Sometimes if we can take immediate action there is a subsequent lessening of the emotional toll. The first thing to do is assure the physical safety of the individual.

"Immediate action is important in lessening the effects of traumatic stress," says Valley Trauma Center Executive Director, Patti Dengler. "Most people who are exposed to a traumatic, stressful event experience some of the symptoms of in the days and weeks following exposure. These symptoms generally decrease over time and eventually disappear. However, about 8% of men and 20% of women go on to develop post traumatic stress disorder, and roughly 30% of these individuals develop a chronic form that persists throughout their lifetimes. By working together as a community, we can promote healing in the wake of this shared disaster." (Valley Trauma Center 7116 Sophia Avenue Van Nuys, California 91406)

The second most important thing is to be as present as you can. Avoid platitudes and false reassurances. A wise minister once said, to a parent after the death of a child, "Did anyone tell you that God needed Maria more that you did?" When the parent nodded yes, the minister continued, "I know I could not worship a God that stole my child from me. Such a God would be cruel, and evil." Avoid saying something as simple as, "I know." You don't.

Show up, and don't try to make things better, as you probably can't. Just be there to listen if the person is ready to talk, to just sit nearby if they are not. Sometimes talking is the last thing a person wants to do. It can be reassuring to tell them you know what happened. Kaspar Kiepenheuer wrote of the importance of being present in dealing with children with cancer:

Initially, I suffered from my helplessness in dealing with these children when I believed I ought to do something; and from my speechlessness when I thought it necessary to say something. It was only later that I learned from the children themselves that what mattered was quite different: that is, to be there, to listen and follow them emotionally. This seemed to be a hard thing to do, particularly when there was nothing to be done or said. (Crossing the Bridge: A Jungian Approach to Adolescence, Translation by Karen Schneider. La Salle: Open Court. 1990, pp.143 -144.)

Do keep in mind that the majority of people will be fine after exposure to a trauma. People who have felt safe and secure prior to the event often have reserves of resiliency to draw upon. Generally, people will be 'shook up' and in shock, then feelings of disbelief, horror, grief and rage may appear. Initially, there may be a preserverative quality about the thought processes, wherein it is impossible to think about anything else. Many clients are reporting 'flashbacks' of the images they saw on television as they try to fall asleep. Sleep may be impacted, and nightmares may occur. Both children and adults may be regressed, with clingy behavior, bedwetting, and a need to stay literally 'in touch' with family and friends. For most children and adults these heightened feelings will diminish in time. We will always remember. The September 11 Terrorist bombing will be marked in the psyche of the nation as much as Pearl Harbor was, or Kennedy's assassination. We will always know where we were when we heard the news.

Colety, age 9

ACCORDING TO THE INTERNATIONAL CRITICAL INCIDENT STRESS FOUNDATION INC. YOU SHOULD CONSIDER THESE ACTIONS WITHIN THE FIRST 24 - 48 HOURS OF A TRAUMA:
* Engage in periods of appropriate physical exercise, alternated with relaxation will alleviate some of the physical reactions.
* Structure your time-keep busy.
* You're normal and having normal reactions -don't label yourself crazy.
* Talk to people -talk is the most healing medicine.
* Be aware of numbing the pain with overuse of drugs or alcohol, you don't need to complicate this with substance abuse problems.
* Reach out- people do care.
* Maintain as normal a schedule as possible.
* Spend time with others.
* Help your coworkers as much as possible by sharing feelings and checking out how they are doing.
* Give yourself permission to feel rotten and share your feelings with others.
* Keep a journal, write your way through those sleepless hours.
* Do things that feel good to you.
* Realize those around are under stress.
* Don't make big life changes.
* Do make as many daily decisions as possible which will give you a feeling of control over your life, i.e. if someone asks you what you want to eat- answer them even if you're not sure.
* Get plenty of rest.
* Reoccurring thoughts, dreams or flashbacks are normal - don't try to fight them-they'll decrease over time and become less painful.
* Eat well-balanced and regular meals (even if you don't feel like it.)
* Remember to breathe

Recommendations for Family and Friends of Those Most Severely Impacted by Post Traumatic Stress:
* Listen Carefully.
* Spend time with traumatized person.
* Offer your assistance and a listening ear if they have not asked for help.
* Reassure them that they are safe.
* Help them with everyday tasks like cleaning, cooking, caring for the family, minding children.
* Give them private time.
* Don't take anger personally.
* Don't tell anyone that they are "lucky it wasn't worse" -traumatized people are not consoled by those statements. Instead, tell them that you are sorry such an event has occurred and you want to understand and assist them.

PREPAREDNESS:
Be prepared. Studies show that being prepared actually helps to lessen PTSD and Trauma Symptoms and helps provide a sense of control and comfort.

* Be aware of surroundings
* Use Common Sense
* Keep emergency phone numbers handy
* Discuss safety techniques with family, friends, neighbors
* Develop and family disaster plan
* Discuss how to protect yourself in case of disaster
* Look at and learn about utility shutoffs.
* Delegate responsibilities
* Plan for special needs (infants, elderly)
* Instruct children how to call emergency numbers
* Re-read first aid training information.
* Draw a floor plan of your house with food, supplies, tools, batteries etcƒ located on it.
* Practice evacuation.
* Determine 2 or 3 remote "safe- reunion" spots
* Where do your children go if they are away from home and something happens?
* Identify an out of town contact or friend to coordinate reunion efforts.
* Share your plan
* Check your earthquake kit- do you have food, water, flashlights, radios, batteries, first aid supplies, fire extinguishers, waterproof matches, blankets, shoes , clothes, diapers, toilet paper, necessary over the counter and prescription medications, moneyƒ
* Stay calm
* Reach out to neighbors. Collaborate. Be kind to one another.

(http://www.icisf.org/)
 
 

FEMA Offers Advice On How To Talk To Children About Terrorist Attacks
Washington, D.C., September 12, 2001

The terrorist events in New York and Washington, D.C., have not spared the children of the
nation, said Joe M. Allbaugh, director of the Federal Emergency
Management Agency (FEMA). They have seen the terrible television
pictures and heard the adults in their lives discussing the tragic events. Yet many adults don't know how to talk to children about the
disaster, or don't know how to recognize that their children are
feeling distress.

"Children affected by disasters may suddenly act younger than they
are or may appear stoic - not crying or expressing concern," said
Holly Harrington, the FEMA for Kids manager. "Parents can help their children by talking to them, keeping them close and even
spoiling them for a little while. We also advise that children not be
overexposed to the news coverage of the terrorist events."

Talking to children about terrorism can be particularly problematic
since providing them with safety guidelines to protect themselves from terrorism is difficult. According to psychologists, questions about terrorism are teaching opportunities. Adults should answer
questions about terrorism by providing understandable information and realistic reassurance. And children don't need to be
overwhelmed with information, so less is better than more in terms of details.

http://www.fema.gov/nwz01/nwz01_99.htm

Pedro, age 10

Lance, age 9
 

After a Disaster: How to Help Child Victims Children who experience an initial traumatic event before they are 11 years old are three times more likely to develop psychological symptoms than those who experience their first trauma as a teenager or later. But children are able to cope better with a traumatic event if parents, friends, family, teachers and other adults support and help them with their experiences. Help should start as soon as possible after the event.  It's important to remember that some children may never show distress because they don't feel upset, while others may not give evidence of being upset for several weeks or even months. Other children may not show a change in behavior, but may still need your help.  Children may exhibit these behaviors after a disaster:  1.Be upset over the loss of a favorite toy, blanket, teddy bear or other times that adults might consider insignificant, but which are important to the child.  2.Change from being quiet, obedient and caring to loud, noisy and aggressive or may change from being outgoing to shy and afraid.  3.Develop nighttime fears. They may be afraid to sleep alone at night, with the light off, to sleep in their own room, or have nightmares or bad dreams.  4.Be afraid the event will reoccur.  5.Become easily upset, crying and whining.  6.Lose trust in adults. After all, their adults were not able to control the disaster.  7.Revert to younger behavior such as bed wetting and thumb sucking.  8.Not want parents out of their sight and refuse to go to school or childcare.  9.Feel guilty that they caused the disaster because of something they had said or done.  10.Become afraid of wind, rain or sudden loud noises.  11.Have symptoms of illness, such as headaches, vomiting or fever.  12.Worry about where they and their family will live.  Things Parents or Other Caring Adults Can Do  1.Talk with the children about how they are feeling and listen without judgment. Let them know they can have own feelings, which might be different than others. It's OK.  2.Let the children take their time to figure things out and to have their feelings. Don't rush them or pretend that they don't think or feel as they do.  3.Help them learn to use words that express their feelings, such as happy, sad, angry, mad and scared. Just be sure the words fit their feelings - not yours.  4.Assure fearful children that you will be there to take care of them. Reassure them many times.  5.Stay together as a family as much as possible.  6.Go back as soon as possible to former routines or develop new ones. Maintain a regular schedule for the children.  7.Reassure the children that the disaster was not their fault in any way.  8.Let them have some control, such as choosing what outfit to wear or what meal to have for dinner.  9.Help your children know that others love them and care about them by visiting, talking on the phone or writing to family members, friends and neighbors.  10.Encourage the children to give or send pictures they have drawn or things they have written.  11.Re-establish contact with extended family members.  12.Help your children learn to trust adults again by keeping promises, including children in planning routines and outings.  13.Help your children regain faith in the future by helping them develop plans for activities that will take place later - next week, next month.  14.Children cope better when they are healthy, so be sure your children get needed healthcare as soon as possible.  15.Make sure the children are getting balanced meals and eating enough food and getting enough rest.  16.Remember to take care of yourself so you can take care of your children.  17.Spend extra time with your children at bedtime. Read stories, rub their backs, listen to music, talk quietly about the day.  18.If you will be away for a time, tell them where you are going and make sure you return or call at the time you say you will.  19.Allow special privileges such as leaving the light on when they sleep for a period of time after the disaster.  20.Limit their exposure to additional trauma, including news reports.  21.Children should not be expected to be brave or tough, or to "not cry."  22.Don't be afraid to "spoil" children in this period after a disaster.  23.Don't give children more information than they can handle about the disaster.  24.Don't minimize the event.  25.Find ways to emphasize to the children that you love them.  26.Allow the children to grieve losses.  27.Develop positive anniversary activities to commemorate the event. These events may bring tears, but they are also a time to celebrate survival and the ability to get back to a normal life.  Activities for Children  1.Encourage the children to draw or paint pictures of how they feel about their experiences. Hang these at the child's level to be seen easily. 2.Write a story of the frightening event. You might start with: Once upon a time there was a terrible ___________ and it scared us all ____________. This is what happened: __________. Be sure to end with "And we are now safe."  3.Playing with playdough or clay is good for children to release tension and make symbolic creations.  4.Music is fun and valuable for children. Creating music with instruments or rhythm toys helps relieve stress and tension.  5.Provide the children with clothes, shoes, hats, etc. so they can play "dress up" and can pretend to be adults in charge of recovering from the disaster and "being in charge."  6.Make puppets with the children and put on a puppet show for family and friends, or help children put on a skit about what they experienced.  7.Read stories about disasters to and with children. This information is provided by Beryl Cheal, an educator with Disaster Training International P.O. Box 30144 Seattle, WA 98103 (206) 781-0701  (source: http://www.fema.gov/kids/tch_aft.htm)

VIOLENCE IN THE PRESCHOOL YEARS
Children growing up with violence are at risk for pathological development. According to Erikson's classical exposition of individual development, learning to trust is the infant's primary task during the first year of life. Trust provides the foundation for further development and forms the basis for self-confidence and self-esteem. The baby's ability to trust is dependent upon the family's ability to provide consistent care and to respond to the infant's need for love and stimulation. Caregiving is compromised when the infant's family lives in a community racked by violence and when the family fears for its safety. Parents may not give an infant proper care when their psychological energy is sapped by efforts to keep safe (Halpern, 1990). Routine tasks like going to work, shopping, and keeping clinic appointments take careful planning and extra effort. When infants reach toddlerhood they have an inner push to try newly gained skills, such as walking, jumping, and climbing. These skills are best practiced in parks and playgrounds, not in crowded apartments. But young children who live in communities racked by crime and menaced by gangs are often not permitted to be out-of-doors. Instead, they are confined to small quarters that hamper their activities, and that lead to restrictions imposed by parents and older family members (Scheinfeld, 1983). These restrictions, which are difficult for toddlers to understand and to obey, can lead in turn to disruptions in their relationships with the rest of the family.
During the preschool years, young children are ready to venture outside of the family in order to make new relationships and learn about other people (Spock, 1988). However, when they live in neighborhoods where dangers lurk outside, children may be prevented from going out to play or even from accompanying older children on errands. In addition, preschoolers may be in child care programs that are located in areas where violent acts occur frequently.
VIOLENCE: THE SCHOOL YEARS
Although the early years are critical in setting the stage for future development, the experiences of the school years are also important to children's healthy growth. During the school years, children develop the social and academic skills necessary to function as adults and citizens; violence at home or in the community takes a high toll.
* When children's energies are drained because they are defending themselves against outside dangers or warding off their own fears, they have difficulty learning in school (Craig, 1992). Children traumatized by violence can have distorted memories, and their cognitive functions can be compromised (Terr, 1983).
* Children who have been victimized by or who have seen others victimized by violence may have trouble learning to get along with others. The anger that is often instilled in such children is likely to be incorporated into their personality structures. Carrying an extra load of anger makes it difficult for them to control their behavior and increases their risk for
resorting to violent action.
* Children learn social skills by identifying with adults in their lives. Children cannot learn nonaggressive ways of interacting with others when their only models, including those in the media, use physical force to solve problems (Garbarino et al., 1992).
* To control their fears, children who live with violence may repress feelings. This defensive maneuver takes its toll in their immediate lives and can lead to further pathological development. It can interfere with their ability to relate to others in meaningful ways and to feel empathy. Individuals who cannot empathize with others' feelings are less likely to
curb their own aggression, and more likely to become insensitive to brutality in general. Knowing how some youths become emotionally bankrupt in this way helps us understand why they are so careless with their own lives and with the lives of others (Gilligan, 1991).
* Children who are traumatized by violence may have difficulty seeing themselves in future roles that are meaningful. The California school children who were kidnapped and held hostage in their bus were found to have limited views of their future lives and often anticipated disaster (Terr, 1983). Children who cannot see a decent future for themselves
have a hard time concentrating on present tasks such as learning in school and becoming socialized.
* Children need to feel that they can direct some part of their existence, but children who live with violence learn that they have little say in what happens to them. Beginning with the restrictions on autonomy when they are toddlers, this sense of helplessness continues as they reach school age. Not only do they encounter the constraints that all children do, but their freedom is restricted by an environment in which gangs and drug dealers control the streets.
* When children experience a trauma, a common reaction is to regress to an earlier stage when things were easier. This regression can be therapeutic by allowing the child to postpone having to face the feelings aroused by the traumatic event. It is a way of gaining psychological strength. However, when children face continual stress they are in
danger of remaining psychologically in an earlier stage of development.
INDIVIDUAL DIFFERENCES AND RESILIENCE
Not all children respond to difficult situations in the same way; there are many factors that influence coping abilities, including age, family reaction to stress, and temperament. Younger children are more likely to succumb to stress than school-age children or adolescents. Infants can be shielded from outside forces if their caregivers are psychologically
strong and available to the baby. Children who live in stable, supportive homes have a better chance of coping because they are surrounded by nurturing adults. If grown-ups are willing to listen to children's fears and provide appropriate outlets for them, children are better
able to contend with the difficulties in their lives. Children are more resilient if they are born with easy temperaments and are in good mental health. If they are lucky enough to have strong parents who can withstand the stresses of poverty and community violence, children also have a better chance of growing into happy and productive adults (Garmezy & Rutter, 1983).
ADAPTABILITY IN CHILDREN
Although what happens to them in the early years is very important, many children can overcome the hurts and fears of earlier times. For children living in an atmosphere of stress and violence, the ability to make relationships and get from others what they miss in their own families and communities is crucial to healthy development. The staff in schools, day care centers, and recreational programs can be resources to children and offer them
alternative perceptions of themselves, as well as teaching them skills for getting along in the world. With time, effort, and skill, caregivers can provide children with an opportunity to challenge the odds and turn their lives in a positive direction.

