International Journal of Cognitive Therapy, 10(4), 269–282, 2017

© 2017 International Association for Cognitive Psychotherapy

KHALEGHI ET AL.
EMOTIONAL SCHEMA THERAPY FOR GAD

Emotional Schema Therapy for

Generalized Anxiety Disorder:
A Single-Subject Design
Mohammad Khaleghi
Department of Clinical Psychology, Kharazmi University, Tehran, Iran

Robert L. Leahy
Weill-Cornell University Medical College, New York, New York

Elyas Akbari, Shahram Mohammadkhani, and Jafar Hasani

Department of Clinical Psychology, Kharazmi University, Tehran, Iran

Afshin Tayyebi
Department of Psychology, Islamic Azad University of Karaj, Karaj, Iran

Generalized anxiety disorder (GAD) is a widespread psychiatric disorder that has

important effects on human health. This study evaluated a new form of therapy
based on emotional schema therapy (EST) that focuses on the individual’s inter-
pretations, strategies, and responses to his or her emotions. Treatment efficacy
was assessed using the single-subject methodology in two patients with GAD. Pa-
tients completed the Leahy Emotional Schema Scale at pre-/post-treatment and at
2-month follow-up; and the Penn State Worry Questionnaire, the Beck Anxiety
Inventory, the Hamilton Anxiety Rating Scale, and the Metacognitions Question-
naire-30 at baseline, after every other therapy session, and 2 months after comple-
tion of therapy. The results showed clinically substantial changes on all outcome
measures in post-treatment as well as at 2-month follow-up. The results offer tenta-
tive support to the view that EST could be an effective therapy for GAD.

Keywords: emotional schema therapy, generalized anxiety disorder, metacognitive

beliefs, worry

Generalized anxiety disorder (GAD) is the most common anxiety disorder, and its
core processes represent the primary ones in all anxiety disorders (Barlow, 2004).
Among clinical patients the prevalence of GAD is considerably greater, with GAD

We appreciate the cooperation of the patients and all staff of Kaj Psychology and Counseling Services Center
as well as Parsian Psychiatry Center in Tehran, Iran.
Address correspondence to Mohammad Khaleghi, Department of Clinical Psychology, Kharazmi Univer-
sity, Tehran, Iran. E-mail: mohammad.khaleghi66@gmail.com

269
270 KHALEGHI ET AL.

appearing as the most prevalent anxiety disorder and the second most common
mental health problem within primary care facilities (Wittchen, Kessler, Beesdo,
Krause, & Hoyer, 2002). According to the Diagnostic and Statistical Manual of
Mental Disorders, fifth edition (DSM-5; American Psychiatric Association [APA],
2013), the 12-month prevalence of GAD is 0.9% among adolescents and 2.9%
among adults in the general community of the United States. Also, the 12-month
prevalence of the disorder in other countries ranges from 0.4% to 3.6% (APA,
2013, p. 223).
Standard cognitive behavioral interventions are less than ideal for the treat-
ment of GAD. For example, in vivo exposure and cognitive challenging strategies
are often only moderately helpful as the target of exposure or cognitive challenges
may change according to worry themes, so that clinicians find themselves chasing
a “moving target” (Robichaud, 2013). Preliminary findings indicate that new pro-
tocols and conceptualizations of GAD have yielded treatment outcomes superior
to earlier cognitive behavior therapy (CBT) interventions (e.g., Roemer, Orsillo,
& Salters-Pedneault, 2008; Wells et al., 2010). On the other hand, attention to
the role of emotion and emotional processing has expanded in recent years (e.g.,
Gross, 1998; Mennin, Heimberg, Turk, & Fresco, 2005). Of particular relevance
to the function of worry, Borkovec, Alcaine, and Behar (2004) has proposed an
emotional avoidance model that suggests that the abstract linguistic nature of
worry temporarily inhibits emotional arousal. The implication of the emotional
avoidance model is that individuals who fear emotion or have difficulty process-
ing their emotions would be more likely to utilize worry as a strategy to avoid
unwanted feelings.
Leahy’s emotional schema model proposes that individuals differ in their
awareness, interpretations, evaluations, and acceptance of “negative” feelings
(Leahy, 2002, 2015a; Leahy, Tirch, & Napolitano, 2011). It is argued in this new
model that the emotions themselves may constitute objects of cognition—that is,
they may also be viewed as content to be evaluated, controlled, or utilized by an
individual. Earlier CBT models have also suggested that individuals appraise their
emotional experience, whether it is the sensations and thoughts accompanying
the experience or the emotion itself (Barlow, 1991; Ellis & Dryden, 1997). The
emotional schema model is a social cognitive model that proposes that individuals
elaborate a theoretical model of their emotions and the emotions experienced by
others, reflecting normalizing and pathological styles of coping with emotions. For
example, the normalizing process entails viewing painful and conflicting emotions
as having shorter duration, being controllable, not dangerous, comprehensible,
similar to the emotions of others, and related to values and believing that they can
be expressed, are validated, and are acceptable. In contrast, negative evaluations of
these emotions may result in problematic coping, such as reliance on avoidance,
drinking, binge eating, substance abuse, blaming, rumination, and worry.
The emotional schema model draws on the metacognitive model, stressing
the negative interpretation of internal experience (e.g., emotions), but differs from
the metacognitive model of Wells (2009) in several ways. First, emotions are dif-
ferent from thoughts and involve physical sensations, action tendencies, and in-
EMOTIONAL SCHEMA THERAPY FOR GAD 271

