The care of elderly as a field of inter-subjective relations: ethic reflections

Katia Cherix Nelson Ernesto Coelho JúniorAbout the authors

Abstract

This paper aims to expand the reflection on the care of elder people inspired by the text “Patterns of intersubjectivity in the constitution of subjectivity: dimensions of otherness,” published in 2004 by Nelson Coelho Jr. and Luis Claudio Figueiredo. Through the use of the aforementioned concept in dialogue with the ideas of empathy in Ferenczi, projective identification in Klein and radical alterity in Lévinas, we intend to show how the contributions of psychoanalysis and philosophy allow questioning the notion of care as linked to charity and love that can lead to the subjection of the elderly. In contrast, we propose an understanding of care in which elderly and caregivers are in a multifaceted inter-subjective relationship that implies tensions and possibilities of transformation without losing sight of the ethical background in which both are respected in their idiosyncrasies and differences.

Elderly; Care; Aging; Psychoanalysis; Ethics


Aging and care

Brazil finds itself in a period of demographic transformation that begets familiar, social and political changes. From 1980 to 2005, the senior population growth was 126.3%, while the total population growth was only 55.3%. In the same period, the segment of 80 years old or more presented a growth of 246%, representing 14% of the elderly Brazilian population. The longevity implies in an increase in the number of dependent senior and caring personnel, being them formal (that exercise caring in a professional situation) or informal (relatives that exercise the caring profession without remuneration). Due to the lack of financial resources and of a assistance network that offers care service for free, most of the elderly in Brazil are given care by women from their family(ccKüchemann1 quotes Karsh2 showing that in a study done in São Paulo, out of 102 that had an AVC, 98% were taken care by relatives. 92.9% of the care takers were women: 44.1% wives, 31.3% daughters and the rest composed by daughters-in-law and sisters., most of the times being old themselves, with no preparation for this kind of job and without a network that provides support so that they can offer quality care to the relatives that rely on them11. Kuchemann A. Envelhecimento populacional, cuidado e cidadania: velhos dilemas e novos desafios. Rev Soc Estado. 2012; 27(1):165-80..

Departing from this wider context, it is possible to direct our look to a more limited scenario: the dependent senior and the caregiver. The dependence degree of a senior is valued according to his capacity to execute daily life activities (DLA), which are divided in: (1) basic activities in daily life – self-caring tasks; (2) instrumental tasks of daily life – indicatives of the capacity for an independent life such as doing domestic tasks, managing his own medication, handling money; and (3) advanced tasks in daily life – indicatives of more complex acts connected to self-motivation, such as work, recreational activities, physical exercise. The dependence translates itself as indispensable help to the achievement of elementary deeds in life33. Caldas C. Envelhecimento com dependência: responsabilidades e demandas da família. Cad Saude Publica. 2003; 19(3):773-81..

The dependence for DLA can be reduced if there is adequate assistance, for example, with house adaptation or use of technology. However, when feeling as a dependent, the individual gets in touch with feelings of fragility and abandonment related to an unstable physical condition that implies a risk of functional decay. The fragile condition will be bigger if, while facing the reality of loss, the subject finds no support. Hence, subjective and cultural factors also contribute to a situation of fragility. As we live in a society in which capitalist factors connected to productivity, beauty and youth are rulers, some seniors can feel that a position of low symbolic and social acceptance is what they have left. Besides this negative social position, there is an existential matter that involves the feeling of finitude. The relationship of dependence, fragility and social exclusion, as well as feelings connected to body change, proximity to death and elaboration of losses can lead some subjects to the feeling of abandonment33. Caldas C. Envelhecimento com dependência: responsabilidades e demandas da família. Cad Saude Publica. 2003; 19(3):773-81..

