Today’s podcast will feature a live therapy session on
September 13, 2022 with Keren Shemesh, PhD, a 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
Part 1 of the Keren
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’s 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:
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 “degree of affection and caring” at 6 for “very satisfied,”
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:
As you can see, the upsetting event was her mother’s 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
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’s my first time alone with her.
She’s 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’m afraid I won’t be able to function. I just
cannot seem to enjoy my time with her. I feel fragile, but I’m
She’s 73, and the signs of aging are obvious now. She needs
more care, and it’s tough to see her aging.
Dad has always been super athletic, and he’s in great shape,
but she doesn’t exercise or take care of herself. She’s frustrated
about aging and is angry with us for not accepting her as she
I don’t want to seem unhappy. I’m overwhelmed and just feel
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.
My biggest problem is that I feel I cannot be me when I’m
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’m in the 5% of women who don’t have any
interest in having children. I’m 46 years old now, and I guess I
could see myself adopting, but having a family is a big job, and
I’ve never had the passion. So, I feel like I’m a disappointment to
them. But we never talk about it.
I sometimes feel invisible and unseen when I’m around them.
They’d be so much prouder of me if I had children they could brag
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’s 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’s goal was to get over her panic attacks, and we discussed
three possible treatment strategies with Keren:
The Hidden Emotion Technique: This technique would be based on
our hunch that Keren’s panic attacks are the direct result of the
many feelings she is consciously, and subconscious trying to hide
and sweep under the rug.
Dealing with the self-critical thoughts on the Daily Mood Log
she provided at the start of the session. LINK
Using Forced Empathy to help her see the world through her
mother’s 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
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’s podcast, you’ll 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.
I want to protect her because it may be hard and upsetting to
I’m not used to being vulnerable with my parents.
I don’t want to rock the boat or change the status quo.
I’m 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’t want to get “close.” Jill tried to finesse
around this by suggesting Keren might aim for a more “honest”
relationship instead of a “closer” relationship.
There are things about me that they’ve rejected, like the fact
that I don’t really want children. And I’m not so sure I want to
make myself vulnerable and get rejected again!
I’m afraid I’ll get swallowed up and enmeshed.
We asked Keren what kinds of feelings she was hiding from her
My feelings of nervousness and intense anxiety, and the intense
somatic symptoms, like the knot in my stomach.
I am scared for her future, since she is not in good health and
she’s not taking care of herself.
I have feelings of anger and resentment about the fact that I’m
not the kind of daughter they wanted.
I’m sad about her health and seeing her struggle.
I feel hurt when I think how I have failed them and let them
I sometimes feel like I don’t 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’s 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.
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’s 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’s had the
chance to do her “homework” 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
Here’s what she like “the least” about the session:
“Nothing. This has been a powerful experience.”
Here’s what she like “the best” about the session:
“This 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.”
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’s emails:
Here is what has happened so 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, I told her that I
love having her over and that it is special to 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 gasket..." 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 myself." I told her that I love her honesty and while
her criticism comes from a caring loving place the how and
when she says things sets tone.
This was a breakthrough because even 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. I have clients who say that they love
the 5 secrets, but like to call it the 3 secrets because
they find it effective enough 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 with my mother will further
trickle during her stay. Perhaps because there 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
I have not had any panic attacks since, but I don't
think they 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
Please describe what you specifically disliked about
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
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.
. . 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
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
About the Podcast
This podcast features David D. Burns MD, author of "Feeling Good, The New Mood Therapy," describing powerful new techniques to overcome depression and anxiety and develop greater joy and self-esteem. For therapists and the general public alike!