Bell, C. (1991). Traumatic Stress and Children in Danger. JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED 2(1): 175-188. Carnegie Corporation of New York. (1994). Saving Youth from Violence. CARNEGIE QUARTERLY 39(1, Winter): 2-5.
Craig, S.E. (1992). The Educational Needs of Children Living with Violence. PHI DELTA KAPPAN 74(1, Sep 10): 67-71. EJ 449 879.
Garbarino, J., N. Dubrow, K. Kostelny, and C. Pardo. (1992). CHILDREN IN DANGER: COPING WITH THE CONSEQUENCES OF COMMUNITY VIOLENCE. San Francisco: Jossey-Bass. ED 346 217. Not available from EDRS.
Garmezy, N. and M. Rutter, Eds. (1983). STRESS, COPING, AND DEVELOPMENT IN CHILDREN. New York: McGraw Hill.
Gilligan, J. (1991). Shame and Humiliation: The Emotions of Individual and Collective Violence. Paper presented at the Erikson Lectures, Harvard University, Cambridge, MA, May 23.
Halpern, R. (1990). Poverty and Early Childhood Parenting: Toward a Framework for Intervention. AMERICAN JOURNAL OF ORTHOPSYCHIATRY 60(1, Jan): 6-18.
Kotlowitz, A. (1991). THERE ARE NO CHILDREN HERE. New York: Doubleday.
Scheinfeld, D. (1983). Family Relationships and School Achievement among Boys in Lower-Income Urban Black Families. AMERICAN JOURNAL OF ORTHOPSYCHIATRY 53(1, Jan): 127-143.
Spock, B. (1988). DR. SPOCK ON PARENTING. NY: Simon & Schuster.
Terr, L. (1983). Chowchilla Revisited: The Effects of Psychic Trauma Four Years after a Schoolbus Kidnapping. AMERICAN JOURNAL OF PSYCHIATRY 140: 1543-1550.
Wallach, L. (1993). Helping Children Cope with Violence. YOUNG CHILDREN 48(4, May): 4-11. EJ 462 996. Zero To Three. (1992). CAN THEY HOPE TO FEEL SAFE AGAIN?:
THE IMPACT OF COMMUNITY VIOLENCE ON INFANTS, TODDLERS, THEIR PARENTS AND PRACTITIONERS. Arlington, VA: National Center for Clinical Infant Programs. ED 352 161.
Zinsmeister, K. (1990). Growing Up Scared. ATLANTIC MONTHLY 256(6, Jun): 49-66.
(source:Violence and Young Children's Development. ERIC Digest. http://www.ed.gov/databases/ERIC_Digests/ed369578.html)

Don't underestimate the children!!! They know what is going on. Every child I saw, even the ones as young as three years old, knew that something bad, and something very real had happened. The children I saw ranged from those who did not see anything on TV to those who were weaned on violent media images--every one of them knew what had happened. They could see the reactions in the adults around them, and, as one charming nine year old told me, "Of course I knew it was real. It was on all the channels." For many adults the initial reaction was one of unreality, or that, "It was like something out of a Tom Clancey novel." Yet we don't assume these adults can't differentiate violent movies from violent truth.

Even babies are sensing that something is wrong. In consultations regarding infants, every parent reported disturbances in the baby's behavior, sleep pattern, eating, etc. Further discussion revealed that the parents themselves were feeling very vulnerable; powerless to protect their new babies from evil. They were asking themselves what kind of world would their children inherit. Would they survive to adulthood? The babies were sensing a 'disturbance in the field'. As the parents were feeling reverberations in their psyches, the infants felt that and reacted.

Martin, age 9

3. After the Disaster

FEMA has on-line How to Help Children After a Disaster: A Guidebook for Teachers

http://www.fema.gov/kids/tch_help.htm
 

 

Signs and Symptoms of Critical Incident Stress

Tragedies, deaths, serious injuries, hostage situations, threatening situations -
these events are known as "Critical Incidents." People who respond to emergencies
encounter highly stressful events almost every day. Sometimes an event is so
traumatic or overwhelming that emergency responders may experience significant
stress reactions.
The Critical Incident Stress Debriefing (CISD) process is specifically designed to
prevent or mitigate the development of post-traumatic stress among emergency
services professionals.
Critical Incident Stress Management (CISM) represents an integrated "system" of
interventions which is designed to prevent and/or mitigate the adverse psychological
reactions that so often accompany emergency services, public safety, and disaster
response functions. CISM interventions are especially directed towards the mitigation
of post-traumatic stress reactions.

SIGNS AND SYMPTOMS OF CRITICAL INCIDENT STRESS table.

* Any of these symptoms may indicate the need for medical evaluation. When in doubt, contact a physician.

source:http://www.icisf.org/CIS.html

International Critical Incident Stress Foundation, Inc.
10176 Baltimore National Pike, Unit 201
Ellicott City, MD 21042

Handouts for Patients

The American Red Cross offers printable brochures on the following topics:

How Do I Deal With My Feelings?
Disasters create an abrupt change in reality. Following the attacks on the World Trade Center
and the Pentagon, for thousands and thousands of people, reality now includes the loss of
loved ones—spouses, significant others, children, other relatives, friends, and neighbors.

Helping Young Children Cope with Trauma
Disasters are upsetting to everyone involved. For a child, his or her view of the world as a safe
and predictable place is temporarily lost. Children become afraid that the event will happen
again and that they or their family will be injured or killed.

When Bad Things Happen
The recent terrorist attacks may have caused you to question a number of things you have
always believed about your own safety, and the safety of your family and friends.

Why Do I Feel Like This?
There are two types of disaster: natural disasters like the damage that results from a hurricane,
a tornado, floods, forest fires, volcanoes erupting and earthquakes, and disasters that result
from an intentional action of a human. When the disaster is human caused, our reactions are
more severe and become much more complicated and difficult to overcome.

These are available on-line as:
Printable Version in English...
Printable Version in Spanish...
Printable Version in Farsi...
Printable Version in Laotian...
Printable Version in Cambodian...
Printable Version in French...
Printable Version in Korean...
Printable Version in Tagalog...
Printable Version in Vietnamese...
Printable Version in Russian...
Printable Version in Chinese...
Printable Version in Arabic...
 

at http://www.redcross.org/services/disaster/keepsafe/attack.html

Acute Stress Disorder and Post-traumatic Stress Disorder 

While the focus of the clinical examples in this course is the Terrorist attack of September 11, Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD) can develop from a myriad of causes. People that have been sexually abused, raped, assaulted or physically abused are one category of people with stress disorders often seen in psychotherapy. Those who have had severe illness or medical interventions likewise may manifest PTSD. I have seen PTSD following infertility treatments, surgeries for breast cancer, in children with cancer, etc.

There are times when a whole community is at risk for ASD and PTSD, such as in the Bay Area following the Loma Prieta Earthquake, and in communities following catastrophic natural disasters, such as hurricanes, typhoons, mudslides, floods, volcanic eruptions., etc. War can cause PTSD, as can acts of aggression against an ethnic group or followers of a religion. According to an abstract of
The Terrorist Bombing in Oklahoma City by Sitterle and Gurwitch,

When compared to natural disasters, the magnitude and severity of
emotional difficulties are likely to be far greater in response to
terrorist incidents. This is especially true of terrorist incidents that
involve large numbers of fatalities, including the deaths of many
children, are the result of deliberate acts of violence, and involve a
protracted rescue and recovery effort. (source: http://dciswww.dartmouth.edu:50080/v3?db=105&page=q&qry=
Topic%20%22%20terrorist%22&dfn=2&srt=-1)

Perhaps we should look to Israel or Ireland to see how a population handles terrorism, as the examples in the US are fortunately few. The opportunity we have is healing at a national level, as the hurting was done to us all.

Initially, many people will manifest signs of Acute Stress Disorder. Immediately after a trauma, you can not use the diagnosis of Post-Traumatic Stress Disorder, as PTSD requires that "Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month." So a more appropriate diagnosis initially is that of 308.3 Acute Stress Disorder 

What is Post-Traumatic Stress Disorder?

A National Center for PTSD Fact Sheet
Post-Traumatic Stress Disorder, or PTSD, is a psychiatric disorder that
can occur following the experience or witnessing of life-threatening
events such as military combat, natural disasters, terrorist incidents,
serious accidents, or violent personal assaults like rape. People who
suffer from PTSD often relive the experience through nightmares and
flashbacks, have difficulty sleeping, and feel detached or estranged, and
these symptoms can be severe enough and last long enough to
significantly impair the person’s daily life.
PTSD is marked by clear biological changes as well as psychological
symptoms. PTSD is complicated by the fact that it frequently occurs in
conjunction with related disorders such as depression, substance abuse,
problems of memory and cognition, and other problems of physical and
mental health. The disorder is also associated with impairment of the
person’s ability to function in social or family life, including
occupational instability, marital problems and divorces, family discord,
and difficulties in parenting.

(source: http://www.ncptsd.org/facts/general/fs_what_is_ptsd.html)

 

309.81 Post-traumatic Stress Disorder  A. The person has been exposed to a traumatic event in which both of the following  were present:  (1) the person experienced, witnessed, or was confronted with an event or events  that involved actual or threatened death or serious injury, or a threat to the physical  integrity of self or others  (2) the person's response involved intense fear, helplessness, or horror.  Note: In children, this may be expressed instead by disorganized or agitated  behavior  B. The traumatic event is persistently re-experienced in one (or more) of the  following ways:  (1) recurrent and intrusive distressing recollections of the event,  including images, thoughts, or perceptions. Note: In young children, repetitive play  may occur in which themes or aspects of the trauma are expressed.  (2) recurrent distressing dreams of the event.  Note: In children, there may be frightening dreams without recognizable content.  (3) acting or feeling as if the traumatic event were recurring (includes a sense of  reliving the experience, illusions, hallucinations, and dissociative flashback episodes,  including those that occur on awakening or when intoxicated). Note: In young  children, trauma-specific reenactment may occur.  (4) intense psychological distress at exposure to internal or external cues that  symbolize or resemble an aspect of the traumatic event  (5) physiological reactivity on exposure to internal or external cues that symbolize  or resemble an aspect of the traumatic event  C. Persistent avoidance of stimuli associated with the trauma and numbing of  general responsiveness (not present before the trauma), as indicated by three (or  more) of the following:  (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma  (2) efforts to avoid activities, places, or people that arouse recollections of the  trauma  (3) inability to recall an important aspect of the trauma  (4) markedly diminished interest or participation in significant activities  (5) feeling of detachment or estrangement from others  (6) restricted range of affect (e.g., unable to have loving feelings)  (7) sense of a foreshortened future (e.g., does not expect to have a career, marriage,  children, or a normal life span)  D. Persistent symptoms of increased arousal (not present  before the trauma), as indicated by two (or more) of the  following:  (1) difficulty falling or staying asleep  (2) irritability or outbursts of anger  (3) difficulty concentrating  (4) hyper vigilance  (5) exaggerated startle response  E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1  month.  F. The disturbance causes clinically significant distress or impairment in social,  occupational, or other important areas of functioning.  Specify if:  Acute: if duration of symptoms is less than 3 months  Chronic: if duration of symptoms is 3 months or more  Specify if:  With Delayed Onset: if onset of symptoms is at least 6 months after the stressor American Psychiatric Association (1994). The diagnostic and statistical manual of mental disorders (4th Ed.). Washington, DC: American Psychiatric Press.

Excerpted from A MINI-COURSE FOR CLINICIANS AND TRAUMA WORKERS 
ON POSTTRAUMATIC NIGHTMARES
By Alan Siegel, Ph.D.

Common nightmare themes
1) falling
2) being chased or kidnaped (animal chasing are more common in children)
3) rejection, abandonment, betrayal, or humiliation
4) natural disasters: earthquakes, tidal waves, tornadoes, floods
5) technological disasters such as explosions, fire, nuclear war and chemical contamination, plane crashes.
6) violent attack and/or injury to self or others.
7) ghosts returning from the dead in a frightening form
8) cars or planes going out of control or crashing
9) being paralyzed or unable to respond an urgent or life threatening challenge
10) illnesses such as cancer, aids, paralysis
11) mortal threats from attackers, thieves, animals or creatures

How posttraumatic nightmares are different?
1) PTSD nightmares are more emotionally intrusive and anxiety-provoking.
2)blank or content-less nightmares may occur before the dreamer can tolerate any recall of the affects connected to the trauma.
3)they may be repetitive and unchanging nightmares with minimal adaptive response to threats arising within the dream.
4) PTSD nightmares insistently repeat some aspects of the trauma but with some elements changed or missing. E.g. A wildfire becomes a rageful animal or a murderer becomes a kidnapper who assaults someone else while the dreamer watches.
5)encapsulation: like a psychological abscess, intolerable emotions and conflicts linked to the trauma continue to infect the psyche but are walled off from consciousness, yet persistent in dreams.
6) fading: as a trauma is resolved, there is less fixation on the trauma as the major theme in dreams and trauma-related conflicts are mixed with current issues and challenges.
(source: http://www.asdreams.org/magazine/articles/seigel_nightmares.htm)

The Association for the Study of Dreams has established a
Nightmare Hot Line : They need volunteers to staff the line. Please go to:
http://www.asdreams.org/nightmare_hotline.htm to help.

What are the Traumatic Stress Effects of Terrorism?

A National Center for PTSD Fact Sheet

Information from past incidents of terrorism
Fortunately, there have been very few terrorist attacks in the United States. One implication, however, is that there is little known about how people are affected by terrorism. A consistent finding is that, while most individuals exhibit resilience over time, people most directly exposed to terrorist attacks are at a higher risk to develop PTSD. Problems with anxiety, depression, and substance use are also commonly reported. Predictors of PTSD include being closer to the attacks, being injured, or knowing someone who was killed or injured. Those who watch more media coverage are also at higher risk for PTSD and associated problems. Research from both domestic and international terroristic events sheds some light on the heightened risk for traumatic stress reactions in individuals exposed to these events:
Oklahoma City Bombing

• Almost half of survivors directly exposed to the blast reported developing problems with anxiety, depression, and alcohol and over a third reported posttraumatic stress disorder (PTSD). People who reported trying to avoid reminders of the bombing and who felt numb afterwards were more likely to develop PTSD and other disorders than people who did not avoid and who were able to experience a range of emotions. Predictors of PTSD, anxiety, and depression included more severe exposure, female gender, and having a psychiatric disorder before the bombing (North, Nixon, Shariat, Mallonee, McMillen, Spitzanagel, & Smith, 1999).
  
• Over a year after the bombing, Oklahomans reported increased rates of alcohol use, smoking, stress, and PTSD symptoms as compared to citizens of another metropolitan city (Smith, Christiansen, Vincent, & Hann, 1999).
  
• In a group of adults who sought mental health services, reactions of being nervous and being upset by how other people acted when the bombing occurred was predictive of PTSD (Tucker, Dickson, Pfefferbaum, McDonald, & Allen, 1997)
  
• Children who lost an immediate family member, friend, or relative were more likely to report immediate symptoms of PTSD than children who had not lost a loved one (Pfefferbaum et al, 1999).
  
