This paper aims to look at the pressing question of how we care for vulnerable members of our society. The shock and outrage that followed the airing of a Prime Time investigation programme, portraying residents with severe disabilities being routinely abused, has prompted questions in relation to what light psychoanalysis can shine on scandals such as the one exposed in Aras Attracta. When confronted with extreme vulnerability we are reminded of our own helplessness, what Freud termed Hilflosigkeit and are therefore faced with something of the Real. It seems essential to explore, from a psychoanalytic perspective, the effect of this kind of work on the subjectivity of carers and clinicians. The unconscious must be acknowledged in this area of work, in order to inform the therapeutic position of clinicians and to examine more closely the role that these so called ‘care homes’ and their inhabitants come to have in society.
Introduction
In December 2014 Prime Time[2] aired a programme revealing widespread abuse in one of the units of Aras Attracta[3], a residence for people with intellectual disability in County Mayo. The programme, using undercover footage, portrayed how the residents of Bungalow 3, who had profound intellectual disabilities, were being beaten, force-fed, jeered at, and routinely neglected by the staff who were entrusted with their care. The level of abuse meted out to the residents and the culture of cruelty that had evolved in Bungalow 3 was, to put it mildly, difficult to watch. The programme provoked public outrage and a media furore which sparked widespread debate regarding the nature of care in Ireland. Despite a previous HIQA[4] investigation in Aras Attracta that had raised serious concerns and made a number of recommendations, it seemed to have effected little or no change in the running of the care facility. Following the exposure of these abuses there is now a Garda and a HSE[5] investigation underway. The genesis of this study is the question of whether a psychoanalytic investigation could shed more light on yet another scandal in the provision of care in Irish society.
Social care
The question of how we care for the vulnerable in society is not without its complexities in the Irish context. Traditionally the institution of the Church was responsible for much of this care and in recent years many abuses have been controversially unearthed which have left a trail of devastation in their wake. The last number of years has seen the professionalisation of care and the emergence of a new profession known as ‘social care’ which is, ‘characterised by working in partnership with people who experience marginalisation or disadvantage or who have “special needs.”’[6] The challenge of working with marginalised and disadvantaged sectors of society necessitates an inclusion of important psychoanalytic concepts in the practice of this new profession. Despite this, psychoanalysis does not seem to have a place within this system. With the move away from caring for people in so-called ‘congregated settings’ towards care in the community, social care is very much a growing field of work. It seems, that while it is easy to speak the language of ‘dignity’, ‘respect’ and ‘person centred-ness’ - the current ‘buzzwords’ in the discourse associated with the caring professions - putting this into practice is a very different thing. The ideal of integrating marginalised sectors of society, such as people with disabilities, into more community-based settings presupposes an open-minded, just and tolerant society. It also assumes that human nature lends itself easily to caring for those in need. The question then begs how could it go so badly wrong in Bungalow 3?
The subjective effect of working with people with disabilities
It is essential to explore in more depth the effect of this area of work on the subjectivity of carers and clinical practitioners. There is no doubt that caring for people with intellectual disabilities is extremely challenging, stressful, and, at times, potentially un-stimulating work. We are often dealing with individuals who are non-verbal. Are we not faced with something of the Real when working with patients who do not speak? And if so, it seems to me that what is of utmost importance is how we respond to their way of being in the world no matter how apparently ‘dysfunctional’ and different to our own. The reaction of the carers in Bungalow 3 was one of total rejection. Although the residents could not speak, they clearly found their own way to convey their message, one which was duly ignored. Who could forget the basic request of one of the residents to go to the toilet, acknowledged by the carers but refused. What would provoke someone to react in this way? Is it the case that being faced with such abject helplessness in the other is too close for comfort? We are reminded of our own vulnerability and the fragmented nature of our subjectivity. We have all experienced a sense of terrifying helplessness, what Freud termed Hilflosigkeit and must overcome this through the process of the mirror stage. Something of our own imaginary perception of ourselves, our own ego, is at stake when we witness extreme helplessness in others. When talking about the origin of the uncanny effect of epilepsy and of madness, Freud states, ‘The layman sees in them the working of forces hitherto unsuspected in his fellow man, but at the same time he is dimly aware of them in remote corners in his own being.’[7] He comes to the conclusion that the uncanny is aroused in us when we confront ‘something familiar which has been repressed.’[8] Maud Mannoni, a psychoanalyst who was well acquainted with Lacan and was a pioneer in her work with children with special needs, also talks about the anxiety among parents and educators. She claims that when adults react by stressing the acquisition of automatisms, ‘It is generally the expression of a fear before the instinctual abyss presented by the child. When one rejects in this way a child with a supposedly very low IQ, what one is really doing is refusing to be pulled down into that abyss’.[9] We are firmly on the terrain of counter-transference here.
