Community Focus

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Alex Mackenzie, current Director of Support Groups and Mentorship Program, is a licensed MFT who has worked extensively in the tech world applying behavioral science in organizations as a consultant, leader, and executive. Licensed for the past 32 years, Alex has also maintains a private practice, volunteers, and supervises. He is passionate about helping develop the mental health field and its practitioners, while reducing mental health stigma and barriers to access.

Gia: In your 30+ years as a LMFT in various positions, from behavioral science consultant in the corporate world to your own private practice, what three (3) factors do you think greatly impact MFTs to the point of destabilizing their efficiency at work?

Alex: <laughs> The "three factors" query makes me think about the "Three Ls of Real Estate: Location, Location, Location". Similarly, my answer is "self care, self care, self care" -- which is analogous to location. Because we use ourselves as instruments, our work is best when our instruments -- ourselves -- are in the best condition. But there are so many parts of being a therapist that put wear and tear on our beings. What I have learned from my mentors and other therapists, which has been borne out in my own personal experience is that the work of therapists makes us particularly vulnerable to:

• Pressure to do too much -- financial, pressure from agencies, responding to needs of the patient/community one serves,
• Our work is historically being undervalued. See my article here on why Therapy is expensive: https://www.alexmackenziemft.com/post/why-is-psychotherapy-so-expensive-1
• For many, rushing from one setting to another and losing time and momentum along the way,
• Therapists' feeling that what they are doing isn't enough,
• Dealing with others' pain and trauma and it becoming ours, in part,
• For many of us, the caring parts of us that make us compassionate therapists also bleed over into sacrificing psychological and practical boundaries.

Gia: What “doable actions” have you witnessed mental health professionals practice that mitigate these destabilizing factors?

Alex: That's the good news. We could talk about this all day, and not be done. Therapists have so many tools we can use for self care. When we do care for ourselves, we feed a self-reinforcing loop in which our self care leads to overall wellness, work gets better and more satisfying as we are bringing our best selves to our work, and that satisfying dopamine reward feeds us the energy we need to plunge into more self care activities.

Of course, self care is very individual -- different people have different preferences, capabilities, access, constraints, and we receive different benefits from self care. Some examples include the obvious like taking care of the "temple" – getting ample physical exercise, a healthy diet, and plenty of good quality rest

Some of our self-care is following the advice we give to our clients:

• Caring for the spirit and psyche through meditation, mindfulness, breathing exercise, accessing or creating art or music, spending time in nature,
• Staying connected to strong social support through quality time with loved ones, community time with friends, enjoying the multiple benefits of volunteering,
• Maintaining balance – not making your job your whole life, including hanging around with non-therapists, pursuing pleasurable activities, learning new skills and keeping the mind active, reading, and even mixing it up in terms of the kinds of clients we see, or varying our schedules by alternating clinical, administrative, teaching, and mentoring work,
• Personally, learning new things is always a source of renewal for me.

Part of self-care is self compassion. When you let self care slip, just redirect yourself, as you do in mindfulness, and start again without judgment. Over time, it becomes a discipline, and we get progressively better at it as we learn what works best for us, individually.

Of course we leverage our skills, keep our ethical guardrails in place, but the foundation of all of that is caring for ourselves.

Gia: In your work as Director of Support Groups, what specific positive outcomes have you witnessed when therapists join a support group?

Alex: This is a really interesting question. We currently have eight (8) support groups running:

1. The Asian Pacific Islander Therapists' Support Group,
2. Pioner@s : Latinx,Hispanic, and Spanish Speaking Therapists' Support Group,
3. The Pre-licensed group,
4. Therapists' Support Group - an open-to-all therapists' support group
5. Newly and Almost Licensed Group,
6. An LGBTQIA+ Therapist Support Group, and finally
7. the 55+ Therapists' Support Group for therapists who are considering or making pivots in midlife. I co-facilitate that group with Liliana Ramos.

People get different things depending on who they are and what group they attend. In some groups, participants find safe space to discuss the unique challenges they face as members of a given community, and sometimes as they serve the community they are part of. I know that in the Group Practice Owners' Group, there has been a lot of sharing of knowledge and resources and practical collegiality around marketing and building a viable business. The Therapists' Support Group is always lively and well attended and the facilitators offer a bit more structure specific to self care and community building, including mindful meditation. The pre-licensed and newly licensed support groups provide a safe, judgment-free zone for the newest of therapists to be vulnerable and talk about the unique challenges of entering the field.

Our 55+ group is just getting off the ground, and like any new group, we are in the early stages of group development where we are navigating structure and process, but it has been a great source of community and shared empathy about the challenges and opportunities of aging as a therapist.

Gia: Can you recall a specific time in your practice when you experienced extraordinary burnout and how it was dealt with?

Alex: In 2010, I was running the Pacific Gas and Electric (PG&E) Employee Assistance Program for Value Options, when the pipeline explosion and fire devastated the Crestmoor neighborhood (San Bruno). As their EAP, our service focus was on the PG&E first responders. It feels a bit strange, even today, talking about the difficulties the counselors encountered because it feels like all the attention and compassion should go first to people of the community, second to the responders, and the wellbeing of the counselors a distant third.

But we were in the midst of a cascading series of events, developing every day, and each day we were guessing what was needed and where. We did many, many ad hoc critical incident debriefings and individual sessions onsite with the affected PGE employees, and there was a lot of pressure. Sometimes we rushed to a site and ended up not doing much, other times, we were overwhelmed. We didn't know from one day to the next what groups would be impacted and how. As a result, there was significant disruption to our personal lives (the counselors) as we had to be available on short notice, and didn't know what we would face when we were deployed. It was one of those times when we didn’t get to ever fully relax and put the tools down and replenish ourselves.

One thing we did very intentionally was to be practical about staffing. We brought in a lot of temporary, contract therapists to give some respite to our staff. We also had to acknowledge that for some therapists, this kind of highly charged environment was exactly where they thrive, and for others it was toxic. We tried to accommodate people's needs to the degree possible. Still, there was significant (short term) burnout. Okay, I experienced burnout!

I think for myself, the worst part was being in a role where there was no "good" outcome, a dynamic which I tried to shield the counselors from. Doing Psychological First Aid (PFA) is a set-up for burnout if you have to do it for a long time because just like we couldn’t “fix” the devastation to the community, there was no way to shelter counselors from the frustration of not being able to do the deep work to help the first responders move through the trauma they experienced.

So to a certain degree, with the caveats I mentioned, we just got through it, practicing Radical Acceptance, knowing that it would end at some point. Still, it was impossible not to get compassion fatigue toward the workers and the community members who lost family members and homes. When the crisis tapered-off, we were all pretty ragged, and sadly, I don't know to what degree some of us are still carrying some of the weight of it or are subject to being triggered by similar events. I would have liked to offer debriefing services to the counselors, but mostly -- understandably, they just wanted to go home to their families after a full day of responding.

Gia: Tell more about Psychological First Aid?

Alex: PFA is an evidence-based way of providing immediately responsive emotional and practical support to people who are struggling to cope with a traumatic event. A big part of it is psychoeducation – briefing on what are normal reactions to trauma (We emphasize “A normal reaction to an abnormal event”), teaching coping mechanisms to use over the next 72 hours, and connecting them with resources they can use– especially if they experience increasing distress. In a way, this is also what we were doing for one another on the fly – acknowledging our psychological “bruises”, talking informally about our sleeplessness, lack of appetite, startle responses, tendency to isolate – and picking the most adaptive coping strategies at our disposal.

Gia: That sounds practical. Anything else you’d add about stabilizing/destabilizing factors that impact on MFTs’ work?

Alex: I guess my final thought would be that, while we’re bombarded with claims about one methodology being the best evidence-based-practice, another having the best way way to train clinicians, yet another matching patient preferences, the most consistently and widely validated research says that the most important factor for positive treatment outcomes is a good relationship between the client and the therapist. Those relationships have empathy at their core, and we are able to be our most empathetic when we are alert, focused – not distracted with our own worries or distortions, and in a peaceful state. In other words, the conditions that arise from good self care.

