EP. 121: BREAKING THE CYCLE OF INTERGENERATIONAL TRAUMA

Jul 16

WITH MARIEL BUQUE, PHD

A health psychologist shares how she addresses intergenerational trauma in her patients and what all clinicians can learn from integrating trauma-informed care into their practices.

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Episode Summary

It is well documented that descendants of Holocaust survivors exhibit greater levels of anxiety, depression, and vulnerability. The trauma of domestic violence can ripple through generations, with maladaptive coping mechanisms and emotional instability perpetuating subsequent cycles of trauma and dysfunction. The brutal history of slavery in the United States is seen today in the form of persistent economic disparities and ongoing social injustices, affecting mental and physical health across generations. All of this, in various forms, is intergenerational trauma. Extending beyond the individual, the emotional and psychological wounds of this type of trauma embeds itself within the family lineage through behavioral patterns, emotional responses, and even biological alterations.

Our guest on this episode is Mariel Buqué, PhD, a health psychologist who specializes in helping individuals experiencing intergenerational trauma. Her book Break the Cycle: A Guide to Healing Intergenerational Trauma (2024) reveals the invisible threads that link the past and present and highlights the necessity for healing not just individuals, but entire family systems and communities. Over the course of our conversation, Dr. Buqué shares how she draws on her experiences as an Afro-Latina immigrant from the Dominican Republic in her work, how a health psychologist connects with patients, how intergenerational traumas happen and their devastating effects on individuals, families, friends, and community members, and more.

Mariel Buqué, PhD is a first-generation Black Dominican psychologist, a world-renowned intergenerational trauma expert, and the author of the bestselling book Break the Cycle: A Guide to Healing Intergenerational Trauma. Her mission is to help reduce the recurrence of Intergenerational ACEs (Adverse Childhood Experiences) within communities of color.
Dr. Buqué earned her doctoral degree in counseling psychology at Columbia University, where she also trained as a 3-year fellow in holistic mental health within Columbia University Irving Medical Center (CUIMC), an initiative that was backed by the United States Health Resources and Services Administration (HRSA). There, she offered culturally-responsive mental health services across multiple specialty clinics, including Columbia Medical’s OB/GYN and Primary Care clinics.
Upon seeing the huge gap in trauma-informed care and trauma-informed institutional action that specifically addresses the needs of underserved communities, Dr. Buqué sought out to develop a holistic system of care, with equity and prevention at the center. This is the method that is central within her consultation and therapy practice, the Break the Cycle Trauma Center (BTC).
In this episode, you will hear about:
• 2:00 - What drew Dr. Buqué to the field of psychology
• 5:19 - What health psychology is
• 8:40 - What occurs in a course of treatment with a psychologist
• 18:30 - An overview of intergenerational trauma
• 28:00 - The far-reaching effects of intergenerational trauma in society and how psychology can help unload the burden
• 35:50 - Breaking the cycle of intergenerational trauma
• 40:30 - The role of stigma in access to mental health care
• 45:10 - Dr. Buqué‘s approach to building trust with patients
• 48:28 - How all clinicians can better empathize and connect with their patients through trauma-informed care
\Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctors Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine, we will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:01] It is well documented that descendants of Holocaust survivors exhibit higher levels of anxiety, depression, and vulnerability. The trauma of domestic violence can ripple through generations with maladaptive coping mechanisms and emotional instability, perpetuating subsequent cycles of trauma and dysfunction. The brutal history of slavery in the United States is seen today in the form of persistent economic disparities and ongoing social injustices, affecting mental and physical health across generations. All of this, in various forms, is intergenerational trauma extending beyond the individual. The emotional and psychological wounds of this type of trauma embeds itself within the family lineage through behavioral patterns, emotional responses, and even biological alterations. Our guest in this episode is Doctor Mariel Buque, a health psychologist who specializes in helping individuals experiencing intergenerational trauma. Her 2024 book, Break the Cycle: A Guide to Healing Intergenerational Trauma, reveals the invisible threads that link the past and present and highlights the necessity for healing not just individuals, but entire family systems and communities. Over the course of our conversation, Dr Buque shares how she draws on her experiences as an Afro-latina immigrant from the Dominican Republic in her work, how a health psychologist connects with patients, how intergenerational traumas happen, and their devastating effects on individuals, families, friends and community members, and more. Ultimately, her insights remind us to be ever mindful of the universe behind each person we encounter and to treat them with the compassion and kindness this calls for.
Henry Bair: [00:02:53] Mariel, thank you for taking the time to join us and welcome to the show.
Dr. Mariel Buqué: [00:02:57] Thank you so much for having me.
Henry Bair: [00:02:59] We are looking forward to exploring this emerging field of intergenerational trauma. But first, can you tell us what initially drew you to becoming a psychologist?
