Introduction
As the global population ages, the prevalence of dementia is a growing concern. The World Health Organization (WHO, 2017) predicted that by 2030, 74 million people will be living with dementia, and that this will increase to 132 million by 2050. The WHO (2017: 32) stated, ‘There is a growing interest in, and call for, the use of innovative health technologies in prevention, risk reduction, early diagnosis, treatment, care and support relating to dementia’. Long-term care homes also include special care units to meet the expected care requirements for people living with middle to late stages of dementia (Biggs and Carr, Reference Biggs and Carr2017; Mobley et al., Reference Mobley, Leigh and Malinin2017). One of the significant features of these specialised units is the inclusion of innovative security technology to monitor residents’ movement in real-time. The surveillance technology is designed to maximise residents’ freedom of movement within the unit but curtail any unaccompanied movement out the unit door (Sposaro et al., Reference Sposaro, Danielson and Tyson2010; Bantry White and Montgomery, Reference Bantry White and Montgomery2014a, Reference Bantry White and Montgomery2014b). While these innovations have myriad physical benefits, scholars are engaging with the social impact of these access technologies (Margot-Cattin and Nygárd, Reference Margot-Cattin and Nygárd2006; Mortenson et al., Reference Mortenson, Sixsmith and Woolrych2015; Niemeijer, Reference Niemeijer2015; Urban, Reference Urban, Heidkamp and Kergel2017). This paper will respond to the question, what are the impacts of security interventions on social relationships and care practices on secure long-term care units for people living with dementia?
Recent research has explored how people who live independently respond to passive sensor monitoring systems in terms of privacy concerns (Berridge, Reference Berridge, Adams, Purtova and Leenes2017), negotiations of trust and safety (Lie et al., Reference Lie, Lindsay and Brittain2016), and the tension between providing assistance while maintaining dignity (Bradford et al., Reference Bradford, Kasteren, Zhang and Karunanithi2018). Researchers have found that residents have negative responses to visible security interventions that impede their freedom (Low et al. Reference Low, Draper and Brodaty2004; Torrington, Reference Torrington2006; Fleming et al., Reference Fleming, Goodenough, Low, Chenoweth and Brodaty2014). The ethical dimension of new security technologies has been explored among care-givers on dementia units as they manage conflicting ethics around autonomy and risk management (Niemeijer, Reference Niemeijer2015; Innes et al., Reference Innes, Kelly, Scerri and Abela2016; Berridge, Reference Berridge, Adams, Purtova and Leenes2017). Social gerontologists have also looked at how experiences and perceptions of later life are shaped by practices of surveillance technology (Peine et al., Reference Peine, Faulkner, Jæger and Moors2015; Peine and Neven, Reference Peine and Neven2018), and specifically, by the locking of unit doors (Tufford et al., Reference Tufford, Lowndes, Struthers and Chivers2018). Moving beyond the existing literature, this paper will use the lens of securitisation theory to explore the social impact of security technology that is being implemented on secure units for people living with dementia.
Securitisation theory argues that securitisation discourse shifts audience concerns beyond the immediate problem and creates a broader zeitgeist that influences how messages about the threat and security response are interpreted (Balzacq, Reference Balzacq2005; Strizel, Reference Strizel2007). Securitisation is
the discursive process through which an intersubjective understanding is constructed within a political community to treat something as an existential threat to a valued referent object, and to enable a call for urgent and exceptional measures to deal with the threat. (Wæver and Buzan, Reference Wæver and Buzan2003: 491)
Elbe (Reference Elbe2006) warned that a dangerous ethos can take hold which deems security as universally beneficial, leading to a cycle of increasing security measures. This insight is particularly pertinent in the domain of health where ethical issues arise when the illness is portrayed as a security threat (McInnes and Rushton, Reference McInnes and Rushton2011; Kamradt-Scott and McInnes, Reference Kamradt-Scott and McInnes2012).
Following Holbraad and Pedersen (Reference Holbraad and Pedersen2012), an anthropological extension of securitisation theory contextualises the production of a health issue as a security threat in webs of social relationships, relations of power and societal value systems. Anthropologists Brightman and Grotti (Reference Brightman and Grotti2014) wrote that borders create ‘socialities of securitization’ marked by asymmetrical power relationships and a discourse of securitisation that alienates local people and promotes a feeling of insecurity in everyday social interactions. The border becomes a ‘contact zone’ that is ‘fragmented with multiple environmental, social, ontological borders, visible and invisible, where distinct collectivities meet, clash and grapple with each other’ (Brightman and Grotti, Reference Brightman and Grotti2014: 17–18). By this account, security discourses are enlisted to favour the perspectives of those with power, raising ethical concerns about power and control in the border's social space, as well as questions about how securitisation affects social relationships.
