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Introduction
It will soon be 50 years since I first walked through the door of a children’s Centre in Australia and into my first real job as a residential youth worker.
There was no orientation and no training, I was just thrown into the action with 10 children and young people to look after in my section of a larger facility. They ranged in age from around 5 to 14 years, a few with intellectual and other developmental disabilities.
There was one other more experienced older woman from whom I took my cues. She was there most weekdays, but I was often on duty alone on the weekends, although there were other workers on the same campus I could call for some assistance if this was needed. It was an intense learning experience for a young man and I can clearly remember walking in on that first day along with many of the challenging issues and events I had to navigate my way through in that position.
A few years later I found myself at university studying psychology and after a 9-year journey that included post-graduate study in another country, I was back in the real world and applying the various skills I had learned.
I had gravitated to psychology because I felt it would provide the insights and skills that were needed to support these children and adolescents and to address their needs – I’m less confident about the adequacy of those skills now.
Yes, I did gain insights and learned some useful therapeutic techniques, but there were also significant gaps – I’m not sure that my training in assessment and treatment really got to the heart of healing and therapeutic change.
We all know what ‘treatment’ or ‘therapy’ can mean and it goes without saying that children and young people who have experienced abuse and neglect along with other forms of maltreatment, may be in need of specialist treatment or therapy. But today I’d like to talk about something that is just as important but less often discussed – the role of ‘accompaniment’.
What is accompaniment?
The Collins Dictionary tells us that to accompany someone is to ‘go along with or in company with’ as in ‘to accompany a friend on a walk’. Accompaniment may not have the professional cashet of therapy or treatment, but it is just as important.
Thankfully, most of us have been accompanied – by parents, partners, friends, coaches, grandparents, siblings, uncles, aunts, teachers, and other mentors.
Accompanying is a way of connecting, a type of relationship. It may be for a season or it may be for a lifetime.
Formal counselling often involves accompaniment along with other ‘treatment’ elements. In fact, there is good evidence that the ‘relational’ elements of counselling contribute more to positive outcomes than the more obvious ‘treatment’ elements. Louis Cozolino in his book Why Therapy works, reminds us that:
The central component in any helping relationship is the establishment of a safe, trusting connection.1
A few months ago I was having a conversation with the CEO of the organisation I work for. His phone rang in the middle of the conversation and he excused himself to attend to the call.
When he returned 10 minutes later, he apologised and explained that the caller was a young man in his late 20’s that called him from time to time and this time he was in something of a crisis and needed some support and reassurance. It turned out that they had first met in a youth shelter some 15 years before when the CEO was a humble youth worker.
In subsequent years the young man had had some successes in career and relationships but he had also struggled at times. That day the CEO was clearly a bit anxious about the young man and his wellbeing.
So, amidst all the crazy demands of a large NGO with around 800 staff members, negotiations with funding bodies, unions, media enquiries, interactions with government regulatory bodies, strategic planning, and so on, he always makes time for the young man.
He might have passed along the young man to one of the professional counsellors or therapists in the organisation (and indeed had helped him to access psychiatric support) but had decided to make time personally when the need arose and had been doing so all these years.
It’s not his real job, it’s not in his job description but perhaps it is just as important – certainly it is vitally important for the young man. He is not providing treatment or therapy but he is providing accompaniment.
Developmental trauma and it’s impacts
Most of the young people in our care for child protection reasons have experienced years of adversity and trauma.
Here are two well-known definitions of trauma:
Trauma is ‘a psychologically distressing event that is outside the range of usual human experience often involving a sense of intense fear, terror or helplessness’.2
Trauma is ‘any event that is extremely upsetting, at least temporarily overwhelms an individual’s internal resources and produces lasting psychological symptoms’.3
Many of us work with children/adolescents who have experienced the particular type of trauma referred to as variously as developmental, complex or relational trauma. Bessel van del Kolk points out that these types of trauma result from exposure to ‘multiple, chronic and prolonged adverse events, most often of an interpersonal nature’.4 It’s these types of trauma that I’ll be focusing on in this discussion.
