Mindfulness is here defi ned as taking an observing stance in a nonjudgmental manner with open awareness in the present moment and with no attempt to control. One can argue that traditional cognitive therapy contains an initial step of mindful awareness, that is, noticing or observing that a thought is only a thought and acknowledging that thoughts come and go with time and situations. However, traditional cognitive therapy uses mindful awareness or detachment as techniques or experiences in therapy to address the content of the thought through logical, factual, and other persuasive techniques (Beck, Rector, Stolar, & Grant, 2009; Beck, et al., 1979; Leahy, 2003a). For example, Figure 5.3 Modifi ed Emotional Schemas Enhancing Exposure
Luck is not a trait.
I am able to overcome obstacles and tolerate discomfort.
The risks of dangerous contamination are nil.
Constructive Discomfort
If I do exposure, I could empower myself.
Strategies to Enhance Exposure
Tolerating anxiety will help me fear it less, act in spite of it, and find out it decreases with time and experience.
Do it anyway—even thought I don’t feel ready.
Give myself credit for overcoming obstacles.
Don’t seek reassurance.
Exposure Learn:
I can tolerate anxiety.
Anxiety subsides.
Rational heuristic:
Emotions don’t predict danger, only facts predict.
stepping back and recognizing that one is having a thought—and that the thought is only a thought—may be considered a fi rst mindful awareness of the thought. How- ever, unlike the traditional mindfulness of breath exercise (or mindful awareness of a thought), the cognitive therapist examines the evaluations and factual nature of the thought, rather than “just allowing it to be.” Th us, cognitive therapy is more proactive in modifying the believability of thoughts than is the case for the ACT therapist.
Emotional schema therapy includes mindfulness techniques, but focuses specifi cally on the schematic content of the beliefs about emotions. One might wonder if EST is similar to cognitive therapy in examining the content of thoughts or whether it is simi- lar to MCT and ACT in stressing the experiential acceptance of emotion. Perhaps the most balanced answer is that EST does both. It would be incorrect to argue that EST involves disputation of emotions—since emotions are really a “given” of experience.
However, EST does involve an appraisal of emotion—or, more specifi cally, it examines the kinds of appraisals that are made. One can also argue that the MCT model of Wells also involves an appraisal of thoughts in terms of responsibility and uncontrollability.
Th ese are clearly appraisals of function or implication, but not of the specifi c content contained in these thoughts.
Th ere is debate as to what exactly constitutes so-called “third wave” approaches to cognitive behavior therapy. For example, should we include ACT, DBT, MBCT, and metacognitive therapy in this category, even if proponents of some of these approaches (e.g., Linehan and Wells) do not characterize their approaches as “third wave” (see Hofmann
& Asmundson, 2008)? However, all of these foregoing approaches stress the focus on the function or process of thinking and experience, rather than the schematic content of thoughts. Although one can argue that cognitive therapy also evaluates the function of thinking (e.g., “What are the costs and benefi ts of this belief?”), most of the emphasis is on modifying beliefs and fostering problem-solving alternatives in coping. Th e emphasis in traditional cognitive therapy is generally on the schematic content of a thought—
especially on its validity—borrowing from information processing models of attention, memory, and valuation of thinking (Beck & Alford, 2008). Emotional schema therapy combines elements of both “third wave” detached awareness and recognition of the pro- cess of thinking, while at the same time assessing the schematic content of beliefs about emotion. Th is is why I refer to them as emotional “schemas.”
Emotional schema therapy is similar to Greenberg’s emotion-focused therapy in its emphasis on emotional experience, expression, evaluation of primary and secondary emotions, viewing emotions related to needs and values, and the fact that emotions may also “contain” meanings (similar to Lazarus’s “core relational themes”); (Greenberg &
Paivio, 1997; Greenberg & Watson, 2005; Lazarus, 1999). However, EST is specifi cally meta-emotional (or metacognitive) in that it directly assesses the beliefs about emotions and how emotions function. Th us, the emphasis is not only on Rogerian processes of expression, validation, and unconditional positive regard, but also on the patient’s implicit theories of emotion. Th is is similar to the approach taken by Gottman and his colleagues (Gottman, Katz, & Hooven, 1997). For example, the emotional schema
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therapist might examine the belief that painful emotions are an opportunity to develop deeper and more meaningful emotions, or the contrary belief that painful emotions are a sign of weakness and inferiority. Th e emotion-focused therapist utilizes expression and validation as central therapeutic techniques—as would the emotional schema therapist.
