Case Study

Long-Distance Therapy

Helping an isolated family heal their trauma

Annie Wenger-Keller
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From the May/June 1994 issue

IN THE SPRING OF 1991, MY MOTHER, A MENNONITE AND a nurse-midwife, called me from rural Pennsylvania. “Can you give me some advice,” she asked, “for the parents of an Amish boy? Since you’re a therapist, you might know better than me what to suggest.”

I thought fast and hard. Pennsylvania is a long way from Iowa, and my instincts were to refer the family. But I knew that the family lived far from any town with a mental health center or private psychotherapist. Getting their son to see a therapist would have been a great burden to the family: the Amish rely almost solely on horse-drawn buggies for transportation, live modestly out of religious conviction and have no health insurance. So I told my mother to go on.

Manuel, a 7-year-old Amish boy, had been brought to a colleague of my mother’s, an Amish lay-midwife named Leah, six months after his family had been robbed. Since the robbery, he had begun to drink large quantities of water and wet his bed at night. Formerly quiet, he had become increasingly hyperactive. His eyes frequently jerked rapidly from side to side and he showed other nervous movements. Leah had treated him with reflexology for six months, but it hadn’t really helped. With the family’s permission, she had turned to my mother, who called me.

The robbery was one of a series against Amish farmers in the region that winter and spring. Three men, apparently operating on the mistaken belief that the Amish hoard large sums of money in their homes, had roamed the countryside at night, holding farmers up with knives and guns and threatening to kill them in front of their families. The Amish were inviting targets because they live in isolated areas, are nonviolent, have no telephones or electricity, and therefore could not quickly summon help.

In May, they struck Manuel Zimmerman’s family, dragging everyone out of bed. They beat Manuel’s father, broke doors and furniture, demanded money and fired a pistol through a door. In the chaos, Mrs. Zimmerman escaped and ran through the darkness over the fields to a neighbor, who called the police. As luck would have it, a Pennsylvania State Trooper was patroling nearby and arrested the men soon after they left the Zimmerman farm.

The robbers were tried, convicted and jailed. At first it seemed that the Zimmermans and their children 7-year-old Manuel, 10-year-old Lois and 5-year-old Anna Mae were unhurt, although they were understandably upset. With the help of their close-knit community, the family soon put the incident behind them. Or so it seemed.

Not everyone reacts to traumatic stress in the same way. In the six months following the robbery, Manuel’s symptoms began to appear. By harvest time, everyone knew something was wrong, and the Zimmermans brought Manuel to Leah. When that didn’t work, they gave Leah permission to consult with the world outside in this case, my non-Amish mother and me. This was where things stood when my mother called me. I told my mother that children like Manuel, who have experienced a trauma and are unable to talk about it, may express it in other ways. The necessary task was to find a way to help him externalize the trauma. I suggested that the whole family sit down together and begin to talk about what had happened the year before, and that the parents encourage the children to draw pictures about the event. I had also learned that there were still bullet holes in walls and doorframes and I suggested the family work together to make repairs. I explained that it was possible that the damage somehow continued to trigger flashbacks of the trauma for Manuel. Since he had never talked about what had happened, I suggested that they attempt to get him to play it out. Knowing that their religious faith was central to their way of life, I also suggested they ask the ministers in their district to come to the house and pray with them that their family and home would recover from the trauma. And, finally, I cautioned that doing these things might not lead to any improvements for a while, if at all, and that they might even see a worsening of Manuel’s symptoms, or more bizarre behavior, before any changes occurred. I encouraged them to be tolerant and accepting of whatever behavior he exhibited and, if he didn’t get better, to consider taking him to a counseling center.

Several months later, I asked my mother how things were going. I learned that the family had quickly carried out many of my instructions and had enlisted the help of Manuel’s siblings in getting him to draw and talk about his experience. The family had made all the final repairs on the home soon after my consultation. Mrs. Zimmerman, however, was the key to what seemed to be the turning point.

One afternoon, while she was drawing with the children at the kitchen table, Manuel drew something that resembled a door, but it was unclear to Mrs. Zimmerman what he was thinking about or referring to. She asked him what it meant, but he refused to talk about it, and she began guessing. She asked if it depicted when the robber kicked the door open. When he didn’t answer, she got up slowly and carefully. While watching him, she backed to the door and said, “Was it when he kicked it like this?” and then kicked the door closed behind her. At this point, Manuel began to laugh, and then ran into a bedroom, where he threw himself on a bed and rolled around, screaming with laughter. Mrs. Zimmerman stayed with him as he continued to laugh and scream for half an hour. Then he calmed considerably, and the family returned to a normal day. After this “Laughing Day,” most of Manuel’s symptoms gradually disappeared.

After I hung up the phone, I wondered what this seemingly elegant outcome had to teach me about the Zimmermans, the Amish and my own role as a therapist. A light touch my long distance call-had apparently been enough to set something in motion that allowed the Zimmermans to set themselves right. I wondered whether other families might do as well with such a light, long-distance intervention. Perhaps we therapists, with all our training, have a need to show how good we are, and to heavy-handedly and invasively improve the families we work with until they meet our ideas of health. For the Zimmermans, it was important to solve their problems with the minimum of expensive help from outside their culture. The family had taken my suggestions and become their own therapists.