Using securitisation theory and the concept of socialities of securitisation, this paper will explore how the security interventions on dementia units create complex contact zones which do not match the ‘home-like’, person-centred environment on the rest of the unit. The first section of the paper will explore how dementia has been securitised in the context of long-term care, and in the broader industry of health-care technology. This section will employ a Foucauldian analysis to understand concerns about the social impact of institutional power, control and surveillance technology. The second section of the paper will draw upon ethnographic research findings to illustrate how the presence of security technology creates socialities of securitisation. The paper will show how the doorway to secure dementia units becomes a border zone where relationships are marked by ethical tensions, power asymmetries, and experiences of insecurity among visitors, staff and residents. The paper will discuss the intersection of socialities of securitisation and the ethical dilemmas of resident autonomy versus protection in a milieu of risk management. Finally, directions for future research will be considered.
Securitising dementia: vulnerability, threat, risk and challenge
Defining dementia as a security threat takes place through discursive practices within a certain socio-political context. Medicine continues to be a site of security measures on national and international scales (Elbe et al., Reference Elbe, Roemer-Mahler and Long2015). The power of the medical institution to define and control bodies has been well-documented in the literature (Goffman, Reference Goffman1968; Foucault, Reference Foucault1973, Reference Foucault1977; Rose, Reference Rose2007). Increasing attention is being paid to medical governance of the ageing body, with a particular focus on the surveillance of people living with dementia (Powell and Biggs, Reference Powell and Biggs2000; Salzmann-Erikson and Eriksson, Reference Salzmann-Erikson and Eriksson2012; Mortenson et al., Reference Mortenson, Sixsmith and Woolrych2015; Biggs, Reference Biggs2018).
The ageing body is located within a political web fraught with power relations. Powell and Biggs stated that
both historically and contemporaneously, the identities of older people and old age have been constructed through expert discourses of ‘decay’ and ‘deterioration’ and the ‘gaze’ helps to intensify regulation over older people in order to normalize and provide treatment for such notions. (Powell and Biggs, Reference Powell and Biggs2000: 7)
More recently, Biggs (Reference Biggs2018) noted that the promotion of dementia as a disease had detrimental effects on the lives of people living with dementia, and strengthened the medicalised narrative of pathology and loss of self, a shift towards routinised and time-poor care, and a movement away from social and emotional considerations. ‘Dementia’, Biggs (Reference Biggs2018: 141) observed, ‘was seen as a threat to security and autonomy and an ability to retain meaningful membership of society’. Constructing dementia as a disease legitimised security interventions that impacted perceptions of, and social relationships to, people living with dementia.
Foucault (Reference Foucault1973, Reference Foucault1977) described how older bodies were subjected to the medical gaze, as well as disciplinary and surveillance techniques. Secure long-term care dementia units begin to resemble Foucault's mechanism of panopticism, the most efficient and effective surveillance technology, because the gaze of a single supervisor can constantly monitor and control the movement of residents’ bodies. Biomedical surveillance constructs the individual ageing body as an object of power/knowledge, then assesses and defines its status against normalised standards of capability. A diagnosis of dementia will, Biggs (Reference Biggs2018: 134) wrote, ‘reinforce[s] the boundary separating the senile from the rest of us, frees sufferers from responsibility for certain forms of conduct, opens private lives to surveillance and stigmatisation’. The doorway of a secure dementia unit becomes more than a passageway; it becomes a border zone at which the institution exercises its power to define dementia along the lines of securitisation discourse. These definitions, as Brauch (Reference Brauch, Brauch, Liotta, Marquina and Selim2003) asserts, include concepts of vulnerability, risk, threat and security challenge.
The language of biomedicine constructs people living with dementia as simultaneously vulnerable, at risk and a threat to safety. Individuals are vulnerable to the symptoms of their illness, at risk of getting lost or injured because of their symptoms, and a potential safety threat to themselves and others around them. Vulnerability is considered a ‘susceptibility to a certain threat and unusual difficulties in coping and recovering’ (Schäfer, Reference Schäfer2013: 12). An individual is deemed vulnerable if he or she is believed to lack sufficient capacities to prevent, prepare for or cope with hazards. For example, the medicalisation of movement continues to subsume wayfaring into the realm of the pathological with problematic clinical terms such as ‘wandering’, ‘exit-seeking’ and ‘elopement’ (Behuniak, Reference Behuniak2011; Graham, Reference Graham2017). This language of pathology constructs the notion that the individual living with dementia is the victim of his or her illness, and that the symptoms pose a risk and threat to wellbeing.
