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In these papers the various authors, and Roger Clough and Phyllida Parsloe especially, struggle to review and revise the implications of deeply held values and attitudes to the provision of care. I want here to expand some of my responses to the struggle, which I shared with them of articulating views which are in part changed, in part more firmly held. So this is, in effect, an attempt to tease out some elements of ideologies as they are called in, and will be called in by our readers, when discussing the public organisation of 'caring' services.
It is significant, first, that one may jib at the term 'ideology'. Surely that is something the other person holds? But I think it a necessary term provided we define it with care.
Relying heavily on Raymond Williams (1976) therefore I want to use it not in the pejorative sense of 'abstract and false thought' nor in the purist social science usage as 'a speculative system,' as distinct from a scientific description of demonstrated facts. I use it rather as a general term to describe how people become conscious of conflict, arising from changes in the ways in which the state and private individuals organise care for themselves and each other, and how they arrange their thinking in consequence.
It is well to begin with elements of ideology implicit in the inversion of my title. 'Being looked after' implies an essential element of some dependency. However much each of us might cherish our independence it would be clearly unrealistic to assume that during our expected life span we shall never need to be dependent on some services and persons. It becomes necessary to say this in a verbal climate where 'dependency culture' has become a pejorative phrase so that our inescapable interdependencies are edited out of political rhetoric appealing to rugged, and sometimes greedy individualism. I mean to use investment not only in the narrow financial sense of putting something in, in the expectation - well or ill-founded - of getting something out later, perhaps with an addition. I want to draw attention to investment in emotional terms, to the clustering of a mixture of hopes, fears and not entirely rational predictions about actions and habits. And I take it as evident that because 'looking after' and 'being looked after' are reciprocal, there is a fundamental social dimension to all our thinking and feeling about these matters. Further, the combination of the assumptions we make about social relationships and power and lack of power associated with independence inevitably produce a strong political element in our investments at all levels from the personal to the national and beyond.
I shall explore therefore, the elements of language use which shape our ideological statements, the nature of our personal emotional investments in the reciprocal processes of 'looking after', and the social and collective attitudes and loyalties associated with such investments. Then I shall suggest where this viewpoint might lead us in terms of thinking and action.
Having drawn attention to the ideological implications of my own chosen language I need to begin with some examination of the language currently used in social welfare discussions. I feel it is all too easy to accept the positive connotations of market choice, consumerism, privatisation and so on. For example privatisation is always used rather than commercialisation and has thus been captured by a current monetarist and market orientated outlook. Private is warm and personal; public by implication cold and bleak: monetary considerations are neutered out.
Certainly there are 'freedoms' in a 'market economy' and we may well be attracted to those and see them as valuable to individuals. But we need to be very cautious lest the capture of language by those economic ideas and their implications subtly subverts rather than properly modifies our views and feelings.
This is saying that the monetarist/market view has achieved what the Italian Marxist Gramsci called an hegemony. Hegemony in this sense ‘stresses not only the political and economic control exercised by a dominant class but its success in projecting its own particular way of seeing the world, human and social relationships so that this is accepted as "common-sense" and part of the natural order by those who are in fact subordinated to it' (as well, one might add as by many of those who initiate these ways of seeing). (Bullock and Stallybrass 1977)
The point has been put with admirable force and brevity by Peter Kellner, political correspondent of The Independent (1988) when he says 'Language is to politics what DNA is to reproduction. Both carry the codes of evolution. Words such as "freedom" and "citizenship" embody ideas. They determine our political culture. Anyone who can persuade us to use those words differently has all but persuaded us to think differently. ...To do so is to be... engaged in the political equivalent of genetic engineering'.
There are numerous instances of this in the language we perforce use in these papers. Consumer, privatisation, dependency, care ... , all are words where meaning has been captured for a limited, often approbative or pejorative sense, by the market/monetarist lobby. Raymond Williams analysed the elements of usage of 'consumer'- the other words were hardly in common political currency in 1976. Especially now we need to be aware of the evolutionary powers of change of usage and to do our own analysis. Some words and ideas, 'public service' for example, lose power by being almost entirely dropped. Undoubtedly public service can be a substantial disservice to the public and it is easy to denigrate it where convenient by pointing to shortcomings in the social services and education. It is less common for Government to point to such disservices in the police or in defence contracting!
