The affective value of care: Assessing the outcomes of social support

Abstract

This paper argues that efforts to assess the outcomes of social care delivery ought to emphasise the generation of affective value. This value derives from the affective labour of caregiving – and the novel subjectivities that are the principal expressions of this labour – as it is organised in the delivery of social support. We ground this claim in analysis of qualitative data collected within housing assistance, community mental health, and substance use treatment services in New South Wales and Victoria. In presenting our findings, we highlight links between the affective labour of caregiving, the embodied and relational experiences of care in organisational settings, and the ways participants spoke of the outcomes of this work. We argue that these findings offer important new insights into the value of social care during a period of profound transition in the Australian care economy. Shaped by the ongoing marketisation of service delivery across this economy, efforts to formally assess the impact of social care in Australia are increasingly cast in terms of measurable service outcomes. Our analysis highlights what these measures often miss. Beyond the transactional service outcomes common to existing evaluation frameworks, we seek to highlight the affective value of care by indicating what else the labour of caring for vulnerable individuals may be shown to afford. Social care yields affective value to the extent that it facilitates the emergence of subjects with the sensitivities, capacities and ‘self-awareness’ necessary for the realisation of service goals like wellbeing, belonging, security, hope and recovery. We close by assessing the implications of this analysis for thinking about the value of social care delivery, and how it comes to matter.

Introduction

Care, in its formal organisation in the provision of social support services, is forever uncertain. What care produces, what it blocks or makes possible, how it works to generate specific outcomes consistent with the goals of social support is rarely straightforward (Fotaki et al., 2020; Tomkins and Bristow, 2023). Care is polyvalent, always a doing, a relational meshwork, an affective outcome (Puig de la Bellacasa, 2017: 3–5). We start with these aspects of care for the orientations they suggest for thinking about the everyday work of care delivery, the value generated in this work, and the ways this value is accounted for in assessments of the outcomes of social support (see Tomkins and Bristow, 2023; also Prichard and Mir, 2010). Questions regarding the value of social care have grown more urgent in recent years with the progressive rationing of service delivery across much of the housing assistance, community health, and social support sectors in many high-income countries (Baker et al., 2020; Batterham, 2019; Power and Mee, 2020). This has typically involved the ‘residualisation’ of social care provisioning (Hobson et al., 2020), including targeted eligibility criteria, caps on funding allocations and associated service entitlements, and the ‘marketisation’ of care delivery under conditions of neo-liberal ‘innovation’ (Carey and McLoughlin, 2016; also Fine and Davidson, 2018; Lynch, 2022). While experiences vary within and between national settings, a feature of the marketisation of social care internationally has been reliance on outcomes-based funding models – including ‘payment by results’ (Albertson et al., 2018), and outcomes-based performance management (Bovaird, 2014) – in which organisational funding arrangements are tied to specific service outcomes rather than discrete service volumes (see also Cluley and Radnor, 2020; Lowe and Wilson, 2017).

Common across the provision of social care in Australia, Canada, the United Kingdom, much of the European Union, the United States and elsewhere (Borgonovi et al., 2018; Fox and Morris, 2021), outcomes-based approaches require services to deliver programs in accordance with explicit care goals, which are then assessed and reported as a condition of ongoing funding. The requirement for agencies to report outcomes for individuals accessing services has renewed debates about the organisational character of care, how it is delivered, and what it produces (see Lynch, 2022; Tronto, 2017). Especially salient have been enduring controversies regarding the kinds of support that are valued within social care settings, and how this value is recognised or ‘counted’ (Tomkins and Bristow, 2023), along with concerns about whose interests are represented in these calculations (Cluley and Radnor, 2020). By explicitly mandating the role of service delivery in the realisation of service goals, a common criticism of outcomes-based funding arrangements is that they tend to restrict assessments of care-delivery to those outcomes that are most amenable to quantification (Fine and Davidson, 2018), while incentivising agencies to ‘cherry pick’ clients for whom a given program outcome might be more readily achieved (Duff et al., 2021). Another common criticism is the contention that such approaches further rationalise care by tethering it to a series of transactional outcomes, neglecting the broader social, ecological or affective dimensions of care and their role in relations of community solidarity, recognition and social justice (Lynch et al., 2021).

Set within the context of the ongoing marketisation of social care delivery internationally, this paper proposes novel ways of accounting for the value of care, the labour required to deliver it, and the ways this value is recognised in the planning and delivery of social support. In considering questions of value, the paper draws from feminist ethics of care (Lynch, 2022; Puig de la Bellacasa, 2017; Tronto, 1993), with an emphasis on the embodied, affective and relational doing of care. We are particularly drawn to the ways care is theorised in this work in relations of ‘affective labour’ (Oksala, 2016), embodied connection (Tronto, 1993, 2017), and felt intimacy (Stewart, 2007). Equally important is the contention that the value of care is a shared relational achievement – an embodied, affective co-production – rather than a material transaction in which care passes from the ‘carer’ to the ‘cared-for’ (Tronto, 1993: 105–6). In exploring these themes, we draw on studies that examine how care is practiced in organisational settings (Fotaki et al., 2020; Mumford et al., 2022), and what this care enables or achieves (Lynch et al., 2021; Tomkins and Bristow, 2023; Tronto, 2017). Read together, these discussions provide keen insights into problems regarding the value of care, who performs it, and how the labour of caregiving may be appropriately recognised and rewarded (Lowe and Wilson, 2017). We contribute to these debates by linking discussions of the value of care with attempts to identify and evaluate the outcomes of care delivery in diverse service contexts (Buse et al., 2018; Cluley and Radnor, 2020). With care increasingly rationalised in these contexts by way of discrete service transactions that may be measured, calibrated and optimised (Lynch et al., 2021), we are especially interested in those aspects of care that extant evaluation logics potentially miss. Drawing on feminist care literature we ask whether greater sensitivity to the relational and affective aspects of care may yield new insights into the outcomes of social care?

