In all of the three categories of care work discussed above, the care nearest the client and the client’s physical body is ranked lowest. The fact that basic care work with old and sick fellow human beings is ranked low cannot be separated from the closeness of the work to body and death. In this sense, the work carried out by social and health care helpers can be the-matised as inscribed in a ‘hierarchy of dirt’.
Lise Widding Isaksen (2003) sees work near the body as re-lated to symbols and values which society attributes to the body and bodily dirt. Male and female bodies are interpreted differently and so are young and old bodies. Bodily care work deals with taking care of bodies which smell and leak in plac-es one usually doplac-es not expose to anyone but one’s sexual partner. Cultural classifi cation of hygiene as strictly private makes it diffi cult to discuss work in this fi eld publicly. We lack a language in which we can speak of the experiences of smelling and touching tabooed bodily liquids without feel-ing vulgar or touchfeel-ing on sexual associations (Krogh Hansen 2006). Isaksen further argues that bodily closeness and inti-macy, which are not related to sexuality but solely to care, are often inscribed in images of the feminine. In intimate hy-giene one most often has to work directly with one’s hands.
Working directly with one’s hands ranks lower than work-ing with tools between oneself and the material. Workwork-ing with tools, ‘marking the world’, is in a society dominated by patriarchal structures, seen as productive and connected to masculinity. Isaksen identifi es a hierarchy of illnesses corre-sponding to the cultural symbolism described above, where illnesses cured by the use of technology gain more status and receive more funds than illnesses which ‘only’ require long-term treatment and basic bodily care.
Working with ‘decay’ and particularly with dying people can bee seen as extreme forms of ‘dirty work’. Both Freudian
psychoanalysis and social anthropology defi ne dirt as ‘mat-ters placed in wrong places’ (Isaksen 2003:175).The fact that maintaining the body takes a hygienic effort, is an aspect of physical life which demands organisation and work. When one gets old or ill, one becomes dependent on the support of others to manage this work. But maintaining the body could not only be understood in physical terms, but also in psycho-logical ones. Maintaining and controlling our own bodies is a part of our very individuality. Losing the ability to manage our own body could, at the psychological level, be understood as a sign of dissolution of the individual. Also for the care worker, encountering this dissolution can provoke anxiety.
In several concrete and symbolic ways social and health care workers perform ‘dirty work’. When analysing my ob-servation notes I realised there was a repeated focus on what I identify as passages. Again and again I had, without being aware of it, noticed how the health care helper trainee locked us in and out of houses and apartments. I had written about ways and hindrances to reach the elderly person needing care, about doors and gates, keys and locks, stairs and bells. While driving between the homes of the clients the trainees told me about diverse causes for nervousness, ranging from not being able to fi nd the way to the clients to the fear of walking into a home one day, fi nding the client dead. The care workers talked about walking into places that were hidden from the outside world, and leaving them. I interpret the focus on the
‘real’ passages as a way of handling—at a symbolic level—the passages between life and death, between control and dissolu-tion, and between clean and unclean which are present in the observation notes. In order to understand the psychological energy expressed in the accounts of such passages it is neces-sary to see them as having both a ‘real’ and a symbolic con-tent. The task of the care worker is to observe the condition of the client and identify potential anomalies. If she fi nds an anomaly, she is expected to report it to the relevant expert outside of the home, such as a nurse or a doctor. But signs
of anomaly are also at a symbolic level signs of decay and death—and therefore frightening.
The following extract from my observation notes focuses on the passage into the house of an old man, an almost laby-rinthine task. The observation gets the character of ‘scene of the crime’. Hanne, the trainee who I accompany, already in the car warns me about what is expecting us ‘in there’:
The next client is an old sick man’, Hanne tells me. ‘He has often faeces all the way up the back of his head when I arrive in the morning. He has to get washed and helped out of bed.’ The man, Peter, lives together with his wife in an old house. In the drive lies a big rolled carpet. Hanne jumps out of the car and moves the carpet so I can park in the drive. In the garden a big dog is jump-ing around. We have to move a wooden pallet and climb a fence in order to get near to the door. Hanne tells me that this is not to prevent the dog from running out, but to prevent anybody from getting in. From the fence and up to the door the grass is worn off, so that you walk on the bare earth. The couple’s car is parked in the middle of the lawn, and things the dog has gnawed are spread all over the lawn.
Hanne rings the bell, and the wife opens, dressed in a dressing gown. She sits in the kitchen and drinks coffee and solves a square puzzle. Some rye bread is put to rise on the kitchen table. It is pret-ty cold. The house lies low. Here I do not consider taking off my boots, as I normally do. Hanne explains why I accompany her, and the wife asks me if I am there to control Hanne’s work.
