Motivation and emotion/Book/2020/Emotional schema therapy

Overview
An emotional schema is the way in which an individual conceptualises their own emotional experience. These schemas can become problematic when maladaptive schemas are utilised as a coping mechanism for intense unpleasant emotional experiences. Such emotions are an integral part of the human condition, without them how would one appreciate the intense pleasant emotions. Emotional schema therapy (EST) involves the identification of negative schemas to address an individual’s appraisals and strategies when an intense emotion such as anger is activated. During EST, the problematic schema is explored and the therapist works to help the patient identify, label, link, differentiate, normalise, and tolerate a range of emotions to increase regulatory flexibility by directly questioning the schemas legitimacy.

Focus questions:
 * What is Emotional Schema Therapy?
 * What are the central themes of Emotional Schema Therapy?
 * Does research support the efficacy of Emotional Schema Therapy?

Emotional schema model
The emotional schema model proposes that individuals have unique conceptualisations of emotions that determine strategies for coping with those emotions. The individual develops a personalised appraisal of the experience and implements a strategy to cope with the emotion, the strategy employed to cope is where a problematic schema may be displayed (Leahy, 2002, 2007a, 2007b, 2012, 2016, 2019). The emotional schema model is concerned with identifying the individual’s theory of a particular emotion, amending that theory, and encouraging adaptive strategies to regulate the emotion (Leahy, 2019).

Emotional schemas are featured throughout the literature and are regularly conceptualised and operationalised in the scope of metacognitive or meta-emotional theories (Edwards & Wupperman, 2019). Metacognitive theory proposes that people possess relatively stable beliefs about the nature and quality of their personal cognitive processes. These beliefs can concern the specific content of thought or the process of cognition and may be instrumental in the shaping of a person’s response and control of cognitive processes (Manser et al., 2012). This theory can be applied to both cognition's and emotions, a person’s unique belief or schema may drive the individual’s appraisals of and response to emotional experiences (Leahy, 2002).

Meta-emotion theory suggests that beliefs regarding emotion are involved in shaping secondary reactions to emotion (Norman & Furnes, 2016). Compared to metacognitive theory, meta-emotion theory focuses specifically on implications of emotional schemas for self-regulation and ensuing emotional experience, rather than specific thought content or cognitive processes (Edwards & Wupperman, 2019). Both theories agree that individuals possess unique beliefs about emotions, processing, and experience. Similarly, the two theories agree that these individual-specific processes are directly involved in determining secondary responses to emotional experiences (Edwards & Wupperman, 2019).

The emotional schema model is consistent with the metacognitive model as it focuses on the role of appraisals of meaning, duration, and the need for the emotional experience to be controlled. The emotional schema model is also consistent with the meta-emotional model in that emotional schemas provide the lens by which emotional experiences are interpreted (Leahy, 2012).

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Emotional schema therapy


If we consider emotional schemas as the lens through which individuals experience emotion, it is plausible that some schemas are distorted, faulty, or not helpful. The emotional schema therapists job therefore, is to adjust and attend to the lens and implement interventions to address the problematic lens, in a similar way that an optometrist assesses eyesight and prescribes lenses to allow for clear vision of the surrounding world. The problematic schemas of emotion don’t allow for an individual to clearly experience their emotions and obstructs constructive ways of coping. In this section we will discuss the central themes of EST, the 14 dimensions of emotions as described by Leahy (2002), concluding with some examples of interventions that may be used in a therapeutic setting.

The goal of EST is to broaden the range of regulatory flexibility to a point where emotional experience is seen as an opportunity to utilise adaptive strategies rather than engaging in and relying on destructive self-perpetuating regulation strategies (Leahy, 2015). EST works to unpack problematic theories (schemas) of emotion, normalise expression and explore with the patient the ways in which these dysfunctional strategies work to exacerbate the negative emotional experiences (Leahy, 2015).

Throughout the remainder of this section, let’s consider Patricia the pessimistic penguin as shown in figure 1. Patricia has recently experienced a significantly troubling life event, Mr. pessimistic penguin and her are divorcing after many years. Patricia fears she will lose control of her emotions, is ashamed of her sadness, is experiencing guilt for feeling angry, is confused about the complexity of her emotions, and has made numerous failed attempts to suppress these feelings. Patricia has been unable to accept her emotions, receive validation, or normalise her feelings.



