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Ambient anxiety within leadership teams and its impact on organizational efficiency in mental health organizations

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Ambient anxiety within leadership teams and its impact on organizational efficiency in mental health organizations

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Content Ambient Anxiety Within Leadership Teams and Its Impact on Organizational Efficiency in
Mental Health Organizations
Taylor Mizuno-Moore, MA, LCPC
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
August 2024

© Copyright by Taylor Mizuno-Moore 2024
All Rights Reserved

The Committee for Taylor Mizuno-Moore certifies the approval of this Dissertation
Eric Canny
Patricia Tobey
Esther Kim, Committee Chair
Rossier School of Education
University of Southern California
2024

iv
Abstract
This dissertation explores the impact of ambient anxiety within leadership teams in mental health
organizations, emphasizing how ambient anxiety influences organizational efficiency. Through
an autoethnographic lens, experiences of sensitivity and anxiety are traced from childhood to
professional life. The study identifies how ambient anxiety, often triggered by external stressors,
manifests within groups, leading to inefficiency and organizational challenges. By analyzing the
roles, dynamics, and unconscious processes within leadership teams, the dissertation highlights
the need for leaders to acknowledge and address ambient anxiety in order to enhance group
effectiveness. The research is grounded in social cognitive theory and group relations theory,
offering insights into how conscious and unconscious factors shape leadership and organizational
outcomes in mental health settings. Through interviews with leaders in the field, the study aims
to provide practical strategies for managing anxiety and fostering a more efficient and supportive
organizational culture.

v
Dedication
Grandma (Bachan) and Grandpa (Jichan), for your bravery.
Mom and Dad, for your unconditional love. I’m so proud to be your kid.
Bryce, for reminding me every day that I’m never alone. You are my favorite hero.
Former employers, for teaching me what I could never learn from a textbook.
Maceo Hernandez, for teaching me that family and identity extends beyond blood.
MaryLu Halperin, for teaching me that sensitivity is a superpower.
Thomas, for your unwavering love and support. You make me better.

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Table of Contents
Abstract.......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
List of Tables ............................................................................................................................... viii
List of Figures................................................................................................................................ ix
Chapter One: Overview and Introduction..................................................................................... 10
Positionality ...................................................................................................................... 14
Background of the Problem .............................................................................................. 16
Purpose of the Study ......................................................................................................... 18
Significance of the Study .................................................................................................. 18
Overview of Theoretical Framework and Methodology .................................................. 20
Definition of Terms........................................................................................................... 22
Organization of the Study ................................................................................................. 25
Chapter Two: Review of the Literature ........................................................................................ 26
Autoethnography............................................................................................................... 27
Group Relations Theory.................................................................................................... 29
Ambient Anxiety in Groups and Organizations................................................................ 34
Leadership and Authority in Groups and Organizations .................................................. 38
Organizational Maturity and Efficiency Theoretical Framework..................................... 45
Conclusion ........................................................................................................................ 51
Chapter Three: Methodology........................................................................................................ 52
Research Questions........................................................................................................... 52
Overview of Design .......................................................................................................... 52

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Data Analysis.................................................................................................................... 56
The Researcher.................................................................................................................. 57
Limitations and Delimitations........................................................................................... 58
Trustworthiness and Credibility........................................................................................ 58
Ethics................................................................................................................................. 59
Chapter Four: Findings ................................................................................................................. 60
Participants........................................................................................................................ 60
Findings for Research Question One ................................................................................ 63
Findings for Research Question Two ............................................................................... 76
Findings for Research Question Three ............................................................................. 86
Summary ........................................................................................................................... 95
Chapter Five: Discussion and Recommendations......................................................................... 96
Discussion......................................................................................................................... 96
Recommendations........................................................................................................... 100
Recommendations for Future Research .......................................................................... 104
Conclusion ...................................................................................................................... 105
References................................................................................................................................... 107
Appendix A: Interview Protocol................................................................................................. 114
Appendix B: A Priori Coding Template ..................................................................................... 118

viii
List of Tables
Table 1: Participant Demographics........................................................................................... 61
Table 2: Summary of Comparative Analysis............................................................................ 62
Table 3: Summary of Findings and Recommendations.......................................................... 101
Table A1: Interview Questions.................................................................................................. 115
Table B1: Coding Template....................................................................................................... 118

ix
List of Figures
Figure 1: Process of Reflexivity in Qualitative Research......................................................... 29
Figure 2: Bandura’s Social Cognitive Theory and Reciprocal Determinism ........................... 47
Figure 3: Application of Social Cognitive Theory ................................................................... 48
Figure 4: Organizational Change Management Process........................................................... 50
Figure 5: Text Exchange 1 With a Wellness Minds Colleague ................................................ 65
Figure 6: Text Exchange 2 With a Wellness Minds Colleague ................................................ 65
Figure 7: Summer 2023 Response Email From Wellness Minds COO.................................... 69
Figure 8: Text Exchange 3 With a Wellness Minds Colleague ................................................ 73
Figure 9: Role Guide Description in the Wellness Minds Leadership Manual ........................ 79
Figure 10: Metric Expectations for Wellness Minds Clinicians................................................. 84

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Chapter One: Overview and Introduction
The summer of 1995 was the first time I had ever heard someone say, “Taylor, you’re so
sensitive.” I was in the bathroom of the local movie theater with my mother after watching my
first film in theaters, A Little Princess. The film ends with the reunification of a father and
daughter after the father, Captain Crewe, has suffered temporary memory loss due to a war
injury. After a desperate attempt for her father to regain his memory, Sarah Crewe is pulled away
from his grasp, but Captain Crewe suddenly regains his memory and yells, “Sarah!” She runs
towards him, and they embrace (Cuarón, 1995). As expected, the audience responded to this
cinematic climax with tears and sniffles. While this is an expected response from an adult
audience, at age seven, I was sobbing uncontrollably. Most likely, my reaction was due to
extreme empathy with the character of Sarah. My mother walked me to the bathroom after the
film ended and washed my face with cold water as I continued to sob. It felt as if the emotions
were coming not just from me but from the other audience members as well, almost as if I was
holding these emotions for them. “Taylor, you’re so sensitive.” It was the first of many times I
would hear these words, and I remembered them into adulthood.
Psychologists Solomon Cytrynbaum and Debra Noumair (2004) use the term “contain” to
refer to acting as a container for a group’s emotions. In organizational psychology, the word
“contain” is often used interchangeably with “hold” (Cytrynbaum & Noumair, 2004). The
construct of “the container” refers to a group dynamics role, meaning that an individual within a
group has been filled up with the emotions of the collective dynamic. The container is often
made the “scapegoat” of the group, which speaks to the “splitting off” of unwanted emotions that
are being placed into a single individual (M. Klein, 1959).
***

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“You’re so sensitive.” This time, it was a thought I had internalized as a narrative. It was
2012, and I was a 24-year-old server and bartender working at a dive bar located on the pier of a
major beach community in California. I worked afternoons on Sundays and evenings on
Thursdays, Fridays, and Saturdays. These are arguably the busiest shifts for anyone working in
the hospitality industry. The general feelings during shifts were chaos, uncertainty, uneasiness,
and disorganization. My first summer working as a server was flooded with errors. I recall once,
on a busy Friday evening in July, mistaking a Pinot noir for a Pinot grigio. The customer wrote
“incompetent” on their napkin before storming out of the bar with frustration. During my break, I
ran to the break room and sobbed. I told myself, “Taylor, you’re so sensitive. Why are you
letting a singular opinion about your performance affect you?”
Reflecting on this experience 12 years later, I missed details signifying that these were
the busiest and most chaotic months for hospitality in this city, as our bar was the go-to joint for
a popular local hockey team. After playoff games, team members would swing by, grab a bite,
and greet the fans. Additionally, our beach was one of the locations for professional beach
volleyball tournaments. Needless to say, our summers were busy. The external chaos and anxiety
in the community were affecting my performance. At the time, it was unknown to me that
external pressure from the community to become the city’s go-to sports bar, and to live up to the
preceding reputation my coworkers held in years prior, was an incredible stressor. This stress
manifested within the staff, which eventually led to inefficiency. Why did leadership not bring
up the anticipated chaos? Where was leadership’s presence? Why did I consider my “sensitivity”
a factor, without considering the external factors contributing to stress? Interesting.
***

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“You’re so sensitive.” I held this narrative into graduate school. It was 2017, and I was a
29-year-old therapist-in-training at a large private university. I had started my master’s program
in Clinical Mental Health Counseling in the summer of 2016. I had also gotten married, moved
across the country, and started my first clinical rotation. However, it was in 2017 that my
“sensitivity” arose. This time, it felt similar to, yet different from, how it had felt in the past. My
“sensitivity” manifested itself as anxiety, confusion, and defensiveness. I thought perhaps this
level of anxiety was normal, given the nature of the program I was in. I had also just completed
two back-to-back group dynamics courses on how to analyze groups and organizations.
However, these feelings lasted through the summer of 2019.
When I graduated from the program, I became a staff therapist and faculty member at the
university. Well into 2021, to my surprise, the feelings of elevated anxiety continued. After I
onboarded into this organization, the structural turbulence within the program and the university
came to light. From 2016 through 2021, my master’s program transitioned through two
university presidents, three program directors, two clinical directors, and five faculty members.
Additionally, the COVID-19 pandemic led to organizational changes that also affected the
university. It was brought to my attention that all of these organizational changes started in 2017.
This time, my “sensitivity” was beginning to make sense. Perhaps it was the training I had been
receiving, but I started to notice a pattern about myself vis-a-vis my environment. And the
question remained: Why was leadership not talking about these changes? Where was the
leadership presence?
***
“You’re so sensitive.” It was 2023, and I was a 34-year-old operations manager and staff
psychotherapist on a leadership team made up of seven mental health clinicians and educators in

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a group practice in a greater metropolitan area. This time, the anxiety felt like hypervigilance,
worry, stress, walking on eggshells, and fear. I became increasingly ambivalent about my
identity, particularly my Asian identity, due to the explicit racism that manifested as a result of
the COVID-19 pandemic. Additionally, the organizational structure had changed dramatically
since the organization was created in May of 2021. Hierarchical roles that were promised to
original staff members no longer existed. New employees were hired into branches of the
organization that had not existed until after their start date. Also, the leadership team consisted of
four more individuals than were planned. New fears regarding my role began to form.
At the beginning of the summer of 2023, I shared my fears with a trusted colleague. Due
to the amount of experience I already had with my “sensitivity,” I was finally able to put my
anxiety into words, and this time as a leader. “I’m scared the structure of this organization isn’t
sustainable for success.” “I’m scared I will be replaced with someone more Asian than me.”
Emphasis on the balance of racial dynamics within the leadership team became a focal point of
development for this organization during and after the COVID-19 pandemic. “I’m scared of
naming the imbalance of power within the leadership team.” My unnamed “sensitivity” was
mostly triggered by implicit racial bias, or by unconscious bias toward a specific racial group or
person. I experienced this during the course of a two-year period in which bias notably
contributed to inefficiency and organizational failures. This period ultimately resulted in my
resignation from the organization in the summer of 2023.
After my departure, it became clear that unproductive defense mechanisms such as
denial, projection, regression, and displacement had all contributed not only to my individual
inefficiency within the organization but also to the inefficiency of the other six members of the
leadership team. Eventually, the unacknowledged anxiety within the leadership team trickled

14
down into other branches of the organization, affecting organizational wellness and efficiency. It
was finally clear why leaders had backed away from turbulent times. I was going through it
myself. It made sense that the discomfort of naming the anxiety could be too much to take on.
Perhaps, it was easier to stay silent than to name the conflict. Easier, but not efficient or
productive.
Leaders in mental health organizations can also be therapists. For the purpose of this
dissertation, the term “leaders” refers to therapists with a secondary role that includes overseeing
or managing other therapists (e.g., billing coordinator and staff therapist) at any level. This dualrole approach to leadership in mental health organizations is unique. Therapists are trained to
move toward discomfort in order to investigate barriers preventing optimal growth. They also
have a thorough understanding of group dynamics and have the ability to identify maladaptive
behaviors when unhelpful group dynamics arise. Together, these skills can be a powerful tool for
effective leadership. This autoethnography dissertation seeks to explain how my lived experience
as a leader and therapist, combined with the lived experiences of other leaders and therapists,
informs the anxiety that arises from within organizational dynamics. It investigates how the
impact of unconscious organizational processes within leadership teams affects team efficiency
in mental health organizations.
Positionality
I am a white-passing, half-Japanese American. My mother is a third-generation Japanese
American (sansei) raised on a small farm in Greeley, Colorado. She moved to Los Angeles,
California in 1959 and pursued high academic achievements, earning her bachelor’s degree in
statistics at the University of California, Los Angeles (UCLA) and her master’s degree in
computer science at the University of Southern California (USC). She spent the first half of her

15
career as part of the first wave of Japanese women in the field of computer science. My father, a
white adoptee, was raised in Malibu, California, and grew up surfing Ventura County Line down
through the South Bay cities through the early to mid-1960s. He was drafted into the United
States Army in 1968 and was deployed to Vietnam, where he spent a little over a year. He
returned from overseas as a helicopter mechanic and spent 36 years in the aerospace industry. In
the mid-1970s, my parents met in Hermosa Beach, California. They married in Ventura,
California in 1977. My brother, the first biracial family member, was born in 1981. I followed in
1988. We are called the yonsei generation, or fourth-generation Japanese Americans.
Holvino (2010) defines the concept of simultaneity as the intersection of layers of
identifiers constructing a sole social identity, influenced by “a number of coexisting identityforming systems of difference always in interaction and transaction with each other at the same
time” (p. 265). The reconceptualization of individual identity as simultaneity speaks to
organizational processes and reflects concurrent operations of identity within social practices
(Holvino, 2010). The concept of simultaneity, for me, acts as a bridge, marrying categories of
identifiers. I am a professional musician, a lifelong student of psychology, and a professional
clinician. I am trained to be emotionally and empathetically grounded, gifting me the ability to
think rationally and thoughtfully. As a clinician and one who profits from capitalist America and
the commercialism of mental healthcare, I am trained to explore how both the individual and the
system at large play into the narratives we carry. As a white-passing minoritized individual, I
constantly find myself experiencing both in-group and out-group processes. My invisible
identifiers allow me to observe through the lens of minoritized people while the group
experiences my presence as the majority. This privilege is a mask. This mask protects the
vulnerability of my marginalized self and allows individuals to disclose their biases while my

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fair skin and lack of exotic features are read as harmless. My identity becomes what the group or
organization needs: a scapegoat, a leader, or a follower, among other such identities bestowed
upon me. The ambient anxiety I hold while in a group or organization acts as a signal to me that
my role is changing to fit the group’s or the organization’s needs. If any individual in a group or
organization is unaware of what this feeling is and becomes consumed by the discomfort,
inefficiency manifests (Bolman & Deal, 2017).
According to Douglas and Nganga (2013), “one’s epistemology is a highly nuanced filter
that is constructed from an amalgamation of the social, political, and historical dynamics of lived
experience” (p. 60). I am able to use my position of power as a trained clinician to advocate for
minority populations within the field of mental health. Some limitations may include my own
personal bias and the countertransference I hold, as this problem is both a professional and
personal passion of mine. Additionally, as an individual, I am working against the system at
large. Implementing systemic change at a foundational level, or, according to Lowe (2021),
within the educational system, must be necessary to execute a reinforced cycle of greater
advocacy for people of color at a systemic level (Lowe, 2021).
Background of the Problem
Robert DeBoard, an organizational psychoanalyst, defines anxiety as the unpleasant
feelings that individuals experience in response to perceived danger. These feelings are
experienced in response to an internal danger that arises from within due to unconscious feelings
and memories (DeBoard, 2014). Social defenses refer to an organization’s defenses against
anxiety (Berzoff et al., 2016). E. Jaques (1965), a psychoanalyst, proposed that maladaptive
behaviors arise (i.e., hostility, suspicion, etc.) when anxiety emerges in a group. These defenses
occur when the situation becomes too painful, and the individuals regress to avoid these feelings

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of anxiety, guilt, and uncertainty. However, due to the arousal of the defenses, the energy in the
group weakens, making it difficult for the group to work on a task (DeBoard, 2014). According
to Schein (2017), when anxiety is felt by an organization, defenses arise, contributing to
inefficiency and resistance to change. This problem needs to be addressed because awareness of
how anxiety impacts efficiency in groups can increase general group dynamic awareness and
organizational competency (McRae & Short, 2010). In order to further examine and understand
the impact of anxiety on groups and organizations, group relations theory, a theoretical
framework used in examining the conscious and unconscious processes affecting individual and
group functioning, must also be investigated (McRae & Short, 2010).
Existing research and my own lived experiences indicate that neurotic anxiety, also
known as ambient anxiety, or anxiety caused by an external source of perceived danger that
results in physical bodily reactions, contributes to inefficiency in mental health organizations
(DeBoard, 2014). While ambient anxiety produces automatic physiological effects that have
developed into purposeful defense mechanisms to combat perceived danger, these bodily
reactions are not appropriate for combating internal anxiety. Internal anxiety may arise when the
ego, or the concept of self, is threatened (Berzoff et al., 2016). Some ambient anxiety manifests
as ego defenses or behavioral responses to perceived danger. These ego defense mechanisms
include: 1) denial, the act of not acknowledging the existence of a threat; 2) projection, the
attribution of a threat to someone in the external world; 3) acting out, the direct and overt
expression of desires; 4) dissociation, the psychological separation of emotion and impact; 5)
regression, the retreat to an earlier human developmental stage; 6) reaction formation, the
transformation of an unacceptable desire into one that is desirable; 7) displacement, the act of
redirecting desires from one person in the external world to another; 8) undoing, an action that