In the room where the old man lies, the air is actually warm and stuffy. He lies in the living room in a hospital bed. The furni-ture is pulled together to get room enough for it. There is a wood burner with piles of briquettes around. The television is on—it is placed so that he can see it from the bed. Around the bed the fl oor is covered with old newspapers.
When Hanne removes the blankets from Peter, he is, as she told me, literally smeared with his own shit. He has a blanket under-neath his duvet, with no cover on. He wears neither underpants nor nappy, but is just lying on a sheet with his faeces running down him. Hanne washes and washes—it takes a lot of fl annels before he is clean. The smell is heavy. Meanwhile the nine o’clock news begins.
Hanne and Peter talk about his wife baking rye bread. The dog enters and lies down on the newspapers while it is gnawing an old bone. Hanne washes Peter’s toes—he does not like that, he says, because he has had a health care helper who was so rough that he is still completely sore.
Hanne looks at some wounds Peter has got on his arms from falling and on his heels from lying so much. The wounds look okay and dry. They both begin to explain to me how he fell. She rubs him with lotion and puts thick socks on his feet. All the time she is wearing gloves.
‘Now we have to go for a walk’, Hanne says ‘and then you will get your reward’. She lowers the bed so that he is able to step out on the fl oor and she takes one of his arms. He is very skinny and completely hunchbacked. Together they walk to the door and open it into the kitchen where he says good morning to his wife.
He only wears a vest and socks.
Slowly Hanne walks with him back to an armchair where a fur plaid and a sheet like the one he had in his bed is placed. Peter sits down in the chair and it turns out that he sits with his buttocks naked right on the sheet. I think it must be so unworthy. He gets a dressing gown around his legs and Hanne places his legs on a footstool. He puts his hands down under the blanket. It strikes me that he may be fi ddling himself a bit. The reward for walking turns out to be a glass of sherry. (11.03.03).
The extract from the observation notes gives a strong image of everyday work in the home-based care of the elderly in Denmark. Not all clients live like Peter, nor are they all so frag-ile. But still the example is not extraordinary. The meetings with situations implying degrading, dissolution and decay on the one hand, control and mistrust on the other, are part of the daily work. Here it is Peter’s wife who expresses the need for control. But a need for control is not only expressed by worried relatives; it is part of the very way basic care work is organised in initiatives such as ‘Common Language’, as was discussed above. One can discuss whether the care provided for an old man like Peter is ‘good enough’. This is not my point here. My point is to draw attention to the strains situa-tions like this put on the care worker; situasitua-tions in which she
is alone and has to be able to contain psychologically both the anger expressed by Peter’s wife and the very despair of his situation.
Looking at the observation, the placing of ‘matters in wrong places’ is obvious. From the time Hanne and I arrive at the house till Peter sits in his armchair the description of mat-ters mixed together in unusual places is a thread through the observation. The urge of the trainee to wear gloves1 and my keeping on my boots could be interpreted as a way of setting bounds. (Krogh Hansen 2006). Setting bounds between one-self and the other person who is ‘dissolving’ and bounds be-tween clean and unclean is in a psychoanalytical perspective a way of protecting oneself from the threatening dissolution.
In spite of the need to set bounds Hanne still cares for Peter.
The situation causes her to feel frustration and anger, but this anger is turned towards Peter’s wife, who expresses her dis-trust towards the helpers working with Peter: After we have left Peter’s house, Hanne explains to me that she herself is the one who has taken the initiative to his little walk in the mornings, by motivating him by the ‘reward’. Hanne is wor-ried that Peter is too thin; she suggests that the wife econo-mises on his food in the same way as she econoecono-mises on the heat in the rest of the house. The wife could not be trusted:
she speaks ill of the helpers behind their backs.
This epilogue of the visit at Peters house points to one of the consequences of not recognising the strains of care work for elderly people and the social and health care helpers’ orienta-tion towards care. Someone like Hanne, who wants to provide best possible care to the benefi t of her client, is faced with mul-tiple confl icting emotions. On the one hand, she experiences the anxiety caused by the confrontation with the decaying body. On the other hand, she encounters the mistrust leading to control and Taylorisation. Her resulting reaction is anger.
In this case, her anger is directed towards the relative, but dur-ing my observations I also often met anger towards one’s col-leagues. Neither type of anger provides a fruitful basis for the cooperation which is a vital condition for the quality of care.
Care work for elderly in a gender hierarchy: devaluation of the care orientation
Why are the strains of care work for elderly people not rec-ognised? Why is the orientation towards care and care ratio-nality not valued as being important, even necessary, for car-rying out this specifi c kind of work? To answer these questions one has to consider the similarities between paid care work and the unpaid care work in the private sphere primarily car-ried out by women. Such reproductive work is generally held in low esteem.
