Changelings:  Children and Psychic Trauma Vincenzo Di Nicola Maisonneuve-Rosemont Hospital University of Montreal
Children and Psychic Trauma <ul><li>To present  the psychic effects of traumatic experiences during childhood and adolesce...
 
The Binding of Isaac <ul><li>  Lay not thy hand upon the lad </li></ul><ul><li>— Genesis </li></ul><ul><li>Abraham command...
The Binding of Isaac <ul><li>Commentaries focus on Abraham </li></ul><ul><li>What about Isaac?  </li></ul><ul><li>What abo...
Eli á n Gonzalez <ul><li>Nov 1999: Eli á n, a 6 year old boy is taken by his mother on a small boat  </li></ul><ul><li>to ...
 
CHANGELINGS <ul><li>Children’s lives are altered by trauma </li></ul><ul><li>They are - in a modern twist on old folktales...
<ul><li>PSYCHIC TRAUMA </li></ul><ul><li>An exceptional experience in which  </li></ul><ul><li>powerful and dangerous stim...
<ul><li>CONCEPT OF TRAUMA  </li></ul><ul><li>(Sigmund Freud,1926) </li></ul><ul><li>Conscious ideas that overwhelm the ego...
<ul><li>TRAUMATIC STRESS  </li></ul><ul><li>(Anna Freud, 1969) </li></ul><ul><li>A shattering and devastating event that  ...
DEFINITIONS OF  THE CONCEPT OF TRAUMA <ul><li>Trauma as an event that is generally outside the range of usual human experi...
CRITIQUES OF  THE CONCEPT OF TRAUMA <ul><li>There has been a loose application of the term trauma (e.g., divorce or living...
TYPES OF TRAUMA Lenore Terr <ul><li>TYPE  I  TRAUMA </li></ul><ul><li>Description : Single event, dangerous, isolated, sud...
TYPES OF TRAUMA Judith Herman <ul><li>PTSD DSM-IV (1994):  </li></ul><ul><li>PTSD </li></ul><ul><li>(Terr’s TYPE I) </li><...
 
Genome   Development   Environment Trauma   Phenotype Social Support Ongoing Stress Coping Psychopathology     Physiopatho...
 
<ul><li>DEVELOPMENTAL MODEL </li></ul><ul><li>Age of the child </li></ul><ul><li>Characteristics of neighbourhood </li></u...
<ul><li>DEVELOPMENTAL FACTORS THAT INFLUENCE A CHILD’S REACTION </li></ul><ul><li>Appraisal of the threat </li></ul><ul><l...
<ul><li>EARLY ADVERSE EXPERIENCE MAY: </li></ul><ul><li>“ Derail” a child’s developmental trajectory </li></ul><ul><li>Com...
Reflection <ul><li>L’enfance est un  </li></ul><ul><li>couteau planté dans la  </li></ul><ul><li>gorge. On ne le retire  <...
Reflection <ul><li>Childhood is a knife </li></ul><ul><li>planted in your throat. </li></ul><ul><li>You don’t remove it  <...
<ul><li>EXPOSURE TO VIOLENCE: </li></ul><ul><li>Affects the way children think about  </li></ul><ul><li>themselves and the...
<ul><li>EFFECTS OF EXPOSURE TO VIOLENCE DEPEND ON: </li></ul><ul><li>Characteristics of the violence itself </li></ul><ul>...
<ul><li>MEANING OF VIOLENCE  </li></ul><ul><li>FOR THE CHILD INFLUENCED BY: </li></ul><ul><li>The nature of the threat and...
<ul><li>PROSPECTIVE FACTORS FOR CHILDREN EXPOSED TO VIOLENCE </li></ul><ul><li>A supportive person  </li></ul><ul><li>(par...
<ul><li>PROTECTIVE FACTORS </li></ul><ul><li>Safety in the environment </li></ul><ul><li>Caregivers who can mediate the da...
<ul><li>EFFECT ON CAREGIVERS </li></ul><ul><li>Caregiver’s ability to listen may be limited </li></ul><ul><li>Caregiver ma...
 
