336 Original articles and reviews Decree 22/97;Ministerialdecree 471/99;Legislative age toculturalandenvironmental assets(Legislative impact onnearbyareas,ecological hazard,anddam- in termsofquantityandhealth hazard,environmental identified throughanalysisof thecontaminatingagents are areascomprisingoneormorecontaminatedsites nation resultinginhealthimpacts”[1]. with astrongpotentialtoproduceenvironmentalcontami- large and/orhazardousindustrialfacilities,producingor sites (CSs) as “localized areas hosting or having hosted Health Organization(WHO)definescontaminated relevant consequences for publichealth.TheWorld jor roleinthecontaminationofsoil,waterandair, with are presentwhichplayed–andcontinuetoplayama- INTRODUCTION Dipartimento diPsicologia,UniversitàdegliStudiTorino, , Antonella Granieri needs-centered healthcareorganization on psychologicalimpacttoacommunity in CasaleMonferrato:fromresearch Community exposuretoasbestos DOI: 10.4415/ANN_15_04_14 Ann IstSuperSanità2015|Vol. 51,No.4:336-341 [email protected]. Address forcorrespondence : AntonellaGranieri, DipartimentodiPsicologia,Università degliStudidiTorino, Via Po14,10123Turin, Italy. E-mail: participants duringthefinalstagesoftheirownlife,orthatsomeoneclosetothem. trust befreetogrowwithinasomato-psychicspaceableaccommodateandsustainthe Only withthecombinedsupportofoncologistsandentirewardstaffwillaninternal community, butit requires time,forpatients,relatives,andtheprofessionalsinvolved. Conclusions. residual life. alone; 2)improvedabilitiesofcaregiverstomanagethedisease;3)enhancedquality impact, inordertoachieve:1)asubjectiveperceptionofthemselvesasnotimpotentand Results. Theclinicalworkoffersaspaceforhandlingtheillnessanditspsychological of theemotionsrelatedtoill-fatedprognosis. choanalytic groupwasarranged,aimedatpromotingthesymbolizationandsignification backgrounds. Startingfromtheresultsobtainedduringafirstassessmentphase,psy- model thatcouldfitintoothercontexts,whilebeingflexibleandadaptingtospecific and administrators,fieldactions,systemthinking.Ourgoalwastocreateareliable site direction:promotingadifferentinteractionbetweenhealthsystempolicy-makers Method. The work carried on in Casale Monferrato since 2006 proceeds inthe oppo- interpersonal processesconnectedtolivinginaspecificcontext. sues areaddressedviatop-downstrategies,butthisapproachisunabletoaddressthe the population,andonitspsychologicalcommunitycomponents.Usuallysuchis- Introduction. Asbestosexposurehasanegativeimpactonboththephysicalhealthof Abstract The NationalPriorityContaminatedSites(NPCS) In the European Union, several industrial facilities An integratedmultidimensionalinterventionpromotesresilienceinthe Decree 152/2006). can move unconscious conflicts between life and death, can moveunconsciousconflicts betweenlifeanddeath, fected: living in such a potentially harmful environment traumatic impactthatisnotlimited tothosedirectlyaf- and thediagnosisofasbestos-related diseasescanhavea mesothelioma andasbestosis). Theexposuretoasbestos tion, oil)inthatitcausesspecificdiseases(i.e.,malignant agents, asbestosdiffersfromothers(e.g.,nuclearradia- cal andcommunitycomponents.Amongcontaminating physical healthofthepopulation,andonitspsychologi- of populationhealth[2]. veillance programalsoensuresapermanentmonitoring d’interesse nazionale). A national epidemiological sur NPCSs, definedassitesofnationalinterest(SIN–siti the MinistryofEnvironmentidentifiesandrecognises thorough processofenvironmentalcleanup.InItaly, Living on or near a CS has a negative impact on the Living onornearaCShasnegativeimpactthe

