Thousands of social workers, psychologists and therapists are set to start a weeklong strike Monday against Kaiser Permanente medical centers throughout California, the largest action of its kind in the nation.
The labor dispute isn't emphasizing wage increases or better benefits. The clinicians feel compelled to act on behalf of their patients, contending that the Kaiser model for providing mental health care is woefully inadequate.
The central grievance surrounds what the NUHW calls continued "systemic understaffing" in Kaiser's psychiatry departments.
On Monday, Kaiser's 2,600 mental health professionals will begin a weeklong action of 65 picket lines across 35 cities in response to failed negotiations. Organized by the National Union of Health Workers (NUHW), the strike is slated to be the largest labor action of its kind in the country.
"We began bargaining almost five years ago," says NUHW president Sal Rosselli. "These clinicians demonstrated at the bargaining table the fact that Kaiser was not obeying the law meeting minimum requirements for access to mental health care. Kaiser dismissed it."
The central grievance surrounds what the NUHW calls continued "systemic understaffing" in Kaiser's psychiatry departments. Not having enough staff leads to appointment delays of weeks, and even months in certain circumstances, that are detrimental to patient health.
"It didn't just happen overnight," Clement Papazian, a clinical social worker in Oakland and president of NUHW's Northern California Chapter of mental health clinicians, tells Truthout. He's been an employee with Kaiser for 25 years witnessing changes, only not for the better. "It's just gotten progressively worse."
Papazian's occupational specialty is in psychiatric emergency and acute care. He's seen the negative impact of lengthy periods in between appointments for patients suffering from bipolar disorder, anxiety, depression and other mental health conditions.
"When people can't get an initial diagnostic or ongoing treatment appointment in a timely manner, we begin to see more people coming into the crisis service, emergency room, psychiatric hospital, intensive outpatient programs - so effectively all of the other services then become overwhelmed," Papazian says.
"There are federal laws that say that mental health care needs to be provided in parity with physical health care. It's not happening yet."
In 2013, the California Department of Managed Health Care fined Kaiser Permanente to the tune of $4 million after a survey concluded they failed to provide timely access to those seeking mental health services. It was the second largest penalty levied by the agency in the history of the state.
After battling for a year-and-a-half, Kaiser finally agreed to pay the fine in September 2014, promising a "comprehensive effort to improve the experience of our members, patients, and purchases in the area of mental health care."
For soon-to-be striking therapists, there's been nothing but a rearranging of the chairs of the deck of the Titanic since then.
"From that point forward, what Kaiser has done is shifted the current static resources without adding staff towards opening up more spots for intakes," Jim Clifford, a Kaiser psychiatry therapist in San Diego for 13 years, tells Truthout.
"Those initial appointments are taking away from the return appointments we previously had, which were inadequate to begin with, and now it's made even worse." Clifford says his inability to see patients with consistency often leads to their symptoms becoming chronic, prolonging recovery.
"There are federal laws that say that mental health care needs to be provided in parity with physical health care. It's not happening yet," Rosselli adds. "We see National Union of Healthcare Workers and the mental health clinicians that we represent as being a catalyst to finally accomplish that."
Why Kaiser Therapists Staged Denver One-Day Strike in '98
For Kaiser Permanente, the problem of woeful mental health services has been its own chronic condition. A little-known, one-day strike took place on July 13, 1998, when more than 50 psychologists and social workers employed at Kaiser Permanente in the Denver/Boulder region of Colorado walked off the job. The group of psychologists and social workers were willing to risk their own livelihoods to draw attention to the travesty their profession had become even as Kaiser warned those planning to participate not to return to work the next day.
Dr. Gordon I. Herz noted, when writing about the strike then, that, "Data the therapists collected showed that Kaiser Members were waiting 2-3 weeks for an initial appointment and 2-6 weeks for return visits. The average wait time for an initial psychiatric medication consultation was 21 days. The therapists had been required to perform 10 initial evaluations per week (up from 4). Consequently, patients were being seen for three visits, at which time there would be room only for new patients on therapists' schedules."
The end result of this aspect of Kaiser Permanente's behavioral health services was too much for psychologists and social workers to accept any longer without speaking out. Psychologist Rachel St. Claire wrote at the time in a letter addressed to the Colorado Psychological Association that her fellow therapists had "first-hand knowledge of psychological harm to patients that have resulted from these patient care practices." Kaiser, in the end, was making the conditions their mental health patients suffered worse, not better.
Not merely content with staging complaints with the status quo, the one-day strikers issued an alternative vision for ethical care.
Dr. Herz wrote, "The therapists defined 'ethical care' to include patients having ready access to providers of their choice; treatment decisions being made by therapist and client; patients being offered a full range of services (not "one size fits all," time-limited therapy or groups); each therapy episode being completed as fully as possible without harmful administrative interruptions in care; patients being provided with possible treatment options and outcomes; and sufficient resources being available to provide consistently high quality treatment."
By the time an article was published about the strike, Kaiser Management had retracted the lockout, and the one-day strike was successful only in highlighting behavioral health service inadequacies without retaliation.
Triage as Treatment: The Status Quo Continued
"As this goes to print, as far as I know," wrote Dr. Herz, in the aftermath of the Colorado one-day strike, "the therapists are still employed by Kaiser, and conditions under which they provide care remain unchanged." Years later, author and psychologist Russell M. Holstein conducted a 2004 study of the behavioral services offered by multiple Kaiser Permanente facilities and confirmed that the status quo that had prompted the 1998 work stoppage remained fully intact.
