Last week we started a conversation with youth health doctor Kelli. This week, even more aspects of her work are discussed, such as the challenges she experiences with parents and guidelines, as well as embedding new insights into daily practice.

We talk about how intense stress completely disrupts a person’s ability to absorb information or understand advice properly.
Kelli: “Yes, it certainly can, and in many settings it is the same as with the guidelines here: if you stick too much to your own programme and certain standard procedures, you don’t see the most important thing, or see it insufficiently, namely: what is going on for the person sitting in front of you? The question then is: do you dare to let go of that structure? Do you dare to be open to the fact that sometimes things go differently? That is actually quite exciting. After all, you also have time pressure; the next person does not want to wait endlessly, so that is often a quest.”

I ask what aspects of her job she likes most and what really makes her happy. She explains that this is very broad and that her idealism plays a major role in it, the wish that parents and children have a good time together: “I wish people more happiness and health, especially because that prevents so much difficulty later on. I know that is a very idealistic idea, but that is ultimately my motivation.”
And the counterpart… which is the hardest?
She looks a bit more serious: “Hmm… then I think of the families that live in excruciating poverty and partly because of that start quarreling, that you look at their situation and think… they are really stuck. How on earth are they supposed to keep their lives in order? Against politics and policy, you still have to look for concrete solutions. In any case, you always look at the individual situation. If there are two children in a family who are constantly arguing, then perhaps they can go to daycare on different days, so that they are not together all the time and there is some peace in the family again. I then organise those kinds of things together with other partners in the healthcare chain, who also know the ‘social map’ well.”

How does Kelli see the biopsychosocial insights embedded in healthcare or in society as a whole?
“Unfortunately, I don’t feel that it is very different now than it was ten years ago. With the help of social media, it is now often easier for parents to find like-minded people or to find professionals with a more holistic view and that can give parents a lot of support. I myself also read along to see what is being discussed on these platforms, but I do not yet have the feeling that there has been a total change in mentality from a policy point of view. Although there is clearly more attention for Infant Mental Health, I still often see that the behaviourist approach is endorsed; that still seems to be ‘main stream’. I do see small undercurrents with more awareness about the impact of toxic stress, but they are small branches that seep through somewhere and I don’t see them becoming waterfalls everywhere.”

We talk about how to deal with what parents indicate on social media, such as: ‘I go to the well-baby clinic, but I don’t listen to what they say there, so in one ear and out the other.’ How can employees deal with that?
“Sometimes parents don’t want to have a consult with certain professionals because they don’t feel heard there. Some parents are more vulnerable than others and are more likely to feel negatively treated, rightly or wrongly. At the same time, the interaction can create conflict for employees: they are trained to properly follow national guidelines, but if the parents want to deviate from these kinds of advice, either for scientific or intuitive reasons, the relationship with the parents can come become strained. We now know that a baby is not a person without feeling, but rather a very sensitive being. If you have crying parents sitting in front of you because their child is crying so much and they have nowhere to go, you want to help find a solution. And that is where friction can arise. We can all happily say that ‘it takes a village to raise a child’, but many parents don’t have a village; they are almost alone. This often leads to a switch from plan A to plan B and to an attempt to ‘adjust’ the baby to the circumstances instead of vice versa. Maybe the parent and the professional are happy then, but the baby is not. Many of the methods used are much ‘easier’ in the sense that you don’t have to change the whole system or get a village around you…” She hesitates, interrupting herself: “Well, easier… I would not be able to, because hormonally I would be driven crazy by the crying…”

Is knowledge about the influence of the social environment on health sufficiently seen, or does the idea that health depends on genes still prevail?
“I do not like the term that we have an individualistic society, but you do see instances of that. For example, I know of a family whose children showed externalising behaviour and this was seen as disruptive at school and at the sports club. The parents were blamed for it: ‘Go and raise your child!’ However, I knew that those parents were doing very well with their children. In such situations it should be possible to surround such a family as a ‘village’, not from the idea of ​‘you are doing it wrong’, but from the question ‘how can I help you?’ People’s lives are often lived separately than together, but I fully realise that is not something you can resolve personally. Political decisions also play a major role in this. This is ingrained in the healthcare system and in the idea that everyone has to stand on their own two feet. Somehow you would hope that parental support would grow organically in a community and that you would not have to set it up as an institution, but that turns out to be difficult in everyday practice.”

