COOPerative Movement?
The coronavirus has infected the physical body. It is everywhere. On September 4, 2020, the Johns Hopkins Coronavirus Resource Center reports 26 million cases worldwide, 6 million in the United States, and 869, 306 global deaths. The spread of the disease has been truly extraordinary. The virus has managed this much destruction in just 8 months.
It has infected the body politic as well. The controversy and confusion over wearing masks in the United States is just one extraordinary example of how our politics and government have been left without defenses. Who do we trust: CDC? The White House? Mayors? Governors? A new study reports, “We consider how differences in COVID-19 epidemiological indicators, state capacity, and partisan politics affect when states adopted broad mask mandates. The most important predictor is whether a state is led by a Republican governor. These states were much slower to adopt mandates, if they did so at all.” (Governor partisanship explains the adoption of statewide mandates to wear face coverings, September 2, 2020)
What other institutions will be forever affected? Education? Social Work? Medicine? Therapy? The Chronicle of Higher Education published (August 27th) a review of the future: The Future of the Academic Work Force: How will the pandemic change the way higher education works? In academe there is a worry that online courses will be managed by instructional designers and faculty will become disposable. Zach Schwartz-Weinstein writes, “That logic of disposability has never been more starkly visible than in the time of Covid-19. The current moment is not an exception to universities’ long histories of complicity with racial capitalism, but their product. That means that a return to normalcy is neither possible nor desirable. But it also means that there is a rich history of struggle within, against, and beyond the university for us to build on and learn from” (Zach Schwartz-Weinstein is a historian of university labor).
In moving to fully online education we must confront many questions and among them will be questions about our values? In education, what we care about (i.e., our values) governs our teaching and our ethical decision making in teaching (we’re not talking here about the NASW code of ethics and deontology). We must do the right thing for students, which is not necessarily the most affordable. And we must look carefully at the values driving the software-driven, online, manualized, formulaic curricula (some of which is owned by textbook companies). How will we articulate and reimagine social work education in an online world?
This quote from E.M. Forster’s 1909 Dystopian story, The Machine Stops, is especially apt at this moment,
She could see the image of her son, who lived on the other side of the earth, and he could see her…. “What is it, dearest boy?” … “I want you to come and see me.” “But I can see you!” she exclaimed. “What more do you want?” … “I see something like you … but I do not see you. I hear something like you through this phone, but I do not hear you.” The imponderable bloom, declared by discredited philosophy to be the actual essence of intercourse, was ignored by the machine. E. M. Forster, “The Machine Stops”
In this story, we no longer labor, we’ve become soft; the machine works for us. Forster’s subjects live in individual, empty cells: there is only a chair, a desk, and the controls of a machine. The environment has been spoiled so people move underground. They live entirely indoors. In this interior world, "night and day, wind and storm, tide and earthquake, impeded man no longer. He had harnessed Leviathan" ("Machine" 10). We no longer confront nature; we experience only the machine and the walls of man-made rooms. Douglas Rushkoff, in his wonderful book, Present Shock, writes about presentism (i.e., present shock). Rushkoff is in conversation with Alvin Toffler, the author of the bestselling book, Future Shock (1970), where the world was said to be changing so fast we were losing our capacity to manage the change. For Rushkoff that future is now. For Toffler the future was speeding toward us. For Rushkoff, we no longer have a sense of a future, of goals, or direction. We are now living in an entirely new relationship with time: always-on “now,” and the present moment is everything we live for. In his book On the Internet, the late Hubert Dreyfus asks: what would be gained and what, if anything, would be lost if we were to take leave of our situated bodies in exchange for ubiquitous telepresence in cyberspace?
We have a colleague, an LCSW (Licensed Clinical Social Worker) who works for a very large public mental/behavioral health agency in New Jersey. After twenty years at this agency, in the midst of the pandemic, his work and life have become intolerable. Not long before Covid-19, practitioners were told that they were to see clients one-half hour each month. Yes, 1/2 hour per month! With Covid-19, he moved his 1/2 hour in-person caseload online. Soon he found that many of his clients lacked devices, internet, and often found it impossible to find private spaces. And in the months after the coronavirus struck his caseload increased along with the severity of patient symptoms. It didn’t matter; the agency forged ahead. The business model for this agency, and many like it, required social workers to see as many clients as possible: 1/2 hour per month. Moving to teletherapy was the best solution to keep the model working. Our friend and colleague, now working 8 hours a day, staring at the screen, one client after another, in thirty minute allotments, lives the dystopian nightmare described by Forster. He’s controlled by the machine, his relationships with colleagues are virtual, supervision and consultation have ceased to exist. His life is all interior. He’s depleted and no longer believes his practice is ethical; this talented practitioner-artisan has decided to retire early.
