TREATMENT
OF
DISSOCIATIVE
IDENTITY DISORDER
IN TURKEY:
A CASE STUDY
Vedas Sar, M.D.
Hamdi Tutkun, M .D.
Vedat Sar, M .D., is Professor of Psychiatry and Director of
the Clinical Psychotherapy Unit and Dissociative Disorders
Program at the Department of Psychiatry, Istanbul Medical
Faculty, University of Istanbul, in Istanbul, Turkey . Hamdi
Tutkun, M .D., is Assistant Professor of Psychiatry, Izzet
Baysal University Medical Faculty in Bolu, Turkey, and a doc-
toral student at the Institute for Forensic Medicine at the
University of Istanbul, During this project, he was a resident
in the Department of Psychiatry, Istanbul Medical Faculty,
University of Istanbul, in Istanbul, Turkey.
For reprints write Vedat Sar, M .D., Istanbul Tip Fakiiltesi
Psikiyatri Klinigi, 34390 Capa Istanbul, Turkey.
ABSTRACT
A 45-year-old housewife diagnosed with DID was treated for 27
months . This patient, one of the first DID cases diagnosed at Istanbul
MedicalFaculty Hospital, was initially treated mainly under inpa-
tient conditions (six months total hospitalization in three successive
admissions) . She reached fusion in eight months . The initial pre-
sentation form of the patient raised important questions about the
interrelationships of hysterical psychosis, childhood trauma, and DID.
INTRODUCTION
The emergence of the clinical work and research on dis-
sociative identity disorder (DID) at the Istanbul Medical
Faculty Hospital originated from efforts toward improving
inpatient psychotherapy for severe psychiatric disorders, but
not from studies about child abuse . Indeed, we detected our
first DID cases among these "difficult" psychiatric inpatients.
These efforts began toward the end of 1992 and increasingly
affected the atmosphere in the oldest university psychiatric
clinic in Turkey, creating motivation for learning and prac-
ticing psychotherapy particularly among young residents.
Now, DID work is routine work for all residents of the clin-
ic, and begins during the first year of training, with inpatient
cases in particular . Although the movement toward study-
ing and working with DID is currently affecting several teach-
ing hospitals in the country, after an initial period of skep-
ticism, the extension of studies on dissociation throughout
the whole country is now closely connected to the develop-
ment of psychotherapy in Turkey in general, and how and
148
in what direction it develops.
The treatment of DID requires the accumulation of clin-
ical experience which is most possible in inpatient conditions,
a safe environment for both the patient and for the neo-
phyte therapist . This environment also ensures team work.
The first author of this paper is in charge of one third of the
whole inpatient facility of the Psychiatry Department . He also
takes the responsibility for the training and supervision of
psychiatry residents in psychodynamic psychotherapy . Several
psychiatry residents who usually train in the Psychiatry
Department for five years participate in the ser vices of the
Clinical Psychotherapy Unit . This academic and clinical orga-
nization embedded in a university psychiatry department
played a critical role in the survival of the efforts during the
difficult beginning period of dissociation work in our coun-
try, and made it possible to resist and prevent interferences
and oppression/restriction in a highly competitive profes-
sional environment.
During the first five years of the study of DID in Turkey,
inpatient and outpatient treatment, research, and training
have been maintained in parallel and uninterruptedly . With
increasing clinical experience, the psychotherapeutical skills
of individual clinicians have been improved, and the range
of patients treated has become diversified . The case presented
here, Halime (a pseudonym), was one of our first patients
diagnosed as having DID . She was admitted into our clinic
initially with the diagnosis of a hysterical psychosis, a cate-
gory in use by many clinicians in Turkey, although it has
never been part of an official classification system . As such,
Halime is one of the patients who led us to propose an explic-
it link between the categories of hysterical psychosis and dis-
sociative identity disorder (Tutkun, Yargic, & Sar,1996).
CASE STORY : HALIME
Background of the Patient
Halime, a 45-year-old housewife with five children, was
living in a semi-urban district 40 kin from downtown
Istanbul . She had completed five years of education and
was married to a 50-year-old farmer . She belonged to a social
circle with a conservative lifestyle typical for this district of
Turkey . She had given birth to 14 children, but nine of the
babies had died shortly after birth.
DISSOCL1TION, Vol. X. No. S. September 1997
SAR/TUTKUN
She was the daughter of a family in Bursa involved with
making textiles at home . She was one of five siblings . She
had an older sister and an older brother . She had one
younger sister and one younger brother . Her father was 20
years older than her mother . Her mother physically abused
her children . Halime was sent to live with her aunt's fami-
ly in another town when she was six years old . The reason
was that her aunt had no children and wanted to adopt
Halime . She lived with this aunt and her aunt's husband
until she was twelve . She occasionally visited her parents.
