. Ko and colleagues (2019) found significant positive correlations between adverse parenting, attachment anxiety and avoidance, perceived defectiveness, and various components of perfectionism. In support of the developmental model of perfectionism contained in the PSDM, Ko and colleagues also found that the relationship   14 between adverse parenting and trait and self-presentational perfectionism was mediated by attachment insecurities and perceived defectiveness.  Other researchers have found that anxious attachment is associated with PSP and SPP, avoidant attachment towards mothers is associated with SPP, and that avoidant attachment towards fathers is associated with PSP (Boone, 2013). In that study, PSP fully mediated the relationship between avoidant attachment with fathers and binge eating (Boone, 2013). Parents’ self-reported levels of perfectionism also appear to be related to their daughters’ levels of perfectionism (Frost et al., 1991), parental criticism has been associated with perfectionism and insecure attachment (Rice et al., 2005), and harsh and authoritarian parenting styles have been associated with maladaptive perfectionism (Kawamura et al., 2002) again suggesting that problems in the important interpersonal relationships are related to the development of perfectionism.  Dunkley and colleagues (2000) conducted a study in 443 undergraduates that sought to identify important mechanisms in the relationship between perfectionism and distress (i.e. depression and anxiety symptomology). Structural equation modeling indicated that perceived social support as well as hassles and avoidant coping were each unique mediators that could fully explain the strong relationship between evaluative concerns perfectionism (a combination of SPP from the Hewitt and Flett MPS, and concerns over mistakes and doubts about actions from the Frost MPS) and distress. Also consistent with the PSDM, Dunkley and colleagues (2009), in a 4-year longitudinal study of a clinical sample, found that negative perceptions of social support at three years mediated the relationship between self-critical perfectionistic attitudes as measured by the DAS and depression/global psychosocial impairment over four years. Other researchers found that perceived social support significantly mediated the relationship between SPP and depression symptoms in a sample of undergraduates (Sherry et al., 2008). Another study evaluated the PSDM by examining the link between the perfectionism and suicide risk in a   15 sample of 152 psychiatric outpatient children and adolescents. Roxborough and colleagues (2012) found that PSP and SPP were associated with suicide risk, and that the relationship between PSP facets, particularly nondisplay of imperfection, and suicide risk was mediated by being bullied, which can be thought of as a measure of objective social disconnection. Furthermore, the relationship between PSP facets as well as SPP and suicide risk was mediated by social hopelessness, which can be thought of as a measure of subjective social disconnection (Roxborough et al., 2012).  Others have found that individuals higher in self-critical perfectionism experienced greater daily negative affect and lower daily positive affect, and that this relationship was mediated by avoidant coping (Dunkley et al., 2014). Specifically, Dunkley and colleagues (2014) identified that individuals higher in self-critical perfectionism often perceived that others in their social network were unwilling or unable to help them in times of stress. Another recent study examining SPP in a group of 127 undergraduates using a five-month two-wave longitudinal design found that SPP at time 1 conferred greater risk for symptoms of depression at time 2, and that this relationship was mediated by greater interpersonal discrepancies and social hopelessness (Smith et al., 2018). That is, individuals with higher levels of SPP were more likely to view themselves as falling short of others’ expectations and were more likely to feel hopeless about future social relationships and this accounted for these individuals’ higher levels of depressive symptoms at time 2, suggesting that SPP has a role in the development of depression through interpersonal mechanisms.  The PSDM presents a comprehensive model of the development of perfectionism, its links to distress, and the intervening mechanisms between perfectionism and various forms of distress. The model conceptualizes perfectionism and its relationship to distress and negative outcomes through an interpersonal lens, and it is through such a lens that I will discuss   16 perfectionism in the context of psychotherapy. The PSDM theorizes that it is interpersonal experiences that create and maintain perfectionism, and that it is also problematic interpersonal behaviors that generate the problems that perfectionistic individuals experience. Psychotherapy is a particularly relevant context in which to explore perfectionism, especially given that perfectionism has been identified as a transdiagnostic vulnerability and maintenance factor that is related to a host of psychological problems that are often treated with psychotherapy.  Relationships are central in psychotherapy: the self-disclosure of the patient, the sense of bond and trust between patient and psychotherapist, and the collaboration between the two are crucial elements of the psychotherapeutic process. Hewitt and colleagues, in a 2018 chapter, extended the PSDM to the psychotherapeutic context. They discuss how a patient’s perfectionism can negatively impact the therapeutic process due to patients’ unwillingness to disclose imperfections, their hostility, and their sensitivity towards judgments of others, and that this then leads to problems with psychotherapy outcomes (Hewitt, Flett, Mikail, Kealy & Zhang, 2017). Hostility and critical behaviors from perfectionistic patients may lead to therapists becoming angry, defensive, or feeling ineffective. These reactions from therapists, if unattended, may then lead therapists to withdraw from or act out against the patient, which ultimately leads to poor treatment outcomes for these patients. For example, a patient high in OOP may repeatedly criticize the therapist and communicate excessively stringent demands for how therapy should proceed, which may lead to the therapist feeling frustrated and full of self-doubt and may damage the therapeutic relationship. This may then impair the therapist’s willingness or ability to work collaboratively with the patient to provide a healing intervention.  Or in another example, Hewitt and colleagues (2017) discuss how perfectionistic patients’ interpersonal sensitivity may cause patients to experience the therapeutic process and relationship as one fraught with danger of judgment and rejection, which then leads these patients to approach the therapeutic relationship with at best caution and with at worst profound distrust and hopelessness. With this stance towards therapy, perfectionistic patients high in interpersonal sensitivity then fail to participate in truthful sharing of their experiences, instead   17 opting for perfectionistic self-presentational styles characterized by non-disclosure and by self-promotion. This may then cause the therapist to feel like they are unable to know important things about the patient’s experience and may impair both the therapist and patient’s ability to feel close to one another, again leading to poorer therapeutic outcomes via social disconnection in the therapeutic relationship. For example, a patient high in SPP may feel the need to present as a perfect patient, at once avoiding sharing aspects of their experience that they may feel are shameful while also experiencing mounting resentment towards the therapist for expecting them to be perfect because they know they are not perfect and will be unable to forever maintain a façade of perfection.  See Figure 2 for a visual summary of the PSDM in the psychotherapy context. With this framework of perfectionism in therapy in mind, in the next sections I will review what we know about the link between perfectionism, interpersonal problems, and problems in the context of psychotherapy.  Perfectionism in the Interpersonal Context  Relationship Problems and Perfectionism In addition to the problems described above, perfectionism has been robustly associated with interpersonal problems. Perfectionists tend towards poorer quality interpersonal relationships. For example, individuals high in perfectionism report a greater frequency of negative social interactions (Dunkley, Sanislow et al., 2006; Flett et al., 1997; Nepon et al., 2011), and individuals with higher levels of SPP report a lack of connectedness and lack of intimacy in their narratives of their friendships (Mackinnon et al., 2014). Individuals high in perfectionism have also been found to have a greater number of interpersonal problems compared to individuals lower in perfectionism (Dimaggio et al., 2015). In romantic relationships, partner perfectionism is related to lower overall adjustment in romantic relationships as well as a higher frequency of negative behaviors and fewer positive behaviors in partner interactions as rated by independent observers (Habke et al., 1997). Furthermore, SPP has been associated with poorer marital adjustment and maladaptive marital coping for both members of the relationship (Haring et al., 2003), and perfectionistic concerns longitudinally   18 predicts dyadic conflict beyond the effects of neuroticism (Mackinnon et al., 2012). In a study of chronic pain patients, Hewitt and colleagues (1995) found that SPP was associated with poor relationship adjustment, and that patients’ relationship adjustment was negatively associated with their partners’ OOP.  Mechanisms Explaining the Relationship Between Perfectionism and Poor Relationship Functioning. Why is it that perfectionists seem to suffer more than their fair share of negative experiences within relationships? In the next section, I discuss two possible answers to this question. The first answer focuses on hostile interpersonal styles, and the second focuses on a tendency to conceal oneself from others.  Perfectionism and Interpersonal Styles. The interpersonal circumplex depicts interpersonal problems in terms of two axes: a control dimension referred to as Dominance and an axis defined by affiliation, often referred to as Warmth (e.g. Wiggins, 1982). Depending on an individual’s relative scores on Dominance and Warmth they can fall into four different quadrants: friendly-dominant, hostile-dominant, hostile-submissive, and friendly-submissive (Carson, 1969). Both other-oriented and self-oriented perfectionism have been found to be associated with behaviors in the hostile-dominant quadrant of the interpersonal circumplex (Habke & Flynn, 2002; Hill, McIntire, & Bacharach, 1997; Hill, Zrull, & Turlington, 1997), with self-oriented perfectionism being linked to agreeable characteristics in women and hostility in men (Habke & Flynn, 2002). Importantly, hostile-dominant qualities have been associated with problems with the development of therapeutic alliance early on in short-term cognitive psychotherapy (Muran et al., 1994), as well as therapists’ describing their patients as seeming interpersonally distant and lacking intimacy in treatment, therapists’ beliefs that these patients have problems with involvement with others, concerns about anger and blame, and lower levels of emotional resonance in psychotherapy (Gurtman, 1996). Researchers have found that interactions with individuals high in OOP are characterized by higher levels of interpersonal hostility and lower levels of agreeableness (Hill, McIntire, & Bacharach, 1997), and OOP has been associated with arrogant, dominant, and vindictive characteristics for both men and women,   19 based on participants’ reports of their interpersonal problems, as well as arrogant and socially distant qualities in men and diverse interpersonal problems for women (Hill, Zrull, & Turlington., 1997). Perfectionism and Self-Concealment. In addition to hostile-dominant behavior, some conceptualizations of perfectionism include behavioral tendencies to conceal one’s imperfections and to promote one’s qualities of perfection. Perfectionistic self-presentation describes the interpersonal expression of perfectionism – where individuals high in PSP attempt to appear perfect to others by promoting an image of themselves as perfect and by concealing their imperfections from others. Individuals high in perfectionistic self-presentation reported being self-conscious about how others might perceive them and may try to present themselves as more perfect (or less imperfect) than they perceive themselves to be in order to gain social acceptance (Hewitt, Flett, Sherry, et al., 2003). All three perfectionistic self-presentation facets (perfectionistic self-promotion, nondisclosure of imperfection, and nondisplay of imperfection) are related to lower self-esteem and greater levels of both self-related and interpersonal distress (Hewitt, Flett, Sherry, et al., 2003).  All three Hewitt and Flett perfectionism traits have been linked to a tendency to conceal one’s imperfections and promote qualities of perfection with correlations ranging between .23 and .66, with the strongest magnitude of correlation found for SPP and nondisclosure of imperfection (Hewitt, Flett, Sherry, et al., 2003).  Kawamura and Frost (2004) found that certain measures of perfectionism were highly related to a tendency towards self-concealment, and that the tendency to self-conceal may account significantly for the psychological distress experienced by perfectionists. Other researchers have found that SPP and other perfectionistic constructs are related to a tendency to suppress negative emotions when experiencing distress (Richardson & Rice, 2015) and a fear of emotional intimacy (Dunkley et al., 2012). DiBartolo and colleagues (2008) examined the relationship between maladaptive evaluative concerns perfectionism and psychological distress and found evidence suggesting that this relationship is mediated by self-concealment as well as contingent self-worth. In a week long daily diary study of 396 undergraduates, Richardson and   20 Rice (2015) found that individuals higher in Discrepancy perfectionism were less likely to engage in disclosure to others in situations of high stress when disclosure is most beneficial, suggesting that individuals high in perfectionism have difficulties revealing that they are experiencing stress to others, thereby missing out on the opportunity for helpful social support. Another study found that based on an initial clinical interview, participants higher in perfectionistic self-promotion and nondisclosure of imperfection were less well liked by their therapists (Hewitt, Chen, et al., 2020).  Cheek and colleagues in a 2018 review and Hewitt, Flett, Mikail, Kealy, and Zhang (2017) discuss how a person high in perfectionism, particularly a person high in SPP, may attempt to come across as a “perfect” patient, working hard to put forward what he or she believes the therapist may want, rather than revealing their true selves to therapists. Psychotherapy is, of course, a highly interpersonal process where patients often must discuss their most personal problems, and as such, a failure to disclose in psychotherapy is negatively associated with symptom improvement (Kahn et al., 2001), and greater levels of discrepancy between what patients talk about in psychotherapy and what they consider to be most important (i.e. lower levels of relevant self-disclosure) is an important negative predictor of psychotherapy outcome (Farber, 2003; Farber & Sohn, 2001).   Perfectionism in Psychotherapy Psychotherapy Process and the Therapeutic Alliance  Before proceeding to further discuss perfectionism in the context of psychotherapy, I will first address some definitional issues and discuss the relationship between psychotherapy relationships and psychotherapy outcomes. The therapeutic alliance is defined as the collaborative and affective relationship between therapist and patient (Crits-Christoph et al., 2013). Alliance is typically subdivided into three components: agreement about the goals of psychotherapy, agreement about the techniques used in psychotherapy, and the affective bond   21 between patients and therapist which includes mutual trust, liking, respect, and caring (Bordin, 1979).  In support of the idea that the ingredients of successful psychotherapy are interpersonal in nature, a meta-analysis of over 200 research reports covering more than 14,000 treatments found that the overall aggregate relationship between alliance and treatment outcome was r = .275 and concluded that the overall relationship between alliance and outcome in individual psychotherapy is robust, even when publication bias is taken into account, and alliance accounts for about 7.5% of the variance in treatment outcomes (Horvath et al., 2011). This impact of alliance on outcome stands irrespective of type of rater, type of treatment, and publication source (Flückiger et al., 2012; Horvath et al., 2011). Although alliance accounts for less than 10% of the variance in treatment outcomes, it stands singularly in the literature as one of the best predictors of psychotherapeutic outcome. To put things into perspective, alliance accounts for much more of the variance in outcome than any differences between different treatment approaches and orientations (Wampold & Imel, 2015). Therapeutic alliance is one of the most important elements of psychotherapy identified thus far in the literature, and the literature supports the idea that the strength of the relationships in therapy is central to its success.  Some have argued that the explanatory power of the alliance for psychotherapy outcomes is simply an artefact of earlier symptom improvement; therefore, it is important to control for early symptom improvement and to focus on the early alliance (before symptom improvement can unduly influence alliance). Indeed, a large body of process-outcome studies indicates that the alliance is an important predictor of outcome across different psychotherapies even after addressing prior symptom change (Crits-Christoph et al., 2011). Analyses of within-patient effects of alliance revealed that therapeutic alliance at a given session predicted next session   22 symptom levels, suggesting that alliance is not just a consequence of symptomatic improvement (Falkenström et al., 2013, 2014). A recent study evaluating the dependability of alliance assessments recommends aggregating multiple assessment of alliance in order to have a dependable measure of alliance, and suggests that because most studies looking at the alliance-outcome relationship use only a single rating of alliance, estimates in the literature of an effect size of about r = .25 are likely underestimating the effects of alliance on outcome (Crits-Christoph et al., 2011).  Group Psychotherapy  Next, I briefly discuss group psychotherapy, which is the chosen treatment modality for the current paper. There are three primary reasons for my interest in group psychotherapy. First, a large body of literature demonstrates the efficacy and effectiveness of group psychotherapy, and group psychotherapy is in general more cost-effective and at least as effective as individual psychotherapy for most mental health disorders (e.g. Burlingame et al., 2013; Yalom & Leszcz, 2005). Second, the vast majority of our knowledge of how perfectionism affects psychotherapy relationships comes from the TDCRP, which specifically examined short-term individual treatments for unipolar depression. It is unclear whether the results from the TDCRP might generalize to a group psychotherapy context. Third, and perhaps most importantly, the setting of group psychotherapy may be particularly illuminating in understanding the interpersonal expression of perfectionism in the psychotherapy setting, in addition to being particularly challenging for perfectionists. Rather than relating and disclosing to a single individual who is likely predisposed towards being helpful towards patients, group psychotherapy necessitates relating and disclosing to a group of strangers with no particular allegiance towards the patient.   23 Groups present a rich interpersonal environment with many more opportunities to form and maintain important relationships compared to individual psychotherapy.  Group cohesion, which is often considered the group psychotherapy analogue to therapeutic alliance, (which has been described as a sense of belongingness in the group and a sense that the patient values the group and feel like they are in turn valued by the group (Yalom & Leszcz, 2005)) has been identified as an important curative factor in group psychotherapy. Yalom and Leszcz (2005) describes the affectively charged interpersonal interactions found in group psychotherapy as the core of group psychotherapy, and the main advantage of group psychotherapy over individual psychotherapy. Group cohesion has been correlated significantly with improved self-esteem in groups (Falloon, 1981), and Burlingame and colleagues’ 2011 meta-analysis indicated an effect size of about r = .25 for the relationship between group cohesion and psychotherapy outcome (Burlingame et al., 2011).  Group climate is a construct related to group cohesion that taps into individual group members’ perceptions of the group’s therapeutic environment. Specifically, group climate measures the degree to which group members feel engaged with the group as a whole, a concept quite similar to group cohesion, the degree to which group members perceive conflict in the group, and the degree to which they perceive that the group avoids responsibility for change (Mackenzie, 1983). Linear change in group climate is a good predictor of group member outcome (Mackenzie et al., 1987; Phipps & Zastowny, 1988; Sexton, 1993). Perceptions of an engaged group climate predicts post-treatment patient satisfaction and perceptions of success from therapy, and lower perceptions of conflict 6 weeks into treatment predicts fewer depression symptoms following treatment (Crowe & Grenyer, 2008).    24  The PSDM predicts that perfectionists’ problematic interpersonal styles, such as their tendency towards self-concealment as well as their tendency towards hostile/dominant interpersonal styles will show themselves in the context of group; only, within groups, these problematic interpersonal styles will play out within multiple relationships with both therapists and other group members. Given the distress and arousal experienced by perfectionists when disclosing their past mistakes to a single therapist (Hewitt et al., 2008), one can expect that this would be intensified in a group format. Self-disclosure appears to be crucial in group psychotherapy, with highly cohesive groups displaying greater levels of self-disclosure (Yalom & Lescz, 2005).  The purpose of this study is to evaluate the PSDM in a group psychotherapy context in order to better understand whether trait perfectionism indeed relates to social disconnection in a psychotherapy context and whether this then accounts for the relationship between perfectionism and treatment outcomes. Because of the multiple relationships present in group psychotherapy (i.e. the relationship between patient and therapist, as well as the relationship between patient and other patients), group psychotherapy provides an incredibly interpersonally rich setting in which to investigate the effects of perfectionism on relationships and treatment.  