Home > affect/care > Stijn Vanheule, “Caring and its Impossibilities: A Lacanian Perspective” [excerpt]

Stijn Vanheule, “Caring and its Impossibilities: A Lacanian Perspective” [excerpt]

“Caring and its Impossibilities: A Lacanian Perspective” [excerpt]
Stijn Vanheule
Organizational and Social Dynamics 2(2): 264-284 (2002)

WHAT ABOUT CAREGIVING PROFESSIONS?
Freud’s and Lacan’s comments regarding neighbour-love and altruism
are directed towards a general attitude rather than professional
caregiving. We suggest the same mechanisms especially apply to
professional caregiving (cf. Ansermet and Sorrentino, 1991; De Soria,
1996).

People engaged in the helping professions are often driven by strong
and sometimes idealised ideas about charity. Many start their jobs with
a rescue-fantasy, wanting to remedy other’s problems. What appeals to
them is the lack they perceive in the person needing help which they
long to suture in one way or another. The ideal of caregiving is thus an
ego ideal for most caregivers. It has a strong narcissistic value (cf.
Grosch and Olsen, 1994) and is rooted in the personal oedipal history

(cf. Freud, 1957; Ferenczi, 1955). But in the reality of caring, professionals are often confronted with
so-called ‘difficult’ clientele that contradict this ideal. Their clients,
especially those who stay in institutions because of a severe pathology,
often cause problems that offend professionals’ best intentions and
their ideas on how problems should be solved (e.g. due to specific
object relatedness and a peculiar position in transference). As we
indicated above, in such cases a strong appeal is made to caregivers’
jouissance, destructiveness and/or sexuality. Since the everyday love of
one’s neighbour already causes subjective contradictions, we can
assume that the contradictions caused in those who are engaged in
professional care are manifold. Consequently, working in health-care
professions tends to elicit strong ambivalence conflicts. Caregivers who
are wrapped up in rescue-fantasies will experience this as especially
problematic. After all, the more grotesque one’s ideas on caring are, the
more shocking the other’s other-ness will be and the more ambivalent
and contradictory one’s own impulses will be.

PROFESSIONAL BURNOUT
We hypothesise that the problem generally known as professional
burnout is connected with this contradiction. Burnout seems to be an
effect of the ego’s refusal to face and tolerate ambivalent impulses.
Maslach and Jackson, the two psychologists who introduced the
concept of burnout in the academic world, define it as “a syndrome of
emotional exhaustion, depersonalization and reduced personal accomplishment
that can occur among individuals who do ‘people work’ of
some kind” (Maslach and Jackson, 1986, p. 1). This definition is widely
accepted (Schaufeli and Enzman, 1998). According to this definition,
burnout has three underlying dimensions. Emotional exhaustion is a
dysphoric feeling of being used up and tired of working. Depersonalisation
is understood to mean the attitude whereby one tends to
withdraw from contacts with clients and addresses others in an
impersonal way. Reduced personal accomplishment indicates that one
feels less competent than before and that one has failed. We believe
these three dimensions of subjective complaints are linked with the
mechanisms described. We will first discuss the theoretical elements of
burnout- dynamics and then illustrate these briefly with a clinical
vignette drawn from a research-project on burnout.lO
As we saw, for Freud and Lacan the harshness of the super-ego
becomes stimulated by an attempted renunciation of one’s own
destructiveness.

The effect of instinctual renunciation on the conscience then is that every
piece of aggression whose satisfaction the subject gives up is taken over bY
the super-ego and increases the latter’s aggressiveness (against the ego).

Following our line of reasoning that a strong appeal is made to
caregiving professionals’ destructiveness and jouissance and the
observation that these tendencies are usually defended against, we
assume that the harshness of the super-ego will indeed be stimulated.
In this case, successful caring will become a bounden duty that one
almost cannot but fail to neglect. Feelings of incompetence and failure
are to be expected as a consequence of this denial and the resulting
severity of the super-ego (cf. reduced personal accomplishment in the
definition of burnout). After all, the main thing the super-ego does is to
confront the ego aggressively with the fact that the ego-ideal is not
attained. Note here that a similar mechanism is at work in what Freud
calls melancholia. The self-denigration prominent in this disorder too, is
nothing but internalised aggression: “self-reproaches are reproaches
against a loved object which have been shifted away from it on to the
patient’s own ego … Their complaints are really ‘plaints’ in the old
sense of the word” (Freud, 1963, p. 248). In this, precisely the aggressive
elements are turned into a sense of guilt (Freud, 1961, p. 139).