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symbolically eliminates the threat; 9) sublimation, the act of transforming a socially
unacceptable desire into a socially accepted and valued desire; and 10) humor, or the overt
expression of a socially unacceptable desire without causing discomfort to society (Berzoff et al.,
2016).
Purpose of the Study
The purpose of this study is to investigate ambient anxiety, experienced as sensitivity,
fear, and acute stress, within leadership teams and its impact on organizational efficiency in
mental health organizations. This study uses autoethnography, in which I set myself as both the
researcher and the subject. The following research questions directed the study:
1. How does ambient anxiety manifest in mental health organizations?
2. How does ambient anxiety in leadership teams affect efficiency in mental health
organizations?
3. How can leaders within mental health organizations be supportive of therapists who
experience ambient anxiety?
Significance of the Study
According to McRae and Short (2010), “research that has been conducted on group
formation and intergroup relations has focused on stress, anxiety, and threat. These variables
have been hypothesized to be the foundation of negative and/or uncomfortable intergroup
encounters among individuals of diverse racial-cultural backgrounds.” Understanding group
dynamics, specifically ambient anxiety experienced in groups and organizations, gives the
opportunity to increase group and organizational efficiency by increasing group awareness of
racial-cultural factors within a group (Schein, 2017). Ambient anxiety contributes to resistance to
change, as a series of fears leads anxious groups and organizations to inefficient and ineffective

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organizational activity (Schein, 2017). Acknowledgment of these change factors from leaders
gives organizations more opportunities to become proactive by reframing unhelpful and
unconscious systemic thinking (Schein, 2017). Marilyn Frye provides a visualization of how
one-way implicit bias affects groups in her 1983 book, The Politics of Reality: Essays in
Feminist Theory. She emphasizes the importance of gaining a broader perspective to understand
complex situations. Using the analogy of a birdcage suggests that focusing too closely on
individual aspects can lead to a limited understanding. Stepping back and considering the
interconnectedness of various elements reveals a systemic pattern. It explains the bird’s inability
to escape, highlighting the significance of a comprehensive view for a deeper understanding
(Frye, 1983). In order to make organizational change, the system as a whole must be
acknowledged before an attempt to restructure is made.
Using a group relations model lens, one must consider both conscious and unconscious
processes that influence interactions involving race, gender, culture, and LGBTQIA+ affiliation.
However, these conscious and unconscious processes have emerged from the roots of the
systemic hierarchy developed since the 1600s (McRae & Short, 2010). To truly rid ourselves of
this systematic hierarchy and, therefore, of the misrepresentation and underrepresentation of
minority populations, a conversation must be had about the history of racism and oppression.
According to Ijeoma Oluo (2019),
We cannot understand race and racial oppression if we cannot talk about it. And we can
never stop the racial oppression affecting millions of lives in this country if we do not
understand how and why it has been able to hold such power over us for hundreds of
years (p. 229).

20
Overview of Theoretical Framework and Methodology
The study utilizes Bandura’s (1989) social cognitive theory as the overarching
framework. Social cognitive theory emphasizes the role of the social environment in motivation
and learning and focuses on the reciprocal interactions among personal (i.e., beliefs, skills,
affect), behavioral, and social/environmental factors. This framework is often used to explore the
operation and outcomes of cognitive and affective motivational processes (Bandura, 2001). This
framework places a greater emphasis on the importance of human agency, where individuals
exert control over their thoughts, feelings, and actions. In a reciprocal manner, people affect and
are influenced by their actions and environments. This interaction is demonstrated by a construct
called reciprocal determinism, in which personal factors, environmental factors, and behavior
continuously interact through influencing and being influenced by each other (Glanz et al.,
2008). Like individuals, groups also affect and are influenced by their actions and their
environments. Furthermore, motivation plays a role in that people are motivated to develop a
sense of agency for being able to largely control the important events in their lives (Schunk &
Usher, 2019).
Key social cognitive motivational processes included in social cognitive theory include
goals, or what people are consciously trying to attain. Self-evaluation of progress—the processes
that individuals use to activate and sustain behaviors, cognitions, and effects that are
systematically oriented toward the attainment of goals—is also included. Outcome expectations,
or beliefs about the expected outcomes of actions that are formed about the likely consequences
of actions based on personal experiences and observations of models, are considered. Values, or
individuals’ perceptions of the importance and utility of learning and acting in given ways, are
included. Additionally, key cognitive motivational processes include social comparisons, or

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comparing ourselves with others on some criterion; and self-efficacy, which is assessed based on
mastery experiences, vicarious experiences, forms of social persuasion, and physiological
indexes (Schunk & Usher, 2019). Some other key concepts emerging in my conceptual
framework include implicit bias and unconscious bias, group dynamics, efficiency, restorative
justice (practices), and transformative justice (practices). Additionally, white fragility and
stereotype threat are key concepts. White fragility speaks to the defensiveness that can arise
when bias is addressed head-on. Stereotype threat speaks to fears associated with racial bias.
Lastly, colorblind racism, which links to implicit bias and racial bias, should also be considered.
Social cognitive theory is an appropriate theory to use in examining my problem of
practice because of its focus on how an organization’s environment contributes to motivation,
action, and efficiency (Bandura, 2001). It is also appropriate because of its focus on how an
individual’s affect affects the social/environmental factors and behaviors within an organization
(Bandura, 2001). Examining my problem of practice through this theoretical framework
illustrates how anxiety contributes to inefficiency by examining the social/environmental factors
within an organization (e.g., organizational anxiety or hostility in the workplace impacting an
individual’s motivation to complete a task, or an individual’s hostility impacting the
organizational team dynamic). This research approach is a mixture of a qualitative
autoethnography research study and a qualitative interview research study. I examine my
personal experiences critically and link the anecdotes to research literature. I also use individual
interviews with leaders of mental health organizations as a form of data collection. Email
listservs for group therapy practices provided by the American Counseling Association (ACA)
were utilized as a recruitment tool for the ideal participants of this study. The research serves
small therapy practices. These risks were considered when I was writing interview questions.

22
Definition of Terms
● Ambient anxiety: Anxiety caused by an external source of perceived danger that results in
physical bodily reactions (DeBoard, 2014).
● Authority: A formal or informal position with the power to make decisions within a group or
organization (McRae & Short, 2010).
● Autoethnography: A researcher’s personal story with an emphasis on a group or culture
(Ellis, 2004).
● Basic assumption: An unspoken behavioral and psychological expectation influencing group
activity (DeBoard, 2014).
● Change management: Effective and efficient implementation of organizational change while
minimizing resistance (McRae & Short, 2010).
● Collective/Organizational efficacy: Confidence or belief in a group’s ability to perform
actions to bring about desired change. Collective efficacy is also the willingness of
community members to intervene in order to help others (Glanz et al., 2008).
● Confrontation: A behavior with the goal of increasing awareness and initiating group change
(McRae & Short, 2010).
● Cultural identity: Identity understood from an individual’s subjective view, which may
comprise multiple identifiers such as race, social class, political affiliation, etc. (McRae &
Short, 2010).
● Defense mechanism: A skill used as assistance in reducing the effect of conflict (Berzoff et
al., 2016).
● Denial: The act of not acknowledging the existence of a threat (Berzoff et al., 2016).

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● Dependency: A basic assumption in which the group behaves immaturely and as if they are
without anything to contribute, while reliance and dependency remain on a leader (DeBoard,
2014).
● Displacement: Redirecting desires from one person in the external world to another (Berzoff
et al., 2016).
● Dissociation: The psychological separation of emotion and impact (Berzoff et al., 2016).
● Ego defenses: Behavioral responses to perceived danger. Ego defense mechanisms include
denial, projection, acting out, dissociation, regression, reaction formation, displacement,
undoing, sublimation, and humor (Berzoff et al., 2016).
● Facilitation/Behavioral capability: Providing tools, resources, or environmental changes that
make new behaviors easier to perform (Glanz et al., 2008).
● Fight-flight: A basic assumption in which the group collectively either fights the danger
created by the group, by establishing a leader to push forward or ignores the activities of the
group altogether and flee (DeBoard, 2014).
● Group dynamics/relations: Psychoanalytic processes involving the formation of conscious
and unconscious processes that manifest within a group holding permeable boundaries
(McRae & Short, 2010).
● Leadership: A process of motivating change in groups and organizations (McRae & Short,
2010).
● Moral disengagement: Ways of thinking about harmful behaviors and the people who are
harmed that make infliction of suffering acceptable by disengaging self-regulatory moral
standards (Glanz et al., 2008).

24
● Outcome expectations: Beliefs about the likelihood and value of the consequences of
behavioral choices (Glanz et al., 2008).
● Pairing: A basic assumption in which the group behaves as if the group has met to “pair off”
and create a new leader (DeBoard, 2014).
● Projection: The act of attributing a threat to someone in the external world (Berzoff et al.,
2016).
● Reaction formation: Transforming an unacceptable desire into one that is desirable (Berzoff
et al., 2016).
● Role: A limiting specialization restricted by the pressures and requirements of the group
(Cytrynbaum & Noumair, 2004).
● Scapegoat: A role in groups when one member is the target of negative and undesirable
wishes (McRae & Short, 2010).
● Self-Efficacy: Confidence or belief in one’s ability to perform a given behavior. Self-efficacy
is task-specific, meaning that self-efficacy can increase or decrease based on the specific task
at hand, even in related areas (Glanz et al., 2008).
● Self-Regulation: Controlling oneself through self-monitoring, goal setting, feedback, selfreward, self-instruction, and enlistment of social support (Glanz et al., 2008).
● Stereotype threat: Anxiety related to a stereotype of an individual’s race or ethnicity. A
phenomenon occurs when anxiety arises as a result of the transparency of race and
experience-based stereotypes associated with each respective race within a group (McRae &
Short, 2010).
● Sublimation: The act of transforming a socially unacceptable desire into a socially accepted
and valued desire (Berzoff et al., 2016).

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● Work mode: An occurrence in which the group is directed towards a goal in order to tackle
and master an activity in service of a primary task (Cytrynbaum & Noumair, 2004).
Organization of the Study
This dissertation is an autoethnography study combined with qualitative data support via
interviews of leaders in mental health organizations, which allows an exchange of information
via personal experience as well as information supported in the research literature. Chapter One
provides an introduction and outline of the study, which explains the history of the problem of
practice, my personal experience with the problem of practice, the significance of this research
study, and the proposed theoretical framework and methodology used in this study. Chapter Two
highlights the relevant literature on the problem of practice and the conceptual framework.
Chapter Three details the research methodology and theoretical framework. Chapter Four details
my lived experience as a clinician on a leadership team affected by ambient anxiety. Chapter
Four also examines themes from my findings. Chapter Five offers proposed recommendations
based on existing literature and findings from this research study.

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Chapter Two: Review of the Literature
The literature review, for an autoethnography, serves as a foundation for a personal story.
It gives the autoethnography legitimization, as data is used to contextualize my personal story
(Chang, 2008). According to Ellis et al. (2011), the researcher is at the core of the study as they
reflectively write and analyze lived experience. Critical autoethnography is a nontraditional
qualitative methodology that uses complexity and insight into a particular lived experience
(Boylorn & Orbe, 2021). When I was first introduced to this nontraditional methodology, it felt
like I lived a set of experiences specifically to write this manuscript. A collection of events over
the past 35 years led up to this moment when I can find the link that connects them all and draw
a hypothesis. The use of data and research to make sense of my stories feels inevitable and quite
satisfying as a psychotherapist.
The following literature supports the stories shared in this autoethnography. I begin each
section with an excerpt of my lived experience related to each section. I then link the literature to
support my hypothesis of ambient anxiety among leaders leading to inefficiency in groups and
organizations. I begin by exploring and detailing group relations theory, which leads to an
examination of the importance of leadership and authority as it relates to group relations theory.
Ambient anxiety is discussed, and efficiency in groups and organizations concludes this chapter.
The literature for this inquiry falls into five major sections. The first section, which
explores group relations theory, contains three subsections: 1) Wilfred Bion, 2) racial and
cultural factors, and 3) basic assumptions. The second body of literature, which discusses
ambient anxiety in groups and organizations, contains three subsections: 1) general anxiety, 2)
ambient anxiety, and 3) organizational ambient anxiety. The third section, which details

27
leadership and authority in groups and organizations, contains four subsections: 1) roles, 2)
valency, 3) the role of leaders, and 4) the importance of followers. The fourth section, which
discusses organizational maturity and efficiency, contains two subsections: 1) self-efficacy, and
2) change management. A conclusion sums up all sections and gives a brief introduction to
Chapter 3.
Autoethnography
Autoethnography Theory
Autoethnography is a genre of academic writing that focuses on the analysis and
interpretation of the lived experience of the researcher. Critical autoethnography combines the
characteristics of autobiography and ethnography by exploring how the self relates to other
individuals in an attempt to understand the lived experience (Ellis et al., 2011). This
autobiographical form of writing connects the researcher’s insights about their lived experience
to identity, values, culture, communication practices, traditions, symbols, meanings, emotions,
values, and political issues (Poulos, 2021). According to Chang (2008), culture is a web of the
self and others, while autoethnography is a study of self in connection to others.
An autoethnography research study involves creating narratives from the researcher’s
personal experiences within a specific culture. This dissertation focuses on a collection of lived
experiences using a group relations theory lens that is used to support my proposed hypothesis
for this research study. In summary, an autoethnography is a qualitative research method used by
researchers interested in narratives that richly contribute to a research study (Poulos, 2021). This
research design is flexible and is an adaptable process, as new insights that arise may guide the
study down unforeseen paths (Chang, 2008).

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Reflexivity
According to Malacrida (2007), qualitative research draws on the researcher’s values and
emotions. While an autoethnography has the potential to gain significant insight into the lived
experience of the researcher and others, the use of this methodology has the potential to trigger
uncomfortable emotions and memories. The concept of reflexivity is highlighted in
autoethnography research to minimize the impact of these triggers (Malacrida, 2007). Reflexivity
can take many forms: reflexive journaling, self-reflection, and active processing (Ellis et al.,
2011). For the purpose of this dissertation, critical self-reflection is utilized throughout the study
to ensure the researcher acknowledges and implements careful consideration of the perspective
of not just the self, but the environment as well. For proper recognition of the environment,
group relations theory must be considered. Figure 1 shows a visual representation of the process
of reflexivity within a qualitative research study.

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Figure 1
Process of Reflexivity in Qualitative Research
Note. Adapted from “Using Vignettes Within Autoethnography to Explore Layers of CrossCultural Awareness as a Teacher,” by J. Pitard, 2016, Forum Qualitative Sozialforschung /
Forum: Qualitative Social Research, 17(1).
Group Relations Theory
From a young age, I was able to “feel” what was happening in a group without explicitly
being told what was happening. I was able to sense when there was tension or anxiety in the
room. I was able to sense when the room felt light and carefree. The ability to notice when an
ambient shift occurred within a group was a particular skill that could be used as a “tool in (my)
toolbelt,” as therapists like to say. I did not realize until I was in my graduate program studying
clinical psychology that these “feelings” had names, or that the emotional shifts I was able to
sense were constructs of group dynamics.
In 2016, I attended my first group relations conference (Tavistock model) as a student
group member. The conference was an experiential, three-day event designed to investigate

30
small and large group dynamics. Some of the most intense feelings I have ever felt in my life
were experienced in 72 hours. I learned more about my identity as it is experienced in groups and
organizations, defenses that arise to protect my identity, and how conflict within groups and
organizations can be directly linked to our identities and implicit bias. I was invited to become a
staff member at the same group relations conference that occurred 3 years later. This time, for
me and the 20 other members of staff, the conference started 4 months early. Dynamics within
the conference’s staff, a group of clinicians and psychologists extensively trained in group and
organizational dynamics, were the target of curiosity. We examined the dynamics of the
“experts” or “consultants,” so going into the conference, we were able to have a foundational
understanding of what we needed to look out for in dynamics that existed during the conference.
This time, more data was being collected and considered. Compartmentalizing my “sensitivity”
was becoming easier, as I was learning how to use how I felt in groups to understand what was
objectively happening.
The following year, I served on the directorate of the next group relations conference.
The COVID-19 pandemic hit earlier in the year, and the world was experiencing arguably
intolerable levels of uncertainty and anxiety. Simultaneously, the conference’s directorate was
experiencing uncertainty and anxiety. We did not know if the conference was to take place in
person, virtually, or not at all. As the four of us came together with the shared task of setting up a
group relations conference during a global pandemic, we were also learning about how we work
together as a leadership team. Ultimately, for the health and safety of everyone, we canceled the
event. The group relations conference taught me how to put language to what I was feeling. It
also taught me how to identify what my anxiety was and how a group’s ambient anxiety impacts

31
the ability to work together. The following section introduces group dynamics constructs and
gives language to feeling-based turbulence experienced in groups and organizations.
The first subsection discusses Wilfred Bion, one of the most influential developers of
group relations theory. The subsection explores racial and cultural factors within groups and
organizations and how they influence how an individual experiences a group or organization.
The third subsection explores basic assumptions or ways a group defends against perceived
threat. These three subsections are important in understanding group and organizational
efficiency because vital comprehension of these topics is needed to conceptualize how ambient
anxiety’s presence in groups and organizations affects efficiency.
Wilfred Bion
Wilfred Bion, a psychoanalyst, developed the original theory of groups and
organizational behavior during his membership at the Tavistock Institute of Human Relations
between 1943 and 1952 (DeBoard, 2014). The group relations conferences I attended were built
upon the Tavistock Institute’s model of group relations. Bion’s discoveries lay the framework
this dissertation builds. Bion concentrated on a mode of operations called work groups, groups
engaging in real time on a specific task while simultaneously tackling the constantly changing
environmental pressures and conflicts of working with other individuals (DeBoard, 2014).
According to Bion’s theory, anxiety manifests when a group feels threatened, leading individuals
to defend themselves against anxieties. As defenses rise, group work is weakened and will likely
discontinue organizational change (DeBoard, 2014). While a general understanding of group
relations is crucial to the foundation of this dissertation, subgroups within group relations theory
must also be considered.

