epubs.surrey.ac.ukepubs.surrey.ac.uk/842536/1/Laura-Lee Edwards E-Thesi… · Web viewdementia”...

How can we understand the attachment process between people with dementia and staff

caregivers: an exploratory study in residential care

Laura-Lee Edwards

Submitted for the Degree of

Doctor of Psychology(Clinical Psychology)

School of PsychologyFaculty of Health and Medical Sciences

University of SurreyGuildford, SurreyUnited KingdomSeptember 2017

© Laura-Lee Edwards 2017

Statement of Originality

This thesis and the work to which it refers are the results of my own efforts. Any

ideas, data, images, or text resulting from the work of others (whether published or

unpublished) are fully identified as such within the work and attributed to their

originator in the text. This thesis has not been submitted in whole or in part for any

other academic degree or professional qualification.

Name: Laura-Lee Edwards

Overview

The ability to form secure attachments shapes the experience of feeling safe

in distressing situations. Dementia is often described as a distressing situation which

activates the attachment system. Consequently, how people with dementia and

caregivers attach to one another informs how safety may be experienced in such

circumstances. This E-thesis has sought to understand how attachment influences the

experience of both the person with dementia and their caregiver.

Part one presents a literature review on the ‘interactive attachment dyad’

between the person with dementia and caregiver. Findings suggested that interactions

within the dyad is a complex phenomenon. Conflicting results across papers

highlighted difficulty in understanding how attachment influences the reciprocal

interactions that take place between people with dementia and caregivers. Part two

presents an empirical paper which set out to qualitatively explore staff caregivers’

understanding of their interactions with, and relationship to, residents in the mid to

later stages of dementia in the care home setting. This sought to consider the

relevance of attachment within the caregiving relationship. Findings highlighted that

caregivers used attachment-focused ways of caring, namely features found within a

secure base and a secure figure. Findings led to suggestions that an attachment-

focused model of care could be considered within policy, clinician and service levels

to improve quality of care for people in the mid to later stages of dementia in

residential care.

Part three of this E-thesis provides an overview of the clinical placements and

experience gained throughout the clinical doctorate training. Part four presents a

table of all academic assessments completed.

Contents Page

Acknowledgements Pages 1-2

Part one: Major Research Project: Literature Review Pages 3-60

Abstract

Introduction Pages 5-12

Method Pages 12-16

Results Pages 17-50

Discussion Pages 51-54

References Pages 55-60

Part two: Major Research Project: Empirical Paper Pages 61-126

Abstract Page 62

Introduction Pages 63-69

Method Pages 69-76

Results Pages 76-90

Discussion Pages 90-99

References Pages 100-105

List of Appendices Page 106

Appendices A-J Pages 107-126

Part three: Summary of Clinical Experiences Pages 127-129

Part four: Table of Assessments Completed During Training Pages 130-131

Acknowledgements

I am extremely grateful to a number of people throughout these intensive

three years of clinical training. Firstly, I would like to thank Dr Kate Gleeson, my

research supervisor, for being a secure base for me. Words cannot do justice to how

grateful I am for her support and belief in me throughout this project, and throughout

clinical training. To have a supervisor with whom you can share how you think, and

who is always available and goes beyond their role, is a true gift. I am also thankful

to Dr Paul Davies, who joined as my second supervisor in the second year; I have

valued having another perspective on the research and someone to encourage me

along the way. Thanks also to Dr Sue Jackson, Dr Sara Murray and Dr Victoria Hill,

who each offered advice and support during initial stages of the research project.

Additionally I would like to express a huge thank you and acknowledgement to all

the care homes and participants who gave of their time, shared experiences and

spoke so honestly with me. I know how stretched it can be in a care home setting; I

have valued their time and have been inspired by their approach to care. I am also

grateful to Dr Laura Simonds who has provided guidance and support throughout all

research-related queries.

I am very thankful to my placement supervisors, and feel privileged to have

had the opportunity to learn and be inspired by each of them. I have valued having

the opportunity to make decisions, to be challenged to think differently, and to have

my learning scaffolded by them. I have also appreciated each of the clients who

trusted me to work alongside them, and provided me with an enriching experience

that I will never forget. Through them I have learned the importance of reflecting on

diversity and power. I am grateful to my clinical tutor Dr Nan Holmes, who has been

supportive, encouraging and always reassuring. Thanks of course to Cohort 43 and

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Team Organic who have been supportive, understanding and ready to lend a helping

hand; what a journey and an incredible three years it has been.

Finally, I am thankful to my friends and family who have graciously

understood when I have not been as available and still cheered me on along the way.

To Mum, Dad, Tracy and Nick who have shown me what it is to support one another

and have incredible love and strength through the challenging and the blessed times.

To my wonderful husband and best friend, Stephen, who has held my hand,

contained me and been a pillar of strength throughout everything; what a blessing it

is to have you by my side. Most importantly, I thank God who comes before all

things, who sustains me and who has been my hope through everything.

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Part One: Literature Review

The interactive attachment dyad between the person with dementia

and their caregiver

Word count: 7,987 (excluding abstract, figures, tables, and references)

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Abstract

Attachment provides an understanding of how we relate to one another, particularly

when in distress. Attachment theory is increasingly used to understand the

experience of the person with dementia and caregiver. Though extensive literature

considers how attachment affects the person with dementia and caregiver separately,

minimal attention is paid to how attachment affects the reciprocal nature of the

dyadic interaction. This review presents an overview and critique of the existing

literature on how attachment influences the dynamic interactions between person

with dementia and caregiver. A comprehensive literature search identified

quantitative and qualitative papers. Six studies were included. Studies were critiqued

across three themes of ‘attachment and behaviour’, ‘attachment, caregiver burden or

caregiver distress’ and ‘attachment, caregiver wellbeing or caregiver satisfaction’.

Despite contradictory findings attachment was seen to influence behaviours across

the dyad, and effect caregiver burden or distress and caregiver wellbeing or

satisfaction, in either helpful or unhelpful ways dependent on attachment style.

Methodological issues affected the validity of findings such as choice of

measurements, reporting on attachment styles, stage of dementia and type of

relationship between people with dementia and caregivers. Owing to the complex

nature of reciprocal interactions, understanding what happens between and within the

dyad is challenging and may not be best answered by quantitative approaches. The

lack of understanding of what happens within the dyad hampers further research.

Future research could include exploratory observational research of interactions that

take place within the dyad, and explore the relevance of attachment theory.

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Introduction

Dementia

Demographic change has resulted in an increase in the number of people

affected by age related cognitive decline such as dementia (Age UK Research, 2014).

Whilst much research is focused on aetiology, prevention and intervention, it is

increasingly recognised that research must also address the issue of how to support

people diagnosed with dementia, including those who care for them (Alzheimer’s

Society, 2017). The National Institute for Health and Care Excellence (NICE)

provide policies and standards endorsed by the Government to inform all areas of

health and social care, including supporting people with health related problems and

carers.

In 2006, NICE published information on principles of care for people with

dementia and their carer, highlighting the importance of considering the person with

dementia and the system around them in providing good quality care. The system

referred to family and those providing professional care (NICE, 2006). Another

guidance outlines ten quality statements in supporting people with dementia to live a

meaningful independent life (NICE, 2013). One of these statements focused on

supporting people with dementia to maintain existing relationships and encourage

new relationships to form. For those involved in caring, being able to relate

effectively and with understanding seems crucial to the well-being of people with

dementia, particularly if entering care.

Historically, little was understood about dementia related behaviours, leading

to medicating what was perceived as ‘challenging behaviour’ in those in the mid to

advanced stages (British Psychological Society, 2013). More recent approaches such

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as Kitwood’s (1997) person-centred approach highlighted the importance of valuing

the person with dementia as an individual. Kitwood (1997) proposed five key

psychological components to consider when caring for people with dementia.

Mitchell and Agnelli (2015) summarise these succinctly: 1. Comfort (related to the

unconscious feeling of trust experienced from another human being); 2. Attachment

(finding a sense of security in unknown situations); 3. Inclusion (feeling connected to

others); 4. Occupation (having a connection to the processes in everyday life); 5.

Identity (respecting and knowing the uniqueness in all individuals). These

components point towards valuing the person with dementia. Being able to

experience secure attachments to others (so one feels safe in unfamiliar situations,

can trust others and feel connected) is vital for people with dementia, as their inner

world breaks down and familiarity becomes more removed from daily living.

Understanding how people with dementia and their carers interact and form

attachments to one another is integral to improving care (NICE, 2006).

Attachment

Attachment theory provides a framework to understand relational

experiences. This theory was proposed by Bowlby (1969) who suggested all humans

have specific ways of interacting with one another, based on a person’s internal

working model. This is shaped by early attachment figures and can take on different

characteristics, thus becoming a framework for the development of future

attachments. Bowlby (1969), and later others (Ainsworth, Blehar, Waters & Wall,

1978; Main & Solomon, 1986), proposed four attachment styles, divided into secure

or insecure. A secure attachment has an internal working model of seeing the self and

others as available, and reliable. There are three insecure attachment styles. The

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avoidant style (sometimes referred to as dismissive) employs an internal working

model of emotionally detached and independent from others; others are perceived as

untrustworthy. The ambivalent style (sometimes referred to as pre-occupied) has an

internal working model characterised by expressions of anger and disappointment,

has high levels of anxiety or strong feelings of depression, and often clings to others.

The disorganised attachment style has an internal working model combining

avoidant and ambivalent characteristics; this may involve feeling highly confused

and having great difficulty in trusting others.

Attachment theory also provides a framework for understanding experiences

across the lifespan, including dealing with loss (Bowlby, 1969) and is used to

understand the relationship between the person with dementia and caregiver.

Attachment theory provides an understanding for help-seeking behaviours when in

threatening situations, such as dementia (Monin, Schulz & Kershaw, 2013).

Nevertheless, there remains a limited body of research using attachment theory in

dementia. This small body consists of three main areas: 1. attachment in people with

dementia; 2. attachment in caregivers to those with dementia; 3. attachment within

the dyad. More attention is given to the area of caregiver attachment and their

experience.

Attachment in people with dementia

Attachment can be triggered in people with dementia due to experiencing

stressful situations (Miesen, 1992). The literature particularly focuses on negative

experiences of frustration as people lose the ability to communicate their needs

clearly. Miesen’s (1992) pioneering research developed the theory of ‘attachment-

related parent fixation’. Miesen (1998) suggested that the person with dementia

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increasingly fixates on their deceased primary attachment figure and consequently

behaves as though that person is alive in order to feel safe and secure. Further

literature highlights that parent fixation and overt attachment behaviours, such as

searching or calling out for an attachment figure, become more apparent in the later

stages of dementia (Browne & Shlosberg, 2005). Another study suggested parent

fixation is more common in nursing homes than in the community (Osborne, Stokes

& Simpson, 2010) and may be a reaction to the environment, and reduced access to

an attachment figure. Conversely, the researchers note that many variables were

unexplored which could have affected this conclusion, such as amount of time

relatives (who rated presence of parent fixation) spent with people with dementia

when living in the community. Nevertheless, Wright, Hickey, Buckwalter, and Clipp

(1995) explain that attachment may be triggered because people with dementia may

desire attachment responses from their caregiver.

Attachment in caregivers to those with dementia

The literature within caregiver attachment falls in to two main themes:

attachment and: 1. caregiver burden and 2. caregiver responses to people with

dementia. Crispi, Schiaffino and Berman (1997) found child caregivers’ attachment

style and attachment-preoccupation was predictive of caregiver burden when parents

with dementia had been placed in to care; a secure attachment acted as a protective

factor and an insecure attachment increased burden. Within the care setting,

Kokkonen, Cheston, Dallos and Smart (2014) found insecurely attached staff

caregivers experienced higher levels of burden. Caregiver attachment has also been

shown to affect emotional responses when caring for someone with dementia.

Markiewicz, Reis and Gold (1997) found ambivalently attached caregivers

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experienced more negative emotional responses in caregiving. In considering son

caregivers to parents with dementia, Daire (2002) found a closer relationship with

their parent during childhood related to less distress when becoming a carer. Cooper,

Owen, Katona and Livingston (2008) found more insecurely attached family

caregivers experienced higher levels of anxiety and burden. Thus, across both themes

of caregiver burden and emotional responses, the studies consistently demonstrate a

negative relationship between an insecure attachment and caregiver experiences.

There are a number of limitations with the above literature, largely relating to

use of attachment questionnaires. Indeed, some questionnaires were specifically

designed for the study, which may have had limited or no psychometric validity

(Miesen, 1993). Other questionnaires were adapted to fit the purpose of the study

(Crispi et al., 1997; Markiewicz et al., 1997) possibly affecting the reliability of the

scale. Some questionnaires were read to participants and thus introduced social

desirability bias (Markiewicz et al., 1997). Researchers reported difficulties in

scoring questionnaires (Browne & Shlosberg, 2005; Osborne, et al., 2010). Lastly,

pre-morbid attachment for people with dementia was rated by family caregivers,

which can lead to a number of biases (Browne & Shlosberg, 2005).

Additionally, small sample sizes were often used (Miesen, 1993; Daire, 2002)

making findings difficult to interpret where underpowered. Further, a larger

proportion of people with a secure attachment took part in the studies; though

significant findings demonstrated an insecure attachment impacts people with

dementia and their caregiver. This limits the generalisability of the results (Crispi et

al., 1997; Browne & Shlosberg, 2005; Osborne, et al., 2010).

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Attachment and the dyadic relationship: people with dementia and their

caregivers

Whilst the literature largely covers how attachment impacts experiences

across separate parts of the dyad, little is currently understood when considering

attachment between the dyad. As noted in the above literature, if attachment style

affects communication and behaviour, how will it affect the dyad? Secure attachment

styles may buffer negative experiences for the person with dementia (Magai, Cohen,

Culver, Gomberg & Malatesta, 1997) and caregiver (Carpenter, 2001). However,

those with an insecure attachment style are likely to have difficulty trusting others,

which could be detrimental for the person with dementia and caregiver. There is a

small body of research considering attachment across the dyad. Taking in to

consideration the importance of this area in dementia care (NICE 2006, 2013), it

makes sense to review this specific body of research.

Previous literature reviews

Three previous reviews have considered the literature relevant to this review.

These can be characterised as: attachment and dementia (Browne & Shlosberg,

2006); dementia and the dyad (Braun et al., 2009); attachment, dementia and the

dyad (Nelis, Clare & Whitaker, 2014).

Browne and Shlosberg (2006) reviewed the literature on attachment theory,

ageing and dementia. The review highlighted that secure attachments serve as a

protective factor in later life, attachment related behaviours are present in older

people, particularly those with dementia and pre-morbid attachment style interacts

with emotional and behavioural symptoms in dementia. However, it did not include

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attachment and carers, or a dyadic perspective, which limits the representation of

literature within this field.

A further review by Braun et al. (2009) focused on the dyadic perspective of

dementia caregiving in spousal relationships. Given its more specific aims, it

reviewed a limited area within this field. It highlighted that minimal studies include

the perspective of the person with dementia and studies do not fully address the

dyadic interaction. It usefully provided three classifications of categorising dyadic

perspectives in dementia care: (1) the dyad incorporates data taken from one member

of the dyad (usually caregiver) and minimal data from the other member (usually

person with dementia), e.g. age and diagnosis; (2) the dyad incorporates data taken

from one member of the dyad, and the other member is indirectly measured, e.g.

caregiver assesses the self and person with dementia; (3) both members of the dyad

complete data relevant to themselves.

The final literature review examined the literature on attachment in people

with dementia and their caregivers (Nelis et al., 2014). The review explored papers

relating to attachment for the person with dementia and attachment relating to

caregivers. The review highlighted that a presence of attachment behaviours exist

across different stages of dementia, insecure attachments were related to

neuropsychiatric symptoms and secure attachments were important for caregivers.

Whilst this review was broader in scope, and therefore included a range of papers, it

did not specifically address the interactive attachment dyad between people with

dementia and caregivers.

Whilst previous literature reviews have considered aspects relevant to this

review, none have specifically explored or critiqued research concerning the

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interactive attachment dyad between the person with dementia and caregiver. Braun

et al. (2009) provide a useful definition of the ‘dyad’ which has been adopted within

this literature review, i.e. papers including data from one member of the dyad and an

indirect measure of the other member, or both members of the dyad completing data

relevant to themselves. Additionally, Goffman’s (1959) sociological dramaturgical

metaphor of human interaction provides a framework for the ‘interactive

attachment’. This theory suggests that human behaviour is determined by the

situation we are in. Therefore, how we respond may not only be shaped by our

attachment style but also by those with whom we are interacting. The ‘interactive

attachment dyad’ may thus be understood as a dynamic relationship wherein each

person responds in relation to the other, informed by each individual’s attachment

style. This is necessary to address as literature shows that dementia affects both

members of the dyad and their responses. It is also necessary that an updated review

be conducted to broaden the body of knowledge within this field.

Aims and rationale

This literature review aims to understand attachment and the influence it may

have between the person with dementia and caregiver. Specifically, it will address

how attachment influences the dyadic interaction and experience between the person

with dementia and caregiver.

Method

Search strategy

Search terms covering the three main research areas of interest were

‘attachment’, ‘dementia’ and ‘carers’. Attachment was considered specifically in

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relation to caregivers and persons with dementia only. Search terms were honed via

discussions with supervisors and through reading past and current literature in order

to provide a more succinct search of the literature.

A comprehensive literature search was carried out with the identified search

terms across seven electronic databases. These were: Psychology Cross Search via

EBSCOhost electronic interface which included PsycINFO, PsycARTICLES,

Psychology and Behavioural Sciences Collection, and MEDLINE; PubMed; Wiley

Online Library and Cochrane Library. Search terms were inputted in to the search

databases as follows: 1. (attachment OR bond* OR systemic OR ‘parent fixation’ OR

‘internal working model’ OR ‘interpersonal relation*’) AND 2. (dementia* OR

Alzheimer* OR ‘mild cognitive impairment’ OR ‘cognitive impairment’ OR

‘cognitive decline’ OR memory) AND 3. (care* OR relation* OR residential OR

‘nursing home staff’ OR ‘nursing home workers’). Search terms were searched by

‘title only’1.

Initial searches were conducted at the beginning of May 2016 and updated

searches took place between 24th and 31st May 2016. Searches took place between

1968 to present using EBSCOhost, 1947 to present using Wiley Online Library and

across all years to present in the Cochrane Library. Automatic date settings on the

databases were used to ensure all potential articles were scanned for a comprehensive

picture of the literature.

1 ‘Title only’ searches were used to enhance the succinctness of the search however it may be that in doing so some papers

could have been omitted. Additionally, a previous scoping review was conducted that involved a search of Abstract and Title,

rather than Title alone.

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Inclusion and Exclusion Criteria

Articles were screened using the specified inclusion and exclusion criteria in

Table 1. The inclusion criteria was developed according to the main areas of interest

of the literature review, i.e. interactive attachment dyad between people with

dementia and caregiver. The exclusion criteria was developed throughout all three

stages of screening: 1. screening titles; 2. screening abstracts; 3. screening full-text

papers.