In depersonalization or the physical and/or mental retreat from
contacts with patients, a person renounces doing what he or she used to
value or still consciously values. From a Freudian point of view we can
qualify thIS kind of withdrawal as inhibition (cf. Freud 1959, Vanhuele
2001b). Freud defines the main origin of inhibitions as’the avoidance of
sexual and hostile impulses. A person renounces an activity since the
execution of it would express impulses one wants to escape from.
Inhibition is a strategy to avoid the psycho-neurotic conflict that would
be evoked by non-inhibited activity. The conflict concerned is a conflict
between two inner tendencies: on the one hand we have a tendency
within the ego (e.g. the desire to do good) and on the other hand a
contradicting impulse (e.g. the desire to ill-treat the other). The subject
chooses to shun this conflict and limits the associated ego-function. This
self-imposed limitatiOn consequently serves as an indication of the
underling conflict one wants to avoid. Depersonalization can be
understood as an effect of inhibition, whereby a professional withdraws
from being confronted with his/her evil tendencies towards
clients. Lacan did not link Freudian inhibition to the withdrawal from
caring, but he indicates similar mechanisms:

The resistance to the commandment ‘Thou shalt love they neighbour as
thyself’ and the resistance that is exercised to prevent his access to jouissance
are one and the same thing … I retreat from loving my neighbour as myself
becaLise there is something on the horizon, that is engaged in some form of
intolerable cruelty. In that sense, to love one’s neighbour may be the cruellest
of choices. (Lacan, 1992, p. 194)

If the activity of caring is contaminated with cruelty, caring as such will
most probably be inhibited. We find the same mechanisms apply to the
influence of sexuality. If sexual arousal enters too, much in one’s uninhibited
love, this love regains its sensual dimension and will
contaminate caring too. Inhibition is to be expected if the ego can’t
stand this ambiguity.

Emotional exhaustion can be understood as the energetic consequence
of the two other mechanisms. On the one hand, continually subjected to
the ever-increasing commands of the super-ego, one gets used up, since
it is inevitable that, despite one’s best efforts, the ideal will never be
accomplished. This may result in the feeling of powerlessness and
usher in an attitude of resignation. On the other hand, exhaustion may
be expected as a consequence of suppressing contradicting tendencies
via inhibition. According to Freud, suppressing affects that are
incompatible with the ego exhausts the ego. In this case the ego “loses
so much of the energy at its disposal that it has to cut down the
expenditure of it at many points at once” (Freud, 1959, p. 90).
Continuous defence consumes psychic energy.

Similar exhaustion is to be expected as a result of the radical
contraction of an ego ideal resulting in the loss of this ideal (e.g. the
ideal of caring; Vanheule, 2001a). According to Freud such a loss will
result in the work of mourning that absorbs the ego: “all libido shall be
withdrawn from its attachments” (Freud, 1963, p. 244). This work of
mourning also exhausts a person since much of the available psychic
energy is consumed. Following this line of reasoning it is no wonder
that, once a work of mourning has been concluded, one may lose
interest in the activities first linked up to the ideal (e.g. professional
caregiving). After all, once one’s ideal is lost, nothing any longer binds
a person to the activity implied.

Let us now turn to the clinical vignette.

Tom, 29 years old, is a social worker, working in a ward for mentally
disabled adults with a psychiatric disorder. Tom describes himself as
burnt out along the three dimensions of burnout described by
Maslach and Jackson. During the interview he appears nervous and
anxious and has difficulties in verbalising. At the end of the interview
he seemed as though he wanted to throw off his yoke and literally
run away from us. While interviewing, we focused on the problems
he experienced in his job. Whereas he first shied away from talking
about possible problems and glossed over negative aspects in
relation to clients, toward the end he was more willing to talk. As
a consequence his story is rather contradictory. At first he says: “I
thought about quitting my job, not because of the guys (his word for
clients he now works with), but because of the team … In my work
with the guys everything goes very well. I have the feeling I’m rather
objective in relation to them .. , Now I think I will go on with them. A
lot of my colleagues left the job and others just work in a routine…
but I go on”. But another dimension gradually showed through: “We
have a lot of problems at the ward. We can’t really affect the guys
and that makes everything difficult. At last you resign and you think
that it’s not that easy to change that guy, … Eh, at last you start
working in a routine and that gives me a bad feeling … Although it
once was a challenge for me … For a long time we had a guy at the
ward and we agreed we would intervene if he became aggressive, we
said we won’t let it happen! But he is so persuasive and so creative
that we had the feeling we couldn’t win … Some colleagues had to
leave the ward because they couldn’t stand the aggression. Then you
start thinking, never mind … You don’t have the energy and the
courage anymore … You can’t persist in staying optimistic and you
start feeling insecure. Then I think, I’m wrong, I did it wrong and you
feel unsure … That’s hard to stand … The way you look at yourself.
You start doubting … Some of our guys are really strange. I know
their behaviour is so-called stereotypical, you know the explanations,
but at last … I tried to empathise with them … At last you don’t even
try anymore. They are just bothering, nothing but strange. That gives
me stress … Then I think, what are we doing over here … They are a
different kind of people. There’s no common ground between you
and them anymore and that’s strange, indeed. As they’re only
different, yes, that’s strange … We want to change them but we can’t.
That’s frustrating, that’s powerlessness … I sometimes think we are
all wrong over here, what we do is erroneous. But in fact, it is the
guys that are pulling the strings.” After our request for an illustration
and his statement that it was difficult to give examples of difficulties,
Tom describes the following situation. “Eh, … We have a manic-depressive
youngster at the ward and it really drives you crazy. He
continuously has periods of heavy laughing, turning into periods of
heavy walking around and not laughing anymore … It’s the same
story over and over again. It last you resign trying to change it. I’m
not manic-depressive, I don t understand him … There are moments
that you think, boy don’t fool with me, don’t you even try to … But
then again you get fed up with it if you try to change hIm. You try to
force the matter. Most often attempts to change his behaviour end up
in the isolation cell, for him. He gets aggressive. Then you start
thinking, I’m wrong, I tried to change him but it went from bad to
worse. Now he’s in the isolation cell and he’s wounded … That
troubles me”. Concerning his desire to have another job he says: I
thought about working as a nurse on a normal ward, where the
clients give you the information you need to help them and talk
normally. Here they don’t. A vital link is missing … At a normal
ward you can ask them questions about what they are doing. That
should be enough to understand them, to empathise with them … I
suppose the contacts will be more normal, they are more
recognisable human beings”.