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Racial and Cultural Factors
Much of the group relations theory research focuses on racial and cultural factors, which
play a vital role in understanding the complexity of group dynamics. According to McRae and
Short (2010), racial identity and racial categorization of group members foster stereotypes and
simplify interracial group dynamics (McRae & Short, 2010). Cultural identity can be understood
from an individual’s subjective view, which may comprise multiple identifiers such as race,
social class, political affiliation, etc. Cultural identity may contribute to a group member’s
inability to join or connect with the group, out of fear of needing to identify with one specific
identity while dismissing other identities (McRae & Short, 2010).
Research also discusses a phenomenon called stereotype threat that occurs when anxiety
arises as a result of the transparency of race and experience-based stereotypes associated with
each respective race within a group (McRae & Short, 2010). The impact of stereotype threat
highlights the implications of unnamed racial and cultural factors within group dynamics
(McRae & Short, 2010). Additionally, “group-level” evaluation or assessment is needed as
sociocultural factors, such as stereotype threat, influence a group’s effectiveness (McRae &
Short, 2010). A model proposed by Schmader et al. (2008) of threat, specifically stereotype
threat, explains how an individual’s performance process is influenced by stereotype threat,
resulting in a state of cognitive imbalance that manifests as stress and anxiety. Once this state has
set in, psychological impairment and anxiety begin to affect self-regulatory processes. A second
model proposed by Schmader et al. (2008) details how stereotype threat is a cognitive imbalance
triggered by a person and/or by situational factors.
Racial and cultural factors became central topics of all group relations conferences in
which I have participated. Much of the group conflict experienced in the conferences was related

33
to race and/or cultural factors in some way, whether consciously or unconsciously. From the
conference experiences, when racial or cultural factors were not explicitly named or
acknowledged, more conflict arose. When they were conscious, and all group members
acknowledged that there may be implicit biases at play, the groups were much more likely to
work collectively. But what does “work” actually mean? “Work” is defined and explored in the
next section.
Basic Assumptions
According to Bion (1968), a work group has two modes of functioning. Work mode
focuses on a group task, while a basic assumption group leans into a mode of group behavior that
no longer focuses on a specific task (DeBoard, 2014). Work mode occurs when the group is
directed towards a goal in order to tackle and master an activity in service of a primary task
(Cytrynbaum & Noumair, 2004). A basic assumption group leans into basic assumptions or
defense mechanisms used to combat anxiety. According to Bion (1968), a group can only
experience one basic assumption at a time but can experience multiple assumptions throughout
the duration of the group life (DeBoard, 2014). Three main assumptions found in basic
assumption groups are dependency, pairing, and fight-flight. Dependency is a basic assumption
in which the group behaves immaturely, and as if they are without anything to contribute, while
reliance and dependency remain on a leader. The leader is viewed as an individual who can solve
all difficulties and problems (DeBoard, 2014). Pairing is a basic assumption in which the group
behaves as if the group has met to “pair off” and create a new leader. This unborn leader
represents the hope of the group and is viewed as the savior the group needs from their anxiety
and fear. This defense prevents the group from dealing with what is actually happening and
denies conflict and anxiety within the group (DeBoard, 2014). Fight-flight is a basic assumption

34
in which the group either fights the danger created by the group by establishing a leader to push
forward or ignore the activities of the group altogether and flee (DeBoard, 2014).
It is the staff’s role in the group relations conferences to explicitly name when a group is
in work mode or if the group has fallen into a basic assumptions group. A common experience is
for a group to become defensive if it is being called out for falling into a basic assumptions
group. The defensiveness stems from the fear of doing something wrong or unproductive. When
a group accepts that the shift has occurred, they are much more likely to work themselves out of
a basic assumptions group and become productive in executing a task. But what anxiety arises in
basic assumption groups? How does it impact inefficiency?
Ambient Anxiety in Groups and Organizations
On the first day of the fall quarter, during the second year of my graduate program in
clinical psychology, my methods professor walked into the classroom, placed her purse on a
table near the front, placed her elbow on the edge of the podium, and calmly stood silent. She
stood in front of the class in silence for five minutes, but it felt like 20. The 22 members of my
cohort filled the silence with waves of laughter, mild groans, and sighs. I felt like I was taken on
a roller coaster of emotions and feelings I had no control over. One student would laugh, and
suddenly I was laughing. Another student would yawn, and then I was yawning. I could almost
feel the silence, the same way you could feel the tension in a room. The silence felt unbearable.
At the five-minute mark, the professor asked us what we felt. We all agreed it felt uncomfortable
and awkward. She then asked about our behaviors: the laughing, the yawning, the sighing. Many
of us shared that it felt like we could not help it, as if the tension in the room took over our
bodies. It was then that she introduced the class to the polyvagal theory.

35
According to Porges (2022), the polyvagal theory emphasizes the regulation of the
autonomic nervous system. It is our body’s natural ability to regulate, to gain a sense of safety.
Mirror neurons, a class of neurons fired to execute motor behaviors when those specific motor
behaviors are observed, play a vital role in self-regulation and explain how behaviors
experienced in groups can feel “contagious” (Haker et al., 2012). Our professor explained that
laughter, yawning, and the groans that trickled throughout the five minutes were triggered by the
polyvagal theory and mirror neurons. Silence from an authority figure is often experienced as
anxiety and discomfort. To regulate this anxiety, the body’s autonomic nervous system takes
over and uses mirror neurons to connect the self with its surroundings. Using mirror neurons, we
began to mimic the behavior of our classmates and literally calmed each other down through
behavior. She then explained, to 22 therapists-in-training, how powerful it would be to name the
anxiety as it came up and to regulate the discomfort not only through behavior but also through
words. We were floored. So, what is anxiety? Does it serve a purpose? How does it impact
efficiency in groups and organizations?
General Anxiety
To understand ambient anxiety, anxiety and stress must first be thoroughly explained.
Anxiety is a response to perceived danger, usually manifesting as fight or flight, an evolved
response to external danger. The physical effects of anxiety assist in survival, while the
psychological effects of anxiety are subjective to the individual experiencing it (DeBoard, 2014).
While much of our understanding of anxiety is linked to external danger, anxiety can now be
understood as a response to subjective, internal dangers arising from within the individual. As a
result of rising internal anxiety, the external environment can be viewed as threatening, leading
to a fight-or-flight response (DeBoard, 2014). Everyone experiences anxiety, and everyone

36
should experience anxiety. It becomes an issue when anxiety becomes a barrier to executing a
task. In the classroom example, the cohort experienced a healthy form of anxiety as it did not
derail the group from the task at hand, which was learning about clinical methods. Even though
anxiety is uncomfortable, that does not mean it is not beneficial.
Ambient Anxiety
According to the American Psychological Association (2018), stress is defined as the
physiological or psychological response to internal or external demands. Stress affects the body
and influences how individuals feel and behave. Physical manifestations of stress include
palpitations, sweating, dry mouth, shortness of breath, fidgeting, accelerated speech,
augmentation of negative emotions, and longer duration of stress fatigue (APA, 2018).
Additionally, the American Psychological Association defines anxiety as apprehension and
somatic symptoms of tension that may include anticipation of impending danger, catastrophe, or
misfortune. Similar to stress, physical manifestations of anxiety include muscle tension,
palpitations, sweating, shortness of breath or heavy breathing, and prolonged durations of
anxiety (APA, 2018).
According to Campbell (1983), ambient stress results from environmental conditions that
are negatively experienced. Ambient stress is a type of stress that comes from the environment
rather than from a specific event or situation. This chronic stressor negatively affects the
psychological and physical wellness of an individual, much like anxiety (Campbell, 1983).
Ambient stress is defined as stress, or the body’s natural reaction to a physical, mental, or
emotional demand resulting from the environment, and anxiety is the response an individual has
to perceived threats from the environment. From these two definitions, I would like to propose
an extension of the construction of ambient anxiety. This can be defined as a response to

37
perceived danger or anticipated danger that comes from the environment and that may manifest
physically, cognitively, or emotionally. Contextually, ambient anxiety was the feeling
experienced in the classroom, as it was a stressor that came from a specific shift in the
environment: silence. Organizations experience this same anxiety. While anxiety is an
uncomfortable experience, anxiety is neither positive nor negative. Only when anxiety derails an
individual, group, or organization from a task does anxiety become a negative experience, as
maladaptive coping mechanisms are at play.
Organizational Ambient Anxiety
Some groups and organizations tend to overcompensate out of concern for perceived
compliance with social pressures. This leads to inefficiency at an individual level, which then
leads to inefficiency at an organizational level; time is then used up, and an organization is
unable to reach its goals (Bolman & Deal, 2017). The feeling that leads an organization to
overcompensate and eventually fail at achieving its goals is organizational ambient anxiety.
Schein (2017) refers to one component of ambient anxiety as “learning anxiety,” a fear of the
inability to learn new behaviors and anxiety’s effect on self-esteem (Schein, 2017). When fears
arise, defense mechanisms kick in.
Defense Mechanisms
To understand defense mechanisms, or how individuals and groups defend themselves
against internal threats, the ego must be explained. The ego was originally understood as the
neutralizer of internal anxiety or tension felt by the individual. Ego functions are responsible for
understanding the physical and psychological needs of the individual. The ego coordinates the
internal and external relationships of the individual and maintains a healthy balance of the
superego, also known as the moral compass of an individual, with a heightened level of self-

38
esteem (Berzoff et al., 2016). Defense mechanisms are used to gain control of an individual’s
behaviors. These defenses protect the individual from conflict within the ego, interpersonal
relationship conflict, conflict in dealing with social normalities, and the individual’s response to
trauma. When any of these conflicts threaten the individual, defense mechanisms automatically
and unconsciously alter the individual’s perception of the perceived danger (Berzoff et al., 2016).
In the classroom example, mirror neurons triggered by silence became a defense mechanism
against ambient anxiety. The mirror neurons triggered a physiological response of laughing,
yawning, and sighing, which are behaviors commonly used to self-soothe during experiences of
distress. So, what happens when defenses arise in an organization? Let’s first explore what the
research shows on leadership and authority. Since this dissertation is an investigation of group
dynamics within leadership teams in mental health organizations through my own lens as a
participant, below I share an experience I’ve had on a leadership team. This shows how group
relations theory can be used to understand the dynamics at play in the following section.
Leadership and Authority in Groups and Organizations
A clinical mentor once compared shifts in a group dynamic, whether involving family,
friends, or work, to a game of musical chairs. In the end, everyone is fighting for a chair in the
system. She said:
Picture a circle of chairs in a room, and everyone in your group/organization is sitting in
a chair. Every chair is different, modified to the needs of each individual. When you add
someone to the group/organization, everyone needs to stand up and change chairs. When
they sit down in their new chair, it’s uncomfortable, as it has already adapted to the needs
of the previous individual. It takes time for everyone to adjust to their new chair, and
some may not want to wait. Leadership and authority in groups/organizations is about

39
communicating to those in the group/organization to be patient and trust the process.
We’re all uncomfortable. But what can we learn from the chairs we’re sitting in? What do
they teach us about our family members, friends, or colleagues? The person people look
to for guidance and direction when faced with an uncomfortable chair is a person of
authority. By navigating the change with the group/organization, the authority figure is
practicing leadership.
From 2021 to 2023, I was the operations manager and staff therapist at a small group
practice that was just getting started. Originally, in 2021, there were three members of the
leadership team: the CEO, the clinical manager, and the operations manager (me). We had three
full-time staff therapists and one part-time staff therapist. By the summer of 2023, the leadership
team grew to seven members: CEO, COO, clinical manager, operations manager (me), cultural
manager, education manager, and social media manager. Our team included two office
coordinators for two different offices in major metropolitan cities, four clinical supervisors, five
social media content creators and educators, and 31 staff therapists representing seven different
states. In 2021, I was given a chair in this organization, and every time we added a new staff
member, I needed to find a new chair and adapt. If you’re keeping track, my chair changed
twenty-five times in two years. Additionally, I was a part of the leadership team. When someone
is experiencing this much change, how are they expected to lead? How are they expected to
guide? How are they expected to do a job when they don’t feel supported?
I voiced my concerns with other members of the leadership team towards the end of 2022
and into the beginning of 2023. I shared that I did not feel I was being set up for success and that
I needed extra support to continue executing my operational tasks (on top of a clinical caseload)
while our staff was five times as big as the original size. Immediately after naming this concern,

40
I felt daily fear and anxiety. “I’m going to get replaced.” “I’m going to be scapegoated.” “I’m
naming something uncomfortable, and nobody wants to talk about it.” “I’m pointing out a flaw
in the system.” In July of 2023, I was offered a demotion to a billing coordinator position.
Instead of receiving support for my existing chair, I was once again asked to change chairs. I
declined and departed from the organization within days. I was replaced by a queer Asian
woman who the organization hired in July of 2023. She was promoted to director of operations
four months later.
Leadership and Authority
A recurring issue in the development of groups and organizations is leadership and
authority (McRae & Short, 2010). Authority can be defined as a formal or informal position with
the power to make decisions within a group or organization. Additionally, authority represents
power, or the capacity to guide, which is given to an individual by group members or individuals
within an organization. While authority is a position, leadership is a process of motivating
change in groups and organizations (McRae & Short, 2010). According to Forsyth (2010),
leadership is “a special form of social interaction: a reciprocal, transactional, and
transformational process in which individuals are permitted to influence and motivate others to
promote the attaining of group and individual goals” (p. 9). Revisiting the words of my clinical
mentor, MaryLu Halperin, RN, LCPC, “The person people look to for guidance and direction
when faced with an uncomfortable chair is a person of authority. By navigating the change with
the group/organization, the authority figure is practicing leadership.”
While much of the focus is on leadership and authority as a whole, racial and cultural
factors add a layer of complexity, as these differences within a group have the tendency to create
tension. The boundaries of subgroups within an organization may shift to a defensive mode if

41
unconscious biases arise. Making these differences conscious, while creating space to talk openly
about these differences, can be used to combat an organization’s need to shift to defensive mode
and transition to work mode. It is the leader’s responsibility to initiate these difficult
conversations in order to create optimal organizational effectiveness (McRae & Short, 2010).
Simultaneously, a leader must hold the complexity of the organization’s dynamic while also
holding a certain level of group dynamics competence and cultural competency in order to
acknowledge their own implicit biases (McRae & Short, 2010).
When reflecting on my previous work experience, there was much more at play than a
game of musical chairs. While the team was made up of therapists and educators, they were also
relatively diverse in terms of race and culture. For me, this was by far one of the most diverse
groups of colleagues I’ve ever worked with. Unfortunately, while diversity was a factor the
leadership team kept at the forefront of our mission, we rarely spoke explicitly with each other
about how these factors were impacting our ability to do “work.” I found it ironic that we were
all formally trained to navigate difficult spaces regarding race and cultural factors with clients,
but we never dedicated the same efforts to understanding these factors in the workplace. This
was a clear example of how turbulence within a leadership team affected its ability to become a
work group. So how were we able to get any work done?
Roles
Role differentiation is a defensive mechanism by which a group manages its tasks and
conflicts. It serves as a way to protect individuals from anxiety by allowing them to exchange
and shift the unwanted parts of the self with those of the group (Gillette & McCollom, 1990).
The group creates roles, or a limiting specialization restricted by the pressures and requirements
of the group. In order for individuals to function within roles, they must be authorized by others