FIGURE 1. A model of emotional schema. Reproduced from Leahy (2015a, p. 44).

terpersonal functioning. Second, the emotional schema model (and the associated
treatment, emotional schema therapy [EST]) focuses on the relationship between
emotions and core values, such that painful emotions may often be the direct re-
sult of important values that the patient maintains. Third, EST places considerable
emphasis on the role of validation and the therapeutic relationship as important
factors in the attachment issues that arise in the sharing of emotion. Fourth, EST
draws directly on evolutionary psychology and the adaptive function of emotion
to help patients normalize their experience. Finally, EST relates current maladap-
tive interpretations of emotion to the patient’s socialization experiences and to
current interpersonal relations (Leahy, 2015b). A diagram of the Emotional Sche-
ma Model is given in Figure 1.
There is empirical support for the role of emotional schemas in psychopathol-
ogy. In a study of 53 adult psychotherapy patients, participants were assessed,
and their responses on the Leahy Emotional Schema Scale (LESS) were corre-
lated with the Beck Depression Inventory and the Beck Anxiety Inventory (Leahy,
2002). In a study of 425 adult psychotherapy patients Risk Aversion, Negative
Beliefs About Emotion (a composite score on the LESS), and Psychological Flex-
ibility were significantly related to depression and to each other (Leahy, Tirch, &
Melwani, 2012). Silberstein, Tirch, Leahy, and McGinn (2012) tested 107 adult
cognitive-behavioral outpatient participants on Dispositional Mindfulness, Psy-
chological Flexibility, and Emotional Schemas. Individuals with higher levels of
dispositional mindfulness also had higher levels of psychological flexibility and
were more likely to endorse more adaptive dimensions of emotional schemas.
272 KHALEGHI ET AL.

