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Addressing Pastoral

Knowledge and Attitudes


about Clergy/Mental Health
Practitioner Collaboration
T. Scott Bledsoe, Kimberly Setterlund, Christopher J. Adams,
Alice Fok-Trela, & Melissa Connolly

Developing partnerships between clergy members and mental health practi-


tioners can be an effective way to promote the well-being of parishioners. This
study explored (a) the demands on clergy in Southern California to provide
mental health services to their parishioners, (b) the level of stress created by
specific needs, (c) congregational resources available to meet these needs, and
(d) referral preferences in clergy collaboration with mental health professionals.
A survey was distributed to a sample of clergy members in which participants
were asked to rate the level of sufficiency of services provided; their current
referral practices; and general attitudes toward collaborating with outside
mental health practitioners. Findings suggest that clergy often provide services
in difficult situations, e.g., crisis intervention and abuse, which can lead to high
levels of clergy stress; and size of church and level of education may be factors
that contribute to such stress. Furthermore, pastors hold positive attitudes
about referring to mental health professionals, and largely endorse referring
to counseling centers over other community resources. Clinical implications
include the need for increased clergy education and training on pastoral care,
counseling, and mental health. Opportunities to implement clergy care inter-
ventions are also noted.

C
lergy are often called on to assist parishioners who may be
experiencing emotional or relational distress. Though many faith
leaders are not properly trained to treat these issues, parishioners
are more likely to seek help from their pastors than consult mental health
professionals (Weaver, 1995; Clemens, Corradi, & Wasman, 1978; Chalf-
ant, Heller, Roberts, Briones, Aguirre-Hochbaum & Farr, 1990; Polson &
Rogers, 2007). Because congregants look for emotional healing within the

Social Work & Christianity, Vol. 40, No. 1 (2013), 2345


Journal of the North American Association of Christians in Social Work
24 Social Work & Christianity

church, it is important that clergy become educated about mental health


problems and also become competent facilitators at connecting parishioners
to the professionals who can best meet their needs. The study explored
(a) the demands on clergy in Southern California to provide mental health
services to their parishioners, (b) the level of stress created by specific
needs, (c) congregational resources available to meet these needs, and (d)
referral preferences in clergy collaboration with mental health and social
work professionals.

Literature Review: Mental Health, Clergy Resources, and


Collaboration with Professional Resources

Parishioners and Mental Health

Studies have shown positive correlations between church attendance


and improved mental and physical health (Larson & Larson, 2003) and
reduced risk for substance abuse and suicide (Koenig & Larson, 2001). Yet
congregants who articulate emotional distress may pose a dilemma for many
faith communities. White, Jackson, and Martin (2003), propose that open
discussion about some disorders within churches may be covered up due
to the fear that it implies spiritual failure (p. 49), and individuals who are
diagnosed with depression and other disorders may be told things like pray
harder when the subject of mental illness is brought up. Nevertheless, it
is estimated that 20 percent of adults fall victim to depression at some time
in their lives (Pettit, Voelz, & Joiner, 2001), which means many church
members also are prone to this mental health condition (Payne, 2009).
Additional prevalence rates of disorders in the general population, such
as anxiety (16.6 percent), substance abuse (8 percent), schizophrenia and
psychosis (1 percent), and suicide, considered the third leading cause of
deaths for individuals between the ages of 10 and 24 (American Psychiatric
Association, 2000), indicate the extent of emotional disturbances from
which church members may suffer. With such a wide range of disorders
and clinical situations, Holinger (1980) notes the importance of proper
assessment in order for individuals to receive the care they need. One step
in achieving this goal may be for pastoral staff and other churchgoers to
develop a sufficient understanding of mental distress to make appropriate
referrals for professional help and provide a supportive community.

Clergy as Mental Health Resources

Clergy often play a crucial role in supporting the emotional well-being


of congregants, and studies have shown that over 40 percent of Americans
seek help from clergy when suffering emotional distress (Weaver, 1995;
Clemens, Corradi, & Wasman, 1978; Chalfant et al., 1990; Polson & Rog-
CLERGY/MENTAL HEALTH PRACTITIONER COLLABORATION 25

