Bathing - the Body and Community Care

Julia Twigg

• Publisher: Routledge
• Year: 2002
• eBook ISBN: 9781134629541
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Community care lies at the intersection of day-to-day life and the public world of service provision. Using the lens of one particular activity - bathing - this book explores what happens when the public world of professionals and service provision enters the lives of older and disabled people. In doing so it addresses wider issues concerning the management of the body, the meaning of carework and the significance of body care in the ordering of daily life.
Bathing - the Body and Community Care provides an engaging text for students and will be of interest to a wide range of audiences, both social science and health science students and nursing and allied professionals

1: The body in community care

Although community care deals with the most basic and everyday needs of people, the ways in which it has been presented often miss the concrete nature of this reality. Accounts of community care tend to be concerned with the institutional framework and the network of government polices that relate to this. These are important subjects, but the dominance of the approach has meant that much of the life has been squeezed out of the subject. The day-to-day reality of people’s lives with its richness and variety is often missing.

This book aims to look at community care in a different way. These are three ways in which it does so. First, by focusing at the front line, it re-positions the analysis more directly at the point where care is actually produced. It is in the dynamics of the care encounter that the nature of what is produced is defined; production and consumption collapse into one another. Second, by looking at the practical activities of washing and bathing, the book reasserts the significance of the ordinary and the day-to-day. It is in the fine texture of these that our lives are located, and it is only through understanding such levels of activity that we can hope to gain insight into how services might impact upon them. Lastly, though community care is essentially about the care and management of the body, this fact has not traditionally been foregrounded in accounts of the sector; and the dominant approach remains a disembodied one. Exploring the provision of bathing and personal care enables us to put the missing body back in.

Refocusing at the front line

It is at the front line that the true nature of care reveals itself. It is there that it is created; and only there can it be judged. We can sense this truth through imaginative engagement. We can picture a continuum of care that at one end represents the best sort of care and at the other verges on abuse. Even if not involving positive cruelty, we can imagine rough handling, denigrating language, sneering or nasty words, a silent refusal to recognise the person, the demeaning exposure of the body, cold indifference to embarrassment or anxiety. At the other end, we can imagine the very best sort of care, where the careworker brings a sense of life and fun into the house, where the older or disabled person is encouraged and sustained, where what is particular about them is endorsed and valued, where care is structured around their preferences, and where lapses of the body are smoothed over. It is not difficult to imagine what these two regimes would mean for a recipient of care. To fall under one or other is to fall into two radically different worlds. And yet both can be described from the outside in similar terms. In both cases, certain tasks are accomplished, an hour of home care received. It is in the fine texture of the exchange that the essence lies. How care is delivered, how the service is forged at the front line is of central significance. And yet we know remarkably little about this front line. Domiciliary care in large measure still takes place in a black box.

This lack of knowledge has implications for the planning and delivery of community care. Currently the institutions of community care operate on an assumption that ‘care’ is unproblematic. In managerial and policy documents, it is often presented in terms of units of service, hours of the workers’ time; and there is an implicit assumption that if you recruit the right person, all will be well and a standard amount of ‘care’, whatever that is, will be delivered. But the nature of care is more complex that this account would suggest. Care is not something that is produced back at headquarters; rather it is created dynamically, at the front line. As with other forms of service work, the processes of production and consumption collapse into one another. Care is not just given; it is also received; and indeed the very processes that create ‘care’ are interactive, dynamic ones. In order to understand the character of these processes we need to look at them from both sides, from the perspectives of both the recipients and givers of care. Care is thus not a simple ‘thing’.

If the front line of care is so significant, why has it not occupied the centre stage of analysis? The site where it occurs is crucial in explaining this. Community care takes place in a special space, that of home and this, and the norm of privacy that applies there, puts limits on our knowledge. At the simplest level it is hard to gain entry into people’s domestic space. It can only be achieved with their agreement, and even then the nature of the social encounter restricts the methodology, effectively limiting it to interviews. Ethnographic and observational studies of older people in their own homes scarcely exist. Such studies as there are are largely confined to institutional settings where access can be negotiated officially and where the presence of the researcher is sanctioned by the semi-public nature of the space.

Research has all too often reflected the values of the service world. Much of the work on community care has focused on the views of higher status actors like policy makers, care managers, social work professionals. The nearer you get to the front line and the lowly-trained, poorly-paid workers who actually deliver the care, the weaker the evidence gets. Research has also been biased by the scope and intensity of the service gaze. The more service dominated an area is, the more we know about it, and the more we attend to it in research terms. From the viewpoint of the policy world, it is service provision rather than day-to-day life that matters. As a result we know most about institutionally-based services and those where professionals are numerous and dominate. We know least about those services that are far from the gaze of the service provider, obscured in the private world of home.

