Post-traumatic embitterment symptoms among woman victims of February 28th post-modern coup of Turkey after two decades: A comparative cross-sectional study

Abstract

Background:

Post-traumatic embitterment disorder (PTED) is characterized by embitterment reaction to stressful life events, which are seen as unjust and as a violation of basic beliefs. On 28 February 1997, a so-called post-modern coup took place in Turkey, declaring a ban on hijab which had a significant impact on women’s lives by eliminating them from public sphere if they were to wear hijab.

Aim:

The aim of this study was to assess the frequency of PTED symptoms among woman victims of the coup after two decades, and to investigate its correlations. Embitterment reaction was also examined in woman victims of 1999 earthquakes of Turkey, and the findings were compared.

Method:

We used PTED, Beck Anxiety Inventory, Beck Depression Inventory and Brief Resilience Scale, and a purpose-designed socio-demographic form.

Results:

Out of eligible 101 hijab ban victims responded, substantial proportion of them (48%) were suffering from chronic embitterment as well as experiencing symptoms of anxiety (37.6%) and depression (26.8%) of moderate-to-severe intensity. There was no difference in the levels of anxiety, depression and resilience between the victims of the coup and earthquake (N = 20), but hijab ban victims were significantly more likely to present with PTED symptoms (p < .05). Women who had family support were more resilient with less likelihood of PTED (p < .05).

Conclusion:

This study provides some important insights into psychopathology of PTED as well as suggesting that it is more likely to manifest in people whose suffering is brought upon by fellow human beings.

Keywords

Embitterment February 28th coup hijab ban PTED Turkey

Introduction

There is a growing evidence of the influence of environmental factors on the aetiology of psychiatric disorders, particularly stress-related psychiatric disorders (Klengel & Binder, 2015). Exposure to a traumatic or stressful event, whether be it natural or man-made, is listed explicitly as a prerequisite criterion for stress-related psychiatric disorders in the diagnostic manuals of psychiatric disorders. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) has a chapter on trauma and stress-related disorders which comprises reactive attachment disorder, disinhibited social engagement disorder, post-traumatic stress disorder (PTSD), acute stress disorder and adjustment disorder (American Psychological Association (APA), 2013). Similarly, International Classification of Diseases–11th version (ICD-11) defines a group of ‘disorders specifically associated with stress’ (World Health Organization (WHO), 2018). While for some disorders in this grouping stressful events are within the normal range of life experiences such as divorce or death of a loved one, for others they are of extremely threatening or horrific nature such as death, threat or rape.

In addition to the list of stress/trauma-related diagnoses described in the DSM-5/ICD-11, another trauma-related diagnosis, namely, post-traumatic embitterment disorder (PTED), was proposed by Linden, a German psychiatrist, and his colleagues following their observations and studies initially in immigrants from East Germany following the fall of Berlin wall (Linden, 2003; Linden et al., 2008a). They observed that after 10 years of re-unification, people from the east of the wall had developed psychological reactions to negative changes in their personal lives, which did not seem to have met the criteria for any of the diagnosis of PTSD, adjustment disorders or depressive disorders according to ICD-10 or DSM-IV. They described that PTED was characterized by distinct psychopathology as a reaction to exceptional, though normal, negative life events such as unemployment, divorce or death of a relative. Linden et al. described that pathogenic mechanism of adverse event stemmed from the violation of the belief and value system of the person rather than the inherent property of the event. It has a characteristic psychological mechanism (experiences of humiliation, frustration, helplessness and injustice) with a highly specific psychopathological profile (embitterment) (Dvir, 2007). The proposed diagnostic criteria for PTED are presented in Table 1 (Linden et al., 2008a).

Table 1.

Diagnostic criteria for post-traumatic embitterment syndrome.

A: Development of clinically significant emotional or behavioural symptoms following a single exceptional, though normal, negative life event

B: The traumatic event is experienced in the following ways:
1. The person knows about the event and sees it as the cause of illness
2. The event is perceived as unjust, as an insult and as humiliation
3. The person’s response to the event involves feelings of embitterment, rage and helplessness
4. The person reacts with emotional arousal when reminded of the event

C: Characteristic symptoms resulting from the event are repeated intrusive memories and a persistent negative change in mental well-being

D: No obvious mental disorder that could explain the abnormal reaction was present prior to the event

E: Performance in daily activities and roles is impaired

Natural and man-made traumas are not uncommon around the world. People’s responses to trauma range from developing no mental health problems, even coming out with post-traumatic growth, to developing severe and impairing psychopathology (Iacoviello & Charney, 2014). One of the factors identified in the literature leading to different reactions to trauma or stress is the concept of resilience. Resilience, as a complex psychosocial construct, is broadly described as healthy, adaptive or integrated positive functioning over the passage of time in the aftermath of adversity (Southwick et al., 2014).

