A story of attachment, loss, inclusion and an ongoing recovery · using Attachment Theory. Lorimer Gardens’ Mary McFarlane attended a seminar presented by Dan Hughes, a Clinical

A story of attachment,loss, inclusion and anongoing recovery

Dealing with bereavement and loss isoften cited as one of the moststressful events you can experience

in life. Trusted advice and guidance focuseson how you should try and express yourfeelings through talking, writing things downand sharing with other people who may havealso lost a loved one. Just imagine trying tocope with attachment and loss if you havecomplex needs which limit youropportunities to communicate accurately

your thoughts, feelings and frustrations.Lizzie is a 20-year-old woman with a great

sense of humour. She spends most of her lifein a wheelchair, needs total assistance to eat,drink and live. Lizzie does not speak butcommunicates through eye pointing. Lizzie’slife story is full of trauma and this case studyoutlines the effect of this on her behaviour, aswell as the work Aberlour undertook – alongwith colleagues in the health sector – to usetherapeutic methods to help her understand

and come to terms with her past.When Lizzie was born there were major

concerns as to whether she would survive.Her first few weeks were spent in a specialcare baby unit. She was diagnosed at six-months-old as having Cerebral Palsy withDyskinesia (affecting muscle tone and use oftrunk and limbs). By the time Lizzie was one-year-old her mum was becoming depressedabout her lack of progress and was beginningto wonder about their future as a family.

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Feature May 2009

Mary McFarlane, a manager at Lorimer Gardens, an Aberlour resource for children and young peopleaffected by complex and multiple disabilities, explains the story of Lizzie, a disabled woman with painfulexperiences of having lost people who were close to her. When her behaviour some years laterdemonstrated clear signs of emotional distress, staff at Lorimer Gardens looked towards AttachmentTheory for answers that would help Lizzie cope more effectively with her past.

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By the time Lizzie was 18-months-old herparents had been to see numerous specialistsat home and abroad. They were assured thatwith a great deal of work they might be ableto teach Lizzie to walk and talk. The exerciseregime was twice a day and was gruelling anddistressing. When Lizzie’s brother was bornshe was three-years-old. At around this time,her parents were given the devastating newsthat Lizzie would never talk and that shewould need intensive care and support forthe rest of her life. After much soul-searchingthe family pursued adoption/fostering forLizzie and, a week before her younger sisterwas born, she was placed with a short-termfoster carer. Lizzie was now four-and-a-half-years-old.

A year later, Lizzie moved to a long-termfoster placement with Margaret, Richard andtheir two sons in Glenrothes. This placementprovided Lizzie with over three years ofstability and happiness, yet tragically this wasshort-lived as her foster mother, Margaret,developed terminal cancer and died. DuringMargaret’s illness Lizzie experienced a ‘sharedcare’ arrangement at Lorimer Gardens, whereshe moved permanently after Margaret died.Richard, her foster father, remains a constantin Lizzie’s life – without fail taking her to thehome games of her favourite football team,Dunfermline FC.

At aged nine, when Lizzie first moved toLorimer full-time, she was a sad anddistressed little girl. Yet after an initialsettling-in period, staff noted that sheappeared to enjoy the new experiences livingat Lorimer could offer her, something thatwould continue for the next five years of herlife, until Lizzie was well into her teens.

Teenage years for any young person arechallenging. It is a time of change, physicallyand mentally, which coincides with anunwillingness to communicate those feelings.When Lizzie turned 14 there was a dramaticdeterioration in her general well-being. Shelost her sparkle, stopped laughing andseemed reluctant to connect with anyone.She also started self-harming, biting andgouging her hands and arms. She would bitestaff and was constantly agitated, not eatingor sleeping well. Staff had to put cottongloves on her hands and arms to prevent herbiting and she was given special walkingsocks to prevent her feet blistering from

constant agitation and movement. Staff alsohad to use upper arm supports to preventinfection and damage to her skin. Workers atAberlour became seriously concerned aboutLizzie’s physical and mental health,convinced that her behaviour was notconnected to her complex physical needs.

