Cognitive and Behavioral Practice 14 (2007) 297302

www.elsevier.com/locate/cabp

Emotional Schemas and Self-Help: Homework Compliance

and Obsessive-Compulsive Disorder

Robert L. Leahy, American Institute for Cognitive Therapy, New York

Many patients will either refuse to enter treatment or will drop out of treatment where exposure and response prevention (ERP) are
employed. Patients may have a number of good reasons for noncompliance with ERP. For example, they may view their intrusions as
conveying responsibility, reflecting higher threat, as personally relevant, and as requiring perfect and certain solutions. Inducing
anxiety, from this perspective, only exacerbates the problem. Moreover, patients may employ beliefs about emotion and anxiety that
conflict with exposuresuch as the belief that anxiety should always be avoided or decreased because it is assumed to rise indefinitely and
cause psychological harm. Homework or between-session self-help necessarily involves exposure with increased anxiety and discomfort. In
the current case study, both meta-cognitive and meta-emotional conceptualization and strategies were employed in the treatment of a
previously treatment-resistant case of OCD, and homework compliance was improved through the use of an emotional schema approach.

C OGNITIVE-BEHAVIORAL THERAPY for obsessive-compulsive

disorder (OCD) has a high rate of efficacy, with many
patients showing clinically significant improvement with
the use of exposure and response prevention (Abramo-
witz, 1997; Abramowitz, Taylor, & McKay, 2005). However,
a significant percent of OCD patients either refuse to
enter CBT treatment, drop out prematurely, or do not
comply with the requirements of exposure treatment
(Whittal & McLean, 1999). Moreover, even among
patients who show clinically significant improvement, a
substantial percent of these patients (75%) are still
affected by unwanted intrusions and difficulties in coping
after successful treatment is completed (Fisher & Wells,
2005).
In recent years there has been an increase in attention
to factors that might interfere with patient compliance,
readiness, or resistance in CBT (Leahy, 2001, 2002a;
Miller & Rollnick, 2002; Westra, 2004). This noncompli-
ance is especially important because the CBT approach to
the treatment of OCD and all anxiety disorders necessi-
tates self-help homework between sessions. In particular,
cognitive therapy approaches to OCDinvolving exam-
ination of beliefs about the nature of one's intrusions and
thought control strategieshave been proposed to
address problems in compliance and to improve outcome
(Clark, 2004; Wilhelm et al., 2005). Given the high rate at
which potential or actual patients do not actually receive
1077-7229/07/297302$1.00/0
2007 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
adequate treatment for OCD, the application of techni-
ques and strategies to increase adherence is an important
issue. In regard to the treatment of OCD, effective
treatment involves repeated exposure, with high rates of
anxiety or emotional discomfort, and with abandonment
of neutralization and safety behaviors (Foa & Kozak, 1985,
1986; Kozak & Foa, 1997). Although the psychoeduca-
tional component is a common initial intervention for
treatment of OCD, it may not address the patient's beliefs
about the nature and implications of anxious experience.
Converging theoretical approaches to the role of
emotional experience may help elucidate important
intervention strategies to address the problem of the
patient's negative response to emotional experience. First,
experiential models, such as those advanced by Hayes,
Linehan, and colleagues from the mindfulness, dialectical
behavioral, and acceptance approaches (Blackledge &
Hayes, 2001; Hayes, Jacobson, & Follette, 1994; Hayes,
Luoma, Bond, Masuda, & Lillis, 2006; Hayes, Strosahl, &
Wilson, 1999; Linehan, 1993), propose that individual
change often involves willingness to experience unplea-
sant thoughts, emotions, and sensations for the purpose
of personal growth and adjustment. Specifically, these
third wave approaches stress the importance of addres-
sing the patient's myths about emotions (emotions are
good/bad, overwhelming, or must be eliminated) and
focus on the present moment, mindful detachment,
observing emotion, and personification of emotion
through the use of metaphor and other experiential
and Gestalt techniques. The driving force here is that
emotional experience cannot be avoided if change is to
298
be achieved. A second approach, which is consistent with
the third-wave models, stresses the underlying emotional
beliefs or philosophies that the patient holds. This
modelemotional schema therapyproposes that indivi-
duals differ as to their beliefs that painful emotions can be
expressed, validated, accepted, and utilized for growth
and that emotions are temporary, not dangerous,
universal, comprehensible, complicated, and not shame-
ful (Leahy, 2002a,b, 2003). This model, which draws on
emotion-focused therapy (Greenberg, 2002) as well as