ers, 2007). The U.S. Surgeon General (as cited in Satcher, 2000) found that
annually one in six adults obtains mental health services from a health care
worker, social service agency, school, or clergy. Consequently, pastors are a
primary mental health resource for tens of millions of Americans (Weaver,
Koenig, & Larson, 1997). The National Institute of Mental Health (as
cited in Hohmann & Larson, 1993), found that clergy are just as likely
as mental health specialists to interact with individuals seeking help for a
Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis,
including individuals with severe mental illnesses such as bipolar disorder
or schizophrenia. Other studies have indicated that millions of Americans
with mental health concerns seek the help of clergy first before any other
helping professional (Abramczyk, 1981; Benner, 1998; Chalfant et al.,
1990; Lowe, 1986; Weaver, 1995). In one study, young adults ranked clergy
higher in interpersonal skills (warmth, caring, stability, and professionalism)
than psychologists (Schindler, Berren, Hannah, Biegel, & Santiago, 1987).
Though congregants look to pastors for emotional support and comfort,
most clergy are not adequately trained to meet the mental health demands
of their congregations (Weaver, 1995).
In their positions as church leaders, pastors are held in high esteem by
parishioners who look to them for solace when suffering emotional distress
or more serious mental health concerns. In their study, Weaver, Koenig,
and Ochberg (1996) noted the impact of a tornado that caused significant
damage to the town of Greenville, South Carolina. Although 69 of the
116 respondents qualified for a diagnosis of acute post-traumatic stress
disorder, not one person visited the area mental health center for help, all
choosing instead to seek counseling from their clergy. But clergy do not
always feel competent to treat parishioners who suffer from depression
and other mental health disorders (Moran, et al., 2005; Weaver, 1995),
and without proper training in treatment for mental health services with
necessary safeguards such as medical backup, provisions for confidentiality,
and supervision, those who are in a position to administer mental health
interventions may not be able to adequately help those in need.
Furthermore, cultural beliefs can affect the way that pastors perceive
mental health treatment and the etiology of certain mental health condi-
tions such as depression, which may be a factor in congregants receiving
proper treatment. Payne (2009) states that while Caucasian American
church leaders tend to believe that depression is based on biological and
genetic factors, African American pastors are more likely to agree that it
stems from a moment of weakness when dealing with trials and tribula-
tions (p. 356). In other cultures, depression may be associated with loss
of face, for example, in a study of Filipino Americans (Abe-Kim, Gong, &
Takeuchi, 2004, p. 685), or, in a Singaporean study, an organically based
problem (Matthews, 2011, p. 50). From a qualitative survey of clergy from
Northern Ireland, some pastors described their own bouts with depression,
26 Social Work & Christianity

with one referring to it as a kind of blackness [that] descended over you


and if I hadnt . . . lifted the phone to speak to someone I mightnt be here
today (Leavey, Rondon, & McBride, 2011, p. 68).
In a study involving 293 self-identified Christians suffering from vari-
ous mental disorders who sought counsel from church leaders (Stanford,
2007), approximately 30 percent of those who completed an anonymous
survey had interactions that appeared to be counterproductive to success-
ful treatment (p. 448). Negative interactions were broken down into three
subtypes: feelings of abandonment by the church, mental disorder char-
acterized as a result of demonic activity, and mental disorders considered
the result of a lack of faith or of personal sin. One survey participant who
described bouts with depression and paranoia reported feeling ostracized
from clergy and congregants when trying to reach out for help and expressed
strong reservations about attending church in the future. Considering the
unique relationship between pastors and parishioners, along with cultural
beliefs and levels of expertise in administering emotional care, avenues are
needed in which potential recipients of mental health services can receive
the treatment they need.
Other literature has explored differences among religious denomina-
tions regarding beliefs about the origins of mental illnesses. A study by
Wesselmann & Graziano (2010) suggested that Roman Catholics are less
likely to believe that mental illnesses had a spiritual cause when compared
to responses from Protestant and Non-Denominational Christians. In a
qualitative study, Payne (2008) found that African American Pentecostal
pastors preached that long term depression is a sign of weakness. These
pastors also transmitted negative views to congregants on seeking help from
a psychiatrist or using psychotropic medications (Payne, 2008). Stanford
and Philpott (2011) found that senior pastors within the Baptist General
Convention of Texas (BGCT) perceived that biological causes were more
significant than psychosocial or spiritual causes of mental disorders, in-
cluding major depressive disorder, anxiety disorders, schizophrenia, and
bipolar disorder. Lafuze, Perkins, and Avirappattu (2002) surveyed clergy
members from three offices of the United Methodist Church in Indiana and
Virginia, and found that most of the respondents (N=1,031), generally had
an informed, scientifically based understanding of the causes of mental
disorders and of the importance of medications in effective treatment.
(p. 900). Indeed, pastors from different religious denominations appear to
have differing beliefs about the underlying causes of mental illness, which
may significantly affect attitudes, referral practices and coordination with
mental health professionals.
CLERGY/MENTAL HEALTH PRACTITIONER COLLABORATION 27

Clergy Stressors

Clergy often report that they have a deep sense of fulfillment in their
work. Rowatt (2001) found that satisfaction with ministry included counsel-
ing and crisis intervention, although these are only two of the many duties
clergy are required to perform in a multifaceted role. However, while pastors
report inherent satisfaction in the ministry, Lewis and associates describe
a sense of urgency attached to the churchs mission that often causes
clergy to become the victim(s) of their own humanity and frailty(Lewis,
Turton, & Francis, 2007, p. 2). Conflicting demands (real or perceived)
from congregation and family often create stress for ministers and spouses,
(Darling, Hill, & McWey, 2004). Interpersonal stressors, including unre-
alistic, ambiguous demands and boundary intrusion from congregants,
appear to be a major source of relational stress for clergy (Hall, 1997; Lee
& Iverson-Gilbert, 2003; Morris & Blanton, 1994; Rowatt, 2001; Weaver,
Flannelly, Larson, Stapleton, & Koenig, 2002). Additional stressors include
emotional exhaustion, burnout, low personal satisfaction, and even a sense
of personal failure as clergy attempt to navigate the overwhelming inter-
personal demands of their unique role (Chandler, 2009; Hall, 1997; Miner,
2007; Rowatt, 2001; Weaver et al., 2002). When caring for congregants
suffering from trauma, clergy and healthcare workers often experience
compassion fatigue and vicarious trauma or secondary traumatic stress
(Stamm, 2002; Cerney, 1995). As such, meeting the mental health needs
of parishioners may be a major source of stress for clergy. It would seem
plausible that the cumulative stress of meeting the mental health needs of
parishioners can result in emotional problems in clergy themselves, thus
reducing their capacity to effectively provide care for parishioners. Col-
laboration between clergy and mental health practitioners may both directly
and indirectly enhance the care of parishioners with mental health needs.