Mary McFarlane, Service Manager atLorimer Gardens, explains how theyapproached the problem: “We sought advicefrom a number of health professionals withvery little success. We were convinced theamount of loss, trauma and change Lizziehad experienced in the past was now causingher behaviour. Staff realised she could havelittle understanding of her past, or ameaningful explanation of what hadhappened, or any real opportunity to grieve.They agreed that Lizzie must have feltabandoned, frightened and somehow felt shewas to blame for the losses. We took the viewthat attachment and loss issues were key toher self-destructive behaviours.”

Having reached this conclusion we agreedwe could help Lizzie by understanding andusing Attachment Theory. Lorimer Gardens’Mary McFarlane attended a seminarpresented by Dan Hughes, a ClinicalPsychologist and Play Therapist, as well asauthor of Building the Bonds of Attachment:Awakening Love in Deeply Troubled Children(Aronson 2006). His dyadic and therapeuticapproach to working with children assists

those who have experienced trauma and lossto start on the road to recovery.

Mary found little research connectingAttachment Theory to caring for childrenwith complex difficulties, but what she foundsuggested, as one 1995 research paper, put it,that: ‘Professional carers need to take onboard that facilitating secure attachmentrelationships for distressed clients may bedifficult for professionals, but partialassuagement of their attachment needs is arealistic clinical goal’ (Clegg JA, Lansdall-Welfare R. Journal of Intellectual Disability: atheoretical review informing three clinicalinterventions).

The team at Aberlour then worked withEdwina Grant, Independent CharteredPsychologist and Person Centred Therapist,who facilitated an initial training day toensure everyone received a basicunderstanding of Attachment Theory. Thishelped staff understand Lizzie’s past and howthey might help her move forward.

Looking back, Edwina explains: “Thetraining showed how inclusion andattachment inform what makes life worthliving for all of us: having warm, close,trusting relationships that grow with us;making choices, developing skills andabilities, having a respected and valued role.It highlighted how everyone needs to beincluded, everyone needs relationships,everyone can communicate, everyone canlearn, and everyone has their own gifts andstrengths, everyone needs support – somemore than others.”

Mary spent time briefing Edwina aboutLizzie’s life story – her personality, her likesand dislikes, talents and struggles. With herbirth mother’s permission, she also sharedthe diary her mother wrote about Lizzie’sfirst years. “There was little doubt in my

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May 2009 Feature

“Lizzie is a 20-year-old woman with a great sense ofhumour. She spends most of her life in a wheelchair,needs total assistance to eat, drink and live. Lizzie doesnot speak but communicates through eye pointing.Lizzie’s life story is full of trauma.”

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Dunfermline Football Club is one of Lizzie’s passions,with her foster-father taking her to every home match

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mind that much of Lizzie’s distressed andchallenging behaviour was an ordinaryhuman reaction to separation and loss,” saysEdwina. Lizzie’s self-harming was deliberateand she seemed numb to hurting herself,offering no reaction to the pain – althoughinterestingly, if she was hurt accidentally shedid react to the pain. Lizzie seemed to beexperiencing powerful feelings with nounderstanding of events and limitedopportunities or means to share her feelings.Some of her behaviours, such as gouging herarms, were deep-rooted – she arrived atLorimer Gardens at seven-years-old withmarks on her arms, and eating had been aproblem since she was a baby. Overall, it wasno surprise she had lost her ‘sparkle’.”

Mary and her team formulated atherapeutic plan aimed at Lizzie’s emotionalrecovery, knowing that she needed: to be andfeel safe; to feel special – loved and cherished;to be accepted; to belong and feel included;to have fun; to be heard and tocommunicate; and to have success.