The focus of this study is the women who were deprived of their rights to education and work because of wearing Islamic headscarf (hijab), and forced to make a choice between their basic human rights as a result of the February 28th post-modern coup of Turkey, which took place in 1997, and affected millions of people over the years (Aslan, 2016). Turkey is a secular republic with 99.2% of population identifying themselves as Muslim (Diyanet İşleri Başkanlığı (DIB), 2014). Yet, public visibility of Islamic headscarf (hijab) has been a symbol of political conflict for many years. From the establishment of modern Turkish Republic, it has witnessed several military coups staged. On 28 February 1997, the government–military tension resulted in a so-called ‘post-modern coup’ when the National Security Council issued some measures against the perceived threat and forced the government to sign it, which has often been referred to as a ‘soft coup’, ‘post-modern coup d’état’ or ‘the February 28th process’ (Aslan, 2016). This was the fourth military intervention in Turkey since the end of the Second World War (Narli, 2011). One of the implications of this coup was the ban on hijab, which remained in place until 2013 when it was officially lifted. Hijab as an Islamic value is an important social, cultural and religious symbol that is central to the identity of millions of Muslim women across the world. The hijab ban, one of the most controversial issues in Turkish politics, influenced the lives of millions of women, eliminating them from the public sphere including employment, education and the services sector, in both state and private institutions. Hijabi women were discriminated, and if they were to participate in the public sphere, they were to remove their hijabs first. Restrictions on hijabs at universities forced women to make a choice: either to remove it or drop out of higher education (Islam & Kavakci, 2010). There were so-called ‘convincing rooms’, very much like interrogation rooms, where female students would end up during their enrolment process to universities. University staff including professors would talk to girls to persuade them to take off their hijabs (Özer, 2015). From then on, women with hijab (headscarf) found themselves on a long, difficult road: from suffering in silence to immigrating to other countries in search of education, work and more (Islam & Kavakci, 2010).

Turkey has experienced some of the worst earthquakes in the world. The earthquake on 17 August 1999 (7.4 magnitude on the Richter scale) led to the death of nearly 18,000 people; 44,000 people were injured and 250,000 buildings were damaged, leaving tens of thousands of people homeless. About 3 months later, on 12 November, the second earthquake (7.2 on the Richter scale) struck the area killing 832 more people (Holzer, 2000; Marza, 2004). Studies conducted to assess the psychological consequences of the earthquakes demonstrated that PTSD was prevalent among the survivors (Tural et al., 2004).

The aim of this study was to assess the frequency of embitterment symptoms among the woman victims of post-modern coup of Turkey after two decades, and to investigate its correlations with socio-demographic variables and symptoms of depression, anxiety and psychological resilience. Embitterment symptoms were also examined in victims of a natural disaster (1999 earthquakes of Turkey) and the findings were compared.

Method

Procedure

The ethics committee of the Medical Faculty of Istanbul Medeniyet University approved the study. We contacted participants through WhatsApp^® networks. We started with using the network of Women’s Rights Organization Against Discrimination (AKDER), which is a nongovernmental organization founded by the victims of the February 28th coup in 1999, and carried on reaching people using a snowballing technique. For the control group, we tried to reach people living in the earthquake region through researchers’ WhatsApp networks. Participation in the study was on a voluntary basis and the data were submitted via Google Forms. The study period was 3 months between February and May 2019.

The inclusion criteria for the main group was being a woman who experienced hijab ban either at school or work life during the February 28th process. For the control group, to control for the influence of the gender, only the woman victims of the 1999 earthquakes in Turkey were contacted. Although the criteria for PTED were initially described as a single exceptional event, there is evidence that embitterment can result from accumulation of stressful events (J. H. Lee & Kim, 2019). Therefore, to control for the influence of other potential traumatic life events, only the data of the victims who perceived the hijab ban/earthquake as the most negative life event and did not have any other major traumatic experiences according to their reports were included in the analysis.