We explore this question in analysis of qualitative data collected as part of a large study of care delivery within housing support services, community mental health, and substance use treatment settings in Australia’s two most populous states, New South Wales (NSW) and Victoria. These service settings were selected for their scale and reach, being among the largest service networks across Australia’s broader social care system (both in terms of service delivery sites, and volume of service ‘episodes’), and for the demographic diversity of the populations accessing care therein (Australian Institute of Health and Welfare, 2024). Interviews and focus groups were conducted with staff across these services, and with individuals with lived experience of care delivery in these settings. Data collection focused on the delivery of care within and between housing, mental health and substance use treatment services, on the ways care is characterised for the purposes of assessing program outcomes, the ways individuals experience support, and what they perceive to be its key outcomes. In presenting our findings, we emphasise links that emerged in our data between the affective labour of caregiving, the embodied experience of care, and the ways participants spoke of the outcomes of this work. We argue that these findings offer important insights into the value of care delivery during a period of profound transition in the Australian care economy. Beyond the transactional service outcomes common to existing evaluation frameworks, our analysis points to the affective value of care by indicating what else the labour of caring-for vulnerable individuals may be shown to afford. Responding to our research question, we show how social care yields affective value to the extent that it facilitates the emergence of subjects with the sensitivities, capacities and ‘self-awareness’ necessary for the realisation of service goals like wellbeing, belonging and recovery. In so doing, we connect our discussion with wider themes of social justice and solidarity (Lynch, 2022) by indicating how practices of caregiving open out to the broader social, affective and material work of sustaining common lives in a community.

The organisation of social care in Australia

Before turning to our empirical material, we briefly describe our research context, including the key policy and organisational developments that have shaped the broader care economy in Australia in recent decades. Of central importance has been the marketisation of health and social care delivery (see Fine and Davidson, 2018 for a review), and the ways this shift has transformed the work of care delivery, how this work is valued, and how the outcomes of social care delivery are measured and accounted for. Like many countries, health and social care services in Australia have experienced waves of policy reform in this time, typically with a focus on enhanced efficiency, greater exposure to market competition (particularly between ‘private’ and ‘public’ service providers), and a more explicit focus on the delivery of targeted service outcomes (see Carey and McLoughlin, 2016; Council to Homeless Persons [CHP], 2020). While a common feature of these reforms has been an emphasis on the principles of person-centred care to drive continuous practice improvements (Duff et al., 2021), growing demand for services, coupled with ‘real-terms’ funding shortfalls relative to this demand, have led to what some have called a ‘straitened’ housing and social care sector in Australia (see Stone et al., 2024). Characteristic features of this straitening have included the rationing of care and support via caps on service support episodes, a tightening of eligibility conditions, and significant increases in the caseloads managed by staff across health, housing and social care services (see CHP, 2020; Fine and Davidson, 2018 for review).

As we have noted, an additional feature of the marketisation of health and social care in Australia has been a significant reorientation of service funding arrangements to emphasise the achievement of service outcomes as a condition of program funding. While this shift has often been touted as a means of driving person-centred care in service design and delivery (Carey and McLoughlin, 2016), it has attracted criticism for the ways it has narrowed discussions regarding what counts as meaningful service outcomes (Clarke et al., 2024). Equally contentious have been debates about evidence in the evaluation of service outcomes, including what constitutes evidence, in whose interests, and according to what kinds of methods of assessment and analysis (see also Tomkins and Bristow, 2023). These debates often turn on the ways program outcomes are framed in health and social care funding arrangements, which in Australia typically emphasise broad goals such as the resumption of good health, enhanced social and economic participation, secure housing, and/or a return to wellbeing (see CHP, 2020; Fine and Davidson, 2018: 508–12). While the discrete funding models that formally mandate these service goals differ within and between individual health and social care programs, all endorse an apparently linear relationship between the delivery of care and the generation of value (Dickinson and O’Flynn, 2016). This was a strong feature of funding arrangements across the services from which participants were recruited for the present study, as we’ll discuss shortly (see CHP, 2020). Yet this policy logic rarely specifies how individual practices of care (or particular instances of service delivery) generate value for particular service users.

This problem goes to the heart of debates about outcomes or results-based funding models in Australia, as elsewhere, with a particular focus on how questions of value may be understood and accounted for in the care economy (Keevers et al., 2012). Discussion of the emergence of an ‘audit culture’ across the Australian social care sector focused on measuring service performance against defined service goals has long emphasised the challenge of linking patterns of service delivery with specific service outcomes such as improvements in wellbeing or reductions in service usage (Prentice and Scutella, 2018). Equally salient has been concern that the integration of outcomes reporting into service funding arrangements has led services to emphasise measures that may be readily monitored and reported, particularly over shorter time periods (CHP, 2020; Duff and Hill, 2022). Typically, in responding to the requirement to identify and report outcomes, Australian social care agencies (included those that participated in the current study) have adapted measures of health and social ‘functioning’ from diverse clinical practice fields (see Batterham, 2019; Keevers et al., 2012). This has included outcomes indicators tracking subjective wellbeing, symptoms management, adherence to medication, and/or service utilisation patterns (Kilbourne et al., 2018; Manning et al., 2017). Attempts have also been made to assess the impact (or service quality) of service providers, often with reference to organisational commitments to person-centred care (Batterham, 2019; Malley and Fernández, 2010). Each approach is grounded in the contention that effective service outcomes are a function of effective service delivery, informed by the available evidence (see Tomkins and Bristow, 2023).