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by Liliana Ramos, LMFT and Vidur Malik, LMFT

Many Marriage and Family Therapists transition from another career field. This can make them stronger as clinicians. Read how Vidur Malik continues to find ways to combine his passion and helping people find theirs.

Liliana: Thank you so much for agreeing to do this interview. Can you introduce yourself by telling us about yourself?

Vidur: I really appreciate you thinking of me for this interview. I am Vidur Malik. I’m an LMFT. I’ve been licensed for three years. I work at Mindful Practices, which is a group practice in Campbell. My specialties are working with clients who are either healing from childhood trauma or are recovering from substance use addiction. I am also an adjunct professor at Santa Clara University’s Counseling Psychology program. I teach biological basis for behavior and will be leading one of the group labs.

Liliana: What led you into your specialties?

Vidur: After I graduated, I went to work at an inpatient dual diagnosis. I was leading groups and working individually with clients who had severe mental health issues, and struggled with high substance use needs. I saw firsthand how shaming and isolating it was to experience homelessness. I saw the wisdom and reliance that the clients had to get through their life experiences. It was cool to give them the opportunity to share their intelligence that they have learned from dealing with people and getting through tough times. This helped me decide to keep working with people who are in recovery because of the richness and intelligence that they have to offer. Moreover, when you’re experiencing addiction, your life gets overtaken by that substance and other people stop seeing your strengths or your gifts. It was meaningful to help people feel like there’s more to them than what they’re using.

As far as childhood trauma, my appreciation for this specialty came from working with children and young adults who disclosed trauma to me during sessions. There were heavy situations in terms of reporting abuse that hadn’t been reported in the past, having to inform families for the first time, and helping the children understand how these experiences impacted them. Helping these children understand what happened to them impacted them, but it doesn’t define them and it doesn’t write the book on the rest of their life. When people go through trauma, especially when it’s relational-based, when someone has hurt them in some way, they start to think that everybody will do that to them. The clinician’s job is to help them see that although there are people in the world who do terrible things, they deserve to be around people who respect them. Also to let them know that it is not inevitable that every relationship will end the way that some have in the past. It is scary to take a leap into the unknown with somebody new, but it can be worth the time and risk when one feels that fulfillment of being with somebody or just being in a situation that feels safe and worth the risk.

Liliana: I hear the passion in helping your clients whose lives you’ve touched. I’m wondering what it is like for you to teach at the university that you graduated from?

Vidur: Working at the university has been awesome. It’s like being back home, being in the same building, and working with the faculty, many of whom were there when we went through the program. I’m there in a new context. It’s great to have the opportunity to build a curriculum, classes, and plan. I feel appreciative to be able to give back to that program because it set me up for this career. I feel well-prepared because of the people who taught us. I hope to contribute in some small way for the students that are there now. It’s a beautiful experience.

Liliana: I hear the love that you have for your career path. I know that you transitioned career paths. Can you talk about your journey from your original career to the mental health profession. What got you to where you are now?

Vidur: My original career was as a sports journalist. I loved sports. I enjoyed writing. I had a naïve idea that I could combine the two without realizing that there’s so much more that goes into reporting than just writing. I pursued a Masters in this field. However, as I got more into the field, I realized that it wasn’t a good fit for me. I think that in order to be a reporter, you have to be very comfortable with confrontation since not everyone will want to share information with you. I deeply admire people who do journalism because it’s important for society to be informed and to hold people accountable. I just knew that I couldn’t do that. It was burning me out in my mid 20’s. I was in New York at the time doing my masters for journalism. I was homesick and wanted to go home.

I enjoyed mentoring, so I decided to go into psychology because I enjoy helping others in a calmer environment. I was accepted by Santa Clara University, which gave me the added benefit of coming home. Making the career switch has been one of the best decisions that I have made.

Liliana: That’s great. What led you to the writing background? You had said that words are important to you.

Vidur: I think a lot of it was just being surrounded by books as a kid. Reading was modeled by my parents. There were always Time Magazines, my parents’ textbooks, and books all over the house. I did a lot of reading as a kid. It felt natural for me to explore that. My first opportunity in writing was for my high school newspaper. I wrote for the sports section of my high school paper. I would cover our school’s baseball and water polo games and write articles. I worked at my colleges’ newspapers as a sports reporter and editor. Then when I went to Columbia for my journalism masters, I took a sports journalism class. This connected me with people who worked at Sports Illustrated, which was always like my dream. I was lucky enough to work for them for a little while and wrote articles that were published by them.

Liliana: Interesting that you said that you were a sports journalist and now you want to go into sports psychology.

Vidur: It’s a new interest of mine. I’ve been reading about just how many professional and collegiate sports teams are really making space for mental health professionals, both from the performance aspect and the clinical work.

Sports is a huge passion of mine as an athlete, a fan, and an admirer of athlete’s accomplishments. I really want to be in that space. I am looking into how to become a certified mental performance coach and hopefully using my skills in the sporting context so that athletes can benefit from it. The track would be similar to the MFT track.

Liliana: Why is it important for you to do the work you’re doing now?

Vidur: I think it feels important because I feel like trauma and mental health issues carry a lot of shame and isolation even though the stigma is decreasing. They make people feel alone and misunderstood; possibly that people don’t even try to understand them. The most important thing and the most meaningful thing that I can do is just hold the space for someone that lets them know that I am going to take the time to understand them. The single most important thing that I can do as a clinician is just letting my clients know, I get you or I’m going to try my best to get you and that what you are feeling and how you are coping makes sense, given what you’ve been through. I want to do that in a way that allows the client to access their strength so they can feel more in control of their life and their relationships.

Liliana: Thank you so much for this opportunity to learn about your career path, your specialties, and the clients who you assist. I wish you the best in your pursuit of sports psychology.

Vidur Malik is an LMFT and clinical supervisor. Vidur works at Mindful Practices, a group practice in Campbell, where he supports children, adults, couples, and families with rewriting painful life patterns in order to live more fulfilling lives. He also provides clinical supervision for Almaden Valley Counseling Services and is an Adjunct Lecturer for Santa Clara University’s Counseling Psychology program, where he received his Master’s degree. Vidur enjoys playing basketball, seeing family and friends, and taking naps on his couch during his free time.

back to November 2024 newsletter  
SCV-CAMFT Director-at-Large Vidur Malik speaks with Saru Sivanesan, LMFT, about his transition from the tech world to psychotherapy, and about how to connect with and support tech workers.

VM: Could you introduce yourself and the work you do, including any clinical specialties?

SS: My name is Sarangan Sivanesan. Everybody calls me Saru. I was a software engineer for 20-plus years, working in Silicon Valley and elsewhere. My bachelor's is in mathematics and computer science, and then had an epiphany at one point in my life and decided to change my career. I went to the Institute of Transpersonal Psychology, now called Sofia University and did my counseling psychology degree there. My focus is working with software engineers and people in the tech field, because I really understand them. I get their problems. Whatever they say, the lingo they use, there’s no explanation needed. I work with a lot of anxiety, depression, complex PTSD, and addiction. I’m trauma trained in EMDR. I work with somatic modalities, some IFS, of course, CBT, DBT, and psychodynamic.

VM: Could you share what your personal epiphany was that led you to the career change?

SS: I was working in software engineering and looking for change. I could just feel something was coming. I went on a soul searching journey to South America. It was during that time when somebody pointed out to me and said ‘Hey, have you thought about being in counseling, you might be really good at this.’ I really liked to mentor people and had two close friends, who were already in the counseling field. In December 2007, I walked into ITP for an open house. And the moment I walked in, I was like, ‘Oh yeah, this is the place.’ It was just very clear.

VM: As you made your way into the field, what drew you to specializing in working with tech workers?

SS: It was as part of that epiphany. It became very clear that I'm meant to work with this population. If I asked my clients ‘how do you feel,’ their first response is ‘I think I feel…’ If you’re thinking about your feeling, then we have some education to do here. I was that person 20 years ago. I just thought, ‘okay, this is something, there is a gap there.’