• Two years after the bombing, 16% of children and adolescents who lived approximately 100 miles from Oklahoma City reported significant PTSD symptoms related to the event (Pfefferbaum et al, 2000). This is an important finding because these youth were not directly exposed to the trauma and were not related to killed or injured victims. PTSD symptomatology was higher in those with greater media exposure and those with indirect interpersonal exposure, such as having a friend who knew someone killed or injured (Pfefferbaum et al, 2000).
  Lockerbie Disaster: The Crash of Pan Am Flight 103
  
• Almost 3/4 of a group of people seeking psychological damages following the crash of Pan Am Flight 103 reported PTSD (Brooks & McKinlay, 1992). Over 50% continued to have PTSD 3 years after the crash (Scott, Brooks, & McKinlay, 1995).
  Subway Attack in Japan
  
• Common experiences of those who were exposed to poisonous gas in the subway included anxiety, fear, nightmares, insomnia, depression and fear of subways (DiGiovanni, 1999).

As indicated above, rates of distress and post-traumatic symptoms have been found to be high in individuals studied following terroristic events. Ultimately, reducing the risk of traumatic stress reactions is best accomplished by abolishing trauma in the first place by preventing war, terrorism, and other traumatic stressors. The next best approach is to foster resilience and bolster support so that individuals have better coping capacity prior to and during traumatic stress. The third best option is early detection and treatment of traumatized individuals to prevent a prolonged stress response.

(source: http://www.ncptsd.org/facts/disasters/fs_terrorism.html)

Following the research of Bessel A. van der Kolk and Rita Fisler, presented in Dissociation and the Fragmentary Nature of Traumatic memories: Overview and Exploratory Study and their citation of numerous authors on trauma [Janet (1889; van der Kolk & van der Hart, 1991), Kardiner (1941) and Terr (1993)] tends to validate anecdotal reports that memories of trauma live in the senses, and that words come later, if at all. These authors have observed that "trauma is organized in memory on sensori-motor and affective levels.... that 'memories' of the trauma tend to, at least initially, be predominantly experienced as fragments of the sensory components of the event: as visual images, olfactory, auditory, or kinesthetic sensations, or intense waves of feelings ." (source: http://www.trauma-pages.com/vanderk2.htm)

"While our understanding of the mind-body complex may be in its infancy from a scientific perspective, it is becoming increasingly clear that the neurochemistry of emotion is a key factor that must be considered if any therapeutic intervention is to have lasting effect. All memory is encoded at the cellular level." (Decoding Traumatic Memory Patterns At The Cellular Level by Thomas R. McClaskey, D.C., C.H.T., B.C.E.T.S.; The American Academy of Experts in Traumatic Stress at http://www.aaets.org/arts/art30.htm)

This is in alignment with what I have noticed in 25 years of being a therapist, treating a large number of children and adults with PTSD, including those impacted by the 1989 Loma Prieta Earthquake in San Francisco. I have found that the use of the elements (earth, air, fire and water) facilitates the healing of trauma embedded in the chakras or energy centers.

How then do we treat trauma?

It appears that words do not encompass the range of the terror, nor do they have the power to heal what is held in the cells and the senses. The Elemental Model for healing incorporates the energetic system of the Tibetan Buddhists with a technique that engages the cells and senses through the use of the elements. Rather than a 'new' model, this is actually an ancient system. The elements often tie into energetic centers in the body called chakras. The western medical system calls them "nerve plexuses". Each energy center is a 'sense center' and is correlated with an element. We will use the Tibetan five point system, rather than the seven chakra system of the Hindus.
 

For treatment of post-traumatic stress, focus is on the lower four chakras. Trauma often impacts very deeply on a victim's life. After the bodily bruises heal, it is necessary to assist the victim in healing the mind and spirit if we wish them to not only survive, but to thrive.
 

Element	Type of Trauma	Physical Reactions*	Psychological** Reactions	Symbols	Therapeutic Goal
Earth:Basic Trust, survival	Life threatening	Life threatening injuries, shock, dissociation	Major depression, suicidal, psychosis, self-destructive behavior	Primitive monsters, catastrophe, being devoured	"I am alive"
Water:Attachment	Attachment abuse	Chills, vomiting, GI disorders, anorexia/bulimia	Abandonment fears, feelings of betrayal, lack of trust	Flooding, bathrooms, sharks	"I can trust again"
Fire: Heart	Stranger Abuse/loss of a loved one	Hot flashes, rage reactions, heart palpitations	Rage, feelings of disempowerment	Fire, wars, weapons	"I can love again"
Air:Communication	Inability to communicate	Difficulty breathing, choked up	Disorientation	Flying, phones	"I can speak again"
Ether:Spirit	disorientation, spiritual crises	Headaches, seizures	Spiritual Crisis	Birds, angels, divinity	'I am"

* Please have these evaluated by a physician before assuming they are related to trauma.  All of the physical reactions listed, and those not listed, may or may not appear when treating PTSD.  This list is not comprehensive, but rather an attempt to correlate an energetic center with a recognizable physical reaction for the purposes of elucidating the model.

**Feelings of initial dissociation, shock, fear and overwhelm may accompany all types of trauma. Alcoholism and addiction may show up at any stage.

Although psychological conflicts do manifest in the body, please remember the scope of your practice and always refer to a physician for the monitoring of physical care. We are not stating that trauma causes illness, but rather that the chakras tend to correlate with specific organ systems.
 

It is useful in diagnosis and treatment to look at the type of trauma in relation to chakra system, to determine energetically where the libido is blocked. The chakras correlate to the endocrine system and various nerve plexuses (Tart, 1975), and have emotional and symbolic aspects as well. While there are five chakras (seven in the Hindu system), trauma and its healing usually are limited to the first four; first, the root or survival chakra; second, the sacral plexus or attachment chakra; third, the navel or power chakra and the heart chakra. (Eliade, 1973). The usefulness of the chakra system in a treatment model is that it combines the physical, the emotional, the spiritual and the symbolic, allowing the diagnosis and treatment to be multifaceted and accurate. Trauma in the first three chakras must be addressed before the client reaches the fourth chakra, throat. The plexus here is the pharyngeal region and the region it rules is communication. This is often why the victim must reenact the crime before he or she is able to talk about what happened.

According to Dr. Cecil Burney, a founding member of the International Society for Sandplay Therapy, in Tibet, every illness is viewed as a problem of the heart. Dr. Burney spoke of a Tibetan lama who expressed amazement about Western medicine and psychotherapy. The lama told Dr. Burney, after hearing about Western psychotherapy, "I do not understand this Western way of healing! It is very strangeƒyou have a person with a problem of the heart; a burning problem, and you have them talk about it. This is just adding air to fire." This refers to the Tibetan belief that all illnesses, whether physical or emotional, are matters of the heart. The element of the heart is fire, and if you talk about a trauma, a feeling or an illness, you are adding air to fire; fanning the flames. The lama told Dr. Burney, "And even worse is when people spiritualize their problems! I never trust people who appear too spiritual. They might be carrying a knife behind their backs." (Cecil Burney, personal communication, 1985. A version of this story appears in Shepherd, S.(1986)

People who have experienced trauma need to go down. An initial spiritual solution is often a bypass; anger smoldering under a fragile facade. Yet, to descend means looking at the shadow, getting angry, and grieving the losses we have experienced in life. Embarking on this journey takes courage.
 

The healing of a trauma would involve a descent, to point the triangle of the heart down through the water to the earth. When Dora Kalff taught about the Tibetan chakras, she would draw a diagram with a square at the base, with a circle on top of it. Then there was a triangle, a horizontal crescent, and at the very top was a flame. Frau Kalff told us that these represented the Tibetan chakras, and that each shape correlated to an element and a part of the body. The elements, in ascending order, represented are Earth, Water, Fire, Air and Ether (or Spirit). The lower elements are associated with matter, the soul, and the feminine. The upper elements of air and ether are connected with the spirit and the masculine. The heart in the center is the bridge between the two; uniting feminine and masculine; soul and spirit. (Dora Kalff, personal communication, 1978)

AIR: COMMUNICATION

FIRE: HEART

WATER: ATTACHMENT

EARTH: BASIC TRUST, SURVIVAL

Frau Kalff taught us of the G-Tumno Tibetan meditation of inner fire. In this meditation, the triangle of the heart points down. Burning issues quiet, as the fire slows. When the fire touches water, mist forms. The tears flow. When the fire connects to the element earth, the person may feel grounded, 'in touch'. At this moment, when the fire descends to the center of the earth, there is a natural arcing up of energy. The life force ascends, allowing the triangle of the heart to simultaneously point upward and downward. In this void arises the thousand petaled lotus of enlightenment. We also know this shape as the Star of David, or the "yantra".

The energetic model of therapy starts with a descent through the elements, and correlates each element with an energy center in the body (chakra) and with a developmental level. Knowing these relationships helps make sense of the very confusing world of the unconscious. Although this information may initially seem complex, we have seen that the elements provide a bridge between the client's psychological, physical and spiritual self, which is readily witnessed in the sandtray.

The descent from one level to the next is through transference tests. If a client does not feel safe, he or she will not go to the next level. The therapist needs to know these levels in him or herself, or the process will not evolve. This is the most common reason we see in our consultation when a therapist says "Joey only plays soldiers - all the time, he does the same tray over and over again". Another reason clients perseverate is that the therapist does not know what is happening and, therefore, fails to empathize. There is also the possibility that the family system is refusing to change, as evidenced by inconsistency in following through or not bringing the client to sessions regularly.

Seth, age 10, played army every week for seven weeks in a row, lighting candles.

This was using the element fire. Seth

was slated to go visit relatives out-of-state, and his anxiety was increasing. The therapist uncovered an incident of inappropriate sexual contact with an older boy. When this was discussed and interventions made with the family so this would not be repeated, Seth's sandtrays immediately changed. He dug down to the blue bottom of the tray and began to add water.

The model we present can be useful in assessing where the client is in his or her own process. People start at various points. When an idea comes into being it goes through the four elemental planes: air, fire, water, earth. A note of caution here: not every client needs to go through all the elements. Some will go just one or two stages, then ascend. Trust your clients -- they will know when it is time to stop. For the sake of the model we will start with the element ether or spirit.

(The description of the Self and the elements is from Amatruda and Simpson, Sandplay,The Sacred Healing: A Guide to Symbolic Process, Trance-Sand-Dance Press: Taos, 1997. Portions of the Elemental Model also appear in that book, as well as in the Journal of Sandplay Therapy, Archives of Sandplay Therapy, and Psyche & Soma)

(illus.credit: Adam McLean)

ETHER/SPIRIT

The fifth or crown chakra is located in the at the at the top of the head and center of the forehead and is sometimes called "the third eye". It is where we get a different picture of the world and is associated with the objectivity of air. When we feel someone is trying to force an idea or perspective on us, it will often produce a tension headache.

It is pure spirit: our direct connection to God or higher power. It often is represented by a crown or halo. It is the sensation of a tingling from the top of your head to the bottom of your toes that assures you that you have just had a moment of truth and insight. It is rarely blocked except in the cases where an individual has chosen to give up their personal authority to another dominating human being such as a cult leader.

 
 
AIR
 

Air is the element of the fourth chakra, which is located in the throat, and radiates to the ears. It is where we hear others and our inner voice, where we communicate. When we get "choked up" we often need to let our feelings out and give them voice.

Air enters after an idea has taken form and we are able to stand back and objectively witness it. Air is Logos, the divine, objective principles of universal order. It governs thinking, intellect, objectivity, communication and often change. The wind is the spirit of the unconscious. In the Medicine Wheel it is the direction of the East, the place of our ancestors, where new life begins, and often where therapy begins. The color of the East is yellow, and its animal is the eagle, for clear vision and for the ability to soar and speak to the spirits. The signs of the Zodiac are Gemini (communication), Libra (relationship and balance) and Aquarius (universal brotherhood). The tarot suit is swords or ñs-wordsî which describe how we use thoughts and words to direct our energy and shape our world.

This is clearly an appropriate place for therapy to start. In feelings it is both detachment and anxiety. In sound it is often the music that makes you feel "spaced out", like harps or some New Age music. It is associated with the 4th chakra of communication and perception. In trays it turns up as salvation and escape - feathers, balloons, sailboats, birds in flight, angels, flutes, harps, saxophones, songs, books, sandstorms, hurricanes, tornadoes, tilted figures. It appears white or shiny. It is the "breath of life", called "ba" in Egypt. It "gives voice". When there are people, animals or monsters talking, singing or yelling, there is air. When it is unbalanced it becomes rigid, pedantic, sterile, over intellectualized. It often signals the process of change occurring. It will add fuel to the fire and move loose earth, cause whitecaps on the water. Air signals life; newborns cry.

Developmentally, intimacy vs. isolation probably bridges both air and water. In adolescence and young adulthood we can reach out and touch others with ourselves. Do we take the chance to converse and share healing? Later are we able to call on our "angels" for help? Are we open to the messenger doves flying in? In disease as isolating as addiction it is often the communication and fellowship shared with AA and other 12 step programs that provide the structure and support for recovery and healing.
 

FIRE

Carrie was wounded in the third, or fire chakra. She came to therapy at age 11, and had been molested by an older boy when she was 7 years old. Her reaction was to deny that it had happened, alternating with periods of severe stomach aches, ruminations about things that disturbed her (i.e., the Children's Crusades in the Middle Ages), as well as outbursts of rage. The chakra impaired was the third, solar plexus and the heart.

The emotional issues of the third chakra are power and love. This girl's growing sense of herself was constrained by the guilt subsequent to the molest. The element associated with this chakra is fire, and indeed she repeatedly lit candles in the sandplay. After she lit the fires, then she could talk about what had happened. During an earlier period of play therapy (with another therapist who did not use sandplay) Carrie had not been able to reach the depths that she descended to in sandplay, nor had she lit fires. In the first therapy, she told only partially of the molest, and her symptoms were only partially alleviated. Because the abuse was not by someone she had trusted, and because her life was not threatened, the obstruction centered around the third chakra. If her history had included previous abuse by a parent, the incident would have impacted the second chakra and possibly the first as well.

Fire in the power chakra "represents the experience of the divine as well as our inner passions". Psychologically, after our baptism into the passions hidden in the deep waters of the unconscious (the second chakra), the third chakra is the experience of emotions flaming up -- "after baptism comes temptation and hell" (Coward, 1985).

Survivors of abuse often have many physical illnesses or injuries during the process of uncovering abuse. Stomach, abdominal and reproductive difficulties (second and third chakra involvement) are common with sexual abuse survivors.

The third chakra is located at the solar plexus and the heart. It is associated with fire, power, reaching out, loving, compassion for self and others as well as the physical body. The third chakra opening makes one feel forceful and intimidating. It is an important chakra to know how to use. The physical sensation can be that of being "hit in the gut". Many of us have had wounds to our hearts when we have taken the risk of loving another and feel we have been burned.

Fire is inspiration. It is the original creative energy. It motivates, inspires, perseveres and destroys. In the Medicine Wheel, this is the direction of the South. It is associated with the color red, the mouse, and the spontaneity of the child. Fire transmutes. The fire signs of the Zodiac are Aries (the beginning ñI amî), Leo (ñI createî) and Sagittarius (ñI teachî). In tarot is the suit of wands which direct the creative force energy to work and become manifest.

