University of Groningen
Canına kıymak – ‘crushing life energy’
Eylem, O.; van Bergen, D.D.; Rothod, S.; Van Straaten, A.; Bhui, K.; Kerkhof, A.J.F.M.
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International Journal of Culture and Mental Health
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Eylem, O., van Bergen, D. D., Rothod, S., Van Straaten, A., Bhui, K., & Kerkhof, A. J. F. M. (2016). Canına
kıymak – ‘crushing life energy’: a qualitative study on lay and professional understandings of suicide and
elp-seeking among Turkish migrants in the UK and in the Netherlands.
International Journal of Culture and
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Canına kıymak – ‘crushing life energy’: a qualitative
study on lay and professional understandings of
suicide and help-seeking among Turkish migrants
in the UK and in the Netherlands
O. Eylem, D. D. van Bergen, S. Rathod, A. van Straten, K. Bhui & A. J. F. M.
Kerkhof
To cite this article: O. Eylem, D. D. van Bergen, S. Rathod, A. van Straten, K. Bhui & A. J.
F. M. Kerkhof (2016) Canına kıymak – ‘crushing life energy’: a qualitative study on lay and
professional understandings of suicide and help-seeking among Turkish migrants in the UK
and in the Netherlands, International Journal of Culture and Mental Health, 9:2, 182-196, DOI:
10.1080/17542863.2016.1161653
To link to this article: http://dx.doi.org/10.1080/17542863.2016.1161653
© 2016 The Author(s). Published by Informa
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Canına kıymak – ‘crushing life energy’: a qualitative study on lay
and professional understandings of suicide and help-seeking
among Turkish migrants in the UK and in the Netherlands
O. Eylem
a,b,c
, D. D. van Bergen
d
, S. Rathod
e
, A. van Straten
a,b
, K. Bhui
c
and
A. J. F. M. Kerkhof
a,b
a
Department of Clinical Psychology, VU University, Amsterdam, The Netherlands;
b
EMGO Institute for Health and
Care Research, Amsterdam, The Netherlands;
c
Wolfson Institute of Preventive Medicine, Queen Mary University of
London, London, UK;
d
Department of Education, Faculty of Social Sciences, Groningen University, Groningen,
The Netherlands;
e
Southern Health NHS Foundation Trust, Southampton, UK
ABSTRACT
Currently, little is known about the views that Turkish migrants hold
towards suicide, which may differ from the narratives held by native
inhabitants of their host countries. Central to improving the provision of
mental health services, furthering our knowledge of these views is
important. The aim of this research was to explore Turkish cultural
understandings on suicide and help-seeking for suicide. A qualitative
study included data from 6 focus groups and 7 individual interviews
with 38 Turkish-speaking lay people and 4 key informants living in the
Netherlands or the UK during the year 2014/2015. Through the analysis
of participants’ stories and narratives, the following key themes emerged
in relation to suicide: suicide as an escape from failure and as a failure in
itself; acculturation orientation; parenting style; and shame and stigma.
There were more similarities than differences between the themes
among laypersons and key informants from two countries. Canına
kıymak (crushing life energy) was a strong metaphor for personal
distress. Suicide was perceived as a failing of responsibilities towards the
family and community. Future research should aim to give voice to all
ethnocultural groups to further the present understanding of suicide
and help-seeking processes in these communities.
ARTICLE HISTORY
Received 17 February 2016
Accepted 1 March 2016
KEYWORDS
Turkish migrants; suicide;
culture; qualitative research
Introduction
Epidemiological differences in suicide rates between countries as well as within countries have been
explained by the context of culture and ethnicity (e.g., Bhui,
2010; Hjelmeland, 2011; Lester, 2012;
Vijayakumar, John, Pirkis, & Whiteford,
2005). The current suicide research literature is limited
by the theories generated from research among Western European societies that were treated as rela-
tively homogenous in terms of ethnicity and religion (e.g., Hjelmeland,
2011). This limitation brings
several challenges to healthcare systems, especially in improving the provision and accessibility of
adequate mental health services for migrants and ethnic minorities. Given these challenges, for
instance in the UK, the recent publication of the updated National Institute for Health and Care
Excellence schizophrenia guidelines (National Institute for Health and Care Excellence,
2014)
© 2016 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (
http://
creativecommons.org/licenses/by-nc-nd/4.0/
), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the
original work is properly cited, and is not altered, transformed, or built upon in any way.