WHAT IS POSTTRAUMATIC  STRESS DISORDER? An extreme reaction to a life stressor  such as violence and trauma
<ul><li>POSTTRAUMATIC  </li></ul><ul><li>STRESS DISORDER </li></ul><ul><li>Re-experiencing </li></ul><ul><li>Numbing/Avoid...
<ul><li>RE-EXPERIENCING </li></ul><ul><li>Posttraumatic play </li></ul><ul><li>Re-enactment play </li></ul><ul><li>Nightma...
<ul><li>NUMBING/AVOIDANCE </li></ul><ul><li>Social withdrawal </li></ul><ul><li>Restricted range of affect </li></ul><ul><...
<ul><li>HYPER-AROUSAL </li></ul><ul><li>Irritability, emotional lability, tantrums </li></ul><ul><li>Night waking </li></u...
DIFFERENTIAL DIAGNOSIS <ul><li>PTSD versus Complex PTSD </li></ul><ul><li>Complex PTSD versus: </li></ul><ul><ul><ul><li>T...
DIFFERENTIAL DIAGNOSIS <ul><li>Complex PTSD versus: </li></ul><ul><ul><li>Attachment disorder </li></ul></ul><ul><ul><li>E...
COURSE OF PTSD <ul><li>PTSD is a chronic illness in 50% of adults  </li></ul><ul><li>In children, signs and symptoms do no...
 
 
 
 
 
 
<ul><li>DEVELOPMENTAL OUTCOMES  </li></ul><ul><li>WITH TRAUMA </li></ul><ul><li>Greater risk for children who have not yet...
Adverse Childhood Events  and Adult Depression Adverse Events Chapman et al, 2004
Adverse Childhood Events  and Adult Ischaemic Heart Disease Adverse Events Dong et al, 2004
Adverse Childhood Events and Adult Substance Abuse Self-Report: Alcoholism   Self-Report: Illicit Drug Use Dube et al, 200...
<ul><li>Percentages of PTSD diagnosis </li></ul><ul><li>Israeli Children  (Laor, 1997)   22-25% </li></ul><ul><li>Palestin...
Physiological Responses to Trauma <ul><li>Increased cortisol Levels </li></ul><ul><li>Higher baseline of stress and startl...
<ul><li>Conditions of early life affect the    </li></ul><ul><li>differentiation and function of billions of  </li></ul><u...
Relationships are the  “Active Ingredients&quot; of Early Experience <ul><li>Crucible of infant experiences are in caregiv...
What about stress and  adverse experiences?  What do we know about the neurobiology of these events?
Tolerable Stress <ul><li>Stress responses that could disrupt brain architecture, but are buffered by supportive relationsh...
Toxic Stress <ul><li>Strong and prolonged activation of the body’s stress management systems in the absence of the bufferi...
Stress Responses <ul><li>Effective response to stress involves shifting resources from everyday functioning toward meeting...
<ul><li>Trauma has well demonstrated effects on the developing brain in various species </li></ul><ul><li>Direct evidence ...
Emotional Stimulus PIT Cortisol Cortisol CRH Amygdala Hippocampus Adrenal Cortex Hypothalamus PVN LeDoux,  Synaptic Self H...
TREATMENT <ul><li>Ambulance arrives AFTER the  </li></ul><ul><li>traumatic experience </li></ul><ul><li>Principles of tria...
TREATMENT <ul><li>Before any possibility of treatment we must  establish a relationship  with traumatized children </li></...
TREATMENT <ul><li>Cognitive therapy (mentalization) </li></ul><ul><li>Critical Incident Stress Management (CISM) </li></ul...
<ul><li>HOW CLINICIANS CAN PREPARE THEMSELVES FOR TRAUMA WORK </li></ul><ul><li>Become well informed about trauma  </li></...
Trauma Studies Today  <ul><li>Phenomenology </li></ul><ul><li>Ethics </li></ul><ul><li>Empathy </li></ul>
Après la Coupe mondiale  - 2006   Photo : V Di Nicola
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Changelings: Children and Psychic Trauma - Pediatric Travel Club - University of Montreal - October 2009

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This presentation for a group of leading North American pediatricians presents the psychic effects of traumatic experiences during childhood and adolescence

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Changelings: Children and Psychic Trauma - Pediatric Travel Club - University of Montreal - October 2009