Fire will burn until all of its fuel is exhausted. Fire was stolen from the Gods by Prometheus or Coyote in American Indian legend, and children often steal fire from adults. Observe how your child clients relate to fire in the sandtray, notice how confident they are in lighting candles. It is prudent to review fire safety rules with children when they light candles, and to have an obvious bottle of water available should quick extinguishing become necessary. Fire teaches through surprise and opposites. It gives man power over nature. Fire is active and initiates projects. It is associated with the third and fourth energy centers, power and love and compassion.

The colors of fire are reds, oranges, yellow; the hottest part is often blue. It is the opposite of water. The color red emotionally is both anger and love. In true love there needs to be room for the anger. Troubled marriage partners often refer to a lack of spark. They may not allow anger or disagreement (fire) into their union. Or there may be so much rage that there is little space for the expression of love. In the tray we may see light, candles, fire, fire engines, stop signs, volcanoes, cinders, suns, birthday cakes, ovens, cooking, pipes and fire-colored objects of all sorts. The sounds would be hissing, crackling, rock and roll.
 

BLACKENING
 

Blackening is a sub-phase of fire. When something is burnt, it is black. Caregivers that feel witchy are in this stage. The concern and warmth they usually manifest is ñburnt outî. The healing is for them to learn to give more to themselves, to relight their own creative fires. Predominately black trays usually appear when the client feels he or she is in the "dark night of the soul". The energy is spent, there is no inspiration, passion, anger, or love. We have entered the void. Fortunately, there is usually still some small sign of hope in these trays. Try to identify it and see if it may provide the elemental cue as to where the healing will begin, but don't say it. Notice for yourself. Empathize with the pain and the darkness. Clients in the blackening stage may be seriously depressed or suicidal. It is important to honor that, and not attempt to bypass the real pain and despair of the time. Until the darkness is fully recognized the light does not enter.

This is the place where we also confront our own shadow and darkness. Many became so enraged by the act of terrorism on September 11 that they became terrorists in their own hearts, seeking retaliation, retribution, revenge. If we had "bombed Afghanistan back to the stone age" we would have been massacring innocent people, just like what was done to us. Hatred and revenge are aspects of the human psyche that we must acknowledge in ourselves for planetary healing to occur. Honor your shadow, by acknowledging some really horrible part of yourself that it is easier to project onto someone else...this work could save the planet, if everybody did it. Speak out against racial and religious stereotyping!!!

Take some time to root out violence in your own heart, and to understand your own aggression. If we fearlessly do this, then we make a tiny step toward changing the consciousness of the world.
 

REDDENING
 

There is a process we have noticed in trays we refer to as reddening. There may be an initial reddening to call attention to the difficulty or wound, then the tray gets black. The return to reddening may appear in the form of healing elements. Red is a predominant color at births and menstruation. It is blood, life force. In Chinese culture, red is the color used at weddings and at many other holidays. During the healing phases you may see the red Buddha, or Quan Yin, red candles, or the red cloak around Christ, apples, roses, pomegranates, or other red items that can nourish body and/or soul. Think about how many mythic and fairytale figures encounter red: Persephone, Snow White, Little Red Riding Hood, Dorothy of the Wizard of Oz, Eve, Sleeping Beauty, etc. This healing through reddening often marks a very transformative part of the healing. When the red appears, the client has been touched by Eros, or true feeling. It is life affirming and fertile.

The Erikson developmental levels associated with fire would be industry vs. inferiority, intimacy vs. isolation, generativity vs. stagnation. In an adult, issues around anger, self expression, and procrastination and self fulfillment often revolve and heal around the element of fire. Are they going to express themselves and their souls' desires this lifetime? The therapeutic process should awaken the client's fire, increasing their inspiration and motivation to engage in life.

 

Josh is eight. His anxiety a few weeks after the bombing was still quite high. School was stressful, he was having a hard time concentrating. His processing of the bombing was complicated by a sudden, serious illness of a very close family friend. Josh was not feeling very safe in the world. He made a huge volcano for his sandtray, perhaps expressing how worried his heart was, how disempowered he felt, and his anger at what had happened to his world. Finally, at the end of the session, it was time to put the fire out, using the cooling waters if the second chakra. Josh was able to reconnect with his feelings of attachment to heal the hurt and anger in his gut and heart. After the session ended, Josh was softer. The vibrating tension in his muscles relaxed. He seemed to melt into his mother's body when she came to pick him up. She seemed surprised by the depth and gentleness of the hug that he gave her.

WATER
 

Second, or attachment chakra trauma often has its roots in betrayal. If a child is sexually abused by a caretaker or parent, the feeling of empathy is damaged. In the body, this can appear as reproductive and urinary tract problems. Behaviorally, a trauma victim will dissociate or not be engaged energetically with the chakras affected by the trauma. When he or she does reintegrate, the symptoms will reflect which chakra has contracted due to the trauma.

When a betrayal takes place, a person is deep in the second chakra "down into the water where the monsters of the deep are faced, and from which rebirth may take place" (Coward, 1985). This is often expressed in sandplay in flooded trays, almost as if the person is feeling as betrayed as humankind must have felt when God flooded the world. The resolution for this often includes a rainbow, symbolizing The Covenant. When this appears, often trust is reestablished.

Water is the element of the second chakra is located below the navel in the abdominal area. Here is the seat of empathy, sexuality and reproduction. Water flows as does empathy and sexuality. When one has been traumatized in this area, the second chakra may develop a physical response. In sexual abuse survivors whose second chakra may have been opened too early and against their will, we often see accompanying issues of gender identity, difficulties with reproductive organs, and problems with trust and attachment to intimate partners.

In the Medicine Wheel water is the element of the West. It signifies introspection and is associated with the color black, the whale, and the bear in the cave. The Zodiac water signs are Cancer (nurturance), Scorpio (release), ending with the mutable water sign of Pisces wherein all is possible, assimilated and given back to spirit.

Water is change. It is where life begins in the womb, in the ocean. It is the place of dreams, feelings, loss, love, compassion, empathy, betrayal, cleansing and healing. The tarot suit that represents water is cups, the vessel from which we express our love. The colors are blues and greens. If the water is murky, there is emotional confusion around the issue. It is soothing music or violent storms. We see it in trays as the blue bottom of the tray itself. It is the unconscious. It can be rivers, ponds, oceans, streams, ducks, fish, octopi, shells, boats, bridges, sunken treasure, skin divers, mermaids, pearls, ice, penguins, polar bears, seals, walruses. When water is out of balance, it floods or there is drought. When water is unrelated, it freezes; there is no connectedness nor understanding and things appear isolated. The "monsters from the deep" appear and threaten to overwhelm. Water can erode valleys, carve mountains, create steam, or put out fire. It cradles intuition and creativity. It releases and cleanses in tears. For an article on "How water reflects our
consciousness" please go to http://www.wellnessgoods.com/art_wat_messages.html

Autonomy vs. shame and doubt and ego integrity vs. despair are Eriksonian stages associated with water. Are we going to continue to create and give with our body and souls until the end of life or do we stop and dry up before our time is over? We physically "dry up" during the process of aging, yet there is little more powerful than the glow of wisdom in the eyes of an older, vibrant person. A most prominent example is Mother Teresa who continued to live, share, give and inspire to the end. At the culmination of therapy a client knows their inner emotions (water) and has assimilated (water) their soul into action.
 

EARTH
 

First chakra trauma is very easy to spot. The client will often appear disoriented and dissociated. They may be in shock. In matching energy, you find yourself spacey and frightened. Survival issues include any incident in which a person's life has been threatened: severe illness, an accident or crime in which a person faced the possibility of death. Veterans of war who exhibit post-traumatic stress disorder often have first chakra disturbances. People with this kind of experience need to descend all the way to the earth in order to heal.

The client's response will often be to repress or deny the traumatic event in order to maintain the integrity of the ego. Exposure to great pain or horror will often create a dissociative reaction, in which the person seems to observe violence rather than experience it. This is essentially a self-protective reaction, a "slipping out of the cocoon" (Kubler-Ross, 1983). The Cherokee would "put their soul in a tree" for protection before they entered battle. Eliana Gil (1987) describes drawings by children who have been violently sexually or physically abused. The pictures show a child being beaten, and in one corner of the paper, high above, a little figure hovers. When asked the child will say that this little figure is him or herself, while the child being abused is "some kid." The bruises on their bodies belie this. The sequelae to this dissociation often includes anxiety, psychosomatic reactions, hyperactivity, regressive behavior, sleep disturbances, trouble concentrating, and constricted or inappropriate affect. In cases of extreme early abuse, multiple personality disorders may develop. The trauma victim often combines the diagnoses of a Dissociative Disorder with that of Post-Traumatic Stress Disorder. There is a seesawing back and forth between dissociating from the event, then being flooded by it. Many adult clients victimized as children will exhibit the same symptomatology, and have within them an inner child who is fragmented and in pain.

How then do we treat the survivor? Encouraging the client to talk about the crime is an important component in therapy, yet too often he or she is unable to put in words what has been experienced. If the person is in a dissociative stage, she or he will, in all honesty, deny that the event has occurred, and if in touch with the incident, in all likelihood is too flooded to give words to what has occurred.

This is where the use of the elements and of sandplay therapy excels as a therapeutic treatment. The sandbox and toys give clients a chance to tell, without words, their own story. Because the world is outside the box, the box and the receptive presence of the therapist provide the "temenos" or sacred space, in which the deepest emotions, fantasies, and events can manifest themselves. Clients recreate the traumatic events in their native language, play. An underlying assumption to this treatment is that the psyche, given the opportunity, will lead the individual to wholeness and health. The centering archetype, the Self, emerges, and the ego organizes around it (Weinrib, 1983). The therapist is non-intrusive, and mirrors the child's play.

The element earth is associated with the first chakra, which is located at the base of the spine. It is associated with the life, death and survival. Food, clothing, shelter are the issues of existence on earth. Danger involving the possibility of death will trigger this chakra to open. For example, if you were crossing the street and a car were rapidly approaching, your first chakra would open wide and move you quickly out of the way.

Earth in the symbolic process is associated with grounding, nurturance, structure, consistency and survival. Its Medicine Wheel direction is North, from where wisdom and the white buffalo emerge. In astrology, earth signs are Taurus (physical existence and bounty), Virgo (service and analysis) and Capricorn (greater social structure). In Tarot, stones, pentacles or discs represent earth issues such as work, money and production.

The quality of the element is feminine and receptive. All life is sustained by the earth. It is the place of planting as well as harvest. In order to make our ideas and dreams manifest, we must bring them to the physical plane: the earth. Earth is the place of renewal. In many forms of meditation students are taught to "ground" or "anchor" into the earth through their feet or "root" chakra and instructed to pull energy up from the earth to cleanse and then release energy back into the earth where it can be transmuted into a new form. Navajo sand paintings use the element earth for curing diseases in much the same manner. The feet connect us to earth; it is where we make the human/spirit connection. The colors associated with earth are often rich greens and browns. Drumming connects us to the earth vibration, the human heartbeat to the heart of the planet. When you hear a beat or rhythm, when people start moving, making themselves real, tapping their toes, swaying; this is earth.

The feeling of earth may be warm or cold, dry or moist. We may experience earth in a tray as being a barren desert, a high mountain top, a lush garden or deep forest. Each of these scenes will elicit a different feeling in both clinician and client. The sign of earth is solid.

The developmental issue associated with earth is trust vs. basic mistrust. Being in a life-threatening situation will cause one to become ungrounded and dissociated. Psychotic and autistic clients are also earth deficient by the nature of their process being so removed from the physical plane; they are dissociated. We can attest to a different level of security that may be seen in these individuals when they are in a more natural environment. In a residential treatment center for autistic/schizophrenic adolescents, one of the programs was to be in the Mendocino woodlands for four weeks. Out of control teenagers were suddenly cooperative and calm. They were able to help with the cleansing of clothes and complete tasks much more successfully than at home. Anxiety falls away and nature fills and inspires. Remember your last walk on the beach, or hike in the woods. We know apartment dwellers who keep a bag of potting soil in the closet, taking it out to feel and smell. It's a little gesture, but it keeps them in touch with something elemental.

Earth provides structure and consistency, a sense that the world is a predictable place. Sandplay provides both the earth and container for therapy to exist. It is important to be able to count on a given reaction following a particular action. How a therapist provides earth in their work is to have a consistent predictable schedule, (i.e., meeting a certain day of week, for determined number of minutes, plenty of notice before vacations, same office) and also in being present. Earth is where therapy and life happen. It is where change needs to manifest to have a result.

Lucia, age 12, made a 3-sided pyramid emerging out of the water. On the left was land with five points protruding. After she completed the tray, she shyly and proudly said that she had her first menstruation that week. She asked me questions about my period, then at the end of the session we both went to the garden, where I gave Lucia a red rose to celebrate her becoming a woman.

Lucia unconsciously recreated the Kinaalda, the Navajo initiation ceremony for girls at the onset of puberty. The central figure in the ritual is Changing Woman who celebrated her first menstruation by "molding the earth." In this way, mountains were created.

 

Larry came for a therapy session ten days after the terrorist attack. He told me his story; being in a building one block away when the first plane hit the tower. The sounds of breaking glass, screams. He couldn't get out..a security guard blocked the exits. No one knew what was going on. The second plane hit; and someone found a TV so they witnessed the attack. He watched in horror and amazement what was occurring at the World Trade Center, only one block away. Then a huge explosion, and everything went dark. No electricity. The windows were blown out of the building. To go or stay? Larry was one of the people you couldn't see on TV, running from the dust and smoke. He was in it. He couldn't breathe. When he tells me about it, he starts to cough again, gasp for air. He can't sleep, and has been having a lot of gastrointestinal troubles since the attack. He did a sandtray: Eleven mounds in the sand; each one contains an egg. At one end a drummer sitting within a triptych mirror, facing a rainbow and a fairy castle. On either side of the rainbow are two sequined animals; a giraffe and an elephant. In the upper left corner is a mysterious masked figure, dancing with a snake. Larry said that the drumming in NY saved him. He was wandering around, feeling lost and disembodied. Shell-shocked. At the street corners were memorials, candles. He couldn't cry. He heard drumming, and it brought him back to his body. Since he has been home, he has been furiously drumming. I often look to where mirrors are placed in a sandtray for guidance as to my interventions. As the drummer is surrounded by mirrors, I felt that Larry needed me to mirror him on an energetic level, focusing on the rhythm of what had happened, rather than on the words. I gave him my small office drum to use after he had done the sandtray. As he drummed the pattern of horror and pain, the tears came. The mysterious figure with the snake...who could that be? It is interesting that he is holding a snake,as the Kundalini serpent is thought to lodge in the root or earth chakra. Could this figure be holding tightly to Larry's serpent, his personal life force? The coiled serpent is the symbol of the root chakra, and this figure is holding a serpent in one hand and wear another upon his mask.

Maria, 35, subsequent to the Loma Prieta earthquake. Notice the serpent under the house.
 

GREENING
 

Greening is a process within the course of sandplay therapy wherein the entire tray seems to be covered in hues of green. From deep within the dark pines, to lime-colored leaves, palms and bushes, sparkling emeralds, waters and figures, green dominates and new growth is heralded. It correlates to an inner season of spring and summer where new life flourishes. This life must still be tended and nurtured to come to the fruition and harvest. The same is true for this phase of the process in the sand.
 

THE SELF

Under the earth, after the descent, archetypes of wholeness may appear.