Her father died when she was fourteen years of age . The
same year Halime was forced to become engaged to a man
whom she had never seen before, and had to marry him,
against her wishes when she was sixteen.
She entered our clinic as an emergency admission in
June, 1994 . This admission was her first contact with psy-
chiatry, although she had visited various internists and gyne-
cologists because of several somatic complaints which could
not be explained in terms of a medical illness . Halime report-
ed that she had experienced a similar episode of two weeks '
duration seven years previously . Her first hysterical psychosis
was treated at home by an internist . Medically, she had been
treated for tuberculosis when she was twenty, and had been
hospitalized for six months then.
Initial Presentation
She was brought to the emergency psychiatric unit early
one day by the nephew of her husband with complaints of
amnesia, headaches, talking to herself, visual and auditory
hallucinations, inappropriate laughing and crying, and
childish talking.
The authors first saw her two hours after the physician
on call had admitted her to the inpatient department . She
was sitting on her bed trying . to knock her head against the
wall . She said that she had a severe headache, a severe brood-
ing feeling, and could hear male and female voices in her
head which ordered her to kill herself, her husband, her older
brother, her aunt 's husband, and her mother . She saw her
dead father and several bearded men in front of her . They
said accusingly, "What have you been up to?" She claimed
that her father controlled her . Sometimes she gazed at a point
and talked to herself . She did not answer questions when in
that state.
Suddenly she became very joyful and said, "Hello, I am
Halime . Who are you? Where am I?" She had become
amnesic as to the time and place and why she had come there.
She could not remember what we had spoken about prior
to that moment . After talking for a few minutes she began
to cry, held her head in her hands and shook it . At that time
she did not answer our questions . She said she was afraid,
and that there were insects on her . She was struggling as if
trying to get rid of the insects . When asked about this, she
answered in a childish manner that she was nine years old,
was living in Bursa (not in Istanbul), and that the insects had
crawled on her when she was trying to hide herself from her
mother.
Then she calmed down, was amnesic to this flashback
(and/or switch) and asked us in a mocking manner who we
were . She was amnesic for the whole interview prior to then.
She said she had enjoyed herself the previous night . She said
that she had not gone home and stayed at a hotel . She did
not know why she was there.
Ten minutes later, sitting on her bed, she began to cry
and shake again . She was screaming, "Leave me . It hurts
very much . Mom, save me!" When she was asked what the
matter was, she answered that she was six years old, that she
was in her aunt 's house and that her aunt 's husband was
doing bad things to her . Meanwhile she was tearing at her
clothes with one hand and trying to cover her body with
her other hand.
During this interview, we observed distinct patterns of
feelings, behavior,and speech ; she introduced herself as dif-
ferent ages and identities . She had visual hallucinations
(brother, her aunt 's husband, father, men with beards, and
insects) and auditory hallucinations (voices telling her to kill
herself, kill her brother, her aunt 's husband, mother, and
husband ; and saying "you committed a sin") and she was talk-
ing to the hallucinated voices . She said that the image of her
father was following her everywhere, that he interfered with
everything . Sometimes she stared into space, did not speak,
and did not answer the questions we asked . Sometimes she
had periods of ten to fifteen minutes' duration in which she
forgot her name, where she lived, and the current time and
place . When she realized what was happening to her she
began to worry.
These acute symptoms of visual and commanding audi-
tory hallucinations, the rapid affective and behavioral
changes, her belief that she was controlled by her father, her
trance states, and flashbacks lasted for six days, waxing and
waning . When they resolved completely she had only partial
recollection of these six days.
What had precipitated the crisis situation in Halime?
She told us that one-and-a-half years before her initial admis-
sion her mother had died in Bursa (a city 200 km from
Istanbul) . For the funeral, she went to Bursa, where she had
not been for a long time . There she encountered her abu-
sive brother, whom she had not seen for many years . She
began to remember long-forgotten childhood experiences.
Afterwards she remembered being abused by her aunt's hus-
band when she was six years old . She went to Bursa again
six months prior CO admission, for a memorial ceremony
one year after her mother 's death . Her memories became
even more intense during that visit . Her symptoms had start-
ed suddenly when she found herself with a young man (the
nephew of her husband) in a hotel room, partially amnesic
for the previous evening . She had been having a good time
with him in a tavern until midnight . Because she could not
go back home, they spent the night in a hotel . When she
149
DISSOCt1?'ION, Vol . 3, September 1997
TREATMENT OF DID IN TURKEY
woke up in the morning she could not remember how she
had spent the night . At first, she complained of headache
and dizziness . On the way to the hospital, the remaining
symptoms had appeared.
