Interpersonal communication in and through family: Structure and therapy in Turkey

Abstract

It is essential for professionals in the mental health sector to identify and understand the different family models and the effects of social transformations. Historically and at present, however, Turkish families live in a ‘culture of relatedness’, with emotional and/or material interdependence between generations. Marriage and family therapy is a newly emerging discipline in Turkey. Although studies on family structure and common problems in families have been made, data on the practice of family therapy are limited. To our knowledge, this is the first paper aiming to describe the practice of family therapies in Turkey, situating them against a backdrop of sociological and social/psychological studies in family structure.

Introduction

Turkey is at the crossroads of eastern and western cultures, making it a unique blend of modernism and Islamic tradition. Turkish society is multi-cultural containing various ethnic and religious minorities; it is also in transition from a rural, agricultural, patriarchal society to one with urban, industrial, and egalitarian features. These are reflected in the heterogeneous composition of family structures and prototypes. Thus, families cannot be described as uniform. Generally, however, Turkish people would describe the family as the smallest social unit, consisting of parents and children and their relatives (mostly related by blood). Although most Turkish households are nuclear, Turkish families are ‘functionally extended’ in a ‘culture of relatedness’ (Ataca, 2006; Baştuğ, 2005; Fişek, 1982; Kağitçibaşi, 1982, 2005). It is crucial for professionals in the mental health sector to identify and understand the various family models and the effects of social transformation in order to develop better tools for interpersonal communication skills. Therefore inter-disciplinary approaches which mingle sociological research with that of psychiatric practice are essential for the improvement of marriage and family therapy.

Marital and family therapy is a newly emerging discipline in Turkey. Although family structure and common problems in families have been studied, data on the practice of family therapy are limited. To our knowledge, this is the first paper aiming to describe the practice of family therapies in Turkey situating them against a backdrop of sociological and social psychological approaches to the structure of family.

Family structure

Demographic data from Turkey

As of 31 December 2010, the population of Turkey is 73,722.988. By the end of 2010 approximately 35 million of the 55 million adults older than 15 were married. The number of divorced people was only 1.5 million (TUIKa, 2011). According to the annual Life Satisfaction Survey, carried out by the Turkish Statistics Institute, 61.2% of individuals at or above 18 years of age in 2010 declared that they were happy; and 70.9% of these individuals mentioned that the people who make them happiest are their own families (TUIKb, 2011). It can readily be claimed that Turkish society is a family focused one.

In the second quarter of 2011, the mean age at first marriage was 26.7 for men and 23.5 for women. The age difference in first marriages between men and women was 3.2 years. Compared to the same quarter of the previous year, the number of divorces had increased by 1.7%. 40.1% of divorces occurred in the first five years of marriage and 24.3% of divorces occurred in the couples who had been married for 16 years or more (TUIKc, 2011).

In 2010, ‘incompatibility’ was the most common reason for divorce. Less common grounds were wilful desertion, adultery, insanity, serious crime or dishonourable conduct, attempted murder by a spouse, cruelty or serious insult (TUIKd, 2011).

Households and families

As noted above, Turkish society is in transition from a rural, agricultural, patriarchal society to something more urban, industrial and egalitarian. By 2010, nearly 71% of the population had become urban (TUIKe, 2011). However, it should be noted that, since this transition has been rapid (beginning in the first half of the twentieth century). By the way, from a socio-demographic and cultural perspective, changes which take place in 100 years is indeed rapid. Most of the urban population has a rural background with traditional values. It must also be noted that the population is heterogeneous, with many possible cultural and religious backgrounds.

According to Kağitçibaşi's model of family change (1996, 2005, 2007), which studies the family as a system situated within a cultural and social structural context, Turkish families in rural areas or urban families with rural backgrounds are characterized by a pattern of interdependence. This suggests collectivism: both emotional and material interdependencies between generations in the family. Urban groups with higher education and income levels, unlike them, may be characterized by ‘psychological (emotional) interdependence’. In this pattern, psychological interdependencies continue while material interdependencies weaken in a context with a ‘culture of relatedness’.

