‘Local Big Tent’ Initiative Highlights Psychotherapy for Social Trauma

The APA Psychotherapy Caucus is active on the national level with an annual meeting, various work groups and initiatives, and a listserv hosting lively online discussions. It serves as a “National Big Tent,” welcoming psychotherapists from diverse theoretical backgrounds. The Caucus has also facilitated creation of “Local Big Tents,” psychotherapy committees at the district branch level, to promote more personal engagement and camaraderie as well as programs to restore and strengthen the use of psychotherapy by psychiatrists.

In keeping with the spirit of Local Big Tents, it was a pleasure to plan and attend the recent virtual and interactive CME conference “Contemporary Psychotherapeutic Approaches to Social Traumas,” held by the Massachusetts Psychiatric Society Psychotherapy Committee. The program drew attendees from at least five states. Topics included intergenerational trauma and resilience, racial trauma, vicarious caregiver trauma, refugee trauma, and prolonged exposure therapy. Several presenters shared painful experiences affecting them personally and professionally, underscoring the need for psychiatrists to be aware of and understand social trauma’s impact on patients and themselves. The conference was particularly timely, given the social upheavals of the past two years, including the COVID-19 pandemic, racial violence, and the horrific Ukraine war. We will highlight three presentations.

Alexandra (“Sasha”) Rolde, M.D., movingly described what permitted her to surmount trauma during her formative years in Holocaust-era Prague. Dr. Rolde said her family reinforced her self-esteem and taught her to make and implement plans and problem-solve—generalizable forerunners of triumph over adversity. Her Jewish mother and Catholic father conveyed she was their raison d’etre, and since she was an Aryan-looking child with a non-Jewish name, she and her mother miraculously survived the war despite her maternal relatives’ deportation.

Dr. Rolde’s aunt survived the camps, became a social worker, and shared horrifying memories with her. Sasha believes her own resilience emerged from her mother’s and aunt’s unwavering hope, despite extreme suffering. Having social support, education, and role models, in addition to being able to compartmentalize some anguish, allowed her to “pay it forward” and adopt an orphaned girl from Russia, earn her M.D., and become a psychiatrist and psychoanalyst. Those elements also enabled her to understand why “some traumatized patients do well and others remain … chronically disabled.”

Nicole Christian-Braithwaite, M.D., persuasively urged psychiatrists to routinely explore patients’ experiences with racism because ignorance about racial abuse has contributed to Black Americans’ disproportionate psychiatric hospitalizations and diagnoses of psychosis. She shared her son’s and her own childhood encounters with racism: She and her 3-year-old son were each taunted in school about their Black American appearance, and her son’s exposure retraumatized her. These are routine occurrences for people of color, and the cumulative effect extracts a significant toll on physical health, mental health, and longevity. Such microaggressions may be unacknowledged, and therapists often inadvertently defend perpetrators—that is, “maybe they didn’t mean it that way.” She emphasized that psychiatrists’ failure to inquire about racial trauma guarantees we will compound the damage. She recommended using racial stress scales like the Everyday Discrimination Scale to foster discussion of underrecognized injuries and also detailed psychotherapeutic interventions:

• Race-based stress and trauma intervention groups to empower recovery by addressing identity and power issues.

• Healing ethno-racial trauma programs to establish sanctuary spaces that model survival strategies and recovery-promoting traditions.

• Trauma-focused cognitive-behavioral therapy.

• Developmental strategies to prepare children for toxic incidents.

These modalities enhance resilience, build positive racial identity, model effective responses to “microaggressions,” and acknowledge that “words matter” despite the absence of malevolent intent. Medical school curricula, residencies, and diagnostic manuals need to include instruction about racism and resultant trauma.

John Bradley, M.D., a retired combat veteran and military psychiatrist, presented on secondary traumatic stress and professional burnout. In the context of COVID-19 and social upheavals, therapists have been helping a wave of new patients and simultaneously living through the shared global traumas. He identified compassion fatigue leading to cynicism, vicarious trauma (VT), and secondary traumatic stress (STS) triggered by hearing patients’ traumas. He enumerated risk factors for VT and STS: Having a trauma history, seeing numerous traumatized patients, intellectualizing patients’ struggles, feeling unsafe due to societal upheaval, doubting one’s effectiveness, rigidly adhering to pedagogy, and viewing ourselves as the primary agents of change. The endpoint—burnout—results from deficient encouragement from leadership, excessive work demands, reduced autonomy, inadequate work-life balance, and social isolation (from lockdowns, quarantines, social distancing, masking).

Recognizing burnout preemptively is critical for preventing emotional exhaustion, helplessness, hopelessness, and potential suicide. Dr. Bradley underscored that therapists must be “containing vessels” to process and detoxify patients’ projections before returning them. With training, supervision and personal therapy to recognize and address countertransference, therapists can mitigate overidentifying with or detaching from patients’ struggles. He said it is crucial to accept that “trauma changes thoughts, feelings, and behavior.” He reminded us to utilize self-comfort measures to tolerate intense feelings and avoid VT, STS, and burnout.

Dr. Bradley’s recommendations for posttraumatic growth include self-affirmation, mindfulness, dark humor, self-care, and connection with colleagues for mutual reinforcement. When encountering human suffering, psychiatrists can easily “forget to reach for the oxygen” to “fortify oneself for the emotional battlefield.” His guiding principles: Set priorities (personal life is paramount; prioritize work tasks), respect people and institutions, act honorably, and leave work at work (by self-nurturing and upholding personal/professional boundaries). This is “essential medicine” when treating people with heart-wrenching social traumas. 

The “pearls of wisdom” from this conference highlight the value of psychotherapeutic principles and practices as well as peer interaction and sustenance. Initiatives like “Local Big Tents” that sponsor regional conferences and bring geographically distant colleagues together will encourage psychiatrists to employ psychotherapy to address contemporary challenges like personal and collective trauma—essential for ourselves, our patients, and society. 

To contact the authors of this article to discuss specific strategies for starting a psychotherapy committee at your district branch, please email [email protected]. To join the APA Psychotherapy Caucus, log in to the APA website and go to “My Profile.” On the left menu, select “Specialty Interests Caucuses and Listservs.” On the new page, check “Psychotherapy,” and you will automatically become a member and receive announcements. ■

Margo P. Goldman, M.D., recently retired from psychiatry and psychotherapy practice in Andover, Mass., and is a founding member of the Massachusetts Psychiatric Society (MPS) Psychotherapy Committee. Her post-retirement professional activities are focused on bolstering psychotherapy by psychiatrists.

Margaret Cheng Tuttle, M.D., M.S., is a psychiatrist at Massachusetts General Hospital, an instructor (part time) in psychiatry at Harvard Medical School, and co-chair of the MPS Psychotherapy Committee. Both are members of APA’s Psychotherapy Caucus.