Materials

Data on various socio-demographic and relevant variables of victims of the coup were collected through a structured data collection form designed by the researchers. The form included questions on age, marital/education/employment status of respondents, age of experiencing the hijab ban and psychiatric history. Our aim was to understand at what point of their life they were affected by the hijab ban and what they did when they faced with it. Hence, we asked about whether the ban was encountered at middle school, high school, university or work life. There was a question about what decision they took at that time: removing hijab and carrying on with education, wearing wig to school/work, leaving/expelled from school, leaving/expelled from work, going back to work/school without hijab after a period of break or moving abroad to continue with education or work. Another question was about whether they had family support with their decision. There was also a question to check if the respondent perceived the ban as the most negative life event and had any other major traumatic events. Those who indicated the ban as the most negative life event with no other major traumatic experiences were instructed to fill out four self-report scales: Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Brief Resilience Scale (BRS) and PTED scale.

For the control group, which included women who experienced the earthquake, data on socio-demographic and relevant variables were collected using another data collection form designed by the researchers. We also asked about their psychiatric history and perception of the earthquake similar to the one described above for the victims of the coup. For those who indicated the quake as the most negative life event with no other major negative life events, we asked to fill out the above-mentioned four self-report scales.

Out of 139 women who responded, 101 described the ban as the most negative life event with no other major traumatic experiences. For the earthquake group, this ratio was 20 out of 65. Only the data of those who described the ban/earthquake as the most negative life event were included in the analysis.

Post-Traumatic Embitterment Disorder Scale

Linden et al. designed the PTED self-rating scale (PTED scale) to assess the features of embitterment reactions to negative life events. It is a 19-item Likert-type scale. Each item has five response options with score ranging from 0 to 4. The mean score of the 19 items is taken as the overall embitterment score. A mean total score of ⩾1.6 (total score above 30.4) suggests prolonged embitterment with strong clinical relevance. A mean total score of ⩾2.5 (total score above 47.5) indicates embitterment of clinically significant intensity. Turkish version was validated both in clinical and non-clinical samples. The test–retest reliability of the Turkish version of PTED scale was very good (r = .97) and the internal consistency was very high (Cronbach’s α = .93) (Linden et al., 2009; Ünal et al., 2011).

Beck Depression Inventory

Beck Depression Inventory is a 21-item self-report questionnaire, on which presence and severity of depressive symptoms are assessed. It describes the symptoms of depression as specified in DSM-IV. Each item is scored on a 4-point Likert-type scale ranging from 0 = absent to 3 = severe. Total scores may range from 0 to 63. It was created by Beck et al. (1996) and adapted into Turkish in 1988 by Hisli et al. with an internal consistency coefficient of .90. Cut-off points are determined as follows: 0–9, minimal depression; 10–16, mild depression; 17–29, moderate depression; and 30–63, severe depression (Beck et al., 1996; Hisli, 1989).

Beck Anxiety Inventory

Beck Anxiety Inventory is a 21-item inventory designed to assess the level of anxiety. Each item is rated on a 4-point Likert-type scale ranging from 0 = not at all to 3 = severe. The total score ranges from 0 to 63. The standardized cut-off points are as follows: 0–7, minimal anxiety; 8–15, mild anxiety; 16–25, moderate anxiety; and 26–63, severe anxiety. It was created by Beck et al. and was shown to be applicable for Turkish population with an internal consistency coefficient of .93 by Ulusoy et al. (Beck et al., 1988; Ulusoy et al., 1998).

Brief Resilience Scale

Brief Resilience Scale was developed by Smith et al. (2008) as a measure to assess the resilience as the ability to bounce back or recover from stress. It is a six-item Likert-type scale (scored from 1 to 5) and is scored by reverse coding items 2, 4 and 6 and finding the mean of the six items. Turkish version was validated by Doğan et al. with internal consistency coefficient of .83. Higher scores indicate better resilience (Doğan, 2015; Smith et al., 2008).

Data analyses

Statistical analyses were performed using SPSS software (version 20.0; SPSS Inc., Chicago, IL, USA). An assessment of normality was initially made with the Kolmogorov–Smirnov test. All numerical data were expressed as mean ± standard deviation. All categorical variables were expressed as number and percentage (n, %). While categorical variables were compared with a chi-square (χ²) test, numeral data were compared with Student’s t-test. As all data were distributed normally, Pearson’s correlation test was used to evaluate the correlations of numerical variables. Significance was set at p < .05.

