The ambiguity of elder care in the Netherlands
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Our care for older people in the Netherlands reveals fundamental contradictions in our culture. The concept of autonomy in connection with independence and self-determination is of great significance in Dutch society, while for older people the curtailment of autonomy is a daily reality.[note 1]Editors’ note: This article is a rigorously abbreviated and edited version of a paper that Klaas van der Veen presented in 1991 at the conference ‘Medicine and Culture’ in Maastricht, and was included in a liber amicorum organized by Sjaak van der Geest (see Van der Veen 1995). Two sections with theoretical considerations about cultural codes that prescribe respectively dependence and autonomy are omitted in this version. The Dutch article was translated and slightly revised for MAT by Sjaak van der Geest for republication on the occasion of the author’s death.
My own experience doing cultural anthropological research in India made me realize that a position as a relative outsider can be of invaluable importance in identifying the core values and cultural codes behind people’s everyday actions. During my first research in the 1960s, I looked with suspicion upon the absolute naturalness with which both parents and children assumed that marriages should serve the interests of parents and family. Similarly, three Asian anthropologists doing research in the Netherlands could not believe that older people preferred to be cared for by professionals rather than by relatives.[note 2]To be precise, two researchers were from India and one was from Nepal (see Chatterji et al. 1991).
Neither did they understand that the elderly in an old people’s home entrenched themselves, as it were, behind the closed doors of their rooms to protect their ‘privacy’.
I will first discuss the experiences of the Indian researchers, especially those that amazed or shocked them and confronted them with their own different cultural codes. I will subsequently contrast their experiences with some statements about elder care in a Dutch policy report. Finally, I will try to place some comments made by the Indian researchers in the context of Dutch cultural codes.
‘A Dutch treat for the elderly’
‘But why could the son not stay a few days with his father in the nursing home?’ the Indian researcher asked, when she witnessed for the first time how an old, demented man was admitted to an institution for professional care. She came from a society where even in hospitals it is taken for granted that aside from the nursing staff, family members are involved in the care of a patient. It was therefore inconceivable that an old and disoriented man was simply left in the care of others. The team that had discussed the admission of this man had completely different ideas, however. For the Dutch, it was important that a hospitalized patient be integrated into the system in order to relieve the relatives as quickly as possible.
Somewhat similar was the reaction of the Indian researcher in an old people’s home. He had been working there for some time when he confessed to me that he could not believe people saying that they would rather stay in the institution than be attended to by their children. Eventually he had no choice but to accept that the statement was sincere. Despite some disadvantages, it was for most people obvious that staying in a ‘home’ was better than relying on their own children.
The researcher who worked in a small village asked his informants why their elderly parents did not live with them. Invariably the answer was that they had too little space. Yet all houses had several bedrooms and a lot of comfort in his eyes. He was equally surprised that in cases where married children did care for an elderly parent, it was taken for granted that they did not all eat together (Pradhan 1990).
All three researchers wondered at the distance between children and elderly parents. The central question was therefore: why this distance? The report Ouderen in de Toekomst: Beeld en Beleid (Elderly in the future: Image and policy) (De Vries and Van Schaik-Colijn 1989) demonstrated that spatial and instrumental distance is consciously sought to prevent emotional estrangement between parents and children. Many opinions about the future of elderly policy are based on this idea.
Image and policy on the elderly in the future
I will quote a few key statements from this report to sketch the policy trend during the period of the research conducted by the Asian anthropologists. The central question of the report was: what future do we want for an ageing Dutch society and what policy can make this future possible? The authors of the report noted: ‘We tried not to think in stereotypical terms like “old, therefore in need of care” but to indicate that ageing is a natural process and that older people are not by definition invalidated’ (p. 21).
Focusing on care, the authors emphasized the importance of respecting and strengthening the independence and autonomy of older people:
Self-determination must be paramount in the design of care… . Only about half of the older people prefer to be cared for by acquaintances (relatives) rather than by professional caregivers but only 21% want to be cared for by their own children… . Various publications show that older people feel less dependent when they receive professional care rather than mantelzorg.[note 3]Mantelzorg (literally ‘mantle care’) is a form of care in which the caregiver and the care recipient stand in a reciprocal relationship to each other. The relationship between the two people has an affective value and care is provided ‘voluntarily’ (De Vries and Van Schaik-Colijn 1989, 76). Various experiments in home care show that it is mostly ‘a mixture of professional care and mantelzorg’ (p. 90).
