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Advancing Healthcare for the Common Good with Stephanie Fox

Sitting in a lecture hall in 2007, one thing Stephanie Fox didn’t want to hear when she started studying to be a therapist was that many people leave the field after 18 months. “I experienced that as quite shocking,” she says. Just a few months into a three year program, the math wasn’t adding up to her if that was true. At the time, she wondered, “If I’m going to be in school longer than I might actually be in the field, how is this worth it?” 

Stephanie Fox

This statistic, perhaps mentioned off-handedly by her professor, shaped Fox’s relation to her work early on. She started exploring what would support her and stave off the seemingly ubiquitous experience of burnout. Mental health, substance use disorder treatment, and social service work, the areas in which Fox has worked, are known to carry a high emotional cost. A distressing 40-70% annual turnover is the current norm in the mental healthcare sector.

Although profound personal experience in therapy may have brought on the leap from being an English major to wanting to work in the mental health field, it was curiosity that ultimately fed Fox in her work. “One of the things that has been meaningful to me is continuing to come back to education and learning more,” she says. “That’s kept the work very dynamic.” There was a period of time when she left the field, but the opportunities for learning and growth kept her inspired overall. She wanted to know how to help other people stay in the field. 

After more than a decade of practice in different clinical settings, Fox returned to the question of how to support mental health practitioners through Antioch’s Graduate School of Leadership and Change. This time she looked beyond her own experience to try and better understand why turnover is so prevalent and what could be done to prevent it. She wonders in her dissertation, “What does it Look Like for Mental Healthcare Organizations to be Healthy Places to Work?

Getting grounded in a new kind of self-care 

One part of creating a healthy workplace in the mental healthcare field is the worker’s responsibility. Providers need to practice a certain level of self-care to keep the emotional toll of the work sustainable. The phrase “self-care” seems to be self-explanatory, but Fox it’s more complicated than making sure to exercise or drink enough water. 

Her relationship with self-care deepened early on in her career. Before she was working in mental health professionally, she was volunteering with a Washington social services organization. At a training, one of the facilitators explained to the group that when working with people it was important the volunteers leave their needs at the door. 

This stayed with Fox through the years and informed her practice. “The people that you’re coming to provide services for are not here to fulfill a need for you,” she says she learned. “So whatever needs you have for validation or feeling like you’re good or likable, those are yours to address.” 

This expanded how she thought about her needs, especially in a clinical setting. Beyond the tasks to keep a person physically healthy, she realized she had to look at her emotional needs as well. She didn’t want her personal validation to come from her clients.

Fox has a friend who offers an example of how being aware of these needs creates a healthier working environment for the provider and their clients. This colleague found herself wanting to share more with her clients during the early months of COVID-19 because her sessions had become her primary source of social connection. “She was able to see this before she inadvertently acted on it,” Fox explains. “She noticed there was more of an impulse to self-disclose than she had previously felt, because she was feeling more lonely.” 

When she became aware of that need, she practiced self-care by reaching out to friends instead, the two had a regular virtual happy hour. But without critical awareness and engagement with her own patterns, that couldn’t have happened. In short, for self-care to be effective at meeting providers’ needs, they first have to know what their needs are. “That is going to look like different ways for everybody,” she says “But I think how you approach your work and how you think about it is the most important place to start.”

However, in her dissertation, participants were wary of the focus on self-care when the clinics they were working at had systemic problems, like high caseloads and inadequate staffing. “You feel like you’re just turning people through and that’s really unfulfilling and stressful,” Fox says. “So you’re trying to find ways to cope with it, but grasping at coping strategies is not sustainable over the long term.”

How organizations can support workers in the mental healthcare field 

Fox discovered both the working environment and practitioner self awareness needed to be addressed to support professionals in the mental health field. “On an individual level, engaging in some type of self-care can have a positive effect,” she says. “But if you’re doing that within a larger system that is a toxic workplace, there’s only so much that you can do personally.” 

One concern about addressing organizational change is that it takes money. But Fox’s interviews reveal that the workplace challenges people face in the mental health field don’t necessitate big investments to remedy them. A small portion of the conversations she had involved better pay or benefits, but more commonly people cited difficult relationships and organizational structuring as problems to solve. “What was surprising to me is that, in the study, what the participants came together and identified as suggestions were super practical and reasonable to implement,” Fox says. 

Although these recommendations can’t be written off because of funding, the realization that creating healthy working environments would necessitate personal change was also daunting. “This is actually a heavier lift—for an organizational leadership team to really be conscientious about how they’re leading their people and communicating,” Fox explains. This means people in positions of power will have to be more self-reflective, rather than putting in quick fixes like retention bonuses. 

What does work look like when everyone’s needs are addressed?

Despite the evidence of high turnover and the emotional toll of working on the field, there’s a narrative that because people are fulfilled by the work that it shouldn’t be impacting them as dramatically as it often is. And if you’re in the work, then there’s this expectation that you are better than human,” explains Fox. “And if you have any of your own mental health needs, that’s because there’s a problem with you.”

That, coupled with the stigma against mental healthcare at a systemic level, leads to a lack of honest dialogue about challenges. Even in a cultural context where mental health is discussed more openly, reimbursement rates from insurance companies remain low and it’s not considered as necessary and vital care. 

This attitude seeps into the perceived value and emotional toll of the work. Fox’s research and work show that the answers to creating a healthier working environment lie in a balance between personal and organizational responsibility that recognizes everyone’s humanity. “What if we operated more from the standpoint that everyone has needs?” wonders Fox. It seems like a simple question, but it’s one that would have a huge impact on the field.