The ambivalence of the gaze

Ethicist Heike Baranzke on shamefulness in caring

“Yesterday I was hosed with water again,” a care home resident said to her daughter, meaning that the last shower was more reminiscent of being maltreated in a car wash than being able to enjoy pleasant personal hygiene in a comfortable environment. Wuppertal ethicist Dr Heike Baranzke has been studying the topic of shame for years and says: ”Shame is a general human emotion, an affect that you can’t defend yourself against and is therefore a very unpleasant feeling. Unpleasant because you feel ashamed when you are seen in a way that you don’t want to be seen.”

The fear of social death

Shamefulness is culturally invariant, the scientist explains and states: “All people are ashamed, even if perhaps not for the same specific reasons.” But what is the reason for that? "Because we humans are inherently social beings. Shame is also referred to as the social emotion par excellence, because we humans are dependent on community living and being recognised. If you have the feeling that you are seen in an unfavourable way, in a way that you don’t want to be seen, this feeling is linked to the very deep fear that the community will no longer want to have anything to do with you, that you may be excluded. And this deep sense of shame is then linked to the fear of what is referred to as ‘social death’.“ Baranzke explains social exclusion using an example from a recent radio programme on the history of capital punishment. “Cultural-historical research shows that in in earlier times, people sentenced to death were not executed by humans, but rather excluded from the human community. They were left in the wild nature, which was full of dangers, thereby ultimately facing  death. In other words, if you visualise these dimensions once again, then you get an idea of how dramatic the root of the feeling of shame is as a fear of being excluded from the community.”

The nature of the gaze

However, shame does not only relate to situations involving personal hygiene, says Baranzke, but also, amongst other things, to situations of helplessness and loss of control. Feeling naked or soiled can characterise a person both physically and metaphorically. In the care sector in particular, this can become a moral issue. And this often happens through eye contact. “Now, there are very different qualities of eye contact,” she explains, “it becomes dangerous, for example, when one is overlooked, snubbed, or not even granted a glance, as was common in so-called ‘Black Pedagogy’. Eye contact can also take the form of an act of submission; this might be a stern look that calls someone to order or compels the other person to lower their gaze. In other words, a great deal happens through this non-verbal way of shaping relationships via eye contact, which can be highly ambivalent, as one can also look at someone lovingly, empathetically or with understanding.” The key question is always whether one is interacting as equals on a level footing or engaging in a power struggle.
All these nuances in the gaze usually occur unconsciously and involuntarily, but in principle should be professionalised within the psychosocial professions. “Anyone working in psychosocial professions – and that includes nursing, teaching, the medical professions and social work – should reflect on this and become aware of their responsibility in shaping relationships.”

In care, the visible body also becomes touchable

In basic care, there are many forms of non-verbal interaction which are simply routine for care staff, but are anything but normal for those in need of care. “In care, we experience that a person, in their physicality, is not only visible and open to being looked at, but also becomes touchable and palpable because of their body. So, alongside the sense of sight, the sense of touch is added as a sensory quality. In this respect, care is a special profession – a ‘touch-based’ profession that always operates on the boundaries of modesty and shame.” As children, the ethicist explains, we learnt that personal care is carried out in private, so that we can then present ourselves to the public looking our best, because we would then appear presentable and people would be happy to interact with us again. In contrast, she says, people in need of care find themselves in a situation where they can no longer carry out this most personal form of self-care on their own. Instead, they are dependent on the support of another, unfamiliar person. “The involvement of a stranger brings personal hygiene into the public sphere. I am no longer alone in my bathroom or bedroom at home; instead, I am now in a space where I am seen – or even touched – by another person whilst being cared for. This is what makes the care profession so challenging, because it is a situation that is precarious both for the person in need of care and for the carer, as the latter must, in principle, carry out acts associated with shame. That is why it is so incredibly important to respond to this situation with a great deal of tact and professional reflection.” After all, one is never simply treating a body. “The human body is always a person’s body; in other words, when you touch a person, you are never merely touching a body, but always also the person inhabiting that body.” Whether it’s genital care or a gynaecological examination, there’s no getting round these acts associated with shame, and one must defuse the situations professionally, for example by avoiding eye contact in such circumstances. “First of all, you have to have the courage to confront this feeling and then address it within these professions, which is uncomfortable for everyone involved.” It is helpful to be aware of this ‘eye contact management’ or the situational ambivalence of looking.