VM: There is this kind of stereotype that like people in tech are logic-based, and not as much feeling based. What are your thoughts on that idea?

SS: That's a great question. I think it's a stereotype and a myth that we need to debunk in many ways. I mean, it's true from the outside perspective because that's how all techies relate - ’What is that program? What's that protocol?’ This is how we talk about things. Many people in the tech industry are from Asian origin, where from the time you’re a kid, you are trained to think logically. And that doesn’t mean they don’t have the capacity to feel. They do have feelings. It's just that it’s not given an importance. So once you start creating that balance and allowing people the space to say, hey, it's okay to feel. It's okay to feel sad. It's okay to feel hurt. That a nominal part of the human experience. And let’s talk about some boundaries and different things. Then it becomes a safer to really explore that problem.

VM: What are some ways that you’ve found are helpful to get a client to lean more into their feelings?

SS: I use myself because it’s a lot safer coming from a third party rather than them having to do it themselves. If somebody had a breakup, I might say ‘If I were you, I’d be feeling sad right now’ They don’t have to access that themselves. They access it through me. Another thing I do is I will pull out a feeling sheet and go ‘let me be sad, some feelings. Just nod if this resonates for you.’ Those are two things that I do use initially because it really opens the door to create some safety and to really titrate into feelings. There’s a lot of homework, learning to access feelings, learning to track the sensation in the body and then map the feeling to the sensation and know this is how it feels in the body. The next is the reactivity to the feeling. People are reactive to the feeling because they don’t know what to do with it. So then it’s creating a gap between the feeling and themselves so that there’s no reaction, there’s no backlash. I’m feeling upset and I’m okay. It’s uncomfortable, but I’m okay. Yeah, there’s like a gradual aspect of it, and an intentionality of only going where the client feels like they can go and then sitting with it.

VM: Do you self-disclose your own background in tech with clients to help them?

SS: Absolutely. I self-disclose because then it’s a familiar thing. It is a familiarity and that connection is very important and I also tell them right away. “I want you to feel connected to me and if at the end of this call you don’t connect then let me know, no harm done.’ I also self- disclose my own personal journey and trauma, anything that is relevant to the client. This area where we live is very individual-driven. Everybody’s here to make the money and strike big. They have community, but the community is with an intention to make connections to do good in their work. Nobody really sits down in the community and opens up and talks about how depressed they feel or how anxious they feel, so quite often people feel very alone in their misery. So I just bring myself into the room and I tell them, you’re your therapist and I feel sad/anxious too at times.’ I try to create an even field and where therapists and client are both human.

VM: What would you say to them to a clinician who may be anxious about working with tech workers to help their clients feel comfortable?

SS: it is so natural for me because I'm part of that tribe. For an arts or psychology major, somebody who’s not a science-oriented person, they also are a great value for this population in the therapeutic community. Someone who is more reflective, they bring in another aspect of the psyche that is very needed too. One of the most important things is to understand that sometimes people in tech can present very linear and driven and type A, but there’s an amazing softer gentler human side to them that can be brought out. It’s being able to look past this initial presentation to what is behind that is what invites that into the room, Being able to do that would be the one of the best ways to connect – connecting with some aspects of tech is useful being informed, but going beyond what is in the forefront of their expression and their expressiveness to what is behind – which is the beauty of the human being.

VM: Is there anything else to share about the work you do or about how clinicians do similar work that maybe we didn’t get to that you’d like to speak to?

SS: One of the things to understand when working with tech folks is that even though it does look like the life is very rich and wealthy, there’s a lot that goes on underneath it that is very stressful, even though it does look like the life is very rich and wealthy, there’s a lot that goes on underneath it that is very stressful. I’ve worked with clients who make a bunch of money and from the outside it looks good, but their life is extremely stressful. I think it's really important to have a lot of compassion for what it takes to be at that level. I know people who work at companies like Apple, Microsoft and Google, and the demands are very high. From a therapeutic perspective, we might say, ‘oh, you have a choice, you can go do something else.’ But it takes a long time to make that shift. I’m very fortunate. I had that epiphany and listened to it. I made the shift, but often people don’t make that shift. So I think it’s important to have that compassion.

Saru Sivanesan has been in private practice for 8+ years and seeing clients for 10+ years. Before becoming a psychotherapist Saru worked as a software engineer for over two decades in some of the leading software companies in silicon valley. As such he has an intimate understanding of the stressor of the silicon valley tech life. Saru's work is trauma informed, with certification in EMDR and training in Hakomi. He enjoys working with tech professionals as he feels he is still part of their tribe.

Resources:

1. The Alchemist by Paulo Coehlo - A great book on following your dream.
2. The Pilgrimage by Paulo Coehlo - A great story about the author's own quest to find his calling by going on a pilgrimage on the road to Santiago
3. Autobiography of a Yogi by Paramahansa Yogananda - An autobiography of a yoga teacher who brought yoga to the west

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Vidur Malik speaks with Cindy Gum, an LMFT, playwright, and co-facilitator of the SCV-CAMFT Licensed Therapists Support Group, about how to support older clients with the many life transitions they experience.

Cindy Gum has been in private practice for 25 years. She co-leads the CAMFT Licensed Therapists Support Group with Nasrin Farr and has recently served as a Supervisor at CHAC in Mountain View. Cindy has written four plays on aging and end-of-life, hosted a public access TV show Healthy Aging, and enjoys writing. She is now refocusing on what she loves most: working in the sand. An avid traveler, she recently visited India and Africa, and she finds joy in her extended 'modern' family. One of her guiding philosophies is, "When the dream changes, change the dream"—and so she has.

Vidur: Could you introduce yourself and the work you do, along with any clinical specialties?

Cindy: I’m a marriage and family therapist with 25 years of experience. I'm really redirecting now toward doing what I love, which is working in the sand with people going through transitions. I currently work from my home office, where I specialize in supporting older adults in transition and teaching Experiential Sand Tray Therapy—a unique approach I developed for working with adolescents and adults.

Vidur: What gave you the idea that Sand Tray work could be helpful?

Cindy: To me, the sand tray offers a powerful way for individuals to safely hold and explore their story. It provides a sense of containment, allowing people to confront their experiences without being overwhelmed. I truly believe that one of the most important things any of us can do is to know we can hold our story without feeling like we’ll ‘fall apart.’ It’s challenging, but once you realize you can hold your story with compassion and respect, it no longer feels larger than you—you become the author, rather than the other way around.

Vidur: For many older clients, I imagine life feels like one constant transition—retirement, losing a partner, or mobility challenges.

Cindy: Absolutely. They're often overwhelmed by many transitions, and it takes a toll. The constant adjustments wear them out emotionally and physically. I like to help my older clients safely examine how their story impacts their life and the transitions in the present.

Vidur: What drew you to working with older clients and end-of-life issues?

Cindy: My connection with this population grew from personal experience, especially after my husband’s spinal cord stroke in 2006. He was 13 years older than me, and over the years, I became more involved with the unique challenges facing older adults. Now, as someone approaching her eighth decade, I feel deeply connected to their experiences—I am my own ideal client.

Vidur: You were recently certified by Stanford University’s Center for Compassion and Altruism Research and Education. What projects are you currently working on?

Cindy: My journey as a long-term caregiver led me to Compassion meditation, which eventually connected me with the Stanford Ambassador program. I created a pilot project—a journaling circle for family caregivers. After a successful year, I expanded it into a free monthly Zoom Journaling Circle at BreathingSpacesfc.com, open to anyone wanting to become a better caregiver to themselves. I also contribute a monthly blog to their newsletter and am currently writing Caregiving YOU, a book that offers practical tools for self-nurturing through self-acceptance, connection, compassion, and trust.

Vidur: In your experience, what have been some of the most effective ways to help older clients feel seen and heard in session?