Dr. Mariel Buqué: [00:03:09] You know, psychology is actually not my first career. So I was actually in the field of communications and advertising. And while I was in, you know, my regular work schedule, I decided that I wanted to add something to my day, which was volunteer work, and I really wanted to do so in my hometown of Newark, new Jersey. And the volunteer work that I was able to pick up was what was available, which was mental health related and more and more, I was able to see that there were professionals in these settings serving my community members from the perspective of mental health, and my mind was blown away because I lived in this community my entire life. And it was when I migrated to the US when I was five. I spent so many decades there, and yet never really got exposed to the fact that people were being helped in this way, and that that could be a way that I could also be helpful. What happened thereafter was that I made a pivot, and I took a leap into actually navigating the graduate school landscape and, um, initiating this career. So it's something that I'm so grateful that happened because I get to live in purpose every day.
Henry Bair: [00:04:35] Now, you'd later go into the field of health psychology. Can you tell us more about what that is?
Dr. Mariel Buqué: [00:04:42] Yeah. Health psychology is a type of psychology that focuses on the full landscape of health and how psychology ties into it. So it is very, very much kind of not subscribing to the idea that we're kind of these fragmented people that have different parts of us that aren't co functioning together. Health psychology really sees the full scope of health and how mental health is interspersed in that. It also, from a research perspective, looks at, you know, the ways in which population health is impacted by mental health discrepancies and disparities. And so the full landscape of health psychology from a clinical and research perspective, is really tying in all the parts.
Henry Bair: [00:05:32] Were there any personal experiences, life experiences that you can share with us that have anchored your career or have really steered your career in a certain direction?
Dr. Mariel Buqué: [00:05:45] Yeah. You know, my very first patient was the person that I worked with for the longest. This person was assigned to me when I first started my we call it holistic mental health now. But back then, you know, it was integrated mental health, meaning we integrate mental and physical into the same perspective of treatment. And I landed at this fellowship was very, very lucky to do so. And within that fellowship, my my first assigned clinical case was that of someone who had actually come in with a number of different panic attacks, and those panic attacks had landed this person at the ER time and again in a total of seven times in one month. And eventually the ER doctors in essence referred this person to psychiatry, which was our department, adult psychiatry, for further evaluation as to what was happening from a mental health perspective in reference to these symptoms, because they couldn't find an organic cause. And the work that I did with this person, and the lessons that I was able to gather, were some of the most incredible that I've been able to land at. And she really will always be kind of like that mark in my career. That allowed me to understand so many of the pieces of pain that can navigate through one person's being at once. She was somebody that eventually, throughout the course of our work together, was also diagnosed with diabetes type two. And the combination of that diabetes type two, with the panic and the anxiety that she was experiencing were so incredibly debilitating. But once we got more answers, more of an understanding of what was going on, some of that even intergenerational history that was living in her mind and body. We were able to actually create a better road map for her to be able to experience some sense of empowerment and to be able to really kind of experience even some relief of her symptoms.
Tyler Johnson: [00:07:58] So one of the things that I wanted to ask you, you know, we've had a couple of psychiatrists on the show and of course, the in some ways the hallmark of most psychiatrists is that they're able to prescribe medication. But psychologists, in contrast, do not prescribe medication. And if medication is necessary, then they might refer to a psychiatrist or another doctor. But I have to say that even though as an oncologist, I have psycho-oncology colleagues who I work with and who are valued colleagues of mine. But I have to say that when I refer patients to the psycho oncology department, which is not unusual, exactly what happens, there is still a little bit of a black box. Could you just talk us through, like when you go to work with a patient, what exactly do you do? What exactly is the work that happens inside of your office?
Dr. Mariel Buqué: [00:08:50] I love the framing of this question, and it's incredibly fair. And to be honest, you know, that black box experience, I think is something that patients also experience. And it's part of the, I think, incredible fear that is out there around mental health because people don't really know what they're walking into. And so whenever we're engaging in work that is psychotherapeutic, we are hoping to do several things. One of which is especially at the onset of treatment, is ameliorate a person's symptoms like really kind of help a person feel more at ease than when they came in. In addition to that, we want to uncover the root of those symptoms. Why is it that this person has been experiencing persistent feelings of anger, irritability, sadness, insomnia for a period of five years. What's the root cause that's keeping the symptoms in place? And so usually the the treatment finds its way in almost kind of like that sequence. We're trying to help to stabilize a person so that they can feel more at ease. They can feel like the work ahead feels more tolerable.
Dr. Mariel Buqué: [00:10:06] And we usually do that with a number of skills. Those can be like relaxation skills. They can be, you know, just straight talk therapy. So talking through the anxiety that's there or the sadness and helping to release that rather than leaving a person to kind of just like hold it and feel internal tension as a result. And then eventually once we can kind of see that a patient is ready, or if they themselves are able to see themselves as ready, really the combination of the two, then we start transitioning into where did this pain come from? What caused it? How did it land in your heart? And sometimes even who caused it? And so we start getting into those pieces which are a bit heavier, sometimes a bit harder to digest, and typically that can look like in traditional talk therapy. Talking through those things in more holistic types of therapies, it can be navigating through that, through imagery exercises, engaging in breathwork, perhaps even sometimes we bring in family members that could be a part of that process into 1 or 2 sessions, to process some unresolved emotions and feelings, and have conversations that can be moderated by a neutral party being the therapist. And so all of that is a part of the process of what happens internally. Um, and there can be so many variations of that, but typically that's what we tend to do.