In Bungalow 3 the refusal of the staff to be pulled down into this abyss created a culture of ‘them and us’ and did not even afford the residents the basic dignity of being called by their first names. The difference and disability of others was not accepted or acceptable. The residents were objectified and rejected as fellow subjects due to the threat they posed to the subjectivity of their carers. Their disability aroused, not only a primitive fear on the part of the staff, but extreme hostility, which saw them act out in an appalling manner. In trying to face up to these stark, psychical and social truths, we are quite evidently a world away from our ideal of partnership set out as one of the main characteristics in the field of social care. Indeed, it is worth mentioning that Freud teaches us that at the root of idealism lies aggression. In Civilisation and its Discontents Freud outlines that man’s tendency to aggression is his greatest challenge to living peacefully with his neighbour. In fact he states that, one’s neighbour has more claim to my hostility and even my hatred…’[10] and moreover his neighbour ‘…is someone who tempts them[11] to satisfy their aggressiveness on him…’[12] The residents in Aras Attracta became the plaything of the staff and were subjected to their cruel, sadistic attacks. Freud highlights that a group of people may bind together in love as long as another group exists to take the brunt of their aggression.[13] The most defenceless in our society, those without a voice, can very easily become the victims of this aggression. They become objects of the other’s jouissance, because they have no perceived use-value in society but persist for the sake of enjoyment. In this way they take up the place of the o object.
The question of learning disability
In 2000, Philip Dodd, Psychiatrist for St Michael’s House Services, wrote a thought provoking paper in The Letter entitled Learning Disability: Two Writers and a Question.[14] His question centred around the apparent exclusion of the patient group that comes under the heading of ‘learning disability’ from the work of the psychoanalytic community. He outlines the brilliant and innovative work carried out by psychoanalysts such as the aforementioned Maud Mannoni and Valerie Sinason, as they follow the essential teachings of Freud. Dodd strongly opines that we must pay attention to the research and practice of these analysts and he states that this important work must continue. Fifteen years on, the question must be asked as to where we are in relation to this particular appeal. Have we taken into consideration their discoveries or have we decided to leave this patient group behind for reasons such as: they are not able to symbolise through speech, they may not be able to develop a transference, their problems are of a biological or organic nature? Such reservations were consistently expressed in relation to working analytically with psychotic patients and as Mannoni so eloquently puts it ‘it took some time to admit psychosis into the analytic kingdom’.[15] In talking about learning disability there is also no doubt that we are talking about patients who have conditions that have organic factors, however, do we reject them because we cannot see them evolving as desiring subjects as with our other, more ‘normal’ patients? Mannoni highlights that an organic factor plays a role but argues that the psychoanalytic approach ‘does not regard this as a basic explanation’.[16] Her work flies in the face of any excuses that preclude people with a learning disability benefitting from analytic work. Lacan himself states
…I rose up against any definition of mental sickness which took cover behind this construction made of a semblance which, in pinpointing itself as organo-dynamic left nonetheless entirely to one side what was involved, in the segregation of mental illness.[17]
The very diagnosis that categorises the patient is a closing down and a defining of the individual that does not allow for subjectivity, for anything new to emerge. Psychoanalysis proposes a different way of working which would allow for an opening up of the patient’s story and in this way it aims to challenge any objectification of the patient.
