Last week, together with social psychiatric nurse Carla Brok, we looked at the importance of paying attention to the context. In fact, this is the biopsychosocial approach that we have discussed before, an approach that recognizes that the physical, the mental and the social constantly influence each other. This week discusses how passion for your work helps to shape your way of working.

I start telling about someone at a foreign campsite who joked about a work appointment during holidays: “Ah well, vocation… vacation… it’s all the same if you love your work!” Working from ‘vocation’, from a calling, often does not feel like work, but simply like a passion and keeping the flow of things going. That is a wonderful way to fill in your work. The idea of ​​calling and passion reminds Carla of a very special situation that she recently supervised, in which the extremely remarkable behaviour of the child turned out to indicate very serious problems and to be partly caused by severe trauma in one of the parents. If she had only looked at the ‘outside’ and the superficial signs, she would have reached a completely different conclusion than what her intuition now led her to: ‘there’s a lot more going on here and it’s really, really serious’.

Eventually, this required a serious intervention, and Carla put in a lot of time, because the story she was told filled her with compassion for the parent’s trauma. “These are difficult situations and it takes courage to dare to see what is really going on”, she says thoughtfully, “and if you can look through the child’s eyes with genuine curiosity, then you can feel compassion, without feeling the need to emphasise shame and guilt. At the same time, you can acknowledge that certain ways in which we organise our society create power differences that cause harm to the child. What the one parent did… that was really wrong, but I managed to keep my interest in their life story. I don’t just accept everything; in fact, I think that I accept very little, but as the years go by I am allowed and able to bring in more and more softness and that benefits all parties. I see the process of becoming milder and softer as a task belonging to getting older.” I think out loud and wonder if bringing in more softness means less defensive behavior in the other person, making it much easier to discuss difficult matters with less need for normative judgment. Guilt and shame can be paralyzing and are hard to face. Without them, one can build a sense of security, that makes reflection possible, paving the way to growth and development.

We broaden our conversation and go from Carla’s experiences with individual families to the question of how she sees the attention for early childhood in Dutch health care. “That depends on the perspective; it has developed enormously since I started working, but at the same time I think it is still far from being enough. I think there is still too much normative thinking about how you should treat a baby. Feeding and sleeping, carrying and cycling, bottle or breast, toys, diapers, how a baby or a mother should behave… everyone thinks about everything and has a judgment about it. How helpful is that for parents?” I express my hesitation and say that I feel some tension regarding this. We have gained many insights over the last decades and we know that we should learn to see through the child’s eyes. Based on the biological blueprint, we also know that some biological setpoints are more difficult to adjust later on. This means we can conclude that some practices actually are more or, in turn, less beneficial. Hitting your child does not seem like such a good idea, to give an example, although that is a normative judgment. Here, Carla agrees: “Oh yes, certainly; parenting is by no means trivial. When someone says ‘We don’t hit that often’ … my alarm bells ring and then I reflect on how to respond without judgment, because I want to hear the story. After all, parental behavior also occurs when I am not there, so enforcing my norms onto the family situation would not work, while at the same time I do want to ensure that the situation improves for the child. If parents think that hitting is a solution to problems, then chances are there are many more things that are not going well.”

Carla is of the opinion that scientific insights are still clearly insufficiently integrated in practice. The current (COVID-related) impoverishment of perinatal care does not improve this either. She tries to navigate these aspects: “It is my responsibility to organize my schedule of care. Some problems are of a different order, of a different importance, and I will not let another person determine how to serve the family interest. I’m too stubborn for that.” That sounds like ‘daring leadership’, to quote Brené Brown, as a deliberate choice to guarantee continuity of care based on deeply felt professional ethics. That takes courage; that requires a willingness to stick your neck out and make time for it, something that fits Carla’s previously mentioned stage of life of generativity: transferring wisdom to the new generation. “And I also think,” she continues, “that there is still far too little attention in the training courses in this line of work to the fact that the parent-child relationship is always reciprocal. It is very important that the child is heard and seen. This sometimes requires thinking and acting outside the lines that are still often drawn in training and practice. Guidance and education for young children is so important; as a society, we should reward that much better. In those early stages, so much can go wrong, but also incredibly much can go right, as long as we make sure that the professionals are well trained and can see and interpret the signals that children give. As a professional you need the feedback of the child, the story of the child, to determine how to proceed in a difficult situation. I can sort of panic if I can’t ‘translate’ the child, if I can’t pick up on the child’s signals. I need them and they form the basis for how I try to keep in touch with the parents so that they and I can give the child what it asks for and what it is entitled to.”

