Case Study


When Therapy Stalls

Scott Sells and Carol Anderson

This article first appeared in the November/December 2004 issue.

Case study by Scott Sells

If the current reign of brief therapies has taught us anything, it’s that effective treatment doesn’t necessarily require clients to spend years gaining “insight” into the buried origins of their symptoms. These days, many therapists are more likely to give clients specific behavioral directives aimed at finding practical, here-and-now solutions to their problems than spend time trying to uncover and heal long-hidden wounds from the past. But this kind of fast-track approach to therapy doesn’t always work–and in some tough cases, it fails abysmally. We give directives, but clients may not follow through. They “forget” to do their homework, don’t take our suggestions, are late for appointments, or fail to come at all. Meanwhile, their symptoms remain the same month after month. Frustrated, we’re all too inclined to blame them for the impasse. Therapy isn’t working, we tell ourselves, because these clients are “impossible,” “resistant,” “uncooperative,” or just plain “untreatable.

But, in fact, some of our most difficult clients–the ones who seem impervious to every therapeutic tool in our repertoire–may actually be telling us in the best way they can that, for all our efforts, we have somehow missed the boat. Their “resistance” may be a kind of language that we’re failing to translate, telling us that we’re not getting to the heart of what’s most important for them. Their resistance, their symptoms, and, most of all, their dysfunctional communication patterns, may represent what I call undercurrents flowing from deep, unhealed wounds from the past–like abandonment, abuse or violence, unacknowledged loss and grief, or role-confusion–which we’re not addressing at all.

Undercurrents are often easy to miss entirely. In fact, the symptoms we’re trying to “cure” with our pragmatic, problem-solving focus may be the only means these clients have devised for protecting themselves from the pain caused by these deep wounds. A client who’s suffered the wound of abandonment, for example, may begin drinking heavily or engaging in self-injury, which temporarily relieves the pain, but makes things worse in the long run. The family of this person may get angry and begin blaming her, leading her to feel even worse, drink more, and so on.

It’s an old, endlessly repeated story. But it’s kept alive by ignoring the fundamental wound that started the cycle in the first place and the undercurrents between the client and others that keep it festering. Even if we succeed in helping these clients relieve their symptoms–get the alcoholic to stop drinking, the anorexic teenager to stop starving herself, the anger-prone man to keep his top on–the change may only last until the next life crisis propels them back into their old ways.

Am I suggesting a revival of old-time, open-ended (often endless), insight-oriented psychodynamic therapy? Not at all. Brief treatment can produce insight, along with symptom relief, and promote deep healing in the process. But we have to be prepared to go beneath the surface dilemmas, to find what the client, and often his or her family, is unconsciously hiding beneath a blizzard of symptoms.

Through the years, I’ve found a way to integrate concepts from solution-focused, structural, narrative, and strategic therapies–buttressed by role-playing, theatrics, dance, and coaching–to tap into the underlying issues that drive my clients’ symptoms. For this kind of brief intervention to work effectively, it must be done with a certain amount of flash and daring–the therapist has to make up in pizzazz what he or she lacks in time.

This kind of work is difficult, demanding, and messy. It isn’t for the faint of heart, since it demands the courage to explore old wounds without retraumatizing clients. And as the following case demonstrates, it often requires us to go a little farther out on a limb than we might be comfortable.

Setting the Stage

I first saw Maria and her mother when I was a consultant at the Department of Juvenile Justice. Known as a “lifer” by other probation officers, Maria had been through every program the Juvenile Justice system had to offer–special community schools, long-term residential treatment, military-style boot camp, and numerous attempts at therapy. She’d undergone 12 separate court-ordered profiles. Her diagnoses included conduct disorder, attention-deficit disorder, intermittent explosive-anger disorder, major depression, bipolar disorder, intermittent anger disorder (belligerent and contemptuous of nearly everyone, she also frequently punched holes in walls), and even early-onset schizophrenia. Since she carried 250 pounds on her five-foot, four-inch frame, eating disorder had recently been added to the list.

Maria was on four different medications when I first saw her. She boasted that she’d already defeated at least six individual therapists (broadly hinting that I’d be next) and then explained her own “case” to me, showing a command of psychological jargon that would put to shame many Ph.D.s.

I’ve found that when an “impossible” and chronically stuck client like Maria walks through the door, undercurrents of an unhealed wound are in play. One clue is that traditional, straightforward, symptom-focused therapies, as well as medication interventions, have been tried multiple times with no effect, even after months or years of treatment. With these cases, I begin by asking the client what’s been tried and hasn’t worked, so I can create my own “stop doing” list and not just keep repeating the same old, same old.

