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What follows is a clarification of the concept of attachment wrote: ‘Psychological development is characterized …by the
in older adulthood. Selected elements of Wilson-derived individual’s becoming increasingly aware of the set-goals he
methods of concept analysis are used to assist in this process. (sic) has developed, by his developing increasingly sophisti-
A critical appraisal of the concept considers principles of cated plans for achieving them, and by his increasing ability
lifespan development alongside the clarified concept. Strat- to relate one plan to another’ (p. 154). Bowlby’s (1969, 1973,
egies for continued development of the concept complete the 1980 descriptions of attachment involved ‘increasing aware-
analysis. nesses’, ‘increasingly sophisticated plans’, and ‘increasing
Beginning with a mother’s bond to her unborn child and abilities’ resulting from the ‘activation within a particular
progressing through life, attachment has been identified as a environment of behavioural systems that are integrated’
critical factor in healthy human development. Researchers in (Bowlby 1973, p. 134). Knowledge about attachment, and in
human development and nursing have studied attachment particular about the formation of new attachment relation-
extensively, but almost exclusively in infancy and childhood. ships with ageing, would lend important support to the
Development of nursing theory using the concept of attach- development of models of health development for older
ment has most frequently involved the study of maternal–fetal adults. The promise of knowledge about attachment in older
(Cranley 1981, Kemp & Page 1987, Mercer et al. 1988) and adulthood lies in the positive consequences resulting from the
parental–infant attachment (Gaffney 1986, Koniak-Griffin vulnerabilities of ageing.
1988). Understanding attachment in the later developmental
phases is clearly needed, considering the hypothesized impli-
Assumptions
cations of early attachment patterns for subsequent health
(Ainsworth 1985, Bowlby 1988, Paterson & Moran 1988). Attachment is viewed as a continuous concept throughout the
Consistent with this emphasis, a systematic analysis of the lifespan. Central to any investigation of attachment is the
concept of parent–infant attachment has been described assumption that ‘the capacity to make bonds with other
(Goulet et al. 1998). The relevance and significance of individuals …is regarded as a principal feature of effective
attachment in later developmental phases is theorized to be personality functioning and mental health’ (Bowlby 1988,
important, but has been studied relatively little (Lipson-Parra p. 3); this has far-reaching implications throughout the life of
1990). Advocates of inquiry into attachment in adulthood the individual. Accordingly, phenomena such as attachment
and ageing call for rigorous work on clearly defining the are of particular interest to nurses who strive to optimize
concept (Knudtson 1976), as its exact meaning and structure growth and development as critical components of health
thus far remained unaddressed. promotion and illness prevention.
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(5), 528–535 529
C. Cookman
base of knowledge was established, the concept was explored the environment with the knowledge that, should the threat
among increasingly older groups, including adolescents, of danger arise, a quick return to an attachment ‘object’ will
adults and most recently older adults. afford safety (the so-called ‘secure base effect’). Attachment
behaviours, then, are the observable components of this
system, seen when this system is invoked to protect the
Beginning descriptions
individual displaying the behaviours. According to Bowlby,
Freud (1926) described a theory of secondary drive to explain an attachment is a bond developed with ‘some other
the bonds that developed between human infants and their differentiated and preferred individual, who is usually con-
mothers. According to this view, there are a small number of ceived as stronger and/or wiser’ (1977, p. 203). Attachments
primary drives designed to meet survival needs such as food, are directed toward a differentiated other, are characterized
warmth, sex and liquids. Secondary drives, including attach- by their relatively long duration and serve the biologi-
ment, were proposed as learned behaviours that supported cal function of survival. Importantly, Bowlby described
these primary drives. As stated by Freud (1926), ‘The reason attachment as a lifespan development concept ‘held to
why the infant in arms wants to perceive the presence of its characterize human beings from cradle to grave’ (Bowlby
mother is only because it already knows by experience that 1979, p. 129).