Gottman's model of emotion coaching and emotional
philosophies (Gottman, Katz, & Hooven, 1996), argues
that individuals will resist exposure and unpleasant
emotional experiences to the extent that they endorse
negative emotional schemas (e.g., Painful emotions are
to be avoided or Painful emotions are dangerous and
need to be controlled).
Moreover, the emotional schema model is a meta-
emotional model, consistent with other meta-cognitive
models of anxiety disorders (Wells, 2003, 2004). The
cognitive model of OCD stresses the role of interpreta-
tions that the patient gives of intrusive thoughts (or
urges). Thus, although intrusive thoughts are universal,
the OCD patient believes that he or she must attend to
and control the intrusive thoughts, that uncontrolled
thoughts will lead to negative consequences either in
action or dangerous outcomes, and that these thoughts
are personally significant (They say something about
me) (Purdon & Clark, 1994; Rachman, 1997; Salkovskis
& Kirk, 1997; Wells, 2000). It appears that acceptance,
mindfulness, emotional schema, and meta-cognitive
approaches would agree that the patient's interpretations
and strategies in handling unpleasant emotional and
cognitive phenomena will have an impact on the course of
anxiety disorders.
Cognitive models of thought suppression indicate that
attempts to control, suppress, or eliminate unwanted
intrusive thoughts may either increase the frequency or
strength of these intrusions, exacerbate OCD symptoma-
tology, and/or increase negative affect and appraisals
(Clark, 2003; Purdon, 2004; Purdon, Rowa, & Antony,
2005; Salkovskis & Campbell, 1994). Thought control
strategies may reaffirm for the patient that thoughts are
out of control, and failures to adequately suppress may
lead to demoralization and increased future failed
attempts to suppress, thereby maintaining the vicious
cycle of OCD obsession and neutralization.
These converging models were utilized in the treat-
ment of a chronically obsessive-compulsive patient who
had earlier dropped out of cognitive behavioral treatment
with the author. Ten years prior to the current course of
treatment, this patient had entered treatment with the
author for her obsessional preoccupations. At that earlier
time, the therapist attempted to employ traditional
Leahy
exposure with response prevention (ERP) for these
obsessions. Although the patient reported a great deal
of stress as a result of her OCD, she terminated treatment
after only six sessions and, during the prior treatment, she
completed almost no self-help homework. Thus, the
current course of treatment, utilizing newer conceptua-
lizations and strategies based on the previously discussed
models, afforded a special opportunity for the therapist to
compare his two treatments of the same patient.
Specifically, how would the course of treatment differ if
we included new meta-cognitive and meta-emotional
conceptualizations and strategies?
Case Example
The patient reentering therapy was a 38-year-old single
woman with a long history of obsessions about possible
mistakes and leaving things undone. Her compulsions
were primarily rechecking doors, windows, locks, and
projects at work. She reported that her earlier experience
in therapy with me had been useful in understanding
OCD, but she felt she had not been ready for exposure,
consequent anxiety, and risking any negative outcomes
and regrets if she were to forego her neutralization. She
had viewed self-help homework, involving ERP or delayed
response, as risking intolerable levels of anxiety that
would go out of control and overwhelm her. She indicated
that she had hoped she could do it on her own. She also
felt some ambivalence about needing someone for help.
Her OCD had spread to more areas of her life since
her initial treatment. This contributed to a sense of
demoralization as she reported feeling both depressed
and helpless about her OCD and angry at herself (and her
OCD). She reported shouting at herself to stop being so
irrational and indicated that her hope in her new phase
of therapy was to eliminate any of her urges or negative
thoughts.
General Plan of Treatment
The new form of therapy was intended to utilize the
advances in understanding of cognitive elements in OCD
(Frost & Steketee, 2002) as well as new approaches to
acceptance and emotional schemas. In particular, the
initial goal in treatment was to educate her about the fact
that individuals with OCD have specific dysfunctional
interpretations of intrusions and utilize problematic
thought-control strategies. In this psychoeducational
phase she was told that people with OCD view intrusions
as personally relevant, they think that they are responsible
for these intrusions, that intrusions are viewed as
dangerous, and that intrusions are viewed as pathological.
She was presented with the following (see Table 1).
In reviewing these evaluations she could quickly see a
number of things: first, she endorsed every one of these
beliefs; second, she was obviously not alone; and third, we
 Emotional Schemes and OCD Homework 299

