Abstract
As a 24-year-old social worker just entering the profession after completing her graduate studies in clinical social work, I am reflecting on entering a field in which the feminist ethics of care that I aspire to do not seem to be structurally supported. My feminist values, my queerness, my womanhood, and my nonwhite skin—as well as my experiences as Affilia’s editorial assistant for the past 2 years—have pushed me to think deeply about this topic. My vision of a feminist ethics of care is best summarized by the social policy scholar Marian Barnes (2012): “Care is not separate from, or in competition with, justice as a core value” (p. 183). In my view, holding justice as a core value in feminist social work means incorporating a relational understanding of social context into its assessment and treatment norms. In further exploring the concept of feminist ethics of care, I turned to the feminist psychologist and ethicist Carol Gilligan (2011): “an ethics of care directs our attention to the need for responsiveness in relationships (paying attention, listening, responding) and to the costs of losing connection with oneself or with others”. Care in feminist social work must include the practice of helping clients to understand and articulate the institutional forces shaping their individual choices and experiences (Harris & White, 2018). Thus, in my view, feminist social work ethics of care requires flexible, relationally responsive, and justice-oriented practice.
In the following pages, I contrast different approaches to care practiced in hospital systems in Boston, MA, where I received training in clinical social work, and the Boston Abortion Support Collective (BASC), where I volunteered as a member. I believe that BASC’s feminist ethics of care, which is grounded in financial flexibility and justice-oriented care outside of professionalized social work, has much to teach the profession of social work.
Systemic Constraints to Feminist Ethics of Care: Hospital Metrics, Billable Care Norms, and Disposability Politics
I completed both of my graduate social work field placements in large, highly regarded hospital systems. As a clinical social work intern in these systems, I quickly learned from coworkers and supervisors that metrics and billable diagnoses, rather than socially contextualized, patient-responsive care, were the institutional drivers behind how care was structured. Hospital systems’ prioritization of patient metrics—intimately tied to insurance reimbursement—promote a norm of decontextualized, symptom-focused diagnosis and treatment. In both hospitals, I was confronted with a number of rigid, binary protocols designed to keep track of clients in terms of cost and risk. Kim (2011), a current member of Affilia’s editorial board, identifies the false binary between risk and safety, naming “a fetishization of safety” (p. 21) in antiviolence organizing. In both of my placements, this fetishization emerged in the form of institutional obsessions with trackable data. The required checklists tracking clients’ “risk factors”—for suicide, addiction, and violence, and so on—did not capture the nuances of whether a client was actually safe or unsafe, especially given that they were often completed just a few minutes after meeting the client.
In these hospital contexts, care work was restricted to billable symptoms and treatment. Hospital systems discouraged me from holistically and collaboratively conceptualizing about what might be contributing to the insomnia of an unemployed housing-insecure client with chronic pain. I was encouraged to think of him only as someone with insomnia—a billable condition—rather than a person whose negative experience of poverty under neoliberal capitalism was contributing to his poor mental health. Institutional norms within hospitals disincentivized acknowledgment of the social factors causing, contributing to, or actively worsening clients’ DSM-V (Diagnostic and Statistical Manual of Mental Disorders-5th edition) diagnoses. To acknowledge these social stressors would be to include un-billable information in medical records that were audited by insurance companies for reimbursement purposes. For insurance companies, clients’ social contexts and experiences of oppression seemed to be irrelevant—yet with clients, understanding and discussing social contexts was essential. More broadly, clinical social work norms within these hospitals discouraged this kind of contextualizing talk with clients, viewing such conversations as political self-disclosure that violated the supposedly neutral professional therapeutic frame.
Hospitals’ institutional norm of ignoring the structural determinants of mental health feeds a “politics of disposability,” wherein marginalized individuals who are unable to thrive under neoliberal capitalism are viewed as burdens to the system rather than as individuals burdened with “innumerable conditions, such as income inequality, incarceration, surveillance, debt, health disparities, shorter life expectancy, and feelings of scarcity, insecurity, and worry” (Cherry, 2018, p. 45). Without social, political, and economic contextualization, clients are deemed lost causes instead of human sites of intersecting systemic oppression. Psychiatric care in these hospital settings focused on acute and discrete symptoms that could be clearly identified and measured, which meant that social determinants of health were inherently decentered. Acuity became a driving force that determined provider decisions about how much time or energy to spend on so-called complex patients. Within the institutional frame of neoliberal disposability politics, I was expected to generate numeric data about clients in ways that were entirely removed from the qualitative and structurally determined challenges in their lives. If clients could not be adequately described using the numbers and key words that insurance auditors were looking for, they were seen as troublesome and difficult to work with. Hospital systems invested in clients who were less disposable, in that their problems were less structurally induced and more psychologically quantifiable.
