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the specifi c content of thoughts, Wells emphasizes the beliefs about the function and nature of thinking itself.
Metacognitive models of “thinking about thinking” have a long history in devel- opmental psychology, from Piaget’s (1932; 1967) description of decentering and non- egocentric thinking (Feff er, 1970) to Flavell’s metacognitive description of role-taking and egocentrism in children and adolescents (Flavell, 2004). Th e initial emphasis on metacognitive or non-egocentric thinking was on the ability to understand informa- tional defi cits of others in relationship to the self and the ability to coordinate the perspectives or thinking of others in relationship to self or to each other. Th e interest in thinking about the nature of thinking was further advanced by Teasdale and his colleagues, identifying several levels of experience, including sensations/perceptions, propositional statements with content, and awareness of the “architecture” or structural organization of experience (Teasdale, 1999a; Teasdale, 1999b). Moreover, there has been considerable interest in “theory of mind,” which has been a focus in terms of the growth of social cognition about other “mentalities,” especially in young children, individuals with autism or Asperger’s syndrome, and in nonhuman primates (Baron-Cohen, 1995;
Bjorklund & Kipp, 2002; Fonagy & Target, 1996). Th e model advanced by Wells draws on prior contributions to understanding theory of mind, but the emphasis in his model is on how individuals comprehend the function and nature of their own thinking, and how to modify dysfunctional or “unhelpful” strategies and interpretations.
For example, consider how the cognitive approach advanced by a pure “earlier”
Beckian (Beck, Emery, & Greenberg, 2005) would diff er from more recent cognitive ap- proaches, including metacognitive models, as applied to OCD. In the original Beckian approach, the therapist would examine the factual and logical content of the intrusive thoughts and consider the costs and benefi ts of ritualizing or neutralizing (Beck, et al., 2005). Th us, the earlier cognitive model stressed propositional statements, content of the thought, and the assumptions underlying the thought. For example, an intrusive thought (“I am contaminated”) would be submitted to factual and logical evaluation—
stressing the content or schematic nature of the thought. However, cognitive models have advanced considerably in the last 30 years to incorporate a wide range of perspectives on how thoughts and sensations are evaluated and which strategies are evoked to cope with these internal experiences. Th ese newer models are considered part of the general cogni- tive therapy model, but place less emphasis on the schematic content of the thoughts.
Th e cognitive model of obsessive-compulsive disorder (OCD) has been elaborated by Salkovskis, Clark and others to examine the evaluations that one gives to these thoughts. Although some might argue that cognitive therapy only emphasizes the con- tent of thinking, in fact Salkovskis, Clark, and their colleagues—all clearly “cognitive therapists”—have focused on the evaluations of intrusions, such as appraisals of personal responsibility, relevance, control, and other factors (Salkovskis, 1989; Salkovskis &
Campbell, 1994; Wells, 2009).
Th e metacognitive approach to OCD illustrates the processes that lead from “intru- sive thoughts” to ritualization, avoidance, and anxiety (Wells, 2009). Rather than focus
on the schematic content of intrusive thoughts, the metacognitive approach proposes that evaluation and control of intrusive thoughts results in OCD and other psychologi- cal disorders (Salkovskis, 1989; Salkovskis & Campbell, 1994; Wells, 2009). Cognitive appraisals of thoughts, rather than the thoughts themselves, underpin OCD. Safety behaviors, thought-suppression strategies, self-monitoring, cognitive self-consciousness, and beliefs that thoughts are out of control are often the consequence of problematic appraisals. Psychological disorders are viewed as the result of the response to thoughts, sensations, and emotions that follow from problematic evaluations of the personal rel- evance of a thought, responsibility for suppressing, neutralizing, or acting on implica- tions of a thought, thought-action fusion, intolerance of uncertainty, and perfectionistic standards (Purdon, Rowa, & Antony, 2005; Rachman, 1997; Wells, 2000; Wilson &
Chambless, 1999). Indeed, one can argue that OCD refl ects a specifi c disorder of “theory of mind”—that is, that the mind should be clear, pure, and free of unwanted thoughts and that the mind needs to be monitored and controlled. Ironically, this disorder of
“theory of mind” suggests that the mind is a potentially dangerous place.