Research from the NIMH Treatment for Depression Collaborative Research Program (TDCRP) From the above review of the psychopathological, health, and interpersonal problems that perfectionists face, it is clear that perfectionism is associated with many negative experiences, both intrapersonally, in the form of various psychopathology, and interpersonally, in the form of perfectionists’ negative interpersonal styles, their lack of social support, and the objective and subjective reality of their social lives which is often characterized by a dearth of close and loving   25 relationships. There are also reasons to believe, due to previous research on psychotherapy relationships and due to theories about perfectionism, that perfectionists may have difficulties forming successful relationships in therapy. Next, let us examine what the research indicates so far about perfectionism in the context of psychotherapy.  The majority of information regarding perfectionism and psychotherapy comes from the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP) study, an extensive randomized clinical trial that compared several forms of brief treatment for depression in a large sample of depressed patients (see Elkin et al., 1985 and Elkin et al., 1989 for a thorough description of the original study). Two hundred fifty patients were assigned to one of four conditions: pharmacological treatment (imipramine) plus clinical management, placebo medication plus clinical management, 16 sessions of manualized cognitive behavioral psychotherapy (CBT), or 16 sessions of manualized interpersonal psychotherapy (IPT). All conditions involved treatment over the course of 16 weeks. The results of the study indicated improvement in depression symptoms for patients in all conditions. Generally, imipramine plus clinical management was most effective in reducing symptoms, whereas psychotherapy treatments were also effective, with similar reductions in depression symptoms for both CBT and IPT treatments, although there was some evidence for the specific efficacy of IPT for severely depressed patients (Elkin et al., 1989). Although the original aim of the TDCRP was to evaluate the efficacy of different psychological and psychopharmacological interventions in treating depression, the TDCRP also included a wealth of other data, including data regarding perfectionism. Blatt, Zuroff, and colleagues oversaw a research program investigating perfectionistic attitudes as measured by the Dysfunctional Attitudes Scale (DAS, Weissman &   26 Beck, 1978) in the context of psychotherapy using TDCRP data. Note that these studies constitute multiple analyses of the same data. Initial analyses by Blatt and colleagues found that DAS perfectionism predicted poorer treatment outcomes, as assessed by residualized gain scores of the five primary outcome measures in the TDCRP (Blatt et al., 1995; Blatt et al., 2010). DAS perfectionism was related to more severe depression symptoms, worse general functioning, and worse social adjustment as assessed by both self-report and interview measures, at end of treatment and in all four treatment conditions (Blatt et al., 1995). Because DAS perfectionism was related to worse outcomes in the TDCRP, but DAS Need for Approval was not, they identified that perfectionism as a primary disruptive factor in the short-term treatment of depression (Blatt et al., 1995).  Another TDCRP analysis building on the work of Blatt and colleagues’ 1995 study found that the negative effect of perfectionism on therapeutic outcomes was also found in ratings by therapists, independent clinical evaluators, and the patients’ reports, indicating that DAS perfectionism was not merely related to patients’ subjective reports of treatment outcomes, but rather, that there appeared to be a clear link between patients’ DAS perfectionism and their outcomes, even as observed by therapists and independent clinical evaluators (Blatt et al., 1998). Pretreatment DAS perfectionism was significantly related to patients reporting fewer beneficial effects of treatment at 18-month follow-up (less satisfying relationships, fewer coping skills, less ability to recognize the symptoms of their depression, less change in depressive attitudes) (Blatt et al., 1998). Furthermore, patients who remained relatively high in perfectionism after treatment were more vulnerable to depression when they experienced stress during the follow-up period compared to individuals lower in perfectionism (Zuroff & Blatt, 2002).    27 Another analysis of the TDCRP data focusing on interpersonal factors in the treatment of depression found that the quality of the patient-reported therapeutic relationship at the second session significantly predicted the likeliness of completing treatment as well as greater symptom improvement (Blatt et al., 1996). Patients with higher pretreatment levels of DAS perfectionism were more likely to complete treatment, but also more likely to show less improvement over the course of treatment (Blatt et al., 1996). Therapeutic relationship quality was no more than marginally predictive of better therapeutic outcome at low and high levels of DAS perfectionism, but significantly predicted therapeutic gain at moderate levels of DAS perfectionism, and this appeared to be true regardless of treatment condition (Blatt et al., 1996). These authors interpreted that finding as: 1) patients low in DAS perfectionism were able to benefit from psychotherapy regardless of quality of therapeutic relationship, 2) patients high in DAS perfectionism had worse psychotherapy outcomes, even with a high quality of therapeutic relationship, and 3) patients with average levels of DAS perfectionism either benefited or did not benefit from treatment depending on the quality of the therapeutic relationship (Blatt et al., 1996).  Zuroff and colleagues (2000) examined the relationship between DAS perfectionism and therapeutic alliance over time in the TDCRP, based on both patient ratings of the alliance on the Barret-Lennard Relationship Inventory (B-L RI, Barrett-Lennard, 1986) as well as observer videotape coding of sessions based on the Vanderbilt Therapeutic Alliance Scales (VTAS; Hartley & Strupp, 1983). Note that observed alliance was split into patient contributions to alliance (the extent to which the patient is open and honest with the therapist; agrees with the therapist about tasks, goals, and responsibilities; and is actively engaged in therapeutic tasks) and therapist contributions to alliance (whether the therapist is committed to helping the patient,   28 whether the therapist conveys his competence, and the extent to which the therapist acknowledges the validity of the patients’ thoughts and feelings) (as per Krupnick et al., 1996). They found that patients with high levels of DAS perfectionism had trouble developing a strong alliance with their therapists. In general, there was an increase in observed patient contributions to alliance over time from Session 3 to Session 9 to Session 15; however perfectionists’ patient contributions to alliance, while in line with non-perfectionists’ from session 3 to 9, failed to increase after session 9 (Zuroff et al., 2000). Furthermore, changes in patient contributions to alliance mediated the relationship between DAS perfectionism and clinical improvement, and including this mediator explained over half of the variance in outcome attributable to perfectionism, from 9% to 4% (Zuroff et al., 2000).  Shahar and colleagues (2004) built on Zuroff and colleagues’ 2000 study, nothing that the remaining direct effect of perfectionism on treatment outcome was still significant after taking into account therapeutic alliance, suggesting the presence of other mediators. Shahar and colleagues (2004) evaluated an additional mediator: the quality of patients’ social networks outside of therapy. The quality of participants’ social networks was operationalized as both the number of relationship domains that were assessed to be either somewhat satisfying or very satisfying, and by the number of people with which the patient reported close and satisfying relationships. They found that the relationship between participants’ pre-treatment DAS perfectionism and worse outcomes in therapy was mediated by lower quality social networks over the course of treatment. Consistent with the PSDM, the authors discussed how perfectionists have difficulty with relationships both within and outside of therapy due to difficulties attending to positive interpersonal cues, avoiding intimacy and self-disclosure, and acting in a hostile manner. They further discussed the possibility that perfectionists project their   29 own self-criticism onto others and therefore expected harsh criticism from others. This expectation then would potentially exacerbate their negative representations of the self and others, leading to a vicious interpersonal cycle. Further analyses found support for DAS perfectionism as a unique predictor of relationship problems, with DAS perfectionism, but not personality disorder features, predicting patients’ contribution to the therapeutic alliance and satisfaction with social networks outside of therapy (Shahar et al., 2003). Finally, in another analysis of the TDCRP data, Hawley and colleagues (2006) used a latent difference score (LDS) analytic framework to examine longitudinal relationships between DAS perfectionism, depression symptoms, and observer-rated alliance. They found that the strength of patient contributions to the therapeutic alliance during an early session of treatment predicted the rate of change in perfectionism, and that perfectionism change predicted the subsequent rate of depression symptom change. This pattern of data supports a personality vulnerability model of the relationship between perfectionism and depression – where perfectionism constitutes a personality factor that increases vulnerability to experiencing depression symptoms.  Other Papers Investigating Perfectionism As a Predictor Of Treatment Outcome Although the bulk of our knowledge about the harmful effects of perfectionism in psychotherapy and particularly the relationship between perfectionism and therapeutic alliance comes from the TDCRP, a number of other studies support the idea that perfectionism is related to worse outcomes from psychotherapy. In a study of 439 clinically depressed adolescents enrolled in the Treatment for Adolescents with Depression (TADS) RCT study, individuals with higher levels of DAS perfectionism continued to show elevated depression scores across the treatment period regardless of the treatment condition to which they were assigned, and DAS   30 perfectionism was related to less improvement in symptoms related to suicidality (Jacobs et al., 2009). Treatment outcomes were partially mediated by change in DAS perfectionism over the 12-week period of treatment, suggesting that smaller decreases in DAS perfectionism accounted for worse outcomes in treatment (Jacobs et al., 2009). Another study using DAS perfectionism, found that higher levels of perfectionism assessed while participants were inpatients for severe depression were associated with higher levels of suicidal ideation six months after hospital discharge (Beevers & Miller, 2004).  Another study examining change in unidimensional perfectionism in a sample of 111 patients with personality disorder diagnoses who received long-term hospital-based psychodynamic treatment found that pre-treatment levels of self-critical perfectionism did not predict decreases in symptomatic distress (Lowyck et al., 2017). However, Lowyck and colleagues (2017) found that changes in self-critical perfectionism were associated with rate of decrease in symptomatic distress over time with a large effect size of r=.81. Kay-Lambkin and colleagues (2017) examined DAS perfectionism as a potential moderator of the relationship between intervention type and outcome in a randomized control trial evaluating several treatments for individuals with concurrent mood and substance use difficulties. They found that individuals with higher levels of pre-treatment perfectionism who received therapist-delivered CBT/MI reported worse depression outcomes than those low on perfectionism. However, those with higher perfectionism scores who received a computerized CBT/MI treatment reported better depression outcomes than those low on perfectionism, providing preliminary evidence suggesting that perfectionists may respond differently to different kinds of interventions. In particular, perfectionists may respond better to a computerized treatment with no direct interpersonal interaction compared to more traditional therapies involving direct therapist interaction.    31 Another study examined the examined the effects of self-critical perfectionism on treatment outcome (i.e. self-reported pain symptoms) in a group of 53 chronic pain patients taking part in a 2-week (4 sessions over 2 weeks) CBT-based psychoeducation intervention for chronic pain, and found that higher levels of pre-treatment self-critical perfectionism were related to negative treatment outcomes, even after taking into account pre-treatment levels of depression (Kempke et al., 2013). Sutandar-Pinnock and colleagues (2003) found that lower scores on the perfectionism subscale of the Eating Disorder Inventory (EDI; Garner et al., 1983) were associated with better treatment response for 55 individuals taking part in inpatient treatment for anorexia nervosa. All of the data reviewed thus far looking at the relationship between perfectionism and treatment outcome are based on unidimensional measures of perfectionism. Next, I will review several studies using multidimensional measurement of perfectionism. First, a study assessing the effectiveness of a psychoeducational intervention for perfectionism found that the amount of improvement in trait perfectionism and perfectionistic automatic thoughts predicted greater improvements in psychological distress (Arpin-Cribbie et al., 2012).  Another study examined session-by-session symptom changes in a sample of 105 adult patients who presented for counseling at a psychology treatment clinic using a short version of the Almost Perfect Scale. In this study, Discrepancy perfectionism was associated with higher levels of interpersonal problems and distress at the outset of psychotherapy, but not at the end of psychotherapy (Rice et al., 2015). Individuals high in Discrepancy began treatment with higher levels of distress and displayed a steeper slope of improvement than individuals low in Discrepancy, until they reached a similar, lower level of distress at the end of treatment as individuals lower in Discrepancy. Also, contrary to other findings regarding the deleterious effects of perfectionism on therapy outcome, individuals high in Standards perfectionism   32 reported lower levels of interpersonal problems at the start of therapy, as well as generally lower levels of interpersonal problems at the end of treatment. These findings did not support the idea that pre-treatment perfectionism is associated with worse treatment outcomes. However, it is interesting to note that participants in the Rice and colleagues study that displayed both high Standards and Discrepancy showed little change in the quality of their interpersonal relationships over treatment compared to other groups (i.e. no improvement), suggesting that even though there were no post-treatment differences in symptom levels, perfectionists appeared to have more enduring interpersonal problems in psychotherapy (Rice et al., 2015).  Chik and colleagues (2008) examined the relationship between perfectionism and treatment outcome for patients taking part in short-term individual and group cognitive therapy (CT) or exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD). They found that pre-treatment Doubts About Actions from the F-MPS predicted less improvement in OCD symptoms following treatment. Another study with OCD inpatients taking part in short-term ERP treatment found that perfectionism (in this case, meeting the DSM-5 OCPD criterion for perfectionism according to clinical interview) predicted worse treatment outcomes even after controlling for baseline OD severity, Axis I and II comorbidity, prior treatment, quality of life, and gender (Pinto et al., 2011).  Enns and colleagues (2002) conducted one of the few studies to examine the impact of change in multidimensional perfectionism, rather than pre-treatment multidimensional perfectionism, on psychotherapy outcome, finding that change scores for SPP but not SOP were associated with improved symptomatic outcome at the end of 12 weeks of group CBT therapy for depression. Interestingly, they found that change in SPP, but not baseline levels of SOP and SPP were associated with therapy outcome.    33 Next, a study by the Hewitt group (2015) evaluated the effectiveness of a short-term psychodynamic/interpersonal group intervention that specifically targeted perfectionistic behavior. The authors found large effect sizes in changes in perfectionism from pre- to post-treatment, with the exception of SPP, which showed a medium effect size. Importantly, change in perfectionism was associated with improvement in depressive symptoms and interpersonal problems. A follow-up paper found that these reductions in perfectionism were not merely based on participants’ self-perceptions, but that close others of the participants taking part in the treatment study also reported that they observed significant reductions in patients’ perfectionism at post-treatment and follow-up, including for SOP, OOP, and PSP facets, but not for SPP (Hewitt et al., 2019).   Finally, a recent study evaluated the effects of perfectionism for group cognitive behavioral treatment of depression in a group of 156 participants. The researchers found that OOP and SPP were associated with smaller reductions in depression over treatment, and path analysis revealed that all three of SOP, OOP, and SPP indirectly predicted smaller reductions in depression through a perceived lack of quality friendships (Hewitt, Smith, et al., 2020). This is the only study reviewed here that investigates the mediating role of relationships in the link between multidimensional trait perfectionism and changes in psychotherapy outcome. These results are consistent with predictions with the PSDM given that the effects of perfectionism on reductions in depression was mediated by social disconnection, albeit outside the group, rather than by social disconnection directly in the psychotherapy context.  Overall, a number of studies examining individuals taking part in treatments for a variety of different presenting problems, with individuals both taking part in inpatient and outpatient treatment, in both individual and group formats provide evidence that at least some forms of   34 perfectionism are related to worse psychotherapy treatment outcomes in most cases, though there remains some questions about what types of perfectionism are most consistently related to psychotherapy outcomes. Most of these studies use pre-treatment perfectionism as a predictor for later outcome. Less is known about how changes in perfectionism affect later outcome. However, preliminary evidence from at least several studies suggest that change in perfectionism may be important and relevant in addition to pre-treatment perfectionism in predicting psychotherapy treatment outcome.   Perfectionism and Interpersonal Phenomena in Therapy  Studies using the Hewitt and Flett CPMB suggest that perfectionism exerts adverse effects on every part of the psychotherapy process. Even earlier than the first session, a study looking at the relationship between PSP and help seeking attitudes found that, individuals high in PSP expressed more negative attitudes towards seeking professional psychological help and expressed less confidence in the mental health profession compared to individuals lower in PSP (Hewitt et al., in prep). Another study divided individuals into three categories: students who were not distressed, students who were in psychological treatment, and students who were distressed but were not in treatment, and found that the distressed but not in treatment group was distinct from the other two groups due to higher levels of SPP (Ey et al., 2000). These studies suggest that individuals high in perfectionistic traits and self-presentation likely are more reluctant to seek help and engage with mental health treatment. Consistent with the PSDM, such patients may be more likely to self-conceal and may have more difficulty establishing a trusting therapeutic alliance.   Hewitt and colleagues (2008) conducted a study investigating the effects of perfectionism on patients’ and therapists’ experiences of an initial clinical interview in a sample of 90   35 participants with various presenting problems. On the participant side, they found that higher levels of PSP were associated with greater distress before and after the interview, more negative expectations and greater experiences of threat prior to the interview, and higher levels of post-interview dissatisfaction (Hewitt et al., 2008). Furthermore, they found that PSP was associated with greater change in heart rate when discussing past mistakes. Altogether, the authors concluded that PSP may lead to greater emotional distress during a clinical interview, perceptions of therapists as more threatening, and may lead to a lower rate of disclosure in psychotherapy (Hewitt et al., 2008).  On the therapist side, Hewitt, Chen, and colleagues (2020) conducted a re-analysis of the 2008 study with a focus on the therapist experience of the interview. They found that participants’ levels of SOP, OOP, SPP, and PSP were negatively related to the extent to which therapist liked their patients, wanted to work with them in the future, and expected patients to benefit from treatment. Specifically, after controlling for patients’ level of distress, OOP and non-display of imperfection were positively related to clinician-rated hostility; SOP, SPP, and non-disclosure of imperfection were related to less favorable clinician impressions of the patient; and OOP and non-display of imperfection predicted less favorable clinician impressions by way of higher levels of clinician-rated hostility. Clinician impressions of patients were based on a composite of clinicians’ ratings of how much they liked patients, how much they would like to continue seeing the patient, and how likely they thought the patients would benefit from therapy.  These studies indicate that perfectionism may have a deleterious effect on both the patient and therapist experience of psychotherapy even as early as the assessment stage of psychotherapy, and that multidimensionally measured perfectionism may negatively affect the relationship between therapist and patient from the initial stages of the psychotherapy process.   36 The importance of this work is underlined by a review of the literature which concludes that patient-rated therapeutic alliance following an initial assessment is significantly related to patient-related alliance later in treatment, supporting the notion that foundations of later therapeutic alliance are built during the initial alliance phase (Hilsenroth & Cromer, 2007), and a large number of studies suggest that early alliance, though not a sole predictor of therapeutic outcome (in fact, there is support that alliance at every stage of therapy is a good predictor of therapeutic outcome), is decisively related to therapeutic outcomes (e.g. Martin, Garske, & Davis, 2000; Strauss et al., 2006).  