Table 1. Inclusion and exclusion criteria

Inclusion criteria Exclusion criteria

Participants were care-recipients with a diagnosis of any type of dementia

Participants were caregivers to those with dementia

Participant caregivers were any type of relationship to person with dementia, e.g. staff, spouse, children

The research focused on attachment between the dyad (i.e. person with dementia and caregiver)

Attachment seen as bi-directional, i.e. how attachment affects both the person with dementia and caregiver

Bi-directional attachment may include a reflexive stance, for example how caregiver attachment affects person with dementia and considers how caregiver attachment affects the self, and vice versa

The paper was in a peer-reviewed journal printed in English

The study was the grey literature (i.e. dissertation or thesis)

The study was a systematic / literature review

The study was written in a language other than English

The study focused on mental health difficulties

The study focused on traumatic brain injury and/or amnesia

The study focused on memory and/or attachment and/or children

The study focused on medical or biological factors

Attachment focus was non-human, i.e. animal bond

The study focused on linguistics

The study included interventions for people with dementia

The study focused on attachment and anxiety in caregivers

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The paper was an article, not research

Attachment was seen as uni-directional, i.e. how one person’s attachment affects the other person, and does not include a reflexive stance (for example, how caregiver attachment affects person with dementia without considering how caregiver attachment affects the self and vice versa)

The study focused primarily on caregiver distress

The search yielded a total of 118 papers. EBSCOhost automatically removed

27 duplicates and identified one paper as ‘unavailable’, leaving 90 articles. The 90

articles were exported onto RefWorks. Articles were scanned in RefWorks and 31

duplicates were identified. This left a total of 59 titles to review. In phase one

screening, 47 titles were removed against the inclusion and exclusion criteria, leaving

a total of 12 abstracts to review. In phase two screening, three abstracts were

excluded leaving a total of nine papers to review. One paper was included at this

stage based upon reading the literature and fingertip searching the reference lists of

included papers. Of note, the authors of this additional paper refer to it as an ‘article’,

based upon a study (Ingebretsen & Solem, 1998). As the paper was published in a

peer-reviewed journal and presented as research, the authors were contacted via

email to clarify details of their study. Contact with the authors was unsuccessful. The

paper was included in this review due to its relevancy to the topic area and meeting

the inclusion criteria. Full-text papers were read in the final phase whereby four more

studies were removed due to not meeting the inclusion criteria. This resulted in a

total of six studies related to attachment as bi-directional (including a reflexive

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element) between the person with dementia and caregiver to be critically appraised.

Figure 1 shows a detailed PRISMA flow diagram of the selection process.

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Excluded as titles did not meet criteria (n = 47)(n=15) grey literature(n=1) animal-bond

(n=4) systematic reviews(n=1) linguistics(n=3) non-English papers (n=1) interventions

(n=5) mental health issues(n=1) review/non-empirical(n=3) traumatic brain injury/amnesia

(n=8) memory and/or attachment and/or children(n=5) biological/medical

Potentially eligible records (n = 59)


Exclusion as abstracts did not meet criteria (n=3)(n=1) attachment and anxiety in caregivers

(n=2) article, non-research


Additional potential relevant articles (n = 1)

Potentially eligible records (N = 10)


Exclusion of duplicates (n = 31)

Exclusion as paper did not meet criteria (n=4)(n=3) attachment as one-directional

(n=1) caregiver distress

Articles included in survey (n =6)

Potential articles identified through database searches (N = 118)*EBSCO Host Psychology Cross Search (n = 86)

(PsycINFO; PsycARTICLES; Psychology and Behavioral Sciences Collection; MEDLINE)

PubMed (n = 24)Wiley Online Library (n = 5)

Cochrane Library (n = 3)*27 duplicates were automatically removed in EBSCO and 1 article was

unavailable

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Figure 1. Flow-diagram of decisions

Results

Six papers were identified; five were quantitative and one was qualitative.

The review demonstrated a scarcity of relevant research in this topic, which may be

due to the complexity of dyadic analysis. Findings relevant to this review have been

extracted from the six papers and will be critically evaluated. Additional findings not

relevant to the review aims are not addressed. Due to the number of issues identified

with measuring attachment, a specific critique on the measures used will be provided

to paint a landscape for the rest of the findings.

The critique of papers was informed by the Quality Appraisal Checklist for

quantitative studies taken from the National Institute of Health and Care Excellence

website (NICE, 2012), which specifically addressed quantitative studies reporting

correlations and associations. The Critical Appraisal Skills Programme was used for

qualitative research (CASP, 2013). Lastly, guidelines detailed in Iain Crombie’s

Critical Appraisal book (Crombie, 1996) enhanced further analysis. Table 2 provides

a more detailed description of the methodologies in each of the studies. Table 3

provides a description of the results and overall critique.

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Table 2. Description of methodology of included studies

Study Aim/Hypotheses Setting Sample Measures

Quantitative

1. Magai & Cohen (1998). Attachment style and emotion regulation in dementia patients and their relation to caregiver burden

To explore the relationship between people with dementia, (PwD) emotional characteristics (including premorbid attachment style), dementia symptomatology and caregiver burden.

Some of the related hypotheses to this literature review were:

Hypothesis 1: PwD who are avoidantly attached would have higher ratings of pre-morbid contempt, anger, emotional inhibition and emotional distance than other attachment patterns.

Hypothesis 2: PwD who have a pre-morbid ambivalent attachment would have higher pre-morbid ratings on anxiety and sadness than other attachment patterns.

Hypothesis 3: PwD who have a pre-morbid secure attachment would have higher ratings on pre-morbid sociability than those with

USA: PwD seen at the Brooklyn Alzheimer’s Disease Centre of Health Science Centre of the New York State University.

N = 168 patient-caregiver dyads.

PwD:

Diagnosis of dementia: based on Diagnostic Statistical Manual-III (DSM), scored moderate to severe stages of dementia according to the Mini Mental State Score Examination (MMSE) (Rolstein et al., 1975) mean 14.2 (SD = 6.9).

Type of dementia: 76% diagnosis of Alzheimer's disease (AD), 24% multi-infarct dementia, or a mix of AD & multi-infarct.

Ethnicity: 80% African-American, 20% Caucasian.

Sex of patients (PwD): 80% female.

Mean age of patients (PwD) 76.2 (SD = 7.3).

Behavioural measures (for PwD completed by psychiatrist): 1. MMSE (Rolstein et al., 1975).2. Behavioural Pathology in Alzheimer’s Disease (Reisberg et al., 1987).

Attachment measure (for PwD completed by caregiver): Attachment Style Questionnaire (Hazan & Shaver, 1987). This was used to assess three types of pre-morbid attachment style (secure, avoidant, ambivalent).

Pre-morbid emotion style measure (for PwD completed by caregiver): Feelings and Emotions Inventory (FEI). This was used to investigate pre-morbid personality traits and thus validate attachment styles.

Burden measures (for caregivers completed by caregiver): Burden Instrument (Zarit & Zarit, 1982).

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insecure attachment styles.

Hypothesis 4: There would be a significant difference between pre-morbid attachment style and behavioural symptoms of dementia. Specifically, those with an avoidant attachment would have higher scores on paranoid delusions than those with a secure attachment, and those with an ambivalent attachment would have higher scores on depression and anxiety than avoidant and secure attachment styles.

Hypothesis 5: Caregiver burden would vary based on pre-morbid factors and behavioural symptoms of PwD. Specifically, ambivalently attached Vs securely attached.

Hypothesis 6: In a regression model predicting caregiver burden, attachment would be a more robust predictor of burden than any other behavioural symptom.

Caregivers: 23% spouses, 54% adult children, 23% other relatives (mainly siblings).

Sex of caregivers: not stated.

An additional 48 patient-caregiver dyads were also seen during the same time period, 22 of whom were on medication and 26 had incomplete protocols. Of those who had incomplete protocols 92% were of African-American descent.

2. Perren, Schmid, Herrmann & Wettstein (2007). The impact of attachment on dementia-related

To investigate the impact of attachment style on dementia-related problem behaviour and caregiver wellbeing over 2 years (data was collected over 3 time points).

Taken from a larger project “Long-term effectiveness of training of caregivers of patients with dementia” (Wettstein,


PwD:

Diagnosis of dementia: based on DSM-III-R, scored mild to moderate stages of dementia

Attachment measure (for PwD and caregiver, completed by PwD and caregiver): 1. Attachment Style Questionnaire (Hazan & Shaver, 1990). This was used to assess three types of attachment style (secure, avoidant, ambivalent).

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problem behaviour and spousal caregivers’ wellbeing

More specific aims were stated in the paper. These were:

Aim 1: How caregiver and PwD attachment styles are associated to problem-related dementia behaviour.

Hypothesis 1: insecure attachment in PwD will have more problem-related behaviour.

Aim 2: to consider whether attachment style associates with certain neuropsychiatric symptoms.

No hypothesis.

Aim 3: to consider the impact of caregiver and PwD attachment style on wellbeing of caregivers.

No hypothesis.

Aim 4: to consider the impact of attachment in marital relationships, where one member has dementia.

Hypothesis 2: a securely attached caregiver, who reports low levels of anxiety and avoidance, will have higher levels of wellbeing.

König, Schmid & Perren, 2005).

Recruitment for the larger project: national and local TV and print media; direct mailing; PwD previously evaluated at the Memory Clinic; suggesting referrals to physicians in Zurich area via direct mailings; verbally through education meetings for physicians.

according to Clinical Dementia Rating and MMSE mean 21.6 (SD = 5.1) at Time 1. Specifically:Time 1: 10.3% very mild, 59.5% mild, 30.2% moderate.Time 3: 38.2% severe dementia.Over the 2 years 22 PwD moved in to nursing homes & 19 died.

60% diagnosis of AD, 25% mixed vascular and AD & 15% other types of dementia.

Caregivers: living in same household or within walking distance of PwD.

Over the 2 years, 7 caregivers declined participation:Time 2: 89% caregivers participated.Time 3: 68% caregivers participated.

Dyads: 93% married, rest of couples cohabiting.

Sex: 62% of couples were male PwD & female caregivers.

Mean age (taken at Time 1): Caregivers: 70.9 years (SD = 10.0); PwD 74.8 years (SD = 7.6).

Attachment styles (taken at Time 1 only): only 39 PwD could report

2. Avoidance and anxiety measure (for caregiver completed by caregiver): Collins & Read (1990) Questionnaire translated in to German and words on measure adapted to ‘avoidance’ and ‘anxiety’ instead of ‘depend’ and ‘close’. Used to enhance reliability of the Attachment Style Questionnaire.

Behaviour measure (for PwD completed by caregiver): Neuropsychiatric Inventory (Cummings, et al., 1994) Reports to have good reliability and validity.

Wellbeing measure (for caregiver completed by caregiver): Overall subjective wellbeing was measured by combining the following 2 measures: 1. a measure used in the Swiss health survey (Weiss, Spuhler, Gruet, Guidani & Noack, 1990) no formal name of measure given. 2. Schedule for the Evaluation of Individualized Quality of Life (Meier, Vodoz & Spiegel, 1999). Extra item added to measure.

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their own attachment style.

3. Nelis, Clare & Whitaker (2012). Attachment representations in people with dementia and their carers: Implications for wellbeing within the dyad

To provide information on the nature and concordance of attachment patterns within the dyad and to examine the relative contribution of attachment representations in PwD and caregivers to the wellbeing of both parties.

Aim 1: Examine the attachment styles of PwD to establish how they view themselves and the availability of others in relationships.

Aim 2: Examine quality and type of attachment bonds between PwD and carers, provide a profile of the attachment representations of carers of PwD, and consider the association between PwD and caregiver attachment styles.

Aim 3: Investigate relationship between attachment style, current functioning and wellbeing including mood and quality of life in PwD

Aim 4: Identify how carers' working models of attachment representations relate to caregiving stress and psychological health,

Taken from the Memory Impairment and Dementia Awareness Study (Clare et al., 2011) and from the initial assessment phase of a randomised controlled trail of a cognitive rehabilitation intervention (Clare et al., 2010). Memory clinics in North Wales.


PwD:

Diagnosis of dementia: based on ICD-10 (World Health Organisation, 1992) criteria for dementia, mean MMSE score 24.43 (SD = 2.64) which is in the mild range.59% of PwD had a diagnosis of AD, 25% vascular & 13% mixed AD & vascular dementia

Sex: 46 female PwD, 51 male PwD.

55% taking acetylcholinesterase inhibiting medication.

Caregivers: 73% spouses or adult children; 80% of caregivers living with PwD. No significant differences between spouse & adult child caregivers in terms of attachment, stress and psychological health, or collateral ratings of functional impairment or problem behaviours. As there were no significant differences between spouses & adult children analyses are based on entire sample.

Sex: 57 female caregivers, 32 male

Attachment measure (for PwD and caregiver, completed by PwD and caregiver): Relationship Questionnaire (Bartholomew & Horowitz, 1991). This was used to assess four types of attachment style (secure, preoccupied/ambivalent, dismissive/avoidant, fearful). This measure produces an outcome on the model of self; internal consistency rated for carers of PwD as 0.81; good stability in attachment classification over an 8-month period; measure is theoretically related to other self-reported measure of self-esteem in adults.

Self-concept measure (for PwD completed by PwD): Tennessee Self-Concept Scale (Fitts & Warren, 1996). Has previously been used by PwD.

Mood measure (for PwD completed by PwD): Hospital Anxiety and Depression Scale (Snaith & Zigmond, 1994). Has been used and validated for PwD.

Quality of life measure (for PwD completed by PwD): Quality of Life-AD (Logsdon, Gibbons, McCurry & Terri, 2002).

Problem behaviour measure (for PwD completed by caregiver): Neuropsychiatric Inventory Questionnaire (Kaufer et al., 2000).

Functional activities measure (for PwD

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and examine how carer attachment styles relate to symptoms of PwD.

caregivers.

Age: range of PwD between 51 to 90 years, mean age 77.98 years (SD = 7.68); range of caregivers between 33 to 89 years, mean age 68.17 years (SD = 13.66).

completed by caregiver): Functional Activities Questionnaire (Pfeffer, Kurosaki, Harrah, Chance & Filos, 1982).

Stress measure (for caregiver completed by caregiver): 15-item Relative Stress Scale (Green, Smith, Gardiner & Timbury, 1982).

Psychological wellbeing measure (for caregiver completed by caregiver): General Health Questionnaire-12 (Goldberg & Williams, 1988).

4. Monin, Schulz, & Kershaw (2013). Caregiving spouses’ attachment orientations and the physical and psychological health of individuals with Alzheimer’s disease

To examine the extent attachment orientations (anxiety and avoidance) of people with AD & spousal caregivers were associated with each partner’s report of the physical and psychological health symptoms of person with AD.

Hypothesis: when both partners are high in attachment insecurity (i.e. anxiety or avoidant) PwD will be more likely to self-report symptoms & caregiver will be more likely to perceive symptoms in PwD than when both partners are low in attachment insecurity, i.e. more securely attached.

Community living individuals; recruited from AD Research Centre at University of Pittsburgh & the local chapter of the AD Association; participants’ data taken from a larger study (Schulz et al., 2010).


PwD:

Diagnosis of dementia: have a consensus-based diagnosis of probable or possible AD or related dementia.

Living in the community with primary caregiver.

Sex: 19% (11) female PwD, 81% (47) male PwD.

Caregivers: spouse, providing minimum of 3 months of in-home care prior to recruitment, primary caregiver.

Sex of caregivers not provided.

Age: mean age of PwD 73.95 years

Attachment measure (for PwD and caregiver, completed by PwD and caregiver): 12-item Experiences in Close Relationships Scale (Brennan et al., 1998; Feeney, 2004).

Physical and psychological symptoms measure (for PwD completed by caregiver and PwD): no formal names given. However scales have been validated and found to be reliable with diverse samples.

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(SD = 8.10); mean age of caregivers 71.10 years (SD = 7.8).

Ethnicity: 94.8% (55) of PwD White, 3.4% (2) Black, 1.7% (1) Asian. This was the same for caregivers.

5. Chen, Uzdawinis, Schölmerich, & Juckel (2014). Effects of Attachment Quality on Caregiving of a Parent with Dementia

To examine the moderating role of attachment quality on the relationship between dementia-specific stressors and caregiver distress, and caregiver satisfaction.

Specifically: apply attachment theory to child caregivers and explore how early and present-day attachment buffers stress when experiencing dementia stressors (i.e. dementia-related behaviour).

Aim 1: Do the attachment measures predict different aspects of caregiving experiences?

Aim 2: What is the impact for caregiver of early attachment & current attachment to PwD?Hypothesis: the impact of caregiving stressors on caregiving burden & satisfaction would be moderated by the quality of the adult child’s attachment to their aging parent.

Data taken from the Families & Caregiving Study (Chen, 2009).

N = 91 patient-caregiver dyads (this is presented as just caregivers in the paper).

PwD:

Diagnosis of dementia: had some “form” of dementia;

65% living in an institutional setting.9% shared household with caregiver.1% independent living facility.20% residing in own community.

Sex: 86% of PwD were Mothers.

Caregivers: children of PwD, provided care for 53 months on average (SD = 44.29).

Sex: 85% daughter caregivers.

Age: mean age of caregivers 55 years (SD = 7.11); age range of PwD 64 to 100 years, mean age of 85 years (SD = 6.96).

Caregiver stress measures (for PwD symptoms completed by caregiver): 1. Cohen-Mansfield Agitation Inventory (Cohenmansfield & Billig,1986; Cohenmansfield, 1995). Found to be valid and reliable with higher scores indicating levels of agitation.2. Minimum Data Set Cognition Scale (Hartmaier, Sloane, Guess et al., 1994), valid and reliable measure of cognitive status with higher scores representing greater cognitive impairment.

Attachment measures (for caregiver completed by caregiver): 1. 25-item Parental Bonding Instrument (Parker, Tupling, & Brown, 1979) for early attachment measure.2. Adult Attachment Scale (Cicirelli, 1995) to measure strength of caregiver’s current attachment bond.

Caregiver perception of stress measures (for caregiver completed by caregiver): 1. Perceived Stress Scale (Cohen, Kamarck, & Mermelstein, 1983). Valid & reliable

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Ethnicity: 91% of caregivers Caucasian.

measure.2. Caregiving Distress Scale (Cousins et al., 2002).3. Caregiver Satisfaction Scale (Lawton et al., 1989).

Social desirability measure (for caregiver completed by caregiver): 10-item Marlowe-Crowne Social Desirability Scale (Gove & Geerken, 1977). Used to measure response bias.

Qualitative

6. Ingebretsen & Solem (1998). Spouses of persons with dementia: Attachment, loss and coping

How do spouses of PwD cope with losses and caregiving tasks during the dementia process, and how their coping is related to the individuals and couples’ history of attachment over 3 (1996-1998) years (follow-up at every 6-9 months).

Recruitment from Memory Clinic at the City Hospital of Oslo.

N = 28 patient-caregiver dyads. PwD: early stages of dementia at recruitment stage. No formal assessment to guide stage of dementia.

Caregivers: spousal caregivers 60-87 years.

Sex of PwD or caregivers not provided.

Semi-structured qualitative interviews (2-3 hours per interview) audiotaped & transcribed. Of note, authors did not detail their analytical strategy.