In a study of 295 adult patients, Tirch, Leahy, Silberstein, and Melwani (2012)
examined the relationship among psychological flexibility (Acceptance and Action
Questionnaire II [AAQ-II]; Bond et al., 2011), mindfulness (Mindful Attention
and Awareness Scale [MAAS]; Brown & Ryan, 2003), and emotional schemas
(LESS; Leahy, 2002). All measures were significantly related to each other. Re-
gression analysis indicated that emotional schemas regarding control of affect were
the primary predictors of elevated Beck Anixety Inventory (BAI) scores, while
psychological flexibility was the primary predictor of elevated anxiety scores on
the Millon Clinical Multiaxial Inventory-III (Tirch et al., 2012).
In a study of 425 psychotherapy patients, Leahy, Wupperman, and Shivaji
(2016) explored the relationship among emotional schemas, metacognitive factors
in worry (Metacognitions Questionnaire [MCQ]; Wells & Cartwright-Hatton,
2004), depression (Beck Depression Inventory-II; BDI-II), and anxiety (BAI).
Negative Beliefs About Emotions were significantly correlated with each of the
five metacognitive factors and with both depression (BDI-II) and anxiety (BAI).
When controlling for anxiety, each of the MCQ factors was significantly related
to Negative Beliefs About Emotion, except for Cognitive Competence, which
was marginally significant (p < .02). Stepwise multiple regression indicated that
Uncontrollability/Danger of Worry and Negative Beliefs About Emotion were
the best predictors of anxiety, and Uncontrollability/Danger of Worry, Negative
Beliefs About Emotion, and Cognitive Competence were the best predictors of
depression.
In a study by Edwards, Micek, Mottarella, and Wupperman (in press), 668
college students completed the Toronto Alexithymia Scale-20, the LESS-II, the
Socialization of Emotion Scale, the Child Abuse and Trauma Scale (Sanders &
Becker-Lausen, 1995), and the Trauma History Questionnaire (THQ; Green,
1996). Mediation analysis of the predictor variables on alexithymia indicated emo-
tion ideology (emotional schemas) completely mediated the effects of emotion
socialization and child abuse. In a study of 325 adult psychotherapy outpatients
by Westphal, Leahy, Pala, and Wupperman (2016), participants completed several
self-report forms: the Millon Clinical Multiaxial Inventory-III (MCMI-III; Mil-
lon, Millon, & Davis, 1994), the Leahy Emotional Schema Scale (Leahy, 2002),
the Self-Compassion Scale-Short Form (SCS-SF; Raes, Pommier, Neff, & Van
Gucht, 2011), and the Measure of Parenting Style (MOPS; Parker et al., 1997).
The subscale for Invalidation on the LESS and the subscales on the MCMI for
major depressive disorder (MDD), posttraumatic stress disorder (PTSD), and
borderline personality disorder (BPD) were of specific interest in this study. In-
validation on the LESS was strongly related to PTSD, MDD, and BPD, and self-
compassion was strongly inversely associated with emotional invalidation. Both
self-compassion and emotional invalidation mediated the relationship between
parental indifference and mental health outcomes. Specifically, patients exposed
to indifferent parenting displayed lower self-compassion and higher emotional
invalidation, which mediated the risk for BPD, MDD, and PTSD. Together, these
foregoing findings illustrate a central role of beliefs about emotions and strategies
EMOTIONAL SCHEMA THERAPY FOR GAD 273

about emotion regulation that mediate a wide range of indices of psychopathol-

ogy.
The aim of the present study was to conduct a preliminary investigation of
the efficacy of emotional schema therapy for GAD. As outlined earlier, a number
of studies support the validity for the EST model of anxiety. This single-subject
study whereby subjects were compared with themselves with repeated measures
over time is a preliminary study in determining whether EST could be an effica-
cious treatment for GAD.

METHOD
DESIGN

The present study was conducted as an A B single-subject design to evaluate the

efficacy of emotional schema therapy in patients with GAD. The study population
comprised all patients with GAD who were admitted to hospital and private cen-
ters in Tehran, Iran in the time span of November to December 2014. Based on a
psychiatrist’s diagnosis as well as a structured diagnostic interview with a clinical
psychologist, two patients with GAD were selected by convenience sampling.

PARTICIPANTS

Two patients admitted to psychology and counseling centers for treatment of

GAD were included in the study. Patients were included if they met the following
criteria: (1) diagnosis of GAD, (2) aged 20–45, (3) lack of a psychotic disorder,
(4) no psychological intervention in the past 2 years, (5) no medication, and (6)
lack of substance use. Prior to the study, informed consent was obtained from the
patients.
Patient 1. Patient 1 was a 25-year-old single woman with a 6-year history of
GAD. She was medication-free, reporting prior use of medication for 1 month
about 5 years previous, with no positive outcome. In addition, she had never re-
ceived psychotherapy. Her main worries were related to family, health, and educa-
tion. She said that she had tried not to think about such worries with little success.
She stated that her main problems included extreme worry about various issues,
insomnia, lack of concentration at work, and fatigue.
Patient 2. Patient 2 was a 30-year-old, married woman with an 8-year history
of GAD. She had received psychotropic medication 6 years prior to this study, but
had discontinued medication after 3 months, and she had never received psycho-
logical treatment. Her main worries were about her children, health, family, and
income. She said that the course of her worry and anxiety had fluctuated for years
but had never completely abated.
274 KHALEGHI ET AL.