Parents feel ambivalent with respect to care provided by their children. Most find it on the one hand a normal thing, but emphasize that the assistance should be limited and refer to small things, to avoid burdening the children… Parents are clearly aware of the limits of the care they are prepared to accept in order not to put the good relationship with their children at risk [italics added by translator]. Rightly so, because when the health of parents decreases and their dependence on children increases, it may jeopardize their good relationship. The daughter who has taken on the care will feel overburdened. (p. 56)
Future independent functioning older people assumes that they are emancipated, meaning that they can make their own decisions regarding the organization of their life. (p. 171)
Depending on other people is not appreciated in Dutch society. It is believed to clash with the ideals of autonomy and self-determination; it is a pitiable position and people do everything possible to neutralize or ignore dependence.[note 4]Note from Sjaak van der Geest, editor and translator of this article: Throughout the paper the author seems to assume that autonomy and dependency are each other’s antipode. Only in the final conclusion (and in the title) does he posit that autonomy, the ability to do what one wants to do, may rather require the acceptance of dependency. Such dependency rests on two options: reciprocity or the power of money (economic or social capital). As Gail Wilson (1993, 63) explains, ‘Autonomy [of older dependent people] can only be maintained if help is available and is offered in ways that respect the wishes of the recipient and do not create one-sided obligations. Autonomy demands either that help is reciprocated in cash or in other material exchanges such as services, or that affective ties are strong enough for an imbalance in material reciprocities to be overlooked. The alternative is independence in the negative sense which means reducing goals and living standards [giving up autonomy] so that help is no longer felt to be needed’.
The cultural codes that affect the actions of individuals appear to be of great importance in this regard. Indeed, research by cultural anthropologists and sociologists has made it clear that in cultural codes, different emphases can be placed on components of the ambiguous human condition.[note 5]The concepts of ambivalence and ambiguity are based on the work of psychologists and psychoanalysts and refer to the simultaneous presence of opposing but related emotional attitudes towards an object (e.g., love and hate). In the work of Bleuler and the early Freud, ambivalence was seen as a ‘deviation’, a psychotic or infantile trait. Later, however, Freud came to the conclusion that ambivalence is an essential characteristic of both the individual and social life of people (see also Elias 1978).
People are always part of a greater whole and they are simultaneously aware of their individuality. They have the ability to see themselves apart from the surrounding community and physical world.
It is important to point out that the emphasis on one or another ‘assumption’ has great consequences for the entire cultural code. If, for example, emphasis is placed on the idea that people are, as it were, independent of each other, the cultural code will press the value and significance of an acquired status. But when the idea that human beings are part of a larger whole is emphasized, it logically leads to a code in which ascribed positions are considered most important.
Care for the elderly
Coming from a society in which the cultural code places different emphases, the Asian researchers had a keen eye for the way in which in the Netherlands relations in the social sphere resembled those in business. This is done, on the one hand, by distinguishing ‘true’ social exchange from all other forms of exchange. Communicating feelings is considered the most characteristic aspect of ‘social’ exchange. On the other hand, this is done by an almost obsessive preoccupation with the aspect that makes it possible in ‘business transactions’ to remain independent of others. This means that only ‘direct reciprocity’ – or ‘balanced reciprocity’ (Sahlins 1974, 194) – is realized, a quick transaction that does not leave any trace of obligation or dependence. The diffuse nature of the cultural code in the social sphere is avoided as much as possible.
Because, as we have seen, ‘social’ interaction is characterized by an exchange of feelings, it is understandable that older people who want to maintain a ‘proper’ bond with their children are keen to separate that part of the (comprehensive) relationship with their children as much as possible from the physical care facets of their relationship. It is therefore understandable that most older people prefer to receive daily care from professionals who are paid for their work. After all, they owe no obligations of outstanding reciprocity to people who have been paid, even if the payment is not done directly by the elderly themselves. It is clear that by such an arrangement they can prevent or ignore their continuing reliance on other people. The ‘takeover’ of care by the state through social insurance legislation (see De Swaan 1988) makes it easier still to avoid direct dependence.
Both parties – caregivers and care receivers – have no social reciprocal obligations. The guarantee of good care becomes wholly dependent on proper task performance. In this situation, professionalization is the most obvious solution. Capturing care in fixed schedules leads to a clarification of the relationship between the elderly and the caregiver.