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Table 3. Description of results and overall critique of included studies

Study Main Findings Strengths Limitations

Quantitative

1. Magai & Cohen (1998). Attachment Style and Emotion Regulation in Dementia Patients and Their Relation to Caregiver Burden

Attachment styles: 56.5% secure, 36.9% avoidant, 6.5% ambivalent.

Significant difference between pre-morbid attachment and pre-morbid emotional regulation: PwD secure: scored higher on sociability.PwD avoidant: scored higher on shyness, emotional lability, intensity of emotional expression, anger, contempt, inhibited emotion, emotional distancing. PwD ambivalent: scored higher on anxiety & sadness.

Significant difference between pre-morbid attachment and behavioural symptoms: PwD avoidant: scored higher on activity disturbance, diurnal rhythm disturbance and delusions.PwD ambivalent: scored higher on depressed affect & anxiety.

Significant difference between pre-morbid attachment & caregiver burden: caregiver burden lowest if caring for

Aims: One of the first papers looking at the dyad; justifies why they only used caregiver reports (and not patient reports).

Method: Large sample; variety of caregiver types.

Results: Controlled for confounding variables.

Discussion: All hypotheses addressed.

Method: Unclear why additional 48 patient-caregiver dyads were included in the paper or reason for commenting on them. Nevertheless non-completers of the extra sample had a greater proportion of African-Americans which may skew perspective; psychiatrist rated behavioural symptoms of PwD but did not explain quality of relationship between psychiatrist and PwD, thus validity of ratings questionable; different caregiver relationships, e.g. spouse/child etc… may reflect different attachment styles. However, attachment styles of caregivers could affect how they choose to rate pre-morbid attachment of PwD thus skewing the data; caregivers completed pre-morbid measures for PwD. Although paper states that there is no difference between caregiver and PwD completing the measures, it does not provide justification for this; both attachment and emotional regulation measures were completed the same week that caregivers completed their burden scale yet pre-morbid ratings may have been affected by caregiver attachment style or PwD emotions at time of rating; excludes direct perspective from PwD; no breakdown of test-retest reliability for Feelings and Emotions Inventory (FEI) yet this measure was developed for the purpose of the study.

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securely attached PwD.

Significant regression model showing PwD attachment style accounts for 8% of caregiver burden.

Results: participants missing in study yet not accounted for or commented upon.

2. Perren, Schmid, Herrmann & Wettstein (2007). The impact of attachment on dementia-related problem behaviour and spousal caregivers’ wellbeing

Attachment styles of caregivers: 75% secure, 24% avoidant, 1% ambivalent.Attachment styles of PwD: 77% secure, 13% avoidant, 10% ambivalent.

Caregivers’ avoidance of closeness & dependency, and anxiety about abandonment were not significantly associated.

Caregivers who were securely attached reported lower levels of avoidance than insecurely attached individuals.

Attachment security of PwD was significantly associated with caregivers’ avoidance & anxiety.

Caregivers caring for securely attached PwD reported lower levels of avoidance than those caring for insecurely attached.

No significant association found for PwD attachment and dementia-related problem behaviour.

Higher levels of caregiver avoidance at Time 1 were associated with higher

Introduction: Good clear literature review & summary which is very methodical.

Method: good explanation of participants; good explanation of changes to Collins & Read Questionnaire (however no test-retest reliability conducted); asks PwD to complete their own attachment measure & reports how many were able to complete it; longitudinal study which increases validity of the study; explains how they managed incomplete data (68 dyads instead of 116) due to missing or incomplete questionnaires and adjusted for this using ANOVAs.

Results: controls for intervention effects of the original study, as well as for sex differences regarding anxiety & wellbeing for the latent growth model.

Method: No breakdown of demographics of participants therefore cannot generalise findings; although data is taken from another project & authors state controlling for the intervention effects, they do not state how; only reports reliability or validity on some of the measures; attachment measure was not validated for the target population; life satisfaction and subjective wellbeing combined as one outcome due to being "highly correlated" yet high correlation reported is between 0.527 and 0.654 which is a medium correlation - by combining these scores it gives a skewed representation of the data; controls for sex differences but does not state how; excludes data with missing values which can skew the results; only assessed attachment once and therefore do not know whether this changes with dementia progression; as a longitudinal study cannot control for all variables which may have contributed to caregiver wellbeing.

Results: number of participants dropped to 115 without accounting for the missing participant; sample size for the longitudinal data was very small as only 1/3 of sample size of PwD was able to complete the attachment measure, therefore results mainly consist of caregiver attachment rather than PwD – authors do not inform how or if other PwD’s

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levels of problem behaviour (agitation/aggression) in PwD over the 2 years.

The higher the level of caregiver avoidance, the lower their wellbeing at all time points (this was significant).

Securely attached caregivers reported higher levels of wellbeing than insecurely attached (significant).

Similar pattern for PwD however not significant, i.e. securely attached PwD associated with higher levels of caregiver wellbeing.

Latent growth model predictions: caregiver anxiety significantly predicted their wellbeing; caregiver avoidance nearly had a significant effect on wellbeing; caregiver attachment did not have a significant impact on changes in problem-behaviour and wellbeing over time; level of problem behaviour significantly predicted level of caregivers’ wellbeing; problem behaviour and attachment are risk factors for low levels of caregiver wellbeing.

attachment styles were assessed; no results presented in tables or figures therefore cannot interpret the results.

Discussion: misleading as states "as hypothesised, we found that attachment style is associated with levels of dementia-related problem behaviour". However, their hypothesis was that insecure attachment in PwD would be associated with dementia-related problem behaviour. Yet results showed that it was caregiver’s avoidance that was significantly related to dementia-related problem behaviour; they conclude that securely attached caregivers report higher levels of wellbeing than insecurely but study had a much higher proportion of securely attached caregivers compared to insecure (75% Vs 25%); authors start discussing data from the original study when this did not form any part of the aims of this paper.

3. Nelis, Clare & Whitaker (2012). Attachment representations in people with dementia and their carers:

Attachment styles of caregivers: 38% secure, 12% fearful, 4% preoccupied (ambivalent), 34% dismissive

Aims: first research that examines the relationship between attachment and subjective emotional experiences

Method: did not use gold standard measure of attachment interviews or observation of attachment behaviours, instead used a 'model of self' and 'model of others' to represent attachment; many measures

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Implications for wellbeing within the dyad

(avoidant).

Attachment styles of PwD: 35% secure, 10% fearful, 12% preoccupied (ambivalent), 42% dismissive (avoidant).

However, uses secure-insecure subgroups due to low figures of fearful and preoccupied.

12 dyads consisted of both partners having secure attachment, 28 dyads consisted of both partners having insecure attachment, 21 dyads consisted of secure PwD & insecure caregiver, 25 dyads consisted of insecure PwD and secure caregiver.

No significant differences for total number of neuropsychiatric symptoms, symptom severity or caregiver distress at symptoms between insecure and secure attachment styles of PwD.

Attachment security (secure/insecure) for PwD or caregiver is not significantly associated with total number of neuropsychiatric symptoms, symptom severity or caregiver distress at symptoms.

No significant interaction effects of PwD and carer attachment security on any of the neuropsychiatric total scores

of PwD and primary caregiver; focus on the reciprocal nature of the attachment dyad.

Method: study using all four attachment styles.

Discussion: Provides explanations for why they have different outcomes to other studies.

did not give reliability or validity; cross-sectional therefore cannot determine direction of relationship between attachment and psychological outcomes for either PwD or caregiver; study collapses attachment styles in to secure Vs insecure therefore findings not as specific.

Results: Though there were no significant differences between adult, child and spouse (relationships) the level of non-significance was not reported.

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suggesting that symptoms and distress at symptoms were not related to attachment security.

Caregiver psychological health was predicted by MMSE of PwD (dementia severity), their model of self and level of distress at symptoms.

Caregiver stress was predicted by MMSE of PwD (dementia severity) and caregiver distress at symptoms.

PwD reported more insecure than secure attachment with most frequent being dismissive (avoidant) attachment style.

Attachment not related to quality of life in PwD but mood and self-concept were strong predictors of quality of life.

No association between PwD and caregiver attachment styles.

PwD working models of attachment did not predict carer wellbeing and vice versa. Therefore, attachment representations may be important for psychological health of PwD and caregivers but no evidence of reciprocal nature of attachment between these dyads.

4. Monin, Schulz & Kershaw Significant interaction between anxious Aims: First study to look at the Method: Small sample size; most PwD were

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(2013). Caregiving spouses’ attachment orientations and the physical and psychological health of individuals with Alzheimer’s disease

attachment of caregiver and PwD on predicting PwD self-reported physical symptoms, i.e. when caregivers and PwD had an anxious attachment, self-reported physical symptoms in PwD was highest.

Significant positive association between PwD avoidant attachment and caregiver perception of PwD physical symptoms, i.e. the more avoidant PwD the more caregiver perceives physical symptoms of dementia.

Significant interaction between caregiver anxious attachment & PwD anxious attachment predicting PwD self-reported psychological symptoms, i.e. when both PwD and caregivers were high in anxious attachment, self-reported psychological symptoms in PwD were highest.

When caregiver and PwD scored high in insecure attachment style they were more likely to notice and report physical symptoms in dementia.

interactive effect on both attachment styles of PwD and caregiver, and how this impacts both partner's reports on symptoms in the PwD.

Caucasian men; data was cross-sectional therefore cannot determine how this changes over time; unclear how many participants were included in the study; interviewer's subjective judgement on whether PwD were able to give reliable answers; as measures were assessed by participants they were not an objective assessment of psychological and physical symptoms of PwD; no reliability or validity stated for the Experiences of Close Relationships measure; measures of physical and psychological symptoms have been reported to be validated and reliable yet no information provided and no formal name given of the said measures; psychological scales were found to be reliable for self-reports and caregiver perceptions, yet the physical symptoms measure was found to have a low reliability - they explain this discrepancy because the index of physical symptoms are not necessarily correlated to one another.

5. Chen, Uzdawinis, Schölmerich & Juckel (2014). Effects of Attachment Quality on Caregiving of a Parent with Dementia.

On average, most caregivers reported mild cognitive impairment for PwD.

On average, most caregivers reported minimal to mild behavioural problems reported for PwD.

Aims: research looking at caregivers’ attachment to PwD and how that can buffer caregiver stress.

Method: due to past difficulties of measuring attachment as a

Method: difficult to compare to other research as no subtype of caregiver attachment is identified; as this study is a correlational design it cannot account for changes that may take place over time, which is likely given the complexity of the attachment relationship between caregiver and PwD; small

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Current attachment & caregiver satisfaction was significant (p = 0.0000001). Medium effect of stronger current attachment associated with more feelings of satisfaction.

Significant association between early attachment & caregiver specific-distress (p = 0.001), i.e. higher attachment security in childhood correlates to less caregiving-specific distress.

The main effect of current attachment correlating to caregiver distress did not reach significance (p = 0.17).

Further analysis testing current attachment as a moderator for caregiver distress was significant (p = 0.03).

Attachment moderates the relationship between behavioural problems & global distress but there is no significant interaction between attachment & behavioural problems.

Securely attached caregivers experience same amount of distress regardless of their parent’s cognitive impairment (p = 0.76).

Less securely attached caregivers experienced significantly more distress when parent was more cognitively

construct the researchers measured the quality of attachment from caregiver to PwD rather than subtypes of attachment.

Results: Variables controlled for when examining cognitive impairment and current attachment interaction as predictors of distress.

sample size limits generalisability of findings; attachment measure was specifically for caregiving daughters’ attachment to elderly Mothers, yet not all caregivers were female.

Results: caregivers reported only mild to moderate feelings in caregiver burden however they considered themselves quite highly attached to PwD (parent) in early attachment and moderately attached to them in present attachment. This specific way in characterising attachment, i.e. present & early attachment, may make it harder to generalise; lots of repeated analyses (12 separate regressions) which could lead to Type I error.

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impaired (p = 0.002).

Model indicates that at low levels of cognitive impairment, attachment security predicts 7.90% of the variability in caregiver distress. At high levels of cognitive impairment there was no significant difference in distress experienced by more & less securely attached caregivers.

When caregivers are securely attached, less distress is experienced when there is a low frequency of behavioural problems but as behavioural problems increase, distress increases (p = 0.02).

Behavioural problems account for 7.40% of the variability in caregiver distress.

When caregivers are less securely attached, more caregiver stress is experienced when the frequency of behavioural problems are low but when behavioural problems increase, caregiver stress decreases (p = 0.03).

When higher cognitive impairment in PwD, the more caregiver distress (p = 0.04) and caregiving-specific stressors (dementia problem behaviours) p = 0.02.

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Qualitative

6. Ingebretsen & Solem (1998). Spouses of persons with dementia: Attachment, loss and coping

Three themes emerged all of which were based on insecure styles of attachment:

1. Be available for me (don’t be helpless be my safety) this was interpreted to represent ambivalent attachment type e.g. when caregiver is angry, nagging or withdrawing the PwD responds with sadness and withdraws.

2. I am not available for you (don’t come too close, don’t disturb my independence) this was interpreted to represent avoidant attachment type e.g. caregiver and PwD have more quarrels, caregiver reminds PwD what to do regularly, PwD feels more on guard, feels criticised & rejected.

3. I am available for you (don’t drift away from me – we belong together) this was interpreted to represent the compulsive caregiving type e.g. when PwD needs more care the

Aims: Only qualitative study exploring caregiver and PwD experiences; clear aims

Method: longitudinal study which marks changes over time.

Results: provides examples in results section; includes how PwD respond to caregivers.

Method: Data taken from another study; no information provided on whether analysis was compared with others (inter-rater reliability); little detail given why some spouses did not want to take part in the study; little demographics given of participants, particularly PwD; unclear whether data was collected in a way that addressed the research issue – provides some information but lacks justification for choices; reflexivity not discussed; no ethical issues discussed; lack of information regarding how data analysis was conducted.

Results: no secure attachment patterns identified or discussed in results – although one sentence on secure attachment was provided at the end of paper; unclear statement of findings.

Discussion: no discussion about credibility of research & little discussion following presentation of results; presents some ideas on how the findings can contribute to interventions for spouses of PwD however no discussion on how the research contributes to existing knowledge.

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caregiver increases care, heightened emotion of sadness and distress for caregiver, caregiver strongly attached to PwD/highly attuned to PwD.

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What is attachment and how is it measured?

The papers understood attachment in various ways, with minimal agreement

on a standardised measure making it difficult to identify patterns in the literature.

Attachment measures. Two studies shared the same attachment measure

(Magai & Cohen, 1998; Perren, Schmid, Herrmann & Wettstein, 2007). Other

studies focused on specific dimensions of attachment. Specifically, three papers used

descriptive paragraphs to categorise attachment styles (Magai & Cohen, 1998; Perren

et al., 2007; Nelis, Clare & Whitaker, 2012). The Attachment Style Questionnaire

(Hazan & Shaver, 1987), recognised as the gold standard tool for attachment, was

used in two studies (Magai & Cohen, 1998; Perren et al., 2007). Yet the studies

understood attachment in different ways; two studies added extra dimensions to the

measure but gave an ambiguous rationale for doing so (Perren et al., 2007; Nelis et

al., 2012). For example, Nelis and colleagues (2012) used a measure with less

theoretical salience to attachment (i.e. self-esteem) which could impact findings.

Another paper considered early and present-day attachment (Chen, Uzdawinis,

Schölmerich & Juckel, 2014); while recognising the dynamic nature of attachment

over time, it led to difficulties in generalising findings.

Reliability, validity and credibility. No study reported substantively on the

reliability and validity of measures, apart from Nelis and colleagues (2012) who

calculated a strong internal consistency (0.81). Three of the studies used descriptive

paragraphs for attachment styles, preventing internal reliability being calculated.

Perren and colleagues (2007) adapted a measure without verifying the effect on

reliability and validity. Magai and Cohen’s (1998) study asked others to complete the

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self-reported attachment questionnaire on behalf of an individual which could further

affect reliability and validity. Ingebresten and Solem (1998) used interviews and

general observations to make sense of attachment styles; while this is a novel way to

understand attachment, it was not clear how observations happened, raising queries

regarding credibility of the study.

Administration of measures. Several approaches were taken to

administering measures. Magai and Cohen (1998) had caregivers complete an

attachment measure on behalf of the person with dementia, potentially allowing the

caregiver’s attachment style to impact the rating. Furthermore, caregiver response

may have been influenced by a desire to positively represent their loved one. Three

other studies had each member of the dyad complete attachment measures for the self

(Perren et al., 2007; Nelis et al., 2012; Monin et al., 2013), enabling people with

dementia to rate their own attachment style. Notably, two of the papers reported on

person with dementia’s ability to complete reliable self-reports (Perren et al., 2007;

Monin et al., 2013). However, Perren and colleagues (2007) omitted to detail how

this was considered and Monin and colleagues (2013) based it on the interviewer’s

judgement. This raises questions about the reliability of the rating. Importantly, self-

rated measures can produce response bias due to social desirability.

Attachment styles. Reporting of attachment styles differed across papers.

One of the papers referred to all of the attachment styles (Nelis et al., 2012), i.e.

secure and three insecure subtypes. However, as few participants were represented

within each of the three insecure subtypes (pre-occupied/dismissive/fearful), they

collapsed the subtypes to create one insecure attachment category during analysis.

Two studies specifically considered secure and the two insecure attachment subtypes

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(Magai & Cohen, 1998; Perren et al., 2007). Two papers focused only on insecure

attachments (Ingebresten & Solem, 1998; Monin & colleagues, 2013). Another paper

placed emphasis on being more or less securely attached (Chen et al., 2014). The

emphasis on either insecure or secure attachment styles may have biased results as

they only considered one aspect of attachment. Furthermore, in assessing for an

insecure attachment only, Monin and colleagues (2013) reported on anxious and

avoidant attachment. As the authors did not explicitly report attachment styles, it was

assumed that an anxious attachment represented the ambivalent attachment style.

Ingebresten and Solem (1998) described three insecure attachments but did not make

reference to specific attachment styles. Instead, descriptions were interpreted and

mapped onto attachment styles for this review.

The above critique poses a larger problem in drawing valid conclusions of

how attachment influences the dynamic interactions within the dyad. Although the

studies have addressed various factors related to attachment, thus giving a wider

perspective, the question remains of how to harmoniously synthesise these findings

to effectively capture attachment and its influence on the dyad. Unsurprisingly, a

wide range of findings were identified, some being contradictory.

Attachment and behaviours

Based on the studies, a relationship was identified between attachment and

behaviours. However, as all of the studies employed divergent aims, findings and

frameworks, there was a certain amount of overlap in the categorisation of results.

Insecure attachment and unhelpful behaviours, including dementia-

related behaviours. Four papers showed a relationship between an insecure

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attachment and unhelpful dementia-related behaviours (Ingebresten & Solem 1998;

Magai & Cohen 1998; Perren et al., 2007; Monin et al., 2013) such as sadness,

withdrawal and irritability. These unhelpful dementia-related behaviours were seen

as negative for the person with dementia and caregiver. Across studies results were

not always conclusive and anomalies persisted between findings. The variance

diminished the extent to which overall conclusions could be drawn. Due to such

differences between papers, the findings will firstly be presented.

