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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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