'Solidarity' is valued when expressed by Polish steelworkers, but seen as ‘an enemy within' when expressed by British miners. Collective power by trade unions is stigmatised as 'baronage' or if it is exercised by dispossessed youth as 'medieval brigandage'. Classically this denigration is done by the people who actually either are Barons, or make up the 'honours' list that ennobles them. Even more ironically it is done by those who exercise the great financial and within-establishment powers which are the modem equivalent of 'baronage'. Freedom and liberty are apparently splendid values, until they are applied to freedom of information or liberty to associate in order to assert inconvenient power.
Why should I feel mildly anxious at using such examples in a set of academic papers? Because, I suggest, all views which challenge the current hegemony are seen as 'party political' if they are even mildly critical of the present Government's views. At its worst, one might feel the universities have been bullied into conformity with the current hegemony and cowed into frightened acceptance of a kind of Newspeak. This is as damaging to clear thought as Orwell's version (1949), though it comes from the authoritarian right rather than authoritarian left and is supposedly validated by a rather exiguous democratic voting process and by 'public opinion' in the form of a market orientated and multi-national 'national' press.
I believe that dominance by such an hegemony is especially dangerous in British society and in our particular discussions. Various comparisons both favourable and unfavourable to us, have been made with North American 'free enterprise' in health and welfare. In making these it is necessary to note all kinds of cultural differences and attitudes to welfare. But it is also relevant to note that ‘privatisation', or a shift between public provision and commercial provision of services, has very different implications for consumers and markets in a state such as Britain, which is highly secretive and whose media are constrained not only by limited ownership but by a lottery of libel law and no constitutional protection. Griffiths' (1988) emphasis on openness and availability of information is rather at odds with our commercial culture and very much at odds with Government culture.
One can see a need for a dictionary of Social Welfare 'keywords' comparable with Raymond Williams' collection. It would certainly help to clarify and enlighten our discussion. For the moment let us return to my specific usages.
I use 'being looked after' not only for it s reciprocal implications but because Phyllida Parsloe has identified a specific and valuable use for the term 'care' as distinguished from 'tending'. I have also avoided 'care' where it might carry other portmanteau implications because it is embedded in a number of political catch phrases and, at the cynical end of the market, appropriated in the slogan 'Securicor Cares'!
I need too, to return to 'investment' for its political meanings and historical resonance. In the present and in market terms it acknowledges the financial investment that is central to the changes in funding which are part of the argument - changes towards huge re-allocations of resources between central and local disbursements, between services, and between contributions via taxes (direct and indirect) and via the state and personal insurance, or towards deals between individuals and commercial concerns.
It can also refer to the individual financial investments one may make, either privately by savings, pension plans etc., or in collective action by friendly societies, or by acceding to a democratic option for national insurance and a national health service contributed to by everyone and available to everyone.
In psychological terms it refers to emotional investment to the whole complex of sometimes contradictory feelings we have towards activities and people who are psychologically important to us. The historical reference is to Freud whose original German term 'Besetzung' translates literally as 'investment' but which was rendered by Ernest Jones as the neologism 'cathexis' which is still rather bewildering to most English readers. (Rycroft, 1972)
My understanding of personal emotional investments in being looked after is the result of being present at many discussions of 'residential and field work', or more recently 'residential and community work' in which, despite the range of skills and understanding represented in the group, discussion has been notable for being passionate, divergent, well informed and thoughtful, but in the end, unproductive.
After a recent dramatic example of this my conclusion was simple: in these discussions we are much more subject to our individual emotional investments than we allow ourselves to recognise. And so we largely discount both in ourselves and others powerful emotional and intellectual constructions which affect and inform what we say and hear.
Put quite simply I am pointing out that when we talk about 'looking after' or 'care' and 'being looked after/cared for' our feelings about the quality and kinds of care we received in infancy and childhood are powerful definers of what we each come to mean by these phrases.