Value is here treated as a reliable function of service delivery, where benefits are assumed to follow from the provision of support, with less regard for the specific ways in which care is delivered in relations between individuals. Another way of making this point is to stress how impact is treated as an effect of service design, where the crucial question concerns the availability of evidence to support the design and continuous improvement of these services (Borgonovi et al., 2018; Keevers et al., 2012). It follows that outcomes assessments emphasise program fidelity, or the extent to which evidence-based interventions are implemented with strict adherence to this evidence (CHP, 2020; Cluley and Radnor, 2020). Value, in other words, derives from the evidence demonstrating ‘what works’ (Tomkins and Bristow, 2023) in the delivery of support for vulnerable individuals, and from the fidelity of program implementation consistent with this evidence (Rhodes and Lancaster, 2019). While human resources are regarded as an indispensable input supporting the realisation of evidence-based outcomes, human resources are often treated in service design and evaluation debates as a fungible service cost, necessary for the delivery of support, but less important than the specific models of care that evidence indicates make a difference in delivering good outcomes for service users (see also Fine and Davidson, 2018; Fox and Morris, 2021; Lynch, 2022).

Care, in these respects, disappears from analytical view, recognised as a service output though downplayed as a source of value in its own right (Lynch et al., 2021: 57–60). This argument is central to debates about the marketisation of social care in Australia, as elsewhere, with scholars pointing to the ways market logics tend to obscure the embodied experience of care, how it is delivered, and what it might be said to produce in service delivery contexts (Fine and Davidson, 2018). Two aspects of these critiques inform our discussion of service outcomes: first scholars have emphasised the ways outcomes-based funding models tend to erase the embodied relations of practice that characterise much service delivery in the care economy (Buse et al., 2018; Lynch, 2022). Second, critics have noted how the program logics that underpin outcomes-based funding models treat outcomes as functions of service design and implementation arrangements, such that variations in service performance become more difficult to explain in the absence of variations in program implementation (Cluley and Radnor, 2020; Duff and Hill, 2022). What this means, once again, is that program outcomes are tied to the program logics that ground service design, diverting attention from the embodied experience of care. In an attempt to overcome these blind spots, and generate more nuanced accounts of the work of social care, a number of scholars have turned to feminist care ethics to develop analytical frameworks more sensitive to the labour of care-giving (Fotaki et al, 2020; Lynch, 2022; Vogus et al., 2020). We follow this lead in our study design, drawing insights from feminist care literature into the embodied and relational experience of care, and its generative potential, as we briefly relate in the next section.

The delivery of social care

Feminist thinkers have emphasised the importance of examining how care is practiced, or laboured over, in any attempt to determine what care may be said to ‘do’ or produce (Fotaki, 2023; Lynch, 2022; Tronto, 2017). This focus on the generative dynamics of care – and its role in the production and ‘reproduction’ of the social and affective dimensions of community life (Fotaki et al, 2020: 7–10) – is central to the analysis presented in the sections to follow. Of particular interest is the challenge of investigating what care achieves in the provision of social support, and how the value of this support is understood and accounted for. Tronto’s (1993: 103) seminal definition of care provided a useful way for us to approach these interests:

On the most general level, we suggest that caring be viewed as a species activity that includes everything that we do to maintain, continue, and repair our ‘world’ so that we can live in it as well as possible. That world includes our bodies, ourselves, and our environment, all of which we seek to interweave in a complex, life-sustaining web.

This definition has long appealed, likely for the way it encompasses a mix of individual, social, collective and relational aspects of care (see Puig de la Bellacasa, 2017: 3–5). Care and care-giving are expansive categories of human endeavour involving diverse practices, modes of sociality, discourses, habits and norms. Puig de la Bellacasa (2017: 5–6) treats this activity as ‘a concrete work of maintenance’ grounded in ‘affective engagement and ethico-political involvement’ aimed at sustaining lives of ‘interconnection and inter-dependency’.

It follows, in the first instance, that the work of care ought to be understood as a mode of practice involving significant emotional or ‘affective labour’ (Oksala, 2016: 283–8). The idea of affective labour is central inasmuch as it signals a sensitivity to the embodied and relational aspects of care, and the ways care is expressed in ‘human contact and interaction, which involves the production and manipulation of affects. . .relationships and emotional responses’ (Oksala, 2016: 284). Affects, in turn, refer to the non-representational dimensions of subjective life, the mix of relational and material forces that circulate among and between bodies as ‘something we do and feel’ (Puig de la Bellacasa, 2017: 162). Affects trace the ways feeling states, energies and embodied capacities ebb and flow in and between bodies according to their interactions (Fotaki et al., 2017: 4–6). Affective labour, in part therefore, seeks the productive organisation of these encounters in order to modify the force of embodied capacitation. In this way, affects express subjective life such that affective labour may partially be understood in terms of the production of subjectivity (Oksala, 2016; also Fotaki, 2023; Puig de la Bellacasa, 2017). We can further exemplify this productivity with reference to Tronto’s (1993: 105–8) four-fold account of the practice of care, particularly her emphasis on the ‘doing’ of care and what it produces. Tronto’s first phase of practice, ‘caring about’, recognises that care is essential for a life lived well, such that the obligation to care for one another is one of the principal ethical conditions of any kind of ‘living in common’. Tronto’s second phase, ‘taking care of’, emphasises the universal need for care, but also the ethical lure of care, in that any form of life in solidarity with others requires not only the recognition of the support needs of others, but also accepting responsibility for addressing these needs. Third, ‘caregiving’ should be regarded as a central dimension of ‘common life’ as individuals come to acknowledge and then respond to the needs of those seeking care. Finally, the obverse of this obligation means that ‘care receiving’ is an equally inescapable dimension of common life, even as Tronto insists that individuals respond to the care they receive in diverse and often unpredictable ways. For Tronto (1993), this means that the idea of ‘caring well’ gives way to empirical considerations, including thinking of care as a practice as opposed to a feeling or principle, requiring sensitivity to the potential for conflict over the way needs are defined and provided for. This tends to shape judgements about what is or is not care, and the ways caregiving is resourced, particularly in practice settings where ‘caring well’ is typically treated as an essential standard for assessing the efficacy of service delivery (see also Power and Mee, 2020).