Cindy: Deep listening is key. I use reflection to validate their decision to seek support, and I allow their story to unfold naturally. This approach helps build trust and opens the door for them to share their needs.

Vidur: What should clinicians keep in mind when working with aging clients who are also caregivers for another aging person?

Cindy: It’s crucial not to assume that the person they’re caring for is necessarily a 'loved one.' Long-term caregiving, especially in marriages or with chronic illness, can create complex emotional landscapes. Caregivers often feel exhausted and frustrated, struggling with their unmet needs while tending to someone else’s. These caregivers need validation, emotional support, and resources. You might direct them to local support groups or online platforms like BreathingSpacesfc.com, which offer free, accessible support circles.

Vidur: What advice would you give to younger therapists who may not have much experience working with aging clients?

Cindy: Building a trusting relationship is key. Listen deeply, and don’t be afraid to acknowledge your age difference by saying something like, ‘I know I’m younger, but I’m here to support you.’ Older clients are life experts—they have so much to teach us. Sometimes, they just need someone to listen. Hearing loss can also impact communication and intimacy. I struggled for a long time to name it, but I eventually called it ‘verbal intimacy.’ When that connection is cut off, it can create a feeling of disconnection. So, be curious, listen, and meet them where they are, just as you would with any other client.

References:

● "Being Mortal: Medicine and What Matters in the End" by Atul Gawande

This book explores the challenges of aging and dying, focusing on the human experience and the emotional complexities that come with growing older. Gawande blends storytelling with medical insight, making it a compassionate and thought-provoking read on what it means to live well until the end.

● "The Gift of Years: Growing Older Gracefully" by Joan Chittister

Chittister, a Benedictine nun and author, reflects on the spiritual and emotional dimensions of aging. The book is divided into short, meditative chapters that explore different aspects of growing older, including accepting change, finding meaning, and embracing the richness of later years.

● "The Emotional Survival Guide for Caregivers: Looking After Yourself and Your Family While Helping an Aging Parent" by Barry J. Jacobs

While focusing on caregivers, this book addresses the emotional strains of aging, chronic illness, and caregiving. Jacobs offers practical advice on how to manage stress and maintain emotional well-being while supporting an aging loved one, making it relevant for both caregivers and those navigating their own aging journey.

● "Successful Aging: A Neuroscientist Explores the Power and Potential of Our Lives" by Daniel J. Levitin

Written by a neuroscientist, this book blends research with practical advice on how to maintain cognitive and emotional health as we age. It emphasizes how high-functioning older adults can make the most of their later years by staying engaged, curious, and connected.

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To commemorate National Recovery Month, SCV-CAMFT Director-at-Large Vidur Malik speaks with Mary Crocker Cook, a therapist, addiction counselor, educator, and author, about how to support clients in recovery from addiction.

Vidur: Could you introduce yourself and the work you do along with any specialties?

Mary: My name is Mary Crocker Cook. I'm a licensed marriage family therapist and licensed addiction counselor. I have been licensed since 1988, and I have always worked in addiction and mental health at the same time.

My private practice is largely general, but I have always taught and worked in addiction. I teach at San Jose City College and run their Alcohol and Drug Studies program

Vidur: What drew you to working in addiction treatment?

Mary: I became licensed in the late 80s. That was when all of the adult child of alcoholic books came out. My clients were all bringing them in and I started reading them and recognized myself, and started on my own recovery journey. In 1990 or so, I was at a network meeting with the clinical supervisor for the El Camino Substance Use Department. I asked her if I could volunteer because I wanted to know what happened in residential treatment. I wound up staying until they closed for about two and a half years. Out of that, I developed academic programs and my own expertise and addiction and just fell in love with it.

Vidur: Are there particular principles that you think should be part of addiction treatment?

Mary: The main thing is motivational interviewing and making sure that people are engaged at their stage of change. The biggest mistake we've made over the years is mismatching our level of care to people's level of willingness. Then people feel like they fail treatment. That's not true. But they failed that level of care because that's not what they wanted.

I'm an ASAM fanatic. In my own private practice when I work with addicts I do the ASAM because I think the multi-dimensional approach is key.

Looking at people's early attachment style is going to also help you figure out how to engage.

I'm on sabbatical for the year from City College because I'm writing my textbook on Attachment -Infused Addiction Treatment based on my own little outpatient here because I also teach codependency from attachment theory.

Vidur: Was there a moment in time when you first noticed the link between attachment style and addiction?

Mary: I have been teaching codependency from this framework for a long time because I kept seeing a combination of developmental history and then behavioral strategies and then medical or immune system damage in all my codependent clients. About five years ago, I started really focusing on addiction from that perspective.

Vidur: How would you say that framework helps clients get insight into their addiction?

I think it makes sense to them. My tagline is, ‘when vodka makes more sense than people.’ I think they get that. They've been through treatment multiple times, it's not that they have an information problem. The problem is application and how their interactions with other people continue to sabotage their use because usually it's a relationship that takes them out.

Vidur: Something I've heard from clinicians is ‘how do I know when a substance use issue is within my scope of practice? And when do I have to refer out to more targeted treatment?’ Are there ways that you can recommend that a clinician can delineate that for themselves?

Mary: My favorite way to do it, even though I'm a specialist, is to have them evaluated by somebody else, and I say, let's do whatever they recommend. So clinicians can send clients over to a treatment center who will do an assessment. That allows them to stay connected to the client before and after treatment.

The other possibility is to say to somebody, ‘what are you willing to do?’ And you start with that. The thing that kills me is people who had bazillion years of therapy and the therapist never said anything. The important thing to me is that they call it. ‘I see the drinking's part of the picture here. Sounds like you're not willing to do much about that, but when I notice it, I will mention it.’

If you cannot do that, you need to refer. if you're afraid to talk about it, or it's too sensitive, or you're going to be weird about it, OK. Send it to somebody who's not afraid of the topic.

Vidur: When working with someone experiencing addiction, what should success look like? Should it always be about relapse prevention?

Mary: I think moving through the stages of change is the goal. It depends on how the client identifies as a substance user. My question is, what's your relationship to substances? What do you think is going on with you in terms of substances? I'm trying to get a sense of what role it plays in their life. The whole point of addiction is you don't connect the dots. Like life is the problem. Alcohol is a solution. They don't see that it connects.

Vidur: How can clinicians build comfort with calling out clients?

Mary: I think they have to see it as a disease and not a symptom. It kills people. What clinicians are worried about is damaging the relationship. They would if they were blaming, but you can look at it out of curiosity, because my worst fear is I'm missing something. I'll even say to people, ‘I'm going to keep asking you this because my worst fear is you're paying me good money and there's a big piece of this puzzle I'm not addressing.’ It's a piece of the puzzle I have to have to be effective in what I'm doing.

Vidur: Is there anything else you’d like to mention that clinicians should know about?

Mary: Something I want to mention is that I am very worried about how many DUIs are in our CAMFT magazine every month.

I teach ethics and I always start with what not to do. I take out the magazine, and I'm like, Oh my god, DUI, DUI, DUI. I'm worried about us.

I think that therapists really don't see substances as a problem for themselves. If I don't think it's a problem for me, I am surely not going to see it for my clients. I don't recognize that I shouldn't be behind the wheel. I might have a little bit of a blind spot.

Also, we need dually certified professionals. We need therapists to go get certification as addiction counselors. We don't have enough of us. Addiction treatment is an actual animal in and of itself.

Vidur: What can therapists do to get certified as addiction counselors?

Mary: In Santa Clara County, you could come over to San Jose City College and take our classes. They can do the certification program online through the California Consortium of Addiction Programs and Professionals.

back to September 2024 newsletter  

References

Facing Codependence by Pia Mellody

This Naked Mind: Control Alcohol, Find Freedom, Discover Happiness & Change Your Life by Annie Grace

The Science of Addiction: From Neurobiology to Treatment by Carlton K. Erickson Ph.D. 