MATERIALS AND PROCEDURE

Structured Clinical Interview for DSM Axis-I Disorders (SCID-I). The SCID-I
is a clinical assessment for making DSM diagnosis. In the present study the Iranian
version of this scale was used, which has been shown to be reliable and valid in
diagnosing major psychiatric disorders in the clinical population in Iran (Sharifi
et al., 2004, 2007).
Leahy Emotional Schema Scale (LESS). The LESS (Leahy, 2002) is a self-report
questionnaire composed of 50 questions intended to tap into 14 dimensions of
beliefs and responses to one’s emotions. The LESS has shown acceptable valid-
ity and reliability (Leahy, 2002). Moreover, in one study, reliability of this scale
using Cronbach’s alpha methods was reported between 0.59 to 0.73, and retest
reliability after 2 weeks was 0.56 to 0.71 in an Iranian sample (Khanzadeh, Edrisi,
Mohammadkhani, & Saeedian, 2013).
Penn State Worry Questionnaire (PSWQ). The PSWQ (Meyer, Miller, Metzger,
& Borkovec, 1990) is comprised of 16 items designed to evaluate the tendency to
engage in excessive and uncontrollable worry. Items are rated on a 5-point Likert
scale. It has been shown to have reasonable psychometric properties (Meyer et al.,
1990). There is satisfactory reliability and validity of the Persian version of this
scale (Dehshiri, Golzari, Borjali, & Sohrabi, 2010).
Beck Anxiety Inventory (BAI). The BAI (Beck, Epstein, Brown & Steer, 1988)
is a 21-item self-report that measures severity of somatic and cognitive symptoms
over the previous week. This scale showed high internal consistency (0.92) and
test-retest reliability over 1 week, r (81) = .75. In addition, the BAI was mod-
erately correlated with the revised Hamilton Anxiety Rating Scale, r (150) =
.51, and was only mildly correlated with the revised Hamilton Depression Rating
Scale, r (153) = .25. Moreover, the Persian version of the BAI showed good reli-
ability (r = .72, p < .001), very good validity (r = .83, p < .001), and excellent
internal consistency (alpha = 0.92) (Kaviani & Mousavi, 2008).
Hamilton Anxiety Rating Scale (HARS). The HARS (Hamilton, 1959) is a
14-item scale that measures anxiety symptoms as assessed by a clinician. Each
item is rated from 0 to 4 and total scores can range from 0 to 56. The HARS has
acceptable psychometric properties (Bech, Grosby, Husum, & Rafaelsen, 1984;
Clark & Donovan, 1994).
Metacognitions Questionnaire-30 (MCQ-30). The MCQ-30 (Wells & Cart-
wright-Hatton, 2004) showed good internal consistency and convergent validity,
and acceptable to good test-retest reliability. Positive relationships between meta-
cognitions and measures of worry and obsessive-compulsive symptoms provided
further support for the validity of the measure and the metacognitive theory of
intrusive thoughts (Wells & Cartwright-Hatton, 2004). The psychometric charac-
teristics of the MCQ-30 were examined in a group of 258 nonclinical participants
as well as in a clinical sample including 25 patients with obsessive-compulsive
disorder, 25 patients with GAD, and 25 normal participants, and the results re-
EMOTIONAL SCHEMA THERAPY FOR GAD 275

flected good psychometric properties in the Iranian sample (Shirinzadeh Dastgiri,

Goudarzi, Rahimi, & Naziri, 2009).

PROCEDURE

Patients completed the LESS at pre-/post-treatment and at 2-month follow-up

and the PSWQ, BAI, HARS, and MCQ-30 at baseline, after every other thera-
py session, and 2 months after completion of therapy. Each patient received 10
1-hour weekly sessions of EST. The evaluations were conducted by an indepen-
dent assessor.