I soon found out that, in spite of the number of therapists to which Maria had been exposed, she’d only received individual psychotherapy. Her family–particularly her brothers and father–had never been involved in treatment, which seemed a mistake to me and helped explain why previous therapy attempts had failed. But just because it seemed like a good idea to bring Maria’s father and brothers into the sessions didn’t mean they’d be willing to come–in fact, they adamantly didn’t want to come in. At this point, persistence and even a little risk-taking for the good of the therapeutic cause was in order.

Maria’s mother, Estela, told me that her husband and two sons went bowling every Friday night. With the permission of both Maria and her mother, I stopped by the bowling alley the very next Friday evening. Needless to say, Maria’s father, Jack, was surprised to see me. “All shrinks are the same,” he told me. “They only want your money, while never leaving their pretty, white offices.” I emphasized that I’d taken my Friday night off specially to come to see him because I thought Maria’s condition was critical. Her overeating was putting too much pressure on her fragile heart and she could have a stroke and die within a year or two. The only thing that hadn’t been tried, I told him, was total family involvement. I needed him and her brothers to help save her.

Jack was taken aback and clearly impressed that I’d made this effort. But even after this plea, he still refused to come in, saying he thought that nothing would help Maria and that she was “too far gone.” I then told him I’d like to cut a deal. I wasn’t a bowler, I said, but if I picked up his ball and bowled a strike, would he regard that as a sign that he was badly needed and must come to the next session. He laughed out loud, but said, “Sure. Go ahead.” Well, I didn’t come close to making a strike, but Jack was so moved by how hard I was trying to help his daughter that he promised to come in, and bring his sons with him.

Working in Stages

One common mistake made by brief therapists with tough clients like Maria is moving too fast. According to psychologist James Prochaska, a majority of clients begin therapy at what he called a “precontemplative” stage of readiness–they still think everyone else except them needs to change. Maria’s mother, father, and brothers were firmly entrenched in this precontemplative stage; they believed that Maria’s symptoms were entirely her problem and had nothing to do with them. If I moved too fast trying to get them to see that Maria’s symptoms derived from deep wounds originating in family issues, they’d all bolt. This would precipitate another treatment failure for Maria and reinforce once again her conviction that she was “untreatable” and “incurable.”

As I found out during this first session with the whole family, Maria had been something of a handful from birth–cranky, irritable, and demanding. But what really set the family on the wrong track was that she discovered very early, during her particularly “terrible twos,” that all she had to do to get her way was throw a major temper tantrum. Maria’s father at first argued that she ought to be disciplined, or at least not encouraged, when she flew into a rage at not getting her every wish gratified, but Estela–very conscious of her own neglectful parents–couldn’t bring herself to deny her child anything, and repeatedly gave in to her demands. After numerous fights about the subject, Jack just abdicated his parental authority and allowed Estela to go on reinforcing Maria’s increasingly overweening demand for power and instant gratification. Long before age 15, she’d come to dominate the household with her furious tirades, violent rages, and threats to run away if she was thwarted. Meanwhile, her father and brothers, repelled by her tyranny, withdrew from her, either ignoring her entirely or responding with bitter anger. This fed Maria’s sense of frustration and feeling that her family had abandoned her.

What I needed at this juncture was a quick success at resolving, even if temporarily, some of Maria’s behavioral symptoms too show her and her parents that therapy was working and earn me some “stripes” in their eyes. So, after an initial session with the whole family, I saw Jack and Estela alone and helped them learn to work as a team to establish a system of rules and consequences that would stop Maria’s violent reactions and get her to be more respectful to them. I engaged them in role-play after role-play to practice how to set limits with Maria and gain some authority over her under a variety of circumstances. This worked very well–by the third session, Maria had become much less prone to outbursts and was treating her parents better. Indeed, Jack and Estela remarked that they “hadn’t had this kind of peace in the family for years.”

The reason for this miraculous transformation, I believe, was the fact that Jack was finally involved in therapy and that Jack and Estela finally came together to work as a team. But even after all this hard work, on day-to-day issues, Maria still relapsed. I suspected there were undercurrents of deeper wounds beneath the surface. If the here and now is better and more hopeful, such wounds often heal by themselves. But if the wound is traumatic, as in Maria’s case, one must go deeper in therapy.