Understanding Addiction: Know Science, No Stigma by Dr. Charles Smith

(3655) everything you thought you knew about addiction is wrong - YouTube

How Childhood Trauma Leads to Addiction - Gabor Maté (youtube.com)

back to August 2024 newsletter 
In honor of National Women’s Equality Day, SCV CAMFT Director-at-Large Vidur Malik speaks with Liz Ojeda, AMFT, about the work she does with female clients who have experienced trauma, violence, and oppression. They also discuss the impact of self-disclosure and therapist vulnerability on the therapeutic relationship.

Vidur: Could you introduce yourself and the work you do along with any specialties?

Liz: I'm Liz. I use she/they pronouns and I take a lot of pride in openly acknowledging that I am queer and Mexican American. Currently I primarily work with survivors of sexual assault, who tend to be women. I help my clients get to the roots of where the trauma and violence are coming from and how that’s showing up in their behaviors.

Vidur: What drew you to working with people who have experienced trauma and violence?

Liz: I started this work really at a domestic violence shelter in undergrad and I've built my way from there. I've done some crisis counseling and went back to a domestic violence (DV) agency in San Mateo. Before I ended up at the group practice I'm with now, I worked primarily with students, mostly in environments where there was a lot of community violence. I did a lot of sex education with students.

A lot of it was also personal experience - seeing it within my family, and then within my community. I went through the training and I found it really enlightening because it gave me language for a lot of the patterns I didn't notice.

Vidur: What drew you to working with female clients in particular?

Liz: Rewinding again to like my own personal narrative, it wasn't until I was older when I noticed some patterns from my grandparents, and then my mom, and then how that carried over to myself and my younger sister. When I learned about my grandmother’s history of how she immigrated to America - she's first generation, she wasn't documented - all of these different parts of her identity helped me get a better understanding of what expectations were placed on her. All of this helped shape my understanding of the roots of violence. For female-identified folks, the amount of history and the amount of trauma that we hold and suppress can show up in our bodies, so I do a lot of somatic work.

Vidur: What are some ways that clinicians can build trust and safety with clients, especially early on with a client who's just experienced a lot of trauma and violence, to make sure we’re not perpetuating systemic oppression they may have experienced?

Liz: When I read this question, I first went to, ‘what is safety? What does that mean?’ I think it's the capacity to feel free and to show up with whatever is coming up. I'm not going to push you to talk about one thing or the other. That helps build that safe environment. I let clients know that there's so much that they probably don't feel like they have control over at any given point in time, but when they're with me, at the very least, they should be able to control what's talked about and what's not, and when they talk about whatever they want to talk about. I find that's a really cool intervention.

Vidur: How do you approach self-disclosure in session?

Liz: I'm not here to hide who I am. It’s taken a long time for me to really own the parts that I was ashamed of in the past. I like to think of that as role modeling. I'm a bit more open with self-disclosure, but I'm not telling everything. I'm not here to make it about me.

Especially for female-identified folks, I think it's so important to just say, ‘me too, you're not crazy. What you're feeling makes total sense.’ The world sucks sometimes. I want to walk down the street and feel safe, and I can't always do that.

Vidur: Would you recommend for male-identifying clinicians working with female identifying clients to name that gender difference in session and invite clients to process it? I’m particularly wondering about cases where female-identifying clients have experienced trauma perpetuated by men.

Liz: As we say for everything, it’s on a case-by-case basis. But for male-identified clinicians or really anyone, if you feel like there's some discomfort in naming it, you probably should name it. If you feel if something is telling you to address it, I don't think it would hurt to name that. Be curious about the client’s experience happening in the room, but also pause and reflect on why this is showing up.

Something I really value in this work is also just taking accountability. In relationships, there's always going to be harm done, some kind of rupture. And I think part of that as well is being mindful of our histories. That can lead to the modeling of vulnerability of ‘I messed up and I want to take ownership of that.’

Vidur: In our training, we often hear that we shouldn’t self-disclose. There’s almost an unlearning I’ve had to do of that when I think of self-disclosing in session. I wonder if you’ve had a similar experience.

Liz: Yes. Something in me was like, ‘I'm going to sneak in like who I am’ because that's how we build connection and that sense of belonging. When a client really like tugs on my own thread or if I'm tearing up in session I'm going to let them know, if appropriate, ‘wow, that really touched me. I'm not going to hide that because I think that perpetuates the idea of the client having to suppress it.

Vidur: Was there anything else you wanted to share?

Liz: We can’t do this work alone. Some pain is meant to be felt with another person. We can’t always hold everything alone. That’s when we feel isolated and scared. There’s a lot of unknown. That’s scary, but sitting with that and creating spaces with each other, with ourselves, and with clients helps us bring it back to, ‘how is this showing up for me?’ As we continue to do our own individual healing work, it’s going to help lead to greater shifts within our community.

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Interview with Gia Reyes, LMFT by Vidur Malik, LMFT, Director at Large

Vidur: Could you introduce yourself and the work you do, along with any specialties:

Gia: My name is Gia Reyes, I'm a first-generation immigrant and LMFT. I specialize in immigration-related mental health issues such as cultural and generational conflicts, migration trauma like the sense of losing one's identity, culture and traditions, and intergenerational trauma, especially for second or third-generation clients or clients with refugee lineage.

Vidur: What motivated you to specialize in working with clients who are experiencing immigration-related mental health issues?

Gia: Being an immigrant myself and knowing how overwhelming and anxiety-provoking moving to another country can be, I really felt that my life experiences and academic learnings provided me a unique lens through which I could assist similar immigrants make some sense of their new life. First-generation immigrants of a certain age have usually lived a ‘life’ in their country of origin and have ‘paid their dues’ in a certain industry, only to find themselves unable to practice in the US due to lack of accreditation or licensing. That alone can cause severe depression and anxiety, even an existential crisis.

Also, having lived here for a few years in my early 20s as a foreign student, I became acutely aware of the huge difference in my experience then and coming back in my early 40s with two kids below the age of 10. It is really fascinating how as an immigrant you experience the same place very differently at different stages of your life.

As a mom, I suddenly found myself doubling down on making sure my kids understood the Filipino language, ate Filipino food and ensured they were aware of the culture, beliefs and traditions, if not adhere to them. Having had the privilege of being able to travel at a young age and being exposed to different cultures, it was still very jarring to have to raise children with very different metrics from what I knew as a child. I knew that for a lot of immigrants, who probably also had a language barrier to hurdle besides the disparity in cultures, the challenges could turn overwhelming on a dime. I was sure that there were so many immigrants who needed help.

Vidur: Do you find that there are commonalities in the immigrant experience, regardless of where in the world you're immigrating from?

Gia: That's such an interesting question because a lot of immigrants come from collectivist cultures where you basically move as a ‘tribe’, and the goals and well-being of the group at large is oftentimes given more priority than individual goals. Then you come to the US, and it's a very individualistic culture, and the second and third-generation family members experience so much internal conflict because of the opposing views of family vis-a-vis American society.

Yes, I've discovered that there are so many commonalities with immigrants regardless of where in the world they come from. Then as you peel away layers, you start to see the nuances of a specific culture.

I have a lot of clients who, whether first, second or third-generation immigrants, experience and/or inflict intergenerational trauma to the next generation, that my mind is truly blown away. And as I’m sure most immigrant therapists have experienced, there is a unique advantage to having that lived experience of growing up in another culture, especially a collectivist culture. There is an innate understanding of certain ‘rules’, such as unquestioned reverence for elders and how it is almost incomprehensible to go against what the family has always believed in or done, even if your Western mind knows, ‘this is so toxic.’

Vidur: In your experience, how do clients figure out how to preserve their cultural identity from where they lived before while adjusting to where they're living now?

Gia: I try to introduce the idea of the “third identity,” as renowned Indian-American psychoanalyst Salman Akhtar has very brilliantly coined - because it is really a “third identity.”

