Life is full of routines, duties, “must do” things. Besides these, there are others - love, joy, sorrow, despair and fear, which are quite few and far between when compared to the routine flow of life. And besides routines and such few exceptions, there are tiny breaking points, turning points in life, such that after a while, at some certain point when you gaze back at your past, you realise that this turning point changed the direction of your life and took you somewhere that you had never dreamed before, that you were unable to predict or even think of.
I deeply appreciate that one morning in the spring of 2006 was one of these few turning points of my life. On that morning, Prof. Dr. Hayriye Elbi, to whom I will be grateful for all my life, invited me to her office in the Department of Psychiatry in Ege University. I was a second year resident in Psychiatry and she was head of the Department. I can still remember what she asked me in front of the open window from where you could see the first blossoms of April. She asked me, while passing me the official letter, whether I would like to study for a PhD degree abroad.
I deeply appreciate that one morning in the spring of 2006 was one of these few turning points of my life. On that morning, Prof. Dr. Hayriye Elbi, to whom I will be grateful for all my life, invited me to her office in the Department of Psychiatry in Ege University. I was a second year resident in Psychiatry and she was head of the Department. I can still remember what she asked me in front of the open window from where you could see the first blossoms of April. She asked me, while passing me the official letter, whether I would like to study for a PhD degree abroad.
If you are a well-educated youngster brought up in Turkey (or anywhere in the East), “abroad” means west and is always charming. So I was enchanted by the idea of being abroad, not by having a PhD degree or any scientific thing. Because at that particular time, a PhD was like a creature that I heard before but never thought to meet, or like an unknown planet far from me. Regardless of where you obtain your medical degree, all the focus shifts onto how to practice medicine, so obtaining a specialist degree was and remains much more important for a young physician.
Even so, I was haunted by the idea of a PhD; I used to know almost nothing about a PhD. How to do one, what to study, where to study and many other considerations were very obscure and were opening up new questions. For example, where to find funding for a PhD. I still remember my online surfing, searches and e-mail traffic through all the well-known names of the universe of psychiatric research. But my attempts were like throwing a message in a bottle from my island to a huge ocean.
I am still thankful to senior colleagues from American and West European universities for their polite and realistic replies, and I would like to apologise for inflating their inboxes! During all those efforts, I was communicating with Prof. Elbi and she was helping me to clarify my thoughts. After six months of online self-torture, I realised that I was heading in the wrong direction. Besides my useless internet-based efforts, I was also dealing with distant determinants of mental health e.g inequalities, job stress, and social class. I still appreciate such factors are important relation to mental health; however I learned that a PhD needs a more focused area of research. Overall it is really an ambiguous, thorny business.
During the summer of 2006, Prof. Elbi suggested to focus on psychosis epidemiology. Her suggestion took me to Prof. Dr. Köksal Alptekin, to whom I will also be grateful for all my life. Prof. Alptekin is one of the best psychosis experts in Turkey, who has a talent for effective collaborative work, international accessibility and encouraging young colleagues to give their all to any challenge they face. So one summer day, in the late afternoon, I knocked on the door of his office to talk about his former epidemiological study about psychosis in the general population. I still remember visiting his meticulously furnished office and his table where the schizophrenia book of Robin Murray and psychoanalytical books lay together. He encouraged me to screen psychotic symptoms and syndromes in the adult general population of Izmir. "But," he said, "there are genes, polymorphisms... Epidemiological fusion is now much more meaningful with field based genetic studies. So I suggest you to collect data on genetic samples and collaborate with Prof. Jim van Os who lives in Maastricht, the Netherlands."
It was an uncanny sunny October day when I took the public bus to Vijverdal almost two hours before my appointment with Prof. Jim van Os. I went there to meet Prof. Meram Can Saka from Ankara University who was in Maastricht for 3 months as a fellow. I wanted to ask him how to find a way of doing a PhD in Maastricht. We smoked and cheated outside the Vijverdal building which used to be locally known as "the end of the road". I was asking Prof. Saka any short-cut to Maastricht as a PhD candidate. I was optimistic and he was, of course, realistic. But he encouraged me while watching my enthusiasm with his wise eyes. After a couple of butts on the floor and a couple of paper cups on the wall, I took the road to academishe zickenhuis Maastricht (azM) to meet Prof. van Os.