Summary of the Research Literature This study seeks to evaluate the PSDM in the context of psychotherapy in order to assess whether perfectionism relates to impaired psychotherapy relationships and whether this then accounts for the worse outcomes that perfectionists appear to suffer in psychotherapy. The TDCRP papers and a number of other studies provide evidence that perfectionism is related to worse treatment outcomes, and the TDCRP papers indicate that this may be due to problems with alliance; however, there remain many unanswered questions. First, although the literature provides some reassurance about the generalizability of the negative effects of perfectionism on treatment outcome across different treatment contexts, there is less evidence about the generalizability of the negative relationship between perfectionism and therapy relationship quality. What we know about the relationship between perfectionism and therapy relationship quality is based primarily on the TDCRP papers, which were based on a single sample of individuals with unipolar depression taking part in individual therapy using a unidimensional measure of perfectionistic attitudes. There is little known about how perfectionism measures reflecting a contemporary understanding of the multidimensional nature of perfectionism may be   37 related to therapy relationship quality. It is an open question whether there exists a relationship between multidimensional perfectionism and therapeutic alliance or other therapeutic relationship quality variables.  Furthermore, the majority of studies examining perfectionism in the context of psychotherapy focuses on the relationship between pre-treatment perfectionistic attitudes, therapy outcome, and therapeutic alliance. There is less known about how change in perfectionism over the course of treatment may affect therapeutic alliance and how that may in turn affect therapy outcome. A small number of studies indicate that decreases in perfectionism may be related to greater improvement in therapy, but it is unknown if this is due to changes in therapy relationship quality, though two studies provide evidence suggesting that at least the quality of outside relationships are important. Given that perfectionism has been identified as a disruptive factor in psychotherapy, there are important clinical implications if changes in perfectionism lead to changes in therapy relationships and therapy outcome. Targeting perfectionism in treatment may then be a promising avenue to improve therapy relationships and therapy outcome. The PSDM posits that the distressing outcomes related to perfectionism (e.g. depressive symptoms) are mediated by social disconnection. Then, one would expect that targeting perfectionism in treatment might lead to greater social connectedness in the therapy setting, which would then lead to better outcomes from therapy. The literature to date has not directly assessed the question of whether changes in multidimensional perfectionism over time are related to changes in therapy relationship quality and therapeutic outcomes in turn.  Description of the Current Study The current study evaluates the PSDM in the psychotherapy context and examines the relationship between perfectionism and psychotherapy relationships beyond the context of   38 individual treatment of depression. The PSDM, when extended to the context of psychotherapy, predicts that individuals high in perfectionism will struggle in psychotherapy due to interpersonal difficulties by both creating and perceiving social disconnection in therapy relationships, and that this will then lead to negative therapy outcomes (i.e. higher levels of depression symptoms and greater interpersonal distress). The current study evaluates this question as well as several others. First, is there a relationship between therapeutic relationship quality and multidimensional perfectionism, an empirically validated, contemporary view of perfectionism? The majority of the research conducted on the relationship between perfectionism and therapy relationships is based on an attitudinal, unidimensional view of perfectionism. Second, much of the research thus far has only looked at pre-treatment perfectionism and its relationship to outcome. The current study takes a closer look at the relationship between perfectionism and therapeutic process, and examines initial levels of perfectionism as well as the effects of changes in perfectionism on changes in therapy relationship quality. Finally, the current study seeks to explicate the relationship between perfectionism and poorer outcomes (greater levels of symptoms and interpersonal distress) in therapy by directly evaluating whether that relationship is mediated by poorer therapy relationship quality. Guided by the PSDM, I predicted that pre-treatment perfectionism would be related to lower quality therapeutic relationships initially, and that as individuals decreased in perfectionism, they would display increases in therapeutic relationship quality, and that this would in turn predict better psychotherapy outcomes.  The current study examines the relationship between initial perfectionism and change in perfectionism over the course of treatment and the concurrent development of therapeutic relationships within the context of a 10-week psychodynamic-interpersonal group psychotherapy aimed at reducing perfectionism. Previous analyses of data from the current study found that participants displayed large decreases in perfectionistic traits over the course of the treatment,   39 and that these decreases in perfectionism predicted decreases in depressive symptoms as well as interpersonal problems (Hewitt et al., 2015). The current study asks whether those decreases in perfectionistic traits were related to the changes in the quality of the participants’ therapy relationships. Perfectionism was assessed pre- and post-treatment, and therapy relationship quality, including patient-therapist relationship quality and patient and group relationship quality were assessed at multiple time points over the course of the 10-week treatment.  Following the PSDM, I predicted that:  Hypothesis 1: Participants’ pre-treatment levels of trait perfectionism would be related to initial quality of therapeutic relationships.  Hypothesis 2: As participants displayed decreases in perfectionism that quality of therapeutic relationships would increase. Hypothesis 3: These increases in therapy relationship quality would then account for improved therapy outcomes.                 40 Method Participants Participants were part of a dataset from the University of British Columbia Perfectionism Treatment Study (Hewitt et al., 2015, 2018).  This project sought to evaluate the efficacy of a short-term, intensive psychodynamic/interpersonal group treatment based on a multidimensional conceptualization of perfectionism. Participants were recruited from the community from the Vancouver, Canada area using posters at college campuses and community centers, newspaper articles in Vancouver newspapers, and radio talk show interviews advertising a group treatment program for perfectionism. Interested potential participants were asked to contact the lab for further information. The recruitment flow was as follows: 262 individuals contacted our lab (98 men, 162 women), 175 individuals took part in a phone screen (55 were unable to be reached, and 30 indicated they were no longer interested in participating). During the phone screen, individuals were briefly asked about their difficulties with perfectionism and were asked questions to ensure eligibility for participation. Individuals were screened out of the study if they endorsed severe psychopathology, prior hospitalizations due to psychotic symptoms, and poor proficiency with the English language as groups were conducted in English. 168 individuals were eligible for further assessment, and of those, 127 scheduled and attended an assessment appointment.  During the assessment appointment, individuals were evaluated for levels of perfectionism. They were eligible to continue if they displayed high levels of at least one form of perfectionism (at least half a standard deviation above the mean based on previous community samples using the Multidimensional Perfectionism Scale and the Perfectionistic Self-Presentation Scale). All but 7 participants met this criterion. Individuals were also screened out   41 of study participation if they endorsed severe psychopathology (i.e. current suicidal ideation, psychotic symptoms, or symptoms or antisocial personality disorder) of if they reported that they had never has a close relationship with another person. A further 15 participants were screened out based on these criteria.  105 individuals were offered positions in groups, with 72 scheduled for at least the first group session. One participant dropped out prior to the start of group due to scheduling difficulties, leaving 71 participants that were assigned to treatment groups based on balancing gender, age, disclosure level, type of perfectionism, and ability to attend all sessions between groups. These criteria were used to limit dropout and facilitate group cohesion (Gans & Counselman, 2010; Yalom & Leszcz, 2005). 61 participants started treatment at this point, and 18 were placed in a waitlist control condition. Individuals were placed on the waitlist when their characteristics (i.e. gender, age, type of perfectionism, and disclosure level) were already represented in treatment groups, or if they were unable to attend all sessions in the initial phase of the study. When two individuals with the same characteristics were considered for treatment vs. control, the individuals were randomly assigned. A total of 60 participants completed the treatment and post-treatment assessment, and 44 participants completed the 4-month follow-up assessment. 53 participants were in the initial treatment condition, and 18 in the waitlist control condition. Those 18 individuals in the waitlist control condition waited 11 weeks (i.e. the duration of a full course of group treatment) and then 17 accepted the offer of psychotherapy.  Group Psychotherapy  Participants took part in a 10-session psychodynamic/interpersonal group psychotherapy focused on treating perfectionism. The primary goal of the group was focused on reducing   42 perfectionism, but other outcomes measured included depression and anxiety symptoms and interpersonal functioning.   Participants completed two pre-group sessions aimed at enhancing participation and benefits from treatment (Mackenzie, 1990). The groups ran for 11 consecutive weeks, with both pre-group sessions taking place during the first week and treatment sessions held weekly over the next 10 weeks. Each session was 1.5 hours in length, and each group was composed of 7 to 10 participants. Therapists were senior level graduate students in clinical psychology. All therapists had at least four years of supervised clinical experience and were trained extensively on the treatment. Each group had one male and one female therapist with a total of two male and three female therapists. The therapists took part in weekly supervision that involved review of videotapes, feedback on each therapy session, and adherence to the treatment protocol. Therapists, from the assessment phase and throughout the treatment process, discussed clinical formulations for each patient, with individualized formulations for the genesis, manifestation, and maintenance of patients’ perfectionism, understood through a lens of past interpersonal experiences (Hewitt et al., 2018). Patients were given feedback about their personal case formulations following the assessment stage. Groups were closed; no new members joined once the group commenced.  Measures Perfectionism Multidimensional Perfectionism Scale (MPS). The MPS is a widely used 45-item scale that assesses trait dimensions of perfectionism: self-oriented, other-oriented, and socially prescribed perfectionism (Hewitt et al., 1991). Participants rate items on a 7-point Likert scale with higher scores indicating higher levels of trait perfectionism. The measure displays good   43 psychometric properties, including high levels of reliability and validity (Hewitt & Flett, 1991a, 1991b; Hewitt et al., 1991).  Outcomes Beck Depression Inventory (BDI). The BDI) is a frequently used 21-item measure of depressive symptoms (Beck et al., 1961). Participants are asked to rate the intensity with which they experience different symptoms in the past week on a four-point scale. A meta-analysis of the BDI’s internal consistency range from α = .81 for nonpsychiatric patients to α = .86 for psychiatric patients (Beck et al., 1988).  Beck Anxiety Inventory (BAI). The BAI is a 21-item measure that assesses various anxiety symptoms including subjective, neurophysiological, autonomic, and panic symptoms (Beck et al., 1988). Participants rate the severity of each symptom over the previous week on a four-point scale. The BAI has demonstrated good test-retest reliability (Beck et al., 1988) as well as good discriminant validity (Beck & Steer, 1991).  Inventory of Interpersonal Problems (IIP). The IIP is a commonly used and well-researched instrument measuring different types of self-reported interpersonal problems, and has been shown to exhibit good sensitivity to clinical change (Horowitz et al., 1988). The IIP contains 127 items assessing the presence and severity of different interpersonal problems, with participants rating each problem in terms of how distressing it has been on a scale from 0 (not at all) to 4 (extremely). Total IIP score is used as a general measure of overall interpersonal distress, while six subscale scores indicate problems in specific areas (difficulties with assertiveness, sociability, intimacy, submissiveness, over responsibility, and being too controlling) (Horowtiz et al., 1988; Horowitz et al., 2002).     44 Therapy Relationship Variables Group Climate Questionnaire (GCQ). The GCQ (Mackenzie, 1983) is a 12-item questionnaire that assesses individual group members’ perceptions of the group’s therapeutic environment. It consists of three factor-analytically derived subscales: Engagement (which includes items assessing self-disclosure, cognitive understanding, and confrontation), Avoidance (the extent to which group members avoid responsibility for change), and Conflict (the perceived level of interpersonal conflict and distrust). Participants rate items on a 7-point Likert scale with higher scores indicating higher levels of Engagement, Avoidance, or Conflict. The Engagement subscale in particular is related to the concept of group cohesion (Mackenzie, 1983). The GCQ is a widely used measure of group climate and its validity has been tested extensively, with various studies indicating the measure’s construct validity (it has been linked to outcome, process, and group differences in a variety of populations (Mackenzie et al., 1987; Tschuschke & Greene, 2002), and displays good internal consistency (Kivlighan & Goldfine, 1991).  The Psychotherapy Process Observational Coding System – Alliance Scale (TPOCS-A). The TPOCS-A is a 9-item observational alliance coding system that draws from a number of different alliance scales (McLeod & Weisz, 2005). The TPOCS-A shows acceptable interrater reliability and internal consistency in both children and adults, and ratings on the TPOCS-A predict symptom reduction at the end of treatment (McLeod & Weisz, 2005). The TPOCS-A was chosen because it differentiates bond and task dimensions of the alliance, and it has a direct analogue for group cohesion, the TPOCS-GC, which is described below.  The Psychotherapy Process Observational Coding System – Group Cohesion Scale (TPOCS-GC). The TPOCS-GC is the group psychotherapy analogue of the TPOCS-A and measures group cohesion between individual patients and other group members (Lerner et al.,   45 2013). To the author’s knowledge, it is the only formal observational coding system for relationships in group psychotherapy that has been psychometrically assessed. The TPOCS-GC demonstrates modest to strong item-level interrater reliability and good internal consistency, and there is evidence of its construct and predictive validity based on its correlations with various conceptually related variables (Lerner et al., 2013).  Data Collection Procedures Participants completed a pre-treatment assessment package, a post-treatment assessment package, and a four-month post-treatment follow-up assessment package. In addition to these questionnaires, participants completed the Group Climate Questionnaire on a session-by-session basis. All sessions were videotaped. Based on these videotapes, a team of undergraduate coders completed coding for observed levels of alliance and group cohesion using the TPOCS-A and the TPOCS-GC for every odd numbered session (sessions 1, 3, 5, 7, and 9).  Coding Procedures Coders. The coding team was comprised of six undergraduate psychology students at the University of British Columbia and myself. All coders conducted TPOCS-A and TPOCS-GC ratings concurrently and were naïve to patient perfectionism scores, treatment outcomes, and session number. Individual client-sessions were coded. That is, coding was completed for each client within each session. The coding team reviewed each client within each session separately. Sessions 1, 3, 5, 7, and 9 were coded for each client. Most previous studies looking at the effects of perfectionism on therapeutic alliance assessed alliance at either a single point over the course of the therapy, or at a maximum of three points during the therapy. By coding every other session, the measurement in the current study offers a finer-grained vision of the development of therapeutic alliance and group cohesion over the course of group therapy. In total, there were 239   46 client-sessions coded for 60 clients after taking into account absences and problems in the initial video recordings. There was one group session that was not properly recorded, and one group session with missing audio, and these two sessions were not coded.  Coder training. Each member of the coding team completed a training period prior to coding client-sessions for the study. Training comprised reviewing TPOCS-A and TPOCS-GC scoring manuals with myself, and reviewing and practicing coding client-sessions selected for training. Five specific client-sessions were selected for training. These client-sessions were selected at random and came from even number sessions of the group therapy. These training client-sessions were not included in the main body of data (odd number sessions) used in this study.  First, all members of the coding team watched and coded the first training client-session with the author. We discussed our notes and discussed all coding items until we came to a consensus on our ratings. The subsequent four training sessions were coded independently but were discussed with the author and with other members of the coding team. Inter-rater reliability was assessed using a two-way mixed random effects, average-measures intraclass correlation (ICC).  An acceptable ICC is >.59 according to Cichetti (1994). Inter-rater reliability was good. ICCs for overall scores on the TPOCS-A and TPOCS-GC training sessions were .90 and .80 respectively. The high ICC indicates a high degree of agreement across raters.  Coding of therapy videos. After completing coding of the training client-sessions, 239 client-sessions were each coded by two coders. Two coders were randomly assigned to each client-session. Client-sessions were coded in random order, with coders blinded to group and session number. Each coder was assigned 2-3 client-sessions per week. Coders were instructed to watch each 1.5-hour client-session in its entirety prior to making ratings on the TPOCS-A and   47 TPOCS-GC. While watching each client-session, coders were asked to take notes about client behaviors and to indicate whether each behavior was in response to a fellow group member or in response to a therapist. Behaviors noted included all verbal utterances by clients as well as overt non-verbal behaviors such as nodding, laughing, touching another client’s shoulder, or crossed arms. Coders also noted other observations, such as when a client spoke very quietly or if they spoke in an aggressive tone. Immediately after watching each client-session and referencing notes, each coder made global subjective ratings on the items on the TPOCS-A and TPOCS-GC.  The coding team met for an hour weekly and discussed scoring on each item for each client-session in order to increase inter-rater reliability. In addition, weekly reliability assessments using ICC(1,1), one way random effects for average measures characterized by consistency, (Cichetti, 1994; Shrout & Fleiss, 1979) were performed and results were discussed in weekly meetings. Once a month, in order to minimize coder drift, all coding team members were assigned the same client-session. We discussed our scoring on each item as a team. Overall, ICC(1,1) was at .84 for TPOCS-A total score .82 for the TPOCS-GC total score. These indicate a high degree of agreement across coders and TPOCS-A and –GC ratings were therefore deemed to be suitable for use in the hypothesis tests of the current study.  Statistical Analyses Hypothesis 1 and 2 Hypothesis 1 was that participants’ pre-treatment levels of trait perfectionism would be related to initial quality of therapeutic relationships. Hypothesis 2 was that as perfectionism decreases, rates of change of alliance, cohesion, and group climate variables would increase. In order to evaluate these hypotheses, I conducted a series of multilevel model (MLM) analyses. Because psychotherapy data is nested by design – that is, researchers take repeated   48 measurements from the same individuals who are clustered into groups – it is important to use statistical techniques that take into account the non-independence of the data (Tasca & Gallop, 2009; Tasca et al., 2009). Rather than using multivariate analysis of variance (like in Zuroff et al.’s 2000 study), recent statistical research suggests that multilevel modeling would be more appropriate when studying change in therapy relationship variables and outcome over time (Tasca & Gallop, 2009; Tasca et al., 2009; Raudenbush & Bryk, 2002). As such, I used a MLM analytic approach, in which repeated sessions at Level 1 were nested within individual participants at Level 2, who were nested within different psychotherapy groups at Level 3.  Outcome variables for Hypothesis 1 were the intercepts of therapy relationship quality variables centered around the first session of treatment: self-reported group climate (subscale scores on the GCQ), observed therapeutic alliance (total score on the TPOCS-A), and observed group cohesion (total score on the TPOCS-GC). Predictors for Hypothesis 1 were pre-treatment levels of SOP, OOP, and SPP. I examined therapy relationship variables at the first treatment session because I expected that individuals who began the study exhibiting higher levels of perfectionism would initially present with more difficulties with forming meaningful interpersonal relationships in group therapy.  For Hypothesis 1, I expected that higher pre-treatment levels of SOP, OOP, and SPP would be related to lower intercepts of therapy relationship quality variables.  Outcome variables for Hypothesis 2 were the slopes of change in the same therapy relationship variables. Predictors for Hypothesis 2 were difference scores on the three perfectionism traits from pre-treatment to post-treatment. The treatment in the current study focused on reducing perfectionism, and one of the main questions of interest is whether reductions of perfectionism lead to clinically important changes in therapy relationships and   49 subsequent therapy outcomes. Specifically, Hypothesis 2 evaluated whether larger reductions in perfectionism were related to greater increases in the quality of therapeutic relationships. For Hypothesis 2, I predicted that larger pre- to post-treatment decreases on SOP, OOP, and SPP would be related to steeper slopes of improvement in therapy relationship quality variables.  For both Hypothesis 1 and Hypothesis 2 statistical analyses occurred in several stages. First, because I expected considerable individual variation in patterns of alliance and cohesion (e.g. Stiles & Goldsmith, 2010), I examined individual plots for each therapy relationship variable session-by-session to get an initial impression of the pattern of the data, and to see if the data appear to follow similar trends (linear, curvilinear, etc.) for different participants. I also inspected these plots for any frequently occurring “hinge-points” in change for clients, especially given previous findings that some perfectionists will stop improving around the midpoint of treatment (e.g. Zuroff et al., 2000).  