  1. 2. Changelings: Children and Psychic Trauma Vincenzo Di Nicola Maisonneuve-Rosemont Hospital University of Montreal
  2. 3. Children and Psychic Trauma <ul><li>To present the psychic effects of traumatic experiences during childhood and adolescence </li></ul>
  3. 5. The Binding of Isaac <ul><li> Lay not thy hand upon the lad </li></ul><ul><li>— Genesis </li></ul><ul><li>Abraham commanded to sacrifice his son </li></ul><ul><li>Angel intervenes </li></ul><ul><li>Isaac replaced by a ram </li></ul>
  4. 6. The Binding of Isaac <ul><li>Commentaries focus on Abraham </li></ul><ul><li>What about Isaac? </li></ul><ul><li>What about his mother Sarah? </li></ul>
  5. 7. Eli á n Gonzalez <ul><li>Nov 1999: Eli á n, a 6 year old boy is taken by his mother on a small boat </li></ul><ul><li>to flee Cuba </li></ul><ul><li>Eli á n’s mother and 10 others died in the crossing </li></ul><ul><li>Eli á n and two unrelated adults survived </li></ul>
  6. 9. CHANGELINGS <ul><li>Children’s lives are altered by trauma </li></ul><ul><li>They are - in a modern twist on old folktales - changelings </li></ul><ul><li>With greater or lesser severity, across more or fewer developmental domains, for decades or for months, trauma alters </li></ul>
  7. 10. <ul><li>PSYCHIC TRAUMA </li></ul><ul><li>An exceptional experience in which </li></ul><ul><li>powerful and dangerous stimuli </li></ul><ul><li>overwhelm the infant and young child’s </li></ul><ul><li>capacity to regulate his or her affective </li></ul><ul><li>state </li></ul>
  8. 11. <ul><li>CONCEPT OF TRAUMA </li></ul><ul><li>(Sigmund Freud,1926) </li></ul><ul><li>Conscious ideas that overwhelm the ego </li></ul><ul><li>Emergence of unacceptable impulses </li></ul><ul><li>An unbearable situation with overwhelming </li></ul><ul><li>affect </li></ul><ul><li>Feeling of traumatic helplessness (where </li></ul><ul><li>external and internal, real and instinctual </li></ul><ul><li>dangers converge) </li></ul>
  9. 12. <ul><li>TRAUMATIC STRESS </li></ul><ul><li>(Anna Freud, 1969) </li></ul><ul><li>A shattering and devastating event that </li></ul><ul><li>alters the course of future development </li></ul>
  10. 13. DEFINITIONS OF THE CONCEPT OF TRAUMA <ul><li>Trauma as an event that is generally outside the range of usual human experience </li></ul><ul><li>— DSM-III (1980) </li></ul><ul><li>An event involving actual or threatened death or serious injury or a threat to the physical integrity of self or others </li></ul><ul><li>— DSM-IV (1994) </li></ul>
  11. 14. CRITIQUES OF THE CONCEPT OF TRAUMA <ul><li>There has been a loose application of the term trauma (e.g., divorce or living with a parent who has an alcohol problem). </li></ul><ul><li>When dealing with preverbal children it is difficult to say if the event has been perceived as life threatening. For this reason some researchers try to draw connections between certain events and PTSD. </li></ul>
  12. 15. TYPES OF TRAUMA Lenore Terr <ul><li>TYPE I TRAUMA </li></ul><ul><li>Description : Single event, dangerous, isolated, sudden </li></ul><ul><li>Response : Recalled vividly, quicker recovery time, </li></ul><ul><li>better prognosis </li></ul><ul><li>Examples : Motor vehicle accident, witnessing homicide or suicide </li></ul><ul><li>TYPE II TRAUMA </li></ul><ul><li>Description : Multiple, chronic, repeated </li></ul><ul><li>Response : Memories are fuzzy, helplessness, dissociation, character changes, more long- standing problems </li></ul><ul><li>Examples : Institutional care, physical & sexual abuse , war, social violence </li></ul>
  13. 16. TYPES OF TRAUMA Judith Herman <ul><li>PTSD DSM-IV (1994): </li></ul><ul><li>PTSD </li></ul><ul><li>(Terr’s TYPE I) </li></ul><ul><li>Description : Single event, dangerous, sudden, isolated </li></ul><ul><li>Examples : Motor vehicle accident, witness to homicide or suicide </li></ul><ul><li>Complex PTSD </li></ul><ul><li>Herman (1992): C-PTSD </li></ul><ul><li>(Terr’S TYPE II) </li></ul><ul><li>Description : Multiple, chronic, repetitive </li></ul><ul><li>Examples : Physical, emotional or sexual abuse, conjugal violence, accumulation of stress in therapists and healers </li></ul>
