Book Reviews — Winter 2015
Memories Lost and Found:
A Son Documents His Neurologist-Father’s Descent into Alzheimer’s
By Professor Edward Shorter
Jonathan Kozol’s engaging memoir of the growing cognitive decline and death of his father, the distinguished Boston neurologist Harry Kozol, is one of many catastrophic tales of Alzheimer’s lining bookstore shelves.
Why would you want to read this one?
For one thing, this book is full of surprising developments. After almost four years in a nursing facility, the father goes home! He had kept asking to go home, and people brushed the request aside, convinced that when you check into a nursing home, you never check out again. But the father returns to live in the family’s grand apartment in the Boston area, where the mother herself has fallen ill and requires round-the-clock care. Everybody is much happier. So this kind of return home is not just the reflexive wish of a dementing mind; it’s possible.
For another thing, the father, as a staff neurologist at the Massachusetts General Hospital, had a very interesting life. He was involved in the affairs of playwright Eugene O’Neil, and the son brings out this story using his father’s records. Ditto Patty Hearst, the heiress who joined a band of radicals, and for whom Harry Kozol is summoned as an outside expert.
Jonathan Kozol essentially becomes his father’s biographer. He intercuts tales of the past — namechecking some of the world’s most distinguished doctors, such as psychiatrists Adolph Meyer and Manfred Bleuler — with more recent discussions at his father’s bedside. As the father loses memories, the son revives them.
Finally, it’s interesting to see what a difference a little bit of money (actually a lot) can make in end-of-life nursing experiences. A good deal of the book is about the various private nurses who are summoned to the father’s and the mother’s bedsides: two for the father in the nursing home, and a special bedroom at home for the mother’s caregivers. It’s clear how a couple million dollars can make gentler the passage into that good night.
Jonathan Kozol: Losing My Father, One Day at a Time (Toronto: McClelland and Stewart/Penguin Random House, 2015), 302pp
Edward Shorter is the Jason A. Hannah Professor of the History of Medicine in the Faculty of Medicine of the University of Toronto and Professor of Psychiatry. He co-authored Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness.
By Barry Gilbert MD FRCPC
This is an excellent introduction to a way of understanding problematic interactions in healthcare, providing a clear map and approach for clinicians. Authors Robert Maunder and Jonathan Hunter are both psychiatrists and faculty members at the University of Toronto whose careers have been spent working with patients who are medically ill. They draw from their extensive clinical experience to ground their approach in real-life encounters.
William Osler said that, “It is much more important to know what sort of a patient has a disease than what sort of disease a patient has.” The authors provide a way of understanding people using attachment theory that has wide application in health care, in health and in life. The book is divided into 3 sections: First, a review of health and health care in the light of attachment; second, a detailed explanation of attachment and the vast body of research underlying it; and, third, a look at relational healthcare, or healthcare informed by an understanding of attachment.
Attachment, in short, is what we need to do in order to feel secure and safe. Attachment theory is about normal people; it is not a theory of abnormal psychology. Most of the time, in the routine of daily life, it is invisible, but in stressful or threatening situations, such as being ill and requiring care, it becomes activated and much more apparent. The authors note: “Illness makes relationships matter more than normal.”
The first third of the book provides some interesting and familiar observations: unexplained symptoms take up a great deal of time in primary care, and in one study, 70% of clinical time was taken up by 13% of the patients, and these patients tended to have problematic relations with their healthcare providers (at least from the providers’ perspective). Primary care practices are full of people with multiple, unexplained symptoms; many Emergency Room visits are from people struggling with addictions. Healthcare providers often find that encounters with high users are difficult, suggesting, say the authors, that part of the problem is relational. At the opposite end of the spectrum are patients whose needs to be self-reliant are so strong that they discount symptoms, delay seeking care and have more difficulty managing chronic diseases like diabetes.
The chapter “Why Else Do We get Sick?” shows that the biology of one’s response to stress is linked to early relational experiences which become consolidated into durable attachment patterns of relating, affect regulation and behaviour. The brain is hierarchical: we have many automated patterns of thinking and feeling, such as our quick, unthinking responses to gestures or tone of voice. These unconscious patterns can be disrupted by conscious thought , but more slowly, and only with persistent effort. This is why a person watching his weight can inhibit his desire to eat cookies all day, but then lapse into old patterns of eating late at night, when he’s tired or in need of comfort. The need to feel secure is much stronger than we think and is one of the reasons it is so difficult to change maladaptive (from one perspective) health behaviours, such as smoking or overeating, when they are highly associated with maintaining a deep feeling of security. The authors cite research showing that people who have high Adverse Childhood Experiences Scores (e.g. abuse, neglect, exposure to violence) have more health problems.