The application of a pathological model that includes words such as ‘exit-seeking’ and ‘elopement’ constitutes the act of securitising dementia. Ibek (Reference Ibek2015: 176) emphasises the role of the speech act in securitisation theory, stating that ‘speaking is doing’ and ‘public utterances about security are never “innocent reflections”’. Indeed, the securitisation process becomes more significant when the actors do not have to demonstrate that an issue represents a present danger but can simply provide evidence for their claim that the issue might pose a threat to security (Ibek, Reference Ibek2015). Clarke and Heyman (Reference Clarke, Heyman and Heyman1999) and Clarke (Reference Clarke2000) found that professional care-givers’ perceptions of risk in dementia were informed by disease models that predicted certain physical and cognitive decline, whereas family members’ perceptions of risk were based on their experiences of the person.
The association between movement and risk has been reinscribed in the biomedical discourse, where psychometric assessment tools have been produced to measure individual risk. Lester et al. (Reference Lester, Gariet and Kohen2012) have outlined risk factors that could lead an individual to wander (e.g. cognitive impairment, older age, male gender, agitation, and a more socially active and outgoing premorbid lifestyle). The authors also recommend the use of assessment tools to measure a person's risk of wandering (Lester et al., Reference Lester, Gariet and Kohen2012). The continued production and dissemination of ‘wandering’ risk assessment scales (Algase et al., Reference Algase, Moore, Vandeweerd and Gavin-Dreschnack2007; Halek and Bartholomeyczik, Reference Halek and Bartholomeyczik2012) reinscribe the disease model upon which clinicians were found to base their perceptions of risk in dementia. Medical expertise and authority have the capacity to influence drastically perceptions about ageing bodies and best care practice.
Discourse from the security industry corroborates biomedicine's construction of vulnerability, risk, threat and challenge. Schäfer states that risk
presupposes some form of uncertainty that cannot be removed, but with a possibility of managing this uncertainty … Framing future events in the form of risk, means that they can be measured or prioritized; but, perception of risk may not be equal to its measurable impact. (Schäfer, Reference Schäfer2013: 13)
The International Association for Healthcare Security and Safety stated that in long-term care facilities:
One of the greatest risks to residents is their ability to leave the facility unseen and put themselves in harm's way. Elopement is associated with wandering, an act whereby the person is disoriented or unengaged in their environment and goes about seeking someone or something, or wanders randomly. (International Association for Healthcare Security and Safety, 2017: 31)
Another example comes from the industry magazine Doors & Hardware: Advancing Life Safety and Security Solutions, where an annexed endnote specifically states, ‘Alzheimer units and dementia units are examples of areas with patients who might have clinical needs that justify door locking’ (Door and Hardware Institute, 2011: 31). Disease-based labelling is the product of the biomedical power to objectify and label people receiving care. York and MacAlister (Reference York and MacAlister2015) exemplify this point with their published list of ‘patient risk groups’ requiring special security attention. The ‘wandering patient’ was one of the defined risk groups:
Wandering patients are a security concern presented by certain types of dementia patients, most frequently those with Alzheimer's disease. It is estimated that each week at least one resident of the nation's nursing home facilities wanders away from a care facility and dies. (York and MacAlister, Reference York and MacAlister2015: 348)
The securitisation discourse surrounding dementia is further informed by anecdotes about wandering and resident safety. These do not originate with the security industry, but instead with visitors and families of people living with dementia. For example, in 2017, the son-in-law of a victim of assault in long-term care wrote to the Canadian Association of Retired Persons (CARP) explaining that his father-in-law (with dementia) was assaulted by another resident (also with dementia) during the night:
There are no security precautions in place (such as bed alarms, hall cameras or door alarms). This is a government run home and it seems to me like there is a systemic breakdown and gross negligence on the part of the home. (CARP, 2017)
The writer concludes, saying, ‘I have been doing some research and [sic] apparently the volume of dementia patients in Ontario is going to double in the next 10 years’ (CARP, 2017). Personal accounts like these grab the attention of policy makers and regulatory bodies. They also reinforce the idea that security devices are the solution for those living with dementia in long-term care.
Balzacq (Reference Balzacq and Balzacq2011: 15–16) recognised the importance of the social context of securitisation: ‘Security practices’, he said, ‘are enacted, primarily, through policy tools’. In Ontario, Canada, Section 67 of the Retirement Homes Act, 2010 states that no resident may be confined to a living space except according to the following:
The licensee of a retirement home may confine a resident of the home to a secure unit of the home by the use of barriers, locks or other devices or controls in the home if the confinement of the resident is included in the resident's plan of care. (Government of Ontario, 2010)
Other criteria must also be met, including a decision that there is ‘a significant risk that the resident or another person would suffer serious bodily harm if the resident were not so confined’ (Government of Ontario, 2010). If a doctor has written into a resident's plan of care that confinement on a secure unit is necessary, then it is legal to do so.
