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Attachment in Old Age: Theoretical Assumptions, Empirical findings and Implications for Clinical Practice

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Attachment in Old Age: Theoretical Assumptions, Empirical findings and Implications for Clinical Practice Clinical Psychology Review 33 (2013) 67–81 Contents lists available at SciVerse ScienceDirect Clinical Psychology Review Attachment in old age: Theoretical assumptions, empirical findings and implications for clinical practice Lies Van Assche a,⁎, Patrick Luyten b,c, Ronny Bruffaerts d, Philippe Persoons a, Lucas van de Ven a, Mathieu Vandenbulcke a a Section of Old Age Psychiatry, Department of Psychiatry, University Hospitals Leuven, KUL, Belgium b Department of Psychology, University of Leuven, Belgium c Research Department of Clinical, Educational and Health Psychology, University College London, UK d Department of Psychiatry, Universitair Psychiatrisch Centrum—Katholieke Universiteit Leuven (UPC-KUL), Campus Leuven, Belgium HIGHLIGHTS ► Attachment as biobehavioral system offers a valuable perspective on aging. ► We provide a qualitative review of empirical research from 1983 to 2012. ► Number and type of attachment figures, but also quality of attachment alter. ► Attachment has an impact on psychosocial functioning in old age. ► Methodological limitations preclude drawing strong conclusions. article info abstract Article history: Contemporary theoretical models that conceptualize attachment as a biologically-based behavioral system Received 30 August 2011 that is activated under threat offer a heuristic theoretical framework to understand processes involved in Received in revised form 3 October 2012 aging and particularly individual differences in coping with the inevitable losses associated with aging and Accepted 7 October 2012 age-related disease, including dementia. This paper provides a systematic qualitative review of research Available online 13 October 2012 concerning attachment in old age published between 1983 and June 2012. Four major findings emerged. fi Keywords: First, studies suggest age-related changes with regard to the number and type of attachment gures, with Attachment older adults, compared to younger adults, having less attachment relations. Moreover, so-called symbolic at- Old age tachments (e.g., to God or a deceased loved one) become more prominent in old age. Second, the quality of Dementia attachment changes with increasing age, with significant decreases in attachment anxiety, but not in attach- Behavior ment avoidance. Third, late-life attachment is in theoretically predicted ways associated with indices of Care giving intraindividual and interindividual functioning. Finally, insecure attachment has a negative impact on subjec- Intervention tive caregiver burden and behavior of patients with dementia. There is some evidence suggesting that attachment-based interventions show positive effects in treating problem behaviors associated with demen- tia. However, these conclusions need to be interpreted within the context of important methodological lim- itations, stressing the need for future research in this domain. Guidelines for future research are outlined. © 2012 Elsevier Ltd. All rights reserved. Contents 1. Introduction .............................................................. 68 2. Attachment theory and old age ..................................................... 68 2.1. Attachment theory: theoretical background and assessment issues ................................. 68 2.1.1. Observation and interview-based approaches of attachment . ............................. 69 2.1.2. Questionnaire-based approaches ............................................. 69 2.2. Attachment and old age ..................................................... 70 3. The present study ........................................................... 71 4. Method ................................................................ 71 ⁎ Corresponding author at: UZ St. Rafaël: Secretariaat Psychiatrie, Kapucijnenvoer 35, 3000 Leuven, Belgium. Tel.: +32 16 341 300. E-mail address: [email protected] (L. Van Assche). 0272-7358/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.cpr.2012.10.003 68 L. Van Assche et al. / Clinical Psychology Review 33 (2013) 67–81 5. Results .................................................................71 5.1. Attachment in later life: names and numbers ............................................71 5.2. Quality of ATtachment in later life .................................................72 5.2.1. Cross-sectional studies ..................................................72 5.2.2. Longitudinal research ..................................................73 5.2.3. Culture, ethnicity, and differences in quality of attachment .................................74 5.2.4. Methodological limitations ................................................74 