I still remember nice weather, sheltering sky with colourful clouds, flying birds over my head, peaceful streets, two-floored Dutch houses without any curtains on their windows, green fields and the road that was seemingly endless. Everywhere was in peace and it was a contrast to anxiety inside me. After a while I understood that I took the wrong route to azM. I was about to be late for one of the most important appointment. Maybe it was alapsus. I don’t know, but I hurried, left streets and walked, even ran through green fields to knock the doors of West. And I could arrive to his office just few seconds to my appointment.
Jim is one of the most inspiring people I have ever met in my life. When you listen to him at a conference, in a lecture or on television, you realise that his words will inspire you, will change your way of thinking about mental health, psychosis, epidemiology, methods, and any issue in psychiatry plagued by myths. But there were three reasons in my forty-five minutes with him that made him unforgettable: Firstly, he gave me those “forty-five minutes” fully. No phone calls, no other work, nothing else and just talking, thinking with me. Secondly he gave me the initial idea, the framework to study wider social environment, social capital and psychosis phenotype which is the heart of this thesis. Third he asked me "Are you clever enough to perform all this research?". This particular question sounded like a miscalculation when I heard it: A miscalculation about me. Yes, it was a realistic, Western type of question. Here, in the East we talk, behave, think indirectly. So this question made me think about what I wanted. He didn't open or close any doors for me. But he asked me whether I held the keys to open the doors. He asked me whether I had patience and perseverance to enter the door that I was seeking... I am and will be grateful to him for all my life too.
Back to Izmir, it took me three hard-working months to find the keys to the door that I was seeking, or I thought was there. I read whatever I found about the psychosis continuum, social capital, social environment, urban living. Furthermore, I was trying to understand gene-environment interaction (GEI), how to study GEI and which gene or genes to analyse. After months of articles, lectures, meetings to create a research proposal and a research team, a study began to take shape with collaboration between the departments of Psychiatry, Genetics and Public Health. I wrote the study, consulted with the research team consisting Prof. Dr. Feride Aksu-Tanık from the department of Public Health, Prof. Dr. Ferda Özkınay and Ass. Prof. Dr. Hüseyin Onay from the department of Medical Genetics. I am grateful to them for supporting me, and their peerless contribution to the TürkSch study. Since studying psychosis, social risk factors, GEI and social capital was a new and challenging work, sometimes I had to convince members of the team of the methods for the study, and sometimes even convince myself.
The research proposal went to the committee of the Scientific and Technological Research Council of Turkey with a last-minute shipment on the last day, in the last hour of application at the start of January. The committee approved our research in April 2007, and it took us two and a half years to complete the study by the end of 2009. During those years we worked with pleasure, curiosity, and pride. The TürkSch study, our research was like a new-born baby. We cared for it, we loved it, we became a part of its development, and many vivid memories remain.
Grant of the research gave me chance to be a member of MHeNS (School for Mental Health and Neuroscience) in Maastricht. And in MHeNS, I met with another person that I learned much from: Dr. Marjan Drukker. I was totally focused on finishing the research and almost never thought about what to analyse, or how and where to write up my results. Yes, research does mean design, aims, and data collection but, primarily, communication. I am grateful to Marjan for her undaunted guidance and companionship. I learned statistics, epidemiology, and research methodology from her. Furthermore I learned things that cannot be found in textbooks: patience, persistence, not exhausting myself. Trying to finish a PhD is a period full of difficulties and such properties of a tutor gain great importance when you are a PhD candidate.