42
and by themselves to carry out each role’s activities (Cytrynbaum & Noumair, 2004). Group
members take on certain roles in order to protect the group from conflict. However, role
differentiation often leads to compartmentalization of certain group members, who become
overwhelmed with anxiety. Changing role differentiation can manifest as the projection patterns
of group change (Gillette & McCollom, 1990).
While group relations research breaks down the construct of roles into several individual
roles and the function of these roles, for the purpose of this dissertation, I focus on two
categories of roles: 1) formal roles and 2) informal or irrational roles. Formal roles, or rational
roles, are consciously observed roles by the group taken up in service of a primary task
(Cytrynbaum, 2017). Formal roles are defined by a job description and are usually assigned by
authority. These formal roles must be understood by the individual who takes on these roles and
must also be understood within the group dynamic. Without this clarity, anxiety and conflict may
arise within the group. For example, some of the turbulence within the leadership team was the
swapping of titles and the misunderstanding of what duties fell under which role. Too much time
was taken away from leadership tasks, due to lack of clarity and the conflict that resulted.
Informal roles, or irrational roles, are taken up by individuals on an unconscious level.
These roles are taken up by group members in response to the anxiety within a group, and as a
way to protect individuals from conflict (Green & Molenkamp, 2005). Because a group is
formed to achieve a particular goal in a short amount of time, the informal role category is
dependent upon a task. Informal roles are also determined by what is going on in the group and
are manifestations of the group’s generalized fantasy, or myths, about the behavior of group
members (Cytrynbaum, 2017). Essentially, these roles are taken up as a defensive and adaptive
function for an individual to cope with what is happening within a group (Gillette & McCollom,

43
1990). While a single individual on a leadership team is given a formal title, they may take on an
informal role if necessary. For example, while a leadership team may look to the most senior
member for direction to accomplish a task, if they are unable to fulfill this expectation, the team
may look to a different member of the team for guidance and motivation. Additionally, research
shows it is important to acknowledge that an individual’s prior social relationships also influence
the group dynamic and influence an individual’s predisposition to take on certain roles. Sentient
relationships, or relationships developed before the group interaction through formal work or
social interactions, affect how group members feel in groups and organizations and therefore
affect the role an individual takes on (R. H. Klein et al., 1992). But how do we make sense of a
pattern within a leadership team of taking on informal roles?
Valency
Experiential-based group dynamics research from The Tavistock Institute in London
introduced the concept of valency, or the predisposition individuals possess to being caught up
by the irrational and unconscious parts of the group (Gillette & McCollom, 1990). The tendency
to hold a valency differs from person to person. The basic assumptions, or assumptions made
about a group dynamic that are unspoken and unrealistic, can vary in degree. Valency also
speaks to an individual’s predisposition to take on certain roles. This predisposition is activated
by the group’s anxiety and can be determined by the individual’s psychological and sociological
identity. It is also the individual’s response to projections from others within the group and the
roles they adopt (Gillette & McCollom, 1990). Projection is when an individual takes a “splitoff” part of an individual and projects it on someone or something else because the self cannot
contain both parts, due to too much internal anxiety (DeBoard, 2014). Splitting describes the
process by which the good parts of the self, the positive parts, or the bad parts of the self, the

44
negative parts, are experienced and noted as two separate parts. This splitting influences how the
individual sees the self and external objects before observing them as a whole (Berzoff et al.,
2016). This phenomenon is also explained by role suction, or the unconscious pressure from the
group for individuals to take on certain roles. This involves the group’s manipulation of an
individual to take on certain behaviors necessary for the survival of the group. Labeling group
members as “the quiet observer,” “the practical voice,” “the emotional one,” etc., illustrates the
valence an individual may have for a certain role (McRae & Short, 2010).
From my experience in group relations conferences, I have always had the predisposition
to have a salient valence in groups. Much of this is due to my complex identity and simultaneity,
the constructs discussed in Chapter 1. The more identities an individual holds, the more
opportunity exists for a group to target this individual and project. This also occurs in individuals
who take on formal and informal leadership roles.
Role of Leaders
Individuals who acquire a valency for leadership usually take on a leadership role. There
are four types of emerging leaders: 1) task, 2) emotional, 3) scapegoat, and 4) defiant (DeBoard,
2014). The task leader is responsible for bringing the group members together. This individual is
an expert in communication and self-exploration while having a great influence on group norms
and goals. Norms, or social norms within a group, refer to the customs, traditions, standards, and
other criteria of conduct (DeBoard, 2014). Conflict arises when the task or work leader exercises
their power and controls the giving or sharing of power with the other members of the group.
The emotional leader is often the most-liked member of the group. This individual is the
motivator of the group change and task while supporting the emotional process of staying
motivated. Conflict arises when the emotional leader forms deep bonds with other group

45
members or denies the need to form these deep bonds. The scapegoat leader often challenges the
group regarding the formation of norms. Conflict arises when the scapegoat is constantly
asserting themselves against group conformity. The defiant leader is hesitant about their
membership and their need for dependence or independence from authority. Conflict arises when
this individual protects the self through the skepticism of other group members (Cytrynbaum,
2017).
From the details of my work experience, I could argue that I have experienced all four
types of emerging leadership roles at different times. Ultimately, the scapegoat leader is the
leadership role I have associated with for the longest period of time. It is important to understand
not only how these emerging leadership roles arise but also the purpose they serve for a team, in
order to avoid conflict that will derail a team from a task. If this is avoided, a team can lead more
efficiently. However, for a leader to emerge in a group, the group must also contain followers.
The role of the follower is dependent, silent, supportive, and accepting of the group. The valency
to become a follower is initiated in the unconscious anxiety related to authority. For example, the
behavior of an individual in the role of a follower (dependent and accepting) is rooted in the need
for approval from authority figures (McRae & Short, 2010). This supports the research showing
that authority is given to an individual by a follower and is not something that previously existed.
Organizational Maturity and Efficiency Theoretical Framework
Now let’s link ambient anxiety in leaders and how it affects organizational efficiency
using Bandura’s (2001) social cognitive theory. The first subsection explores the research
literature supporting social cognitive theory and its relationship with self-efficacy. I pull the
previously explored constructs and apply them to Bandura’s (2001) model.

46
Self-Efficacy
Throughout the research literature, social cognitive theory is used in a variety of fields for
a variety of purposes. In this dissertation, I explore how social cognitive theory applies to
organizations. Social cognitive theory emphasizes the role of the social environment in
motivation and learning and focuses on the reciprocal interactions among personal (i.e., beliefs,
skills, affect), behavioral, and social/environmental factors (Bandura, 2001). Similar to cognitive
behavioral therapy (CBT), founded by Aaron Beck in the 1960s, social cognitive theory draws
from the CBT triangulation of thoughts, feelings, and behaviors (Kendall & Hollon, 1979).
Bandura (1969) elaborates by introducing the term reciprocal determinism, also known as triadic
reciprocity. Reciprocal determinism (Figure 2) breaks down the dynamic interaction between
environment, behavior, and psychological processes. Bandura (1969) highlighted the importance
of internal processes, such as motivation, and their impact on self-directed behavior. Selfdirected behavior and other influences on behavior, illustrated by Bandura’s (1969) reciprocal
determinism or triadic reciprocity, contribute to self-efficacy, or the gaining of confidence in
performing a new behavior (Berzoff et al., 2016).

47
Figure 2
Bandura’s Social Cognitive Theory and Reciprocal Determinism
Note. This visual was adapted from collected research on social cognitive theory and reciprocal
determinism from Bandura (1969, 2001), Berzoff et al. (2016), and Kendall and Hollon (1979).
In this dissertation, the focus is on social/environmental factors and their link to
organizational efficiency. Each autobiographical excerpt from the previous chapters and sections
articulates a change in the environment (e.g., audience members crying in a theater, chaos in a
crowded bar, hierarchical shifts in a higher education program, sudden prolonged silence from a
professor, and continued role-switching in a mental health organization). The change in each of
these environments was acknowledged via conscious and subliminal psychological processes
(e.g., sensitivity, stress, anxiety, confusion, defensiveness, hypervigilance, worry, and fear),
ultimately leading to a behavior change (e.g., tears, poor work performance as a server/bartender,
laughter, yawning, and fleeing an organization), as seen in Figure 3.

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Figure 3
Application of Social Cognitive Theory
Note. The application of this visual was adapted from collected research on social cognitive
theory and reciprocal determinism from Bandura (1969, 2001), Berzoff et al. (2016), and
Kendall and Hollon (1979).
Bandura’s (1969, 2001) theory explains that change can be initiated at any point in the
triangulation. So what does the research literature say about how to manage this change?
Change Management
According to Lewin (1947), change in groups and organizations occurs in three steps: 1)
the reappraisal of values and a reapproach to problems with an open mind, 2) the execution of
new behaviors, and 3) the maintenance of the new commitment to change and new behaviors
associated with change (Lewin, 1947). Lewin divides change into three steps, while further

49
detailing each step with expected sub-steps. Step 1, or creating motivation for change, also
known as “unfreezing,” includes disconfirmation, the creation of anxiety, resistance to change,
and the creation of psychological safety. Step 2, or learning new behaviors, includes the adoption
of “role model” behavior and trial and error. Step 3, or internalizing new behaviors, includes the
incorporation of these new behaviors into an individual’s identity and relationships (Lewin,
1947).
Additionally, self-awareness plays a key role in organizational change
management. Groups and organizations must also follow three principles to effectively create
change: 1) increase the organization’s ability to appreciate others’ reactions to changed behavior,
2) increase the organization’s ability to reflect on the state of interpersonal relationships within
the organization, and 3) increase the ability to execute the necessary behaviors for change
(DeBoard, 2014). Group dynamics research shows that groups and organizations with the most
apparent change display greater ability to relate to others within the group/organization,
increased interdependence, greater acceptance of others within the group/organization, and
overall elevated levels of insight related to an individual’s role (DeBoard, 2014). To sum up,
groups and organizations must self-reflect, acknowledge social defense mechanisms, manage
group/organization-level ambient anxiety, and establish, execute, and maintain new behaviors
toward change (DeBoard, 2014).
According to Kotter and Cohen (2002), change initiatives occur in eight stages: 1) build a
sense of urgency for change; 2) use a team with skills, credibility, connections, and authority to
manage the change process; 3) create a vision and strategy to make change happen; 4)
communicate this vision and strategy using a variety of communication techniques (e.g., words,
symbols, body language); 5) minimize barriers to change and motivate individuals; 6) thoroughly

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communicate progress and growth toward desired outcomes and celebrate successes; 7) refuse to
let difficulties and conflicts get in the way of progress; and 8) foster a new culture to support
change (Kotter & Cohen, 2002). Kotter and Cohen (2002) emphasize the importance of feelings
as change agents. Data gathering and data analysis are used too much in the processes leading up
to organizational change and often dismiss human needs within the organization.
Figure 4 shows a generalized illustration of an organizational change management
process. This change initiative focuses on three main phases from a leader’s perspective: 1)
unfreeze, 2) change, and 3) refreeze. Acknowledgment and awareness of the organization’s
environment are key in the efforts to drive change.
Figure 4
Organizational Change Management Process
Note. This modified illustration of Kurt Lewin’s change theory is based on “Group Decision and
Social Change,” by K. Lewin (1947) in T. N. Newcomb & E. L. Hartley (Eds.), Reading in
Social Psychology (pp. 459–473), Holt, Rinehart & Winston.

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Conclusion
The literature presented for this inquiry supports my hypothesis that ambient anxiety
among leaders leads to inefficiency in groups and organizations. Utilizing the main components
of an autoethnography research study, I used my personal experience to pull literature relevant to
this study. I shared my experience in group relations conferences and linked it to group relations
theory. I detailed my first explicit experience with ambient anxiety, which led to a discussion of
how ambient anxiety manifests in groups and organizations and how it affects leaders. I then
shared my experience at my previous workplace and discussed the importance of leadership and
authority as they relate to group relations theory. I concluded with an exploration of how ambient
anxiety among leaders affects efficiency in groups and organizations and discussed
organizational maturity. The next chapter will discuss research methodology and design.

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Chapter Three: Methodology
This chapter discusses the research design, methodology for data collection, and data
analysis for examining how ambient anxiety within leadership teams affects organizational
efficiency. Specifically, the study examines the experiences of leaders in mental health
organizations. The chapter begins with a restatement of the research questions, followed by an
overview of the research design. Next, the chapter describes sampling, instrumentation, data
collection procedures, the research setting, the researcher, limitations and delimitations,
trustworthiness and credibility, and ethics. The final section focuses on limitations and
delimitations related to the study.
Research Questions
1. How does ambient anxiety manifest in mental health organizations?
2. How does ambient anxiety in leadership teams affect efficiency in mental health
organizations?
3. How can leaders within mental health organizations be supportive of therapists who
experience ambient anxiety?
Overview of Design
This study contains two types of data: an autoethnography, in which I share a collection
of personal experiences and anecdotes that highlight the theoretical and conceptual frameworks
used in this research study; and a set of interviews of seven to 12 participants, to capture data
about ambient anxiety’s connection to organizational inefficiency in mental health organizations.
According to Merriam and Tisdell (2016), qualitative research is motivated by an interest in a
phenomenon that extends existing knowledge and aims to gain insight to inform practical

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application. A qualitative research study allows the researcher to explore participants’ lived
experiences. The research is given a voice by the participants (Merriam & Tisdell, 2016).
Autoethnography
According to Ellis et al. (2011), autoethnography research consists of retrospectively
writing and analyzing anecdotes from the researcher’s life (Ellis et al., 2011). A collection of
lived experiences using a group relations theory lens is used to support my proposed hypothesis
for this research study. Ellis (2004) describes the autoethnography process as a back-and-forth
process through the eyes of the researcher. Introspection and extrospection are used in tandem in
the analysis process. The goal is to use a series of personal stories to make sense of how ambient
anxiety is experienced by an individual and how it affects organizational efficiency (Ellis, 2004).
Adams et al. (2015) explain that an autoethnography: 1) uses a researcher’s personal experience
to reflect on others’ experiences; 2) acknowledges and values relationships of the researcher; 3)
practices critical self-reflection, also known as reflexivity, or the ability to name and interrogate
the relationships between an individual and society; 4) puts processes and struggles on display;
5) balances methodological concerns and humanity; and 6) supports social justice.
According to Le Roux (2017), reporting a lived experience requires self-reflection and
gives the researcher the ability to take a step back from an experience, acknowledge their
positionality, and examine the experience objectively (Le Roux, 2017). Through critical selfreflection, also known as reflexivity, of my personal experiences with ambient anxiety in groups
and organizations, I present data from my records.
Documents and Artifacts
The documents and artifacts from my personal experience are used as data for this study.
According to Billups (2020), documents comprise a wide range of archival materials, and

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artifacts comprise of video and audiovisual recordings, art, and cultural objects (Billups, 2020).
“The corroboration of stories, narratives, conversations, and shared experiences with tactile,
tangible evidence in the form of documents, writings, publications, notes, and material culture
objects form the central focus of qualitative explorations” (Billups, 2020, p. 3). In addition to
these documents and artifacts, memories can also be included. According to Coffey (1999),
“Ethnography is an act of memory because fieldwork and the resulting texts cannot be separated
from the memories that shape them” (p. 127). In some cases, life experiences that are far too
numerous to record provide a sense of what the researcher “carries around in (their) head” (Wall,
2008, p. 45). Letters, emails, messages, and excerpts from an organization’s manual are all used
as supplementary data to support the life experiences of the researcher.
Interview Method
Eight participants’ stories are explored via a semi-structured interview. The interview
allows participants to give insight into their lived experiences and tell their stories of how
ambient anxiety affects them as individuals and how it manifests in their organization. This
method of data collection from participants involves using my own lived experience to make
sense of others’.
Sampling
The researcher is able to focus on attributes crucial to the study using a criterion-based
purposeful sampling approach (Merriam & Tisdell, 2016). Interview participants were clinical
mental health therapists in leadership roles at mental health organizations. These participants
were appropriate for this study because they represent the population of clinicians affected by
ambient anxiety in mental health organizations. I used a typical purposeful sampling strategy
because it “highlights what is typical, normal, and average” (Merriam & Tisdell, 2016). Email

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listservs for group therapy practices provided by the American Counseling Association (ACA)
were utilized as a recruitment tool for the ideal participants of this study. As a professional
member of the ACA and a National Certified Counselor (NCC), I have access to the NCC
listservs (National Board of Certified Counselors, 2024). NCCs holding leadership roles in
mental health organizations were also recruited via LinkedIn. Qualified participants were
contacted via email. In order to protect participants’ anonymity, pseudonyms replace participant
names.
Instrumentation
Creswell and Creswell (2018) note that a sample size depends on the design of the study;
one to two participants are needed for narrative, but there is no minimum number of participants
for basic qualitative research (Creswell & Creswell, 2018). The semi-structured interview
consisted of 15 closed and open-ended questions designed to collect data that informs how
ambient anxiety manifests within mental health organizations and how ambient anxiety affects
organizational efficiency. This interview approach (See Appendix A) includes probing questions
that may deepen a response if an answer is too narrow (Merriam & Tisdell, 2016). The interview
asked participants about their experiences with ambient anxiety in their organization, with a
focus on ambient anxiety within leadership teams and its impact on organizational efficiency.
Data Collection Procedures
Semi-structured interviews were conducted between May and June of 2024 and took
place via a video conferencing platform. Interviews took 45 minutes and were recorded with
participants’ permission. Transcription software was used to transcribe interviews, and recorded
data was kept on a password-protected server. All data will be destroyed after five years.

