The effect of schema therapy on emotion regulation, happiness, and procrastination in health center employees

Schema therapy has been used in the treatment of various disorders, including depression, anxiety, personality disorders, and couples' incompatibility and has suggested promising outcomes. Therefore, the present study aimed to investigate the effects of schema therapy on emotion regulation, happiness, and procrastination among the staff of healthcare centers. This was a quasi-experimental study with a pretest-posttest and a control group design. The experimental groups received eleven 90-minute (once a week) schema therapy sessions, while the control group received no intervention. The statistical population consisted of the staff of comprehensive health centers in the east of Tehran City, Iran. In total, 40 samples were selected through systematic sampling method. The subjects were randomly divided into the test and control groups (20 samples per group). Considering the experimental nature of the study and eliminating the effect of pretest, the study groups were compared using the Analysis of Covariance (ANCOVA). In addition, Multivariate Analysis of Covariance (MANCOVA) and Analysis of Variance (ANOVA) were applied for testing the primary and secondary hypotheses, respectively. The obtained data were analyzed applying statistics like mean and standard deviation, as well as Multivariate Analysis of Variance (MANCOVA) in SPSS. There were significant differences between the two experimental and control groups in terms of emotion regulation (P<0.000) and happiness (P<0.003). However, there was no significant difference between the two groups in procrastination (P<0.689). According to the obtained data, conducting schema therapy has improved emotion regulation and happiness in the experimental group compared to the controls. However, the intervention only slightly improved procrastination in the experimental group members and such increase was not statically significant.


Introduction
Schema therapy, developed by Jeffrey E. Young, is a modern and integrated approach. It is mainly based on the development of the concepts and methods of standard cognitive-behavioral therapy. It is believed that schema therapy is a valuable and comprehensive model, consisting of the integration of the principles of cognitive-behavioral therapy, Gestalt, attachment theory, object-relation theory, constructivism theory, and psychoanalysis [Young, Klosko, & Weishaar, 2003]. The fundamental concept of this approach is "initial maladaptive schemas" [Sempertegui, Karreman, Arntz, & Bekker, 2013]. Schema therapy has been used in the treatment of a variety of disorders, including depression, anxiety, narcissistic personality disorder, borderline personality disorder, obsessive-compulsive personality disorder, and in couples' incompatibility and has suggested promising outcomes [Mitragotri, Kost, Kellogg, Warner, & Elstrom, 2012]. Emotion regulation refers to a process by which individuals modulate their emotions in a conscious or nonconscious manner to appropriately respond to environmental demands [Tortella-Feliu, Balle, & Sesé, 2010]. Emotion regulation is considered as an essential issue in mental health [Garnefski & Kraaij, 2006]. Emotion regulation and its relation to biopsychological health is an important research area [Connelly & Denney, 2007]. Longitudinal studies have also highlighted that emotion regulation skills could predict mental health status [Berking et al., 2008]. Prior research suggested that emotion regulation problems are prevalent among a wide range of mental disorders [Gross & Muñoz, 1995]. Otto et al. argued that success and happiness result from emotion regulation and recognized emotion reappraisal beneficial in reducing the effects of negative emotions ]. According to previous research studies, happier people benefit from a better biopsychological health status, live longer, and gain more occupational and social success [Scalmani et al., 2006]. Happiness reduces stress perception and enhances working ability [Hillis et al., 2004]. Procrastination is defined as suspending or delaying to perform a necessary task and delegating it until the deadline [Lay, 1986]. Experimental evidence suggests a correlation between procrastination and numerous mental health issues, academic performance matters, and social problems [Sirois, 2004]. A critical aspect that should be considered in organizations' human resources is developing constructive and satisfying interpersonal relationships. Improving early maladaptive schemas could affect such matters. To our knowledge, there is no study available regarding the effectiveness of schema therapy on emotion regulation, happiness, and procrastination among working staff. Therefore, the present study aimed to investigate the effects of schema therapy on the above-mentioned components among the staff of comprehensive healthcare centers.

Participants and methods
This was a quasi-experimental study with a pretest-posttest and a control group design. The experimental groups received eleven 90-minute (once a week) schema therapy sessions, while the control group received no intervention. The statistical population consisted of the staff of comprehensive healthcare centers in the east of Tehran City, Iran. In total, 40 samples were selected through systematic sampling method. The subjects were randomly divided into the test and control groups (20 samples per group). Considering the experimental nature of the study and eliminating the effect of pretest, the study groups were compared using the Analysis of Covariance (ANCOVA). In addition, Multivariate Analysis of Covariance (MANCOVA) and Analysis of Variance (ANOVA) were applied for testing the primary and secondary hypotheses, respectively. The obtained data were analyzed applying descriptive statistics like mean and standard deviation, as well as inferential statistics, including Multivariate Analysis of Variance (MANCOVA), in SPSS.  (Ferrari, 1989). The obtained scores are rated on a Likerttype scale. There are 5 possible options to respond to the items in this questionnaire ranging from one to five. The higher the achieved score, the greater the procrastination level. Negative items are scored reversely. In the present study, Cronbach's alpha coefficient for the whole test was calculated as 0.79.