Facing concrete situations of dependence and illness that mark some aging stories, it is possible to meditate about these experiences in the subjects’ lives and in the impact of their reactions on the ones around them. The theme of senior care makes us think about the caring story of each one, which resounds both in the senior and in his caregiver and remits us to inaugural caring experiences. In psychoanalysis, the human baby is born in a very fragile condition, needing another human to take care of it, for it depends entirely on others to the satisfaction of his or her vital needs. This condition causes sensations of abandonment(ddLaplanche and Pontalis5 indicate that the state of abandonment (Hilflosigkeit) influences in a decisive way the structuration of the psyche, destined to constitute itself entirely in the relationship to others. In an aging dependence situation, it is possible to think that the individual would see themselves submerged in excitement of which they don’t have control, in a similar situation to an experience lived by a baby. and distress that will leave their psychic marks. This first experience of bonding creates a psychic structuring condition and inaugurates the relationship to the other as foundation for the subject. Thus, since the beginning, we are in some level in a dependence situation to the other person. This experience lived by the baby is different from the senior’s dependence situation, because the senior was already made subject and has great possibilities of giving meaning to the situation of dependence and caring. However, in some way, primitive experiences of fear, trust, pleasure, hate and love lived in the first care relationship stay as a matrix to the following ones. Going from this experience of dependence and vital care, one of the greatest threats that can strike the human being is the fragility of bonds and the fear of losing the other’s love, which somehow protects him from danger and suffering44. Goldfarb D. Velhices fragilizadas: espaços e ações preventivas. São Paulo: Editora PUC-SESC; 2006. Velhices: reflexões contemporâneas; p. 73-86.

In order to deal with the distress caused by this situation of proximity to dark aspects of aging such as loss of body functionality, cognitive losses and physical dependences, we may think that the caregivers make use of several defense mechanisms to keep their mental health while facing such rude daily lives. One of this mechanisms seems to be the infantilization of the senior, that allows the caregiver to reduce the caring level to the familiar and enjoyable care of a child, protecting themselves from the fact that the senior is an adult, with a singular subjective story and that the situation of dependence in which they are found can be in the horizon of each one of us. In some way, this identification with the senior can be felt as dangerous or undesired. A research done in Cuiabá33. Caldas C. Envelhecimento com dependência: responsabilidades e demandas da família. Cad Saude Publica. 2003; 19(3):773-81. with senior family caregivers elucidates this point:

“The senior becomes a child […] you try to give his medicine, he chokes, if there is dry food, you can’t give it […] He gets stubborn, you say “don’t do that” […] he does […] (C14); […] It’s worse than taking care of a newborn child. You look at him and you don’t see an adult person, because he becomes a child. He wines because he doesn’t want to eat, gets all childish, you know? Then he laughs, like a little baby, so cute […] [laughter]”. (C7)

It is possible to deduce from this report that while looking at the senior as a “newborn child”, the caregiver deprives them from playing a part of independent individual and making decisions of their own regarding their own care. In this context, taking care of someone eventually implies in deciding for someone. Many caregivers refer to care as a love act. Behind this talk it is possible to see that the caregiver puts themselves in a place of power in which he gives the senior a bath, gives food, gives attention and therefore looks for certain social recognition as someone who makes sacrifices for another being, a merciful and generous figure, a wealthy entity capable of giving everything and owning nothing. By this logic, the senior finds themselves in a position of someone who has nothing and needs everything, so the “doing for the other” ends up being the primordial meaning behind the care. This sort of care deprives the other from their independence and possibilities for expression of their subjectivity33. Caldas C. Envelhecimento com dependência: responsabilidades e demandas da família. Cad Saude Publica. 2003; 19(3):773-81.. As shown above, the senior’s attempts of expression are understood as “stubbornness” and rebellion against the caregiver’s supposed authority.

