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When the Hidden Emotion isn\'t Hidden!

Today\\u2019s podcast will feature a live therapy session on September 13, 2022 with Keren Shemesh, PhD, \\xa0a licensed clinical psychologist and certified TEAM-CBT therapist. The entire session was recorded and will be presented in two consecutive podcasts. The two co-therapists are Jill Levitt, PhD, a clinical psychologist, and Director of Clinical Training at the FeelingGoodInsititute.com.

Part 1 of the Keren session

I will summarize the work that Dr. Jill Levitt and I did with Keren according to the familiar sequence of a TEAM-CBT Session: T = Testing, E = Empathy, A = Assessment of Resistance (formerly Paradoxical Agenda Setting), and M = Methods, with a final round of T = end-of-session Testing.

In today\\u2019s podcast, we will include the T, E, and A. In Part 2, we will include M = Methods and the final T = Testing.

T = Testing

Just before the start of the session, Keren completed the Brief Mood Survey (BMS) which you can review at this link:

Keren\'s Pre-Session BMS

As you can see, her depression score was only 3 out of 20, indicating minimal to mild depression. There were no suicidal thoughts, and her anxiety score was 10 out of 20, indicating moderate anxiety. She was also moderately angry (7 out of 20) and her happiness score was 10 out of 20, indicating very little happiness. Her relationship satisfaction level with her mother was 19 out of 30, indicating lots of room for improvement. However, she rated \\u201cdegree of affection and caring\\u201d at 6 for \\u201cvery satisfied,\\u201d which is the highest rating on this important item.

We will ask her to take the BMS again at the end of the session, along with the Evaluation of Therapy Session, so we can see what the impact of the session was on her symptoms, as well as how empathic and helpful we were during the session.

These ratings will be important, because the perceptions of therapists can be way off base, but the perceptions of our patients will nearly always be spot-on.

Keren also brought a partially completed Daily Mood Log, which you can see at this link:

Keren\'s Daily Mood Log (DML) at the start of the session

As you can see, the upsetting event was her mother\\u2019s visit from Israel. She had moderately to severely elevated negative feelings in nine categories, along with 17 negative thoughts, along with her rather strong beliefs in all of them. Most of her thoughts were of a self-critical nature, with lots of Hidden Should Statements as well.

E = Empathy

At the start of our session, which took place in front of our Tuesday evening training group at Stanford, Keren described her struggles like this:

On Wednesday I woke up at 3 AM with panic attacks, one after another, and no way of getting back to sleep. I get somatic symptoms, I felt weak, nauseated, with no strength, almost paralyzed, and emotionally unstable.

This was four days after my mother arrived form Israel. In the last 20 years, she and my dad visited me only once, on my graduation. I always had to visit them in Israel every year and was frustrated they none came to visit me in the Bat Area.

On my last visit in May, I expressed my frustration about them not visiting me. They took it to heart and made plans to come for the Jewish high Holidays. My mom arrived first a few days ago and It\\u2019s my first time alone with her.

She\\u2019s a Jewish mom and she stresses me out. Of course, I was really excited when she first arrived, but after four days I feel overwhelmed. This is SO MUCH WORK!

I feel sad. I\\u2019m afraid I won\\u2019t be able to function. I just cannot seem to enjoy my time with her. I feel fragile, but I\\u2019m hiding it.

She\\u2019s 73, and the signs of aging are obvious now. She needs more care, and it\\u2019s tough to see her aging.

Dad has always been super athletic, and he\\u2019s in great shape, but she doesn\\u2019t exercise or take care of herself. She\\u2019s frustrated about aging and is angry with us for not accepting her as she is.

I don\\u2019t want to seem unhappy. I\\u2019m overwhelmed and just feel bad!

David and Jill empathized, and Jill emphasized how much her parents must love her, coming from such a great distance to be with her, but also acknowledged how hard it must be for them and for Keren to be living at such a great distance. Jill pointed out that one of the issues Keren may be struggling with is the belief that their time together should be fun and conflict-free, since the time is so precious.

Keren continued:

My biggest problem is that I feel I cannot be me when I\\u2019m around them . . . . They want me to be a different version of myself. . . . They want me to be a mother, and they want grandchildren. But I\\u2019m in the 5% of women who don\\u2019t have any interest in having children. I\\u2019m 46 years old now, and I guess I could see myself adopting, but having a family is a big job, and I\\u2019ve never had the passion. So, I feel like I\\u2019m a disappointment to them. But we never talk about it.