Aberlour staff realised these needs had tobe met within the context of a secureattachment relationship. The staff wereacutely aware that all her close relationships,except Richard, her foster father, were withpaid professionals. To meet Lizzie’s needs, theaction plan – which had the permission andsupport of Lizzie’s family – commenced inFebruary 2007. It included the following: •Richard to continue his weekly visits tospend time with Lizzie, extending this fromgoing to see Dunfermline play to spendingtime with her in her home at LorimerGardens.• Four members of the Lorimer team

becoming Lizzie’s ‘anchors’, committed tospending individual time with her every day,helping her to feel special and doing thingsthat she enjoyed – reading to her, holding

hands, watching TV, cuddling her, telling herabout their day and encouraging her to tellthem stories from her day. Lizzie cannotspeak words but she can most definitelycommunicate, not only with eye pointingbut with sounds that clearly indicate hermood, from grouching to giggling. A vitalpart of the work was to engage Lizzie in eyecontact, responding to Lizzie’s reactions andallowing her to lead the conversation. Theteam thought a good time and place wouldbe in Lizzie’s bedroom, between her cominghome from day-care and tea-time. Lizzielikes this time to stretch out on her bed, inher own room which allows heruninterrupted time and privacy. As a staffteam Lorimer is committed to a person-centred approach and had to ensure thatLizzie had the choice not to participate – anoption she has only chosen on a fewoccasions.

• Mary McFarlane put together aphotographic Life Story Book for Lizziestarting from when she was a baby,explaining the events in her life, includingthe separation from her family and thedeath of Margaret, while also celebrating herpast and present successes. One member ofthe Lorimer team would read this withLizzie, acknowledging the privacy of such astory.

• Using relaxing, pleasurable sensoryexperiences to give Lizzie an opportunity toenjoy and trust touch. These included Reiki,hand massages, foot massages and nailpainting. We also began removing Lizzie’sgloves a few minutes at a time, to give herback as much freedom as possible.

• Creating opportunities to have fun andlaugh with Lizzie.

• To acknowledge and stay (safely) withLizzie’s anger and emotional pain. We alsoassisted her in opening up her strongfeelings by showing empathy – ‘this is hardfor you’, ‘you look upset’, ‘I am here to helpyou stay safe’, ‘I want to stay with you justnow’ – rather than deny these feelings or tryto joke or talk her out of it (‘don’t be angry’,‘no need to be upset’, ‘let’s cheer you up’, or‘you’ll be ok’).

• To talk to Lizzie appropriately about feelingsand about how staff are feeling,

demonstrating emotions in their faces aswell as verbally.• Realising that Lizzie’s problems withsleeping could be as simple as not feelingsecure in her bed. Staff bought a larger duvetand tucked it tightly round Lizzie and underthe mattress. She now sleeps soundly.

• Good communication and recording in theteam to be clear what is working and what isdifficult and/or challenging.

• Continued consultation between the teamabout understanding Lizzie’s feelings andbehaviour, the pace of unfolding the plan,monitoring success and tackling challenges.The plan has proven extremely effective,

with Dr C.R Steer, Consultant Paediatricianfrom The Victoria Hospital, Kirkaldy, amongthose to have commented on the positivechanges in Lizzie’s overall well-being due tothe therapeutic work undertaken by staff indealing with her attachment and loss.Reflecting on the plan, Mary McFarlane says:“The change in Lizzie is amazing and all thishas been achieved through a new approachtailored to her specific needs, without havingto increase her medication. Lizzie has hersparkle back, she is much morecommunicative and vocal, smiling andlaughing. Her eye contact is much better andshe is now interested in what is happeningaround her. People who know her havecommented on how happy, healthy and wellshe is looking. Lizzie’s close staff anchors havenoted how responsive she is, especially duringher special time with them. The agitation andbiting has lessened. Lizzie loves skin-on-skincontact and is now able to enjoy theexperience of both massage and Reiki. It islovely to see her lying still, calm and totallyrelaxed.”

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“Lizzie must have felt abandoned, frightened andsomehow felt she was to blame for the losses. We tookthe view that attachment and loss issues were key toLizzie’s self destructive behaviours. Having reached thisconclusion we agreed we could help Lizzie byunderstanding and using Attachment Theory.”

Feature May 2009

The care at Lorimer Gardens is provided within alongstanding positive partnership arrangement withthe City of Edinburgh Council, the commissioningauthority with responsibility for her care planning.This article was written by Mary McFarlane, theManager at Lorimer Gardens, with help from RitaCrawford, Assistant Services Manager, and EdwinaGrant, Independent Psychologist and Person CentredTherapist. It includes the methodology of DanHughes, Clinical Psychologist and Play Therapist.

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