Tyler Johnson: [00:11:40] Okay. So I want to follow up that question and answer by asking another question. And I recognize that the outset of this question that I may be trafficking in sort of a professional stereotype, but at least if I'm doing that, you can help me to see why it's a stereotype and how it's unhelpful or how we need to push past it. Right. So I love the television program The West Wing. I know that it's a little bit old now, but I still think it's a beautiful and well done show, especially the first three seasons, and still watch episodes from time to time. And so at the end of the first season, and I apologize here for the spoilers for anybody who was planning on, you know, watching it 20 years after it aired.
Tyler Johnson: [00:12:16] But at the end of the first season, there's an assassination attempt on the president's life. And while the president is not hit or is only grazed, I don't remember one of his staff members. I think it's the vice chief of staff or something is almost mortally wounded. In other words, I think his pulmonary artery is lanced and he has to be rushed into critical surgery. And it's only by virtue of the incredible talent of the surgeons that he is saved. And so the point of this is just to say that then about a season later, he starts to have these mysterious psychological, but also medical problems, and they sort of look around and look around and look around and try to figure out what's wrong with him. And then after all of that, looking around, they finally think to have him see a therapist. And the therapist spends an episode. There's this very artfully done episode where the therapist talks with him a lot and sort of after talking and talking and talking, they finally come to the fact that he is sort of experiencing a subliminal form of basically PTSD, and that every time he hears a certain kind of sound, he's reminded of the assassination attempt, and then he's sort of viscerally reliving the assassination attempt. And that's why he's feeling so anxious and having all of these sort of physical and psychological symptoms.
Tyler Johnson: [00:13:28] But the reason that I bring this up is because in the episode, the way this is depicted is it's like they're looking and they're looking and they're looking and they're looking. And then as soon as they make that connection, bam, there's this sort of psychological release. And then the suggestion is that he gets all better, right? It's like taking antibiotics for his infection or something like he just then the tension resolves and he goes on to be just fine or mostly fine after that. So I guess the question that I'm asking is, does that really happen? Like, are there really times where you're working with one of your patients and then you like, come upon this one thing and that sort of fixes the problem in some complete way? Or is it more the case that even if you do find, quote unquote, the cause for some problem, that that's really only the beginning of an answer, and then you have to keep working through until you get to a deeper level and a deeper level and sort of the exploration never really ends.
Dr. Mariel Buqué: [00:14:20] Yeah, it is a fair question and one that in different iterations and variations, I tend to get from folks. And the truth is that healing work actually looks more like the latter. We never quite arrive at healing, and then we're fine and okay. And I think that that's a part of maybe the healing myth that we in society would need to dispel further so that, you know, people can feel sometimes even more at ease with their own healing journey. Sometimes people feel like, you know, I'm not better. It's been five years and what's happening? But the truth of the matter is that uncovering the root of something can be very cathartic and liberating. But that uncovering is where the work starts. As you mentioned, it's where we start doing some of the integration work, as I call it, which is basically us going back into your day to day life and identifying the ways in which that root cause has been impacting all the different dimensions of your life. And that's why therapy takes this form of being like a weekly process. Because next week you might come back into my office and tell me that you had a conversation with a colleague, and that that conversation all of a sudden brought up a lot of those physical sensations and that hot, burning kind of like sensation that you had when you were ten years old and you would get bombarded with a ton of, like, nasty words from your father.
Dr. Mariel Buqué: [00:16:07] So now this colleague that says something that was presumably benign but took you back, created that same experience. Now, the difference between that experience right now and you're being able to bring that into therapy and us being able to unpack it and talk through it, is that there is more awareness. And also this basically like 2 to 3 second window that you have between the stimulus, which was what the colleague said, and your response, which could have been yelling, slamming a door and leaving anything else. So now we have two seconds of reflection that you can engage in to understand, oh, this is taking me back to that moment when I felt deeply vulnerable. I'm not in that hurtful past. I'm here now. And you can reroute your mind. You can reroute your body to not no longer be experiencing the past. And that's the place where we are in the integration we're applying to a person's day to day experiences. Eventually, whatever that trigger was, or whatever that sensation was, or whatever those emotions and those thoughts were will dial down. They may not completely absolve themselves, but they'll be more tolerable and not overwhelming in the ways that they have been in the past. And that's what the healing looks like.