Last January, curious about how Manuel was doing, I called my mother. She went out to the Zimmerman farm, and called me later with an update. The Zimmermans talked to her freely and said that involving Manuel through talking and drawing had been a great help to them all. Their children, they said, still occasionally talk about the robbery among themselves. They told my mother that they continue to take Manuel for reflexology treatments because from time to time they see his symptoms recur. When this happens, they guess he has had a flashback and talk directly to him about it at once.

When they bring it up, my mother said, Manuel will talk about his memories, but he doesn’t initiate these conversations. He’s still a rather quiet, nonverbal child, and not a complainer, his parents said.

They no longer see him as a child with serious problems, but one who needs extra attention and help occasionally. The family, and their community, have apparently resolved the trauma and incorporated it into the past.

Although I know that some therapists might think that Manuel did not get enough help since he still had occasional flashbacks, I’m satisfied, and the Zimmermans continue to function effectively and happily in a world without television or paid mental health professionals.



I WAS IMPRESSED WITH WENGER-Keller’s faith in the ability of Manuel’s family and the local minister to help him move past his problem. I also admired her skill in proposing a series of concrete tasks talking about the robbery, drawing pictures, repairing the damage to the house, praying that served to empower everyone involved. Wisely, she cautions the family that change may be slow and things may get worse before they get better. In this way, she strengthens the family to cope resourcefully with whatever happens and addresses the graduality that often characterizes recovery from trauma.

Some therapists who treat Post-Traumatic Stress Disorder (PTSD) might see the release of Manuel’s affect in response to his mother kicking the door as the turning point in this case. But it has been my experience with treating PTSD that a release of affect alone is insufficient. Here, I think Manuel’s mother helps him develop a new set of associations to the robbery her own unexpected actions, his screaming and laughter in response that serve as markers connecting him to the safety of the present instead of simply triggering a reliving of the trauma. Nor should the generalized expectations of relief suggested by the repair of the door, the opportunity to talk about the robbery and use of prayer be underestimated.

As a solution-focused therapist, I would proceed a little differently in a case like this. I would begin by asking the family what was different about the times when Manuel appeared least affected by the robbery and I would explore whether these exceptions to the problem could be intentionally replicated by either Manuel or other family members. I might also consider drawing a straight line, like a road, with one end signifying the robbery and the other signifying “all better,” comfortable feelings. I would ask what small thing Manuel thought would move him just a little bit down that road. I would then continue to ask him what other things would move him gradually a bit further and further until the “all better” point was reached. I would then encourage him to experiment with acting out his hunches regarding this road map as a means to resolution of the trauma.

Another possible intervention would be to suggest that Manuel draw a picture of the robbery, a second picture of things being all better, and a third picture depicting how the family got from the first to the second picture. However, given the outcome, neither of these interventions appeals to me as much as the actual therapist’s simple and respectful empowering of Manuel and his family.



JOHN WEAKLAND, OF THE MENTAL RE-search Institute once told me, “People get into trouble when they make a big deal of a little thing or don’t pay attention to a big deal.” Here, Manuel’s parents avoid speaking of a traumatic incident, probably out of their sincere belief that discussing it would make their small son feel worse. As a result, they inadvertently communicate the message, “This event was so terrible, we can’t even talk about it.” Under the veil of a protective family silence, strong emotions begin to fester, leading to physical symptoms and unusual behavior. By not paying attention to what was a big deal, they wind up creating more problems, not only for Manuel but for the entire family.

Giving the parents permission to discuss the event, perform some practical, hands-on repairs (I wondered why no one had done anything about the bullet holes), and pray with the ministers all sound like good ideas for a family that had been acting as if a terrifying event had not happened. But I became a little uncomfortable when the family was told to tolerate and accept “whatever behavior [Manuel] exhibited.” I’m not sure what the author means, but some degree of limit setting for a distressed child is always useful. ( “You can punch your Hulk Hogan doll, Johnny, but you can’t punch me.”) A child who has been through a stressful event a robbery, abuse, divorce has had his or her fundamental sense of security and trust disrupted. The last thing the kid needs is to feel is beyond the control of the caregivers who are supposed to provide that security.

The epiphany in this case occurs when Manuel’s mother kicks the door, which would have been a wonderful strategic intervention if it had been planned by the therapist. In this case, it clearly couldn’t have happened if the family hadn’t already taken the therapist’s suggestion and normalized the robbery experience. Apparently, Manuel improves, although some readers might be uncomfortable that Manuel continues to show symptoms. I agree with the author that no more “treatment” is necessary now. In my own practice, I usually ask families who seem to respond to brief interventions if I can call them at an agreed-upon future date to check in to see how they’re doing.

There have been many studies about which children are most at risk following a stressful event. While there are no absolute predictors, my guess is that one of the most important variables is the “goodness of fit” between the child and his or her family. Thus, it is possible that a quiet, nonverbal child in a family well-adapted to that particular temperament could cope quite well with a trauma. Nevertheless, I feel children like Manuel, who by temperament, language and cognitive development are far less likely to express their feelings and reactions, are more likely to develop physical and behavioral symptoms following a traumatic event. With any client experiencing the persistent effect of trauma, it’s always useful to begin by considering whether their difficulties have received too much or too little attention.

Annie Wenger-Keller, M.S.W., is codirector of the Awareness Center. Yvonne Dolan, MA., is a private psychotherapist and consultant in Denver, Colorado. Larry Diller, M.D., practices behavioral pediatrics and family therapy in Walnut Creek, California, and is an assistant clinical professor in pediatrics at the University of California, San Francisco.