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Research Setting
As this is a qualitative autoethnographic research inquiry, the interview questions target
participant experiences that parallel my experiences with ambient anxiety. The questions were
designed to validate the research provided in the literature review. I facilitated eight separate
semi-structured interviews via Zoom. I explained the purpose of this research in an email to each
participant and invited each qualified participant to sit for an interview. I let each potential
participant know that the interview would take 45 minutes and would consist of 15 questions.
Data Analysis
Qualitative interviews and transcript analysis are methods employed in the study to
analyze the data collected via interviews. Interpreting interview data lets the researcher make
“sense” out of what is shared. Data analysis for the eight interviews included transcribing
participant interviews, while interview transcriptions were coded manually. A codebook for
these transcriptions is found in Appendix B. According to Gibbs (2018), “coding is a way of
indexing or categorizing the text in order to establish a framework of thematic ideas about it”
(Gibbs, 2018). The analysis of verbatim transcriptions utilized Gibbs’ case-by-case comparative
strategy in order to enhance credibility and trustworthiness. This analysis strategy highlights
similarities and differences between transcriptions and highlights patterns (Gibbs, 2018). The
researcher compiled and organized the data into sections or groups, also known as themes or
codes (Creswell, 2007). Themes and codes are consistent phrases, expressions, or ideas that
repetitively occur in interviews (Kvale, 2007). A coding template (See Appendix B) was used as
a guide for the construction of the codebook. A priori coding that aligned with the research
questions, interviews, and conceptual framework was utilized. While most of the interview data

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was used for Chapter Four, not all interviews provided data that aligned with the purpose of this
study. Results were determined from coding and are examined in Chapter Four.
The Researcher
According to Villaverde (2008), positionality is defined as “how one is situated through
the intersection of power and the politics of gender, race, class, sexuality, ethnicity, culture,
language, and other social factors” (Villaverde, 2008). My positionality is the intersection of my
many identifiers and how these identities overlap and blend. As a clinician, and one that profits
from capitalist America and the commercialism of mental healthcare, I am trained to explore
how both the individual and the system at large play into the narratives we carry. In the therapy
room, implicit biases are explored, and awareness is raised at both an individual and a group
level. This is a transactional, therapeutic space created by queer people of color. Awareness
about settler colonialism is explored, processed, reinforced, and extinguished, all within a 50-
minute session.
I identify as both an individual within the marginalized population and, according to
Lowe (2021), an “expert” in the field and a representative of my organization’s leadership team.
I can use my position of power as a trained clinician to advocate for minority populations within
the field of mental health (Lowe, 2021). I am also trained as a consultant in group dynamics,
which has provided me with the education and training to identify and name both conscious and
unconscious group dynamic constructs. Through the lens of my positionality, I can identify a
number of these constructs from my implicitly biased perspective. I would like to acknowledge
and name these dynamics and what can manifest from these dynamics to validate the experiences
of other Black, Indigenous, and people of color (BIPOC). Ethically, it is the responsibility of the

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researcher to acknowledge how my positionality plays a role in this autoethnography (Merriam
& Tisdell, 2016).
Limitations and Delimitations
For this qualitative autoethnography, limitations and delimitations are critical
components that must be considered. Some limitations may include my personal bias and the
countertransference I hold, as ambient anxiety in mental health organizations is both a
professional and a personal passion of mine. Additionally, as an individual, I am working against
the system at large. Implementing systemic change at a foundational level, or, according to Lowe
(2021), within the educational system, must be necessary to execute a reinforced cycle of greater
advocacy for Black, Indigenous, and people of color (BIPOC) at a systemic level. Additionally,
potential research gaps include the lack of measures and assessments for group dynamic
awareness, making it difficult to measure levels of consciousness within groups and
organizations. Since the study was conducted with eight participants, expanding the study to
include more voices from therapists in leadership roles, specifically men of color, must also be
considered.
Trustworthiness and Credibility
According to Merriam and Tisdell (2016), qualitative research is based on different
assumptions and different world perspectives, so credibility, transferability, dependability, and
confirmability should be adopted into the study (Merriam & Tisdell, 2016). Two forms of rigor
considered for methodology were the application of methods and interpretation, as they
contributed to the trusted interpretation of qualitative data. Additionally, “personal criteria” such
as the credibility of the topic and its ability to resonate with the audience need to be considered
in qualitative research (Merriam & Tisdell, 2016). When I was coding data associated with this

59
study, these “personal criteria” were considered and revisited. It is important to acknowledge that
while this dissertation is a qualitative autoethnography research study, encouragement of the
reproduction of my personal contributions is not the intent (Merriam & Tisdell, 2016).
Ethics
The University of Southern California (2024) is committed to respecting the rights and
dignity of all persons. I have complied with the university code of ethics, specifically within the
common rule as defined by the U.S. Department of Health and Human Services policy for the
protection of human subjects (Title 45, Part 46, Subparts A and C). I have followed the
guidelines provided by the university and adhered to the guidance of my committee.
There can be a risk of harm if interviews are conducted in a manner that dismisses the
experiences of the participants. Additionally, asking participants to relive what could be
potentially traumatic experiences is also risky. These risks were considered when I was writing
the interview questions. Participants were informed of the potential risks, and participation in the
interview was voluntary. Participants were assured of confidentiality. Pseudonyms were used to
protect participants’ identities. After interview answers were coded appropriately, results were
concluded and disclosed in my dissertation. No compensation was provided. Additionally, when
I was detailing my own personal experiences, pseudonyms were used in place of real names and
dates were changed to protect confidentiality.

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Chapter Four: Findings
In this study, we explored the manifestations of ambient anxiety within mental health
organizations and its impact on leadership efficiency, as well as how leaders can support
therapists experiencing this form of anxiety. This chapter begins by describing the participants of
my study, providing context to better understand their experiences and perspectives. The findings
for the first research question are detailed. Various manifestations of ambient anxiety, including
physical and emotional responses, dismantling of group dynamics, communication challenges,
and stress and burnout, are paired with personal anecdotes and interviewee experiences. Findings
for the second research question are then examined. Personal stories and interview insights
illustrate the impact of ambient anxiety on leadership efficiency and organizational functioning.
Lastly, an exploration of the findings for Research Question Three are detailed. All is supported
by my own personal experiences and those of the interviewees.
Participants
The study included eight participants, counting myself, representing therapists in
leadership roles in mental health organizations. Seven study participants were female, and one
was male. Four identified as women, three identified as genderqueer, and one identified as a
man. Additionally, three were White, two were Biracial (Black/White), one was Biracial
(Asian/White), one was Asian, and one was Black. All participants were leaders and therapists in
mental health organizations with 30 or more employees. Table 1 provides an overview of the
participants’ demographic information, including sex, gender, race, professional role, and
respective pseudonyms. Table 2 summarizes a comparative analysis showing the overarching
themes, codes, and sub-codes that emerged from interview data.

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Table 1
Participant Demographics
Pseudonym Sex Gender Race Professional Role
Avery female woman Black leader/therapist
Cameron female woman Asian leader/therapist
Charlie female genderqueer White leader/therapist
Jordan female woman Biracial (Black/White) leader/therapist
Morgan female woman White leader/therapist
Quinn female woman White leader/therapist
Riley male man Black leader/therapist
Sam female genderqueer Biracial (Black/White) leader/therapist
Taylor female genderqueer Biracial (Asian/White) leader/therapist

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Table 2
Summary of Comparative Analysis
Research Question Themes Codes Sub-Codes
How does ambient
anxiety manifest in
mental health
organizations?
Manifestations of
ambient anxiety in
mental health
organizations
Physical and
emotional responses
Physical reactions
Emotional stress
Dismantling of group
dynamics
Perception of safety
Team dynamics
Professional identity
and values
Misalignment with
organizational values
Walking on eggshells
Communication
challenges
Misunderstandings
Fear of speaking up
Stress and burnout Burnout due to high
expectations
Emotional exhaustion
How does ambient
anxiety in leadership
teams affect
efficiency in mental
health
organizations?
Impact of ambient
anxiety on leadership
efficiency
Decision-making
processes
Quick decisions
Cautious approach
Clarity of
communication
Miscommunication
Clarity of roles
Organizational
priorities
Budget constraints
High patient load
Leadership
fragmentation
Accessibility of leaders
Trust issues
Fragmentation
Isolation from team

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How can leaders
within mental health
organizations be
supportive of
therapists who
experience ambient
anxiety?
Support for therapists
experiencing ambient
anxiety
Organizational and
structural
interventions
DEI committees
Training programs
Humanizing
leadership practices
Relationship leadership
Open communication
channels
Emotional and
psychological support
Peer support
Professional
development
Stress and anxiety
management
strategies
Coping skills for stress
and anxiety
Organizational
culture interventions
Training programs
Formal and informal
channels for feedback
Findings for Research Question One
The first research question in this study is, how does ambient anxiety manifest in mental
health organizations? In this section, manifestations of ambient anxiety are discussed. These
include physical and emotional responses, dismantling of group dynamics, communication
challenges, and stress and burnout. All are paired with my personal anecdotes and with
interviewee experiences as supportive evidence.
Manifestations of Ambient Anxiety in Mental Health Organizations
Manifestation refers to the act or process of bringing something into existence or making
it evident. According to this study, manifestations of ambient anxiety in mental health
organizations include physical and emotional responses, dismantling of group dynamics,
communication challenges, and stress and burnout.

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Physical and Emotional Responses
Physical or somatic responses are manifestations of ambient anxiety in mental health
organizations. These refer to the bodily symptoms and physical manifestations that arise from
stress, anxiety, or other emotional states (Selye, 1956). These reactions are how the body
responds to perceived threats or stressors. They can include a wide range of symptoms, such as
increased heart rate, sweating, muscle tension, headaches, gastrointestinal issues, fatigue, and
sleep disturbance. Emotional responses refer to the psychological and emotional strain or tension
resulting from adverse or demanding circumstances (Selye, 1956). Physical or somatic reactions
and emotional stress are profound manifestations of ambient anxiety in mental health
organizations.
Charlie, an interviewee, shared similar experiences. “I feel ambient anxiety going into
every meeting with clinical leadership … the ambient anxiety in my body stems from previous
experiences and communication.” According to Charlie, their physical and emotional responses
to ambient anxiety come from both past meetings and anticipated future meetings with their
leadership team. Jordan, another interviewee, also identified these manifestations. “It really
brought up not only mental health issues but physical health issues as well.” Jordan was able to
recognize that their ambient anxiety branched into two manifestations, mental and physical.
While Charlie and Jordan both experienced physical and emotional responses in their respective
organizations, my personal experience with these, particularly with physical responses, is quite
intense. While I have experienced these specific manifestations of ambient anxiety in many
situations, there is one experience that stands out due to the severity of my reactions.
One of the more recent and dynamic examples of physical and emotional manifestations
of ambient anxiety took place in the summer of 2023. The leadership team at Wellness Minds

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(the organization I joined after Health Alliance) had returned from a leadership retreat. I had
been feeling overworked for over a year and felt overwhelmed by the number of responsibilities
put on my plate (Figure 5). I was becoming increasingly afraid that my feelings of overwhelm
would be read as incompetence and that I would be fired (Figure 6). These emotional
manifestations of ambient anxiety are highlighted in Figures 5 and 6.
Figure 5
Text Exchange 1 With a Wellness Minds Colleague
Note. A text conversation between a trusted Wellness Minds colleague (left) and me (right) in the
winter of 2023.
Figure 6
Text Exchange 2 With a Wellness Minds Colleague
Note. A text conversation between a trusted Wellness Minds colleague (left) and me (right) in the
summer of 2023.

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I decided to voice my fears about the sustainability of my role. I scheduled a meeting
with the CEO and COO. As the meeting approached, I felt like I was running a marathon—hot
and sweaty, with my heart racing and feeling like it was going to beat out of my chest. My face
flushed with terror as I emphasized the need for additional support in my operational tasks and
requested a reduction in my clinical metric expectations. These were physical manifestations of
ambient anxiety, experienced as a direct result of requesting a meeting.
In this meeting, instead of receiving support, I was demoted from “operations manager”
to “billing coordinator,” a role where I would be managed by the clinical manager. The clinical
manager later confided that they had not been consulted about taking on an additional direct
report before I was given this new role. The job description for “billing coordinator” included
managing clinician’s fee metrics, client outstanding balances (OBs), payment plans for clients,
and insurance claims, in addition to my current clinical caseload. This position was not
considered a “leadership” position and would require me to step down from the leadership team.
Upon reading the job description for “billing coordinator,” my stomach sank, and my heart
pounded even harder. I felt like I was in a sauna, drenched in sweat. Despite trying to mask my
disappointment, I lost control, and tears began to well up. I was experiencing both emotional and
physical manifestations of ambient anxiety. Even though my compensation would remain the
same, I realized there was a good chance I would never receive the necessary support from
Wellness Minds. I felt like I needed to leave as soon as possible to avoid the uncomfortable
feelings of ambient anxiety that emerged from this situation. I immediately began drafting my
exit plan (Figure 7).

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Figure 7
Summer 2023 Message to Wellness Minds Leadership Team
Shortly after sending my letter, I was emailed detailing additional tasks and
responsibilities I would need to complete—offboarding and training my potential
replacements—on top of my already overwhelming workload. When I received the email listing

68
these new responsibilities (Figure 8), my body instantly got hot and sweaty. I had a wave of
severe nausea and threw up on my home office rug. Again, physical manifestations of ambient
anxiety took over my body.

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Figure 8
Summer 2023 Response Email From Wellness Minds COO

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The feeling of fear and panic was the strongest I had felt in over a decade. I spent the
entire night crying, panicking, feeling nauseated, and getting sick. I was scheduled to meet with
the COO the following day to discuss the tasks in detail, but every time I thought about this
meeting, I became nauseous. My body was telling me something was very wrong, and I needed
to leave the situation as soon as possible. I emailed the CEO and COO that I could not meet
because it was affecting my health and I needed an alternative plan. I received a response from
the COO, stating that the tasks assigned to me were “time-sensitive” and that the meeting was
mandatory. All of the same strong, physical manifestations of ambient anxiety came flooding in,
with more intensity, within minutes of receiving this reply. I replied firmly, stating that I would
not be attending the meeting, in order to take care of my physical and mental health.
Two weeks later, I fully transitioned to my own private practice, but the acute anxiety
lingered for three months after I left Wellness Minds. Despite no longer working under anyone, I
was gripped by a constant fear of punishment, manifesting as daily panic attacks, nightly
vomiting and dry heaving, insomnia, and difficulty eating, all of which prevented me from
meeting with clients. I soon discovered that I was not alone in experiencing these intense
physical and emotional responses to ambient anxiety.
When looking back on the entirety of this experience, I can recognize that my ability to
“contain” the organizational anxiety stemmed from the first-time departure of a core leader,
which manifested in my body both physically and emotionally. I see that as an individual with a
vulnerable valency to hold emotion, particularly anxiety (as exemplified in Chapters One and
Two), I took on a “working” role in the organization as the working group’s “container.” I’m
curious if others within the organization also experienced these manifestations of ambient
anxiety when the organization needed to, once again, move chairs.

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Dismantling Group Dynamics
Dismantling group dynamics is another manifestation of ambient anxiety. It refers to the
shared values, beliefs, norms, and practices that shape the behavior and interactions of members
within an organization (Schein, 2017. It encompasses the collective attitudes, standards, and
customs that guide how employees approach their work, interact with one another, and perceive
their roles within the organization. The perception of safety in team dynamics also significantly
contributes to organizational culture (Schein, 2017).
Pairing, a concept from group dynamics discussed in Chapter Two, illustrates how
organizational culture is influenced by anxiety. Pairing takes place when anxiety levels increase
and safety from uncomfortable feelings is found in one other individual. When two people in a
group “pair-off,” the group dismantles a leader’s authority. When this shift takes place, authority
can be taken away from the “formal” leader and given to a different individual. Simultaneously,
there can be more than one pair in a group. Pairing occurred consistently at Wellness Minds.
Over two years, our leadership team frequently fell into basic assumption groups, with
the pairing assumption proving harmful toward group cohesion. My relationship with the clinical
manager was often perceived by the leadership team as a “marriage” or “partnership.” It was
even joked by a member of the leadership team that the operations manager and the clinical
manager needed a “divorce,” which emphasized that the closeness of the existing relationship
may have been viewed as intimidating. We became one pair. Similarly, the CEO and COO had a
close relationship, which was also viewed as an intimidating “marriage” within the leadership
team. They became another pair. Additionally, the cultural manager and the social media
manager were paired off due to their personal relationship outside of work. Cohesiveness within
leadership was experienced in pairs rather than throughout the leadership team. After my

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departure from the organization, I left the clinical manager alone as a singleton. I learned that the
clinical manager received sympathy emails and messages from team members, as if I had passed
away. While colleagues offered condolences for their loss, they shared with me that grief and
mourning were some emotions that came up for them, months following my departure. The
feelings experienced by the leadership team were a result of pairing.
Communication Challenges
Communication challenges are another manifestation of ambient anxiety in mental health
organizations. In the workplace, this phrase refers to the difficulties and barriers that impede the
effective exchange of information, ideas, and messages among employees, teams, and
management within an organization. These challenges can arise from various sources, affecting
productivity, morale, and overall organizational effectiveness (Clampitt & Downs, 1993).
Misunderstandings and miscommunication are some manifestations of ambient anxiety.
During my tenure as a leader at Wellness Minds, the leadership team was tasked with
deliverables for the first time. I was explicitly informed that I could present my deliverable in
any manner that would best help me understand the data. I felt that the task was clear, but I still
experienced ambient anxiety about the general successful completion of this task. When the time
came, I presented my deliverable in a unique format, different from everyone else’s on the team.
Instead of receiving feedback on my approach or an opportunity to receive clearer instructions
about the expectation of the task, I was placed on a performance improvement plan and
reprimanded for “not completing the deliverable.” The reprimand and the punitive response left
me feeling powerless to push back out of fear of further punishment, which significantly elevated
my anxiety and my fear of making mistakes (Figure 9).