I still recall what a Peruvian professor of mine in grad school said, “I feel more American when I’m in Peru and I feel more Peruvian when I’m in the US.” It blew my mind because it totally resonated with me! There is this sense of not fully belonging anywhere, of being in some space that is unknown. . . a space with no label. Hence the need to ‘integrate’ all the parts of ‘you’, to have trust and confidence in this “third identity.” That is your core and authentic self.

Almost organically, I have leaned into the therapeutic modalities of Internal Family Systems, Psychodynamic Psychotherapy and Trauma-focused Therapy.

Vidur: What would you say are the best ways for clinicians to ensure that clients who have recently immigrated to the US feel safe in session and feel fully seen and heard?

Gia: I think that in most cases, especially for new immigrants, it is a better fit to find an immigrant therapist. Just because intuitively, an immigrant therapist would know how to address sensitive topics that a non-immigrant therapist may not deem so, and also know the stigma that therapy might have in the client’s country of origin.

I would recommend listening for a couple of sessions, just asking questions and refrain from giving any opinion until you have done some research into the particular culture. Luckily, we live in the Bay Area where the population is so diverse that it is not a stretch to find resources on practically every ethnicity in the world.

Vidur: What has your experience been like in terms of finding your own identity after your immigration experience?

Gia: It has not been an easy road for me either, let me start with that! I had a thriving business in the Philippines but because of the political and economic uncertainty then, I felt the need to seize an opportunity that presented itself, to establish a life with my kids in North America.

Then after my divorce, I seriously thought of going back to the Philippines but my kids, who at that point had spent more than half their lives in the US, were basically opting to stay here. The Asian mom in me kicked in, because I wasn’t going to leave them alone here! And that is when I had to really assess and determine what I wanted to do ‘for the rest of my life.’

So I decided to go back to graduate school, get licensed as a psychotherapist, go into private practice and hopefully help other people, particularly immigrants, find happiness and joy in their life. I want to think that my “third act” is also my way of manifesting the idea that ‘older’ immigrants can reinvent themselves. It takes a lot of gumption, but I believe all immigrants have that.

Gia Reyes is a LMFT in private practice. . . she is also a mom, writer, foodie, avid gardener and energy healer. In her mid-fifties, she decided to pursue a Master’s degree in Clinical Psychology and took on the daunting task of 3,000 hours of internship, getting licensed as her sixth decade was approaching. Gia is a firm believer that her lived experiences of being an entrepreneur, consultant for several multinationals, living in different countries and just “bouncing back when necessary,” greatly complements therapeutic modalities like Internal Family Systems, Psychodynamic Psychotherapy, DBT and ACT.

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Interview with Alex MacKenzie, LMFT by Vidur Malik, LMFT, Director at Large

Vidur: Could you introduce yourself and the work you do?

Alex: I work primarily in private practice. I do a lot of couples work, which is really my favorite thing. I do work with a lot of LGBTQIA+ folks and I also have gotten really interested in working with what I like to call mid-adulthood or “third act” stage of life. I love working with people who are intentional about how they use this last part of adulthood – whether that's retiring, refocusing their career, whatever is meaningful and fulfilling for them. 

The intersection of those – that's kind of my favorite place– when I can work with LGBTQIA+ couples who are in that sweet spot of their life and identifying what that looks like for them as a couple. 

Vidur: How did you realize that was the sweet spot for you?

Alex: Well, honestly, it matches my personal experience. 
I had a sobering experience with getting a cancer diagnosis and so that brought things into sharper focus in terms of recognizing that I don't have the luxury of saying, “Well, maybe I'll do that later.” In mid-adulthood, you're at a time in your life where you don't really have that luxury. But it's an interesting paradox because limitations are really liberating in that they really clarify  this is the time – right now, and either you're going to do it or you're not. 

The third act is a sweet spot in that it’s the wisest, most fearless, most curious point in life. It can be a moment when you have less to prove, and the unneeded armor falls away, treating you to the joy of being the most authentic version of yourself.  

Vidur: What do you particularly enjoy about working with clients in that stage of life in a couples setting? 

Alex: My simple answer to that is I love “love.” I find it really inspiring to help people who may have become a little alienated from each other or who may not be communicating optimally to find that place where they can love each other and support each other in whatever their individual and collective pursuits are, and live the life they truly want. 

Vidur: What drew you to working with the LGBTQIA+ community in particular?

Alex: One thing is identification. Another is when I was going through my graduate program and doing my first internships, it was the community’s moment of reckoning with the AIDS crisis. 

I was in San Francisco at that time and I saw a lot of need and a lot of suffering and alienation. Sometimes crises bring people closer together, and sometimes they push people apart. I really wanted to be a part of the coming together and healing whatever ruptures could be could be healed. At that time, multiple traumas were playing out at the same time. We didn't know what caused AIDS, and gay men were dealing with this horrible question, ‘does my love kill me or kill somebody else?’ There was a lot of division and judgment about, ‘well if those people weren't doing those activities then we wouldn't be having this problem’ and kind of other-ing parts of the community. There was a lot of negative energy pointed at the gay community and even within the community there was a lot of, ‘I'm going to get my safety by differentiating myself from that part of the community, which is seen as objectionable.’

I really wanted to be part of working with people however I could, in groups, individually, and couples to heal some of those ruptures. 

Vidur: How have you found that therapy has helped heal some of those wounds? 

Alex: Therapy helps people who grew up with trauma - including the trauma of having to hide from your parents who you are, the trauma of feeling like society is hostile toward you and that you’re not safe - examine those thoughts and say, ‘well, there are places where I can be safe.’

Realizing that there are relationships where we can be safe and be okay. Accepting that our partners are not looking at us the way that some hostile parts of society does, or the way that a family may have,  if the family was rejecting. So reducing some of that defensiveness where it's not needed by re -examining –   reappraising those kinds of beliefs. 

And of course,  communication, helping people learn how to listen to each other with empathy, and teaching couples how to listen to each other and how to assert themselves heals ruptures and builds bonds. 

Vidur: What are some things that you would recommend for clinicians working with LGBTQIA+ clients to do to make sure that their clients feel safe with them? 

Alex: The first thing I think is that if you identify as LGBTQIA+ to come out to your patients, to let that be visible on your website or however you make yourself known. If you're LGBTQIA+ identified, then one of the first things I would say is to ask your clients if they feel you’re an appropriate clinician for them. It's legitimate to feel like you want to work with somebody who can understand you, and while you don’t have to come from the exact same experience to understand, it’s important to at least open up that conversation. 

I would say the next thing is to explore your own biases and work to expose yourself to information that contradicts those biases and acknowledge how and when they come up. It’s hard not to make assumptions that you understand things that you may not – our biases are insidious in that they just seem true. We all have them.

There’s a thin line between being open to learning from clients about their culture or their experience versus having them have to do the emotional labor of teaching you. I would advise just being aware of that line. It’s important to continue to check with yourself and your clients about how you're navigating that line. 

Vidur: As a gay man, I'm wondering whether you've noticed a parallel process in terms of the trauma that you might have had to deal with and whether that comes up when you support your clients with their trauma? 

Alex: Yeah– Isn’t it for all of us the lifelong unwinding of our own trauma?. There are some times when clients are talking about something that stimulates my own triggers in some way, and I have to use what I know about managing my own trauma response. I might feel tearful, for example, or even angry on their behalf.

Sometimes, something comes up that I'll just disclose, ‘I really relate to what you're saying, this is kind of triggering for me. Let me just acknowledge that and we'll work through it as best we can,’ and I try not to make that the client's job, of course. 

Vidur: How meaningful has it been to support the LGBTQIA+ community and the healing that you wanted to contribute to? Is that something you think about? 

Alex: Thanks for asking that because it's really something that's part of this life stage - looking back and asking, ‘how satisfied am I with what I've done?’

I feel rewarded, validated, and happy when I think of where the community has come and what we’ve achieved. Most of us of my age and many who are a bit younger never thought we'd have a serious conversation about marriage equality, and the fact that we today have marriage equality is quite amazing. 