Further Evaluation
During subsequent interviews different identities and
personality fragments took full control spontaneously, and
they had various combinations of amnesia and knowledge
about one another . These identities also had carried out
many aspects of the patient's life for which Halime was
amnesic (e .g., extramarital relations, travelling to several
places) . Sixteen personality states and fragments were iden-
tified in the first ten interviews . The number increased to
21 in the course of further treatment.
Beginning with the first interview, the therapist followed
the sudden changes in behavior, speech, thought, and affec-
tivity. He came to recognize which personality each char-
acteristic pattern of appearance and behavior "belonged
to ." Every time these changes occurred, the therapist
inquired whether the patient was having dissociative expe-
riences such as depersonalization, passive influence, or
amnesia at that moment . If the answer was yes, she was
requested to describe it in detail . Her perception of her-
self and her environment, and whether her identity had
changed was recorded . If a change in identity had occurred
and there was an alter personality, new to the therapist, a
new anamnesis was gathered . Indeed, the therapist sought
to establish when and how each particular alter was formed,
and to learn her specific role in the alter system . The alters
met with this method have been listed below.
Alter Personalities and Fragments Found Initially
Halime One ("Sad Halime') : The host was a depressive person
who suffered flashbacks of sexual abuse by one aunt 's hus-
band when she was six years old (including vaginal pene-
tration), by her older brother (nine years her senior) from
ages nine to twelve years (including anal penetration),
being given at age six to another childless aunt, and various
other emotional and physical abuses . She was amnesic to the
activities of the other personalities . She appeared depressed
and preferred to stay at home . She attributed all her com-
plaints to the sexual abuse by her first aunt's husband ; that
she was sent to stay with her second aunt's family in anoth-
er town between six and twelve years of age ; and to the fact
that she had to submit to sexual abuse by her brother (who
usually exploited her when Halime visited her mother 's
home) ; that her mother battered her frequently and often
forced her to leave home, forced her to do heavy housework,
and insulted her ; that she was engaged to a man (her cur-
rent husband) she did not want to marry when she was four-
teen, and married to him when she was sixteen . The first
aunt, whose husband abused Halime, lived in the neigh-
150
borhood of Halime's parents' house.
She remembered these events vividly as she was reliving
them . She heard voices commanding her to kill her broth-
er, her first aunt's husband, mother, and herself . These voic-
es were commenting about her behavior .Sometimes she saw
the images of her father and bearded men she did not know.
Halime Two (`Happy Halime) : Happy Halime liked traveling,
dressing up, went out for entertainment at night, and did
not worry about the childhood traumas . She had had two
extramarital relations about which the host was not aware.
Joyful, she got on well with everybody . She did not worry about
the difficulties of life and her past . She liked to have fun, to
drink, go out, dress well . She went out secretly with her friends
and used alcohol . She was aware of all the other 45-year-old
alter personalities (Halimes) . Happy Halime had given all
these Halimes names according to their prominent person-
ality styles.
Halime Three (`Happy-Go-Lucky Halime ') : She spoke in slang
and called people by perjorative names . She said that she
had a difficult marriage, that her husband did not under-
stand her and that nothing would ever change . She experi-
enced a gap in memory when other personalities took con-
trol during the interviews . She did not know about the other
personalities.
Halime Four ( "Normal Halime") : She also called herself
"Normal Halime ." She was aware of most of the 15 person-
alities . She said that she was neither Sad Halime, nor Happy
Halime, nor the mocking happy-go-lucky one . She said "I
am the real normal Halime, the others are the sick parts of
me ." She said that she sometimes was able to observe what
occurred when the other personalities took control.
HalimiFive (Angry, Nervous, Serious Halime) : This personal-
ity was aware of some of the other personalities . She want-
ed to get a gun and kill her brother, brother-in-law, husband,
and mother . She believed that she would be able to forget
the pain of the past if she did this . She wanted to kill Sad
Halime in order to save her from the pain of this life, and
Happy Halime because of her problematic behavior and
extramarital relationships . She believed that Sad Halime and
Happy Halime were not part of her, and she thought that
she would survive when they died . Angry Halirne was a frag-
ment.
Halime Six ( "Suicidal Halime ') : She could not bear her child-
hood memories and current life, cried often, and had
attempted to commit suicide several times in the past . She
had amnesia for all other parts of an interview when she took
control . She only remembered that what she herself had told
us previously.
DISSOCIATIONX. No . 3, September 1997
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Child Alters : There were seven child alters . Six of them were
formed during sexual abuse . There were two fragments, each
six years old . One of them repeatedly relived the beginning
of the sexual abuse by her aunt's husband (the man coming
into the house ; her being taken to the bed and undressed
forcefully, crying, pleading, resisting ; having her head cov-
ered by a pillow) . The second fragment relived the period
after the completion of the rape (suddenly coming to her-
self in the bed ; her aunt's husband threatening her with death
if she revealed the assault ; pain in the genital area ; dressing;
going to the toilet).