Collaboration among Clergy and Mental Health Practitioners

Historically, the relationship between traditional religious leaders


and mental health practitioners has included elements of mistrust (Bland,
2005). In a study conducted by Polson and Rogers (2007) that involved
213 churches of five denominations, it was found that clergy rarely made
referrals to mental health professionals and preferred to provide their own
counseling to congregants with emotional problems. This sense of skepti-
cism may also affect laypersons views of therapy.
Many church leaders may view counselors foci on scientific research
and secular psychotherapeutic approaches as contrary to Christian values.
As a result, when clergy refer parishioners with emotional problems to men-
tal health professionals, they tend to recommend those with shared religious
belief systems. Openshaw and Harr (2009) interviewed 24 pastors from
28 Social Work & Christianity

both rural and suburban areas of the Dallas/Fort Worth metroplex about
their attitudes toward referring congregants to counselors for professional
help. Although the overriding opinion was that mental health conditions
should be addressed through intervention and support, the majority voiced
a preference for counselors with excellent skills and spiritual sensitivity
(p.12). Additionally, in a survey conducted by VanderWaal, Hernandez, and
Sandman (2012) involving 179 Christian clergy members in Kent County,
Michigan, respondents indicated that they would likely refer their congre-
gants to a professional counselor, preferably Christian, if the individuals
had a mental health or substance abuse disorder.
Yet Weaver (1995) argues that the two fields of ministry and mental
health share many common values. Emphasizing the need for collaboration,
he states that pastors and counselors should work together more effectively
for the best interest of those they are called to serve (p. 129). Weaver et
al. (1996) note the importance of partnerships between parishioners and
mental health experts when addressing serious mental health issues such
as traumatic stress.
What kinds of relationships between mental health professionals and
clergy could most benefit parishioners suffering from emotional problems?
Lish, McMinn, Fitzsimmons, and Root (2005) proposed six innovative
working relationships involving clergy and Christian psychologists. One
relationship involved the psychologist facilitating small group meetings to
achieve conflict resolution when a division among congregation members
occurred. Another involved using the therapist to establish a program of
caregiving to enhance the congregational ministry. When 200 randomly
identified clergy were surveyed, however, the opinions of these innova-
tions were less than enthusiastic, with clergy only responding favorably
to consulting with Christian psychologists about counseling strategies as
needed (76 percent interested). Beyond noting a shared Christian com-
mitment, an additional study suggests that idiographic relational factors
between specific clergy and psychologists determine the effectiveness of
collaboration, rather than categorical characteristics of clergy or psycholo-
gists (McMinn, Ammons, McLaughlin, Williamson, Griffin, Fitzsimmons,
& Spires, 2005). In other words, there are no clear factors that appear to
determine effective collaboration other than clergy and Christian mental
health professionals building a relationship of mutual trust and referral.

Organizations That Promote Collaboration

Programs such as Clergy Outreach and Professional Engagement


(C.O.P.E.) advocate cooperation among clergy and mental health profes-
sionals for the purpose of pooling valuable expert knowledge and reducing
the caregiving burdens of clergy and clinicians through consultation and
collaboration (Milstein, Manierre, Susman, & Bruce, 2008, p. 220). Bland
CLERGY/MENTAL HEALTH PRACTITIONER COLLABORATION 29

(2005) states that in order for psychologists and clergy to work together,
there must be an intentional goal to do so built on mutual participation. His
model proposes that psychologists teach and train pastoral staff and lead
classes about recognizing mental health problems to develop a dynamic
healing community that includes empowering congregation members
with lay-caring skills (p. 36).
Since 2004, California has witnessed a transformation of the public
mental health system, beginning with the implementation of the Mental
Health Service Act (MHSA). The vision of MHSA, to promote mental health
recovery and resiliency through consumer-driven services and community
collaboration, incorporates spirituality and faith, a historically neglected
area in an individuals recovery. According to Lukoff, Mahler, & Mancuso
(2009), the addition of spirituality provides a holistic approach to the treat-
ment of serious mental health problems. This reinforces the significance
of clergy members collaboration with counseling professionals as a vital
component of addressing parishioners diverse needs.
Several faith-based initiatives have been implemented to support
mental health recovery. On a federal level, the Substance Abuse and Mental
Health Service Administration (SAMHSA), an agency of the U.S. Depart-
ment of Health and Human Services (HHS), established the Faith-Based
and Community Initiative in 2000. It has served as a model of effective
partnerships between federal programs and faith-based and community
organizations in addressing the needs of those at risk for mental health
and substance abuse problems (HHS, SAMHSA, 2009).
In 2008, the Center for Multicultural Development at the California
Institute for Mental Health (CIMH) established the Mental Health and
Spirituality Initiative. The goal of the initiative includes collaboration with
faith-based organizations, mental health services providers, consumers,
family members, and communities to reduce the stigma of mental illness
and increase access to services by underserved individuals. In the Southern
California area, the Los Angeles County Department of Mental Health has
established a clergy advisory committee as part of efforts to advocate for
the rights of consumers, fight stigma, and increase much needed services
(Los Angeles County Department of Mental Health website, n.d.).Such
efforts offer faith leaders opportunities to collaborate with mental health
professionals when addressing the diverse emotional needs of parishioners.

