The Tavistock, between Melanie Klein and family systems

Sebastian Kraemer: Would you like me to tell you about the Tavistock first?

Yes; then I will ask you questions about your specific work.

The Tavistock is the only public clinic in England devoted to psychoanalysis, because psychoanalysis, you know, is generally a private practice; but the Tavistock is exclusively public, it is the government that pays the salaries of the psychologists, the psychiatrists, and so on. Almost all the work is psychoanalytic psychotherapy, or related to it… Over the last twenty years, systemic groups have developed in the children’s department. Well, I wasn’t there from the beginning, I was a medical student at the time, but I believe one or two people from there went to New York and, for one reason or another, they started training people in family therapy; and there were great conflicts, because they used video and the one-way mirror, and people asked: “How can you do that? The patients are going to have fantasies about the video and the camera.” Well, they did it, they carried on, and today they enjoy great prestige in family therapy training.

Does that come from the United States, or…?

As I see it, since 1977, the year I started doing family therapy with them, we have had various influences: Virginia Satir, Harry Aponte, Salvador Minuchin, Luigi Boscolo and Gianfranco Cecchin, from Milan; that was my education, from the structural to the systemic. Family therapy is beginning to be respected at the Tavistock. In the children’s department, where I am a psychiatrist, there is a large family therapy group, the systemic group, and a large group of psychoanalytic psychotherapists.

Do they work with families too?

Not much; they work mainly individually. They also work with families, but not strategically: they work with the countertransference, and so on. I find the psychoanalytic group in the children’s department very interesting, because they mainly train child psychotherapists; there are several disciplines — social workers, psychiatrists, psychologists —, and they follow Melanie Klein.

Melanie Klein?

Yes, those are the two big parts into which the children’s department is divided: Klein on one side, family systems on the other. What is interesting is that both work in the “here and now”; you know, Klein is not historicist, that is the important thing. And what I find most interesting in my experience is that these two traditions work well together and have a lot to offer each other, even though the styles are different. The Kleinian style is serious, there isn’t much laughter, but it is very immediate… it is not a historical reconstruction. We have a small group of trained psychologists and social workers, who work according to… well, in fact: “Do what you can!”, “Yes, do what you can!” I think that is a good way of working if one manages to get along with the others, so we have no school of thought in this small group. Were you there this morning? (He is referring to the consultations carried out by Dr Kraemer during his stay in Buenos Aires, as part of his teaching demonstrations at the GUIAS institute — Grupo Universitario de Intercambio, Interacción y Asistencia en Salud Mental.) Well, in the morning as in the afternoon, the three cases I presented were individual therapies. In the end, all of them ended up as individual therapies, and for me that is perfectly systemic; in conclusion, individual therapy is what is appropriate in those cases, and it is not anti-systemic, because systems include individuals and the work one does with them.

Thinking rather than feeling

Interesting, but tell me more about Melanie Klein and the systemic.

I think the answer is that I don’t do both at the same time. In the systemic here and now, you look at people and the way they relate to one another; in the Kleinian here and now, you look at yourself — the transference is obviously the most active fact in the room, and if you are the patient and I am the therapist, I am all the time wondering what you might be thinking of me. When I work in that way, I feel uncomfortable, I sweat, because the patient is interested in me. But when I do family therapy, they are not interested in me; they are happy to answer my questions, but I make sure they are interested in themselves. It is different, but we are always talking about the present; of course, one can ask questions about history and so on, but the main therapeutic force is what people think now, what they think of one another. That is another thing that links Melanie Klein to… “Melano-systemic” therapy, it is the emphasis on thinking about problems and feelings. I believe that, since W. Bion — who was Klein’s patient and was famous for his work with groups, although he gave it up in 1948 to go on doing individual psychoanalysis —, his contribution, as I see it from the outside, concerns the way people think, the way they think about their feelings — but the way they think. Likewise, if you talk to a family about each of its members, in a systemic way, I prefer to ask “What do you think?” about mum and dad, rather than “What do you feel?”.