Once again, the security industry responds to these policies and discursively co-constructs perceptions of vulnerability, risk, threat and challenge with respect to people living with dementia. For example, an advertisement for security technology designed for dementia care stated:
A wandering patient is one of a caregiver's greatest worries. But with patient safety alarms, you can rest assured knowing that you will be alerted if your patient or loved one gets up from a bed or wheelchair, or if a door is opened. These specially designed alarms monitor patient movement, and alert the caregiver or facility staff when this happens. These safety alarms are an important part of a fall prevention program, as it can be dangerous for many patients to leave their beds or wheelchairs without supervision or aid. Patients with Alzheimer's disease or dementia often have tendencies to wander and get lost in their confusion, but patient safety alarms can help alert you when this happens, helping to prevent this fearful risk. (RehabMart, 2017)
Future risk of elopement or border transgression is constructed by the securitisation discourse of dementia from perspectives of both the biomedical field and the security industry. In both home care and long-term care settings, real-time movement monitoring systems can identify the immediate location of an individual, allowing staff to monitor whether the individual or others are at risk of harm (Adams, Reference Adams2001; Caspi, Reference Caspi2014). These security solutions are what care-givers and family members are requesting in personal stories of abuse, such as the letter to CARP cited above. Devices for monitoring personal movement can also be purchased in the form of smartphone applications. For example, iWander is an Android application that remotely monitors a person's movement using a GPS-based service. Care-givers can then be alerted if iWander shows that the person with dementia is exhibiting non-normal activity, or wandering (Sposaro et al., Reference Sposaro, Danielson and Tyson2010). Indeed, it seems as though everyone wins, but there are tensions created by the securitisation of dementia.
The biomedical community assumes the power to define people living with dementia as vulnerable, even among champions of humanistic dementia care. For example, proponents of the culture change movement seek to ‘motivate further efforts to humanize long-term care environments and improve the quality of life for our most vulnerable citizens’ (Shield et al., Reference Shield, Tyler, Lepore, Looze and Miller2014: 396). The culture change literature speaks of making the facility ‘more appealing and home-like’ in order to ‘skillfully connect residents to their identities and prior roles’ (Shield et al., Reference Shield, Tyler, Lepore, Looze and Miller2014: 396). Ironically, culture change practices focus on the home-likeness of the facility contained within the secure perimeter, but conveniently overlook the effects of the secured perimeter itself. Surely, the keypads and security devices at the doorway do not connect residents to their previous roles, unless they spent significant time in another secure environment.
York and MacAlister (Reference York and MacAlister2015: 47) noted the danger regarding health-care security; namely that institutions will follow the adage, ‘more security is better’ when individual facilities begin to exceed national security standards and ‘raise the bar’ with increasingly advanced protection systems. As institutions respond to the securitisation discourse by implementing more security technology, it becomes increasingly important to consider the implications for the people who live in and around these secure environments. The literature is beginning to consider the social impact of securitised thresholds on subjective experiences of dementia and perceptions of people living with dementia (Mortenson et al., Reference Mortenson, Sixsmith and Woolrych2015). The following section will contribute to this new frontier of discussion by considering the ways in which the secure long-term care unit doors construct socialities of securitisation which are lived by residents, care staff and visitors.
Methods
The research for this paper was conducted as part of a larger ethnographic research study examining sociality in long-term care. The university institutional review board approved the research. Informed consents were obtained as part of the larger study. Data collection took place between February 2015 and August 2017 in a Canadian long-term care facility on two secure units for people living with dementia. Each unit had an average of 35 male and female residents, ranging from 82 to 102 years of age (average 87.5 years of age), as well as staff and visitors who came and went throughout the study period. Fieldwork for this research involved participant observation and informal interviews with recreation staff who worked on the units. According to Wolcott (Reference Wolcott2005), participant observation is a naturalistic approach to data collection wherein the fieldworker's own experience is a research instrument. Fieldnotes of observations were documented and coded offsite. Fieldnotes comprised observations as well as comments from residents and family interacting at the secure unit doorway. Informal interviews were conducted with staff members to capture their social experiences at the secure doorway. The ethnographic vignettes presented in this paper were chosen for their capacity to convey the nuance of the social interactions at secure unit doorways.
Results: ethnographic accounts
The door to the secure dementia unit is one of the most fraught places in the long-term care facility. It is a border zone where frictions are intensified and beliefs about identity, power and the ethos of care are intensely negotiated. Recalling the work of Brightman and Grotti (Reference Brightman and Grotti2014), securitised borders create a social environment that has an inherently othering effect on groups of people, creating socialities of securitisation marked by insecurity and asymmetrical power relationships. The secure unit doorway involves many social actors, each with their own assumptions, beliefs and claims to institutional power. Following securitisation theory, the practice of security is open to exploitation because it suspends the normal rules for conduct and in turn justifies controlling groups of people. The following ethnographic data will illustrate how the securitisation contributes to othering and feelings of insecurity, and how social orders within families are disordered at the secure doorway, undermining residents’ sense of autonomy, dignity and selfhood.