The place of the truth
So how are we to approach this work? In her introduction to The Retarded Child and his Mother Mannoni immediately sets out that her book does not provide remedies but aims to be truthful which cannot fail to be a ‘disturbing factor’. Given that the truth can be so unpalatable, her work is unflinchingly brave in its approach. By listening to what the child in analysis is saying, by not objectifying him in any way and not having any particular instructive end in mind, she encourages the patient to speak his truth. It is necessary that adults do not foreclose this due to their own repression in order to allow the child produce their own words. She looks at the symbolic world that the child is born in to, the desires of the parents and the purpose that the illness serves within the family. She argues in favour of the same analyst receiving the child and the parents for analysis, stating
Psychoanalysis cannot isolate the ‘sick’ child’s symptoms from the parents’ words. …What is needed is to evoke beyond the wall of language, a locus of truth, truth of a knowledge which the child suppresses in his parents by his symptoms[18]
Mannoni is particularly interested in the relationship between the mother and the child for if the place of the child is to fill up the lack in the mother it is impossible for him to find a place to exist for himself. She states that what is important is ‘the locus from which the subject is speaking, whom he is addressing, and for whom.[19] Admittedly, Mannoni’s work focuses on working with children and in a lot of cases this analytic, therapeutic work will not happen at this early stage. Therefore the child may become locked into certain behaviours and ways of being such as the residents of Bungalow 3 who suffered from quite acute symptoms. However, is it not possible that we would find dynamic ways to work with such patients or, at the very least, be open to trying to listen to their suffering? In The Knowledge of the Psychoanalyst, Lacan makes a poignant comment regarding his weekly case presentations at St. Anne’s Psychiatric Hospital. He states ‘I mean that the people who are here under the heading of being within the walls, are quite capable of making themselves understood, provided one has the proper ears for it!’[20] How can we have the proper ears for this work? How can it be supported and encouraged, rather than the complete rejection, the not wanting to know that was so blatant in the care staff of Aras Attracta?
The case for psychoanalytic supervision
It is important to point out that external, systemic regulations can only go so far in the regulation of the provision of care. Indeed, it is hard to have faith in the regulatory bodies when their involvement in monitoring care, at times, fails so badly. In addition, the bureaucracies of paperwork have the effect of distancing staff from the people they are serving even more. How can we be in partnership with someone when required to write reams of reports in relation to their ‘case’? The most likely reaction to this awful abuse will be an introduction of more regulation, further subjecting the residents to the master discourse which has already failed them so badly. What can we learn from psychoanalysis in this regard? How does the analyst endeavour to regulate his practice? Firstly, by doing his own analysis. In speaking freely and fully in an analytic space we endeavour to uncover our own unconscious motivations in order to know from where we act and speak. Analytic supervision requires a further scrutiny of the resistances, defences and impasses that arise in the psychoanalytic work. The analyst is constantly required to question and take responsibility for his own prejudice. The oft quoted phrase ‘the only resistance is that of the analyst’ does not let the psychoanalyst away with much. Surely regular supervision, providing a space to speak about the challenges of the work is essential for anyone supporting the vulnerable in society? Not only does it provide an opportunity for carers and practitioners to speak about the challenge of trying to sustain an energy for the work with all its trials, tribulations and potential for non-satisfaction, but it also allows for a different kind of questioning to emerge. This questioning often relates to the position taken up regarding the patient and the work itself and will always be inextricably linked to the clinician’s own particular story.
Has the Unconscious been excluded?