Ingebresten and Solem’s (1998) qualitative study primarily considered

spousal caregiver coping and experience of loss, and its relationship to the individual

attachment patterns and history of attachment patterns within the dyad. There were

varied findings across attachment styles and behavioural responses of people with

dementia. Some caregivers, characterised as having an ambivalent attachment, were

reported as responding to the changes taking place within their spouse with anger,

nagging and withdrawal, viewing their partner with dementia as unavailable.

Behavioural responses varied for people with dementia. Some unhelpful dementia-

related behaviour (sadness and withdrawal) were identified. However, some people

with dementia responded positively towards their caregiver; this positive response

generally stopped the cyclical process of anger for the caregiver. One caregiver,

categorised as ambivalently attached, initially responded with anger which subsided

with time. A range of findings were noted for couples categorised as avoidantly

attached. One dyad showed a sense of feeling ‘trapped’ by dependency; when

subjects became too close they were prone to push each other away. Unhelpful

dementia-related behaviours included being on guard and irritable towards the

caregiver. Contrastingly, another dyad demonstrated independence could be kept; the

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caregiver maintained an independent life and the person with dementia maintained

their distance by ‘appearing vacant’. Compulsive attachment patterns illustrated that

caregiver responses were initially despairing but through giving persistent support to

their spouse, dementia-related behaviour often subsided. Although this qualitative

study had similar findings to some of the quantitative studies regarding attachment-

related behaviours, there were still a number of differences with how each dyad

influenced one another, despite being within the same categorised attachment style.

Magai and Cohen (1998) examined pre-morbid attachment style of the person

with dementia, as rated by caregivers. They found pre-morbid insecure attachment

(avoidant/ambivalent) was significantly related to more negative pre-morbid

emotional regulation (e.g. avoidant attachment correlated with anger and emotional

distancing; ambivalent attachment correlated with higher anxiety and sadness). Pre-

morbid insecure attachment also correlated to unhelpful dementia-related behaviours

(e.g. avoidant attachment correlated to more activity disturbance and delusions;

ambivalent attachment correlated to more depressed affect and anxiety).

Perren and colleagues (2007) completed a two-year longitudinal study

examining how attachment impacts dementia-related problem behaviour and spousal

caregivers’ wellbeing. Their paper drew upon a larger intervention study. The

authors reported controlling for the intervention effects but did not state how. This

study found a similar pattern to Magai and Cohen (1998); namely, a positive

association between insecure attachment style and unhelpful neuropsychiatric

symptoms in the person with dementia. However, the authors only found this

significant association for insecurely attached, specifically avoidantly attached. Thus,

40

in contrast to Magai and Cohen (1998) there was no significant association between

insecure attachment (in people with dementia) and neuropsychiatric symptoms.

Monin and colleagues (2013) found further contradictory findings. The

authors examined the extent to which people with Alzheimer’s disease (AD) and

their caregivers’ attachment orientations were associated with the physical and

psychological health of the person with AD. They found that when both members of

the dyad were high in insecure attachment (specifically, anxious-ambivalent) people

with AD reported more physical symptoms and higher levels of psychological

symptoms. The authors also found a positive association between avoidant

attachment in people with AD and caregivers’ perception of the physical symptoms

in dementia.

Critique. Contradictory findings may be owing to methodological factors.

The qualitative study used a mixture of interviews and observations to understand

how attachment and behaviour manifest in the dyad. In contrast, all three quantitative

studies took a slightly different approach to measure dementia-related behaviours.

For instance, two papers used a behavioural tool addressing either the pathology in

AD or a measure only validated for people with AD (Magai & Cohen, 1998; Monin

et al., 2013); yet both samples included participants with various types of dementia.

Therefore, these tools were not entirely appropriate for the sample. Importantly, the

measure used by Monin and colleagues (2013) was developed by the authors of the

study (Schulz, et al., 2010), which may have introduced a degree of bias; they may

have been more invested in promoting their measure instead of using the most

appropriate measure for the study. Indeed, the measure was developed specifically

for those scoring more than 16 on the Mini Mental State Examination tool (Schulz, et

41

al., 2010). However, Monin and colleagues (2013) did not report stage of dementia,

thus affecting confidence in the findings.

Across studies there were differences in reporting reliability and validity of

the behavioural scales. Magai and Cohen (1998) specifically reported on the inter

rater-consistency, whereas Perren and colleagues (2007) reported using a valid and

reliable measure but gave no results to confirm. It was positive that Monin and

colleagues (2013) reported their measure to be valid and reliable across a diverse

sample, particularly given the mixed ethnicities within their sample. Yet whilst they

reported on cultural validity it was only validated for African-American and Hispanic

caregivers of older adults; their sample comprised of White, Black and Asian

participants. Interestingly, Magai and Cohen (1998) had participants from different

ethnicities but did not address cultural validity of the behavioural measure. Perren

and colleagues (2007) omitted demographic details on ethnicity altogether. It is

therefore uncertain whether this critique extends to their findings. Notably, Monin

and colleagues (2013) used a physical and psychological measure to consider

behavioural manifestations in the person with AD. Specifically, they reported low

reliability on the physical symptoms measure. Though the authors explained their

anticipation of this (i.e. the tool comprises of physical symptoms not necessarily

related to one another), questions still arise regarding the validity of any conclusions

drawn. The consequent vagueness, common to several of these studies, brings in to

question the credibility of their findings.

Among these studies, there were variances in administering behavioural

measures. Perren and colleagues (2007) had caregivers complete the measure whilst

Magai and Cohen (1998) had a psychiatrist, whose quality of relationship to the

42

person with dementia was not described. Arguably, proxy ratings may not be

reliable. Interestingly, whilst one could argue that family members provides a more

accurate picture of the person with dementia, it cannot be assumed that it is unbiased.

Monin and colleagues (2013) had both members of the dyad complete the

behavioural measure, thus including the person with dementia’s perspective; this was

a useful inclusion, uncommon amongst the studies. Yet, self-report measures are

based on a person’s ability to self-reflect; in the case of dementia the ability to use

higher level cognitive processing skills is questionable. Furthermore, the stage of

dementia was not reported, making it difficult to interpret findings.

Stage of dementia differed across studies, with one study (Monin et al., 2013)

not reporting this. One study included participants in the early stages (Ingebresten &

Solem, 1998) while another included moderate to severe (Magai & Cohen, 1998). In

Perren and colleagues (2007) longitudinal study, roughly 69% of people with

dementia were in the very mild to mild range of dementia and 30% were in the

severe range at Time 1. By Time 3 (two years post-intervention), 38% had

deteriorated towards the severe range. It was unclear how many participants this

figure represented as 19 participants with dementia were reported to have passed

away over the two years. Given that the authors did not report how many participants

were included in the final phase of data collection, there remains a question as to

whether the findings had sufficient power to make valid and reliable conclusions.

It is difficult to determine the weight of the findings in Ingebresten and

Solem’s (1998) qualitative paper. The authors describe their paper based on research

evidence and present clear aims. However, key information is missing in the paper

including ethical approval; demographic details of the sample; the measure to assess

43

stage of dementia; how data were analysed, including the use of reflexivity. These

omissions undermine the quality of the study, and make it difficult to assess their

contribution to our understanding of the dyad.

Overall, there appears to be a connection between an insecure attachment and

unhelpful behaviours. The results of quantitative papers reflected this connection (i.e.

insecure attachment was significantly related to unhelpful behaviours) and the

qualitative paper highlighted how unhelpful behaviours were demonstrated in people

with an insecure attachment. However, owing to the multiple differences in design

(i.e. quantitative and qualitative, and differences between quantitative studies) it is

difficult to draw clear conclusions.

Secure attachment and helpful behaviours. Across the studies there was

evidence to suggest a secure attachment has a positive impact on behaviour. Magai

and Cohen (1998) found pre-morbid secure attachment in people with dementia

correlated with higher levels of sociability. Perren and colleagues (2007) found a

secure attachment in people with dementia had a positive impact on caregivers, as

reflected in lower levels of caregiver avoidance. Ingebresten and Solem (1998)

suggest a secure attachment helps caregivers to accept change and maintain contact

with the other party.

Critique. There is a small body of evidence to suggest a secure attachment

has a positive impact on helpful behaviour in the dyad, both for person with dementia

or caregiver. Positively, the above two quantitative papers had a large sample making

results more generalisable. Despite the large sample the majority of dyadic

participants were rated securely-attached (Magai & Cohen, 1998; Perren et al., 2007)

44

thus findings were biased towards a securely-attached perspective. Ingebresten and

Solem (1998) briefly reported on secure attachment and helpful behaviours but

without evidencing examples. It was also unclear whether the helpful behaviour was

common for both or one member of the dyad. Also, the two longitudinal studies

(Ingebresten & Solem, 1998; Perren et al., 2007) extracted data from another study;

this could bias findings as authors may extract data to advance their paper.

There is some evidence to suggest a secure attachment has a positive impact

on behaviours within the dyad however this is minimal and the validity is partly

questionable.

Contradictory findings regarding attachment and behaviour. One paper

appears to contradict the research outlined above, suggesting that attachment has no

relationship with behaviour. Nelis and colleagues (2012) explored attachment within

the dyad, and the effect on wellbeing of both members. They reported a series of

insignificant findings, including insignificant interactive effects between attachment

style (insecure/secure) and neuropsychiatric symptoms within the dyad.

Critique. Contradictory findings may owe to a number of factors. First, the

study recruited samples in the earlier stage of dementia possibly suggesting that

when dementia is mild, behavioural symptoms are minimal. Yet, the behavioural

measure was completed by caregivers who showed a higher proportion of secure

attachments. In such cases, more securely attached caregivers may perceive stressful

situations as less threatening and therefore report minimal neuropsychiatric

symptoms in their loved ones. Lastly, reliability and validity of the neuropsychiatric

45

measure was not reported; it is unclear whether this measure is valid for caregivers of

people with dementia.

Attachment, caregiver burden or caregiver distress

Three papers reported a relationship between attachment and caregiver

burden or distress.

Insecure attachment and caregiver distress. Chen and colleagues (2014)

examined the moderating role of attachment quality (early and present attachment)

on behavioural problems in parents with dementia, as predictors of caregiver distress.

Participants were child caregivers supporting parents with dementia. Findings

revealed that caregivers with less secure present-day attachment experienced greater

levels of distress when cognitive impairment was perceived as high. Conversely,

caregivers with less secure present-day attachment experienced lower levels of

distress when cognitive impairment was perceived as low. In using a regression

model, caregivers with less secure present-day attachment experienced higher stress

levels when there was a lower occurrence of behavioural problems in parents with

dementia.

Critique. Positively, the authors reported controlling for a number of

variables. However, given that attachment relationships are a complex phenomenon,

additional factors may not have been controlled for. Indeed, the authors highlight that

the correlational design meant shifts in relationships over time could not have been

monitored, thus potentially compromising the validity of the findings. The authors

also acknowledged that their use of repeated analyses may have increased the

possibility of a Type I error. Also, the study had a small sample size, compromising

46

the generalisability of these findings. As discussed regarding other papers, the data

was taken from a larger study which may have biased findings somewhat.

Secure attachment, caregiver burden and distress. Two studies reported

on the positive impact a secure attachment has on caregiver burden and distress.

Magai and Cohen (1998) asked caregivers to complete a burden measurement tool.

They found caregiver burden was lowest when the person with dementia was pre-

morbidly securely attached. Taking a slightly different approach to measuring

distress, Chen and colleagues (2014) used various caregiver stress scales to measure

different aspects of stress (a person with dementia’s agitation and level of cognition,

and caregiver’s perceived stress, distress, and satisfaction2). Surprisingly, findings

revealed that a secure attachment did not buffer distress; caregivers with a present-

day secure attachment reported significantly more distress when parents were

perceived to have low levels of cognitive impairment. Conversely, both securely and

insecurely attached caregivers experienced, to an extent, the same amount of distress

when cognitive impairment in their parent was perceived as high. In using a

regression model, when considering secure present-day attachment and lower

occurrence of behavioural symptoms, caregivers experienced lower stress levels.

They also found that those with early secure attachment experienced lower levels of

caregiving-related distress. Furthermore, children who are securely attached as

individuals may respond sooner to a parent’s cognitive changes than those who are

insecurely attached. Consequently, initial experiences of heightened distress were

apparent in more securely attached participants, due to earlier recognition of parents’

cognitive decline.

2 Satisfaction will be discussed under the theme of attachment and wellbeing as it was considered a positive facet of wellbeing.

47

Critique. As described above, Magai and Cohen (1998) conclude that pre-

morbid secure attachment significantly lowers levels of caregiver burden. By

contrast, Chen and colleagues (2014) found a secure attachment in caregivers had a

significantly negative effect on stress levels. Although both papers considered similar

variables, they employed a different way of exploring the effect; Magai and Cohen

(1998) considered the impact of the person with dementia’s attachment on caregiver

burden whereas Chen and colleagues (2014) considered the impact of caregiver

attachment on caregiver distress. Solely reviewing how one member of the dyad

reports on their subjective experience (Chen et al., 2014) could introduce bias into

the findings and restricts the extent to which comparisons and evaluations may be

made between studies.

Interestingly, Magai and Cohen (1998) reported that pre-morbid attachment

and caregiver burden measures were completed by caregivers within the same week.

Yet, rating pre-morbid attachment within the same week may have influenced

caregivers’ perception of burden, thus affecting the reliability of the data.

Contrastingly, Chen and colleagues (2014) did not report the timeframe of

completing measures; it is unclear whether a similar problem might have also

affected their data.

No relationship between attachment and caregiver distress. Nelis and

colleagues (2012) found that caregiver attachment (secure and insecure) did not have

a significant impact on caregiver distress. They reported that attachment security

across the dyad had no significant effect on caregiver distress nor was it a predictor

of caregiver distress. Similarly, Chen and colleagues (2014) also found no significant

difference between present-day caregiver attachment (secure or insecure) when

48

cognitive impairment was high. They also found attachment had no significant main

effect regarding the interaction between present-day attachment and cognitive

impairment on distress. There was also no main effect between present-day

attachment and behavioural problems on distress, and no significant interaction

between early attachment and cognitive impairment on distress. Early attachment

also showed no significant main effect as a predictor of distress.

Critique. Both of the papers mentioned above appear to agree that there is no

clear relationship between attachment and caregiver distress. Interestingly, both

papers included participants in the mild stage of dementia. This may suggest that

there is no relationship between early stage dementia and caregiver distress

regardless of attachment style, perhaps because the attachment system is not fully

triggered. As previously addressed, though participants in Chen and colleagues

(2014) study rated their parents to have mild cognitive impairment, the validity of

this remains questionable in light of caregivers’ tendency to rate themselves as

securely to moderately attached. Both studies had a similar, and smaller, sample size

which limits the generalisability of the results. Both studies extracted data from a

previous larger study which might have been selectively chosen to fit prior

expectations. Regardless, the variance between these studies makes it difficult to

comparatively critique or verify conclusions.

Attachment, caregiver wellbeing or caregiver satisfaction

Three papers reported a relationship between attachment and caregiver

wellbeing, and satisfaction. Caregiver satisfaction was measured in one paper and

has been included in this section as it has been considered a facet of wellbeing.

49

Insecure attachment and wellbeing. One study showed a negative

relationship between insecure attachments and wellbeing. Perren and colleagues

(2007) found that avoidance and well-being were negatively correlated. This was

true throughout all three chronological stages of the study (i.e. before intervention,

and one and two year post-intervention).

Critique. The longitudinal design and the repetition of findings at each

chronological stage is a strength of this study. Using a slightly different approach to

understand wellbeing, the authors amalgamated the outcome of two measures (life

satisfaction and emotional wellbeing) but did not report reliability or validity of these

measures. Nevertheless, both measures were highly correlated.

Secure attachment, wellbeing and satisfaction. Two studies showed some

agreement for the positive impact of secure attachment on wellbeing. Perren and

colleagues (2007) found a secure attachment correlated with higher levels of personal

wellbeing. Chen and colleagues (2014) found that present-day securely attached

caregivers experienced greater levels of satisfaction; present-day attachment

predicted 33% of the variance within satisfaction.

Critique. Both studies highlighted positive findings regarding secure

attachment on wellbeing. Again, both findings were extracted from larger studies.

However, one of the papers was a longitudinal study (Perren et al., 2007), adding

strength to these findings. Interestingly, Chen and colleagues (2014) did not report

on reliability or validity of the satisfaction measure. This makes it difficult to deduce

definitive conclusions from their findings. Nevertheless, it is positive that both

studies highlighted a similar relationship between secure attachment and wellbeing.

50

No relationship between attachment and wellbeing. Three papers found

inconclusive evidence with regards to attachment on wellbeing. Using a prediction

growth model, Perren and colleagues (2007) found that caregiver avoidance could

not significantly predict wellbeing. The authors conclude that attachment did not

have a significant impact on any changes in caregivers’ wellbeing over time. Nelis

and colleagues (2012) found that working models of attachment did not predict

quality of life. Likewise, model of self (for person with dementia) was not

significantly related to caregiver wellbeing. Chen and colleagues (2014) considered

the interaction between cognitive impairment and present-day attachment as a

predictor of caregiver satisfaction; attachment did not moderate this relationship.

Additionally, there was no significant interaction between present-day attachment

and behavioural problems on caregiver satisfaction. Lastly, caregivers’ early-

attachment and stressors (level of cognitive impairment and behaviour) had an

insignificant predictive value in determining caregiver satisfaction.

Critique. The three papers addressed the predictive value of attachment on

wellbeing, and each concluded that attachment has no predictive value. Given that all

three studies used a mixture of study designs (longitudinal and correlational), the

strength of this finding appears fairly reliable. Yet while two of the studies reported

controlling for possible confounding variables in the prediction models (Perren et al.,

2007; Chen et al., 2014), one study did not report on this (Nelis et al., 2012). It

therefore cannot be assumed that all factors were controlled for in the analyses, thus

the validity of findings remains questionable. Lastly, all papers had small sample

sizes; this could lead to the studies being underpowered which increases the chances

of a Type II error.

51

Discussion

It is increasingly important that people with dementia are supported to live a

meaningful life, which includes sustaining valuable relationships (NICE, 2013).

Attachment may play an important role making it necessary to understand how

attachment impacts the dyad. Despite this, minimal research exists in this area, and

that which does remains unclear. This may be owing to the complex nature of

interactions in a dyad and difficulties when exploring the interaction.

Difficulties in drawing conclusions largely relate to attachment measures.

The studies adopted a range of ways to understand attachment (e.g. Chen et al., 2014;

Ingebresten & Solem, 1998). Although this may enrich our understanding of

attachment, research has not captured attachment across the dyad including its

reciprocal nature. Additionally, variation in administration of measures, classification

of attachment styles and difficulty in measuring reliability and validity, made it

challenging to draw valid conclusions of how attachment impacts the dyad.

Nevertheless, findings suggest that attachment impacts experiences within the dyad.