Henry Bair: [00:17:37] Yeah. Thank you so much for sharing with us your process and what that actually looks like. It's really helpful, again, because it's, you know, I think throughout my entire medical training in medical school specifically, I think I maybe worked with a psychologist twice over the course of like five years. And that was in the context of my psychiatry clinical rotation. I was mostly working with psychiatrists. I was at the VA health care system, at the inpatient psychiatry unit, and there was a psychologist on staff. And I think by the end of that rotation, I still didn't really know what the psychologist's role was because I often did not get to see their individual interactions with patients. It was mostly they would join the interdisciplinary rounds in the morning when we would talk as a team all together about each patient. So that was really helpful. What you just shared with us. I'd like to turn next to what you've devoted your career to, which is intergenerational trauma. This is a term again, like I also don't recall really hearing over the course of medical school, maybe once or twice. I think in the context of our psychiatry block, we had a session where we had patients come in to share their experiences. I think this was a context of the descendant of a Holocaust survivor pointing out the increased rates of things like depression and PTSD anxiety among descendants of survivors. I don't even recall if the word intergenerational trauma was used by at least this concept was introduced to us. I think for a lot of our listeners, it will also be a fairly new concept. Can you share with us exactly what you mean by this term?
Dr. Mariel Buqué: [00:19:22] Absolutely, yeah. Intergenerational trauma is the only type of trauma that can be handed down our family line. And it happens at the intersection of our biology and our psychology. So it's very nature nurture in that way. And when it comes to our biology, there's a lot of complex ways in which it shows up, or at least the biological undercurrent of intergenerational trauma tends to live in our family line. But most notably, what we have known is that if we had a parent, a grandparent or distant ancestors who themselves have actually experienced chronic trauma or have have been in psychological distress for a prolonged period of time, that it is likely that that could have shown up in their genetic encoding, most notably in the DNA tags that they have that can turn on or off according to how they're experiencing their social environment. And upon conception, both on the maternal and paternal side, there is a possibility for transmission of that genetic messaging. What can that do? That can actually make a person potentially more susceptible to developing the symptoms of post-traumatic stress disorder or other kinds of trauma in their own lifetimes. How does that happen? There are a lot of hormonal changes that can happen, really at the outset of a person's like initial point of life that are all a part of that biology that's intermixed in their epigenetic makeup. So we have all of that. That's really kind of like at the the original imprints of what's happening once this life is being formed. But once that baby is now birthed, we have everything else that happens in the baby and the child and the adult's psychology or their social world. Anything that can happen that can actually trigger that vulnerability that they have and can make it so that they now become the new bearers of trauma and develop trauma symptoms, which makes the trauma intergenerational.
Henry Bair: [00:21:34] And how did you again, because given the dearth of formal institutional resources about training and really general awareness of this condition. Entity, group of entities. How did you come upon this field of work and how have you, for lack of a better term, learned the skills required to address it?
Dr. Mariel Buqué: [00:21:59] The coming upon was something that happened in my therapy room. It actually wasn't something that I, um, really had prior knowledge of in any capacity, really kind of like the rest of us. But where I worked, I worked in a place where the predominant population that we served were black and Latin, and there were a lot of people that were coming in with very similar histories, people that were coming in with histories where maybe there was domestic disputes in their home, and they would recall the fact that there were domestic disputes in their home growing up. So their parents were also, you know, kind of in turbulent relationships, and so were their parents. So now the grandparents were also in these kinds of relationships, and we would hear stories of all sorts. I mean, any kind of trauma that you could possibly imagine. And we would hear these stories being replicated generation after generation when we were doing evaluations of our patients, which are usually the first to third session that we that we have with someone where we're just like gathering a lot of history.
Dr. Mariel Buqué: [00:23:10] All of that was coming up time and again. And when we, the clinicians, would debrief and clinical team meetings, I would sit there and just be absorbing a lot of these ways in which people would be bringing in these layers of generational pain, and none of us clinicians were actually naming it. And part of the reason why we weren't naming it was because we weren't trained to name it. We weren't trained to really look at what our patients were suffering from, from that lens. And I found that that created, as I saw it, a real disservice to the people that we were serving in particular, because I remember the there were many people that I had the honor to work with in that clinic, but I remember one of the patients that had the longest history in that clinic was there for 28 years. And for 28 years, this person came in every week into session, both individual and group, and was identified as having major depressive disorder. And I would have this person in my group. I would interact with this patient all the time, and I always thought like when I would hear her stories, you almost kind of had to hold on to your seat because the level of pain and trauma and anguish that this person had had to suffer since she was a little girl, and the level of trauma that was in her family line was almost to the point of unbelievable.
Dr. Mariel Buqué: [00:24:46] And it made me start questioning how we were diagnosing, how we were looking at patient care, how we were holding people's pain with them and what we were doing to help people transition from that pain and not be perpetual patients within a system for 28 years. And so, luckily, and this was something that I think luck really kind of is the thing that I, I'd have to say was there in addition to of course, I think being a Spanish speaking clinician definitely helped me to be a part of this program. But, um, my mentors had rallied around me and wanted to create an integrated mental health care grant that we would basically develop and then integrate within the medical system that we were all a part of. And so they decided to place me as a clinician that would rotate around all of the ambulatory care clinics that would serve folks in cardiology and ob gyn, a number of different specialties. They placed me as a clinician on staff that would, in essence, like conduct psychotherapy. But in addition to that, we would be doing that from the perspective of holistic and integrated mental health care. So I would bring in elements of meditation and breathwork into the work that I would do with someone that was experiencing post traumatic stress disorder, but also and potentially some sort of postnatal depression, or somebody that was experiencing a long history of heart disease but had also been experiencing a mental health condition like anxiety.