5.3. Attachment, intraindividual and interindividual functioning .....................................74 5.3.1. Attachment and emotion .................................................74 5.3.2. Attachment and well-being in old age ...........................................75 5.3.3. Attachment and grief ...................................................75 5.3.4. Attachment and adversity ................................................76 5.4. Attachment and dementia ....................................................76 5.4.1. Attachment in dementia and links with BPSD .......................................76 5.4.2. Attachment in dementia and possible effects on care giving .................................76 5.5. Attachment-focused interventions in old age ............................................77 6. Discussion ...............................................................77 7. Directions for future research ......................................................78 References ..................................................................79 1. Introduction attachment behavioral system promotes well-being and survival across theentirelifecourse(Fonagy & Luyten, 2009; Mikulincer & Shaver, In western societies, the number of older adults is rapidly increasing 2007; Sbarra & Hazan, 2008). Congruent with the assumption that attach- since the second half of the 20th century, following advances in ment may provide a potentially heuristic framework for stress-related healthcare and nutrition (Christensen, Doblhammer, Rau, & Vaupel, processes involved in aging, attachment in old age has been the subject 2009; Mathers et al., 2001). This rapid increase is associated with major of considerable research over the past two decades, particularly since challenges for developmental and health care research (Jacobzone, the publication of two earlier reviews (Bradley & Cafferty, 2001; Browne Cambois, & Robine, 2000). Many developmental approaches agree that & Shlosberg, 2006). The current review builds on these previous reviews aging involves a redefinition of issues with regard to both self and related- which have identified a number of themes in the literature, and extends ness (Baltes, 1987; Blatt, 2008; Kastenbaum, Derbin, Sabatini, & Artt, these earlier reviews by using a systematic search strategy, rigorous inclu- 1972). More specifically, old age is typically associated with loss of phys- sion and exclusion criteria, the inclusion of more recent studies, and its ical, cognitive and social function (Baltes, 1987; Hébert, 1997; Maylor, focus on the role of different methodological traditions in the assessment Moulson, Muncer, & Taylor, 2002). On the interpersonal level, older adults of attachment, and measurement issues generally, in explaining extant become increasingly confronted with loss of loved ones. Moreover, findings in this field. The present paper provides a critical review of this age-related diseases such as dementia present a further challenge for body of research published since 1983 up to June 2012. Referring to many aging individuals. Indeed, the prevalence of the most common Baumeister and Leary's (1997) criteria for writing a narrative review, form of dementia (i.e., Alzheimer's type), has been reported to be the following overlapping goals are addressed: (a) evaluating the value between 5% and 13% in those over the age of 65 years to 43% at the age of attachment theory in our understanding of the transition to old age of 85 years and older (Alzheimer's Association, 2011; Copeland, Dewey, through a critical survey of the state of the knowledge, and (b) the iden- & Saunders, 1991; Evans, 1990; Folstein, Anthony, Parhad, Duffy, & tification of gaps in our knowledge concerning attachment issues in old Greenberg, 1985; Sulkava, Wikström, Aromaa, Raitasalo, Lehtinen, age with the aim to inform future research and current clinical practice Lahtela, et al., 1985). However, old age is also associated with positive (Baumeister & Leary, 1997). changes that coincide with reduced social contacts and a more limited First, we summarize the main findings of attachment-based theo- time perspective (Carstensen, Isaacowitz, & Charles, 1999). Carstensen retical perspectives on old age. Next, we review extant research in (1995), for instance, argues that with increasing age the emotional expe- this area. This is followed by a critical discussion of methodological rience in everyday life becomes more profound and complex, and emo- issues and limitations of existing research. Finally, we outline a num- tion regulation is more efficient. Inspired by Baltes' selection, ber of guidelines for future research. optimization and compensation (SOC) model of aging, she has proposed that aging is associated with motivational shifts that direct attention to 2. Attachment theory and old age emotional goals rather than instrumental goals.
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