By Olivier Piedfort-Marin, ESTD representative for Switzerland
Switzerland has the specificity of having three main national languages: German, French, and Italian. The language barriers between the different parts of Switzerland play a big role in the way information and culture flow more or less within the country. A minority of bilinguals make this border less rigid. As a small country, Switzerland evolves in many domains under the influence of the big neighbouring countries, which are France and Germany, and to a lesser extent, Italy. Psychology and psychotraumatology are among the fields in which this influence can be felt, and psychotraumatology as well. In the German-speaking part of Switzerland, the concepts of complex trauma and dissociation developed mainly under the influence of renowned German specialists, such as Luise Reddemann, Michaela Huber, and our German-speaking colleague Ellert Nijenhuis.
The concepts of trauma, complex trauma and dissociation developed in the Germanspeaking part of Switzerland in continuity with Germany, where colleagues developed a modern understanding of trauma and dissociation inthe late 1980s and even more so in the 1990s, also empowered by the development of EMDR. Switzerland is therefore part of the wellestablished DeGPT, the German-speaking society for psychotraumatology, which in 2008 held its 10th annual congress in Basel, Switzerland.
In the French speaking part of Switzerland, called the Romandie, the French influence of Freudian and Lacanian psychoanalysis is strong. Pierre Janet, although French, has been mostly forgotten in his own country. Psychotraumatology in France is still under the strong influence of Freudian psychoanalysis, possibly with little adaptation of the theory and practice. This influences psychotherapy in the French-speaking part of Switzerland. Thanks to the work of David Servan-Schreiber (2002), modern concepts of psychotraumatology made a break-through in France at the beginning of the century with the development of EMDR, also with an important audience in the Romandie. It seems that Servan-Schreiber was reluctant about the concept of dissociation, in opposition to German EMDR trainer Arne Hoffmann. In fact the concept of structural dissociation came to France from the Romandie. Quite a few French colleagues attended the first intensive training on structural dissociation (Van der Hart, Nijenhuis, & Steele, 2006), given by Ellert Nijenhuis for a French audience in 2009 in Fribourg, Switzerland.
This situation may explain why the concepts of complex trauma and dissociation developed stronger in the German part of Switzerland, than in the French part. A few bilingual colleagues, like Eva Zimmermann, now president of the ESTD, took a key role in developing these concepts in the French speaking part. In the small Italian-speaking part of the country, the situation seems to be at the beginning of its development.
Switzerland also has a few researchers in the field. In the German-speaking part of the country, Christophe Müller-Pfeiffer et al. (2012) conducted a renowned study on the prevalence of dissociative disorders and studied the global functioning and disability of these disorders. Yolanda Schlumpf et al. (2013, 2014) conducted an fMRI study comparing dissociative patients, healthy controls, and DIDimitating actors in different tasks. The results of this important study strengthen the theory of structural dissociation of the personality and give no support to the sociocognitive model of DID. At present she works on affect dysregulation and neurophysiology in dissociative disorders and borderline personality disorder. In the French part, a study is in preparation on the inter-judge validity of the French version of the SCID-D (Steinberg, 1994) the gold standard diagnostic tool still not published in French. We must also consider Professor Maerker from University Zurich, president of the working group “stress-related disorders” of the WHO ICD11 Revision. He is in favour of the integration of complex PTSD as a new diagnosis in the next ICD, due to be published in 2017 (Maerker et al., 2013; Cloitre et al., 2013).
