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The Perception of Psychotherapy in Turkey

Abstract

This research explores the perception of psychotherapy in Turkey. The main aim of this study is to understand participants living in Turkey in relation to their views and experiences of psychotherapy, and to examine several aspects of the perception of psychotherapy in Turkey by using in-depth interviews with twenty participants. Some themes are highlighted by using the information gathered by interviews. These include: the family is very important in Turkish culture and so the family`s attitude affects people’s views and experiences; keeping family secrets hidden is valued, so telling them to a psychotherapist in order to solve them may not be a solution; the high cost of private psychotherapy in Turkey is the main factor affecting people’s attitudes towards it; state hospitals, in which psychotherapy services are free, may not be preferred because of negative beliefs about state workers and state hospitals. The data gathered may present some shared views of the Turkish people, however it is important to consider that, Turkey has a large population and a homogenous culture including many different languages, religions, sects, habits, views and life styles, so it is not possible to reflect all.

Keywords: Counselling, counseling, psychotherapy, perception, mental health, Turkish, Turkey

Introduction

Perception of psychotherapy is subject to several factors those actually affect not only the perception but practice as well. I will examine issues that might influence the perception and the practice of psychotherapy in Turkey.

Kagitcibasi (1994) stated that even today psychology is not given sufficient value in Turkey as it is not thought to be the solution to important problems. This situation is similar in the developing countries. In addition, according to Kagitcibasi (1994), the large number of women in the area of psychology lowers the status of this area. Because Turkish society has a patriarchal structure, in which women are secondary to men.

Formal institutions in Turkey do not provide the teaching of psychotherapy, thus there is no formal institution to grant the title of ‘psychotherapist’ (Psikoterapi Portali [Psychotherapy Portal], 2011). In Turkey, psychotherapist skills are provided at clinical psychology master’s degree but clinical psychology programs may not provide being a fully competent psychotherapist. Add to this, only some information of psychotherapy and some facilities to practice psychotherapy are provided in medical schools of psychiatry. Further education on psychotherapy is needed for the ones those want to become competent enough.

It is considerable to review formal education departments, from which people in Turkey may become psychotherapists. Undergraduate psychology education is a four-year program in arts and sciences faculties, which provides general information regarding all areas of psychology. Psychiatry experts specialize for four years after six years of medical faculty undergraduate education. They receive an education mostly based on drug treatment. Undergraduate programmes called ‘counselling’ in Turkey teach school counselling rather than psychotherapy, so they mainly work as guidance counsellors at schools and at other training units. The reason for giving school counselling in the undergraduate education is defined by Korkut (2007) as the need for school counsellors in Turkey. Counselling focused on school counselling started in 1950s in Turkey and developed influenced by the developments in the United States (Korkut, 2007). However, guidance and counselling graduates may label themselves as psychotherapist and offer psychotherapy.

Although psychologists had been requesting to formally known for forty years (Paker, 2010), there was no mental health law regarding to control the competency of psychotherapy practitioners until 22 May 2014, and psychology graduates and psychiatry experts may practice psychotherapy as if they were competent enough, because there was no law to control whether they are competent. Although this health law is not satisfying for psychotherapy practitioners, with this law definitions of health occupations are made, and duties of these occupations such as ‘psychologist’ and ‘clinical psychologist’ are defined. According to the law, a psychologist works under the responsibility of a clinical psychologist, and a clinical psychologist works under the responsibility of a specialist in medicine. Counsellors are not included in the health law. Psychologists are able to conduct psychological tests those they are certificated, and clinical psychologists are able both to conduct psychological tests and to offer psychotherapy, but in situations those are defined as illness they must be leaded by a specialist. For clinical psychologists, they are not needed to lead by a specialist for situations such as family, occupation and social environment related problems.

There are nearly 1.500 psychiatrists, 10.000 psychologists adding 2.000 new graduates every year, and approximately 700-800 clinical psychologists in seventy-five million population of Turkey (Turk Psikologlar Dernegi Tanimlar Komisyonu [Turkish Psychological Association Definitions Commission], 2011). Therefore, there is not enough number of mental health practitioners, and if only psychiatrists can take main responsibility of private mental health services, the number diminishes. There is another negative influence of psychiatry dominated mental health services, which is that medicine taking for mental illnesses had been increased related to dominant view of basing mental illnesses on biology among psychiatrists. Drug treatment hegemony causes people suffered from mental illnesses in Turkish society has been complaining about ‘they are not understood’. The other reasons of their complaints are patient intensity and inadequate number of experts in hospitals (Turk Psikologlar Dernegi Tanimlar Komisyonu [Turkish Psychological Association Definitions Commission], 2011).

