Accountability from Somewhere and for Someone: Relating with Care

Abstract

In contemporary care institutions, accountability procedures and devices are increasingly pervasive and considered crucial for monitoring quality. Such accountability practices are based on the idea that accountability and care belong in two separate domains. The distinction between accountability ‘from nowhere and for everyone’ and accountability ‘from somewhere and for someone’ problematises this implicit split. Taking seriously the observations of everyday caring and accounting by care professionals, who resist splitting care and accountability from the outset, demands a reconceptualisation of the relation between care and accountability as reciprocal and co-emerging. Both accountability and care are highly circumstantial, emerging, relational notions and it is not clear-cut who or what cares or accounts for what, whom, where and how. Paying due attention to the generative interweaving of accounting and caring, that is, to the narrative work of care professionals, affords the potential to turn universal abstract norms of what good care should be into meaningful care. Creatively reconnecting care experiences, observations, records and relations generates accountability with care. Care professionals do this by daring to prioritise speculatively what matters most in a specific situation without falling back on the reassurance of clear-cut norms of good care and by daring to admit that even while prioritising a certain course of action, they might not know its consequences. Such a speculative commitment and the inclusion of the researcher's experiences in trying to be accountable are crucial for studying accountability as a matter of care and as relatedness in the making.     

Learning to feel at home. Governing homelessness and the politics of affect

The emotional and affective dynamics of homelessness are an established matter of concern in geographical research. Geographers have called attention to homelessness as an embodied phenomenon and to the emotional distress that affects people experiencing homelessness. What has achieved less attention though are the politics of affect that characterize spaces of care. Attempts to make homeless people ‘housing ready’ often target emotions and try to provide clients with a sense of belonging and feelings of responsibility in matters of housekeeping and homemaking. The paper takes these attempts to create emotionally stable ‘housing ready’ selves as a point of departure to open a set of broader questions concerning the nature of encounters between the welfare state and its citizens. It shows how spaces of care address ‘housing readiness’ as a personal ability and thereby abstract from the complex affective entanglements and prepersonal conditions that characterize dwelling. To highlight the paradoxical effects of therapeutic approaches to dwelling as a subjective emotional skill that can be mastered, I contrast the notion of ‘housing readiness’ with recent work in the field of affective geographies that allows for a different articulation of dwelling as a dense web of practices, atmospheres and relations between people, spaces and things.     

A brief episode of psychosis: Elli's story

This paper explores the notion of a GP practice as a ‘secure base’, suggesting that greater attention could usefully be paid to the importance of attachment relationships in primary care. If professionals feel secure and respected within ‘the practice’ then ‘the practice’ itself is more likely to be able to function as a ‘secure base’ for its patients. It is suggested that this concept could be developed further to provide a conceptual framework for practices to examine their function as therapeutic organizations. A short resumé of John Bowlby's attachment theory is outlined. Illustrations are given of how different attachment styles – secure, avoidant, ambivalent or disorganized – might affect patient care. A case of a mother (with postnatal depression) and her infant is considered in detail to illustrate the value of early intervention in a mother-infant relationship. Professionals are also attached to the practices where they work and the author reflects on his own retirement from being a GP (after 35 years). Finally, the paper describes another case – of a patient who was able to relive, and possibly repair, some of her earlier traumatic childhood separations through her relationship and parting from her GP as retirement approached.     

The ‘Connection’ Health Care Providers Make with Dying Patients

SUMMARY

The literature confirms illness and hospitalisation can become spiritual encounters for patients and their families. Further, it has been established that both patients and their families are better equipped to deal with loss and change if they have a healthily developed spiritual sense of self. The aim of the study sought to determine the benefit or otherwise of a previous model of spiritual care. It asked ‘from the perspective of the nurse and other health care providers, what constitutes spiritual care giving?’ An ethnography was undertaken where data consisted of field notes, interviews, records, and diary entries. This paper reports on interview data, from which themes were derived. The major theme titled their space is expressed via a new model of spiritual care. It was shown that when caring for patients and their relatives, nurses and other health care professionals enter the world of the other to determine the other's needs. In so doing they typify agapé (altruistic love), where the individual cares for a complete stranger as if that stranger were family. This connection with the patient and their family is the foundation for spiritual care.     