The kind of emotional investment I am describing here, is however rather wider than just the accommodation one makes an as infant to one's caring figures and the reality and more especially the fantasy involved in that. I think that when we, as 'carers', talk and think about the care we think should be given we relate it specifically to our own 'care career'. That would include infancy but also the stage of identification with parents illustrated by Erikson's (1950) statement about five year olds seeing their parents as 'powerful, beautiful, and dangerous'. It would also include our experiences of 'institutional' care, of teachers individually and of the ego-ideals and role models or comparable models and attributes to be avoided, which schools either deliberately foster or leave to the apparent accident of individual attachments. (By way of example my own mixed experience of boarding school life is doubtless showing through here).
Round about twelve years old, and then progressively in mid and late adolescence, I think we get to a political view of the world of some kind. That is to say, we realise we do not have just to 'act' the scripts of power but could take some small part in consciously writing them. And I would guess that it is then that our individual investments of feelings and thoughts about being looked after and looking after rub down into a pretty settled pattern. That pattern will influence us very much if we become parents and will then be challenged, in part confirmed, certainly modified. Similarly our experience of caring for our parents or other relatives in their old age, will confirm and/or modify the pattern.
This is to stress that when we discuss patterns of care for others, and when we think of the care we ourselves would like to experience, such investment patterns will be very powerful. They will not necessarily overwhelm our consideration of other patterns or acceptance of other, different, but congruent patterns. They may however lead us to read 'evidence' in the light of our own preferred pattern and therefore, although we shall have to acknowledge other people's right to their preferred pattern, we shall be likely to stick increasingly firmly and passionately to our own.
I shall return to the implications for our thinking of accepting the power of these individual emotional investments. It is vital however not to dismiss them as producing just a tiresome emotional wobble in our rational judgements. Our early experience is a necessary fuel for our aspirations as well as our fears. For the moment I want to move on to the collective elements of personal investments.
My feelings and thoughts about personal investment in collectives were set going some time back by discovering that I was hugely indignant at finding that private firms and non profit making charities bought blood from the National Health Service at a cost that did not then reflect costs to it.
But my indignation was political more than personal. What seemed terrible was that a gift freely made out of common concern for one's fellow beings (even if with a frisson of righteous self satisfaction) should be corrupted into a financial transaction and a source of personal profit to some unknown set of proprietors or shareholders (albeit with benefit to presumably needy recipients). I mentioned this to a social work colleague whom I respect for his thoughtful concern and he recounted, with some shamed bewilderment, a similar angry feeling when, at a roundabout, he failed to give way to an ambulance because he saw it was from a private/commercial hospital. What a corruption of our values: it seemed that in different ways we could both withhold behaviour that might be of value to other people - giving blood, giving way - and feel, mainly anger, and residually some shame.
A part of our response is a conflict of liberal values; giving is good but not to those who already have in abundance. The resentment against giving to those already comparatively well off (though both of us are even better off) could be construed as envy but is, I think, as likely to be a sense of social justice thwarted by the power structures we live in and a recognition that the disadvantaged in our society are almost certain to remain locked in a web of disadvantage. In my case the fact that the onward passage of my gift, eased by blood-money, would fall outside my control felt a further insult. Could I go and give blood to the National Health Service and have it labelled 'N.H.S. Only' as well as Group 0 Rhesus positive etc ... ? Would that be an anti-social act?
These incidents led me to think further about gifts and loyalties and in particular about gifts to collectivities. To a known friend a gift is near total: if they then give it away or put it in a cupboard that is their right and the givers' and receivers' minor hurts are mostly to do with a loss of confidence in accurate perceptions of one another. But generally, no bones are broken. It is rather different giving blood - it is, -eventually, giving to an anonymous other, via an organisation, a collective with a known purpose and an explicit and/or implied set of values. In that respect giving blood is akin to giving loyalty, as well as to paying dues to a trade union or professional collective. One part is self protective - this is a gift/investment which one expects to be able to benefit from, if one needs to, by being freely able to tap into the combined gifts of others to the collective. Another part is loyalty out of comradeship generated by similar work, crafts, opportunities, oppressions. On the self protective side one can make a kind of actuarial calculation of monetary costs and potential benefit of subscription rates against the possibility of needing legal advice etc., but the accounting for loyalty is more complex. Or perhaps it isn't. In the crude Marxist terms all loyalties, whether capitalist, entrepreneurial, bourgeois or working class, derive from material gain and loss. The market ideology actually mirrors this assumption. Life is nasty, brutish and (comparatively) short – individual interests and achieving them by market means (enterprise) are paramount.