In adapting and extending Tronto’s account of care, and the practices and affective labour involved in caregiving, organisational scholars have tended to emphasise the work involved in the formal delivery of care (Duff and Hill, 2022; Gherardi and Rodeschini, 2016; Vogus et al., 2020), along with the organisational structures, policies and relations that frame this labour (Ashforth and Humphrey, 2022; Fotaki et al., 2017; Kanov et al., 2017). These interests have produced a rich scholarly corpus, as much concerned with the ‘caring organisation’ as with care in organisations (Fotaki et al., 2020; Mumford et al., 2022). Concern for the ‘caring organisation’ has emerged within discussions of human resource management and organisational behaviour, with a focus on policies and procedures that promote employee wellbeing within an organisational ‘culture of care’ (Eisenberger et al., 2020). Other strands of work have explored the affective labour involved in delivering care within organisational settings, with a focus on formal caregiving roles within human and social support services (Dodson and Heng, 2022; Fotaki et al., 2020). Often drawing from Tronto’s work and the care ethics it has helped to inspire, this work treats care as a mode of affective labour capable of yielding great value for caregivers and recipients, but often associated with significant costs for each. This latter body of work is more relevant to our research question, providing insights into the outcomes of social care by emphasising the relational and affective aspects of care delivery (see Duff and Hill, 2022; Mumford et al., 2022; Tomkins and Bristow, 2023; Vogus et al., 2020).

Methods and analysis

To answer our research question, we undertook a study of care delivery conducted within a sample of residential mental health, housing assistance and support, and substance use treatment settings in Victoria and New South Wales (see author withheld for details regarding study design and methods). These states were selected because of the diversity of social care and support programs offered in each of these three domains, for the volume of clients served therein, and the relative sophistication of outcomes monitoring frameworks in use across these fields compared to other Australian jurisdictions (CHP, 2020; Duff et al., 2021). Indeed, debates about the value and efficacy of these monitoring frameworks have long endured across these service domains, with outstanding questions regarding the best outcome measures to guide program assessments, and how direct and in-direct outcomes ought to be considered, partially informing our qualitative design, research aims and approach.

Guided by feminist understandings and critiques of social care (see Fotaki et al., 2020; Lynch, 2022), qualitative research proceeded in two phases. The first involved interviews and focus groups with a sample of service providers in Victoria and New South Wales. Participants included staff with current responsibilities for service delivery (including counselling or treatment support roles; and/or program management or staff coordination roles). Interview and focus group questions examined pathways into and out of support services, with emphasis on service design, service availability and gaps, and responses to individuals with complex health and social care needs. With an interest in the value of social care, these interviews also examined how providers understood the goals of treatment, the outcomes that care-giving is expected to produce, and how they are measured or assessed. During this phase (June 2019–March 2020), 17 interviews (10 in Victoria and 7 in NSW) and four focus groups (1 in Victoria and 3 in NSW) were completed with service providers, involving 35 participants in total. All interviews and focus groups were conducted in person at participants’ normal place of work. This contact also provided an opportunity to establish relationships to help facilitate recruitment for the ‘service user’ interviews.

The second phase of data collection involved interviews with a sample of individuals with lived experience of mental health inpatient stays, housing assistance (i.e. placement in supported housing programs) and/or residential substance use treatment in Victoria or NSW. Recruitment information was circulated via the communication channels of agencies that participated in the first phase of research and through professional networks via social media. This second phase was disrupted by COVID-19-related restrictions particularly in Victoria, which meant that not all interviews could be completed in person. In instances where it was not possible to conduct discussions in person, interviews were completed online (via MS teams). Twenty-five interviews (15 in Victoria and 10 in NSW) were completed in this phase of the study (July–October 2021). Interviews explored experiences of service support, the models of care individuals had been exposed to, including screening, assessment, planning and ‘after-care’ arrangements, along with questions of service outcomes and care goals.

Each phase of data collection was conducted with sensitivity to the specific ‘forms of attention and attachment’ (Stewart, 2007: 5) conveyed by participants in their discussions of social care (either in terms of delivering care or receiving it). This work adhered to Dewsbury’s (2010: 321–4) seven injunctions for the conduct of ‘affect-based’ qualitative research, with a particular focus on ‘points of impact, curiosity and encounter’ (Stewart, 2007: 5) as they emerged in discussions of the role of affective labour in the delivery of care. This method involved close attention to the embodied dispositions exhibited and described by participants in the course of conversation. It required keen focus on the ‘immediate and embodied’ (Dewsbury, 2010: 322) presence of our participants as they spoke about their work, as we cautiously prompted further consideration of the purposes of care and the feeling states generated in its delivery. This involved us asking considered questions, paying attention, responding to feeling states, listening carefully, all in the service of a ‘present moment focus’ (Dewsbury, 2010: 323) whereby we sought opportunities to elaborate the felt (non-representational) but still recuperable affective labour of delivering and receiving care. To this end, we were further guided by efforts to elaborate how interview methods might be used to cultivate modes of ‘affective attunement’ suitable for the exploration of affect, practice and embodiment as relevant to our research aims (see Willink and Shukri, 2018). Data analysis was organised by way of an abductive coding approach informed or ‘framed’ (Timmermans and Tavory, 2012: 174) by Tronto’s (1993: 105–8) account of the four facets of the practice of care as noted above, along with consideration of the role of affective labour in the expressions of subjectivity (Oksala, 2016). Data was transcribed and independently coded by the first and second authors, with ongoing discussion to resolve discrepancies, and to identify and allocate data excerpts to nominal categories in a first round of coding. This was followed by more detailed analysis relative to our abductive focus on care, practice and affective labour, resulting in ongoing analytical refinements as key themes emerged. Consistent with this abductive approach, we present our findings with a focus on those aspects that most ‘surprised’ us, that provided ‘unexpected’ insights (Timmermans and Tavory, 2012: 174) into the labour involved in ‘taking care of’ individuals and the affective value that follows from this labour, as it is expressed in the transformations of subjectivity.