They aresupposedtoundergoa • • • • • Key words

mentalization resilience psychological effects asbestos contaminated sites

- 337 Community exposure to asbestos

intense feelings of helplessness, hopelessness, guilt, and exposure, and to environmental exposure [22, 23]. For shame, as well as rage and the desire for revenge [3, 4]. over 80 years, Casale Monferrato was one of the larg- At the intrapsychic level, depression, fears, and anxiet- est asbestos-cement producers, and the Eternit factory ies emerge, while at the interpersonal level, social with- granted jobs and prestige for the population, until 1986, drawal, loss of the sense of belonging, and loss of social when production of such cement was declared illegal in cohesiveness are often observed [5-13]. Casale’s District (its production was declared illegal on Such evidence strongly suggests the need to adopt an a national level in 1992, Law 257/1992). The exposure integrated approach toward the patient, improving the was not only limited to production itself, but also to: reviews development of active strategies by taking into account • transportation of raw asbestos and final products be- the particular features of the subject and his or her liv- tween the factory, the warehouse, and the railway sta-

ing environment. tion; and

• use of scrap materials by citizens for upholstery, in MIND DEVELOPMENT AND SOCIAL maintenance of private streets, and/or for thermal insu- CONTEXT lation in attics; Studies in neuroscience and psychoanalysis have • illegal unloading from the ’s rivers, creating the articles demonstrated that significant interactions with the “white shores” where inhabitants used to spend warm other are a necessary process in the creation and de- days. velopment of one’s psychological reality: they influence In the Casalese community asbestos was present cognition and the maintenance of high-quality social in- at every level: it was produced, consumed, and was a teractions. Based upon this process and related experi- major driving force of the local economy. Although as- riginal ences, memory traces are stored in the brain and active- bestos production was advantageous on many levels, in O ly participate in the modeling of mental representations time it became evident that this production was nev- integrated with affect and somatic expressions [14, 15]. ertheless dangerous for the residents, causing deaths, Body-based relational experiences profoundly impact and will continue to harm those residing in the Health the maturation of experience-dependent structures in District [3, 10]. As noted by the International Agency the right hemisphere, which is involved in communicat- for Research on Cancer, all forms of asbestos are carci- ing and regulating affect. These embodied functions, nogenic to humans. It causes mesothelioma and cancer typical of the psychoanalytic construct of “subjective of the lung, larynx, and ovary. Positive associations have implicit self,” have a fundamental impact on every sub- been observed between asbestos exposure and cancer sequent intersubjective interaction and on stress regu- of the pharynx, stomach, and colorectum [24]. Among lation [16, 17]. Cerebral structures in the right hemi- pathologies caused by asbestos exposure, malignant sphere play a major role in “the innate psychobiological mesothelioma (MM) has received major attention. It need for affiliation and social connection, and thereby for is a rare form of tumor with a fatal prognosis, which emotional regulation and personal growth” ([18], p. 179) develops almost exclusively from environmental expo- during the lifespan. FMRI research shows that the sub- sure to asbestos. The incidence of MM in 2008-2012 cortical amygdala responds to directly perceived emo- was 72.8/100 000 and 33.2/100 000 among women tional stimuli, while the ventromedial cortex responds in Casale Monferrato, and 42.2/100 000 among men to cognitively elicited emotions. In most favorable con- and 20.1/100 000 among women in its health district, texts, the orbitofrontal cortex takes control of amygdala with a total 223 diagnosed cases of MM. Over 4/5 of operations, coordinating exteroceptive and interocep- these were not related to occupational exposure. On a tive functions more flexibly in response to condition physical level, its impact is devastating: pain, respiratory changes [19]. In the more evolved stages, these aspects distress, fatigue, sleep disorders, and loss of appetite. are integrated with language. Therefore, living in a spe- The average survival rate is approximately nine months cific context sets in motion an interpersonal process from diagnosis, and only 8% of patients are still alive that has important consequences for ideation and be- after three years. Moreover, the latency from exposure havior (for research on gene-environment in the devel- to onset varies between twenty and forty-five years, opment of human diseases see [20, 21]). probably because of the numerous genetic mutations Caring for communities forced to deal with living in a that occur in the mesothelioma, and specific symptoms CS implies taking into account the aspects mentioned appear only later on [25, 26]. This implies that people above. From a psychological point of view, it is impor- living in the Casalese area are still at risk of developing tant to mentalizing the loss, and to develop abilities that MM, since the first symptoms can appear only thirty help in facing the internal conflict that arises from living or forty years after exposure, and deaths will continue in a place that is both a bearer of life and death. These for at least twenty more years [27-30]. Despite being have to be promoted on two different fronts: individual common knowledge, it remains a challenge to properly and social-interpersonal-transpersonal [3, 10]. address the problem in terms of accommodation, sup- port, and therapy. ASBESTOS EXPOSURE IN CASALE Usually, such issues are addressed via top-down strat- MONFERRATO egies: actions are planned on the “drawing board”, of- Casale Monferrato is a town located in North-West ten actions focused on the pathology itself instead of Italy, which is well known for the high level of mortal- more broadly, based on the interconnection between ity of its residents following asbestos exposure. Several patients, caregivers, and the general population. The lung diseases are connected both to past occupational former approach is unable to adequately address the 338 Antonella Granieri