In most definitions of trauma there are two components – the overwhelming event/s and the impacts of these events.
In terms of the traumatising events, Sandra Bloom tells us that the trauma framework has shifted our perspective from a pathologizing one in which we seek to label a young person, and then treat them – to one that focuses on understanding what they have experienced. She is well-known for the dictum: The question is not ‘What is wrong with you’ … it is ‘What has happened to you’.5
Focusing on the impacts, we know that there are many aspects of development that can be affected, these include the domains of:
In terms of the subjective impacts, Louis Cozolino tells us that:
The traumatised young person is ‘drowning in a sea of fragmented and overwhelming emotions, sensations, and frightening thoughts.’7
Shifts in our understanding of trauma
In recent years there has been a perceptible shift away from an exclusive focus on ‘what happened’. This has included a re-thinking of what trauma is, how it develops, and what we can do about it.
If I were to ask what the ‘essence’ or the ‘essential experience’ of trauma’ might be, I guess that most would focus on the severe impacts on emotions and thinking, perhaps on the bodily impacts, perhaps on detrimental changes in outlook, hopefulness, and self-confidence.
Here however, is Bessel van der Kolk, one of the prominent thinkers and researchers in the field – ‘The essence of trauma is feeling God-forsaken, cut-off from the human race’.8
I had to think about this when I first read it. Van der Kolk (and an increasing number of other trauma specialists) focuses on the sense of separation, on being alone – not connected with family, with kin, with peers, with compatriots, with culture.
The more I’ve thought about this the more I think he is right.
I came across this piece from a young man remembering his first day in a children’s home:
I turn to the spot where I last saw Mum, hoping that she’s changed her mind, but there is no trace of her…My new home is filled with boys about my age. They’re everywhere. Oh geez. Oh geez. I’m so alone – so all alone. Even my own parents do not want me.9
Yes, of all the possible emotions such as anger and even rage or hopelessness it is the aloneness and sense of abandonment that has stayed with him.
Others are echoing this theme. Here is Peter Fonagy, Director of the Anna Freud Centre in London:
An adverse event becomes traumatic when it is accompanied by a sense that one is not accompanied – that one’s mind is alone.10
At the very heart of the trauma experience is the feeling that we are on our own, that there is no one accompanying us, walking with us through the experience.
It is often this fact in itself, not necessarily the actual event or the immediate impacts of the event, that shifts the experience from a very difficult, even an emotionally fraught one, to a traumatic one.
Stephen Porges tells us that connectedness is responsible for the survival of the human race:
Connectedness evolved as the primary biological imperative in mammals in their quest for survival.’11
Porges joins other researchers in calling into question the received wisdom that ‘it is the fittest who survive’ – no, the strong evidence suggests it is the best connected who survive, those who can lean on and derive their strength from others when they are in need.
But of course, the defining experiences of our children and young people are experiences of disconnection, of separation, of emotional abandonment.
Here is Bonnie Badenoch, one of the more compelling thinkers about trauma today:
Trauma is a relational experience in that embedding of trauma may arise not primarily from the nature of events, but from who is with us before, during, and after overwhelming happening (or non-happening in the case of neglect).12
So we need to understand not just the event and the impact of the event, but the relational context of the event.
Not long ago I was asked to review a paper for a journal. The authors used a definition of trauma that captures this emerging perspective. Trauma occurs when:
Interpersonal rejection, isolation, betrayal and emotional deprivation compromises our biological imperative for social engagement and connection.13
Remember that adage that we need to understand ‘what happened’? Just recently I was privileged to attend a two-day seminar with Bessel van der Kolk, and he came up with this: The question is not only ‘What has happened to you’, but also ‘Who was with you?’
