A New Program Aims to Make Therapy More Accessible to Restaurant Workers. Will It Reach the Back of House?

Andrew, a front-of-house manager at a small Italian restaurant in Cary, is in therapy—a cost he has to pay out of pocket. In more than a decade working across the Triangle, from back waiter to bartender and wine distributor, he’s seen it all. 

But until recently, he hadn’t heard of Southern Smoke Foundation (SSF) or its program to help hospitality workers access mental healthcare. That program, Behind You, launched in 2020 through the University of Houston and is now expanding to North Carolina.  

SSF is a Houston-based nonprofit founded in 2015 by James Beard Award-winning chef Chris Shepherd. Its Emergency Relief Fund has distributed more than $16 million in direct cash grants to food and beverage workers nationwide facing crises like medical emergencies, lost wages, and natural disasters. This year, SSF was named a James Beard Foundation Impact Award honoree. 

Andrew—who asked to be identified by first name only, as he still works in the industry—is uninsured and has struggled to afford therapy; his doctor approved a payment plan to help manage the cost.

“Sometimes it’s choosing ‘Do I pay my bills or neglect those things so that I can actually get counseling?’” he said. “[Therapy is] usually toward the bottom of my list of expenses and fiscal responsibilities.”

As of July 1, Andrew and other North Carolinians who work at least 30 hours a week for six months at a food and beverage establishment can apply for up to 20 free counseling sessions through UNC-Chapel Hill’s clinical psychology training clinic. The statewide program has a small caseload—six to eight active patients, with others cycling in from a waitlist as treatment ends. SSF said it expects it to take about a year to expand beyond that initial capacity.

As of 2021, only 32% of hospitality workers reported having access to employer-sponsored healthcare coverage. According to Census Bureau data cited by the National Restaurant Association in 2023, 81% of restaurant employees have some form of health insurance, though 71% of that coverage is private insurance often held under a spouse or parent’s plan—statistically, nearly half of restaurant workers are 26 and under—and employer-sponsored coverage remains rare across the industry. Even insured workers may struggle to afford or schedule mental healthcare. 

North Carolina’s Behind You launch is funded by a grant SSF provides to UNC-Chapel Hill, supported primarily by the Behind You Classic, a golf tournament hosted by Triangle chef-owners Sam Ratto of Videri Chocolate Factory, Matt Fern of the now-closed (ish) delicatessen, and Adam Cunningham of Longleaf Swine, a Raleigh barbecue restaurant with locations in Chapel Hill and North Raleigh opening later this year. 

Fern and Ratto learned about Behind You through SSF cofounder Shepherd in 2024 and began raising money to bring it to North Carolina. Across two years, the event has raised $75,000. The Behind You pilot at the University of Houston has facilitated more than 11,000 counseling sessions since 2020, and the program now operates through university partnerships in 13 other states as well as the District of Columbia.

The program’s name comes from the kitchen call workers often use to signal they’re close behind a colleague—a warning in a space of sharp tools, hot surfaces, and constant motion. SSF’s framing extends the phrase: In an industry defined by long shifts and high stress, everyone needs someone behind them. 

An Industry Gap

There is, of course, an inherent tension baked into this model—the restaurant owners helping fundraise for healthcare are part of an industry in which employee health benefits remain rare.

Cunningham said he has tried to obtain insurance for Longleaf Swine’s mostly Hispanic and Latino kitchen staff but could not make the cost work. The quotes came back with monthly per-employee premiums and deductibles so high the plans seemed like “insurance in name only.” He said he didn’t feel comfortable bringing that kind of coverage to his staff of more than 50 full-time employees because it might not meaningfully protect them if something did happen.

He pointed to larger restaurant groups, like those run by Raleigh’s Ashley Christensen and Scott Crawford (who has been outspoken about the toll that the industry can take), as examples of operators that do offer benefits. But smaller businesses lack the scale, he said.

Fern, who began therapy for the first time this year after 32 years in the industry, was more direct.

“I don’t want to have to raise money for healthcare,” he said. “But because we have to, we’re going to.”

Long hours, physical strain, financial precarity, and a culture that stigmatizes asking for help can make burnout feel like an ordinary condition of restaurant work.

The Substance Abuse and Mental Health Services Administration has consistently identified accommodations and food services as the industry with the highest rates of illicit drug use and substance use disorders. Nearly 17% of workers in the sector meet the criteria for a substance use disorder, and roughly 19% report illicit drug use in a given month. Fewer than a quarter of food service companies offer Employee Assistance Programs, compared to more than 97% of large companies nationally.