We talk about how difficult it can be, to develop your basic ability to keep seeing perspective. This requires not only compassion towards the other, but also towards yourself – after all, you shouldn’t burn out as a result of disappointment about everything you can’t change. Carla: “I experience it as very important to keep my own social life in order, because that is the source from which I recharge when work demands a lot from me and I encounter many sad situations. Mindfulness helps me with this, as does trust in my intuitive perceptions and my old tendency to look a little further than what is directly observable. I actually keep working on those skills, because you really need them. I succeed better at that as I’m getting older. I move along with what the different phases of life require of me and they all have different accents when it comes to meaning. And in order to continue to experience life as meaningful, you need to be able to co-regulate with other loved ones, so that you regain your balance when you have lost it for a while. Walking with a friend, drinking tea with someone, telling your story to an attentive listener … those are very precious experiences in life.”

Due to another appointment we have to wrap up, but we conclude that we could have easily explored many more themes. I thank Carla for her time and her openness; I say that I have heard many beautiful things and that I look forward to working out her story!

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.

Last week we got a first glimpse into the work of Social Psychiatric Nurse Carla Brok. Today we will discuss, among other things, what she experiences as the essence of her work.

We ended last week with Carla’s statement that she feels she did not make things easy on her parents as a child. This is a comment many children make when at an adult age, they look back on their childhood. Other variations are: ‘I regularly had my ass kicked, but I really had it coming; I was to blame’ or ‘My parents sometimes had really loose hands, but that was no wonder, because sometimes I was unbearable, so I get it.’ I continue to have a hard time listening to these qualifications and forming thoughts about it. What can we deduce from it if a child interprets its own past behaviour in this way…? If it entered the world with this idea, how has it affected the child’s self-image and what are the consequences for functioning as a person?
I look at Carla and say softly and with a smile, “… but they didn’t make it easy for you either, did they?” She can agree with that: “No! No, no, certainly not… All kinds of patterns came up there, that have also been repeated later on, but to which I was more alert by then and I could handle better. I am someone who wants to stay true to herself and there are many things where I am not willing to compromise. The fact that I left home so early for my training certainly helped.”

Yet she sometimes looks back on that training time with mixed feelings; when she tells others about what she went through in psychiatry in the late 1970s, they sometimes get cramps in their stomachs from the fierceness she was dealing with: the raw seamy side of life, which requires resilience and skill that you actually have not yet been able to build up at the age of 17. “I don’t wish that on anyone; as a society we should not expect all this from young people in this way, because that can easily be traumatic for anyone standing by, watching it and wondering: ‘What are we actually doing here?’ I learned a lot and I am grateful for that , but that could also have been done in a different, more compassionate way…” Carla tells about the different psychiatric trends over the decades, how they changed from much to almost no medication, from forced procedures to antipsychiatry (where the idea is that the medical model focuses far too much on ‘deviant behaviour’, is too stigmatising and should hold more space for the ‘non-average’ person), and from nursing to sociotherapy.

For some time now, Carla has been working in outpatient, specialist mental health care with parents and young children and I ask how she would describe the essence of her work. She says that she is now more involved in policy development and how everything should be organized. “I specifically focus on how care is arranged for parents and children. Children always have my immediate attention and from their perspective I look at the adult.” When I show that I am surprised, she admits that such a vision is indeed still far from being the standard. She ponders a bit and continues: “I think I am in a different phase in my life now, in the phase of generativity, in the phase that emphasises sharing, and that is how it feels. What I am allowed to pass on is, among other things, that wisdom of … ‘folks, we must be more focused on the children and see the world and what we do as adults through their eyes’. That is my drive.” She laughs and says that this is the shortest description of what she is doing and what she has to do so that, on their life journey, the young can take the wisdom learned by the ones already older.