Eating and Grief

After careful questioning of the family, I discovered the wound. Maria’s acting out behavior escalated dramatically after her grandmother died two years previously. More important, I learned that she began to eat compulsively at the same time. As it turned out, the grandmother had actually raised Maria and her brothers while their parents had worked, and had been a deeply beloved figure in their lives. Unfortunately, when she died very suddenly, the children weren’t allowed to go to the funeral, or visit the grave site. Even talking about Grandma was discouraged–their parents told them they weren’t to bring up “sad things.” This inability to grieve created a deep wound in Maria’s heart and set in motion the birth of a dysfunctional undercurrent.

Unable to talk about her feelings, Maria conceived the notion that her grandma’s death must somehow be her fault. “If I’d been a better girl, maybe she’d still be alive,” she said sadly in the session. From that time, Maria made an unholy vow to protect her wound. The vow was that she’d never allow herself to get close to anybody, because that person might die and leave her. This inner vow became a self-fulfilling prophecy. In her effort to protect herself, she turned away from her family, antagonizing and alienating them, which made them angry and dismissive of her, thus increasing her own feelings of rejection. She assuaged these miseries by stuffing them–overeating became a kind of symbolic cork that kept her feelings temporarily tamped down.

Once I had a handle on the underlying issues, I could begin actively implementing what I call “undercurrent therapy,” which provides the link between brief and long-term psychotherapy. Once you understand the source of deep wounds from the past, you can work with the undercurrents in the present through brief interventions aimed at changing the communication patterns that maintain the symptoms. The point isn’t simply to improve communication patterns in general–as is often the point of brief therapy that doesn’t involve past issues–but to change those patterns that have emerged and hardened around specific, long-festering wounds.

Challenging the Rules

Undercurrents always manifest themselves in unspoken family rules. My first strategy was to break the power of these rules in Maria’s family by drawing on Michael White’s techniques for externalizing the symptom and normalizing it. In Maria’s case, I used a giant poster board to sketch an image of each undercurrent as a dysfunctional family rule.

Rule #1: “Maria was born ‘uncontrollable’ and ‘difficult,’ and nothing could be done except give her what she wanted to quiet her down, and otherwise leave her alone.” I drew a very big “symptom baby,” which I also labeled “drunk with power,” and showed her being overfed from a gigantic formula bottle. The picture was to graphically symbolize how the baby’s “symptoms”–her temper tantrums–were completely indulged and rewarded from the very beginning, until they grew bigger, finally becoming a full-fledged conduct disorder. I also drew as part of the same cartoon a picture of Mom and Dad disagreeing on what to do.

Throughout this drawing process, I paused continually to emphasize that what happened wasn’t anybody’s “fault”— it was the baby’s normal reaction to the wrong bottle formula given by a mother who meant only the best. Normalizing the symptoms is critical to avoiding blame, erasing the boundary between the “problem child” and the rest of the family, and rallying everyone to fight a common enemy–the symptom, not the symptom bearer. During this process, you could hear a pin drop as everybody in the family sat on the edge of their chairs, watching with wide eyes as this mini-drama about themselves unfolded on the poster board.

They were clearly eager for the next act. So, I obliged and drew a series of pictures of a baby continuing to get bigger and stronger from years 5 through 13. On a picture I labeled “Year 13,” I drew a tombstone with the words, “Our beloved grandmother dies.” I drew each family member, including Maria, with big gashes in their arms and in their hearts that, I explained, represented unhealed wounds. I drew a picture of the funeral without the kids present, another of a grave site that I explained went unvisited by family members, and a dinner scene that showed everybody in the family at dinner with their lips sown shut, representing the prohibition on talking, grieving or crying. I labeled this set of pictures Rule #2: “Never, ever mention Grandma or her death.”

At this point, the tears flowed freely from everybody in the room. After the family recovered their composure, I began working on Rule #3: “Maria is and always has been ‘the problem,’ and the rest of the family is fine.” I began drawing pictures illustrating the beginning of Maria’s eating disorder with the unhealed wound of the grandmother’s death. It was a connection that had never occurred to anybody in the family, including Maria, and they were all stunned. They all agreed that they’d never thought of Maria’s problem in this way, but that it made sense now.

At this point, Rule #3 began breaking up, as the family’s belief system changed. The eating disorder, which had been thought of as totally Maria’s problem, the family now realized was connected to the whole family’s inability to grieve properly. As Maria listened to her parents and brothers talk about this new realization, I could see her shoulders visibly relax, as if a large weight had been lifted from them.

