Embracing Touch in Dementia Care, A review of Luke Tanner's book

“With the onset of cognitive impairment, the experience of touch will increasingly determine someone's sense of relationships, their expectations of caregiving interactions and the intentions of their carers.” (p45)​

​Luke Tanner’s book comes from his recognition of “the power of touch but also the negative impact of a clinical, task-oriented culture of care” (p17) and inside this culture, he seeks to explore the question of touch in dementia care. 
Through case studies and discussion, the book explores different types of touch and how these types of touch can affect the person being cared for. Tanner discusses issues such as consent with cognitive impairment, misuse of and abusive touch, intimacy, relationships, sexuality, sensory issues, attachment disorders, types of touch, and types and effects of different care giving environments.
In his experience working in dementia care homes, Tanner has found a lack of discussion and lack of precision in policy regarding touch, but has found a general culture of prohibition of intimate touch - such as hugging - though no explicit prohibition has been made.

In this vague cultural norm, Tanner finds some types of touch are more readily acceptable than others. Massage, for instance, is “acceptable” whilst hugging or hand holding is not - even when the latter might feel more appropriate, helpful and supportive to the recipient of the touch.

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Tanner states: “In the absence of a focused discussion and debate on touching in professional care and caring relationships, attitudes towards touch within the care sector of vulnerable to becoming overly determined by discourses of abuse, exploitation and litigation.” (p15)
Tanner describes four “models of care and cultures of touch” which he believes most cultures of care fall into:
- The Clinical Service; 
- The Confused Service; 
- The Creative Service; 
- The Congruent Service.

This book has a very clear perspective starting point - the beneficiary styles of certain types of touch, and the detrimental effect of touch being restricted to what is only considered clinically “necessary.”

Much touch in dementia care is limited to perfunctory clinical touch, and Tanner discusses the reasons why, and the serious consequences of this type of care.

Much space in this book is given to the factors involved in different types of touch, and why certain cultures of touch might be encouraged in spite of negative outcomes.
Tanner offers plentiful discussion points, many of which will feel intuitive to us as fully trained Biodynamic massage practitioners. I imagine, from what Tanner says, that from the point of view of a care home worker, much of the discussion will bring fresh insight into a subject that has never before had the light of consciousness shined upon it. 

​Tanner is seeking a radical culture change.

Tanner offering free hugs in London.

Tanner proceeds to discuss the individual nature of the experience of touch. Again, this covers content we will be familiar with from our Biodynamic Massage training. He also discusses touch specifically from the point of view of those with cognitive impairment.

Tanner says that “caregiving depends on one person's ability to offer help and another person's ability to receive it.” (p60) Early attachment is a factor in what is brought up for those with dementia: “dementia often undermines someone's capacity to draw on sophisticated coping mechanisms and the knowledge and insights they have acquired in the shorter term” so that “someone experiencing dementia will be more reliant on the primitive coping mechanisms lay down in their early life.” (p62)

Reverting to early attachment styles for an insecure avoidant attachment can mean a care recipient is mistaken for having more severe dementia than they actually have, when they are simply acting out early coping mechanisms, such as an inability to reach out for help due to a fear of the consequences, in spite of a real need for care.
Tanner describes providing specific, individualised care informed by knowledge of insecure attachment disorders, in order to best reach the dementia patient with the care offered. This is important because “A person's attachment style can be as much a determinant of their quality of life as their level of dementia.” (p71) The right care will significantly reduce stress levels of the patient and “Caregiving situations can either make or break secure attachment.” (p72)

Embracing Touch in Dementia Care is a book helpful for anyone working in a care home setting and is interesting for anyone who works with touch, generally. Many of us will have experienced clients who are hard to reach and resistance to care. Particularly in regard to insecure attachment, there is plenty in this book that will be helpful for any practitioner in reaching out to those clients and providing them with the right support to help them feel safe and able to receive touch, and able to connect with their bodies through that touch.

Tanner's description of attachment disorders is full of understanding and humanity. He writes with none of the "condemning the other" tone that psychology books often imply, and which can feel harsh and humiliating to any reader who might associate with these descriptions. In our “one size fits all” society, normal parenting alone can lead to attachment disorders. An understanding of attachment disorders therefore helps explain why certain people find certain things more traumatic than others where a "disability” masks mental health problems. For instance, in the case that the client is particularly sensitive or autistic, building a secure attachment is that bit more difficult, and “normal” parenting is likely to lead the child to trauma.

I also enjoy the humanity Tanner expresses in his case studies and descriptions of care homes. I have my own experience in working with people in care environments and hospitals and always remember one man I worked with called Peter. He was a big, burly fellow and was being encouraged to do a jigsaw puzzle. I sat with him to do the puzzle but he showed little or no interest. I instinctively asked him about what he liked doing when he was at home and he told me “I like doing my motorcycles.”

I was struck with the indignity of making this skilled mechanic sit down at a table and do a jigsaw puzzle, and the implication that if he didn't engage, it was a problem with his recovery rather than, as I felt, a result of a natural lack of interest. I was a young, inexperienced member of staff and I didn't understand a fraction of the huge momentum behind the way patients are treated in care environments. I simply felt disappointed and concerned.

In terms of discussing activities, discussing medication, discussing anything, I observed a “them and us” atmosphere where the patient was excluded and not consulted or informed. This is clearly discussed by Tanner as detrimental to patient care. I felt the patient was secondary to “getting the job done” as simply and efficiently as possible, and a “one size fits all” policy was what I found in evidence. The trail of desolation this practice left in its wake was, as Tanner describes in his concluding chapter, basically unseen. (p197) 

Poor care is hiding in plain sight.

I'm glad to read Luke Tanner's book, and hope it has the impact it deserves in the area of the institutional care of vulnerable people.

By Ruth Baigent, 9th April 2018
First published in the Journal for Biodynamic Massage, Vol. 19, Issue no. 2, Summer 2018