she satisfies all its needs without delay’ (Vol. 20, p. 137). This Ainsworth (1985) viewed attachment as a type of ‘affec-
theory was first brought into question by the work of Lorenz tional bond’ that individuals may form throughout their lives,
(1935) in his experiments with young birds. These demon- some of which ‘may be identifiable as attachments, some as
strated that, in the hours following hatching, ducklings would having attachment components, whereas others may not
follow any moving object they saw, including rubber resemble attachments in some critical way’ (p. 799). Accord-
balloons and cardboard boxes. Over time, the ducklings ing to this description, an attachment is an affectional bond.
would follow these objects and no others – findings that Ainsworth extended Bowlby’s conceptualizations about
brought serious questions about the validity of any theory of attachment. In particular, she demonstrated that individuals
secondary drive. Experiments by Harlow and Zimmerman at a very young age develop cognitive schemas, or internal
(1959) added to the scepticism. These researchers raised eight representations about the relative degree of safety afforded by
infant monkeys with two surrogate mothers – one of cloth attachment figures. Called ‘patterns of attachment’, Ains-
and another made from wire. Half of the infants were then worth et al. (1978) demonstrated that most infants display
‘fed’ by these surrogate mothers. Monkeys of both groups confidence in the protective abilities of their attachment
spent no more than 1 or 2 hours a day on the wire monkey figure (mothers), and this is indicative of a ‘secure’ pattern of
and an average of 15 hours a day on the cloth monkey. Some attachment behaviours. Others, however, display behaviours
of the monkeys who were fed by the wire model managed to indicative of ‘insecure’ attachment and characterized by
suck the teat of the wire model while maintaining a grasp on angry and resistant behaviour mingled with contact-seeking
the cloth one. The researchers concluded that ‘an infant fed (Ainsworth 1982).
from a lactating wire mother does not become more Hinde (1982) differentiated between attachment beha-
responsive to her, as would be predicted from a drive-derived viour, an attachment behavioural system and attachment.
theory, but instead becomes increasingly more responsive to Attachment behaviour refers to proximity keeping. An
its non-lactating cloth mother’ (Harlow & Zimmerman attachment behaviour system ‘refers to a system postulated
1959, p. 423). At this point in the evolution of thinking as controlling several types of attachment behaviour’ where
about attachment, substantive doubts arose about the role of ‘…the system is either switched on, with the resultant display
attachment strictly viewed as a strategy for meeting basic of attachment behaviour or, when a ‘‘set goal’’ is reached,
needs. switched off’ (Hinde 1982, p. 64). Attachment is defined as a
These doubts led Bowlby (1969, 1973, 1980) to propose a ‘label for a relationship or for aspects of a relationship,
new definition of attachment based on his studies of the assessed over a span of time’ that ‘…refers to an aspect of
concept among young war orphans. Bowlby (1980) described interpersonal relationships’ (Hinde 1982, p. 65).
attachment as a natural protective system that evolved within
the species because it enhanced an individual’s chances for
Attachment in adolescence
survival. This view holds that infants who are predisposed to
maintain proximity to an attachment ‘figure’ are afforded In adolescence, the parental attachment system is believed to
protections from predation. This system promotes healthy persist, although peer relationships become increasingly
development wherein an individual can confidently explore important. At the same time, however, the secure base
530 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(5), 528–535
Nursing theory and concept development or analysis Attachment in older adulthood
provided by parents ‘remains indispensable nonetheless for concept: (1) the similarity of emotional characteristics, (2) the
optimal functioning and mental health’ (Bowlby 1988, p.3). generalization of experience, and (3) the temporal linkage. As
Further evidence for the hypothesized persistence of parents theorized by Weiss (1991), ‘in adults as well as in children,
as primary attachment figures for adolescents are provided by attachments appear to be relationships critical to continuing
Weiss (1982) in his description of a Separation Distress security and so to maintenance of emotional stability’ (p. 75).