This topic brings us to the intergenerational aspects of parenting problems. Parents sometimes seem to be individually ‘blamed’ when things do not work out, but in most cases they try really hard and have been through many things themselves, which makes it difficult for them to provide the child with what they need. Does that kind of knowledge seep through to practice, I ask Kelli.

“One of the tasks of the youth health doctor is to refer to the GGZ if more support is deemed necessary. If there is one thing that is difficult to say to parents, it is that you think that not only the child, but also the parents themselves or others within the household need support to solve their problems. However, it is very difficult to raise the issue if parents themselves are not yet aware of certain bottlenecks and there is no request for help. This is especially so because in principle I am the child’s doctor, and not the parent’s. Only when parents learn to see that their own attitude influences the functioning of their child, will things change. That is sometimes really a ‘pink elephant’ in the consulting room and there is certainly progress to be made there…”

We look at the terms ‘toxic stress’ and ‘trauma’ and what you could or should understand by them.
“Trauma is very common, but it is often still thought that the word is about a serious event, such as a difficult birth. That it can also be about more insidious forms, as a result of your attitude towards the child, that is more difficult. That touches people in a more intense way and can feel like failure. I think the same applies to toxic stress. I don’t use that term much, but I did read some work by Jack Shonkoff about it. I think we can imagine what it does to a child to be systematically belittled or beaten or not given food, but I think more subtle forms are more difficult to grasp.”

I ask Kelli what, in her opinion, should change with regard to policies in order to work more on prevention of problems.
She thinks and smiles: “Well… if you look at it very utopian way, then of course you would like us to create a society in which children can grow up in an environment that suits them and that guidelines to that end provide state of the art knowledge, and that invasive, heavy interventions are reserved for the few situations in which they are necessary, and are not part of standard documents. A real step needs to be taken there, so that parents receive less conflicting information. But then…” She hesitates, looks at me and grins broadly: “… these are of course monstrously large social issues; you can’t just change that!” We laugh together at her term ‘monstrous’. However, she does see achievable goals: “On a small scale, of course, you hope that you can always give parents something with which they can manage their own situation as well as is possible.”

I notice that Kelli regularly brings up the guidelines and I ask about their influence.
“Well… in principle, those guidelines form the frameworks within which we work. Not everyone can interpret this in their own way. So you want the summary to actually represent the latest insights. This gives professionals the feeling that they are acting responsibly. Therefore, there needs to be more awareness regarding the influence of early childhood and of its nuances. Everything that goes badly wrong later on, starts somewhere small, when things are not so intense yet, and that is where you want to be present. Every euro invested now, you will eventually get more than tenfold back through prevention, but many policies are linked to four-year cycles… so to the short-term, actually.”
Finally, Kelli indicates that her own motherhood has taught her a lot that she experiences as valuable. She hopes to be able to support other parents as well with such a learning process in which the children are a strong motivational force.

We wrap up and I thank Kelli for her time and her beautiful story!

Last week we finished with the importance of building a physical, non-verbal foundation for managing stress and emotions. We also discuss the role of breastfeeding in this.
Beatrijs says that two things are important to her when it comes to breastfeeding: ‘I think sex education starts at birth. The baby’s brain is saturated with oxytocin in an important phase, which is good for your stress coping system. And all the so-called nutritional benefits…’ She hesitates, challenges the lactation consultant in me and says: ‘… Fine, sure, whatever!’ Now she is bursting with laughter. She then continues on the value she sees in the breastfeeding relationship between mother and child for later sexual development. “I see sucking the nipple as the first form of kissing, of really close physical intimacy. Following the biological blueprint, a child can enjoy that for two years or even longer. All the while, the child may delight in that breast, the smell and the mother’s body, while its brain is drenched in oxytocin, endorphins, and prolactin. That total delight… and the surrender, the self-regulation, the drinking and meanwhile just stroking it with that little hand… and reaching for the mother’s face and mouth… fantastic! In my opinion, that is the foundation of a sexual education.”

