How the Rhizome Therapy Cooperative Counters Burnout

“One of the things I don't think a lot of people outside the mental health field realize,” says clinical social worker Evelyn Heflin, “is that a lot of community mental health agencies, because they're underfunded, and private practices that are larger agency format, really sort of take advantage of the therapists at the bottom.” 

Faced with unsustainable caseloads, a lack of additional support, and inadequate pay for the work they do—a situation grown drastically worse since the COVID pandemic began—over half of mental health clinicians reported experiencing burnout in surveys conducted between 2021 and 2024. Having dealt with these circumstances firsthand in their work as therapists, Evie Heflin and Nern Ostendorf were inspired to start Rhizome Therapy Cooperative, a worker-owned therapy practice in Cincinnati where they specialize in working with LGBTQ+ individuals and take an anti-oppression-informed approach to therapy.

“We really wanted something where we could support therapists at all levels of experience in a system that was as non-hierarchical as possible,” says Heflin.

Ostendorf describes the co-op model as a kind of callback to the values of equity and mutual aid they and Heflin learned from their shared background in community organizing. Before they were colleagues, the two became friends through their enthusiasm for bicycles and advocacy around issues like transportation. During their years working in community mental health (CMH), they had talked about starting a private practice, which is often the next step for newly-licensed clinicians. Both were aware, however, that such businesses risked becoming similarly hierarchical and exploitative of therapists still working toward licensure. They also considered setting up a nonprofit organization, an avenue Ostendorf was reluctant to pursue due to negative experiences they’d had working for nonprofits. Finally, Heflin’s research into other models lead to Co-op Cincy, a network of worker-owned businesses in Greater Cincinnati, and its co-op development training program. “In many ways, we were pleasantly surprised with how well it fit with our personal values as individuals and some of the personal projects we've gotten involved with in the past,” Ostendorf recalls.

The surging demand for mental health services since the start of the pandemic has drawn attention to the issue of therapist burnout, which connotes the emotional exhaustion, disengagement and sense of inadequacy practitioners often experience due to their work. Other factors like low compensation and the amount of unpaid time spent on documentation for insurers and funders, have been known to cause burnout and high turnover among CMH staff since long before this crisis, as evidenced by a 2018 review of 62 studies from the previous 20 years. These conditions drive many clinicians to leave the behavioral health field, which has led to a workforce shortage that in turn creates bigger workloads and longer wait lists for other providers, keeping people from accessing the care they need.

The review of studies published between 1997 and 2017 concluded that “the promotion of professional autonomy” would reduce burnout across all roles in the mental health field. Established healthcare cooperatives in countries like Spain and Brazil have demonstrated for decades how self-governance breeds better working conditions while expanding access to quality services for patients. As with most industries in the US, the co-op model has been slow to gain traction among mental health providers who want more influence over the decisions that impact them and the people they work with. Still, the handful of worker-owned therapy practices that have sprung up across the US in recent years have already shown signs of this transformative potential, which Rhizome Therapy Cooperative hopes to carry forward.

After earning a master’s degree in social work in 2014, Heflin began work at a community mental health agency, something many therapists do to accrue the hours of supervised clinical experience required to become licensed. In 2017, she informed Ostendorf of an opening for a mental health case manager at the same CMH, which lead to Ostendorf pursuing a master's in social work during their five years in that position. Having continued at the agency after Heflin left to work with adolescents as a social worker at Cincinnati Children's Hospital, they say there was a long period where conversations about unionizing were very common among the staff.

“Oftentimes it is, at least to me, a good sign that there is real attention to both how the therapists are doing and how the clients are doing.” The pressure to complete mountains of insurance paperwork and meet targets from funders, Ostendorf says, is a distraction that diminishes care and devalues the relationship that is central to the work therapists do.

Having decided to explore the cooperative route with Co-op Cincy, Heflin and Ostendorf completed the network’s Co-op U program in August of 2024. Ostendorf says the 14-week course provided a foundation for all the things to consider when starting a business in general, and specifically with a cooperatively owned business. “It breaks everything into manageable chunks, like creating the idea for your co-op and the individual aspects of putting together your business, looking at finances, looking at your values, looking at your bylaws, what that incorporation process looks like. And then it allowed us to set aside a little bit of time each week to do the homework that's assigned and to slowly build out what felt like a really good cooperative business plan.”

What Heflin appreciated most was having access to coaches who could connect them to resources. “I have felt like people who hardly know us very quickly became invested in the vision of our co-op. I would have never expected that.”

Heflin remembers being frustrated with the lack of autonomy therapists in CMH had over what kind of support to provide to clients. “After working there for a couple years,” she says, “I noticed that there was a really big unmet need of LGBTQ folks finding therapists and mental health services that were affirming and that were able to see those individuals for who they are.” Before the end of her stint there, she started a program at the agency specifically for gender-nonbinary individuals, which eventually shifted into working with LGBTQ folks.

