An excerpt from the book "Organizational Memory of Psychiatry in Türkiye," published by the Turkish Psychiatric Association.
When the Association for Cognitive and Behavioral Therapies (KDTD) asked me to write a chapter about its founding, organization, and activities, I couldn't have imagined how difficult it would be. After all, writing a historical account of a field that one perceives as one's own child, to which one dedicates a significant portion of one's time, and upon which one has even built one's life philosophy, in an unbiased and non-judgmental manner, wouldn't be easy. And it wasn't... I hope that the sections stemming from my love for the field, which may appear to contain some judgment, will remain within the readers' limits of tolerance.
PRE-ESTABLISHMENT PROCESS
Twenty-two years ago, while working in London with my former professor and now friend, Prof. Isaac Marks, whom I greatly respected, I realized I had a dream. This dream was to establish a Behavioral Therapy Association in our country, as in many others (Cognitive Therapies were not yet on the agenda at that time), and to create an environment where professionals from different disciplines working in the field could work together harmoniously under one umbrella. However, my experiences before going to England provided evidence that it was not easy to achieve collaboration between professionals from different disciplines working towards the same goal, while being aware of their own limitations and boundaries. On the other hand, the problem was not limited to the disagreements between psychiatrists and psychologists on various issues. In those years, many psychiatrists had a somewhat skeptical, even cynical and demeaning, view of the field of "behavioral therapies." Of course, science requires skepticism. While it is partly understandable to look at a newly developing or emerging field with skepticism, it was not easy to understand a cynical and demeaning perspective. The fact that dynamic-oriented psychotherapies were the dominant psychotherapy approach of that period presented another challenge. The dynamic school, by its very nature, argued that behavioral approaches did not adequately address the underlying causes of psychopathology and suggested that behavioral approaches could only provide symptomatic improvement. Clinicians who emphasized a biological orientation tended to be wary of all psychotherapeutic approaches in the treatment of psychiatric illnesses.
In short, at that stage, what we had was a new treatment approach, accepted by only a few experienced psychologists, applied in a limited way, and generally not viewed favorably by psychiatrists. Moreover, it was a new approach criticized by a significant portion of both psychiatrists and psychologists interested in psychotherapy, who found it symptomatic and mechanistic. Beyond all this, it was a period when research in the field of biological psychiatry was gaining importance and momentum. Thus, the Cognitive and Behavioral Therapies Association (KDTD) was born in 1995, as a baby born under such unfavorable conditions for its own development. In this article, where I will describe its developmental period from infancy to adulthood, I would also like to talk a little about what happened during the gestation period before the baby's birth. In the 1980s, "behavioral therapies" were limited to the well-intentioned practices of a few well-trained psychologists, mostly confined to Hacettepe University, their efforts to introduce the field to assistants, and some presentations and conferences at scientific meetings. In 1988, after receiving practical training in various psychiatric disorders (Anxiety Disorders, Couple and Sex Therapy) at the Psychiatric Institute and Maudsley Hospital in England, where behavioral therapies found application, my first task upon returning to Turkey was to contact and collaborate with valuable psychologists who had dedicated themselves to these areas in the 1980s. These efforts were supported by two experienced and esteemed faculty members of psychology at the time. One of them was Professor Işık Savaşır, who is no longer with us. He was the mentor of many psychologists who teach in the field of psychology today. Professor Savaşır was a humble, humane, knowledgeable, and compassionate clinician and researcher who supported the training programs we initiated after the association was founded and made significant contributions to the training of many psychologists. The other was Professor Perin Yolaç, who served as the vice president of the association when it was first established and later played important roles in the initial training programs. Collaboration with these experienced and valuable psychologists has not only ensured better integration between psychologists and psychiatrists, but has also strengthened the newly established association and secured its acceptance within professional circles.