The Prime Minister's curiously ignorant or ideologically blinkered remark 'There is no such thing as Society - only individuals and families' is a denial of collective interests. Even families are seen as in necessary and productive conflict with one another for the resources of education and health. This is the arguably pessimistic face of Toryism and of course there are evils, envies and hatreds enough in the world to be able to pick nasty instances out to confound 'woolly liberals'. At the centre of the conflict between this polar position and any standpoint even marginally to the left of it is a question about one's investment in collectives. Is it purely material? Or material plus protective with Hobbes's leviathan centralist and authoritarian state the final solution to our need for protection from one another? Or is it partly material, partly protective, but partly firmly altruistic in its affirmation of our membership one of another? When you contribute to a collective, whether in blood, money or loyalty, is it only to the members of that collectivity? Does one contribute thus just out of in-group calculation or loyalty or in part, because of a belief in collective provision as a good thing in itself? And how does one then deal with one's common humanitarian feeling (if they exist) for those outside the collective?
Our attractions, towards these positions and variations on them, will be much influenced, if not determined, by our personal investments, and social and political formations. That surely means that we have to judge the realities of ‘community' 'care' from a moral and political position and the different implications of the two words 'community' and 'care', is a start. Phyllida Parsloe has begun on Care. Raymond Williams is instructive on Community which, he says,
can be the warmly persuasive word to describe an existing set of' relationships, or the warmly persuasive word to describe an alternative set of' relationships. What is most important, perhaps, is that unlike all other terms of social organisations (state, nation, society) it never seems to he used unfavourably, and never to be given any positive opposing or distinguishing term.
(Since Williams wrote, 'revolving door' has perhaps crept in as a rather awkward oppositional phrase to community care).
Perhaps behind this accounting for loyalties is the contrast of 'individualism:independence' and 'collectivism:dependence'. 'Fraternity' has an honourable political history as an epitome of loyalty, common heritage and inter dependency. However its gender implications are now unacceptable and 'humanity' is too general. Interestingly too there is an element of exclusivity and clubbiness which is, to some, an offensive flavour of 'fraternity'. 'Sorority' in U.S.A. usage has similar connotations though it is interesting that actual brotherhood, as an empathic fellow feeling is perhaps more common in ‘sisterhood'. We need a gender free alternative; 'interdependency' feels a bit factual and material, 'mutuality' is perhaps better though missing the elements of individual difference and a common responsibility. Or we have to settle for 'fraternity' in a broad political sense and let the gender problem remain in the wings.
So what are the implications of this discussion for thinking and action? In terms of thinking (in which I include feeling) I believe they are:
1) In discussion and argument with others about looking after someone (and implicitly being looked after somehow) we need to be (a) more conscious and (b) more open about our care careers and their probable effect on our ideological formation and personal investments (financial and emotional).
2) We should recognise that residential care and community care (in their ordinary senses) are likely to have as much in common as is different, and that our ideologies and investments will apply across the board. Thus we may fail to look for 'contrary instances' i.e. awkward evidence disconforming to our point of view because, for instance, we fear the potential isolation of community care and value, even with some anxiety and reservation the more evidently present collective of residential care. Conversely we may fear the invasion of privacy of residential care and welcome the potential being aloneness of community care.