Two nine-year-old fragments similar to the above re-lived
being raped by the brother.
Another nine-year-old fragment relived the period when
she was hiding in a closet to avoid her mother . This frag-
ment described the insects in the closet, which had climbed
all over her . According to her husband and her daughter,
this fragment took control at home repeatedly during the
night . During these periods the patient walked back and forth
in the room, did not recognize the members of her own fam-
ily, tried to remove the insects on her clothes, and cried.
A 12-year-old fragment re-experienced the rape by her
brother.
Another child personality said that she had come to
Istanbul from the city where she was living at thirteen years
of age in order to get engaged . She did not know the per-
sonalities older than herself . Her orientation to time and
place was in accordance with her age.
Snow White and The Queen : Two identities had been formed
from childhood imaginary playmates : "Pamuk Prenses"
(Snow White) and "Kralice" (The Queen) . They both
enjoyed parties at nights where the Queen looked after, pro-
tected, and controlled the young "Pamuk Prenses " and envi-
ously competed with her at the same time . Snow White
danced and sang.
When Snow White took control she saw her husband and
children as "the relatives of that poor woman in the neigh-
borhood (Sad Halime) ." The Queen said that the former
was her daughter, and she punished her because she did not
obey her . She said that she was a friend and confident of
Happy Halime . These identities had been formed at about
the age of twelve ; they knew the other personalities, but they
saw themselves as distinct from all the others.
Alters of Different Ages : There were four alters characterized
mainly by their different ages . A 16-year-old alter was living
as if it were the time just after the marriage . This alter had
flashbacks of having sexual intercourse with her husband.
An 18-year-old alter said that she had two children and want-
ed to die . She did not know of any other alter.
A 20-year-old personality said that she was in hospital for
the treatment of tuberculosis . She liked the hospital and the
people there, and had had three children . She did not know
any personality other than herself.
A 23-year-old alter was not satisfied with her marriage.
She was formed when Halime became involved with extra-
marital relationships . This alter personality took usually con-
trol when she came to downtown Istanbul . She then would
change her conservative dressing style (e .g., took off her head-
kerchief, put on tights, and adopted a hair style more like a
sophisticated urban lady rather than that of a peasant
woman) . During the phases of outpatient treatment, it was
apparent because of this dressing style that this alter was
actively participating in daily life . This personality maintained
two separate extramarital relationships (one for 15 years and
one for five years) and several "friendships" in downtown
Istanbul.
TREATMENT OF HALIME
The Context of Treatment
Because of several considerations, the beginning of
Halime 's psychotherapy was conducted for the most part in
a hospital setting . First, she found it difficult to come to ambu-
latory treatment because of the distance between her home
and the hospital, and because of the restrictions imposed by
her husband . Second, she repeatedly developed crises in the
form of hysterical psychosis episodes and was admitted to
the clinic under emergency conditions which required
prompt hospitalization . Third, since she was one of our first
DID patients we considered it preferable to work under inpa-
tient conditions as we could not otherwise manage to hold
the patient in ambulatory treatment . Fourth, inpatient treat-
ment provided better opportunity for team work ; i.e ., sev-
eral residents could take part in the treatment at different
periods, as physicians on call in particular, which is very
important during hospital treatment.
The first author remained the stable person who was in
charge as inpatient director, supervisor of the team, and also
personally intervened during crisis situations . The second
author remained the primary therapist of the patient and
managed the outpatient therapy . Halime would come to town
and stay one night with her sister so that she could come to
treatment on two consecutive days . He continued to treat
the patient concomitantly with the inpatient team during hos-
pitalization periods . He saw her two or three times every week
for one-and-a-half hour interviews on the inpatient unit . Such
an arrangement was the only possible solution for provid-
ing effective and intensive treatment for an almost perma-
nently unstable patient in a university clinic that was in the
process of learning how to treat DID.
Drugs were used to address target symptoms . Trazodone,
alprazolam, and a fluoxetine at various doses were used at
different times . No neuroleptics were used . Halime attempt-
ed suicide twice using drug overdoses when she was in hos-
pital, arranging to have drugs brought from outside the unit
and hiding them until she was ready to ingest .
151
DISSOCIATION, Vol
TREATMENT OF DID IN TURKEY
Initial Stabilization
The patient was in chaos . The aim during this stage was
to stabilize her, establishing contracts with several alters so
that ambulatory treatment could be possible . Suicidal
ideation and attempts, self-mutilative behavior, somatic
complaints, and conversion symptoms were controlled.