In a resident's shoes: experiencing otherness in an environment of insecurity
At my field site, the unit door created an environment of insecurity from the visitors’ perspective. Before entering the secure dementia unit, visitors were greeted by printed signs taped to the unit door that warned them about residents who were at risk of eloping. The signs were made of white computer paper print-outs, some of which were mounted against a bright pink or red paper background. Each sign included a picture of the resident ‘at risk’ and a message reading ‘If you see this resident, DO NOT open the door.’ The aesthetic of the photo was not necessarily complimentary, often looking like a blurry mugshot that was taken quickly, perhaps upon the resident's early arrival at the facility. Over the years, staff had noticed that the number of signs had increased as the demographic entering the secure unit was younger and more able-bodied. At one point during my fieldwork, there were nine warning signs papering the entry door, with only the narrow vertical window left uncovered. Through this window, the residents of concern were often seen looking out into the hallway and were heard trying the handle of the door. The warning signs, frequent sound of alarms and required use of security keypads with codes that changed monthly caused visitors to approach the unit door with trepidation. The following ethnographic account will illustrate the socialities of securitisation that are negotiated at the border zone of the locked door of the secure dementia unit.
One afternoon at the long-term care facility, I sat at a table covered with art materials alongside one of the recreation and creative arts staff, Sandy,Footnote 1 who recounted an experience she had on the secure dementia unit. As discussed, the door to the unit had numerous posted signs warning entering visitors not to let specific residents through the door. Sandy explained that she had spent the afternoon visiting residents on the secure unit with her roving art cart. Sandy wore plain clothes with an identification badge instead of the uniform of scrubs worn by direct care nursing staff. This more casual appearance tended to put residents at ease and normalised social encounters between recreation and creative art staff and the residents. Sandy also had white hair, like many residents on the unit. Having put away her art cart and materials for the day, she approached the exit door of the unit. She happened to approach the door at the same time as a resident's family member was keying in the security code of four numbers and a symbol to unlock the door and leave. Assuming the family member would hold the door open for her as a staff member, Sandy kept her pace and began to follow the visitor through the unlocked door. Suddenly, the visitor spun around and tried to close the door on Sandy to keep her inside the unit. ‘No, no!’, the visitor shouted. Holding up her hand to stop Sandy who was now behind the locked door, the visitor spoke loudly through the small window in the door, ‘You can't come out! You have to stay inside.’ Sandy said that the look on the visitor's face was of sheer terror, likely a reflection of her own expression. Sandy felt a wave of intense panic hit her, feeling suddenly trapped inside the unit, experiencing for herself what a resident would feel in that situation. Sandy's story drew to a close as she recalled that the visitor practically ran away from the scene. Sandy, too, was shaken by the experience.
This vignette illustrates the intensity of the relations at the secure threshold. The exit door is an interface where people are defined and divided, and where they grappled with each other through the tension of asymmetrical power relationships. Sandy recalled that she experienced a sudden flash of insight when she was thrust into the residents’ shoes. She was trapped, her freedom of movement restricted by a locked door, and addressed as if she were a threatening entity that had to be contained within the unit space. Her selfhood as a full-status member of society was undone in that member, replaced by a status as an ‘other’. The encounter was fraught with power tensions for both Sandy and the visitor. The security practices at the threshold of the unit are embedded in a biomedical context that legitimises the hierarchical power structure. The presence of the security interventions defines people living with dementia as vulnerable and positions them as a potential threat to both themselves and others.
Contested selfhoods and re-ordered social roles
During my fieldwork, I observed that the appearance of the unit doors affected how people approached the unit. As noted, with its warning signs and security messages, the appearance of the door to visitors on the outside was markedly different than the door as viewed from the inside. The practices of security technology influenced staff and visitors’ comportment, as well as their relationships with their loved ones who were residents on the secure unit, often in ways that revealed the limits of residents’ autonomy, and in so doing, compromised residents’ dignity and selfhood.
The environment of the secure doorway primed visitors to proceed with caution and approach residents as potential security threats. To leave the unit, the visitor had to enter a code on the keypad to unlock the magnetised door to the outside hallway, while remaining vigilant to loitering or fast-moving residents who may escape through the open door. This feeling of looking back over one's shoulder fostered a sense of insecurity and distrust between visitors and residents. Following Foucault (Reference Foucault1973), ‘the gaze’ is characteristic of biomedical power and surveillance technology. At the secure doorway, the securitised gaze constructed residents as deviant bodies around whom staff and visitors were trained to exercise vigilance. During fieldwork, I noted that family members also adopted the securitised gaze.