Table 1 need certainty. We were able to use traditional cognitive

Interpretations of intrusive thoughts
therapy techniques to modify each of these beliefs. For
Maladaptive Example example, her belief that she needed certainty was
Interpretation of Your modified by examining all the things she was already
Obsessions doing without certainty (e.g., driving, eating in restaurants,
Overly important These thoughts are strange, weird. meeting new people, dating). Her belief that she needed
I shouldn't have these thoughts. immediate results was examined for costs (demoralization
They mean there is something
and frustration) versus benefits (the hope to completely
wrong with me. I am completely
different from other people because eliminate having problems). She was also able to identify a
of these thoughts. No one else has number of areas of life that were important to her where
these thoughts. she did not expect immediate results (e.g., work, friend-
Need to be controlled I need to get rid of these thoughts ships, investments). Her perfectionism was challenged by
immediately. If I don't, they will get
changing the goal from not having problems to having
worse and overwhelm me.
Perfectionistic I need to be perfect. I can't stand more solutions for the problems that arise.
the idea that things are not going She felt that many of these rational responses could be
exactly the right way. helpful to her in challenging her view that her thoughts and
Inflated responsibility Since I noticed that I have these urges were problematic. This then set the stage for
thoughts, I now have a
beginning with exposure with response delay. The initial
responsibility to take action. I
should get rid of them. I should target would be her compulsion to check windows and doors
make sure I do everything I can at least five times before leaving the apartment. The
think of doing to neutralize any bad response delay would be to check once and then wait at
consequences that could arise. least 10 minutes before checking again. Subsequent to
Overestimation of These thoughts are dangerous. If
response delay, she would try ERP. These behavioral
threat they are not controlled or
eliminated, then terrible things will experiments would then allow her to test out her beliefs
happen. Things will unravel. about intrusions, urges, emotional chaos, sense of respon-
Intolerance of I can't stand not knowing things for sibility, and the danger of giving up safety and certainty.
uncertainty sure. I need to eliminate any risks, Thus, the emotional schema model would be employed to
any uncertainty. Until I am
address her problem with self-help homework.
absolutely sure, I have to keep
neutralizing. I have to keep
Emotional Schema Strategies
watching out for any danger.
Identifying beliefs about urges. Response delay and
response prevention activated her beliefs about her
knew how she thinks. This rapid psychoeducation, based emotional urge to check. These beliefs included the
on cognitive models of OCD, enhanced her motivation to following: My anxiety will continue to rise, I could go
participate. She felt, You really understand how I think. crazy, I won't be able to function, and These urges and
This led to the next stage of preparation for ERP. We anxieties are a sign that I am entirely different from other
utilized Socratic dialogue to examine and test out each of people. She indicated her shame (I would be ashamed
these assumptions. Again, the final form of this could be for people to know about these feelings). She indicated
presented in a table of rational responses and techni- that she had to get rid of any anxiety or urge in order to
ques. Specifically, I provided her with the following function." Other beliefs included the following: Expo-
rational responses to each of her negative and dysfunc- sure will lead to increase of the urge, I cannot control
tional strategies (see Table 2). the urge, I need to eliminate the urge, I need to act on
it immediately, It will overwhelm me, Exposure will
Challenging Beliefs About Thoughts and Change make everything worse, and I won't be able to stop
Processes thinking about it.
The therapist and patient were able to identify a What is learned about urges with ERP? Her beliefs about
number of potentially dysfunctional interpretations and the nature of urges, thoughts, and emotions could be
strategies that the patient had for her intrusive thoughts tested out through ERP. When she was asked what had
and urges to neutralize. These included the following: My happened in the past when she had left her apartment
worries are realistic, I shouldn't be irresponsible, with excessive checking, she indicated, I don't recall ever
Something awful will happen if I don't check, I need doing that. Thus, she was instructed to gather the
to be ready (comfortable, not anxious) to change, I need evidence about these beliefs by finding out what
to focus on how bad I feel to control my feelings, I need happened 1 minute, 10 minutes, 1 hour, and 6 hours
immediate results, I need to get completely better, and I after ERP. At the next session, she reported the following:
300 Leahy