Why?

Because feelings are something private, and people don’t know how to explain what they feel; they say “good”, “bad”, “cold”, “hot”. But if you ask them what they think, you will get their opinions, and that is something typically human: you cannot ask an animal what it thinks, but you can imagine asking an animal how it feels; a cat might say “frightened”, “comfortable”, but it makes no sense to ask it what it thinks. I believe the traditional view people have of therapy around the world is that… well, you have a person, with a certain feeling, she cries and that’s it; she cries for her mother and she gets better. I think that is not therapy; I think therapy is when one thinks what one feels and when one has an experience: what is therapeutic is a new thought, an emotional thought, and I think that is the basis of change in any form of therapy — a cognitive experience.

Redefinition, the basis of all therapy

In systemic therapy, redefinition is used; what do you think of this technique?

As I understand it, redefinition is the basis of all therapies. Redefinition takes place in psychoanalysis as well as in systemic family therapy. When someone lives through a confusing experience, about themselves or about another person, redefining makes the new thing less confusing. I mean: it may be more confusing, but it is new. I think that, to be therapeutic, it must be linked to unconscious fantasies; that is, I don’t agree with just any redefinition, it has to do with the relationship, and the right redefinition approaches the fantasies in the same way in psychoanalysis, in systemic, strategic, structural therapy, even if the therapist doesn’t know it. From my point of view, we are all psychoanalysts, even if we use neither the transference nor the other psychoanalytic techniques; we do the same… I am not talking about the MRI: I think they are genuine behaviour therapists, I am not sure I understand their work; but I am thinking of the other therapists I know — Minuchin, Palazzoli, Haley, etc. —: they represent a new understanding of relationships, so that I can combine, in my understanding, psychoanalytic thinking and systemic thinking.

When you speak of unconscious fantasies, does that mean that, in your work, you look for these fantasies?

No, that is the difference. The technique, in psychoanalysis, consists of looking for these unconscious fantasies; what I am saying is that in systemic family therapy these unconscious fantasies are mobilised, but not looked for — and that is the important point. We talk about experiences, but we don’t try to settle into another person’s heart; we talk directly. And that is why I think systemic therapy is a redefinition of psychoanalysis, because one has a new perspective on an old idea; of course, the method is different, but I believe the principles of therapy are the same. So it is a different position, a different activity, different feelings, but I believe the effect is the same.

That is interesting, because I think Bateson or Milton Erickson didn’t think of that.

I think not. And the reason I think they didn’t is that psychoanalysis in the United States is fairly primitive, conservative, expensive; they have no State-funded psychoanalysis. The Tavistock, being public, is more flexible — that is one reason; but I also believe the English school is more creative, perhaps because it mixes more Melanie Klein and Anna Freud and all those who followed them: Bion, Winnicott, Balint, etc. Many of them passed through the Tavistock, for example Bion and Balint; Winnicott did not. For one reason or another, the English school is more creative, more spontaneous. Winnicott and Whitaker have a lot in common; but, in general, American therapists don’t know much about English psychoanalysis. Haley, in particular, when he talks about psychoanalysis, talks about fantasies that are his own; I believe he doesn’t have a very precise idea of what psychoanalysis is in its modern practice.

Of course, through his books on psychotherapy, one realises that he understands very well what it is about.

When you speak of modern psychoanalysis, what are you referring to?

Well, I am talking about the psychoanalysis I know in London.

The Tavistock?

The Tavistock and…

Psychoanalysis in the here and now…

Yes, it is probably a combination of many things: Kleinian psychoanalysis, which is here and now; the middle group — Winnicott, Balint, etc. —, which is more flexible, more playful (in the sense of play, translator’s note); Jungian psychoanalysis, fairly developed in London — my analysis was Jungian, my father was a Jungian —, so I find it natural to have different influences in my own work.