Home care and the provision of bathing provide classic examples of these biases. Despite the fact that home care represents the largest part of the noninstitutional budget of social services, it has received relatively little policy or research attention. The literature on home care is sparse, and little of it addresses the concrete nature of the activity. Personal care has been similarly neglected as a subject, despite the fact that it lies at the heart of complex packages of care and is a crucial element in enabling older and disabled people to remain living at home – the key policy objective of the last three decades. Personal care has partly been neglected because policy analysts have been squeamish in pursuing these private, bodily areas; and in the chapters that follow, I will try to get behind the screens of policy decorum to explore more fully the nature of personal care.

Re-valuing the mundane

As Siegfried Giedion wrote in his classic account of the impact of mechanisation on daily life which includes a section on bathing: ‘for the historian, there are no banal things’ (Giedion 1948, p. 3). The same is true for the social scientist, and one of the purposes of this book is to reassert the significance of the day-to-day and the mundane. Such levels of analysis have traditionally been neglected in accounts of community care. We need to explore them, however, if we are to grasp something of the day-to-day textures of people’s lives and the sources of implicit meaning and significance that are embedded in them. Activities like bathing and washing play a central part in domestic life. They are one of a number of forms of body maintenance that permeate our lives. The round of getting up, dressing, eating, sleeping, excreting provides the bedrock of social existence, the fundamental structures that order our day-to-day existence. These activities, however, exist at a level that is rarely brought into conscious articulation or review; indeed in modern western societies we are largely educated to ignore them, regarding them as too trivial or too private for comment. But such activities offer a rich source of implicit meaning in people’s lives, sustaining and expressing relationships, endorsing values and beliefs, providing an existential coherence to individuals’ lives.

We can see this clearly in relation to the parallel area of food and food practices. Until the 1980s food was a neglected topic within sociology, considered too mundane, too much a matter of common sense, to be of interest to a discipline concerned with higher-status sources of power and meaning. The shift towards a new interest in the household and the private sphere, largely engineered by feminism, however opened up possibilities for exploring the significance of everyday life; and the new focus on food formed part of this (Murcott 1983, Twigg 1983, Charles and Kerr 1988, Wood 1995, Lupton 1996, Beardsworth and Keil 1997, Bell and Valentine 1997). As a result we can now see how food and food practices underwrite social structures, reinforcing relations of power and authority within the family and more widely. Diets and dieting offer regimens of health and well being that bring a daily coherence to people’s lives. Through ideologies such as vegetarianism, food and food avoidances can be linked to wider political, philosophical, and spiritual ideas, embodying and reinforcing these values on a day-to-day basis. Food thus plays a central part in existential order.

Bathing and washing present a parallel, though perhaps less obvious, example of such meanings embedded in the day-to-day; and in Chapter 2, I will explore the history of these activities in the west and their links to the development of modernity. Part of the purpose of this chapter is to destabilise our common-sense understanding of what bathing and washing are about. Bathing has historically been located in a variety of discourses, of which the discourse of hygiene is not the sole or even always the dominant one. Bathing has had many meanings. Exploring these historically enables us to gain access to aspects of current practice that might otherwise remain hidden. For example, baths have often been used as rites of passage into institutions; and something of this sense remains in relation to their use by individuals at home to mark the passage of the day or week. Baths also have a history as part of coercive techniques designed to produce docile bodies; and being given a bath at home or in an institution can contain this sense, in potentiality at least. Historical trends in the treatment of the body also reflect wider shifts within society associated with High Modernity, and I will explore how these have consequences for the management of the body in disability.

By focusing on a specific activity like bathing we can also gain some access to the day-to-day lives of older people. How do they manage, how do they structure their days, what part does body care play in this? Looking at bathing enables us to see something of how domestic life works. The domestic ordering of life has a profound significance for our sense of self and of being in the world. In Chapter 4, we will explore the spatial and temporal ordering of the home, and the consequences for these of the coming of care.