The Art of Touch

The care crisis in hospitals and care homes is ever-present. There is a shortage of staff everywhere. It sometimes seems difficult to preserve the dignity of the person being cared for when there is simply no time for explanations. In this context, Baranzke speaks of the ‘art of touch’ and explains it with an example from history: “In her book *Desecration and Shame*, Katharina Gröning describes the example of the paediatrician Emmi Pickler, who, decades ago, in the first half of the 20th century, cared for orphans appropriately and demonstrated how, precisely through the nature of touch – which has a quality all of its own – these children were able to develop well. They were never touched carelessly, but in a way that respected them as distinct beings and supported them in building up their psychological defences.”
In care work, this form of touch must now also be diversified, because, as Baranzke explains, “when working in intimate care, it is better – in the spirit of ‘undoing shame’ practices (‘undoing shame’ means overcoming the paralysing effect of shame, Editor’s note) it is better to wear gloves, keep the touch as functional as possible and avoid eye contact. However, when working in elderly care – for example, with people who are being showered or bathed, or even receiving a massage – gloves can disrupt their sense of well-being.” Although it is already well recognised in practice that care is a relational profession which must always establish a relationship of mutual respect between people, there is still a lack of awareness of just how much care is also a profession of touch, in which one must master the art of touch and must not, through overstepping boundaries or carelessness, wound the other person’s emotional skin. “You must always seek verbal reassurance as well, for example by asking: ‘May I touch you now?’”

Care home and hospital structures are subject to product logic

The researcher notes that the structural depersonalisation in nursing homes and hospitals can have a very negative impact on nursing care and says: “And this is due to economisation and a lack of time. On the one hand, this is based on a concept of work that follows a product logic, i.e., a production logic. This entire DRG system in the healthcare sector (the DRG system - Diagnosis Related Groups - is a flat-rate billing system that regulates the reimbursement of inpatient hospital services in Germany, editor’s note) originally comes from the Chicago automotive assembly line factories, where work was divided up until the finished car emerged. This idea is still reflected in our healthcare system. In care, however, you never just touch a body, but always an embodied person, i.e., in all psychosocial professions you can never work without prior relationship work, recognition work.” In our society, however, relationship work is neither recognised nor paid as work, i.e., it is not regarded as work, despite the fact that relationship work requires time. However, if this time is not granted, for example because there are too few relationship workers in these professions for the tasks at hand, then it is impossible to prevent the person receiving care from being reduced to a body. ”And then you can no longer achieve humane treatment! You can also draw a connection to the much-discussed care robots. Carer robots are incapable of this relationship work. That’s another way of thinking in terms of product logic.”

Strengthening the care relationship

Together with Dr Helen Güther from the private Witten/Herdecke University, Baranzke wrote an article entitled “Beschämbarkeit - Zur pflegeethischen Relevanz einer brisanten Vulnerabilität” (Shamefulness – On the relevance of explosive vulnerability to nursing ethics). She writes about the ’human-blind healthcare system’. In fact, we could regain our sight if “we actually recognise the indispensability of the experiential dimension of personal recognition, i.e., if we step out of our logic and say that it makes a fundamental difference, not only that we have done something together, but that we have done something together as people. A caring relationship is also always dependent on the cooperation of the person receiving care, otherwise it can easily lead to power struggles that can also turn violent. Preventing violence therefore also plays a major role here. We need to be aware of this basic need to experience being recognised as a person, to be able to cooperate, to be allowed to participate and to be invited. Being aware of this basic need is fundamentally important; our society depends on it. Humans are social beings who need to be recognised by the community and this basic social need never ends.”

Uwe Blass

Dr Heike Baranzke is a lecturer in theological ethics in Catholic Theology in the School of Humanities at the University of Wuppertal.