Editor’s note (Feb. 2, 2023): A majority of Resilience Lab clinicians voted in favor of unionization. The mail-in vote was counted by the National Labor Relations Board on Feb. 1. The clinicians will be represented in collective bargaining efforts by District Council 37 of the American Federation of State, County & Municipal Employees.
Unprecedented changes and long-simmering labor challenges make the behavioral health industry fertile ground for unionization efforts.
Notably, New York City-based Resilience Lab may be the first of the venture-backed startups to the behavioral health market to see its workforce unionize. The clinicians of the mental health provider are in the midst of a mail-in unionization effort.
The Resilience Lab case fits into broader trends in the behavioral health sector and the American economy. For the last few years, unionization has enjoyed increased popularity as workers at some of the planet’s largest companies turn to organized labor to address their grievances. The company is a software-focused outpatient mental health provider that offers care in person and via telehealth.
“Unions are enjoying a tremendous amount of momentum that they have not seen in a very long time,” J. Trent Scofield, a near-30-year-veteran labor attorney with Baker, Donelson, Bearman, Caldwell & Berkowitz PC, told Behavioral Health Business.
The highest-profile examples in 2022 were movements among workers at Starbucks (Nasdaq: SBUX) and Amazon.com Inc. (Nasdaq: AMZN).
The U.S. National Labor Relations Board (NLRB) sent mail-in ballots to the full-time and part-time mental health practitioners employed by Resilience Lab on Dec. 29, 2022. The ballots must be received by an NLRB regional office by Jan. 26 to be counted on Feb. 1.
The co-founders maintain that clinicians prematurely jumped to unionization to address their frustrations. They also say unionization would hobble Resilience Lab’s potential and jeopardize its future as an employer of therapists.
The unionization efforts are in response to how the company has handled significant business decisions, including rejigging how providers get paid, according to current and former employees interviewed by BHB. Sources also question the company’s growth strategy and its similarity to other tech-focused mental health startups.
“Human service workers are at the forefront of the mental health crisis in New York and the U.S., and it’s essential these clinicians be given the support they need to provide the best care to their patients,” Henry Garrido, District Council 37 executive director, said in a statement. “We intend to secure a strong contract for Resilience Lab that sets a high bar across the telehealth industry.”
Resilience Lab clinicians have engaged with District Council 37 of the American Federation of State, County & Municipal Employees (AFSCME), which is affiliated with the American Federation of Labor and Congress of Industrial Organizations (AFL-CIO). Resilience Lab management has retained legal counsel and has apparently engaged St. Louis-based Greer Consulting Inc., which helps companies “overcome their internal struggles in order to remain union-free while improving productivity and profits,” according to its website.
Should the clinician vote in the majority to form a union, District Council 37 will begin the collective bargaining efforts. The organization maintains that should Resilience Lab unionize, it would be the first of its kind.
“Did this come out of the blue? Yes,” Resilience Lab co-founder and CEO Marc Goldberg told BHB. “Should we have done a better job at communicating with our teams? Yes, absolutely. Are we accountable for the result? Yes. Did we ever envision that this was going to develop that way? Of course not.”
The rise in union popularity and therapist frustration
Some level of simmering discontent between workers and employers at all levels and industries over the last few years has led to the phenomena of “quiet quitting” and “quiet firing.” These passive modes of separation feature unresolved issues causing disengagement and eventual decoupling at the individual and, potentially, collective levels.
In behavioral health, the workforce picture is rather grim.
Layoffs defined last year in large part. And the pressures of finding and retaining staff, especially low-wage frontline workers, worsened with wage and consumer price inflation. These largely COVID-driven pressures worsened the existing shortage of behavioral health providers of all types in the U.S.
While some federal rule changes seek to work around the edges of the shortage, the imbalance between the demand and supply of behavioral health providers, especially those with high levels of training and education, remains.
Between the shortage and competition with other industries for workers, employees collectively have the advantage over employers.
“They know that they have the power to shut places down. They have the power to negotiate,” Matthew Burr, the owner of Burr Consulting LLC and human resources consultant, told BHB. He is also a mediator and fact-finder for the State of New York.
Burr also noted an increased interest in union activity after concerted efforts in the 1970s and 1980s to tamp down unions. He mentioned notable events such as the air traffic controller strike. Over the last 40 years or so, right-to-work laws have made a measurable difference in union participation.
But today, unions haven’t been this popular since 1965. The polling company Gallup finds 71% of Americans approve of unions, up 23 percentage points from a historic low of 48% in 2009, the depths of the Great Recession.
Union members told Gallup that better pay and benefits (65%), employee representation (57%) and job security (42%) were the top three reasons they joined a union.
Non-union members have a strong antipathy toward membership — 58% of Gallup poll respondents had no interest in union membership.
Union membership lags way behind the rise in popularity. However, that may change.
The NLRB announced in December that unionization applications increased by 25% in the fiscal year 2022, the largest single-year increase since fiscal 1976 and the largest percentage increase since the fiscal year 1959. The recently passed omnibus bill also increased the NLRB’s budget for the first time since 2014.
