Matthew Berrisford is a Charge Nurse at The Meadows Community Hospital, Pennine Care NHS Foundation Trust. He tweets @berrisfjord
One of the most useful pieces of advice I can share with a colleague working in dementia care is this: whenever confronted with what you perceive to be attention-seeking behaviour, reframe it to yourself as attachment-seeking behaviour.
Attachment is a hard-wired evolutionary mechanism in all mammals. Simply put, in order to survive, infants must imprint upon a main carer (typically one or both parents) to ensure that their essential needs are met.
These needs are not purely physical (food, drink, protection); the relationship itself is essential. This fact is aptly demonstrated by animal experiments (Harlow’s monkeys and Skinner’s rats, for example) which consistently show that infant mammals raised in isolation – with no access to a main carer to imprint upon – age quickly and die younger.
An additional and critical component of attachment is that it informs our knowledge, understanding and expectations of how relationships between ourselves and others are formed – within what Bowlby called an ‘internal working model’.
Ainsworth, a colleague of Bowlby’s, went on to define the quality of early attachments as either secure, insecure, or absent, and both Ainsworth and Bowlby proposed that the quality of these early relationships might inform – but not guarantee – how future relationships are formed. Those relationships might include other attachment figures such as romantic partners, offspring, friends, colleagues and carers.
Attachment and dementia
Bère Miesen tells us that, ‘Attachment behaviour is any behaviour that aims to obtain or keep an attachment figure close to oneself.’ A person living with dementia might demonstrate attachment-seeking behaviours that include: searching and calling out for a parent, exit-seeking, loud and continuous crying, and rejecting attempts by carers to engage them.
This will come as no surprise to the person working in dementia care. Think of the patient (you’ve met them) who spends each day pacing the hospital ward corridor, checking bedrooms and banging on doors, and all the while crying out for their Mum or their Dad.
Sometimes that same patient might offer detailed explanation of why they need to find their parent(s) and what the consequences will be if they don’t, and you’ll know that at that point they are disorientated or displaced in time.
On other occasions, that same patient might be crying out for their Mum or their Dad, yet they seem to be describing their husband, wife, son or daughter. This might be a disruption of language in dysphasic patients or it might be that the patient is seeking attachment with a person who, at that time, embodies the attachment archetype (“Mum!”).
Miesen has observed in his dementia studies that the need for reassurance from an attachment figure increases as cognitive ability declines, and that many severely cognitively impaired dementia patients develop a ‘parent fixation’.
Miesen states, ‘Whoever feels afraid will go in search of attachment figures’. Consider the disorientated person with dementia, pulled from a home life that is anchoring them to known reality and transplanted into a hospital ward full of unknown threat. Fear would be the logical reaction and the corresponding need to seek out an attachment figure.
Continuity offers recognition and form to the structure of daily life. Without it, life descends into chaos. A person with dementia is not only at risk of losing their ability to maintain a structure to their daily life, they are at risk of having that structure ripped down for them the moment that they are admitted into full-time care.
Fostering attachment in dementia care
Consider what foster carers do: they provide warmth, comfort, safety, consistency and love. And they do it knowing that it is only a temporary arrangement as a vulnerable person enters and leaves their care. And they do it repeatedly, despite the gain and loss, because they understand the intrinsic value of a secure base that another person can use to project themselves forwards from.
Foster care is an excellent example of the adaptability of interpersonal attachment. It’s also a very good template for dementia care.
Carl Rogers’ philosophy of client-centred therapy has informed many schools of thought and approaches to practice in dementia care. Validation, Resolution Therapy and Person-Centred Care all share the same Rogerian ancestors: a willingness to relate to someone, and to treat that person with empathy and unconditional positive regard.
More recently, the practice of Adaptive Interaction, developed by Maggie Ellis and Arlene Astell, has demonstrated how to build upon a ‘communication repertoire’ using nonverbal means. Techniques include matching facial expressions, movements, gaze and touch. By mirroring the person with dementia, you have an opportunity to reflect back and validate their own experience of being alive.
In the field of child development, Elizabeth Meins has spent the past twenty years studying Mind-Minded Parenting. To be ‘mind-minded’ is to treat a child as an autonomous, thinking being and to reflect back to the child that you understand their experience of being alive. Again, this might include paying attention to a child’s gaze or interests in objects, imitating actions, and commenting on their thoughts and feelings. Crucially, Meins found that there appears to be a correlation between being a ‘mind-minded’ parent and secure parent-child attachments.
By no means do I intend to infantilise people living with dementia by drawing these comparisons, but I do hope that common sense will prevail in our understanding of the significance of attachment figures in dementia care. By adopting the role of foster carers, we all have an opportunity to provide a secure base that a person with dementia can anchor themselves to regardless of the length of time they are with us. The trick is to be with them.