THE ESTABLISHMENT OF THE ASSOCIATION AND ITS INTEGRATION PROCESS INTO THE EUROPEAN UNION
Our association, founded in 1995, also included founding members Psychologist Dr. Buket Erkal Tegin, Psychologist Dr. Mehmet Akif Sayılgan, and Psychologist Dr. Ceylan Daş Tuğrul. Each of them made significant contributions to subsequent training programs. Associate Professor Dr. Haluk Özbay was also among the founding members of the association. Although he wasn't directly involved with Cognitive-Behavioral Therapy at that time, his open-minded approach to innovation provided significant support to the association during its establishment phase.
When I returned to the country, I set another goal for myself besides establishing the association. This goal was to integrate our association into the European Association of Behavioral Therapy (EABT) after its founding. However, it was first necessary to get to know this association better and learn about the membership requirements and benefits. Collaborating with an institution or organization with similar aims but an older history than ours, organizing joint events, exchanging information, and keeping association members constantly informed about new developments would be a meaningful initiative. Let's not forget that information was not as easily accessible as it is now. In this process, I first became a member of the British Association for Behaviour Therapy (BABP) in 1988. Then, in order to obtain the accredited therapist title of the same association, I went through various stages, gave working group presentations, panel discussions, and conferences in various countries besides England, and received the accredited therapist title after a supervised training exchange process.
BABP membership and the personal accreditation process were very motivating for me. Through BABP, my knowledge of EABT increased. EABT represented an umbrella organization where associations formed within various countries were brought together under one roof. In other words, associations such as the British, French, Italian, and Turkish Behavioral Therapy associations were represented by individual members, while EABT represented a structure composed of these member associations. So, it was not individuals but associations formed by individuals that were represented in EABT. Although it was possible to participate in and observe EABT meetings as an individual member of any member association, decisions regarding EABT policies were made by representatives of the associations of the member countries. From 1989 to 1995, until the establishment of our association, I participated in all the European Union Congresses both as an active participant and as a member of BABP. During this period, I met many colleagues, exchanged scientific knowledge, and even developed friendships with some that I believe will last a lifetime, both from representatives of various associations and from the European Union's governing board.
In addition to these developments abroad, I have been working diligently since the 1990s to promote and disseminate Behavioral Therapy within Turkey. I organized panels, conferences, working groups, and introductory meetings at various national and local congresses. Articles written for various journals were also an important part of this promotional and dissemination effort. During this process, I received more support than I anticipated from many of my psychiatrist colleagues. Feeling like a psychiatrist promoting the field, I focused on all the new treatments that behavioral therapy was addressing (Depression, Anxiety Disorders, Personality Disorders, Schizophrenia, Eating Disorders, etc.). The aim was to acquire and disseminate updated information in every area of behavioral therapy. However, perhaps due to the excitement and courage that comes with being young, my more independent attitudes than expected and desired, and perhaps some behaviors stemming from my style that seemed assertive, I must have disturbed some of my professors at the time, and I sometimes encountered obstacles as well as support. My purpose in writing this is to convey that nothing comes easily. Of course, another purpose is to advise younger colleagues to prioritize healthy growth over rapid expansion and not to be discouraged by obstacles, while also suggesting to more experienced colleagues that they shouldn't immediately get angry at younger colleagues, but rather act maturely and make more effort to win them over and bring them alongside them, rather than dismissing them…
Another significant change in this process was the integration of the Cognitive and Behavioral schools, which had developed separately until 1991, under the name Cognitive Behavioral Therapies. In short, Cognitive Therapies enhanced the explanatory power of behavioral therapies and provided clinicians with meaningful content to work with, in other words, it led to a better understanding of phenomenology.
Behavioral therapies, a pragmatic treatment approach based on stimulus-response relationships and learning theories, have also facilitated a better understanding of the processes between stimulus and response through cognitive therapies. In other words, this integration has resulted in an evidence-based treatment approach that deeply examines phenomenology and psychopathology, alongside concepts of effectiveness and pragmatism, and is highly effective in understanding various psychopathological conditions.
Cognitive therapies, by focusing on insight-based clinical observations rather than the experimental psychology/psychopathology findings that behavioral therapies focus on, by referencing the foundations of psychopathology (childhood learning), and by emphasizing the therapeutic relationship, have been more easily accepted even by therapists who are not keen on behavioral therapies.