We tried to help the patient accept the diagnosis .We
helped the alters listen to one another during interviews . She
became aware of the amnesias between alters . The Schneid-
erian symptoms such as hearing the commenting and com-
manding voices of other alters, being passively influenced,
depersonalization, and identity alterations experienced in
daily life {such as feeling and seeing herself at different ages
and gender), and the relationship of these experiences to
the information about the periods for which she was amnesic
were explained to the patient.
She sometimes saw her body as if it were a child 's.The
information gathered from child alters (childhood abuse,
the information which the child alters have about the per-
sonality system) was transmitted to the host personality who
was amnesic to the behavior when the child alters were in
charge . She could realize that an alter personality existed
and was responsible for some of the behavior for which she
was amnesic.
Beginning with the first interview we managed to get all
the alters to watch and listen to each other . That helped to
establish communication between them.
Work On Trauma
The parts which contained traumatic memories were the
two six-year-old fragments (reliving the abuse by her aunt's
husband) , two nine-year-old fragments (reliving abuse by her
brother) and a nine-year-old fragment (reliving the incident
of the closet with insects while hiding from her mother,) and
a 12-year-old fragment (reliving another period of abuse by
her brother) . These were, at the beginning, child alters who
were experiencing flashbacks, and were disoriented as to time
and place, being fixated on the time of the traumatic expe-
rience . These alters were calmed by providing orientation
to time and place . They were told that the events were in the
past and there was no more danger . At appropriate times,
the abreaction of the traumatic events suffered by each alter
was achieved by using hypnotherapeutic techniques . The
adult personalities were made to listen to the revelations of
the child alters ; e .g., adult alters were referred back to the
time when the traumatic experience occurred, using age
regression, and the incidents were described by the affect-
ed alter . For that purpose the patient created an image of a
screen in her mind and the alter described all the events as
if she were watching them on the screen, and other alters
envisioned the events on a screen as well.
On several occasions during that period, Halime ran
along the corridor in the hospital, trying to take her clothes
off . Halime was actually trying to undress herself with one
hand while trying to prevent this with the other . With time,
we realized that there were two alter personalities fighting
each other . One was a child alter, and the other was Metin,
an abuser . She was crying and speaking like a young girl . She
was begging to be saved from her brother.
A few minutes later she spoke like a man with a thick
voice, and swore at those around her . At that time, an alter
personality emerged that said that he was Halirne 's brother.
The alter introduced himself with the name of "Metin ." He
threatened to kill any alters who disclosed traumatic events
concerning him . He believed that he would be ridiculed if
still more were revealed . Other alters had been aware of Metin
before as a voice inside their heads . Merin said that he first
raped Halime when she was nine years old, and had con-
tinued to do so for a long time . He had beaten her so she
would not reveal these events to anyone . He had threatened
her in many ways . Afraid, Halime had not told anyone about
these assaults . Metin opposed her revealing these events in
treatment . This male alter also threatened the therapist, and
demanded that the story of his activities not be told to the
patient 's husband and children, or to the other physicians
in the hospital . He insisted that the therapist stop the treat
ment.
After a certain time we were able to establish a rela-
tionship with Metin and explain to him the situation Halime
was in . We told him about Halime's illness, his situation as
an alter, and the nature and meaning of the therapeutic pro-
cess . Metin, who had been very energetic and angry, began
to say : "I can not speak anymore . You have exhausted my
energy . My power diminishes ." He spoke less and less.
In time Metin transformed from a swearing aggressive
personality into one who tried to protect and save Halime.
He came to watch the other alters in order to adapt to the
alter system . He wanted to have a place among them at the
end . He asked how he could be forgiven for all the harm he
had caused . Then he changed into a powerful helper.
Another abuser alter, the "aunt 's husband, " appeared
following Metin . It was not difficult for the "aunt's husband"
alter to follow the same behavioral transformation as Metin
had undergone . Usually, simple contracts were repeatedly
used in controlling these male alters . For example, Metin
promised not to undress Halime . However, he did not keep
his promise during the first days of the contract . He said, "I
am a bad person, I make promises but do not keep them ."
We discussed "badness" with hits and were able to overcome
this difficulty.
All other alters gradually shared their information about
traumatic events, and their support was gained.
Fusion and Integration
While the treatment was progressing, periods of co-
consciousness and co-presentness among all alter personal-
ities increased . It came to the point when all alters together
could make decisions as to which alter should take control
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DISSOCIATION . N . 3. September 1997
SAR/TUTKUN
of the body at a given moment in time . Some of the alters
told the therapist that they no longer had a reason for stav-
ing separate or taking full control of the body . They said that
they would not speak anymore . They wanted to fuse at a con-
venient time.
We realized that there were no other personalities
except these alters who were already aware .of each other.