Next, I assessed whether the data violated the assumption of independence by calculating the intraclass correlation coefficient for each dependent variable (i.e. are data independent from each other across groups?), which indicates the necessity of using MLM modeling. According to Kenny, Kashy, and Bolger (1998) when the intraclass correlation for the grouping variable is less than .05, the effect of dependence in the data can be ignored.  Models of different measures of alliance and cohesion (i.e. TPOCS-A total score, TPOCS-GC total score, and the three GCQ subscales) were analyzed separately. Models were estimated using the mixed function in IBM SPSS Statistics 23 under maximum likelihood. For each outcome measure, I used an iterative process to evaluate the effects of different perfectionism trait dimensions and self-presentational facets. See Table 1 for a summary of the process I used to evaluate the effects of perfectionism on alliance and cohesion.    50 Hypothesis 1. For each therapy relationship quality outcome measure, I evaluated four, increasingly complex sets of models. I first fit Model A: the unconditional means model, which partitions and quantifies outcome variation across participants without regard to time, in order to establish whether there is systematic variation in the outcome variable across participants worth exploring. The unconditional means model takes the following form:  Level 1: !!"# =  !!!"+ !!"# Level 2: !!!" =  !!!! + !!!" Level 3: !!!! = !!!! + !!!! The outcome variable !!"# for occasion i for person j nested in group k is composed of deviations around  !!!", the person-specific mean, !!!! , the group mean, and !!!!, the grand mean. At level 1, the observed value of Y deviates from individual j'’s true mean !!!" by !!"!. At level 2, the individual mean !!!" deviates from the group mean !!!! by !!!" . At level 3, the group mean !!!! deviates from the grand mean !!!! by !!!! . The level 1 residual !!"# represents “within-person” variation whereas the level 2 residual !!!" represents “between-person” variation, and the level 3 residual !!!! represents “between-group” variation. The primary reason for evaluating the unconditional means model is to assess the amount of outcome variation that exists at each level in order to determine if there is sufficient variation at that level to warrant further analysis.  In the next step, I fit Model B: the unconditional growth model, which introduces the time predictor into the model.  The unconditional growth model takes the following form:       51 Level 1: !!"# =  !!!" +  !!!"(!"!!#$% − 1)+  !!"# Level 2: !!!" =  !!!! + !!!"    !!!" =  !!"! + !!!"   Level 3: !!!! = !!!! + !!!! !!"! = !!"" + !!"! At level 1, the observed value on the outcome variable for person j in group k on occasion i is expressed as a function of the individual’s mean value on the outcome variable !!!" , the individual’s change trajectory (i.e. slope) !!!" and a level 1 residual term !!"# . At level 2, individual i's mean !!!"  deviates from the group mean !!!! by !!!", and individual i's change trajectory !!!" deviates from the group mean rate of change !!"! by !!!". At level 3, group k’s mean value !!!! deviates from the grand mean !!!! by !!!!, and its mean change trajectory !!"! deviates from the grand mean slope !!"" by  !!"! . The primary reason for evaluating the unconditional growth model is to determine whether there is statistically significant variation in individual initial status or rate of change that level 2 predictors could explain.  Next, if Models A and B indicated that there was significant non-explained variation in initial status and rate of change in my outcome measures, I proceeded to evaluate Models C through H. These models include perfectionism variables as level 2 predictor variables. Models C through H separately evaluated pre-treatment SOP, OOP, and SPP as predictors of individual differences in intercepts of therapy relationship variables. The level 1 equation is identical to that of Model B: the unconditional growth model, but the level 2 and 3 equations now include perfectionism terms. At level 2, !!"! is a coefficient representing the predictive effects of pre-treatment perfectionism traits on individual initial status in alliance/cohesion/group climate (intercept), whereas !!!!  represents the predictive effects of perfectionism on individual rate of   52 change (slope) in alliance/cohesion/group climate. This !!"!  coefficient is the primary result of interest to Hypothesis 1. !!!"  and !!!" are residuals associated with individual i  and group k. Level 3 is the same as for Model B, but now includes equations defining two new coefficients: !!"! and !!!! from the level 2 model. !!!! ,!!"! ,!!"! ,!!!!  are residuals associated with group k. Models C through H take the following general form, and represent the uncontrolled effects of perfectionism on alliance/cohesion.  Level 1: !!"# =  !!!" +  !!!" !"!!#$% − 1 +  !!"# Level 2: !!!" =  !!!! + !!"!!"#$ +  !!!" !!!" =  !!"! +  !!!!!"#$ + !!!"    Level 3: !!!! = !!!! + !!!! !!"! = !!"! + !!"! !!"! = !!"" + !!"! !!!! = !!!" + !!!! Finally, if Models C through H explained significant variance above and beyond the unconditional means model and the unconditional growth model, and perfectionism coefficients were significant, I proceeded to models I to N, which represented the controlled effects of perfectionism on alliance, cohesion, and group climate. Covariates included age, gender, and pre-treatment levels of psychopathology (i.e. BDI, BAI, and IIP scores). These models take the general form:  Level 1: !!"# =  !!!" +  !!!" !"!!#$% − 1 +  !!"# Level 2: !!!" =  !!!! + !!"!!"#$ + !!"!(!"ℎ!" !"#$)+  !!!" !!!" =  !!"! +  !!!!!"#$ + !!"!(!"ℎ!" !"#$)+ !!!"  Level 3: !!!! = !!!! + !!!! !!"! = !!"! + !!"! !!"! = !!"! + !!"! !!"! = !!"" + !!"! !!!! = !!!" + !!!!    53  Hypothesis 2. I followed the same process as for Hypothesis 1 for Hypothesis 2 with the same form. The change was that difference scores in perfectionism traits from pre- to post-treatment replaced pre-treatment perfectionism predictors in Hypothesis 1. Furthermore, whereas the primary coefficient of interest for Hypothesis 1 was !!"!, a coefficient representing the effect of pre-treatment perfectionism traits on initial status (intercept) in relationship quality measures, the primary coefficient of interest for Hypothesis 2 was !!!! ,which represents the predictive effects of change in perfectionism on individual rate of change (slope) in relationship quality measures.  Hypothesis 3. My third hypothesis was that the link between smaller decreases in perfectionism over the course of treatment and worse outcomes (i.e. less improvement in depression symptoms symptoms and a greater level of interpersonal distress) following group would be mediated by perfectionism’s effects on therapy relationship variables (i.e. less improvement in therapy relationship quality over the course of treatment). Note that previous analyses of this dataset have already found that change in perfectionism was related to changes in depression symptoms and interpersonal distress. That is, individuals with smaller decreases in perfectionism over the course of treatment also displayed smaller improvements in depression symptoms and interpersonal distress (Hewitt et al., 2015). Mediation analyses (Baron & Kenny, 1986) evaluate whether a variable acts as a mediator (M) – that is, if it accounts for the relationship between a predictor variable (X) and a criterion variable (Y). Variable M is considered a mediator if X significantly predicts Y (the c-path), X significantly predicts M (the a-path), and M significantly predicts Y after controlling for X (the b-path) (Baron & Kenny, 1986). The indirect effect refers to the effect size of the mediation, or the product of the a-path and the b-path.     54 If the data supported Hypothesis 2, I planned to proceed to evaluate Hypothesis 3 with a series of mediation analyses following Preacher and Hayes’ (2008) PROCESS procedure for testing the significance of indirect effect. The PROCESS procedure involves directly evaluating the significance of the indirect effect using a bootstrap approach to obtain the confidence interval for the effect size of the indirect effect, and provides greater statistical power and does not assume multivariate normality in the sampling distribution as opposed to traditional meditational analyses (Preacher & Hayes, 2008).  Although my data was nested in structure, a non-multilevel mediation was planned for this set of analyses, as all pertinent variables were at the person level (i.e. the variables of interest were participant perfectionism; participant slopes of alliance, group cohesion, and group climate over time; and patient outcome). The mediation model tested was as follows: where change in perfectionism (the predictor variable X,) is related to symptoms of depression and interpersonal distress post-treatment (the criterion variable Y) via the mediating effect of rate of change in therapy relationship variables (the mediator variable M). These analyses were only conducted for perfectionism traits and therapy relationship variables that were significant after tests of Hypothesis 2.  Power Analysis  The basic analytic plan for this dissertation evaluated the effects of pre-treatment perfectionism on initial therapy relationship quality and changes in perfectionism on the rate of change in therapy relationship quality. In order to calculate the power for the multi-level models described above, I used the R package simr using a method described by Green and MacLeod (2016). Power calculations using the simr package are based on Monte Carlo simulations of hypothetical data. The package produces power curves to assess trade-offs between power and   55 sample size. It was necessary to specify the effect size of four terms for this power analysis: the intercept of therapy relationship quality, the effect of pre-treatment perfectionism on the intercept of therapy relationship quality, the slope of therapy relationship quality, and the effect of changes in perfectionism on the slope of therapy relationship quality.  The intercept was set at a standard score of 0, and the other effect sizes were set at .2, .5, and .2 respectively with five repeated measurements in a sample of 60 participants and α = .05. Effect sizes were set based on an approach assuming a small positive effect size of .2 where there was limited or conflicting evidence suggesting a specific effect size (Cohen, 1992).1 The effect size of the slope of therapy relationship quality was set at .5 based on the work of Hilsenroth, Peters, and Ackerman (2004) who described moderate to large early-late alliance correlations based on reviews of a large number of studies reporting the relationship between early and late alliance. Based on the power analysis there was virtually 100% probability of detecting the described effect sizes, 95% CI[99.63] in 600 simulations. The cut off for attaining 80% power was at approximately 25 participants with 5 repeated measures each. No separate power analysis was conducted for Hypothesis 3 as this hypothesis was more exploratory and its evaluation was dependent on finding significant results in Hypothesis 1 and 2.                                                     1 For example, Zuroff and colleagues (2000) found that there was no significant effect of DAS perfectionism on initial therapeutic alliance in the TDCRP study; however Hewitt and colleagues (2008) found effect sizes as high as r = .50 between some components of perfectionism and participants’ perceptions of interpersonal processes during a clinical interview. Therefore the effect size of the relationship between pre-treatment perfectionism and initial therapy relationship quality was set at .2.   56 Study Summary This study aimed to investigate the role of perfectionism throughout the group psychotherapy process. To better understand the interpersonal experience of perfectionistic individuals in psychotherapy, I assessed the development of therapeutic relationships on a session-by-session or every-other-session basis as a function of perfectionistic traits, using the perspectives of multiple raters including self-report and independent observers. Overall, I hypothesized that 1) individuals with higher levels of pre-treatment perfectionism would display worse initial therapy relationship quality, and that 2) as individuals displayed decreases in perfectionistic traits the quality of their therapy relationships would improve, and that 3) improvements in therapy relationships would mediate the relationship between decreases in perfectionistic traits and improvements in depression and in interpersonal functioning.                 57 Results  Descriptive Statistics  There were a total of 71 participants, 24 male and 47 female, and the mean age was 41.55 (10.40). 60 participants completed the treatment and completed post-treatment measures. The total dropout rate from pre- to post-treatment was 15.5%, which are similar though somewhat lower than average compared to dropout rates reported elsewhere for adult psychotherapy (Swift & Greenburg, 2012). 44 participants completed the 4-month follow-up measures. The means and standard deviations for self-report perfectionism and distress measures at pre-treatment, post-treatment, and follow-up can be found in Table 2. The perfectionism and distress measures data were normally distributed.  Perfectionism Perfectionism traits were tested for gender differences; there were no significant differences. Pre-treatment perfectionism scores were compared to norms from non-clinical undergraduate and clinical samples (Hewitt & Flett, 1991; Hewitt, Flett, Sherry, et al., 2003). Perfectionism scores on all trait and self-presentational subscales were significantly higher in the current sample compared to both non-clinical undergraduate and clinical samples (SOP: non-clinical t(1175) = 11.13, p<.001, d=1.61 and clinical t(332) = 8.57, p<.001, d=1.27; OOP: non-clinical t(1175) = 10.01, p<.001, d=1.13 and clinical t(332) = 9.53, p<.001. d=1.26; SPP: non-clinical t(1175) = 8.99, p<.001, d=1.02 and clinical t(332) = 5.17, p<.001. These higher scores were expected given that the current study specifically recruited participants scoring highly on one or more perfectionism subscales. Means and standard deviations in changes in perfectionism were as follows: SOP M=-16.17, SD=16.15; OOP: M=-9.79, SD=13.48; SPP M=-11.41, SD=16.63. Participants displayed significant decreases in all perfectionism traits (see Hewitt et   58 al., 2015 for greater detail on changes in perfectionism) and there was notable variability in the degree of change in perfectionism traits from pre- to post-treatment.  Alliance, Cohesion, and Climate Measures The means and standard deviations for self-rated group climate and observer-rated therapeutic alliance and group cohesion can be found in Table 3. See Table 4 for a summary of Pearson correlations between alliance, cohesion, and climate measures. As expected self-rated Engagement on the GCQ was negatively related to Conflict and Avoiding on the GCQ. Observer-rated group cohesion was positively related to Engagement and negatively related to Conflict on the GCQ. Observer-rated alliance and observer-rated group cohesion were also positively related. However, observer-rated alliance was not significantly related to any of the self-report group climate subscales.  Observer-Rated Alliance and Cohesion. See Table 5 for interrater reliability (ICC) for all TPOCS-A and TPOCS-GC items and total scores. For items on the TPOCS-A and -GC, ICC ranged from .33 to .88 (M=.70, SD=.13). Overall TPOCS-A and TPOCS-GC ICCs were .84 and .82 respectively. According to Cicchetti’s (1994) guidelines, ICCs below .40 reflect “poor” agreement between raters, ICCs between .40 to reflect “fair” agreement between raters, ICCs between .60 and .74 reflect “good” agreement, and ICCs .75 and higher reflect “excellent” agreement”. Based on these guidelines, the mean degree of agreement between raters in the current study fell in the “good” range. Interrater reliability on overall scores on the TPOCS-A and –GC, the primary outcome variables of interest from the coder ratings for the current study fell in the “excellent” range.  TPOCS-A and –GC overall scores did not display substantial ceiling or floor effects. Mean observer-rated therapeutic alliance (i.e. TPOCS-A score) was somewhat lower for the   59 current study compared to previous studies (e.g. Lerner et al., 2011), t(255) = 8.16, p<.001, d=-.179. This may be a result of the different foci for psychotherapy in the current study versus Lerner et al.’s 2011 intervention study. In the current study, therapists focused primarily on group process and focused the group’s attention primarily on interactions between group members, whereas Lerner et al.’s study examined a more skills-based intervention, where therapist-group member interactions were presumably more salient compared to group member-group member interactions. Mean observer-rated group cohesion (i.e. TPOCS-GC score) was very similar to previously reported values (e.g. Lerner et al., 2013, t(255)=.34, p=.73, d=-.041). Although there was notable variability between participants on scores (TPOCS-A, M=2.68 (.47) with a range of 1.28 to 4.11; TPOCS-GC, M=3.26 (.42) with a range of 2.00 to 4.31), there was limited change in scores across sessions. A one-way ANOVA showed that there were no significant mean differences in alliance or cohesion scores between sessions (TPOCS-A, F(4,225)=1.99, p=.10; TPOCS-GC, F(4, 225)=.31, p=.87).  Self-Rated Group Climate. The means and standard deviations on the three Group Climate Questionnaire subscales across sessions were as follows: Engaged (M=5.48, SD=.78), Conflict (M=2.56, SD=.95), and Avoiding (M=3.14, SD=.98). These scores differed somewhat from other studies using the GCQ. Compared to Mackenzie’s original 1983 validation study, scores from the current study were somewhat higher on all three subscales. Compared to a more recent study (Ogrodnizcuk & Piper, 2003) using a similar short-term psychodynamic-interpersonal group psychotherapy protocol, participants in the current study also obtained somewhat higher scores on all three subscales when comparing mean GCQ subscale scores in the current study to midpoint subscale GCQ scores in the Ogrodniczuk and Piper study.    60  Change Trajectories For Dependent Variables. I examined graphs of individual change trajectories for all dependent variables (i.e. GCQ subscales, TPOCS-A, and TPOCS-GC) to inspect the data for the presence of linearity and to identify any “hinge” points or curvilinear changes in the data. Based on visual inspection of the data, the change in alliance, cohesion, and group climate for participants over time appeared to be roughly linear. I also conducted MLM analyses with coefficients for both linear and quadratic effects of time in order to see if there were significant quadratic trends in the data. Using Bonferonni correction for multiple analyses, these analyses indicated that there were no significant quadratic trends in the data.  Further analyses did not include a quadratic term representing curvilinear change of the dependent variables over time.  See Figure 3 for mean change trajectories.  See Figures 4 through 8 for linear change trajectories by participant for all therapy relationship variables. See Figures 9 through 13 for individual change trajectories for four randomly selected participants.   Clustering in dependent variables. I examined the effects of nesting in unconditional and time-only models, in order to determine the need for multilevel modeling. Significant variance (ICC>5%) existed at all three levels of analysis: at the within-subjects level (level 1), between-subjects level (level 2), and between-group level (level 3), indicating the need to model these effects in subsequent analyses (Guo, 2005). At least 5% of the variance was attributable to group membership (level 3 variance) for all alliance, cohesion, and group climate outcome variables except for the Engaged subscale of the Group Climate Questionnaire and observer-rated group cohesion from the TPOCS-GC. For these variables, a 2-level MLM was used instead, with repeated measurements at level 1 nested in participants at level 2. See Table 6 for a summary of multilevel variance and ICCs for alliance, cohesion, and group climate measures.    61 Effect of Perfectionism on Intercepts and Slopes for Alliance, Cohesion, and Group Climate  Missing data MLM using maximum likelihood estimation is robust to missing data as long as it is either missing at random (MAR) or missing completely at random (MCAR) (Quené & van den Bergh, 2004). When data is MCAR, the observed values are a random sample of all the values that could have been observed – that is, any data that is missing is missing completely at random. When we say that data is MAR, the probability of missingness can depend on any observed data. If data is non-missing at random, then the probability of missingness depends on unobserved data (Singer & Willet, 2003). As a first step, in order to determine a strategy for dealing with missing data, Little’s test was conducted to evaluate whether missing data was missing completely at random (MCAR; Little 1988). The data did not appear to be MCAR !!(87) = 377.55, p < .001. Therefore, there was a need to determine whether the data was MAR or not missing at random. This is difficult to assess directly since the criterion for data to be not missing at random depends on unobserved predictor variables. Instead, I used a pattern mixture model (Atkins, 2005; Hedeker & Gibbons, 1997) in order to assess the effects of missing data. This approach adds additional variables to multi-level models that represent potential patterns of missing data and then fit a multilevel model stratified with these patterns in order to see if that pattern of missing data changes the results of the MLM analyses. I added a dummy variable to represent study dropout and after conducting pattern-mixture models for all Hypothesis 1 and 2 analyses, there were no differences in significance between these models and the main analyses, indicating that missing data due to dropout did not appreciably bias study results.      62 Hypothesis 1  Separate multilevel analyses were conducted for each dependent variable: the three group climate subscales, observer-rated alliance, and observer-rated group cohesion, in order to evaluate whether pre-treatment perfectionism traits were related to initial scores on therapy relationship variables at session 1 of treatment. Pre-treatment perfectionism traits were mean centered scores on SOP, OOP, and SPP. See Tables 7 through 11 for a summary of results. Results for all models (Models A through E) are reported.   There was significant unexplained inter-individual variance τπ0 at session 1 after taking into account mean scores at session 1 and mean change trajectories for GCQ Engaged, GCQ Conflict, GCQ Avoiding, and TPOCS-GC. There was no unexplained inter-individual variance in initial status for TPOCS-A after taking into account the mean score at session 1 and the mean change trajectory for the sample. Further analyses examining the effects of pre-treatment perfectionism on initial status on the dependent variables, !01 revealed no significant effects of pre-treatment perfectionism traits (SOP, OOP, or SPP) on initial status on any of the dependent variables, indicating that in the current sample pre-treatment levels of trait perfectionism did not significantly account for differences between participants on group climate, group cohesion, or therapeutic alliance at session 1 of a 10 week group therapy treatment.  