I sometimes feel invisible and unseen when I\\u2019m around them. They\\u2019d be so much prouder of me if I had children they could brag about.

Keren also shared her frustration and anger with her mom for not taking better care of her health. Since her mom has been in town, Keren has arranged all kinds of fun activities for them to do together, but Keren\\u2019s joy is dampened by the many unspoken feelings she is constantly trying to hide, for fear of conflict and upsetting her parents.

A = Assessment of Resistance

Keren gave us an A+ in Empathy, so we went on to the Assessment of Resistance phase of the session, where we set the Agenda. Keren\\u2019s goal was to get over her panic attacks, and we discussed three possible treatment strategies with Keren:

1. The Hidden Emotion Technique: This technique would be based on our hunch that Keren\\u2019s panic attacks are the direct result of the many feelings she is consciously, and subconscious trying to hide and sweep under the rug.

2. Dealing with the self-critical thoughts on the Daily Mood Log she provided at the start of the session. LINK

3. Using Forced Empathy to help her see the world through her mother\\u2019s eyes, as we did in a fairly recent podcast with Zeina, another member of our Tuesday training group who was in conflict with her mother.

Keren expressed considerable enthusiasm for options 2 and 3. I (David) pointed out that she appeared to be ignoring / avoiding the first option, and raised the question of whether that meant it might be the most productive, but scariest, of the three options.

Keren conceded that this rang true, and wanted to start out with learning to express her feelings more openly and directly, but in a respectful and loving way.

In next week\\u2019s podcast, you\\u2019ll find out what happened!

Part 2 of the Keren session: M = Methods

We began the Methods part of the session with a bit more Paradoxical Agenda Setting, and listed some really GOOD reasons NOT to open up more to her mother.

1. I want to protect her because it may be hard and upsetting to her.

2. I\\u2019m not used to being vulnerable with my parents.

3. I don\\u2019t want to rock the boat or change the status quo.

4. I\\u2019m not sure I want a closer relationship with my mother. NOTE: David and Jill were thinking that we often resist intimacy because we have negative pictures in our mind of what real closeness is. For example, if you think it means something yucky and upsetting, you obviously won\\u2019t want to get \\u201cclose.\\u201d Jill tried to finesse around this by suggesting Keren might aim for a more \\u201chonest\\u201d relationship instead of a \\u201ccloser\\u201d relationship.

5. There are things about me that they\\u2019ve rejected, like the fact that I don\\u2019t really want children. And I\\u2019m not so sure I want to make myself vulnerable and get rejected again!

6. I\\u2019m afraid I\\u2019ll get swallowed up and enmeshed.

We asked Keren what kinds of feelings she was hiding from her mother.

1. My feelings of nervousness and intense anxiety, and the intense somatic symptoms, like the knot in my stomach.

2. I am scared for her future, since she is not in good health and she\\u2019s not taking care of herself.

3. I have feelings of anger and resentment about the fact that I\\u2019m not the kind of daughter they wanted.

4. I\\u2019m sad about her health and seeing her struggle.

5. I feel hurt when I think how I have failed them and let them down.

6. I sometimes feel like I don\\u2019t really belong.

At this point, I became so absorbed in the session that I stopped taking notes, so you will have to listen carefully to the recording of the session which was fascinating.

I do recall, however, that we began working on communication, using the Five Secrets of Effective Communication (LINK), as well as tips on how to proceed, taking it one step at a time and not trying to do it all at once, and role playing practice.

Then we did some Externalization of Voices with the thoughts on Keren\\u2019s Daily Mood Log, using several strategies: Self-Defense, the Acceptance Paradox, and the CAT, or Counter-Attack Technique.

You can see the Daily Mood Log she completed after the session, based on the work we did in the session, at this LINK.

Keren\'s end-or-session Brief Mood Survey and Evaluation of Therapy Session

In addition, Keren and Jill will be with us to record the follow-up.

T = End-of-Session Testing

You can review Keren\\u2019s BMS and EOTS (Patient\\u2019s Evaluation of Therapy Session) at the end of the session at this LINK.

Keren\'s end-or-session Brief Mood Survey and Evaluation of Therapy Session

As you can see, her depression score fell to 1, indicating substantial improvement, while her suicidal thoughts and urges remained at 0. Her feelings of anxiety vanished, but her feelings of anger remained fairly elevated, falling from 7 to 4. We would not expect further improvement in this dimension until she\\u2019s had the chance to share more of her feelings with her mom.