Syndrome, likened to homesickness and seen most acutely
during hospitalization of children. Weiss (1982) described
Attachment in older adulthood
four elements of this syndrome:
• Focusing of attention on the parent’s absence Attachment has been examined in older adulthood (Knudtson
• Difficulty focusing on other matters 1976, Troll & Smith 1976, Weiss 1986, West et al. 1987,
• A state of tension that discourages sleep and appetite Shaver et al. 1988, Cicirelli 1989). Bradley and Cafferty
• An impulse to search for parents (2001) described attachment as relevant for ageing in three
Weiss (1982) concluded that adolescents ‘…continue to major areas: (1) care giving and chronic illness, (2) bereave-
demonstrate…that their sense of security is dependent on ment and coping with loss, and (3) adjustment to ageing and
their parents’ continued accessibility’ (p. 175). Developmen- well-being in old age. Writers have acknowledged that the
tal growth results in ever more frequent and long-lasting conditions imposed by severe chronic illness such as Alzhei-
excursions away from the secure base provided by the mer’s disease and stroke are significant attachment-related
parents. Eventually, attachments involving peers as signifi- phenomena (Wright et al. 1995) that involve both the ill
cant attachment figures come to supplement those established person and their caregiver. Issues surrounding loss and
in childhood. bereavement have long been acknowledged as developmental
challenges that confront older adults (Havighurst 1952).
Similarly, the influence of attachment processes on well-being
Adult attachment
in older adulthood has long been acknowledged (Antonucci
From his earliest writings, Bowlby (1969) asserted that 1976, Troll & Smith 1976, Kahn & Antonucci 1980).
‘attachment behaviour in adult life is a straightforward Beyond hypothesizing about the continued relevance of
continuation of attachment behaviour in childhood’ (p. 207). attachment for ageing, systematic efforts specifically designed
Later attachment theorists echoed this appreciation for the to explore the specialized nature of concept for older
continuous quality of attachment with development. Accord- adulthood are sparse (Cookman 1996).
ing to Parkes and Stevenson-Hinde (1982): ‘…the properties
of attachment in children are just those required for effective
Wilsonian concept analysis elements
pair bonding in adults, and (that) this may account for the
very evident capacity of human adults to display attachment’ The following section uses the three main components of a
(p. 183). Heard and Lake (1986) wrote that: ‘Individuals concept analysis as described by Walker and Avant (1995) to
have a natural propensity to have ‘‘companionable interac- further this clarification of attachment: antecedents, critical
tions’’ in specifiable circumstances with peers, that is, people attributes and consequences.
of broadly equivalent intelligence, stamina, capacity to
handle fear and panic, and competence in pursuit of interests’
Antecedents
(Heard & Lake 1986, p. 431). Companionable interaction
with select others (commonly referred to in attachment Common to many perspectives on attachment is the notion of
literature as ‘attachment figures’) leads to a state of assuage- humans as potentially vulnerable to dangers that are lessened
ment where ‘…an affective experience of mental and physical when in the company of another or others: ‘Separation from
well-being’ (Heard & Lake 1986, p. 431) is experienced. an attachment figure is found to be one of a class of situations
Attachment figures were viewed within a system theory of each of which is likely to elicit fear’ and ‘comprise(s), among
social networks. Individuals develop networks of ‘preferred others, darkness, sudden large changes of stimulus level
relationships’ that refer to ‘relationships in which individuals including loud noises, sudden movement, strange people and
regularly expect to find opportunities for companionable strange things’ (Bowlby 1977, p. 205). Kobak and Duemmler
and/or supportive interactions which are experienced as more (1994) described three categories of antecedents to attach-
rather than less effective’ (p. 433). ment, defined as ‘attachment system activators’. Fear-provo-
Weiss (1991) identified three features of adult attachment king situations that lead to searches for ‘safe havens’ are the
as evidence that attachment is a developmentally continuous first. This is consistent with Bowlby’s (1969) and Ainsworth’s
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(5), 528–535 531
C. Cookman
et al. (1978) initial descriptions of attachment as serving the central, core ideas used to represent the phenomenon of
evolutionary and protective functions. Additionally, the attachment both in earlier development and in adulthood and
fearful experiences associated with vulnerability and depend- beyond.