Other difficulties in drawing conclusions related to adaptations of various

measures (e.g. Perren et al., 2007), and inconsistencies in reporting reliability and

validity. This suggests measures do not fully capture the dynamic experiences of the

dyad, which is not surprising as interactions are a complex phenomenon. There were

also a variety of methodological approaches, such as taking data from a larger study

and being unclear how this was controlled for (e.g. Monin et al., 2013). Also,

different caregiving relationships were considered within (e.g. Magai & Cohen,

1998) and across papers thus making it harder to draw conclusions. For example,

attachment between spouses is likely to differ to attachment between child and

52

parent, and this is likely to impact the intensity of experiences in various ways.

Lastly, though the studies included a variety of people in different stages of

dementia, many were in the mild stage; only one study focused solely on the mid to

later stage of dementia (Magai & Cohen, 1998). This highlights an apparent lack in

the literature on understanding the interactive attachment dyad in the mid to later

stages of dementia.

Despite the above problems, some interesting conclusions may be drawn. The

literature is generally clear that attachment impacts behaviour in the dyad.

Specifically, there is a pattern between insecure attachment and unhelpful behaviours

(e.g. Ingebresten & Solem, 1998); when one part of the dyad was insecurely attached

it had negative repercussions on the dyad (e.g. Monin et al., 2013). It also appears

that a secure attachment positively influences behaviour. However, this conclusion is

tentative as not all studies conclude this (Nelis et al., 2012; Chen et al., 2014).

Additionally, there may be a relationship between secure attachment and caregiver

burden or distress. As only one paper considered burden (Magai & Cohen, 1998),

and therefore there are no contradictions across papers, it can tentatively be

concluded that a secure attachment in people with dementia buffers caregiver burden.

However, given the conflicting results in measuring attachment and caregiver

distress, conclusions are tentative. Lastly, it can also be concluded that a secure

attachment has a positive influence on wellbeing. Specifically, whilst no other

studies have considered these areas, there seems to be a relationship between a

secure attachment and wellbeing (Perren et al., 2007) or satisfaction (Chen et al.,

2014). Another reliable finding is that attachment is not predictive of wellbeing or

satisfaction.

53

Strengths and limitations

This review has importantly highlighted a paucity in the literature regarding

the interactive attachment dyad between the person with dementia and caregiver.

Further, in addressing the studies which consider this, it has raised a number of

contradictory findings that are important to consider when thinking of future

research. Also, this is the first literature review to consider the interactive element of

the attachment dyad. This is an important contribution to the field as dementia affects

the individual and system around them. Indeed, caregiving is an interpersonal

process and the dyadic relationship impacts the outcome for both members

(Kokkonen, et al., 2014). Further, this is the first literature review to include

quantitative and qualitative studies which is important to consider, as it provides a

fuller understanding of the research field.

However, it should be highlighted that the qualitative study was not identified

through the searched databases; this may be due to the search terms or search

strategy. It therefore cannot be assumed that there are no further applicable

qualitative papers relevant to this review. Additionally, the findings are difficult to

follow, which can be owing to the highly complex nature of the interactive

attachment dyad. Also, some of the findings were grouped together to create a more

coherent narrative of the findings (e.g. wellbeing and satisfaction) though it may be

argued that these are separate constructs in their own right. Though conclusions are

tentative, they highlight the lack of empirical evidence, giving justification for

54

further research. Also, the grey literature was not included in the review based on the

inclusion criteria which may have led to important contributions being missed.

Future research

Given the number of methodological limitations and the dearth of research

within this field, future research should address how attachment manifests itself

within the dyad. The conflicting results found throughout the quantitative papers may

suggest that exploratory research is needed to understand attachment within the dyad.

Indeed, a number of studies suggest observations would enhance this understanding

yet few studies incorporate this. Whilst Ingebresten and Solem (1998) included

observations in their study, they did not comment on how this informed their results.

Including observations, with transparency in the results section, would offer credible

accounts of attachment in the dyad. Furthermore, observational research could

address this within the mid to severe stages of dementia, closing an important gap in

the literature. Furthermore, this could inform caregivers in care home settings and the

community; this seems particularly pertinent as staff caregivers’ attachment style

impacts their response to people with dementia in care homes (Froggatt, Small &

Downs, 2006). Additionally, more exploratory research will aid understanding of

how attachment in staff can impact people with dementia and vice versa. As

Kokkonen, and colleagues (2014) suggest, this could enhance experiences in the care

home setting. This could also open up further areas of research such as creating more

suitable measures for the field. Lastly, future research may also consider carrying out

further replications of studies in order to clarify contradictory findings.

55

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& Mental Health, 14 (8), 928-937.

Perren, S., Schmid, R., Herrmann, S., & Wettstein, A. (2007). The impact of

attachment on dementia-related problem behavior and spousal caregivers' well-

being. Attachment & Human Development, 9 (2), 163-178.

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evidence. Retrieved from http://www.ageuk.org.uk/Documents/EN-GB/For-

professionals/Research/

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development in the context of aging and chronic illness: The role of attachment

in Alzheimer’s disease and stroke. International Journal of Aging and Human

Development, 41, 133-150.

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Part Two: Empirical Paper

How can we understand the attachment process between people with

dementia and staff caregivers: an exploratory study in residential

care

Word count: 9, 903 (excluding abstract, figures, tables, and references)

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Abstract

The formation of secure attachments are important in order to feel safe and secure

when in threatening situations. Dementia has regularly been described as a

threatening situation which causes the attachment system to be activated. Attachment

related behaviours are often seen in the mid to later stages of dementia, and

consequently are relevant within the care home setting. Current literature focusing on

attachment related behaviours between carers and people with dementia focuses on

the influence of attachment styles on each member of the dyads’ experience. There

were several contradictions between the findings of these papers, which made it

difficult to establish how people with dementia and caregivers formed relationships,

and the role that attachment might play within the caring dyads. This was a

qualitative explorative study which set out to explore the attachment relevant

behaviours between people with dementia and staff caregivers in residential care

home settings. Seven staff caregivers for residents in the mid to later stages of

dementia were recruited across two residential care homes. Semi-structured

interviews were conducted, transcribed and analysed using thematic analysis. Three

themes were identified: Creating a home, Forming a relationship and Distraction.

Carers connected the care home with qualities they thought lay at the heart of a home

and family life. Carers and residents built a relationship with each other, which

included a process of learning to trust and being recognised as someone important to

the residents. Difficulties in communicating with residents were also identified.

Carers also used distraction to defuse distress in residents and keep residents pre-

occupied. A care home setting shares many of the features usually associated with

the concept of a secure base in attachment theory. The findings suggest that an

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attachment-focused model of care may be useful to consider across policies,

clinicians and service-levels. Future research is considered.

Introduction

The increase in the number of people with dementia in Britain, in part the

result of gains in life expectancy, has resulted in a pressing need to better understand

how to care for people with dementia (Department of Health [DoH], 2016).

Government prioritisation of addressing the growing prevalence of dementia has

focused attention particularly upon improving dementia care, so that people are well

cared for and encouraged to have independence for as long as possible (DoH, 2015).

Government strategies and policies have increasingly highlighted the needs of the

growing number of people with dementia living in care homes. Approximately one

third of people with dementia live in residential care homes as their needs require a

higher level of care. In recent years attention has been drawn to the quality of care of

such individuals, as it has become apparent that they are more likely to be admitted

into hospitals for health-related conditions related to their care, such as dehydration

(DoH, 2015).

Quality of care is regulated by the Care Quality Commission (CQC), an

independent care regulator of health and social care in England. The CQC have a

number of fundamental set standards used to assess care homes. These are: to

provide person-centred care; to treat residents with dignity and respect; to ensure

consent to treatment is always sought; to prioritise safety when providing care (e.g.

through qualifications and training); to safeguard residents; to ensure food and drink

is provided; to ensure premises and equipment are suitable for care; to establish a

complaints process; to provide good governance to ensure set standards are met; to

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maintain staffing levels and ensure the quality of staff, and to ensure a duty of

candour; to maintain a visible display of care home ratings (CQC, 2017).

Interestingly, these set standards appear to focus on regulations that can be easily

monitored, as they show the outward signs of a good functioning care home.

However, these regulations appear to lack a focus on monitoring what creates a good

quality care home environment. What makes a care home a place that residents with

dementia feel safe and cared for, and want to live in? This aspect of care does not

seem to be fully covered in the set standards, as monitored by the CQC. It is

particularly important to consider how residents feel safe and secure in a care home,

especially in light of recent reports of abuse that have taken place in the care home

setting, such as Winterbourne View (DoH, 2012).

Kitwood (1997) pioneered a person-centred approach to caregiving for people

with dementia. He proposed that there are five psychological components in person-

centred care - comfort, attachment to others, being included, having a connection to

the processes of everyday life and having an identity. These five components relate

to valuing the person with dementia and provide a useful framework for

understanding how to create a safe environment, and home, for people with

dementia. This also highlights the importance of relationships when considering the

wellbeing of people with dementia. This focus on relationships is linked to a growing

interest in exploring the relevance of attachment theory in understanding of people

with dementia and their caregivers. This has expanded our understanding of caring

and the relational processes that take place between people with dementia and their

caregiver. A growing body of literature shows that attachment may be relevant to

establishing appropriate ways of caring for people with dementia (Miesen, 1992,

2006).

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Attachment theory

Attachment theory provides a useful framework for understanding relational

experiences. This theory suggests that an attachment is formed to a security figure in

early life for protection and comfort (Bowlby, 1969). This idea has been extended to

identify specific attachment styles such as secure and the three insecure attachment

subtypes (Ainsworth, Blehar, Waters & Wall, 1978; Main & Solomon, 1986).

Furthermore, Bowlby (1973) extended his theory for experiences across the lifespan,

suggesting that internal working models of attachment inform how we understand the

self and others, and thereby how we relate to others in adult relationships. Bowlby

(1969) also purported that attachment relevant behaviour is heightened in loss or

poor health; situations which are common in dementia.

Attachment and dementia

The research literature suggests that attachment may be highly relevant for

people with dementia. A small body of research has identified that people with

dementia become fixated on their parents (Miesen, 1992; Browne & Shlosberg,

2005; Osborne, Stokes & Simpson, 2010); a phenomenon otherwise known as

‘parent fixation’. Miesen (1998) pioneered research on parent fixation as he found

that people with dementia often call out, or search for, their deceased parent; he

explains that as dementia causes one to feel threatened, it activates the attachment

system so the person seeks safety and security. Furthermore, studies have found that

parent fixation is more predominant in the later stages of dementia (Browne &

Shlosberg, 2005) and is more common in nursing homes than in the community

(Osborne et al., 2010). This suggests it is particularly important to consider

attachment related behaviour for those in the mid to later stages of dementia, and of

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its presence in care home settings. Interestingly, parent fixation is often viewed as

‘challenging behaviour’ in the care home setting (Miesen, 1993). However, Miesen

(1993) has suggested that this, and a number of distressing behaviours shown by

people with dementia such as wandering and crying, could be conceptualised as

attachment related behaviour rather than ‘challenging behaviour’.

Attachment related behaviour has also been found to manifest itself in other

ways within the care home setting. A more recent study observed people with

dementia living in a care home adopting a transitional object as an attachment figure;

residents were seen to call objects, such as a doll or cards, after their own family

members (Stephens, Cheston & Gleeson, 2012). The authors highlighted that the use

of transitional objects in people with dementia may increase with cognitive

impairment as it becomes more difficult to make sense of their inner world. It

therefore seems that attachment related behaviour may be highly relevant for people

with dementia in the care home setting, and particularly for those in the mid to later

stages. Yet despite the relevance of attachment theory in the care home setting, it has

still not been included within Government policies largely because there is limited

empirical work to establish the processes involved. This may in part be due to the

current literature providing more of a theoretical framework to attachment related

behaviour in the care home, rather than exploring empirically how attachment related

ideas may directly influence and direct care. This is important to consider as being

cared for in older age can be seen as a protective role, which complements

attachment ideas (Bowlby, 1980). This seems particularly pertinent when applying it

to the person with dementia and caregiver dyad. Indeed, as caregiving involves

interpersonal processes, it is important to consider how this dyadic relationship

shapes the outcome for both members (Kokkonen, Cheston, Dallos & Smart, 2014).

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Furthermore, Miesen (2006) suggests that how staff caregivers respond to people

with dementia in the care home setting is vital to quality of the caregiving

relationship. Thus, understanding how people with dementia and staff caregivers

interact and form attachments with one another is essential in understanding how to

provide better care in the care home setting.

Literature on attachment in people with dementia and their caregiver

A recent literature review (Edwards, 2017) explored the interactive

attachment dyad between people with dementia and their caregivers. It aimed to

understand how attachment influenced the interactions and experiences of both

members of the dyad. Interestingly, the review highlighted that a very small body of

research considers the interactive element within the dyad, which may be owing to

the complex nature of attachment and the dyad. Across the six papers considered in

the review, five were quantitative and one qualitative. Three themes were identified.

The first theme highlighted that attachment can influence behaviours across the dyad

in either helpful or unhelpful ways, depending on whether attachment was seen to be

insecure (Ingebresten & Solem, 1998; Magai & Cohen, 1998; Perren, Schmid,

Herrmann, & Wettstein, 2007; Monin, Schulz & Kershaw, 2013) or secure (Magai &

Cohen, 1998; Perren et al., 2007). The second theme showed a relationship between

attachment and caregiver burden or distress, again depending on insecure (Chen,

Uzdawinis, Schölmerich, & Juckel, 2014) or secure (Magai & Cohen, 1998; Chen et

al., 2014) attachment styles. Lastly, it was seen that either insecure (Perren et al.,

2007) or secure (Perren et al., 2007; Chen et al., 2014) attachments influence

caregiver wellbeing and satisfaction. Crucially, although the review identified how

attachment may influence the experience within the dyad, it highlighted that many

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contradictions exist across the papers. One study in particular (Nelis, Clare &

Whitaker, 2012) disproved many of the findings from its predecessors. Another

important finding was that the studies had little agreement of how to conceptualise

and measure attachment. Another interesting finding is that much of the research

relates to the earlier stages of dementia, with minimal focus on the mid to later

stages. Yet, as already highlighted, this is essential to our understanding of how to

care for people with dementia in care homes, particularly as those in the mid to later

stages are more likely to be in care due to their level of needs (Alzheimer’s Society,

2017).

Attachment across the dyad is clearly important to our understanding of how

to provide care and respond to people with dementia. Furthermore, attachment

related behaviours in the mid to later stages of dementia is highly evident. However,

the current literature either theoretically informs how attachment ideas may relate to

people with dementia, or how attachment affects responses within the dyad. It

therefore does not provide an understanding of the interactions that take place

between people with dementia and their caregivers, nor does it give a clear

consideration to the relevance of attachment in a caregiving relationship. Thus, the

question of how to create a safe care home environment for the person with dementia

in the mid to later stages remains unanswered. Understanding this is essential for

informing and improving care.

As highlighted by previous research, understanding the dyadic interactions

cannot simply be answered by applying a quantitative approach through the use of

questionnaires or measures. It therefore seems that a more exploratory qualitative

approach to understanding how attachment relevant behaviours between the dyad are

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important to creating a safe caring environment for people with dementia in the care

home setting is needed. Ideally, an observational study would have captured this

more vividly. However as this was not achievable within the time frame of the

project, interviews with staff caregivers in residential care were considered for

gaining their insight into their relationships with residents, in order to develop a

deeper understanding of the interactions, and attachment relevant behaviours, that

take place with the dyad.

Research aim

This study aims to explore the ways in which carers understand attachment

relevant behaviours between the person with dementia and their caregiver in

residential care, in order to consider the relevance of attachment in caregiving within

residential care home settings.

Method

Design

A qualitative methodological approach was used to explore how staff

caregivers in residential care understand attachment related behaviours between

themselves and residents with dementia.

Qualitative data was collected using semi-structured interviews with care

staff who were employed at the care home. Semi-structured interviewing was chosen

as it allowed for a richer and more detailed understanding of the nuances and

processes that take place within the dyad. It also provided the researcher greater

flexibility in adapting the questions according to each participant; if interesting topics

arose that the researcher had not already considered it was explored further. This

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design was also employed as it hoped to find new insights for clinical practice and

future research.

Thematic Analysis (TA)

Thematic analysis (Braun & Clark, 2006) was chosen as a method for data

analysis it is not tied to any theoretical orientation; this allowed for greater flexibility

in identifying themes within each transcript and those which were repeated across

the data set. Alternative methods of analysis were considered: interpretative

phenomenological analysis (Smith, Flowers & Larkin, 2009) was not chosen due to

its emphasis on human experience and the specific meaning each person makes (the

aim of the project was to understand what was happening across participants from a

broader perspective); grounded theory (Charmaz, 2002) was not chosen as the aim

was not to generate a theory.

An inductive approach (Frith & Gleeson, 2004) was adopted throughout

analysis. This allowed for themes to be identified directly from the data rather than

being confined to preconceived ideas of the researcher. A theoretical approach was

not suitable as it restricted ways of understanding the attachment process between

staff and residents. Indeed, the little that is understood between the dyad utilises

ideas from attachment theory; adhering to just this theory would have prevented new

insights being identified. Nevertheless, the researcher’s theoretical orientation

towards attachment theory was made transparent throughout analysis via discussions

in supervision and keeping a reflective audio diary.

Latent content was chosen as part of analysis rather than semantic as the

researcher’s aims were to consider underlying meanings and assumptions whilst

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considering the wider research question, and because this is more broadly used

within constructionist approaches (Braun & Clarke, 2006)

Epistemological position

The analysis adopted a social constructionist approach. This idea posits that

the understanding individuals make for themselves and the wider social system (both

socially and culturally) are constantly interacting with one another to make sense of

meaning (Burr, 1995).

Position as a researcher

As I was naturally drawn to a particular theory and epistemological

assumption, I considered my position within both of these areas. I therefore reflected

on my upbringing, morals, beliefs and personal and professional experiences. This

helped to make transparent my own prejudices and opinions when conducting

interviews and interpreting the data (appendix A).

Ethical considerations

Ethical approval was sought and confirmed by the University of Surrey

Faculty of Health and Medical Sciences Ethics Committee (appendix B).

Consultation with the Service User and Carer Advisory Group was sought

during the development of the original research project (appendix C). This was to

ensure that the participant information sheet and consent form were comprehensible.

Following the revised project, these forms were slightly adapted to incorporate the

new process of interviewing, however the main layout and information remained the

same.

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All participants were informed that they may feel ‘judged’ due to the

questions raised in the interviews. To prevent this a thorough rationale for the

research was provided and an opportunity to ask questions. Participants were also

reminded of their right to refuse consent and told they would not be questioned if

they declined participation. All participants were also given up to one week of

completing the interview to withdraw and thus provided with contact details of the

lead researcher and research team.

All data was kept securely to protect confidentiality. Signed consent forms

were stored in a sealed envelope, locked filing cabinet, in the supervisor’s office at

the University of Surrey. Semi-structured interviews was audio recorded and

transferred on to a password protected file on an encrypted memory stick until

transcribed, after which it was deleted. All data was anonymised during transcription

to protect participants.