There is no doubt that the hospital systems provided tangible benefits to clients. Both of the hospitals in which I interned were easily accessible to uninsured individuals and individuals on Medicaid. Patient financial services and case managers were on hand to support such patients in navigating those systems and to aid them in obtaining other services. Psychiatrists were on hand to prescribe medications that improved my clients’ quality of life. The availability of these resources was overshadowed, however, by the persistent hospital-wide mentality of resource scarcity. This mentality was no doubt reinforced by the reality of long clinic waiting lists that resulted in overbooked staff time. Institutional norms dictated that time and money were precious resources that could rarely be spared beyond set session times and billing rates. Despite my own desire to do things differently, I fell into patterns of standardized measurement with clients at times where holistic engagement might have been more therapeutic. Encouraged by hospital norms, I decontextualized clients’ symptoms in their mandatory treatment plans; the hospital’s concern with insurance reimbursement loomed ever-present in the back of my mind. The capitalist, metric-focused structures determining hospital care standards did not allow me to integrate sociopolitically contextualized feminist ethics of care into my clinical work with clients.
Abortion Support in Boston: Possibilities for Justice-Based Caregiving
Outside of my clinical social work internships, I was involved in community-based work with BASC, a volunteer group where feminist ethics of care were more integrated into the organization’s processes and community. BASC is a collective of volunteers who provide physical, logistical, emotional, and practical support to clients before, during, and after their abortion procedures, whether they are surgical abortions carried out at clinics or medication abortions conducted at home. Through its all-volunteer collective, BASC provides rides or money for public transit, companionship and emotional support in clinics or at home, and simple remedies for pain/nausea during and after procedures. BASC also coordinates with a local abortion fund to secure any necessary funds to cover the cost of any abortion procedures that are not covered by clients’ insurance plans.
BASC’s feminist care ethics are relationally responsive, in part due to the flexibility that is enabled primarily by its financial structure. Whereas hospital systems rely on insurance reimbursements that strictly determine what kinds of care are possible within them, BASC’s work is primarily funded by individual donors from within the geographic area. Operating without 501(c)(3) nonprofit status was a consensus-based decision made by the collective. Financial accountability within BASC entails transparent use of funds for client needs, complete reimbursement to volunteers for abortion support costs, and budgetary norms that are not created or enforced by anyone but the members of BASC. Outside of a nonprofit or insurance billing model, BASC’s volunteer care workers are liberated from the documentation demands of insurance companies and grant reports. When making decisions about budgeting and spending as a collective, BASC is not beholden to mandatory standardized documentation that expects care workers to exclude or ignore the key structural forces operating in clients’ lives. In this way, BASC resists the tendency to shift accountability toward funders, instead channeling collective energy toward responsiveness to clients’ situations. This is reminiscent of Gilligan’s (2011) definition of ethics of care, which emphasizes the importance of “responsiveness” in caring relationships. In the case of BASC, that relational responsiveness emerges in flexible funding decisions made with the intention of meeting client needs.
Feminist ethics of care within BASC are also fostered through its collective management structure, which eschews a formal hierarchy of professional leadership and a board of directors. All members have an equal vote in organizational decisions. BASC members of all identities and experience levels can become directly involved in all of its processes: making funding decisions, planning trainings, managing volunteer reimbursements, and negotiating collaboration with clinics and local agencies. BASC operates as an accountability-based collective, meaning that accountability to clients and fellow collective members is valued above accountability to funders. Through affinity and accountability subgroups for members of privileged and marginalized identity categories, BASC is able to assess areas where it may be failing marginalized members and clients. In the spirit of accountability to BASC’s transgender and nonbinary members and clients, the collective has adopted degendered language in its materials about its services. In the spirit of accountability to its members and clients of color, BASC has stopped using the word “doula,” a word originating from the ancient Greek word for woman slave (Moore, 1991), to describe what BASC does. Class accountability processes have ensured that the collective does not overpolice members who use funding to flexibly support clients through their abortion procedures—for example, BASC does not require receipts to be submitted before reimbursement when members report how much they have spent while supporting clients. This trust-based accountability structure serves as evidence that alternative forms of power-conscious flexible care are possible.
As BASC grapples with questions of identity and power internally, it grows in its capacity to respond to client needs with care that more fully integrates feminist and social justice principles. In practice, this means engaging in conversations with clients, collaboratively working to understand institutional forces that shape and constrain clients’ individual lives. Unlike hospital systems in which such conversations were proscribed as unprofessional self-disclosures, BASC encourages its membership to have open conversations with clients about the effects of structural constraints—including limits on health-care coverage, child welfare system involvement, and contraceptive access restrictions.