Professionalization is fully in line with the Western image of independent individuals who come together based on a common task or paid job. The ideological need to legitimize claims on others (not just colleagues) through a strong task performance promotes commitment. The Asian researchers were impressed by the degree of punctuality and sense of duty of caregivers (both professional and voluntary). It is important to note how much these qualities are tied to the belief that people should be free to choose one another.
The concepts of ‘individuality’ and ‘privacy’ played a major role in the study by the Asian colleagues. The significance of ‘appointments’ in this context was part of the analysis of why the residents of a care institution meet each other in ‘public spaces’ (the recreation room, coffee corner, etc.) but rarely in someone’sprivate room. Children, old friends, and ‘official’ people were, however, received by residents in their own room.
The researchers noted that the great importance given to ‘privacy’ did not only count in the sphere of care for the elderly. In the Dutch language, the concepts of private and privacy refer more generally to the ability to be completely oneself in one’s own environment. Chowdhury (1990) discusses these concepts in the context of a care home for the elderly. To him, viewed from his Indian background, the emphasis on the ability and obligation to ‘be oneself’ behind the closed door of one’s room was not at all obvious.
This brings us back to the magic that a look from the outside brings. The ambivalence in the human condition excludes simple and satisfactory solutions. Future policy for the elderly seems strongly influenced by the idea that people should first and foremost be independent and autonomous individuals. The realization of other, equally essential dimensions of the human condition can therefore be compromised.
I have tried to outline the principles of the policy for older people in the Netherlands. ‘Being yourself’ and ‘self-determination’ are presented as both problems and solutions and constitute a central principle that is supported by a complex of values within the culture. It becomes clear that when people are very dependent on other people, it makes no sense to create ideals, rules, and arrangements in which this very dependency is ignored or denied.
Professionalization, contract conditions, and an apparent neutralization of emotional aspects offer only a partial solution. This solution is all the more deceptive as people are less aware of the ambiguity that they – like Bowlby’s (1973, 359) ‘truly self-reliant person’ – can only find self-determination in dependence on others.[note 6]‘Paradoxically, the truly self-reliant person … proves to be by no means as independent as cultural stereotypes suppose. An essential ingredient is a capacity to rely trustingly on others when occasion demands and to know on whom it is appropriate to rely’ (Bowlby 1973, 359).
Bowlby, John. 1973. Separation, Anxiety and Anger. New York: Basic Books.
Chatterji, Roma, Veena Das, Sanjib D. Chowdhury, Rajendra Pradhan, and Klaas W. van der Veen. 1991. The Welfare State from the Outside: Aging, Social Structure and Professional Care in the Netherlands. Unpublished report. New Delhi/The Hague: Submitted to Indo-Dutch Programme on Alternatives in Development.
Chowdhury, Sanjib D. 1990. ‘Privacy, Space and the Person in a Home for the Aged’. Etnofoor 3, no. 2: 32–47.
De Swaan, Abram. 1988. In the Care of the State: Health Care Education and Welfare in Europe and the US in the Modern Era. Oxford: Polity Press.
De Vries, H., and H. van Schaik-Colijn. 1989. Ouderen in de Toekomst: Beeld en Beleid [Elderly in the Future: Image and Policy]. Utrecht: Department of Planning, Organization and Administration, University of Utrecht.
Elias, Norbert. 1978. What Is Sociology? London: Hutchinson.
Pradhan, Rajendra. 1990. ‘Much Ado about Food and Drinks. Notes towards an Ethnography of Social Exchange in the Netherlands’. Etnofoor 3, no. 2: 48–68.
Sahlins, Marshall. 1974. Stone Age Economics. London: Tavistock Publications.
Van der Veen, Klaas W. 1995. ‘Zelfbeschikking in Afhankelijkheid? De Ambiguïteit van Ouderenzorg in Nederland’. In Ambivalentie/Ambiguïteit: Antropologische Notities, edited by Sjaak van der Geest, 57–65. Amsterdam: Het Spinhuis.
Wilson, Gail. 1993. ‘Money and Independence in Old Age’. In Ageing, Independence and the Life Course, edited by Sara Arber and Maria Evandrou, 46–64. London: Jessica Kingsley Publishers.