Treating Chronically Traumatized Children: Don' t Let Sleeping Dogs Lie!

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In the area of child and adolescent psychotherapy, it is well accepted that trauma processing is essential for the long-term prognosis of traumatized children. The AACAP practice parameters1 recommend that trauma-focused psychotherapy be first-line treatment for children with posttraumatic stress disorder (well before antidepressants, which, although commonly used, have little evidence to support their use in pediatric trauma). It is also apparent that trauma processing is no easy treatment for the child, the family, and the therapist. In adult studies, as many as 50% of patients may be nonresponders.2 Often, a child is unable to tolerate processing traumatic memories, or the child’s family is unable to tolerate the child’s response to treatment. While these issues are little discussed in research papers, the clinician treating children and adolescents faces them every day. Why is this, and what to do? That is where this compact (204 pages), practical book comes in. The author, Arianne Struik, is a psychologist who has treated traumatized children for over 20 years in the Netherlands and recently relocated to Australia, where she is Director of the Institute for Chronically Traumatized Children.

What is not so apparent is the idea that a child must be diligently prepared to undertake trauma processing and that this preparation can require as much, if not more, time and effort as the trauma processing itself. Therein lies the utility of this book for child and adolescent psychotherapists who treat trauma. Instead of focusing on the so-called “meat” of therapy (the trauma processing), this text shows the reader what needs to be in place so that a child can tolerate and benefit from the therapy itself. Struik endorses the importance of processing traumatic experiences and provides a strongly hopeful approach that she calls the “Sleeping Dogs method,” in reference to her overarching goal: “Don’ t let sleeping dogs lie.”

The Sleeping Dogs method specifically targets children who have experienced “chronic traumatic events” (defined as consistent traumatic experiences prior to age 8, typically chronic child abuse or neglect). The method’s name comes from the idea that, often, when trauma processing is unsuccessful, the child is labeled as “not ready,” with the implicit notion that therapists should wait until the child is ready. While the idea is that the child needs additional therapy to prepare for trauma processing, this does not always end up happening, and the trauma eventually recedes back into the patient’s mind. The memories lie dormant only to later wreak havoc on the patient’s life. The Sleeping Dogs method focuses on individual therapy with the child, tailored to the child’s particular trauma. It also emphasizes the importance of the parent/caretaker, including parent-child therapy and direct interventions (or referrals) for the parent.

In much the same way the Sleeping Dogs method takes its time to meticulously set the groundwork for trauma processing, so, too, does the author present the theoretical basis of her work. In chapter 1, the author uses basic neurobiology to frame how children think and interact with the world and, therefore, how they can connect with the principles outlined in the book. Her explanations of the impact of trauma and how therapy works consistently utilize this framework. Throughout the text, the author does an immaculate job of making sure the reader has a solid base of understanding that makes the entire book easy to digest.

Adapted from work with adults by Spierings (the Three Tests trauma-focused psychotherapy model) and Perry’s neurosequential model,3 the 6 tests that make up the Sleeping Dogs method are delineated. The series of checklists, or “tests,” that need to be completed in a specific order (as one “test” tends to build on the framework set by its predecessors) are systematically described. After outlining the method in chapters 2 and 3, the author then describes each test in detail in chapters 4-9. Five individual tests need to be passed (these include the Safety test, ie, the child needs to be currently safe physically and emotionally; the Daily Life test, ie, the child’s current life needs to be reasonably predictable and functional; and the Emotion Regulation test, ie, the child needs to be able to contain his or her emotions sufficiently). The sixth and final test is the Nutshell test—whether the child can describe an overview of the traumatic experiences while containing their emotional response (“staying within his window of tolerance”). This assessment not only functions as a barometer of a child’s progress through the tests, but also allows the therapist to see from the outset if a particular child is already able to begin trauma processing.

The author pulls in numerous case examples to illustrate how different children might become “stuck” on different tests and what can be done to overcome these obstacles. The author gives explicit practical advice on how to speak with both the child and the family through hypothetical, in-session conversations between the therapist, child, and parent. Each chapter ends with a checklist of what must occur in order to pass each particular test. Chapter 10 concludes the narrative by outlining integrated, practical applications for the method. Several worksheets for clinicians can be found in the appendices as well as online at the author’s website (www.ariannestruik.com/).

The author expertly weaves the 6 tests within a child-friendly analogy, introduced at the beginning of the book, that serves as a narrative framework to help communicate her approach. The analogy represents the child’s trauma as a dragon guarding a princess. Trauma processing is represented by having to fight this dragon in order to rescue the princess. However, without proper training, the “prince” (the child) will be defeated by the dragon. Therefore, the child must practice his or her skills behind a secure wall (ie, the 6 tests outlined by the author, with a secure holding environment representing the wall). Once the prince is fully trained, he is ready to try to defeat the dragon and rescue the princess. While the analogy is not perfect or the only one that could be used (and the author acknowledges this), it is quite uncanny how much easier the author’s thought process becomes to follow when referring back to this analogy.

The utility of this text cannot be underestimated. The Sleeping Dogs method targets a population of children that desperately needs to be able to engage with the therapist because of the severity of their trauma and the suffering that results. So, the first highlight of this book is that it dares to delve into a difficult area of therapy. The second highlight is that not only does the author have a solid approach to this population, but the text outlines this approach in such an organized way that it can be broadly adapted and applied by therapists.

This book will be a welcome addition to the shelves of any child and adolescent therapist who engages in trauma processing. It is particularly well suited for residents in child and adolescent psychiatry or interested general psychiatry residents who want an expert’s concise, on-the-ground approach to psychotherapy with children. Chock-full of detailed language explaining what to say to kids and how, the book is full of clinical guidance and wisdom. Although it is focused on traumatized children, it provides a coherent model of how to intervene with a much broader array of children. While the book appears to be written for beginning therapists, it is a great read for experienced clinicians as well, who will appreciate the author’s practical integration of cognitive-behavioral, psychodynamic, solution oriented, and narrative approaches to psychotherapy. This is a book by a real therapist working with real kids. The thoughtfulness applied to not only the methods but also the way in which the author’s message is delivered is a strength that will be appreciated by all who learn these tests and dare to challenge “sleeping dogs.”

References

1. Cohen JA, Bukstein O, Walter H, et al. Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry. 2010;49(4):414-430. PubMed

2. Schottenbauer MA, Glass CR, Arnkoff DB, et al. Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008;71(2):134-168. PubMed doi:10.1521/psyc.2008.71.2.134

3. MacKinnon L. The neurosequential model of therapeutics: an interview with Bruce Perry. Aust N Z J Fam Ther. 2012;33(3):210-218. doi:10.1017/aft.2012.26

Joshua Russell, MD

David L. Kaye, MD

[email protected]

Author affiliation: University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York.

Potential conflicts of interest: None reported.

J Clin Psychiatry 2015;76(12):e1599-e1600

dx.doi.org/10.4088/JCP.15bk10201

© Copyright 2015 Physicians Postgraduate Press, Inc.