I do like to think that our work as therapists has contributed to where the community has come to today. The fact that young people –  12, 13, 14 years old are self-identifying and there's growing understanding that gender is on a spectrum is amazing. We’ve created the safety to have some of those conversations. 

Part of satisfaction is acceptance of my own limitations. I sure wish I’d come pre-loaded with all the learning of these years, because I could have helped more, could have done better. 

Occasionally I'll run into a client or a couple (I worked with), and just seeing that they made it is just amazingly satisfying. 

As a community, we still have a long way to go. We are evolving, growing, encountering new challenges, and having to re-fight some old battles. I’m still here for it.  

Alex Mackenzie, MFT is a psychotherapist in private practice who has been licensed for more than 30 years.  He works with a diverse population, and has special interest in working with the LGBTQIA+ community of which he is a member, with age 50+ persons making the most of their "third acts", and with couples.  Alex volunteers as a board member for SCV CAMFT, and as a clinical consultant for Almaden Valley Counseling. He is an avid reader and writer, and rabid downhill skier and spends as much time as possible in the healing natural environment.   His website is alexmackenziemft.com

References:  

10 Principles for Doing Effective Couples Counseling -- Gottman Julie and John\
The Courage to Be Disliked -- Kishimi, Ichiro and Fumitake Koga
Learning to Love Midlife -- Conley, Chip
Stonewall Generation: LGBTQ Elders on Sex, Activism, and Aging -- Fleishman, Jane and Kate Bornstein

back to May newsletter
Interview with Siobhan Cassidy, LCSW by Vidur Malik, LMFT, Director at Large

Vidur: Could you please introduce yourself and the work you do?

Siobhan: My name is Siobhan Cassidy. I'm a licensed clinical social worker. I'm originally from New York. About five years ago, I moved to California and transferred my license. Originally, I was in San Diego. I just got to the San Mateo County area in October of last year. I'm excited to be a part of this chapter and get to know people as I’m moving my practice here. I specialize in young people, kiddos, and teens, and specifically grief and life transitions. Sometimes that comes up as a formal grief, but many times it also comes up as grief of friendships, transitions from elementary to middle school, or in thinking that their college journey didn't turn out.

Vidur: What initially drew you to working with a child population? Within that, what drew you specifically to supporting children with different types of grief?

Siobhan: It was by accident. I was in graduate school in New York, working with addictions, family members, and high schoolers. It was during a time of significant heroin and opiate abuse, and the dying part of it and the people who are left behind. With my second practicum, I always wanted to work in health care, so I worked at the Cancer Institute in New York. That was all ages. I loved working with kids. I find it to be easier. They are little superheroes.

Vidur: What in particular makes working with kids easier than other populations?

Siobhan: Kids just want to play. There is this innate curiosity about them, whereas when we grow older, we get stuck in our ways. With kids, I just find it a little bit more approachable, and maybe that's also my personality.

Vidur: I noticed your website is really refreshing in terms of the language and acknowledging that much of therapy terminology can feel condescending or not very real. What was it like for you to come up with your descriptions of who you are and the work you do?

Siobhan: Thank you for that. It came from my patients. Ever since the pandemic, there's been this influx of therapists on social media. Now kids are coming in and they're saying, ‘my parents are narcissists’ and things like that. How can I get something that could be complex down to the nitty gritty so you know what you're getting in session? This is also how I speak, so I wanted that to flow over my marketing so they know what they're getting.

Vidur: I would imagine that working with death and really heavy issues like cancer, you have to just be real about it, and you can't really beat around it.

Siobhan: I’ve actually had feedback from my patients saying they need the directness in death. For example, if I have a patient who lost their wife, that person is no longer married, and saying it directly gives language for something that's new.

Vidur: Do you think that that shows up in working with kids too, acknowledging the elephant in the room?

Siobhan: It's interesting with kids because it's almost like they're already there. Kids are in these environments are surrounded by adults telling them how to think. Instead, they want the truth and they want to talk about things that are real for them. I almost find that if you just give them permission, welcome it, or model it, they themselves will then come out and find the words. If they don't have the words, that's okay because then we can do expressive arts or we can make words up.

Vidur: What else has come up for you as unique challenges of working with child populations that maybe aren't there with adults or other populations?

Siobhan: It's very difficult to be a young person. They're this individual human being that was born into this world. Then they're around these adults who have to say no a lot to keep them safe. They also have to maybe go to a school that they don't want to go to, be around people they don't want to be around. There's a lot of “no.” The way I approach that is by giving them permission to be themselves. They can tell me ‘no’ and practice saying ‘no.’ Here is a ‘yes’ area.

Vidur: We've all had some experience working with kids, and  a lot of clinicians get nervous about it. What are some things that you’ve found are the best ways to make therapy engaging and relevant for kids as opposed to an obligation?

Siobhan: I think it's rolling with the resistance. It's rolling with the idea that some of them might not want to talk. and they might want to sabotage it. I've also had children test me, ‘who are you? what do you like? why are you going to ask these questions and I don't know anything about you?’ I have an open book with appropriateness. I share that I'm a member of the queer community, I like to watch this show, my favorite color.

I have done so many CPS reports in my time. I use that approach of, ‘this is because I care about you.’ Sometimes if I'm getting information that might be reportable, I don't make them shut up right away. I want them to tell me more, tell me more of your experience, and know that maybe I'll sit with that for a session, and I'm not going to do anything. Then it might build, and then I'll bring to them because this is a working alliance. And I say,  I'm going to do this CPS report, but what is our goal between me and you?’

I have this rule that I tell them in the beginning, they're the driver, and at the halfway mark, I always check in: ‘How's it going? Do you want to continue? Are you over it today?’ Because otherwise, why are we trying this out for 45 minutes if they're checked out? Might as well just do half the time.

Vidur: Are there other things that you wanted to share about yourself or about working with kids that you think would be relevant?

Siobhan: I know this is an area that a lot of clinicians suffer with. Unfortunately,the context (of working with kids) sometimes is very upsetting, so it's constantly checking in with yourself.

I have this way now where if a child is telling me something that their safety is at risk and something's going on, where I just sit with my feelings and slow down and tell them, ‘okay, let's take a breather.’ Having one safe person in the world is so important to them, so if a kid is not engaging with me, and they don't want to be here, they might just be testing you to see if you will be there because no other adult might be there for them in a safe way. It might take a long time to get their rapport going.


Siobhan Cassidy’s biography

Siobhan Cassidy is a cis-gendered, queer woman, who is a first generation Irish-American. She is a licensed clinical social worker and is licensed in California and New York. Siobhan's specialties include grief and loss, sexual education and sexuality/LGBTQA+ folks, neurodivergent/ADHD struggles, and college/early career support. She has much experience with grief and loss after a decade of work in clinical hospital settings with children and adults.

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Interview with Taylor Barragan, LMFT by Vidur Malik, LMFT, Director at Large

Vidur: Could you please introduce yourself and the work you do?  

Taylor: I'm Taylor Barragan. I am an LMFT and a psychiatric mental health nurse practitioner (NP). I work most frequently with conditions like  anxiety, depression, bipolar disorder, and adult ADHD. I’m primarily working as a therapist right now, but in the summertime I plan to relaunch my practice with an approach including medication management integrated with psychotherapy, as well as complementary interventions and lifestyle recommendations tailored to each patient's unique needs. Personalized treatment will be guided by the patient's history, specific lab results and grounded in evidence-based medicine.

Vidur: What originally inspired the shift to pursue the psychiatric nurse practitioner program?

Taylor:  It was a culmination of things. Around the time I got licensed,  my husband moved to Ohio for nursing school, and I found myself so interested in everything that he was learning. I was asking him so many questions. At some point he was like, ‘you should just go back to school.’ Around that same time, I had a few therapy clients that had tried medication and within a couple of weeks, they were not as anxious and could actually tap into the emotions or insights that they couldn't previously access in session. I realized that was like the missing piece for this client. I wanted to know more - why did a provider make that decision with that medication or how are these other lifestyle things impacting how effective that medication is?