While considering about the situation of infantilization as protection against illness and death situations, we may consider hierarchy relationships as if in a hospital. Varella66. Varella D. O médico doente. São Paulo: Companhia das Letras; 2007. presents an interesting report about the experience he had while hospitalized:

A lab technician used a tourniquet to draw blood and connect the serum bottle: “It’s just going to be a little sting”. It was an endless series of diminutives that would come to be pronounced. […] The diminutive’s job infantilizes the citizen. Laid with a gown and bracelet, with no strength to act on their own and surrounded by people saying “Come on, let’s take your medicine”; “Open your mouthy”; “Raise your leggy” What maturity could resist that? (p. 24)

The other as a peer: the empathy at meeting

Other than establishing a relationship of authority, of knowing about the other, we may thing that taking care gets another meaning in an intersubjective relationship. Recognizing the other as a constituted subject in this relationship means to reckon the other’s needs and wishes, in the sense that there is something familiar with them which I can identify myself with, and something about them that implies a radical alterity that I can get in touch with, but never reduce it to something known. In papers published about senior care, aspects of body caring are highlighted, most of them from the life quality and autonomic perspectives. This type of care lined in the values of biomedicine can show itself as extremely technic and effective to the maintenance of biological life, but tends to not account for affective, psychological and ethical aspects at stake in this relationship. In an attempt to amplify the look into this caring accord, we search for contributions from philosophy and psychoanalysis authors.

Coelho Jr. and Figueiredo77. Coelho Júnior N, Figueiredo LC. Figuras da intersubjetividade na constituição subjetiva: dimensões da alteridade. Interações. 2004; 9(17):9-28., based in writers in the area of philosophy, psychology and psychoanalysis, present four possible patterns to the understanding of different modes of intersubjectivity; in other words, ways of relating the “Me” with the “other”. The first pattern was called transubjective intersubjectivity, for it refers to pre-subjective experiences of existence, to a field of Me-Other non-differentiation. The second pattern, inspired by the work of Lévinas, is called traumatic intersubjectivity, as it postulates the other’s presence as simultaneously constitutive and traumatic. The third pattern refers to the interpersonal intersubjectivity, and it is the only pattern that presupposes a symmetric relationship between the Me and the Other, as it points to a field of relationship between two independent subjects, fully constituted. The last pattern, called “intrapsychic intersubjectivity”, shows a psychic functioning based in the psychoanalytic theory, in which there would exist a relationship between the Me and its psychic objects, the “introjected” objects. This type of conceptuality allows us to refine our gaze upon the relational processes and measure the complexity involved in the intersubjective dynamics, processes in constant transit and transformation.

In order to articulate these concepts with the theme of senior care, we will begin our reflection in the beginnings of psychoanalysis, when Freud88. Freud S. La iniciación del tratamento. Madrid: Biblioteca Nueva; 1913. Obras completas de Sigmund Freud, v. 2, p. 1564-70. and Ferenczi99. Ferenczi S. A técnica psicanalítica. São Paulo: Martins Fontes; 1992. Obras completas, v. 2, p. 407-20. use the word “empathy” (Einfühlung), which means the possibility of being with the other in their suffering, the capacity of understanding the other’s feelings, putting oneself in their place. Freud considers fundamental the experience of empathy for therapeutic work, and nevertheless, in his work, the word reveals a more cognitive then affective meaning, referring to the annalist’s cognitive capacity to put him or herself in the patient’s place, in an unsymmetrical relationship that keeps the doctor’s authority.