Dr. Mariel Buqué: [00:26:37] And so I would come in and I would not only join them in the sessions with their physician, but I would also have my own sessions with the person, and we would start integrating the care and collaborating as a team, rather than seeing the patient care as disjointed. And so that was something that I was able to participate in literally from the conceptualization stage of this fellowship, because we received a grant, they placed me as one of the coordinators to actually create the protocol and the structure of how we would integrate this system of care. And then I was placed as a rotating clinician within it. And then I trained others on how to do so. So it was an unbelievable experience that helped me to see how healing can happen in a more expedient way, how it could happen even when there's depths of trauma. And it helped me to see another way to actually engage in psychotherapy and, and really perhaps center patient equity and make the work more client centered than the traditional models.
Tyler Johnson: [00:27:59] I want to ask an important question, but I'm going to set it up and frame it in a way that might seem a little bit funny, which is to go back to a speech that Barack Obama, then-Senator Obama, gave when he was running for president the first time, so he had not yet been president. At one point, a big flash point arose because some, I think, video got out of sermons that had been given by Barack Obama's longtime pastor, whose name was Jeremiah Wright. And in some of those sermons he critiqued in unsparing and sometimes provocative terms, many institutions, including the United States, including saying things like God damn America, that was one of the most sort of infamous catchphrases during this time. And so you can imagine that once the video of this surfaced, then there were all these questions about how could Barack Obama and his family have been attending church with this pastor for so long? And then now he was trying to run for president, and did he share some of these views and whatever else? And so that led to then-Senator Obama giving a speech at the Constitution Center in Philadelphia, where he talked about the place of racism in America, and to try to sort of contextualize the Reverend Wright's speeches and to try to understand why he, Barack Obama, thought that him having attended church with this pastor was not disqualifying in terms of him running, he Barack Obama, running for president.
Tyler Johnson: [00:29:21] And so I found that speech to be enormously skillful, even beautiful. And the reason that I say that is because he begins by he does a little bit of sort of textual analysis of the sermons themselves, but then he goes and tries to frame for people who have not been the subject of overt racial discrimination. So especially for people with light skin, he tries to help them to understand what it is like to live your life, being the subject of overt racism and fearing that you will soon be, or that you may, in the next five minutes, be the subject of overt racial discrimination. And as part of that, then Senator Obama wrote, quote, for the men and women of Reverend Wright's generation, the memories of humiliation and doubt and fear have not gone away, nor has the anger and the bitterness of those years. That anger may not get expressed in public in front of white coworkers or white friends, but it does find voice in the barber shop, or the beauty shop, or around the kitchen table. At times, that anger is exploited by politicians to gin up votes along racial lines or to make up for a politician's own failings. And occasionally it finds voice in the church on Sunday morning in the pulpit and in the pews. The fact that so many people are surprised to hear that anger in some of Reverend Wright's sermons simply reminds us of the old truism that the most segregated hour of American life occurs on Sunday morning.
Tyler Johnson: [00:30:53] So that part of things is perhaps not so surprising, given the political context and what then-Senator Obama was trying to do. But what's really, really interesting to me is that then he turns his focus, in effect, from the experience of black people who have been the direct subjects of overt racism and now turns to talking about people who do not have that same set of experiences. And he writes in part, quote, in fact, a similar anger exists within segments of the white community. Most working and middle class white Americans don't feel that they have been particularly privileged by their race. Their experience is the immigrant experience. As far as they're concerned. No one handed them anything. They built it from scratch. They've worked hard all their lives, many times, only to see their jobs shipped overseas or their pensions dumped after a lifetime of labor. They are anxious about their future and they feel their dreams slipping away. And in an era of stagnant wages and global competition, opportunity comes to be seen as a zero sum game in which your dreams come at my expense. And then he goes on from there. What's so strikes me as being beautiful about this speech is that, in effect, he is leaving no one out. He is turning to all of us and asking us to extend ourselves in empathy in virtually every direction.
Tyler Johnson: [00:32:19] He's effectively reminding us of that old line from a hymn that in the quiet heart is hidden sorrow that the eye can't see. Right. Which is to say that if you don't know of a reason to have empathy for the person next to you, it's probably because you just don't know them well enough. But at the same time that also suggests to me something profound and potentially overwhelming, at least if you're a therapist, about the human condition, which is that now we talk a lot about intergenerational trauma, but it would seem sort of the the deeper truth that seems to come from Senator Obama's remarks is that it would seem like everyone has some version of intergenerational trauma. Right? It would seem like everyone has things that they have inherited from their parents, or their ancestors, or their past, or the way they grew up or whatever. That is hard. And I would almost think that as a therapist it would seem overwhelming, because no matter who's coming into your office, no matter what conversation you have, it would feel like there will always be those things from the past to discover and to work through. And so I guess I'm wondering, am I overstating the problem? Am I being too broad, or does it really feel like these kinds of problems are just that ubiquitous?