Results

Out of 139 women who responded, 101 (73%) reported that hijab ban was the most negative life event they experienced in their life. From the victims of earthquake, 20 out 65 (30%) described the earthquake as the most negative life event.

We carried out rest of the analysis on the data of women from both groups who indicated that hijab ban/earthquake was the most traumatic event according to their experience as described in the ‘Method’ section. Socio-demographic features of groups included in the analysis are presented in Table 2. There was a statistically significant difference between ages and education status of the victims of hijab ban and earthquake.

Table 2.

Socio-demographic features.

	February 28th	Earthquake	p-value
Age (years), M ± SD	43.30 ± 6.32	39.70 ± 4.73	.006 *
Marital status, n (%)
Single	11 (10)	3 (15)	.891**
Married	83 (82)	16 (80)
Divorced	7 (6)	1 (5)
Education, n (%)
Primary school	0 (0)	4 (20)	<.000**
High school	2 (2)	3 (12)
University	99 (98)	13 (65)
Employment, n (%)
Unemployed	16 (15)	5 (25)	.342**
Employed	85 (85)	15 (75)	.342**

Student’s t–test; **chi-square test.

p-values with statistical significance are in bold.

According to the cut-off scores of PTED scale as defined by Linden et al. (2009), 48% of the hijab ban victims reported chronic PTED symptoms that could be of clinical relevance, and 20% of them were experiencing PTED symptoms in significant intensity. Among the hijab ban victims, 32.7% reported to have mild anxiety, 19.8% moderate anxiety and 17.8% severe anxiety according to BAI scores. Depression levels as measured by BDI were as follows: 29.7% suffering mild, 23.8% moderate and 3% severe depressive symptoms.

Table 3 shows that victims of hijab ban reported significantly more embitterment symptoms compared to those of earthquake. There was no difference in the levels of reported anxiety, depression and resilience between the two groups.

Table 3.

Comparison of mean PTED scale, BDI, BAI and BRS scores between victims of hijab ban and earthquake.

	February 28th	Earthquake	p-value*
Embitterment	31.41 ± 19.85	19.95 ± 20.20	.028
Depression	11.86 ± 8.08	8.78 ± 8.51	.158
Anxiety	14.15 ± 11.26	9.75 ± 9.03	.065
Resilience	16.66 ± 4.55	18.40 ± 4.01	.095

PTED: Post-Traumatic Embitterment Disorder; BID: Beck Depression Inventory; BAI: Beck Anxiety Inventory; BRS: Brief Resilience Scale.

Student’s t-test.

p-values with statistical significance are in bold.

We compared each item of the PTED scale between the victims of February 28th coup and earthquake and found some differences as presented in Table 4.

Table 4.

Comparison of items of PTED scale.

PTED scale questions	February 28th	Earthquake	p-value*
During the last years there was a severe and negative life event
1. That hurt my feelings and caused considerable embitterment	1.96 ± 1.43	1.40 ± 1.31	.109
2. That led to a noticeable and persistent negative change in my mental well-being	1.57 ± 1.17	0.95 ± 1.19	.330
3. That I see as very unjust and unfair	2.67 ± 1.37	1.20 ± 1.64	.000
4. About which I have to think over and over again	2.35 ± 1.38	1.35 ± 1.56	.004
5. That causes me to be extremely upset when I am reminded of it	2.52 ± 1.39	1.75 ± 1.51	.027
6. That triggers me to harbour thoughts of revenge	0.99 ± 1.18	0.60 ± 1.18	.182
7. For which I blame and am angry with myself	1.16 ± 1.20	0.95 ± 1.23	.461
8. That led to the feeling that there is no sense to strive or to make an effort	1.29 ± 1.28	0.80 ± 1.05	.107
9. That makes me to frequently feel sullen and unhappy	1.55 ± 1.22	1.30 ± 1.34	.406
10. That impaired my overall physical well-being	1.46 ± 1.36	1.05 ± 1.39	.219
11. That causes me to avoid certain places or persons so as to not be reminded of them	1.58 ± 1.39	1.15 ± 1.46	.209
12. That makes me feel helpless and disempowered	1.65 ± 1.43	0.85 ± 1.18	.021
13. That triggers feelings of satisfaction when I think that the responsible party having to experience a similar situation	1.57 ± 1.53	1.20 ± 1.57	.322
14. That led to a considerable decrease in my strength and drive	1.34 ± 1.44	0.80 ± 1.19	.116
15. That made that I am more easily irritated than before	1.69 ± 1.38	1.15 ± 1.34	.110
16. That makes that I must distract myself in order to experience a normal mood	1.68 ± 1.40	1.15 ± 1.46	.126
17. That made me unable to pursue occupational and/or family activities as before	1.32 ± 1.43	0.65 ± 1.18	.050
18. That caused me to draw back from friends and social activities	1.20 ± 1.31	0.60 ± 1.04	.054
19. Which frequently evokes painful memories	1.78 ± 1.35	1.05 ± 1.19	.026

PTED: Post-Traumatic Embitterment Disorder.

