The psyche speaks in metaphors

Kathleen Stock points out a drastic conflict at the Tavistock GIDS between storytelling and actual real world drugs and surgeries.

A crucial yet underappreciated part of the story is the clinic’s strong emphasis on psychoanalysis and psychodynamic approaches to mental health. The founder of the Tavistock, Hugh Crichton-Miller, was explicitly influenced by Freud and Jung. And when Domenico Di Ceglie founded the Gender Identity Service for children in 1989, later commissioned nationally as the only English NHS provider, he too was heavily influenced by psychoanalytic methods.

And the thing about those is, they’re much closer to the storytelling end of the spectrum than they are to the medical end.

In a 2018 article describing his process, Di Ceglie quotes a Jungian perspective approvingly: “the psyche speaks in metaphors, in analogies, in images, that’s its primary language, so why talk differently? We must write in a way that evokes the poetic basis of mind… it’s a sensitivity to language.”

Lalala, it’s all so profound, know what I mean?

This intellectual focus upon the fluidity and construction of meaning, and upon the power of narrative to create more stable personalities, is also heavily present in the published work of Bernadette Wren, Head of Psychology for 25 years at what insiders tweely call the “Tavi”. By her own description, she was “deeply involved” with the GIDS team for much of that time. Alongside psychoanalysis, she adds post-structuralist philosophy to her formative influences, citing figures such as Richard Rorty and Michel Foucault as important in her thinking.

All very well if you’re a lit crit, not so hot if you’re an actual doctor handing out meds.

True to the relativism of these philosophers, in Wren’s intellectual vision there are no objective truths but only a series of subjective narratives. She writes: “If the idea of living in the postmodern era means anything, it is that in all our activity together we are in the business of making meaning.” She continues: “In our time, it is hard to see any knowledge or understanding as ‘mirroring’ nature, or ‘mirroring’ reality.”

Awesome, man. Now about those blockers.

Against this intellectual background, the Tavistock’s flannel about being a thoughtful service sheltering from the storm of our present culture wars starts to make more sense. At least historically, senior clinicians at the Tavistock have never believed there is anything but certain context-bound forms of thought, floating about in a post-modern void. They have assumed meaning is constructed, not found. They have denied that there is any certain or timeless knowledge, but only specific cultural dynamics to navigate in the here and now. Under such an approach, what else could you do but be “thoughtful”?

And creative, and poetic, and fluid.

A recognition of ambiguity within the life of the psyche would be perfectly fine — indeed, I assume, therapeutically helpful — if all that had ever happened at GIDS was that people sat around talking to one other. But the general relativist stance of senior clinicians was made incredibly dangerous for patients by the presence of an additional factor in the therapeutic mix, nestling somewhat anomalously among Di Ceglie’s stated foundational aims for his service. Alongside commonplace psychodynamic goals such as “to ameliorate associated behavioural, emotional and relationship difficulties”, “to allow mourning processes to occur”, “to enable symbol formation and symbolic thinking” and “to sustain hope”, we also find: “to encourage exploration of the mind-body relationship by promoting close collaboration among professionals in different specialities, including paediatric endocrinology.”

Thud. Lalala, look at the pretty birdies, lalala here comes Fotherington-Tomas, lalala hello sun hello sky hello grass hello…paediatric endocrinology?

I don’t know about you, but when I read this, the birds — or rather the mermaids, perhaps — stop singing.

Same. There’s exploration, and then there’s medication and surgery.

For it’s at this point that it becomes clear to the percipient reader that these people think it a reasonable goal to alter a child’s healthy bodily tissue in order to accommodate a mind which is, by their own admission, constantly developing. It’s true they don’t think medicalisation is inevitable for every particular child, and it’s also true that they admit lots of uncertainty and liminality. But still, this option is on the table at GIDS, courtesy of friendly endocrinologist colleagues and their injections.

If they admit lots of uncertainty and liminality, why aren’t they more cautious? A lot more cautious?

Worse, with the availability of a medicalised option, there seems to have been little real recognition among managers that its presence put the remit of the service on an entirely new footing — one that absolutely required stringent standards of truth and falsity, and a thoroughly old-fashioned belief in the existence of prior standards of right and wrong. Talking to children about their identity issues and co-creating meaning with them may be an art, but giving them gonadotropin-releasing hormone analogues (GnRHa) is still very much a science — or at least it should be.

It’s so obvious when she spells it out, isn’t it. I’d love to know why it wasn’t obvious to the people at GIDS.

During GIDS’s experiment in administering these unlicensed drugs, doubts were already emerging about the poor quality of the evidence base, and about the potentially negative effects of GnRHa on brain maturation, bone density, kidneys, height, sexual function, and mature genitalia formation.

Trivial stuff like that.

Yet the Patient Information Sheet offered to patients and their parents by clinicians minimised the then-suspected risks. And though the process was widely advertised as a harmless “pause” on puberty, of the initial 44 children in their initial cohort for the treatment, almost all went on to cross-sex hormones, raising the question of what made this treatment a meaningful pause for reflection in any real sense.

Storytelling gone desperately wrong.

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