You are very open-minded.

Yes, like an anthropologist. But here too, you see that the Jungians in Zurich are different from those in London; all of this evolves in a very different way from the original ideas. Freud would not recognise what is going on in London today, and Jung would not recognise it either. The other day I was reading that Freud did not consider himself a good therapist, whereas Klein was brilliant, gifted, natural. I believe that is an important distinction: the American tradition is Freudian, more rigid, intellectual, cautious and… medical! “Here is the treatment, you take it, and I am going to talk to you about yourself and your past, about what you are doing now…” Well… The Kleinian tradition is more… surprising, more shocking; a good Kleinian intervention is irresistible, it is very simple, you cannot avoid it, it is very obvious.

What are these interventions like?

Well… about envy, for example. Klein was very concerned with envy, as a destructive force. If you tell someone that they are hungry for something, that it is an envious state, it means they are envious of you. If it is true, there is no escaping it… it is so obvious to be envious. There you have something very direct, an entirely immediate redefinition.

So, if you say that all therapists redefine, you don’t agree with the position of certain theorists or therapists about a single truth.

I believe in the concept of truth; I believe that every map is more or less true, which means it is also more or less false. What I mean is that a redefinition cannot be just any redefinition; it must be linked to an experience.

An experience of the patient.

Yes, in fact an experience of the heart, and that is why I believe the psychoanalytic basis is important, because it refers to what people experience in their bodies. Last year, I was telling myself that psychoanalysis actually deals with the holes of the body. It is something shocking, thinking about intellectual experiences in terms of infants; because I believe Freud’s ultimate contribution was to bring these symptoms or these ideas back to infantile experiences, and, in a certain way, this touches on that, although from another angle. I don’t believe they are unaware of it, but I doubt that a family therapist would allow himself to acknowledge his psychoanalytic basis; remember, though, that Palazzoli and her colleagues trained in psychoanalysis in the United States.

A small task: goals, brevity and the function of the symptom

What are the goals of therapy, from your point of view?

I look for the main task, which is not for people to be well, but to discover what I, myself, have to do; and sometimes what I have to do is very little. Winnicott — and I am talking about a psychoanalyst, not a systemic therapist — wondered what was the minimum he needed to do with children. So I think the goal, not so much of therapy as of clinical activity, is to discover what there is to do. I never have a goal, because that seems too ambitious, like wanting to make everything better. I simply have a task…

A small task?

A small task; for example, with an alcoholic, that he stop drinking today — tomorrow is another day. I work with what there is to do now and, at the end of the “now”, I ask the person consulting what we do next, and then we see each other again tomorrow or in a month.

I like to take leave of the clinical situation immediately, to force myself to think why we should see each other again, to avoid becoming dependent on patients. Clinical work is addictive; one sees patients again even when one doesn’t wish to — why? I always ask: why do you have to see them again? That is the danger of psychoanalysis: it breeds repetitive meetings and an addiction to therapy. One of the main contributions of brief and systemic therapy is the refusal to go on indefinitely.

It is appealing to hear that from someone who is in psychoanalysis; it is going to make a strong impression in Argentina.

Well, remember that I don’t do psychoanalysis; my work is based on psychoanalysis, but I am not a psychoanalyst. I respect psychoanalysis, but I have no psychoanalytic goals; I don’t get too involved with my patients, whereas my analyst colleagues do. But… of course, I care about my patients, and I sometimes wake up in the middle of the night.

I find this business of the small task close to the MRI model.

Yes, I believe it is. They ignore relationships from the emotional point of view; they are interested in games, but not in families… I resist the term family therapy, it is a trap; perhaps you don’t need to do it. I prefer to think in terms of systems; as I said above, I do family therapy if I am forced to; what I look for is the emotional connection between the symptom bearer and the family, which, in my case, of course involves a child and their family.

Are you referring to the function of the symptom?

