Can Unions Help with Problems Faced by Agency Therapists?

By Frank Kashner, MSW, LICSW; December 21, 2012

Frank Kashner reflects on how unions can help social service agencies. This is an excerpt from a longer article detailing interactions with managers and coworkers in a local child and family social service non-profit agency.

Social Service Agency workers suffer low pay, poor supervision, burdensome paperwork, and contradictory, self-defeating mandates, all of which degrade the quality of care to needy clients. Agencies, organized hierarchically, pay high executive salaries, and fail to question government and MCO policies, which also may degrade client care. Unions, facing structural obstacles, have been largely unsuccessful in organizing agency workers and have never focused on the quality of client care as it is affected by and affects agency workers. Graduate schools fail to prepare students for the difficult conditions students will face after graduation.

Some social service agencies, funded primarily by Medicaid, and administered through Managed Care Organizations (MCO), provide mental health (MH) care to the poor. Services are provided by clinicians with Bachelors and Masters Degrees in psychology, social work, mental health counseling, or other MH field as well as by other professionals.

To the general public, agencies have a halo effect of goodness by virtue of caring for the poor, and being (mostly) not-for-profit. According to Yeheskel Hasenfeld, one of the few social scientists who have studied social service agencies, they are “viewed as symbols of the caring society”. But to clients, they can “represent formidable bureaucracies burdened by incomprehensible rules and regulations, … where services are delivered by rigid and occasionally unresponsive officials” (Hasenfeld, 1992, p. 3).

For their workers, Hasenfeld observes that agencies “are a source of great frustration, by constraining them from serving their clients in accordance with their professional norms and values, by denying them the resources they need to serve their clients, by burdening them with too many rules and regulations,, and by discounting their own views on the best ways to serve clients” (Hasenfeld, 1992, p. 4).

Agencies have accountability to MCOs in the form of voluminous, mandatory, clinician generated paperwork. Agency accountability to other funders often takes the form of Power Point presentations, which focus on usage statistics rather than on actual outcomes. Agencies have no accountability for the efficacy of their services to the clients themselves, and no accountability for the quality of their management to their own employees. Rubber stamp boards of directors support golf tournament fundraisers, bask in the halo of being charitable, and do not ask hard questions. Clients and clinicians can “vote with their feet” and leave the worst agencies, but both groups have diminishing choices. Agencies do not publish data on employee wages, working conditions, or rate of employee turnover.

Similarly, there is little data on client satisfaction, perceived quality of care, incidence of clients having multiple providers due to employee attrition, client perception of respect and empowerment, or the effect upon clients of employee dissatisfaction. There is usually no community or client advisory board. “Clients are enrolled, given service, and discharged, often without demonstrable change in their condition. And all these activities are accompanied by a blizzard of paperwork explaining, justifying, and certifying what was done” (Kirk & Kutchins, 1992, p. 166).

Agencies do some social good if only by offering an institutional means of getting clients access to care givers. Research shows that one-on-one psychotherapy is mostly helpful due to the relationship formed between therapist and client (Wampold, 2001).

Can unionization be part of a solution to the problems faced by agency therapists? Unions came into existence to solve particular kinds of problems, such as long hours of work for too little pay, unsafe working conditions, favoritism in placement and promotion, discharge without warning or cause, no sick, vacation, or retirement pay, hierarchical and disrespectful management, no grievance procedure, and discrimination based upon nationality, race, age, gender, and physical ability. Unions may secure collective bargaining, wage and benefit improvements, reduction in hours, increased safety, and for some, the right to strike. They can be a defensive bulwark against capricious, greedy, self-serving, ignorant, or hostile managers.

The number of workers in unions has decreased dramatically due to anti-union legislation which put limits on labor rights, the movement of industrial work off shore, myopic, corrupt or do-nothing union leaders, and a failure of schools to educate future workers about labor, working conditions, rights, and struggle (see for example Fantasia, 1988; Fletcher Jr. & Gapasin, 2008; Green, 2000; Kashner, 1978).

Unions, like corporations, exist within a framework of laws and court precedent. Achieving a union involves a lengthy and sometimes dangerous process of card signing and an election governed by the National Labor Relations Board. The process itself can be difficult but it can also be empowering and invigorating, drawing participants closer, building solidarity, and giving them a sense of their own power never experienced before (Fantasia, 1988, pp. 11, 132 – 138).

A look at the plight of agency social workers shows many of the kinds of problems normally addressed by unions. Struggles around pay and working conditions can be supported by union membership. Unions can offer a venue for certain fundamental rights like discharge-only-for-cause and a grievance procedure, which would be helpful to agency workers. An important reason for the lack of success of unions attempting to organize agencies is that unions do not address the content or quality of care, which can limit union attractiveness to agency employees.