Hypothesis 2  Separate multilevel analyses were conducted for each dependent variable: the three group climate subscales, observer-rated alliance, and observer-rated group cohesion, in order to evaluate whether change in perfectionism traits over the course of treatment were related to rate of change in GCQ subscales over the course of treatment. Changes in perfectionism traits were mean centered difference scores in SOP, OOP, and SPP from pre- to post-treatment. See Tables   63 12 through 16 for a summary of results. Results for all models (Models A through E) are reported.   There was an linear increase in GCQ Engaged, !10 = .046, p < .001 and a linear decrease in GCQ avoiding, !10  = -.032, p < .05 over the course of treatment sessions. There were no significant linear increases or decreases in the other dependent variables. Further examining the unconditional mean and unconditional growth models for all dependent variables revealed no remaining unexplained inter-individual variance in linear change after taking into account mean initial scores and mean linear change in dependent variables (i.e. τπ1 did not significantly differ from 0). This indicated no need to add further variables to explain variance between participants in linear change in any dependent variables. Furthermore, no perfectionism difference scores were significantly related to linear change in any dependent variables (i.e. no !11 differed significantly from 0 for any dependent variables). This indicates that in the current sample change in perfectionism traits from pre- to post-treatment were not significantly related to participants’ linear change in therapy relationship quality over the course of treatment.   Simple difference scores were used in Hypothesis 2 analyses, which sought to evaluate whether changes in perfectionism from pre- to post-treatment accounted for the rate of change in therapy relationship variables. These were chosen for the purpose of simplicity and ease of interpretation. However there is notable debate about the superiority of simple difference scores versus residualized change scores (e.g. Williams & Zimmerman, 1992) in modeling longitudinal change. In order to rule out that results were due to the choice of simple difference scores, Hypothesis 2 analyses were repeated using residualized difference scores to represent changes in pre- to post-treatment perfectionism. There were no differences in the pattern of results   64 compared to results obtained using simple difference results, and no perfectionism difference scores were significantly related to linear change in any therapy relationship variable.  Hypothesis 3  My third hypothesis was that greater decreases in perfectionism would be related to greater improvement in outcomes in therapy (i.e. less severe depression symptoms and less interpersonal distress) due to the mediating effects of improvements in therapy relationship variables over the course of the treatment (i.e. alliance, cohesion, and climate measures). The general form of the mediation I examined was: change in perfectionism (X) being related to change in treatment outcome (Y) mediated by changes in therapy relationship variables (M). Perfectionism variables were pre- to post-treatment change scores for SOP, OOP, and SPP. Outcome variables were pre-to post-treatment change scores for the BDI, BAI, and IIP. Relationship variables were individual OLS slopes for GCQ Engaged, GCQ Conflict, GCQ Avoiding, TPOCS-A overall score, and TPOCS-GC overall score.   However, because the data did not support Hypothesis 2 (i.e. changes in perfectionism were not related to changes in alliance, cohesion, or group climate), I did not proceed to evaluate Hypothesis 3.           65 Discussion  This study sought to understand how pre-treatment trait perfectionism as well as changes in trait perfectionism relate to the quality of therapy relationships and outcomes over the course of a short-term group therapy aimed at reducing perfectionism. I evaluated three hypotheses. First, I expected pre-treatment perfectionism to be related to initial therapeutic relationship quality at session 1. Second, I expected larger decreases in perfectionistic traits throughout the course of therapy to be linked to greater increases in the quality of therapy relationships. Third, I expected the link between decreases in perfectionistic traits and therapeutic improvement to be mediated by improvements in therapy relationships. The data from the current study supported none of these three hypotheses. This was the case for all three perfectionism traits: SOP, OOP, and SPP. This was also the case for all types of therapy relationship variables, including those focusing on participant-group relationships (i.e. group cohesion and group climate variables) and those focusing on participant-therapist (i.e. alliance variables), and for both self-report and observer-rated relationship quality, suggesting that irrespective of choice of measures, pre-treatment perfectionism and changes in perfectionism do not affect therapy relationships in group psychotherapy.  Perfectionism and Therapy Relationships  These findings are surprising given a body of literature supporting the idea that perfectionism is related to relationship difficulties and difficulties in psychotherapy. Research from the TDCRP indicate that DAS perfectionism is related to at least some measures of therapeutic alliance, and a larger body of literature indicates that perfectionism is related to interpersonal problems in general. For example, Zuroff and colleagues (2000) found that observer ratings of some aspects of the therapeutic alliance failed to increase for individuals high   66 in perfectionism after the halfway point of therapy. In addition, they found that changes in some aspects of the alliance mediated the relationship between perfectionism and worse treatment outcomes.   The PSDM posits that perfectionism is related to failures in social connection. There is empirical support for this in a number of non-therapy contexts and in the context of an initial clinical interview. Hewitt and colleagues (2008, 2020) found that, even as early as an initial clinical interviews, individuals higher in perfectionism were perceived as more hostile and were less liked by their therapists, and that from participants’ perspectives, individuals higher in perfectionism also experienced more distress and perceived more threat during these clinical interviews (Hewitt et al., 2008). The PSDM predicts that in a therapy context perfectionism should be related to problems in establishing high quality therapeutic relationships. There is also at least one study that provides support for the idea that decreases in perfectionism are linked to increases in therapeutic alliance quality (Hawley et al., 2006). Hypotheses 1 and 2 addressed the question of whether a link exists between perfectionism and therapy relationship quality, with the expectation that higher initial perfectionism would be related to initially lower therapy relationship quality (Hypothesis 1) and that decreases in perfectionism would be linked to increases in therapy relationship quality (Hypothesis 2). That these findings were not supported necessitates a thorough examination of the discrepancy between the current study’s findings and the study’s hypothesized results. The next section of this paper will discuss and evaluate various possible reasons for this discrepancy.  Possible Reasons For Null Findings First, most of what we know about the link between perfectionism and problems with therapy relationships come from the TDCRP, which examined this link in the context of   67 individual treatment for unipolar depression. The current study examined the link between perfectionism and problems with therapy relationships in the altogether different context of group therapy specifically targeting reducing perfectionism in a sample of individuals high in perfectionism. Differences between the TDCRP and the current study include differences in variables and in the measurement of said variables, differences in the format of the treatment (i.e. group rather than individual treatment), differences in the foci of treatment (i.e. directly addressing perfectionism and its interpersonal effects rather than focusing on depression symptoms), and differences in participants (i.e. individuals self-referring for problems with perfectionism vs. individuals with unipolar depression).  Differences in the Assessment and Measurement of Perfectionism Only a selection of perfectionism measures has been studied in relation to issues with therapy relationship quality. The TDCRP papers operationalized perfectionism using residualized perfectionism subscale scores from the Dysfunctional Attitudes Scale, which measures the presence and severity of depression-related cognitions. The DAS perfectionism subscale was derived from factor analysis and supposedly measures self-directed cognitions regarding high standards and a need for perfection (Brown & Beck, 2002). It is unclear precisely how DAS perfectionism is related to multidimensional conceptualizations of perfectionism. Some authors have argued that DAS perfectionism is a more state-like factor rather than reflecting more enduring personality traits like the Hewitt-Flett perfectionistic traits (Brown & Beck, 2002), though these authors have also compared DAS perfectionism to SOP from the Hewitt-Flett MPS. Others suggest that DAS perfectionism is more closely related to SPP (Dunkley et al., 2002). Given the differences between DAS perfectionism and the Hewitt-Flett   68 perfectionistic traits, one might expect to find that these two different ways of measuring perfectionism may be differentially related to therapeutic relationships.  However, if anything, one would expect the Hewitt and Flett perfectionistic traits to be more closely related to difficulties in therapy relationships compared to DAS perfectionism. DAS perfectionism in the TDCRP was related to difficulties in establishing alliance later in therapy; however initially there were no differences in alliance quality between individuals higher and lower in perfectionism (Zuroff et al., 2000). In Hewitt et al.’s studies (2008, 2019), however, perfectionism traits were related to interpersonal difficulties as early as an initial clinical interview. Furthermore, one would expect that the more enduring and characterological perfectionism described by the Hewitt and Flett perfectionism traits to exert greater effects on therapy relationship quality than the state-dependent cognitions related to perfectionism measured by the DAS. Therefore, differences in the assessment of perfectionism do not appear to explain why the TDCRP papers found that perfectionism was related to therapeutic alliance while the current study does not. Next, one notable difference between the current study and previous studies is that the current study focuses on change in perfectionism in addition to pre-treatment perfectionism. Most of the research conducted so far examining the relationship between perfectionism and relationships in therapy has used solely a measure of pre-treatment perfectionism, rather than looking at change in perfectionism. The current study sought to better understand the effects of changes in perfectionism. The rationale for this was that given that the treatment in question was focused on reducing perfectionism, it is a clinically relevant question whether reductions in perfectionism would be accompanied by increases in therapy relationship quality. If this were indeed the case, the data would then support the clinical utility of reducing perfectionism and   69 would provide some understanding of the mechanism of how reducing perfectionism may be clinically useful. This study did not find support for the idea that as perfectionism decreases therapy relationship quality increases.  Because there is a pre-existing literature from the TDCRP suggesting that pre-treatment perfectionism is related to therapeutic alliance, one might assume it may be that only pre-treatment perfectionism, but not change in perfectionism that is related to therapy relationship quality. However, Hypothesis 1 investigated the relationship between pre-treatment perfectionism and initial therapy relationship quality, and study analyses did not find support for a link between pre-treatment perfectionism and initial relationship quality. Furthermore, although the majority of studies looking at perfectionism and therapy relationships evaluated the effects of pre-treatment perfectionism, a small handful of studies suggest that change in perfectionism is an important factor to consider for psychotherapy process and outcome. Several studies (Enns et al., 2002; Hewitt et al., 2015, 2019; Lowyck et al., 2017) found that changes in perfectionism were related to therapy outcome, including the rate of improvement of clinical symptoms and interpersonal problems, although these did not directly evaluate the relationship between change in perfectionism and changes in therapy relationship quality.  One study specifically evaluated the relationship between change in perfectionism over the course of treatment and therapeutic alliance. Hawley and colleagues (2006) found that the therapeutic alliance during a session early in treatment predicted the rate of change in perfectionism over the course of the treatment, which in turn predicted the subsequent rate of depression symptom improvement. Hawley and colleagues discussed the clinical implications of theses results, suggesting that one an important goal for therapists should be to establish a strong alliance early in therapy in order to reduce the deleterious effects of perfectionism on treatment, which they theorized may allow perfectionistic patients to become more capable of disclosing   70 personal information and more meaningfully engaging with therapy due to a reduction of fear of being rejected or criticized by the therapist. Although Hawley and colleagues evaluated a model where alliance led to change in perfectionism, rather than a model where changes in perfectionism led to changes in alliance, their conceptualization of the relationship between changes in perfectionism and alliance is very much compatible with the hypotheses of the current study.  The intervention in the current study used a psychodynamic-interpersonal framework based on the work of Mackenzie (1990) and Yalom and Leszcz (2005). The therapy focused on perfectionism-related relational dynamics within the group, such as those described by Hawley and colleagues. The rationale was that addressing perfectionism-related interpersonal patterns manifest in interpersonal interactions within the group would increase awareness of these patterns and allow for opportunities for group members to try out more adaptive interpersonal styles within and outside the group. One component of the PSDM describes how perfectionism leads to interpersonal difficulties, but the PSDM also includes a developmental component that posits that perfectionism develops due to failures of attachment and social connection. Therefore, one of the overarching rationales of the treatment in the current study was that by allowing for successes of attachment and social connection within the group, group members’ difficulties with perfectionism would decrease.   The evidence in support of change in perfectionism leading to improvements in therapy relationships has relatively little direct empirical evidence. However, the theory behind the PSDM and at least one study (Hawley et al., 2006) suggest that this would indeed be the case, and several studies found that change in perfectionism is related to the rate improvement in therapy, including improvements in interpersonal problems (Enns et al., 2002; Hewitt et al., 2015; Lowyck et al., 2017). Therefore, the null findings in the current study are difficult to understand.     71 Measurement of Therapy Relationships Next, there were differences in the measurement of therapy relationships between papers stemming from the TDCRP and the current study. Interestingly, initial analyses of the TDCRP data did not find a direct relationship between DAS perfectionism, therapeutic alliance, and outcome. Blatt and colleagues (1996) found no significant direct relationship between perfectionism and alliance following the second session of treatment (r = -.09) and only found an interaction effect. Blatt and colleagues’ 1996 study found that patient-rated alliance following the second session of therapy was not related to therapeutic outcome at low or high levels of perfectionism, but predicted therapeutic gain at moderate levels of perfectionism. That study used the Barret-Lennard Relationship Inventory (B-L RI; Barret-Lennard, 1962), a patient-rated measure of alliance based on Carl Rogers’ concept (1959) that the therapist’s empathic understanding, unconditional positive regard, and congruence with the patient underlie therapeutic change. The B-L RI measures patient perceptions of therapist empathic understanding, level of regard, unconditionality of regard, and congruence between the patient and the therapist.  Zuroff and colleagues (2000), on the other hand, used observer ratings of therapy videotapes based on the Vanderbilt Therapeutic Alliance Scale (VTAS; Hartley & Strupp, 1983) and did find a direct relationship between perfectionism and alliance. Individuals higher in perfectionism were observed to have poorer alliance in the latter half of therapy compared to individuals lower in perfectionism. Items from the VTAS are based on Bordin’s (1979) three-part conceptualization of the therapeutic alliance into bond, agreement on tasks, and agreement on goals of therapy, and the scale is divided into three parts: therapist contribution to the alliance, patient contribution to the alliance, and therapist-patient interaction. Zuroff and colleagues’ 2000   72 study specifically found that perfectionism was related to problems in the patient contribution to the alliance and not in therapist contribution to the alliance.  There are a number of ways to explain the discrepant findings between the Blatt et al. 1996 study and the Zuroff et al. 2000 study. First, the Blatt study measured alliance after the second session, while the Zuroff study found that perfectionism was only related to alliance in the latter half of therapy. It may have been that if Blatt and colleagues obtained B-L RI ratings during later points of therapy, then they may have found a direct effect of perfectionism on alliance. Second, the Zuroff study used observer ratings of alliance while the Blatt study used patient ratings of alliance. There is some evidence to suggest that observer ratings of alliance may be a more reliable measure of alliance, given research suggesting that self-ratings of alliance may be artificially high, suggesting that patients are inclined to inflate their alliance ratings (e.g. Fenton et al., 2001; Shelef et al., 2005). Shelef and Diamond (2008) discuss how there may be demand characteristics for patients to report high levels of alliance. Previous research indicates that observer ratings of alliance were more normally distributed and more predictive of outcome than patient-self report (Fenton et al., 2001; Shelef et al., 2005). Therefore, it may be that perfectionism’s effects on alliance are more likely to be apparent in observer ratings of alliance. One of the strengths of the current study is that it included both self-report and observer-rated measures of alliance and other therapy relationships. However, in the current study, patient changes in perfectionism were not related to ratings of therapy relationship quality nor observer ratings of therapy relationship quality.  Differences in Treatment Format One obvious difference between the current study and the TDCRP is that the TDCRP dealt with individual treatment, while the current study deals with therapy taking place in a group   73 context. Might this explain the null findings in the current study? A number of meta-analyses support that there no differences between individual and group therapies in their efficacy (e.g. McRoberts, Burlingame, & Hoag, 1998), and therapy relationship variables similarly predict therapy outcome in individual and group therapy, and the effect size of this relationship is similar (r = .28 vs. r = .25 respectively in Horvath et al., 2011 and Burlingame et al., 2011). These suggest that at least some of the therapeutic mechanisms in both group and individual therapy depend on interpersonal factors taking place during treatment. One would expect that if perfectionism relates to relationship variables in individual treatment, that it would be similarly if not more strongly related to relationship variables in group treatment. Yalom and Leszcz (1995) describe a concept they call the social microcosm, where in group therapy, group members’ interpersonal styles and problems are expected to emerge in the group itself and affect how the group member perceives and experiences the group. The assumption is that participation in group therapy will influence group members’ interpersonal styles and help them improve their functioning in relationships outside of therapy, and this leads to the prediction that, if anything, one would expect a stronger negative relationship between perfectionism and relationship quality in group therapy compared to in individual therapy. Furthermore, given that individuals high in perfectionism endorse difficulties with self-disclosure and given the necessity for self-disclosure in front of a larger audience in group therapy, one would again expect that perfectionism should negatively impact the quality of therapy relationships in group therapy.  One of the strengths of the current study is that it assessed different kinds of therapy relationship variables, with measures of both patient-therapist (therapeutic alliance) and patient-group (group cohesion and group climate) therapy relationship variables. Again, perfectionism was not related to changes in any of these variables.    74 Limited Variability Between Participants and Limited Variability Across Sessions One striking finding from the current study is that there was limited variability between participants in change in therapy relationship variables. After accounting for the effect of session number, there was no significant remaining person-level variance in change in therapy relationship quality variables, indicating no further need for person-level predictors to explain variance between participants in change in therapy relationship quality. This was the case for all therapy relationship quality variables, irrespective of whether the therapy relationship quality variables addressed patient-therapist or patient-group relationships, or whether the variables were self-report or observer-rated. In other words, participants in the current study were remarkably similar in their rate of developing therapy relationships. In addition, with the exception of the Engagement and Avoiding subscales of the Group Climate Questionnaire, there was no significant effect of time for therapy relationship variables. Engagement increased over the course of the 10-week group while Avoidance decreased. However, for three out of the five relationship variables (GCQ Conflict, observer-rated alliance, and observer-rated group cohesion), participants did not display linear changes over time.   This lack of variability in rate of change in therapy relationship quality was unexpected. Previous research using observer-rated therapeutic alliance and group cohesion have found that both early alliance and change in alliance predicted outcome (Lerner et al., 2011), and that changes in group cohesion predict therapy outcomes (Lerner et al., 2013). Ogrodnizcuk and Piper (2003) investigated the relationship between group climate and outcomes in a psychodynamic-interpersonal group therapy similar to the therapy approach used in the current study. They found an increase in Engagement over the beginning, middle, and end of a 12-week   75 group psychotherapy protocol, but no change over time in either the Conflict or Avoiding subscales.  