In the vignette we notice the super-ego is at work in self-reproaches
and self-doubt (e.g. for having tried to change cltents and having failed,
and for his own routine in working) (cf. reduced personal accomplishment).
His difficulties in ‘admitting’ negative aspects in his relation
with clients too indicate a moral rigor. Withdrawal from contacts is
evident in his description of the job as a routine and in his renouncing
the attempt to influence clients (d. depersonalisation). Inhibition more
generally appears during the interview as Tom has problems with
verbalising and giving examples. Exhaustion is reflected in his
description of the job as stressing and in the feehng he has no energy
and courage anymore. He tends to his work in a disengaged way, like
in a routine.

Notice that all the interactions with clients he described begin from
an idea of changing them, that is, of modelling clients along his own
ideas. He wants them to fit into his conception of how humans are and
how help can be given. Aggressiveness towards clients is difficult to
admit and is only indicated indirectly. It seems he wants to run away
from it and this attitude is repeated during the interview. He has
difficulties talking about negative aspects in relation to his clients and
at the end of the interview he literally flees from us. Aggressiveness
nevertheless seems to influence his attitude in his work. For example,
he has the impression that clients are taking advantage of him (cf. his
idea that the clients are pulling the strings and that the manic-depressive
client is fooling him). This position seems to bother him and
stimulates him to intervene harshly himself (cf. his idea he would
‘force’ the matter, that they shouldn’t fool him, that he couldn’t win).
This interaction ends in a situation of violence he tells almost nothing
about (cf. his remark that the manic-depressive client was wounded). It
is indirectly signalled, in the way he introduces his interventions. It is
remarkable that all of his attempts to make contact with clients or to
change clients end up with the idea that they are radically different
from him. He can’t empathise and blames this failure as the reason why
he retreats from caring. We notice that his insisting ideas about being
able to change clients are constantly retracted. By abdicating and
retreating from true interaction, he seems to avoid the question of
whether his clients are ‘really human’ like him. He prefers to cling to his
ideas about the possibility of changing clients and, like any good
neurotic, fantasises about working with an easier popUlation that
would fit better with his conceptions.

CONCLUSION
In this paper we situated burnout as a subjective reaction to the
ambivalence evoked by professional caregiving itself. Caring confronts
the caregiver with psychic antitheses, since an appeal is made
simultaneously to sexuality, destructiveness and jouissance. Because
they are incompatible with the ideal of caring, these are tendencies the
caregiver shuns away from and defends against. This defence results in
conflicts between ego and super-ego, inhibition and exhaustion. We
found these three mechanisms to explain the three core burnout
symptoms: feelings of reduced personal accomplishment, depersonalisation
and emotional exhaustion.

This paper focused on the function of caring in the basic relation
between subject and other. We concentrated on the mechanisms within
the primal relation all professional caring is based on. The way
professional caregivers deal with the basic conflict discussed undoubtedly
determines the functioning of professional organisations and
caregiving institutions. We believe that the avoidance of both
imaginary conflict and the inherent impotence all caregivers are
confronted with, not only results in difficulty at the level of the primal
caregiving relation, but that it will be reflected and repeated in the
broader organisational context as well.

Based on the mechanisms described, we conclude that intervention,
such as psychoanalytic supervision, should concentrate on the ego’s
experience of antithesis (e.g. the conflicting experience of aggression).
Antithesis should be recognised, verbalised and worked through. so
that it is no longer automatically defended against. This implies that
supervisors should break through people’s spontaneous tendency to
avoid the taboo of aggression and sexuality and the tendency to disown
these dimensions. As in psychoanalysis proper, professionals should be
stimulated to say what’s on their mind and to go into incidents they
experience as compromising. In this way, the conflicting nature of
contradiction may be diminished to the extent that it no longer seeks
expression via subjective complaints. Intervention should focus on the
symbolic roots upon which the imaginary caregiving relation is based
(i.e. the caregiver’s own oedipal history) and on the real impotence in
relation to which it functions as a defence.

Categories: affect/care
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