Participants were informed that should any risk issues towards residents be

identified through interviewing, or risk from residents to staff caregivers, then this

would be discussed with the care manager and university supervisors. In such cases,

they were informed that confidentiality may need to be broken and safeguarding

considered and that the care manager, university supervisors and lead researcher

would co-jointly make such decisions.

Recruitment

Recruitment initially proved challenging as the care home who had originally

agreed to the study retracted consent when discussing the use of an audio recorder to

record interviews. Residential care homes were thus recruited via the website

www.carehomes.co.uk. Care homes that provided dementia care in the South of

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http://www.carehomes.co.uk/

England was searched and the lead researcher made contact with care managers via

telephone. Non-probability sampling, specifically convenience sampling, was used to

recruit care homes and staff. This sampling method was chosen due to time

restrictions of the project. However, whilst this sampling method could shape the

data somewhat, the purpose of the project was to provide further insight in to an

under-represented research area. Additionally, the purpose of the study was not to

make generalisable claims but to gain a more meaningful insight in to the attachment

relevant behaviours in the care home between the person with dementia and

caregiver, and to consider the relevance of attachment to caregiving.

Care managers who agreed to the research were emailed participant

information sheets (appendix D) and consent forms (appendix E) to read and were

given further information of the project. Care managers informed staff of the project

at team meetings and asked members of staff who wished to participate to inform

them. The care manager arranged times for interviews to take place with staff

members. The researcher met with the care staff, provided them with the participant

information sheet and consent form, and discussed the project in detail. Any

questions that participants had were answered. Recruitment closed when seven

interviews had been arranged and completed.

Participants

Staff caregivers were recruited for semi-structured interviewing across two

care homes, both of which were located across the South of England. This number of

participants was considered acceptable based on the chosen data analysis (Braun &

Clark, 2013). All staff caregivers recruited were employed to care for those with

dementia in the mid to later stages.

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Of the seven participants, all were female (n = 7), one was a care manager (n

= 1) and six were carers (n = 6). Two of the participants were European (n = 2), five

were non-White (n = 5) and six staff were non-native English-speakers (n = 6). This

was considered a homogenous sample as all participants had a role for caring for

residents with dementia in the United Kingdom. Although homogeneity of

participants could be argued against, this range of carers was in line with a thematic

analysis approach as it provided a broader perspective of understanding the

attachment process between staff and residents within the staff caregiving role.

Although the care homes recruited cared for people across all stages of

dementia, staff were advised by the care manager and lead researcher to reflect on

their care for those in the mid to later stages of dementia only.

Interviews

Interview schedule. An inductive interview schedule was devised via

discussions with university supervisors and a care manager from a residential care

home to people with dementia in the South of England (appendix F). Questions

addressed caregivers’ understanding of the person with dementia including their

attachment experiences. It also addressed caregivers’ reflection of their own

attachment experiences and how they thought it impacted the dyadic interaction.

Process. Participants were interviewed on the care home premises; a spare

room in the care home was used to conduct the interview. Following the lead

researcher discussing the project in detail, participants read through the participant

information sheet and completed the consent form if they wished to continue. The

interview schedule acted as a guide for all interviews which provided some

consistency across interviews. Prompts aided the researcher to probe for further

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detail during interviews. Interviews were audio-recorded and ranged between 37 and

62 minutes.

Analysis

The six stages of thematic analysis by Braun and Clarke (2006) was

followed: (1) The researcher transcribed the interviews verbatim to immerse

themselves in the data by repeatedly reading the data, and noting interesting ideas

(appendix G). Additionally, case-by-case analysis was used to produce an

understanding directly rooted in the experience of staff caregivers and their

understanding of people in the mid to later stages of dementia. Pseudonyms were

given to protect confidentiality. (2) An initial coding framework was then developed

by pasting the data from each transcript in to separate tables (appendix H) and coding

meanings. This started the process for stage three. (3) The initial codes were then

grouped in to potential broader themes. This guided thinking around how the

different codes fitted and related to one another, thus creating overarching themes.

This also aided in developing the thematic map (appendix I). (4) Potential themes

were then reviewed within supervision. Themes which had little supporting data

were removed, some themes were collapsed together to provide a more coherent

theme and others were broken down further. This aided the development of the

thematic map (appendix J). (5) Themes were named and defined so that the data was

transparent and clear. (6) The themes were written up and discussed in supervision to

ensure it produced a clear narrative.

Credibility

Credibility was informed by Yardley’s (2000) four principles necessary for

good quality qualitative research: (1) sensitivity to context of the research area was

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developed through understanding and critiquing the literature surrounding the topic

of study. Additionally, understanding of the socio-cultural setting of the study was

developed through familiarisation of the Care Quality Commission Standards that

care homes are required to meet; this external social pressure was likely to have

shaped carer responses to the research question. These ideas were discussed in

supervision to help with reflexivity; (2) commitment to the process of analysis was

undertaken by immersion with the data and by regularly checking that themes related

to the full context in which the data was situated. Rigorous analysis was maintained

via weekly discussions with supervisors; (3) transparency was maintained by

detailing all aspects of the data collection process and discussions in supervision; (4)

the impact and importance of the research was addressed by discussing the need for

this research and its implications on the wider social context of government

initiatives, specifically care for people with dementia within this paper.

Reflexivity

The researcher kept a reflective diary whilst completing the interviews. This

was recorded on an audio recorder as soon as an interview was completed and re-

listened to a few times to consider thought processes. This aided in the researcher’s

awareness of their assumptions and also in further discussions in supervision

throughout the data collection and analysis process.

Results

Three major themes were identified within the data, each consisting of a

number of subordinate themes. These themes are illustrated in Figure 1 of the

thematic map and will be described in detail below, alongside the use of quotes for

illustration. Some quotations were shortened using ellipses for more succinct

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examples. Each theme captures the essence of what participants were saying about

how they relate to the residents and how they perceive residents relating to them.

Figure 1. Thematic map

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Creating a homeWe are all part of a

family

A home allows the individual freedom

A home is a place of safety

Creating a sense of belonging

We are like the caring parent-figure

Forming a relationship

Residents learning to trust Building bonds with

residents matters

Communication can be challenging

Creating a home

Creating a home was an overarching theme that encompassed five subthemes

that connected the care home with various qualities that they felt lay at the heart of

the concept of home; qualities that might be associated with a more typical home and

family life. This included ideas that a home is a place of safety and security; a place

of belonging where you would be cared for and your needs would be met as if you

were part of a family, and where you would have a sense of freedom and

independence in order to pursue lifestyle choices.

We are all part of a family. Many of the participants talked about the

residents as if they were their own family members. Participants talked about

wanting to help residents feel that they were part of a family because they were

saddened by their beliefs that residents were unhappy to be away from their own

families:

“…I think they miss their family, may be sometimes they don’t understand

why they here and they are, because even they asking, ‘I go home?’

sometimes, you know resident, ‘I go home?’, one resident all the time she’s

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DistractionDiffusing distress in the residents

Keeping residents preoccupied

saying ‘I go home?’ and we explain to her ‘you’re at home, this is your

home, this is your family, this is your everything, and you where do you go?

You’re at home’…” (Participant 4; lines 323-329).

“…because they no family, they come to this home – we are their family we

have to support them, we have to, I can’t talk [tearful – wipes tears]”

(Participant 5; lines 257-259).

One participant spoke about feeling empathy with residents because she herself was

away from her family and missed her Mother. She talked about the way a

relationship with the resident fulfilled her own needs to ‘belong’ as well as meeting

what she perceived were the needs of the resident:

“it made me feel a little bit better, a little sad, because they know that they

need their family, so because you’re here as a staff, you are their family you

have to make them feel like they are your family. Sometimes I did ask them

“would you be my Mum?...because they missing their children…the same as

I miss my Mum, I miss my Mum for many years I haven’t seen, so the same as

how I feel the way they feel, so I offer myself ‘will you be my Mum?’”

(Participant 7: lines 383-394).

Another participant described feeling pleased that a resident was interested in her life

and connected this to how she considered family members to communicate:

“…Joy [resident] asking me ‘how are you?’ she asks ‘how are you today?’

she finally it’s nice asking staff how are you…I feel good er because she, she

know what she what question she ask you, she know she want to know about

me too not just erm about her…like I’m talking with you now and she feel like

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she is like err family member and she asking me - I asking her.” (Participant

4; lines 307-319).

A home is a place of safety. It was important to carers that residents knew

they were in a secure environment; that they were safe in their home and had no need

to be afraid or upset, regardless of whether the carers were with them or not with

them:

“yeah they err, people with dementia they are they worried quite often”


“oh they feel so sad, neglected, they feel neglected and they even start

crying…” (Participant 7; lines 565-566).

“…sometimes we have to make them know that they are in the safe place

because sometimes they don’t think that, that, may be that place is not safe

for her for them or anything, so we as a carer we have to make let them know

that that ok, they’re in a safe place there’s nothing that will happen anything

happen to them” (Participant 3; lines 543-548).

“erm, but it it’s yeah, that’s how I actually you know, kind of getting the

balance right, I’m not here all the time so it’s actually establishing the trust

to feel that you know, that place that she’s in somewhere safe and secure,

even if I’m not here.” (Participant 2; lines 186-189).

Participants who described wanting to create a safe environment often

described the distress that residents experienced in the care home. One

participant openly stated that residents were often worried, whilst many

described how their distress looked.

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A home allows the individual freedom. Part of creating a home involved

letting the residents make choices about their lives and activities as if they were in

their own home. This was seen as providing a sense of autonomy that is essential to

‘feeling at home’:

“…may be she think that is her own home, this is, she going to pay the bills,

she can’t pay the bills, that’s why she doing this – turn the lights [off], turn

everything, turn the microwave turn the toaster everything…but sometimes

we ask, sometimes we asking her to ‘please can you put the light on?’ she

says ‘no’. Then after second time ‘yeah’, she put the light on and I ask ‘we

have to use the microwave can you put the switch?’, she er doing it now.”


“yeah, she can do what she wants and she have agreed with somebody ‘no’

or ‘yes’, I think they, this talk with them and give them choice help them feel

they’re not forgotten, not er, becoming down and, normal, living in house, in

their house.” (Participant 4; lines 285-288).

Sometimes residents were reluctant to experience the opportunity of choice, but with

support and by allowing them space to decide, they often changed their mind:

“yeah yeah, yeah when I hold her hand and I ask I her if she want to and she

said to me, urm, ‘may be later, not now’… so when I come back second time,

so she allowed me to do it.” (Participant 3; lines 79-80 & line 99).

Creating a sense of belonging. Participants frequently spoke about the sense

of belonging that helped create a feeling of ‘being at home’. This involved carers

making particular effort to know and understand the residents as an individual,

learning about the residents’ background so that they knew their likes and dislikes

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and their life stories. This allowed them to respond in ways that connected directly to

the individual:

“...we have er, a care plan…we have a life story and then when they admitted

to the home, we tell them ‘bring their life story’ then we go through the life

story, and then we understand all the every, each and every resident how they

are past – what they did, what job they did, what they like, dislike.”


Another way of creating a sense of belonging was through using the residents’

language and sense of humour. For example, where a resident kept referring to a

specific sum of money, the carer used the same phrase in talking with her:

“…I sort of do her thing, ‘I’m going to charge you 50 thousand’ and she

[resident] go ‘50 thousand that’s too much!’ [laugh] yeah and we have this

kind of banter…” (Participant 2; lines 620-622).

Participants also connected with the residents by joining in on activities together. In

doing all of this participants entered a shared world with the residents, which

reinforced a sense that they were ‘known’ in their home:

“I just changed the music and put the music on, and then normally we just

start when they are sitting down you can dance, just like dancing with them,

then she starts putting her hands up and starts dancing with you…and then

after that she will be just lovely.” (Participant 1; lines 200-205).

We are like the caring parent-figure. Another common way of talking about

family relationships, was likening residents to children in need of care and

themselves to the parent-figure:

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“…and then I make her ready, put the bib, put the everything ready and

[say] ‘can you open your mouth? I bring your food - it’s try, nice or not? Hot

or warm or not warm or cold? How do you like this?...feeding like child by

spoon, she bite, she swallow and again, ‘are you ready to next spoon? Are

you OK? Are you swallow?’”. (Participant 4; lines 614-623).

“…just like you’re looking after the baby, when you look after the baby she’s

tantrum tantrum and then if you follow their tantrum she keep doing it all the

time you know, but it’s just like clients with the dementia…” (Participant 7;

lines 179-182).

There were a number of different ways in which participants put themselves in the

role of a caring parental figure. Participants described frequently checking if they

were OK by asking and by observing to ensure they were safe:

“we feel she’s not safe because she walking and we observe her all the time

because she’s not safe[ty].” (Participant 4; lines 403-404).

“…so you have to keep reminding her that ‘Mary, you can keep walking with

the zimmer frame because we are holding you so you’re not going to fall

down.’” (Participant 3; line 573-575).

Participants described helping residents to start an activity and then stepping back to

let them continue while being nearby to encourage or help if they needed someone to

intervene, in the way a parent might encourage a new activity:

“…and sometimes you have to start with someone to start feeding the person

then they can continue on their own or just reminding them the spoon is

there…” (Participant 1; lines 554-556).

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They also spoke about the importance of reassuring and soothing both verbally and

non-verbally:

“… I normally sort of say, you know, ‘I’ll come and check on you again.’”


“… I’ll tend to so to kind of stroke her back as well and actually help helping

her to stand up will be by sort of, kind of, sort of you know, holding her so

she can kind of do most of it by herself, it’ll be the real, it’ll be touching her

back kind of that kind of, reassuring” (Participant 2; lines 378-382).

Forming a relationship

Much of the data focused on the relationship between carers and residents;

specifically how these relationships were built and where the challenges lay in

keeping them going. Part of building a relationship included a process whereby

residents learned to trust carers as their familiarity with carers grew. Connections

were established through displays of affection, or becoming recognised as someone

important to the residents. Another component of relationship formation between

carers and residents involved challenges that carers encountered when

communicating with the residents. This theme was organised in to three subthemes:

Residents learning to trust. Participants described a process of learning to

trust. There was a recognition that residents would respond to, and wanted to be

cared for by someone more familiar compared to someone they did not know:

“I don’t know, maybe she feel not secure enough or, I don’t know. Or maybe

she wasn’t, because I’m I’m the new staff, she don’t know me know much like

the other old staff.” (Participant 3; lines 83-85).

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“…she wouldn’t have allowed the district nurses to kind of attend to her if

I’m not around, and even I am around and she doesn’t like the person that

doesn’t get, you know that doesn’t happen…” (Participant 2; lines 539-541).

This was evident in physical displays of affection and in overt dependency on

specific carers:

“…they attach to you, they may be they think that they’re attached to, that’s

why they take the hand and kissing, kissing…I just, ah, oh how nice it is nice

that I, just make me cry that’s all [tearful, wipes eyes]…because we are also

someone they like…” (Participant 5; lines 240-248).

“…sometimes she’s holding your hand, she’s holding my hand and going to

say ‘are you going to be with me all day?’ and I say ‘yes just let me know

what you need’”. (Participant 7; lines 226-228).

Building bonds with residents matters. Participants were often conscious of

the importance of their role in forming a bond with residents. A common way that

carers described forming a relationship was through perceiving residents’ ‘special

connection’ to them as individuals. This made carers feel acknowledged and special

to residents. Other participants spoke about feeling more fond of particular residents,

suggesting that there were some they liked more than others. Interestingly, one

participant quickly corrected herself after suggesting such a perspective since it was

not deemed appropriate to have favourites:

“…I want them to be happy, to be in good mood to recognise that I’m also

here you understand? It’s also self-recognition…that when I come in I want

them to say ‘oh she’s here, she’s here, maybe it might be different’…”.


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“…I have an attach with the residents; I love them to bits, you know

especially when I’m going and feel like they don’t want me to go, but I have

to tell them ‘I work all day, I am tired, I’m coming back tomorrow…’.”


“yeah I think so, I mean, yeah yeah probably, especially her I don’t – did I

say especially her? (smile) – I don’t like her sort of being kind of quite

distressed actually” (Participant 2; 1011-1013).

Communication can be challenging. Unsurprisingly, there were many

challenges in knowing how to communicate with the residents. Many of the residents

had difficulty with – or no use of – language, making it difficult to understand how

the residents were feeling. They depended on an uncertain communication through

trial and error:

“half of our residents don’t actually have the language skills, you need

someone who is able to pick up on the nuances, pick up on, who can actually

kind of say ‘OK, that person cannot happy with this…” (Participant 2; lines

857-860).

“…I wish if you could switch sometimes to see what is exactly up and then

you would know how to deal with it but it’s just trial and error.” (Participant

1; lines 326-328).

Additionally, one participant described a feeling of frustration due to residents

frequently changing their mind regarding what they wanted. In this instance it was

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easy to become impatient; nonetheless, the participant recognised the importance of

suppressing these feelings since residents’ moods were so variable:

“I took the cup cos she pushed it away so I take it and put it away…then I

continue to give everyone. Now everyone is holding their cups of tea and

she’s looking like and she said ‘where’s my cup of tea dear?’…and you

thought ‘ah for goodness!’ where it’s like sometimes that’s what I said – you

have to snap out of it quickly cos they can sort of come in to your face and

then within a few minutes it’s just a smile all over again.” (Participant 1;

lines 490-501).

Distraction

While talking about the relationships within the home, and building of bonds,

participants also talked about how they drew on different techniques in order to help

them manage some of the difficulties in residents’ behaviour. They frequently

described residents feeling upset or distressed for various reasons and wandering

around the care home, crying or agitated. To help manage this distress, participants

described distracting residents to divert their attention away from being upset. This

commonly involved giving the residents food and drink, staying with them longer

than usual or suggesting activities. Another function of distraction was to keep

residents from being bored or restless. In such cases, participants described using

more light-hearted ways of interacting with residents to keep them preoccupied and

lift their mood. Within this overarching theme of distraction there are two subthemes;

one focused on defusing distress and the other on keeping residents pre-occupied to

prevent distress.

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Defusing distress in the residents. When participants observed the residents

feeling distressed they sought to defuse distress by diverting their attention.

Strategies included offering food and drink, encouraging them to sit together or

suggesting a favourite activity. By providing choices of food or activities,

participants helped residents to shift their attention away:

“I just say ‘any one for tea?’... she sat down had a cup of tea and then, and

then we just started talking to her to distract her from whatever sort of is

happened before.” (Participant 1; line 85 & lines 150-152).

“yeah so after the food she was wandering and I said ‘Anna, look at look at

me, you want a cup of tea?’. So I give her a cup of tea she agreed to, so I give

her tea, so she sit back down and after she fell asleep in her chair [laugh]”


“distract her because she’s crying and sad, it we making, if she play piano

she be happy, and then we go sometimes asking ‘you want to teach me

piano?’ then she says ‘yes, one day I will teach you.’” (Participant 6; lines

616-618).

Interestingly, one participant explained that distraction was not always useful in

defusing distress. On such occasions the participant left the resident to calm down

alone but continued to watch her in order to make sure she was OK:

“and when you try to even, when I try to call her, ‘Anna, relax, come and

have a seat; you’re going to have your food now’, she start [saying] ‘I’m

going to my Mum, I’m going to see my Mum, leave me alone’…I was leave, I

watch her, make sure she don’t hurt herself but I leave her alone to calm

down…” (Participant 3; 309-318).