interpersonal processes connected to living in a specific the community was subjected. context, undermining any chance of achieving effective In such a context, as well as in other CSs, a cumula- results inside the community it was initially planned for. tive trauma originates, leading to a misunderstanding The work that has been conducted in Casale Mon- of the message sent by those in need of care to those ferrato since 2006 proceeds in the opposite direction, who are supposed to provide care (e.g., health person- promoting a different interaction between health sys- nel, institutions, organizations, etc.), ultimately influ- tem policy-makers and administrators, field actions, encing the way the request for healthcare is conveyed. and “system thinking” [31, 32]. Such a trajectory ulti- Moreover, since the entire population is considered reviews

mately allows coordination among policy, practice, and at risk, the care providers to whom the subject relates research. during his evolution, are immersed themselves in the

and This model is the result of a decennial work in the experience of living on a CS. A vicious circle is then

field, and arose progressively from evidence. Our goal established, based on the pathogenic stimulus. This was to create a reliable model that could fit into other implies a peculiar problematic clinging to the other in contexts as well, such as different tumors (e.g., sarcoma, order to achieve novel psychological realities not exclu- breast cancer) or different fields, while being simulta- sively based on the reality of the illness itself. Thus, it articles

neously flexible and adaptable to the specific circum- is not possible to interact with such communities only stances of all backgrounds. in terms of communication of the risks or in terms of the content of the message. Rather, an accurate analy- TOWARD AN INTEGRATED MODEL sis of the psychological characteristics of the receiver is riginal OF TREATMENT required. Most notably, an analysis of those character- O The residents of Casale Monferrato became subjects istics of the community mental life that are connected of a community tragedy, in which illness and death were to living in a CS. given a “geographical connotation”: the traumatic expe- The need for an integrated model of treatment riences became connected to the workplace, affecting emerges as it allows: the entire community. In such a situation subjective- • facilitation of a feeling of responsibility toward one’s ness had subsided and the sense of self melded with the own health, and increases the adherence to treatment; sense of being part of a group through mass identifica- • acceptance and treatment of the psychological dis- tion [3, 10, 33]. Thus, the individual self gave way to tress of both patients and caregivers from a multidi- an ideal communitarian self, giving rise to fluctuations mensional perspective; between the feeling of being appointed and the feeling • development of active strategies, starting from the of being resistant to the illness. specific features of the subject’s living environment. The multifaceted nature of the problem characterized the community both as an oppressed one, a victim of A CLINICAL PSYCHOLOGY INTERVENTION society and profit, and as a united community with the The repeated health requests made by the citizens led political and social agenda of obtaining recognition for institutions to implement novel multidisciplinary inter- the damage suffered. In time, the community assumed ventions, with a strong accent on the evaluation of both an image of resilience to the public opinion, but they patient’s and caregiver’s intrapsychic and relational dy- talked in a kind of automatic way about the meaning of namics. There was a need for the entire community to living in Casale, and being able to face the fear of death. find a “third” interlocutor, namely an institutional fig- However, this attitude did not really help in evolving, ure, who would foster new reasoning about the prob- both on a somatic and on a psychological level, an ap- lem. Thus, in 2006, first the Health Service and then propriate and shareable representation of what was the Regione contacted the post-graduate spe- meant by living in a polluted environment. They were cialization School in Clinical Psychology, of which the somehow unable to embrace the essence of resilience, Author is Director. intended as a midway space that allows the transition This work, and the geographical proximity to Casale from dying to attachment to life [34]. In the beginning, Monferrato, drove the author to a profound reasoning facing death used to be contained; people died one by about what contribution a psychoanalytically oriented one, as if they were oppressed by some kind of a “cyni- clinical psychology approach might bring, despite such cal and wicked evil”, or death simply was considered massive trauma arising from living on a polluted area. the price to pay for industrialization and the wealth and This contribution could not ignore the importance of opulence consequently acquired. Things would have data underlined by institutions, because of their value been different if the deaths had occurred all at once. on academic, political, and legal levels. An open confrontation about dying from asbestos re- lated diseases was extremely difficult, as it meant tak- Evaluation of psychological effects clinically observed ing the risk of being identified as wanting the plant to in patients and relatives be closed, which would inevitably trigger a reaction The intervention considered a first research phase from the shareholders. No worker could place his own on a representative sample of citizens, for evaluating physical and psychological survival in second place, but the dimensions of personality and cognitive, affective, seeking these goals meant somehow colluding with the and behavioral functioning. The research aimed to: 1) industrial governance. Nevertheless, the constant in- identify a communication strategy for risk exposure and crease in the number of deaths finally offered the op- diagnosis, based on the citizens’ specific personality or- portunity to obtain recognition for the offence to which ganizations; 2) promote a change in citizens’ health re- 339 Community exposure to asbestos