  14. 18. Genome Development Environment Trauma Phenotype Social Support Ongoing Stress Coping Psychopathology Physiopathology (PTSD, Anxiety, Vulnerability (Immune, Metabolic, Depression, Cardiovascular) Substance Abuse) Long-Term (Mal) Adaptation
  15. 20. <ul><li>DEVELOPMENTAL MODEL </li></ul><ul><li>Age of the child </li></ul><ul><li>Characteristics of neighbourhood </li></ul><ul><li>Degree of community resources </li></ul><ul><li>Amount and quality of support </li></ul><ul><li>Experience of previous abuse </li></ul><ul><li>Proximity to violent event </li></ul><ul><li>Familiarity with victim or perpetrator </li></ul>
  16. 21. <ul><li>DEVELOPMENTAL FACTORS THAT INFLUENCE A CHILD’S REACTION </li></ul><ul><li>Appraisal of the threat </li></ul><ul><li>Intra-psychic meaning attributed to event </li></ul><ul><li>Emotional and cognitive means of coping </li></ul><ul><li>Capacity to tolerate strong affects </li></ul><ul><li>Ability to adjust to other’s life changes </li></ul><ul><li>Ability to deal with loss and grieving </li></ul>
  17. 22. <ul><li>EARLY ADVERSE EXPERIENCE MAY: </li></ul><ul><li>“ Derail” a child’s developmental trajectory </li></ul><ul><li>Compromise a child’s ability to regulate </li></ul><ul><li>affects </li></ul><ul><li>Compromise early and future relationship </li></ul><ul><li>problems </li></ul>
  18. 23. Reflection <ul><li>L’enfance est un </li></ul><ul><li>couteau planté dans la </li></ul><ul><li>gorge. On ne le retire </li></ul><ul><li>pas facilement. </li></ul><ul><li>Wajdi Mouawad </li></ul><ul><li>playwright </li></ul>
  19. 24. Reflection <ul><li>Childhood is a knife </li></ul><ul><li>planted in your throat. </li></ul><ul><li>You don’t remove it </li></ul><ul><li>easily. </li></ul><ul><li>Wajdi Mouawad </li></ul><ul><li>playwright </li></ul>
  20. 25. <ul><li>EXPOSURE TO VIOLENCE: </li></ul><ul><li>Affects the way children think about </li></ul><ul><li>themselves and the world around them </li></ul><ul><li>Affects to extent to which they view </li></ul><ul><li>relationships as trustworthy and </li></ul><ul><li>dependable </li></ul>
  21. 26. <ul><li>EFFECTS OF EXPOSURE TO VIOLENCE DEPEND ON: </li></ul><ul><li>Characteristics of the violence itself </li></ul><ul><li>Developmental phase of the child </li></ul><ul><li>Family and community context </li></ul><ul><li>Response to violence exposure by family, </li></ul><ul><li>school, community institutions </li></ul>
  22. 27. <ul><li>MEANING OF VIOLENCE </li></ul><ul><li>FOR THE CHILD INFLUENCED BY: </li></ul><ul><li>The nature of the threat and the damage </li></ul><ul><li>The child’s relationship with the victim or </li></ul><ul><li>perpetrator </li></ul><ul><li>Severity and duration of violence </li></ul><ul><li>Proximity of violence to child </li></ul>
  23. 28. <ul><li>PROSPECTIVE FACTORS FOR CHILDREN EXPOSED TO VIOLENCE </li></ul><ul><li>A supportive person </li></ul><ul><li>(parent, relative, friend, teacher) </li></ul><ul><li>A safe place </li></ul><ul><li>(home, safe haven in the neighbourhood) </li></ul><ul><li>Resources to find alternative ways of coping </li></ul><ul><li>(adaptive temperament, intelligence) </li></ul>
  24. 29. <ul><li>PROTECTIVE FACTORS </li></ul><ul><li>Safety in the environment </li></ul><ul><li>Caregivers who can mediate the dangerous </li></ul><ul><li>environment and help regulate experiences </li></ul><ul><li>Support systems in the environment </li></ul>
  25. 30. <ul><li>EFFECT ON CAREGIVERS </li></ul><ul><li>Caregiver’s ability to listen may be limited </li></ul><ul><li>Caregiver may not be able to hear child’s </li></ul><ul><li>distress </li></ul><ul><li>Caregiver may need to protect herself from </li></ul><ul><li>feelings of vulnerability and trauma </li></ul><ul><li>Parent may have more trouble tolerating </li></ul><ul><li>child’s resultant anxiety and aggression </li></ul>
  26. 32. WHAT IS POSTTRAUMATIC STRESS DISORDER? An extreme reaction to a life stressor such as violence and trauma
  27. 33. <ul><li>POSTTRAUMATIC </li></ul><ul><li>STRESS DISORDER </li></ul><ul><li>Re-experiencing </li></ul><ul><li>Numbing/Avoidance </li></ul><ul><li>Hyper-arousal </li></ul>