Results: ‘Caring about’ and ‘taking care of’ individuals in services

In talking about the everyday work of ‘taking care of’ clients, service providers often spoke of the importance of determining what people wanted or needed from services, while balancing these assessments with consideration of what services might actually be able to deliver. These discussions were said to typically lead to the generation of a tailored ‘care-plan’ including the identification of formal (albeit often aspirational) service goals. It is interesting to note how often service providers talked about these discussions in terms of outcomes assessment arrangements, including for example goal-setting activities in which service users identify aspirational service goals which are later formally evaluated as part of ongoing case management, and then reported as part of outcomes assessment monitoring. Discussion of goals and outcomes is thus an integral part of care planning as people identify what they need help with, and what ‘taking care’ of them might entail. Highlighting how formalised care planning has become in social care settings in Australia, Lola a mental health service manager, stressed how ways of assessing outcomes have been progressively standardised:

They [care-planning and outcomes] definitely go together, I mean obviously we want to know we’re measuring things that matter, and we want to focus on what clients care about, but this is hard work, and everything has been streamlined. Like when we’re planning [with clients] we use indicators from the same outcomes tools that everyone uses so we can compare across services. We use the same broad fields, like wellbeing, service utilisation, family and social connections, and all the health and risk behaviours that we’re trying to work on. This provides fairly useful indications of how things are tracking, but we’re going for speed and efficiency over depth, and I’m not sure we report this properly. – Lola, Service Manager (Mental Health Treatment), Victoria

In contrast, service users tended to emphasise the importance of focused case management, with care plans explicitly tailored to their individual circumstances, as Sarah noted in discussing her experience of treatment for her substance use:

She [case manager] picked up on the issue [with my daughter] early on, and how much this was stressing me out. You know what was I going to do with her while I was [in treatment] trying to get better? . . . So she just started to make referrals to organisations that could help us. She had youth workers come and take [my daughter] to the supermarket, or take her and get credit for her phone, take her out. Whether it was looking at schools and taking her to school interviews, whether it was finding guitar lessons for her and giving her a myki card [public transport pass] so she could travel to get to her guitar lessons, but they made it so she could independently continue on doing those activities without my involvement physically. She was always thinking two steps ahead. – Sarah, Service User (Mental Health Treatment/Housing Support), Victoria

Right from the outset then we would note a discrepancy – sometimes modest, other times much starker – between the ways outcomes are stipulated in formal program monitoring work, and the outcomes discussed by service users. For instance, ‘taking care of’ Sarah and her daughter involved a series of referrals by which Sarah’s daughter was able to access the help she needed to settle into her community, while also giving Sarah time to focus on her treatment. What we’d like to draw out of this account is the ‘unexpected’ (Timmermans and Tavory, 2012: 174) realisation that the care that matters for Sarah is the help her daughter received settling into school, building connections in her community, finding a guitar teacher and exploring local shopping precincts, rather than necessarily the care that Sarah herself received. Yet the former is not the typical focus of addiction treatment evaluations, which emphasise instead outcomes to do with the care recipient’s substance use patterns, even if their personal belonging is occasionally included in assessments (Manning et al., 2017).

Other participants alluded to this discrepancy in the salience of program outcomes, in which formal evaluation tools like the ones described by Lola emphasise individual health indicators, while both service providers and participants with experience of service delivery emphasise instead the value of ‘living-well’ in the community, within supportive social networks with a strong connection to place. In a further ‘surprise’, we found that the key to this social value of care is the work of connecting individuals to new resources in their community, as Annabel put it in her discussion of ‘good care’:

Anything I need help with, she’s [case worker] on to it, working out the referral. Like I wanted to lose some weight, so she referred me to an exercise physiologist who then found me a great women’s gym and my case worker sorted out the membership fees. It’s made to suit me. In our case management sessions, we do goal setting and each month that gets reviewed, and we see how much progress I’ve made on each goal and what actions I’ve done. – Annabel, Service User (Mental Health Treatment/Housing Support), NSW

In follow up questions about these monthly reviews, Annabel spoke of how her mental health and wellbeing were typically the focus, including weight loss indications in this specific case, with briefer consideration of her experiences of inclusion and belonging. Others too spoke of the ways goal setting and review sessions tended to privilege ‘check box forms’ as one service provider in a housing agency put it, with less time to discuss longer-term goals like community engagement and belonging. While reportedly common, such arrangements tend to downplay (if not omit altogether) the subjective value of joining a gym, for example, which in Annabel’s case at least, inspired novel ways of ‘living with’ others in a community. Yet what we learned from these reports, rather unexpectedly again, is the extent to which this outcome depends for Annabel, and for others we interviewed, on the acquisition of social competencies that we should like to treat as novel objects of care, consistent with what our participants told us of the work of ‘taking care’ of people in housing and social care services. Our analysis revealed the extent to which care involves the identification and cultivation of select social competencies, which themselves express the affective value of social care insofar as this cultivation (or capacitation) is a crucial means of facilitating experiences of community belonging. While belonging and inclusion are key goals of program delivery across study sites, the means by which individuals achieve these goals are typically obscured in existing outcomes evaluation efforts.

Cultivated in the affective labour of ‘caring about’ vulnerable individuals, select social and emotional competencies embody the affective value of care in direct proportion to their realisation or enactment (see also Duff and Hill, 2022). Practically, this means that accessing support in the community, and then maintaining it, depends for example, on a capacity to manage one’s relationships in more effective ways, with less conflict and greater civility. In this respect at least, the delivery of care involves affective and embodied activities and interactions by which individuals are supported to cultivate competencies, attitudes and orientations that figure as means of achieving discrete care outcomes like community belonging, employment or improved social and family relationships. It is well known that a capacity to maintain civility is a critical condition of caregiving and ‘care-receiving’ in care settings (Gherardi and Rodeschini, 2016). Annabel’s report suggests that this capacity has a much wider reach, insofar as her goal of losing weight depends, in part, on a capacity to maintain relationships with her case worker and exercise physiologist, but also with other women socially at her gym.