Absolutely. I think of it in terms of sacrifice, an idea I took from Palazzoli: the child sacrifices himself, tries to help, to save… And this idea is not very popular among brief therapists; Steve de Shazer doesn’t like it at all. I believe he is naive — he is brilliant, but I believe he is naive; I believe he ignores one of the most powerful pathways of change: the devotion and loyalty of children towards their parents. I believe it is a central idea in any therapy: what children do for their parents. It is a secret, a fantasy: “I can save my parents, but I mustn’t tell them, because they would say to me: who do you think you are?”

In general, do you look for the meaning of the symptom?

Exactly. The Freudian idea is that the symptom has a meaning, and I believe systemic therapists have replaced the word “meaning” with “function”. I believe this difference is made to avoid thinking of any alliance with psychoanalysis. I have this irritating idea that family therapy is in an ethical struggle with psychoanalysis, that it has to prove it is newer, more powerful and has nothing to do with Freud; but that is not the case.

That is going to be shocking for systemic therapists! Well, I believe your two opinions, on psychoanalysis and on systemic therapy, are going to have a great impact. It is hard to see this clinically: a linear orientation, which looks for the aetiology, and another, circular, which does not…

But meaning is not aetiology; it works as an active psychoanalytic accessory. The transference is not linear, it is circular, between you and me: what you think of me, what I think of you, what you think I think of you, and so on.

If you stay in the present…

Yes, but we also use the transference to gather information about the past. I believe the transference is a system, a present system; it is what you think I am… What I mean is that one cannot necessarily carry out both forms of work together, because they have different modes; but, intellectually, I have no difficulty in accessing both, and even in using them at different moments. In a given situation, however, one has to define where one is working; of course, it is easy to admit that the countertransference is always at work; anyone who reflects on themselves can accept that there are influences from others. But I distinguish between an interpretation from the transference and a systemic interpretation.

Request, follow-up and readings

Do you work with what the consultant brings, or do you look for something more?

Well… I think that distinction is a fantasy, a false polarisation, because the client asks for something, a negotiation begins with the “seller” and, after half an hour, the client asks for something else; I think the work, in the brief therapy consultation, really consists of changing the nature of the problem. I feel comfortable in a consultation that takes half an hour, three quarters of an hour or an hour, as long as I know why the client is there.

Do you usually work in three or four sessions?

Well… yes, sometimes I work with fewer sessions. I also work in a hospital, and there I try to be as brief as possible, and often with the longest possible interval: two months, three months. I don’t know why; I don’t want to stay involved, they are the ones who have to stay involved with one another.

Do you do follow-ups?

Yes, I send them a questionnaire six months or a year after the last meeting; it is a very simple questionnaire, they have to indicate whether the problem is much better, better, unchanged, worse or much worse.

… the problem you defined with them.

I don’t ask which one, only “the” problem; I send it to the family and they are the ones who decide what the problem is. Then I ask: have you had any problem at all? I send them a stamped envelope…

Do they reply?

More than half; it is not statistically valid, but it satisfies curiosity. If they don’t reply, it is sent to them again saying: “Sorry, we have not received your reply, perhaps you could send it back.” But it is addressed to the clinic, not to the therapist, which is an important point, because I think they feel accountable to the therapist; this way, they don’t feel obliged to say they are well.

What do you read most?

I read mainly psychoanalysis. After practising systemic therapy for more than ten years, I now believe I have systems in my blood and am in no danger of losing them; so I can read what I like — the history of Argentina. My wife wishes to become a psychoanalyst, she goes to analysis every day; so I too have to read psychoanalysis seriously, and this helps me rethink psychoanalysis; in fact, I am continuing my own analysis, which I had finished four years earlier.

Do you think it is very important for the therapist to have an analysis?

I really do believe so; I believe one can have a richer contact with people…

Would you like to add anything?

I am very grateful to have had the opportunity to express what I think.

It is we who are grateful to you.