In agencies, we see kinds of problems not normally addressed by unions, including poor service delivery, treatment mandates based upon questionable science, inattention to underlying social conditions, lack of community involvement, hostile management, and crushing bureaucracy and paperwork (McNeely, 1992, p. 244). To agency workers, faced with problems generated at all levels of society, “the forces arrayed against them seem overwhelming and often mysterious”(Fletcher Jr. & Gapasin, 2008, p. 93)

Some agency problems are attributable to MCO mandates. Agencies comply with MCO directives, and also change agency offerings based upon current fad and funding. They pass extra paperwork requirements on to the clinicians, adopt dubious evidence based programs, and participate in often muddled wrap-around services. Agency management rarely questions the necessity or efficacies of MCO and government mandates and programs, nor do they collect and communicate back up the hierarchy ladder the actual experiences in the implementation of those programs by clients and clinicians.

Paula Dressel views poor working conditions and pay in agencies as an effect of social welfare work being considered “women’s work”. She asserts that “the numerical dominance of women in social work has not translated into authority, power, and pay equity or equality”. She tells the history of women and social work that “set the stage for the exploitation of women in social welfare agencies”. She claims that social norms give women individual coping strategies that are inadequate to the problems they face which “usually require collective action for their alleviation”. While factors external to the individual are the source of problems, “women may believe they are unsuccessful because of their own inabilities” (Dressel, 1992, pp. 207 – 218).

It is ironic that clinicians and clients both view themselves as being at fault for having problems and for being unsuccessful. I recently received a new Fee Schedule from an MCO. For 50 minutes of Psychotherapy, the schedule pays Doctors and Psychologists (mainly male) almost $22 dollars more than it pays Social Workers (mostly female). If anything, research shows that Social Workers, more relationally oriented, are likely to do a better job. Isn’t this a fundamental issue of unequal pay for equal work? The voices of agencies, graduate schools, professional organizations, and social workers ourselves are mute on this and many other issues of social justice.

Because most of their clients are poor, agencies often have practices that would not be tolerated by clients with greater resources and expectations. Kirk and Kutchins say, “…within the agency there are forces that, unless checked, accentuate the inequality of practice. The unequal distribution of power resources among clients, a reflection of social class differences, also results in unequal access to quality services. It is not surprising, therefore, that poor clients tend to receive poor services. One of the most striking consequences of the inequality of practice is that clients from low socioeconomic groups are more likely to interact with social service agencies whose primary function is social control and surveillance rather than prevention and rehabilitation. Nowhere is this pattern more apparent than in service for children and youths” (Kirk & Kutchins, 1992, p. 268).

Most agencies would say that they are about treatment and rehabilitation, yet their reliance on short term symptom management and behavioral goals, their treatment of clinicians, resultant high clinician turnover, and their unquestioning acceptance of MCO demands, makes that claim questionable in important aspects. They often do not uphold their own stated values, are not effective in the solving some of the problems they claim to solve, maintain feudal relations of power, and respond to therapist need and occasional complaint with the violence-like threat of discharge.

We clinicians should organize ourselves, across discipline and level. The Internet can offer ways to communicate anonymously, compare grievances, and determine actions. The realm of actions can include planned conversations and alliance creation, as well as letters, petitions, publication, direct address of the Board, empowering clients to organize themselves, addressing legislators, utilization of our professional organizations, pressuring the MCOs, and work actions. Unions can be helpful, but only when agency workers ourselves are controlling the content and process.

Bibliography

Dressel, P. L. (1992). “Patriarchy and Social Welfare Work.” In Y. Hasenfeld (Ed.), Human Services as Complex Organizations. Newbury Park: Sage.

Fantasia, R. (1988). Cultures of Solidarity. University of California Press.

Fletcher Jr., B., & Gapasin, F. (2008). Solidarity Divided. Berkeley: University of California Press.

Green, J. (2000). Taking History to Heart. Amherst: University of Massachusetts Press.

Hasenfeld, Y. (1992). “The Nature of Human Services.” In Y. Hasenfeld (Ed.), Human Services as Complex Organizations. Newbury Park: Sage.

Kashner, F. (1978). “A Rank and File Strike at G.E.” Radical America, 12(No. 6, November-December 1978), 17.

Kirk, S. A., & Kutchins, H. (1992). “Diagnosis and Uncertainty in Mental Health Organizations.” In Y. Hasenfeld (Ed.), Human Services as Complex Organizations. Newbury Park: Sage.

McNeely, R. L. (1992). “Job Satisfaction in the Public Social Services.” In Y. Hasenfeld (Ed.), Human Services as Complex Organizations. Newbury Park: Sage.

Wampold, B. E. (2001). The great psychotherapy debate : models, methods, and findings. Mahwah, N.J.: L. Erlbaum Associates.