Based in clinic experience, Freud creates concepts to account for new aspects of therapy work. One of the most important was the concept of Transference (Übertragung), presented in 18951010. Freud S. Psicoterapia da histeria. Rio de Janeiro: Imago; 2006. Obras completas, ESB, v. 2, p. 181-217., which designates the fact that the patient transfers to the annalist feelings they have or had related to other people in their life. Initially, he believed that the transference was a resistance that would prevent the patient from getting in touch with memories connected to the traumatic events. However, he realized that the transference would present itself as an important tool to the psychoanalytic process, since through it and by the repetition of relationship patterns, he could access the patient’s repressed contents1111. Freud S. A dinâmica da transferência. Rio de Janeiro: Imago; 1912/2006. Obras completas, v. 12, p. 129-43.. Nonetheless, the concept of countertransference11. Kuchemann A. Envelhecimento populacional, cuidado e cidadania: velhos dilemas e novos desafios. Rev Soc Estado. 2012; 27(1):165-80.eeThe countertransference would be the group of the annalist’s unconscious reactions to the target of analysis. As the psychoanalytic treatment started to be seen increasingly as a two-way relationship, the importance for analyst to be careful with the feelings triggered by him in the analysis subject was recognized. In an initial moment of the post-Freud psychoanalysis, the countertransference was defined as something negative to be controlled. Afterwards, it began to be understood as a therapeutic tool that allow bigger understanding of the patient’s psychic functioning (LAPLANCHE & PONTALIS, 2001), mainly with the pioneer work of Paula Heimman (1950). (Gegenübertragung), which earned a big spotlight in contemporary psychoanalysis, was understudied by Freud. At first, the countertransference was also felt as an issue, as an unconscious resistance in the annalist about getting in touch with the contents exposed by the patient1212. Freud S. As perspectivas futuras da terapêutica psicanalítica. São Paulo: Companhia das letras; 1910/2013. Obras completas, v. 9, p. 287-301.. At second, Freud highlights the importance for the annalist to be watchful of their unconscious contents, for bigger comprehension of the patient’s psychic functioning1313. Freud S. Recomendações aos médicos que exercem a psicanálise. São Paulo: Companhia das letras; 1912/2010. Obras completas, v.10, p. 147-62..

In the same period, Ferenczi developed a theory stressing the importance in the annalist’s countertransference feelings. Unlike Freud, while making progress in his theory’s development, Ferenczi proposed a technique in which the annalist could have a more active role, in order to trigger elaborations in the patient. Going forward, he started using the concept of empathy, or “psychological tact”, to guide the treatment. The annalist is then seen as an elastic band that can shape itself to the patients’ needs. While taking risks in this heterodox position, Ferenczi amplified the field of Psychoanalysis, in the sense of thinking about how the annalist’s ideas and affections end up inevitably twining with the patient’s for being in an intersubjective relationship1414. Coelho Júnior N. Ferenczi e a experiência da Einfühlung. Ágora. 2004; 7(1):73-85..

Taking the reflection about the concepts of empathy, transference and countertransference further, it is possible to meditate on some facts: as Freud could be seen, in the beginning of his practice, as someone who would put himself as authority in relationship to his patients, a lot of caregivers seem to feel like that regarding the patients they take care of, forgetting the possibility of getting in touch with the subject of his affections, as indicated by Ferenczi. While taking care of a dependent person, it is possible to whether have and empathic relationship and put oneself in the other’s position, in order to better understand their needs, or feeling in a relationship of power, in which the other is the subject. Obviously, the relationship between the caregiver and the senior has no therapeutic objective as analytic situation, but it is a relationship of great physical and psychic proximity in which transferences related to each one’s neurosis inevitably happen. This means it is possible that some elderly people relive experiences tied to their childhood and other dependence and care situations with the caregiver, as well as the caregiver can also relive experiences tied to their personal story. In this way, the relationship of care is understood as singular, characterized by each one’s affective stories, however it is hoped that the one in position of giving care is prepared or willing to get in touch with someone in a situation of fragility, dependence and suffering. This availability implies in feeling identified to each other, listening, meeting in a second moment and, therefore, responding to their needs in a third.