I indicate that I do not know the term “generativity” and Carla explains that it is a concept from psychoanalyst Erik Erikson’s stages of personality development. It is the phase in which you pass on acquired wisdom to the younger generation, as your legacy. You can see it as a life task that fits the later stage of life: “Before, when working with parents, I often felt more like a co-parent; now my clients see me as a grandparent and that’s fine.”
She explains how it is helpful that she was once trained to always look at the relationship: “What I see is a reflection of what is behind the behaviour and so I can almost read the child based on the story of the parent.”

Now she is on a roll and tells enthusiastically about how she supports colleagues through intervision, about the life stories that are sometimes so harrowing, about the invisible pain that lies hidden under ‘inadmissible’ parental and child behavior. She talks about how parents sometimes form an image of their child that is disadvantageous for the child and that does not correspond with what she, as a professional, notices in a detailed observation. This can lead to painful situations, in which the professional must really initiate actions that prevent the parental trauma from leading to a young child growing up lacking continuity in care, and developing a disorganised attachment style. That is difficult, precisely because Carla always strives to not separate parents and child from each other. In order to protect the child, she sometimes really has to take a stand, such as when mutual respect and joy appear to be missing from the relationship. She experiences micro-observations (extensively reviewing and discussing interactions recorded on video) as a very valuable tool. This method enables her to guide a practitioner through supervision and to identify what can be observed in the interaction and relationship formation between parent and child. Is the child really seen by the parent? Are body movements and eye contact properly interpreted? Does the parent see if the child is avoiding or withdrawing from contact or is not really absorbed in the relationship? What does the professional see and what does that mean? Is that really about what can be observed or does it have to do with the professional’s own views and fears, with the story we tell ourselves when we have a hard time understanding ourselves and the other? Can the professional reflect on their own experiences or feelings and how they colour the interpretation of parental behavior? These are intense, difficult, and often uncomfortable questions about one’s own thinking pattern, about what we think the other thinks, about what adults think in relation to the baby or the child.

Carla: “It is very important to first really visualise the body language without judgment. A naked child who sucks on his own hands or fidgets in his own crotch is engaged in self-regulation. If a parent does not understand this and (as a result of certain normative views) only corrects that behavior, but does not see the underlying need, this usually leads to insufficient co-regulation between parent and child.” She explains that it is important to investigate whether the parent can mentalise, can relate to the child, can learn to see what is going on in the baby. “A child who looks away asks with his body: ‘Mom, what are you actually doing?’ or ‘Do you see that I’m gone for a bit?’ If you take a step back and just look at the baby… what do you see, what do you feel, what do you think? I also really encourage young colleagues: ‘Keep looking at the baby and stay in touch with the parents. Help them to interpret what there is to see, because if you do not do it, if you do not create space for the emotions, feelings and thoughts, how should this unique relationship recover if until now, parent and child struggle understanding one another?’ This is what matters, not the normative judgments or the thought patterns of the health care provider.”

Next week we will look at the importance of taking the full context into account in order to make an accurate estimate of what is going on with a child or within a family.

Through the beautiful landscape of the Achterhoek, past a number of small villages, I drive to Carla Brok, my respondent of this February afternoon. I cross her doorstep around 2.00 pm; tea, butter cookies, chocolate and other sweet treats are awaiting on the wonderfully large table in the spacious kitchen that is attached to the old premises. We have communicated by e-mail and texting, but did not yet meet, so we take some time to get acquainted. The advice is still to not shake hands and it remains strange, such a distant way of meeting and greeting each other for the first time. Nevertheless, the ice is quickly broken and almost immediately we are caught up in a substantive conversation. We both laugh when I interrupt our animated exchange and ask for permission to turn on the voice recorder so that I can return to all of her beautiful stories once home.