She sees an important learning process for both boys and girls there. “Boys who are breastfed for a long time develop an enormous admiration and familiarity with the female body and its limits. They get abundant amounts of oxytocin and endorphins through the milk and through suckling, which supports a favorable wiring in their brain. Through their mothers , girls can learn to give the same non-verbal oxytocin showers to their own child. Oxytocin is the word – I’m from the Oxytocin Church!” We laugh about it together, because I too am a passionate admirer of this important hormone.

I ask if there are things she found difficult in her job.
“Because of the foundation that I have been given, there is a lot of confidence in my body and I could always use that in my profession. That has always helped me in my work and because of that there are no big things that I found difficult. I did most of it on my intuition and it worked great!”
Yet this question brings her to her own childhood, in which she grew up in a large Catholic family in the province of Brabant. She was the fourth of eight, with a mother who was actually constantly overworked in caring for the children and the family doctor’s practice of her husband, Beatrijs’s father. “The summer I was born, my mother happened to have a very good assistant in the practice and three good maids in the house, which made her feel relaxed and I breastfed longer than the others. So I’ve been lucky enough to have a good base, I think. My mother was a very sweet woman, but she was always overworked and too busy with everything. My father was a real patriarch, who was afraid of intimacy. Although I have enjoyed his intellectual inspiration and my mother’s gentleness and pursuit of personal growth, as children we have sometimes been lacking in personal attention. As a result, self-doubt can sometimes strike enormously under high voltage.”

Another major traumatic event in her young life comes to her mind that has affected how she handles things. As a four-year-old girl, she got viral meningitis and not just herself, but all the children in the family. At first they were all isolated, but when some of the kids were allowed to go home and she was left with her little brother, she didn’t see her parents for weeks. She and her brother thought their parents had forgotten them; they felt utterly abandoned, were unable to walk in the end, and only had the comfort of each other’s closeness. When they were picked up and brought home after six weeks, everyone seemed very happy and that didn’t match at all with how she felt. “I think that was my first depression. I imploded to survive and in difficult situations in my life I still find it hard to deal with those emotions. I can hold on for a very long time, but if everything goes wrong and it really doesn’t work out… then I have to be careful that I don’t implode.”

She says she got a nasty knock from it at the time, but was still able to develop well because she already had the strong foundation of the years before. In this context, we talk about how she views the importance that is attached in the Netherlands to those early years of life. Beatrijs: “I think this is not seen enough. This is evident from the duration of women’s maternity leave. Some feminists often call me out on this: ‘There you have Beatrijs Smulders again with her sow leave!’ They make a swear word of it! I think the lack of continuity of care in childcare for small babies is harmful.”

This topic touches on the idea of ​​safety or lack thereof and I ask her if she knows the concept of ‘toxic stress’.
“Most certainly, yes! What I understand by this is that a child goes through drastic things and experiences severe stress and does not have the tools to absorb that stress and cannot turn to their parents for this. We need a certain amount of adversity to grow. That is inevitable; that’s how evolution works. Children are born as fragile gold nuggets and you should try to keep them intact for as long as possible. The development of our stress coping system through the protection of our parents is of vital importance. However, parents can’t keep protecting you, so you also need to develop a healthy ego that fills that function later in life. And when there is a setback, you hope that your stress coping system is strong enough on a fundamental level to allow you to grow through it. Sometimes you don’t succeed. Then people break. Women who were abused by their father as children… that is something a child can hardly cope with. Then you close and break and it takes a lot of effort to become whole again. The insecurity you experience as a result will affect the rest of your life.”