We discussed the remaining stages of the treatment . We lis-
tened attentively to the opinions of all the individual alters.
Their consent for a fusion was obtained.
A depressive mood affecting all the personalities devel-
oped as the amnestic barriers disappeared . All parts were
deeply affected upon learning the whole life story . The final
integration occurred in stages after a dream about fusion.
Halime dreamed of a black eagle . A white eagle fought with
this black eagle and won . Halime was deeply affected by this
dream when she woke in the morning . She remained in a
trance state for three to four hours . During that trance state
episode she relived her whole life beginning from her child-
hood . She described it as taking 45 minutes, and appearing
like a movie in fast motion . She had been able to listen even
to the sound of the wind in the grass . Afterwards she said
she felt that the time of fusion had come ; she believed that
her dream was a cue for that . We asked the patient how she
thought fusion should proceed . All the alters met together
and discussed how to process it.
This "meeting " occurred during an interview . Halime
closed her eyelids and reported her inner experience . First,
the child alters wanted to join Normal Halime, and did so.
They transformed into a ball of light . The other alters no
longer experienced them as alter personalities . During the
same interview the 23-year-old alter and the 16-year-old alter
formed part of this . Sad Halime was transformed into Lady-
like Halime during this period of treatment . This new per-
sonality fused with Happy Halime . Angry/Serious Halime
wanted to stay separate . Suicidal Halime joined the ball of
light . The combination of the Happy Halime and the Lady-
like did so too .The remaining Angry/Serious Halime fused
with the ball following a severe headache brought about by
her first resisting the fusion.
Two male alters disappeared after apologizing ; they said
that there was no need for them anymore . Snow White and
the Queen said that they were entities who did not exist in
real life ; they found it difficult to fuse . They decided to give
their characteristics to Halime, and disappeared . Halime-, her
eyes still closed, waved goodbye to them.
The therapist did not intervene during this process.
Halime opened her eyes and said : "This is my victory ." The
day after, Halime spoke about the changes in her percep-
tions . She could no longer hear the sound of the grass . She
said that she had been experiencing happy times as vividly
as sad ones . Now, both the traumatic memories and her happy
memories felt relatively subdued . She was disappointed at
not being able to experience Snow White and The Queen
any longer.
The patient was discharged from the hospital two weeks
after integration without any problem . In an interview dur-
ing ambulatory treatment an interesting event occurred . She
had gone to Inegol (a district of Bursa where she had lived
as a child) a few days before the interview . During this inter-
view she was amnesic to all the previous treatment and to
her childhood traumatic experiences . When the therapist
reminded her about the treatment and her hospital stay, and
oriented her, she began to remember everything again as if
an accelerated movie . This occurred over the period of half
an hour as a series of flashbacks, which she saw inwardly while
she kept her eyes closed.
Postfusion Treatment
During the post-fusion period the main issues in the
treatment were her feelings about the abusers, her wish to
confront her brother about his abusive behavior, her
thoughts of disclosing the abusive incidents to her siblings
and to all her family, her general anger towards the whole
world and people, her sexual difficulties with her husband,
and her wish to meet and know people with life stories sim-
ilar to her own.
The first happiness of the patient after the final fusion
gave way to a mourning reaction . The therapist also recog-
nized that he was now in a very difficult stage of treatment.
During that time, the patient became very friendly with a
woman whom we had diagnosed with PTSD . Halime met her
in the hospital . This woman was being treated with the diag-
nosis of depressive disorder . Her husband and child had been
killed in a traffic accident many years ago . She was the same
age as Halime . Halime said that it was the first time in her
life that she had had such a close friend.
Halime complained of aches and pains in her genital
areas, stomach, and back . Such symptoms were prominent.
We had known the origin of these pains since the pre-fusion
period (rapes and her mother 's whipping her) . We spoke
about them . We used fluoxetine, 40 mg . per day, and alpra-
zolam, 3 mg . per day, to relieve her distress.
Two months after the final fusion, while she had prob-
lems with her husband, she developed an alter who cried
and claimed that her whole life was a tragedy, and who want-
ed to die . This alter did not have the characteristics of a full
personality, and was similar to the 45-year-old Suicidal
Halime . However this alter was active only during interviews
and did not show any suicidal acts during daily life . She spon-
taneously appeared during interviews, spoke a while and dis-
appeared after a few minutes . We decided that this was not
a relapse to full DID, but rather a condition within the lim-
its of a DDNOS . This alter also fused within one month.
Halime 's most important marital problem concerned her
sexual life . She was very young when she was engaged and
married against her will . She saw the first years of her mar-
riage as the continuation of her experiences of childhood
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DISSOCIATION, Vol . 3, September 1997
TREATMENT OF DID IN TURKEY
abuse . During the last year and a half, her relationship with
her husband was very bad . The recovered memories of abuse
had caused her to be conflicted about sex ; she complained
about her husband's sexual demands . After fusion sexuali-
ty did not disturb her any more and the flashbacks did not
occur . However she still did not enjoy being with her hus-
band.