The U.S. Bureau of Labor Statistics recently found that union membership among workers fell to 10.1% in 2022, a 0.2 percentage point decrease from 2021 and the lowest rate on record since BLS’ recordkeeping on the matter started in 1983.
Union activity in the health care sector, including strikes, will likely continue at high rates going into 2023, according to Modern Healthcare which pointed to a continuation of several issues spilling over from 2022.
In October, Kaiser Permanente reached a new agreement with 2,000 mental health staffers in Northern California after a 10-week strike.
The organization, one of the nation’s largest health insurance and health care providers, is still facing an ongoing dispute in Hawaii. Kaiser Permanente’s mental health employees started a strike at the end of August.
At the end of 2022, Hawaii Sen. Mazie Hirono and other high-profile Democrat senators — including Elizabeth Warren, Bernie Sanders and Ron Wyden — sent an open letter to Kaiser Permanente pressuring leaders to stop “engaging in years-long contract disputes.”
Frustrations of Resilience Lab providers
Unionization efforts tend to pop up in times of discontent when workers feel like they need additional options to address concerns in the workplace.
“In my world, there is something fundamentally broken [when] employees feel like they have no alternative other than to pay an outside third party to represent them in connection with their dealings with their employer,” Scofield said.
In the case of Resilience Lab, many clinicians took issue with how management handled communications and negative feedback. They have also bristled against a major shift in how providers are paid.
Resilience Lab rolled out new measurement-based care software over the summer of 2022. Several therapists took issue with a lack of clarity around the rollout. Aggressive policing of internal chats deepened the frustration of clinicians, therapists told BHB.
The therapists also challenged the standardized assessment the platform used, the GAD-7 and PHQ-9, echoing the concerns of others about their value in assessing care outcomes.
In July, 60 Resilience Lab clinicians signed a letter detailing their dismay with how management handled the situation.
Multiple therapists identified the letter and management’s response to it as the first steps toward organizing. Near the end of August, a group of therapists approached unions for support and engaged with District Council 37.
Clinicians could make up to $68,000 with $55,000 coming from a salary before management released a new employment contract. In October, Resilience Lab reduced the base salary to $15,600, shifting the remaining potential salary to per-session payments.
Goldberg said the new contract calls for about 35 hours of clinical work per week and still will generate up to $85,000 per year for clinicians. For 25 sessions per week, a Resilience Lab clinician would receive around $65,000 per year.
What’s next
Goldberg and his co-founder and wife, Christine Carville said they intend to follow the law and negotiate in good faith should the majority of the clinicians vote in favor of unionization. Carville is also Resilience Lab’s chief clinical officer.
However, they don’t want the union vote to prevail, saying that it would not help the company in its mission to expand access to care or provide high-quality care.
“In 10 years, when we have rolled all across the U.S., [maybe things will] be different. But today, we don’t believe that it’s going to be helpful,” Goldberg said. “But the question is not for us, the question is for our clinicians and they will vote.”
During organizing efforts, employers are barred from taking action against employees solely on the basis of their involvement with organizing, Scofield said, adding that early involvement of legal counsel will help ensure managers’ responses are lawful.
However, the best response to labor relations is to simply address and solve issues between employees and managers, Scofield added, saying it’s vital for companies to audit practices and establish “positive” employee relations programs.
“An ounce of prevention is worth far more than its weight in gold,” Scofield added.
Outside of union activity, therapists are looking to a new but well-funded segment of behavioral health to address a number of their complaints with traditional care settings — digital mental health platform companies. (Platform in the tech startup sense refers to a service or software that enables work, as opposed to the traditional definition of a major initial investment company.)
Unionization isn’t the only way that clinicians are changing the workforce. Many providers are going to work for themselves. Jake Cooper, CEO, and founder of Grow Therapy, a digital mental health platform, said his and similar companies address four “pain points” for mental health clinicians — working with insurance, increasing panel sizes, practice management technology and a provider community.
“We believe that providers deserve sustainable and fulfilling careers and, in most cases, they do not have one at their current employer,” Cooper said. “Not only are they getting paid minimally, working significant clinical hours, they’re also undertaking significant unavoidable administrative burdens.”
This has led to a notable ascension of companies like Grow Therapy. In the fourth quarter of 2022, Grow Therapy announced it raised $80 million in a Series B equity and debt funding round and that it was expanding into 22 states.
Similar companies include Alma and Headway. Alma, Headway and Grow Therapy have raised about $417 million, including financing data for Alma and Headway from Crunchbase.
In the case of Grow Therapy, providers must contract with the company as 1099 contractors for the sake of contracts with payers and other business processes. Outside of basic quality standards, the company does not dictate to therapists how to practice.
“You will vote with your feet by leaving [the company] or, especially in areas where there’s not a practical ability to move, you will try to improve conditions from within through organizing,” Cooper said. “To be blunt, I’m unsurprised by recent organizational activity.
“It is a symptom of providers working in settings that do not adequately support them.”
Companies featured in this article:
Baker Donelson, Burr Consulting, Greer Consulting, Grow Therapy, Kaiser Permanente, Resilience Lab
