Religion, Culture and Meaning-Making Coping: A Study Among Cancer Patients in Turkey

Prior to each interview, the participants read and signed an informed consent form explaining the study purpose and ensuring confidentiality. Face-to-face interviews in Turkish were conducted at the hospital or the clinic, by the same interviewer; they lasted from 40 to 60 min, and a semi-structured questionnaire was used. The interviews were conducted from April 2015 through July 2015; the transcriptions were completed by the end of November 2015. The interviews were transcribed verbatim by the same interviewers to avoid divergence in the interpretations. Once all the interviews had been completed, the same person translated them to English.

The group of participants included both men and women, between 20 and 71 years of age. Among the 25 participating patients, the number of women far exceeded the number of men (18 and 7, respectively). They identified themselves as non-religious, spiritual, or religious. Two people reported not having a religion, though this does not mean they deprecated spiritual or existential coping. The participants had various types of cancer. Their stage of cancer varied from earliest to severe; their social status also varied, including housewives, retirees, and the currently employed. Most participants were living with their spouse and had children; 5 were 20–39 years of age, 14 were 40–59 years, and 6 were 60 + . Ten participants were high school graduates or less, and 15 college graduates or higher. Concerning employment status, 1 participant was a housewife, 11 were not working (because of the diagnosis and the treatment schedule, patients stopped working for undetermined period), 10 worked, and 3 were retired or on leave. With regard to their religious affiliation, 21 were Muslims, 2 believed in God but did not have any religious affiliation, and 2 were atheists.

Following transcription, the interview data were coded based on the themes found in the study using a template analysis style, a theory-driven analysis (Malterud 2014). Categorization of the themes was based on a modified version of Pargament’s RCOPE used by Ahmadi in the qualitative Swedish study (Ahmadi 2006: 45–47) as well as the results of both the qualitative and quantitative Swedish studies (Ahmadi 2006, 2015). The three themes—religious, spiritual, and existential coping—were each divided into categories, such as finding meaning, gaining control, gaining comfort, among others (see “Appendix 1”). These categories, in turn, were specified by sub-categories, such as benevolent religious reappraisal, spiritual prayer, and search for meaning. The categories or sub-categories were then linked to relevant codes in the material, such as the code “Wondered whether God had abandoned me” for the category “Punishing God reappraisal,” or the code “Illness caused me to appreciate life” for the category “Benevolent religious reappraisal.” The coding continued until the inter-rater agreement reached a high level. After the coding process, we established the essential characteristics of the different methods the informants used to cope with cancer. Here we proceeded from the project aim, using the results of previous studies in the project (Ahmadi 2006, 2015). Regarding religious coping, we proceeded from the Five Key Religious Functions that constitute the basis of RCOPE (Pargament et al. 2000: 521).

Within the framework of the present study, we gathered data on the meaning-making coping strategies used by people who are very vulnerable given that they are facing life-threatening disease. It is clear that bringing these issues to the fore, which is related to very fundamental layers of an individual’s ego, is of ethical relevance.

This being the case, it is essential to establish a cooperative relationship with potential respondents—one that is based on trust. Here, we made it clear to potential respondents that: participation was voluntary; data would be treated with confidentiality and not made available to anyone outside the research team; agreement to participate could be canceled at any time without any consequences for the respondent; and the results obtained from the study would be published such that identification of individual respondents would be impossible.

This study was approved by the Regional Ethics Board in Uppsala (Reg. no. 2015-126).

Below, we provide a concise list and brief discussion of the meaning-making coping methods the Turkish participants reported using during their illness.

The present results show that the RCOPE methods seem to be highly relevant for the Turkish interviewees. This can be explained by the fact that, for these interviewees, religion is a “larger part of [their] orientation system” (Ahmadi 2006: 28). In another paper on the same study (Ahmadi et al. 2016a), we discuss the use of these methods in detail. In the present article, we provide a brief summary of some of the most important religious coping (RCOPE) methods used by interviewees in the Turkish study.

