By Prof. Dr. Vedat Şar, ESTD representative for Turkey

Although dissociation and dissociative disorders have usually been an ordinary part of the daily clinical work in psychiatric settings and emergency wards of hospitals in Turkey, the onset of modern dissociation studies is closely linked to the clinical work and research conducted on dissociative identity disorder (DID). Namely, prior to these studies, dissociative disorders were considered as merely transient “reactions” on the basis of an “underlying trait” (i.e., “neurosis” or “personality disorder”) rather than constituting a chronic process themselves. As an academician and clinician who started his professional career in the early 1980s, the author of this column has been a participating witness of this “paradigm shift” (Kuhn, 1962) in his professional sphere departing in the 1990s. This column is an attempt to take a snapshot of dissociation studies in Turkey two decades after this turning point.

The Clinical Psychotherapy Unit and the assigned Dissociative Disorders Program of the Istanbul University Faculty of Medicine which were founded and led by the author between 1994- 2014, embraced thousands of dissociative clients referred by professionals from all over the country. Dozens of young clinicians in training - usually psychiatric residents - participated in this endeavour of research and treatment. Networks of collaboration with volunteering professionals from other institutions in diverse places widened the resources of research in particular. These strivings contributed to the development of overall psychotraumatology in Turkey, and provided a framework to delineate complex trauma and its clinical consequences.

While a general understanding of complex trauma and dissociation has developed somewhat hesitantly and only over years upon scientific strivings based on consistent publications of research, the recognition of “acute trauma” as a focus of interest occurred in Turkey rather abruptly. While such interest was rather limited to sequelae of human rights violations such as the psychological consequences of torture (Başoğlu, 1992), in resemblance to the role of combat PTSD played in North American psychiatry, it was the two large-scale earthquakes hitting the most developed Marmara area in 1999 and leaving twenty thousand casualties proved to play an instrumental role for the awakening of this interest on a wider scope. These tragic events have also constituted an opportunity for several clinicians to get acquainted with EMDR, which is flourishing in Turkey after a refractory period of one decade.

The almost endemic character of natural and man-made disasters in the region (e.g., the recent coal-mine disaster in Soma/Manisa of western Turkey, politically motivated terrorism lasting for decades) remains as a factor which keeps this interest alive. Yet against these major natural and man-made disasters, as a constant factor in the background, clinicians in psychiatric and medical settings continue to be exposed abundantly to patients who have complex childhood trauma histories and/or suffer from various types of dissociation. For instance, half of the adolescents applying to an outpatient unit of a university child and adolescent department in Istanbul had a dissociative disorder (Sar et al., 2014a). Curiously enough, they did not differ in childhood trauma histories from non-dissociative psychiatric controls as assessed by the Turkish Version of the Childhood Trauma Questionnaire (CTQ) - Short Form (Sar, Ozturk, & İkikardes, 2012). Aside from constituting a risk group due to the developmental period of adolescence, apparently different types of traumatization as well as additional factors may have played a role in this astonishingly high prevalence. Nevertheless, there are collateral observations causing alarm over some psychological unrest in the community: e.g., substance use has been on the rise among adolescents in particular (Tamar-Gürol et al., 2008). Functional neurological (conversion) symptoms (a type of somatoform dissociation) are also endemic in Turkey (much more prevalent than in Western Europe & North America and the Far East) - another clue in this direction (Şar et al., 2009).

Are There Really Cultural Differences?

The Turkish experience shows that childhood trauma leading to dissociative disorders does not occur only in the hands of overtly sadistic or abandoning parents or caretakers but may be subtle and also occur in so-called “apparently normal” families of the middle or upper-middle class (Ozturk and Sar, 2006). A well known example of the latter is the phenomenon of the overprotective parenting which leads to disturbances of attachment and of interpersonal boundaries interfering with a healthy sense of self and sense of agency in their offspring (Kogan,2007; Kohut,1971). While these parental aberrations do not exclude overcontrol issues, they should also be considered as a consequence of a diffuse sense of diminished safety in the community (Berlinski, 2010; Sar and Ozturk, 2013b). Nevertheless, this is the undeliberate transgenerational transmission of trauma. Turkish culture, with some Mediterranean flavour, is a rather relational one. This is one reason why parental overprotection is perceivedas normative. While itself being an origin of developmental psychopathology under certain conditions, this may be an advantage to shorten the treatment duration. One reason for this opportunity is the heightened power of the therapist-patient relationship provided that it is managed toward a therapeutic direction. Interestingly, this may also have its repercussions in the internal world of patients; i.e., alter personalities may be relational among themselves as well (Colin Ross, personal communication, 2013). However, this turns to an obstacle in patients who are still heavily influenced by a rather boundary-violating or oppressive relational context. Anyway, therapeutic alliance becomes the highest priority in a relational culture, whereas active involvement of and taking feed-back from the patient should accompany this.