In this respect then, the labour of care involves efforts to connect individuals with sources of enduring support in their communities, such as the gym in Annabel’s case, or to local services in the case of Sarah’s daughter. Yet these outcomes rely on the affective labour whereby individuals are supported by staff to cultivate select social and affective competencies that figure as the necessary conditions for enduring participation in these communities (see also Duff and Hill, 2022; Waters-Lynch and Duff, 2021). For individuals in care, facilitating access to these forms of community support entails a kind of ‘affective pedagogy’ (Hickey-Moody, 2013) by which a series of social, emotional and material competencies (habits, practices, sensitivities) are slowly cultivated. This pedagogy is an important aspect of the practical work of ‘taking care of’ individuals in the services included in this study, although it is typically all but ignored in the outcomes measures used to assess the impact of this work in these programs. Here, indeed, is a concrete instance of the affective character of care by which service staff strive to cultivate the social and emotional competencies necessary for those in care to participate more fully in their local communities. Delivered by way of these practices, care ‘works’ to the extent that it inculcates social competencies and then organises their deployment, as Steve, a substance use counsellor, explained:

The way [our] program is designed, everything we try to teach clients, the support and everything, it’s about pushing people to achieve what they want to achieve, like really good friendships, knowing your place in life, where you fit in, who you like to hang out with, where you belong. So, trusting friendships, loving friendships at the end of it [treatment]. That for me is the goal of treatment. They’re the best things, self-confidence and all that. If you’ve got that it’s pretty special. I think about it [care] this way, like my job is to help to teach people how to do that, how to have friends, how to achieve their recovery goals. – Steve, Service Provider (Substance Use Treatment), Victoria

This passage is replete with references to the affective labour by which Steve works with his clients to identify and develop a host of social and affective competencies. This includes the self-awareness cultivated in long clinical conversations about an individual’s personal histories that help them to identify ‘what they want to achieve’ in care, how to ‘belong’. These insights suggest an affective value to the extent that individuals in care put these skills to work in the cultivation of a supportive community grounded in ‘really good friendships’ that can support one’s ‘recovery goals’. As Steve notes, many of his clients have never experienced this kind of community (friendship and peer support) before, and so the work of treatment involved for him at least, helping clients learn how to cultivate and sustain ‘loving friendships’ and greater ‘self-confidence’. What’s more, Steve regards these achievements as the ‘goal of treatment’, as the ‘best things’ clients may experience as a result of their time in care.

The next quotation provides further indications of the affective labour central to the cultivation of these social capacities, including for Richard in this instance, at work:

I learned in [drug] treatment so much about honesty, about talking to your friends, not closing down, talking about your situation, so that’s really helped. Like at work now, I feel I can talk to him [boss] without so much bullshit. I have to leave work early sometimes, like for appointments, so I can just say to him, “look this is going down, I need some time”. He’s really aware and really supportive, that makes a huge difference to someone in my situation. I’ve been working really hard at that [maintaining dialogue at work] and it’s really helping. – Richard, Service User (Substance Use Treatment), NSW

Learning how to manage one’s relationships differently by, for example, speaking with greater ‘honesty’ rather than ‘closing down’, is critical for sustaining more meaningful social networks with less conflict. These affective skills, in turn, are the foundation for more effective communication with others, providing a way for Richard to maintain stable employment. The crucial point of our analysis is that access to the community, to work and to enduring social networks, with all the affective, social, therapeutic and economic benefits they may potentially avail, is conditioned by this capacity to develop and maintain social connections. Self-awareness, and a capacity to identify and manage one’s emotions, stand out in the interview material as key social and emotional competencies that the affective labour of caregiving helps individuals to cultivate. Coming to understand oneself, and one’s unique emotional habits, introduces the possibility of modifying these patterns in cultivating stronger personal relationships, a more contented sense of self, and a better understanding of the factors that might have led to interpersonal conflict in the past. Many participants spoke of the value of this kind of ‘training’ and how they were seeking to apply lessons derived from their experience of care to other parts of their lives, as Bianca explains:

What really clicked for me [in drug treatment] was all the work on regulating your emotions, and that’s something I wasn’t aware of, but it gave me a lot of answers about myself. Once I understood what regulating your emotions was all about, I was able to start implementing that in my everyday interactions. This was really important for me, I mean after all this training, I now have a pretty good understanding of myself, and also a broader understanding of why I turned to drugs in the first place. So the support [from staff] has been great, just the growth, from week to week, it’s been amazing. Now I understand why most of my relationships have been so toxic but also really how to avoid that now. – Bianca, Service User (Substance Use Treatment), NSW

When pressed to identify the practices they employed to promote these outcomes, staff working in mental health and/or substance use treatment emphasised the work of ‘emotional regulation’, resilience and integrity, ‘self-awareness’ and ‘being authentic’ as the keys to maintaining health and wellbeing over the longer term. Describing what this work entails, the mental health counsellor Vinh noted how:

We see people with really complex needs, right across their mental health and housing and their family and social life. I mean people haven’t always learned about honesty and trust and authenticity, or they really struggle [with this] because of some of the things they’ve experienced in life. I really start with like ‘who am I’ questions, and ‘how am I feeling’ questions to try and dig out what people want to achieve [in treatment]. This part of the process is just long conversations, patience, active listening, coaching and training people to think about how they might manage challenges in their lives in different ways. – Vinh, Service Provider (Mental Health Treatment), NSW

A number of service providers mentioned how demanding this work is, listening to often ‘traumatic’ life histories, identifying techniques that might help individuals make different choices in life, reflecting on their social and emotional lives, all of which involves the management of ‘affects. . .relationships and emotional responses’ that Oksala (2016: 284) highlights in her discussion of affective labour. Moreover, this labour has material benefits, as the following excerpt illustrates, in this case by helping Adam to secure stable housing following a period of drug treatment, something that he had reportedly long struggled with. For Adam, the key to this outcome was the support he received from his caseworker to cultivate the relational capacities by which he could more effectively manage the difficulties he had previously encountered searching for housing, for example, by negotiating with landlords and housemates:

I was leaving rehab, and I needed somewhere to live, [but] there are so many options, it was overwhelming. But if people are encouraged and equipped with the ability to go and meet a few people, a lot of the time they can come to an arrangement with somebody they get along with, not just these crisis houses. But a lot of people don’t have the skills to be able to go and discuss it with private landlords. So that’s what rehab did for me, with my caseworker’s help and with the peer support worker, I’ve got a bit more confidence to manage these conversations now, so I’ve been able to get into housing with that support. – Adam, Service User (Housing Assistance and Support), Victoria

It’s important to stress in Adam’s account how his access to secure housing depended at least in part on the prior work of cultivating a set of affective competencies by which Adam learned how to improve his relationships, to cultivate his social networks within a web of relations of trust and reciprocity, so that he might later maintain his housing (see Power and Mee, 2020). Learning how to make a home, to get along with others, to manage conflict more effectively, to establish good relationships with bosses and colleagues, all of the skills so essential for the maintenance of wellbeing figure among the central objects of care as it is formally practiced in the social care services involved in this study. Caregiving may thus be reimagined after the work of Tronto (1993, 2017) and Puig de la Bellacasa (2017), as an affective practice of weaving together the rudimentary threads of sociality. Caregiving organises affective and material competencies, and then puts them to work in the service of wellbeing in a community:

The last few months I’m getting out more, I’m settling in [to the area]. I’m talking more with the locals. Like there’s a little boy across the road that comes out and he’s always looking for the dogs like when we do our afternoon walk, he’ll come over and say hello. I’ve got the lady next door that comes in once a week with a plate of chocolate chip muffins. So we’re starting to find, like it’s not just a house anymore, it’s a home, and I’m finding that I feel, not only do I feel in my own personal journey, like I’m not a strain on the system like I was, I feel like, not that I’m giving back, but I feel like I’m not in trouble with the law and stuff like that. So I’m not a strain on taxpayers, like I’m living in my community more. – Matt, Service User (Mental Health Treatment/Housing Support), Victoria

Matt here provides a poignant description of ‘ordinary’ community life (Stewart, 2007). Yet for individuals with experiences of adversity – periods of mental illness, instances of housing insecurity, ‘trouble with the law’ – living life well, in all of its mundane details, requires sustained community support. The point we wish to emphasise is how much of the practice of care involves helping individuals to access these community supports in and through the cultivation of distinctive social and affective competencies. This may be as direct as helping individuals develop greater self-confidence and emotional awareness so that they can enjoy ‘talking more with the locals’, walking with one’s dog, becoming friendly with the neighbours, feeling as if they belong. These skills are the social and affective keys that unlock access to social networks within a community. In each instance, the cultivation of these competencies might be usefully described in terms of the work of shaping, producing or fashioning particular experiences of subjectivity (Oksala, 2016). Instances of this labour stand out in our data, yet they are all but absent in discussions of the outcomes of social support.

Discussion: Social care as a labour of transforming subjectivity

Our analysis has emphasised the relational and affective aspects of care in an effort to generate insights into the outcomes of social care delivery. We argue that these outcomes should be understood in terms of the affective value that derives from the practice of ‘taking care of’ vulnerable people. As it is delivered in the housing and health services that participated in this study, care is organised in support of the realisation of a series of distinctive social, affective and material competencies. After Puig de la Bellacasa (2017: 20), these skills may be said to express a ‘collective disseminated force . . . distributed across a multiplicity of agencies, materials and supports’. Expressed in these forces as they variably affect bodies in service settings, care forges a ‘thick mesh of relational obligation’ (Puig de la Bellacasa, 2017: 20). This mesh is a product of the affective, social and material labour of care as it begins to work on the affective, social and material dimensions of subjectivity. Importantly, none of these aspects are recognised in the formal outcomes assessment arrangements in use across the care economy in Australia, which as we’ve noted emphasise instead matters of individual ‘functioning’ including measures of recent substance use or subjective wellbeing indexes. Of course, these aspects matter, but care also targets the social and affective bearings of subjectivity in an affective labour that seeks the very modification of this subjectivity (see also Duff and Hill, 2022). This affective labour is performed in group work and recovery sessions by clinicians and peer support workers, and by care recipients themselves, as they labour to realise new forms of self-care, emotional regulation, personal insight and self-knowledge, such that they might come to communicate differently with others, develop new strategies for maintaining their relationships, new ways of managing difficult emotions, and new ways of living in solidarity with others (see Lynch, 2022). Crucially however, this labour should be treated as a necessary preliminary phase of the broader task of enabling individuals to realise new means of participating in (or belonging to) their communities.

Care in these respects has both a proximal and more distal goal, expressed in the first instance by way of the affective labour of a vital subjectivation as care recipients slowly acquire novel social and affective sensitivities and capacities. Although crucial in its own right, this affective labour also serves a more distal goal, establishing the social and affective means of living in solidarity with others, in ways that are more sensitive to others’ needs, and to the values of social justice that ground collective life. This capacitation relies on the affective labour by which service users cultivate the means of engaging more fully with their community. This is the affective value of care, realised in the work of subjectivation by which individuals are enrolled in the relational obligations of social life. Others too have observed this affective mode of organising (Ashforth and Humphrey, 2022; Fotaki et al., 2017; Sage et al., 2020; Waters-Lynch and Duff, 2021), particularly as it begins to transform what Woodward (2011) calls ‘affective life’. In this regard, social care may be treated as a mode of organising that operates in and on affective life, and the embodied capacities that it expresses in the realisation of diverse forms of affective value (Cluley and Radnor, 2020: 220). Sage et al. (2020: 347) add that this organisational mode intervenes within ‘affective encounters themselves’ according to select ‘interests and agendas’.