In a study (Voltan, Yildirim, & Ergene, 1996a) conducted in Ankara, the capital city of Turkey, psychotherapy was found to be more recognised amongst women than men. It is more recognised among women between the ages of nineteen to thirty-five, among divorced people, among the upper socioeconomic class and among university graduates. In another study (Voltan, Yildirim, & Ergene, 1996b) conducted in Ankara, the characteristics of people who have psychotherapy were examined. People who have psychotherapy generally have enough information about it, and psychotherapy is more common with those of the upper socioeconomic status and with educated people.

In Turkey, people may avoid using mental health services because of the fear of stigmatisation. Because of this, they may hide the fact that they use mental health services (Taskin, 2007). They may only tell their family and very close friends, concealing the fact from others (Taskin, 2007). Related to this, they cited that they experienced extreme sadness and would be frustrated if they were called as ‘mentally ill’ by others (Taskin, 2007).

The rate of seeking help from resources other than mental health services is not low and it is common for women, whose religious beliefs are strong, to seek help from religious ‘healers’ called hodja (Taskin, 2007). The main problem about this issue is that these people may be knowledgeable about mental illnesses and mental health services. Even though people may say that they would prefer to use mental health services, in practice they may prefer to seek help from hodjas (Taskin, 2007).

Being strongly religious is common among people who have low socioeconomic status. Among religious people, the rate of having psychotherapy is low whereas amongst people who stated that they are moderately religious or non-religious, the psychotherapy rate is higher (Voltan, Yildirim, & Ergene, 1996b). In particular, moderate or non-religious people think that psychological health professions are primary help resources (Voltan, Yildirim, & Ergene, 1996b).

Problem Statement

The aim of this study is to understand Turkish participants' views and experiences of psychotherapy, and to examine several aspects of the perception of psychotherapy in Turkey.

As a developing country, Turkey faces several difficulties in psychotherapy field, in both offering and having it. Difficulties are in both theory and the practice. The main stream psychotherapy theories may be regarded as white and Western, therefore, there are difficulties in offering this white and Western psychotherapy in a collectivist and patriarchal culture. As globalization continues to get different places in the world closer, it is inevitable to modify Westernized psychotherapy to the other cultures, which are quite different from the West (McGuiness, Alfred, Cohen, Hunt, & Robson, 2001). It is important to draw differences between Western culture and Turkish culture in order to make clear the need of modifying attitudes of psychotherapists.

The importance and meaning of psychotherapy is mostly not well-known in Turkey, which is to say that the request of psychotherapy is low, and even people try it, it is harder for Turkish people to keep having it until they reach the desired outcome. Psychotherapy is vague and confused with other disciplines such as psychology, social work, and even psychiatry (Dogan, 2000, p. 62). Healthcare services regarding psychological disorders are relatively few and the use of health centres for psychological disorders is very low (Demir and Aydin, 1997). One of the reasons is that there is low level of education and income (Raney & Cinarbas, 2005). Low level of income causes people to attend to their food and accommodation needs, which are more urgent than their psychological problems (Raney and Cinarbas, 2005). Also, in Turkey where ninety-nine per cent of the population is Muslim, treatment methods are predominantly sought in religious elements such as asking religious ‘healers’ for help, using folkloric medicine, visiting holy places and praying, giving adak (to make vows) and carrying amulets (Raney & Cinarbas, 2005).

The difficulties faced in both offering and having psychotherapy may negatively affect the perception of psychotherapy in Turkey.

Research Questions

‘The perception of psycyhotherapy in Turkey’ is investigated. Turkish people’s thoughts about and their experiences of psychotherapy is aimed to be figured out. What they know about and expect of psychotherapy is researched. Do they truly know what psychotherapy is? Whom they believe that psychotherapy is for? Do they consider having psychotherapy if they suffer from psychological problems? Whether their experiences of psychotherapy are positive if they have it, whether they believe in its benefits is examined. Add to these, people’s thoughts in Turkey about other people that have psychotherapy are investigated. What people think about other people having psychotherapy? Do people tell that they have psychotherapy or they need to hide it because of stigmatization?

Purpose of the Study

Where psychotherapy stands in Turkey and in Turkish mind, and how it differentiates than widely accepted Western understanding and practice is aimed to be found out in participants’ experiences.

Research Methods

Qualitative methods of research are used in order to gather depth information from participants. Thematic analysis is used and main themes obtained from semi-structured interviews of subjects' are presented. Results are gathered from in-depth interviews with twenty participants.