Consistent Gains and Consolidations

What have been the gains in the past two decades which have been consolidated? First of all, the field of dissociation is one of the best represented areas of research in Turkish psychiatry. The quality and sincerity of the scientific work received significant acclaim internationally. These trailblazing steps were mostly taken on a voluntary basis against the lack of significant grants and an institutional policy framework. In fact, the scope of devoted time and energy, and the amount of the carried responsibility by the leaders of this work have been beyond imagination. The outcomes have been integrated to the international literature and are disseminated; hence, they have served their mission fully. Furthermore, almost all dissociation measures have been translated into Turkish and have been validated. This is an excellent opportunity for domestic researchers as well as for those in other countries who conduct crosscultural comparisons. As well, many clinicians have become familiar with descriptive features of DID and its subtreshold forms (other specified dissociative disorders type one) to a degree sufficient to diagnose the disorder easily and accurately. Dissociative disorder research has also started to be generalized by various centers (Yanartas et al., 2014) and a new wave of studies tend to include dissociation measures in general psychiatric research to investigate the “gray” areas and possible relationships with other psychiatric categories (Şar and Ross, 2006). In addition, assessment of childhood trauma has become part of research designs in diverse settings and domains. Finally, patients with DID and its subtreshold forms are no longer overtly stigmatized by mental health professionals compared to the 1990s when even the clinicians in the field could share this fate despite their struggle for the prosperity of their dissociative patients in an unsupportive professional environment by volunteering for extra work and carrying enormous professional risks.

The Charm of “Small” Tools

Most clinicians and researchers know very well by their experience that in breaking out a novel area of knowledge the introduction of an easyto-administer assessment tool can serve to be a more efficient tool than complex contributions. The Dissociative Experiences Scale (DES) has been an excellent example thereof for the dissociative disorders field; i.e., the first instrument translated into and validated in the Turkish language, which assesses dissociation. It has shown that dissociation can be measured and how this can be done. Turkish Version of the CTQ is another strong candidate to become such a “hero”. Literally hundreds of dissertations using this instrument in Turkey are in the pipeline not limited to mental health sector but are also devoted to didactics, social work, education, and other disciplines. The knowledge emerging from these studies will certainly reach a critical amount in triggering motivation to serve this population better. However, it is important how these findings would be contextualized and interpreted which remains to the next phase.

Childhood Trauma: A Mere Fact

The current scientific endeavour with CTQ is not a surprise because childhood abuse and neglect have been a hot topic on the daily agenda of the country since early 2000s, particularly due to the abundance of emerging cases reported by national mass media in a detailed manner. Besides being sensational, they become a topic of discussion due to conflictsand dilemmas arising in forensic procedures in particular. One recurring reason of these public debates has been a former provision in the Turkish criminal code as applied to sexual assault cases, which recognized any permanent harm on bodily and/or mental health of the victim resulting from the perpetrator’s acts as leading to an aggravated form of sexual assault with a potential increase in criminal penalties up to threefold. Hence, as part of judicial procedures, many clinicians used to be assigned as expert wittness by criminal courts in order to evaluate the psychological condition of the victim to determine whether the criminal act caused a psychiatric illness.

Rather than the accuracy of the trauma history itself (which is to be proven before the court by the preponderance of all other available evidence not limited by the expert wittness’ evaluation), the impact of the event on the victim’s mental health became usually a point of debate: Was the mental health of the alleged victim affected by the action in terms of development of a “mental disorder”? However, this stance of the legislative system created questions from the clinicians’ perspective: What was the boundary between a “normal response” to traumatic stress and a “pathological” one? Was it justice that the perpetrator would get a less severe penalty in conditions when the victim is resilient? The assumption of harm as inherent by the act’s nature to the victim’s mental health eventually played a role in the amendmend of the stated provision. The impact of this amendmend on criminal enforcement and on involvement of forensic psychiatry and psychology as expert wittness in these procedures is yet to be unfold. Hence, “false memory” is momentarily not the main focus of controversies in Turkey as the courts inquire for collateral evidence. Yet, one wonders if such controversies among scientists and clinicians have their basis in forensic procedures and lawmaker’s decisions prominent in a particular country.

Satanic Ritual Abuse has never been an issue in Turkish psychiatry (there are no patients who claim it; therefore it seems to be a culture-bound syndrome); however, the existence of ritual abuse has proven itself at least on one occasion in the past decade: The Hezbullah in Turkey (not to confuse with the Lebanese Hezbullah which are independent entities) killed some of their estranged members in villa houses by torturing, videotyped these sessions, buried the corpses in the basement, and the perpetrators continued to live in upper flats of the same house with their spouses and children as if nothing happened. Cults of other types exist which address adolescents and young adults; however, the issue did not lead to a public discussion on mind control. Nevertheless, “where a system of oppression has become institutionalized it is unnecessary for individuals to be oppressive” (Florynce Kennedy,1916-2000). Alternatively, where individual and/or societal oppression is “normative” (real) it becomes less subject of a direct psychiatric symptom (fear).

Lloyd deMause (2002) considers war and institutional violence as a societal reenactment of widespread traumatizing childrearing practices. He underlines the role of mass conflicts about different childrearing practices (“psycho-classes”) even in civil wars.