Building Stronger Clergy/Counselor Relationships for the Future

Despite the proposed need for collaboration among clergy and men-
tal health practitioners, it may be unreasonable to assume that new and
dynamic relationships between the two would emerge spontaneously. As
stated, a mutual mistrust often has affected these relationships (Bland,
2005) and genuine progress would likely take time. Weaver (1995) sug-
30 Social Work & Christianity

gests a practical approach to integrating the spiritual and mental health


domains within the church, which would involve incorporating a brief
model of parish-based pastoral counseling, training in faith expression and
counseling integration, and teaching self-care coping skills. This would aid
clergy in becoming skilled facilitators in the mental health network, not
treating psychotherapists (Weaver, 1995, p. 147). Additionally, continuing
education would be needed for clergy to remain abreast of new trends in
mental health care (Polson & Rogers, 2007). With a dynamic referral pro-
cess to supplement practical mental health components within the church,
the emotional needs of parishioners could be more adequately addressed.
In summary, research indicates that many congregations include a
significant number of parishioners who are suffering from mental health
difficulties. Parishioners are likely to first seek help from clergy, who may
or may not have the education, training, and/or experience to meet these
needs, and may experience these demands as stressful. Clergy appear to
vary in their level of competency to address these needs, as well as prefer-
ences of collaborating with and referring to other helping professionals.
Facilitating collaboration could result in better parishioner mental health,
as well as improved mental health of clergy themselves.
This study sought to explore these issues among clergy in Southern
California by asking the following:
What mental health needs do clergy perceive in their congregations?
What mental health needs do clergy currently meet?
What mental health needs are met by congregational resources
other than clergy?
What mental health needs are currently unmet?
What demands for mental health assistance are the most stress-
ful for clergy?
How prepared are clergy to meet these needs? Where did they
receive their preparation?
What are the referral and collaboration patterns and preferences
of clergy?

Method

Instrumentation

The researchers used a modified version of an established survey in-


strument with permission from the authors Openshaw & Harr (2009). The
original instrument was created to collect answers to open-ended questions
through an interview format. Based on the survey instrument, the research-
ers constructed a questionnaire to collect written data through closed and
open-ended questions. A written survey instrument was selected because
of its ease of use for participants, and for the opportunity to collect a large
CLERGY/MENTAL HEALTH PRACTITIONER COLLABORATION 31

sample size for quantitative and qualitative data analysis. The researchers
obtained permission from their universitys Institutional Review Board to
survey participants. Each participant signed an informed consent form and
confidentiality statement before completing the survey.
The survey contained 14 major questions, with one question (#10)
subdivided into 17 parts. The initial six items gathered demographic
information through a multiple choice format. The remaining questions
assessed (a) participants previous attendance at workshops on mental
health (provided by the researchers), (b) their perceived knowledge about
mental health, (c) types of mental health and/or social service interven-
tions provided by a clergy member or other church member, (d) whether
services were perceived as needed if determined as unmet, and (e) levels
of perceived stress as a result of providing these services. Additionally,
participants were asked:
To rate the level of sufficiency of the services provided,
To indicate where they referred congregants for outside mental
health services,
To indicate with whom they wished to collaborate for outside
mental health services, and
To comment on their general attitude toward referring their
congregants to outside mental health professionals.
The survey was distributed on three separate occasions through a
convenience sampling method. In November 2010, the researchers at-
tended two area ministerial association meetings during which clergy were
invited to complete the survey. In total, 16 completed surveys were received.
In June 2011, to increase the sample size, the researchers expanded the
demographic participant area by sending survey packets to 260 clergy in
Southern California. These individuals were identified from a list provided
by the universitys theology department and campus pastors office. The
researchers selected individuals on the list who were active church leaders
serving in a pastoral role. The individuals surveyed by mail were offered a
$5 gift card as incentive for completing the survey.

Participants

Of the 276 surveys distributed, a total of 87 were completed and


returned (31% response rate). To focus the research, four surveys were
eliminated from the sample because the participants were not working in
the Southern California area; nine other surveys were eliminated because
the participants did not indicate that they were currently acting as members
of the clergy for their parish. This elimination process resulted in a final
sample size of 74 participants. The age of the participants ranged from 28
to 79 years with the average age being 53.6 years. The sample included
both male (70.3 percent) and female (29.7 percent) participants with 7
32 Social Work & Christianity

percent identifying as Asian, 1 percent as African American, 11 percent as


Latino, and 81 percent as Caucasian. Eighty-seven percent of the subjects
identified themselves as Protestants. In terms of denominational affiliation,
24 percent of respondents identified themselves as United Methodist, while
four percent identified as Baptist and Brethren in Christ, respectively. When
asked about their knowledge of mental health, 19 percent indicated that
they were very knowledgeable, 77 percent endorsed having some knowl-
edge, while the remaining 4 percent indicated that they were not at all
knowledgeable of mental health issues.