Lessons for Feminist Social Work From Abortion Support Work
Care models like the BASC’s are not entirely new. As Kemp and Brandwein (2010) have written, underground feminist collectives provided first-trimester abortions when abortion was still illegal in the United States. Earlier this year, media attention turned to the history of the “Jane” collective in Chicago, named for the pseudonym that clients would ask for when calling for then-illegal abortion services. This collective started as a referral service in the 1960s, but eventually began performing the abortion procedure themselves (Lampen, 2018). At the time, illegal abortion collectives like the “Janes” existed outside of formal nonprofit structures, as the work they were doing was in essence civil disobedience. The strength of the “Janes” lay in their collectivist values and freedom from the kinds of rigid protocols that dominate hospital systems (Bart, 1995). Similarly, BASC is strengthened by its collective accountability structure, members’ shared value of justice-based care, and the group’s capacity to provide flexible support to clients by virtue of its financial norms. Both BASC and the “Janes” are also notable for their existence outside of professionalized social work structures.
Commenting specifically on the professionalized nature of anti-violence social work, Mehrotra, Kimball, and Wahab (2016) observe that as social service organizations with feminist roots begin to require degrees and credentials to work within them, many feminists and women of color decry these organizations’ shift “away from its community-based, feminist, grassroots structures and analysis” (p. 155). The very strengths that work to prevent such a shift, however, also pose significant challenges for the collective. As a collective committed to integrating power consciousness into its work, there is also a significant risk of falling into reductive binaries of power and identity that are ultimately unhelpful in maintaining cohesion within BASC. While identity politics can be useful for understanding how power may be operating within the collective, they can also become tools of exclusion, collapsing any possibility of individuals’ identities existing somewhere between marginalization and privilege. Though BASC has occasionally held groups for individuals who identify within the in-between—for example, middle-class members or members who are self-identified white-passing people of color—it has been difficult to collectively think and act outside of the binary accountability-and-affinity framework. BASC’s care work is enhanced by its decision to prioritize feminist understandings of client experience and divest from metric-based documentation—clients are more freely able to have their needs met without having to navigate checklists and billing codes—but this comes at a cost as well. Without thorough documentation or consistent metrics on client experiences, BASC’s records do not have the legitimacy that comes from measurable patient improvement reports generated from insurance-mandated treatment plans.
As a group operating without regular large-scale funding, BASC’s dependence upon individual donors poses a financial risk for the group. There is no way to know if there will continue to be consistent financial support for the work that BASC does. Perhaps this financial precariousness is inevitable within a neoliberal capitalist state. This financial support depends upon the individual will of hundreds of small donors. While BASC has opted out of a nonprofit structure, it still faces labor-based constraints. It is completely reliant upon the time and energy of a membership with the capacity to do unpaid care work. This, in essence, has a gatekeeping function, excluding individuals without the energy and free time to devote to unpaid care work for BASC clients. Professionalism, however, also serves a gatekeeping function. This perspective is corroborated by Smith’s (2007) critique of the nonprofit industrial complex’s tendency toward professionalization: “By trying to do grassroots organizing through this careerist model, we are essentially asking a few people to work more than full-time to make up for the work that needs to be done by millions” (p. 10). In essence, the professionalization of care work excludes individuals without educational access from providing justice-based care.
BASC—with its strengths and difficulties—can be viewed as a case study of feminist ethics of care. The collective’s work is done outside of the professional bounds of social work, and yet it holds significant implications for the approaches of feminist social work practitioners and scholars alike. Inspired by the legacy of underground feminist collectives before it, BASC is revisioning the feminist delivery of care. During a time in which neoliberal forces continue to constrain and shape service provision in the United States, feminist social work and feminist ethics of care are more necessary than ever. In order to ensure the survival of feminist social work when such work is actively devalued and dismissed by policy makers, creative strategies of survival are necessary. I believe that some of these survival strategies exist outside of social work, in community-based grassroots collectives such as BASC. These collectives demonstrate that it is possible to do care work while also maintaining a justice-based lens with clients. However, within structures that are more financially dependent upon the state for funding, a total transformation toward justice-integrated care may not be possible. As a newcomer to this work, I am excited by these opportunities for power conscious and creative collaboration within and outside of the nonprofit industrial complex. By learning from and collaborating with organizations outside of agencies and nonprofits, feminist social work is better positioned to fight for its survival.