quests, which instead of being related to automatic pro- debilitating and fatal illness was somehow prevented by cesses and psychological features (i.e., the fear of aerial an unconscious fantasy of being “stripped” of their pro- contagion) would be grounded in real health needs; 3) fessional identity, feeling naked in front of the psychic develop a psychotherapeutic group intervention to ad- pain [3, 10, 33]. dress health needs. The clinical work focused on promoting the acknowl- Results showed how asbestos exposure configured edgment of a dysfunctional emotional regulation, col- itself as a traumatic event, leading to the loss of the luded with work resources, environment and citizens, healthy aspects of the self, confidence, and hope for the characterized by denying the connotations of death re- reviews future. Both patients and relatives showed an impov- lated to the production of asbestos. erished affective life, somatizations, social withdrawal, Session after session, the group was gradually able

difficulties in decision making as individuals and as a to develop new expressions of resilience, putting aside and group, an amplified sense of discouragement and de- the subject “asbestos”, while acknowledging at the same moralization, deep feelings of helplessness and vulner- time the motivation to fight to obtain recognition of the ability toward real or imaginary threats, a general sense damages. This change, which was not easy nor painless, of failure in life, and the perception of lacking the nec- was achieved through the processing of “psychological articles essary resources to face everyday life [7, 9]. The repeat- hubs”, in which aggressiveness and rage represented the ed requests for help subtended the profound need for preferred channel of communication. help in handling what was happening to the community, Becoming able to tolerate such aggressiveness, and to create a mental representation of it, and to be able to reclaiming the right to live despite the illness, led to an at least start putting into words the related affects [9]. evolution of the more conflicted interpersonal relations. riginal This was most notably so for topics of life and death, O The multifamily group such as the effects, shared between the participants, Starting from the results obtained during the first of living in Casale, particularly those related to being a assessment phase, a psychoanalytic group [35] was survivor. They became citizens not only as individuals, arranged, aimed at promoting the symbolization and but also as a group, sustained by a more healthy resil- signification of the emotions related to the ill-fated ience resulting from the expression and analysis of every prognosis. The group constituted the most appropriate different shade of trauma, rather than just an aggrega- setting in promoting a deep change in a traumatized tion of people sharing a common goal. As individuals, community, aimed at the development of Ego resources they became able to gradually gain strength starting to better sustain those suffering parts of the Self. In- from their own pain, becoming more evolved and able deed, during sessions new narrations about the somato- to express themselves, carrying on their personal and psychic distress developed [3, 10, 33]. social behaviors. Namely, it has been conducted a multifamily group The psychotherapeutic work allowed for the matura- based on the model first introduced in Argentina by tion of new perspectives. Social interventions were no Jorge Garcìa Badaracco [36, 37], for taking care of dif- more focused on the corrupt nature of the events, but ficult psychiatric pathologies (the groups were led by rather deeply rooted in the shared experiences of feel- the author of this contribution Antonella Granieri and ings arisen by living on a CS. It could be rightly said Francesca Viola Borgogno, an individual and group psy- that the mind recovers the possibility of entering into chotherapist candidate of the Italian Society of Psycho- a dialogue with the feelings connected to the trauma, analysis). According to the original setting, the group without bypassing them towards actions that are appar- was open to anyone who wished to join: patients, rela- ently more assertive of one’s sense of Ego. The analytic tives, health and assistance workers, and generally to work created a space where thinking about the asbes- any interested citizen. The choice of this specific kind tos-related trauma could become a prelude to action. It of psychotherapeutic intervention was connected to the could be said that through public-a(c)tion, the analytic fact that the multifamily group was a particularly suit- word is turned into a language of effectiveness [38]. able instrument for helping pleural mesothelioma pa- tients, who joined according to their specific timetable CONCLUSIONS in relation to their physical condition. Living on a CS leads to important consequences at Sessions were carried out weekly and lasted one hour the level of 1) “being” (that is, health and somatopsy- and half. Every session was audio-recorded and tran- chic well-being); 2) “belonging” (the sense on being scribed verbatim at a later stage. About fifty people part of a community also when relating to economical joined the group after it was first established, with an features); 3) “becoming” (projecting one’s expectations average of fifteen attendees per session. Most partici- into the future) [39]. pants suffered the loss of more than one relative, oth- An integrated multidimensional intervention is there- ers were affected by pleural mesothelioma or other fore more efficient than other approaches, and allows asbestos related pathologies, while the health person- acceptance of, and caring for, both patients and caregiv- nel participated only occasionally, due to “hospital ers in psychological distress. The aim is to offer a con- emergencies”. This attitude underlined a difficulty in veying space for starting to handle the illness and its differentiating the somatic features of the pathology psychological impact, in order to achieve: from the psychological distress that emerged inside the 1. a subjective perception of themselves not as impo- group. The chance of getting deeply involved with the tent and alone in face of the illness and death; physical and psychological pain of those affected by a 2. improved caregivers’ abilities to manage the disease 340 Antonella Granieri