Data Analysis

Quantitative Methodology

All analyses were conducted with a commonly used statistics software


program (PASW Statistics 18.0). Response frequencies, means, and percent-
ages were calculated for descriptive statistics. Pearson bi-serial correlation
analyses were conducted to explore relationships between demographics
and Level of Stress variables. ANOVAs, t-tests, and Chi-square analyses
were conducted to explore demographic group differences in Services
Provided and Needed but Unmet variables. Finally, an overall level of
stress variable was created by averaging the individual levels of stress ex-
perienced by clergy in the provision of various services at the clergys place
of worship. This overall level of stress served as a dependent variable in a
linear regression. In addition, linear regression analyses were conducted
using each of the levels of stress associated with the provision of individual
services. Predictor variables included the clergys age, ethnicity (white or
non-white), gender, size of church, level of education, years of experience
in the job, and whether the clergy attended seminary.
Limitations. It should be noted that the sample size for this study was
relatively small. Furthermore, the sample consisted largely of older, male,
Caucasian, Protestant clergy, while populations less represented included
female, younger clergy, and Catholic priests.

Qualitative methodology

Grounded theory, a research measure for analyzing qualitative infor-


mation which is conditionally confirmed through collecting and making
sense of the data related to the issue at hand (Smith & Davis, 2010, p. 54),
was used to ascertain the themes and patterns present in the answers to the
open-response items of the questionnaire (e.g., How did you obtain your
knowledge of mental health?). This entailed the researchers collaboratively
consulting with one another and the processes of open and axial coding
were utilized to describe the data, determine the prominently common
CLERGY/MENTAL HEALTH PRACTITIONER COLLABORATION 33

themes, and categorize responses accordingly. Because participants provided


both singular and multiple responses, the process of axial coding was used
to form new relationships between themes. For example, a category for
coursework was created under which subheadings were grouped together
such as Undergraduate, General and Pastoral/MDiv/Seminary. Each
response was then coded, for a total of 159 responses.

Results

Quantitative Results

Descriptives

As part of the survey, participants were given a list of services and asked
to identify those that were provided by clergy and/or non-clergy at their place
of worship (See Table 1). Of the services listed, participants indicated that
those most often provided by clergy were premarital and marital counseling
(87%), grief and bereavement (55%), issues related to depression (53%), and
parenting issues (51%). Services mostly provided by non-clergy included
homeless assistance (19%), financial help (16%), assistance with substance
abuse (12%), and help with finding employment (12%).

Table 1: Services, Providers, and Level of Stress for Providers


Respondents (N=74)

Ser- Level of stress providing


Services and those who provide them vices these services
needed
(C) Clergy; (NC) Non-Clergy; (H) High; (M) Moderate
but
(C/NC) Both Clergy & Non- (L) Low; (NP) Not Provided
unmet
Clergy; (NP) Not Provided

(C) (NC) (C/ (NP)


% % NC) %
(H) (M) (L) (NP)
%
& % & %
1. Hospital/ 35.1 1.4 32.4 31.1 6.8 1.4 16.2 54.0 28.4
Nursing Home
2. Homeless 28.4 18.9 36.5 16.2 12.2 2.7 33.8 36.5 27.0
Assistance
3. Premarital/ 86.5 1.4 6.8 5.4 2.7 6.8 18.9 60.8 13.5
Marital Coun-
seling
4. Financial 33.8 16.2 25.7 24.3 16.2 4.1 20.3 45.9 29.7
34 Social Work & Christianity

5. Parenting 51.4 9.4 21.6 17.6 5.4 4.1 27.0 44.6 24.3
Issues
6. Grief/ Be- 55.4 4.1 35.1 5.4 5.4 5.4 25.7 55.4 13.5
reavement
7. Substance 25.7 12.1 41.9 20.3 18.9 10.8 16.2 23.0 50.0
Abuse/
Addictions
8. Employ- 14.9 12.1 20.3 52.7 24.3 8.1 14.9 18.9 58.1
ment/ Job
Search
9. Crisis Inter- 44.6 5.4 23.0 27.0 9.5 17.6 29.7 12.2 40.5
ventions
10. Gay/Les- 33.8 2.7 8.1 55.4 21.6 6.8 18.9 21.6 52.7
bian Issues
11. Stress/ 44.6 6.8 13.5 35.1 16.2 9.5 28.4 17.6 44.6
Anger Manage-
ment
12. Depression 52.7 5.4 13.5 28.4 13.5 5.4 23.0 32.4 39.2

13. Severe 2.7 5.4 68.9 17.6 9.5 12.2 12.2 66.2
Mental Illness 23.0
14. Suicide 41.9 2.7 9.5 45.9 10.8 25.7 13.5 14.9 45.9

15. Legal Is- 18.9 9.5 13.5 58.1 16.2 6.8 17.5 14.9 60.8
sues (e.g., jail,
undocumented
persons)
16. Abuse 41.9 5.4 17.6 35.1 13.5 18.9 21.6 16.3 43.2
(spousal, child,
elder)
17. Other 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
(specify:___)