Student’s t-test.

p-values with statistical significance are in bold.

There was a significant correlation between PTED and anxiety, depression and reverse correlation with resilience among victims of hijab ban, as presented in Table 5.

Table 5.

Correlations between PTED scale and BDI, BAI and BRS scores.

	BDI	BAI	BRS
Embitterment	r = .647p < .000	r = .506p < .000	r = −.510p < .000

r: Pearson’s correlation; PTED: Post-Traumatic Embitterment Disorder; BID: Beck Depression Inventory; BAI: Beck Anxiety Inventory; BRS: Brief Resilience Scale.

Among the hijab ban victims, 53% faced with the ban at university, 23% at work life, 20% at junior high school and 4% at middle school. Out of the hijab ban victims, 36% reported to have left or been expelled from school, 21% left or expelled from work, 14% wore a wig, 11% removed hijab, 12% moved abroad to continue with education/work and 7% returned to work/school by removing hijab after a period of resistance. There did not appear any relation between PTED scores and the life stage/age they encountered the ban, and their decision at that time (p > .05). There was no relation between embitterment symptoms and current age, marital/employment/education status of hijab ban victims, either (p > .05).

There was a correlation of family support with symptoms of embitterment, anxiety and resilience. This relation was not observed with depression (Table 6).

Table 6.

Comparison of PTED scale, BDI and BAI scores between those with and without family support.

	With family support	Without family support	p-value*
Embitterment	28.25 ± 19.01	44.20 ± 18.34	.002
Depression	11.13 ± 7.94	14.94 ± 8.18	.078
Anxiety	13.19 ± 11.69	18.05 ± 8.43	.041
Resilience	17.13 ± 4.53	14.75 ± 4.21	.033

PTED: Post-Traumatic Embitterment Disorder; BID: Beck Depression Inventory; BAI: Beck Anxiety Inventory; BRS: Brief Resilience Scale.

Student’s t-test.

p-values with statistical significance are in bold.

Discussion

We assessed the presence of PTED symptoms and its associations among the hijab ban victims of February 28th post-modern coup of Turkey, and compared it with the victims of earthquakes, both of which took place around the same time, more than two decades ago. We found that a substantial proportion of women who faced hijab ban were suffering from embitterment as well as experiencing symptoms of depression and anxiety. There was no difference in terms of reported anxiety and depression between the victims of February 28th coup and earthquake, but hijab ban victims were significantly more likely to experience PTED symptoms. To the best of our knowledge, this is the first study demonstrating embitterment symptoms among the victims of hijab ban, and measuring anxiety and depression using psychometric instruments.

Our results showed that majority of women (73%) reported hijab ban as the most negative life event for them, compared to less than one-third of the earthquake victims (30%). We also found that nearly half of women who faced hijab ban were suffering from chronic embitterment, and one-fifth reported PTED symptoms in significant intensity, despite the fact that the ban was lifted 7 years ago. Although there was no difference between the resilience levels of two groups, women who faced hijab ban were significantly more likely to present with embitterment symptoms. Interestingly, this difference was not evident in the symptoms of anxiety or depression. It is possible to interpret these findings from two perspectives.

First, presence of more PTED symptoms among the victims of hijab ban in comparison with those of earthquake is in line with several previous epidemiological studies on PTSD that man-made disasters have more adverse psychological effects than natural disasters. Galea et al. (2005) reported PTSD in a ratio of 5%–60% following natural disasters and 25%–75% following man-made disasters. Similarly, in one of the world mental health surveys, it was suggested that man-made disasters are associated with higher rates of PTSD than natural disasters (Bromet et al., 2017). It is therefore important for clinicians to be more vigilant in searching post-traumatic psychopathology among victims of man-made disasters in particular.