and straightening families’ and patients’ competences Moreover, it is important to underline the centrality in devising strategies to deal with the end of life; of cohesiveness during the sessions, for both patients 3. enhanced quality of residual life, encouraging the and relatives, in order to achieve a continuous partici- recovery of lost or abandoned healthy habits, due to a pation. Only with the combined support from oncolo- perception of oneself – and the context – as diseased gists and the entire ward staff – nurses in first instance, and dying. who are those who will actually follow the patients in It should be noted that the shared meaning of care managing the different phases of the disease – will an and rescue offered to the citizen can play an important internal trust be free to grow within a somato-psychic reviews

role in promoting resilience [40]. Such intervention re- space able to accommodate and sustain the participants quires time, for patients, relatives, and the professionals during the final stages of their own life, or that of some-

and involved. Indeed, reaching a definitive deadly diagno- one close to them.

sis is a particularly complex step. The patient should be notified of this by the oncologist and the clinical Conflict of interest statement psychologist jointly, once a third space that includes The author has no conflicts of interest to declare. psychological features has been created. This space is articles the therapeutic multifamily group, where new seeds of Received on 23 June 2015. reasoning can sprout. Accepted on 13 August 2015. riginal REFERENCES O

1. World Health Organization. Regional Office for Europe. vey; 2012. Available from: www.mesothelioma.uk.com Contaminated sites and health. Report of two WHO work- 12. Moore S, Darlison L, Tod AM. Living with mesothelioma. shops: Syracuse, Italy, 18 November 2011; Catania, Italy, A literature review. Eur J Cancer Care 2010;19(4):458-68. 21-22 June 2012. Geneva: WHO; 2012. Available from: 13. Northhouse LL, Katapodi MC, Schafenacker AM, Weiss www.euro.who.int/__data/assets/pdf_file/0003/186240/ D. The impact of caregiving on the psychological well-be- e96843e.pdf. ing of family caregivers and cancer patients. Semin Oncol 2. Pirastu R, Pasetto R, Zona A, Ancona C, Iavarone I, Nurs 2012;28(4):236-45. Martuzzi M, Comba P. The health profile of populations 14. Barbasio CP, Granieri A. Emotion regulation and mental living in contaminated sites: Sentieri approach. J Environ representation of attachment in patients with systemic Public Health 2013. Epub 2013 Jun 18. Lupus Erythematosus: A study using the Adult Attach- 3. Borgogno FV, Franzoi IG, Barbasio CP, Guglielmucci F, ment Interview. J Nerv Ment Dis 2013;201(4):304-10. Granieri A. Massive trauma in a community exposed to 15. Granieri A. Corporeo, pensiero, affetti. Intreccio tra psico- asbestos: Thinking and dissociation in the population of analisi e neurobiologia. [Body, affects and thinking. The Casale Monferrato. Br J Psychother, 2015;31(4):419-32. link between psychoanalysis and neurobiology]. Torino: 4. Guglielmucci F, Franzoi IG, Zuffranieri M, Granieri UTET; 2011. A. Living in contaminated sites: Which cost for psychic 16. Gallese V. Psychoanalysis and the neurosciences. Inter- health? Mediterr J Soc Sci, 2015;6(4S3):207-14. subjectivity and body-self: Notes for a dialog. Psyche (Ger- 5. Arber A, Spencer L. It’s all bad news: The first 3 months many) 2015;69(2):97-114. following a diagnosis of malignant pleural mesothelioma. 