Participants also were given a list of services and asked which were
needed but unmet (See Table 1). Of the services listed, the greatest needs
were employment (24%), gay and lesbian issues (22%), substance abuse
(19%), stress and anger management (16%) and legal issues (16%). From
the same list, participants were asked to rate each service in terms of the
level of stress it caused: high, moderate, and low. Those that most partici-
pants endorsed as highly stressful related to suicide (26%), abuse (spousal,
child or elder) (19%), and crisis intervention (18%). Services identified as
either highly or moderately stressful (combined percentages) were crisis
intervention (47%), homeless assistance (36%), suicide (39%), abuse
(spousal, child or elder) (41%), and stress and anger management (38%).
CLERGY/MENTAL HEALTH PRACTITIONER COLLABORATION 35

Given the choice of (a) counseling center, (b) physician, (c) hospital, or
(d) other, when asked to whom they would refer for outside mental health
services, most participants provided multiple responses and the majority
(84%) chose counseling centers. When given the same choices and asked
with whom they wished to collaborate, counseling centers also represented
the preferred choice over other options (84%).

Correlations

The only significant correlation among demographic variables was a


small, positive correlation between Participant Age and Experience in this
Job (r=0.31, p<.01), indicating that the older the clergy member, the more
years of on-the-job experience he or she endorsed. Small but significant
correlations between demographic variables and Level of Stress variables
were also found, such as Participant Age and Level of Stress: Employ-
ment/Job search (r=0.31, p<.01). A minor negative correlation occurred
between Highest Level of Education Completed and Level of Stress: Grief/
Bereavement (r= -0.34, p<.01), meaning that pastors with higher levels
of education generally experienced lower levels of stress when providing
services to congregants suffering from grief and bereavement. Other small
but significant correlations between demographic variables and Level of
Stress variables included Size of Church and Level of Stress: Suicide (r=
-0.33, p<.01); and How Knowledgeable Are You About Mental Health?
and Level of Stress: Suicide (r= -0.30, p<.01), indicating that pastors of
larger churches and those with some knowledge of mental health generally
experienced less stress.

Group Differences

Among demographic variables, a number of group differences oc-


curred. Participants under age 39 felt less stress than those over 60 (F=4.927,
p=0.10), males endorsed more stress related to homeless assistance than
females (t=2.609, df=7, p=.011), and non-white clergy endorsed more stress
related to homeless assistance than white clergy (t=-2.051, df=72, p=.044).
Clergy of the smallest (under 50) churches generally endorsed more stress
than clergy of the largest (500+) churches (SS=15.670, F=2.658, df=4,
p=.040) and significant differences were found in Level of Stress: Suicide
between the largest and smallest churches.

Predictive Models

According to the regression model (significant at F=2.152, df=7,


p=.050), those who did not attend seminary experienced a higher overall
level of stress compared to those who had attended seminary (t=2.762,
36 Social Work & Christianity

p=.007). Statistically significant results were also found for level of stress
related to providing stress and/or anger management services (F=2.739,
df=7, p=0.015). Clergy members who experienced a higher level of stress
providing help to parishioners in this area were likely to be more educated
(t=2.164, p=.034) and less likely to have attended seminary (t=3.735,
p=.000). Additionally, the regression model was statistically significant for
some participants who worked with parishioners endorsing suicidal ide-
ation (F=2.207, df=7, p=.045). Specifically, clergy who were part of smaller
churches experienced more stress with regard to the provision of care for
congregants who exhibited some level of suicidality (t =-2.356, p=.021).

Qualitative results

Participants provided qualitative feedback by answering two questions


pertaining to their views of mental health. For the first, they identified
ways in which they obtained their knowledge of the subject (See Table 2).
The most frequent responses were personal study/research, seminars/
training/workshops, and undergraduate coursework. Some noted that
they possessed expertise in the field (e.g., Licensed MFT and Certified
Pastoral Counselor, M.Ed in Professional counseling, and MA in the
field of counseling), while personal experiences played a key role in some
participants understanding of the field, as evidenced by responses such as
the following: My daughter has a bipolar condition, Mothers schizophre-
nia . . . and ...I was married to a psychiatric social worker for 40 years.
Several responses identified multiple experiences that contributed to the
subjects knowledge of mental health, such as the following participant
response: Seminary classes, ongoing reading, observation of people across
33 years of pastoring, and self-awareness.

Table 2: How Participants Obtained


Their Knowledge of Mental Health
Respondents (N=74)*

Resources Percent (%) Frequency


Coursework:
Undergraduate, General 13.2 21
Pastoral/MDiv/Seminary 9.4 15
Counseling Degree 5.0 8
Seminars, Training, Workshops 17.6 28
CLERGY/MENTAL HEALTH PRACTITIONER COLLABORATION 37

Experience:
Personal 11.3 18
Occupational 12.6 20
Not Specified 7.0 11
Personal Study, Research, Reading 18.2 29
Consultation with Mental Health 3.8 6
Other Responses 1.9 3
*159 total responses; most participants indicated that they obtained their knowledge of mental
health from multiple sources.

