Therapists: Let’s Go On Strike! (Oh Wait, We Can’t)
By Barbara Griswold, LMFT (April 21, 2026)
It’s no secret: The biggest complaint therapists have about working with insurance is low reimbursement rates. So I am often asked why as clinicians we don’t form a union and go on strike to bring about higher rates.
“If you hang around therapist forums long enough, you will see it happen,” writes Joel Blackstock LICSW-S, MSW. “Someone posts a thread, usually after receiving a contract from an insurance company offering 1998 rates for 2025 work, and asks the obvious question: ‘We are the ones providing the care. The system collapses without us. Why don’t we just all go on strike? Why don’t we form a union and demand fair pay?’”
He acknowledges it is a logical question, especially since almost every other type of worker including teachers, nurses, screenwriters and mill workers band together to negotiate better terms. Why not therapists?
Unfortunately, there’s a reason why we can’t start painting clever signs for the picket line. “The answer is that for private practice therapists, forming a union is a federal crime,” Blackstock states bluntly.
Why a therapist union would be a crime
“In the eyes of the federal government, a private practice therapist is not a ‘worker.’ You are a business entity,” he writes. “Even if you are a solo practitioner struggling to pay rent in a subleased office, seeing clients between crying in your car and eating lunch at your desk, the law views you as the CEO of a micro-corporation. You are classified as a 1099 independent contractor, not a W-2 employee, and that distinction makes all the difference in the world.”
The primary reason therapists cannot unionize dates back to the Sherman Antitrust Act of 1890, which was designed to prevent large corporations from conspiring to fix prices and destroy the free market.
Some common examples of unlawful behavior
Blackstock gives examples: “If two workers at Starbucks talk about their wages and agree to ask for a raise, that is ‘collective bargaining,’ which is protected by the National Labor Relations Act. But if two private practice therapists talk about their reimbursement rates and agree to ask Blue Cross for a raise, that is ‘price-fixing.’”
In the eyes of the Federal Trade Commission, he says, this would be the same as if gas stations conspired to raise gas prices. The FTC considers it a serious violation of antitrust law by therapists, which could lead to criminal penalties, including fines and imprisonment.
Even comparing reimbursement rates in an online therapist exchange can get you in trouble.
So, the law that was meant to break up huge monopolies is now used to prevent private practice therapists from banding together to ask for cost-of-living adjustments.
And this affects a lot of therapists
“About half of all licensed therapists are in individual private practice, immediately rendering them ineligible to unionize, since they aren’t employees, writes Ben Caldwell LMFT of High Pass Education. “And thousands more work for government entities in states where such workers cannot unionize by law.”
But there has been progress
However, Caldwell writes that there have been some changes on this front. “It remains true that many therapists working for public mental health systems are legally prohibited from unionizing, and many others work in solo private practices where unionization is not possible,” he says. “However, there’s also been some consolidation in mental health care … Mental health apps are one part of this trend, but by no means the only one—many group practices have been growing as well.”
He notes that “when groups of employees work for the same employer, unionization becomes both possible and worthy of consideration. Unionized employees generally enjoy better pay and working conditions than their non-union counterparts, even in smaller companies.”
Since the coronavirus pandemic, there has been a surge in union activity among health care workers who are able to unionize (Bronfenbrenner, 2023; Lazaro & Lancaster, 2024). In a 10-week strike in 2022, 2,000 Kaiser Permanente mental health workers walked off the job to fight for reduced workloads as well as to gain more time with patients and reduced treatment wait times (Mensik, 2022). In October 2023, 75,000 Kaiser workers went on strike, making it the largest health care worker strike in U.S. history (Delouya, 2023).
If a therapist union is not possible, what can we do?
- Ask the health plans you work with for a raise in your reimbursement rates. Read my article for step-by-step tips on how to ask for raises (and yes, they are possible!) — click here
- Read more about therapists and unions
- Read Blackstock’s full article here, to understand the history of this dilemma
- Read Caldwell’s first article here, with four suggestions about how to fight back
- Read Caldwell’s second article here about increasing your bargaining power
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Barbara Griswold, LMFT is a private practice coach and the author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working With Insurance — And Whether You Should, 10th edition. Check out Barbara’s online catalog of helpful online courses, practice forms, and other therapist resources related to insurance, documentation, and running your therapy business here.