I observed that the tension between family members and residents increased around the doorway. Interactions were particularly strained when a family member left while the resident had to stay on the unit. For example, I witnessed the adult children of residents ask a staff member to distract their parent in one part of the unit so that they could leave the unit without the parent following. I also saw family position themselves in the hallway just beyond the sightline of the window in the door so that they could have a conversation without upsetting their loved one on the unit. These were condoned strategies of handling a pragmatically difficult situation that had been learned over the course of their parents’ residency in long-term care. Nevertheless, these moments were uncomfortable for each of the exiting family members, the resident who was left behind and the staff who assumed responsibility for redirecting the resident afterwards. Negotiation of restricted space beyond the unit's perimeter impacted family relationships physically and emotionally. In my fieldnotes, I documented the following family interaction that illustrates the potential tension that arises between spouses at the secure threshold.
One afternoon, I was walking towards the unit door after returning a resident to his room following a choir rehearsal. In front of me, a new resident and his wife walked hand-in-hand towards the exit door. The resident was an 82-year-old army veteran, who walked with a purposeful stride without the assistance of a walker or cane. I had encountered him on previous occasions, and his self-presentation suggested that he was a proud man who was still accustomed to determining his own schedule and dictating his comings and goings. When we crossed paths, our encounters happened to be near the doorway and consisted of him asking me where he could find a telephone to make a phone call or an elevator to get to an appointment he had. He was always trying to find a way to exit the unit. Uncomfortably, I offered that I had seen a telephone back through the dining room and around the corner at the nursing station. I experienced pangs of ambivalence as he thanked me with a tone of sincerity before turning and walking away from the door in pursuit of the promised telephone that would connect him with the outside world. This resident lived on the secure unit because his short-term memory had declined to the point where leaving the unit unattended may have been dangerous for him if he got lost. It was not comfortable to offer false information to re-direct him, but it was in-line with everyday practice and it kept him on the unit.
This day, he was walking his wife out after their visit. I stayed back a polite distance to give them space to say goodbye to one another. I was surprised by what happened next. After a hug and a quick kiss on the cheek, the wife said to her husband, ‘I have to go, and you have to stay here.’ ‘That's alright’, he said, ‘I will just walk out with you to the parking lot.’ ‘No’, she said, ‘You don't come outside with me. You stay here.’ ‘Well, why can't I come with you?’, he asked her. With a louder and more stern tone, she said ‘Because you aren't allowed to! And if you stand too close to the door, I can't leave either because you'll set off the alarms.’ Her husband stood looking confused and more distressed than before. ‘I'm coming with you’, he stated. ‘No, you aren't. I am going, and I will see you tomorrow’, his wife said as she moved quickly towards the door as a staff member came through with a cart of fresh laundry. Turning on his heel, the man moved towards me, stopped with his arms outstretched and asked me, ‘What kind of goddamn place doesn't let a man walk his own wife to the car?’ Not waiting for an answer, he continued walking while swearing under his breath in frustration.
The presence of security technology prevented the resident's practice of his traditional values that, as a husband, he should accompany his wife to her car. His sense of selfhood as a husband, his masculine identity and his authority were all challenged by the security practices embodied by his wife. Her admonishment that he would ‘set off the alarms’ undermined his dignity, casting him as a problematic entity whose presence was impeding her freedom. By the same token, the security technology may have prevented the resident's wife from performing her identity as she usually would, causing her to venture out on her own when she may have enjoyed being escorted to her car in the past. This couple may have followed traditional gender roles, and contrary to the tradition that associates the masculine with the public, and the feminine with the domestic, the securitisation of dementia enforced an inverted reality: the male resident was secured in the domestic-institutional domain, while the female visitor moved freely into the public domain. At the threshold, the interpersonal tension between husband and wife was exacerbated by the tension between the resident's own values and the facility's safety and security protocols for people living with dementia. Friction between family members was not uncommon in long-term care settings. However, tensions ran higher with the complex emotions and power struggles between generations and spouses as the securitised milieu redefined social roles and hierarchies. The following section will discuss these ethnographic findings with respect to the impact of securitisation on social relationships and moral attitudes towards care for people living with dementia.
Socialities of securitisation: towards security-friendly ethics of dementia care
Recalling that securitisation justifies a new exceptional logic of practice, it follows that the securitisation of dementia is accompanied by an exceptional logic of care practice. Secure units continue to raise tensions about ethical care for people living with dementia (Øye and Jacobsen, Reference Øye and Jacobsenin press). Moral tensions are palpable between residents’ freedom and autonomy versus their dependence (Høy et al., Reference Høy, Lillestø, Slettebø, Sæteren, Heggestad, Caspari, Aasgaard, Lohne, Rehnsfeldt, Råholm, Lindwall and Naden2016), protection (Biggs and Carr, Reference Biggs and Carr2017), and infantilisation and assumed incompetence (Heggestad et al., Reference Heggestad, Nortvedt and Slettebø2013). Heggestad et al. (Reference Heggestad, Nortvedt and Slettebø2013) found that people living with dementia experienced secure care units as a prison without bars. At my field site, the institution's risk assessment determined that the application of locks to control residents’ movement to an outdoor garden space was justified given the potential risk to their safety. Renn (Reference Renn2008) noted that cultural attitudes towards risk reinforced by the institution, as well as the personal risk biases of the institution's care staff, inform the perception of justified risk-mitigation strategies. Following Biggs (Reference Biggs2018), it appears that security is prioritised above residents’ agency, dignity and sense of self.