Many of our colleagues and practicing therapists have declared: “I really have adjusted to it and have grown to like it.” Others have said they don’t plan to return to their offices. Like many working for large corporations and tech companies, will therapists now all be working from home, in their pajamas, in their cells? Will teletherapy replace face-to-face contact? What does social work do? Will we all be employed by megatherapy corporations. Talkspace, with Covid-19, has spent millions of dollars advertising on primetime television, often paying celebrities like Michael Phelps to promote the product. See below: “Join 1 Million Talkspace Users.” Users? Wow. Just 1 Million users? Can you imagine an agency with a caseload of 1 million.
https://www.talkspace.com/
One talkspace advertisement entices “users” to imagine time saved: commute, drive, and pack in a therapy session: therapy while driving. Yes, therapy while driving! Time saved! Kill time while having therapy. Autotherapy! They’re told they can reach their therapists any time of the day, any day of the week. Betterhelp, another popular teletherapy company promises:
So therapy mimics the world as described by Rushkoff: we are now living in an entirely new relationship with time: always-on “now,” and the present moment is everything we live for. As Betterhelp says, “anytime, anywhere.” Who wouldn’t sign up for that? How do we understand this deepening commodification of the therapy relationship? What values govern this scaling up of the helping relationship? It works as a business model, for sure. Are there alternative models? What is desirable? What is feasible? What do we value?
Private practice, solo or group, has been artisanal (there are clear exceptions: where practice has been manualized) and when all goes well the practitioner works in close relationship with colleagues, regularly consults on difficult cases, and those early in their careers receive high quality supervision (no longer the case). The business model is small owner: I provide a service, and you pay an agreed upon fee, with or without public or private insurance. It is a small business; it is not scalable to a million users. Most private practitioners top out at 20 to 30 clients and that’s a number often difficult to manage. And when that number is exceeded, the quality of the therapeutic relationship and the working alliance is threatened. In his book, The Craftsmen, Richard Sennett describes the work of the artisan, the apprenticeship model, which applies to therapy, artisanal baking, surgery, plumbing, and many of the trades. We’ve a very close friend in Pittsburgh, who owns an artisanal bakery, Five Stars; he is the model craftsman: he bakes with perfection and expects the same of his apprentices. There is a deep desire to do things well and when that desire is compromised, for Sennett, the quality of craft work changes and the quality of relationships in the work change along with it. We believe that good practice is small practice, artisanal practice, in settled social spaces. Perhaps it was in the medieval workshop, or artisanal bakery, with a small number of highly skilled craftsmen, where this tradition of perfectionism flourished (and continues in many places). It was in these small workshops where one cared about the choice of the material, the methods, and the relationships with colleagues. Especially important was the relationship with the master craftsmen, those with the skills and wisdom necessary for high quality. Even before the pandemic of 2020, these kinds of craft relationships in the world of therapy had mostly disappeared. And now with the shift toward online, "flexible working" we believe the pride of craftsmanship has received a potentially fatal blow. Below we offer some hope: a shift toward the Mental Health COOP.
When in Pittsburgh, you must visit the Five Star Bakery
Surely the insurance (private and public), pharmaceutical, and teletherapy corporations, the largest players in the mental health market, are scooping up much of the mental health market through scaling up (e.g., Amazon). So much so it is nearly impossible for new professionals to sustain themselves as private practitioners using the solo business model. There is the cost of medical insurance for the provider. There is the cost of rent. There is the personal isolation that comes with private practice, especially in a world where many report feeling more isolated than ever. And then there is the problem of student debt. There is the problem of manualized, shake-n-bake social work, psychology, and counseling curricula (all failing to provide skilled practitioners). There is the ever-growing threat to our private associations and institutes (important to note here that when the baby boomer therapists and institute faculty retire, which is all very very soon, independent institutes will be threatened like the spotted owl or the monarch butterfly). Thus, we need a new model of protecting and keeping small, local, practice alive during this troubled time of scaling up mental health. How? What is to be done? How do we keep practice ethical?