For the final qualitative response, participants were asked to discuss


their general attitudes about referring congregants to outside mental health
professionals (See Table 3). A majority of responses were favorable, and
almost 70 percent supported such referrals without reservation. Comments
included, Im completely comfortable referring my congregation to outside
services, I have experienced the benefits of counseling and support our
members to look for that kind of expert help, and I affirm this fully. A
number of responses indicated a favorable opinion of referring to spiritu-
ally-based professionals: I wish to collaborate with MH professionals so
that congregants receive the spiritual aid they need and Helpful! When
I know they are Christ-centered, I consider it a great partnership. A few
responses indicated reticence to refer outside the church, as in the following:
ConcernI need to know the professional well and trust her/his approach
and Each referral is a lesser or greater risk of trusting our congregants
emotional, relational needs to outside mental health professionals. One
response implied a negative view toward mental health intervention: We
have not had this type of situation occur so far, but if it presents itself our
first resource would be prayer and faith.

Table 3: Participant Attitudes about Referring


Congregants to Mental Health Professionals
Respondents (N=74)*

Attitudes Percent (%) Frequency


Positive (no reservations) 68.9 51
Positive if professional 14.9 11
is Christian or part of a
Christian organization
Cautious (must know the 12.2 9
professional and his/her
faith background
38 Social Work & Christianity

Attitudes Percent (%) Frequency


Negative (would not .01 1
refer)
Other .03 2

Discussion

Clergy members often provide highly valuable resources to congregants


experiencing emotional challenges and congregants are more likely to seek
services within the church than through outside mental health service
providers (Weaver, 1995; Clemens, Corradi, & Wasman, 1978; Chalfant et
al, 1990; Polson & Rogers, 2007). Offering such care can be difficult and
even stressful for pastors, who do not always feel competent to identify
problematic emotional issues experienced by parishioners. Therefore, the
ability to exercise sound judgment to determine when to best coordinate
with mental health professionals is an important component in improving
the emotional health of parishioners.
In the current study, respondents affirmed that they provided services
for their congregants in many stress-related situations. Pastors acknowl-
edged that intervening in situations involving suicide, crisis intervention,
homeless assistance, and abuse caused them the most personal stress, and
in these and other areas (e.g., employment), many considered such needs
to be unmet at their churches. Issues of this nature are often complex and
may require coordination with trained professionals (e.g., social workers),
especially during periods of crisis. Education and training in these areas
may be helpful in determining the best plan of care for congregants in need.
Clergy members who experienced the highest levels of stress included
those working in the smallest churches and those who were non-white. It
is plausible that clergy from the smallest churches have the least resources,
and possibly have higher demands than those from larger churches. It
would be worthwhile to further explore why non-white clergy experienced
more stress, specifically whether cultural beliefs about the origins of men-
tal health conditions were significant factors. These individuals may also
benefit from developing collaborative relationships with outside mental
health professionals.
Education also affected the level of stress experienced by clergy.
Specifically, pastors with the highest levels of education endorsed lower
levels of stress when providing grief and bereavement services and those
who attended seminary endorsed less stress than clergy who did not attend
seminary. This may indicate the significance of general and theological
education in dealing with the on-the-job demands inherent in the ministry.
The study also focused on clergy knowledge of mental health issues and
CLERGY/MENTAL HEALTH PRACTITIONER COLLABORATION 39

treatment. The majority of participants had obtained their education about


mental health through self-study and research, while some had acquired
knowledge through personal and familial experiences. Such findings sug-
gest that clergy value possessing knowledge of mental health and are aware
that congregants may look to them as first responders. Many participants
may thus welcome further training on mental health issues.
An overwhelming percentage of participants reported positive attitudes
toward referring congregants with emotional challenges to mental health
professionals, preferring counseling centers to any other single resource.
In fact, almost 70 percent endorsed referrals to such professionals without
reservation. This result differs significantly from previous research (e.g.,
study by Openshaw & Harr, 2009, involving 24 clergy members from the
Dallas/Fort Worth area, and a study by VanderWaal, Hernandez, & Sand-
man, 2012, involving 179 clergy from Kent County, Michigan), and may
reflect a bias in Southern California subculture that is more amenable to
accessing the services of counseling professionals. The efforts of the state
public mental health system to involve clergy members, as leaders in the
faith community, may also affect these results.
As clergy are called upon to intervene in crises, recognize serious
mental health issues, and provide referrals and ongoing support and
spiritual direction, they may benefit from collaboration with mental health
professionals to address these issues. According to Weaver (1995), pastors
and counselors would benefit from collaboration, especially given the
shared common values and dedication to serve those in need. The nature
of effective collaborative relationships between clergy and mental health
professionals should be further explored. Doing so may improve the mental
health services to congregants in need.