I just really love school too. Part of that I think too is having ADHD myself. School provides a structure, and I like learning. I interviewed some colleagues who were psychiatric nurse practitioners and after researching how I could integrate my background as a therapist, I decided to make the leap.

Vidur:  What type of work do you envision doing with your background in therapy and psychiatry?

Taylor:  I have some clients that would prefer to see one provider for medication management and psychotherapy in an ideal world. What's coming down the line in the summer is relaunching my practice to include medication management.

But if somebody is already working with a therapist and that is established, I would love to be able to better collaborate with therapists and make that a cornerstone of how I practice. I don’t think school provides enough training  on how to collaborate with a patient’s psychiatrist or psychiatric nurse practitioner. I also don't think that medical schools or psych NP schools do that very well either. There is often confusion about things like “What cadence should we be talking on? How should that communication go? Who leads that? What are we reinforcing in each other's work because this is our common goal for this client?”

Vidur:  What are some ways clinicians can maintain relationships with psychiatrists and ensure coordination of care?

Taylor: It can be really hard to get a hold of psychiatrists or psych NPs. They may not have a direct number. I think that there's just a natural grittiness to the beginning of even making contact, and that takes a little bit of persistence. That gets difficult too because then you might spending a lot of time trying to get a hold of this person's psychiatrist outside of session that you’re not necessarily getting paid for. So you can reserve that time in the session with the client, because it is really important. You can use one of those sessions as a case consultation with the client there.

You can also talk through the main concerns, what you’re working on, and what would they would like you to reinforce during sessions. Getting an understanding about if that client is prescribed something, why that was the choice, and side effects that you should be looking out for. And if you are noticing that somebody is having side effects, being able to have a secure way to send a message to the provider.

In addition, psychiatric providers may only be seeing a client once a month, and then sometimes down to once every three months. So as the therapist, you're getting way more face-to-face time with that client than the provider is most likely. I don't think that everybody involved oftentimes appreciates just how much insight the therapist has; if somebody's doing well or not.

Also, if somebody is not sleeping well and they are on a medication that can cause issues with sleep. The psychotherapist can ask, ‘Hey, did you talk with your psychiatrist or psych NP? Can you take that in the morning?’ Just understanding how you can play a role in reinforcing things, being able to report back key things that you discussed with the psychiatrist.

Vidur:  It sounds like there is a lot more insight clinicians can provide to psychiatrists than we might realize.

Taylor: So much, like sleep habits and quality, medication compliance, or substance use. If somebody is having side effects from a medication and they don’t like taking it but don't want to tell their psychiatric provider, it’s important to have the conversation with the patient about how important it is to let their provider know. It’s importance to reinforce, “Hey, we’re all on the same team. Your provider should know how you’re feeling about the treatment or they have no way of knowing what is or isn’t working.”

 I think that's where things get really messy. Patients may be on a few different medications, and you can't tell if they've had an adequate trial of one because maybe they weren’t taking it because they were having side effects. If we had a better structure for how the therapist could feel empowered to help monitor and relay some of that information, it would be way less confusing and ultimately lead to better patient outcomes.

Vidur: Are there particular topics related to psychiatry that clinicians should like keep ourselves educated on in order to support our clients?

Taylor: Reducing stigma about medication can start just by referring a patient to a psychiatric provider. Patients trust us as psychotherapists, and reiterating that going to a psychiatric provider does not mean they have to immediately take what is recommended is really important. It just starts the process. I was talking to a psych NP a few weeks ago and she said that she always refers patients to psychotherapy, but not every therapist is willing to refer to psychiatry early on in treatment.

Depending on how severe somebody's symptoms are, early intervention is key. Research shows that for conditions like moderate to severe MDD, schizophrenia and bipolar disorder, the longer the delay in treatment, the more treatment resistant they do become. There is also much discussion in the field whether “treatment resistant depression” is actually a case of missed bipolarity, specifically type 2. So for patients who are seeking therapy for mild depression, for example, if symptoms are not improving and instead getting worse, it’s important to refer for an integrative psychiatric medication evaluation.

The other important thing is to remind patients to not start and stop their medication on their own. Again, therapists see the client so much more frequently than a psychiatric provider, so its important to encourage the client to discuss this with their provider and also update the psychiatric provider about any issues with medication consistency. Research on MDD, for example, shows that symptoms should be first treated to remission, and then continued at maintenance with the medication, and psychotherapy, for 6-12 months before tapering (Altamura et al., 2007; Altamura et al., 2008; Kato et al, 202; Paquin et al., 2022). So it’s important for patients to know that for everyone, medication doesn't have to be forever, but it’s really important to decrease stigma about taking medication, reinforce and provide hope for patients, and collaborate with their provider during treatment. Therapists should also be aware of new and exciting emerging treatments like esketamine, and rapid acting antidepressants that are not monoaminergic like conventional antidepressants.

About Taylor

Taylor Barragan, LMFT, PMHNP-BC, APRN, PMH-C is a Licensed Marriage and Family Therapist and Board-Certified Psychiatric Mental Health Nurse Practitioner. She earned her Master of Arts in Counseling Psychology from Santa Clara University and her Master of Science in Nursing in Advanced Practice Psychiatric Nursing from Case Western Reserve University. She is a member of Sigma Theta Tau International Honor Society of Nursing, Postpartum Support International (PSI), American Nursing Association (ANA), and SV-CAMFT.
With a focus on integrative and holistic treatment, Taylor's telepsychiatry practice, which will launch in Summer 2024, offers medication management, complementary and supplemental therapies, and psychotherapy services for teens and adults. As a Perinatal Mental Health Certified (PSI) provider, she has a particular passion for supporting neurodivergent parents through the perinatal period, from preconception through postpartum. Taylor also earned a certification as a lactation counselor to better understand the mental health impacts of lactation and related challenges during the postpartum period.
Taylor's expertise also extends to executive functioning challenges at work and during the transition to parenthood. Her strengths-based and relational approach integrates psychodynamic and cognitive-based psychotherapies, emphasizing enhancing daily functioning and quality of life. Taylor is committed to providing affirming, culturally competent care tailored to each client's needs.

Recommended resources for therapists:

Psych Meds Made Simple
Handbook of Clinical Psychopharmacology for Therapists
Clinical Psychopharmacology Made Ridiculously Simple

References

Altamura, A. C., B. Dell'Osso, Mundo, E., & L. Dell'Osso. (2007). Duration of untreated illness in major depressive disorder: a naturalistic study. International Journal of Clinical Practice (Esher), 61(10), 1697–1700. https://doi.org/10.1111/j.1742-1241.2007.01450.x

Altamura, A. C., B. Dell'Osso, Mundo, E., & L. Dell'Osso. (2007). Duration of untreated illness in major depressive disorder: a naturalistic study. International Journal of Clinical Practice (Esher), 61(10), 1697–1700. https://doi.org/10.1111/j.1742-1241.2007.01450.x

Bobo, W. V., & Shelton, R. C. (2010). Efficacy, safety and tolerability of Symbyax® for acute-phase management of treatment-resistant depression. Expert Review of Neurotherapeutics, 10(5), 651–670. https://doi.org/10.1586/ern.10.44
Kato, M., Hori, H., Inoue, T., Iga, J., Iwata, M., Inagaki, T., Shinohara, K., Imai, H., Murata, A., Mishima, K., & Tajika, A. (2021). Discontinuation of antidepressants after remission with antidepressant medication in major depressive disorder: a systematic review and meta-analysis. Molecular psychiatry, 26(1), 118–133. https://doi.org/10.1038/s41380-020-0843-0

Paquin, V., LeBaron, N., Kraus, G. E., Yung, E. C., Iskric, A., Cervantes, P., Kolivakis, T., Saint-Laurent, M., Gobbi, G., Auger, N., & Low, N. (2022). Examining the association between duration of untreated illness and clinical outcomes in patients with major depressive and bipolar disorders. Journal of Affective Disorders Reports, 8, 100324–100324. https://doi.org/10.1016/j.jadr.2022.100324

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