The emphasis that cognitive behavioral therapies place on measurement and evaluation, and the positive results they achieve in treating various clinical conditions using scientific methodology, have drawn the interest and attention of biologically oriented physicians to this field. During the same years, the appearance of cognitive behavioral therapies as an alternative treatment in international presentations on psychopharmacology was noteworthy.
During the same years, there was a similar increase in interest in the field among psychiatry residents in our country. The most concrete example of this was the publication of the results of a study conducted by the Association of Psychiatry Residents and Specialists (PAUD), which was founded by residents and specialists before the establishment of the Turkish Psychiatric Association, in the PAUD Bulletin. Dr. Nurper Erberk Özen's article titled "From PAUD" clearly revealed that the topics that faculty members in an educational role and residents in a training role wanted to teach and receive training in were not similar. While the survey results showed that residents most wanted to receive training in Cognitive Behavioral Therapy (CBT), it was observed that the instructors did not attach as much importance to this field as the trainees. This interest and sensitivity of residents and specialists gave impetus to the desire and efforts of the association, which was founded in 1995, to provide training, and in the 1997-98 academic year, a supervised modular training program lasting 300 hours was initiated for a multi-disciplinary group of 50 people, one in Ankara and the other in Istanbul. This training was conducted with great effort and dedication by a limited number of instructors, without expecting any financial compensation, and was completed in 2001. I express my gratitude to all the instructors for their contributions. In addition to the founding members whose names I mentioned earlier, Assoc. Prof. Dr. Gonca Soygut and Assoc. Prof. Dr. Hakan Türkçapar were other colleagues who made significant contributions to this training process.
During the same period, our association became a member of the association that changed its name from EABT to EABCT (European Association for Behavioral and Cognitive Therapies) in 1996, and in 2001, it was given the honor and task of organizing the EABCT European Congress in Istanbul. I can say that the trust built through scientific and social ties established with professionals from different parts of the world over the last 12 years (1988-2000) played a significant role in the rapid development of this process. The suggestion to organize the European Congress in Türkiye in 2001 came again from my colleagues and fellow European country representatives. When we were selected from among the candidate countries to host the same congress, we undertook this task with a sense of responsibility and pride. With the efforts and contributions of my colleagues in the association, this task was successfully completed. Although the dates of our congress coincided with the September 11, 2001 massacre in New York, and this situation negatively affected all of us, especially our American colleagues, our congress has remained one of the congresses frequently praised in the EABCT community even today. At this congress, our first students who completed their training and passed the exams between 1998 and 2001 received their certificates from international authorities. After this congress, our association rapidly increased its membership and today, with nearly 500 members, it has become one of the medium-sized associations in the European Union. Since its establishment (1971), EABCT has had 26 presidents. I was given this honor between 2000 and 2002. The presidency of the European Association for Behavioral and Cognitive Therapies was the greatest honor of my professional life. I currently hold positions in various working units of EABCT. I hope that in the coming years, other professionals from our country will also take active roles in the management of this association.
A SELECTION OF THE CONGRESSES AND MEETINGS ORGANIZED WITH THE CONTRIBUTIONS OF KDTD DURING ITS EARLY YEARS.
Our association was the first organization to hold a multidisciplinary congress on Sexual Dysfunction, one of the key areas addressed by Cognitive and Behavioral Therapies. In collaboration with the Departments of Psychiatry, Urology, and Obstetrics and Gynecology at Ankara University Faculty of Medicine, the “National Symposium on Sexual Function and Fertility Disorders” was held in Ürgüp in 1996, with the participation of over 600 professionals from the Urology, Gynecology, and Psychiatry departments. At the end of the symposium, the task of regularly organizing congresses related to sexuality was assigned to our association by the congress general assembly. Subsequently, the Sexual Education, Treatment and Research Association (CETAD) was established, and four members of our association became founding members of CETAD (Mehmet Sungur, Ceylan Tuğrul, İlkten Çetin, Ercan Özmen). Our association, together with CETAD, organized the 1st CETAD Days in Istanbul in 1998. The next Congress on Sexual Problems and Treatments was held in 1999, and the 4th National Congress on Sexual Function and Disorders was held in 2001, both in Istanbul, in collaboration with CETAD.