Second, emergence of a difference between the groups in embitterment symptoms but not in depression or anxiety seems to support Linden’s description that PTED has a distinct psychopathology. PTED was characterized by feelings of embitterment, rage and helplessness and that the event is perceived as unjust, an insult and as humiliation by the victim. We determined embitterment symptoms using the structured PTED self-report scale; hence, it was not possible to document detailed subjective experiences of the participants. However, examining the each item of PTED scale that the participants filled in, it was evident that hijab ban victims compared to the victims of earthquake were more likely to perceive the event very unjust, get extremely upset with painful emotions when reminded of the event and ruminate more with feelings of helplessness and disempowerment. They were also more likely to blame the event for a decline in their occupational and family activities. Similarly, themes of PTED were evident in previously conducted studies among hijab bans. In a face-to-face survey carried out on 1,112 women aged 18–50 years from eight big provinces of Turkey, who were graduates of high school or above, and who were affected by headscarf bans applied in various periods, it was reported that 71% of women felt that their personality was ‘damaged/torn’, 63% felt ‘insulted’, 47% felt ‘shame’ every time they had to take off their hijab and 46.5% felt ‘sinful’. The rate of those who felt that their honour was hurt because of the news and comments in the media was 66.5%, the rate of those who said that the trust in their country was shaken by the state’s attitude towards hijabi women was 63.9% and that of those who felt ‘upset for being treated like a criminal’ was 54.1% (Güveli & Kadı, 2007). In a qualitative thesis study conducted on 30 women, it was reported that some women felt that their lives would never be the same and that this ban gave them a sense of being late for life. They attributed this to the fact that they did not finish their schools in time or were not able to work in the jobs they wanted. They described that they did not feel their ‘normal’ self after the hijab ban and that it left them with a heritage to get involved in a certain identity. Some reported experiencing physical and psychological reactions when reminded of the ban and described avoidant behaviour: for example, not being able to enter the school building even after the lift of the ban (İşıker, 2011). These experiences are all in line with the specific characteristics of PTED as a distinct reaction to negative life events.

There was no correlation between the embitterment symptoms and the age of exposure to ban, their decision when faced with the ban and the current age, marital/employment/education status. These findings imply that embitterment is independent from all these factors, and in fact suggest that patho-mechanism of PTED stems from the violation of belief and the value system of the person, which is in line with the original description by Linden. This was actually demonstrated by previous qualitative studies where women expressed very similar narratives despite having faced the ban at different conditions and followed a different life path in terms of what they did about hijab ban (İşıker, 2011; Uysal, 2019). The dilemma of observing a religious belief or ignoring it for the sake of education, career or work seemed to be at the heart of these bitter emotions.

There was a significant correlation between PTED and anxiety, depression among victims of hijab ban. This is in line with the literature, which shows that there is considerable comorbidity between embitterment and other common psychiatric disorders, notably major depression, dysthymia and generalized anxiety disorder (Linden et al., 2008b). There was a significant negative correlation between resilience and embitterment, which is expected by the nature of the resilience concept, and is well supported by the evidence (Iacoviello & Charney, 2014). What was more interesting was that despite there was no difference between their resilience levels, hijab ban victims were more likely to present with embitterment compared to victims of earthquake. This might be attributed to the previous observations that PTED has a distinct patho-mechanism characterized by a combination of features which do not commonly occur in people exposed to natural disasters: personal insult, feelings of having been let down, frustration, revenge and appraisals of social injustice (Pirháčová, 1997).

Those who had family support during the process appeared to be more resilient with less embitterment and anxiety symptoms. This is not surprising, as for some, a common emotional implication was a sense of confusion and pressure due to being caught in between their families – who either pushed them away completely because they were insistent on wearing the hijab or who pressured them to take it off for education – and their desire to reconcile their professional futures and religious conviction (Islam & Kavakci, 2010; Özer, 2015). Our finding is consistent with previous research which demonstrated that embitterment was negatively correlated with perceived social support. A cross-sectional study on chronic embitterment among people seen by occupational health professionals showed that embittered staff perceived their organization as being unsupportive and as showing low levels of procedural justice (Sensky et al., 2015). In a study on 48 victims of Sewol ferry disaster, it was reported that perceived social support was negatively correlated with embitterment and acted as a mediator for post-traumatic embitterment (S. H. Lee et al., 2017).