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Keeping residents pre-occupied. Two participants repeatedly described

residents being bored or not having much to do. In response, carers used distraction

in ways which appeared to be jovial, entertaining and fun for the residents. In doing

so, residents were able to engage more with the carers and have a more meaningful

day. Here also, distraction had an additional function; whilst helping residents have a

better day, it also served to ensure a more manageable shift for carers:

“I want to do something like that, I want to make them happy, that is the only

way, otherwise they only pick up a cup of tea and drink it, that’s not

enough…er, important to me, er that the jobs going to be smoother, easier,

they are happy, they are awake, they can eat and drink properly…”


“I think some people need some work, she need they need they before they

did something like that, if it’s sitting down eating not enough, they they want

to do something…” (Participant 5; lines 339-341).

“she also happy when she concentrate at work sometime, she same person

[previously explained resident used to work at a restaurant], we have to give

more serviette she folding nicely nicely keeping it like that like that, giving

different colour, folding nicely, putting there, I think then I know this person

like that we need to distract her manners like this she’s happy” (Participant

5; lines 332-336).

“when I come in they tend to I do I make them laugh a lot, I try to make them

laugh a lot… I think laughing is healthy, you know that someone at least for

that moment, someone is not depressed or down” (Participant 6; lines 335-

339).

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“I just feel, I don’t feel, I feel may be there’s something is lacking there might

not be something lacking but I think noise is good, at least with noise you can

tell who is happy, you can tell, but when everybody is just seated looking you

can’t tell who is happy, you can’t who wants that or who wants, sometimes

they even tell me ‘oh there was a party downstairs’ and it was in the morning

they say ‘oh you remember we had a party last night when it was just

dancing and music?’” (Participant 6; lines 456-463).

“it also make my work easier, I don’t know for some reason when I’m here I

tend to dance a lot…yeah because I know it makes them laugh” (Participant

6; lines 411-415).

Discussion

As the current literature either theoretically informs us about how attachment

ideas may relate to people with dementia in a care home setting, or how attachment

affects responses between the dyad, there was insufficient evidence to understand

how interactions between people with dementia and staff caregivers take place in the

care home setting. This study set out to explore carers’ understanding of their

interactions with residents in the care home and their relationships with the residents,

in order to consider the relevance of attachment to the caregiving relationship. Three

major themes were identified: creating a home, forming a relationship and

distraction. Within each of these themes there was a common thread of carers

communicating to residents that their needs would be met, they were available for

residents, and staff would take care of them. The findings from this study suggest

that a care home setting shares many of the features usually associated with the

concept of a secure base in attachment theory (Bowlby, 1969). Key findings of this

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study, which have relevance for attachment theory, include themes regarding the care

home as a ‘home’ and this was considered as a place of safety, where individual

freedom was possible, a sense of belonging was created, and carers were relating to

residents as though they were family members and could be cared for as though they

were parent-figures. Alongside this, themes emerged that suggested a relationship

was formed between carers and residents; residents went through a process of

learning to trust and carers made a conscious effort to build bonds that mattered with

the residents. Within their relationship, communication was challenging, which led

carers to find alternative ways to understand how to best support residents. Despite

carers’ persistence in trying to understand what residents wanted, caring for people

with dementia in the mid to later stages fostered an uncertainty in carers; carers

described having to ‘guess’ what residents wanted or needed through a process of

trial and error. In addition, carers often employed strategies to manage difficulties

that arose when caring for residents. The strategies were used to distract residents

from any distress they were feeling or to keep residents pre-occupied. These

strategies, while interesting, have less relevance to attachment theory and will

therefore not be the focus of this discussion. In brief, themes emerged that suggest

that carers believed that they were regarded as available, constant and providing

containment for the residents.

Some themes appeared to map on to the particular features of attachment

styles. Specifically, a secure attachment suggests that others are safe and reliable,

allowing the individual the freedom to explore and learn whilst feeling contained

during unsettling experiences (Bowlby, 1969). The themes highlighted that

caregivers created an environment that was likened to features within a secure

attachment, and a secure attachment base. In the theme ‘creating a home’ carers tried

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to create an environment that was safe for the residents, where any distressing

feelings would be contained and their needs would be addressed. Carers encouraged

individuals to make choices, which provided residents a sense of autonomy and

independence; further, when residents did not want to make a decision, carers

allowed residents the space to decide, which often led to a change in mind. These

ideas relate to attachment theory as the secure figure allows the individual freedom

and space to make decisions, whilst also making it known that they will remain

available. Carers created a sense of belonging for the residents, by making them feel

‘known’ within the home. In doing so carers felt they were offering a home

environment where they could relate to one another like family members. Carers also

became like a caring parent-figure to the residents whereby they repeatedly checked

and observed that residents were content. Carers also communicated safety to

residents verbally, and importantly, non-verbally; such ways communicated residents

were being soothed and reassured.

Within the theme ‘forming a relationship’, some features of an insecure

attachment style were identified. An insecure attachment can be characterised as a

lack of trust towards others (Ainsworth, et al., 1978; Main & Solomon, 1986). This

appears to have been seen within the subtheme ‘residents learning to trust us’; here,

residents mistrusted carers initially, if caregivers were unfamiliar to them. Residents

also seemed to show anxiety when familiar caregivers were not present and strangers

were present, echoing some ideas from the strange situation procedure (Ainsworth et

al., 1978). For example, residents showed anxiety when external nurses were present.

However, carers were seen to respond in ways that continued to model a secure base

to residents. What is more, reciprocal attachment bonds were formed, which may

have partly been due to carers modelling a secure base. Thus, both members of the

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dyad communicated a relationship which demonstrated a sense of being loved or

wanted, such as through residents showing physical displays of affection to carers, or

carers interpreting their relationship with residents as important. This idea also

relates to Miesen’s (1993) findings that people with dementia are more settled when

around those they feel safe with.

The findings from this study also suggest that, at least from staff perspectives,

the care home setting may be considered a place to create a secure base for residents

– suggested by the carers under the theme ‘creating a home’. Though not explicitly

stated, this is in line with the National Institute for Health and Care Excellence

(2013) quality standards, which outline ten statements of care for people with

dementia. Specifically, three statements seem to be reflected in the identified themes:

1) ‘to give people with dementia choice and control in making decisions’ was seen

under the theme ‘a home allows the individual freedom’ as carers provided choices

for residents to make decisions; 2) ‘ensure meaningful activities are provided for

people with dementia’ was seen under the theme ‘creating a sense of belonging’, as

carers learned about residents’ life stories to educate themselves of their likes and

dislikes; 3) ‘support people with dementia to maintain and develop relationships’ was

seen more broadly across the themes ‘creating a home’ and ‘forming a relationship’.

Through using these quality standards of care, it showed that people with dementia

were able to live a more meaningful life which appeared to enhance the attachment

relationship between residents and carers. It also seemed to suggest that utilising

attachment ideas when caring for people with dementia may be important in a

residential care home setting.

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Interestingly, Vygotsky’s (1978) theory of Zone of Proximal Development

resonates with the subtheme ‘we are like a caring parent figure’. Carers described

teaching residents the beginning stages of an activity (e.g. eating) and then stepped

back to allow them to continue the activity alone, staying nearby to encourage or

offer help if needed. In doing so carers were seen to scaffold residents’ learning and

facilitate independence. This finding may indicate that in some instances, residents

are able to take back some control of activities of daily living when given

encouragement and support. This appears to support the idea that carers worked in a

way consistent with ideas related to attachment, as they were fostering a sense of

being taken care of and nurtured. However, although this behaviour that fits with the

Zone of Proximal Development was described, no interview made any reference to

this theory, and it is unlikely that their understanding of this way of supporting

residents was directly informed by the theory. This is intriguing in that providing

staff with some knowledge of such a theory may be helpful in further developing this

way of supporting residents to manage more challenging activities.

The findings appear to suggest that ideas related to a secure base and secure

figure (Bowlby, 1969), fit well with carers’ understanding of good care, and may be

useful in developing an attachment-focused model of care. Based on the findings,

such a model seems to incorporate ideas around carers communicating to residents

that they are available for them, residents were safe and ‘known’, facilitating

independence through choice and becoming like a caring parent figure who may

scaffold learning experiences for residents. An attachment-focused model of care

may also include ideas relating to the relationship between caregivers and residents.

For example, though residents may display some insecure attachment behaviours, it

would be important for staff to continue modelling securely attached ways of

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relating, as detailed above. However, it must be said that this suggestion is based on

carers reports of their understanding of the way good quality care is facilitated. This

study did not assess the impact of this approach to care directly.

Clinical implications for Clinical Psychologists

A number of clinical implications may be taken from this study. It seems that

an attachment-focused model of care may be useful to consider across policy

making, clinician and service level. Regarding policies, the British Psychological

Society (BPS) outline that psychosocial interventions for people with dementia

should be used to manage psychological and behavioural distress (BPS, 2013). These

psychosocial interventions are based upon the ‘unmet needs model’ (Cohen-

Mansfield, 2000), which suggests people with dementia become distressed as they

can no longer independently meet their own needs, and so their needs are left unmet.

However, this study highlights an attachment-focused way of caring may also be of

use for people with dementia. As highlighted, this would include carers responding

to residents in ways that communicate a safe base. Clinically, this study is of benefit

to psychologists working in older people services. Specifically, psychologists who

are part of challenging behaviour services for people with dementia could consider

more integrative formulations which draw upon ideas of attachment. Psychologists

could also consider attachment-focused interventions for people with dementia in

residential care homes. It is also worth considering the relevance of attachment

theory in training staff in care homes.

Secondly, the findings may relate to ideas of continuity of care for people

with dementia. The King’s Fund (Freeman & Hughes, 2010; The King’s Fund, 2012)

highlights that an important component of continuity of care is ‘relationship

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continuity’. This suggests that having a professional healthcare worker whom one is

familiar with and has known for some time, is important in creating trust, instilling

confidence and cultivating a sense of security for patients. Although this publication

(The King’s Fund, 2012) has been created for the general population, based on the

findings from this study it may have particular relevance for people with dementia.

Indeed, participants in this study believed it was important to build a relationship

with the residents, which included getting to know residents. Residents were

described as more willing to allow carers to help them if they were perceived to be

more familiar. Though this was a small study, it appears to suggest that continuity of

care could be considered in the care home setting. Care managers of residential

homes may consider how best to create continuity of care for residents. They may

also wish to consider how employment of new staff could create an unsettling

situation for residents and how to support staff in creating a ‘safe’ relationship with

residents.

Thirdly, the CQC (2017) informs that care homes should be meeting certain

pre-determined standards of care. However, participants from this study have

suggested that other aspects of care, that do not form part of the pre-determined

standards, are also important for care. For example, creating a home that feels safe,

provides choice, creates a sense of belonging and where carers scaffold learning,

seem to be suggested as important standards of care by the participants. Interestingly,

a recent article (Redmond, 2017) highlighted that the CQC has not fully addressed

the basic care needs of individuals when carrying out regulation checks, such as

services creating a home environment and providing choices to those in care (e.g.

what clothes they would like to wear). Importantly, these basic care needs seem to be

part of our most basic human needs (Maslow, 1954), i.e. safety, and a sense of love

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and belonging. This study suggests that governing bodies may wish to consider how

people with dementia experience safety and a sense of belonging in the care home.

Limitations

To my knowledge, this study was the first to explore staff caregivers’

understanding of attachment-relevant behaviour towards residents with dementia,

and their understanding of the relationships in the care home setting. Whilst it has

provided insights that would not have otherwise been uncovered, there are a number

of limitations.

This study asked participants to discuss their care of those with dementia in

the mid to later stages only. This limits whether the findings can be extended to those

caring for people in the earlier stages of dementia. Furthermore, during the

interviews it became apparent that some participants were describing residents in the

earlier stages of dementia, which was confirmed by participants during the interview.

Whilst participants were reminded that the focus of the research was on residents in

the mid to later stages, it may have still been difficult for carers to distinguish

between residents in the earlier to those in the mid to later stages of dementia. Thus,

it is unclear whether the findings are wholly representative of people in the mid to

later stages of dementia. Furthermore, participants cared for residents in the early

through to the more advanced stages of dementia, and were informed at the

beginning of the study to only focus on residents who were in the mid to later stages.

As this focus wavered, it may have been more useful to initially identify the residents

in the mid to later stages.

The participants of this study were ethnically diverse, and while they could

converse in English it was not their first language. This created some difficulty in

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communicating with carers and at times, answers given suggested a

misunderstanding of the initial question. Additionally, it is of clinical significance

that carers who spoke of a strong sense of a family were mainly from non-

Westernised countries; different cultures may place more or less emphasis on being

‘together’ or being more autonomous. Given the wide diversity of cultures and

backgrounds of participants, there may have been cultural expectations placed upon

caring thereby shaping the findings of the study.

Lastly, the study relied on staff perceptions of their relationship with

residents, and how they interacted with residents. However, this is subject to social

desirability bias as carers may have been answering questions either according to

what they think was right, what they thought was the right answer or in ways that

protected the care home. However, all participants spoke openly in their accounts,

and one participant displayed an emotional connection to residents. This gave the

researcher reason to believe that participants spoke honestly in their accounts.

Future research

Alongside addressing the above limitations, future research could carry out a

focused ethnography in the care home setting of people with dementia and

caregivers’ interactions. Observations could be the main method of data collection

alongside conversations with staff to supplement observations. This would capture

the experiences of both members of the dyad. It would be an important contribution

to the field as people with dementia’s perspective – particularly within the mid to

later stages of dementia – is often missed in research.

Future research could also look at the effectiveness of attachment-focused

interventions for people with dementia who display behaviour that challenges.

99

Attachment-focused interventions may consider ideas from attachment theory, such

as promoting ways of soothing individuals.

Qualitative research could also be used to explore attachment relevant

behaviours or ways of relating for people in the earlier stages of dementia. This

would not only help to include an understanding of the attachment process for those

in the earlier stages of dementia – which would be of benefit to services – but would

include the perspective of people with dementia rather than relying on proxy

information which is not truly representative of people with dementia.

Conclusion

In conclusion, this study set out to explore carers’ understanding of their

interactions with residents in the care home, and their relationships with the

residents, in order to consider the relevance of attachment in caregiving. The analysis

demonstrates that the way in which carers described relating to residents with

dementia in the care home is consistent with some aspects of an attachment

approach. Although this is the first and a small study showing the relevance of

attachment in the care home setting for people with dementia and their caregivers, it

is worth further exploring ways that clinicians, services and policy-makers may wish

to consider care for people with dementia that look to make the person feel safe,

secure and that their needs will be taken care of. Further research should aim to

explore the experiences of attachment relevant behaviour in the care home for both

members of the dyad and consider attachment-focused interventions to care.

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List of Appendices to the Empirical Paper

Appendix A: Position as a researcher – removed for E-thesis

Appendix B: University of Surrey Faculty of Health and Medical Sciences Ethics

Committee Ethical Approval

Appendix C: Service User and Carer’s Advisory Group form – removed for E-thesis

Appendix D: Participant Information Sheet

Appendix E: Consent Form

Appendix F: Inductive interview schedule

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https://www.kingsfund.org.uk/blog/2012/03/why-continuity-care-crucial-patients

https://www.kingsfund.org.uk/blog/2012/03/why-continuity-care-crucial-patients

Appendix G: Initial ideas on transcript (pages 1-5)

Appendix H: Example of tables of codes

Appendix I: Thematic Map

Appendix J: Revised Thematic Map

Appendix A: Position as a researcher (removed for E-thesis)

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Appendix B: University of Surrey Faculty of Health and Medical Sciences

Ethics Committee Ethical Approval

109

Appendix C: Service User and Carer’s Advisory Group form (removed for E-

thesis)

110

Appendix D: Participant Information Sheet

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PARTICIPATION INFORMATION SHEET

Project TitleHow can we understand the attachment process between people with dementia and staff caregivers: an exploratory study in residential care.

InvitationMy name is Laura-Lee Edwards and I am a trainee Clinical Psychologist conducting research as part of my doctorate in Clinical Psychology, based at the University of Surrey. Taking part in the study is entirely up to you. Before you decide I would like you to understand why the research is being conducted and what it would involve for you. I will go through this information sheet with you to help you decide whether or not you would like to take part, and to answer any questions you may have. This should take about fifteen minutes. Please feel free to talk to others about the study if you wish.

What is the purpose of the study?When in the mid to later stages of dementia a person’s inner world increasingly feels more uncertain and insecure. Because of this, moving in to a residential care home can be a challenging experience to manage. There are lots of new relationships with care staff to develop. The person with dementia may begin to express a form of “attachment” to staff caregivers to feel safe and secure. Staff responses to this can affect how the person with dementia experiences safety, and also affect how they (person with dementia) respond. This is why you have been invited to take part in this study – the purpose is to understand the “attachment” behaviours people with dementia may be trying to express to you in the care home.

Why is the research being conducted?Current research suggests that people with dementia develop behaviour that is perceived as challenging. As such, services are currently shaped by managing “behaviour that challenges”. Yet some research suggests that this behaviour may also be the person trying to seek safety from others. Additionally, this behaviour does not have to be challenging - it can sometimes be positive or even neutral. This behaviour is otherwise known as “attachment”. The “attachment” system affects both the person with dementia and their caregivers. This research aims to explore and further our understanding of the “attachment process” between the person with dementia and their caregivers. This hopes to add to our knowledge of better understanding and supporting people in the mid to later stages of dementia.

Why have I been invited to take part?As a staff caregiver I would like to hear how you experience the interactions in the care home and your understanding of this for both yourself and the person with dementia.

What does taking part involve?I would like to carry out a semi-structured interview with you. I’d like to meet

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with you for roughly one hour to ask you questions and explore your experience of interactions with the residents who are in the mid to later stages of dementia in the care home. You will be asked about what happens in those interactions and what you think is happening in those interactions. The interviews will be audio recorded.

What are the possible disadvantages or risks of taking part?I do not expect anyone to experience any risks in taking part. You might feel that you are being quizzed or judged about your work but this is not the aim of the research. I just want to get a sense of the interactions that take place between yourself and residents.

What are the possible benefits of taking part?I hope that this will raise even more awareness in your understanding of your interactions with residents, which could help to further enhance the care you give. You could also be contributing to deepening our understanding of the needs of people with dementia, which can be so easily misunderstood. This will hope to support services, and caregivers, to better meet the needs of people with dementia in care homes.

Do I have to take part?No, you do not have to take part. Participation is entirely voluntary and it will not affect your employment whether you do or do not decide to take part. If you decide to take part but then change your mind, you can withdraw your data up to one week after completing your interview without giving a reason. However, after one week of completing your interview you will not be able to withdraw your data. Your employment will not be affected if you change your mind.

Will my information be kept confidential if I do take part?Yes. All of the information given will be anonymised and pseudonyms will be used. This means those reading the research will not know who has taken part because all personal identifiable information will be removed. The audio recordings of the interviews will be transcribed by Laura-Lee and also a professional transcriber who will therefore also listen to the recordings, but will be obliged to adhere to a strict confidentiality agreement which has been authorised by the University of Surrey Faculty of Health and Medical Sciences Ethics Committee. All files will be kept on password protected documents on an encrypted memory stick.

