Cynthia J. Cranford’s sociological orientation is well reflected in an approach that links micro-level interactions between personal support workers and care recipients to broader systems of funding, gendered and racialized labour markets, collective organization, and program models. Although intimate tensions in domestic and personal support work have been established in previous scholarship, Cranford expertly knits these tensions to intersecting axes of marginalization, and to larger theoretical frames that signal our collective responsibility for addressing the social contexts of care and care work.
Cranford provides a multi-level comparative analysis of four different models of in-home support programs: one in Los Angeles and three in Toronto. All programs are state funded, some are means tested, and all are privately delivered (for-profit or not-for profit) with clients/consumers directly or “de facto” acting as employer (perhaps least so for the Toronto home care program). Only one program (in Los Angeles) appears to primarily serve older adults (the unfortunate term “elderly” is used); the other three appear to primarily serve adults living with lifelong disabilities (although demographic data are at times unclear). Cranford aims to present a nuanced view of the positive and negative aspects of the four programs and does not shy away from critical engagement with the data.
There is, nonetheless, plenty of interest for gerontologically oriented readers. Home care is often devalued, and discursive framings of its purpose has shifted over time, from supporting everyday quality of life to providing “extras” that can be done without or could be done by family. Increasingly, home care’s primary value is assumed to lie in diverting people from costlier institutional forms of care (Ceci & Purkis, Reference Ceci and Purkis2011). Yet programs rooted in independent living models, such as Toronto’s well-funded attendant program (Chapter 6), demonstrate the possibilities for re-envisioning what home care for older adults might look like: “rather than a predetermined set of tasks, [agency managers] expected attendants to do the personal-support-related tasks the consumer wanted done in the time they had, with few limits” (p. 140). For me, this description was inspiring.
Cranford’s case studies not only prompt us to consider alternate models of home care for older adults (as most home care for older adults in Canada resembles the third case study presented), but also illustrate the need for collective representation of home care clients/consumers, worker unionization, and supports for everyday interactions between clients/consumers and workers. The book is structured around the central idea of tension “between flexibility for recipients and security for workers” (p. 3) and a need for balance in this regard (“flexible security”). At the intimate level, flexible security hinges on respectful relationships being recognized and valued.
The finding that client/consumer participants strongly desired labour market level flexibility (e.g., hiring and firing workers) might in part reflect their self-selection into programs that provided such flexibility, as well as the client/consumer sample (i.e., primarily adults of various ages, living with long-term disabilities). A preference to self-direct one’s care, Cranford notes, was perhaps less of a priority for older adults, who “did not have such an articulated critique of medical expertise” as those who had lived with lifelong disabilities (p. 52). This finding fits well with other research (Fitzgerald Murphy & Kelly, Reference Fitzgerald Murphy and Kelly2018) which indicates that the increased choice offered by direct funding models “com[e] with increased legal responsibilities and often administrative tasks that many older people and their supports find burdensome” (p. 37). Cranford also notes that older adults may be less likely to complain or ask for another worker when treated disrespectfully.
Old age is not of course, the focus of the book. Rather, Cranford excels in highlighting complex processes of racialized labour markets, which tend to funnel migrant women into precarious personal support work (e.g., Chapter 1); in drawing out intersecting axes of marginalization shaping home care clients/consumers’ desire for flexibility (Chapter 2); and in demonstrating how programs that enhance labour market flexibility, especially when inadequately funded, can erode the employment security of a gendered and racialized workforce, leaving both clients/consumers and workers on their own to negotiate everyday relational tensions over knowledge, skill, time, and tasks.
The primary shortcoming of the book is the lack of clear, in-depth information about the methods of interviewing and analysis, as well as a lack of details about the data and sample. Initially we learn that 300 people, including workers and clients/consumers in the four programs, as well as key informants, were interviewed. Methodological comments (e.g., that some people were interviewed in groups, some in dyads) had little elaboration. Descriptive information about participants (e.g., types and ranges of care that clients/consumers needed and/or received, socio-demographic backgrounds) is revealed in subtle ways throughout the book rather than clearly at the outset. Unreferenced material in the notes section indicates key details needed to grasp earlier claims about the findings (e.g., “half of the clients in my sample… while nine others…” p. 112). Specifically, in terms of participants, the Los Angeles case study included 15 worker interviews and focus group interviews with 31 consumers; the Toronto home care study included 44 clients and 52 workers; the Toronto attendant program study included 29 consumers and 19 workers; and, I deduced, the Toronto direct funding study included approximately 12 consumers and workers.
Further, I would have preferred a clearer definition of “relational work” (especially vis-a-vis “emotion work”), as repeated claims are made about the need to value and support this work. Relational work appears to include efforts made by clients/consumers or workers to suppress or control their emotions even when disrespected or treated poorly, to be friendly yet professional, and to resolve conflict and compromise over knowledge, skill, time, and tasks. It includes negotiating the symbolic “fine line” (p. 72) of separating personal support from household servitude, as well as how clients/consumers and workers come to know each other as individuals, and to interact in a responsive, flexible way. At times, “relational work” is presented as interdependent and reciprocal; at other times, it is presented as driven more by self-managers or positioned as a skill that can be taught to both clients/consumers and workers or as mutual respect that can be mandated, with less attention given to the potential negative consequences of relational work, for example, engaging in long-term surface acting (Hochschild, Reference Hochschild1983).
Readers of Cranford’s book will develop a clear sense of how home care workers and clients/consumers navigate interactions and complex layers of inequalities, primarily as individuals, with few collective or structural supports. Cranford highlights the importance of coalitions between unions and community-based organizations (e.g., immigrant, disability, and senior’s groups) and, more importantly, suggests how this can be done, so as to promote both flexibility and security in the home care sector. Democratic alliances among movements need to be guided and organized through “an intimate community unionism” (p. 163) across multiple levels and lines of difference, embedded in universal social funding, oriented to home care as a citizenship entitlement, and conceptualized as an interdependent relationship structured by power and inequality.
Cranford’s work is significant in the context of COVID-19, supporting calls that have been made during this time for increased attention to and funding for the home care sector, a sector that has seen decades of cutbacks or lack of increases in funding as it is increasingly being relied on to meet post-acute needs as well as to respond to the expectations and preferences for people to live at home for longer. When paired with Levitsky’s (Reference Levitsky2014) work, readers will not only be particularly motivated to create lasting positive change, they will also see how this can be realized through collective action.
