Complexity of Trauma Dog Bite Clinical Case

1
Complexity of Trauma Dog Bite Clinical Case

• Alessia de Paola Gottlieb, M.D.
• Robert Pynoos, M.D.
• The National Child Traumatic Stress Network

Robert S. Pynoos, Alan M. Steinberg, Lisa
Aronson (1997) In Trauma and Memory Clinical
Legal Controversies Appelbaum PS, Uyehara LA,
Elin MR, (Eds) New York Oxford University Press
2
Case Background

• A 5-year-old boy was bit by an unrestrained dog.
• The mother was not initially present.
• Neighbors used metal garbage can lids to fend off
  the attacking dog.
• The dogs teeth pierced the boys skull,
  inflicting injuries that required neurosurgery.

3
Pre-conditions of SafetyThe First Session

• The boy insisted that his mother stay in the room
  during the therapy session.
• The boy tied a string to the door knob and jammed
  chairs against the door.

4
Rescue Moment through the Eyes of Prior Trauma
Experience of the ChildThe Second Session

• The boy played that he was in a toy ambulance,
  that he was alone, and gagging while the
  ambulance accelerated to a dangerous speed.

5
Checking and Reenactment Behavior in the Service
of ProtectionThe Third Session

• The boy permitted the mother to be out of the
  room but frequently checked on her.
• The boy required that the mother carry him high
  off the ground when moving from the hallway into
  the therapists office.

6
Internal DangerThe Next Session

• The boy accused the therapist of peeing and
  pooping in her pants.

7
External DangerIdentification with the
AggressorThe Next Session

• The boy played at attacking the therapist like a
  dog, growling and drooling all over her.
• He jumped at her repeatedly, trying to create a
  frightening sense of surprise.

8
Intervention Fantasies to Manage Autonomic
Arousal (to quiet his fears)

• The boy began to hide in the office.
• He let an imagined dog into the office while he
  hid in a box so that the dog could not find
  him.
• After the search, he instructed the dog to say,
  Nothing here to eat, Im going now.

9
Concerns over Injury and Repair

• The boy, no longer required to wear the
  protective helmet, chose a favorite stuffed
  animal turtle.
• The boy would launch the turtle of the shelf and
  have it land on its feet.
• The boy had the turtle join him in the box chosen
  as a protective area.

10
Fears of Recurrence and Protective Plans Sparked
by a New Puppy in the Home

• The boy became preoccupied with how to climb a
  ladder up to his slide to get away, if necessary,
  as the puppy grows up.
• Only after the puppy was moved to grandparents
  house was the boy able to address his worst
  moments of the traumatic experience in therapy.

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Later SessionsApproaching the Visciousness and
Helplessness of the Experience

• Step 1 Appeasing the dog or keeping him at bay
• The boy hid in the office while directing the
  therapist to act like a hungry, maniacal dog.
• The boy offered the dog food and the dog
  acted satiated, calm, and grateful.

12
Later SessionsApproaching the Central Action

• Step 2 Imagining ways to take revenge.
• The boy pretended to pee on the dogs face.
• The boy played at sneaking up on the dog,
  jumping on him, and biting him all over.

13
Expressing His Worst Fear

• The boy decapitated dolls in the office.