Nuclear family households consisting of parents and their children have always been the norm in Turkey, including the rural areas (Ataca, 2009; Baştuğ, 2005; Duben, 1985; Duben & Behar, 1991; Timur, 1972). While 81% of households in Turkey consist of nuclear families; only 13% consist of extended families. The average size of households in 2006 was 3.9 individuals (ROFS2006, 2010). However, Turkish families are considered to be ‘functionally extended’ (Abadan-Unat, 1986; Ataca, 2006; Baştuğ, 2005; Fişek, 1982; Kağitçibaş, 1982; Kandiyoti, 1974). This means that, although demographic studies show them in nuclear family settings, Turkish families experience their lives as extended, with close social ties. Members of an extended family feel responsible to each other, giving continuous emotional (and sometimes economic) support. They also may be involved in each other's decision-making processes. Moreover, it is common for Turkish families to live in close proximity, e.g. in the same apartment building or block as their parents (10.6%) and/or siblings (5.6%), or in the same neighbourhood (19.5% with parents; 23.2% with siblings; 16.3% with aunts and uncles), with strong emotional bonding and social contact by the members of the extended family (ROFS2006, 2010; see also Ataca, 2009; Baştuğ, 2005; Duben, 1982). Such kinship relations, where individuals interact with a wide network of relatives, locate the Turkish family within the spectrum observed in the Mediterranean region (Baştuğ, 2005).

The traditional Turkish family is patriarchal, patrilineal and patrilocal. Women have a subordinate and dependent position vis-à-vis their husbands (Ataca, 2006; Kağitçibaşi, 1982, 1990; Sunar, 2005). With regard to male and female sex roles, women's intra-family status, power relations, communication between spouses and decision-making processes, women's status is inferior to that of men. The general picture of inequalities reflects the pattern of Middle Eastern-eastern Mediterranean sex roles (Kağitçibaşi, 1990). There is also a generational hierarchy which makes the mother stronger than the children (Ataca, 2006; Fişek, 1995). Traditionally, mothers-in-law, charged with policing the daughters-in-law, have the most powerful status of any female in the family (Yakali-Camoglu, 2007). Olson (1982) describes Turkish families as having a ‘duofocal structure’, claiming that after marriage husbands and wives have same-sex social networks of friends and/or relatives (see also Kandiyoti, 1977 and 1982).

In line with gender roles in a patriarchal society, there is a strict division of labour (Fişek, 1993; Sunar & Fişek 2005). Housework and childcare are considered female duties. According to Research on Family Structure 2006 (ROFS2006, 2010), nearly 90% of the housework, such as cooking, ironing and laundry are done by women. However, in line with the transition from a traditional, patriarchal society to a modern one, the same research shows that 83.6% of the population thinks that it is appropriate for women to have professional occupations outside the house. Turkish women make up 32% of professionals in scientific and technical jobs, 35% of managerial personnel, and 11% of entrepreneurs, directors and top management positions (Aycan, 2004; Aycan & Eskin, 2005). As a consequence, we can talk of a shift with regard to gender roles from a more traditional family model to a more egalitarian one, for the urban upper/middle class professional population in particular (Aycan, 2004; Aycan & Eskin, 2005). However, as the above survey of family structure also shows, most women in Turkey may be defined either as ‘working’ or ‘non-working housewives’ since they are responsible for housework and childcare, whether they work outside the house or not (Kandiyoti, 1985; Özbay, 1982).

Turkish families, in rural areas in particular, would rather have sons than daughters, focusing on their material contributions to the welfare of the family (Kağitçibaşi, 1982, 1996). Urban families, however, show less boy preference and stress the ‘psychological’ values of children, such as a loving relationship between parents and children. Moreover, urban middle-class mothers see their daughters rather than their sons as potential help in old age (Ataca, 2006; Ataca & Sunar, 1999; Sunar & Fişek 2005). Children of both sexes tend to stay at home with their parents until they marry; and they frequently continue interacting and communicating with their parents after marriage (Ataca, 2006; Baştuğ, 2005; Koç, 2002).