3) In particular I think we have to be very careful when our discussion involves what I call, generically, category shifts i.e. when we move from consideration, for example, of the dependencies of old people to those of children. This is a crude example to which the Williams Committee (1967) drew attention but where in their enthusiasm for a generic approach to residential care they probably, failed to heed their own warning. To be sure, there is considerable intellectual challenge in category comparisons: what, if anything do client groups have in common and what forms of organisation are appropriate to deciding on and delivering service to them? But I think the strong personal and emotional valencies involved quite often lead us to argue from a position in relation to say, children, and then shift the argument when we, or someone else, changes categories and raises the example of the mentally handicapped or the elderly.
Category comparisons and poorly acknowledged category shifts are perhaps even more tricky when they involve different categories which cut across client groups. For example: do the individuals (children, adults, whatever) start from a secure base of their own - house, or family, or 'your own people' - or from a fractured and uncertain base - of insecure accommodation, a fragmented or lost family, social isolation, near total, or in an isolated subgroup?
Similarly the kind and amount of dependency is an emotionally loaded cross-dimension. There are big differences between major physical dependencies linked with intact and sturdy emotional independence as compared with apparently quite minor emotional and social dependencies (e.g. partial deafness or aphasia) for people who can be physically totally independent. Again comparative privilege or deprivation in both material and emotional terms in our own lives must be related to senses of power and autonomy or relative impotence and heteronomy (abiding by rules made by others).
Most of those discussing this document or making the policies it addresses will have been relatively privileged. Perhaps we can sympathise intellectually and from experience empathise with the power deprived but I suggest that as well as our infantile experiences of care experienced as 'good' and 'bad' our fantasied and actual childhood experiences of power and autonomy influence our perception of, and reaction to, empowering others.
What are the implications of this discussion for action and the evaluation of actions? I distinguish three threads:
1) If we take it seriously and personally then I think that recognition of the power and influence of personal emotional investments derived from childhood experience (what psycho-analysis would call the counter transference) may be a crucial key to understanding how care systems, whether residential or domiciliary, work when they work well. By work well I mean that they remain relatively stable over a period of time and give 'good enough' satisfaction to those cared for and to their carers. This may depend as much on the basic congruence of the personal investments of the care staff as on very particular forms of organisation or regime and will often be centred round an individual or small group of individuals whose personal investment patterns are clear and perhaps articulated into a theoretical or value statement. This would also partly account for the charismatic elements in systems which work well and imply also both lower and upper limits to the size of the staff group.
It would also be the case that care systems work when there is some' goodness of fit' between the personal investment patterns of staff as to looking after and those of recipients as to being looked after.
There may also be an implication for persisting but disfunctional care systems - punitive old peoples' homes, overpowering and dependency confirming children's homes as well as sketchy and rather unreliable home care systems. Personal emotional investments have a negative side of fear, hatred and envy and a congruence of these in a group of staff could produce horrific consequences and a community difficult to penetrate and publicly evaluate and highly resistant to any change from within.
2) Recognition of the gender connotation of 'fraternity' and its replacement by the notion of 'mutuality' prompts consideration of masculine and feminine forms of organisation and management. Any care system which is to deliver effectively, and with appropriate variations for individuals, whether it is residentially or home based has to rely on an intricate and shifting management of minute particulars. Various women authors have pointed out the managerial skills required in the organisation of that most intimate form of mutuality, the family, and the largely unacknowledged juggling and balancing act that women manage hour by hour and week by week. A part of this is to do with tending but much of it is to do with fairness, respect and love expressed both directly and in physical provision. Maintaining an effective care system in a residential base certainly calls on these skills. It looks as though maintaining a rich and inter connected variety of individualised care systems (which is what an expanded and improved community care system demands) will require managerial skills and organisation of a kind that is perhaps more akin to the feminine than masculine style. This would be so regardless of which sex delivers the care to the recipient. The present pattern and implicit assumption for the future is that women will be doing the job. At what levels will they also he responsible for its organisation and how will they be able to influence the small scale social services hegemony which informs it?