I explain that trauma is also described as a deep wound in the mind, a broken connection with the self, and loss of authenticity. When a wound can heal properly, there is less scar tissue. This is important, because the properties of scar tissue are that it is not so flexible, that it does not grow like the rest, that it puts things under tension when everything else does grow, and that it has few nerve endings and therefore lacks sensitivity. These are characteristics that can also become visible in the personality through trauma. Beatrijs sees her trauma from the hospital as a scar: “Fortunately, the rest is so healthy that I can live with it! But people are vulnerable and sometimes you only have to hear three times in a very vicious way that you are worth nothing and then you are already traumarised somehow, because your sense of security is damaged, which can have major consequences. Then it comes down to the strength of the early foundation to get you through.”

Finally, we discuss briefly what Beatrijs considers important for the policy for a good start in life.
“I think the autonomy of midwives in primary care is very important, so that they can continue to practice their wonderful profession and continue to support pregnant women and women in labour. Across the board, I think it’s time that women get to play a bigger role in society and work towards change. Unfortunately, women do not always have access to that power; they are sometimes put up against each other in unsolidary ways with the wrong means of power,  and are not raised and socialised into supporting other women in making a head start and rising in the speed of nations. But things are getting better; luckily there are hordes of women ready to take on a role as change agent in society, women who can make a world of difference for newborn children!”

We wrap up; I thank Beatrijs for her time and the fun we had together. It is wonderful to see that in so many disciplines, there are champions who advocate for the importance of a healthy, safe first 1000 days in a human life. Through her book ‘Blood’ people can get an insight into the start of her life as a midwife. In time, the second and third parts of the trilogy will appear, parts that Beatrijs is now working on daily.

The sun is shining when I arrive at Amsterdam Central. I open my folding bike and ride across the busy station square on the center side towards the Prins Hendrikkade. Just after the Odebrug, I turn right towards the canal house of today’s interviewee. With my now folded bicycle I climb the eight steps of the stairs to the front door. From behind the wrought-iron gate around the platform at the top, you can look out over the ships moored in the canal and the buildings on the other side of the water. I ring the bell at the left of two identical mirrored doors with beautiful wood carvings, both of which have brass letterboxes a third from below. The top two thirds consist of an opaque relief glass window decorated with a cast iron artwork with flowers and circular curls. To the left of the door on the wall, which is covered with white glazed tiles with flowers in two shades of blue, hangs a small glass case altar with prayer candles and a statue of the Virgin Mary. After I ring the bell, I hear firm footsteps on the floor in the hall. Then the front door opens with a swing and a broadly smiling Beatrijs Smulders stands in front of me. She welcomes me warmly and after I have parked my bike in a corner, we walk across the white marble floor through the long corridor to the back, to the spacious kitchen where we already talked to each other before. We chat for a while, while Beatrijs makes tea and then we get started.

I would like to hear from her how she got into this profession. That is currently a much discussed and widely read story, because the first part of the autobiographical trilogy she is writing has recently been released and is entitled ‘Bloed’ (‘Blood’). She describes in detail her fascination for the profession. “It took me a while to realize this was my destiny and actually I got into it through sexuality. As a girl, I already took a quite cheerful stance regarding that subject; I always carried with me a positive idea about sexual energy. Years later, once I was a midwife, I realised that I actually see a child as the materialised result of sexual energy. You make love together, which leads to conception, and essentially that is a form of love that is being materialised through sex – the most precious thing you can have, the connection between two people who love each other and from which a gold nugget emerges. I sometimes have a discussion in my head with Rutger Bregman, who says in his book ‘De meeste mensen deugen’ (‘Most people are virtuous’) that most people are good, but I say that all people are virtuous at birth. After that, unfortunately, much of this inner goodness can be damaged and many people become traumatised. At the moment, I still see a lot of oppression and too much lust for power in society. These are the themes that I have been working on in my profession all my life.