The body in community care

Though there has been an explosion of work on the body in the last decade, this has not been reflected in the literature on community care. There are a number of reasons for this. One concerns ways in which the subject has traditionally been described and analysed. The dominant discourses constructing the field have been those of social work and managerialism. Social work has however never wholly claimed community care (as it has work with children and families) and its emphasis on casework and interpersonal relationships means that its theorising traditionally stops short of the body. Furthermore since the 1980s and the rise of the New Public Management (Ferlie et al. 1996), community care has increasingly been dominated by a managerialist discourse that stresses issues of efficiency and effectiveness, and focuses, in relation to home care, on allocation and targeting, and in which the day-to-day realities of low level carework are overlooked. Managerialist discourse is itself notably disembodied, drawing on traditions like economics, accountancy and organisation and methods that prize abstraction and emotional distance. The body has little place in these analyses; indeed it represents just those qualities of embedded, messy, concreteness that such forms of analysis aim to transcend. Managerial accounts of home care are notable for their disembodied, aetherialising quality; and it is hard from reading them to gain any real sense of what the work entails.

A second reason for the neglect of the body as a topic in community care arises from the concern of social gerontology to avoid the excessive focus on the body and its decline that is characteristic of the biomedical model that dominates both professional and popular accounts of aging. In this, older people are defined in terms of their bodies and their malfunctioning. Much of the success of the Political Economy Approach within gerontology in the last twenty years has derived from its capacity to transcend this bodily emphasis and locate the problems of older people, not in their declining physical capacities, but in the surrounding social and economic structures that result in them being differentially poor, marginalised, and lacking in social and material resources (Townsend 1986, Phillipson and Walker 1986, Minkler and Estes 1991). The desire to avoid an oppressive identification of older people with the body and its decline is compounded by what Andrews (1999) terms the seductiveness of agelessness: the model of aging that denies the significance of the body and emphasizes the eternally young self below the mask of age. This has been influential in both popular and academic accounts that have sought to present a positive account of aging. Some theorists have argued for a radically social constructionist approach to old age that denies the relevance of the physical body altogether.

Similar processes have occurred within the disability movement where since the 1980s there has been a conscious attempt to get away from an emphasis on the bodies of disabled people – their failure, their dysfunctionality – and seek instead the social sources of disability. An emphasis on the bodily is seen as potentially demeaning to disabled people. At worst it presents them as the rejected Other of the freak show, subject to the prurient, pitying gaze of dominant society; and disabled women in particular have written of the distress and anger caused by being the subject of a voyeuristic speculation on what is ‘wrong’ with their bodies (Morris 1993, Lonsdale 1990). The Social Model of Disability, associated with the work of Oliver, Finkelstein and others, offered a way of getting away from this narrow focus on impairment, asserting instead that it was society not the body that disabled people (Oliver 1990, Morris 1993). More recently, this dominant framework has itself been subject to critique. Hughes and Paterson (1997) argue that the social model by looking only at disability, consigned the bodily (in the form of impairment) to the theoretical shadows, or worse the realm of bio-medicine, leaving large parts of the subjective experience of disabled people invisible and untheorised. Work by Shakespeare (1994), Hughes and Paterson (1997) and others has begun to explore the possibilities of using post-structuralist and phenomenological approaches to the body to develop a sociology of impairment.

Just as social gerontology and disability studies have been slow to take up the issue of the body so too the new sociology of the body, which has exploded over the last decade, has been reluctant to apply its analyses to older people. With the exception of pioneering work by Featherstone and Hepworth (1991) (and latterly Öberg (1996) and Katz (1996)) writing about the body has emphasised younger, sexier bodies. In part this reflects the way the subject emerged out of feminist and queer theorising around the construction of sexualities and the status of the body in this, but the bias towards youth also reflects a more general bias in the representation and treatment of bodies in culture: it is not just in academic literature that older bodies are absent.

The mainstream literature on the body is also marked by the remnants of an older cultural conflict in which the body’s worth and goodness is asserted against what is perceived as an enduring Manichean strain in western culture. This discourse of the ‘good body’ is part of a wider twentieth century secularising project in which bodily pleasure, desire and freedom are asserted against what is presented as a repressive past; and it has links with the postmodern presentation with the body as a site of consumption and pleasure (Featherstone 1991). This consciously up-beat, positive emphasis, however, is ill-at-ease when faced with what I will term ‘the negativities of the body’ – dirt, decay, decline, death – and it is precisely these negativities that lie at the core of some at least of the experience of aging, however much positive accounts may wish to downplay them.