Klein1515. Klein M. Notas sobre alguns mecanismos esquizoides. Rio de Janeiro: Imago; 1985. Inveja e gratidão; p. 17-43., while studying premature defense mechanisms, introduces the concept of projective identification in the psychoanalysis field. She refers to the other’s act of externalizing affections that cannot be supported in the interior of the psychic equipment. This mechanism is unconscious, and the issuing part does not recognize that what was projected into the other belongs to it. This type of intrapsychic mechanism has real consequences to the intersubjective relationship, since the external object can react to the subject’s strange behavior related to the previous, reaffirming its fantasy. At first, this concept was conceived only as a defense mechanism with intrapsychic repercussions, but psychoanalysis quickly started to understand it as a possibility of communicating with the other, in order to trigger feelings inside the other to make itself understandable.

One of the psychoanalysts that worked the most with these rudimental ways of communicating was Bion, showing that a child is capable of relating to the external world through meditation done by the mother, which works as a continent that welcomes and translates the scaring contents projected by the child, subsequently giving them back to the child in order for him or her to become responsible for their own contents. It is possible to deduce that this field of non-verbal communication inaugurated in the relationship mother-baby is maintained in adult relationships. In therapy work, as well as in the relationship between the mother and the baby, the ideal is that the annalist can receive these identifications, elaborate them and give them back to the other, so that they can recognize more and more their feelings and give meaning to them. Therefore, the annalist uses his or her own thinking to give continence and meaning to the received affection, instead of reacting emotionally.

Bringing these concepts elaborated by Klein and Bion to the work field of senior caregivers, we may think that a weakened elder can be overloaded with scaring feelings and project them into others. On the other hand, the caregiver is summoned to do a psychic work similar to the one performed by the mother/continent, to welcome and give meaning to these feelings without reacting to them. The relationship between caregiver, senior, family and institution is extremely complex and singular, however, we can propose an annalistic angle in which the senior puts the caregiver in a position of assumed knowledge and depositary of resources they no longer believe being able of practice themselves. While looking at it more closely, it realizable that the caregiver’s power is intrinsically connected to the senior’s passivity and subjectivity and, as a result, would not be of interest of this caregiver, who finds themselves narcissistly nurtured by that position of power, to strengthen the senior’s independence. Furthermore, the caregiver, as well as an analyst that gets a new patient, needs at least to accept occupying this position of assumed knowledge in order to, in a second moment, move from this place and help the senior rediscover in themselves the resources they needed to temporarily project into the other.

The psychoanalytic concepts of transference, countertransference and projective identification reveal an aspect of the intrapsychic “intersubjectivity” concept, formulated by Coelho Jr. et al.1414. Coelho Júnior N. Ferenczi e a experiência da Einfühlung. Ágora. 2004; 7(1):73-85. present in the relationship of care giving. This means that, when we relate to someone, we are not relating to an integrated and one-dimensional subject, but with a subject populated by “others”, by objects, stories and past identifications, which make themselves constantly present in the current intersubjective relations. We can, then, imagine the encounter of a subject inhabited by multiple “others” with another equally “multiple” subject. This encounter, with multifaceted aspects of each one, requires comprehension and care.

It gets clear that the job of taking care generates a lot of stress, mostly when the elderly find themselves in a situation of great suffering, chronical pain or cognitive losses. Oliveira1616. Oliveira A, Caldana R. As repercussões do cuidado na vida do cuidador familiar do idoso com demência de Alzheimer. Saude Soc. 2012; 21(3):675-85., in a research done with relatives that took care of seniors with Alzheimer’s, found that this relationship would generate tension, exhaustion and stress in the caregiver. The relatives (mostly daughters who took care of their fathers) reported feeling compassion while identifying themselves with the tough situation being lived by the senior, as well as a certain satisfaction in being able to give back the care they once received. On the other side, ambiguous feelings would alternate while facing daily situations, as anger, impatience, loneliness, shame, frustration and fear. They expressed difficulty in keeping self-control in the process of care giving, while confronting such intense feelings.

