“Mostly it is loss that teaches us about the worth of things”
Dave (not his real name) had mesothelioma; a particularly unpleasant form of lung cancer related to exposure to asbestos. He was angry; he had been given a pile of leaflets when he left hospital, on the day that he was diagnosed, and all of them focused on the negative – not one of them, in his opinion, had a good thing to say about his type of cancer. He was angry that they didn’t tell the truth; by describing his disease as being terminal the authors were in the wrong. He wanted to be told that there was a happy ending – and who could blame him? When he talked about his illness, he kept describing himself as strong “I’ve never been kept down by anything, so I won’t be letting this thing get the better of me”. He was angry about all sorts of things; the fact he could not muster up the energy to keep fit on his treadmill, the fact that the chemotherapy meant that he needed to avoid risk of infection and his wife had insisted he stay at home rather than going out with the grandchildren, who were all a bit sniffly and snotty that day. He was angry about needing to leave work – “I’ve been a mechanic all my life”. He was upset about his wife having to care for him – “makes me feel useless”. He listed all the things that he couldn’t do, all the things that he had lost, and all the ways in which he didn’t feel like himself any more”.
According to Buddhism, the root of all suffering is attachment; to ideas of self, to other people, to our role, to material possessions. To feel sadness about losing something, the thing that one has lost must be something to which one feels attached, and the depth of pain of a loss depends on the nature of the attachment to the thing that is lost – be it material, relational or functional. Losses would not sting unless the thing being lost was something to which the person is attached. We are all hopelessly and helplessly attached; looking around me, I see photographs of my children, my devoted and daft dogs are fighting under my feet, my husband’s shoes lie on the chair next to me… all symbols of the things to which I feel connected in different ways and to different degrees.
Loss is at the root of grief. In order for the loss of something to cause suffering, one has to have had an attachment to it. SN Goenka tells an anecdote about how you might feel as you watched your favourite wristwatch fall from your wrist, and smash to the ground, into hundreds of pieces. Naturally, he says, you might feel upset, you might feel aggrieved. But if your friend has the same watch and drops and breaks it, you do not feel the same depth of emotion; you might even offer platitudes – “don’t worry, you can buy another one”, or “it never suited you anyway”, finding yourself bewildered by the tears being shed by your friend about the loss of this inanimate object. The meaning of the watch might be something unique to the friend; perhaps it was owned by his now-deceased father, or was bought for him by a long-gone lover. The root of the suffering at the smashed watch was not in the destruction of the metal, glass and leather, but in the nature of the attachment to the whole thing.
In psychology, attachment is not thought of so much in terms of material possessions or roles, but to “lasting psychological connections between people”. Otto Rank suggested that people suffer from two fears: the fear of life (in which separation anxiety finds its root, fear of life refers to a need to be part of something greater than oneself, to create meaning out of existence), and the fear of death (and loss of that thing we call the “self”). He suggests that we are “thrown back and forth” between these two poles for all of our lives. According to Freud humans manifest paradoxical instincts towards death and love, Thanatos and Eros; the paradox of destructiveness and separation, alongside the pleasure and pain of love and connection, describe in secular terms a similar perspective to that put forward within Buddhism. Would we fall in love if we were truly aware of the impermanence of all things, including our relationships and ultimately our mortal bodies? Freud says yes, of course – the source of meaning in life is connection and attachment, this is part of the nature of being human, and yet this is our very weakness and the thing that opens us up to grief.
Bowlby observed that when children feel threatened or upset, they seek security in the form of a reliable adult who symbolises safety and security. Early in life, a pattern of attachment is established in which the presence of threat or danger causes us to seek out protection from people we perceive to be stronger than ourselves. These patterns were shown to apply across the lifespan: adults, too, seek security in response to threat.
The people we care for are all experiencing losses of one sort or other – otherwise they would have no need of health care. As people face illness and debility, they involuntarily become “patients” – in many cases, experiencing the vulnerability that accompanies this transition. Facing life-limiting illness presents a particular set of threats – people fear losing independence, security, health, control, comfort … and ultimately, life.
Unsurprisingly, the state of becoming a patient frequently leads people to seek reassurance and security from attachment figures in the form of the health professionals caring for them. Feeling vulnerable can make people regress to patterns of behaviour associated with earlier life, and an admission to a hospital or being given bad news can catalyse this process.