CONTACT O. Eylem o.eylem@vu.nl
INTERNATIONAL JOURNAL OF CULTURE AND MENTAL HEALTH, 2016
VOL. 9, NOS. 1–4, 182–196
http://dx.doi.org/10.1080/17542863.2016.1161653
suggests the need for improving existing knowledge on cultural views of mental health, suicide and
help-seeking processes among these highly diverse populations.
Currently, there is insufficient information on cultural views of suicide among migrants. The
existing literature suggests that besides acculturation orientation, individual meanings and religious
beliefs are important factors determining migrant views on suicide (Bhui,
2010). In the UK, for
instance, Muslim communities seem to be more often morally opposed to suicide compared to
Hindu communities (Kamal & Lowental,
2002). Several methodological issues exist with the current
literature. Very often, the cultural groups studied are too broad (e.g., Muslims and Hindus) and the
cultural, ethnic and religious variations within these broad categories are ignored (Colucci & San
Too, 2015). As a result, not much is known about suicide and help-seeking patterns among some
ethnic groups within these broad categories, such as the Turkish speaking communities, despite
their long history of migration in Western Europe.
The Turkish diaspora in Europe mainly comprises three main groups: Turkish Cypriots, main-
land Turks and Kurdish communities. These groups migrated to Europe for different historical
and political reasons (Enneli, Modood, & Bradley,
2005). Besides the cultural, ethnic and religious
differences between these groups, there are commonalities shared by all as a result of their history
of interaction. For example, traditionalism (the strong religious and ethnic identification with
their heritage culture) is common among the Turkish migrants in Germany, Belgium and the Neth-
erlands (e.g., Ersanilli & Koopmans,
2010). The traditional family structure emphasizing conformity
and the importance of family honour seems to persist in Turkish migrant families, especially in
Germany, Belgium and The Netherlands (Güngör,
2008). In recent years, there has been a shift
among young Turkish women from traditional conservative gender role attitudes toward more ega-
litarian ones (e.g., willingness to study, participate in public life, share responsibility) even though
their attitudes toward family obligations and parental authority do not often differ from those of
men (e.g., Gungor & Bornstein,
2009; Phalet & Schonpflug, 2011).
Suicide is often proposed to be prohibited by the Islam (the dominant religion in this group) and
therefore expected to be protective against suicide (Lester,
2006). It is also believed that Muslim popu-
lations are protected from suicide because of their traditionalism and strong sense of community cohe-
siveness (Lester,
2006) as such characteristics would give them access to their informal network (family,
friends) to seek help. Nevertheless, the growing literature on suicide in this population indicates that
Turkish-speaking communities in Europe face special risks of suicidal behaviours, which reflect the
risks in their countries of origin (Schouler-Ocak,
2015). For instance, the age standardized suicide
rate in Turkey is 7.9/100000, which is higher than the rates in Iran, Italy, China and the UK (World
Health Organisation,
2012). In the Netherlands, Turkish migrants most often die by suicide at a younger
age compared to indigenous Dutch people (Turkish men: 32, Turkish women: 32; Dutch men: 48, Dutch
women: 51 [Garssen, Hoogenboezem, & Kerkhof,
2006]). Furthermore, although completed suicide
rates appear to be mostly lower in Turkish migrants in Europe, rates of suicidal thinking and attempted
suicide do not appear to be lower, as many studies report increased rates (e.g., the Netherlands, Belgium,
Germany) compared to indigenous populations (Burger, van Hemert, Bindraban, & Schudel,
2009;Lin-
dert, Schouler-Ocak, Heinz, & Priebe,
2008; van Bergen, van Balkom, Smith, & Saharso, 2012). The con-
sistency in these suicide trends between mainland Turkey (Bağlı &Sever,
2003;Sayıl & Devrimci-
Özgüven,
2002) and host countries in Europe suggests the continuity of an interplay between cul-
ture-specific risk factors (e.g., honour-related issues) and universal risk factors (e.g., unemployment)
leading to suicide through (or regardless of) the migration process (Schouler-Ocak,
2015).
