When Dawn Sánchez takes on a new therapy client, she’s upfront about the money stuff.
At the Alliance Psychological Services of New York, the out-of-pocket costs for people without insurance is, ideally, $80 or $90 per session. That money goes toward operating costs like an electronic health record as well as hourly pay for all the workers, set at $40 an hour.
But the therapy rate is flexible—a negotiable sliding scale based on the needs of the patient and decided by consensus among the rest of the therapists. Some clients pay $30 per session. Another, currently between jobs, pays zero—something the group felt was worth it to avoid gaps in mental health care. Others pay $150, or more.
“There’s no secrets. There’s no exclusion. There’s no cliques,” said Sánchez, a Black and Latina licensed clinical social worker at the Alliance. The transparency in the client-therapist relationship creates a dynamic of trust, which grows from the structure Sánchez and her co-workers have built themselves.
The Alliance is a worker cooperative—a business owned by its workers with democratic decision-making processes. Though cooperatives can be hierarchical, the Alliance specifically operates as a non-hierarchical collective. Worker-owners at the Alliance say the co-op model offers autonomy and sustainability to continue doing work they spent years training to do, while offering better, equitable care for the clients they serve.
“It’s empowering,” said Sánchez, who works part-time at the co-op while continuing a full-time job at a nonprofit. The co-op, which extends authority to workers regarding hourly pay, sick time, and the cost of their services, is a game changer. Basic things like having access to the organization’s bank account “shatters everything you’ve ever grown up with or seen.”
“You just feel,” she said, “like you’re trusted.”
How it started
In 2017, Billy Somerville had finished training to become a clinical psychologist.
But he quickly disliked what he saw in the field: paternalism toward patients, therapy as a luxury due to cost barriers, and a lack of transparency about money with patients and mental health professionals.
He set out to start a private practice to offer services that aligned with his values and goals as a therapist—a non-capitalistic approach that extends agency to clients. He soon realized he wanted to collaborate with others, and that’s when he learned about cooperatives.
In 2018, he launched the Alliance in Ridgewood, Queens, with his friend Kara O’Brien, who still leads administrative tasks and finances. Ten months in, he was able to bring on another therapist as a co-owner. Now, there are five therapists in total.
“What really appealed to me was we can work together in a horizontal way,” Somerville said. “We can afford trust to one another.”
It took some time and legal advice to make it work. In New York State, health professionals with different licenses can’t co-own the same entity or share profits, nor can licensed professionals and other non-licensed workers, like those who do administrative work. The Alliance created an umbrella entity to encompass distinct professional limited liability corporations for each kind of license professionals have.
Building a sustainable work model
The flexible sliding scale costs of therapy and the control therapists have over their workloads have not stopped the Alliance from making enough revenue to increase compensation for workers.
Since first launching in 2018, the worker-owners have raised wages from $30 to $40 an hour. They offer sick days at $160 per day.
“It shouldn’t really be that shocking that cooperation can produce things that competition cannot,” Somerville said. “But in our cultural context, here in the U.S. in 2022, that is a shocking idea for some people that you don’t need the profit incentive or that you don’t need to be competing with each other in order to reach your best.”
Having autonomy over their work lives is also a factor in creating better conditions.
Claudia Maisch, a Latina licensed master social worker, chose to cap her caseload at 30 clients. The limit felt sustainable for her—a choice that didn’t exist in previous workplaces.
“You decide what is sustainable for you as a worker,” said Maisch. “Our goal isn’t to make as much money as possible and liquidate the business. The goal for us is how do we build a sustainable model that’s sustainable for workers where we get paid as much as we need to get paid in order to live comfortably [and] provide fees that are accessible.”
Three of the five therapists are people of color, a sign the model may disrupt the therapy industry, where psychologists are overwhelmingly white. Social workers—most of whom intend to become licensed clinical social workers who can offer therapy services—entering the field are mostly women and more diverse than other health professions; recent graduates of Master of Social Work programs were about 66% white, 22% Black, and 14% Hispanic, according to a 2020 survey from the Council on Social Work Education. But the educational debt burden is worse for people of color.
Newly graduated Black and Hispanic social workers carried an average of $66,000 and $53,000 in debt, respectively, compared to $45,000 and $48,000 for white and non-Hispanic social workers, according to the council’s survey. That’s astronomical compared to social workers’ mean starting salary of $47,100.
“The therapy world in general is just very white to begin with,” Sánchez said. The cost of education and licensing is something people of color don’t often have access to, she said. She hopes a co-op model can attract more people to becoming mental health professionals, though it doesn’t solve all of the gatekeeping problems within the field.
Maisch says the business model may make starting a business more accessible to new therapists. “You are sharing the overhead costs with colleagues,” Maisch said.
The co-op model and burnout
Maisch is the newest therapist at the co-op. She’ll be a member for six months before transitioning to formal co-ownership.
After Maisch finished her master’s in social work last year, she interned at a domestic violence shelter offering services to women often living in small spaces with their children, dealing with day-to-day crises that made trauma-processing in therapy sessions difficult. Her role during the pandemic was more like triage services, ensuring families had enough food to eat or scheduling drop-offs of basic necessities at the shelter. She saw her co-workers become overwhelmed, as they worked without adequate resources to meet clients’ needs and feared losing their jobs if grant money dried up.
In a private practice position after that, she felt her employer was scaling up too quickly, capitalizing on the pandemic-induced mental health crisis at the expense of working conditions for therapists.
“People would feel really under-resourced,” said Maisch. “It was wild.”
Health professionals are highly susceptible to burnout. During the pandemic, one study found about one in four social workers reported symptoms of post-traumatic stress disorder—seven times higher than a 2015 survey of social workers.
Research has found that mental health workers’ burnout symptoms are directly related to work dynamics and structures. In 2018, a review of 62 studies across 33 countries found high caseloads to be consistently associated with higher rates of burnout, while “a sense of autonomy at work and perceived capacity to influence decisions that affect work” were associated with lower rates of burnout. Ambiguity of a mental health professional’s role was found to be associated with increased emotional exhaustion in two studies.
A study looking at Black therapists’ burnout found that experiencing or witnessing cultural racism was significantly associated with burnout symptoms, as well as higher work hours per week.
Maisch is well aware of this dynamic. In a seminar for her master’s program, she argued worker co-ops could reshape the social work field by both improving working conditions, which would affect quality of care for clients.
Soon after she graduated, the Alliance was looking for another partner. She joined the team earlier this year, drawn to its transparency and non-hierarchical structure.
“The co-op model allows us to more fully align with our code of ethics—not just in theory and talking, but in practice,” Maisch said.