The Family is often considered to be the primary way in which care is delivered – whether this is for children, the ill, those with particular needs and older people.  And while many families are effectively engaged in these different sorts of care, the fact is, as charity Age UK point out, there are 2.6 million people in England aged over 50 are unable to get care, including hundreds of thousands who are stuck on waiting lists for support or even just waiting to have their needs assessed. That means millions left struggling to meet their basic needs like go to the toilet, eat, get dressed or wash because they can’t do these things unaided.

We clearly have a challenge with the family unit being the leading mechanism for care to be delivered outside of public health services.  We make a case that different sorts of approaches can be used as ‘interventions’ for effective delivery of care: to do this we explore the nature of family in the delivery of care from a behavioural science perspective. The intention is to bring different thinking to this space in an attempt to address some of the longstanding challenges. A large part of this is to consider how friendship can be a key ingredient of the means we have available to draw on to deliver care.

The value of friendship

In her book, Radical Intimacy, writer Sophie K Rosa suggests the COVID era taught us that new approaches to care are possible. She made the point that many of us were able to find solace and pleasure in more communal approaches to care.  These included getting to know our neighbours better, grass-roots development of Community led Food co-ops, collaborative home schooling and the proliferation of WhatsApp groups to co-ordinate delivery of provisions to people isolating and to ask for, or offer, other kinds of support. 

There is a great deal of psychological research that suggests these sorts of approaches offer stable, healthy friendships which are crucial for our well-being and longevity. People who have friends are more satisfied with their lives, less likely to suffer from depression and are less likely to die from all causes, including heart problems and a range of chronic diseases.

So not only can friendships offer a means of delivering and receiving care, but the mechanism itself fosters wellbeing. This offers us an interesting lens for care alternatives that go beyond considering the family as the primary unit.

But what about the family?

The family is of course in many ways a highly successful and effective means of delivering care, offering people with various needs a stable caring set of relationships.  But at the same time, it often places the burden of care on one person, with women doing a disproportionate amount of the work. Of course there is movement for gender equality in this regard but as Alva Gotby points out, for women care work is typically performed on top of waged work.

Following on from last week’s article, Gotby suggests we could do well to think of families as work relations: arrangements of work, care and economic distribution entangled in property relations through practices of inheritance and privatisation of kinship. Whilst this might seem a very unfamiliar way of looking at families for many us, it is perhaps more easily understood by those that are structurally excluded – when family are no longer around or want nothing to so with them. 

In addition, the nuclear family is ever more unstable with high divorce rates; no new models are taking its place which is a problem as access to care and resources remains tied up to membership of family. Writer and psychotherapist Esther Perel talks about expectations that mean a single person (in a couple) is meant to provide what a village would provide:

“We keep wanting more. We are asking from one person what once an entire village used to provide.”

What alternatives are there?

As Rosa points out, we saw in COVID that care can come from ‘kinship’ that is not exclusive to families – friends in the community we live in can also provide this role.  Alternative models of care based on these sorts of relationships often come from groups that are frequently marginalised in society.  Perhaps because these groups have little to lose, they often lead the way in alternative ways of living that can act as inspiration for more radical care delivery structures.

Rosa highlights the African American tradition of ‘othermothering’ in which being an extra parent of someone else’s child means there is a guardianship of the community as a whole. Stephanie Coontz writes that black families have historically also been less likely to institutionalise the elderly as these people were instead cared for within extended kinship networks.

There is also a long history of working-class camaraderie outside the family, with sociality less anchored in familial terms. So whilst the family is a key part of care, there is a much more extended care network available through wider family ties, friendships and community engagement. As Rosa puts it:

“Most working-class people understand it perfectly well because, globally, most working-class people are…raising children that aren’t theirs with friends, siblings, cousins, partners, neighbours. Because this is all they’ve ever known culturally.”

Queer communities have also traditionally looked for care and support from places other than the nuclear family, Rosa writes about the QueerCare network, a trans-feminist autonomous care organisation providing training support and advocacy for queer and trans people aiming to build communities in which people know how to look after each other, with the necessary resources from nutritious food to medical equipment to legal support.

Rosa also writes about the way sex workers demonstrate the power of community care in the face of stigma and exclusion in mainstream services. Mutual aid includes organising meet-ups to share info and resources, building community safety networks online, and creating hardship funds and workers’ co-ops during times of crisis.

Projects of world making

It is clear from these examples that there are many different ways of organising ourselves and delivering care that loosen our reliance on the family.  This allows for more expansive forms of intimacy and emotional practices based on shared aims, rather than the privatised arrangements that come with family.  Other examples show the the possibilities of these more creative practices in different areas of care:

Housing: This recent article sets out how almshouses offer a form of collective care that has very real benefits: this is the oldest form of social housing in the world: they were exempt from the UK right to buy legislation and remain a permanent part of the community. A recent Almshouse Longevity Study found that those living in an almshouse receive a longevity boost of almost two and a half years – equating to an extra 15% of future life for someone aged in their early 70s.

Health: Peer support networks for those with chronic illnesses offer digital tools clearly offer opportunities for people to do just this, connecting us with others who might be a similar position and offering relevant experience and expertise.  These have been very successful in healthcare where people connect with others, in particular for instances of chronic conditions. People can be very creative, have plenty of ideas and sometimes even physical resources that they bring to an issue; so the opportunity, as peer support systems gain momentum is that it is possible to co-create with people as partners in the behaviour change challenge rather than treat them as passive recipients.

Food: Human geographer Megan Blake created Food Ladders, an evidence-based tool that helps local organisations increase everyday food security and connect communities by looking at the root issue of vulnerability. The framework identifies three crucial interventions to help small communities create cohesion when facing with high levels of food insecurity: Catching: provision of emergency food, food banks, access to social services to ‘catch’ the individual and help them cope with their immediate situation. Capacity building: to support those who are not in crisis but don’t have regular access to nutritious food. This is based on creating networks and social relationships through food such as voucher schemes, holiday clubs and shared cooking activities. Self-organised community change: supporting the local community, encouraging the creation of self-organised projects such as  cooperative food growing, regular social cooking to overcome loneliness.

Conclusions

Writer M.E. O’Brien suggests that “new heterogeneous family structures are a symptom of desperation as much as they are of the practice of care.” We can see how rethinking care to focus on friendship certainly offers interesting ways to support people that is less reliant on the ‘privatised’ care of families. These work for many people but far from all, either the care giver or the receiver.

It feels as if there are some key learnings for behavioural science practitioners here:  first, when considering when ‘interventions’ in the area of care, then it is important to be educated on the considerations that people such as Rosa highlight: that care delivered through families is not always available to everyone and that even when it is, there can be challenges for all involved. 

Second, more can be done to understand the psychology of different forms of friendship and the ways in which this can be a brought more to the fore as a means of supporting individuals and communities. 

Finally, there seems to be a relative lack of behavioural science on this topic – we call for a greater focus on the behavioural mechanisms that can facilitate the development of non-traditional caring communities and a better understanding of the effectiveness of the way in which both the public and private sector is able to both instigate but also support activities in this area.