In a culture of audit, regulation, inspection and apparently justified fear about poor care, it is understandable that families are taking action to expose gross abuse by secretly fiming the conduct of staff in homes for the elderly. So much so that the Care Quality Commission has produced guidance for relatives in England who are considering doing this.
But are we in danger of assuming the worst of carers: that those working with the elderly or with adults with learning difficulties are all depraved and have entered the field expressly to prey upon the weak and the old. This is far from the truth. And the truth behind many of the problems that we have is that we really don’t value carers or what they do.
In Sweden it takes three years of training to become a care assistant and the profession is respected and paid relatively well. In the UK, anyone can walk into a care home and get a job and both the social status and the pay that comes with such roles is chronically low. This means that untrained and unsuitable people, people whose life experiences and family situations are not suited to a professional life of care and compassion, arrive in the field among the greater numbers of those who are.
If care wasn’t complex, it wouldn’t go so badly wrong as it did at Winterbourne View and Mid-Staffordshire – the latter of which led to the Francis Report. Care, and especially care that comes with therapeutic benefits, requires workers to have knowledge of the theory of care, human development and relationships and, crucially, enough knowledge about themselves for reflective practice to become possible. So what happens when this education isn’t available?
Three attitudes to caring
Psychoanalysts Melanie Klein and Isabel Menzies Lyth developed ideas about how our personal experiences and our psychological make-up affect our capacity to care for others. In Love, Guilt and Reparation (1937), Klein showed how altruistic behaviour and self-sacrifice is predicated upon a capacity to deal with our own feelings of guilt, while Lyth’s Social systems as a defence against anxiety demonstrated that nurses, driven by anxiety, adopted impersonal working practices which ran counter to the therapeutic aims of the hospital.
In my view, born out of years of work in social care and conditioned by research and teaching carers, there are broadly speaking three underlying attitudes which can be observed in those working with vulnerable human beings: gratitude, reparation and retaliation.
Each of these attitudes has to do with the way workers relate to their clients. And each way of relating derives from the carer’s response to their own personal experiences. For example, many carers come into social care having experienced difficulties in life such as losing a parent, having a sick sibling or experiencing other kinds of adversity. How they respond to these experiences deeply affects their capacity to care. Let’s look at each in turn.
Carers in this group thankfully make up the majority of carers. For them, any difficult life experiences draw them into a deeper relationship with their emotional lives. Their way of relating to those they care for is exemplified by a desire, in some cases an unconscious one, to give back something of the care they and their relatives have received from professionals, or would like to have received.
Carers in this group have had similar experiences to the first group but their conscience tells them that they have not always managed their feelings well and they feel some guilt for hurting others. The way they relate to those they care for is exemplified by a compulsion to make reparation, to vicariously make up for the wrongs they feel they have done to others. This desire is well catered for in social care as there are plenty of opportunities to act well, show kindness and work off these feelings of guilt.
The third group have also experienced difficulties with loss, family illness, or adversity but their own early parental care may also have been less than adequate. As a consequence people who come into this group fail to positively identify with those for whom they care. They seem unable to develop a warm or compassionate attitude but rather, due to previous hurts, take a “once bitten twice shy” approach. They affect a self-protective hardened, emotionally distant demeanour and deal with difficult feelings by retaliation.
In the worst instances their lack of self-refection, coupled with denial of their own difficulties, can lead to conduct which is abusive and reprehensible. When a number of carers of this kind work in a single organisation the culture becomes understandably liable to misconduct and abuse.
We’re all culpable in mistreatment
With some trepidation about making myself unpopular, I assert that we are all culpable in the mistreatment of the elderly and the vulnerable because we tend to accept this woeful status quo. It seems we are struggling to grow up and take responsibility for the elderly and the infirm.
One might hope that the government would step in but they are, predictably, several steps behind. Successive waves of regulation and guidance do not appear to have improved the situation because it is internal regulation at a personal level that is required.
To this end, at the Centre for Psychoanalytic Studies at the University of Essex, we launched a new therapeutic care degree for the next generation of care workers and healthcare assistants who will work with troubled children, adults and the elderly – and who deserve to be properly equipped to do so.
Having attended a recent government briefing on the implications of the new Social Care Act 2014, and hearing the presentation by King’s College London’s Social Care Workforce Research Unit, I am left with the stark fact that no real plans are in place to improve the workforce by imparting any kind of theory or reflective practice. We have to get on and do this ourselves. Since we are all going to be recipients of care, it falls to us all to make a difference.