Findings

According the information gathered by in-depth interviews from twenty participants that live in Turkey highlighted several themes about psychotherapy field in Turkey.

The Importance of Family

In collectivistic Turkish culture, relationships within the family are very important. For people, caring for the family is most important, and individuals may consider their family first before their freedom, personal benefits and independent choices. Considering that the family is seen as culturally and morally valuable, people are judged socially if they do not care about their family, so there is added social pressure on them (Metz, 1995). Many people have internalised this cultural value, so many Turkish people do not need to be judged to take responsibility for their family.

Related to the importance of family, Turkish people’s thoughts and actions may be influenced highly by their family, and encouragement coming from within is very important to maintain thoughts and actions. Therefore, Turkish people’s experiences and thoughts of psychotherapy are also mainly influenced by their family.

I think that considering family and maybe inviting family members to psychotherapy may be beneficial for Turkish clients. I believe that family problems should be solved within the family circle, otherwise the client may return with the same problematic thoughts and acts.

Keeping Family Secrets Hidden

Another problem, which is related to considering the family to be highly valued, is the tendency to keep family secrets within the family. It may prevent Turkish people having psychotherapy. As several participants mentioned this issue and said that it is important in Turkish culture to keep negative experiences within the family, and what has happened within the family should not be told to other people, not even to a psychotherapist.

Stigmatisation

In Turkey people may avoid going to psychotherapy because they are afraid of stigmatisation (Taskin, 2007). Psychological problems are seen as a negative thing, so having psychotherapy demonstrates that one has psychological problems. People who have psychotherapy may be judged in a negative way. Having psychological problems may be described as ‘being insane’, so it is exaggerated and stigmatised (Taskin, 2007).

Having psychological problems may be regarded as an ‘abnormal’ situation, which is also shameful, and perceiving it as shameful may be related to a belief in the Islamic religion. This religion values fatalism, so religious people may tend to be fatalistic in their thoughts, judging other ‘abnormal’ people as deserving what they experience, because they believe God sends goodness and badness.

Participants indicated that they may tend to hide that they have psychotherapy, or sometimes they were secretly asked about a good psychotherapist to be referred, and experienced other situations that people hide from each other that they had psychotherapy because they were afraid of stigmatized.

Preferring Religious Healers

In Turkey, ninety-nine percent of the population is Muslim (Turkiye [Turkey], 2010), and Muslim people may prefer to see an Islamic religious healer for treatment (Taskin, 2007). These religious healers are called ‘hodjas’, and their actual duty is not to heal people but to lead religious practices such as ‘namaz’, to read the Quran to other people and to give religion-oriented advice. However, religious people trust hodjas without questioning because of their faith, and they believe that hodjas are the most religious people, cannot act in a wrong way, and they are most trustworthy. Even though in recent years the media has showed many examples of hodjas, who have tried to take advantage of girls sexually, and demonstrated that their healing methods are fake, there are still people who prefer hodjas to heal them. A study (Taskin, 2007) demonstrates that people preferring hodjas may have knowledge about psychological disorders, and they may state that they would prefer mental health services in a case of psychological disorder, but in reality they prefer hodjas as a treatment method. Another study (Voltan, Yildirim & Ergene, 1996b) shows that people preferring hodjas have low socioeconomic status and are highly religious.

Lack of Turkish Resources about Psychotherapy

There may be a shortage of Turkish psychotherapy related literature. However, it is fair to say that Turkish resources about psychotherapy have been increasing daily. Some of the participants indicated that they have become aware of positive influences of psychotherapy by reading foreign resources.

“What would the neighbours think?”

In Turkey there is a very common idiom: “What would the neighbours think?” People try to shape their acts according to this idiom as they care about being judged negatively. People know about each other much more than in individualistic cultures, as they talk about each other and try to learn about other people`s experiences. This is to say that they follow each other and in the case of someone acting incompatibly with strict society rules, then that person would be stigmatised, disliked and left out of the group and of society. Therefore, Turkish people are afraid of being left out of society; Turkish people are afraid of “What would the neighbours think?”

Especially in families, elders warn their children: “Do not do that, do not do this! What would the neighbours think then?” In houses, it is a tradition to have a ‘guest room’ for visitors which is always kept clean and tidy, because they do not want others to see an untidy and unclean part of the house. They also do not want others to know the negative experiences and events of their lives.