Study instruments:
The contents of the 11 sessions of schema therapy provided to the test group are presented in the below table. Educating and implementing cognitive techniques 5, 6, 7 Educating and implementing experimental (emotional) techniques 8,9,10 Educating and implementing the techniques of breaking behavioral patterns 11 Performing posttest

Results
The current study was conducted on 40 samples, who were randomly divided into the test and control groups (20 samples per group). All 20 participants in the experimental group completed the study. Table 2 presents the demographic data of the samples. The age of the study samples ranged from 26 to 51 years, and their mean age was 37.92 years. Moreover, the majority of the study participants were married (80%) females (77.5%).
In addition, most of the subjects benefited from higher education levels (BA & MA=, 71%).  Table 3, although the mean difference between the two groups in the happiness variable was low, the mean scores in the experimental group were slightly higher, indicating that the application of the schema therapy in the experimental group increased the happiness in the subjects. Moreover, concerning emotion regulation, the mean scores of the experimental group were higher, indicating that the application of the schema therapy improved their emotion regulation. Eventually, the mean scores of the experimental group were slightly higher in terms of procrastination, indicating that schema therapy caused a slight increase in procrastination in the experimental group. As per Table 4, the Levene's test results were not significant for any of the variables. Therefore, the Analysis of Variance (ANOVA) could have been used to test the achieved data.
Furthermore, Multivariate Analysis of Covariance (MANCOVA) was used to investigate the therapeutic effect of schema therapy on the studied employees' emotion regulation, happiness, and procrastination. By controlling pretest scores and comparing posttest scores, the two experimental and control groups were compared. According to Table 5, there was a significant difference between the two groups in terms of happiness, emotion regulation, and procrastination. Therefore, the experimental intervention was effective in the variables mentioned above.
The multivariate test difference was statistically significant; thus, the one-way Analysis of Covariance (ANCOVA) was applied to examine group differences regarding the dependent variable. The ANCOVA results are presented in Table 6. There were significant differences between the two experimental and control groups in terms of happiness (P<0.003) and emotion regulation (P<0.000). However, there was no significant difference between the two groups in procrastination (P<0.689).

Discussion
The MANCOVA results revealed that the difference between the two groups was significant in terms of emotion regulation and happiness components (P<0.0001). Therefore, schema therapy has increased happiness in the experimental group. Diener argued that happiness is associated with three components, as follows: the cognitive component, i.e., thinking and processing that leads to one's optimism; the emotional component which causes positive and happy mood; and the social component that reflects one's tendency toward communicating with others and the resulted joy of effective communication [Diener, 2005]. Therefore, understanding the schemas and treating them can be an essential step in developing emotion regulation skills and increasing happiness accordingly. This finding was consistent with other studies [ The literature highlights that emotion regulation predicts positive compatibility. Moreover, the capability to effectively manage emotions could impact biopsychological and interpersonal happiness [Gross, 2002]. These study findings were consistent with some of the previous research findings [Abbasi, Pirani, & Salehi, 2017], [Calvete, Orue, & Hankin, 2013].
In the case of procrastination, there was a negligible difference between the mean scores of two test and control groups. The slightly higher mean scores of the experimental group indicated that schema therapy slightly improved procrastination in them. It can be concluded that the schema therapy did not affect the procrastination and the observed difference could only be due to a random basis. Possibly, many contextual factors, including perfectionism and the lack of planning skills might affect procrastination in individuals. Moreover, encouraging procrastinating people to engage in group therapy, which is focused on changing behaviors is much harder than other situations.
A study limitation included strict sample selection to a specific region of Tehran. In addition, controlling the effect of some demographic factors, such as intelligence, economic status, etc. was disregarded in the present research; such issues might affect the generalizability of the obtained data. The experimental nature of the study which targets assessing causal relations might be another limitation; thus, further study is suggested to investigate the study variables through more comprehensive research methods.
The achieved study results could be beneficial in improving employee's emotion regulation strategies and job satisfaction, leading to their increased working efficiency and effective communication skills.

Conclusion
According to the obtained data, conducting schema therapy has improved emotion regulation and happiness in the experimental group compared to the controls. However, the intervention only had slightly improved procrastination in the experimental group members, and such an increase was not statically significant.