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.
4. Problematic schemas include catastrophizing an emotion; thinking that one’s emotions do not make sense; and viewing an emotion as permanent and out of control, shameful, unique to the self, and needing to be kept to the self.
5. Emotional control strategies, such as attempts to suppress, ignore, neutralize, or eliminate through substance abuse and binge eating, help confi rm negative beliefs of emotions as intolerable experiences.
6. Expression and validation are helpful insofar as they normalize, universalize, improve understanding, diff erentiate various emotions, reduce guilt and shame, and help increase beliefs in the tolerability of emotional experience (Leahy, 2009b).
All of the foregoing are part of the psychoeducation and underlying philosophy of emo- tion guiding EST.
Emotional schema therapy assists the patient in the following: the identifi cation and labeling of a variety of emotions; normalizing emotional experience, including painful and diffi cult emotions; linking emotions to personal needs and to interpersonal com- munication; identifying problematic beliefs and strategies (schemas) that the patient has for interpreting, judging, controlling, and acting on an emotion; collecting information, using experiential techniques, and setting up behavioral, interpersonal, and emotional
“experiments” to develop more helpful responses to one’s emotions (Leahy, 2002, 2003b, 2009a, 2009b).
Th e emotional schema therapist utilizes a number of cognitive, experiential, and behavioral interventions in order to test and modify dysfunctional emotional schemas and emotion control strategies. For example, consider the negative interpretations of emotion depicted in Figure 5.1. Guilt or shame over emotion may be addressed using standard cognitive therapy techniques. For example, the patient may equate having an emotion (anger) with being an angry, hostile, mean person. Standard cognitive therapy techniques, such as distinguishing between a thought and a behavior, can be used to chal- lenge the view that emotions and behavior are equivalent. Other cognitive techniques can be used to examine positive, virtuous, or helpful behaviors that the person has en- gaged in to counter the view that one should be ashamed of an emotion. Normalizing the emotion, by examining how everyone has feelings of anger, can dissipate guilt and shame. Th e therapist can help the patient realize that choosing not to act on an angry or sexual feeling is actually a “moral choice” and that choices have more moral or ethical relevance when there is temptation to act otherwise. Guilty or shameful feelings about emotion may also be addressed by normalizing an emotion by establishing consensus that others share these feelings. Attribution interventions, derived from the “analysis of variance” model of Jones and Davis, help the patient examine the distinctiveness of an emotion (“you and others feel this way when you are responding to Sarah”), consensus (“almost everyone has these feelings at times”), and consistency (“you sometimes have these feelings but sometimes you don’t”) ( Jones & Davis, 1965; Kelley, 1972; Weiner, 1986). Examining how emotions may co-vary with situation and time, while recognizing
that others may often share the same emotional response, helps to reduce dispositional inferences about the self. Th us, if Carol knows that she is seldom jealous except when around Mark (low consistency) and that others would respond the same way toward Mark, given his behavior (high consensus and high distinctiveness), then Carol is less likely to make an inference that she is a “neurotic jealous person.” Reducing negative dispositional inferences related to emotion can also help reduce the sense of shame or guilt and the belief that one will continue feeling this way no matter what the circumstances.
For example, in the case of Carol’s jealousy, her feelings were elicited when Mark, her boyfriend, said he was having dinner with his fl irtatious ex-girlfriend. Carol said she felt jealous, angry, and anxious, but added that she worried that she was “becoming that jealous girlfriend that men hate.” She indicated that she worried that her jealousy would alienate Mark. Using an attribution analysis, she was able to recognize that she almost never expressed jealousy toward Mark in other situations and had seldom acted jealously with former partners. Moreover, when she collected consensus data from her friends they generally agreed that Mark was being insensitive and that her feelings were justifi ed.
We conceptualized her jealousy from an emotional schema model as “angry, agitated, worry” and examined how a multifaceted cognitive-behavioral model could be helpful.
Specifi cally, we normalized jealousy as an ethologically valid and useful emotion that protected potential genetic investment, indicated that emotions and behaviors are dif- ferent, used a mindful detachment of noticing and not judging the emotion, linked her jealousy to her higher values of commitment and honesty, and focused on relationship enhancement skills and diplomatic assertion, rather than reassurance seeking, pouting, or attacking (Leahy & Tirch, 2008).