Start first by asking yourself some questions about how people seek a therapist. There are at least four concerns: You might first wonder about the kind of organization where the therapist works. Does the therapist commit to a particular philosophy and practice and is their primary mission patient well-being or to the demands of large bureaucracies (like our colleague mandated to see clients 1/2 hour per month). Does the therapist get essential and consistent consultation and supervision? Supervision has become increasingly difficult and compromised in large organizational settings. And what kind of supervision and consultation do the talkspace therapists receive?
Second, when considering a therapist, one might also wonder about how a therapist is compensated. A fairly compensated therapist is free to focus on what you bring to each session, not on their worries. This may seem obvious: NOT SO. In many group, for-profit practices in New Jersey, the owners split fees with therapists, giving the therapist a lower percentage of the total fee (sometimes a significant percentage—we have heard of cases where the owner takes 75% and leaves the emerging practitioner 25% or less). Many ethical codes explicitly forbid splitting fees. In large mental health organizations, therapists are usually salaried and the organization strives to keep expenses below revenues; and this calculation can often compromise the nature and quality of the relationship between the therapist and the patient. Think of our friend and colleague described in this post: 1/2 hour per month.
With the private practice model increasingly threatened by corporate teletherapy and large mental health organizations bending their ethics to the business model, the Amazon model, the Present Shock Model, we’re wondering about alternatives. How do we protect the therapist/client relationship? What model might be both desirable and feasible? How do we maintain the small and local?
We are proposing a movement: a clinical, mental health cooperative movement. The COOP will be a vehicle for students, early career professionals, and veteran practitioners to connect and cooperate and benefit from all that was great about the small practice but without the stress of competition. The coop will act to ensure personal financial well-being, ethical practice, and create an independent space for the reproduction of small-scale, local mental health practice. We need new modes of social-economic-spatial-temporal sites for the distribution of mental health goods and services where patients can experience transformation and providers cooperatively share the burden of expenses (rent, education, supervision, consultation, and administration) and share the income fairly among providers. We are proposing small COOP models of no more than 20 members. COOPs can be built in any community to support the number of clinicians in the COOP; the members of the COOP can specialize in particular services needed in those communities.
A particular COOP's values and mission would be determined by the COOP, not by the pecuniary logics of for-profit or nonprofit bureaucratic administrations—thus, practice could work outside of the Big PHARM-INSURANCE, industrial complex, which now controls and mandates types of therapy, frequency of therapy, and access. No administrator would be allowed to mandate seeing a client once a month.
A COOP would be collectively managed: administration, marketing, intake, insurance and payment, building maintenance, etc.;
A COOP would provide consultation and supervision on site;
A COOP would provide ongoing development of members--reading and discussion groups, informal consultation etc.;
A COOP would provide member coverage when away on vacation, family leave, illness, crisis management, etc, and when the therapist is away, unlike private practice, the COOP continues to accept referrals;
A COOP could develop a large enough caseload to effectively have an internal feeder from the local community to allow group therapies a stable population, providing a more economical model to consumers and an economic model for the COOP;
A COOP could negotiate with organizations and corporations (with schools, employee assistance programs, daycare centers, for example) an Employee Assistance Program group therapy rate so the various organizational or corporate constituents (workers, students, parents) could get access to the COOP's cost-effective, group work: $50/$60/$75 per member per group session; many individuals cannot afford private practice therapy fees, nor need individual therapy.
A COOP would be the entity that holds the caseload; cases would be distributed among clinicians based upon referral, case, availability, expertise etc. AND, a diversity of clinician expertise and focus (children, adults, domestic violence, severe mental illness, etc. ) will increase referrals, whereas private practitioner's referral base is always limited to their specific expertise and focus only; this should increase access to consumers;
These are just some of the possible benefits.
The COOP might be the only way to offer ethical practice during this time when the therapy relationship is undergoing commodification. The COOP will provide a sustainable workplace for new professionals in mental health and clients will benefit by access to smaller and local mental health. Taking care of both provider and patient is ethical practice. It’s time to choose!
References
Dreyfus, H. L. (2008). On the internet. London: Routledge.
Forster, E. M. (2020). The machine stops. Open Road Media.
Rushkoff, D. (2014). Present shock: When everything happens now. Current.
Sennett, R. (2008). The craftsman. New Haven: Yale University Press.