ence are thought to precede attachment behaviours (Bradley
& Cafferty 2001), as are exhaustion, distress, and illness
Consequences
(Rholes et al. 1998). Challenging situations that lead adults
to seek out attachment figures to provide a secure base are a The consequences of attachment seemingly follow from the
second antecedent of adult attachment. Thirdly, conflictual early directions provided by Bowlby. Consequences repre-
interactions are hypothesized to be attachment system acti- sent linear extensions of early attachment experiences and
vators by Kobak and Duemmler (1994). Importantly, ante- subsequent personality development initially formed by the
cedents of attachment need not represent actual or ‘real’ infant towards the mother. Hence, the consequence of
danger; simply being alone is sufficient to result in attachment attachment would be the relative persistence of a specified
behaviour (Bowlby 1977). pattern of behaviour throughout one’s life. According to
Bowlby (1988), the scientific task remaining for researchers
interested in attachment is to test the hypothesis that ‘each
Defining attributes
person’s resilience or vulnerability to stressful life events is
Defining attributes are a ‘list of characteristics’ that ‘help you determined to a very significant degree by the pattern of
and others name the occurrence of a specific phenomenon as attachment he or she develops during the early years and
differentiated from another similar or related one’ (Walker & …to clarify to what degrees and in what ways the early-
Avant 1995, p. 39). Ainsworth (1985) listed three criteria of developed patterns influence subsequent development’ (p. 8)
attachment that can serve as defining or critical attributes. Ainsworth (1985) described these consequences of attach-
Firstly, Ainsworth (1985) stated that ‘…attachment figures ment in terms of secure, anxious and avoidant patterns of
are never wholly interchangeable with or replaceable by attachment.
another, even though there be another with whom one is also Heard and Lake (1986) described assuagement as an
attached’ (p. 799). This notion of an attachment figure as outcome of attachment, defined through a description of its
‘preferred and differentiated’ is a widely accepted central three features: ‘(1) an affective experience of mental and
feature of attachment. A ‘…desire to maintain closeness to physical well-being, a feeling of satisfaction and enjoyment
the partner as well as a need to keep proximity to him’ in what one is doing, (2) a sense of confidence and self-
(Ainsworth 1985, p. 800) is reflective of a notion of esteem in the ability to achieve short or longer-term aims,
proximity-keeping that is a second defining attribute. Her which are consistent with stages of life, abilities and
third criterion is the secure base effect, described as ‘the interests, and (3) awareness that one’s personal supportive
experience of comfort and security in relationship to the environment is secure and that opportunities for compan-
other and yet the ability to move off from this secure base ionable and supportive interactions are available’ (p. 431).
with confidence to engage in other activities’ (Ainsworth Assuagement enables individuals to consider the conse-
1985, p. 800). quences of their actions, to see issues from another’s point
Weiss (1991) identified three critical features of adult of view, to reappraise past experiences and to integrate new
attachment: (1) proximity-keeping (to a parent or other approaches with known routines to carry out short- and
attachment figure), (2) secure base effect, and (3) separation longer-term plans. It appears that this view offers a
protest. The first two closely mirror those identified by confounding view of the defining attributes and conse-
Ainsworth (1985). Separation protest arises when proximity quences – namely in its reference to the ‘secure base’ as a
between the person and attachment figure is interrupted result of the concept. For the purposes of this clarification,
(Weiss 1991). Weiss asserted that the secure base effect the notion of a secure base is a central defining attribute of
described by Ainsworth (1982) also applied to adult forms of the concept, not what follows from it. According to Heard
the concept, and also that whereas, the infant displayed more and Lake’s conceptualization, attachment results in the
immature behaviours to represent the ‘secure base effect’, possibility of two dichotomous outcomes: assuagement as
adults displayed mature forms of what was essentially the described above, and a negative outcome called dissasuage-
same behaviour. In adulthood, separation protest leads to ment. Here ‘…an individual suffers loss of a sense of
active attempts at reunion with the attachment object, as confidence and competence in his (sic) ability to manage not
opposed to the crying or withdrawal that may evidence it in only to external circumstances, but also to his own feelings
infancy. Taken together, these three criteria seem to represent and thoughts, and tends to lose faith in what previously
532 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(5), 528–535
Nursing theory and concept development or analysis Attachment in older adulthood
Figure 1 Antecedents, defining attributes, and consequences of Nurses and others working with older adults can use
attachment in older adulthood knowledge about attachment to enhance care for their older
2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(5), 528–535 533
C. Cookman
534 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(5), 528–535
Nursing theory and concept development or analysis Attachment in older adulthood
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