Implications of Teacher Life–Work Histories for Conceptualisations of ‘Care’: Narratives from Rural Zimbabwe

Schools are increasingly seen as key sites for support to HIV‐affected and other vulnerable children, and teachers are assigned the critical role of identifying and providing psychosocial support. Drawing on the life–work history narratives of 12 teachers in Zimbabwe, this paper explores the psychosocial processes underpinning teachers' conceptualisations of these caring roles. The influence of prolonged adversity, formative relationships, and broader patterns of social and institutional change in teacher identity formation processes speak to the complex and embodied nature of understandings of ‘care’. In such extreme settings teachers prioritise the material and disciplinary aspects of ‘care’ that they see as essential for supporting children to overcome hardship. This focus not only means that emotional support as envisaged in international policy is commonly overlooked, but also exposes a wider ideological clash about childrearing. This tension together with an overall ambivalence surrounding teacher identities puts further strain on teacher–student relationships. We propose the current trainings on providing emotional support are insufficient and that more active focus needs to be directed at support to teachers in relation with their students. © 2015 The Authors. Journal of Community & Applied Social Psychology published by John Wiley & Sons Ltd.     

People with intellectual disability as neighbours: Towards understanding the mundane aspects of social integration

Although people with intellectual disabilities (ID) are increasingly expected to relocate from traditional institutional care to ‘regular’ neighbourhood housing facilities and socially integrate in these neighbourhoods, little is known about how they are perceived and appreciated as neighbours. This paper reports on interviews carried out with 30 neighbours without ID who were neighbours of small‐scale care facilities for people with ID. Interviews addressed the neighbours' everyday experiences of neighbouring in general, and neighbouring people with ID in particular. Neighbouring, for these informants, called for a fine balance between friendliness without over‐involvement. While they were generally positive about their interactions with their neighbours with ID, it emerged that the formal nature of the care facility and the interaction style of some of the neighbours with ID often contravened informants' assumptions about neighbouring. Informants expressed concern about a possible lack of appropriate distance, reciprocity and accountability among their neighbours with ID. The nature of the care facility, with paid staff, often group activities, formal means of achieving the everyday small tasks which neighbours sometimes do for each other, and a high turnover of residents, all undermined the possibility of a typical neighbourly relationship. In conclusion, we suggest that integration of people with ID into everyday neighbouring relationships raises complex challenges for care organizations that need to find a balance between supporting the needs of people with ID they care for, adequate support and mediation for other neighbours when necessary, and all the while avoid becoming overly involved in neighbouring as a formal partner. Copyright © 2010 John Wiley & Sons, Ltd.     

The “religiosity gap” in a clinical setting: experiences of mental health care consumers and professionals

ABSTRACT

In Western countries, professionals in mental health care (“professionals”) tend to be less religious than “consumers”. This qualitative study explores the meaning of this “religiosity gap” for professionals and consumers in mental health care. Both a regular, secular and a Christian clinic in the Netherlands participated in this study. Content analysis was applied to 35 consumer interviews and 18 interviews with professionals. Consumers reported negative experiences (e.g., perceived disrespect and a lack of confidence) and/or negative expectations (e.g., misunderstanding and misinterpretation) related to a religiosity gap. They also mentioned advantages of a “religiosity match”, like safety and confidence and appreciated professionals’ religious/spiritual self-disclosure. Professionals in secular care setting tended to avoid religion and spirituality. In both clinics, they tended to neutralise religious/spiritual differences and be reticent in self-disclosure. Professionals are recommended to recognise the relevance of a religiosity gap and to consider different strategies in approaching religion/spirituality.     