During this process, the 1st European Convention on Sexual Dysfunction was organized in 2000 in collaboration with our association and SIMSED (Society for Investigation and Management of Sexual Disorders), thus marking the first international congress in the field of sexuality. My esteemed colleague Jeff Qureshi, who is no longer with us, served as co-chair of this congress.
Our association has also conducted studies on "Smoking and Health" outside the field of sexual health, and played a significant role in organizing the National Congress on Smoking and Health in 1997, with the participation of WHO, UNICEF, and the Canadian Public Health Association. The "National Committee on Smoking and Health" continues its valuable activities. I was involved in this committee during its founding years, and I had the opportunity to share information with the public and professionals on cognitive/behavioral approaches to quitting smoking. Subsequently, we established the first "Smoking Cessation Center" in Türkiye within the Department of Chest Diseases at Ankara University.
In 1997, our association, in collaboration with the Department of Psychiatry at Ankara University Faculty of Medicine, organized the first SCID and BPRS training in Ankara and Istanbul through Dr. Joseph Ventura from UCLA.
STANDARDIZATION OF EDUCATION AND CONGRESSES AND MEETINGS HELD BY THE ASSOCIATION AFTER ITS ESTABLISHMENT
In line with developments in the European Union (EABCT), our association established "minimum training standards" and "codes of ethics" in 1997. To my knowledge, our association was the first among organizations providing services in the field of mental health to establish training standards and codes of ethics. A modular training program, combining theoretical and practical components, was initiated in Ankara and Istanbul with 6 qualified and dedicated supervisors. Due to the scarcity of qualified instructors, this training, initially started with 50 participants in 1997, was completed with 36 participants after four years in two different cities. Those who successfully completed the 300-hour training received their certificates at the 31st EABCT congress held in Istanbul in 2001. Instructors involved in this process included Mehmet Sungur, Perin Yolaç, Gonca Soygut, Hakan Türkçapar, Mehmet Akif Sayılgan, and Ceylan Daş Tuğrul. Buket Erkal and Uğur Yüreğir also participated in delivering some of the theoretical lessons. I express my gratitude to them for their efforts and dedication. Unfortunately, due to the small number of instructors, the difficulties they faced in the intercity training process, and the retirement of some of them, the same comprehensive training could not be given a second time. Following my transfer from Ankara University to Marmara University at the end of 2001, I planned to shorten the training period in Istanbul and provide training to a larger number of students on more specific topics, and these trainings are still ongoing. The training on "Cognitive Behavioral Approaches in Assessment, Case Formulation and Treatment in Anxiety Disorders and Depression" was given by me from 2002 to 2006 with 75 hours of theory and 75 hours of practice, and from 2006 to 2008 with 100 hours of theory and 100 hours of practice. These trainings were conducted for psychologists and psychiatrists coming from Istanbul during the week and from outside Istanbul on weekends. To date, more than 100 professionals have completed these trainings. A similar 80-hour training program is offered in Ankara by Dr. Hakan Türkçapar.
In addition to these long-term trainings, our association has organized activities every year under the name "KDTD events" to provide opportunities to become acquainted with innovations in the field. These events were organized as working groups lasting one or two days, providing our members with the opportunity to meet directly with individuals whose names they were familiar with from books and to observe their practices. I would like to express my gratitude to these international authorities, who, thanks to our long-standing friendships, have shown the courtesy of sharing their knowledge with us even though we have sometimes been unable to adequately compensate them for their efforts. The names I can recall from these individuals are: Isaac M. Marks, Paul Salkovskis, E. Thomas Dowd, Robert Leahy, Nick Tarrier, Claudia Herbert, Ed Craighead, Frank Dattilio, Padmal de Silva, Michael Crowe, Edna Foa, Jesse Wright, Ian Falloon, Patricia Dardenne, Jeff Qureshi, Tom Borkovec, Mervin Smucker, Joseph Ventura, Don Baucom, Philip Kendall, Arthur and Sharon Freeman, Keith Dobson, Antonio Pinto, Ceu Salvador, Dominic Lam, Raymond Novaco, Mark Freeston, Tamie Ronen, and Michael Rosenbaum. Some of these individuals were honorary members of our association and supported all of our international initiatives. Sadly, three of them are no longer with us. Their personalities, work, and friendships will always remain with me: Ian Falloon, Jeff Qureshi, and Padmal de Silva.