The dynamics between health professionals and the people for whom they care are influenced by the attachment patterns that are played out in the patient-professional relationship (for more, read this).
Yet the attachment that patients seek is not always welcomed by the health professionals. The first nursing research on the “unpopular patient” was undertaken in the 1970s, yet many of the findings still ring true – nurses at that time were observed to have negative perceptions of patients who were seen as overly dependent, “bellringers”, or malingerers. Yet these patients are potentially the most vulnerable; they are the ones who seek attachment and safety from the health professionals around them.
People exhibit different styles of attachment to authority figures: secure, anxious and avoidant. This second style of attachment is particularly interesting in the case of vulnerable people in hospital; attachment anxiety refers to whether a person feels that the other will be available in their time of need. A “bellringer” might just be an anxiously-attached individual, frightened that they will be abandoned, and testing out the presence and responsiveness of her carers by frequent pushing of boundaries. These types of behaviours have been called hyperactive attachment strategies (for some illuminating case studies describing different attachment styles in patients in palliative care settings, see here)
Attachment style of health professionals is also important. People who are able to develop more secure attachments have been shown to be more able to provide sensitive care. An anxious or avoidance attachment style can lead to feeling disinclined towards compassionate behaviour; an anxious person will focus on self-preservation, avoid closeness and connection out of fear, and block out anything that might increase the sense of anxiety, such as the suffering of another person. An avoidant attachment style can lead to health professionals distancing themselves from anything which makes them aware of their own vulnerability, thus separating themselves from the possibility that the plight of the person might be something that they, too, may one day experience. This approach can lead to pity, as opposed to empathy, which can further increase the distance between the health professional and the patient.
Care and compassion have always been the rally cry of the nursing profession, but with this comes a price. If we are mandated to care and connect with our patients, as indeed we often do, then it goes without saying that our connections will be deeper, our attachments stronger, and therefore our sense of loss in response to theirs will be greater. The logical opposite to this is to maintain a detachment from those people under our care who are facing loss of life – this has found it’s way into the healthcare literature under the pseudonym of “professional distancing“.
At one time it was popular to encourage students in nursing and medicine to maintain a healthy detachment from their patients, in order to enable them to psychologically manage the level of suffering that they witness in their daily work. Indeed, in the 1970s there were publications aimed at such students with titles like… suggesting that the process of professionalisation involves developing detachment. In modern times the patient is placed at the centre of care, viewed as an active participant, a collabator in co-created goals of care. Yet something is awry; if it were not so, why would there be evidence that suggests that empathy in both medical and nursing students declines during their training and in subsequent years. One reason for this is supposed to be that in striving towards professionalism, students realise that in order to survive they need to not get too involved in their patients’ stories and losses, the pressures of the health service to minimise risk and maximise efficiency are antithetical to the time required to connect and attach to patients. There is still a felt need to justify and explain the distance that they create as a means of protecting themselves from adverse effects of exposure to suffering, or to help with objectivity in the consultation.
The “experience” of compassion can only occur when
(1) there are affectional ties (ie attachment) between people
(2) there is awareness of suffering
(3) this awareness of suffering generates discomfort or distress in the observer.
In other words, it is not possible to be compassionate without experiencing the attachment and associated emotions that arise in the space between us and those we care for (for more on this, see Schulz).
The high demands of the clinical environment can increase levels of general anxiety, but they can also affect people’s attachment styles and patterns. The importance of good and supportive teamwork is directly implicated in the development of securely attached individuals, which then renders them less likely to distance themselves from sources of suffering in the name of self-protection. Being unsupported in the workplace can lead to stress, burnout and compassion fatigue.
In developing and sustaining a compassionate team, it is worth bearing attachment theory in mind. Frontline health professionals, particularly in nursing, are frequently assigned the position of being the strong and reliable “other” for the suffering patient, the security figure whose role it is to enhance the self-esteem and confidence of the vulnerable and the dispossessed. There will be times when they, too, need to identify a person who embodies wisdom and security in order that their own attachments can be sustained. Supporting staff does more than reduce absences and enhance the quality of working relationships; it has a direct and palpable impact on the quality of care, and meeting the needs of an increasingly vulnerable population of patients. It enables staff to fulfil a role for which they are often unprepared, that of representing an attachment figure for people who are experiencing palpable and painful losses.