Middlesex University Research Repository An open access repository of Middlesex University research http://eprints.mdx.ac.uk Zorba, Akile Berfu (2019) Attitudes towards mental illness in Turkish and Greek speaking Cypriot communities living in Cyprus. PhD thesis, Middlesex University. [Thesis] Final accepted version (with author’s formatting) This version is available at: https://eprints.mdx.ac.uk/27964/ Copyright: Middlesex University Research Repository makes the University’s research available electronically. Copyright and moral rights to this work are retained by the author and/or other copyright owners unless otherwise stated. The work is supplied on the understanding that any use for commercial gain is strictly forbidden. A copy may be downloaded for personal, non-commercial, research or study without prior permission and without charge. 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See also repository copyright: re-use policy: http://eprints.mdx.ac.uk/policies.html#copy Attitudes towards Mental Illness in Turkish and Greek Speaking Cypriot Communities Living in Cyprus Akile Berfu Zorba M00445155 A thesis submitted to Middlesex University in partial fulfilment of the requirements for the degree of Doctor of Philosophy. School of Health and Education August 2019 I Abstract The aim of this thesis was to assess and explore attitudes of the Turkish (TC) and Greek (GC) speaking Cypriot communities towards mental illness. The attitudinal similarities and differences of the two communities were also investigated along with the factors that contribute to these. Despite the negative consequences of stigma noted in previous literature, this is the first collective study to be carried out with these communities. A mixed method sequential explanatory design was used. A total 519 participants was recruited from the two communities via convenience sampling. Twenty-one of these participants were then interviewed using a one-to one, semi-structured interview technique during the qualitative phase of the thesis. Interviews were analyzed using the Interpretative Phenomenological Approach. Findings showed a significant relationship between familiarity factor, culture factor and attitudes. Differences between TC and GC participants in terms of these factors were also found. TCs reported significantly less favorable attitudes towards mental illness compared to GCs. They were also found to be more collective in their culture, and reported significantly less one-to-one contact with mental illness compared to GCs. Four dimensions of stigma were also extracted using a Principal Component Analysis on the AQ-27 scale; Threat, Hospitalisation, Pity and Perceived-Control. Results of the three-step hierarchal model, which was created in line with previous research, showed culture and familiarity as the strong explanatory factors of these four dimensions. While collectivism was found to be a positive predictor of these dimensions individualism and familiarity factors were found to be the negative predictors of them. From the II demographic factors investigated ‘Sex; and ‘Age’ were also found to be significantly predicting the ‘Threat’ and Hospitalisation’ dimensions of stigma respectively. While being a woman positively predicted the Threat dimension, being older positively predicted Hospitalisation dimension of stigma. Knowledge factor was, however, not found to be one of the explanatory factors of the stigma dimensions in this research. Illuminated in the themes; 1) Community Tightness, 2) Current Cultural Values, 3) Culture and Mental Illness Stigma, 4) Structural Factors and Mental Illness Stigma, 5) Strategies to Tackle Mental Illness Stigma, the IPA analysis of the interview data revealed that the communities’ cultural orientations were related to their perceptions, understanding and explanations of mental illness. In line with the quantitative study’s findings participants also revealed that the structural factors; familiarity with mental illness, policy and regulations around these issues were effective in their understanding of and perceptions about mental illness consequently attitudes towards those with mental health problems. The results of the qualitative and quantitative studies are further discussed throughout the thesis and a number of important recommendations