However, EST views validation as a process that aff ects other cognitive (or schematic) evaluations of emotion. Th us, validation leads to a recognition that one’s emotions are not unique, that expressing emotion need not lead to being overwhelmed, that there is generally less guilt and shame with validation, and that validation assists the patient in
“making sense” of feelings. Th us, validation leads to changes in beliefs about emotion which can then lead to changes in the emotion itself (Leahy, 2005b).
Detached mindfulness, exposure, distress tolerance, and other experiential tech- niques are used in EST to test beliefs about one’s own emotions—that is, they are subsumed, broadly speaking, as “cognitive therapy” interventions by virtue of positing hypotheses that are tested out against experience. Similar to the metacognitive model to which EST owes a great deal of infl uence, emotions are an “object” of thinking and experience and are distinguished from reality or from a necessary way in which the world is experienced. Th us, just as the metacognitive therapist assists the patient in recogniz- ing, “this is just a thought,” the emotional schema therapist assists in recognizing, “this is just a feeling that you are having for the present moment.”
For example, mindful awareness of the emotion of jealousy entails recognizing that one has the feeling (as well as where one feels it, e.g., bodily sensations), acknowledging that the emotion may come and go over time and situations, and attempting to adopt a nonjudgmental stance toward the emotion, while accepting the feeling of jealousy as one of many emotions that may come and go. Imagery of an emotion as a series of ocean waves ebbing and fl owing on a beach, while thinking “these feelings come and go,” refl ects the mindful awareness of the feeling. Detached observation, including descriptions, metaphors (“it feels like a dark cloud over my head”), and imagery enhance the acceptance of an emotion while relinquishing emotion suppression strategies. For example, the jealous patient could stand back, acknowledge her feelings, recognize that they come and go, notice where in her body she is feeling jealous, while noticing that observing and letting go of the emotion is followed by the reappearance of the feeling.
As a result, the emotion becomes less frightening. In EST (similar to metacognitive therapy), mindful detachment helps test the belief that emotions are overwhelming and need to be suppressed (Wells, 2009). Specifi c cognitive content about emotion is identi- fi ed: “What happens when you just stand back and observe?”, “What happens when you don’t suppress the emotion?” We use Rumi’s poem Th e Guest House (1995) to illustrate that an emotion can be an unexpected guest that shows up, is welcomed, and treated with courtesy. However, specifi c cognitive tests are conducted about the duration, over- whelming quality of an emotion, and judgments about emotions.
Part of emotional schema therapy is to reduce the moralistic judgments that are often made about certain emotions. Indeed, popular beliefs that some emotions are dangerous or “bad” only add to the lack of acceptance, the guilt, and even the fear of an
emotion. Emotional schema therapy takes the view that all emotions have had adaptive value in the history of the species and, therefore, are part of human nature. Th is includes disparaged emotions such as envy, jealousy, resentment, desires for revenge or hatred, and all varieties of sexual feelings. Similar to the metacognitive and cognitive models of intrusive thoughts (Clark, 2005; Purdon & Clark, 1993; Wells, 2009), the emotional schema therapist treats emotions as “mental events” that occur internally, sporadically, and involuntarily and that carry no immediate relevance to moral turpitude. Some patients say to themselves, “what’s wrong with me that I feel this way?”, resulting in feelings of shame and guilt and a tendency to ruminate. Th e emotional schema therapist can assist the patient in changing this evaluative thought to, “I notice that I have a lot of feelings that come and go, and this is one of those feelings that I have.” Indeed, one can view emotions as originating in the amygdala, with little conscious control over the feelings that occur (LeDoux, 1996). Just as visual illusions operate out of conscious awareness and control, so also do emotions become activated without conscious will or choice (Gray, 2004). Moralistic concepts such as “wrong” or “guilty” are more relevant to willful choices that are consciously made—that is, choices involving action where alternatives are considered. If we view moral evaluation as appropriate (at times) only for free conscious choice unimpeded by duress, provocation, or diminished capacity, then one would not view “emotion” as a moral choice. Guilt and shame about an emo- tion is a “category error” in that a moral category is misapplied to a physiological or experiential phenomenon (Ryle, 1949). For example, it would make no sense to say that
“You had a visual illusion because you are irresponsible” since visual illusions are not amenable to conscious choice. Emotional schema therapy helps the patient recognize that an emotion is not the same thing as a moral choice, thereby reducing the feelings of guilt over an emotion. For example, the married patient who fantasizes about a man other than her husband may be dissuaded from her guilt by recognizing that fantasies are common experiences and that feelings are not actions. Accepting that feelings and fantasies may come and go—and that they do not necessarily refl ect anything pejorative about the person experiencing them—can help reduce the “anxiety about emotion” so often characteristic of patients with an active fantasy life. Moreover, helping the patient recognize that “temptation” is a necessary component for a true moral choice helps reduce the sense of “guilt” over having temptation, since there cannot be a meaningful moral decision without consideration of alternatives.