What I see is, among other things, that we are increasingly medicalising childbirth in western healthcare. For many women, this makes giving birth a disempowering experience. That is very unfortunate, because if you guide women in a positive way during childbirth, then birthing a baby is an empowering event, something that makes you experience a positive energy. Then the pregnancy and childbirth work love-unleashing, definitely also when that child comes out of your body. This affects you throughout your life, both you yourself and your child. The hormones during an unmedicated birth help with this: oxytocin, prolactin, endorphins… they help in the development of feelings of love and the ‘love gaze’, the first glance that mother and child exchange when they are both completely intoxicated by that beautiful mix of hormones. The breastfeeding relationship is a continuation of this. For months after the birth, a breastfed baby’s brain and body are marinated in oxytocin and endorphins, the hormones of happiness, connection and empathy. I am convinced that breastfeeding promotes future feelings of empathy in a child. A child who is allowed to breastfeed for a long time, thus receives a gift for life. Such a child is given the opportunity to optimally develop body awareness in the non-verbal stage of life. That helps to enjoy directly what is there, without the intervention of the compulsion of words and thoughts. No mindfulness training can compete with a start like that!”

I ask her how she views that good start, what period she associates with it.
“That first year is crucial. That we, as a society, still inflict upon women and children this routine of taking these little ones to a daycare setting after three months… that is something I consider a big digression. It is important to invest in a child’s first 1000 days. This means that both partners should be able to work less, not only mothers, but also their partners, so that partners can support the mothers in caring for the baby. This is important for bonding and for the development of the brain, which grows so incredibly fast in the early years. During the entire pregnancy, the child was in the womb and a sensitive hormonal adjustment has developed, which continues during the delivery and afterwards through the breastfeeding relationship. No one can take over that role; no one can replace that breast. Human children are all evolutionarily born premature; a baby is, as it were, still a larva, which, like the great apes, should simply be stuck to the breast for at least another nine months. Our intellectual, rational, feminist frames say: ‘No! After three months, the child can go to daycare!’ I experience that as the contemporary alienation that women are forced into by the law. I am happy to see that in addition to the mothers, there are also many fathers in the Netherlands who start working part-time when their children are small. That’s great and working from home during the corona crisis has made it clear that much more is possible there than we thought.”

Beatrijs pays tribute to women such as Hedy d’Ancona and Sigrid Kaag, who, once their children were older, plunged into politics and built wonderful careers. She believes that women should have the courage to plan their careers together with their partner and to ensure that both of them devote time to taking care of the children. She realises that not everyone sees it that way, but “breastfeeding is crucial for the human foundation, not only for nutrition, antibodies and bonding, but above all for healthy brain development and a healthy stress coping system. For a long time, that was a statement that could be harshly criticised for, but by now, science has clearly shown how important stress regulation is in the early years, so I’d like to make that point anyway!” She laughs out loud and resolutely bangs her fist on the table.

We talk about what Beatrijs sees as the essence of her work as a midwife.
“Well, I see two things… I think it’s important to support and promote women’s autonomy so that giving birth is a sexual, liberating and empowering experience. In addition, I see such a birth also as a way to heal old pain, to become whole, as a woman and as a mother. Becoming a mother is an important process in a woman’s life and when you can do it in an empowering way, it is love-unleashing and a reinforcing factor in your harmony with yourself. And that, in turn, helps in bonding with the child and with the harmony between you and your child. This nurtures the non-verbal bond of trust. You fall in love with your child and that infatuation, that unleashing of love, forms the basis, whatever terrible things can happen afterwards. If a child is allowed to discover the world in safety and security during the first few years and can learn from the parents how to deal with stress and emotions in a good way, then you lay a wordless, non-verbal physical foundation. That is then in your body. You can always fall back on it when you are under stress; you radiate that. It is in the wiring of your brain and that supports a strong stress coping system.”

Next week we will further discuss the role of breastfeeding and oxytocin, the importance of a good foundation for overcoming traumatic experiences, and the importance of security.

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.