In another scenario, in an Institution of Long Permanence for Seniors (ILPS), Barbieri1717. Barbieri N. O dom e a técnica: cuidado de velhos asilados [dissertação]. São Paulo (SP): Escola Paulista de Medicina, Universidade Federal de São Paulo; 2008. reflects on the care offered by professional caregivers in an institutional framework. The senior care institution, for historical reasons, is faced as a charity place that offers help to the elderly, who are seen as abandoned, despite of the monthly payments for the services provided. The author argues about how this historical mark stablishes an uneven relationship between the senior and the caregiver, between the needy and the merciful. In this case, the care giving is not faced as an intersubjective field of mutual recognition, but as a coercive field in which one exercises power over the other, not only the caregiver over the senior, but the senior over the caregiver and the institution over both.

In the author’s opinion, the relationship of asymmetry between the one giving care and the receiving it is not equivalent to an inequality relation, but refers to the encounter in which a demand helps and the other wants to help. In theory, this relationship with distinct positions would not presuppose a hierarchy of power. However, in practice, caregivers would give priority to a technical model of care that would not open room for the recognition of the senior as a capable and powerful individual. Caregivers reported having a relationship of “love” with the seniors, which would exist beyond their professional relationship, although with no perspective of recognizing the alterity. The proximity to the weakened old age triggers reactions of attachment to the senior or separation related to the transference of feelings regarding previously lived relations. The professionals pointed out that they need to be careful not to confusing themselves and establishing the same relationship they do with a relative that the senior reminds them of. Besides that, they emphasized suffering physical and verbal aggressions, but while in the institution context, they could give meaning to these experiences as part of their job condition, in order not to retaliate or feel personally depressed with the happening.

By this point, we can have a brief reflection on how it is to be in an intersubjective relationship with a senior suffering from cognitive losses and, therefore, incapable of identifying the inside and the outside, the Me and the Other. A confused senior make the others repeatedly relive intrapsychic situations, which may not be directly connected to the shared reality. Hence, the caregiver needs to exercise great effort to situate themselves inside the patient’s psychic reality, which is being exteriorized, in order to signify their behaviors in another way, since they are not directly connected to the intersubjective reality lived in the present. Considering the intersubjectivity patterns77. Coelho Júnior N, Figueiredo LC. Figuras da intersubjetividade na constituição subjetiva: dimensões da alteridade. Interações. 2004; 9(17):9-28., we can deduce that, at this point, the caregiver needs to be willing to take part in a transubjective intersubjective relationship, in which he shares with the other a field of indifferentiation and the impacts this experience causes in both subjectivities.

The other as a radical alterity: the traumatic (mis)meeting

Many theories have given importance to the alterity in the constitution of the “Me” processes, valuing studies about intersubjective ways of communication. The notion of intersubjectivity, understood as capacity of establishing deductions about intentions and feelings of others, involves the capacity of “reading” other people’s mental states. This notion, that somehow reminds us of the concept of empathy, opens an interesting field for the reflection on every kind of human relationship.

In this line of thinking, Lévinas, a 20th Century philosopher, disciple of Husserl and scholar of Heidegger’s works, brings up a peculiar point of view regarding the presence of the other as simultaneously constitutive and traumatic. The author stresses:

There is something about the other that challenges me and imposes me a responsibility. The other’s face exposes their vulnerability and asks for care, in a muted voice. The meeting with the other’s radical alterity, the 'illeity', the other’s other, the him and the thy, what comes from the other and is not assimilated by the presented myself. Therefore, the relationship to another person will always surpass our understanding and our assimilation capacity. There will always be a surplus that surpasses me because there is no way for it to be transformed in something similar to me, and thus be assimilated.

Lévinas offers us an ethical question that could be briefly seen as the Other preceding the Me and simultaneously constituting and traumatizing it, with its presence that imposes a difference. The contact with the alterity can bring pain and suffering, demanding transformation of the Me and effort to deal with this alterity. There is no full adaptability between the Me and the Other, their presence causes a traumatic experience77. Coelho Júnior N, Figueiredo LC. Figuras da intersubjetividade na constituição subjetiva: dimensões da alteridade. Interações. 2004; 9(17):9-28..