Confidentiality may need to be broken if you speak of any risk to residents or to yourselves. In such cases, I will need to speak to the care manager and my university supervisors about this.

Research data will be securely stored for a minimum of ten years in line with University of Surrey policy and in accordance with the Data Protection Act 1998. It is helpful to store this information for ten years should we need to clarify information. After a minimum of ten years, the research information will be destroyed securely.

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What happens next?If you would like to take part then please make sure you understand this information sheet and ask any questions that you may have. If you agree to take part then please sign the attached consent form.

What will happen after the research is completed?The results will be written up anonymously for my thesis which is part of the PsychD in Clinical Psychology training at the University of Surrey. The anonymised data will be looked at by University of Surrey teaching staff, markers and qualified Clinical Psychologists who work for the NHS. It is also hoped that the anonymised results will be published in a scientific journal and presented at the Faculty of Older People Conference. The care home will also receive a copy of the outcome of the research.

Who is funding the research? The University of Surrey is funding the research as it is part of the training for the PsychD Clinical Psychology qualification.

Who has reviewed this study? The research has been reviewed and received a favourable ethical opinion from the University of Surrey Faculty of Health and Medical Sciences Ethics Committee.

What if there is a problem? Any complaint or concern about any aspect of the way you have been dealt with during the course of the study will be addressed; please contact Laura-Lee Edwards, the lead researcher or Dr Kate Gleeson, academic supervisor, or Dr Paul Davis, academic supervisor on the details below.

Contact details of researcher and supervisors

Researcher: Laura-Lee Edwards, Department of Psychology, University of Surrey, Guildford, GU2 7XH; Email: XXX

Supervisor: Dr Kate Gleeson, Department of Psychology, University of Surrey, Guildford, GU2 7XH; Email: XXX ; Phone: XXX

Supervisor: Dr Paul Davis, Department of Psychology, University of Surrey, Guildford, GU2 7XH; Email: XXX; Phone: XXX

Thank you for taking the time to read this Information Sheet.

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Appendix E: Consent Form

CONSENT FORMHow can we understand the attachment process between people with dementia and staff caregivers: an exploratory study in residential care.

Name of researcher: Laura-Lee Edwards

Please read through this sheet, tick the box to show that you agree to each statement and sign in the space provided at the next page.

1. I confirm that I have read the information sheet for the above named study. I have been given a full explanation of the research by the lead researcher and what will be expected of me. I have been advised of possible disadvantages of the study. I have had the opportunity to ask questions and if I did have questions, these have been answered satisfactorily.

2. I understand that my participation is voluntary and that whether I agree or do not agree to take part will not affect my employment. I understand that I am free to withdraw up to one week after completing an interview without giving any reason and without my employment rights being affected. However, I understand that after one week of completing the interview I will not be able to withdraw my data from the study.

3. I understand that the interview will be audio recorded and during transcription it will be anonymised and pseudonyms given. I understand that an external professional transcriber may also listen to the audio recording but that they will adhere to a confidentiality agreement as authorised by the University of Surrey Faculty of Health and Medical Sciences Ethics Committee. I understand that the research will not contain any information that would reveal any personal information, as informed in the information sheet.

4. I understand that the research data will be kept securely, as per the Data Protection Act 1998 and University of Surrey policy, and that this will be destroyed after a minimum of 10 years following Laura-Lee Edwards qualifying from the PsychD Clinical Psychology training course.

5. I understand that the anonymised data will be looked at by the University of Surrey teaching staff, markers and qualified Clinical Psychologists who work for the NHS.

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6. I understand that the research may be published after the study has been completed and that all data will be anonymised.

7. I understand that Laura-Lee Edwards may need to break confidentiality if she hears of any risk to residents or from the residents. I understand that in such cases she will speak to the care manager and her university supervisors.

8. I confirm that I have read and understood the above and freely consent to participating in this study.

Name of staff caregiver (BLOCK CAPITALS)…………………………………

Signed …………………………………

Date…………………………………

For Laura-Lee Edwards, lead researcher to complete:

Name of researcher / person taking consent (BLOCK CAPITALS)

…………………………………..

Signed…………………………………..

Date…………………………………..

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Appendix F: Inductive interview schedule

Inductive interview schedule for semi-structured interviews with staff caregivers

Prompts for the main questions are italicised below each question however this is not exhaustive

Introduction to interview: I would like to have been carrying out observations but am unable to do so at this time. So instead I would like get an idea of what your experience is of the interactions with residents in the care home who are in the mid to later stages of dementia. I want to understand interactions and patterns that may be taking place. I would like you to think of as many instances as you can – it can be from your shift today or the one before that etc....

1. Can you recall anything in particular that happened between you and a resident? It can be positive, neutral or even a more challenging experience. I’d like you to describe it to me, without judgement. Just try to explain the facts.

- Who was there?- What was going on?- Were there any noises?- What did they do?- What did you do?- What happened next?- Do you think I got a full picture of it?- Is there anything else that would be helpful to know?- What happened afterwards?

2. What was your understanding / interpretation of what was happening for the resident (person with dementia)?

- What do you think they (person with dementia) were thinking?- What did you see that made you think that?- What do you think they were trying to communicate (to you)?- How do you think it felt for them when they did X?- What do you think made it happen?- And anything else you noticed?

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3. What was your understanding / interpretation of what was happening for you?

- How did it feel for you when the resident did X?- What did you see that made you think that happened?- What was your emotion at that time?- What were you thinking?- What do you think made you think that?

4. How do you think your interaction with the resident changed because of what happened between you?

- What do you think caused that?- Anything else that could have caused that?

5. How do you think the resident’s interaction with you changed because of what happened between you?

- What do you think caused that?- Anything else that could have caused that?

6. Has your understanding of what happened in that interaction changed at all?

- What has made it change?

<Then move on to the next interaction…>

7. Looking back over what we’ve talked about is there anything else you would like to add?

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Appendix G: Initial ideas on transcript (page 1)

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Appendix G:Initial ideas on transcript (page 2)

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Appendix H: Example of a tables of codes

Theme: Creating a home

Data extract Coded for (latent)P1: 214-219I think she was happy she felt happy or may just like to appreciate that you ask someone to say what sort of music and she say something different from what was going on and then I just thought may be the song that was on she just might not have liked if for her to think of going over to someone taking the box but with this one she started singing along to it

1.Being appreciated2.Given choices / independence

3.Thinking of their likes / dislikes

P1: 618-624ahhhh the two that are outside there because ahhh normally people ask them you want to come in for your cup of teas or you want it out there…so I just went out to them and asked them are you going to have your cup of teas outside or you’re coming in, and the there’s a lady and man and the lady said you are a darling I knew you would come out here when I come in yeah that sort of thing

1.Giving choice

2.Being considered / thought about

P1: 677-684I think she felt happy about it you know it’s like at least we are being considered to say whether people ask us whether we want this or that sort of thing as of ummm, in their mind, may be, what I thought is like, if you are having a meal you have to sit on the table definitely and then you can go out but with this where someone is asking you whether are you having your lunch outside or are you having your tea outside or…that sort of…it’s like you’re sort of being respected isn’t it yeah

1.Being considered

2.Freedom to choose

3. RespectedP1: 992-993P1: yeah, he smiled, yeah it’s just, it’s that feeling that you have and to make someone have the comfort and feel safe

1.creating a sense of safety and being comfortable

P2: 139-143so I have to tell her you know I don’t understand so you have to tell me that in in English. And when when she had her sort of kind of family around she’s sort of you know actually telling you in her language to come and to come and see me OK, so you know reassurance

1.Staff perceived as family

P2: 144-154Me: so she starts speaking in her own Mother tongue, her own language?

P2: yeah yeah

Me: and when she’s able to do that how do you think she’s then feeling inside?

P2: probably assurance is probably, I I think, we all sort of, you know, we feel part of something and I think that that for me that’s you know, the kind of you know, the the sort of feel part [emphasis on word] of something so that you don’t feel so alienated, that’s how I look at it

1.Belonging

P2: 186-189erm, but it it’s yeah, that’s how I actually you know, kind of getting the balance right I’m not here all the time so it’s actually establishing the trust to feel that you know, that place that she’s in somewhere safe and secure, even if I’m not here.

1.Creating a safe place for residents even when not present

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P3: 543-548yeah safe and more confidence. Sometimes we have to make them know that they are in the safe place because sometimes they don’t think that that may be that place is not safe for her for them or anything so we as a carer we have to make let them know that that ok they’re in a safe place there’s nothing that will happen anything happen to them

1.Place of safety

2.Role of carer – for residents to feel safe3.Reassure

P3: 549-555Me: how do you think that how do you do that? What things do you do? That’s really interesting, so how do you do it?

P3: so I try I keep ask err if they want to do anything or if they want to eat something or if they want drink like yesterday er Mary ask if she can have a sandwich “I want a cheese salad” I said “ok Mary I will make you cheese salad” so I make a cheese salad so she was happy for that

1.Offering choices

2.Providing for their needsP4: 85-88if they you when you talking nicely, ask them “are you resting, how do you feel? How do you like today?” they they want to talk, they feel you they are not forgotten people and they like when somebody talk to them

1.Being interested

P4: 102-105yeah may be more respect to them when you talking to them like family, you know, “how are you today?” you know like that and may be they feel they are important, they needed, they they feel like that, I think (laugh)

1.Showing you care2.Relating to them as family

P4: 168-171“do you want to toilet, do you want to go?” we leave it for a few seconds a few minutes, and other staff coming and asking her “can I help you” it’s different way, different face, different asking and in the end it’s working (laugh) year

1.Giving resident choice2.Giving resident space / time

3.Different approachesP4: 246-258P4: they have the choice, because if you just say to them what you want it’s not workingMe: and how do you think it feels to have the choice? How do you think they feel when you give them a choice?

P4: err, because they feel they are kind of like normal person it’s not, something wrong with them, they feel they have normal doing the normal going the normal life

Me: mmm

P4: - I think is my opinion. When you’re talking with them, when you give to them chance “what do you wearing today?”

Me: mmm

P4: “this dress, or this t-shirt or this jumper or something” and they feel they, like, like at home, what I want what I do

1.Indepedence

2.Giving a sense of normality

3.Given freedom to choose / independence

P4: 323-329P4: this means because I think they miss their family, may be sometimes they don’t understand why they here and they are, because even they asking, “I go home” sometimes, you know resident, “I go home”, one resident all the time she’s saying “I go home” and we explain to her “you’re at home, this is your home, this is your family this is your everything, and you where do you go? You’re at home” – you explain to them like that

1.Missing family

2.Residents want to go home

3.We are their family

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P5: 521-533I feel I feel she er I feel she sad, means she can’t understand she she’s think about her memory is going er er past, may be she think that is her own home this is she going to pay the bills she can’t pay the bills that’s why she doing this, turn the lights turn everything, turn the microwave turn the toaster everything but you explain it

1.Care home perceived as own home2.Having control

P6: 127-130And then every morning she says “I wonder what my Mum would say to me if she sees me like this I wonder what my Mum would say” every morning she has to talk about her Mum

1.Always returns to Mum

2.Fixated on parent

P6: 544-546she feels good, she feels even when you rub her hand or you rub the cream she feels even if it’s actually just water but it just someone with that feeling someone cares

1.Being present / touch with resident communicates caring

P7: 141-144so that she feels that somebody loves her because she knows she’s here she thinks that nobody’s with her anymore but the staff is here for them we are here for them it’s like a family because if I care I am a carer – if I care if I care

1.Feeling loved

2.We are there for them like family – relating as family

P7: 243-247yeah especially I don’t have family here I treat them like my own family. Sometimes when I was erm sitting with them just like when they sitting around you’re there on your own you have to talk to them one by one not only one person you have to talk to you have to talk to them one by one

1.Family replacement2.Giving attention to all

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Appendix I: Thematic Map

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Appendix J: Revised thematic map

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Part Three: Summary of Clinical Experience

Year one: Adult, split placement Primary Care and Health-Pain Management

I completed a year-long split placement across primary care and pain management.

My primary care placement was within an Improving Access to Psychological

Therapies (IAPT) service. I worked with adults aged 18-65. I provided one-to-one

psychological assessments for clients with a range of presenting problems. I provided

therapy for clients presenting with a range of diagnoses such as social anxiety

(including unstable personality traits), obsessive compulsive disorder, eating

disorder, depression and post-traumatic stress disorder, using Cognitive Behavioural

Therapy (CBT) as per service requirements. I completed a service evaluation entitled

‘Meeting the National Standards in a Primary Care Service: hitting targets and

commissioning in an Improving Access to Psychological Therapies service’. Taking

on leadership roles, I set up a reflective practice group, delivered training on pain

management to the team, and co-facilitated a service user group. My Pain

Management placement was at a day hospital, working with clients between ages 18

to older adults. I was involved in Multi-Disciplinary Team (MDT) assessments,

worked alongside the MDT to deliver therapeutic pain management groups and

delivered therapy for a client presenting with chronic pain and depression. I used

Acceptance and Commitment Therapy as my main therapeutic model. I administered

two neuropsychological assessments for clients who had experienced a stroke using

the WTAR, WAIS-III and the WAIS-IV, including report writing. Across both

placements, I used the following psychometrics: PHQ-9, GAD-7, SPIN, OCI, BDD-

YBOCS, Impact of Life Events Scale, PTSD Scale, Pain Rating Scale, HADS, Pain:

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S-E Questionnaire, Roland Morris Disability Questionnaire, CORE and Session

Rating Scale.

Year two: Intellectual Disabilities

I completed a six months placement working with clients presenting with an

intellectual disability across the community, including residential care. Clients were

between ages 18 to older adults, and had a diagnosis of mild to profound intellectual

disability and Downs Syndrome. Clients presented with a range of difficulties such

as anxiety, low self-esteem and behaviour that perceived to challenge. I used the

systemic model throughout this placement and provided narrative therapy. I also

completed a number of behavioural support plans, including behavioural analysis. I

facilitated network meetings, delivered staff consultations and wrote care plans.

Leadership roles involved: teaching Assistant Psychologists on ‘Using CBT for

clients with an intellectual disability’, presenting a complex case presentation at the

team meeting and writing a presentation for residential staff on ‘LD and sexuality’. I

carried out formal intellectual disability eligibility and dementia assessments. I used

the WAIS-IV, Oliver and Crayton, HALO, DLD, Early Signs of Dementia and Life

Events Checklist. I also used psychometrics CORE-LD and ABAS.

Year two: Older People including a Challenging Behaviour Service

This was a six month placement working with older people (ages 66 and over)

presenting with a range of difficulties including depression, panic disorder with

agoraphobia, life adjustment and memory problems. I saw clients in the community

including residential / nursing care home settings, and inpatient wards. My main

therapy models were CBT and systemic, and I completed behavioural support plans

using the Newcastle Model. I also provided staff consultation. I carried out dementia

screenings using ACE-III and dementia assessments using: WAIS-IV, TOPF, Boston

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Naming Test, Hopkins Verbal Learning Test-R, DKEFS, WMS-IV, Hayling and

Brixton. I also used the following psychometrics: HADS, BAI, GAI, PSWQ-PW,

Penn State Worry, IoU, CBS Scale and Modified Barthel Index. I scored, interpreted

results and wrote reports. I also provided dementia assessment feedback to

clients/families.

Year three: Complex Needs Service (specialist)

I completed a six month placement in a tertiary service for clients presenting with a

diagnosis of a personality disorder (and various complex needs). I co-developed a

psycho-educational group for clients with a personality disorder, and I co-facilitated

with various members of the MDT. I also wrote new material for the group and

handouts. The main model of therapy was mentalisation based treatment (MBT).

Using this model, I co-facilitated a therapy group for young people and observed a

weekly group for six months. I delivered one-to-one therapy using brief

psychodynamic psychotherapy which incorporated MBT therapy. I also carried out

assessment and reviews with the Consultant Psychiatrist.

Year three: Child and Adolescence Mental Health (CAMHS)

I completed a six month placement in a Tier 2 CAMHS and complex learning

disabilities (LD). I worked with children aged 3-17, directly and indirectly. Within

Tier 2, I provided assessments, referred to other services and provided family

consultation. Family consultation was based on the family therapy model, using Brief

Solution Focused therapy and ideas from narrative therapy. Within complex-LD, I

provided CBT for young people, arranged and facilitated TAC meetings, worked

alongside family, schools, social services / other members of the MDT, provided

consultation to social services and completed behavioural support plans. I completed

neurodevelopmental and cognitive assessments using WAIS-IV, WIAT-II, RCADS

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(child/parent), Strengths and Weaknesses questionnaire, Social Communication

Questionnaire and Conners (parents/teachers).

Part Four: Table of Assessments Completed During

Training

PSYCHD CLINICAL PROGAMME

TABLE OF ASSESSMENTS COMPLETED DURING TRAINING

Year I Assessments

ASSESSMENT TITLE

WAIS WAIS Interpretation (online assessment)

Practice Report of Clinical Activity

Clinical Skills Assessment: Adult Mental Health Practice Report of Clinical Activity

A Cognitive Behavioural Therapy assessment including formulation with a female in her late 20s for Obsessive Compulsive Disorder

Audio Recording of Clinical Activity with Critical Appraisal

Adult Mental Health Audio Recording of Clinical Activity with Critical Appraisal

A Cognitive Behavioural Therapy intervention with a female in her early 30s for Obsessive Compulsive Disorder

Report of Clinical Activity N=1

Clinical Skills Assessment: Adult Mental Health Report of Clinical Activity N=1

A Cognitive Behavioural Therapy assessment and intervention with a female in her early 30s for Obsessive Compulsive Disorder

Major Research Project Literature Survey

What do we currently know about the attachment style between the person with dementia and the caregiver?

Major Research Project Proposal

An explorative study: how do people with dementia and their caregivers experience the attachment relationship?

Service-Related Project A Service Evaluation on Meeting the National Standards in a Primary Care Service: hitting targets and commissioning in an Improving Access to

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ASSESSMENT TITLE

Psychological Therapies service

Year II Assessments

ASSESSMENT TITLE

Report of Clinical Activity – Formal Assessment

A formal assessment of an Intellectual Disability eligibility assessment for a female in her early-to-mid 30s with queried Autism Spectrum Disorder

PPLD Process Account My experience of a personal and professional learning group: a process account

Year III Assessments

ASSESSMENT TITLE

Presentation of Clinical Activity

Assessment and intervention for an older person in her early 80’s for depression

Major Research Project Literature Review

The interactive attachment dyad between the person with dementia and their caregiver.

Major Research Project Empirical Paper

How can we understand the attachment process between people with dementia and staff caregivers: an explorative study in residential care

Report of Clinical Activity

Brief psychodynamic psychotherapy for a young pregnant lady in her early 20s presenting with emotionally unstable personality disorder

Final Reflective Account

On becoming a clinical psychologist: A retrospective, developmental, reflective account of the experience of training

My journey to becoming a qualified clinical psychologist: learning about the safe base

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