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Figure 9
Text Exchange 3 With a Wellness Minds Colleague
Note. A text conversation between a trusted Wellness Minds colleague (left) and me (right) in the
winter of 2023.
An interviewee, Morgan, emphasized the need for reassurance to mitigate their anxiety.
They recounted the following:
Anxiety led me to go to another leadership member to say, “Hey, did anyone else see that
this happened?” There are mixed messages in terms of what the expectations are. In a live
meeting, some directions may be laid out. Then later, if I’ve noticed that there’s a trend
of folks … for instance, if we have been asked to present our reports for the month, kind
of like the data that we have collected over the last 30 days, and if there’s sort of a trend
of many people creating PowerPoints for this report, then it sort of becomes the norm,
even though a presentation wasn’t laid out in the initial directions.
According to Morgan, increased levels of anxiety led them to reach out to leadership to clarify
expectations. They explain that whatever becomes the most common result of unclear
communication then becomes the expectation for future tasks. This is never explicitly named or
documented, leaving ample opportunity for future blunders. These experiences highlight the
cyclical effect that ambient anxiety has on communication.

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Stress and Burnout
Stress and burnout are other manifestations of ambient anxiety in mental health
organizations. Burnout due to high expectations and emotional exhaustion are significant impacts
on organizational efficiency. Burnout is a state of chronic physical and emotional depletion
resulting from prolonged exposure to stressors, particularly in the workplace (Maslach et al.,
2001). Emotional exhaustion is a component of burnout and refers to a state of feeling
emotionally overextended and depleted of emotional energy. It manifests physically, cognitively,
emotionally, and behaviorally (Maslach et al., 2001).
In my experience working in a mental health organization, I was constantly in a state of
ambient anxiety and afraid of not meeting my metric expectations. The focus shifted from the
quality of work I was doing with clients to the number of hours I was clocking with clients and
to doing administrative tasks. I noticed a change in my mindset when I had eight clients
scheduled for the day versus five. Consistently, the night before a workday, I check my calendar
to see which clients I’ll be meeting with the next day. I do this mostly to carve out time the next
morning for any preparation I may need to do for my clients (e.g., familiarize myself with any
updates to their medical chart, pull resources I may need for their sessions, etc.). When I saw
more than five clients on my calendar for the next day, anxiety would arise. My clinical “sweet
spot,” or the time of day I feel most alert and competent, is between 11:00 a.m. and 2:00 p.m.
This means that on most days, between 9:00 a.m. and 11:00 a.m., I’m preparing for my day-of
clients. However, most clients want to meet with me after 5:00 p.m. This extends my day to 8:00
p.m. and sometimes 9:00 p.m. On days when I see five clients or more, my day is usually
extended to a 12-hour workday. Seeing more than five clients a day creates anxiety because I

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know my clinical care is not optimal when I’m tired. So, on the evenings prior to a clinical day
of five or more clients, anxiety increases.
Jordan’s experience similarly explains how the ambient anxiety related to organizational
budget created pressure to see more clients, inevitably leading to burnout. Jordan shared:
One of the biggest anxieties, and we’d have this discussion at every staff meeting, was
meeting budget for the year … which then led to client burnout, but it also led to lower
patient care because the staff member was trying to make sure they gave everybody the
amount of time that was needed. I think when individuals and clinicians don’t feel safe to
really speak up, then it leads to higher burnout.
These experiences highlight how high expectations and pressure to meet financial targets
contribute to emotional exhaustion and burnout. When the emphasis is placed on meeting metrics
rather than providing quality care, it not only diminishes the well-being of clinicians but also
compromises client care.
This lack of cohesiveness exacerbated feelings of isolation and fear of speaking up,
ultimately leading to burnout as individuals navigated these complex dynamics. Sam, an
interviewee, highlighted the impact of anxiety on organizational group dynamics, stating, “I’ve
seen more things fall through the cracks than normal … people feel really burnt out and
overworked.” According to Sam, due to people experiencing burnout and being overworked, the
organization encountered more errors and mistakes than usual. Charlie also shared:
When anxiety exists in the leadership team, the clinicians, while they are supportive of
each other, are more apprehensive about bringing concerns to the leadership team
because they already see that they’re under stress. So they’re less likely to be forthright
with what’s going on.

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According to Charlie, clinicians within their organization resist reaching out to leaders because
they do not want to contribute to the higher levels of stress. As a result, they are unlikely to be
transparent with any conflicts they are experiencing.
Findings for Research Question Two
The second research question in this study is, how does ambient anxiety in leadership
teams affect efficiency in mental health organizations? This section discusses the impacts of
ambient anxiety on leadership team efficiency. These include decision-making processes, clarity
of communication, organizational priorities, fragmentation of leadership teams, and professional
values. All impacts of ambient anxiety on leadership efficiency are paired with personal
anecdotes and interviewee experiences.
Impact of Ambient Anxiety on Leadership Efficiency
According to this study, ambient anxiety impacts decision-making processes, clarity of
communication, organizational priorities, fragmentation of leadership teams, and professional
values. All of these factors impact leadership efficiency.
Decision-Making Processes
Decision-making processes impacted by ambient anxiety affect leadership efficiency in
mental health organizations. This phrase refers to the systematic methods and practices that
individuals or organizations use to make choices and arrive at conclusions (Bazerman & Moore,
2012). Effective decision-making is critical for both personal and organizational success and
involves several stages, such as identifying decisions and reviewing their outcomes.
In my experience at Health Alliance, in the position I obtained immediately after graduate
school, I felt significant pressure and ambient anxiety for the organization to take a stance on
various political and social issues, such as the COVID-19 pandemic and the Black Lives Matter

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movement. It felt like there was an unnamed expectation for the organization to make a
statement, but also, the speed with which these statements were made public felt crucial in
mitigating anxiety. However, this urgency often diverted attention away from essential clinical
work, impacting the quality of care provided to clients.
Charlie echoed this sentiment, noting that the decision-making process has often felt
rushed by their manager and that this sense of urgency trickles down to other members of
leadership, leading to sub-optimal outcomes: “We tend to kind of move with this false sense of
urgency and respond pretty poorly, in my opinion.” According to Charlie, decision-making
processes feel unnecessarily rushed. This rushed feeling, modeled by members of higher
leadership, puts pressure on the organization to make decisions quickly, especially when
organizational values are considered. When decisions are made too quickly, there is a higher
likelihood of making substandard choices. These choices and decisions then may not accurately
reflect the values of the organization, leading to more complex feelings about the competency of
the organization and its ability to carefully consider alternative choices and decisions. This false
sense of urgency can compromise the quality of decisions as the focus shifts from careful
deliberation to rapid response. The pressure to quickly address external issues can pull focus
away from core responsibilities, such as providing effective clinical care, ultimately affecting the
organization’s efficiency and the well-being of its members.
Clarity of Communication
Clarity of communication impacted by ambient anxiety affects leadership efficiency in
mental health organizations. Miscommunication refers to the failure to convey information
accurately between parties. It can occur due to various reasons, including unclear messaging,
language barriers, or differences in interpretation (Mañas et al., 2018). Miscommunication can

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lead to misunderstandings, errors, and conflicts within an organization. Lack of clarity in roles
refers to situations where employees do not have a clear understanding of their job
responsibilities, authority, and expectations (Mañas et al., 2018). Miscommunication, confusion,
and lack of clarity in roles significantly impact leadership efficiency and contribute to ambient
anxiety.
During my first year at Wellness Minds, the clinical manager and I had different job
titles. I was given the title of clinical manager, and they were given the title of operations
manager. We realized that our job titles did not align with our job responsibilities and that, in
fact, our titles would align better if we switched titles. I had mostly operational responsibilities
and they had clinical-focused responsibilities. We ended up switching job titles while our job
responsibilities remained unchanged. This led to considerable and understandable confusion
within the organization about who to approach for various issues. I felt immense guilt for not
knowing how to direct my subordinates. Additionally, there was some overlap in job
responsibilities between the clinical manager role and the operations manager role, contributing
to this confusion. This lack of clarity often resulted in us doing twice the amount of work, as it
was not clear who was responsible for what tasks. This issue was consistently highlighted in staff
feedback for over a year.
In an attempt to address the confusion, we created a “role guide” in our organization’s
manual (Figure 10) to help clarify responsibilities. However, confusion persisted, which felt
frustrating and contributed to the ambient anxiety I was already feeling.

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Figure 10
Role Guide Description in the Wellness Minds Leadership Manual
Note. Names of leadership team members are withheld to protect identity. Every blacked-out text
is a different name of a member of leadership.

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Charlie, an interviewee, also experienced significant miscommunication and confusion,
which adversely affected their leadership and efficiency. Charlie shared:
I sat in with one of our Illinois providers, who was receiving a fee decrease. They had
requested a meeting because they were nervous about a change in the company regarding
an adjustment of an expected average fee. I went into that meeting with my own
understanding of the situation. When they asked, “If the understanding is just to support
me, then why was I told that I will not receive a raise with my next contract renewal?” I
didn’t have an answer. I couldn’t support them.
According to Charlie, one of their direct reports asked to meet with them to understand the
reasoning behind an organizational change of adjusting clinician fees. Meanwhile, Charlie had
their own understanding of why this change was made, which was to support clinicians in
meeting their metric expectations. However, due to an unclear and undetailed understanding of
the reasoning behind this change, Charlie was unable to provide their direct report with an
answer.
These experiences highlight leaders’ struggles to support their teams effectively when
communication is unclear. This leads to increased anxiety, inefficiency, and overall
organizational dysfunction.
Organizational Priorities
Organizational priorities are impacted by ambient anxiety and affect leadership efficiency
in mental health organizations. Simultaneously, organizational priority factors such as budget
constraints and high client/patient caseloads significantly impact organizational efficiency and
also contribute to ambient anxiety. During my time at Wellness Minds, I was expected to
manage a caseload of 15 clients per week in addition to my operational responsibilities. By my

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second year, the company had tripled in size, making it increasingly difficult for me to maintain
this caseload while tackling my operational expectations. As a result, I extended my work hours
to manage the added workload, leading to errors in my deliverables and past-due task
assignments.
Jordan also encountered similar challenges at their organization. They noted, “People
would take on five clients, which doesn’t seem like a lot, but when you’re dealing with highacuity patients, it becomes just one more thing, leading to clinician burnout.” Jordan further
explained that the pressure to take on more clients was primarily driven by budget needs: “There
was always a push to ensure that all the patients were coming to the program because the
priority, the top thing was budget, budget, budget.” According to Jordan, when their organization
prioritized budget and monetary expectations, more clients were assigned to clinicians. As a
result, burnout among clinicians increased, affecting the quality of client care.
These experiences highlight the effects of prioritizing budget constraints and high
caseloads. When financial pressures force therapists to take on more clients than they can
effectively manage, it not only leads to burnout but also compromises the quality of care
provided to clients. This cycle of overwork and stress highlights the urgent need for balanced
caseloads and adequate support to maintain staff well-being, client satisfaction, and
organizational efficiency.
Leadership Fragmentation and Isolation
Leadership and organizational fragmentation and isolation impacted by ambient anxiety
affect leadership efficiency in mental health organizations. The pairing that took place within the
leadership team at Wellness Minds created a wedge between the paired-off couples (e.g., the

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CEO and COO, and the Clinical Manager and Operations Manager), making it difficult to create
a sense of cohesion within the team.
Charlie highlighted how ambient anxiety exacerbated existing gaps within the leadership
team, leading to increased feelings of separation. “I think it causes actually more separation
between the leadership team members and creates a rift between those making decisions. It tends
to lead to more separation, more talk among members, and ultimately more distance and
mistrust.” According to Charlie, ambient anxiety contributed to more distance between members
of the leadership team and more fragmentation between the leaders in charge of making
organizational decisions. This separation also led to fragmentation within the organization as a
whole, contributing to growing feelings of mistrust between leadership and team members.
Cameron also experienced heightened anxiety and self-doubt due to a lack of inclusion in
decision-making processes. The absence of transparency regarding the rationale behind decisions
fueled their uncertainty and sense of exclusion:
I think it can make certain people second guess what decisions they make in leadership
… so I think there are lots of worries about whether or not I’m making the right judgment
call. I would like there to be more transparency from the leadership end. Even being in
my leadership roles, I think there are still lots of things I don’t know and things I don’t
understand about the organization and why certain decisions are made.
According to Cameron, the separation between leadership members led to poor communication
from higher leaders about what decisions are made and why decisions are made. When decisions
were made without rationale being communicated to other leaders, Cameron experienced
feelings of worry and ambient anxiety. When leadership teams were divided and a lack of

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transparency took place, it created an environment of mistrust and anxiety, ultimately
undermining organizational efficiency and cohesion in their organization.
Professional Values
Professional values are impacted by ambient anxiety and affect leadership efficiency in
mental health organizations. Professional values refer to the principles, standards, and ethics that
guide behavior and decision-making within a particular profession. These values are fundamental
beliefs that shape how professionals conduct their work; interact with clients, colleagues, and
society; and uphold the integrity of their profession. Key aspects of professional values include
integrity, accountability, competence, confidentiality, respect, equity, and justice (Schwartz,
1992).
When I first joined Wellness Minds, the organization’s values closely matched my own.
With a small team of eight, there was a strong emphasis on minimizing corporate culture and
embracing an anti-capitalist mindset. However, as the organization expanded, it began to adopt a
more corporate hierarchy, with performance metrics that focused on the number of clients and
the average fees charged (Figure 11).

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Figure 11
Metric Expectations for Wellness Minds Clinicians
Note. A comparison of metric expectations between 2021 and 2022 at Wellness Minds.
By early 2023, I felt increasingly disconnected from the organization’s evolving values,
which triggered anxiety whenever leadership referenced the mission statement: “Our
commitment to tenderness, liberation, and community drives our inclusive therapy and coaching
framework for all identities. We are a values-based practice; think of us as more of a movement
than a business.”
Quinn, one of my interviewees in a leadership position, shared a similar experience. They
recounted feeling confused and anxious when the organization’s practiced values did not align
with its stated mission. Quinn explained:
It makes you feel like you can’t do your job … because people are coming to you, and
you’re in line with this mission statement, and that’s how people want to grow. I think

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culturally that’s something I’ve noticed too, as someone who my entire life has been very
liberal as a queer person, as maybe years ago, I would’ve considered myself radical, but
compared to Gen Z, I feel like I am conservative and there’s not space for me to actually
share how I feel … that it wouldn’t be accepted and it wouldn’t be safe.
According to Quinn, feeling unsafe in their work environment is keeping them from sharing any
misalignment of personal values. As a result, they experience feeling incompetent in their job,
making it difficult to lead their team.
The external pressures from political unrest also significantly contribute to ambient
anxiety. This is highlighted during my time at Health Alliance, a mental health organization
within a private university system in a predominantly White, affluent Midwestern city. During
my second year at the organization, the COVID-19 pandemic struck. In the summer of 2020,
Health Alliance leadership publicly supported the Black Lives Matter (BLM) movement and
related organizations. However, shortly after, I received a donation request in the mail from
Health Alliance, creating a sense of mistrust and apprehension. The contradiction of preaching
the support of BLM-related organizations and a private, White organization asking for donations
was unsettling.
Quinn also shared a similar experience when their organization remained silent after the
terrorist attack in Israel on October 7th, despite the organization’s reputation for speaking out
against violence and injustice. Quinn noted, “When the October 7th terrorist attack happened in
Israel, my organization was very quiet … colleagues were very upset by that silence after
October 7th.” This silence created significant psychological distress. Quinn elaborated, “It’s
walking on eggshells. It’s the elephant in the room that no one’s talking about.” According to
Quinn, when an organization remains silent about their values, it can lead to feelings of distress

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from the organization directed toward leadership. An organization that is known to be vocal
regarding morals and values, but does not speak out about their values when political unrest
arises, leads to unnamed disappointment circling within the organization.
The combination of social identity stress and cultural and political factors further
exacerbates ambient anxiety. Riley, a therapist who recently stepped into a leadership role,
discussed the pressure to take a stance on political unrest and to advocate for the
unacknowledged. Riley shared, “Within the profession, there are not a lot of Black therapists. As
a Black person … when thinking about ambient anxiety as it relates to my role as a clinician, I
often felt the pressure of advocating for different types of services.” This added external pressure
contributes significantly to the ambient anxiety experienced by individuals in similar positions.
Findings for Research Question Three
The third research question in this study is, how can leaders within mental health
organizations be supportive of therapists who experience ambient anxiety? This section details
organizational support for therapists. Organizational support for therapists experiencing ambient
anxiety is paired with personal anecdotes and interviewee experiences.
Support for Therapists Experiencing Ambient Anxiety
Support for therapists experiencing ambient anxiety includes organizational and
structural interventions, the humanization of leadership practices, emotional and psychological
support, and organizational culture interventions. All are discussed in the following sections and
paired with personal anecdotes and interviewee experiences.
Organizational and Structural Interventions
Organizational and structural interventions are one way to support therapists experiencing
ambient anxiety. These interventions refer to deliberate actions and strategies implemented by an