When the ego dies, the Self appears. The Self is the eternal center in each of us. The totality of wholeness, the Self can never be hurt, no matter how profound the trauma or disability an individual may face in life. Witnessing a Self tray is a deeply moving experience. The energy in the therapy room brightens. The client and therapist are enlivened. There is often a tingling up and down the spine that happens in the presence of spirit, truth and new birth. The air shimmers. The appearance of a Self tray is exactly that – a new birth. It is the new growth from the soil, the light in the darkness. There is a union of opposites and elements. Fire and earth, water and air often appear balanced in these trays. Candles are often lit, mirrored objects reflecting Self appear, as well as sparkling, luminescent figures. There is symmetry with the placement of figures creating a mandala in the sand.

It is very important to honor this new birth as an infant, a being that needs attention, care, nurturance and love. Be with it in that wonderful mother/infant symbiotic state.

(The description of the Self and the elements is from Amatruda and Simpson, Sandplay,The Sacred Healing: A Guide to Symbolic Process, Trance-Sand-Dance Press: Taos, 1997.)

Andre, age 9, came to the sand shortly after the war started. He made this sandplay: "This is the Americans versus the Terrorists", he said. The "terrorist" here is hardly human, perhaps a reflection of a 9 year-old's perception that what occurred on September 11 was beyond the range of his comprehension of how people treat each other. He then wanted to create another sandpicture: Andre looked at this silently after lighting the candles. A (young) man of few words, all he said was, "It's a meditation." When Andre left the playroom, he was singing. The heaviness had left his body as he skipped up the stairs. He seemed to have encountered the Self, and a tiny bit of wholeness and safety was restored to his world.

This webpage, designed by Neil Cooper, is gratefully acknowledged. It looks at the more familiar seven point chakra system from the Hindus, as opposed to the five point Tibetan chakra system used in prior discussion.

In India tradition Kundalini is taught, which means coiled serpent, and refers to the energy at the base chakra, which can under certain conditions of attunement be made to rise like a bolt of invigorating force up the spine to the head, through rising up the Sushuma (the middle of the three main subtle energy channels along the spine - the others are the Ida and Pingala). This awakening is often associated with prickly sensations on the skin or feelings of hot and cold. Yoga students are sometime a little wary of the unpleasant side effects if the mind is not cleansed of impurities. In China these life force energies maybe referred to as the chi energies. This is something that can also be experienced in a different manners through mind over matter and it begins a spirit experience that entails the quickening of the spirits chakra, where the main solar-plexus chakra opens firstly and triggers all the surrounding chakra to open in a cascading effect slowly moving up to the head and down to the feet at the same time, until all the chakra are fully opened throughout the etheric body. The individual many feel full of energy and somewhat like a Christmas tree has been illuminated inside their spirit, accompanied by feelings of floating and euphoric energies are experienced, along with the realization that the spiritual self within has awakened and taken control, this experience may last up to 10 minutes before all the chakras slowly close back to what is normal. Each chakra has its own base colour and although the base colour of each chakra can change at times and can vary a little from one person to another, the colours given in the diagram are assumed to be the normal base colours for the majority of individuals but not all. The chakra can produce variations of colours and layers within the aura that can be seen to change throughout the daily events of our lives, this is somewhat dependent on how we are feeling and what we are doing. Each of the chakra is capable of going through changes that produce a new blending of colours in the aura and within the spirit and this is often done as a form of spiritual attunement to our feelings or to the task that we may be performing at any given time. Often our moods, emotions, health, spirituality including any disharmonies are reflected through the aura as one chakra opens as another may close. These chakra energy centres send out energies and the colours of several chakras can be reflected through the aura at any given time. This blending is somewhat likened to an artist mixing colours on a mixing pallet and can bring a new variation of colours that can be seen in the aura. Spiritual colours are made up of the primary and secondary colours, which are refracted through the spirits energy field in a considerable variety of colours and shades from pastels to vivid bold colours. Those who can see aura can see anywhere from one to several layers of colour within the aura energy field one blending into the next. This can be seen in the example shown on the aura page. None of the chakra ever closes completely, if they did we would simply cease to exist and it is only the spirit that makes mortal life possible, without the spirit present there is no life, for it truly is the spirit within that animates our mortal beings into life. The chakra on the most part are self-regulating to our needs and natures at any given point and they can work together or independently depending on our needs and uses. There are particular times when it is to our advantage to learn how to open and close the chakra, these times are when we are attuning to perform spiritual work of some kind or when we are developing spiritual and psychic awareness and abilities, such as channeling the healing powers and in meditation both psychically and clairvoyantly. Opening the chakra helps channeling and attunement to the spirits natural abilities and sixth senses, heightening the spirits vibration and sensitivities to help us perceive what is beyond our normal mortal perceptions. (source: http://www.angelfire.com/or2/spiritspeaks/chakra.html)

Elements in the office

While sandplay therapy is the one therapy that makes use of the actual elements (earth, water, fire and air) in a container, it is possible to have the elements accessible to your clients without a sandplay setup. One idea is to have a table near where the patient sits so that he or she can play with the figures. Things to include on the table might be:

Earth: Rocks, a 'Zen table' which is a small rectangular frame which contains sand and rocks, and comes with a small rake, plants.

Water: A small fountain, seashells, small ceramic, glass or plastic fish and sea creatures.

Fire: A votive candle, or a box of birthday candles and a bowl of sand. (Beware of the size of fire you will permit if you have a smoke alarm in the office), a figure of a small campfire. One idea is to have a floating candle, so that you have water and fire together.

Air: Feathers, a small fan, figures of birds or butterflies.

Other modalities that use cellular memory

While I have had little experience with the following therapeutic techniques, they are being used for the treatment of trauma. They are included here as they seem to access cellular memory.

Eye Movement Desensitization and Reprocessing-EMDR therapy is a "complex method of psychotherapy that integrates many of the successful elements of a range of therapeutic approaches in combination with eye movements or other forms of rhythmical stimulation in ways that stimulate the brain’s information processing system." (For more information go to http://www.emdr.com/ )

Thought Field Therapy "Thought Field Therapy (TFT) provides a code to nature's healing system. When applied to problems TFT addresses their fundamental causes, balancing the body's energy system and allowing you to eliminate most negative emotions within minutes and promote the body's own healing ability. We provide common recipes (algorithms) or codes in our books and tapes. Specific or individual Codes are
elicited through TFT's unique assessment procedures taught in Steps A, B, and C training programs." (source: http://www.tftrx.com/alternative_medicine.htm)

A description of how to do TFT by Charles R. Figley, PhD Psychosocial Stress Research Program and Clinical Laboratory appears at: http://www.trauma-pages.com/tft.htm

TIR or Traumatic Incident Reduction, is a systematic method of locating, reviewing and resolving
traumatic events. Once a person has used TIR to fully and calmly view a painful memory or chain of
related memories, life events no longer trigger it and cause distressing symptoms. TIR has proven useful in relieving a wide range of fears, limiting beliefs, suffering due to losses (including unresolved grief and mourning), depression, and other PTSD symptoms. The TIR technique can be traced to roots in
psychoanalytic theory and desensitization methods; however, it is carried out in a thoroughly person-centered, nonjudgmental and respectful context. (source: http://www.healing-arts.org/tir/gallery.htm)

Hypnosis and Body Work also are thought to be able to assist the individual in the healing of trauma.

5. Psychopharmacology

When are medications indicated in the treatment of trauma?

 