After fusion, Halime even thought of leaving her hus-
band and her family . Her family members did not know any-
thing about the abuse story and found it difficult to under-
stand the whole treatment process, which took a long time.
In particular, Halime was afraid that her husband would not
believe the abuse she had suffered nor would other mem-
bers of her family, since she had not spoken about them till
she was 45 years old.
In the post-fusion period Halime participated in an ini-
tiative by DID patients who had met one another in our clin-
ic . They met in a cafe in the city every week, planned to estab-
lish a society in order to make DID known to the community
as a disorder, to help one another and other patients suf -
fering from DID . This project continued for almost one year
and produced many difficulties for both patients and ther-
apists . Some of them, including Halime, participated in a
television program and disclosed their childhood histories.
Although attempts were made to keep their identities secret,
many people in her circle identified Halime and learned of
her story . Gradually this adventurous movement made a tran-
sition to more benign and loose relationships among the
patients, because of the difficulties that occurred between
the patients, and by virtue of the active intervention of their
therapists . Fortunately, Halime's daily life and marital con-
ditions were not badly affected by these events.
Halime's treatment lasted 27 months, including the pre-
and post-fusion periods . We had only telephone contact and
indirect contact with her afterwards . We had our last phone
contact in December, 1997, when we were preparing this
paper . She no longer had pseudopsychotic episodes and
amnesic periods, nor any cues of alter activity, and she had
not had any post-traumatic symptoms, nor did she require
a new psychiatric admission . She said that she wanted to par-
ticipate in social work in order to help people with person-
al histories similar to hers . She was worried about her two
daughters, aged 16 and 13, and had apprehensions about
their personal safety.
DISCUSSION
This 45-year-old patient decompensated after a visit to
her parents ' home . This visit to the scene of some of her child-
hood abuses elicited long-forgotten memories of childhood
mistreatments.
Halime reached final fusion in eight months and the
whole period of psychotherapy lasted 27 months . In the light
of our subsequent experiences, we believe that the duration
of this treatment was relatively short for a patient with 21
alters . Halime is one of the oldest of our DID patients . The
mean age of our first 60 patients was only 22 .5 years ; 28.3 %
of them were 18 or younger (Sar et al ., 1997) . We believe
that there were several reasons why this treatment was con-
cluded so rapidly . The traumatic environment which had
caused the disorder did not exist anymore : Her abusive moth-
er and her aunt's husband were dead . She had not seen her
brother for almost 20 years . She was living far from the place
where she had lived while she was abused . In contrast to that,
most of our DID patients are still in their twenties and are
confronted with ongoing abuse or the destructive interfer-
ence of family members, which makes treatment more dif-
ficult . We believe that Halime had encapsulated the traumatic
experiences and had kept them out of awareness until her
children were grown up . She had enough strength to keep
most of her psychopathology contained for most of her life.
Because of these reasons we could carry out the metab-
olization of trauma relatively easily . Even her extramarital
relationships were ended . There was no need for negotia-
tion between alters because of this situation . Overall, there
were no big conflicts between alters . The most influential
factor perpetuating the separateness was the need to keep
the trauma history hidden . Several alters had different
knowledge about the past . The persecutory alters who tried
to prevent the disclosure of abusive experiences to the fam-
ily did create some difficulties for the therapist, but these
were managed.
Such a rapid treatment far from one's home atmosphere
leads to changes unexpected by the patient's family mem-
bers . Halime's children knew their mother as a energetic,
lovely, and overprotecting mother, but at the same time, as
a person who intermittently showed unexpected behavior.
She never spoke about her traumatic past to her family . She
said : "I was a person who seemed happy during the day but
cried at night ."Her husband knew of her problems indirectly
through the difficulties in their sexual life . After the treat-
ment, the family members, especially the children still liv-
ing at home (three daughters) , were more aware of her other
facets as a person.
In the case under discussion the initial part of the treat-
ment was conducted in an inpatient setting . The reasons for
hospital management was rapid switching, recurrent episodes
of "hysterical psychosis" (Tutkun, Yargic, & Sar, 1996),
decompensation following discharge from the hospital after
briefer stays, the existence of alters who were unstable when
faced with recovering traumatic memories, the frequent pres-
ence of child alters, the inability of the patient to come to
downtown Istanbul for frequent ambulatory interviews
because of geographic distance, and the lack of support of
her family for treatment . Because Halime did not want to
disclose her painful past to her family, her relatives were not
able to understand her psychiatric condition and to support
the long-term treatment plan.