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organization to improve its overall functioning, address specific issues, and enhance the wellbeing and performance of its employees. These interventions often involve changes to policies,
procedures, structures, and practices to create a more supportive, efficient, and productive work
environment (Cummings & Worley, 2014).
Cameron shared that their organization created a DEI committee to improve efficiency
and effectiveness. “We’ve created a DEI committee that holds monthly meetings, and those
meetings are open to everybody to join to bring up their concerns and thoughts.” Charlie also
shared a similar format at their organization. “I think something that’s been working really well
… we’ve created a DEI committee that holds monthly meetings.” Training programs are
additional types of interventions aimed at supporting therapists that were shared by interviewees.
Jordan discussed a training they attended with the intention of mitigating anxiety and decreasing
levels of emotional exhaustion. “We did have a training one time on compassion fatigue, which I
think was an attempt on leadership to address ambient anxiety.”
Additionally, Riley shared that the formality of these training programs and
organizational structures (e.g., DEI committees) needs to be paired with the opportunity to create
an informal channel for feedback. They said, “There needs to be more channels for folks to just
take the mask off, and be themselves, and be open, and just to be honest, without the fear of their
job being at stake.” According to Riley, organizations need to provide their team members with
more opportunities to be vulnerable with leadership team members about how they are feeling.
Additionally, being vulnerable about your feelings with your leader should not compromise job
security.
While I was on the leadership team at Wellness Minds, we attended leadership retreats
aimed at creating cohesion within the team, to increase our efficiency and effectiveness. At my

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last leadership retreat, we engaged in a mixture of team activities that focused on having a
common goal (i.e., team-building exercises) while highlighting our individual strengths. This
gave room for more connection between team members, as we were actively given opportunities
to communicate our thoughts and feelings in a safe environment. I found that these types of
informal bonding experiences enabled us to humanize each other. As a result, we were able to be
more vulnerable and empathize with each other. This created a psychologically safe environment
for me to speak up and voice my opinions and concerns.
Humanizing Leadership Practices
Humanizing leadership practices are another way to support therapists experiencing
ambient anxiety. This refers to behaviors that prioritize the dignity, well-being, and development
of employees. These practices emphasize empathy, authenticity, respect, empowerment,
recognition, appreciation, inclusivity, and genuine concern for individuals; they recognize
individuals as whole persons rather than merely resources or means to an end. Humanizing
leadership seeks to create a positive and supportive work environment where employees feel
valued, understood, and motivated (Northouse, 2018). Humanizing leadership practices focus on
what connects us as human beings. For example, empathizing and leaning into the shared
psychological distress employees experienced during the COVID-19 pandemic, without
emphasizing the needs of the organization, would be a humanizing leadership practice.
In the fall of 2020, while I was employed at Health Alliance, I suffered an ectopic
pregnancy and needed to undergo emergency care. I had an extremely supportive clinical
supervisor with whom I shared this news. After I shared this vulnerable information with her, she
told me that my health needed to be the priority and that our clinical team would look after my
clients while I took medical leave. It decreased my anxiety significantly to hear this, and I was

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able to shift my focus to my health and wellness. To this day, I truly believe I would have quit
my job at that point if I didn’t have this supervisor’s support. The humanizing leadership she
modeled created more opportunities for effective and efficient care after I returned to work two
months later.
Morgan expressed something similar about how a relational dynamic in leadership led to
a greater working relationship.
I had two different direct supervisors or my managers as a manager. So for some time,
my manager was also the same person who served as CEO for the company. I felt like I
had a good working relationship with them. They had a very relational leadership style. I
felt like I could bring things to them, and when I did, they felt heard.
Riley also emphasized the importance of humanizing employees. “There needs to be
some just recurring moment remembrance of, oh yeah, we’re all just people who are also just
trying to figure this out.” These experiences highlight the relational dynamics within leadership
teams, emphasizing good working relationships, support among team members, and cohesive
interactions.
Emotional and Psychological Support
Providing emotional and psychological support is another way to support therapists
experiencing ambient anxiety. This recommendation includes implementing emotional and
psychological support through peers, both professional and otherwise. Peer support refers to the
process of giving and receiving non-professional, non-clinical assistance. This support is
provided by individuals who have similar experiences and have undergone similar struggles.
Peer supporters have shared personal experiences with the same issues faced by those they are

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helping, allowing for mutual understanding and empathy. Appropriate forms of peer support may
include support groups and one-on-one peer support.
Several interviewees shared how having peer support impacted their team wellness,
cohesion, and productivity. Sam shared, “If I want to address it head-on, I’ll just talk to other
friends about it, and maybe have them help remind me of the value that I or my team brings to
the company.” Quinn also shared, “[My manager] will check in with me if he’s walking by my
office. He’ll be like, ‘Hey, how are you doing?’ And because he’s built that relationship, I feel
like I can be honest with him about some things.” Morgan touched on this as well. “I think
relationally, I’m very close with several members of the leadership team, and we try to support
each other in different ways.”
These anecdotes illustrate the significant impact of peer support in fostering a supportive
and cohesive work environment. When employees feel understood and supported by their peers,
it enhances their psychological safety, reducing feelings of isolation and stress (Northouse,
2018). This mutual support system enables individuals to process their experiences more
effectively, leading to improved mental health and resilience. Furthermore, maintaining close
relationships and open communication channels within the team promotes a culture of trust and
collaboration (Northouse, 2018). Regular check-ins by peers and managers not only provide
emotional support but also help identify and address issues early, preventing them from
escalating. Integrating peer support into mental health organizations creates an environment
where employees feel valued and empowered, ultimately enhancing overall team productivity
and well-being. This approach aligns with Bandura’s (2001) social cognitive theory, which
emphasizes the importance of social support and observational learning in shaping behavior and
improving psychological outcomes.

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Additionally, stress and anxiety management strategies are another way to support
therapists experiencing ambient anxiety. This recommendation is for stress management
strategies in the form of coping techniques and personal development. Stress management
strategies are techniques and approaches used to help individuals cope with, and reduce the
negative effects of, stress and anxiety. These strategies aim to both enhance an individual’s
ability to handle stress effectively and improve overall well-being. They may help individuals
alleviate feelings of worry, fear, and apprehension, and may improve overall mental health
(Porges, 2022).
In my experience, maintaining my wellness was necessary in order for me to provide
ethical and effective care. When I realized that my health or psychological well-being hindered
my ability to care for clients, it was necessary for me to prioritize coping strategies that I knew
would support my physical and mental health. Many interviewees shared their experiences with
stress and anxiety management strategies and their impact on their organizations. For example,
Quinn noted, “Some policies of sick time are now called holistic health time. So you can take it
off for sick as well as mental health.” This shift in policy highlights an organizational
commitment to recognizing and addressing mental health needs alongside physical health,
fostering a supportive environment for staff well-being. Riley shared, “I tried to be a lot more
honest about my general capacity. I’m trying to not only name what my capacity is with folks on
the leadership team, but also trying to be up-front about changes in our workflows and additional
support for our well-being.” Riley’s approach emphasizes the importance of transparent
communication, and of proactive adjustments in workflows, to support mental health.
Additionally, Charlie shared some of their personal coping strategies: “A lot of deep breathing, a
lot of tending to myself and my nervous system in ways that I know helps, so coping tools,

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tuning into the senses, finding a mantra that helps me ground.” These individualized strategies
highlight the effectiveness of practical coping mechanisms, tailored to personal needs, in
managing stress.
These experiences illustrate that implementing a variety of stress management strategies
within mental health organizations can significantly mitigate ambient anxiety. Policies
acknowledging mental health needs, open communication about capacity and workflow
adjustments, and personal coping techniques like deep breathing and grounding practices
collectively contribute to a healthier work environment (Porges, 2022). By adopting these
strategies, mental health organizations can create a culture that supports employee well-being,
reduces stress and anxiety, and ultimately enhances the quality of care provided to clients.
Integrating these stress management strategies aligns with Bandura’s (2001) social cognitive
theory, which supports that individuals learn and adapt through interactions with their
environment. By providing employees with effective coping mechanisms and supportive
policies, organizations can foster a resilient workforce capable of handling stress and anxiety
more effectively. This holistic approach not only improves individual well-being but also
contributes to a more productive and cohesive organizational culture (Northouse, 2018).
Organizational Culture Intervention
Organizational culture intervention is another way to support therapists experiencing
ambient anxiety. According to Schein (2017), ambient anxiety contributes to resistance to
change, as a series of fears leads anxious groups and organizations to inefficient and ineffective
organizational activity. Acknowledgment of these change factors from leaders gives
organizations more opportunities to become proactive by reframing unhelpful and unconscious
systemic thinking (Schein, 2017). To sum up, in order to initiate and execute organizational

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change, the system as a whole must be acknowledged before an attempt to restructure is made
(Frye, 1983). The recommended three-part intervention addressing systemic change includes the
following: 1) raise awareness (unfreeze), 2) shift focus to team relationships (overt change), and
3) foster new culture (refreeze).
Step One. Step One includes raising awareness within an organization, also known as the
unfreeze stage (Schein, 2017). Ambient anxiety manifests when a group/ organization feels
“threatened.” This occurs at an unconscious level, leading individuals to defend themselves
against anxieties. As defenses rise, group work is weakened and will likely discontinue
organizational change and efficiency (DeBoard, 2014). “Group-level” evaluation or assessment
is needed, as sociocultural factors, such as stereotype threat, influence a group’s effectiveness
(McRae & Short, 2010). Making these differences conscious, while creating space to talk openly
about these differences, can be used to combat an organization’s need to shift to defensive mode
and can help it transition to work mode (Berzoff et al., 2016). Once-per-month or biweekly
meetings, facilitated by group relations experts/ consultants, can raise awareness around
organizational group dynamics. Once-per-month check-ins dedicated to addressing ambient
anxiety experienced in the organization can also be implemented. Optional psychological support
can also be provided by the organization.
Step Two. Step Two includes shifting focus to team relationships, also known as overt
change (Schein, 2017). Group dynamics research has shown that groups and organizations with
the most apparent change had a greater ability to relate to others within the group/ organization,
increased interdependence, greater acceptance of others within the group/ organization, and
overall elevated levels of insight related to an individual’s role (DeBoard, 2014). Cultural
identity can be understood from an individual’s subjective view and may contribute to a group

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member’s inability to join, or connect, with the group/ organization out of fear of needing to
identify with one specific identity while dismissing other identities (McRae & Short, 2010). An
individual’s performance process is influenced by stereotype threat (Schmader et al., 2008). In
addition to once-per-month or biweekly meetings (suggested above), optional identity seminars
can be implemented. Identity seminars are short meetings dedicated to understanding employees’
identities and cultures.
Step Three. Step Three includes fostering a new culture, also known as refreeze (Schein,
2017). “Refreeze” means to internalize new behaviors, including incorporating these new
behaviors into an individual’s identity and relationships (Schein, 2017). When a group accepts
that a shift has occurred toward fostering a new organizational culture, they are much more likely
to work themselves out of conflict and to become productive in executing a task (DeBoard,
2014). Fostering a new culture is refusing to let difficulties and conflicts get in the way of
progress (Kotter & Cohen, 2002). It requires consistent dedication to raising awareness of
organizational dynamics, to work towards a common goal. Toward this end, annual and biannual
meetings dedicated to macro-level reflection on relational goals and organizational goals can be
implemented. These may include retreats, seminars, workshops, and/or informal bonding time.
Addressing ambient anxiety requires a multifaceted approach, including clear
communication, alignment of values, supportive organizational culture, and humanizing
leadership practices. These interventions can help create a more supportive, cohesive, and
efficient work environment, ultimately improving the well-being of mental health professionals
and the quality of care provided to clients.

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Summary
This chapter introduced participants and detailed study findings. Three research questions
were answered: 1) How does ambient anxiety manifest in mental health organizations? 2) How
does ambient anxiety in leadership teams affect efficiency in mental health organizations? 3)
How can leaders within mental health organizations be supportive of therapists who experience
ambient anxiety? Various manifestations of ambient anxiety, including physical and emotional
responses, dismantling of group dynamics, communication challenges, and stress and burnout,
were paired with personal anecdotes and interviewee experiences. Ambient anxiety’s impact on
decision-making processes, clarity of communication, organizational priorities, fragmentation of
leadership teams, and professional values were also paired with personal anecdotes and
interviewee experiences. Lastly, support for therapists experiencing ambient anxiety was
discussed. Organizational and structural interventions, the humanization of leadership practices,
emotional and psychological support, and organizational culture interventions were supported by
anecdotal evidence and interviewee experiences.

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Chapter Five: Discussion and Recommendations
This chapter discusses the findings from Chapter Four and provides my three
recommendations as a participant and researcher. The discussion begins by exploring what my
expectations were going into the study. It then develops into a discussion of the findings listed in
Chapter Four. Organizational interventions, including structural interventions, humanizing
leadership practices, and emotional and psychological support in the form of stress and anxiety
management strategies, are reviewed, with learning points and a supplementary reflection from
the researcher’s perspective. Chapter Five concludes with recommendations for future research.
Discussion
Initially, I started this research study because I believed that mental health organizations
run by therapists should prioritize the psychological well-being of the therapists and the
organization as a whole. From my personal experience, organizations were not doing enough to
address feeling-based conflict in organizational dynamics. I felt like nobody was taking time to
pause and ask, “What’s going on here?” There is some irony in questioning how uncomfortable
feelings felt by therapists impact their work and efficiency. After conducting this research study,
I now realize that while a mental health organization represents psychological wellness, it is, in
the end, a business. Therapists are not business people. They are therapists by training. A
therapist with expert business education is rare, and this study suggests that that might be what
mental health organizations need to mitigate ambient anxiety and run a successful business with
contented therapists. The needs of the business must be balanced with the needs of the
individuals running the business.
Usually, there is a minimal hierarchal dynamic present between therapists (e.g., therapists
new to the field versus seasoned professionals, clinical supervisors versus supervisees, etc.). For

97
the most part, all therapists have equal power in an organization. The horizontal hierarchy, or a
hierarchy with minimal levels of authority, shatters when a secondary role is added (e.g.,
operations manager and therapist, COO and therapist, etc.). It is important to note that
organizations that internalize a medical model or a more traditional organizational model are
different from those that internalize a therapeutic model. Medical models (i.e., hospitals and
universities) emphasize a top-down hierarchy, while therapeutic models (i.e., private practice)
model a horizontal hierarchy, giving equal power across clinicians. The findings of this study
show that ambient anxiety experienced in mental health organizations by therapists in leadership
roles is triggered by the secondary role, the hierarchical role. Other factors that could also
implicitly affect dynamics should be considered, such as gender, race, age, etc.
Bandura’s (2001) social cognitive theory, which emphasizes the reciprocal interactions
between personal factors, environmental influences, and behavior, focuses on how ambient
anxiety affects individuals and organizational dynamics in mental health settings. This theory
showed up in my findings. For example, organizational changes such as role changes and a
growing team (environmental factors) triggered ambient anxiety (personal factors). Ambient
anxiety (personal factors) triggered communication challenges (behavior). Emotional and
psychological support (behavior) triggered safety in communication with leadership (personal
factors). Using this theory as a framework shows that any change to ambient anxiety will result
in a change in environmental influences and/or behavior.
According to this study’s findings, ambient anxiety leads to significant physical and
emotional reactions among mental health professionals. My personal anecdote from my
experience at Wellness Minds, much like Charlie’s and Jordan’s experiences, highlights the
body’s reaction to perceived threats. The organizational culture of pairing and complex team

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dynamics also influenced levels of ambient anxiety. This aligns with Schein’s (2017) definition
of organizational culture and its impact on behavior and interactions within an organization. The
basic assumption groups and perceived “marriages” within the leadership team created an
environment of isolation and fear, exacerbating feelings of burnout and anxiety. Additionally, the
misalignment between personal and organizational values, coupled with external political and
social pressures, contributed to ambient anxiety. Interviewees like Quinn experienced confusion
and anxiety when organizational practices did not align with stated values (environment), leading
to a sense of disconnection (personal factors). Political unrest, such as the organization’s
response (or lack thereof) to significant events like the October 7th terrorist attack
(environment), further heightened anxiety and mistrust among employees (personal factors).
Lastly, communication breakdowns and misunderstandings also contributed to ambient anxiety.
The lack of clear communication regarding deliverables and role expectations (environment)
created a sense of powerlessness and fear of making mistakes (personal factors). Interviewees
like Charlie and Morgan highlighted the importance of clear communication and reassurance to
mitigate anxiety and foster a supportive environment.
According to my findings, ambient anxiety impacts the efficiency and effectiveness of
mental health organizations. Interviewee Charlie experienced how ambient anxiety (personal
factors) led to rushed decision-making processes (behavior), resulting in sub-optimal outcomes
(environment). The pressure to quickly address external issues diverted attention from essential
clinical work, impacting the quality of care provided to clients. This aligns with Bandura’s
(2001) social cognitive theory, in which environmental stressors influence behavior and
decision-making, creating a cycle of anxiety and inefficiency. Additionally, miscommunication
and role ambiguity significantly impacted leadership efficiency. The frequent changes in roles