Psychopharmacology of Pediatric Posttraumatic Stress Disorder By Craig L. Donnelly, M.D. ABSTRACT Objective: To review the current knowledge of pharmacotherapy in the treatment of Posttraumatic Stress Disorder (PTSD) in children and adolescents and to provide a rational approach to medication use in Pediatric PTSD. Literature is reviewed on the neurobiolgical systems involved in trauma as well as studies in the pharmacology of adults and children with PTSD. There are too few studies in the current Pediatric PTSD literature to make firm treatment recommendations. The effectiveness of targeting pharmacological agents at PTSD symptom clusters and associated comorbid conditions remains to be verified in controlled clinical trials. The state of psychopharmacology for Pediatric PTSD is in its earliest stages. Key Words: Children, Adolescents, Drug Therapy, Pharmacology, Treatment, PTSD. INTRODUCTION Posttraumatic Stress Disorder (PTSD) is a complicated condition involving multiple neurobiological systems which may result in dysregulation of cognitive, affective and behavioral domains of functioning. This article reviews the literature on the pharmacological treatment of Pediatric PTSD. The relevant neurobiological systems that may contribute to the pathophysiology of the disorder are identified and a rational approach to the treatment of PTSD in children is presented. An important caveat is that children are not simply "small adults". Even in the adult literature there are too few well controlled studies and too many inconsistent results to make recommendations with full confidence. Still, there is the need for a rational point of departure for the use of pharmacological treatments in children suffering from symptoms of PTSD. PTSD entered the diagnostic nomenclature with the introduction of DSM III (APA, 1980) in 1980 yet it was not immediately recognized in children. Currently, in the general population prevalence rates range between 3-6% (Kessler et al., 1995). Trauma exposure affects approximately one third of the entire population in the United States (Breslau 1998; Solomon and Davidson, 1997) and approximately 10-20% of these individuals will develop PTSD. Giaconia et al. (1995) found that more than 6% of children and adolescents age 18 years and younger met criteria for a lifetime diagnosis of PTSD. DIAGNOSTIC CRITERIA AND CLINICAL PRESENTATION The cardinal features of PTSD include initial exposure to a traumatic event, with the subsequent development of three clusters of symptoms related to the initial traumatic experience: re-experiencing of the trauma, avoidance behavior and hyperarousal (DSM IV, APA, 1994). By this definition, intense stress or severe humiliation, in the absence of threat of death or injury does not qualify as a traumatic event. In children B-cluster symptoms (re-experiencing) may involve repetitive play in which traumatic themes are reenacted or expressed, recurrent frightening dreams, or intense distress at reminders of the trauma. In children, avoidance (C-cluster), involves efforts to avoid thoughts, feelings or memories of the trauma and are common as is an inability to recall important aspects of the trauma experience. Restriction of affect, detachment and a markedly diminished interest in regular activities can reflect numbing. Children may also exhibit a sense of a foreshortened future where the expectation of growing up, living long, or engaging in the normal activities of life are lost. The D-cluster symptom, hyperarousal, may manifest in children as hypervigilance, a persistent state of high arousal with scanning of the environment for danger signals, and demonstrate an exaggerated startle response, make children appear hyperactive, erratic in their behavior and deconcentrated. Symptoms are debilitating, may vary over time and it should be noted that partial symptomatology is quite common, and may be the target for intensive treatment even in the absence of meeting full syndrome criteria (Pfefferbaum, 1997). The clinical presentation of PTSD in childhood can be extraordinarily heterogeneous with a bewildering array of symptoms. There is compelling evidence that the type, magnitude, proximity to and duration of exposure to traumatic events, as well as factors intrinsic to the individual child and parents, are important in the development and expression of PTSD (Pfefferbaum, 1997; Zohar et al., 1998). Terr (1991) has suggested a useful distinction between single incident trauma (Type I Trauma) versus chronic, recurrent traumatic exposure (Type II Trauma). Despite the complicated mix of variables related to the type of trauma, developmental age and factors intrinsic to the child, there can be a rational approach to pharmacological treatment of PTSD in children and adolescents. This entails an adequate understanding of the neurobiological systems which may be dysregulated by trauma exposure, their relation to each of the symptom clusters, the particular target symptoms of pharmacological agents, and identification of existing comorbid syndromes that frequently accompany PTSD symptoms. COMORBIDITY Children and adults with PTSD commonly meet criteria for other psychiatric disorders (Brady, 1997; Breslau et al., 1991; De Bellis, 1997; Goenjian et al., 1995). Comorbidity can be thought of as the rule rather than the exception and multiple comorbidities are the rule within the rule. Affective disorders, anxiety disorders and substance abuse disorders appear to be the most common comorbid conditions in individuals with PTSD (Brady, 1997; Kessler et al., 1995; Kulka, 1990; Solomon and Bleich, 1998). Children with PTSD may be more likely to have comorbid conditions because traumatic insults occur in developmental epochs that are particularly sensitive to disruptions in neurobiological maturation. Developing coping skills, interpersonal relations and the achievement of developmental milestones such as language acquisition, self regulation, security and trust may be disrupted by trauma. Traumatic experiences set the stage for development of other debilitating conditions. In younger children these may manifest as attachment disorders, impaired social skills, aggressiveness, impulsivity and sexualized behaviors, depending on the nature of the trauma. In older children and adolescents anxiety disorders, Depression, Somatization, Dysthymia, alcohol abuse and substance abuse appear as common comorbid conditions. Comorbid attachment disorders are often observed in younger children. Understanding psychiatric comorbidity has important implications for the pharmacological treatment of PTSD. NEUROBIOLOGICAL SYSTEMS Little is known about the specific neurobiological systems that are disrupted in children with PTSD. The state of the neurobiological science for these systems is neither straightforward nor definitive and the methodology for investigating the complex effects of trauma on these systems does not yield easily to clear conclusions. Theories of the neurobiology of stress and trauma have been extensively reviewed (Bremner et al., 1993; Charney et al., 1993; Friedman, Charney and Deutch, 1995). The physiological systems involved in the reaction and adaptation to trauma and stress include the immune system, the neuroendocrine system and the central nervous system (CNS). These systems work in a dynamic, extensively interconnected and highly integrated fashion to regulate cognition, affect and behavior. This review will focus on the neurotransmitter systems of the CNS. Animal model and human data suggest that at least eight neurobiological systems mediate the mammalian stress response and may be involved in PTSD (Friedman and Southwick, 1995). These include the adrenergic, dopaminergic, serotonergic, gamma-amino butyric acid/benzodiazepine, opioid, n-methyl d-aspartate and neuroendocrine system (including the hypothalamic-pituitary adrenal, growth hormone, thyroid and gonadal axes). ADRENERGIC AND DOPAMINERGIC (CATECHOLAMINE) SYSTEMS The catecholamines norepinephrine, epinephrine and dopamine are involved in arousal, anxiety, frontal lobe activation, mood regulation, reward dependence, working memory, thinking and perceiving (Bremner, Davis and Southwick, 1993). Stress induced high catecholamine levels in the brain can produce functional lesions that impair working memory, attention regulation, motor activity and impulse control (Annsten, 1999). Uncontrollable and unpredictable stress is known to increase the responsiveness of the locus ceruleus, the major norepinephrine nucleus in the brain (Chronister and DeFrance, 1981) affecting widespread brain areas (e.g., cerebral cortex, hypothalamus, amygdala) which subserve functions of memory, emotion, arousal and attention. It is this noradrenergic activity that is believed to mediate sympathetic and parasympathetic mechanisms involved in the mammalian "fight, flight or freeze" response. This system is thought to be less developed and adaptive in young children (Perry et al., 1995). Stress exposure is also known to enhance dopamine turnover in the prefrontal cortex and other areas of the brain (Deutch and Roth, 1989). It is well known that cocaine and amphetamines, which increase dopamine turnover, can result in hypervigilance and paranoia. SEROTONIN SYSTEM The neurotransmitter Serotonin (5-Hydroxytryptamine, 5-HT) is widely distributed in the central nervous system and is thought to subsume a variety of functions including drive satiety, mood, aggression, anxiety, compulsive and impulsive behaviors (Gonzalez-Heydrich and Peroutka, 1990). It may be an important neurotransmitter in psychiatric symptoms or syndromes commonly associated with PTSD such as aggression, obsessional/intrusive thoughts, alcohol and substance abuse and suicidal behavior (Friedman, 1990). Suicidal behavior is known to be associated with both childhood maltreatment and low 5-HT functioning (Benkelfat, 1993; Van der Kolk et al., 1991). Few studies have directly investigated this relationship in patients with PTSD though evidence is mounting as to the role of Serotonin in PTSD (Connor and Davidson, 1998). There are significant phenomenological overlaps between PTSD symptoms and their comorbid conditions which share mediation by Serotonergic systems. This, together with the fact that the Catecholamine and Serotonin systems in the CNS share extensive interconnections implicates Serotonin as an important neurotransmitter in the pathophysiology of PTSD. GABA/BENZODIAZEPINE SYSTEM Benzodiazepine receptors are functionally linked to receptors for the inhibitory neurotransmitter gama-aminobutyric acid (GABA). This system is clearly involved in the neurobiology of anxiety and stress. Benzodiazepines can block typical stress induced responses to inescapable shock (Drugen et al., 1989). The effect of the Benzodiazepine/GABA system on mediating anxiety and stress appears to be a complex one involving locus ceruleus (NE) activity and reduced stress induced prefrontal cortical dopamine activity (Friedman and Southwick, 1995). Despite these intriguing relationships there are no published studies on the Benzodiazepine receptor system in patients with PTSD. OPIOID SYSTEM The stress induced increase in endogenous opioids is an important adaptive neurobiological response that contributes to pain analgesia (Bremner et al., 1993). Endogenously administered opiates decrease locus ceruleus firing rates and diminish the overall capacity of an organism to react to stress. Both diminished and excessive opioid activity have been hypothesized in PTSD (Glover, 1992; Van der Kolk, 1989) Whether numbing symptoms are related to endogenous opioid hypersecretion, as it appears to be in some cases, and whether individuals with PTSD exhibit hyper- or hypo-endogenous opioid secretion resulting from trauma exposure remain open questions. It is tempting to speculate that the emotional numbing, constriction of affect and the high incidence of self injurious behaviors reported in both children and adults with maltreatment histories may reflect dysregulation in the endogenous opioid system (Van der Kolk et al., 1991; Yeo, 1993). NEUROENDOCRINE SYSTEM The complexities of the multiple neuroendocrine axes as related to stress and trauma in childhood have been reviewed by De Bellis (1997). The chief systems thought to be involved in stress reaction and adaptation are the Hypothalamic-Pituitary-Adrenal (HPA), Hypothalamic-Pituitary-Growth Hormone (HPGH), Hypothalamic Pituitary-Thyroid (HPT) and the Hypothalamic-Pituitary-Gonadal (HPG) axes. There are few studies detailing the dynamics of these complex feedback systems in traumatized children. While little is known about the specific effects of trauma on the HPGH and HPT axes in children, these axes are known to be important in the normal growth, development and maturation in childhood. De Bellis (1997) has speculated that alterations in brain development, intelligence, physical status and pubertal development may occur from stress dysregulation of these neuroendocrine systems, especially during childhood. PHARMACOLOGICAL AGENTS Because of the lack of empirical studies in Pediatric PTSD it is difficult to recommend a clear treatment hierarchy. It should be emphasized that the initial treatment of choice for pediatric PTSD is probably Cognitive-Behavioral Therapy (CBT), as it is likely to be less risky and has more supporting data at the present time then does pharmacotherapy (March et al., 1998). Outpatient psychotherapy has generally been considered the preferred initial treatment with pharmacology used as an adjunct (Practice Parameters, 1998). Pharmacology has two central roles in Pediatric PTSD treatment. First, is the direct targeting of disabling symptoms so that the traumatized child may pursue a normal growth and developmental trajectory. Second, is to help children tolerate confronting emotionally traumatic material and work through the resultant distress in psychotherapy and in life. Effective pharmacotherapy may require a multisystem approach in which several agents are used to target separate clusters of symptoms of PTSD and, or comorbid conditions that occur with it. What is known about the effectiveness of pharmacotherapeutic agents in Pediatric PTSD? The answer is surprisingly very little. Recently published textbooks of Pediatric Psychopharmacology and reviews of the treatment of anxiety disorders in childhood and PTSD provide little guidance in the use of pharmacological agents in PTSD (Allen et al., 1995; Kutcher, 1995; Pfefferbaum, 1997; Practice Parameters, 1998). A Medline literature search using the key words: Children (age inclusive 2-18 years), Drug Therapy, PTSD, between 1980-1999 yielded just 13 citations. The following section will review specific classes of medication in relation to target symptoms in PTSD. Data from Pediatric studies will be presented when available. Adrenergic Agents Adrenergic agents such as the alpha-2 agonists Clonidine and Guanfacine and the beta antagonist Propranolol reduce sympathetic arousal and may be effective in the symptoms of hyperarousal, impulsivity and activation seen in PTSD (De Bellis, 1994; Marmar et al., 1993). Perry et al. (1994) in an open label trial of 17 children with PTSD, using relatively low doses of Clonidine, found significant improvement in anxiety, arousal, concentration, mood and behavioral impulsivity in these children. Harmon and Riggs (1996) reported the use of Clonidine in the transdermal patch for effective reduction in PTSD symptoms in all 7 patients in their open label trial. Horrigan (1996) in a single case study reported the effectiveness of Guanfacine in reducing PTSD associated nightmares in a 7 year old child. There is evidence that when tolerance develops to one agent, e.g. Clonidine, replacement with Guanfacine can provide renewed suppression of PTSD symptoms over time (Horrigan, 1996; Horrigan and Barnhill, 1996). In an uncontrolled study of children with PTSD Famularo et al. (1988) found that Propranolol significantly reduced PTSD symptoms over the 5 weeks of treatment in 8 of 11 abused children. Intrusion and arousal symptoms appeared to be the most responsive to treatment in this study. Beta blockers have been identified as a treatment of rage outbursts in the Pediatric literature (Coffey, 1990) although their anxiolytic effects have not been established in children, as has been suggested in adults. Additionally, several researchers have observed that the alpha-2 adrenergic agents may be more effective than the psychostimulants for ADHD symptoms in maltreated, sexually abused or other children with comorbid PTSD (De Bellis et al, 1994; Marmar et al., 1993). The alpha and beta adrenergic agents appear to be relatively safe given that baseline and periodic monitoring of cardiovascular status is assessed. Dopaminergic Agents No citations were identified for the use of dopamine blocking agents (neuroleptics) in the treatment of Pediatric PTSD. Despite neuroleptics being a mainstay of adult PTSD treatment in the 1970's, currently these agents are reserved for patients with refractory PTSD who exhibit paranoid behavior, parahallucinatory phenomena or intense flashbacks, self destructive behavior, explosive or overwhelming anger or psychotic symptoms. There has been a shift toward the use of the newer atypical neuroleptics such as Risperidone, Olanzapine and Quetiapine owing to their apparent lower risk of side effects such as extrapyramidal symptoms and tardive dyskinesia (Friedman, 1998). These agents should be reserved for only the most debilitating and extreme cases of PTSD in children. Serotonergic Agents A number of successful case reports, open trials and randomized controlled trials have been published with the SSRI's though surprisingly, there are no reports of the use of SSRI's in Pediatric PTSD. SSRI's may be useful in Pediatric PTSD because of the variety of symptoms associated with Serotonergic dysregulation including anxiety, depressed mood, obsessional thinking and compulsive behaviors, affective impulsivity, rage and alcohol or substance abuse (Friedman, 1990). The suggestion of the SSRI's acting in a fairly rapid, broad spectrum fashion in adult PTSD warrants controlled investigation in childhood populations. Buspirone is an nonbenzodiazepine anxiolytic Serotonin 5-HT1A partial agonist that reduced anxiety, flashbacks and insomnia in a small open label trial in combat veterans with PTSD (Wells et al., 1991). No controlled studies of this agent have been published in childhood populations. Cyproheptadine is an antihistaminic 5-HT antagonist that has shown limited utility in reducing traumatic nightmares (Brophy, 1991). Because of its sedative action and generally safe side effect profile, it may be a useful agent in sleep onset problems and nightmares in children with PTSD. SSRI's are receiving widespread application in child and adolescent disorders such as Depression, OCD and other anxiety disorders (Allen et al., 1995; Kutcher 1997). These agents are likely to prove useful as "broad spectrum" first line agents in the treatment of Pediatric PTSD. Agents such as Nefazadone, Trazadone and Cyproheptadine, used alone or in conjuction with the SSRI's, may be particularly useful in sleep dysregulation and trauma related nightmares that frequently occur in Pediatric PTSD patients. Adrenergic and Serotonergic Agents: TCA's There have been three randomized clinical trials and multiple case reports and open label trials with the TCA's in PTSD, although none have been reported in childhood (Ver Ellen and Kammen, 1990; Southwick et al., 1994). It appears that the TCA's Imipramine and Amitriptyline produce moderate global improvement in adult PTSD (45% of patients treated) (Southwick et al., 1994). Desipramine was found to be no better than placebo in a controlled crossover trial (Reist et al., 1989). TCA's appear to reduce symptoms of reexperiencing and depression related to PTSD in adults. No studies have been undertaken with these agents in Pediatric PTSD. These agents should probably be reserved for second line treatment in Pediatric PTSD, in situations where SSRI therapy has been unsuccessful and where symptoms of insomnia, reexperiencing, and related depression and panic anxiety are present. GABA-ergic Agents Although the Benzodiazepines are clearly effective in the treatment of adult anxiety disorders and have been widely utilized in the treatment of PTSD in adults only four publications were found using these agents in PTSD. No studies have been conducted in childhood. Adult studies indicate that they have little effect on core PTSD symptoms of reexperiencing, avoidance or numbing (Friedman, 1998) and pose the risk for rebound effects such as anxiety, sleep disturbance and prominent rage reactions. Use of Benzodiazepines for Pediatric anxiety disorders other than PTSD have yielded mixed results. Graae et al. (1994) used Clonazepam to treat 15 children age 7-13 years with mixed anxiety disorders and found no differences versus placebo on general functioning. Two subjects experienced marked disinhibition necessitating withdrawal from the study and 10 children had untoward side effects. Simeon et al. (1992) compared Alprazolam to placebo in a double blind randomized trial for the treatment of Avoidant or Overanxious disorder in 30 children and adolescents. No significant differences were found between the two treatment groups. Based on both the adult literature and the limited experience with Benzodiazepines in the Pediatric anxiety literature these agents cannot be recommended as first line treatments for Pediatric PTSD. They may improve symptoms of insomnia, anxiety and irritability but do not seem to affect the core symptoms of reexperiencing, numbing or avoidance. Clinicians treating children should be aware of the troublesome and sometimes serious side effects of disinhibition, sedation and irritability when using these agents, and they should be reserved for use as a last resort in treating patients with Pediatric PTSD. Opioid Antagonists Opioid antagonists have been utilized with mixed results in adults with PTSD. No clinical trials with these agents have been published in children and adolescents with PTSD. The opioid antagonists may have limited utility in treating debilitating self-mutilative behavior and perhaps in reducing substance abuse related comorbidity in adolescent patients with PTSD, although these are hypotheses that bear empirical testing in this population. Miscellaneous Agents: Anticonvulsants, Lithium Carbonate, Buproprion, Psychostimulants Trauma exposure may induce sensitization or kindling phenomena in limbic nuclei in the human CNS. A number of open label trials have been conducted with antikindling/anticonvulsive agents with adult PTSD patients. Carbemazepine has received the most attention and has been shown to be effective in markedly reducing flashbacks, traumatic nightmares, intrusive recollections and sleep disturbances in Vietnam veterans with PTSD (Lipper et al., 1986). Loof et al. (1995) reported the use of Carbemazepine in 28 children and adolescents with sexual abuse histories. By treatment end 22 of 28 patients were asymptomatic regarding PTSD symptoms. Half of this group were comorbid for ADHD, Depression, ODD or Polysubstance Abuse and were treated with concomitant medications, e.g. Methylphenidate, Clonidine, Sertraline, Fluoxetine or Imipramine. In patients who cannot tolerate Carbemazepine, Valproic Acid may be a useful alternative as it has demonstrated success in an open label trial with Vietnam veterans in reducing Cluster C (avoidant) and Cluster D (hyperarousal) symptoms (Fesler, 1991). While there have been no published controlled trials of the use of anticonvulsants in the treatment of Pediatric PTSD these agents are commonly used in children and adolescents with seizure disorders. They may be a useful treatment intervention for debilitating avoidant/numbing, hyperarousal and sleep dysregulation in children with PTSD, or in situations where overwhelming anger and aggressiveness/explosiveness predominate. Lithium Carbonate has a complex mechanism of action involving the phosphoinositide second messenger system. No published trials exist for the use of Lithium in Pediatric PTSD. The same brain areas that are involved in the stress response also mediate motor behavior, affect regulation, arousal, sleep, startle response, attention, and cardiovascular responsivity. Hence, it is not unusual for traumatized children, particularly those exposed to chronic trauma like maltreatment, to exhibit what appears to be a constellation of anxiety plus ADHD and other disruptive behavior symptoms. It is worth noting that many children are treated for ADHD with psychostimulants by family physicians, pediatricians and psychiatrists without recognition that there is underlying trauma. Many children in fact have favorable responses in reduction of hyperactivity, impulse dyscontrol and attention impairment, with the psychostimulants such as Methylphenidate or Dextroamphetamine. Similarly, Buproprion is often considered a second line agent for ADHD symptoms and may be a useful agent when affect dysregulation or depressed mood occurs with ADHD symptoms. There have been no research studies in children or adolescents looking at the use of stimulants or Buproprion in Pediatric PTSD. CONCLUSIONS It is apparent that there are gaps in the current state of knowledge in the neurobiology and psychopharmacology of Pediatric PTSD. A rational approach to the pharmacological treatment of Pediatric PTSD may be based on a convergence of evidence from the adult literature, an understanding of basic neurobiological mechanisms and pharmacological agents and their target symptoms in PTSD symptom clusters and the comorbid conditions that occur with PTSD. In selecting pharmacologic agents for Pediatric PTSD it is helpful to use a stepwise approach based on identification of symptom clusters. There must be an accurate diagnosis of PTSD or subsyndromal PTSD symptoms that are debilitating enough to warrant pharmacological intervention. Comorbid conditions such as Depression, ADHD, Attachment Disorder and Substance Abuse Disorders must be identified. Clinicians must identify the target symptoms or symptom clusters for treatment and specify reasonable treatment goals (e.g. reduction in sleep latency, frequency of nightmares, or avoidance behavior). Selection of therapeutics must entail an appropriate segregation of targets for psychosocial (e.g., CBT) versus biological (e.g., pharmacological) treatments, and CBT should be in place before consideration is given to pharmacotherapy. Medications are unlikely to be effective in settings where trauma exposure or abuse is ongoing in the life of a child. It should be remembered that reduction in even one symptom, e.g. insomnia, may provide significant relief and improvement in overall functioning. Medications such as the SSRI's, that target broad band symptom clusters, should be considered initially, but the use of targeted polypharmacy should be used when necessary. As a general approach, one should start with a broad spectrum agent such as an SSRI, which cover symptoms of affect dysregulation, panic, comorbid depression and anxiety symptoms. If ADHD symptoms are also present the adjunctive use of a stimulant or Wellbutrin should be considered. The alpha agonists Clonidine and Guanfacine should be considered if insomnia, hyperstartle, hyperarousal symptoms are problematic. This review is a rational point of departure for clinicians treating children and adolescents with PTSD. Clinicians are faced with the difficult task of treating this complicated and debilitating disorder in children and adolescents in the absence of publication of well controlled clinical trials. REFERENCES Allen, AJ, Leonard, H, Swedo, S: Current knowledge of medications for the treatment of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry 34:976-986, 1995. Annsten, AFT: Development of the Cerebral Cortex: XIV. Stress impairs prefrontal cortical function. J Am Acad Child Adolesc Psychiatry 38: 220-222, 1999. American Psychiatric Association: Diagnostic and statistical manual of mental disorders, 3rd edition (DSM-III). Washington, D.C., American Psychiatric Association, 1980. American Psychiatric Association: Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV). Washington, D.C., American Psychiatric Association, 1994. Benkelfat, C: Serotonergic mechanisms in psychiatric disorders:new research tools, new ideas. Int Clin Psychopharmacol 8 Supplement 2):53-56, 1993 Brady, KT: Posttraumatic stress disorder and comorbidity:recognizing the many faces of PTSD. J Clin Psychiatry 58(Supplement):12-15, 1997 Bremner, JD, Davis, M, Southwick, et al.: Neurobiology of posttraumatic stress disorder. In Oldham, JM, Riba, MB, Tasman, A, editors: Review of Psychiatry. Washington, DC, American Psychiatric Press, pp183-205, 1993 Breslau, N: Epidemiology of Trauma and Posttraumatic stress disorder in psychological trauma. In Yehuda, R, editor. Washington, DC: American Psychiatric Press; 1-29, 1998. Breslau, N, Davis, GC, Andreski, P. Peterson, E: Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 48:216-222, 1991 Brophy, MH: Cyproheptadine for combat nightmares in posttraumatic stress disorder and dream anxiety disorder. Mil Med 156: 100-101, 1991 Charney, DS, Deutch, AY, Krystal, JH, Southwick, SM, Davis, M: Psychobiological mechanisms of posttraumatic stress disorder. Archives Gen Psychiatry 50: 294-305, 1993 Chronister, RB, DeFrance, JF: Functional organization of monoamines. In Palmer, GC, editor: Neuropharmacology of central nervous system and behavioral disorders. New York, Academic Press, pp 435-462, 1981. Coffey, BJ: Anxiolytics for children and adolescents: traditional and new drugs. J Child Adolesc Psychopharmacol 1:57-83, 1990 Connor, KM, Davidson, JRT: The role of Serotonin in posttraumatic stress disorder:neurobiology and pharmacotherapy. CNS Spectrums, The International Journal of Neuropsychiatric Medicine 3(7) Supplement 2:42-51, 1998 De Bellis, MD: Posttraumatic stress disorder and acute stress disorder. In Ammerman, RT, Hersen, M editors:Handbook of prevention and treatment with children and adolescents: intervention in the real world context, pp 455-494, 1997 De Bellis, MD, Putnam, FW: The psychobiology of childhood maltreatment. Child and Adolescent Pchiatric Clinics of North America 3 (4):663-678, 1994 De Bellis, MD, Lefter, L, Trickett, PK, Putnam, FW: Urinary catecholamine excretion in sexually abused girls. J Am Acad Child Adolesc Psychiatry 33:320-327, 1994 Deutch, AY, Roth, RH: The determinants of stress-induced activation of the prefrontal cortical dopamine system. In Uylings HBM, VanEden, CG, DeBruin, MA, editors: The prefrontal cortex: its structure, function and pathology. Amsterdam, Elsevier Science Publishers, pp 367-403, 1989 Drugen, RC, Ryan, SM, Minor, TR, Maier, SF: Librium prevents the analgesia and shuttlebox escape deficit typically observed following inescapable shock. Pharmacol Biochem Behav 21:749- 754, 1984 Famularo, R, Kinscherff, R, Fenton, T:Propranolol treatment for childhood post-traumatic stress disorder, acute type: a pilot study. Am J Dis Child 142:1244-1247, 1988 Fessler, FA: Valproate in combat-related post-traumatic stress disorder. J Clin Psychiatry 52(9): 361-364, 1991 Friedman MJ: Current and future drug treatment for posttraumatic stress disorder patients. Psychiatric Annals 28:8, 461-468, 1998 Friedman, MJ: Interrelationships between biological mechansims and pharmacotherapy of post-traumatic stress disorder. In Wolfe, ME, Mosnian, AD editors. Posttraumatic stress disorder: etiology, phenomenology, and treatment. Washington, DC: American Psychiatric Press: 204-225, 1990 Friedman MJ, Southwick SM: Towards Pharmacotherapyfor Post-traumatic Stress Disorder. In: Neurobiological and Clinical Consequences of Stress: From Normal Adaptation to PTSD. Edited by Friedman, MJ, Charney, DS, Deutch, AY. Philadelphia, Lippincott-Raven Publishers, pp 465-481, 1995 Friedman, MJ Charney, DS, Deutch, AY: Neurobiological and clinical consequences of stress: from normal adaptation to ptsd. Lippincott-Raven Press: Philadelphia, PA. 1995 Giaconia, RM, Reinherz, HZ, Silverman, AB, Pakiz, B, Frost, AK, Cohen, E: Traumas and posttraumatic stress disorder in a community population of older adolescents. J Am Acad Child Adolesc Psychiatry 34:1369-1380, 1995 Glover, H: Emotional numbing: a possible endorphin-medicated phenomenon associated with post-traumatic stress disorder and other allied psychopathological states. J Trauma Stress 5:643-675, 1992 Goenjian, AK, Pynoos, RS, Steinberg AM et al.: Psychiatric comorbidity in children after the 1988 earthquake in Armenia. J Am Acad Child Adolesc Psychiatry 34:1174-1184, 1995 Gonzalez-Heydrich, J, Peroutka, SJ: Serotonin receptor and reuptake sites: pharmacologic significance. J Clin Psychiatry 51: 5-12, 1990 Graae, F, Milner, J, Rizotto, L, Klein, RG: Clonazepam in childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry 33:372-376, 1994 Harmon, RJ, Riggs, PD: Clinical perspectives: clonidine for posttraumatic stress disorder in preschool children. J Am Acad Child Adolesc Psychiatry 35:1247-1249, 1996 Horrigan, JP : Guanfacine for posttraumatic stress disorder nightmares (letter). J Am Acad Child Adolesc Psychiatry 35: 975-976, 1996 Horrigan, JP, Barnhill, LJ: The suppression of nightmares with guanfacine (Letter). J Clin Psychiatry 57:371, 1996 Kessler, RC, Sonnega, A, Bromet, E, Hughes, M, Nelson, CB: Posttraumatic stress disorder in the national comorbidity survey. Arch Gen Psychiatry 52:1048-1060, 1995 Kulka, RA, Schlenger, WE, Fairbank, JA, Jough, RL, Jordan, BK, Marmar, CR, Weiss, DS: Trauma and the vietnam war generation. New Yourk: Brunner/Mazel, 1990 Kutcher, S, Reiter, S, Gardner, D: Pharmacotherapy approaches and applications . In March, JS, editor, Anxiety disorders in children and adolescents. New Yourk: Guilford, pp 341-385,1995 Kutcher, S: Practitioner review: the pharmacotherapy of adolescent depression. J Child Psychol Psychiatry 38(7):755-767, 1997 Lipper, S, Davidson, JRT, Grady, TA, Edingar, JD, Hammett, EB, Mahorney, SL, Cavenar, JO: Preliminary study of carbemazepine in post-traumatic stress disorder. Psychosomatics, 27:849-854, 1986 Loof, D, Grimley, P, Kuller, F, Martin, A, Shonfield, L: Carbemazepine for ptsd (letter). J Am Acad Child Adolesc Psychiatry 34(6):703-704, 1995 March, JS, Amaya-Jackson, L, Murray, MC, Schulte, A: Cognitive-behavioral psychotherapy for children and adolescents Marmar, CK, Foy, D, Kagan, B, Pynoos, RS: An integrated approach for treating posttraumatic stress. In Pynoos, RS, editor, Posttraumatic stress disorder: a clinical review. Sidran Press, Lutherville, MD, pp 239-272, 1993 Perry, BD, Pollard, RA, Blakely, TL, Baker, WL, Vigilante, D: Childhood trauma, the neurobiology of adaptation, and "use dependent" development of the brain: how "states" become "traits". Inf Ment Health J 16:271-291, 1995 Perry, BD: Neurobiological sequelae of childhood trauma:ptsd in children. In Murburg, MM editor. Catecholamine function in post-traumatic stress disorder: emerging concepts. Washington, DC: American Psychiatric Press, 233-255, 1994 Pfefferbaum, B: Posttraumatic stress disorder in children: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 36:11, 1503-1511, 1997 Practice Parameters: Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry Supplement 37:10, 4S-26S, 1998 Simeon, JG, Ferguson, HB, Knott, V: Clinical, cognitive, and neurophysiological effects of alprazolam in children and adolescents with overanxious and avoidant behaviors. J Am Acad Child Adolesc Psychiatry 31: 29-33, 1992 Solomon, Z, Bleich, A: Comorbidity of posttraumatic stress disorder and depression in israeli veterans. CNS Spectrums, The International Journal of Neuropsychiatric Medicine 3(7) Supplement 2:15-21, 1998 Solomon, SD, Davidson, JRT: Trauma, prevalence, impairment, service use, and cost. J Clin Psychiatry 58(Supplement): 5-11, 1997 Southwick, SM, Yehuda, R, Giller, Charney, DS: Use of tricyclics and monoamine oxidase inhibitors in the treatment of PTSD: a quantitative review. In Marburg, MM, editor, Catecholamine function in post-traumatic stress disorder: emerging concepts. Washington, DC: American Psychiatric Press, pp 293-305, 1994 Terr, L: Childhood traumas: an outline and overview. Am J Psychiatry, 148:10-20, 1991 Van der Kolk, BA, Greenberg, MS, Orr, SP: Endogenous opioids, stress induced analgesia and posttraumatic stress disorder. Psychopharmacol Bull 25:417-421, 1989 Van der Kolk, BA, Perry, JC, Herman, JL: Childhood origins of self-destructive behavior. Am J Psychiatry 148:1655-1671, 1991 Ver Ellen, P, van Kammen, DP: The biological findings in post-traumatic stress disorder: A review. J Appl Soc Psychology 20: 1789-1821, 1990 Wells, GB, Chu, C, Johnson, R: Buspirone in the treatment of post-traumatic stress disorder. J Clin Psychiatry 55:517-522, 1991 Yeo, HM, Yeo, WW: Repeated deliberate self-harm: a link with childhood sexual abuse? Arch Emerg Med 10:161-166, 1993 Zohar, J, Yehuda, S, Amital, D, Iancu, I, Zinger, Y: Current Diagnostic issues and epidemiological insights in ptsd. CNS Spectrums, The International Journal of Neuropsychiatric Medicine 3(7) Supplement 2:11-14, 1998 Craig L. Donnelly, M.D. Assistant Professor of Psychiatry and Pediatrics Director of Pediatric Psychopharmacology Section of Child and Adolescent Psychiatry Department of Psychiatry Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire 03756 Reprint requests to Dr. Donnelly, Section of Child and Adolescent Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, 03756, telephone (603) 650-5835, FAX (603) 650-5842, Email Craig.L.Donnelly@Dartmouth.edu (http://www.ncptsd.org/treatment/literature/children/childpsychopharm.html)