Some interviewees have used existential meaning-making coping, finding power inside oneself, as a way to deal with the stressors brought about by cancer. As the same study conducted in Sweden (Ahmadi 2006) also confirmed, finding oneself and searching for inner possibilities as well as actualizing one’s inner force may be a spiritual outcome. As Ahmadi (2006: 112) explains, a spiritually oriented person who faces difficult events may search for the “sacred” in herself/himself and find a force greater than the self—a source of strength. Ahmadi emphasizes that “Here, we are neither witnessing ‘the incorporation of the sacred into the self’” (Pargament 1997: 253), as is the case in religious conversion, nor ‘dying unto oneself’ or ‘loss of self’ through unification with a greater existence, as in the case of self-inhibition” (Ahmadi & Ahmadi 1998). What we are perhaps witnessing is what Fromm (1950) calls self-realization when he discusses “humanistic religion.” Through realization of the self when facing a stressful situation caused by illness, some of our informants found a way to give meaning to their life and, thereby, cope with their illness.

Altruism, expressed by informants as “being a good person,” was found to be one of the existential meaning-making coping methods used by some informants.

Ahmadi (2006: 139) explains:

“Human altruism is not only an act, but is interwoven with an emotion: empathy. Altruism is then as a prosocial behaviour a voluntary intention/act to help others at some cost to oneself (time, effort or money)” (ibid.).

A similar coping method was found in the study among Swedes (Ahmadi 2006: 139–141).

Although Swedish and Turkish ideas about what constitutes prosocial behavior seem to be similar, there are disparities between individualistic versus collectivistic ways of thinking. If among Swedes altruism takes the form of improvement of la Condition Humaine (Ahmadi 2006: 140), in the Turkish case, it concerns helping people in need in one’s vicinity and is primarily construed as a religious duty.

Below, Hinde and Groebel (1991: 90) explain the reason for differences in prosocial behavior connected to individualistic and collectivistic ways of thinking. It should be mentioned, however, that they are referring mainly to China and Japan and that most countries in Asia are not individualistic but collectivistic.

“Asian considerations of what constitutes prosocial behavior are very similar to those of the west: altruism, kindness, considerateness, sympathy, aiding…

However, Asian considerations differs from those in the west because of their conception of the role of the individual in relation to family and society. We in the west place great emphasis on the importance of the individual and on the development of an independent, self-directed child.”

In Eastern societies, however, the emphasis is on the interrelation between the child and members of the family and society (ibid.).

Another factor that should be taken into consideration here is religion. In societies where religion plays a significant role in the interrelation between people, any sense of altruism may be related to religious belief and duties. In Islam, altruism takes the form of hospitality and generosity, which are foundational virtues. There are several duties like fasting,¹zakat,² and sadageh,³ which are intended to help develop a sense of empathy and altruism among Muslims (Homerin 2005). In Turkey, this factor, i.e., the role of religion, was quite noticeable in our interviews concerning this coping method.

In a collectivistic society like Turkey, the importance of family gives rise to another coping method: “Family love.”

As Mahoney et al. (2003: 222) maintain:

“For many people, family relationships involve more than biological, psychological, and social processes; people often believe these bonds tap directly into the spiritual realm…in short, people often view family relationships as sacred.”

According to these authors, people can sanctify the entire family system (ibid.).

As our study among cancer patients in Turkey shows, sanctification of the family may serve as a coping method. Actively trying to get better and not allowing the problems of illness to disturb family relations or make family members unhappy can be a potent method of dealing with the psychological problems brought about by cancer. In this connection, religion may play an important role. According to Zimmerman (1974: 6), “the most sacred or divine aspect of society is considered to be family system and being religious is tantamount to being a good husband, a good wife, or a good parent, child or kinsman.”

Given that our interviewees, cancer patients in Turkey, were socialized in a group-oriented society, where religion is an important component of the dominant culture, it is understandable that “love of family” seems to have played a role in their existential meaning-making coping.

We found that, for some of our interviewees, the search for existential meaning, i.e., thinking about the meaning of life and death, has functioned as an existential meaning-making method of coping with their illness.

In the Turkish case, the interviewees were believers who were contemplating existential issues in the context of religiosity.

We found that going through the painful journey of having cancer caused some interviewees to appreciate their present life and the moments they experienced in everyday life. This brought about “a turning point” that caused them to change their proprieties in life. This new attitude has helped them cope with their illness, called “positive life perspective coping method” (Ahmadi et al. 2016b).