Although politically motivated violence (i.e., terrorism) has been a problem in Turkey for decades, uncovering the psychological factors nurturing “human resources” of terrorism remains a neglected task (Moghaddam, 2006; Solinski, 2014) which is, in fact, a “mysterious” phenomenon globally. The recent mass violence of unprecedented scope in Middle East under an alleged ideological-political cover renewed this yet unanswered question; e.g., the phenomenon of ISIS possibly attracting individuals with an ultramalignantly hypertrophied, detached, and degenerated “sociological self” (Sar and Ozturk, 2007, 2013). The incidents of individual violence against civilians and children occurring from time to time in prosperous Western Europe and North America also created importantquestions about the psychological set up of the individuals involved in such inhumanities. Violence is known to be a phenomenon escalating in a circular fashion as shown in case history of a young man with DID and PTSD, who was raised up in a “normatively” violent environment and could not prevent himself from falling into assaultive behavior in early adulthood repeatedly (Sakarya et al., 2013).

What About Controversies regarding DID per se?

Jacques Lacan (1966) stated against master’s discourse which occupies the academia subtly in an era of power struggle: “Over centuries, knowledge has been used against truth”. One has to nurture a truely “scientific discourse” (Lacan, 1966) while working with dissociation and complex trauma; i.e. having the courage of asking questions and being open to questions without sticking on any given reference (Sar, Yargic, & Tutkun,1997). It is rather ironical that clinicians and researchers who work with dissociative clients are warned against the possibility that “DID appeared only as a consequence of the diagnostic interview conducted by the authors” (Chodoff, 1997), i.e., by asking questions.

Rather than “mainstream” psychiatry, sceptical attitudes against DID as a concept seem to be related to concerns about professional territories as represented by “schools” of psychotherapy. Narrow and rigid interpretations of various “schools” of psychotherapy tend to be presented almost as universal tools by “authority figures” who are not prepared to extend the insights of their respective fields to new domains, including complex trauma and dissociative disorders, in an objective and non-biased fashion. After the de facto removal of the concept of “neurosis” from mainstream practice, personality disorders (the DSM-5 cluster B disorders in particular) have served as a diagnostic niche in psychiatry for those who tend to avoid a diagnosis of dissociative disorder. The opposite of this attitude is a rather superficial one, i.e., restricting the field of psychotraumatology simply to the inquiry of the “stressor agent” and excluding the depth of human subjectivity in understanding the complex consequences of “trauma” in the “internal” world. Tragically, this attitude is also well correlated with scepticism about DID and either limits the clinical scope of psychotraumatology to PTSD or considers post-traumatic phenomena as a merely “normal” response to extreme stress. In fact, an in-depth understanding of complex trauma is a prerequisite of developing mastery in the psychotherapy of dissociative disorders and can be learned by proper training, which requires the “unlearning” of rigid interpretations of widely recognized or allegedly universal treatment models.

Where Do We Go from Here?

While DID is a well accepted diagnostic category in Turkish psychiatry currently, the basic challenge still remains: Delivery of accurate psychotherapy to the high number of patients who suffer from dissociative disorders. This is due both to quantitative and qualitative insufficiency of human resources and the increasing administrative and academic shortcomings in an era of collapsing service structures in hospitals of state universities during a long and ongoing period of forced privatization in the health sector. While there is an improvement of the access to general health services for large masses due to increased investment and automatization, psychotherapy of the trauma-related psychiatric disorders does not benefit from this development inside of the medical model. Keeping possible pitfalls in mind, one should consider that “evidence-based treatment” has become a motto of the era. In fact, dissociative disorders constitute a group suitable for controlled studies on efficiency of psychotherapy. Nevertheless, appropriate theoretical modeling and establishing a bridge between the theoretical model and the clinical practice is necessary. Erik Erikson’s legacy, “self-identity”, remains a neglected but important concept in psychiatry and clinical psychology. Without addressing the needs and operations of the “post-traumatic self” (Wilson, 2006), any therapeutic intervention model will operate from “outside” the patient’s personal world rather than working from “inside” and will remain limited in efficiency. Hence, the dissociative disorders field should never give up in defending the “I” of DID. A truely (non-iatrogenic) sociocognitive understanding of DID is not opposedto the trauma-model (Sar et al., 2013a) because psychological trauma itself has societal roots. Such an understanding of DID would require a treatment model covering social and psychological dimensions of self-identity (Sar and Ozturk, 2007). Future DID should become a broader concept than it was in the past, covering various presentations beyond multiple personalities, such as “dissociative depression” (Sar, 2011, 2013c), acute psychotic reactions (Tutkun, Yargic, &Sar, 1996), phenomena such as possession (Sar et al., 2014b), borderline (Sar et al., 2006), and somatic appearances including functional neurological (conversion) symptoms (Sar et al., 2009), which become predominant for subgroups of patients. The DSM-5 (American Psychiatric Association, 2013) addressed this issue by providing a broader definition of DID than the previous one; nevertheless, an effective subtyping remains as a work for future.