17. Schore AN. The right brain implicit self lies at the core of Psycho-Oncology 2013;22:7. psychoanalysis. Psychoanal Dialogues 2011;21(1):75-100. 6. Dooley JJ, Wilson JP, Anderson VA. Stress and depres- 18. Schore JN, Schore AN. Regulation theory and affect reg- sion of facing death: Investigation of psychological ulation psychotherapy: A clinical primer. Smith Coll Stud symptoms in patients with mesothelioma. Aust J Psychol Soc Work 2014;84:178-95. 2010;62(3):160-8. 19. Schore AN. The effects of a secure attachment relation- 7. Granieri A. Amianto, risorsa e dramma di Casale. Risvolti ship on right brain development, affect regulation, & psicologici nelle persone affette da mesotelioma e nei loro infant mental health. Infant Ment Health J 2001;22:7-66. familiari. [Asbestos: resource and tragedy for Casale 20. Caspi A, Moffitt TE. Gene-environment interactions Monferrato. Psychological aspects in people affected by in psychiatry: joining forces with neuroscience. Nat Rev malignant pleural mesothelioma and in their caregivers]. Neurosci 2006;7(7):583-90. Genova: Fratelli Frilli; 2008. 21. Hunter DJ. Gene-environment interactions in human 8. Granieri A. L’amiante, la double peine. Casale Monferrato: diseases. Nat Rev Genet 2005;6:287-98. atteintes physiques, traumatismes psychologiques, résistances. 22. Bourdès V, Boffetta P, Pisani P. Environmental exposure [Asbestos, the double pain. Physical harm, psychological to asbestos and risk of pleural mesothelioma: Review and trauma and resilience]. Fréjus: Sudarenes; 2013. meta-analysis - Environmental exposure to asbestos and 9. Granieri A, Tamburello S, Tamburello A, Casale S, Cont mesothelioma. Eur J Epidemiol 2000;16(5):411-7. C, Guglielmucci F, Innamorati M. Quality of life and 23. Goldberg M, Luce D. The health impact of nonoccu- personality traits in patients with malignant pleural meso- pational exposure to asbestos: What do we know? Eur J thelioma and their first-degree caregivers.Neuropsych Dis Cancer Prev 2009;12(6):489-503. Treat J 2013;9:1193-202. 24. World Health Organization. International Agency for 10. Guglielmucci F, Franzoi IG, Barbasio CP, Borgogno FV, Research on Cancer. IARC Monographs on the evaluation Granieri A (2014). Helping traumatized people survive: A of carcinogenic risks to humans. Arsenic, metals, fibres, and psychoanalytic intervention in a contaminated Site. Front dusts. Volume 100 C. A review of human carcinogens. Avail- Psychol 2014;5:1419. DOI: 10.3389/fpsyg.2014.01419. able from: http://monographs.iarc.fr/ENG/Monographs/ 11. Mesothelioma UK. National mesothelioma experience sur- vol100C/mono100C.pdf. 341 Community exposure to asbestos