We found that more than one-third of hijab ban victims were experiencing moderate-to-severe anxiety symptoms, and more than one-quarter were suffering symptoms of depression of moderate-to-severe intensity. It appeared that only 4% of women received psychiatric/psychological help before the ban, but this went up to 30% after exposure to the ban. Our results are supported by earlier researches, which reported significant psychological distress among the victims because of ban. In a qualitative study carried out by interviewing 10 hijab victims, all women reported to have had experienced some psychological problems as a result of the February 28th process, and some reported to have had experienced anxiety and depression (Uysal, 2019). In the above-mentioned face-to-face survey conducted on 1,112 women, although researchers did not use any validated instrument to measure psychological difficulties experienced by the participants, 9.2% of women admitted to receiving treatment for psychological problems, and actually only 3.8% said that they did not experience any psychological distress (Güveli & Kadı, 2007). A qualitative thesis study conducted by interviewing 30 hijab ban victims revealed that some received medication and/or psychotherapy for their psychological problems during the process, and some said they did not seek help for various reasons despite feeling the need (İşıker, 2011). All these findings underscore the fact that hijab ban brought along a significant mental health burden on its victims.

Limitations

This study comes with several limitations and therefore our results should be interpreted with caution in comparative studies. The cross-sectional design of the study renders it difficult to identify any causal relationship among the factors. Selection bias may have occurred, as those who responded are likely to be different from those who did not. Although we attempted to make the two groups as comparable as possible, there was a difference in the age and education status of the two groups, which might have an impact on the findings. Some additional relevant factors, such as self-efficacy, coping style and current social support systems, should be included in future studies to gain a better understanding of PTED.

Conclusion

This is the first study demonstrating the embitterment symptoms among women who were exposed to hijab ban, and forced to make a choice between their basic human rights. We observed that significant proportion of these women, despite more than two decades passed, still suffer from embitterment with some also having co-existing anxiety and/or depression. Those who had family support appeared more resilient and were less likely to present with embitterment. This study provides some important insights into psychopathology of PTED as well as suggesting that it is more likely to be associated with man-made disasters than natural ones, and that it can continue to present decades after. Better understanding of the consequences of negative life events would have implications for therapeutic and hopefully preventive interventions for those suffering embitterment symptoms at the hands of fellow human beings.

Footnotes

Acknowledgements

The authors would like to thank AKDER (Women’s Rights Organization Against Discrimination) for its help with reaching the victims of the hijab ban, and all the women who participated in the study.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Aynur Görmez

References

American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing.

Aslan

. (2016). ‘Unarmed’ we intervene, unnoticed we remain: The deviant case of ‘ February 28th Coup’ in Turkey. British Journal of Middle Eastern Studies, 43(3), 360–377.

Beck

A. T.

Steer

Brown

(1996). Manual for the Beck Depression Inventory-II (BDI-II). Psychological Corporation.

Beck

A. T.

Epstein

Brown

Steer

R. A.

(1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56(6), 893–897.

Bromet

E. J.

Atwoli

Kawakami

Navarro-Mateu

Piotrowski

King

. . . Demyttenaere

(2017). Post-traumatic stress disorder associated with natural and human-made disasters in the World Mental Health Surveys. Psychological Medicine, 47(2), 227–241.

Diyanet İşleri Başkanlığı. (2014). Türkiye’de dini hayat araştırması [Research on religious life in Turkey].

Doğan

(2015). Adaptation of the Brief Resilience Scale into Turkish: A validity and reliability study. The Journal of Happiness & Well-Being, 3(1), 93–102.

Dvir

(2007). Posttraumatic embitterment disorder: Definition, evidence, diagnosis, treatment. Psychiatric Services, 58(11), 1507–1508.

Galea

Nandi

Vlahov

(2005). The epidemiology of post-traumatic stress disorder after disasters. Epidemiologic Reviews, 27(1), 78–91.

10.

Güveli

Kadı

İ. H.

(2007). Social, economic and psychological effects of the headscarf ban on women in Turkey. Hazar Group.

11.

Hisli

(1989). The validity and reliability of Beck Depression Inventory for university students. Psikoloji Dergisi, 7, 3–13.

12.

Holzer

T. L.

(2000). Implications for earthquake risk reduction in the United States from the Kocaeli, Turkey, earthquake of August 17, 1999 (Vol. 1193). US Government Printing Office.

13.

Iacoviello

B. M.

Charney

D. S.

(2014). Psychosocial facets of resilience: Implications for preventing posttrauma psychopathology, treating trauma survivors, and enhancing community resilience. European Journal of Psychotraumatology, 5(1), 23970.