"Triage as Treatment: Phantom Mental Health Services at Kaiser Permanente," was published in the Independent Practitioner journal. Dr. Holstein's 2004 examination found that weekly sessions for mental health patients were, by in large, not available to those who would benefit from them, except in the most unusual circumstances.
The situation led one person interviewed by Dr. Holstein to conclude that within the confines of the Kaiser model "clinicians are more like greeters than treaters."
Like the Denver/Boulder region therapists, a chief reason cited in the study for this was the overburdened caseloads of psychologists and social workers. Therapists were required to take on six to 10 new patients a week. The study was, in part, prompted by recollections of the strike that were brought back to mind following an unrelated lawsuit that resurfaced the very troubling notion that the prioritization of profits over patients had led to inadequacies in care.
In assessing the viability of Kaiser Permanente's behavioral health services, or lack thereof, Dr. Holstein developed a very simple seven-question survey. He made random phone calls to various facilities and asked to speak with clinicians.
When possible, the following questions were asked:
1. How soon can somebody be seen?
2. Are there any situations or circumstances that result in restricting the length or frequency of individual treatment?
3. Are patients informed of these practices, if so, how?
4. Is there a policy or practice that requires a number of intakes per week per treating practitioner?
5. Are patients free to choose the treatment modality (e.g., individual, family, couple or group psychotherapy) that they will be most comfortable with?
6. Are weekly individual psychotherapy sessions available to those who need it (e.g. with a DSM IV (Diagnostic and Statistical Manual of Mental Disorders) Axis I diagnosis)?
7. How many hours remain per week for ongoing individual, conjoint or family therapy for the average therapist?
Dr. Holstein's attempt to conduct a clean survey was railroaded by the resistance and run-around he was met with by Kaiser Permanente administrators. As a result, the sample rate of responses was small, yet nevertheless consistent.
The findings of the questionnaire concluded that Kaiser patients were unable to choose the course of treatment that might have been best suited to their recovery. Part of the reason for this was the multiply attested practice of taking in as many as six to seven new patients a week - a caseload similar to that which, in part, prompted the 1998 one-day strike in Colorado.
"We've found the smoking guns that directly link the denial of care to suicide."
In all but two of the facilities surveyed, a quota for intakes was admitted to. Other respondents noted the utility of offering "group psychotherapy" - a less desirable form of treatment by some patients, particularly those with anxiety - as compensation for the scarcity and irregularity of weekly appointments that resulted. The situation led one person interviewed by Dr. Holstein to conclude that within the confines of the Kaiser model "clinicians are more like greeters than treaters."
"Triage as Treatment" went on to note that the "gag order" that had been a part of the labor dispute settlement in Colorado seemed to permeate in a culture of fear among Kaiser's clinicians. Few were readily available to criticize the system they operated under. A culture of silence among therapists fed into the already existing culture of silence among mental disorder sufferers.
Pickets for Patients
Kaiser mental health workers in California are ready to speak out from San Francisco to San Diego because there haven't been substantial changes over the years, and the crisis only looms larger. With the Affordable Health Care Act going into effect, the health insurance nonprofit was able to, in part, add a quarter million new members in the state last year.
The NUHW filed a lawsuit against the health-care exchange that administers Obamacare in California. "Our position was to work together to first make Kaiser provide adequate care and staffing for its own current members, which it does not do, before it accepts hundreds of thousands of more patients," Rosselli says. "During this time, there are also five different class action lawsuits by patients and families of patients that have committed suicide. We've found the smoking guns that directly link the denial of care to suicide," he claims.
Mental health workers say the impending strike is very much a working-class issue. "Many of the patients that have a Kaiser Permanente plan are working people; they're truck drivers, they clean hotels, they make food," says Elizabeth White, a Los Angeles-based Kaiser psychiatric social worker for 16 years. With the Great Recession and its ripple effects, people continually come through her office with economic devastation morphing into mental maladies. "I've had several patients who've lost their house - resulting in a depression that they've never had before," she says.
Kaiser's problems with staffing and consistent appointments prevents her from effectively using preferred and proven models of treating depression, whatever the underlying cause may be.
A Kaiser spokesperson responded to the December 31st strike notice with a statement in the Santa Rosa Press Democrat calling it "irresponsible," while noting contingency plans are in place for patients for the pickets.
"No one wants to not come in for patients but we've chosen to give the employer the necessary preparation time," says White. She's prepped people on her caseload with emergency hotline numbers along with self-care tools to make it through the strike week. "This is not an easy decision to make but Kaiser gave us no choice."
Mental health workers have been unionized since 2000, but it wasn't until 2010 that that they decertified from SEIU, which Rosselli called "a company union in bed with Kaiser" and entered into a representation arrangement with NUHW.
"Being a bottom up, democratic organization, NUHW listened to the interests of mental health workers and set upon a mission to express those interests in policy and action," Papazian says. The union points to Kaiser's $14 billion in profits since 2009 as more than enough to adequately staff its psychiatry departments.
"The staffing situation in mental care is very complicated," Rosselli says. "Our proposal is simple: Set up a clinic of psychologists and Kaiser managers by medical center to come up with the appropriate staffing solution for that facility with the help of a third-party mediator if an agreement could not be reached. That would settle the strike."
If the impasse continues, mental health workers are ready to picket for their patients. The cost of complacency is too high. "I had a young person of color in my office who is a gifted athlete struggling in school say to me point blank that he does not see a future for himself," says White.
"That is a child who needs to be seen weekly, who needs intervention."