The groups in the current study appear to differ from previously researched groups. Although group members displayed some changes in group climate subscales over time, they did not display the expected increases in alliance and cohesion over time. Further, there were no significant differences between individuals in their rate of change in therapy relationship variables. Compared to previous studies, participants in the current study displayed higher mean scores on all three group climate subscales, similar scores on observed group cohesion, and somewhat lower scores on alliance. Overall, the participants in the current study showed some mean differences in therapy relationship variables compared to previous studies, and displayed notably less change in therapy relationship variables and were more similar to each other in the trajectory of their therapy relationships compared to previous studies.   The Special Case of a Perfectionism Group One potential reason for the limited variability in change in therapy relationship quality in this study is the particular composition of the group. Group members in the current study were recruited from the community using advertisements for a group treatment for perfectionism. These were groups of individuals who were motivated enough to respond to these advertisements, take part in a lengthy assessment process, and were interested in addressing their perfectionism. In other words, participants began groups with at least some perception of perfectionism being a problem in their lives and with the knowledge that the group was going to focus on perfectionism. While it is impossible to directly assess the impact of the special case of a perfectionism group on the results of the current study given the absence of a control group   76 where perfectionism was not the focus, one would expect that attending a group manifestly focused on perfectionism to exert some effects on participants’ behavior.  One point to consider is that previous researchers found a moderating effect of perfectionism on the link between some types of alliance and therapy outcome. In Blatt and colleagues’ 1996 study, they found that patient-rated alliance was not related to therapy outcome at low and high levels of perfectionism, but predicted therapeutic gain at high levels of perfectionism. They interpreted this finding to mean that individuals at low levels of perfectionism benefited from treatment regardless of the quality of the alliance, while individuals at high levels of perfectionism were resistant to the therapeutic effects of the intervention that they would not benefit regardless of the quality of the alliance. As part of the inclusion criteria for the current study, all participants had to score at least half a standard deviation above community means in at least one measure of perfectionism, and therefore all participants in the current study were individuals high in at least one form of perfectionism. Consistent with Blatt and colleagues’ findings, change in therapy relationships was not related to changes in therapy outcome (given that there was no inter-individual variability in change in therapy relationships) for participants in the current study. However, participants in the current study did benefit from treatment, and showed significant decreases in perfectionism and distress from pre- to post-treatment (see Hewitt et al., 2015). Therefore, mechanisms that account for participants’ improvements during therapy other than changes in therapy relationship quality must be at work.  One notable thing about the current study was that participants were conscious of being treated for perfectionism, and participants’ perfectionism was frequently directly acknowledged and discussed over the course of treatment. Perhaps the salience of perfectionism in the therapy affected how individuals interacted with therapists and the group. The emphasis of the   77 intervention was to address perfectionism-related relational patterns described by members in the context of their relationships outside of therapy, their relationships with themselves, as well as those manifest within the group itself. Participants were informed of this during two orientation sessions prior to the start of therapy, and these ideas were reiterated throughout the course of therapy. One would expect participants to be especially aware of how their perfectionism might impact their relationships with therapists and other group members. Individuals high in perfectionism have a tendency to carefully monitor their self-presentation and hide parts of themselves that they perceive that others might reject (Hewitt, Flett, Sherry, et al., 2003). Various authors have discussed how individuals high in perfectionism might attempt to play at being the perfect patient in therapy (e.g. Cheek et al., 2018), and one might expect that participants in the current study might work extra hard to manage their interpersonal interactions within the group in such a way that some of the more interpersonally damaging behaviors that usually accompany perfectionism may have been hidden away during the course of the group. If participants were successfully managing their presentation within the group, then one would expect self-reported and observer-rated relationship quality to be uniformly high over the course of therapy. This may explain why changes in perfectionism did not lead to improvements in therapy relationships.   Next, although anecdotal, one thing I observed while watching videotapes of sessions was that participants in the group often seemed to identify strongly with the other group members. Group members often discussed their identities as perfectionists and therefore as separate from other people in the world. Often, participants repeated a refrain that went something like: I am so grateful for the group because here is a group that finally understands me, but I cannot expect this kind of understanding from others. Perhaps perfectionism still   78 exerted negative interpersonal effects, but other group members were protected from these effects. This possibility is consistent with data indicating that the groups in the current study reported particularly high levels of engagement with the group compared to previous studies, and the finding that participants displayed relatively lower levels of alliance with the therapist compared to previous studies.  As part of the TDCRP, Shahar and colleagues (2004) discussed how the remaining direct of effect of perfectionism on therapy outcome was significant even after taking into account the mediating effect of alliance. They evaluated an additional mediator and found that the quality of patients’ social networks outside of therapy also acted as a significant mediator of the link between perfectionism and therapy outcome. Likewise, Hewitt, Smith, and colleagues (2020) found that ratings of patients’ satisfaction with outside friendships partially mediated the relationship between pre-treatment perfectionism traits and changes in depression symptoms in a group therapy for depression. In the current study, decreases in perfectionism were related to improvements in distress (see Hewitt et al., 2015), but changes in therapy relationships did not account for this relationship. Therefore, there are still unknown mediators of this relationship that might explain the mechanisms of the therapy in the current study. Perhaps, one potential explanation of the findings of the current study is that relationship quality in therapy was stable, but improvements in interpersonal relationships outside of therapy occurred as participants decreased in perfectionism.  Another important thing to consider is that the nature of the intervention as an intervention focused on perfectionism may have affected not only the participants of the study, but also the therapists and the content of the intervention. Therapists were taught about the potential negative effects of perfectionism on therapy process and outcome, and were trained and   79 received supervision on how to manage issues related to perfectionism in treatment. Therapists were instructed on how to manage countertransference reactions to patient perfectionistic behavior and actively addressed perfectionism-related interpersonal dynamics throughout the therapy. Prominent areas of discussion included members’ reactions to empathic failures, tolerance of therapists’ limitations, interpersonal feedback, conflicts and tensions within the group, and the use of perfectionism as a mean of creating safety or protecting the self against abandonment, rejection, and criticism. Given this focus on perfectionism’s interpersonal effects, one potential explanation for null findings in the current study is that therapists were able to mitigate the negative effects of perfectionism on therapy relationships, and that therefore therapy relationship quality was good throughout treatment, even before perfectionism started to decrease.  Future Directions and Conclusions The current study investigated how pre-treatment perfectionism as well as changes in perfectionism during a group therapy intervention designed to reduce problems with perfectionism were related to initial and changes in therapy relationship quality over the course of treatment. The fact that this study investigated this within an intervention designed to reduce perfectionism is both a strength and a weakness of the current design. First, little is known about how multidimensional perfectionism is related to therapy relationship quality, as papers addressing this question come from a single sample (the TDCRP study). Further, relatively little is known about how changes in perfectionism might lead to improvements in therapy relationships, although at least one study provides preliminary evidence that decreases in perfectionism may be related to improvements in therapeutic alliance. The design of the current study allowed for further investigation into a relatively unstudied question with important   80 clinical implications. If directly targeting perfectionism might mitigate perfectionism’s negative effects of therapy relationships and on therapeutic outcome, then reducing perfectionism may be an important clinical target. Furthermore the current study evaluated whether changes in therapy relationship quality might mediate the relationship between perfectionism and psychotherapy outcomes as one would expect from the Perfectionism Social Disconnection Model.  However, the current study was not able to find support for the idea that pre-treatment multidimensional perfectionism was related to initial therapy relationship quality, or that reductions in perfectionism were related to improvements in therapy relationship quality. It is unclear whether these results were due to the unique characteristics of the participants in the current study. Although there was good variability in the degree of change in perfectionism among participants, all participants began the group at high levels of perfectionism and entered the group motivated to reduce their perfectionism. Furthermore, participants in the current study were asked to stay attentive to the negative interpersonal consequences of their perfectionism and given individualized, interpersonally focused feedback about the development, maintenance, and particular manifestation of perfectionistic behavior during the assessment stage (Hewitt et al., 2018). The salience of perfectionism and its interpersonal consequences may have prompted participants, especially participants with a pre-existing tendency to present as perfect, to behave differently within the group so that the negative effects of perfectionism on therapy relationships were hidden from view. Alternatively, the intervention itself may have mitigated the negative interpersonal effects of perfectionism, given that content of the intervention and the training of study therapists were designed to address the interpersonal problems associated with perfectionism. In the end, it is impossible to directly determine whether these reasons may have   81 accounted for null findings in the current study, though of course one must consider the possibility that perfectionism, in some cases, is simply not related to therapy relationship quality.  Previous research suggests that perfectionism is related to problems in therapy relationships, and that decreases in perfectionism may lead to improvements in therapy relationships. However, no support was found for the hypothesis that pre-treatment perfectionism was related to initial therapy relationship quality, or that decreases in perfectionism were related to improvements in therapy relationships in the current study. The study’s tertiary hypothesis that the relationship between decreases in perfectionism and therapy outcomes would be mediated by improvements in therapy relationship quality was not directly evaluated given the null findings for the study’s initial hypotheses.  Future research should further investigate the relationship between perfectionism and problems with therapy relationships. Most of the studies examining the relationship between perfectionism and therapy relationships stem from the TDCRP, a single study using a unidimensional measure of perfectionism focused on perfectionism-related cognitions. Given the discrepancy between the results of the current study and the TDCRP findings, it is important to investigate if the relationship between perfectionism and problems in therapy relationships continues to hold when using multidimensional measurement of perfectionism, and whether the TDCRP findings are replicable in this case. Initial work should seek to address this question during interventions that do not explicitly target perfectionism, as interventions that explicitly target perfectionism may meaningfully alter participants’ behavior during therapy.  This work should employ multi-rater, multi-method assessment of perfectionism and of therapy relationships (i.e. using both self- and observer-rated measures) at multiple time points. One of the weaknesses of the current study was that perfectionism was measured only at pre- and   82 post-treatment, and therefore it was only possible to assess associations between changes in perfectionism and changes in therapy relationship quality, rather than to draw any causal conclusions about the link between change in perfectionism and change in therapy relationship quality. Ideally, perfectionism and therapy relationship variables should be measured every session so that change in perfectionism from one session to the next can be used to predict subsequent changes in therapy relationship quality.  It would also be interesting to investigate the link between perfectionism and therapy relationship quality during longer-term interventions. The intervention in the current study took place over 10 sessions. Given evidence from the TDCRP suggesting that perfectionism only exerts detrimental effects on therapeutic alliance following the halfway point of a 16-week group, it would be interesting to examine perfectionism’s effects on therapy relationships as group processes continue to unfold beyond the initial stages of therapy. Mackenzie (1983) described three phases in group therapy: an initial phase characterized by group members beginning the engagement process, finding similarities between each other, and deciding whether or not to commit to the group; a differentiation stage, where differences between group members become more salient and more conflict occurs between group members; and an individuation stage, characterized by the development of a deeper appreciation and acceptance of differences between group members against the background of a cohesive and supportive atmosphere.    Finally, given Shahar and colleagues’ (2004) and Hewitt, Smith, and colleagues’ (2020) findings that the quality of interpersonal relationships outside of therapy partially mediated the relationship between perfectionism and therapy outcome, it would be informative to investigate the relationship between multidimensional perfectionism and changes in interpersonal relationships during the course of treatment including interpersonal relationships within the   83 treatment (i.e. therapist relationship quality and group member relationship quality) as well as interpersonal relationships outside the treatment (i.e. the quality of patients’ social networks outside of therapy).  In conclusion, the current study did not find support for the hypotheses that pre-treatment perfectionism or decreases in perfectionism are related to therapy relationship quality in a group therapy treatment targeting perfectionism. This is despite a body of literature suggesting a link between perfectionistic cognitions and problems in therapeutic alliance. Future research should seek to better understand this discrepancy and to clarify the relationship between perfectionism and difficulties in therapy relationships.     84 Tables  Table 1  Taxonomy of Multilevel Models for Change Model Level 1 model Level 2 model Level 3 model A: unconditional means !!"# =  !!!"+ !!"# !!!" =  !!!! + !!!" !!!! = !!!! + !!!! B: unconditional growth !!"#=  !!!"+  !!!"(!"!!#$%− 1)+  !!"# !!!" =  !!!! + !!!" !!!" =  !!"! + !!!" !!!! = !!!! + !!!! !!"! = !!"" + !!"! C-E: uncontrolled effects of perfectionism !!"#=  !!!"+  !!!" !"!!#$%− 1 +  !!"# !!!" =  !!!! + !!"!!"#$+  !!!" !!!" =  !!"! +  !!!!!"!"+ !!!" !!!! = !!!! + !!!! !!"! = !!"! + !!"! !!"! = !!"" + !!"! !!!! = !!!" + !!!! F-H: controlled effects of perfectionism !!"#=  !!!"+  !!!" !"!!#$%− 1 +  !!"# !!!"=  !!!! + !!"!!"#$+ !!"!(!"ℎ!" !"#$)+   !!!" !!!"=  !!"! +  !!!!!"#$+ !!"!(!"ℎ!" !"#$)+ !!!" !!!! = !!!! + !!!! !!"! = !!"! + !!"! !!"! = !!"! + !!"! !!"! = !!"" + !!"! !!!! = !!!" + !!!! !!"! = !!"# + !!"!       85  Table 2  Self-Rated Perfectionism and Outcomes at Pre-Group, Post-Group, and at Follow-Up  Pre (n= 71) Post (n= 60) Follow-up (n= 44) Perfectionism traits         SOP 87.99 (9.15) 71.23 (17.69) 64.45 (10.94)      OOP 72.50 (13.92) 63.26 (17.60) 60.02 (4.92)      SPP 69.04 (16.38) 56.44 (17.79) 62.27 (10.21) BDI 17.39 (8.50) 10.83 (8.22) 9.98 (8.50) BAI 15.26 (10.25) 10.28 (7.40) 9.00 (7.87) IIP 1.71 (.69) 1.38 (.63) 1.48 (.98)  Note. SOP = self-oriented perfectionism; OOP = other-oriented perfectionism; SPP = socially prescribed perfectionism; BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory; IIP = Inventory of Interpersonal Problems      86  Table 3  Alliance, Cohesion, and Group Climate Means and Standard Deviations Across Sessions  S1 S2 S3 S4 S5 S6 S7 S8 S9 S10 TPOCS-A 2.60 (.63)  2.63  (.37)  2.72  (.37)  2.66 (.47)   2.87 (.49)  TPOCS-GC 3.25 (.45)  3.24 (.37)  3.23 (.41)  3.28 (.40)  3.32 (.51)  GCQ Engaged 5.20 (.76) 5.19 (.70) 5.44 (.68) 5.58 (.71) 5.42 (.76) 5.44 (.77) 5.59 (.80) 5.71 (.73) 5.66 (.93) 5.66 (.81) GCQ Conflict 2.67 (.88) 2.60 (.93) 2.72 (1.04) 2.54 (.86) 2.68 (.97) 2.53 (.83) 2.65 (1.04) 2.39 (.76) 2.76 (1.16) 2.07 (.80) GCQ Avoiding 3.35 (1.05) 3.33 (1.01) 3.24 (.86) 3.15 (1.02) 3.05 (.82) 3.12 (.84) 3.01 (1.07) 2.93 (.96) 3.07 (1.01) 3.09 (1.08)      87 Table 4  Pearson Correlations Between Alliance, Cohesion, and Climate Measures Variables 1 2 3 4 5 1. GCQ Engaged -     2. GCQ Conflict -.26*** -    3. GCQ Avoiding -.17*** .29*** -   4. TPOCS-A .060 -.12 -.029 -  5. TPOCS-GC .22*** -.30*** -.081 .62*** - Note. *p < .05; **p < .01; *** p < .001      88 Table 5  Intraclass Correlations for TPOCS-A and -GC TPOCS-A Item ICC Experience therapist as supporting? .78 Hostile toward therapist? .88 Positive affect?  .56 Sharing?  .81 Client appeared uncomfortable? .68 Client and therapist appeared uncomfortable? .73 Therapeutic tasks outside session? .59 Not comply with therapeutic tasks?  .61 Work together equally on tasks?  .66 Bond score .84 Task score .73 Total score .84 TPOCS-GC Experience group as supporting?  .75 Hostile toward group? .85 Positive affect? .78 Sharing? .79 Client appeared uncomfortable? .62 Maintained professional working relationship? .33 Interaction alive and energetic? .63 Client and group appeared uncomfortable? .63 Total score .82 Participation % .72     89 Table 6  Multilevel Variance in Alliance, Cohesion, and Group Climate  Unconditional Model Time only (with residuals)  Level 1 Level 2 Level 3 Level 1 Level 2 Level 3 Variance component (ICC) σ2  τπ  τβ σ2 τπ0 τπ1 Total ICC at level 2 τβ0 τβ1 Total ICC at level 3 GCQ engaged  .29 (.48) .31 (.52) 0 (0) .25 (.49) .26 (.51) .003 (.006) 1 0 (0) 0 (0) 0 GCQ conflict  .67 (.76) .13 (.15) .08 (.091) .62 (.71) .16 (.18) 0 (0) .18 .093 (.11) .004 (.005) .12 GCQ avoiding  .60 (.62) .32 (.33) .050 (.052) .58  (.62) .28 (.30) .001 (.001) .30 .076 (.081) 0 (0) .081 TPOCS-A   .16 (.72) .052 (.23) .010 (.045) .14 (.54) .058 (.22) .001 (.004) .22 .059 (.23) .001 (.004) .23 TPOCS-GC .097 (.55) .080 (.45) 0 (0) .086 (.50) .086 (.50) .001 (.006) .51 0 (0) 0 (0) 0 Note. σ2 = Level 1 (within-subject) variance; τπ = Level 2 (between-subject) variance; τβ = Level 3 (between-group) variance; τπ0 = Level 2 intercept variance (between-subject individual difference in intercept); τπ1 = Level 2 slope variance (between-subject individual difference in slope); τβ0 = Level 3 intercept variance (between-group individual difference in intercept); τβ1 = Level 3 group variance (between-group individual difference in slope); ICC = intraclass correlation (percent of total variance in the model accounted for by the given variance component).     