14.

İşıker

(2011). Inside and outside as an obligation area, ‘February 28th and women with headscarf: Unexplain(able)ed story of a mental and psychological transformation. İstanbul Bilgi University.

15.

Islam

M. K.

Kavakci

(2010). Headscarf politics in Turkey: A postcolonial reading. Springer.

16.

Klengel

Binder

E. B.

(2015). Epigenetics of stress-related psychiatric disorders and gene× environment interactions. Neuron, 86(6), 1343–1357.

17.

Lee

J. H.

Kim

(2019). Exposure to negative life events and post-traumatic embitterment symptoms in young adults in Korea: Cumulative and differential effects. Psychopathology, 52(1), 18–25.

18.

Lee

S. H.

Nam

H. S.

Kim

H. B.

Kim

E. J.

Won

S.-D.

Chae

J.-H.

(2017). Social support as a mediator of posttraumatic embitterment and perceptions of meaning in life among Danwon survivors of the Sewol ferry disaster. Yonsei Medical Journal, 58(6), 1211–1215.

19.

Linden

(2003). Posttraumatic embitterment disorder. Psychotherapy and Psychosomatics, 72(4), 195–202.

20.

Linden

Baumann

Lieberei

Rotter

(2009). The post-traumatic embitterment disorder Self-Rating Scale (PTED Scale). Clinical Psychology & Psychotherapy: An International Journal of Theory & Practice, 16(2), 139–147.

21.

Linden

Baumann

Rotter

Schippan

(2008a). Diagnostic criteria and the standardized diagnostic interview for posttraumatic embitterment disorder (PTED). International Journal of Psychiatry in Clinical Practice, 12(2), 93–96.

22.

Linden

Baumann

Rotter

Schippan

(2008b). Posttraumatic embitterment disorder in comparison to other mental disorders. Psychotherapy and Psychosomatics, 77(1), 50–56.

23.

Marza

V. I.

(2004). On the death toll of the 1999 Izmit (Turkey) major earthquake. ESC General Assembly Papers, European Seismological Commission, Potsdam, Germany.

24.

Narli

(2011). Concordance and discordance in Turkish civil-military relations, 1980–2002. Turkish Studies, 12(2), 215–225.

25.

Özer

G. D.

(2015). Persuasion rooms as a psychological torture method. Ekin Publications.

26.

Pirháčová

(1997). Perceived social injustice and negative affective states. Studia Psychologica, 39, 133–136.

27.

Sensky

Salimu

Ballard

Pereira

(2015). Associations of chronic embitterment among NHS staff. Occupational Medicine, 65(6), 431–436.

28.

Smith

B. W.

Dalen

Wiggins

Tooley

Christopher

Bernard

(2008). The brief resilience scale: Assessing the ability to bounce back. International Journal of Behavioral Medicine, 15(3), 194–200.

29.

Southwick

S. M.

Bonanno

G. A.

Masten

A. S.

Panter-Brick

Yehuda

(2014). Resilience definitions, theory, and challenges: Interdisciplinary perspectives. European Journal of Psychotraumatology, 5(1), Article 25338.

30.

Tural

Ü.

Coşkun

Önder

Çorapçioǧlu

Yildiz

Kesepara

. . . Torun

. (2004). Psychological consequences of the 1999 earthquake in Turkey. Journal of Traumatic Stress: Official Publication of the International Society for Traumatic Stress Studies, 17(6), 451–459.

31.

Ulusoy

Sahin

Erkmen

(1998). Turkish version of the Beck Anxiety Inventory: Psychometric properties. Journal of Cognitive Psychotherapy, 12(2), 163–172.

32.

Ünal

Güney

Kartalcı

Ş.

Reyhani

. (2011). The study of the reliability and validity of the Turkish version of Post Traumatic Embitterment Disorder Self-Rating Scale (PTED Self-Rating Scale). Dusunen Adam the Journal of Psychiatry and Neurological Sciences, 24(1), 32–37.

33.

Uysal

(2019). Psychological effects of Islamophobia on Hijab Ban victims in Turkey in the context of February, 28 Hijab Ban process and religious coping. Yakın Doğu Üniversitesi İslam Tetkikleri Merkezi Dergisi, 5(2), 281–314.

34.

World Health Organization. (2018). International classification of diseases for mortality and morbidity statistics (11th revision).