As previously illustrated, at my field site the securitisation discourse became a determining factor for social relationships at the doorway of the secure unit. Balzacq (Reference Balzacq and Balzacq2011) stated that security practices are embedded in politics and enacted through policy tools. In the context of long-term care, security protocols and techniques, such as memorised exit keypad codes, warning signage about specific residents, and sign-in and sign-out procedures, constitute institutional tools through which security was enforced. The securitisation of dementia is constructed through an extraordinary logic that Bright (Reference Bright2012) argues breaks with normal social conduct. At no other space in the care facility would a visitor have shut Sandy in and shouted that she should not be allowed to leave. The visitor perceived Sandy to be a resident with dementia whom she thought was trying to elope, and panicked as a result of the risk that this might occur. The securitisation of the unit's doorway created an environment of risk and (in)security.
Being a part of the (in)secure environment around the unit doorway required visitors and staff to follow security protocols. As described above, warning posters around the unit door drew the gaze of staff and visitors before entering the unit, signalling the security risk posed by the residents beyond the doorway. To exit the unit, staff and visitors had to recall a ‘secret’ keypad code, conceal it from nearby residents and quickly open the door to slip out before a resident could follow. If a resident wearing a security device was within a certain range of the door, the code would not unlock the door or an alarm would sound. In both cases, moving the resident away from the doorway area without explanation had an othering effect, suggesting that the resident was out of place and was outside the arena of honest communication, as will be discussed later. When the alarm was activated, the soundscape became securitised, drawing attention to the ‘deviant’ resident who transgressed the secure boundary. The resident was criminalised in that moment, similar to someone who activates a store security alarm with an unchecked item or an airport security alarm with a forgotten metal object. The security protocols and sounding alarms construct the resident as a deviant body when he or she has committed no offence whatsoever.
There is an embodied dimension to socialities of securitisation that normalises the power asymmetry between the staff, volunteers, visitors and the residents living with dementia. Bourdieu (Reference Bourdieu1977) argued that through habituated action, people use past experience to internalise ideas about who they are in the social order and what to expect in a given situation. Inequalities in the social order come to be normalised, or taken for granted, through repeated symbolic messages and social encounters that reinscribe the dominant group's perspective. Staff, volunteers and visitors who routinely spent time on the secure unit learned a new habitus of security. This new habitus included a sense of watchfulness, finger dexterity with the electronic keypad and rapid footwork to slip through the door quickly (particularly when residents were nearby). The habitus also included a verbal repertoire of white lies and phrases to redirect residents away from the door or ask staff members for assistance removing residents from the doorway space. By the end of my fieldwork, I could tell new staff and visitors by the way they fearfully approached the unit door or failed to visually scan for residents near the door as they entered or exited, sometimes nearly leaving the unit with an ‘at-risk’ resident on their heels.
Social encounters were shaped by the medicalising environment, deeply shifting people's perceptions of, and attitude towards, one another, especially with regard to the movement of people living with dementia (Graham, Reference Graham2017). Illustrated in the above ethnographic accounts, staff and visitors were conditioned to see residents as deviant bodies (even family members became deviant bodies in this space), and residents became conditioned to see staff and visitors as captors, confining them without just cause. The asymmetrical power relationships were embodied through repeated security practices, subtle gestures and learned verbal responses enacted in social encounters at the doorway. Despite the routinised security practices, negotiating the secure doorway day-to-day was an anxious experience because there was no comfortable social script for these social interactions.
The securitisation of dementia justifies an alternative moral code of care wherein risk assessment and mitigation become the hallmarks of good care. This, in turn, negatively affects social relationships on secure units. Biggs (Reference Biggs2018) writes that care is increasingly routinised and carried out in a time-poor work environment which inherently justifies actions that do not meet residents’ needs. In addition to residents’ autonomy, their personhood as legitimate members of the long-term care community is questioned. The securitisation of dementia effectively disqualifies people living with dementia from social engagement and from honest communication (Biggs, Reference Biggs2018).