Objectless activity: Marx's ‘theses on feuerbach’

According to Friedrich Engels (Ludwig Feuerbach and the end of classical German philosophy) the so‐called ‘Thesen über Feuerbach’ are ‘the brilliant germ of the new world conception’. For Karl Korsch ('Review of Vernon Venable’, Journal of Philosophy 42 [1945], no. 26) there are ‘magnificently summed up’ in them the ‘texts of Marx and Engels's first (Hegelian and post‐Hegelian) period’. Even given the important distinction between the ‘young’ and the ‘mature’ Marx these two opinions are not incompatible. The present paper's concern, however, is with the relationship of the ‘Thesen’ to the materialist conception of history. Once the ‘Thesen’ are read as a consistent whole it is clear that they are incompatible with any non‐social (non‐human) nature; hence with the ontological independence of nature from man; hence with any materialism, historical or otherwise. Furthermore, taken as a whole the ‘Thesen’ form an attempted solution to the problem of the justification of ideals, a solution both activist and dogmatist. Since the attitude expressed in the ‘Thesen’ underlies both Marx's ‘theory of alienation’ and his ‘critique of political economy’ neither of these can lay claim to the status of knowledge.     

On the scrap‐heap at 45: The human impact of mature‐aged unemployment

This paper reports on a qualitative study conducted in Adelaide, South Australia into the impact of mature‐aged unemployment and under‐employment on the individual. Data were collected by means of six individual and group interviews with a total of 27 participants (17 men and 10 women). The participants were asked about the impact on their quality of life, their expectations for the future and their short‐term and long‐term financial situation. The results suggest that there is a substantial ‘lost generation’ of mature‐aged unemployed people who are characterized by shrinking horizons and impaired quality of life. The participants expressed frustration at being unable to contribute to society and support their own adult children. Inability to use their skills and talents, with consequent skill depreciation, can lead to what we label the ‘peg‐down phenomenon’, an intermediate step between becoming unemployed and entering the ranks of the discouraged job‐seekers that ultimately leads to a premature exit from the workforce. This cohort is different from other age groups of unemployed people because of the unique developmental characteristics of middle‐aged people, compounded by financial and caring demands from both the younger and older generations. The paper concludes with policy recommendations, including expanding social inclusion policies to address the needs of this cohort and early intervention with more focused job‐specific training.     

Queer Patients and the Health Care Professional—Regulatory Arrangements Matter

This paper discusses a number of critical ethical problems that arise in interactions between queer patients and health care professionals attending them. Using real-world examples, we discuss the very practical problems queer patients often face in the clinic. Health care professionals face conflicts in societies that criminalise same sex relationships. We also analyse the question of what ought to be done to confront health care professionals who propagate falsehoods about homosexuality in the public domain. These health care professionals are more often than not motivated by strong religious convictions that conflict with mainstream medical opinion on homosexuality. We argue that they ought to be held accountable for their conduct by their professional statutory bodies, given that they abuse their professional standing to propagate sectarian views not representative of their profession. Lastly, we propose that medical schools have special responsibilities in training future health care professionals that will enable them to respond professionally to queer patients seeking health care.     

Representing the Good: Pastoral Care in a Secular Age

In ‘a secular age’ (Taylor 2007), pastoral care is no longer exclusively associated with specific religious traditions and communities. Pastoral caregivers who work in secular institutions provide care to religious and nonreligious people alike, and in several Western societies the term pastoral care is used in relation to nonreligious (humanist) care. In secular contexts, the term ‘pastoral care’ is often replaced by the term ‘spiritual care.’ Spiritual care, however, is provided by various professionals, so pastoral caregivers face the challenge of developing adequate and convincing language to explain what is distinctive about their work. In this article, the authors turn to philosophical language in order to develop a conceptual understanding of pastoral care that does not depend on the specific worldview—religious or nonreligious—of either pastoral caregivers or receivers of pastoral care. Using the work of Taylor (1989, 2007) and Murdoch (1970), we explain pastoral care as engaging with people’s attempts to orient in ‘moral space’ and the distinctive quality of pastoral care as ‘representing the Good.’ Murdoch associates ‘the Good’ with a secular idea of transcendence that is both a movement beyond the ego and an engagement with the reality of human vulnerability, suffering, and evil. We argue that pastoral caregivers who ‘represent the Good’ have the task not only of supporting the existential and spiritual processes of individuals but also of promoting dialogue and social justice and of critiquing dehumanizing practices in the organizations in which they work and in society at large.     

