By Judit Molnár and Ildikó Kuritárné Szabó, ESTD representatives for Hungary
Psychotherapy has a long and rich history in Hungary. At the very beginning of the 20th century, Hungary was the first non-German-speaking country where psychoanalysis developed strong roots and became a flourishing approach in psychological thinking. With the influence of this innovative approach and the relevant perspectives of the Budapest School of Psychoanalysis – notably those of Sándor Ferenczi –, the long-lasting effects of childhood traumatization were recognized and embedded in psychological thinking very early in our country. After the years of the 50’ and 60’s socialist era, when psychotherapy was not only unbacked but even prohibited, psychotherapy revived, and the role of psychological trauma gradually regained its deserved place in psychological understanding. However, in the so-strongly related field of traumagenerated dissociation, we have been taking only the first steps.
TRAUMA WORK IN HUNGARY – OPPORTUNITIES AND CHALLENGES
According to the very first representative ACE study in Hungary (Nagy, Kósa, Kuritárné, under review), 22.9% of the Hungarian general population experienced at least one childhood adversity before the age of 18, while four or more ACEs were found in 4.27% of the respondents. Considering the decades-old national silence about intrafamiliar abuse, these results most probably underestimate the prevalence of child abuse and maltreatment, especially sexual abuse in our country.
At a social level, a number of small foundations (e.g., Eszter Foundation, NaNe, Anoni Mara Community) is committed to help survivors of family violence and intra-familial child abuse. However, they function with scarce financial and infrastructural resources, so many of their members do their work on a voluntary basis. The Cordelia Foundation, a member of the International Rehabilitation and Research Council for Torture Victims (IRCT), has been dealing with the support of torture survivors and severely traumatized asylum seekers. However, due to the above-mentioned lack of resources, their potentials are far from the needs of this special population. The KÚT Foundation, founded by Teréz Virág, has been dealing with Holocaust trauma, including help for Holocaust survivors and the traumatization of the 2nd and the 3rd generation.
Public mental health institutions, however, are still not prepared to recognize and treat complex traumatization. They would rather treat the many comorbid mental disorders stemming from childhood traumatization, without recognising that the polysymptomatic clinical picture is often the consequence of an abuse history.
Specialization for treating particular disorders is not typical in our country. There are a few psychotherapeutic regimes and systems, in which treatment is tailored to specific mental disorders (e.g., eating disorders or borderline personality disorder), but no trauma centres or trauma-focused inpatient units exist in Hungary. It creates a major gap in the mental health care of traumatized patients.
Opportunities for psychotherapy in public health are scarce, especially for long-term therapies, so the rest of such treatments take place in private practice. As we can see from our supervision experiences, many traumatized individuals seek help among private practice therapists. Clinicians are mostly psychodynamically oriented, considering childhood (intrafamiliar) aversive experiences as having significant influence on the development and later functioning of the personality. However, due to the lack of awareness of the special treatment needs of complex traumatized patients, and particularly the unique structural characteristics of dissociative individuals, therapies focusing on complex traumatization and dissociation are barely available in our country.
TRAUMA-GENERATED DISSOCIATION – THE FIRST STEPS: ENCOUNTERS
The prevalence, the structural and functional characteristics of dissociative disorders, such as the specific treatment they require, have come into the focus of our work and thinking only in recent years.
Basically, there are two main professional groups in Hungary, who are dedicated to broadening awareness and improving knowledge about traumagenerated dissociation in recent years.
The initial steps can be linked to the University of Debrecen, where some of us as clinical psychologists, working with patients suffering from severe personality disorders, recognized the long-lasting effects of childhood traumatization and its particular effects on the development and functioning of the personality. After years of peersupervisions, the “Borderline and Trauma Work Group” was established in Debrecen under the leadership of Ildikó Kuritárné Szabó. The members of the group are senior clinicians, who use hypnosis, guided imagery, and ego-state techniques with their patients. These methods drew our attention to the unique structural (dissociative) characteristics of many complex traumatized individuals, so we felt the strong urge to improve our knowledge in this field.
Since there was no available literature on traumarelated dissociation in Hungarian, we looked for international sources and discovered the theory of structural dissociation of the personality, which has become the framework for our work with dissociative patients.
In the absence of relevant trainings in our country, we have been trying to further develop our knowledge by joining trainings abroad. It was a milestone on our road when in 2015, the authors of this report participated in the ESTD Conference in Timisoara. Besides the inspiring lectures of Suzette Boon, Eli Somer, and Liora Somer, we had the possibility to meet Anca Sabau and her colleagues. This very dedicated Romanian team has been making major efforts to increase knowledge for the recognition and treatment of dissociative disorders, mainly with organizing conferences and workshops that are affordable and available for Central and Eastern European countries as well. In the recent two years, some of us repeatedly participated in professional events in Timisoara, so we could learn from excellent experts in the field, including Suzette Boon, Anna Gerge, Renée P. Marks, and her colleagues. In the fall of 2016, we attended Suzette Boon’s workshop in Katowice, Poland. Alongside with deepening our knowledge on phase-oriented trauma treatment, we became acquainted with Polish colleauges as well. Meeting professionals of surrounding countries drew our attention to the importance of forming and maintaining such contacts. We have similar goals, we face similar challenges within related financial, economic, and cultural conditions, so strengthening our cooperation in education as well as in research could be fruitful and supportive for all of us.