Turkish people’s considering the judgment of others is a significant factor for thinking negatively about having psychotherapy. People would avoid having psychotherapy; even if they think they urgently need it, they would keep it a secret from other people. A study (Taskin, 2007) demonstrates that some people in Turkey avoid using mental health services, because they are afraid of stigmatisation, and some others having psychotherapy tell this only to their family and very close friends.

Psychologists vs. Psychiatrists

In the interviews, participant used a confused way of referring to their psychologist, psychiatrists and psychotherapists.

In Turkey, both psychologists and psychiatrists may become psychotherapists. However, the difference between psychiatry, psychology and psychotherapy is not well known (Dogan, 2000). People do not know whom to call psychologist, psychiatrist or psychotherapist. Turkish people acknowledged them by considering that one of them gives medicine, one of them does not. Therefore, they may call a psychotherapist “a psychologist”, and they may call “the psychiatrist” when they have need of a medicine cure.

High Cost of Private Psychotherapy

The main reason that psychotherapy is not common in Turkey may be related to its high cost. Thus, psychotherapy is perceived as belonging to a small number of people, to the elite, who earn large amounts of money. Added to this, not only being rich is enough but it is also necessary to have a high socio-cultural status (Voltan, Yildirim, & Ergene, 1996b; Taskin, 2007).

According to statistics (Inequality of income distribution statistics, 2011), inequality within the distribution of income is highest in Turkey compared to the rest of Europe. In 2008, the lowest twenty percent of the population took 5.8 percent of total income, while the highest twenty percent of the population took 46.7 percent of total income (Gelir Dagilimi Istatistikleri [Income Distribution Statistics], 2008). According to the study researching life standards in Turkey (Gelir ve Yasam Kosullari Arastirmasi [Income and Life Standards Research], 2009), 88.8 percent of the population cannot afford to have a one week holiday away from home; 58.7 percent of the population cannot afford to eat meat, chicken or fish once every two days; 57.7 percent of the population are in debt; and for 25 percent this debt severely diminished their life standards. 38.5 percent of the population lives in inadequate housing; and 82 percent of the population cannot renew their old furniture because of financial problems.

The high cost of counselling plays a big role in its perception. Because of this shortage of money among people in Turkey, it is understandable why private psychotherapy is perceived as a luxury.

Psychotherapy Services in State Hospitals

Participants who had psychotherapy in state hospitals mostly indicated their negative experiences. Some of the participants complained about conservative manner of the state hospital workers. A homosexual participant was negatively influenced because of a psychiatrist offering psychotherapy to him in order to ‘normalize’ him, to help him to become a heterosexual.

Conclusions

The research of perception of psychotherapy in Turkey, has found several significant points to examine: The importance of the family, hiding family secrets, stigmatisation, preference for religious healers, lack of Turkish resources about psychotherapy, “what would the neighbours think?”, psychologists versus psychiatrists, the high cost of private psychotherapy, and psychotherapy services in state hospitals.

The field of psychotherapy in Turkey is still developing. It is not a well-structured field yet. There is no education to offer the label of ‘psychotherapist’, but psychotherapy is regulated under the responsibility of some occupations. In this way, it may be interpreted as that psychotherapy is not considered as an independent way of treatment, but a part of treatment process. It increases the value and usage of psychological tests and drug treatment.

It is also understood that Turkish people are not well-informed about psychotherapy, the implication of it and about its benefits. An awareness campaign might be helpful about it. Turkish people should be leaded to consider psychotherapy as a treatment method when they experience psychological problems. However, an awareness campaign will not be enough; easy access should be supplied for the ones who consider psychotherapy as a treatment method. There should be institutions, foundations and associations to offer free or low-cost psychotherapy.

People working in psychotherapy field are also responsible for increasing awareness and easy access. They may offer free or low-cost psychotherapy in certain days for disadvantaged people who want to have psychotherapy. They need to support literature by doing translations or writing about their researches in the field.

Additionally, it is an important to consider that Turkey has a large population and Turkish culture is not homogeneous. In different regions and within different groups, there are different values, beliefs, norms and attitudes. The information gathered from only twenty participants may reflect a small part of these differences; however, I believe that some important aspects of the perception of psychotherapy in Turkey are evaluated. With further research, more comprehensive study might be done, different cities in different regions of the country, or different groups having different language, religion or sect may be compared. Interviews with people working in the psychotherapy field would be also significant to identify difficulties and lacks in the field.

Acknowledgements

The author(s) declare that there is no conflict of interest.

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About this article

Published online: 01.05.2015
Pages: 220-230
Publisher: Future Academy
In: Volume 13, Issue 2
DOI: 10.15405/ejsbs.165
Online ISSN: 2301-2218
Article Type: Original Research
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