Recommendations for Pharmacological Treatment of Acute Stress Reactions

A National Center for PTSD Fact Sheet
Pharmacological treatment for acute traumatic stress reactions (within one month of the trauma) is generally reserved for individuals who already have received individual or group debriefing and/or brief crisis oriented psychotherapy. If these approaches are ineffective, pharmacotherapy should be considered. To date there have been no controlled pharmacologic treatment trials for acute stress reactions. Consequently, the present recommendations are based on controlled studies of insomnia, anxiety and depression, as well as anecdotal experience. Further, there are no FDA approved medications for acute stress reactions and the only FDA approved medication for PTSD is sertraline. Prior to receiving medication, the trauma survivor should have a thorough psychiatric and medical examination. Ongoing medical conditions, psychiatric diagnoses, current medications and possible drug allergies should be assessed. In addition,
questions regarding alcohol, marijuana, and other drugs should be asked since these substances may interact with prescribed medications or may complicate an individual’s psychological and physiological response to the trauma. For individuals with medical and/or surgical concerns, special precautions may be needed when prescribing psychotropic medications. Further, it is extremely important to consider possible drug interactions in individuals who are taking other prescribed or over-the-counter medications. In some cases psychotropic medications may be needed even before a complete medical and psychiatric evaluation has been completed. The acute use of medications may be necessary when the survivor is dangerous, extremely agitated, or psychotic. In such circumstances the individual should be taken to an emergency room. In the emergency room short-acting benzodiazepines (e.g. lorazepam) or high potency neuroleptics (e.g. haldol) with minimal sedative, anticholinergic and orthostatic side effects may prove effective. Atypical neuroleptics (e.g. risperidone) also may be useful at relatively low doses in treating impulsive aggression. After a disaster some survivors experience extreme and persistent arousal in the form of anxiety, panic, hypervigilance, irritability and insomnia. Empirical research has shown that hyperarousal during the first few weeks following trauma is a risk factor for the development of PTSD. Techniques to reduce arousal include relaxation and breathing exercises, social support, psychotherapy and pharmacotherapy. Pharamacologic agents for the treatment of trauma-related arousal include benzodiazepines and antiadrenergic agents such as clonidine, guanfacine and propranolol.
Benzodiazepines are useful because they are effective and fast acting. In recent trauma survivors, they can reduce anxiety and arousal and improve sleep. However, prolonged use may not be indicated. In a study of trauma survivors with an acute stress disorder (i.e. occurring 1-3 months after the trauma), the short-term use of benzodiazepines for sleep was associated with an acute reduction in posttraumatic stress symptoms (Mellman et al 1998). However, another study found that the early and more prolonged use of benzodiazepines was actually associated with a higher rate of subsequent PTSD (Gelpin et al 1996). It is recommended that benzodiazepines be used to treat extreme arousal, insomnia and anxiety but
that their use be time limited. Other pharmacologic agents also may be helpful in treating insomnia in persons suffering from acute traumatic stress. Low dose trazadone, nefazodone and amitriptyline are possible choices. Antiadrenergic agents have not been studied for the treatment of acute stress reactions, however several open trials have been conducted in chronic PTSD. These agents have been useful in some patients for the control of hyperarousal, irritable aggression, intrusive memories and insomnia. Low dose propranolol also has been successfully used for stage fright and performance anxiety because of its acute efficacy in modulating physical and cognitive manifestations of stress. However, clonidine, guanfacine and propranolol should be prescribed judiciously in survivors with cardiovascular disease as they
may reduce blood pressure or, in the case of clonidine, induce rebound hypertension if blood levels fall due to infrequent dosing or sudden discontinuation. Further, these agents should not be prescribed to persons with diabetes as they may interfere with counterregulatory hormone responses to hypoglycemia.

Recent trauma survivors may also suffer from debilitating symptoms of depression. Since all three symptom clusters of PTSD respond to SSRI’s, and because depressive symptoms originating soon after trauma may predict PTSD, it is recommended that SSRI’s be considered for persistent post-traumatic depression. In addition, SSRI’s may be useful to control anxiety and irritability. It is important to note that traumatized women, compared to men, may be particularly responsive to the beneficial effects of SSRI’s. In any case, the SSRI’s as well as other antidepressants, should be administered in a "start low and go slow" dosing regimen, as some individuals may develop increased anxiety, agitation, or occasionally even psychotic or manic symptoms in response to them. Some individuals have pre-existing psychiatric disorders at the time that they experience trauma, including pre-existing PTSD. Trauma may exacerbate these conditions, making careful assessment of psychotherapeutic and pharmacologic needs essential. It is imperative that current treaters are contacted and that continuity of care is maintained. It is also possible that trauma will precipitate disorders other than depression, traumatic grief, acute stress disorder or
PTSD. In such cases, careful assessment and diagnosis should inform appropriate treatment.
Finally, it is essential that treaters educate patients about potential medication side-effects, interactions with alcohol, other medications, or substances of abuse, and remain in close touch with patients after initiating these, as well as other psychotropic agents. This will allow treaters to gauge the seriousness of any side-effects, encourage compliance, and forestall untoward complications due to extreme or otherwise idiosyncratic reactions to these medications. In addition, the added therapeutic support can help to relieve the psychological burden in persons suffering from posttraumatic distress.