ADAPTING EST FOR PATIENTS WITH GAD

EST is a principle-based intervention not defined by a specific format, but includes

a range of emotion regulation techniques that address the patient’s beliefs about
emotion (e.g., durability, control, comprehensibility, distinctiveness) as well as
identifying and modifying maladaptive coping (Leahy, 2015a; Leahy et al., 2011).
The emotional schema therapist follows a structured approach to assessing current
beliefs about emotions, developing a case conceptualization of how these beliefs
maintain negative mood, how these emotional schemas are related to maladaptive
styles of coping, and how emotional schemas can be modified (Leahy, 2015a). In
the first session, a case conceptualization based on the emotional schema model
was developed with each patient, followed by validating difficult emotions and
by psychoeducation about generalized anxiety disorder and worry. As a home-
work, patients were asked complete an activity schedule, identify emotions and
thoughts, and review a form that summarizes the functions of emotions. In the
second session, the case conceptualization was completed. During this stage, the
therapist and patient collected information about the patient’s beliefs about emo-
tion, typical maladaptive coping strategies, the origin of some of these beliefs
about emotion, and the impact of these beliefs and strategies on depression, anxi-
ety, anger, interpersonal relationships, motivation, and work. Then the patient’s
problematic coping strategies as well as emotional schemas were identified. Sub-
sequent treatment sessions involved validating the patient’s emotions, identify-
ing and labeling emotions, normalizing emotions, stress reduction, challenging
emotion myths, practicing acceptance of emotions, and identifying useful coping
strategies such as acceptance, expression, behavioral activation, and the develop-
ment of more meaningful supportive relationships to cope with emotions instead
of problematic strategies such as worry, rumination, substance abuse, avoidance,
and suppression. In addition, the clinician introduced mindfulness, examining the
costs and benefits of certain emotional schemas and coping strategies as well as
self-monitoring of emotions. Specific beliefs about emotions (emotional schemas)
were identified and addressed, for example, predictions about the durability of
276 KHALEGHI ET AL.

FIGURE 2. Patient 1’s scores on the PSWQ, BAI, HARS, MCQ-N, and MCQ-P during
pre-/post-treatment and at 2-month follow-up.

anxiety, distinguishing emotions from actions, and making sense of emotions by

linking emotions to current thoughts, situational triggers, and prior history (see
also Leahy, 2015a, 2015b; Leahy et al., 2011). The last session focused on linking
emotions to higher values, making room for emotions, and reviewing a written
version of techniques that were used.

RESULTS

It should be noted that given the aim of the study, the two components of the
MCQ-30, negative metacognitive beliefs about worry (MCQ-N) and positive
metacognitive beliefs about worry (MCQ-P) are reported here. Also, in order to
facilitate the interpretation of findings, the emotional schemas were divided into
two parts: maladaptive emotional schemas (LESS-M: including rumination, guilt,
uncontrollability, validation, blaming, over-rationalization, and simplistic view)
and adaptive emotional schema (LESS-A: including emotional self-awareness,
expression of feelings, comprehensibility, relating emotions to higher values, ac-
ceptance, and consensus). As indicated in Figures 2 and 3, each patient showed
substantial decreases at the first sessions in scores on the BAI, HARS, and PSWQ,
as well as in metacognitive beliefs about worry, with relatively stable decreases
over the course of treatment. Also, these changes were maintained at follow-up.
Although patient 2’s scores on the HARS and MCQ-P showed a slight deterio-
EMOTIONAL SCHEMA THERAPY FOR GAD 277

FIGURE 3. Patient 2’s scores on the PSWQ, BAI, HARS, MCQ-N, and MCQ-P during
pre-/post-treatment and at 2-month follow-up.

FIGURE 4. Emotional schemas for patient 1 at pre-/post-treatment and 2-month

follow-up.
278 KHALEGHI ET AL.

FIGURE 5. Emotional schemas for patient 2 at pre-/post-treatment and 2-month

follow-up.

FIGURE 5. Emotional schemas for patient 2 at pre-/post-treatment and 2-month

follow up.

ration at 2-month follow-up, these post-treatment scores were still substantially