In the second section, the authors give a detailed account of attachment, grounding it in biology and the evolutionary impact of prolonged dependency after birth. The attachment system, with behaviours like crying, clinging, and following, serves to keep the infant safely close to the adult. As the paediatrician and psychoanalyst Donald Winnicott observed: “There is no such thing as a baby; there is always a baby and someone.” Attachment begins and develops in the early relationship with the parent. Babies need to learn what is dangerous but also how to feel safe and secure. Most children have developed attachment patterns by the age of 12 months. The varied experiences a child can have growing up can have one of two outcomes in the adult: either a tendency towards secure attachment or towards what is called insecure attachment. Through the period of young adulthood, most people make a shift from their parents to peers, especially through romantic relationships, as their main source of feeling safe and secure.
To understand who your own attachment figures are, think of who you like to be with; think of a person you don’t like to be away from (such as when you travel); who you seek out for advice and will be with when you are feeling upset; and who provides a secure base for you, encouraging your growth and even creativity. The more functions a person meets, the stronger the attachment bond.
Attachment patterns are set early and appear to be quite stable throughout life. About 60% of adults have secure attachment patterns. The rest have insecure attachment, which divides into two main types: People with attachment (separation) anxiety become anxious and distressed when they feel too disconnected from people they feel safe with; people with attachment avoidance tend to feel smothered and uncomfortable with too much closeness. People with insecure attachment patterns have more trouble inhibiting maladaptive behaviour using “top down” thinking; they tend to have more difficulty “mentalizing”, or being able to imagine what other people might be experiencing (some recent psychotherapies teach mentalizing in hope that it will help people make more secure attachments).
The authors explain how the nature of the interaction with a patient can alert the clinician to different attachment styles. Remember that the stress of needing health care will bring out attachment behaviour — seeking a feeling of safety and security — from people. Attachment helps regulate feelings; if your relationships are calm and nurturing, you can find solace in hard times. But if your relationships are fraught with conflict, or you find it difficult to tolerate being too close to people, you may react by shutting down awareness of any emotional needs or diminishing them. Or you may turn to other sources of soothing, such as drugs, which can sometimes provide some of the same release of oxytocin — “the bonding hormone”- as closeness to an attachment figure can provide to a more securely attached person. Insecurely attached people have more trouble with powerful maladaptive responses and have more difficulty inhibiting them. An important issue for health care providers, the authors say, is that people with high attachment anxiety will often be heavy users of health care and will come to their provider looking for help to feel safe and secure; they are not primarily (at least to start) coming to identify a disease to be treated.
One striking finding the authors describe at length is that the clinical narrative provided by a patient can be revealing pathognomonic of their attachment style. I found these descriptions accurately described my daily experience in different clinical settings. Securely attached people will give a coherent history with clear chronology and an appropriate amount of detail (they can mentalize and determine what the provider most needs to hear, and inhibit their anxiety enough to be coherent). In contrast, high attachment anxiety leads to a narrative that is disjointed, hard to follow and over inclusive of detail that confuses the listener. People with high attachment avoidance provide a narrative that is flat and remarkably devoid of detail, leaving the clinician with little information to go on. These narrative styles reflect difficulties with mentalizing the needs of the other and reflect fears/expectations of the other: that the clinician will abandon the patient if the tale is not dire enough (anxious attachment) or will be unresponsive regardless of what is said, hence little is provided or risked in the narrative (avoidant attachment).
The third section of this book is replete with clinical pearls, providing a systematic approach to meeting the different needs of people with different attachment styles in the clinical encounter. The emphasis is not on changing attachment styles — this is attempted through psychotherapy and the research on this is in its infancy — but on adapting to our patients’ different styles. While an anxiously attached patient will do best with a calm, active approach, with the care provider taking charge to a sufficient degree to allay anxiety, almost the opposite is needed for the avoidant patient, whose need for self-sufficiency must be recognized in the clinical relationship. The authors make clear that health care will be more healing and comprehensive when it takes account of what each patient needs to feel safe and secure at a time when stress brings out old established ways of seeking safety and security.
This book is well constructed, building on previous chapters as the evidence and more detail accumulates. It never strays far from its clinical roots; there is always an apt clinical example told with compassion and often humour. It is well grounded in evidence in much more comprehensive detail than I can convey here. The authors do well to compress and summarize a vast literature and make it into a fascinating story that moves from the individual to the health system at large. They end with some thoughts about how an understanding of attachment needs could inform the health systems we design in future — as understanding the attachment needs of children led to a revolution in hospital care , with parents being able to stay with their children throughout hospitalizations. There is much more we can do.
This book is written to appeal to a wide clinical audience, including physicians, nurses and other care providers. The understanding this book promotes could go far in improving the care all clinicians offer to their patients.