I then reinforced this lesson about Rule #3 by drawing Maria’s stomach filled with food as a giant metaphorical cork that kept the entire family’s unresolved grief and loss bottled up inside her own body. I also drew other family members standing next to Maria’s stomach–Dad looking depressed, Mom looking anxious and sad, the kids with report cards full of Fs, signaling their failing school grades. Underneath this picture, I drew a bubble that said, “If we focus on Maria and her problems, we can distract ourselves from our own pain.”

Finally, I drew a picture of what a hopeful future would look like if the wounds were healed. In this picture, Maria’s family is visiting the grave site and sending good-bye notes attached to helium balloons up to Grandma. In the final picture, I drew a “‘Thank you, Maria’ Party,” with a big cake that read, “We, the family, want to thank you, Maria, for distracting us from our own pain. But now we’d like to fire you from this job. We love you, and you can now heal.”

The family burst into spontaneous applause and hurrays as I finished the cake inscription, and then laughter when Maria said she liked her job and didn’t want to be fired just yet. Her father replied that she could keep the job for a bit longer, but only until “good, old Steven Spielberg over there” helps us make a new family movie.

All this occurred in a two-hour session, and the family left exhausted by what they’d done, and excited and hopeful about the “coming attractions” I promised them.

Reestablishing Healthy Undercurrents

At this point in the therapy, another potential crisis looms in which many therapists can get lost. Having uncovered and opened the family wound, they may not be able to close it and teach the family how to shift from the old, dysfunctional communication patterns to healthier ones. In particular, this family needed to learn how to establish healthy undercurrents of communication around the issue of grief.

My first step in Maria’s case was to meet with the parents individually. We first reenacted the unhealthy undercurrents that the family had engaged in. I played the part of each parent while they took turns playing the kids. I role-modeled such dysfunctional rules as “Not talking about grandmother’s death.” I also reprised some older, dysfunctional patterns, including one I called “Doing nothing when Maria has temper tantrums and punches holes in the wall.” At first, I’d intentionally do it all wrong, so the parents would laugh and correct me on “the proper” way to mess up. After watching me use dysfunctional undercurrents, the parents switched roles and they intentionally did the undercurrents all wrong.

This “doing it the wrong way” had a beneficial paradoxical effect. The more they did the dysfunctional undercurrent dance badly, the less they wanted to continue to do it at all. In this way, the pump was primed for the parents to engage in the healthy undercurrent of openly grieving and working together as a team to consistently discipline Maria. I then role-modeled the correct way. The parents practiced these new, healthy undercurrents over and over again (25 times), until they felt confident. It took two, one-hour therapy sessions to accomplish this goal.

Knowing that I needed to have a high pizzazz quotient to help Maria’s family develop healthier undercurrents quickly, I brought the whole family together again. I had plenty of props available. I supplied actor’s make-up, which everyone applied to one another. I also had a director’s chair, a director’s hat, and a director’s blow horn, as well as poster-sized flash cards that read “Action” “Take Two,” and “Freeze.” I’d purchased a camcorder and told the family we were going to make two new movies. They’d be titled: “A Family That Grieves Together Stays Together” and “Consistent Discipline Prevents that Old ‘Drunk-with-Power’ Feeling.” The whole family began laughing and really began getting into the spirit of the thing, particularly the kids, as I assigned them different roles like “lighting director,” “flash card holder,” and “makeup artist.”

After this preparation, the kids and parents were ready to act out healthy undercurrents. The kids immediately got into the role-plays. I’d asked the parents to bring to the session some healthy food–fresh fruit, whole wheat crackers, etc.–and junk food. In one scene, Maria acted out overeating the junk food to protect the rest of the family, and the family gathered around, hugged her, removed the junk food, and started talking about happy memories of their grandmother. As they did this, they gave Maria the low-fat healthy food to eat. In another scene, they wrote good-bye cards to their grandmother.

I recorded all of this on my camcorder. The family took the video home and then proudly showed it to the rest of their extended family. They popped popcorn to watch the movie. Everyone both laughed and cried. I encouraged all this to reinforce and solidify new, healthy undercurrents.

Once these new undercurrent routines were in place and the unhealthy family rules destroyed, remarkable changes quickly occurred in the family. Maria immediately started losing weight and her remaining acting out quickly subsided. Old photos of the grandmother were brought out of boxes and framed. The family started visiting the grave site once a month and on holidays. The parents started to hold hands and date again. The brothers even started getting Cs. As the here-and-now undercurrents were altered, old wounds began to heal.