Similarly, the metacognitive model proposes that panic disorder is maintained by perfectionistic expectations of how emotions and sensations function, the need to monitor threat “from within,” and the need to avoid situations that may provoke physi- ological arousal (Wells, 2009) Similar to Acceptance and Commitment Th erapy (ACT;
Hayes, Strosahl, & Wilson, 2003), metacognitive approaches to anxiety stress the role of avoidance and failed attempts at suppression. Metacognitive and cognitive models, how- ever, provide detailed descriptions of these underlying “theories of mind” and propose specifi c behavioral experiments to test explicitly derived hypotheses about these proposi- tions about mind and sensations. It is noteworthy that there appears to be convergence between these metacognitive and ACT approaches in the use of mindfulness-enhancing interventions and in utilizing the observing role toward thoughts and sensations as therapeutic interventions.
However, more traditional cognitive models of anxiety and depression (in contrast with the metacognitive emphasis described above) stress the schematic content of spe- cifi c disorders. Th us, depression is characterized by content related to a negative view of self, experience, and the future; anger is related to humiliation and blocked goals; social anxiety to inadequacy and judgment by others; and obsessive-compulsive disorder to danger and responsibility. Metacognitive models, in contrast, stress the process of think- ing and strategies for control—that is, “this is just another thought” off ers a metacognitive detachment from a thought, while “when you use these safety behaviors you maintain your fear that things are really unsafe” indicates how specifi c coping strategies maintain the disorder. Traditional cognitive models, which use the Socratic technique to collect evidence to test the content of thoughts, are based on an assumption that thoughts are often biased and distorted. In contrast, metacognitive models stress that overutilization of thinking, worrying, rumination, and avoidance are the core problematic processes.
Both ACT and metacognitive models share some common ground in focusing on the beliefs about how the mind functions rather than simply on the content of those beliefs.
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Changing the function or implication of a thought and how one responds to the
“occurrence” of a thought are common therapeutic strategies for both metacognitive and acceptance models (Hayes, Strosahl, & Wilson, 1999; Wells, 2009).
In this chapter, I outline an approach that is consistent with some aspects of tradi- tional cognitive therapy, but also consistent with metacognitive and acceptance-based models. I refer to this as emotional schema therapy (EST) (Leahy, 2002; Leahy, 2007b;
Leahy, 2009b). As indicated, traditional cognitive models of psychopathology have proposed that emotions may be exacerbated or evoked by cognitive content (“auto- matic thoughts”) or that moods may be primed, evoking the latent cognitive schemas that perpetuate further emotional arousal (Beck, 1976; Miranda, Gross, Persons, &
Hahn, 1998; Segal, et al., 2006). Th us, in traditional cognitive models, emotion either precedes, accompanies, or is a consequence of cognitive content. However, it is argued from the view of EST that emotions themselves may constitute an object of cognition—
that is, they may also be viewed as content to be evaluated, controlled, or utilized by the individual (Leahy, 2002). Th is approach is derived from the fi eld of “social cogni- tion” (which is now often referred to as “theory of mind”), with its emphasis on “naïve psychology” models of intentionality, normalcy, social-comparison, and attribution processes (Eisenberg & Spinrad, 2004; Leahy, 2002, 2003b; Weiner, 1974). If one can argue that the metacognitive model stresses disorders of theory of mind, the emotional schema model stresses disorders of the theory of emotion and mind. Specifi c styles of self-refl ective thinking and evaluations of one’s own thoughts and feelings can lead to problematic appraisals and strategies of emotional regulation. Th ese ideas serve as foun- dational theory for what I call “emotional schema therapy.”
I have introduced the concept of “emotional schema” to suggest that people have a specifi c set of beliefs for processing, appraising, and reacting to their emotions. (Th is is diff erent from the use of the term “emotion schema” by Greenberg, who views emo- tions as containing the cognitive content that may contribute to pathology, or Izard’s concept of emotion schema, which refers to emotion-cognitive interactions; Greenberg
& Paivio, 1997; Greenberg & Safran, 1987; Izard, 2009). I view emotional schemas as a set of interpretations and strategies—similar to the use of the term “schema” in Beck’s cognitive model (Beck & Alford, 2008; Beck, Rush, Shaw, & Emery, 1979; Leahy, 2002).