I have served as the coordinator of the Turkish Psychiatric Association's "Cognitive Behavioral Therapies Working Unit" since its establishment. I would like to emphasize that the coordination between the Cognitive Behavioral Therapies Working Unit of the Turkish Psychiatric Association and the TPD's CBT working unit has been quite beneficial for those receiving training. This coordination has resulted in the organization of courses and panels on CBT at both the National Psychiatry Congresses and the Spring Symposiums every year, and these courses have consistently had the highest participation rates. These developments reflect the interest and sensitivity of our young colleagues towards the subject, while also keeping our motivation to provide training consistently high. The conferences and workshops we organize for psychologists and psychological counselors outside the psychiatry profession have ensured that CBT is becoming an increasingly popular and accepted field of study across a wide range of mental health professionals.
Although our association organized its European congress in 2001, its first national congress was held in Istanbul in 2007. This first congress, which was delayed to ensure the development of sufficiently trained therapists in our country to organize a nationally focused congress, was attended by 350 people and was successfully completed thanks to the contributions of the participants. It was decided that the congress would be held every two years.
THE ASSOCIATION'S FUTURE GOALS
Cognitive behavioral therapies have become a popular psychotherapeutic approach in the 21st century because they are short-term, economical approaches directly aimed at problem-solving, are built on a scientific foundation such as learning theories, create strong bridges between scientific methodology and clinical practice, and, most importantly, yield brilliant results in treatment applications.
Considering criteria such as effectiveness, safety, applicability, side effects, superiority over alternative treatments, potential for misuse, and usability in the prevention of mental illnesses, it is undeniable that cognitive behavioral therapies are a highly advantageous form of treatment.
Another valuable and significant aspect of CBT is that it is the type of psychotherapy most supported by evidence within the framework of evidence-based medicine.
Considering that the primary aim of our association is to expand DBT (Dialectical Therapy and Cognitive Behavior) training within the country and to increase good and ethical practices, it can be said that our most important goal in the future is to train qualified therapists who will teach these practices. It is quite clear that the increasing demand for interest in the field and participation in the courses offered can no longer be met by a limited number of trainers. In line with this goal, the number of accredited therapists should be increased. A "Certification and Accreditation Committee" has been established within the European Union (EABCT). Associations of member countries of the EABCT send the names of their members who have completed the training programs standardized by the European Union to this committee. The committee, through the associations, examines the training of the members in terms of content and duration, and after approving the competency level of the trainers, it accredits the members who meet the criteria. Individuals who complete this accreditation process are included in the list of "registered therapists" recognized and accepted by the European Union. The first accreditation committee of the European Union consists of 3 people elected by the vote of the Union's country representatives on March 11, 2006. I believe that being given one of these prestigious assignments will facilitate the alignment of our country's educational standards with the European Union. The periodic re-accreditation of accredited therapists is expected to be part of a later process. Some members of our association will soon complete this training process and will be among the therapists recognized and accepted by EABCT.
It is not possible to say that Cognitive and Behavioral Therapies are yet sufficiently widespread and of high quality in the field of Child Psychiatry in our country. In the coming years, more effort should be made to develop the necessary knowledge and skills in the treatment of mental disorders seen in children and adolescents. For this purpose, in previous years we brought 3 international authorities on "CBT applications in Children and Adolescents" to our country and had working groups. However, in order to ensure the continuity of education, we plan to support some volunteer professionals working in the field of child psychiatry to receive formal training in the same field.