In sum, I believe Maria’s six previous therapists failed because they only focused on her superficial symptoms and didn’t see them as undercurrents resulting from unhealed past wounds. Furthermore, focusing on undercurrents–the dysfunctional communications stemming from the wounds–would have required them to involve family members and address the upside down family hierarchy, which they didn’t do. As is too often the case these days, they also relied overmuch on the “magic” of medications to solve problems that required a more hands-on therapeutic approach.

Overall, therapy with Maria and her family involved a total of only 12 sessions, with another three over the course of a year for tune-ups and maintenance. By the way, in case you’re wondering, the family did have that party for Maria, and they did fire her from the job of overeating. Deep healing can be brief and still be effective.

Case Commentary

By Carol Anderson

Scott Sells describes a case in which he creatively engages a family in treatment, presents it with a more positive and workable reality, shores up a weak and ineffective parental coalition, and begins working through issues of unresolved loss. His therapeutic interventions are grounded in a tapestry of some of the best family therapy models, skillfully applied and delivered in a thoughtful, entertaining, and poignant way that’s clearly acceptable to this family. While he doesn’t overtly address the need to respect those with worldviews other than our own (through culture, class, or ethnicity), it’s clear that this family felt respected and heard. He listened to family members, as Lily Tomlin once said, with an intensity most people save for talking.

Clearly, he deserves a medal for how he engaged the virtually absent father. There aren’t many places I’d less want to be than in a bowling alley on a Friday night reaching out to someone who doesn’t want therapy. I was so impressed that I almost immediately forgave him for blaming the mother. Most therapists are so interested in working with those who are ready and eager to accept what they have to offer, that they see a small percentage of those in need, and aren’t even conscious of the numbers who fall by the wayside. Jeannie Miranda’s research found it took an average of six phone calls from the therapist before they got low-income, minority mothers to attend one session. Effectively engaging clients is no small matter.

I’m disconcerted by only two issues. One is the implication that the discovery of the particular “undercurrents” in the case was THE truth. As I’ve gotten older, I find the search for single truths more and more problematic. The “unfinished mourning” explanation provided the family with one truth that gave them a better story to tell about themselves. It helped to unite the parents and move Maria out of a dysfunctional role. It’s an effective explanation, but there could have been others.

In fact, this particular reality actually has some inconsistencies as an explanation for the family’s troubles. Yes, Maria became worse when her grandmother died, but since birth she’d had problems sufficiently serious to cause significant parental discord. So what was happening back then? Whatever it was might have provided another truth. This wonderful explanation worked, but it’s no doubt one of many.

Finally, although I totally applaud this work, I’m left disturbed by the implication, perhaps unintended, that this intervention provided a happily-ever-after ending. I wonder if good outcomes are ever really quite so tidy? Even when clients exit the door, happy, grateful or just relieved, life and therapy is messy. But then I’m a morose Scandinavian, and as someone I know has said “What can you expect from someone who grew up in an Ingmar Bergman movie?”

Author’s Response

If I indicated to the reader that the discovery of undercurrents is “the truth,” I apologize. My premise is that it’s one of the most helpful ways that I know of to make a connection between a symptom and whatever’s fueling the symptom. The undercurrent is the root system beneath the soil of what’s seen by the naked “therapeutic eye.”

Yes, Maria did have behavioral problems before the wound of her grandmother’s death, and I acknowledged this. I used traditional structural-strategic methods to address this piece of her history. But it wasn’t enough. The wound of her grandmother’s death inflicted a different kind of damage than that inflicted by the history of inverted hierarchy and inconsistent parenting. It bruised the heart and created a different kind of trauma. Therefore, different methods were needed that required reframing, restorying, and the creation of new undercurrents or sequences of communication.

Many of my cases are not so tidy. They only seem tidy when, as in the game Jenga, I find the right piece to pull. Granted, there were other undercurrents that I didn’t know about or address, but I think one important undercurrent can heal a lot of others–like a pebble’s outward ripples when it’s thrown into a pond.


Scott Sells, Ph.D., clinical director of the Savannah Family Institute, is also an instructor in advanced clinical practice at Savannah State University and serves as a consultant to the Department of Juvenile Justice. He’s the author of Treating the Tough Adolescent and Parenting Your Out-of-Control Teenager. 

Carol Anderson, Ph.D., is administrator of the Western Psychiatric Institute and Clinic in Pittsburgh. She’s the author of  Flying Solo and Mastering Resistance, and the coeditor of Women in Families