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and responsibilities without clear communication led to confusion and inefficiency. This lack of
clarity and support from leadership teams exacerbated ambient anxiety, hindering effective team
functioning. Budget constraints and high client caseloads placed immense pressure on therapists,
leading to burnout and decreased quality of care. Employees like Jordan experienced the effects
of emphasizing financial targets over well-being (environment), creating stress and overwork
(personal factors), and compromising both staff and client well-being (behaviors). Fragmented
leadership teams and a lack of transparency created mistrust and isolation among team members.
Interviewees Cameron and Charlie experienced the absence of cohesive decision-making
processes and inclusion (environment), leading to increased anxiety and inefficiency (personal
factors and behavior), further impacting organizational effectiveness (behavior and
environment). High expectations and emotional exhaustion contributed to burnout among
therapists. The pressure to meet performance metrics and financial targets shifted the focus from
quality care to quantity, leading to increased anxiety and compromised patient care.
Also, the findings of this study show that support for therapists experiencing ambient
anxiety involved organizational and structural interventions. The interviews with Cameron and
Riley demonstrate that implementing DEI committees and training programs aimed at addressing
compassion fatigue and promoting inclusivity can help mitigate ambient anxiety. However, these
formal structures need to be paired with informal channels for feedback and support to create a
psychologically safe environment for employees. Additionally, empathetic and relational
leadership practices are crucial in supporting therapists experiencing ambient anxiety.
Interviewees like Morgan attested that supervisors who prioritize the well-being and dignity of
employees (behavior), as seen in the support provided during personal crises, can significantly
reduce anxiety (personal factor) and foster a positive work environment (behavior). Bandura’s

100
(2001) theory emphasizes the role of supportive environments in shaping behavior and emotional
well-being, highlighting the importance of humanizing leadership practices.
While many of the interviews provided data supporting the purpose of this study, not
every interview bore fruit. Quotes and data were not pulled from the interview with Avery.
While Avery provided helpful data for understanding mental health organizations, their
information did not align with the overarching findings. This was mostly due to the unique
organizational structure of Avery’s organization, which splits off into several smaller teams
versus a smaller number of bigger teams.
This study’s findings highlight the impact of ambient anxiety on mental health
professionals and organizational dynamics. When Bandura’s (2001) social cognitive theory is
integrated, it becomes evident that the reciprocal interactions between personal experiences,
environmental stressors, and organizational behavior create a cycle of anxiety and inefficiency.
The following section discusses my three recommendations for organizational interventions.
Recommendations
Three recommendations based on Chapter Four findings are discussed in this section.
Organizational interventions, including structural interventions, humanizing leadership practices,
and emotional and psychological support, are detailed. Examples of these recommendations are
explained, along with a supplementary reflection from the researcher’s perspective. Table 3
outlines each recommendation and links it to its respective findings from Chapter Four.

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Table 3
Summary of Findings and Recommendations
Research Question Findings Recommendations
How can leaders
within mental health
organizations be
supportive of
therapists who
experience ambient
anxiety?
Organizational and
structural
interventions
Diversity, equity, and inclusion (DEI)
committees, supplementary clinical training
programs, and leadership development
Informal and “lower-stakes” opportunities to
engage with leadership
Humanizing
leadership practices
Relational focus
Practicing self-care, boundaries, work-life
balance, and wellness
Emotional and
psychological support
Implementing emotional and psychological
support through peers
Coping techniques and personal development
Stress management strategies are techniques
Recommendation One: Organizational and Structural Interventions
The first recommendation to support therapists experiencing ambient anxiety, detailed in
Chapter Four, is organizational and structural interventions. These interventions refer to
deliberate actions such as changes to policies, procedures, structures, and practices to create a
more supportive, efficient, and productive work environment. These strategies target an
organization’s overall function, address specific issues, and enhance the well-being and
performance of its employees (Cummings & Worley, 2014).
Diversity, equity, and inclusion (DEI) committees, supplementary clinical training
programs, and leadership development (e.g., leadership retreats, leadership meetings, and
leadership exercises) are helpful interventions in mental health organizations that were shared by
participants in this study. Additionally, a participant suggested informal and “lower-stakes”

102
opportunities to engage with leadership. Specifically, a possible key factor for clear and honest
communication within an organization that participants mentioned was vulnerability expressed
with and by leadership, without fear it may compromise job security. By implementing these
interventions, organizational culture has a greater opportunity to thrive, while increasing
channels of communication between leadership and team members. Additionally, these
interventions may close the gaps created by any fragmentation within leadership and create a
more cohesive working environment.
Both this study and my personal experience show that greater efficiency and decreased
levels of mental distress (in the form of ambient anxiety) occur in organizations that focus on the
relational aspect of team building as well as on the clinical work itself. My biggest takeaway
from one of my classes in my doctoral program came from Dr. Anthony Maddox: “People invest
in people. Not products” (personal communication, 2021). This highlights the importance of
social connection and demonstrates why investing in team dynamics should be prioritized.
Recommendation Two: Humanizing Practices by Leadership
The second recommendation to support therapists experiencing ambient anxiety, detailed
in Chapter Four, is humanizing leadership. Humanizing practices refer to behaviors that
prioritize the dignity, well-being, and development of employees. These practices also highlight
empathy, authenticity, respect, empowerment, recognition, appreciation, and inclusivity
(Northouse, 2018). Generally, humanizing leadership practices focus on what connects us as
human beings. As discussed in Recommendation One (Organizational and Structural
Interventions), focusing on social connections and individuals is key in supporting therapists
experiencing ambient anxiety. These humanizing practices need to be practiced by leaders, as
they serve as models for the organization.

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Several participants shared that being a part of a relational-focused organization was an
important factor in fostering the relationships within their respective organizations. I, too,
expressed gratefulness for the way leadership showed up for me during a difficult time for my
mental and physical health. I’ve learned it’s important for leaders, first and foremost, to meet
their team as humans. Care and consideration of the well-being of team members sends an
important message that we, collectively as humans, are the priority. Mental health organizations
are populated by clinicians and clients alike who are actively practicing self-care, boundaries,
work-life balance, and wellness. It only makes sense that the organization itself also follows
these practices.
This recommendation can be broken down into two steps. Firstly, stay mindful of who is
responsible for hiring. When a team is being built, you’re looking for skills beyond clinical
skills. It’s important to invest in the individuals that make up a team. Staying mindful of what
these clinicians represent and what they can bring to the table that is unrelated to their clinical
background needs to be made a priority. Secondly, it’s a big ask to encourage team members to
share these parts of themselves because the status quo is not asking your employees to be
vulnerable with that information. The establishment of trust needs to be folded into onboarding
training in order to create psychological safety and potentially model this kind of vulnerability.
Ultimately, the goal is to create a sense of belonging in the organization.
Recommendation Three: Psychological Support for Every Individual
The third recommendation to support therapists experiencing ambient anxiety, detailed in
Chapter Four, is emotional and psychological support. This recommendation focuses on
implementing emotional and psychological support from peers (both professional and
otherwise), therapists, support groups, etc., for every individual in an organization. Peer

104
supporters have shared personal experiences with the same issues faced by those they are
helping, allowing for mutual understanding and empathy. Concurrently, therapists should feel
encouraged to seek out therapy on their own. Personal therapy can be beneficial for personal and
professional life.
This third recommendation can also come in the form of coping techniques and personal
development. Stress management strategies are also a form of coping. Stress management
techniques and approaches must be used to help individuals cope with, and reduce, the negative
effects of stress and anxiety (American Counseling Association, 2023). These strategies aim to
enhance an individual’s ability to handle stress effectively and to improve overall well-being.
They may help individuals alleviate feelings of worry, fear, and apprehension, and may improve
overall mental health (Porges, 2022). In this study, stress and burnout were the main
psychological impacts of ambient anxiety on organizational efficiency. Targeting emotional
factors like stress and burnout, coupled with providing psychological support before ambient
anxiety rises, will prevent the chances of organizational efficiency from increasing. Prevention
techniques may include active practice of coping strategies while emotions are stable. Practicing
while emotions are not heightened allows for a greater opportunity to clock when an emotional
shift takes place. Individuals can then address any contributing factors before heightened levels
of distress occur (American Counseling Association, 2023).
Recommendations for Future Research
To further address ambient anxiety in mental health organizations, future research should
utilize larger and more diverse samples to enhance the findings. Studies should be conducted in
various settings, such as inpatient and outpatient settings, to determine if results are consistent
across different environments and populations. Additionally, researchers should find ways to

105
expand Bandura’s (2001) social cognitive theory, or create a theory designed to investigate the
impact of specific constructs on the problem of practice (e.g., capping clinical caseloads at a
specific number of clients and monitoring the outcomes). It is important to consider new
variables that may influence outcomes, using a quantitative component such as subjective units
of distress (SUDs), to measure ambient anxiety. Implementing longitudinal research designs will
help examine the evolution of this problem over time. Incorporating participant feedback will
also ensure that future studies effectively address their needs and concerns. It is crucial to
continue to refine and enhance ethical considerations and practices, as this study and future
studies involve a secondary population, clients/ patients.
Conclusion
In this study, I explored the intricate dynamics of ambient anxiety within mental health
organizations and its impact on organizational efficiency. The irony of psychological turbulence
taking place in an organization that provides psychological care was a key factor in my choice to
focus on mental health organizations. By integrating the theoretical framework, Bandura’s
(2001) social cognitive theory, I was able to put language to the chaos, leading to further
understanding of how and why ambient anxiety exists in organizations. The findings of this
study shed light on the manifestations of ambient anxiety—ranging from physical and emotional
responses to organizational culture and communication challenges. This study impacts mental
health organizations that strive to create supportive and efficient work environments by offering
them practical insights and recommendations. Recognizing the symptoms of ambient anxiety,
and understanding where it comes from, permits leaders to implement targeted interventions
such as peer support, stress management strategies, and organizational culture shifts. These
measures can significantly enhance the well-being of mental health professionals, leading to

106
greater client/ patient care and overall organizational efficiency. The significance of this study is
that it can lead to greater group dynamic awareness and organizational competency. As mental
health organizations continue to navigate the complexities of providing care in an ever-changing
socio-political world, it becomes increasingly critical for them to understand and mitigate
ambient anxiety. The importance of this study lies in its potential to catalyze change, driving a
shift towards more resilient and supportive mental health organizations.
This theory is applicable across many fields. It’s multidimensional if we have the
language for it. Integrating systems training in onboarding and organizational culture doesn’t
have to be limited to mental health organizations. Ambient anxiety is everywhere, and its
visceral nature is hard to escape. For me, rigidity in systems towards change felt like a slap in the
face everywhere I turned. This study shows that I’m not alone in this feeling.
As I reflect on being both a participant and a researcher in this study, it strikes me how
valid the many emotions I felt in my younger years truly were. Now, they make sense. I can link
the chaos of a restaurant on the beach to thoughts of incompetence. I understand that when
leadership changes roles, change anxiety trickles down into the organization. It makes sense to
me that deep empathy with a movie character shared by a theater full of people can lead to
sobbing. If, in the end, this study was created only to validate the emotions of seven-year-old
Taylor, that’s OK. If, though, it creates a possible future where curiosity leads to greater
organizational change and efficiency, that’s optimal and more fulfilling. After all, I am a
therapist. And I’m so sensitive.

107
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Appendix A: Interview Protocol
Research Questions:
1. How does ambient anxiety manifest in mental health organizations?
2. How does ambient anxiety in leadership teams affect efficiency in mental health
organizations?
3. How can leaders within mental health organizations be supportive of therapists who
experience ambient anxiety?
Respondent Type:
Survey participants will be clinical mental health therapists in leadership roles at mental health
organizations.
Introduction to the Interview:
Thank you for taking time out of your day for this approximately 45-minute interview. My name
is Taylor Mizuno-Moore, and I am a doctoral student at USC. I am interested in investigating
ambient anxiety within leadership teams and its impact on organizational efficiency. I am
interested in how anxiety is experienced by leaders in mental health organizations.
Some of the questions I am about to ask you might create an uncomfortable emotional response.
This is normal. We may pause and take a break at any point during the interview. We can always
skip a question if something is too difficult to discuss. Do I have your permission to participate in
the interview?
We are conducting this interview via Zoom. I will not disclose your name or any other personal
identifiable information (PII). All information will remain confidential. I will be using
pseudonyms in place of your real name. I’ll also use a transcript service called Rev (Rev.com) to
transcribe this recording to better analyze the data collected.
Do you have any questions about this interview, prior to me beginning the recording? (Answer
questions accordingly)
Do I have your permission to record this interview? (If the answer is yes, then continue)
I will go ahead and begin recording now.

115
Table A1
Interview Questions
Interview Questions Potential Probes RQ
Addressed
Key Concept
Addressed
1. Tell me a bit about your
role/job.
What organization do you
work at, what do you do,
and how long have you
been doing it?
Introduction
2. Tell me about a typical
day for you at X
organization.
Introduction
3. I would like to know
more about how you
personally identify. Tell
me about your identity.
How do you identify (race,
ethnicity, gender, age,
spirituality)?
Explore
participant’s
relationship with
identifiers.
4. Tell me about your
experience in the field
as someone who
identifies with these
identifiers.
Allow the
participant to
explain how these
identifiers are
experienced in a
work environment.
5. Tell me about your
relationships with other
members of your
leadership team.
Are you closer to members
of your leadership team
than others?
Are you more distant with
members of your
leadership team than
others?
Give the participant
the opportunity to
explain their
relationships with
individuals on their
leadership team.

116
6. My definition of
ambient anxiety is a
response to perceived
danger or anticipated
danger that comes from
the environment that
may manifest
physically, cognitively,
or emotionally. Have
you ever experienced
ambient anxiety?
Have you experienced
ambient anxiety within
your leadership team?
RQ1
Clarify if the
participant has or
has not experienced
ambient anxiety.
7. How often do you
experience ambient
anxiety within your
leadership team?
If so, how did you manage
it?
RQ1
Give the participant
an opportunity to
connect ambient
anxiety with the
leadership team.
8. What does efficiency
mean to you at your
organization?
Has ambient anxiety
within your leadership
team affected your
individual efficiency at
your organization?
RQ2 Clarify efficiency.
9. Has ambient anxiety
within your leadership
team affected your
individual efficiency at
your organization?
What did this look like? RQ2
Understand how the
participant
experiences
efficiency.
10. Tell me about a time, if
ever, when you noticed
your ambient anxiety
influencing your
efficiency.
RQ1
RQ2
Connect ambient
anxiety to
efficiency.
11. What, if any, are the
barriers preventing you
from achieving desired
performance outcomes?
RQ2
Give the participant
the opportunity to
identify barriers to
efficiency.

117
Conclusion to the Interview:
(name of participant), thank you very much for sharing your thoughts and insights. Your
participation is appreciated and will inform organizational efficiency in the future. You’ll be
notified of the research results after the completion of this research study.
(end recording)
12. Is anxiety or ambient
anxiety a topic of
conversation within
your leadership team?
Are there policies and
procedures in place to
address it if/when it comes
up? RQ1
Give opportunity
for the participant to
explore current
organizational
interventions to
anxiety.
13. Tell me about a time, if
ever, when you noticed
ambient anxiety within
the leadership team
influenced a leader’s
efficiency.
How did you respond?
Were you able to connect
this experience to ambient
anxiety?
RQ1
RQ2
Connect ambient
anxiety within a
leadership team to
efficiency.
14. What, if any, forms of
support could you
benefit from in terms of
managing ambient
anxiety?
RQ3
Give the participant
an opportunity to
name helpful
ambient anxiety
interventions.
15. In what ways, if any
could you feel
supported specifically
by leaders in your
organization when you
experience ambient
anxiety?
RQ3
Give the participant
an opportunity to
name helpful
ambient anxiety
interventions from
leaders.

118
Appendix B: A Priori Coding Template
Table B1
Coding Template
Research Question
Area of Conceptual
Framework
(a priori code)
Code
(thematic codes)
1. How does ambient anxiety
manifest in mental health
organizations?
Environmental Factors
Psychological Factors
Behavioral Factors
2. How does ambient anxiety
in leadership teams affect
efficiency in mental health
organizations?
Environmental Factors
Psychological Factors
Behavioral Factors

119
3. How can leaders within
mental health organizations
be supportive of therapists
who experience ambient
anxiety?
Environmental Factors
Psychological Factors
Behavioral Factors

Abstract (if available)

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Asset Metadata

Creator Mizuno-Moore, Taylor (author)

Core Title Ambient anxiety within leadership teams and its impact on organizational efficiency in mental health organizations

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2024-08

Publication Date 09/09/2024

Defense Date 08/28/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag Anxiety,efficiency,leadership,mental health,mental health organizations,OAI-PMH Harvest,organizational change

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Kim, Esther (committee chair), Canny, Eric (committee member), Tobey, Patricia (committee member)

Creator Email mooretay@usc.edu,taylor@mizunoconsulting.com

Unique identifier UC11399AJWN

Identifier etd-MizunoMoor-13504.pdf (filename)

Legacy Identifier etd-MizunoMoor-13504

Document Type Dissertation

Format theses (aat)

Rights Mizuno-Moore, Taylor

Internet Media Type application/pdf

Type texts

Source 20240910-usctheses-batch-1210 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu