Interview by Glenn Gossling 2020, for In Mind magazine
‘The experience and expression of gender diversity – as well as the responses to it – necessarily arise within and take form and colour from particular cultural and historical landscapes and these become part of the internal experience of gender.’
Bernadette Wren is a Consultant Clinical Psychologist and Systemic Family Therapist who worked at the Tavi for twenty five years as a clinician, trainer, supervisor and head of the Psychology discipline. In her time at the Tavi she was deeply involved with the GIDS team, working there initially in 1997-2000 and then from 2011 until her retirement in 2020. In that time she has seen significant change, but much continuity too, in the challenges to that service. “At the time I went back, even though the team was tiny, there were many differences between the clinicians in how they conceptualised the clinical and theoretical issues. Real tensions existed.”
Bernadette was interested in how a team could flourish in the face of these substantially different perspectives amongst team members. She was also concerned by a sustained sense of mistrust – “if that’s not too strong a word” – emanating from the wider organisation. There had been an institutional review in 2005 which expressed quite a cautious and critical position: GIDS had still not found a home at the Tavi.
She finds it troubling that people continue to engage in the debate through simplistic, over-confident assertions about truth and falsity, right and wrong, using a small number of case examples as paradigmatic of the whole clinical field. “In how I have practiced as a clinician and in what I’ve written, I’ve tried to highlight the immense complexity of the questions the work raises.” Indeed, she says she came to work at the Tavistock because it felt like a serious institution, so there’s disappointment in the recent failure of critics of the service to find platforms to engage in serious debate, within the Tavi itself, about the current gender controversies.
But she does talk very positively about the place she has worked. Looking back on her time at the Tavi Bernadette says, “I’ve been very happy to work here, I’ve had fantastic colleagues, I’ve had great opportunities. There probably aren’t many places that would allow me to combine my interests in philosophy and ethics, as well as in psychology, social science, politics and the environment. That has been possible for me here!” Still, she acknowledges, “I’ve always liked to occupy myself slightly on the edge of things, always bringing to debates a critical, rather than an established voice”.
Bernadette came to the Tavi with degrees in Philosophy and in Psychology. After undergraduate study, she had started a PhD exploring Ludwig Wittgenstein’s theory of ‘other minds’ but abandoned this as she was unhappy in the rarified and competitive academic environment. She held a range of jobs in journalism and teaching until she became interested in psychology which appealed as a more collaborative field of study, combining the empirical, the philosophical and the clinical.
Bernadette qualified as a clinical psychologist in 1988 and worked at Great Ormond Street Hospital for six years specialising in eating disorders. She joined GIDS in 1997 after qualifying at the Tavi as a family therapist on M6. She says, “After I qualified, there was a very part-time job going in the Gender Identity Service, then housed in a tiny office at the Portman. I think I was the fourth staff member. At the time it really wasn’t comfortable being at the Portman; we felt very marginalised.” In fact one of the early, very public, critiques of gender clinics came from within the Portman in 2002, when a group of adult clinicians wrote to the Telegraph strongly asserting the ‘delusional’ nature of transgender identities.
Bernadette takes a thoughtful view of this, saying, “The Portman then, as now, would have been the clinic taking on as adult patients people who were among the small number voicing regret for the surgeries they had undergone. But clinicians tended to build their whole understanding of trans identities on working with that group of patients. In GIDS, meeting very young people, we saw things differently.”
In 1995 Domenico de Ceglie set out the therapeutic aims and values for GIDS by which the service still abides. These include the ‘unconditional acceptance and respect’ for young people’s expression of their gender identity. “Those therapeutic aims still represent the core values of the service – they’re Domenico’s lasting legacy,” says Bernadette. “He grasped that if you want to have a genuine engagement with young people you have to take very seriously what they feel and what they say.” And she adds: “if you want to know how GIDS still operates, read Domenico’s aims.”
After her initial years at GIDS, and having completed in 2000 her doctorate (looking at patterns of communication in the families at GIDS), Bernadette took up a broader Tavi post combining a training role and clinical work in one of the Child and Family teams (“Team 5, which became Team 1, and later still the North Camden Community Team”). She began teaching research methods, and supervising research studies in the Child & Family PhD (run with Birkbeck College) and the D Clin Psych with Essex University (where she was a Teaching Fellow). In an institution still struggling at times to recognise the value of research in psychotherapy, she was soon providing research teaching on a wider range of courses, both systemic and psychoanalytic. From this work, she developed exciting initiatives, with a small number of colleagues, aimed at bringing together research students from all disciplines in the trust. These initiatives included the annual Tavistock Research Week, the annual Doctoral Research Conference and the Cross-Doctoral training programme. She was also instrumental in re-establishing the Tavistock Research Ethics Committee. Bernadette was especially committed to exploring research outside the dominant experimental paradigm: she valued qualitative research methodologies with their particular forms of disciplined analysis and their openness to reflecting on the epistemological uncertainty intrinsic to their knowledge claims. “And I enjoyed helping trainee family therapists get to grips with the relevant research base in their areas of clinical expertise”, although she was also highly critical of the politicisation of the notion of the ‘evidence-base’ in CAMHS practice.
She engaged in a range of clinical collaborations: working with parents who have poor mental health, with high conflict families, and, more substantially, in a clinical/research project enquiring into ‘domains’ processes in family communication. She developed an interest in how complexity can be understood when applied to clinical work, and she was a founder-member of the Tavi Evolutionary Psychotherapy Group, exploring the relevance of modern evolutionary theory to conceptualising therapeutic interventions. Bernadette co-authored papers on all of these topics with fellow Tavistock staff members. In 2002 she was appointed editor of the journal Clinical Child Psychology and Psychiatry.
Another enterprise to which Bernadette made a passionate commitment was to establish the ‘Green Group’ in 2005, aiming to raise awareness about climate change in the Tavi, and to pose questions about how we were living and working in our buildings. With a small energetic team, she spearheaded an expert architectural survey of the Belsize Lane buildings. She says now that she’s “very proud to have organised a number of Climate Awareness Days for staff, and to have led on the banning of polystyrene and non-recyclable paper from the trust.”
In 2008 she became head of the Child Psychology discipline and in 2011 the Trust-wide Head of Psychology at a time when Psychology had become by far the largest discipline at the Tavistock. As Head of Discipline she helped develop collaborations between the other heads of discipline, because in a time of cuts, redundancies and service redesigns, it became increasingly important to work together more closely to protect the integrity of the clinical work and clinical trainings.
Then in 2012 she returned to GIDS, for one day a week initially, “but I quickly got drawn further back in,” she says. From 2015, as the demand for social recognition of transgender identities grew more intense, GIDS expanded rapidly. Between 2012 and 2017 the annual number of referrals expanded almost tenfold from 208 to over two thousand. “Not only did the numbers grow, but we were getting referred many troubled young people about whom we knew very little, except what was written in a short referral letter. Many of them needed a lot of support, but we couldn’t always get their local CAMHS to help. It was a slow moving crisis for us and it has never been resolved.
“A lot of the problems we face have arisen from managing a service where referrals have expanded fast. In particular, in dealing with what you might call the arrivals and the departures – who comes into the service, and why, and what support do they actually require? In terms of departures, we face the problem of moving our young people on in a timely way, after the age of 18, to adult services – either adult mental health or specialist gender adult services.”
And of course, there was the added pressure of GIDS being subject to intense media scrutiny and criticism from trans advocacy groups, as well as, increasingly, from ‘trans-critical’ voices.
The growth in numbers was0 one thing, and the criticism from across the spectrum of views was another. But as Bernadette explains there was more to it than that. “There are morally complex, there are clinically complex, there are politically complex issues that we are grappling with and there aren’t any easy answers. One of the things about the gender field is you can’t plausibly develop a foundational theory of gender identity in which to ground the work. As a culture, we have largely given up trying to work out why somebody is gay because that began to feel like a really oppressive endeavour. Sexuality and gender identity – these are multi-layered human experiences that don’t yield to easy causal explanations. You’re better off trying to help people to live well, rather than trying, probably fruitlessly, to establish the story of how they came to feel that way.”
Looking back on the time she has spent here Bernadette says, “The things that have interested me most at GIDS have been the ethical issues in the work, I mean questions of autonomy and the right to self-define in defiance of normative expectations. Plus the political dimension of the work regarding who has authority to speak for and about young people and to define how it is possible to feel and to live. You can’t take the politics out of this work because whatever we say and do is against the backdrop of the horrible experience of sex and gender minorities in our social world. In that sense, you cannot be a ‘neutral’ clinician – all of us will have our commitments to where we think justice lies in this field. I‘m very far from saying as clinicians we have to ‘affirm’ everyone unquestioningly and to the maximum degree, but you have to be aware that a trans identity has been a shameful one, and still is to a large extent, and that people coming with these gender preoccupations, need our respect and support. “Not everything we do at GIDS is about medical intervention. Some young people are unsure what they want to do – they just know that their experience challenges conventional categories of sex, gender and sexuality. And some of the work is about helping people to continue to live in a body that feels, at least for now, incongruent and deeply uncomfortable. But one of the characteristic things about the young people who come to GIDS is that this is not an idea that has formed in their heads in a short space of time. If that were the case, we would still be curious about that story, we wouldn’t be dismissive of it, but it is not the typical story. The typical story is: ‘I didn’t tell anybody about this for years and now I’ve found the courage to say it.’”