Many improvements in the status of women have emerged with the New Civil Code of 2001. However, it must be noted that in Turkey there is no reference to homosexuality in either the Civil or the Penal Code. Gays and lesbians do not have a right to marry or any legal standing as partner or co-parent; nor do most people accept their lifestyles as legitimate (Çarkoğlu et al., 2012).

Family therapies

The recognition of family therapies as a separate discipline started in Turkey in the mid-1980s. At first, some therapists who were trained in family therapies in western countries came home with the new knowledge and started working with families there. To begin with, family therapies were applied and taught without any structured training. In time, reflecting the trends in western countries with more established training institutions, standards in Turkey rose, the content of training was improved and more emphasis was laid on supervision (Dokur & Profeta, 2009a).

Family and couple therapies are usually provided by psychologists, psychiatrists, psychological counsellors and social workers. According to the figures reported by the Family and Marital Therapy Association of Turkey, 13% of the 321 professionals trained in family and couple therapies are psychiatrists, and 77% are psychologists. The percentage of psychiatrists is similar to the numbers reported by other member associations of the European Family Therapy Association (EFTA). The percentage of social workers is 3%, lower than the average in EFTA member countries (EFTA, 2012). This may be a reflection of the scarcity of social workers in Turkey (WHO, 2005).

Unfortunately, the ratio of professionals in mental health to the general population is one of the lowest in WHO's European region. The number of psychiatrists per 100,000 population is 1, much lower than the median number of psychiatrists in the European region, which is 9.8 per 100,000 population. The same discrepancies exist between Europe and Turkey in terms of psychologists and social workers in the mental health sector (WHO, 2005). This results in a high workload, notably for professionals working in state and university hospitals. Therefore, the time allocated to each family or individual is very limited, which makes it difficult to carry out any kind of therapy. Training and supervision in psychotherapy are recommended by the Psychiatric Association of Turkey (Tükel et al., 2009), but in practice, many trainees receive no structured psychotherapy training during their residency (Eraslan, 2006). Other institutions and associations have been trying to meet this lack of training in psychotherapy and family psychotherapy.

In recent years, family therapy in Turkey has gained more general attention and is being used for more specific needs, such as couple therapy and marital counselling. In order to provide common ground for specialists working in this area, the Family and Marital Therapy Association – Turkey (AETD) was founded in 1997. It is the first and currently the only association working in this area.

Within a relatively short time, the Family and Marital Therapy Association has been able to organize many activities, including one national symposium, six national congresses and one world congress. The most important aspect of the work carried out by AETD in Turkey is in the area of training and supervision. Training programmes of an international standard are now applied. One important example is the 500-hour Family and Couple Therapy Training Programme which leads to an international certificate. Family therapies have also been included in combined sexual and marital therapy programmes.

In addition to these certified training programmes, master and doctorate programmes in different universities have been created to address the need for more structured and scientific work in this area, which has brought more therapists into it. Almost all the mental health professionals in Turkey are mainly located in the larger cities and the western side of the country (WHO, 2005). At first, reflecting the general distribution of mental health, family therapists were located mainly in the three biggest cities, but family therapy has recently become available in some smaller cities, though more is still needed.

In Turkey, psychiatric and psychotherapeutic fees are not usually reimbursed by private insurance firms. As a result, mental health financing relies mainly on the public social security system or is paid for by individuals (WHO, 2005). Most family therapists are psychologists (EFTA, 2012), but most psychologists work in private clinics, not funded by the state or private insurance, which in turn creates a need for national family therapy services. In university hospitals, family and couple therapy is embedded in outpatient or inpatient services. Some state hospitals, in contrast, have specialized centres to address this need. Although, as noted above, the high workload of state institutions limits access to the workers in these settings, the increase in the number of settings is encouraging.