Emotional schema therapy shares with ACT a recognition of the role of values in clarifying what can incentivize choice in the face of hardship. Th e role of values, of course, is not new; it can be traced to ancient Greek and Roman philosophy, in which
“values” were equated with “virtues”—that is, character habits such as courage, integrity, and self-control (as espoused by, e.g., Aristotle, Plato, Epictetus, Seneca, and Cicero).
Th ese virtues were often identifi ed with the Stoic tradition, but they have continued for almost 2,000 years in Western philosophy and religion. Emotional schema therapy is not neutral about which values matter, but rather takes the position that classic virtues (as described by Aristotle) and values of compassion, kindness, and fairness (as described
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by Rawls) can inform the moral and ethical choices that the patient considers (Rawls, 2005). Aristotle viewed virtue as the qualities in a person that you would admire, and so the goal is to become a person that you would admire yourself. I have found it help- ful to ask patients to attend to this simple question: “What are the personal qualities in someone who you would admire?” followed by, “How could you become a person who you would admire?”
Self-esteem is not based on popularity, achievement, power, wealth, or hedonism; it is based on the discrepancy between the qualities that you would admire and those that you recognize in yourself. Th e implicit social contract of fairness and justice is another way in which moral and ethical choices may be made. Specifi cally, how would you want to be treated if you did not know your actual or eventual status in society? Th is “veil of ignorance” model of ethical choice encourages consideration of fairness, compassion, kindness, and justice, rather than hedonistic or self-centered concerns of getting one’s own way.
Th us, the patient who considers acting out a fantasy of infi delity can examine the choice in terms of the virtues of integrity and self-control and in terms of the implicit social contract of fairness and reciprocity underlying the primary relationship. Th e ten- sion that underlies the choice helps clarify the commitment to these virtues and values and may clarify one’s identity and the problems and strengths of the relationship. Th us, in EST, values are not arbitrary or neutral but are examined in the light of virtue and implicit social contracts of fairness and justice. Indeed, the concept of fairness has been extended by Nussbaum to recognize that compassion and protection of the very “weakest”
(e.g., the disabled) may necessitate expanding the sense of social contract to focus more on kindness, compassion, and universal suff ering rather than on eff ective contracts for determining justice (Nussbaum, 2005). It is far beyond the scope of this chapter to examine the implications of virtue, justice, compassion, and other moral sentiments, but it is worth emphasizing that emotions often have an evaluative and even moral component implied in their evaluations. Helping patients realize that values, virtues, and compassion can have emotional costs may help some tolerate—even grow—from the diffi culties that arise in life.
Similarly, evaluations of emotions often imply that “feeling this way means I am crazy,” a belief based on the assumption that “sanity” is characterized by purity of emo- tion. Th is is similar to the metacognitive process of evaluating intrusive thoughts as weird, disgusting, or crazy and the belief that unless these thoughts are suppressed or eliminated the person will lose control and go insane (Wells, 2002). Th e meta-emotional strategy in EST is to evaluate this “theory of emotion” by considering the following:
“You have had these emotions many times, but you have not gone insane. How do you account for this?”; “Other people that you respect have these emotions but they are not insane. Why is that?” and “If you allowed yourself to accept the emotion rather than at- tempt to suppress it, what do you predict will happen?” Th ought fl ooding can be used, in which the patient repeats over and over, “I notice that I have this feeling right now, and I accept this feeling at this moment.” Th is usually results in an increase of anxiety
followed by a decrease as the thought is repeated until it becomes boring (Freeston, et al., 1997). Attempts to suppress emotions (or thoughts) confi rm the belief that emotions cannot be tolerated, similar to the confi rmation of beliefs about suppressing intrusive thoughts. Acknowledging repeatedly that one has an emotion—by enhancing conscious acceptance—is a form of exposure to recognizing, accepting, and tolerating the emo- tion, and disconfi rms the belief that an emotion must be eliminated lest the individual go insane.