Within the varied services that participated in this study, these interests and agendas mainly concern reportable service outcomes that focus on matters of individual functioning, subjective wellbeing and community attachment. The major insight advanced in our analysis is the contention that these disparate outcomes follow from the affective labour of ‘taking care of’ individuals by supporting them to identify, cultivate and maintain select social and affective competencies. Care works directly on the affective encounters by which individuals experience common life, according to the novel practices and competencies that facilitate this sociality. This analysis helps to exemplify the affective labour of care as it modifies the rudiments of affective life, as caregivers seek to inculcate a series of social, affective and emotional competencies that themselves express forms of affective value by which individuals are able to access, create and sustain experiences of belonging and community. It suggests, moreover, that making sense of the varied outcomes of social care delivery requires greater sensitivity to the affective labour of this capacitation, and the work done in care to cultivate particular kinds of subjects endowed with particular kinds of affective capabilities. This work of subjectivation is oriented to the larger project of connecting care recipients to those diverse communities and social networks that might enable them to sustain experiences of wellbeing in common (Duff and Hill, 2022).

Responding to our research question, our specific claim is that social care affords varying kinds of affective value to the extent that it expresses subjects capable of identifying, accessing and sustaining life in a community. Instances of this value may be observed in Matt’s account noted above of his experiences developing novel social ties in his neighbourhood, along with Annabel’s example of how she was encouraged to ‘get more involved in the community’ at her local gym. Additional examples of the affective co-production of solidarity in social life may be observed in Bianca’s discussion of the social and emotional skills she developed during her time in treatment, or Richard’s reports of the benefits of learning how to be ‘more honest and real’ in his relationships. The affective value of these competencies is expressed in the novel social relations they support, in new forms of attachment, a reliance on the care of others, and a new capacity to care for others in turn. This is the attachment by which communities form, such as the sociality enacted within Adam’s new housing, at the park for Matt, or at Annabel’s women’s only gym. The relations of solidarity evinced within these spaces are made in and through complex emotional and affective encounters. This is what Puig de la Bellacasa (2017: 20) means when she emphasises the social, affective and material force of our ‘relational obligation’ to others within a community, and the resources, encounters and relations that sustain them. This force is equally apparent in the reports presented above of the ways individuals in care cultivate the capacity to identify, access and sustain a community in this common life.

Our analysis has important implications for the ways social care is delivered, and for how the outcomes of this work are evaluated, just as we must acknowledge some significant limitations. The first thing to note is the deeply affective bearing of care, both in terms of the affective labour involved in its practice, and the affective value that this care may be shown to generate. This labour is the principal means by which successful program outcomes are realised, although the value of this labour is mostly ignored in formal evaluations, including the time it takes to cultivate relations of trust and solidarity such that the competencies that this labour seeks as its major outcomes may be cultivated. Managing symptoms of mental distress, placing people in secure housing, and reducing the incidence of substance use are crucial goals, but these outcomes are sustained over the longer term in the realisation of social and emotional competencies that transform individuals by working on subjectivity itself. The affective labour involved in these latter aspects of social care barely features in outcomes evaluations, missing much of the value of this care. It follows that such evaluations ought to be revised to enable greater sensitivity to this affective bearing, mainly by assessing how practices of care are co-produced in relations between individuals and groups in organisational settings, and how this work supports the expression of novel social, emotional and affective sensibilities like emotional regulation, self-awareness, honesty and a regard for social justice. Efforts to assess services outcomes need to take this affective context into account, by recognising how much of the work of ‘caring for’ individuals in support settings involves a kind of affective modulation of subjectivity. This is to insist that the goals of recovery and wellbeing, community belonging and social and economic participation, are themselves a function of a set of affective capacities that take time and care to cultivate. This time needs to be valued, and the housing agencies, community mental health services and substance use treatment settings that deliver this support ought to be more generously resourced to deliver this care, something that the ongoing marketisation of care mostly undermines.

Yet there are limitations of course to these arguments. First and most importantly, for individuals experiencing mental distress or homelessness, the most crucial outcome is the immediate effort to reduce this suffering. Questions of subjectivity and affective competencies must follow from this immediate focus. This would suggest that our findings are most relevant for the community care sector with its focus on recovery and social support, rather than clinical or acute health and social care settings where treatment is the main focus. Likewise, our research design has no doubt failed to address aspects of the gendered and embodied delivery of social care that a more immersive, perhaps ethnographic field method, would have been more sensitive to. Had we more time to observe and ask questions of group discussion sessions and similar developmental activities in our study sites, we would likely have been able to tease out aspects of the affective labour involved in this work, and more of its affective value. It is further likely that other kinds of affective labour are involved in the delivery of care in other kinds of services, disability support and family violence agencies for example, suggesting the need for caution in extending our analysis to these settings.

Conclusion

We have sought here to redefine the value of social care delivery by indicating how the affective labour involved in ‘taking care of’ vulnerable individuals helps to nurture the ‘life-sustaining web’ that Tronto (1993) describes. Where the delivery of social care may be said to be effective, where it delivers social, economic and/or personal value, these outcomes are locally realised in experiences of community solidarity (Lynch et al., 2021). Sustaining these experiences is, in turn, a function of the affective labour that variously shapes and modifies the subjective bearings of individuals in care. It involves connecting the affective and the social as they are entangled in the practice of care in organisational settings. Properly scrutinizing these entanglements has the advantage of illuminating logics of care in these settings and what this work may be shown to generate. Efforts to identify and assess the value of social care must become more sensitive to the affective labour involved in this care, as well as the affective value generated therein. Tools for measuring the outcomes of social care ought to become equally sensitive to this affective value, along with its uniquely social and material contexts. Social lives are made in those relations and attachments that reveal the affective value of care in a commons, in the solidarity of a life lived well with others.