FURTHER STEPS: BOOKS AND TRANSLATIONS
Our first practical initiation in Hungary was to create opportunities through which colleagues and all interested professionals could also gain knowlegde about trauma-related dissociation. The lack of available literature and trainings assigned the tasks for us, so we continued our activities on two levels.
In 2015, Ildikó Kuritárné Szabó and Eszter TisljárSzabó edited a book about complex traumatization with the title: “I wish I hadn’t been hurt. Intrafamiliar childhood traumatization and its Consequences: Theory and Practice”. Chapters of the book were written by members of the working team and some lecturers of the University of Debrecen. The book was very well received by Hungarian professionals; within two months, it was ready for its second edition. The favorable reception motivated the group to edit the next volume on trauma-generated dissociation. This book is composed of translations of essential articles on the topic of dissociation, followed by some related case-reports and theoretical chapters written by our colleauges. According to our plans, this book will be published in May 2018.
In the meanwhile, the Hungarian translation of “The Haunted Self” is also in progress. Since the theory of structural dissociation of the personality and phase-oriented trauma treatment is the basis of our work, we feel it essential to have this book available in Hungarian as well.
Another goal of ours was to make trainings more accessible for professionals, so we started to organize conferences and workshops in our country. The very first conference on complex traumatization and dissociation took place in Debrecen in the fall of 2016, with Professor Eli Somer and Liora Somer. The event attracted more than 160 professionals, mainly clinical psychologists and psychiatrists, who received the lecturers’ presentations enthusiastically and gratefully. Thereafter, in the spring of 2017, Liora Somer conducted an inspiring art therapy workshop in Debrecen, where participants had the possibility to learn about the use of creative methods in therapeutic work.
To our greatest pleasure, last year, we obtained the possibility to organize the very first ESTD conference in Hungary. Our invited speakers are Prof. Onno van der Hart and Dr. Suzette Boon, who will give a two-day conference in Debrecen on 11-12 May 2018 about the understanding, diagnosis, and treatment of complex trauma-based dissociation. Before the event, a pre-conference workshop will be conducted by Dr. Renée P. Marks on dissociation in childhood and adolescence. The conference and the preliminary workshop have already generated great interest among Hungarian colleagues as well as from professionals from countries in Eastern and Western Europe.
TEACHING AND CONFERENCES
Besides organizing professional events, authors of this report, as university lecturers, find it also very important to integrate knowledge about complex trauma and dissociation into university courses as well. We teach childhood traumatization and basic concepts of the theory of structural dissociation at different levels, from the education of the psychology master’s programme to the training in postgraduate clinical psychology and the mental health specialization.
Last year, we presented conference lectures on complex traumatization and trauma-related dissociation at several professional forums in Hungary, while in the spring of 2017, we gladly accepted the invitation of the Romanian team to give two lectures in Timisoara at the Voices of Silence conference.
The framework of university research includes studies of adverse childhood experiences (ACE) in several samples with the supervision of Ildikó Kuritárné Szabó. Anikó Nagy conducted the first representative study with the ACE-10 in Hungary, with a sample of more than 2000 individuals in her PhD study. She also used the ACE design to measure ACE scores among psychiatric patients, somatic patients (e.g., in oncology), and individuals in jail. Part of the research is the investigation about the cumulation of adverse childhood events (ACE) and the outcomes of these (the dose-response effect) in clinical and non-clinical samples, with special regard to dissociation, post-traumatic cognitions, and affect regulation. Another PhD was done on the childhood traumatization of borderline inpatients, showing the very frequent abuse history of all types of abuse, and the high level of dissociation among those who suffered the most severe abuse.
THE HUNGARIAN EMDR ASSOCIATION
The other, above-mentioned main society, which has been contributing to increasing the knowledge about complex traumatization and related dissociation, is the Hungarian EMDR Association. Professionals belonging to the common goal of offering EMDR trainings and supervisions in order to learn and use the method in clinical practice in Hungary. The first EMDR Level I training course was held by Eva Zimmermann in Budapest 2015. Further trainings and EMDR supervisions will be given by Judit Havelka and Erzsébet Bíró. The organization also provides trainings in specific topics related to complex traumatization. Erzsébet Bíró regularly conducts workshops on early attachment traumatization, while Judit Havelka speaks of modern theories of complex traumatization. They also invite international experts to participate, including Dolores Mosquera on borderline personality disorder and complex traumatization last summer.
First, we have been applying for grants in order to make further translations on the topic, as there is a strong need among practising clinicians for literature available in Hungarian. Besides, we feel a strong need to build up professional support networks for therapists who have started working with complex traumatized and dissociative patients. Thus, we plan to cooperate with an international supervisor several times a year. In the longer run, our main goal is the establishment of a trauma and dissociation centre in Debrecen.
FOR ALL THE SUPPORT WE HAVE RECEIVED…
… we would like to say grateful thank to Prof. Onno van der Hart, Dr. Suzette Boon, Anca Sabau, Prof. Eli Somer and Liora Somer, who inspire and support us on our path. We are grateful to our colleagues who contribute to this work in our country, either by translating in their free time or by offering their help for organizational tasks. And to our patients who trust us, whom we are learning so much from, and who inspire us to develop further, professionally and personally, as well.
From ESTD Newsletter Volume 7 Number 1, March 2018