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DISSOCIAT10V, Vol
SAR/TUTKUN
There are also DID patients in our program who have
been treated until integration without any hospitalization and
who never had emergency admissions . Despite our experi-
ence with Halime, in general we have concluded that
patients who need inpatient psychiatric treatment may
require a longer overall treatment duration.
During the inpatient treatment period, the general prob-
lems created by these patients originate mostly from self-
mutilative behavior and suicide attempts . We found that
flashbacks usually occurred during the evenings and near
midnight . Sometimes the flashbacks of one patient trigger
similar reactions among other dissociative patients on the
unit . The isolation room of the unit is used in overcoming
such difficult times . We experienced all these events in our
work with Halime.
Flashbacks can not be managed in a uniform manner
because of the rotation of both the attending residents and
the residents who are on call at night . Although this can be
somewhat problematic, it also makes it possible to hospital-
ize several DID patients simultaneously, to detect possible DID
cases in other parts of the clinic's facilities, and to incorpo-
rate the treatment of DID into the experience the whole clin-
ic, including medical students, interns, and nurses . Although
the daily problems originating from skeptic attitudes have
never been lacking, it has been possible to absorb and trans-
form this skepticism into valuable experience and insight,
especially for the staff who work in the inpatient facility . The
other teams in the clinic, who work mainly in ambulatory
units, have remained relatively unaware of this important
experience.
For a while, our DID patients behaved as a group and
united against some nurses or residents . They reacted badly
if they felt a resident on call had a negative attitude toward
them . Many factors contributed to the origin of counter-
transference reactions to the DID patients ; this was expressed
(at the least) in unempathic manners during staff contact
with the DID patients . Also, conflicts originating from staff
matters were projected onto the DID patients, and the divid-
edness in staff perceived by the patients was considered to
be staff splitting by colleagues prone to see DID as a per-
sonality disorder of the borderline variety . Some of the res-
idents believed that dissociative patients had been given spe-
cial rights . It was difficult to teach the residents and at the
same time not to put the patients in the position of special
privileged patients . Some of the nurses believed the DID
patients . Some of them disagreed with the diagnosis, and
some of them treated the DID patients badly . There was even
a time when a substitute attending resident, temporarily cov-
ering for the therapist who was responsible for the patient 's
case was skeptical about the disorder . However, the system
as a whole continued to function in a constructive direction,
sometimes with the help and determination of the patients.
The simultaneous training of psychiatric residents in psy-
chodynamic psychotherapy by the first author, who has also
been the person responsible for supervising the inpatient
work, enabled sufficient harmony in the clinic to maintain
therapeutic work . At the same time, this complex organiza-
tion needed special attention to maintaining boundaries and
coordination among all parts.
In Turkey, arranged marriage at an early age, being given
an adult role in the family early in life, or being sent to
another family during childhood have been frequently
observed among women who live in rural areas (Sar,1983).
The oldest daughter seems to be the sibling most at risk for
such treatment (Ozturk, 1976 ; Sar & Sar, 1991) . Loss of one's
father during adolescence and/or the existence of a neglect-
ful and hostile mother are factors making such events more
likely (Sar,1983) . However, the frequent existence of child-
hood sexual abuse among these individuals and its direct rela-
tionship to the development of dissociative psychopatholo-
gy has been recognized in our country only after the rise of
interest in dissociative identity disorder in 1990s (Sar,1995;
Sar,Yargic & Tutkun, 1996).
Currently Turkey is undergoing tremendous economic
and cultural change . The family dynamics characteristic in
rural areas that played such an important role in the life of
Halime, no longer prevail throughout most of Turkey,
although extreme contrasts still can be observed between dif-
ferent regions . The establishment of modern telecommu-
nication technology and the development of mass media,
especially in the last decade, have strongly accelerated social
change . The emergence of a strong feminist movement seems
inevitable . Even some religious practices have begun to
change (e .g., recently, it is acknowledged by religious author-
ities that women also can be present among men during the
ritual burial ceremony ["cenaze namazi"] at the mosque).
A systematic prevalence study conducted by our team in
our clinic demonstrated that, excluding previously diagnosed
dissociative disorder patients, at least 5% of all inpatient
admissions consisted of DID cases (Tutkun, Sar, Yargic, Ozpu-
lat, Yanik, & Kiziltan, 1998) . This finding provides a power-
ful rationale for maintaining the challenging clinical area
of study in a university department, pursuing research
endeavors, and integrating the difficult area of practice into
the mainstream of clinical psychiatry . It is both a challenge
and a test for an institution to improve and maintain its qual-
ity at a level sufficient both to contain and to offer compas-
sionate competent treatment to such sensitive, complex, and
deeply-wounded patients . M
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