Table 2
Rational responses to beliefs about thoughts

Problem
You have odd thoughts and images
Motivation to change
You have negative evaluations of thoughts
and images:
They are threatening
They represent something awful about you
You believe that there is a high probability of
something bad happening
You believe that you need perfect solutions
You believe that you are responsible for
eliminating any threat
You think you need to suppress all thoughts
and images
You believe that you have no control
Engaging in compulsions
You continue with a compulsion until you
have a felt sense of completion
What to Do
Everyone has odd thoughts and images. This is normal. It means nothing about you.
Examine the costs of having OCDfeeling anxious, worried, out of control, ashamed,
impaired in work and relationships. Are you willing to tolerate some discomfort to
change this? How will your life be better if you do change this?
These odd thoughts and images don't mean anything about you or the future.
They are not threatening. People do not go crazy from these images or thoughts.
They do not represent anything about you as evil or out of control. Look at all the
evidence about how decent you are. Ironically, people who think that their
obsessions indicate lack of control or lack of decency are overly conscientious.
Thoughts do not predict that something bad will happen. Reality is not determined
by your thoughts.
There are no perfect solutions. You can aim for good enough or just as good as.
Inflated beliefs about responsibility place a burden on you. You are not responsible for
eliminating any possibility of a negative-you are only responsible for acting like a
reasonable person would act. How would a reasonablenon-OCD person act?
Suppression never worksthe thoughts come back. You can actually practice
repeating your worst obsessionsfor example, It's possible that I can
become contaminated or It's possible that I could overlook something. Repeat this
for 20 minutes each dayuntil you are bored.
You are basing this belief on the fact that you do not have total control over your
thoughts and images. It's impossibleand unnecessaryto control thoughts and
images. List all of the behaviors and outcomes that you have control of each day.
You will probably find out that you have a lot more control than you think.
Each time you practice a compulsion you reinforce your belief that you have to
eliminate obsessions and that compulsions are the only alternative for you. Rather
than practice compulsions you can delay engaging in a compulsion and you can
practice exposing yourself to the things that make you obsessand completely refrain
from the compulsion. Using Exposure and Response Prevention (ERP) can dramatically
reduce your obsessions and your motivation to use compulsions.
You have been engaging in your compulsion until you felt that things were either done
completely or that you felt a sense that you had done enough. If you do engage in a
compulsion, try to terminate it prior to a sense of completiondo things imperfectly.