90 Table 7  Hypothesis 1: Multilevel Analyses Examining the Effects of Pre-Treatment Perfectionism on Initial Status for GCQ Engaged     Model A Model B Model C SOP Model D OOP Model E SPP Initial status, π0i Intercept γ000  5.45*** (.070) 5.26*** (.072) 5.26*** (.071) 5.26*** (.072) 5.26*** (.072)  Perf !01    .012 (.008) .003 (.005) -.002 (.004) Rate of change, π1i Intercept !10  .046*** (.009) .045*** (.009) .046*** (.009) .046*** (.009)  Perf !11   -.001 (.001) 0 (.001) 0 (.001) Level 1 Within-person σ2ε .30*** (.019) .26*** (.017) .26*** (.017) .26*** (.017) .26*** (.017) Level 2 In initial status τπ0 .31*** (.058) .26*** (.061) .24*** (.059) .26*** (.061) .26*** (.061)  In rate of change τπ1  .002 (.001) .002 (.001) .002 (.001) .002 (.001)  Covariance σ01  .001 (.006) .002 (.006) .001 (.006) .001 (.006)   -2LL 1089.09 1043.04 1040.34 1042.76 1042.80   AIC 1095.09 1055.04 1056.34 1058.76 1058.80   BIC 1108.16 1081.18 1091.20 1093.62 1093.66     91 Table 8  Hypothesis 1: Multilevel Analyses Examining the Effects of Pre-Treatment Perfectionism on Initial Status for GCQ Conflict    Model A Model B Model C SOP Model D OOP Model E SPP Initial status, π0i Intercept γ000  2.60*** (.12) 2.72*** (.13) 2.72*** (.13) 2.72*** (.14) 2.73*** (.13)  Perf !01   .007 (.005) -.004 (.009) .007 (.006) .004 (.005) Rate of change, π1i Intercept !10  -.031 (.028) -.028 (.025) -.028 (.026) -.029 (.024)  Perf !11   .001 (.001) -.001 (.001) 0 (.001) Level 1 Within-person σ2ε .67*** (.042) .62*** (.039) .62*** (.039) .62*** (.039) .62*** (.039) Level 2 In initial status τπ0 .13*** (.039) .16* (.070) .16* (.070) .14** (.069) .16** (.067)  In rate of change τπ1  0 (0) 0 (0) 0 (0) 0 (0)  Covariance σ01  -.003 (.006) -.003 (.006) -.001 (.006) -.005 (.006) Level 3 In initial status τβ0 .082 (.054) .093 (.069) .091 (.068) .10 (.073) .095 (.070)  In rate of change τβ1  .004 (.003) .004 (.003) .004 (.003) .004 (.002)  Covariance σ01  0.010 (.011) -.010 (.011) -.012 (.011) -.012 (.011)   -2LL 1489.06 1460.98 1460.75 1459.08 1459.78   AIC 1497.06 1478.98 1482.75 1481.08 1481.78   BIC 1514.49 1518.20 1530.69 1529.02 1529.71     92 Table 9   Hypothesis 1: Multilevel Analyses Examining the Effects of Pre-Treatment Perfectionism on Initial Status for GCQ Avoiding    Model A Model B Model C SOP Model D OOP Model E SPP Initial status, π0i Intercept γ000  3.18*** (.11) 3.32*** (.13) 3.33*** (.13) 3.32*** (.13) 3.32*** (.12)  Perf !01    .002 (.006) 0 (.006) -.007 (.005) Rate of change, π1i Intercept !10  -.032* (.013) -.034* (.013) -.033* (.013) -.032** (.013)  Perf !11   -.002 (.001) -.001 (.001) 0 (.001) Level 1 Within-person σ2ε .60*** (.037) .58*** (.039) .58*** (.039) .58*** (.039) .58*** (.039) Level 2 In initial status τπ0 .32*** (.073) .28** (.094) .28** (.094) .28** (.094) .27** (.93)  In rate of change τπ1  .001 (.002) .001 (.002) .001 (.002) .001 (.002)  Covariance σ01  .002 (.011) .002 (.011) .002 (.011) .003 (.010) Level 3 In initial status τβ0 .050 (.051) .076 (.074) .078 (.073) .078 (.075) .064 (.068)  In rate of change τβ1  0 (.001) 0 (0) 0 (.001) 0 (.001)  Covariance σ01  -.004 (.006) -.004 (.006) -.004 (.007) -.004 (.006)   -2LL 1458.62 1449.86 1446.49 1449.09 1448.13   AIC 1466.62 1467.86 1468.49 1471.09 1470.13   BIC 1484.05 1507.06 1516.41 1519.01 1518.05     93 Table 10  Hypothesis 1: Multilevel Analyses Examining the Effects of Pre-Treatment Perfectionism on Initial Status for TPOCS-A     Model A Model B Model C SOP Model D OOP Model E SPP Initial status, π0i Intercept γ000  2.67*** (.054) 2.59*** (.10) 2.59*** (.10) 2.59*** (.10) 2.59*** (.10)  Perf !01    .010 (.006) .002  (.004) .004 (.003) Rate of change, π1i Intercept !10  .023 (.016) .024 (.016) .024 (.016) .023 (.016)  Perf !11   0 (.001) 0 (.001) 0 (.001) Level 1 Within-person σ2ε .16*** (.018) .14*** (.018) .14*** (.018) .14*** (.018) .14*** (.018) Level 2 In initial status τπ0 .052** (.018) .058 (.033) .048 (.032) .057 (.033) .054 (.032)  In rate of change τπ1  .001 (.001) .001 (.001) .001 (.001) .001 (.001)  Covariance σ01  -.001 (.006) -.001 (.006) -.001 (.006) -.001 (.006) Level 3 In initial status τβ0 .010 (.011) .059 (.036) .057 (.038) .058 (.038) .056 (.038)  In rate of change τβ1  .001 (0) .001 (.001) .001 (0) .001 (.001)  Covariance σ01  -.009 (.005) -.008 (.006) -.008 (.006) -.008 (.006)   -2LL 288.09 268.09 236.67 267.86 266.41   AIC 296.09 286.09 285.67 289.86 288.41   BIC 309.85 317.03 323.49 327.68 326.23                  94 Table 11  Hypothesis 1: Multilevel Analyses Examining the Effects of Pre-Treatment Perfectionism on Initial Status for TPOCS-GC     Model A Model B Model C SOP Model D OOP Model E SPP Initial status, π0i Intercept γ000  3.26*** (.041) 3.22*** (.049) 3.22*** (.049) 3.22*** (.049) 3.22*** (.049)  Perf !01    .006 (.005) .001 (.004) .004 (.003) Rate of change, π1i Intercept !10  .009 (.009) .010 (.009) .009 (.009) .009 (.008)  Perf !11   .001 (.001) 0 (.001) 0 (.001) Level 1 Within-person σ2ε .097*** (.011) .086*** (.011) .087*** (.011) .086*** (.011) .086*** (.011) Level 2 In initial status τπ0 .080*** (.019) .088** (.028) .084** (.028) .088** (.028) .083** (.027)  In rate of change τπ1  .001 (.001) .001 (.001) .001 (.001) .001 (.001)  Covariance σ01  -.002 (.004) -.003 (.004) -.002 (.004) -.003 (.004)   -2LL 202.62 198.71 194.13 198.38 194.50   AIC 208.62 210.71 210.13 214.38 210.50   BIC 218.94 231.34 237.63 241.89 238.00               95 Table 12  Hypothesis 2: Multilevel Analyses Examining the Effects of Change in Perfectionism on Rate of Change for GCQ Engaged     Model A Model B Model C SOP Model D OOP Model E SPP Initial status, π0i Intercept γ000  5.45*** (.070) 5.26*** (.072) 5.29*** (.078) 5.29*** (.078) 5.29*** (.079)  Perf !01    .004 (.005) .005 (.006) .002 (.005) Rate of change, π1i Intercept !10  .046*** (.009) .052*** (.009) .052*** (.009) .052*** (.009)  Perf !11   0 (.001) 0 (.001) 0 (.001) Level 1 Within-person σ2ε .30*** (.019) .26*** (.017) .25*** (.018) .25*** (.018) .25*** (.018) Level 2 In initial status τπ0 .31*** (.058) .26*** (.061) .27*** (.068) .27*** (.067) .28*** (.068)  In rate of change τπ1  .002 (.001) .002 (.001) .002 (.001) .002 (.001)  Covariance σ01  .001 (.006) -.001 (.006) -.001 (.006) -.001 (.006)   -2LL 1089.09 1043.04 926.59 926.28 926.93   AIC 1095.09 1055.04 942.59 942.28 942.93   BIC 1108.16 1081.18 976.64 976.32 976.98     96 Table 13  Hypothesis 2: Multilevel Analyses Examining the Effects of Change in Perfectionism on Rate of Change for GCQ Conflict    Model A Model B Model C SOP Model D OOP Model E SPP Initial status, π0i Intercept γ000  2.60*** (.12) 2.72*** (.13) 2.72*** (.14) 2.72*** (.12) 2.72*** (.14)  Perf !01   .007 (.005) .010 (.009) -.009 (.006) .003 (.005) Rate of change, π1i Intercept !10  -.031 (.028) .14*** (.021) -.032 (.025) -.032 (.026)  Perf !11   -.001 (.002) 0 (.001) -.001 (.001) Level 1 Within-person σ2ε .67*** (.042) .62*** (.039) .60*** (.040) .60*** (.040) .60*** (.039) Level 2 In initial status τπ0 .13*** (.039) .16* (.070) .17* (.076) .15** (.059) .16** (.059)  In rate of change τπ1  0 (0) 0 (0) 0 (0) 0 (0)  Covariance σ01  -.003 (.006) -.004 (.007) -.008 (.005) -.007 (.006) Level 3 In initial status τβ0 .082 (.054) .093 (.069) .095 (.074) .070 (.064) .096 (.078)  In rate of change τβ1  .004 (.003) .005 (.003) .004 (.002) .004 (.003)  Covariance σ01  0.010 (.011) -.011 (.012) -.010 (.012) -.015 (.013)   -2LL 1489.06 1460.98 1303.98 1306.91 1310.01   AIC 1497.06 1478.98 1325.98 1328.91 1332.01   BIC 1514.49 1518.20 1372.80 1375.72 1378.82     97 Table 14  Hypothesis 2: Multilevel Analyses Examining the Effects of Change in Perfectionism on Rate of Change for GCQ Avoiding    Model A Model B Model C SOP Model D OOP Model E SPP Initial status, π0i Intercept γ000  3.18*** (.11) 3.32*** (.13) 3.27*** (.13) 3.27*** (.13) 3.26*** (.12)  Perf !01    .006 (.006) .001 (.007) .007 (.006) Rate of change, π1i Intercept !10  -.032* (.013) -.035* (.012) -.035* (.012) -.035** (.012)  Perf !11   0 (.001) 0 (.001) -.001 (.001) Level 1 Within-person σ2ε .60*** (.037) .58*** (.039) .59*** (.042) .59*** (.042) .59*** (.042) Level 2 In initial status τπ0 .32*** (.073) .28** (.094) .28** (.10) .28** (.10) .28** (.10)  In rate of change τπ1  .001 (.002) 0 (.002) 0 (.002) 0 (.002)  Covariance σ01  .002 (.011) .002 (.011) .002 (.011) .002 (.010) Level 3 In initial status τβ0 .050 (.051) .076 (.074) .062 (.069) .073 (.076) .047 (.064)  In rate of change τβ1  0 (.001) 0 (.001) 0 (.001) 0 (0)  Covariance σ01  -.004 (.006) -.002 (.005) -.002 (.005) -.001 (.004)   -2LL 1458.62 1449.86 1313.12 1314.67 1313.08   AIC 1466.62 1467.86 1335.12 1336.67 1335.08   BIC 1484.05 1507.06 1381.92 1383.46 1381.87     98 Table 15  Hypothesis 2: Multilevel Analyses Examining the Effects of Change in Perfectionism on Rate of Change for TPOCS-A    Model A Model B Model C SOP Model D OOP Model E SPP Initial status, π0i Intercept γ000  2.67*** (.054) 2.59*** (.10) 2.59*** (.12) 2.59*** (.11) 2.59*** (.12)  Perf !01    -.004 (.003) -.006 (.004) -.005 (.003) Rate of change, π1i Intercept !10  .023 (.016) .026 (.020) .026 (.019) .026 (.020)  Perf !11   0 (.001) .001 (.001) 0 (.001) Level 1 Within-person σ2ε .16*** (.018) .14*** (.018) .12*** (.017) .12*** (.015) .12*** (.017) Level 2 In initial status τπ0 .052** (.018) .058 (.033) .055 (.033) .056 (.029) .051 (.031)  In rate of change τπ1  .001 (.001) .001 (.001) 0 (0) .001 (.001)  Covariance σ01  -.001 (.006) 0 (.005) .002 (.003) .001 (.005) Level 3 In initial status τβ0 .010 (.011) .059 (.036) .087 (.10) .075 (0) .091 (.055)  In rate of change τβ1  .001 (0) .002 (0) .002 (0) .002 (0)  Covariance σ01  -.009 (.005) -.014 (0) -.013 (.005) -.014 (0)   -2LL 288.09 268.09 220.00 217.50 219.65   AIC 296.09 286.09 242.00 239.59 241.65   BIC 309.85 317.03 278.39 275.98 278.05                 99 Table 16  Hypothesis 2: Multilevel Analyses Examining the Effects of Change in Perfectionism on Rate of Change for TPOCS-GC    Model A Model B Model C SOP Model D OOP Model E SPP Initial status, π0i Intercept γ000  3.26*** (.041) 3.22*** (.049) 3.23*** (.054) 3.23*** (.054) 3.23*** (.054)  Perf !01    -.001 (.003) -.001 (.004) -.003 (.003) Rate of change, π1i Intercept !10  .009 (.009) .010 (.009) .010 (.009) .010 (.009)  Perf !11   0 (.001) 0 (.001) 0 (.001) Level 1 Within-person σ2ε .097*** (.011) .086*** (.011) .084*** (.011) .084*** (.011) .084*** (.011) Level 2 In initial status τπ0 .080*** (.019) .088** (.028) .095** (.031) .095** (.031) .093** (.031)  In rate of change τπ1  .001 (.001) .001 (.001) .001 (.001) .001 (.001)  Covariance σ01  -.002 (.004) -.003 (.004) -.003 (.004) -.003 (.004)   -2LL 202.62 198.71 171.38 172.78 171.26   AIC 208.62 210.71 187.38 188.78 187.26   BIC 218.94 231.34 213.84 215.24 213.73       100 Figures  Figure 1  Perfectionism Social Disconnection Model    Reprinted from Perfectionism: A Relational Approach to Conceptualization, Assessment and Treatment (p. 97), by P. L. Hewitt, G. L. Flett, & S. F. Mikail, 2017 by The Guilford Press. Copyright 2017 by The Guilford Press. Reprinted with permission.       101 Figure 2  Perfectionism Social Disconnection Model in the Psychotherapy Context     Reprinted from Perfectionism: A Relational Approach to Conceptualization, Assessment and Treatment (p. 135), by P. L. Hewitt, G. L. Flett, & S. F. Mikail, 2017 by The Guilford Press. Copyright 2017 by The Guilford Press. Reprinted with permission.      102 Figure 3  Change Trajectories for Alliance, Cohesion, and Climate Variables                   103 Figure 4  Linear Change Trajectories for GCQ Engaged by Participant                    104 Figure 5   Linear Change Trajectories for GCQ Conflict by Participant       105 Figure 6  Linear Change Trajectories for GCQ Avoiding by Participant                    106 Figure 7  Linear Change Trajectories for TPOCS-A by Participant                    107 Figure 8  Linear Change Trajectories for TPOCS-GC by Participant      108 Figure 9  Change Trajectories For GCQ Engaged for Participants 2, 42, 60, and 106               109 Figure 10   Change Trajectories for GCQ Conflict For Participants 2, 42, 60, and 106            110 Figure 11   Change Trajectories for GCQ Avoiding For Participants 2, 42, 60, and 106           111 Figure 12   Change Trajectories for TPOCS-A For Participants 2, 42, 60, and 106         112 Figure 13   Change Trajectories for TPOCS-GC For Participants 2, 42, 60, and 106                            113   References Antony, M. M., Purdon, C. L., Huta, V., & Swinson, R. P. (1998). Dimensions of perfectionism  across the anxiety disorders. Behaviour Research and Psychotherapy, 36(12), 1143-1154. Arpin-Cribbie, C., Irvine, J., & Ritvo, P. (2012). Web-based cognitive-behavioral psychotherapy  for perfectionism: a randomized controlled trial. Psychotherapy Research, 22(2), 194-207. Atkins, D. C. (2005). Using multilevel models to analyze couple and family treatment data: basic  and advanced issues. Journal of Family Psychology, 19(1), 98-110. Baker, H. S., & Baker, M. N. (1987). Heinz Kohut’s self psychology: An overview. American  Journal of Psychiatry, 144(1), 1-9. Bardone-Cone, A. M., Wonderlich, S. A., Frost, R. O., Bulik, C. M., Mitchell, J. E., Uppala, S.,  & Simonich, H. (2007). Perfectionism and eating disorders: Current status and future directions. Clinical Psychology Review, 27(3), 384-405. Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in social  psychological research: Conceptual, strategic, and statistical considerations. Journal of personality and social psychology, 51(6), 1173-1182. Barrett-Lennard. G. T. (1986). The relationship inventory now. In L. S. Greenberg & W. M.  Pinsoff (Eds.), The psychotherapeutic process. A research handbook (pp. 439-476). New York & London: Guilford Press.  Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical  anxiety: psychometric properties. Journal of consulting and clinical psychology, 56(6), 893-897.                        114   Beck, A. T., & Steer, R. A. (1991). Relationship between the Beck anxiety inventory and the  Hamilton anxiety rating scale with anxious outpatients. Journal of Anxiety Disorders, 5(3), 213-223. Beck, A. T., Steer, R. A., & Carbin, M. G. (1988). Psychometric properties of the Beck  Depression Inventory: Twenty-five years of evaluation. Clinical psychology review, 8(1), 77-100. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for  measuring depression. Archives of general psychiatry, 4(6), 561-571. Beevers, C. G., & Miller, I. W. (2004). Perfectionism, cognitive bias, and hopelessness as  prospective predictors of suicidal ideation. Suicide and Life-Threatening Behavior, 34(2), 126-137. Bieling, P. J., Summerfeldt, L. J., Israeli, A. L., & Antony, M. M. (2004). Perfectionism as an  explanatory construct in comorbidity of axis I disorders. Journal of Psychopathology and Behavioral Assessment, 26(3), 193-201. Blasberg, J. S., Hewitt, P. L., Flett, G. L., Sherry, S. B., & Chen, C. (2016). The importance of  item wording: The distinction between measuring high standards versus measuring perfectionism and why it matters. Journal of Psychoeducational Assessment, 34(7), 702-717. Blatt, S. J., Quinlan, D. M., Pilkonis, P. A., & Shea, M. T. (1995). Impact of perfectionism and  need for approval on the brief treatment of depression: the National Institute of Mental Health Treatment of Depression Collaborative Research Program revisited. Journal of Consulting and Clinical Psychology, 63(1), 125-132.                        115   Blatt, S. J., Zuroff, D. C., Bondi, C. M., Sanislow III, C. A., & Pilkonis, P. A. (1998). When and  how perfectionism impedes the brief treatment of depression: further analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of consulting and clinical psychology, 66(2), 423-428. Blatt, S. J., Zuroff, D. C., Hawley, L. L., & Auerbach, J. S. (2010). Predictors of sustained  therapeutic change. Psychotherapy research, 20(1), 37-54. Blatt, S. J., Zuroff, D. C., Quinlan, D. M., & Pilkonis, P. A. (1996). Interpersonal factors in brief  treatment of depression: Further analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 64(1), 162-171. Boone, L. (2013). Are attachment styles differentially related to interpersonal perfectionism and  binge eating symptoms?. Personality and individual differences, 54(8), 931-935. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working  alliance. Psychotherapy: Theory, research & practice, 16(3), 252-260. Brown, G. P., & Beck, A. T. (2002). Dysfunctional attitudes, perfectionism, and models of  vulnerability to depression. Perfectionism: Theory, research, and treatment, 231-251. Burlingame, G. M., McClendon, D. T., & Alonso, J. (2011). Cohesion in group  psychotherapy. Psychotherapy, 48(1), 34-42. Burlingame, G. M., Strauss, B., & Joyce, A. (2013). Change mechanisms of small group  treatments. Bergin and Garfield’s handbook of psychotherapy and behavior change, 640-689.                         116   Campbell, R., Boone, L., Vansteenkiste, M., & Soenens, B. (2018). Psychological need  frustration as a transdiagnostic process in associations of self-critical perfectionism with depressive symptoms and eating pathology. Journal of Clinical psychology, 74(10), 1775-1790. Carson, R. C. Interaction Concepts of Personality. Chicago: Aldine, 1969.  Cheek, J., Kealy, D., Hewitt, P. L., Mikail, S. F., Flett, G. L., Ko, A., & Jia, M. (2018).  Addressing the Complexity of Perfectionism in Clinical Practice. Psychodynamic Psychiatry, 46(4), 457-489. Chen, C., Hewitt, P. L., & Flett, G. L. (2015). Preoccupied attachment, need to belong, shame,  and interpersonal perfectionism: An investigation of the perfectionism social disconnection model. Personality and Individual Differences, 76, 177-182. Chen, C., Hewitt, P. L., Flett, G. L., Cassels, T. G., Birch, S., & Blasberg, J. S. (2012). Insecure  attachment, perfectionistic self-presentation, and social disconnection in adolescents. Personality and Individual Differences, 52(8), 936-941. Chik, H. M., Whittal, M. L., & O’Neill, M. L. (2008). Perfectionism and treatment outcome in  obsessive-compulsive disorder. Cognitive Therapy and Research, 32(5), 676-688. Cicchetti, D. V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and  standardized assessment instruments in psychology. Psychological assessment, 6(4), 284- 290. Cockell, S. J., Hewitt, P. L., Seal, B., Sherry, S., Goldner, E. M., Flett, G. L., & Remick, R. A.  (2002). Trait and self-presentational dimensions of perfectionism among women with anorexia nervosa. Cognitive Therapy and Research, 26(6), 745-758. Cohen, J. (1992). A power primer. Psychological bulletin, 112(1), 155.                        117   Cox, B. J., & Enns, M. W. (2003). Relative stability of dimensions of perfectionism in  depression. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement, 35(2), 124-132. Crits-Christoph, P., Gibbons, M. B. C., Hamilton, J., Ring-Kurtz, S., & Gallop, R. (2011). The  dependability of alliance assessments: The alliance–outcome correlation is larger than you might think. Journal of Consulting and Clinical Psychology, 79(3), 267-278. Crits-Christoph, P., Gibbons, M. C., & Mukherjee, D. (2013). Psychotherapy process-outcome  research. Bergin and Garfield’s handbook of psychotherapy and behavior change, 6, 298-340. Crowe, T. P., & Grenyer, B. F. (2008). Is therapist alliance or whole group cohesion more  influential in group psychotherapy outcomes?. Clinical Psychology & Psychotherapy, 15(4), 239-246. DiBartolo, P. M., Li, C. Y., & Frost, R. O. (2008). How do the dimensions of perfectionism  relate to mental health?. Cognitive Therapy and Research, 32(3), 401-417. 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. Dunkley, D. M., Berg, J. L., & Zuroff, D. C. (2012). The role of perfectionism in daily self- esteem, attachment, and negative affect. Journal of Personality, 80(3), 633-663. Dunkley, D. M., Blankstein, K. R., Halsall, J., Williams, M., & Winkworth, G. (2000). The  relation between perfectionism and distress: Hassles, coping, and perceived social  support as mediators and moderators. Journal of Counseling Psychology, 47(4), 437-453.                       118   Dunkley, D. M., Blankstein, K. R., Masheb, R. M., & Grilo, C. M. (2006). Personal standards  and evaluative concerns dimensions of “clinical” perfectionism: A reply to Shafran et al.(2002, 2003) and Hewitt et al.(2003). Behaviour research and therapy, 44(1), 63-84. Dunkley, D. M., Sanislow, C. A., Grilo, C. M., & McGlashan, T. H. (2006). Perfectionism and  depressive symptoms 3 years later: Negative social interactions, avoidant coping, and perceived social support as mediators. Comprehensive psychiatry, 47(2), 106-115. Dunkley, D. M., Ma, D., Lee, I. A., Preacher, K. J., & Zuroff, D. C. (2014). Advancing complex  explanatory conceptualizations of daily negative and positive affect: Trigger and maintenance coping action patterns. Journal of Counseling Psychology, 61(1), 93-109. Dunkley, D. M., Sanislow, C. A., Grilo, C. M., & McGlashan, T. H. (2009). Self-criticism versus  neuroticism in predicting depression and psychosocial impairment for 4 years in a clinical sample. Comprehensive psychiatry, 50(4), 335-346. Dunkley, D. M., Sanislow, C. A., Grilo, C. M., & McGlashan, T. H. (2004). Validity of DAS  perfectionism and need for approval in relation to the five-factor model of  personality. Personality and Individual Differences, 37(7), 1391-1400. Egan, S. J., Hattaway, M., & Kane, R. T. (2014). The relationship between perfectionism and  rumination in post traumatic stress disorder. Behavioural and cognitive psychotherapy, 42(2), 211-223. Egan, S. J., Wade, T. D., & Shafran, R. (2011). Perfectionism as a transdiagnostic process: A  clinical review. Clinical psychology review, 31(2), 203-212. Elkin, I., Parloff, M. B., Hadley, S. W., & Autry, J. H. (1985). NIMH treatment of Depression  Collaborative Research Program: Background and research plan. Archives of general psychiatry, 42(3), 305-316.                       119   Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F., Glass, D. R.,  Pilkonis, P. A., Leber, W. R., Docherty, J. P., Fiester, S. J., & Parloff, M. B. (1989). National Institute of Mental Health treatment of depression collaborative research program: General effectiveness of treatments. Archives of general psychiatry, 46(11), 971-982. Enns, M. W., & Cox, B. J. (1999). Perfectionism and depression symptom severity in major  depressive disorder. Behaviour Research and Psychotherapy, 37(8), 783-794. Enns, M. W., Cox, B. J., & Inayatulla, M. (2003). Personality predictors of outcome for  adolescents hospitalized for suicidal ideation. Journal of the American academy of child & adolescent psychiatry, 42(6), 720-727. Enns, M. W., Cox, B. J., & Pidlubny, S. R. (2002). Group cognitive behaviour therapy for  residual depression: Effectiveness and predictors of response. Cognitive Behaviour Therapy, 31(1), 31-40. Ey, S., Henning, K. R., & Shaw, D. L. (2000). Attitudes and factors related to seeking mental  health treatment among medical and dental students. Journal of College Student  Psychotherapy, 14(3), 23-39. Falkenström, F., Granström, F., & Holmqvist, R. (2013). Therapeutic alliance predicts  symptomatic improvement session by session. Journal of Counseling Psychology, 60(3), 317-328. Falkenström, F., Granström, F., & Holmqvist, R. (2014). Working alliance predicts  psychotherapy outcome even while controlling for prior symptom improvement. Psychotherapy Research, 24(2), 146-159.                        120   Falloon, I. R. (1981). Interpersonal variables in behavioural group psychotherapy. British  Journal of Medical Psychology, 54(2), 133-141. Farber, B. A. (2003). Patient self-disclosure: A review of the research. Journal of Clinical  Psychology, 59(5), 589-600. Farber, B. A., & Sohn, A. (2001). The relationship of patient disclosure to psychotherapy  outcome. In annual conference of the Society for Psychotherapy Research. Monte-video, Uruguay. Fenton, L. R., Cecero, J. J., Nich, C., Frankforter, T. L., & Carroll, K. M. (2001). Perspective is  everything: The predictive validity of six working alliance instruments. The Journal of psychotherapy practice and research, 10(4), 262-268. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. (1994). Structured clinical interview  for Axis I DSM-IV disorders. New York: Biometrics Research.  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 (p. 5–31). American Psychological Association. Flett, G. L., Hewitt, P. L., Blankstein, K. R., & Gray, L. (1998). Psychological distress and the  frequency of perfectionistic thinking. Journal of personality and social psychology, 75(5), 1363-1381. Flett, G. L., Hewitt, P. L., & De Rosa, T. (1996). Dimensions of perfectionism, psychosocial  adjustment, and social skills. Personality and Individual Differences, 20(2), 143-150. Flett, G. L., Hewitt, P. L., & Dyck, D. G. (1989). Self-oriented perfectionism, neuroticism and  anxiety. Personality and Individual Differences, 10(7), 731-735.                       121   Flett, G. L., Hewitt, P. L., Garshowitz, M., & Martin, T. R. (1997). Personality, negative social  interactions, and depressive symptoms. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement, 29(1), 28-37. 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. Flett, G. L., Hewitt, P. L., Whelan, T., & Martin, T. R. (2007). The Perfectionism Cognitions  Inventory: Psychometric properties and associations with distress and deficits in cognitive self-management. Journal of Rational-Emotive & Cognitive-Behavior Psychotherapy, 25(4), 255-277. Flett, G. L., Nepon, T., & Hewitt, P. L. (2016). Perfectionism, worry, and rumination in health  and mental health: A review and a conceptual framework for a cognitive theory of perfectionism. In Perfectionism, health, and well-being (pp. 121-155). Springer International Publishing. Flückiger, C., Del Re, A. C., Wampold, B. E., Symonds, D., & Horvath, A. O. (2012). How  central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis. Journal of Counseling Psychology, 59(1), 10-17. Frost, R. O., Lahart, C. M., & Rosenblate, R. (1991). The development of perfectionism: A study  of daughters and their parents. Cognitive psychotherapy and research, 15(6), 469-489. Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of  perfectionism. Cognitive psychotherapy and research, 14(5), 449-468.                         122   Frost, R. O., Turcotte, T. A., Heimberg, R. G., Mattia, J. I., Holt, C. S., & Hope, D. A. (1995).  