Although sharing some commonality with the idea of emotion-thought connections as described by Beck and Lazarus (Beck, 1976; A. Lazarus, 1984), emotional schema ther- apy focuses less on how emotions arise from thoughts and more on how the content of thoughts about emotions perpetuates unhelpful coping strategies. While acknowledging that emotions may be linked to cognitive content, behavioral, attentional, and memorial processes, EST emphasizes the theory of emotion implicit in the individual’s response to his or her emotional experience. Moreover, the emotional schema model is predicated on the view that there are numerous potential schemas and strategies that are utilized in response to one’s own emotions. Let us consider an example of these diff erent schemas.
Ken is going through a breakup with his girlfriend, who text-messaged him that the relationship is over. Ken realizes that he is feeling angry, confused, sad, and anxious, and
he discusses this with his friend, Dave. Fortunately, Dave validates the entire range of feeling that Ken is having, and adds that “relief ” might be another possible feeling. In his discussion and expression of his feelings, Ken begins to realize that all his feelings make sense—even the ones that appear to contradict themselves (e.g., sad and relieved).
He says he realizes that right now he will feel badly, but that these feelings will not last forever and he can still get things done even though he is feeling down. Th e relevant emotional schemas for Ken are that he can express his emotions and have them validated by others, his emotions are temporary and not overwhelming, his emotions make sense, he can tolerate confl icting feelings, and he does not avoid his emotions but acts in spite of them. Ken is not likely to be a candidate for therapy, because, even in the face of pain- ful emotions, he accepts, tolerates, and integrates this experience into his life.
In contrast, Brian is having more diffi culty with a similar breakup. Feeling ashamed of his feelings, overwhelmed, and confused by his emotions of anger, anxiety, sadness, and confusion, he decides to keep his feelings to himself. He cannot understand how he could have so many diff erent feelings, as he ruminates to determine “once and for all” how he “really feels.” Th is rumination leads to further avoidance and brooding on the past, a sense that he cannot escape from his feelings, and his reliance on alcohol to calm his unquiet mind. Brian illustrates a number of problematic emotional schemas:
lack of expression and validation, belief that his feelings don’t make sense, avoidance, rumination, reliance on alcohol to numb feelings, and a failure to accept the temporary, but diffi cult, feelings that he is experiencing. Rather than “process” his emotions, he gets stuck in them and relies on worry, rumination, avoidance, blaming, self-absorption, and substance abuse. Th is activates a vicious cycle of further dysregulation, resulting in more reliance on the failed strategies that he believes will provide him with safety from himself.
A schematic depicting emotional schemas is shown in Figure 5.1. Emotional schemas are evaluated with the Leahy Emotional Schema Scale (LESS), which assesses 14 dimen- sions (Leahy, 2002) of how one interprets, evaluates, controls, or responds to their own emotions. Th is schematic illustrates that awareness of an emotion, labeling emotions, and diff erentiating emotion are the fi rst steps in coping with emotion. Indeed, current advances in neuroscience suggest that bringing emotion under conscious “top-down”
control may activate the prefrontal cortex (PFC), thereby recruiting the ability to ap- praise, plan, and regulate emotion (Delgado, et al., 2004; Phelps, Delgado, Nearing,
& LeDoux, 2004). At the next step, the individual pursues emotional avoidance (bingeing, purging, substance abuse, etc.) and/or appraises the emotion negatively.
Appraisals include attribution (e.g., consensus, generalization, personal relevance, blam- ing), consequences of emotions, and evaluations of negativity (e.g., shame and guilt).
Strategies of coping include avoidance, rumination, and worry, or acceptance, expres- sion, and the seeking of validation. Th us, emotional schemas include behavioral, inter- personal, emotional, and cognitive appraisal responses.
