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 ControversiesAppelbaum PS, Uyehara LA, Elin MR, (Eds) New York: Oxford University Press

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 dog’s teeth pierced the boy’s skull,

inflicting injuries that required neurosurgery.

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.

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.

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 therapist’s office.

Internal DangerThe Next Session

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

External DangerIdentification with the Aggressor

The 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.

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, I’m going now.”

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 it’s feet.

• The boy had the turtle join him in the box chosen as a protective area.

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 grandparent’s house was the boy able to address his worst moments of the traumatic experience in therapy.

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.

Later SessionsApproaching the Central Action

• Step 2: Imagining ways to take revenge.• The boy pretended to pee on the

“dog’s” face.• The boy played at sneaking up on the

“dog,” jumping on him, and biting him all over.

Expressing His Worst Fear

• The boy decapitated dolls in the office.