The current study explores the cultural views on suicide and help-seeking for suicidal behaviours,
which are vital to guide the suicide prevention and management efforts in Turkish communities.
Given the diversity within Turkish populations and the difficulty in previous studies of identifying
a representative Turkish immigrant sample (e.g., Unlu Ince, Cuijpers, van’t Hof, Wouter, Christen-
sen, & Riper,
2013
), the current research attempted to include various ethnic and religious groups
representing the Turkish diaspora (i.e., Kurdish, Turkish Cypriot, Alevi and Sunni Muslims) from
different generations (first, second and third) in two host countries in Europe. In the existing
INTERNATIONAL J OURNAL OF CULTURE AND MENTA L HEALTH
183
literature, the main limitations for the generalizability of previous qualitative studies of culturally-
specific factors leading to higher attempted suicide rates among Turkish migrants are their exclusive
focus on one Turkish subpopulation (Alevi [e.g., Cetin,
2015]) and the lack of information about the
Turkish subpopulations participating in the study (Razum, Zeeb, Akgun, & Yilmaz,
1998; van Bergen
et al.,
2012). The reason for running the current study in two countries was to see whether differences
in historical and ideological contexts preceding migration to these countries and/or host country fac-
tors had an influence on Turkish people’s understanding of suicide and help-seeking for suicide.
Methods
Design
This qualitative study was conducted in the Netherlands and in the UK. It concerned in-depth one-to-
one interviews with key informants and laypersons, and focus-group interviews with laypersons. Key
informants were professionals who were well known to the community through their profession or net-
works. Lay persons were young adults from the community aged 18 and over, who had knowledge of
suicide events in Turkish communities (through word of mouth or through the media), who were either
born in Turkey or who had at least one parent and/or grandparent born in Turkey and sufficient com-
mand of the English, Turkish or Dutch language. Not agreeing with the ground rules of the focus-group
meetings (not disclosing personal information, not using group meetings as a therapy session) was an
exclusion criteria. Laypersons’ agreement with the ground rules was checked during the informed con-
sent process prior to the focus-group meetings. Focus groups were chosen as a method to interview
laypersons as this method would be more likely to permit access to a broad range of perspectives ident-
ified within Turkish culture in comparison to individual interviews. Individual interviews with key
informants were chosen as a method in order to have more in-depth information on suicide events
that key informants come across in their network of community members. Ethical approval for this
study was granted by the Medical Ethical Committee of the VU Amsterdam University in the Nether-
lands and by the Queen Marry University of London Research Ethics Committee in the UK.
Recruitment and sampling
Participants were recruited through social media and through liaison with key people and ethnocul-
tural community groups. A search for relevant non-governmental organizations and community
groups on Facebook resulted in 30 relevant pages and 36 groups. A standard text was shared as a
post in all these pages and groups. This text was shared in LinkedIn, Twitter and through the What-
sApp application of the iphone. Additionally, the first author (O.E.) approached potential partici-
pants from their networks through face-to-face contact and through email, based on their
knowledge of potential key informants, participants or community groups .
Group and individual interview procedures
At the beginning of each group interview, participants were asked the open-ended question: We are
here today to talk about your opinions and knowledge on suicide in the Turkish-speaking commu-
nity. Let’s start with what the concept ‘suicide’ brings to your mind and what people try to commit
suicide in your opinion and why?
A topic guide was then used to guide the conversation towards the main areas of interest: defi-
nitions and views of suicide, knowledge and perceptions of risk factors, normat ive evaluation of
the behaviour, coping behaviour, help-seeking behaviour and barriers. This guide was established
on the basis of relevant literature and discussions with clinicians working with Turkish populations
in each country (the Netherlands and the UK). Participants (key informants and lay persons) were
asked to relate their understanding of the Turkish culture to suicide and related help-seeking.
184
O. EYLEM ET AL.