Emotional schema therapy addresses the issue of “emotional reasoning” and “emo- tion heuristics” so often a part of anxious and depressive thinking, but also as a major
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component of thinking in nonclinical individuals (Kahneman & Frederick, 2005;
Slovic, Finucane, Peters, & MacGregor, 2002). Anxious and depressed patients often predict events based on their current emotional state, very much as if their emotions are signs of external danger. Similar to “thought-action fusion,” emotional reasoning and emotional heuristics are often implicit and seldom examined. By recognizing that emotions are mental events that are separate from external reality, the emotional schema therapist encourages a detached, mindful awareness of the emotion, while encouraging diff erentiation, labeling, and linking emotion to thoughts and variation across time and situations.
A core emotional schema is the belief that diffi cult emotions will last indefi nitely and interfere with functioning. Th is is similar to the concept of “durability” or “aff ec- tive forecasting,” in which people in general tend to predict that pleasant or unpleasant emotions will last longer than they actually do (Gilbert, Pinel, Wilson, Blumberg, &
Wheatley, 1998; Wilson, Wheatley, Meyers, Gilbert, & Axsom, 2000). Th e reason for this distortion in predicting the durability of emotion is unclear, but may refl ect lack of consideration for coping strategies that will be employed for aff ect regulation, situ- ational variants, or even nonconscious coping. Th is predictive bias appears to be more pronounced with anxious and depressed individuals and may account for the fear of
Emotions:
• anger
• anxiety
• sexual
• sadness
Attention to emotion
Emotion is normal Emotional
avoidance Negative Interpretations:
• guilt
• lack of consensus with others
• simplistic view
• incomprehensible
• cannot accept emotion
• overly rational
• accept
• express
• experience validation
• learn
• lose control
• long duration
• rumination
• worry
• avoid situations that elicit emotions
• blame others Emotion is problematic
• dissociation
• bingeing
• drinking
• drugs
• numbness
Figure 5.1 A Model of Emotional Schemas
experiential exposure. Reluctance to engage in exposure treatment is often a conse- quence of the belief that anxious arousal will last indefi nitely and overwhelm the indi- vidual. Emotional schema therapy directly addresses the issue of aff ective forecasting by identifying this dimension, collecting information through behavioral experiments, and re-evaluating the schematic bias (Leahy, 2007b; Leahy, 2009a).
Other dimensions assessed include the belief that one’s emotions are unique to the self, that there is no general consensus in how people would feel given the circumstance.
Indeed, much reassurance-seeking is an attempt to normalize one’s emotional responses by seeking validation that one’s emotions make sense and are shared by others. Guilt and shame about emotion often is associated with increased anxiety or depression about emotional experience, further exacerbating an overfocus on emotion, rumination, and dispositional self-labeling. In the two examples above, Ken is able to normalize his emo- tion, partly by expressing these feelings and obtaining validation from his friend, and he is able to temporize the emotion as an adjustment response to a diffi cult, but temporary, experience. Consequently, he dwells less on the emotion, is less ruminative, and is able to act in spite of the emotion that he accepts for the time being. In contrast, Brian is
“stuck” in his emotion, harbors these emotions privately due to feelings of shame and an overvaluation of autonomy, and is unable to continue until he “gets things sorted out.” A key premise of emotional schema therapy is that it is not the emotion per se that is the problem, but the interpretations and strategies employed and the ability or willingness to act in spite of these feelings. EST shares a similar view of some aspects of this process with ACT and metacognitive therapy. A key diff erence, however, is in emphasizing the specifi c interpretations, theories, and strategies that are employed and how these confi rm or disconfi rm underlying theories of emotion regulation that are employed by the individual. For example, in emotional schema therapy, the emphasis is on clarifying and modifying the specifi c theory of one’s emotion, using cognitive or Socratic evaluations, experiential tests, behavioral experiments, and other interventions to assist in normalizing, temporizing, linking emotion to values, and fi nding expression and validation. Wells’ model stresses thinking, not emotion, and does not attempt to modify theory of emotion. All three models—ACT, metacognitive theory, and EST—
are meta-experiential models, rather than simply focusing on the schematic content of appraisals of external stressors.