The German social-psychologist Regina Becker-Schmidt (2002) argues that there exists a fundamental connection be-tween gender, work and the valorisation of fi elds of work.
With a critical theoretical and feminist point of departure, she analyses how on the one hand gender, seen as a structural category, and on the other hand power and status are inter-twined in hierarchical structures depending on their position in relation to the social spheres. Becker-Schmidt further argues that the importance of dealing with gender arrangements as relational lies in the possibilities this gives for analysing how unequal circumstances in one social sphere are connected to hierarchical constellations in another social sphere. From this perspective, individuals as well as social sectors can be viewed as elements in relation to each other. With a starting-point in the historical social division of labour, in this case in the separation of men’s work in the public sphere and women’s work in the private sphere, it is possible to see how the social spheres are mutually dependent. Thus, social spheres can be understood as inscribed in a gender and power hierarchy due to their gendered connotations. The gendered connotations are connected to the question of whether the sphere and its institutions are regarded as ‘productive’ and thereby ‘male’ or they are regarded ‘reproductive’ and thereby ‘female’.
The Danish psychologist Simo Køppe (1997) describes how in the wake of the introduction of capitalist economy in North European societies an ideology was introduced which saw housework as work that was the payment in itself. Because
of the gratifi cation that women received from their work, no monetary compensation was needed. The home and the in-timate sphere became the centre for emotions and humani-ty—the place that balanced the economical rationality of the productive public sphere. At the same time as work linked to the sphere of reproduction was economically devalued, it be-came ideologically upgraded. Nevertheless, following the dif-fusion of the capitalist way of production, power and prestige became associated with money. As the private sphere was iso-lated from the public sphere of social exchange, it was at the same time made dependent on and subordinate to this sphere.
The economical contribution from the male head of family in the form of wages made the work of the man more presti-gious than housework, because it stemmed from the sphere of social exchange, where work was paid for by money. The female work in the home was not paid for, even though it was a prerequisite for the male ‘productive’ work.
In a similar vein, Becker-Schmidt points out that work which historically and traditionally has existed outside the money economy of capitalist society tends to be regarded as less worth than work for which a wage is paid. Care work has almost en-tirely been carried out in the home—by women—and the low valuation connected to this sticks to the work even when it be-comes publicly fi nanced wage labour. In this perspective the unequal relationship between a rationality of care and an eco-nomical and technical rationality can be seen.
The above-described gender hierarchy of productive and re-productive work is inscribed in the professionalisation process where attempts to professionalise care work go hand in hand with economical-technical rationality. The following quota-tion is from my notes from an observaquota-tion at a Social and Health Care School in October 2003. It illustrates the idea of being able to separate one’s subjective motivation from the work one is doing:
Male teacher: ‘One should be able to be in other people’s shoes, but also to take them off again. What do I mean by that?’
1. Female trainee: ‘That you should leave the problems when you go home.’
2. Female trainee: ‘Being a professional means that you do not slide into the same mood as the other person.’
Male teacher: ‘Maybe it is a prejudice, but men are normally better than women to be professional—or to be ‘cold in the ass’.’
3. Female trainee: ‘That is our mother instinct.’
Male teacher: ‘Yes, a caring gene… But one should not carry the problems home.’
Certainly, it can be a problem if the care worker identifi es too strongly with the person she is helping, but placing profes-sionalism on an equal footing with being indifferent is an in-sult both towards the orientation of care workers and towards the needs of the elderly people the care workers are supposed to give care. It gives an unrealistic image of professionalism, which—when seen in an existential light—is impossible to reach, because it sets aside the very character of the caring relation.
Entering relations of care with elderly and sick people can function as a memento mori of the temporal limits of one’s own lives, thus awakening an existential anxiety. But the rela-tion of care can also awake an existential joy (Noddings 1984).
Both anxiety and joy are fundamental aspects of meeting ‘The Other’ in the caring relation and both require involvement.
Ignoring this fact potentially leads to quite the opposite of professionalism, i.e. to a situation where the care worker tries to ‘put up shutters’ between what is ‘personal’ and what is related to work. Denying that in relational work the worker uses her feelings makes it impossible to handle the emotions in a conscious way, and thereby only leads to ‘pseudo-profes-sionalism’.
An intention to professionalise social and health care help-ers by teaching them to be immune towards the infl uenc-es of care work can of course originate from the consider-ations of their wellbeing and satisfaction with their work. But it could also be interpreted in connection with the esteem of
the work in a gendered hierarchy. Putting up shutters between
‘personal’ and ‘professional’ is the logic of the public sphere, whereas the tendency to let time, work tasks, involvement
‘personal’ and ‘professional’ is the logic of the public sphere, whereas the tendency to let time, work tasks, involvement