Beyond Stewardship? Dietrich Bonhoeffer on Nature

This article questions whether the model of stewardship is helpful in considering Christian responsibility towards non‐human nature and proposes a different way of treating the issue of care of the environment. In an extended engagement with the theology of Dietrich Bonhoeffer, the article argues that human relations to non‐human nature are best understood by seeing humanity as historical, political and natural. In theological formulation, humanity must be understood asimago dei, imago civitatis andimago mundi. Therefore the place of humanity cannot properly be understood without reference to both God and nature. Humanity, nature and God thereby constitute a ‘common realm’. A new test of Christian responsibility towards non‐human nature is introduced: of primary interest is how historical, political and natural humanity acts in ways which either reveal or obscure the ‘common realm of God, nature and humanity’. At this point, theological self‐understanding moves beyond the model of stewardship.     

The Problem with “Caring” Human Rights

Although Daniel Engster's “caring” human rights are, on the surface, a compelling way to bring the concept of care into the international political realm, I argue they actually serve to perpetuate some of the same problems of mainstream human‐rights discourses. The problem is twofold. First, Engster's particular care theory relies on an uncritical acceptance of our dependence relations. It can, therefore, not only overlook how local and global institutions, norms, and the marketplace shape our relations of (inter)dependence, but also serve to further naturalize our current dependence relations. Second, Engster's caring human rights are only minimally feminist, which means that they do not pay attention to the way in which women's full and equal political participation is a necessary component to challenging and overcoming the oppression, marginalization, and exploitation of women and their caring labor worldwide. Although I am sympathetic to Engster's goals and some of his proposed policy solutions, I argue that we should not abandon the critical, feminist lens of care ethics in favor of “caring” human rights that cannot overcome the care critique of mainstream human‐rights discourses.     

Significance of nature in a clinical setting and its perceived therapeutic value from patients’ perspective

The effect that nature can have on the development of mental health and the implications for recovery is important for understanding the impact nature has on humans, as well as delineating possible alternative venues for treating psychological problems. The present qualitative study examined how individuals understand the significance of nature in relation to their mental health and treatment. A total of 12 participants in residential treatment for varying nonpsychotic mental health issues were interviewed about previous and present experiences with nature and the meaning these experiences have for them in recovery. Thematic analysis resulted in the creation of two main themes: «being human in nature», which included three sub-themes ‘experience of nature’, ‘effects on focus and attention’ and ‘change and the transformative in nature’, and «nature, the patient and treatment», with two sub-themes ‘nature as therapy’ and ‘nature and therapy’. Participants describe a feeling of coming closer to themselves, to their problems and existential meanings when in nature. In addition, they report being able to make new relational experiences with other patients, and that some experiences in nature can function as symbolic tools in therapy. The study underlines the complex interrelationships between nature and humans and points to new lines for future research.     

The spirit and development of Neo‐Gonfugianism

The ideal of human life as a life of sagehood is the core of Confucian thought. In neo‐Confucianism the stress is on the self‐perfectibility of man, and the central concern of neo‐Confucianist thinkers has accordingly been with the question of how man can cultivate his own potentiality to be a sage. The different answers they give are in the form of teachings about the ‘way’, these teachings incorporating different philosophical views of mind, human nature, and the universe. The author outlines the views of successive neo‐Confucianists and their versions of the ‘way’, seeing their teachings as developments towards the doctrine presented by Wang Yang‐ming (b. 1472), whose thought can be seen in particular as a synthesis of the views of Chu Tzu and Lu Shiang‐shan.     

How Opposites (Should) Attract: Humility as a Virtue for the Strong

This article first examines pervasive present‐day attitudes toward humility (‘The Contemporary Distaste for Humility’) before turning to Thomas Aquinas and Zhu Xi for their more positive treatments of this disposition (‘Thomas Aquinas and Zhu Xi on Humility’). It then considers their ideas about how humility is related to our human limitations (‘Humility Grounded in Our Finite Nature and Knowledge’), before surveying how they think it should be expressed in our relationships with our neighbours (‘Humility in Community’). The article looks at what Thomas and Zhu have to say about excessive pride in rulers (‘Humility and Authority’) before closing in the Conclusion with some thoughts about the viability of humility as a virtue for the strong, and its especial importance in contemporary politics.