Her feelings of happiness only increased from 10 to 13, again any further improvement would not be expected until she\\u2019s had the chance to do her \\u201chomework\\u201d following the session. However, her satisfaction with her relationship with her mom increased from 19 to 26 out of 30, which is substantial, while still leaving some room for improvement.

On the EOTs, you will see that our Empathy and Helpfulness scores were perfect, along with our scores on the Satisfaction with Session, Commitment to homework, unexpressed Negative Feelings, and honesty scales.

Here\\u2019s what she like \\u201cthe least\\u201d about the session:

\\u201cNothing. This has been a powerful experience.\\u201d

Here\\u2019s what she like \\u201cthe best\\u201d about the session:

\\u201cThis has been empowering. The hidden emotion is like a blind spot. I know it is there, but I cannot see it. I loved when David pointed to my avoidance, and I am glad we focused on the hidden emotion. Jill and David were able to see the depth in situation and I feel seen and understood.\\u201d

Follow-Up

We exchanged a number of emails following the session, and will also talk to Keren and Jill live on the podcast so you can catch up on what happened.

But here is an excerpt from one of Keren\\u2019s emails:

Here is what has happened\\xa0so far:

On Friday morning, she made some comments about my gray hair and that the fridge gasket was not properly clean. I got really annoyed, but did not say anything. To be honest, I was too angry to use the 5 secrets and needed time to cool off. About after half an hour later, on our way to the acupuncturist,\\xa0I told her that I love having her over and that it is special\\xa0to me that we spend time together. She thanked me for everything that I am doing for her on this trip. Then I added: "this morning, when I came to check on you, you commented on my hair and then you told me to clean the fridge\\xa0gasket..." I was going to follow up with 5 secrets, but before I was able to finish, she interrupted me and said "Gosh, I am so critical! I am sorry, I didn\'t mean it that way. I can see now why your sister gets upset with me. I can\'t believe\\xa0myself." I told her that I love her honesty and while her criticism\\xa0comes from a caring loving place the how and when she says\\xa0things sets tone.

This was a breakthrough because\\xa0even though I did not finish using the 5 secrets I got through to her and felt heard. It was encouraging for me to feel that I could be understood and accepted by her.\\xa0 I have\\xa0clients who say that they love the 5 secrets, but like to call it the 3 secrets because they\\xa0find it effective\\xa0enough to use only 3. (I still encouraged them to use all 5). I can see now what they mean, I did not finish my 5 secrets spiel and got some good results.

I believe that my conservation\\xa0with my mother will further trickle during her stay. Perhaps because\\xa0there is a lot to cover, or perhaps it\'s the way we communicate.

In either case, I feel good about having the talks that I previously dreaded.

I have\\xa0not had any panic attacks since, but I don\'t think\\xa0they have completely gone. I believe they will be there to remind me to address certain emotions that need addressing.. . .

I will keep you posted and may even send this to the group. Just need to think about it a bit longer.

Responses from the Tuesday Group
who observed our work with Keren

Here are just a few of the comments from the 35 therapists who observed the session. This is part of the feedback we get on the quality of our teaching at the end of every Tuesday training group.

Please describe what you specifically disliked about the training/

Nothing. The live work was fascinating to watch. David and Jill were masterful as always!

This was a truly moving and inspiring and helpful session. I can\'t think of anything I didn\'t like about it.

Nothing I disliked. I think I would have liked to see Keren do more deliberate practice with the 5 secrets with grading and more roleplaying. Conceptualization was a bit hard to follow.

Please describe what you specifically liked about the training.

Thank you for such an authentic, moving, beautiful session. And tour-de-force demonstration of TEAM therapy.

Observing David and Jill as co therapists in service of Keren was an amazing learning opportunity! The power between them was exponential and felt like they successfully addressed every angle. . .\\xa0 I had not considered using EOV and loved how effective that was in crushing Keren\'s thoughts. I also loved how Jill finessed gently guiding her to address Hidden Emotion, having clear conviction that this was where the "action" was.

I can understand what Keren said that she wants to be closer but does not want to be enmeshed.

I think that it helped us in our work with immigrants and those who live away from where they were born. The discussion about the desire to be a parent or not, was another aspect of the work that I really respected.

Excellent class tonight! Keren\'s gift to the class was priceless and David and Jill\'s masterful teaching was outstanding as always. Thank you!!!

I got to feel closer to her and to several group members through their sharing. David touched me with the notion that opening up to one\'s parents is an important gift that many of them don\'t get to receive.

Thanks for listening today!

Rhonda, Keren, Jill, and David