For Ostendorf, the co-op model feels like a strong antidote to the unequal power dynamic that exists between therapists and clients, and in the nonprofit world. “Social work as a field has some roots in philanthropy, and those with resources showing up and helping those without resources.” Rhizome’s collaborative structure corresponds with the anti-oppression informed approach they and Heflin both take to therapy.

“I think at the core of it is that the client, the individual—they're the expert,” Heflin explains. “They know their lives the best. They know the way in which their identities intersect and how that impacts them. We essentially use the therapeutic tools that we have to help them navigate that.” 

Another big component of anti-oppression informed care is self-reflection, or looking at the privileges one has and thinking about how that can interfere with a therapeutic relationship or with a client's healing process. For example, Ostendorf says a surprising number of people living with disabilities will come in to work with them and talk about how other therapists made them feel dismissed, as if their problems weren’t real. “I think taking an anti-oppression informed approach is to say, how is the world outside not meeting you where you're at? How does the society that we've created collectively make day-to-day living hard for you in a way that other people don't even have on their radar?”

This approach also emphasizes looking beyond the individual and looking at the social picture. “There are so many things that prevent people from achieving and being their complete selves,” says Heflin. “There are issues with economic justice. There are issues with people having access to resources and being able to navigate these complex social institutions that aren't designed in any way to benefit them.” While medical insurers require providers to submit a diagnosis for their clients when filing for reimbursement, Heflin personally questions what value diagnoses have beyond that. “With a diagnosis,” she says, “it's so focused on the individual. What they've experienced, what's going on in their internal world. But you can't submit a diagnosis like experiencing racism to an insurance provider.”

Ostendorf agrees it’s important, at least for now, for the practice to diagnose clients who have insurance in order to expand access to as many people as possible. In doing so, the co-op members also try to be completely transparent about the systems they have to work within, what the benefits and costs are, and to work together with clients on what other choices are available to them if, for whatever reason, they don’t want to have a diagnosis filed. 

“Because I think we have a bit of a niche as a community space, we have to kind of negotiate role conflicts all the time anyway. As queer clinicians, we work in a small community and we have to negotiate being members of the population that we work with and how we deal with that anyway. I feel like a co-op model kind of leans into that even more and says, hey, we're all in this together. That kind of large expanse between the person who's providing the service or support and the person who's receiving it feels much closer.”

Compared with their experience working in community mental health, Ostendorf has found the therapy co-op to be “more adaptable.” The Medicaid-only model of the program where they worked, while allowing them to work with the most vulnerable people, often had the regrettable downside of forcing people to leave before they were ready. “Let's say they stabilize and start building community, and maybe they find a more sustainable, better-fitting job, and at some point in time they stop qualifying for Medicaid anymore. Just when you get to that stabilization point and they're feeling more excited about their life, more connected, they no longer qualify for services at your treatment center, and you have to have a premature farewell.” While the co-op has been very intentional about accepting Medicaid, Ostendorf says the objective is to be able to extend the support past that stabilization point if the person feels they have more to work on.

“A big trend in private practices for therapy right now is a movement away from accepting insurance to people having to self-pay,” says Heflin. “We acknowledge that that is not a realistic thing for a lot of people. Paying $140 a session just isn't something that is accessible.” Rhizome accepts different insurance plans, including Ohio Medicaid, and operates on a sliding scale for people who don't want to use insurance.

Ostendorf predicts Rhizome will be able to expand its sliding scale rates as the business grows. “It's a nice little math equation that if we get paid, and our bills get paid, and the business is sustainable, then a portion of whatever extra money we have will be put back into being able to provide additional therapy at lower rates, which sort of extend the range.”

Co-op Cincy continues to help Rhizome with the startup by providing one-on-one coaching, advising on processes such as setting up a board. Ostendorf says being plugged into this larger co-op network has been an opportunity to connect with other people with shared values. “I think that helps us feel like we're part of a bigger movement or bigger community of people that are striving toward similar goals.”

When the practice has business needs, Co-op Cincy connects them to other co-ops in the network. Rhizome’s office space is provided by another co-op, and their web design is being contracted by another co-op that offers a generous discount to fellow co-ops. “There's already a personal relationship there and there is that kind of built in accountability,” says Heflin. “We've really been able to rely on those already-established networks, and I think that it has felt a lot less lonely getting started.”

“I think the discipline of social work is well suited to cooperative models,” says Ostendorf. The skillset that therapists have, they suggest, could be particularly useful in providing support for other groups of therapists who might want to do this in the future. “So it's been kind of interesting to show off what we're doing and have people get excited about it.”

Header image via Co-op Cincy website.