Along this line, scholars continue to grapple with the ethical validity of deceptions and benevolent manipulation in the care of people living with dementia. The literature has questioned the use of environmental interventions (e.g. sensory cues, fake bus stops and disguised exits) that aim to reduce ‘wandering’ and ‘exit-seeking’ behaviour (Lorey, Reference Lorey2019; Casey et al., Reference Casey, Lynch, Murphy, Cooney, Gannon, Houghton, Hunter, Jordan, Smyth, Felzman and Meskellin press). For example, Biggs and Carr (Reference Biggs and Carr2017: 6) documented environmental cues and sensory prompts at nursing homes, noting ‘Visual cues, smells, and sounds were used to attract residents to certain areas at certain times or reduce interest in thoroughfares and specialist equipment’. Lorey (Reference Lorey2019) observed that even the dementia-friendly care village ‘De Hogeweyk’ in the Netherlands applied a ‘confining solution’ that has been both praised for its innovation and condemned for its specious ethics. These innovative securitised approaches to care construct people living with dementia in a way that impinges on their dignity as cognisant older adults. Through the lens of securitisation theory, such interventions constitute a form of co-securitisation because the intention is to control residents’ movement. Deception and lying have been found to be a pervasive communicative strategy among care-givers of people living with dementia, and have been rationalised as ways to manage behaviour, ease distress, increase compliance, save time and improve residents’ overall wellbeing (Tuckett, Reference Tuckett2012; Russell, Reference Russell2018). ‘Therapeutic lying’ was considered acceptable if care-givers lied to someone they knew and for whom they felt empathy, with the intention of alleviating distress rather than to deceive (Casey et al., Reference Casey, Lynch, Murphy, Cooney, Gannon, Houghton, Hunter, Jordan, Smyth, Felzman and Meskellin press). At the secure doorway, staff, visitors and residents do not always know each other well. The nature of the social encounter is marked by an environment of insecurity that has already constructed the resident as an ‘at-risk’ individual threatening to breach the secure perimeter. Empathy for the other may be difficult to engender in such a fraught context.
Through securitisation, security-friendly ethics may become synonymous with dementia-friendly care. The ethical dilemma about whether secure units are in the residents’ best interest continues, but the problem becomes more complicated as the politics of care shift in favour of technological innovation. As I have argued in this paper, the impacts of security technology on social relationships within secure units are situated in a biomedical environment that increasingly endorses and invests in health security. As health care embraces security technology in dementia care, the securitisation of dementia becomes increasingly accepted. This may lead to a recalibration of ethical stances about the use of security interventions for people living with dementia. In the new milieu of securitisation, concerns about the personal and social impacts of security technology may be overshadowed by the drive towards security. Securitisation theory warns us that security begets more security and becomes self-justifying (York and MacAlister, Reference York and MacAlister2015). Indeed, securitised care practices appear to contribute to socialities of securitisation on secure units in ways that undermine the autonomy, dignity and selfhood of people living with dementia.
Conclusion
This paper explored both the way in which dementia has become a security issue, and some of the effects that the presence of security technology has for people living on secure dementia units and their care-givers. The securitisation of dementia has been co-constructed through medical discourse, the security industry and anecdotal accounts from residents’ family members expressing concern for the safety of their loved ones. I have suggested in this paper that the securitisation of dementia has influenced understandings of vulnerability, risk, security threat and security challenge inherent to caring for people living with dementia.
Ethnographic accounts from fieldwork on a secure long-term care dementia unit were used to illustrate the way in which security practices at the unit thresholds created socialities of securitisation. I argued that the securitisation of dementia created an environment of insecurity in which visitors learned a habitus of vigilance and trepidation on the unit. Relationships between visitors and residents were marked by tension as family structures and social roles were disordered in the space of the secure doorway.
Future research should continue to investigate the social impact of security and surveillance technologies on spaces of dementia care through participant observation and long-term site visits. This will enable researchers to capture the nuance in social relationships at the secure doorway. It would be worthwhile to explore further the ways in which issues of vulnerability, risk, security threat and security challenge are discursively constructed by various stakeholders and participants associated with the field of dementia care. Moreover, it is incumbent upon researchers, technology developers and care-givers to consider how the introduction of security and surveillance technologies is influencing how ethics in dementia care are being understood and practised.
Strengths and limitations
As with most ethnographic research, generalisability may be limited because the research was focused on a single site. However, given the duration of research, the vignettes included in this work are representative of patterns of social interactions and brief, but fraught, encounters at the secure doorway. The strength of ethnographic research is that it captures the complexities and nuances of social relationships as they play out in everyday life, thereby offering insight into the social tensions at the secure doorway.
Financial support
This work was supported by the Social Sciences and Humanities Research Council of Canada (grant number 767-2015-1245).
Conflict of interest
The author declares no conflicts of interest.
Ethical standards
The Carleton University ethics board approved the research (IRB #102012).
