Last week we discussed with social psychiatric nurse Carla Brok the role of the care provider in identifying problems in families and how the care provider’s life stage can play a major role in this. Today, we will discuss the importance of taking into account the full context.
Carla talks about a very recent experience with a client, where the child was seen as a ‘rascal’, which often gives rise to the idea that the child needs to be tinkered with. “It is often easier to project your own thoughts onto what your client presents to you than to really look without judgment; even I find this hard sometimes after all these years. It is very difficult to take that step back and just look, without judgment. I try to convey that to the younger colleagues and I am very open and direct about it. It is nice to notice that some people keep coming back to you, precisely because you choose a different approach than the usual one.” I say that it seems like a very nice compliment to receive, the fact that people come back. Carla smiles: “Yes, that’s true… The funny thing is that I really go into depth and ask a lot from people, but I am nevertheless much less strict with people than they often are with themselves. We all make mistakes and that often feels awful, but my advice would be ‘learn from the mistakes and take that learning with you’. People often know that they were wrong; you do not have to rub that in again. It does not help the learning process, while that is exactly what it is all about: the process. To the psychotherapeutic communities where I used to work, the group process was central. Now that is all gone, because it takes too long and it is too expensive. Now, cognitive behavioural therapy (CBT) often has the upper hand, because it seems cheaper and more effective, but is it…?”
She indicates that the method often comes first, rather than the human story. We then talk about Evidence-Based Medicine, and how founder David Sackett put a lot of emphasis on the context, on the story of the person behind the disease (and of the professional behind the method of treatment). “Exactly”, Carla says, “because it’s all about the curiosity about that context. My curiosity from the past has brought me to where I am now; if I had conformed or assumed that certain questions simply go unanswered when it comes to health… I would never have achieved what I have achieved. Staying curious is the only way to move forward.” We put this in the context of an emerging approach: not ‘What’s the matter with you?’ should be the question, but ‘What happened to you?’; not ‘What’s the problem?’, but ‘What’s the story?’. With this you can invite people to interpret their own history and give meaning to what happened to them, what choices they made and how they benefited them. “Children in one way or another get the story of the parent at all times. I see it as my job to make adults sensitive to the children, so that they see that the child adapts in several ways to deal with the parent’s suffering. The child deserves recognition for what they have to deal with. Through a joint effort, we can then try to at least partially safeguard the children from the negative consequences of that parental story.”
I ask Carla what is most remarkable, inspiring or motivating to her in her work. “I’m not a protocol thinker, so what I do with parents and children is really just asking, ‘What can I do for you?’ To see what you can achieve if you give your full attention and let people talk about their life story, about the influence of events… I think that’s wonderful! This often involves making toxic stress visible. Recently, there was another situation with a ‘cry baby’ … whatever that may be …” She makes a difficult face and I ask her how she looks at that label: “In my mind it doesn’t stick. I would not know what that is, a ‘cry baby’. But hey, it is what I regularly hear, while it is often mainly about the parental perception which is driven by social conventions and convictions, not even always about the actual behavior of the baby. When you talk to fellow caregivers about what such a family needs, the ‘cleanliness, quiet, and order’ often come up. I personally cannot handle those concepts, but you have to meet each other somewhere in the middle and find a way to optimally support the family together. The wishes and needs of the family are of course leading, but if you are on a home visit with two different caregivers at the same time and you both have a different view of what the baby needs in particular, it can be very complicated. If I can then have the parent look at what the baby is showing, exactly as I do with intervision, and ask the parent what that evokes, what feeling it gives and where in the body that feeling is perceived … then often the most beautiful things happen. This is very special, because apparently you can appeal to parental wisdom in this way, while in my experience I don’t really say particularly wise things at all!”
We laugh out loud together and I suspect that in that context her whole being is just radiating something that makes the process flow again; the connection returns and a child can surrender to sleep, for example. “It is painful to experience how parents often still want their baby to not cry, while the unrest that gives rise to that crying has not been resolved. With my age and experience, I do not panic, but I remain emotionally available, for the parent and for the baby. In society, we often try to ignore and hide emotions and tears, not giving them the close attention they deserve. That is strange, because we are meant to become disrupted by the crying of another person, especially a baby! The message of that crying is ‘I SENSE DANGERRRR! I feel really insecure!’ You cannot solve that with quiet and order! What can help is to start carrying the baby. Then there is often much more relaxation and the crying takes on a different tone. Trying things out can help lead you on the right track. That is your feedback; that is what happens in the unique relationship between parent and child. I am allowed to witness this with respect and I am allowed to empower the parents in their skills of looking and learning to interpret.”
Carla continues by saying that parents often do not want advice, but respect for the relationship. “Everything that happens between them is communication; that is my basic starting point and that colours my basic attitude. I find it very painful when I see that certain protocols are being used that lack respect for that relationship and for the steps that are being taken. I cannot always ensure that another healthcare provider will override such a protocol for the sake of the child, and that breaks my heart. The only thing I can do in such a case is to alert the parents to what it does to them if the child’s interests are not paramount. I hope they will develop the courage to stand up for their child and oppose such practices, but sometimes that is simply too ambitious when parents are still struggling with many problems. What I can do is ensure that I maintain a good relationship with the client, so that I can visit them again and continue to guide them. The relationship with such a care provider is also important, because I hope that in the next situation I will be able to respond more quickly and that I can suggest other perspectives. Continuity and generativity are important aspects in this; the fact that I can organize my work freely makes a huge difference to how effective I can be.”
Next week, we’ll take a look at Carla’s ideas about how passion for your work affects the way you work and her views on the extent to which certain insights are applied in youth healthcare.