3) In terms of both thinking and action I believe we have to be careful and more knowledgeable in our understanding and use of 'market' analogies and arguments. In terms. of rhetoric and resonance we must beware of the 'ripe tomatoes piled in the sun' associations and remember that markets have a bottom, shoddy end, as well as a classy, up market end. So too, in perhaps a narrower range, does municipal provision. More carefully we may need to know that economists tend to use 'market' as a convenient abstraction and talk mainly in terms of markets in products and money - rather than in services which is the form of exchange we are discussing.
Marks & Spencer is the favoured example of enlightened market provision in goods. A comparable and financially modest paragon of the provision of services is hard to find. Certainly for example car servicing is notoriously unreliable and sometimes crooked. Choosing a service package is rather unlike choosing a fish pie or a pair of shoes. It isn't an often repeated decision, more a once in a lifetime choice like buying a family home. Goods are bought in small quantities and often. Care packages - if small - may be bought frequently but will more often be one-off or intermittent. Once one buys into a service one often feels locked in - to a solicitor or garage - for fear of a devil one doesn't know. Moving to another service provider is emotionally costly and distracting.
Most of those involved in planning in the wake of Griffiths will perhaps have only limited experience in real world economics and will have a job to hold their own, unless they prudently inform themselves, as to the slips and slides that 'good economic sense' may be prone to when important distinctions are elided. And the Griffiths model of care managers assumes a kind of public servant broker, without commission, as a powerful influence on markets in services. We shall need to be better informed, and catholic in our consultation with alternative economists to steer a way with knowledge through this miasma!
4) Perhaps one action we can take is to pick up the ball and run with it ourselves - as in rugger or lacrosse as the gender takes you. I mean by this that Griffiths in particular works from an auditing of services and delivery systems. Despite the fact that the recommendations are so contrary to the Government's ideological assumptions of the structural inadequacies of local authorities at least it will be difficult for them to deny the importance of an audit of change. They will try hard of course - scarcely an edition of BBC's 'Question Time' goes past without a Minister proving statistically how much better things are in the Health Service while a well informed grass roots audience voices its scepticism. They know what matters from personal experience. So it is incumbent on us to spell out, as these papers begin to do, the kind of comparative figures the Government ought to collect and publish if it is to apply to the changes it brings about the kind of auditing it calls in support to fuel the changes.
As the Government decisions on Griffiths are implemented it may be necessary to have alternative plans to commercial attempts to steal the ball. Management buy outs (when not forbidden) are one such. Prison Governors have recently given backing to a non profit making organisation to run remand facilities so as to pre-empt a return to the privatisation of gaols from which Howard and Fry rescued us in the nineteenth century. The Friendly Society element of Trades Unions, which was all that could survive when their other activities were prescribed by law may have to be recovered or re-invented. Neither of these have the same public investment (financial and moral) as democratically elected bodies but turning round the Thatcher revolution may not be best done by statutory controls, rather by radical enabling legislation and by grass roots action.
In conclusion then, what are ideologies made of? Snips and snails and puppy-dogs' tails or sugar and spice and all things nice! Certainly pejorative and approbative terms are a part of the currency in which ideologies are presented or dismissed and I have proposed that we need to look very closely at meanings and our attachments to them. Although we should not get into the adman's world of dealing only in such currency we may need to coin usage and to capture, at least some meanings. Challenging a contemporary hegemony is difficult: the capture of words for a limited but positive image necessarily both defines and confuses because it seeks to appropriate all previous and often contrary association of the words. Just at present 'active citizenship' is the current attempt to capture meaning and convert it to image. This is to address the problems of rhetoric - which can be used to disguise but has also to be used to persuade - and the disguise/persuade elements have to be judged by appeal to the basic values behind the rhetoric.
In the field of caring and being cared for I suggest we each need to examine our super-ordinate values, to be able to make some ranking of other important values below them and to bear the conflicts that are bound to arise without compromise of the superordinate and to articulate all this in appropriate language. This is philosophically a difficult task. We shall need all the help we can muster from moral philosophy and from examination of our own personal emotional investments to accomplish it.
Association of Therapeutic Communities |
PLANNED ENVIRONMENT THERAPY TRUST |
Charterhouse Group |
Therapeutic Community Open Forum |
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This page authored by: Craig Fees