There are more names that I will remember for their unforgettable role in my PhD story. One of them is the coordinator, secretary, clinical interviewer, -driver, data and human resources collector, booklet distributor- of the TürkSch study, Nesli Zağlı. I would like to thank Prof. Dr. Cengiz Kılıç for providing CIDI 2.1 training, Prof. Dr. Baybars Veznedaroğluand Prof. Dr. Bülent Kayahan for sharing their clinical expertise in psychosis phenomenology, Ass. Prof. Dr. Özen Önen Sertöz for her help in lay interviewer training,Dr. Hür Hassoy for providing key information on socioeconomic status and demographic features, Dr. Umut Kırlı for his primary participation in the longitudinal arm of the study,Meriç Selvi for her concentrated effort in entering and checking the data and co-coordinating the field work. I am also grateful to the interviewers of the TürkSch study, and to the respondents who kindly participated in the study in their homes as well as in the hospital.
I was lucky to be a resident of the Department of Psychiatry at the Ege University which provided us a social environment with gentle handling, encouragement and esteem. I would like to thank all academic staff and my co-senior residents. I want to particularly mention Prof. Dr. Işıl Vahip and Prof. Dr. Simavi Vahip for sharing their knowledge and experience about psychiatry, mood disorders, psychoanalysis, and a profession that has to be embodied with honesty, humanitarian views and thoroughness.
I was also lucky to be a part of MHeNS. I would like to thank Judith Allardyce for sharing a room for six months, and colleagues in MHeNS: Maria de Gracia Dominguez, Nicole Geschwind, Margriet van der Werf, Margreet Oorschot, Rebecca Kuepper, Johan Lataster, Bart Rutten, Trees Soute, and Ron Mengelers. I likewise would like to thank all the members of the MHeNS.
Maastricht was a cross-road to meet lifelong friends: Ed van Hees, Gwenda Engels, Seda Yenil, Eda Yenil, Yeliz Angın, Lotte Smeets, Jan William Hees. I will always remember the night and songs in Café de Poort where we met.
Maastricht was also the home of my early days of marriage to Deniz. She accompanied me with her support, love and friendship while I struggled with the aches of the PhD. A baby was first born to our minds in Maastricht. And Deniz was pregnant for Sedef, our daughter, when we were back to Turkey. Now, we are a four-person family with our son, Mercan. We were a couple before Maastricht and we became a family after. I am grateful to her for her support and patience.
I would like to thank Martti, Sezen, Patrick Groenen and Handan Arık. They were our family in Holland and their house was our house when we were there.
I would like to thank my dear mom, dad and sister for giving me not only life, but also freedom to go where I want. I would like to thank my extended family (my friends and colleagues) who were indirectly involved in the emergence of this thesis. And I would like to thank Alexandra East and Işık Ezber for proof-reading.
The TürkSch study and my PhD also gave me opportunity to become a member of the Department of Psychiatry at the Dokuz Eylul University. I would like to thank my new academic family. I want to particularly mention Assoc. Prof. Dr. Halis Ulaş for his companionship from the first days of my interest in psychiatric research.
Also Karl Marx, Sigmund Freud and Jim Morrison. I am not someone who can devote himself to a single field. I am an eclectic person. That is the way I can experience life. So I am not fully devoted to Marxism (as a way of understanding social and political conditions), the philosophy of psychiatry (as a way of understanding human conditions) or rock music (as an expression of contemporary culture and life). But they constituted my past to a great extent. They are, to some extent, my architects. My days were full of diving into and swimming in them. I adored them. And while writing this thesis, I recognized that they were symbolising hope in me: Karl Marx for égalité (equity), Sigmund Freud for fraternité (brotherhood) and Jim Morrison for liberté (freedom). Although I am not pessimistic, the future ain't what it used to be. If you want, you can see big dark clouds everywhere. "Society is a crazy breed" and "we are diving for dear life", which is full of little personal earthquakes, "when we could be diving for pearls". Pearls of sound, words, emotions, nature... So I wanted to cite in the beginning of this thesis my symbols of pearls, that I could be diving instead of diving for life which is is full of routines, duties, “must do” things. Besides routine of life, there are others - love, joy, sorrow, despair and fear, which are quite few. And besides routines and such few exceptions, there are very few turning points of life. And this thesis was the pearl of an exceptional turning point in my life.
Thank you.
(Photo: Deniz Arık Binbay; after defense - 02.12.2014, Maastrciht)
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