Urges rise and then fall; Giving up control leads to
feeling more in control; I am not overwhelmed; Urges
can be toleratedtherefore, no need to control them.
Modifying shame and guilt about OCD. Her anxiety was
not only due to her OCD but also to anxiety and shame
about having OCD. She would get angry at herself and at
her intrusive thoughts, further exacerbating her OCD.
Her shame thoughts were the following: I shouldn't have
OCD; It's a sign of my failure; I'm a loser; No one
would want me if they knew I had this problem; and I
feel ashamed to be in therapy. These thoughts were
challenged with the following: OCD is an adaptation that
has been useful in evolution (protect against contamina-
tion, mistakes, loss); Everyone has wild' thoughts and
urges; Thoughts and feelings are not the same as
actions; There is nothing malicious in being neurotic.
Further, she was told that all of the anxiety disorders may
be viewed as adaptations to threats in a primitive
environment (Marks, 1987)including avoiding contam-
ination, assuring safety, and correcting mistakes. In fact,
many features of safety-seeking may also be hard-wired
(Szechtman & Woody, 2004). Normalizing the existence
of anxiety and indicating its protective value was helpful in
reducing shame and guilt.
Changing the relation to the urge. Her view was that the
urge controlled her and overwhelmed her. I asked her to
give me a visual image of what the urge would look like if it
were a real phenomenon outside of her. She pictured the
urge as a large black cloud enveloping her and pushing
her down. I asked her to imagine the urge as a small,
cartoon-like character, dressed in a circus outfit, sitting in
a chair, with his legs dangling over the side. I asked her to
imagine the urge as having a high-pitched squeaky voice.
Her mood lifted as she laughed at this image.
I asked her to talk to the urge. She began scolding the
urge, telling it she would squash it and eliminate it
completely. This was another example of her lack of
acceptance and overengagement with the urge. I sug-
gested that this would only add to the sense that the urge
had power over her. Rather than eliminate the urge, I
 Emotional Schemes and OCD Homework
recommended we find a space and placehere at the
party, here in her life. The urge would be there, but she
could simply be polite to it, much as she might be to an
unwelcome guest at a party. The goal would no longer be
to control or eliminate the urge, but simply notice it,
acknowledge its presence, give it the right to be alive
and walk out the door without checking. She asked,
What if I still have the urge later? I suggested that she
say, Hellohow is your day going? and then get on with
her activities. (Similar ideas are conveyed in Acceptance
and Commitment Therapy; see Hayes et al., 1999).
I provided her with a vignette that described an
urge that shows up at a therapist's office without an
appointment (Leahy, 2007). The dialogue in the story
is between a therapist and an urge that feels ignored.
The therapist is empathetic and curious about the
urge, who appears more and more concerned about
losing his place in the world. The therapist takes the
urge on a sight-seeing tour of New York City. The
patient greatly enjoyed the story and recognized that
the urge (or intrusion) could be viewed as a prankster
who was no longer getting any response. She indicated
that this personalization and externalization of the
urge was quite helpful in feeling less controlled by the
urge and less angry at herself and her intrusions.
This new way of relating to the urge was immensely
helpful to her: she could abandon her perfectionism and
her dysfunctional thought/urge control strategies.
Indeed, the more she could treat the urge as background
noise (rather than her central focus), the less controlling
the urge felt. This allowed her more ability to engage in
ERP.
Outcome
The patient gradually improved over the course of
treatment (which continued for 14 months on a biweekly
basis). Her checking at home was dramatically reduced
and for many behaviors, the checking was eliminated.
New stresses at work resulted in a setback that activated
her belief that nothing had changed. However, within
2 weeks she had been able to reverse the setback and then
examine her dichotomous thinking about improvement
versus perfection. We agreed that she would have to make
room in her life for intrusions and urgesand that an
occasional setback could be interpreted as a sign that she
had improved (You can't have a setback unless you have
improved). Moreover, the goal in therapy was not to
eliminate intrusions and urges, but rather to live with
them as guests and background noise.
We also examined her beliefs about intrusions, urges,
threat, responsibility, and uncertainty. Her new self-
instructional program included the following observa-
tions: intrusive thoughts are accepted, urges are
welcome, intrusions and urges are temporary, obser-
301
ving allows us to let go,' andfor ERPpractice makes
progress.
Including a meta-cognitive and meta-emotional
phase of therapy appeared to overcome many of the
barriers to treatment for this patient. Homework
compliance was significantly improved once the in-
session meetings were focused on her reasons for
resistancethat is, her problematic emotional and
meta-cognitive schemas about emotional arousal and
intrusive thoughts. It is suggested here that ERP allows
the patient not only to test beliefs about the danger in
the world if compulsions are eliminated, but also to test
out beliefs about the nature of intrusions, urges, and
emotion. Developing a new view of how emotions and
urges are processed can allow anxious patients to
engage in anxiety-provoking behavioral exposure,
thereby facilitating homework compliance.
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Address correspondence to Robert L. Leahy, American Institute for
Cognitive Therapy, 136 East 57th St., Suite 1101, New York, NY 10022;
e-mail: aict@aol.com.
Received: May 13, 2006
Accepted: August 5, 2006
Available online 27 June 2007