lower than at pretreatment. The two patients’ scores on 13 components of the
LESS at pretreatment, post-treatment, and 2-month follow-up indicated that the
scores were substantially lower at post-treatment than pretreatment for most of
the maladaptive emotional schemas (rumination, guilt, uncontrollability, valida-
tion, blaming, over-rationalization, and simplistic view) and higher for the adap-
tive emotional schemas (emotional self-awareness, expression of feelings, compre-
hensibility, relating emotions to higher values, acceptance, and consensus; Figures
4 and 5). The exceptions were for rumination, guilt, and over-rationalization in
patient 1 and rumination and guilt for patient 2, which showed slight increases at
follow-up but were still lower than pretreatment scores. Percentage improvements
for pre- to post-treatment and follow-up are presented in Table 1.
Furthermore, the results of regression analysis to estimate the degree of
change across time for each patient and outcome measures (PSWQ, BAI, HARS,
MCQ-N, and MCQ-P) across all sessions are as follows. For patient 1: PSWQ
(R2adj = 0.983, p = .001), BAI (R2adj = 0.900, p = .001), HARS (R2adj =
0.927, p = .001), MCQ-N (R2adj = 0.930, p = .001), MCQ-P (R2adj = 0.941,
p = .001); and for patient 2: PSWQ (R2adj = 0.911, p = .001), BAI (R2adj =
0.742, p = .01), HARS (R2adj = 0.805, p = .01), MCQ-N (R2adj = 0.877, p =
.001), and MCQ-P (R2adj = 0.820; p = .001). Thus, there was substantial clinical
improvement over the course of treatment for each of these outcome measures.
EMOTIONAL SCHEMA THERAPY FOR GAD 279

TABLE 1. Percentage Improvement of Two Patients

Percentage
improvement
Post- Percentage 2-month at 2-month
Group Patient Pretreatment treatment improvement follow-up follow-up
LESS-M 1 10.14 3.57 64 4.28 57
2 9.57 3.28 65 3.28 65
LESS-A 1 3 8.5 64 8.66 65
2 3.16 9.33 66 9.5 66
PSWQ 1 63 32 49 30 52
2 54 29 46 26 51
BAI 1 34 7 79 7 79
2 32 9 71 9 71
HARS 1 37 11 70 9 75
2 36 12 66 14 61
MCQ-N 1 16 6 62 6 62
2 19 8 57 8 57
MCQ-P 1 17 9 47 8 52
2 18 9 50 10 44
Note. LESS-M = Leahy Emotional Schema Scale - Maladaptive emotional schemas; LESS-A = Leahy Emotional Schema
Scale - Adaptive emotional schemas; PSWQ = Penn State Worry Questionnaire; BAI = Beck Anxiety Inventory; HARS =
Hamilton Anxiety Rating Scale; MCQ-N = Metacognition Questionnaire - Negative beliefs about worry; MCQ-P = Metacog-
nition Questionnaire - Positive beliefs about worry.

DISCUSSION

The aim of this study was to assess if EST can be an effective treatment for GAD.
The results of this single-subject study provide preliminary evidence for effective-
ness of EST on GAD in two patients who attained clinically significant gains
and maintained these gains at 2-month follow-up. A substantial reduction on all
maladaptive emotional schemas and a substantial increase on adaptive emotional
schema dimensions were obtained. In addition, substantial changes were observed
on the other measures, the BAI, MCQ-30, PSWQ, and HARS, at post-treatment
as well as at 2-month follow-up. The emotional schema model proposes that when
an emotion is activated, negative beliefs and interpretations about emotions can
determine whether these emotions will continue, exacerbate, or decrease. In EST,
the validation of the patient’s emotions, psychoeducation about emotions, nor-
malizing emotions, acceptance, emotional self-awareness, tolerating mixed feel-
ings, linking emotions to higher values, mindfulness, and making room for emo-
tions can lead to increasing acceptance of emotion and a decrease in the reliance on
worry as a coping strategy (Leahy, 2015a). The data from this study offer tentative
support for this model.
One interesting finding was that the patients’ metacognitive beliefs about
worry, especially negative beliefs, changed in treatment. Studies have shown that
280 KHALEGHI ET AL.

metacognitive factors of worry may be activated partly because of negative beliefs

about emotion (Leahy et al., 2011, 2016). By modifying beliefs about emotion
(adaptive and maladaptive) during EST, the reliance on worry as a strategy to cope
with emotions may be decreased, thereby modifying the underlying metacognitive
factors of worry.
There are a number of limitations in this study. First, the study is limited to
the two patients and, therefore, caution should be considered in generalizing from
these preliminary results. Second, only one therapist was used in the present study,
and it may be problematic to generalize from the results obtained here. Another
limitation is the design of the study. The main problem of the A B design is the
lack of a sufficient number of baseline measures and, therefore, future case studies
could consider the multiple baseline designs. However, the two patients who were
treated with EST both made substantial improvement during treatment and main-
tained this improvement at 2-month follow-up. The present research could be
considered as a preliminary test of the effectiveness of emotional schema therapy
for patients with GAD.

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