Working with marginalised, vulnerable groups is stressful, it challenges at an emotional level, it can be frustrating work and the vulnerability and lack in another human being can provoke very raw anxiety in oneself. However, we must turn our attention to the systems which are in place to deal with these issues and challenges. Something radical has obviously failed in these systems, something is rotten in the state of our care system, something has not been addressed by the regulatory bodies. Could we be so bold as to say that the exclusion of the unconscious from this so-called ‘interpersonal work’ and from the discourse of care has had serious ramifications? Have we decided to completely neglect Freud when he stated Wo Es war, soll Ich werden? As Lacan states‘The unconscious is the chapter of my history that is marked by a blank or occupied by a lie: it is the censored chapter. But the truth can be refound; most often it has already been written elsewhere.’[21]Hence the contention that psychoanalysis must be taken seriously when talking about social care. What is our fate if we do not speak about the effect of unconscious mental processes in these challenging settings? Surely a psychoanalytic investigation not only aids our understanding of what went awry in Aras Attracta, but could help us to put structures in place to prevent such occurrences in the future. Such structures would take into account the unconscious position of both patients and staff. If, when working with children Mannoni deemed it essential to ask questions regarding the purpose the illness served in relation to the family, then surely we need to examine more closely how groups such as those with special needs are treated and the position they are given in a wider societal context. It cannot be taken as a given that inclusion and integration of segregated groups will happen as a matter of course. The obstacles to this happening must be examined and analysed. Psychoanalysis is indeed well placed to undertake this examination because these obstacles may be deeply buried and hidden beneath the well-meaning language of partnership and integration. Because psychoanalysis does not tend to look at things in a simplistic way but rather takes into account and does not shirk away from the complexity of the issues it is faced with. And finally, because Lacan reminds us that psychoanalysis is a moral experience and the position of the analyst is the ‘most responsible of all’. It seems incumbent upon us to enter into the debate. What, we may ask, could be the alternative?
Stephanie Metclafe
e-mail address for correspondence: stephaniemetcalfe2@hotmail.com
Keywords: intellectual disability, social care, the uncanny, Freud, Lacan, Mannoni, psychoanalytic supervision
[1] This paper represents the author’s work within a cartel of The Irish School for Lacanian Psychoanalysis and was presented at its Inter-Cartel Study Day on 28th February 2015.
[2] Prime Time is a current affairs programme aired by RTE, the National Television channel
[3] Aras Attracta is a care facility for people with disabilities located in Swinford in County Mayo, Ireland. The buildings and grounds were donated to the Western Health Board by the Sisters of Mercy after 1974 and in 1988 the first residents moved in to the facility. Aras Attracta is named after Saint Attracta who is the patron saint of the diocese of Achonry.
[4] HIQA, The Health Information and Quality Authority, is a regulatory body established in 2007 to monitor the provision of health and social care services in Ireland.
[5] HSE is an acronym for the Health Service Executive which provides all of Ireland’s public health services in hospitals and communities across the country.
[6] Share, P. & Lalor, K. Applied Social Care, (Dublin: Gill and Macmillan, 2009), p. 7
[7] Freud, S. The Uncanny (1919). Standard Edition XVII, London, Hogarth Press. p. 243.
[8] ibid., p. 247.
[9] Mannoni, M. The Retarded Child and the Mother Trans. A.M. Sheridan Smith. London: Tavistock, 1973. p. 33.
[10] Freud, S. Civilisation and its Discontents (1930). Standard Edition XXI, London, Hogarth Press. p. 110.
[11] Freud is here referring to those about us, our neighbours.
[12] ibid., p. 111
[13] ibid., p. 114
[14] Dodd, P. ‘Learning Disability: Two Writers and a Question’ in The Letter. Irish Journal for Lacanian Psychoanalysis 20, Summer/Autumn 2000. pp. 167-182.
[15] Sinason, V. Mental Handicap and the Human Condition. Great Britain, Free Association Books Limited, 1992. p. 68.
[16] Mannoni, M. The Child, his Illness and the Others. London, Karnac Books, 1970. p.212
[17] J, Lacan The Knowledge of the Psychoanalyst (1971-72). Trans C. Gallagher at www.lacaninireland.com. Session of 6th January, 1972
[18] Mannoni, M. op. cit. p. vii.
[19] ibid., p.53
[20] Lacan, J. op. cit. Session of 6th January, 1972.
[21] Lacan, J. ‘The Function and Field of Speech and Language’ in Ecrits. Trans B. Fink. New York, W.W. Norton & Company, 2006. p. 215