Practice Implications

The results of this study suggest that clergy possess varying degrees
of education and training regarding pastoral care, counseling, and mental
health issues. Though higher levels of education, in general, and seminary
training, in particular, may prepare clergy for the demands of meeting men-
tal health needs of parishioners, few respondents from the current study
reported prior graduate-level coursework or continuing education related
to these topics. To address this gap in clergy education and training, the
primary investigators are creating a series of seminars for Southern Califor-
nia clergy through the community counseling center at a local university to
address the needs that emerged in the major findings. Seminars will inten-
tionally target pastors with congregations that may have limited resources.
Clergy will be invited to participate in continuing education seminars
on (a) knowing when and how to refer to mental health professionals, (b)
developing a congregation-specific resource list, (c) mental health issues
40 Social Work & Christianity

such as depression, suicidality, family violence (child abuse and domestic


violence), and anger management, and (d) working with non-mental
health professionals to provide financial and job assistance to parishioners.
Professional development seminars, with a spiritual emphasis, may also
be developed, focusing on the counseling services offered most by clergy,
such as premarital or bereavement counseling. Furthermore, training in
undergraduate and seminary institutions should include supplementary
curriculum to prepare clergy for the practical realities of the pastoral role.
Faculty at these institutions may also consider conducting ongoing seminars
for the pastoral staff or parishioners of local congregations.
The results of this study indicate that clergy are regularly exposed
to many forms of mental illness, including chronic and severe mental ill-
ness, crisis intervention, and suicide. These findings suggest that pastors
are likely in need of support while caring for their congregations. The
primary investigators will also address clergy mental health by provid-
ing a series entitled Clergy Care Days. These workshops will access
multiple university departments to provide clergy with (a) personalized
mental and physical health assessments, (b) a detailed self-care plan, and
(c) resources for professional development, spiritual direction, emotional
support through peer groups and psychotherapy, exercise and nutrition
planning, and personal financial planning.

Limitations

There were a number of limitations inherent in this study, most notice-


ably the small sample size. The 74 participants did not accurately represent
the highly populous Southern California region with its numerous religious
denominations and the results of the study should be considered cautiously.
It is therefore important to compare the findings of this study with those of
larger sample sizes when generalizing results to larger populations.
Demographic variables also represented important limitations of the
current study. The sample was composed largely of older, male, Caucasian,
Protestant clergy, while populations less represented included female, non-
white, younger clergy and Catholic priests, among others. Because of the
multicultural blend of pastors in the area of study, the respondent sample
is not truly indicative of the pastors of the highly diverse population of
Southern California.
Finally, survey construction issues may have presented challenges
to participants. Although the survey focused on problems inherent in the
mental health field, respondents were asked to comment on and compare
problems related to psychiatric disorders (e.g., depression, substance
abuse/addictions) with areas outside of the mental health spectrum, such
as Employment/Job Search and Hospital/nursing home. Future surveys
CLERGY/MENTAL HEALTH PRACTITIONER COLLABORATION 41

would need to carefully delineate such categories while firmly establishing


their relevance to the mental health field.

Future Research

The focus of future research should be on continued exploration of


resources that pastors of all denominations and cultures can use to meet
the mental health needs of their congregants. This may include data on
collaboration with mental health professionals, clergy stress, and referral
preferences by demographic variables (age, gender, denomination, and
size of church). Also specific to the study at hand, future research should
include a larger participant base and focus on congregant emotional needs,
both met and unmet, that create the most stress among clergy members, as
well as regression models highlighting any demographic factors that predict
clergy responses to survey items.
For many parishioners, pastors are a direct gateway to fulfillment in
their relationship with God and, as such, a crucial resource for leading a
full and purposeful life. With this in mind, aiding clergy members through
research on mental health may be vital to the improvement of emotional
and spiritual functioning of many individuals who engage in religious
practices. v

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T. Scott Bledsoe, PsyD, Azusa Pacific University, Assistant Professor, Depart-


ment of Graduate Psychology, 701 E. Foothill Blvd./P.O Box 7000, Azusa, CA
91702-7000. Phone: (626) 815-6000 x5514. Email: tsbledsoe@apu.edu.

Kimberly Setterlund, MSW, LCSW, Azusa Pacific University, Assistant Profes-


sor, Director of Field Education, Department of Graduate Social Work, 901 E.
Alosta Ave./P.O. Box 7000, Azusa, CA 91702-7000. Phone: (626) 857-2402.
Email: ksetterlund@apu.edu.

Rev. Christopher J. Adams, MAT, MSMFT, PhD, Azusa Pacific University, As-
sociate Campus Pastor for Community Care, Campus Pastors Office, Division
of Student Life; Adjunct Professor Departments of Graduate Psychology and
Theology, 901 E. Alosta Ave./P.O. Box 7000, Azusa, CA 91702-7000. Phone:
(626) 815-3855. Email: chrisadams@apu.edu.

Alice Fok-Trela, PsyD, Clinical Psychologist, Graduate of Azusa Pacific Uni-


versity, Azusa, CA 97102-7000. Email: alicensfok@gmail.com.

Melissa Connolly, MA, Azusa Pacific University, Graduate Student, Depart-


ment of Graduate Psychology, 701 E. Foothill Blvd./P.O Box 7000, Azusa, CA
91702-7000. Phone: (626) 815-5008. Email: maconnol@gmail.com.
CLERGY/MENTAL HEALTH PRACTITIONER COLLABORATION 45

Key Words: mental health, counseling, congregants, parishioners, col-


laboration, clergy, faith leaders, pastors, clergy stressors

Authors Note: This study was funded in part with support from the Lilly Endow-
ment Grant, Office of Christian Leadership and Vocation, Azusa Pacific University.
The Clergy Questionnaire used in this study may be obtained by contacting the
authors. It was adapted from a questionnaire by Openshaw, L. & Harr, C. (2009).
Exploring the relationship between clergy and mental health professionals. Social
Work & Christianity, 36(3), 301-325. Used with permission of the authors.
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