Even if our "powerful psychotherapeutic weapon (PTD)" is 100% effective, the crucial question is what percentage of professionals are using this powerful tool for change appropriately, effectively, and ethically. Even if it's 100% effective, if only %5% of professionals are using this power, it significantly reduces the weapon's effectiveness. Because widespread daily use is as important as effectiveness. To this end, our association's most important future goal is to train more mental health professionals through courses offered within the association, enabling more professionals to benefit from supervised training and provide further training and supervision. To this end, starting from the 2008-2009 academic year, a training program has been planned that includes the use of DBT (Dialectical Behavioral Therapy) in the treatment of Anxiety Disorders, Depression, as well as Alcohol and Substance Addiction, Eating Disorders, Personality Disorders, Schizophrenia, Bipolar Disorder, psychosomatic illnesses, anger management, low self-esteem, pain, insomnia, and various functional disorders (such as irritable bowel syndrome). This training, planned in a way that allows our students who have received training to serve as instructors, is determined according to EABCT (Educational and Biological Research Council of Turkey) standards. The training aims to both target individuals without prior knowledge in the field and to fill in any gaps in the knowledge of those who have already received basic training.
Organizing national and international congresses to ensure continuity in education, update knowledge in new and controversial areas, and impart skills has been one of the fundamental activities of our association since its establishment. In this context, I would like to mention two important announcements regarding future activities. Our association has been honored and tasked with organizing the 7th International Congress of Cognitive Psychotherapy (ICCP), held every three years, in 2011. I have also been elected as the president of this congress by the International Association of Cognitive Psychotherapy (IACP). Aware of this responsibility, the association has already begun preparations and has completed the necessary preparations to make the first announcement at the 6th meeting, to be held in Rome in June 2008. Ten years after the European Congress we organized in 2001, I have no doubt that this international congress, to be held in Istanbul in 2011, will be supported by the Turkish Psychiatric community and enriched by valuable contributions. In other words, the fact that the journey that began in 1995 with various concerns and difficulties continues 16 years later with acceptance and support at both national and international levels is the most important concrete evidence that all the efforts have achieved their purpose.
Following the 1st National Congress of the Cognitive and Behavioral Therapies Association, which we held for the first time in 2007, we will be holding our 2nd congress in Istanbul in 2009. As with the previous congress, this will be a national congress with international participation and will serve as preparation for the international congress to be held in 2011. After that, this congress will continue every two years.
In the coming years, psychotherapy must move from being an art to a more evidence-based, scientific practice. One of the significant obstacles in the process of psychotherapy becoming a clinical science is the lack of a "common language." Different therapists give different names to the same therapeutic intervention, or the same name is used for different therapeutic interventions. Even if therapeutic interventions are referred to by the same name, they involve different procedures, leading to confusion and causing different results in different hands. To prevent confusion and to make the work more scientific, "Developing a Common Language in Psychotherapies" is a problem area that needs to be addressed in the coming years. For example, when therapists tell their patients to "confront what you fear," they think they are performing exposure therapy, and when patients become even more afraid by confronting the feared object/situation, it is perceived that they have not benefited from such therapy. However, not every encounter with the feared object/situation is therapeutic. It should not be forgotten that many fears arise as a result of inappropriate encounters with the feared object. Therefore, "addressing the issue" will only be successful if the process is well-defined (how, for how long, under what conditions, etc.). To this end, we are striving to establish a working group within KDTD similar to the one we founded within EABCT under the name "Developing a Common Language in Psychotherapies," of which I am a member.
Every service provided to people is valuable. In the coming years, providing services to those who wish to access therapists but cannot due to various difficulties (economic, geographical, etc.) through the internet is an area that absolutely needs to be considered. Internet-based CBT applications, free from commercial concerns, controlled, appropriate to the purpose, and proven effective, can be very valuable. The aim should not be to replace therapists, but simply to create a good option for those who cannot access this help or who avoid face-to-face help. We will also strive to establish a working unit under the association's umbrella in this area.
On behalf of our association, I would like to express my gratitude to Professor Dr. Orhan Öztürk for wanting our history to be included in this valuable resource and for undertaking such a service on behalf of Turkish Psychiatry despite his advanced age.
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