A common belief about emotion that interferes with exposure therapy is that one’s anxiety will last indefi nitely and will eventually incapacitate the person. Th ese emotional schemas lead the patient to “wait until I feel ready,” relying on self-calming, reassurance, procrastination, avoidance, and other strategies to avoid experiential chaos. In some cases, the patient may argue that he is “too fragile” and, therefore, unable to engage in exposure until the self is “stronger” (Leahy, 2007a; Leahy, 2009a, 2009b). Th e therapist can help the patient examine the functional value of the belief that one is “too fragile.” For example, one patient acknowledged that he evoked the
“I am too fragile” belief prior to considering exposure and did not generally have this belief at other times. Th e consequence of the belief was that it decreased his likelihood to do exposure, thereby maintaining his belief in his fragility and limiting the enjoy- ment of his life. He recognized that he was highly invested in trying to convince his therapist that he was too fragile and that—indeed—he had succeeded with several other therapists in convincing them of this limitation. Th e therapist elicited specifi c predictions about the intensity and duration of his anxiety, should he do exposure, and the behavioral impact in terms of disability that this would have over the course of the day. His dire predictions were recorded, and he, in fact, did engage in the exposure and recognized over the next two days that he felt better. During the next session, his dire
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predictions were examined as functioning to preserve his avoidance and fragile-self beliefs, further reinforcing his belief that he needed to avoid. His other beliefs about emotional “readiness,” pathologizing himself (“I must be psychotic”), reassurance seek- ing, and advertising his “sickness” to others in order to lower his and their expectations were also conceptualized as emotional schema strategies predicated on his view that avoidance was the best strategy. His emotional schemas were subsumed by a threat detection approach to life that he believed “kept him safe.” Unfortunately, he had to acknowledge that he was both safe and sorry.
Avoidance of anxiety-provoking situations is usually based on faulty assessments of risk. For example, in the case above, the risk of contamination was exaggerated.
However, the risk of maintaining OCD was minimized. I have found it useful to use a risk-risk paradigm, borrowing from the risk model advanced by Cass Sunstein (as ap- plied to regulatory principles; Sunstein, 2005). According to the risk-risk model there is never a completely risk-free choice. Doing something or doing nothing both carry risks.
Exposing oneself to “contamination” carries the small risk of getting sick, whereas not exposing oneself carries a higher risk of maintaining OCD. However, OCD patients overestimate risk of contamination by virtue of accessibility, emotion, and familiarity heuristics and maintain their beliefs that they cannot tolerate anxiety by avoiding and escaping. Unfortunately, “testing” the contamination of a substance generally cannot yield adequate data (“I might not get cancer for 10 years”), so the emphasis in emotional schema therapy is on tolerating anxiety.
We have found that the concept of “constructive discomfort” empowers patients to face their fears in a way that they believe that they are building “mental muscle” (Leahy, 2005c; Leahy, 2007a; Leahy, 2009a, 2009b). Constructive discomfort implies that tolerat- ing and using discomfort in the service of important goals is a useful strategy in life.
Indeed, the goal is “to do what you don’t want to do that can help you get what you need to get.” Similar to distress tolerance, willingness, and other empowering concepts from ACT and dialectical behavior therapy (DBT), constructive discomfort is a focus of EST.
Consider an OCD patient contemplating exposure to “contamination.” Rather than focus on the content of the contamination (e.g., examining the evidence that there is real danger), the emotional schema therapist examines beliefs about the durability and overwhelming nature of experiencing anxiety. Th e focus is on the patient’s theory about anxiety—and how to cope with it. Problematic coping strategies are identifi ed (e.g., waiting to feel ready, seeking reassurance, pathologizing the self as fragile), and these strategies are identifi ed as “confi rmatory” processes that maintain the belief that anxi- ety cannot be tolerated (see Figure 5.2). Th ese beliefs about tolerating anxiety are then examined and modifi ed by examining the evidence about emotional schemas regarding durability, danger, and fragility and by setting up behavioral experiments to test the pre- dictions elicited in the session (see Figure 5.3). Th e goal is not to prove that the stimulus is uncontaminated. Th e goal is to modify beliefs about emotions and problematic strate- gies of emotional control and avoidance.