The impact of that access gap falls unevenly. Latino workers make up roughly 26% of restaurant and food service employees nationally and 43% of restaurant laborers, according to National Restaurant Association data. More than one in five Latino adults report a mental health condition, but in 2021, only 36% received treatment, compared with 52% of white adults.

Fern sees his own experience as inseparable from the industry.

“I’m a functional alcoholic,” he said, attributing it partly to daily stress requiring a coping mechanism. “And a lot of that I would attribute to the insane amount of stress on a day-to-day basis and how at the end of the day that becomes a coping mechanism. People in our industry get addicted to cocaine or anything prescription like Adderall, things that kind of feed that adrenaline and excitement—I think we’re all adrenaline junkies at some point.”

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Ratto participated in a Behind You pilot through the University of Houston in 2025 and received cognitive behavioral therapy.

“It’s not throwaway care,” he said. “It’s literally a person who is training in this modality of how to help people work through things.”

Mo Ray has spent 17 years in the food and beverage industry. She lived for years with a rare cancerous tumor, mistaking its symptoms for fatigue from long service-industry shifts. The tumor was discovered only after she got her first restaurant job with health insurance. Complications from the surgery left her with mobility, hearing, and speech impairments.

“I lived with cancer for years and had no idea because I did not have insurance and could not take care of it,” Ray said. “So many of the symptoms I just chalked up to fatigue and burnout.”

She also witnessed a coworker take their own life at her workplace. Ray said the hotel neither stopped operations nor brought in counselors.

“Everybody had to continue working,” she said. “Not even halting operations.”

Getting the Word Out

Caterina Bill, SSF’s chief mission officer, described the North Carolina coalition as “industry leader-based, not chef-based,” with brewers, agriculturalists, and other industry figures involved. North Carolina applicants who had previously applied for the Emergency Relief Fund are now being notified, and organizers are distributing cards with a QR code workers can share without management involvement.

Fast-food, quick-service, and chain-restaurant workers can qualify if they meet the program’s requirements, but there isn’t a campaign specifically targeting those employees. An SSF spokesperson instead cited the organization’s ongoing networking and outreach.

Ray had never heard of the effort and said the golf fundraiser reinforces her impression that the organization is closer to owners than hourly workers. “You don’t see poor people doing that,” she said. “That’s a rich man’s game.”

Cunningham acknowledged that outreach remains unfinished. After focusing on raising the money, he said, the organizers are only now asking, “How do we spread the word?”

Awareness is not the only limitation. The design of the care may also determine who can use it.

Jennifer Kirby, director of adult services and training at UNC-CH’s clinical psychology training clinic, oversees the partnership. Services will launch in English only. SSF said workers needing care in other languages will be referred to low-cost or sliding-scale multilingual community resources, with no announced timeline for adding Spanish-language care through the program. 

Andrew, the front-of-house manager in Cary, communicates with back-of-house staff in Spanish. He called the program’s language limitations a “significant exclusion” that leaves out “a large chunk of the back of house in restaurants where often English is not their first language.”

Ray said the limitation is especially significant for immigrant workers facing mounting fear and stress.

“There are people who are losing their lives,” she said. “Especially in this era right now where ICE is doing everything it’s doing, and people are scared, and they’re falling apart, and they need access to so many things, mental health being one of them.”

Doctoral psychology students in their second through fifth years of training and advanced graduate social work students will provide the therapy, under the supervision of licensed faculty clinicians. The trainee-delivered model, which SSF has used since its Behind You pilot launched at the University of Houston in 2020, allows the program to provide free care at scale by partnering with university training clinics where graduate students need supervised clinical hours to graduate.

Ray questioned whether trainee-delivered treatment constituted equal access.

“I understand the importance of it,” she said, comparing the training-clinic model to a teaching hospital, “but are we not worthy of the same sort of professional care and access as someone else?”

After the 20 free sessions, clients may continue at UNC-CH’s sliding-scale clinic at a rate SSF describes as affordable or, in some cases, receive a brief extension of the free care.

Andrew qualifies for the program and affirms that he will apply without hesitation. Until he was interviewed for this story, however, he did not know Behind You existed.

“It’s here to help you,” Cunningham said. “Don’t be scared to talk about your feelings and personal feelings. Because everyone’s going through it, and no one wants to talk about it.”

Whether workers like Andrew learn about the program before counseling once again falls below rent, groceries, and other bills on the priorities list is the question the program’s North Carolina rollout must now answer.

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