  28. 34. <ul><li>RE-EXPERIENCING </li></ul><ul><li>Posttraumatic play </li></ul><ul><li>Re-enactment play </li></ul><ul><li>Nightmares </li></ul><ul><li>Dissociative reactions </li></ul><ul><li>Distress at reminders </li></ul>
  29. 35. <ul><li>NUMBING/AVOIDANCE </li></ul><ul><li>Social withdrawal </li></ul><ul><li>Restricted range of affect </li></ul><ul><li>Loss of skills (regression) </li></ul><ul><li>Constriction of play </li></ul><ul><li>Avoidance </li></ul>
  30. 36. <ul><li>HYPER-AROUSAL </li></ul><ul><li>Irritability, emotional lability, tantrums </li></ul><ul><li>Night waking </li></ul><ul><li>Decreased concentration </li></ul><ul><li>Hyper-vigilance </li></ul><ul><li>Exaggerated startle response </li></ul>
  31. 37. DIFFERENTIAL DIAGNOSIS <ul><li>PTSD versus Complex PTSD </li></ul><ul><li>Complex PTSD versus: </li></ul><ul><ul><ul><li>Traumatic grief </li></ul></ul></ul><ul><ul><ul><li>Complicated grief </li></ul></ul></ul>
  32. 38. DIFFERENTIAL DIAGNOSIS <ul><li>Complex PTSD versus: </li></ul><ul><ul><li>Attachment disorder </li></ul></ul><ul><ul><li>Emergent personality disorders, especially Cluster B </li></ul></ul>
  33. 39. COURSE OF PTSD <ul><li>PTSD is a chronic illness in 50% of adults </li></ul><ul><li>In children, signs and symptoms do not decrease </li></ul><ul><li>In a longitudinal study (Laor, 1997) more severely stressed pre-school children decreased their symptoms after 30 months, but less stressed children did not. </li></ul><ul><li>A plausible explanation is the vulnerability of the rapidly developing and immature central nervous system (Schore, 2002). </li></ul>
  34. 46. <ul><li>DEVELOPMENTAL OUTCOMES </li></ul><ul><li>WITH TRAUMA </li></ul><ul><li>Greater risk for children who have not yet </li></ul><ul><li>attained optimal potential development </li></ul><ul><li>Knowing developmental status is crucial to </li></ul><ul><li>understanding the experience of infant and </li></ul><ul><li>childhood exposure to violence and trauma </li></ul>
  35. 47. Adverse Childhood Events and Adult Depression Adverse Events Chapman et al, 2004
  36. 48. Adverse Childhood Events and Adult Ischaemic Heart Disease Adverse Events Dong et al, 2004
  37. 49. Adverse Childhood Events and Adult Substance Abuse Self-Report: Alcoholism Self-Report: Illicit Drug Use Dube et al, 2002 Dube et al, 2005
  38. 50. <ul><li>Percentages of PTSD diagnosis </li></ul><ul><li>Israeli Children (Laor, 1997) 22-25% </li></ul><ul><li>Palestinian children from Gaza 41% </li></ul><ul><li> (Thabet, 1999) </li></ul><ul><li>Cambodian refugees children 48% </li></ul><ul><li>(Kinzie, 1996) </li></ul><ul><li>Iraqi children with destroyed shelter 78-88% </li></ul><ul><li>(Dyregrov, 2002) </li></ul><ul><li>Palestinian children exposed 54% severe </li></ul><ul><li>to military violence 33.5% moderate </li></ul><ul><li> (Quonta, 2003) 11% mild or </li></ul><ul><li> doubtful </li></ul>
  39. 51. Physiological Responses to Trauma <ul><li>Increased cortisol Levels </li></ul><ul><li>Higher baseline of stress and startle response </li></ul><ul><li>Tension and contraction of muscles </li></ul><ul><li>May affect the growth and pruning of neural connections </li></ul><ul><li>May contribute to dissociative states, memory, learning and cognitive abilities </li></ul>
  40. 52. <ul><li>Conditions of early life affect the </li></ul><ul><li>differentiation and function of billions of </li></ul><ul><li>neurons in the brain. </li></ul><ul><li>This early experience sets up the </li></ul><ul><li>pathways (connections) among the </li></ul><ul><li>different centers in the brain. </li></ul>The Biology of Brain Development
  41. 53. Relationships are the “Active Ingredients&quot; of Early Experience <ul><li>Crucible of infant experiences are in caregiving relationships </li></ul><ul><li>Nurturing and responsive relationships build healthy brain architecture that provides a strong foundation for learning, behavior and health. </li></ul><ul><li>When protective relationships are not provided, elevated levels of stress hormones disrupt brain architecture by impairing cell growth and interfering with the formation of healthy neural circuits. </li></ul>