Dr. Mariel Buqué: [00:33:35] Well, yes. And I don't believe that it is far reaching. In fact, I do believe that it is in the web of interconnected stories and pain that we can really centralize the healing. Now, there have been people that have asked me specifically like, why focus on trauma or why, you know, kind of like veer your work in this direction. It's very heavy. It's very dark. For me, it's been a question that I've had to reflect upon because to be frank, I found that I don't have the luxury of not getting into the weeds with patients within conversations that can help enlighten people, and even within this book, to really kind of get into a lot of the heavy and the digging work. I thought that it was necessary because I started zooming out into the world just in my mind and looking at what's happening in our world right now, where we have this ever evolving global mental health crisis and a lot of people throwing theories kind of everywhere, many of which are indeed true. We do have a loneliness epidemic. We do have, you know, kind of issues with social media. And then we also have a world that is overexposing us to a lot of trauma. There's a lot of vicarious trauma, there's a lot of actual trauma. There's a whole entire collective crisis that we just got through living through together, uh, the Covid 19 pandemic that we just kind of glossed over and, like, just went back to our lives like, that never happened. But it was a really scary moment where many of us thought we wouldn't live for the next day. And so when I, you know, start thinking about getting into the weeds with folks, I start thinking about also how the other side of that, the other side of untangling that web, is that I get to see a person that feels like they're carrying the load a different way, like it feels lighter.
Dr. Mariel Buqué: [00:35:45] I think the most rewarding work that I have been able to see has been I no longer work with kids, but with teenagers who have actually been carrying a very heavy load, and to see them almost kind of become their true self almost for the first time, and really feel the lightness of being is something that is so deeply rewarding that for me, it makes so much sense to get into the weeds, to do the heavy lifting so that I can see this human on the other side, feeling like their load is lighter and they can carry it well, and they have a sense of empowerment around the load rather than feeling like the load is overtaking them. And I always say, you know, there are many stories of trauma and traumatic incidents and people being overtaken by their trauma. But there are also a lot of stories of survivorship and people actually exercising incredible resilience to get through the tribulations of life. And that is a possibility. And it is even more of a possibility when we have a guide, if that's a therapist and that person, if we have support, meaning our social network and if we have skills. So the skills that you learn in treatment, the skills that you might learn through reading actual texts, all of that taken together can be what we, in essence, would have in the healing toolbox to get a person to that other side.
Henry Bair: [00:37:23] And so when we consider how intergenerational trauma happens, you know, there are some mechanisms that doesn't really take a whole lot of leap of faith to realize it happens. You know, things like behavioral transmission, things like individuals who have been through trauma may develop behaviors like substance abuse or emotional unavailability that might be passed down to subsequent generations, and then things like environmental and social factors, like people who have experienced trauma may raise their kids in socioeconomic environments that lack community support, that expose them to undue stressors. And then on top of that, you know, when we asked you to define it earlier, one of the first things you talked about was actually epigenetic and genetic factors, right? Which I think that is probably what most people don't realize at first. Right. So when a patient thinks about all these things that were totally out of their control and happened long before they even, you know, started long before they even came into this world, I can't help but think that a lot of people would feel almost defeated. Right. It's like, well, all these things accumulated over years, decades, maybe even centuries now, like I am bearing the brunt of all of this. And I'm wondering, as you approach a patient who's recognizing all these things, how do you initiate trying to to the point of the title of your book to break that cycle? Like, what is the point? Where do you start? How do you even change their mindset into thinking that it is possible to break the cycle?
Dr. Mariel Buqué: [00:38:59] Yeah. Well, I mean, the key here is to look at the emotion that's being experienced at every juncture of the healing process. So part of what we're talking about here is the emotion of overwhelm, right. Being overtaken by the fact that, wow, so many generations ago, so many people go there was trauma and suffering, and now it's landed on me in a way that feels almost unbearable. We have overwhelm sitting right in front of us. And so what do we do with that overwhelm? It's a matter of like really helping a person to navigate through the experience of how overwhelm is overtaking them, the sensations that they're feeling in their body, the thoughts that are running through their minds. If we can think of ourselves just in whatever circumstance that we may have encountered, where we felt overwhelmed Most often it feels so consuming that we tend to kind of lose sight of our thoughts. We really haven't identified what emotions are floating around. We're not really present. We're more so kind of just like trying to survive. And when we give the power back to that person, allow them to understand how to sit with the experience of overwhelm. It helps them to absorb it differently. And when it comes to all of these layers of generational trauma, it's really critical for us to understand that it may have landed on you to actually hold all of these generations of burdens, but you can also be the one to unload and allow it to no longer continue.