The inclusion of family members in the treatment decisions and processes is common practice in daily care, in both psychiatric and medical illnesses. However, the number of published studies about the use of family therapy for these conditions is limited. The psychosocial treatment of schizophrenia is an important area where family therapy is applied in several Turkish institutions (Aker & Sungur, 2001). Studies have reported positive results with family treatment (Dogan et al., 2002; Yildiz, 2009). Family-focused therapy was successfully implemented in a Turkish clinic for bipolar disorders (Özerdem et al., 2009). Studies have been written on the use of family therapies in alcohol dependency (Kalyoncu & Karagözoğlu, 2003), for mental illness prevention in earthquake survivors (Sayil et al., 2001) and childhood obesity (Garipağaoğlu et al., 2009).

Culture is an important factor affecting the nature of marital relationships and perceived satisfaction (Fisiloglu & Demir, 2000; Güney, 2011). Therefore, the structure and values of the society and the preceding cultural changes should be borne in mind in therapy for couples and families. One review found that most of the studies on marriage and relationships conducted in Turkey reflected the situation of well-educated Turkish people living in urban areas (Güney, 2011). Given the fact that most mental health professionals work in large cities and western parts of Turkey, it is possible that the clients of family therapists may also be a selected urban population, able to ask for and afford family therapy. With this possible limitation in mind, we can say that the main issues addressed in marriage and family therapy in Turkey are similar to those in other countries. The demand for couple therapy for cohabiting couples, gays and lesbians has recently been increasing, reflecting the transformation in the population addressed. When the ‘functionally extended’ nature of the family, the powerful status of mothers-in-law and the pattern of material and emotional interdependencies between generations in the family are taken into consideration, one would expect the issues related to communication with the extended family to be an important variable in marriage and family therapy. Some reports on the experiences of family therapy support this expectation, claiming that the extreme cohesion in the family and boundary problems are an important issue in Turkish families (Kurter et al., 2004), while Dokur, one of the authors of this paper, reports that problems with the extended family are not the main problematic issues in daily practice, and that problems in communication and the relationship of the couple are projected as problems with the extended family. These contradictory statements may be the result of different patient samples or the transformation in society. Inter- disciplinary research which combines sociological and social/psychological studies of family structure with the findings in family therapy are needed to clarify this contradiction.

In the beginning, a systemic and structural approach was the main method applied by Turkish family therapists (Sungur, 2004). Later, an experiential approach also became acceptable and is becoming an important method in daily practice (Dokur & Profeta, 2009b).

Conclusion

In Turkey, the rapid transition from a rural, agricultural, patriarchal society to an urban, industrial, and egalitarian one has not stopped marriage being the norm. Notwithstanding the rise in the number of people getting divorced, the family is very important in the life of a Turkish adult.

Although nuclear family households form the large majority in Turkey and always have, Turkish families live in a ‘culture of relatedness’, with emotional and/or material interdependence between generations (Kağitçibaşi 1982; 2005). Turkish families can be placed within the spectrum observed in the Mediterranean region (Baştuğ, 2005).

Nevertheless, the interest in marriage and family therapies in Turkey is growing. In order to meet the demand, structured training programmes have been created in independent associations and universities. However, the number of mental health professionals available is generally insufficient and worst in the smaller cities and state hospitals. This results in limited access to every kind of therapy, including family therapy. Given the importance of family in the well-being of Turkish adults (TUIKb, 2011) and the general family-focused perception of life, where the welfare of the family takes precedence over that of the individual, it is clear from the increase in divorce rates that more therapists and family therapy centres are needed, most of all in hospitals and outpatient clinics run by the state.

There are many descriptive studies on the structure of the family, or factors which affect relationships in Turkish families or couples. However, data on the practice of family therapy is very limited. What are needed are carefully designed studies describing the methods and methodology of family therapy. We believe that such research, when combined with the data from sociology and social psychology, will lead to more effective and culture-specific therapeutic approaches.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Acknowledgement

The authors would like to thank Mehmet Sungur for his valuable contributions.