Central themes

 * 1) Painful and difficult emotions are universal: EST seeks to highlight that life is at times painful and unpleasant. The emphasis is on the capacity to feel and express the full range of emotion and acknowledge that unpleasant emotions are a part of life and rather than work to suppress them, one needs to actively make space for them (Leahy, 2015).
 * 2) Emotions serve an evolutionary purpose: EST considers emotion from an evolutionary perspective and posits that emotions evolved to protect a species and are genetically determined. This scope can allow an individual to identify and rationalise emotions as serving specific purposes related to survival by asking “what if our ancestors didn’t have these emotions?” (Leahy, 2015).
 * 3) The impact, escalation, and maintenance of an emotion is determined by the schema: EST sees emotions as responses occurring in a particular context. It is therefore necessary during therapy to contextualise the emotion and examine what goals, or values may be threatened by the emotional experience. This technique allows the patient to consider the consistency of the unpleasant emotion across time, situations and relationships. The schema of the emotion overrides logical examination of the emotion and why one might be feeling it in the first place, this can cause one to lose focus of the fact that the emotional experience with time will dissipate as has done in the past. By thinking of the emotional experience in context and across time, an individual can separate the self from the emotion and grasp that as surroundings change emotions will likewise change. Considering the purpose of the emotion can be an important first step in modifying the associated schema (Leahy, 2015).
 * 4) Problematic schemas are self-perpetuating: The schemas and strategies for coping with negative emotions work in a cyclical way and intensify the experience of the emotion. An individual may be willing to do anything to avoid the emotional experience due to overgeneralisation of the negative appraisal,  this could include staying in unhealthy relationships or engaging in substance abuse. This theme of EST sees schemas as the problem, the negative emotions are arising not necessarily out of the current situation, whatever it may be, rather what one believes about what the situation and the coping strategy is employed based on the problematic schema (Leahy, 2015).
 * 5) Problematic schemas of negative emotions are the target for EST: EST has the patient work towards accepting unpleasant emotions rather than suppressing them, and exploring more adaptive strategies such as mindful awareness or by imagining the negative emotion as a song playing in the background in its own space, rather than front and centre in an all-consuming obstruction of the pursuit of other activities or experience of other emotions (Leahy, 2015).
 * 6) Expression and validation techniques are utilised to normalise, universalise, differentiate, and understand different emotions as well as reduce shame and guilt and increase efficacy to tolerate uncomfortable emotions: Validation is arguably the most important theme of EST. It is the acknowledgment of the element of truth in an individual’s thoughts and feelings. It’s not an outright agreement, but rather the therapist mirroring the thoughts and feelings back to the patient in a more accurate depiction. Validation is crucial in addressing all 14 emotional schema dimensions. Expression and validation complement one another to create a shared understanding of the patient’s feelings, the therapist can remark “that makes sense” or “I can understand why you feel this way” (Leahy, 2015).
 * 7) Increase personal empowerment and self-efficacy: This feature is the name of the game for EST. A main focus during therapy is to increase self-empowerment and self-efficacy when engaging with difficult emotions, rather than what may be seen in more classic cognitive behavioural therapy (CBT), specifically exposure techniques which as noted by Leahy (2007a, 2007b) are contributing factors of noncompliance and drop out of patients receiving treatment for generalised anxiety disorders (GAD) and obsessive-compulsive disorder (OCD). This explains why EST is an extension of and often an effective precursor to CBT exposure techniques, working first on the efficacy to deal with intrusive and unpleasant emotions, lays the groundwork when using exposure to unpleasant emotions. The emphasis is on the ability to tolerate the emotions not remove them, and build the capacity for resilience while focusing on the big picture. EST here is guided by future orientation, goal orientation, problem solving, personal responsibility and accountability, discomfort, delayed gratification, persistence, planning, learning, risk taking, and productivity (Leahy, 2015).

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Leahy emotional schema scale
In order to identify emotional schemas and the ways in which an individual appraises and responds to emotional experiences the EST therapist will employ the Leahy Emotional Schema Scale II (LESS II) developed by Robert L. Leahy (2002) shown in figure 2. The scale consists of 28 items on a 6-option Likert scale (Movariadi et al., 2019) reflecting each of the 14 different dimensions as highlighted in table 1. The clinical utility of identifying a patients schemas is instrumental to EST and the foundation of the therapy (Leahy, 2015).

If a schema is appraised as normal or valid it is likely to be accepted with adaptive strategies such as problem solving and expression being employed. Yet, if an emotion is conceptualised as irregular, undesirable or in any way problematic it is likely to be pathologized with resulting maladaptive strategies being relied on such as avoidance, rumination, and blame (Edwards & Wupperman, 2019). The goal of EST is to amend emotional schemas from problematic to positive, for the individual to appraise emotions, specifically their own in resourceful ways. The following table summarises the 14 dimensions along with the associated negative beliefs or schemas (Silberstein, 2012), an example specific to Patricia, and examples of therapeutic interventions (Leahy, 2007).