Given the pervasive experiences of neglect that mar the lives of so many children in the child protection system, he might well have added, and ‘Who was not with you?’
The roles of accompaniers
So, what is it about connections and being accompanied at times of crisis that is so important?
Well, there is the obvious immediate physical comfort, soothing and support. But there is also the pressing need to make sense of what has happened. Here is Fonagy again:
Normally an accessible other mind provides the social referencing that enables us to frame frightening or otherwise overwhelming experiences.14
Have you seen that video ‘Removed’? There is a part where the little girl is who is being removed from her abusive home, expresses concern about her younger brother who is being removed to another placement – ‘Who is going to hold him and tell him it’s going to be alright’ she frets out loud, ‘And who is going to do it for me?’
That’s the social referencing that Fonagy alludes to.
And those challenging behaviours that we encounter are often the result of children having to find ways to cope with overwhelming experiences without such accompaniment.
Here is Kinniburgh:
A child who receives inconsistent, neglectful, or rejecting caregiving is forced to manage overwhelming experiences by relying on primitive coping skills such as aggression, dissociation and avoidance.15
For many of our children and young people, no-one was around to comfort and walk with them through the early adversities, indeed, those whose role it was to protect were often the ones who caused the harm. The embedded impacts of those wounds have shaped their emotions, thinking and behaviours. It is these problematic emotions and behaviours that we see and experience daily, and they can blind us to the underlying traumatic drivers. Felitti and Anda the lead authors of the influential ACE study into the links between childhood adversities and later problematic social, health and behavioural outcomes, tell us that traumatic childhood experiences are often ‘lost in time and concealed by shame, secrecy and social taboo.’ 16
So what do these children and young people most need from us?
Here’s Bonnie Badenoch again:
The ability to offer the safe sanctuary of presence is central to treating trauma … if we felt alone, we needed accompaniment. If we were frightened we needed protection. If we were shamed we needed acceptance. If we were hurt, we needed comfort …17
Notice that all of the responses that Badenoch mentions are relational qualities – presence, company, protection, acceptance, and comfort.
I don’t see treatment or therapy in this list. Now I do stress, I am not denigrating treatment and therapy – many children and young people do need this, and it’s part of my own work. I just want to point out that it’s not the most important piece - and indeed, it’s not the piece that will nourish and heal and guide the young people through life.
Some of those children in my first residential home may well have needed formal treatment at some point, and that obvious need was what led to my choice of career. But more than this, they all needed accompaniment while they were with us, and they most certainly needed it when they went out to make their way in the world.
A few other thoughts about ‘accompaniment’:
At its root, the ability to learn self-regulation is dependent on there being available, trustworthy, empathic and committed caregivers.19
And here is Stephen Porges weighing-in on how children learn how to self-regulate:
Self-regulation is a product of … ‘the mutual, synchronous, and reciprocal interactions between individuals … It is through processes of co-regulation, an individual develops a capacity to self-regulate.20
So you may not have advanced clinical skills but you may just have what the young person needs the most. Here is Bruce Perry one of the pre-eminent research psychiatrists:
The more healthy relationships a child has, the more likely he will be to recover from trauma and thrive. Relationships are the agent of change.23
Some of us (and I’m including myself here) have roles that involve the provision of case management, supervision, training, or administration that often limit our capacity to actively accompany our young people. In such cases we must ensure that appropriate accompaniers for the young people are found and supported.
Remember that shift of focus that the trauma perspective brought, it’s not what’s wrong with you but what happened to you that’s important?
I quoted van der Kolk who added ‘Who was with you?’
If I can be so bold, I think we could well add another part to the question: The question is not only ‘Who was with you? but ‘Who is with you now?’
References
1. See for example, Cozolino, L. (2016) Why therapy works: Using our minds to change our brains. New York: W. W. Norton, p. 154. Also Asay, T. P. & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Qualitative findings. In M. A. Hubble, B. L. Duncan & S. D. Miller. The Heart and soul of change: What works in therapy (pp. 33-56). Washington, DC: American Psychological Association.