Dr. Mariel Buqué: [00:40:37] And that's a place where we can start the work. Now with me, the work never really starts in in all of this digging anyways. Traditional psychotherapy, like I mentioned, especially like in a hospital system and in other systems, we typically take a person in via a referral or self-referred, and we start an evaluation process where we start digging through all of the layers of why exactly are you sitting here? What brings you in, in the way that I work with folks, and very much the ways that I structured this book very intentionally so is that I first start with grounding. How can we help you to understand what's going on in your body without any other trigger or stimulus that can be in your environment. How do we just understand the body better? How do we understand what kinds of thoughts are your default thoughts on a day to day basis? What emotions are there? How can we really help to help you to utilize that knowledge to further ground yourself? And then what techniques can we employ so that not only your mind, but also your body can feel like it's in a more settled place and readier than it was before to actually start doing some of that digging work that's going to get you into that place of overwhelm.
Dr. Mariel Buqué: [00:42:00] But because now you have a skill set on how to regulate, and you have a skill set on how to ground yourself, you're not going to be stuck in that overwhelming place for too long. I think that a and also a beautiful byproduct of doing that digging work and getting to the point of recognition, while there's so many layers to this, there's so many people that didn't do the healing work or couldn't do it. And, you know, now it's on me, is that it also opens people up to a sense of compassion. Very often we might see parents, grandparents in a very one dimensional way, and this allows us to almost kind of create multiple dimensions of how we're able to view their lives and connect those dimensions to our own in a way that allows us to see their full humanity, how they may have erred, the reasons why. And it allows us to to really kind of release sometimes the pent up rage that has been there many times with good reason, but that can be actually hurting us in the long term.
Tyler Johnson: [00:43:10] You know, it's so funny because a number of years ago we went to Argentina when I did a an away rotation there when I was in medical school, and we stayed with this family. And, you know, the family was relatively well-to-do and very nice, put together, wonderfully well adjusted. You know, whatever you want to say. People. And I remember this one day all of us were just sort of sitting around talking, and the mother and the family started to gather her things together as if she was, I don't know, going to the store or going out with friends or something. And I said, oh, where are you headed? And she said, as you know, we have a couple of teenage daughters and sometimes things are kind of hard and complicated. So I'm just going to see my therapist. I go once a week and it's really helpful. She said that and then sort of walked out the door. And the best way that I can describe my reaction was that I sat there in sort of stunned silence because it was like, oh my gosh, does she not know that? You don't tell people that you're going to see a therapist? That's kind of like embarrassing or something, right? And it's so funny in retrospect because, of course, if she had been going to, you know, whatever, go to the internist or if she had had, heaven forbid, cancer and was going to see the oncologist or was going to see the cardiologist or whatever, nobody would think twice about telling all of their, you know, friends or loved ones or whatever that they were going to see those doctors.
Tyler Johnson: [00:44:29] But for some reason, if you're going to see someone for help with your mental health, it's still, I think, at least in the United States, carries a stigma with it. It feels somehow shameful, like it's somehow your fault. And I don't know to this day if her way of approaching that was a personal difference or a cultural difference or where it came from. But I just in retrospect and now thinking about the way that things work culturally here, it really is such a shame, because getting help for issues that have to do with mental health may be the very thing for many people. That is the key to being able to break these cycles of what can sometimes be intergenerational trauma that is experienced and then inflicted and experienced and inflicted over the course of generations.
Dr. Mariel Buqué: [00:45:17] Absolutely. Because a part of what has kept many people and perhaps entire lineages, like in pain, has been the fact that people are either unwilling or unable to seek mental health care, and a large part of that for many generations has been because of stigma. Although there are other barriers and some barriers that impact certain populations more than others, including, you know, access to care, access to culturally competent care, access to trauma informed care. Right. Like there's layers. But the stigma is something that I think can be seen in a very global way. And it has been such a deterrent for people to be able to get adequate care and absolve themselves from the pain that they're holding. And then what happens is that, you know, that pain oftentimes needs to be discharged. Right? And so who can it be discharged onto? Usually people that are in close proximity, family members, children, sometimes colleagues, right. Friends, community members. And so a community that you feel is so beloved can be impacted by the pain that is going on unsolved within you, because the society that you exist within has made it so that you have relegated your pain to the shadows, rather than sorting it through in the ways that you would if your pain were physical.
Henry Bair: [00:46:53] You know, to Tyler's point about the stigma around it and to your point about how much contributes to trauma and intergenerational trauma, I would imagine that it takes a great deal of trust for your patients to come find you, and then open up to you and then share all these things. And you mentioned that you you do not start off your relationship with a patient by just digging into all of this. It takes you over sessions before you actually start to uncover a lot of the root causes. Do you have an approach? What is your secret to building that kind of trust with patients?
Dr. Mariel Buqué: [00:47:35] Well, I will say sometimes I'm shocked myself as to how much people trust me with their pain. But when I'm grateful and honored to hold it with them. But in part, I think that the reason why is because I don't thrust them into further pain at the outset of our relationship. And that, I think, can be very helpful for people to experience when they've gone to five other therapists. And each of the sessions, the first sessions especially look exactly the same. What brought you in? What's your family history? What's your history of, you know, mental health diagnoses, medication history. And it feels very robotic and monotonous. And sometimes it lacks connection. And that connection, what we've known over decades of studies of trying to understand what is the of course there are many, but what is the most important mechanism of healing in the therapeutic relationship? And it is precisely that the relationship. It's how a foundation of not just that trust is formed, but also a foundation of almost feeling like, uh, there is a container and a space that feels safe and that feels like it doesn't it Doesn't feel like a person needs to escape it or crawl out of their skin because they're so incredibly overwhelmed within it.
