Professionals and ACE-awareness; Episode 3 – This time: Carla Brok; Part 2

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.

Professionals and ACE-awareness; Episode 3 – This time: Carla Brok; Part 1

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.

Professionals and ACE-awareness; Episode 2 – This time: Henriëtte Markink, Part 3 (final)

Last week, we spoke in detail about the diverse aspects that Henriëtte sees as the essence of her work. Inextricably connected to that, for her, is the importance of a childhood during which babies and young children can be gracefully little and playful on the one hand and in which, on the other hand, not all things hard and complicated are kept away from them. As we have learned, experiencing and understanding intense events will prepare you for what life has to bring. “I regularly notice that ill family members, for example, are hardly or not at all talked about, about what their illness means for all involved. There can be a lot of grief in life and I often think: ‘Go ahead, deal with it!’ Do not allow children to give these things a wide berth, but let them go straight through it, obviously with the support of a stable adult. You don’t have to be rich or highly educated to do this, as long as everything can have a place. Sometimes it seems as if everything in our society has to go well. I speak with people who are mourning and they say that in our present-day communities they have no place to go to with their sorrow. After three months, they say, you just have to get back to ‘business as usual’ and I recognise that – supposedly, things are only allowed to go well for us.”
I ask her whether she thinks that the concept of ‘toxic positivity’ plays a role here. This is a form of excessive positivity that minimises or invalidates authentic and tough emotional experiences of others.
Henriëtte: “Yes, I think that we often make things seem too positive; maybe everything around the lockdown is interesting seen in that context. Now, it feels very legitimate to say you are not doing so well or that things are hard on you.”

Related to this, we speak about toxic stress, a resulting form of chronic stress. She speaks about how she uses the work of Peter Levine to address this stress through bodily exercises and how she has started to read in Stephen Porges’ book on the polyvagal theory: “A client of mine spoke about that, and is very excited about the fact that we now do exercises based on that theory.” The polyvagal theory explains how important our sense of true safety is for the parasympathetic part of our autonomous nervous system. “When I explain to people that the effects they feel due to their lack of security are purely biological, they are often very relieved. Many keep hearing from others that they are strange or that they do everything wrong, if they do not succeed in going through life with more peace of mind.”

We return to a little detour we made before about the influence of survival strategies from childhood, how they can be effective initially to keep it together, but become disruptive and sometimes even self-destructive in the longer run: because of psychological trauma or ACEs, people often lose the connection to themselves and experience a deep division within themselves. I mention the idea of loss of authenticity following the lost connection to self. “Hmmm… I don’t know about that… in my experience, many of the people I see really rather have their own character, but they are often quite unstable ánd quite sturdy, sturdy in their instability. That is the ambiguous part: there is also a lot of strength in the vulnerability of trauma. People can be so lost to themselves… they get all tangled up in their history and no longer know where their roots are, where they come from. Everything that happened, has become one big knot that together we then try to unravel.”

I listen carefully and somehow get the feeling that regarding ‘authenticity’ we are having two different conversations. I explain that in this context, trauma expert Gabor Maté speaks about the coherence between the innate urge to connect with others on the one hand and the need for self-expression on the other: attachment versus authenticity . His position is that if a child has the feeling that their unique personality can not be shown, because one way or another it does not fit with what is comfortable for the parents, that uniqueness will lose out in favour of the attachment relationship. After all, a child cannot survive without the parents, so there only seems to be one way out: suppress the authenticity and be seen a little less (as discussed last week),  be less enthusiastic, dedicate less attention to personal interests or development… anything to make sure that the attachment relationship is not (further) disturbed.

Her face lights up: “Aaaah, yes! Explained that way, I see what you mean! That also explains the loyalty to parents after incest experiences, for example… at least you remain attached somehow that way. Wow, this is beautiful!” I recognise her eagerness, as I had a similar feeling when I read about the importance of prosocial behaviour as described by anthropologist Sarah Blaffer Hrdy. As humans, we are so wired for connection and attachment that we do not passively wait for it to happen, but that already as babies we actively seek out contact: the nicer people think we are, the bigger our chances for survival.
Therefore, Blaffer says, like Frans de Waal and Rutger Bregman (two authors on empathy research), that the idea of innate egotism is a myth. The problem is, however, that it is truly very hard to remain prosocial if you are on guard the whole time due to the experience that sooner or later, you will be ‘spit out’ again, as we also discussed last week. The sympathetic (‘fight-or-flight’) system will then take the upper hand at the expense of the normal functioning of the parasympathetic (‘tend-and-befriend’ or ‘calm-and-connect’) system that calms us down again. The last two, with the oxytocin hormone as one of the leading actors, are under severe pressure these days, because many people experience only a minimal amount of positive social interaction. Thus, levels of stress hormones remain higher, with short tempers and lack of patience as a consequence. Clearly, positive interaction is also crucial in childhood. Sometimes a child has to turn down their authenticity; a child cannot get away from the family system (without severe repercussions) and can only try to make the best of life within that constellation. If you have to become a little ‘invisible’ to earn your mother’s love, then that may seem the best way to survive. After the first 1000 days, such behaviour can already be strongly internalised – a very sad situation with great impact in the long term.

Henriëtte has been listening closely: “Really, this is terrific. This is something I can explain to my clients; then we are back more or less, with the psychoeducation we discussed before. Really, I think this is going to be the future, much more attention for the parasympathetic system: how can we activate that part of the nervous system and what do we need to achieve that? That also includes lifestyle and doing things you really like. I started a vegetable garden, for example, and with it, I have already been able to inspire several of my clients: they get a lot of energy from having their own!”

The ‘calm-and-connect’-system activated: secure closeness

We laugh out loud together when I say that her remark reminds me of something again: “Not another book, no?!” It is such a treasure to see how we mutually provoke further thoughts and ideas. This time, the concept of ‘salutogenesis’ comes up. This approach asks about the origins of health, leading to very different follow-up steps than western medicine’s more common ‘pathogenesis’ (the questions about the origins of disease). Salutogenesis is prospective (looking ahead – how can we maintain this?) and proactive (what does one need to stay healthy?) and searching from trust and confidence towards the good things in life. Pathogenesis is more retrospective (looking back – how did this problem arise?) and reactive (what can we do to solve the problem?) and working from avoidance (of risk factors). The founder of the concept, Aaron Antonovsky, described it like this: ‘Pathogenesis sees life as a river full of risks that you should not end up in. This view focuses on prevention (do not fall in) and treatment (do not drown, we will save you). Salutogenesis says that all of us are always in that river, because in life, anything can happen to us at any time. What to do…? Learn to swim!’

Henriëtte smiles enthusiastically: “If you would ask me now what the essence of my work is, I would say: learn to swim together… and sometimes maybe to be a cheerleader on the shore, to encourage the swimmers!” Many people can do with some positive encouragement, she says. “Many people are so lonely; there is a lot of pain and people often are very accusatory and punitive towards themselves. Often, they had a difficult place or role within their family of origin and often they suffer from disorders and complaints that make you wonder: ‘If only one person would have taken a close look at this story, it would have been clear that this is not normal and that there must be much more behind it. Temporary blindness, a sudden stutter, behaviour like pulling plants from their pots… we cannot keep looking away from things like that only because we do not know how to handle them. We have to study them much more closely. That also leads to the question: ‘How to approach parents who have given you the impression that they are not creating a secure base for their children to grow up in?’ That is difficult, because there, too, a punitive approach is probably not going to do any good.

I ask which policy changes she considers necessary and where she sees opportunities to create them. “I think that the increased attention for psychotrauma is a positive point. Finally, it can be mentioned. I am well aware that I may be in my own bubble when I think there is no way to escape books and tv programmes that deal with this topic and that all of it is already obvious to everyone… it is probably not yet completely obvious, but I really do see progress. There is a lot of knowledge to share, but I feel I am also never done with knowledge collection, as there is always so much left to learn! I remain curious, for more knowledge, but also towards the people I see. In listening to them, it is all about pure attention. And the most important is to give that attention without judgment. People are often very judgmental towards themselves and if you as a professional don’t judge, they can have a more compassionate and less judgmental look at their own history and learn to understand it.”

By now, a few weeks have passed. Through e-mail and telephone, we have been in touch about the blog texts and we both look back at our conversation with great delight. Shortly, I will visit Henriëtte and interview a colleague of hers for still more fascinating stories!
A few days after Henriëtte’s visit, Stephen Porges’ book was on my table, a tip she gave and one of the titles that had been on my reading list for a long time. I have started reading it by now and will dedicate a blog to it in the near future!

Professionals and ACE-awareness; Episode 2 – This time: Henriëtte Markink, Part 2

Last week, we discussed Henriëtte Markink’s start of her work with people with trauma. Today, we travel on with her, on our way to more ‘value-ful’ insights of her discovery journey.

I ask about her workplace and she tells how, as a nurse practitioner/trauma therapist, she presently works in a small organisation for mental health. “In the smaller practice where I work right now, we strive for short communication lines and also for short waiting lists. Someone who had had to wait for a long time once said to me: ‘I had a terrible winter. I could easily have been dead.’ That person was very angry with me, and I understood that, even though I had done my utmost to get that client their turn as soon as possible.”
I look at her and try to read her body language. “It sounds as if for you, there is an ethical component to those waiting lists…?”
She nods with a fierce look on her face: “The waiting lists for psychotrauma treatment, sometimes up to three quarters of a year, are really a big and nation-wide problem and I most certainly consider that an ethical issue. I do suspect, however, that behind those waiting lists, there is a political game related to health insurers and their conditions towards health ‘buyers’ [organisations that contract health care – the way this works in the Netherlands], but I do not know enough about that, so I’d better not venture an opinion on that.”
She holds her hands alongside her face in a gesture of wearing blinders: “At a certain point, I decided to maintain a proper distance from all those political and policy issues, to no longer get all frustrated about them, and to only work from a patient-oriented perspective.”

This brings us to the essence of her work; I explicitly ask how she would define it. “The essence of my work…” She looks thoughtful and thinks in silence for a bit. “Yes, that I find a tough question… there are many things that come to mind… Of great importance in working with people with childhood trauma is to give them hope, to deguiltify them, to give them the space they themselves do not take up… but in the end, the essence is careful listening, because people have a chronic need to be heard and seen. That applies to everyone, of course, but if you have been ‘pulled from the clay’ [as the Dutch saying goes] in a nice way, if you have been raised well, there will not be this incessant need in adulthood to be both seen and not seen at the same time.”

We continue to talk about ‘not wanting to be seen’: “This morning, I had an online group treatment session with a colleague and we asked everyone to stand still and pay attention to how they felt, how things were right now. For many, this was very confronting. Some said: ‘I want to LEAVE!’ Someone else said: ‘This was a HORRIBLE hour!’ This person hardly made it through.” I ask how that was visible, now that so much has to be done with the help of computer screens. Henriëtte breaks open in a big smile: “Oh, that was very clear!” She turns her head and averts her eyes, looks at the ceiling, to the left, to the right, at her shoes: “This person was constantly looking around and it was very clear that the theme we discussed, was a topic to be avoided. That is very hard to notice, because finally there is a group where people do listen, but then this person cannot find the courage to be heard, because they failed to be heard all throughout their lives. These people are so hit and hurt and harmed by all that happened to them, that the confrontation with their pain in a loving, attentive environment is almost too much for them. That is why I always strive to listen to people with compassion and without judgment. You have to teach them to feel that they really deserve to be heard. So often, these people have not been listened to in the most dreadful ways…”

We get to the question of how trauma is defined in her work environment. She indicates that they stick with the description of the DSM-5, the Diagnostic and Statistical Manual of Mental Disorders. For PTSS, this comprises among other issues sexual abuse, physical abuse, witnessing a sudden death, and their effects, such as nightmares, avoidance and mood swings. She differentiates between situations where a person is or is not well supported after serious events; this support, she says, can make the difference between developing trauma or not. This reminds me of the description of trauma by Gabor Maté: ‘‘Trauma is a psychic wound that hardens you psychologically and that then interferes with your ability to grow and develop. It pains you and now you’re acting out of pain. It induces fear and now you’re acting out of fear. Trauma is NOT what happens to you. Trauma is wat happens inside of you as a result of what happens to you.’

Henriëtte thinks along: “That is a beautiful description! What I find problematic is that neglect and bullying are not in the DSM, although they have a huge impact. Still a lot has to change there. And at the same time, the word ‘trauma’ also seems to have become a ‘waste bin’ category for all kinds of problems. When something doesn’t work out, people sometimes say: ‘It gives me a trauma!’ On the one hand, you make it too simplistic that way, but on the other hand this might be a sign of this topic slowly but surely getting more attention from society. When I became a sociotherapist, almost no one wanted to work with traumatised people. Do you know the book by Judith Herman? It was my ‘bible’, and in fact it still is. Wholeheartedly recommended.”

Why Judith Herman’s book is still her ‘bible’, is because it is still very current: “Herman explains how the question of whether or not trauma can be discussed, is very closely related to societal trends regarding the topic. Somehow, you know, all of us do NOT want to know at all those appalling things that have happened. We do not want to know about sexual abuse, about physical abuse, about parents who do that or let that happen. We do not want to be able to imagine all that – it is too painful. Now that we have more treatment options, it seems as if there is more room to discuss these issues. Despite all that, the work with traumatised people is still highly complex and if you are not transparent and ‘down to earth’ towards your clients and you harbour a hidden agenda, then things get out of hand. You will get friction and people will start looking for the boundaries. They are very good at that, because they have had to do so all of their lives. Then you get into this atmosphere of: ‘I will try and see whether I can really trust you or not. When will you, too, spit me out again, because you are fed up with me?’

We look at each other and let the intensity of such a primal perception sink in. “Some people are so damaged… their whole lives, they have not experienced anything different than that. Because we know more about neurophysiology now, it is a bit easier for therapists to understand what happens if people show behaviours that are hard to deal with and, to then sit and lean back and not become personally triggered. It happens… I’m human, too, and then I realise they have touched upon my own vulnerabilities … (she laughs), but with more professional experience it is much easier to return to and to establish or restore the connection. Connection… that is also part of the essence of my work. It may take a long time before that needed connection is there, but when it’s there, it’s there!”

We talk about what gives Henriëtte most satisfaction in her work. “The progress, the growth, the fact that people learn to see how powerful they really are, how much strength they have. Many of my clients feel extremely vulnerable, despite their apparently normal lives, with families, jobs and studies. I always try to point out how powerful they are, because otherwise they would never have been able to make it until here, straight through all of the misery. Many people with childhood trauma have comorbidities: numerous issues intermingle, but they are not always being linked to trauma. Then people sometimes get a message that more or less says: ‘Well, sorry, but your problems are too complicated; we cannot treat those with method X or Y.’ People are often given the runaround… In many places, there is still a need for much more psychoeducation to make sure that both in healthcare and in society at large, we call come to understand much better why people turn out and behave the way they do, about how their personality has been shaped.
That childhood plays an important role in many problems and disorders, and should get much more attention, is a true fact according to Henriëtte: “I wish that children would be much better listened to, also in youth care and social services. When thinking of all the adults I see, I’m not so sure I would be able to help them if they were children. I think I might feel too overwhelmed, too afraid of a bad ending. The adult clients at least survived until now! It really makes me sick, to see what children and young people have to go through right now due to the lockdown. Overall, I think child wellbeing is not given priority in our society; there is too much focus on achieving, even when they are still babies. Sometimes, at the age of three months, it seems they are already supposed to eat vegetables…” She wiggles to and fro on the couch and lets her head fall from left to right and to the front: “Spin… spin… spin…” We laugh about the sad image of a baby who cannot sit yet, but from whom so much is already expected. “Just let them be babies!”

That is a great motto: give babies the space to just be, with all needs attached, while simultaneously being aware of the fact that in all of their vigour and vulnerability, babies are full-fledged humans with rich emotional lives. When we respect their needs and feelings, we help them to view themselves and the world with compassion.
Next week, we will continue our journey with Henriëtte and we will, among other topics, address security and authenticity.

Professionals and ACE-awareness; Episode 2 – This time: Henriëtte Markink, Part 1

When I open the front door, Henriëtte Markink, nurse practitioner, stands before me with a bright smile. We have never met before, but straight away I have the feeling that we are going to have a beautiful conversation. Already in the hallway, we start a lively chat, about the charm of old houses. Those have their user’s manual and idiosyncrasies and also their strengths and weaknesses, but mostly, we agree, they show their own character in a wonderful way. You can feel it, if you are in a building that has a long history and in which highs and lows have taken place. Only in hindsight I realise that this aspect is a guiding line through our conversation.

It is the beginning of January; the Christmas tree is gone, but a couple of last decorations give away that the holidays are only just over. Because darkness still sets in early, I have lit a couple of candles and we drink a fresh, hot tea with a sweet new year’s treat. It has already been leaked to the media that tomorrow’s press conference will announce that the present lockdown, that started mid-December, will be prolonged by another three weeks. We speak about our concerns regarding the impact of this on the degree to which stress is rising for many. Many people only have very limited opportunity to have positive social experiences these days, or they struggle with income insecurity or with working from home while all the kids are there. Henriëtte lives in the Achterhoek, the eastern middle part of the Netherlands, and her partner is in the restaurant and catering business, so they both experience the present problems in a very direct way, she through extra work with stressed out patients, he through a lack of work with dinner guests. Both are dealing with the complexity of finding creative solutions.
He came to Assen with her, so that together they had a little outing. We laugh about it, but also discuss how strange and sad it is, that you almost get nervously excited now and then, when you sit at the table with other people and have a good time together. It is that deeply rooted in us, that need for human contact. If it is lacking, many get stranded and stuck. Henriëtte sees in her environment that life is very complex for some young people at the moment and that, as a consequence of loneliness and boredom, drug use increases.

Via this topic of the present corona circumstances, we land at her work with patients suffering from psycho-trauma and stress-related issues in a small institution for mental health. Through a moving interview with her  about those topics, I got acquainted with her views. I decided to take a bold step and asked whether I could have a conversation with her, because I find it so hopeful and inspiring to speak with professionals who consider the early years to be at the heart of the foundation under the life that follows. “In situations of drug use, there is usually only one question being asked: ‘How are you going to change your habits?’ – but that is not enough. It reminds me of a patient who said to me: ‘Never before did I tell so much about the background of my trauma as I do with you now.’ She felt guilty about a lot of things, which usually makes me ask: ‘Can you take a step back and look at those events; how old were you? Can you still remember how and what happened? Can you put things in that former context?’ For many people with childhood trauma, this is hard, but if you help them and explain what happens in the body in relation to such experiences, then they become aware that as a child, you do not have to feel guilty.”

After her studies to become a nurse (graduated in 1983 for HBO-V), Henriëtte obtained a first year in Sociology at the University of Amsterdam and next to her studies, she worked as a nurse on a psychiatric ward. After that year, she got a permanent job at a psychiatric admission department. After the birth of her children, she became a socio-therapist and she got in touch with young adults that sometimes brought quite an amount of baggage from their childhood: “Those youngsters came from a certain nest and there was a lot behind their stories. By then, I had become very interested in child development and attachment and bonding; I have always found that a very fascinating subject. My employer was looking for a socio-therapist for a trauma group. That was very rare in those days, but after a long session in a think tank in the institution where I worked, they decided they wanted a female socio-therapist for that group and I was fully into it. I was pretty naive when I entered, because I didn’t know very much about trauma treatment at the time. Also, I did not really have a clue about the effect of trauma on the human life course. Fortunately, I was working with a very experienced clinical psychologist in an era in which there was still time available for intervision, even though the literature did not yet have much to say about the topic. Slowly but surely, more treatment options arose, in which physical methods played an important role, such as psychomotor therapy, trauma-sensitive yoga or other more body-oriented approaches in the psychological treatment. The most important, however, was that people could tell their stories and that they could listen to themselves telling their own stories, that they would come ‘out of their heads’ and would be more present in their bodies and become more sensitive to their feelings. I was completely fascinated by their narratives. In the group sessions, people described these narratives to us as therapists, but by doing so they were also opening up to the group.

They would come once a week for a whole day. During that day, it was important for them to learn and see what their survival mechanisms were. We discussed the usefulness of those coping strategies and how good it was that they had worked until now, but that they had stopped working and even become dysfunctional. Then, the question became how they could change that and how they could break their patterns.”

When she was looking for more challenges, she started studying to become a nurse practitioner (graduated 2010), a discipline still in its early stages then. “The point is…what I had noticed, was that people with trauma in their history had a lot of physical issues and pathology, such as asthma,  infections, chronic fatigue, sleeplessness, arthritis and fibromyalgia, but also long and traumatic birthing experiences. The more I saw, the more I thought that this could not be a coincidence…or was it? That, I wanted to dive into. Thus, I decided to do a literature review for my studies to find out more about physical illness after a trauma history and that is how I became aware of the ACE-study by Anda and Felitti. And I kept reading and found that there was much more that showed a correlation between chronic stress and physical issues. Both for me and for my clients, much fell into place! Finally, I was able to explain to them that it wasn’t all that strange that they suffered from this and that and so and so. If your body is constantly tense, it is not so hard to imagine that this will influence your joints, your breathing, your heart. To be able to tell them that, works very ‘deguiltifying’ for people. Yet, when it comes to very serious diseases, I am very careful. I explain that chronic stress can lead to physical disease, but I do not mention asthma or cancer, even though we know that with chronic stress, chances of cancer also increase. I remember a woman who was once a client of mine and who died of cancer after a long period of time; she said to me: ‘You don’t have to tell me that; I know that this is the cause.’ So yes…”

We sit in silence for a while, after she tells this. It is always impressive to hear how people’s inner wisdom can sometimes lead to intensely sad conclusions like this one. It is not easy for a healthcare provider to decide on how to handle these insights. If someone is not ready to consider this correlational option, in a stage of life where nothing can be changed about the former events anymore…does it still work ‘deguiltifying’ or rather retraumatising…? And less personal, but more at the societal level…If statistics provide us with these correlations, how can we take care that much more attention is being paid to those links by all policymakers and healthcare providers who are in favour of real prevention? Quite often, the narrative about people with certain diseases and addictions is quite different. Henriëtte: “About people with psychotrauma-related disorders, there was this idea that they neglected themselves, were either addicted or sensitive to addiction, inclined to be sexually overactive with a lot of promiscuity and unprotected sex, which was supposed to cause them to contract all kinds of diseases. In the scientific literature, however, this view has been flawed already quite some time ago. We have known for a while now that many diseases stem from what happens inside your body. And now that the last years have provided us with so much neurocognitive research data, we have found out that our brain…yes, well…I was about to say… infects our bodies! That is not the right wording, but I mean that an overstimulated brain has an enormous impact on our health. I really savour studies like these, because they give us so much more insight in what goes on in people as a result of stress and trauma!”

I look at her and cannot resist the urge to put on the table that impossible term that at the same time summarises all the aspects so brilliantly: psychoneuroimmunoendocrinology. For a couple of minutes, we have much fun about this word, but we conclude that this is what it is all about, about the physiological processes that call into question the dualistic thinking: body and mind are not separate aspects of humanness. Together, they are one big system, in which the psyche, the neurological system, the immune system and the hormonal system are intricately and inextricably connected. “Isn’t that beautiful?”, Henriëtte says, “and in fact, we have known this for a long time! In my view, we can only head towards really good treatment if we can let go of dualism completely, but we still have a long way to go to get there…”

Next week, we travel further with Henriëtte and hear more about her experiences in her work with people with childhood trauma.