  42. 54. What about stress and adverse experiences? What do we know about the neurobiology of these events?
  43. 55. Tolerable Stress <ul><li>Stress responses that could disrupt brain architecture, but are buffered by supportive relationships that facilitate adaptive coping. </li></ul><ul><li>Generally occurs within a time-limited period, which gives the brain an opportunity to recover from potentially damaging effects. </li></ul><ul><li>Precipitants include death or serious illness of a loved one, injury, or natural disaster. </li></ul>
  44. 56. Toxic Stress <ul><li>Strong and prolonged activation of the body’s stress management systems in the absence of the buffering protection of adult support. </li></ul><ul><li>Disrupts brain architecture and leads to stress management systems that respond at relatively lower thresholds, thereby increasing the risk of stress-related physical and mental illness. </li></ul><ul><li>Precipitants include extreme poverty, physical or emotional abuse, chronic neglect, severe maternal depression, substance abuse, or family violence. </li></ul>
  45. 57. Stress Responses <ul><li>Effective response to stress involves shifting resources from everyday functioning toward meeting a threat </li></ul><ul><li>This involves redirection of energy resources: </li></ul>behavioral physiological exploration hyper-vigilance physical growth breakdown of energy stores
  46. 58. <ul><li>Trauma has well demonstrated effects on the developing brain in various species </li></ul><ul><li>Direct evidence of damage to the human brain is limited, largely because of technological limitations in assessing brain functioning </li></ul><ul><li>Still, already it seems clear that the greater plasticity exists earlier, but prolonged traumatic exposure increases risks for long term harm </li></ul><ul><li>Proximal questions that need to be addressed include sensitive periods, differential effects in different domains, and remediable effects of early interventions </li></ul>
  47. 59. Emotional Stimulus PIT Cortisol Cortisol CRH Amygdala Hippocampus Adrenal Cortex Hypothalamus PVN LeDoux, Synaptic Self HPA Pathway Control ACTH
  48. 60. TREATMENT <ul><li>Ambulance arrives AFTER the </li></ul><ul><li>traumatic experience </li></ul><ul><li>Principles of triage, crisis intervention </li></ul><ul><li>Identify, remove child from traumatic situation </li></ul><ul><li>Secondary prevention: </li></ul><ul><li>— attenuate symptoms </li></ul><ul><li>— redirect the traumatic pathway </li></ul>
  49. 61. TREATMENT <ul><li>Before any possibility of treatment we must establish a relationship with traumatized children </li></ul><ul><li>We create a healing environment that includes our own self-care based on empathy in order to hear the trauma story (Richard Mollica, 2006) </li></ul><ul><li>We must honour interpersonal ethics in working with children and families (Di Nicola, in press): </li></ul><ul><li>- unfolding </li></ul><ul><li>- coherence </li></ul><ul><li>- dignity </li></ul><ul><li>The face-to-face encounter - Philosophy is first ethics (Emmanuel Levinas, 1998) </li></ul>
  50. 62. TREATMENT <ul><li>Cognitive therapy (mentalization) </li></ul><ul><li>Critical Incident Stress Management (CISM) </li></ul><ul><li>Eye Movement Desensitization and Reprocessing (EMDR) </li></ul><ul><li>Medications (treat symptoms) </li></ul><ul><li>Treatment of comorbidity (substance abuse) </li></ul><ul><li>Combined therapies </li></ul>
  51. 63. <ul><li>HOW CLINICIANS CAN PREPARE THEMSELVES FOR TRAUMA WORK </li></ul><ul><li>Become well informed about trauma </li></ul><ul><li>Engage in de-briefing about event </li></ul><ul><li>Engage in ongoing self-care </li></ul><ul><li>Frequently examine responses, resistances, </li></ul><ul><li>and tensions related to trauma materials </li></ul>
  52. 64. Trauma Studies Today <ul><li>Phenomenology </li></ul><ul><li>Ethics </li></ul><ul><li>Empathy </li></ul>
  53. 65. Après la Coupe mondiale - 2006 Photo : V Di Nicola

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