Facing these proposals, it is possible to return to psychoanalysis to meditate on the Me/Other relationship marked by the original abandonment. Through its scream, the baby summons the other to meet its needs. This aid shows itself as “foreign help”, since a nearby unknown character will come to aid – the mother figure – which can be felt whether as a hostile object when it does not succeed at satisfying the baby or as a good and powerful object capable of partially satisfying its needs1818. Schneider M. A proximidade em Lévinas e o Nebenmensh freudiano. Cad Subj. 1997; 5(1):71-90.. This interchange between presence and absence will allow the baby to develop a waiting capacity and the thought that he or her will become, after a series of experiences, a Me capable of taking care of itself and the other. In psychoanalysis, the other’s presence can also be understood as traumatic, since the mother invades the baby with her sexuality, expectations and affections, with her radical and incomprehensible alterity.

It gets clear that we are affected by the other way more than what we can represent about who they are. The uncanny other dislodges the subject from the known, triggering an uneasiness. Therefore, living ethically would be to constantly get back to this opening and this possibility of affection towards the other, letting itself undo; letting itself be affected by the other’s suffering and by the unknown that foments a constant work of self-transformation.

Bringing up the reflection on the traumatic intersubjectivity pattern to the field of senior care, we find ourselves facing an ethical question, since recognizing the other in their radical alterity implies that a full knowledge about the other is never possible. Thus, a relationship of respect presupposes an opening for contact, listening, discovering of something foreign to what I am, master or know. To remain constantly in this open and welcoming position to the foreign is a hard task, as it demands constant transformation of the Me. Notwithstanding, between a constantly open position and a constantly closed one – in which the other would be reduced to something I already know and imagine about it – there is a vast spectrum of forms of intersubjective relationships that involve recognizing or not the other as a subject who possesses knowledge about themselves. To open room for the senior to talk about themselves and participate the care giving activity provides a field of intersubjective meeting in which they can express their subjectivity and the caregiver to transform him or herself to offer singular care that meets the demands and limits of that unique relationship. Not only the caregiver, with their background about the definitions of giving care and aging, together with their personal life story, can “traumatize” the senior in the sense of impacting them and producing effects in their subjectivity, but also the senior, with their own life experiences, “traumatizes” the caregiver, who needs to deal with excitements that can be exacerbated and meet no other objects than the caregiver, to get comfort and meaning.

Conclusion

According to Almeida and Ribeiro Jr1919. Almeida D, Ribeiro Júnior N. Ética, alteridade e saúde: o cuidado como compaixão solidária. Bioethikos. 2010; 4(3):337-42., Heidegger argues that the care belongs to the human existence in all of its spheres, as it presents itself in three dimensions: sorge (taking care of oneself), fürsorge (taking care of someone) and besorgen (taking care of something). Inspired by Lévinas’s philosophy, they come up with a kind of health professionals practice in which, untouched by the alterity, the professional sees in the other an extension of themselves. Disregarding the other’s alterity and being affected by meeting it, it is not possible to offer an ethical care, because a responsible act references the achievement of the professional’s freedom provided by the other’s subjectivity.

Therefore, it is possible to think that, for Lévinas2020. Lévinas, E. Autrement qu’être ou au-delà de l’essence. Den Haag, Netherlands: M. Nijhoff; 1974., the ethic registry is previous to the psychic, since the Other precedes the Me. The ethic configures itself as a Me-Other relationship in which the element that constitutes the ethic subject’s definition is composed by the Other and not the Me. Hence, the Me is implicated by the Other since its beginnings and the subjectivity has its origin outside the Me. For psychoanalysis, the Other is also of extreme importance in the constitution of the Me, through taking care of the helpless baby and the transmission of culture through language. It is possible to think that, when we reach adult age, we feel relatively autonomous, free and independent from the other’s care, but with aging, the situation of dependence, helplessness and care returns and will be determined by the quality of previous care experiences.