Switzerland offers a wide range of possibilities to learn about complex trauma and dissociation. Colleagues indeed have great possibilities to learn from international leaders in the field and from experienced Swiss colleagues. Luise Reddemann is regularly providing training in her method, Psychodynamic Imaginative Trauma Therapy (Reddemann, 2011). Ego state therapy (Watkins & Watkins, 1997) is well developed in the Germanspeaking part of the country. Michaela Huber (1995) has been coming to Switzerland for many years. Ellert Nijenhuis is also regularly teaching the theory of structural dissociation of the personality and Enactive Therapy (Nijenhuis, 2015) in both French- and German-speaking regions. Other presenters invited to Switzerland include Peter Levine, Andrew Moskowitz, Giovanni Liotti, Maggie Phillips, and Peter Heller, to name a few. The University of Zurich offers a Master’s programme in psychotraumatology. The Institut im Park (IIP) proposes the certification programme of the DeGPT. The Schweizer Psychotraumatologie Institut (SIPT) proposes several specialized certifications in psychotraumatology. In the Romandie, the Institut Romand de Psychotraumatologie (IRPT) newly offers a Diploma in Psychotraumatology and a Diploma in the treatment of dissociative disorders.
In the field of complex trauma, Switzerland now has a good number of psychotherapists in most of the regions. EMDR, Psychodynamic Imaginative Trauma Therapy (L. Reddemann), Ego State therapy, are the main concepts of psychotraumatology, as well as traditional psychotherapy approaches that may be adapted for such patients (i.e., dialectic behavioural therapy, schema therapy, systemic therapy, and psychodynamic therapy).
In the field of dissociative disorders, the situation still needs improvement. Originally, a few Swiss colleagues went to Germany to be trained by Ellert Nijenhuis or Michaela Huber in the diagnosis and treatment of dissociative disorders, and in the theory of structural dissociation of the personality. Then trainings and supervisions were organized in Switzerland. Michaela Huber gave her first training in 2005 in Schaffhouse and Ellert Nijenhuis in 2005 in Fribourg. Since then, both are regular invited trainers and supervisors in the field of dissociative disorders in Switzerland. There is still a large need for psychotherapists and supervisors specialised in this field. Most of them work in private practice. Access to specialised therapy is therefore limited for highly dissociative patients with financial difficulties. Castagna is a centre for victims in Zurich, which provides specialized health care and information also for severe dissociative patients. In other parts of the country, several centres for sexual abuse victims may offer specialized treatments for patients with complex trauma but fewer offer services for patients with dissociative disorders.
We notice that a good number of colleagues show a great interest in dissociative disorders, but few do an extensive training in this field. At least the knowledge of this disorder is expanding, but the number of specialists should grow even more to better respond to the needs of the patients. The situation is less positive when it comes to university hospitals or private clinics. The sociocognitive model of dissociative disorder has lost influence since the 1990s, but remains strong in some professional associations. More and more colleagues working in university hospitals show an interest for the field of complex trauma and dissociation. Nevertheless, there is still reluctance to implement psychotraumatology in public psychiatric services. In the whole country, to our knowledge, only three clinics have a unit dedicated to severe trauma patients: Klinik Meiringen, Integrierte Psychiatrie Winterthur (IPW), and Klinik Clienia in Littenheid. The last opened the first trauma inpatient unit in the country in 2006 under the direction of Bernd Frank, with a second unit in 2010. There is no specialized inpatient unit in the French part nor in the Italian part. Inpatient treatment for dissociative patients is always a struggle when needed. Nevertheless, we can observe an overall better consideration of patients with complex trauma and dissociative disorders in the public health system. Sollievo, a private institution lead by Jan Gysi, proposes an integrated outpatient health care program, with nursing and social care, and trauma-oriented psychotherapy.
The development of the field of dissociation in Switzerland will have its highlight with the organization of the ESTD conference in the Swiss capital Bern in November 2017. In 2007, a first meeting took place with the Swiss members of the former ISST, now ESTD. In 2009, an afternoon of presentations was first organized by local ESTD representatives and 20 people attended. Activities developed considerably and in 2014, a whole day of presentations attracted 330 participants in Bern. In the Romandie, the interest is not yet as strong but developing, with the recent creation of the Francophone Association of Trauma and Dissociation (AFTD). The local ESTD representative Jan Gysi has developed interesting relationships with the Swiss Crime Prevention Office, leading to the organisation of a seminar on dissociative identity disorder and ritual violence, bringing together psychotherapists and police officers. With this back-up, the Conference of Bern is due to be a success. Looking forward to see you all in Bern !