 {"If you deny that a situation has elicited a negative emotion, how might you address the problem?" Is an intervention for which dimension? + Acceptance - Rumination - Duration - Control
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Emotional schema therapy in action
The effects of EST on migraine intensity and cognitive emotional strategies was investigated in a group context by Shahsavani et al. (2020). The study included 16 participants (20-40 years) that identified as female. They were randomly assigned to either a waiting list control group or the EST group. Participants in the EST group received 12 sessions of group EST, the design of the study was a pre-test and post-test comparison of questionnaire scores as well as a one month follow up. Significant support was delivered by the post treatment and follow up test compared with the scores of the control group who did not receive EST via an analysis of variance with repeated measures. Furthermore, the participants who received EST showed significant improvement in utilising adaptive emotional regulation strategies, these findings support the effectiveness of EST. The group format however, did not yield significant differences as compared to other EST in a one-on-one context.

An additional study examining EST in a group setting was conducted by Morvaridi et al., (2019) examining the efficacy of EST on symptoms of social anxiety disorder and use of emotional schemas of 24 participants (18-35 years) who identified as females in a quasi-experimental design with pre-test and post-test measures. Participants were randomly assigned to either a waiting list control group or the EST group. The EST group received 10, 120-minute group sessions. The emotional schema model garners support from this study as participants after EST sessions experienced reduced anxiety symptoms, increased reappraisal, and decreased suppression. Additionally, the participants post EST produced more positive schemas and decreased use of negative schemas which was reported as an increase of the consensus dimension and a decreased schema on the shame and guilt dimensions.

Mazloom et al., (2016) investigated emotional schemas from a different angle, this study strived to assess direct and indirect impacts of emotion schemas as a predictor of post-traumatic stress disorder (PTSD) symptoms on 678 high school students who reside and attend school in earthquake-stricken areas of eastern Azerbaijan utilising the LESS II scale. The students who were between 14 and 18 years of age had all experienced an earthquake in the summer of 2012. In this instance, a direct impact of emotional schemas was not found. It was concluded that this was because EST therapy would not act in a direct way to the trauma or significant life event but rather act as a mediator between the emotional schema and the symptoms.

The efficacy of EST on generalised anxiety disorder (GAD) was explored by means of a single-subject study conducted by Khaleghi et al., (2017). The participants were selected via convenience sampling from the hospital where they were receiving treatment for GAD following a psychiatric diagnosis, both participants identified as female and were aged 25 and 30, and had five plus years history with the condition including unsuccessful attempts at various types of treatment. Data extracted from pre and post treatment completion of the LESS II, in addition to a two month follow up indicated clinically significant changes on all measures for both participants indicated by an increase in adaptive emotional schemas and decrease in maladaptive schemas, providing support for EST as an effective intervention for GAD.

While there is evidence to support EST throughout the literature, there is also evidence to question the applicability of EST cross-culturally (Wei et al., 2013) as well as the methodology of the above-mentioned studies. Suh et al., (2019) investigated the reliability and validity of the LESS II within a Korean sample of 1478 college students. The study found the suppression and rationality dimensions of the scale particularly problematic with different responses to the items being due to profound cultural differences. Moreover, the translation of the reverse test items to Korean was found to be inappropriate and when these items were removed the test showed greater validity within the sample. The researchers after examining each dimension within the Korean sample, removed items that were not able to assess emotions adequately in this cultural context and redesigned it to be more applicable to the Korean sample, it is noted though that more work needs to be done inclusive of other cultures especially when highlighted by Edwards and Wupperman (2019) that research within this field has largely been conducted in western cultures.

Edwards and Wupperman (2019) further cite varying conceptualisations and little theoretical incorporation within the existing literature and suggests that there is an unclear relationship to similar constructs, and that measures about specific schemas often assess different concepts. In addition, there is limited empirical research on the developmental perspective of emotional schemas, exploration towards understanding person-specific experiences, interpersonal relationships and events during childhood would be welcome contributions to the existing body of knowledge.

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Conclusion
EST, based upon emotional schema theory, addresses the problematic appraisals one harbours about their own emotions which has a mediating effect on the strategies employed to cope with those emotions. The EST approach with the accompanying LESS II with its 14 dimensions, gives the therapist a tool to directly address the problematic schemas helping them to identify the problematic schemas and amending them to more adaptive ones to ensure their emotional experience does not endure and become all consuming. EST can be employed across a range of different contexts to help people accept and process their emotions in healthier ways. While the efficacy of EST is widely supported there are acknowledged limitations, particularly its applicability cross-culturally.