are given in a hope to diminish stigma of mental illness in TC and GC communities. III Acknowledgements I am indebted to my principal supervisor Prof. Irena Papadopoulos and my co- supervisor Assoc. Prof. Nicholas LeBoutillier for their continuous, patience, motivation, immense knowledge and constructive feedback. Their guidance helped me in all the time of research and writing of this thesis. To the participants who opened their homes and hearts to me, thank you for your generosity of time and help. I would also like to thank all of my friends (particularly to Gibran) who supported me in writing, and incented me to strive towards my goal. Similar, profound gratitude goes to Maria, who has been a truly dedicated friend. After all it is not easy to find a friend who would translate all the tools you use in your Ph.D! Finally, a very special “Thank you!” goes to my family, my father Mehmet, mother Nalan and sister Razge and husband Hakan. Words cannot express how grateful I am for all of the sacrifices that you have made on my behalf. Your support for me was what sustained me thus far. You all have been a constant source of strength and inspiration for me. You gave me the most needed kick on my backside whenever I needed one that ultimately made it possible for me to see this project through to the end. This thesis is dedicated to the people of Cyprus who manage to remain united despite all the challenges that are faced in our divided island. IV Contents Abstract I Acknowledgements III List of tables X List of figures XII Chapter 1: Introduction 1.1 Introduction 1 1.2 Definitions of Mental Illness and Mental Health 1 1.3 Facts about Mental Health 2 1.4 Components of Stigma 9 1.4.1 Ignorance 9 1.4.2 Prejudice 10 1.4.3 Discrimination 12 1.5 Critical Evaluation of the Stigma Theories 14 1.6 Factors behind Stigma of Mental Illness 18 1.7 Self-Stigma 19 1.8 Consequences of Public Stigma on Individuals with Mental Illness 20 1.9 Various Approaches to Fight Mental Illness Stigma 22 1.10 The study’s context: Mental Illness Stigma in 2 Major Communities of Cyprus 23 1.11 Conclusion 24 V Chapter 2: Literature Review 2.1 Introduction 26 2.2 Cultural Studies on Attitudes towards Mental Illness 26 2.3 Explanation of the Individualism and Collectivism Dimensions in Detail 28 2.3.2 Horizontal-Vertical Dimensions of Individualism & Collectivism 29 2.4 Perceptions and Explanations of Mental Illness 31 2.4.1 Religious and Spiritual Beliefs 33 2.4.2 The Notion of Save Face and Social Prestige 35 2.4.3 Deviant Behaviour and the Threat Perception 37 2.4.4 Perceived Cause of the Illness 38 2.5 Mental Health Literacy and Mental Health Related Stigma 40 2.6 Familiarity and Mental Health Related Stigma 46 2.8 Conclusion 54 Chapter 3: Historical Account of Cyprus 3.1 Introduction 56 3.2 Brief History of the Island 58 3.3 Trauma and Its impact on attitudes towards mental illness 62 3.4 Increased Identification of Northern and Southern Cypriots with Turkey and Greece respectively 67 3.5 Recent Developments that took place in either side of the island 72 3.6 Reflexive Account-1 77 3.7 Conclusion 78 VI Chapter 4: Methodology 4.1 Introduction 81 4.2 Defining “Paradigm” 83 4.3 Positivist and Interpretivist Paradigms Explained in Detail 84 4.4 Justification for using a Mixed-Methods Approach 85 4.5 Emergence of Mixed Methods Research as a New Era and Pragmatism Explained 87 4.6 Advantages and Disadvantages of Mixed Methods Research 89 4.7 Steps in Conducting a Mixed Methods Research 91 4.8 Pragmatism Paradigm Explained in Detail 93 4.8.1 Suitability of the Pragmatism Paradigm to this Project 95 4.8.2 Ontological Issues/Considerations in Research 96 4.8.3 Epistemological Issues/Considerations in Research 98 4.8.4 The Theoretical Perspective of the Researcher 101 4.9 Methodological Assumptions 102 4.10 Ethical Considerations 104 4.10.1 Respect for the Autonomy, Privacy and Dignity of Individuals and Communities 105 4.10.2 Scientific Enquiry and Social Responsibility 106 4.10.3 Maximising Benefit and Minimising Harm 107 4.11 Evaluation of the Mixed Methods Research and Techniques to be used 109 4.12 Theoretical Perspectives of IPA- Phenomenology, Interpretation VII and Idiography 113 4.13 4.13Possible Challenges of Interpretatıve Phenomenological Analysis 119 4.14 Reflexive Account-II 121