2. Perry B. (2002). Surviving childhood. An introduction to the impact of trauma. Child Trauma Academy. http://www.childtraumaacademy.com/surviving_childhood/lesson01/printing.html
3. Briere, J., & Scott, C. (2014). Principles of trauma therapy: A guide to symptoms, evaluations and treatment, 2nd Edn. (DSM-5 Update). Thousand Oaks, CA: Sage Publications.
4. van der Kolk, B. (2005). Developmental Trauma Disorder: towards a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 33(5), 401-408.
5. Bloom, S. & Farragher, B. (2013). Restoring Sanctuary: A new operating system for trauma-informed systems of care. New York: Oxford University Press, pp. 7-9.
6. See Cook, A., Spinazzola, J., Ford, J., Lanktree, C., et al., (2005). Complex trauma in children and adolescents, Psychiatric Annals, 35(5), 390- 398.
7. Cozolino, L. (2016). Why therapy works: Using our minds to change our brains. New York: W. W. Norton & Company, p. 199.
8. van der Kolk, B. (2014). The body keeps the score: Mind, brain and body in the transformation of trauma. London: Allen Lane, p. 335.
9. Attributed to Waln K. Brown, co-author of Brown, W. & Seita, J. (2009). Growing up in the care of strangers: The experiences, insights and recommendations of eleven former foster kids. Tallahassee, FL: William Gladden Foundation Press.
10. Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2017). What we have changed about minds about. Part 1: Borderline personality as a limitation of resilience. Borderline Personality Disorder and Emotion regulation, 4(11), 1-11. DOI 10.1186/S40479-017-0061-9. p. 6.
11. Porges, S. (2015). Making the world safe for our children: Down regulating defence and up-regulating social engagement to ‘optimise’ the human experience. Children Australia, 40(2), 114-123, p. 115.
12. Badenoch, B. (2017). The Heart of Trauma: Healing the Embodied Brain in the Context of Relationships. New York, NY: W. W. Norton, p. 12.
13. Marshall, N. & Murucci, L. (2023). The neuroscience of care: A polyvagal informed approach for child and youth care practitioners. Relational Child & Youth Care, Vol 35, No. 3., 20-44.
14. Fonagy et al., op cit. p. 6.
15. Kinniburgh, K., Blaustein, M., Spinazzola, J. & van der Kolk, B. (2005). Attachment, self-regulation and competency: A comprehensive intervention framework for children with complex trauma. Psychiatric Annals, 35(5), 424-430.
16. Felitti, V. J. & Anda, R.F. (2010). ‘The relationship of adverse childhood experiences to adult medical disease, psychiatric disorder and sexual behaviour: implications for healthcare’. In R. A. Lanius, E. Vermetten and C. Pain, The impact of early life trauma on health and disease (pp. 77-87), Cambridge: Cambridge University Press, p. 86.
17. Badenoch op cit., p. 11-13.
18. Li, J. & Julian, M.M. (2012). Developmental relationships as the active ingredient: A unifying working hypothesis of ‘what works’ across intervention settings. American Journal of Orthopsychiatry, 82(2), 157-166.
19. Schore, A. (2012). The science and art of psychotherapy. New York: W.W. Norton, Chapter 1.
20. Porges, S. (2017). The pocket guide to the Polyvagal Theory: The transformative power of feeling safe. New York, NY: W. W. Norton, p. 25.
21. Porges, 2015, op cit, p. 122.
22. Benard, B. (2004). Resiliency: What have we learned? San Francisco: West Ed.
23. Perry, B., & Szalavitz, M. (2006). The boy who was raised as a dog: What traumatized children can teach us about loss, love and healing. New York: Basic Books, p. 230.
Adapted from a presentation at the 2023 Reclaiming Youth at Risk conference, Sioux Falls, SD
