Mel was 11 years old when she was referred to the Keys Attachment Centre after three foster care breakdowns.

She has three siblings, all of whom are being looked after by foster carers.

When she first started school, her teachers expressed worries about her lack of care and her aggressive behaviour towards other children.

Mel and her siblings witnessed a lot of violence at home between their mother and her many male partners.

Mel had experienced a large number of short-term, temporary 'care' arrangements in which she would be looked after by one or more of her mother's friends.

Various concerns eventually led to Mel being placed with foster carers at the age of five. Over the next five years, Mel reacted with great distress in any situation that she perceived to be threatening.

If someone unexpectedly knocked on her bedroom door, she would yell, scream and run out into the street shouting 'They're going to kill me' while literally pulling chunks out of her hair.

Each of her several foster carers said that Mel was 'unresponsive' and 'switched off' for much of the time, except when there were violent outbursts of anger and aggression, directed mainly at the foster mother or female carer. She never laughed or smiled and had no sense of humour.

Foster carers found her very difficult to handle and each placement would end with an urgent request to have her removed. They felt the more they tried to get close to Mel, the more frightened and determined she was to push them away.

From knowledge of Mel's pre-placement care, it seems that she would only get a cuddle from her mother after there had been violence and she began to associate blood and violence with comfort and care - that you could not have love until there had been hurt and aggression.

It also seemed that at times of distress, Mel took on the role of carer for her mother, suppressing her own attachment needs to meet those of her parent.

In foster care, Mel constantly threatened to hurt herself or run away, particularly when she felt that she could not be in control.

Other children rejected and taunted her. She would hoard food, take other children's audio-tapes, watches and earrings, both in her foster homes and at school.

She would regularly wet herself but not wash so that there was a constant smell of urine around her. Her knickers would be soiled but she either put them back on or would hide them in her bedroom.

At school, she would tell fantastic stories about how she had recently been raped, and that boys were always having sex with her, but investigations suggested that these incidents had not really happened. Rather, it was felt that Mel had seen, and even possibly experienced, a lot of sexual activity in the home of her birth mother.

An important therapeutic aim in working with Mel was to help her to recognise that in her dealings with caring adults, she was operating on the assumption that first you had to experience pain and violence before you could get love and attention.

Through holding and role play, Mel was helped to recognise this association, by relinquishing control, she could then experience care that was not conditional on the prior expression of hurt and aggression. She was also helped to distinguish between her needs and wants.

It seemed to Mel that the only way to gain proximity with her mother was to reverse roles and 'parent her parent'. In her play, Mel repeatedly enacted adults being violent towards each other followed by her, the child, providing them with comfort.

The developmental price paid for this strategy was that Mel had to deny her own attachment needs; she could not admit or acknowledge her own strong feelings; she had to be in control; she could not afford to be dependent on adults; she was the emotional provider and not the receiver.

Although Mel felt on familiar ground with her mother and therefore believed that was where she was best placed, so long as she continued to believe this to be true she could not acknowledge that her mother had failed to provide her with care and protection, and that this failure had caused her much neglect, distress and considerable anger.

It was necessary for Mel to begin to recognise and understand both her own needs and her mother's unwillingness and inability to care for her.

Mel was eventually able to articulate that her mother 'hadn't done her job properly' and that for a vulnerable child that was hurtful as well as sad.

Her anger and sadness at the realisation that her birth mother would never be capable of looking after her safely began to be redirected away from her female foster carer towards her own mother.

In the past, Mel was unable to let her fear show. She could only keep profound feelings of distress at bay by being in control and not letting anyone close to her.

The holding and cognitive restructuring allowed Mel to accept contact and comfort from her carers without first causing hurt.

She learned to say that she would like a cuddle without first having to attack her carer. It was as if she was beginning to see herself in her own right, with her own needs.

Mel began to talk about feeling anxious when a preferred carer was not immediately available and how this sometimes made her feel cross and angry.

Connections began to be made between her feelings and behaviour. She also allowed herself to feel dependent and explore the emotions that go with that.

'I get butterflies in my tummy when I'm looking forward to someone coming,' she said, 'and that's exciting and it also makes me feel glad.'

Previously, Mel refused to allow other people to have that kind of emotional effect on her.

The therapy also helped her to make chronological sense of her many care experiences and during exercise would say things like 'Yes, I was there. Yes, and then I went there', as if all the comings and goings were beginning to fall into place and with it the scattered fragments of her life. As the child and carers work through each stage of treatment, there is a growing understanding of how early upsets, traumas and maltreatments have adversely affected her and she begins to make sense of herself and learns to trust and allow others to care for her.


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