(source: http://www.ncptsd.org/facts/disasters/fs_medication_disaster.html)

 

Janelle responded well to a change in her medication, particularly an increase in her antidepressant and an additional medication for her flashbacks. She is slowly regaining the ground she lost after the Terrorist attack. She still feels quite fragile, and in her sessions she continues to show regressed content, such as doll play, rather than the talking she had been capable of prior to September 11. She now has found the word for 'flashback' again, and has been able to communicate with the staff at the vocational center when she begins to feel overwhelmed. She is coming back, but it is still a long, long journey for Janelle.

 

Excerpted from:Psychopharmacology and Posttraumatic Stress Disorder by Stanley R. Platman, MD [International Journal of Emergency Mental Health, 1999, 3, 195-199.] Posttraumatic stress disorder may develop after exposure to severe stress, such as combat, accidents, assaults and natural disasters. Pharmacotherapy can be a useful adjunct in the comprehensive treatment of these patients. The presence of comorbid conditions, including depression, panic disorder, substance abuse and traumatic brain injury, should be carefully evaluated. Symptoms of PTSD that are associated with central nervous system hyperarousal or reexperiencing of the traumatic event appear to be the most responsive to pharmacotherapy. Social withdrawal and dulled responsiveness have not been shown to be alleviated through standard pharmacological interventions. Pharmacotherapy can assist in the patient’s ability to participate in psychotherapy. Panic attacks, fear, hallucinations, insomnia, and other disturbing symptoms can interfere with the patient’s ability to participate meaningfully in the intellectual and emotional tasks of psychotherapy. By reducing the intensity of these debilitating symptoms, medications can actually facilitate the psychotherapeutic process, permitting symptom reduction to be achieved. In PTSD complicated by comorbidity, medications can alleviate conditions such as mania and depression, which make psychotherapy impossible. In the most severe and psychotherapy-refractory patients, medications may be the only viable alternative. Patients with disabling flashbacks, nightmares, startle, panic, and other debilitating symptoms may find some relief only in psychotropic medication. Clearly, more research is required before we can approach the pharmacotherapy of PTSD in the same informed fashion in which we approach the pharmacotherapy of depression or anxiety. In addition, no prospective double-blind studies have looked at combinations of medications, treatment-resistant patients, related substance abuse problems, treatment duration or relapse, or likely response rate. A paper written for the American Society of Clinical Psychopharmacology (Marshall, 1995) outlined some guidelines for the use of psychotropic medications in PTSD. They are: • Serious comorbid conditions known to respond to medication: psychosis, major depression, panic disorder, social phobia, etc. • Preexisting conditions that are medication responsive. • A history of prior failure of an adequate trial of psychotherapy (approximately three months). • Individuals who are not psychologically minded, who prefer medication treatment, or who otherwise appear unable to enter into a collaborative psychotherapeutic relationship. • A patient’s inability to tolerate the acute distress sometimes associated with PTSD psychotherapy. Psychopharmacologic Considerations in the Treatment of PTSD Learned Helplessness Clonodine Benzodiazepines Tricyclics MAOIs Hyperstartle Clonodine Intrusive Ideation MAOIs Selective serotonergic reuptake inhibitors (SSRIs) Tricyclics Panic Alprazolam Clonazepam Depressed Mood and Avoidance SSRIs. e.g., sertraline Impulsive Rage Lithium Carbamazepine Sleep Disturbance Trazodone published by International Critical Incident Stress Foundation, Inc. http://www.icisf.org/Acrobat%20Documents/TerrorismIncident/PTSDPsychoPharm.PDF

6. Spirit

Future Action on a Personal and Community Level

Sometimes the most crucial part of changing the world is changing ourselves; bringing shadow material to consciousness, and pulling back projections. As we educate ourselves, racial and religious stereotyping diminish. After the September 11 bombing, many realized how little they knew of Islam, or the Middle East. We are learning how far away Osama bin Laden and the Taliban are from the tenets of Islam. We need though, as a culture, to understand the fear and disempowerment, the rage and pain that feeds terrorist acts. Not to excuse them, but to do what we can to prevent future generations of terrorists. No nation is exempt from terrorism.

Consciousness and compassion are the keys. Search always for the light in the darkness.

Contributions of time and energy are also important. In this course, there have been references to:

The American Red Cross needs volunteers, and will provide training. If you can, give blood. Go to:

http://www.redcross.org/donate/volunteer/ for more information.

The Green Cross Projects (GCP) is a humanitarian service organization originally started by the Traumatology Institute in response to the Oklahoma City bombing in 1995. The goal of GCP is to provide immediate trauma intervention to all areas of our world when a crisis occurs. This includes assistance in the most recent world disaster, the issue of violence in the media, the crisis in Kosovo and discussions on other events, such as the rampage tragedy in Littleton, Colorado (USA). For the most recent information, other than this web site, members are urged to read the most recent issue of the e-journal,
TRAUMATOLOGYe and the Newsletter. http://www.greencross.org/

The Association for the Study of Dreams has established a Nightmare Hot Line : They need volunteers to staff the line. Please go to: http://www.asdreams.org/nightmare_hotline.htm to help.

Education

In the West, we need to educate ourselves and our children about other cultures and religions. A good place to start is Understanding Islam, Beliefnet's Islam Primer, at http://www.Beliefnet.com/index/index_40118.html. According to this site,

"The word Islam derives from two Arabic words that point directly to the central
tenets of the faith: first, the word "taslim," which means submission; and then
the word "salam" which means peace. At the very core of Islam is submission
to God and the call to peace.
The prophet Muhammad ordered his fellow Muslims to salute all people –
fellow Muslims and non-Muslims alike – with peace. The traditional salutation
in Islam is: "Al Salamu Alaikum" – "Peace on You."

Compassion Fatigue

 

"All strong souls first go to hell before they do the healing of the world they came here for. If we are lucky, we return to help those still trapped below." - Dr. Clarissa Pinkola Estes

 

Cora came to therapy looking exhausted. She is a therapist with a huge caseload, including children, adolescents and adults. Her task is complicated by the paperwork required by the many managed care panels on which she serves. Her pallor was gray, she had dark circles under his eyes. "I don't know how much more of this I can hear. I feel like a sponge that is saturated, there is no way to wring it out. I am carrying so much pain right now. And I don't even want to talk about it, because I don't want to burden you as well. I know that you work with children as well as adults, and I think that you're probably all filled up too." I reassured her that she could talk about how much she was carrying, but also felt that she needed us to speak as peers, as well as patient to therapist. We spoke of the horror, and how much we were holding for ourselves, our families, and our patients. She went on to add, "I also feel that we are doing this for the country and the world as well. That therapists somehow hold the heart and soul of the people, and we have to feel all the feelings." Cora is probably unconsciously doing the Tonglen Meditation, or The Seven Points of Mind Training Exchanging Self for Others. "The core practice involves taking on others' sorrow and pain and sending them your joy; not as a masochistic practice but with the aim of getting away from the self-centeredness and self-seeking that cause us so much pain. These practices were brought to Tibet in the eleventh century by the Indian Buddhist teacher Atisha." For more on this, please go to: http://www.theflow.org/tonglen/

Compassion Fatigue is when we are tired, and have no more room for compassion. Perhaps we are overwhelmed, or filled up, with all the stories and all the pain. Compassion fatigue doesn't only happen to therapists; doctors, ministers, EMTs, all those in the 'Helping Professions' can reach the point at which there is no more help to give. Caretakers also can suffer from this; a parent with a disabled child, a spouse taking care of a partner with Alzheimer's, a person whose partner has a chronic or terminal illness can all get to the place of being empty.

The term Compassion Fatigue, coined by Dr. Charles Figley of Florida State University, is defined as "a condition common to professional care-givers that is described as a union of secondary
traumatic stress and burnout. Secondary trauma occurs when one is exposed to extreme events that were directly experienced by another person. Burnout is a state of physical, emotional and mental exhaustion caused by an overwhelming depletion of ability to cope with one's everyday environment. (source: http://www.psychink.com/press.html)

There is a copy of the Compassion Satisfaction and Fatigue (CSF) Test, written by B. Hudnall Stamm & Charles R. Figley at: http://www.isu.edu/~bhstamm/satfat.htm

There is a concept called Vicarious Traumatization or VT. "Vicarious traumatisation refers to the cumulative transformative effect upon the trauma therapist of working with survivors of traumatic life events. .... It is a process through which the therapist's inner experience is negatively transformed through empathic engagement with clients' trauma material" http://www.massey.ac.nz/~trauma/issues/1998-2/steed.htm

In Professionals Coping with Vicarious Trauma Josef Ruzek, Ph.D. in the NCP Clinical Newsletter 3(2): Spring 1993 quotes J. L. Herman(1992. Trauma and Recovery. U. S. A.: Basic Books):

"Engagement in this work thus poses some risk to the therapist's own
psychological health. The therapist's adverse reactions, unless
understood and contained, also predictably lead to disruptions in the
therapeutic alliance with patients and to conflict with professional
colleagues. Therapists who work with traumatized people require an
ongoing support system to deal with these intense reactions. Just as no
survivor can recover alone, no therapist can work with trauma alone".
http://www.ncptsd.org/treatment/cq/v3/n2/ruzek.html

  What we can do

Kuan Yin

(source: http://www.tbsn.org/english/library/sutras/kuanyin.htm)

A helpful meditation is to give all your pain, and that of your clients, and that of the the world, to Quan Yin.

The lines from T.S. Eliot's Four Quartets "Oh dark dark dark"  keep running through my brain, as I contemplate what is happening to the world.

I begin my own process of grief. I ask for the help of Kuan Yin, the Bodhisattva of Compassion, to help me hold the pain and grief. Her name means "She Who Hearkens to the Cries of the World".  She is also known as Quan Yin, Kannon, Avalokitesvara, Miao Shan and Tara.

Here she is depicted with a bottle, pouring out her endless compassion and mercy on us all. (For more images of Kuan Yin, please go to Kuan Yin.) One story of Kuan Yin states that she was on the threshold of Nirvana when she heard the cries of human pain. She (or He; Kuan Yin is sometimes referred to as male) stopped and would not cross. She will stay with us until all the tears have been shed.
 

Quan Yin is one of the most universally beloved of deities in the Buddhist tradition. Also known as Kuan Yin, Quan'Am (Vietnam), Kannon (Japan), and Kanin (Bali), She is the embodiment of compassionate loving kindness. As the Bodhisattva of Compassion, She hears the cries of all beings. Quan Yin enjoys a strong resonance with the Christian Mary, the Mother of Jesus, and the Tibetan goddess Tara.
In many images She is depicted carrying the pearls of illumination. Often Quan Yin is shown pouring a stream of healing water, the "Water of Life," from a small vase. With this water devotees and all living things are blessed with physical and spiritual peace. She holds a sheaf of ripe rice or a bowl of rice seed as a metaphor for fertility and sustenance. The dragon, an ancient symbol for high spirituality, wisdom, strength, and divine powers of transformation, is a common motif found in combination with the Goddess of Mercy. Sometimes Kuan Yin is represented as a many armed figure, with each hand either containing a different cosmic symbol or expressing a specific ritual position, or mudra. This characterizes the Goddess as the source and sustenance of all things. Her cupped hands often form the Yoni Mudra, symbolizing the womb as the door for entry to this world through the universal female principle. Quan Yin, as a true Enlightened One, or Bodhisattva, vowed to remain in the earthly realms and not enter the heavenly worlds until all other living things have completed their own enlightenment and thus become liberated from the pain-filled cycle of birth, death, and rebirth.

(source: http://www.crystalinks.com/quanyin.html)

Tikkun Olam

In the Kabbalah, an ancient Jewish mystical text, is the concept of 'tikkun olam'. "The true self within
something is referred to in Kabbalah as a holy spark, and the Zohar tells us that nothing can exist without having a spark of holiness at its core. The process of removing barriers to release these sparks is known as tikkun, correction or repairing. To repair the world at large through good works is tikkun olam, and to repair one's individual soul is tikkun nefesh. " (source: http://web.wt.net/~cbenton/kabbalah/klippot.htm)

Thich Nhat Hanh

Buddhist teacher Thich Nhat Hanh, quoted in Buddhist teachers with Berkeley ties counsel pacifism by Don Lattin (S.F. Chronicle, 10/14/01) was asked what he'd say if he could speak to Osama bin Laden.

"The first thing I would do is listen," he replied,
"listening with great will to understand the roots
of suffering that are the cause of the violent
action."
Does he favor a military strike against the
terrorists or the nation's that are harboring them?
No.
"All violence is injustice," he said. "The fire of
hatred and violence cannot be extinguished by
adding more hatred and violence to the fire. The
only antidote to violence is compassion."
Then what would he do?
"We have to find a way to stop violence, of
course. If need be, we have to put the men
responsible in prison."
Why is this happening to America? Why do they
hate us?
"The deep reason for our current situation is our
patterns of consumption. U.S.A. citizens
consume 60 percent of the world's energy
resources yet they account for only 6 percent of
the total world's population."
(source: http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2001/10/14/LV223812.DTL)

 

Chögyam Trungpa

There is a moving article entitled "The Four Foundations of Mindfulness Meditation" by Chögyam Trungpa. Included are discussions and practices for Mindfulness of Body, Mindfulness of Life, Mindfulness of Effort and Mindfulness of Mind. This article is at http://www.shambhala.org/teachers/vctr/fourfoundations.html

Your own spiritual practice

Whether you are Jewish, Christian, Islamic, Buddhist, Pagan, or ????, now is a good time to revive your spiritual practice, be it praying, walking in the woods, meditating, etc. Anything that allows us to feel connected to some force who is greater than ourselves, and who will help us hold the pain, is a good thing right now.

Stop and take breaks. Turn off the TV and the radio. Exercise, Take your vitamins and try to eat healthy food. (Yes, Mom). Reread your favorite books from childhood. Surround yourself with beauty. Go for walks. Kiss and hug your family and friends. Drink really good coffee and tea. Keep a journal. Doodle. Laugh. Practice 'random acts of kindness and senseless acts of beauty'. Cry when you feel like crying. Dance. Wear your favorite clothes, so you look like a million dollars (even if you don't feel like a million dollars). Honor your shadow, by acknowledging some really horrible part of yourself that it is easier to project onto someone else...this work can save the planet, if everybody did it. Speak out against racial and religious stereotyping. Honor your heroes. Listen to Louis Armstrong singing, "What a Wonderful World."

One meditation that helps me is adapted from the Tibetan Book of the Dead. What I try to do every night as I fall asleep is to remember:

one beautiful sight from the day...

a sound that gave me pleasure (could be music, or bird song, or my partner saying, "I love you")...

a delicious taste...

a wonderful smell...

a soothing touch...

One pleasing memory for each sense, to help me appreciate being on this little planet.

Suzanna, age 9

Hope

It is important to remember and reaffirm the healing power of the human spirit, and the resiliency of the heart. Please try to not lose hope as you do this crucial work. Healing is possible. There is a part in each of us, called by different names: the Self, the soul, the spirit, the being...that can never be harmed or injured, no matter what has happened to the body or psyche of the person traumatized. If we as healers can hold onto this light, even in the darkest times, then healing is not only possible, it is probable.

Go well in your journey as a healer.

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