The understanding of the relationship between seniors and caregivers as an act of love and sacrifice, as a favor, an act of goodness, brings ethical implications to the one who exercises that function, professionally of informally, as well as to the ones depending on that kind of service. For cultural matters tied to charity, it is possible to understand that whoever is in position of caregiver can, even unconsciously, search for a social recognition that would come from subjecting the other, putting the old person who lost their functional aspects in the position of incapable and dependent.

Ferenczi’s99. Ferenczi S. A técnica psicanalítica. São Paulo: Martins Fontes; 1992. Obras completas, v. 2, p. 407-20. concept of empathy draws our attention to the similarities in the other, in order to possibly feel identified with the situation of suffering that allows us to offer care based authentically in the need and will communicated by the senior. However, Klein’s projective identification concept takes us to the field of unconscious trades in which the senior can deposit in the caregiver contents related to feelings of fear and aggression, creating paranoid situations that break confidence in the relationship, as well as the caregiver can see themselves taken by emotions triggered by such projections and react in a passionate way, fed by a relationship of aggression and fear.

Besides that, Lévinas2020. Lévinas, E. Autrement qu’être ou au-delà de l’essence. Den Haag, Netherlands: M. Nijhoff; 1974. gives prominence to the traumatic aspect of every relationship, as the contact with alterity will also have a “strange” part that will force us to leave a known and comfortable place. Whether for the empathy’s angle, the trauma or the network of intrasubjective emotions that exist in the relationship of care, this work’s objective was to promote questioning about the complexity of this relationship. The situation of fragility of dependent seniors and the minor support found by caregivers to exercise this function bring great ethical implications to all of us, since we can find ourselves eventually in this situation of being taken care of or taking care of someone, and then become more watchful so that this caregiving situation can be multiple, respecting every involved aspect in a complex intersubjective relationship.

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  • c
    Küchemann11. Kuchemann A. Envelhecimento populacional, cuidado e cidadania: velhos dilemas e novos desafios. Rev Soc Estado. 2012; 27(1):165-80. quotes Karsh22. Karsh UM. Idosos dependentes: famílias e cuidadores. Cad Saúde Pública. 2003; 19(3):861-6. showing that in a study done in São Paulo, out of 102 that had an AVC, 98% were taken care by relatives. 92.9% of the care takers were women: 44.1% wives, 31.3% daughters and the rest composed by daughters-in-law and sisters.
  • d
    Laplanche and Pontalis55. Laplanche J, Pontalis JB. Vocabulário de psicanálise, São Paulo: Martins Fontes; 2001. indicate that the state of abandonment (Hilflosigkeit) influences in a decisive way the structuration of the psyche, destined to constitute itself entirely in the relationship to others. In an aging dependence situation, it is possible to think that the individual would see themselves submerged in excitement of which they don’t have control, in a similar situation to an experience lived by a baby.
  • e
    The countertransference would be the group of the annalist’s unconscious reactions to the target of analysis. As the psychoanalytic treatment started to be seen increasingly as a two-way relationship, the importance for analyst to be careful with the feelings triggered by him in the analysis subject was recognized. In an initial moment of the post-Freud psychoanalysis, the countertransference was defined as something negative to be controlled. Afterwards, it began to be understood as a therapeutic tool that allow bigger understanding of the patient’s psychic functioning (LAPLANCHE & PONTALIS, 2001), mainly with the pioneer work of Paula Heimman (1950).

Publication Dates

  • Publication in this collection
    16 Nov 2016
  • Date of issue
    Jul-Sep 2017

History

  • Received
    19 July 2015
  • Accepted
    01 Aug 2016
UNESP Botucatu - SP - Brazil
E-mail: intface@fmb.unesp.br