And so, right from the start of our conversation, we are in the middle of what trauma-informed professionals see passing by, of its impact on the body, and of the questions about how to deal with it, especially when it comes to culturally coloured situations. “I have a lot to do with cultures other than the Dutch, but the fear that a mother with her offspring goes through with a story like this… that fear is separate from culture. That would be tough and intense for everyone.”
With the topic of ‘physiology’ on the table almost immediately, Carla tells of a situation that has preoccupied her for the past week, illustrating how a troubling start in life can have repercussions long afterward. “The mother came to me because her 12-year-old child was showing problem behaviour. As I always do, I also asked her about her pregnancy and she said that there was a troublesome event back then: she had been chased. With her big belly and her older children in the back, she had been followed by a bunch of men in a car and had barely been able to shake them off. After driving around criss-cross for a while she luckily lost the men! Only then did she return home to avoid being chased to her front door. This mother spoke very vividly about what had happened to her, how much stress it had caused and how scary it had been. I thought it was shocking; I listened attentively, asked her how she felt about it and what it had done to her, but strangely enough, this mother was impressed by my inquiry. It was part of her culture, she said, that women are chased by men. She had received all kinds of therapy, but no one had ever asked her about this traumatic experience, and she had never told the story before; she was totally amazed that I took so much time for it. I asked her what she thought the impact of such an experience would be on the mother and what it could mean for the baby in the womb. That was a completely new idea for her, so yes… my experience is that the influence of physiology on later problems is still very underexposed. ”

I find that an interesting statement; I share with Carla my experience that universalism in anthropology is a very difficult topic. I indicate that I do not understand that very well, because how can you passionately oppose violence, social exclusion and discrimination, if a basic tennet is to downplay the most fundamental of human commonalities? Are the needs that connect us as human beings not far more numerous than the things that separate us? And isn’t physiology a prime example of this? For example, science has taught us what we have all known from experience for millennia: perception of safety supports human stress regulation and socially competent behaviour. Of course there are cultural differences with regard to what is perceived as safe or unsafe, but that the body reacts to insecurity with a stress response… that is universal. If it weren’t, we would probably be extinct as a species: responding to danger with fighting, fleeing, or freezing is a survival response. When a child exhibits remarkable behaviour, questions that should arise are: “Who responds to whom? What underlying processes are at play here, in the child or in the adult? Is the behavior stress-related?” The fact that Carla interprets the child’s behaviour as a possible symptom of trauma in the mother due to excessive stress, bears witness to an understanding of physiology. Her approach to the situation says something about how she views the interaction between people who are close to each other and how she sees behaviour as an expression of an emotion that indicates an underlying need.

I look at her, stating my guess that she has many more stories that are worthwhile. She smiles and says: “To be honest, I always think I have nothing to say! To me, it usually all feels so logical!” Perhaps this is not surprising, from her perspective, because she has been in the field of guiding people for about 40 years now, even though her work has acquired different accents, a different name and a different training over the years. “I always say that I still work as a Social Psychiatric Nurse, because I was once trained that way. Nowadays people who do this type of work are called Nurse Practitioners. The essence, however, is that I have really been trained as a practitioner, generalist practitioner in social psychiatry; that is in my blood after all these years.” I ask how old she was when she started this work. “I was 17 years and 7 months, just old enough to start the in-service nurse training. It was a very honorable profession at the time, so I had the blessing of my parents and left home at an early age. At a young age, I already had to deal with quite serious patient issues. After this, I moved on to the Social Health Care and started working in ambulant mental health care.”

I ask her if there was a reason for her interest in this field, because it is not exactly a light-hearted choice. She looks surprised and thinks for a moment. “Yes, there was! I come from a family nest with a chronically ill father with a stern Catholic background and an incredibly caring mother from a much less stern Protestant family. I am the third in a family with four children, and it was clear to all of us that caring for our father came first. He had been ill since I was born and was hospitalised every year for dying limbs. That was of course intense and his situation was central; he was always in pain and that put enormous pressure on our family. Despite retraining, my father eventually became incapacitated for work and the illness and pain that literally consumed his body eventually consumed his life. Contrary to the expectations, he nevertheless lived until over seventy. The fact that as a child, despite all the worries, I remained very curious and always wanted to know everything, because I don’t get myself moving when I don’t understand things… I don’t think that was easy on my parents. They had no mental space to satisfy my curiosity. As an adult I can understand that, but in those days as a child I could not. I did not just accept everything, but I now think that I did not make it easy on my parents.”

Next week we will hear more about what it is that brought Carla to her career choice and what she experiences as the essence of her work.