Reactions to mistakes among subjects high and low in perfectionistic concern over mistakes. Cognitive Psychotherapy and Research,19(2), 195-205. Gans, J. S., & Counselman, E. F. (2010). Patient selection for psychodynamic group  psychotherapy: Practical and dynamic considerations. International Journal of Group Psychotherapy, 60(2), 197-220. Garner, D. M., Olmstead, M. P., & Polivy, J. (1983). Development and validation of a  multidimensional eating disorder inventory for anorexia nervosa and bulimia. International journal of eating disorders, 2(2), 15-34.  Gaudreau, P. (2019). On the distinction between personal standards perfectionism and  excellencism: A theory elaboration and research agenda. Perspectives on Psychological Science, 14(2), 197-215. Green, P., & MacLeod, C. J. (2016). SIMR: an R package for power analysis of generalized  linear mixed models by simulation. Methods in Ecology and Evolution, 7(4), 493-498. Guo, S. (2005). Analyzing grouped data with hierarchical linear modeling. Children and Youth  Services Review, 27(6), 637-652. Gurtman, M. B. (1996). Interpersonal problems and the psychotherapy context: The construct  validity of the Inventory of Interpersonal Problems. Psychological Assessment, 8(3), 241- 255. Habke, A. M., Hewitt, P. L., Fehr, B., Callander, L., & Flett, G. (1997). Perfectionism and  behavior in marital interactions. In Poster presented at the Annual Meeting of the Canadian Psychological Association, Toronto, ON.                        123   Habke, A. M., & Flynn, C. A. (2002). Interpersonal aspects of trait perfectionism. In G. L. Flett  & P. L. Hewitt (Eds.), Perfectionism: Theory, research, and treatment (p. 151–180). American Psychological Association. Haring, M., Hewitt, P. L., & Flett, G. L. (2003). Perfectionism, coping, and quality of intimate  relationships. Journal of Marriage and Family, 65(1), 143-158. Hartley, D. E., & Strupp, H. H. (1983). The therapeutic alliance: Its relationship to outcome in  brief psychotherapy. Empirical studies of psychoanalytic theories, 1, 1-37. Hawley, L. L., Ho, M. H. R., Zuroff, D. C., & Blatt, S. J. (2006). The relationship of  perfectionism, depression, and therapeutic alliance during treatment for depression: Latent difference score analysis. Journal of Consulting and Clinical Psychology, 74(5), 930-942. Hedeker, D., & Gibbons, R. D. (1997). Application of random-effects pattern-mixture models for  missing data in longitudinal studies. Psychological methods, 2(1), 64-78. Hewitt, P. L. (2020). Perfecting, Belonging, and Repairing: A Dynamic-Relational Approach to  Perfectionism. Canadian Psychology. https://doi.org/10.1037/cap0000209.  Hewitt, P. L., Chen, C., Smith, M. M., Zhang, L., Habke, M., Flett, G. L., & Mikail, S. F. (2020).  Patient perfectionism and clinician impression formation during an initial interview. Psychology and Psychotherapy: Theory, research and practice. Hewitt, P. L., Dang, S. Deng, X., Flett, G. L., & Kaldas, J. (2016). Perfectionism, help seeking,  and ratings of therapeutic experiences. Manuscript in preparation.  Hewitt, P. L., & Flett, G. L. (1991a). Dimensions of perfectionism in unipolar  depression. Journal of abnormal psychology, 100(1), 98-101.                        124   Hewitt, P. L., & Flett, G. L. (1991b). Perfectionism in the self and social contexts:  conceptualization, assessment, and association with psychopathology. Journal of personality and social psychology, 60(3), 456-470. Hewitt, P. L., & Flett, G. L. (1993). Dimensions of perfectionism, daily stress, and depression: a  test of the specific vulnerability hypothesis. Journal of abnormal psychology, 102(1), 58- 65. Hewitt, P. L., Flett, G. L., Besser, A., Sherry, S. B., & McGee, B. (2003). Perfectionism Is  Multidimensional: a reply to. Behaviour Research and Psychotherapy, 41(10), 1221-1236. Hewitt, P. L., Flett, G. L., & Ediger, E. (1996). Perfectionism and depression: Longitudinal  assessment of a specific vulnerability hypothesis. Journal of Abnormal Psychology, 105(2), 276-280. Hewitt, P. L., Flett, G. L., Ediger, E., Norton, G. R., & Flynn, C. A. (1998). Perfectionism in  chronic and state symptoms of depression. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement, 30(4), 234-242. Hewitt, P. L., Flett, G. L., & Mikail, S. F. (1995). Perfectionism and relationship adjustment in  pain patients and their spouses. Journal of Family Psychology, 9(3), 335-347. Hewitt, P.L., Flett, G. L., & Mikail, S. F. (2017).  Perfectionism:  Conceptualization,  assessment, and treatment.  New York: Guilford.  Hewitt, P. L., Flett, G. L., Mikail, S. F., Kealy, D., & Zhang, L. (2017).  Perfectionism in the  Therapeutic Context: The Perfectionism Social Disconnection Model and Clinical Process and Outcome.  In J. Stoeber (Ed.) The Psychology of Perfectionism: Theory, Research, Applications (p. 306-329). New York: Routledge.                       125   Hewitt, P. L., Flett, G. L., Sherry, S. B., & Caelian, C. (2006). Trait Perfectionism Dimensions  and Suicidal Behavior. In T. E. Ellis (Ed.), Cognition and suicide: Theory, research, and therapy (p. 215–235). American Psychological Association. Hewitt, P. L., Flett, G. L., Sherry, S. B., Habke, M., Parkin, M., Lam, R. W., McMurty, B.,  Ediger, E., Fairlie, P., & Stein, M. B. (2003). The interpersonal expression of perfection: perfectionistic self-presentation and psychological distress. Journal of personality and social psychology, 84(6), 1303-1325. Hewitt, P. L., Flett, G. L., & Turnbull, W. (1992). Perfectionism and multiphasic personality  inventory (MMPI) indices of personality disorder. Journal of Psychopathology and Behavioral Assessment, 14(4), 323-335. Hewitt, P. L., Flett, G. L., Turnbull-Donovan, W., & Mikail, S. F. (1991). The Multidimensional  Perfectionism Scale: Reliability, validity, and psychometric properties in psychiatric samples. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3(3), 464-468. Hewitt, P. L., Habke, A. M., Lee-Baggley, D. L., Sherry, S. B., & Flett, G. L. (2008). The impact  of perfectionistic self-presentation on the cognitive, affective, and physiological experience of a clinical interview. Psychiatry,71(2), 93-122. Hewitt, P. L., Mikail, S. F., Flett, G. L., & Dang, S. S. (2018). Specific formulation feedback in  dynamic-relational group psychotherapy of perfectionism. Psychotherapy, 55(2), 179-185. Hewitt, P. L., Mikail, S. F., Flett, G. L., Tasca, G. A., Flynn, C. A., Deng, X., Kaldas, J., &  Chen, C. (2015). Psychodynamic/interpersonal group psychotherapy for perfectionism: Evaluating the effectiveness of a short-term treatment. Psychotherapy, 52(2), 205-217.                       126   Hewitt, P. L., Newton, J., Flett, G. L., & Callander, L. (1997). Perfectionism and suicide ideation  in adolescent psychiatric patients. Journal of Abnormal Child Psychology, 25(2), 95-101. Hewitt, P. L., Norton, G. R., Flett, G. L., Callander, L., & Cowan, T. (1998). Dimensions of  perfectionism, hopelessness, and attempted suicide in a sample of alcoholics. Suicide and Life-Threatening Behavior, 28(4), 395-406. Hewitt, P. L., Qiu, T., Flynn, C. A., Flett, G. L., Wiebe, S. A., Tasca, G. A., & Mikail, S. F.  (2019). Dynamic-relational group treatment for perfectionism: Informant ratings of patient change. Psychotherapy. Hewitt, P. L., Smith, M. M., Deng, X., Chen, C., Ko, A., Flett, G. L., & Paterson, R. J. (2020).  The perniciousness of perfectionism in group therapy for depression: A test of the  perfectionism social disconnection model. Psychotherapy. https://doi.org/10.1037/pst0000281 Hill, R. W., McIntire, K., & Bacharach, V. R. (1997). Perfectionism and the big five  factors. Journal of social behavior and personality, 12(1), 257-270. Hill, R. W., Zrull, M. C., & Turlington, S. (1997). Perfectionism and interpersonal  problems. Journal of Personality Assessment, 69(1), 81-103. Hilsenroth, M. J., & Cromer, T. D. (2007). Clinician interventions related to alliance during the  initial interview and psychological assessment. Psychotherapy: theory, research, practice, training, 44(2), 205-218. Hilsenroth, M. J., Peters, E. J., & Ackerman, S. J. (2004). The development of therapeutic  alliance during psychological assessment: Patient and therapist perspectives across treatment. Journal of Personality Assessment, 83(3), 332-344.                        127   Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual  psychotherapy. Psychotherapy, 48(1), 9-16.  Horowitz, L. M., Alden, L. E., Wiggins, J. S., & Pincus, A. L. (2002). IIP: Inventory of  interpersonal problems: Manual. Stockholm: Psykologiförlaget. Horowitz, L. M., Rosenberg, S. E., Baer, B. A., Ureño, G., & Villaseñor, V. S. (1988). Inventory  of interpersonal problems: psychometric properties and clinical applications. Journal of consulting and clinical psychology, 56(6), 885-892. Huan, J. Y., Rice, K. G., & Storch, E. A. (2008). Perfectionism and peer relations among  children with obsessive-compulsive disorder. Child psychiatry and human development, 39(4), 415-426. Imber, S. D., Pilkonis, P. A., Sotsky, S. M., Elkin, I., Watkins, J. T., Collins, J. F., Shea, M. T.,  Leber, W.R., & Glass, D. R. (1990). Mode-specific effects among three treatments for depression. Journal of Consulting and Clinical Psychology, 58(3), 352-359. Izydorczyk, B. (2014). The results of research aimed at identifying psychological predictors of  impulsive and restrictive behaviours in a population of females suffering from anorexia or bulimia nervosa. Archives of Psychiatry and Psychotherapy, 16(2), 29-42.  Jacobs, R. H., Silva, S. G., Reinecke, M. A., Curry, J. F., Ginsburg, G. S., Kratochvil, C. J., &  March, J. S. (2009). Dysfunctional attitudes scale perfectionism: A predictor and partial mediator of acute treatment outcome among clinically depressed adolescents. Journal of Clinical Child & Adolescent Psychology, 38(6), 803-813. Kahn, J. H., Achter, J. A., & Shambaugh, E. J. (2001). Client distress disclosure, characteristics  at intake, and outcome in brief counseling. Journal of Counseling Psychology, 48(2), 203-211.                       128   Kawamura, K. Y., & Frost, R. O. (2004). Self-concealment as a mediator in the relationship  between perfectionism and psychological distress. Cognitive Psychotherapy and Research, 28(2), 183-191. Kawamura, K. Y., Frost, R. O., & Harmatz, M. G. (2002). The relationship of perceived  parenting styles to perfectionism. Personality and individual differences, 32(2), 317-327. Kay-Lambkin, F. J., Baker, A. L., Palazzi, K., Lewin, T. J., & Kelly, B. J. (2017). Therapeutic  alliance, client need for approval, and perfectionism as differential moderators of response to eHealth and traditionally delivered treatments for comorbid depression and substance use problems. International journal of behavioral medicine, 24(5), 728-739. Kempke, S., Luyten, P., Van Wambeke, P., Coppens, E., & Morlion, B. (2014). Self-critical  perfectionism predicts outcome in multidisciplinary treatment for chronic pain. Pain Practice, 14(4), 309-314. Kenny, D. A., Kashy, D. A., & Bolger, N. (1998). Data analysis in social psychology (In D.  Gilbert, S. Fiske, & G. Lindzey (Eds.). The handbook of social psychology (Vol. 1, pp. 233–265). Kivlighan Jr, D. M., & Goldfine, D. C. (1991). Endorsement of therapeutic factors as a function  of stage of group development and participant interpersonal attitudes. Journal of Counseling Psychology, 38(2), 150-158. Ko, A., Hewitt, P. L., Cox, D., Flett, G. L., & Chen, C. (2019). Adverse parenting and  perfectionism: A test of the mediating effects of attachment anxiety, attachment avoidance, and perceived defectiveness. Personality and Individual Differences, 150, 109474.                        129   Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., & Pilkonis, P. A.  (1996). The role of the therapeutic alliance in psychotherapy and pharmacopsychotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of consulting and clinical psychology, 64(3), 532-539. Lerner, M. D., McLeod, B. D., & Mikami, A. Y. (2013). Preliminary evaluation of an  observational measure of group cohesion for group psychotherapy. Journal of clinical psychology, 69(3), 191-208. Limburg, K., Watson, H. J., Hagger, M. S., & Egan, S. J. (2017). The relationship between  perfectionism and psychopathology: A meta-analysis. Journal of Clinical Psychology, 73(10), 1301-1326. Little, R. J. (1988). A test of missing completely at random for multivariate data with missing  values. Journal of the American statistical Association, 83(404), 1198-1202. Lowyck, B., Luyten, P., Vermote, R., Verhaest, Y., & Vansteelandt, K. (2017). 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. Machado, B. C., Gonçalves, S. F., Martins, C., Hoek, H. W., & Machado, P. P. (2014). Risk  Factors and Antecedent Life Events in the Development of Anorexia Nervosa: A Portuguese Case-Control Study. European Eating Disorders Review, 22(4), 243-251. MacKenzie, K. R. (1990). Introduction to time-limited group psychotherapy. American  Psychiatric Pub.                       130   MacKenzie, K. R. (1983). The clinical application of a group climate measure. In R. R. Dies &  K. R. MacKenzie (Eds.), Advances in group psychotherapy: Integrating research and practice (pp. 159– 170). Madison, CT: International Universities Press. MacKenzie, K. R., Dies, R. R., Coché, E., Rutan, J. S., & Stone, W. N. (1987). An analysis of  AGPA Institute groups. International Journal of Group Psychotherapy, 37(1), 55-74. Mackinnon, S. P., Sherry, S. B., Antony, M. M., Stewart, S. H., Sherry, D. L., & Hartling, N.  (2012). Caught in a bad romance: Perfectionism, conflict, and depression in romantic relationships. Journal of Family Psychology, 26(2), 215-255. Mackinnon, S. P., Sherry, S. B., Pratt, M. W., & Smith, M. M. (2014). Perfectionism, friendship  intimacy, and depressive affect in transitioning university students: A longitudinal study using mixed methods. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement, 46(1), 49-59. Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with  outcome and other variables: a meta-analytic review. Journal of consulting and clinical psychology, 68(3), 438-450. McGee, B. J., Hewitt, P. L., Sherry, S. B., Parkin, M., & Flett, G. L. (2005). Perfectionistic self- presentation, body image, and eating disorder symptoms. Body image, 2(1), 29-40. McLeod, B. D., & Weisz, J. R. (2005). The psychotherapy process observational coding system- alliance scale: measure characteristics and prediction of outcome in usual clinical  practice. Journal of Consulting and Clinical Psychology, 73(2), 323-333. McRoberts, C., Burlingame, G. M., & Hoag, M. J. (1998). Comparative efficacy of individual  and group psychotherapy: A meta-analytic perspective. Group Dynamics: Theory, Research, and Practice, 2(2), 101-117.                       131   Minarik, M. L., & Ahrens, A. H. (1996). Relations of eating behavior and symptoms of  depression and anxiety to the dimensions of perfectionism among undergraduate women. Cognitive psychotherapy and research, 20(2), 155-169. Muran, J. C., Segal, Z. V., Samstag, L. W., & Crawford, C. E. (1994). Patient pretreatment  interpersonal problems and therapeutic alliance in short-term cognitive psychotherapy. Journal of Consulting and Clinical Psychology, 62(1), 185-190. Nepon, T., Flett, G. L., Hewitt, P. L., & Molnar, D. S. (2011). Perfectionism, negative social  feedback, and interpersonal rumination in depression and social anxiety. Canadian  Journal of Behavioural Science/Revue canadienne des sciences du comportement, 43(4), 297-308. O'Connor, R. C. (2007). The relations between perfectionism and suicidality: A systematic  review. Suicide and Life-Threatening Behavior, 37(6), 698-714. Ogrodniczuk, J. S., & Piper, W. E. (2003). The effect of group climate on outcome in two forms  of short-term group therapy. Group Dynamics: Theory, Research, and Practice, 7(1), 64- 76. Phipps, L. B., & Zastowny, T. R. (1988). Leadership behavior, group climate and outcome in  group psychotherapy: A study of outpatient psychotherapy groups. Group, 12(3), 157-171. Pinto, A., Liebowitz, M. R., Foa, E. B., & Simpson, H. B. (2011). Obsessive compulsive  personality disorder as a predictor of exposure and ritual prevention outcome for obsessive compulsive disorder. Behaviour research and therapy, 49(8), 453-458.                         132   Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and  comparing indirect effects in multiple mediator models. Behavior research methods, 40(3), 879-891. Quené, H., & Van den Bergh, H. (2004). On multi-level modeling of data from repeated  measures designs: A tutorial. Speech Communication, 43(1), 103-121. Raines, A. M., Carroll, M. N., Mathes, B. M., Franklin, C. L., Allan, N. P., & Constans, J. I.  (2019). Examining the relationships between perfectionism and obsessive-compulsive symptom dimensions among rural veterans. Journal of Cognitive Psychotherapy, 33(1), 58-70. Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchical linear models: Applications and data  analysis methods (Vol. 1). Sage. Rhéaume, J., Freeston, M. H., Dugas, M. J., Letarte, H., & Ladouceur, R. (1995). Perfectionism,  responsibility and obsessive-compulsive symptoms. Behaviour research and psychotherapy, 33(7), 785-794. Rice, K. G., Lopez, F. G., & Vergara, D. (2005). Parental/social influences on perfectionism and  adult attachment orientations. Journal of Social and Clinical Psychology, 24(4), 580-605. Rice, K. G., Sauer, E. M., Richardson, C. M., Roberts, K. E., & Garrison, A. M. (2015).  Perfectionism affects change in psychological symptoms. Psychotherapy, 52(2), 218-227. Richardson, C. M., & Rice, K. G. (2015). Self-critical perfectionism, daily stress, and disclosure  of daily emotional events. Journal of counseling psychology, 62(4), 694-702.                          133   Roxborough, H. M., Hewitt, P. L., Kaldas, J., Flett, G. L., Caelian, C. M., Sherry, S., & Sherry,  D. L. (2012). Perfectionistic Self-Presentation, Socially Prescribed Perfectionism, and Suicide in Youth: A Test of the Perfectionism Social Disconnection Model. Suicide and Life-Threatening Behavior, 42(2), 217-233. Sexton, H. (1993). Exploring a psychotherapeutic change sequence: Relating process to  intersessional and posttreatment outcome. Journal of Consulting and Clinical Psychology, 61(1), 128-136. Shafran, R., Cooper, Z., & Fairburn, C. G. (2002). Clinical perfectionism: A cognitive– behavioural analysis. Behaviour research and therapy, 40(7), 773-791. Shahar, G., Blatt, S. J., Zuroff, D. C., Krupnick, J. L., & Sotsky, S. M. (2004). Perfectionism  impedes social relations and response to brief treatment for depression. Journal of Social and Clinical Psychology, 23(2), 140-154. Shahar, G., Blatt, S. J., Zuroff, D. C., & Pilkonis, P. A. (2003). Role of perfectionism and  personality disorder features in response to brief treatment for depression. Journal of Consulting and Clinical Psychology, 71(3), 629-633. Shelef, K., & Diamond, G. M. (2008). Short form of the revised Vanderbilt Therapeutic Alliance  Scale: Development, reliability, and validity. Psychotherapy Research, 18(4), 433-443. Shelef, K., Diamond, G. M., Diamond, G. S., & Liddle, H. A. (2005). Adolescent and parent  alliance and treatment outcome in multidimensional family therapy. Journal of consulting and clinical psychology, 73(4), 689-698. 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.                       134   Sherry, S. B., Law, A., Hewitt, P. L., Flett, G. L., & Besser, A. (2008). Social support as a  mediator of the relationship between perfectionism and depression: A preliminary test of the social disconnection model. Personality and Individual Differences, 45(5), 339-344. Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations: uses in assessing rater  reliability. Psychological bulletin, 86(2), 420-428. Singer, J. D. & Willett, J. B. (2003). Applied longitudinal data analysis: Modeling change and  event occurrence. Oxford university press. Sirois, F. M., & Molnar, D. S. (2016). Conceptualizations of Perfectionism, Health, and Well- Being: An Introductory Overview. In Perfectionism, Health, and Well-Being (pp. 1-21). Springer International Publishing. Slaney, R. B., Rice, K. G., Mobley, M., Trippi, J., & Ashby, J. S. (2001). The revised almost  perfect scale. Measurement and evaluation in counseling and development, 34(3), 130- 145. Smith, M. M., Sherry, S. B., McLarnon, M. E., Flett, G. L., Hewitt, P. L., Saklofske, D. H., &  Etherson, M. E. (2018). Why does socially prescribed perfectionism place people at risk for depression? A five-month, two-wave longitudinal study of the Perfectionism Social Disconnection Model. Personality and Individual Differences, 134, 49-54. Stiles, W. B., & Goldsmith, J. Z. (2010). The alliance over time. The therapeutic alliance: An  evidence-based guide to practice, 44-62. Stoeber, J. (2012). Dyadic perfectionism in romantic relationships: Predicting relationship  satisfaction and longterm commitment. Personality and Individual Differences, 53(3), 300-305.                        135   Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Brown, G. K., Barber, J. P.,  Laurenceau, J.-P., & Beck, A. T. (2006). Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders. Journal of consulting and clinical psychology, 74(2), 337-345. Sullivan, H.S.  (1953).  The interpersonal theory of psychiatry.  New York, NY:  Norton & Co. Sutandar-Pinnock, K., Blake Woodside, D., Carter, J. C., Olmsted, M. P., & Kaplan, A. S.  (2003). Perfectionism in anorexia nervosa: A 6–24-month follow-up study. International Journal of Eating Disorders, 33(2), 225-229. Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A  meta-analysis. Journal of consulting and clinical psychology, 80(4), 547-559. Tasca, G. A., & Gallop, R. (2009). Multilevel modeling of longitudinal data for psychotherapy  researchers: I. The basics. Psychotherapy Research, 19(4-5), 429-437. Tasca, G. A., Illing, V., Ogrodniczuk, J. S., & Joyce, A. S. (2009). Assessing and adjusting for  dependent observations in group treatment research using multilevel models. Group Dynamics: Theory, Research, and Practice, 13(3), 151-162. Tschuschke, V., & Greene, L. R. (2002). Group therapists’ training: What predicts  learning?. International journal of group psychotherapy, 52(4), 463-482. Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what  makes psychotherapy work. Routledge. Weissman, A. N., & Beck, A. T. (1978). Development and validation of the Dysfunctional  Attitude Scale: A preliminary investigation.                        136   Wiggins, J. S. (1982). Circumplex models of interpersonal behaviour in clinical psychology. In  P. C. Kendall & J. N. Butcher (Eds.), Handbook of research methods in clinical psychology (pp. 183-221). New York: Wiley.  Williams, R. H., & Zimmerman, D. W. (1982). Comparative validity of simple and residualized  difference scores. Psychological Reports, 50(1), 91-94. Yalom, I. D., & Leszcz, M. (1995). The therapeutic factors. The theory and practice of group  psychotherapy, 70-101. Yalom, I. D., & Leszcz, M. (2005). Theory and practice of group psychotherapy. Basic books. Zuroff, D. C., & Blatt, S. J. (2002). Vicissitudes of life after the short-term treatment of  depression: Roles of stress, social support, and personality. Journal of social and clinical psychology, 21(5), 473-496. Zuroff, D. C., Blatt, S. J., Sotsky, S. M., Krupnick, J. L., Martin, D. J., Sanislow III, C. A., &  Simmens, S. (2000). Relation of therapeutic alliance and perfectionism to outcome in brief outpatient treatment of depression. Journal of consulting and clinical psychology, 68(1), 114-124. Zuroff, D. C., Shahar, G., Blatt, S. J., Kelly, A. C., & Leybman, M. J. (2016). Predictors and  moderators of between-therapists and within-therapist differences in depressed outpatients’ experiences of the Rogerian conditions. Journal of counseling psychology, 63(2), 162-172.    

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