Dr. Mariel Buqué: [00:49:10] And I think that that's what I aim to do the most, is to ensure that a person feels like the container that I've created is a safe one, and that they can outpour all the layers of what they're coming in with in a way where they feel like they can trust that I can hold it with them and almost kind of regather them before the end of session, because one of the other things that tends to be pretty common for us clinicians is that, you know, we'll find kind of like the end point of a session and then transition into escorting a patient out. And oftentimes a person experiences intense emotions after these sessions, and they don't really kind of have a way to orient themselves well. Instead, what I tend to do is that I bring in some relaxation methods at the end of our sessions, so that a person can segue out of treatment in a way that feels gentler.
Henry Bair: [00:50:12] I'd like to close with this question, which is, you know, many of our listeners, I would gather the majority of our listeners are not going to be health psychologists, are not going to be focusing their time on treating patients with intergenerational trauma. But a lot of health care is traumatic. A lot of treatments can be traumatic. A lot of the diagnoses process, that communication can be very delicate. What lessons can you abstract away from your clinical practice and your personal experiences about how all healthcare professionals can better empathize and connect with their patients?
Dr. Mariel Buqué: [00:50:44] Well, I think that, for starters, we can potentially learn a bit more about trauma. It is incredibly unfortunate and probably a disservice to the health care field as a whole. And by as a whole, I mean even the individuals that are in supportive roles that don't get any trauma training, that we are working with, the trauma that is very visibly there, even if it's emotional trauma. And we haven't been equipped on really just identifying it beyond helping to absolve it. Right. Like identifying it and sitting with it and being able to have gentle bedside manner right with with patients as a result. And I think that it can be incredibly helpful for any of us to just take that added effort and, and try to orient around what trauma is, how it can show up, and how it can impact a person on a physical level that that can tell us a lot about maybe the intersection of the mind and body within our own respective fields in a way that I think can only do us clinicians so much more good. It can enhance our care, but also enhance our capacities. Right. And so, um, for many of us who love to nerd out and understand, you know, how to help people feel better, this can be an opportunity to just like, you know, enhance your learning and really dig into something that albeit, um, foreign, might actually really set your practice apart.
Henry Bair: [00:52:21] Yeah. And to your point earlier about how understanding the undercurrents, the burden that's been passed down to you over generations, uh, allows you to see those around you as more than one dimensional beings. I think that's also something that that is so valuable here. Right. Because too often I think in healthcare, not helped by the fact that we often have so little time with our patients. For most of us at least, it's really easy to to flatten patients just to the one dimensionality of that visit, how they present during that visit or their disease entity. So I think that your call for all of us to be more compassionate in recognizing the multidimensionality of everyone, that everyone is just a tip of so much more that they bring in to their experiences is a very powerful, uh, mindset for all of us to adopt.
Tyler Johnson: [00:53:08] Yeah. So I just wanted to pick up on that point and sort of take it just a little bit further, which is to say, I think a lot of doctors have this sense that they like, quote, don't want to be the patient's therapist. In other words, they don't even want to accidentally unroof or unearth some of these deeper psychological issues because they don't have the time or the wherewithal or whatever to address them. And on the one hand, of course, that's a good thing, right? If you're not a psychotherapist, you shouldn't pretend to be a psychotherapist. You shouldn't try to be a psychotherapist. You don't have the skill set to be a psychotherapist. So of course, that, you know, is fair as far as it goes. But on the other hand, in talking to you and in talking to some other guests that have been on our program, what I have gathered over time is that while that's true, it is also true that there is a presence that we bring with us into the room, with the patient, whatever our precise role is, whatever kind of doctor we may be, there is a way to approach a patient as a three dimensional or four dimensional human being, a holistic person that is more than just treating them as this broken bone, or this kind of cancer or this kind of medical problem to be solved. And being aware of that difference and striving to bring that holistic presence with you into the room, has the potential for qualitatively changing the encounter with the patient so that rather than feeling like all you did was come to address their one problem, they feel like you were there as a person to help and take care of them as a person. And I think that imbues the entire encounter with a type of grace and a type of presence that otherwise just can't be there.
Dr. Mariel Buqué: [00:54:51] Mhm. Wow. That's powerful. Thank you for that.
Henry Bair: [00:54:54] With that we want to thank you so much again, Mariel, for taking the time to join us for sharing your insights. I'm sure it's going to be so valuable to our listeners.
Dr. Mariel Buqué: [00:55:02] Thank you so much for having me.
Henry Bair: [00:55:07] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.theDoctorsArt.com. If you enjoyed the episode, please subscribe, rate, and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:55:26] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:55:40] I'm Henry Bair.
Tyler Johnson: [00:55:41] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.