25. Lo Iacono M, Monica V, Righi L, Grosso F, Libener R, research. Health Res Policy Syst 2010;8:37. Vatrano S, Bironzo P, Novello S, Musmeci L, Volante 33. Granieri A, Borgogno FV. Pensabilità e dissociazione in M, Papotti M, Scagliotti GV. Targeted next-generation una popolazione colpita da trauma massivo: Una ricerca sequencing of cancer genes in advanced stage malignant intervento di matrice psicoanalitica. [Thinking and dis- pleural mesothelioma: a retrospective study. J Thorac On- sociation in a community exposed to massive trauma: A col 2015;10(3):492-99. psychoanalytic research intervention]. Il Vaso di Pandora. 26. Marinaccio A, Binazzi A, Cauzzillo G, Cavone D, Zotti Dialoghi in psichiatria e scienze umane 2014;22(2):83-102. RD, Ferrante P, Gennaro V, Gorini G, Menegozzo M, 34. Granieri A. L’incontro psicoanalitico con una mente Mensi C, Merler E, Mirabelli D, Montanaro F, Musto gruppale traumatizzata: percorsi di resilienza. [The psy- reviews

M, Pannelli F, Romanelli A, Tumino R. Analysis of laten- choanalytic encounter with a traumatized group mind: cy time and its determinants in asbestos relates malignant journeys of resilience]. In: Rozenfeld A (Ed). La resil-

mesothelioma cases of the Italian registers. Eur J Cancer ienza: una posizione soggettiva di fronte alle avversità. Pros- and 2007;43(18):2722-8. pettive psicoanalitiche. [Resilience: a subjective position in 27. Fazzo L, Menegozzo S, Soggiu ME, De Santis M, San- front of adversities. Psychoanalytic perspectives]. : toro M, Cozza V, Brangi A, Menegozzo M, Comba P. Fratelli Frilli; 2014. Mesothelioma incidence in the neighbourhood of an 35. Bion WR. Experiences in groups: and other papers. :

asbestos-cement plant located in a national priority con- Tavistock; 1961. articles taminated site. Ann Ist Super Sanità 2014;50(4):322-7. 36. García Badaracco J. Comunidad terapéutica psicoanalítica 28. Fazzo L, Minelli G, De Santis MD, Bruno C, Zona A, de estructura multifamiliar. [Multifamiliar Psychoanalysis Marinaccio A, Conti S, Piratsu R, Comba P. Mesothelio- in Therapeutic Communities]. Madrid: Tecnipublicacio- ma mortality surveillance and asbestos exposure tracking nes; 1989. in Italy. Ann Ist Super Sanità 2012;48(3):300-10. 37. García Badaracco J. Psicoanálisis Multifamiliar. Los otros riginal 29. Furlan C, Montanarino C. Pleural mesothelioma: Fore- en nosotros y el descubrimiento de sí mismo. [Multifamiliar O casts of the death toll in the area of Casale Monferrato, Psychoanalysis. We and the others in the discovering of Italy. Stat Med 2012;31(29):4114-34. ourselves]. Buenos Aires: Paidos; 2000. 30. Magnani C, Ferrante D, Barone-Adesi F, Bertolotti 38. Seganti A, Albasi C, Granieri A. Linguaggio e sensazioni: M, Todesco A, Mirabelli D, Terracini B. Cancer risk “Tra il dire e il fare”. Strategie di costruzione dialogica after cessation of asbestos exposure: A cohort study of della salute. [Language and sensations: “Between say- Italian asbestos cement workers. Occup Environ Med ing and doing”. Strategies for a dialogic construction of 2008;65(3):164-70. health]. Ricerca in Psicoterapia 2003;6:1-2. 31. El-Jardali F, Adam T, Ataya N, Jamal D, Jaafar M. Con- 39. Fauci AJ, Bonciani M, Guerra R. Quality of life, vulner- straints to applying system thinking concepts in health ability and resilience: A qualitative study of the tsunami systems: A regional perspective from surveying stake- impact on the affected population of Sri Lanka. Ann Ist holders in Eastern Mediterranean countries. Int J Health Super Sanità 2012;48(2):177-88. Policy Manag 2014;3:399-407. 40. Stratta P, De Cataldo S, Bonanni R, Valenti M, Masedu 32. Jansen MWJ, van Oers HAM, Kok G, de Vries NK. Pub- F, Rossi A. Mental health in L’Aquila after the earth- lic health: Disconnections between policy, practice, and quake. Ann Ist Super Sanità 2012;48(2):132-7.