The desire to emphasise the positive and to downplay the darker side of care is a established part of the progressivism of social policy as a discipline. Emphasising models of good practice, focusing on user empowerment, promoting normalisation, eradicating oppressive language: all have been part of attempts by reformist bodies and individuals to improve practice through presenting it within an optimist framework. (The work of the Joseph Rowntree Foundation with its active promotion of such frameworks through its research agenda is an example of this.) But such consciously up beat approaches frequently involve presenting an idealised account that suppresses the darker realities of care. Smith and Brown (1992) argue that such processes of self censorship have been central to movements like normalisation where images and language are controlled in pursuit of a more positive approach, and that this has led the social policy literature to deny the darker elements in carework.

In the chapters that follow we will explore the ways in which bodily themes resonate through the subject of community care. Before doing so, however, we need to review the main elements of the new literature on the body.

New interest in the body

The new interest in the body that has sprung up across the arts and social sciences in the last decade has its roots in a complex set of intellectual and social influences. All start in some degree, however, from a dissatisfaction with the dominant rationalistic account that has characterised the social sciences since their inception in the eighteenth century. Social science is part of the Enlightenment project that has privileged the rational, controlled and abstract over the disordered, uncontrolled and concrete. In this intellectual process, emotions and the body were relegated to a secondary status and a discredited (and as we shall see, gendered) set of categories. Sociology in particular, in its struggle to establish its own intellectual territory and to throw off the spectre of biological reductionism, engaged as a distancing exercise, in which the conceptual realm of the social was secured and established by means of excluding the biological and handing that over to science. The price of this exercise of disciplinary definition was however, Turner argues in his ground-breaking book of 1984, the effective exclusion of the body and its concerns from sociological analysis (Turner 1984, 1991, Williams and Bendelow 1998). The body came to be seen as distinct from the rational actor, something to be transcended or ignored. The legacy of the rational actor has been particularly strong in certain social sciences, notably economics and in its related practical fields such as management sciences. In so far as topics like social services have fallen under the influence of such thinking, this has acted as a break on the development within them of theorising on the body.

Not all sociological theorising in the past excluded the body, and Turner has outlined an oppositional tradition from Nietzsche through Schopenhauer to Marcuse and Foucault in which the body, as the seat of desire, irrationality and pleasure, offers the basis for a radical critique of capitalist rationality (Turner 1991). The pedigree is a complex one and encompasses a range of contradictory theorists. All however are united in their critique of the narrow rationality of the dominant social science paradigm.

The most sustained challenge to the rationalistic account has come from feminism. From its inception, feminism has been concerned to show the ways in which women’s bodies are controlled and manipulated within patriarchy, focusing on a range of issues from abortion and reproductive rights, through rape, pornography and the wider media commodification of women’s bodies, to dieting and the imposition of beauty ideals (Martin 1987, Smart 1989, Wolf 1990, Lovenduski and Randall 1993, Davis 1995, 1997). A series of social institutions – medicine, religion, marriage, the law – are implicated in the control of women, through the control of their bodies. Patriarchy was shown to operate directly on and through the bodies of women (Walby 1990). This was not just a matter of representation, but extends to the physicality of the body itself. Women, as Young (1990) showed in her seminal essay ‘Throwing like a Girl’, are encouraged to develop bodies that are weak, hesitant, reactive and soft; and this is in contrast to the active bodily confidence encouraged in men. These gendered differences, particularly around diffidence and modesty, have consequences for the experience of the body in relation to care.

Feminism has also been concerned to explore the ways in which women have been presented within culture as more embodied than men – to the extent that they come to represent the Body itself – and the ways in which this has been used to justify exclusionary practices (Jordanova 1989, Bashford 2000). Women are reduced to their bodies, confined within the matrixes of sexuality and reproduction. Women’s bodies have traditionally been presented negatively as lesser, in some sense pathological compared with the male norm: fluid, soft, weak, uncontrolled and leaky compared with the hard, strong defined, contained bodies of men. Women are caught in a set of dichotomies in which they represent the devalued, unmarked, silenced categories of nature, the body, the emotions in contrast to culture, the mind, reason.

Malestream sociology ...

Table of contents

• Cover Page
• Bathing – The Body and Community Care
• Title Page
• Copyright Page
• Preface
• 1: The Body in Community Care
• 2: Cultures of Bathing and the Body in High Modernity
• 3: Bathing, Washing and the Management of Personal Care
• 4: The Spatial and Temporal Ordering of Care
• 5: The Medical/Social Boundary and the Rationalisation of Community Care
• 6: The Employment World of the Careworker
• 7: Carework as Bodywork
• 8: Carework as Emotional Labour
• 9: The Power Dynamics of Care
• Conclusion
• Appendix: The Study
• References